Comparison of conjoined tendon-preserving posterior approach and conventional posterolateral approach in hemiarthroplasty for femoral neck fracture in the elderly: A multicenter (TRON group) retrospective study.

BACKGROUND: Femoral neck fractures (FNF) are one of the most common traumatic injuries in the elderly. The conjoined tendon-preserving posterior (CPP) approach was developed as a modification of the conventional posterolateral (PL) approach in hemiarthroplasty (HA) for displaced femoral neck fractures (FNF) to reduce postoperative dislocation. We hypothesized that the CPP approach would result in fewer dislocations and similar functional and radiographic outcomes compared to the PL approach. PATIENTS AND METHODS: This was a retrospective multicenter (TRON group) study. We evaluated the rate of complications, and functional and radiographic outcomes for patients aged >65 years who underwent HA via the PL approach or the CPP approach from 2017 to 2019 and followed up for at least 24 months. To adjust for baseline differences between the groups, a propensity score-matching algorithm was used in a 1:1 ratio. RESULTS: We identified 135 patients who underwent HA via the PL approach and 135 patients via the CPP approach. The mean follow-up period was 32.4 ± 14.0 months. The incidence of dislocation was 6 in 135 patients (4.4%) in the PL group and 0 in 135 patients (0%) in the CPP group, and there was significant difference (p = 0.04). Operation time was equivalent between the two groups (73.1 ± 30.4 vs. 71.8 ± 30.0 min; p = 0.72). The rate of varus insertion of stems in the PL group lower than that in the CPP group (19.3% vs. 33.3%; p = 0.01). Postoperative Parker's mobility score was similar between the two groups at 12 months follow-up (6.17 vs. 6.27; p = 0.81). CONCLUSION: The CPP approach showed a significantly lower dislocation rate, similar functional outcome and more varus stem insertions compared with the PL approach in this retrospective study.

Squamous cell carcinoma arising from an ischial pressure ulcer initially suspected to be necrotizing soft tissue infection: A case report.

BACKGROUND: Pressure ulcers are the most common complications in bedridden patients or those with spinal cord injuries. Marjolin's ulcer refers to a malignant transformation arising from burn scars or chronic nonhealing wounds-such as pressure ulcers-over many years. Squamous cell carcinoma is the major histopathologic type of Marjolin's ulcer, and the gold standard for diagnosis is tissue biopsy. Medical professionals may have difficulty distinguishing pressure ulcers from Marjolin's ulcer, especially when the latter presents with invasive infections. Thus, malignant transformations arising from pressure ulcers are frequently overlooked. Herein, we describe a case of squamous cell carcinoma arising from pressure ulcers on the left ischium, which was initially identified as a necrotizing soft tissue infection. CASE REPORT: A 59-year-old paraplegic patient presented with stage 3 left ischial pressure ulcer, which involves full-thickness skin loss and extends into deep subcutaneous tissue, and arrived at our hospital with suspected sepsis. Upon physical examination, the patient presented with fever and shivering. Initial examination and imaging findings revealed the presence of necrotizing soft tissue infections. Three weeks later, rapid increase in granulation in the deep part of the ulcer was observed. Samples from multiples ulcer sites were collected for tissue biopsy. Finally, histological examination revealed well-differentiated squamous cell carcinoma. The patient received radiation therapy and chemotherapy and died 11 months after the diagnosis. CONCLUSION: Malignant transformations arising from pressure ulcers may closely resemble pressure ulcer infections. In these cases, tissue biopsies should be performed during primary care for the infection to exclude malignant transformations.

Acetabular fracture non-union with pelvic discontinuity treated with two-stage total hip arthroplasty after intra- and extra-articular plate fixation.

Surgical intervention for the treatment of acetabular fracture non-union is often challenging. Here, we present a case of acetabular fracture non-union with pelvic discontinuity in a patient who underwent cemented total hip arthroplasty (THA) after intra- and extra-articular plate fixation. The case was a 70-year-old male with left T-shaped acetabular fracture non-union neglected for 5 months after the injury. The anterior and posterior columns were not healed, and the articular surface was displaced toward the medial side with a protrusion of the collapsed femoral head. As the first surgical intervention, we performed intra- and extra-articular plate fixation after femoral head decapitation. We fixed non-union regions from the inferior acetabular margin to the anterior column using a pelvic reconstruction plate bent three-dimensionally at the acetabular curvature on the intra-articular side. Furthermore, we fixed that of the posterior column on the outside of the acetabulum using a bent pelvic reconstruction plate. Union of the anterior and posterior columns was observed at 4 and 6 months after the first surgical intervention. At 7 months, we performed a cemented THA without additional bone grafting. At 1-year follow-up, the patient did not have left coxalgia and could walk without any gait supports. Based on our experience, we propose this surgical protocol as a useful treatment option for cases of acetabular fracture non-union.

A Possible New Radiographic Predictor of Progression of Osteoarthritis in Developmental Dysplasia of the Hip: The Center Gap.

BACKGROUND: Patients with comparable severities of developmental dysplasia of the hip (DDH) may variably progress to osteoarthritis (OA) over time. Although joint congruency may be associated with OA progression in patients with DDH, it has only been assessed subjectively. We assessed the gap between the rotational centers of the acetabulum and femoral head (center gap) as a possible predictive measure of OA progression in patients with DDH. QUESTIONS/PURPOSES: In patients with bilateral DDH, we asked: (1) What is the probability of OA progression (Tönnis grade) or symptom development (pain) in the asymptomatic contralateral hip of patients with DDH undergoing unilateral joint-preserving surgery? (2) Is the center gap measurement associated with OA progression or symptom development in these hips? (3) Is the center gap measurement correlated with previous radiographic parameters? METHODS: A total of 297 patients (319 hips) underwent unilateral eccentric rotational acetabular osteotomy at our institution between July 1989 and December 1999. We performed no other joint-preserving surgery to treat patients with DDH during this timeframe. The inclusion criteria for the study were patients younger than 55 years of age, the contralateral hip classified as Tönnis Grade 0, no previous surgical interventions, and asymptomatic at the time of eccentric rotational acetabular osteotomy (155 patients, 155 hips). The exclusion criteria were a contralateral hip without dysplasia (four patients, four hips), loss to followup before 10 years (42 patients, 42 hips [27%]), or missing medical records or radiographs (21 patients, 21 hips [14%]). The remaining 88 patients (88 hips; 11 males and 77 females) with a mean age of 39 years (range, 17-53 years) and mean followup of 20 years (range, 10-27 years) were analyzed. From the institutional database, radiographic parameters including the center gap in the AP view were assessed using radiographs at the time of eccentric rotational acetabular osteotomy, and the Tönnis grade was recorded 1 year postoperatively and annually thereafter retrospectively. We defined migration of the rotational center of the femoral head based on the rotational center of the acetabulum in the horizontal plane as center gap X (mm) and in the vertical plane as center gap Y (mm) and defined the absolute value between the centers as center gap distance (mm). Using κ statistics, intra- and interobserver reliabilities were determined to be 0.896 and 0.857 for center gap X, 0.912 and 0.874 for center gap Y, and 0.912 and 0.901 for the center gap distance, respectively. When patients reported any contralateral ipsilateral hip pain during clinic visits, the hip was considered symptomatic. Kaplan-Meier survivorship analyses were performed with OA progression or symptom development in the nonoperative hip as the endpoint. Multivariate analyses were performed to assess risk factors for each outcome using the Cox proportional hazards model. Correlation analyses between the center gap and other parameters including lateral center-edge angle, femoral head extrusion index, acetabular depth-to-width index, femoral head lateralization, minimum width of the joint space, head sphericity, and joint congruency were performed using Pearson's correlation coefficient. RESULTS: At 20 years postoperatively, the probability of OA progression in the nonoperative hip was 13% (95% confidence interval [CI], 7.1-22.1) and the probability of symptom development was 34% (95% CI, 24.7-46.1). The center gap X measurements in the groups with OA progression (lateral 2.0 ± 2.1 [SD] mm) or symptom development (lateral 0.9 ± 2.4 mm) took a more lateral direction than those in the group without OA progression (medial 0.4 ± 2.1 mm) or symptom development (medial 0.5 ± 2.0 mm) (OA progression, p < 0.001; symptom development, p = 0.005). The center gap Y measurements in the groups with OA progression (distal 2.7 ± 7.1 mm) or symptom development (distal 2.1 ± 6.0 mm) took a more distal direction than those in the group without OA progression (proximal 1.6 ± 6.2 mm) or symptom development (proximal 2.5 ± 6.1 mm) (OA progression, p = 0.027; symptom development, p = 0.001). Independent risk factors for OA progression were the femoral head extrusion index (hazard ratio [HR], 1.11; 95% CI, 1.01-1.22; p = 0.028) and the center gap X (HR, 1.52; 95% CI, 1.07-2.16; p = 0.019), whereas no independent risk factors for symptom development were found. The center gap in the horizontal plane had no correlations with any other radiographic parameter studied. CONCLUSIONS: The center gap in the horizontal plane had a modest association with OA progression in this group of patients with DDH. Future studies are needed to determine the normal value of the center gap for patients without DDH and to assess the center gap in lateral radiographic views. LEVEL OF EVIDENCE: Level IV, prognostic study.

Do femoral head collapse and the contralateral condition affect patient-reported quality of life and referral pain in patients with osteonecrosis of the femoral head?

PURPOSES: The objectives of this study were to investigate patient-reported outcomes and referral pain at the first visit in patients with osteonecrosis of the femoral head (ONFH) and to clarify the influence of collapse of the femoral head and the contralateral condition. METHODS: The study included 105 patients (130 hips) with ONFH at the first visit, who were divided into two groups based on the presence of bilateral walking hip pain (bilateral group 25 patients, 50 hips) and unilateral hip pain (unilateral group 80 patients, 80 hips). We compared the Short Form-36 (SF-36), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and visual analog scale (VAS) responses for hip, knee, and low back pain between the groups to investigate the influence of the contralateral condition. Regarding the influence of femoral head collapse, we investigated these subjects based on the stage classification in the unilateral group. RESULTS: The physical component summary (PCS) of the SF-36 and all domains of the JHEQ were poorer in the bilateral group than in the unilateral group. In addition, the VAS score for low back pain was significantly poorer in the bilateral group than in the unilateral group. Regarding the collapse of the femoral head, the SF-36 for the PCS and JHEQ for pain had a significant relationship in the ONFH stage. The VAS scores for hip and knee pain had a significant relationship in the ONFH stage. CONCLUSION: Collapse of the femoral head and the contralateral condition of ONFH strongly affect patients' activities of daily life.

Promethazine Hydrochloride Inhibits Ectopic Fat Cell Formation in Skeletal Muscle.

Fatty degeneration of skeletal muscle leads to muscle weakness and loss of function. Preventing fatty degeneration in skeletal muscle is important, but no drug has been used clinically. In this study, we performed drug repositioning using human platelet-derived growth factor receptor α (PDGFRα)-positive mesenchymal progenitors that have been proved to be an origin of ectopic adipocytes in skeletal muscle. We found that promethazine hydrochloride (PH) inhibits adipogenesis in a dose-dependent manner without cell toxicity. PH inhibited expression of adipogenic markers and also suppressed phosphorylation of cAMP response-element binding protein, which was reported to be a primary regulator of adipogenesis. We established a mouse model of tendon rupture with intramuscular fat deposition and confirmed that emerged ectopic adipocytes are derived from PDGFRα+ cells using lineage tracing mice. When these injured mice were treated with PH, formation of ectopic adipocytes was suppressed significantly. Our results show that PH inhibits PDGFRα+ mesenchymal progenitor-dependent ectopic adipogenesis in skeletal muscle and suggest that treatment with PH can be a promising approach to prevent fatty degeneration of skeletal muscle.

The impact of musculoskeletal diseases on mortality-comparison with internal diseases: A 15-year longitudinal study.

BACKGROUND: Aging is associated with an increased incidence of diabetes (DM), hypertension (HT), hyperlipidemia (HL), as well as musculoskeletal disorders, such as osteoarthritis (OA) and osteoporosis (OP). However, the impact of musculoskeletal disorders on mortality remains unclear. This study investigated the risk of mortality if having knee OA or OP. METHODS: 601 participants (mean age 67.8 ± 5.3 years) who underwent musculoskeletal check-ups in Yakumo town were enrolled in this study, 248 were males and 353 were females. The following parameters were assessed: age, sex, body mass index, smoking habit, alcohol drinking habit, physical exercise habit, knee OA, OP, HT, DM and HL. Kaplan-Meier survival curves for smoking, drinking and physical exercise habits, knee OA, OP, HT, DM and HL were prepared, and the log-rank test was performed. Furthermore, the Cox hazard model was used for multivariate analysis of all variables. RESULTS: Knee OA, OP, HT, and DM were associated with a significantly higher mortality rate. Cox regression analysis results showed a hazard ratio of 1.972 for OA (95%CI: 1.356-2.867), 1.965 for DM (1.146-3.368), 1.706 for smoking habits (1.141-2.552), and 1.614 for OP (1.126-2.313). Cardiovascular diseases were the most common causes of death. CONCLUSIONS: Smoking, knee OA, OP and DM were all associated with increased risk of mortality. Knee OA had a high hazard ratio, comparable to that of DM. These findings suggest that interventions against smoking, knee OA, OP and DM may reduce the risk of mortality.

Identification, Isolation, and Characterization of Mesenchymal Progenitors in Mouse and Human Skeletal Muscle.

Mesenchymal progenitors residing in the muscle interstitial space contribute to pathogeneses such as fat infiltration and fibrosis. Because fat infiltration and fibrosis are hallmarks of diseased muscle, it is important to establish an accurate and reproducible method for isolating mesenchymal progenitors for research on muscle diseases. In this chapter, we describe methods based on fluorescence-activated cell sorting (FACS) to purify mesenchymal progenitors from mouse and human skeletal muscle using the most reliable marker for mesenchymal progenitors, PDGFRα. These methods allow concurrent isolation of the muscle stem cells called satellite cells. The quality of isolated mesenchymal progenitors is confirmed by their remarkable adipogenic potential without myogenic capacity, while purified satellite cells possess robust myogenic activity with no adipogenic potential. Simultaneous isolation of both mesenchymal progenitors and satellite cells from mouse and human tissues provides a powerful platform for studying skeletal muscle regeneration and diseases.

Cell-Surface Protein Profiling Identifies Distinctive Markers of Progenitor Cells in Human Skeletal Muscle.

Skeletal muscle contains two distinct stem/progenitor populations. One is the satellite cell, which acts as a muscle stem cell, and the other is the mesenchymal progenitor, which contributes to muscle pathogeneses such as fat infiltration and fibrosis. Detailed and accurate characterization of these progenitors in humans remains elusive. Here, we performed comprehensive cell-surface protein profiling of the two progenitor populations residing in human skeletal muscle and identified three previously unrecognized markers: CD82 and CD318 for satellite cells and CD201 for mesenchymal progenitors. These markers distinguish myogenic and mesenchymal progenitors, and enable efficient isolation of the two types of progenitors. Functional study revealed that CD82 ensures expansion and preservation of myogenic progenitors by suppressing excessive differentiation, and CD201 signaling favors adipogenesis of mesenchymal progenitors. Thus, cell-surface proteins identified here are not only useful markers but also functionally important molecules, and provide valuable insight into human muscle biology and diseases.

Validity of radiographic assessment of the knee joint space using automatic image analysis.

OBJECTIVES: The present study investigated whether there were differences between automatic and manual measurements of the minimum joint space width (mJSW) on knee radiographs. METHODS: Knee radiographs of 324 participants in a systematic health screening were analyzed using the following three methods: manual measurement of film-based radiographs (Manual), manual measurement of digitized radiographs (Digital), and automatic measurement of digitized radiographs (Auto). The mean mJSWs on the medial and lateral sides of the knees were determined using each method, and measurement reliability was evaluated using intra-class correlation coefficients. Measurement errors were compared between normal knees and knees with radiographic osteoarthritis. RESULTS: All three methods demonstrated good reliability, although the reliability was slightly lower with the Manual method than with the other methods. On the medial and lateral sides of the knees, the mJSWs were the largest in the Manual method and the smallest in the Auto method. The measurement errors of each method were significantly larger for normal knees than for radiographic osteoarthritis knees. CONCLUSIONS: The mJSW measurements are more accurate and reliable with the Auto method than with the Manual or Digital method, especially for normal knees. Therefore, the Auto method is ideal for the assessment of the knee joint space.

Sarcopenia and sarcopenic leg as potential risk factors for acute osteoporotic vertebral fracture among older women.

PURPOSE: Sarcopenia-related falls and fractures among women with osteoporosis are becoming an emerging problem because of rapid aging worldwide. We aimed to investigate the association between sarcopenia, given by the muscle mass of the arms and legs, and osteoporotic vertebral fracture (OVF) among female patients. METHODS: This cross-sectional study examined 216 women with fresh OVF (OVF group) diagnosed by magnetic resonance imaging and 1,608 women from an outpatient clinic who did not have a OVF [non-fracture (NF) group]. We performed whole-body dual-energy X-ray absorptiometry to analyze body composition, including skeletal muscle mass index (SMI; lean mass/height2) and bone mineral density (BMD). We used stepwise logistic regression analysis to determine the risk factors associated with OVF. RESULTS: After controlling for age, the OVF group showed lower appendicular SMI (5.62 vs. 5.97 kg/m2, P < 0.001), lower arm SMI (1.36 vs. 1.42 kg/m2, P = 0.004), lower leg SMI (4.27 vs. 4.55 kg/m2, P < 0.001), and higher prevalence of sarcopenia (42.3 vs. 25.9 %, P < 0.001), compared with the NF group. Reduced leg muscle mass and presence of sarcopenia were independent risk factors for acute OVF in multivariate analysis (odds ratio = 1.4, P = 0.002; odds ratio = 1.96, P < 0.001, respectively). CONCLUSIONS: We found higher prevalence of sarcopenia and lower leg muscle mass among patients with acute OVF compared with patients who did not have an OVF. These results suggest that sarcopenia may be a risk factor for OVF.

Sex- and age-related differences in mid-thigh composition and muscle quality determined by computed tomography in middle-aged and elderly Japanese.

AIM: Sex- and age-related differences in mid-thigh composition and muscle quality remain unclear. The present study aimed to clarify these differences using computed tomography in middle-aged and elderly Japanese. METHODS: A total of 2310 participants (age 40-89 years), who were randomly selected from the local residents, underwent computed tomography examination of the right mid-thigh. Thigh circumference and cross-sectional areas of the thigh, muscle, quadriceps, non-quadriceps, fat, and bone were measured. Knee extension strength and muscle quality index (knee extension strength/quadriceps cross-sectional area) were also assessed. Sex- and age-related differences in these indices were analyzed. RESULTS: The thigh cross-sectional area in men and women decreased by 0.6% and 0.5%/year, respectively, because of a decrease in muscle cross-sectional area (men 75.2%, women 40.6%), fat cross-sectional area (men 24.4%, women 59.6%) and bone cross-sectional area (men 0.5%, women -0.2%). Muscle cross-sectional area in men and women decreased by 0.6% and 0.4%/year, respectively, because of a decrease in quadriceps cross-sectional area (men 65.6%, women 81.6%) and non-quadriceps cross-sectional area (men 34.4%, women 18.4%). Muscle quality in men and women decreased by 0.4% and 0.3%/year, respectively. CONCLUSION: Thigh cross-sectional area decreased with age mainly because of a decrease in muscle cross-sectional area in men and fat cross-sectional area in women. The rate of decrease in muscle cross-sectional area was 1.5-fold higher in men than in women. Muscle cross-sectional area decreased with age mainly because of a decrease in quadriceps cross-sectional area, especially in women. Decrease in muscle quality with age was similar in both sexes.

Use of alfacalcidol in osteoporotic patients with low muscle mass might increase muscle mass: an investigation using a patient database.

AIM: Sarcopenia causes a decline in physical performance and decreased quality of life. However, there is little evidence for effective treatments. Because of the similarities between osteoporosis and sarcopenia, alfacalcidol used for osteoporosis might be beneficial for low muscle mass. Therefore, we investigated the effect of alfacalcidol on muscle mass in patients with low muscle mass. METHODS: In this retrospective cohort analysis, patients from an osteoporosis database were divided into two groups: alfacalcidol-treated patients (vitamin D group; n = 156) and a control group without drug treatment (n = 233). Muscle mass was evaluated in terms of the skeletal muscle index (SMI; kg/m(2)) obtained from dual-energy X-ray absorptiometry measurements that were taken at the start and end of a 1-year period. Low muscle mass was determined using specific SMI cut-offs for Japanese individuals. RESULTS: Both the vitamin D group (mean age 73.7 ± 9.8 years) and the control group (mean age 72.3 ± 11.9 years) were primarily women (n = 141, 90.4%; n = 189, 81.1%, respectively). Low muscle mass was identified in 32.7% (n = 51) of the vitamin D group and 32.2% (n = 75) of the control group. The mean appendicular SMI in the vitamin D group did not change significantly over the 1-year period. The change was significant among the patients with low muscle mass (5.30 kg/m(2) vs 5.49 kg/m(2)). The mean appendicular SMI in the control group decreased significantly over the 1-year period (6.09 kg/m(2) vs 5.99 kg/m(2)). The change in the patients with low muscle mass was not significant. CONCLUSIONS: The vitamin D group maintained muscle mass, and the SMI increased in patients with low muscle mass. Thus, the use of alfacalcidol might be effective in osteoporotic patients with low muscle mass.

[Comparison of the Supreme Laryngeal Mask Airway(SLMA), single use, with the reusable Proseal Laryngeal Mask Airway(PLMA) in anesthetized adult Japanese patients].

BACKGROUND: Supreme laryngeal mask airway (SLMA) is a single use, new supraglottic airway device with anatomically designed curved airway conduit. It has second channel for gastric tube insertion. We compared the performance of the SLMA with that of the Proseal LMA (PLMA), the older reusable LMA, during anaesthesia in spontaneously breathing adult patients. METHODS: One hundred adult patients were studied in a prospective randomized controlled study. Insertion time, first attempt success rates, leak pressure, ease of gastric tube placement, and the incidence of blood staining on removal, as well as sore throat and hoarseness were compared. For statistical analyses, Student's t test, Mann-Whitney's U test, and Fisher's exact test were used where appropriate, and P<0.01 considered significant. RESULTS: SLMA provided faster insertion time (11 vs 18 seconds, P<0.01). Leak pressure was higher for PLMA (25 vs 28cmH2O, P<0.01). First attempt success rates, gastric tube placement and the incidence of complications were similar. CONCLUSIONS: Our result indicated that SLMA can be inserted faster without inserting one's finger into patient oral cavity. Leak pressure was lower but acceptable for clinical use in spontaneously breathing anesthetized adult patients.