Novel susceptibility loci for steroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus.

Osteonecrosis of the femoral head (ONFH) involves necrosis of bone and bone marrow of the femoral head caused by ischemia with unknown etiology. Previous genetic studies on ONFH failed to produce consistent results, presumably because ONFH has various causes with different genetic backgrounds and the underlying diseases confounded the associations. Steroid-associated ONFH (S-ONFH) accounts for one-half of all ONFH, and systemic lupus erythematosus (SLE) is a representative disease underlying S-ONFH. We performed a genome-wide association study (GWAS) to identify genetic risk factors for S-ONFH in patients with SLE. We conducted a two-staged GWAS on 636 SLE patients with S-ONFH and 95 588 non-SLE controls. Among the novel loci identified, we determined S-ONFH-specific loci by comparing allele frequencies between SLE patients without S-ONFH and non-SLE controls. We also used Korean datasets comprising 148 S-ONFH cases and 37 015 controls to assess overall significance. We evaluated the functional annotations of significant variants by in silico analyses. The Japanese GWAS identified 4 significant loci together with 12 known SLE susceptibility loci. The four significant variants showed comparable effect sizes on S-ONFH compared with SLE controls and non-SLE controls. Three of the four loci, MIR4293/MIR1265 [odds ratio (OR) = 1.99, P-value = 1.1 × 10-9)], TRIM49/NAALAD2 (OR = 1.65, P-value = 4.8 × 10-8) and MYO16 (OR = 3.91, P-value = 4.9 × 10-10), showed significant associations in the meta-analysis with Korean datasets. Bioinformatics analyses identified MIR4293, NAALAD2 and MYO16 as candidate causal genes. MIR4293 regulates a PPARG-related adipogenesis pathway relevant to S-ONFH. We identified three novel susceptibility loci for S-ONFH in SLE.

Long-term outcomes of the mayo conservative hip system in patients aged 30 years or less with osteonecrosis of the femoral head: mean follow-up of more than 10 years.

INTRODUCTION: Historically, total hip arthroplasty (THA) in very young patients has been associated with lower survivorship. However, the long-term outcomes of THA using short stems for osteonecrosis of the femoral head (ONFH) in very young patients remain unclear. Therefore, this study aimed to investigate the long-term outcomes of the Mayo conservative hip system, a short metaphyseal stabilised stem, in patients with ONFH aged ≦30 years. MATERIALS AND METHODS: We retrospectively reviewed 104 joints in 76 patients with ONFH who underwent THA using the Mayo conservative hip system with a minimum follow-up of 8 years. The mean follow-up period was 12.5 (range, 8-19) years. Patients were categorised into two age groups (≦30 years, n = 21 and > 30 years, n = 83). Radiographic evaluation was used to assess stem sinking, stress shielding, and spot welds. The clinical evaluations were performed using the Japanese Orthopedic Association (JOA) hip score. Postoperative major complication and revision surgery rates were also assessed. RESULTS: The patient characteristics were similar between the two groups, except for the age. Revision surgeries were performed in five cases, with similar implant survival rates between the groups. Dislocations occurred in the older age group alone (four joints). One case of intra-operative periprosthetic femoral fracture was found in the younger age group. Stem sinking of > 3 mm occurred in one and seven joints in the younger and older age groups, respectively. Spot welds were observed in most joints (93.2%) in modified Gruen zones 2 and 6 without significant differences between the groups. Stress shielding showed no significant differences in the frequency of occurrence or location between the two groups. Furthermore,the JOA score showed no significant difference between the two groups. CONCLUSION: The use of short stems in patients aged ≤ 30 years with ONFH showed favourable long-term outcomes.

High-degree posterior rotational osteotomy for extensive collapsed femoral head osteonecrosis in teenagers: remodeling and results with a mean of 10-year follow-up.

INTRODUCTION: This study evaluated the effectiveness of high-degree posterior rotational osteotomy for teenagers with extensively collapsed femoral head osteonecrosis. MATERIALS AND METHODS: We reviewed 40 hips in 35 patients with severely collapsed femoral head osteonecrosis treated by this procedure with a mean follow-up period of 9.7 years (range 5-25 years). Thirteen hips had a history of steroid administration. Nine had slipped capital femoral epiphysis. Nine had femoral neck fracture. Two had traumatic dislocation and fracture. Seven had no apparent risk factors. The mean age of the patients (18 women and 17 men) was 14.8 years. All femoral heads were extensively collapsed below the acetabular roof, and 20 hips showed preoperative joint space narrowing (ARCO stage 4). Lateral radiographs of the femoral head revealed extensive lesions from the posterior to anterior portion. The mean degree of posterior rotation was 118° with intentional varus positioning [mean: 19° (range 10-30)]. The pre- and postoperative extent of the viable area of the femoral head was assessed using conventional anteroposterior radiographs and 45-degree flexion radiography. Further collapse, joint space narrowing, femoral head morphology, and congruency with the acetabulum based on the Stulberg classification were assessed using conventional anteroposterior radiographs. The clinical assessment was conducted using the Merle d'Aubigné hip scores at the last follow-up. RESULTS: The viable area of the femoral head on the loaded portion was seen during a short period after operations. The necrotic lesions were gradually improved postoperatively. The mean extent of viable bone below the acetabular roof was 48% at less than 6 months after surgery and 92% at the final follow-up. The mean extent on 45° flexion radiography was 54% at less than 6 months after surgery and 89% at the final follow-up. Further collapse was prevented in 38 hips (95%). In 19 of 20 hips with preoperative narrowing of the joint space, the joint space was first improved, but narrowing progressively observed in 9 of 40 hips at the final follow-up. Thirty-four hips had excellent or good clinical outcomes, whereas 6 had fair or poor outcomes. CONCLUSIONS: We concluded that this procedure is effective at delaying the progression of degeneration if adequate area of viable bone can be moved under the loaded portion of the acetabulum in teenagers with severe femoral head osteonecrosis.

Structural and functional analyses of calcium ion response factors in the mantle of Pinctada fucata.

The pearl oyster, Pinctada fucata, is cultured for pearl production in Japan. The shell of the pearl oyster consists of calcium carbonate and a small amount of organic matrix. Despite many studies of the shell matrix proteins, the mechanism by which calcium elements are transported from the mantle to the shell remains unclear. Investigating the molecular mechanism of calcium transportation, we prepared artificial seawater with a high concentration of calcium ions (10ASW) to induce calcification in the pearl oyster. When pearl oysters were cultured in 10ASW, unusual nanoparticles were precipitated on the surface of the nacreous layer. SDS-PAGE and 2D-PAGE analyses revealed that some calcium-sensing proteins (Sarcoplasmic Ca-binding Protein (Pf-SCP) and Pf-filamin A) might be related to the synthesis of these nanoparticles. The recombinant proteins of Pf-SCP can bind to calcium ions and accumulate nanoparticles of calcium carbonate crystals. However, transcriptomic analysis of the pearl oysters grown in 10ASW showed that the matrix protein genes in the shell did not differ before and after treatment with 10ASW. These results suggest that, despite increasing calcium transportation to the shell, treatment with a high concentration of calcium ions does not induce formation of the organic framework in the shell microstructure. These findings offer meaningful insights into the transportation of calcium elements from the mantle to the shell.

Human mesenchymal stem/stromal cells suppress spinal inflammation in mice with contribution of pituitary adenylate cyclase-activating polypeptide (PACAP).

BACKGROUND: Adult human mesenchymal stem/stromal cells (hMSCs) from bone marrow have been reported to exhibit beneficial effects on spinal cord injury (SCI). A neuropeptide, pituitary adenylate cyclase-activating polypeptide (PACAP) is known to decrease neuronal cell death and inflammatory response after ischemia, SCI, and other neuronal disorders. Recently, we found that expression of the gene for mouse PACAP (Adcyap1) was greater in animals receiving hMSCs with neural injury such as ischemia. However, the association of PACAP with hMSCs to protect nerve cells against neural injuries is still unclear. METHODS: Wild-type and PACAP-gene-deficient (Adcyap1 (+/-) ) mice were subjected to spinal cord transection, and hMSCs (5 × 10(5) cells) were injected into the intervertebral spinal cord on day 1 post-operation (p.o.). Locomotor activity, injury volume, retention of hMSCs, mouse and human cytokine genes (which contribute to macrophage (MΦ) and microglial activation), and Adcyap1 were evaluated. RESULTS: hMSCs injected into wild-type mice improved locomotor activity and injury volume compared with vehicle-treated mice. In contrast, non-viable hMSCs injected into wild-type mice, and viable hMSCs injected into Adcyap1 (+/-) mice, did not. Wild-type mice injected with hMSCs exhibited increased Adcyap1 expression, and observed PACAP immunoreaction in neuron-like cells. Gene expression levels for IL-1, tumor necrosis factor α (TNFα), interleukin-10 (IL-10), and transforming growth factor ß (TGFß) decreased, while that for interleukin-4 (IL-4) increased, in hMSC-injected wild-type mice. In contrast, IL-1, TGFß, and IL-4 gene expression levels were all abolished in hMSC-injected Adcyap1 (+/-) mice on day 7 post-operation. Moreover, the mice-implanted hMSCs increased an alternative activating macrophage/microglial marker, arginase activity. The human gene profile indicated that hMSCs upregulated the gene of IL-4 and growth factors which were reported to enhance Adcyap1 expression. Finally, we demonstrated that hMSCs express human ADCYAP1 and its receptor gene after the inflammation-related interferon-γ (IFNγ) in vitro. CONCLUSIONS: These results suggest that hMSCs attenuate the deleterious effects of SCI by reducing associated inflammatory responses and enhancing IL-4 production. This effect could be mediated in part by cell-cell cross-talk involving the neuropeptide PACAP.

Proprioceptive illusions created by vibration of one arm are altered by vibrating the other arm.

There is some evidence that signals coming from both arms are used to determine the perceived position and movement of one arm. We examined whether the sense of position and movement of one (reference) arm is altered by increases in muscle spindle signals in the other (indicator) arm in blindfolded participants (n = 26). To increase muscle spindle discharge, we applied 70-80 Hz muscle vibration to the elbow flexors of the indicator arm. In a first experiment, proprioceptive illusions in the vibrated reference arm in a forearm position-matching task were compared between conditions in which the indicator arm elbow flexors were vibrated or not vibrated. We found that the vibration illusion of arm extension induced by vibration of reference arm elbow flexors was reduced in the presence of vibration of the indicator elbow flexors. In a second experiment, participants were asked to describe their perception of the illusion of forearm extension movements of the reference arm evoked by vibration of reference arm elbow flexors in response to on/off and off/on transitions of vibration of non-reference arm elbow flexors. When vibration of non-reference arm elbow flexors was turned on, they reported a sensation of slowing down of the illusion of the reference arm. When it was turned off, they reported a sensation of speeding up. To conclude, the present study shows that both the sense of limb position and the sense of limb movement of one arm are dependent to some extent on spindle signals coming from the other arm.

Costal osteochondral autograft for reconstruction of advanced-stage osteochondritis dissecans of the capitellum.

BACKGROUND: Advanced-stage osteochondritis dissecans of the capitellum affecting the lateral wall may result in osteoarthritis, and suitable treatment is needed to avoid permanent deformation and impaired function. We aimed to assess postoperative outcomes of costal osteochondral autograft for treatment of this condition. METHODS: We included 22 young overhead athletes (mean age, 13.9 years) with advanced osteochondritis dissecans of the humeral capitellum who underwent costal osteochondral autograft. All patients had elbow pain and wide-range articular cartilage lesions. We evaluated clinical and radiographic outcomes at a mean follow-up of 27 months (range, 12-77 months). RESULTS: All patients achieved rapid functional improvement and returned to their former sports activity levels. The baseball players were able to play catch within 62 to 164 days (mean, 107 days) and returned to full pitching activity within 123 to 339 days (mean, 226 days). We assessed mean elbow function by the clinical rating system of Timmerman and Andrews and the Japanese Orthopaedic Association sports score; the scores improved from 121.5 and 53.7 points preoperatively to 169.2 points and 86.1 points, respectively, at the time of follow-up. Four patients required additional minor surgical procedures, including screw removal, loose body removal, and shaving off of spur formation. No patient showed obvious radiographic changes of osteoarthritis. All patients were satisfied with the final outcomes and had good functional recovery. CONCLUSION: Costal osteochondral autograft gave satisfactory results for advanced osteochondritis dissecans of the humeral capitellum with extensive lesions affecting the lateral wall.

Residual deformity after femoral neck fracture affects the location of osteonecrosis of the femoral head.

Aims: The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs. Methods: Patients aged younger than 55 years diagnosed with ONFH after FNF were retrospectively reviewed. Overall, 65 hips (38 males and 27 females; mean age 32.6 years (SD 12.2)) met the inclusion criteria. Patients with stage 1 or 4 ONFH, as per the Association Research Circulation Osseous classification, were excluded. The ratios of anterior and posterior viable areas and necrotic areas of the femoral head to the articular surface were calculated by setting the femoral head centre as the reference point. The PTA was measured using Palm's method. The association between the PTA and viable or necrotic areas of the femoral head was assessed using Spearman's rank correlation analysis (median PTA 6.0° (interquartile range 3 to 11.5)). Results: We identified a negative correlation between PTA and anterior viable areas (rho -0.477; p = 0.001), and no correlation between PTA and necrotic (rho 0.229; p = 0.067) or posterior viable areas (rho 0.204; p = 0.132). Conclusion: Our results suggest that residual posterior tilt after FNF could affect the anteroposterior localization of necrosis.

A novel birnavirus identified as the causative agent of summer atrophy of pearl oyster (Pinctada fucata (Gould)).

The Akoya pearl oyster (Pinctada fucata (Gould)) is the most important species for pearl cultivation in Japan. Mass mortality of 0-year-old juvenile oysters and anomalies in adults, known as summer atrophy, have been observed in major pearl farming areas during the season when seawater temperatures exceed about 20 °C since 2019. In this study, we identified a novel birnavirus as the pathogen of summer atrophy and named it Pinctada birnavirus (PiBV). PiBV was first presumed to be the causative agent when it was detected specifically and frequently in the infected oysters in a comparative metatranscriptomics of experimentally infected and healthy pearl oysters. Subsequently, the symptoms of summer atrophy were reproduced by infection tests using purified PiBV. Infection of juvenile oysters with PiBV resulted in an increase in the PiBV genome followed by the atrophy of soft body and subsequent mortality. Immunostaining with a mouse antiserum against a recombinant PiBV protein showed that the virus antigen was localized mainly in the epithelial cells on the outer surface of the mantle. Although the phylogenetic analysis using maximum likelihood method placed PiBV at the root of the genus Entomobirnavirus, the identity of the bi-segmented, genomic RNA to that of known birnaviruses at the full-length amino acid level was low, suggesting that PiBV forms a new genus. The discovery of PiBV will be the basis for research to control this emerging disease.

High-Degree Valgus Osteotomy for Severe Femoral Head Osteonecrosis After Femoral Neck Fracture with Nonunion: A Case Report.

CASE: A 15-year-old adolescent boy had severe groin pain because of extensive osteonecrosis of the femoral head with collapse, joint space narrowing, and nonunion after a failed internal fixation for femoral neck fracture. We performed a 60° valgus osteotomy that moved the posteromedial small viable portion of the femoral head to the weight-bearing acetabular area. The femoral neck nonunion and the necrosis healed completely, and the spherical contour of the femoral head was regained after postoperative hip joint remodeling. CONCLUSIONS: Good remodeling and congruency were achieved by performing high-degree valgus osteotomy to obtain sufficient viable area below the acetabular roof.

Salusin-ß accelerates inflammatory responses in vascular endothelial cells via NF-κB signaling in LDL receptor-deficient mice in vivo and HUVECs in vitro.

The bioactive peptide salusin-ß is highly expressed in human atheromas; additionally, infusion of antiserum against salusin-ß suppresses the development of atherosclerosis in atherogenic mice. This study examined the roles of salusin-ß in vascular inflammation during atherogenesis. Infusion of antiserum against salusin-ß attenuated the induction of VCAM-1, monocyte chemoattractant protein (MCP)-1, and IL-1ß and as well as nuclear translocation of NF-κB in aortic endothelial cells (ECs) of LDL receptor-deficient mice, which led to the prevention of monocyte adhesion to aortic ECs. In vitro experiments indicated that salusin-ß directly enhances the expression levels of proinflammatory molecules, including VCAM-1, MCP-1, IL-1ß, and NADPH oxidase 2, as well as THP-1 monocyte adhesion to cultured human umbilical vein ECs (HUVECs). Both salusin-ß-induced VCAM-1 induction and monocyte/HUVEC adhesion were suppressed by pharmacological inhibitors of NF-κB, e.g., Bay 11-7682 and curcumin. Furthermore, the VCAM-1 induction was significantly prevented by the phosphatidylinositol 3-kinase (PI3K) inhibitor LY-294002, whereas it was accelerated by the ERK inhibitor, U-0126. Treatment of HUVECs with salusin-ß, but not with salusin-α, accelerated oxidative stress and nuclear translocation of NF-κB as well as phosphorylation and degradation of IκB-α, an endogenous inhibitor of NF-κB. Thus, salusin-ß enhanced monocyte adhesion to vascular ECs through NF-κB-mediated inflammatory responses in ECs, which can be modified by PI3K or ERK signals. These findings are suggestive of a novel role of salusin-ß in atherogenesis.

Interleukin-1 participates in the classical and alternative activation of microglia/macrophages after spinal cord injury.

BACKGROUND: Microglia and macrophages (MG/MΦ) have a diverse range of functions depending on unique cytokine stimuli, and contribute to neural cell death, repair, and remodeling during central nervous system diseases. While IL-1 has been shown to exacerbate inflammation, it has also been recognized to enhance neuroregeneration. We determined the activating phenotype of MG/MΦ and the impact of IL-1 in an in vivo spinal cord injury (SCI) model of IL-1 knock-out (KO) mice. Moreover, we demonstrated the contribution of IL-1 to both the classical and alternative activation of MG in vitro using an adult MG primary culture. METHODS: SCI was induced by transection of the spinal cord between the T9 and T10 vertebra in wild-type and IL-1 KO mice. Locomotor activity was monitored and lesion size was determined for 14 days. TNFα and Ym1 levels were monitored to determine the MG/MΦ activating phenotype. Primary cultures of MG were produced from adult mice, and were exposed to IFNγ or IL-4 with and without IL-1ß. Moreover, cultures were exposed to IL-4 and/or IL-13 in the presence and absence of IL-1ß. RESULTS: The locomotor activity and lesion area of IL-1 KO mice improved significantly after SCI compared with wild-type mice. TNFα production was significantly suppressed in IL-1 KO mice. Also, Ym1, an alternative activating MG/MΦ marker, did not increase in IL-1 KO mice, suggesting that IL-1 contributes to both the classical and alternative activation of MG/MΦ. We treated primary MG cultures with IFNγ or IL-4 in the presence and absence of IL-1ß. Increased nitric oxide and TNFα was present in the culture media and increased inducible NO synthase was detected in cell suspensions following co-treatment with IFNγ and IL-1ß. Expression of the alternative activation markers Ym1 and arginase-1 was increased after exposure to IL-4 and further increased after co-treatment with IL-4 and IL-1ß. The phenotype was not observed after exposure of cells to IL-13. CONCLUSIONS: We demonstrate here in in vivo experiments that IL-1 suppressed SCI in a process mediated by the reduction of inflammatory responses. Moreover, we suggest that IL-1 participates in both the classical and alternative activation of MG in in vivo and in vitro systems.

Interaction between vibration-evoked proprioceptive illusions and mirror-evoked visual illusions in an arm-matching task.

We studied the influence of false proprioceptive information generated by arm vibration and false visual information provided by a mirror in which subjects saw a reflection of another arm on perception of arm position, in a forearm position-matching task in right-handed subjects (n = 17). The mirror was placed between left and right arms, and arranged so that the reflected left arm appeared to the subjects to be their unseen right (reference) arm. The felt position of the right arm, indicated with a paddle, was influenced by vision of the mirror image of the left arm. If the left arm appeared flexed in the mirror, subjects felt their right arm to be more flexed than it was. Conversely, if the left arm was extended, they felt their right arm to be more extended than it was. When reference elbow flexors were vibrated at 70-80 Hz, an illusion of extension of the vibrated arm was elicited. The illusion of a more flexed reference arm evoked by seeing a mirror image of the flexed left arm was reduced by vibration. However, the illusion of extension of the right arm evoked by seeing a mirror image of the extended left arm was increased by vibration. That is, when the mirror and vibration illusions were in the same direction, they reinforced each other. However, when they were in opposite directions, they tended to cancel one another. The present study shows the interaction between proprioceptive and visual information in perception of arm position.

Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association.

BACKGROUND: The Japanese Orthopaedic Association Hip Score is widely used in Japan, but this tool is designed to reflect the viewpoint of health-care providers rather than that of patients. In gauging the effect of medical therapies in addition to clinical results, it is necessary to assess quality of life (QOL) from the viewpoint of patients. However, there is no tool evaluating QOL for Japanese patients with hip-joint disease. METHODS: With the aim of more accurately classifying QOL for Japanese patients with hip-joint disease, we prepared a questionnaire with 58 items for the survey derived from 464 opinions obtained from approximately 100 Japanese patients with hip-joint disease and previously devised evaluation criteria. In the survey, we collected information on 501 cases, and 402 were subjected to factor analysis. From this, we formulated three categories-movement, mental, and pain-each comprising 7 items, for a total of 21 items to be used as evaluation criteria for hip-joint function. RESULTS: The Cronbach's α coefficients for the three categories were 0.93, 0.93, and 0.95, respectively, indicating the high reliability of the evaluation criteria. The 21 items included some related to the Asian lifestyle, such as use of a Japanese-style toilet and rising from the floor, which are not included in other evaluation tools. CONCLUSIONS: This self-administered questionnaire may become a useful tool in the evaluation of not only Japanese patients, but also of members of other ethnic groups who engage in deep flexion of the hip joint during daily activities.

Comparison of expression patterns of shell matrix protein genes in the mantle tissues between high- and low-quality pearl-producing recipients of the pearl oyster, Pinctada fucata.

The production of a cultured pearl is the result of a complex interplay between the donor and recipient oysters. However, there is a paucity of information on the relationship between donor and recipient oyster gene expression patterns and pearl quality. Shell matrix proteins affect not only the formation of the shell, but also that of the pearls. We compared the gene expression patterns of five shell matrix proteins (msi60, nacrein, msi31, prismalin-14, and aspein) in the mantle edge (ME), which forms the prismatic layer, and the mantle center (MC), which forms the nacreous layer, between high- (HP) and low quality pearl- (LP) producing recipient oysters. After culturing for about two months, ME and MC tissues were collected from nine recipient oysters: four with HP, five with LP. In the ME, the average threshold cycle (ΔC(T)) for aspein was higher in HP than in LP (t-test, p = 0.03). Additionally, in the MC, the average ΔC(T) for msi60 was lower in HP than in LP (p = 0.06). This means the relative expression level of msi60 in the mantle of HP was higher than that of LP, and expression level of aspein in the mantle of HP was lower than that of LP. Pearl quality was closely related to the expression patterns of shell matrix protein genes of recipient oysters.

Combined effects of preceding muscle vibration and contraction on the tonic vibration reflex.

As a result of intrafusal thixotropy, muscle contraction at a short length followed by passive lengthening enhances the subsequent tonic vibration reflex (TVR). We studied the effects of muscle vibration, contraction, and their combination on the subsequent TVR in the left biceps in 20 healthy men. The preceding vibration (20 or 80 Hz) conditioning at a short or long length was applied to the muscle belly with and without a contraction. After conditioning, distal tendon vibration (80 Hz) was used to elicit the TVR at the test length. The strength of the TVR was measured by surface electromyography. Conditioning with 80-Hz vibration at a short length followed by passive lengthening enhanced the subsequent TVR, which was greater in the presence than in the absence of a conditioning contraction. These results suggest that vibration and contraction work synergistically to develop intrafusal thixotropy.

Evaluation of instability after transtrochanteric anterior rotational osteotomy for nontraumatic osteonecrosis of the femoral head.

BACKGROUND: Transtrochanteric anterior rotational osteotomy results in improvement of joint congruity and prevention of progressive collapse and osteoarthritic changes in patients with femoral head osteonecrosis. However, this procedure remains controversial for patients with extensive collapse due to potential osteoarthritis caused by postoperative instability. The purpose of this study was to evaluate hip instability after osteotomy and determine the relation between instability and radiological and clinical outcomes. METHODS: In all, 27 hips of 24 patients that were followed up for a mean period of 3.8 years were included. Instability was defined as more than 1 mm translation of the femoral head in transverse computed tomography scans obtained at 0 degrees and 45 degrees flexion of the hip joint. Hips were divided into instability and stability groups. RESULTS: Eleven hips (40%) developed instability after surgery. Osteophytes on the femoral head in 10 hips of the instability group and 2 hips of the stability group had increased in size at follow-up. There was a significant relation between postoperative instability and osteophyte formation. Joint space narrowing was not seen in any of the cases. There was no significant difference between the groups in either the postoperative intact ratio of the femoral head or the Japanese Orthopaedic Association hip score. CONCLUSIONS: Neither instability nor osteophyte formation on the femoral head after transtrochanteric anterior rotational osteotomy correlated with progressive osteoarthritic changes or clinical outcome in the presence of an adequate femoral head intact ratio facing the weight-bearing area.

Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients.

BACKGROUND: Existing reports describe the decline of the mortality rate by conducting surgery for hip fractures within 24 h; however, the theory is still controversial. We have compared the perioperative mortality rate, improvement of mobility, and duration of hospital stay for early surgery (within 24 h) and delayed surgery (beyond 24 h) between two groups. METHODS: We studied 536 cases of proximal femoral fracture in patients >60 years who were treated between September 2003 and December 2006. There were 91 men and 445 women, who had a total of 257 femoral neck fractures and 279 trochanteric fractures. In all, 270 patients were operated on within 24 h after injury and were defined as the early group; 266 patients were treated surgically more than 24 hours after injury and were defined as the delayed group. Based on admission laboratory tests, co-morbidity, dementia, preoperative mobility, and residential environment before injury, we compared the duration of hospital stay, mobility at discharge, and mortality rates between the early group and the delayed group. RESULTS: There was no significant difference in duration of hospital stay between the two groups. Improvement of mobility was 52% in the early group and 41% in the delayed group, with the difference being significant (P < 0.05). Inpatient mortality rate was 5.6% in the early group and 2.6% in the delayed group, but the difference was not significant. In the early group, men with co-morbidity, dementia, and abnormal laboratory values upon admission showed a significantly higher mortality rate. CONCLUSIONS: Early surgery was useful for improving mobility, but it showed a higher mortality rate in patients with a compromised somatic condition at the time of the injury. For independent patients with a stabilized somatic condition, surgery should be performed within 24 h. For unstable cases, we believe it is better to provide early surgery after stabilizing the patient's condition to the greatest possible extent.

[Bone disease with Pain. Non-traumatic osteonecrosis of the femoral head].

The etiology and pathogenesis of non-traumatic osteonecrosis of the femoral head is still unknown although many studied has been performed. Using Magnetic resonance imaging, decision of the extent and location of the necrotic lesion, exist of bone marrow oedema has been developed. The revised criteria for diagnosis, classification, and staging of the disease from specific disease investigation committee of Japanese ministry of health, labor and welfare was established. As joint preservation operation, transtrochanteric rotational osteotomy, curved varus osteotomy were proved to be effective. Hip arthroplasty for maintaining bone stock has been developed for the treatment of young patients.

[Transtrochanteric rotational osteotomy for the treatment of non-traumatic osteonecrosis of the femoral head].

Non-traumatic osteonecrosis involving the femoral head frequently occurs in young patients especially due to steroids administration or other some reasons. In cases of extensive lesion of the weight-bearing area, collapse is usually progressive. Preservation of the joint in young patients to avoid joint replacement procedures is important and widely accepted. Transtrochanteric rotational osteotomy for the femoral head osteonecrosis is ideal procedure moving the remained viable femoral head area to the loaded portion below the acetabular roof, thus hip joints can be preserved for long term by remodeling even if the stage is progressed preoperatively. This procedure is technically difficult, but should be common in orthopaedic surgeons.