Mortality after hip fracture in Japan: the role of nutritional status.

PURPOSE: To assess factors that influence 4-year mortality following hip fracture surgery in a Japanese population. METHODS: Records of 129 hips in 24 men and 103 women aged 50 to 103 (mean, 79) years who underwent surgery for femoral neck or trochanteric fractures were reviewed. Clinical data reviewed included age, gender, body mass index (BMI), side of fracture, fracture type, fracture stability, surgery type, interval from admission to surgery, length of hospital stay, number of pre-fracture comorbidities, pre-fracture ambulatory level, pre-fracture place of residence, preoperative dementia, preoperative skeletal traction, blood haemoglobin level, serum albumin level, number of postoperative complications, and postoperative delirium. Univariate and multiple logistic regression analyses were performed to identify the relative contribution of the variables to mortality. Receiver operating characteristic (ROC) curves were used to identify optimal cut-off levels. RESULTS: The 4-year mortality was 48%. Multiple logistic regression analysis showed that serum albumin level (p = 0.0004, odds ratio [OR] = 5.8541) and BMI (p = 0.0192, OR = 1.1693) significantly influenced mortality; the cut-off points were 36 g/l and 18.9 kg/m square, respectively, based on the ROC curves. Kaplan-Meier curves showed that survival rates were significantly worse in patients with values below these cut-off points. CONCLUSION: Serum albumin level and BMI on admission are predictive of mortality after hip fracture surgery.

Risk factors leading to total hip arthroplasty in patients with subchondral insufficiency fractures of the femoral head.

PURPOSE: To retrospectively evaluate factors leading to total hip arthroplasty (THA) in patients with subchondral insufficiency fractures (SIF) of the femoral head. METHODS. 5 men and 22 women aged 51 to 85 (mean, 72) years with SIF of the femoral head initially underwent conservative treatment. THA was later performed for 13 patients, as the hip pain became worse secondary to joint space narrowing and/ or femoral head collapse. Patient demographics and radiological variables were retrieved. Risk factors leading to THA in patients with SIF of the femoral head were identified. Receiver operating characteristic curves were used to determine optimal cut-off values for the significant risk factors. RESULTS: 2 men and 11 women aged 62 to 85 (mean, 74.9) years underwent THA and were followed up for 0.2 to 62 (mean, 13) months. The remaining 3 men and 11 women aged 51 to 81 (mean, 68) years underwent conservative treatment and were followed up for 9 to 93 (mean, 28) months. Patient age was the only risk factor for THA (p = 0.047, odds ratio = 1.13), the cutoff value being 71 years (sensitivity, 77%; specificity, 64%). The survival rate was significantly lower in patients aged 71 years or older than in those aged younger than 71 years (p < 0.05). CONCLUSION: Elderly patients with SIF of the femoral head are at higher risk of undergoing THA.

Subchondral insufficiency fracture of the femoral head may be associated with hip dysplasia: a pilot study.

BACKGROUND: Subchondral insufficiency fracture of the femoral head occurs mainly in elderly patients with osteoporosis. Spontaneous resolution is observed after nonoperative treatment in some patients whereas other show progressive joint destruction requiring THA. Several studies report the occurrence of subchondral insufficiency fracture of the femoral head in dysplastic hips. QUESTIONS/PURPOSES: We asked whether the extent of hip dysplasia or osteoporosis was greater in patients with subchondral insufficiency fracture of the femoral head than in normal control subjects. PATIENTS AND METHODS: We compared the clinical and imaging findings of 13 patients with subchondral insufficiency fractures of the femoral head and 12 patients scheduled for TKA with asymptomatic hips. Age, gender, and body mass index were comparable in the two groups. RESULTS: Higher mean Sharp angles, lower acetabular head indices, lower center-edge angles, and higher acetabular roof angles in patients with subchondral insufficiency fracture of the femoral head than in those with asymptomatic hips suggested a greater degree of hip dysplasia. Bone mineral density and serum levels of Type I collagen cross-linked N-telopeptide and bone alkaline phosphatase were similar in the two groups. CONCLUSIONS: We speculate an excessive amount of stress on the acetabular edge from dysplasia may be associated with the occurrence of subchondral insufficiency fracture of the femoral head.

Contrast-enhanced MR imaging of subchondral insufficiency fracture of the femoral head: a preliminary comparison with that of osteonecrosis of the femoral head.

INTRODUCTION: Subchondral insufficiency fracture of the femoral head (SIF) may be confused with osteonecrosis of the femoral head (ON) due to clinical and imaging similarities. MATERIALS AND METHODS: Contrast-enhanced MR images in patients with SIF (ten hips in ten patients) were retrospectively reviewed and compared with those from patients with ON (ten hips in six patients). RESULTS: Low-signal intensity bands on T1-weighted images were present within the femoral head in all hips examined. The segment proximal to the band was contrast-enhanced following IV gadolinium administration in nine of ten hips (90%) with SIF and in none of the 10 hips with ON. CONCLUSION: These results suggest that the presence of contrast enhancement in the segment proximal to the low-signal intensity band in the femoral head may serve as a supplemental diagnostic measure for the differentiation of SIF from ON.

Analysis of wear and oxidation on retrieved bipolar polyethylene liner.

BACKGROUND: For bipolar prostheses, most of the previous studies attributed the occurrence of osteolysis to wear debris generated from the bearing surface. We looked closely into the wear debris and reported on our findings with respect to the oxidation index and the rate of wear in ultra-high molecular weight polyethylene (UHMWPE) inserts retrieved from bipolar prostheses after various spans of time in vivo. METHOD: The inserts were retrieved from the heads of three types of bipolar prosthesis (UH1, UPF1, UPF2). We retrieved 24 bipolar prostheses from 23 patients whose mean implantation period was 10.0 years (2.7-15.4 years). RESULTS: All the retrieved polyethylene had a burnished bearing surface. In all, 92% (22/24) of these inserts had indentation and roughness at the rim and flange, suggesting neck-cup impingement; periprosthetic fracture occurred in the other two inserts. The mean linear wear rate was 0.035 mm per year. The average maximum oxidation index for the inserts with osteolysis was 3.34, and it was was 3.49 for the inserts without osteolysis. We, therefore, could not detect any significant difference between the aforesaid groups of inserts. CONCLUSIONS: The results strongly suggest that most of the polyethylene wear debris was not generated from the bearing surface. Moreover, the wear debris generated from neck-cup impingement may well be the cause of an inflammatory reaction, which in turn has a strong potential to become the primary cause of osteolysis.

Co-occurrence of subchondral insufficiency fracture of the femoral head and contralateral femoral neck fracture in a rheumatic patient receiving steroid treatment.

We describe a 79-year-old woman with rheumatoid arthritis who suffered from subchondral insufficiency fracture of the femoral head (SIF) and contralateral femoral neck fracture. Radiographs obtained two months after the onset of thigh pain showed collapse of the right femoral head and contralateral femoral neck fracture. MRI revealed a subchondral serpiginous low-intensity band in the right femoral head on the T2-weighted image. This case report suggests that SIF should be considered in the differential diagnoses of rheumatic patients who suffer from thigh pain without antecedent trauma.

Short-term wear of Japanese highly cross-linked polyethylene in cementless THA.

INTRODUCTION: Production of polyethylene wear from acetabular liners is thought, in part, to mediate the periprosthetic osteolysis. This study examined the in vivo wear performance of Japanese highly cross-linked polyethylene (Aeonian) in cementless total hip arthroplasty. MATERIALS AND METHODS: Ninety-five hips received a highly cross-linked polyethylene liner, while 20 hips were implanted with conventional polyethylene. Two-dimensional linear wear was measured on radiographs and volumetric wear was then calculated. Both linear and volumetric wear rates were examined for the 1-year postoperative period as well as for the time frame beginning after 1 year ending with the final follow-up. RESULTS: The amount of linear wear was significantly lower in the cross-linked group at 3 and 5 years postoperatively (P < 0.01 and < 0.001, respectively). Linear and volumetric wear rates after 1 year postoperatively for hips with the cross-linked polyethylene were significantly reduced by 57 and 59%, respectively, when compared to rates for those who received conventional polyethylene (P < 0.01). A multiple logistic regression analysis revealed that cross-linking was a significant factor influencing linear wear rate after 1 year postoperatively with an odds ratio, exp(ss) = 10.033 (P < 0.001). CONCLUSION: These results suggest that the highly cross-linked polyethylene reduces penetration of the femoral head and may be an optimal bearing surface for patients receiving total hip arthroplasty.

A subchondral fracture in transient osteoporosis of the hip.

Although subchondral changes are reported to be associated with transient osteoporosis of the hip (TOH), the etiology of this disorder is unknown.In this paper, we describe a 45-year-old man with TOH who underwent both MRI and CT examinations. Plain radiographs obtained 2 months after the onset of hip pain showed a focal loss of radiodensity in the left femoral head. MRI revealed a bone marrow edema pattern in the left femoral head and neck with an associated subchondral serpiginous low signal intensity line on the T1-weighted images. A CT scan showed a subchondral fracture in the corresponding area. The hip pain and imaging abnormalities resolved spontaneously following conservative treatment. This case study demonstrated that a subchondral fracture of the femoral head was associated with TOH using MRI and CT examinations, and suggests that the presence of a subchondral fracture may be important for the pathophysiology of TOH.

Toxic effects of povidone-iodine on synovial cell and articular cartilage.

The objective of this study was to investigate the toxic effects of povidone-iodine (PVI). A series of MTT assay of cultured synovial cells stimulated by PVI have been made. Test for assay of membrane-toxic effect of PVI and lactate dehydrogenase (LDH) has also been carried out. After making intraarticular injection into rats' hind knee joints with 0.1 ml of PVI every day for 1 week, we have extracted the knee joints and blood from rats in four divided groups on the 0, 1st, 3rd, and 7th day. Our microscopic analysis was performed that cartilage and synovium membrane were stained with hematoxylin, toluidine blue, and safranin O. Iodine, glutamic oxaloacetic transminase, creatine phosphokinase (CPK), and LDH in rat sera have been measured. We were able to confirm cytotoxicity in the synovial cells placed in PVI concentration of more than 6.25 x 10(-2)%. In comparison with the positive control, LDH, in this case, was released at the concentration level of 33.3%. Independent of period of stimulation, LDH was released the most in the PVI concentration of 6.25 x 10(-2). The histopathological analysis of articular cartilage has indicated clear morphological alterations in rats' synovium; especially, toluidine blue staining and safranin O staining were seen in the metachromasia of articular cartilage. However, no fissures or erosive changes in the articular cartilage, which were usually observable in the case of osteoarthritis, were observed. In the synovium inflammatory cells, which were mainly plasma cells and lymphoid cells, no neutrophils were infiltrated. The degree of infiltration has increased steadily day by day. Fibrin deposition has been observed even in the synovium of 1-day stimulation. On the 7th day, a serum total iodine concentration has been 544 microg/dl, 4,440 IU/ml for CPK concentration, and 2,049 IU/ml for LDH concentration, while the control concentrations have been 7.1 microg/dl, 491 IU/ml, and 700 IU/ml, respectively. Our experiment has disclosed that PVI preparation is strongly cytotoxic to synovial cell and articular cartilage.

Spinal epidural hematoma after removal of an epidural catheter: case report and review of the literature.

We report a case of spinal epidural hematoma after removal of an epidural catheter. The patient had no background of anticoagulant therapy or coagulopathy; sudden severe back pain occurred immediately after removal of the catheter. The chance of this occurring is estimated to be between 1:150,000 and 1:190,000. We studied 40 previous reports from 1952 to 2000, and we also investigated anticoagulant therapy and pathologic states, puncture difficulties and bleeding at the point of insertion, and its onset. In 23 cases (57.5%), anticoagulant therapy had been performed, and in 5 cases (12.5%), coagulopathy or liver dysfunction had been recognized. In 20 cases (50%), the initial symptoms were recognized within 24 hours after removal of the epidural catheter. Although spinal epidural hematoma is a very rare condition, it is a serious complication of continuous epidural anesthesia.

Five- to fifteen-year clinical results and the radiographic evaluation of acetabular changes after bipolar hip arthroplasty for femoral head osteonecrosis.

We have studied 36 hips in 30 patients with osteonecrosis of the femoral head who were treated with bipolar hip arthroplasty. Follow-up period was 5 to 15 (average 7.7) years. Five hips were revised. Hips were divided into 2 groups. Sixteen hips with Ficat stage II or III osteonecrosis were assigned into group I, and 15 hips with Ficat stage IV osteonecrosis were assigned into group II. There was no statistical difference between the clinical results of the 2 groups (P = .74). Radiographically, there was minimal migration in group I. There was a statistical significance in superior migration between subgroups with and without osteolysis in group II (P < .01). We emphasize that bipolar hip arthroplasty is indicated for Ficat stage II or III in osteonecrosis of the femoral head.

A computer simulation of rotational acetabular osteotomy for dysplastic hip joint: does the optimal transposition of the acetabular fragment exist?

For young patients who have early signs of coxarthrosis resulting from acetabular dysplasia, periacetabular osteotomies for correcting abnormal stress distribution can be useful for preventing the progression of the disease. However, it is difficult to confirm the optimal transposition of the osteotomized acetabular fragment. To deal with this problem, we devised a computer program to support preoperative planning. Hip images obtained by computed tomography were loaded into our program, and a three-dimensional voxel model was created. Then, osteotomy was simulated and the pressure distribution was analyzed with a rigid-body spring analysis (computational nonlinear mechanical analysis). The three-dimensional pressure distributions in seven dysplastic hips were evaluated before and after virtual rotational acetabular osteotomy. A peak pressure was calculated for every 5 degrees of rotation of the acetabular fragment. The peak pressure decreased gradually and increased again afterward, indicating the optimal transposition of the acetabular fragment. The postoperative peak pressure decreased to about 40% in the most improved case. This program allows the hip joint mechanics to be evaluated easily so that the advantages and disadvantages of various surgical methods can be examined biomechanically prior to surgery.

Age-related quadriceps-dominant muscle atrophy and incident radiographic knee osteoarthritis.

Muscle atrophy is common in the elderly. However, the etiologic role of muscle atrophy associated with osteoarthritis of the knee has not been studied in detail. We assessed the association between age-related muscle atrophy around the knee joint and incident radiographic osteoarthritis of the knee. Twenty-one women in their thirties and 17 women in their sixties participated. They had no history, symptoms, or objective findings of any knee problems, and none of the participants was limited in performing daily activities. Radiographs of the knee joint were graded for the presence of osteoarthritis, and the cross-sectional imaging around the knee joint was carried out using computed tomography. Incident radiographic osteoarthritis was observed in 6 of the 17 women in their sixties. Quadriceps-dominant muscle atrophy was marked in the elderly women with radiographic osteoarthritis. In a multivariate analysis, the risk of incident radiographic osteoarthritis of the knee was significantly increased among women with a higher hamstrings/quadriceps cross-sectional area ratio. The results suggest the possibility that age-related quadriceps-dominant muscle atrophy may play a role in the pathogenesis of osteoarthritis of the knee.

Synovectomy, debridement, and continuous irrigation for infected total knee arthroplasty.

Since 1990, a total of ten joints in nine patients with infected total knee arthroplasty have been treated in our department within 21 days of the onset of infection. Their radiographs showed no evidence of implant loosening or "moth-eaten" appearance. They underwent synovectomy, debridement, and continuous irrigation without implant removal. Continuous irrigation was maintained for 7-29 days. It was possible to retain implants in eight joints of seven patients. Two joints of two patients were removed. Pain disappeared in all eight joints in which the implants were retained. Four patients could walk with one cane; one patient could walk with one crutch. Range of motion in five joints remained over 100 degrees. We recommend synovectomy, debridement, and continuous irrigation to cure an early stage infection of total knee arthroplasty.

Infliximab acts directly on human osteoclast precursors and enhances osteoclast formation induced by receptor activator of nuclear factor kappaB ligand in vitro.

Infliximab is known to protect against the development of joint destruction. In the present study, we sought to determine whether Infliximab acts directly on human osteoclast precursors and influences monocyte-osteoclast differentiation induced by receptor activator of nuclear factor kappaB ligand (RANKL) in vitro. Peripheral blood mononuclear cells (PBMCs) isolated from rheumatoid arthritis (RA) patients and normal controls were cultured in the presence of RANKL and macrophage colony stimulating factor. Infliximab, antihuman tumor necrosis factor alpha (TNFalpha), antihuman TNF soluble receptor p55 (TNFR p55), and antihuman TNF soluble receptor p75 (TNFR p75) antibodies were added. Osteoclast formation was determined by assessing the number of tartrate-resistant acid phosphatase (TRAP) staining cells and the extent of lacunar resorption. Addition of Infliximab resulted in a marked increase in the number of TRAP-positive multinucleated cells (TRAP(+) MNCs) and in the extent of lacunar resorption compared with the control cultures. Antihuman TNFalpha antibody showed the same effect; however, the addition of neither TNFR p55 nor TNFR p75 antibody affected the extent of TRAP(+) MNCs and lacunar resorption. Our results suggest that infliximab acts directly on early osteoclast precursors, and stimulates osteoclast formation and lacunar resorption induced by RANKL in vitro.

Subchondral cyst of the tibia secondary to Wilson disease.

We present the case of a 40-year-old male patient who had been suffering from Wilson disease for over 20 years, whose knee was diagnosed as osteoarthritis combined with subchondral cyst of the tibia. Preoperative examinations (X-ray, CT and MRI) confirmed the diagnosis. The microscopic examination detected thickening of the synovial membrane, and histopathological findings revealed that lymphoid cells and plasma cells were infiltrated at the synovial membrane. On copper-specific staining, no copper pigmentation was identified. However, the energy-dispersive X-ray (EDX) microanalysis revealed copper pigmentation in high concentration. These findings may contribute to our better comprehension of the development process of the arthropathy in patients with Wilson disease. The combination of subchondral cyst with Wilson disease is extremely rare, as only about 16 such cases have been reported in the English literature.

Biomechanical study of load transfer of the pubic ramus due to pelvic inclination after hip joint surgery using a three-dimensional finite element model.

We studied load-stress distribution in the pelvis using a three-dimensional finite element model. The results showed that the load-stress on the pubic superior ramus was high in the normal pelvic position without sagittal or coronal inclination following that of the acetabulum in the pelvis. The load-stress on this area was not affected by sagittal pelvic inclination, but it was affected significantly by coronal pelvic inclination. The superior pubic load-stress on the side of the longer leg was higher than that on the opposite side. The tensile stress on the pubic ramus on the side of the longer leg significantly increased compared with compressive stress. We had a patient who had an insufficiency fracture of the pubic ramus on the side of an overcorrected leg after hip joint surgery, so we examined the cause of it. Although insufficiency fractures of the pubic superior ramus are caused by various static and kinetic factors, the alternation of coronal pelvic inclination is an especially important factor in such fractures after hip joint surgery.

Limb salvage for malignant bone and soft-tissue tumours of the shoulder girdle.

We treated 15 patients with malignant bone and soft-tissue tumours of the shoulder girdle using limb salvage operations involving resection of the proximal humerus, scapula and clavicle. The oncological and functional outcomes were evaluated in all patients after an average of 5 (1-13) years. Oncological evaluation revealed that in 11 patients with adequate surgical margins six were continuously disease free and two had no evidence of disease. Three patients with marginal surgical margins had all died. We suggest that only where adequate surgical margins can be obtained should operations be performed. Forequarter amputation is still indicated in patients with complicated neurovascular involvement. Functional evaluation showed that scapular resections, especially glenoid resections, provided poor results (mean score 54%) in comparison with patients without such resection (mean score 82%).

Proinflammatory cytokine (TNFalpha/IL-1alpha) induction of human osteoclast formation.

TNFalpha and IL-1alpha are potent stimulators of bone resorption in vivo and in vitro. Recently, it has been demonstrated that these two cytokines directly induce osteoclastogenesis in mouse marrow cultures. This study determined whether TNFalpha (+/- IL-1alpha) is also capable of inducing human osteoclastogenesis. The CD14(+) monocyte fraction of human peripheral mononuclear cells was cultured with TNFalpha +/- IL-1alpha in the presence of M-CSF. TNFalpha induced the formation of multinucleated cells (MNCs) which were positive for TRAP, VNR and cathepsin K and showed evidence of resorption pit formation. IL-1alpha stimulated TNFalpha-induced lacunar resorption two- to four-fold. Osteoprotegerin, the decoy receptor for RANKL, did not inhibit this process. Anti-human IL-1alpha neutralizing antibodies significantly inhibited resorption without inhibiting the formation of TRAP(+)/VNR(+) MNCs. These results suggest that, in the presence of M-CSF, TNFalpha is sufficient for inducing human osteoclast differentiation from circulating precursors by a process which is distinct from the RANK/RANKL signalling pathway.