Fragility Fracture Network-Japan: The challenge of establishment of a national hip fracture database and successful achievement of nationwide health system change for hip fracture care in Japan.

BACKGROUND: In April 2022, a new reimbursement scheme for hip fracture was implemented by the Japanese health ministry. Japan is one of the world's most aged societies, facing a significant, rapidly growing burden of osteoporosis and fragility fractures. The incidence of hip fractures is projected to increase from 240,000 in 2020 to 320,000 by 2040. In 2015, Fragility Fracture Network-Japan (FFN-Japan) was formally established as a nonprofit organization in order to create the optimal fragility fracture care system in Japan. METHODS: FFN-Japan launched the Japan National Hip Fracture Database (JNHFD) in 2017, initially with only eight participating hospitals across Japan. The number of patients enrolled from May 2017 to the end of 2020 in the JNHFD from the 16 hospitals registered the patients during this period with amounting to 4271 patients in total. FFN-Japan invited officials from the Ministry of Health, Labor and Welfare (MHLW) to participate in round table meetings to discuss the data collected in the JNHFD and to consider opportunities for nationwide improvement in hip fracture care. RESULTS: The proportion of patients who underwent surgery within 36 h of arrival at hospital was 48.1% in 2018, 58.6% in 2019, and 44.9% in 2020 indicating the delay of surgery. Regarding secondary fracture prevention, initiation of osteoporosis treatment during the in-patients was 60.2% in 2018, 54.0% in 2019, and 64.5% in 2020 indicating the inadequate post fracture care. In April 2022, the Central Social Insurance Medical Council of the Japanese MHLW announced a new reimbursement scheme for hip fracture care including two key components: Early surgery (within 48 h from injury) and Secondary fracture prevention immediately after fracture. DISCUSSION: The new reimbursement scheme of hip fracture care in Japan will catalyze and underpin major improvements on acute multidisciplinary care and post-fracture care with secondary fracture prevention. FFN-Japan played a key role on these policy changes to the health system by means the close collaboration and ongoing communication with the government. CONCLUSION: Within five years of establishment of the JNHFD, FFN-Japan in collaboration with visionary leaders from the Japanese government have successfully achieved a major reform of the Japanese health system's reimbursement of hip fracture care. This reform has laid the foundation for transformation of management of this debilitating and life-threatening injury that currently afflicts almost a quarter of a million older Japanese citizens each year.

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle.

INTRODUCTION: Traumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study. PATIENTS AND METHODS: The subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs. RESULTS: The 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001. CONCLUSION: Intra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.

Plasma acrolein level in rheumatoid arthritis increases independently of the disease characteristics.

OBJECTIVE: This study aimed to clarify whether plasma acrolein level actually increases in rheumatoid arthritis (RA) patients, and to elucidate whether any relationship exists between the levels and the RA background variables. METHODS: Plasma levels of protein-conjugated acrolein (PC-Acro) in 84 patients (RA group) and 298 normal individuals (Control group) were measured by enzyme-linked immunosorbent assay procedures. The data were statistically analyzed with Wilcoxon rank-sum test, multiple logistic regression analyses and Spearman's rank correlation coefficient. RESULTS: The RA group showed significantly higher PC-Acro levels than the Control group (median [interquartile range]: 80.5 [63.2-105.2] and 65.9 [58.9-78.1] nmol/ml, respectively). Of background factors giving influence to PC-Acro level in the combination of the two groups, 'diagnosis of RA positive' indicated strong correlation to high PC-Acro level (odds ratio: 2.96; 95% confidence interval: 1.54-5.71). These increases of PC-Acro in the RA patients did not correlate to their disease duration and/or inflammatory variables: PC-Acro level could elevate even in early RA patients showing negative inflammatory findings. CONCLUSION: Plasma levels of PC-Acro increased with RA, but the levels did not correlate with RA background variables. This report provides the basis for further studies of early diagnosis of RA as well as its pathogenesis.

Comparison of histopathology and preoperative 18F-FDG-PET/CT of osteomyelitis aiming for image guided surgery: A preliminary trial.

OBJECTIVE: There are currently no robust methods for accurately localizing the infection focus of osteomyelitis. Accumulation of fluorodeoxyglucose (FDG) is nonspecific, and it is well-known that it can indicate inflammatory cells and sites of inflammation, and its effectiveness in detecting osteomyelitis has been reported recently. However, the optimal cut-off value for the Standardized Uptake Value (SUV) in detecting the focus of osteomyelitis through 18F-FDG-PET/CT is not known. We investigated the optimal SUV cut-off values using 18F-FDG positron emission tomography (PET)computed tomography (CT) to visualize the infection focus of osteomyelitis accurately. PATIENTS AND METHODS: Initially, we investigated a case where osteomyelitis was bacteriologically detected after orthopedic surgery on lower limb. Based on the surgical pathology, we explored the optimal SUV cut-off value of the 18F-FDG PET/CT image taken before surgery. The SUV cut-off value was varied, using the GE Rainbow Color Scale on a dedicated workstation. We searched for the most accurate visualization of the extent of the infectious lesion. Subsequently, using the SUV cut-off value decided on the basis of the first case studied, we investigated the accuracy for diagnosing osteomyelitis. A total of sixteen patients underwent 18F-FDG PET/CT for suspected osteomyelitis (one case involved the upper extremity and 15 cases the lower one). All patients underwent surgery. The final diagnosis was made by means of bacteriologic culture of surgical specimens and histopathologic analysis. We compared surgical pathology and preoperative 18F-FDG PET/CT. RESULTS: In the first case studied, the infection was most accurately localized with a SUV with a lower level of 2.00 and an upper of 8.00. Upon comparing the pathological findings and the 18F-FDG PET/CT, we set a SUV with a lower level of 2.00 and an upper level of 8.00. In thirteen cases, infection was detected with positive pathological findings. Preoperative 18F-FDG PET/CT showed high accumulation in these cases. In the remaining three cases, no infection was detected on either pathological findings nor 18F-FDG PET/CT findings. CONCLUSIONS: The infection focus of osteomyelitis was accurately visualized by setting the SUV cut-off lower level to 2.00 and upper level to 8.00. We believe that this 18F-FDG PET/CT technique is helpful for image guided surgery of osteomyelitis.

Ankle joint reconstruction by circular frame external fixator for a severely comminuted and contaminated open tibial pilon fracture (AO 43-C3.3). Case report.

A severely comminuted and contaminated open tibial pilon fracture is one of the most challenging fractures we face. Although nowadays conducting multiple operations over various stages is a common treatment option taking into account the possibility of soft tissue damage, a gold standard protocol for severe pilon fractures has not yet been established. This case concerns a 56-year-old gentleman who suffered a severely comminuted and contaminated Gustilo 3b open tibial pilon fracture (AO 43C3.3) that was successfully treated using a circular frame external fixator without flap. Two years six months after the injury, there were no indications of any skin conditions at the site of the open wound, the range of ankle motion had been maintained and independent walking was possible. The score under the JSSF (Japanese Society of Surgery of the foot) ankle/hind foot scale was 81. This indicates that use of a circular frame external fixator is a useful treatment method in the event of a severe open pilon fracture where there is a large osteochondral bone defect.

Normal sequential changes in neutrophil CD64 expression after total joint arthroplasty.

BACKGROUND: Neutrophil CD64 has been reported to be a sensitive and specific infection marker. Its measurement is thus considered to be useful in early diagnosis of post-operative periprosthetic infection. However, even its normal sequential changes after non-infectious total joint arthroplasty have remained ambiguous. Accordingly, we analyzed 2-week sequential neutrophil CD64 expression changes after total joint arthroplasty in order to clarify its normal postoperative kinetics. PATIENTS AND METHOD: From 41 patients who underwent primary total joint arthroplasties, peripheral blood samples were obtained at 1 day before (baseline) and 1, 3, 5, 7, and 14 days after surgery, and CD64 expression per cell was quantitatively measured. C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR) and white blood cell count (WBC) were simultaneously measured. RESULTS: No cases of postoperative local infection were observed. Levels of CD64 significantly elevated from day 1, peaked at day 3, and decreased significantly following day 5. Statistical analysis confirmed that significant differences existed between the baseline level and the levels at days 1 and 3, while no significant differences existed between the baseline level and those at days 5, 7 or 14. In 17 patients, CD64 peaked at over 2,000 molecules/cell, the level reported to be a cutoff value for distinguishing infection. Multiple regression analysis showed that the sole parameter of baseline CD64 level significantly explained the peak CD64 level. Postoperative CD64 peaks ranged from 1.6 to 2.7 times (median 1.9) the baseline levels. CRP, ESR and WBC also showed rapid elevations and all but WBC remained significantly higher than baseline at day 14. CONCLUSION: CD64 levels rise significantly, peaking within about 3 days following normal total joint arthroplasty, but decrease rapidly to near baseline within about 5 days. The data obtained can be expected to form a possible basis for early diagnosis of postoperative periprosthetic infection.

Neutrophil CD64 expression as a diagnostic marker for local infection and crystal-induced arthritis.

The usefulness of neutrophil CD64 expression was examined in diagnosing local infection, including soft tissue, bone, and joint infections. Among 99 patients suspected of local infection, 31 were confirmed and 68 patients were not. The CD64 level of patients with local infection was significantly higher than in those without infection [4,193 ± 1,132 vs. 1,017 ± 59 molecules/cell (mean ± standard deviation); p < 0.001]. The area under the curve of CD64 calculated by receiver operating characteristic curve analysis was larger than that of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), or white blood cell (WBC) count. In addition, CD64 levels of patients with crystal-induced arthritis remained within cutoff value (2,000 molecules/cell). These data suggest that measuring CD64 expression can be a useful diagnostic marker for local musculoskeletal infection and crystal-induced arthritis.