佐粧 孝久

15歳男。バレーボール部に所属し、13歳時より左膝の違和感を自覚しており、疼痛が増悪したため受診した。左膝関節内側皮下に可動性のある腫瘤を触知し、左膝可動域(ROM)は伸展-10°、屈曲120°であった。単純X線では大腿骨外側顆膝蓋関節面の骨透亮像と遊離骨片を、CTでは同部位に2×2cm大で深さ3mmの骨欠損像を認めた。MRIのT1強調像で病変部は低輝度領域として描出された。手術を施行し、膝蓋関節面の病変部には不安定な骨軟骨片が存在しており、これを除去したところ欠損部は3×2cm大となった。遊離体は骨成分を有し、軟骨面の変性は軽度であったため骨接合に用いた。脛骨近位より皮質骨を採取して2×20mmの骨釘を3本作成し、骨軟骨片2個の骨層および母床を新鮮化した後、生体吸収性ピン5本と骨釘を用いてこれらを固定した。術後4ヵ月で疼痛、腫脹、ROM制限はなく、X線上の骨透亮像も消失していたため、骨癒合良好と判断してスポーツ復帰を許可した。術後1年で左膝ROMは伸展0°、屈曲145°であり、MRI上の低輝度領域もほぼ消失している。

Knee pain is predominant among osteoarthritis (OA) patients, but the mechanism is poorly understood. We investigated subchondral bone as a source of OA knee pain using immunohistochemistry. Fifteen medial-type OA knees with minimum involvement of the lateral compartment determined by X-ray as well as magnetic resonance imaging that received total knee arthroplasty (TKA) were involved. Each pair of the medial femoral condyle (MFC) and lateral femoral condyle (LFC) was compared obtained at the time of TKA. Osteocartilaginous MFC and LFC specimens were histologically examined and stained with antibodies against cyclooxygenase 1 (Cox-1), cyclooxygenase 2 (Cox-2), substance P, tumor necrosis factor-alpha (TNF-α), and neuron-specific class III beta-tubulin (TUJ1), a pan-neuronal marker. Formation of cystic lesions was more frequently seen in the MFC. The lesions were composed of vascular endothelial cells, osteoclasts, and mononuclear cells and were present in similar proportions between the MFC and the LFC. Four out of 15 MFC specimens were positive for Cox-1, 15 for Cox-2, and 13 for TNF-α. No LFC specimens were positive for any antibodies. Substance P-positive and TUJ1-positive fibers were found in the subchondral area of the MFC, but not in the LFC. Pathological changes in the subchondral bone can be a source of knee pain, which was detectable by the positive immunoreactivity of substance P, Cox-2, TNF-α, and TUJ1, in the subchondral bone of affected compartments. The relatively immediate reduction in pain obtained by TKA might account for the involvement of the subchondral bone in knee pain because most of the affected subchondral plate is excised in TKA (debridement effect of TKA). © 2009 Clinical Rheumatology.

症例は37歳女性で、右膝痛と腫脹を主訴とした。小学生時に関節血症が出現し、中学生時に再発した。2ヵ月間に5回の関節穿刺を受け血性関節液であった。疼痛は増強し跛行を呈し、原因検索で施行したMRIで腫瘍性病変を指摘された。膝蓋跳動が陽性で関節穿刺で血性関節液35mlが採取された。膝関節は0°から45°と著明な可動域制限を認め、膝前面に限局した強い圧痛があり、触診できないほどであった。単純X線で異常所見は認めずMRIで膝蓋下脂肪体にT1で高輝度である腫瘍性病変が存在し、ガドリニウム造影MRIで腫瘍病変にほぼ均一な造影効果を認めた。関節鏡では膝蓋下脂肪体から外側谷にかけ、ブドウ房様に微小血管の集簇した腫瘍性病変が存在した。腫瘍性病変を一塊に摘出し、病理検査結果は海綿状血管腫であった。膝前面の疼痛は劇的に改善し圧痛は消失したが、術前より存在した可動域制限は改善せず、術後4週時に0°から60°あったため関節受動術を施行し、術後6ヵ月に関節可動域は0°から110°に改善し、関節血症再発も認めていない。

症例は79歳女性で、歩行困難と左膝の自動伸展不能で受診した。6年前より両膝関節痛および関節可動域制限が出現した。両側変形性関節症の診断で保存加療されたが症状の増悪を認めた。78歳時に人工膝関節置換術(TKA)を施行された。左内側関節裂隙に圧痛を認めたが関節水腫や腫脹は認めなかった。関節可動域は伸展-20°、屈曲110°であった。単純X線でKellgren&Lawrence分類グレード3の関節症変化を認めた。立体FTAは179°であった。左膝蓋骨骨折の既往があったが画像上膝蓋骨の骨折後の変形を認めなかった。術前の計画に従いTKAを施行した。術後5日目にベッドに端座位で座っている状態から転倒し、患側膝を過屈曲した後から、歩行困難、膝痛と伸展障害が出現した。左膝関節の腫脹および膝蓋骨への中枢への変化を認め、膝蓋腱は触知できなかった。受傷後の画像所見で単純X線で膝蓋骨高位を認め、Insall-Salvati indexは2.2であった。脛骨結節の剥離骨折と考えられる2mm程度の小骨片像も認め、TKA術後の膝蓋腱断裂と診断された。

3D-2D registration法を用いて生体における荷重位および非荷重位での足関節底屈運動における距腿関節、距踵関節の3次元動態を定量的に測定・比較した。対象は足関節に外傷・障害の既往がない健常者7名で、平均年齢は32歳であった。方法として脛骨/腓骨複合体、距骨、踵骨の3次元骨モデルを作成してX線画像に投影し、骨モデル輪郭をX線画像の輪郭に合わせることにより、各骨モデルの3次元空間上の位置を決定して距腿関節と距踵関節の3次元動態を測定した。その結果、距腿関節の主な運動は底、背屈であり、荷重位では非荷重位と比べて、より底屈、内転位にあった。距踵関節の主な運動は回内、外であり、荷重位では距腿関節とは逆に、より背屈、外転、回内位にあった。荷重位と非荷重位における関節動態の差は、荷重位では距腿関節、距踵関節が共同して働き、距踵関節の適合性が高まって安定することが示唆された。

BACKGROUND: Understanding the effect of weightbearing on subtalar and ankle joint kinematics is critical for the diagnosis and treatment of foot disorders. However, dynamic in vivo kinematics of these joints are not well studied. The purpose of this study was to compare in vivo kinematics during nonweightbearing and weightbearing activities in healthy subjects. METHODS: Seven healthy subjects with a mean age of 32 (range, 23 to 42) years were enrolled. Oblique lateral fluoroscopic images of nonweightbearing and weightbearing dorsiflexion-plantarflexion activities were recorded. Three dimensional subtalar, ankle, and ankle-subtalar joint complex kinematics were determined using 3D-2D model registration techniques with 3D bone models and single-plane fluoroscopy. RESULTS: During the weightbearing activity from 20 degrees dorsiflexion to 15 degrees plantarflexion, the subtalar joint was significantly more everted, dorsiflexed, and abducted, and the calcaneus showed a significantly more posterior position, than during the nonweightbearing activity. The ankle joint was significantly more plantarflexed and adducted during the weightbearing activity than the nonweightbearing activity. The ankle-subtalar joint complex was significantly more everted, and the calcaneus showed significantly greater posterior position than the nonweightbearing activity. CONCLUSION: These observations provide basic quantitative descriptions of weightbearing and nonweightbearing kinematics for healthy joints. CLINICAL RELEVANCE: These data can serve as the basis for comparison with pathologic feet for both diagnostic and therapeutic purposes.

Background: Knee kinematics during pivoting activities are not well studied, but might provide insight critical to understanding the pathology of the anterior cruciate ligament deficient knee. The purpose of this study was to compare in vivo kinematics during weight bearing pivot and squat activities in patients with unilateral anterior cruciate ligament deficient knees, and to contrast those kinematics with the uninjured contralateral knees. Methods: Eight unilateral anterior cruciate ligament deficient patients with a mean age of 41 (SD 7) years were enrolled. Anterior cruciate injury was confirmed by positive Lachman test and MRI. Lateral fluoroscopic images of pivot and squat activities were recorded for both anterior cruciate ligament deficient and contralateral knees. Three-dimensional tibiofemoral kinematics and centers of rotation for each knee were determined using 3D-2D model registration techniques. Findings: During pivoting, the tibia of the anterior cruciate ligament deficient knee was significantly more anterior than the contralateral knee during tibial neutral to internal rotation. The pivot activity showed lateral centers of rotation in both anterior cruciate ligament deficient and contralateral knees while squatting showed medial centers of rotation. Interpretation: This dynamic method might be useful to objectively characterize restoration of dynamic function in knees with various types of anterior cruciate ligament reconstructions. These results also indicate kinematics during squatting type activities cannot be extrapolated to predict knee kinematics during pivoting types of activities. © 2008 Elsevier Ltd. All rights reserved.

60歳以上に対する鏡視下手術について疾患別、術式別にJOAスコア、満足度調査、後にTKAとなる症例の割合を調べた。その結果、外側型変形性膝関節症、半月板切除術、特発性膝関節血症については、保存療法が奏功しない場合に鏡視下手術を積極的に勧めてもよいと考えられた。内側型変形性膝関節症や膝骨壊死については、再手術の可能性、年齢を考慮して手術を施行する必要があると考えられた。(著者抄録)

Small peptides including the Arg-Gly-Asp (RGD) motif have been used in studies on cell-extracellular matrix (ECM) attachment due to their ability to disturb integrin-mediated attachment on the cell surface. As another biological action of RGD peptides, several reports have shown that RGD peptides are incorporated into cytoplasm and induce apoptosis by direct activation of caspase-3. This study evaluated the effect of RGD peptides on chondrocytes and synovial cells and studied the involvement of caspases. Chondrocytes and synovial cells were isolated and cultured from the knee joints of New Zealand White rabbits. Cells were incubated in serum-free medium with peptides (RGD, RGDS, GRGDSP, GRGDNP, RGES), and the survival rates were evaluated. The rate of apoptotic cells was measured by flow cytometry in cells treated with RGDS, GRGDSP, and RGES. Caspase-3, -8 and -9 activity was measured in cells treated with RGDS and GRGDSP. Osteochondral explants harvested from rabbits were also incubated with RGD peptides (RGDS, GRGDSP, and GRGDNP), and the survival rate of chondrocytes was evaluated. The survival rate of cultured chondrocytes was significantly decreased in the GRGDSP- and GRGDNP-treated groups. The survival rate of synovial cells was significantly decreased with four of the RGD peptides (RGD, RGDS, GRGDSP, and GRGDNP) at 5 mM, and in the RGDS- and GRGDSP-treated groups at 1 mM. Flow cytometric assay revealed increases of apoptotic chondrocytes with GRGDSP and increases of apoptotic synovial cells with RGDS and GRGDSP. Caspase-3 was activated in chondrocytes treated with GRGDSP and it was also activated in synovial cells treated with RGDS and GRGDSP. Caspases-8 and -9 were not activated in chondrocytes or in synovial cells. The survival rate of chondrocytes in explants decreased in the superficial layer with all three RGD peptides (RGDS, GRGDSP, and GRGDNP) and in the middle layer with GRGDSP. RGD peptides induced apoptosis in cultured chondrocytes as well as in cells in cartilage explants and synovial cells, presumably through direct activation of caspase-3.

Objective: The purpose of this study was to develop a new technique of gene transfer utilizing radial shock waves. The effects of radial shock waves on gene transfer in rabbit chondrocytes were examined by varying the parameters of exposure conditions in vitro. Methods: Chondrocytes were obtained from New Zealand white rabbits and cultured in a monolayer. A luciferase-encoding gene expression vector, or vector alone, was added to chondrocyte cell suspensions, and the cells were then exposed to radial shock waves. Parameters such as pressure amplitude, number of pulses, frequency, and DNA concentration were varied, and luciferase activity was measured 48 h after transfection. Transfection efficiency of radial shock waves was compared with the FuGENE6 transfection method using a green fluorescence protein (GFP)-encoding gene vector by fluorescent-activated cell sorter (FACS) analysis. Results: Radial shock wave exposure significantly increased luciferase activity over 140-fold as compared to the control under the optimal exposure conditions. Both pressure amplitude and number of pulses were relevant to transfection efficiency and cell viability, but frequency was not. Transfection efficiency increased in a dose-dependent manner with DNA concentration. FACS analysis showed 4.74% of GFP-encoding gene using radial shock waves. FuGENE6 transfection was almost similar in transfection efficiency to radial shock wave. Conclusion: In spite of certain degree of cell disruption, radial shock waves significantly augmented reporter gene transfection in rabbit chondrocytes in vitro. Radial shock waves may potentially contribute to the treatment of the cartilage morbidities by enhancing the potency of tissue healing and gene transfection of growth factors. (c) 2007 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Irregularly described contour of the femur and the tibia on magnetic resonance (MR) imaging is commonly seen in osteoarthritic (OA) knees. The aim of this study is to examine the relationship between irregularity of contour of medial femoral condyle (tentatively named I-index) and severity of OA. Twenty-six medial-type OA knees with a mean age of 63.8 were studied. All patients had undergone MR imaging to measure the I-index using image analysis software, and its relationship to Lysholm score was examined. The I-index negatively correlated with Lysholm score (r = -0.55, p < 0.01). The I-index for each Kellgren and Lawrence grade was significantly different. We have concluded that the I-index is a potent indicator to objectively describe the severity of OA especially for the advanced stage OA.

Objective: Although there have been several reports on the use of extracorporeal shock wave therapy (ESWT), the efficacy of ESWT for knee osteoarthritis (OA) has not been clarified. The aim of this study is to investigate the effect of ESWT on OA in a rat knee model. Methods: The rats were divided into three groups: (1) control, (2) OA, and (3) ESWT (knee OA + shock wave therapy). Behavioral analysis consisted of measuring the duration of walking on a treadmill. The expression of calcitonin gene-related peptide (CGRP) in dorsal root ganglion (DRG) neurons innervating the knee using immunohistochemistry was examined in the three groups at their peak time point on the treadmill. Results: Walking duration was significantly extended 4, 7 and 14 days after ESWT in rats with knee OA (peak time point: 4 days), again decreasing by days 21 and 28. Immunohistochemical studies revealed that the OA group had significantly higher percentages of CGRP positive neurons in the DRG than were found in the control group. In addition, ESWT reduced the ratio of CGRP positive DRG neurons in the OA model. Conclusion: The improvement in walking ability and the reduction of CGRP positive neurons in DRG indicates that ESWT is a useful treatment for knee OA. (C) 2007 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Many studies have reported successful outcomes less than 10 years after anterior cruciate ligament (ACL) reconstruction. However, longer-term outcomes have not been analyzed. We assessd outcomes 24 years after anterior cruciate ligament reconstruction with iliotibial tract and compared them with shorter-term results in the same patients. Between 1979 and 1981, 45 patients underwent combined intra- and extra-articular ACL reconstruction with iliotibial tract. Follow-up evaluations of these patients were performed at 6, 13, and 24 years after surgery, which included manual and instrumental laxity testing, functional assessments, and radiography. Twenty-six (60%) patients of the original ACL reconstruction cohort participated in all three follow-up assessments. Three patients had undergone meniscectomy prior to ACL reconstruction and 18 underwent meniscectomy together with ACL reconstruction. Eleven patients underwent subsequent meniscectomy. The mean Lysholm score was 96.2, 93.8, and 87.8 at 6-, 13-, and 24-year follow-up, respectively. A significant decrease in mean Lysholm score was found between 13- and 24-year follow-up. The mean KT-1000 side-to-side difference was 3.5 mm at 24-year follow-up. Overall knee laxity did not change significantly during the follow-up period. At 24-year follow-up, 17 (71%) patients had moderate or severe degenerative changes on radiographs although about 50% of the patients participated in regular sports activities and no patient required regular clinical intervention.

The aim of this study was to evaluate the qualitative change in reparative cartilage after autologous chondrocyte implantation (ACI). Ten knees of 10 patients were studied. The signal intensities of reparative and normal cartilage were evaluated by fat-suppressed three-dimensional spoiled-gradient recalled (FS 3D-SPGR) MR imaging. The signal intensity (SI) index (signal intensity of reparative cartilage divided by that of normal cartilage) was defined and the change in SI index was investigated. Histological and biochemical evaluation was done at the second look arthroscopy. The SI index was at its lowest level immediately after ACI and increased with time to 9 months thereafter. After 9-12 months, the SI index settled to almost level and was maintained at that value for at least 2-3 years postoperatively. The average of the SI indexes after 12 months to the last examination was 74.2 ± 4.6 (range 64.2-82.8), which means signal intensity of reparative cartilage was maintained at a value lower than that of normal cartilage. The total ICRS score was 11.6 ± 2.3 points (mean ± SD), The GAG concentration was 107.9 ± 17.0 μg/mg (mean ± SD) in normal cartilage and 65.9 ± 9.4 μg/mg in reparative cartilage. The quality of reparative cartilage as hyaline cartilage was inferior to that of normal cartilage. In the present study, the time course change in the SI index indicates that the major maturation process of implanted chondrocytes neared completion in 9-12 months. Minor changes, such as matrix remodeling with reorganization of the collagen fibers in reparative cartilage, may continue, but an almost identical condition seemed to be maintained during the first 2-3 years of follow-up. SI index does not always reflect all properties of reparative cartilage but may be a useful parameter for noninvasive evaluation. Copyright © 2005 Cognizant Comm. Corp.

1)家兎関節軟骨欠損に対し骨膜移植を施行した際,HA投与群は生食投与群に比較し24週まで良好な修復をする傾向が見られた. 2)特にsurface regularity及びintegrationの2項目では良好な修復を示した(P<0.05). 3)骨膜移植をしない軟骨欠損のみにHA及び生食を投与した群はいずれも修復が不良であった. 4)12週での修復軟骨の生化学的分析でHA投与群と生食投与群で有意な差は認められず,ただし正常関節軟骨とはいくぶん異なった性質の修復軟骨が形成されていた. 5)Area healed(%)ではHA群と生食群では有意差は無く,HA群の方が修復が抑えられているということは無かった

当科での腸脛靱帯を用いた前十字靱帯再建術,10年以上の長期成績を報告した.著者等の術式ではLachmanやAnterior drower signが陽性のままであったものも見られたが,回旋不安定性に対しては長期にわたり充分な制動効果があり,膝機能判定基準による評価も満足すべき結果であった