木村 青児

BACKGROUND: The purpose of this study was to clarify 1) the measurement error of the pronation angle using the first metatarsal axial radiograph with the pronation angle along the longitudinal axis of the first metatarsal as the reference standard, 2) the influence of variability in the foot position on the measurement error, and 3) the intra- and interrater reliability of pronation angle measurement using digitally reconstructed radiographs. METHODS: Digitally reconstructed radiographs of the first metatarsal were generated from the computed tomography images of 10 feet without hallux valgus (non-HV group) and 10 feet with hallux valgus (HV group). In total, 135 images were created at different degrees of supination, plantarflexion, and adduction from each foot to simulate the first metatarsal axial view. Then, the pronation angle of the first metatarsal was measured. The measurement error was determined using the mean error and 95% limits of agreement. Simple linear regression analysis was used to test the correlations of the measurement error with pronation, plantarflexion and adduction angles. The intra- and interrater reliability of measurement was assessed using the intraclass correlation coefficient and minimum detectable change values. RESULTS: The mean measurement errors were 0.1° for both the non-HV and HV groups. There was no significant correlation of the measurement error with pronation, plantarflexion or adduction angles for both groups. Additionally, the intraclass correlation coefficients for the intra- and interrater reliability were more than 0.9 in both the non-HV and HV groups with the minimum detectable change values ranging from 0.7° to 1.4°. CONCLUSION: The measurement error of first metatarsal pronation using the axial view was clinically acceptable. The measurements were not influenced by the variability in foot position while obtaining the radiograph. The first metatarsal axial view could be used to quantify the first metatarsal coronal rotation.

BACKGROUND: The purpose of this study was to determine the diagnostic accuracy of ultrasonography for the diagnosis of avulsion fractures of the distal fibula for lateral ankle sprain in children and compare it to that of radiography. METHODS: Children who sustained lateral ankle sprain were prospectively surveyed. They underwent both ultrasonography and radiography at the first clinic visit to diagnose any concomitant avulsion fractures of the distal fibula. The patients underwent follow-up radiography 4 weeks later to obtain the reference standard diagnosis. The measures of diagnostic accuracy (i.e., sensitivity, specificity, positive predictive value, and negative predictive value) of the initial ultrasonography and radiography were calculated; they were then compared using the McNemar test. Totally, 52 patients (with a median age of 9 years) were analyzed. RESULTS: On the reference standard (follow-up) radiographs, 32 patients (62%) were found to have avulsion fractures of the distal fibula. The sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography were 94, 85, 91, and 89% respectively; and 81, 100, 100, and 77% respectively for radiography at the first visit. There were no significant differences in sensitivity and specificity between the two diagnostic methods (P = 0.22, 0.25). CONCLUSIONS: Ultrasonography has a high diagnostic accuracy, which is comparable to that of radiography, for the diagnosis of avulsion fracture of the distal fibula. Ultrasonography may be used as an option of imaging modality for lateral ankle sprain in children.

The objective of this research is to mechanically and histologically evaluate the capacity of different PRP concentrations to promote tendon healing. 60 New Zealand white rabbits were used. In 20 rabbits（L-PRP group）, 1.0 mL of low-concentration PRP was applied to the Achilles tendon tear transection site on both hindlimbs of each animal. The other 20 rabbits（H-PRP group）, 1.0 mL of high-concentration PRP and in the remaining 20 rabbits（S group）, 1.0 mL of saline were applied. Ten rabbits from each group were slaughtered at 4 and 8 weeks following the transection surgery, with subsequent histological evaluation of the right legs, and mechanical evaluation of the left legs. Platelet counts were 3.8 times higher for L-PRP and 12.8 times higher for H-PRP than for whole blood. The semi-quantitative Bonar scale（0 is normal）decreased significantly from the S to L-PRP to H-PRP groups（P＝0.03）. The values for ultimate load, ultimate stress, elastic modulus, and stiffness increased from the S to L-PRP to H-PRP groups. A significant difference was observed between the groups for stiffness（P＝0.03）. Our results showed that PRP preparations with a high concentration of platelets were superior in the promotion of histological and mechanical healing of the Achilles tendon.

OBJECTIVE: We investigated the effect of administration of intra-articular mesenchymal stem cells (MSCs) on cartilage repair at different timings, and the distribution of MSCs in the knee. DESIGN: A partial thickness cartilage defect (PTCD) was created on the medial femoral condyle in 14-week-old Sprague-Dawley rats. Intra-articular injection of 1 × 106 MSCs was performed at 3 time points, namely at the time of surgery (0w group), at 1 week after surgery (1w group), and at 2 weeks after surgery (2w group). For the control, 50 μL phosphate-buffered saline was injected at the time of surgery. The femoral condyles were collected at 6 weeks after creation of PTCD and assessed histologically. To investigate the distribution of MSCs, fluorescent-labeled MSCs were injected into the knee joint. RESULTS: In the control group, the cartilage lesion was distinguishable from surrounding cartilage. In the 0w group, hypocellularity and a slight decrease in safranin O stainability were observed around the injured area, but cartilage was restored to a nearly normal condition. In contrast, in the 1w and 2w groups, the cartilage surface was irregular and safranin O stainability in the injured and surrounding areas was poor. Histological score in the 0w group was significantly better than in the control, 1w, and 2w groups. At 1 day postinjection, fluorescent-labeled MSCs were mostly distributed in synovium. However, no migration into the PTCD was observed. CONCLUSIONS: Early intra-articular injection of MSCs was effective in enhancing cartilage healing in a rat PTCD model. Injected MSCs were distributed in synovium, not in cartilage surrounding the PTCD.

内側型の変形性膝関節症あるいは膝関節特発性骨壊死に対して人工膝関節単顆置換術を行った13例14膝(U群)と、内側開大型高位脛骨骨切り術を行った7例9膝(H群)の術後成績をForgotten Join Score 12(FJS)を用いて比較し、FJSに影響を及ぼす患者因子について検討した。平均観察期間はU群21.9ヵ月、H群20.9ヵ月で、いずれも良好な可動域(ROM)とKOOSが得られ、平均FJSはU群65.3±22.8点、H群71.1±15.8点であった。患者背景、客観的評価、患者立脚型評価を比較した結果、年齢はU群が有意に高く、Body Mass Index(BMI)とKOOSのADL項目はH群が高い傾向にあったが、性別、術前大腿脛骨角、術後ROM、KOOS、FJSに有意差はなかった。また、年齢、BMIを含めたいずれの項目もFJSとの有意な相関を認めなかった。

PURPOSE: The purpose of this study was to clarify radiographic and clinical outcomes, as well as their association, of ankle sprain in children. METHODS: Patients who sustained a first-time ankle sprain were prospectively surveyed. Patients underwent radiography of the ankle in the mortise, lateral, anterior talofibular ligament (ATFL), and calcaneofibular ligament views at the first clinic visit to assess avulsion fractures of the distal fibula. Patients with avulsion fractures underwent radiography after 8 weeks to assess bone union. The treatment method was not standardized and was determined by the patient, their parents, and the treating physician. Recurrent sprain and quality of life were evaluated by using the Self-Administered Foot Evaluation Questionnaire and reviewing the medical records of patients. The association between avulsion fracture and recurrent sprain was assessed using univariate and multivariate analyses. RESULTS: A total of 143 patients with a median age of 9 (range 6-12) years were analyzed. Avulsion fractures were present in 89 (62%) patients. The sensitivity of the ATFL view for the diagnosis of avulsion fractures was 0.94, whereas that for the anteroposterior and lateral views was significantly lower at 0.46 (P < 0.001). Only 17% of fractures united at 8 weeks. Of 114 (follow-up rate, 80%) patients who were followed up for a median period of 24 months, recurrent sprain occurred in 41 (36%) patients. The incidence rate was significantly higher in patients with avulsion fractures than in patients without the fractures (44 vs. 23%, P = 0.027). In multivariate logistic regression analysis, avulsion fracture was independently associated with recurrent sprain (P = 0.027). CONCLUSION: More than one-third of patients experienced recurrent sprain. The presence of avulsion fracture was associated with an increased risk of recurrent sprain. Patients with avulsion fracture and their parents should be informed about the risk of recurrent sprain and subsequent ankle instability, and careful follow-up is needed for these patients. LEVEL OF EVIDENCE: III.

Purpose: Our aims were 1) to estimate the duration of short interfering RNA (siRNA) effect on matrix metalloproteinase-13 (Mmp-13) levels by a single intra-articular injection using a mouse knee osteoarthritis (OA) model and 2) to test whether repeated injections results in any additional suppressive effect on cartilage degradation compared to a single injection. Materials and Methods: OA was induced in 9 weeks old male C57BL/6 mice by destabilization of medial meniscus (DMM). Chemically modified siRNA targeted for Mmp-13 was injected into the knee joint at 1 week post-DMM surgery. Control group of knees received that for non-targeted genes. Synovial tissue was collected to measure Mmp-13 expression levels by quantitative polymerase chain reaction (qPCR) at 2, 3, and 6 weeks after surgery in each group. To test the effect of multiple injections, we created four experiment groups according to the number of injections. Histological assessment of articular cartilage was performed at 8 weeks post-DMM surgery. Results: In the Mmp-13 siRNA-treated group, expression levels of Mmp-13 mRNA were decreased by 40% compared to the control group at 2 weeks after surgery (p = 0.04), before returning to baseline at 3 weeks after surgery. A significant improvement in the histological score was observed in all Mmp-13 siRNA-treated groups compared to the control group (p < 0.05). However, no significant differences were seen between the single and multiple injection group. Conclusions: Our results suggested that the duration of siRNA effect in the knee joint lasts for at least 1 week, and that no further benefit is achieved by multiple injections.

BACKGROUND: The purpose of this study was to clarify the 2-year clinical and radiological outcomes of nonoperative treatment using foot orthosis for hallux valgus patients. METHODS: Patients who underwent nonoperative treatment using foot orthosis were surveyed prospectively. Foot orthoses were made by one certified orthotist using the standardized method. Pain and quality of life were evaluated using subjective and objective assessment measures at 3, 6, 12, 18, and 24 months. Furthermore, radiological outcomes, patient satisfaction, and adherence to treatment were surveyed. RESULTS: A total of 53 patients (50 women and 3 men; median age, 63 years) were included for analysis. The pain visual analogue scale score significantly decreased over time, with the lowest score observed at 12 months. The treatment effect was maintained over 24 months (median score, 52, 21, and 27 points at baseline, 12 months, and 24 months, respectively; P < .001). The Japanese Society for Surgery of the Foot hallux scale, American Academy of Orthopaedic Surgeons Foot and Ankle Scale, and 36-Item Short-Form Health Survey bodily pain subscale also improved, although the treatment effects were maximal at 6 months and decreased thereafter. At 24 months, 43 (81%) patients continued to use the orthosis, with the median visual analogue scale score for patient satisfaction of 76 points. The hallux valgus angle and intermetatarsal angle did not change during the 24-month period. CONCLUSION: Nonoperative treatment using foot orthoses decreased pain in patients with hallux valgus. The effect of treatment was maintained up to 2 years with a relatively high degree of patient satisfaction. However, treating physicians should inform patients to set realistic expectations and be aware that a limited degree of pain reduction is expected.

BACKGROUND: Radiographs of the feet are the reference standard for measuring the hallux valgus angle. However, the availability and use of radiographs are constrained due to cost and radiation exposure. Less invasive, nonradiographic assessments have been proposed, although measurement using self-photography has not been reported. OBJECTIVES: To determine (1) reliability of photographic hallux valgus angle (pHVA) measurement using the same photographs of the feet, (2) reliability of repeated self-photography trials, and (3) measurement error when the radiographic hallux valgus angle (rHVA) is estimated using the pHVA. METHODS: In this reliability study, participants took photographs of their own feet using a digital camera. The intrarater and interrater reliability of pHVA measurements were then assessed using the intraclass correlation coefficient (ICC) and 95% minimum detectable change (MDC). The participants took photographs twice, and the reliability of repeated self-photography trials was examined. Participants also received radiographs of their feet, from which the rHVA was measured. The measurement error was assessed using the mean difference and 95% limits of agreement. RESULTS: The intrarater and interrater ICC of pHVA measurement was 0.99, with MDCs less than 2°. The ICC of pHVA measurement for repeated self-photography was 0.96, and the MDC was 6.9°. The pHVA was systematically lower than the rHVA, by 5.3°. CONCLUSION: Measurement of the pHVA using self-photography was reproducible, although pHVA measurement underestimated the rHVA. The pHVA can be a useful nonradiographic method to quantify hallux valgus deformity. J Orthop Sports Phys Ther 2019;49(2):80-86. Epub 12 Sep 2018. doi: 10.2519/jospt.2019.8280.

平成28年5月に運動器検診を受けた小学3年生〜中学3年生の児童生徒885名を対象として、下肢柔軟性と膝・踵の痛みの発生頻度との関連について検討した。運動器検診の下肢機能に関連する項目で、しゃがみ込みができない割合や立位体前屈で指先が床に届かない割合は小学6年生から中学1年生を境に増加しており、検診時に膝に圧痛があった者は49名(5.6%)、踵に圧痛があった者は6名(0.7%)で、いずれも男児に多くみられた。膝痛のある割合は中学1年生から増加、踵痛は全体として頻度は少ないものの、比較的低学年で多く発症する傾向にあり、下肢柔軟性が低下する時期と膝や踵の疼痛が発症する時期が一致することが示された。また、膝痛がある群では立位体前屈で指先が床に届かない者の割合が多く、ハムストリングと大腿四頭筋の柔軟性が低かった。

運動器検診の際に下肢柔軟性を測定した小学3年生〜中学3年生のうち、検診時に膝の圧痛がなかった836名と踵の圧痛がなかった879名を対象として、健診から9ヵ月間に膝・踵の圧痛を新規発症した者の割合(新規発症率)と月ごとの膝・踵の圧痛を有する者の割合(有訴者率)を算出した。その結果、膝の圧痛の新規発症率は22%で、小学4年生以上で高い傾向にあり、有訴者率は概ね13%以下で推移していた。踵の圧痛の新規発症率は15%で、中学生に比べて小学生に多い傾向にあり、有訴者率は概ね8%以下で推移していた。また、膝・踵の圧痛の発症と下肢柔軟性との関連について検討した結果、膝痛の新規発症例278膝ではheel buttock distanceが有意に大きく、膝痛の発症に大腿四頭筋のタイトネスが関与している可能性が示唆されたが、踵痛の発症と下肢柔軟性との関連は認めなかった。

OBJECTIVES: The purposes of this study were to clarify 1) the prevalence of foot and ankle pain and 2) the factors associated with foot and ankle pain among nurses. METHODS: Nurses working at a university hospital in Japan were recruited to participate in this cross-sectional, questionnaire-based study. The occurrence of foot and ankle pain in the previous month was assessed by using the Standardized Nordic Questionnaire and the Manchester Foot Pain and Disability Index. Subjects also answered questions on footwear-related factors, including using the visual analog scale for shoe comfort. In addition, information on personal factors and psychosocial factors was collected using the Job Content Questionnaire. The relationships between the presence of foot and ankle pain and the associated factors were examined using multiple logistic regression analysis. RESULTS: Responses of 636 nurses (response rate, 67%) were included for analysis. The prevalence of foot and ankle pain was 23% and 51% when using the Standardized Nordic Questionnaire and the Manchester Foot Pain and Disability Index, respectively. The prevalence of pain that prevented the nurses from performing activities of daily living and work was 4% and 17%, respectively. A low level of shoe comfort, personal factors (age and body mass index), and psychosocial factors (low job control and high job strain) was independently associated with the presence of foot and ankle pain. CONCLUSIONS: Foot and ankle pain occurred frequently in nurses. Shoe comfort, personal factors, and psychosocial factors were associated with foot and ankle pain.

ハイテクニーII人工膝関節を用いて膝蓋骨非置換人工膝関節置換術を行った28例29膝(男性4膝、女性25膝、手術時平均年齢71.4歳)を対象に、術後PF(膝蓋大腿)関節へ中期的に生じるX線学的変化について解析した。術後平均観察期間8.0年の結果、外側傾斜や外側偏位については術前後で有意差はみられず、比較的良好に保たれていた。だが、関節症性変化については硬化像の進行を72.4%、骨棘形成の進行を62.1%、関節裂隙の狭小化の進行を82.8%で認め、全例において何らかの関節症性変化の進行が確認された。

BACKGROUND: The purposes of this study were to clarify the incidence of anxiety and depression among patients with chronic foot and ankle diseases and to examine the independent association of anxiety and depression with pain and quality of life. METHODS: Patients who visited the foot and ankle clinic from April 2015 to November 2016 were recruited. Anxiety and depression in patients were assessed using the Hospital Anxiety and Depression Scale. Pain and quality of life were evaluated using the visual analog scale (VAS) and Self-Administered Foot Evaluation Questionnaire (SAFE-Q), respectively. Furthermore, patient characteristics, including age, sex, body mass index, pain in other body areas, social support, employment, and household income, were surveyed. A multiple regression analysis was performed to examine the independent association of anxiety and depression with pain and quality of life. A total of 250 patients were included in the analysis. RESULTS: The prevalence of anxiety and depression was 30% and 27%, respectively. The VAS and all SAFE-Q subscale scores were significantly worse in patients with anxiety or depression than in patients without the same (median VAS 63 vs 49 for anxiety, P = .005; 68 vs 47 for depression, P < .001). Furthermore, the multiple regression analyses showed that the presence of anxiety ( P = .02) and depression ( P < .001) was independently associated with increased pain, and it led to low scores on all SAFE-Q subscales ( P < .001 for all subscales). CONCLUSION: About 30% of patients with chronic foot and ankle disease had anxiety or depression. The presence of these psychological symptoms was independently associated with worse pain and impaired quality of life after controlling for patient characteristics. Clinicians need to recognize the possibility of concurrent anxiety and depression to provide a more holistic treatment for chronic foot and ankle disease. LEVEL OF EVIDENCE: Level IV, case series.