山口 智志

症例は14歳、男性。2年前から繰り返す右膝関節痛の精査目的に当科へ紹介となった。右膝関節内側に限局する圧痛を認めたが、経過を通して明らかな腫脹、関節血症は生じなかった。MRIで右膝関節内側谷部に腫瘍性病変を認め、関節鏡下腫瘍切除術を行った。切除検体の病理学的検査で海綿状血管腫の確定診断となった。術後症状は軽快し再発なく経過している。若年者のスポーツ整形外科診療では膝関節痛を主訴に受診する例が多くみられるが、繰り返す膝関節痛を呈する場合には腫脹や関節血症のエピソードがなくとも本疾患を念頭に置く必要がある。(著者抄録)

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.

本研究の目的は、前向き縦断研究によって小学3年生から中学3年生において膝痛を新規に発症する危険因子を解明することである。5月時点で膝痛を認めなかった835名を対象に、下肢柔軟性や下肢形態を評価するとともに、年に3回の身体測定を行い身長の変化率を算出した。さらに毎月の自己記入式アンケートによって運動量と膝痛の有無を調査した。5月から1月までの膝の新規疼痛発症の有無を目的変数とし、学年、性別、身長の変化率、HSS Pedi-FABSに換算した活動量、大腿骨内側顆間距離、Q角、foot posture index、踵臀距離、下肢伸展挙上角、足関節背屈角度を説明変数として多変量解析を行った。小学3年生に比べて小学6年生と中学3年生で膝痛の発症が多く、活動量が高いほど膝痛の発症率が高かった。年齢と活動量が膝痛の新規発症について危険因子となることが示唆された。(著者抄録)

身体活動不足が健康に与える影響の大きさは、肥満や喫煙に匹敵し、定期的な運動習慣の確立や身体活動量の維持、増加は世界的な課題となっている。ロコモ対策の観点からみても、壮年・中年期の運動習慣は高齢期以降のロコモやサルコペニアと関連があるため重要である。ロコモ度テストをアウトカムとした運動介入の効果を検証した研究はいまだ少ないが、高齢者を対象としたロコモーショントレーニング(片脚立ち、スクワット)やウォーキングによりロコモが改善しうることが示されている。(著者抄録)

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.

Weber type A骨折は、足関節果部骨折のなかでも比較的頻度が低い。本稿では、Weber type A骨折の診断、手術適応と手術の実際について、近年の報告を交えて述べる。また、受傷機転が類似している足関節外果先端の裂離骨折(特に小児)についても詳述する。(著者抄録)

＜文献概要＞外反母趾に対する装具療法は,最も広く行われている保存療法の1つだが,その効果に関するエビデンスは少ない.適切な靴の指導は除痛効果と発症予防効果が期待できる.足底装具(インソール)は,除痛には有効だが変形矯正効果はない.母趾を外転位に保つ装具は,軽度から中等度の変形に対して除痛効果と多少の変形矯正効果を期待できるが,変形が強い例では着用により痛みを生じることがあり注意が必要である.テーピングも,外転装具と同様に除痛効果と多少の変形矯正効果が報告されている.実臨床では,患者の症状や希望に合わせてこれらを適宜組み合わせて治療を行う.

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.

The objectives of this study are (1) to examine age-dependent longitudinal differences in histological responses after creation of partial-thickness articular cartilage defects (PTCDs) in rats and to use this model (2) to objectively evaluate the effectiveness of interventions for cartilage repair. Linear PTCDs were created at a depth of 100 μm in the weight-bearing region of the medial femoral condyle in rats of different ages (3 weeks, 6 weeks, 10 weeks and 14 weeks). One day, one week, two weeks, four weeks and twelve weeks after PTCD generation, spontaneous healing was evaluated histologically and immunohistochemically. Effects of interventions comprising mesenchymal stem cells (MSCs) or platelet-rich plasma (PRP) or both on 14-week-old PTCD rats were evaluated and compared with natural courses in rats of other ages. Younger rats exhibited better cartilage repair. Cartilage in 3-week-old and 6-week-old rats exhibited nearly normal restoration after 4-12 weeks. Cartilage in 14-week-old rats deteriorated over time and early signs of cartilage degeneration were observed. With injection of MCSs alone or MSCs + PRP, 14-week-old PTCD rats showed almost the same reparative cartilage as 6-week-old rats. With injection of PRP, 14-week-old PTCD rats showed almost the same reparative cartilage as 10-week-old rats. This model will be of great use to objectively compare the effects of interventions for small cartilage lesions and may help to advance the development of disease-modifying osteoarthritis drugs.

BACKGROUND: Medial meniscal extrusion (ME) is a biomarker to predict later development of knee osteoarthritis (KOA). On the other hand, we have reported osteophyte formation at the posterior condylar notch of the femur served as a biomarker for the same purpose. The purpose of this study is to compare capacity of the two biomarkers in predicting KOA development. METHODS: Two cohort of knees were established utilizing publicly available data from the Osteoarthritis Initiative (OAI). No OA group (NOA) consisted of knees that were grade 0 or 1 on Kellgren and Lawrence grade (K/L) both at baseline and 48 months later, and pre-radiographic-OA group (PROA) consisted of knees that were grade 0 or 1 at baseline but grade ≥2 48 months later. Baseline MR images were evaluated in terms of ME and osteophyte formation at the posterior condylar notch. ME was evaluated both by meniscus subluxation index (MSI) indicating the ratio of the extruded width of the medial meniscus to the width of medial meniscal body and by the medial radial displacement (MRD) indicating actual extruded width. The size of the osteophyte was assessed using a semi-quantitative whole-organ magnetic resonance imaging score (WORMS). The predictive accuracy of KOA was assessed by the area under the receiver operating characteristic curve (AUC) and optimal cutoff was determined for each parameter. RESULTS: The AUC for MSI was 0.654 (0.561-0.748: 95% CI) and the cutoff value was determined as 17%. That for MRD was 0.677 (0.584-0.770) and the cutoff value was 2.2 mm. The AUC for the WORMS score at the posterior condylar notch was 0.667 (0.579-0.756) and the cutoff value was 2. CONCLUSIONS: Similar predicting capacity of KOA development was found both in ME and osteophyte formation at the posterior condylar notch. Using these simple parameter, mas-screening for KOA development would be possible.

症例は17歳の男性である。運動時の外傷を契機に右膝内側の痛みが出現した。内側関節裂隙の圧痛と荷重時痛を認めたが、画像上は明らかな異常所見はなかった。保存治療に抵抗性であり、MCSを疑い関節鏡手術を施行した。関節鏡視にてMCSが確認され、半月の縫合にて症状は軽快した。MCSは画像所見に乏しく診断に難渋することが多い。本症例でも術前検査では確定診断に至らず、関節鏡にて診断・治療がなされ良好な結果を得た。(著者抄録)

＜Key Points＞◎足部・足関節疾患は多くの疾患を含んでおり、それぞれ病態が異なる。◎足部形態の異常が痛みの発生や治療法の選択に関わることが多い。◎保存療法の第一歩は、足の負担を軽減する靴の選択や調整、インソールやサポーターなどの装具の着用である。◎薬物療法は、その他の保存療法と併用することにより治療効果を高める。◎病態にあわせて非ステロイド性抗炎症薬や神経障害性疼痛治療薬、オピオイドなどを選択する。(著者抄録)

Cartilage degeneration is believed to be the primary event in the development of osteoarthritis (OA). On the other hand, meniscal degeneration is observed with high prevalence, and some researchers have pointed out that pathological changes in menisci precede that of cartilage. The purpose of the present study is to investigate comprehensive gene expression pattern of cartilage and menisci in the initial phase of surgically induced OA and to compare them. Secondary OA was surgically induced in 10-week-old male Wistar rats by anterior cruciate ligament transection (ACLT). Articular cartilage and menisci were separately dissected from six ACLT- and six sham-operated rats. Each specimen was analyzed by microarray, histological, and immunohistochemical analysis 3 weeks after surgery. Of the 36,685 transcripts detectable by microarray, the number of upregulated transcripts in ACLT menisci was >2.5-fold compared with that in ACLT menisci in any given threshold. Cluster analysis using the Database for Annotation Visualization and Integrated Discovery (DAVID) showed genes related to OA, such as response to stimulus, angiogenesis, and apoptosis, which were predominantly found in menisci in ACLT rats. Representative proteases including Adamts2, 4, Mmp2, 12, 13, 14, 16, extracellular matrix genes including versican (Vcan), lumican (Lum), syndecan1 (Sdc1), and Prostaglandin endoperoxide synthase2 (Ptgs2) were up-regulated in menisci, but were not up-regulated in cartilage. Our results indicated that the molecular changes that occurred in menisci preceded those occurred in cartilage in the very early phase of surgically induced OA models.