山口 智志

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。

2019年1月に千葉大学医学部附属病院にスポーツメディクスセンター(SMC)が設置された。SMCは地域に根差しスポーツと医療の連携にある課題を吸い上げる。病院内・自治体・三師会・スポーツ協会・各スポーツ団体・アカデミアなどと連携し、組織横断的に課題を解決に導き、スポーツと医療の連携の深化、スポーツを起点とした健康増進など地域への貢献を目的とする。当面はスポーツ現場の課題である安全救護の充実に取り組み、スポーツイベントや団体の緊急時行動計画立案、医療者・関係者への救護医療の技術支援などを行い安全なスポーツ環境を創出する。2020年以降は、アスリートのみならず地域住民も対象に、公衆衛生学的観点も含めたスポーツと医療に関する研究と実践を行う。これらから得られた知見や実践の知恵を地域社会へ還元し貢献する。本報告では『地域密着の医療・スポーツ連携で未来を拓く』を掲げるSMCの理念と取組・今後の展望について解説した。(著者抄録)

2015年1月〜2017年7月に国内8施設において末期変形性足関節症(OA)に対して足関節固定術(AF)もしくは人工足関節全置換術(TAA)の手術を行い1年以上経過した75歳以上の35例(男10例、女25例、平均年齢78.3±2.6歳)を対象として、術後の状態をThe Japanese Society for Surgery of the Foot(JSSF) scale、the Self-Administered Foot Evaluation Questionnaire(SAFE-Q)を用いて評価した。全35例中、stageはIVが最も多く、necrosisを背景としたOAも3例認めた。平均経過観察期間は18.5±7.7ヵ月であった。臨床評価では、JSSF scaleは52.6→89.6と有意に改善し、SAFE-Qの下位尺度である痛み・痛み関連、身体機能・日常生活の状態、社会生活機能、靴関連、全体的健康感の全てにおいて有意に改善した。術中骨折は3例発生し、術後合併症として感染1例、弛み4例、癒合不全1例、再手術2例が発生した。

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.

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)