山口 智志

Objectives: To compare the effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament (ACL) reconstruction animal model. Methods: Anterior cruciate ligament reconstruction using the plantaris tendon as graft material was performed on both knees of 24 rabbits (48 knees) to mimic ACL reconstruction by two different suspensory fixation devices for graft fixation. For the adjustable fixation device model (Socket group; group S), a 5 mm deep socket was created in the lateral femoral condyle (LFC) of the right knee. For the fixed-loop model (Tunnel group; group T), a femoral tunnel penetrating the LFC was created in the left knee. Animals were sacrificed at four and eight weeks after surgery for histological evaluation and biomechanical testing. Results: Histologically, both groups showed a mixture of direct and indirect healing patterns at four weeks, whereas only indirect healing patterns were observed in both groups at eight weeks. No significant histological differences were seen between the two groups at four and eight weeks in the roof zone (four weeks, S: mean 4.8 sd 1.7, T: mean 4.5 sd 0.5, p = 0.14; eight weeks, S: mean 5.8 sd 0.8, T: mean 4.8 sd 1.8, p = 0.88, Mann-Whitney U test) or side zone (four weeks, S: mean 5.0 sd 1.2, T: mean 4.8 sd 0.4, p = 0.43; eight weeks, S: mean 5.3 sd 0.8,T: mean 5.5 sd 0.8, p = 0.61, Mann-Whitney U test) . Similarly, no significant difference was seen in the maximum failure load between group S and group T at four (15.6 sd 9.0N and 13.1 sd 5.6N) or eight weeks (12.6 sd 3.6N and 17.1 sd 6.4N, respectively). Conclusion: Regardless of bone tunnel configuration, tendon-bone healing after ACL reconstruction primarily occurred through indirect healing. No significant histological or mechanical differences were observed between adjustable and fixed-loop femoral cortical suspension methods.Cite this article: Y. Sato, R. Akagi, Y. Akatsu, Y. Matsuura, S. Takahashi, S. Yamaguchi, T. Enomoto, R. Nakagawa, H. Hoshi, T. Sasaki, S. Kimura, Y. Ogawa, A. Sadamasu, S. Ohtori, T. Sasho. The effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament reconstruction: An animal study. Bone Joint Res 2018;7:327-335. DOI: 10.1302/2046-3758.75.BJR-2017-0238.R2.

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。

In most anterior cruciate ligament (ACL) reconstructions, grafts are fixed to the femoral side first followed by the tibial side. Various techniques have been reported to achieve optimal tension on the grafts, but once the grafts are fixed it is difficult to adjust graft tension further. To enable post fixation tension control we have invented a new graft configuration using an adjustable loop-device (TightRopeTM, Arthrex, FL, USA) on the tibial side. In this paper, biomechanical properties of this configuration using soft tissue were examined in terms of graft diameter and various suture techniques (referred to as base suture) to make a closed circle to support TightRopeTM. Two experiments were conducted under different conditions. In each experiment, cyclic load, followed by a pull-to-failure load, was applied to the grafts and elongation and failure mode were recorded. (1) To evaluate the effects of diameter, 5.0 or 6.0 mm grafts were prepared by a single locking loop stitch as the base suture (SLL5, SLL6). (2) To evaluate different base sutures, 5.0 mm tendons were used, and grafts were prepared using five kinds of base sutures (SLL, ZLL: zigzag locking loop, DZLL: double zigzag locking loop, DK: double Krackow, DK w/o TR: double Krackow without TightRopeTM). In the first experiment, tearing was observed in 2 of 6 cases in the SLL5 test group, whereas no tearing was observed with SLL6. In the second experiment, no tearing was observed with DZLL or DK. Elongation was smaller in these two groups compared to the other groups. Mechanical strength decreases with a smaller graft diameter. Biomechanical properties differed with different base sutures and, among them, the double-zigzag-suture stitch and double Krackow provided less elongation and higher ultimate load in this graft configuration.

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.

The purpose of this study was to clarify the association of locomotive syndrome with present and past physical activities, as well as gait speed. Subjects were recruited from the participants of the specific health checkups in Oamishirasato City. The presence of locomotive syndrome was assessed using the stand-up test, two-step test, and 25-question geriatric locomotive function scale. Present physical activity was measured using the International Physical Activity Questionnaire. Questionnaires were also used to assess past physical activity and usual gait speed. The association of each locomotive syndrome risk test with the physical activities and gait speed was examined using univariate analysis and multiple logistic regression analysis. A total of 172 subjects with a mean age of 67.5 years were enrolled. Sixty-nine（40%）and 13（8%）subjects were classified as having stage 1 and 2 locomotive syndrome, respectively. Among the four groups classified by physical activity level, the proportions of subjects with positive stand-up test were higher in the groups of lowest and highest physical activity（P＝0.048）. Faster gait speed was a significant predictor of the negative two-step test（P＝0.08）, negative 25-question geriatric locomotive function scale（P＜0.001）, and absence of locomotive syndrome（P＝0.002）. The associations remained significant in the multiple regression analysis, after adjusting for age, sex, and body mass index. In conclusion, present physical activity was associated with the stand-up test, whereas self-reported usual gait speed was associated with the two-step test and 25-question geriatric locomotive function scale.

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.

【目的】変形性膝関節症(膝OA)患者における運動療法によるメンタルヘルス改善効果の検討を目的とした。【方法】膝OA患者を(1)「薬物治療群」8例と、(2)薬物治療に加えて運動療法を行う「運動療法群」12例の2群に分け、自記式アンケート調査により3ヵ月間の治療前後の臨床症状(Knee Osteoarthritis Outcome Score;KOOS、Visual Analogue Scale;VAS、36-item Short-Form Health Survey;SF-36)及び睡眠の質(ISI)を検討した。同時に活動量も測定した。【結果】薬物治療群は臨床症状の全項目で治療前後に変化がなかったが、運動療法群ではKOOS(疼痛、activities of daily living;ADL、スポーツ、QOL)と臥位の疼痛VASで有意な改善を認めた。活動量は薬物治療群、運動療法群ともに全項目で治療前後に変化はなかった。【結論】運動療法を行うことで短期的にKOOSやVASの臨床症状を改善したが、メンタルヘルス、活動量は変化しなかった。(著者抄録)

Background: Adolescent athletes are a high-risk population for stress fractures. We report four cases of stress fractures of the second proximal phalanx, which had not been previously diagnosed as the location of the stress fracture of the foot, in teenage athletes. Case report: All fractures were on the plantar side of the proximal phalangeal base, and the oblique images of the plain radiograph clearly depicted the fractures. Notably, three out of the four patients had histories of stress fracture of other locations. While three athletes with acute cases were able to make an early return to play with simple conservative management, the chronic case required surgical treatment for this rare injury. Conclusion: Although a rare injury, it is important that clinicians be aware of this type of stress fracture, as a timely diagnosis can avoid the need for surgical treatment and allow an early return to play.

Kinematic changes have been shown to accompany severe knee osteoarthritis, but no studies have analyzed early-stage osteoarthritic knee kinematics in the transverse plane during functional activities. The purpose of this study was to analyze kinematics of early-stage osteoarthritic knees using model registration techniques. Fifteen early-stage osteoarthritic knees from eight females with a mean age of 52 years old (range, 43-57years old) were involved in this study. A radiologist confirmed with plain radiographs that knees had Kellgren-Lawrence grade-1 or -2 arthritic changes. Fluoroscopic images of squat and pivot activities were recorded for each subject. Three-dimensional surface models of the distal femur and proximal tibia were created from CT images, and anatomic coordinate systems were embedded in each model. The three-dimensional position and orientation of the femur and the tibia were determined using model-image registration techniques, and tibial anteroposterior translation and internal/external rotation relative to the femur were calculated. The contact points of the medial and lateral femoral condyle were also computed. Compared to healthy knees, osteoarthritic knees showed lateral contact points that were significantly shifted anteriorly in both pivot (P<0.001) and squat (P=0.001) activities and greater tibial external rotation in pivot activity (P=0.007). The medial contact point location was similar to healthy knees, but the amount of anteroposterior translation was smaller (P<0.001). These kinematic changes might change stress distributions in the medial compartment during weight-bearing activities. The changes in kinematics possibly have some influence on initiation or progression of knee osteoarthritis.

T1 rho and T2 mapping are magnetic resonance imaging (MRI) techniques to detect early degenerative changes in cartilage. Recent advancements have enabled 3D acquisition for both techniques. The objective of the present study was to examine the correlation of 3D T1 rho and 3D T2 mapping with macroscopic and histological characteristics of knee cartilage. Twenty-one patients who underwent total knee arthroplasty due to osteoarthritis with involvement of the medial compartment but with minimum involvement of the lateral compartment were enrolled. Prior to surgery, five series of MRI were acquired with a 3-T scanner. 3D T1 rho/T2 analyses were performed following determination of regions to be assessed using in-house software that incorporated three series of MRI acquisitions data (3D-MERGE, 3D-SPGR, and 3D-CUBE). During surgery, the cartilage of the lateral compartment was macroscopically assessed with the International Cartilage Research Society (ICRS) articular classification system. The extracted specimens were histologically assessed using the OARSI histology score. Three regions of interest (ROI) were assessed for each slice (two slices per knee): the central lateral femoral condyle (cLFC), the posterior portion of the lateral femoral condyle (pLFC), and the lateral tibia plateau (LTP). For each ROI, the mean T1 rho and T2 relaxation time, the ICRS grade, and the OARSI score were compared. Neither the T1 rho nor the T2 reflected the macroscopic grading. The T1 rho could discriminate between histological grades 1 and 2. However, the T2 could not. The T1 rho relaxation time was higher in the pLFC than in the cLFC even in the same grade. Compared to T2 mapping, T1 rho mapping may have an advantage in differentiating grades I and II cartilage degeneration on OARSI histological grading system.

BACKGROUND: An intra-articular injection of platelet-rich plasma (PRP) may be an effective treatment for osteoarthritis (OA). However, its efficacy in ankle OA has not been investigated yet. The purpose of this study was to assess the safety and efficacy of an intra-articular injection of PRP in patients with ankle OA during a 24-week period. METHODS: Twenty ankles of 20 patients with varus-type ankle OA who received intra-articular injections of PRP were evaluated. PRP was extracted from whole blood by using the double-spin technique. Three injections of 2-mL PRP were administered to the ankle at an interval of 2 weeks under ultrasonographic guidance. Adverse events and efficacy were assessed at 4, 12, and 24 weeks after the last injection. Clinical outcomes were assessed by using the visual analog scale (VAS) for pain, the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). RESULTS: No serious adverse effects were observed during the follow-up period. The VAS and JSSF scale scores significantly decreased from baseline to 4, 12, and 24 weeks after treatment ( P < .001). The mean score in the pain-related subscale of the SAFE-Q significantly improved from baseline to 12 weeks after treatment ( P = .04). Overall, the amount of pain reduction was maximal at 12 weeks after the last injection, and the effect was reduced at 24 weeks. The patients with late-stage OA had worse scores in all outcomes than those with early-stage OA. CONCLUSION: Intra-articular injections of PRP resulted in no serious adverse effects and significantly reduced pain in the patients with ankle OA. PRP treatment can be safe and effective and may be an option in the treatment of ankle OA. LEVEL OF EVIDENCE: Level IV, case series.