山田 治基

Background. Osteoarthritis (OA) of the hip is a major disease that affects the healthy lifespan of a population. It is necessary to fully understand the patients' conditions before a systematic treatment can be applied. However, a nationwide epidemiological study regarding hip OA has not yet been conducted in Japan. The present study examined the current status of patients with hip OA, including the disease etiology. Methods. This is a multiinstitutional study of new patients presenting with hip OA at the orthopedic outpatient clinics of 15 institutions in five geographical areas of Japan. The collected data from each patient included the sex, age, treatment history for developmental dysplasia of the hip (DDH), the clinical score of the hip joints based on the Japanese Orthopaedic Association (JOA) scoring system, and the pelvic inclination according to anteroposterior radiographs. In addition, the etiology was determined from the following 17 options: primary OA, acetabular dysplasia, intragluteal dislocation, osteonecrosis, trauma, Perthes disease, slipped capital femoral epiphysis, infection, rheumatoid arthritis, ankylosing spondylitis, neuroarthropathy, endocrine diseases, metabolic diseases, hereditary bone diseases, synovial chondromatosis, generalized OA, and others. Results. There were a substantially larger number of female patients than male patients. This difference regarding sex was present in each generation. The mean age of the patients was 58 +/- 14 years. The peak age at presentation was approximately 50 years. Most patients had no history of therapy for DDH. The older patients had lower gait and activities of daily living scores. The etiology was assessed to be acetabular dysplasia in most of the patients. A lower frequency of elderly patients demonstrated acetabular dysplasia. The patients who had a pelvic posterior inclination increased with increasing age. Conclusions. The patients with hip OA in Japan were unique in regard to age distribution, sexual heterogeneity, and disease etiology.

We are planning a multicenter survey on coxarthrosis and acetabular dysplasia in Japan. To collect reliable data, we performed a preliminary study to elucidate the observer agreement on assessment items. We collected radiographs of hip joints in eight patients with various findings of coxarthrosis. Twelve registered orthopedic specialists evaluated them regarding the roentgenographic stage of coxarthrosis and five indexes of acetabular dysplasia (acetabular angle, center-edge angle, acetabular roof obliquity, acetabular head quotient, approximate acetabular quotient). To assess observer agreement, we calculated the value of the kappa statistic for stages and the coefficient of variation for the indexes. The same 12 specialists then assessed the coxarthritis stage on the same radiographs 1 month after the first evaluation based on our own descriptions of the roentgenographic stages. For the first evaluation of the roentgenographic stage, the value of the kappa statistic was 0.448; and for the second evaluation it was 0.600. The results of the coefficient of variation for the indexes of acetabular dysplasia, ranked in ascending order, were as follows: acetabular angle, acetabular head quotient, acetabular roof obliquity, center-edge angle, approximate acetabular quotient. For the upcoming multicenter survey, clear descriptions of the stages of coxarthrosis and selection of appropriate indexes can be helpful for collecting dependable results.

Cementless total hip replacement (THR) is rapidly being accepted as the surgery for arthritic diseases of the hip joint. The bone-ingrowth rate in porous-type cementless implants was about 90% over 10 years after surgery, showing that biological fixation of cementless THR was well maintained on both the stem and cup sides. As for the stress shielding of the femur operated using a distal fixation-type stem, severe bone resorption was observed. The severe bone resorption group showed continuous progression for more than 10 years after surgery. Stem loosening directly caused by stress shielding has been considered less likely; however, close attention should be paid to bone resorption-associated disorders including femoral fracture. Cementless cups have several specific problems. It is difficult to decide whether a cup should be placed in the physiological position for the case of acetabular dysplasia by bone grafting or at a relatively higher position without bone grafting. The bone-ingrowth rate was lower in the group with en bloc bone grafting, and the reactive line was frequently noted in the bone-grafted region. Although no data indicated that en bloc bone grafting directly led to poor outcomes, such as loosening, cup placement at a higher site without bone grafting is now selected by most operators. The polyethylene liner in a cementless cup is thinned due to the metal cup thickness; however, it has been suggested that the apparent relation between the cup size and the wear rate was absent as long as a cementless cup is used. Comparative study indicated cementless THR was inferior with regard to the yearly polyethylene wear rate and incidence of osteolysis on both the stem and cup sides. Meta-analysis study on the survival rate between cement and cementless THR reported that cemented THR was slightly superior. It should be considered that specific problems for cementless THR, especially with regard to polyethylene wear, do occur.