Osteomyelitis after trauma or surgery can be problematic, especially pedal osteomyelitis including calcaneal osteomyelitis. Here we report the results and problems associated with surgery for pedal osteomyelitis in five patients (four men and one woman). The mean age of the patients was 37 years (range 12-51 years). Four developed infection after surgery and one after contusion. Treatment involved thorough debridement of the infected area and filling of the dead space with artificial bone or cement beads incorporating a DDS (Drug Delivery System). Until the infection had subsided, we repeated this operation every 3 to 4 weeks. Finally, we performed a subtalar arthrodesis in one patient, a desis of the cuneiform bone in one, and auto-bone graft in three. The bacteria detected were MSSA in two patients, MRSA in three patients (including one case of MRSA combined with fungus). All of the infections subsided within a mean period of 9.6 months (range 5-21 months). The mean operation time was 3.2 hours (range 1-5 hours). We used mainly a DDS that released antibiotics from cement or artificial bone. There was no complication associated with this treatment. Since the calcaneus has poor vascularization and a large proportion of cancellous bone, pedal osteomyelitis, especially in the calcaneus, is challenging to treat. Filling the dead space using a DDS is effective for control of infection.

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A study was conducted to assess the accuracy of two-dimensional analog templating in the surgical planning for patients undergoing total hip arthroplasty using the TAPERLOC stem. We retrospectively reviewed the preoperative radiographs of 47 hips (37 females, 8 males) between 43 and 89 years of age. Forty percent of the implanted components (19/45) were estimated precisely, corresponding to the size placed intraoperatively. Sixty-six percent (31/47) were accurate to within 1 component size. Stem alignment was neutral in 44 hips and in the valgus position in 3 hips. There was no subsidence of the stem or intraoperative femoral fracture. Accurate determination of the component size for the TAPERLOC stem preoperatively is limited in analog templating.

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In modern Japan, it is now rare to see an untreated case of bilateral development dysplasia of the hip(DDH)in young children who are able to walk. Here we report a rare case of bilateral DDH in a girl aged 4 years and 9 months with a chief complaint of lumbar lordosis augmentation. No abnormality had been evident at medical examinations, and no gait abnormality had been evident after she had started to walk. She was examined at an orthopedic clinic because of lumbago at the age of 4, but was followed up without any notable abnormality after simple lumbar radiography. She was examined at our hospital because of marked lumbar lordosis at the age of 4 years and 9 months. By this time she had developed a staggering gait, and bilateral DDH was noted on a plain radiograph. Open surgical reduction was performed. An intraoperative stabilization test was performed, and we decided not to add osteotomy and used an extensive anterolateral approach alone.

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The present study examined the short-term results of cementless total hip arthroplasty (THA) using SUMMIT stems. We treated 30 patients during the period between May 2009 and May 2010. The average age of the patients at the time of surgery was 68 years, and the average postoperative follow-up period was 16 months. There was no early stem subsidence after surgery. The average Japanese Orthopaedic Association hip scores increased from a preoperative mean of 42 to a mean of 93 at one year after surgery. No complications occurred. Of the 30 hips, 20 (66%) showed roentgenographic signs of stem osseointegration at one year. Stress shielding occurred in 17 hips (59%), but was not progressive. These short-term data indicate that the SUMMIT stem is capable of delivering good results.

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Purpose : THA have been aggressively performed for elderly patients in order to improve ADL and QOL. We have performed metal-on-metal THA in this setting.
Methods : The subjects comprised 28 patients, in whom 30 hips were treated. There were 5 hips in 5 males, and 25 hips in 23 females, all of whom were over 75 years old and underwent metal-on-metal THA at our hospital from July, 2010. The average patient age was 79.0 (75 to 89) years, and the primary diseases were OA in 27 hips, ION in 2, and RA in one. We observed the preoperative pelvic inclination angle measured in APP in the spine and standing position, intraoperative blood loss, operation time, complications, and the cup setting angle after surgery.
Results : The average preoperative pelvic tilting angle was -2.1 degrees in the supine position, and - 4.2 degrees in the standing position. In both positions, 11 hips were forward tilting and 19 were backward tilting. Mean intraoperative blood loss was 224 (10 to 1000)g, and the mean operation time was 78.2 (45 to 125) min. There were no complications such as intraoperative fracture, postoperative dislocation, infection, or loosening. The postoperative average cup setting angle was 40.0 (28 to 57) degrees in inclination, and 12.5 (-12 to 35) degrees in version.
Discussion and Conclusion : It is known that the pelvis shows retroversion in the elderly, and therefore it is important for orthopaedic surgeons to consider postoperative dislocation when treating such patients. Metal-on-metal has the advantage of low wear, a wide range of motion, and high resistance to dislocation. Therefore it is considered a good technique for elderly patients with advanced backward tilting.

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We report our experience with a case of glomus tumor that caused intractable pain in the right thumb. The patient was a 72-year-old man with a one-year history of right thumb pain for which the cause could not be identified, despite visits to multiple medical institutions. On initial examination, marked tenderness in the proximal phalanx of the right thumb and pain with movement of the right thumb were observed. No other clear abnormalities were seen. MRI showed a well defined tumor in the proximal phalanx of the right thumb that was hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging. The tumor was surgically resected, after which the pain disappeared. The present case suggests the need to consider glomus tumor as a cause ofidiopathic finger pain.

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Chondroblastoma of the femoral head is surrounded by articular cartilage on one side and the epiphyseal plate on the other. Because of the particular location of this tumor, it is not easy to perform curettage without damaging the articular cartilage or epiphyseal plate. An 18-year-old man was referred to our hospital with a 6-month history of left coxalgia without any episode of trauma or sports injury. Radiographs and CT showed a 15x15mm focal osteolytic lesion circumscribed by an osteosclerotic rim in the weight-bearing area of the left femoral head. We performed curettage of the tumor via a hole along the femoral neck created under image intensifier guidance. The hole was created using the Coring Reamer System from the cortex to the femoral neck, and a bone column was obtained in a single procedure. An endoscope was used to ensure correct curettage, and then cancellous bone was grafted onto the curettage site and the bone column was grafted over the hole. After surgery, MRI and CT showed early remodeling at the bone column graft site. At the last follow-up, two years after surgery, the patient was free of local recurrence. The functional result was an ISOLS score of 100% and a JOA score of 100%. We think that it is important to create a hole large enough to curette, but without weakening the femoral neck. Our surgical method seems to achieve both of these objectives.

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Pathological fractures and so-called shepherd's crook deformity of the proximal femur are serious problems in patients with fibrous dysplasia. We treated 4 such patients who had proximal femoral fractures (1 man and 3 women, mean age 15.5 years, 1 monostotic type and 3 polyostotic types) between 1985 and 2005. The mean follow-up period was 8 years. The fractures united in all patients, but varus deformity of the hip worsened in two patients after surgery. In one male patient with a monostotic fracture, the femoral neck angle did not change and the tumor enlarged.
In one female patient with a polyostotic fracture, although the femoral neck angle did not change, osteoarthritis of the hip developed. We considered that osteosynthesis with plates or intramedullary nails was useful for these fractures. However, as osteosynthesis is sometimes impossible in patients with severe varus deformity of the hip, valgus osteotomy with external skeletal fixation might be useful for such patients.

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Calcifying aponeurotic fibroma is a relatively rare, benign soft tissue tumor that is one of the superficial fibromas and typically occurs in the distal extremities of children and adolescents. We report a case of calcifying aponeurotic fibroma developing in the lower back region, which is a fairly uncommon site. This is the first reported case of a multiple calcifying aponeurotic fibroma occurring in the back. Histologically, poorly marginated proliferation of fibroblasts and cartilage formation accompanied by central calcification were characteristic features.
Calcifying aponeurotic fibroma is an ill-defined mass and has a tendency to infiltrate into the surrounding tissues. Because of its high local recurrence rate (50%), an appropriate excision is required and long-term postoperative follow-up is recommended.

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We report the use of heavy ion radiotherapy for a case of osteosarcoma in the pelvic bone of a 55-year-old man. Radiography revealed a radiolucent lesion with a pathological fracture in the right iliac bone. Computed tomography revealed that the tumor, measuring 14x12cm, was located in the iliac bone with infiltration within and beyond the pelvis. Magnetic resonance imaging revealed that the tumor was located in the iliac bone and had invaded the sacrum. The tumor was subsequently diagnosed as an osteoblastic osteosarcoma by needle biopsy. Because we thought that surgery would be excessively invasive and lead to loss of motor function, we selected heavy ion radiotherapy after doxorubicin and cisplatin chemotherapy. The 2-year course after heavy ion radiotherapy was uneventful, without recurrence or distant metastasis.
It is difficult to treat osteosarcomas in the pelvic bone because of associated anatomical problems and potential loss of function after surgery. Carbon ion radiotherapy has been reported to be effective and safe for bone sarcomas. However, high-grade bone sarcomas such as osteosarcoma have been reported to have a high recurrence rate. The long-term outcomes of carbon ion radiotherapy for bone sarcomas are uncertain. Although carbon ion radiotherapy should be considered for treatment of bone sarcomas, its indications should be assessed carefully, especially in high-grade malignancies.

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We evaluated the clinical results of treatment for bone metastases in the extremities associated with pathological fracture.
Thirty-four patients (11 men and 23 women, mean age 62 years) were treated at our institution between August 2006 and July 2011. The site of the primary tumor was the kidney in 4 patients, lung in 5 patients, breast in 14 patients, and other sites in 11 patients. Pathological fractures were found in the humerus in 5 patients, femur in 23 patients, and tibia in 2 patients. Surgical treatment was performed in 28 cases.
Pathological fracture of the femur was treated by resection and prosthetic replacement in 12 cases. The remaining fractures of the femur were stabilized using locking nails (n=6) or plates (n=5). Humeral lesions were stabilized using locking nails (n=3) or plates (n=2). Pathological fractures of the tibia were stabilized using plates (n=2). Postoperative performance status (PS) of the patients with pathological fractures recovered to that before the trauma in almost all patients. Postoperative complications occurred in 6 cases, including temporary palsy of the radial nerve in 2 patients, deep infection in 1 patient, plate breakage in 1 patient, and periprosthetic femoral fractures in 2 patients.
The average survival after fracture was 10.5 months for patients who underwent surgery and 3.5 months for patients who were treated conservatively. These figures suggest that patient selection for treatment should be based on prognosis.

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Because of the extended survival of cancer patients resulting from improvements in medical treatment, those with metastatic spinal tumors are increasing. Accordingly, it is necessary to reconsider the classification of spinal metastases and the surgical strategies used for treating them. In this study, we evaluated the postoperative outcomes and prognoses of patients with spinal metastases, and on the basis of our findings suggested suitable treatment strategies.
Eighteen patients with metastatic spinal tumors underwent surgical treatment between January 2000 and May 2011. The mean age of the patients was 64 years (range 42 to 78 years). All were followed for more than 3 months. The mean Tokuhashi score was 11.1 (range 7 to 15) points. Irrespective of the Tokuhashi score, all the patients except for one survived more than 6 months after surgery. At 3 months after surgery, 7 patients had recovered from paralysis, and 9 had achieved reduction of their severe back pain. Five patients recovered and maintained their activities of daily living. In terms of the Japanese Orthopedics Association score, 35% of the patients achieved improvement. In this series, no exacerbation of paralysis and no skeletal-related events occurred.
Surgery for metastatic spinal tumors produces good result, even in patients with advanced cancer. Furthermore, molecular-targeted drugs are effective for a proportion of cancers, and the survival rate has increased even in patients with rapidly progressive tumors. Our findings suggest that the indications for surgical intervention in patients with metastatic spinal tumors need to be reconsidered.

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We report the outcome of patients with metastatic spine tumors showing high-grade malignancy using the Tokuhashi scoring system. A retrospectively compared 21 patients with such tumors (group H) and 29 patients with spinal metastases showing low-grade malignancy (group L). There were 18 men and 3 women in group H, and 16 men and 13 women in group L, and the average patient ages were 55 years and 65 years, respectively. All of the patients were scored with the Tokuhashi scoring system and evaluated for neurological symptoms with the ASIA Impairment Scale (AIS).
Results : The rates of improvement in the AIS score and gait ability were almost the same in both groups. Among patients who we were able to follow postoperatively for 6 months or more, 7 in group H and 4 in group L died within 6 months. The mean survival period was 12 months in group H and 17 months in group L.
Conclusions : The outcome after treatment in group H was almost the same as that in group L. This may have been due to progress in the treatment of malignancy. Further studies to determine the indications for surgery in such patients are warranted.

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We investigated the safety and palliative effect of magnetic resonance-guided focused ultrasound surgery (MRgFUS) for pain associated with bone metastases.
Patients and Methods : Eight patients (mean age, 62.3 years), who met the eligibility criteria for this clinical study approved by our Institutional Ethics Committee based on the cooperative protocol, were treated with MRgFUS. The main inclusion criterion was localized painful metastatic lesions of the bone in patients for whom other pain palliation treatments had proved ineffective. The targeted sites included the sacrum (n=2), ilium (n=2), scapula (n=2), and femur (n=2), and the mean follow-up period was 6 months. All the procedures were performed as a single-session treatment using the ExAblate 2000^TM (InSightec Ltd.) treatment system, which is integrated into the patient table of the MRI scanner. The study endpoints were a change in the intensity of the worst pain due to bone metastases as a result of the treatment, as measured on a numerical rating scale (NRS) ; interference of pain with daily activities, as determined by the Brief Pain Inventory (BPI-interference) ; a change in the imaging appearance; and safety.
Results : Pain relief was obtained in all patients early after treatment, with a reduction in the median NRS score from 7.0 (range : 4-8) at the baseline to 1.0 (range : 0-3) at the end of follow-up, as well as in the BPI-interference scores. The mean time required for a single-session treatment was 86.8 min (range : 40-126 min), with a mean number of sonications of 17.0 (range : 10-27) and a mean energy applied of 771.5J (range : 306.5-1240.7J). No significant growth of tumors was observed, nor were there any treatment-related adverse events.
Conclusions : These results suggest that MRgFUS has a non-invasive palliative effect on localized pain in patients with bone metastasis.

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We reviewed ten patients with rheumatoid arthritis who were able to discontinue treatment with biologic agents after achieving clinical remission. The decision to discontinue treatment was made on the basis of a DAS28-CRP value below 2.0 and a MMP-3 improvement ratio of less than 0.4 for more than six months. Seven patients who were receiving infliximab, two receiving adalimumab, and one receiving etanercept discontinued their treatments, among whom six and one who had been receiving infliximab and adalimumab, respectively, were subsequently maintained successfully without re-introduction of the treatment. One patient who had been receiving infliximab has remained in remission without any drug treatment. However, one patient who had been receiving etanercept needed to re-start the treatment because of flare-up of the disease activity three years after discontinuation, while another patient who had been receiving infliximab needed to start golimumab twenty-one months after discontinuation, and one who had been receiving adalimumab also needed to start abatacept just six months after discontinuation. In order to maintain clinical remission after discontinuation of biologic agents, monitoring of indices such as DAS28 and MMP-3 is insufficient, and careful attention to disease activity is also important.

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We describe our experience with atypical cases of basicervical fracture of the femur. The fracture line lay between the anterior aspect of the subcapital portion and the posterior aspect of the neck base, running through the neck with a shearing fracture line as viewed in the coronal plane. We treated ten cases : seven by hemiarthroplasty and three by osteosynthesis. Bone union was obtained within six months, and there was no implant failure or complication. For diagnosis of this fracture, careful radiological assessment is important, and for effective treatment the special characteristics of this fracture should be considered. Cases of this type present difficulty with reduction and acquisition of stable fixation because of the cortical defect of the calcar or shortness of the anterior portion of the proximal fragment.

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We treated 28 patients with femoral trochanteric fracture using a short femoral nail with a blade, the Inter Blade Nail System (IBN, Nakashima Medical Co., Ltd. Japan), between October 2010 and July 2011. The mean patient age at the time of surgery was 85 years, the mean operation time was 31 minutes, and the mean follow-up period was 137 days.
The mean tip-apex distance was 15.0mm, and there was no significant difference between the IBN and other short femoral nails. The mean telescoping measure was 5.9 mm. Walking ability was maintained in 67% of the patients postoperatively.
In conclusion, the use of the IBN appears to be usefull for femoral trochanteric fractures, since our clinical result has shown similar result of the conventional model.

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In our hospital, we have been treating unstable type III & IV intra-articular fractures of the femoral neck (by Garden's classification) using our own original technique employing 3-hook pins. Here we selected and evaluated 48 cases in which we judged that intra operative reduction of the fracture had been performed correctly.
Good functional results were noted in 44 cases where fixation of the fractured bones had been complete during the operation. However among the remaining 4 cases, the fracture was classified as Minamizawa type III in 1 case, and type IV in 3.
We consider that Minamizawa type IV femoral neck fracture may be more amenable to an end-prosthesis than to osteosynthesis, whereas for type I and II cases, good operative results can be expected with our 3-hook pin technique if the fractured bones are reduced correctly during surgery.

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Objective: We investigated clinical results and postoperative complications in patients with lateral lumbar disc herniation. Patients and Methods: Between 2005 and 2009, 10 patients underwent surgical treatment for lateral lumbar disc herniaton. The patients comprised 6 males and 4 females with an average age of 62 (45-93) years. The surgical procedures included osteoplastic hemilaminectomy in 4 patients, herniotomy via a postero-lateral approach in 5, and unilateral facetectomy and herniotomy via a postero-lateral approach in one. Surgical outcomes were assessed on the basis of the Japanese Orthopaedic Association score (JOA score), and postoperative complications were investigated. Results: The average JOA score was significantly improved from 9.7 points preoperatively to 20.6 points postoperatively. Postoperative complications included leg pain due to intraoperative neural damage, complex regional pain syndrome (CRPS), peroneal nerve palsy, and subcutaneous hemorrhage in one patient each. The patients with leg pain and CRPS had extraforaminal herniation at the L5/S level, and underwent herniotomy via a posterolateral approach. Conclusions: Surgical outcomes were mostly satisfactory. However, several complications occurred. When lateral lumbar fenestration is performed, it is essential to protect the L5 nerve root from intraoperative injury.

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Lower back pain (LBP) is the most common complaint among patients visiting orthopedic clinics. However, treatment modalities available in Japan vary. The aim of this study was to survey the actual conditions of conservative treatment for LBP in Ehime prefecture. We sent out questionnaires inquiring about conservative treatment for LBP to all (287) orthopedic surgeons in Ehime prefecture, and obtained 144 replies (response rate, 50.2%). Commonly used (more than 90%) treatments for LBP were oral NSAIDs, NSAID plasters, and teaching self-care. Less often used (30-70%) treatments for LBP included muscle relaxants, NSAID suppositories, injection into the trigger point, exercise therapy, and application of a lumbar corset or lumbar traction. We found that exercise therapy was applied for acute and chronic LBP at the same frequency. In the guidelines for LBP, exercise therapy is not indicated for acute cases. Thus, better familiarity with the guidelines for LBP appears to be necessary.

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The anti-seizure drug, pregabalin, is used for treatment of neuropathic pain and degenerative lumbar disease. The objective of this study was to evaluate the effect of pregabalin (150-300 mg/day) in patients with chronic lower back/leg pain. We assessed 47 patients (17 men and 30 women) with an average age of 65 years (range 20 to 81 years), and an average disease duration of 87 months (range 3 to 480 months). All patients were assessed using a visual analogue scale (VAS, 0-100 mm), the Self-Rating Depression Scale (SDS, 20-80 points), and the Oswestry Disability Index (ODI, 0-100%). After 8 weeks, pregabalin improved lower back pain, leg pain, SDS and ODI significantly (P<0.01). Pain was improved significantly in the depression group as well as the normal group (P<0.01). Accepted sleepiness (51%), dizziness (19%), weight gain (16%) and rash (5%) were detected after medication. The use of the hypnotic agent was decreased in half of the cases after medication. Pregabalin is safe and effective for decreasing lower back pain and leg pain in patients with depression.

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Medical care in remote rural areas is becoming a serious issue of concern in Japan. Medical services at Ibuki clinic, located on an isolated island, are provided by part-time doctors of internal medicine and orthopaedic surgery. In this study, we investigated the satisfaction of patients with orthopaedic problems and the characteristics of the patients' disabilities at the clinic. A questionnaire revealed that 23 patients were satisfied with the treatment they had received at the clinic. We analyzed the prevalence rate of musculoskeletal ambulation disability symptom complex, chief complaints, plain roentgenogram, and JOA score of 19 patients who constantly visited the clinic. There were 2 males and 17 females, with a mean age of 81 years. Fourteen patients had musculoskeletal ambulation disability symptom complex. Their chief complaints were knee pain (50%), lower back pain (25%) and shoulder stiffness (13%). All sixteen patients with knee pain were diagnosed as having osteoarthritis. No statistically significant correlation between Kellgren-Lawrence Grade and JOA score was observed. Among 7 patients with lower back pain, including duplications, there were 5 cases of osteoporotic vertebral compression fracture, 4 cases of spondylosis of the lumbar spine, 3 cases of lumbar spinal canal stenosis, and one case of postoperative adjacent spinal segment disorder.
In remote rural areas, orthopedic surgeons play important roles in the welfare of elderly people with locomotive syndrome.

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There has been a major concern regarding the decreasing of medical doctor in the rural region in Japan.
Minamiuwa Prefectural Hospital (MPH), the only hospital providing emergency medical service in this area, is facing similar problem.
Ainan is a city of 25,000 residents, and 32.3% of them are over the age of 65. In 2002, 23 doctors were working in the MPH as full-time staffs, but the number has decreased to 10 at the year of 2011. The full-time orthopedic surgeon has decreased from 2 to 1. Thus, it is very important to reduce preventable fracture cases because of the limited medical resource.
As the only full-time orthopedist working in this region, I have launched a project named “version Minamiuwa”. This is a very simple exercise explained as follow : lift up her/his hip and hold for 3 seconds with her/his palm on the quadriceps muscle so that she/he can feel the contraction of muscle. The excise is to be repeated 50 times a day.
There are several goals we are trying to achieve through this project. First, we are aiming to promote understanding of the importance of locomotive organs. Second, we are trying to draw the attention of local residents to pay special awareness of the medical crisis we are facing in the rural in Japan : lacking of medical staffs.

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The shortage of medical staff in rural areas of Japan is an ongoing problem. As anesthesiologists are becoming centered on urban areas, rural-based orthopedists are becoming less able to secure safe anesthesia for patients with cardiac disease or those taking anticoagulant drugs.
This study was conducted to determine whether safe anesthesia of the upper and lower limbs can be obtained using ultrasound-guided peripheral nerve block by an orthopedist working alone. The proportion of patients showing a fall in blood pressure in the nerve block group was 16%, being significantly lower than the 31% of patients receiving spinal anesthesia for bone and joint surgery of the lower limbs. In addition, in the nerve block group, no patients required vasopressor agents. Symptoms of local anesthesia toxicity developed in one patient who underwent hip joint operations.
In four patients with humerus proximal part fracture, stable anesthesia was obtained and the proportion showing blood pressure reduction was 23%.

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Specialized rheumatologists at rheumatology centers should be more aware about primary care physicians' attitudes toward medical cooperation for treating rheumatoid arthritis (RA) patients. A questionnaire survey was carried out. A total of 51 physicians consisted of 15 Rheumatology Board certification (RA-certified) and 36 non-certified physicians. Most physicians replied that they could accept treating RA patients, after stable control of arthritis had been achieved at a rheumatology center. Non-RA-certified physicians were more likely than RA-certified physicians to feel it difficult to accept patients who have been prescribed disease-modifying antirheumatic drugs and to treat RA symptoms, whereas they were less likely to feel uncomfortable about controlling RA complications (p<0.05). These results are mainly due to primary care physicians not being sufficiently informed about the latest RA treatment. In order to establish medical cooperation in RA treatments, more vigorous education of primary care physicians, especially non-RA-certified physicians, should be conducted by specialized rheumatologists at rheumatology centers.

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We reviewed patients with musculoskeletal tumors treated at our institution between April 1999 and March 2011 in the light of the current shortage of specialists in this field. The subjects were 866 patients. The proportion of those with musculoskeletal tumors increased over the study period, whereas that of patients with other malignant tumors showed no remarkable change. Every year, 80-90% of the treated patients had been referred from nearby clinics, and some of these patients were returned to the original clinics after treatment at our institution. The proportion of such returnees was 29.3% in 1999, and had risen to 62.8% in 2010. In the studied district, general orthopedic surgeons do not attempt to treat musculoskeletal tumors even if they are not malignant because of the risk of misdiagnosis. However, if all patients with musculoskeletal tumors become concentrated at a specialized institution, the number of orthopedic surgeons qualified to deal with them will eventually become insufficient. One way of preventing this problem is to return such patients to their referring clinics after treatment, and assigning follow-up to them. If specialists still remain fully occupied, it will become necessary for specific institutions to specialize in the treatment of malignant tumors, and for benign tumors to be treated at other hospitals.

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Deep venous thrombosis (DVT) has been widely recognized as one of the most serious complications that can occur after total hip arthroplasty (THA) or total knee arthroplasty (TKA). The present study was conducted to evaluate the efficacy and safety of enoxaparin for preventing DVT after THA or TKA.
One hundred patients who underwent THA (47 cases) or TKA (53 cases) between September 2008 and June 2010 were included. There were 24 males and 76 females, with an average age of 71 years (range : 34 to 87 years). The patients were divided into two groups. Group E included 59 patients who received 2000 IU of enoxaparin twice daily for 14 days after surgery, and group C included 41 patients who did not receive enoxaparin. The plasma D-dimer levels were measured at 1, 3, and 7 days after surgery. The presence or absence of DVT was examined by ultrasonography at 7 days after surgery. The age at surgery, body mass index (BMI), operation time, volume of transfusion, the incidence of DVT and D-dimer levels were compared statistically between the two groups.
There were no significant inter-group differences in the age at surgery, BMI, operation time, or volume of transfusion. The incidence of DVT was 8.5% in group E and 14.6% in group C, the difference being non-significant. D-dimer levels were significantly lower in group E than in group C at 3 and 7 days after surgery. There were no complications caused by enoxaparin.
The results of this study indicate that enoxaparin is effective for prevention of DVT after THA and TKA.

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We performed opening-wedge HTO with the use of a DynaFix Plate and 60% β-TCP Graft in 21 patients between 2008 and April 2011. The mean age of the patients was 64.4 years (range 58-72 yr). The medial osteotomy site was fixed with a DynaFix VS osteotomy plate, followed by grafting with porous 60% β-tricalcium phosphate (TCP). The limb was not immobilized with a knee brace postoperatively, and full weight-bearing was allowed from the fourth week in principle. Rigid fixation allows early full weight-bearing and discharge within four to five weeks after surgery.
The mean preoperative and postoperative femorotibial angles were 182.9 degrees and 172.3 degrees, respectively, and the mean JOA score improved from 58.6 to 85.5 points.
The complications during surgery included fissures of the tibial lateral cortex in one knee, tibial lateral plateau in four knees, and tibial medial plateau in one knee. There was no pseudoarthrosis.
The correction can be adapted intraoperatively based on an X-ray image of the whole lower extremity, but the femorotibial angle in three patients exceeded 175 degrees. The mean correction angle was 10.6 degrees. We recommend open wedge osteotomy for patients with a femorotibial angle of less than 185 degrees.

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Cyclops lesions are nodular structures that form anteriorly along anterior cruciate ligament (ACL) grafts after ACL reconstruction. The purpose of this study was to investigate the occurrence rate and pathogenesis of cyclops lesions after reconstruction of the ACL. We evaluated 40 patients by follow-up arthroscopy after anatomical bi-socket ACL reconstruction with hamstring tendons. Ten patients (25%) showed cyclops lesions, and 4 of these (10%) had extension loss.
We investigated the pathogenesis of cyclops lesion based on the impingement theory. All patients underwent measurement of intercondylar notch dimensions and graft size by MRI. We found that a narrower notch and larger graft size were associated with the formation of cyclops lesion.

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As the medial patellofemoral ligament (MPFL) has recently been shown to provide the primary restraint in lateral patellar translation, MPFL reconstruction has become a common procedure. The purpose of this study was to compare the short- and mid-term results of MPFL reconstruction using the gracilis tendon in comparison with the semitendinosus tendon.
We reviewed 29 patients (11 men and 18 women) who underwent MPFL reconstruction with hamstring tendons in our hospital. The mean patient age was 22.9 (range 13 to 40) years and the average follow-up period was 3.48 years (range, 6 months to 8 years 7 months). Among them, 21 patients underwent MPFL reconstruction using the gracilis tendon as a graft (group G), and 8 patients did so using the semi-tendinosus tendon (group ST). Clinical and radiological evaluations were performed in both groups.
The mean Kujala score improved from 55.9 points preoperatively to 96.2 points postoperatively in group G, and from 58.4 points to 96.7 points, in group ST, respectively. Postoperatively, patella apprehension signs became negative in all cases, and no patella dislocations occurred in either group. Furthermore, patellofemoral alignment was improved after surgery in all cases.
Although there were no significant inter-group differences in the average values of any clinical or radiological parameters, the ratio of patients who found it impossible to sit in the Japanese style with the legs folded at 180° was significantly higher in group ST than in group G. This suggests that caution may be necessary for ROM recovery in patients who undergo MPFL reconstruction using the semitendinosus tendon rather than the gracilis tendon.

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Appropriate coronal alignment of the lower extremity is essential for the long-term success of total knee arthroplasty (TKA). Previously, we documented that the palpable dorsal pedal artery (DPA) is a reliable anatomical landmark of the ankle center, which is important for positioning of the extramedullary tibial guide. In this clinical study, we investigated the advantages and pitfalls of the DPA palpation technique in TKA, and the accuracy of tibial component positioning in the coronal plane. Fifty knees were evaluated using the DPA palpation technique (S group), in comparison with historical controls without DPA palpation (C group). Prior to skin incision, the DPA was carefully palpated and marked at the tibiotalar joint level (S point). During surgery, the extramedullary tibial guide was placed with the same rotation to the proximal tibia, and the distal end of the guide was set at the S point. There was no difference in the patients' background characteristics between the C and S groups. Postoperative anteroposterior X-ray examination showed that the accuracy of tibial component positioning within 2 degrees was 92% in the S group and 72% in the C group (p=0.02). It is concluded that the DPA palpation technique is simple and useful for preventing malpositioning of the tibial component.

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In recent years, the importance of the medial patellofemoral ligament (MPFL) for patellofemoral joint (P-F joint) stability has become widely recognized. We describe the effect of plication of the MPFL in total knee arthroplasty (TKA) for osteoarthritis, in terms of radiographic features. We classified treated patients into three groups according to the surgical procedure employed : Group 1 - MPFL plication only ; Group 2 - MPFL plication with added lateral release if necessary ; Group 3 - only lateral release if necessary. Congruity of the P-F joint was better in Groups 1 and 2 than in Group 3. In Group 1 there was more osteosclerotic change on the lateral facet of the patella than in Group 2 or 3.
In TKA, added plication of the MPFL improved the congruity of the P-F joint, and osteosclerotic change on the lateral facet of the patella was decreased by addition of lateral release if necessary. Better long-term results of TKA can be expected with the addition of MPFL plication, and lateral release if necessary.

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