Insufficiency fracture of the proximal tibia after total knee arthroplasty (TKA) is a rare complication. We report the case of a 65-year-old woman who sustained insufficiency fractures of both proximal tibia without trauma more than 10 years after TKA. The patient was unable to walk for three years because of bilateral severe knee pain due to rheumatoid arthritis. At our hospital, she underwent total arthroplasty of the right knee in 1991, and underwent total left knee arthroplasty in 1992. After TKA, her knee pain was relieved and she could walk with a crutch. In 2001, she felt pain in the right proximal tibia during gait without trauma, and visited our hospital three weeks later. Roentgenography showed a fracture line at the proximal tibia and fibula. In 2003, the patient sustained an insufficiency fracture of the left proximal tibia without trauma. Both tibial fractures were healed conservatively. The cause of these fractures may include generalized osteoporosis and malalignment of the tibial components. When a patient who has undergone TKA and has generalized osteoporosis complains of pain in the surrounding leg, the possibility of tibial insufficiency fracture should be considered, not only in the early post-operative phase (during which activity is increased due to rehabilitation) but also in the late post-operative phase, even in cases with no history of trauma.

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Since the digestive tract traverses the respiratory passage at the pharynx level, defects in pharyngeal swallowing are some of the most difficult and distressing disorders to deal with. It is common to see patients with swallowing disorders suffering not only from malnutrition but also from pneumonia due to aspiration. Several surgical procedures have been employed to treat patients with swallowing disorders. These surgical procedures are classified into two groups based upon their main purpose. One group of operations aims to improve the impaired bolus transit, and the other to prevent aspiration. These surgical procedures are reviewed.

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Preface…Fumio ETO 187

Symposium Introduction…Andrew M COLE 188

What is Rehabilitation Medicine? A British View…Christopher D WARD 189

Training System for Specialist Rehabilitation Physicians in China…WANG Maobin 194

Rehabilitation Medicine Training in Australasia…Andrew M COLE 196

Postgraduate Training and Certification of Physiatrists (Rehabilitation Physicians) in Japan…Shin-Ichi IZUMI 199

Residency Training in Rehabilitation Medicine at the University of Washington : Developments over the last 40years…Lawrence R ROBINSON 205

Summary Discussion…Andrew M COLE, Moderator 210

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