We present the outcome of 136 Charnley total hip arthroplasty using first- to third- generation cementing. First-generation refers to the conventional Charnley method. Second-generation uses multiple small anchor holes, doublecementing on the acetabular side, and an intramedullary plug. Retrograde filling using a cement gun on the femoral side. In third-generation, a pressurizer is also used. We reviewed the long-term outcome in 102 arthroplasties using first and second generation and middle-term outcome of 34 arthroplasties using third generation. At 27 years after surgery, survival was 61% with loosening of the acetabular component as an end point, and 92% with that of the femoral stem using first and second generation. At 20 years, survival was 83% and 97% using second generation. Radiolucency scores using our evaluation at 5 years suggest that long-tem effects of third generation can prospectively surpass those of second generation.

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Objective: We report clinical results and the X-ray findings in cementless total hip arthroplasty (THA) with a proximally porous-coated femoral stem for rheumatoid arthritis (RA) .
Methods: Between 1997 and 2006, 32 primary cementless THAs were conducted for RA in 27 patients. Of these, 21 (26 hips) were enrolled in this study a minimum of 9 months follow-up after surgery (mean, 41 months; range, 9-84 months) . Subjects were 1 man (1 hip) and 20 women (25 hips), with a mean age at surgery of 60 years (range, 46-78 years) . Clinical evaluation was made preoperatively and postoperatively using the JOA score. Postoperative radiographs were evaluated for loosening, sinking, pedestal, radiolucent line, stress shielding, canal-filling ratio, cortical hypertrophy and spot welds.
Results: JOA score improved from 30 to 71 points. The circumscribed radiolucent line was observed in 2 cups and 11 stems, but loosening was not observed in either. All components were thus stable and had bone ingrowth.
Conclusion: Cementless total hip arthroplasty with a proximally porous-coated femoral stem in patients with RA appears to be promising.

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In total joint arthroplasty, debris from the wear of ultra-high molecular weight polyethylene is widely recognized as a major cause of osteolysis. Clinical interest has been renewed in the use of metal-on-metal bearings. Metal surface coatings, however, are subject to delamination in local contact, i.e., the head-and-insert rim and area of polar contact in total hip arthroplasty. In local contact, contact stress is very high and the articulation surface is easily damaged. Studies have been conducted on reducing metal wear debris and corrosion by introducing surface treatment.
We applied carbon ion implantation (CII) and diamond-like carbon (DLC) films to a cobalt-chrome alloy substrate using plasma source ion implantation. Once films were prepared, we put them through simple geometry wear tests under high contact pressure -an average load of 1030 MPa- to establish tribological properties. CII-coated bearings showed less wear, lower friction coefficients, and higher resistance to catastrophic damage compared to uncoated Co-Cr alloy and DLC couples, even under high contact pressure. The CII-coated surface thus offers potential advantages as a hard coating for articulating joints.

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Objective: Cup angles in total hip arthroplasty (THA) vary between standing and supine and with chronological changes in pelvic inclination. We studied these chronological changes in pelvic inclination and cup angles standing and supine after THA.
Methods: Subjects were 37 hips of 36 patients (mean age : 64 years) . Pelvic inclination angle (PTA) (Kitajima et al.) and cup angle (Lewinnek et al.) were measured in radiographs of the pelvis standing and supine and chronological changes in these parameters clarified. We also studied the correlation between PTAs and cup angles.
Results: PTA decreased with time after THA, and averaged 4.5 degrees greater supine than standing. Due to retroversion of the pelvis after THA, the cup anteversion angle tended to increase 1.6 degrees in standing position one year after THA. A significant correlation was seen between PTA before THA and postoperative change in cup angles (p<0.05) .
Conclusions: Pelvic position varies between standing and supine. Cup angles tend to be anteverted after THA because the pelvis tends to tilt with time, particularly in standing. Patients with a large PTA before THA tend to have a large postoperative change in cup angle. Special attention thus is required when positioning the acetabular component in patients with anterior pelvic tilt.

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Objective : We assessed the results of bipolar hemiarthroplasty for displaced femoral neck fractures in the normal hips of rheumatoid patients.
Methods : Bipolar hemiarthroplasty was conducted on 10 displaced femoral neck fractures in the normal hips of 9 rhematoid patients averaging 68.2 years old. Women numbered 8 and men 1. Average follow-up was 2 years 5 months ranging from 10 months to 5 years 1 month. Clinical results were assessed by Japanese Orthopaedics Association scoring, especially for pain. Plain x-rays of hips at follow-up examination were compared to x-rays taken immediately after surgery.
Results : Central migration was observed in only one case at the final examination, but no complaints about the hip joint were found.
Conclusion : Our results suggest that bipolar hemiarthroplasty for displaced femoral neck fractures in the normal hips of rheumatoid patients may prove to be the procedure of choice, but careful evaluation is necessary for indications of THA especially for patients with longer life expectancy.

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Objective : We radiologically studied the validity of bone cutting and postoperative soft tissue conditions in excessive external rotation of the femoral component modulated by the balanced gap technique in total knee arthroplasty.
Methods : The study was conducted on 34 cases in which the femoral component was externally rotated 1 degree over the clinical epicondylar axis, defined as the excessive external rotation group (E group), and 67 cases in which components were internally rotated between 1°and 5°from the clinical epicondylar axis, defined as the control group (C group) . Varus and valgus instability and the α βγδangles of the Knee Society roentgenographic evaluation for the validity of operation, preoperative condylar twist angle, external rotation degree of the femoral component, symmetry of the flexion gap on the trans-epicondylar view, patella tilting on the skyline view, and postoperative flexion of the knee were investigated.
Results : The preoperative condylar twist angle was significantly smaller in the E group (5.3±1.8°) than in the C group (7.8±2.3°) . The external rotation angle of the femoral component was significantly larger in the group (7.7±1.9°) than in the C group (5.4±2.4°) . No significant differences were seen between the two groups in patella tilting or postoperative flexion angle. The flexion gap in E group was significantly closer to rectangular than in the C group.
Conclusion : Our results suggest that a small CTA may lead to excessive external rotation of the femoral component by the balanced gap technique. Such cases demonstrate satisfactory soft tissue balance, ROM, and patella tracking without complications.

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We compared the difference in invasion between MIS-TKA and conventional TKA using blood tests (muscle enzymes and CRP) . Subjects numbered 45. We conducted MIS-TKA (group M) with a mini-mid vastus approach on 23 knees and conventional TKA (group C) with a mid vastus approach on 22 knees. We measured CK, LDH, AST and CRP on pre- and post operation days 1, 2, 5, 7, and 14, and calculated the rising index (RI) . CKRI peaked on day 1 after surgery in both groups. LDHRI and ASTRI f luctured little during this period. No significant differences were seen between groups. Invasion by the analysis of muscle enzymes and CRP showed no significant difference between groups.

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Objective : We evaluated short-term results of unicompartmental knee arthroplasty (UKA) in patients with osteoarthritis of the knee (OA) .
Methods : Of 32 patients (33 affected knees) who had undergoning UKA 6 months or more before, 25 (26 affected knees) - 3 men with 3 affected knees and 22 women with 23 affected knees - were studied. Their mean age was 78.7 (4.6 years (range: 69-90 years) . Mean follow-up was 13.2 months (range: 6-24 months) . Preoperative classification was based on Koshino's X-ray classification. Clinical evaluation used scoring for osteoarthritis of the knee prepared by the Japanese Orthopaedic Association (JOA score) . Changes in femorotibial angle (FTA) after surgery from its preoperative level, the necessity of postoperative blood transfusion, and the presence of postoperative complications were also evaluated.
Results : Disease was often rated as grade 2 or 3 based on Koshino's classification. Four patients (4 knees) rated as grade 4 had some accompanying disease, and total keen arthroplasty (TKA) was avoided for reason of disease. Average JOA score improved significantly from 54.3 (5.8 before surgery to 87.2 (5.3 after surgery (P=0.0002) . FTA also improved significantly (183.2 (4.8 degrees before surgery and 176.7 (3.3 degrees after surgery, P=0.0018) . Mean postoperative blood loss was 150.8 (77.5 mg, and no patient required a blood transfusion after surgery. Postoperative complication -medial tibial plateau fracture- developed in one patient (one knee), requiring replacement by TKA.
Conclusion : Short-term outcome after UKA was favorable on the whole. Even for cases where TKA is not possible for reasons such as accompanying disease, UKA may be a valid alternative, if its indication is assessed carefully. Adequate preoperative assessment of individual cases is essential in replacement by TKA to deal with post-UKA tibial plateau fracture.

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We studied 23 periprosthetic fractures after total knee arthroplasty (TKA) treated between January 2002 and April 2007. Seven TKAs were done for osteoarthritis patients, 15 for rheumatoid arthritis patients, and one for a Bechet patient. Women numbered 20 and men 3. Their average age at TKA was 69 years, ranging from 50 to 85. The average duration between TKA and fracture was 98 months, ranging from 3 to 276. Nine fractures were treated conservatively and 14 surgically. Of 23 fractures, 20 were femoral supracondylar. Internal fixation was done using instruments such as condylar plates, retrograde intramedullary nails, Ender's nails, and cancellous screws. Of 20 femoral supracondylar fractures, 19 did not show loosening on rentgenogram and were easily treated conser-vatively or surgically.

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Objective : We first analyzed the ulnar proximal stump behavior after the Sauvé-Kapandji procedure in rheumatoid wrists added to stabilization using flexor carpi radialis and extensor carpi ulnaris. We then studied whether the forearm axis of rotaion corresponded to a line connecting the center of the radial head to the proximal ulnar stump.
Methods : The procedure was done for distal radio-ulnar joint disorders of the wrist caused by rheumatoid arthritis. We retrospectively studied 19 hands. Mean patients age at surgery was 62.8 years. We evaluated the history of rheumatoid arthritis, pain relief, swelling, grip strength, radioulnar distance, complications, and the radio-ulnar distance at the stump using computed tomography during pronation, supination, and neutral positions of the forearm in 15 of the 19 hands operated on.
Results : No patients showed any sign of pain at the proximal ulnar stump or any scallop sign. Grip strength increased significantly, as did wrist pronation, supination, and extension. Wrist flexion was not significant. The rate of complications was low. Radiographically, the radio-ulnar distance of the neutral wrist decreased from 13.5±3.0 mm in pre-operatively to 10.7±2.0 mm at the final check. No significant difference was seen in wrist supination, pronation or neutral position. In all cases, the line connecting the center of the radial head to the proximal ulnar stump served as the forearm axis of rotation as comf ormed by computed tomography.
Conclusion : Our procedure added to the Sauvé-Kapandji procedure for the wrist in the rheumatoid arthritis effectively stabilized ulnar proximal stumps.

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Purpose: We replaced the first metatarsophalangeal (MTP) joint with a Swanson hinge toe implant and conducted resection arthroplasty of the other toes for forefoot deformity in rheumatoid arthritis (RA) . We assessed the effect of the first metatarsal bone excision volume.
Patients and Methods: Subjects were 19 RA women who underwent implant arthroplasty of the great toe with resection arthroplasty of the other toes for forefoot deformities. They were divided into two groups by first metatarsal bone excision volume. Group A consisted of 11 patients and 18 feet with the bone removed only the width that an implant could be entered. Group B consisted of 8 patients and 11 feet with the bone removed the same volume as for the other toes. Radiological assessment and complications were studied retrospectively and statistically analyzed between groups.
Results: The mean hallux valgus angle (HVA) in group A, decreased significantly from 44.8° to 28.8° and in group B from 43.5° preoperatively to 15.1° postoperatively, and to 32.7° in group A and 16.0° in group B at the last follow-up (p<0.01) . Significant differences were seen between groups postoperatively and in follow-up (p<0.01) . The angle between the first and the second metatarsal bones and that between the first and fifth were not significant. Conclusion: Our results suggest that increased bone excision of the first metatarsal bone in implant arthroplasty of the great toe may correct and maintain HVA of RA forefoot deformity.

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Objective : We studied postoperative results and limitations of posterior decompression and fixation for rheumatoid arthritis (RA) superior cervical vertebral lesions.
Subjects and Methods : Subjects were 18 patients with RA - 2 men and 16 women- with a mean age of 60.7 years at surgery. Mean postoperative follow-up was 5 years and 10 months. The disease type was evaluated as arthritis mutilans (MUD) in 12 patients and multi-articular destructive type (MES) in 6. In fixation, occipital bone to superior cervical vertebral fixation was done in 14 and C1-C2 fixation in 4.
Results : According to Renawat's pain grade scaling, improvement was achieved in 5 of 6 in the MES group and in 9 of 12 in the MUD group. The neural deficit class improved in 4 of 6 in the MES group and in 2 of 12 in the MUD group. In 8 of 11 without subaxial subluxation (SAS) before surgery, SAS occurred after surgery. Few patients experienced exacerbated symptoms.
Conclusion : In the MES group, postoperative results were good. In the MUD group, improvement of neural deficit was poor. After surgery, SAS was frequent, 50 techniques must be selected carefully.

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Objective : Patient-controlled analgesia (PCA) is a self-adjustment analgesic system in which patients push a button to infuse analgesic drugs when they feel pain. We use intravenous injection PCA for postoperative pain control after spine surgery. We evaluated the efficacy in PCA for spine surgery in rheumatoid arthritis (RA) patients. We also studied the detection threshold of pain in RA patients.
Methods : We retrospectively studied 16 consecutive RA patients -7 men and 9 women- averaging 65.1 years old who underwent spinal surgery with intravenous injection PCA from September 2005 to May 2007. We also studied 20 consecutive spondylosis patients -12 men and 8 women - averaging 65.1 years old that we did spinal operations on with PCA in the same period as the RA group. We packed 20 mg morphine hydrochloride and 2 mg droleptan in the infusion pump diluted with saline to make 80 ml. We observed the visual analog scale (VAS) at rest and moving, the frequency of bolus use, and side effects.
Result : The average duration of PCA was 35.3 hours in RA group, which used an average of 5.2 bolus infusions 0-12 times. Bolus use decreased more than 24 hours after surgery. In the spondylosis group, average bolus infusion was 7.7 2-15 times, much more than in the RA group (p<0.05) . One case of the spondylosis group showed respiratory failure (less than 8 times breathing per minute), forcing us to stop PCA. Questionnaires showed that the degree of satisfaction of PCA patients was very high.
Discussion : Intravenous injection PCA for postoperative pain control after spine surgery was effective and safe in RA patients. The results of bolus use indicated the possibility of the change of pain detection threshold in RA patients.
Conclusion : Intravenous injection PCA was effective for postoperative pain control after spine surgery in RA patients.

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