Background and Purpose : Operative indications in orthopedic practice often differ from surgeon to surgeon. This incongruity and ambiguity of treatment proposals has been left poorly solved up to the present time. An ‘Operative Indication Score’ was invented for the purpose of helping to clarify the decision-making process and explanation of surgical indication, and was applied to patients undergo-ing or considering elective spinal surgery.
Methods : The sum of values given to 8 attributes including severity, tendency, effectiveness, risk, urgency, mental status, ability of the surgical team and negative relationships was designed to indicate relative degree of necessity for operative treatment. Three hundred patients undergoing elective spinal surgery and 124 new outpatients consulting for operative treatment were analyzed.
Results : The total score distribution demonstrated that there was a diversity of strength of operative indications. Patients undergoing a cervical operation tended to have higher total scores (stronger indications) in comparison to those undergoing a lumbar operation. The mental subset had significant relationships with the short-term clinical outcome.
Conclusion : The proposed scoring system is a unique psychological support tool designed to help not only surgeons to make and propose clinical decisions in a transparent manner, but also patients and colleagues to share the decision making. Although multi-centric, statistical analyses will be needed for wider clinical use, the authors' early experience suggested promising practical usefulness.

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Introduction: Objective assessment of disease severity of osteoarthritis of the knee joint (OA knee) is fundamental to establish adequate treatment system. Regrettably, there is no such a reliable system. Grading system based upon X-ray findings or measurement of joint space narrowing is widely used method for this purpose but they are still far from satisfaction. Our previous study elucidated that measuring irregularity of the contour of the femoral condyle on MRI (irregularity index) using newly developed software enabled us to assess disease severity of OA objectively. Advantages of this system are expressing severity by metric variable and semi-automatic character. In the present study, we examined relationship between treatment selection and irregularity index.
Material and Methods: Sixty-one medial type OA knees that received total knee arthropaslty (TKA), arthroscopic surgery (AS), and conservative treatment (CT) were involved. Their x-ray grading, irregularity index were recorded at the time of corresponding treatment. Irregularity index of each group were compared. As for AS group, pre- and post-operative knee score employing JOA score were also examined to study relationship between irregularity index and improvement of knee score.
Results: 1) All the four parameters that represent irregularity of femoral condyle were significantly higher in TKA group than in AS group, whereas no significant difference was observed between AS group and CT group.2) Negative correlation was observed between irregularity index and improvement of knee score after arthroscopic surgery.
Discussion: Although treatment selection was determined by skillful knee surgeon in this series, irregularity index could indicate adequate timing of TKA. It also served as an indicator to predict outcome of arthroscopic surgery, and could be used as to show limitation of arthroscopic surgery.
Conclusion: Our new system to assess disease severity of OA knee can serve as an index to determine treatment options.

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Purpose: The purpose of this study is to verify the hypothesis that there is the laterality of indication in total knee arthroplasty (TKA) .
Materials: Fully documented 966 arthroplasties were extracted from the TKA database, in which diagnosis except OA and RA, history of trauma and /or previous operation were excluded. Bilateral simultaneous TKA and TKA performed on the opposite side after the first TKA were also excluded, thus remaining 625 cases, of which 464 OA and 161 RA, and 102 males and 523 females.
Results: In OA and RA, there was no laterality at male while left side knee was operated more on female. Also strong significance at female makes whole group into left side laterality.
Discussion: The reason of left side laterality remains unknown but functional difference of the limb is suspected. In Japan, majority of the population are right-footed. When right-footed, left limb is always bearing weight. Excessive weight bearing on left side continues for life. Weaker muscle strength in female affects more load to joint than that in male, thus causing more deterioration to female's left side cartilage.

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Objective: To evaluate the usefulness of D-dimer value for the early diagnosis of venous thromboembolism (VTE) after total knee arthroplasty (TKA)
Materials and Methods: TKA was performed in fifty-two patients with osteoarthritis. The patients were 16 males (17 joints) and 36 females (38 joints) with a mean age of 72 years (range 63-86 years) at the time of surgery. We performed pulmonary perfusion scintigraphy to diagnose pulmonary thromboembolism (PTE) on the day of surgery, pre-and post operation. The 1^st 4^th and 7^th day after operation, the D-dimer values were examined in the peripheral blood. The ultrasonography and venography on the lower extremities were also performed on the 4^th day to diagnose for deep vein thrombosis (DVT) . First, we divided the patients into two groups: 1) DVT negative patients as normal group, 2) DVT positive patients as DVT group, and compared the D-dimer values between the two groups. Following that, the patients of DVT positive were divided into two groups. 1) PTE positive or DVT which was existed above knee joint (severe thromboemborism group) . 2) DVT below knee joints (mild thromboemborism group) .
Results: The D-dimer values of normal group was 15.1±1.8μg/ml on the 1^st day, 8.9±0.7μg /ml on the 4^th day and 11.9±0.7 μg/ml on the 7^th day. The values of DVT group were 18.8±2.2 μg/ml on the 1st day, 13.4±1.7μg/ml on the 4^th day and 19.2±2.0μg/ml on the 7^th day. The values of 4^th and 7^th day were significantly difference between the two groups. The D-dimer values of mild thromboemborism group was 15.8±1.7μg/ml on the 1^st day, 9.45±1.3μg/ml on the 4^th day and 17.5±1.3μg/ml on the 7^th day. There were eight patients in severe and twenty-four in mild thromboemborism groups. The results of severe thromboemborism group were 27.7±6.8μg/ml on the 1^st day, 25.3±3.4μg/ml on the 4^th day and 24.9±6.2μg/ml on the 7^th day. There was statistically significant difference between severe thromboemborism group and other two groups on the 1^st, 4^th and 7^th day. The D-dimer value kept the high levels in the severe thromboemborism group until 7th day.
Conclusion: The D-dimer values were higher than normal limit on the 1^st day, became lower on the 4^th day and became higher again on the 7^th day in the normal and mild groups. In the severe group, however, the values was higher on the 1^st day compared to the normal and mild groups and it did not show the decreasing change until 7^th day. Therefore, the comparison of the D-dimer values on the 1^st and 4^th day was thought to be useful for early diagnosis of high risk VTE cases which have PTE or severe DVT.

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Objective : When the conservative treatment failed after at least for 3 months, we make surgical intervention on the osteochondritis dissecans in the knee joints. We examined the operative outcome of operative treatment.
Materials and Methods : 25 patients (26 knee joints) were 21 men 4 women, 13 right knees and 13 left ones. The mean operative age was 16.4 years-old (range 10 to 27 years-old), and the mean follow-up periods was 21.0 months (range 7 to 115 months) . We used ICRS classification for the assessment of the area of the lesion, the starting time of running, recovery time of sports, recovery level of sports and knee pain at follow-up.
Results : In arthroscopic drilling, there were 5 patients. The mean operative age was 13.0 years. All cases were stage I on ICRS classification. The area of lesion was 190 mm², and in turn 2.1 months, 4.7 months, 98% and no knee pain. In fixation with absorbable pins, there were 3 patients. The mean operative age was 17.7 years. All cases were stage II on ICRS. The area of lesion was 367mm², and in turn 3.0 months, 6.3 months, 90%, and only 1 patient complained occasionally slightly knee pain. In biological fixation with osteochondral plugs, there were 3 patients. The mean operative age was 14.7 years. At ICRS, 1 in stage II and 2 in stage III. The area of lesion was 417mm², and in turn 3.0 months, 4.7 months, 86.7% and no knee pain. In osteochondral grafts, there were 14 patients. The mean operative age was 18.8 years. 6 patients were in stage III and 8 patients were in stage IV on ICRS. The area of lesion was 244.7mm², and in turn 4.6 months, 6.3 months, 97.5% and only 1 patient complained occasionally of slightly knee pain.
Conclusion : The operative treatments we chose had good clinical outcome including sports performance.

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Objective: Retrograde intramedullary nails are widely used for the internal fixation of femoral supracondylar and diaphyseal fractures, and stable outcomes are obtained. In this study, we investigated the clinical results and complications of retrograde intramedullary nails.
Methods: The subjects comprised 26 patients with femoral diaphyseal and supracondylar fractures (11 males and 15 females) treated with retrograde intramedullary nailing between January 1999 and October 2004. The age at the time of injury was 27-97 years (mean: 69.2 years) . The duration of follow-up was 8 months-4 years and 1 month (mean: 1 year and 1 month) . The fracture type was diaphyseal fracture in 6 and supracondylar fracture in 20 patients. And focusing on PF arthralgia, the patients were divided into P and N groups with and without postoperative PF arthralgia, respectively, and the age, ROM, shortening on Xp at the final examination, femoral angle, and Lindahl's angle were compared between two groups.
Results: The mean bone union period was 16.2 weeks. On Xp evaluation, the femoral angle (FA) and Lindahl's angle (LinA) were measured in the frontal and lateral views, respectively. The mean FA was 80.6°, and LinA was 31.3°. Clinical evaluation was performed following Neer's evaluation, and was excellent in 10, satisfactory in 11, unsatisfactory in 4, and indicated failure in 1. Symptoms around the knee joint remained after bone union in 9, and 4 patients reported PF arthralgia, which was the most frequent. In the group with PF arthralgia (P group), the mean age was significantly lower (42.8±21.6 years), and the mean range of motion in flexion was significantly wider (114.1±13.3°) .
Discussion: The postoperative outcome of retrograde intramedullary nailing for femoral diaphyseal and supracondylar fractures were investigated in patients of our department. Fixation was satisfactory, but an influence on the joint cartilage was unavoidable due to the surgical procedure. Application for young patients should be carefully decided upon.

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Original text for job: Arthroscopic versus open rotator cuff repair. A comparison of early clinical outcome.
Objective: To compare surgical invasiveness and early clinical outcome of arthroscopic and open rotator cuff repair.
Methods: Twenty-two patients who had undergone arthroscopic rotator cuff repair and twenty patients who had open repair were evaluated retrospectively. Both groups were comparable in age, gender, duration of symptoms, and size of rotator cuff tear. Comparisons included surgical time, duration of immobilization, duration of hospitalization as well as preoperative and postoperative Japanese Orthopaedic Association (JOA) score. Range of motion in active forward flexion was also compared at 3, 6, and 12 months postoperatively.
Results: The mean surgical time was significantly longer in the arthroscopic group compared to the open group. On the contrary, duration of immobilization and hospitalization was shorter in the arthroscopic group. Mean preoperative JOA was 72.1 in the arthroscopic repair group and 72.5 in the open group. JOA score improved to 95.2 in the arthroscopic group and 92.6 in the open group at 12 months after surgery. JOA score had improved postoperatively in both groups but no significant difference was noted between the groups. The arthroscopic group showed a slightly more rapid recovery in active flexion, however, there were no significant differences in functional outcome.
Conclusion: Functional recovery tends to be rapid in arthroscopic repair. No significant differences in the JOA score were noted at 12 months postoperatively. Although arthroscopic repairs in this study included the beginning of the learning curve, clinical outcome was comparable to that of open repairs. Our results are encouraging for continuing to perform arthroscopic cuff repair.

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Objective: It is well known that rheumatoid patients often suffered severe joint destruction of forefoot. We reported middle-term result of forefoot arthroplasty in rheumatoid patients, who were able to stand and walk soon after surgery with non-weight bearing orthosis of forefoot to prevent disuse atrophy.
Methods : Eighteen feet of 12 patients were operated. Eleven patients were suffered from rheumatoid arthritis (RA), and one was due to systemic lupus erythematosus. Eleven were women and one was man. Mean age at surgery was 68 years (49-79) . Mean duration of affected disease was 195 months (48-360), and follow-up period was 18 months (12-79) . Modified Mitchell method was applied for 6 toes, modified Mann method for 9 toes, resection arthroplasty of metatarsophalangeal (MTP) joint for two and arthrodesis of MTP joint for one, respectively. For lesser toes, metatarsal bone offset osteotomy with preservation MTP joint was applied for 4 feet, and resection arthroplasty of MTP joint for 14 feet. We surveyed radiographic measurements during follow-up.
Results : The patients were able to walk one or two days after surgery with non-weight bearing orthosis of forefoot. After 3 weeks, the patients were allowed to walk by full weight bearing with arch support. No patients showed disuse muscle and bone atrophy. Japanese society for surgery of the foot RA foot ankle scale was improved from 43.3 (21-68) to 65.3 (42-91) in average. Mean hallux valgus angle was improved from 38.8 (21-54) degree to 20.4 (12-48) degree, M1M2 angle to 9.2 (3-16) from 14.2 (10-20), and M1M5 to 25.5 (18-33) from 31.0 (20-37), respectively. However, the correction of hallux valgus angle decreased at latest follow-up compared to that at post-surgery. Recurrence of deformity was formed in four cases of modified Mitchell method, two of modified Mann method, and one of arthrodesis at latest follow-up, though they have few complains clinically.
Conclusion : The forefoot arthroplasty in RA patients with non-weight bearing orthosis of forefoot was useful to prevent disuse atrophy, because they were able to stand and walk soon after surgery. It is necessary to improve this method to prevent recurrence of deformity even though the patients do not seem to have significant clinical problems.

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Background : We investigated the clinical and radiological results of Swanson Flexible Hinge Toe for rheumatoid forefoot deformities. The purposes of the present study were to assess the results of Swanson Flexible Hinge Toe implant arthroplasty for rheumatoid great toe deformity concomitant with resection arthroplasty for lateral toes deformities.
Methods : There were 17 feet in 10 rheumatoid arthritis women and the average age at the time of surgery was 68 years. Patients were followed for an average of 9.1 months. A Swanson Flexible Hinge Toe implant was placed in the first metatarsophalangeal joint in all feet.
Results : The average hallux valgus (HV) angle was corrected from 36.8° to 23.4° (p<0.01) . The averaged visual analogue scale (VAS) score for forefoot pain was improved from 7.0 to 1.4 (p<0.01) . The VAS and satisfaction scores were improved after this surgery. Patients whose satisfaction score was grade 5 showed significantly smaller postoperative HV angles than those with satisfaction scores of grade 4 and under (p<0.05) . Patients with postoperative HV angles under 25° showed higher satisfaction scores than those with 25°or more (p<0.01) . The surgical corrective HV angle was about 16°. Patients with a postoperative HV angle of under 25°were significantly more satisfied with the surgery.
Conclusion : Patients with postoperative HV angles under 25° were satisfied with Swanson Flexible Hinge Toe implant arthroplasty.

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Treatment of anti-tumor necrosis factor-alpha (TNF-α) antibody has been administered to patients with Rheumatoid Arthritis (RA) . Anti-TNF α therapy is effective for most of RA patients, however, joint symptoms last with some cases. In these years, some reports have mentioned that synovectomy is one of the effective methods for such cases. We report that synovectomy was useful for the patient having polyarthralgia despite infliximab treatment, and inflammatory cell infiltration decreased in the synovial tissue compared with the past specimens.
The patient was 50 years old woman who was diagnosed as RA in 1986. She was treated by prednisolone and methotrexate (MTX), and attained remission once. In 2001, however, she was diagnosed as RA due to reappearance of polyarthritis again. She began to take prednisolone at 10mg in a day because she hoped pregnancy. For her symptoms became worse, we performed synovectomy in 2002. After the delivery, she began to take MTX at 8 mg in a week in 2005, and then infliximab therapy was administered to her in 2006. Her CRP (C-reactive protein) level had decreased by this therapy, but joint swelling and tenderness still lasted. Therefore, we performed synovectomy for some joints which had been severely swollen. In the pathological findings of this excised synovial tissue, it was observed that synovia increase and inflammatory cells infiltrate. However, compared with the specimens of synovial tissue excised four years ago, the degree of the cell infiltration decreased. After that synovectomy, her symptoms and DAS28-CRP score improved. Thus, it is supposed that decrease of cell infiltration into synovial tissue is an evidence of inf liximab treatment being effective, and to raise an efficacy of that therapy, synovectomy is one of the useful methods.

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This is the report about the surgical treatment for patient operated 5 month after injury with the neglected dislocation fracture of the hip joint. The patient is 39-year male. After being carried to another hospital by an ambulance because of the motorbike accident, he had a operative treatment for the fracture of the right lower leg and open fracture of the left ankle joint.
After dischage the hospital, he was permitted to bear partial weight on crutches. He had x-ray check the hip joint after 4 month operation, because he felt pain in right hip joint. Then the dislocation fracture of the right hip joint become clear and the patient was introduced to our hospital. The results of x-ray and CT, femoral head had dislocated posterosuperior severely with fracture of the femoral head (Pipkin type 1) and acetabular fracture. The femoral head had traumatic change and partial necrosis by MRI. The patient was preoperativeiy treated with femoral pin traction. As for the treatment, we performed open reduction used a plate, a screw and fixed the acetabular bone and performed build-up by a transplantation bone for large acetabular bone defect. At one year postoperatively, union has occurred and the expansion of the hemoral head necrosis was not found. Poperative two years, he works as a bus driver and doesn't have pain during walking. JOA score is 82 points and no joint transformation was found in X-ray diagnosis. It is often appointed in the surgical treatment for the neglected dislocation fracture of the hip joint that complications of high ratio of necrosis and cartilage disorder happen and arthrosis proceeds soon after the surgery. In this case, surgical treatment was selected because of patient's age, health condition and requests into consideration. among the selections such as articular head resection, arthrodesis and total hip arthroplasty. So far, the short term results are regarded good after surgery, but want to perform follow up carefully.

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We report on a woman with hypophosphatemic osteomalacia (39 years old) who was misdiagnosed as having Fibromyalgia syndrome (FMS) . Her chief complaint was sciatica at her first visit to our institute. She had no neurological abnormalities, and no abnormal findings were detected by MRI or roentgenograms. Medication was not able to improve her symptoms.
She had found out about FMS on the Internet, and believed herself that she was suffering from FMS. She visited another hospital by herself and was diagnosed as with FMS. She took some medicines, but her symptoms worsened. Two years later, she came to our hospital and complained that her height had become shorter by 5cm than it had been when she was younger. Her hematology was examined and showed hypophosphate and high ALP, indicating that she had osteomalacia. Her family history was unremarkable, and no tumor could be detected in her limbs by MRI. After vitamin D3 was taken, her back and leg pain decreased. A diagnosis of FMS should not be made without consideration of other metabolic diseases such as osteomalacia.

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