Objective and Methods: In order to detect the onset of osteoarthritis, super long-term follow-ups were performed on corrective osteotomies done since 1969 on young patients under 40 years of the age with bowlegs, knock knees and flexion rotational deformities around the knees. Among them 57 knees (29 left, 28 right) of 45 patients (19 male, 26 female) were followed-up for more than 10 years with an average of 18.8±5.8 years. The follow-up period ranged from 30 to 38 years in 7 patients with 7 knees, from 20 to 29 years in 9 patients with 11 knees and from 10 to 19 years in 29 patients with 39 knees. A supracondylar femoral osteotomy was performed on 12 knees of 11 patients, high tibial osteotomy above the tibial tuberosity on 10 knees of 8 patients and below the tuberosity on 49 knees of 38 patients.
Results and Conclusion: At the final follow-up the varus and valgus deformities were satisfactorily corrected in all cases to obtain straight limb alignment and correction of the rotational deformities. At the final follow-up the age of these patients ranged from 42 to 71 years and no osteoarthritis was noted except for 9 knees in which 7 knees had dull pain after strenuous sport with osteoarthritic abnormalities such as osteophytes and so on revealed by x-ray imaging. The remaining two knees, where the initial deformity was due in one case to pyogenic arthritis and in the other to Morquio syndrome, developed secondary painful osteoarthritis and total knee replacements were performed 27 years and 10 years, respectively, after the initial osteotomies. Two patients developed symptoms and radiographic osteoarthritic abnormalities in the knees contralateral to the initial osteotomy side at the final follow-up, at the age of 71 years, 35 years after the initial osteotomy in one and at 67 years of age, 33 years postoperatively in the other.

View full abstract

The prevalence of venous thromboembolism (VTE) after spinal surgery is 6.84/10000 operations according to a nationwide survey by the Japanese Anesthesia Association. Prevention of VTE after spinal surgery is basically mechanically achieved as follows: 1: active exercise of the legs; 2: early ambulation; 3: elastic stockings with graded compassion; and 4: intermittent pneumatic compression. However mechanical prevention is associated with some complications, such as skin trouble or compartment syndrome.
Enoxaparin or fondaparinux is usually used for prevention of VTE after joint replacement surgery. In spinal surgery, postoperative epidural hematoma is the common complication without the use of an anticoagulant. Postoperative administration of an anticoagulant is a good prevention method for VTE after surgery, but it may cause epidural hematoma after spinal surgery, so anticoagulant therapy for prevention of VTE can not be used in spinal surgery.
Epidural catheterization after surgery is a useful method for decreasing the postoperative pain, but there is the risk of epidural bleeding especially on removal of the catheter. Preventive anticoagulant therapy should therefore be started after removal of the epidural catheter.

View full abstract

We treated 63 rheumatioid arthritis patients with tocilizumab and clinically evaluated the efficacy. We analyzed c-reactive protain (CRP), MMP-3, total cholesterol, trigriceride and the disease activity score (DAS) 28 after using tocilizumab up to 14 weeks. Serum IL-6 and TNF-α levels were measured at 0, 4, 8, 12 weeks in 8 patients. We found that CRP and DAS28 at 2 weeks were not correlated significantly, but were significantly correlated at 4 weeks. Within 2 weeks after administering tocilizumab there was therefore dissociation between DAS28 and CRP, which however recovered at 4 weeks. DAS28 and MMP-3 were significantly well correlated at 4 weeks after tocilizumab administration. Higher MMP-3 levels demonstrated higher DAS28 values even when CRP was negative. IL-6 increased at 4 weeks but decreased thereafter. TNF-α decreased at 4 weeks which was maintained to 12 weeks after using tocilizumab. Therefore MMP-3 levels can demonstrate DAS28 values better than CRP during treatment of tocilizumab. Serum IL-6 concentration may be associated with DAS28 which is correlated with MMP-3.

View full abstract

Objective: With the proper safety procedures, we investigated the possibility of reducing the infusion time of infliximab (INFX) in patients with rheumatoid arthritis (RA) to 1 hour to decrease the burden of infusion on patients.
Methods: In patients with RA treated at least 5 times with 2-hour infusion of INFX without adverse infusion reactions, the infusion time was reduced to 90 min. Only in patients successfully treated with 90-min infusion of INFX without infusion reactions at least twice was the infusion time further reduced to 1 hour.
Results: Thirty patients (26 females & 4 males, mean age: 49.1±15.6 years, history of RA: 8.2±8.8 years) were treated with 2-hour INFX infusion. Five of the 30 showed various infusion reactions, whereas 25 of the 30 were treated successfully without infusion reactions 12.4±6.5 times. Twenty-two of the 25 patients were subsequently treated with 90-min infusion 3.4±2.5 times and only 1 patient showed a mild infusion reaction. Seventeen of the 21 were then treated with 1-hour infusion 6.1±4.1 times and only 1 patient showed a very mild infusion reaction. The infusion reaction occurring when the infusion time was reduced to 90 min was treated with the administration of antihistamine and acetaminophen, and the infusion of INFX was completed with a decreased 2-hour infusion rate. In the case of the patient who had an infusion reaction associated with the 1-hour infusion, the reaction was very mild and it was successfully treated immediately by simply slowing down the infusion rate to 2 hours.
Conclusion: The infusion time of INFX can be safely reduced by up to 1 hour without severe adverse effects in patients with RA who have been successfully treated at least 5 times with a 2-hour INFX infusion rate without infusion reactions.

View full abstract

Objective: We performed surveillance for surgical site infection (SSI) following orthopaedic surgery in our hospital.
Methods: Five hundred sixty three patients underwent orthopaedic surgery in 2007 in our hospital (232 males and 331 females). The mean age at the time of surgery was 61 years (14˜92 yrs). The Centers for Disease Control and Prevention (CDC) guidelines combined with our original infection control protocol were applied for all patients. The evaluation of SSI for each case was performed according to the Japanese Nosocomial Infections Surveillance (JNIS) guidelines.
Results: SSI was recognized in 11 cases (1.9%). Limb amputation was the most frequent surgery in SSI cases (5 cases). Six patients from the 11 SSI patients (55%) had MRSA or MRSE infection. No SSIs were seen in those patients who underwent primary TKA or THA for osteoarthritis.
Conclusions: As the causes fininor SSI, dialysis, patients whose serum albumin was under 3.5 mg/dl, and administration of corticosteroids were thought to be significant.

View full abstract

Objective: Severe osteoarthritis of the hip may cause abnormal spinopelvic alignment, commonly known as hip-spine syndrome. No prospective clinical reports have however appeared regarding the influence of total hip arthroplasty (THA) on the improvement of spinopelvic alignment. The purpose of this study was to examine chronological changes in pelvic orientation and spinal alignment after THA.
Methods: A total of 59 patients who underwent THA were included in this prospective study. The anterior pelvic plane (APP) (DiGioia, et al.), lumbo-sacral angle (LSA), lumbo-lordotic angle (LLA), and thoraco-kyphotic angle (TKA) were measured as parameters of spinopelvic alignment on standing radiographs before and 3, 6, and 12 months after THA. Chronological changes in those parameters after THA were investigated.
Results: APP and LSA decreased with time, indicating posterior pelvic tilt after THA. LLA and TKA showed no significant change after THA.
Conclusions: Posterior tilting of the pelvis was seen after THA.

View full abstract

Objective: As Idiopathic osteonecrosis of the femoral head (ION) frequently develops during adolescence/middle age, the joint should be preserved for treatment. Since 2004, in addition to the original curved varus osteotomy, we have intentionally performed anterior or posterior rotation without incising the articular capsule to obtain a more extensive, viable area in the loaded portion. In this study, we investigated the extent of the viable area loaded portion after original and modified curved varus osteotomies.
Methods: The subjects consisted of 34 patients (18 males, 16 females, 38 joints) who underwent curved varus osteotomy. From these patients, 12 patients (14 joints) underwent a modified curved varus osteotomy. The INO stage was 2 in 9 joints, 3A in 18 joints, 3B in 9 joints and 4 in 2 joints in terms of classification by the Japanese Organizing Committee of ION. The necrotic type was B in 11 joints and C-1 in 27 joints as per the Japanese Organizing Committee classification. The mean varus angle was 21°, the mean anterior rotational angle was 18° and the posterior rotational angle was 30°. The mean rate of the viable area for the loaded portion on anteroposterior radiographs before surgery was 33%. Investigations were performed on the varus angle of postoperative radiographs, the intraoperative anterior/posterior rotation angles, the percent viable area in the preoperative/postoperative weighted portion, and leg length discrepancy. Clinical results were evaluated according to the hip score of the Japanese Orthopaedic Association (JOA hip score). In addition, in patients for whom transtrochanteric curved varus osteotomy was combined with anterior/posterior rotation, we measured the extent of the viable area in the loaded portion when the extent of curved varus osteotomy without rotation was performed based on a schematic drawing that we prepared.
Results: The mean JOA hip score improved from 65 to 96.5 points at final follow up. In the schematic drawing, the rate when curved varus osteotomy without rotations was performed was calculated as 65%. The rate was 84% when this procedure was combined with anterior/posterior rotation. In this study, the combination of transtrochanteric curved varus osteotomy and anterior/posterior rotation significantly increased the percent viable area from 65% to 84%.
Conclusions: The modified curved varus could be a viable approach for patients with a viable area in the anterior or posterior region. The extent of the post operative viable area on the loaded portion proved to be better than the original procedure.

View full abstract

Introduction: We compared the clinical results for the treatment background with the use of a biological agent after total knee arthroplasty (TKA) in patients with rheumatoid arthritis.
Methods: The study followed 31 knees in 25 patients who had undergone TKA from February 2005. Patients were divided into two groups according to the baseline use of the biological agent. The biological agent group (BA group) consisted of 12 knees in 8 patients, and the non-biological agent group (nBA group) consisted of 19 knees in 17 patients. There were no significant differences in the patients’ background except for age. The period of use of the biological agent before surgery ranged from 6 to 30 months (avg. 15.2 months).
Results: Significant differences were seen on postoperative knee function score and improvement of the score between the two groups (p<0.01). No complications including deep infection were observed in either of the groups.
Conclusion: The use of a biological agent may adversely affect the clinical results after TKA in rheumatoid patients. On the other hand, no deterioration was observed with the use of the biological agent.

View full abstract

Objective: We performed total knee arthroplasty (TKA) without patella resurfacing in patients with osteoarthritis of the knee (OA). This study was designed to evaluate pre- and postoperative changes in patellofemoral joint pain (PF pain) and the relation between patellofemoral joint pain and patellofemoral joint stability.
Methods: Thirty-three patients (34 affected knees) were enrolled into the study, who had undergone Low Contact Stress (LCS) mobile bearing knee arthroplasty (Depuy, Warsaw, Ind) 5 years or more before the study. There were 4 males (4 affected knees) and 29 females (30 affected knees) with a mean age of 75.9±5.6 years (range: 64-85 years). The mean follow-up period was 5.5±0.6 years (range: 5-7.5 years). PF pain was defined as any of the followings: pain around the patella, tenderness of the anterior patella, pain upon standing up, or pain upon ascending or descending stairs. We investigated the presence or absence of PF pain before and after TKA, and the patients were divided into two groups, i.e., a group of patients having PF pain at the final evaluation (group A) and patients having no PF pain (group B) at the final evaluation. Patella height, lateral shift ratio, and tilting angle were compared between the groups. Clinical evaluation was based on the Japanese Orthopaedic Association scoring system (JOA score) for knee osteoarthritis.
Operations were performed by one surgeon via the midvastus approach with cementless fixation. During the operation, osteophytes around the patella were resected, and osteophytes on the articular surface were shaped using a bone saw. For statistical analysis we performed Mann-Whitney’s U test and adopted a significance level of P<5%.
Results: Preoperative PF pain was found in 26 patients (26 affected knees) and postoperative PF pain in 7 patients (7 affected knees) at the final evaluation. In these patients, however, the pain was less severe than it had been preoperatively and all 7 patients who had postoperative PF pain also had preoperative PF pain. The patella height and lateral shift ratio were not significantly different between groups A and B (P=0.77, P=0.41, respectively). The tilting angle was significantly different between group A (mean 6.0±2.0) and group B (mean 3.7±2.7) (P=0.04).
Conclusions: Treatment of the patella in total knee arthroplasty remains controversial. This is partly because each procedure has advantages and disadvantages, and the use of different surgical techniques or prostheses in each procedure complicates the comparison of the various procedures. In this study, we found that PF pain may remain when preoperative PF pain is present and the postoperative tilting increases on the X-ray angle. If patella tilt or abnormal patella tracking is observed during TKA, patelloplasty or lateral release should be performed.

View full abstract

We investigated periprosthetic fractures adjacent to total knee implants. In our hospital, periprosthetic fractures occurred in 9 (1.3%) of 700 patients who had undergone a total knee arthroplasty (TKA). Four patients who underwent TKA in another hospital but were treated for periprosthetic fractures in our hospital were added to the study. All 13 suffered from collagen disease, including RA, and had taken steroids for an extended period of time. The fractures were caused by minor accidents, such as falls. Non-surgical treatment was performed in one case, while the other 12 patients were treated surgically. In 9 cases, the bone mineral density (BMD) was measured near the time of injury. The results of the examination were as follows: BMD (lumbar spine): 0.527-0.758 g/cm ², T score: 52-75%, and Z score: 66-94%; BMD (femoral neck): 0.341-0.502 g/cm ², T score: 45-66%, and Z score: 52-80%. Nearly all patients suffered from severe osteoporosis. RA patients may be more likely to be osteoporotic because of the constant presence of inflammation, long-term steroid use, and a lower amount of physical exercise in daily life. It is thus advantageous to detect osteoporosis in its early stages and begin medical care for it as quickly as possible.

View full abstract

Objective: In patients with hip fracture we have frequently identified postoperative knee joint pain, which may adversely affect the rehabilitation outcome. The purpose of our study was to clarify the relationship between knee osteoarthritis (OA) and postoperative knee pain after hip fracture.
Materials and Methods: Thirty four patients with acute hip fracture were enrolled in the study, and divided into two groups; patients with (OA group) or without (non-OA group) radiographic knee osteoarthritis. Radiographic knee osteoarthritis was defined as a severity greater than grade 2 using the Kellgren-Lawrence Grade. We compared the age and number of patients with intertrochanteric fracture, knee effusion at the time of surgery, and postoperative knee pain during rehabilitation between the 2 groups. In addition, synovial fluid was collected with syringes in 10 randomly selected with knee effusion at the time of surgery, and one drop of synovial fluid from each patient was analyzed for calcium pyrophosphate dihydrate crystals using a compensated polarized light microscope.
Results: Eighteen of the 34 patients were allocated to the OA group. Patients in the OA group were significantly older than those in the non-OA group. Seven patients in the OA group and 11 in the non-OA group were diagnosed as having a femoral neck fracture (P=0.16). Twelve patients in the OA group and 4 in the non-OA group had knee joint effusion on the hip fracture side at the time of surgery (P=0.037). Five patients in the OA group and 3 in the non-OA group had postoperative knee pain during rehabilitation (P=0.69). Most patients with postoperative knee pain in both groups had knee effusion at the time of surgery. In addition, calcium pyrophosphate dihydrate deposit (CPPD) was seen in 8 of 10 patients.
Conclusion: In many patients, knee effusion was found at the time of surgery, and this phenomenon basically originated from CPPD. Postoperative knee pain after hip fracture could be caused by CPPD even if the patients did not have radiographic knee osteoarthritis.

View full abstract

Destruction and dislocation of the metacarpophalangeal (MP) joints are common lesions in rheumatoid fingers. Forty-six MP joint replacements were carried out in 13 women and one man with a mean age of 51.3 (range 31-79) years. We examined the short-term results of a Swanson MP arthroplasty in patients with rheumatoid arthritis. The range of motion and grip strength were measured at a mean final follow-up of 4.6 (range 2-7.6) years. Subjective outcome was determined with the JSSH version of Quick DASH. An X-ray analysis was undertaken to identify any implant failure and re-deformity of joints. The arc of MP joint motion and grip strength did not improve, but on the other hand, flexion deformity and ulnar deviation of the MP joint significantly improved postoperatively. Implant fracture occurred in one case in which an implant without a titanium grommet was used. None of the cases suffered any silicone synovitis or infection during the follow up period. Our results showed that the Swanson flexible implant provided pain relief, and corrected palmar dislocation and ulnar deviation but did not improve the arc of motion.

View full abstract

Objective: The present study describes the short term results of total ankle arthroplasty (TAA) using the FINE Total Ankle System.
Materials and Methods: TAA was performed on 18 ankles in 16 patients with RA. Fourteen were women and two were men. The mean age at the operation was 65 years and the mean follow-up period was 2.8 years. Clinical evaluation was performed using the JOA score and we also assessed the range of motion, radiographic results, and complications.
Results: The mean JOA score improved from 40.8 to 70.9 The mean plantar flexion improved from 30.9° to 36.6° and the mean dorsiflexion improved from 4.4° to 6.9°. The X-ray findings showed loosening two cases. There were five cases with complications; one of infection, two of delayed wound healings, and two with medial malleolus fractures. Three cases required reoperation. The revision rate was 17%.
Conclusions: The short term results of TAA using the FINE total ankle system were relatively good, however careful follow-up is required.

View full abstract

Subjects: Six lower extremities in 5 female rheumatoid arthritis (RA) patients were examined. The average age at the time of surgery was 61.8 years (range: 53-68 years) and the average post-operative follow-up period was 34.0 months (range: 14-45 months).
Surgical Procedure: The first metatarsophalangeal joint was replaced with a Swanson flexible hinge toe implant with a grommet. Metatarsal head resection was performed for the remaining toes.
Results: There were no cases of implant displacement or damage, post-operative infections, or recurrence of plantar callosities. The average hallux valgus angle was 41.0 before surgery, 15.3 immediately after surgery, and 26.8 at the final examination. Improvements were seen in the Japanese Society for Surgery of the Foot (JSSF) RA foot ankle scale from an average of 39.8 points before surgery to 81.3 points at the final examination.
Conclusions: This surgical procedure provides excellent pain relief and is esthetically pleasing, but requires careful monitoring in the long term.

View full abstract

This report describes a case of low tibial osteotomy (LTO) for varus-type osteoarthritis of the bilateral ankles. The patient was a 53 year-old woman with pain, swelling and varus deformity of the bilateral ankles. Tests for rheumatoid arthritis were negative, and the final diagnosis was varus-type osteoarthritis of the bilateral ankles. Conservative therapy was not able to improve her symptoms. From the radiological findings, the osteoarthritis of the ankles was classified as intermediate stage. At first, we performed a left LTO with an opening wedge osteotomy. We aimed to achieve a TAS angle of 94° and a TLS angle of 80°. After nine months, we performed a right LTO using a locking plate. The short-term results have shown good alignment correction and bony fusion. Absence of ankle pain was achieved and there was improvement of ankle motion. Initial stability could be acquired by using a locking plate, and positive rehabilitation was able to be performed from the early stage.

View full abstract