The new Japanese Orthopedic Guideline for the Prevention of Venous Thromboembolism was published in November 2008. Management of anticoagulants and antiplatelet drugs according to the Guideline is summarized. Anticoagulation therapy or intermittent pneumatic compression is recommended to prevent venous thromboembolism after high-risk surgery such as total hip arthroplasty, total knee arthroplasty, and hip fracture surgery. Fondaparinux and Enoxaparin, new anticoagulants that have shown excellent efficacy in Japanese clinical studies, are recommended as anticoagu1ants instead of unfractionated heparin or warfarin. Major bleeding such as epidural hematoma, intracranial bleeding and intestinal bleeding is a warning sign, because the incidence of major bleeding with these new anticoagu1ants has been approximately 2% in Japanese clinical studies, and dose reduction is recomrnended in fragile patients who are advanced age, lower weight and/or renal disfunction, An epidural catheter inserted should be removed more than two hours before administration of the initial dose of these anticoagulants. Antiplatelet drugs such as aspirin are not recommended for the prevention of venous thromboembolism because of their lower efficacy than anticoagulants, but they are one option for prevention of venous thromboembolism instead of antico-agulants in patients who are at high risk of bleeding.

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Objective: We examined the safe perioperative management of orthopaedic surgery in the patients with rheumatoid arthritis who were being treated with biological agents.
Materials and methods: Twenty-four patients were divided into an Infliximab group (n=17) and an Etanercept group (n=7), and we assessed the changes in disease activity in the perioperative period and the incidence of postoperative complications.
Results: A flare-up in the postoperative period occured in 2 patients in the Infliximab group and in all patients in the Etanetcept group. A postoperative wound surface infection developed in one patient in the Infliximab group. Poor wound healing was observed in two patients in the Etanercept group, but both wounds healed promptly in response to appropriate treatment.
Conclusion: There were no serious complications in any of the patients in this study. Safe perioperative management appered to be possible in patients being treated with biological agent, but attention should be paid to wound healing in such patients.

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Objective: Tumor necrosis factor (TNF) is a key cytokine driving synovial inflammation in rheumatoid arthritis (RA), and the introduction of anti-TNF therapies has dramatically improved the treatment of active RA. Patients with RA who experience treatment failure with one an ti-tumor necrosis factor (anti-TNF) agent, whether because of lack of efficacy or toxicity, are frequently switched to a second anti-TNF agent. The aim of this study was to assess the efficacy of etanercept in RA as second-1ine therapy after infliximab in comparison with eternercept as first-line therapy,
Methods: We assessed 74 patients with active RA treated with etanercept, 64 of whom received it as first-1ine therapy and 10 of whom received eternercept as second-line therapy after infliximab. EULAR response criteria and calculation of the DAS28 activity index at baseline and after 24 weekswere used to evaluate the efficacy of eternercept.
Results: In the first-line therapy group, etanercept was stopped due because of toxicity in 3 cases and inefficacy in 2 cases. In the second-line therapy group, all patients were still being treated with etanercept at 24 weeks of follow up. A moderate or good response according to the EULAR criteria was achieved in 88.1% of the patients in the first-line therapy group, and in 70% in the second-line therapy group.
Conclusion: The soluble tumor necrosis factor (TNF) receptor, etanercept provided a well tolerated and effective treatment option for some patients, even when infliximab was ineffective.

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Objective: Although biological agents have greatly contributed to improving drug therapy for rheumatoid arthritis (RA), the Disease-modifying antirheumatic drug (DMARD) methotrexate (MTX) remains the golden standard and anchor drug for the treatment of RA. However, some patients treated with MTX respond poorly or experience a clinical relapse, and in this study we have tried combination pulse therapy with MTX and mizoribine (MZR) in such patients.
Methods: Combination pulse therapy consisting of MTX (6 or 8 mg/week) and MZR (300 mg/week) was tried in RA patients who were poorly con trolled by MTX (monotherapy or combined with another DMARD). MZR (100 mg) was administered only once concomitantly with MTX. Efficacy was assessed at 3 months and 6 months by using the EULAR response criteria based on the DAS28-CRP4 score. Treatment was judged "effective" when the patient showed a moderateor good response, and "ineffective" when the patient showed no response or treatment was discontinued before the 3 months because the symptoms did not improve.
Results: Twenty-eight patients were treated with the combination therapy. Mild side effects occurred in 3 patients (7%), gastrointestinal discomfort in two and abnormal liver function test results in one patients. There were no major complications related to therapy. Compliance rate at 3 months and 6 months, was 68% and 54% respectively, and the efficacy rate was 26% and 37%, respectively. The clinical improvement of the patients who responded to the combination therapy was gradual and lasted up to 6 months. The CRP values and DAS28 scores increased by 71% and 30%, respectively, compared to baseline.
Conclusion: The results of this study suggest that combination pulse therapy with MTX and MZR is safe and effective in patients with RA. This combination therapys hould be available as another option for RA patients who show a poor response or experience a clinical relapse after MTX therapy.

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Objective: We identified 225 rheumatoid arthritis (RA) patients who required surgery after failure to prevent joint destruction by drug therapy alone, and we analyzed postoperative functionality on the basis of a questionnaire survey.
Methods: We recruited 157 of 225 RA patients who required joint replacement, fixation, or arthroplasty in the upper and lower extremities to participate in this study. The mHAQ (modified health assessment questionnaire) wasused to assess their physical condition and the Fujibayashi classification was usedt or neasure functional improvernent of the upperand lower extremities aftersurgery. We also assessed the impactof the number of joints treated on physical function and the influence of the length of the postoperative period on functional improvement and physical status.
Results: No significant postoperative improvement in function of the upper extremities was identified at follow-up. By contrast, significant improvement was reported in the lower extremities according to the Fujibayashi classification more than ten years after surgery. The changes assessed by the mHAQ showed significant improvement with in ten years of surgery, but not there after. Significant improvement according to the mHAQ was seen both for ≦2 and ≧3 joints.
Conclusions: To improve the quality of life of RA patients it is therefore recormnended that surgical intervention is performed earlier to maintain better physical status and functionality of the upper and lower extremities.

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Objective: Recent clinical studies with metal-on-metal total hiparthroplasty have shown mostly good results, and encouraging results have also been reported in active, high-demand patients. We reviewed the mid-term clinical and radiographic results of metal-on-metal total hip arthroplasty.
Methods: Between February 1998 and Septem ber 2003, 42 primary total hip arthroplasties with the Metasul metal-on-metal articulation were performed in 38 patients, and the patients were monitored for at least 3 years. We evaluated them by means of the JOA score for clinical results and radio-graphic analysis after a mean follow-up time of 6.6 years.
Results: The mean preoperative JOA score was 48.5 points, and it had improved to 94.5 points at the time of the final follow-up evaluation, Threehips (7,1%) were revised: two because of septic failure, and one because of frequent dislocation. Survivorship of metasul hip system at the time of the final follow-up examination (6.6 years) was 93.0% (end point: revision). The radio graphical analysis showed radiolucent lines around the cup and around the stem in 11.9% and 66.7%, respectively. However, there were no clear signs of loosening, migration, or osteolysis in relation to either the cup or stem comporlent in any of the patients.
Conclusions: Our mid-term results with the use of the Metasul metal-on-metal articulation are encouraging. However, since some radiolucent lines were observed around the cups and the stems in this study, longer follow-up is necessary to identify osteolysis or any other possible long-term noxious effects associated with meta1-on-metal articulation.

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TKA was performed to the cases of valgus knee and varus knee, and improvement of clinical results were examined. Good clinical results, were acquired by each in the femorotibial angle, the range of motion, and the Japanese Orthopaedic Association knee score. When the navigation system made from Stryker was used to carny out a detailed examination, FTA of preoperation was considered that reform only byosteophyte excision and deep fibers of the MCL elevation operation is possible for 190 degrees or less and flexion contracture with a case 5 degrees or less. Next, the valgus knee was also examined. All of the clinical results were good, the some as for the varus knees. We used correction through a lateral approach to treat the valgus knees. A rotation alignment of femur and a skin necrosis needs cautions for using lateral approach. Therefore, the dissection should be deep to the superficial fascial layer to maintain the blood supply to the skin. Moreover, at least rotation alignment is considered for posterior condylar axis to consider it as a reference grade, and for synthetic judgment of surgical epicondylar axis, Whiteside line, etc., to be more important for determination as for it.

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Objective: Some surgeons have reported that MIS-TKA has many advantages. In the past we reported finding no difference between MIS and conventional TKA in operative injury by muscle enzymes. The present study comparared muscle enzyme recovery after MIS and conventional TKA in rheumatoid arthritis (RA).
Methods: TKA procedures were performed on 89 RA knees of 80 patients, MIS-TKA in 44 of the knees and conventional TKA in the other 45 knees. Blood samples were collected to measure serum CPK, aldorase (ALD), and myoglobin (MG) before the operation and on postoperative days 1, 2, 4, 7, and 14 to determine how many days after each procedure (MIS-TKA, conventional-TKA) were needed for the value to return to the preoperative levels.
Results: All muscle enzymes recovered to their preoperative values after MIS-TKA and conventional TKA: CPK in 6.8 days, 6.5 days respectively; ALD: in 11.7 day and 8.4 days respectivly; and MG: in 13.6 days and 3.8 days, respectively.
Conclusion: The postoperative decrease in muscle enzyme values was slower after MIS-TKA. The faster rehabilitation after MIS-TKA, which caused greater muscle damage, is thought to have been responsible for these result.

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Purpose: We conducted a retrospective study of the mid-term results of cementless TKA inthcumatoid arthritis (RA) patients.
Method: The subject of the study was 61 knees of 52 RA patients treated by cementless TKA over a 5-year period. We assessed changes in ADL after surgery baseed on the JOA (Japan Orthopedics Association) knee score and performed a radiological analysis by the method of the Knee Society.
Result: Two patients developed in fection and required replacement of the prosthesis. The overall survival rate was 96.7%. The average JOA score was 94.17 postoperatively as opposed to 53.85 preoperatively, showing a mean improvement in ADL. There were no major radiolucent signs or evidence of loosening radiologically even at 5 years. No revisions of TKA were required because of loosening or sin king.
Conclusion: The mid-term results of cementless TKA in RA patients were good in terms of ADL, even thogh sinking or loosening occurred in some patients.

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We reviewed the short-term results of total knee arthroplasty (TKA) with the Genesis II total knee system after a mean foi!ow-up period of 3 years 9 months. The subjects were 33 patients (40 knees) with OA and 12 patients (12 knees) with RA. There were 9 men and 36 women, and their mean age at the time of surgery was 71.O years. A mobile CR (postevior cruciate retention design), fixed CR, and mobile PS (postevior stabilizer design) were used in 22 knees, 6 knees, and 19 knees, respectively. Patellar resurfacing was performed in 12 knees (23.1%), and lateral release was performed in 10 knees (19.2%). No subluxation of the patella was observed postoperatively. Although the mean angle of the components was generally satisfactory, the mean angle of the femoral component was variable, and a notch formed in 21.2%. Complications reported consis backward dislocation in 1 patient (1 knee), heterotopic ossification in 1 patient (2 knees), and supracondylar femoral fracture in 1 patient (1 knee). The JOA scores improved. No radiolucent line or loosening were observed, and the results were satisfactory.

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We evaluated post operative recovery of knee function and walking ability by 10 total knee arthroplasty (TKA) patients and lO unicompartmental knee arthroplasty (UKA) patients. Although there were no significant differences in preoperative knee function between the UKA group and TKA group, patients in the UKA group began to walk sooner either with the aid of a walker or T-cane, than in the TKA group, and 10-m walking speed was faster in the UKA group than in the TKA group. Recovery of range of motion of the knee, especially flexion, was significantly faster and better in the UKA group than in the TKA group, and recovery of quadriceps muscle strength was faster in the UKA group. These result ssuggest faster and better recovery of knee function in UKA patients because of the smaller surgical incision than in TKA patients.

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Objective: The purpose of this study was to compare the short-term results of minimalally invasive total knee arthroplasty (MIS-TKA) by standard large incision TKA and to discribe improvements inspecial surgical instruments and operative technique for MIS-TKA.
Methods: Forty knees of 37 patients (71 males and 30 females) who underwent primary MIS-TKA (MIS-TKA group) and thirty knees of twenty six patients (41 males and 22 females) who underwent primary standard TKA (standard group) were assessed, and range of motion, JOA score, operationtime, intraoperative bleeding, and component positioning in the two groups were compared.
Results: Mean operation time was significantly longer and mean range of motion at the time of discharge from the hospital was significantly greater in the MIS-TKA group than in the standard group. No significant differences were observed many other clinical parameters evaluated in this study.
Conclusion: Special surgical instruments are needed to perform MISTKA properly, and the operative technique needs to be improved to perform MIS-TKA because of the limited visibiiity. Although the MIS-TKA operation time in our series was more than 20 minutes longer than required to perform the standard procedure, the one-year postoperative clinical outcome was the same as after standard TKA. We do not expect MIS-TKA to increase the long-term failure rate, but careful follow-up is necessary in the future.

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Objective: To evaluate the effect of the length of the skin incision for minimally invasive total knee arthroplasty (MIS TKA) through a mini-midvastus approach.
Methods: We compared the early results of 100 MIS TKAs performed through skin incisions shor ter than 10 cm (Group I) and 10 cm or more in length (Group II). There were 51 knees in Group I and 49 knees in Group II. The evaluation included operation time, blood loss, range of motion, clinical score, alignment of components, rehabilitation, complications, and subjective patient satisfaction.
Results: At 3 months postoperative flexion was greater in Group I than in Group II, and rehabilitation was more rapid in Group I, but no significant differences in any other parameters were found between the two groups.
Conclusion: MIS TKA through the smaller skin incisions yielded better early results in this study.

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Objective: The lateral wedged insole with a subtalar strapping (hestrapped insole) for patients with medial compartment osteoarthritis (OA) of the knee has the disadvantage of permitting knee buckling in patients with anterior-posterior laxity. To resolve this problem, we modified treatment with the strapped insole by combining it with an elastic knee orthotic device and we assessed its efficacy.
Method: Fifty eight patients with OA of the knee were prospectively randomized into a group treated for four weeks with a heat-retaining knee sleeve (heat-retaining sleeve, n-20), a group treated for four weeks with a relatively long elastic mechanical knee sleeve with hinged struts (functional sleeve with struts, n-19), and a group treated for four weeks with a short sleeve without hinged struts (functional sleeve without struts, n-19). All patients were instructed to use the strapped insole as adjunctive therapy. Patients were permitted to stop using the orthotic device at any tim e during the course of the 4 week study if any discomfort developed that they had not experienced before using it.
Results: A higher propotion of patients stopped using the functional sleeve with struts (13/19, 68.4%) than stopped using the heat-retaining sleeve (2/20,10%) or the functional sleeve without struts (4/19, 21.1%).
Conclusion: The functional sleeve without struts may be more comfortable and effective than the heat-retaining sleeve and functional sleeve with struts for constant routine use with the strapped insole.

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We performed ankle arthrodesis using a finned intramedullary nail to treat 8 rheumatoid arthritis patients and 2 osteoarthritis patients. The short-term results have shown good alignment corection and bony fusion under weight bearing in the early post operative period in every case. A radiolucent line on a fin and delayed union were observed in one case each, and the patients complained of calcaneal pain at 2 months or 1 year postopretively. Ultimatelly, stable radiographic fixation and absence of ankle pain were achieved in every case. The finned intramedullary nails were a very useful means of ankle arthrodesis, even in patients with severe osteoporosis.

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Introduction: We attempted to identify factors related to duration of hospitalization for femoral neck fractures in elderly patients.
Methods: We analyzed 247 cases of femoral neck fractures treated surgically in patients over 65 years of age. The mean age of the patients was 79 years old. The patients were classified in to a group hospitalized for > 5 weeks and a group hospitalized for < 5 weeks, and the groups were compared in relation to gender, age, osteoporosis, residence, general condition, type of fracture, walking ablity, cognitive function, interval between the fracture and surgery, duration of confinement to bed, and interval between the fracture and the start of weight-bearing.
Results: There were no signifficant differences between the two groups in gender, age, osteoporosis, residence, general condition or walking ability. There were significant differences between the two groups in type of fracture, cognitive function, interval between the fracture and surgery, duration of confinement to bed, and the start of weight-bearing. A multiple linear regression analysis showed that type of fracture, cognitive function, and interval between the time of the fracture and end of confinement to bed had an affecton the duration of hospitalization.
Conclusion: The predictors of prolonged hospitalization were displaced fracture, absence of cognitive dysfunction, and delayed rehabilitation.

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Objective: We performed arthroscopic surgery in 6 cases of calcific tendimtis that had not been improved by conservative treatment and we obtained good results in every case. In this article, we review the important points in regard to the operations.
Methods: The 6 patients who underwent arthroscopic surgery between 2005 and 2007, 3 males and 3 females were followed up for more 6 months (mean: 15.1 months); (range: 7-26 months) Average age at surgery was 50.6 years old (range: 26-76 years). We performed ASD (arthroscopic subacromial decompression) and arthroscopic resection of calcium deposits in every case. In 5 cases, rotator cuff repair was performed by simple side-to-side suture or suture anchor. Arthroscopic capsular release was added in the one case with joint contracture secondary to diabetes mellitus. Because there was an articular side tear in on e case, we made the tear complete and performed dual row fixation. The clinical results were evaluated by comparing scores on the UCLA scales before and after surgery.
Results: The UCLA scores improved from an average of 20.3 poin ts preoperatively to 33.8 points postoperatively.
In case 1, persistence of calcium was seen on the postoperative X-rays, and the pain improved, but night pain persisted for about 4 month s. In case 2, we confirmed the presence of calcium in the perioperative X-rays and completely resected the calcium deposits. The patients UCLA score improved from 20 points to 35 points with in two weeks after the operation.
Conclusion: We performed arthroscopic surgery to treat calcific tendinitis of the shoulder in 6 cases and obtained good results.

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