Since 1961 we have used the Spitzy operation combined with a vertical osteotomy of the outer cortex of the ilium for patients with arthritis secondary to acetabular dysplasia or subluxation. We present herein on the long-term results of a modified Spitzy shelf operation in 119 hips with a mean follow-up of 23.8 years. Preoperative osteoarthritic change, the age at operation and shelf height were important factors in determining the outcome. Of the 61 hips in the pre-stage and the initial stage of osteoarthritis, 87% had good long-term results, compared with 51% of 58 hips with advanced osteoarthritis. The correct technical procedure is essential. A graft placed too high is resorbed due to lack of loading, and a graft placed too low produces impingement on the femoral head and accelerates the degenerative changes. However, the relatively uncomplicated nature of the operation gives it an advantage over other pelvic osteotomies. The general considerations are also described.

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Objective: We evaluated the efficacy of reconstructive surgery for hip diseases before skeletal maturity, including acetabular dysplasia after developmental dysplasia of the hip (DDH), Legg-Calve-Perthesdisease (LCPD) and slipped capital femoral epiphysis (SCFE).
Materials and methods: Seventy-one of 294 cases with DDH were treated with triple innominate osteotomy due to residual acetabular dysplasia. Twenty-five patients with difficult LCPD, which had been overlooked for longer than 6 months or showed significant collapsed epiphyses after the initial treatment, underwent surgical treatments. In 14 cases with unstable SCFE, causative factors of avascular necrosis and an appropriate strategy were investigated.
Results: For cases with acetabular dysplasia and difficult LCPD, reconstructive hip surgery such as a triple osteotomy showed excellent results. Seven of 14 cases with unstable SCFE had avascular necrosis. Delayed reduction of an unstable slip without joint aspiration appeared to increase the risk of development of osteonecrosis.
Conclusion: Reconstructive surgery during the infant and adolescent stages can provide excellent remodeling and congruity, leading to reasonable function of the hips for the long term. Appropriate methods of treatment and optimal timing for the correct indication are the most important considerations.

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We report on the results of over ten years’ experience of rotational acetabular osteotomy in patients from the age of 10 to 19 yr. We have performed the rotational acetabular osteotomy procedure using osteotomy of greater trochanter in 2700 hips since 1978.
Period: The mean follow-up periods were 16.2 years (range, ten to twenty-five years) in pre-to early-stage patients, and 17.0 years (range, ten to twenty-three years) in advanced-to end-stage patients.
Underlying diseases: One hundred sixty eight hips demonstrated congenital dislocation (63.4%), forty-eight showed acetabular dysplasia (18.1%), thirty had Perthes disease (11.3%), and seven had purulent arthritis. Four patients also had cerebral palsy. Patients from the age of 10 to 19 yr were characterized by the prevalence of congenital dislocation and a high percentage of these patients had undergone surgery, in many of whom trochanteric tractions had been performed.
Results: The mean JOA score improved from 84.6 points pre-operatively to 95.0 points at follow-up in primary-to early-stage patients, and from 69.3 points to 88.6 points in advanced-or end-stage patients. THA was performed in two patients with bilateral or advanced disease.
Conclusion: Rotational acetabular osteotomy in young patients showed good long-term results, and was effective for controlling the progress of coxarthrosis.

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Background: We reviewed the published papers reporting on long-term results of hip and knee arthroplasties based on the Finnish Arthroplasty Registry.
Methods: All articles published in international peer-reviewed orthopaedic journals were analyzed and results of those studies were summarized in this review article.
Results: Cementless total hip replacements, as well as cementless stems and cups analyzed separately, showed a significantly reduced risk of revision for aseptic loosening as compared to the cemented hip replacements in osteoarthritic patients aged less than 74 years. When all revisions were taken into account, however, there were no significant differences between the groups. In patients aged less than 64 years, none of the cemented or cementless total hip replacement designs studied yielded an excellent (>90%) 10-year survivorship. In patients aged 75 years and over, there were no significant differences between different total hip replacement concepts; all of them showed >90% survivorship at 10 years. In younger (<55 years) patients with rheumatoid arthritis, all-poly cementless cups showed a significantly better survivorship than modular cementless cups. On the knee side, unicondylar knee arthroplasties (UKAs) had a 60% and TKAs an 80% survival rate at 15 years with any revision as the end point. The overall survival of UKAs was significantly worse than that of TKAs (p<0.001). All three UKA designs studied had significantly poorer overall survival than the corresponding TKA designs from the same manufacturers. Of the UKA designs, the Oxford meniscal bearing had the highest survivorship of 81% at 10 years, while several TKA designs showed a 10-year survivorship exceeding 90%. In a theoretical cost-benefit analysis, the cost saved by lower implant prices and shorter hospital stay associated with UKA as compared to TKA did not cover the costs of the extra revisions.
Conclusions: Cementless total hip replacements have comparable long-term survivorship with cemented replacements in all age groups. In patients aged less than 74 years, cementless stems seem to produce better long-term survivorship than cemented ones. In patients aged 75 years and over, there were no significant differences in the results. Multiple wear-related revisions of the cementless cups in the present study indicate that excessive polyethylene wear is a significant clinical problem with modular cementless cups in all age groups. At a nation-wide level, UKA had a significantly poorer long-term survival than TKA. What is more, UKA did not have even a theoretical cost benefit over TKA in our study. Based on these results, we can not recommend the wide-spread use of UKA in treatment of unicompartmental OA of the knee.

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Glucosamine is an aminosaccharide with a molecular weight of 179.2 and the source of various aminosugars that make up the extracelluar matrix and glycoproteins. It also has biological effects on chondrocytes and other cells; for example, glucosamine is known to suppress the production of PGE 2 and MMPs from chondrocytes. Glucosamine has been used to treat osteoarthritis (OA) since the 1960s, however, clinical trials have reported inconsistent results. According to a recent meta-analysis, effect size of glucosamine was decreased to 0.35. The study showed the following two points; 1) only products of a specific company are effective and 2) glucosamine hydrochloride was ineffective. Regarding industry bias, controversy exists as to whether well-designed clinical studies supported by pharmaceutical companies thus show robust results on efficacy. Both glucosamine hydrochloride and its sulfate dissociate are absorbed as glucosamine in the oral mucosa. Careful analysis of clinical trials using glucosamine hydrochloride do not inevitably show that it is ineffective. Chondroitin sulfate is a high molecular weight compound composed of galactosamine and glucuronic acid. The meta-analysis showed negative results, partly because the quality of products is heterogeneous. To elucidate the efficacy of these products, investigation into the diagnosis and evaluation of OA is important.

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Recently, there has been a boom in the use of complementary and alternative medicine in arthritis patients. In a 2006 Japanese report, the annual turnover of glucosamine was 15 billion and a shark cartilage (chondroitin) is 2 billion, although the clinical evidence for the use of glucosamine and chondroitin exisit for osteoarthritis (OA), no such evidence exist for rheumatoid arthritis (RA). Though a multicenter collaboration study, we administered glucosamine/chondroitin to 22 RA patients and 46 OA patients for 3 months. Although partial of improvements were found in OA, no efficacy was seen at all in RA. To examine the effect of oral hyaluronic acid (HA), the HA concentration of the knee joint was measured after HA was administered orally to 6 rabbits for 7 days. There was no HA concentration difference between the HA treatment group and control group. There is an antiinflammatory effect with bromelain, and there is an antioxidant action in quercetin or selenium. However, there is no clinical evidence that these are effective compared with non-steroidal antiinflammatory drugs (NSAIDs) or any of the existing anti-oxidization agents. Although the herbal remedies have been used as an alternative painkiller for many years, some of them (cats claw, feverfew and white willow etc.) increase hemorrhagic tendency, and they should be administered with care in some patients (pregnant woman or digestive ulcer patient etc.). Folic acid and vitamin B6 are effective for adverse reactions associated with methotrexate (MTX), vitamin B5 is also effective for morning stiffness and arthritic pain. Omega 3 fatty acids have an antiinflammatory effect and have improved on clinical symptoms, blood data and inflammatory cytokine levels in RA patients. Although complementary and alternative medicines are occasionally effective, they are not a radical treatment and there is also the problem of cost or side effects (herbal therapy etc.), so they are not strongly recommended in RA patients.

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VTE is one of the most serious complications following total hip and knee arthroplasty, and remains a genuine threat to the life of a patient. This article summarizes guidelines for preventing VTE after total hip and knee arthroplasties in the U.S., Europe, and Japan. Since 2007, the use of Fondaparinux and Enoxaparin has been permitted under Japanese insurance. We can use anticoagulant drugs in the same way as they are used in the U.S. and Europe. For this reason, the Japanese Orthopaedic Association published a revised edition of its Guidelines for Preventing VTE in 2008. For patients undergoing elective THA and TKA, active movement of the ankle and early ambulation are important principles. As specific mechanical methods of thromboprophylaxis, which include graduated compression stockings, intermittent pneumatic compression devices and venous foot pump, increase the venous outflow and reduce stasis within leg veins, mechanical methods are recommended for these patients. The use of one of the following anticoagulant options is recommended for these patients with clinical risk factors: Enoxaparin, Fondaparinux, and Warfarin. Clinical risk factors include previous VTE, congenital and acquired thrombophilic disorders, prolonged immobility, and paralysis. The use of anticoagulant drugs in all patients with total joint arthroplasty is, however, still controversial, so we must use these drugs, while considering their risks and benefits. We demonstrated the protocols of the prevention of VTE after total hip and knee arthroplasty in our hospital. In this study of consecutive 398 total hip and knee arthroplasties from August in 2007 to July in 2008, the overall prevalence of VTE in THA and TKA was 7.7%, and 36.4% with having a symptomatic VTE rate of 0%, and 1.0%, respectively. There was no occurrence of pulmonary embolism within one year.

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Fatal pulmonary embolism after hip surgery is the most serious postoperative complication. However, it has generally been accepted that this disease is rare in the Asian population because of genetic factors and dietary patterns. Since 1992 we started chemical prevention for this disease after having experienced three cases of fetal pulmonary embolisms after pelvic osteotomy. Pelvic osteotomy has high risks not only for pulmonary embolism but also bleeding. We started low dose unfractionated heparin from 1000 unit per day to 4000 units per day. Unfractionated heparin at 1000 units per day had no preventative effect, but 2000 units per day or 4000 units per day could prevent post operative symptomatic venous thromboembolism without any bleeding complication.

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Deep venous thrombosis (DVT) and pulmonary embolism (PE) are serious complications of total hip arthroplasty (THA). We assessed DVT and PE after THA with 64-slice multi-detector row CT (MDCT), which can detect DVT and PE simultaneously within one minute. We examined 114 cases of THA (101 patients) and 11 of revision THA (10 patients) between May 2006 and September 2007. There were 87 women and 14 men. The mean age at operation was 62.6 years (range, 3684 years). All patients used a venous foot pump (VFP) on both legs until walking. Compression stockings were routinely used for 2 weeks after walking, and no drug prophylaxis was performed. At day 7, patients underwent combined MDCT pulmonary angiography and indirect CT venography of the lower limbs, with analysis of results by a radiologist. DVT was revealed by MDCT in 7 patients (6.1%). PE was detected in 5 patients (4.4%). None of these lesions was symptomatic. The incidence of DVT or PE was 8.7% in patients who underwent primary THA and 27% in those who underwent revision THA. A cutoff value of 10.0 µg/ml for the D-dimer on day 7 had high sensitivity (100%) but low specificity (55%) in the diagnosis of DVT. Our incidences of DVT and PE in primary THA were quite low, possibly due to accelerated rehabilitation and usage of the VFP. The D-dimer level under 10 µg/ml on postoperative day 7 appears to be an indicator of lack of occurrence of DVT after THA.

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The early results of minimal incision surgery (MIS) were compared with those of the standard procedure using the Revelation Hip System (DJO Surgical). From June 2004 to December 2005, 40 primary total hip arthroplasties (38 patients) were performed. In the 40 hips, 22 hips underwent MIS (initial skin incision of less than 10 cm) and 18 hips underwent the standard procedure. At the final investigation, 21 hips from the MIS group and 17 hips from the standard group were followed up. The average follow-up was 41 months (3452 months). Two surgeons (YT, NW) performed all surgeries in this series. All operations were started with the MIS procedure (initial skin incision of less than 10 cm), but when the surgeons considered it was impossible or not suitable to continue the MIS approach during the operation, an additional skin incision and soft tissue release were applied. Each surgeon decided whether MIS was appropriate for each patient or not. The antero-lateral approach (modified Dall) was used for all surgeries. The same rehabilitation program was used for both groups postoperatively. The applicability of MIS was significantly less in male patients (males: 2/8, females: 20/32). There was a correlation between patients height and the length of skin incision (p < 0.05). No significant differences between the two groups were found in CRP, CPK and D-dimer (CRP: 14.2/12.5 mg/dl, CPK: 396.7/368.1 mg/dl, D-dimer: 14.2/5.2 mg/dl). Both intraoperative blood loss and operation time were less in the MIS group (blood loss 529.4 ml vs. 766.7 ml, operation time 101 min vs. 115 min). The postoperative days until the patient was able to do active straight leg raising (SLR) were 17.4 in the MIS group and 22.8 in the standard group, and number of days in hospital was 22.6 versus 29.2, respectively. However, no significant differences with duration of hospitalization were found statistically. On radiographic findings, the lateral inclination of the acetabular cup was 42.7 in the MIS group versus 40.9 in the standard group, showing no significant difference (p = 0.459). The hip score according to the Japanese Orthopedics Association (JOA) was not significantly different between the two groups at the final follow-up (88.1 in MIS group, 85.9 in standard group). At 3, 6, 12, 18, 24 and 30 months after operation, JOA hip scores were not significantly different between the two groups. There were no revision cases in this study until the final follow-up. In the present study, intra-operative hemorrhaging and operation time were significantly less in the MIS group. However, for the other parameters, no significant differences were found in the laboratory data, radiographic findings, hospitalization, or JOA scores.

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Purposes: In the total knee replacement arthroplasty (TKA), installment of a better suitable component is necessary to achieve satisfactory range of motion region and joint stability. For this purpose, it is important to know the shape of the knee joint. In the present study, we measured skeletal shapes of knee joints among Japanese patients selected as subjects with artificial knee joints.
Methods: 3D-CT images based on the volume rendering method were used to assess 132 knees (males 22 knees, females 110 knees) in 132 cases from patients with an average age of 75.0 years (53 to 88 years) in whom a TKA was indicated due to the diagnosis of osteoarthritis of the knee. The measurements at the femoral side were made at the femoral width (FW), medial femoral length (MFL), and lateral femoral length (LFL). On the other hand, the measurements at the tibia side were made perpendicular to the tibial axis that is the expected cut surface and at a position 10 mm from the outer joint surface: tibial width (TW), medial tibial length (MTL), and lateral tibial length (LTL). We studied the mean skeletal size and variance based on the measurement data.
Results: The measurement results at the femoral side were FW: 76.2 ± 4.9 mm (SD), MFL: 60.6 ± 4.3 mm and LFL: 60.0 ± 3.7 mm. The measurement results at the tibia side were TW: 69.9 ± 5.2 mm (SD), MTL: 47.0 ± 3.7 mm and LTL: 40.8 ± 3.6 mm. In the cases of both femur and tibia, the ratio between width and length was found to change with size.
Discussion: According to the results, in both the cases of the femur and tibia, the A-P length did not increase proportionally to the width, but it was suggested that the shape became flat as the skeletal size increased. The present results agreed with the results reported in the past although the measurement positions and methods were different. In many cases, they did not match with the component sizes in 3 types of knee prosthesis (KU 4+, PFC Σ, and Scorpio). Therefore, it seems to be important to add flatness of femur and tibia to side variations of knee prostheses.

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Objective: Indications of revision total knee arthroplasty (TKA) combined with tibial tubercle osteotomy (TTO) at our facility and the complications of this procedure are investigated.
Method: Revision TKA was performed on 39 knees, and was combined with TTO for 24 knees. The operation was conducted via the parapatellar approach. The tibial tubercle (TT) was everted, with the anterior tibial muscle kept attached as far as possible (Whiteside, 1990). This procedure was applied to: (1) delayed two-stage exchange arthroplasty for infected TKA (13 knees), (2) cases with poor preoperative range of flexion (7 knees), and (3) cases with patella infera (4 knees).
Results: Revision TKA combined with TTO allowed a good operative field of view. In 4 knees, the patellar tendon became detached, necessitating reconstruction. Combined TTO appeared to be necessary for 28 knees (72%). Bone union was obtained in 21 knees (83%). Complications occurred in 3 knees (dislocation and fracture of the TT), and one of these 3 knees was fixed again. Dislocation of the TT occurred in the remaining 2 knees for which re-fixation was not performed, however, no clinically significant extension lag was observed.
Conclusion: If arthroplasty with an augmentation-type prosthesis is combined with TTO, the basal cancellous bone of the TT is sometimes lost. Dislocation and fracture of the TT are more likely to occur in the absence of the basal cancellous bone. TTO performed by the technique reported by Whiteside was not associated with any clinically significant extension lag.

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Objective: Most patients with rheumatoid arthritis (RA) have the joint damage in their wrists and fingers, but joint destruction in the large joints has a severe influence on the activities of daily living (ADL). We therefore scored almost normal joints including the bilateral shoulders, elbows, hips, knees, ankles and the neck based on a point system, with the maximum possible score being 12 points (Neck Large Joint (NLJ) Score 12). As the progressive group 102 RA patients treated with 153 total knee arthroplasties (TKAs-TKA group) were followed up for 5 to 15 years. As the control group 104 early RA patients followed up for 10 to 20 years were selected.
Methods: We evaluated the functional scores for the Japanese Orthopaedic Association (JOA Score), Neck Large Joint Score 12 (NLJ Score 12), Disease Activity Score (DAS) 28 and the RA class.
Results: The JOA score was 42 points at operation, 81 at 5 years and 72 at 10 years. The NLJ score 12 was 8.8 at 5 years, 7.3 at 10, 6.7 at 15, 5.8 at 20, 4.2 at 25 and 3.3 at 30 years. DAS 28 did not correlate with the JOA score and NLJ Score12. In the TKA group the destruction of four large joints had occurred at five years from onset and that of one large joint in the next five years. On the other hand in the early RA group with conventional DMARDs therapy, destruction of one large joint occurred every five years.
Conclusion: RA patients treated with TKA were the progressive group, because the destruction of four large joints in the RA TKA group occurred during the first five years from onset.

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Objective: It is well known that the patients with rheumatic diseases, such as rheumatoid arthritis (RA), systemic lupus erythematosus and psoriatic arthritis, often develop small joint destruction symmetry. We report herein on the mid-term result of bilateral simultaneous forefoot arthroplasty with the modified Mann methods in patients with rheumatic diseases.
Methods: Ten feet on five patients were operated on. Four patients had RA, and the other had systemic lupus erythematosus. All were women. The mean age at surgery and duration of the affected disease were 54.2 years (5057) and 179 months (115264), respectively. The modified Mann method was applied with a follow-up period of 32 months (range, 1166 months). For lesser toes, metatarsal bone offset osteotomy with preservation of the metatarsophalangeal (MTP) joint was applied for six feet, and resection arthroplasty of MTP joint for four feet. We surveyed radiographic measurements during the follow-up.
Results: The mean operation time and duration of hospitalization were 204 (185228) minutes and 29 (2537) days. The patients were able to walk one or two days after surgery with non-weight bearing orthosis of the forefoot. After three weeks, the patients were allowed to walk using full weight bearing with an arch support. Neither disuse of muscle nor bone atrophy was seen in any patient. The Japanese society for Surgery of the Foot RA foot ankle scale was improved to 74 (5896) from 39 (3345) on average. The mean hallux valgus angle improved to 20 (1129) degree from 39 (2751), M1M2 angle to 9 (516) from 14 (1020), and the M1M5 angle to 24 (1931) from 30 (2535), respectively. However, the correction of the hallux valgus angle had decreased at the most recent follow-up compared to that post-surgery. Recurrence of deformity of more than 20 degree of hallux valgus angle formed in three cases at the most recent follow-up, though they had few complain clinically.
Conclusion: The bilateral simultaneous forefoot arthroplasty with the modified Mann methods in rheumatoid patients was useful to prevent disuse atrophy and decrease the operative and hospitalization times, because the patients were able to stand and walk very quickly postoperatively with a non-weight bearing orthosis of forefoot after bilateral surgery. It is necessary to improve this method to prevent causing re-deformity, although none of the patients complained about the evident clinical problems.

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Infections of the sacroiliac joint are uncommon and diagnosis is usually delayed. Bone and joint involvement in tuberculosis accounts for 1.8% of all tuberculosis cases (2006, Japan). Approximately 1% to 10% of skeletal tuberculosis occurs in the sacroiliac joint. We describe a 74-year-old woman with tuberculous sacroiliitis presenting with right buttock pain and difficulty in walking. MRI of the pelvis showed an increased STIR signal in the right sacroiliac joint suggestive of sacroiliitis possibly of infectious origin. Open biopsy, computed tomography of the chest and bone scintigraphy established the diagnosis of tuberculous sacroiliitis without tuberculosis at other sites including the lung. Treatment with four antitubercular drugs was initiated. Soon after the medication was started, the patient became pain-free and able to walk without canes. Sacroiliac joint infection must be included in the differential diagnosis of low back pain or buttock pain. For the treatment of tuberculosis, early diagnosis will promote a better prognosis.

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