Objective: It is known that tacrolimus is effective in patients with rheumatoid arthritis (RA) that is poorly controlled by methotrexate (MTX) . However, there is no clear evidence as to whether tacrolimus when combined with MTX is more effective than tacrolimus alone. We studied retrospectively the efficacy of tacrolimus alone and in combination with MTX in an attempt to determine when therapy with tacrolimus should be changed because of lack of efficacy.
Methods: Seventy three RA patients treated with tacrolimus were analyzed retrospectively; 37 of 73 patients had received MTX concomitantly. Disease activity and clinical response were assessed by disease activity score 28/C-reactive protein (DAS28-CRP) and EULAR response criteria, respectively. The ratios of DAS28-CRP remission at 1, 3, 6, and 12 months from administration of tacrolimus were examined. Furthermore, the clinical response and CRP levels at 1 and 3 months were evaluated for prediction of remission at 12 months. We assessed CRP by calculating the ratio of the CRP level at the evaluation point to that at administration.
Results: At 12 months, DAS28-CRP remission was observed in 29.4% of patients in the MTX group and in 19.4% of the non-MTX group. In patients with high disease activity, no patients achieved remission at 1 month; however, at 3 months 19.2% of patients in the MTX group and 0% of the non-MTX group were in remission, and at 12 months, the results were 30.8% for the MTX group and 14.3% for the non-MTX group. Patients who had achieved moderate or good responses at 3 months made up 88.9% of patients in remission at 12 months and 42.9% of patients not in remission at 12 months. The CRP ratio at 3 months was 0.36 in patients in remission at 12 months and 0.86 in patients not in remission at 12 months. Patients whose CRP ratio at 3 months was less than 0.4 were significantly more likely to achieve remission at 12 months than those with a CRP ratio greater than 0.4 (odds ratio 23.1, p<0.0001) .
Conclusion: These data suggest that tacrolimus therapy combined with MTX is more effective than tacrolimus therapy alone, and that alternative treatment should be considered when the CRP ratio is greater than 0.4 at 3 months.

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Objective: Total hip arthroplasty (THA) in a completely dislocated hip can still be combined with a proximal femoral osteotomy for positioning the acetabular component in the true acetabulum. However, the bone stock and bone quality of the true acetabulum in a completely dislocated hip is usually poor. Therefore, the acetabular component must be place low in the hip center. This study investigated the perioperative results of low hip center acetabular components.
Methods: THA combined with a subtrochanteric osteotomy was performed on 67 completely dislocated hips. These hips were divided into three groups based on the hip center. The cup size, number of screws, and complications of the acetabular component were compared.
Results: Eleven hips (16%) were assigned to the high hip center group, 50 (75%) to the middle hip center, and 6 (9%) to the low hip center. There was no significant difference in the cup size and the number of screws between the three groups. One case of cup loosening was observed in the middle hip center group.
Conclusion: The perioperative results of placement of an acetabular component in the low hip center in completely dislocated hips showed good acetabular component fixation. The low hip center seems to be a good option when patients undergo THA for a completely dislocated hip.

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Objective: Previously, total hip arthroplasty (THA) for elderly patients suffering from osteoporosis and patients with rheumatoid arthritis (RA) has been done using cement to provide ridged primary fixation. Recently, however, the implants for cementless THA have advanced remarkably. Several authors have reported satisfactory results for cementless THA carried out in elderly patients and patients with RA whose bone qualities were considered to be poor. In this study, we attempt to demonstrate, using short-term results, the efficacy and safety of cementless THA carried out with the S-ROM system in elderly patients older than 70 years of age.
Methods: Between January 2006 and December 2007, 184 cementless THAs were performed using the S-ROM system at our institution. Cases in which simultaneous bilateral THA and revision THA were performed were excluded from this study, leaving 134 THAs in 134 patients. Among these 134 patients, 44 were older than 70 years of age, and 26 were followed up for a minimum of 24 months. The average age of these 26 patients (4 men and 22 women) at the time of surgery was 75.4 years. Initial diagnosis was osteoarthritis in 25 hips and rheumatoid arthritis in 1 hip, and the mean follow-up period was 31.2 months. We evaluated the clinical results (in terms of JOA score) and the radiographical findings.
Results: The mean JOA score was 41.7 preoperatively and 91.8 at the final follow-up. In all 26 patients, the S-ROM stem was biologically fixed by bone ingrowth fixation regardless of the canal flair index. In seven patients, femoral component subsidence of more than 2 mm was found, but there were no differences in clinical outcomes. In three patients, femoral fracture at the site of implantation occurred when press fitting, necessitating rigid fastening at the fracture site by circumferential wiring with nonabsorbable suture. Thus, postoperative treatment could be managed by a clinical approach in the same way as for the other patients.
Conclusion: In this study, we demonstrated satisfactory short-term results of cementless THA using the S-ROM system for patients whose bone quality was considered to be poor.

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One hundred eighty-four patients (26 men and 158 women with an average age at operation of 66.7 years) underwent total hip arthroplasty using tapered wedge-shaped cementless stems between 2005 and 2009. The average body mass index of the patients was 23.2 kg/m² and the primary diagnosis was osteoarthritis in 158 hips (79%). We performed radiographic evaluation (femoral canal shape, bone quality, stem alignment, bone reaction, and stem stability) in order to clarify the indication of tapered wedge-shaped cementless stems for patients with stovepipe canal and type C bone. We developed a novel technique for measuring the three-dimensional implant position, including the precise bone geometry and density data, using pre- and postoperative CT images and a 3D surface registration algorithm. We estimated micromotion (MM) between stem and bone by using this technique in order to analyze the primary stability of the stem. Femoral canal shape (Noble) was stovepipe in 15.5%, normal in 79.5%, and champagne-flute in 5.0%. Bone quality (Dorr) was type A (30.5%), B (62.5%), or C (7.0%). Stem stability was established through bone ingrowth fixation (Engh) for all canal shapes and bone types. The highest value of MM was 236.0 µm and the average was 61.0 µm. The percentage of the area with an MM value higher than 150 µm for the porous-coated surface was 13.6%. In conclusion, good stability of tapered wedge-shaped cementless stems was found in patients with stovepipe canal and type C bone by radiographic and biomechanical analyses.

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Introduction: Replenishing the bone defect is an important factor in revision total hip arthroplasty (THA). Various methods have been used to complement massive bone defects, and recovering the bone stock is an important issue. In this study, we used a large volume of hydroxyapatite (HA) to reconstruct the acetabulum, and examined the postoperative results.
Methods: From the patients who underwent THA at our hospital, 12 patients (12 hips) were selected who suffered from severe pain and whose acetabulum showed a significant amount of bone defect on radiographic analysis. Two patients were men and ten were women; they had a mean age of 63 years (2676). Eleven had osteoarthritis and one had avascular necrosis of the femoral head after traumatic injury. The mean observation period after the revision surgery was 12.8 years. We constructed the acetabulum using a large amount of HA granules and then fixed the cup with cement. In five patients, we also used Kerboull cross plate as the inner layer. Three patients also underwent revision of the femoral side. The JOA score was used for clinical evaluation. A plain anteroposterior radiogram was used for radiographic evaluation. We examined the following three factors: (1) collapse of the HA, (2) conditions of bone formation in the interface of the bone bed and HA, and (3) loosening and displacement of the cup.
Results: The mean JOA score improved from 51 to 67 after the surgery. On radiographic evaluation, bone formation was observed after about 3 months. After approximately 1 year, the interface of the bone and the HA was incorporated. After incorporation, there were no further changes on radiography. Collapse of the HA and displacement of the cup were not observed during 9.3 years of follow-up.
Discussion: When performing revision THA in patients with acetabulum bone defects, autologous bone, HA, allogeneic bone, or Kerboull and a large cup could be used to complement the defects. However, taking into consideration quality, quantity, and infection problems, HA can be effective in massive bone defects. Initial fixation and collapse on load bearing are the conventional concerns when HA alone is used during surgery, but these were not observed in our patients. We believe that using HA is effective for complementing large bone defects.

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Objective: We developed a new assistant device which is useful during bipolar hip arthroplasty (BHA) using the direct anterior approach (DAA). Trial reduction during DAA-BHA is difficult; however, the device, which we named “half cup”, makes it easy.
Methods: A single surgeon performed 15 DAA-BHAs between July 2008 and November 2009 in patients with femoral neck fractures. We divided the patients into two groups: those operated on using the half cup (HCU) or those operated on not using the half cup (HCN). In the HCN group (6 hips), conventional trial reduction was not performed; however, in all cases reduction of the inner head to acetabulum was performed as a substitute. In the HCU group (9 hips), trial reduction with the half cup was performed in each case. We evaluated the operating time, complications (e.g., fractures), and leg length discrepancy on X-ray in the two groups.
Results: The mean operating time was 78.2 (6684) min in the HCN group and 69.8 (6083) min in the HCU group. No complications were seen in either group. The mean leg length discrepancy was +0.5 (-3 to +5) mm in the HCN group and -0.7 (-2 to 0) mm in the HCU group. It seemed that the range of leg length discrepancies in the HCU group was smaller than that of the HCN group, and there was no positive value of discrepancy in the HCU group. Trial reduction was easily done in the HCU group.
Conclusion: In DAA-BHA, there were no significant differences in operating times or complications between the groups. However, the range of leg length discrepancies in the HCU group was less than that of HCN group. The half cup assistance device clearly made trial reduction easy and was useful for choosing appropriate implants.

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Objective: Arthroscopic synovectomy of the hip in patients with rheumatoid arthritis (RA) has not been reported. We investigated whether arthroscopic synovectomy is effective for rheumatoid hip by evaluating six patients followed for longer than 4 years after surgery.
Methods: Six patients who fulfilled the American Rheumatism Association (ACR) diagnostic criteria for RA were included in the present study. All patients were categorized according to Larsen. All patients were women with a mean age at operation of 57 (range 39-75) years and a mean follow-up period of 4.1 (range 4-4.5) years. The Larsen grade, disease activity, JOA score, and other treatments were examined.
Results: Before the operation, one patient was categorized as Larsen grade 1, one as grade 3, and four as grade 4. At the final evaluation, one patient was categorized as Larsen grade 3 and the others as grade 4. We observed a temporary improvement of serum C-reactive protein levels in all patients; however, 6 months after the operation, these had returned to preoperative levels. The mean JOA score improved from 45.3 to 56.5. All patients received preoperative treatment with disease-modifying antirheumatic drugs (DMARDs) and had a history of steroid use. Four patients used biologics during the postoperative follow-up period.
Conclusion: Arthroscopic synovectomy of the hip was useful for ameliorating joint pain but was not useful for managing structural damage. Four of the six patients managed to avoid total hip arthroplasty in the medium term.

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Objective: The gap balance has a relationship with the flexion angle in total knee arthroplasty (TKA), and the rotational position of the femoral component influences the gap balance in flexion. The objective of this study was to determine the relationship between the rotational position and the flexion angle after TKA.
Methods: Ninety-eight knees treated by posterior-stabilized TKA were evaluated in this study. The condylar twist angle (CTA) was measured, using the epicondylar view technique reported by Kanekasu et al., as the deviation of the posterior condylar axis (PCA) from the clinical epicondylar axis (CEA) at 1 year after the operation. Knees with external rotation compared with the CEA were assigned to the external rotation group, those positioned between the surgical epicondylar axis (SEA) and the CEA were assigned to the middle group, and those with internal rotation compared with the SEA were assigned to the internal rotation group. The flexion angle was measured for all knees.
Results: The external rotation group (n=12) had a CTA of 1.6°±1.0° and a flexion angle of 129.3°±9.4°, the middle group (n=37) had a CTA of -1.3°±1.1° and a flexion angle of 124.2°±12.5°, and the internal rotation group (n=49 knees) had a CTA of -5.4°±1.7° and a flexion angle of 118.4°±11.0°. The flexion angle in the internal rotation group was significantly lower than that in the external rotation group (p<0.05).
Conclusion: These results suggest that the flexion angle is lower when the femur component is placed in an internally rotated position relative to the SEA, compared to the angle when the femur component is placed in an externally rotated position relative to the SEA.

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Objective: Since porous tantalum resembles cancellous bone, it is unlikely to show stress shielding caused by physiological loads closer to normal on the peri-implant bone. Tantalum also has a high coefficient of friction and high porosity, and so strong fixation can be achieved immediately after surgery. We studied the interim results in patients with osteoarthrosis (OA) of the knee who had undergone total knee arthroplasty (TKA) using a porous tantalum tibial monoblock component.
Methods: The study involved 23 joints in 23 patients: 4 men and 19 women. The mean age at surgery was 74.0 years and the mean follow-up time was 5 years and 8 months. In preoperative testing, the range of motion, JOA score, and the presence/absence of a radiolucent line in plain X-rays were examined.
Results: The mean JOA score was improved. In many patients, the tip of the tibial components’ peg came into contact with cortical bone. The placement angle was rather good. No radiolucent line was observed in the examination. The mean operating time was 72.8±16.2 min and the minimum was 45 min.
Conclusion: The interim results for TKA using a porous tantalum tibial component to treat OA were good. Porous tantalum can be used as a material for cementless TKA to treat OA. A porous tantalum tibial component is a good choice after high tibial osteotomy in patients with OA.

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At our institution, the FINE Total Knee System (FINE) (Nakashima Medical, Okayama, Japan) has been used since December 2001. The femoral component of FINE was designed to automatically reproduce the physiological joint line at an oblique angle of 3° in the posterior condyle. The articular surface of the tibial medial condyle was designed to show high conformity and to obtain an increased conformity rate to the femoral component, thereby leading to enhancement of tibial internal rotation, with stability in the early stage of flexion secured simultaneously. Conversely, the articular surface of the tibial lateral condyle was designed to allow femoral rollback, thereby allowing tibial internal rotation by medial pivot motion. Some possible reasons for these observations are that FINE was designed to allow tibial internal rotation at 25° to approximately 30° and to allow high conformity of the inside and rollback of the outside. The number of operations performed has increased at Toho University, and 1008 joints had been treated by September 2009. The results achieved reflect the medial pivot motion and the clinical performance that were part of the design concept. However, the most important factor is operational technique. For example, it is important to do soft tissue balancing and to perform correct osteotomy and implantation. The implant design requires millimeter accuracy in placement, and care is necessary to avoid the possibility that an error of 1 mm or 1 might invalidate the design concept.

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Objective: We investigated the efficacy of our protocols for preventing venous thromboembolism (VTE) using physical therapy and unfractionated heparin.
Methods: Between 2006 and 2008, total knee arthroplasty (TKA) was performed on 129 joints in 117 patients (19 joints in 17 men and 110 joints in 100 women; average age, 72.8 years; 99 joints in patients with osteoarthritis, 30 joints in patients with rheumatoid arthritis). All patients were treated with unfractionated heparin (100 U/kg per day, continuous intravenous drip injection for 10 days) immediately after surgery in addition to undergoing physical therapy. The D-dimer levels were measured preoperatively and postoperatively on days 1, 3, 6, 10, and 14. VTE was diagnosed using lower extremity venous ultrasonography and multidetector row computed tomography (MDCT) when the D-dimer level increased to more than 10 µg/ml.
Results: The incidence of VTE was 20.9% among patients who underwent primary TKA. Pulmonary embolism (PE) was detected in seven patients (5.4%), but none of the lesions were symptomatic. A significant increase (P<0.05) in the D-dimer levels on postoperative days 6, 10, and 14 were observed in patients with VTE. The preoperative D-dimer levels were significantly higher (P<0.05) in patients with rheumatoid arthritis than in those with osteoarthritis. All seven patients diagnosed as having PE were affected with calf-type deep vein thrombosis (DVT), and six of these patients had soleal vein thrombosis. Regarding the factors associated with VTE, the only significant difference (P<0.05) that was observed was that the occurence of VTE in the operative limb was significantly greater than that in the nonoperative limb.
Conclusion: Unfractionated heparin administration in combination with physical therapy was useful for preventing VTE after TKA, and changes in the D-dimer levels were relevant to the onset of VTE. Even in cases with calf-type DVT, attention should be given to the possibility of an increased risk of PE.

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Objective: With the use of magnetic resonance imaging (MRI), idiopathic osteonecrosis of the knee can now be diagnosed at an early stage. We report the clinical results of 34 patients with this disease, some of whom received conservative treatment and some of whom underwent surgery.
Methods: Eleven male and 23 female patients with a mean age of 62.3 years (range 47-77 years) were involved in this study, and 36 knee joints were treated. Twenty-five patients (27 knees) had pathological changes in the medial femoral condyle, two in the lateral femoral condyle, four in the medial tibial plateau, and three in the patella.
Results: Surgery was performed on 16 knees with lesions of the medial femoral condyle, and the other 11 knees received conservative treatment. In these two groups, the body mass index (BMI) and the extent of necrosis showed significant differences. Of the four knees with lesions of the medial tibial plateau, two underwent surgery and two healed with conservative treatment.
Conclusion: In this study, we found that the use of MRI facilitated the early diagnosis of idiopathic osteonecrosis. There was a significant difference in BMI and the extent of necrosis between patients undergoing surgical and conservative treatments.

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Objective: We studied the effectiveness of autotransfusion by preoperative blood donation on lumbar spine surgery carried out at our hospital.
Methods: The study was based on 311 cases of surgery performed for lumbar spine injury during the period 2005-2007 for which the avoidance of allogeneic transfusion by means of autotransfusion was carried out. There were 113 male and 298 female subjects with an average age of 60.8 years at the time of surgery. The study looked at (1) the avoidance of autotransfusion; (2) the type of surgery and amount of bleeding, classifying surgery according to vertebra number and the use or nonuse of instruments; (3) the change in hemoglobin level before and after surgery; and (4) the discarding of (surplus) donated autologous blood in the above cases.
Results: Allogeneic blood transfusion was judged necessary in one case, giving a total avoidance rate of 99.7%. No complications with the patient were identified at the time of blood donation. In cases where instruments were used, bleeding was between 50 and 3600 g, averaging 944 g; in cases where instruments were not used, bleeding ranged from small amounts to 1400 g, averaging 286 g. Preoperative blood donation ranged from 400 to 1200 g, averaging 664 g. The hemoglobin concentration in the donated blood averaged 13.8 g/ml; following donation, the level was 12.7 g/ml just prior to surgery, 11.4 g/ml on the day after surgery, and 12.6 g/ml 2 weeks following surgery.
Conclusion: Bleeding and surgical time increase with vertebra number; both were significantly higher in cases with instrument use than in cases without instrument use. With an avoidance of allogeneic blood transfusion of 99.7%, autotransfusion by preoperative blood donation was found to be effective.

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Objective: The objective of this study was to clarify the characterizations of polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome.
Methods: Seven patients with PMR and 12 patients with RS3PE were compared in terms of the type of onset, the complication rate of carpal tunnel syndrome (CTS), the initial usage of doses of prednisolone (PSL), the tendency of recurrence, and laboratory examination results. The latter included a blood examination and C-reactive protein (CRP), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (CCP) antibody titers. Statistical analysis was done by chi-squared or Mann-Whitney tests. Results: The acute onset ratios for the PMR and RS3PE groups were 28.5% (2/7) and 75% (9/12), respectively (p=0.01). The complication rates of CTS were 4/7 (57.1%) and 6/12 (50%) and the serum concentrations of CRP (mg/dl) were 5.8 and 6.04 in the PMR and RS3PE groups, respectively. The recurrence rate was 6/7 (88%) in the PMR group and 4/12 (33%) in the RS3PE group (p=0.03). In this article, a case of PMR with concomitant CTS was presented as a sign of recurrence. We report the singular behavior of CTS in a female patient with PMR during treatment of PMR with PSL. At first the patients CTS condition was not noticed, but it became evident after treatment with PSL was initiated and even became exacerbated when the PMR condition had subsided and PSL treatment terminated. The CTS condition was relieved by surgically releasing the median nerve from compression and by resuming administration of PSL.
Conclusions: It was observed that patients with PMR were more likely to experience chronic onset and recurrence compared with those with RS3PE syndrome. Both diseases were likely to be complicated with CTS.

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