Locomotive organs play an important role in preserving the ability to perform activities of daily living. Loss or dysfunction of locomotive organs due to osteoporosis or other bone- or joint-related disease can result in decreased independence and bedridden status. Osteoporosis, in particular, is a major problem in older people because of bone fragility and results in pain and/or impaired walking ability after hip fracture and kyphosis after vertebral fractures. Risk factors for osteoporosis and osteoporotic fractures are low bone mineral density, prevalent fractures, excessive alcohol intake, and smoking. Furthermore, our study demonstrated that vitamin D deficiency (low 25-hydroxyvitamin D level) is associated with hip and vertebral fractures in Niigata, Nagoya, Tottori, and Kumamoto. Serum vitamin D level appears to be an index of fracture risk. Risk factors including vitamin D level should take into consideration in the aged population.

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Objective: Recently, the number of total knee arthroplasty (TKA) procedures has increased and this has led to an increase in the number of patients requiring revision TKA. The importance of preoperative planning in revision TKA is well known; however, it is difficult to use X-ray film during preoperative planning. Three-dimensional templating software called Athena has been reported to be useful in primary TKA. However, it is unclear whether Athena is useful as preoperative planning software in revision TKA. We investigated this theme using X-ray film and computed tomography (CT) images of inserted implants. We also report a case in which Athena was useful in revision TKA.
Methods: From October to December 2008, we investigated ten knees of seven patients who had undergone primary total knee arthroplasty, taking X-ray and CT images after surgery with a provided specific marker. We measured the resected bone thickness of bilateral distal femur and posterior condyles without cartilage and compared these bone thicknesses to the calculated thickness of the same sites; the implant positions were simulated postoperatively using Athena.
Results: Absolute values of the resected bone thickness from the calculated thickness of the medial and lateral distal femur were 1.4±0.36 and 0.9±0.20 mm, respectively. The absolute values of medial and lateral posterior condyles were 1.7±0.45 and 1.7±0.46 mm, respectively.
Conclusion: The absolute values of resected bone thickness from the calculated thickness in Athena were less than 2 mm in distal femur and posterior condyles. Our data has proved the satisfactory accuracy of Athena using X-ray film and CT images of inserted implants. We also experienced the preoperative planning of revision TKA using Athena. The epicondylar axis was identified and the rotational angle and position of the existing femoral component were evaluated. We were able to evaluate the joint line, with or without bone defects, and determine the necessity of an augmentation block in the femoral component. We concluded that Athena can be very useful in revision TKA as preoperative planning software.

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Objective: Curved periacetabular osteotomy (CPO) has been widely used to treat acetabular dysplasia. Computed tomography osteoabsorptiometry (CTOAM) is a useful method of predicting the long-standing stress distribution by measuring the pattern of subchondral bone density. The method is based on the theory that the distribution of subchondral bone density is directly related to the distribution of mechanical stress action on the joint. The purpose of this study was to evaluate the change in the stress distribution of the acetabular roof in a dysplastic hip before and after CPO.
Methods: We have been using CPO for patients with arthritis secondary to acetabular dysplasia since 2004. Seven hips that had undergone CT preoperatively and 24 or more months postoperatively were analyzed. The average patient age was 30.1 years (range, 17-54 years) and the average center-edge angle (CEA) was 4.8° (range, -5.6° to 17.4°) preoperatively and 33.9 (range, 15.7°-45.7°) postoperatively. CT values of the acetabular roof were uploaded to a computer and analyzed by software specifically designed for this study. The values were measured at each coordinate point and mapping data were depicted using a grayscale. For qualitative analysis, we transferred the grayscale mapping image to a color-scale map and compared mineralization patterns. The area ratio of the high-density area was analyzed.
Results: The stress concentration patterns seen before surgery were classified into two types: anterolateral, which was seen in four hips, and central, which was seen in the remaining three hips. When a comparison was made between CT scans at 1 year after surgery and scans at more than 2 years after surgery, the high-density area in four hips decreased, while three hips showed an increased high-density area. Three of the four hips with decreased bone density had a preoperative CEA of more than 10, and the other hip, that of a 55-year-old woman, had a preoperative CEA of -5.6°. All three hips with increased bone density had CEAs in the range from -5° to 3°.
Conclusion: A relationship between preoperative CEA and postoperative changes in stress concentration was found. Our results showed that CPO changed the stress concentration of the acetabulum, and the change may vary with the extent of preoperative dysplasia.

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Objective: The aim of this study was to evaluate the quality of cartilage in osteoarthritis (OA) of the knee with or without surgical treatment using 3-T delayed gadolinium-enhanced magnetic resonance image of cartilage (dGEMRIC) and T2 mapping.
Methods: This study included two groups: patients with primary medial OA of the knee (OA group: 10 men, 10 women; mean age, 56 years old) and OA patients after high tibial osteotomy and drilling of the medial femur sides (HTO group: 1 man, 2 women; mean age, 58 years old). In the OA group, cartilage of the femorotibial (FT) joint classified by Kellgren-Lawrence (KL) grade was analyzed using dGEMRIC and T2 mapping. In the HTO group, cartilage of the FT joint was evaluated.
Results: In the OA group, dGEMRIC on all sides of KL I joints revealed significantly increased cartilage compared to KL II joints. T2 mapping of the lateral femur and lateral tibial sides of KL I joints showed significantly decreased cartilage compared to KL III joints. In the HTO group, dGEMRIC of the medial femur side showed transient increases 2 and 7 years after HTO; however, the T1 value had decreased 10 years after surgery. In contrast, T2 mapping yielded the opposite results.
Conclusion: The evaluation of cartilage in OA knees using dGEMRIC and T2 mapping is useful for identifying early-stage OA (grade I) and determining the efficacy of various OA treatments.

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Objective: Venous thromboembolism (VTE) is a serious complication of total knee arthroplasty (TKA). The efficacy and safety of fondaparinux in the management of VTE was compared with that of aspirin. The dose-response relationship between 1.5 and 2.5 mg of fondaparinux was also evaluated.
Methods: The incidence of postoperative VTE was evaluated in 76 cases (62 patients) of TKA using 1.5 mg fondaparinux in 29, 2.5 mg fondaparinux in 17, and aspirin in 30 cases. Patients were examined for D-dimer 7 days after surgery; the postoperative blood loss was assessed from 1 to 7 days.
Results: The mean values of D-dimer were 9.66, 8.12, and 14.35 μg/ml in the groups administered 1.5 mg fondaparinux, 2.5 mg fondaparinux, and aspirin, respectively. The mean blood loss with 1.5 mg fondaparinux, 2.5 mg of fondaparinux, and aspirin was 167.8, 410.5, and 307.3 ml, respectively. The D-dimer values in the 1.5 and 2.5 mg fondaparinux groups were lower than those in the aspirin group.
Conclusion: Based on these findings, we infer that fondaparinux may effectively help prevent VTE following TKA. In addition, evaluation of postoperative blood loss demonstrated the safety of VTE treatment using 1.5 and 2.5 mg fondaparinux.

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Objective: Deep venous thrombosis (DVT) is a common complication after total knee arthroplasty (TKA) despite the use of prophylaxes. The blood stasis caused by use of a tourniquet during TKA is considered to be a major cause of DVT or pulmonary embolism (PE) after surgery. On the other hand, the use of a tourniquet is able to provide a bloodless field to facilitate surgery and allow cement interdigitation for fixation of components. We performed a prospective study to assess the relationship between the use of a tourniquet and the incidence of DVT after TKA.
Methods: Between July 2005 and December 2006, 39 patients (51 knees) who underwent primary TKA at our hospital participated in this study. Patients with a history of DVT or PE, a high preoperative serum level of D-dimer, and complications such as chronic renal failure, recent myocardial infarction, heart failure, or malignant tumor were excluded. Primary diagnoses of the patients were osteoarthritis in 41 knees, rheumatoid arthritis in 5 knees, and idiopathic osteonecrosis of the femoral and/or tibial condyle in 5 knees. Patients were divided into three groups (group A: unilateral TKA with a tourniquet, group B: bilateral TKA with a tourniquet, group C: unilateral TKA without a tourniquet).
 We performed venography on both legs preoperatively. Postoperative venography and pulmonary perfusion scintigraphy were also performed 9-15 days after surgery. To evaluate the swelling of the lower legs after TKA, we measured the circumference of the thigh, lower leg, and foot every week after surgery. Lower leg volume was measured at the same time.
Results: The average age at the time of the surgery was 73.5 years (69-81) for group A, 76.4 years (70-80) for group B, and 66.6 years (55-79) for group C. The average body mass index (BMI) at the time of the surgery was 25.8 (19.0-31.0) for group A, 27.9 (23.9-33.3) for group B, and 26.3 (22.5-29.9) for group C. The average age and BMI were not different between the three groups. The average time of surgery was 156 min for group A, 208 min for group B, and 149 min for group C. The average time of surgery was not difference between group A and group C. The average time of tourniquet application during surgery was 111 min in group A and 86 min for each leg in group B. The average time of tourniquet application during surgery in group A was significantly longer than that in group B (P<0.05). The average blood loss (during surgery/after surgery) was 200/825 ml in group A, 290/1468 ml in group B, and 507/801 ml in group C. The average blood loss in group C during surgery was significantly higher than that in group A (P<0.01). The average total blood loss and blood loss after surgery were not significantly different between the three groups. The mean value of serum D-dimer was significantly higher 1 week and 2 weeks after surgery compared with the mean value before surgery in all groups (P<0.05). The mean value of serum D-dimer in group B was significantly higher than that of the other groups 1 week and 2 weeks after surgery (P<0.05). The mean circumference of the foot in group B was significantly larger than that of other groups 1 week and 2 weeks after surgery (P<0.01). DVT was found in 6 of 19 patients (31.6%) in group A, 8 of 12 patients (66.7%) in group B, and 1 of 8 patients (12.5%) in group C. PE was found in 5 of 12 patients (41.7%) in group B; all cases of PE were asymptomatic and were identified as limited lesions of the lung. All cases of DVT in group B were found in the limb operated on first.
Conclusion: The incidence of DVT was low in the unilateral TKA group without a tourniquet. There was no difference in the average total blood loss between the three groups. We recommend performing TKA without a tourniquet.

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Objective: Patellar clunk syndrome is a complication of posterior-stabilized total knee arthroplasty and is related to the intercondylar box of the femoral component. The etiology of this syndrome is multifactorial. We investigated the incidence of patellar clunk syndrome after mobile-bearing posterior-stabilized total knee arthroplasty and considered the causative factors of this syndrome.
Methods: A total of 243 patients (192 women, 51 men; average age, 74.1 years) in whom 330 consecutive mobile-bearing total knee arthroplasties were performed using the Vanguard RP prosthesis (Biomet, Warsaw, IN, USA) were examined postoperatively to check for the presence of patellar clunk during knee extension. The patella had been resurfaced in 252 knees and had not been resurfaced in 78 knees. Radiographic analysis was performed in patients with patellar clunk.
Results: Six knees were diagnosed with patellar clunk syndrome (incidence, 1.8%). The patella had been resurfaced in all of these patients. The mean period of onset of symptoms was 4.5 months (range, 3-6 months), and the mean postoperative flexion angle was 120.8 (range, 110-125). No specific joint line changes were observed, and the patellar height was within the normal range. The mean tilting angle of the patella in patients with patellar clunk was 0.3 (range, -1 to +2).
Conclusion: The Vanguard RP prosthesis allows hyperextension of 12 and prevents the post from impinging against the anterior margin of the intercondylar box. However, the position of the box seemed to be one of the factors affecting patellar clunk syndrome. Further, an excellent range of motion is another important factor.

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Objective: Qvistgaard, et al. and Im, et al. reported the feasibility of guidance using ultrasound (US) for intra-articular hyaluronic acid (HA) injections for patients with knee osteoarthritis (OA) using lateral and medial patellar approaches, respectively. This study was designed to compare the accuracy rates and intensity of pain on injection between the lateral and medial approaches.
Methods: One hundred and sixteen patients with “dry” knee OA received injections using the lateral and medial approaches. Air (1 ml) was injected with simultaneous recording of US signals. Once intra-articular positioning of the needle was considered adequate, HA was injected and lateral radiographs were taken to confirm the accuracy from the air shadow. After each injection, participants reported the highest subjective pain level during injection using a visual analog scale (VAS).
Results: The accuracy rates when using the medial approach (110 out of 116, 94.8%) were significantly higher than those when using the lateral approach (96 out of 116, 82.6%), (P=0.003). However, the mean VAS pain level for injection via the lateral approach (31.2%±21.2%) was significantly lower than that for injection via the medial approach (38.4%±20.6%), (P=0.01).
Conclusions: In the lateral approach, the straight surface of the US probe does not match the curved surface of the thigh and the direction of the needle at the insert site was unclear. In the medial approach, the needle punctured through retinaculum tissue to reach the intra-articular space, and thus the VAS pain level during the injection was higher compared with that of the lateral approach.

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Objective: Total elbow arthroplasty (TEA) is a recognized procedure for the treatment of the painful arthritic elbow. We studied the clinical long-term results of TEAs in patients with rheumatoid arthritis.
Methods: Between 1993 and 1999, 21 elbows were replaced using Kudo Type-5 prostheses. In total, 4 humeral components and 17 ulnar components were fixed with cement, and 14 humeral components and 1 ulnar component were fixed without cement. Perioperative complications, changes in clinical symptoms, radiographic changes, and survival rates were assessed for an average of 11.9 years.
Results: Intraoperative fracture of the medial epicondyle occurred in two patients. These patients had exhibited neurapraxia of the ulnar nerve. One elbow was dislocated and immobilized with a brace. The mean arc of flexion/extension was 99° (66° at the preoperative examination) and supination/pronation was 127° (98° at the preoperative examination). Radiological loosening assessment was conducted using standard anteroposterior and lateral views. Three ulnar components had global radiolucent lines suggestive of loosening. The results of Kaplan-Meier survivorship in patients with loosening were 100% at 5 years after operation and 83% at 10 years.
Conclusion: Kudo Type-5 TEAs provide good pain relief in the arthritic elbow leading to high patient satisfaction and long-term survivorship.

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Objective: The objective of this retrospective study was to determine the responses to tocilizumab among 34 patients with rheumatoid arthritis (RA).
Methods: Information from 34 patients with RA who were treated with tocilizumab was analyzed. Disease activity was assessed using disease activity score 28 (DAS28). Treatment responses at week 12 and 24 were assessed using the response criteria of the European League Against Rheumatism (EULAR).
Results: Thirty-three (97.1%) patients completed 24 weeks of tocilizumab treatment. The mean DAS28-ESR values at weeks 12 and 24 decreased significantly compared to baseline values. The mean (±SD) DAS28-ESR value decreased significantly from 4.90 (±1.65) at baseline to 2.19 (±1.10) at week 24. At week 24, using the EULAR response criteria, good, moderate, and no responses were 63.6%, 30.3%, and 6.1%, respectively. A good or moderate response was achieved in 93.9% of patients. The overall incidence of adverse events (AEs) was 70.6% (serious AEs: 11.7%). All serious AEs improved with adequate treatment.
Conclusions: Tocilizumab was safe, tolerable, and clinically effective after 24 weeks for patients with RA.

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 This case report concerns a 44-year-old man who developed idiopathic osteonecrosis of the femoral head (ION), for which total hip arthroplasty was performed. The patient developed pure red cell aplasia (PRCA) at 33 years old and received steroid pulse medical treatment for this condition. Internal use of steroid medicine was continued for 6 years. The patient needed frequent red blood cell transfusions, receiving on average 1200 ml a month to improve anemia resulting from PRCA, but developed hemochromatosis and ION. To treat the left hip joint disorder, total hip arthroplasty was performed. Histologically, the synovium of the hip joint was papillary, and hemosiderin was deposited in this. We diagnosed this synovitis as hemosiderotic synovitis. In this case, nonconformity of the morphology of the joint was found along with denaturation of the cartilage as a result of ION. The possibility of synovitis and arthropathy were associated with internal hemorrhage of the joint, grit necrosis, immunoreaction caused by the damaged organization, and hemochromatosis.

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 Although fragments of glass are frequently embedded in human tissues as foreign bodies, most of these are found during primary treatment. A 35-year-old man presented to our hospital with complaints of locking in the right knee 13 months after a glass-related injury. Clinical evaluation revealed swelling and significant effusion without signs of infectious arthritis such as local warmth and redness. Joint puncture produced 60 ml synovial fluid mixed with blood. The presence of three foreign bodies in the knee joint was detected by both plain radiography and computed tomography. Arthroscopy identified these fragments as glass pieces trapped in the medial joint space, and demonstrated a meniscal tear and a widespread defect in the articular cartilage. After removing all three fragments, subchondral drilling was performed in the area with the cartilage defect. The symptoms subsequently improved. A second arthroscopy performed 3 months following the initial operation revealed that the area with cartilage defect was covered with fibrous cartilage. Considering the articular cartilage defect and meniscal tear occurring at a young age, there is a possibility of progression to osteoarthritis in the near future. The presence of foreign bodies in human tissue is a serious clinical problem. Most fragments embedded in an injured patient&rsquo;s limb are easily visible on standard roentgenograms. A careful radiographic search is necessary in the management of patients who may have been exposed to foreign bodies.

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