Reactive arthritis and inflammatory bowel disease (IBD)-associated spondyloarthropathy are diseases requiring differentiation from rheumatoid arthritis. Reactive arthritis occurs after preceding infection of the urogenital tract with Chlamydia trachomatis or after a preceding infection of the gut with enterobacteriae and runs a relatively rapid clinical course. The typical joint pattern is an asymmetric arthritis that develops predominantly in the lower limbs and presents as an oligo- or monoarthritis in the majority of patients. Moreover, the disease is frequently complicated by sacroiliac arthritis and is often associated with extra-articular manifestations such as urethritis, diarrhea, and ophthalmic symptoms (conjunctivitis, uveitis) . IBD-associated spondyloarthropathy is induced by IBDs such as ulcerative colitis and Crohn's disease and is characterized by clinical manifestations such as peripheral or axial arthritis and also by extra-articular manifestations such as ophthalmic and mucocutaneous symptoms. Juvenile idiopathic arthritis (JIA) is the general term for chronic arthritis of unknown cause occurring in children under the age of 16 years. JIA is classified into seven types: systemic, rheumatoid factor (RF)-negative polyarticular, RF-positive polyarticular, oligoarticular, psoriatic, enthesitis-related, and undifferentiated arthritis. Systemic JIA is characterized by systemic symptoms such as high fever (spiking fever), skin rash, pericarditis, and lymphadenopathy, as well as joint symptoms; however, polyarticular JIA is mainly characterized by joint symptoms, suggesting the existence of differences between these pathologic conditions. Moreover, most children with RF-positive polyarticular JIA are positive for anti-cyclic citrullinated peptide (anti-CCP) antibodies, but those with systemic and oligoarticular JIA are negative for anti-CCP antibodies. In general, the pathologic manifestations of polyarticular JIA are considered to be similar to those of adult rheumatoid arthritis, while systemic JIA is called Stills disease; if this condition occurs after the age of 16, it is referred to as adult-onset Stills disease. Adult-onset Stills disease is an important cause of fever of unknown origin, requiring differentiation from seronegative rheumatoid arthritis or malignant rheumatoid arthritis.

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Objectives: Japanese orthopedists can play an important role in care prevention in an aging society. According to the report of nursing care levels published by the Ministry of Health, Labour and Welfare, a major cause of requiring light care is bone and joint disease, while, on the other hand, a major cause for requiring more extensive care is cerebral infarction and dementia, among others. This fact suggests that Japanese orthopedists should be given the opportunity to promote care prevention related to bone and joint disease. We report the effect and significance of an underwater exercise scheme that we conducted as care prevention and community support projects.
Subjects and Methods: We conducted two sets of underwater exercises (a knee pain course and an obesity course) for elderly people with knee osteoarthritis and overweight people in two municipal areas (Ino town and Muroto city, Kochi Prefecture, Japan). Fifty-three elderly people (Ino town) and 50 (Muroto city) with knee osteoarthritis participated in this study. Overweight participants in Ino town and Muroto city numbered 37 and 23, respectively. The underwater exercise in this study consisted of stretching, strength training, and underwater walking. The obesity group was taught aerobic exercises that were regulated using the Karvonen formula (k = 0.4). Underwater exercise was done for 60 min at a time, two or three times a week. Elderly people with knee osteoarthritis carried out these exercises for 6 weeks, and overweight people carried them out for 20 weeks. Muscle strength (quadriceps and gluterus medius) was evaluated using a hand-held dynamometer and UP & GO tests in the joint disability and obesity groups. Moreover the former was investigated using the Japanese Knee Osteoarthritis Measure (JKOM) and the latter’s weight, abdominal circumference, and blood pressure was measured.
Results: Muscle strength of the lower extremities significantly increased in the joint disability and the obesity groups. The joint disability group significantly improved from 32.4 to 24.3 in the visual analog scale score of the JKOM. The obesity group significantly decreased in weight, abdominal circumference, and blood pressure.
Conclusion: Underwater exercise makes it possible to alleviate the load on the knee joint as a result of the buoyancy principle and enables exercise that requires larger forces than that on land through the use of water viscosity. Underwater exercise, therefore, is intensive, efficient, and effective. From the standpoint of health promotion and prevention of nursing care, underwater exercise is of great significance as an exercise for elderly people with joint disorders.

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Objective: We report an investigation of the clinical results in cases of infection following total knee arthroplasty (TKA).
Methods: The treatment strategy for infected artificial knees at our hospital is to perform debridement and irrigation soon after the infection is diagnosed in an attempt to preserve the components. If the infection is not brought under control by this treatment, the components are removed and a two-stage revision is performed. A total of 35 patients (35 joints) were treated for postoperative infection following TKA at our hospital. The following aspects were investigated for 32 patients (32 joints) who could be followed up for more than 1 year after treatment for infection: 1. the presence of risk factors for infection, 2. the timing of infection onset, 3. the time from the onset of infection until treatment was started, 4. causative organism, and 5. clinical outcome.
Results: In the 32 patients with infection after TKA who were followed up, twelve prosthetic joints (37.5%) were ultimately preserved, while the other 20 (62.5%) were removed. Among patients in whom treatment was started within 2 weeks of the onset of infection, 12 of 16 joints (75.0%) were preserved, but for cases in which treatment was started after 2 weeks, None of 16 joints were preserved. The prosthetic joint was preserved in all 5 cases for which Streptococcus was the cause of infection in the joint. In contrast, only 1 of 9 prosthetic joints (11.1%) infected with methicillin-resistant Staphylococcus aureus and none of the 5 joints infected with Staphylococcus epidermidis were preserved. Of the 20 joints from which the prosthesis was removed, a two-stage revision was completed in 16 joints with a mean waiting period of 7.1 weeks. Infection was controlled in 14 of these 16 joints (87.5%).
Conclusion: In patients suffering infection after TKA, 37.5% of the components could ultimately be preserved. The time from onset of infection until the start of treatment and the causative organism are thought to be important factors in selecting the type of treatment and in the prognosis of infection.

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Introduction: Rheumatoid arthritis (RA) frequently affects the finger joints. Persistent synovitis of finger joints is believed to cause not only bone destruction but also various severe deformities of the hands. We report five cases of surgical intervention for finger deformities in RA patients.
Patients and Methods: Case 1 involved a 51-year-old woman who presented with severe finger deformities (thumb deformity, 2345MP ulnar deviation, and volar dislocation). She had undergone multiple surgeries of the fingers: 12345MP arthroplasties. Case 2 involved a 70-year-old woman who presented with severe finger deformities (thumb deformity, 2345MP flexion contracture, and volar dislocation). She had undergone multiple surgeries of the fingers: wrist synovectomy, 1CM joint arthroplasty without implant, 1MP joint arthrodesis, 2345MP arthroplasty with implants, and tendon transfer. Case 3 involved a 59-year-old woman who presented with severe finger deformities (thumb deformity, 2345MP swan-neck deformity, volar dislocation, and ulnar deviation). She had undergone multiple surgeries of the fingers: wrist synovectomy, 1MP joint arthroplasty without implant, 1IP joint arthrodesis, 2345MP arthroplasty with implants, and lateral band mobilization of 345PIP joints. Case 4 involved a 65-year-old woman who presented with severe finger deformities (thumb button-hole deformity, 345MP dislocation/ulnar deviation). She had undergone multiple surgeries of the fingers: wrist synovectomy, 1MP joint arthroplasty without implant, 345MP arthroplasty with implants, and 5PIP arthrodesis. Case 5 involved a 44-year-old woman who presented with swelling and severe instability of the left wrist. She had undergone total wrist fusion with β-tricalcium phosphate.
Results: The patients were satisfied with the functional and cosmetic improvement after the surgery.
Conclusion: We recommend surgical intervention for finger deformities in RA patients.

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Osteoporosis, a reduction in bone strength, is a disease of increased fracture risk, leading to enforced morbidity due to chronic pain and skeletal deformity and a consequent increase in mortality. Thus, a reduction of fracture risk is just a prerequisite, and decreases in morbidity and mortality are expected as further goals of osteoporosis treatment. Evidence has accumulated to indicate that treatments with amino-bisphosphonates and selective estrogen receptor modulators reduce fracture risk, maintain activities of daily living and quality of life, and decrease the death rate. The bone and joint destruction of rheumatoid arthritis is suspended by methotrexate and/or biological agents. The repair of bone erosion is obtained by drug therapy, but the repair of articular cartilage is difficult. Nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular injection of hyaluronic acids and glucocorticoids are used for patients with osteoarthritis. However, there are currently no clinical interventions proven to restore cartilage and inhibit disease processes in osteoarthritis. The upper gastrointestinal tract injury associated with NSAIDs is a serious clinical problem. As a result, the use of COX-2 inhibitors and the use of oral NSAIDs with misoprostol or a proton pump inhibitor are recommended for gastroprotection. Also, the use of opioids and/or pregabalin is recommended as a further step in the treatment of chronic pain in bone and joint diseases.

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The lumbar facet joint has been considered an origin of low back pain along with the intervertebral disc. However, there has been considerable controversy over the facet joint as a specific source of pain. Several researchers have tried to postulate a definition of “facet syndrome”, although it has not yet been determined as a unique clinical entity. The following subjects were discussed in the current report: (1) functional anatomy of the facet joint, (2) historical background, (3) facet syndrome, (4) facet joint and lumbar spinal stenosis, (5) facet joint injection and the medial branch of the dorsal ramus block, and (6) basic studies and future perspectives.

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Objectives: We investigated the factors affecting polyethylene (PE) wear in cementless total hip arthroplasty (THA) patients followed up for more than 10 years after the operation.
Methods: Forty-one patients who underwent cementless THA (43 hips) were successfully followed up for more than 10 years postsurgery. The diagnoses were osteoarthritis (35 hips) and avascular necrosis of the femoral head (4 hips). The average age at surgery was 57.9 years, and the average follow-up period was 11.1 years. In all cases, the following Biomet prostheses were used: finned porous socket (Mallory/Head), Ringloc Type (ArCom) and Bi-Metric stem, with 28-mm head made of either CoCr (22 hips) or zirconium (21 hips). We studied the correlation between the PE wear on X-ray and the following factors: patient age, sex, weight, body mass index, PE thickness, setting angle and position (upper deviation ratio, outer deviation ratio) of the THA, lever-arm ratio, and osteolysis.
Results: There was a significant difference in average annual liner wear between the group with osteolysis (a.v. 0.09 mm) and the group without osteolysis (a.v. 0.06 mm). No significant difference was found for the other factors.
Conclusion: Our previous study on Hexloc conventional type PE liners established the factors affecting wear as follows: femoral head, age at operation, inclination angle, and liner thickness. In this study on the Ringloc acetabular liner (ArCom), however, we did not find any correlation of those factors to the wear, suggesting that better clinical outcomes can be expected by improving the locking mechanism and PE wear resistance. Considering the high wear rate in the group with osteolysis, we assumed that a long-term follow-up study on the correlation between osteolysis and PE wear would be useful.

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Objective: Large-diameter metal-on-metal total hip arthroplasty (LDMOM-THA) has been proposed to reduce wear and postoperative dislocation. This study assesses the clinical effectiveness and complications of LDMOM-THA.
Methods: We performed cementless LDMOM-THA in 14 patients (15 hips). The mean age of patients at the time of surgery was 65.3 years (range 39-86 years). Adaptation of LDMOM-THA was done for elderly patients who had high risk for postoperative dislocation and for high-activity patients who required a large range of hip joint motion. All procedures were performed using a posterolateral approach and general anesthesia. The mean diameter of the head of the femoral component was 45.5 mm (range 40-50 mm). Average follow-up was 4.5 months. Preoperative and postoperative Japanese Orthopaedic Association (JOA) hip scores were recorded for all patients.
Results: The average preoperative JOA score was 45.8, contrasted against 86.7 at the last follow-up. The average preoperative range of motion of the hip joint was 60.5 in flexion, -10.2 in extension, 10.5 in abduction, and 5.4 in adduction, contrasted against 98.2, 4.5, 20.4, and 10.3 at the last follow-up. Four patients were able to squat on their heels. One superficial wound infection occurred, but no intraoperative fracture, dislocation, deep infection, deep-vein thrombosis, or pulmonary embolism occurred.
Conclusion: Our findings suggest that LDMOM-THA can produce satisfactory results in the short term. For elderly patients, LDMOM-THA was useful, especially for those with weak muscles and reduced cognitive function; the procedure was also useful for patients who required a large range of hip joint motion postoperatively.

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We investigated the relationship between motor function and ambulation ability for 22 patients (24 hips) who underwent total hip arthroplasty at our hospital before surgery and at 1, 2, and 3 weeks after surgery. Compared to before surgery, there was no decrease in hip abductor muscle strength after surgery, but there were significant decreases in quadriceps muscle strength at 1 and 2 weeks after surgery. Possible reasons for the lack of decrease in hip abductor muscle strength after surgery are extension of the angle of rotation of the hip joint and alleviation of pain when walking. Since quadriceps muscle strength is related to the ability to walk with a T-handle walking stick after surgery, postoperative physical therapy programs should pay attention to the quadriceps muscles.

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Objective: The purpose of this study was to evaluate the factor of joint space narrowing (JSN) from the perspective of femoroacetabular impingement on postoperative patients who had undergone surgery for slipped capital femoral epiphysis.
Methods: After a mean follow-up of 7.7 years, we reviewed 19 hips in 17 patients who had undergone surgery for slipped capital femoral epiphysis. The mean age at the time of surgery was 12.7 years. The type of surgeries were in situ pinning in 7 hips, pinning after reposition in 1 hip, simple flexion osteotomy in 2 hips, Southwick osteotomy in 4 hips, and Sugioka’s osteotomy in 5 hips. We investigated the frequency of JSN and the relationship between JSN and various factors (neck-shaft angle, CE angle, AC angle, postoperative posterior tilting angle, cross-over sign, posterior wall sign, medial proximal femoral angle, alpha angle, head-neck offset ratio, and bony prominence).
Results: JSN was found in six hips (32%). All JSN in these hips was less than 2 mm. JSN was correlated with the head-neck offset ratio (P = 0.003) and bony prominence (P = 0.04).
Conclusion: We found significant correlation between the head-neck offset ratio and bony prominence, and these factors were associated with cam type impingement and JSN. However, further longitudinal studies are required to confirm whether a cam-type deformity will ultimately develop to progressive osteoarthritis.

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Objective: We studied the relationship between rotation of the femoral component and patellar tracking by computed tomography (CT) and X-ray imaging before and after total knee arthroplasty.
Methods: Fifty-six primary total knee arthroplasties using the Duracon total knee system (Stryker) were carried out in 53 patients. The femoral components were implanted in 3 external rotation to the posterior condylar axis. The posterior condylar angle (PCA) and the condylar twist angle (CTA) were measured by CT before and after the operation, and patella tilt was measured using X ray and CT imaging before the operation.
Results: The average PCA before TKA was 3.86°±2.19° and the average CTA was 7.38°±2.20°. The average PCA after TKA was 0.43°±2.54° and the average CTA was 3.95°±2.63°. Patellar tilt after the operation was 1.07°±5.75° as measured by CT (0° knee flexion), 3.70°±5.91° at 30 knee flexion, 1.84°±5.51° at 60° knee flexion, and 0.39°±4.65° at 90° knee flexion. Patella tilt tended to increase after the operation in patients in whom the CTA and PCA also increased after the operation. The correlation between PCA and patella tilt was higher than that between CTA and patella tilt after the operation.
Conclusion: In TKA, it is preferable to set the femoral component parallel to the surgical epicondylar axis (SEA) to improve patellar tracking after the operation.

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Objective: The objective of this study was to evaluate the clinical results and problems associated with ankle arthrodesis using an intramedullary nail with fin.
Methods: Ankle arthrodesis was performed using an intramedullary nail with a fin to treat eight rheumatoid arthritis (RA) patients and two osteoarthritis patients. The mean age at surgery was 59.2 years and the mean follow-up time was 3 years and 6 months. All arthrodesis operations were performed by the transfibular approach. The distal portion of the fibula was removed and used as a bone graft. The articular cartilage of the talocalcaneal joint was not removed. Clinical evaluation was assessed by the patients’ pain and the union of the tibiotalar and talocalcaneal joints.
Results: Tibiotalar arthrodesis was achieved after surgery in all patients. The patients were able to bear weight fully in an average of 5.6 weeks and the preoperative pain levels were ameliorated. Talocalcaneal arthrodesis was not achieved in five cases. These patients experienced gradually increasing pain in the talocalcaneal joint; therefore the implant was surgically removed. However, two of those patients with RA showed persistent pain and another patient with RA developed a valgus deformity of the calcaneus.
Conclusion: An intramedullary nail with a fin was found to be a very useful means of arthrodesis for patients with RA requiring union of the tibiotalar and talocalcaneal joints. Careful postoperative observation of the talocalcaneal joint is necessary, because nonunion of the talocalcaneal joint can cause further pain.

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