Objective: We radiologically examined changes in spine and lower extremity alignments in patients after they underwent total hip arthroplasty with shortening osteotomy for high dislocation of the hip.
Methods: The present study involved eight hip joints in seven patients (six women and one man). The Crowe classification was type III in two hip joints and type IV in six hip joints. The mean age of the patients at the time of operation was 59.1 years, and the mean follow-up period was 1 year and 9 months.
Results: The mean leg length discrepancy decreased from 4.4 cm before surgery to 1.8 cm after surgery. The mean Japanese Orthopaedic Association score improved from 48.4 points before operation to 78.8 points at the final observation. The femorotibial angle of the operated sides improved from a mean valgus angle of 167.6° before surgery to 172.3° after surgery. Lateral pelvic tilt improved from a preoperative mean angle of 12.5° to a postoperative mean angle of 7.9°. Lumbar spinal curvature decreased from a mean Cobb angle of 20.0° before surgery to 15.1° and after surgery. Pain of the low back and knee joint showed improvement with these alignment changes.
Conclusion: Some patients with marked leg length discrepancies had pelvic tilt and secondary low back pain and knee joint pain, but reconstruction of the hip joint in the primary acetabulum with osteotomy was effective for improving not only the leg length discrepancy but also the lumbar and knee joint alignments.

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Objective: We studied roentgenographically the adverse factors affecting femoral neck fractures treated with Hansson pins.
Methods: Between January 2007 and June 2010, we performed 75 femoral neck fracture fixations with Hansson pins. The average age at surgery was 70.2 years (range: 43-96 years) and the average follow up was 13.5 months (range: 6-38 months). To study the association with complications, the following clinical factors were evaluated: the Garden alignment index (GAI) of the lateral view, the distance of the subchondral bone of the femoral head from the Hansson pin, and the height of the distal Hansson pin.
Results: The GAI of the lateral view was statistically significantly lower in the necrosis of the femoral head group (155.0±25.2) than in the non-necrosis of the femoral head group (174.1±11.0, P < 0.05); the GAI of the lateral view was also significantly lower in the non-union group (158.3±16.9) than in the union group (174.3±11.4, P < 0.01). No significant difference was found in the distance of subchondral bone of the femoral head to the Hansson pin between the non-union group and the union group. The height of the distal Hansson pin was significantly different between the subtrochanteric fracture group (−6.8±6.1 mm) and the non-subtrochanteric fracture group (5.2±6.2 mm, P < 0.05).
Conclusions: To achieve favorable reduction, position and pin position are important to lower the risk of complications.

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Background: For patients with osteoarthritis of the knee who experience persistent deep flexion pain, we offer, at our institution, the option of unicompartmental knee arthroplasty (UKA) using the Oxford high-flex knee prosthesis (Biomet, Warsaw, Indiana, USA), which is designed for deep flexion. We report the outcome of patients treated with the Oxford implant.
Methods: Twelve patients (1 man, 11 women) with a mean age at the time of surgery of 67.1 (range: 54-78) years with a preoperative Japanese Orthopaedic Associate score of 61.7 (range: 40-75) points were included in the study. Preoperatively, all patients experienced pain when climbing or descending stairs or squatting. The mean time since surgery was 15.6 (range: 6-24) months.
Results: All symptoms improved after surgery. The mean flexion angle improved from 134.5° (range: 100°-140°) before surgery to 140° (range 130°-150°) after surgery. Of the various items scored, the pain score for climbing and descending stairs improved from a preoperative 11.3 points (range: 5-15) to a postoperative 20 points (all scored 20 points).
Conclusion: Preoperative pain during flexion improved after surgery in all cases, suggesting that UKA is an effective treatment method.

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Objective: The aim of the present study was to examine the association between the incidence of surgical site infection (SSI) and the duration of antimicrobial prophylaxis (AMP) and to analyze whether a short-duration AMP is appropriate for surgery in patients with rheumatoid arthritis (RA).
Methods: The clinical records of 508 patients with RA who underwent orthopedic surgery from 2004 to 2010 were retrospectively reviewed. The incidence of SSI in the short-duration group (AMP discontinued within 36 h after surgery) was compared with that in the long-duration group.
Results: SSI was recognized in 10 patients (2.0%). Although the incidence of SSI in the short-duration group (1.5%) was lower than that in the long-duration group (2.3%), the difference was not statistically significant (p = 0.8). There were also no significant differences in the incidence of SSI between different AMP agents (piperacillin, cefazolin, cefmetazole, and cefotiam).
Conclusion: The incidence rates of SSI did not differ between patients receiving AMP for a short or long duration. Our results were similar to those of previous studies on SSI in total joint arthroplasty mainly for osteoarthritis. Based on these findings, we recommend a short duration of AMP, even in patients with RA.

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Objective: This study was performed to evaluate the synovium of patients with rheumatoid arthritis (RA) who had undergone treatment with tumor necrosis factor α (TNFα) inhibitors.
Methods: Synovial tissue specimens were obtained during total knee arthroplasty from 62 RA patients (11 men, 51 women). Thirty-two RA patients had undergone treatment with anti-TNFα agents (biologics group: B group) and the other 30 RA patients had not (non-biologics group: N group). Fifteen RA patients had been treated with infliximab and 17 with etanercept. We further divided the B group into two subgroups: one in which the treatment was effective (B+group: DAS28 ≤ 3.2) and one in which the treatment was not effective (B−group: DAS28 > 3.2). The effectiveness of biologics was evaluated using the histological scoring system reported previously by Koizumi, by the synovitis score of the OMERACT RA magnetic resonance imaging scoring system (RAMRIS), and by the intraoperative macroscopic findings as reported by Østergaard. Koizumi's synovitis scoring system is made up of five items. The clinical laboratory data before surgery, such as matrix metalloproteinase-3 (MMP-3) levels and DAS28 scores, were also evaluated and the correlations with the histopathological findings were examined within each group.
Results: There were no significant differences in total Koizumi scores between B+, B−, and N groups. However, the scores of synovial cell proliferation were significantly different between the B and N groups. There were no statistically significant correlations between the Koizumi score and clinical data (such as the DAS28 score and MMP-3 level) for any pair of groups. Synovitis RAMRIS scores were very similar in the B and N groups, but macroscopic findings in the B group, for both B+ and B− subgroups, were significantly lower than those in the N group.
Conclusion: These results suggest that clinical data do not always reflect the conditions of severely arthritic joints in patients treated with TNF-α inhibitors.

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Objective: We assessed the effect of deep vein thrombosis (DVT) on the restoration of the range of motion (ROM) after total knee arthroplasty (TKA).
Methods: Ninety-five knees in 85 patients who underwent primary unilateral TKA were investigated. The same posterior-stabilized prosthesis was implanted in all knees by using a uniform surgical technique. Physical prophylaxis was prescribed for all knees; in addition, 1.5 mg fondaparinux was injected subcutaneously once daily for 10 days after surgery in 77 knees (81.1%) as prophylaxis against DVT. DVT was confirmed using ultrasound when symptoms of DVT occurred or when plasma D-dimer levels on postoperative days 3 or 7 were ≥ 10 μg/ml. We found that 15 patients had developed DVT. The fifteen knees with DVT (group D) and 80 knees without DVT (group C) were compared.
Results: Patient characteristics such as age at surgery, gender, and body mass index were similar in the two groups. The ROM was not significantly different between the groups before surgery or at 3 months after surgery. However, the average active flexion at 1 week after surgery was 81° for group D and 89° for group C. The average postoperative days on which the patients achieved 90° of flexion were 11.8 days for group D and 7.0 days for group C. These differences were statistically significant (P = 0.019, P = 0.0064, respectively).
Conclusion: This study showed that DVT delayed the return of early flexion after TKA. Leg pain and swelling associated with DVT, transient discontinuation of postoperative rehabilitation, and anxiety about the development of pulmonary embolism during physiotherapy may interfere with the restoration of ROM.

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Objective: Total elbow joint arthroplasty has limited longevity and is therefore not appropriate for younger rheumatoid arthritis (RA) patients. Arthroplasty using an inter-positional membrane may be another surgical option for this population. However, clinical results for joint arthroplasty using an inter-positional membrane have not traditionally been favorable because rheumatoid activity could not be controlled. Today, rheumatoid activity can be controlled with biologics; therefore, the utility of the inter-positional membrane procedure was re-evaluated.
Methods: An 8×6-cm sheet of fascia was detached from the patient's tensor fascia lata muscle to produce a JK membrane. The fascia was stretched on a frame and kept in a 2% chromic acid potassium solution for 24 h. Then, the fascia was exposed to direct sunlight to reduce the dichromic acid. The fascia was washed in running water for 24 h and was then stored in phenol with the addition of 70% alcohol. Elbow arthroplasties were performed on three elbow joints in two young female RA patients (32 and 34 years old). The first patient had a significantly damaged right elbow joint with severe joint dysfunction. A JK-membrane arthroplasty was done in 2003, when the patient was 34 years old. Biologics were administered with methotrexate after the surgery. The second patient demonstrated bilateral ankylosed elbows as a result of idiopathic juvenile arthritis. Bilateral JK membrane arthroplasties were performed in 2010, when the patient was 32 years old. Several operative and manual manipulations were necessary to increase the range of motion following surgery. Biologics were administered with cyclosporine.
Results: Joint function was significantly improved in all three joints without pain after the JK-membrane elbow arthroplasties. In the first patient, the Japan Orthopaedic Association (JOA) elbow score improved from 21 points before surgery to 85 points after surgery, and active elbow flexion improved to 110° following surgery. In the second patient, the JOA elbow score was 55 and 82 points in the right elbow and 52 and 83 points in left elbow before and after surgery, respectively. Active flexion improved to 120° for the right elbow and 110° for the left elbow following surgery. RA was well controlled in both patients.
Conclusion: Elbow arthroplasty using an inter-positional membrane appears to be useful in young patients when RA activity is controlled with biologics.

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Recently, the benefits of converting an ankylosed or arthrodesed hip to total hip arthroplasty have been well documented; however, there are few reports showing the results of minimally invasive total hip arthroplasty (MIS-THA) for ankylosed hip. In this study, we report a case of arthrodesed hip treated by MIS-THA using the anterolateral-supine approach (ALSA). A 37-year-old man with arthrodesed hip presented to our hospital with chronic low back pain in November 2010. At presentation, the right hip was fused at 5° of flexion, 10° of adduction, and 15° of external rotation. The right lower limb was 2 cm shorter than the left. The patient's body mass index was 22.2. The preoperative Japanese Orthopaedic Association (JOA) hip score was 67. Examination and radiographs of the lumbar sacral region were normal. The patient underwent MIS-THA utilizing ALSA in June, 2011. The surgical time was 107 min and the estimated blood loss during surgery was 587 ml. At present, 4 months postoperatively, he is pain-free and is able to walk, run, and squat. The range of motion of the right hip are flexion 100°, extension 10°, abduction 45°, and adduction 30°. The postoperative JOA hip score was 96. Converting MIS-THA for hip ankylosis is technically difficult; however, with careful planning, successful outcomes can be expected. Utilizing MIS-THA for ankylosed hip avoids damage of the abductor muscle, leading to better muscle and hip function. It is our belief that in the hands of an experienced surgeon, MIS-THA using ALSA can be safely performed for takedown of ankylosed hip with good functional outcomes.

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Objective: The tramadol hydrochloride/acetaminophen combination tablet (Tramcet) is a nonnarcotic analgesic and is expected to have efficacy for relief of chronic pain in patients who have failed to respond well to nonsteroidal anti-inflammatory drugs (NSAIDs). This report describes the use of Tramcet in clinical practice by eight patients suffering from knee osteoarthritis (OA) that was poorly controlled with NSAIDs.
Methods: Seven patients were treated initially with a single daily dose of tablets (one tablet contained tramadol and acetaminophen); the dose was titrated up to three tablets t.i.d as necessary. An initial dose of three tablets per day was administered to the eighth patient, and this dosage was maintained for 4 weeks. All patients were simultaneously administered metoclopramide to prevent nausea and emesis, side effects that were anticipated to occur most frequently. The effectiveness was evaluated by changes in the pain visual analog scale (VAS) from baseline to each visit to the clinic. Adverse events (AEs) were monitored for all patients. Additionally, patients were examined for hepatic function after more than 4 months' treatment with Tramcet.
Results: Seven of the eight patients continued Tramcet treatment over 4 weeks. There were large improvements in VAS in six patients in the first 2 weeks of treatment. Although there was no marked change of VAS in one patient for 2 weeks of treatment at a dose of 1 tablet q.d., the VAS improved after the dose was increased to 2 tabs b.i.d. for weeks of treatment. Only one patient discontinued the administration early due to AEs (nausea, sleepiness, and stomach ache). Constipation occurred in another patient, but it resolved without treatment. There were other noteworthy AEs, including those relating to liver function.
Conclusion: Tramcet was useful for the relief of chronic pain caused by knee OA that was poorly controlled with NSAIDs.

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A case of methicillin-resistant Staphylococcus aureus (MRSA) pyogenic arthritis and sepsis after total knee arthroplasty is reported in a patient with rheumatoid arthritis. Treatment using linezolid was successful without removing the artificial joint. A 70-year-old woman who was under treatment for rheumatoid arthritis underwent total knee arthroplasty for right gonarthrosis. Seven days after surgery, she developed delirium, knelt on the floor, and then hit the knee, causing a hematoma. Seven days later, she developed fever, and a large amount of pus was drained from the right knee wound. MRSA was detected by culture. Sensitivity testing showed good sensitivity for arbekacin and vancomycin. Arbekacin was administered, and the joint was incised in order to wash it out, followed by continuous perfusion. Arbekacin was added to the perfusion fluid, and vancomycin was intravenously infused. Since the implant was well fixed to bone, it was not removed. However, the fever did not improve, and MRSA was detected in the perfusion fluid, blood, and the operative wound in the patellar tendon by culture. After eight days of perfusion, intravenous infusion of linezolid was initiated at 600 mg twice a day, and vancomycin was added to the perfusion fluid. The day after initiation of infusion of linezolid, the fever had resolved, C-reactive protein levels had decreased, and blood bacterial culture was negative. Linezolid was discontinued 18 days after the start of administration because the white blood cell count had decreased, and the knee wound was closed. No sign of relapse of infection developed after discharge.Linezolid has good tissue transfer and is considered to transfer to bone and joints at a high rate. It was used to successfully treat a prosthetic joint infection with sepsis.

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