Objective: We investigated the clinical features and treatment outcomes of Japanese patients with ankylosing spondylitis (AS) and the psoriatic arthritis (PsA) in our hospital.
Methods: From April 2002 to March 2013 inclusive, we diagnosed and treated eight AS patients (4 males and 4 females) and ten PsA patients (5 males and 5 females), respectively. We investigated HLA-B27 positivity and the family histories of the patients in addition to clinical symptoms, the response to non-steroidal anti-inflammatory drugs (NSAIDs), and the effect of anti-tumor necrosis factor (TNF) biologic agents.
Results: Sixty-six percent of AS patients were human leukocyte antigen (HLA)-B27 positive, but a positive family history was found in only 12.5% of all cases. Several patients had HLA testing in those with PsA, but only two cases were HLA-B27 positive. Enthesitis was identified in 35.7% of AS patients and 60% of PsA patients, respectively. NSAID monotherapy produced an insufficient effect for both sets of patients, but especially PsA patients. Anti-TNF biologic agents including infliximab and adalimumab, reduced the Bath Ankylosing Spondylitis Disease Activity Index in AS patients from 5.2 to 2.8, and the Disease Activity Score 28 in PsA patients from 3.82 to 1.75, respectively.
Conclusion: HLA-B27 was a modestly helpful marker for the diagnosis of AS in our Japanese patient study population. Anti-TNF biologic agents had a high efficacy for treatment in both sets of patients with AS and PsA.

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Objective: Since 2004 we commenced opening wedge high tibial osteotomy (HTO) in our department for treating medial osteoarthritis of the knee for patients with high levels of daily activity. Based on this experience we evaluated the problems and improvements with this procedure.
Methods: Eighty-five patients with 118 knees were evaluated who underwent opening wedge HTO between February 2004 and December 2012, inclusive. The mean age of the patients was 64 years. The diagnosis of 87 knees were medial osteoarthritis and 31 knees were osteonecrosis of the medial condyle, respectively. In excess of half of the knees were at Hokkaido UNIV. system stages 2 or 3 preoperatively. Corrective osteotomy was performed at a femur-tibial angle of 170 degrees with a plate and hinge being used for fixation. Auto-transplantation of the iliac crest with conjugated β-tricalcium phosphate granules were used for bone grafting.
Results: Two patients' knees required reoperation due to the loss of correction resulting from malunion, and one patient who underwent simultaneous bilateral opening wedge HTOs was later converted to total knee arthroplasties due to over-correction.
Conclusion: With careful selection of patients with indications for knee surgery, good short-term and intermediate-term results can be achieved by medial opening wedge HTO. Further evaluation of this procedure is required for long-term surgical outcome.

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Objective: In total knee arthroplasty (TKA), precise placement of the tibial tray is necessary for good long-term results. However, the conventional tibial cutting guide may produce errors. Consequently, we have developed a new tibial cutting guide for TKA using a 3-dimensional (3D) templating system (Lexi Zed Knee, Japan). The accuracy of this system was evaluated by the image free Navigation System (Brainlab, Collibri)
Methods: Forty-one patients' knees were evaluated intraoperatively. Thirty-six patients' knees had osteoarthritis and five had rheumatoid arthritis, respectively. Computed tomography (CT) scanning of the lower extremities was undertaken for preoperative planning with use of the 3D templating system. The planning for the survey was carried out according to the CT free Navigation System. During the TKA procedure, this guide was calibrated according to the 3D preoperative plan and its coronal and sagittal alignments were measured by the navigation system. We defined valgus as positive in the coronal plane and posterior inclination as positive in the sagittal plane, respectively. The angle between the line perpendicular to the tibial anteroposterior axis and the transmalleolar axis was defined as tibial rotation.
Results: The average coronal alignment was 0.23±0.75 degrees (2∼−1 degrees). The average sagittal alignment was 0.35±0.85 degrees (2∼−1.5 degrees). The relationship between the alignment and tibial rotation was significant in the sagittal plane, but it was not in the coronal plane.
Conclusion: The accuracy of this guide in all knees was within two degrees. As a result, this new tibial cutting guide using the 3D templating system may be clinically useful in TKA procedures.

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Objective: It is known that biologic agents inhibit the progression of joint destruction in rheumatoid arthritis (RA). For this reason, these agents have recently been used for the treatment of RA. The purpose of this study was to evaluate the effectiveness of orthopedic surgery in RA patients treated with biologic agents.
Methods: Two hundreds and twenty-nine surgeries were performed and evaluated on RA patients treated with the following biologic agents: infliximab (49), etanercept (130), adalimumab (25), tocilizumab (19), and ABT (6). All patients underwent orthopedic surgery from 2003 to 2012, inclusive. The mean age at operation was 57 years old.
Results: At the time of follow-up, there was one deep infection and four wounds with delayed healing related to the biologic agents. In spite of the observed minor complications, the postoperative clinical course of these patients was good, and the results of the surgeries were excellent.
Conclusion: Orthopedic surgery in patients with RA treated with biologic agents is considered to be safe with an acceptable infection complication rate and excellent surgical outcome.

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Objective: To understand the safety profile and to develop experience in the administration of tocilizumab (TCZ) therapy in patients with elderly-onset rheumatoid arthritis (EORA). To estimate the effectiveness of tocilizumab therapy in EORA patients, we analyzed several parameters of inflammation, in addition to cytokines, and disease activity.
Methods: Twelve patients with EORA, all in their seventh decade of life, were administered tocilizumab therapy. Hematological and biological parameters were measured regularly. Rheumatoid arthritis disease activity was also measured by using the Disease Activity Score 28 and the Simple Disease Activity Index, respectively.
Results: Administration of tocilizumab rapidly decreased hematological parameters, especially C-reactive protein levels. The average patient baseline serum levels of interleukin-6 (IL-6) were initially elevated at 216.8 pg/ml (range 15.3-1,630 pg/ml), whereas in seven patients (58%) it decreased in last follow-up period. Three patients (25%) had increased baseline serum tumor necrosis factor-α levels compared to nine (75%) patients that did not have such elevations. Serum hemoglobin levels increased from an average of 11.4 g/dl prior to tocilizumab therapy to 12.8 g/dl after the commencement of therapy (p < 0.005). Three patients developed localized dermatological herpes zoster virus infections, but there were no severe complications in the follow-up period.
Conclusion: Tocilizumab therapy in patients with EORA was effective without severe side effects and IL-6 blockade may constitute a major therapy for this disease.

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Objective: It is difficult to treat fractures of the distal end of the humerus. These commonly occur in elderly patients with osteoporosis, and in adults who are injured by high impact trauma. The treatment of this fracture requires rigid fixation to permit early range of motion exercises postoperatively. The purpose of this study was to evaluate the results of internal fixation with the ONI transcondylar plate.
Methods: The study was undertaken from March 2009 to April 2012, inclusive. There were eight patients in total composed of two males and six females, with the average age being 67.2 years (range, 36 to 89). The average duration of follow-up was 20 months (range, 6 to 43). The method of fixation included three bilateral plates and five one-sided plates. One subject who was not included in final study population group was excluded due to suffering a cerebral infarction, and that the fracture of the humerus was old. Based on the AO classification, the study included three patients of type A2, three patients of type of C2 and two patients of type C3, respectively.
Results: The average of Japanese Orthopedic Association (JOA) score was 84.8 (range, 50 to 100). The average range of motion was −14.1 degrees (range, −50 to 0) of extension and 133.1 degrees (range, 125 to 145) of flexion. The average operation time was 191 minutes (range, 117 to 370). The average difference of affected and unaffected carrying angles was 5.6 degrees. Postoperative complications included numbness in the ulnar nerve distribution in three patients and re-displacement of the articular surface in one patient.
Conclusion: Our study showed good results using the ONI transcondylar plate for internal fixation of the humerus. The posterior approach has low invasiveness and is the appropriate method for this type of fracture.

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Introduction: Secondary hip osteoarthritis (OA) potentially occurs as a consequence of the combined effects of acetabular dysplasia and age-related changes in lumbar alignment. The purpose of this study was to examine the effects of age-related spinal changes on the onset of secondary hip OA from the viewpoint of “total alignment” including both spinal and pelvic morphologic angles.
Methods: Seventy-three patients with unilateral end-stage secondary hip OA and accompanying acetabular dysplasia underwent total hip arthroplasty. The study subjects were classified into a “middle-aged” group composed of 25 patients aged less than 60 years, and an “elderly” group composed of 48 patients aged 60 years or greater, respectively. Radiographs were taken in the full spine lateral view with the patients standing with fingers crossed in front of the pelvis. Sagittal spinal alignment was measured according to the methods proposed by Jackson et al and Wiltse et al.
Results: The results indicated that the C7 plumb line shifted anteriorly and the pelvis rotated posteriorly in the elderly group, while the PR-S1 values were smaller in the elderly group.
Conclusion: Middle-aged patients appear to possess a compensatory mechanism by maintaining sagittal lumbo-pelvic alignment when compensating for acetabular dysplasia. Conversely, the onset of secondary OA in elderly patients is likely a consequence of degenerative changes in lumbar alignment attributable to aging.

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Objective: Recently, use of a M/L tapered stem has been widely utilized for minimally invasive surgery for total hip arthroplasty (MIS-THA). Reliable long-term results including functional improvement, pain relief, and implant survival have been well documented with standard-length tapered stems. However, there have been only a few reports showing the results of MIS-THA treated by a single surgeon using an anterolateral-supine approach with a standard-length M/L tapered stem and a short-length M/L tapered stem. Here, we compared short-length M/L tapered stems to standard-length M/L tapered stems in terms of intraoperative complications, short-term survival, biological fixation of the stem, and the direction of stem insertion after undergoing MIS-THA using the anterolateral-supine approach, and with treatment by a single surgeon.
Patients and Methods: We retrospectively reviewed the records of 45 patients who had undergone the MIS-THA procedure using an anterolateral-supine approach, from January 2010 to March 2012, inclusive. Twenty-five patients (total of 28 hips) had standard-length M/L tapered stems (K group) and twenty patients (total of 22 hips) had short-length M/L tapered stems (M group). In respect of groups K and M, the average age at the surgery was 66.0 and 63.5 years, and the average body mass index was 22.8 and 22.5 kg/m², respectively. The mean postoperative follow-up period of groups K and M was 14.0 and 15.3 months, respectively. We clinically assessed the Japanese Orthopedic Association (JOA) hip score, the complication rates, and postoperative thigh pain. Radiological assessment included the estimated direction of stem insertion. During the most recent follow-up, radiological evidence of bone atrophy, spot welds, radiolucent zones, osteolysis, and sinking of the stem over 2 mm in depth, were assessed. Biological fixation was evaluated and classified into four types: bone ingrowth, suspected ingrowth, suboptimal fixation, and unstable fixation.
Results: There was no significant difference in complication rates, the existence of postoperative thigh pain, JOA hip score, implant survival, or direction of stem insertion between the two groups. Biological fixation was classified into bone ingrowth fixation in all cases of K and M group.
Conclusion: Although long-term follow-up is required, our results support the concept that stem length does not affect the stem survival, stem alignment, or functional outcome of MIS-THA with M/L tapered stem using the anterolateral-supine approach.

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Objective: To investigate the prevalence of surgical site infection (SSI), which is a major complication of surgical treatment, in patients with rheumatoid arthritis (RA) treated with biological agents.
Methods: This study included 207 patients with RA who underwent surgical treatment. Of these, 30 patients were male and 177 patients were female. Biological agents were used to treat 75 patients, and 132 patients were treated with conventional disease-modifying antirheumatic drugs (DMARDs). We compared the prevalence of SSI between these groups using Fisher's exact test.
Results: The prevalence of SSI was 5.3% in the biological agents group and 1.6% in the conventional DMARDs group, respectively. No statistically significant difference was observed between the prevalence in these two groups. However, regarding joint replacement surgery, the prevalence of SSI in the biological agents group was 11.4%, which was significantly higher than that of the conventional DMARDs group (1.2%; odds ratio = 9.93, P = 0.03).
Conclusion: Careful perioperative management is required to prevent SSI in patients with RA undergoing joint replacement surgery who are treated with biological agents.

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Objective: To compare the clinical outcome of the Swanson versus the AVANTA silastic implant arthroplasty procedures of the metacarpophalangeal (MCP) joints for patients with rheumatoid arthritis of the hands.
Methods: A total of 48 Swanson and 70 AVANTA implants were inserted into 38 hands of 34 patients (1 male, 33 female). The mean age of the patients at surgery was 61.9±4.8 years in the Swanson group and 61.0±6.2 years in the AVANTA group, respectively. The average follow-up period was 60.7±20.5 and 21.3±9.1 months in the Swanson and the AVANTA groups, respectively. Pre- and postoperative clinical evaluations included active MCP extension and flexion, grip strength, pinch ability, ulnar deviation, osteolytic or sclerotic changes demonstrated by radiography, and overall hand function as assessed by use of the HAQ, Hand20, and DASH scoring systems. Statistical analyses were performed using the Mann-Whitney U test.
Results: The mean postoperative active extension was −13.3°±16.2° in the Swanson group, and −10.7°±10.2° in the AVANTA group (p = 0.72). Flexion was 58.6°±19.8° in the Swanson group, and 59.3°±21.5° in the AVANTA group (p = 0.78). According to the Parkkila criteria, the Grade I and more radiographic osteolysis was seen in the Swanson group (71.9%) as compared to the AVANTA group (62.9%), respectively. The functional scores at the final follow-up were 1.4±0.7 and 1.2±0.8 (p = 0.48) for the HAQ-DI, 57.8±23.1 and 44.5±25.1 (p = 0.19) for the Hand20, and 54.9±21.6 and 41.8±21.6 (p = 0.12) for the DASH disability score in the Swanson group and the AVANTA group, respectively. There were three implant fractures in the Swanson group. No patients had revision surgery during the follow-up period.
Conclusion: Although the AVANTA group was more inclined to obtain a greater range of motion and better functional outcome compared to the Swanson group, there was no statistically significant difference between the two groups. The Swanson group may be associated with a higher implant failure rate due to the silastic mechanical property of the prosthesis, which was identified due to a longer period of follow-up compared to the AVANTA group.

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Case: A 48 year-old male was treated by MIPO for a distal radius fracture. A subcutaneous hematoma was noticed on the second postoperative day, which gradually enlarged. Rehabilitation was interrupted by the pain emanating from the hematoma. The patient was referred to our hospital two months later. A 30×60×15 mm large immobile elastic-like firm mass was palpated on the palmar side of the wrist. Range of motion (ROM) of palmar flexion, dorsal flexion, radial deviation, and ulnar deviation were 40, −20, −5, and 10 degrees, respectively. Pronation and supination were 20 and 0 degrees, respectively. Grip power was 0 kg and tip-palm distance was 50 mm. Plain radiography revealed bone union. Removal of the implant and resection of the hematoma were undertaken. Six months postoperatively, ROM had improved in palmar flexion, dorsal flexion, radial deviation and ulnar deviation to 75, 45, 10, 10, 75, and 55 degrees, respectively. Tip-palm distance reached 0 mm.
Discussion: MIPO is a method of minimally invasive surgery to fix a fracture via a small incision. Hence, it is important to understand the local anatomy and the indication for intervention A closed procedure by MIPO might have damaged a blood vessel whilst inserting the plate, that lead to hematoma formation. Median nerve palsy may have been avoided if the hematoma had been removed promptly.
Conclusion: We experienced a patient with a median nerve palsy caused by a massive postoperative hematoma as a complication of MIPO for a distal radius fracture.

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Objective: A rupture of the patellar tendon following total knee arthroplasty (TKA) is a challenging complication. Several techniques for treatment have been reported, including cast immobilization, direct surgical repair, the use of semitendinosus grafting, hamstring tendon autogenous grafting, the use of an artificial ligament, or transplantation allografting of the bone patellar tendon-bone (BTB) or the entire extensor mechanism. We report two cases of previously infected total knee arthroplasties (TKAs) following reconstruction of the patellar tendons.
Case 1: A 73-year-old female with bilateral TKAs for osteoarthritis fell down and ruptured her right patellar tendon. The patient was referred to our institution because of bilateral knee infection from methicillin-resistant Staphylococcus aureus (MRSA) following synthetic grafting procedures. Arthrodesis of the right knee and a staged revision TKA of the left knee was performed following the resolution of the infection. There has been no recurrence of the infection to date, and the patient is ambulatory.
Case 2: A 61-year-old female with osteoarthritis, who underwent bilateral TKAs, fell down and ruptured her right medial collateral ligament and left patella tendon. The patient was referred to our institution with Staphylococcus epidermidis infection following reconstruction of her patellar tendon by a synthetic graft procedure. A staged revision TKA and a tendon reconstruction by BTB allograft was chosen as the most appropriate treatment. The patient is currently ambulatory with an extension lag of 30°, and there are no signs of recurrent infection.
Discussion: Reconstruction of the knee extension mechanism is most important for patients with a rupture of the patellar tendon following TKA; treatment options for an infected TKA with reconstruction of the extensor mechanism must be carefully considered. Resection of the patellar tendon is required in order to resolve such infection. Use of autogenous semitendinosus or gastrocnemius grafting, tendon allografting, and synthetic grafts have been reported with varying success. In our report, patellar tendon allografting with attached bone demonstrated good results as exhibited by adequate bone union and the avoidance of harvesting autogenous tissues.

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   This report describes the surgical treatment for an unreduced traumatic dislocation of the hip with 3-dimensional (3D) replica construction and implantation of a total hip arthroplasty (THA).
   A 63-year-old male patient, was referred to our hospital because of right hip pain related to a motorbike accident for which he had undergone conservative treatment of a right lower leg fracture 42 years previously. At three months post-fracture, the patient underwent a radiographic review of the hip joint because of ongoing pain in his right hip. A dislocation fracture of the right hip was identified, but it was subsequently neglected.
   When the patient visited our hospital radiographs and computed tomography scanning showed a posterosuperior dislocation of the right hip with severe post-traumatic arthritis. Because of the severely abnormal anatomy, we constructed a 3D replica for pre- and intraoperative planning. By using 3D replica, we were able to examine installation position of cup and resection range of soteophyte before operation. Additionally, we performed a THA without complications even as for the limited view using 3D replica as intraoperative navigator. At 18 months postoperatively, the short term result indicated a good functional result.

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