Background and Design: Eccentric rotational acetabular osteotomy (ERAO), allows for the consistent achievement of the desired displacement of the femoral head. To our knowledge, a method of preoperative planning for this procedure has not been reported. We propose two methods of preoperative planning based on the assumption that all points inside the osteotomy circle rotate θ degrees around the center of this circle when the acetabulum is rotated θ degrees around the center. The objectives of this study were to confirm the above assumption and to examine the appropriate radius of curvature for the osteotome used during ERAO.
Methods: In July 2012, ERAO was performed on four patients with acetabular dysplasia based on the surgeon's planning diagram. The horizontal and vertical distances between the preoperative and postoperative centers of the femoral head were measured on the surgeon's planning diagram, on our planning diagram obtained with the first method, and on radiographs, respectively. We also performed preoperative planning by our second method. The radius of curvature of the osteotome was then measured from our preoperative planning data.
Results: The horizontal and vertical distances on our diagrams corresponded closely to the distances on the radiographs. In contrast, the horizontal distances on the surgeon's diagrams were larger than those on the radiographs. The radius of curvature of the osteotome was 37, 32, 32, and 41 millimeters (mm) in case 1, 2, 3, and 4, respectively.
Conclusion: The present study demonstrated that the horizontal distance and the vertical distance on our planning diagrams corresponded closely to the distances on the radiographs, suggesting that our assumption was verified. Our two methods of preoperative planning are both suitable for ERAO. Finally, an osteotome with a radius of curvature less than 50 mm is appropriate for ERAO.

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Objective: Techniques for the revision of total hip arthroplasties are usually complex, and surgeons may need to chose from among several options during such surgery. Here we report the short-term outcomes of revision surgeries involving such techniques.
Methods: We reviewed 14 hips in 13 patients (mean age 67 years, range 52-78 years) followed over a mean period of three years (0.5-6.0 years). Acetabular revision surgery involved cementless cup placement in three hips or impaction bone grafting with cement in seven hips. Femoral revision surgery involved the cement-in-cement technique in three hips, impaction bone grafting with cement in nine hips, and allograft-prosthesis composite use in one hip.
Results: No femoral stems required re-revision. Re-revision was required for only one acetabular cup using impaction bone grafting with cement for aseptic loosening and a metal mesh should be placed due to a thin acetabular medial wall.
Conclusion: Techniques for revision of total hip arthroplasties must be selected accounting for the extent of bone deficiency on an individualized basis.

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Objective: In total hip arthroplasty the medial peak of the medullary cavity in the femoral neck is referred to as the bony index of stem anteversion. We measured the difference between stem anteversion upon stem insertion into the medial peak of a medullary cavity, and actual femoral neck anteversion (FNA) using three-dimensional preoperative software known as Athena® (Soft Cube, Osaka, Japan).
Methods: Computed tomography (CT) scans were obtained from 79 patients with osteoarthritis (64 women; 120 hips without degenerative changes) who were candidates for total knee arthroplasty. CT data of the femur were used to measure FNA using Athena.The proximal femoral shaft axis was defined as the line connecting the centroids of the transverse slices taken just below the lesser trochanter to the proximal third of the femur. The position of the femoral head center was defined as the center of the sphere of best fit to the head surface. We defined three points: A, the point at which the axis of the proximal femoral shaft passes over a slice perpendicular to the proximal femoral axis just 1 cm above the lesser trochanter; B and C, the medial peak of the medullary cavity and the point projected onto the femoral head center on the same slice, respectively. The neck axis was defined as the line connecting A and C. The stem anteversion axis was defined as the line connecting B and C. The α angle represented the difference between stem anteversion and FNA was the angle between the stem axis and the neck axis.
Result: The α angle was −0.1±2.3° (−5.7° to 4.9°), and an outlier was observed in two cases.
Conclusion: The α angle was approximately 0° and therefore, stem anteversion appeared to be highly correlated with actual FNA when the stem was inserted into the medial peak of the medullary cavity. In the two cases with outliers, the medial peak of the medullary cavity was difficult to identify because the medial shape of the neck was round.

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Objective: This study aimed to investigate the frequency of acute painful arthritis following intra-articular injections of hylan G-F 20 (Synvisc). We also examined the patient characteristics that affected the frequency of inflammatory flares after intra-articular injections of hylan G-F 20.
Methods: The present study group consisted of 166 knees from 137 patients with a history of osteoarthritis, who received three once-weekly intra-articular injections of hylan G-F 20. A total of 446 injections were administered to study group. To analyze the patients' factors that affected the occurrence of arthritis, logistic regression analysis was performed with the following factors as explaining variables: gender, patient age, body mass index, stage of arthritis based on the Kellgren-Lawrence classification and disease duration.
Results: Twenty patients (12.6%) suffered from an acute flare reaction after more than two injections of hylan G-F 20. Twelve patients developed asymptomatic joint effusions, whereas eight patients had joint effusions with severe painful arthritis. All the patients showed improvement at one week post-aspiration of the joint effusions with the added use of corticosteroid injections, or oral non-steroidal anti-inflammatory drugs. Logistic regression analysis revealed that only patient age affected the occurrence of arthritis (odds ratio 0.955: 95% confidence interval 0.914-0.999).
Conclusion: This present study showed that the frequency of acute arthritis after injection with hylan G-F 20 is higher than with other hyaluronic acid. Patient age appears to be a significant factor for predicting the risk of arthritis.

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Objective: Three-dimensional preoperative planning software has become popular over the past several years, especially for total hip arthroplasty (THA). Although femoral neck anteversion (FNA) has been evaluated based on the posterior condylar axis (PCA), it cannot be used in cases undergoing total knee arthroplasty (TKA) or those with marked degenerative changes in the posterior condyles. As a result, the determination of FNA is difficult using software. In such cases, the clinical epicondylar axis (CEA) can be used. In this study, we measured FNA using the CEA.
Methods: Computed tomography (CT) scans were obtained from 79 patients with osteoarthritis (64 women; 120 hips without degenerative changes) who were candidates for TKA. CT data of the femur was used to measure FNA by the three-dimensional preoperative software called Athena® (Soft Cube, Osaka, Japan). The mean condylar twist angle (CTA) was 5.8±1.7°. The longitudinal dimension was defined as the medial and lateral epicondylar prominence and the centroid of the transverse slices taken just below the lesser trochanter. The proximal femoral shaft axis was defined as the line connecting the centroids of the transverse slices taken just below the lesser trochanter to the proximal third of the femur. The position of the femoral head center was defined as the center of the sphere of best fit to the head surface. The femoral neck axis was defined as the line connecting the femoral head center and the point at which the axis of the proximal femoral shaft passed over the transverse slice, just one centimeter above the lesser trochanter. The neck axis, PCA and CEA were projected onto a field perpendicular to the proximal femoral axis, and FNA was measured as the angle of the neck axis, and the PCA and CEA as the pFNA and cFNA, respectively.
Results: The pFNA and cFNA values were 27.3±9.0° (8.9-60.6°) and 21.4±8.8° (1.9-52.4°), respectively. The difference between pFNA and cFNA, which was approximately 6°, was believed to be due to the CTA. pFNA was highly correlated with cFNA (r = 0.979, p < 0.01).
Conclusions: The FNA value, based on the CEA, measured by three-dimensional preoperative software was approximately 21°. CEA is useful for measuring FNA, and cFNA is helpful in determining the stem anteversion in THA.

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Objective: This prospective randomized study was undertaken to compare the effect of postoperative bleeding control after total knee arthroplasty (TKA) by the drainage clamp method with or without intra-articular drug administration in the immediate postoperative period.
Methods: From 44 consecutive knee surgeries in 42 patients who underwent primary TKA, 12 patients were excluded from the study for the following reasons: three patients required release of tourniquet intraoperatively because of prolonged surgery, eight patients were anemic preoperatively and who were at an increased risk for blood transfusion, and one patient who had received combined anticoagulation therapy perioperatively. Thirty-two knees in 31 patients (average age, 74 years; range, 61-89 years) were included in this study and they were divided into three groups; lidocaine-epinephrine or tranexamic acid administered into the TKA immediately after surgery constituted groups A and B respectively, whereas group C received no drug administration as a control. After drug administration, the drainage tube remained clamped for two hours postoperatively, which was subsequently opened until its removal on the second postoperative day. Total drainage fluid amounts and the total amount of postoperative bleeding were calculated from the changes of serum hemoglobin level and these were compared statistically among the three groups.
Results: The total drainage fluid amounts in group A, B and C were 788±358ml, 568±284ml and 836±333ml, respectively. The difference between group B and C was statistically significant (p < 0.05). The total amounts of postoperative bleeding in group A, B and C were 1538±329ml, 852±209ml and 1519±195ml, respectively. There was a significantly decreased amount of bleeding in group B compared with groups A and C (p < 0.05).
Conclusion: Immediate postoperative administration of tranexamic acid into total knee arthroplasties was shown to be effective in the control of postoperative bleeding, compared with lidocaine-epinephrine administration and control.

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Objective: Deep vein thrombosis (DVT) is a known perioperative complication from total knee arthroplasty (TKA), and is a major cause of fatal pulmonary embolism. However, methods for screening DVT have not been well established. The purpose of this study was to establish a method for screening DVT after TKA by comparing the onset of DVT, associated risk factors as well as the comparison between unilateral and bilateral TKA cases.
Methods: There were 659 subjects who were evaluated for DVT postoperatively following TKA. There were 576 unilateral TKA cases and 83 bilateral TKA cases, respectively. The incidence of DVT, the time of onset of thrombosis and the associated risk factors were also examined.
Results: The incidence of DVT after TKA was 24.5% in unilateral cases and 42.0% in bilateral cases, respectively. Regarding onset of DVT, the incidence during postoperative (PO) days 1-2 was significantly higher in both unilateral and bilateral cases (P < 0.01), but with it being significantly higher in bilateral cases (P < 0.01). The significant risk factors of DVT included older age more than 73.0 years (P < 0.05), female sex (P < 0.05), body mass index more than 26.4 (P < 0.05), preoperative D-dimer value more than 1.9ng/ml (P < 0.05), D-dimer value at PO day 1 more than 77.8ng/ml (P < 0.01), D-dimer value at PO day 7 more than 11.7ng/ml (P < 0.05), and preoperative presence of DVT (P < 0.01), respectively.
Conclusion: DVT associated with TKA develops within two days postoperatively in many cases, while it develops at day 14 with a higher frequency in bilateral cases compared with unilateral cases. This study indicates that it is acceptable to perform DVT screening for up to seven days in cases of unilateral TKA, but this should be extended by a further seven days in cases of bilateral TKA to ensure that DVT is not missed in this high risk group.

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Objective: Pharmacological agents and mechanical compressive devices are used for preventing venous thromboembolism (VTE) during and after total hip arthroplasty (THA) and total knee arthroplasty (TKA). In addition, elective postoperative ultrasonography is used as a screening tool to detect deep vein thrombosis (DVT) and if found, warfarin is frequently used for its treatment. We aimed to evaluate the efficacy of pharmacological agents, mechanical compressive devices, and warfarin therapy for preventing VTE during and after elective THA and TKA.
Methods: Twenty-six patients were identified to have DVT and they received therapeutic warfarin following either elective THA or TKA and were followed up for 10 months after surgery by postoperative ultrasonography and D-dimer level evaluations.
Result: The range of serum D-dimer levels were 0.44-17.54 (mean 2.55) μg/ml, 3.85-32.89 (mean 12.62) μg/ml, and 0.63-14.5 (mean 2.62) μg/ml before surgery, seven days postoperatively, and at the 10-month follow-up visit, respectively. DVT was not detected in 14 patients (54%) at three months and in 22 patients (85%) at 10 months postoperatively. Warfarin was discontinued in all except one patient (92%). There were no cases of warfarin-related bleeding complications.
Conclusion: The use of warfarin therapy to treat symptoms in patients who develop DVT in the postoperative period are effective prophylactic measures against VTE.

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Objective: To investigate the clinical and radiographic results of total shoulder arthroplasty (TSA) for damaged shoulder joints with osteoarthritis (OA) and rheumatoid arthritis (RA).
Patients and Methods: From 1999 to 2012 inclusive, we performed 19 total shoulder arthroplasties in 17 patients. A total of sixteen shoulders, five with OA and 11 with RA, from 15 patients were followed up for more than six months. All patients were female, with an average age of 71 years, and an average follow-up period of three years. Preoperative magnetic resonance imaging showed that the supraspinatus tendon was intact in five shoulders (intact group), and torn or thin in 11 shoulders (damaged group), respectively. Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score, Disabilities of the Arm, Shoulder and Hand (DASH) score and range of motion (ROM). Radiographic loosening of the humeral stem and glenoid component was evaluated according to the criteria described by Stewart.
Results: The average JOA score improved from 39.9 points preoperatively to 80.3 points at the final follow-up. The average DASH score improved from 70.1 points to 56.0 points. The range of active flexion, abduction and external rotation significantly improved postoperatively. Radiolucent line evaluation around the glenoid component was observed in two shoulders. There was no significant difference in the improvement of the JOA score between the intact group and the damaged group. In both groups, pain relief was experienced postoperatively, but the improvement in ROM consisting of flexion, abduction and external rotation, was significantly greater in the intact group than in the damaged group. The postoperative JOA score showed a strong inverse correlation with the preoperative DASH score.
Conclusion: The results of the current study showed satisfactory clinical outcomes of TSA for OA and RA, particularly with the treatment effect of good postoperative pain relief. Clinical outcome may depend on the preoperative status of the rotator cuff and the function of the upper extremity.

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Objective: To assess the effects of a postoperative critical care pathway of community medical coordination in patients with hip fracture.
Methods: Retrospective chart reviews were conducted for patients with hip fractures operated from December 2008 to May 2012, inclusive. We commenced using a postoperative critical care pathway from September 2010. The patients were divided into two groups between pre-introduction (group B; 67 women and 25 men; mean age, 80.4 years) and post-introduction (group A; 144 women and 24 men; mean age, 82.2 years) of the critical care pathway. The analysis consisted of gender, age, operative procedure, length of time between injury and surgical intervention, duration of hospitalization, mobility on discharge from our hospital compared to the final observation, and return rate to our hospital.
Results: Group A had a significantly shorter length of hospital stay compared to group B (27.1 versus 39.4 days, respectively; P < 0.01). Although both groups regained mobility at the final observation, group A had improved ability compared to group B (72.7 and 56.5%, respectively; P < 0.01). Return rate to our hospital was significantly increased in group A compared to group B (85.2 and 53.2%, respectively; P < 0.01).
Conclusion: The critical care pathway shortened the length of hospitalization, and contributed to improved walking ability. We have been able to continue the treatment of osteoporosis and fracture prevention therapy during follow-up visits to our hospital.

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Objective: Accelerated infliximab (IFX) infusions were officially approved by the Health and Labor Ministry of Japan in May 2012. Since May 2006, IFX infusion times have been shortened in some patients with arthritis who have not experienced any adverse infusion reactions (IR) from the standard 120-minute infusion time. In this study, the tolerability of shortened IFX infusion times from over the six years of experience was investigated.
Methods: Patients with arthritis who completed an IFX infusion without any IR on at least five 120-minute infusion occasions were allowed to shorten their infusion times. Infusion times were gradually shortened to 90, 60, and 30 minutes with a primary goal of 60 minutes. Anti-allergy medication was not used routinely. The infusions were conducted in the outpatient chemotherapy treatment facility.
Results: Among 71 outpatients with arthritis (58 females and 13 males), 69 had rheumatoid arthritis, 1 had psoriatic arthritis, and 1 had ankylosing spondylitis treated with IFX; 13, 29 and 11 patients received 90-minute, 60-minute and 30-minute infusions, respectively. There were 23 observed infusion reactions among 1,787 infusions of IFX (incidence rate: 1.29%). With respect to infusion time, seventeen cases of IR occurred in the 120-minute (73.9%), four in the 90-minute (17.4%), one in the 60-minute (4.3%) and one in the 30-minute (4.3%) infusion periods, respectively. Three cases of IR occurred when the dose of IFX was increased and five when the infusion time was shortened. However, all the symptoms of IR were minor and the infusions were safely completed by extending the infusion time and/or using anti-allergy medication.
Conclusion: The infusion time of IFX can be safely shortened to just 30 minutes by following proper protocols and maintaining close observation, for the convenience of patients.

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Introduction: Although previously published studies have documented a high perioperative risk in patients with liver failure undergoing major orthopedic surgery, little information is available on clinical outcomes following bilateral MIS-THA performed in a one-day session for this group of patients. Here, we report a patient with liver cirrhosis and idiopathic osteonecrosis of the hips treated by bilateral MIS-THA in a one-day session.
Case: A 64-year-old man with liver cirrhosis presented to our hospital with complaints of severe bilateral hip joint pain in 2011. Radiographic examinations and magnetic resonance imaging showed that the patient had bilateral idiopathic osteonecrosis (Stage IIIb, Type C-II). He underwent bilateral MIS-THA using bone cement in a one-day session in January 2012. The postoperative course was uneventful and after one year, he remains pain-free and is able to mobilize without walking aids.
Conclusion: In general, patients with cirrhosis have an increased risk of bleeding complications during MIS-THA because of underlying coagulopathy and thrombocytopenia. The present case showed the successful use of bone cement in MIS-THA for preventing postoperative bleeding in the patients with cirrhosis and also demonstrated that patients with Child-Pugh class-A cirrhosis may have a good clinical outcome following bilateral MIS-THA when performed in a one-day session.

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Introduction: Distal humeral hemiarthroplasty (DHH) is an attractive treatment option to address concerns about the potential for complications associated with the presence of polyethylene or an ulnar component following total elbow arthroplasty. However, there are very few accounts in the literature regarding DHH outcomes when Japanese manufactured prostheses have been used. We report about early- to mid-term results in three cases of humeral hemiarthroplasty.
Case 1: A 32-year-old patient with rheumatoid arthritis with a bony ankylosis of the elbow and with 30 degrees of extension, underwent DHH treatment using the Osaka University Model Elbow System, (MMT Co., Ltd., Japan). At four years follow-up, the preoperative Japan Orthopedic Association (JOA) score of 47 improved to 96 points, and the flexion and extension range of motion (ROM) improved to 136 and 8 degrees, respectively. Radiologically, there were no radiolucent lines at the implant interface.
Case 2: A humeral supracondylar fracture in a 93-year-old female with a history of heart failure underwent DHH treatment using the Fine Elbow System (Nakashima Medical Co., Ltd., Japan). However, the patient died from an exacerbation of cardiac failure at three months postoperatively. Flexion and extension ROM was 110 and 30 degrees, respectively at the last follow-up. There were no radiological complications in the elbow, and bone fusion was confirmed in the osteotomized area of the olecranon used for the surgical approach.
Case 3: DHH was performed for a distal humeral comminuted fracture in a 76-year-old female using the Fine Elbow System. At the 1-year follow-up, the JOA score was 89 points and the flexion and extension ROM was 120 and 10 degrees, respectively. There were no radiological signs of implant protrusion into the ulna.
Discussion: This short- and mid-term review suggests that DHH may be an effective treatment for selected elbow disease. However, DHH should be used with caution until studies of long-term outcome demonstrate its efficacy.

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