Physiological environments are severe corrosive conditions for the metallic biomaterials. The objective of this study was to characterize the corrosion behavior of carbon ion implantation (CII) which is a process originally developed for the fabrication of diamond-like carbon. The corrosion behaviors were examined using the potentiodynamic anodic polarization measurement in deaerated 0.9% sodium chloride solution at 37°C according to the Japanese Industrial Standards (JIS) T-0302. CII was applied to titanium alloy substrates by plasma source ion implantation. Polarization curves showed that the CII-treated surfaces kept lower current densities than the untreated titanium alloy under the biological condition (−0.5V∼+0.5V). The corrosion behaviors of CII-3hr and CII-4hr were similar, but CII-3hr showed pitting corrosion at around 2.7 V. CII surface engineering can be considered as beneficial for improving the corrosion resistance of titanium alloy in the physiological environment.

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Objective: Although polarizing microscopes are commonly used for the diagnosis of pseudogout, they are very expensive and not always available in small hospitals. We investigated visualizing calcium pyrophosphate dehydrate (CPPD) crystals using Gram stain, and investigated the usefulness of this technique for the diagnosis of pseudogout.
Methods: Twenty patients with suspected monoarthritis were investigated in our hospital. Aspirated joint fluids were assessed with both a polarizing microscope and Gram stain. Patients were diagnosed as pseudogout in the presence of CPPD crystals confirmed via a polarizing microscope. We visualized the joint fluid via Gram stain to detect crystals and bacteria. We estimated the sensitivity and specificity of the Gram stain for the diagnosis of pseudogout.
Results: Twelve patients were diagnosed as pseudogout, two patients had gout, two patients had septic arthritis, and four patients had other diseases. Using the polarizing microscope, 12 patients were CPPD-positive, and eight patients were CPPD-negative. Using Gram stain, 11 patients were crystal-positive, and nine patients were crystal-negative. The sensitivity and the specificity of Gram stain for the diagnosis of pseudogout was 92% and 100%, respectively.
Conclusion: Gram stain may be useful in the diagnosis of pseudogout.

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Most Japanese patients with osteoarthritic hips develop this secondarily to the acetabular dysplasia. Therefore, patients with an early stage of osteoarthritis can be more easily and effectively treated than those with primary osteoarthritis of the hips. Pelvic osteotomy with articular cartilage is one of the most promising options for successfully treating this disease. The main indication for performing osteotomy is usually the occurrence of osteoarthritic hips at an early stage. Additionally, advanced stage cases may also be included once they have demonstrated good congruity during abduction.

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Background: Little information is available regarding mid- and long-term outcomes with the JACE unlinked elbow prosthesis.
Design: We evaluated the J-alumina ceramic elbow (JACE) total elbow arthroplasty (TEA) in 17 patients with rheumatoid arthritis (RA) to provide additional information regarding this prosthesis.
Methods: JACE TEA was performed on 25 elbows in 17 patients with RA, among whom one was revised and one was lost to follow-up. Accordingly, 22 elbows in 15 patients were radiologically and clinically reviewed during a mean follow-up of 83.5 months. Outcomes were evaluated by changes in the range of motion and Japanese Orthopedic Association (JOA) functional evaluation scores for the elbow joint.
Results: Both the range of motion and JOA functional evaluation scores for the elbow joint were significantly improved by the final examination. Intraoperative fractures occurred in two patients (8%) elbows. Aseptic loosening, prosthesis dislocation, deep infection, and ulnar nerve palsy were not identified in any cases.
Conclusion: In cases with adequate bone stock in the humeral condyles and retained ligamentous integrity, JACE TEA can yield satisfactory functional results using cement, which appears to be crucial for JACE prosthesis implantation.

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Objective: To evaluate the risk of adverse events in patients with rheumatoid arthritis (RA) treated with biological agents (BAs) undergoing lower limb arthroplasty.
Methods: This study included 94 patients with RA who underwent lower limb arthroplasty. Thirty-seven patients were treated with BAs including infliximab (6 patients), etanercept (18 patients), adalimumab (4 patients), tocilizumab (7 patients), abatacept (2 patients), and 57 patients were treated with conventional disease-modifying antirheumatic drugs. We examined the incidence of perioperative adverse events which included surgical site infections (SSIs), delayed wound healing, and RA flare-ups in both the BA- and Non-BA groups. The statistical differences between each group were examined using Fisher's exact test.
Results: Two cases of SSIs were observed in both groups, but there was no statistically significant difference [P = 0.645, OR 1.57 (0.21-11.68)]. One case of delayed wound healing was observed in both groups [P = 1.00, OR 1.56 (0.09-25.68)]. Two cases of RA flare-up were observed in the BA group, but none were observed in the non-BA group [P = 0.152, OR 8.09 (0.38-173.7)].
Conclusion: In this small study, the risk of perioperative adverse events in patients with RA treated with BAs undergoing lower limb arthroplasty was not increased.

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Objective: We performed a retrospective study of total knee arthroplasty (TKA) in rheumatoid arthritis (RA) patients with large bone defects, severe valgus deformities, or severe flexion contractures.
Methods: Between 1999 and 2010, 40 knees in 30 patients underwent primary TKA with stem extension, metal block augmentation, and/or constrained condylar knee (CCK) prosthesis at Kyushu Medical Center. The preoperative diagnosis was RA in all 27 female and three male patients. The mean age at the time of the surgery was sixty-one years old. The mean duration of follow-up was 5.9 years. Three knees received posterior-stabilized TKA (NexGen® LPS or LPS-flex, Zimmer®) with tibial stem extension, 26 knees received posterior-stabilized TKA with tibial metal block and stem extension, and 11 knees received CCK (NexGen® LCCK, Zimmer®).
Results: The average pre- and postoperative knee extension/flexion angles were −15°/111° and −1°/114°, respectively. The pre- and postoperative Japanese Orthopaedic Association scores averaged 44 and 75. According to the Knee Society roentgenographic evaluation, the average α, β, γ and δ angles were 94°, 90°, 1° and 85°, respectively. On average, a 19 mm deep peripheral tibial bone defect was treated with a 9 mm thick metal block and 11 mm thick polyethylene insert, restoring the joint line 11 mm proximal to the fibular styloid. No progressive radiolucency, and no subsidence of components or changes in alignment were observed. The complication rate was 10%. There was one early failure, consisting of a fragile supracondylar femur fracture, which was revised with a femoral stem extension. There were three late failures consisting of a case of knee instability, which required polyethylene insert revision, a case of traumatic supracondylar femur fracture which required an internal fixation, and a case of acute infection which required an intraarticular antibiotic infusion after debridement, while retaining the implant.
Conclusion: Primary TKA in patients with severe deformities due to RA demonstrated favorable clinical outcomes, but a complication rate of up to 10% can be expected at the intermediate-term follow-up.

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Objective: The low contact stress (LCS) mobile bearing knee arthroplasty (DePuy Orthopaedics Inc, Warsaw, Indiana) has been in extensive use. Most of the results have been reported in predominantly osteoarthritis (OA) patients. There have been only a few studies with respect to the performance in patients with rheumatoid arthritis (RA) over an intermediate to long-term period. The objective of this retrospective study was to report 5 to 20 year clinical results in such patients.
Methods: Between July 1988 and June 2013, the senior author (T.Y.) performed 143 primary LCS mobile bearing total knee arthroplasties (TKAs) in 107 patients with RA. The mean age of the patients at the time of the surgery was 68 years.
Results: More than five years after the procedure, 64 patients (87 knees) were alive and 13 patients had died. Fifty two (56 knees) of 64 patients (87 knees) were followed clinically and radiographically. We revised two knees during the 2 to 14 year period of follow-up. One patient had a revision using a ceramic implant (KU-4) because of metal allergy. The other patient underwent an additional patellar replacement because of anterior knee pain 14 years after the primary surgery. The mean clinical Japanese Orthopedic Association score was 85 (70 to 95), at final follow-up and the mean passive range of motion was 129° (95° to 155°). The survival rate was 96% at 91 months. No radiological evidence of loosening was noted in 27 cementless knees. Thirty-three knees had no replacement of the patella. Fourteen patients had surgery to other joints in addition to their TKA with other arthroplasties in seven and treatment of seven fractures.
Conclusion: We found good clinical results for the LCS mobile knee arthroplasty in patients with RA, which were similar as the results in patients with OA.

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Objective: We performed unicompartmental knee arthroplasty (UKA) in patients with osteoarthritis and osteonecrosis of the knee. Appropriate joint stability is essential prior to UKA. We performed medial retinacular release from the medial tibia joint surface nearly 15mm, taking care intraoperatively to avoid over-correction of the femorotibial angle (FTA). This study was designed to evaluate the short-term and mid-term results of UKA in patients with osteoarthritis and osteonecrosis, and to determine whether joint stability was maintained postoperatively.
Methods: Seventy-four patients (74 affected knees; 15 males, 59 females) who had undergone UKA at least 6 months previously, were included in this study. The mean patient age was 77.5±5.1 years (range, 60-94 years). The Japanese Orthopaedic Association (JOA) score was used for the clinical evaluation of osteoarthritis of the knees. Radiological evaluation employed component angle, FTA on radiograph, the angle of inclination on stress radiograph and the femoral-component rotation angle (FCRA) on computed tomography scan. The component angle includes the femoral-component angle (FCA), the tibial-component angle (TCA), the lateral femoral-component angle (LFCA), and the lateral tibial-component angle (LTCA).
Results: The average JOA score improved significantly from 55.9±9.4 preoperatively to 86.0±5.5 postoperatively (P < 0.05). The average component angles were as follows: FCA 95.9±3.6°, TCA 88.8±2.0°, LFCA −1.0±6.1° and LTCA 87.7±2.3°, respectively. The average FTA also improved significantly from 181.4±5.3° preoperatively to 174.7±4.1° postoperatively (P < 0.05). The average FCRA was 0.22±4.7°, which was almost parallel to the epicondylar axis. In flexion, medial instability was found in seven patients (7 affected knees), and in extension, lateral instability was found in 17 patients (17 affected knees).
Conclusion: Short- and mid-term outcome and short-term joint stability after UKA were gener-ally favorable. The cases of joint instability after UKA included three patients (3 affected knees) who had required extensive medial retinacular release. These results suggest that joint stability after UKA may be influenced by prior lateral laxity, prior instability, and surgical technique.

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Objective: The purpose of this study was to evaluate the clinical outcome after open wedge high tibial osteotomy (OWHTO) with osteochondral autologous transplantation for spontaneous osteonecrosis of the knee.
Methods: Between 2009 and 2012, seven knees in seven patients who underwent OWHTO with osteochondral autologous transplantation, were enrolled in this study. Inclusion criteria involved patients who had persistent pain due to spontaneous osteonecrosis of the medial femoral condyle. There were two women and five men with a mean age of 61 years at the time surgery. All patients were evaluated by clinical, radiological, and arthroscopic examinations preoperatively and over 1 year postoperatively. Statistical evaluation was performed using the Student's paired t-test. The significance level was set at p = 0.05.
Results: All the patients achieved radiographic union at the osteotomy site and underwent the second surgery for removal of the fixation plate. The mean Japan Orthopaedic Association score significantly improved from 64 points preoperatively to 89 points at final follow-up. The mean femorotibial angle significantly reduced from 181° to 169° at the final follow-up. The weight-bearing line significantly shifted to 65% from 23%. Concerning articular cartilage lesions, the preoperative International Cartilage Repair Society grades (II: 1 case III: 5 cases, IV: 1 case) were improved (I: 1 case, II: 6 cases) postoperatively. Conversely, the range of motion, tibial slope and the Insall-Salvati ratio showed no significant differences between the two examination periods.
Conclusion: The present study demonstrated that OWHTO with osteochondral autologous transplantation significantly improved the short-term clinical result of spontaneous osteonecrosis of the knee. Radiological examination also showed that the knee alignment procedures had been performed correctly. In addition, postoperative cartilage repair assessment was dramatically improved. These results suggest that OWHTO with osteochondral autologous transplantation may be a useful treatment for spontaneous osteonecrosis of the knee.

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Total knee arthroplasty (TKA) is a common but painful orthopaedic surgical procedure. Adequate perioperative analgesia is very important for promoting the recovery of motor functions and postoperative rehabilitation. Formerly, neuraxial analgesia, such as epidural or subarachnoidal analgesia, has been used to provide appropriate perioperative analgesia. However, with the need to provide perioperative anticoagulant therapy after TKA, the use of peripheral nerve blocks has replaced neuraxial analgesia. The development of ultrasound technology has also led to the popularization of ultrasound guidance when performing peripheral nerve blocks. Peripheral nerve blocks provide much better postoperative analgesia and range of motion. Especially, the combination of a continuous femoral nerve block (CFNB) and intravenous opioids is considered to be a standard analgesic procedure for knee surgery. However, CFNB also leads to weakness of the quadriceps muscle. Recently, an adductor canal block and periarticular injection have been reported as alternative forms of analgesia for CFNB by some investigators. It is crucial for anesthesiologists to master the procedures for performing peripheral nerve blocks and to recognize which combination of analgesic methods is best for each patient.

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Introduction: Total hip arthroplasty (THA) has excellent stability and functionality in the treatment of neuropathic hip arthropathy. However, caution is required when performing surgery because of possible complications, such as dislocation and loosening. Here, we report our experience of a case in which THA was carried out for a patient with neuropathic hip osteoarthritis.
Case: A 50-year-old women complained of difficulty walking. In June 2004, she developed eyelid ptosis without a known trigger. The following month, she sought medical advice and she was hospitalized and diagnosed with neurosyphilis. Since August 2007, the patient had observed swelling extending from her right hip joint to her right thigh without any known cause, in addition to shortening of her right lower leg. Radiographic images showed a clear destruction of the femoral head. She was instructed to with respect to mobilizing, but eventually she began using a wheelchair. In February 2008, the patient attended her first examination at our hospital hoping for an operation to enable her to walk again unaided. Roentogen and computed tomography imaging showed that the right femoral head was destroyed and had almost disappeared. Moreover, bone destruction was evident around the load-bearing part of the acetabulum. Heterotopic ossification was also observed on the outer side of the acetabulum and outside the periphery of the greater trochanter. Magnetic resonance imaging revealed extensive hyperplasia of the joint capsule and synovium, with visible joint effusion. Although considerable destruction of the hip joint was observed in this case, the patient had no pain and the range of motion was mildly limited. Taking these findings together with her past history of neurosyphilis, we diagnosed her with a neuropathic hip joint and performed a THA. Although there is a high risk of dislocation in THA for neurogenic hip arthropathy, we were able to avoid this using an appropriate instrument with braces, thereby achieving a positive outcome.

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Humeral medial condyle fractures in severely affected patients with rheumatoid arthritis (RA), following minor trauma or occurring spontaneously, have been reported in recent years. Thinning and mutilating deformities of the distal humeral bony structure are considered to be the major causative factors. It is unknown whether osteosynthesis or arthroplasty is superior as treatment. We herein report some early-term results about open reduction and internal fixation (ORIF) using an anatomical plate, which was employed exclusively for two patient cases of humeral medial condyle fracture. The cases involved two elderly women of 76 and an 86 years of age with mutilating RA of Larsen grade 5. From a posteromedial approach in a lateral position, following anterior transposition of the ulnar nerve, the fracture fragment was fixed with an anatomical plate for each patient, respectively. At the postoperative 1-year follow-up for case 1, and the 9 months follow-up for case 2, the range of motion with respect to flexion and extension was 115/−50° and 134/−28°, and the JOA scores were 49 and 61 points, respectively. Radiographically, bone fusion in both cases was not confirmed. The poorest outcome was nonunion with an obvious radiolucent zone around the screws in case 2. Fortunately, these patients were asymptomatic in the operated areas within their limited scope of activity. At a minimum, both patients regained a level of activity equivalent to their preoperative level of Steinbrocker Class 4. These cases suggest that ORIF for humeral medial condyle fractures in severely destructive RA of the elbow may pose challenges from the perspective of bone union. ORIF should be used with caution and only when artificial arthroplasty is contraindicated.

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Introduction: Amyloid A (AA) amyloidosis is mainly a complication of connective tissue diseases including rheumatoid arthritis. AA amyloidosis resulting from the deposition of AA protein in various target organs, commonly in the kidney and gastrointestinal tract, may lead to multiple organ dysfunction. Tocilizumab (TCZ), an anti-interleukin (IL)-6 receptor antibody, is reportedly useful in the treatment of AA amyloidosis complicating rheumatic diseases by the suppression of serum AA levels and improvement of the clinical symptoms. We report a patient with rheumatoid arthritis (RA) complicated with reactive AA amyloidosis, who remarkably improved following the treatment with TCZ.
Case: An 80-year-old woman had suffered from RA for 5 years and was treated with methotrexate and other disease modifying anti-rheumatic drugs. She was admitted to the hospital because of anemia and extremity edema. She also experienced chronic diarrhea, continuous renal dysfunction, and bilateral knee arthritis. She was diagnosed with AA amyloidosis from a biopsy of the duodenum. TCZ was given as treatment for the RA considering past side effects of other drugs. After the second course of TCZ, joint symptoms and inflammation subsided including other clinical symptoms that gradually improved.
Conclusion: The present case showed the successful use of TCZ for the treatment of RA complicated by AA amyloidosis. Single use of TCZ is effective without combination therapy, and it has less severe side effects. It may be possible to use TCZ safely for elderly patients.

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