Objective: The objective of this study was to investigate the location of coracoid graft and screw direction and to examine the clinical results of a modified arthroscopic Bankart-Bristow (ASBB) procedure in high-demand collision and contact athletes with traumatic anterior shoulder instability.
Methods: This study reviewed the clinical results of surgery in 22 collision and contact athletes ranging from 15 to 24 years of age (average age, 19.5 years). The mean follow-up period was 25 months (range, 24-36 months) after surgery. The period of return to preoperative sports activities after surgery was evaluated in each case. Clinical outcome measures included the Japan Shoulder Society Shoulder Instability Score (JSS-SIS) and the Rowe Score. Thirty-five shoulders of 33 cases were evaluated with regard to improvement in the range of motion (ROM) at 1, 2, 3, 4, and 6 months postoperatively. Sixteen cases were evaluated in terms of coracoid graft location (horizontal position: HP; vertical position: VP) and screw direction (the angle of screw to glenoid surface: A-angle) using computed tomography scan images.
Results: All of the cases returned to their preoperative sports between 3 to 5.5 months postoperatively (average, 4.1 months). No cases experienced re-dislocation. At the time of the last investigation, the average JSS-SIS and Rowe Scores were 98.4 and 98.5 points, respectively. There were significant improvements of ROM in all the directions gradually over time. The recovery rates of ROM at 4 months after surgery were 96.5% for flexion, 96.9% for abduction, 90.3% for 1^st external rotation (ER), 95.3% for 2^nd ER, and 97.1% for 3^rd ER, respectively. The average settled angle of the coracoid graft from the sagittal view was 32.1 ± 12.8°, which was considered a suitable position of the glenoid between the 3 o'clock and 5 o'clock position. The average HP was −0.7 ± 0.4 mm and the average A-angle was 23 ± 9°.
Conclusion: In this study, the modified ASBB procedure transferred the coracoid process to a more suitable position of the glenoid neck, and allowed an early return to preoperative collision sports in high-demand athletes with traumatic anterior shoulder instability.

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Objective: Conservative treatment is indicated for a proximal humeral fracture without displacement. It is difficult to maintain conservative treatment for some elderly patients because of spinal deformities and different levels of cognitive understanding. Usually, conservative treatment is indicated for elderly patients because of other co-morbidities. When fracture displacement is identified, it is not always possible to change the treatment plan because of the patients' underlying general conditions, which can lead to nonunion of proximal humeral fractures.
Methods: We analyzed three patient cases including one male and two females, with an average age of 86.5 years. We evaluated the waiting time until operation, Japan Orthopedic Association (JOA) score and radiographic studies.
Results: One patient waited 1 year, another waited 2 years and another waiting time was unknown. The preoperative JOA score for pain was 5, for function it was 1.7, and for range of motion it was 4.3; the postoperative JOA score for pain was 23.3, for function it was 3.3, and for range of motion it was 10.3, respectively. We found the union of the greater tuberosity in one case on a follow-up postoperative radiograph.
Conclusion: Hemiarthroplasty for nonunion of proximal humeral fractures can relieve a patient's pain and improve their quality of life. Shoulder function depends on the tuberosities. Our cases could not establish complete union of the tuberosities, such that their shoulder functions were not improved. In order to get tuberosity union, it is important to improve intraoperative methods including a change of the implant.

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Objective: Synvisc® is expected to be more effective than conventional hyaluronic acid therapy for treating osteoarthritis of the knee. However, an increased incidence of local adverse effects with multiple courses of Synvisc® has been reported, and single-course treatment is generally recommended. The present study investigated the effectiveness and safety of multiple courses of Synvisc® treatment in patients with osteoarthritis of the knee.
Methods: Among 45 patients treated with Synvisc® for osteoarthritis of the knee, we investigated 18 who underwent a second course of synvisc 6 months after the initial treatment and seven who subsequently underwent a third course 6 months later. Visual analog scale (VAS) scores during movement were assessed prior to administration and 1 week, 2 weeks, 3 months and 6 months after the administration of Synvisc® for each course.
Results: In the 18 subjects who underwent two courses, the VAS average scores for the first course improved significantly at 3 months after the administration from 54.4 to 30.9; however, at 6 months, their pain had recurred with an average VAS score increasing from 30.9 to 40.7, respectively. A second administration of Synvisc® delivered a significant improvement in the average VAS scores at 1 week after the administration from 40.7 to 32.9, and this effect persisted at 6 months with scores from 32.9 to 30.3, respectively. However, three of the seven subjects who underwent a third course of treatment experienced local adverse effects.
Conclusion: Multiple courses of Synvisc® treatment may be effective for persistent pain relief in osteoarthritis of the knee; however, the incidence of local adverse effects was high with use of multiple courses. Physicians should inform their patients of the increased risk of local adverse effects when considering multiple course treatment.

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Objective: The C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) are common markers of inflammation in patients with rheumatoid arthritis (RA). The serum amyloid A (SAA) level is also a sensitive inflammatory marker, and biologic agents (BA) including tocilizumab (TCZ), an inhibitor of interleukin-6 (IL-6), have been reported to decrease the SAA level. However, to date, few reports have compared the SAA levels, disease activity, other inflammatory markers and prospective outcomes following treatment with BA. The aim of this study was to assess the disease activity and levels of SAA and other inflammatory markers in patients with RA receiving such agents.
Methods: The subjects included 32 patients with RA who were commenced on biologic treatment during or after July 2008 (17 patients received tumor necrosis factor (TNF) inhibitors and 15 patients received TCZ). The swollen joint count, tender joint count, Disease Activity Score (DAS) 28-ESR score and levels of SAA, ESR, CRP and matrix metalloproteinase-3 were assessed before treatment and at two, four and six months after treatment, respectively.
Results: No significant differences were found between the groups at baseline. At two, four and six months after treatment, the SAA, ESR and CRP levels in the TCZ group were significantly lower than those in the TNF inhibitor group, respectively. The DAS28-ESR scores obtained six months after treatment was significantly correlated with the SAA, ESR and CRP levels obtained two and four months after treatment in the TNF inhibitor group and with the SAA levels obtained two and four months after treatment in the TCZ group.
Conclusions: The DAS28-ESR score was used as an endpoint in this study. Comparatively high values have been reported for both efficacy and remission rates, particularly in patients treated with TCZ, which directly inhibits the inflammatory response. Furthermore, there are reports of relationships between the DAS28-ESR score and clinical disease activity index and simplified activity disease index values, thus indicating that DAS28 assessments are sufficiently useful. In this study, the DAS28-ESR scores obtained at six months after treatment significantly correlated with the SAA levels obtained after two and four months, but only in the TCZ group. These results suggest that it may be possible to use the SAA level as a predictive factor for the therapeutic effects of TNF inhibitor and/or TCZ therapy in patients with RA.

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Objective: Biologic treatment is known for its slow efficacy when switching drug classes for patients with rheumatoid arthritis (RA). We developed a new useful method to acquire a quicker response to biologic agents when switching drug class, called the K-method. The purpose of this study was to investigate the efficacy of the K-method for golimumab in patients with RA for up to 24 weeks.
Methods: The K-method uses 40 mg of triamcinolone acetonide (Kenacort-A®) 1 ml and 2 ml of 1% lidocaine hydrochloride (Xylocaine®) via an injection into the swelling or painful joints on the same day of biologic treatment. Ten cases using the K-method with golimumab, included one male and nine females, with a mean age of 69.8 years, and a mean disease duration of 12.4 years. The patients used an average of 7.3 mg/week of methotrexate and 3.3 mg/day of prednisolone. Analyses were carried out with respect to the C-reactive protein (CRP), Disease Activity Score with CRP (DAS28-CRP), and matrix metalloproteinase (MMP-3) for up to 24 weeks.
Results: The mean DAS28-CRP decreased from 5.94 to 3.80 at four weeks and to 2.58 at 24 weeks, respectively. The mean CRP changed from 4.4 mg/dl to 1.4 mg/dl at four weeks and to 1.3 mg/dl at 24 weeks, respectively. The mean MMP-3 changed from 296 ng/ml to 213 ng/ml at four weeks and to 173 ng/ml at 24 weeks, respectively. The European League Against Rheumatism response of the K-method was 70% in the good category and 30% in the moderate category after one day and more than a moderate response in all cases up to 24 weeks. No side effect was recognized using the K-method for up to 24 weeks.
Conclusion: The K-method is useful when switching drug classes to biologic agents to acquire a higher rate of good response from the first day with it being a safe procedure in daily practical RA treatment.

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Objective: The aim of this study was to investigate recent changes of knees in patients with rheumatoid arthritis (RA).
Methods: We analyzed the changes of the number of surgeries for patients for both upper and lower extremities between 2000 and 2013, inclusive. In 203 cases of total knee arthroplasty (TKA), the radiological findings, clinical data, and the usage of medications was analyzed.
Results: The number of surgeries for patients with RA affecting the lower extremities was significantly decreased over time; conversely, the number of surgeries for the upper extremities was increased. In our registry, the ratio of surgery for RA affecting the knees was significantly decreased, whereas the number of toe surgeries was increased. In cases of TKA, the average Larsen grade did not show a major change. In respect of the preoperative femoral-tibial angle (FTA), although cases of severe varus deformity have decreased recently, the average FTA showed no change per year. In older patients, an increased number of cases with the spur formation were observed; half or more of the cases showed spur formation after 2011. In addition, an increased dose of methotrexate and a reduction in the dose of prednisolone was observed year on year.
Conclusion: In our registry, the ratio of surgery for RA of the knees was significantly decreased. An increased number of the cases with spur formation may reflect the relative increase of RA of the knees, which may produce an osteoarthritis-like change.

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Objective: To determine the influence of total knee arthroplasty (TKA) on various parameters concerning local and general disease activity in patients with rheumatoid arthritis.
Methods: We analyzed the effect of rheumatoid arthritis (RA) disease activity and health-related quality of life. Twenty-two patients with RA were analyzed in this study who underwent TKA. All patients were female, and the average age was 62.4 ± 9.3 years. RA disease activity and quality of life were measured using the Disease Activity Score (DAS) 28, the Simple Disease Activity Index (SDAI), and the modified health assessment questionnaire (mHAQ). C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and matrix metalloproteinase-3 (MMP-3) were used as clinical outcome measures. We analyzed the change of drugs including methotrexate (MTX), prednisolone (PSL) and biologic agents; these were measured at three months, six months and one year postoperatively.
Results: mHAQ improved from 0.89 to 0.52 by 3 months, and statistically significant differences were found in five items in items of mHAQ. ESR decreased from 38.0 to 31.4 mm/h, CRP decreased from 1.0 to 0.7 mg/dl and MMP-3 decreased from 272.6 to 130.9 ng/ml, respectively. There was an improvement trend post-TKA until one year, but a statistically significant change was found only with MMP-3. There was a statistical improvement in the Visual Analogue Scale (VAS) for pain. A statistically significant difference was also identified for all items including general VAS and doctor VAS. The DAS28-CRP and DAS28-ESR showed a trend towards improvement from three months, which was statistically significant. Conversely, there was no statistical difference for use of MTX or PSL.
Conclusion: In this study, TKA was shown to be associated with improvement in disease activity and health-related quality of life measures in patients with RA. In the evaluation of disease activity, a trend towards improvement was shown using the DAS28 and SDAI scoring systems. In addition, levels of MMP-3 were associated with improvement. TKA is associated not only with local but also general disease activity utilizing the “treat to target” concept.

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Objective: In total knee arthroplasty (TKA), if osteotomy is performed to remove an equal amount of the thickness of the distal femoral component in patients who exhibit severe abrasion in the distal femoral condyle, a large degree of osteotomy is required, which can result in an increase of overhang in the proximity of the posterior femoral condyle. We simulated the position of the components by using the preoperative planning software Athena® (Soft Cube, Osaka, Japan), and measured the distance of overhang of the posterior femoral component.
Methods: The subjects were 202 knees from 137 consecutive patients with varus osteoarthritis who were scheduled to undergo TKA. Computed tomography (CT) scans of each lower extremity were obtained preoperatively for each patient. The thickness of the distal and posterior condyle was 9 mm in this component of the investigation. Overhang in the posteromedial and posterolateral condylar areas was measured following three distal femoral osteotomy procedures as follows; 1) 9 mm was removed from the distal medial condyle, 2) 9 mm was removed from the distal lateral condyle, and 3) measurement was performed at the level of the femoral intercondylar notch.
Results: The 9 mm distal medial condylar osteotomy value for the posteromedial condyle was 1.6 ± 1.3 mm and for the posterolateral condyle was 2.8 ± 2.3 mm, respectively. The 9 mm distal lateral condylar osteotomy value for the posteromedial condyle was 3.0 ± 1.7 mm and for the posterolateral condyle was 4.1 ± 2.0 mm, respectively. Osteotomy at the level of the femoral intercondylar notch on the medial side was −0.1 ± 1.2 mm and on the lateral side was 1.0 ± 1.9 mm, respectively.
Conclusion: When osteotomy was performed at the level of the femoral intercondylar notch, it seemed to have less of an abrasive effect on the joint surface. As a result, the posteromedial condyle was able to maintain its original form, and overhang in the posterolateral condyle was the smallest in the three procedures. It suggests that this procedure may be able to restore the original form of the femoral condyle.

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Computer-assisted surgery, particularly the image-free knee navigation system, is clinically useful because the exact mechanical axis of the lower extremity is achievable during total knee arthroplasty (TKA). Moreover, intra-operative kinematic analysis also enables the surgeon to predict the postoperative kinematics. The image-free knee navigation system has advantages including the appropriate implantation of the TKA based on the mechanical axis of lower extremity leading to the maximal expression of design concepts and kinematics. However, there are several issues and pitfalls of the axial decision and kinematic analysis using this system. In this paper, these issues are discussed and the solutions for them are also described from the experience of 871 cases of TKA in our institution.

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Objective: The purpose of this study was to evaluate the efficacy and safety of the drained-clamped method with intra-articular infusion of tranexamic acid (TA) for reducing blood loss in total knee arthroplasty (TKA).
Material and Methods: From November 2011 to July 2014 inclusive, 72 patients with a diagnosis of osteoarthritis underwent unilateral primary TKA using a computed tomography (CT) free navigation system. Patients were randomly divided into two groups: group T (n=40) was given 2000 mg (40 ml) of TA and group W (n=32) was given 40 ml sterile saline only. After tourniquet release and wound suture, TA or saline was infused into the knee joint in addition to the drained-clamped method for 2 hours. We evaluated the hematocrit, hemoglobin levels and the postoperative estimate of bleeding in all cases. In addition, lower extremity venous ultrasonography was performed for the investigation of venous thromboembolism in the latest 40 patients and contrast-enhanced CT was performed in the latest 34 patients without a previous history of asthma and diminished renal function. The present study received institutional review board approval, and informed consent was obtained from all patients.
Results: Group T had lower hematocrit and hemoglobin levels at postoperative day 1. Group T had higher hemoglobin levels at postoperative days 3 and 7, respectively. The postoperative estimate of bleeding in group T was 739.2 ± 318.9 ml on average, which was significantly less than group W which was 999.8 ± 414.1 ml (p < 0.01).
The rate of asymptomatic deep vein thrombosis and pulmonary embolism was 57.1% and 29.4% in group T, and 36.8% and 11.8% in group W, respectively. There were no significant differences between the two groups.
Conclusion: The drain-clamped method with intra-articular infusion of TA was safe and effective for reducing the amount of blood loss in TKA.

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Objective: From April 2005, we evaluated the rate of venous thromboembolism (VTE) in all total hip arthroplasty (THA) cases using multi detector computed tomography (CT) scans on postoperative day one. We report two original physical therapy methods, namely intermittent calf massage (ICaM) and intermittent passive ankle motion (IPAM), that have proven to be highly effective for VTE prophylaxis.
Methods: 868 THA cases from April 2005 to June 2013 were included for analysis. Graduated compression stockings and intermittent pneumatic compression were used postoperatively in all cases. In cases prior to 2007, no VTE prophylaxis methods were used in a traditional posterolateral approach (Group I: n=179). Elastic bandages were used during surgery in cases from 2007 to 2011 with a minimally invasive approach (Group II: n=506). From 2011, ICaM and IPAM were additionally performed (Group III: n=183). VTE incidence rate, age, sex, operation time, and blood loss were compared between the three groups.
Results: The incidence rate of VTE was 30.2% (54 cases) in Group I, 15.6% (79 cases) in Group II, and 0.5% (1 case) in Group III, presenting a significant decrease in VTE by applying ICaM and IPAM. Operation time was significantly longer in the Group I. VTE positive patients were also significantly older in all three groups.
Conclusion: In our study, the incidence rate of VTE was reduced by 50% through a decrease in operation time and the use of elastic compression bandages (Group II). Furthermore, the incidence rate of VTE was reduced considerably to 0.5% through the simple use of ICaM and IPAM methods (Group III). ICaM and IPAM are highly effective methods for VTE prophylaxis and we hope to see it applied worldwide.
Summary: We report two original physical therapy methods, intermittent calf massage and passive ankle motion that have proven to be highly effective for VTE prophylaxis during total hip arthroplasty.

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We experienced a rare case of a solitary bone cyst in a 65-year old female patient with a 37-year history of rheumatoid arthritis (RA), and who was treated with biologic agents. Since December 2012, the patient had experienced sustained rest pain in her left arm despite using non-steroidal anti-inflammatory drugs. Her RA disease activity was controlled as evidenced by a normal C-reactive protein (CRP) level of 0.13 mg/dL, and a Disease Activity Score (DAS) 28 of 2.4, whilst using methotrexate 12 mg/week, and abatacept 500 mg intravenously. There was no swelling or tenderness observed in her left arm, and the range of motion (ROM) of her left shoulder was normal with a negative impingement test. Her Japanese Orthopedic Association (JOA) score was 67 points consisting of 10 points for pain, 12 points for function, 25 points for ROM, 5 points for radiographic changes, and 15 points for stability, respectively. A T2-weighted short-tau inversion recovery magnetic resonance imaging scan showed a 3 × 4 cm homologous high intensity area, which was suspected to be a solitary bone cyst in her left humerus. Surgical decompression and drainage of the cyst was performed using an absorbable cannulated screw. One month postoperatively the patient's left arm pain had resolved with a normal ROM of the shoulder, and a JOA score of 99.

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We report a case of coxitis knee in which revision total knee arthroplasty (TKA) was performed using a constraint-type implant because severe valgus instability had resulted from the primary TKA. A 77-year-old woman with congenital dislocation of the hip had left gonalgia and gait disorder. She had undergone initial TKA in another hospital at age 66. Severe valgus instability of the left knee and relative lower left limb shortening were observed. Both hip joints had an abduction limit of 10°. X-ray investigation showed that the wear on the TKA was severe, and the femorotibial angle was 130°. Both hip joints had advanced dislocations of Crowe type IV. We diagnosed her condition as coxitis knee presenting with high valgus instability caused by the abduction limit of the ipsilateral hip joint. The ipsilateral THA and the separation of the adductor muscles were reinforced. Revision TKA was reinforced four months later. Because the medial loosening was severe, a restrictive-type TKA (Biomet OSS) was used. The gonalgia disappeared after surgery, and improvement in gait was obtained. Both ipsilateral knee dysfunction originating from adduction contracture of the hip joint and contralateral knee dysfunction caused by length differences in the lower limbs have been reported; the latter condition is known as long leg arthropathy. This case was considered to be knee dysfunction caused by the abduction limit of the hip joint. Excessive valgus stress might have resulted from medial collateral ligament dysfunction and the severe wear of the insert. Two or more factors may contribute to coxitis knee, and examining the condition based on the overall balance of both lower limbs is necessary.

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