Objective: There have been many reports about arthroscopic treatment for labrum injury accompanied by acetabular dysplasia or femoroacetabular impingement. Meanwhile, poor results including catastrophic failure in arthroscopic surgery for hip disorders have been reported. The purpose of this study was to investigate the results of arthroscopic surgery for labrum injury in order to determine the better application of arthroscopic surgery for its treatment.
Methods: There were 143 hip joints from patients with labrum injuries that underwent arthroscopic surgery. The cohort were divided into three groups; 28 joints without acetabular dysplasia (non-D group: CE angle < 25°), 30 joints with mild acetabular dysplasia (mild-D group: CE angle 20°-25°), and 85 joints with acetabular dysplasia (D group: CE angle > 20°). The morphology of each labral tear was arthroscopically evaluated and categorized into partial or complete peripheral longitudinal tear, radial flap tear, degenerative tear and inverted limbus. Clinical scores by the Japanese Orthopaedic Association (JOA) were evaluated both in the preoperative and postoperative phase. Osteoarthritic changes on the plain radiographs of the hip joint were also evaluated.
Results: There were more cases with partial peripheral longitudinal tears in non-D and mild D groups, while there were more cases with degenerative tears in D group. In D group, there were three joints with 80 points or more of the JOA score, six joints with less than 80 points of the JOA score, 15 joints which finally resulted in total hip arthroplasty (THA), and 61 joints combined with rotational acetabular osteotomy. Arthroscopic findings in 15 joints finally resulted in THA and were characterized by inverted limbs in eight joints and degenerative tears with instability in all joints. On the other hand, arthroscopic findings in three joints with JOA scores of 80 points or more were characterized by partial peripheral longitudinal tears without instability and minor degrees of chondral injury in all cases.
Conclusion: Our results suggest that arthroscopic surgery for labral tears with mild dysplastic hip joints should be avoided in cases with inverted limbs, labrum injuries with instability, or major degrees of chondral injury.

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Objective: The medial opening wedge high tibial osteotomy (OWHTO) is a standard procedure in the treatment of varus osteoarthritis. This is potentially associated with various complications. The purpose of this study was to analyze complications and potential mistakes in surgical technique.
Methods: A total of 160 knees (38 male and 122 female) suffering from varus osteoarthritis underwent the OWHTO between 2008 and 2011. Medical records, operative reports, and radiographs were retrospectively reviewed for all patients who experienced a complication postoperatively. All complications were identified for analysis.
Results: The average Japan Orthopaedic Association score improved from 51.8 points to 85.3 points. The average of FTA changed from 182.7° to 170.5°. The average of %MA changed from 22.3% to 60.8%. The average of posterior tibial slope changed from 6.4° to 7.1°. The average Carton index changed from 0.92 to 0.62. There were 21 knees (13.1%) with lateral cortex fractures, one (0.6%) with screw failure, one (0.6%) with arterial injury, and five (3.1%) with infection.
Conclusion: With careful selection of patients with indications for knee surgery, good short-term and intermediate-term results can be achieved by OWHTO. The OWHTO is associated with a moderate frequency of complications. Although there are technical advantages offered by the OWHTO, their influence on the frequency and type of complications experienced by patients in our series was not apparent. Further evaluation of this procedure is required for long-term surgical outcome.

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Recently, disease modifying anti-rheumatic drugs and biologic agents have caused a paradigm shift in the treatment of rheumatoid arthritis (RA). Consequently, improved medical control of joint destruction has led us to reconsider the benefits of joint preservation. With good perioperative medical management of RA, surgical repositioning of the metatarsophalangeal (MTP) joints by metatarsal shortening and consequent relaxation of surrounding soft tissue is considered to be successful. This provides longitudinal decompression of the ray without tendon lengthening. This is beneficial for the joint's range of motion and for improving gait. It can be performed preferentially in the early-to-intermediate disease stages, instead of a joint-sacrificing procedure. The author would like to introduce this technique and the outcomes of joint-preserving surgery by CMOS involving three different proximal osteotomies for forefoot deformities in patients with RA.

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Objectives: Rheumatic diseases are chronic systemic autoimmune inflammatory diseases. However, the etiology of many rheumatic diseases remain unknown. Microparticles (MPs) are complex structures composed of a lipid bilayer that contain transmembrane proteins and enclose soluble hydrophilic components derived from the cytosol of a donor cell, including deoxyribonucleic acids, ribonucleic acids or nucleus proteins themselves. Plasmacytoid dendritic cells (pDCs) play an important role in innate inflammation in rheumatic diseases. The aim of this study was to assess the reaction of pDCs by stimulating them with MPs in a model of rheumatic disease.
Methods: Human submandibular gland cells were treated with tumor necrosis factor-alpha, tamoxifen and cyclohexamide to induce apoptosis. MPs and apoptotic bodies (ABs) were collected by centrifugation into pellets. Pellet 1 was ABs-rich (P1), pellet 2 was both ABs- and MPs-rich (P2), and pellet 3 was MPs-rich (P3). The expression of Toll-like receptor (TLR) 7 and TLR9 on a pDC cell line (GEN 2.2) were measured by quantitative reverse transcription polymerase chain reaction after the cells were stimulated by P1, P2 and P3, respectively.
Results: The expression of TLR7 and TLR9 on pDCs was 2.0 and 4.1 times increased by P1 stimulation, unchanged and 1.5 times increased by P2 stimulation, and 2.4 and 3.8 times increased by P3 stimulation, respectively, compared to a non-stimulation group.
Conclusion: MPs and ABs can induce the expression of TLR7 and TLR9 on pDCs. MPs and ABs may play a role in the onset and maintenance of rheumatic disease via TLR pathways.

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Background: In total knee arthroplasty (TKA), postoperative pain control affects patient recovery and satisfaction. Periarticular injection with a multimodal protocol has been reported to be effective for pain control. There have been few studies describing only single periarticular injection using various kinds of medications for TKA. In this study, we assessed the efficacy of single periarticular injection compared with epidural infusion on postoperative pain and analgesic requirements after TKA.
Methods: Sixty-one female patients with osteoarthritis were randomized into two groups to receive either intraoperative single periarticular injection with ropivacaine, morphine, epinephrine, methylprednisolone, ketoprofen, and saline (Cocktail group), or continuous epidural infusion for three days postoperatively (Epidural group). For rescue analgesia, intravenous patient-controlled analgesia with morphine was used for 24 hours postoperatively. The intensity of knee pain (0-100 mm on visual analog scale (VAS), for 1 to 21 days postoperatively), morphine requirements (for 24 hours), and side effects were recorded.
Results: VAS for pain at rest was lower in the Cocktail group than in Epidural group on postoperative day (POD) 1, which was statistically significant (10.3 vs 39.6, p < 0.05). On POD 2, POD 3, POD 4 and POD 5, the VAS in the Cocktail group was lower, but the differences were not statistically significant (p = 0.317, 0.364, 0.332, and 0.097, respectively). After that, and up to POD 21, there was no further statistical difference of VAS for pain between the two groups. Morphine consumption during the first 24 hours was lower in the Cocktail group compared to Epidural group (212 vs 451 μg, p < 0.05). There was no statistical difference between the two groups with respect to the incidence of side effects.
Conclusions: Periarticular injection with multimodal medications provided superior pain relief and reduced morphine consumption compared with continuous epidural infusion after TKA.

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Background: An intraoperative fracture of the acetabulum during primary total hip arthroplasty is a rare complication. Until now, there has been no report evaluating the use of computed tomography (CT) for this complication. Occult fracture which can not be confirmed by intraoperative findings or by postoperative radiography can be assessed by evaluating the acetabulum using postoperative CT.
Methods: Between 2004 and 2012, 549 primary total hip arthroplasties (THA) with uncemented components were performed at our institution. We excluded 94 hips with a history of pelvic osteotomy, trauma and infection; thus, the study included 455 hips. Acetabular component designs were categorized as true hemispherical and PSL cups, and then each design was analyzed for fracture risk. In 243 hips with PSL cups, reaming was carried out of the acetabulum bed to 1.8 mm under the true largest external diameter, as the component to be inserted. We used preoperative and postoperative CT imaging to evaluate fractures. We reconstructed CT images of axial, sagittal and coronal sections. All potential fractures lines were evaluated in at least two planes.
Results: In two hips (0.43%), periprosthetic fractures of the acetabulum were found intraoperatively. In 41 hips (9.0%), occult fractures of the acetabulum were confirmed using postoperative CT whereas they had not been identified perioperatively or by postoperative standard radiography. These fractures do not require particular additional treatment and may remain subclinical in the postoperative period. PSL cups were associated with a significantly higher fracture rate than were hemisherical cups (p < 0.05).
Discussion and Conclusions: The fracture rate of acetabulae that occurred during THA, associated with uncemented components, was 0.4%. The intraoperative occult fracture rate of acetabulae, associated with uncemented components, was 9.0%. We found a high rate of fracture in association with the use of PSL components.

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Objective: We performed unicompartmental knee arthroplasty (UKA) on patients with osteoarthritis (OA) of the knee and evaluated the clinical results. This study aimed to evaluate whether the severity of preoperative patellofemoral (PF) joint OA related to the final clinical results.
Methods: A total of 109 patients (125 affected knees) who had undergone UKA six months or more before the study were enrolled, included 14 males (15 affected knees) and 95 females (110 affected knees) with a mean age of 78.0 ± 5.3 years (range, 61-94 years). Clinical evaluation utilized the scoring system for OA of knees prepared by the Japanese Orthopaedic Association (JOA), and we investigated postoperative PF pain. We also performed radiological measurements using patient radiographs. Operations were performed by one surgeon, and intraoperative removal of osteophytes around the medial femoral condyle were undertaken. For statistical analysis we performed Mann-Whitney's U test and adopted a significance level of P < 0.05.
Results: The average JOA score improved significantly from 56.5 ± 11.0 preoperatively to 85.0 ± 5.6 postoperatively (P < 0.01). Postoperative PF pain was found in seven patients (8 affected knees) at the final evaluation. However, in these patients, the pain was less severe than it had been preoperatively. Postoperative radiological evaluation was generally favorable.
Conclusion: Clinical and radiological evaluation of UKA was generally favorable. However, we need to consider that postoperative PF-pain may persist in patients with severe PF-OA who experienced preoperative PF pain. We consider that it is important to assess patients' preoperative PF pain along with the severity of OA when considering proceeding to UKA.

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Objective: Few studies have been published about assessing agricultural and sporting activity after unicompartmental knee arthroplasty (UKA) and/or total knee arthroplasty (TKA). In this study, agricultural and sports participation were analyzed using a self-administered questionnaire in 100 patients who had undergone UKA.
Methods: A total of 100 patients were enrolled in this study, comprising 70 women and 30 men with a mean age of 75.7 years (range, 58-86 years) with a mean of 4.9 (range, 1-18 years). All 100 patients were given a self-administered questionnaire about their agricultural and sporting activities after UKA was performed. These results were compared to those after TKA.
Results: Thirty-eight patients engaged in agricultural activities before surgery, and 31 of 38 patients continued agricultural activities after UKA. 79.5% of patients returned to agricultural activities after UKA. Forty-four of 51 patients continued these after TKA, and the return to agriculture rate was 86.2%. Thirty-two of 38 patients participated in sporting activities after UKA. Fifteen of 30 patients participated in sporting activities prior to surgery, and only 40.0% of patients returned to sports after TKA. However, in the UKA, 73.7% of patients returned to sports after surgery.
Conclusion: With respect to agricultural activities, there was no significant difference between the UKA and TKA group. Patients had a significantly greater return to sporting activities after UKA than patients who had undergone TKA.

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Objectives: We studied patients who underwent anterior cruciate ligament (ACL) reconstruction and second-look operation and evaluated the synovialization of the graft, and discussed the factors influencing this occurrence and the clinical results.
Methods: The study cohort consisted of 133 patients who underwent ACL reconstruction using single bundle multi-strand hamstring tendon graft, operated by a single surgeon, and 97 knees were eventually assessed which had a second-look operation. Re-injury, complex ligament injury, injury with fracture, infection, and bilateral injuries were excluded. Finally, 88 knees (46 male, 42 female) were examined, and the average age at the time of operation was 25.4 (range, 14-46) years old. Gender, age, body mass index (BMI), notch width index (NWI), Tegner activity score (TAS), duration from injury to reconstruction, duration from reconstruction to second-look operation, Lysholm score at second-look operation, anterior translation measured with a KT-2000 arthrometer, femoral tunnel angle (FA), tibial tunnel position (TP), and graft size were examined.
Results: Fifty-five knees (62.5%) had good synovialization of the graft, which were more than 80 percent covered by synovium. The patients were divided into two groups as follows: ‘good-group’ with synovialization and without partial tears for 51 knees and a ‘fair-group’ with synovialization for 37 knees, respectively. No significant differences could be found in gender, age, BMI, TAS, duration from injury to reconstruction, or duration from reconstruction to second-look operation. NWI was significantly higher in the good-group versus the fair-group (p = 0.029). Clinically, no significant differences could be seen in the Lysholm score, KT-2000, TP or graft size. FA was significantly larger in the fair-group than in the good-group (p = 0.049).
Conclusion: NWI and FA may be related to the synovialization, which suggests potential impingement could influence synovialization of the graft. Therefore, anatomical reconstruction and accurate tunnel position might be an advantage for better synovialization.

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Objective: In the pharmacological therapy of osteoarthritis of the knee, various medicines have been prescribed to control knee pain. The purpose of this study was to evaluate the efficacy of a tramadol hydrochloride-acetaminophen (TRAM) combination in patients with osteoarthritis of the knee.
Methods: We prescribed TRAM to 46 patients with osteoarthritis of the knee who were unable to achieve adequate pain relief using non-steroidal anti-inflammatory drugs (NSAIDs). The patients included 15 men and 31 women, with a mean age of 79.7 years. According to the change in their knee pain intensity after the administration of TRAM, patients classified their pain as one of the following: ‘disappeared,’ ‘decreased,’ ‘mildly decreased,’ ‘unchanged,’ or ‘increased.’.
Results: Knee pain ‘disappeared’ in two patients, ‘decreased’ in 13, ‘mildly decreased’ in 12, was ‘unchanged’ in 18, and ‘increased’ in one patient. Nine patients discontinued taking TRAM due to side effects, all of which subsequently resolved.
Conclusion: Because tramadol acts as a μ-opioid receptor agonist, it is believed that the TRAM combination directly decreases the pain by inhibiting its transmission. In this study, approximately 60% of all patients who could not achieve sufficient pain relief using NSAIDs could do so using TRAM. However, some patients had to discontinue the medication because of side effects. We think it is necessary to devise a suitable analgesia regimen for patients with osteoarthritis of the knee using TRAM.

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Objective: Recently, Dr. Yamamoto suggested that the cause of idiopathic osteonecrosis of the knee results from an insufficiency fracture. He showed that the necrotic lesion of the knee exists peripheral to the fracture line by using pathological methods. It appears that osteoporosis is related to spontaneous osteonecrosis of the knee (SONK). Therefore, we examined the bone mineral density (BMD) of patients with SONK for underlying osteoporosis.
Patients and Methods: The study subjects comprised 50 patients treated in our hospital over a five-year period from April 2007 to April 2012. The age of the patients were 50-89 years old (mean age 71.0 years), with there being eight males and 42 females. There were 41 patients with pathological changes in the medial femoral condyle, and nine patients with changes to the medial tibial plateau. These patients underwent BMD examinations of the vertebral column and femur with dual energy x-ray absorptiometry. They were all tested within six months after the onset of this disease, and in 17 cases, we examined the tibial plateau bone mineral density.
Results: The rate of osteoporosis of these patients was 28%, using BMD, with there being only one male patient affected. In addition, 38% were considered osteoporotic with the use of femur BMD, with only female subjects being affected. The tibial plateau BMD of these patients were slightly lower than those of osteoarthritic patients.
Conclusions: The ratio of osteoporosis in patients with SONK was higher than that of unaffected persons. In our study, male patients with SONK rarely had underlying osteoporosis. The use of BMD in patients with SONK may be a useful adjunct for assessing the underlying disease in affected patients.

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Objective: We analyzed radiological results of Swanson implant surgery for rheumatoid arthritis affecting the forefoot. Special attention was paid to the incidence of recurrent hallux valgus deformity. Factors affecting such recurrences were analyzed.
Methods: Postoperative radiological results with a minimum follow-up period of 12 months after surgery were analyzed in 54 cases (87 joints). The mean age at the time of surgery was 67.7 years (range, 53-84 years). The mean duration after surgery was 40.8 months (range, 12-93 months). Hallux valgus angle (HVA) and intermetatarsal M1-M2 angle (M1M2) were analyzed preoperatively, in the immediate postoperative period, at six months postoperatively, and at the final follow-up. The change of HVA from the immediate postoperative period to the final follow-up was calculated as the change of HVA (ΔHVA). The toe lengths of the hallux including soft tissue shadow were divided into three groups as follows: Type E (hallux length 3 mm longer than the second toe), Type G (hallux length 3 mm shorter than the second toe), and Type S (hallux length within 3 mm of the second toe). The relationship between toe length type and radiological findings were then analyzed.
Results: The average preoperative HVA was 38.4 ± 16.5°, and the average HVA in the immediate postoperative period was 21.1 ± 10.1°, which was statistically maintained during the follow-up period. The average M1M2 showed no changes during the follow-up period. Cases whose ΔHVA were over 15° were observed in early cases in the surgical series. There was no statistical correlation between the changes of HVA and the follow-up period, preoperative HVA, or HVA in the immediate postoperative period. Type G showed significantly less changes of HVA when compared to Type E. Also, with the shortening of the length of hallux by toe length type, the HVA at the final follow-up was significantly decreased.
Conclusion: Surgical skills are needed for Swanson implant surgery for rheumatoid arthritis of the forefoot, because cases of recurrent hallux valgus have been frequently observed in early surgical series. Finally, the shortening of the length of the hallux is important for preventing recurrent hallux valgus deformity.

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Objective: Methotrexate (MTX) drastically improved rheumatoid arthritis (RA) therapy when introduced in Japan from 1999 onwards, especially after permitting the increase to the maximum dosage of 16 mg per week from the year 2011. The use of MTX for patients with RA may reflect trends in disease severity, management and health outcomes.
Methods: We examined the number of patients who had taken MTX, the mean dosage of the drug and associated adverse effects in our patient cohort from the last decade.
Results: The total dosage of MTX increased from 185 mg/person/year to 546 mg/person/year. We had a total of 552 patients in our clinics by 2012. The percentage of patients who had been treated with MTX was 49.0% (264/552). The mean dosage per week had increased from 4.9 mg/week in 2002 to 10.7 mg/week in 2012. Adverse effects occurred in 14 patients, all of whom were hospitalized.
Conclusion: The mean dosage of MTX for patients with RA has increased year by year. It may play an important role for improvement of disease activity and attitudes, and quality of life in patients with rheumatoid arthritis.

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   Despite performing patellar resurfacing in total knee arthroplasty (TKA), a significant proportion of patients still experience anterior knee pain (AKP). Here, we report a patient with AKP following TKA with patellar resurfacing for whom we successfully treated the lateral part of the patella with resection, in an area that was not covered by the patellar component.
Case: A 78-year-old woman experienced increasingly worse AKP that began three years after undergoing primary TKA with patellar resurfacing. The original surgery had been undertaken for spontaneous osteonecrosis of the medial femoral condyle. On a physical examination, there was tenderness at the lateral side of the patella. Radiographic examination did not demonstrate loosening of the implants, and there were no signs of infection.
   The presumed cause of the AKP was thought to be due to impingement between the lateral part of the resurfaced patella and the femoral component from the original implant through malposition. In this case, the femoral component was implanted with 9-degrees of internal rotation in relation to the clinical epicondylar axis.
   As a result, the patient underwent reoperation, which was performed through the standard medial parapatellar approach. The lateral part of the patella that was not covered with the patellar component was removed with an oscillating saw. Lateral release was not performed.
   Postoperatively, her AKP was significantly improved. The pain visual analog scale (VAS; scale 0-10) improved from 8.5 down to 1.0. Her Knee Society Knee Score improved from 33 to 83, and her Knee Society Function Score improved from 45 to 85, respectively.
   Since AKP after TKA can have multiple etiologies, it is difficult to specify all causes and to treat the pain effectively. In this case, we were able to identify the impingement as a cause of AKP in this patient. If malposition of the implanted component is the cause of AKP, revision TKA is a possible solution. However, revision TKA is more invasive than lateral osteotomy of the non-covered component of the patella. We believe that in order to prevent future AKP following TKA, it is important to prevent this aforementioned impingement and, therefore, we perform this lateral osteotomy procedure on all primary TKA patients.

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Background: Mycobacterium tuberculosis is a rare cause of prosthetic joint infection. We report a case of postoperative Mycobacterium tuberculosis infection after total knee arthroplasty.
Case: An 85-year-old woman who had continuous pain and swelling of the right knee for two months was evaluated by arthrocentesis, which revealed yellow synovial fluid. The synovial fluid culture was negative and so a diagnosis of osteoarthritis of the right knee was made. Total knee arthroplasty was undertaken and six weeks postoperatively, the synovial fluid culture and tissue biopsy yielded M. tuberculosis. Pulmonary tuberculosis was not detected on chest computed tomography or sputum examination. A diagnosis of tuberculous prosthetic joint infection was made, and anti-tuberculous therapy with isoniazid, rifampicin and ethambutol was initiated. At a 7-month follow-up, the radiography showed no signs of prosthesis loosening and C-reactive protein levels had returned to baseline without requiring prosthesis removal.
Conclusion: The early diagnosis of tuberculous prosthetic joint infection and appropriate treatment can produce good results without the need for prosthesis removal; the present case suggests the possibility of treatment of tuberculous prosthetic joint infection with anti-tuberculous chemotherapy alone in selected cases. When septic arthritis is suspected, tuberculous arthritis must also be considered.

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