Objective: Early operation is considered to have a better outcome for elderly patients with hip fractures. However, elderly patients are often managed on long-term antiplatelet agents/anticoagulant therapy. Therefore, such patients may be at increased risk of perioperative bleeding and other complications. The aim of this study was to evaluate the safety of hemiarthroplasty for hip fracture in patients taking antiplatelet drugs (APDs).

Methods: A retrospective chart review was conducted. Thirty-one patients taking APDs underwent hemiarthroplasty for hip fractures in our hospital between January 2014 and December 2015. All patients had APDs discontinued after admission until two days post-surgery. Patients were divided into two groups, an ‘early’ group (surgical delay<5 days after admission) or a ‘delay’ group (surgical delay>4 days after admission). We investigated the patients’ hemoglobin (Hb) levels, walking ability, the length of hospitalization, postoperative complications and transfusions associated with APDs.

Results: There was no significant difference with postoperative Hb level and the amount of transfusion between the two groups. There were also no complications related to spinal anesthesia between the two groups. The ‘early’ group had better walking ability (P=0.045) and shorter hospitalization in 9 days (P=0.024) compared to the ‘delay’ group. The ‘delay’ group significantly increased in the risk of postoperative complications than the ‘early’ group (P=0.003).

Conclusion: There was no significant difference in perioperative bleeding after early hemiarthroplasty in patients taking APDs with hip fractures. Therefore, this study demonstrates that early operation for hip fractures is safe and, in doing so, there may be better outcomes for patients taking such medications.

Objective: In total knee arthroplasty (TKA), it is important to reconstruct the knee alignment precisely to have satisfactory outcomes in terms of function, desensitization, and durability. In the coronal and axial plane, there is vast literature concerning alignment. However, the proper alignment in the sagittal plane and its clinical impact on function and outcome has not been studied to any great extent. Although the posterior tibia slope (PTS) has been proven to be important in TKA, and used when cutting the proximal tibia, it is difficult to measure PTS intraoperatively, and also it differs between normal and degenerative knees.

Methods: We focused on the articular capsule insertion on the tibia, which is more detectable intraoperatively. We defined the posterior capsule slope (PCS) as a new index, and evaluated and compared it with PTS in 51 autopsied knees. We measured the angle between the anterior cortex of the tibia, as one of the axes, and the line connecting the anterior edge and the posterior edge of the medial tibia plateau, and defined it as PTS. We also measured the angle between the anterior cortex of the tibia and the line connecting the anterior edge and the posterior edge of the capsule insertion point and defined it as PCS. We compared the data between PTS and PCS in terms of gender, side and whether there was the presence, or not, of degenerative change.

Results: There was a strong correlation between PTS and PCS, though there were no statistically significant difference between the two parameters. This was the same in all groups.

Conclusion: PCS may be useful for reconstructing the proper sagittal alignment in TKA.

Objective: Total knee arthroplasty (TKA) has shown good clinical results when utilized in osteoarthritis (OA). However, limited data regarding the efficacy of TKA in rheumatoid arthritis (RA) has been reported. The purpose of this study was to assess the patient-based score of TKA in patients with rheumatoid arthritis (RA group) compared to patients with osteoarthritis (OA group).

Methods: 50 knees of 50 patients diagnosed with RA or OA, undergoing TKA from June 2013 to December 2014, were included in this study. The RA group included 24 RA knees of 24 patients (6 male and 18 female 66.3±9.2 years old) and the OA group included 26 OA knees of 26 OA patients (4 male and 22 female 73.2±5.6 years old). All the patients were assessed using the 2011 Knee Society Score (2011 KSS) preoperatively and at 6 months postoperatively. The 2011 KSS includes four parts: an objective knee indicator, a patient satisfaction score, a patient expectation score, and a functional activity score. Both groups were compared preoperatively and at 6 months postoperatively. The correlations between each part of the 2011 KSS pre- and postoperative scores were examined in both groups.

Results: Preoperatively, the RA group patient expectation score was significantly lower in comparison with the OA group (P=0.029). Postoperatively, there were no significant differences in all parts of the 2011 KSS between either group. In the RA group, the postoperative functional activity score had positive correlations with the preoperative functional activity score (P=0.023). In the OA group, the postoperative objective knee indicator and the functional activity score had positive correlations with the preoperative functional activity score (objective knee indicator; P=0.024, functional activity score; P=0.010).

Conclusion: In view that RA patients appeared to have more negative views about the outcome of surgery to ameliorate their disease in the preoperative period, as health professionals, we should strive to provide better explanations to RA patients to reduce their anxiety. Postoperative functional activity scores had positive correlations with preoperative functional activity scores in both groups, indicating that encouraging preoperative functional activity scores had the possibility to increase postoperative functional activities.

Objectives: Despite marked progress in the medical treatment of rheumatoid arthritis (RA), some patients still require surgical reconstruction of damaged joints. To clarify the effect of wrist, hand and elbow surgeries, we evaluated patient reported outcomes using a Japanese version of the disability of the arm, shoulder and hand (DASH) questionnaire, in addition to our own original questionnaire.

Methods: We studied a prospective cohort of 70 patients who underwent upper extremity surgery. Surgical sites included elbows in 16 patients, wrists in 34 patients, and hands (thumb or fingers) in 32 patients, respectively. In 12 patients, wrist and hand surgeries were performed concurrently. Patients were evaluated by the DASH questionnaire and the disease activity score-28 using C-reactive protein (4) (DAS28-CRP (4)) at just prior to surgery, at 6 months and at one year after surgery. Postoperatively, original questionnaires were sent to the patients to try and ascertain the level of their satisfaction. The strength of the association between the original satisfaction score and each item of DASH was measured using the Spearman’s rank-order correlation test.

Results: The mean DASH score preoperatively was 47.3, which decreased to 40.8 (P<0.05) at 6 months and to 39.5 (P<0.01) at one year after surgery. The mean DAS28-CRP (4) score decreased from 3.3 to 2.4 (P<0.01) and then to 2.4 (P<0.01). Eighty-three percent of the patients completed our original questionnaire and 86% of them were “most satisfied” or “satisfied” with the surgically-treated site. The score of “27. Weakness in your arm, shoulder or hand.” had a negative correlation with their present condition, the usability of their hands, and their level of satisfaction.

Conclusion: The wrist, hand and elbow surgeries for patients with RA improved specific function of the surgically-treated site as well as disease activity. Power in the upper extremity without pain appeared to be the determinant of patient satisfaction.

Objective: Tenascin-C (TNC) is an extracellular matrix glycoprotein. In this study, we examined the effects of full-length TNC on joint cartilage protection in murine osteoarthritis (OA) models and on synovial inflammation in OA joints. In addition, we performed an in vitro study to reveal the mechanism of repairing cartilage using full-length TNC.

Methods: In this in vivo study, fourteen male BALB/c strain mice (8-weeks-old) were used. Both knee joints were exposed and the anterior cruciate ligament and medial collateral ligament were transected. 10 μg/mL of TNC were injected into the knee joint (group Ⅰ). The control group had injection of phosphate buffered saline (PBS) (group Ⅱ).

 Mice were sacrificed at 4 days, 2 weeks, and 4 weeks postoperatively. Cartilage was evaluated using the Mankin score, and synovitis was evaluated using the Synovitis score.

 An in vitro study was also performed on human cartilage specimens, which were obtained from patients who underwent total knee arthroplasty for the treatment of OA. Chondrocytes were isolated and cultured, and they were treated with 0, 1, or 10 μg/mL of TNC. We also compared the expression of many kinds of messenger RNA after exposure at each dose by real-time polymerase chain reaction. We evaluated the expression of TNC, inflammatory cytokines [TNF-α, IL-1β, NFκB], anabolic factors [TGFβ, TIMP3, bFGF], and catabolic factors [ADAMTS-4, -5, and MMP-3, -13].

Results: With the in vivo study, the average Mankin scores were significantly better in group Ⅰ than group Ⅱ at 4 weeks (group Ⅰ; 1.1, group Ⅱ; 3.2 (P<0.05)). At 4 days and 2 weeks, no development of OA was found in either of the two groups. Low-grade synovitis occurred in both groups at 4 days, 2 weeks, and 4 weeks. There were no significant differences in average synovitis scores between two groups at 4 days, 2 weeks, and 4 weeks.

 The in vitro study revealed that TNC upregulated the expression of endogenous TNC, TNFα, IL-1β, NFκB, TGFβ, TIMP3 and ADAMTS-4, MMP-3, and MMP-13. But 10 μg/mL of TNC downregulated the expression of ADAMTS-5.

Conclusion: This study has demonstrated that 10 μg/mL of full-length TNC can prevent articular cartilage degeneration for 4 weeks without promoting synovitis. The in vitro study demonstrated that TNC upregulates itself and anabolic factors. However, TNC also downregulated the expression of ADAMTS-5 which contributed to cartilage degradation.

Objective: Total hip arthroplasty (THA) is a very useful procedure for the treatment of degenerative arthritis. In Japan, cementless stems are used in approximately 75% of all THA procedures. Therefore, research on the outcomes obtained with cementless stems are important. The objective of our research was to study the factors associated with remodeling of periprosthesis bone.

Methods: Ninety-six patients who underwent cementless THAs in our hospital were recruited for our study. The patients were divided in two groups according to the position of the cementless stem observed from radiographs taken immediately in the postoperative period, namely the ‘center’ group and the ‘varus’ group, respectively. We retrospectively compared the outcomes in each group, i. e., the Japanese Orthopaedic Association score, postoperative bleeding, canal flare index, stress shields, cortical hypertrophy, radiolucent line, and spot welds.

Results: Postoperatively the position of the stem included 77 ‘center’ cases and 19 ‘varus’ cases. Patient characteristics were not dissimilar between the two groups, and clinical outcomes did not differ significantly either. Cortical hypertrophy was observed in 30 and 13 cases in the ‘center’ and ‘varus’ groups, respectively. In addition, the radiolucent line was observed in 36 cases (46.7%) in the ‘center’ group and in 14 cases (73.7%) in the ‘varus’ group. These phenomena were significantly more frequent in the ‘varus’ group.

Conclusion: The position of stem insertion influenced the remodeling of the periprosthesis bone. Varus positioning of the stem may cause distal stem micromotion. Although no clear differences were noted in the clinical outcome in this study, it is important to consider the long-term stability of THA prostheses. This study revealed that cortical hypertrophy and a radiolucent line were more frequently observed in association with varus stem insertion of THAs.

Objective: To evaluate bone formation in the osteotomy gap after opening-wedge high tibial osteotomy (OWHTO) and to investigate risk factors for delayed bone healing.

Methods: Fifty-seven knees in 51 patients (mean age, 62.7±9.7 years) who underwent OWHTO were enrolled in this study. We divided the osteotomy gap into the lateral hinge and four zones on anteroposterior radiography, and defined the zone in which trabecular bone continuity can be seen as gap filling. According to this definition, bone formation in the osteotomy gap was evaluated at 3, 6, and 12 months postoperatively, in addition to when they had plate removal, and at the final follow-up (mean, 60.8±21.5 months). We also investigated the following factors affecting bone formation including age, body mass index, diabetes mellitus, postoperative femorotibial angle (FTA), opening width, lateral hinge fracture, and direction of the osteotomy line.

Results: The mean FTA changed significantly from 180.0°±2.2° preoperatively to 168.6°±1.8° postoperatively. This correction was maintained at the last follow-up. The lateral hinge united at 3 months postoperatively in 49 knees (86.0%). At one year postoperatively, gap filling in 55 knees (96.5%) reached to zone 1 and in 48 knees (84.2%) to zone 2. At plate removal, gap filling reached to zone 2 in all cases, and progressed further without loss of correction after plate removal. Presence of a lateral hinge fracture (Takeuchi classification type 2) and an osteotomy line below the safe zone, both significantly delayed bone formation.

Conclusion: Bone formation progressed from the lateral to medial direction after OWHTO. The presence of a lateral hinge fracture (Takeuchi classification type 2) and an osteotomy line below the safe zone were both risk factors for delayed bone formation.

Objective: The purpose of this study was to evaluate sporting activity and clinical outcome following medial open-wedge high tibial osteotomy (OWHTO) in middle and older-aged patients with medial osteoarthritis (OA).

Methods: Between 2009 and 2014, 22 patients (25 knees) who underwent OWHTO with a locking plate were enrolled in this study. All patients were active in sports on a regular basis prior to surgery, but were unable to perform sports at the time of surgery. Inclusion criteria involved patients who had medial OA or spontaneous osteonecrosis of the knee. There were 10 men and 12 women with a mean age of 60.3 years (range: 41-74 years) at the time of surgery. We performed a biplanar osteotomy of the tibia intraoperatively. A beta-TCP spacer was implanted in the opening space. Then, a locking plate was implanted onto the tibia. All patients underwent sporting activities, clinical and radiological examinations, with determinations of complications prior to surgery and at the final follow up periods after surgery (mean 37.2 months, range: 13.0-73.1 months).

Results: Postoperatively, the mean Japan Orthopaedic Association score significantly improved from 68.2 to 92.6 points (Total score: 100 points, P<0.001). The Tegner activity level scale did not show significant changes pre- and postoperatively (4.1 to 3.8). However, three patients who engaged in high impact sports (competitive skiing and marathon) had decreased Tegner activity level scale after surgery.

Conclusion: The present study has demonstrated that OWHTO for the treatment of OA in middle and older-aged patients significantly improved the short-term clinical outcome and allowed patients to return to sporting activities similar to their preoperative levels.

Objective: We have developed a posterior-stabilized (PS) total knee prosthesis for Japanese patients. The purpose of this study was to examine in vivo kinematic characteristics of the new prosthesis, compared to a popular high-flexion PS prosthesis.

Methods: We analyzed 14 knees with the new PS prosthesis (group A) and 14 knees with a popular high-flexion PS prosthesis (group B) as a control group. Lateral radiographic knee images were recorded at five positions: extension standing, at 90° and at maximum flexion lunge, and at 90° and maximum flexion kneeling. The 3-dimensional position and orientation of the implant components were determined using model-based shape matching techniques.

Results: The maximum implant flexion angles tended to be greater in group A than group B, averaging 117°±8° and 109°±14° at maximum lunge (P=0.054), and 119°±7° and 110°±14° at maximum kneeling (P=0.061), in groups A and B, respectively. The femoral centers were located more posterior in group A than group B at the 90° flexion positions (P<0.001), although there were no significant differences at maximum flexion positions. The femoral center positions had a strong negative correlation with implant flexion angles at maximum lunge in group B, but not in group A.

Conclusion: Our newly developed total knee prosthesis designed for Japanese knees appears to perform comparably to a conventional high-flexion PS design with greater posterior femoral translation at 90° knee flexion.

Objective: To investigate and quantify the effects of the intraoperative position on radial inclination, ulnar variance and transfer of the ulnar styloid in normal wrists.

Methods: Plain radiographs were taken of thirty volunteers wrists (15 male and 15 female) in three different positions including sitting with the forearm in the neutral position, and reclined in the supine position with the forearm pronated and supinated, respectively.

Results: The results revealed that ulnar styloids were transferred in both the intraoperative supine positions, and the radial inclination was significantly increased in the supine position with the forearm pronated, especially in males (P<0.05).

Conclusions: The results of this study indicate that intraoperative forearm rotation may affect the accuracy of evaluating wrist measurements.

 Multiple exostoses often produce joint disorders resulting from limb deformities, which may sometimes require operations such as osteotomy or arthroplasty. We report a case of bilateral total hip arthroplasty (THA) for hip osteoarthritis (OA) and distal femoral varus osteotomy for knee osteoarthritis with valgus limb deformity in a 71-year-old woman, who complained of difficulty walking due to bilateral knee and hip pain. The left knee pain had appeared along with multiple exostoses at about 50 years of age. The symptoms progressed with the left knee pain increasing and left hip pain then appearing, along with instability due to the left leg valgus deformity. Both hip joints developed severe OA with exostoses and coxa valga, and a pronounced contracture. The left knee developed lateral OA due to the valgus deformity of the distal femur and the proximal tibia. We initially performed a left THA, followed by the same procedure on the right hip. The hip pain subsequently subsided, and the range of motion was markedly improved. However, the pain and instability of the left knee persisted. As a result, a left distal femoral varus osteotomy (closed wedge) was performed for improvement of lower limb alignment. Two years postoperatively, the bilateral hip and left knee pains have remitted, walking ability has improved, and the left knee OA has not progressed any further. In summary, bilateral THAs and distal femoral varus osteotomy enabled stabilization of this patient’s gait through the improvement of lower-limb alignment, pain relief, and the recovery of joint function.

 We report a case of a 33-year-old man with severe heterotopic ossification around the hip, ten months after a hip resurfacing arthroplasty. The patient had a history of a bone cyst which was treated with curettage and beta-tricalcium phosphate grafting on the right hip prior to index surgery. However, eight months postoperatively, avascular necrosis occurred affecting the right hip. The hip joint was exposed using a modified Hardinge approach. A Cormet Resurfacing Prosthesis (Corin, Cirencester, United Kingdom) was implanted. At three weeks after the index surgery, a small ossification occurred around the hip which was observed via a plain radiograph. Ten months postoperatively, the ossification had progressed and the hip joint developed complete ankylosis. However, the patient did not complain of any pain around the hip. Therefore, no further treatment was required. According to the literature, this is a rare case of severe heterotopic ossification that led to ankylosis of the hip joint.