Objective: To evaluate the differences excepting the morphology of the hip joint between primary and secondary hip osteoarthritis (OA) due to dysplasia.

Methods: Eighteen primary and 50 secondary hip osteoarthritis due to dysplasia were examined. Laboratory studies and dual X-ray absorptiometry were performed. The number of spinal bodies bridged by intervertebral osteophytes were counted in the lumber spinal radiograph according to Resnick’s criteria of diffuse idiopathic skeletal hyperostosis (DISH). The sum of the length of bilateral enthesophytes in the iliac crest and the degree of sacroiliac joint degeneration were evaluated by pelvic computed tomography.

Results: The mean age of primary and secondary OA was 76 and 63 years old, respectively. The occurrence of primary OA was found in a significantly older age group than secondary OA. The primary OA patients had significantly higher levels of leucocytes, fasting blood sugar (FBS), and fibrinogen than patients with secondary OA. There was an increasing number of spinal bodies with DISH in patients with primary OA. Despite the absence of statistical significance, the patients with primary OA tended to have higher body mass index (BMI), alkaline phosphatase, erythrocyte sedimentation rate, and C-reactive protein. In patients with primary OA, bilateral enthesophytes in the iliac crest tended to be longer, and the degree of sacroiliac joint degeneration tended to be higher.

Conclusions: Advanced age, higher levels of FBS and BMI in patients with primary OA in this study supports a previous report that aging and the metabolic syndrome lead to low-grade systemic inflammation in OA. There may be cases with this OA subtype as a phenotype of DISH in patients who present with primary OA.

Objective: We performed total hip arthroplasty (THA), combined with preoperative autologous blood transfusion and perioperative cell salvage. Phlebotomy for the preoperative autologous blood transfusion was undertaken one month before surgery and the cell salvage device, OrthoPAT^®, was used intraoperatively and postoperatively. We examined the effect and utility of cell salvage during the perioperative period.

Methods: 140 patients were included in the study, and they received both perioperative cell salvage and 400 mL of preoperative autologous blood transfusion for primary THA in the period from May 2013 to June 2014, inclusive. Hematometry was performed before collection for the preoperative autologous phlebotomy, immediately in the postoperative period and at one and seven days postoperatively. From results of the hematometry, we estimated perioperative blood loss including the calculated blood loss.

Results: In the group where the OrthoPAT^® did not indicate the need for erythrocyte salvage, there was significantly less operative hemorrhaging, or bleeding in the postoperative drain compared to the control group. Moreover, the autologous hematocrit was low. There was a tendency that when there was a large amount of erythrocyte salvage there was also a greater amount of multiple haemorrhaging in addition to bleeding in the postoperative drain.

Conclusions: In view that perioperative blood loss cannot be estimated prior to surgery, and the average volume of blood loss including the calculated blood loss can exceed more than 600 mL, it is recommended to prepare for perioperative cell salvage. We consider that perioperative cell salvage is one effective choice as a measure against bleeding during THA.

Objective: The Triathlon^® cruciate-substituting (CS) insert has a 2.54 mm anterior elevated lip and the same posterior geometry as the cruciate-retaining (CR) insert. Manufacturers claim that the insert can provide excellent posterior stabilization without decreasing rotational freedom and can be used with either posterior cruciate ligament (PCL) retention or sacrifice. The purpose of this study was to evaluate range of motion (ROM) and anteroposterior stability in the CS insert in comparison with those in the CR insert for the same total knee arthroplasty (TKA) with PCL sacrifice.

Methods: Intraoperative measurements were performed using the Stryker knee navigation system^® in 15 osteoarthritic knees in 15 patients (2 male and 13 female; mean age, 74 years). Operation was performed under general anesthesia by using the navigation system. The PCL was sacrificed in all knees. After implantation of all the components, either a CR or CS trial insert was inserted. Following this, ROM was measured using gravity after transient capsular suture. Next, the anterior and posterior displacements between the centers of the femoral and tibial components were measured in manual stress testing at 90° of flexion. The posterior displacement was also measured by applying 5 kg of weight at the proximal tibia.

Results: The ROM was similar between the CR and CS inserts. During manual stress testing, maximal posterior displacement was significantly smaller with the CS insert than with the CR insert (10.6±2.5 mm vs. 11.3±2.8 mm, P=0.0104). The maximal anteroposterior displacement was significantly smaller with the CS insert than with the CR insert (13.1±4.4 mm vs. 15.9±5.0 mm, P=0.0002). The maximal posterior displacement with the weight was also significantly smaller with the CS insert than with the CR insert. However, the average difference was 1.0 mm.

Conclusion: Our results show that intraoperative ROM was similar between the CR and CS inserts in TKA with PCL sacrifice. The anteroposterior stability at 90° of flexion was significantly greater with the CS insert than with the CR insert. However, posterior stabilization was poor with the CS insert. We do not recommend use of the CS insert in TKA with PCL sacrifice.

Objective: The purpose of this study was to investigate the association between sagittal lumbo-pelvic alignment and knee osteoarthritis (OA) in patients with degenerative spondylolisthesis (DS).

Methods: A total of 111 patients with DS (30 men and 81 women) with a mean age of 73±8.2 years (range: 51-93 years) who underwent corrective posterior lumbar interbody fusion (PLIF) were included in the study, and were divided into two groups: 1) the ‘OA group’ (n=31): PLIF combined with knee OA of Kellgren-Lawrence grade 2 or more, and 2) the ‘non-OA group’ (n=80): PLIF without knee OA. Preoperative lateral view radiographs of the lumbar spine in the standing position were evaluated by measuring the following factors: pelvic incidence (PI), lumbar lordosis (LL), PI-LL, sacral slope (SS), and pelvic tilt (PT).

 An unpaired students t-test was used to evaluate the differences between the OA and non-OA groups for univariate analyses. We also performed multivariate logistic regression analysis to evaluate the odds ratio for potential risk factors for the occurrence of knee OA. The threshold for significance was a P value of<0.05.

Results: PI in the OA group (57.6±6.8°) was significantly larger than in the non-OA group (50.7±8.3°) (P<0.001). LLs in the OA group (34.9±11.3°) and the non-OA group (38.8±14.7°) were not significantly different. SS in the OA group (24.6±7.8°) was significantly smaller than in the non-OA group (28.2±8.9°) (P=0.04). PT in the OA group (33.4±7.8°) was significantly larger than in the non-OA group (22.4±8.5°) (P<0.001). PI-LL in the OA group (23.2±10.5°) was significantly larger than in the non-OA group (11.9±13.5°) (P<0.001). Multivariate logistic regression analysis indicated that increases in PI, age and decrease in LL were significantly associated with knee OA (P<0.05).

Conclusions: Larger PI, PT and PI−LL values in patients with DS are thought to be associated with knee OA.

Objective: The aim of the present study was to investigate the association between disease activity of rheumatoid arthritis (RA) and radiographic progression in patients using biological agents and undergoing total knee arthroplasty (TKA).

Methods: The study population included 40 patients (5 men, 35 women) with RA who were being treated with biological agents and who were scheduled to undergo TKA. Biologic agents had been initiated at our hospital after performing joint X-ray examinations. The mean age was 60.7 years and the mean duration of disease was 13.8 years. We evaluated the disease activity of RA using the 28-joint Disease Activity Score with C-reactive protein (DSA28) and radiographs using the Larsen grade at the time of initiation of biologic agents, and at the time of TKA. Clinical response at surgery was defined according to the European League Against Rheumatism (EULAR) response criteria based on the DAS28.

Results: From the time of initiating biological agents to the time of undergoing TKA, the mean DAS28 score decreased significantly from 4.60 to 3.45. According to the EULAR response criteria, good responses were seen in 14 patients, moderate responses were seen in 15 patients, and no responses were seen in 11 patients, respectively. Thirty-two knee joints were grade Ⅰ/Ⅱ at the initiation of biological agents, but 25 of 32 knee joints showed more than two grades of progression on the Larsen grade at the time of TKA. The good response group indicated 1.57 grades of progression on the Larsen scale, while the no response group showed 2.10 grades of progression on the scale.

Conclusion: Grade Ⅰ/Ⅱ pre-existing damage from RA showed progression even in patients treated with biological agents. These results show that poorer response to biological treatment is associated with more progressive radiographic changes.

Objective: Iguratimod (IGU) was newly approved in Japan in 2012. In this retrospective study, we have investigated the efficacy and safety of IGU in patients with rheumatoid arthritis (RA).

Methods: One hundred thirty nine patients were treated with IGU at our institution during the period of 2012-2014. Among those patients, 109 who were able to continue using IGU for over 12 months were divided into three groups. M−: 44 patients who started IGU due to intolerance to methotrexate (MTX), M+: 25 patients in whom IGU was added because treatment with MTX was unable to control the disease, and B+: 40 patients in whom IGU was added because treatment with biological agents was unable to control the disease. The results were assessed by disease activity index, inflammatory reaction, and autoantibody values.

Results: Adverse reactions including exanthema and abdominal pain were observed in 25 patients (18.9%). Nine patients who experienced adverse reactions such as liver damage were able to continue the treatments by reducing the amount of IGU to 25 mg/day. DAS28-ESR (4) showed a significant improvement, on average from 5.03 at baseline, to 3.62 at six months. C-reactive protein levels decreased from on average from 2.4 mg/dl to 1.0 mg/dl, respectively. This trend continued for 30 months and was maintained. Matrix metalloproteinase-3 and rheumatoid factor (RF) IgM values also showed significant decreases. At one year, there were obvious improvement rates in the DAS, which was observed in M−, B+and M+groups, respectively. Patients with high RF values showed clearer improvements than those with lower values.

Conclusions: Though there is significant value of using methotrexate and biological agents in the treatment of RA, some patients have to discontinue such drugs due to intolerance, lack of efficacy, and adverse reactions. Under these circumstances, IGU should be considered as an additonal treatment option.

 Ankylosing spondylitis (AS) is a chronic inflammatory disorder characterized by bone formation, syndesmophytes, and ankylosis of the sacroiliac joints and spine. Recently, tumor necrosis factor inhibitors such as infliximab and adalimumab have been shown to be efficacious for AS. However, patients with AS often suffer from arthralgia and problems related to ankylosis of the spine due to the delay in the diagnosis of AS. Those patients often benefit from surgical treatments.

 We have treated total of 72 patients with AS in our hospital. Among them 32 operations were performed on total of 19 patients. Total hip arthroplasties were the most performed surgical procedure. Surgeries for spinal fractures and spinal deformity have also been performed.

Introduction: Revision total hip arthroplasty (THA) with femoral bone deficiency poses a considerable challenge to the orthopaedic surgeon. When the proximal femur is deficient, there are few options for reconstruction, including long distal fixation uncemented implants, proximal femur replacement stems, allograft-prosthesis composites, and impaction bone grafting (IBG). IBG has become an accepted technique to treat severe femoral bone loss during complex revision THA procedures. However, the procedure of IBG of the femur is recognized as technically demanding, and one of the reasons for this is the frequent occurrence of intraoperative periprosthetic femoral fractures. For preventing periprosthetic femoral fracture, we report our experience of two cases in which femoral IBG with locking compression plate (LCP) for revision THA was undertaken.

Case 1: A 77-year old woman underwent THA for hip osteoarthritis 17 years previously.

Case 2: A 61-year old man underwent THA for hip osteoarthritis 10 years previously, and revision surgery of the stem for loosening two years previously.

 In both instances, the femoral shaft was fixed by LCP with cable-wire or ultra-high molecular weight polyethylene before removal of the stem. A stem with cement was fixed using the IBG method. There was no fracture, infection or subsidence in either case.

Conclusion: Our results indicate that our method could be a potential solution to use femoral IBG with LCP for maintaining bone stock and preventing intraoperative periprosthetic fracture.

 Any incongruity of the patellofemoral (PF) joint after total knee arthroplasty (TKA) results in postoperative pain and restrictions in range of motion (ROM), which is one of the major causes of revision TKA. We report our experience with two patients who developed lateral patellar facet syndrome (LPFS) following TKA.

Case 1: A 72-year-old woman underwent left TKA approximately two years previously and developed left knee pain two months postoperatively. On a physical examination, the lateral side of the PF joint demonstrated tenderness, crepitus, and ROM of the left knee was −5° in extension and 120° in flexion.

Case 2: A 69-year-old woman who underwent right TKA approximately two years previously experienced pain of the right knee and difficulty in flexion about one month postoperatively. On a physical examination, the lateral side of the PF joint demonstrated tenderness, crepitus, and the ROM of the right knee was −5° in extension and 90° in flexion.

 On radiographic examination, the impingement in both cases was between the femoral component and the lateral edge of the patella in the skyline view. We diagnosed LPFS in both cases, and at surgery, we partially cut the lateral edge of the patella, resurfaced the non-coating part of the patellar lateral component, and added a lateral release, respectively. In both cases, the tenderness on the lateral side of the PF joint disappeared in the early postoperative period, and the ROM of the knees was improved.

Discussion: Common causes of painful knee after TKA includes LPFS, where friction occurs between the femoral component and the lateral edge of patella. We suggest that when selecting the prosthetic model for TKA, the possibility of LPFS must be considered in order to try and prevent this complication.