Objective: The aim of this study was to identify specific factors associated with reduced bone mineral density (BMD) of the lumbar spine and femoral neck in patients with rheumatoid arthritis (RA) treated with disease-modifying anti-rheumatic drugs (DMARDs), which were either conventional (cDMARDs) alone or biologic (bDMARDs), after the latter medications were approved for use in Japan.

Methods: Ninety-one patients were treated with bDMARDs and 61 with cDMARDs, respectively. We examined factors associated with BMD loss in the lumbar spine and femoral neck. The percentage of least significant change (LSC) was used as the criterion to identify BMD reduction. LSC≥2.4% indicated lumbar BMD reduction, and LSC≥1.9% indicated femoral neck BMD reduction.

Results: Although the average Disease Activity Score 28-C-reactive protein values were 2.3 and 2.5 in the cDMARDs and bDMARDs groups, respectively, more than one-third of patients in both groups (40.9% and 38.5%, respectively) had LSCs of BMD in the femoral neck. Multivariate stepwise binomial logistic regression analysis revealed no statistically significant risk factors for LSC indicating reduced BMD in the cDMARDs group. In contrast, multivariate stepwise binomial logistic regression analysis showed that lack of anti-osteoporosis drug therapy was a risk factor for the LSC, indicating reduced BMD in the lumbar spine in the bDMARDs group. Multivariate logistic regression analysis also showed that the lack of anti-osteoporosis drug therapy and low body mass index were risk factors for the LSC of BMD of the femoral neck in the bDMARDs group.

Conclusion: Although treatment with bDMARDs and cDMARDs achieved successful control of disease activity, the femoral neck BMD continued to decrease. Thus, it is important to start anti-osteoporosis drug treatment before progression of bone loss becomes apparent in patients undergoing bDMARDs treatment.

Objective: Intra-articular hyaluronic acid (HA) injection is most frequently used as a conservative treatment for osteoarthritis (OA) of the knee in Japan. Recently, international investigators have reported the effect of intra-articular hypertonic-glucose (HG) injection for knee OA. The author assessed the characteristics of HG injections compared with HA injections using a crossover trial.

Methods: After an injection wash-out period of four weeks, 45 participants with OA of the knee received HG injections every two weeks for a total of four weeks (HG phase). Following another injection wash-out period of four weeks, the participants crossed over to the HA injection treatments every two weeks for a total of four weeks (HA phase). The Lequesne index for OA of the knee and visual analogue scale (VAS) for subjective knee pain at two and four weeks were compared with those at the baseline in each injection phase. The participants were asked the VAS for the highest subjective pain during an injection, and the VAS was compared between the HA and HG injections. Paired t-tests were used as statistical assessments.

Results: The most frequent reason given for withdrawing in the HG phase was increasing knee pain (seven of the 45 participants, 15.6%). At both the two and four weeks assessments, the remissions of Lequesne index and VAS for subjective knee pain were not significantly different between the HA and HG phases (P>0.05). The VAS during HG injections was significantly lower than the VAS during HA injections (P=0.021).

Conclusion: The efficacy of intra-articular HG injections was not significantly different from those of HA injections for OA of the knee. Furthermore, 15.6% of participants withdrew in the HG phase due to increasing knee pain. However, the highest subjective pain during an HG injection was less than that of an HA injection.

Objective: Unlike distal deep vein thrombosis (DVT), proximal DVT has a high risk of causing pulmonary embolism (PE). The purpose of this study was to investigate the risk factors of proximal DVT after total knee arthroplasty (TKA) in Japanese patients.

Methods: The study included 460 knees in 376 patients who underwent primary TKA (FINE^® Total Knee System) between March 2011 and May 2017 at our hospital. Patients included 70 men and 306 women, with a mean age of 72.6 years. To evaluate the presence or absence of DVT, all patients received Doppler ultrasonography (US) preoperatively and on postoperative days (PODs) 2 and 14. Patients with preexisting DVT were detected preoperatively and were excluded from the study.

We investigated the following as risk factors: age, gender, rheumatoid arthritis, range of motion, hypertension, diabetes mellitus, hyperlipidemia, history of venous thromboembolism, hormonal therapy, malignancy, bilateral TKA, operative time, postoperative anticoagulant therapy, and plasma D-dimer values on PODs 3, 7, and 14. We compared these risk factors between the proximal DVT-positive and DVT-negative groups.

Results: DVT was detected in 127 knees (27.6%), including 11 knees with proximal DVT (2.4%). A univariate analysis demonstrated that there was a significant difference in age between the proximal DVT-positive and DVT-negative groups. However, no significant differences were found between the two groups by a multivariate logistic regression analysis.

Conclusion: To our knowledge, this is the first study to investigate the risk factors of proximal DVT after TKA. However, we could not identify independent risk factors from this study.

Objective: Ultrasound assessment is considered a useful method for detecting synovitis in patients with rheumatoid arthritis (RA) due to its greater sensitivity compared with a clinical joint examination. The purpose of this study was to investigate the effectiveness of ultrasound assessment after knee joint surgery in patients with RA.

Methods: We evaluated eight patients with RA (7 females and 1 male; average age of 56 years) who underwent total knee arthroplasty (n=4) or arthroscopic knee synovectomy (n=4). Ultrasound assessment was performed at baseline and at one, three, and six months after knee joint surgery in 26 upper limb and 16 lower limb joints, respectively. Ultrasonographic arthritis was defined as ultrasound-detected synovitis with a gray scale (GS) imaging score≥2 and a power Doppler (PD) signal score≥1. The disease activity score including C-reactive protein (DAS28-CRP (4)) was also evaluated at baseline and at one, three, and six months after surgery.

Results: In all cases, the DAS28-CRP (4) improved from 3.72±1.16 at baseline to 2.51±0.70 at 3 months after surgery. There were also decreases from baseline to three months after surgery in the number of joints with ultrasonographic arthritis (4.9±5.2 to 0.7±0.8), total GS score (10.0±14.2 to 4.1±5.6), and PD score (8.4±15.3 to 2.0±3.6). However, these values had slightly increased at six months after knee joint surgery.

Conclusion: Objective ultrasound assessment detected improvement of arthritis at three months, but with relapse at six months after surgery. Thus, ultrasound scanning can more accurately evaluate RA disease activity after knee joint surgery.

Objective: A tibial component with stem is frequently used in revision total knee arthroplasty (TKA) because it improves the mechanical stability of the tibial components. However, it is possible that the tibial component stem interferes with the cortex of the proximal tibial metaphysis. In this study, we investigated the percentage of interference between the tibia component stem and tibial cortex in patients with primary TKA by computed tomography-based 3-dimensional (3D) preoperative planning software.

Methods: This was a retrospective simulation study. We analyzed 102 knees that underwent TKA in our hospital by using 3D template software. There were 13 men and 48 women with a mean age of 76.2 years (SD, 8.0 years; range, 54-91 years). The tibial implants, namely Vanguard^TM PS system I-beam and Vanguard^TM SSK system supplied by Zimmer-Biomet Holding Inc., were used for the simulation in this study. We identified the following types of simulation: type A- no contact between the tibial component stem and the tibial cortex; type B- some contact between the stem and the tibial cortex; and type C- the stem undoubtedly invaginated, or perforated the tibia cortex.

Results: The Vanguard^TM PS system I-beam simulation results showed that 91 knees (89.2%) corresponded to type A, nine knees (8.8%) to type B, and two knees (2.0%) to type C, respectively. The Vanguard^TM SSK system simulation showed that 61 knees (60.0%) corresponded to type A, 36 knees (35.2%) to type B, and five knees (4.9%) to type C, respectively. Female patients has especially small sized tibial components and tended to fall within the B or C type simulations by the Vanguard^TM SSK system.

Conclusion: A tibial component with stem is useful for mechanical stability in revision TKA, but it should be borne in mind that some cases have a possibility of an interference between the stem of tibia component and the tibial cortex.

Objective: A pulley release usually results in an excellent surgical outcome in trigger finger treatment. However, unsatisfactory results are found in some patients due to persistent flexion deformity of the proximal interphalangeal (PIP) joint. We performed an ulnar slip superficialis tendon resection (USSR) in such patients, and relatively good results were obtained.

Methods: Fourteen digits including two index fingers and 12 long fingers in eight female and six male patients, who had undergone USSR, were retrospectively evaluated. The average patient age was 71.5 years old. With respect to the affected digit, the coronal diameter ratio of the flexor tendons to proximal phalanx at the proximal one third level of the aforementioned bone (tendon/bone ratio), was calculated. As a control, the same ratio was also calculated in the ring finger of the ipsilateral hand. The affected digit’s preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores and active extension angles of the PIP joints were evaluated. The postoperative evaluation was performed at the patients’ final visit, and the average follow-up time was eleven months (6 to 19 months).

Results: The average tendon/bone ratio was 87.4% (78.0 to 98.9%) in the affected digit and 67.5% (53.1 to 75.5%) in the control. The preoperative active extension angle of the PIP joint of affected digits was −26.2 degrees on average preoperatively (range: −15 to −45), and −9.1 degrees (range: 0 to −20) after the procedure. The preoperative average DASH functional score was 38.5 points (range: 23.2 to 69.6) and 8.9 points (range: 0.86 to 24.1) postoperatively. The active extension angle improved by 17.1 degrees on average, and the DASH functional score decreased by 29.6 points on average. These differences were significant (P<0.05).

Conclusion: USSR can be a meaningful procedure in trigger finger patients with flexion deformity of the PIP joint.

Purpose: The purpose of this study was to investigate factors affecting Knee Injury and Osteoarthritis Outcomes Score (KOOS) in the intermediate term (more than five years) after opening-wedge high tibial osteotomy (OWHTO).

Subjects and Methods: We investigated 84 patients with 90 knees who underwent OWHTO between June 2007 and October 2010 inclusive. The patients had been followed for more than five years and comprised 21 men with 25 knees, and 63 women with 65 knees (mean age=65.7 at the time of surgery; 71 knees with medial osteoarthritis (OA), and 19 knees with osteonecrosis (ON)). The average observation period was 74.3 months (range: 60-102 months). The KOOS was calculated during the final investigation, and its relation to various factors before or after the surgery were also analyzed. Factors examined prior to surgery included the femorotibial angle (FTA), range of motion (ROM), and intraoperative correction angle, while the factors after surgery (during the final investigation) included FTA and ROM.

Results: The FTA showed optimum alignment from 168.3° to 180.4°, while the intraoperative correction angle was 12.1° on average. The ROM (flexion/extension) was unchanged overall, ranging from 125.4°/−1.1° to 126.5°/−1.0°. The KOOS during the final investigation was 82.0 for symptoms, 81.6 for pain, 85.5 for function in activities of daily living (ADL), 61.0 for function in sports and recreation, and 66.1 for quality of life (QOL). The ROM after surgery was positively correlated with all five items of the KOOS, with the score increasing as the bending angle after surgery also increased (symptoms R=0.402 P<0.01, pain R=0.399 P<0.01, ADL R=0.306 P<0.01, sports and recreation R=0.394 P<0.01, QOL R=0.271 P<0.01). The other variables were not correlated with KOOS.

Discussion: The intermediate-term results of OWHTO in our clinic were overall indicative of good outcomes for patients. ROM after surgery was also related to KOOS, suggesting that appropriate aftercare is also important.