Objective: The purpose of this study was to investigate the change of whole leg length after total knee arthroplasty (TKA) and its correlated factors.

Methods: A total of 37 knees (8 men and 29 women) with a mean age of 78±5.8 years (range: 66-86 years) who underwent primary TKA, were enrolled in the present study. We obtained radiographs of the lower limbs in their entirety in a standing position before and three weeks after their TKA. We measured the mechanical axis (MA) length, mechanical axis deviation (MAD) at the knee joint, hip-knee-ankle (HKA) angle, and knee flexion (KF) angle.

A paired t-test was used to evaluate changes of each parameter after TKA. We also performed univariate and multivariate analyses to evaluate factors which correlated with the change in MA length. The threshold for significance was a P value of<0.05.

Results: Every measured parameter except for MA length changed after TKA. Preoperatively, MAD 43.7±21.1%, HKA angle−8.2±8.0°, KF angle 14.7±7.3°; Post operatively, MAD 9.1±7.4%, HKA angle−0.7±2.8°, KF angle 11.6±7.3°; P<0.05. In univariate analyses, the postoperative change in MA length significantly correlated with the change in MAD (R=−0.58, P<0.001) and KF angle (R=−0.39, P=0.02). In the multivariate analysis, the change in MAD was the only factor which correlated with the change in MA length (R²=0.40, P<0.001).

Conclusion: MAD which is an indicator of the coronal lower limb alignment, influences the MA length. Therefore, we may consider the leg length change when performing TKA and bring the lower limb into neutral alignment in patients with severe varus or valgus deformity.

Objective: Disease-modifying biological agents and other new drugs have improved disease activity and inhibit joint damage in patients with rheumatoid arthritis (RA). This study examined the effectiveness of combination therapy with medications and rehabilitation in patients with early RA.

Methods: The study enrolled 18 patients with early RA (disease duration<1 year) and all the patients were treated with medications targeting the disease. The patients were divided into two groups based on the time of their first visit. One group consisted of 10 patients who underwent occupational therapy (OT) for two months after their first visit to our outpatient clinic. The OT included upper and lower extremity exercises, and education on how to protect theirs hands from damage during daily activity. The other group consisted of the remaining eight patients who were not treated with OT. The changes in the DAS28 score, C-reactive protein, patient’s general health (0～10, 0: best; 10: worst) Health Assessment Questionnaire, and the number of painful joints in the hand were examined for up to six months.

Results: At the first visit, in the patients undergoing OT, the DAS28 score and patient’s general health were 5.3±1.5 (mean±SD) and 7.8±2.2, respectively, and 5.8±1.7 and 8.5±2.5 in the remaining patients. At one month, in the OT patients, the DAS28 score and patient’s general health were 3.1±1.4 and 2.3±1.6, and 4.8±2.0 and 5.5±3.3 in the remaining patients, respectively. Improvement of the patients’ general health and DAS28 score in the patients undergoing OT was good. At six months, the DAS28 score and patient’s general health were 2.2±1.0 and 0.95±1.3 in the patients undergoing OT, and 2.1±0.78 and 0.88±0.95 in the other patients, respectively.

Conclusion: Combination therapy with medications and rehabilitation was effective in the early phase in patients with early RA.

Objective: The guidelines for the management of rheumatoid arthritis issued by the Japan College of Rheumatology 2014, equally recommend uncemented total hip arthroplasty (THA) for patients with rheumatoid arthritis (RA), compared to cemented THA. In our institution, all THAs have been performed with cement. In the current study, we aimed to evaluate the clinical benefits of cemented THA for patients with RA.

Methods: Eighty-two patients with RA (98 joints) were retrospectively reviewed after they had cemented THAs performed at our institution, from January 2006 to November 2014, inclusive. There were 12 males (14 joints) and 70 females (84 joints). The mean age was 64.3 (range, 34-83) years old, the mean height was 152.4 (range, 132.8-170.0) cm, the mean weight was 50.0 (range, 32.1-75.0) kg, and the mean disease duration from development of RA to index surgery was 13.3 (range, 0.5-46) years, respectively. All THAs were performed via the direct lateral approach in the lateral position using a complete polyethylene socket and polished tapered stem with antibiotic-loaded acryl cement (ALAC). Eighty-two joints out of 98 could be followed up after two years from the index surgery, and 41 joints of the 98 could be followed up after five years. We evaluated the survivorship of implants, the clinical outcomes, and the occurrence of adverse events including deep infection, dislocation, and aseptic loosening.

Results: Of 98 THAs, only one revision THA was performed for multiple dislocations within the first year after the index surgery. The mean Japanese Orthopaedic Association hip score improved from 39.3 points preoperatively to 83.4 points two years after the index surgery in 65 patients (82 joints), and to 86.3 points five years after the index surgery in 30 patients (41 joints).

Discussion: There were no revision THAs for deep infection or aseptic loosening, and only one revision THA was performed for multiple dislocations. It is considered that cemented THAs using ALAC by optimal surgical techniques (using modern cementing techniques including bone-bed preparation, use of bone plagues, retrograde injection with cement gun, pressurization, and vacuum mixing) has great benefits for patients with RA due to the longevity and the resistance to deep infection.

Conclusion: Use of cemented THAs in patients with RA is an effective option with good device survival, and minimal associated dislocations or infections.

Objective: The influence of the shape of the patellar component is still unknown in total knee arthroplasty (TKA). The purpose of this study was a comparative investigation of radiological assessments and clinical outcome in two different types of patellar component.

Methods: Thirty cases of primary TKA with varus knee osteoarthritis were enrolled in this study. We used the Attune knee system (DePuy Synthes Inc) ; in 15 knees we used a dome-type patellar component (D-type), whereas in the other 15 knees we used an anatomical-type (A-type). Examination items were as follows: 1) Pre- and postoperative patellar tilting angle by lateral and axial views of knee joint plain radiographs. The tilting angle of lateral view was defined as between the cutting surface of the patella and the anterior cortex of the femoral distal portion. 2) Postoperative Japanese Orthopaedic Association (JOA) score. 3) The presence of anterior knee pain. Statistical analysis was performed using the paired t-test, with a level of significance defined with a P value of<0.05.

Results: The mean preoperative tilting angle in the lateral view of light flexion was 28° (D-type) and 30° (A-type), respectively. The mean postoperative angle was 41° (D-type) and 39° (A-type), respectively. The mean preoperative tilting angle of the axial view was 3° (D-type) and 4° (A-type), respectively. The mean postoperative angle was 1° (D-type) and 1° (A-type), respectively. The mean postoparative JOA score was 84 (D-type) and 86 (A-type), respectively. No cases developed anterior knee pain.

Conclusion: The D-type component is designed with a central convexity. The lateral tilting angle tended to strongly tilt posteriorly compared to physiological patella positioning with this design. The A-type component had adequate thickness of its superior and inferior poles and medial and lateral sides. It had an adequate contact area to the femoral component. Therefore, we predicted that the A-type comes close to physiological patellar tilting. However, from the results of this study, there was no significant statistical difference. There was no difference in the postoperative outcome of both component types.

Objective: The management of postoperative pain from total knee arthroplasty (TKA) is very important for improving patient function and to shorten the length of hospital stay. Safety and effectiveness are required for postoperative pain management. Non-steroidal anti-inflammatory drugs (NSAIDs), especially loxoprofen and diclofenac, are commonly used for postoperative pain. However, gastric mucosa disorders and renal dysfunction caused by such therapies are problematic. Tramadol, a synthetic opioid, has a different mechanism of action compared with NSAIDs. Celecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor, has fewer gastrointestinal adverse effects than traditional NSAIDs. This study aimed to compare the analgesic effect of tramadol and celecoxib after TKA.

Methods: Sixty-one patients with osteoarthritis underwent TKA in our institution and were enrolled into this study. Thirty patients were treated with tramadol (Group T), and 31 patients were treated with celecoxib (Group C), respectively. Group T patients received 450 mg tramadol per day, and Group C patients received 400 mg celecoxib per day, beginning on the day after surgery until day 14. The primary outcome was a visual analog scale (VAS) pain score measured on postoperative day 1, day 4, and day 7. Secondary outcomes included range of motion (ROM) on postoperative day 21, creatinine clearance and the rates of adverse effects.

Results: There was no significant change of the VAS score, ROM or creatinine clearance between the two groups. Three (10%) patients from Group T stopped oral analgesia because of nausea and vomiting. Three (10%) patients from Group C stopped oral analgesia because of drug rash or drug-induced liver dysfunction. There were no patients with new-onset acute renal dysfunction.

Conclusion: There was no significant differences between the analgesic effect of tramadol and celecoxib in the postoperative period following TKA.

Objective: The healing time of atypical femoral fractures (AFFs) is longer compared to normal femoral fractures. There is a high incidence of delayed union and subsequent revision surgery. Intramedullary nailing and teriparatide are recommended for both complete and incomplete AFFs. Few reports have examined the efficacy of low-intensity pulsed ultrasounds (LIPUS) for atypical femoral fractures.

Methods: We retrospectively surveyed all patients with subtrochanteric and diaphyseal femoral fractures who underwent surgical treatment at our hospital between 2010 and 2016, inclusive.

Results: A total of six patients with six femoral fractures were diagnosed with AFFs. The mean age at injury was 62.2 years (range: 53 to 81 years). Five fractures occurred in women; four were in patients whose previous treatment had included bisphosphonates and corticosteroids. One fracture occurred in a patient treated with denosumab. All patients had symptoms of hip or thigh pain during the prodromal period. All fractures were fixed with intramedullary nails. Five fracture were treated with LIPUS after surgery. All fractures had healed within six months.

Conclusion: LIPUS might be helpful for the healing of AFFs.

Objective: In rheumatoid arthritis (RA), synovial inflammation induces cartilage and bone destruction. As a result, glucocorticoids are used as disease modifying treatment. Because of the adverse side effects from glucocorticoid use, the medical treatment for osteoporosis is very important. The treatment rate (TR) for fractures in patients with osteoporosis has been reported to be approximately 13%-25%. However, the TR for patients with RA has not been reported previously. In this study we report the TR for patients with RA and osteoporosis.

Methods: We reviewed 80 patients with RA retrospectively who had an average age of 67.3±10.6 years old. There were 18 males (68.6±9.9 years old), and 62 females (66.8±10.9 years old), respectively. Selected osteoporosis treatments included bisphosphonates, teriparatide (parathyroid hormone derivative) and denosumab. The TR was investigated and compared in aspects of their age, sex, dose of glucocorticoids, duration of rheumatoid arthritis, use of biologic agents, level of estimated glomerular filtration rate (eGFR), level of C-reactive protein (CRP) and Disease Activity Score (DAS) 28-CRP.

Results: The total TR for patients with RA was 47.5%. The TR increased significantly in response to age (<70 years old 37.8%; ≥70 years old 60.0%; P=0.049), dose of glucocorticoids (0 mg/day 16.7%; 0 mg< <5 mg/day 60.9%; 5 mg≥/day 89.5%; P<0.001), duration of RA (<5 years 36.4%; 5 years-15 years 40.7%; >15 years 67.9%; P=0.047), and level of CRP (CRP<0.3 33.3%; 0.3≥CRP 59.1%; P=0.025). There were no significant differences in respect of sex, use of biologic agents, level of eGFR or DAS28-CRP.

Discussion: The TR of osteoporosis in patients with RA was higher compared to patients with fractures. In general, the risk of osteoporotic fractures increases depending on age and sex. The risk of osteoporotic fractures in patients with RA is known to increase with rheumatoid disease activity, glucocorticoid use, and disease duration, etc. In this study, the TR increased with age and factors related to RA. Sex was not associated with the TR.

Conclusion: In patients with RA, treatment for osteoporosis should be strongly considered especially in those individuals with longstanding disease, high disease activity and use of glucocorticoids.

 Although the numbers of surgical procedures are growing for patients with hemophilia, there are only a few reports available regarding patients undergoing total hip arthroplasty (THA) with acquired forms of hemophilia. We report a case of THA performed in a hemophilia A patient with history of an inhibitor.

 A 50-year-old patient hemophilia A, who had a high-responder inhibitor, suffered from pain in his right hip after an operation for a femoral neck fracture. De Palma and Arnold-Hilgartner radiologic classifications were determined as grade Ⅳ and stage Ⅴ, respectively. THA with neutralization therapy using factor Ⅷ was performed according to the hemostatic treatment guidelines for hemophilia patients without inhibitors, established by the Japanese Society of Thrombosis and Hemostasis. On the 8^th postoperative day, factor Ⅷ administered as a continuous infusion after a bolus injection decreased to 12.1%, while the activated partial thromboplastin time prolonged to 95.9 sec, suggesting an anamnestic immune response. Thus, bypass therapy was performed using recombinant activated factor Ⅶ to achieve adequate hemostatic control, and no complications were subsequently noted. At three years and two months postoperatively, no stem subsidence or loosening were found radiologically. The Japanese Orthopaedic Association hip score improved from 43 to 71 points.

 Although no serious complication after THA was noted in our case, we suggest that as compared to hemophilia patients without inhibitors, more care should be taken in managing those with a previous inhibitor history due to an anamnestic immune response.