Total knee arthroplasty (TKA) was carried out simultaneously on bilateral knees by two teams in a single procedure. The patients of the study consisted of 154 cases (308 knees) with osteoarthritis (OA) in 84 and rheumatoid arthritis (RA) in 70 patients. Comparisons were made of functional score and range of motion (ROM) before and after operation, mean total blood loss, operative time, duration of hospital stay, and operative and postoperative complications. The simultaneously performed bilateral procedures did not influence the functional score, ROM after operation, or average intra-and postoperative blood loss. No increase in the incidence of operative and postoperative complications was found. The operative time in the simultaneous TKA was significantly shorter than the time in a staged operation. Simultaneous bilateral TKA is beneficial for the patient requiring bilateral knee replacements.

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The purpose of endoscopic spine surgery is to be a simple minimally invasive alternative to conventional open surgery, and reduce the approach-related trauma without rib resection and long incision of uninvolved tissue. The surgical technique required newly-developed longer tools for the restricted access and new methods of visualizing, illuminating and magnifying the operative field.
The surgical technique of discectomy continues to be refined and improved in alternative and less invasive procedures. Recently, a laparoscopic approach for anterior interbody fusion at the lumbosacral level has been reported. But it may be technically difficult to access and decompress the spinal cord and spinal root involvement. A lateral approach based on the technique of Watkins, while providing excellent access to the root and extraforaminal disc, does not permit adequate visualization of the far-lateral extraforminal area from the posterior approach. To resolve this, we propose a novel lateral lumbar approach using retroperitonecoscopy for decompression of extreme lateral disc involvement, making a longitudinal separation between the psoas major and the quadratus lumborum. Another approach to the lateral lumbar spine is the foraminoscope of an arthroscope 4mm in diameter and 30°oblique scope using a 10-cc syringe and dilator. One enlarges the small space between the back muscles successively and inserts the syringe and makes a cavity with the dilator. This new approach is the most direct, efficient anatomical route to the lateral involvement of lumbar and lumbosacral spine and offers the advantages of minimally invasive surgery.
There were some minor but no major complications. This procedure provides adequate nerve decompression and fusion with clear visualization and minimal dissection of the abdominal muscles without surgical invasion to the paraspinal muscles and rib resection.

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Early diagnosis and treatment can prevent the progression of joint disease, so appropriate examinations are needed that can recognize subtle cartilage degeneration at an early stage and evaluate treatment efficacy. In 58 patients with osteoarthritis (OA) of the knee, several joint markers were investigated to determine the correlations between their levels and radiographic findings. The levels of chondroitin 6-sulfate (C6S), chondroitin 4-sulfate (C4S), and type II procollagen C-peptide (pCOL II-C) were high in the patients, but the C6S/C4S ratio and the hyaluronic acid (HA) concentration were low compared with the levels in normal controls. A negative correlation was found between radiographic progression and both the C6S level and the C6S/C4S ratio, while a positive correlation was found between radiographic pro-gression and the pCOL II-C level. These results suggest that joint markers, especially C6S, the C6S/C4S ratio, and pCOL II-C, reflect damage to articular cartilage, and that measure-ment of these markers in joint fluid may be useful for the diagnosis and monitoring of early OA without radiographic abnormalities. Moreover, these parameters could possibly be applied to evaluation of therapeutic efficacy.

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Mechanical stress loaded on articular cartilage is one of the most inportant factors in the development of osteoarthrosis (OA) . The purpose of the present study is to determine the response in articular chondrocytes to the loaded mechanical stress. To create an experimentally-induced OA model, the anterior cruciate and collateral ligaments of the rabbit knee joint were transected and expression of protein kinase C (PKC) was examined immunohistochemically. The PKC activator 12-o-tetradecanoyl-phorbol-13-acetate (TPA) was then administered intra-articularly. To determine the involvement of gas mediators, hydrostatic pressure was loaded on the cartilage taken around the defect which was made on the medial femoral condyle of the rabbit knee joint. The levels of superoxide anion and NO in the culture medium were measured. Bovine chondrocytes were subjected to cyclic mechanical stretch. Proteoglycan synthesis and PKC activity were measured. Chondrocytes of the OA model were stained positively with anti -a- PKC antibody. Intra-articular administration of TPA prevented the development of OA changes. Cyclic tensile stretch loaded on the chondrocytes decreased proteoglycan synthesis and PKC activity. Thus, PKC is clearly involved in the stress mediated degradation of articular cartilage. Cartilage defect leads to degradation of surrounding cartilage and to an enhanced superoxide anion and NO synthesis. These data indicate that these gas mediators are involved in development of OA.

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Spontaneously hypertensive rat (SHR), a rat model for human essential hypertension, has been characterized for idiopathic osteonecrosis of femoral epiphysis, resembling that of human Perthes' disease. Previous studies on the pathogenesis of the Perthes' disease-like lesion in SHR suggested a mechanically vulnerable epiphysis of SHR. However, there have been no previous reports investigating the possible cause (s) of the mechanical vulnerability in the femoral epiphysis. The postnatal development of the epiphyseal cartilage is dependent, at least in part, on the postnatal upregulation of insulin-like growth factor-I (IGF-I) . The present study immuno-histochemically compares the expression pattern of IGF-I in the femoral epiphysis of SHR with that of its normal control rats. The elucidated abnormal expression pattern of IGF-I may result in abnormal differentiation and growth of the epiphyseal cartilage, which may further lead to the mechanically vulnerable epiphysis of SHR.

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To assess the association between HLA-DRBI *0901 and RA in Japanese patients, we ana-lyzed the frequency of HLA DRBI *0901 in 852 such patients. We found that the homozygote of DRBI *0901 is significantly related to RA in Japanese patients. There were some differences in the frequency of the DRBI *0901 allele between subgroups, defined by age at onset and disease severity, although the corrected P values did not reach the satistially significant level. Because DRBI *0901 does not possess shared epitope, our study suggested the presence of the additional responsible epitope other than the well-known shared epitope.

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The authors carried out two-stage revision on two patients using vancomycin-impregnated Polymethylmethacrylate beads to treat methicillin-resistant Staphylococcus aureus (MRSA) infection following hip arthroplasty. The outcome of both cases was good and there was no recurrence of infection during the one-year follow-up period. Although our study series is small and the follow-up period brief, this method may be useful in such cases.

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We studied patellofemoral symptoms and patellar complications of 51 knees in 37 patients with rheumatoid arthritis treated by total knee arthroplasty. The patients were followed for a period of between 10 and 21 years, (average follow-up time 12 years and 8 months) . At total knee arthroplasty the patellar surfaces were replaced in 43 knees, and were not replaced in 8 knees. In all 43 knees in which the patella was replaced, a high-density polyethylene patellar component was used which was fixed with cement. Of the 43 knees, 9 (20.1%) had anterior knee pain, and 1 (2.3%) had a dislocation. There were no cases of patellar fracture or loosening of the patellar implant. Of the 8 knees without patellar replacement, 4 had anterior knee pain. Radiographs showed that erosion and subluxation of the patella had occurred in 3 of the 8 knees and a stress fracture in one. In addition to this study series, we have encountered 2 patellar fractures and one dislocation of the patella following total knee arthroplasty. In spite of these complications the overall rate of complication for patellar replacement is generally very low; we feel that the patellar surface should be replaced in rheumatoid patients undergoing total knee arthroplasty.

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We investigated the use of a costochondral autograft with rib bone in an articular cartilage defect. Japanese white rabbits were used. The articular surface of the intercondylar groove of the knee joints was exposed and a small drill hole 4 mm in diameter was made beyond the subchondral bone. The autologous costal cartilage graft with (group I) or without (group II ) rib bone was transplanted in this small hole. The rabbits were sacrificed at 3, 6, 12, 24 or 48 weeks after operation in order to evaluate the bony union and maintenance of the cartilage matrix.
In group I, bony fragment of the graft was united to the subchondral bone of the host at 6 weeks after operation. At 48 weeks after transplantation, the surface of the graft was smooth and there were few fissures in the matrix and no necrosis of the chondrocytes. By contrast, in group II irregularity on the surface and the clefts in the matrix were seen at 48 weeks after operation. There was significant difference between group I and II using the histological grading score (total 10 points) devised by the author.
A thin layer of cartilage of the graft with bone may be advantageous to the chondrocytes, allowing diffusion of nutrients from the joint fluid. The costal cartilage graft with bone yielded greater stability because of the bony union between the graft and the host. The costal cartilage near the rib bone to contain the collagen type II was more like the articular cartilage than the costal cartilage far from the rib bone. It is therefore suggested that costal cartilage graft with rib bone might provide a useful treatment for osteochondral defects of the articular cartilage.

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A case of arthro-osteitis in the first and second metatarsal bones associated with pustulosis palmaris et plantaris is reported. A 10-year-old girl complained of painful swelling in her right foot. Pustulosis also developed in her palms and on the soles of her feet. She also had tonsillitis. Both the erythrocyte sedimentation rate and level of C-reactive protein were moderately elevated. Roentogenograms showed periosteal bone formation and osteolytic change in the first and second metatarsal bones. The patient was treated with nonsteroidal anti-inflammatory drugs (NSAIDS) and antibiotics. After treatment the pain subsided and pustulosis decreased within several weeks. In addition, her tonsillitis improved. Roentogenograms showed a reduction in the size of the osteolytic lesions. No recurrence of symptoms had occurred as of the last follow-up examination.

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Polycentric knee prosthesis for total knee arthroplasty was introduced in the early 1970s, based on the concept that normal knee movement might be simulated by separate prosthetic replacement of opposing joint surfaces. This prosthesis consists of four parts: two Vitaliuw femoral components and two polyethylene tibial components. Because of complications and high failure rates, this prosthesis is no longer recommended for bicompartmental use. We report the case of a 70-year-old woman whose polycentric total knee arthroplasty was performed 25 years before. Radiographs of the knee showed severe loosening and sinking of the components, but relatively good axial alignment. We conclude that correct axial alignment is highly important for longevity of total knee arthroplasty.

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