We started using a“critical path”care planning system for total hip arthroplasty in 1999 to provide standardized, efficient and reliable team care. In this study, we investigated the effects and problems of critical path planning for both patients and medical staff. The patients consisted of two groups : 1) patients treated before the introduction of the critical path system (n=43), 2) patients treated with critical path (n=26) .
Postoperative hospitalization significantly decreased when using critical path charts (p<0.01) . Total medical costs per patient also significantly decreased (p<0.01) . In both groups, patients indicated the merits of using critical path charts, saying that they could easily explain the postoperative course to their family and they could better prepare for discharge. However, some patients pointed out the difficulty of understanding the medical terms in the path charts, and felt resistant to the fixed program. The critical path system made the nursing work more efficient. All medical staff recognised that the critical path facilitated efficient and reliable team care for patients, but the critical path system should be improved to allow for individual patient needs.

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After total knee arthroplasty, we measured bone mineral density in femoral condyles, using the DEXA method.
This study was to investigate factors affecting bone mineral density around the prosthesis.
The subjects of this study were 46 cases, 54 joints, with osteoarthritis (the average age at operation was 73.4), and about 25 cases, 36 joints, with rheumatoid arthritis (the average age at operation was 63.1) . Advantim prostheses (by Wright Medical) were implanted in all cases. DEXA methods were used to measure bone mineral changes, and for each femoral condyle, the anterior femoral condyle (area A), central femoral condyle (area B) and posterior femoral condyle (area C) were established, and bone mineral densities were assessed at intervals at each area.
Three patterns of bone mineral density change were found:
type 1, with density increase in area C.
type 2, with density increase in area B.
type 3, with density increase in areas B and C.
We have observed that various bone mineral changes were generated regularly by load-bearing transmission in femoral condyles after TKA. For example, bone atrophy was produced in anterior condyles by stress shielding, and bone ingrowth created in posterior condyles by load-bearing. Load-bearing is much affected by gait.

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Eighty-one patients (98 knees) with varus gonarthrosis who had a high tibial osteotomy were followed for at least ten years, the average follow-up being 14 years. The results showed that the rate of knees graded as satisfactory was 87% at 2 years, 77% at 7 years, and 66% at the last follow-up evaluation.
Factors influencing long-term results were age at the time of surgery, preoperative roentgenographic stage, postoperative femorotibial angle, obesity, and degenerative changes of the opposite knee and the lumbar spine.
We believe that the alignment obtained by osteotomy is the most important factor in bringing good long-term results, and the optimum femorotibial angle should be 168° (166°-170°) .

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Correction loss is one of the most important problems after high tibial valgus osteotomy (HTO) for the treatment of osteoarthritic knees, because clinical results are said to relate closely to the femorotibial angle (FTA) . We examined the changes of FTA with at least five-years follow-up in fifty-four knees, and among them 12 bilateral cases were examined for differences of FTA between right knee and left. The average FTA deteriorated year by year, and gained 4 degrees in five years. Using Kaplan-Meier survivor-ship analysis, 87% of patients at 5 years, and 78% of patients at 10 years, did not go beyond 176 degrees of FTA. The average difference of FTA in bilateral cases was around only 2 degrees all through the time. Five out of 24 knees of bilateral HTO showed deterioration of FTA beyond 176 degrees; one case suffered simultaneous deterioration, and her FTA was 183° in her right knee and 182 degrees in her left. Two of the other 3 knees showed between 7 and 10 degrees difference between right and left knees, but those differences were quite similar to those of preoperative FTA. These facts indicate the existence of a tendency to return to the former deformity in osteoarthritic knees, and this cannot be controlled by osteotomy for long periods of time.

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High tibial osteotomy (HTO) was performed on 1025 medially osteoarthritic knees in 918 patients from 1972 to the present. In this time 455 knees which had HTO before 1990 were observed. Many patients died or were missing during the follow-up period, so only 206 knees out of 455 knees (48 male knees, 407 female knees) were investigated directly and by telephone.
The results differed depending on the OA stage at the operation and the FTA just after HTO. 32 out of 44 knees at stage 2 were satisfactory (73%), 25 of 93 knees at stage 4 were satisfactory (26.8%), but poor in 73%.
Eighteen percent of patients with over 173° FTA after HTO were satisfactory and 50% of patient with less than 172° were satisfactory. In stage 4, FTA after HTO of 167°-165° should be attained to keep good long-term results.

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We report problems in treating infected Total Knee Arthroplasty (TKA) based on our experience of 7 knees.
Seven cases (7 knees), with infection after TKA, were studied. The original joint diseases were 5 knees with OA, 1 knee with RA, and 1 knee with osteonecrosis combined with SLE. All cases had a history of multiple surgeries including the infected knee. Infected implants were observed in 2 LCS, 1 Rotating-Hinge, 1 AMK, 1 Deltafit 7000, 1 Scorpio, and in 1 MGII which was removed by another hospital. Detected microorganisms were MRSA in 2, MSSA in 2, and MRSE in 1. Surgical treatment for these infected knees involved removal of the implant, debridement of infected tissue, insertion of cement blocks including antibiotics, and continuous irrigation with 5 liters of physiological saline and 1 liter of oxidizing water for 2 weeks. Revised TKA or arthrodesis was performed on patients several weeks after continuous irrigation. Four knees had revised TKA, 3 knees had arthrodesis, and 1 patient underwent above-knee amputation after arthrodesis. The mean follow-up period after surgery was 19 months.
None of the patients had any symptoms of infection at follow-up. Good bony union was achieved in 2 of the arthrodesis cases. The mean ROM of revised TKA was 65 degrees. ESR value, CRP value, and the number of white blood cells were normal in the 5 cases without RA or SLE.
Multiply operated cases need strict infection prevention after TKA. In the patients with RA and SLE, it was difficult to control inflammation. Careful observation of infected knees is necessary, because of the short-term follow-up period.

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This study evaluates the postoperative results of arthroscopic lavage for rheumatoid arthritic (RA) knees. From 1984 to 2000, arthroscopic lavage for RA knee was performed in 33 knees of 27 patients. Twenty three knees in 17 patients were followed up more than 1 year after lavage. The average age at surgery was 61.9 years old (range, 39 to 89) the average follow-up time after surgery was 24.7 months (range, 12 to 99) .
The patients had grade 0 to grade III radiographic changes by Larsen's criteria. Joint effusion, preoperatively observed in 18 knees, disappeared in all knees postoperatively. Pain disappeared in all 6 knees with grades 0 and I, 7 of the 11 grade II knees, and 4 of the 6 grade III knees. Good results included full relief of effusion and pain in 100% and 93% of the patients at 1 month, in 83% and 75% at 1 year, and in 77% and 50% at 3 years after lavage respectively. Arthroscopic lavage appeared to be a promising treatment for RA knees at Larsen's grades 0, I and II .

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We describe a rare case of an iliopsoas bursitis occurring with rapid and severe destruction of a rheumatoid hip joint. The iliopsoas bursitis developed within several days after walking became impaired. The process could be explained as follows: the acute compression of the femoral head and destruction of the top of the acetabulum might be attributed to the severely increased pressure within the hip joint. Due to that high pressure, there may have been a leak into the iliopsoas bursa from the hip joint, and then debris and fluid overflowed into the iliopsoas bursa, generating a giant cyst diagnosed as iliopsoas bursitis. We performed total hip arthroplasty, and there has been no sign of recurrence of this bursitis in the 6 months after the operation.

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Bone grafts are needed in most revision THA cases. We treated 2 patients (RA, OA) using autografts of resected femoral head, preserved in subcutaneous space. The patients underwent revision THA 2 months after contralateral primary THA ; bone chips from preserved femoral head material were impacted into acetabular bone defects and the intramedullary femoral canal.
Post-operative X rays showed homogenous patterns within 9 months after surgery.

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