With reviews of the medical treatment system, changes in social consciousness, and questions about medical treatments, outcome management is becoming the most important issue with which the medical institutions of Japan have to grapple.
Outcome management deals with 4 parameters, namely clinical outcome, customer satisfaction, financial outcome, and length of hospital stay.
The critical path system, taking these 4 parameters into consideration, serves as a very effective tool for clinical management.
This paper describes the effectiveness of outcome management by the critical path system with total knee arthroplasty, and the prospects for critical path use in joint surgery more generally.

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The results of 10 infected joint replacement arthroplasties (9 patients) were retrospectively studied. Six patients with postsurgical or hematogenous infection, without evidence of loosening of the components, were treated by irrigation, debridement, and retention of the prosthetic components. In 5 of those 6 cases (83%) with postsurgical or hematogenous infection, the components were retained by debridement without further evidence of infection. In spite of late chronic infection, only one patient treated by irrigation, debridement, and retention of the components resulted in failure. In the other 3 cases, loose components were removed. This study shows that irrigation, debridement, and retention of the components can result in a high success rate in patients with postsurgical or hematogenous infection with stable components. In case of loose components, the components should be removed.

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Thirty-three bipolar revisions with bone-allografting were performed for cavitary acetabular deficiency at revision. We used 80°C heat-treated or freeze-dried bones as allograft. The average follow-up period after surgery was 3 years 9 months (range, 1-10 years 3 months) . The operative time averaged 157 minutes (range, 55-290 minutes) and mean intraoperative blood loss was 648ml (range, 40-1700ml) . Outer head size averaged 42mm before revision and 47mm after it. The mean CE angle after surgery was 22° (range, 2-35°) and the mean medial thickness of the acetabulum after surgery was 15mm (range, 5-25mm) . There were 6 hips with perioperative complications, and 2 hips with postoperative complication without dislocation. Medial migration averaged 3.2mm (range, 0-14mm) and superior migration averaged 3.7mm (range, 0-15mm) at 1 year after surgery. Eventual migration figures were 4.7mm (range, 1-17mm) and 6.6mm (range, 1-18mm) at the last follow-up period. Radiographic evidence showed satisfactory bone incorporation of allograf ts. However, one hip required a second revision at four years after surgery, due to rapid progressive allograft resorption. The clinical score was assessed by the hip rating score of the Japanese Orthopaedic Association, and the mean score increased from 49 preoperatively to 83 points postoperatively at the last follow-up period. These results reveal that a bipolar endoprosthesis with allografts is a useful and safe procedure for cavitary acetabular deficiency at revision.

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The KT plate is a metal supporter for a deficient acetabulum, designed by C. Tanaka. Between April 1999 and March 2000, we performed total hip arthroplasty with KT plates and morcellized bone graft for seven patients (eight hips) with severe bone loss in the acetabulum. The preoperative diagnoses were rheumatoid arthritis in four hips (three patients), osteoarthritis in three hips (three patients) including two revision surgeries, and rapidly destructive coxarthropathy in one hip. All seven patients were women, and the average age at surgery was 68.4 years old (range, 52-82 years) . Patients were followed for 7 to 18 months (mean, 12.3 months) . All patients, except the two who received revision surgery, started weight bearing at 3 to 7 weeks after operation. In spite of the early weight bearing, no collapse of the grafted bone or loosening of the KT plate was observed, and the clinical courses of the patients were encouraging.

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Eight knees with severe valgus deformity were treated with total knee arthroplasty. All patients were women, and the mean age for the patients was 55 years. The group included six knees with rheumatoid arthritis and two knees with osteoarthritis. Pre-and postoperative axial alignment was measured on weight-bearing long-standing radiographs. Clinical data summarized using the 100-point scoring system developed by the Knee Society. The femoro-tibial angle (FTA) averaged 156.5° (range, 139-160°) preoperatively and 174.5° (range, 170°-180°) postoperatively. The Knee Society mean knee score was 26 (range, 15-40) preoperatively and 89 (range, 68-100) postoperatively. The Knee Society mean postoperative functional score was 43 (range, 10-60) preoperatively and 53 (range, 10-70) postoperatively. There were three complications in the group. These were two superficial wound problems and one patellar subluxation. All patients were satisfied with the operation. All knees were stable with a functional range of motion at the last follow-up.

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The effects of lateral wedged insoles on lower extremity alignment in cases of medial compartment osteoarthritis of the knee (knee OA) were evaluated. Novel insoles with elastic subtalar fixation, and traditional shoe-insert wedged insoles, were prepared for 97 new female outpatients with knee OA. Randomization was performed according to birth date. Standing radiographs were used to analyze the femorotibial, talocalcaneal and trochanter tilt angles for each subject with and without their respective unilateral insole. In the participants wearing the elastically fixed insole (n = 49), significant correlation was observed between correctional angles with the insole and femorotibial angles without the insole (p = 0.002), and between correctional angles with the insole and talus tilt angles without the insole (p = 0.028) . These significant correlations were not found in the group with the inserted insole (n = 48) . The novel fixed insole leads to valgus angulation of the talus, resulting in correction of the femorotibial angle in patients with varus deformity of knee OA, and may have a similar therapeutic effect to that of high tibial osteotomy.

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The purpose of this study was to investigate the relationship between the clinical findings and radiological changes in patellofemoral joints after high tibial valgus osteotomy for medial and patellofemoral osteoarthritic knees with varus deformity.
Two hundred and nine knees in 153 patients (117 women and 36 men, with an average of 64.3 years) were followed for an average of 4.5 years (range, 2-11 years) .
Clinical findings for patellofemoral joints involved retropatellar crepitation, grating pain, tenderness around the patella, pain in deviating the patella (medially, laterally, proximally, distally), and pain in holding the patella against knee extension.
The width of joint space was measured in both the medial and lateral compartments of the Patellofemoral joints. Patellar height was evaluated using the ratio of patellar ligament length to patellar length (the Insall-Salvati ratio) and patellotibial distance.
In clinical findings, all kinds of patellof emoral provoked pain were relieved significantly after osteotomy.
The mean width of joint space in medial compartments was 5.5mm before osteotomy and 4.2mm at the final follow-up. That in lateral compartment was 4.7mm and 4.8mm respectively. Consequently, patellar tilt and shift were improved after osteotomy.
Patellar position was slightly lower after osteotomy.
The results suggested that patellofemoral pain was relieved and patellar position was improved after high tibial osteotomy.

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Repairing a defect or injury of articular cartilage is a significant challenge. Osteochondral graft, periosteal transplantation, drilling, and chondrocyte transplantation have been attempted clinically for articular surface defects. We evaluated repairs of articular cartilage by mosaicplasty.
Four knees of 4 patients (2 men and 2 women) that underwent mosaicplasty were evaluated in this series. Mean patient age at surgery was 41 years. All knees underwent follow-up MRI, 2 knees underwent follow-up arthroscopy and needle biopsy after informed consent was obtained. The mean period from surgery to final follow-up was 21 months. The mean period from surgery to follow-up arthroscopy was 11 months.
Four cases of mosaicplasty presented satisfactory regeneration of the articular cartilage as seem by MRI or arthroscopic examination. Two knees, after receiving mosaicplasty, demonstrated regeneration of hyaline cartilage even around the gaps in mosaicplasty, by needle biopsy. However, the structure of hyaline cartilage around the gaps in mosaicplasty differed from that of normal hyaline cartilage.
Several reports described a good clinical outcome of mosaicplasty. However, only Hangody reported good hyaline cartilage regeneration at the recipient site and fibrous cartilage at the donor site. Our results demonstrated regeneration of the hyaline cartilage in the gap area of mosaicplasty, but the structure of hyaline cartilage differed from normal. There is a risk of renewed degeneration due to the poor structure of hyaline cartilage. Mosaicplasty is a sure method of repairing hyaline cartilage where there is a small defect in the articular surface. However, one report pointed out the risk of articular degeneration at the donor site after mosaicplasty. One of our cases demonstrated bony defect at the donor site 21 months after mosaicplasty. Adequate observation of both the donor site and recipient site is needed after mosaicplasty.

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Seventy-three knees of 59 patients (51 female, 8 male) were operated on since 1988. The age at operation ranged from 70 to 92 years old (average 74 years) . Follow-up periods ranged from 6 to 116 months (average 36.7 months) . Results were investigated using standing A-P radiographs. Preoperative status was classified in 4 stages.
For most of the patients, MRI was taken before surgery.
All patients were clinically evaluated by JOA score (Japanese Orthopaedic Association score), and patients' satisfaction.
Result; 1. 63% of patients had complained of acute or subacute gait disturbance. 2. Radiographic findings showed that 80% were unchanged and 20% were worse after surgery. 3. Types of meniscal tears were mostly transverse tears, L shaped flap tears, horizontal tears, and mixed. 4. Average JOA score significantly improved from 44 to 85 points, and 90% of patients were satisfied with their post-operative results.
Conclusion; We conclude that arthroscopic meniscectomy in aged patients provided satisfactory clinical results.

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