Objective: To compare long term results of inverted-V shaped high tibial osteotomy (HTO) and wedged HTO for medial compartmental osteoarthritis.
Methods: One hundred and eight osteoarthritic knees treated with HTO were evaluated. Fifty two of those knees had been treated with inverted-V shaped HTO (Group V) . Their average age at surgery was 59.5 years old (range 43-75 years old), and their average follow-up period was 14.1 years (range 10-19 years) . The other 56 knees had been treated with wedged HTO according to Coventry (Group W) . Their average age at surgery was 59.8 years old (range 47-72 years old), and their average follow-up period was 12.0 years (range 10-17 years) in group W. There was no significant difference in preoperative clinical and radiological factors between group V and group W.
Results: Knee scores were improved by surgery from 58.1 ±8.1 to 85.1 ±9.7 in group V, and from 60.2 ±11.5 to 81.4±11.4 in group W. The percentage of patients evaluated as good (knee score more than 90 points) was significantly larger in group V (42% in group V versus 21% in group W) . The femorotibial angle (FTA) at final follow up in standing X-ray was 164.7 degrees in group V. In group W, FTA at final follow up in standing X-ray (171.0 degree) was significantly larger than in group V. Correction loss of more than 3 degrees within one year after surgery was observed in 7 % of group V.On the other hand, 29% of patients in group W had a change in tibial plateau angle of more than 3 degrees. This was statistically significant.
Conclusion: The present study showed that inverted-V shaped HTO decreased correction loss after surgery compared to wedge HTO. This result seems to confirm that patients treated with inverted-V shaped HTO have significantly better clinical results than patients with wedged HTO.

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Thirty one cases of rotational acetabular osteotomy (RAO) combined with femoral valgus osteotomy in our institute were retrospectively reviewed. The follow-up period was over 5 years. The original disease in all cases was osteoarthritis after hip dysplasia. Thirteen cases were pre/primary stage, 17 cases were advanced stage, and one end-stage.
The radiological follow-up results showed that 20 osteoarthritic hips preserved their joint space, 10 had progress of osteoarthritic changes, but none had revision surgery including THA. Seven out of those ten cases progressed to end-stage and these cases were all bilateral cases. This study suggested the medialization of the femoral head is an essential part of this surgery and when this in done, the clinical results may be good. This surgery may expand the surgical indications for RAO in combination with femoral valgus osteotomy.

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The results of resection arthroplasty for forefoot deformity with rheumatoid arthritis (RA) in 22 feet of 14 patients, after follow-up of more than 5 years, were evaluated clinically and radiologically. Recurrence of callosities or toe deformities had occurred in 31.8% of feet. These complications were associated with the lack of length of the resected lesser metatarsal heads, especially the second. This study analyzed radiographic changes of the hallux valgus angle (HVA) and two intermetatarsal angles, one between the first and second (M1M2) and the other between the first and fifth (M1M5) . They were measured before the surgery, 3 weeks and 6 months after the surgery, and at the last follow-up at more than 5 years. The average HVA significantly decreased from 40.6° preoperatively to 9.41° postoperatively and increased again to 21.1° at 6 months after surgery. However, no deterioration of HVA was detected from 6 months after the surgery to the last follow-up at more than 5 years. The average M1M2 and M1M5 angles also decreased significantly postoperatively (from 13.1° to 11.5° and from 34.3° to 28.4°, respectively), and increased again at 6 months after the surgery (13.2° and 32.1°, respectively) . Again no deterioration of M1M2 and M1M5 angles was detected from 6 months after the surgery to the last follow-up at more than 5 years. In the present study, forefoot resection arthroplasty was a stable procedure for the patient with RA in the long term. The authors have recognized problems with recur-rence of callosities or toe deformities associated with poor alignment and length of the resected lesser metatarsal heads, and especially resection of the first and second metatarsal heads should be done with skepticism and caution.

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Objective: Aseptic necrosis of the talus due to trauma or steroid use is well documented, but idiopathic cases are still poorly understood, especially regarding the clinical features. This study was made to clarify the clinical features of idiopathic aseptic necrosis of the talus in Japan.
Method: We reviewed 44 cases (54 feet) of idiopathic aseptic necrosis of the talus that were reported in Japan, which including 2 cases (2 feet) treated by ourselves. The following subjects were investigated: gender, age, affected foot, symptoms, time from onset to diagnosis, past history, complications, history of smoking and drinking, radiological findings, locations of necrosis, treatment methods, and histological findings. We classified radiological findings into four types. Type I : no joint surface of the talus was collapsed; type II : only the tibio-talar joint surface of the talus was collapsed; type III: only the talocalcaneal joint surface of the talus was collapsed; type IV : both the tibio-talar and talo-calcaneal joint surfaces of the talus were collapsed.
Results and Conclusion: There were 28 females and 15 males, and their mean age was 51 years (range 21 to 80 years) . There were 34 unilateral involvements and 10 bilateral involvements. All patients complained of ankle pain. The mean duration from onset to diagnosis was 2 years and 11 months (range 1 month to 21 years) . One patient had a history of alcoholism, and one patient had a complication of multiple osteonecrosis. Four patients had a habit of moderate smoking (20-40 cigarettes per day) . Necrosis was seen frequently in the body of the talus (79%) . A radiographic review revealed that type I findings were seen in 16 feet, type II in 25, type III in 2, and type IV in 9. Reduction in pain was observed in 7 feet that received conservative therapy; however, neither radiograms nor MRI showed any evidence of remodeling of necrotic areas in the talus. Thirty nine feet were given operative treatment (arthrodesis: 30 feet; replacement of the talus: 4 feet; free vascularized bone graft: 2 feet; total ankle replacement: 1 foot; vascular bundle graft 1 foot; curettage and free bone graft: 1 foot) . All except one foot that was given curettage and free bone graft showed satisfactory results. In all cases, histological findings were concordant with typical findings of avascular osteonecrosis (e.g. empty lacunae, necrotic debris) . We performed tibio-calcaneal fusion with a sliding inlay graft of anterior tibia and iliac free bone graft in two cases, and achieved satisfactory results.

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Objective: The purpose of this study was to examine the clinical results of the McLaughlin procedure for rotator cuff tears according to different rehabilitation programs.
Methods: A retrospective study was performed on a consecutive series of 52 rotator cuff repairs. The average age was 60 years at surgery. Thirty three cases were male and 19 cases female. The follow-up duration was 5 months or more. After the surgery, 28 cases were given a zero-position cast for 3 weeks and 24 cases were given a arm-rest at ninety-degrees abduction for 3 weeks.
Results: The average JOA score for all cases improved from 63 to 89 points after surgery. The final scores were 89 points in both the cast and the arm-rest groups. Seven cases of the cast group suffered neurologic disturbance of the upper extremity. The average stay in hospital was 47 days for the cast group and 37 days for the arm-rest group.
Conclusion: The arm-rest group showed fewer complications and shorter time in hospital than the cast group after the rotator cuff repair.

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A randomized prospective study was performed to analyze the incidence of complications, such as deep vein thrombosis (DVT) of the lower extremities and pulmonary embolism (PE), after total knee arthroplasty (TKA) .
TKA was performed in twenty-four patients with rheumatoid arthritis. The patients were divided into two groups, one group with full time use of a tourniquet (the TT group) during surgery, and the other group with partial use of a tourniquet (the PT group) . For the PT group, a tourniquet was applied only during the time of fixing the components. All components for both groups were fixed with bone cement. The operation times, the amounts of blood loss, the extent of swelling of lower limbs, and the results of blood examinations including D-dieter, and thrombin antithrombin IlI complex (TAT) were compared between the two groups.
The PT group showed significantly more intra-operative blood loss than the TT group, but there was no difference in post-operative blood loss between the two groups. There was no significant difference in operation time, circumferences of the lower limbs, and values of D-dieter, TAT, and hemoglobin between the two groups. Two cases in the PT group showed evidence of postoperative DVT. There was no case of symptomatic PE in the current study, but the incidence of asymptomatic PE was 25.0% in the PT group and 16.7% in the TT group (not significant) .
The partial use of tourniquet did not decrease the incidence of DVT and PE with the numbers available in this study.

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The accuracy of osteotomy in total knee arthroplasty (TKA) has been increased due to the development of instruments. However, soft tissue balance in TKA has not been developed instrumentally, although soft tissue balance in TKA is one of the factors affecting the clinical results of TKA. Recently, various commercially available soft tissue balancers have been developed to improve soft tissue balance in TKA. Using a mechanical testing machine, we examined the real gap force produced by 4 commercially available balancers, 3 torque wrench types and 1 spring type, under recommended torque or compression forces. The real gap force under the same indicated torque varies among the 3 torque wrench types. The real gap force in the spring type closely matched the indicated force. The linearity of 3 torque-wrench types was much less than that of the spring type. Inter- and intra-observer differences of the 3 torque-wrench types were much higher than those of the spring type. We recommend the standardization and flexibility of applied forces.

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A subvastus approach for total knee arthroplasty (TKA) demands lateral release in case everting the patella is difficult. We reported two cases of TKA using a subvastus approach with a small lateral release, which preserved the synovial layer of the capsule and was limited within the length of the patella.
Case 1. A 60-year-old female with osteoarthritis of both knees was referred to our hospital. She was obese and her body mass index (BMI) was 31.8. There was difficulty in everting the patella when a TKA of her right knee was done via a subvastus approach. The small lateral release, which involved only the fibrous layer, was added. Then, the dislocation of the patella became possible.
Case 2. A 73 year-old male with osteoarthritis of his right knee visited our hospital. A lateral plain radiograph showed an infra-patella whose LT/LP ratio was 0.72. The patella was everted in the same manner as in case 1, and TKA was performed. One option for obtaining a good surgical view in TKA involves turning the patellae over. Lateral release makes dislocation of the patellae easier. A subvastus approach offers the advantage of preserving the vastus medialis muscle; however, there are some cases in which there is difficulty in everting the patellae. In such cases, a small lateral release, involing only the fibrous layer, may be beneficial in reducing damage to the circular vascularity of the patella and exposure of the implant under the skin.

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An RA patient with a severely valgus knee was treated with total knee arthroplasty (using a Nexgen LCCK) . The patient was a woman aged 77 years. Pre-and postoperative axial alignments were measured on weight-bearing long-standing radiographs. Clinical data summarized using the Japan Orthopaedic Association score (JOA score) . The f emoro-tibial angle (FTA) was 145°preoperatively and 175°postoperatively. The preoperative flexion angle was 90°and the postoperative flexion angle was 120°. The preoperative JOA score was 26 points and the postoperative JOA score was 61 points. The patient was satisfied with the results of the operation.

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