We reviewed data for 65 patients (3 men and 62 women, 71 joints) who underwent minimally invasive total knee joint arthroplasty (MIS-TKA) . The average age of patients at operation was 73.6 years (range, 60-83 years) . Sixty patients had an underlying diagnosis of osteoarthritis (aligned 57 varus, 2 valgus, and 1 patellof emoral), and 5 patients had rheumatoid arthritis. The average alignment of affected limbs on standing was 4.7° of varus. We compared the results of this group to those of standard TKAs by a conventional approach. All joints were of the posterior cruciate-stabilized design (LPS-Flex, fixed type) and were fixed with bone cement. Whereas the flexion range after surgery averaged 124.2±8.7° in the MIS group and 125.3±9.4° in the standard group, the postoperative regimen was easier and faster for the MIS group (the average time to obtain 90° of flexion was 6.6 days for the MIS group and 11.5 days for the standard group) . There was no significant difference between the groups in terms of postoperative X-ray alignment and component positioning. There were no infections, extensor mechanism or neurovascular complications in MIS-TKA. The mini mid-vastus approach was associated with a more rapid functional recovery after TKA, without compromising implant positioning.

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Purpose: Minimally invasive surgery for TKA has been used in our institute since April, 2004. Our concept of MIS-TKA includes 1) to be performed by general orthopaedic surgeons, 2) not to insist on a small incision, 3) to be performed for all cases, 4) to minimize invasion to the extensor mechanism without patellar eversion. The purpose of this study is to evaluate the early results of MIS-TKA performed with the mini-midvastus approach, in comparison with conventional TKA with the midvastus approach.
Methods: From January, 2003 to March, 2004, 57 consecutive TKA were performed with the conventional midvautus approach (the Standard group) . From April, 2004 to October, 2005, 60 MIS-TKA were performed (the MIS group) . We used the GENESIS II posterior stabilized knee (Smith & Nephew, Memphis, USA) and the Bi-surface knee (JMM, Osaka) .
Results: Mean hospital stay was significantly shorter in the MIS group than in the Standard group. There were no significant differences in recovery of ROM, amount of total bleeding, or postoperative knee alignment.
Conclusion: MIS-TKA with the mini-midvastus approach could be indicated for almost all patients undergoing TKA and resulted in early recovery after TKA. Recognition of error patterns seems very important for the procedure, because there was a learning curve noted in our results. Preoperative simulation with the 3D-template software would be useful for MIS-TKA.

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Objective: Anti-cyclic citrullinated peptide (anti-CCP) antibody has been known to be a specific autoantibody of rheumatoid arthritis (RA) . The objective of this study was to examine the availability of anti-CCP antibody in early RA.
Methods: 109 patients with RA were included in this study, and thirty of them had early RA, that was within one year of onset. Anti-CCP antibody and rheumatoid factor (RF) were measured in all serum samples, and their sensitivity as RA markers was analyzed during the time from onset of the disease.
Results: Anti-CCP antibody was found in 79% of all RA patients, but in only 70% of early RA patients, which was almost the same sensitivity as for RF, In addition, 12% of all patients were positive for anti-CCP antibody, but negative for RF.
Conclusion: Taking into consideretion the high specificity, anti-CCP antibody seems useful in the diagnosis of early RA.

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Objective: To report the results of a pilot study of Etanercept without MTX treatment for RA, using the same dosage of Etanercept allowed in Japan as in Europe and the U. S.
Methods: Seven RA patients (one male, six females, ages 54-73 years old; stage 1: one; 4: six; class 1: one; 2: three; 3: three) were given subcutaneous Etanercept twice a week. All RA patients underwent general close inspection including HRCT and a tuberculin test as well as infectious disease screening before Etanercept administration.
Results: Finally, 6 of the 7 RA patients completed this pilot study without severe complications. One of 2 Infliximab invalidity patients canceled this study due to itching and non-effectiveness. Prophylaxis by isoniazide was performed for the patient with a history of pulmonary tuberculosis. Three of the 6 continuative patients were able to reduce their subcutaneous Etanercept to once a week, given reduced RA activity. Above all, early RA was controlled well with only Etanercept. In each case, RA inflammatory activity was controlled by this trial although symptoms of the destroyed joints remained. We tried to do this subcutaneous Etanercept administration if possible from an early stage, to prevent RA joint destruction (operation evasion) .
Conclusion: The pilot study of Etanercept without MTX treatment for RA showed Etanercept to be safe and effective.

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We introduced a critical path plan for total knee arthroplasty (TKA) for rheumatoid arthritis (RA), and we have recently used a path which hastened the load time. We reviewed differences in periods of hospitalization and rehabilitation.
TKA was done for 56 RA patients. Twenty for whom the crrtical path was not used were called Group A; 21 for whom the critical path was used were called Group B; and 15 for whom the load-hastening path was not used were called Group C.
The mean hospitalization lengths were: 22 days for Group C, 27 day for Group B, and 41 days for Group A. Post-operatively there were no significant differences between the groups in terms of range of motion or JOA score, nor were there any post-operative complications. Hospitalization was shortened by induction of the critical path plan; there was no particular problem following induction of that plan, and use of the plan for TKA in cases of RA was possible regardless of the activity of RA.

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Objective: Arthrodesis is commonly performed for severely damaged ankle joints in patients with rheumatoid arthritis (RA) . Several problems are encountered when this surgery is performed on patients with severe bone loss, osteoporosis, malalignment, tendon imbalance, and skin deficiencies. We report three RA patients treated for severe ankle deformity by ankle arthrodesis.
Methods: The average age at the time of the surgery was 75 (67-87) years and the average duration of known RA was 43 (25-59) years. Problems and difficulties during surgery, postoperative complications, completion of bone union, and the necessity of a second surgery were examined retrospectively. Clinical results were evaluated according to the Ankle-Hindf oot Scale of the American Orthopaedic Foot and Ankle Society.
Results: In all three cases, staples and/or screws were utilized for the internal fixation of the tibia and the talus. No retrograde intramedullary nail was used due to a lack of bone stock from the talus and the calcaneus. Fibular plating was performed in one case for severe osteoporosis. Sk52in grafts were necessary in one case due to skin necrosis around the surgical incision. In one case, after talo-tibial arthrodesis, severe varus deformity of the subtalar joint progressed, and an additional subtalar arthrodesis was performed. At the most recent follow-up, adequate bone union had been achieved, and the scores on the Ankle-Hindfoot Scale improved from those before surgery for each patient.
Conclusion: Arthrodesis is commonly performed for hindf oot deformity in patients with RA. In the presence of severe deformity, bone loss, osteoporosis, skin problems, or an imbalance of soft tissue, care should be taken to prepare for problems and complications during and after the procedure.

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Objective: To investigate the effect of LCAP therapy for RA patients, we examined CRP level and DAS28-CRP levels and discussed the factors that affect the results.
Methods: Seventeen RA patients (4 males and 13 females) with a mean age of 62.5 years, and a mean duration of illness of 11 years underwent LCAP therapy. Prior to LCAP therapy, their CRP levels were evaluated, with a mean of 5.44 mg/dL. The concomitant drugs were PSL for 14 patients, SASP for one patient, MTX for nine patients, Bc for two patients, MZR for one patient, LEF for one patient, ACT for one patient, and GST for one patient. DAS28-CRP was evaluated in 13 patients. CRP level (n=17) and DAS28-CRP scores (n=13) before and after the LCAP therapy were compared, and correlations with patients' background and status of complications were investigated. Statistical significance was analyzed by using multiple regression for the correlation between patients' background and therapeutic results, and Wilcoxon's signed-rank test for CRP level and DAS28-CRP as to various factors influencing the results.
Results: CRP levels decreased by 20% or more in 9 of the17 patients (52.9%), and for DAS28-CRP, improvement of a moderate response or more was seen in 7 of the 13 patients (53.8%) . Combined use of MTX was defined as a factor that affected the treatment results. Comparison of CRP levels before and after LCAP therapy showed that in the MTX combination treatment group, there was a decrease in CRP level (p=.0504) and significant improvement in DAS28-CRP (p=.0280) . There was no complication due to LCAP therapy.
Conclusion: LCAP therapy had no serious adverse effects, and is worth trying before biological preparations.

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Objective: Metal on metal resurfacing hip arthroplasty is a procedure which can save local bone source. We have resurfaced 4 joints with this procedure since 2001. The objective of this paper is to report the short-term results.
Subjects and methods: The subjects were 2 male and 2 female adults. Their average age at the time of operation was 49 years (range 46-52 years) . All of the resurfaced THAs were done for osteoarthritis. We used a metal on metal bearing hip system named Cormet (Corin Japan KK) . We used a lateral approach involving osteotomy of the greater trochanter because this would protect the artery feeding the femoral head. The mean follow-up period was 2 years (range 1-3 years) .
Results: The mean JOA score improved from 54 points (33-69 points) before surgery to 90 points (89-97 points) after surgery. So far, there has been no indication of loosening of the implants, although two screws that were fixed to the greater trochanter have loosened. Also, none of the patients has yet experienced any pain, and all have indicated satisfaction with the treatment.
Conclusions: With those middle aged patients, we were concerned about which treatment would be more beneficial, osteotomy or THA. The historical failures of resurfacing THA resulted from production of debris. To avoid that problem, a metal on metal bearing device has been applied. In our cases, all the patients are satisfied, but we do not know the long-term results, so continued observations will have to be made.

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Delayed bladder rupture caused by an acetabular fracture fragment is rare. We report a 75-year old woman who had unusual hip joint and thigh pain caused by urinary leakage from a late bladder laceration secondary to acetabular fracture six months earlier. Imaging findings revealed urinary extravasation around and within the right-side hip joint and thigh. Surgical repair of the bladder wall followed by drainage of the urinary pool resulted in complete recovery of bladder function. Physicians should be aware of such a rare late complication in patients with acetabular fracture.

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Design: A report of an unusual case.
Objective: To describe an unusual case presenting with intermittent sub-occipitalgia due to 30-year-old pseudo-arthrosis of the odontoid process.
Case File: A 55-year-old man was referred to our hospital complaining of intermittent sub-occipitalgia pertaining to Anderson-D'Alonzo type II ununited fracture of the dens. Medical history revealed neck trauma in a serious motorcycle collision 30 years earlier, but no fracture-dislocation of the cervical spine was identified at a local hospital. The patient returned to physically-demanding work as a labourer 10 days after the trauma, and upper neck pain continued with remissions and sometimes worsening. Radiological examination showed pseudo-arthrosis of the odontoid process, with 8 mm anterior subluxation of the dens on neck flexion. Neck discomfort disappeared after posterior reduction and C1-C2 fusion.
Conclusion: A 30-year symptomatic worsening associated with pseudo-arthrosis of Anderson-D'Alonzo type II odontoid fracture is unusual. Awareness of this condition is important to reduce possible morbidity and to provide early treatment.

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Hinge-type total knee arthroplasty (hinge TKA) is often used for functional reconstruction in cases of severe bone loss and joint instability. We report two patients with knees severely damaged by rheumatoid arthritis (RA), treated with hinge TKA (Finn Knee System, BIOMET), who showed good improvements in walking ability from an early postoperative stage. Case 1: a female, aged 66 years, with class III stage IV RA. Her left knee was severely damaged; (figure 1) . She lost the ability to walk at about 65 years old, and crawled on the ground (figure 2) . Case 2: a female aged 55 years, also with class III stage IV RA. She received right TKA at age 42 and left TKA at 43, but her left knee became unstable from around age 52, and it continued to deteriorate.
Both patients achieved a stable gait soon after hinge TKA. The postoperative Japan Orthopaedic Association score (JOA score) was 30 points preoperatively for case 1, but at final follow-up three years postoperatively, the JOA score was 83 points, showing excellent progress. For case 2, the preoperative JOA score was 46, and at final follow-up two years postoperatively, it had improved to 75 points, again indicating excellent progress.
For these two patients, hinge-TKA provided immediate pain relief even at early follow-up, and allowed early weightbearing and aggressive rehabilitation, without evidence of early mechanical failure. The two patients were satisfied with these operation results.

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