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The Bone & Joint Journal
Vol. 100-B, Issue 8 | Pages 1018 - 1024
1 Aug 2018
Ando W Yasui H Yamamoto K Oinuma K Tokunaga H Inaba Y Kobayashi N Aihara M Nakanishi R Ohzono K

Aims

The purpose of this study was to compare two different types of metal-on-metal (MoM) bearing for total hip arthroplasty (THA): one with a large femoral head (38 mm to 52 mm) and the other with a conventional femoral head (28 mm or 32 mm). We compared clinical outcome, blood metal ion levels, and the incidence of pseudotumour in the two groups.

Patients and Methods

Between December 2009 and December 2011, 62 patients underwent MoM THA with a large femoral head (Magnum group) and 57 patients an MoM THA with a conventional femoral head (conventional group). Clinical outcome was assessed using the Harris Hip score, University of California, Los Angeles (UCLA) activity score and EuroQol-5D (EQ-5D). Blood metal ion levels were measured and MRI scans were analyzed at a minimum of five years postoperatively.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_4 | Pages 15 - 15
1 Feb 2017
Higashi H Kaneyama R Shiratsuchi H Oinuma K Miura Y Tamaki T Jonishi K Yoshii H
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Objective

In a cruciate retaining total knee arthroplasty (CR-TKA) for patients with flexion contracture, to ensure that an extension gap is of sufficient size to install an implant, the amount of distal femur bone resection needed is frequently larger in a patient with knee flexion contracture than in one without contracture. In this study, we compared the distal femur bone resection amount, the component-secured extension gap margin value, and the range of motion at 6 months after surgery between patients with knee flexion contracture and those without knee flexion contracture.

Method

We examined 51 joints including 27 joints in patients with preoperative extension limitation of less than 5 degrees (the F0 group) and 24 joints in patients with limitation of 15 degrees or larger (up to 33 degrees; the FC group) who underwent CR-TKA with LCS RP (DePuy Synthes) between May 2013 and April 2014. In case with an extension gap 3 mm or smaller than the flexion gap after initial bone resection, we released posterior capsule adequately, trying to minimize the distal femur additional bone resection amount as possible. With installation of a femoral trial, the component gaps were measured using spacer blocks. The measured parameters included the intraoperative bone resection length, gap difference (FG − EG, i.e., difference between the flexion gap [FG] and extension gap [EG]), and range of motion 6 months after surgery.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_10 | Pages 66 - 66
1 May 2016
Takayama S Oinuma K Miura Y Tamaki T Jonishi K Yoshii H Shiratsuchi H
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Objective

While the short-stem design is not a new concept, interest has risen with increasing utilization of less invasive techniques. Especially, short stems are easier to insert through the direct anterior approach. In the radiographic evaluation of patients who underwent primary uncemented total hip arthroplasty (THA) using a TaperLoc Microplasty femoral component (Biomet, Warsaw, IN, USA), cortical hypertrophy was occasionally detected on three-month postoperative radiographs. The purpose of this study was to evaluate the radiographic changes associated with cortical hypertrophy of the femur three months postoperatively.

Methods

Between May 2010 and September 2014, 645 hips in 519 patients who received the TaperLoc Microplasty stem were evaluated. Six hips in four patients were lost to follow-up. Finally, 639 hips in 515 patients were included in this study; 248 hips underwent bilateral simultaneous THA and 391 hips underwent unilateral THA. There were 103 males and 412 females (average age, 63 ± 10.1 years; average height, 156 ± 8.13 cm; and average weight, 58 ± 12.2 kg). The postoperative radiographs immediately taken after the operation and three months postoperatively were compared. We evaluated cortical hypertrophy around the stem. Cortical hypertrophy >2 mm on anterior-posterior X-ray was defined as “excessive periosteal reaction” (Figure 1).


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_10 | Pages 71 - 71
1 May 2016
Tamaki T Miura Y Oinuma K Higashi H Kaneyama R Shiratsuchi H
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Background

Pre-operative autologous blood donation is recommended as a means of reducing the need for allogeneic transfusion before simultaneous bilateral total hip arthroplasty (THA). However, there have been few reports on the optimal amount of autologous donation for this procedure. In this study we sought to determine the amount of autologous blood required for patient undergoing simultaneous bilateral THA using the direct anterior approach.

Methods

We retrospectively enrolled 325 consecutive patients (650 hips) underwent simultaneous bilateral primary THA from January 2012 to June 2014. Thirty-three patients were men and 290 patients were women. The patients’ mean age at THA was 59.1 years. All THAs were performed using the direct anterior approach. Intraoperative blood salvage was applied for all patients and postoperative blood salvage was not applied for any patients.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_8 | Pages 76 - 76
1 May 2016
Kaneyama R Higashi H Shiratsuchi H Oinuma K Miura Y Tamaki T
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Introduction

The conventional bone resection technique in TKA is recognized as less accurate than computer-assisted surgery (CAS) and patient-matched instrumentation (PMI). However, these systems are not available to all surgeons performing TKAs. Furthermore, it was recently reported that PMI accuracy is not always better than that of the conventional bone resection technique. As such, most surgeons use the conventional technique for distal femur and proximal tibia resection, and efforts to improve bone resection accuracy with conventional technique are necessary. Here, we examined intraoperative X-rays after bone resection of the distal femur and proximal tibia with conventional bone resection technique. If the cutting angle was not good and the difference from preoperative planning was over 3º, we considered re-cutting the bone to correct the angle.

Methods

We investigated 117 knees in this study. The cutting angle of the distal femur was preoperatively determined by whole-length femoral X-ray. The conventional technique with an intramedullary guide system was used for distal femoral perpendicular resection to the mechanical axis. Proximal tibial cutting was performed perpendicular to the tibial shaft with an extramedullary guide system. The cutting angles of the distal femur and proximal tibia were estimated by intraoperative X-ray with the lower limb in extension position. When the cutting angle was over 3º different from the preoperatively planned angle, re-cutting of distal femur or proximal tibia was considered.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_8 | Pages 38 - 38
1 May 2016
Higashi H Kaneyama R Shiratsuchi H Oinuma K Miura Y Tamaki T Jonishi K Yoshii H
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Objective

In Total Knee Arthroplasty (TKA), it is important to adjust the difference of the flexion-extension gap (gap difference) to get the good range of motion and the sufficient stability. However the effect of the gap adjustment on the post-operative knee flexion angle(KFA) is unknown. We investigated the relationship between the gap difference and the postoperative KFA improvement rate.

Methods

179 knees that underwent LCS RP TKA were investigated more than 6 months after surgery(Feb/2013∼Sep/2014). The patients were 49 men and 130 women, of average age 70.6 years (50∼88) and BMI 26.3 (17.0∼55.2). Among them, 175 knees were knee osteoarthritis and 2 joints were rheumatoid arthritis, 2 joints were avascular necrosis. The extension gap was typically prepared with a measured resection, and a small temporary flexion bone gap was prepared with a 4mm resection of the femoral posterior condyle using the pre-cut method(fig 1). Then we measured the gaps under the installation of the Pre-cut Trial(PT; Kaneyama 2011)by the off-set spacer with 1mm increments in patella reduction position(fig 2,3). The final amount of bone resection was determined by comparison of the measured gaps and gaps required for implantation. We calculated the differences between the final extension gap and the final flexion gap and their relationship with knee flexion angles at 6 months postoperatively were analyzed.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_10 | Pages 70 - 70
1 May 2016
Tamaki T Oinuma K Miura Y Kaneyama R Higashi H Shiratsuchi H
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Introduction

Acetabular osteotomy is considered to be an alternative treatment for acetabular dysplasia, particularly in adolescents and young adults because the long-term results of total hip arthroplasty (THA) in such patients remain controversial. To our knowledge, few reports have described the relationship between the types of osteotomies and surgical difficulty. We compared the operative and clinical results of THA following the 3 main types of acetabular osteotomies, including Chiari osteotomy, rotational periacetabular osteotomy (RAO), and shelf acetabuloplasty.

Methods

Operative records of 13 hips following Chiari osteotomy (Chiari group), 22 hips following RAO (RAO group), and 16 hips following shelf acetabuloplasty (Shelf group) were retrospectively reviewed. Operative records of 2475 primary THAs without previous osteotomies during the same period were reviewed as a control. The direct anterior approach was used for all hips


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_9 | Pages 47 - 47
1 May 2016
Miura Y Oinuma K Tamaki T Kaneyama R Higashi H Shiratsuchi H
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Introduction

Total hip arthroplasty (THA) is becoming a common procedure because it dramatically relieves the patient's pain. Accordingly, young patients who hope to take THAs are also increasing. The results of THAs in the young patients have historically shown relatively poor survivorship. However several improvements of components may promise good long term results in active young patients. There was no consensus about the appropriate time for performing THA. The purpose of this study is to review the results of THAs younger than 40 years.

Material and methods

A retrospective review of 14 primary THAs in 12 patients was conducted. The mean age was 27.0 (range 17–30). Ten were female (83%) and 2 were male (17%). The average follow –up period was 38.3 months (range 18–64). All operations were performed using direct anterior approach (DAA). All patients were allowed full weight bearing as tolerated in the immediate postoperative periods. All were cementless THA and the articulation bearing were ceramic/ceramic in 5 hips (33.3%), metal/highly cross linked polyethylene in 8 hips (53.3%), and ceramic/ highly cross linked polyethylene in 2 hips (13.3%). All patients were followed clinically and radiographically. Patients were evaluated at 4,6,12 weeks and each year postoperatively. Patients were allowed sports at 3 months postoperatively without limitations.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_9 | Pages 98 - 98
1 May 2016
Oinuma K Tamaki T Kaneyama R Higashi H Miura Y Shiratsuchi H
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Introduction

Bulk bone grafting is commonly used in total hip arthroplasty (THA) for developmental dysplasia. However, it is a technically demanding surgery with several critical issues, including graft resorption, graft collapse, and cup loosening. The purpose of this study is to describe our new bone grafting technique and review the radiographic and clinical results.

Patients and Methods

We retrospectively reviewed 105 hips in 89 patients who had undergone covered bone grafting (CBG) in total hip arthroplasty for developmental dysplasia. We excluded patients who had any previous surgeries or underwent THA with a femoral shortening osteotomy. According to the Crowe classification, 6 hips were classified as group I, 39 as group II, 40 as group III, and 20 as group IV. Follow-up was at a mean of 4.1 (1 ∼ 6.9) years. The surgery was performed using the direct anterior approach. The acetabulum was reamed as close to the original acetabulum as possible. The pressfit cementless cup was impacted into the original acetabulum. After pressfit fixation of the cup was achieved, several screws were used to reinforce the fixation. Indicating factor for using CBG was a large defect where the acetabular roof angle was more than 45 degrees and the uncovered cup was more than 2 cm (Fig.1). The superior defect of the acetabulum was packed with a sufficient amount of morselized bone using bone dust from the acetabular reamers. Then, the grafted morselized bone was covered with a bone plate from the femoral head. The bone plate was fixed with one screw to compact the morselized bone graft. The patient was allowed to walk bearing full weight immediately after surgery. We measured the height of the hip center from the teardrop line and the pelvic height on anteroposterior roentgenograms of the pelvis and calculated the ratio of the hip center to the pelvic height. We defined the anatomical hip center as the height of the center less than 15 % of the pelvic height, which was nearly equal to 30 mm, because the mean pelvic height was 210 mm.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_4 | Pages 56 - 56
1 Jan 2016
Tamaki T Oinuma K Miura Y Higashi H Kaneyama R Shiratsuchi H
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Background

In total hip arthroplasty (THA), the importance of preserving muscle is widely recognized. It is important to preserve the short external rotator muscles because they contribute to joint stability and prevent postoperative dislocation. However, despite careful capsular release and femoral rasping, damage to the short external rotator muscles may occur. The Optymis Shot Stem preserves more bone and surrounding tissue than does a traditional primary stem. We investigated the usefulness of the stem in terms of the extent of preservation of the tendon attachment on the greater trochanter.

Method

In this study, we enrolled 31 consecutive patients (39 hips; 6 males, 25 females) who underwent THA. Simultaneous bilateral THA was performed in 8 patients. The patients’ mean age was 56.1 years. Diagnoses included developmental dysplasia in 35 hips (Crowe group 1: 31 hips, group 2: 4 hips), and sequel of Perthes disease in 4 hips. All THAs were performed via the direct anterior approach without traction tables. The femoral procedure was performed with the hip hyperextended, and posterior capsular release was performed if the femoral procedure became technically difficult. We compared the following among patients: the operative time, intraoperative blood loss, length of hospital stay, rate of posterior capsular release, postoperative radiographic findings, WOMAC score before and after surgery, and any complications.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_2 | Pages 90 - 90
1 Jan 2016
Kaneyama R Shiratsuchi H Oinuma K Higashi H Miura Y Tamaki T
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Introduction

A small medial extension gap (EG) needs posterior soft tissue release to avoid undesirable additional resection of the distal femur in total knee arthroplasty (TKA). However, the effect of this procedure on the EG is not always sufficient because the EG is influenced not only by the posterior soft tissue but also by the medial collateral ligament (MCL). We hypothesize that contracture of the posterior capsule prevents full elongation of the MCL in extension and we investigated the efficacy of posteromedial vertical capsulotomy (PMVC) on the medial EG which separate MCL from the posterior capsule (Fig. 1).

Materials and Methods

The PMVC was performed on 128 knees in which the medial extension gap was considered too small. The EG was initially created with a standard femoral distal cut and tibial cut. To estimate the gaps more precisely before flexion gap (FG) adjustment at the final step of the surgery, we performed a 4 mm precut of the posterior femoral condyle and measured the gaps with the patella reduced after setting a precut trial component that had a usual distal part and 4 mm thick posterior part of the femoral component. This situation was the same as after setting the usual femoral trial component by using the measured resection technique with preservation of the posterior cruciate ligament (PCL) (Fig. 2). The semimembranosus tendon was not released in any cases.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_3 | Pages 43 - 43
1 Jan 2016
Miura Y Oinuma K Tamaki T Kaneyama R Higashi H Shiratsuchi H
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Introduction

Total hip arthroplasty (THA) using short design stem is surging with increasing movement of minimally invasive techniques. Short stems are easier to insert through small incisions preserving muscles. We have used these types of short stems since 2010. Almost all of the patients have shown good clinical results. However, two patients developed fatigue fractures on femurs post operatively. We have reviewed the clinical and radiographic results of these patients.

Patients and methods

From April 2010, we have performed 621 THAs with short design stems, MicroplastyR, Biomet, using a muscle preservation approach, the Direct Anterior Approach (DAA). The age ranged from 31 to 88 years old.

Case1: 56y.o. male, BMI 23.1kg/m2. Preoperative diagnosis was bilateral osteoarthritis. Simultaneous THAs were performed on bilateral hips. He was allowed to bear as much weight as he could tolerate using an assistive device immediately after surgery, and followed standard hip precautions for the first 3 weeks. He was discharged from hospital seven days after surgery and returned to his job two weeks after surgery. He noticed sudden left thigh pain three weeks after surgery without any obvious cause. Crutches were recommended to partially bear his weight. Six weeks after surgery, a fracture line became visible on the radiographs and new callus formation also became visible. Three months after surgery, he felt no pain and was able to walk without any crutches.

Case2: 66y.o. female, BMI 27.5 kg/m2. Preoperative diagnosis was bilateral osteoarthritis. THAs were performed on the hips at a six month interval. The right hip was operated on first, followed by the left hip. She was discharged from hospital four days after surgery and returned to her job six weeks after surgery. Two months later after left hip surgery, she suddenly felt pain on her left femur without any obvious cause, and was unable to walk. Three weeks later, X-rays showed fatigue fracture lines and new callus formations. After two or three months using crutches, her pain improved and X-rays showed good callus formation and no stem subsidence.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_4 | Pages 57 - 57
1 Jan 2016
Tamaki T Matsumoto K Oinuma K Miura Y Higashi H Kaneyama R Shiratsuchi H
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Background

In total hip arthroplasty (THA), the importance of preserving muscles is widely recognized; therefore, muscle-sparing approaches are widely used. Recently, we reported that there are bony impressions, that we called the obturator attachment (OA), on the greater trochanter that indicate the insertions of the short external rotator tendons. In this study, we used a three-dimensional (3-D) template to evaluate damage to the insertions of the short external rotator muscles during a femoral procedure.

Methods

We investigated 12 hips in 10 patients who underwent THA. Preoperative CT imaging of the hip was performed, and 3-D reconstruction of the greater trochanter was used to visualize the bony impressions that indicate the insertions of the obturator internus and externus muscles (Fig 1A). We performed preoperative 3-D templating of two different femoral prosthesis (flat tapered-wedge stem: J-Taper, cylindrical straight stem: PerFix910) and then evaluated the extent of damage to the OA during the stem placement (Fig 1B, 1C). The extent of damage to the OA was classified using the following scale: grade 0, no damage of the insertion area; grade 1, less than 1/3; grade 2, equal to or more than 1/3–2/3; grade 3, equal to or more than 2/3; grade 4, complete.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_3 | Pages 30 - 30
1 Jan 2016
Matsumoto K Tamaki T Miura Y Oinuma K Shiratsuchi H
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Background

In total hip arthroplasty (THA), preservation of the short external rotator muscles are considered to be important because they contribute to joint stability and prevent postoperative dislocation. Recently, we reported that there are bony impressions on the greater trochanter that indicate the insertions of the short external rotator tendons. In this study, we reported a method to visualize the bony impressions using preoperative CT images, and evaluate the reliability and accuracy of this method.

Methods

Thirty-three hips from 24 consecutive patients undergoing THA were enrolled. The mean age was 65.3 years. Preoperative diagnoses included hip osteoarthritis in 27 hips, rheumatoid arthritis in 4 hips, idiopathic osteonecrosis in 1 hip, femoral neck fracture in 1 hip. Preoperative CT of the hip region was obtained and three-dimensional (3D) reconstruction of the greater trochanter was performed to visualize the bony impressions, that we called the obturator tendon attachment (OTA), indicating the attachment area of the obturator internus and externus muscles.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_2 | Pages 84 - 84
1 Jan 2016
Jonishi K Kaneyama R Higashi H Oinuma K Shiratsuchi H
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Introduction

Incorrect restoration of the joint line during total knee arthroplasty (TKA) can result in joint instability, anterior knee pain, limited range of motion, and joint stiffness. Although restoration of the correct joint line (i.e., creating an optimal gap in extension and flexion) should be considered in all TKA procedures, no surgical techniques have been established for restoring it. We performed the femoral posterior condylar precut technique (Kaneyama R. Bone Joint Res. 2014; 3) in 91 TKA cases and evaluated the joint line by measuring the thickness of the surgically removed femoral bone and femoral components.

Methods

A total of 91 knees in 73 patients who underwent primary TKA between June and December 2013 were reviewed retrospectively. The posterior cruciate ligament was preserved in all patients. First, in the femoral posterior condylar precut technique, the extension gap was created by the measured resection technique. Then we created a temporary gap in flexion 4 mm smaller than that created by the measured resection technique and remove posterior osteophytes and soft tissue for good ligament balance. Once the component gap was determined, final femoral posterior condyle cutting was performed to create an optimal gap and rotation. We evaluated the joint line from the differences in thickness between the surgically removed femoral bone and femoral components, and revised the thickness of the bone saw accordingly. The value was positive when the joint line had been raised and negative when it had been lowered.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_2 | Pages 39 - 39
1 Jan 2016
Higashi H Kaneyama R Shiratsuchi H Oinuma K Miura Y Tamaki T Jonishi K Yoshii H Lee K
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(Introduction)

In Total Knee Arthroplasty (TKA), closed drains have been conventionally used to prevent hematoma. Recently reported “no-drain” methods have been demonstrated to be safe and effective, especially for decreasing hemorrhage. However, there has been no report of a major study on a no-drain method in simultaneous bilateral TKA, only a few small studies. Therefore, this study evaluated the efficacy of no-drain placement in simultaneous bilateral TKA.

(Methods)

Our study included 75 patients (150joints) with preoperative hemoglobin(Hb) level of at least 11.0 g/dl who underwent simultaneous bilateral TKA performed by the same surgeon in our department between January 2012 and December 2013.

There were 12men and 63women, of average age 70.7 ± 7.9years (mean ± SD) and BMI 25.6± 3.8 (mean ± SD). Among them 72 patients had knee osteoarthritis and 3 patients had rheumatoid arthritis. The patella was not replaced in any of the cases. TKAs were performed separately on each knee. A tourniquet was applied between the initial skin incision and the postoperative dressing, and 1000 mg of tranexamic acid was injected into each joint after wound closure.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_4 | Pages 146 - 146
1 Jan 2016
Yoshii H Oinuma K Tamaki T Jonishi K Miura Y Shiratsuchi H
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Purpose

Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) is subjective assessment of coxarthropathy and reflects the satisfaction level of the patient. Recently, the use of JHEQ as a postoperative assessment of total hip arthroplasty (THA) has become widespread. The aim of this study was to investigate the clinical outcomes of bilateral simultaneous THA through the direct anterior approach (DAA) using JHEQ.

Methods

This study included 34 patients (41 hips) who were treated with first THA at our hospital from January to March 2013 and were available for evaluation of clinical outcomes 1 year after surgery. Of these, 7 (2 males and 5 females; mean age, 54.7 years) underwent bilateral simultaneous THA (group B), and 27 (2 males and 25 females; mean age, 64.2 years) underwent unilateral THA (group U). Thirty patients were preoperatively diagnosed with hip osteoarthritis, and 4 were diagnosed with avascular necrosis of the femoral head. All patients were treated through DAA in a supine position under general anaesthesia. Items for evaluation included clinical outcomes, Japanese Orthopaedic Association Hip score (JOA score) and JHEQ.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_3 | Pages 100 - 100
1 Jan 2016
Oinuma K Tamaki T Miura Y Jonishi K Kaneyama R Shiratsuchi H
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Introduction

Bulk bone grafting of the cup is commonly used in total hip arthroplasty (THA) for developmental dysplasia. However, it carries a risk of the graft collapse in the mid-term or long-term results. The purpose of this study is to describe our new bulk bone grafting technique and review the radiographic and clinical results.

Patients and Methods

We retrospectively reviewed 85 hips in 74 patients who had undergone bulk bone grafting in total hip arthroplasty for developmental dysplasia between 2008 and 2013. We excluded patients who had any previous surgeries or performed THA with the femoral shortening osteotomy. According to the Crowe classification, 4 hips were classified as Type 1, 28 as Type 2, 35 as Type 3, and 18 as Type 4. Follow-up was at a mean of 4.0 years (1 to 6.1). The surgery was performed using the direct anterior approach on a standard surgical table. The acetabulum was reamed for as close to the original acetabulum as possible. The pressfit cementless cup was impacted into the original acetabulum. After the pressfit fixation of the cup was achieved, two or three screws were used to reinforce the fixation. The superior defect of the acetabulum was packed with sufficient amount of morselized bone graft. Then, the bulk bone was placed on the morselized bone graft and fixed with one screw. Post-operatively, there were no restrictions to movement or position. On the first day after surgery, the patient was allowed to walk with full weight-bearing. We measured the height of the hip center from the interteardrop line and the pelvic height on anteroposterior roentgenograms of the pelvis and calculated the ratio of the hip center to the pelvic height. We defined the anatomical hip center as the height of the center less than 15% of the pelvic height.


Bone & Joint Research
Vol. 3, Issue 4 | Pages 95 - 100
1 Apr 2014
Kaneyama R Otsuka M Shiratsuchi H Oinuma K Miura Y Tamaki T

Objectives

Because posterior cruciate ligament (PCL) resection makes flexion gaps wider in total knee replacement (TKR), preserving or sacrificing a PCL affects the gap equivalence; however, there are no criteria for the PCL resection that consider gap situations of each knee. This study aims to investigate gap characteristics of knees and to consider the criteria for PCL resection.

Methods

The extension and flexion gaps were measured, first with the PCL preserved and subsequently with the PCL removed (in cases in which posterior substitute components were selected). The PCL preservation or sacrifice was solely determined by the gap measurement results, without considering other functions of the PCL such as ‘roll back.’


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 97 - 97
1 Dec 2013
Kaneyama R Shiratsuchi H Oinuma K Miura Y Higashi H Tamaki T Jonishi K
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Introduction:

Total knee arthroplasty (TKA) should aim to adjust the component gap (CG) difference between extension and flexion. However, this difference cannot be measured without placement of a femoral component. The bone gap reportedly decreases in extension after component setting. In contrast, it may be possible to use the mean value of the CG difference in several patients to adjust femoral resection amount beforehand. The purpose of this study is to evaluate the technique of adjusting CG difference using the mean values with measured resection technique (MRT) in TKA.

Materials and methods:

The subjects were 222 knees (40 male knees, 182 female knees; mean age 70.4 years). To adjust the CG difference after estimation, the femoral posterior condylar pre-cut technique was used. Extension gap was created by usual bone resection; 4 mm of the femoral posterior condyle was pre-cut, and after all osteophytes and soft tissues had been treated, a pre-cut trial component (thickness of 8 mm for distal femur and 4 mm for posterior condyle without the anterior portion) was mounted, achieving the same condition as the setting of a femoral component in MRT (Fig. 1). When the posterior cruciate ligament (PCL) could be easily preserved by intraoperative gap assessments, the PCL was preserved (190 knees, 86%).


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 418 - 418
1 Dec 2013
Matsumoto K Tamaki T Miura Y Oinuma K Shiratsuchi H
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Introduction:

The lateral radiographs are useful in evaluation of the acetabular cup anteversion. However, this method was affected by variations in pelvic position and radiographic technique. In this study, we employed the ischial axis (IA) as an anatomical landmark on the lateral radiographs, and we investigated a relationship between IA and the anterior pelvic plane (APP) using three-dimensional computed tomography (3D-CT). Using these findings, we report a new method for accurate measurement of the acetabular cup anteversion on plain lateral radiographs using IA as an anatomical reference.

Materials and Methods:

At first, preoperative3D-CT images were obtained in 109 patients who underwent total hip arthroplasty. The diagnosis was osteoarthritis in all patients. The angle between the IA (defined by a line connecting the anterior edge of the greater sciatic notch and the lesser sciatic notch) and APP (defined by the bilateral anterosuperior iliac spine and the symphysis) was measured on 3D-CT (Fig. 1). Secondly, postoperative lateral radiographs were obtained at 2 weeks, 4 weeks, 12 weeks, 24 weeks, and 52 weeks after surgery in 15 patients. The angle between a line tangential to the opening of the cup and a line perpendicular to APP was measured (Fig. 2). Three methods of acetebular cup position assessment were compared: 1) the present method, 2) Woo and Morrey method, and 3) software (2D template, Kyocera) method.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 358 - 358
1 Dec 2013
Jonishi K Kaneyama R Shiratsuchi H Oinuma K Miura Y Higashi H Tamaki T
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Introduction

In posterior cruciate ligament (PCL)-preserving total knee arthroplasty (TKA), it is important to determine whether the PCL is properly functioning after surgery. As the PCL is partly damaged during the operation, we cannot rule out the possibility that excessive tension further damages the remaining PCL resulting in dysfunction or that initial functioning of the PCL is lost due to excessively low tension. However, it is normally difficult to examine whether the PCL has remained intact and is still functional after TKA. The objective of this study was to visualize knee joint flexion after TKA by MRI and evaluate the PCL based on these images.

Method

PCL-preserving TKA was performed in 41 knees using the Fine Total Knee System® (Nakashima Medical, Okayama, Japan) where a titanium component can be selected for both the femur and the tibia. We visualized knee flexion positions by MRI at 6 months after surgery and evaluated visualization or non-visualization of the PCL, the relationship between knee flexion angle and PCL elevation angle against the plane of the tibial joint vertical to the tibial axis, and the forms of PCL based on the MRI data.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 547 - 547
1 Dec 2013
Tamaki T Miura Y Oinuma K Kaneyama R Shiratsuchi H
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Background:

The direct anterior approach (DAA) is one of the muscle sparing approaches in total hip arthroplasty (THA). The advantages of the DAA-THA include low dislocation rate, quick recovery with less pain, and accurate implantation. However, complications related to the learning curve have been reported. The aim of this study was to analyze the first 100 cases of DAA-THA performed by 2 surgeons.

Methods:

The records of first 100 consecutive primary DAA-THAs performed by 2 orthopedic surgeons who have np experience of DAA-THA previously were retrospectively reviewed. All operations were performed using DAA in the supine position without the special traction table. The surgical result, the early clinical results, complications, and accuracy of prosthesis placement were investigated.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 548 - 548
1 Dec 2013
Tamaki T Nimura A Oinuma K Shiratsuchi H Iida S Akita K
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Background:

In anterior approaches for total hip arthroplasty (THA), the femoral part of the procedure requires the release of the capsule from the greater trochanter. However, it is unknown whether any other tendons of the short external rotator muscles are also damaged during capsular release procedures. The aim of this cadaveric study was to identify the bony landmarks on the greater trochanter, which indicate the individual short external rotator muscle insertions.

Methods:

Forty-four hip regions from 28 embalmed cadavers were dissected. At first, micro-computed tomography (micro-CT) images were obtained to identify bony impressions on the greater trochanter. Then, the soft tissues around the greater trochanter were removed and their insertions were identified to assess correlation with micro-CT images.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 90 - 90
1 Mar 2013
Kaneyama R Shiratsuchi H Oinuma K Miura Y Tamaki T
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Introduction

In TKA, it is important to make the equal extension and flexion gap (EG and FG) of the knee. Although, this principal concept applies to all knees, flexion contracture is known to have difficulties to achieve the equal EG and FG because of its smaller EG than usual. Whereas, it is also well known that PCL resection makes FG wider than EG, however, many surgeons recommend PCL resection in case of flection contracture because it is easy to manage during surgery, nevertheless the risk of further gap unbalance. Although, flexion contracture is not rare in TKA, the controversial problem of the PCL resection for the flexion contracture still remains even in today.

Materials and methods

To investigate this contradiction, we measured intra-operative EG and FG of the knee with 20 degree or more pre-operative flexion contracture. The gaps were measured by 3 different ways; a tension device system with 30 and 40 pound tension (group 1 and 2) and a spacer block system which had 1 mm increment thickness variation (group 3). The cases were 41, 46 and 51 knees in group 1, 2 and 3 respectively. Group 1 and 2 have overlapping in 27 knees.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 209 - 209
1 Mar 2013
Kaneyama R Shiratsuchi H Oinuma K Miura Y Tamaki T
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Introduction

Although, the total knee arthroplasty (TKA) procedure is performed to make the same extension gap (EG) and flexion gap (FG) of the knee, it is not clear how the gaps can be created equally. According to earlier reports, the gaps after bone resection (bone gaps) differ from the gaps after the trial component of the femur is set (component gaps), because of the thickness of the posterior condyle of the femoral component and the tension of the posterior capsule. The surgeon can only check the component gaps after completing the bone resection and setting the trial component and it difficult to adjust the gaps even when the acquired component gaps are inadequate. To resolve this problem, we developed a “pre-cut trial component” for use in a pre-cut technique for the femoral posterior condyle (Fig. 1). This specially made trial component allows us to check the component gaps before the final bone resection of the femur.

Materials and methods

The pre-cut trial component is composed of an 8-mm-thick usual distal part and a 4-mm-thick posterior part of the femoral component, and lacks an anterior part of the femoral component. With this pre-cut trail component, 152 knees were investigated. The EG was made by standard resection of distal femur and proximal tibia. The FG was made by a 4 mm pre-cut from the posterior condylar line of the femoral posterior condyle (Fig. 2). The rotation of the pre-cut line is initially decided by anatomical landmarks. Once all of the osteophytes are removed and the bone gaps are checked, the pre-cut trial component is attached to the femur and the component gaps are estimated with the patella reduction (Fig. 3). In our experiments, these gaps were the same as the component gaps after the usual trial component was set via the measured resection technique. Finally, the femur is completely resected according to the measurements of the component gaps with the pre-cut trial component.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 327 - 327
1 Mar 2013
Shigemura T Kishida S Iida S Oinuma K Nakamura J Harada Y
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Objectives

The purpose of the present study was to describe the long-term results of THA for ONFH in patients with SLE.

Methods

From 1994–2001, 18 cementless THAs (14 SLE patients) were included in the present study. Four hips (3 patients) were lost to follow-up. The remaining 14 hips (11 patients) were available for evaluation. The mean follow-up period was 13.1(range, 10.0–16.4) years. The follow-up rate was 77.8%. The mean age at the time of surgery was 35.2 (range, 27.4–51.0) years.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XL | Pages 128 - 128
1 Sep 2012
Oinuma K Tamaki T Kanayama R Shiratsuchi H
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Background

Short stem has potential advantages of bone and muscle preservation. Current papers demonstrate that direct anterior approach (DAA) is a significant minimally invasive muscle-sparing approach to total hip arthroplasty. Theoretically, a short length stem with a reduced lateral shoulder is the most appropriate design for DAA.

Objectives

To clarify the necessity of the standard length stem in tapered-wedge stem.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XL | Pages 188 - 188
1 Sep 2012
Tamaki T Oinuma K Kaneyama R Shiratsuchi H
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Background

Minimally invasive surgery is being widely used in the field of total hip arthroplasty (THA). The advantages of the direct anterior approach (DAA), which is used in minimally invasive surgery, include low dislocation rate, quick recovery with less pain, and accuracy of prosthesis placement. However, minimally invasive surgery can result in more complications related to the learning curve. The aim of this study was to evaluate the learning curve of DAA-THA performed by a senior resident.

Methods

Thirty-three consecutive patients (33 hips) who underwent primary THA were enrolled in this study. All operations were performed by a senior resident using DAA in the supine position without the traction table. The surgeon started using DAA exclusively for all cases of primary THA after being trained in this approach for 6 months. Operative time, intraoperative blood loss, complications, and accuracy of prosthesis placement were investigated.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XL | Pages 87 - 87
1 Sep 2012
Kaneyama R Shiratsuchi H Oinuma K Otsuka M
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Introduction

Some authors have reported that if PCL is resected, flexion gap(FG) will become wider than extension gap(EG). Sacrifice or sparing of PCL influences the equality of EG and FG. Meanwhile, measured resection technique(MRT) and gap technique(GT) has different system to adjust gap and balance. There are no criteria for choosing between CR or PS component and MRT or GT nevertheless its influences on gap and balance in TKA.

Materials and Methods

EG and FG were measured intra-operatively with PCL intact to assess the characteristics of EG and FG. EG was created ordinarily. To measure FG before the final femoral cutting with PCL intact, small temporary FG was created by a pre-cut of the femoral posterior condyle with a 4-in-1 femoral cutting guide bigger than the measured size. After removal of all osteophytes, the gaps were measured by a tension device. To compare both gaps, FG was corrected by the amount of the pre-cut. According to EG and corrected FG, a component type was selected. If there was enough FG with PCL intact, CR component was implanted and if not, PS component was selected. If necessary, soft tissue was released. Finally, the optimal size of the femoral component for adequate EG and FG was estimated and rotation of the femoral component was decided. One hundred and fifty three knees with osteoarthritis were investigated.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 110 - 110
1 Jun 2012
Kaneyama R Shiratsuchi H Oinuma K Nagamine T Miura Y Tamaki T Sha G Akada T
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Introduction

There is no criteria to select cruciate retaining (CR) or posterior substitute (PS) component in total knee arthroplasty (TKA). In this study, extension and flexion gaps were measured intra-operatively with posterior cruciate ligament (PCL) remained to reveal characteristics of the gaps. Component type selection, CR or PS, was decided intra-operatively according to the gaps in each knee.

Materials and methods

One hundred and sixty knees with osteoarthritis were investigated. Extension gap (EG) was made by resection of 8 mm distal femur and 10 mm proximal tibia. After measurement of femoral AP size, about 4 mm bigger 4-in-1 femoral cutting guide than measured size was used for pre-cut of femoral posterior condyle[Figure 1]. With this technique, flexion gap (FG) was made 4 mm smaller than usual measured resection. The gaps were measured by a tension device with 30 pounds tension and FG was corrected by the amount of pre-cut. According to the EG and corrected FG, component type was decided. Too small FG usually needed PCL resection or (and) smaller size of femoral component to make enough final FG. On the other hand, large FG needed careful consideration to sacrifice PCL for adequate final FG. In these cases, CR component was selected usually. If necessary, soft tissue was released for good ligament balance. As the final step of the surgical procedure, the size of femoral component was decided for adequate final FG. It was changeable up to 4 mm larger than measured size[Figure 2].


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 68 - 68
1 Mar 2009
oinuma K shiratsuchi H saito Y michinaga K
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Objectives: The direct anterior approach (DAA) is a distal portion of Smith-Peterson approach to the hip joint. Independent from the length of skin incision, no muscular dissection has to be done for total hip arthroplasty (THA). We have developed minimally invasive THA using DAA on the standard surgical table. The purpose of this study is to present the clinical results of 162 THAs with this approach and to know whether DAA can be safely performed on a standard surgical table.

Patients and Methods: Between August in 2004 and June in 2006, 189 primary THAs in 167 patients were performed through DAA in our hospital. We excluded patients with severe developmental dysplasia (12 hips) and with previous hip surgery (7 hips). The severity of dysplasia was graded according to the Crowe classification. We excluded Crowe type 3 or 4 osteoarthritis which requires a modified procedure to cope with the difficult anatomic situation and a different rehabilitation protocol, although it was possible to perform THA with DAA. In order to assess the recovery rate and safety of a rapid rehabilitation protocol after surgery, we also excluded patients with walking disability of uninvolved lower limb (8 hips). Thus, the results included 162 hips in 149 patients (125 women and 24 men). They were followed for at least 3 months postoperatively. The mean age was 62.6 years. The mean BMI was 23.1. The preoperative diagnosis was osteoarthritis in 142 hips, avascular necrosis of the femoral head in 11 hips, femoral neck fracture in 7 hips and rapid destructive cox-arthrosis in 2 hips. In patients with osteoarthritis, 136 hips (95.7%) are secondary to developmental dysplasia (Crowe 1: 112 hips, Crowe 2: 24 hips). Only 5 hips (5.4%) were primary osteoarthritis. The Bicontact total hip stem was used in 135 hips, the CentPilar system in 21 hips and others in 6 hips.

Results: Mean surgical time was 70.1 (range: 45 to 150) minutes. Mean operative blood loss was 368 (range: 73 to 1053) ml. Patients were able to walk over 50 meters with T-cane an average of 4.7 (1~30) days after surgery. Complications included one cup migration, one traumatic dislocation, one transient femoral nerve palsy, one heterotopic ossification and one asymptomatic stem subsidence (4 mm) in the early period postoperatively. The cup migration occurred 1 month after surgery and required re-surgery through the same incision. The radiographic analysis showed a mean cup inclination of 42.1 ± 7.1 degrees and a mean anteversion angle of 16.9 ± 4.3 degrees. The femoral component coronal alignment was within 3 degrees of neutral position in 159 hips. Varus alignment of more than 3 degrees was found in 3 hips.

Conclusion: We confirmed that the direct anterior approach was a safe and reproducible technique on the standard surgical table and allowed the prosthesis to implant correctly with no muscular dissection and no risk of denervation.