Patient self-reported outcome scales have recently been used to evaluate total knee arthroplasty (TKA) outcomes. Many follow-up studies have been conducted on patients undergoing TKA; however, they have mostly reported outcomes after unilateral TKA. We believe that a longitudinal study after bilateral TKA will be more useful in evaluating the quality of life (QOL) of such patients. The objective of this study was to longitudinally evaluate QOL using the Japanese Knee Osteoarthritis Measure (JKOM). Objective outcomes were assessed using the Knee Society Score (KSS) and the Timed Up and Go test (TUG) for more than 5 years after bilateral TKA. Furthermore, QOL and objective outcomes were compared between younger (age ≤ 80 years at the final follow-up point) and older (age > 80 years) age groups.Introduction
Objectives
The popliteus tendon is a component of the posterolateral corner of the knee, which controls the external rotation of the tibia. In our clinical practice, the femoral footprint of the popliteus tendon is occasionally excised as the bone is resected during total knee arthroplasty (TKA). Although the excision of the popliteus tendon femoral footprint could result in excessive external rotation of the tibia and may have adverse effects on the long-term outcomes of TKA, little attention has been paid to the popliteus tendon femoral footprint during TKA. The purpose of the present study is to assess the frequency of the excision and its associated risk factors. One hundred eleven knees of 90 patients with varus knee osteoarthritis who underwent primary TKA were included in the present study. There were 13 males and 77 females, and their average age was 74 years. The NexGen knee replacement system (Zimmer, Warsaw, IN, USA) was used in all cases. The excision of the popliteus tendon femoral footprint was intraoperatively evaluated, and the patients were divided into three groups depending on the status of the femoral footprint, i.e., the preserved, partially excised, and completely excised groups. The thickness of the distal femoral osteotomy, femoral component size, and background data including height, body weight, gender, and age were compared among these groups. Analysis of variance followed by Student–Newman–Keuls test were used to compare the continuous values and ordinal scales. Gender was compared using Fisher's exact test and residual analysis. Statistical significance was set at p < 0.05.Introduction
Methods
Precise implant matching with a resected bony surface is a crucial issue to ensure a successful total knee arthroplasty (TKA). Extremely undersized or oversized components should be avoided. Therefore, we should measure the exact anthropometric data of the resected bony surface preoperatively or intraoperatively. The purpose of this study was to intraoperatively analyze the exact anthropometric proximal tibial data of Japanese patients undergoing TKA and correlate these measurements to the dimensions of current prosthetic systems. Three hundred and seventy-three knees in 299 Japanese patients were included in this study. There were 246 women and 53 men with a mean age of 74 (range: 63–85) years. All TKAs were performed by 3 senior surgeons (TS, AK, and NM). The bone cut in the proximal tibia was made perpendicular to the longitudinal axis of the tibia in the frontal plane. Intraoperative measurements of the proximal tibial cut surface were taken after proximal tibial preparation. Akagi's line (center of the posterior cruciate ligament tibial insertion to the medial border of the patellar tendon attachment) was adopted as the anteroposterior axis line of the proximal tibia. A mediolateral (ML) line was drawn perpendicular to Akagi's line. Then, anteroposterior (AP), lateral anteroposterior (lAP), and medial anteroposterior (mAP) lines were drawn as shown in Figure 1.Introduction
Patients and Methods
Various methods to manage medial tibial defects in primary total knee arthroplasty (TKA) have been described. According to Vail TP, metal augmentation is usually indicated for defect depth of >10 mm of the medial tibial plateau. The outcomes of metal augmentation have been described as excellent. Nevertheless, we believe that it is mandatory to preserve as much of the bone as possible for future revision surgeries. Therefore, we performed autologous impaction bone grafting even for large bone defects (defect depth of ≥10 mm) in primary TKA. The objectives of this study are to describe our bone grafting technique in detail and to assess the radiological outcomes of the grafted bone. Between 2003 and 2011, 26 TKAs with autologous impaction bone grafting for ≥10 mm medial tibial defects were performed. The preoperative diagnoses were osteoarthritis in 17 knees, rheumatoid arthritis in 2 knees, osteonecrosis of the medial tibial condyle in 6 knees, and Charcot's joint in 1 knee. The average mediolateral width and depth of the medial tibial defects, measured after the horizontal osteotomy of the tibial articular surface, were 17.8 mm (range, 10–25 mm) and 12.0 mm (range, 10–23 mm), respectively. The average patient age at surgery was 73.2 years (range, 56–85 years). The patients were followed up for an average of 55 months (range 27–109 months). Bone grafting technique: Multiple drill holes (white arrow) were made on the floor of the defect (A) and a morselized cancellous bone was impacted using the grip end of a metal hammer (white asterisk) and firm manual pressure to fill the defect. Thus, the firm impaction prevented bone cement from entering the space between the graft and the tibial host bed. An assistant's index finger (black asterisk) was used as a bank (B). The tibial component was fixed on the grafted bone (white asterisk) with bone cement (C). Internal fixation devices were not required, and stem extension was used in only Charcot's joint (defect depth=23 mm). Aftertreatment was the same as that for the usual TKAs without bone defects.Introduction
Methods
We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used. During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations. External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery.
We investigated the use of hypoxia-inducible factor (HIF) proteins as prognostic markers in chondrosarcoma and the relationship of HIF to the biological characteristics of cartilage tumours. The expression of HIF-1α, HIF-2α, proliferating cell nuclear antigen (PCNA) and microvessel density (MVD) were measured immunohistochemically in 29 specimens of cartilage tumour. There was no HIF-1α and HIF-2α staining in any of the nine benign cartilage tumours. In 20 specimens of chondrosarcoma, the rate of HIF-1α and HIF-2α expression was 40% and 25%, respectively. The tumour size (≥ 8 cm), histological grade (grade 2 and grade 3) surgical margin (marginal and intralesional) and HIF-1α expression (positive) correlated significantly with a shorter disease-free survival. There was a significant association between HIF-1α and the MVD and a strong trend towards a correlation between HIF-1α and the PCNA index or histological grade. Our findings suggest that HIF-1α protein may be a useful objective marker in the assessment of the prognosis in chondrosarcoma, since it plays an important role in tumour angiogenesis and cell proliferation.
We assessed the usefulness of vascularized bone transfer for treatment of aggressive musculoskeletal tumours. Classification by reconstruction method with vascularized bone transfer of our 33 patients was made into five types: 1) intercalary type in 6 cases, 2) arthrodesis type in 5 cases, 3) arthroplasty type using fibular head in 8 cases, 4) hybrid type with recycling autograft as heat treated bone or irradiated bone in 4 cases, and 5) inlay type after curettage of benign tumour chiefly for femoral head and/or neck in 10 cases. From October 1975 to December 1999, 33 patients composed of 18 males and 15 females with age ranging from 9 to 69 years (average of 30 years) received vascularized bone transfer. There were 28 cases of bone tumour and 5 cases of soft tissue tumour. In 31 cases we grafted the fibula of 8 to 20 cm in size and in 2 cases the ileum of 8 cm in size. Postoperative follow-up period ranged from 10 months to 15 years with average of 65 months. Primary union was achieved in 31 cases postoperatively between 1.5 month and 4 months with average of 3 months. As complication, we observed fracture of the graft in 4 cases and local recurrence in 3 cases. Postoperative functional evaluation ranged from 33.3% to 96.7% with average of 76.7%. As for oncological therapeutic results, continuous disease free cases accounted for 27, case of no evidence of disease for 1, case alive with disease for 1, and cases of death of disease for 4. Intercalary transfer of vascularized bone is best indicated for defect of long bone. Arthrodesis was performed in only one knee joint where reconstruction with prosthesis is usually indicated. In arthroplasty type, remodeling of fibular head was observed. In hybrid type, rapid bone union and low complication rate can be expected when compared to recycling autograft alone. In inlay type, femoral head necrosis even after wide curettage can be prevented.
