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Objective To evaluate the impact of spinopelvic parameters and hip contracture on change in the pelvic tilt (PT) after Total hip arthroplasty (THA). Methods One hundred patients (15 male and 85 female) who underwent THA were included in this prospective study. Radiographic data were obtained preoperatively and 1 year after THA. Radiographic parameters included sagittal anterior pelvic plane (APP), sagittal vertical axis (SVA), sacral slope (SS), pelvic inclination (PI), and lumbar lordosis angle (LL). The APP was defined as the angle between the anterior pelvic plane and the vertical plane. A positive value indicates pelvic retroversion. Postoperative changes in PT were divided into three groups: the PA group (pelvic anteversion, ΔAPP 5°), and the PT group (minimal change, ΔAPP ≤ ± 5°). The Kruskal–Wallis test and the Steel–Dwass test were used to compare the preoperative and postoperative spinopelvic parameters among the three groups. The Spearman's rank correlation coefficient was used to evaluate the correlation between ΔAPP and spinopelvic parameters. Results Minimal change in pelvic tilt was observed in 59% of patients, while pelvic anteversion was observed in 16% of patients and pelvic retroversion was observed in 25% of patients. There were no significant changes in the spinopelvic parameters, including TK, LL, SVA, LL, SS, and APP after THA. The Femoral angle (FA) was significantly decreased after THA (P

Background Postoperative pain is a significant concern of patients before surgery. Multimodal pain management is an effective method of pain control after major orthopedic surgery. Acetaminophen is the most commonly used analgesic for the management of pain. It was hypothesized that 1000 mg of intravenous acetaminophen (IA) dosed every 6 hours would significantly reduce the postoperative pain score at rest and the opioid consumption volume in patients who would undergo total hip arthroplasty (THA) when compared to a control group. Methods A single-center, prospective, open-label randomized control study was conducted. A total of 97 patients undergoing unilateral primary THA were divided into 2 groups: the study group (IA) (n = 45) and the control group (n = 52). The study group received administered IA after surgery, while the control group received only a standard pain control. Both groups received a preoperative femoral nerve block and postoperative intravenous fentanyl citrate. The primary outcome was the evaluation of the pain score at rest 24 hours after surgery. The pain score was measured using the Numerical Rating Scale. The primary outcome of this study was analyzed using generalized estimating equation. Results The IA group had a significant improvement in Numerical Rating Scale score at rest 24 hours after THA compared to the control group (−0.91, 95% confidence interval −1.56 to −0.26, P = .006), suggesting a positive effect of IA usage for pain relief. The total fentanyl citrate consumption after surgery for 24 hours was significantly lower in the IA group than those of the control group (52.07 ± 7.64 vs 57.83 ± 12.44 mg, P Conclusion Postoperative administration of IA significantly reduced the postoperative pain score and opioid consumption volume after primary THA. IA was useful as one role of multimodal pain management after THA. Level of Evidence: Level 2.

Introduction: We have developed and utilized the Gravity-guide (G-guide) as a simple manual instrument for intraoperative assessment and adjustment of stem anteversion (AV). Since 2013, we simultaneously measured stem AV using the G-guide and image-free navigation during THA procedure. The purpose of this study was to compare the measurement accuracy of the G-guide and navigation system using the postoperative CT results as a reference. Methods: In total, 59 hips in 56 patients who underwent primary THA using both the G-guide and image-free navigation system were included in the study. All patients underwent postoperative CT examination, and the femoral stem AV was assessed using a 3D image analysis system (Zed hip, LEXI, Japan). The AV angle derived from the postoperative CT image analysis was used as the reference value to assess the accuracy of the two intraoperative measurement systems. Results: The discrepancy between the G-guide and the postoperative CT-measured values averaged 5.0° ± 3.9°, while the corresponding value for the navigation system was 5.2° ± 4.1°. Acceptable accuracy with a measurement error of less than 10° was achieved in 86% and 90% of the cases for the G-guide and navigation measurements respectively. Conclusion: Consequently, it was shown that both navigation and G-guide measurements can achieve comparative accuracy and are clinically useful.

In the combined anteversion (CA) technique for total hip arthroplasty (THA) with a cementless stem, cup anteversion is strongly influenced by the native femoral anteversion. It is hypothesized that in cases with large native femoral anteversion, cup anteversion can be decreased, and anterior cup protrusion from the anterior edge of the acetabulum could occur due to the achievement of optimal CA. In this study, the accuracy of CA in THA with the CA technique using imageless navigation and the relationship between the protrusion of the anterior edge of cup and optimum CA was retrospectively evaluated. Ninety-seven patients (104 hips) who underwent primary THA by the CA technique using image-free navigation were enrolled in the study. The femoral stem was placed following the individual femoral anteversion so that the target cup anteversion could be determined following a mathematical formula (37 = femoral stem anteversion × 0.7 + cup anteversion). Results The resulting CA values effectively achieved accurate CA with 39.49 ± 5.03° postoperatively. On the other hand, anterior cup protrusion was measured by computed tomography image. A cup protrusion length of more than 3 mm was indicated for 60 cases (57.7%). All included patients were divided into two groups: Group 1 as protrusion positive and Group 2 as protrusion negative. In Group 1, preoperative femoral anteversion and postoperative stem anteversion were significantly higher, while postoperative cup anteversion was significantly lower. However, the postoperative CA value indicated no significant difference between the groups. The CA (stem-first) technique with image-free navigated THA could effectively achieve accurate CA. On the other hand, a large number of cases revealed anterior cup protrusion due to the low cup anteversion.

The purpose of the present study was to investigate the results of total hip arthroplasty (THA) using the Bicontact D stem with a minimum 10 year follow-up that focused on patients with developmental dysplasia of the hip (DDH). One hundred five patients with osteoarthritis due to DDH who underwent primary THA were included in this study. The mean final follow-up period was 12.7 ± 1.2 years (range 10–15 years). All cases were evaluated both clinically and radiographically, and Kaplan–Meier survivorship was determined as stem revision for any reason as the end point. Modified Harris hip score averaged 89.0 ± 1.1 (range 60–98) at the final follow-up. The survivorship was 99.0% (95% confidence interval 93.4–99.9%) at 15.0 years, and only one hip with a well-fixed stem required stem revision due to recurrent dislocations. Cortical hypertrophy (CH) was observed in 40 of 105 hips (38.1%), and stress shielding (SS) progressed to grade 3 or 4 in six hips (6 of 105 hips: 5.7%) during the study period. Among the six hips with progressed SS, Dorr type C proximal femoral geometry was seen in five hips. This study of 105 THAs using the Bicontact D stem that focused on DDH patients with a minimum 10 year follow-up period achieved satisfactory clinical and radiological outcomes. Dorr type C proximal femoral geometry could be considered a risk factor for progressed SS.

Background Unloading of the proximal medial femoral cortex is usually associated with an increased bone strain at the distal part of the prosthesis, which may cause distal femoral cortical hypertrophy (CH). The objective of this study was to determine the factors that may be considered a predisposition to distal femoral CH and its effect on the stress shielding (SS) or durability of the fixation of the stem. Methods A total of 240 total hip arthroplasties were performed between January 2006 and December 2016, with all hips implanted with a Bicontact stem. The minimum follow-up period was more than 2 years, and the mean follow-up period was 7.2 years. The radiographic outcome was assessed on an anteroposterior hip radiograph. CH and SS were assessed on postoperative radiographs in the Gruen zone. We defined CH that appeared in zone 3 or 5 as ‘the focal type’ and defined CH that appeared in zones 2, 3, 4, 5, and 6 as ‘the diffuse type.’ SS followed the procedures from the Engh classification. Results CH was found in 72 hips (30% of the 240 hips), the focal type was found in 23 hips (9.6% of the 240 hips), and the diffuse type was found in 49 hips (20.4% of the 240 hips). SS was found in 41 hips (17.1% of 240 hips), including 32 hips with SS, which was found after the development of CH. One hip was from the focal-type CH and 31 hips were from the diffuse-type CH. SS, which is typically found in Engh classification types 1 and 2 developed in 13 hips, and SS, which is widely seen in Engh classification types 3 and 4 developed in 19 hips. All 19 hips with progressed SS were found after the diffuse-type CH had developed. In addition, among the 19 hips with progressed SS, Dorr type A was found in 0 hips, Dorr type B in 8 hips, and Dorr type C in 11 hips. Conclusions According to the results of our radiological evaluation, development of the diffuse-type CH after total hip arthroplasty using Bicontact stems is one of the critical causes of the later development of SS and could be predicted to progress to SS. To prevent the development of the diffuse-type CH, the indication to choose a Bicontact stem for a Dorr type C with osteoporotic bone should be considered.

Purpose: The purpose of this study was to examine the accuracy of implant orientation and leg length in total hip arthroplasty (THA) with an image-free navigation system based on a comparison of the intraoperative navigation and postoperative CT evaluations. Material and Methods: A consecutive series of 111 patients (118 hips) who underwent THA using the current version of the image-free navigation system constituted the basic study population. Subsequently, a total of 101 patients (108 hips) meeting the inclusion and exclusion criteria were selected as study subjects for the analysis. THA was performed using an image-free navigation system that was capable of adjusting both the prosthetic position and leg length. Postoperative CT examination was performed for all study subjects, and the prosthetic position and leg length were measured on CT images using the image analysis software. Subsequently, the intraoperative navigation results and the corresponding values obtained from the postoperative CT measurements were compared to test the accuracy of the navigation system. Results: The average discrepancies between the intra- and postoperative assessments were 6.8°, 3.7°, and 5.7° for cup anteversion, cup inclination, and stem anteversion, respectively. The corresponding value in leg length averaged 4.1 mm. Conclusion: Average discrepancies between the intra- and postoperative measurements were less than 10° in all prosthetic alignment parameters and less than 5 mm in leg length. Intraoperative assessments with the use of the image-free navigation in THA could afford satisfactory result.

Kerboull-type acetabular support rings (KT) and allogenic bone graft were used for severe periacetabular bone loss with primary and revision total hip arthroplasty (THA). The purpose of this case–control study is to evaluate the risk factors related to poor outcomes of surgery. Sixty patients underwent primary THA and revision THA using allogenic bone graft with KT for large acetabular deficiency. These patients were retrospectively evaluated postoperatively and followed-up by radiograph. The minimum follow-up period was 4 years and averaged 7 years. A radiological failure was defined by the following criteria: 1) substantial migration defined as change in the angle of inclination of more than 5 degrees or migration of more than 5 mm, 2) breakage of the screw or device, 3) acetabular revision due to aseptic loosening. Expected risk factors were defined as female, age >75 years, body mass index (BMI) >25%, medical history of hypertension, renal failure, liver steatosis, diabetes, hyperlipidemia, cardiac infarction, smoking, American Academy of Orthopedic Surgery (AAOS) classification III or IV, bleeding>500 mL, time of surgery >3hours, high hip center-type KT, inclination of KT >45 degrees, screw angle >25 degrees, morselized bone graft, Kawanabe's classification stage 3 or 4 and revision surgery. Nineteen hips (31.6%) revealed radiological failure according to our criteria, and revision THA was performed in 2 hips (3.3%). In the statistical analysis, morselized bone graft and high hip center-type KT were identified as factors of poor outcomes of surgery.

Combined anteversion (CA) technique (stem-first procedure) is generally accepted as the optimal technique to attain an appropriate CA value in total hip arthroplasty (THA). However, cup anteversion is strongly influenced by the native femoral anteversion. Accordingly, anterior protrusion of the cup in the acetabulum might occur. The purpose of the present study is to investigate the achievement of the optimal CA while avoiding anterior cup protrusion and examine the significance of our new CA technique with cup-first procedure in hybrid THA. Seventy-nine hybrid THAs with the cup-first procedure used a CT-based navigation system for cup positioning. In the preoperative planning, cup anteversion was aimed at approximately 20°. However, in actuality, sufficient cup coverage in the original acetabulum based on individual anatomy is given priority over cup placement based on CT-based planning to ensure adequate cup coverage. The target stem anteversion was determined following Widmer’s mathematical formula (37.3 = femoral stem anteversion × 0.7 + cup anteversion). Cemented stem was inserted according to the target stem anteversion angle. Regarding the assessment of overall alignment, the calculated Widmer’s CA values during surgery and postoperative CT evaluation were 34.1° ± 6.0° (range 20.7°–51.2°) and 35.1° ± 6.7° (range 21.6°–50.7°). There were 72 hips (91.1%) within 25°–50° of CA. Cup protrusion length averaged 2.0 mm ± 2.6 mm (0–8.8 mm) in the axial view and 0.4 mm ± 1.0 mm (0–3.6 mm) in the sagittal view. Cup protrusion length of more than 5 mm was indicated in 10 hips, and no hips observed more than 10 mm. Our new CA technique (cup-first procedure) with hybrid THA was able to achieve optimal CA value while avoiding anterior cup protrusion.

In total hip arthroplasty (THA), combined anteversion (CA) is used as a parameter for assessment of overall prosthetic alignment. The purpose of this study was to comparatively examine the CA value in patients who underwent primary THA using the image-free navigation system either with a cup-first or stem-first technique. Eighty-three hips undergoing primary THA using the OrthoPilot® image-free navigation system (B. Braun-Aesculap, Tuttlingen, Germany) were included in this study. The patient population was divided into two groups depending on the procedure used: cup-first technique and stem-first technique. In the cup-first group, inclination and anteversion (AV) angles were targeted at 35–45° and 15–25°, respectively, while stem antetorsion (AT) was determined for each patient based on the amount of individual native femoral AT angle. In the stem-first group, the femur was prepared first with the target angle corresponding to the native femoral AT and the cup AV was decided considering the CA calculated with Widmer’s formula (aiming at the optimal Widmer’s CA of 37.3°). Better consistency in Widmer’s CA values was attained in the stem-first group as indicated by the smaller SD values. In the assessment of overall alignment, Widmer’s CA values were within the satisfactory range (37 ± 5°) in 41.9 and 92.3 % of the subjects in the cup-first group and the stem-first group, respectively. The stem-first technique with image-free navigated THA could effectively achieve accurate and consistent control of the CA value and thus is expected to improve the surgical outcome.

The purpose of this study was to evaluate the preoperative radiographs with cases of developmental dysplasia of the hip (DDH) leading to rotational acetabular osteotomy (RAO) or curved peri-acetabular osteotomy (CPO), and examine the frequency of femoroacetabular impingement (FAI) related bone morphology in the acetabulum and femoral head-neck junction. Twenty-four hips with hip dyaplasia who underwent CPO or RAO were included in this study. Six hips had grade 0 and eighteen hips had grade 1 OA according to the Tonnis classification. We excluded patients with moderate and severe hip osteoarthritis and major femoral head deformities. Preoperative radiograph was evaluated on sharp angle, center-edge angle, alpha angle, crossover sign and posterior wall sign. Crossover signs were revealed in 7 hips (29.2%); posterior wall signs were revealed in 16 hips (66.7%); and cam-type deformities with an alpha angle of ≥50.5˚ were observed in 19 hips (79.2%) in preoperative evaluation. As determined using the Tonnis scale, no progression of osteoarthritis was found in 16 of the 24 hips; there was a one-grade progression in 8 hips. Among the 8 hips, either positive cross-over sign or posterior sign in acetabulum, and an alpha angle of ≥50.5˚ in femur were observed in six hips with progression of osteoarthritis. The presence of cam-type deformity and acetabular retroversion in patients who underwent RAO or CPO was relatively high in preoperative radiographs, and caution should be employed during surgery in patients with DDH. There is a possibility of secondary FAI due to excessive forward coverage of the bone fragments after RAO and CPO.

Background The number of hemodialysis patients has been progressively increasing in our country. On the other hand, chronic hip arthropathy associated with long-term hemodialysis is a devastating problems affecting patients' quality of life. In our previous study, we proposed a classification system for radiological abnormalities seen in hemodialysis-related hip lesions. The purpose of the study was to propose the surgical strategy for hip disorders caused by long-term hemodialysis. Methods Patients with a history of hemodialysis for more than 10 years, 191 hip lesions in 165 consecutive patients who visited our institute due to hip symptoms. Various abnormalities were identified in 116 out of 191 hips. A retrospective assessment of the patient record and radiographs was performed for the included subjects examining the natural course of the disease process as well as the results of surgical treatment. Results Seventy-six hip lesions (69.0%) were conservatively managed at the time of the initial visit. Surgeries were performed for 75 hips (64.7%) during the study period. Among those, surgical treatment was indicated for 40 hips at the time of the initial visit. On the other hand, surgeries were performed for 35 hips during the subsequent follow-up period due to progression of the disease process. Conclusions Based on the analysis of our surgical experiences by the retrospective chart review, we have established a flowchart of the treatment strategy for chronic hip arthropathy in long-term hemodialysis patients. Study design This study is retrospective clinical study.

The aim of this study was to examine the clinical characteristics of patients who required revision and the rate of early complications after revision for metal-on-metal total hip arthroplasty (MOM THA) and metal-on-polyethylene total hip arthroplasty (MOP THA). Matched cohorts were selected by retrospective review from a single-center database of revision THAs for failed MOM and MOP THAs from 2010 to 2014. A total of 140 hips in 140 patients comprised the study population; 39 revisions were performed for failed MOM THAs (MOM group), and 101 revisions were performed for failed MOP THAs (MOP group). Data included patient demographics, reason for revision, type of revision procedure, any complication within 90 days after surgery, admission type, and discharge disposition. Primary diagnosis, time from primary THA to revision, operative time, blood loss, and length of stay were reviewed. The analysis showed the time from the index primary procedure to first revision was earlier ( P =.01) in the MOM group despite no significant intergroup differences in age, gender, primary diagnosis, or body mass index. Surgical morbidity, as indicated by operative time, blood loss, and length of stay, was lower in the MOM group. The stem was retained more often in the MOM group. There was no significant difference between the groups in overall complication rate. These findings indicate that when performed at an earlier time period before extensive soft tissue reaction to metal ions, revision following MOM THA is not associated with an increased complication rate compared with revision following MOP THA. [ Orthopedics. 2017; 40(1):e164–e169.]

Major vascular injury is one of the most devastating complications in total hip arthroplasty (THA). Risk for intraoperative vascular injury is increased when the normal vascular anatomy is distorted by previous surgery or dislocation with displacement. Therefore, an appreciation of the vascular anatomy in relation to the anticipated surgical field is critical to avoid this complication during preoperative assessment for a complicated THA.Preoperative three-dimensional (3D) CT angiography was performed for 24 complicated THAs when altered vascular anatomy around the acetabulum was suspected. When assessing the CT images, the presence of apparent proliferation of vessels close to the original acetabulum as well as a distance of10 mm from the artery to the acetabulum was deemed a potential risk factor for intraoperative vascular injury. Additionally, the relationships of clinical characteristics and the presence of these risk factors were analyzed to identify the patient population at risk.The incidence of proliferation of collateral vessels was higher in patient groups with proximal femoral migration of 5 cm or more and multiple previous surgeries prior to the index THA. Moreover, in three ankylosed hips, lateral deviation of the main vascular trunk with an artery-acetabulum distance of10 mm was identified in all cases.Preoperative 3D-CT angiography in cases of complicated THA revealed altered vascular anatomy which may increase the risk for intraoperative vascular injuries. Patient characteristics related to the risk for this complication were marked proximal femoral migration, multiple previous surgeries, and hip ankylosis. Preoperative image examination of the vascular anatomy is thought to help reduce the risk of inadvertent vascular injury in these complicated THA cases.

Proximal femoral fractures are common in elderly patients. Recently, use of regional blockade has gained popularity as a means of relieving pain among this patient population. Among the procedures, fascia iliaca compartment block (FICB) is believed to be advantageous because of its safety and efficacy.In this study fifty-six consecutive patients who sustained a proximal femoral fracture were assigned to two groups. For 31 patients in group 1, FICB was used to control pre and postoperative pain. FICB was performed by an orthopaedic resident on arrival of the patient at the hospital and in the immediate postoperative period. Systemic administration of non-steroidal anti-inflammatory drugs (NSAIDs) alone was adopted for pain control for 25 patients in group 2. The severity of pain was assessed by use of a visual analog scale (VAS).Neither blockade-associated complications nor analgesic failure were encountered among patients who underwent FICB (group 1). In this group of patients, the mean preoperative VAS scores before FICB and at 10 min and 12 h after the blockade were 91, 31, and 36 respectively, indicating significant pain reduction. The corresponding values for group 2 patients were 92, 92, and 81. In addition, postoperative pain was also successfully managed by FICB with mean VAS scores at immediate, 6-h and 12-h time points of 15, 22, and 31 respectively, whereas the corresponding values for the group 2 patients were 62, 49, and 59. Consequently, significant differences in VAS scores were demonstrated between the groups in both the pre and postoperative periods.FICB is clinically safe and efficient, providing consistent analgesic effects irrespective of the performing doctor's experience of elderly patients with proximal femoral fracture.

Synovial osteochondromatosis of the hip is a rare condition, and the surgical treatment approach for this condition requires complete removal of loose bodies combined with synovectomy. While these, procedures are generally accepted as the optimal treatment method, this is still controversial topic. Recent studies have reported that open surgical procedures remain acceptable for synovial osteochondromatosis of the hip. These procedures include the dislocation of the femoral head, and complications such as femoral head necrosis and bursitis or great trochanter non-union due to trochanteric osteotomy have been reported. The present study reports a modified technique for surgical dislocation through a Z-shaped capsular incision without trochanteric flip osteotomy for the treatment of synovial osteochondromatosis of the hip.

Various types of hip lesion associated with long-term haemodialysis have been observed. We present a new radiological classification system of haemodialysis-related hip arthropathy. In total, 103 hip lesions were analyzed in 84 patients undergoing haemodialysis for more than ten years. The hip lesions were classified into 3 types; Type I - cystic type with further subdivisions based on cyst location, Type II - arthritic type, and Type III - deformity of the femoral head. Surgery was performed on 60 hips. We believe our classification system assists decision making on behalf of these patients.

Adjustment of leg length discrepancy is an important factor influencing the outcome of total hip arthroplasty (THA). However, leg length discrepancy after THA has been reported to be associated with inferior clinical outcome in previous studies. A new version of the imageless navigation software "OrthoPilot THAplus" has been developed to assess the leg length adjustment and offset value. The clear advantage of this system is the elimination of the need for femoral pin insertion, which is associated with potential complications and additional surgical invasion.In this study, the accuracy of this newly developed system was evaluated in 50 consecutive hips implanted with primary THA. The operative results of these 50 patients were compared with those of another 50 consecutive primary THA patients operated on with the previous navigation system that was not equipped with the leg length adjustment system.After surgery, the average leg length discrepancy in the THA plus group was 0.9 mm (range -5 to 5 mm), while the corresponding value in the other group with the older software was 2.9 mm (range -13 to 20 mm), showing a significant difference.The accuracy and reproducibility of new software added to the imageless THA navigation system in achieving equalization of leg length were assessed. Comparison of the surgical results as compared with the control group performed with the conventional navigation system showed the advantage of this system over the previous system.

Rationale Total hip arthroplasty (THA) concomitant with subtrochanteric femoral shortening osteotomy for Crowe type IV dysplastic hip has been reported. However, the combination of subtrochanteric femoral osteotomy and revision THA has only been mentioned in one case report. Patient concerns A 67-year-old female had a history of congenital dislocation of both hips. Diagnoses Right hip was diagnosed the aseptic loosening of THA with extremely high replacement of the acetabular component. Interventions Revision THA concomitant with subtrochanteric femoral shortening osteotomy using a cement stem was performed. Before the revision surgery, primary THA with subtrochanteric shortening osteotomy was performed on the opposite side. Regarding leg length, the actual leg length of the affected side was 9 mm longer, and the subjective leg length discrepancy was 45 mm shorter in the affected limb due to pelvic obliquity. Subtrochanteric osteotomy was performed with an amount of osteotomy equal to the amount of distal translation of the hip center to the original acetabulum. Outcomes As a result, pelvic obliquity improved, and the subjective leg length discrepancy disappeared after revision surgery. Lessons The combination of subtrochanteric femoral shortening osteotomy with revision THA resulted in a satisfactory outcome.

The number of hemodialysis patients has progressively increased in Japan. Among the orthopedic complications in this population, chronic hip arthropathy associated with long-term hemodialysis is one of the most devastating problems. Total hip arthroplasty (THA) is often indicated. However, varying results have been reported for THA in these patients. This study was undertaken to assess the risk-benefit ratio of THA performed in patients with dialysis hip arthropathy. We evaluated 17 patients (19 hips) with dialysis hip arthropathy who underwent THA. The duration of hemodialysis before surgery ranged from 10 to 27 years. Histological examination of the tissue samples revealed accumulation of amyloid deposits in all cases. Three patients died within 2 years after operation; the remaining 14 patients (16 hips) were followed for a minimum of 3 years. The cumulative survival rate of the prostheses in these 16 hips up to the latest follow-up was 94%. Regarding surgery-related complications, deep infection occurred in one hip, and revision THA was required in one patient with recurrent dislocation and aseptic loosening. THA for dialysis hip arthropathy in long-term hemodialysis patients is associated with substantial local and general risks. Despite the substantial risk, THA for this patient population seems to afford reasonably satisfactory results.

Implant positioning is one of the critical factors that influences postoperative outcome of total hip arthroplasty (THA). Malpositioning of the implant may lead to an increased risk of postoperative complications such as prosthetic impingement, dislocation, restricted range of motion, polyethylene wear, and loosening. In 2012, the intraoperative use of smartphone technology in THA for improved accuracy of acetabular cup placement was reported. The purpose of this study was to examine the accuracy of an iPhone/iPad-guided technique in positioning the acetabular cup in THA compared with the reference values obtained from the image-free navigation system in a cadaveric experiment. Five hips of 5 embalmed whole-body cadavers were used in the study. Seven orthopedic surgeons (4 residents and 3 senior hip surgeons) participated in the study. All of the surgeons examined each of the 5 hips 3 times. The target angle was 38°/19° for operative inclination/anteversion angles, which corresponded to radiographic inclination/anteversion angles of 40°/15°. The simultaneous assessment using the navigation system showed mean±SD radiographic alignment angles of 39.4°±2.6° and 16.4°±2.6° for inclination and anteversion, respectively. Assessment of cup positioning based on Lewinnek's safe zone criteria showed all of the procedures (n=105) achieved acceptable alignment within the safe zone. A comparison of the performances by resident and senior hip surgeons showed no significant difference between the groups ( P =.74 for inclination and P =.81 for anteversion). The iPhone/iPad technique examined in this study could achieve acceptable performance in determining cup alignment in THA regardless of the surgeon's expertise. [ Orthopedics. 2016; 39(4):e621–e626.]

Thirty-six patients who underwent primary unilateral total hip arthroplasty (THA) were randomly allocated to 4 groups with different pain control protocols; continuous femoral nerve block (FNB group), single-shot caudal epidural block with morphine (EB group), intravenous patient-controlled analgesia with fentanyl (IV-PCA group), and systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs group). Postoperative pain was assessed using the numerical rating scale (NRS) scores and the analgesic effect was compared among the groups. The NRS upon arrival at the recovery room and 6 hours after surgery in the FNB, EB, and IV-PCA groups were significantly lower than that in the NSAIDs group. The amount of additional analgesics requested by the patient was smaller in the FNB, EB, and IV-PCA groups as compared to the NSAIDs group. Regarding the complications related to the analgesia, 5 of the 9 patients in the IV-PCA group complained nausea and vomiting and received antiemetic drugs. Delay in the rehabilitation process due to drowsiness was encountered in 3 patients in this group, while no patient in the FNB and EB groups suffered from delayed rehabilitation. Considering both the analgesic effect and the potential risk of complications, continuous femoral nerve blocks and caudal epidural blocks for are recommended for postoperative pain control after THA procedure.

The transverse acetabulum ligament (TAL) has been used as an intraoperative anatomical landmark to position the acetabulum cup in total hip arthroplasty (THA). However, the validity of the use of TAL has not been clarified. The purpose of this study was to examine the orientation of the cup component aligned with the TAL in cadaveric study. The 31 hips in 25 whole-body embalmed cadavers were examined. The donors were 12 men and 13 women. Simulated THA procedure using image-free navigation system was performed and a trial cup with a diameter of approximately 2 mm less than the size of the acetabulum were inserted and snugly fitted on the TAL through the posterior wall of acetabulum. The orientation of the cup component was measured using an image-free THA navigation system. The measured radiographic anteversion and inclination angles averaged 18.2±7.2° (range: 2.0-33.2°) and 43.5±4.2° (range: 33.1-51.0°) respectively. Based on the Lewinnek’s safe zone criteria, 26 hips (80.6%) were judged to be within the. Moreover, in the analysis of the gender difference of TAL angles, the average anteversion angle was shown to be significant larger in female than male population. The TAL can be effectively used an intraoperative landmark to align the acetabulum component helping reduce the risk of dislocation after surgery. In the intraoperative judgment, a gender difference in the alignment of the TAL should be taken into consideration.

In total hip arthroplasty (THA), combined anteversion (CA), the sum of cup anteversion (AV) and stem antetorsion (AT) are used as parameters to assess the appropriateness of overall prosthetic alignment. In this study, we evaluated the CA value based on the post-operative computed tomography (CT) measurements in our patient population who underwent THA using the OrthoPilotTM image-free navigation system (B/BRAUN-Aesculap, Tuttlingen, Germany). During surgery, cup alignment was adjusted with the use of the navigation system while the positioning of the femoral stem was arbitrarily adjusted by the surgeon. Seventy-nine THAs were included in the study. Post-operative CT assessment for the prosthetic alignment showed the average cup inclination and AV values to be 40.5°±4.1° and 20.6°±4.6°, respectively, demonstrating the effectiveness of the navigation system by small values of standard deviation. By contrast, the AT value measured for the stem showed wide variability (mean 23.6°±11.2°). Consequently, the resulting CA was also inconsistent (mean 44.4°±11.2°) and only 61 of the 79 THAs (77.2%) were defined as satisfactory.

We have been using an image-free total hip arthroplasty (THA) navigation system (OrthoPilot; Aesculap, Tuttlingen, Germany) to ensure accurate and reproducible acetabular cup orientation. In this study, the accuracy of this system in the assessment of acetabular cup orientation was evaluated by comparing the intraoperative inclination and anteversion angles presented by the navigation system and the corresponding postoperative values obtained by computed tomography measurement. In the intraoperative accuracy analysis, we additionally examined the influence of factors such as body mass index and soft tissue thickness on assessment error. Intraoperative and postoperative results obtained from 115 consecutive navigated THAs were compared and analyzed. In both inclination and anteversion angles, good agreement was observed; a discrepancy of more than 5° was observed in 1 and 3 cases, respectively. In the analysis of factors potentially affecting the accuracy of the intraoperative assessment, no correlation between each parameter and the intraoperative and postoperative discrepancy was demonstrated.

Multiple insufficiency fractures occurred in two patients with mutilating rheumatoid arthritis (RA), leading to substantial disabilities. Both patients received long-term oral glucocorticoid therapy and underwent multiple lower-extremity surgeries such as total hip arthroplasty (THA) or Total knee arthroplasty (TKA). The multiple fractures were located in the pelvis and lumbo-sacral region. Fractures in both patients were treated conservatively. Although bony union and resumption of activities were achieved in one patient, the other patient was not able to resume ambulation. For RA patients with combined risk factors for insufficiency fractures, aggressive preventive intervention and careful clinical assessment for early detection and management are warranted.

We have used the Orthopilot (Aesculap AG, Tuttlingen, Germany) computed tomography (CT)-free navigation system to ensure accurate and reproducible acetabular cup orientation. In this system, cup orientation is assessed with respect to bony configuration as determined by palpation of the anatomical landmarks (the bilateral anterosuperior iliac spines and the upper margin of the pubic symphysis). In this study, intraoperative cup orientation as presented by the OrthoPilot navigation system was compared with the value obtained through postoperative radiological assessment using CT Digital Imaging and Communications in Medicine (DICOM) data and Medical Image Processing, Analysis, and Visualization (MIPAV; National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland). Intra- and postoperative results obtained from 27 consecutive navigated total hip arthroplasties (THAs) were analyzed. For cup positioning, the desired inclination and anteversion angles were set within the "safe zone" proposed by Lewinnek. In the intraoperative evaluation, the mean inclination angle as determined by the navigation system was 43.5 degrees +/- 2.17 degrees (range, 39.9 degrees to 46.6 degrees ) after the final implantation. In contrast, the mean inclination angle determined by postoperative calculation using MIPAV was 44.9 +/- 3.3 degrees (range, 38.1 degrees to 55.0 degrees ). A discrepancy of5 degrees was observed in only 1 hip. For the anteversion, the mean intra- and postoperative values were 11.1 degrees +/- 5.6 degrees (range, 0 degrees to 17.8 degrees ) and 13.5 degrees +/- 5.9 degrees (range, 5.1 degrees to 21.6 degrees ), respectively. Again, a discrepancy of5 degrees was observed in 1 case. Mean differences between the intra- and postoperative values were 1.9 degrees +/- 1.9 degrees and 2.6 degrees +/- 1.6 degrees for inclination and anteversion, respectively. A good agreement between the intraoperative values presented by the navigation system and those in the postoperative CT evaluation was observed, and the validity of this navigation system was confirmed.

We have used the Orthopilot (Aesculap AG, Tuttlingen, Germany) computed tomography (CT)-free navigation system to ensure accurate and reproducible acetabular cup orientation. In this system, cup orientation is assessed with respect to bony configuration as determined by palpation of the anatomical landmarks (the bilateral anterosuperior iliac spines and the upper margin of the pubic symphysis). In this study, intraoperative cup orientation as presented by the OrthoPilot navigation system was compared with the value obtained through postoperative radiological assessment using CT Digital Imaging and Communications in Medicine (DICOM) data and Medical Image Processing, Analysis, and Visualization (MIPAV; National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland). Intra- and postoperative results obtained from 27 consecutive navigated total hip arthroplasties (THAs) were analyzed. For cup positioning, the desired inclination and anteversion angles were set within the "safe zone" proposed by Lewinnek. In the intraoperative evaluation, the mean inclination angle as determined by the navigation system was 43.5 degrees +/- 2.17 degrees (range, 39.9 degrees to 46.6 degrees ) after the final implantation. In contrast, the mean inclination angle determined by postoperative calculation using MIPAV was 44.9 +/- 3.3 degrees (range, 38.1 degrees to 55.0 degrees ). A discrepancy of >5 degrees was observed in only 1 hip. For the anteversion, the mean intra- and postoperative values were 11.1 degrees +/- 5.6 degrees (range, 0 degrees to 17.8 degrees ) and 13.5 degrees +/- 5.9 degrees (range, 5.1 degrees to 21.6 degrees ), respectively. Again, a discrepancy of >5 degrees was observed in 1 case. Mean differences between the intra- and postoperative values were 1.9 degrees +/- 1.9 degrees and 2.6 degrees +/- 1.6 degrees for inclination and anteversion, respectively. A good agreement between the intraoperative values presented by the navigation system and those in the postoperative CT evaluation was observed, and the validity of this navigation system was confirmed.

Intraosseous lipoma is a rare benign bone tumor. Removal is required when there is pain or the lesion is large enough to lead to a pathological fracture. However, conventional surgery requires non-weight-bearing for at least 6 weeks. Here, we present a case with bilateral calcaneal intraosseous lipomas successfully treated by the use of endoscopically assisted curettage.A 30-year-old female noted pain in both heels for 1 year. Radiological findings revealed well-defined lytic lesions at the neck of both calcanei. Magnetic resonance (MR) images showed hyper-intense signals on the T1 and T2 sequences. Curettage was performed through small bone fenestrations in the medial and lateral aspects under observation with a 2.7-mm-diameter Hopkins telescope. The bone void was filled with beta-tricalcium phosphate (beta-TCP). Full weight-bearing was permitted the day after the surgery.Endoscopically assisted curettage is feasible in patients with benign bone tumors of the calcanei to avoid a long period of non-weightbearing post-operatively.

エタンチオール存奪下での各種カルボニル化合物を電解反応を検討した。アントラキノンのような芳香族ケトン類の電解反応では,カ々ボニル基が還元されアントラセンおよび相当する芳香族炭化水素が得られ,ヘテロ原子を有するキノン類ではカルボニル基がはずれ,チオアルキル基が1個結合した化合物および二量化した化合物が得られた。芳香族や脂肪族ケトン,アルデヒドでの反応では相当するジチオアセタールが容易に得られた。

alpha-Galactosylceramide (alpha-GalCer) shows antitumor effects by activating natural killer (NK) cells indirectly through stimulation of the secretion of cytokines by NKT cells, whereas interleukin (IL)-18 shows antitumor effects by activating NK cells directly. In the present study, we examined the antitumor effect of the combined administration of alpha-GalCer and IL-18. An injection of NK cell-sensitive mouse B16 melanoma cells into a mouse tail vein produced pulmonary metastasis. The daily administration of alpha-GalCer or IL-18 alone for 4 days starting 1 day after the injection of B16 melanoma cells markedly suppressed the number of pulmonary metastatic foci, and their combined administration enhanced the antitumor effect compared with single administration. The antitumor effect of their combined administration was completely abolished by treatment of mice with anti-asialo GM1 serum, which depletes NK cells but not NKT cells. Combined administration of alpha-GalCer and IL-18 enhanced the cytotoxicity of NK cells and increased the number of NK cells in the lung. Analysis of NKT cell-dependent and NK cell-independent secretion of cytokines, to which NK cells can respond, showed that the administration of alpha-GalCer increased the secretion of IL-2, IL-4, interferon-gamma, IL-12, granulocyte-macrophage colony-stimulating factor, tumor necrosis factor-alpha, and IL-10, and the combined administration of alpha-GalCer and IL-18 enhanced the secretion of IL-2, IL-4, interferon-gamma, and granulocyte-macrophage colony-stimulating factor further but only slightly. These results show that IL-18 in combination with alpha-GalCer exerts an antitumor effect on NK cell-sensitive tumors primarily by the direct stimulation of NK cells by IL-18 and the indirect stimulation of NK cells by alpha-GalCer through its activation of NKT cells.

エタンチオール存奪下での各種カルボニル化合物を電解反応を検討した。アントラキノンのような芳香族ケトン類の電解反応では,カ々ボニル基が還元されアントラセンおよび相当する芳香族炭化水素が得られ,ヘテロ原子を有するキノン類ではカルボニル基がはずれ,チオアルキル基が1個結合した化合物および二量化した化合物が得られた。芳香族や脂肪族ケトン,アルデヒドでの反応では相当するジチオアセタールが容易に得られた。

Survivors of the atomic bombs of Hiroshima and Nagasaki were interviewed in this investigation to determine the effect of dental radiographic examinations on the assessment of ionizing radiation from the bombs. Diagnostic radiography is an important source of ionizing radiation exposure for populations throughout the world. More particularly, it is acting as a contaminant in the ongoing assessments of the effects of ionizing radiation from the Hiroshima and Nagasaki atomic bombs. Therefore, this extensive investigation was conducted to determine the magnitude of dental radiographic exposure. Most other large studies have dealt with the exposure of populations; this one is unique in that it focuses on the exposure individual patients receive. Interviews of 2,968 persons and records supplied by personnel of 207 hospitals and dental clinics established the frequency of and technical factors used in dental radiography. One of the findings of this investigation was that only half of the radiographic units had the filtration required by governmental regulations. The majority of dentists used intermediate rather than high-speed film. Darkrooms were a rarity, and instead, special film packets were most frequently used; processing solutions are injected into the packets, permitting instant processing in lighted areas.

A 47-year-old man underwent ceramic cup arthroplasty when he was 22 years old. Revision total hip arthroplasty was performed 25 years later because of limited range of motion without implant loosening. Histologic examination revealed that the femoral head and ceramic implant were well fixed through a thin fibrous membrane. The energy-dispersive X-ray analysis indicated that calcium and phosphorus were detected in the same peak pattern as cancellous bone in the bone-ceramic interface.

Dosimetry and biological effects of 40 and 50 keV low-energy X-rays generated by a SOFTEX Model CMBW-2 apparatus were studied. Doses were measured using a thin-window parallel-plate ionization chamber; beam quality was assessed using aluminum absorbers; exposure rates per unit current were determined according to the X-ray tube current and exposure times; and thermoluminescent (BeO chip) dosimeters were used to ascertain dose distributions in the irradiation field. The average correction factors for nonuniformity were calculated from the measured dose distributions. The means for ascertaining accurate exposures and doses using these methods are discussed. The dose-survival relationship of Chinese hamster V79 cells were assessed by irradiating them with 40 and 50 kV soft X-rays, 180 kV X-rays, and 60 Co gamma rays. Soft X-rays with three distinct effective energies were tested by changing the tube voltage kV and aluminium filter thicknesses; namely (1) 40 kV without filter, (2) 40 kV with a 0.2 mm thick aluminium filter and (3) 50 kV with a 0.7 mm thick aluminium filter. The effective energies obtained according to attenuation measurements using aluminium for these soft X-rays were 8.1, 11.7 and 18.5 kV, respectively. In this study the relative biological effectiveness (RBE) at 10 per cent survival compared with 60Co gamma rays ranged from 1.5 to 1.6. The RBE of 180 kV X-rays relative to 60Co gamma rays was 1.29. This study provided experimental data for the RBE of V79 cells in the intermediate energy range between hard and ultrasoft X-rays, data for which were previously reported by Goodhead and co-workers (1977, 1979, 1981).