Summary Statement

The Dkk3-derived cells represent a branch of the periosteal mesenchymal lineage that produces fibrocartilage as well as regenerating the periosteal structures.

Expecting the low wear property and the longevity, since October 1998, we have been using the alumina on alumina bearing for the hip arthroplasty. Until July 2008, for dysplastic 1078 hips we have implanted the bearing couple. Among them, we evaluated 86 hips in 79 patients (male 3, female 76) with the primary arthroplasty, Spongiosa Metal II Total Hip System (GHE: ESKA implants, Lübeck, Germany/Biolox Forte^®: Ceramtec AG, Plochingen, Germany), osteoarthritis secondary to developmental dysplasia, age 60 or below, and a minimum of five years follow-up. The preoperative diagnosis included the failed pelvic and/or femoral osteotomy, avascular necrosis after DDH, dislocation, and subdislocation. The average age at the surgery was 53 (27 to 60). The average of follow-up period was 6.3 (4.6 to 9.1) years. The implants have a macro-porous structure on the surface. To set the metal shell in the intended position, the sclerotic lesion was adequately resected by the chisels and then we used the acetabulum reamers. Otherwise the sclerotic lesion would prevent the reamer to go into the suitable direction. We reamed the acetabulum until the lamina interna to use the maximum size of the metal shell (i.e. to use the liner as thick as possible) and at the same time for the medialization of the hip center. To avoid impingement, the osteophyte was resected without hesitating. We added the adductor tenotomy for 19 hips, the extensive release of the flexor tendons (including the quadriceps origin, the sartroius origin, and the gluteus maximus insertion) for three hips, and the release of the extensor insertion (the gluteus maximus) for two hips, and the release of the flexor insertion (the iliopsoas) for two hips.

The hip score was improved in all patients. The average amount of the hip score was 59 before the surgery and was 90 at the final follow-up. A positive Trendelenburg sign was observed in 53 hips (62%) before the surgery and 12 hips (14%) at the final follow-up. We had no revision, no bearing failure (alumina fracture or excessive wear), no dislocation, and no squeaking in these patients. The average inclination angle of the cup was 41 (29 to 49) degrees. The average anteversion angle of the cup was 19 (13 to 27) degrees. No patient required the revision surgery. At the final follow-up, all implants were stable. In the acetabulum, the radio-lucent line was observed in two hips (2%) (zone I). In the femur the line was observed in 13 hips (15%). All lines existed in the proximal femur. There was no cystic osteolytic lesion. The prevalence of these periprosthetic reactions was less than those in the same type implant with the polyethylene on alumina bearing.

Some authors alerted that the alumina on alumina articulation should only be applied in when the optimized implant orientation is obtained so as to prevent the impingement and dislocation. Fortunately the alignment in this study was within the safe zone. However, we must always be very careful of the joint alignment, range of motion, and the muscle tension during the surgery to avoid the bearing failure, as setting an adequate alignment and obtaining a firm uncemented fixation of the cup is relatively difficult in dysplastic hips. From this view point, Spongiosa Metal II cup suits the use of the alumina on alumina bearing especially for dysplastic hips.

We apply a hydrocolloid-gel sheet (C-12, Karayaheive, Alcare, Tokyo, Japan) for the hip arthroplasty. The sheet is a kind of wound dressing film made of the Hevea sap. The Hevea sap has been widely applied for the stoma or cosmetics (e.g. facial mask, UV protection moisturizer, hair lotion). We use it since October 2004. It applies the moist wound healing mechanism without preventing the self-wound-healing. The surgical exudate is kept under the sheet to apply the moist wound healing mechanism. The sheet had been improved originally as a wound dressing material. Because of its very strong adhesiveness, we use it also as an alternative to the epidermal suture. In our method, we do not use any epidermal suture or staples. We use an anterolateral approach making an arcate incision. After the subcutaneous tissue was sutured just like as in the case of using the epidermal sutures or staples, the sheet was attached to the skin. Both the sheet and the overlaying gauze were not changed until the removals on the tenth day after surgery.

We have applied this wound closure method for 814 primary surgeries. Among them, we evaluated 56 hips in 49 patients (three males and 46 females) (including seven patients of the simultaneous bilateral surgery) with minimum of two years follow-up. The average age at the surgery was 61 (40 to 77). The diagnosis at the surgery was dysplastic osteoarthritis for 50 hips in 45 patients, primary osteoarthritis for five patients in three hips, and rheumatoid arthritis for one hip. The uncemented implants were used for all patients. In all patients, a good wound healing was obtained. The wound dehiscence occurred in two patients, however the wound healed later by attaching the hydrocolloid-gel sheet again. The hyperplastic scar was observed in one hip.

Though Orientals have less ability of wound healing than Caucasian, a satisfactory wound healing was achieved without any epidermal suture. Comparing the conventional skin closure methods, the hydrocolloid gel sheet brought about less pain; as no removal of staples was necessary, less time and labor, less medical waste, and better wound healing. As the disadvantage, some sensitive patients might mind the smell of the exudate under the gel sheet. The wound closure method using the hydrocolloid-gel sheet was very useful for the hip arthroplasty.

“Karayahesive” is a viscoelastic film made of Karaya gum. The Karaya gum includes some polysaccarides and is exted from Karaya gum tree (Sterculia urens). It applies “Moist Wound Healing Mechanism” which has been proposed by plastic surgeons. According to this mechanism, the spontaneous wound cure can be promoted by preventing wound becoming dry, keeping a wet environment around wound, and reducing the inhibitors against wound healing. It was originally developed as a wound dressing material to use after the ordinal skin closure. We remarked its strong adhesiveness, as a modification, we use it as an alternate for epidermal suture. Since June 2006, we have been using it for 183 knees. Among them, in this study, we evaluated 158 knees in 183 (18 male, 165 female) patients with minimum of two months follow-up. The diagnosis at the surgery was osteoarthritis for 137 knees, rheumatoid arthritis for 20 knees, and aseptic necrosis of the femoral condyle for one knee. The average age at the surgery was 70.8 (40 to 84). The average of follow-up was 8.5 (two to 21) months. In all knees we used a parapatellar medial approach. Without any epidermal suture, the wound was closed by attaching Karayahesive. Before attaching Karayahesive, we made the ordinal subcutaneous suture just like as the conventional skin closure. We wipe off the blood to dry the skin. Without any epidermal suture, we attached Karayahesive to reduce the wound tension. After attaching it, we made the ordinal gauze dressing and compression bandage. No dressing change was necessary until the removal. Karayahesive was removed two weeks after the surgery, together with clot and overlaying dressings. After the removal, most patients require no additional dressing and could go into bathtub on the same day. The excellent primary wound healing was obtained in 152 knees. In six knees, the wound disrupted. However, re-attach of “Karayahesive” provided early healing of the disrupted wound successfully. Comparing the ordinal epidermal suture, the patients complained less pain at the removal and irritation after the surgery, and Karayahesive provided better wound healing. It saved time and labor as no epidermal suture and no dressing change were necessary. It saved cost of the medical waste. On the other hand, it was difficult to observe the wound; as it was concealed by clot. We had to be very careful not to miss early symptom of the infection. In conclusion, for the knee arthroplasty Karayahesive was not only very useful wound closure material but also the excellent alternate for the epidermal suture.

Our purpose was to evaluate the incidence of anterior knee pain after ACL reconstruction and the associated affecting factors.

The study assessed 50 ACL reconstructed knees: 29 males and 21 females. The age at surgery was from 14 to 39 years old, with 23.7 years old on the average. The ACL injury was unilateral in all cases, and the normal side was defined as the control. We treated chronic ACL-deficient knees by reconstruction of the ligament through a limited arthrotomy using one-third of the patellar tendon (BTB) with the Kennedy LAD as a graft. Anterior knee pain was classified into 4 group: absent, trace-mild, moderate, and severe. We evaluated the height of the patella, knee extension strength, anterior laxity, leg rotation, Lysholm score, and loss of extension. Anterior laxity and leg rotation were measured by a three-dimensional analyzer.

Ten of the fifty knees (20%) had anterior knee pain. Knee extension strength (reconstructed side/control side) was 71.1% in the cases with anterior knee pain and 84.2% in the cases without anterior knee pain. A significant difference was found between these values. Regarding leg rotation, 4 knees showed normal leg rotation (physiological screw home movement) in the cases with anterior knee pain, compared to 31 knees in the cases without anterior knee pain. There was a significant difference in the incidence of anterior knee pain between the cases with normal leg rotation and the cases without. Other factors failed to show any significant correlation. In this study, knee extension strength and leg rotation had a correlation with anterior knee pain.

We report the results of distraction osteogenesis (callotasis) for the reconstruction of extensive defects after the excision of skeletal tumours in the limbs. Bone transport was performed in ten patients (five osteosarcomas and five giant-cell tumours), shortening-distraction in three (two osteosarcomas and one Ewing’s sarcoma), and distraction osteogenesis combined with an intramedullary nail to reduce the time of external fixation in six (three osteosarcomas, two chondro-sarcomas, and one malignant fibrous histiocytoma).

The mean length of the defects after excision of the lesion was 8.4 cm. The mean external fixation index was 39.5 days/cm for the group treated by bone transport, 34.1 days/cm for the shortening-distraction group, and 24.0 days/cm for the group treated by distraction and an intramedullary nail. Functional evaluation gave excellent results in 12 patients, good in five and fair in two. There were ten complications in 19 patients, all of which were successfully treated.

We also classified reconstruction using distraction osteogenesis into five types based on the location of the defects after resection of the tumour: type 1, diaphyseal; type 2, metaphyseal; type 3, epiphyseal; type 4, subarticular reconstruction; and type 5, arthrodesis.

Our results suggest that reconstruction using distraction osteogenesis provides bone which will develop sufficient biomechanical strength and durability. It is beneficial in patients with an expectation of long-term survival and in growing children.