藤田 順之

OBJECTIVES: Whether to resurface the patella in total knee arthroplasty for patients with rheumatoid arthritis remains controversial. This study evaluated long-term clinical and radiographic outcomes after total knee arthroplasty without patellar resurfacing. METHODS: Of 100 knees in 74 patients who underwent total knee arthroplasty without patellar resurfacing, 64 knees in 49 patients were available for follow-up (mean, 13.6 years). Clinical evaluations included the presence of anterior knee pain at final follow-up, Knee Society Score, Knee Society Functional Score and Kujala score. Plain radiographic evaluations assessed patellar thinning and its relationship with clinical outcomes. We also compared outcomes between remission and non-remission groups based on Disease Activity Score in 28 joints using C-reactive protein at final follow-up. RESULTS: The incidence of anterior knee pain was 9.3%. At follow-up, Knee Society Scores and Functional Scores had improved significantly (p < 0.05). Although patellar thinning progressed, it did not appear to affect clinical outcomes or incidence of anterior knee pain. Disease activity did not differ significantly between groups or by presence of anterior knee pain. CONCLUSIONS: Long-term outcomes of total knee arthroplasty without patellar resurfacing in rheumatoid arthritis were favourable, indicating that this approach is acceptable.

OBJECTIVES: Patients with lumbar spinal stenosis (LSS) exhibit significantly different scoring patterns on the visual analogue scale (VAS) chart for low back pain (LP), buttock and lower limb pain (PL), and buttock and lower limb numbness (NL). This study investigated the usefulness of these preoperative scoring patterns on the VAS chart in predicting surgical outcomes in older adults undergoing LSS surgery. METHODS: Time-course data from patients aged ≥65 years who underwent LSS surgery at two institutions were retrospectively assessed. All participants completed the Zurich Claudication Questionnaire and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, which included the VAS chart, before surgery and at 6 months and 1 year postoperatively. RESULTS: In total, 334 participants were evaluated. Patients with equal preoperative scores across all three scales showed the highest average postoperative reduction in the three VAS scores. By contrast, those with the highest preoperative VAS scores for LP or NL had the lowest reductions. Based on the multivariable analysis, the highest preoperative VAS scores for LP (relative risk: 2.1) and NL (relative risk: 2.1) were significantly associated with poor surgical improvement in older adults with LSS. CONCLUSIONS: This study demonstrated the potential clinical utility of the preoperative VAS chart in predicting surgical improvement in older patients with LSS. Patients with equal preoperative VAS scores for LP, PL, and NL were more likely to have favorable surgical outcomes, while those with the highest preoperative scores for LP or NL were at higher risk for poor outcomes.

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CASE: We report a case of a 65-year-old man attempting suicide through anterior neck stabbing with an ice pick. Computed tomography showed spinal canal penetration at C4-5 near the midline, sparing the trachea, esophagus, and major vessels. The foreign body was removed under general anesthesia; cerebrospinal fluid leakage was noted, and the wound was tightly closed with a fibrin-based sealant. No motor or sensory deficits were present preoperatively or postoperatively. CONCLUSION: This case shows that penetrating cervical spinal canal injuries may occur without neurological impairment. Careful extraction under general anesthesia, ideally with neuromonitoring, is recommended to minimize complications.

INTRODUCTION: With ongoing societal aging, the demand for regenerative medicine has increased. Recently, reports demonstrating the efficacy of knee regenerative therapies have increased, although substantial proportions of these studies involved relatively younger populations. However, in Japan, where our hospital is located, it is common for patients well beyond the WHO-defined elderly age of 65 years to present with a desire for regenerative therapy. This retrospective cohort study investigated the utility of autologous protein solution (APS) knee joint injections by comparing their effects in patients aged 80 years and older and those younger than 80 years. METHODS: From July 2021 to August 2023, we administered single APS injections into the knee joints of patients diagnosed with osteoarthritis. Clinical assessment was conducted at baseline and at one and six months post-injection. Forty-one patients (44 knees) who completed all scheduled assessments were included in this analysis. Subjects were stratified into group E (≥80 years old) or group Y (<80 years old). Clinical evaluations included assessments of joint range of motion, inflammatory biomarkers (C-reactive protein), radiographic Kellgren-Lawrence classification, MRI findings including bone marrow edema, and standardized patient-reported outcome measures (Knee Injury and Osteoarthritis Outcome Score {KOOS} and Knee Society Score {KSS}), with KSS subdomain scores normalized to a 100-point scale. RESULTS: No distinct intergroup differences were observed for knee range of motion, blood test parameters, or MRI findings. Group E had the highest scores on the KOOS activities of daily living and quality of life subscales at one month post-APS administration; both subscale scores decreased at six months post-administration, whereas these subscale scores consistently increased over time in group Y. Compared with the findings in prior research reporting the minimum clinically important difference after platelet-rich plasma administration, the findings at six months after APS administration were superior for all KOOS subscales, excluding sports, in both groups. Concerning KSS scores, most subscale scores consistently increased throughout the follow-up period in both groups, whereas the expectation subscale score tended to decrease over time, likely reflecting the evolution of expectations after surgery. CONCLUSIONS: Intra-articular APS injections demonstrated clinical efficacy in patients aged 80 years and older. When the analysis was limited to those who continued follow‑up at both one and six months after treatment, a tendency toward a shorter duration of effect was still observed, indicating the need for careful patient selection.