Synovial fluid is a liquid component which bathes articular cartilage, synovial membrane and intra-articular ligaments, and plays an important role for maintaining normal joint function. Hyaluronic acid is one of the most important components and gives viscosity to synovial fluid. This report deals with pathophysiology of synovial fluid, particularly, that of hyaluronic acid.
It has been said that molecular weight of hyaluronic acid decreases in arthritic synovial fluid. However, molecular weight of hyaluronic acid in synovial fluid can be estimated only by calculating approximately. It might be true that molecular weight of hyaluronic acid in arthritic synovial fluid is low, but it would be at most a half or one-third of that of normal synovial fluid. Author emphasized that molecular weight of hyaluronic acid is not so depolymerized as generally considered in arthritic synovial fluid. With regard to distribution of molecular weight of hyaluronic acid in synovial fluid, molecular size of hya-luronic acid less than 75×10⁴ was not found.
Stringing property and mucin clot formation, which are charateristic nature of synovial fluid, are not so important manifestations of viscosity, but that of viscoelasticity. These properties are reduced in arthritic synovial fluid. This has been considered to be caused by depolymerization of hyaluronic acid. However, this is not always true, as molecular weight of hyaluronic acid in arthritic synovail fluid is not so small as generally believed. It appeared that small amount of certain protein bound to hyaluronic acid is mainly partici-pated in manifestation of these properties.
Hyaluronic acid is produced by synovial membrane and is secreted into joint cavity. It is transferred again to synovial membrane after relatively short period and is catabolized there to some extent. Then, it is depolymerized in liver and kidney. Thereafter, it is partially excreted into urine and majority of it is excreted through expiration after being catabolized to carbon dioxide.
Hyaluronic acid offers essential environment to maintain normal function of articular cartilage. Cartilaginous degeneration would take place when metabolic mechanisms of hya-luronic acid are disturbed. In joint diseases, if one could create normal articular en-vironment by administration of exogenous hyaluronic acid, it might be possible to protect and restore joint function.

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Glycosaminoglycan peptides prepared by papain hydrolysis were obtained from osteoar-thritic and normal human femoral heads of different regions. The following results were obtained:
1. Marked depletion of keratin sulfate in the osteophytic and peripheral weight bearing areas.
2. Average length of glycanic chain was definitely elongated in the osteophytic area and increased in some extent in the peripheral weight bearing area.
3. Chondroitin-4-sulfate/chondroitin-6-sulfate ratio decreased in the central and weight bearing areas.
4 In residual original cartilage, balanced loss of matrix glycosaminoglycans, meanwhile, in regenerated matrix of the repaired cartilage regions, fragility of proteoglycan aggregation and impaired metabolic cegulation of glycanic chain in biosynthesis.

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The activity and properties of cholinesterase (ChE) of the motor endplate in human skeletal muscle were studied in isolated muscle membrane. Using acetyl-beta-methylcholine as a substrate, the ChE activity was 1.05±0.53 (μmoles/30 min/mg protein) in muscle mem-branes, and 1.59±0.054 in soluble fractions. Using butyrylcholine as a substrate, the ChE activity was 0.102±0.0102 in muscle membranes, and 0.010±0.0023 in soluble fractions. The types of ChE activity in human muscle membrane and its soluble fraction were determined by the effect of inhibitors of pseudocholinesterase and acetylcholinesterase. DFP inhibited the ChE activity of the muscle membrane by 8.0% at 10^-7M, and of the soluble fraction by 4.6% at 10^-7M. BW 284 C₅₁ completely inhibited ChE activity of the soluble fraction at 10^-5 M, while 9.5% of ChE activity of muscle membrane remained in the presence of 10^-5M BW 284 C₅₁. Thus, ChE activity of human muscle membrane and its fraction consists of more than 90% acetylcholinesterase and less than 10% pseudocholinesterase. By Sephadex G-200 chromatography, the soluble fraction of human muscle membrane was separated into three peaks of ChE, and the molecular weight of ChE isoenzymes were 655, 000, 291, 000 and 52, 000, respectively.

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Rheumatoid arthritis (RA) is a relatively common disease in Japan, and the number of cases receiving surgical treatment are gradually increasing through the progress of both operative techniques and new materials for artificial joints.
Two hundred and eighty general anaesthesias for bone and joint surgery for RA were performed during the last eight years in our hospital, and some special problems have been noticed from our experience. The clinical results and the statistical findings of the RA group are as follows.
1. Loss of body weight (44.2±8.9 kg).
2. Anemia: Decrease of hemoglobin (10.6±1.8 g/dl), and red blood cells (391±55.7×10⁴. mm^-3).
3. Ventilatory impairement were seen in RA group (36.2%).
4. ECG change were also seen in RA group(37.1%).
5. 26.9% of RA group showed the difficulties of endotracheal intubation. The frequency was six times that of the non-RA group. Atlanto-axial subluxation, temporo-mandibular ankylosis and restriction of cervical spine movement caused the difficulty of oral intubation.
6. The transient fall in systolic blood pressure occured following release of tourniquet.
7. The sudden fall in arterial pressure and/or cardiac arrest rarely occured during surgery using bone cement.
8. Side effects were seen in the cases of long-term administration of steroid, aspirin and indomethacin.
9. Preoperative blood transfusion for anemic patient was effective.
In regard to the difficulties of oro-tracheal intubation, a new method of retrogade blind naso-tracheal intubation was designed. The process of the method is the following.
Epidural anesthesia needle is inserted into the trachea through the cricothyroid membrane, and through it a guide string is threaded. As the guide string, a continuous epidural catheter reinforced with fishing gut which is introduced into the cavity of the catheter is used. The guide string passes through the vocal cords and is fished up from the nose after passing through the pharynx. The endotracheal tube is threaded over the guide string at the nose. Thus, it is able to pass into the trachea easily. The guide string is withdrawn from the nose, and the endotracheal tube is connected with the anesthesia machine.

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The degree of osteomalacia was evaluated in 23 severely handicapped children, in whom 11 patients received anticonvulsant drugs, by using microdensitometry method which had been developed by Inoue.
They were all supplemented with calcium and vitamin D, and were classified into two groups according to their mobility;in group 1 the children were unable to crawl and confined to bed;in group 2 the children could crawl but could not walk.
The five of eight parameters (MCI, ΔGSmin, ΔGSmax, Σ/GS, and ΣIGS/D) were sig-nificantly lower in group 1 than in group 2. No significant difference was found between the patients with and without anticonvulsants therapy.
These results suggest that immobilization might be one of the important factors in the bone diseases of severely handicapped children.

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Forty-seven patients with temporomandibular arthrosis during the 11-month period from July 1980 to May 1981 were studied clinically. Factors analyzed were age, sex, etiological factors, clinical symptoms, method of therapy and therapeutic results.
The patients consisted of 8 males and 39 females. The female patients represented the overwhelming majority. The largest age group was patients in their 20's with 14 cases, and followed by patients in 30's, 40's and 50's in order of frequency.
The chief complaints were pain in 28 patients (59.5%), limitation of motion in 11 (23.4%) and crepitus in TMJ in 8 patients (17.2%). The appearance of initial symptoms tended to occur in the same order as that of the chief complaints, namely, pain, limitation of motion, and crepitus in TMJ.
The interval from the first appearance of symptoms until the initial visit to the hospi-tal was from 1 to 3 months in 14 cases which was the largest group: the shortest period was 3 days and the longest period was 8 years. Before visiting our department, 18 patients (38.3%) had been treated previously at orthopedic, neurological or dental department as recorded in their past histories.
The symptoms observed during the initial examination included pain, which was seen in 89.4%, i, e., the greatest majority of cases, followed by limitation of motion in 46.0%, mandibular devitation upon opening the mouth in 25.5% and crepitus in TMJ in 19.2%. About 50% of 47 patients suffered from complications involving 2 or more symptoms.
The etiological factors included tooth malalignment, malocclusion, excessive opening of the mouth, external injury, the presence of a dental prosthesis, orthodontic treatment, or such bad habits as grinding of the teeth. The number of patients for whom no etiological factor was clearly determined was rather large.
The following methods of therapy were used either singly or in combination: drug thera-py, bite plate, occlusal equilibration, dental treatment, and etc. In only 4 patients complete relief of all symptoms were obtained but in the remaining 43 cases the symptoms were improved to the point that they did not cause a severe interference with daily activities, but some symptoms still remained, which suggests the great difficulty in diagnosing and treating temporomandibular arthrosis.

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The myo-moniter, bite plane and occlusal adjustment therapy were applied to 33 patients with temporomandibular syndrome, 7 male and 26 female patients. The therapy was considered to be effective in 28 (84.8%) out of these 33 patients, and there was a marked improvement of subjective symptoms such as pain and trismus. The therapy was highly effective against temporomandibular syndrome caused by occlusal disharmony, enabling improvement of occlusal disharmony without the risk of excessive or inappropriate grinding of teeth or denture.

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Temporomandibular syndrome is seen in the face and jaw often due to a combination of psychologic and physiologic reactions. Pain and jaw dysfunction arise from increased muscle spasm caused by occlusal disharmony as a physiologic factor.
Causes and treatments of temporomandibular syndrome were studied in 20 patients. The results suggested that interceptive and deflective occlusal contact was one of the major causes when mandible was shifted from centric position to centric occlusion. Muscle spasm could arise from the occlusal contacts and abnormality of chewing habits.
The treatments were performed by occlusal equilibration and insertion of the bite-plate on incisal tooth. Nearly all of the patients were cured by these treatments.
Drug treatments in short term resulted in almost no sufficient effects. Simple psycho-therapy had good results on the reduction of the duration of treatment

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A case of arthrosis of the jaw joint is presented. The patient was a slender, nervous woman of 42 years old. In 1967 and the subsequent years she underwent extraction of teeth 7, 7, 6 and 6 without any prosthetic treatment. It was in 1975 that she had a denture put in. In 1978 she developed dull pain with languor in the left ascending branch. In 1979 the denture was replaced with a new one. This resulted in aggravation of the pain and the development of the protruding sensation of the left mandibular angle and cheek. She visited orthopedic surgeons and otorhinologists, but with no symptomatic improvement. The area of pain was extended to the left maxillary tuberosity and the occipital region as well, together with the protruding sensation of the maxillary front teeth and the mandibular anterior teeth. In addition, there was severe stiffness of the right shoulder, causing her to consult dentists one after another. In Feb. 1980 she developed malocclusion with linguoversion of the mandibular anterior teeth.
In Oct. 1980, because of this unbearable pain she visited the outpatient clinic of a dental college. About that time she had the right shoulder sunken with pain developing in the back. No symptomatic improvement was obtained with 12 attempts at occlusal equilibration made by means of the bite raising plate followed by acupuncture anesthesia.
Then she was referred to our clinic because of convenience for ambulatory treatment.
The chief complaints at the time of the first examination was pain in the right jaw joint during opening of the mouth with tenderness in the retroauricular and buccal regions homolaterally and a sensation of heaviness in the right shoulder, which prevented her from doing household duties satisfactorily. Physical examination revealed that the maximum opening of the mouth was 4.1 cm with transposition to the left of the middle of the mandible by about 0.5 cm and slight protrusion of the right mandible. There was a denture of 876 678 replacing the missing teeth. The teeth 765 were metal-crowned and extruded downward compared to the corresponding teeth on the left. The tooth 7 suffered bucco-version during occlusion. The Yatabe-Guilford personality test revealed a personality of AC type with the desire to lead others and emotional instability. A test for rheumatoid factor was negative. X-ray examination by tomography of the jaw joints during opening and closure of the mouth and frontal view revealed abnormal levels of the left glenoid fossa and condyle head. There was a marked right-left difference in the angle of condyle path as determined by the check bite technique.
Therapeutically the occlusal curvature and dentition of the upper jaw were adjusted by modifying the metal crowns of 765. Occlusal equilibration of the mandible was achieved by repair of the denture. The results obtained were satisfactory.

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Aseptic necrosis (AN) is seen in various diseases. It may also occur during the course of collagen diseases, especially systemic lupus erythematosus (SLE). Clinical manifestation, surgical treatment and histological findings in the patients with collagen diseases (2 cases of SLE, 2 polyarteritis nodosa (PN), 6 rheumatoid arthritis (RA)) who presented AN on X-ray pictures were described. The interval between the onset of collagen diseases and that of AN was rather short in SLE and PN (2.5 years, 2.0 years respectively), but quite long in RA (13.0 years). There was no causal relationship between AN and the corti-costeroid therapy. Most commonly involved sites for AN were the femoral heads (8 cases, 11 heads), the femoral condyles and talus in order of frequency. AN seen in SLE and PN were symmetric and polyarticular, though in RA it was solitary and localized to femur. Surgical treatment was done in 8 cases and 11 sites ; 5 of total hip replacements, 2 of total knee replacements (TKR), bone peg insertion in femoral head and talus, varus osteotomy of femur, and synovectomy of hip joint. All but TKR had excellent results. The his-tological findings was characterized by necrotic cartilage and trabecula and myelofibrosis. The arteioles of synovial capsule caused hyalin degeneration, narrowing and obstruction with little an inflammatory cell infiltrate. So the inflammation was thouguht to be burn-ed-out rather than active.
These results suggested that the main pathogenesis of AN was the degenerated arte-rioles and disturbed circulation, that the corticosteroid might promote it, and that there should be more AN in RA with active vasculitis.

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Aseptic necrosis of the femoral head is considered to be an avascular necrosis of the femoral head with unknown origin and may sometimes degenerate adult hip joints. Many instances of this lesion result in arthrosis secondarily and consequently the activity of daily life are disturbed.
We have 17 cases or 23 joints of aseptic necrosis of the femoral head during 9 years from 1972 to 1980. The cause and the therapy of aseptic necrosis of the femoral head were reported in this article.
Steinberg described more than twenty causes of aseptic necrosis. In our 17 cases, 6 cases were so-called idiopathic necrosis, 5 were induced by steroid, 3 by alcohol and liver dysfunction and other 3 by femoral neck fractures.
These 17 cases or 23 joints were divided into 3 types according to the x-ray findings of collapse types at initial examination.
Fifteen joints were condense type, 7 were compression type and only one joint was saucer type. Of these 15 joints of condense type at initial examination, 9 joints became compression type within 2 years and the number of saucer type increased from one joint to four. Progression of aseptic necrosis was seen in all cases including arthroplasty. Eight joints were treated conservatively and others were treated operatively.
Based on these findings, we suggested the following therapeutic regimen according to the etiology of aseptic necrosis. Patients with so-called idiopathic necrosis of the femoral head should be treated conservatively with mainly non-weight bearing exercise and if the progression of illness was found, operation by bone-nailing and arthroplasty should be done considering patients' ages. Patients with steroid-induced aseptic necrosis might progress to articular-ankylosis more rapidly than other cases if no therapy was done, and therefore arthroplasty should be considered in earlier stages than other cases.

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Though many cases of chondrosarcoma have been reported since the first report of Phemister in 1930, there have been only ten cases of chondrosarcoma of the ribs reported in Japan. There are several ways of treatment for this disease including surgical resection, irradiation, chemotherapy. But any effective treatments have not been established yet.
Case: A 49-years-old woman was admitted because of the swelling of the left lower chest wall and abnormal shadow on chest X-ray film. Diagnosis of the chondrosarcoma. was made by local incisional biopsy. Surgical treatment couldn't be performed because of the evidence of massive metastasis to the lung. Both the irradiation therapy (Linac 6000 rads) and the chemotherapy (Adriamycin 60 mg) were unsuccessful. The patient died of aggressive metastasis to the lung and the spine four months after her first consultation.
Autopsy findings: Primary tumor was originated from the right 11 and 12 ribs. There were multiple metastatic lesions in the lung and the spine. The right lobe of the liver was markedly pressed to the left with the partial atrophy of the right lobe.

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During the past 2 years from 1980 to 1981, a total of 1154 patients with traumatic fractures were treated in 10 hospitals of the National Sanatorium. The age of these atients ranged from 3 months to 96 years old with 504 patients (43.7 per cent) between 20 to 50, 324 patients (28.1 per cent) over 60, and 127 patients (11.0 per cent) under 10 years old. There were 674 male and 480 female patients.
The site of the fracture was the spine in 309 (26.7 per cent), the femoral neck in 153 (13.3 per cent), the ankle area in 127 (11.0 per cent), the clavicle and rib in 112 (9.7 per cent), and the tibia in 90 (7.8 per cent) patients.
The major cause of the fracture was the accidental fall in 597 (51.7 per cent), the traffic accident in 195 (16.9 per cent), and the trauma during exercise in 139 (12.0 per cent) pa-tients. Seven-hundred and seven (61.3 per cent) patients were treated non-surgically, however 109 patients (75.7 per cent) with femoral neck fracture, which was most frequently seen among the elderly patients, were treated surgically. Twelve patients died during the treatment period due to secondary complications, of whom 10 were over 60 years old.

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