This report describes the results of elbow synovectomy on 14 elbow joints in 11 patients (four males and seven females) with advanced rheumatoid arthritis. The average age at the time of the operation was 55 years, ranging from 22 to 77. According to the standard classification of RA, three elbow joints were stage II and 11 were stage III. The follow-up period after surgery averaged 2.7 years (ranging from 3 months to 5.3 years).
Pain improved in 13 out of 14 (93%). Range of motion improved in 6 elbow joints (43%), depending on direction of movement. For instance, flexion improved more than extension. On the whole, satisfactory results were obtained in 84% of the patients.
At present, treatment of advanced elbow joint in RA is difficult. Total joint replacement is a promising method of treatment, but it is still developing. Our experience in synovectomy of the elbow joint is satisfactory, and we think that it is useful as an alternative surgery for advanced elbow joint in RA.

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Since 1984, We have performed total ankle joint replacement on five patients with severely damaged ankle joints. Four of them had rheumatoid arthritis; the fifth had osteoarthritis of the ankle. The average follow-up period after surgery was 2 years, ranging from 6 months to 6 years and 3 months. This report describes the clinical results and radiological findings at the time of follow-up.
The clinical results were evaluated using the scoring system created by the Japan Orthopedic Association (highest score: 65 points). The average pre-operative and post-operative scores were 18.2 and 42.2 points, respectively, an improvement ratio of 56.6%. The greatest improvements were seen in reduction of pain and deformity and improvement in the ability to walk.
Radiological findings of sinking were observed in only one case, that which hads a follow up at 6 years and 3 months. No abnormal findings were seen in the other cases.
Previously we used joint fusion for the treatment of severely damaged ankle joints. However, our experience indicates that total ankle joint replacement produces better results in pain relief and the ability to walk. However, due to short period of follow-up in our study, careful observation is still needed before making any conclusions.

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This report describes our experience in using extensible nails for two patients with deformity of the lower limbs. The extensible nail, which was devised by Bailey in 1963, has the ability to lengthen with bone growth.
Our cases were a 5 year-old girl with deformity of the both thighs and an 8 year-old boy with deformity of the left leg. In the first case, we operated on both femurs according to the method of Bailey-Dubou. On the right side, the girl's postoperative condition proceeded well, without complication. By 9 months after surgery, the nail had lengthened favorably with her bone growth. But on the left side, the distal femur fractured spontaneously one month after surgery and the nail migrated into the knee joint. After a second operation to change the size of the nail, her condition improved. In the second case, the same operation was performed on the boy's left tibia. His postoperative condition was quite well, with no trouble or complications observed.
Theoretically, the extensible nail is useful. However, an atraumatic technique to manipulate the nail and an appropriate rehabilitation program are needed in order to obtain better results.

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Fracture or dislocation of the cervical spine often causes a severe degree of palsy. Fortunately, there exist some cases with little or no palsy of the spinal cord, in spite of fracture or dislocation of the spine. In such cases, extremely atraumatic manipulation should be taken in reducing the dislocation, so as not to aggravate the palsy.
We have experienced five such cases of fracture or dislocation of the cervical spine with little or no palsy. The purpose of this study is to describe the method and results of treatment.
Surgery (combined with both posterior and anterior approaches) was done in all cases. In four cases, posterior reduction was performed under local anesthesia, and then anterior interbody fusion with plate fixation under general anesthsia. In the fifth case, in which reduction wes obtained before operation, posterior wiring and anterior fusion without plating were performed under general anesthsia. The results of all five cases were satisfactory, with no aggravation of palsy.
Recent advances in spinal cord monitoring using electrophysiological means are revolutionary, although not yet perfect. Local anesthesia is still useful in manipulating the unstable spine to prevent further aggravation of spinal cord injury. Pain during surgery can be overcome by a detailed explanation of the situation to the patient.

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Intertrochanteric fracture is one of the most common trauma in the elderly. We treated intertrochanteric fractures with Ender nailing for several advantages, which are minimally traumatic with little blood loss and allow early weight-bearing.
We report the outcomes of 123 intertrochanteric fractures (30 males and 93 females) treated during last 10 years. The age at the surgery ranged from 51 to 93 years with a mean of 73.
The average duration of postoperative observation was 1 year and 2 months (range: 1 month-10 years). Subjective symptoms and walking ability were evaluated and X-ray assessments were carried out.
Seventy-eight out of 118 patients (66%) maintained their walking ability after surgery. Patients who started to walk within 14 days have a good result. Pain and decreased ROM of the knee were complained by 24% of the patients. The more increasing occupying ratio of nails in femoral intramedullary cavity, the less the risk such as backing out of nails, the varus deformity of femoral neck and knee troubles.

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The purpose of this study was to observe the degeneration of the intervertebral discs in experimental models of unstable cervical spines. Seventeen Japan white rabbits (8-12 weeks old), on which cervical laminectomy (from C3-C6) had been performed, were the subjects. X-P and MRI were taken at regular intervals after surgery, and histological studies were done immediately after the rabbits were killed.
Instability of the intervertebral spaces observed in X-P appeared mostly in the lower cervical spine. At the level of C6-7, displacement of the vertebral body (more than 20%) was found in 70% of the cases two months after surgery. Degeneration and herniation of the discs, detected by MRI, were later confirmed by histological studies.
The next step will be to clarify the role of each posterior element of the cervical spine in preventing instability and degeneration of the intervertebral spaces.

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This report describes three cases of sciatica due to unusual causes, which we recently experienced in our department. The final diagnosis were lumbar gas herniation, lumbar arachnoid cyst and lumbar adhesive arachnoiditis, which showed radicular pain of the lower limb caused by intra- or extradural compression of the lumbar and/or sacral nerve root.
Based on the patient's symptoms and neurological findings, ordinary examinations, for example myelogram, CT scanning and MR imaging, were perfomed, but definite diagnosis was not obtained. Therefore, nerve root infiltration and thiopenton pain study were added in the second and the third cases in order to get more positive evidence. The diagnosis was finally confirmed by surgical exploration and postoperative recovery.
Through this experience we would emphasize that a nerve root infiltration is useful in determining the involved nerve root which create lumbar radicular pain and a thiopenton pain study is also useful in assessing psychogenic involement in the symptoms.

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Between 1979 and 1989, 42 patients (63 knees) suffering from rheumatoid arthritis received total knee replacements in our department. 15 patients did not return for follow-up examinations, including 5 who died during the follow-up period. The remaining 27 patients (41 knees) were followed for an average of 4.7 years. The clinical results were evaluated using the criteria of three universities proposal.
By the end of the follow-up period, the mean knee score had improved from 34.2 points preoperatively to 60.0 points postoperatively. The incidence of postoperative complications, including loosening, patellar dislocation, infection and femoral fracture, was 24 percent. Revision surgery was necessitated by loosening (2 knees) and patellar dislocation (1 knee). In our study, the prognosis was affected markedly by the complications.

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Four patients with Kienböck's disease were treated with triscaphe arthrodesis (Watson et al., 1980) combined with silicone rubber implant or tendon replacement. The mean age of patients was 46 years old ranged from 35 to 57. Dominant hands were involved in 3 patients. The average follow-up period was 20 months with range of 6 to 32 months.
Clinical and radiological results were satisfactory and all patients returned to original occupation at the time followed up.
The results indicate that this operative procedure is the treatment of choice for the advanced stage of Kienböck's disease.

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We have experienced two patients with non Hodgkin's lymphoma in spinal epidural space. These two patients, a 62-year-old male (case 1), and a 41-year old male (case 2), manifested signs and symptoms of neurological involvement before the diagnosis of malignant lymphoma was established by tissue examination. The tumors were located in the thoracic (case 1) and lumbar regions (case 2). Laminectomy and tumor removal was followed by chemotherapy with or without radiation therapy. The primary regions in case 1 was a paraaortic lymph node and the spleen. In case 2, the primary region was the liver. The authors take a skeptical view of the existance of primary spinal epidural lymphoma, which has been reported a few times.

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Between 1973 and 1988, 11 patients with spastic cerebral palsy underwent patellar advancement operations for correction of the patella alta and knee flexion deformity. Seven of these patients had both knees operated on, so that in all, there were 18 operations. The average age at the time of operation was 21 years and 11 months and the average follow up, 7 years and 3 months.
To determine patellar height, the ratio of the articular length of the patella to height of the lower pole of the articular cartilage above the tibial plateau, is calculated from a lateral radiograph of the knee, flexed beyond 30 degrees. According to Blackburne's criteria, normal values lie between 0.54 and 1.06. In our case, the mean value at pre-operation was 1.16, and that at post-operation, 0.57.
By bringing the patella down to normal position, the leverage of the quadriceps femoris is reestablished and full extension of the knee in all patients is made possible.

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Three patients on chronic hemodialysis developed carpal tunnel syndrome were reported. The disease was found in the side of the arterio-venous fistula in one patient and the opposite side in two patients. Operations were carried out because of severe symptom. The duration of hemodialysis at the time of the operation was 12 years on an average, ranging from six years to 16 years. At surgery, the median nerve was found to be compressed under the thickened flexor retinaculum in all cases. In the carpal tunnel, there found grayish synovial proliferation adhered to median nerves. The histological examination of flexor retinaculum, synovial membrane and epineurium of the median nerve obtained at the operation revealed amyloid deposits. Surgical decompression of the median nerve at the wrist resulted in the immediate relief of the symptom.

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Dislocation of the acromioclavicular joint, which is a relatively frequent trauma, has not yet been treated with an unified method.
Based upon the opinions of anatomical repair of the dislocation, we successfully reduced 20 cases with primary repair of the coracoclavicular ligament. The subjects were 20 cases of Tossy's classification grade III (15 males, 5 females), aged 17-70 years (averaging 33.1).
Mean follow-up time after the operation was 5.5 months (3-13 months). All cases received both primamy repair of the coracoclavicular ligment and acromioclavicular internal fixation with K-wires, and some cases viewed resection of injured acromiclavicular disc and repair of iojured softtissues such as the trapezius and deltoid muscle.
K-wires were extracted 4 weeks after operation in principle. Pain, Range of motion of shoulder joint, X-ray findings, and other clinical signs were examined postoperatively. Restricted R. O. M., pain, subluxation and calcification were noted in 4 cases, and only 1 case showed disturbed A. D. L., Our results were practically satisfactory, suggesting the serviceableness of the present treatment for the dislocation.

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We have treated 20 patients with the Neviaser procedure for acromioclavicular dislocation and evaluated 17 patients, using Kawabe's criteria, more than six months after operation.
Results were considered“excellent”in 15 cases and“good”in two. In five cases, X-rays revealed subluxation at the acromioclavicular joint, and in three of them, we recognized migration of the K-wire, braking of the small bony attachment, and non-union of the attachment.
Adding primary repair of the coracoclavicular ligament to the procedure had no detectable effect on the study.
We think the advantage of this procedure is that it maintains the stability of the acromioclavicular joint without restricting its motion.

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Cushing's syndrome is a chronic hypersecretion of adrenocortical hormones with pathognomonic symptoms. The authors encountered a case of Cushing's syndrome with multiple pathological fractures and osteoporosis. A 30-year-old male had remarkable osteoporosis and multiple pathological fractures in Th7, bilateral costae and ischia. This case was diagnosed as Cushing's syndrome accompanied by adrenocortical tumor based on findings in endocrine test, X-P, CT, scintigraphy, and others. As a treatment, a surgical excision was carried out. The tumor was shown to be adenoma. The osteoporosis and multiple pathological fractures are steadily healed by this treatment.

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