The change of patellar height after displacement of tibial tuberosity and its effect on the improvement of clinical signs of knees were studied.
Anterior or antero -medial displacement of tibial tuberosity was done on 36 knees (anterior displacement 14 and antero-medical displacement, 20) with patello-femoral arthrosis of 29 patients (4 men and 25 women, with ages at operation ranging from 47 to 79, averaging 58.3), and antero -medial or medial displacement of tibial tuberosity was done on 25 knees (antero-medial displacement, 10 and medial displacement, 15) with patellofemoral disorders (recurrent patellar dislocation, 11 and patellar subluxation, 14) of 24 patients (2 men and 22 women, aged from 14 to 37, averaging 22.4) . Patellar height was measured from the lateral view by Insall-Salvati's method using the ligament/patella ratio. The ligament/patella ratio of the older (arthrosis) group was decreased significantly (p<0.01) after operation, from 1.10 to 0.94. The ratio of the younger (patellar dislocation) group showed no significant changes, but that of 7 knees with a high patella (more than 1.2 on the ligament/patella ratio before operation) decreased significantly (p<0.001), from 1.47 to 1.31. The postoperative patella baja had no poor effects on the improvement of clinical signs.

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The survival rate of cementless total knee replacements has been analyzed using the Armitage method on 206 cementless type TKR (Okayama Mark-II) (RA, 151 knees; OA, 55 knees) which were done over 14 years from 1975. The survival criterion is that the prosthesis are still in situ and all such prostheses are regarded as having survived, regardless of whether the patient experiences pain or loss of function.
We have revised nine knees (RA, 6 knees; OA, 3 knees) and removed two knees (RA, 1 knee; OA, 1 knee) . The results indicated that for rheumatoid patients the overall probability of survival for cementless TKR was 98.1% after 5 years, and 92.9% after 10 years. The figures for osteoarthritics indicated an overall probability of 95.1% after 5 years, and 88.2% after 10 years. These results seem to be satisfactory compared with those previously reported with cemented TKR.

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Arthroplasties were done on 13 knees in 12 patients of unicompartmental osteoarthritis using a PCA unicompartmental knee, and the patients were followed for at least two years. The clinical findings showed satisfactory results according to the criteria of the Japanese Orthopaedic Association (JOA) . The JOA score was a mean of 51.9 before surgery and 83.5 at follow-up. The mean postoperative flexion was 118°. The position of the tibial component was respectively 85.6±3.0° and 88.2±2.0° in the AP and lateral views. The mean of the postoperative femoro-tibial angle (FTA) when standing was 177°. There was no correlation between clinical results and these radiographic parameters except in one case, who had a pain in the operated on knee during walking. Her FTA was 183°, and radiography showed there to be a few loose beads. Totally, loose beads were found in 9 uncemented femoral or tibial components. These results suggest that uncemented components might be unstable for some postoperative periods. Therefore, we prefer to use cement in the PCA unicompartmental arthroplasty.

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A total of 29 rheumatoid patients (43 hips) were treated by total hip arthroplasty from 1978 to 1985. Here we report the results of a follow-up examination more than 5 years after surgery in 18 patients (27 hips) . Of the other 11, 8 had died, 2 had late infection, and one refused the follow-up examination. The average age of those followedup was 54, ranging from 42 to 72, and the postoperative periods varied from 5 to 11 years with an average of 7 years, 2 months.
Most of those patients assessed their results as being satisfactory and the function of their operated -on hips was favorable. Loosenings and migrations of the socket were found to be more frequent than those of the stem side. The survival rates were 82% after 5 years, 70% after 7 years, and 50 % after more than 10 years.
In order to maintain the quality of life of rheumatoid arthritis patients who undergo total hip replacement, the most important factor is to ensure careful post-operative management.

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Bone resorption of the medial femoral neck was measured in 84 Charnley total hip arthroplasties of 11 males and 5 4 females, with an average age of 57.2 at operation. The average follow-up period was 11.7 years. Also measured were the position of the stem in the femoral canal, the thickness of the methylmetacrylate at the medial femoral neck, loosening of the socket, and the amount of socket wear. The average amount of bone resorption was 3.4 mm (range 0 to 33 mm) . Loosening of the socket was found in 15 cases. In 40 hips the stem position was valgus, in 42 hips it was neutral and in only 2 hips it was varus. The average thickness of bone cement was 4.6mm and the average socket wear was 1.3 mm. The amount of bone resorption was larger in the socket loosening group (p <0.02), and the coefficient of correlation between the amount of bone resorption and wear of the socket was 0.38 (p <0.001) . We think loosening of the socket and wear of the socket are major factors in bone resorption.

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We have recently experienced 5 cases of localized giant cystic bone destruction (geode type) occurring in rheumatoid hips. The patients, one male and 4 female, were aged between 49 and 65. They were all in an advanced stage of RA, 2 in Steinbrocker stage III, 1 in stage N and the remaining 2 in Mutillans-type stage III-C. Three had experienced either unilateral or bilateral total knee replacement, and one underwent contralateral total hip replacement.
Four out of the 5 showed similar geode-type bone destruction in contralateral hip joints. All cases had been asymptomatic at the time of roentgenographic detection of bone lesions. Later, however, 3 developed pathological fracture medialis colli femoralis, and 2 presented early hip joint deterioration. One received bipolar-type artificial capital replacement, and total hip replacement was performed on 4.
The postoperative courses were favorable. Villous hypertrophy of the hip joint synovial membrane was found to be remarkable during the operation. Pathohistologically, exudative proliferative synovitis accompanied with immunoglobulin positive chronic inflammatory cellular infiltration was noted. The geode -type bone destructive region was also full of granulation tissues accompanied with f ibronectin -positive fibroblasts, hyperplasia of collagenic fibers and with bone-cartilage fragments. Fibrinoid (rheumatoid) necrosis was observed in 2 cases. Pathological findings suggested the likelihood of RA-induced synovitis having infiltrate into the bone leading to bone destruction due to hyperplastic rheumatoid granulation. Geode-type bone destruction needs attention as a type of RA hip joint lesion in view of the high probability of its progressing to early articular deterioration, and of its possible attributability to the incentive-free fractura medials colli femoralis observed in some of the advanced RA cases.

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A follow-up study on bipolar endoprosthesis for patients under 60 years old was made on 3 6 hip joints in 3 4 patients (osteoarthritis: 13 joints; avascular necrosis of the femoral head: 15 joints; and femoral neck fracture: 8 joints) . The average age was 52. The clinical results assessed by the JOA score and roentgenographical study of migration and sinking of the prosthesis were followed during periods ranging from 2 years to 9 years and 7 months. Twenty-eight joints were satisfactory. Sinking only and migration only were seen in 3 joints: both sinking and migration were observed in 4.

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We report here on our technical improvement of the Chiari pelvic osteotomy, and its procedure in which the Smith-Petersen approach is used and the lateral side of the iliac crest is osteotomied by chisel. Between 1981 and 1989, 83 patients (91 hips) were treated by Chiari pelvic Osteotomy, 14 men and 69 women ranging in age at surgery from 10 to 58 years. The average age was 30.2. The follow-up period ranged from one to 8 years with an average of 2.8. Clinical results, evaluated by JOA hip score and X-ray findings (sharp angle, slope of acetabular edge, acetabulo-head index and CE angle), were good except in one case in which degeneration of the hip joint had advanced after operation. The results of remodelling of the new acetabular were especially excellent in the 56 hips in which the height of the osteotomy from the acetabular edge was less than 1 mm on X-rays. Chiari pelvic osteotomy is a useful method for treating osteoarthritis of the hip, and it is important that pelvic osteotomy be performed within 1 mm from the acetabular edge.

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We have experienced 7 RA patients with ossification of the posterior longitudinal ligament of the spine (OPLL) . According to lateral X-ray pictures, 5 cases were segmental type and 2 cases were mixed type. The results showed that segmental ossification is more frequent in OPLL with RA than in ordinary OPLL. No spinal cord dysfunction suspected of being associated with OPLL was noted.

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The results of 5 Neer total shoulder replacements were reviewed in 5 patients with rheumatoid arthritis. All of them had nocturnal pain, limitation in range of motion, and low activity of daily living. Postoperatively the pain was reduced in all cases, which was related to there being an improvement in the activity of daily living, whereas the range of motion was only slightly improved.
Short-stem prosthesis with bone cement should be used in some patients with rheumatoid arthritis, as elbow replacement may be done in the near future. In 4 shoulders, short-stem prosthesis was used and roentogenologically all of them showed neither mechanical loosening nor breakage of the components after an average of 14 months of follow-up.

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Operations for loose shoulder have been performed on 63 shoulders of 44 cases since 1977 of 10 males (11 shoulders) with an average age of 20.5 and 34 females (52 shoulders) with an average age of 18.4. Collagen in capsules and skin from 3 cases of shoulders reported on produced relatively immature collagen fibers in comparison with those from other cases. This suggests that the biochemical characteristics of collagen in operated-on cases may be similar to those in Ehlers-Danlos syndrome.

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Dorsal wrist synovectomy was performed in Kakogawa National Hospital on rheumatoid patients. Sixty patients, 5 males and 5 5 females, with an average age of 50, who had surgery on 75 wrists, were followed for 1 to 17 years, with an average of 7.1 years. Over 90% had excellent subjective and objective results. Results of activity of daily living showed there to be significant recovery after wrist synovectomy. Although Darrach's procedure had an affect on carpal translocation, this deformity was not correlated with clinical results. On the other hand, severe carpal collapse with carpal translocation was correlated with clinical results and ADL disabilities.

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A 35-year-old woman suffered from spastic coma which lasted for 40 days due to herpes encephalitis. Heterotopic ossification at the right elbow appeared 3 months later, when she had recovered completely from the herpes encephalitis. The ossification resulted in bony ankylosis of the elbow with accompanying ulnar nerve palsy. Three months after the onset of ankylosis, surgical mobilization of the right elbow joint and anterior submuscular transfer of the ulnar nerve were performed. EHDP was administered postoperatively for 3 months. By 8 months active flexion of 120° and active extension of minus 10° were regained without recurrence of the ossification. The authors suggest that the surgical removal of neurogenic heterotopic ossification at an early stage may be warranted after recovery from central paralysis.

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This report concerns two patients with rheumatoid arthritis who, in spite of no clear history of trauma, sustained ipsilateral femoral shaft fractures after total hip replacement (THR) . Case 1 was a 73-year-old female who developed left femoral shaft fracture 2 years after THR. Case 2 was a 44-year-old female who was ambulatory with a T-cane when routine follow-up X-rays demonstrated bilateral femoral shaft fractures at the same time. Left THR had been performed 6 years prior to the incident, while right THR had been carried out for a revision of infection 5 years before.
At first we tried conservative therapy for Case 1, only to fail. Finally THR was performed on her left hip as a revision. The patient can walk by herself without any support now. On Case 2, bilateral THR was also performed as a revision. A month has passed since then and there have been no problems so far.
The common finding of the two patients with fractured femur (s) was loosening of the femoral prosthesis. It was not clear when the fractures had happened. We suggest, therefore, that it is necessary to follow THR patients closely by X-ray examinations at short intervals; when loosening is discovered, surgical intervention to revise the prosthesis should be undertaken as soon as possible.

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An atypical case is presented of avascular necrosis of the femoral head which had shown progressive concentric narrowing of the joint space prior to the appearance of rarefaction. Angiography revealed occlusion of the medial femoral circumflex artery. Histological investigation showed not only necrosis of the bone and bone marrow but also chondronecrosis. From these observations, we postulated that the ischemia of the capsule and the femoral head caused by arterial occlusion had led to the necrosis of both cartilage and bone.

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