Clinical assessment of centrifugal lymphocytapheresis for refractory and active rheumatoid arthritis was carried out by open comparison of a group with a brief course (less than eight procedures) and one with a longer course (more than twelve procedures) . Lymphocytapheresis treatment by a continuous flow blood cell separator improved clinical symptoms in 54.5/s of the patients with refractory rheumatoid arthritis for longer than at least six months.
In general the longer course of procedures tended to be more effective and with the brief course an effect was noted if a depletion of a critical number of lymphocytes had been completed during the procedures. As for complications, neither serious disorders nor hepatitis occurred, although supplementary blood transfusion was required in a few cases who had developed anemia during the procedures.

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Ceramic-coated metal implants were devised to improve the clinical results of total hip replacements. Alumina (Al₂O₃) ; titanium nitride (TiN), and hydroxyapatite (HAP) -coated stainless steel implants were inserted into the mid -diaphyseal region of the femurs of adult dogs. Titanium oxide (TiO₂) and HAP-coated titanium implants were inserted into the distal epiphyseal region. Follow-up quantitative histological comparisons were performed for a period of up to 9 6 weeks. HAP-coated implants showed better biocompatibility than both stainless-and titanium-based materials. It would appear that HAP-coated titanium alloy is the most promising composite for use as the material of artificial joints.
We also investigated how bone reacted to HAP and Al₂O₃ in experimentally-induced osteoporosis, and bone was demonstrated to have a superior affinity to HAP than to Al₂O₃. So HAP-coated implants seem to be suitable for artificial joints in elderly patients.

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Ten rheumatoid patients who suffered from occipitocervical pain with or without neurological deficit were surgically treated for subluxations of the cervical spine. Long posterior fusion from the occipit to the lower cervical spine was performed by the use of Luque's segmental spinal instrumentation. The average follow-up period was 19 months, Improvement of occipitocervical pain and neurological signs were obtained in 8 patients However, the other 2 experienced neurological deteriorations and severe neuralgia of the upper extremities afterwards. Consequently, removal of instruments and salvage laminoplasty were necessary. At present, long posterior fusion with Luque's SSI is our first choice for surgical treatment of rheumatoid cervical spondilitis, because of the high incidence of adjacent subluxation after short fusion. However, the longevity with Luque's SSI should be clarified by long-term follow-up studies.

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Arthroscopy sometimes reveals cases with hypermobile lateral meniscus which appears to cause internal derangement of the knee joint. As there is as yet no definitive concept of a hypermobile lateral meniscus, the diagnosis and treatment of it are likely to be difficult. We have experienced 12 knees in 10 cases with hypermobile lateral meniscus which were confirmed by arthroscopy. Stabilizing surgery was performed for lateral meniscus repair under arthroscopy in 9 knees (7 cases), while the remaining 3 knees (3 cases) were left untreated.
The onsets were in the higher grades of elementary school and in junior and senior high school, and most cases had bilateral involvement. Only one case had an apparent history of injury of the knee, and the others were thought to be non-traumatic. The main symptoms were locking and catching of the joint, while general joint laxity was present in 6 cases. Arthrography and arthroscopy did not show any abnormality in the ACL, PCL, or medial meniscus, and did not reveal patella dislocation, patella subluxation, or discoid meniscus. Under arthroscopy, abnormal hypermobility of the lateral meniscus was recognized, strongly indicating a weak connection between the posterior portion of the lateral meniscus and the coronary ligament and the popliteus muscle. Satisfactory results were obtained in the cases which were treated by stabilization of the lateral meniscus using arthroscopy.

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Arthrodesis was performed for 12 Interphalangeal (IP) joints of the great toe in 8 patients with rheumatoid foot complicated by the IP joint deformity. All patients had been diagnosed preoperatively as having either definite or classical rheumatoid arthritis. The age at the time of operation ranged from 48 to 66 years (average : 56years) . The length of follow-up period was from 10 to 70 months (average : 37 months) . Good correction of the deformity as well as painlessness was obtained in all of the cases.

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Ten patients, 4 women and 6 men, from 16 to 41 years old (average : 25.8) with an old rupture of the lateral ligament of the ankle which had been treated with a modified Lee procedure were assessed in follow-ups ranging from 6 months to 2 years, 5 months (mean: 1 year, 8 months) .
The causes of the initial injuries were sports in 8 patients and falling down in 2. Stress X-ray films were obtained preoperatively and postoperatively. The talar tilt angle was reduced 15.8°, from an average of 19.40 preoperatively to 3.60 postoperatively, and the anterior drawer was reduced 3.2mm, from means of 9.1mm to 5.9mm. All but two patients were improved and symptomless. We concluded that modified Lee procedure is simple to perform and able to provide the majority of patients with satisfactory results.

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Since 1990 we have been doing trials using fibrin sealant for hemostasis at exposed cancellous bones in total knee replacement. We examined the difference in the volume of bleeding and frequency of blood transfusion between two groups. One was of 21 joints of TKR with which fibrin sealant was used and the other was of 44 joints of TKR with which it was not. The volume of intraoperative bleeding, the volume of postoperative bleeding, and the total volume of bleeding were significantly reduced in the fibrin sealant group. The frequency of blood transfusion was also significantly reduced in it. Based on the above results, we conclude that fibrin sealant is useful for hemostasis in total knee replacement.

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The anterior cruciate ligament (ACL) is the most important ligament for anterior stability of the knee joint. The ACL is often ruptured by trauma, but is also injured in rheumatoid arthritis (RA) and osteoarthritis (OA) . We studied macroscopic findings of the ACL in RA (131 knees) and OA (41 knees) in the cases which received total knee replacement (TKR) from 1985. The injured ACL was classified into three types: N type (almost normal), E type (elongated ACL) and L type (torn ACL) . The incidence of the types was 29.8% (N type), 25.2 % (E type) and 45.0 % (L type) in RA, and in OA, 31.7 % (N type), 24.4 (E type) and 43.9% (L type) . There were no differences between RA and OA in this.
Anterior stability was examined by stress radiography with a Telos instrument before TKR, and the related macroscopic findings of the ACL were discussed in relation to anterior stability. The E type was found to be the most unstable of the three types in both RA and OA. This can be caused by other factors such as destruction of bone and cartilage and other soft tissue injury.

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Magnetic resonance (MR) imaging examinations were performed on 37 knees after anterior cruciate ligament (ACL) reconstruction with iliotibial autograf is . T₁, T₂ and proton-weighted sagittal images were obtained. T₁ weighted images were clearly visible in only three cases (8%) . In contrast, using T₂ and proton-weighted images, the results of 35 of the cases (95%) were clearly visible. The other two cases had ill-defined images, which revealed that the reconstructed ACL was loose. It was concluded from this that T₂ and proton-weighted images are suitable for evaluating reconstructed ACL. In comparison with the normal ACL in T₂ and proton-weighted images, the reconstructed ACL showed a high signal at the tibial side and a linear high density line within the graft. The high signal at the tibial side was found to be caused by roof impingement.

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From September 1978 to March 1991, there were 132 total knee replacements in 9 4 patients with rheumatoid arthritis at our hospital. Total Condylar Knee (TCK) was used for 5 7 knees, the Miller-Galante (M/G) for 67, and other kinds of implants for 8. We investigated the prognosis of the patients in the TCK and M/G series, and functional and radiological assessments were made. Twelve patients in the TCK series and 2 patients in the M/G series had died by the time of the follow up. The most serious complication that influenced the prognosis of the patients was infection. Knee function and activity of daily living of the patients were satisfactory in both series. Radiological assessments were also good.

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The results of application of the Kyocera unicompartmental knee arthroplasty are presented. This operation was performed on 20 knees in 18 patients between September 1988 and December 1990. The indicated disease was osteoarthritis of the knee of the medial type in 19 cases and of the lateral type in one. The patients consisted of 15 females and 3 males with an age range of 62 to 81 (mean age : 72) . The postoperative course ranged from 6 to 3 3 months (mean period: 16 months) .
The results showed a marked improvement in pain with the pain disappearing completely in 17 out of 2 0 knees. The mean postoperative flexion was 121.40 . Sitting on the heels was possible with 3 knees.
The postoperative FTA averaged 175.80. In postoperative X-rays, the weight-bearing axis passed through the center or slightly to the medial side of the knee joint, and slight under-correction was seen. These operative results with the Kyocera unicompartmental knee arthroplasty were better than those with the previously used Marmor-type because of strict operative indications, design of the prosthesis and improvement of surgical procedures.

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The DOH elbow prosthesis is a non-constrained type composed of a humeral mold with a stem (made of COP from 1985 and titanium alloy from 1987) and an HDP ulnar component with a stem.
The clinical and radiological results of 48 total elbow replacements in which such a prosthesis was implanted in 35 patients with rheumatoid arthritis were reviewed retrospectively. These cases were followed over at least 3 years (average 4.3 years) .
Final average motion did not decrease as compared with 3 months after the operation. Extension and supination were rather improved at the time of follow-up, and on radiographs there were no remarkable changes around ulnal components, but radiolucent lines were observed around humeral components in 18 elbows. The incidence of proximal migration was very high in non-cemented humeral components (5 in 9 elbows), and low in cemented humeral components (6 in 3 9 elbows) . Progression of the migration had a tendency to stop in time.

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