Acetabular bone grafts have been performed often in total hip arthroplasty (THA) for secondary osteoarthritis with the acetabular dysplasia which is frequently observed in Japan. Fiber-mesh blocks made from pure titanium were embedded in muscle-pedicle or free rabbit iliac grafted bones in order to examine whether bone ingrowth might occur from the grafted bone to the fiber mesh implant. Bone ingrowth was observed in the fiber mesh blocks embedded in the muscle-pedicle iliac bone, but not in the embedded blocks in the free iliac bone to which no blood was supplied. It is therefore supposed that initial bone ingrowth into the rough surface of the socket may not be expected from free bone grafts for acetabular defects in cementless THA.

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We evaluated various hemostasis methods in 131 operations of uncemented total knee replacement with rheumatoid arthritis patients. Those methods were intended to reduce the volume of intra- and post-operative bleeding and total blood transfusion. The results were as follows: 1. Less blood loss was observed and less blood transfusion was needed when the tourniquet was released after skin closure and a pressure dressing was applied than when the tourniquet was released before closure. 2. Less blood loss was seen and less transfusion was necessary when the tourniquet was released with intracapsular pressure raised by injection of isotonic sodium chloride solution and by clamping the suction drain for one hour after the pressure dressing was applied than when the tourniquet was released without the pressure raised. 3. Less intraoperative blood loss was observed when bone wax was impregnated at the exposed cut surfaces of cancellous bones after inserting the prosthesis.

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We have performed bipolar hip arthroplasty, combining acetabuloplasty with the use of the femoral head, for patients with hip dysplasia. Clinical and X-P evaluations were made in 34 joints of 30 cases of secondary osteoarthritis caused by CDH or hip dysplasia. The age at operation ranged from 39 to 69 years, an average of 53. The Osteonics Omnifit cementless stem with bipolar head was used in all cases. Evaluations were made at 3 years after operation, using the criteria of the Japanese Orthopaedic Association. The average preoperative score of 48 was increased to 85 postoperatively. The roentgenographical evaluations were of the outer head migration postoperatively, the medial acetabular width at the operation, and the original acetabular coverage angle of the outer head.
The results were as follows: Migration of the outer head of more than 3mm was seen with 15 joints (44%) . But such migration affected no clinical results except decrease of flexion range. The preoperative acetabular medial wall width was 16.7mm and the postoperative 7.9mm; accordingly, the intraoperative acetabular wall reaming was 8.8mm on an average. The average original acetabular coverage angle of the outer head was 890. The cases with insufficiency of medial acetabular reaming or original acetabular coverage of the outer head showed greater upward or lateral migration, and an average of llmm of medial displacement and 8mm of distal displacement were seen in them. To prevent outer head migration, both adequate reaming of the thickened acetabulum and fitting of the outer head in an anatomical position are very important.

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Bipolar hip arthroplasty was performed on 117 hips with acetabular dysplasia, 100 of them with acetabuloplasty using autograft. The average age of the patients at the time of operation was 59.5 years (range : 19 to 86 ) . The postoperative outcome was followed for an average period of 3.4 years (range: 1 to 6), and the clinical results were assessed by the hip rating score of the Japanese Orthopaedic Association. Postoperative migration of the outer head was measured from serial roentgenograms. Improvement of pain and ROM score reached a plateau within a year whereas improvement of gait score reached a plateau within 2 years. The ADL score gradually improved up to 5 years. The migration of the outer head within the first year was 4.4mm on an average, but the amount of the migration was reduced in the second or third year. While no additional migration was noticed in about 70% of hips after 3 years, in some cases it took 5 to achieve complete stabilization of the acetabulum. In the cases in which the femoral head was pulled down more than 5mm from the original position with the bone graft, the amount of the migration was greater than in the cases in which it was less than 5mm. These results demonstrate that is better to replace the head without grafting the bone at the load-bearing area for the construction of the acetabulum even in dysplastic cases.

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Eleven cases (12 hips) underwent second revision of a total hip replacement. The mean age at the second revision was 61 years (range: 31 to 79) ; 2 patients were men and 9 women. Loosening of a component was the most common reason for the revision. Supplemental rings or wire-mesh reinforcements were used for revision of the acetabular that had poor bone stock. On the acetabular side, an allograft was used in 4 hips; on the femoral side, a long stem was used in 11 hips. The mean operative time was 298 minutes (range: 195 to 525), and the mean bleeding volume was 2278 ml (range: 810 to 4800) . The mean length of follow up after the second revision was approximately 5 years.
The clinical results were a mean total JOA score of approximately 70 in the maximum period of follow up. In the final roentgenographic examinations there was a clear zone with 3 acetabular components and 5 femoral components, and loosening of 1 acetabular component and 2 femoral components. We have yet to experience a third revision.

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Heterotopic ossification after total knee arthroplasty (TKA) is rarely seen. We performed uncemented TKA on 70 knees in 56 patients with osteoarthrosis and rheumatoid arthritis, and heterotopic ossification was observed in 4 knees of 4 cases. It began to form sometime between 2 months to 5 years postoperatively for 2-4 weeks and reached its peak at 6 weeks. The maximum diameter of the newly formed bones was 11-25mm, and the location was in the suprapatellar region in all cases. The possible etiology might be rasped bone dust from the anterior femur, or damaged surrounding soft tissue in the AMK-type operation, or severe preoperative malalignment in cases with rheumatoid arthritis. We have to carry out further examination of other factors to determine what caused flexion disturbance in 2 cases.

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In 17 patients with rheumatoid arthritis, 25 knee prosthetic replacements (total condylar type in 8, anametric type in 9, geometric type in 3, Macintosh type in 3, and McKeever type in 2) were followed up for a minimum of 10 years (mean period: 12 years) . Among 20 total joint replacements, 2 prostheses required revision because of loosening or late infection after 7 and 5 years, respectively. Malposition of the tibial component was considered to be the factor responsible for loosening of the implant. In 5 hemiarthroplasties, 4 prostheses were revised after an average of 14 years (due to loosening in 2 and osteoarthritic change in the femur in 2) . Although improvement of pain and function was obtained in the majority of the cases, the 7 patients with multiple joint replacements had less improvement of pain and more deterioration of function than those with one or two replacements.

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The results of surgical treatment for extensor tendon rupture in rheumatoid patients are reported. Forty cases (3 males and 37 females) were followed up for an average of 9 years and 10 months (from 6 months to 16 years) . Ages ranged from 30 to 78 years with an average of 54.9, and the duration of the disease was from 2.5 to 38 years, 9.8 on an average. Surgical treatment was done in 32 right hands and 8 left hands. The tendon ruptures were located in the thumb (4), and in the middle (9), ring (27) and little fingers (33) . Surgical procedures included tendon transfer in 25, end-to-end suture in 8, and bridge tendon graft in 7 hands. Synovectomy of the wrist joint and resection of the distal ulna were performed in all cases. The wrist, MP, and PIP joints were fixed in extended position in a plaster cast for a week and active flexion exercise was encouraged with a modified Swanson's splint for 4 to 5 weeks.
The results were assessed by the ROM of the MP joints, the ADL of the operated-on hands and the radiographic changes. Most patients were satisfied with the postoperative results of MP ROM and ADL except those with end-to-end suture, in which marked limitation of the flexion in the MP joint took place. The ROM of the MP joints tended to decrease in parallel with the progression of the disease. Tendon transfer of rheumatoid hand combined with synovectomy and resection of the distal ulna end gives satisfactory results in the treat-ment of ruptured extensor tendons.

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We have performed arthroscopic reconstruction of the anterior cruciate ligament (ACL) using the Kennedy LAD and iliotibial tract on 85 knees in 85 cases from February 1989 to January 1991. The mean follow-up period was 2.3 years. There were no major postoperative complications, such as infection or chronic edema caused by synovitis. Three LAD prostheses were found to be torn and 7 to be partially abraised; 4 knees showed anterior notch impingement.
The overall results of ACL reconstruction with the Kennedy LAD and iliotibial tract were satisfactory in both objective and subjective evaluations. Smoothing of the edge of the femoral bone tunnel was thought to be an important technical aspect.

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To examine bony lesions associated with anterior Cruciate ligament (ACL) injuries, magnetic resonance (MR) imaging was performed on 55 knees with ACL injuries. With respect to the period between ACL injuries and MR imaging, the knees were divided into acute (within one month), subacute (from one month to one year) and chronic (over one year) groups, containing 19, 16 and 20 knees, respectively. Occult bony lesions not shown in roentgenography were observed more frequently in the acute group (13/19) than in the other two groups (subacute group, 5/16 ; chronic group, 1/20), located in the lateral compartment of the knee joint. In the acute group, bony lesions had high signal intensity on T2-weighted images and low signal intensity on proton density images. In the subacute and chronic groups, bony lesions were less pronounced and had low signal intensity on T2-weighted images. These findings suggest that bony lesions are frequently associated with and occur simultaneously with ACL injury.

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Two cases of rheumatoid spondylitis in the lumbar region are reported. The first is a 65 y/o woman with a 27 year history of rheumatoid arthritis (RA) who had developed low back pain about one year before with progressive lumbar discitis on the L 3/4 level. A 64 y/o man whose onset of RA was in 1983 is the second case. His low back pain started one month prior to admission and progressive, destructive discitis was observed on the L 3/4 level likewise. Radiography revealed clear destruction of the end-plate of the L 3/4 disc in both patients. Surgical intervention was undertaken and anterior interbody fusion of the L 3/4 was performed, combined with Luque's segmental spinal instrumentation. Sections of the removed tissues demonstrated chronic inflammatory changes, most characteristic of which was granulomatous tissue invading into surrounding vertebral bones, quite reminiscent of rheumatoid pannus in the joints. No evidence of infection or malignancy was discovered. Thus, the diagnosis of rheumatoid spondylitis which is lacking in any specific findings can be made only by thoroughly ruling out other causes involving the vertebral discs.

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In order to understand the natural course of the pathological conditions of baseball elbow, a long-term follow-up study was made of 32 cases, aged 22.4 years on an average, who had not been surgically treated. At least 4 years had passed since their first consultation at our department; their mean age then had been 15.3. Plain roentgenography and tomography were performed for all cases.
Baseball elbow was classified into 4 types according to the site involved; the radiohumeral joint type (RH type) corresponding to osteochondritis dissecans, the ulnar collateral ligament impairment type (UCL type), the osteoarthritic type (OA type) showing osteoarthritic changes at the first consultation, and the miscellaneous type including the olecranon type. There were 8 cases of the RH type, 8 of the UCL type, 6 of the OA type and 10 of the miscellaneous type. All 32 cases were also divided into a non-stress group (n=15) and a stress group (n=17) based on the magnitude of stress on the elbow joint after the first consultation.
Pathological conditions were evaluated clinically according to the site involved, the amount of stress, and the location of spur formation. RH type and OA type patients often felt pain upon movement, and the excursion of the impaired elbow had decreased slightly compared to that of the healthy elbow. Patients with the UCL type and the miscellaneous type showed satisfactory outcomes compared to those with the other two types. In the stress group, 12 of the 17 patients (70%) showed osteoarthritic changes which were not seen in the 3 patients (18%) with UCL type and the 2 patients (12%) with miscellaneous type. Patients with RH or OA type invariably developed elbow osteoarthritis when they stressed their elbow joints by playing baseball. RH-type patients also showed marked deformity at the humeroradial joint as well as spur formation at the ulnar margin of the humeroulnar joint. In UCL-type patients, only a few spurs were formed, but only at the medial epicondyle; it was notable that no spurs were detected at the humeroradial joint. We concluded that RH-type baseball elbow is difficult to treat conservatively.

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As the numbers of orthopaedic surgeries for elderly patients has increased, the management of preoperative and postoperative conditions for such patients has come to play an important role in surgeries being successful at Yokosuka-Hokubu-Kyohsai Hospital. In 241 (83.1%) females and 49 (16.9%) males, whose ages ranged from 75 to 96 years (mean: 82.2), 277 cases were with trauma, and of these 266 (96%) were fractures. The most common site was the femoral neck (211 cases; 79.3%) . The most prevalent preoperative complication was hypertension, followed by dementia, and cardiovascular disease. Postoperatively, these were dementia decubitus, and digestive organ disease in that order. The fact that aggravation of dementia status after surgery had the most effect on results suggests that pre-and post operative management for this condition is indispensable for obtaining satisfactory results.

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