Fourteen rheumatoid patients who suffered from occipito-cervical pain with or without neurological deficit were surgically treated for subluxations of the cervical spine. Long posterior fusion from the occipital to the lower cervical spine was performed using Luque's segmental spinal instrumentation. The average follow-up period was 20 months. Improvement of occipito-cervical pain and neurological signs was obtained in 11 patients. However, the 3 remaining patients died within 3 months post operation from other complications. All surgically treated patients were very severe conditions for anesthesia and surgeries. At present, long posterior fusion with Luque's SSI is our first choice for surgical treatment of rheumatoid cervical spondylitis because of the high incidence of adjacent subluxation after short fusion. However, longevity with Luque's SSI should be clarified by long-term follow-up studies.

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A femoral-head graft to the acetabulum was performed at the time of cementless total hip arthroplasty in patients with acetabular dysplasia. In this follow-up study, the findings for 14 hips of 12 patients have been analyzed. The mean follow-up period after surgery was 5.7 years, with a range of 5-7 years. Roentogenographic analysis showed grafted bone formation from 6 months to 2 years (average 1.0 year) in all patients. In 9 of 14 hips (64%), the lateral side of the grafted bone was resorbed within 1 to 4 years (average 2.0 years) . Bone scintigraphy showed that accumulation of Tc-99m in the grafted bone increased from 6 weeks to 3 months and declined in 5 years. These findings indicate that the grafted bone is inclined to resorb at the stress shielding area.

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We evaluated the clinical results and radiographical acetabular cup setting angles after Harris-type total hip replacement (THR) for rheumatoid arthritis (RA), to determine the most suitable angle of acetabular cup setting with Harris-type THR system. Between 1986 and 1991, we performed THR in 48 RA patients, and 42 hips (34 patients) were evaluated.
There were 8 males and 26 females, whose average age at the time of surgery was 55.4 years. The prosthesis that we used in all cases was the Harris precoat THR system with cement. Anteroposterior radiographs were made postoperatively to evaluate the acetabular cup setting angles (cup angle), anterior tilting angles (tilt angle), bulging out angles (bulge angle) and radiolucent lines around the prosthesis. The averages of the cup angle, tilt angle and bulge angle were 43.4°, 19.7° and -4.8°, respectively. In our test group, the cup angles were less than 40°, there was no more improvement in range of motion, especially with abduction, than in the other group, with cup angles over 40°. Radiolucent lines were most frequently observed in the former group. Cup angles were 50° or more and cup angles were less than 40°. Bulge angles were less than -20°, much lower than the other group, but there was no correlation between tilt angle and the radiolucent lines. Also, there was no correlation between these angles and functional improvement. In the test group, the cup angles were between 40° and 50°, and were lower than the other two groups in the frequency of radiolucencies. We therefore concluded that the most suitable angle for acetabular cup setting was 40°- 50°, and we recommend a cup setting angle of 45° for actual practical operations.

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Clinical results and problems encountered in bipolar endoprosthesis replacement for avascular necrosis of the femoral head were evaluated in 44 patients (57 hip joints) . Average age at the time of operation was 42 years and follow-up was for an average period of 78 months. The JOA hip score after surgery increased from 58.7 to 92.6 points. X-rays revealed migration of the outer head in 5 patients (8.8%), varus position of the outer head at the acetabulum in 7 (12.3%), varus angulation of the stem in the femoral medullar canal in 9 (15.8%), subsidence of the stem in 6 (10.5%), and a radiolucent zone in 19 (33.3%) . There was little relation, however, between clinical results and radiological findings. Complications included 3 infections, 1 dislocation, and 1 fracture of the polyethylene bearing insert.

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A case study of osteoarthritis of the knee was performed to investigate the physical constitution of patients and other factors associated with severity of symptoms, using a self-administered questionnaire. Subjects were 474 patients forty years of age or over, newly diagnosed at three university hospitals during the period October 1991 to September 1992. Severity of symptoms was assessed by asking patients to gauge the extent of difficulty they had when using a Japanese-style toilet (squatting position), rising from a chair, ascending or descending stairs, walking without a cane or other support, etc.
Among the subjects, symptoms for the 360 female patients were more severe with increasing body weight and body mass index (BMI) at both the time of initial examination and at forty years of age. Blue collar workers showed more severe symptoms than did other types of workers. Severity was negatively associated with previous sports/ recreational habits. There was a positive association between symptoms and younger age of delivery of the first child. Among the 114 male patients, there was a negative association between drinking habits and onset of symptoms.

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An investigation was carried out to assess the usefulness of magnetic resonance imaging for imaging of the knee joint, especially for detecting articular cartilaginous lesions associated with osteoarthritis of the knee. A total of 141 patients with osteoarthritis were examined (23 male, 118 female) . Their age range was 40-93 (mean age 66.2) . Using radiography examinations, patients were classified according to Hokkaido University Classification Criteria; 22, 49, 46, 16, and 8 patients were classified as Type I, II, III, IV and V, respectively. Articular cartilage defects were examined using MRI, and the number of such defects increased as the x-ray stages progressed. The appearance of a low signal intensity area in the bone marrow was examined using MRI, and the number of patients observed to have such areas increased as the x-ray stages progressed. JOA OA scores were significantly low for patients with meniscal tears. Patients were classified and results reviewed using MRI examinations. Classification by MRI of articular cartilage lesions correlated with the JOA OA scores. Low signal intensity areas in the bone marrow were frequently observed in advanced osteoarthritis cases, and there was correlation between FTA and MRI classifications of these areas. MRI is extremely valuable in detecting articular cartilage lesions in the knee joint, showing those lesions which cannot be detected by conventional radiography examinations. Thus, MRI is judged to be a clinically useful method for diagnosis of osteoarthritis.

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Arthroscopic Bankart suture repair (Morgan's technique) was performed on 20 patients with recurrent anterior dislocation or subluxation of the shoulder. The re-dislocation rate was 5% (1/20), and re-subluxation occurred in two patients postoperatively. Patients who suffered a re-dislocation were operated on again according to the Bristow procedure. The symptoms of the two patients with re-subluxation were not pronounced, and they received conservative treatment. In Morgan's technique, the position of the anterior portal is important. It should be at inferior a point as possible in order to facilitate the suturing process. The reattachment point of anteroinferior glenohumeral ligament-labral complex (AIGHLC) is also important. But sometimes AIGHLC is not clear, and the amount of tension of AIGHLC must be determined by pulling with a grasper. The reattachment point must be determined based on the anatomical figure and the tension of the AIGHLC. When the thread is tied on the fascia of the deltoid muscle, it is difficult to determine its strength. The thread is usually tied so as to make a dimple of about 1 cm at the posterior suture point. If these technical problems can be overcome, arthroscopic Bankart suture repair (Morgan's technique) may be a useful procedure for treatment of anterior dislocation.

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Total ankle replacement was performed for 7 ankles of 6 patients with rheumatoid arthritis. All but one patient had previously had arthroplastic surgery on some other weight-bearing joint. The average follow-up period was 2 years and 9 months. Relief of pain was obtained for all but one patient, who had severe valgus deformity on the ipsilateral knee. Arc of motion was increased from 24 degrees to 30 degrees, on average. The range of motion required for normal level walking, however, was obtained for three ankles only. The gain in ROM was observed to be related to the improvement in walking ability. The ROM of the patients' tibio-talar joints seems to play a significant role in their walking ability. In follow-up x-rays, radiolucent lines were observed in 3 ankles: 1 on the tibial and 2 on the talar. Sinking of components was observed on 3 ankles: 1 on the tibia and 2 on the talus. Sinking of components seemed to correlate to the extent of bony involvement of the tibio-talar joint before surgery. There was no relation between the x-ray findings and clinical results.

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An arthroscopic partial resection of triangular fibrocartilage complex (TFCC) was performed on 8 patients with TFCC lesion. All cases had a history of trauma. Arthroscopy revealed that 7 patients had traumatic TFCC lesion and only one had a degenerative TFCC lesion. Clinical results of the procedures were evaluated using Kido's criteria. Results were excellent for 7 of the cases, in which the TFCC lesions seemed to be traumatic in origin. Results for the remaining case were poor, indicating a degenerative TFCC lesion (class 2B) associated with fibrillation of the ulnar side of the lunate. Outcomes were good for traumatic TFCC lesions (class 1A) treated using arthroscopic partial resection; however, degenerative TFCC lesions may require ulnar-shortening osteotomy or use of Wafer's procedure when positive results cannot be obtained using arthroscopic partial resection.

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We have encountered two cases of joint infection with methicillin-resistant staphylococcus aureus (MRSA) . The infections were believed to have resulted from exposure to S. aureus in the hospital, and hosts whose immunity was compromised by such factors as multiple trauma. The infections were successfully treated by radical debridement with antibiotics, however, residual joint function was severely restricted. Preventing exposure to pathogens in the hospital is emphasized as crucial in avoiding infections of this kind.

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We report on metallosis in bilateral knees which occurred after total knee arthroplasties with cementless Press Fit Condylar total knee prostheses. Our operative findings indicate that the metallosis was due to lateral subluxation of the patellar component and polyethylene wear of the metal-backed patellar component; furthermore, in one knee, it was due to breakage of the polyethylene caused by concentrated contact pressure on the large patellar implant, which gave rise to a large moment arm. Body weight and range of motion played important roles in failure of both knee prostheses. We concluded that, in the case of elderly and overweight Japanese patients, total knee arthroplasty places significant demands on the patellar component.

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