There are few choices for operative treatment for end-stage coxarthrosis. No one doubts that total hip arthroplasty is the most useful treatment method for such hips. However, this method should not be easily indicated for patients under 50 years of age. Alternative methods for arthroplasty include valgus intertrochanteric osteotomy, rotational acetabular osteotomy, and muscle release operation. Valgus intertrochanteric osteotomy may be indicated under the following conditions: the hip has a range of flexion greater than 70 degrees and adduction greater than 20 degrees, and there is good congruity of the joint in the adducted position without severe acetabular dysplasia. The rotational acetabular osteotomy is rarely indicated for a hip in the end stage, but may be done under the follow-ing conditions: the hip has good range of motion, for example flexion greater than 100 de-grees and abduction greater than 20 degrees; circumferential curvature of the femoral head and acetabulum are nearly equal. A muscle release operation is not necessarily reliable.
In conclusion, we should at first consider alternative surgeries other than arthroplasty in younger patients with end-stage coxarthrosis.

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Primary total hip arthroplasties were performed in 60 patients (63 hips) between the ages of 40 and 59 using Harris-Galante prostheses. The minimum follow-up period was five years. The average follow-up period was six years and nine months. The average age of the patients at operation was 52.8 years. The average preoperative J.O.A. score (similar to the Harris hip score) was 43.5 points, which improved to 91.5 points at the final follow-up examination. Seven hips had thigh pain. Three had component loosening and the remaining four had no pain within three years and six months after operation. Two hips developed femoral osteolysis more than five years after operation. The incidence of thigh pain and femoral osteolysis is less frequent in comparison with that in the United States. The reason for this is that in Japan the rehabilitation program after THA is slower, activity of the patients is lower, and weight of the patients is lighter, compared to those of patients in the United States. Therefore, the possibility that the incidence of osteolysis after THA will increase in the future in Japan is being considered.

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Five patients underwent muscle release around the hip joint, according to O'Malley's method as modified by Itami, for treatment of bilateral severe coxarthrosis. However, the procedure was done only for the unilateral hip. Average follow-up period after surgery was 8.2±3.4 years. Though this procedure relieved pain, favorable results were limited because of insufficient improvement of ADL, ROM and gait ability. There was no additional surgery, even in the contralateral hip, in any of the cases.
Twelve hip joints of eight patients underwent pelvic osteotomy, such as Chiari osteotomy, for treatment of bilateral severe coxarthrosis with acetabular dysplasia. Four contralateral hip joints underwent arthrodesis, muscle release, and shelf operation in addition to varus osteotomy of the femoral head, and bipolar total hip arthroplasy in each. Four patients underwent pelvic osteotomy bilaterally. Average follow-up period after surgery was 9.8±1.7 years. Six hip joints which received this procedure in patients less than 39 years of age obtained good results 10 years after surgery. However, two hips of six hip joints which received this procedure in patients more than 40 years of age had to be replaced with a total hip prosthesis, one 3 years and the other 10 years after surgery. Therefore, in bilateral severe coxarthrosis with acetabular dysplasia in patients more than 47 years of age total hip arthroplasty should be a first choice for improvement of ADL, ROM, and gait abil-ity. Thereafter, pelvic osteotomy can be done for preservation of the joint.

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We reviewed the results of valgus osteotomy, with and without acetabuloplasty, performed between October 1983 and August 1992 on 42 patients with far advanced osteoar-thritis in congenitally dislocated, subluxated, or displastic hip. All patients were over 40 years of age (average age at time of operation, 49.0 years) . The follow-up period averaged 7 years 8 months.
Japanese Hip Society scores improved from a preoperative average of 49.3 points (25-68 points) to a postperative average of 88.3 points (52-100 points) . None of the cases re-viewed required additional surgery such as total hip replacement.

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Advanced OA of the knee showed severe joint space narrowing, opening of the lateral facet, and medial subluxation of the femur, hence bilateral adaptation of the medial and lateral facets might be difficult by HTO. The most serious cause of wear of the joint cartilage was the load placed on the medial facet of the knee owing to a biased Mikulicz line. HTO reduces subluxations by changing the alignment from varus to valgus. Twenty-four unstable knees of 80 knees which underwent HTO were selected for this study. The lateral facet of 13 knees of 24 knees was reduced by HTO (reduced group) and 11 knees were stationary (subluxed group) . Radiographical evaluations were performed on the width of the medial and lateral joint space (MJS, LJS), deviation of the Mikulicz line (DEVM), medial subluxation of the femur (MSBF), inclination of the femur (INCA), joint convergence angle (JCA), condylar plateau angle (CPA), and the ratio of width of the tibia and femur (RTFW), denoting the index of femoral rotation. The MJS in the reduced group showed an increase of more than 1 mm (average 1.88 mm) but the LJS showed 0.42 mm. The INCA of the reduced group was 3° greater than that of the subluxed group. There were no remarkable changes in position of the Mikulicz line in the knees and CPA, JCA, MSBF and RTFW between the two groups: the degree of the response to HTO varied among the knees. These findings suggest that various subluxations were reduced via different complex ways by HTO, and it is difficult to predict the reposition of the lateral facet and the opening of the medial joint with pre-operative Xp.

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We reviewed 48 patients (24 men and 24 women) who underwent 53 primary operations for thoracic outlet syndrome (TOS) . Age at the time of surgery ranged from 15 to 60 years (average 28.0 years) . We performed 43 transaxillary first-rib resections, 8 scalenotomies via a supraclavicular approach, and 2 combined operations (transaxillary plus supraclavicular approach) . In 56.6% of the patients, single or multiple anatomical abnormalities were noted. Twelve patients (25%) had a history of neck trauma. The average follow-up period was 10 years (range 6 to 17 years) . Good or excellent results were obtained in 74.4% of the transaxillary first-rib resections, 50% of the scalenotomies, and 100% of the combined operations. As for complications, no permanent nerve injury occurred. We conclude that transaxillary first-rib resection is a safe and effective treatment for TOS. This study confirmed that the success rate of transaxillary first-rib resection did not decrease during a long-term follow-up period. However, scalenotomy was less effective for TOS. Anatomical abnormalities, preoperative neurological deficits, and gender had no effect on the results. A history of trauma did not have a negative effect. In a majority of the patients with fair or poor results, not only compression but also stretching of the brachial plexus were suspected as the underlying pathophysiology. Excluding such patients in final assessment would yield better long-term results thoracic outlet decompression.

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Eighty-five knee replacements using a total condylar knee prosthesis in patients with rheumatoid arthritis (RA) were followed for 5 to 16 years (mean 8.3 years) . Three cases developed an aseptic loosening but only one case required revision surgery. The ten-year cumulative survival rates were 98.0% when revision was considered an indication of failure, and 95.4% when radiographic evidence of loosening was considered an indication of failure. No replaced knee developed primary or secondary infection. According to the Knee Func-tion Scoring System devised by three universities, scores averaged 42.6 points preoper-atively, 77.9 points one year postoperatively, and 69.8 points at the final follow-up. The decrease in the average total score between the one-year and the final follow-up evaluation was attributed primarily to a decrease in the score for walking ability and ADL. In some severe RA cases with multiple joint destruction, postoperative scores for walking ability, ADL and pain decreased with time. Durability of the total condylar knee prosthesis was good in RA patients, and the results of our investigation suggest that prevention of systemic progression of RA severity is important to maintain good knee function obtained after the arthroplasty.

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In order to find the incidence of loosening of the femoral component after total knee arthroplasty (TKA) for rheumatoid patients and to clarify the relationship between the radiographic findings and loosening, 168 knee joints in 112 rheumatoid patients who received cementless TKA have been reviewed. The mean age of patients at surgery was 56.1 years (range: 22-75) . The average follow-up period was 5.5 years (range: 2-16) . Depending on the time, five different prostheses were used, such as the Mark- II (Okayama University, Kodama-Yamamoto), Mark- III (Okayama University, Kodama-Yamamoto), KC-1 (Kyoto Ceramics), Ortholoc- II (Whiteside), and Ortholoc modular knee system (Whiteside) . Twen-ty femoral components were revised because of loosening. The incidence of loosening of the femoral component (11.9%) was statistically equivalent to that of the tibial component (8.3%) . The cumulative survival rates of the Mark- II and Mark-III were 93.5% at the 5th post-operative year, 82.1% at the 10th post-operative year, and 54.3% at the 15th post-op-erative year; that of the KC-1 was 94.7% at the 5th post-operative year, 59.5% at the 10th post-operative year, and 44.7% at the 11th post-operative year; that of the Ortholoc- II was 87.8% at the 5th post-operative year, 79.8% at the 6th post-operative year; and that of the Ortholoc modular knee system was 100% at a mean 29.9 post-operative month (38 months maximum) . Migration of the femoral component in 15 joints, and the radiolucent zone with-out migration in 5 joints, were the radiological findings based on which revision surgery was decided. In respect to migration of the femoral component, posterior tilt and sinking were common findings in all five prostheses; no tendency was found dependent on a particular prosthesis. Radiolucency was recognized in 56.7% of all the joints. The incidence of revision surgery correlated with extension of the radiolucent zone around the femoral component. Radiolucency, located between the anterior flange and the anterior cortex of the femoral condyle, was recognized in 41.1% (anterior radiolucency) . It was more remarkable here than in other zones of interface between the femoral component and the femoral condyle. Anterior radiolucency was found in all five prostheses. Anterior radiolucency was radiographically classified into six types. It was found that revision surgery was performed more frequently in joints which demonstrated radiolucency of the following two of the six types: one that was parallel to the anterior flange with continuity to the anterior chamfer, and another that was also parallel to but without continuity to the anterior chamfer. The thickness of the radiolucent zone in the latter type was more than 2 mm. No relationship was observed between the installation angle and loosening of the femoral component. In summary, the author concludes that radiolucency is a common finding for the cementless TKA in rheumatoid patients, the presence of a thick anterior radiolucent zone would suggest the possibility of the necessity of revision surgery of the femoral component for actual or potential loosening.

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Results of arthrograms of the shoulder were evaluated in 29 patients (32 shoulders) with rheumatoid arthritis. Arthrograms were evaluated according to DeSmet's classification. Arthrographic findings were as follows: diffuse nodular filling defects (66%), irregular capsu-lar attachment (69%), bursal filling defects (41%), rotator cuff tear (41%), lymphatic drainage (25%), frozen shoulder (25%), biceps sheath “ampulla” (13%), and synovial cyst (13%) . Contrast medium in the rotator interval region was observed in two cases which did not show any indication of rotator cuff tear. We classified synovial cysts into 3 types: Type 1, 3 cases; Type 2, 6 cases; and Type 3, 4 cases. The pathomechanism of the synovial cyst in the rheumatoid shoulder was suggested to include valve mechanism, which can be observed in popliteal cysts of the rheumatoid knee. Rotator interval and synovial cyst should be paid attention to when the destruction process mechanism of the rheumatoid shoulder is discussed.

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Thirty-five knees in 25 patients over 65 years of age (average 71 years) with medial osteoarthritis treated by high tibial osteotomy (HTO) were clinically reviewed. Patients were evaluated 5 to 12 years postoperatively (mean, 8.3 years) . Satisfactory results were obtained for 81.2% of the knees at the five-year follow-up evaluation and in 74.3% at the final follow-up evaluation. Only one knee required TKA after 11 years. The femorotibial angle (FTA) at the one-year and final follow-up correlated significantly with clinical results of the final follow-up. FTA at one year after surgery was one of the main factors that influ-enced long-term results. The mean FTA immediately after surgery was 167.1°in patients who subsequently had excellent improvement scores. The change in FTA over time was minimum in patients with an angle corrected to or close to 168°. Clinical results were satisfactory even in those patients over 70 years of age.

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Twenty-one elbows in 17 rheumatoid arthritis patients were followed from 3 to 21 years (average 118 months) . The disease in the majority of patients was at an advanced stage. Surgery was performed through a lateral or postero-lateral incision. Fourteen elbows were treated with synovectomy and insertion of a silastic radial head implant; synovectomy with radial head resection was performed in 6 elbows and one elbow was treated with synovectomy only. Pain was diminished in all but one elbow. Range of motion (ROM) improved in 18 elbows, but remained the same as the preoperative level in three elbows. Improvement in ROM was more evident in elbows treated with synovectomy and radial head resection than those without such treatment, and was most apparent in supination of the forearm. Destructive changes in the humeral trochlea and capitellum were less advanced in elbows treated with synovectomy and insertion of radial head implant. Results were graded as satisfactory in 18 elbows (86%) . Synovectomy was effective for relief of pain in the rheumatoid elbow. Considerable improvement in motion can be expected after radial head resection, but insertion of a radial head implant is recommended to minimize destructive changes in the humeral trochlea.

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Nerve supply to the posterior longitudinal ligament has been the focus of considerable interest in order to gain insight into the pathogenesis of low back pain. Much attention has been paid to the sinuvertebral nerve, the meningeal branch of the vertebral nerve, which supplies proprioceptive, nociceptive and autonomic fibers back to the spinal canal. Recent developments in immunohistochemistry have enabled identification of various nerve fibers. In the present study, nociceptive and sympathetic innervations to the rat posterior longitudinal ligament were investigated through immunohistochemistry and immuno-electromicroscopy for calcitonin gene-related peptide and tyrosine hydroxylase, respectively. The posterior longitudinal ligament received two distinctive nerve networks, i.e., superficial and deeper networks. The superficial network supplied both nociceptive and sympathetic fibers of the sinuvertebral nerve origin, while the deeper network supplied the nociceptive alone. Resection of the dorsal root ganglia suggested that the former network received nociceptive fibers from the dorsal root ganglia of multiple levels, while the latter received nociceptive fibers unisegmentally. More peripherally, the superficial network was characterized by interdigitating, naked nerve endings of the presumable sympathetic and nociceptive axons. A special neuromodulatory function between the sympathetic and nociceptive axons was proposed as a possible function of the superficial network, while the deeper network was considered in pure sensory terms.

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