To determine the factors which may contribute to medial longitudinal arch (MLA) collapse, considering the medial side of the foot as a whole with particular concern toward the hindfoot, bilateral weight-bearing plain X-ray films of 73 patients' feet with rheumatoid arthritis (RA) were followed-up. All patients were classified into three subsets of the disease according to the number of joints with erosion (NJE) : least erosive subset (LES), more erosive subset (MES), and most erosive subset, including mutilating disease (MUD) .
A follow-up study showed that natural courses of the deformities located at the level of the forefoot (medial longitudinal arch angle -MLA angle-) or at the level of the hindfoot (calcaneal angle -CA-, midtalar head height -MTH-, and talar head displacementr -THD-) are related with disease severity; particularly, the severe RA cases (MES and MUD) which demonstrated obvious collapse of the medial longitudinal arch (MLA), mainly located at the talonavicular joint.
These results suggest the importance of classifying RA patients into subsets, according to disease severity, at an early stage of the disease to determine the deformities which may play a role in causing MLA collapse, and selecting the proper surgical indication that may give more support to MLA postoperatively.

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The purpose of this study was to investigate the most important factor affecting the remodeling process of the anterior cruciate ligament (ACL) graft in the dog. In the first group, the ACL was devitalized in situ by freeze-thaw cycles (5 times), designed to simulate an ideally placed and oriented autogenous ACL graft. In the second and third groups, the ACLs were removed with both femoral and tibial bone plugs in a bone-ligament-bone fashion. Then, in the second group, after devitalization by freeze-thaw cycles (5 times), the graft was reduced and fixed in an anatomical position. Also in the third group, the graft was reduced and fixed, but without freezing. The specimens were observed at one and six weeks postoperatively using microangiography, hydrogen washout technique, and histology.
In the first and second groups, the blood flow of the ACL at one and six weeks detected by the hydrogen washout technique was about 50% of that of the normal control, and microangiographic observation showed limited revascularization. Histologically, there was homogeneous cell necrosis throughout the graft at one week, and foci of the acellular area were also found even at six weeks.
In contrast, in the third group, the blood flow of the ACL at one week was about 80% of that of the normal control, and abundant revascularization was observed by microangiography. Histologically, cells in the ACL graft remained viable and no acellular area was observed in this group. The six-week graft appeared to be similar to that of native ACL except for a slight increase in cellularity and vascularity. Therefore, the biological remodeling process in the third group was markedly different from that in the other two groups. Based on these results, it is suggested that viability of the cells within the graft might play a crucial role in the postoperative remodeling process.

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We have performed a comparative study on knee motion after total knee arthroplasty (TKA) and varying degrees of posterior cruciate ligament (PCL) preservation. Thirty-six knees were followed for more than 6 months after TKA. These knees were divided into 3 groups: one in which PCL was preserved, with a bone island in the tibial plateau (11 joints) ; the second in which PCL was preserved, without a bone island (16 joints) ; and the third in which PCL was cut (9 joints) . Observation of motion of the knee joint after TKA was divided into 3 patterns: gliding (rolling back), forward gliding, and slipping. No significant difference was observed between the 3 groups in the roll back motion.

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The effects of total knee arthroplasty (TKA) on activity of rheumatoid arthritis (RA) were investigated. Subjects were 37 TKA cases (74 joints) who underwent simultaneous bilateral TKA for RA between 1988 and 1994 (4 males, 33 females; mean age at operation, 59.2 years; postoperative follow-up, 2 years, 7 months average) . RA activity was investigated pre- and postoperatively in these cases using the Lansbury index (morning stiffness, grip strength, joint count, erythrocyte sedimentation rate), CRP and rheumatoid factors. The Lansbury index and CRP showed significant improvement, but there was no correlation between pre- and postoperative rheumatoid factors. At over 5 years after TKA, 15 cases tended to show exacerbation of activity. At 5 years postoperatively, the Lansbury index failed to show significant difference with the preoperative level. RA activity decreased by TKA, presumably because the inflamed synovial membrane and joint cartilage had been removed at the time of TKA. However, in long-term cases there was a trend to exacerbation in those showing recovery.

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To examine the relative frequency of patients with idiopathic osteonecrosis of the femoral head (ION) and its trend in recent years, all inclusive patients with ION who underwent surgery during the past 16.5 years at our hospital were studied. The total 16.5-year period was divided into 3, and change of the number of patients with ION per 10, 000 initial visit patients at our department during the 3 periods was analyzed. The analysis was performed by classifying patients by gender and inducible factors (steroid and alcohol) .
The total number of patients with ION did not show any significant changes during the period. The number of patients with ION with steroid use, especially female patients, had increased significantly, whereas female patients without any inducible factors significantly deceased. Our results should be tested in a larger sample study.

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Between 1991 and 1995, 70 total knee arthroplasties (TKA) were performed using the Miller-Galante II (MG II) prosthesis. Two patients were male and 57 were female. Mean age of the patients at time of operation was 72 years (range 55 to 81 years) .The patients were followed for a mean of 3.0 years (range one to five years) . The arthroplasties were performed for rheumatoid arthritis in 9 and for osteoarthritis in 50. According to the Japanese Orthopaedic Association (JOA) score, a pre-operative score of 43.1 points improved to 80.8 points postoperatively. There were no complications such as dislocation, infection and loosening. Radiographs showed that the femoral and tibial components were positioned with good alignment, and the average femorotibial angle recovered from 184.5 degrees to 175 degrees. At the time of this intermediate report we believe that arthroplasties with use of MG II are acceptable and provide stable femorotibial alignment, but recognized technical difficulty in positioning of the patellofemoral joint.

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We reviewed 100 cases to study the effect of use of physiological saline with epinephrine for the control of bleeding during total knee arthroplasty. We compared two groups, one which used epinephrine, and the other which did not and was the control group. The amount of total blood loss was an average 422.7 ml in the epinephrine group compared with 523 ml in the control group (p <0.005) . The patients in the two groups were similar as to sex, age, knee disease, and surgical technique, with the exception of the use of epinephrine. The technique to use epinephine is simple: Mix 1μl epinephrine with 200 ml physiological saline. Gauze soaked in 150 ml of the physiological saline with epinephrine is used to cover the operative field as a hemostasis perioperatively. After the incision is sutured, the joint cavity is filled with the remaining 50 ml of physiological saline with epinephrine through a drainage tube and drainage clamp. The closed suction drainage is opened one hour after operation. This new technique using physiological saline with epinephrine is simple, inexpensive and effective.

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A follow-up study was conducted to examine the postoperative clinical outcomes of modified Spizty's method (Spizty) and combination of Spizty and intertrochanteric osteotomy (combined operation) . Fifty-four patients (65 hip joints) aged from 17 to 52·years (average age 34.2 years) who underwent the operation at least five years prior were studied. Seventeen of 54 cases (19 joints) were classified as pre-stage osteoarthrosis of the hip; Spizty was performed on 12 joints and the combined operation on 7 joints. The remaining 37 cases (46 joints) were early stage osteoarthrosis; Spizty and the combined operation were performed on 23 joints each and some cases underwent additional muscle release. Clinical assessment according to the Japanese Orthopaedic Association score (JOA score) was performed. AHI, CE and Sharp's angle in reontgenogram were measured. Results before and after operation were compared. In the pre-stage cases, JOA score improved from 77.3 before operation to 93.2 points after operation; AHI increased from 60.7 to 96.3%; CE angle increased from 9.2° to 41.8°; and Sharp's angle decreased from 49.0° to 37.8°. In the early stage cases, JOA score improved from 66.3 before operation to 89.4 points after operation; AHI increased from 52.6 to 93.8%; CE angle increased from 2.4° to 37.00; and Sharp's angle decreased from 51.4°to 39.3°. No statistically significant differences in improvement were detected between the two stages or the two surgical methods. AHI, CE and Sharp's angles in the postoperative reontgenograms improved to within normal range in all cases. Sufficient covering of the acetabular shelf to the femoral head is speculated to account for the clinical improvement. These surgical methods are easy to perform and postoperative clinical outcomes are stable, and they are useful for treatment of pre-and early stage osteoarthrosis in young and middle-aged adults.

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Fully advanced rheumatoid elbow joints of 20 patients (23 joints) were treated with total elbow arthroplasty (TEA) and skin interposition-resection arthroplasty. Results were evaluated according to the elbow functional assessment of the Japanese Orthopedic Association and serial X-ray examination.
Non-constrained surface-replacement type prostheses (mainly DOH type) were employed in 17 joints of 14 patients who suffered from intractable pain with joint instability and/or contracture. The mean age of patients at surgery was 59 years, 8 months. They were followed up for 3 years and 9 months on average. Pain relief, joint stability and increased range of motion was observed and results were clinically good. X-rays indicated loosening of the humeral component with aging in 11.8% of cases. One patient developed complications due to deep infection and the prosthesis was removed.
Skin interposition-resection arthroplasty was performed in 6 patients, with a mean age of 42 years. Patients were followed up for an average of 5 years and 2 months. Results were also clinically good, showing relief from pain and improvement of joint function. However, it was thought that there were problems with progressive humeral bone absorption and joint instability. Therefore, we think that more research needs to be done in this area.

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