This study was done to evaluate the long-term outcome of total hip arthroplasty (THA) for rheumatoid arthritis (RA) at the Senami RA center and to discuss the management of infection following THA. Infections occurred in 6 hips (2.8%) out of 212 THAs in RA patients during a 15-year period. Two resulted in an early-onset infection within 1 year after operation and 4 resulted in late-onset infection after more than 1 year. Initially, each case was treated with antibiotics and local debridement, however, in 5 cases the prostheses finally had to be removed. After removal, 2 cases were diagnosed as so-called “Girdle stone, ” 2 underwent revision, and one case died because of sepsis. There was no recurrence of infection in any of these cases.
Although, intraoperatively, a sterile procedure is very important in the prevention of postoperative infection, especially in RA patients, preexisting infections should be treated pre-and postoperatively, because host susceptibility to infection increases dramatically. At our center, specific attention has been given to predisposing conditions, such as diabetes mellitus, renal insufficiency, skin ulcers, and ingrown toe nails, etc., so there have been no infections at the center since 1989.

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We report two cases of patients with rheumatoid arthritis in whom involvement of the lumbar vertebrae was surgically treated.
Case 1 was a 75-year-old woman. Plain X-rays of the lumbar spine showed an osteolytic change of L2/3 intervertebral disc space with MRI findings of low signal change in T1-weighted image and high signal change in T2-weighted sequence. Posterior fixation with Luque rods was performed from L1 to L4 with facet fusion at the L2/3 level, followed by anterior fusion from L2 to L3. Histological examination of the resected samples from L2/3 disc space showed degenerated cartilage, bone with some necrotic trabeculae, and fibrous tissue with massive fibrinoid necrosis with infiltration of lymphocytes.
Case 2 was a 65-year-old man. Plain X-rays of the lumbar spine showed disappearance of L3/4 intervertebral disc space with anterior subluxation of L3 on L4. Posterior fixation with Luque rods and anterior fusion were done from L3 to L5. The resected materials at L3/4 and L4/5 intervertebral disc space were destroyed bone with highly vascular fibrosis and partly fibrinoid necrosis with palisading histiocytes. As the grafted bone disappeared, an additional surgery was performed : decompressive laminectomy of L3 and L4 and pedicular screw fixation from L2 to L5 with postero-lateral fusion. Pathological examination of granulomatous tissue around the L3/4 facet joint showed, as in the first operation, fibrous tissue with histiocytes, lymphocytes, plasma cells, and partly fibrinoid necrosis.
Characteristically, MRI showed post-operative spontaneous reduction of posterior bulging of the L2 body in Case 1, and fluid retention at the L3/4 intervertebral disc level anteriorly and around the spinous process posteriorly in Case 2.

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Autologous costal perichondrium was transplanted to a full-thickness articular cartilage defect in a rabbit knee. The result was compared with a non-treated defect in the contralateral knee and with autologous fascia grafting. In the costal perichondrium grafting group, repair tissue was created by mesenchymal cells from bone marrow, not by the perichondrium. The non-grafted and fascia grafting group showed no improvement.

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Surgical treatment for osteonecrosis of the femoral condyle remains controversial. We evaluated 9 knees in 8 patients with spontaneous osteonecrosis of the femoral condyle, which were treated with arthroscopic multiple drilling. Two of the cases were in men and 7 were in women. Average age of the patients at time of operation was 60.9 years, ranging from 52 to 73 years. The follow-up period ranged from 5 months to 3 years and 11 months. Radiographic assessment was classified according to Koshino's staging system. In 2 knees of stage 4, which underwent drilling only, both the necrotic area and varus-knee deformity increased. In one knee with poor results, the area of necrosis assessed by the MRI was larger than that assessed by the radiograph. Clinical results were evaluated according to criteria of the Japanese Orthopaedic Association (JOA score) . The result of one knee of stage 4 was poor. Good results were obtained in the 5 cases of both stage 1 and stage 2, which showed less than 178 degrees of femoro-tibial angle (ETA) and necrotic area less than 13 millimeters in diameter. In the two cases of stage 4 with more than 179 degrees of FTA and necrotic area greater than 14 millimeters in diameter, the combination of drilling and high tibial osteotomy gave good results.

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Two hundred and eighty-four Charnley low friction arthroplasties were performed between 1972 and 1989 for coxarthrosis at Okayama University Hospital. Aseptic failure of fixation, defined as migration of the component, was seen in 20 acetabular components and 14 femoral components. Factors affecting aseptic failure were radiologically studied. The risk factors affecting aseptic loosening of the acetabular component were excessive reaming of the acetabulum, malposition of the acetabular component, and nonunion of the greater trochanter. Massive wear of the polyethylene was also an important factor. Biological response to wear debris seemed to affect the aseptic loosening of the acetabular component. The risk factors affecting aseptic loosening of the femoral component were poor cementing technique, low canal filling of the femoral component, and unfavorable geometry of the medullary canal (a socalled stovepipe canal) . Wear of the polyethylene was not an affecting factor. These results show that the mechanism of aseptic loosening of the femoral component is mechanical in nature, whereas the mechanism of aseptic loosening of the acetabular component is both mechanical and biological.

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We evaluated 38 patients with rheumatoid arthritis who had surgical treatment for cervical spine disorders at Nagoya National Hospital. The average follow-up period was 93 months (range 3 to 199 months) and the average age at operation was 57.3 years (range 39 to 75 years) . Of 38 patients, 31 underwent posterior fusion, 4 underwent anterior body fusion, 2 were treated with laminectomy, and one with both posterior fusion and resection of odontoid. Neck pain and the neural deficits were evaluated pre- and postoperatively according to Ranawat's scale. In 30 patients, neck pain had improved ; in 8 cases there was no improvement. No case showed an increase in pain. As for neurological deficits, in 12 patients the condition had improved ; in 26 cases there was no improvement. Eighteen patients who died during the follow-up period were analyzed. Average age at death was 67.5 years. The most common causes of death in our series were heart failure, infectious diseases, and cerebrovascular disease. Distribution of causes of death was no different from that in rheumatoid arthritic patients who had no treatment for cervical involvement. We conclude that functions of activities of daily living were good postoperatively, and surgical treatment for cervical lesions had no effect on life expectancy in our patients.

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The purpose of this study was to investigate the pathomechanism of osteoarthritis (OA) of the knee. Plain radiographs and magnetic resonance (MR) images in 56 patients with unilateral symptomatic knee were examined. All patients were older than 40 years. Presence of osteophytes and OA grade were recorded based on radiographic findings. Femoro-tibial angle (FTA) was also measured on weight-bearing and nonweight-bearing radiographs. Meniscal degeneration was graded based on MR findings. These variables were compared between symptomatic knees and asymptomatic knees. Presence of osteophytes and OA grade were similar in both knees. There was significant difference in weight-bearing FTA, while no difference was seen in nonweight-bearing FTA. MR grade of the medial meniscus was significantly higher in symptomatic knees than in asymptomatic knees, which was remarkable at the posterior portion. No significant difference in the MR grade was found in the lateral meniscus. These data suggest that minor instability secondary to cartilage wear in the medial compartment and degenerative tears in the medial meniscus may be associated with symptoms in osteoarthritic knees.

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The effect of retinoic acid on the gene expression of matrix metalloproteinases, MMP-1, MMP-2, MMP-3, MMP-8, MMP-9 and MMP-13, in the human chondrocytic cell line, CS-OKB, was investigated. The CS-OKB cells were cultured in the presence or absence of retinoic acid (1-10μM) for 3 days. The expression of mRNA of the MMPs was analyzed semiquantitatively by reverse transcription-polymerase chain reaction. Retinoic acid significantly suppressed the mRNA expression of MMP-2, -8, -9 and -13. Among these, MMP-13 mRNA expression was the most strikingly suppressed.

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Fusion defects are produced when polyethylene raw materials do not completely fuse, resulting in spaces forming on the boundary of the incomplete fusion. Judging from a review of cases of both Bioceram and Charnley prosthetic sockets, when polyethylene thickness is less than 9 mm, volumetric wear rate tends to increase, with an increased number of fusion defects. However, when the thickness the polyethylene sockets is greater than 9 mm, the number of fusion defects does not seem to affect volumetric wear rate. In the sockets studied, the maximum size of fusion defects does not affect volumetric wear rate. In conclusion, a correlation between wear and the number of fusion defects cannot be concluded.

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