Rheumatoid arthritis (RA) is a chronic inflammatory disease with progressive joint damage. Until recently, non-steroidal anti-inflammatory drugs (NSAIDs), followed by traditional disease-modifying anti-rheumatic drugs (DMARDs), were considered the treatments of choice. However, many patients fail to gain a satisfactory response to DMARDs. Tumor necrosis factor (TNF) is an important inflammatory mediator that plays a crucial role in RA. The TNF antagonist (Remicade) was approved by the Japan Ministry of Health in July 2003. It is thought that progression of joint damage and functional disability are lowered by TNF antagonists. Ongoing post-marketing surveillance of the TNF antagonist for serious adverse events is necessary to determine the true incidence rates, and whether a reassessment of the overall risk-benefit ratio of TNF antagonist will be required. This paper describes the clinical and radiological efficacy of Remicade.

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We describe the clinical features of 17 patients with pustulotic arthro-osteitis (PAO), all having the typical skin rash of palmoplantar pustulosis (PPP) and osteitis. Arthro-osteitis with intersterno-costoclavicular or manubriosternal lesions was observed in all 17 cases. Osteitis was also seen in spinal, sacroiliac, and peripheral joints. The majority of osteo-arthritis was monoarthritic or oligoarthritic in type. Polyarthritis resembled rheumatoid arthritis in some cases, but the arthritis was asymmetrical, and followed a monocyclic course. Bone and joint lesions followed a variable and intermittent clinical course over an extended period. Histological examination revealed similar inflammatory changes in skin and bone lesions, with infiltration by lymphocytes and polymorphonuclear leucocytes. These results suggested that PPP and PAO have common aetiological factors.

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We reviewed the clinical and radiographic results of posterior fusion for upper cervical spinal lesions in 31 rheumatoid patients managed between 1973 and 1982.
The average age of the patients at the time of surgery was 54 years and ranged from 34 to 72 years.
The average duration of follow-up was 156 months (13 years) and ranged from 122 to 192 months (10-16 years) .
The subjects included 19 patients who had undergone atlantoaxial posterior fusion (McGraw method) for anterior subluxation of C1 on C2, 8 patients who had undegone occiput-atlas-axis fusion for vertical subluxation and 4 patients who had undergone spinal fusion above and below C2.
All 5 patients who had developed tetraparesis prior to surgery improved with direct traction and continued to do well. Of the 20 patients with myelopathy, 13 improved with surgery, but the myelopathy persisted in seven patients. Ranawat's evaluation of these 20 patients before and after surgery indicated that 18 showed improvement.
All 31 patients had complained of neck pain, and only one patient with pseudoarthrosis continued to complain of severe neck pain following surgery. No patients suffered aggravated symptoms or complications from the surgery.
Among the 19 people with anterior subluxation of C1 on C2 were two cases of radiographical pseudoarthrosis and six cases of reduction failure. Clinical radiographic signs improved in all of these patients and all patients remained stable. We studied microscopic lesions in four of the seven patients who had died after surgery and all patients exhibited bony fusion, which indicated that the surgery was successful. Spinal demyelinization around the compressed site was apparent, however, and this was similar in non-operated autopsy cases.

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Objective: To clarify the clinical features of pseudogout (also called calcium pyrophosphate dehydrate (CPPD) crystal deposition disease) showing a variety of symptoms.
Methods: The clinical features of 73 patients with pseudogout were surveyed. Of those, 23 were male and 50 were female. The average age was 82.8. We surveyed (1) age, (2) the number of punctured joints, (3) The appearance rate of postoperative or posttraumatic pseudogout, (4) the number of recurrent cases, (5) X-ray findings on the affected joints, and (6) complications and family history.
Results: By age, patients in their eighties came on top of the list at 56.2%, followed by those in their seventies at 23.3% and those in their nineties at 16.4%. By joint, the knee joint accounted for 83.6%, the ankle joint 6.8% and the elbow joint 5.5%. Of the surveyed patients, 20.5% of the patients had pseudogout attacks postoperatively or following other medical trauma. The attacks began on postoperative day 4.1 on the average. A recurrence of attacks was noted in 37.0%, and 11.0% of the patients had attacks in multiple joints. X-ray findings revealed characteristic calcifications in 83.0% of the cases and arthritic changes in 77.4%.
Conclusions: Our present study seems to indicate that (1) pseudogout should be suspected when we examine elderly patients with acute arthritic symptoms, especially when they have a history of similar arthritic episodes. However, suppurative arthritis seems to be the most important disease in differential diagnosis. (2) We should note that pseudogout attacks occur also in joints with no radiological evidence. (3) There seems to be a close relationship between the CPPD crystal deposition disease and osteoarthrotic changes and joint destruction. Therefore, we should carefully follow up patients with pseudogout to minimize progression of their joint damage.

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Introduction: We considered that proximal fixation is best for cementless THA, and have used custommade stems based on the morphology of the medullary space in the proximal femoral region. For smooth insertion of a stem into the femoral medullary space, the stem is designed to be as short as possible. In this study, we investigated the results of treatment using a custom-made THA stem with a length of 10cm or less, and evaluated the optimal length of the cementless stem for Japanese patients.
Subjects and methods: The subjects were 56 patients (58 hips) who had undergone treatment using an Expert system ver. 1 custom-made stem (Japan Medical Material, Osaka, Japan) and follow-up observation for more than 5 years. The patients were 15 males (15 hips) and 41 females (43 hips) with a mean age of 57 years (range 21-74 years) at the time of surgery. Their mean height was 154 cm (140-181 cm) . The mean follow-up period was 6.5 years (5-9 years) . The stem surface was sandblasted in 31 stems and hydroxyapatite (HA) -coated in 27 stems, and the mean stem length was 95 mm (83-100mm) . Clinical evaluation was performed using the JOA score, and thigh pain was examined. Radiographically, the stem stability and stress shielding were examined according to the Engh classification.
Results: The mean JOA score improved from 43 points (17-74 points) before surgery to 87 points (68-97 points) after surgery. Thigh pain was observed in 3 of the 31 hips in the sandblasted group (9.7%) and in 4 of the 27 hips in the HA-coated group (14.8%), but it disappeared in all of the hips within 6 months after surgery. With regard to stem stability, 1 of the 31 hips in the sandblasted group was radiographically determined to be in a stable fibrous fixation, while in the remaining hips, it was bone ingrown. Stress shielding of grade 3 or higher was observed in 8 of the 58 hips (14%) .
Discussion: We evaluated patients who had undergone treatment using a custom-made stem with a length of 10 cm or less, in whom good outcomes were clinically and radiographically observed. Stems manufactured mainly in Europe and America are generally too long for Japanese patients, and short stems as evaluated in this study are considered better for proximal fixation. Furthermore, short stems are useful from the viewpoint of bone conservation.

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Between 1991 and 2003, 14 revision total hip arthroplasties (THA) were performed in 14 patients using hydroxyapatite (HA) for acetabular bone defects. The preoperative diagnosis was osteoarthritis in all patients. All patients were women. The average age at operation was 58.7 years old (range 40-68 years old), and the mean follow-up period was 7.6 years (range 1-13 years) . The clinical result were assessed by the hip rating score of the Japanese Orthopaedic Association (JOA score) . The preoperative average of 52.6 points (range 46-62 points) significantly improved to the postoperative average of 84.7points (range 78-90 points) . Direct bonding of host bone to HA was observed radiologically. In X-ray evaluation, there was no loosening nor osteolysis. There was no complication. Acetabular reconstruction with HA granules provided satisfactory clinical and radiological results.

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The usefulness of arthroscopic fat pad resection after total knee arthroplasty was evaluated. From March of 1996 to December of 1999, 207 cases underwent TKA at our hospital, and 152 cases achieved postoperative flexion angles greater than 120°. Among the 152 knees, 8 knees of 8 patients continued to suffer anterior knee pain. Arthroscopic surgery was performed in 8 knees (8 patients) with anterior knee pain associated with high flexion angles (average = 131.9±9.9) . Preoperatively, it was confirmed that the symptom was significantly decreased by local anesthetic injection into the infrapatellar fat pad. Arthroscopically, impingement and fibrosis of the fat pad were confirmed and fibrous structures were removed. Postoperatively, the anterior knee pain disappeared and all knees are symptom-free after a mean follow-up of 3 years. Complications such as patella baja and patellar necrosis have not been observed. These results have demonstrated the usefulness of arthroscopic fat pad resection in patients with anterior knee pain due to chronic fat pad impingement associated with deep knee flexion.

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Recently, surgical drainage has been the first choice of treatment for septic arthritis of the knee. One of the most important factors in treating septic arthritis is the time until the start of drainage. The intra-articular distension-irrigation system (IADIS) offers some advantages over surgical drainage, including ease of starting immediately, lower cost, and no complex preparation.
Sixteen patients with septic arthritis of the knee who underwent IADIS between 1993 and 2002 were evaluated retrospectively. Their ages ranged from 13 to 79 years (mean=53) . The time until the start of drainage ranged from 2 to 30 days (mean=10.4) . Twelve of the sixteen patients recovered from septic arthritis of the knee with only IADIS combined with antibiotic therapy, although three of these twelve patients required repeated IADIS. We have obtained satisfactory results of IADIS that bear comparison with those of surgical drainage. The time until the start of drainage was significantly shorter in the group with excellent results. In summary we suggest that IADIS for septic arthritis of the knee is treatment alternative to surgical drainage when arthroscopic surgery can not be performed immediately.

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Case 1: A 61-year-old woman came to us with a 6-month history of right shoulder pain and swelling due to repeated hemarthrosis. The shoulder joint had a mildly limited range of motion and she reported no history of trauma. Although an MRI examination showed a supraspinatus tendon tear, there were no significant positive signs associated with a rotator cuff tear. During surgery, pigmented synovitis and an isolated complete supraspinatus tendon tear were noted, and a synovectomy and supraspinatus tendon repair (McLaughlin's method) were performed. Histologic evaluation of the synovium did not confirm pigmented villonodular synovitis, because of a lack of nodular formation. Six years after surgery, the patient has no shoulder pain or recurrence of hemarthrosis.
Case 2: A 53-year-old woman with a 1-year history of repeated hemarthrosis of the left shoulder came to our department. Her shoulder showed remarkable swelling, though the range of motion was normal and there were no significant signs of a rotator cuff tear. She reported no history of trauma. During a glenohumeral arthrography examination, there was no leakage of contrast medium into the subacromial bursa. During surgery, remarkable localized synovitis of the subacromial bursa and a bursal side tear of the supraspinatus tendon beneath the synovitis were revealed, so a synovectomy and side to side repair of the supraspinatus tendon were performed. Histologically, nonspecific synovitis was noted. One year after surgery, no recurrence of hemarthrosis has been seen.
Discussion: Chronic hemarthrosis of the shoulder joint is a relatively rare condition, usually correlated with a rotator cuff tear that is often massive. Thus, reports of chronic hemarthrosis associated with a small or partial rotator cuff tear are scarce. Our findings in the present cases suggest that the cause of hemarthrosis is synovitis secondary to supraspinatus tendon deficiency, even when associated with only a small or partial tear.

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We report a patient who had intrapelvic migration of the acetabular component about one year after total hip arthroplasty (THA) which caused pressure on the external iliac artery and led to disseminated intravascular coagulation (DIC) .
This 74 years old woman had received THA for osteoarthritis in her left hip joint in 1996, and had also had THA for osteoarthritis in her right hip joint in 2002. When she visited our hospital in 2004, she had many subcutaneous hemorrhage spots in both her upper limbs, slight fever, slight loss of appetite, and sharp pain in her right hip joint. No pulse was palpable in her popliteal artery or dorsalis pedis artery. The intrapelvic migration of the right acetabular component was revealed by X-rays, and there was a hematoma in front of the femoral head prosthesis, seen by computed tomography, and angiography revealed the entire occlusion of the right external iliac artery. During the operation, we tried a doppler echo of the right femoral artery, but there was no blood flow, so we decided to perform disarticulation of the right hip.
According to the literature, if the acetabular wall is overreamed, the risk of vascular injuries will be higher with intrapelvic migration of the acetabular component. We think it is necessary to perform angiography or magnetic resonance angiography as soon as possible if intrapelvic migration of the acetabular component is revealed during the course of observation after operation.

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