There is no fixed“functional position”of the elbow joint, because flexion at least to 115°and extension to-40°is mandatory to make the hand reach to both ends of GI-tract, i. e., for the upper limb to be useful.
Operative mobilization of the stiff elbow joint can be classified into 4 types corresponding to the characteristic features of the pathology causing the contracture.
(1) Capsular and ligamentous release, (2) joint toilet in cases with the synovial proliferation and cicatrization occasionally associated with free bodies and osteophytes., (3) resection interposition arthroplasty, or (4) replacement with an artificial joint in cases with extensive cartilage damage and fibrous or bony ankylosis.
In type 1 and 2 operations, posterior approach in which temporary severance of triceps insertion to the olecranon preserves tendinous continuity to the forearm, is recommended to cope with extension or combined extension and flexion contracture, and a less extensive lateral approach in flexion contracture with the added medial approach if needed.
The aimed for ROM has to be acquired during operative procedure, because increase of ROM by postoperative exercise is unpredictable. However, elongation of triceps or biceps should be avoided whenever possible.
Early postoperative full ROM exercise after type 1, 2 and 3 operations by means of the author's“ self-controlled passive motion”system or motor-driven“continuous passive motion”assures reaching the final goal of ROM whithin one month and possibly better final ROM.
Type 3 operation is still useful for mobilizing the elbow joint, because an ideal artifical elbow joint has not yet been produced.
After type 3 and 4 operations, careful protective use of the mobilized elbow joint is mandatory to maintain the improved ROM.

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Tumoral calcinosis, first described by Inclan in 1943, is a rare disease of obscure etiology characterized by the formation of large, painless, juxta-articular calcified masses.
A 9-year-old boy was admitted to our hospital in 1984 with limited flexion of the left knee due to a mass at the anterior aspect. He had noticed skin eruptions at both knees and the right elbow one year previously. There was repeated chalky white discharge but no history of trauma at the locations.
Physical examination revealed several eruptions and painless masses at the extensor aspects of the knees and elbows. X-ray examination of the left knee showed a well-demarcated lobulated periarticular mass which was radiologically identified as calcification.
Laboratory examination showed normal serum levels of calcium, phosphorus and alkaline phosphatase. He didn't have renal disease, collagen disease or parasitic disease. Intense uptake of^99mTc bone scan showed in the lesion. Excision of the mass at the left knee was performed. Calcification existed in subcutaneous fat and the connective tissues, but didn't involve bone, synovial membrane and muscles. Histologically, the lesions were characterized by microscopic lobules containing calcified mass which were separated by fibrous connective tissues. Electron microscopy showed needle-like crystal deposits both intracellularly, within mononuclear cells and extracellularly. In X-ray diffraction analysis there was a characteristic pattern of bone hydroxyapatite. Chemical analysis showed that the Ca/P ratio of the mineral supported the X-ray diffraction evidence.

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The patient, 36-year-old male, first came to our clinic with the complaints of a subcutaneously located huge tumor-like formation of the anterior aspect of his left femur around the knee joint and slight limitation of the affected knee joint motion.
Plain X-ray showed no marked abnormality, but angiography demonstrated a significant hypervascularity at the affected area, CT scan showed the invasion of a tumor-like tissue into the quadriceps muscle.
With such results, the possibility of a malignant soft-tissue tumor could not be excluded.
In the subsequent operation, a huge tumor 15cm by 13cm in diameter, and weightjngd 230g was excised. The tumor had a connection to the joint cavity and had also entered the muscle.
Histological examination showed lamitation of synovial-like cells, hemosiderin deposits and sparse foamy cells, which are the characteristic features of pigmented villonodular synovitis. The most striking pathological findings were the direct invasion of the muscle fiber.
Radiation therapy with a total of 2800rads was initiated post-operatively. Now, 7 months after the operation, the patient is well and without local recurrence, but the significant limitation of joint motion has remained.

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A deviation of any HLA antigen was looked for in a total of 32 patients with pustulosis Palmaris et plantaris and Intersterno-costo-clavicular ossification. Separated lymphocytes were tested for HLA-A, B, C and DR antigens using the microlymphocytotoxity technique (8th International Workshop Method) . Antigen frequencies were compared with 300 healthy controls.
HLA-Bw39 was found in 12.5% of the patients, while this antigen occurred in only 6.5% of the controls. In two locus association the frequency of Bw51 with Aw24 was 22% in patients against 2% among controls.
The frequency of Bw51 with DR2 was 18.7% against only 0.92%. Thus the frequencies of Bw51 and Bw39 antigens was significant different between the patients and controls. This high incidence of these B antigens of great interest, though the difference could not be confirmed statistically.

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Llectins are known to be sugar-binding proteins found in plant extracts. Ten types of fluorescence isothiocyanate conjugated binding lectins Concanavalin-A (Con-A), Dolichos Biflorus Agglutinin (DBA), Griffonia Simplicifolia-I Agglutinin-I (GS-I), Griffonia Simplicifolia Agglutinin- II (GS-II), Arachis Hipogaea Agglutinin (PNA), Maclura Pomifera Agglutinin (MPA), Ricinus Communis Agglutinin-I (RCA-I), Glycine Max Agglutinin (SBA), Ulex Europaeus Agglutinin (UEA-I), and Wheat Germ Agglutinin (WCA), have been used for revealing histochemical lectin receptors on the osteoarthritic synovial membrane.
Tissues were fixed with 95% cooled alcohol and, paraffin-embedded methods were used. In the results GS-I, SBA, PNA and MPA, were positively stained in the cytoplasm of the syovial lining cells. In the subliming layer Con-A bound to small lymphocytes and partially to histiocytes, and UEA-I was shown to bind specifically to synovial vascular endotherial cells. Paraffin serial sections were also incubated in a neuraminidase solution overnight in order to create receptors.
After that process significant positive increases of PNA and SBA receptors were seen in rheumatoid arthritic synovial lining cells, but, not a remarkable one in osteoarthritics.
This study suggests that since varied lectin receptor, were seen on the osteoarthritic synovium, this lectin binding analysis will be a useful method of classification of the cell markers.

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The energy consumption from the aspect of physiological respiratory metabolismwas investigated in patients with RA. Three male and 27 female patients with self-locomotive ability and without pneumocirculatory dysfunction and hepatorenal disorder were chosen from outpatients with RA: Ten healthy volunteers were used as a control group. The experiment was performed by a modification of the Majima's tread mill method. The expiratory gas was analyzed and the heart rate was recorded with an electrocar Biographic monitor at varying belt-speeds and slopes of the tread mill to investigate the relation between the minute heart rate and oxygen uptake (VO₂) .
When the minute oxygen uptake in response to a certain heart rate was used as an index of the physical strength, the index was significantly reduced in RA patients compared to healthy subjects. When analyzed by the class, the index was inversely related with the class and was remarkably reduced in class 3. The pattern of 24-hr heart rate demonstrated a higher ratio of heart rate at rest in patients with higher class, suggesting a reduction of activity in daily life.

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For the past 21 years stiff elbows mainly following trauma were treated with an operative method, in which postero-lateral skin incision was used.
The feature of this method is to maintain at exposure of the elbow joint, the continuity of the triceps tendon by wide subperiosteal stripping, so that early commencement of motion is possible postoperatively and also so good exploration of the elbow joint can be obtained.
Out of 53 cases, 44 were followed for more than 5 years. The average range of motion was 99 degrees, and 89% of these were graded excellent or good according to Knight's criteria.
From these results, this operative method is thought to be very useful for arthroplasty of the elbow.

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The clinical results were analysed using a new surface replacement type of elbow prosthesis made of alumina ceramics, both with an old type composed of a humeral mold (poliycystalline alumina) and an ulnar plate (HDP), and a recently developed new type replacing the ulnar plate with a ceramic peg (Fig.1) .
Twenty-three elbows of 19 rheumatoid arthritic patients were operated on with the ceramic prosthesis, and followed up for 36 months on an average (old type; 51 months, new type; 21 months) . Average age at operation was 53.1 years (32-72 years) . Two patients died during the follow-up time, and the other 17 patients were studied clinically and roentogenologically.
The criteria for operative indication for this prosthesis was painful contracture (flexion up to 100 degrees), painful instability due to joint surface destruction and ankylosis, but fairly good bone stock seen remaining on X-ray examinations.
In operative procedures the posterior approach modified from the Campbell method was made, and trimming of the humeral end was carried out by using a cutting guide (Fig.2) ; anterior angulation (30 degrees) of the humeral component was very essential for obtaining better flexion range and prosthetic fixation. In postoperative care, splintage was continued for over 6 weeks, but active ROM exercise was started at 3 weeks. Clinical evaluations were done by R. B. Brigham hospital scores and X-ray examinations were made every six months.
Postoperative assessment particularly showed sufficient pain relief and good stabillity. There was average post-operative improvement of 53 points in clinical score assessment; in the old type from 29.6 to 77.0 points, and in the new type from 20.5 to 78.6 points (Fig. 3) .The results were somewhat better in new type, because of development of operative technique and prosthetic design. In postoperative ROM, the average flexion/extension was 125/30 degrees and average pronation/supination was 35/38 degrees (Fig. 4) .Such improvement of flexion/extension was very advantangeous in daily life actirities such as face washing, hair dressing and eating, but the limited rotation disturbed management in hand work.
Some complications (Table 1) were experienced mainly due to early operative inskillfulness. Antero-posterior subdislocation was cured with a longer splintage and flexor muscle exercise, but slight lateral instability under 10 degrees was still observed. Olecranon fracture was fixed with wires at revision.
This ceramic elbow prosthesis is now used for limited cases but the clinical result was be very promising for the reconstruction of destructed rheumatoid elbows.

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Ten hip arthroplasties of secondary osteoarthritis was performed on seven young adults by the Bateman UPF prosthesis. The average age of the patients at the time of surgery was 45 years, and all were female. After the operation, every patient was improved, especially with respect to pain.
We concluded that the deepening of the acetabulum in the origenal site and the use of a self-locking stem are impotant.

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Using bone cement in hip surgery was introduced by John Charnley (1960) .
However, the loosening is still a major problem.
In 1973 the first isoelastic RM prosthesis without cement was inserted clinically.“Iso”means“equal”and so“isoelastic”means simply equal elasticity, and thus equal behavior, between the bone and implant, regardless of the original deformation behavior of the bone.
We report about our first experiences inserting an isoelastic RM prosthesis. We implanted the first cementless prosthesis in 1983.17 patients have been observed. We don't find loosening.

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Ipsilateral hip and knee replacements as a single surgical procedure were performed on a total of 12 joints of 4 patients with rheumatoid arthritis. The number of operations totaled 6. In 2 of the 4 patients, bilateral hip and knee replacements were performed. A striking improvement in the walking ability was achieved in all of the cases. Regarding complications, only mild thrombophlebitis was seen in one patient.
For a patient who needs Ipsilateral or bilateral hip and knee replacements, this surgical technique is thought to be very usefur from the following aspects. First, the number of operations can be reduced by this technique. Second, this technique enables very efficient postoperative rehabilitation.

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The significance of locus minoris resistentiae, which occurs in large foreign bodies such as artificial joints, is discussed with the review of 317 prosthetic replacements of the femoral head and 171 artifical total joint replacements carried out during these 12 years.
Three cases with infected femoral head prosthesis, who were all composed of compromised hosts, were enforced to remove the prosthesis infected by exogenous negative bacteria. Three cases with infected artificial knee joint, two of which were successfully managed without removal of the artificial joint, were suffered at a delayed or late stage after operation. One case in which the infected artificial knee joint was removed had many severe complications.
One case of total hip replacement has not suffered from postoperative infection during these 3.5 years, although a large amount of bacteria in the mucinous specimen taken from the surgical field were afterwards demonstrated by culture.
A twelve-year retrospective review of 2, 100 aged in-patients suffering from skeletal diseases yielded 22 cases with suppurative skeletal infections. On the other hand, the mean mortality of the aged patients by infection of other organs was 13% in the cases over 70 years old and 29% over 80.
Generally, risk of joint sepsis including that with artificial joints is not high, compared to the other organs such as respiratory or urogenital organs in the aged patients. Of the 6 cases with infected artificial joint, 4 cases with a compromised host were enforced to remove their artifical joints. To minimise the risk of postoperative infection of an artificial joint, it is important to take care of the artificial joint as a sanctuary having locus minoris resistentiae, but it is more important to control the associated diseases, namely minoris resistentiae generalis.

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Treatment of the femoral neck fracture seems to be still confused when encountered in rheumatoid arthritis and no general agreement on the treatment has yet been reached. We reported six cases treated by open reduction and internal fixation in 1980. However, most of them have had various complications during these four years excluding one case with Garden-2 grade displacement and fixed with multiple pinning. Therefore, we have concluded that osteosynthesis can only be indicated on relatively young patients who have slight to mild osteoporosis, up to 3 grade in Garden's classification, and well controlled in RA activity.
We have treated 11 rheumatoid cases with 13 femoral neck fractures up to present, and the results are reported in this paper. All cases were women with definite or classical RA. Average age at operation was 64.4 years (from 39 to 78 years) . RA stage of these patiens was 3 or 4 and class was 2 to 4. Clinical results were assessed by the hip score of the Japanese Orthopedic Association. Grade of osteoporosis on the X-ray film of the hip joint was evaluated by the Singh Index. The average follow-up period was 2.6 years.
Osteosynthesis was performed on two hips according to the indications mentioned above. No complications were experienced in these cases and the final clinical score at follow-up (average 2. 7 years) was 92 and 83 points respectively.
Femoral head replacement was selected in 8 hips which showed marked displacement or over moderate osteoporosis. Austin-Moore type prosthesis was used in 4 hips and bi-articular hip prothesis (Bateman type) in 4 hips. One patient died by heart failure 8 months after the operation. Average clinical score of the other 7 patients was 75 points and there is no significant difference between the two types of prosthesis at present. Though no difinite determination of which prosthesis is better could be made because of the shortness of the follow-up study, bi-articular hip prosthesis can bechosen due to biomechanical superiority.
Three patients who had high activity or severe osteoporosis received the Chernley-Müller type of total hip replacement (THR) . Their average clinical score was 69 points and lower than in hemiarthroplasty. One of them showed stem loosening and complained of moderate pain on walking. No complaints about the hip joint have been found in the other two cases but their RA activity with disability has advanced recently. Careful evaluation is necessary for indication of THR.
With respect to pathomechanism, no inducing accident could be detected in the four cases. All were relatively old women and had a long period of disease. Two of them had history of long steroid administration and two had an ipsilateral TKR operation from 6 to 12 months before. Singh Index was 2 or 3 in these cases. The mechanism in these cases seemed to be a stress fracture. The patients who have the inducing factors such as previous TKR or steroid administration should be watched carefully.

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Shelf operation has not been performed recently but it is our conclusion through our previous experience that if the shelf is made at the right position, satisfactory results will be obtained.
However, it is disadvantageous in this procedure to put a cast on for a long time. This causes patients discomfort. The author has used bone cement to prevent this with prior experience of use of bone cement with bone graft in cases of total hip replacement. Grafted bone for the shelf is fixed strongly with bone cement immediately, and therefore, it is not necessary to put a cast on after operation.
From April 1982 to October 1984, shelf operation with bone and bone cement was performed on 32 joint of 20 patients, and a follow-up study was made on 23 joints at last 7 months after operation, and an average of 18 months. Patients were allowed to walk on the 4th post-operative day.
Patients have no hip pain even when walking after operation, and satisfactory results was obtained in all cases.

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Four cases of idiopathic transient osteoporosis of the hip are reported and compared with 101 similar cases, published in world literature. Typical cases can be diagnosed early by clinical symptoms, laboratory data, X-ray findings and bone scintigrams. Idiopathic transient osteoporosis of the hip occurs frequentry in men and rarely in women without pregnancy, and is distinguished from that of the hip in pregnancy.

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