From the point of view of the contour line diagram of the thickness of the cartilage, the patella was classified into 3 groups, namely, 1) the thick central type from the center part of the lateral facet to the central ridge, 2) the thick outside type at the outside of the lateral facet and 3) the thick peripheral type at the outside peripheral part of lateral facet. A review was made on the relation of these to the degeneration of cartilage.
The test samples used were 115 patellae of corpses. The degeneration of cartilage was classified into rough surface, velvet formation, defective cartilage and peripheral elevation. The cartilage surface was divided into 7 sections, namely, medial ridge, central ridge, odd facet, medial facet, the two apex sides and the base side of the lateral facet.
All cases showed some degeneration of cartilage. Rough surface was often observed at the medial facet and seldom at the lateral facet. There were numerous observation of velvet formation at the medial ridge and fewer at the odd facet or apex side. Defective cartilage was often seen at the part from the medial facet base to the central ridge. Peripheral elevation was observed frequently at the medial ridge and medial facet apex.
With respect to classification by the thickness of the cartilage, the central type was often observed on rough surfaces, and there were fewer other changes (sites) and no particular features. The outside type showed numerous velvet formations on the base side from the medial facet to the lateral side. Defective cartilage was frequently observed at the medial facet base, and peripheral elevation at the medial facet apex. The peripheral type showed numerous rough facet from the odd facet to the medial ridge. There were many observations of defective cartilage from the medial facet base to the central ridge. Peripheral elevation was often observed at the medial ridge, and there were few velvet formations.

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The components of the cartilagenous intercellular matrix - proteoglycans, hyaluronic acid, collagen and structural glycoproteins - are degraded during inflammation and following trauma by enzymes of varied origin (Table 1) . The loss of the matrix as long as it is not completely compensated for by a new synthesis, leads to advanced degeneration of the cartilage.
Even today it is not certain to what extent cartilage specific enzymes (that is, the enzymes produced by the chondrocytes) are responsible for the degradation of the intercellular matrix.
There exist numerous biochemical indications that proteases (for example, cathepsin D. elastase) as well as glucuronidase are present in articular cartilage. It is assumed that these enzymes are intracellularly produced by the rough endoplasmatic reticulum (er) and then stored in an inactive form in the lysosomes of the cells. It is a matter for speculation as to how these enzymes reach the intercellular space and in which form they are present.
According to Thyberg and Friberg (1970, 1972), the enzymes are presumably present in the matrix even under physiological conditions, partially in vesicles, which are similar to primary lysosomes. The authors could show, by electron microscopy that acidic phosphatase, the key lysosomal enzyme, is present in the“matrix dense bodies”originate through an in toto excretion from the chondrocytes.
In order to study the meaning of cartilage specific enzymes after blunt trauma of the articular cartilage, we produced cartilage contusions in animal experiments and investigated electron microscopically the time dependent activity of the lysosomal enzymes in the matrix.
Since a morphological representation of the specific enzymes which degrade the matrix (above all, the proteases) is not directly feasible because these enzymes or their respective reaction products could not be coupled on an electron dense substance, we therefore used the acid phosphatase as the lysosomal key enzyme and the arylsulfatase for the electron microscopic investigations.

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We studied the mechanisms of extension lag after knee surgery. The position of the patella was measured by using the method of Insall-Salvati.
Subjects: There were four groups of subjects. Group I consisted of 17 knees of non-surgically treated rheumatoid arthritis (RA), Group II was 21 knees of surgically treated RA: 9 synovectomies and 12 total knee replacements (TKR) ; Group III and IV were two controls: 274 non-surgically treated knees having various knee diseases and 16 TKR knees having osteoarthritis (OA) .
Results: 1) The patellar height of the non-surgically treated RA knees tended to decrease; 2) there was a temporary increase in the patellar height just after surgery in the surgically treated RA knees; 3) there was no correlation between patellar height and aging; and 4) TKR OA knees showed no change in patellar height after surgery.
Conclusion: The course of the non-surgically treated RA knee showed a tendency for the patellar height to decrease due to knee contracture. In the case of the patellar tendon being released by synovectomy or TKR, there was a temporary increase in patellar height which caused extension lag. However, as this temporary increase became less, the extension of the surgically treated knees improved.

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Since total replacement with artificial joints was introduced as surgical treatment of rheumatoid arthritis (hereinafter referred to as RA), it has been possible to rehabilitate patients with severe RA who have become unable to walk and become bedridden. On the other hand, however, there seems to be a tendency to apply this treatment without sufficient consideration because of its favorable results in postoperative short term courses.
Investigation was made on five patients who became bedridden after they had undergone polyarticular replacement for hip and knee joints. The patients consisted of one man and four women whose ages ranged from 50 to 68 years with a mean of 61 years. They had been suffering from the disease for 10 to 30 years with a mean of 16 years. Three of them died 1.5, 2 and 6 years (4 months after re-replacement), after the operation. The cause of death was cardiac insufficiency in two patients and cerebral infraction in one. The patients had become bedridden due to internal complications including acute hepatitis, gastric ulcer and hypothyroidism (due to chronic thyroiditis) or infections in artificial knee joints.

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This is to report the analysis of the factors which influenced the progress of two rheumatoid arthritis cases who received surgical operations on the hip joint 20 years ago.
Case 1 The first case was 48 years old at the onset of the disease and had received hip-joint operations five times since the age of 55. Factors which worsened the condition of the case were frequent gastroenteric disorders, complications due to Sjögren's Syndrome and/or osteoporosis, the use of metal-to-metal prosthesis, and an injury caused by a fall. Favorable factors were the slow development of the RA symptoms in the upper limbs, light body weight, financial stability, and the fact that the cup arthroplasty received proved to be successful for seven years.
Case 2 The second case was 25 at the onset of the disease and had received three knee and hip operations after the age of 30.
Factors which worsened the condition of this case were the deformity in the knuckles which appeared shortly after the onset, the fact that the case became widowed, and the heightened inflammation of the knee. Favorable factors, on the other hand, were the patient's youth, optimistic personality, and the fact that the cup arthroplasty received proved to be successful for nine years.
It is necessary to consider factors such as those mentioned above and to have a long-term perspective of treatment when undertaking surgical reconstruction of a joint on RA cases.

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Purpose
Intraarterial injection therapy was proposed in 1942 by Nakayama and his co-workers as an effective pain-relief method. However, in recent years, this therapy has been virtually discarded. We reevaluated this therapeutic method in patients with radicular ischialgia, osteoarthritis and rheumatoid arthritis of knee joint.
Methods
For intractable pain of the lower limbs, 20m1 of 20% dextrose solution and active vitamin B₁ were injected at the speed of 5-6 sec. into Arteria (A.) femoralis. The hemodynamics of A. dorsalis pedis before and after the injection were examined by the doppler and hydrogen-clearance methods. The behavior of the adrenocortico steroid hormone was also examined before and after the injection.
Results
Intraarterial injection therapy was performed in more than 50 patients. The pain was relieved successfully in the majority of the patients.

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Pelvic radiographs of 200 consecutive Japanese patients admitted for hip surgery at the Hospital of Kobe University in Japan were compared with those of 199 consecutive Caucasian patients admitted for the same purpose to a New England Hospital in USA over a similar 4.5 year between 1972 and 1976.
The incidence of primary osteoarthritis was 1.0% among the Japanese osteoarthritic patients and 57.8% among the Caucasian osteoarthritic patients, that of secondary osteoarthritis was 75.5% among Japanese and 21.1% among Caucasian; and that of secondary osteoarthritis in the wide sense which includes burned-out rheumatoid arthritis, ankylosing spondilytis, old septic arthritis or tuberculosis, old fracture or dislocation and old avascular necrosis, etc., was 23.5% among Japanese and 21.1% among Caucasian. Excluding these underlying diseases as“non-osteoarthritic”from secondary osteoarthritis, the incidence of primary osteoarthritis came to 1.3% among Japanese and 73.3% among Caucasian, and that of secondary arthritis came to 98.7% in Japanese and 26.7% in Caucasian.
It would appear that genetic factors are implicated in the etiology of osteoarthritis of the hip.

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Two months after delivery a forty-year-old woman suddenly had a severe pain in her left hip joint. She had suffered from mild pain there for six years. X-ray revealed rapid a collapse of the head of her left femur, due to avascular necrosis. On admission about two years after the onset of the severe pain, radiolucent zones (Looser zone) appeared in both rami of the pubic bone and the ribs. No other changes were detected in the spine or other sites.
No abnormalities were detected in the blood analysis. Biochemical examination revealed a low value of serum Ca and a slightly high value of urine Ca, but those of serum P, urine InP, Ca²⁺, PTH, 25-OH D₃, 1, 25- (OH) ₂D₃ and BMC (bone mineral content) were all within normal range.
In an examination of the adrenal gland, the morning value of cortisol was revealed to be abnormally high, but ACTH was normal. As no suppression was observed in the rapid suppression test, Cushing's syndrome was suspected, but could not be confirmed by the standard suppression test (Liddle's method) as the value of urine 17-OHCS decreased to the normal level after administration of 2mg of Dexamethasone for two days. The bilateral adrenal gland was hypertrophic in scintigraphy.
From these facts, we concluded that she had had subclinical hyperadrenalism, and that the pregnancy had temporarily aggravated the hyperadrenal state, which in turn might have given rise to changes in the metabolism of lipid and vitamine D. This may have been the cause of the avascular necrosis of the femoral head and the remodeling of the pubis and the ribs.

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A 33-year-old female patient with initialy complaints of asthma for about ten years had acute, rapidly progressive generalized vasculitis. Her symptoms included fever, chest pain, wheezing, abdominal pain, diarrhea, mononeuritis multiplex and skin necrosis on the extremities.
Laboratory examinations demonstrated eosinophilia, serum IgE 7200 IU/ml, and positive antiENA. Endoscopy showed ulcerative colitis endoscopy and histopathologic study of a skin specimen showed vasculitis with eosinophylic infiltration.
The addition of cycrophosphamide to high dose prednisone was followed by gradual and complete remission of clinical and laboratory abnormalities.

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We have performed 81 endoprosthesis in our hospital, using 38 Austin-Moore types, 11 Thompson types, 25 Bateman U. P. F. types and other types. In these, 12 revision cases have been experienced; 3 so-called hips with unexplained pain, and 9 proximal migrations including 5 distal migrations, and one stem breakage of Judet type.
Technical problems and practical solutions with respect to these revision surgeries were described and also the clinical results after revision. Some acetabular erosion was observed in the hips with unexplained pain during surgery.
The proximal migration in revision cases is independant of body weight, prosthetic head/femoral head ratio and osteoporosis. However there was an increased R. I. uptake (Tc. -scintigram) in the hips with unexplained pain.

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Progressive muscle weakness occurred rapidly in a 67-year-old rheumatoid patient. In the beginning cervical myelopathy was suspected from the findings of myelography, however, electrophysiological examination revealed that the clinical symptoms of this patient were due to polyneuritis. Steroid injection improved muscle weakness dramatically and as this weakness got less, increased tendon reflex and pathological reflex became apparent. Therefore we assumed that cervical myelopathy existed in combination with polyneuritis in this patient.

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The monoarticular type of rheumatoid arthritis is very rare, especially in the hip joint. A 64-year-old woman who had suffered left hip joint pain for three years was admitted and from laboratory investigations was diagnosed as having infectious arthritis. A synovial biopsy was done, but the histology was characteristic of non-specific chronic synovitis. One year later the patient was admitted again because of severe pain of the left hip joint. A monoarticular type of rheumatoid arthritis was strongly suspected and synovectomy was chosen as the treatment. The synovium obtained from surgery showed the typical pathological changes of rheumatoid arthritis. Over the next seven months laboratory findings returned to normal and the spontaneous pain disappeared.

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The nerve supply to the posterior longitudinal ligament (PLL), intervertebral disc (IVD) and their attachment to the vertebral body (enthesis) of the lumbar spine was investigated by AchE enzymehistochemistry.
In the vertebral portion of the PLL, there was a nerve network supplied by the sinu-vertebral nerve. In the deep layer of the intervertebral portion (enthesoperidiscal region), there was a dense nerve plexus supplied through other roots. Nerve fibers and terminals were found only in the PLL and the superficial layer of the annulus fibrosus. In the nerve plexus of the enthesoperidiscal region, nerve terminals were small in number in comparison with abundant nerve fibers, but many free endings were found in the enthesis. The clinical implications of this fact show in the frequent occurrence of enthesopathy.
The density of the nerve plexus in the intervertebral portion of the PLL was different according to the level of the spine. This is much related to the extensibility of the PLL.
Experimental study revealed that these nerve fibers and terminals are derived mostly from the dorsal roots of the spinal nerves, and that the vertebral portion of the PLL is supplied bilaterally and polysegmentally, and the intervertebral portion, bilaterally and unisegmentally.
These results suggest that the abundant nerve fibers are related not only to the regulation of movement and posture of the spine through perceptive action, but also to the local circulation, metabolism and the occurrence of inflammation, especially in the enthesis.

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