The indication of total hip replacement (THR) in bilateral osteoarthritis (OA) of the hips in patients between the ages of forty and forty nine was discussed.
In fifty-four patients, eleven received bilateral THR and seventeen, unilateral THR. In the latter, radiological changes in the alternative side after THR were investigated. And the natural histories of the bilateral hips of ten patients who had been observed for five to thirteen years and had not received surgical procedure were examined radiologically.
Two of the twenty-eight patients operated-on had one-stage THR of bilateral hips because they had to return to work within two months. In eleven non-operated-on hips with OA of the end stage, radiological and clinical improvement was not seen, but in thirteen hips of early and advanced OA, clinical findings such as pain, walking ability and ADL improved, and in two hips, widening of the joint space was observed radiologically. Thus it seemed that the development of OA changes in non-operated-on hips was interrupted by the relief of the stress on the hips.
From the above findings it is concluded that THR might be indicated in patients who have to return to work quickly because of some social circumstances, and in the patients whose OA changes of the non-operated-on hip may increase after any surgical procedure except THR.

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When the joint surfaces of one hip are congruent in all positions and the opposite hip has congruent joint surfaces in adduction, lateral displacement of the greater trochanter with muscle release is indicated for the former hip and valgus intertrochanteric osteotomy for the latter.
The patient stands up after the first month. She puts about 10 kg on the osteotomized hip when she walks. No active exercises should be done. She uses two crutches for 6 months and one crutch after that.
Two patients were successfully treated by this procedure.

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Surgical treatment was performed on 21 patients in their forties with bilateral osteoarthritis of the hip. The average follow-up time was 5.5 years. THR was done on only one side in 10 patients, and on both sides in four cases over a five-year period. In two cases a second operation was done after five years. THR was done on one side and a shelf was made on the another in four cases. One patient was treated with a bilateral shelf operation. THR was performed on relatively young patients with severe pain and who could not take a long time for treatment. The average pre-operative score was 34 and the post-operative one was 86.
Revision was done in two cases but just stems were changed and not the cups. Satisfactory results were obtained in most cases.

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A functional evaluation of 350 hip joints in patients who had undergone hip-joint surgery was carried out, and the correlation between activity of daily living (ADL) and range of motion (ROM) was analyzed. Of the assessment categories adopted by the Japan Orthopedic Association, the 5 activities of ‘cutting of nails’, ‘putting on and removing of socks’, ‘bowing from the kneeling position’, ‘standing up’ and ‘crouching’ showed a strong association with ROM. Flexion, abduction and internal rotation were found to be related to ADL at a ratio of 6 to 4 to 4.
The degree of difficulty in ADL was divided into 5 levels, and the angle required (movement limits) in each of these was investigated. It is possible to deduce the range of motion required once the ADL is evaluated, and a functional evaluation of the hip joint can be made even without direct examination. Furthermore, a hip-joint functional evaluation standard (I, II) was devised in consideration of the Japanese living style and housing situation.

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From 1975 to 1985, 51 Charnley type total hip replacements (THR) were performed at our hospital on rheumatoid arthritis patients. The average age at time of operation was 51.3 years with a range of 29 to 73 years. The average period of follow-up was 3.9 years with a range of 6 months to 10.3 years. The mortality rate of patients operated on was 15.8%, which was higher than that of osteo arthritis patients who had received THR at our hospital. There was a high rate of radiological changes, which was to be expected in patients with great increase in activity after receiving THR. The clinical assessment was stable in all patients except 2 who had cervical lesions. Patients given steroids had no significant radiological changes. There were good results with the bone grafts performed on protrusio acetabuli hips.

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We followed 48 patients (48 joints) for more than 5 years after femoral head replacement with an Austin-Moore type prostheses. Twenty-two had died, 3 were missing, one was re-operated on with a total hip prostheses, so 22 could be evaluated clinically. The average length of follow-up was 7.4 years, and the average age at the most recent follow-up was 74.9 years old. Though 12 patients could enjoy out door lives, 5 were limited to indoors and 5 were always in bed. But in 7 of the 10 patients who could not walk satisfactorily, poor results were due to systemic complications such as rheumatoid arthritis, hemiplegia, and senile dementia.
Radiograms of 15 patients were evaluated; loosening was found in 2 (13%), distal migration in 11 (73%), and central migration in 6 (40%) . The loosening caused severe pain which resulted in an inability to walk, but distal migration did not affect clinical results. Central migration seemed to cause hip pain which was not so severe that it disturbed daily life. It was often seen in cases with smaller prostheses in diameter compared with the other femoral head.

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Impact load applied to a normal knee joint will be attenuated by its visco-elasticity but one applied to an implanted knee will not be because of the rigidity of the components and will break cancellous bone in the bone-prosthesis interface.
A new prosthesis has been worked out which includes silicone rubber and has a shock absorbing mechanism. Testing of the fatigue tolerance and the bio-compatibility of the silicone rubber hadgood results. In the dropped weight test, the new prosthesis implanted in the cadaver knee joint attenuated the impact load more than the conventional knee prosthesis.
On this basis, we will be able to develop a new viscoelastic prosthesis (Shock Absorbing Knee Prosthesis) which will result in less mechanical loosening of implanted knee joints.

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Twenty joints of 11 patients using the Yoshino/Shoji total knee prosthesis were studied. We attempted to eliminate the error arising from individual differences, differences in the size, shape and rotation of the knee joint, and so on. For this purpose three points of the prosthesis were selected to obtain data on. This was input to a computer in order to separate the data for rotation accompanying flexion, and then the instant-center, the PAL-curve and the patella curve were investigated. X-rays of the knees were taken at 0, 30, 60, 90 and 120 degrees of flexion.
All of the knee joints showed polycentric movement. The instant center seemed to drop to a lower point upon flexion, but was not displaced very much to the posterior except in the case of sitting with one's legs under one, Japanese-style. The PAL curve and patella curve were smooth, indicating a smooth action of the knee joint. No definite tendency could be identified in regards to rotation.

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The functional evaluation and the radiographical assessment of 120 consecutive knematic total knee replacements were reviewed after a minimum of two years. Eighty-eight percent of the I, II, and III type Kinematic knees had excellent or good results. Seven knees (6%) had complications which required reoperation. A radiolucent zone of more than 1mm width appeared in 6 knees (5%) . And although the knee alignment and surface geometry of prosthesis of all the cases were not ideal, the radiological findings had no relation to knee function. The results of the II type Kinematic knees were almost the same as those F.C. Ewald et al reported in 1984. When compared with a previous series of Total Codylar and Anametric knees, the Kinematic knee is superior to them both with respect to JOA score and in the range of motion, and the complications with it were less.

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Non-hinged total knee arthroplasty is being performed throughout the world. However, in patients with rheumatoid arthritis who have muscle weakness, ligamentous laxity and severe joint destruction, subluxation may be easily complicated after a non-hinged surface replacement total knee arthroplasty. For this kind of patient, a total knee should have a kind of stabilizer per se. We have performed Kinematic stabilizer total knee arthroplasty on 11 rheumatoid patients. Stability could be gained in walking, and postoperative flexion was more than 110 degrees in 55% of the cases. Therefore, Kinematic stabilizer total knee arthroplasty seems to be useful for rheumatoid knees.

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We macroscopically examined the articular cartilage, menisci and cruciate ligaments on 34 rheumatoid knees which belonged to Stage 3, according to Steinbrocker's classification, during total knee replacement (TKR) . These findings were also compared with the duration of disease and the occurrence of varus-valgus deformity.
The degree of destruction of articular cartilage was severer in the femuro-tibial joint than in the patello-femoral joint. In both no difference could be found between the weight-bearing part and the non-weight-bearing part with respect to the rate of cartilage loss and that of eburnation.
Most menisci had disappeared on both the medial and lateral sides, but in cases in which it remained, the peripheral part and the posterior segment were observed.
As for cruciate ligaments, the anterior cruciate ligament showed a far greater defect rate than the posterior cruciate ligament. We could not find an exact relationship between the macroscopic findings in relation to lesions and the duration of the disease of the knee. No statistical difference was found between the severity of medial and lateral lesions and the femoro-tibial angle in the standing position.

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The incidence of cervical lesion in rheumatoid arthritis (RA) was studied on roentgenograms taken preoperatively. Four roentgenograms (antero-posterior, lateral including stress views) were examined by one of our members (Y. M.) . The total number of cases was 63. All were diagnosed as classical RA and had had surgical treatments. There were 9 males and 54 females averaging 57 years in age, ranging from 30 to 76, with a contraction period of 16 years on an average. Cervical lesion was found in 48 cases, and subluxation in 41; an incidence of 76% and 65% respectively. When operative treatments were selected for these RA patients, careful management was essential, especially during general anesthesia and the operation.
Magnetic Resonance Imaging was applied on 10 RA patients and compared with the. plain roentgenograms and clinical findings. Four cases had atlanto-axial subluxation (AAS), 2 had vertical subluxation (VS), 1 had subaxial subluxation (SAS), and 4 had multiple disc narrowing. Only 2 cases showed compression of the spinal cord from the front and discontinuity of the spinal fluid. But MRI doesn't give good contrast yet and requires too long a time to take for RA patients. It was concluded that the best method for RA cervical lesion was to apply the short spin echo method on the stressed neck.
Halo-vest was applied on the 6 operated cases including 2 cases of AAS, 2 of VS and 2 of SAS. The method of operation was anterior body fusion in the 2 SAS cases and posterior fusion in the other 4. The average follow-up period was 10 months (4 to 20 months) . All cases became able to walk with or without aids. Though the short follow-up study indicated satisfactory results, general complications, such as ileus and gastric ulcer, occurred in 4 cases during Halo-vest fixation.

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In rheumatoid arthritis, subluxation of the atlanto-axial joint is common. However the symptom of spinal cord compression isn't. In our department, occipitocervical fusions were performed over the past three years in three patients with rheumatoid arthritis associated with quadriparesis and gait disturbance due to anterior and superior subluxation of the atlanto-axial joint. Skull traction was carried out to reduce the subluxation. Satisfactory reduction was obtained in one patient only. A halo brace was applied to maintain the reduced position before the operation. Laminectomy of the atlas, enlargement of the foramen magnum to relieve the spinal cord from the compression and occipitoaxial fusion were performed. Walking was permitted within one week after operation. Almost complete recovery of the neural involvements had been obtained by the time of the follow-up evaluation. None of them had pseudoarthrosis. Though a fracture of the grafted bone was noticed in one case, it could be treated conservatively. A postoperative infection which occurred in one patient was cured by the suction and irrigation method. Application of the halo brace is therefore considered to be a useful apparatus for managing the atlanto-axial subluxation.

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Successful anterior spinal fusion in rheumatoid spondylitis is hard to achieve because of the accompanying osteoporosis.
Anterior cervical fusion was performed in five rheumatoid patients with subaxial cervical subluxation. All of the patients were quadriplegic before surgery except one who showed segmental signs only. Halo-vest external fixation was applied before operation and was maintained during and after it. The Robinson-Smith method was used in three and subtotal somatotomy combined with strut bone grafting was done in the other two. Anterior fusion was reinforced with an anterior cervical plate in three.
Neurological improvement was obtained in all of the patients. Grafted bone was crushed and absorbed in one without cervical plate reinforcement. Those whose cervical fusion was strengthened with plate all obtained rigid fusion.

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Rheumatoid glanulomatous lesion of the lumbar spine has been reported only rarely. A 59-year-old female patient with a 19 year history of seropositive rheumatoid arthritis sufferred from low back pain. An X-ray of the lumbar spine showed a narrowing of the 4th disc and erosion including the apophyseal joint. A glanulomatous lesion between the 4th disc and the edge of the vertebral body was found on operating. Histological diagnosis of the glanulation was chronic non-specific inflamation.

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Nineteen knees in eighteen cases of osteochondral fracture that operative findings were recorded in detail on were studied with respect to patellar cartilage lesions around the osteochondral defect. On the abnormal articular surface, the incidence of each type of lesion observed was as follows: fissure, 12 knees; softening, 13 knees; fibrillation, 5 knees; ulcer, 1 knee; and repair-like changes, 8 knees. Most of the fissures were deep enough to reach the subchondral bone and ran in the longitudinal direction in the superolateral portion near the osteochondral defect. This could be thought to result from the shearing force passing from the medial to the lateral side of the patella. These articular lesions may be one part of post-traumatic chondropathy like post-traumatic chondromalacia patellae and fracture of the patella are, but they were not progressive, unlike post-traumatic chondromalacia patellae, and were almost painless, unlike fracture of the patella.

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Arthroscopically-controlledlateral release for recurrent dislocating patella was reviewed in 5 knees at an average of 7.2-monthshort-term follow-up. Eighty per cent of the patients were rated good or excellent. The results with this procedure were as good as with other major surgical procedures. Over 20° of Q angle and failure to maintain good quadriceps muscle strength were the major reasons for fair and poor results. In the properly selected and motivated patient, this procedure offers an effective alternative to major patella realignment procedures.

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We examined 31 patients with chronic anterior Cruciate ligament (ACL) injury. It was often associated with medial meniscus tear (76%) and lateral meniscus tear (52%) . Twenty-nine cases were followed from 6 to 18 months. The interesting fact was found that some of these torn ACL had been ruptured in one or more minor traumas.
The torn ACL insufficiency cases were then divided into two types arthroscopically, complete rupture and partial rupture or elongation, and were evaluated statistically.
Arthroscopy can play a significant role in the evaluation of the torn ACL and the choosing of surgical or non-surgical treatment of it.

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We reviewed the cases of seven knees in six patients, 5 males and 1 female between 11 and 17 years old, with osteochondritis dissecans of the femoral condyles. The lesions were seen in the classical site in 3 knees, the extended classical site in 1, the medial infero-central site in 1 and the lateral infero-central site in 2. Four patients were engaged in athletics, and in the two patients with osteochondritis dissecans of the lateral femoral condyles, one had an associated discoid lateral meniscus and the other had associated genu valgum.
The etiology of osteochondritis dissecans is multifactorial. In our study, however, repetitive microtrauma was suspected as the cause.
After reviewing the literature the authors synthesized the treatment schema in accordance with age, location of lesion, width of osteochondral defect, the condition of the fragment and associated disorders.

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High tibial osteotomy has become a common surgical treatment for osteoarthritis. From July 1976 to July 1985, we performed high tibial osteotomies on 99 knees in 91 patients using Bauer's and Koshino's wedge osteotomy. We fixed bone with two Steinman pins. Of these patients, more than 5 years had elapsed since operation in 51 with 57 operated-on knees, and we did a follow-up on them with respect to operating technique and prognosis. Four patients had died and 12 were unavailable. The period of follow-up on the remaining 40 knees in 35 patients was, on an average, 7 years and 3 months. We made evaluations based on the Yokohama City University evaluation table of knee joints. After including patients'judgments, we classified knees into 4 grades; excellent, good, acceptable and failure. The total results were as follows: good, 22 knees; acceptable, 16 knees; failure, 2 knees.
These results were worse than those over a shorter period. Among 6 knees operated on with hemi-open, 2 had delayed union. The causes of delayed union on 5 other joints were the following; in 3 joints the fit of the inside bone cortex was inadequate, so that a dent occurred; in one joint there was a superficial infection; and in one joint the Steinman pin inserted was not positioned well. The cases which had a FTA showing 164°-174° had good results. Excessive osteotomy met with better results than insuffient osteotomy.
We also examined the proceeding of FTA on patients with non-union peroneal bone at this time. Some of those with valgus or varus deformities were getting worse than those with good-union peroneal bone. It is important for obtaining stable results with high tibial osteotomy to perform optimum osteotomy and then promptly accomplish and support bony-union.

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Lectins are known to be sugar-binding proteins found in plant extracts. Thirteen types of fluorescence isothiocyanate-conjugated lectins, Urex europaeus 1 (UEA-1), Arachis hypogaea (PNA), Griffonia simplicifolia 1 (GS-1), Dolichos biflorus (DBA, Glycine max (SBA), Ricinus communis 1 (RCA-1), Maclura pomifera (MPA), Canavalia ensiformis (Con-A), Griffonia simplicifolia 2 (GS-1), Triticum vulgalis (WGA), Lens culinaris (LCH), Limulus polyphemus (LPA) and Helix pomatia (HP) were used for revealing histochemical lectin bindings on the osteoarthritic articular cartilage.
Cartilage tissues on loaded areas were fixed with 95% cooled alcohol, and paraffin-embedded. methods were used. In the results WGA, LCH and Con-A were positively stained in the cytoplasm and pericellular matrix of the cartilage. In the glucose-specific lectins, no differences were found between osteoarthritic (OA) cartilage and normal control (NC), while in the galactose-specific lectins, MPA, RCA-1 and GS-1 were stained positively and DBA slightly on the OA cartilage, but not on the NC.
Cartilage matrices were thus shown to bind specifically with WGA, LCH, Con-A and GS-2. In the glucose-specific lectins, OA cartilage matrices were bound more specifically than those of normal control. In the galactose-specific lectins, osteoarthritic cartilage matrices were bound RCA-1 partially, but there were no differences between OA cartilage matrices and NC.
This study suggests that since varied lectin binding was seen on the articular cartilage, OA cartilage is bound with lectins stronger than with normals, and, the contents of the carbohydrate component are higher than in the normal control.

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Internal fixations using a compression hip screw were performed in 18 cases with intracapsular fractures of the femoral neck. These cases were divided according to Garden's classification into the following sub-groups; Stage II (3 cases), Stage III (8 cases) and Stage IV (7 cases) .
The method of reduction for the Stage III group is different from that for the Stage IV. In the former, vigorous internal rotation and abduction are necessary, while in the latter, overtraction should be avoided. Because of the wide range for rotationary displacement permissible, about 60°rotation is acceptable. However, the deformity ascribed to adduction is a contraindication for the procedure.
The method of operation differs from the fixation of a compression hip screw for extracapsular fractures. Prior to reaming, two guide pins must be inserted in the acetabulum in parallel with each other. The lag screw should be inserted deep into the site beneath the subchondral bone, aiming at the lower one-third of the femoral head.
Weight bearing can be started at the end of the 2nd week postoperatively and despite the presence or absence of bony union, progression to walking on crutches can be achieved on stabilization of the patient's gait. But great care should be taken to assure that the patient doesn't falling down. When this occurred, the X-ray finding of note was the appearance of a space due to a cutting interaction between the lag screw and the cancellous bone of the femoral head. Examination of AP and axial view X-rays are of this space mandatory for the determination of the presence.

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Stress fractures in patients with longstanding rheumatoid arthritis are more common than is generally appreciated. Ten such patients are described. Most of the stress fractures were in the lower extremities. Osteoporosis due to RA and corticosteroid treatment and angular joint deformities of the knees are important factors in their genesis. Unaccustomed increase in ambulation after reconstructive surgery such as total joint replacement is also another predisposing factor in the occurrence.
Pain and swelling arising from stress fractures are easily mistaken for rheumatoid synovitis. Early recognition and adequate treatment are important to avoid further displacement of the fracture.

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A 45-year-old male suffering from renal insufficiency for 9 years, which had been treated by hemodialysis, complained of marked swelling and severe arthralgia of the right sternoclavicular joint. Rentgenography showed periarticular calcification of the joint. After arthrotomy and currettage, swelling and pain dramatically subsided. Histological analysis revealed granulomatous reactions consisting of histiocytes and foreign body giant cells. The calcific material was proven to be hydroxyapatite by X-ray diffraction study. The arthritic symptom was postulated to have been derived from crystal-induced inflammation caused by hydroxyapatite aggregates.

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Spontaneous osteonecrosis of the knee was described as a distinct entity in 1968 (Ahlbäck et al) . The etiology of this lesion remains unknown, although micro-trauma and vascular insufficiency have been suggested as causes.
Typically the patient is a female in the sixth and seventh decade, sudden onset is characteristic, and the lesion occurs mainly on the medial femoral condyle. Radiographs show a subchondral radiolucency on the weight-bearing area with subsequent flattening, collapse and sclerosis.
We report on idiopathic osteonecrosis of the femoral condyle occurring in two sisters.

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