The symptoms, surgical findings and results in 72 cases of joints with “Rotator interval” lesion of the shoulder that have been operated in the past 13 years are as follows;
1) “Rotator interval” lesion can be classified into two types: the contracted type and the unstable type.
2) The unstable type occurs in a young person who has a past history of minor trauma and/or sport injury. The elapsed time from the occurrance of the symptoms to the surgery is unbelievably long, and various abnormal changes have been observed in the surgery.
3) The contracted type is found in the elderly and many of these cases clearly have a history of a trauma. Bursal adhesion around the “Rotator interval”, including the coracohumeral ligament can be noted in surgery.
4) The patients ages, the history of any sport's injury, recurrency of the trauma and extent of the injury participate in the occurrence of two compatible types observed in the “Rotator interval” lesion.
This report also explains the operative technique in detail.

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It is well known that injury of the rotator cuff causes pain and limitation of motion in the shoulder joint. However, along with the injury, there are various degrees of degeneration in the subacromial bursa and joint capsule. As each cases have many sorts of symptoms, it is not easy to know the details of the injury. This is especially true in the case of an incomplete tear of the rotator cuff, when sometimes even the typical changes cannot befored with arthrography.
As it seems to be important to inspect the pathological changes of the rotator cuff (i.e. supraspinatus tendon), we have usually performed arthrography, subacromial bursography and then occasionally arthroscopy. This report discusses about injuries of rotator cuff which have risen from degeneration.

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Bursal side tears of the rotator cuff cannot be diagnosed with shoulder arthrography, and so have been overlooked for a long time. We have experienced eight cases of such bursal side tears and report chiefly on their diagnosis and the treatment in this paper.
Eight cases consisted of six males and two females, with ages ranging from 33 to 51. In the clinical findings, motion pain was noticed in all cases but there was motor disturbance and subacrominal effusion in only two cases. Crepitus was seen in six cases and painful arc in six cases out of seven.
Subacromial bursography was performed in seven cases and five cases had positive findings. Surgical repairs were carried out in all eight cases. After anterior acromioplasty, small tears were simply sutured and large tears were sutured with shoe-lace sutures. Postoperative results were all good.
The clinical differences between bursal side tears and common tears including joint side tears of the rotator cuff were discussed. Trauma, motion pain and drop arm sign were noticed at almost the same rate in bursal side tears as in others. But painful arc, crepitus on elevation and subacromial effusion were found with bursal side tears more than with other tears.
Subacromial bursography was shown to be useful in large bursal tears of the rotator cuff. When bursal side tears are diagnosed by it, surgical procedure should be carried out as soon as possible. But when they are diagnosed clinically, surgical procedure should be considered only after considerable conservative therapy is performed.

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The value of arthrography in the diagnosis of rotator cuff tears has been well established; however, non-perforated cuff tears cannot be diagnosed in that way. Therefore, little has appeared about then in the literature. Sixteen cases with non-perforating superficial surface cuff tears, which were resistant to our ordinary conservative treatment, were treated surgically in our clinic.
Based on a review of these cases, the clinical signs, the value of bursography, the pathomechanism, and the operative procedures used were described. Two types of episodes, (direct injury or strained-prolonged abduction of the arm), and the clinical signs (night pain, painful arc, crepitus and tenderness) were well documented. Arthrographically, cuff tears were not confirmed in all of the cases. Subacromial bursography was performed in 7 cases and various findings were observed. During the operation, superficial surface cuff tears were always found present at the “critical portion”. The authors' operative procedure was used first, which included resection of the diseased subacromial bursal tissue, enbloc resection of the diseased cuff, and the anterior acromioplasty described by NeerII. Then this resected cuff was repaired by use of Willson's method. The relationship is discussed between subacromial bursitis and the irregularities or defects at the “critical portion” due to non-perforating superficial surface cuff tears.

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In surgical repairs of rotator cuff tears, some types of acromioplasty have been done for the reconstruction of the suprahumeral gliding mechanism. We devised a new acromioplasty to prevent postoperative impingement without weakening the leverage of the deltoid.
The incision was made along the “suspender line” from the posterior edge of the acromion to the coracoid. The acromion was osteotomized anteroposteriorly just lateral to the acromioclavicular joint. The anterior portion of the deltoid muscle was split bluntly, and then the osteotomized lateral fragment was reflected laterally with the deltoid. After excising the entire coraco-acromial ligament and repairing cuff tears with Mc Laughlin or fascial graft methods, the lateral fragment was displaced posteriorly about 1.5 to 2cm (approximately one third of the width of the acromion), and reattached to the medial fragment with Kirschner wires or small plates. The undersurface of the anterior stump of the medial fragment was beveled. Postoperatively, the arm was fixed on an abduction splint, and passive motion exercises over 90 degrees while in the brace were begun within seven days. Active exercises were allowed from three weeks after operation.
Fifteen cases, with complete tears in eleven and partial tears in four cases, were operated on with this procedure. Thirteen shoulders with longer than six months of follow-up period were evaluated with Wolfgang's rating criteria from twelve to fifty-six months following surgery. Results of all cases were excellent.
The value of this procedure is thought to be that it provides better exposure and facilitates appropriate surgical repairs, and that a residual impingement can be prevented without weakening the leverage of the deltoid muscle. This procedure is especially indicated in large tears of cuff tendons.

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We have so far performed 1285 operations on 424 RA patients, of which joint replacement in the lower limbs was performed on 177 patients. Most of the cases were not able to walk or had extreme difficulty in doing so due to severe articular pain and motor disorder. The joints which underwent replacement were: hip, 88; knee, 254; and ankle, 8, or a total of 350. Numbers of the joints involved per patient were: 1 in 64 cases, 2 in 78 cases, 3 in 13 cases, 4 in 19 cases and 5 in 3 cases. These replacements were performed continually in a short period due to the malfunction of multiple joints. On the other hand, there were cases who were repeatedly admitted to the hospital to receive operations because joints began to malfunction one after another after a long period.
Results of the replacements were good in general, with 85% rated as satisfactory as the patients had been relieved from pain and regained good motility with remarkably improved walking. However, there were cases in which operative purposes were not achieved due to various causes.

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Since 1975, the authors have performed 25 TKRs for rheumatoid arthritis knees, 33 TKRs for osteoarthritis knees and one TKR for a tuberculous knee. The number of Geomedic-type TKRs used with bone cement were nine including three for RA knees. That of the Okayama Univ. Mark II-type TKRs without bone cement were 50 including 22 for RA knees. The results were clinically evaluated using the Three-University-Method for knee function and followed up with roentgenograms. As far as RA TKRs were concerned, the score was 43.7 preoperatively, which increased to 77.3 in Mark II-type TKRs with an average follow-up of 36.1 months, and increased to 52.0 in Geomedic-type TKRs with an 82 month follow-up. In OA cases the preoperative score of 50.1 increased to 85.5 in Mark II-type TKRs with an 14.8 month follow-up and to 74.5 in Geomedic-type TKRs with a 105 month follow-up. The Geomedic-type TKRs in OA maintained a relatively high clinical score for a long time even when there was some radiolucent line along the tibial component. The Mark II-type TKRs also maintained a high clinical score but without any radiolucent line or sinking in long term follow-up cases. These was one case of mutilans type JRA in which one Geomedic-type TKRand one Mark II-type TKRwere performed. Both sides of the TKR showed absorption of bone tissue and sinking of femoral and tibias components of the TKR prosthesis. With respect to the improvements in score, the improvement in pain was the main factor, and then walking function and ADL. There was no significant improvement in the ROM of the knee.

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Sixty geometric total knee arthroplasties in rheumatoid patients were analyzed for three to eleven years after operation, with a mean follow up time of six years and two months.
From the clinical and radiographic data, four conditions were defined as “failures”. These were (A) ROM: less than forty degrees, (B) lateral instability: more than ten degrees, (C) mechanical axis: deviation from tibial plateau laterally or medially, (D) loosening.
There were seven “failures” in (A), five in (B), nine in (C), fifteen in (D), and the overall failure rate was 37% (22 arthroplasties) .
These results emphasize the importance of meticulous surgical technique in achieving firm stability and neutral lower extremity alignment.

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The results of total knee replacement for rheumatoid knee joint are dependent on the severity of knee deformity. In this study, knee deformities are divided into 4 types. Those are 1) moderate change, 2) stiff joint, 3) instability and 4) severe flexion contracture because of degree of bone defect, limited range of motion and flexion contracture.
The courses and degree of recovery of 98 knee joints which had been replaced by Kodama-Yamamoto Mark II in 59 patients with rheumatoid arthritis from 1983 through 1984 in Matsuyama Red Cross Hospital are analysed in each type. The results in the severe flexion contracture type and the stiff joint type are less successful than in others. In spite of long term exercises over 6 months, the degree of recovery of severe flexion contracture was walking with 2 crutches and extension lag remained at about 10°. Flexion contracture remained at about 15°. The degree of recovery of stiff joint was walking with one cane or one crutch, but the maximum flexion was about 80°.
The factors which made results unsatisfactory were in order of importance 1) muscle weakness, 2) decreased range of motion and 3) big bone defect. Therefore we conclude that the timing of an operation is important in obtaining good results after total knee replacement.

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A surface replacement type of total-knee prosthesis has been under development in our department since 1968. The design of the prosthesis was changed from the B, C, D, E and F type to the Mark-II type which is generally used at the present. In the initial cases, the B and D type were mainly used without any bone cement, and the posterior cruciate ligament was left intact.
Twenty-five cases underwent our total knee replacement (TKR) up to 1975. Twenty knees of these, including one osteoarthritis (OA) and fourteen rheumatoid arthritis (RA) patients, minus six who had died and four who were not examined, were studied by a clinical score system (three university score) and roentogenography in a follow-up after ten years.
Four patients (one OA, three RA) gained over 70 points in the total score ten years postoperatively. These cases had good range of motion (ROM) in extension/flexion from 0 to 90 degrees, and no loosening of the prosthesis was found roentogenographically. Three knees were revised because of prosthetic loosening with motor pain and instability. With respect to postoperative ROM, six knees had over 70 degrees in flexion, but contracture with gradual decrease of ROM was found in six knees. However, patient evaluation was good due to pain relief even if the ROM was less than 60 degrees. No infected cases and no broken prostheses were experienced, but prosthetic loosening was observed in cases with advanced osteoporosis.
In the surface type of TKR without bone cement, significantly better long term fixation of the prosthesis with a good clinical course can be provided if the prosthesis is set in the correct position and the bone structure is not so porotic.

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Ten patients with avascular femoral head necrosis and four normal adults were examined by magnetic resonance imaging (MRI) . In addition, the relationship between MRI and pathophysiology of three operated-on avascular femoral heads was evaluated. The medullary cavities of the normal femoral heads had a strong signal intensity on the saturation recovery (SR) image due to fat marrow, and the T₁ relaxation time was 160±11msec. In avascular femoral head necrosis, the necrotic area had a low signal intensity on the SR image and a prolonged T₁ relaxation time, while the reactive fibrous area had more prolonged T₁ relaxation time. For these reasons, MRI was found to show the pathological changes of avascular femoral head necrosis and can be expected to be useful for making early diagnoses and operation planning.

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A 63 year-old woman had a 30 year history of rheumatoid arthritis and was in stage 4 and class 4. Her neurological summary at hospitalization was C3 central cord syndrome including respiratory disturbance. The most remarkable findings of the radiographs were the backward dislocation of the atlas due to disappearance of the odontoid process and the lateral tilting of the occiput toward the right side (24 degree) due to severe collapse of the lateral masses of C1, C2 and C3.
No complete block was encountered in the myelogram and also no marked insufficiency of the vertebral artery was found by angiogram.
Her neurological disorders improved after putting her into a Halo-jacket to prevent further displacement by serious destruction of the upper cervical spine. She recovered from the condition of total dependency to partial independence, namely she can feed herself using orthosis.

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A case of thoracic myelopathy caused by rheumatoid involvement of the eighth thoracic vertebra is reported. Pathogenesis of thoracic involvement and pathomechanism of the onset of myelopathy are discussed.
A 43 year-old woman had affected classical RA (mutilans type) since 1967. On July 25, 1983, the patient suddenly had weakness of both lower extremities, hypesthesia below the umbilical line and urinary disturbance. Roentgenographic assessment revealed a rotatory subluxation of the eighth on the ninth thoracic vertebra and collapse of the eighth thoracic vertebral body. Also, vertical subluxation combined with subaxial subluxation were evident on the cervical level. A myelogram showed a complete block at the level of the collapsed vertebra.
An anterior decompression with interbody fusion of the seventh to ninth thoracic vertebra was carried out on December 5, 1983. The patient had an uneventful recovery with neurological improvement to that state which was present prior to the onset of the neurological symptoms.
Histological examination revealed rheumatoid inflammatory granulation in the entheso-peridical region, disc space and vertebral body.
It was supposed, by study of retrospective roentgenographic examination, that the destruction of the disc and vertebral body had developed through the three years before the onset of clinical symptoms.

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A 35-year-old man was admitted our hospital in 1984 with recurrent intra-articular bleeding of the right knee.
Neither he nor his family had any no history of trauma or bleeding tendency. Physical examination revealed slight swelling and Warmth in his right knee. But redness, tenderness and limitation in range of motion were absent. The Rumpel-Leede test was negative. Blood pressure was within normal limits. Laboratory examination showed only a rather low level of anti-hemophilic factor 8th of 44% and a high level of triglyceride of 224mg/dl. But X-ray examination of the right knee joint showed a high density mass lesion.
With such results, we suspected the possibility of pigmented villonodular synovitis and idiopathic hemarthrosis, and performed arthroscopy and synovectomy. Arthroscopically, the synovium showed a yellow-brown villous proliferation and partial petechia. In the subsequent operation, we found proliferative yellow-brown synovium. There were some petechia and soft nodules, but no typical nodules of pigmented villonodular synovitis in it.
Histological examination showed a proliferation of lining cells, siderosomes, invasion of lymphocytes, and proliferation of capillaries, but no evidence of the hemangioma and foam cells which are typical in pigmented villonodular synovitis. After the operation, as durings it, there was no abnormal bleeding. A year later hemarthrosis had not occurred and he acquired good range of motion of the right knee joint.
Finally we diagnosed his disease as idiopathic hemarthrosis of the right knee joint.

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A woman, aged 64, had a history of rheumatoid arthritis (RA) for 10 years and received a two-stage reimplantation for the salvage of an infected total knee arthroplasty (TKR) . It was performed 1 year after the removal of the infected implants and after confirmation of no infection. Bacteria can be excluded as a cause in our study because synovium and granulation tissues were routinely cultured at the time of filling and removal of cement beads with antibiotics.
A pus discharge recurred 3 months after reimplantation surgery, although there was no evidence of infection. She died of sudden unconsciousness with right hemiplegia 5 months after the surgery.
Autopsy revealed thrombus in the left atrial auricle, left internal carotid artery and middle cerebral artery. No changes due to RA were found in the heart, lung or lymphnodes. No signs of angitis were observed.

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A statistical study of weight distribution on the plantar surface of 46 feet of 23 RA patients, including 9 feet that Clayton's operation had been previously performed on, was carried out by the prescale method. Twenty normal feet were measured for comparison by the same procedure. These estimations were computerized for analysis.
Postoperative patients of Clayton's procedure showed a pressure 48% less than that of the non-operated group, so that the weight distribution appeared to be relatively normal. On normal feet, a predominantly high potential appearance was not observed except on the hind-ends of the foot. However, in RA patients, a predominately high potential figure appeared in metatarsal heads, especially in the area of the llnd and IIIrd metatarsal heads.

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