Patello-femoral disorders with anterior knee pain have become one of the most important subjects in orthopaedic surgery. The greater part of them are those with chondromalacia patella, patello-femoral compartment osteoarthritis, mal-tracking patella and painful shelf. The synovial impingement syndrome in the lateral patello-femoral facets, however, was rarely found and reported here as a new disease entity. Lateral shift and degree of lateral tilt of the patella shown on roentgenograms were found to be the most useful indications for deciding to perform medialization of the tibial tuberosity. Measurements were done in knees with surgical indication of patients with ages of less than 40 years. The former was 9.9 mm±4.8 mm in 13 knees. The latter was 24.6°±9.7°in 18 knees. Subluxation of the patella is, thus, defined by either more than 5 mm of the former or more than 15°of the latter.
Clinical results of medialization or advancement of the tibial tuberosity revealed that improvements of symptoms were noted in 75-85% of the 26 knees operated on, except for those with retropatellar crepitation, improvement of which was found only in 20% of the cases. The position of the patella, however, was lowered after the above surgeries in 58.8% of 34 knees operated on, especially in the elderly. Fracture of the fragment was observed in 2 of 50 operated knees as a complication, but ended in there being satisfactory results. In 9 knees articular cartilages were observed at surgery and at the time of removal of internal fixation, usually one to two years after the initial surgery. All of the knees showed regeneration of degenerated cartilage postoperatively. The dege-neration grading and regeneration staging attempted were found to be satisfactory for evaluation of disorders.

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Ten synovectomies and ten cutis arthroplasties of the elbow were performed in patients with rheumatoid arthritis. Of 10 synovectomies, 2 were simple synovectomy without excising the radial head and 8 were radical synovectomy with the combined procedures of release of soft tissues and bone resection. These patients were followed up postoperatively for a minimum period of five years (average, 6.3 years in synovectomy and 7.6 years in cutis arthroplasty) . Postoperative clinical result of synovectomy was graded as excellent in two, good in seven, and fair in one elbow. The result of cutis arthroplasty was graded as excellent in one, good in five, and fair in four elbows.
It is considered that relief of pain and improvement of mobility can be expected even at an advanced stage by radical synovectomy, and cutis arthroplasty is of value for elbows with fibrous or osseal ankylosis.

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Thirty-two synovectomies of the elbow in 26 patients were followed up for at least 5 years, the average term of follow-up being 9 years, 3 months. The radial head was only conserved in 9 elbows. In 17 patients, the radial head was resected, and in 6 synovectomy was combined with radial head resection and the insertion of a silastic implant. The improvement in motion was slight in extension and in pronation, and evident in flexion and in supination. Pain was diminished in all except 4 elbows.
From these long-term results, it is suggested that synovectomy seems to be valuable in treating the rheumatoid elbow.

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Twenty-one wrists in 15 patients with rheumatoid arthritis who had received dorsal wrist synovectomy with resection of the distal ulna were followed up for 5 to 18 years, with an average of 7.1 years.
Only three wrists (14%) showed mild pain and had a slight recurrence of synovitis. The other 18 had excellent and durable pain relief.
Progress of bony change took place more slowly in the operated-on wrist joint than in the opposite side until 4 or 5 years post operatively. However, at the time of follow-up, X-ray that both wrist joints had similar destructive bony changes and examination showed 12 wrist joints (67%) had become ankylosis. However, in such cases rotational movement of the forearm remained with the functional range as an effect of the resectioning of the distal ulnar end, and the patients seldom had disability in the use of their wrist joint in daily living.
We concluded that although synovectomy of the wrist joint cannot prevent joint destruction, this procedure is effective for pain relief of the wrist joint in patients with rheumatoid arthritis.

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A DOH-type total elbow prosthesis (nonconstrained type with an intramedullary stem), was designed to obtain firm fixation and reduce bone resection, was implanted into 24 elbows in 22 patients with rheumatoid arthritis.
Postoperative assessment was performed according to the revised criteria by Dee-Kudoh. The average period of follow up was 16 months with a minimum of five. Excellent results were obtained in 17 elbow joints, fair in 5 and poor in2. The cause of poor results was postoperative instability of prostheses, but one of the two was evaluated as fair after re-operation.
We assume that firm fixation of the implanted prosthesis and exact repairing of the fascial layers around the joint are mandatory for initiating early exercise and obtaining a satisfactory range of motion of the operated-on joint.

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The delicate and harmonious function of the hand, controlled by the shoulder and elbow movements, enables us to do whatever we want. Particularly, the shoulder has great flexibility due to the glenohumeral joint, scapular and clavicular movements. The intended action cannot be performed until the subtle coordination of the muscles involved is achieved. The function of the muscles involved in the shoulder movements, especially the rotator cuff muscles, were analyzed using fine wire electrodes and an eight-channel penwriting galvanometer. Electromyogram and joint movements were synchronized and recorded on the same plane on a 16mm movie film or video tape. These film data were analyzed aualitatively with a film motion analyzer and a computer.
It was concluded that the rotator cuff muscles act as the main stabilizer of the glenohumeral joint. However, not all of the rotator cuff muscles are active during the mover or synergist actions in the shoulder movements.

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In order to elucidate the pathogenesis of ANFH, 26 femoral heads were examined pathologically. Nine heads from 8 patients were the idiopathic type, 10 heads from 8 patients were the steroidinduced type, and 7 heads from 7 patients were post-traumatic type. All cases received tetracycline preoperatively. Cole's H.E. stain and Villanueva bone stain were done and contact microradiogram was taken from the undecalcified ground sections of the whole-head. Trabecular bone dynamics and pathological findings were investigated by utilizing light and fluorescense microscopy.
In the idiopathic type, empty lacunae in the repaired trabeculae and necrotic debris deposits in the bone marrow space were observed in the necrotic portion. Tetracycline uptake was observed at the trabeculae of the sclerotic band just beneath the demarcation line. These findings suggested good repairing activity in the bone, and that chronic recurrent necrosis existed within the femoral head. In the steroid induced type, generally, there were only a few fibrous tissue formations at the demarcation line and thin bony trabeculae, with little tetracycline uptake. These suggested diminished repairing in new bone formation in this type. In the post-traumatic type, usually wide necrosis was observed with poor repairing, but on the other hand, remarkable repairing was also observed in several cases.

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From years May, 1980 through May, 1986, 131 total hip replacements were performed at our department, using the Charnley-type prosthesis (RA, 99 hips: OA, 32 hips) . In all cases we osteotomized and reattached the greater trochanter by either the three wire method or the cruciate wire method.
The cases of THR able to be followed up were divided into the RA group and the OA group. In the RA group there were 73 patients (4 men, 69 women) with a range of age from 26 years to 78 years (average, 55.6) . In the OA group there were 29 patients (6 men, 23 women) with a range of age of 47 years to 75 years (average, 63.5) .
The patients who had non-union of the greater trochanter after THR were analyzed and compared with patients who had no trochanteric problem by the review of the clinical records, the analysis of the grade of osteoporosis using preoperative roentogenograms of the hips, and the pull length of the greater trochanter at surgery. In the RA group, disease severity and medical treatment were also included in the comparative study.
Out of 131 hips, 19 hips (14.5%), i.e. 16 RA (16.2%) and 3 OA (9.4%), showed non-union of the greater trochanter. In the RA group there was a slight correlation between degree of severity of osteoporosis and non-union of the greater trochanter, but hardly any difference among the other factors.
The symptoms due to non-union of the greater trochanter were postoperative dislocation (2 hips), mild pain of the trochanteric region (6 hips), and free (11 hips) .

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We investigated clinical and roentgenological results on 24 THR performed at our clinic in 22 cases whose progress we were able to follow up for at least 5 years and a maximum of 12 years and 10 months. The clinical results were evaluated according to the JOA hip score and were found to be: for the Müller type, 45.5 (preoperatively), 89.3 after 5 years, and 76.5 after 10 years; for the T-28 type, 53.9 (preoperatively), and 92.0 after 5 years. In regards to ROM, the degree of improvement in adduction, abduction and rotation tended to be greater than the degree of improvement in flexion.
During the postoperative roentgenographic evaluation of 5 cases with the Muller type for more than 10 years, a radiolucent line of less than 2 mm at zones I, II and N on the cup side was seen in all 5 and a radiolucent line wider than 2 mm was seen in 2 out of the 5 indicating cup migration. A revision was performed on one of these cases. On the stem side, sinking of less than 5 mm was observed in 2 cases at 5 years after the operation using the Müller type, and at an average of 10 years afterwards, sinking of more than 5 mm was seen in 2 cases, one of which was judged to be varus migration. Since we have only had experience in using T-28 for a relatively short period (5 years and 2 months), it is difficult to compare it to the Müller type, but thus far it is considered to have produced satisfactory clinical and roentgenological results.

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Homologous or autogenous bone grafts were need to reinforce the medial acetabular wall when a total hip replacement was performed in 18 joints of 13 RA patients with painful protrusio acetabuli.
There was an average follow-up period of 2 years, 9 months, with a range of 6 months to 12 years. The results date of this short follow-up study suggest that bone grafting might be a reliable procedure to supplement THR for protrusio acetabuli to date.

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From 1968 to 1985, 375 total hip replacement (THR) and 63 revisional surgeries by total hip prosthesis were performed in our clinic.
The revisional THR surgery was done on patients 49.5 years old on an average and an average of 5.6 years after the first surgery. We evaluated these revisional cases by the J.O.A. score and got follow-up results of 76.8 points, or less than the 85.5 points in first surgery cases of the Charnley type. The most predominate cause for revisional surgery was component loosening (48 joints), and other causes were stem breakage, fracture of femoral shafts and bone perforation.
In the endoprosthesis cases, trouble caused by central migration was seen in 9 joints of 11, and all of the 4 joints with distal migration were accompanied by central migration troubles. So we thought that the main problem with one-piece endoprosthesis might be trouble between the acetableum and the metal head. Therefore, we developed a new ceramic bipolar hip prosthesis in which the outer head was composed of alumina ceramic, which is more bio-inert than a metal head. Our alumina ceramic bipolar hip prosthesis has been clinically applied, and there have been good results with it to date.

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Total-hip replacement has been performed on 165 cases and 172 joints in Nihon university hospital and its related hospitals from January, 1970 to December, 1984. Among them, 85 cases and 91 joints have been pursued for over 5 years, and a follow-up survey is possible for 50 cases and 55 joints. For these cases, clinical assessment before and after operations have been performed with the evaluation-criteria of coxarthrosis by the Japanese Orthopaedic Association, and review has also been made on the cases of replacement. No distinct differences have been observed with respect to sex whereas, there was a tendency for poor results in the cases who were less than 50 at the time of operation. Revision-causes were loosening of socket or stem, fracture or cortical perforation of the femur, and protrusio acetabuli. The revision rate was 5.8% including the surface-replacement arthroplasty and at an average of 8 years and 9 months after operation. The possibility was also shown that the need for revision increases over the long-term course.

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We clinically studied the sacroiliac changes in patients with rheumatoid arthritis (RA) from various angles to attempt to obtain a deeper understanding of such changes. It is of atmost importance yet very difficult to evaluate the radiographic changes that provide the basis for the diagnosis; one often finds it impossible to differentiate whether the changes in question are due to inflammation or due to degeneration.
Pathological changes of sacroiliac joints in patients with RA usually progress latently, but if they are monitored them carefully, it may be able to demonstrate their association with clinical symptoms in a considerably large percentage of the patients. And it has been found that inflammatory changes of the sacroiliac joints are more common among patients with RA with a longer duration and in an advanced stage; they have an especially closer correlation with RA of a severe stage with that has badly affected the cervical spine and the hip joint.
Pathohistological studies generally fail to demonstrate any evidence of severe synovitis as may be usually observed with other joints, but they reveal a lot of pannus formation. In addition, subchondral bone tissues present evidence of rather mild destruction, with a tendency towards fibrosis being noted in an early stage.
We succeeded in demonstrating the following points by this study:
1) Radiological sacroilitis in patients with RA is not as rare as it is usually estimated to be.
2) Tomography is the most useful for evaluation of radiological inflammatory changes (erosin) at the sacroiliac joints.
3) Associated clinical symptoms run parallel with radiographic grades to some extent.
4) The extent of radiographic sacroiliac inflammation is correlated with the severity of RA.
5) Patients present only mild synovitis but there is evidence of chronic inflammation accompanied by pannus formation, with pathological changes strongly appearing at the chondral bone of the sacral side.

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Three cases with lumbar spinal lesions caused by severe lumbar compression fractures in rheumatoid arthritis (RA) are reported on.
They were 61, 60 and 69 year-old females with classical RA, all with severe low backache with paraplegia caused by compression of the cauda equina. They also had vesico-rectal disfunction and were unable to walk. Such cauda compression was clearly indicated by myelography and computer tomography of the responsible focus corresponding to the neurological findings.
Two cases were conservatively treated with bed rest and pelvic traction for about two months, following application of a corset. Paraplegia disappeared but mild low backache remained in one case and the other was still unable to walk due to knee pain after joint replacement. In the one case operated on, laminectomy with posterolateral fusion was done after conservative treatment for four months, as clinical symptoms advanced, including complications of vesicorectal disfunction. Paraplegia was almost cured with respect to muscle and sensory recovery, but neurogenic bladder still remained.
The pathomechanism of the lumbar spinal lesion in RA seemed to be that the instability of the spine due to vertebral body fracture and facet erosion probably with rheumatoid inflamation, advancing to the dislocation of the spine. Basically, severe osteoporosis in the disease course, aging and steroid administration can be related to the causes of the lesion.
In advanced RA cases with palsy, care of the spinal column lesion is very difficult with respect to acheiving a complete cure, but is necessary for maintaining the patient's life.

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In order to study the use of polypropylene mesh as a substitute for the Achilles tendon, experiments were conducted on a mesh graft to the Achilles tendon in rats, and both histological and microangiographical studies were carried out. With rats under ether and pentobarbital anesthesia, right achilles tendon was transected. During the fourth postoperative week the wound was reopened and the gap of the tendon was bridged with a polypropylene mesh graft.
Histological findings showed neogenic capillaries and a few fibroblasts in the edematous interstitial tissues on the third postoperative day. During the first postoperative week, there are minimal foreign body histiocyte reaction with a remarkable increase of fibroblasts; a granulation tissue involving a lot of capillaries appeared and a remarkable edema was noted locally. During the fourth postoperative week, fibroblasts decreased in number and capillaries were still visualized. During the second postoperative month, fibroblasts decreased remarkably in number, but however, collagen fibers increased and were well aligned.
Microangiographic findings showed newly formed vessels at the portion of graft on the third postoperative day. During the first postoperative week, hypervascularity and continuity between proximal and distal vessels were seen in the neogenetic tissue. During the fourth postoperative week, the vessels around the polypropylene mesh increased.
It was concluded that the polypropylene mesh can be used as scaffold for proliferating neogenetic tissues when it is grafted to the transected Achilles tendon in rats.

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The infecting organisms coagulase-positive staphylococcus aureus were injected into the knee joints of rabbits to produce experimental pyogenic arthritis. These were sacrificed in groups of three at intervals of 15 and 30 minutes, of 4. and 24 hours and of 3, 7, 14 and 28 days after intra-articular injection. No organisms were detectable after 14 days in joint fluid, but the destruction of articular cartilage progressed, and the inflammatory synovitis continued after the absence of infection. This study also confirmed the pathological changes of the articular cartilage by the invasive pannus at the early stage of infection.

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Four cases of mal-angulated ankylosis of the hip joint are reported on. The cause of ankylosis was suspected to be gonococcal arthritis.
All patients complained of low back pain and gonalgia. X-ray findings of the knee joints and lumbar spines showed severe degenerative deformities.
To correct these biomechanical disadvantages, arthroplasty using a Bateman UPF prosthesis have been performed in two cases. The others are still under observation. In the two patients treated, the results were excellent in one case and satisfactory in the other.
This procedure is of great value for such cases, especially in older patients complaining of low back pain or gonalgia.

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Four patients with ossification of achilles tendon, three of whom had undergone local excision of the ossified mass are reported on.
Case 1 was a 16-year-old man who had hard swelling on the right heel for one year. Roentgenographic examination of the right foot revealed, in the region of the tendon, a 4-cm area of ossification which excised.
Case 2 was a 52-year-old man who had congenital club foot conservatively. Roentgenographic examination showed bone formation in the body which had been treated of the left tendon, and at its insertion into the right os calcis. The formation was operated on.
Case 3 was a 55-year-old man whose Achilles tendon was raptured while walking. Roentgenographic examination showed an ossified mass at this site, and a spur on the calcaneus. Open operation was performed, and tendon ruptures were seen in the proximal and distal end on the fragment. A tendon suture was necessary.
Case 4 was a 31-year-old man who had been seen twelve years previously, for pain and swelling on both heels. Roentgenograms showed bone formation at the tendon insertion into both os calsis. No operation was performed.
We also reviewed 65 cases which have been reported on including these four cases. Of the cases where ossification occurred in the body of the tendon, 87.5% had had previous surgery of trauma. While on the other hand, only 51.2% of the cases occurring elsewhere in the body had. Tendon rupture occurred at the distal end of the ossification in all the reviewed cases except in Case 3 above.

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In patients of rheumatoid arthritis (RA) with severe bone atrophy, there is a danger of femoral shaft fracture during or after total hip replacement (THR) . Two cases of femoral shaft fractures after THR in RA patients were treated in our hospital.
The first case was a 44-year-old woman. She suffered a femoral neck fracture 6 months before THR and was cured by multiple pinning. The femoral shaft fracture happened 7 years after THR, when she was moving to a bed from a wheel chair. The fracture was healed by 6 months of conservative therapy.
The second case was a 58-year-old woman. She suffered a trochanteric fracture 4 months before THR and was cured by traction. The femoral shaft fracture happened 7 weeks after THR, when she was training for walking in a pool. Open reduction and bone gfafting was performed, because the prosthesis was intact. But the fracture resulted ultimatelly in pseudarthrosis.
Neither patient can walk by her own efforts yet.

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We report a case of malignant rheumatoid arthritis (MRA) that was complicated with intestinal infarctions after on occipito-cervical fusion operation for subluxation of the upper cervical spine. Our conclusions are as follows: First, we did not make the diagnosis of MRA at the time of her first admission mainly because of overlooking symptoms of polyneuritis such as numbness of extremities and muscle weakness. Second, inadequate steroid therapy made the symptoms of MRA worse. Third, this case suggests that the peripheral arteritis type of MRA can progress to the systemic arteritis type. Finally, the possibility of intestinal infarctions should be thought about when we meet a patient of MRA with abdominal symptoms.

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A patient without any traumatic history left knee pain with an acute flare and knee effusion. When outpatient arthrocentesis yielded turbid fluid, crystal induced arthritis and prulent arthritis were suspected. The gram stain test was negative and intracellular calcium pyrophosphate dehydrate (CPPD) crystals were seen by compensated polarized light. Staphylococcus aureus was identified. The joint was probably seeded by hematogenous infection. The patient was immediately given antibiotics and was operated on for debridement and closed drainage of his knee joint.

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