Long term follow-up results of wrist synovectomy with Clayton's tendon transfer were evaluated clinically and radiologically. Twelve wrists of 10 patients with classical rheumatoid arthritis (all women) were operated on. The average age at operation was 54 years, and the average follow-up period was 7.6 years, with a range from 5 to 11.5. Two wrists were Stage II; 9, Stage III; and 1, Stage N.
All patients obtained almost complete relief of pain after surgery. The pain in 8 wrists disappear-ed completely. The preoperative average arc of dorsal-palmar flexion was 59°; postoperatively it was 39°. The rotation of the forearm has been well maintained. The radial rotation of the wrist, as measured by Shapiro's method, was significantly reduced after surgery (p < 0.01) . Clayton's mea-surement showed that the ulnar drift of fingers was kept at less than 15°in 7 wrists. Only two wrists progressed to the severe stage of over 30 degrees. Therefore, the wrist synovectomy is consid-ered to be beneficial in relieving pain and preventing the progression of ulnar drift. However, little im provement of wrist motion can be expected with this operation.

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The effect of transcutaneous electrical nerve stimulation (TENS) on wrist joint pain was studied in 12 patients, 3 men and 9 women, with rheumatoid arthritis. The patients ages ranged between 32 and 72 years, and rheumatoid arthritis had been diagnosed from 3 to 38 years previously. The pain threshold due to electrical stimulation was also measured. Electrical stimulation was done for 15 minutes through an electrode on the wrist joint with using a constant current stimulator with a frequency of 50 or 250 Hz. The pain threshold in daily use, grasping power and ROM were measured before and after TENS and increased on an average of 2.5 mA (P<0.01) . These pain threshold results correlate well with those of the CRP test (r=-0.5, P0.05) . Thus it seems to be possible to assess the pain in patients using this method. The change of grasping power after TENS was observed to increase with 14 joints and decrease with 2 joints. It did not change in 4 patients. The increase in power with all 20 joints was, on the average, 11.9 mmHg (P<0.01) . ROM improved in 4 joints of 2 patients. From these results, TENS is considered to be a useful from of physical therapy for RA wrists.

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We investigated the accuracy of radiography and computed tomography in the diagnosis of distal radio-ulnar joint (DRUJ) congruity in 10 healthy hands and 84 rheumatoid hands. Operated-on joints were excluded from this series. The CT study of DRUJ was done in positions of 90°, 70°, 45°, 20° and 0° in pronation and supination of the forearm. The radiographic study was done of the lateral view of the wrist with the forearm in neutral rotation, and of the P -A view with the forearm in full pronation. The evaluation was done with Mino's and Snook's criteria. All computed tomograms showed good congruity in the 10 healthy hands, so we evaluated radiograms using these results. In healthy hands, the accuracy of the lateral radiograms was 60% and of the P-A view ones' 80%. In the computed tomograms, good congruity was noted in 29 joints, subluxation in 57 joints and dislocation in no joints in 84 rheumatoid hands clinically diagnosed as having DRUJ incongruity, The accuracy of the lateral view radiograms was 60.5% and of the P-A view ones' 35.7%. Evaluation of the P-A view radiogram was impossible in 18.9% due to bony destruction of the ulnar styloid process in RA. In the lateral view radiograms of 23 joints which showed subluxation in natural rotation by computed tomography, subluxation was noted in 11 joints, good congruity in 8 joints and dislocation in 4 joints.
This study suggests that as the radiographic evaluation of DRUJ incongruity is difficult in rheumatoid hands because of severe bony and articular destruction, computed tomography is necessary for the diagnosis of DRUJ subluxation.

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The Schlein total elbow prosthesis has a hinged, semi-constrained structure with stems on both the humeral and the ulnar components. This structure seems to be rather favorable in comparison with a conventional hinged elbow prosthesis such as the McKee and Dee prostheses, but neverthless there are some undesirable points: 1) the intramedullary stems are narrow and short especially in the humeral component, and 2) the HDP (high density polyethylene) bearing insert of the ulnar component tends to dislocate.
Therefore these were compensated for by 1) extending the humeral stem to about 15 cm, fitting a Küntscher nail of 8 mm or 9 mm in diameter; 2) extending, if necessary, the ulnar stem to about 12 cm, fitting a Küntscher nail of 6 mm in diameter; and 3) forming a hook at the HDP tray in order to prevent the dislocation of the HDP bearing insert.
Total elbow replacement using this modified Schlein prosthesis has been performed in six cases. In the three patients with rheumatoid arthritis, a 69-year-old female (7 years from surgery), a 60-year-old female (1 year) and a 56-year-old male (8 months), almost perfect relief from pain was achieved. The improvement of the range of motion was from -70°-100° to -60°-140°, -80°fibrous ankylosis to -70°-130°, and -20°-40° to 0°-130°, respectively. The increase of range of flexion gave great satisfaction to all patients by their reacquisition of the ability to wash their face and feed themselves. They do not show, roentogenologically, either mechanical loosening or breakage of the components, and have had good clinical courses.

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The first report of a rupture of an extensor tendon associated with an arthritic distal radioulnar joint was that of Vaughan-Jackson in 1948. In 1962, Vaughan-Jackson reported on 25 patients who had had ruptures of the extensor tendons and concluded that the ruptures were secondary to mechanical irritation from the subluxated distal part of the ulna. Since then numerous hypothesis have been advanced to explain the cause of tendon rupture. During the past six years we have had 9 cases of the Vaughan-Jackson syndrome: 7 with rheumatoid arthritis, and 2 with osteoarthritis of the distal radio-ulnar joint. Five hands in 7 rheumatoid patients were repaired at operation in addition to receiving dorsal tenosynovectomy. According to our operative findings, the present indication for prophylactic tenosynovectomy is persistent dorsal tenosynovitis despite adequate medical treatment including medications, splinting and occasional cortisone injection.

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1-EMG revealed a reduction of the power to abduct the scapula in cases of so-called unstable shoulder (loose shoulder) . We checked the lower fibers of the serratus anterior and upper fibers of the trapezius of such patients (9 cases, 17 shoulders) and of normal volunteers (8 cases, 13 shoulders) . These two groups could be clearly differentiated by simple X-ray findings. Using the RBSM (Rigid Body Spring Model) method of Kawai, a normal shoulder and an unstable shoulder were computer simulated. The simulation showed that at 1500 abduction there was a large reduction in the raising power of the scapula of the unstable shoulder; the capsule was weaker and the resultant force of the humeral head was directed toward the inferior edge of the glenoid.

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Based on the radiological analysis of 9.464 cases, we carried out a statistical study of intraarticular calcification. In the first study, which was performed in a general hospital in Osaka, there were 3, 305 male and 3, 891 female cases; in the second, performed in a clinic of a neighboring city, there were 719 male and 1, 489 female cases. The frequency of intraarticular calcification was 4.1% in males and 4.4% in females in the first study, and 11.4% in males and 21.4% in females in the second, a significantly higher rate than in the first, especially in females. The difference in the character of the groups is considered to be the main reason for this difference in the results.
The frequency of calcification in both studies was the highest in the knee joint. Calcification of the meniscus, which is characterized as a CPPD deposition disease, was seen in 23.6% of the patients older than 50 years, and the frequency increased with age.

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In the past 5 years at our clinic, a total of 100 cases (107 feet) underwent operations because of an old tear of the ATF ligament. They could be divided into 3 groups by the complaints of the disability in doing sports as follows:
I. Instability
(1) Mechanical instability (14 cases)
(2) Functional instability (86 cases)
II. Ankle pain
(1) Pain caused by tension force (40 cases)
(2) Pain caused by impingement (32 cases)
III. Symptoms of ankle arthritis (4 cases)
All six cases of“loss of ligament”were in category 1 (1) . In II (1), there were many cases of old ATF ligament avulsion fracture, and of impingement of the talofibular joint by a tear of the ATF ligament at the inferior side where it is attached to the fibula. We named this the “L-shaped tear”.
The prognosis was good in most of the patients. But 2 of them complained of instability of the subtalar joint in the neutral position and of pain due to tendinitis of the peroneal muscle. These problems could be solved by using a lateral-wedged foot plate.

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The purpose of this study was to assess dynamic joint control (DYJOC) training used as rehabilitation of old knee ligament injuries. Twenty-two students were divided into DYJOC training and isotonic muscle training groups, and each trained for seven weeks. Comparisons were made before and after the training of peak torque value (PTV) and peak torque time (PTT) of the hamstrings and/or quadriceps using KIN.COM and Cybex II, and of gravity center deviation (GCD) . No significant difference was shown on KIN.COM between the two groups. However, the PTT in the DYJOC training group and the PTV in the isotonic muscle training group showed significant improvement on the Cybex II (30RPM), and the GCD was improved significantly in the DYJOC training group. There was no correlation found between isotonic muscle strength and PTT in a total of 164 sessions.
In a separate study, DYJOC training was done, after reconstruction of the anterior cruciate ligament, in 13 cases and Non-DYJOC training, i.e., traditional muscle training, in another 13. A high level of sports' activity after the reconstruction was obtained by seven of eight cases in DYJOC training and by three of six in Non-DYJOC training. It can be said that DYJOC training is very important for old ligament injuries with respect to neuromuscular coordination, thus shortening the time lag of muscular reaction, permitting the smooth performance of motions in sports, and preventing reinjury.

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We have evaluated 15 patients after replacement of a ruptured anterior cruciate ligament with a free graft of the medial third of the patellar tendon, combined with a MacIntosh lateral tenodesis. The results were excellent or good in all cases, and 12 of the patients were able to return to their original athletic activity. The technique of operation for free graft using the patellar tendon is described in detail.
There have been many reports about problems in obtaining ligamentous isometricity using the over-the-top method, but this method is much more easier to perform than making a drill hole in the ideal position on the lateral femoral condyle.
In our opinion, technical factors are often responsible for this reported difficulty, and certain aspects of the operation technique deserve emphasis.

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Thirty knees of twenty-five patients with chondropathy of the patella were operated on by Cave and Rowe procedure in our clinic from 1981. Two years' follow-up studies were performed in twelve patients. These patients consisted of six with idiopathic chodromalacia patellae and six with recurrent subluxation of the patella. Results were classified into four grades according to clinical findings: excellent, good, fair and poor. Five patients showed excellent results, seven good, and none fair or poor. At the time of surgery the subchondral bone exposed at the bottom of the ulcerative lession was frequently found to be hard and screlotic on the articular surface of the patella.
In arthroscopic findings of two cases one year after surgery, there was intercaleted synovial-like membrane around the chondrectomized surface of the patella which might be a layer created from fast tissue inplanted by operation.

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Eight knees in 5 patients are described with a type of habitual subluxation of the patella that differs from the classical description. The unique feature of these patients is that the patella subluxates laterally each time the knee is actively extended, with spontaneous reduction on flexion.
Radiographic evaluation of the patellofemoral joint in these 8 knees showed abnormalities of the sulcus angle, congruence angle, lateral patellofemoral angle and patellofemoral tilting angle. CT scanning of the patella revealed that the patella was subluxated laterally when the knee was fully extended. Moreover, when the quadriceps was contracted in the extended position of the knee, the patella was found to subluxate more laterally.
Although the primary cause of this type of habitual subluxation of the patella is still unknown, we suggest that abnormalities of the vastus medialis attachment and dysplasia of the vastus medialis may play an important role in the subluxation in addition to the malalignment of the knee joint.

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This animal experiment was carried out using 30 S-D rats 8 weeks after birth. After excision of cartilage, the articular surface of the patella was covered with a infrapatellar fat pad with a pedicle.
These rats were sacrificed weekly from 1 week to 16 weeks after surgery. The implanted fat tissues were found to be changed into a synovial like membrane which covered the excised patellar surface. There were no bony or cartilagenous reproduction mechanisms on the central portion of the excised patellar surface even 16 weeks after surgery. But there were synovial membranous reproduction mechanisms on the edge of the excised surface. These tissues were regenerated in cartilage tissue. There was only mild degeneration of the femoral articular cartilage on the implanted group in comparison with the simultaneous non-implanted (only-excised) group. These results suggest that the implanted fat tissue may act as a intercalated membrane between the patella and the femoral articular surfaces.

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Varus deformity is frequently observed in osteoarthritis of the knee joint. However, research regarding the role of the muscles in it is rare, and this study was attempted to analyze muscle functions.
To determine the muscle activities in the lower extremity, a surface electromyogram and integrated electromyogram were taken under isometric contraction while the subject was in the standing position. The integrated action potentials were measured in 91 knees of osteoarthritis with the FTA varying from 173°to 198°, and in 10 normal younger subjects with a FTA of 175°: The results and conclusions are as follows:
1) The integrated EMG activity of the quadriceps muscle, hamstrings, tensor fascia latae, adductor magnum and peroneus longus muscles in varus knees had a tendency to be more active than those in the normal knees, and the EMG activity of these muscles increased as the FTA increased. Moreover, the EMG ratio of the lateral muscle to the medial muscle in the quadriceps muscle and hamstring also increased as the FTA increased.
2) There was no significant difference between varus and normal knees in the EMG activity of the gastrocunemius and tibialis anterior muscles.
3) In cases with high tibial osteotomy, the EMG activity had returned to the normal pattern.
4) In the cases with lateral wedged insole, the EMG showed the same changes as with high tibial osteotomy.
5) It appears that the muscles in the lower extremity act as dynamic stabilizers of the knee in the malaligment of degenerative genu varum. The lateral muscles around the knee joint act as resistant forces against varus deformity through biofeedback mechanisms.
6) Muscle exercise of the muscles around the knee, not only the quadriceps but also other muscles, is thought to be important in the treatment of arthritic knee joint.

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Rheumatoid arthritis affecting the cervical spine has been well described in the literature, but scant attention has been paid to less common rheumatoid involved in the thoracic and lumbar regions.
Granulomatous nodules have been described by us in the subchondral regions and enthesis of the spine. Here we tried to classify the radiological changes of the spine making reference to biochemical blood examination, particularly with respect to osteocalcin.
The rheumatoid change in the spine which might be induced by so-called rheumatoid granulation was shown to be in 67% in the cervical, 23% in the thoracic and 11% in the lumber. The high value of osteocalcin was present in most of the cases with stage III and IV of RA.

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The radiological and clinical changes relating to cervical involvement in a group of 50 rheumatoid patients who had had the disease an average of 15.5 years were studied for an average follow-up period of 4.8 years.
In the initial study, thirty (60%) of 50 patients already had radiological changes of the rheumatoid cervical spine, consisting of atlanto-axial subluxation (AAS) in sixteen, AAS combined with vertical subluxation (VS) in ten, AAS with subaxial subluxation (SAS) in two, VS alone in one and C1/2 spontaneous fusion in one.
In the final review, thirty-seven (74%) had radiological changes of the cervical spine, consisting of AAS in nineteen, AAS with VS in eight, VS in three, SAS in three and VS with SAS in three. The remaining patient had combinations of all three types. AAS had progressed in sixteen patients (32%), VS in seven (14%) and SAS in seven (14%) . An improvement of AAS had occurred in seven patients, but six of them had accompanying VS or SAS. An improvement of VS occurred in one patient who had an absorption of the odontoid process. The development of VS and SAS was found in a patient with pre-existing AAS.
Although neck pain was the one symptom of the rheumatoid cervical disease that showed any tendency to improve, neural involvement was progressive.
Radiological progression of cervical involvement was correlated to high continuous activity of rheumatoid arthritis.

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We have experienced in 7 cases, 9 knees with total replacements after high tibial osteotomy. Deformity of the proximal tibia caused by the high tibial osteotomy seemed to have made the total knee arthroplasty procedure more difficult. Some of the wedge osteotomies might have reduced the bone stock of the proxial tibia, and the oblique rotation osteotomy made a rotational deformity of the lower leg. Furthermore, a central peg type tibial component may not be acceptable because of deformities of the proximal tibia caused by the anterior displacement of the tibial tuberosity.
The degree of deformity of the proxial tibia with arch osteotomies was surveyed in our series and biomechanically investigated with a rigid body spring model. As a result, the knee with overcorrected high tibial osteotomy was found to be unsuitable for future total knee replacement.

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Model AID-1 was designed to be a more effective and efficient gait training device intended to help the patient, return to the activities of daily life as early as possible. It is a robot for gait training that can be operated through the use of human hands and feet in simple situations where powerful muscle force is required. The patients are lifted by the machine with a compressed-air drive mechanism. Any possible shocks are prevented and compensated for smoothly by a shock absorber that detects sudden changes in load due to factors such as unsteady gait or falling down to the ground.
Actual gait training using model AID-1 was carried out on 44 cases with dysfunction due to multiple causes such as multiple weight bearing in cases of RA, femoral neck fracture, bilateral osteoarthritis of hip joints, incomplete spinal cord lesion and so on. In all these cases the patients were easily able to stand up and walk from a sitting position in a wheelchair.

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We studied C-reactive protein (CRP) binding on peripheral lymphocytes of patients with rheumatoid arthritis and with normal controls.
The method employed was the immunofluorescence technique using fluorescein conjugated IgG fraction sheep anti-human CRP (Cappel Laboratory), analysed by use of flowcytometry (Spectorum-III) .
The results indicated that in patients with rheumatoid arthritis, an elevation of circulating lymphocyte-binding CRP is higher than in normal controls. There was no evidence of correlation between the amounts of CRP binding lymphocytes and serum levels.

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Four cases of chronic arthritis associated with pustulosis palmaris et plantaris are reported. All patients were female, and arthritis was either monoarthritis of the oligoarthritis type or asymmetrical. Synchronous excerbation and remission of skin and joint changes were noted. Destructive changes were not found in roentgenographic examination in the course of the disease. In all cases, laboratory findings showed a moderate elevation of the erythrocyte sedimentation rate, positive CRP and negative serological test for the rheumatoid factor.
The microscopic appearances of the synovial membrane did not differ from those in rheumatoid arthritis. The medical management of this disease was aimed at the suppression of skin lesions and joint inflammation, and most patients with mild to moderate arthritis responded to NASAIDS administration. Tonsillectomy might have had some efficacy in subsiding the arthritis, when the patient had inflamed tonsils, associated with the arthritis.
The etiology and pathogenesis of pustulosis palmaris et plantaris and its associated arthritis remained unclear. There are also no obvious correlations with any certain histocompatibility antigen (HLA B-27) .

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Kinematic total knee replacements were performed on 96 joints in 68 cases from October 1981 to September 1985. Out of these 68 cases, tibial component breakage occurred in one knee after surgery.
The patient was a 65-year-old man who had rheumatoid arthritis associated with long-standing pain in the right knee. The knee was replaced in July 1982 with a Kinematic total knee of the anteriorly joined type. After the surgery he was free of pain and his right lower extremity showed a straight alignment. But 32 months after the surgery the right knee began to have varus deformity and he suffered from knee pain again. Radiography revealed bone resorption under the medial part of the tibial component and breakage there.
The right knee was revised. Under the tibial component, medial tibial plateau erosion was found, filled with granulation tissue. The breakage surfaces of the tibial component showed partly a wavy area and partly a shiny area. It was concluded that the component breakage was almost certainly due to fatigue under stress on the medial portion of tibial component. This fatigue fracture of the tibial component of Kinematic anteriorly joined type was caused by a weak point in its structure between the anterior flange and the medial component, and by bone absorption under the medial component.

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