The pathology of the lumbar spine, especially its instability, was studied in 104 patients with classical and definite RA. When horizontal and angular displacement was assessed by the method of Dupuis, the former was noted in 24% of the patients at flexion and in 14% at extension, while the latter was noted in 26%. RA-induced instability was considered to be ascribable mainly to erosion in the facet (apophyseal) joint (Type 1) and to erosion, collapse and destruction of the disc and vertebral body (Type 2) . Lumbago was experienced sometimes in 59% of the patients, but always experienced in only 11.5%. There was no significant difference in the stage and duration of RA, Lansbury's articular quotient, BMA and MCI between instability and non-instability groups.

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Postoperative complications were studied in 115 knees in 92 patients who underwent knee joint replacement using various types of semiconstrained artificial knee joints; the modular type, the total condylar type, the kinematic stabilizer type, or the porous-coated type arthroplasty. Complaints around the patella, noted in 25 knees (21.7%), consisted of pain of the soft tissue around the patella in 12 knees, catching during extension in 7, and click or crepitus in 7. Patellar subluxation was observed in 1 knee.
These complaints, especially catching, are related to the high femoro-tibial angle (FTA) preoperatively, and to the prosthetic type with tight patello-femoral compressioning. Since there were no complaints and no abnormalities in the alignment of the femorotibial components, displacement of tendons and ligaments of the patello-femoral components appeared to be responsible for these complaints. Since there were no such complaints. Since there were no such complaints in patients with reduced retinacular tension, procedures to reduce tension of the lateral retinaculum for high femoro-tibial angle knees are considered to be necessary for the prevention of them.

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Rheumatoid cervical spine has been investigated in our clinic since 1983 in order to reveal pathological changes and to establish better methods of treatment.
A survey was conducted in January 1983 on 879 out-patients with definite or classical rheumatoid arthritis according to ARA criteria. From them, 265 patients with local symptoms derived from the cervical spine were selected for objective tests and radiographic examination of the cervical spine. The results were the following:
1) Objective signs and symptoms were found in 30.1 percent.
2) Subjective symptoms consisted of neck pain (76.2%), crepitation (58.5%) and a feeling of stiffness in the shoulders (57.5%) . Objective symptoms were pain on rotation (51.3%) and extension (29.0%), and restricted range of motion (18.9%) .
3) Radiographic abnormalities involved with rheumatoid arthritis were observed in 149 patients, consisting of the atlanto-axial subluxation type (58.1%), the basilar impression type (8.1%), the subaxial subluxation type (2.7%), the combined type (3.7%), the osteoarthritis type 15.4%) and others (7%) .
4) The frequency of hyper-reflexia, pathological reflex, sensory disturbance and muscle weakness was higher in the basilar impression and the subaxial subluxation types than in the atlantoaxial subluxation type.

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Total knee replacement has been performed in 134 joints of 101 patients from 1974 to 1985. The factors that influenced the range of motion after total knee replacement were analyzed in 70 of these joints. It was found that the type of implants, the preoperative range of motion and the flexion contracture had an influence on the postoperative range of motion, while the preoperative diagnosis, the time of starting physical therapy, the postoperative femorotibial angle, and the tilt of each component did not.

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Osteoarthritic changes were evaluated on 11 knees in 11 patients who had, after the age of 40, a total excision of injured meniscus of the knee without there being any joint space narrowing (less than 3 mm) in a standing antero-posterior radiogram. This series included 9 lateral menisci and 2 medial excisions in 4 men and 7 women, whose ages at operation ranged from 40 to 63 years with an average of 49 years. The average follow-up period was 5 years and 7 months after operation, with a range of from 1 year to 11 years and 1 month.
At the time of the follow-up, in 10 knees out of 11, the knee function scores using the criteria of the Japanese Society of the Knee (the second tentative one) were more than 80 points. The standing femoro-tibial angle (FTA) of 8 knees with lateral meniscus injury showed no difference before and after meniscectomy. In 2 knees with medial meniscus injury, each standing FTA of the involved side increased by 3 and 4 degrees, but there was no difference between the standing FTA of the involved side and of the uninvolved side. At the time of the follow-up, the joint space of 7 knees in a standing radiogram revealed no change, and the joint space of the other 3 knees became a little thinner, but not less than 3 mm. No medial and lateral instability was caused by total meniscectomy. It is considered, though, that severe osteoarthritic changes indicated for operation (high tibial osteotomy, total knee replacement etc.) may develop in rare cases after total meniscectomy even in patients older than forty.

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The alignment after the barrel-vault type high tibial osteotomy was evaluated in detail from the day of surgery to complete bone union in 30 osteoarthritic knees with varus deformity.
The femorotibial angle changed from 166.4±2.3 degrees measured immediately after the operation into 168.7±4.5 at the time of complete bone union.
A relapse of more than five degrees was seen to the varus direction in five knees and to the valgus direction in one knee. The former showed delayed union and the latter had been unstable before the operation.
The starting point of the weight-bearing might be considered to account for delayed union and relapse in the varus direction. It is recommended that patients should not be loaded for four weeks after the operation. Because these changes occurred mainly in the 6th week after the operation, careful attention should be paid in after treatment concerning the weight-bearing, especially after the removal of external fixation.

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Some cases of idiopathic osteonecrosis of the medial femoral condyle treated conservatively get better, whereas others show no remarkable change or become worse. Fourteen cases of idiopathic osteonecrosis of the medial femoral condyle that received long-term conservative treatment at our clinic were evaluated. We investigated the association between age and size of osteonecrosis at the onset, FTA, body weight and prognosis.
The average age at the onset was 68 years with a range of 55 to 91. The average period of followup was 3.2 years with the range of 1 year to 7 years. Of the fourteen cases, three had improved according to roentgenological findings, four were unchanged and seven had gotten worse. The prognosis of this disease did not correlate with the age at the onset, but did correlate with the size of osteonecrosis and FTA. Moreover, the tendency to have a poor prognosis was shown with the cases who were obese.

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Since joint replacement was introduced as a surgical treatment of rheumatoid arthritis (RA), patients with severe RA who have become unable to walk or are bedridden have been able to increase their daily life activities through receiving an operation.
A study was made on 12 patients who received over three joint replacements for hip, knee and ankle joints. Another study on complications was done on 31 patients who had undergone two joint replacements or more. The results with multiple joint replacements were good in general, but there were a few cases in which operative purposes were not achieved because of complications.
We proposed a new functional criteria to evaluate multiple joint replacement for RA.

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Four patients who had old osteochondral fracture of the patella have undergone autogenous osteochondral graft from the non-weight bearing area of the lateral femoral condyle.
The osteochondral fracture had been caused by traumatic (1), recurrent (2) or habitual (1) dislocation of the patella. The average age of the patients at the time of grafting was 21.5 years (range, 13 to 31) .
The mean follow-up interval after operation was 1.1 years (range, 8 months to 1-year, 4 months) . The grafted fragments were found at arthroscopy to be in place without cartilage breakage or sapphire pin protrusion. Two patients required arthroscopic manipulation, but finally all cases regained a full range of motion, and were relieved of their patello-femoral pain, swelling and dislocation. Only one patient had retropatellar crepitation.

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In order to make clear the movement of the carpal bones during active flexion-extension and radial-ulnar deviation of the wrist, a cineradiographic analysis of 60 normal wrists of 30 normal volunteers was carried out. The forearm was fixed in the neutral position with a specially- designed supporting device.
The radio-lunate angle, radio-scaphoid angle and scapho-lunate angle were all measured during flexion-extension of the wrist in the lateral view. The radio-lunate angle showed a large change in the first half of flexion and extension of the wrist from the neutral position to the maximal flexion and extension. The same tendency was observed in the radio-scaphoid angle.
In the antero-posterior view, the lunate angle formed by the ulnar tangent line of the lunate and the longitudinal axis of the radius, the perpendicular distance from the ulnar edge of the lunate to the line parallel to the longitudinal axis of the radius at the ulnar edge of the radius, and the height of the scaphoid were measured, respectively. When the wrist deviated from the radial side to the ulnar side, the height of the scaphoid increased in accordance with the dorsal flexion of the scaphoid. While the lunate was found only to slightly flex ulnarly in the same position from the radial deviation to about 20° of the ulnar deviation of the wrist, the lunate not only flexed ulnarly but slide radially in the remaining ulnar deviation.
The center of rotation described by Youm was also examined and the following result was obtained: The center of rotation existed from maximal radial deviation to 20°of the ulnar deviation. However, in maximal ulnar deviation, the center of rotation moved to the radio-distal direction, coordinating with the radial slide of the lunate bone.
Many authors have reported kinesiological analyses of the wrist based on various methods. Nevertheless, there has been controversy concerning the angular contribution of each carpal row to the total arc of the flexion-extension of the wrist. From our analysis, the mid-carpal joint had a share of 53% during flexion-extension and 59% during radial-ulnar deviation of the wrist, respectively.
Cineradiographic analysis was also made on a representative case with dynamic abnormality of the carpal alignment, showing the usefulness of cineradiography.

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Radiographic changes of the thumb and wrist were examined in 150 patients with rheumatoid arthritis. The relations of radiographic changes of IP, MP and CM of the thumb to the duration of the disease, deformity of the thumb, and radiographic changes of the wrist were investigated. Each Steinbrocker's stage (I-IV) was subdivided into two (a and b) and the radiographic findings were classified into 8 stages.
Stages IIIa and up (≥IIIa) were found in 70% for wrist joint (W), 40% for CM, 25% for MP, and 20% for IP. By duration of disease, the corresponding figures in cases of less than 5 years were 34% for W, 14% for CM, 5% for MP, 2% for IP, and those in cases of 20 years or longer were 89% for W, 75% for CM, 60% for MP, and 40% for IP. The wrist joint showed bone destruction comparatively early, while the bone destruction of thumb's joints, particularly of IP joints, was less remarkable. More than 90% of the patients with IIIb bone destructions of the IP and MP joints showed severe bone destruction of the wrist joint. In contrast, about one-half of the patients with ≥IIIb bone destruction of the wrist joint showed only ≥ IIb bone destructions of the IP and MP joints.
Deformity of the thumb was found in 102 thumbs (34%), with Type 1 deformity accounting for a large majority (76 thumbs) . In Type 1 deformity, the frequency of ≥IIIb bone destructions of the MP joint was slightly high as compared with the CM joint. About a half of the cases of Type 1 deformity showed very little alterations (≥IIa) of the MP joint. It was thought that early synovitis without associated bone destruction could be a causative factor in deformity of the thumb.

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In a study of case of loose shoulder in junior high school students, we found 95 “loose shoulders” (15%) in 631 students (boys 12.4%; girls 17.7%) . With respect to laterality, 67 students (70%) were bilaleral cases, 12 (12.6%) were right and 16 (16.8%) were left.
Some complaints with “loose shoulder” were registered by 21 students (22%) . Stiffness of the shoulder girdle and mild pain of the shoulder joints were the main ones, and appeared to be related to throwing in athleties. The multidirectional instability that Neer II had described was recognized in 11 of the 95 students, but they had complaints of multi-directional instability more than of “loose shoulder”.

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Through the clinical experience of performing head bipolar hip prosthesis, we came to believe that it might be possible to improve this prothesis by changing the head from a metalic one to an alumina ceramic one. We accordingly developed a new bipolar hip prosthesis with an alumina ceramic outer head which is much more bioinert than a metallic one. This prototype model was tested with static load, impact force and repeated load, and having passed these tests well, we judged that it had enough strength for practical clinical use.
Therefore we used this model clinically in femoral neck fracture, aseptic femoral head necrosis and osteoarthritis. No problems in clinical and X-ray findings have been shown in these cases to date, and all patients have rated the results as satisfactorily. The center was made offset in this model, in expectation of the so-called self-centering effect. This effect is discussed biomechanically using a mathematical model from the point of view of the differences of the head size and the frictional coefficient between metal and alumina ceramics.

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The range of motion of the hip was analyzed clinically and radiographically after joint replacement with the Bateman UPF prosthesis. A smaller range of motion was obtained with it than with the conventional Austin Moore-type prosthesis, Thompson-type prosthesis, or a prosthesis for total replacement.
In vivo observation of the prosthesis with a image intensifier reviealed that relative motion between the inner head and the bearing insert took place first, and secondarily after the prosthetic neck impinged against the rim of the outer head and acetabulum.
The relative motion along the two bearing surfaces was found to be smaller than expected, due to the scar tissue formed around the prosthesis.
The position of the outer head showed large variation among the implanted prostheses, and a smaller range of motion in hip abduction and flexion was observed in patients with valgus and a retroverted position of the outer head, while a larger range of motion was obtained with varus and an anteverted position of the outer head.
The position of the outer head was controllable by managing the hip position after joint replacement.

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During the last S years, 139 patients (147 joints) were treated by arthroscopic meniscectomy in our hospital. Of these, 4 patients (4 joints) required reoperation. All of the reoperative cases had had incomplete discoid lateral menisci and partial meniscectomy had been performed at the time of initial surgery.
At the time of reoperation, horizontal tears were present in three cases and a degenerative tear of the anterior horn in the other.
Arthroscopic partial meniscectomy has produced a short disability period and possibility of rapid return to sport's activity. But the results of partial meniscectomy on the incomplete discoid lateral meniscus have been worse than those on the other types of meniscus. The incomplete discoid menisci are thicker than the normal type menisci. Horizontal tears are often present and this seems to be a reason for the worse results.
So, it is more important in such cases to carefully probe and evaluate the remaining portion (especially the anterior portion) of the meniscus.

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Clinical results of cases with and without resection of the painful synovial shelf were compared and the factors related to residual complaints were investigated. The subjects comprised a total of 43 knees in 39 patients with synovial shelf syndrome (27 resected shelf knees in 25 patients and 16 unresected shelf knees in 14 patients) . Excellent or good results were obtained in 22 (82%) of the 27 resected shelf knees and in 9 (56%) of the 16 unresected shelf knees. Resection of the shelf thus yielded more favorable results. It did not relieve all complaints, though, and in more than half the resection cases, some difficulties remained. The type B (Sakakibata's classification) nonresected shelves, also showed very good results in several cases.
The factors relating to residual complaints included operation procedure (release or partial resection), patelao-femoral congruity, additional burdens of knee arthropathies due to aging and lesions in patellar and medial femoral condylar cartilage. In particular, problems in differential diagnosis with regard to the patellar subluxation syndrome seem to have substantial influence upon the therapeutic results in the synovial shelf syndrome.

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This study is an attempt to analyze the natural course of an isolated anterior cruciate ligament tear with antero-lateral rotatory instability.
The results of following 20 athletes treated initially by nonsurgical means for this injury showed there is a clear relationship between activity level and giving way: the more active the athlete, the more giving way there is: and the more the giving way, the more meniscus injury there is. It is important to suggest this fact to an injured athlete with antero-laterla rotatory instability.

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The immunity to proteoglycan (PG) antigens of human articular cartilage was assessed by liquidphase radioimmunoassay in patients with rheumatoid arthritis (49 cases), and osteoarthritis (35 cases) and in healthy donors (64 cases) . IgG anti-PG antibodies were detected only in patients with rheumatoid arthritis (30%), whereas IgM antibodies were detected both in patients with RA (18%), and with OA (6%) . No antibodies were detected in normal controls.
The anti-PG titre had no statistically significant relationship with clinical parameters such as the erythrocyte sedimentation rate, the duration of disease, the number of affected joints and the titre of IgM rheumatoid factor.
Both native PG and core protein showed an inhibitory activity in this assay, suggesting that cartilage PG acquires its autoimmunogenicity in the inflammatory milieu of RA or OA. The IgG antibody production in RA may reflect the possible abundance of B cell differentiation factors in the lesion.

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