Twenty-five RA patients who showed spastic quadriparesis and were treated by various surgical methods were studied. Their pathogenesis was classified into 6 groups according to x-ray findings and the type of surgery performed.
Three cases who had posterior subluxation of the atlas are described. In several cases rheumatoid granulations were found in the spinal canal at unstable segments and in multiple facet ankylosis at other levels.
Some cases who had anterior fusion surgery showed an unsatisfactory course. Therefore two methods of surgery are recommended for subaxial lesions in RA with severe cervical myelopathy. If there is multiple level involvement, posterior decompression and posterior fusion should be chosen. If destruction of the cervical vertebral body is found, anterior and posterior fusion is indicated.
For deciding the suitable treatment for RA patients with cervical myelopathy, what is most important is meticulous evaluation of their pathogenesis.

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We examined 6 cases of rheumatoid arthritis in the upper or lower cervical spine by plain radiography, myelogram, X-ray CT and magnetic resonance imaging (MRI) . Among these, MRI provided the best resolution of tissuse surrounded by bones, as well as of minute differences among various tissues. Enhancement of the differences between normal and diseased parts within tissues was also made possible with MRI by altering the imaging parameter. MRI was useful not only for depicting boney abnormalities in the cervical spine that are associated with rheumatoid arthritis, but also for directly observing the effects of the disease process on the spinal cord.

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It is frequently seen that radiological change in the cervical spine of rheumatoid patients worsens with time as the disease progresses. In the present study, we measured the degress of atlanto-axial subluxation, vertical subluxation and subaxial subluxation on plain radiographs of the cervical spine at intervals of a certain period of time in 58 patients with rheumatoid arthritis and compared radiological changes in the former with those in the latter. The interval between the first radiograph to the second was one year to 12 years with the average of 5 years.
Those cases in which radiological progression in at least one of these 3 subluxations was more than 3 mm were classified into the progressive group (P) (26 cases), and those cases in which radiological progression was less than 3 mm were classified into the non-progressive group (N) (32 cases) . Statistical assessment was performed on the differences between the progressive and the non-progressive groups with regards to such items as age, duration of the disease, stage of the disease, carpal height ratio, and atlanto-axial angle.
The results are as follows;
(1) The range of motion in C1-C2 was more increased in the P-group than in the N -group.
(2) The atlanto -axial angle in flexion was more decreased in the P -group than in the N - group.
(3) The carpal height ratio was more decreased in the P-group than in the Ngroup. The difference was statistically significant.
(4) Neurological deficits were frequently found in patients with an CiA-P diameter of less than 14mm.

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A 72-year -old female had been suffering from severe rheumatoid arthritis for 28 years with destruction of the atlanto-axial joint. This allowed the migration of the dens through the foramen magnum, resulting in fatal cervicomedullary compression. An autopsy was performed.
We suggested that atlanto-axial posterior fusion would have been insufficient for severe vertical subluxation over a long period and that transoral anterior decompression and fusion would have been indicated for this case.

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The purpose of this report is to describe a new method for the functional evaluation of rheumatoid elbow on a numerical scale of 100. Forty points are allotted for pain, 30 for motion, 20 for function, 6 for instability and 4 for muscle strength. Our new rating scale was applied to 33 rheumatoid elbow joints in 20 patients. Patients were divided into four grades; grades 1 and 2 by the radiological criteria of Steinbrocker, and grades 3 and 4 by that of Hastings and Kwok.
The functional rating went down in accordance with the progress in radiological grades. The correlation between functional rating and radiological grades was statistically significant. This result indicates the usefulness of our new rating scale for the functional evaluation of the rheumatoid elbow joint.

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A follow-up study of the Inoue-type non-constrained elbow arthroplasty was done in seven patients with rheumatoid arthritis after an average of 39.6 months.
The range of motion of the forearm and the elbow was improved postoperatively in all of the cases, but two of them complained of instability with pain during motion, and one of instability without pain.
X-ray examination showed that the humeral component of the implant had migrated proximally in all three cases. No significant correlation was found between the extent of migration and the preoperative amount of bone stock or bone destruction.
From the biomechanical point of view, the humeral component of the implant would be improved by widening it, and the radial head should be preserved or replaced with an implant.

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We investigated the roentogenological findings of wrist and hand of 97 cases (190 joints) of rheumatoid arthritis. In 55 cases (107 joints), we studied the function radiographically using the antero-posterior view and lateral view.
In rheumatoid arthritis, the radiological findings of wrist and hand show various patterns. Carpal bones are sometimes translocated ulnar wardly by the destruction of the radio-carpal ligaments and the ulno-carpal ligaments complex. Unstable wrist sometimes exists, but is gradually stabilized as time passes. In the period in which there is carpal instability, we should be cautious about doing an operation such as synovectomy that excises the ulnar head.

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Macroscopic, light microscopic and scanning and transmissions electron microscopic investi-gations were performed on the articular cartilages of 51 knees of 41 young (3 males, 38 females; 13-24 years; mean, 18 years), who had unstable patellae clinically and had shown to have chondropathia patellae by arthroscopy.
Fissuring was almost always observed macroscopically, but swelling and softening were rarely observed. These findings suggest the early period changes of chondropathia patellae.
Chondropathia patellae was characterized light-microscopically by changes of the matrix. The stainings of hematoxylin eosin, saf ranin 0 and toluidine blue were decreased by edematous changes of the affected matrix. In particular, the decline of the safranin 0 staining indicated the decrease of proteogrican.
Scanning electron microscopy showed rough and edematous collagen networks on the area of central ridge even in regions which were observed as normal macroscopically.
Transmission electron microscopy showed the displesion of considerable deposits of amorphous electron dense material in the matrix and that immature collagen fibrils of rather short spacing periodicity were dispersed there. The obvious derangement of the polarity and periodicity of the collagen fibril was confirmed. The impregnated granules of the immature collagen fibril stained by PAM (periodic acid methenamine silver) presumably represented the precursor of regenerative collagens.
These findings of chondropathia patellae were similar to those of the early period changes of osteoarthritis of the knee. But it is considered that chondropathia patellae has more powerf ull potential of being repaired by synovia and articular cartilage itself than osteoarthritis does.

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The predicted appropriate alignment of the knee joint after tibial osteotomy was investigated by computer simulation, with respect to the interaction of pressure acting on the tibial joint surface, the femorotibial angle (FTA) and the Mikulicz line. The Rigid Body Spring Model (RBSM) program was used as sof twear. Forty-nine knees (26 cases of osteoarthritis, 10 postoperative cases of upper tibial osteotomy, and as a control 23 knees) were investigated.
It was found that a 174° of FTA showed the best postoperative alignment, providing more than 90% uniformity of stress force distribution on the tibial joint surface.

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The number of cases of failure of total knee arthroplastry have been increasing, especially in those patients with the old type of prosthesis. We have performed revision surgery on 7 cases.
Four of them had been implanted with hinge joints. All the components of the hinge joint were removed in 2 cases because of infection. Reimplantation of the femoral component and bolt were carried out on 2 cases because of loosening and remarkable wear.
Arthrodesis was necessary in one case which had infection of the knee implanted with a surface replacement type of prosthesis.
In 2 cases with mechanical failure of the Geomedic knee prosthesis, a cylindrical knee prosthesis developed by us was reimplanted With the transplantation of banked bone. The reimplanted knees have maintained good functioning, although the length of the follow-up period is too short for significant evaluation.

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Total knee replacement was performed on 592 knees (463 patients) in our hospital and Dohgo Spa hospital from 1980 to 1987. Revision operations were conducted on 3 9 knees (34 patients) . Eleven knees (10 patients) on which total knee replacement had been performed in other hospitals were included in these cases.
The causes and operative techniques of the revision operation were investigated. The causes consisted of loosening (26), infection (2), fracture (6), pain around the patellae (3), pain on the anterior tibia (1) and decreased range of motion (1) . Sinking of the tibial component was seen in patients with rheumatoid arthritis.
Revision operations for failed total knee replacement were easy to perform, except in the cases with loosening and sinking. Then reimplantation was difficult because of bone defect and porosis. In general, reimplantation was done using a small femoral prosthesis with a stem and thick tibial component with a bone graft. In the case of severe bone defect and porosis, a stem type femoral prosthesis with a bone graft and plastic plate was used for severe femoral loosening, and a stem and thick tibial component with a bone graft was used for severe tibial sinking.

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A follow-up study was done of 16 knees in 12 female patients who had osteoarthritis of the knee with varus deformity and had been operated on using the Marmor modular knee. The oldest patient was 80 years old, and the youngest 57, with an average age of 69.4. The average follow-up period was 3 years and 5 months, with a range from 2 years and 4 months to 5 years and 3 months.
At the time of follow-up, the knee function was scored according to the criteria of the Japanese Society of the Knee (the second tentative one) . In 13 knees out of the 16, the score exceeded 70 points. The femoro-tibial angle (FTA) was evaluated in 14 out of the 16 with the standing antero -posterior radiogram. It was more than 180 degrees in 7 knees. While it is said that the ideal FTA is from 170 to 175 degrees, all except one of the knee function scores of the seven were more than 70 points.
Our tentative conclusion is to prefer the unicompartmental arthroplasty to the total knee arthroplasty for osteoarthritis of the knee, for it rarely is subject to panarthritic changes.

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We developed a total knee prosthesis (TKP) of alumina ceramic which preserves the posterior cruciate ligament (PCL retention type) . The wear of the ultra-high molecular weight polyethylene (UHMWPE) on the tibial surface of this alumina ceramic TKP was compared with that with a Vitallium Kinematic TKP. Gait simulation cycles were repeated 106 times under the load condition reported by Morrison, and using a newly developed knee simulator.
The abrasion loss of the UHMWPE wearing surface was measured with a surface form analyzer. The ultramicrostructure of the UHMWPE wearing surface was observed with a scanning electron microscope (SEM) . Elements on the UHMWPE wearing surface were analysed with a X-ray micro-analyzer.
The wear of the UHMWPE tibial surface of the alumina ceramic TKP was less than that with the Kinematic TKP. The mean of the maximum wear depth was 0.04mm in the alumina ceramic TKP, and 0.20mm in the Kinematic TKP. Observations using the SEM showed that scratches on the wearing surface of the Kinematic TKP were deeper than those on the alumina ceramic TKP. No metallic atoms were detected by X-ray analyses on the UHMWPE tibial surface in either prostheses.
It was considered that the differences of wear between the alumina ceramic TKP and the Kinematic TKP were due to the wear properties of the materials and the surface design of the components.

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Simultaneous bilateral total knee replacement was successfully carried out in five voluntary patients (ten knees), who were bedridden with knee contracture. There appear to be many benefits in this, if it is performed with careful planning and preparation. Precise evaluation of general preoperative conditions, repetitive simulation of operation procedures by RBSM, careful hemostasis during operation, and postoperative low pressure drainage under intensive care contributed to success. Our results show that simultaneous total knee replacement is not as deleterious as it has been considered, and that it encourages the patient to approach rehabilitation aggressively.

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The purpose of this study was to define the grading of articular cartilage degeneration in osteoarthritis of the knee according to arthrotomy findings, and to compare it with radiographic abnormalities. Degenerative findings of the articular cartilage were observed in 63 osteoarthritic knees of 56 patients with varus deformity, 7 men and 49 women, whose ages ranged from 49 to 83 years with an average of 66.8. Articular cartilage degeneration was classified into nine categories as follows: normal (Grade 0), discoloration to yellow (Grade I ), softening with unevenness (Grade ii), fasciculation and attrition (Grade III), erosion (Grade IV -a), ulcer with exposed subchondral bone (Grade IV-b), eburnation of exposed subchondral bone (Grade IV-c), bone destruction in an area less than 5 mm in depth (Grade V -a), and bone destruction in an area of 5 mm or more (Grade V -b) . Fifty-one of these knees were treated by high tibial osteotomy, eleven by unicompartmental knee replacement, and one by total knee replacement. Standing radiograms were taken of all the knees, and the abnormalities were then evaluated using the radiographic grading of osteoarthritis of the knee (Yokohama City University Criteria) . One knee was in Grade II, three in Grade HI, ten in Grade IV-a, eighteen in Grade IV-b, twenty-seven in Grade IV-c, and four in Grade V-b. There tended to be a positive correlation between the grade of articular cartilage degeneration and the radiographic gradings.

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Thirty-three patients with fracture of the Intercondylar eminence of the tibia were treated in our hospital between 1977 and 1986. The average age at the time of fracture was 29.9 years. Sixteen of the 33 cases were treated conservatively with plaster cast; the other 17 were treated by open reduction and fixation. Eleven fractures in the operated-on group were fixed with a ceramic nail.
The average period of follow up was 4 years and 11 months. Sixteen cases without any complicated injury had excellent results; those with such an injury were less comfortable.
Since 1981 we have been using ceramic nails for the internal fixation of this fracture. Internal fixation with ceramic nails is a useful method for repairing a fracture of the Intercondylar eminence of the tibia.

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The effect of diode laser irradiation on the mitogenic proliferation of cultured human lymphocytes was examined. DNA synthesis of the lymphocytes was inhibited by laser irradiation at a low energy fluence and enhanced at a higher energy fluence.
The results suggest that low-watt laser irradiation can interfere with the immune response in vitro. Similar interference might occur in patients with rheumatoid arthritis subjected to laser therapy.

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Fifty-nine knees with a mean follow up period of 2.5 years after meniscectomy were evaluated clinically and radiographically.
The results were the best in the lateral discoid group. The factors associated with poor results were ligament injury, an age at operation of over 40 years, and original cartilage damage. Osteoarthritic changes shown on the roentgenograms were also related to poor results, except with the discoid group. Preoperative duration of symptoms and the type of meniscal tear had no relationship to the results in this short-term study.

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Nineteen cases who had been treated with the modified Bristow procedure for recurrent subluxation and dislocation of the shoulder were clinically evaluated with the J.O.A. scoring system of the shoulder. The average follow-up period was 22.8months (1.9 years) . At the time of surgery the average age was 22.9 years.
The average score at follow-up was 94.1 points (/100points) . The range of motion was the same as that of the unaf feacted side except external rotation, in which there was an average loss of 19.9% (13.2°) . No patient has suffered redislocation. One shoulder (5.3%) subluxated 8 months after surgery and was treated with the Bankart procedure 15 months later. Some patients gave up sports after the injury.

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Total hip replacement with a bone graft to reinforce the medial acetabular wall was performed in 13 hips in 11 patients with protrusio acetabuli secondary to rheumatoid arthritis.
There was an average follow-up period of 2 years, 6 months, with a range of from one year to 4 years, 3 months.
Clinical assessment before and after operation showed that on the average the total JOA hip score improved from 27.5 to 72.9, and the pain score from 9.1 to 38.2. Roentgenological examination showed that all bone grafts were united with bone within 3 months and that protrusion did not progress. In 7 hips, physiological remodelling of the medial acetabular wall occurred.

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It is well known that psoriasis can be a complication with arthropathy, but it is rarely reported to be involved with the hip joints. Recently, however we have experienced two such cases, one with ankylosis of the hip and the other with enthesopathy of the iliopsoas tendon.
Case 1 was a 69-year-old female, diagnosed as having psoriasis about 10 years previously. She had also had osseous ankylosis of the bilateral hip joints from about 3 years ago. In view of the occurrence of both skin lesions and arthropathy in a ship as well as typical nail change and DIP joint dysfunction, this case was diagnosed as psoriatic arthropathy.
Case 2 was a 35-year-old male, regarded as having psoriasis from about 5 years ago. His dermal lesions were improved by treatment with etretinate. He complained of lumbago and right coxalgia about 6 months after the treatment was started. In spite of the improvement of the skin lesions, ossification progressed along the iliopsoas tendon. Then, the treatment was suspended. With this the progressive ossification ceased. Thus the symptoms might have been induced by the side effects of etretinate rather than by psoriatic arthropathy.

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A 61-year-old male patient with rheumatoid arthritis developed an osteolitic lesion in the 2nd and 3nd lumbal vertebral bodies.
The Histolongic findings of the lesions were comparable to those found in rheumatoid subcutaneous nodules. the patient also developed episcleritis, pleurisy and subcutaneous nodules, suggesting rheumatoid vascuritis.
We concluded that the lesion was caused by the formation of rheumatoid nodulelike granulation in the lumbal vertebrae.

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