In order to evaluate the function of the rheumatoid elbow joint, we prepared a scoring system for assessment of the function of the elbow joint. The scoring system has 100 points totally: pain (40 points), range of motion (20 points), flexion or extension contracture (10 points), varus or valgus deformity (10 points), stability (10 points) and function (10 points) .
Using this we evaluated, pre- and postoperatively, 20 joints in 18 cases of Synovectomy of the elbow joint and 8 joints in 7 cases of total elbow replacement (TER) . The prosthesis used for this TER series, prepared by our department, was made of alumina ceramics and high density polyethylene.
In the cases of synovectomy, an average of 43.4 points was gained post-operatively and 35.5 points was gained on an average in the cases of TER. This scoring system proved useful for the functional evalution of the rheumatoid elbow.

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In the treatment of RA elbow, it is important to make adequate evaluation of the joint. We advise functional evaluation with impairment level factors, such as arthralgia, ROM and elbow instability. Due to Gade's theory, we think that the range in ADL should be given more importance than other ranges of motion.
In this study on 108 elbows in RA patients, we determined that the important range seemed to be 110° -130° in flexion and -40° in extension.
To get an index for the functional value of motion, in the future, we intend to analyze more patients with a mathematical method such as multiple regression analysis.

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Since August 1983, 16 elbows of 13 rheumatoid patients (4 male and 9 female) have been replaced with a ceramic prosthesis. Their ages ranged from 39 to 77 (average 62.8) and the followup period ranged from 3 to 50 months, with an average of 20 months. Postoperative clinical results assessed by the R.B. Bringham point score system were raised by an average of 34.6 points (from 33.2 to 69.2) . The gain was mainly due to remarkable pain relief after surgery. Postoperative ROM of the elbow was improved by the average of 30° in flexion and 15° in supination.
In first 8 cases, in which a prosthesis without a stem was used, several complications were observed; dislocation in 2, fracture of the coronoid process in 1 and humeral condyle in 1. In particular, the incidence of proximal migration (loosening) of the humeral component was very high (7/8) . On the other hand, in the latter 8 cases in which a prosthesis with a stem was used, the prosthetic component remained more stabilized. The stem seemed to prevent the component from loosening.
In patients of rheumatoid arthritis with severe bone atrophy, bone cementing might be considered appropriate.

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Dislocation of the acromioclavicular joint is often observed, but its therapy has not been established. We have performed operations on cases of Grade III and a part of Grade II according to Tossy's classification. Formerly we used the Neviaser's method, but sometimes there were unsatisfactory results, such as decline of muscular strength (especially that of the deltoid muscle), contracture of the glenohumeral joint and deformation of the acromioclavicular joint.
Since 1980, a modified Neviaser's method has been performed in our clinic. The modified points are: 1) detachment of the deltoid muscle is held at a minimum, and 2) the fixative part of the coracoclavicular ligament is changed to the posterosuperior area of the clavicle. Ever since we have had satisfactory clinical results in all cases.

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Among the several lesions of “baseball shoulder”, a condition with (1) pain in the posterior part of the joint and radiating pain to the deltoid in throwing a ball, (2) tenderness on the quadrilateral space, and (3) osteophyte formation in the posteroinferior margin of the glenoid in X-P is diagnosed to be ‘Bennett lesion’. However, its etiology and surgical treatment have not been clearly defined as yet.
Nineteen such cases (19 joints) were treated in our clinic between April 1981 and March 1987. Among them, five were treated operatively. All were male, and their ages were from 18 to 34 years, an average of 28.7 years, and their baseball lives were from 9 to 21 years, 17.6 years on an average. The postoperative follow-up periods ranged from 6 months to 6 years, with an average of 2 years and 6 months.
Roentgenologically, they divided into two groups. One was the‘capsular type’ (4 joints), in which an osteophyte was seen in the posteroinferior capsular insertion of the glenoid. The other one was the‘musculo-tendinous type’ (1 joint), in which an osteophyte was seen on the origin of the long head of the triceps. In the capsular type, the posterior portion of the humeral head made contact with the osteophyte during the abduction and external rotation. This contact was removed by operation. In the musculo-tendinous type, the axillary nerve was entrapped in the quadrilateral space by the thickened long head of the triceps. At operation, the adhesion of the axillary nerve was released and the quadrilateral space was widened by partially resecting the long head of the triceps. The shoulder pain in throwing was relieved in S patients. In 3 patients, followed up for more than 1 year, the throwing level was restored to the level before the disorder started.
It is concluded that Bennett lesion, which has never been improved with long-term conservative measures, should be treated surgically, based on individual pathogenesis.

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Thirty-five patients who had throwing injuries to the shoulder underwent arthroscopy of the shoulder in order to investigate the internal derangement. The average age was 21.6 years and the average duration of symptoms prior to arthroscopy was 14.0 months.
The throwing sports involved were baseball (23), volleyball (8), tennis (2) and others (2) . All patients complained of pain in the shoulder during overhead activity and had not responded to conservative therapy.
At arthroscopy, superior labrum separation was found in 16, anterior labrum tear or disruption in 9, posterior labrum flap tear in 1, and isolated rim rent of the supraspinatus in 5.
Thus, 31 of the 35 (89%) demonstrated internal derangement of the shoulder, especially at the superior or anterior labrum portion, which is similar to the impingement syndrome or anterior subluxation clinically, and makes it difficult to demonstrate characteristic objective findings for such a throwing shoulder.
We believe that it is necessary to perform a thorough arthroscopic examination for throwing injuries to the shoulder in order to establish an accurate diagnosis and appropriate management of the injury.

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The Kodama-Yamamoto knee prosthesis is a non-cemented, surface replacement type. The first surgery using it was carried out in 1970, and since then it has been improved twice. The prosthesis used since 1975 is called the Mark II, and that used since 1985, the Mark III. From the first prothesis through Mark III, we have had consistent success with the non-cemented, surface replacement design.
Surgery using the Kodama-Yamamoto Mark II was conducted from 1980 to 1984 on 350 knee joints of 225 patients at the Matsuyama Red Cross Hospital and the Dogo Onsen Hospital. In 1987, a survey was conducted of 335 joints of 214 patients (follow-up rate, 95.1%), varying from 2 to 7 years after surgery, and a resultant evaluation was made. Excluding cases of mortality, 31 out of 312 knee joints (9.9%) suffered some problems after surgery caused by infection, aseptic loosening, continuing pain, instability or decrease in range of movement. Seventeen knee joints (5.4%) still continue to be problematic.

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We designed a brace for the lower extremity to support and treat the joints affected by sprain injuries.
The effectiveness of the brace was assessed by radiography and gait analysis. The brace was made of elastic woven rubber, further support being provided by coiled springs of piano wire on both sides, stretching from front to back of the ankle. Sideways (lateral and medial) movement of the joint was controlled by attaching rubber straps to each side. A silicon rubber wedge sole was inserted into the heel part of the brace.
To control internal rotation of the ankle joint for sprains of the external type, a 5mm wedge was used to enhance the external rotation. Conversely, for internal rotation sprains, a wedge sole was used with the thickest part to the middle.
The brace was tested on new injury cases of stage I and II injuries in non-sports players. and stage III cases after surgery. It was also evaluated as a support during sporting activities to prevent injury to people who have had corrective surgery.
Eleven cases (3 new, 3 old, and 5 after surgery) have been followed up. Stress radiography and three dimensional gait analysis demonstrated improved stability and control of the ankle joints. The results indicate that the brace is providing the desired supprot, and by compensating for external and internal rotation, may be preferable to the conventional taping method.

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The posterior cruciate ligament (PCL) has an important function for stability and the movement of the knee joint even in arthroplasty. At first the design of the surface replacement type of total knee replacement (TKR), especially of the tibial plate, was considered most important for achieving stability. But recently biomechanical studies on knee replacement have indicated that lopsening of the prosthesis is increased by resectioning of the PCL.
We studied the difference in the range of motion (ROM) between PCL-retention and PCL-resection in our prosthesis (Okayama, MarkII) in 54 knees using the PCL-retention method, and in 74 knees using the PCL-resection method. In a follow-up of over 3 years, the ROM of the PCL-retention TKR was 90.0°, and that of the PCL-resection was 79.8°. Although the results were largely influenced by limited preoperative movement of the knee joint, especially due to flexion contracture, there was no difference between the PCL-retention and PCL-resection groups.

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Thirty-three knees in 21 arthroplasty patients with a Miller-Galante porous knee prosthesis were evaluated clinically and radiographically. The mean age was 64 years (range 31-83 years) and 15 (71 %) were female. The mean follow-up was 12.3 months (range 7-18 months) . The primary diseases were osteoarthritis (14 in 9 patients), rheumatoid arthritis (16 in 10 patients) and others (3 in 2 patients) . The clinical evaluation consisted of the Japanese Knee Society Score for osteoarthritis and the preliminary evaluation score proposed by three universities for rheumatoid arthritis. The radiographical evaluation was done by three-times magnified tangential X-ray analysis for condensation, lucency and subsidence in the tibial component interface.
The clinical evaluation showed that there was good improvement with the 13 knees with osteoarthritis (90.9%) and the 16 knees with rheumatoid arthritis (100%) .
Twelve months after the operation, condensations were seen at the lateral side (17%) and the anterior side (56%) . Lucencies wider than 2 millimeters were observed at the medial, center, lateral and anterior areas in 2 knees (22%) . No subsidence was found. Loosening of the screw was seen in 4 knees (12%) and of them were anterior screws.
In conclusion, satisfactory results were found in our short-term follow-up study of the Miller-Galante porous knee prosthesis. We stressed the importance of choosing an adequate tibial component, on which can cover the tibial bony surface almost completely.

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The functions of the knee and radiographical changes were analyzed in 30 consecutive patients with 46 posterior stabilized condylar knee prostheses. The patients were followed for an average of 1.6 years (range, l to 2.6 years) .
Scores in each item of the knee function rating except range of motion increased significantly after surgery. Flexion contractures and femorotibial angles were significantly improved, but the average degrees of flexion and ranges of motion were the same after operation as before. All these results except pain were significantly correlated with the preoperative state. Relief of pain was successfully achieved regardless of the preoperative degree of pain. Good flexion arcs were correlated with posterior positioning of the tibial prostheses.
Nine knees (19.6%) had radiolucent zones at the bone-cement interface. Data analysis of age, degree of obesity, knee function score, postoperative range of motion, postoperative femorotibial angle, tilting of components, and positioning of components demonstrated no statistically significant characteristic of this group in comparison with the group without radiolucent zones. The only factor that correlated with the presence of radiolucent zones was tibial cementing length, i.e., the vertical distance from the tip of the tibial central peg to the distal end of the cement. The average tibial cementing length of the knees without radiolucent zones was 26.2 mm, which was significantly longer than the 10.0 mm of the knees with radiolucent zones.
Comparison of the 12 knees in 8 rheumatoid patients with 38 knees in osteoarthritic patients indicated that the arthroplasty relieved joint pain and improved the range of motion more successfully in rheumatoid knees than in osteoarthritic knees. However, the RA patients scored worse than the patients with osteoarthritic postoperatively in the categories of gait and daily activities, in which involvement of other joints was probably the major obstacle.

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Using the PCA total knee system, the authors performed total knee replacement (TKR) on 16 cases (24 joints) of RA from July 1984 to September 1987. This number included 6 cases (7 joints) where preoperative flexion contracture exceeded 30°. The patients ranged in age from 37 to 65 years, with an average age of 55, 2 years. The postoperative follow-up period extended over an average of 1 year and 5 months.
Only minor additional bone resection was carried out in order to facilitate insertion of the prdsthesis. There were no major bone resections and no special treatments were performed on posterior structures. The amount of bone to be resected, as measured by simple X-ray photos, was in a somewhat larger amount than in cases with mild deformities.
The preoperative limit of extension was an average of 42.1°. While immediately following surgery there was no complete extension, only an average of 25°, the postoperative improvement after 6 weeks was an average of 2.9°. The range of motion, an average of 56.4°preoperatively, had become an average of 91, 4°at the time of the survey. The total number of points in evaluating knee joint function, an average of 28.3 before surgery, became an average of 81.3 points.
From the above results it is concluded that even without any special treatment being performed on posterior elements during TKR for flexion contracture knee, postoperative flexion contracture can be expected to readily impxove, leading to excellent clinical results.

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A long-standing flexion contracture of 9 rheumatoid knees was treated with a serial corrective cast method followed by a surgical posterior capsuloplasty. Wilson's procedure with Z-plasties in the iliotibial tract and the biceps tendon was employed for the posterior capsuloplasty. The follow-up periods ranged from 7 months to 9 years with an average of 2.4 years.
The initial average contracture of 64.4 degrees was corrected to 16.9 degrees with a practical range of motion. Of the 9 joints treated, 6 had enough ability for weight bearing and showed a favorable remodeling of the joint surfaces in roentgenographs, while 3 required total joint replacement because of pain. The results encourage us to stress the importance of the soft tissue rebalancing, even if the articular surface is destroyed and total joint replacement is being considered.

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Twenty five femoral neck fractures in 24 patients with rheumatoid arthritis (RA) are reported on.
The patients were one male and 23 females, with an age distribution of from 35 to 78 (average 64) . By Steinbrocker's stage classification the majority of the cases were stage III and IV because of advanced RA. Their ADL was class III according Steinbrocker's class classification. Those patients with fractures usually had accompanying joint impairments in the lower extremities, especially in the knee jont, and advanced osteoporosis as well.
The sites of the femoral neck fracture were the subcapital region in 76% and the trochanter region in 24%. Seven cases out of 19 subcapital fractures had spontaneous fracture.
Six cases of trochanteric fracture showed favorable bone union, except for one case which was revealed to have had the bone cut off by the lag screw. On the other hand, the 5 cases with subcapital fracture showed poor results during conservative treatment as well as after osteosynthesis. Four of these developed pseudoarthrosis and osteonecrosis of the bone. Forteen cases received hip replacement surgery immediately after the fracture, and good results were obtained.

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Studies were made of 9 RA cases with stress fracture of the pelvic bone. Among the cases with fracture of os pubis or os ischii, several were observed with osteoporosis due to rheumatic disease, disuse and prolonged use of steroids. Increase in body weight (the upper half of the body was heavy or the lower limbs were thin) was seen in many cases who were also complicated by disorders of the sacro- iliac and hip joints, suggesting that stress tends to be applied to the symphysis pubis in front of the pelvic bone when walking in the flexion posture. The site of the fracture was mostly the symphysial surface of the corpus ossis pubis and ramus ossis iscii, which are the regions where the muscles and ligaments are attached.
The occurrence of fatigue fracture and dislocation of the bone are ascribable to muscular action. The loading of stress being concentrated in the forward direction at the corpus ossis pubis and symphysis pubis causes compression fracture. If the symphysis pubis cannot bear the load, torsion is repeatedly applied to the ramus ossis ischii and ramus ossis pubis, causing bending fracture in these regions.
Thus it was considered that fatigue fracture of the pelvic bone is caused by combined factors such as dynamic elements, fragility of bone accompanying RA and abnormality due to RA lesions in the lower limbs.

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We have analysed our results after performing 21 cup arthroplasties in 18 patients with osteoarthritis. Pain was completely relieved in 44% of the patients. The range of motion of the hip had deteriorated, but 72% of the patients were satisfied with the overall results. The satisfactory results obtained confirm the effectiveness of this operation where it is indicated.

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Resection arthroplasty of the metatarsophalangeal joint for deformed rheumatoid forefoot is popular and many operative procedures have been reported on, but only a few long-term follow-up studies have been carried out in Japan.
Of 32 feet operated on in 21 patients by us, 23 feet of 14 patients were followed up in this se-ries from 5 to 16 years, the average follow-up period being 11 years and 6 months.
Our operative procedure was similar to that in Lelievre's operation, except that the metatarsal heads were resected in 9 feet and the metatarsal joints were excised in 14 feet.
The overall clinical results were almost satisfactory in all feet. But one foot had pain because of recurrent hammer toe, and another had difficulty in getting shoes due to overlapping toes.
The X-ray findings at the time of follow-up showed the recurrence of hallux valgus in most feet, but the degree of deformity was less after operation.
The first metatrasophalangeal joint was fused in 6 cases, but these cases had no complaints and were satisfactory.

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Valgus high tibial osteotomy is a widely accepted method of treatment of medial gonarthrosis. It is commonly believed that the alignment obtained by the osteotomy is important in obtaining satisfactory long-term results. We evaluated the results in 30 patients (35 knees) who had had a high tibial osteotomy for medial gonarthrosis. The mean length of follow-up was 2 years and 7 months (range, one to 5 years) .
We measured the tilt angle of the joint surface to study the opening of the medial joint space after operation. This is the angle of intersection of the surface of tibial plateau and the tangent line of the medial and lateral femoral condyle. Radiographs were taken of the alignment and the tilt angle when supine and when in the one leg stance before and after operation. In the supine and the stance positions, the average of the femorotibial angle of 182.7 and 187.7 degrees was corrected to 166.8 and 167.0 degrees postoperatively, respectively. The respective average of the preoperative tilt angles of 3.2 degrees when supine and 7.1 degrees when in the one leg stance were changed to 2.9 and 3.8 degrees. In 28 of 35 knees, the postoperative tilt angle when in the one leg stance was between the preoperative tilt angle when supine and when in the one leg stance. In 2 knees it was increased over the preoperative tilt angle when in the one leg stance. In 5 knees it was decreased to less than the preoperative tilt angle when supine.
Consequently, when doing preoperative planning for high tibial osteotomy, it is better to determine the corrective angle from the A-P radiograph both when supine and when in the one leg stance.

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Synovial fluid reflects the pathology of joint diseases, and examination of synovial fluid is most helpful for making a rapid and accurate diagnosis in most types of joint diseases. It is important to examine the fluid immediately after aspiration, especially for determining the glucose level.
We found that the synovial glucose levels were low in two cases of septic arthritis. The mean of the two glucose levels was 9mg, less than that of other joint diseases. In a few cases of rheumatoid arthritis and pseudo gout, low glucose levels were also observed, but these were due to the glucolytic action of white cells a long time after aspiration. The synovial fluid was divided into three conditions and examined after 6 hours and 24 hours. We recommend that the synovial fluid to be used for glucose determination be placed in a tube containing sodium fluoride.

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Recently human B lymphocytes expressing the T cell antigen-CD5 (Leu1, OKT1), the 67kd surface protein, have been found in normal blood and lymphoid organs. These circulating CD5⁺ B cells coexpress B cell differentiation antigens CD20, CD21, CD19, surface IgM, IgD and HLA-DR. We researched these CD5⁺ B cells using two-color immuno-fluorescence analyses. In 39 RA patients (7 males, 32 females), the CD5⁺ antigen was detected on an average in 13.8% (±13.6 SEM) of the B cells of peripheral blood in comparison with an average of (5.8±2.5% SEM) in healthy controls. The CD5+ B cell/total B cell ratio did not have a statistically significant relation with any clinical parameters such as ESR, duration of disease, rheumatoid factor, number of affected joints, stage of drug treatment, except for age. On the other hand, the increase in CD5⁺ B cell subpopulation appeared in the patients with rheumatoid factor and who had a relatively short duration of disease. This study suggests that the CD5⁺ B cell subpopulation plays some role in the spectrum of the disease.

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To know the causative and growth factors of calcification of cervical yellow ligaments, we carried out a morphological investigation of 4 cases. This included CT scanning, histological, ultrastructural and crystallographical studies.
The results were as follows:
1) The CT scan showed various kinds of calcified masses of spotty, nodular and mushroom shapes. The larger the mass a case had, the more serious the symptoms of myelopathy were.
2) The larger masses contained more hydroxyapatite (HA) than calcium pyophosphate dihydrate (CPPD) or calcium phosphate.
3) In the non-alcified area of ligaments, a deposit of calcium crystals was observed inside the fibroblasts, which were surrounded by the proteoglycan (PG) layer, the collagen fiber layer and the layer of matrix vesicles. On the other hand, in the calcified area, many chondrocytes and matrix giant bodies (MGB) were observed.
These facts suggest that the degeneration of cells occurred first, and then the matrix vesicles derived from these cell components grew into MGB influenced by PG, collagen and chondrocyte. They also suggest that matrix vesicles play an important role in the maturation of crystals from CPPD to HA.

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Posterior dislocation of the shoulder is a rare condition, comprising only 2% of shoulder dislocations. The diagnosis is often missed and the treatment then becomes difficult.
It is most important that correct diagnosis is made initially with adequate physical examination and radiographic findings in the anterioposterior and axial positions.
We have experienced treating two cases of unreduced posterior dislocation fracture of the shoulder. Open reduction was carried out on one case which had been overlooked for one month and had been treated as a fracture of the major tuberosity. Rotational osteotomy of the proximal humerus was done on another one which had been missed for three months and had been treated as a rotator cuff tear. Some limitations of shoulder motion were observed in both cases, but there were no restrictions on daily living.

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Proper interpretion of wrist radiography requires a standardized radiographic technique. We obtained posteroanterior and lateral radiographs in 100 normal volunteers in standardized position (forearm in zero rotation) to analyze the normal wrist. We measured the carpal alignment and carpal height ratio, and the structural indeces of the distal end of the radius such as variancy, radial inclination and volar tilt. The average and standard deviation which was obtained in this study is a reliable index for Japanese.

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