One of the most serious complications after total prosthetic arthroplasty is deep wound infection. The causes of the infection are considered as follows: contact infection, droplets infection, incompletely disinfected prosthesis, airy infection, and flora residents of skin and haematogenous infection. In order to prevent such postoperative infection, various prophylactic measures should be taken. Those which we have taken since 1971 at Tokushima University can be classified into three:
1) reinforcing basic sterile surgery, 2) administening antibiotics, and 3) performing surgery in a clean-air operating room.
The administration of antibiotics consists of systemic and local administration. Systemic administration means giving both 1 st generation cephem and 2nd and 3rd generation cephem or synthetic penicillin from the day before surgery to the day of the removal of the wound sutures. Local administration is carried out in two ways, by intraoperative wound irrigation with saline containing aminoglucoside, and by using Simplex-p bone cement mixed with cephaloridine (2 g per 40 g pack of polymer) or dibekacin sulfate (1 g per 40 g pack of polymer) .
The clean-air operating room which we have used since 1974 is a horizontal laminar-air-flow system of the hard wall type with 300 air changes an hour.
Under these prophylactic measures, 368 total prosthetic replacements (total hip replacement, 293; total knee replacement; 70; and others; 5) have been performed. Postoperative deep wound infections have occurred in 3 cases, all of which were late infections. In the 1st case, a 63-year-old woman with RA, a late deep infection occurred 8 years after total knee replacement. Staphylococcus aureus was isolated from the wound. In the 2nd case, a 55-year-old man with chondrosarcoma of the left whole humerus, was recognized to have inflammatory signs on the elbow region 1.5 years after total humerus and elbow replacement. But microogamsms were not isolated from the wound. In the 3rd case, a 57-year-old woman with latent tuberculous gonitis, tuberculous arthritis reoccurred 1.5 years after total knee replacement.

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The rate of postoperative infection after total hip replacement in Japan is about 0.8% and that after total knee replacement is about 2.1%. These are about the same figures as in the United States and European countries. The late infection rate in Japan is 25.7% in total hip replacements and 17.6% in total knee replacements. The main causative microorganisms are Staphylococcus aureus and epidermidis.
Among the many risk factors of postoperative infections of total joint replacement, we propose the importance of the toxicity of the bone cement and wear debris. This is based on our experimental data about the depressive action of methylmethacrylate monomer upon the chemiluminescence of leucocytes after phagocytosis.

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Infection rates of total hip replacement in our clinic were 0.18% of 548 THR (lcases) for early infection and 1.12% of 447 THR (5 case) for late and deep infection in cases followed up more than 4 years.
Infection seemed to occur most frequently in RA cases and hips operated-on multiple times.
Two out of the 6 infected cases revealed bacteria with culturing of the hip joint tissue.
Bone scintigraphy was beneficial for diagnosis of the extent of infection.
The possibility existed in one case that infection was caused by intramuscular injection into the gluteal muscle.

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Between 1971 and 1986, 253 arthroplasties were performed in 218 patients at the Medical College of Oita. All of them received bacteriologic analysis of the synovial tissue in operation.
Four patients were found to have staphylococcus epidermidis. The diagnosis of infection can be much more difficult to make in the patient with a chronic low-grade infection due to staphylococcus epidermidis. A culture of tissue removed at the time of surgery is the most reliable technique for diagnosis of it.

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We operated on 140 knee joints of 100 patients with rheumatoid arthritis from 1971 to 1981. Clinical and radiological data has been taken on 105 knees of 71 patients, 7 men and 64 women, 1 to 10 years after operation. Their ages at operation ranged from 22 to 88.
The arthroscopical irrigation that was performed with local anesthesia on 41 knees in 33 patients was effective for persistent hydroarthrosis, especially for cases of the scar formation type. Surgical synovectomy on 26 knees in 24 patients had a protective effect against bone and cartilage destruction, especially for cases at an incipient X-ray stage and with well-controlled RA activity. Total knee replacement of 58 knees in 40 patients made it possible for handicapped RA patients with severe disability to walk. Many patients needed not only knee replacement but that of 3 or 4 joints, such as total hip replacement. We have to make adequate planning and take preventive care against complications of TKR such as infection, loosening and so on, when performing joint reconstructive surgery on handicapped RA patients.

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It is thought difficult to replace a severely damaged joint with a non-hinged surface replacement knee prosthesis. We performed Kinematic stabilizer knee replacement on 16 severely damaged knees in 10 patients displaying 30 degrees or more of flexion or -45 degrees or less of extension. It was necessary to use a modified surgical technique to perform surface knee replacement on such damaged knees. We detached the collateral ligaments of both sides, cut enough bone to realign the femur and the tibia and then sutured the collateral ligaments with correct alignment. Although there was not enough gain in range of motion, all patients were completely free of pain and had markedly increased walking ability after surgery.

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The results of resurfacing or not resurfacing the articular cartilage of the patella were reviewed in 127 knees (81 cases) - 61 cases with rheumatoid arthritis, 18 cases with osteoarthritis and 2 cases with osteonecrosis. These were all replaced with Kodama-Yamamoto MarkIII prosthesis. The duration of follow-up was between 6 months and 2 years 3 months (average, l year 5 months) .
The operated-on knees were divided into two groups. Group A consisted of 32 knees in which the patella was resurfaced; group B was 95 knees in which the patella was not resurfaced. A compatative study was done using the knee assessment chart designed by three universities, by measuring the patella position using the methods of Insall-Salvati preoperatively and postoperatively, by the presence or absence of patello-femoral pain (P-F pain), and by the change of P-F joint observed by X-ray.
There was no difference in ROM, clinical assessment and the patella position between group A and B. But the incidence of P-F pain was 4.2% in group A and 14.3% in group B. The incidence of erosion of the patella seen on X-ray was 8.4% in group B. No loosening of the patellar prosthesis was seen in group A. It is recommended, therefore, that the patella be resurfaced in the course of a total knee arthroplasty.

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Thirty-one knees in 23 patients were operated on for osteoarthritis or rheumatoid arthritis using the Miller/Galante modular knee. Clinical results after an average follow-up of one year (6 to 19 months) were as follows: Total scores which had been 42.1 in RA patients and 46.7 in OA patients on an average, respectively, before operation were 87.0 and 86.7 at the time of follow-up. The range of motion showed increases postoperatively that compared with other total knee prostheses. There were no loose components and no complete radiolucent lines. From the points of view of total blood loss and postoperative rehabilitation, we concluded that cementless fixation for all parts of total knee prostheses was indicated only for the patient less than 70 years old.

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Six rheumatoid and osteoarthritic knees with severe medial bone loss were replaced with Miller-Galante prosthesis, using an iliac bone graft.
In all cases, the bone defects occupied most of the medial tibial condyles, involved the medial and posterior cortices, and had a depth of 1 to 3 cm.
The proximal tibia was resected at the subarticular level to set the prosthesis. After step-cutting the bottom of the bone defect, iliac bone blocks were grafted on top of each other facing the cortical crest outwards, and were fixed by lateral stapling. Moreover, they were also fixed vertically with the setting screws for the tibial prosthetic base plate.
At follow-up, which ranged from 10 to 21 months, femorotibial angle was improved, on an average from preoperative 202° to 175°. The preoperative range of knee motion averaged -15° in extension and 75° in flexion, while the postoperative was -5° and 80° respectively. No sinking of the tibia! component and no absorption of grafted bone were observed on X-rays. The tibial components were sepported by grafted bone.
Our procedure which retains as much bone stock as possible may be useful in the replacement surgery for the severely damaged knee.

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A clinical study was made on 13 patients (14 joints) with regard to the association between osteoarthritis and medial meniscus tear. There were 12 males and one female. Their mean age was 39.5 years with a range from 21 to 65 years.
Two patients had coxarthrosis, but the cause responsible for the tear could not be established in the remaining patients. No patient had osteoarthritic changes either roentgenographically or arthroscopically.
The type of tear of these patients was characteristic. A flap and a horizontal tear always existed on the posterior segment of the medial meniscus. These tears were considered to be degenerative ones, and they may be the early stage of medial-type osteoarthritis for their specific location. Roentgenographical study revealed that the tibial posterior declining angle of these patients was significantly less than that of the control group. The decreases in declining angle may thus cause an abnormal stress on the medial meniscus.

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Stress fractures of the femoral neck in 4 patients of advanced age (6 hips) are reported. When a fracture of the femoral neck occurs in an aged person without trauma, it may be difficult to differentiate a stress fracture from a pathological fracture, because the bone of an aged person is weak.
Two of the patients had osteomalacia, and the other two, including one with prolonged use of steroid, had rheumatoid arthritis. In all 4 cases, there were no roentogenographic findings except for bone atrophy when they first complained of hip pain, but after several weeks we found fractures of the femoral neck. The four cases were diagnosed as stress fracture produced by normal or physiological stress.

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We examined 12 cases (13 joints) of total surface replacement of the hip an average of 6 years and 4 months after operation (4 years for the shortest, 7 years and 7 months for the longest), and obtained the following results:
1) Of these 13 joints, 7 showed loosening, a high incidence rate of 53.8%.
2) Statistical examination of cases with loosening and non-loosening revealed that occurrence of loosening depended upon whether the preoperative condition of the hip joint on the nonoperated side was normal or abnormal, namely, loosening develops when there is an excessive load upon the hip joint of the operated side.
3) In revision cases, from histological findings of tissue necrosis it would seem that there was some mechanical stress, which was followed by reactive proliferation of histiocytes, leading to fragility.
4) From the morphological viewpoint, the above suggests that it is preferable that the load on an artificial joint be dispersed over a wide area.

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The purpose of this paper is to describe a new surgical procedure for the treatment of protrusio acetabuli of patients suffering from rheumatoid arthritis. Bone grafts are used to reinforce the medial acetabular wall, and to correct the position of the head of a bipolar hip prosthesis. The advantage of this procedure is that it does not require bone cementing over the grafted bone.
This procedure has been carried out for 16 hips of 15 patients. No migration nor loosening has been observed, and all the hips have become functional.

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By means of cineradiography and an Image analyzing system the authors analyzed, in 40 normal shoulders and 40 loose shoulders, the motion of the center of the humeral head and the instant center of the humerus to the glenoid between each 10-degree arc of motion during upward movement of the arm in the scapular plane. The results are as follows:
1. In normal shoulders, the motion of the center of the humeral head can be divided into two groups; one in the range between 0 and 60 degrees; the other between 90 and 150 degrees. The latter is distributed upwards and laterally in comparison with the former. All of the instant centers are distributed medially, that is, to the side of the glenoid, in comparison with those of the center of the humeral head.
2. In loose shoulders, the motion of the center of the humeral head can also be divided into two groups: one in the range between 10 and 80 degrees; the other between 100 and 150 degrees. The latter is distributed medially and downwards in comparison with the former. The motion of the instant center can also be divided into two groups: one in the range between 10 and 90 degrees; the other between 100 and 150 degrees. The former is distributed in the same area as in normal shoulders, but the latter is distributed laterally in comparison with all of the center of the humeral head. This result is different from that in normal shoulders.
3. Thus it was able to be shown that the motion of the glenohumeral joint in loose shoulders is abnormal between 100 and 150 degrees during upward movement of the arm in the scapular plane.

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Arthroscopic surgery of the shoulder is a relatively new advancement in the field of arthroscopy. The establishment of its indication and surgical technique are very important themes for shoulder surgery.
To evaluate the clinical and arthroscopical results of arthroscopic surgery of the shoulder, 29 patients who had had labrum tears, anterior instability, and on joint-side tear of the rotator cuff with subacromial impingement syndrome were studied to made clinical assessments (minimal follow-up period: 6 months), and 14 patients who underwent second-look arthroscopy were studied to assess arthroscopic stapling.
The overall clinical results of the arthroscopic surgery were satisfactory in 76%. Arthroscopic stabilization with stapling was confirmed in 79%. Accuate assessment of intra or extra-articular pathology as well as refined surgical technique and the determination of indication were found to be the most important things for getting more satisfactory results.

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Elbow plasty with the radio-posterior approach was performed under the macroscopic observation on 9 primary severe osteoarthritic elbows, 8 joints in 7 male patients and 1 in a female. Ages ranged from 48 to 73, with an average of 57.6.
All joints showed remarkable degenerative changes where the cartilage was eroded, and the subchondral bone was exposed in the humero-radial joints. These changes were shown to be well obviated by the air arthrogram radial oblique view and the lateral tomogram on the double contrast arthrogram.
Our results suggest that the humero-radial change is related to the compressive and shearing force caused by the severe valgus deformity and heavy work, and that the primary osteoarthritic elbow started at the humero-radial joint.

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Arthrodesis of the first metatarsophalangeal joint and Swanson's implant arthroplasty were compared for hallux valgus in rheumatoid arthritis. A newly created ceramic ‘boomerang’ pin was used for the athrodesis.
Relatively good results were obtained by the arthrodesis. On the other hand, recurrence of hallux valgus deformity occurred in 67% of the patients who were treated with Swanson's implant. Many of them had hindfoot deformity, and as it is closely related to the ‘disease subsets’, it seems that they are important for determining the method of surgical treatment.

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Since 1980 we have developed a surface replacement type of elbow prosthesis composed of a humeral mold (policrystalline alumina) and an HDP ulnar component with a ceramic peg. No cement has been used for prosthetic fixation. All patients operated on were suffering from definite or classical rheumatoid arthritis. By 1985 this ceramic prosthesis had been used on 21 elbows in 21 rheumatoid patients. Taking into account clinical evaluation over the 3 years, the design of the humeral mold was then changed into a stemmed prosthesis mainly due to the loosening on the mold (17%) that occurred with the original. From 1986 a humeral mold with a sapphire stem (10 cm in length) has been used for 5 elbows in 5 rheumatoid patients, using bone cement in 2 of them. In our operative procedure, the posterior approach described by W.A. Souter has been commonly used, but special instruments for correct cutting of the bone and setting of the prosthesis were developed by us.
In the clinical evalution, R.B. Brigham Hospital's scoring system was applied for the assessment of the original surface replacement type of prosthesis; an arerage score of 29.6 preoperatively had improved to 77 at an average of 66 months postoperatively. However, the Mayo Clinic's scoring system was introduced for the evaluation of the stemmed prosthesis replacement; the score was 51.2 preoperatively and 86, 8 postoperatively (using the R.B. Brigham Hospital's scoring system, 29.0 preoperatively and 83, 0 postoperatively were obtained in the same patients) . With respect to clinical evaluation, the pain and functional scores are given so much weight in the Brigham Hospital's scoring system that the score seemed to show too much improvement. Therefore we decided that the Mayo Clinic's scoring system was better for assessing the exact condition of the elbow function.
Postoperative complications such as instability and prosthetic loosening seemed to be decreased after the design chanage to a stemmed prosthesis and instrument developments though the follow-up time is still short.

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Total elbow replacement with the Swanson prosthesis, a new type of constrained prosthesis, was performed on 26 elbows in 22 patients from 1973 through 1984, and the results were evaluated using a scoring system. The follow-up period was more than two years, with an average of 63.9 months. Preoperative diagnoses were of rheumatoid arthritis in 21 patients, post-traumatic arthritis in 3 and hemophilic arthritis in one and Charcot's joint in one.
Results were excellent in 17 elbows (65%), good in 7 (27%) and poor in 2 (8%) . Complete postoperative relief of pain was observed in 24 of 26 elbows (92%) . The range of flexion of the elbow and rotation of the forearm were much improved. However, the average range of extension decreased 10 degrees.
Complications included ulnar nerve paresthesias in 3, triceps weakness in 2, loosening in one, infection in one and fracture of the humeral shaft in one. Whereas 4 cases showed radiolucent lines radiographically, only one case had loosening (3.8%) . This constrained prosthesis has a design consisting of Vitallium with a high density polyethylene bushing around the metal pin and a wellfitted prosthesis which reduces the incidence of loosening. It is well indicated for patients with grossly unstable elbows such as in advanced rheumatoid arthritis.

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Twenty-eight subjects were examined to determine the clinical usefulness of magnetic resonance imaging (MRI) using a 0.22 Tesla, Toshiba NMR-CT, for the lumbar spine in rheumatoid arthritis. The study included 12 patients with classical RA, 3 with definite RA (RA group) and 13 patients whose pathological lumbar condition included lumbar spinal canal stenosis, spondylolysis, spondylolisthesis and intervertebral disc lesions. Computation images were produced to determine the “spin-lattice” relaxation time (T₁) and the “spin-spin” relaxation time (T₂) . MRI was shown to be excellent for the evaluation of rheumatoid nodular changes, slight compression fractures and erosion of vertebral bodies, and permitted quantitative determination of the severity of intervertebral disc degeneration on the basis of T₂.

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The serum pancreatic secretory trypsin inhibitor (PSTI) concentration was measured in 60 cases of rheumatoid arthritis (RA) by radioimmunoassay. The serum PSTI concentration was significantly higher in patients with RA than that in controls, and it was correlated with ESR, IgG, joint count (%) and Lansbury index. The correlation coefficient between PSTI and joint count was higher than that between ESR and joint count, and that between CRP and joint count. It is concluded that serum PSTI concentration expresses the activity of the inflammation in RA and that serum PSTI could show the area of involved joints.

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Pustulosis palmaris et plantaris (P.P.P.) is a skin disease of unknown etiology. It is commonly associated with sternocostclavicular hyperostosis, sacroiliitis and vertebral hyperostosis, but rarely with coxarthritis. This is a case report of P.P.P. associated with coxarthritis.
A 45-year-old male noticed a skin eruption on the palms beginning about 1975. Ten years later, he noticed changes in the fingernails and had low back pain. He received no treatment. He had left coxalgia in March of 1986 and came to our hospital in April. Laboratory tests showed ESR 61/hr, CRP (3+) and RA (-) .
The range of motion in the left hip and lumbar spine was restricted. He had swelling and oppressive pain in the sternocostclavicular region. Radiographic findings indicated both osteolytic and osteoplastic changes in the left hip and sternocostclavicular region, accompanied with ankylosis in the lumbar spine.
Later the patient was diagnosed as having P.P.P. by a dermatologist. A bone scintigram taken in October, 1986, indicated high uptake of isotope in the sternocostclavicular region, lumbar spine and left hip. Open biopsy of the left hip was performed in November. Histological examination revealed nonspecific chronic inflammation, while bacteriological examinations were negative.
Nonsteroidal anti-inflammatory drugs were not effective in relieving the pain. Thus, prednisolone (PSL) was concomitantly administered for one month and the skin eruptions disappeared within 2 weeks after the beginning of this treatment. However, the eruptions recurred soon after the administration of PSL was discontinued. The pain was relieved immediately after administration of PSL, but this also recurred as worse as before once PSL was discontinued.
As the pain was not relieved, and the range of motion of the left hip was restricted, we performed total left hip replacement (THR) in February of 1987. Histological examination of synovium taken at the time of the THR revealed nonspecific chronic inflammation, which may be the same as that found in the biopsy in November.

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We have performed 426 total hip replacements since 1968. Here we report on a follow-up of 160 patients (197 joints) for more than 5 years after total hip replacement with the Chamley type, the Osaka-Shidai (Shidai) -type, the Muller-type, the Weber-Huggler type and the Surface Replacement (SRA) -type prostheses.
At 7 years after surgery, revision surgery had been performed in 10-20% of the Shidai and Muller types, and in 52% of the SRA type, but in none of the Charnley type. Component loosening was found in 40-48% of the Shidai and Muller type, 8% of the Chamley type and 48% of the SRA type.
In the Shidai type, stem loosening was found much more than socket loosening. All SRA type loosening cases involved prosthetic head loosening. The clinical results with the Chamley type were the best of all the types in J.O.A. scores, while those with the SRA type were the worst.
In the Charnley cases in which the greater trochanter was pulled down distantly, there was a high incidence of complication; for example, a clear zone between bone cement and bone tissue, wire breakage, and non-union of the greater trochanter.

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