From 1960, after the development in our clinic of the Katayama-Hirakawa type cup for mold arthroplasty, 32 cases, 6 male and 26 female, were operated upon using it. Removal of the cup took place in 6 cases due to breakage of the cup or infection following the operation.
Follow-up studies were undertaken on 15 cases, 3 male and 12 female. The ages of the patients at the time of operation ranged from 21 to 52, the average being 40. The follow-up period was between one year, 4 months, and 27 years, and 27 years, and the average was 10 years, 7 months.
The postoperative results have been evaluated by the 100 point rating hip scale of the Japanese Orthopaedic Association. The postoperative score was 55 points on the average compared with a preoperative one of 43. For the cases within 7 years of surgery, the postoperative range of motion of the operated on hip joint was good, but residual pain existed. On the other hand, in the long-term follow-up cases of over 25 years, the postoperative range of motion was poor, but there was no pain. All patients in the latter group were satisfied with the operation.

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Of 39 patients who had a SOM total hip replacement at Tanabe National Hospital from 1973 to 1979, 15 (16 hips) were re-evaluated about 10 years postoperatively by clinical examination and roentogenograms. One hip had been revised for aseptic loosening after 9 years.
Clinical examination using the criteria of the Japanese Orthopaedic Association revealed a score for about 11 years of 87, compared with 71 after operation. Follow-up radiographs showed a 19 percent incidence of migration or tilting of the acethabular component and a 25 percent incidence of the femoral component. Thus the total incidence of loosening of either component was 44 percent, but even so the clinical results were excellent.

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The relationship was studied between various radiological measurements (atlant-dental interval, the space available for the spinal cord, Ranawat's method, Redlund-Johnell's method) and cord compression on MRI images in 46 rheumatoid arthritis patients with upper cervical lesion.
According to the MRI images, cord compression existed in 29 patients (63%) . It was observed in 16 out of 17 cases that were evaluated by Redlund-Johnell's method as having severe vertical subluxation.
From this study it could be concluded that MRI measurements are available for the diagnosis of spinal cord compression which is usually diagnosed by the space available for the spinal cord, Ranawat's and Redlund-Johnell's methods. These methods are more valuable than measurement of the atlant-dental interval.

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MRI findings in the upper cervical spine of 9 patients with RA were reviewed to correlate them with those using plain radiography and CT. In myelopathy, the measurements of the space available for the spinal cord (SAC), Ranawat's method and the atlanto-axial angle in plain lateral radiograms were shown to be very useful, while the atlant-dental interval (ADI) was not. But there was no correlation between the classification of the odontoid process and spinal cord shapes shown in CT and myelopathy. High-signal intensity of pre-and post-odontoid space on Ti-weighted images was observed in 6 cases. MRI was also useful for evaluation of the spinal cord shape and deviation, and of abnormality of the lower cervical spine and vertebral body. In the future, MRI will be considered superior to CT for observing the upper cervical spine in RA.

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For the rheumatoid elbow, many types of surgery are possiible, including synovectomy and total elbow replacement. Although some forms of elbow evaluation have been used, there has not been a good one for the rheumatoid elbow to date, and we have tried to make a functional evaluation form. It consists of pain (25 points), R.O.M. (30 points), synovitis (15 points), joint stability (15 points) and X-ray findings (15 points), a total of 100 points altogether. This evaluation form is introduced and its clinical application with respect to the long-term results of synovectomy is shown.

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Radiological and clinical evaluations were carried out on 67 rhematoid wrists in 53 patients who were treated by synovectomy of the extensor sheath and the wrist joint combined with Darrach's procedure in the period from 1966 to 1986 in the authors' orthopaedic department. Based on preoperative X-ray findings, 14 wrists in 12 cases were classified into grade I or II according to Larsen's classification, hence into the group of early synovectomy, and the other 53 wrists in 41 cases were classified into grade III or more, hence into the group of late synovectomy. The follow-up period after the surgery was 10.1±6.4 years (mean±S.D.) in the former group, and 8.2 ±5.5 years in the latter. There was no significant difference in results between the two groups.
In the radiological follow-up, the degree of carpal collapse in the operated-on wrists was the same as in the opposite, non-operated-on rheumatoid wrists. However, ulnar shift of the carpus was significantly accelerated in wrists that received on operation combined with Darrach's procedure in which two years or more had elapsed (p≤0.01) . Volar subluxation of the carpus was negligible both in the operated-on and in the non-operated-on rheumatoid wrists.
In the group of early synovectomy, the progress of carpal collapse was slower than in the late synovectomy group. However, that of ulnar shift was more rapid, so that it is thought that either reconstruction of the triangular fibrocartilage complex in sufficient tension or radiolunate limited fusion is necessary, combined with Darrach's procedure, to prevent progress of ulnar shift.
In the late synovectomy group, the progress of ulnar shift was more slow and the postoperative improvement of function was steady, especially in regard to pain relief, suppression of the recurrent synovitis, and the continuous improvement of forearm rotation.
In conclusion, the synovectomy for the rheumatoid wrist, combined with Darrach's procedure, is worthwhile not only in the early stage, but also in the late stage, in combination with preventive measures against progressive ulnar shift of the carpus, except in cases of mutilans type.

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The technical problems of the arthroplasty for the rheumatoid fused elbow were reviewed in two Kudoh-type 3 elbow replacements and five DOH type elbow replacements in 6 patients.
The difficulties were solved by the use of bone cement for osteoporosis, the elongation of the tendon for the shortening of the triceps muscle, and partial resection of the epicondyles or tendon graft for defects in the supporting tissue around the elbow joint.
The postoperative mean range of motion was from an extension of (-) 43° to a flexion of 127°, which was useful in ADL, and good muscle power was regained even in the long-term fused elbow.

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Four cases of thumb CM joint disorders in rheumatoid hand were treated, two by trapezium resection arthroplasty with a Swanson implant, and the other two by arthrodesis of the CM joint. Follow-up study of these cases showed that there were functional limitations of the thumb and hand in the arthrodesis cases due to the carpal bone fusion developing after the postoperative period. On the other hand, in the cases of arthroplasty with a Swanson implant, good thumb function had been kept for a long period after operation.
For rheumatoid thumb the surgery which preserves the function of the CM joint should be selected.

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Foot pressure measurement under the rheumatoid arthritic foot has been performed using a newly designed gum sensor measurement device. The sensor can pick up the pressure from changing capacitance. The sensitivity of the sensor is below 20g/cm²and the range is from 450g/cm²to 2500g/cm². The device is composed of 960 of these sensors and 8 frames/second of foot pressure measurement can be made. The clinical measurement was made on classical rhuematoid arthritic patients.
The pressure distributions and foot deformities could be divided into 3 types. Type 1 had minimum foot deformity but the pressure under the toes was decreased (5 feet) . Type 2 had a moderately deformed forefoot and there was almost no pressure under the toes (6 feet) . Type 3 was a markedlly deformed foot with no forefoot pressure distribution (10 feet) . In Type 2 the pressure under the metatarsal head was calculated and compared to that of the normal subject. In rheumatoid arthritic patients, the peak of the pressure was 2 times larger than that of normal persons (pressure/cm²/weight) and the location of the peak was shifted laterally. These results suggest that sole pain in rheumatoid arthritic is related not only to static foot deformity but also to the dynamic abnormality in walking.

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A clinical study was made of resection arthroplasty for forefoot deformity in 27 cases of rheumatoid arthritis. The results were satisfactory in almost all cases except for 4 in which revision had to be performed because of exacerbation of hallux valgus. A dorsal approach was used in order to cut short digital extensor tendons and elongate long digital extensors. Postoperative spontaneous fusion occurred at the MP joint of the great toe in 7 cases and the results with these cases were excellent.
In order to know the pathomechanism of the forefoot deformity in RA, an EMG study of short digital extensors, medial and lateral hamstrings was performed. It was found that the more the knee externally rotated, the more the digital extensors and lateral hamstring contracted. Since con-tracture of the knee in flexion and external rotation is commonly seen in RA, it may cause deformity of the forefoot.

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A clinical study of 11 adult patients with symptomatic “rigid” flatfoot is reported on. Of the patients, 10 were females and one of them was a bilateral case. The age of the patients ranged from 48 to 80 with a mean of 60.6. Every patient had symptoms of pain and swelling at the attachment of the tibialis posterior tendon and was unable to invert the affected foot because of peroneal spasms. Yokokura's arch index in these cases was decreased about 30 percent on an average compared with the standard value. No tarsal coalition was seen in any case radiologically, but the accessory navicular bone was seen in 7 feet of 6 patients. In every case the deformity was not flexible, so attempts at manual reduction had ended in failure. Then triple arthrodesis was per-formed on 5 patients, and all the results were satisfactory.

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Two hundred-and-sixty-seven knees (181 patients) received cementless Mark II/III total knee replacement in our hospital from 1983 to 1986. Bone graft was used on 38 knees 23 with rheumatoid arthritis, 7 with osteoarthrosis and one with osteonecrosis in 31 patients who had severe bone defect.
Twenty-two knees (19 patients) could be followed more than 6 months and 17 knees (15 patients) more than one year. X-ray findings showed complete union in almost all cases, atrophy or sclerosis of the grafted bone in a few cases, and crushing of the grafted bone in 3 cases. Clinical results, which include gait, range of motion, stability and pain, were satisfactory except in cases which had crushed grafted bone.
These three cases were reviewed. The first case was a patient with rheumatoid arthritis and had received a wedge-shaped bone graft for repair of a fractured medial tibial plateau after total knee replacement. The second case was a patient with rheumatoid arthritis in whom a wide plate-shaped bone graft had been used because of a large bone defect of the medial tibial plateau. The cause of the crushing was thought to be the varus positioning. The last case was a patient with rheumatoid arthritis, osteoporosis and severe flexion contracture. A wedge-shaped bone graft was applied for repair of a fractured anterior tibial plateau after total knee replacement.
In conclusion our results show that, it would be better to set a plate-shaped bone block on a horizontal flat bed, and for a bone graft to be compact enough to avoid crushing due to osteoporosis and flexion contracture, especially in the case of using a wide graft.

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We discussed the cases of TKR in RA in which continuous passive motion (CPM) was applied and compared them with controls in which it wasn't applied. The range of motion in the CPM group was improved earlier than in the control. No increase of postoperative bleeding was noticed in the CPM group. Enough range of motion was obtained by applying CPM for 12 hours a day. Our aim in cases of TKR with RA is to attain the T cane gait, and the rehabilitation term of the CPM group was shorter than that of the control. Improvement of ADL early in the postoperative course in RA patients can be expected using CPM. Its application for cases of TKR in RA is effective.

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Compared to early hinged prostheses (i.e., Walldius, Shiers, GUEPAR, etc.), the kinematic rotating hinge has some good innovations. Axial rotation and distraction are allowed, and flexion and extension take place between metal and polyethylene surfaces. These changes should lead to the reduction of the complications (loosening, deep infection, fracture) very often seen in early hinged prostheses.
We evaluated the clinical results of 13 knees (11 RA, 2 OA) replaced by the kinematic rotating hinge knee prosthesis since 1982. It was used for severely deformed, stiff unstable knees, for revision cases and for the adjustment of leg length discrepancy and correction of malalignment of the legs. The average follow-up period was 31 months. Clinical results were satisfactory and there were no serious complications.

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We have performed anterior cruciate ligament reconstruction with a modified Marshall method using the Kennedy LAD on 23 knees in 23 cases since February 1986. The mean follow-up period is 12.8 months.
As for postoperative complications, no knee suffered from infection or chronic edema caused by synovitis. One knee was found to be torn. This therapeutic method was shown to be satisfactory in both objective and subjective evaluations.
The use of the Kennedy LAD allows positive postoperative treatment to be done at an early time. The augmented reconstruction with LAD is expected to provide better results than the reconstructive procedure that uses only the autogenous tissue.

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The results after meniscectomies were evaluated. The patients were divided into two groups according to their activities. Group A consisted of 23 patients under thirty at the time of surgery, while 28 patients over thirty were classified as Group B. The mean age at surgery was 15.8 years in Group A and 44.5 years in Group B. The mean duration of follow-up was 5.4 years and 7.0 years in Group A and Group B, respectively.
The clinical results and roentogenographic findings in Group A were compared with those of Group B. In Group A, the clinical results were excellent, independent of quadriceps muscle atrophy and roentogenographic findings at follow-up. But in Group B, the clinical results were directly related to these factors. The surgeon should therefore take pre-existing degenerative arthritis into consideration before perfoming a meniscectomy on a relatively aged patient. The long-term results of meniscectomies in young patients should also be further investigated.

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Severe bowlegs due to Blount's disease (9 knees) and rickets (8 knees) were treated with a short leg corrective brace. The femora-tibial angle (FTA), and the degrees of tibia vara and femora vara were measured on standing antero-posterior roentgenograms. If the FTA was more than 195°or the tibia vara was more than 15°, short leg corrective braces were indicated. The braces were applied around the clock except during bathing. Radiographic examination was done every 2 months, and the change of the FTA and tibia vara was observed. In both diseases, the FTA was improved followed by the correction of the tibia vara. The duration of the bracing was from 5 to 12 months, an average of 9.1 months, in the case of Blount's disease and 14 to 35 months, an average 30.6 of months in the case of rickets. In the patient with rickets who did not respond to medical therapy, the application of the brace was prolonged.

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The main causes of infection after total joint replacement are considered to be wound contamination during surgery and haematogenous dissemination. However, higher incidence rates are found in cases with previous surgery failure or with a history of repeated Intraarticular injections.
The results of bacteriological examination were retrospectively studied in 100 consecutive knees in 76 patients who underwent knee joint replacement. Indigenous bacteria was isolated in 13 of 100 knees. Propionibacterium acnes was the most prominent organism. All 13 of the knees had histories of repeated intraarticular injections.
Clinical and roentgenographical data should be meticulously checked to exclude potential infection cases before total joint replacement. Culturing of synovial homogenate taken at the time of surgery was confirmed to be useful for detecting latent joint infection. Pathological examination should be also routinely carried out to check for the existence of microabscess.

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The muscle strength of the peroneal muscles in foot and ankle disease as well as in a control group were analysed in 120 feet (60 cases) . Among the patient group, those with ankle and subtalar instability numbered 20 feet, and those with ankle and subtalar osteoarthritis numbered 41 feet. The control group consisted of 26 feet.
The average strength of peroneal muscles measured using an original apparatus with a strain gauge to measure the muscle strength at ankle eversion, was 4.4 kg±0.8 in the control group. Muscle strength was distributed from normal to weak in the instability group, and in the osteoarthritic group was less than 80 per cent of the control group. Muscle strength was found to be related to the term of disease, general joint laxity, clinical evaluation and radiographic stage.
The results revealed that pain in the foot and ankle and instability of the ankle and subtalar joint cause a weakness in the muscle strength of the peroneal muscles; therefore the patient experiences giving way and is conscious of an unstable feeling in the ankle. There are two factors involved in giving way in the foot; one is the static factor resulting from the degree of ligamentous instability, and the other is the dynamic factor resulting from weakness of the peroneal muscles.

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A 18-year-old man with hemophilia A complainted of pain, snapping and occasional locking of his right knee. The knee was found to be slightly swollen, to test positive with a McMurray test on the lateral meniscus and to have an atrophied quadriceps. The range of motion was from 10°to 150°. Roentogenograms showed enlargement of the intercondylar fossa, narrowing of the joint space, cyst formation and bone destruction. Under arthroscopy a bucket-handle tear in the lateral meniscus was found and subtotal meniscectomy was performed.
Replacement therapy of factor VIII concentrates was done before, during and after the surgery. The patient was injected with 15000 units of facter VIII concentrates in all and discharged 8 days after operation. Thus arthroscopic meniscectomy proved effective, for bleeding was well controlled using facter VIII concentrates. The patient only had to have a short admission, though he had had the HIV antibody due to the replacement therapy of facter VIII concentrates since 4 months of age. Much of the success was also due to the cooperation of doctors and other staff during his admission.

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