Human cartilage tissue was found to produce two types of proteoglycan monomers distinguished by density gradient centrifugation under dissociative conditions and with different molecular sizes (PGI and PGII) as shown in cultured rabbit costal chondrocyte.The incorporation of ³⁵S-sulf late and distribution of the molecular sizes of PG were studied to determine the differentiated phenotypes of chondrocyte in osteoarthritic hip cartilaginous tissues (weight-bearing area of the femoral head, non-weight bearing area of femoral head, primary (original) aetabulum and secondery acetabulum) . The tissue from the weight-bearing area showed the highest incorporation of ³⁵S-into PG and produced PGI with larger molecular size. The primary acetabulum lost its cartilaginous properties and produced PGII only. On the other hand, the secondary acetabulum produced relatively large PG molecules suggesting cartilagenous differentiation of mesenchymal cells.

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Studies on the movement of the wrist joint have been increasingly appearing in recent years, especially from the view point of carpal instability. Nevertheless, there have not been many reports which describe the supporting function and movement control ability of ligamentous structures around the wrist joint. A great number of fresh human amputated hands would be required for proper studies, and it would be very difficult to obtain such specimens in Japan due to social reasons. In order to clarify the supporting function and movement control ability of the ligamentous structure around the wrist, we have used wrist joints taken from crab-eating monkeys, which have structures very similar to those of the human wrist. The results suggest that the volar and dorsal ligaments have the supporting function and ability to control during volar-dorsal flexion movement, and also that the volar ligaments possess the ability to cotrol the rotatory movement of the forearm. However the dorsal ligaments have little ability to control the rotatory movement of the forearm.

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Unlike with cervical and lumbar spinal lesions, posterior decompression of thoracic canal stenosis is not so effective because of physiological kyphosis of the thoracic spine, especially when a stenosing factor exists in the ventral part of the spinal canal. Our new method of full-circular decompression through a single posterior approach resolves this problem. After performing wide laminectomy at the affected levels, a long air-driven burr is introduced at each segment through the central spongiosa of the pedicle bilaterally into the vertebral bodies making a V-shaped canal in them. The posterior aspect of the vertebral bodies, the floating triangular bones, are pushed down anteriorly into the vertebral bodies and the spinal canal is ultimately enlarged.

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Six patients with rheumatoid lumbar spine involvement underwent instrumentation surgery and are reported on. Five patients were in stage 4 and one in stage 3. The preoperative symptoms were lumbago (5 cases), paresis of the lower extremities (4 cases), disturbance of urinary bladder and rectum function (2 cases) and intermittent claudication (1 case) . Roentgenograms showed osteoporosis (6 cases) and compression fracture or collapse (5 cases) . The instruments used for surgery were Mizuno's spinal plate (2 cases), Luque wiring (1 case), a segmental square spinal instrument (2 cases) and ceramics (1 case) . After surgery stable fixation of the spine was obtained in all cases.

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When treating patients with secondary osteoarthritis of the hip, it is important to know the typical natural history, and the factors contributing to the progression of osteoarthritis. This is especially true in determining when to proceed to surgery.
We have made studies of several such factors affecting the natural history of prearthrotic patients followed up at our clinic. The subjects of our investigation were 35 patients (49 joints) diagnosed as prearthrosis and observed conservatively for more than five years. From A-P view X-ray films, we determined the CE-angle, the AHI, the Sharp angle and the degree of the femoralhead deformity, and then investigated the load distribution in the joints using a finite element method (FEM) .
Results showed that the progression of osteoarthritis was rare in patients younger than 30. In patients over 30, many progressing cases were seen in those with CE-angles less than 10°, and/or AHI's under 65. Under FEM, an uneven load distribution was observed in progressing cases, leading us to assume that a mechanical instability was present.

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We made comparative examinations on cases of preosteoarthritis treated by rotational acetabular osteotomy to study the relationship between clinical and radiographic evaluations. Many conventional radiographic evaluations have been made chiefly from the frontal plane only. We tried using a modified inlet view to ascertain more accurately the acetabular coverage.
The results were that no direct correlation was observed between pain, gait and mobility, and the angles of CE and AC. With respect to the degree of pain, whether the limbus has been damaged (as determined by arthrographic study) is important as an indicator in the osteoar-thritis of relatively young patients in the second and early third decades. The inlet view was found to be useful for evaluating the preoperative and postoperative acetabular coverage.

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We have studied the clinical pathology and treatment of prearthrosis by analyzing clinical, radiological and arthroscopic data on secondary coxarthrosis due to congenital dislocation of hip the joint (CDH) .
In the clinical and radiological studies, we examined 87 joints in 71 patients of prearthrosis out of 300 joints of 150 cases of coxarthrosis due to missed CDH. The symptoms occurred after adolescence and so CDH was not discovered in infancy and childhood. Also, in the arth-roscopic study, we examined 24 joints in 19 cases of pre-arthrosis including both those which were surgically treated and those which were not.
There was a high incidence of prearthrosis in the cases of coxarthrosis due to missed CDH. The distribution of this symptom was spread through the age groups, but there were less cases in the 60s and 70s groups. As for the symptoms of the disease, 60% of the patients had arthralgia and the remainder had lower back pain, thigh pain, and knee joint pain. The initial symptoms occurred mostly in the teens and 20s, and about 50 % received an initial examination less than one year from the occurrence of the first symptoms.
Classification by joint compatibility on radiographies showed that there were more type A (remained acetabular dysplasia) than type B (remained subluxation), but type B tended to be in a more advanced early stage than type A. Therefore, it can be observed that type B, the group with worse compatibility, progresses more quickly in coxarthrosis than type A does, the group with better compatibility.
In arthroscopies of the hip which we have performed, a slight irregularity of the femoral head cartilage and fibrillation of the cartilage in the acetabulum were observed. We could not diagnose any symptoms in 20 % of the arthroscopy cases.
With respect to treatment, 1) coxarthrosis which has poor compatibility with an insufficient acetabular covering and a CE angle of less than 10° should be operated on, since it is presumed that coxarthrosis progresses quickly in the early stage, and 2) coxarthrosis which has a slightly better compatibility with an insufficient acetablar covering and a CE angle of less than 10° is also suitable for operation. But for the coxarthrosis which does not belong to either 1) or 2), we consider that it is better to continue observing the natural progress and not to operate.

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Proximal displacement of the femoral head can been seen sometimes after Chiari pelvic osteotomy. In order to clarify the causes of the displacement, a quantification analysis was performed to evaluate the preoperative and postoperative factors of this osteotomy. Statistical analysis showed that 54% of the causes could be explained as being due to 1) the angle of the osteotomy, 2) obesity, 3) the difference of the acetabular trochanteric distance, 4) the preoperative C.E. angle, 5) changes of the lever arm, and 6) the stage of coxarthrosis.
Paying attention to the following things is considered important in the operation to get good results: 1) making the angle of the osteotomy f r om 11° to 20°, and 2) keeping the difference of the acetabular trochanteric distance within 20mm, 3) the changes of the lever arm within 15%, and 4) the approximate acetabular index within 30%.

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Bipolar femoral head replacement (BFHR) for acetabular protrusion with the use of bone graft reinforcement to the medial and proximal acetabular wall proved to be a successful surgical procedure. Slices of bone obtained from the femoral head and bone chips were grafted and tamped firmly with a bone set.
In 5 cases of BFHR followed for an average of 10 (6-12) months, radiography showed that the bone grafts had healed in place with only a slight collapse. There was great improvement with respect to pain and function of the hips by the JOA hip score and there was no further protrusion.

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Two hundred and eleven low-friction arthroplasties in 167 patients followed for 5 years or more after surgery were studied radiologically. The first 92 simple hemispherical sockets were fixed with the old cement fixation technique in which only a few large anchor holes were bored before fixation. A hundred and nineteen sockets were fixed with the new technique in which multiple small anchor holes were bored. This modification of the fixation technique significantly improved the postoperative radiological findings, namely socket demarcation grading and socket wear.
From the results of a statistical comparison of various items between a group of 190 stems without subsidence and a group of 21 stems with subsidence, the stem-filling ratio in the medullary canal and the packing of cement distal to the prosthetic tip were considered to be the operative factors correlated with stem subsidence. Calcar resorption and atrophy of the femoral cortex were considered to be the biological factors.

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Total hip replacement (THR) was performed on 89 hip joints in 65 cases from March, 1974, to June, 1983, in the Kakogawa National Hospital. In order to clarify the characteristics of THR in RA patients, a follow-up study was conducted on the 41 patients (61 joints) with rheumatoid arthritis (RA) . The degree of pain, the function of the lower extremities and whether or not there were lucent lines on radiographs were examined. Of the 41 patients, 20 females and one male (32 joints), could be directly examined. Three had moved and their new addresses were unknown, and 17 had died. The ages of the 21 examined at the time of operation ranged from 16 to 77 years (mean: 52.0 years) . The postoperative follow-up period varied from 5 to 14 years (mean: 8.1 years) .
After THR, the patients had no pain in the hip joints, and the range of motion of the joints was favorably maintained. However, the function of the entire lower extremities remained such that indoor and outdoor walking was possible only with the support of various walking aids. The presence of the lucent line on radiographs did not necessarily correlate with clinical symptoms Loosening of the acetabular component was observed during the follow-up period in two patients and was treated with a revision operation. The mechanical load on the prosthesis is small in RA patients. As expected, loosening occurred in cases in which there were some problems in the operative procedure itself. Taking the life expectancy of RA patients into consideration, it is reasonable to set the age for THR application lower than that for patients with other diseases.

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From 1965 to 1987, 17 2 patients with steroid-induced osteonecrosis of the femoral head in 296 joints have visited our university hospital clinic. This osteonecrosis has occured frequently in young patients. There has been a high incidence of involvement of both sides of the femoral head.
We have treated 176 of these joints with osteotomy or replacement with artificial joints. Transtrochanteric rotational osteotomy (TRO) was performed on 120 joints, with a success rate of 77.6 %. As this is equal to that in cases of idiopathic osteonecrosis, showing that TRO is useful for treating steroid- induced osteonecrosis. For making the decision to perfom a osteotomy, it is important to investigate the position and extent of the intact area in the femoral head. Tomography, CT scan, and MRI are useful methods for doing this.

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Since 1986 we have performed 3 types of techniques for high tibial osteotomy (HTO), i.e., wedge, oblique and barrel vault osteotomies, on 72 knees in 57 cases. The clinical results of 50 cases (64 knees) showed that oblique osteotomy is an excellent technique and that the age of the patient is one of the important factors for obtaining good results.
We did gait analysis by means of a force plate and a hi-speed video system on HTO postoperative patients, and compared the results with those with osteoarthritis of the knee, with TKR knee and normal knees.
From the point of view of knee flexion angle, the patterns with HTO postoperative patients are more similar to those of patients with osteoarthritis of the knee than with persons with normal knees. The recovery of the knee flexion angle is not as good as that with TKR postoperative patients.

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We performed bilateral total knee replacement (TKR) on nine patients using the Kodama-Yamamoto Mark-III prosthesis and resurfacing the articular surface of the patella unilaterally. The results of the replacement of the articular surface were compared with those of the side with no replacement. All but one of the nine cases underwent simultaneous bilateral procedures. There were seven cases with rheumatoid arthritis and two with osteoarthritis, eight women and one man (average age, 61.7 years) . The average follow-up period was 2 years, 3 months.
There was no difference in clinical evaluation using the knee assessment score designed by the three universities between the side of the resurfaced patella (P plus side) and the un resurfaced side (P minus side) . But there was more incidence of patello-femoral pain and crepitus in the P minus side than in the P plus side. The incidence of radiographical change of the P-F joint was a high 44.4% in the P minus side. No loosening of the patellar prosthesis was seen in the P plus side.
We therefore consider that routine replacement of the P-F joint is advisable with Mark III knee arthroplasty.

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Interleukin 1 (IL - 1) has been detected in the synovial fluids of patients with rheumatoid arthritis (RA) and, among all inflammatory factors, is now considered to be the one most important in joint destruction. We detected as well IL -1 in the synovial fluids of 15 RA patients examined by radioimmunoassay (0.2-0.6ng/ml) . However, synovial fluids failed to exhibit any IL -1 biological activity in a mouse thymocyte assay, suggesting the presence of an IL -1 inhibitor in these synovial fluids. Such an IL -1 inhibitor activity was shown to be associated with a 50-70 kDa fraction in gel-filtration chromatography using a Sephadex G- 75, and to suppress thymocyte proliferation by IL -1β . This inhibitory factor may have a regulatory function in the chronic inflammatory process in RA.

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In order to understand the pathomechanism of cervical subaxial subluxation (SAS) in rheumatoid arthritis, the authors analysed the radiological findings of 31 cases operated on for atlanto- axial subluxation (AAS), vertical subluxation (VS) and subaxial lesion (SAL) .
SAS (≥2mm) was found in 90% of the patients. The distance of anterolisthesis (AL) was 4.5 ± 2.1 mm, whereas that of posterolisthesis (PL) was 2.6 ±1.1 mm (p<0.01) . AL was found most frequently in C4/5, while PL occurred most often in C3/4. PL was accompanied with AAS in 85% of the cases. There was less mobility of the lower cervical spine (at least four levels were spontaneously fused) in 88% of the AL cases. Postoperative anterolisthesis occurred at the next lower disc level in 2 of 13 cases which had received posterior fusion for SAL. Destruction of the posterior spinal column due to RA granulation was found in 73 % of the AL cases during surgery. Also, there was postoperative AL in all of the laminectomized SAL cases.
The destruction of the posterior spinal column due to RA and the decreased mobility due to spontaneous fusion may play an important role in producing AL in SAS. AAS may have a tendency to cause PL in relation to the kyphotic change of the closed lower cervical spine.

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That there is cervical spine involvement in rheumatoid arthritis is well known. However, bone destruction of the cervical spine is sometimes revealed through X-ray examination without there being any obvious clinical manifestation.
The cervical spines of 23 rheumatoid arthritis patients were investigated though lateralview plain X-ray films which were taken for an average period of 8.5 years (range, 5 to 15.4 years) . The criterion of Ball and Schilling was applied to investigate them and the following results were obtained : 1) The X-ray findings of the cervical spine showed that there was deterioration in accordance with the stage and class classifications of Steinbrocker's criteria. 2) Change in the upper cervical spine involvement, erosion of the dens, ventral dislocation of the atlas and basilar impression were clearly revealed as the rheumatoid arthritis progressed. But there was little relationship between these changes and neural deficit. 3) Changes in the middle and lower part of the cervical spine due to rheumatoid arthritis went together with the degenerative change, that is, spondylosis. However, osteoporosis was identified in most cases of subaxial subluxation in the cervical spine of rheumatoid arthritis.

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A posterior instability of the shoulder is often found in the shoulder joint having slackness in the joint capsule and/or any defect of the postero -inferior margin of the glenoid. On the contrary, reports of posterior dislocation are very rare.
The purpose of this study was to clarify, through our clinical experiences of unstable shoulder, the causes of posterior instability of the shoulder. This is often observed in two groups, those of either “loose shoulder” or “posterior dislocation”. Since 1978, we have treated, with glenoid osteotomy including postero-inferior repair of the glenoid, 39 loose shoulders having the tendency of posterior instability and 14 shoulders with posterior dislocation. There was no significant difference in age or sex in the two groups. The results have been good in 80% of the cases.
Our findings were that obvious retrotilt and shortening of the transverse diameter on the glenoid are found in posterior dislocation. Hypo- or dysplasia of the postero-inferior margin of the glenoid can be one of the causes of posterior instability in loose shoulder.

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Since November 1984, semi-constrained total elbow replacement (STER) has been used for treating severely destructed RA elbows in our department. Eight elbows in 8 patients, 1 male and 7 female, were treated with STER (6 Schlein, 2 Coonrad-IIB) . The average age at operation was 64 years, and the follow-up term ranged from 7 months to 43 months (an average of 22.7) . Two RA-affected elbows which had sustained supracondylar fracture of the humerus were treated with STER to achieve early motion.
The average flexion improved from 116° to 137°, 34 to 44° in pronation and 59 to 67°in supination. However, the average loss of extension increased from 23°to 34°. Using the elbow-evaluating system of the R. B. Brigham Hospital, an average preoperative score of 27.1 had improved to 67.8 at follow-up. The pain was reduced markedly (11.4 to 45.7 ), but the function of the upper limb was not improved that much. No infection or any loosening of the STER has been encountered, but one case resulted, 14 months postoperatively, in a skin defect at the olecranon due to thinned subcutaneous tissue and the excessive size of the prosthesis. The lesion was completely healed by a fasciocutaneous flap.
The authors think that STER is indicated in cases of RA elbow either with ligamentous instability or with extensive bone loss

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The recognition of carpal instability as a clinical entity is relatively recent. The relationship between perilunate dislocation and dorsif lexed intercalated segment instability (DISI) of the wrist has not been clearly established.
A roentgenographic analysis was carried out on the wrists of 17 patients, 14 with perilunate dislocations with fractures of the scaphoid and other bones, and three with perilunate dislocations without fractures, treated by closed reduction or open reduction.
After injury, 12 of the 17 patients had open reduction of their dislocations and the other 5 had closed reduction. From these studies it was concluded that 1) the cases of perilunate dislocation with non-union of the scaphoid and the old cases of perilunate dislocation with or without scaphoid fracture tended to show DISI deformity, and that 2) the fresh cases of perilunate dislocation treated with closed reduction showed normal alignment of the carpus.

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Reduction of DISI deformity was carried out in 3 cases of scapholunate dissociation, 3 cases of reduced perilunate dislocation with persistent carpal deformity, and 15 cases of chronic scaphoid fracture. The chronic scaphoid fractures were treated by Kirshner wire reduction, bone graft and internal fixation with a Herbert screw. Various methods of reduction including Fisk's method and Cooney's method were employed in reducing the DISI deformity in the cases of scapholunate dissociation and perilunate dislocation.
Satisfactory reduction could be obtained in 14 cases of scaphoid fracture. In the cases with scapholunate dissociation and perilunate dislocation, reduction gave some degree of improvement of the DISI deformity, but in none of the cases was normal carpal alignment achieved, despite the use of multiple procedures for maintaining reduction, such as repair of the volar carpal ligament and temporary fixation between carpal bones with Kirschner wires. The results show that DISI deformity with a ligamentous origin is difficult to reduce and that additional procedures are necessary to maintain the reduction which was supposed to be accomplished by traction provided by an external fixator.

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In order to evaluate the function of the rheumatoid carpal bone, we measured the palmar pressure by using the hand print. Twenty patients with rheumatoid arthritis were studied. We divided the palm pressure into four parts, the thenar, the mid-palmar, the hypothenar and the metacarpo-phalangeal portions. The palmar pressure of healthy hands had two peaks, in the thenar and the hypothenar portions. The center of pressure was slightly towards the radial side. In rheumatoid arthritis patients, the palmar pressure had only one peak, in the midpalmar portion, and the center of pressure was slightly towards the ulnar side. These findings suggest that this assessment system using hand prints is useful for making functional evaluations of rheumatoid hands.

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Wrist pain is an important cause of upper-limb disability in daily human activities. There are many causes of wrist pain and this subject has received considerable attention in the orthopaedic and hand surgery literature during the past decade. Clinical examinations and radiographs usually clarify the cause when the problem is avascular necrosis of a carpal bone, tumor, arthritis, disruption of the intercarpal ligament or even chronic infection. However, theare occasional cases which remain diagnostic enigmas in that there is chronic wrist pain without there being any cause or radiographic findings.
We treated 174 patients who had been suffering from wrist pain. In 50, specific physical examination and standard radiography failed to reveal a source of pathology, and they were followed for symptoms of chronic wrist pain. Further diagnostic studies including arthrography and RI scintigraphy revealed local pathology. It is only after an accurate diagnosis is established that a rational therapeutic procedure can be determined.

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