A surgical method for the treatment of Kienbock's disease, strut bone grafting, is described in a preliminary report. Our method is appropriate for patients in the relatively early stages of this condition in which significant bone collapse has not been observed on X-rays. The actual operative method consists of thorough curettigg of the necrotized portion of the affected lunate and the subsequent insertion of a columnar-shaped bone graft into the cavity resulting from the curettage. The reason for using this method is to prevent further collapse of the lunate by inserting a tight-fitting colummar-shaped bone. This strut bone grafting was performed on 6 male patients (age, 22 to 39: average 32) . Five of these cases showed significant improvement in clinical symptoms and postoperative X-rays revealed that the development of lunate collapse was prevented (follow-up periods of 15 months to 4 years; 2 years and 3 months on an average) .

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Suprascapular nerve palsy with solitary atrophy of the infraspinatus muscle which was caused by ganglion is presented. The patient was a 30-year-old male nailer. In operative findings, the cyst was spindle-shaped, extending itself as if it were enveloping the nerve, and had no pedicle with the capsule or the adjacent tissue. It is very likely from the clinical findings that the ganglion was of intraneural origin, perhaps in the epineurium of the inferior branch of the suprascapular nerve. No such case has been reported previously.

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We measured the bone mass of the second metacarpal bone by micro -densitometry (MD) and the bone density of the third lumbar vertebra by dual photon absorptiometry (DPA) to determine the osteoporotic changes in rheumatoid arthritic patients. All patients had been treated with non-steroidal anti-inflammatory drugs and/or gold compounds, but none with corticosteroid. A significant correlation (p<0.001) between age and metacarpal index (MCI), was observed by MD as well as between age and bone mineral density (ΣGS/D) . The bone density measured by DPA also showed a significant correlation (p<0.001) with age.
Vertebral osteoporosis progresses after menopause even in rheumatoid arthritic patients. Both MD and DPA showed the bone density in the Stage N group to be significantly lower than that in the Stage j group (p <0.05) . The bone density measured by DPA in the group with active inflammation was significantly lower than that in the group with inactive inflammation (p <0.01) .

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The usefulness of MRI in carpal avascular necrosis was investigated in 20 cases, 16 in lunates, 3 in scaphoids and 1 in triquetrum, with T1 and T2 weighted images of the spin echo and T2 weighted images of the field echo.
Early diagnosis of carpal bone necrosis was possible when the T1 weighted image showed a moderate low intensity signal. A high intensity signal in the T2 weighted image indicated the onset of revascularization, and a favorable prognosis. A normal signal indicated healing of carpal avascular necrosis.
MRI was found to be very useful in establishing the diagnosis and in determining the prognosis of carpal osteonecrosis.

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Based on the clinical results of total replacement of 29 rheumatoid elbows with the almina ceramic surface replacement prosthesis designed by Dr. H. Inoue, and on the observation of progressive radiological change of 114 elbows, we modified the design of this elbow prosthesis for better initial stabilization of the humerus component as follows: A sapphire stem 6.5 cm in length and either 8 mm or 10 mm in diameter was attached to the point at the posterior one third of the humerus component in a sagittal plane so that the center of rotation could be shifted anteriorly, and anterior angulation of the humerus component would be made unnecessary. The stem could accordingly be inserted straight down into the medullary canal of the humerus and fixed tightly to the distal stump.
This new type of prosthesis was clinically used in 12 rheumatoid elbows. The ages of the patients at the time of operation ranged from 49 to 76, 65 on an average. The follow-up period ranged from 8 to 20 months. The average rating by Inglis's scoring system had improved from a 39.9 points preoperatively to 81.6 points one year after operation. The width of the radiolucent zone along the interface of the ceramic component and bone decreased in comparison to that produced in the previous type. Although the follow-up period is still short, this new type of elbow prosthesis seems applicable for those cases with advanced destruction of the trochlea, with age-related osteoporosis, or in revision surgery.

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Fifteen cases of lumbar disc hernia were treated by aprotinin injection into the herniated disc. There was improvement of clinical symptoms in 11 (73%) of 15 patients. Most of the clinically improved group showed significant change in postoperative magnetic resonance imaging. This series suggested that a shape change of the protruding disc may have some relation to the mechanism of aprotinin injection therapy.

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Many reconstructive methods for the anterior cruciate ligament deficient knee have been reported. Success of the anterior cruciate reconstruction depends on an accurate assessment of patients and correct diagnoses. Since March 1986, we have arthroscopically reconstructed the anterior cruciate ligaments with a Leeds-Keio artificial ligament in 71 knees of 44 men and 27 women with a mean age of 25.6 years (range, 16 to 52) . The mean period from injury to reconstruction was 34.6 months (range, 4 months to 10 years) . Here we studied and compared Intraoperative arthroscopic findings and postoperative results in 55 knees followed for 12 months or more.
The arthroscopic findings of the anterior cruciate ligament were as follows : In 36 knees the ligament had disappeared, in 31 a ruptured end was seen, and in 4 the ligament was thin and elongated. Meniscal injuries were seen in 63 knees (medial memiscal injuries in 34, lateral ones in 12, and medial and lateral ones in 17) . Full-thickness damage of articular cartilage was seen in 17 knees (damage of the medial femoral condyle in 4 knees, of the lateral femoral condyle in 8, and of the patelloffemoral cartilage and patellofemoral cartilage in 4) . The space of the femorotibial joint was narrowed after intra-articular reconstruction in all. But an abnormal opening of the femorotibial joint space remained in 36 knees (or the medial side in 23, on the lateral side in 12, and on both sides in one) . In 32 of these knees, combined intra-articular and extra-articular procedures were performed.
The post-operative results showed that there was a correlation between the method of meniscal surgery, the grade of chondral damage and additional extra-articular surgery, and that an abnormal opening of the femorotibial joint space remained after intra-articular reconstruction in 27 knees.

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Our experience is presented in performing arthroscopic partial menisectomy for the treatment of 130 knees for medial osteoarthritis, in 39 men (42 knees) and 83 women (88 knees), aged 39 to 83 (mean: 64.3) . The follow-up period ranged from 6 months to 3 years and 3 months (mean: 1 year and 6 months) .
In our investigation, the Hokudai classification was used for the roentgenographic classification, and the partly modified Fujisawa classification was used for the arthroscopic grade. The pre-and post-operative comparative investigations were conducted applying the scoring of JOA knee evaluation in roentgenographic stage, PTA, and the grade. The cases whose grade had advanced postoperatively and/or in which an additional operation was performed, as well as the postoperative ROM were also investigated.
Good results were obtained in the mean score of all cases, which was increased from 72.5 preoperatively to 84.3 postoperatively. Significant improvement was obtained in cases of stage II and III or with an 1700, but not in those which were stage II-III or more, or had an FTA of more than 1840, because there was great variation in scores. As the grade advanced the score decreased in cases in which the meniscus and especially inarticular surface had a marked tendency. In other cases of advanced stages, good results were obtained although the FTA was increased, and no signs of aggravation were reported.

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The results of ACL reconstruction using the Leeds-Keio ligament in 31 patients were reviewed. Two types of artificial ligament were used. Dacron was used in 2 patients and Leeds-Keio ligament was used in 31 patients. The age at the time of surgery ranged from 15 to 38 years (average, 25.6), and the length of follow-up ranged from 1 to 3 years (average, 1 year, 10 months) . Assessment by our scoring system suggested that this artificial ligament is effective for ACL reconstruction.

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This study was carried out to show the clinical effects of medial displacement of the tibial tuberosity in young patients with patellar dislocation or subluxation. It had been done on 12 knees with patellofemoral disorders of 12 patients (3 men and 9 women, ranging in age from 15 to 36 (average 22.9) . Follow-up assessment was performed at an average of 2.4 years after surgery (range, 1.3 to 3.6) .
Preoperative pain on going downstairs had been noted in 8 knees and was relieved in all of them postoperatively. Retro-patellar crepitation was relieved in 4 of 11 knees, patellar pain on grating in 5 of 6, tenderness around the patella in 6 of 8, pain on passive motion of the patella in 7 of 9, and extension pain on holding the patella in 5 of 6. The delay in
key words: patello-femoral joint, patellar subluxation, patellar dislocation, chondromalacia, displacement of tibial tubercule
improvement of retro-patellar crepitation may bedue to cartilage regeneration. The patellar subluxation was observed to be repositioned in the sky-line view in all knees. Patellar height measured on lateral view X-rays by the Insall-Salvati method showed on the average no change postoperatively.

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Roentgenographic measurements were carried out on 56 knees in 34 patients suffering from patello-femoral (PF) disorders. Twenty-six knees of 13 apparently normal volunteers without any signs or symptoms in their PF joints were also measured for control.
The items to be measured were selected as follows : the posterior inclination angle of the tibial plateau and the LT/LP value from the lateral view of the knee, the femorotibial (FT) angle, the location of the tibial tubercle, and the location of the cross-sectional center of the rectus femoris muscle in the coronal plane as determined by a computer-aided tomography scanner.
Every difference of the items above between the two groups was found to be statistically significant except the FT angle. Remarkable difference was found between the locations of the cross sectional center of the rectus femoris muscle and between the locations of the tibial tubercle.
The cause of the PF malalignment was considered to be the laterally deviated location of the tibial tubercle and the laterally located cross-sectional center of the rectus femoris muscle. Evaluation of these anatomical factors would provide more scientific basis for the treatment of PF disorders.

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The porous total knee replacement designed by Miller and Galante has been performed on 31 knees in 23 cases from November 1986 to June 1988 in the Kure National Hospital. We evaluated the postoperative results over an average follow-up period of 2.7 years (ranging from 2 to 3.6 years) on 6 knees in 4 men and 25 knees in 19 women, with ages ranging from 49 to 81 (average 69.0) . The original diseases were 5 cases of rheumatoid arthritis (7 knees) and 18 cases of osteoarthritis (24 knees) .
Each knee was evaluated preoperatively and postoperatively by the functional evaluation score system proposed by the three universities. Preoperative and postoperative femoro-tibial angle, alignment of each component, degree of lateral displacement of the patella on the patellofemoral groove, occupancy ratio of the component to the tibial surface, amount of resection of the tibia, radiolucent line and sclerotic line adjacent to the component were investigated with roentgenograms.
Postoperatively the clinical score improved from 36.9 to 80.3 points in rheumatoid knees and from 48.5 to 87.3 in osteoarthritic knees.
In each case, the insertion angle of the components was close to ideal. The degree of lateral displacement of the patella was significantly decreased in cases with lateral retinacular release. The mean occupancy ratio of tibial component to tibial surface was 95.8% on A-P and lateral view X-rays, showing that the components used are small for the tibial surface. The mean resection of the tibia was 7mm from the surface of the lateral plateau in varus knees. Only 2 rheumatoid patients had radiolucent lines surrounding the tibial component. In 2 rheumatoid knees and 11 osteoarthritic knees there were sclerotic lines surrounding the pegs of the tibial components.
In general, the short-term results of total knee replacement using this prosthesis were satisfactory. The long-term radiographic observation has shown that the choice of a tibial component of adequate size is mandatory to prevent the component from sinking.

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From January 1985 to June 1989, we have performed total knee replacement (TKR) using the Kodama-Yamamoto Mark III prosthesis on 54 knees with rheumatoid arthritis (RA) which had severe f lexion contructure exceeding 30° in 37 cases, 31 women and 6 men, with an average age of 54.2 years.
No traction or cast fixation was carried out preoperatively. During the TKR, we did not intend to achieve complete extension position by such methods as posterior release or tendon transfer, because of excessive bone resection and soft tissue preparation. Preoperative flexion contructure was an average of 37.1° and postoperative flexion contructure remained 17.2°. It had improved to 5.2° by the time of discharge. We conclude that preoperative traction and cast fixation, posterior release, and tendon transfer are not necessary in TKR for the severe flexion contructure RA knee. Even without these, postoperative flexion contructure gradually improves.

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Functional results and postoperative radiological changes were compared between a total condylar knee (TCK) group and a porous-coated anatomic knee (PCA) group. Sixty TCKs in 46 patients were followed up to 10 years, and 39 PCAs in 31 patients up to 4 years. All of the functional results except range of motion were statistically improved after surgery in each group. The average range of motion decreased after surgery in the TCK group, while there was no statistically significant difference between the average range of motion before surgery and that at the latest follow-up in the PCA group. In the TCK group, data on component position had no correlation with postoperative range of motion, while, in the PCA group, patella position was correlated with it. There was no difference in the incidence of radiolucent zones between the two groups. No radiolucent zones developed into component loosening. Various items were analyzed concerning the development of radiolucent zones. In the TCK group, the ratio of osteoarthritic joints and the average obesity index were significantly higher in joints with radiolucent zones than in those without, but in the PCA group, no investigated variables were correlated with the development of radiolucent zones.

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The long-term results and problems of 20 knee joints in 19 cases with osteoarthritis (OA) with the Savastano's unicompartmental arthroplasty limited to a single compartment of the knee are reported. The average age at the time of surgery was 62.2 years. The diagnosis was medial compartment OA in 18 knees and lateral compartment OA in 2 knees. Of the 15 cases which were followed for 10 years on an average, about 80 % of the cases showed satisfactory results within 5 years, with knee function scores of more than 75 points. However, poor results were noted in 3 knees in the first 5 years, and in 2 knees thereafter. The long-term results of unicompartmental replacement in 15 knees, including 3 knees which required revision and arthrodesis, were rated as excellent in 4, good in 5, fair in 1 and poor in 5 (2 revision 1 arthrodesis and 2 with loosening) . The average postoperative functional score was 76.8.
Observation of radiographical findings showed that the average standing FTA was 186.3° (preoperatively) and 174.8° (postoperatively) in medial compartment knee OA. But some cases showed an increase of PTA, and a final angle of over 180° was noted in 6 knees. A clear zone appeared around the femoral and tibial components in 4 and 11 cases respectively. The clear zone expanded with passage of the time in 7 cases, and this tendency was marked in the knees with a 6 mm prosthesis. These cases ultimately developed loosened joints. Our results suggested that body weight, osteoporosis, stability of the tibial component, and setting of the prosthesis seemed to be related to loosening.
The prognosis 10 years after surgery was “good” in 9 knees, accounting for 60 % of all those treated. Therefore we believe that if the indicated cases are carefully chosen, unicompartmental arthroplasty can be one of the most useful surgical procedures for knee OA.

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In a retrospective study of 18 knees in 14 rheumatoid patients followed for an average of 7.5 years after synovectomy, the effect of the operation and the clinical course were assessed. Of operated-on patients, 29% had died, total knee replacement arthroplasties had been performed on 44 % of the 18 at an average of 3 years 5 months after synovectomy, and only 11 % of the 18 knees were good clinically.
We believe that the long-term results of synovectomy of rheumatoid knee are not so good and depend on the control of disease activity.

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Thirty-nine uncemented total hip prostheses were implanted in 34 patients whose mean age was 59.6 years. The patients were evaluated after operation at periodic intervals by two methods: clinically, using the JOA (Japanese Orthopaedic Association) hip rating scale, and radiographically, with serial radiograms at 6 month intervals. At 2 to 4.3 years, the results were excellent (80 to 100 points) in 29 (74%) of the 39 hips, good (70 to 79 points) in 6 (15%), fair (60 to 69 points) in 3 (8%), and poor (less than 60 points) in one (3%) . Factors such as age, degree of obesity, and progression of the disease did not influence the clinical results. Serial radiographic evaluations revealed that radiolucent zones appeared in 14 hips (36%) . The canal fill was determined by calculating the stem diameter (numerator) and diameter of the intramedullary canal (denominator) at three stem levels, and it was significantly lower in those patients with radiolucent zones than in those without them (p<0.01) . The cortical index was determined by calculating the cortical thickness of the femur (numerator) and the femoral diameter (denominator) at three stem levels. It also was significantly lower in those patients with radiolucent zones than in those without them (p<0.01) . The lower incidence of thigh pain in cases with high distal canal fill was significant.

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Radiological and pathological studies were performed in 8 femoral heads and necks with giant erosions of 7 female patients with classical rheumatoid arthritis. Six hips of 5 cases received total hip replacements (THR) and the resected heads were examined pathologically. Radiologically, five of the giant erosions displayed a sclerotic wall on X-rays at the first visit, and there was no change in size by the THR thereafter. However, postoperatively a radiolucent area gradually appeared and progressed to the giant erosions. No further expansion occurred. All of the giant erosions arose from the lateral side of the femoral neck. The lesions were composed of fibrous granulation tissue of numerous mesenchymal cells and rich collagen fibers, and connected to the subsynovial tissues around the femoral neck. Pathologically, the giant erosions appeared to be an invasion of granulated tissue from proliferated subsynovial tissue at the lateral femoral neck where a thin cortex existed, although intra-articular pressure may have had some role in the invasive process.

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In the pathologic changes caused by rheumatoid arthritis of cervical vertebrae, it is necessary to choose an operation method with respect to the conditions of the illness. We have, therefore, assessed clinically and radiographically the indications of operative procedures on 12 cases treated surgically: 6 cases of atlantoaxial subluxation (AAS), 2 cases of vertical subluxation (VS), 3 cases of basilar impression (BI), and one case of hyperostosis on the atlantoaxial joint. The McGraw method mainly was applied for AAS, a modified Newman method for VS and BI (posterior decompression was applied for 2 of the cases simultaneously), and transoral anterior fusion for hyperostosis.
Pain, dizziness and drop attack were lessened in all cases. Two out of the 4 cases with myelopathy recovered, and the other 2 worsened one or one and half years after operation. One of the BI cases developed a new myelopathy after occipto-axial fusion. All worsening was due to insufficient decompression and the advancement of subaxial lesion after operations for fixation. Fixed-type cases of AAS, VS and BI with a space available for the spinal cord of less than 12 mm, all need occipto - cervical fusion after posterior decompression (C1), and when the cases are accompanied with subaxial lesion they need to be fixed or decompressed.

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