The problems regarding homografs of the joint in the aged would be related to the immunological and technical difficulties caused by dealing with degenerative tissues and by the long operating time required for microsurgery.
Therefore replacement using artificial joints is basically indicated for the aged even if the technique of homografs of the joint is established in the near future.
The author concludes that it is necessary to proceed with developments of the homograft technique for the younger patients and of artificial joints and other devices for the elderly.

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In order to study the pathology of juxta-articular osteoporosis in RA, histological and histomorphometrical investigations were performed on bone from tibial proximal metaphysis in rheumatoid knees. Bone specimens were obtained during total knee replacement in 16 patients with RA (49-71 years : mean, 60.8) and 10 patients with osteoarthritis (70-84 years: mean, 75.8) . All of the patients were females.
Histological findings were correlated with ESR, duration and amount of steroid administration in RA patients. Trabecular thinning, perforation and disconnection were examined histologically in bone specimens from both RA and OA patients and compared.
The area of eroded surface was increased more in RA than in OA and the mean width of the trabecula was decreased more. With regard to the relation between histological and clinical findings in RA, the bone resorption rate was closely related to aging, ESR, and the history of steroid administration, especially to ESR, which is a parameter of inflammation.
In summary, juxta-articular bone atrophy in RA was characterized histologically by an increase of bone resorption and by trabecular thinning, which was influenced to a great extent by the inflammatory activity of RA.

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The bone mineral content in skeletal bones seems to be decreased due to the implication of abnormal calcium regulating hormones in the destructive change of bones in patients with rheumatoid arthritis (RA) . This study shed light on the clarification of the relationship between calcium regulating hormones and bone mineral content in axial bone and the bone change in phalanx bone. The bone mineral content (QCT) in axial bone was measured with computed tomography and the bone change in phalanx bone was done with microdensitometry in patients with RA and osteoporosis. Bone metabolic markers such as bone GLA-protein (BGP), mainly c-terminal and mid-region recognized parathyroid hormone (p-PTH-84), and intact PTH 1-84 were also assayed in patients with RA.
The decrease of QCT values in females with RA was shown at an earlier age than that in females with osteoporosis. But no significant difference in QCT values in the patients with RA and osteoporosis in the eighty-year-old group was recognized. The bone change indices in phalanx bone such as width of cortex (MCT) and sigma GS/D in RA patients over 50 years old were more increased than those of female patients with osteoporosis at the same age. The more destructive bone changes there were in patients with RA, the more increased was the bone metabolic maker.
From these results it could be concluded that the decrease of bone mineral content in axial bone and destructive changes in axial bone seemed, in part, to be responsible for abnormal calcium regulating hormones.

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To assess the presence of generalized osteoporosis in rheumatoid arthritis (RA), we measured bone mineral density (BMD) by quantitative computed tomography in the 3rd lumbar spine of 81 patients with RA. BMD was reduced in almost all of the postmenopausal patients and in about one-third of the premenopausal patients. In both groups, the score of erosion on X-rays and physical activity had a significant correlation with BMD.
In premenopausal patients, 1, 25-dihydroxyvitmin D₃ significantly reversed generalized osteoporosis. Disease modifying drugs such as gold and Lobenzarit disodium prevented bone loss and decreased the rate of bone resorption significantly. Steroids showed no significant effect on bone loss.

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To study glenohumeral rhythm, ball roll (B), rotational movement of the humeral head, and gliding (G), its parallel translation by sliding, were measured in 60 healthy subjects during elevation of the arm, using an image analyzing system.
The B value reached a maximum at 0°-10°and the G value at 10°-20°. As the arm was elevated, the G value decreased and the B value tended to gradually stabilize after some decrease. The B+G value reached a maximum in the early range of elevation, and superior migration of the humeral head was most notable during this period. Although the value decreased until 400, the humeral head continued to rise. The value alternated between positive and negative after 300, and the amplitude of the fluctuation increased after 900. The |G|/B ratio was always below 1.0 between 0° and 300 and remained at about 1.0 until 900, but above that the rhythm was disturbed. Glenohumeral movement was divided into 3 phases by the B +G value and the |G| /B ratio, as follows; 1st (0°- 30°), ball roll>gliding; 2nd (30°- 90°), stable phase, and 3rd (90°-150°), unstable phase.

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Painful shoulder disorders have pain and restriction of mobility as the principal symptoms, and almost all of them occur from regressive degeneration. The differences in the main symptoms and the response to treatment depend on the degree of this degeneration. Therefore, it is important for treatment that the nature and site of these pathological lesions be as accurately defined as possible. The author considered that in the case of painful shoulder disorders, knowledge of both the rotator cuff, especially the bursal surface of the supraspinatus tendon, and the subacromial bursal region was indispensable, and that the clinical examinations should be approached from the subacromial side. Thus subacromial bursography and subacromial bursoscopy were adopted. The purpose of this report is to assess the clinical effectiveness of these methods and to discuss the etiopathogenesis of painful shoulder disorders.
Subacromial bursography was performed on 138 joints. An unevenness of the surface on the supraspinatus tendon, a decrease of bursal capacity, and irregular linear shadows in the bursal space could be found.
Subacromial bursoscopy was done on 51 joints. The main changes which could be observed with a bursoscope were, as in the case with the supraspinatus tendon, irregularity and fibrillation of the tendon surface and isolation and exfoliation of the tendon fibers, and in the synovial bursa, plica formations on the upper wall and funicular substances between the upper and lower walls. The author judged the distinct isolation and exfoliation of the tendon fibers to be a partial tear of the supraspinatus tendon. It should be remarked that partial tears were observed in over 40% of the cases already diagnosed as periarthritis.
It was concluded from the results of clinical examinations that the primary pathological focus of painful shoulder disorders should first take be on the bursal side of the rotator cuff. Subacromial bursography and bursoscopy are considered to be the only methods for early detections of pathologies and are very effective and essential examinations for painful shoulder disorders.

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Ultrasonography of the rotator cuff was performed preceding surgery and/or arthrography on 26 patients who had sustained rotator cuff injury.
The sensitivity of ultrasound in detecting a tear of the rotator cuff was 83% and the specificity was 64%. As signs of showing cuff tear, “defect” and “thinning” were reliable, but the “high echogenic band” was not. Tears smaller than 1.5 cm could not be detected. The small size transducer was found to be preferable because it is handy and time saving compared to the standard one.
It appears that ultrasonography can be used as one of the diagnostic tools for rotator cuff tear, especially for an incomplete tear which is difficult to detect by other methods.

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In the period from 1970 through 1988, 101 fractures of the scapula were treated at Nobuhara Hospital. The ages of the patients at the time of injury, mostly as the result of vehicular accidents, ranged between 13 and .81 years (average; 45.1) . The fractures were predominant by males (75 cases; 74.3%) . The majority of cases (55 cases; 54.5%) involved fractures of the scapular body and fractures of the acromion were second most common (26 cases; 25.7%) .
Of these 101 fractures, 74 were treated conservatively. Traction in position was applied in 26, with good results. Surgical treatments were performed on 27: 6 osteosyntheses, 2 glenoid osteotomies, 1 corrective osteotomy, 2 bone graftings for non-union of the scapular body, 1 excision of bony fragment, 1 acromionectomy and 17 operations for other complications of the shoulder girdle.
In general, satisfactory results were obtained in 90 cases. However, 7 fractures treated with conservatively and 4 operated-on fractures had varying degrees of pain and loss of elevation. But all 26 fractures treated in the zero position had complete functional recovery. Traction in the zero position is recommended as the first choice of therapy for scapular fractures.

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Since 1979 we have performed operations for loose shoulder on 75 joints in 60 cases, and since 1984, inferior capsular shift on 47 joints in 38 cases (males, 10 joints in 10 cases ranging from 17 to 30 years old; females, 37 joints in 28 cases ranging from 13 to 28 years old) .Two joints in 2 cases had to be reoperated on, and the collagen in the capsule, muscle and skin of their shoulder joint had relatively immature fibers compared with that in other cases. Recently we have performed capsule's opening shift as an additional operation and have met with good results.

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The mechanism of the joint destruction in rapidly destructive coxopathy (RDC) was studied by analyzing the bone resorption factors in joint liquid.
The joint liquid revealed bone resorbing activities. Prostaglandins (PGs) were found to play a partial role in joint destruction. The values of interleukin-1β (IL -1β) of the joint liquid were higher than those with osteoarthritis. When the joint liquid was tested for proteolytic activity by zymography performed with SDS/polyacrylamide containing gelatin two gelatin-degrading activities with molecular weights of 95KDa and 57KDa were observed. Cells cultured from synovia obtained at surgery revealed a gelatinolytic activity with a molecular weight of 95KDa in the primary culture. PGs, IL-1β and gelatinase seem to act synergetically as promotion factors in the rapid destruction of the hip joint in RDC.

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Superselective angiography of the femoral medial circumflex artery was performed on 55 hips of 52 cases with osteoarthritis following congenital dislocation of the hip, and the vascular changes of the arteries supplying blood to the femoral head were investigated.
With lateral displacement of the femoral head, stenosis of the superior retinacular arteries at the origin was disclosed and the area of the vascularity springing from these arteries was decreased. On the other hand, the vascularity of the inferior retinacular arteries was increased. Cases having cystic lesions of the femoral head showed an increase in vascularity of both the superior and the inferior retinacular arteries.
With the progress of the disease, the retinacular arteries became markedly curved and winding in the advanced stage accompanying deformity of the femoral head, and there was increased vascularity of the inferior retinacular arteries. From these results, the blood supply of the femoral head with osteoarthritis was proved to be involved in the progress of the disease.

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Large doses of steroid were given to adult rabbits over a six-month period to investigate the mechanism of avascular necrosis. The steroid caused an increase in the serum cholesterol and fatty metamorphosis of the liver.
Bone marrow blood flow was measured by the hydrogen washout method, which was performed in the proximal tibia. The bone marrow blood flow was found to decrease. Histological observations identified an increase of the number of empty lacunae, a reduction in bone formation rate, and a degeneration of marrow fat. These observations may help to define the mechanism for avascular necrosis inducedby systemic steroid.

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The effectiveness of the halo vest in the treatment of cervical spinal lesions was investigated in 40 RA patients who underwent spinal fusion with the help of the apparatus. Preoperative application of the vest was quite useful in obtaining neurological recovery in all of the 11 patients with ‘upper’ cervical lesions including irreducible subluxation, in 15 of the 16 with reducible subaxial subluxation and in 2 of the 4 with irreducible subaxial subluxation.
Cervical spinal fusion without decompression of the spinal cord was then performed on those cases who had demonstrated favorable neurological recovery with the vest. In order to obtain solid bone fusion, the vest was kept on for three more months post-operatively. Solid union was demonstrated radiographically in 18 of 21 patients with ‘upper’ cervical spinal lesions and all 15 patients with subaxial lesions. Posterior spinal fusion was performed on all of them. In 6 patients with subaxial subluxation who underwent anterior spinal fusion, collapse of the grafted bone was observed. Pseudoarthroses developed in 2 of them, with the recurrence of preoperative neurological symptoms.

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Hindfoot deformity is not a rare condition in rheumatoid arthritis. Severe deformity causes pain which is a result of abnormal weighing, so it is necessary to correct the deformity in such cases. But sufficient correction cannot be obtained with the conventional method, triple arthrodesis. Therefore, we have developed a new surgical technique for correcting severe hindfoot deformity in rheumatoid arthritis. It consists of the following procedures: (1) removal of the navicular bone; (2) resection of the articular cartilages; (3) reduction of the deformity; (4) return of the navicular bone; and (5) fixation with k-wires.
The improvements of the calcaneal pitch of the feet treated with conventional triple arthrodesis and with the new technique were -1°±3° and + 6°+4°, respectively. The good correction with the new technique was certified not only by plain X-ray pictures but also by frontal tomograms and footprints.

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The short-term follow-up results of arthroscopic ACL reconstruction using Leeds-Keio artificial ligaments are reported. The indications for the artif ical ligament are patients with a recreational level of sports activity or patients who want a quick return to sports participation. Middle-aged people are good candidates.
During the period from June 1987 to June 1988, arthroscopic ACL reconstruction using Leeds-Keio artificial ligament was performed by us in 18 patients, 11 men and 7 women, with an average age of 27 (range, 16-45 years) . The average follow-up period was 18 months (range, 12-25 months) . Fourteen had been injured during sport activities and 4 had been involved in traffic accidents.
We used the tubular type of Leeds -Keio artificial ligaments in double fashion. The reconstruction of the ACL was done through arthroscopic control and lateral extra-articular reinforcement was combined as in the Fujikawa method. A 6mm bone tunnel was made at the isometric points of the femur and tibia with a drill guide system.The ligament was firmly fixed with two barbed staples at the exit of the tunnel so that CPM machine could be applied with limitation of motion on the second day after the reconstruction. Partial weight-bearing walking was allowed on the second week postoperatively and full weight-bearing on the fourth week. Thus the rehabilitation period was shortened and the patients could make an early return to the normal activities of daily life.
At the follow-up, mild knee pain was present in 11 cases at the lateral reinforcement site, and there was giving way in 2 cases and swelling in 2. Straight ADS test was positive with a hard end point in 1 patient and trace in 8. The Lachman test was positive in 1 and trace in 4. Jerk test was trance in only 1. The ROM showed a loss of an average of 3.10 in extension (0°-40°) and 141° in flexion (120°-150°) . Thus the results within this short term are satisfactory and we consider this method to be a good technique for ACL reconstruction in selected patients.

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The results were reviewed of high tibial osteotomy in 14 patients (17 knees) performed between 1977 and 1982; the mean length of follow-up was 8.9 years in a range of 5.8 to 11.2 years. In most of the cases, the surgery done was wedge osteotomy. Clinical evaluation was made using the knee scoring system of the ‘three universities trial plan’.
All cases except one showed satisfactory results. The evaluation score of knee joint function was an average of 83.6 points compared to a preoperative score of 58.3. The preoperative femorotibial angle (FTA) averaged 185.9°, the postoperative one 169.0°, and the one at follow-up 169.1°. Seven cases showed flexion loss postoperatively, and these had a tendency of developing patella baja and a decrease of the posterior tilting angle of the tibial plateau.

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Nineteen knees with the tibial condyle defect were treated with a cementless total knee arthroplasty using a sapphire nail for the fixation of grafted bones. The follow-up time was 1 to 4 years, with an average of 36 months. The prostheses used were the ceramic KC-1 type and the Okayama University Mark II type.
At the follow-up, 6 of the 19 knees showed collapse of the grafted bones. In 3 of the 6, bony sclerosis, radiolucent line or bony absorption was seen radiologically at the interface between the sapphire nail and bone. Five of the 6 were suffering from rheumatoid arthritis. In 2 of them, bone slices from the femoral condyle were used. Sapphire nail breakage was seen in 2 knees; one was with collapsed grafted bone and the other was not. However, with or without collapse of the graft bone assessment, there were satisfactory results clinically. Advantages can be expected from using sapphire nails because of their non-degradable and biocompatible nature. Nevertheless, in osteoporotic knees, there is little advantage to using them and these nail are not sufficient for securing grafted bone. The choice of the graft bone can also be one of the main problems in the cementless total knee arthroplasty for treating osteoporotic knees with tibial bony defect.

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Twenty-nine unicompartmental arthroplasties for osteoarthritis of the knee were studied with a 5-to 11-year follow-up period. Superior results were obtained with the preoperative radiological stages 1, 2 and 3. The causes of failure included tibial fracture, tibiofemoral subluxation, loosening of the tibial components and deterioration of the contralateral tibiofemoral joint. Because the bulk of failures can be explained by mechanical causes and improper indication, adequate preoperative assessment and precision of surgical procedure are required.

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Since 1979, 13 knees in 11 males and 43 knees in 32 females, totalling 58 knees in 43 cases, have undergone total condylar type TKR in our hospital. The primary diseases were rheumatoid arthritis in 13 knees in 11 cases, osteoarthritis in 44 knees in 31 cases, and hemophilia A in 1 knee in 1 case. The shortest follow-up period was 5 years and the longest 8 years and 8 months, averaging 6 years and 3 months.
Clinical assessment was made based on knee scores in addition to X-ray evaluations. The average knee score of 50.5 preoperatively improved to 72.4 postoperatively, with remarkable improvement seen in pain, whereas the range of motion narrowed. X-ray evaluation showed that there was an improvement of FTA from preoperative 182.60 to 178.70; however, there were a few large variations. A radiolucent zone (RLZ) developed in 10 knees (17.2%), but no loosing or sinking was observed. No correlation was observed, with assessment scores, between the angle and position where the component was inserted and RLZ. In the cases with low assessment scores and in cases where RLZ had developed, there was presumed to be more correlation with the presence of obesity or with complications. Favorable results were obtained by adequate treatment also in cases which developed complications postoperatively. No decrease in supportiveness by the removal of PCL or obvious disorders caused by cementing have been observed so far, and patients have been satisfied.

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Bipolar hip arthoroplasty for hip destruction due to rheumatoid arthritis was performed on 16 joints in 10 cases. Bone grafting was performed on 8 joints. The clinical results and roentgenographical progress in migration or sinking of the prosthesis were followed for 10 to 48 months.
At the time of follow-up, walking ability was increased in 8 cases and not changed in 2 cases. Progression of central migration of the outer head was seen in 6. Subsidence of the femoral stem was noted in 4. Migration of the outer head had generally stopped within 6 months, but progressed over one year in some cases. The ways of obtaining firm bone grafting and the suitable timing for weight bearing must be further studied.

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Surgical treatment of the hip joint with massive skeletal defect is difficult for an orthopaedic surgeon. Bipolar hip prosthesis with massive bone grafting has been done by us on 43 hips of 33 rheumatoid arthritis patients with acetabular protrusion. Partial weight bearing was allowed from 10 days to 3 weeks. Experience has shown that a massive bone graft using extracted femoral head is better than bone fragments as the procedure for acetabular reconstruction.
Adequate bone coverage for the steep acetabular edge was essential for successful reconstruction of 13 secondary displastic hips of 11 patients. Non-weight bearing periods were from 4 to 12 weeks, depending on the amount and site of the grafted bones, as massive bone grafts were very slowly revascularized and incorporated.
The isotope activity was evaluated at the grafted skeletal area of the 12 hips which were examined. All of them showed high activity at the site of grafted bone with in 3 month after surgery. The high activity became less active in 2 patients, in 26 months in one and in 51 months in the another.

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Cementless total hip replacement in RA has rarely been reported, probably because of technical difficulties with fixation of a prosthesis due to osteoporosis and protrusion of the acetabulum. The present study concerns midterm results (follow-up of up to 3 years and 7 months, averaging 21; 1 months) for 15 cases with the cementless total hip replacement (JIAT total hip endoprosthesis) developed in Japan. The clinical results have so far been satisfactory in view of the remarkable improvement in pain and some improvement in ADL.
Examination of the tissue change around the prosthesis in a case which died 3 years, postoperatively revealed preserved trabecula a round the prosthesis and stable anchorage.

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We evaluated 27 patients (54 joints) with rheumatoid arthritis who underwent simultaneous replacement of two lower extremity joints in our hospital, with regard to postoperative results, anesthesia, hemorrhage volume, transfusion volume, hospitalization period, and complications. The 27 patients consisted of 20 with simultaneous bilateral TKR, 4 with simultaneous THR and TKR, 2 with simultaneous TKR and TAR, and 1 with simultaneous bilateral THR. Selected for the control group were 4 patients with bilateral TKR and 6 with THR and TKR in which the replacements had been done at different times.
Favorable postoperative results were obtained both in the double joint simultaneous replacement group and in the control group. There were no significant differences in transfusion volume or complications, either, though with respect to anesthesia and hemorrhage volume per operation, extreme caution should be exercised with surgical invasion in two-joint simultaneous replacement groups. The hospitalization period of the two-joint simultaneous replacement group was approximately half as long as that of the control group.
These findings have demonstrated that simultaneous replacement of two lower extremity joints on patients with rheumatoid arthritis allows them to attain functional goal early and to reduce social, economic psychological burdens on their families.

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Nine cases of excision arthroplasties for infected hip replacements were reviewed at follow-ups of 1 to 13 years (mean 5.5) to assess the efficacy of this procedure. In 4 cases, the greater trochanter had been inserted into the acetabulum and the hips fixed by external fixators (coaptation arthroplasty), while the simple Girdlestone procedure had been performed in the other 5 cases. Clinical results consisting of JOA score, leg-length discrepancy, walking ability, patient's assessment of this procedure, assessment of muscle power and X-ray findings were compared between these two procedures.
Satisfactory pain relief was provided in 80% of the patients by the simple Girdlestone procedure and in 100% by the coaptation arthroplasty. In walking ability, the coaptation arthroplasty showed better results than the Girdlestone procedure (all patients needed walking aids) ; 2 needed two crutches in the Girdlestone group, 1 needed one crutch in the coaptation group and the others needed a single cane. Leg-length discrepancy was also less in the coaptation group (mean 3.9cm), and abduction of the hip was more limited. However, there was no significant difference in JOA score between the two groups, and all patients were satisfied with the excision arthroplasties. X-rays of the coaptation group after the removal of a cup-socket hip prosthesis showed a marked development of bony spikes in the acetabulum in 1 and the joint space-like finding was detected in 1.
It was concluded that the coaptation arthroplasty seems to be a better salvage procedure in the management of infected hip replacements than the simple Girdlestone procedure.

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