The upper cervical spine (C1/C2) is often involved in the course of RA. Atlanto-axial subluxation and basilar impression secondary to the upper cervical involvement are the major problems. Recently some diagnostic imaging methods (i.e., computed tomography (CT), magnetic resonance imaging (MRI), etc.) have been offering more information about the anatomical change of the upper cervical region caused by RA. We report here on the clinical efficacy of CT and MRI in the diagnosis of upper cervical lesions of RA patients.
CT reveals bone lesions clearly, and the functional analysis of C1/C2 during flexion, extension, and rotation of the cervical spine is useful. MRI offers good information about soft tissue changes including compression of the spinal cord, and when combined with Gadlinium-DTPA, defines the relationship of periodontoid pannus and bone more clearly. Postoperative MRI is also available for seeing the effects of surgery on spinal cord compression.

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A new surgical technique of proximal radial shelf arthroplasty was used in which the resected radius head is fused with a ceramic screw at the level of the proximal radio-ulnar joint so that the resected proximal stump of the radius is in pseudoarthrosis with the bony shelf. This technique was employed on 4 elbow joints, i.e. on 3 rheumatoid elbows with late synovectomy and joint debridement, and on an osteoarthritic elbow joint in which interposition arthroplasty with an OMS membrane (a chromicized swine mesentry) had been performed. The relatively short follow-up of this new procedure has revealed satisfactory clinical results without post-operative pain on motion, any limitation of range of elbow motion, or muscle weakness. This new technique seems promising to prevent instability and valgus deformity of the elbow, joint, which tend to develop after resectioning of the radius head.

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In the past eight years, 15 cases of old radial head dislocation were seen in our department, of which 9 were male and 6 were female. The age at injury ranged from 2 to 46 years. Five cases weren't operated on though the 4 over the age of 2 0 had dull pain on motion of the elbow joint. Ten cases had surgery. The time from injury to operation ranged from 2 months to 8 years, with the time for 7 being over one year. The radial head was reduced by wedge osteotomy at the proximal ulna in 4 cases, by annular ligament reconstruction in 2, and by both procedures combined in 4.
Follow-up took place after an average of 2 years and 2 months, ranging from 4 months to 7.5 years. The radial head was redislocated in 6 cases out of the 10. Reduction was maintained in 2 cases out of the 4 in which reoperation was done; annular ligament reconstruction could not maintain radial head reducation in the other 2.
Radial head reduction with wedge osteotomy at the proximal ulna with or without annular ligament reconstruction is recommended for treating old radial head dislocation.

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A follow-up study was made of the patients with rheumatoid arthritis who had undergone multiple total joint replacement. The systemic functional ability of patients was estimated using a modified Barthel index. In 84% of the patients, improvement of the activities of daily living was achieved. However, in the other 16%, in whom there was severe cervical myelopathy, muscular atrophy, or/and osteoporosis, the results of the surgery were not satisfactory. It seems that indication for multiple total joint replacement in severe active rheumatoid arthritis should be determined by considering the neurological function, muscular strength, bone mineral content of the skeletal system, and the social background of a patient.

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For the treatment of knees with ACL injuries, we used a modified Marshall's method including reinforcement with a Kennedy LAD. By improving the postoperative physiotherapy regimen, we have also attempted to achieve safe and early rehabilitation. As a result, without sacrificing the function of the transplanted ligament, recovery of normal daily activities was achieved in 4 to 6 weeks after operation.
However, the strength of the quadriceps did not sufficiently recover early after the operation. It was suggested that this might occur because the taking of a tendon from the knee extension mechanism impeded the recovery of the muscular power of the quadriceps.

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Since the end of 1977, we have performed unicompartmental arthroplasty in 64 cases of osteoarthritis of the knee. A five-year follow-up study on postoperative radiological changes could be done on 14 of these cases (16 joints) .
When the immediate postoperative femorotibial angle (FTA) was less than 1800, varus deformity of the knee hardly ever developed. On the other hand, when, the FTA was more than 18.0 the FTA increased with time. In those cases in which the immediate postoperative FTA was around 1750, wearing of tibial component (HDP) was noticed as much as the degree of narrowing of lateral joint space, and weight loading seemed to be distributed to both medial and lateral compartments. In one case, osteoarthritic change in the lateral compartment developed to some extent.
In cases in which overcorrection of the FTA is performed, excessive loading of the lateral compartment will take place and osteoarthritic change will develop there. However, undercorrection will result in excessive loading of the medial compartment and an increased tendency for wearing of HDP tibial components. In summary, the immediate postoperative FTA is important in order to make this arthroplasty successful. The results of the present study, show that an immediate postoperative FTA of 175° may be optimal.

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In order to retain as much bone stock as possible, we have chosen the non-cemented total knee prosthesis. The tibial component with a long peg has been used for the purpose of achieving initial stability.
Fourteen knees in 13 patients with bone graft for severe tibial defect were replaced with the non-cemented total knee arthroplasty and followed for 6 to 98 months. Postoperative clinical results have been very good. We conclude that the non-cemented total knee prosthesis can be used in the knee with severe tibial defect.

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Early synovectomies were performed on 170 rheumatoid knees from 1963 to 1979. Among these cases 19 patients were selected for follow-up who fulfilled the requirements of having bilateral knees in (1) Stage I (Steinbrocker classification) before surgery, (2) synovectomy performed on one knee, and (3) a length of post-operative follow-up of more than 10 years. Clinical and radiographical values were compared between the operated-on side and the non-operated-on side in each patient.
Pain and recurrence of joint effusion in the operated-on side was significantly reduced in comparison to in the non-operated-on one. The range of motion remained unchanged bilaterally. Radiographs of both knees showed a slight progress of degenerative changes. The average radiographical stage was more advanced in the non-operated-on knee than that in the one with synovectomy. It is therefore suggested that early synovectomy not only ameliorates the symptoms of the affected knees but also slows down the progress of radiographic stages.

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Fifty-two patients with avascular necrosis of the femoral head (ANF) were examined to determine the prognosis and decide on treatment. In steroid-induced or bilaterally-involved ANF, collapse of the femoral head occurred more quickly than in idiopathic or unilaterallyaffected patients. According to pathological classification, using Kaplan-Meier's survivership methods, the prognosis of type II patients was poorest and that of type I-C was poorer than that of type I-B.

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In 11 patients (17 joints) younger than 39 (RA, JRA) who had received a cemented THR operation, long-term results over a period of 14.6 years on an average were examined. The following were obtained:
1) Three patients (6 joints) (35%) out of the 11 had died, 4 patients (5 joints) (29%) showed good results with persistent practical walking capacity up to the present, and 3 patients (5 joints) (29%) showed poor results.
2) Poor postoperative results were most influenced by the condition of RA; remission or near remission makes operative effects long sustaining.

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We have studied radiologically and clinically on the short-term results of the cementless PCA total hip system in 20 patients (22 joints) with secondary OA of the hip. Of these, 18 were females and 2 were males. The ages at the time of operation ranged from 48 to 77 years (mean : 60.3 years) . The postoperative follow-up period varied from 6 to 29 months (mean: 10 months) .
In the radiological evaluation, “press fit”of the stem at the isthmus was recognized in 19 cases (86.4%), “sinking”of the stem in no cases, and“cortical hypertrophy”in 1 case. There were radio-opaque lines or bone sclerotic lines in 5 cases (22.7%) . In 3 cases out of these 5, press fitting of the stem was not achieved. The reason for the occurance of this radio-opaque line is unclear, but we consider stress force at the tip of the stem and micro -movement of the stem to be important factors. The clinical results of these patients are now satisfactory. On the acetabular side, no bone changes were seen around the components, and primary fixations were achieved. Loose beads were recognized in 3 cases (13.6 %) . In 1 case, 1 bead in the 8th month, and 2 beads in the 15th month were recognized postoperatively around the acetabular component. We beleive that there were some micro-movements in this case, but the clinical results were very good (from 38 points to 90 points) and the patient has no problems now. The average setting angle of the acetabular components in A-P views was 47.9°. Clinical results were somewhat better in those in which the argle was under 45° than in those in which it was over 45°. For clinical evaluation, we used the 100 point system (JOA score) and the results were satisfactory (from 32.6 points before operation to 85.5 points after operation) . In the analysis of the points, 56% of the cases had improved with respect to“pain”.

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Hemi-arthroplasty with a Bateman-type prosthesis has been performed on 53 cases of either femoral neck fracture or osteonecrosis of the femoral head since 1981 in our department. Of these, a long-term follow-up study of more than five years was done on 15 joints of 15 cases. The sex distribution was 3 men and 12 women, aged from 40 to 79 (mean: 61) . The period of follow-up ranged from 61 to 96 (mean : 76) months.
Clinical evaluation by the JOA assessment criteria revealed excellent results in 5 cases and good in 10. The average score was 86.2.
As to radiological results, there were 6 cases of‘clear zone’around the stem, and 3 cases of distal migration of the stem; however, there were no cases of proximal migration of the outer head. Based on the above, the overall postoperative results were considered to be quite satisfactory.

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The long -term results of cemented total hip replacement (THR) have not been entirely satisfactory. The number of revision surgeries necessitated by having used bone cement have increased recently. Therefore cementless THR has been used more and more. Its great strong points are the of use biological fixation without cement, and the potential for reducing late failure due to loosening.
From August 1986 to May 1989, 60 hips were treated with THR in Ehime University, 24 with cementless THR (Harris -Galante porous system), and 36 with cemented THR (Harris precoat system) . A comparison was made of the two.
The average postoperative JOA hip score was 80.4 in cementless, and 83.0 in cemented THR. Thus the short-term results achieved using cementless implants are about as good as those achieved using cemented implants.
There being many advantages to cementless THR, many cases may be treated with it in the future. The most important point in using it is to achieve rigid temporary fixation until bone ingrowth can occur.

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Sixty-two knees in 41 patients with an average age of 70, who had had a Miller-Galante total knee arthroplasty, were followed for a period of 21.5 months. Rheumatoid arthritis was the diagnosis in 21 patients and osteoarthritis in the other 20.
No one had patellar replacement, and 90.9 % of the knees were rated good to excellent according to the Japanese Knee Society Score Sheet. One patient required bannister support for both ascending and descending stairs. Twenty-eight patellae (45%) had shifted laterally (lateral shift ratio of more than 30 %) on skyline-view roentgenograms postoperatively.
The patello-femoral joint of the femoral component of the Miller-Galante porous knee prosthesis and the tibial component are flatter than in any other total knee prosthesis, and the tibial component is more rotatable. These component designs are thought to be among the important causes of patellar subluxation, and it is recommended that careful attention be paid to technical details when using this prothesis.

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Among 60 knees treated by total knee arthroplasty over the last six years, 3 cases with rheumatoid arthritis had late infection two to four years after surgery. Although continuous irrigation for two weeks using a solution mixed with antibiotics was performed intensively after removal of the prosthesis in 2 of the cases, suppurative inflammation of the knees was not healed.
Gentamycin-polymethyl methacrylate (PMMA) beads were then applied locally to the knees following curettagement, and removed three or four months thereafter. The clinical results of this procedure were favorable and the patients were able to walk with a brace during the treatment. Moreover, the removed PMMA beads revealed an inhibitory band on staphyrococcus aureus agar.

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Enlargement of the iliopsoas bursa as a complication of a hip joint disease such as rheumatoid arthritis, osteoarthritis, synovial osteochondromatosis, pigmented villonodular synovitis and septic arthritis has been documented. Numerous intrapelvic complications with total hip arthroplasty have also been reported, including iliacus hematoma, peripheral nerve palsy, vascular injury, and extrinsic compression of the bladder, ureters or vagina. A pelvic mass causing vesical compression is another complication of total hip arthroplasty. We are reporting the following unusual one : an iliopsoas bursal distension, clinically mimicking an abdominal neoplasm, which was caused by acetabular loosening of a total hip arthroplasty twenty years afte operation.

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The tissue inhibitor of metalloproteases (TIMP) has some important regulatory roles in collagen degradation. The TIMP concentration was examined in 27 specimens of joint synovial fluid from 13 RA patients and in 18 specimens from 13 OA patients using the sandwich enzyme immunoassay method.
The TIMP concentration was higher in the RA group than in the OA group, and was correlated with the following coefficients of rheumatoid activities in the RA group: the amount of erythrocyte sedimentation rate (ESR), the amount of serum C-reacting protein (CRP), the number of white blood cells (WBC), and the amount of serum rheumatoid factor.

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Since 1987, fifteen patients had the combined reconstruction of the anterior uciate ligament insufficiency, using the central one-third patellar tendon and the ilio-tibial tract (De jour's method) . This operative procedure is characterized by the confirmed fixation of the bone -patellar tendon - bone graft with steel and screws.
The results of the first 7 patients, 5 males and 2 females, were followed for a minimum of 12 months to a maximum of 24, the average being 16.1. Their ages ranged from 16 to 43, the average age being 26 years and 8 months. No patients had giving -way and all jerk tests were negative. The average radiological Lachman's test was 12.1 ± 1.6 mm (mean ± SD) preoperatively. All patients were satisfied with the results of this surgical intervention.

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Thrombophlebitis commonly occurs in Bchcet disease and causes various symptoms. It is, however, very rare that a thrombosis causes nerve palsy. A case of brachial plexus palsy due to compression by venous thrombosis in the axillar area is reported. A 40-year - old man has been afflicted with Bghcet disease since 1982. He had a few month's history of a radiating pain and numbness on his left arm down to his fingers. Examination revealed a soft and egg-sized tumor in the left axilla. Tinel's sign was positive. Total resectioning of the tumor was done. The tumor was 20×20mm in size and connected to a branch of the axillar vein.
The Brachial plexus was directly compressed by the tumor. Histological examination proved this tumorous condition to be an intravenous thrombosis.

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We measured the patellar tilt and patellar shift in recurrent dislocation of the patella and postoperatively using computed tomography with full extension of the knee.
Patellar tilt and patellar shift were improved significantly after operation.
Three methods have been used for operating on recurrent dislocation of the patella: A, arthroplasty of which uses soft tissue, for example, the Baker method or the Kouno method; B, medial displacement of tibial tuberosity, for example, the Elmslie-Trillat method or the Groeneveld method; and C, only lateral retinacular release and medial plication. Comparing A, B and C, patellar tilt and patellar shift were improved significantly in A and B but not significantly in C. We have concluded that measurement of the patellar tilt and patellar shift using computed tomography with full extension of the knee is useful for postoperative evalution of recurrent dislocation of the patella.

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Although a number of cases of spontaneous medial dislocation of the long head of the biceps brachii muscle have been reported, lateral dislocation of this tendon has not. We describe a man with habitual lateral dislocation of the long head of the biceps tendon, and discuss the pathomechanics of this unusual condition. Enhanced computed tomography was useful for diagnosis in this case.

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Although the structure of the enthesis is similar to that of joint cartilage, the vascular distribution at the tendon insertion is not well-known. We examined the vascular supply of human adult enthesis using scanning electron microscopy and light microscopy. While the unmineralized f ibrocartilage layer of the enthesis was avascular, the capillaries which extend from the bone marrow to the tidemark were observed. The distribution of these capillaries was similar to that in the articular cartilage. The function of these blood vessels is discussed.

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