Forty-six knees of 28 male and 18 female patients who were between 14 and 49-years-old (average 26.5-years-old), had anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BTB) graft from 1996 to 2001. The interval from magnetic resonance imaging (MRI) varied from 1 to 51 months (average 10.1 months). We studied the differences in signal intensity on T1-and T2-weighted (T1W and T2W)MRI to evaluate autografts after ACL reconstruction. In 11 of the knees followed up more than 13 months after ACL reconstruction, we also analyzed the relation between MRI signal intensity and KT-2000 knee arthrometer measurements, between MRI signal intensity and Lysholm Score.
Between 1 and 3 months after the operations low signal intensity was reported in 56% of T1W and in 78% of T2W images. Between 4 and 12 months, middle signal intensity was reported in 81% of T1W and in 78% of T2W images. After more than 13 months, low signal intensity was reported in 64% of T1W and in 73% of T2W images. Significant difference was not recognized between MRI signal intensity and KT-2000 knee arthrometer measurements, between MRI signal intensity and Lysholm Score.
In summary, autografts tended to show low intensity from 1 to 3 months after the operations, and from 4 to 12 months the intensity strengthened, and again weakened after 13 months. Signal intensity and the clinical score did not correlate.

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We present two cases of inner head dislocation of a bipolar prosthesis with a self-centering system. In the first case, a 69-year-old man, a farmer, with bilateral steroid-induced aseptic necrosis of femoral heads underwent replacement of the bipolar prosthesis in 1991 (left) and 1993 (right). Stem loosening and cup migration in the right hip occurred 10 years after surgery. In 2002, he fell and the subsequent radiograph revealed the dislocation of the inner head. Total hip revision arthroplasty was carried out. A broken ring stopper and a large amount of polyethylene wear debris were found during the surgery. In the second case a 52-year-old man, a physical laborer, with bilateral alchoholic aseptic necrosis of the femoral head underwent replacement of the bipolar prosthesis in 1994 (left) and 1995 (right). In 2001, when he was working in half sitting position, severe right hip pain occurred, a radiograph taken at that time revealed the dislocation of the inner head. Acetabular socket revision was carried out. A broken bearing insert and a large amount polyethylene wear debris were also observed during the surgery. The key similarities observed in both cases are 1) acetabular reaming at first surgery, 2) large neck diameter of the femoral stem, 3) migration and varus fixation of the outer head, 4) physical labor. It is considered that these conditions induced poor oscillation of the inner head resulting in broken bearing insert and dislocation.

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We performed total hip arthroplasty (THA) in 10 patients 80-years-old and older between 1998 and 2002. Seven hips were diagnosed with osteoarthritis, and 4 hips rapidly destructive coxopathy (RDC). The age of the patients operated on ranged from 80 to 85 years old (average, 81.4 years). The follow-up period was from 4 months to 4 years (average, 2 years and 6 months).
The clinical results were evaluated with the JOA scoring system score. The average value of pain subscore improved remarkably in comparison to the preoperative score. The average gait and ADL subscores, however, did not improve as much. Poor preoperative ADL values strongly influenced postoperative ADL improvement. There were no complications.
Patients with preoperative muscle strength deterioration, especially in cases of RDC, had little improvement in ADL after THA. As a result, we believe that THA should be performed as early as possible on patients 80-years-old and older.

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Some cases of tibial malunion have occurred following a tibial fracture. This report is on two cases of postfracture tibial malunion in post traumatic fractures, which had been treated by plate and screws.
The first case is of a 50-year-old man with varus and reflexional deformity of the tibia. The second case is of a 25-year-old man with external rotational deformity of the tibia. The deformities were assessed on radiographs and CT images. Both were treated by osteotomy with intramedullary locking nail. The first case was treated after 1.1 years from osteosynthesis and the second case was treated after 1.8 years. Radiographic signs of fracture healing were apparent at 3 months after the second operation.
Tibial alignment improved, and the patients had no complications during or after osteotomy.

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Tibial plateau fractures are difficult to treat and often result in malunion which involves persistent varus or valgus deformities of the knee and causes many disabilities. We report two cases, a 61-year-old man and a 58-year-old man. Average follow-up period after varus correction was seven months, without complication. They were suffered tibial plateau fractures of their right knees, in traffic accidents. Both fractures were total depression type according to Hohl’s revised classification. The first case was treated initially with casting. The second case was treated by open reduction and the internal fixation. However, during the initial surgical follow-up period, malunion of the right knee occurred, and the patients complained of gait disturbance. We realigned these varus deformities using the focal dome osteotomy reported by Paley, et al with the Ilizarov external fixator. We achieved complete realignment of the proximal and distal tibial axes. In both cases, correction with bone union was satisfactory. The patients’ gait disturbance, and the limitation of the range of motion of the knee completely resolved.

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Diffuse pigmented villonodular synovitis (DPVS) rarely involve the shoulder joint. A 44-year-old man affected with DPVS in his right shoulder joint was treated successfully by open synovectomy followed by radiotherapy (RT). Before operation, he complained only of omalgia of the right side, and the joint was not restricted. A radiograph showed erosive change on the acromion and the greater tuberocity. Arthrograms and MRI showed a torn rotator cuff. We did not operate on the bone and rotator cuff, because the condition was asymptomatic and not severe.
RT has a risk of aggravating joint function. However, it is difficult to resect completely the synovium in DPVS, and the recurrence rate of DPVS is very high. As recurrence and/or multiple operations further damage the affected joint, we selected this moderately invasive procedure.
We found that with carefull technique, radiotherapy was useful in preserving function in the shoulder joint in this case.

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Some reports have indicated that prognoses in patients with a metastatic spinal tumor from a primary thyroid cancer (other than an undifferentiated type) are better than prognoses in those from other primary sites. However, it is often difficult to reconstruct the spinal column after en bloc spondylectomy. We report a case of surgical reconstruction after spondylectomy of a massive metastatic lumbar spinal tumor from thyroid cancer.
A 62-year-old man had lumbar pain and gait disturbance due to the tumor at the L4 level. We performed the operation used a pedicular screw system for reconstruction of the posterior spinal column followed by reconstruction of the anterior spinal column using LIFT Vertebral Body in July 2001.
The Japanese Orthopaedic Association back score (JOA score, full point is 29) was used to evaluate clinical symptoms. The JOA score improved from 17 points to 24 points at 16 months after surgery. The patient’s prognosis continues to be good. The LIFT Vertebral Body was useful for rigid reconstruction of the anterior spinal column and maintenance of good lumbar spinal alignment in this case.

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14 video-assisted thoracoscopical surgeries (VATS) for pulmonary metastasis in cases of bone and soft tissue sarcomas were performed between March 1990 to July 2002, and were followed for 2 to 50 months (mean, 22.1 months). The mean age at diagnosis was 31.6 years (14-73 years). The histologic diagnosis of the primary tumor was osteosarcoma in 8 patients, chondrosarcoma in 2, malignant peripheral nerve sheath tumor in 2, and others in 2. Surgical treatments for primary lesions were 9 wide resections, and 5 amputations. Bilateral pulmonary metastases were in 6 cases and unilateral one were in 8 cases. Four patients had more than 5 pulmonary metastastic lesions each, and 10 patients had less than 5 lesions.
This study was performed to compare two groups for factors of prognosis including the type of surgical procedure, bilateral or unilateral location, the number of metastases, and the period between surgical treatment for the primary lesion and appearance of metastases. The 3-year survival rate after surgical treatment of primary lesion was 44.9%. The current study showed no significant difference between the groups, but a tendency of better prognosis was seen in the unilateral cases, in cases with fewer than 5 lesions of pulmonary metastasis, and in cases in which metastasis was detected after 1 year or more after surgical treatment of the primary tumor.
In order to improve clinical results for pulmonary metastasis, it is important to resect pulmonary metastases when positive indication has been fully discerned.

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Traumatic posterior dislocation of the glenohumeral joint is rare compared. We report two cases of traumatic posterior fracture dislocations of the shoulder joint. In one, a 69-year-old woman, was injured in a traffic accident on June 7, 2002, and immediate closed manipulative reduction without anesthesia was successful. There was no complication. The follow-up period was 6 months. She had no symptom. Radiographs showed union of the fracture with no evidence of avascular necrosis of the humeral head. The other patient, a 75-year-old woman, was injured in a fall on March 23, 2002 and 15 days later, she was treated with prosthetic hemiarthroplasty for an anatomical neck fracture. At the follow-up at 6 months the shoulder was pain-free, and had 120° of flexion.

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A 41-year-old male bicycle racer was injured in a race and diagnosed with a distal clavicle fracture (Neer type II). Two days after the injury, his formerdoctor performed that tension band wiring operation. Following surgery and after he started bicycle training, displacement of the Kirschner wire and dislocation at the fracture site were observed. He was then referred to our hospital, where surgery was carried out. Under general anesthesia, the Kirschner wire was extracted and the region of malunion was scraped. After grafting cancellous bone from the iliac bone, the fracture site was fixed with a BEST acromioclavicular joint plate. Elevation of 90° was prohibited after surgery. But, the patient wanted to do bicycle training before returning to the races. Seven weeks after surgery, under local anesthesia, we separated and removed the hook that fixed the plate to the acromioclavicular joint. Elevation up to 135° was possible two weeks after removal of the hook. He started simulation races after three weeks, and returned to racing after six weeks. At five months after the plate fixation surgery, elevation had increased to 170°, and there was almost no difference in the range of motion between the left and right shoulder joints.
In the treatment of a Neer’s type II distal clavicle fracture in athletes, including professional bicycle racers, strong internal fixation is necessary for early sports rehabilitation. However, when an acromioclavicular joint plate with a hook is used, it is necessary to restrict elevation to 90° before the plate is removed, and consequently it takes a long time to return to the original sport. In the present case, removing only the hook part of the joint plate at around two months after surgery has allowed early return to the original sport.

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We treated a rare case of bilateral osteochondritis dissecans of the talus. The patient was a 30-year-old man with periodic complaints of bilateral ankle pain after standing for long periods during a six year period. In April of 2002, there were abnormalities of both medial talar domes on radiographs and MRI. The talus on the right side was stage 2, and the left talus was stage 3 according to Bernt and Harty’s classification. The right talus was grade 2, and the left talus was grade 3 according to Kumai’s MRI classification. The diagnosis was bilateral osteochondritis dissecans. Arthroscopic examination found irregularity and softening in both medial talar domes. The right talus was treated by transmalleolar drilling, and the left talus was treated by fragment fixation with bioabsorbable osteosynthetic implants. After operation the patient used patellar tendon bearing braces (PTB) for two months on the right side, and for four months on the left side. The follow-up period was 15 month. The preoperative JOA score was 88 points for the right side and 76 points for the left side. The postoperative JOA score was 92 points for each sides.

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Four patients with chronic osteomyelitis were treated by antibioticimpregnated cement beads between 1996 and 2002. The average age of the patients was 52 years (range 29 to 69 years). The average follow-up period was 32.5 months (range 12 to 72 months). The primary diseases were two cases of femoral shaft fracture, one case of femoral neck fracture and one case of open fracture of the lower leg. The cause of infection were methicillin-resistant staphylococcus aureus (MRSA) in 2 patients, staphylococcus aureus and staphylococcus epidermidis in 1 and staphylococcus aureus in 1.
We performed surgical debridement and inserted antibiotic-impregnated cement beads into the bone marrow and the dead space. The cement beads contained 2 or 3 antibiotics that had sensitivity for the bacteria. The cement beads were removed in 7 weeks after surgery. In all cases the infection was controlled and reconstructive surgeries were performed.
Antibiotic-impregnated cement beads were considered to be effective treatment for the chronic osteomyelitis in these cases.

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Our hospital is the principal hospital in the Masuda area of Shimane Prefecture, but as it is also an emergency hospital, the admission period in each patient is restricted to within 17 days. The number of long-stay beds in nearby hospitals is also limited. Under such circumstances, we have been trying to shorten the admission period.
[Subjects and Methods] The subjects were 243 patients (51 males, 192 females; mean age, 80.0 years) with fractures in the femoral neck and trochanter region, who underwent treatment in our hospital between January 1, 1997 and December 31, 2002. Our plan consisted of the setting of the date of discharge at an early stage of admission for each patient, confirmation of the intention of the family to care for the patient, arrangement of a transfer of the patient to another hospital, if it was wished, in cooperation with MSW, early start of load-bearing, and introduction of the clinical path.
[Results] The period of admission decreased significantly from 72.0 days before the introduction of the clinical path to 43.5 days after its introduction. The outcome as evaluated by the poor-outcome/good-outcome ratio did not change significantly (from 13/193 to 2/48). The functional outcome as evaluated by walking ability had worsened from 77/116 to 23/27. This was particularly evident with patients with fractures in the trochanter region,in which the functional outcome ratio was 51/68 and 15/13 before and after the introduction, respectively.
[Discussion and Conclusions] Focus on early discharge of patients, shortened the rehabilitation period was shortened, resulting in worsening of the functional outcome at the time of discharge.

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This study examined factors affecting the period of the hospital stay of patients who underwent bipolar hemiarthroplasty (BHP) for femoral neck fracture. During the period 2000—2003, 45 patients (11 men and 34 women)with a mean age of 75.3 years (range, 51-91 years) were enrolled in this study. A univariate analysis of the following variables was performed: age, preoperative period of the hospital stay, preoperative complication of diabetes and/or dementia, postoperative complication, period until out of bed activity after surgery, environmental conditions of the home, and walking ability was performed. The period of the hospital stay was significantly shorter in patients over 85-years-old compared with those younger than 85 years (25 days/41.5 days). It was also significantly shorter in patients who were out of bed within four days compared with others (2.9 days/12.8 days).
The results of this study showed that elderly patients and starting rehabilitation soon after surgery resulted in reduction of the hospital stay. In contrast, preoperative complications such as diabetes, and high level walking activity were important predictors of prolongation of the hospital stay.

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We reported a novel method of primary arthroplasty of the proximal Interphalengeal joint (PIP) by rotatinal osteotomy of the proximal phalengeal head. A 58-year old man sustained an Incompiete amputation of the left index finger with 60% of the dorsal articular surface missing of the proximal phalengeal head on February 23, 2002. On the same day, he underwent arthroplasty that used the Intact volar articular surface in a rotational osteotomy of the neck of proximal phalengeal head with repaired vessel and nerve. There was no complication. Eighteen months later the PIP joint had an active renge of motion of 0 to 60°and a passive range of motion of 0 to 90°with satisfactory result.
The technique is a useful alternative to other forme of arthroplasty, and is able to provide satisfactory functional results when there is a dorsal defect of the head of the proximal phalanx.

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Flexor tenosynovitis of the palm and distal forearm sometimes causes median nerve palsy, and obstruction of finger movement. Six hands of 5 patients were treated for this pathological condition with tenosynovectomy and release of the carpal tunnel and flexor retinaculum between 1998 and 2003. One patient was a 52-year-old man with bilateral tenosynovitis caused by overuse of his hands, and 4 women were from 53 to 81-years-old.
Sensory recovery was obtained in 6 weeks after surgery in cases of chronic tenosynovitis. Finger movement improved in 3 months after surgery. The grip power in the man’s case was not enough to resume the previous level of physical labor even 6 months after surgery, although the women patients regained almost full function of their hand. The follow-up periods ranged from 3 months to 1 year.
Recovery from median nerve palsy was satisfactory, but the surgical procedures of tenosynovectomy and after treatment for physical laborers requires improvement.

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Recently, several new dorsally and volarly placed plates for the distal radius were developed and the current study used volarly placed plates for unstable distal radius fractures.
Twenty-two patients (3 males and 19 females), with a mean age of 65 years (range 21-83 years) were treated using internal fixation with the AO volar distal radius plate between March 2001 and July 2003 at our hospital. The mean follow-up period was 16 weeks (range 7-32 weeks). According to the AO classification, 1 was A2, 11 were A3, 9 were C2 and 1 was C3. There were 4 double fractures. Five patients received hydroxyapatite grafts. Bony union was gained in all patients. Clinical results according to Saito’s classification were excellent in 9 cases, good in 12 cases and fair in 1 case. The average volar tilt was 5.2°. The average ulnar tilt was 23.3°. There was a postoperative loss of reduction in 7 cases, but the displacement was slight and the clinical results were relatively good. Locking the buttress pin on the AO volar distal radius plate is very effective to maintain stable repositioning. We found the AO volar distal radius plate useful for the treatment of the dorsally displaced fracture of the distal radius in this series.

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The authors performed femoral lengthening in two children using the Ilizarov technique. One was a 10-year-old boy with congenital shortening of the right femur (Pappas class IX). He had an 8 cm. limb-length discrepancy, which was treated by 8 cm. lengthening of the right femur in 1997. During the lengthening, the half-pins broke, which required the insertion of additional pins. At 16 years of age, his right lower limb was 2 cm. shorter than the left one, but he had good gait without a lift in the shoe.
The second patient was a 10-year-old boy with septic growth arrest of the right distal femur. He had an 8.5 cm. discrepancy, and 10 cm. femoral lengthening was achieved in 2001. However, at one month after the removal of the Ilizarov apparatus, the patient fell and fractured his right osteoporotic femur. It was fixed with an Ender nail, but a slight loss of length and varus deformity occurred. He had a 1 cm. discrepancy at 12 years of age.
In both children, the intended lengthening of the femur could be achived by the Ilizarov method, but the complications required additional surgery.

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We report the utility of the distally based sartorius muscle flap for the soft tissue defect after total knee arthroplasty (TKA).
A 67-year-old woman underwent osteosynthesis with a condylar plate due to a supracondylar fracture of the right femur in 1999. Four years later, TKA with the V-Y plasty of the quadriceps muscle was performed, because the severe contracture (0-40 degrees) and osteoarthrosis had developed. Several days after the surgery, necrosis of the skin and subcutaneous tissue in the supracondylar area occurred, and the sutured quadriceps muscle separated. This skin and muscle defect exposed the femoral component. A month later, we performed the sartorius muscle flap graft with a free skin graft. Although bacteria containing gram-positive rods had been cultured, we preserved the prosthesis by intensive irrigation. The sartorius muscle was detached near its origin, and folded at the distal third of the muscle belly. The muscle flap was covered with a thin skin graft from the inguinal region. Six months later, the femoral component was completely covered with the grafted tissue, and there was no recurrence of infection. Plain x-ray images showed no evidence of loosening, and she could walk without pain using a soft knee brace.
The distally based sartorius muscle flap is useful for coverage of the supracondylar area of the knee joint, because it can easily provide muscle bulk with a reliable vascular supply.

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The authors investigated retrospectively the risks to patients from osteoporotic vertebral fractures during 7 operative and postoperative days, and compared them with those of traumatic vertebral fractures.
The osteoporotic vertebral fractures group (Os group) had 4 patients (means age 78.3 years, 71-81 years, 1 men and 3 women), and the traumatic vertebral fractures group (Tr group) had 6 patients (means age 59.8 years, 52-69 years, 4 men and 2 women). The affected vertebral levels were Th 12 in 1 patient, L1 in 7 patients, L2 in 1 patient, L3 in 1 patient. The implants used were the Liberty ANTARES spine system, and Lift-J vertebral cage. They were examined and treated on admission for concurrent illness which might have affected the results of the treatments. Case reports were examined for data on concurrent illness, the change of blood pressure during the operation length of time under systolic pressure was 90 mmHg, the duration of high body temperature (higher than 37°C), and postoperative complications such as atelectasis and dementia, and infection of the operative wound.
The Os group had more severe concurrent illnesses on admission than did the Tr group, for example aneurysma dissecans, uncontrollable diabetes mellitus, and severe hypertension. The blood pressure of Os group was more changeable than that of Tr group despite the use of the medications to control blood pressure. The duration of the high body temperature in Os group was prolonged. There were no major postoperative complications. There was no infection of the operative wound.
When we treat the Os group, we have to recognize the risks that the patients of Os group have more severe concurrent illness which might affect the results of the treatments and further more their lives, and their blood pressure during the operation is more changeable than that of the Tr group.

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Surgical treatment for osteoporotic vertebral pseudarthrosis with neurological deficits has been a challenging problem because of the fragility of the osteoporotic bone. We developed a new less-invasive surgical procedure, consisting of transpedicular injection of bioactive calcium phosphate cement (CPC) into the vertebral body after correcting the wedge deformity, partial laminectomy and posterolateral neural decompression by impacting the retropulsed bony fragments anteriorly, and posterolateral bone grafting combined with a short-range pedicle screw fixation augmented by the CPC. Six patients with a minimum 6-months follow-up were evaluated. Age at operation was 77 years and follow-up period was 11 months on average. All patients showed 1 grade neurological recovery on Frankel grade. According to a 10-point pain rating scale, average preoperative back pain was 8.8 points, and it was 1.0 at the final follow-up. Average preoperative and postoperative kyphosis angle of the fused segments were 51°and 13°, respectively. In 15°, the correction was maintained at the final follow-up. The posterolateral fusions were all successfully completed. This procedure could achieve reconstruction of anterior load sharing mechanism, direct neural decompression, and correction of kyphotic deformity through a single posterior approach in a relatively less invasive manner.

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