Three hundred five cases of the femoral neck fractures have been treated using cannulated cancellous screw since 2001. The purpose of this study was to investigate the clinical results of this method. Using the Garden classification, 77 fractures were classified as type 1, 53 were type 2, 98 were type 3 and 77 were type 4.
Failure cases after the osteosynthesis of the femoral neck fracture were 27 cases (8.9%). Using the Garden classification, 3 fractures were classified as type 1, 3 were type 2, 5 were type 3 and 16 were type 4.
The femoral neck fractures were treated using cannulated cancellous screw, and good results were obtained.

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From April 2002 to June 2005, 17 cases of cervical spinal cord injury without damage to the vertebral column were treated by laminoplasty. There were 13 men and 4 women whose mean age was 65. 5 years (range 46 to 84 years). The surgical outcomes were evaluated by the Frankel classification system. Some symptoms were improved, and there was no progression of the neurological deficits in all of the patients. For the purpose of early rehabilitation, and prevention of deterioration, early decompressive surgery is recommended for the patient with spinal cord compression.

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A 64-year-old construction worker who had penetrating trauma of the abdomen by two iron reinforcing rods at a construction site was transferred to our hospital in stable condition. Although it was difficult to differentiate the intraabdominal injuries, X-ray and CT findings suggested canal impaled injury at the L4 level, and fractures of left radial head (AO 21-A2) and right radial distal end (AO 23-B1). After stabilized the fractures by splint an emergency celiotomy was performed to remove one of bars penetrating the abdomen, which revealed no serious damage in the intraperitoneum. Then, the L4 laminectomy was performed. The second bar had caused the light dural injury to the left root of L4. After the bar was removed and the duramater repaired, the wound was irrigated copiously with saline solution. Gentamicin 120mg/day for 4 days and Ampicillin 3.0g/day for 8 days were administrated after surgery. Although no infection was observed following surgery, paresthesia in the left area of L4-5 and loss of muscular strength in the left lower leg appeared. The operation was performed against left radial head facture after 3 weeks. The patient was discharged 2 months after surgery with long leg brace, and one cane gait. He became able to walk with shoe brace 6 months after surgery. Interdepartmental teamwork was important to save the patient. Procedures adequate for the penetrating trauma are open the wound, irrigate copiously, and monitor the drainage system for signs of infection.

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Between January 2002 and December 2004, 45 patients with lumbosacral radiculopathy were treated with selective nerve block . There were 31 men and 14 women whose mean age at the time of treatment was 52.4 years (range 20-79 years). The primary diseases were lumbar disc herniation in 32 patients and lumbar canal stenosis in 13 patients. In all cases, the radiculopathy was from a single lumbosacral nerve root. All of the patients underwent conservative nerve root block , 19 (42.2%) had good results (conservative group). The 26 patients (57.8%) who had poor results underwent surgical treatment (operative group). Differences between the groups on pain and Japan Orthopaedic Association (JOA) scores after the nerve block were significant, although pretreatment JOA scores and duration of symptomatic periods were not significantly different. Duration of the effect of the nerve block was longer in the conservative group. In general, the hernia size was larger on MRI in the operative group, and 25 of patients in the operative group exhibited sensory disturbance. We concluded that the nerve root block was useful and should be tried one time before operation in lumbosacral radiculopathy.

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We treated 25 cases minimum or nondisplaced femoral neck and trochanteric fractures in the elderly from April 2000 to June 2005. All of the fractures were treated conservatively. Eighteen of the cases (72%) were occult fractures. MRI examination was found to be useful. Bone union was achieved in all cases, and 95. 5% recovery of walking ability without severe side effects during hospitalization (mean 13 weeks). We conclude that the first treatment indication of the minimum or nondisplaced femoral neck and trochanteric fracture in the elderly is conservative treatment.

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The purposes of this study were to assess arthroscopically the results of meniscal suturing and analyze the predictive factors affecting meniscal healing.
Forty-two torn menisci in 41 patients (range 13-47 years, average 24 years, Male/Female: 18/23) treated arthroscopically. The meniscal sutures were evaluated by second-look arthroscopy at 22 months postoperatively. The interval between the injury and the time of surgery ranged from 2 weeks to 15 years. There were 19 lateral and 23 medial meniscal tears associated with 30 anterior cruciate ligament injuries. The length of the tears ranged from 6 to 30 mm (mean,17 mm). The distance from the capsule to the tear ranged from 0 to 4 mm (mean, 1.8 mm).
Clinically, 37 patients (90%) had no symptoms at follow-up. Twenty-four menisci (57%) healed completely (wi thout a marked visible unhealed area), 14 (33%) healed incompletely, and 4 (10%) showed no evidence of healing. There were no relationships between outcome and age, gender, injured side, or time from injury to suturing. Both the distance from the capsule to the tear and the length of the tear were longer in the unhealed menisci. Stable knees after the ACL reconstruction had a high healing rate.
In conclusion, the healing potential of the meniscal suturing seems to be affected by the distance from the capsule to the tear site, tear length, and knee joint stability.

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Although there are many reports that MPFL reconstruction for recurrent patellar dislocation is effective and safe, there are few reports of patella fracture after MPFL reconstruction. We treated a patellar fracture after MPFL reconstruction. A 17-year-old female, who had undergone reconstruction of the left MPFL with semitendinosus tendon five months before, fell from her bicycle and hit her left knee. She sustained a transverse fracture of the patella congruent with the distal bone tunnel made at the reconstruction. We performed open reduction and internal fixation of the fracture, and there were no postoperative complications after five months.

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We report a case of lumbar disc herniation with conjoined nerve roots treated with microendoscopic discecotomy. A 27-year-old man complained of lower back pain with sciatica in his left leg. Physical examination showed hypesthesia in the right leg without muscle weakness or atrophy. Lumbar myelography, CTM and MRI revealed a space-occupying mass which might have been caused by a herniated disc at the L5/S1 level on the right side. He underwent microendoscopic discectomy. Operative findings showed entrapment of the S1 root conjoined with the L5 root. Axillary discectomy was required because the nerve roots had lost mobility. The symptoms were completely relieved after surgery.

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Various techniques for the surgical treatment of far lateral lumbar disc herniation (FLLDH) have been reported. However, these invasive techniques incur various bony and soft tissue damage. We report the cases of 2 patients who underwent microendoscopic discectomy for FLLDH by a newly modified minimally invasive technique. Two male patients, aged 56 and 25 years, had FLLDH. Indications for surgery included radiculopathy that failed to respond to conservative treatment. Both patients completed the Japan Orthopaedic Association (JOA) instrument for scoring low back pain, before and after surgery. The extraforaminal triangle approach (EFTA) to the affected intervertebral disc was used with a limited release of the inferior-medial portion of the intertransverse ligament. This release provided adequate exposure of the herniated disc and exiting nerve root. The operation time of each case was 140 minutes, intraoperative blood loss was 56 ml or less than five ml. The hospital stays were 9 days and 16 days, respectively. The improvement of JOA scores were 81% and 89%, respectively, at one month after surgery. In both cases, there was minimal blood loss, no medial facetectomy or disruption of the pars interarticularis. The EFTA required less dissection and manipulation of nerve structures than other techniques, and is, therefore, a safer and less invasive surgical management for the treatment of FLLDH.

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We reported a case of osteochondroma in a lumbar intraspinal lesion. Osteochondromas are most commonly located in the extremities. It is rare in the spinal region.
The patient was a 43-year-old man with right coxalgia and numbness of medial right thigh. There was no sign of disease in his right hip joint. MRI and CT imaging revealed a mass lesion occupying the spinal canal at the L2 to L3 levels, which had compressed the dural tube. Complete resection was performed as a microscopic surgical technique in 2004. At surgery, a firm and cartilaginous tumor originating from the facet joint was radically excised. After surgery the patient's neurological deficit had resolved. Histological examination revealed that the lesion was osteochondroma. Such lesions are rare in the lumbar spine and osteochondroma arising from the lumbar facet joint is unique.

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The authors assessed functional disability scale scoring for cervical spondylotic myelopathy and generic quality of life (QOL) in patients who have undergone laminoplasty. The study involved a prospective cohort of 18 surgically treated patients with cervical compressive myelopathy. The clinical state and generic QOL of the patients were assessed by the Japanese Orthopaedic Association score (JOA score) and the Medical Outcomes Study Short Form-36 version 1.2 (SF-36) before treatment and at 6 months after surgery. The JOA score showed that clinical state had improved significantly. The score on 5 of 8 scales and 1 component summary measure of the SF-36 (General Health (GH), Vitality (VT), Social Function (SF), Role Emotional (RE) score and Mental Component Summary Measure (MCS) of the SF-36) improved significantly, although, every score in all of the scales had increased after surgery. Significant correlation was observed between JOA score and the SF-36 scale for Bodily Pain (BP), Physical Functioning (PF), SF and the Physical Component Summary measure (PCS). These results suggest that SF-36 was responsive and able to assessed generic QOL which could not be assessed by JOA score in patients with cervical compressive myelopathy.

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This report is a case presentation of revision arthroplasty by KLS tumor hip prosthesis for comminuted fracture of the femur after infection of femoral head prosthetic replacement. An 81-year-old woman became infected after femoral head prosthetic replacement in 2004. At the removal of the hip prosthesis and insertion of a cement spacer, periprosthetic comminuted fracture of the femur occurred. Generally, such a case with bone loss is treated by plate and allograft, usually bone plate or impaction bone graft. Because it was difficult to get allograft in our region, we performed revision arthroplasty by KLS tumor hip prosthesis with bone cement impregnated with antibiotics. We used a polyethylene acetabular cup with bone cement instead of a semi-constrained socket, because we expected loosening of a semi-constrained socket would occur in the weak bone. The prosthesis dislocated twice postoperatively. After application of a hip orthosis, no dislocation occurred. At ten months after the revision arthroplasty, the patient was able to walk with a walker, and felt no pain. A radiograph showed no evidence of prosthesis loosening and there was no recurrence of infection. Revision arthroplasty by KLS, one of the treatments for periprosthetic femoral fracture with bone loss, was successful in this patient.

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The aim of this report is to describe a diagnostic protocol that can differentiate enthesopathy from referred pain of the hip or spinal origin.
Enthesopathy at the pelvic insertion of rectus femoris was causative in 4 patients: a man aged 92 years, and three women aged 67, 71 and 89 years. They had a past history of spinal disorders, and weight loss in a short period, and marked degenerative changes in spine or hip on diagnostic imaging.
Initially, we considered hip or spinal disorders. Subsequently, we developed a diagnostic provisional protocol that includes characteristics of pain, provocation tests, and knee extension against resistance, which can be corroborated by analgesic blocking with steroid.
The clinical usefulness in the diagnosis and treatment of the lesion is described. Such lesions may not be rarely encountered in an aging population, and it should be differentiated from referred pain of hip or spine.

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We prospectively evaluated the clinical outcome of 41 patients (mean age, 42.4 years) with early weight bearing and functional treatment after surgical repair of acute Achilles tendon rupture according to a prospective intra- and postoperative protocol. All patients underwent open repair using the Triple-Tsuge suture and the cross-stitch epitenon suture. Postoperatively, the patients wore a plantigrade short leg cast for a several days (mean duration, 6.2 days), followed a removal walker brace during by early weight bearing. Ankle range-of-motion exercise continued for several weeks (meanduration, 4.4 weeks) after surgery. The mean sick leave time (length of absence from work)was 4.8 weeks. All of the 26 patients who were involved in sports returned to preinjury sports level by 4.0 months. Forty of the tendons (97.5%) healed without rerupture, and one suffered a partial rerupture at 35 days. Although published results of conservative treatment are undoubtly satisfactory, there remains a considerable risk of rerupture. Consequently, functional postoperative protocol after surgery is preferred to conservative treatment with respect to hospitalization time, and return to work and sports. Admittedly, this requires cooperation of the patients.

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Precise femoral component setting is important for smooth patella tracking and good ligament balance in total knee arthroplasty. Most surgeons often use the posterior condylar line (PC line) and set the femoral component of the implant at 3° external rotation from the line. In contrast, some reports recommend using the transepicondylar axis (TEA) of the patient as the indicator. We report a new radiographical technique for assessment of TEA of the femur in total knee arthroplasty. The patient lies in the supine position, and flexes the knee as much as possible. The X-ray is applied to the knee at right angles to the skin. We measured the external rotation angle between the PC and clinical TEA lines, and the internal rotation angle between the clinical TEA and anterior condylar lines (AC line) in 34 patients (43 knees). The former angle was 5.6°±2.8° and the latter was -6.3°±2.9°. Both angles had almost the same values as the ones measured on CT scans and Kneeling View radiographs. Our new radiographical technique seems useful for assessment of the transepicondylar axis of the femur in total knee arthroplasty.

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The results of osteosynthesis for intracapusular fracture of the femoral neck with cannulated screws in 85 patients (21 men, 64 women) between January 2000 and May 2005 were reviewed retrospectively. Thirty-two patients had a non-displaced fracture and 53 patients had a displaced fracture. The mean age of the patients at the time of the operation was 70 years (range, 38 to 93 years). The patients were followed radiographically and clinically for mean period of 19.3 months (range, 6 to 60 months) excluding patients who underwent second operation. There were 11 cases of non-union, all of which were displaced fractures. The non-union rate was 21% in displaced fractures. Late segmental collapse (LSC) occurred in 4 patients, three of whom had a displaced fracture and one had a non-displaced fracture. The LSC rate was 4.7%.
Fifty-nine non-union cases (13 men, 46 women) were evaluated using magnetic resonance imaging (MRI). The mean age of the patients at the time of the operation was 67 years (range, 38 to 92 years). The mean period of follow-up was 21 months. (range, 6 to 60 months) About 3 months after operation 32 of 59 patients (54%) showed a band of low signal intensity on T1-weighted images indicating osteonecrosis in the femoral head. We classified it into 2 types: Type I (large type) lesion was over half of the weight bearing the region of the femoral head, and type II (small type) was less than half the region. There were 21 patients (36%) with type I signals and 11 patients with type II (19%). All of the cases of collapse of the femoral head occurred in 4 patients with type I signals.
Although we are relatively satisfied with the clinical outcomes, it is necessary to continue to follow the 21 patients with osteonecrosis of the femoral head.

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Infection is one of the most serious postsurgical complications of total knee arthroplasty (TKA). We reviewed the results of treatment for infected TKAs in our institution. We performed 1103 TKAs between 1989 and 2005. Nine of them had chronic infection after TKA. The mean duration of follow up was 4.5 years. The infection rate was 0.82%. The patients with chronic infection were 2 men and 7 women, 2 of whom had osteoarthritis and 7 had rheumatoid arthritis. The mean age of the 9 patients was 57.8 years. Three of the nine successfully retained their prosthesis after intravenous antibiotic treatment, debridement, and irrigation. However, 6 cases required arthrodesis. Major factors associated with treatment failures were long duration between occurrence of infection and start of treatment. Rheumatoid arthritis patients tended to have arthrodesis instead of reimplantation, because of comorbidities and soft tissue losses.

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We performed a randomized prospective study to assess the clinical effectiveness of postoperative continuous cryotherapy in patients who had received total knee arthroplasty (TKA). Fourteen patients who had received TKA were randomized into two groups; an icing group and a control group. “Icing group” patients had a cooling pad of ICING SYSTEM V2000^® (Japan Sigmax, Tokyo, Japan) applied to the knee postoperatively. Pain was measured according to the amount of analgesics and by a visual analogue pain scale (VAS). Blood loss was recorded as total drain output over 48 hours and as total hemoglobin decrease from preoperative to postoperative day 2. Additionally, range of motion (ROM), length of hospital stay after surgery, and operative complications were recorded. Blood loss tended to be smaller, and VAS was significantly lower in the “icing group” than in the “control group”. There were no significant differences between the groups for ROM or length of hospital stay, and there were no complications caused by icing. The continuous icing system appeared to be effective for the reduction of postoperative blood loss and pain, and had some advantages; ease of use, limited need for nursing intervention, and delivery of consistent cold temperatures.

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The purpose of this study was to evaluate the management of refractory frozen shoulder using arthroscopic capsular release. This report concerns the 19 cases of failed nonoperative treatment that subsequently were treated by arthroscopic capsular release from 1999 to 2005. There were 9 men and 10 women, the mean ages was 55.2 years (range 45-68 years). Ten patients had primary frozen shoulder, and 9 patients had secondary frozen shoulder (4 rotator cuff pathology, 5 diabetes mellitus). Follow-up averaged 8.6 months (range 5-23 months). Each case was evaluated according to the ROM of shoulder (flexion, external rotation and internal rotation) and the shoulder score of the Japanese Orthopaedic Association (JOA score).
The results of this study showed that the ROM of shoulder improved from a preoperative mean of 90 degrees flexion, 16 degrees external rotation to a postoperative mean of 165 degrees flexion, 43 degrees external rotation. The JOA score improved from a preoperative mean of 50.4 points to a postoperative mean of 84.7 points (p<0.01). None of the patients had any complication or recurrence of shoulder stiffness.
We found that arthroscopic capusular release was a safe and effective tool in the management in these cases of refractory frozen shoulder.

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We devised a new method for the treatment of burned fingers using negativepressure dressing (NPD) together with early therapeutic finger exercise, and achieved good results.
A 38-year-old man was injured when his right fingers were caught in a heat press. The index and small fingers received second degree burns, and the middle and ring fingers received third degree burns.
After adequate debridement, using clean techniques, the wounds were covered with a hydrophilic polyurethane sponge. A drainage tube was placed on top of the sponge, and the whole region was covered with a film dressing. Then the hand was placed in a commercially available, gas sterilized, sealable bag. The mouth of the sealed bag was fixed to the forearm with film dressing to ensure a tight seal. The tube was connected to an aspirator equipped in the ward, and a negative pressure of -15 to -17 kPa was maintained during rest periods. During therapeutic exercise of the fingers, aspiration was stopped and the negative pressure was reduced to allow space in the sealed bag for the fingers to move freely.
Eight weeks after the start of NPD, adequate granulation and wound regression were achieved, and NPD was terminated. Two weeks after termination of NPD, the wound was almost epithelialized. At the last follow-up 17 weeks after injury, TAM was 97.4% in the middle finger and 94.7% in the ring finger.
The method we used allows therapeutic finger exercise at the initiation of NPD, which probably kept joint contracture and scar contracture to a minimum.

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Hemihypertrophy refers to the unilateral overgrowth of the limbs. The shorter limb is considered to be unaffected an important treatment. Three patients with idiopathic hemihypertrophy of lower extremity were treated by lengthening of the unaffected leg with an Ilizarov external fixator. Corticotomy and lengthening were performed at the proximal tibia. The ages at corticotomy were 6, 8, and 20 years, respectively. The amounts of lengthening were 4cm, 4.5cm and 2cm respectively. Healing indices were 33 days/cm, 31 days/cm, and 65 days/cm respectively. Complications included pin tract infection, breakage of a half pin, and fracture of lengthening callus, all of which were treated successfully. Both of the skeletally immature patients had slight valgus deformity of the treated leg at follow-up examination a few years after lengthening. However, all three patients expressed satisfaction with the results of lengthening.

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We report here a rare case of enormous gouty tophus with skin necrosis. In 2005, a 43 year-old Japanese man presented with 2 large, firm subcutaneous masses at his left ankle joint. He had complained of pain in his great toe for 10 years, which had been diagnosed as gout, but not treated systemically. He reported that the masses at his left ankle developed 1.5 years before surgery. Despite the enormous lump with skin necrosis in the lateral aspect of his left ankle joint, he could walk painlessly and smoothly. The clinical findings revealed masses in the lateral, medial and anterior aspects of the left ankle joint. The size of the lateral mass was 10×10×2 cm and the medial mass was 5×3×1.5cm. The area of skin necrosis on the lateral mass was 5×4 cm. When the masses were surgically excised, all of them were found to be connected under the skin. Histological appearances were consistent with gouty tophi. The lateral wound was not closed completely, and wet dressing treatment was continued. At 8 weeks after surgery, the wound had healed.

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Locking Compression Plate (LCP) provides stable fixation with fewer screws than a conventional plate and screw system. There is no need to contour the fixator to the bone precisely as it does not require large areas of contact with the bone. The plate also preserves the periosteal blood supply, minimizes soft tissue damage, and is, therefore, a more biological fixation. The purpose of this retrospective study was to evaluate LCP for clavicle shaft fractures in two successive case series of consecutive. Conventional plate was applied in 20 cases from September 2001 to June 2003, LCP was applied in 18 cases from September 2003 to October 2005. There were 17 men and 3 women in the conventional plate group, and 12 men and 6 women in the LCP group. The average age of the conventional plate group at the time of surgery was 34.5 years (range 14 to 76 years), 41.8 years (range 16 to 74 years) of LCP group. According to the AO fracture classification, there were 11 simple fractures, 2 segmental fractures, and 7 comminuted fractures in the conventional plate group, 7 simple fractures, 10 segmental fractures, and 1 comminuted fracture in the LCP group. There were no significant differences between the groups in surgical time, time to bone union, or shoulder ROM. Because there was only 1 comminuted fracture, we can only speculate that LCP would be beneficial for comminuted or displaced fractures in terms of preservation of blood supply in soft tissues, and we would expect it to shorten surgical time for severely comminuted fractures.

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Eighteen patients with proximal humeral fractures were treated by internal fixation using the Polarus humeral nail since October, 2000 to March, 2005. Among the patients fourteen were available for follow-up (3 men and 11 women, aged from 68 to 91 years, mean 80.3 years). There were 2 2-part surgical neck fractures with impaction, 11 2-part surgical neck fractures without impaction, and 1 3-part surgical neck and greater tuberosity fracture, according to the Neer classification.
The mean range of motion was 113 degrees in flexion, 103 degrees in abduction, 28 degrees in external rotation at side, and typically L1 in internal rotation at the side. Bony union was confirmed radiographically in all but one patient, who underwent hemiarthroplasty because of varus deformity at 2 weeks after the first operation. The mean postoperative JOA score was 83.2 points (range 66 to 98 points).
The Polarus humeral nail was a useful option for the proximal 2- or 3-part humeral fractures in these aged patients with osteoporosis.

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The anterolateral acromial approach leads to the proximal humerus, between the deltoid muscle fibers.
We report usefulness of this approach to fix proximal humeral fractures with Locking Humerus Spoon Plate [SYNTHES]. We treated 10 shoulders (2 men 8 women) from August 2004 to July 2005. The mean age was 66 years(range 47-79 years). All patients underwent operation by this approach. Active·passive ROM exercise started the day after operation. The patients obtained good ROM and scored a mean 88 points on the JOA shoulder score. All of the patients had bone union, but one developed humeral head necrosis after bone union.
The approach need not be detached from the muscle origin on the clavicle, which allows early active ROM exercise without immobilization. The patient can get good shoulder ROM. Wide surgical exposure may damage the tenuous remaining blood supply, but it does not damage the anterior potion of the shoulder, especially the anterior circumflex humeral artery. So it should decrease complications such as humeral head necrosis.

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