We have reported a rare case of lumbar burst fracture with delayed neurologic deficits in a 67-year-old female, who had received steroid therapy for 13 years to treat mixed connective tissue disease. She had gait disturbance with muscle weakness and sensory loss of the lower extremity for five years after a minor trauma. She complained of low back pain, lower extremity pain, numbness and mild dysuria. The Japanese Orthopaedic Association back score was zero. A lumbar X-ray showed a burst fracture of L4 vertebral body and osteoporosis. A myelogram showed spinal canal stenosis at the L3-L5 level, a lateral flexion and extension X-ray disclosed instability.
Posterior decompression and posterolateral fusion from L3 to L5 were performed. Six months after surgery, a bony union was achieved and stability of the L3-5 lumbar spine was obtained. Gait disturbance and mild dysuria improved: The JOA score was 18 points. The pathogenesis of neurologic deficits was compression of the neural tissues due to spinal canal stenosis, following a lumbar burst fracture and instability of the lumbar spine.

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Operative treatments for pathological fractures by metastasis of bone tumors, multiple myeloma and disorder of endocrine system often have been avoided because of the prognosis of patients, invasion of the operation and weakness of the bones. We treated such cases by internal fixation with interlocking nail for the purpose of improving the activity of daily living (ADL), decreasing the pain and preventing from bedsores.
In all cases, amount of bleeding during the operation was little, patients got pain relief and left beds in early postoperative days. They did not need external fixation after the operation. In this method, rigid internal fixation by interlocking nail can be obtained even in the cases with weak bones due to minimal operative invasion. The procedure can be good choice for the treatment of pathological fractures in long bones and its prophylaxes.

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Due to risks associated with the transfusion of homologous blood, interest has grown in autotransfusion during and after surgical operations. This study examined the efficacy and safety of postoperative autotransfusion after total knee arthroplasty (TKA).
A study group of 18 joints, 16 TKA patients who received autologous blood reinfusion was compared with a control group of 30 joints, 27 TKA patients who did not receive autologous blood reinfusion. All cases of study group were retransfused with washed blood cells 6 hours postoperatively, using the Collect First system (Haemonetics Corporation) and CellSaver Haemolite 2 (Haemonetics Corporation). Both groups were operated on in the same manner with the NexGen knee system (Zimmer).
Results showed that the number of patients who needed homologous blood transfusions was reduced from 33.3% in the control group to 5.3% in the study group, the exception being a revision TKA case. There were no complications with autologous blood reinfusion.
We conclude that postoperative retransfusion in TKA procedures can be used safely in clinical practice to decrease the need for homologous transfusion.

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We evaluated the relationship between clinical symptoms and the radiographycal findings in patients with osteoarthritis of the knee.
There were significant correlations between the score of pain on walking and either the radiographical width of the medial femoro-tibial joint space or the femorotibial angle. This score was significantly reduced in patients who showed marked differences in femorotibial angle between the standing and supine position. These findings suggested that the joint instability is one of the factors of knee pain. There was no relationship between the incidence of osteophyte formation and the score of pain on walking.

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One hundred and twenty knees in 90 patients, 1 to 60 months after arthroscopic anterior crucate ligament (ACL) reconstruction with double-looped autogenous semitendinosus and gracilis tendons were studied by magnetic resonance (MR) imaging. The knees with poor stability were excluded from this study. Examinations were performed at 0.2T with spin echo proton density sagittal and oblique axial images.
The percentage of grafts with high signal intensity on sagittal images increased up to 12 months after surgery, and then decreased over the subsequent 12 months. The mean signal intensity of the grafts in the 7 to 12 and 13 to 18 month postoperative groups was significantly higher than in the 1 to 3 month group. The mean signal intensity of the grafts in the 19 month and greater group was significantly lower than in the 7 to 12 month postoperative group.
On oblique axial images, high signal intensity areas covered the grafts 1 to 3 months after surgery. The high signal intensity subsequently extended into the intertendinous bundles. The entire graft gradually became a low signal intensity bundle again after 12 months.
MR high signal intensities observed in functional ACL grafts may depict the normal remodeling process of grafts.

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We reviewed the results of posterior and combined anteroposterior spinal fusion with instrumentation for seven juvenile idiopathic scoliosis patients. The operative procedures were Harrington in 3 cases, CDI in 1 case and combined anteroposterior fusion in 3 cases.
The postoperative follow-up on them ranged from 5 years and 4 months to 16 years and 2 months with an average of 10 years and 3 months. The average Cobb angle was 72.1 degrees before the operation and 39.0 degrees after the operation. Overall, therefore, scoliotic curves were corrected by 33.1 degrees. The rate of correction was 51.5%. This study demonstrates that the long-term effects of Harrington instrumentation on the Cobb angle is limited. In the combined anteroposterior fusion cases, there is a great correction of the instrumented curve (postoperative, 39.0 degrees), but a loss of correction of 9 degrees is generally observed.

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We report a case diagnosed as tethered cord syndrome treated by surgery. The case involved a 13 year old boy. His complaints were left leg pain and gait disturbance. He had no anomalies and no urinary incontinence, but showed muscle weakness in his left leg and cavus deformities on his feet. His MRI films revealed the tethered cord with a lipomatous tumor at the level of S2.
In surgery, we could not untethere his spinal cord by cutting of the filum terminale alone. We used the additional technique of cutting the left S4, S5 nerve roots using microscopic technique so we could untethere his spinal cord and release the tumor. Histological findings of the lipomatous tumor was lipoma including striated muscles partially.
Seven months later, his complaints disappeared and he now leads a normal school and sports life.
We feel this lesion requires microscopic surgery for the release of tumor.

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We evaluated the results of six patients who underwent distal fibular fixation surgery. An antiglide plate was used to correct each of the six ankle fractures. The follow up period ranged from six to twenty three months, with a mean of fifteen months. Results were evaluated according to Burwell's criteria.
According to Burwell's radiographic criteria all cases showed an anatomical reduction. All cases were good in the objective criteria and five of the six cases were good in the subjective criteria.
We conclueded that distal fibular fixation with an antiglide plate is a good surgical procedure for a fracture of the ankle.

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Since 1979, a modified Schlein system (semi-constrained type) was used for elbow replacement in RA patients in our department. Since 1993, we have used a Pritchard Mark II system (semi-constrained type) with cement fixation. The clinical and radiological results of total elbow replacement in which such a prosthesis was implanted in RA patients were reviewed retrospectively.
There were 1 man and 5 women with a mean age of 61.3 years (range 45-73 years). Mean elbow function score according to the Japanese Orthopaedic Association rating improved from 46.7 to 77.8. Mean flexion improved from 105°to 126.7°, while mean extension improved from -51.7°to -23.3°.
Radiolucent line were observed around the humeral component in one case, but dislocation, sinking and loosening were not observed in radiographs.
We conclude that the Pritchard Mark II system is useful for total elbow replacement in patients with RA.

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We experienced two cases of congenital dislocation of the hip (CDH), on whom rotational acetabular osteotomy and varus osteotomy were performed.
Case 1 is a 12-year-old girl in whom congenital of dislocation of the right hip was pointed out at birth, for which Riemenbügel procedure and overhead traction were performed. She began to complain of right coxalgia and limp from the age of 11 years and consulted our clinic in May 1996. X-ray revealed subluxation of right hip and operation was performed on July 26 of the same year. At present one year postoperatively, she can walk without crutches and has no coxalgia.
Case 2 is a 12-year-old girl, in whom dislocation of the left hip was pointed out twice during infancy, but she did not undergo treatment. She developed left coxalgia from the age of 10 years and visited our clinic for examination in November 1996. X-ray revealed complete luxation of left hip and following direct traction for 2 weeks, operation was performed on February 17, 1997. At present 5 months postoperatively, she can walk with crutches but without any coxalgia.
With the advancement made in both diagnosis and treatment of CDH, there are only very few cases of residual CDH in children of school age, but treatment of these cases is difficult. Though some investigators have reported that the natural course of CDH in older children without operation is comparatively satisfactory, we elect surgical treatment in cases with severe pain and possible development of coxarthrosis in future. In our two cases the femoral head has been reduced to almost the normal position, but careful continued follow-up observation is necessary.

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We followed the natural course of osteoarthritis of the hip radiographically in 17 patients (20 hips) for an average term of 11 years.
And we measured the Sharp angle, CE angle, slope of acetabular roof, acetabular head index, head lateralization index, and the flattening of femoral head at first consultation.
Roof osteophytes were found on the hips of six patients at the last consultation, in which the head lateralization index tended to be higher. It was concluded that predicting a course of roof osteophyte formation was difficult.

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We investigated the preoperative neurological findings in 16 patients with compression cervical myelopathy caused by disc herniation, which did not accompany canal stenosis. Anterior fusion at one intervertebral level was performed on all the patients. The mean age of these patients was 56 years (ranging from 34 to 76).
The purpose of this investigation is to evaluate the relationship between the disc level causing compression cervical myelopathy and segmental neurological findings.
We concluded that 1) segmental neurological findings allowed to determine the location of compressive factors, 2) the level which was most responsible for biceps tendon reflex was C6, and 3) routine examinations including deltoid and scapulohumeral reflex tests are necessary for determining the precise disc level.

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Reconstructive operations using silicone block instead of autograft were performed in our department for bone defects in hands and feet of children. Study was made on the postoperative results and indications of procedure.
From 1988 to 1997 this procedure was performed on 14 patients composed of 5 males and 9 females whose ages at time of the operations ranged from 0 to 13 years with a mean of 5.1 years. The insertion sites of silicone block were the thumb in 4 patients, the finger in 2 patients, the palm in 2 patients, the toe in 3 patients and the foot in 3 patients. The causative diseases were synbrachydactyly in 4 patients, cleft foot in 3 patients, hypoplastic thumb in 1 patient, hypoplastic ulnar ray in 1 patient, amputated thumb in 3 patients, osteomyelitis in 1 patient, and bone absorption caused by blood flow disorder in 1 patient. Follow-up periods ranged from 2 years and 2 months to 14 years and 4 months with a mean of 3 years and 7 months.
Use of silicone block brought about improvement in activity of daily life and in the level of cosmetic satisfaction in all 14 patients. Joint transfer, wrap-around flap, web space plasty, and bone graft were performed as final reconstructive operations following removal of silicone block in 4 of the 14 patients. However, block removal had to be made because of infection and skin necrosis in 4 patients. The remaining 6 patients now await secondary reconstructive operations, but they do not complain of pain or discomfort. It is considered that in children recostruction of the hand and foot with temporary use of silicone block is a useful palliative operation until the final reconstructive operation is performed.

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Tibial condyle fracture is an intra-articular fracture. In treating central depression fracture or sprit depression fracture, it is necessary to raise the cartilage in the depressed part and to fill the resulting bone defect.
In the present study, we used hydroxyapatite granules (bone ceram) to fill bone defects in treating tibial condyle fractures, and obtained satisfactory results.
The subjects were nine patients with reratively good ADL treated in our hospital between 1994 and 1997. Their ages at the time of injury varied from 68 to 93 years, with a mean age of 74.4 years, and they included three men and six women.
For surgery, AO L-shaped buttress plates were used in four patients and MAY anatomical bone plates were used in five as materials for internal fixation of the fractures, and a mean of 7g of hydroxyapatite was used per patient to fill bone defects.
During follow-up, articular surface depression improved from a mean of 12.9 to 1.9mm on radiographic images.
Further, both the range of motion of the knee joint and ADL returned nearly to the levels present before fracture for all 9 patients.
Hydroxyapatite exhibits good bioaffinity and strength and is considered useful for treating fractures in aged patients, in whom sampling of autologous bone is difficult.

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We describe 44 patients who underwent reconstruction of the anterior cruciate ligament with a Leeds-Keio prosthesis supplemented by an extra-articular stabilization. They were assessed subjectively at 15 to 98 months postoperatively, using the Lysholm score and the knee rating score (Noyes et al.) by questionnaire or telephone interview. The results showed that 23 could be classified as excellent, 14 good, 4 fair, and 3 poor. There was not significant fall in the postoperative score between one to two years and three to four years, and more than five years after the replacement. In our opinion, the results of reconstruction of the anterior cruciate ligament with a Leeds-Keio prosthesis are almost satisfactory.

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We evaluated the flexion angle and flexor strength of the knee after anterior cruciate ligament (ACL) reconstructon.
Patients included 28 males and 23 females. The average time from surgery to follow up was 1 year and 4 months. We classified the patients into three groups according to the substitute used for ACL reconstruction. In 14 cases the allogenic fascia lata was used (allo group), in 19 cases the semitendinosus tendon was solely used (ST group), in 18 cases both the semitendinosus and gracilis tendons were used (STG group). The average isokinetic hamstring torque (180deg/sec) of the reconstructed knee compared to body weight was 10.5% in the allo group, it was 9.9% in the ST group, it was 9.0% in the STG group. These results confirmed that there were no statistically significant differences in the three group. On the other hand, flexion lag was 2.6° in the allo group, 7.2° in the ST group and 11.1° in the STG group. These results suggest that hamstring strength is weaker in the deep flexion position due to the fact that more hamstring tendons were harvested during ACL reconstruction.

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Osteomyelitis of the patella is uncommon, because of the anatomy and the circulation of the patella. We recently experienced a case of osteomyelitis of the patella in a nine-year-old male.
He hit his left knee against a desk and suffered pain in his left knee. There was extreme tenderness and swelling on his left knee and his temperature rose to 37.9°C. Laboratory studies showed a white blood cell count of 12300/mm³, and CRP of 2.93mg/dl. Roentgenograms showed osteolysis of the lateral part of the patella. T1-weighted MR images showed a low signal intensity and T2-weighted MR images showed a high signal intensity in the greater part of the patella. Antibiotics were not so effective, and on the twenty-fifth day from onset, we performed a curettage of the lesion. Eight months after the surgery there were no signs of inflammation, and he reported no complaints.
We emphasize that in cases of osoetmyelitis of the patella surgical therapy should be performed at an early stage, if antibiotics do not prove effective.

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We experienced a rare case of osteomyelitis of the ischium in a patient with diabetic nephropathy who required hemodialysis.
Bone scintigraphy and MRI were helpful to the diagnosis. The results of these tests and a bone biopsy led to the diagnosis of osteomyelitis of the ischium. Good results were obtained by administration of antibiotics for eight weeks.

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We report our expeirence of a rare case of MRSA pyogenic arthritis of the hip in a healthy adult man without underlying disease.
The patient was a 42-year-old man. In the evening of August 12, 1996, left coxalgia developed without an identifiable cause. The pain increased gradually, leading to gait disturbance, and the patient visited our department on August 16. At the time of this visit, leukocytosis and a high CRP level were found, along with a fever of 37 degrees. Bone scintigraphy revealed uptake in the left hip joint, while MRI studies revealed pyogenic arthritis of the hip. Culture of joint puncture specimen yielded MRSA. Systemic administration of antibiotics to which the MRSA was sensitive, curettage and debridement with opening of the hip joint and closed continuous irrigation using saline with antibiotics eliminated the pyogenic arthritis of the hip.
ROM exercise using CPM was employed to prevent articular contracture, with satisfactory results.

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We report a cace diagnosed as necrotizing fasciitis involving life-saving treatment by surgical debridement and intensive anesthesiological care.
A 34 year old woman suffered from severe pain in her left thigh. She went into shock and became unconscious the third day after onset of the pain. Large blare containing blood and skin necrosis were observed down the left side of her body from abdomen to ankle. Emergency debridement of the necrotic tissue was performed under intensive monitaring of her circulatory dynamics. She gained consciousness four days after the debridement. Hemodialysis was needed for a month period to prevent renal failure. Later, new skin was grafted to the area of debridement. From a clinical standpoint, clinicians must be aware of the presence of this lesion for succesful treatment.

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There are various remedies for finger tip injury including replantation by microsurgery, as well as various flaps and a conservative treatment using aluminium foil. We attempted to treat such iujuries in a number of patients using artificial dermis and obtained good results. This paper reports our experience.
The subjects were 10 patients (11 fingers). According to the classfication of Allen, one finger was were type II, eight fingers were type III and two fingers were type IV.
The artificial dermis used was Terudermis made by Terumo Co. Under local anesthetic, the cut cross-section was covered with artificial dermis and the silicon film was removed at around four weeks after operation. Then we waited for the wound to heal. The wound was disinfected twice a week on an outpatient basis.
In all cases, the injury at the cut cross-secton was healed. The average healing period was 49.6 days. The recovery of sensation in the finger tip was good and the restriction of movement of the DIP joint was slight, so the results were satisfactory.

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We present two cases of identical twins with cleidocranial dysplasia. The first sister visited us at 11 months of age owing to an abnormal protrusion of the central part of bilateral clavicle. The second sister also complained of deformity of the right clavicle. In both cases, the diagnoses were confirmed by the presence of two separate fragments of the clavicle, a large fontanelle and delayed ossification of the pubis and the ischium.
In May, 1997, it was proven that this hereditary disorder results from heterozygous loss of the CBFA1 gene which is essential for osteoblast differentiation and bone formation during the development of the skeleton.
We consider that the surgical treatment of the clavicular defect to restore bone continuity may be difficult because both fragments of the clavicle were slender and dysplastic. Moreover, as the clavicular defect causes little, if any, pain and functional disability, it seems preferable not to attempt any surgical treatment.

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We reviewed 18 elbows of 15 patients with cubical tunnel syndrome treated conservatively using a flexible night splint. There were eight women and seven men with an average age of 52.4 years (range 15-74). They were divided into two groups; responders (12 elbows) and non-responders (six elbows). The average age, duration of symptoms, Akahori's staging, motor nerve conduction velocity, sensory nerve conduction velocity, and amplitude of compound muscle action potentials in responders were 57.2 years, 23.3 months, stage 2.8, 45.2m/s, 42.2m/s, and 5.6mV, respectively, while those in non-responders were 58.3 years, 23.5 months, stage 1.7, 52.6m/s, 54.4m/s, and 5.3mV, respectively. There was no significant difference between the two groups.
Non-responders included three elbows showing less compliance and two with double crush syndrome. The remainder was in stage V according to Akahori's staging. In responders, nine elbows were stage III, and three remainding elbows were in stage I, II, and IV, respectively.
In conclusion, we could not clearly determine indications for conservative treatment of cubital tunnel syndrome with flexible night splint in our series. However, we considered that this splint should be applied to the patients not only in stage I and II, but also those in stage III.

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We report a case of posterior dislocation of the shoulder due to tonic convulsion. The patient was a 46-year-old man who had aleady been admitted to our hospital for assessment of anemia. He had a sudden convulsion, and afterwards he complained of severe pain in his left shoulder. We couldn't examine him in detail because of his severe pain and we obtained little information from the plain X-ray film except for the presence of a humeral fracture, so it was difficult to assess the injury correctly. Two days later, CT scanning showed that this injury was a posterior fracture dislocation of the shoulder.
The correct diagnosis was delayed by misreading the anteroposterior X-ray film and the presence of another fracture. If patients have severe rest pain even after stabilization of an injured extremity, we must think of this type of injury. CT scanning is a useful adjunct for making a diagnosis of posterior dislocation of the glenohumeral joint.

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We observed 2 patients with an inflammatory disease that occurred in the femoral neck. An evident inflammatory sign was not observed. Osteomyelitis or bone tumors such as osteoid osteoma was suspected by the radiological findings. These patients underwent curettage and resection of the lesion. Histological findings showed a diagnosis of chronic osteomyelitis in both patients.

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