Eight patients (3 males, 5 females) with paralysis due to osteoporotic burst fractures of thoracolumbar spine underwent decompression and reconstruction with instrumentation. The average age at operation was 74.4 years. Eight patients had nine burst fractures, seven had a fracture at single level and one patient had two contiguous vertebral fractures. The most frequent level of fractured vertebra was 12th thoracic vertebra. Operative procedures were anterior/posterior in four cases, posterior in three and anterior decompression and fusion in one, using instrument. The average duration of follow-up was 47 months. Seven patients could not walk before the operation. Six of these improved by more than one grade on Frankel and Eismont classification and were able to walk after the operation. Kyphotic deformity of all patients was corrected at the operation. In six patients, loss of correction of kyphotic deformity occured during the follow-up. However, in two patients reduction of kyphotic deformity was maintained during the follow-up period. Three of the four patients in whom pedicle screw was used had loosening of the screw. Posterior instrumentation had many problems in our series. In case of short spinal fusion with posterior instrumentation, significant loss of reduction occured. One patient with anterior decompression and fusion with use of the Kaneda device and artificial vertebral spacer maintained reduction of kyphotic deformity and showed good results.

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It is difficult to differentiate recurrent lumbar disc herniation (LDH) from scar tissue by plain MRI and myelogram.
We evaluated the use of enhanced MRI in the diagnosis of recurrent LDH.
20 patients with recurrent symptoms after surgery for LDH were studied. We described and classified the MRI findings, then compared the diagnostic results following enhanced MRI and findings in the reoperation.
The increased signals were found around discs in recurrent LDH. The MRI suggested suspected recurrent LDH in 4 cases, recurrent LDH in 15 cases, and 17 cases were found in surgery. There were abnormal enhanced zones between anuli fibrosi and end-plates in 3 (3/5) early recurrent LDH patients.
Our observations indicate enhanced MRI is informative for diagnosing recurrent LDH.

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Six elbows in 7 patients with rheumatoid arthritis that received total elbow arthroplasty (TEA) with insertion of non-constrained prosthesis (Kudo elbow type 4 or 5) were examined. The patients were all female and the average age at operation was 58.1 years (range 49-63 years). The clinical follow-up was conducted for a mean of 3 years and 7 months (range 6 months-6 years and 2 months). In pre-operative Steinbrocker X-ray classification, there were 6 Stage III elbows and 1 Stage IV elbow. In each case, local findings (pain and swelling), radiographic study and range of motion were investigated, as well as ADL valuation.
In all cases, pain and swelling disappeared or diminished. Ranges of elbow flexion and forearm supination and pronation improved. In ADL, actions which require elbow flexion, such as washing the face, taking a meal and dressing improved. However, complications included 2 cases of ulnar neuritises and 1 case of prosthetic loosening. The findings suggest that TEA is effective for patients who demonstrate ADL disabilities due to pain and Imitation of ROM.

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We discuss the treatment of isolated medial collateral ligament (MCL) injury of the knee joint and our results.
The subjects were 45 of 77 athletes who had complained of pain in the inner part of the knee caused by variable sports activity and a feeling of instability during the past 12 years (1986-1997).
The diagnosis of isolated MCL injury was confirmed by valgus stress roentgenograms under anesthesia and by arthroscopy.
The severity of injury varied, but injury lesions were all above the joint space of the knee in this series.
We decided on conservative treatment so that these athletes would be able to return to athletic competitions completely within 12 weeks in all cases.
Regarding their return to competitions, 37 cases (82%) have recovered to the level that there is no marked difference in either muscle force or range of motion (ROM) between the injured and uninjured sides. Most of the remaining eight cases (18%) were women. Although they did not return to competitions because it was off season or for other reasons, their ability to move has recovered to a satisfactory athletic level.
Whether conservative or operative treatment is chosen for athletes, the results of the treatment should be satisfactory. We concluded that at least the results of our conservative treatment for isolated MCL injury, which involves breakage of both layers (superficial and deep) above the joint space of the knee, were good.

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The opinion vary as to whether conservative treatment or operative treatment should be taken for medial collateral ligament (MCL) injuries of the knee. In the present study we discussed the absolute indication for operation for MCL of the knee. The subjects were 32 cases treated in our hospital over the past 9 years. All cases were operated on according to the operative indication on our hospital's assumption and obtained successful results regardless of the injured lesion.
In the case of athletes' MCL injurys of the knee, only valgus stress affected the knee 2-dimensionally in a few cases, while not only valgus stress but also external rotation with the knee-semiflexion 3-demensionally in many cases. Therefore it is problematic to decide which therapy to use easily based on the severity of valgus stress only. In order to have athletes return, we suppose it is necessary to diagnose generally and correctly using arthroscope or other means. The problem is whether or not we can identify correctly the injured lesion preoperatively.

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Pustulosis palmaris et plantaris (P.P.P.) is a skin disease of unknown etiology. It is commonly associated with sternocostoclavicular hyperostosis, but rarely with gonitis. This is a case report of P.P.P. associated with gonitis.
A 66-year-old female noticed a skin eruption on the palms and soles and developed knee pain which begun about 1983. She has received no treatment for her knee pain. She came to our hospital in 1998.
Anterior chest wall symptoms were not observed. The range of motion in the left knee was restricted.
Radiographic findings indicated osteo-sclerosis and narrowing of the medial joint space in the left knee. A bone scintigram indicated high accumulation of isotope in the sternocostoclavicular region, lumbar spine, sacroiliac joint, left knee, and left ankle.
HLA B27 was never found, and RA factor was negative.
As the pain was not relieved after tonsillectomy, we performed total knee arthroplasty. Histological examination of synovium revealed non-specific chronic inflammation. Bacteriological examination was negative.
After the operation she has not had a recurrence of the symptoms.

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An interbody titanium mesh cage filled by cancellous bone chips in combination with a pedicle screw system was applied for patients with unstable lumbar spine complicated with neurological deficit. Surgical procedures consist of partial laminectomy including medial facetectomy, posterolateral fusion with a DYNALOK fixation system and posterior interbody fusion using a Sofamar Danek interbody fusion cage.
Eighteen cases have been operated on by this procedure from 1995 to 1998. They were 8 males and 10 females. The average age at operation was 64.3 years. Fusion disc levels were as follows: L2/3 in 3 cases, L3/4 in 1 case, L4/5 in 12 cases, L3/4 and L4/5 in 2 cases. The average follow-up period was 24.5 months taking from 6 to 34 months.
The average recovery rate was 80.3% according to the assessment criteria of the Japan Orthopaedic Association. All cases returned to social life without low back pain and motor disturbance. Operative complications such as neurological impairment and instrumentation failure were not observed. The average operating time was 3 hours 45 minutes and the operative bleeding volume was 1000ml on average.
In conclusion, an interbody titanium mesh cage combined with a pedicle screw system is one useful fusion method for patients with unstable lumbar spinal conditions.

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This is retrospective study on the lumbar spinal canal stenosis (LSS) which is concerned with the relationship between calcium deposits in the ligamentum flavum and cauda equina syndrome. The distance of intermittent claudication and residual urine volume were used as assessment of the function of cauda equina. Cauda equina syndrome was significantly aggravated in cases of LSS where there was calcium deposits in the ligamentum flavum, as opposed to cases of LSS where there were no such deposits.

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We reported four cases of transient osteoporosis of the hip and reviewed the literature. Four patients of transient osteoporosis of the hip are described whose clinical findings are pain in the hips, slight limitations of motion with pain, and negative laboratory findings with complete spontaneous recovery. Plane radiographs revealed diffuse osteoporosis of entire femoral heads and necks. Radionuclide bone-scanning revealed diffuse, homogeneous and increased uptake involving entire femoral heads and necks and extending to the intertrochanteric regions. MR imaging showed low signal intensity of bone marrow on T1-weighted images and high signal intensity relative to the intensity of normal bone marrow on T2-weighted images extending to the metaphyseal regions. The low bone mineral density (BMD) of the proximal femurs was observed by dual energy X-ray absorptiometry (DXA). Early differential diagnosis from avascular necrosis of the hip is necessary by using the above mentioned methods.

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A comparative biomechanical study was performed to investigate the relationship between the bone mineral density of the femoral neck and fixation failure using a compression hip screw and a Gamma nail for the Evans type 1 intertrochanteric fracture of the femur in cadavers. There was a positive correlation between the strength of fixation and bone mineral density in both the compression hip screw and Gamma nail groups (R=0.684, p<0.05). No statistical differences in the strength of fixation were observed between two groups (p<0.05). The strength of fixation to failure was significantly less for specimens with a bone mineral density of <0.6g/cm² compared to those with a bone mineral density of ≥0.6g/cm². A bone mineral density of <0.6g/cm² may be the critical value for fixation failure even if with a compression hip screw or a Gamma nail. However, further biomechanical and clinical studies are required before this threshold value can be used clinically.

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We surgically treated 13 Supracondylar and intercondylar fractures of the femur between 1995-1997. Patients included 1 male and 12 females between 67-90 years old. For surgery, we used AO Condylar Plate, Dynamic Condylar Plate, Inter-medullary Supracondylar Plate, and an N-Plate. According to the evaluation of Neer, the outcome was excellent in 4 cases, satisfactory in 5 cases, unsatisfactory in 3 cases, and a failure in 1 case. The outcome was affected by complications and fracture type (we use AO classification), not the implant of fixation in our study.
For aged patients, especially for those who have osteoporosis, any implant cannot realize enough rigid internal fixation. We mostly use N-Plate because we can use this implant regardless of fracture type, but we try to use lesser invasive device to reduce the patient's stress.

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We had performed closed reduction and osteosynthesis with cannulated cancellous screws for almost all femoral neck fractures for 2 years. The results in patients over the age of 60 years, who were followed for at least 6 months after the operation, are presented here and the indication for osteosynthesis is proposed.
Twenty-six fractures of 24 patients were available for study. Excellent results were obtained in 20 of all fractures (77%); in all 9 non-displaced fractures (100 %), in 5 of the 9 Garden-stage-III fractures (56%) and in 6 of the 8 Garden-stage-IV fractures (75%). All 4 displaced fractures which were operated on 2 or more days after injury had poor results. Four of the 7 displaced fractures without medial spike in the femoral head fragment had poor results. Three of the 4 displaced fractures classified to the posteriorly displaced type had poor results. All 3 displaced fractures which were fixed in underreduced position had poor results.
In non-displaced fractures the treatment of choice is osteosynthesis. The displaced fractures, which occurred on the day or the day before, should also be treated with closed reduction and internal fixation, if they have medial spike in the femoral head fragment or are anteriorly displaced. The rest of the displaced fractures should be considered candidates for primary prosthetic replacement.

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We evaluated acetabular reconstruction with an impacted bone graft and an F-S cup supporter in cemented revision THR. 19 patients (21 hips) were reviewed clinically and radiographically at an average of 3.5 years (range, 1 to 9.5). According to the classification of acetabular deficiencies proposed by the A. A. O. S., 5 hips were Type II (cavitary), and 16 hips were Type III (segmented and cavitary). Acetabular defieciency was filled with a 5-10mm morcelized autograft and allograft chips, and impacted with trial head prosthesis. Then, an F-S cup supporter and a socket were placed with cement following a two-stage procedure. There was no definite radiographic evidence of the acetabular loosening according to the system of Murloys study. The average JOA hip score was 45.8 points preoperatively and 72.8 points at final review. Despite the shourt-term follow-up, we consider that the results of acetabular reconstruction with impacted bone graft and F-S cup supporter were satisfactory.

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Thirty-eight consecutive patients with cervical cord injury were reviewed. Data were collected regarding Frankel's grading, age, treatment, type of injury and JOA score.
There were 20 central type and 18 transverse type cervical cord lesions. Fourteen patients underwent operative treatment. Patients with central cord type cervical cord injury showed good neurological recovery, while patients with transverse type cervical cord lesions revealed poor neurological recovery, especially elderly patients.

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We studied velocity-controlled voluntary knee movements in 18 patients with compression myelopathy (11 males and 7 females). Mean age was 60.9 years old (range: 49 to 74 years). The patients were divided into F group (free gait, n=13) and S group (gait with support, n=5). Isometric peak torque values were measured in knee flexor and extensor muscles, and isokinetic peak torque values were determined in maximal voluntary concentric movements of those muscles at constant angle-velocities of 40, 80, 120, 160 and 180 degree/sec. The relative strength (% of isometric peak torque value) of the isokinetic motion was then calculated. The isometric strength of the knee flexor and extensors was larger in the F group than in the S group. This may suggest that the muscles in the S group had undergone disuse atrophy. In both groups, the relative strength decreased as the velocity increased, and, the degree of reduction in strength of the flexors at the high velocities of 160 and 180 degree/sec was significantly (p<0.05) greater in the S group than in the F group. These results indicated that isokinetic strength at a high velocity might reflect the gait ability in patients with compression myelopathy.

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Pilon fractures are severe ankle injuries caused by high energy such as falling or traffic accidents. In the past 5 years we surgically treated 16 patients with Pilon fractures.
We classified the patients according to the AO classification system. One of the patients had AO Type B fractures and the remainder, AO Type C. We basically fixed the fractures with screws, wires, and plates. However, as it was difficult to maintain the reduction only with internal fixation, or the condition of the soft tissue was severe, we added external fixation for 7 patients.
Clinical results were assessed by Burwell functional scales. All patients were ranked“good or fair”by X-ray and 13 were ranked“good or fair”clinically.
We have 5 principles for Pilon fractures. 1) Using wire traction and an Icing System before operation 2) Antomical reconstruction with operation 3) Bone grafts for bone defects 4) Stable internal fixation and early joint movement 5) Using external fixation if it is difficult to maintain the reduction only with internal fixation, or the condition of the soft tissue is severe.

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Recently, snowboarding has been undergoing a dramatic increase in popularity. As the number of snowboarders increases, snowboard injuries are also on the rise. We experienced two cases of spine and spinal cord injuries caused by snowboarding. Both patients were injured during failed snowboarding jumps. Case 1 was a 26-yearold-man. He complained of backache, but had no neurologic deficits. Plain X-ray films and CT scans revealed a burst fracture of L1. This patient was successfully treated by conservative methods. Case 2 was a 21-year-old man who developed paraplegia secondary to fracture-dislocations at Th 8-Th 9. He received high dose methylprednisolone sodium succinate therapy as well as open reduction and posterior fusion with the TSRH spinal system. Stability and good alignment of the injured spine were achieved but his neurologic deficits showed no improvement. Several authors have reported that the incidence of spinal injuries is significantly greater in snowboaders than skiers. Novice snowboarders, especially when jumping, have a great risk of falling backwards and thus sustaining axial load and flexion injuries. We think that a broad education program is essential in order to reduce the number of such injuries.

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We experienced three cases of old (at least before eleven months) fractures and fracture-dislocations of the thoracolumbar and lumbar spine. Two cases of the lumbar spine injury have been operated laminectomy soon after these injuries at the near hospital. One case of the thoracolumbar spinal injury has been treated by conservative therapy. All cases have paralysis, local pain and malalignment.
We treated them surgically using decompressive laminectomy and posterior instrumentation.
In conclusion, the local pain has decreased for all cases, and paralysis has improved for two cases with cauda equina injury.

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Conservative treatment of congenital clubfoot following spina bifida is difficult. We report three cases in which good results occurred after our operation. Case 1: She was a 3 year old female and her paralytic level was L5. Her varus deformity reoccurred after treatment at another hospital, and so we performed postero-medial release (PMR) and split transfer of tibialis anterior tendon. Case 2: He was a 2 year old male and his paralytic level was L3. At 2 year 5 months we performed a Lichtbrau operation. Case 3: She was a 11 months old female and her paralytic level was L4. At 11 months we performed PMR. After operations all 3 cases have gained plantigrade feet.
Getting the plantigrade is the most important goal in treating foot deformities with spina bifida patients. We think that the correction of bony alignment is essential and, in cases with muscle imbalance in the foot, a corrective operation like the split lateral transfer of the tibialis anterior is also necessary.

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Extra-abdominal desmoid tumors are benign lesions but difficult to cure because of their infiltrative nature and tendency to recur. Fifteen patients were treated at our department between 1966 and 1998. Six of them were men, and 9 women. Eleven underwent their first operation at-our department and 4 had recurrent tumors after surgery at other hospitals. Local recurrence was observed in one patient with intralesional resection (100%), and one of 8 with wide resection (12.5%). However, 2 patients with marginal resection did not have a second operation. Resection with inadequate margin at that first operation led to poor clinical results.

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Two cases of giant cell tumor (GCT) in the distal femur are reported in this study. The first case was 44-year-old female complaining of right knee pain, en bloc resection was performed. The second case was 49-year-old male with pathological fracture caused in the traffic accident in the left distal femur. In this case, the tumor was extending to the articular cartilage, so en bloc resection of the tumor including articular cartilage of the medial edge was performed and curettage of residual tumor mass was added beneath the articular cartilage. In both cases, iliac cancellous bone grafting with A-W glassceramic granule was performed into the bony defect, and covered with an iliac bone block combined with reconstruction of the medial collateral ligament.
No complication nor severe functional loss of the knee joint were seen after the operation in both cases. On roentgenographic evaluiation, no local reccurrence have been detected for more than two years. GCT is known as a locally aggressive neoplasm, so careful attention for reccurrence should be paied after the operation.

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We evaluated treatment results in 19 patients who underwent surgery at our department between 1988 and 1998. The course was observed for 0.5-81 months (mean, 20.0 months). Six patients survived, but the other 13 died. The site of metastasis was the spine in 9 patients and other areas in 10 (four limbs in 8 patients and the ribs and pelvis in 1 each). Concerning the evaluation methods, the degree of postoperative improvement in paralysis and the quality of life (QOL) were evaluated in the patients with spinal metastasis, and changes in pain and the QOL were evaluated in the patients with metastasis in other areas. The degree of improvement in paralysis was evaluated according to Frankel's classification, changes in pain according to the Verbal Rating Scale (VRS), and the QOL according to the Performance Status. In the patients with spinal metastasis, the paralysis improved after operation in 6 patients and was aggravated in the other 3 while the QOL improved in 4 patients, did not change in 3, and was aggravated in the other 2. In the patients with metastasis in other areas, pain improved in 8 patients and was aggravated in the other 2 while the QOL improved in 5 patients, did not change in 4, and was aggravated in the other 1.

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A case of oncogenic hypophosphatemic osteomalacia in a 62 year-old man is reported. The patient was admitted because of progressive trunk pain and a soft tissue tumor was detected at the lateral side of his left thigh. Laboratory data showed a high serum alkaline phosphatase level, hypophosphatemia, and a low serum 1α, 25(OH)₂D₃ level. After the tumor was removed, clinical symptoms improved and laboratory data was corrected. Macroscopically, the tumor was a tenosynovial giant cell tumor.
Since both 1α-hydroxylation of vitamin D₃ and phosphate transport occur in the proximal tubule of the kidney, the tumor may produce a humoral factor which alters the function of the proximal tubule cell, inhibiting 1α-hydroxylase activity and renal phosphate resorption.

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We treated a 73 year-old male patient with rheumatoid arthritis (RA) who had many complications after total knee arthroplasty (TKA). The patient underwent TKA of the right knee joint on August 4, 1994. Skin necrosis of the knee occurred 3 days after the operation. We performed three operations following this diagnosis. The first one involved skin necrosis, dehridment and re-suturing. The second and third were bipedicled skin flap and musculocutaneus operations, respectively. Fourteen months after TKA, a right patellar fracture occurred without any trauma. We operated twice, and the patient returned to ordinary daily activity. However, an infection of the right knee joint occurred, and we performed synovectomy and patellectomy. In all, we performed six operations due to complications after TKA. After the patellectomy, the patient had no pain and could walk with a T-cane.

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We report two cases of tuberculous arthritis of the knee joint. The patients were female and complained of continuous knee pain. Tuberculous arthritis were diagnosed by culture of joint fluid and arthrodesis were performed while the patients were treated with chemotherapy pre- and postoperatively. The clinical result of these patients was good and they walked with a cane.
For the tuberculous arthritis, correct diagnosis is often difficult because tuberculosis is not suspected. When there is persistent joint fluid retension or continuous knee pain, it is necessary to suspect the tuberculous arthritis.

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Bone bruises on MR imagings of 35 patients with ACL injury were evaluated, and were correlated with subsequent arthroscopic and clinical findings.
32 patients (91.2%) had bone bruises on MR imagings. All of the MR imagings taken within 3 months from ACL injury had bone bruises and 50% of the imagings taken 3 to 4 months after injury had bone bruises, whereas none of the imagings taken longer than 4 months after injury had bone bruises. In most cases, the lesion was located at the middle site of the lateral femoral condyle and the posterior site of the lateral tibial plateau. There was no correlation between the presence of bone bruises and meniscal tears, and no correlation between the presence of bone bruises and articular cartilage lesions. There were bone bruises at the medial femoral condyle due to MCL detachment from the condyle. Bone bruise evaluation is useful in diagnosis of ACL injury and/or MCL detachment.

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We evaluated the clinical outcome of arthroscopic surgery with the Holmium YAG laser on the knee joint. This study involved 56 patients (26 males and 30 females) with 60 knees. The average follow-up period was 16.2 months (ranges, 1-27 months). Lateral meniscal injuries (total 24 cases) involving discoid menisci (12 cases), medial meniscal injuries (15 cases), recurrent dislocation of the patella (8 cases), rheumatoid arthritis (3 cases), osteochondral fracture (2 cases), and others (8 cases) were treated accordingly. Laser was appllied for partial menisectomy, synovectomy, plica excision, lateral retinacular release, photochondroplasty and debridement. Inflammatory symptoms one week after surgery, pre- and post-operative Japanese Orthopaedic Association scores were used for evaluation. Six patients complained of movement-evoked pain and 2 patients showed swelling on the knee joint one week after surgery. However, almost complete relief in all of them occured after 2 weeks. In all cases, the postoperative JOA score surpassed that of preoperative period. Using this laser, we were able to slant the meniscal stumps and resect the osteochondral fragments arthroscopically. We conclude that arthroscopic surgery of the knee joint with the Holmium YAG laser is very useful for operative treatment of highly inaccessible sites.

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The aim of this study was to evaluate the pre and post-operative changes in the triangular fibrocartilage complex (TFCC) by arthroscopy.
Six wrists (5 men and 1 woman) of subjects aged between 23 and 47 years were investigated by arthroscopy. Three were classified as Palmer 2C (arthroscopic TFC debridement), 2 were Palmer 1A+1B (arthroscopic TFC debridement and suture) and 1 was Palmer 1D (arthroscopic TFC suture) pre-operatively.
Post-operative arthroscopy was performed after an average follow-up period of 8 months (ranging from 3 to 11 months).
The clinical results of arthroscopic surgery were excellent in 1 case, good in 2 cases and poor in 3 cases. According to Palmer's classification, the cases of excellent and good results belonged to class 1 and the case of poor results belonged to class 2C.
Arthroscopically, 2 cases of Palmer 1A+1B and 1 case of 1D were healed but 2 cases of Palmer 2C re-ruptured and 1 case of Palmer 2C showed severe synovitis. Based on these results, arthroscopic wide resection and/or the wafer method or the Milch method should be considered for cases of Palmer 2C.

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No standard treatement for hemodialysis shoulder arthropathy (HDS) has been established yet. We performed arthroscopic surgery in 5 shoulders of 5 cases, 3 males and 2 females. The average age was 62 years and the average term of hemodialysis 11 years. The cases were divided into two types, synovitis type with remarkable joint effusion and swelling (Type 1) and “so-called hemodialysis shoulder” by Okutsu (Type 2). Only synovectomy was performed for the Type 1, and subacromial decompression, including C-A ligament release and/or acromioplasty, was added for the Type 2. The JOA score for the shoulder joint was remarkably improved postoperatively (from 52 points to 92 for the type 1 and from 61 to 92 for the Type 2). One case of the Type 1, in which only synovectomy was performed, developed a recurrence of shoulder pain attributable to the impingement. Pathological synovial proliferation of the glenohumeral joint, which may damage the articular cartilage, was found in all cases. From the above facts, a combination of synovectomy and subacromial decompression may give better long term results.

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We report here a case of periosteal chondroma and discuss the characteristics of this tumor. The patient was a 62-year-old woman who complained of swelling on the ulnar side of the left index finger without any other symptoms. Roentgenography revealed a tumor shadow with clear margins and calcification on the ulnar side of the middle phalanx of the index finger. This tumor compressed the bone cortex, resulting in an impression. The tumor was enucleated with its capsule connecting to the periosteum, and the underlying cortical bone was abraded. Histological examination revealed no nuclear atypia, and the diagnosis was chondroma. There has been no evidence of recurrence for 10 months after operation.
Periosteal chondroma is a relatively rare tumor in Japan, and only 160 cases of it had been reported to the Japan Bone Tumor Registry by 1991; the origin of 48 of those cases was the phalanx. The histological findings of periosteal chondroma are sometimes similar to those of malignant tumors, and diagnosis must be made after taking all the clinical findings, such as duration of the illness and presence or absence of pain, into consideration. For treatmemt, en block resection including cortical bone has been recommended in many reports, but we believe that enucleation with tumor capsule and abrasion of the underlying cortical bone are sufficient.

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Insufficient release of the tendon sheath and neurovasucular injuries are likely to occur in subcutaneous release of the tendon sheath. Therefore, we performed prospective studies in 19 trigger digits of 15 patients to evaluate the effectiveness and complications of this technique. There were 13 women and 3 men; their ages ranged from 6 to 70 years (mean 53). The operative procedures included incision of the skin with a skin cutter for insertion of Angiocath^® and longitudinal release of the A1 pulley performed according to Abe's method. After subcutaneous release, we opened the skin on the A1 pulley and examine the length of the incision in the A1 pulley and complications such as injuries to tendons, nerves and vessels.
Fifteen digits were completely free of click although complete release of the A1 pulley was found in 7 digits out of 19.
Tendon injuries were found in 9 digits. However, they exhibited no clinical symptoms probably because of their longitudinal direction. There were no injuries of digital nerves or vessels in our series.
This subcutaneous procedure can be performed easily and safely, however, disappearance of click does not mean complete release, and care should be taken to release the sheath distally enough.

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Trigger fingers are frequently seen in the out-patient clinic. There are two kinds of operative procedure for the trigger fingers: one is the open method, which involves incising enough skin to do a wide resection of tendon sheath and the other is the closed method, which involves inserting a small scalpel through the skin and cutting the tendon sheath subcutaneously. Ninety-two trigger fingers were classified according to our preoperative grading system and treated by the later procedure. The results were evaluated excellent, good, fair and poor. Eighty-one fingers were evaluated as excellent, 8 fingers as good, 3 fingers as fair and no fingers as poor. There were no complications with neuro-vascular injury and infection after treament. We concluded that this procedure was minimally invasive, effective, convenient and safe.

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We reported 2 cases of spontaneous anterior interosseous nerve (AIN) palsy and posterior interosseous nerve (PIN) palsy.
The AIN and PIN were almost normal in appearance but the hourglass-like constriction was found after interfascicular neurolysis.
The constrictive neuropathy was suggested to be the result of edema and mechanical stress from repeated elbow and/or forearm motions.
The nerve functions recovered after interfascicular neurolysis. Resection of the constricted part followed by suturing the cut ends or nerve graft was not necessary.
When the AIN and PIN are explored, interfascicular neurolysis should be performed to confirm the hourglass-like constriction.

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We performed nerve conduction studies in 30 patients (41 hands) with carpal tunnel syndrome (CTS). We measured the compound muscle action potential (CMAP) of abductor pollicis brevis (APB) and the 2nd lumbrical muscle (L2). The potentials of these muscles were compared for selection of the treatment for CTS. The CTS patients were classified according to the abnormalities of the APB and L2. In 24% terminal latency (TL) of APB was longer than that of L2. In 7% no CMAP was recordable for APB while that of L2 was recordable. The TL of APB and L2 were similar in 59%. We examined the process of recovery in 17 patients (20 hands) at more than 2 months after ECTR. In 4 cases, the CMAP of the APB was not recordable preoperatively and only that of L2 showed recovery. In one case where recovery of the CMAP of the APB was not good, we considered that the recurrent branch of the median nerve was predominantly involved. In cases like this the value of ECTR is debatable.

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Study was made of 12 cases of radiologically diagnosed cystic lesion in the lunate bone. Pathohistologically, 7 cases were interosseous ganglion and 2 cases were osteonecrosis. In MRI, interosseous ganglion showed lower intensity than the surrounding bone in T1-weighted image and higher intensity in T2-weighted image. However, osteonecrosis showed extensive lower intensity area in both T1- and T2-weighted images. The usefulness of MRI was thus suggested for cases of radiologically diagnosed cystic lesion in the lunate bone.

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Isolated traumatic posterior dislocation of the radial head without fracture of the ulna is extremely rare in adult. There have been only a report of 8 cases which described the same dislocation, but 4 reports of those weren't completely diagnosed at the first episode.
A 56-year old right-handed woman complained of pain and limited range of motion of the left elbow after falling down a flight of stairs. We diagnosed our patient as dislocation at first visit by proper X-ray imaging technique. Thus immediate manual reduction was made and the range of motion exercise was started in the early stage. This case kept good range of motion.
We conclude that it should be careful to assess radiological findings for diagnosis at first visit, otherwise dislocation may cause articular contracture.

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We treated eight elder patients who had proximal humeral fracture with hemiarthroplasty, and report their clinical results. In this study, their mean age was 68.9 and their average course after operation was 33.1 months.
Function and range of motion were evaluated according to the JOA scoring system.
Three patients with rotator cuff injury in the shoulder joint had significantly worse results than the other patients. Age and interval before operation were related to worse results. On the other hand, better results were obtained for tuberosity union for diaphysis and absence of head elevation at abduction.

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We operated 47 patients (10 males and 37 females) with proximal femoral fractures (17 neck fractures and 31 trochanteric fractures) under spinal anesthesia with bupivacaine. Age range was from 70 to 102 years with a mean of 83. We performed hip arthroplasty to neck fracture and osteosynthesis with Ender nails to trochanteric fracture. We compared seventies (group A: 24 patients) with ninties (group B: 23 patients) as to the concetration and volume of bupivacaine, past history before injury and in or post-operative complications.
Of these patients, group A was anesthetized with a mean of 2.4ml of 0.38% bupivacaine and group B with a mean of 2.4ml of 0.25% bupivacaine. Many past histories before injury were recognized all patients in both groups. But there was no apparent difference between group A and B in the rate of illness. During operation, temporary hypotension was recognized in nine patients of group A and four patients of group B. There was statistically significant difference between group A and B. We used vasopressor to all these patients. There was no other complications.
In conclusion, spinal anesthesia with bupivacaine is an useful and safty method for the operation of proximal femoral fractures.

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We report a case of successful management of pulmonary embolism (PE) after total hip arthroplasty (THA) in a 59-year-old woman.
PE developed 15 days after THA with the sudden onset of dyspnea and loss of consciousness. Based on the patient's history and clinical findings, such as complete right bundle branch block (RBBB) and right ventricular dilatation, we suspected PE and immediately started antithrombotic therapy in our ICU unit. On the next day, pulmonary scintigraphy showed wedge-shaped defects in both lung fields. Pulmonary arteriography revealed blockage of the main pulmonary artery at the level of its bifurcation into right and left pulmonary arteries. Deep venous thrombosis (DVT) of the right leg was confirmed by venography.
In order to treat the embolism, urokinase was injected through a catheter inserted into the pulmonary artery and heparin was also administrated intravenously. A filter was inserted into the inferior vena cava to prevent the recurrence of PE. After 4 days of intensive treatment, recanalization of the pulmonary artery was showen by pulmonary arteriography and the general condition gradually improved. The patient was discharged 64 days after the onset of PE for rehabilitation.
We conclude that immediate diagnosis and treatment of PE after THA can contribute to a good outcome.

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Fat embolism syndrome (FES) is a life-threatening complication that occurs after fractures, and is commonly associated with fractures of long-bones or the pelvis. In this paper, we documented a patient who developed FES during the operation for a femoral shaft fracture. The patient was a 52-year-old male. He was referred to our hospital because of multiple trauma including a right femoral shaft fracture, cerebral contusion and respiratory distress. The FES occurred following internal fixation for the femoral shaft fracture using an unreamed femoral nail, and the patient died despite every effort. The diagnosis of FES was confirmed by autopsy. In spite of early stabilization of fractures and the use of an unreamed nail, which was recommended to prevent FES, we could not prevent FES in this case. This suggests that special attention should be paid to FES.

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