Twenty-eight Hybrid total hip arthroplasties in 22 rheumatoid arthritis patients were reviewed after a follow-up period of 1 to 7, 9 years (mean 3 years). The average age of patients was 61 years. The average preoperative JOA score preoperatively was 38.3 points and increased to 70.1 points. Radiographic analysis showed radiolucent lines on the acetabular component were seen in 24% of the cases and migration in 7%. Radioluent lines on the femoral-side of the prosthesis were seen in 7% of the cases. We are able to recommend Hybrid total hip arthroplasty as a potentially useful method for patients with rheumatoid arthritis after a short follow-up period.

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Despite the popularity of total hip arthroplasty, clinical indications for cup arthroplasty still exist in younger patients with severe coxarthritis. Cup arthroplasty has been successfully used in the treatment of hip disease for fifteen years, especially in pain control.
Total hip arthroplasties were performed for nine patients, mean fifteen years after cup arthroplasties. The two diagnostic categories were four patients with degenerative coxarthritis and five patients with rheumatoid arthritis. The clinical results of the patients were evaluated with the use of the Japanese Orthopaedic Association's score (JOA score). We also reviewed the radiographic findings, the pathological changes of their femoral heads, operative times and bleeding volumes in total hip arthroplasties.
The mean individual score for pain was improved by cup arthroplasty and total hip arthroplasty, but the improvements of range of motion, gait, and activity of daily life were not sufficient.

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The treatment of osteomyelitis is still a difficult problem in orthopaedic surgery. We reviewed the results of the treatment of osteomyelitis in last four years.
The patients were 8 males and 1 female. The age of the patients ranged from 30 to 75 years (averaged age was 56 years old). The site were five femurs, four tibias, one humerus, and one ulna.
The pathogens cultivated were Methicillin resistant staphylococcus aureus (MRSA) in 5 cases, Methicillin sensitive staphylococcus aureus (MSSA) in 4, Pseudomonas Aeruginosa in 2, and Methicillin resistant staphylococcus epidermidis (MRSE) in 1.
In all the patients, debridement and resection of the infected bone were performed at first. After resection, in 6 of 9 patients, the defects of bone were small, and we performed muscle flap transposition. In 2 cases with MRSA and 1 case with MRSE, the defect of bone was large, and vascularized bone graft was performed.
In all cases, the osteomyelitis healed after the operation.
Recently, osteomyelitis with MRSA is increasing, and its treatment is more difficult than those with other pathogens. In treatment of osteomyelitis with MRSA, the debridement and resection of infected dead bone are most important as well as those with other pathogens. The vascuralized bone graft is very useful for the reconstruction of large bone defect after debridement.

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We report fixation of intramedullary nail in surgical treatment of fractures of long bones in elderly patients. The cases consist of 5 females with an average age of 84 years old (range; 76 to 93 years old). Of these, two were femoral supracondylar fractures, and three were humeral neck fractures. All the patients had casts only for one week after the surgery, and after that we used only soft brace in all cases. The cases of femoral supracondylar fractures gained ROM from 0 to 120 degree in knee flexion/extension within 2 to 3 weeks after surgery, and they complained of no pain in these periods. One could walk with no cane or crutch support and another could walk their full weight bearing within 4 weeks after surgery. The cases of humeral neck fractures started rehabilitation with pulley exercises after removal of sutures and gained active ROM of 90 degrees of abduction within 4 weeks after surgery. In all cases bony union was obtained within 6 to 12 weeks. The results indicate that the fixation of intramedullary nail in surgical treatment of fractures of long bones is a favorable treatment for elderly patients.

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We report a case of chondrosarcoma followed up on the X-ray for 17 years.
The patient is a 32-year-old man, who has the pain and mass of the left leg. Seventeen years ago, he complained of pain for the first time and was followed by a hospital under the disgnosis of the osteochondroma. After that, the pain and mass increased gradually and he consulted our hospital on March 1998. After the biopsy, that showed chondrosarcoma, the above knee amputation was done.
We could observe the X-ray from 1981 to 1998 retrospectively, and guessed the osteochondroma, periosteal chondroma or chondromyxoid fibroma changed to chondrosarcoma.
We consider it is important to follow them carefully because chondrosarcoma arise uncommonly in benign tumors, even if they were diagnosed as the benign tumor at the first.

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Whether or not dislocation of the radial head should be reduced is difficult to determine in the treatment of old Monteggia fractures in children. The subjects were 8 patients (6 boys and 2 girls) who underwent open reduction of the radial head. Patient's age at the time of the operation ranged from 2 to 10 years. The period from injury until the operation ranged from 30 days to 1300 days. Surgical procedures were as follows; open reduction in 3 cases and osteotomy of the ulna in 5 cases. Results were evaluated regarding pain, ROM and X-ray findings, as well as ADL evaluation. No patients complained of pain, but some complained of limitations of the forearm pronation. Osteoarthritis of the humero-radial joint was found in 3 patients. Poor results were obtained in patients whose radial heads were left in the dislocated position for long periods before the operation, or those that failed to be reduced in the correct position during the operation.

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Intraspinal neurenteric cysts are thought to be caused by genetic abnormalities in the early stages of cervical vessel development. Our subject was a 15-year-old boy who complained of myotonia of the four extremities. MRI revealed a double-lobed cyst at the C2 level of his spine. The cyst was resected through C2-level laminoplasty.
Histological study revealed that the cyst was a neurenteric cyst, of the C Wilkins type.

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We examined knee isometric extension strength at various flexion angles in 16 patients with compression myelopathy (11 men and 5 women), whose mean age was 61.1 years (range: 44 to 79). Isometric peak torque values were measured in knee extensor muscles at three flexion angles (20, 40, 60 degrees). The patients were compared with the control group who did not show any symptoms indicating myelopathy (n=5; mean age, 60.8 yrs.). The isometric extension strength in the patients group was significantly (p<0.05) weaker than in controls at all three flexion angles. The peak torque at 60 degree flexion was the highest compared to that at 20 or 40 flexion in both groups. Compared to the peak torque at 60 degree, the % torque values at 20 and 40 degrees were 24.4 and 70.0% in the patients group, respectively. On the other hand, the values in the control group were 50.2 and 80.8%, respectively. The % torque at 20 degree in the patients group was significantly lower than that in the control group (p<0.05). These data indicated that knee extensor isometric strength of the patients with myelopathy markedly decreased as the knee joint extended.

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Pulmonary Embolism (PE) is one of the most dangerous complications in orthopaedic and accident surgery. Here we report on two cases of successful management of PE after orthopaedic surgery.
The case 1 of 46-year-old woman with L₄ degenerative spondylisthesis, she received an anterior interbody fusion in September, 1988. At 30 days after surgery, she complained of acute chest pain and went into shock. Based on X-ray findings, ECG readings, heart echo and some laboratory evaluation, PE was highly suspected. Anticoagulant therapy (heparin) and thrombolysis therapy (urokinase) were immediately started in the ICU.
The case 2 of 58-year-old woman with left hip osteoarthritis, she received the THA in August, 1998. She complained of dyspnea and went into shock 15 days after surgery. Heart echo, chest CT, and pulmonary arteriography clearly indicated PE, and immediate anticoagulant and thorombolysis therapy was started in the ICU. Fortunately, both cases had successful results.
Fatality rate of PE is very high, and PE after surgery has been increasing in Japan. Several reports detail the risk factors associated with this lesion. Therefore, orthopaedic surgeons should take care of this disease, especially on risk factors and early diagnosis.

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Thrombo-embolic complications are one of the greatest sequelae in orthopaedic surgery. Pulmonary embolism (PE) is frequently caused by deep vein thrombosis (DVT). In recent years, the frequency of DVT after lower extremity surgery is as high in Japan as in Western countries. We report two patients with a history of PE in whom an inferior vena cava (IVC) filter was inserted prophylactically. There was no sign of PE after the operation. Insertion of an IVC filter is a safe and effective method of preventing PE, especially in high-risk patients.

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We treated severe bone defects and severe ligamentous instability of the knee by a modular system in total knee arthroplasty.
The patients were 4 men and 4 women. The primary diagnoses were osteoarthritis of the knee (4 knees), revision total knee arthroplasty (2 knees), steroid arthroplasty (1 knee), and osteoarthritis of the knee with medial condylar fracture of the femur (1 knee). Seven knees were repaired by Deltafit 7000 (Stryker) and one knee was repaired by Intercondylar knee (Manson).
The advantages of modular system in total knee arthroplasty were acquisition of the stability of the knee joint and reduction of rehabilitation hours. The disadvantages were the long duration times of the operation, due to its complicated methods, the appearance of the stress shielding, and the detrimental effects on the bone marrow.
Using the modular system in total knee arthroplasty might be most appropriate for knees with severe ligamentous instability and bone defects, and for osteoarthritic knees with intra-articular fractures or osteotomy.

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We reviewed eight posterior-stabilized total knee arthroplasties in six selected patients in which a surface arthroplasty could not suffice. The mean follow-up period was 1.7 years. There were one man and five women. The mean age at the operation was 73.8 years. There were four primary arthroplasties and four revisions. The diagnosis was osteoarthritis in six knees and rheumatoid arthritis in two. The maximal extension improved from- 28.8 degrees to -9.4 degrees. The maximal flexion was 110.0 degrees before the operation and 110.6 degrees at the latest follow-up. The average JOA score for osteoarthritis improved from 55.8 to 79.2. There were no cases of anterior/posterior or medial/lateral instability. A transient pulmonary embolus was found in one patient but no other complications were observed. The indications of posterior-stabilized prosthesis are severe varus deformity with massive bone defect in the medial tibial plateau, flexion contracture, and cases of unstable revision.

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In 18 patients with osteoarthritis of the knee, 28 ACG-S total knee prostheses were implanted without using cement. Clinical results and roentgenographic features were assessed with mean follow-up of 2.9 years. On the femoral side, no radiolucent lines were seen at the interface between bone and the implant. On the tibial side, radiolucent lines were noted in 9 knees (32.1%). These lines were seen only around the non-porous coated stem. In 6 knees, the radiolucent lines were less than 2mm thick and not progressive. In one knee a progressive radiolucent line of more than 2mm in thickness was noted. There was no statistically significant correlation between the occurrence of radiolucent lines and postoperative clinical results. The postoperative axial alignment and the placement of the prosthetic component had no significant influence on the occurrence of radiolucent lines. The occurrence of radiolucent lines was closely associated with preoperative contracture and malalignment of the knee. The porous-coated cementless total knee arthroplasty is a valuable procedure for the treatment of osteoarthritis, however, fixation with cement is recommended in severely deformed knees in which ligamentous balance cannot be maintained at the operation.

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We will report the case of an acetabular displacement after a rotational acetabular osteotomy (RAO). The patient was 49 years old female. Before the operation, an x-ray of the hip joint showed acetabular dysplasia and a narrowing of the joint space (in an advanced stage). RAO was performed and, simultaneously, an anterior rotation of the acetabulum was performed aggressively due to the stage of osteoarthritis. Immediately after the operation, x-ray showed good congruity and coverage of the femoral head. However two weeks after surgery, joint congruity was lost, and reoperation was performed. An electron microscope examination revealed that the screws had crack lines. So, the displacement of the acetabulum was thought to be caused by a break following the crack lines of the PLLA screw.

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Two cases of divergent dislocation of the elbow in children are reported.
Divergent dislocation of the elbow has been explained as occurring from falling full on the outstretched hand with the body pivotting on the hand, causing a hyperpronation force at the elbow. We obtained good results in both cases by closed reduction.

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A 57-year-old male machine operator gradually developed a motion pain in the left elbow about 6 years ago without any known causes, which got worse with time. On his first visit to our clinic, active ROM was full. No signs of acute inflammation were found. While extending the elbow from full flexion with the forearm pronated, a cord like mass moving over the radial head with a painful snap was palpated. A plain X-ray revealed an exostosis in the radial neck. No abnormal pathology was found on an arthrogram. The conservative treatment with 1% xylocaine and steroid injection did not relieve the symptom and an operation was performed. In the operation, an enlarged annular ligament was found incarcerated, covering over the anterior part of the radial head in an extended position, which was reduced with a click to the normal position in the neck by 110° flexing. The snapping disappeared by excising the enlarged incarcerated part. At the last follow-up, 7 months after the operation, he was completely free from the symptoms.
The cause of a snapping elbow, a relatively rare disorder, can be either intraarticular or extraarticular. In our case, the exostosis around the radial neck made it shallower, increasing the possibility for the annular ligament to slip over the head into the joint.

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Supracondylar fracture of the humerus is one of the most common elbow injuries in children. Cubitus varus is one of the significant complications.
The authors have treated 29 cases of supracondylar fractures in children by early closed reduction with percutaneous pinning over the past 10 years; 17 patients were examined after an average of 4.1 years after the injury.
In postoperative follow up of this series, no patients had complained of motor disturbances or deformities, especially cubitus varus.
This method is easy to perform, maintains tight fixation and allows for early discharge. For these reasons, we concluded that this method is excellent for the treatment of the supracondylar fractures in children.

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Minimally invasive technique are becoming more widespread in orthopedic field. A microendoscopic discectomy (MED) system developed in recent years enables us remove the lumbar disc herniation as accurately as when the standard open procedures is used.
Twenty-three patients were subjected to discectomy using the MED system. The patient population consisted of 17 men and 6 women aged 16 to 57 years (mean, 35.2 years). Herniation affected discs at L4-5 (15) and L5-S1 (9) levels. One patient had two herniated discs. Discectomy proved successful for 22 discs of 24 discs operated on. The average Japanese Orthopedic Association scores for low back pain improved from pre-operative 15.8 to post-operative 28.3, showing an average improvement rate of 94.9%, which was not significantly different from that obtained in 50 patients treated according to the modified Love's method. Our Results showed that the MED system was considered as a beneficial method in treatment of lumbar disc herniation.

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In the past 5 years, we have encountered 20 subjects who required repeat surgery for degenerative spondylolisthesis. We analyzed these patients data with regard to clinical symptoms, surgical results, and the main factors necessitating repeat surgery. The main factors necessitating repeat surgery were insufficient decompression of the lateral recess at the affected level and canal stenosis of the upper level after fusion. Patients who underwent fusion of the vertebrae during the initial surgery showed good improvement after the second surgery according to Hirabayashi's criteria, while those who did not undergo fusion showed less favorable results. Based on these observations, it can be concluded that sufficient decompression and adequate fusion should be achieved during the initial surgery.

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We report surgical results for lumbar degenerative spondylolisthesis in 26 older patients. Posterior decompression and posterolateral fusion with Luque instrumentation were used to permit early ambulation after the surgery.
The mean age of the patients at the time of surgery was 68.3 years (range, 57-83 years). The average follow-up duration was 30 months (range, 6-96 months). The surgical outcome was evaluated using the Japanese Orthopaedic Association score (JOA score, 15 points at the maximum score). The preoperative mean JOA score was 3.8 (range, 1-8) and postoperative score was 11.5 (range, 5-15). The mean recovery rate of the JOA score was 68.8%. In this series, there was a group (4 cases) who had unacceptable recovery rates of 40% on average. They had had severe muscle weakness in ankle dorsiflexion for more than 4 months before surgery.
Our data suggest that this method is useful for the treatment of lumbar degenerative spondylolisthesis, even in the presence of osteoporosis.

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78 knees of 73 patients (average age, 37.1 years) with torn menisci were retorospectively studied to clarify the relevance between the tear characteristics and the frequencies of cartilage lesions.
The frequency of cartilage lesions were significantly lower in the lateral discoid group than that in the lateral and medial meniscal injury groups.
Articular cartilage lesions were more frequent in the lateral meniscal injury group than that in the other two groups and the frequency increased in the patients over 40 years of age.
Complex, flap, and bucket handle tears were more often associated with articular cartilage lesions than the other type of tear.

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We examined the characteristics of the articular cartilage surface layer lesions in 129 knee observed at arthroscopy. Exfoliation of the membranous tissue in the articural surface was noted in 51 of 129 knees (65 lesions). The site was the patellofemoral joint in 43 lesions and the femorotibial joint in 22 lesions. Two types of morphology, mop-like exfoliation (43 lesions) and flap-like exfoliation (22 lesions) were observed. Mop-like exfoliation was noted on the articular surface of the patella in 38 of 43 lesions (88.3%), and flap-like exfoliation was recognized in the femorotibial joint in 17 of 22 lesions (77.2%). Flap-like exfoliation of the membranous tissue was closely associated with the primary disease regarding the site, and mop-like exfoliation was noted mostly in the articular surface of the patella.

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The effectiveness of high tibial osteotomies using Citieffe curvilinear osteotome blades and a Charnley's external fixator was examined.
Dome high tibial osteotomies were performed for patients suffering from varus gonarthrosis, and during a period between 1988 and 1995, after multiple drillings of the affected areas, 1cm wide blades were used to osteotomise the proximal tibia. This method was adopted in 20 cases, operating on a total of 21 knee joints. Since 1995, we began operating on such osteotomies using curvilinear osteotome blades developed by Citieffe Co., Ltd. instead of conventional type of blades, and operated on 21 knees.
According to the results of anterior-posterior X-rays taken immediately after the osteotomies, the average contact rate of the surfaces of the bones cut with Citieffe's curvilinear osteotome blades was 85.2%, while that with 1cm wide osteotome blades was only 68%. The average time period needed for bone union after the osteotomies was 52.8 days for the bones cut with Citieffe's curvilinear osteotome blades while it took an avarage of 77.8 days for bones cut with 1cm wide osteotome blades.
These results led to the conclusion that the use of Citieffe's curvilinear osteotome blades in osteotomy is more effective than the use of 1cm wide osteotome blades, resulting in faster bone union in weight bearing bones and a higher contact rate of the surface of the bones which were cut.

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This study was performed to compare the efficacy, safety, and cost-effectiveness of outpatient local anesthesia and inpatient spinal anesthesia when performing knee arthroscopy.
The outpatient local anesthesia had some benefits: short durations of operative time and anesthetic time, few complications, lower cost. However it had a time limitation of effective anesthesia, difficulty in case of bleeding, and rarely, poor control of pain.
The indications of outpatient knee arthroscopy were partial resection of the meniscus, biopsy of the synovium, cartilage debridement, removal of a joint mouse, and resection of the plica.

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We report on results in surgical treatment of four patients with ruptures of the patellar ligament without systemic disorders such as chronic renal failure and diabetes mellitus.
The patients included 4 males ranging in age from 31 to 62 years (mean, 43.5 years). Three ruptures were fresh and one was treated seven weeks after the injury. The patellar ligament was ruptured at the middle of the ligament in two cases, and avulsion fractures of the lower pole of the patella were found in the others. They were treated by supplemental fixation with wire in addition to ligament repair (modified McLaughlin's procedure).
Active ROM exercise of the knee was started within one week after surgery in all patients. The extension lag in all patients disappeared about three weeks after the surgery. All patients recovered almost full range of motion of the knee without any extension lag about 4 months following surgery.

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We report a case of sterno-costo-clavicular hyperostosis. The patient, a 61-year-old man, complained of pain in the bilateral sterno-clavicular joints and sterno-costal joints. In 1989, pain appeared and was not improved by medical treatment. He visited our department, whereupon it was diagnosed as sterno-costoclavicular hyperostosis. However NSAIDS were not effective for his pain. His symptoms became severe, and in August 1996, he had a checkup again. We recognized bony swelling as inflammation in the right breastbone and collarbone areas. With XP and CT, the bilateral sterno-clavicular joints and sterno-costal joints showed sclerotic change. He had pustulosis palmartis et plantaris and chronic tonsillitis. We initiated steroid therapy, but it was not effective, so we performed tonsillectomy. After the tonsillectomy, inflammation and anterior chest pain disappeared. Furthermore, we administered cefem series antibiotics for 3 months. Most of his symptoms disappeared. Actinomyces lumps in the tonsils ware pathologically examined, and non-specific inflammation and reactivity bone increases were revealed by bone biopsy of the right sterno-claviclar joint. The histological examination indicated the infection lesion in the tonsil and immunoreaction in the sterno-claviclar joint.

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We reviewed a series of twenty-two patients who had a fracture of the shaft of the clavicle treated by open reduction through a small skin incision and intramedullary fixation with an ACE cannulated cancellous screw (5mm in diameter). There were seventeen male and five female patients. The average age of the patients was forty-six years (range, fifteen to eighty-nine years). The average duration of follow-up was nine months (range, three to twenty-four months). All patients achieved clinical and radiographic union eventually, although delayed union occurred in one (4.5 percent) of them, and redisplacement in another (4.5 percent). There were no neurovascular complications or infections. Intramedullary fixation has several advantages compared with other treatments, such as percutaneous pinning or fixation with a plate and screws. It can be performed through a cosmetically acceptable small incision; the pain can be relieved immediately after operation; and, after healing, the screw can be extracted through a small incision under local anesthesia and/or brachial plexus block.

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We have utilized intramedullary fixation with Kirschner wires for displaced proximal humeral fractures. Kirschner wires were curved slightly and inserted from the deltoid tuberosity to the humeral head. We evaluated the results of eight patients who underwent this treatment.
They included one male and seven females, with a mean age of 55 years (range 17-92 years). The follow up period ranged from 5 to 52 months, with a mean of 23 months. Results were evaluated according to Neer's criteria, and the clinical score for the shoulder function by the Japanese Orthopaedic Association (JOA score).
According to Neer's criteria six cases were excellent and two cases were satisfactory. The average JOA score was 93.1 points.
This treatment is low invasive and the patients can start exercising the shoulder soon after its completion. We concluded that intramedullary fixation with Kirschner wires is a good surgical procedure for displaced proximal humeral fractures.

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We report the case of a patient with chronic renal failure whose concurrent rupture of bilateral quadriceps tendon was treated successfully. The knee of a 33-year-old male who has been treated for chronic renal failure with conservative therapy, gave out when he was going downstairs and became unable to walk any more.
On admission the patient could not extend his knees activelly. Physical findings, X-ray studies and MRI showed rupture of the bilateral quadriceps tendons.
On February 2, this rupture was repaired by the Fujikawa technique using the Leeds-Keio (L-K) ligament. The day after surgery the CPM exercise was started. At the end of two weeks, the patient was permitted walking with knee braces and crutches. At the end of four weeks the knee braces was removed. The repairing using L-K ligament has resulted in earlier recovery.

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