The authors studied the relevancy of unstable degenerative spondylolisthesis to cervical spondylotic myelopathy (CSM) in elderly patients. Of the 68 patients, all over 65 years old, surgically treated for CSM during the past 10 years, 26 vertebrae of 23 patients showed a horizontal displacement of the vertebra of 3.5mm or more, estimated by flexion/extension radiography before surgery. Twenty-one patients had less than 2mm or no horizontal displacement. The displacements occurred at the C3 on C4 and C4 on C5 levels in 12 each. C3 tended to displace posteriorly, and C4 anteriorly. In these patients, the entire range of motion (52.2±3.2°) of the cervical spine with cervical spondylolisthesis was significantly greater than those (40.9±4.0°) without cervical spondylolisthesis. Further, 20 of 26 displacements were responsible for CSM as evidenced by both MRI before surgery and spinal cord evoked potential studies during surgery.
The current study's findings suggest that there is a higher incidence of degenerative spondylolisthesis of the cervical spine in elderly CSM patients than has been previously described. The spondylolisthesis, if associated with a relatively greater mobility, results in spinal cord compromise at the upper cervical levels.

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The authors treated a case of spinal extradural cyst on sacral region. A 48-year-old man presented with pain in the area of lumbosacral region, urinary disturbance and hypesthesia is the periphery of the anal and the posterior aspect of both thighs. Motor disturbance was absent.
Magnetic Resonance Imaging (MRI) and myelogram showed a cystic lesion in the sacral area which was widening the spinal canal and compressing the thecal sac. The patient was prone on the image table for the second myelographic examination. The contrast medium was injected very slowly, and revealed that the cyst was communicated with the sabarachnoid space. The patient underwent laminoplasty of the sacrum, and the cyst was extirpated after ligation of the connection and repair of the fissure of the dura to prevent the recurrence of the cyst.
The paient had an uneventful postoperative course, and neurological improvement was obtained after surgery.

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The natural history of degenerative lumbar scoliosis is still obscure. In order to clarify the risk factors of the curve progression of lumbar scoliosis, the relationship of the initial radiological findings and the curve progression was investigated. A review was conducted on the radiographs of 575 adult patients over 40 years old with low back pain who visited Kochi Medical School hospital in 1994. Out of them, 153 (26%) proved to have degenerative lumbar scoliosis of more than 5 degrees. The natural history of the curve progression was investigated in the 53 patients who were followed for more than 1 year. The age of the patients ranged from 41 to 83 years old. The mean follow up period was 7 years and 5 months.
Radiological investigation demonstrated that the curve progression did not relate to the initial magnitude of the curve, sex, age, the covexity of the curve, the degree of osteoporosis and antero-posterior vertebral slippage on the X-ray taken at the initial visit. It was found that the risk factors of the curve progression are vertebral rotation and L4 vertebral tilt to the pelvis. The appearance of body spur formation of the vertebrae was thought to signal suppression of the curve progression. Further investigation with a larger number of patients and longer follow up duration is necessary to identify more precisely the risk factors of the curve progression.

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The pathogenesis of lumbar canal stenosis with degenerative scoliosis is still unclear. The purpose of this study is to analyze the pathogenesis and surgical results of this special condition. Twenty-six patients (average age, 66.8 years) with degenerative scoliosis (Cobb angle, over 10 degrees) underwent surgery. Eighteen patients underwent laminectomy, and 8 patients had laminectomy and spinal fusion. Nine patients had one level degenerative spondylolisthesis. Twelve patients had cauda equina symptoms, 9 had radicular symptoms, and 5 had both symptoms. In the latter 14 patients with radicular symptoms, 8 had symptoms at the concave side and 6 at the convex side. Myelograms and CT myelograms showed compression of the nerve root caused by degenerative scoliosis consistent with the symptoms at the concave side in 6 patients. The average preoperative Japanese Orthopaedic Association score was 10.8, and at the latest review, 16.9. Five patients with degenerative spondylolisthesis had scoliosis at the spondylolisthesis level, and rotational instability was revealed on preoperative CT. In no case did the Cobb angle increase over 5 degrees after operation in the patients who had laminectomy.

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Ossification of the anterior longitudinal ligament (OALL) of the cervical spine is commonly asymptomatic. Three cases of dysphagia due to OALL are reported.
Case 1 was a 61-year-old male who had severe dysphagia after pontine hemorrhage. Cervical X-rays and CT showed OALL in the C3 to C6. Video fiberscope demonstrated obstruction of the hypopharynx. Case 2 was a 70-year-old male who had undergone cervical laminoplasty for ossification of the posterior longitudinal ligament 8 years ago. He developed dysphagia. Cervical X-rays and CT showed OALL in the C5 to C7. Video fiberscope demonstrated obstruction of the esophagus. Case 3 was a 57-year-old male developing progressive dysphagia. Cervical X-rays and CT showed OALL in the C5 to C7. Video fiberscope demonstrated obstruction of the hypopharynx.
All three cases showed a mechanical obstruction thought to be secondary to OALL, and had significant relief of dysphagia after resection of the bony mass.

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A cervical collar is commonly used for a wide variety of cervical disorders which require immobilization of the cervical spine. However, those who have difficulty in sufficiently elevating upper extremities are unable to put on and remove conventional rear-open collars by themselves. For such patients the authors developed a specially designed front-open soft collar which incorporates a pair of pull-cords with a ring at each end. Six adult patients with cervical spine disorders caused by rheumatoid arthritis (5), and C5 radiculopathy due to cervical spondylosis, were able to use the device without assistance. The front-open collars took these patients only 15 seconds on average (range, 5-33 seconds) to put on and 8 seconds (range, 4-16 seconds) to remove.

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The authors evaluated the anterior-posterior radiographic assessment on weight bearing position at conventional extension, flexion of 15°, 30° and 45°in 18 patients (26 joints) with osteoarthritis of the knee. Their average age was 67 years (53-83 years), 6 men 12 women, average femoro-tibial angle of 179.5° (162-193°).
The joint widths in the middle and shortest portions of the medial joint were markedly narrower in flexion position at 15°, and significantly narrower at 30° than in the extension position.
The joint widths in the shortest portion of the lateral joint were significantly narrower in flexion positions at 30°, and 45°than in the extension position. However, there was no significant difference between flexion and extension in the middle portion of the lateral joint in the same position.
The differences in femoro-tibial angles between various flexed and extended knees in flexion at 15°was smaller than that at 30°and 45°.
The authors suggest that 15°of flexion was effective to assess narrowed joint spaces because patients with osteoarthritis mainly have varus deformity. Further evaluation of a comparative study of the view using flexion in a large number of cases is required.

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The authors have developed a new external fixator for high tibial osteotomy to treat patients with medial osteoarthritis of the knee. Fifteen knees of 14 patients (5 males and 9 females, mean 64.1 years old) who underwent this treatment were followed up more than 2 years (mean 2.7 years). Surgical outcome was evaluated with the Japanese Orthopedic Association score (JOA score), femorotibial angle (FTA) and postoperative complications, The FTA significantly decreased from 182.4±3.2° to 167.8±2.4°. The JOA score significantly improved from 63.3±10.8 point to 80.0±13.4 point. There were no patients who showed peroneal nerve palsy, delayed union or deep infection. These results showed that high tibial osteotomy using this external fixator is effective for the treatment of the medial osteoarthritis of the knee.

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Of the 112 cementless primary total knee replacement (TKR) performed between 1993 and 2000, 22 knees with severe varus deformity, all of which were osteoarthritis, required autogeneic bone graft of the tibial defect, and 15 of the knees (10 patients) were followed for 17 to 85 months (mean, 34 months). The mean age at operation was 71 years. PFC type (Osteonics 3000 & 7000) PCL retaining prosthesis for 13 knees, and posterior-stabilized prosthesis for 2 knees were used in the procedure. In 7 knees with the defect greater than 8mm in height, bone grafting was performed with screw fixation. Preoperatively, the mean knee score according to the Japanese Orthopaedic Association was 46.7 points. At the time of latest follow-up, it was 82.3 points. The mean preoperative and postoperative ranges of motion were 113.7 and 116.0 degrees, respectively. In one knee, 2° residual varus deformity remained, but no implants were loosened. Radiographs were evaluated for clear zone, sinking, and the state of the grafted bone every half year. Clear zone less than 1mm on the tibial plateau at high rate, and sinking less than 2mm on the anterior margin of tibia at 5 knees were noted, but none was progressive. Incorporation of the grafts was present in all knees. Of the 5 bone grafts that demonstrated 1 or 2mm of collapse, two were accompanied by peripheral bone resorption. The surgical technique to reinforce the initial stability of the prosthesis is necessary to permit early rehabilitation. Cementless TKR with bone graft seemed to be a successful procedure even for the severely deformed knees with osteoarthritis in the current study.

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We reported four cases of infection after total knee arthroplasty (TKA) which required the removal of implants. Three cases were osteoarthritis and one was rheumatoid arthritis. Two cases were staphyloccocus aureus, one case was staphyloccocus epidermidis and one case was MRSA on culture of joint fluid. The therapy after removal of implants was a primary revision TKA, a secondary revision TKA and two arthrodesis with insertion of cement beads containing antibiotics or continuous irrigation.
In all cases the infection was controlled. Revision TKAs had good fixation without loosening and sinking. Complete fusions were obtained by arthrodesis.
We recommended that in treat infected TKA the degree of infection, variety of the bacteria and complication had to be investigated sufficiently and planned the therapy after removal of implants.

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A rare case of snapping hip caused by a desmoid tumor on the greater trochanter of the femur was reported. The patient was a 71 year-old man who complained of snapping and pain on the greater trochanter of the left femur without any other symptoms. MRI showed the tumor in the postero-lateral area of the greater trochanter and at the distal end of the tensor fasciae latae type muscle. Tumor resection was performed and histopathological diagnosis confirmed the tumor type. There has been no recurrence of the tumor or pain. Desmoid tumor rarely affects the elderly and the incidence in the hip is very rare (5.7%).

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In the surgical treatments of malignant pelvic tumors, it is often difficult to obtain an adequate surgical margin and the methods of reconstruction are still under discussion.
The surgical treatments for 13 malignant pelvic tumors (nine male and four female patients) and one giant cell tumor (male) resected in our hospital between Nov. 1987 to Aug. 1999 were investigated to evaluate the surgical results. The mean age at the time of operation was 42.3 years (17 to 80 years), and the average follow-up period was 40.5 months (5 to 132 months).
Seven of 9 patients with tumors that were resected with inadequate margin (intralesional and marginal margin) died of tumor metastasis, as did 2 of 4 patients with tumors that had wide resection. Local recurrences were recognized in 3 of the 9 patients with inadequate margin, and none with wide resection.
Reconstructions of the pelvic ring were perfomed in 4 cases of 6 cases with interruption of the pelvic ring by the tumor resection. Another 2 cases were performed internal hemipelvectomy and ilio-femoral fixation substituting the reconstruction of the pelvic ring. Two cases reconstructed with fibula graft and the case of ilio-femoral fixation showed especially good results in the postoperative functional evaluation (Enneking's functional evaluation system).
As prognosis and the frequency of local recurrence tend to be related with the method of tumor resection in our series, many efforts should be paid to obtain an adequate margin. Two patients with rigid fixation using fibula graft and ilio-femoral fixation showed good results in Enneking's functional evaluation system.

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Limb salvage procedure has been accepted with the progress of chemotherapy. On the other hand there is a problem of leg length discrepancy in the reconstruction of the lower extremity in younger children.
The authors treated two children with osteosarcoma by reconstruction with extendable endoprosthesis. The patients were 12 and 10 years old at operation, and stage III B and stage II B respectively. Follow-up period were 5 and 8 months. Howmedica Growing Kotz System was used as the extendable implants. When seen for follow-up, functional evaluation showed 47% and 30%, and leg length discrepancy became 4cm and 1cm. In the first case 2.5cm of elongation procedure was performed after 5 months.
This systematic prosthesis can be elongated easily with the use of two screw devices via small skin incisions. According to Kotz et al, the length of elongation at one time should be within 1.5cm because of the complication of transient peroneal palsy. Shiller et al reported that the mean length of the total elongation gained of 6 patients who reached skeletal maturity was 13.15cm requiring 53 planned procedures.
In growing limbs in which the eventual shortening can be predicted, extendable endoprosthesis is useful as the reconstruction of the defects after resection of malignant bone tumor.

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Luxatio erecta humeri is a relatively rare type of glenohumeral dislocation. In Japan 40 cases have been reported. We treated a 20-year-old man injured in a motorcycle accident and a 51-year-old woman who fell upside-down. The clinical examinations revealed no neurological or vascular disturbance. Closed reduction by the traction method was achieved without complications under general anesthesia. The treated shoulders were immobilized in a sling for about three weeks before immobilization shoulder exercise began. They were able to regain a full range of motion of their shoulder and had no complaint of pain or recurrent dislocation at 29 and 5 months follow-up periods.

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It is difficult to obtain successful union in nonunion of the scaphoid fracture with avascular necrosis. Masatomi reported a pedicled vascularized bone graft from the dorsum of the distal radius based on the posterior division of the anterior interosseous artery. The authors adopted this method for 2 cases with failed scaphoid union following conventional free iliac bone graft and Herbert screw fixation.
Case 1: A 20 year-old man with right proxymal scaphoid nonunion, who received free iliac bone graft and Herbert mini screw fixation 11 months after injury. The authors used this technique to treat the nonunion 8 months after the initial operation.
Case 2: A 23 year-old man with right proximal scaphoid nonunion, who received free iliac bone graft and Herbert screw fixation 2 months after injury. The authors used this technique to treat the nonunion 1 year after the internal fixation.
Both cases achieved successful bone union. Wrist pain was diminished markedly in both cases. The authors believe this method to be one of the admirable procedures for difficult nonunion of the proximal third of the scaphoid.

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Streptomycin-loaded bone-cement beads were used in the treatment of tuberculous arthritis of the elbow joint in a 89-year-old man. He had no history of pulmonary tuberculosis. He was treated with isoniazid, rifampicin, and ethambutol for 2 months. Then sinovectomy and intraarticular debridement of the elbow joint and curettage of the radial head were carried out, but the elbow failed to demonstrate any improvement. Seven weeks after debridement and curettage, streptomycin-loaded bone-cement beads were applied to the radial head. A functional elbow brace was used for six months. ROM exercises began six weeks postoperatively.
At the six month follow-up, the elbow was pain free, with limited flexion (100° flexion, -10° extension). Standard Laboratory test showed no signs of infection. X-ray images showed no evidence of necrosis, or new bone formation. The patient recovered without complication.
Based on this limited experience, it appears that streptomycin-loaded bone- cement can safely and effectively be used in the treatment of tuberculous arthritis.

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Dislocation of the femoral head from the acetabular shell after total hip arthroplasty is a disturbing complication for both patient and surgeon. To prevent the dislocation, the authors developed a guide and a technique for positioning the acetabular shell. The risk of dislocation for each patient was evaluated with a scoring sheet the authors designed.
In this prospective study, total hip arthroplasties were done in 44 patients. 36 patients had degenerative coxarthritis, 3 patients had rheumatoid arthritis, and 5 patients had avascular necrosis of femoral head. Follow-up period was from 12 months to 32 months (mean 16 months). The average age of the patients at the time of operation was 62 years. The clinical results of the patients were evaluated with the Japanese Orthopaedic Association's score (JOA score). The risk of dislocation was also evaluated. In this study, the dislocation rate was 2.3per cent. This rate is lower than in previous studies by the authors.
To prevent dislocation of hip, using the author's shell positioner guide and dislocation scoring sheet might be found to be useful for patients and surgeons pending further study.

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We reported the results of nine ipsilateral femoral fractures after total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA) which were combined with a loose femoral component. Nine patients, three men and six women, were operated on with Huckstep prosthesis between November 1990 and November 1999. According to Johansson's classification, there were six type I fractures, three type II fractures and no type III fracture. All cases underwent the revision THAs which were cementless, long femoral components (Huckstep prosthesis). We attemped to restore femoral bone volume and bone quality with allograft and articial bones (hydroxyapatite and AW glass ceramic).
All fractures were fused without complications and all femoral components had good fixation without loosening and sinking. Finally, the hip scores of the Japanese Orthopaedic Association were from 68 to 98 points (average, 77 points).
Revision THAs with Huckstep prosthesis were possible to maintain the reposition, correct the leg length and restore the bone stock with bone graft.

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A drug delivery system using allografts were used to prevent recurrence of the infection after total hip arthroplasty. From 1990 to 1999, allograf is were used to reconstruct bone defects in 6 patients, 5 females, 1 male, average age 62 years old, Staphylococcus epidermidis (2 patients), Proteus mirabillis (1 patient), unknown (2 patients) during the two-stage revision of a total hip arthroplasty that had failed due to infection. Reconstruction was performed by removing the old prosthesis and treating the infection by thorough debridement, antibiotic-impregnated cement beads and continuous irrigation of involved region. The allogenic bone chips were centrifuged at 3000rpm for 30 minutes with antibiotic active against bacteria that commonly cause infection of hip prosthesis.
At an average of 4.5 years after the reimplantation, no patients had recurrence of the infection. The average Japanese Orthopaedic Association hip score was 85 points. Allogenic bone was uniformed with autogenic bone.
The findings in these 6 cases appear to support the statement that antibiotic-impregnated allogenic bone provides slow release of the antibiotic and can be used for bone reconstruction, suggesting that it could be effective for reconstruction when infection occurs after THA, in certain cases.

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Five acetabular revision arthroplasties were performed with allograft bone and hydroxyapatite using the KT plate in 5 patients. The average age of the patients at the time of revision was 74 years. According to Gustilo's classification, acetabular bone defect was type II for 3 hips, and type III and type IV for 1 hip each. The mean follow-up of the series was 1 year. The mean preoperative JOA score was 41 versus 64 at the latest follow-up. No loosened prostheses were observed. This study, though limited in size, indicated that acetabular allograft reconstructions reinforced by KT plate were able to provide satisfactory results.

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The authors report four cases of revision hip arthroplasty with massive deficiency of acetabular bone (AAOS classification, type 3). Autograft, allograft and A-W glass ceramics were grafted in the area of bone deficiency, and the Kerboull cross shell was implanted to reconstruct the acetabulum in each case. All four hips were type 3 according to the American Academy Orthopaedic Surgeons' classification. The revision arthroplasties were performed in our hospital from 1995 through 2000.
The patient in the first case was an 88 year-old woman. In 1984, she was performed the left THA in our hospital. In 1998, left coxalgia recurred and the abnormal sound of the joint occurred. The range of motion of left hip joint was extremely limited.
The patient in the second case was a 75 year-old woman. In 1978, she was performed the left THA. In 1995, left coxalgia recurred. Because she had suffered from osteoarthritis of right hip joint too, she was performed a right THA in advance. Autograft from that operation was used in left revision arthroplaty.
The patient in the third case was a 79 year-old woman. In 1985, she was performed the left THA in our hospital. In 1999, left coxalgia recurred, and infection was recognized and all implants were removed. After the infection improved, we performed a left revision arthroplasty.
The patient in the fourth case was an 82 year-old woman. In 1987, she was performed the right THA in our hospital. In 2000, right coxalgia recurred. Inner head was dislocated from acetabulum.
In all of our cases, coxalgia disappeared and there is no loosening although clinical course is still short term.

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Bipolar femoral head replacement (BHP) was performed on 9 hips of 7 rheumatoid arthritis (RA) patients. The average age was 60.6 years (range 29-81), average disease duration was 18.4 years (range 1-42), and average postoperative follow-up period was 50.8 months (range 20-90). We analyzed the clinical results using the hip score of the Japanese Orthopaedic Association (JOA score) and Fujibayashi's classification. Köhlerline-cup (KC) and tear drop line-cup (TC) length and CE angles were measured on X-ray images for the evaluation of medial and upward migration. CE angle' was defined for the 4 cases with the bone graft on the accetabular edge.
The JOA score, especially the JOA pain score, and Fujibayashi's class improved significantly (p<0.05) postoperatively. KC length decreased and TC length increased in 77.8% (7 of 9 hips). Two joints in two patients with marked upward migration dislocated postoperatively. No statistically significant correlations of medial or upward migration with CE angle or CE angle' were found.
The authors conclude that bipolar femoral head replacement might not be indicated for some patients with RA.

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This report was based on our clinical results of treatment of 23 hips in 16 patients (9 male with 15 hips and 7 female with 8 hips) with atraumatic osteonecrosis of the femoral head (ONFH), that were treated with bipolar hemiarthroplasty from 1985 to 1998. The average age at operation was 53 years old (23-72), and the mean follow-up interval was 62.7 months (15-145). The cases included 5 idiopathic, 9 steroid-induced and 9 alcohol-induced necrosis. According to the Japanese Ministry of Health staging of ONFH, two hips were stage 2, seventeen were stage 3, and four were stage 4. The mean Japanese Orthopaedic Association (JOA) score at preoperation was 52.0 points (24-79) (pain 14.1, ROM 17.3, gait 9.1 and ADL 11.5), and at the final follow up was 91.4 points (40-100) (pain 37.0, ROM 18.2, gait 17.9 and ADL 18.3). The distance of migration of the femoral head correlated negatively with the JOA score, but the distance of sinking of the stem correlated with the JOA score (p<0.001). Stem sinking was observed in 4 hips, and the worst JOA score was associated with 8.5mm stem sinking. Careful follow-up to monitor sinking of the stem should be continued for the ONFH patients treated with bipolar hemiarthroplasty.

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In Japan's aging society, to preserve their level of activity the number of patients with intra-articular femoral neck fracture needing some surgical treatments is increasing steadily. The authors have treated these patients using the Hansson-pin hook system, a newly developed osteosynthesis procedure, from Nov. 1998. The authors compared the clinical results of fixation with Hansson-pins (13 cases) with these of Bipolor Hip Prosthesis (16 cases). Clinical results of the former were significantly better than these of the latter regarding surgical times, blood losses and periods of hospitalization. Bone union was speedy.
In conclusion, Hansson-pins hook system is a useful procedure for the treatment of intra-articular femoral neck fractures.

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We treated unstable intertrochanteric fractures with the modular trochanteric plate (TP) in addition to the dynamic hip screw (DHS). The mean follow-up period was 9 months. The cases consisted of 1 male and 6 females with an average age of 85 years old (range, 76 to 93 years old). According to AO classification, all cases were 31-A2. The patient were able to bear full weight within 8 weeks after operation. In all cases callus formation was obtained within 6 to 8 weeks. Limited fracture impaction was found in 5 cases with telescoping of 4.9mm (range, 0 to 10mm). Infection, breakage of implant, and cut-out of the lag screw did not occur. In unstable intertrochanteric fractures, the addition of TP to the DHS is a favorable treatment.

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They authors treated 62 femoral shaft fractures and 2 subtrochanteric fractures in 64 patients with the Russell-Taylor Intramedullary Nail. Their mean age was 40 years (13 to 83). Fifty femoral nails and 14 reconstruction nails were used during the period from 1991 to 1999.
Six fractures were pathological, 2 fractures resulted in septic non-union, and 2 patients were lost to follow-up. Excluding these 10 fractures, 54 cases were classified by the type of fracture (AO group), the location of the fracture, and type of fixation. In each case, the authors analyzed time to full weight bearing and bone union retrospectively. The time to bone union was evaluated by radiographic findings.
The average time to full weight bearing was 17 weeks (6 to 40 weeks), and the average time to bone union was 19 weeks (8 to 52 weeks). There was not any difference in the type of fracture and the location of the fracture. The average time to bone union of the dynamization group (Static lock) was 26 weeks (12 to 52 weeks), which was the longest, however dynamization by the removal of the locking screw is useful in the case of delayed union.
Two cases early in the series of 54 required insertion of additional distal locking screws postoperatively. Since then, even if the case was a simple fracture, the authors tried to static lock the interlocking nail. Russell-Taylor Intramedullary Nail was very useful for femoral shaft fractures and subtrochanteric fractures in these cases.

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The combined femoral fracture defined as occurring simultaneously in two or more parts in neck, shaft or condyle of femur is rather uncommon. We reviewed results of fourteen patients with combined femoral fracture from 1985.
There were seven men and seven women with an average age of 46.3 years (range, 30∼68 years old). The average follow-up period was 18.6 months (range, 10∼36 months). All patients were injured in traffic accidents. Based of the Aoyagi's classification, one of the fractures was GIa, five were GIb, four were GIIa, three were GIIb, and one was GIV.
All patients had associated injuries. There were seven patella fractures, seven ipsilateral fractures. Major nonorthopaedic injuries occurred in nine patients.
All patients treated with a variety of operative stabilization methods, and union was achieved in all cases. The functional evaluations based on Karlström's criteria were rated as follows; 2 cases excellent, 3 good, 5 fair and 4 poor.
Our results suggest it important to perform static fixation and early ROM exercise.

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Two patients with hypopituitarism complicated with slipped femoral epiphysis presented for treatment. The heights of both men (22 and 30 years old) continued to increase in adulthood despite low levels of growth hormone and somatomedin.
In order to close the systemic epiphyseal line, hormone replacement therapy was performed with T4 (75μg per day) orally, adrenocortical hormones (20mg per day) orally, and testosterone (250mg once per two weeks) intramuscularly. Moreover, to prevent slipping and thus to close the epiphyseal line, the slipped femoral epiphysis was pinned in situ using canulated cancellous hip screws.
Radiographic images of patient 1 showed that the proximal epiphyseal line of the femoral head had become closed after a year of treatment, and the hip screws were removed. His rate of increase in height has been reduced to 0.4mm per year. In patient 2, we found partial closure of the proximal epiphyseal line of the femoral epiphysis after 4 months of treatment, and this patient is under observation. Both patients were free of hip pain with no further worsening of the slipping.
Based on our experience of these two patients, we speculate that certain endocrines with growth hormone-like action (for example, insulin) are involved in incomplete closure of the epiphyseal line and continued growth.

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