The authors performed 11 total hip arthroplasties with Kerboull cross shell in 11 patients (1 man and 10 women) from 1998 to 2001. The average age of the patients at the time of operation was 66 years (range, 41-80), and the follow-up intervals were 6-42 months. Acetabular deficiency according to AAOS (American Academy of orthopaedic surgeons classification) was type II for 6 hips, and type III for 5 hips. The types of bone graft were autograft bone in 2 hips, and allograft in 9 hips (with hydroxyapatite particles in 5 of the 9 hips). Full weight-bearing was allowed after 4∼8 weeks in order to stabilize the femoral component. The mean preoperative JOA (Japanese Orthopaedic Association) score was 21 versus 73 at the latest follow-up.
The authors had to bend the pallet of the Kerboull cross shell to adapt to the bone in each case. Loosening and radiolucent line was observed in 1 case of bonenecrosis after radiation therapy for uterine cancer. There was no loosening or radiolucency in the other 10 cases. Our results suggest that bending the pallet of the Kerboull cross shell did not cause problems in these cases, however the follow-up is still short term.

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We reviewed 15 total knee arthroplasties for rheumatoid arthritis (RA) patients from 1994 to 2002. The subjects were 2 men (2 knees) and 9 women (13 knees). The mean age at the operation was 66.1 years (60-74 years). The average follow-up period was 2.6 years (3 months-6.3 years). RA activity was well controled in the all patients. All of the defects were at the medial tibial plateau. The Deltafit 7000 implant was used in 14 knees and the Nexgen flex implant, 1 knee.
For the bone defect, bone cement for 8 knees, 10°metal wedge for 2 knees, 20°metal wedge for 3 knees, metal block with hydroxyapatite for 1 knee, and autograft for 1 knee were used respectively. The average point score of the Japanese Orthopaedic Association (JOA) scoring system for RA knees improved from 39.0 to 87.5. All types of augmentations worked well. In conclusion, in TKA for RA patients, we used metal wedge, metal block and autograft respectively according to the volume of bone defect, and could obtain good results. In cases with massive bone defect, it might be necessary to use combination of various augmentations, because single method was not enough to cover the defect.

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The purpose of this retrospective study was to analyze sagittal obliquity of reconstructed anterior cruciate ligament (ACL) using the central third of the patellar tendon from 1996 to 2001 with magnetic resonance (MR) images, and to correlate sagittal obliquity with clinical results. MR images were taken between 1 and 51 months (mean: 11.8 months) after surgery on 40 knees (24 men and 16 women). The mean age was 26.0 years (range: 14 to 49 years). MR images of a group of 80 normal ACL were also analyzed as a comparison group. Sagittal obliquity was measured between the anterior surface of the ACL and the proximal growth plate of the tibia in the sagittal plane (ACL tilting angle).
The mean ACL tilting angle of the reconstructed ACL (61.6±6.0 degrees) was significantly larger than that of normal ACL (49.1±6.2 degrees). The ACL tilting angle did not correlate significantly with the KT-2000 side-to-side difference, and did not correlate significantly with the Lysholm score. Although tibial and femoral tunnels were created at the ideal place, the ACL reconstructions were not precisely anatomical.

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For the treatment of lumbar spine instability due to infection, we used spinal instrumentation after control of infection. Treatments for chronic infection in the 2 cases were not altered for the operations.The first patient, a 70-year old woman, had serious low back pain and paresis of lower extremities during sitting and standing. She had already been treated with antibiotics for 1 year under the diagnosis of tuberculosis in lumbar spine. Extensive destruction of L2 and L3 vertebrae, spinal canal compression, and abcesses in the iliopsoas muscle were observed by CT and MRI. The lateral view radiograph showed severe instability at the L2/L3 level in flexion/extension posture. The extrafocal posterior fusion (T12, L1 and L4, L5) with pedicle screw/rod system and anterior decompression with bone graft were performed. Tuberculosis infection was confirmed by PCR. Five months after the operation, she could walk without any support. The second patient, a 72-year old woman, complained of serious low back pain and paresis of left leg. She could not walk because of severe left leg pain persisting for about 1 month. Antibiotics had been administered for three years under the diagnosis of pseudomonas infection. The L5 vertebra was collapsed resulting in serious instability. The spinal canal was compressed by necrotic tissue. The lesion extended to L4 and the sacrum. The extrafocal posterior fusion (L2, L3 and pelvis) with screw/rod system were performed without decompression of the spinal canal. Nine months after the operation, she could walk with a cane.

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To examine whether the extent of respiratory disorder is related to the severity of cervical spondylotic myelopathy (CSM), we investigated respiratory functions: forced vital capacity for 1 second; FEV₁%, % vital capacity (%VC) in patients with CSM and lumbar spinal canal stenosis (LSS).
In the CSM group (n=30), there were 19 men and 11 women. In the LSS group (n=32), there were 14 men and 18 women. In the CSM and LSS groups, the average ages were 66.7 and 64.8, the average heights were 159.4 and 156.2, and the average body weights were 54.9 and 58.1, respectively. There were no significant differences in age, height and body weight in these groups. The FEV₁% in CSM and LSS groups were 80.2%, 84.6%, and %VC in these groups were 87.9%, 100.2%, respectively.
In the CSM group, the JOA spinal score decreased as the %VC decreased (correlation r=0.361). These findings indicate that %VC appears to correlate with the severity of CSM.

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We studied the surgical outcome in 6 cases of cervical spondylotic myelopathy with athetoid cerebral palsy (Athetoid cervical myelopathy). All of the patients underwent unilateral open-door laminoplasty with autogenetic iliac block bone graft. There were 3 men and 3 women with a mean age of 49.0 years (range, 37 to 60 years) and a mean follow-up period of 2 years and 11 months (range, 5 to 106 months). There were 2 cases of canal stenosis within 13mm of anteroposterior diameter, and all the cases had instability of 2mm or more. Bone union was acquired in 5 cases. The mean JOA score (Scoring system of Japanese Orthopaedic Association for cervical spondylotic myelopathy)was 5.3 (range, 1-8) before surgery and improved to 8.2 (range, 3-12) after surgery. Functional scores of lower extremities improved in 4 patients. The mean improvement rate was 25.7% (range, 13-44%). Surgical treatment for athetoid cervical myelopathy is difficult because of its severe multisegmental instability and canal stenosis. Laminoplasty with one block bone graft was to be useful for these cases.

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We report a case of agenesis of the odontoid base after atlantoaxial posterior fusion.
A thirteen-year-old boy presented in 1991 with a chief complaint of gait disturbance. He had distal dominant sensory disturbance and a spastic gait.
Agenesis of odontoid base (Greenberg type III) was observed on plain radiographs. Atlantoaxial instability was apparent in the flexion position. Space available for spinal cord was 7 mm in flexion and 17 mm in extension. MRI showed severe spinal cord compression at C1/C2 level. Atlantoaxial posterior fusion (Gallie procedure) was performed in 1991, and Halo-vest was applied for two months after surgery.
Neurological deficits were not observed at the final follow up of 11 years after surgery. Lordosis of the upper cervical spine (C1 to C3) had not changed over the eleven years and the spinous processes of C1, C2 and C3 had united. Although the growth rate of C3 vertebral height was not different from the lower vertebrae, that of C2 was smaller than that of the lower vertebrae. Growth of grafted bone was also observed. A defect of the first cervical sclerotome may have contributed to the cause of smaller growth rate of C2.

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Since 1991 to 2002, callotasises using the Ilizarov technique in cases of limb lengthening and correction of angular, axial, translational limb deformities have been performed.
There were osteogenetic diseases in 30 patients (48 limbs), clubfeet in 2 patients (4 limbs), Blount disease in 4 patients (4 limbs), deformities after fracture in 4 patients (4 limbs) and others in 8 patients (8 limbs). All cases were classified as severe.
Complications with the Ilizarov technique recorded in case files of 48 patients (68 limbs) were investigated.
Duration of using the Ilizarov external fixator, the distances of lengthening, the duration of limb lengthening and the incidence of complications were investigated. Complications, included superficial infections in 47%, and serious infections, in which Ilizarov wires were removed, in 10%. Talipes equines was in 30%, and delayed consolidation in 17% were recorded. No complications were seen in 16%.
Complications were fewer and less severe in treatment of short duration to correct alignment deformities. In contrast, complications were more frequent and severe in the cases requiring limb lengthening.

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We reviewed retrospectively the cases of 8 children who were surgically treated for Chiari I malformation with scoliosis and syringomyelia. The patients were 5 males and 3 females, ranging in age from 7 to 16 years (mean, 10.8 years). The follow-up periods ranged from 12 to 51 months. Clinical symptoms found in all patients included scoliosis (100%), dysbasia (38%), headache (25%), nocturnal enuresis (25%). The duration of symptoms ranged from 12 to 60 months. All patients underwent foramen magnum decompression (FMD) and duraplasty (DP) with preservation of the arachnoid membrane. Simultaneously, four patients underwent C1 laminectomy, 3 patients underwent C1 laminoplasty, and 1 was unspecified. Postoperatively, scoliosis improved in 6 cases, remained unchanged in one case, and progressed in one case. Mean Cobb’s angle decreased from 54.0°(range, 31-78°) to 44.4°(range, 16-76°). Cobb’s angles less than 25°were achieved in 2 patients (25%) with scoliosis less than 40°and they were able to discontinue use of the brace. Three patients (37.5%) with scoliosis that remained sever (>50°) required an additional corrective operation. Three other patients (range, 25-50°) continue to use the brace. Clinical symptoms improved in 4 cases, but nocturnal enuresis continued in 1 case. Magnetic resonance images showed a decrease in size of the fistula in 4 patients, and an increase in one patient. It was thought that the operation when Chiari I malformation was less than 40°Cabb’s angle resulted in improvement of the spinal deformity.

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Septic arthritis is an important but infrequent complication of Salmonella infection. We describe a case of Salmonella oranienburg in septic arthritis of the hip. The patient was a 14-year-old girl with a fever of 38.3°C and had severe pain in her left hip, but no diarrhea. She had had symptoms consistent with a common cold for about 1 month. She presented to us on the first day the pain in her left hip appeared. The radiograph showed no sign of infection, but signal changes in her left hip were seen on MR images. An aspiration of the left hip joint yielded yellow turbid fluid, and from which S. oranienburg was isolated. We administered the antibiotics imipenem, piperacilin and panipenem, and did open aspiration of the joint twice. After operation, swelling and pain was improved in her left hip. At the 8-month follow up, she could walk without pain.
The possibility of Salmonella infection should be considered in the diagnosis of septic arthritis.

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The authors have treated soft tissue injuries at the insertion to bone using bone anchor since 2001. In the present study, 10 patients (6 men, 4 women) underwent surgery (age range, 17-74 years; mean, 45.4 years), and of these, 4 patients had rupture of the lateral ligament of ankle, 3 patients had rupture of the ulnar collateral ligament of the metacarpophalangeal joint of thumb, 2 patients had fracture of the greater tuberosity of humerus, and 1 patient had rupture of patellar tendon. The follow-up periods were between 4 and 18 months (mean, 12.2 months). All cases except the fractures of the greater tuberosity of humerus resulted in good fixation on stress radiographs. Surgery was repeated in 1 case of fracture of the greater tuberosity of humerus due to displacement of the bone anchor 2 weeks after the initial procedure. In another case, additional cancellous screw fixation was required because the bone anchor had insufficient strength. In general, bone anchors are less invasive, suitable for use in a small field and in intra-articular surgery. They can also shorten the duration of surgery. However, because the bone anchor did not have sufficient strength in 2 patients with fracture of the greater tuberosity of humerus, caution should be exercised before using bone anchors in such cases.

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Salmonella is a common pathogenic bacteria often associated with food poisoning, and purulent osteomyelitis represents less than 1 percent of all Salmonella infections. The authors report a rare case of Salmonella osteomyelitis in the proximal femur in a healthy adult.
On July 2, 2002, a 30-year-old man was referred to our hospital for coxalgia of the right side with fever which had persisted for 4 weeks without response to intravenous antibiotics (CEZ 1 g/day and ISP 400 mg/day for 7 days). Initial radiographic findings showed a 3×1.5 cm, radiolucent lesion in the proximal femur.
The next day, open biopsy and curettage were performed. Bone abscess material was obtained for culture at operation, and Salmonella braenderup was identified as the causative pathogen. Intravenous antibiotics were administered for 24 days (CTM 2 g/day for 6 days, CP 2 g/day for 3 days and ABPC 2 g/day for 15 days), oral LVFX 300 mg/day for 13 days, and continuous perfusion for 2 weeks after operation.
At follow-up, 2 months after the operation, the patient had no functional deficit, could perform daily activities, and farming tasks without any problems. The radiolucent lesion was reduced.
Salmonella osteomyelitis commonly arises without digestive trouble as a prodromal symptom and may recover well with treatment for general purulent osteomyelitis.

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We describe 19 patients with supracondylar fractures of the humerus in children (1 to 10-years-old) treated between 1993 and 2001 by overhead transolecranon pin traction. The mean follow-up period was 9.3 months (2 to 18 months). According to Abe’s classification, there were 6 type III fractures and 13 type IV fractures. The fractures were managed initially by closed reduction under general anesthesia, and the arms were suspended by transolecranon pin. In most cases (n=17), the pins were removed at 3 weeks and the arms were protected by applying casts. The results of the treatment were assessed using criteria of Flynn et al.: functional factor; 10 cases were excellent, and 9 cases were good, cosmetic factor; 15 cases were excellent, and 4 cases were good. Varus deformity occurred in none of the cases, and no Volkmann’s contracture were seen. We could not find any relationships between the fracture type and the outcomes. The disadvantage of the traction method is that hospitalization is required for approximately three weeks, which is longer than other methods.

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The cases of eight patients (5 women, 3 men) who had an comminuted fracture of the distal end of the humerus treated between 1999 and 2002 in the authors’ hospital were reviewed retrospectively, Their average age was 37 years (range, 23 to 59 years). The average range of follow-up periods was 13 months (range, 8 to 20 months). Using the AO classification system, 1 fracture was classified as type C1, 4 were type C2, 3 were type C3. The operative procedures included were percutaneous pinning (1 case), open reduction and internal fixation (screw+wire, 1 case, screw+Tension Band Wiring, 3 cases, screw+plate, 2 cases). The average period of postoperative external immobilization was 7 weeks (range, 1 to 8 weeks). The average postoperative range of motion, was -19 degrees of extension (range, -40 to 15), and flexion was 116 degrees (range, 90 to 125). The average Japanese Orthopedic Association score (JOA score) at final follow-up was 84.2 points (range, 73 to 91). The clinical results of such cases in our hospital was comparable to the results of other hospitals.
We consider that rigid internal fixation and early rehabilitation are necessary to obtain good clinical results.

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Seven cases of acromioclavicular dislocation (Tossy classification Grade3) were treated using our original procedure since 1997. The purpose of this retrospective study was to investigate the clinical results of this method. The average age of these patients (6 men, 1 woman) was 36.6 years (12 to 48 years). The average follow-up was 12 months (7 to 15 months).
Under the image intensifier, the dislocated acromioclavicular joint was reduced. Artificial ligament was used for reconstruction of the coracoclavicular ligament. The reconstructed ligament was fixed to 2 holes in the clavicle with interference screw. If necessary, Kirschner wire was inserted across the acromioclavicular joint. This wire should be removed after 6 weeks.
The post operative results were evaluated by Kawabe’s evaluation system. The average Kawabe’s score was 95.7 points (85 to 100 points). No patient showed clinical symptoms at the last follow-up, but 3 cases had subluxation of the acromioclavicular joint postoperatively. It is concluded that we had good results with this method in the cases in this series, but the device for more rigid fixation should be discussed.

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Since 1994, 51 patients have undergone arthroscopic repair of superior labrum anterior and posterior (SLAP) lesions. There were 45 men and 6 women ; the average age was 29 years (range, 16 to 63 years). There were 43 thorowing arthletes, 8 heavy laborers, and 38 right and 13 left shoulders. No patient had an inflammatory disease or condition that would have affected our results. The average follow up period was 4 years (range, 0.5 to 7.5 years). In all cases the specific diagnosis was confirmed arthroscopically : SLAP type I was found in 4 cases, type II in 41 cases, type III in 2 cases, and type IV in 4 cases. Our operative indications are SLAP type II on MR arthrogram (MRA) or SLAP type I, type III and type IV, which is indistinguishable from SLAP type II on MRA. Operative treatment was performed arthroscopically for SLAP type I (debridement, 4 cases), type II (Caspari, 8 cases, suture anchor of the biceps tendon to the bony superior glenoid, 33 cases), type III (suture anchor 2 cases). In some type IV lesions, an additional procedure was used (suture anchor, 1 case, with debridement open tenodesis, 3 cases). Eleven of the cases (22%) had cuff tear (SLAP type II, 9 cases, type III, 1 case, and type IV, 1 case), which were arthroscopically repaired. We used Japan Shoulder Society (JSS) sports score to evaluate our clinical and functional results. Improvements were significant. All patients had good results and returned to their previous levels of activity. Arthroscopic repair of the detached and floating biceps labrum complex gave excellent early results, restored the anatomical configuration and provided good stability.

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Since 1994, 20 patients have undergone arthroscopic Bankart repair (Caspari 8 cases, suture anchor 12 cases). There were 17 men and 3 women ; the average age was 25 years (range, 14 to 62 years). No patient had an inflammatory disease or condition that would have affected our results. There were 10 right and 10 left shoulders. Eighteen patients had more than three dislocations, two patients were treated for initial dislocation. The average follow up period was 4 years. We used Rowe score to evaluate our clinical and functional results. Improvements were significant. The early results of our series reveal a 10% rate of redislocation (2 cases). Results of 18 patients were excellent and did not have dislocations. One patient, a baseball pitcher, redislocated the shoulder after Bankart repair with suture anchor technique of the bicepslabrum complex (BLC). Reoperation was performed with transglenoid suture technique. One month after operation, the other patient had a mental disorder. One month after operation, he had a gran ma epileptic siezure and redislocated the shoulder. He changed to conservative treatment. There were not any other complications. There was not a correlation between the cases with BLC suture anchoring and conplications. We performed the transglenoid suture technique for cases of Yoneda’s classification type 2, and the BLC suture anchor technique for type 1 cases. We think the transglenoid suture technique is stronger than the BLC suture anchor technique, but in general the rate of complications is also higher. It seems to be a good method for treatment, but might not be the most appropriate choice in all cases of labroligamentous detachment.

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The modified Bosworth’s method has been performed since 1994 for fresh cases of acromioclavicular dislocation belonging to grade III of the Tossy classification. 16 cases treated at our hospital were retrospectively studied by direct examination and questionnaire survey. 11 patients were men and 5 were women, whose mean age was 42 years. The mean period from injury to surgery was 14 days. The mean follow-up period was 4 years and 2 months.
Evaluation was made according to the Japan Shoulder Society (JSS) score for acromioclavicular joint. Radiological evaluation was made of subluxation, osteoarthrotic changes, and coracoclavicular ossification. In addition, the correlation of results to radiological findings and that of results with period of internal fixation was studied.
We observed subluxation in 1 shoulders, osteoarthrotic changes in 4 shoulders. And we simultaneously obserbed coracoclavicular ossification, subluxation and osteoarthrotic changes in 1 shoulder. Of the full score of 90 points of the JSS score, the score ranged from 50 to 90 points with a mean of 80.0 points. These results were satisfactory, being comparable to those of other treatment. No adverse effect of postoperative subluxation, osteoarthrotic changes of acromioclavicular joint, coracoclavicular ossification, and longer period of internal fixation was observed on our clinical results.

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The purpose of this study was to devise radiographic indications for treatment for epiphyseal lesion of the olecranon in baseball players. Eleven players diagnosed as this lesion between 1995 and 2002 were retrospectively evaluated. The mean age at first presentation was 14.2 years (range, 12 to 16 years). The lesion was classified into 3 types, based on radiographic appearances; unclear margin in type I, clear margin in type II, and sclerotic change in type III. Of the 11 lesions, 3 were type I, 4 type II, and 4 type III. Conservative therapy was performed at least 3 months on all the subjects. Conservative management produced healing in all type I lesions, 75% of type II and none of type III. All type III lesions and 25% of type II were required operation including bone graft with tension band wiring. These findings suggest the radiographic findings of this lesion are an essential indicator of treatment.

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Radiographs of 1728 outpatients (mean age, 54.6 years ; range, 15 to 99) taken from 1995 to 2000. in our institution were examined for age, sex, level, direction, degree of slip and lumbar lordosis. We excluded cases with lumbar spinal compression fracture and degenerative lumbar scoliosis (over 10 degrees) and postoperative lumbar spine. Three surgeons independently read the radiographs.
Spondylolytic spondylolisthesis was found in 63 (3.6%) of the patients, and it occurred at the L5 in 71.4% of them. Its frequency was equal in both sexes. Degenerative lumbar spondylolisthesis was found in 140 (8.1%) of the patients and in 66.4% of them, it occurred at the L4 level. It was more common in elderly women than men by a ratio of 3 : 1. Lumbar retrolisthesis was found in 119 (6.9%) of the patients, and in 72.5% of them, it occurred at the L2 and L3 levels. It was more common in the elderly patients and the frequency was equal in both sexes.
Almost all of the cases of anterolisthesis were seen in the lower lumbar spine, but the cases of retrolisthesis were seen in the L2 and L3 levels in this series.

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We presented the first case report of simple bone cyst in the pedicle of the lumbar spine.
The patient was a fifty-year-old woman with low back pain. Radiographs of the lumbar spine showed a radiolucent lesion with surrounding bone sclerosis in the right pedicle of the third vertebra. Computed tomography showed that the right pedicle was slightly expanded and completely occupied by the cyst. T1-weighted magnetic resonance imaging (MRI) showed uniform low intensity and T2-weighted MRI showed a uniform, very high intensity. Signal enhancement by gadoliniumdiethylenetriaminepenta-acetic acid did not appear in the area of the lesion. The cystic lesion, which contained 2 ml of serosanguineous fluid, extended to both the vertebral body, and the lamina. At operation to remove the cyst, the cavity was filled with calcium-phosphate bone paste. Subsequent histological examination showed a thin layer of connective tissue at the inner surface of the cyst. One year after the operation, no recurrence was detected in the lumbar vertebra and she returned to work.

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Ewing sarcoma is a high-grade, malignant neoplasm which often occurs in children and adolescents. It is commonly treated with a combination of chemotherapy, radiation therapy and surgical resection. However, sufficient surgical margin cannot be achieved sometimes because commonly affected sites are the pelvis and the proximal femur. The authors describe a patient with Ewing sarcoma of the pelvis who was treated with internal hemipelvectomy combined with chemotherapy and radiation therapy.
A 14-year-old boy was referred to us for the treatment of pelvic osteomyelitis. Radiographs and computed tomographs showed osteoblastic and osteolytic lesion in the right pelvis, and a pathological fracture of the acetabulum. Magnetic resonance images showed the entire right side of the pelvis was affected. A bone scan showed increased uptake in the same region. Open biopsy revealed a small round cell malignant tumor consistent with Ewing sarcoma.
A course of preoperative chemotherapy diminished the increase of the uptake of the bone scan. Then we undertook total internal hemipelvectomy. Complete removal of the tumor with a sufficient margin was achieved, which included the right hip joint. The osteotomized trochanter was fixed against the sacrum with cancellous screws, and a pedicle screw system connected the lumbar vertebrae and the femoral shaft. The surgery was followed by radiation and chemotherapy.
The patient remained disease free at the two-year follow-up. He could walk with two crutches, although the affected limb was shorter by 8 centimeters.

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