Five cases of osteochondral lesion of the talus treated arthroscopically, were reviewed. The 3 men and 2 women patients ranged in age from 13 to 70. (mean age, 31. 8 years). The lesions were classified according to the radiographic stages described by Berndt and Harty. One ankle had stage-II lesion, three stage-III, and one stage-IV. The operations were performed under lumber anesthesia without a joint distraction system. All cases were performed debridement of osteochondral lesions and drilling. The results were assessed by Berndt crinical criteria subjectively, and the examination on X-ray and magnetic resonance imaging objectively. The average follow-up period was 7.4 months (range, 4 to 10 months).
Four patients had good results and one had a fair result. The fair case was a 70-years patient who had swelling of the ankle. All cases improved the osteogenesis on X-ray, and the cartilage like tissue covered the lesion. There were no major complications.
The arthroscopic treatment of the small osteochondral lesion of the talus can be useful in selected patients in a short period. The long-term results are still less predictable.

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Numerous kinds of materials are manufactured as substitute materials for bone defects. Our previous choice for benign bone tumors or tumor-like lesions was only curettage or to fill bone defects with autologous bone or hydroxyapatite as bone substitute materials. Such cases all had fine clinical results. But, recently we have used beta-tricalcium phosphate (beta-TCP) because it is well absorbed.
Between March 2000 and October 2001 we used beta-TCP on 10 cases as a bone substitute material. The volume of bone defect ranged between 1 ml and 20 ml and the mean follow-up period was approximately 6.7 months. We recognized the absorption of beta-TCP and the formation of new bone had started on radiographs within 1 or 2 months after implantation. Then beta-TCP was gradually absorbed and new bone was formed. Due to the short follow-up period in the current study, beta-TCP was not absorbed completely, but the absorption was expected to continue. Longer follow-up periods are expected to show both complete absorption of beta-TCP, and morphogenesis to newly formed host bone.
Beta-TCP was a useful bone substitute material in this study.

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Malignant peripheral nerve sheath tumor is the most common malignancy of the peripheral nerve. But chemotherapy or irradiation do not improve local control of this tumor. From 1985 through 2001, seven malignant peripheral sheath tumors were treated at our department. Five patients were men and two were women, whose mean age was 48 years old. Four patients had coexistent neurofibromatosis. Surgical excision was performed in six patients. Local recurrence occurred in three patients, all of whom had neurofibromatosis and marginal resection. Two patients without neurofibromatosis remain disease free, although one of them underwent marginal resection. The authors could not find any effect of either chemotherapy or irradiation on local control of the tumors. Complete resection of such tumors with negative margins is advisable for local control of the disease and survival.

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The authors evaluated the medical costs in the acute phase of femoral neck fracture that had treated operative procedure. We random selected 10 patients without complication from 82 patients with femoral neck fracture that were surgically treated in our hospital, an acute care facility between July of 2000 and June of 2001. Four patients were treated by yen-nail, 3 patients by femoral head replacement and 3 patients by cannulated cancellous hip screw (CCHS). Hospital stays were less than 20 days in 3 patients, 21 to 30 days in 3, and more than 31 days in 4. In terms of the average medical cost per day, femoral head replacement had the highest cost and CCHS had the lowest cost. A minimized length of hospital stay increased the average medical cost per day. We believe that minimizing the length of hospital stay in the acute care facility and the close relationship with institutions for the aged that provide long-term nursing care are indispensable for medical cost control of femoral neck fractures.

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We reported the cost comparisons in bipolar hemiarthroplasty (BHP) for femoral neck fracture in 24 elderly patients who underwent BHP from April, 2000 to March, 2001. The case records were divided into three groups : group A ; five patients aged 50 to 65 years, group B ; 10 patients aged 66 to 80 years, and group C ; nine patients aged more than 81 years. The relationships of medical cost with length of hospital stay, age, and pre-operative complications were investigated. The mean length of hospital stay was 31.6 days in group A, 37.5 days in group B, and 40.2 days in group C. The pre-operative complication rate was 80%, 50%, and 78%, respectively. The mean medical costs for the three groups were 2, 200, 000 yen, 2, 420, 000 yen, and 2, 340, 000 yen, respectively. There were statistical correlations between length of hospital stay and medical cost (r=0.631).
The results of this study showed that the prolongation of hospital stay resulted in an increase of the total medical cost. Due to the aging population, medical insurance systems have been facing extremely severe financial conditions since the total medical cost has increased.

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The rate of bone and joint tuberculosis in elderly patients recently has increased. The treatment for elderly patients especially for tuberculous spondylitis is difficult because many such cases have comorbidities and palsy.
This study compared treatment results for tuberclous spondylitis in elderly (over 70 years old) and younger patients. It also compared the result of operative and non-operative therapies in the elderly patient group.
The authors treated 43 patients from 1992 to 2001, their mean age was 64.4-years (range 24∼90 years). Elderly patient group included 19 cases, in 10 of the 19 cases we operated, and the other 9 cases had no operative therapy. In the non-operative group, many patients had severe complications.
The evaluations were as follows. In the younger group, 12 cases were excellent, 5 cases were good, 3 cases were fair. In the elderly group, 5 cases were excellent (all were in the operative group), 3 cases were good (1 operative case, 2 non-operative cases), 4 cases were fair (1 operative case, 3 non-operative cases), 4 cases were poor (all patints died, 2 operative cases, 2 non-operative cases). In the non-operative group, deformation of vertebral bodies and palsy remained.
Surgical treatment can provide reconstruction of the spinal structure and recovery of palsy. However, surgical treatment carries risk because such patients tend to have many comobidities. To avoid such risk, ideal treatment for these patients is early detection and early chemotherapy.

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The authors report a retrospective investigation to compare the clinical results of patients with post-fracture osteoporotic vertebral pseudoarthrosis at the thoracolumbar junction with those of patients with union.
This study compared a group of 4 women patients aged 75 to 78 years (mean age, 76 years) with pseudoarthrosis in whom the interval after injury was 4 months or more with a group of 10 patients with union group aged 68 to 89 years (mean age, 77 years). Three patients in the pseudoarthrosis group had fracture at Th12, and 1 patient at L1. Three patients in the union group had fracture at Th12, and 7 patients at L1.
The Japanese Orthopaedic Association (JOA) score was used to evaluate clinical symptoms. Change in the degree of vertebral wedging in the flexion and extention positions was regarded as indication of instability in the fracture site. Bone mineral density was measured by Dual energy X-ray absorptiometry procedure using lumbar vertebral frontal images. Type I collagen cross-linked N-telopeptide (NTx), bone specific alkaline phosphatase, and osteocalcin levels were measured as markers of bone metabolism.
In the pseudoarthrosis group, JOA scores for lumbar pain, sensation, and daily living activities were significantly (p<0.05) lower than those in the union group. The degree of instability in the fracture site and the value of bone absorption markers were significantly (p<0.05) higher in the pseudoarthrosis group. There were no significant differences in other parameters.
In the patients with the vertebral pseudoarthrosis, limitations in daily living activities were more marked than those in patients in the union group. In the patients with limitations in daily living activity and higher bone absorption markers, the effects of conservative therapy were limited.

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We report five cases of posterior spinal shortening surgery for paraplegia after osteoporotic vertebral fracture. The 5 patients were three women and two men. The average age was 70.6 years (range 64-76 years). Fracture level was Th11-L1. Average follow-up period was seven months (range 2-13 months).
The vertebra was shortened by resecting the posterior part of the spine and the application of compression force. We tried to decrease the angle of kyphosis as much as possible. Kyphosis was improved as a result. The spine was decompressed by removal of the fractured pieces.
All patients had improved walking ability. None of the implants showed damage, and there were no signs of loss of reforming at last follow-up.
It is difficult to compare posterior spinal shortening surgery to the anterior fusion by Kaneda, however, posterior spinal shortening was a successful choice for treating these cases of delayed paraplegia after osteoporotic vertebral compression fracture.

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We report a rare care of a symptomatic sesamoid in the interphalageal joint of the great toe. A 29-year-old woman had a painful keratosis on the plantar side of the right great toe for 10 years. Plain radiographs showed a 5×10cm-sized sesamoid on the plantar side of the interphalangeal joint. Ultrasound sonography showed the sesamoid between the capsule and flexsor hullcis longus tendon. We resected the sesamoid using the plantar approach. At 6 months after surgery, she had no pain in the IP joint of the right great toe. Some authors have reported that a sesamoid on the interphalangeal joint of the great toe in adults was identified 95.5% of the time in anatomic assessments and 56.3% of the time in radiographic assessments. Although many people have an asymptomatic sesamoid on the interphalangeal joint of the great toe, it should be included in a differential diagnosis of painful keratosis on the plantar side of the great toe.

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Anterior cruciate ligament (ACL) is acknowledged to consist of anteromedial (AMB) and posterolateral bundles (PLB). Endoscopic bi-socket ACL reconstruction using multiplied hamstring tendon autografts were performed in 13 patients (3 females, 10 males) since 2000. The mean age at the time of the operation was 28.7 years (range 12 to 48 years). The follow-up period ranged from 7 to 32 months.
This technique was reported by Rosenberg T. D., two femoral sockets were created through a single sockets of the tibia. ACL ruptures of 2 patients were caused by traffic accidents, and the others were caused by non-contacted force.
The knees were evaluated at the final follow-up using manual instability tests (Lachman test, pivot shift test), range of motion (ROM), side-to-side differences of anterior displacement of tibia with the KT-1000 knee arthrometer, JOA score, Lysholm score and IKDC (International Knee Documentation Committee) standard knee evaluation form.
In the postoperative results, the Lachman test was negative in 11 patients, and false-positive with firm end point in 2 patients. The pivot shift test was negative for all patients. The mean degree of knee extension was -0.2±0.8°, and that of knee flexion was 148.2±3.2°. The mean side-to-side differences of knee arthrometer values by manual maximum force was 0.2±1.8 mm. The mean JOA score was 88.2±10.5, Lysholm score was 95.2±5.3.According to IKDC score at the final follow-up, 6 patients were graded as A, 5 as B, 2 as C, and none of the patients were graded as D.
The results of this study show that bi-socket ACL reconstruction was a useful method, which obtained good outcome regarding knee stability in these cases.

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Calcium crystal deposition rarely occurs in the ligamentum flavum of the cervical spine. It may cause a variety of symptoms such as myeloradiculopathy.
We report three cases of calcification of the ligamentum flavum in the cervical spine. The patient in Case 1 was a fifty-three-year-old man. The chief complaint was numbness of arm and leg, and gait disturbance. Japanese Orthopaedic Association (JOA) score was 4 points. Radiograph and computed tomography (CT) showed calcification in the ligamentum flavum at the C5-6 level. The patient in Case 2 was forty-nine-year-old man. The chief complaint was pain and numbness in the left arm. JOA score was 16 points. There was calcification in the ligamentum flavum at the C5-6, 6-7, 7-Th 1 levels. The patient in Case 3 was a seventy-one-year-old woman. The chief complaint was gait disturbance and loss of coordination. JOA score was 8 points. There was calcification in the ligamentum flavum at the C4-5, 6-7 levels. The symptoms in all cases were improved by laminoplasty and resection of calcified component. There was no reccurense of calcification. They were satisfied with this treatment.
CLF is more common in elderly women, but it rarely cause symptoms. Calcification often occurs in the middle and lower cervical spine, especially at the C4-5, 5-6 levels, and neurological deficit progresses rapidly. CT gave the most diagnostic information showing oval-shaped calcified lesions anterior to the laminae with clear margins.

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Retrospective magnetic resonance imaging (MRI) study was done for 11 hips of seven children with dysplasia epiphysealis capitis femoris (DECF) to evaluate the signal intensity of the each epiphysis. The mean age at the time of first presentation was 2 years and 5 months (range 1 year to 3 years and 5 months). Two hips in which the epiphysis had not appeared on the radiographs showed a rounded and low signal intensity area in the cartilaginous head on T1-weighted and T2-weighted MRI. Five hips that had granular structures in the epiphysis on the radiographs. All of these epiphysis showed low signal intensity on T1-weighted MRI. Three of them showed both intermediate and high sigial intensities on T2-weighted MRI. One of the remaining two epiphysis showed low signal intensity and the other showed intermediate signal intensity on T2-weighted MRI. The surfaces of four epiphysis were irregular on the radiographs and their T1-and T2-weighted MRI showed high intentity areas. Judging from combination of the T1-and T2-weighted MRI there were no necrotic findings in these cases of DECF. Signal intensities of these epiphysis were the same as those of growing femoral epiphysis, but they appeared to be delayed for their age. Eleven hips were followed-up, 4 were bilateral, and 3 were unilateral. One of the 11 hips had MRI at 14 month intervals (twice), and 1 hip had MRI at 5 month intervals (3 times). Signal intensity of the epiphysis had changed from low intensity to high intensity according to the growth on the T1-and T2-weighted MRI during the follow-up. Based on our MRI findings, the one of the causes of DECF appeared to be the immaturity of the femoral epiphysis.

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We investigated the prognosis of 24 cases (27 limbs) of major lower extremity amputation caused by arteriosclerosis obliterans (ASO) and diabetes mellitus (DM) from January 1992 through July 2002. The average age of the patients was 69.7 years (range 31 to 92 years). The average follow-up period was 33 months (range 1 day to 9 years and 8 months). Thirteen cases were caused by ASO, and 11 were caused by DM. Hip disarticulation was performed in 2 limbs (7.4%), above-knee amputation was in 15 limbs (55.6%), below-knee amputation was in 10 limbs (37%). Survival rate for the 24 lower limb amputees was 65.1% at 1 year, 44.8% at 5 years. Five-year survival rate of 13 patients with ASO was 49.0%, and that of 11 patients with DM was 41.6%. Although one patient died of sepsis caused by stump infection, the other causes of death were pulmonary complications (35.7%, 5 patients), renal failure (28.6%, 4 patients), cardiovascular complications (21.4%, 3 patients), and cerebral hemorrhage (7.1%, 1 patient). These results show a limited life expectancy after amputation because of general complications.

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The authors report a case of osteomeylitis of the femur associated with palmoplantar pustulosis. A 48-year-old woman and the chief complaint were left thigh pain and palmar eruption. There was no abnormality on plain roentgenographs at the time of the first examination. The pus of palmar eruption was clear. The patient did not have a history of psoriasis and did not use oral steroids before then. The destructive thinning image suggests periostial reaction appeared inside the left femur through the plain roentgenograph of one month later. Trabecular bone was destroyed in pathological study. Permeation of organization ball and neogenesis of capillary vessels also appeared. Treatment with the antibiotic (MINO 200mg/a day) was performed and the symptom was reduced. At the same time, palmar eruption was diagnosed as palmoplantar pustulosis in pathological study. Department of dermatology also did a treatment for the palmoplantar pustulosis in parallel, and it also became light.
With this case, immunological test of those other than a HLA antigen was not performed and the generating mechanism is unclear. The authors think that there may be a close relation between osteomeylitis of the femur and palmoplantar pustulosis cause they generated at the period and became light in parallel. When condition gets worse, the authors think that tonsillectomy may be needed from an immunology view point.

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