Scapulothoracic dissociation (STD) is the result of a severe blunt injury to the shoulder girdle, the force being applied to the anterolateral portion of the shoulder. STD is characterized by a lateral displacement of the scapula from the thoracic cage with a poor prognosis. This study presents an analysis of 7 STDs associated with neurovascular injuries that treated from 1990 to 2003. All were males with an average age of 33.1 years (range 17 to 64 years). The average follow-up period was 2.1 years (range 1.6 to 3 years). All patients had brachial plexus injury and subclavian or axillary artery injury and multiple open and closed fractures of the ipsilateral upper extremity. Four patients underwent repair of the damaged artery using vein graft. Intercostal nerve transfer for the brachial plexus paralysis was done in 5 patients. Only 1 patient (aged 64 years) in this series required disarticulation of the shoulder on the second day of the hospital stay due to inadequate vascular function. Primary amputation should be not considered in patients with adequate vascular function from collateral circulation. The decision of the initial management of patients with STD is difficult. The ultimate goal is to seek the best possible functional outcome in each patient.

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This article is a case report of a resection of symptomatic talocalcaneal coalition. A 26-year-old man presented with hindfoot pain and paresthesia of the medial plantar nerve region of 5 years’ duration. Plain radiographs revealed talar beaking, and computed tomography showed the area of coalition measured 44% of the area of the posterior facet. Conservative treatment with an arch support and oral anti-inflammatories for 2 months prior to operation had not given any improvement. At operation, a 1.5×1.5 cm ganglion was visible, which impinged on the medial plantar nerve. We excised the ganglion and talocalcaneal coalition. At the postoperative follow-up examination at 8 months, the patient was asymptomatic, and the result was satisfactory. The indications for resection of a talocalcaneal coalition include failure of non-operative treatment, a coalition that is less than one-half of the surface area of the talocalcaneal joint, and the absence of degenerative arthritic change. The indications for arthrodesis of talocalcaneal joint include a coalition that is more than one-half of the surface area of the talocalcaneal joint or the presence of degenerative arthritic change.

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We retrospectively evaluated radiological findings taken after treatment for bone deficit with β-tricalcium phosphate (β-TCP) in 16 patients (6 men and 10 women). The mean age at the time of surgery was 59 years (range: 31 to 74 years). The intra-articular factures (6 radius, 3 tibia and 8 calcaneus) were stabilized and the trabecular bone defect was filled with β-TCP block. The mean duration of follow-up was 14 months (range: 6 to 31 months). All cases achieved good bone union without complications. In most cases absorption of the β-TCP occurred in the 3 months after operation. β-TCP can be used to supplement of the autograft.

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We assessed clinical results of plate fixation for fractures of the proximal humerus.
Nineteen cases of humeral fracture treated from 1998 to 2002 by symmetry plate were investigated. The patients were 5 men and 14 women, with an averaged age of 59 years (range, 19-85 years). The mean follow up period was 1 year 11 months (range, 1-5 years 3 months). The types of fracture were 2-part fractures in 12, and 3 -part fractures in 7 cases. All patients were evaluated by the Japan Orthopaedic Association (JOA) shoulder score.
The average postoperative JOA score was 78.4 points (range, 54.5 to 100 points). Ten cases had good clinical results. Nine cases had poor results. There was a significant correlation between postoperative JOA score and age, existence of complications, and postoperative neck-shaft angle. Our findings indicate that anatomical reduction and reinforcement by calcium phosphate were important to gain satisfactory functional results of osteosynthesis.

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Thirty-six patients (mean age, 64 years) with proximal humeral fractures were treated using Locking Humeral Spoon Plate (LHSP)(Synthes, Japan) from 2001 to 2003. The purpose of this study was to investigate the clinical results of this method. Using the AO/ASIF classification, 6 fractures were classified as 11-A2, 10 were A3, 12 were B1, 4 were B2, 1 was B3, 2 were C1 and 1 was C3.
The average postoperative flexion was 121.7°, the average abduction was 111.4°and the average external rotation was 44.8°. Thirty three patients healed without complication. One patient healed with varus deformity over 5°. In two patients, the plate cut out necessitated revision surgeries in which the LHSP was replaced with a longer plate, or humeral head prosthesis.
The LHSP maintained angular stability between plate and screws, and allowed exercise immediately after the operation. It is important to position the plate to avoid the medial side of the intertubercular sulcus, and to avoid impingement of the shoulder motion. It is possible to stabilize fractures of the 11-C3 type with the LHSP.
The LHSP internal fixation system offered us a new approache for treatment of these proximal humeral fractures.

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The objective of our study was to investigate the clinical results of early weight bearing after the surgical procedure using the compression hip screw (CHS) system for intertrochanteric fractures of the femoral neck in elderly patients.
There were 65 patients (5 men,60 women) with intertrochanteric fractures of the femur, whose ages ranged 70-102 years (mean 84.0 years) at the time of the surgery. The fracture type (Evan’s classification) and osteoporotic index (Singh classification) were evaluated in each patient. Pre and postoperative gait ability were compared to patients’age,fracture type, and postoperative CHS lag-screw telescoping phenomenon.
Fractures were grouped according to Evan’s classification of fracture type, (19 cases in Grade 1, 34 cases in Grade 2, 10 cases in Grade 3, and two cases in Grade 4), Singh’s classification of osteoporotic index, (10 cases in Grade 1, 34 cases in Grade 2, 16 cases in Grade 3, and 5 cases in Grade 4). Forty-three patients (66%) maintained their pre-injury gait-ability. The telescoping phenomenon of the CHS lag-screw ranged from 3-18 mm was found in 18 cases, and in 4 cases it was more than 10 mm. Cut out of CHS lag-screw occurred in one case. The surgical outcome did not correlate to patients’age, fracture type, or postoperative CHS lag-screw telescoping phenomenon. Postoperative complications adversely influenced the clinical results of the CHS system in these elderly patients with intertrochanteric fracture of the femur.
Early weight bearing is useful as postoperative management for aged intertrochanteric fractures of the femur.

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We reviewed 24 cases (13 men and 11 women, mean age 69.1 years, mean height 157 cm, mean weight 57.1 kg) to investigate the rate of pulmonary embolism after spinal fusion with pedicle screws.
All of the patients completed inhalation therapy for the prevention of pulmonary embolism before the operation. Their legs were compressed by an intermittent pressure flow pump during the operation. They also wore elastic stockings before and after the operation until they discharged from hospital. We measured SpO₂ when supplemental oxygen inhalation was stopped the day after operation. The patients were allowed to walk from the third to fifth post-operative day. Clinical signs were checked during the first five post-operative days. D-dimmer levels and blood gas levels were examined during the sixth to eighth post-operative days. Between the seventh to nineth post-operative days, all patients were examined for pulmonary embolism by lung scintigraphy. The pulmonary embolisms were classified into four groups (large, middle, small, and mosaic defect).
Pulomnary embolism was diagnosed in 12 patients (50%) (4 middle defects,4 small defects, 4 mosaic defects). Four patients in the non-pulmonary embolism group had clinical signs. Ten patients in the pulmonary embolism group had clinical signs, and 7 patients had fever higher than 38.5°C. There were no significant differences in age, sex, BMI, operation time, bleeding amount, arterial blood gas levels, SpO₂ or D-dimmer levels between the 2 groups.
The rate of the pulmonary embolism after the spinal fusion with pedicle screws was higher than we had expected.

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The external skeletal fixator is a useful device to maintain the alignment of the bone and bone-cartilage fragments for the fracture of the proximal interphalangeal (PIP) joint of fingers. Robertson’s traction method is conventional, but the traction system is bulky, needs frequent adjustment, and makes motion exercise difficult. Recently, some traction devices have been developed which allow early active motion after surgery. The treatment of a 24-year-old man with an intra-articular fracture of the PIP joint of the index finger is reported in this case report. A Meira’s mini external skeletal fixation system was applied to maintain the alignment of the joint. This titanium system is small, permits easy adjustment of the traction force, and allows early active range of motion training. The bony union was completed and the joint congruity was good at 2 months after surgery. The range of motion of the PIP joint was 75 degrees at 6 months after surgery. Meira’s mini external skeletal fixation system was useful for the treatment of the fracture of the PIP joint.

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It is difficalt to maintain reduction of the fracture during conservative treatment for intra-articular or palmar displaced fractures of distal radius. Therefore, various surgical treatments such as percutaneous pinning, external fixation, and plate fixation were developed. In this study, we examined the effect of palmar-side plate fixation for these fractures.
Ten patients (2 men and 8 women) with a mean age of 58 years at the time of the injury (range, 31-74 years) were included in this study. The follow up after the operation ranged from 5.5 to 20 months (mean, 12 months). The type of fracture was classified according to Saito’s classification (one sinple Smith’s fracture, five comminuted Smith’s fracture, two comminuted Colles’ fracture and two palmar Barton · chauffeur’s fracture). All the patients had internal fixation using a plate and screws via the palmar approach. 4 patients were added Kirschner wire fixation and 6 patients were grafted β-tricalcium phosphate for bone defect. In 9 of the 10 cases, good reduction according to radiographic parameters including volar tilt,radial inclination, and ulnar variance was obtained at the time of the surgery,and was maintained during the follow up period. In one elderly patient with osteoporosis, the volar tilt and ulnar variance were not maintained. According to the evaluation criteria of Saito, there were 4 excellent, 5 Good, and one fair result. Patients with fair results had contracture of fingers and wrist joint in the post operative period.
We concluded that palmar plate fixation for intra-articular or palmar displaced fractures of the distal radius was a useful surgical procedure in this case series, although postoperative reduction was not maintained in one elder patient with osteoporosis.

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We report the results of a novel method using the forearm venous flap with the medial antebrachial cutaneous nerve for reconstruction of a composite soft tissue defect of a digit, which included a digital nerve, artery, and skin. Four patients underwent the reconstruction (1 index finger, 2 middle fingers, and 1 ring finger) were evaluated. The length of the medial antebrachial cutaneous nerve grafts ranged from 2 to 5.5 cm, with a mean length of 3.6 cm. All of the venous flaps were successful. In the 3 patients for whom the follow-up period was over 6 months, the sensibility scores of the tips of the treated fingers were 11, 6, and 5, respectively, on s-2 PD and all 3 could sense filament #6 on the Semmes-Weinstein test. The results of this study show that, in patients with composite soft tissue defect including a digital nerve, artery and skin, forearm venous flap with the medial antebrachial cutaneous nerve grafting should be considered as a clinical alternative for nerve reconstruction of the digits.

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Giant cell tumor of bone (GCT) is known for its extremely high recurrence rate among bone tumors, and if it arises primarily at the femoral neck, particular attention must be paid. We studied primary GCT at the femoral neck in 8 patients, which was difficult to diagnose and treat in 8 patients treated between 1990-2001. The patients, 7 men and 1 woman,were first diagnosed with GCT at mean age of 31 years rage, 19-73 years, and followed up for a mean period of mean 80.0 months range, 24-156 months. One patient had preoperative open biopsy, and the remaining 7 patients had excisional biopsy, to decide the treatment method after rapid pathological examination during the surgery. The initial surgical method was total hip arthroplasty (THA) in 2 patients, bipolar hip arthroplasty (BHA) in 1 patient, curettage with open reduction internal fixation (ORIF) in 2 patients, curettage and cementing in 2 patients, and the arthrodesis of the hip joint in 1 patient. Local recurrence was observed in 2 patients who underwent the curettage and cementing. GCT is a borderline bone tumor, THA and BHA should be avoided for the initial surgery, as they can be feasible later. The initial surgical method should be excisional or incisional biopsy, taking precedence of the method to allow the recovery surgery, even though the altimate diagnosis is malignant GCT.

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This report was based on a retrospectire study of clinical results of 35 patients (20 bone tumors: 11 osteosarcomas, 4 chondrosarcomas, 4 chordomas and one Ewing’s sarcoma; 15 soft tissue tumors: 5 liposarcomas, 3 malignant fibrous histiocytomas, 3 leiomyosarcomas, 3 synovial sarcomas and one rhabdomyosarcoma). The average age at the time of operation was 44 years (12-85 years), and the mean follow-up period was 52 momths. All tumors were resected by wide margin and all osteosarcomas, Ewing’s sarcoma and all synovial sarcomas were treated with neo-adjuvant chemotherapy. The limb-salvage rate and 5-year survival rate were retrospectively analyzed by the Kaplan-Meier method. The 5-year survival rate was 69%, and the limb-salvage rate was 71%.

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The authors report a case of arthroscopic curettage for intraosseous ganglion on the humeral head. A 39-year-old man had pain on the right shoulder for three months. Plain radiographs showed a multilocular osteolytic lesion on the right humeral head. Plain computed tomography (CT) demonstrated a multilocular cystic lesion. Contrast medium-enhanced CT revealed a network-like enhancement of the rim of the cystic lesion. Plain magnetic resonance imaging (MRI) showed low signal intensity on T1-weighted images, and high signal intensity on T2-weighted images. Curettage of the lesion under arthroscopy by ankle scope was followed by an iliac bone graft. Histological findings were consistent with intraosseous ganglion. At 6 months after operation, the patient had little pain in the right shoulder, and retained almost full range of motion on the right shoulder. The patient has not shown signs of local recurrence to date.

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A rare case of exostosis in the lamina of lumbar spine is reported. The patient was a 39-year-old man who complained of lumbago, and presented with a mass in the lumbar spine,and bilateral masses in the lower limbs. Plain radiographs showed a bony prominence in the lamina of the fifth lumbar vertebra, and in bilateral tibias and femurs. CT images of the lumbar spine revealed that the bony prominence grew into the subcutaneous tissue, but did not invade the spinal canal. As malignancy of these tumors are known to occur, an operation was performed in February, 2003. Operative findings showed that the surface of the tumors were rough, and covered with a cartilage cap. We resected them from lamina and tibias. The histological diagnosis was benign multiple exostosis. The thickness of the cartilage cap was 0.86mm. After operation, lumbago disappeared rapidly. There have been no signs of local recurrence to date.

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We report a case of hemangioendothelioma in a thoracic spinal intraduralextramedullary lesion. The patient was a 61-year-old man with a 5-month history of lower-extremity sensorimotor deficit. The enhanced intradural-extramedullary nodule at the Th 10-11 level was revealed by preoperative MRI. At surgery in 2003, the long axis size of the lesion was 2 cm, and the lesion was firmly attached to the spinal cord parenchyma. Complete resection was performed as a microscopic surgical technique. Four months after surgery the patient’s neurological deficit had almost resolved. Hemangioendotheliomas are a common tumor in cutaneous lesions. However it is rare in the central nervous system. It has been reported that resection and careful follow-up are the recommended treatment.

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We report a case of pathologic fracture at the odontoid process in a hemodialysis patient surgically treated in 2002.
The 65 year-old man had a diagnosis of diabetes mellitus at age 33 years, and started hemodialysis for chronic kidney failure at age 51 years. The patient complained of severe pain at the back of his neck when put on his socks.
A pathological fracture of the odontoid process and a retro-odontoid pseudotumor were detected. The instability at the C1/2 level was ADI=1 mm and SAC=19 mm at the extension position,and ADI=7 mm and SAC=13 mm at the flexion position. The osteolysis and fracture appeared at the base under the odontoid process on three-dimensional CT.
The patient underwent transarticular fixation by Magerl technique with atlas claw hook, and bone graft without laminectomy of C1 vertebra. He wore a soft collar on his neck for four weeks.
One year later, the pain at the nape of his neck had improved,and he was free of neurological signs. Bone union between C1/2 appeared on the radiographys. However the retro-odontoid pseudotumor showed no change in size MRI 9 months after surgery.
This case indicates a possibility exists for the spontaneous pathologic fracture of the odontoid process in patients in long-term hemodialysis.

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Nineteen patients aged 80 and older (super-old group) underwent either an anterior microsurgical decompression and fusion (15) or laminoplasty (4) for cervical spondylotic myelopathy (CSM) during a 10 year period from September 1993 to April 2003. Of the 15 patients treated by anterior surgery, 12 had a single-level operation at level C3-4 or C4-5 based on the spinal cord evoked potential and MRI, and 3 patients had two-level operation. Although functional improvement was neutralized by other age-related condition, impairing ability to walk, such as osteoarthritis of the knee (7 patients), the hip (1 patient), or lumbar stenosis (2 patients), the average Japanese Orthopaedic Association (JOA) score significantly improved from 6.1 before operation to 10.6 at a mean follow-up of 22 months. A high incidence (42%) of delirium characterized postoperative transient complication in this age group. The improvement rate of JOA score in the super-old group was not significantly different (43% vs 52%) from that of a younger group of patients aged between 60 and 80 who had an operation for CSM in the same period of time. Despite frequent comorbidities impaired general health in CSM patients 80-years-old and over, functional recovery after surgical intervention was similar to the younger group.

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We report a 14-year-old girl with Marfan syndrome whose pulmonary function improved after surgical treatment for scoliosis. The patient was refered to our hospital with dyspnea, and progressive scoliosis. Her spine had a right convex single thoracic curve (T5—12), and the Cobb angle was 100°. The curve was corrected to 60°with traction. It was classified as King and Moe type III, and Lenke type 1A-. The curvature had progressed from 40°at 11 years of age to 100°just prior to the operation. Her pulmonary function was impaired with a % vital capacity (%VC) of 58.7%. First, we performed anterior release (T7—10) and bone graft. Two weeks later, posterior correction using the Cotrel-Dubousset system was performed with rib resection on the right side between the 7 th rib to 10 th, and between 5 th rib and 10 th on the left side. The curve was corrected to 60°just after surgery. Two years after the final operation, the Cobb angle was 76°with a correction loss of 26.6%. Her pulmonary function had improved to a %VC of 89.7%.
Scoliosis associated with Marfan syndrome tends to be progressive, and has many complications. Fortunately, this case had no severe complications, and had a good clinical course after operation. We considered that rib resection was useful in correcting the pulmonary dysfunction in this case.

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The purpose of this study was to clarify the effectiveness of microsurgical medial and lateral foraminal widening for lumbar foraminal stenosis. Five patients (three men, two women, age range from 45 to 78 years) with L-5 foraminal stenosis and associated leg pain underwent this operation. The mean follow-up period was 10.2 months. The clinical results, as rated by the Japanese Orthopaedic Association score (JOA score), improved significantly. Preoperative and postoperative scores were 12.6±3.9, and 21.8±3.0, respectively. Postoperative radiographs showed neither lumbar instability nor the fracture of pars of interarticularis. We found that microsurgical foraminal widening was effective and valuable for the treatment of these patients with lumbar foraminal stenosis, by maintaining the mobility of the lumbar spine.

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A literature search found 15 cases of simultaneous spinal cord and vertebral body infarction. The authors report what might be the first case of lumbar radiculopathy with lumbar vertebral body infarction.
In 2002, a 64-year-old woman complained of sudden numbness, weakness of the right leg, and lumbago. Her objective findings showed radiculopathy of the right L5 level. The straight leg raising test was negative. T2 weighted MRI of the lumbar region showed increased signal in the right L5 root, and a geometric lesion on the right parasagittal and axial images. Bone scan showed a partial cold spot in the right side of L5. Computer tomography showed a slight sclerotic change in the right side of L5 6 weeks later.
Her leg weakness and lumbago had improved at 6 months after examination and the follow-up MRI showed restoration of the vertebra.
We speculated the 5 th lumbar artery supplied blood to L5 without anastomosis in this case, and the embolization of that artery caused the lumbar infarction.

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The authors report 2 cases of cementless hip prosthesis in which component loosening was cased by failure of porous coating. The first cases was a Harris Galante type stem of 17 years after surgery. Since 1 year after surgery separation of fiber mesh coating from the stem was detected on radiographs. At revision surgery, no bone ingrowth was observed on the stem. The second case was PSL socket with a beaded titanium coating. At revision surgery, a number of beads were found to have fallen from the socket surface. Some of the beads had migrated into the joint surface, and induced metallosis. The loosening of the prosthesis is attributed to failure of the porous coating. This report calls attention to the need for close follow-up observation of patients with these prostheses.

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We treated 5 patients (5 men) for traumatic hip dislocation with femoral head fracture in our hospital between 1997 and 2003. The mean age at time of fracture was 48.6 years (range, 19-68 years). Duration of follow-up was an average of 13.5 months. The fracture type in these cases were classified according to Pipkin’s classification into type I (1 case), type II (2 cases), type III (1 case), and type IV (1 case). 3 cases of type I and type II were treated by osteosynthesis. 1 case of type III was treated by hemiarthroplasty. 1 case of type IV was treated by bone fragment extirpation 8 weeks after failed conservative treatment by only closed reduction. None of the cases developed avascular necrosis or osteoarthrosis during the follow-up period.

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We consecutively treated 45 femoral trochanteric fractures in 45 patients (18 men, 27 women) with the adjusting sliding (AS) hip screw between February 2002 and July 2003. The mean age for them was 79.7 years (range, 46-96 years), and the follow-up period was 4 months (range, 2-12 months). According to Evans classification, 20 cases were the stable type, and 25 were the unstable type. To assess the utility of the AS hip screw on both types, we reviewed ability gait, surgical complications, and radiological findings. The pretrauma ability gait was maintained in 80% of the stable type 16 of 20 cases and in 76% of the unstable type 19 of 25 cases, respectively. There were no surgical complications such as cutting out, breakage implant, or infection in any case. The radiological examination revealed that all of the fractures had good bony fusion. These results indicate that the AS hip screw yielded desirable outcomes in both types. The good results were attributed to the firm reduction achieved at operation, and the design of the plate which allowed manipulation even after insertion of the lag screw into the femoral head.

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Since 1996, we have treated osteoporotic vertebral fractures and the pseudoarthrosis by transpedicular injection of calcium phosphate cement (CPC) into the vertebral body. The fate of the CPC in the vertebral body and the long term clinical benefits are unknown, although excellent short-term results have been reported. The case files of 6 patients (5 females, 1 male) with osteoporotic vertebral fractures treated with the CPC injection were reviewed clinically and radiologically. The average age at operation was 62.8 years and the average follow-up period was 77 months (range 49-84 months). There were no reports of low-back in any patient during follow-up. Radiological examinations revealed that the postoperative loss of correction appeared as vertebral wedging deformity (average 12%), but continued loss was not observed after 3 months. Excellent clinical and radiological results were maintained over the 3-year follow-up period. The CPC absorption was limited to marginal areas contrary to our expectations.

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Pigmented villonodular synovitis (PVS) leads hemoarthrosis as one of the representative signs. We report a rare case of PVS originating below the patella tendon, which limited the joint extension. A35-year-old man with first onset pair and locking of the knee, which was attributed to an extra-articular neoplasm based on findings of MRI. The tumor showed low intensity on T1-weighted images, and high/iso intensity on T2-weighted images. The tumor was successfully resected in 2002 by open surgical procedure and diagnosed as PVS. There have been no signs of recurrence for 15 months following the operation. MRI was very important for diagnosis. It should be considered that tumors, including PVS, may cause limitation of extension and locking of the knee.

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The purpose of this study was to evaluate the results of the primary fixation of osteochondral fracture with bioabsorbable pins and wire, combined with a lateral release and a medial plication for fresh patellar fracture-dislocation from 1996 to 2003. Five patients (3 men and 2 women) were followed up for 6 to 80 months (mean : 33.2 months) after surgery. The mean age was 20.6 years (range : 12 to 39 years).
Bony union of the osteochondral fragments appeared on radiographs within 2 months in 4 patients,and in 3 months in 1 patient whose wire had broken. All patients had normal range of motion of the knee at final follow-up. There were no recurrences of patellar dislocation, but in 1 patient there was a recurrence of patellar subluxation and an apprehension sign. There was thigh muscle atrophy in 4 patients. Fibrillation of cartilage of the osteochondral fragments was found on arthroscopic examination. The results of the primary fixation of osteochondral fracture with bioabsorbable pins and wire, combined with a lateral release and a medial plication for fresh patellar fracture-dislocation were relatively good.

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