Pavlik harness is very useful method in the treatment of congenital dislocation of the hip of infants, but some dislocated hips cannot be reduced by the initial conservative treatment. We reviewed 11 hips of 11 patients (10 girls, 1 boy) affected by congenital dislocation of the hip which were treated initially with the Pavlik harness at our hospital from 2000 to 2004. Our study focused on the hips which were not reduced initially. The average age of the patients at the first visit was 3.3 months (range, 1.0-6.5 months), and the average age at the first treatment with the Pavlik harness was 3.7 months (range, 2.5-5.0 months). The average follow-up period was 22.3 months (range, 5.0-46.0 months). Nine hips were reduced with only the Pavlik harness between 3 to 18 days. Two of the 11 hips were not reduced initially, and underwent skin traction and open reduction. Though the severity of dislocation at the first visit was different, both of the hips were treated with the Pavlik harness for 5 to 8 weeks without reduction, and we suggest this treatment worsened the dislocation. We conclude that when the hip is not reduced by the initial treatment with Pavlik harness within 2 or 3 weeks, we should identify the factors obstructing the reduction, and consider subsequent treatments.

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Femoral head fracture following idiopathic osteonecrosis of the femoral head (ION) is rare. The patient was a 50-year-old woman with Systemic Lupus Erythematosus (SLE). In 2003, 10 months after the onset of SLE, she developed pain in the left hip without any history of injury and was subsequently unable to walk. Roentgenographs showed a left femoral head fracture, but osteonecrosis was not apparent. Femoral head replacement was performed. There was no significant collapse of the femoral head. Subcondral tissue showed complete necrosis. At the superior portion of the fracture, there were invading fibrous connective tissue, resorption of live bone, new woven bone formation, and appositional bone formation, as well as the ordinary fracture.
This case was diagnosed as fracture of the femoral head head following ION according to the microscopic examination findings. The femoral head fracture was the first sign of ION.

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We treated 9 patients (9 hips) with rapidly destructive coxarthropathy (RDC). We performed total hip arthroplasty (THA) for all cases, 1 with cementless, 3 with cemented and 5 with hybrid. The average age of the patients was 79 years (range from 73 to 85 years). The average follow-up period was 2 years 6 months (from 1 year to 6 years 4 months). The average postoperative JOA score improved from 34.3 to 81.3 points. There were no appearances of radiopaque lines, loosening, or migration on the radiographs. There were no complications.
The causes of RDC are not clear, however, it has been suggested that subchondral insufficiency fracture might play an important role in the initiation of RDC, and that the progression of RDC is accelerated by posterior pelvic tilt and bone fragilities of osteoporosis.
In general, the clinical results of THA for RDC are poorer than those of THA for osteoarthritis. We think that acetabular reconstruction is important for good long-term results because of early loosening of the socket in THA for RDC. When the degree of acetabular destruction is remarkable, we perform acetabular reconstruction using the K-T plate or cup supporter for RDC as indicated.

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This paper describes the surgical techniques used for revision total knee arthroplasty (TKA) in 11 revisions performed from 1997 to 2003. The case records were studied retrospectively. The mean age at revision TKA was 78.6 years (range 72 to 85 years). The average time to revision TKA was 6.9 years (range 6 moths to 17 years). The most frequent reasons for failure were polyethylene wear and metallosis. A posterior stabilized prosthesis was used in 7 knees and a nonlinked constrained prosthesis was implanted in 4 knees. An extension stem was regularly used for fixation of the tibial component. A stemmed femoral component was used in 4 knees with massive bone loss in the distal femur. The average JOA score improved from 52.3 to 71.8. Careful preoperative planning and appropriate selection of implant design are important for a successful outcome.

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Periprosthetic femoral fracture are difficult to treat, especially in cases with loose stems. We report the results of surgical treatment of three patients 1 man, 2 women, aged from 76-86 years with periprosthetic femoral fractures after hip replacement. Fractures were classified according to the Vancouver classification (Duncan and Masri) as type B2 (n

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The purpose of the study was to evaluate the S-LOCK^® system for total hip arthroplasty (THA) in patients with severe osteoporosis. The stems we used had a porous coating on the proximal half. All were fixed with interlocking screws. Eight patients (10 hips) underwent THA with the S-LOCK^® system between June 2002 and July 2004. There were 2 men (2 hips) and 6 women (8 hips) whose mean age at operation was 53.4 years. The cases included osteoarthritis (1 hip in 1 patient), idiopathic osteonecrosis of the femoral head (3 hips in 3 patients), and rheumatoid arthritis (4 hips in 2 patients). A stovepipe-like canal appeared on radiographs in all cases. The mean follow-up period was 12.9 months (range 4 to 25 months). Japanese Orthopedic Association scores increased from 35 to 78 points. There were no indications of thigh pain or loosening in any of the cases.

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When a well-fixed cementless socket is removed during revision total hip arthroplasty, blood loss and operation time increase. If the resulting bone deficit is large, a graft may be required and rebuilding may be difficult. In cases of revision THA where stability of the outer shell is good, and the shell is undamaged, only the inner cup might require replacement. We reported the results of 7 cases of revision THA of the inner cup of the acetabular side in 7 patients treated from January 2002 to April 2004. Of these patients, 1 man and 6 women, the average age at operation was 66.5 years (range 61-74 years). The average period from the initial THA to the revision THA was 7.3 years (range 4-13 years). The average follow-up period was 21.5 months (range 16-32 months). The average operation time in these cases was 126 minutes (range 75-160 minutes). The average blood loss was 300 ml (range 130-480 ml).
We found this method to be less invasive than removal of the outer shell, and bone stock was preserved. An additional benefit was the ability to compensate for a poor installation angle of the original outer shell during replacement of the inner cup.

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We have examined the results of 16 allografts (3 man and 13 woman) used in the revision of total hip arthroplasty (8 osteoarthritis and 8 non-osteoarthritis cases) between March 2003 and September 2004. The mean age at the time of surgery was 68 years (range: 49 to 80 years). The mean duration of follow-up was 19 months (range: 2 to 40 months). There were no differences in JOA scores before or after surgery between the OA and non-OA groups. There was no postoperative infection. Union of allograft was observed in all cases. The period required for union was significantly longer in non-OA groups (28.7 weeks) compared to OA groups (14.9 weeks). One block bone graft was resorbed after plantation, while all of the chip bone grafts had good union. These results suggested that graft-bone union can obtain better with chip bone than with block bone grafts.

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Deep venous thrombosis (DVT) is one of the most common complications that occur after total hip (THA) and total knee arthroplasty (TKA). We investigated the incidence of DVT following THA or TKA arthroplasty on 10 hips in 10 patients and 10 knees in 10 patients in our institution from May 2003 to July 2004. The diagnosis of the DVT was made with ultra sonography, magnetic resonance angiography, and venography. Despite preoperative prophylaxis against thrombosis such as stocking and foot pomp, the incidence of DVT was three (30%) after THA and is seven (70%) after TKA. DVT was detected in more patients who had undergone TKA than THA. There were no cases of fatal thromboembolism. However there were 2 cases of proximal DVT, one after THA and one after TKA, in which intravenous filter placement was performed. These results suggest that the preoperative prophylactic measures used were insufficient to prevent DVT after arthroplasty. Therefore, it is important to reduce the risk factors in the post-surgical period especially following TKA.

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Ossification of the ligamentum flavum usually occurs at the thoracic or thoracolumbar spine. There are few reports of ossification of the ligamentum flavum of the lower lumbar spine.
We report on a case of the lumbar canal stenosis with ossification of the ligamentum flavum. The patient was a 53-year-old woman with severe leg pain. Computed tomography and magnetic resonance imaging revealed ossification of the ligamentum flavum at the right L4/5.
We performed partial laminectomy at the right L4/5 and removed the ossified ligamentum flavum to the right L5 superior process using a micro-operating scope. The patient’s severe leg pain disappeared after the operation.
The mechanism of ossification of the ligamentum flavum was unclear in this case.

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The authors report a retrospective study of clinical results of 12 patients (13 disks) who were suspected of having spontaneous (non-postoperative) pyogenic spondylodiskitis, and underwent percutaneous diskectomy and drainage (PD).
The patients were treated between 2001 and 2004. The 12 patients were 8 men and 4 women, whose ages ranged from 42-82 years. Three of 13 disks were at the level of thoracic spine, and 10 disks were at the lumbar spine. Five of 13 disks were treated under CT guidance, and 8 disks were treated under image intensifier guidance. All of the patients complained of local pain, but none of them had neurological deficit.
Speciments PD, all cases had microbiologic analysis, and the choice of antibiotic treatment depended on the organisms isolated from the disk. The follow-up of all patients included clinical examinations, blood testing for inflammatory signs, as well as neurological examinations, and MRI.
The drainage duration was from 8-41 days, with an average duration of 22.8 days. Specific organisms were isolated in 8 of the 13 disks. (61.5%) Staphylococcus aureus were identified in 7 of the 13 disks, of which 2 cases were MRSA. All patients had clinical improvement during the follow-up period.
The duration of inflammation was from 8-88 days, with an average duration of 24.4 days. In the cases with MRSA, the duration of inflammation was from 54-88 days, with an average duration of 71.0 days. 2 cases had recurrence, but improved using antibiotics. No neurological complications were found during the procedure.
During the early stage of spondylodiskitis, PD is an efficient and safe procedure. But when MRSA is isolated from the disk and granulation tissue, irrigation or further decompression and reconstructive surgery must be considered.

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Recently, instrumentation has become more and more rigid. But rigidity has it’s limits, which is why the author has treated patients more than 70 years old with spondylolisthesis or degenerative lumbar scoliosis using flexible transpedicular instrumentation. The authors presented a series of 25 cases with the Twinflex flexible spinal instrumentation for lumbar fusion. The mean follow-up period was 19.6 months range from 6 months to 55 months.
The 25 cases included 13 cases of spondylolisthesis, 7 cases of degenerative lumbar scoliosis, and 5 cases with both lumbar diseases. The degenerative lumbar scoliosis group tended to have longer fusion.
The mean Japan Orthopaedic Association (JOA) lumbar score for the 25 cases improved from 12.8 points before operation to 24.7 points at a mean follow-up of 19.6 months. However, the mean improvement in JOA score for the lumbar degenerative scoliosis group was lower. Although the authors did not specifically attempt reduction, the percentage of slip and tilt angles were improved at the first post-operative week. Finally, the spondylolisthesis group had no correction loss, but the degenerative lumbar scoliosis group had correction loss. In one case, a clear zone around the transpedicular screws appeared on radiographs, and in two cases transpedicular screw cut out occurred. None of the cases had screw fracture or rod failure. Infection was not a complication in any case.
At the last follow-up examination, there were no significant differences in lordosis between anteflexion and retroflexion on radiographs.
We concluded that Twinflex flexible spinal instrumentation was a useful device for spinal fusion in patients more than 70 years old.

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Interbody fusion from an anterior/posterior approach should be chosen as the surgical treatment for degenerative lumbar disease with anterior column deficiency. The new technique called Cantilever Transforaminal Interbody Fusion is an effective and safe fusion procedure for degenerative lumbar disease. 21 men and 16 women had this surgery. The mean age at surgery was 60 years. Diagnoses were, degenerative spondylolisthesis (22 cases), recurrent herniated disc (3 cases), lateral stenosis (3 cases), spinal stenosis (3 cases), degenerative scoliosis (2 cases), degenerative disc disease (2 cases), spondylolytic listhesis (1 case), and herniated disc (1 case). The mean follow-up period was 20 months. The mean operation time was 259 min. The mean blood loss was 471 ml. Local and artificial bone was used for the bone graft in 6 cases, local and iliac crest bone in 14 cases, and only local bone in 17 cases. The JOA score increased from 12.3 to 24.1 out of 29 points at the latest follow-up. In the conventional PLIF procedure, the surgeon must retract the dural sheath out to the midline. In the TLIF technique, the path to the disc runs diagonally to the vertebral foramen, reducing the risk of neural damage from retraction. The Cantilever technique with IBS restores lordosis, and puts compressive loading on the bone graft, which enhances the likelihood of fusion.

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A 47-year-old man who was diabetic and undergoing hemodialysis, had his left leg amputated because of necrosis and MRSA infection of the foot. He received intravenous vancomycin hydrochloride (VCM) therapy. We found tumorous swelling of the right sternoclavicular joint 14 days after the operation, and performed local drainage immediately and detected MRSA in the discharge. We continued intravenous VCM therapy, but failed to prevent dislocation of the joint. Then joint resection and continuous irrigation were performed, but serous fluid containing MRSA collected in the dead space after the drainage tube was removed. We tried local infusion therapy of VCM under guidance of ultra-sound image. The concentration of VCM was 25 mg/ml, and 2 ml of the solution was infused 5 times at 7-day intervals. The inflammation subsided, and no recurrence was observed for 5 years.
Infection of the sternoclavicular joint is uncommon. Some authors recommend resection of the joint with ipsilateral pectoralis major muscle flap when the expansion of the inflammation is not minimal. Our experience concurs with this opinion. Although, local infusion of VCM is not officially approved, and is not recommended easily, it may be the treatment of choice in some special situations.

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We report 2 cases of vasculitis syndrome in which skin ulcers were the first symptom of the disease. The first patient was a 52-year-old woman with broad skin ulcers on the both lower legs. The pulse was detectable at the popliteal arteries, but not at her right toes. We diagnosed periarticular nodosa and started steroid-pulse therapy and administration of immunosuppressive drugs. After therapy, the skin ulcers improved dramatically. The second patient was a 79-year-old man with swelling and a skin ulcer on the left foot. Because ischemic necrosis worsened,we performed lower leg amputation. Since we diagnosed vasculitis syndrome, we started steroid-pulse therapy. Thereafter, the skin lesions improved. Although these 2 cases did not meet the criteria for vasculitis syndrome,the effect of steroid-therapy supported our diagnosis. It is considered that vasculitis syndrome should be considered and treated in cases of skin disease without apparent cause.

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Osteomyelitis localized in the talus is uncommon because of the anatomy and the vascular supply. We report one case of osteomyelitis of the talus in an infant. The patient was a 16-month-old girl, who refused to bear weight on her right foot. There was swelling on her right ankle. Radiographs showed mostly normal findings, immobilization in plaster and treatment with antibiotics were performed. Nine days later, well-defined osteolytic lesion in the body of the talus was apparent on roentgenograms. Computer tomography (CT) showed the damaged cortex of the talus. Plain magnetic resonance imaging (MRI) showed low intensity on T1-weighted images, and high intensity on T2-weighted images in the greater part of the talus. After sixteen days of treatment, we undertook surgical drainage with bone biopsy. The diagnosis of osteomyelitis was confirmed by histological examination of the curetted bone. After the operation, the patient was treated with antibiotics. There have been no signs of recurrence for 21 months following the operation.
If good results are not obtained by splinting and administration of antibiotics at an early stage, surgical treatment should be performed.

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We presented 5 cases of septic arthritis in children. Average age of the patients was 4-year-old (range 10 months - 11-year-old). The involved joints were 3 hips, 1 knee and 1 ankle joint. Average duration from onset of arthritic symptoms to visiting hospital was 7.2 days (range 1-14 days). Diagnosis was made according to elevated body temperature, laboratory tests including white blood-cell count and CRP level, and findings of joint aspiration. As septic arthritis is an emergency, surgical drainage and antibiotics administration should be done as soon as possible. Average duration of drainage was 7 days (range 4-8 days), and average duration for intravenous injection of antibiotics was 18 days (range 10-36 days). Causative organisms were detected in 3 cases. Clinical symptoms in all cases improved, as did laboratory findings of CRP level and white blood cell count. Two cases had residual abnormal findings on plain X-ray photographs. Recently, it is recommended that cefotaxime, ceftriaxone or carbapenems should be used as the first choice of antibiotics against septic arthritis, if the causative organism has not been identified.

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We investigated the outcome of surgical treatment for adult acquired flatfoot caused by posterior tibialis tendon dysfunction (PTTD) treated by calcaneocuboid distraction arthrodesis (CDDA).
Between 2001 and 2003 we performed CDDA on 9 feet (PTTD stage 2) of 9 patients (1 man and 8 women, average age 53 years; range 48-56 years). The average follow-up period was 19 months (range 8-32 months).
Surgery was performed under spinal anesthesia. The calcaneocuboid joint was distracted 1 cm with a lamina spreader while a tricortical iliac crest bone graft was inserted into the joint. One graft had no internal fixation of the grafted bone, 1 graft was fixed with two crossed Kirschner wires, and 7 grafts were fixed with a cortical screw. The average AOFAS score improved from 58.6 before operation to 81.7 at the most recent follow-up. Plain radiography showed improvement of the arch of the foot. In 2 cases, one without internal fixation and one fixed with Kirschner wire, the grafted bone collapsed in 8 weeks and 12 weeks after surgery, respectively. Both of the patients underwent re-operation to fix the bone graft fixed with a cortical screw. At the most recent follow-up, bone union had occurred in all cases. CCDA with rigid fixation of the grafted bone was effective for the treatment of stage 2 in these cases of PTTD.

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We report a case of a patient with osteomyelitis after finger replantation with dog bite. The patient was a 60-year-old man who accidentally injured his right thumb and index finger with a power saw. After 30 minutes, the index finger was recovered from his dog’s mouth. Finger replantation was done for both fingers on the same at the patient’s request. The thumb was successfully replanted, but the index finger became infected 4 days later. Serratia, Porphyromonas and gram-negative bacillus were detected in the pus. Though we changed antibiotics, we could not help amputating index finger post operation 38 days.
Bite injury of the hand represents a potentially devastating problem in terms of wound infection and long-term disability if not treated appropriately. Treatment with antibiotics, surgical drainage, debridement and copious irrigation proved to be effective. But in our case, we could not perform debridement sufficiently for replantation.
We suggest that amputated fingers with bite injury be replanted with greatest care.

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During the period from 1997 to 2004, prosthetic arthroplasty using PSS (physio-shoulder system) was performed in 5 shoulder with proximal humeral fractures. The patients were 5 women with an average age at the operation of 67.6 years (range, 57-77 years). Follow-up term after operation ranged from 3 months to 7 years (average, 3.2 years). Operative results were evaluated according to the Japan Orthopaedic Association (JOA) score.
The average postoperative JOA score was 63 points (47-78 points). Although the scores of ROM were poor, pain relief was relative and activity of daily life. For aged patients, prosthetic arthroplasty is one of the useful treatment of the proximal humeral fractures.

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This study was designed to verify the effects of joint distension in frozen shoulder. 15 patients were served as subjects. After completing history, physical examination and informed consent, joint distension was performed at the time of arthrography. After joint distension, all patients underwent rehabilitation at once or twice a week. The subjects were divided into two groups according to their shoulder flexion angle; A: under 90 degrees (7 cases, mean age: 47.8 years), B;over 90 degrees (8 cases, mean age: 53.8 years). All patients were followed at least 3 months after joint distension and were evaluated for pain, activity of daily life (ADL) and range of motion (ROM) of the Japanese Orthopedic Association shoulder score (JOA score). Each parameter was compared between groups A and B. The Mann-Whitney’s U test and the Wilcoxon’s signed-rank test were used for statistical analysis. P values<0.05 were considered significant.
Total JOA score in groups B improved from 37.0 points to 60.2 points 3 months after joint distension (p<0.05). The pain, ADL and ROM scores in group B were higher than those in group A. All parameters in group B significantly improved after joint distension (p<0.05), but those in group A had no significant differences.
We consider that joint distension is effective for a patient with slightly restricted range of motion in frozen shoulder. For a patient with severe contracture of the shoulder, another conservative and/or operative treatment should be indicated.

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We used a bridging type Stablelock external fixator as a subsidiary fixation device following internal fixation of distal radial fracture. Herein we summarize the short-term results of 38 distal radial fractures in 8 men and 30 women between 31 and 86-years-old (average age 62 years, 14 right radii and 24 left radii). All subjects underwent surgery between July 2003 and May 2004. The interval until surgery was 0-14 days, the average was 4 days. The observation period was 2-7 months, average 3.8 months. We used the evaluation classification by Saitou, the fracture type was accord-ing to the AO classification, which also measured radial inclination (RI), volar tilt (VT), ulnar variance (UV), and radial length (RL), using the mean values of the postoperative period. The average score was 4.2 points: Excellent in 13, Good in 24 and Fair in 1 case. The average active ROM was: flexion 53.3°, extension 51.3°, internal rotation 72.2°, external rotation 82.7°. Grip strength was 65% in comparison to the healthy side. The amount of correction loss was more equal in comparison with other reports. Using the bridging type Stablelock external fixator the operation time was short. By using this external fixator the results that were obtained were equal almost with the results that were obtained by using the other non-bridging type external fixator, if attention is paid to the occurrence of reflex sympathetic dystrophy.

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We treated two patients, a 41-year-old man, and a 52-year-old woman with bone metastasis of the proximal humerus. Diagnoses were metastasis of thyroid carcinoma and renal cell carcinoma. The method for reconstruction was replacement with a modular endoprosthesis (Kyocera limb salvage System: KLS System). The rotator cuff and deltoid muscle were attached to the prosthesis. The average follow-up period was 18.5 months. The mean International Society Of Limb Salvage (ISOLS) score was 63%. The pain score was good, but function was poor. There were no signs of loosening or radiolucent areas, but a proximal migration of the prosthesis was observed on plain radiographs. This seemed to contribute to subacromial impingement and limitation of shoulder range of motion (ROM). The titanium KLS System allowed the monitoring for recurrence of the tumor with magnetic resonance imaging (MRI). These cases illustrate the usefulness of prosthetic replacement for reconstruction in the proximal humerus with the salvage system, although it limited shoulder ROM.

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The authors report two cases of the treatment for pathological fracture of a proximal humeral bone cyst with a novel method using several Kirschner wires (multiple pinning methods).
One of 2 patients, aged 5 and 13 years, had solitary bone cysts in active phase. The radiologic appearance in all cases was a large lytic defect with pathological fracture in the proximal metaphysis of the humerus. One of the patients had a recurrence of the cyst after conservative treatment at another hospital. The duration of follow-up after surgery ranged from 15 to 18 months. All patients showed pain relief, normal joint function, no migration of wires, and complete or incomplete healing of the lesion without recurrence.
We believe that the procedure provides good fixation of fracture and pain relief in the early stage after surgery. Moreover, there is radiological evidence for the continuous decompression effect by Kirschner wires to heal solitary bone cysts.

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We reviewed retrospectively the clinical results of 211 patients with cervical spondylotic myelopathy were surgically treated from 1993 to 2002. The average age at the time of surgery was 60 years (range 32 to 83 years). The average follow-up period was 46.6 months (range 6 to 134 months). Sixty-three patients underwent anterior interbody fusion (group A) and 148 patients underwent laminoplasty (group E). The outcome was assessed functionally and radiographically. The functional assessment was according to the Japanese Orthopaedic Association (JOA) score, recovery ratio (RR). The radiographic outcome was assessed by sagittal alignment, canal space, and the union of grafted bone.
The average age at the time of surgery was 52.9 years in group A and 63.0 years in group E (p<0.05). The mean preoperative JOA score was 10.6 in group A and 9.1 in group E (p<0.05). There were no significant differences in RR between group A (64.2%) and group E (59.1%). The preoperative alignment of cervical spine was not associated with clinical results in group E. However, one patient in group E required anterior interbody fusion because of progression of kyphosis and recurrent myelopathy. The presence of pseudoarthrosis was not associated with clinical results in group A. Three patients in group A required laminoplasty because of recurrent myelopathy at adjacent disc space or pseudoarthrosis. Those three patients also had developmental canal stenosis.
We cannot compare group A and E directly, because the preoperative backgrounds of these two groups were different. Both laminoplasty and anterior interbody fusion resulted in satisfactory clinical outcome. However, choice of the appropriate method depends on the patient’s background.

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We compared the surgical results for cervical spondylotic myelopathy with MRI abnormalities of multilevel cord compression among 60 patients who had anterior microsurgical decompression followed by fusion at a single most appropriate level and 43 patients who had multilevel laminoplasty.
Multilevel recording of ascending spinal cord evoked potentials after epidural stimulation precisely identified the levels of abnormality during anterior surgery before decompression procedures. The anterior and posterior groups showed no statistical difference in preoperative data including duration of symptoms (5.8 months vs 7.4 months), JOA functional score (8.1 vs 8.4), sagittal diameter of spinal canal (12.5 mm vs 12.5 mm)and the number of cord indentations (3.29 vs 3.14). However, the patients were significantly older in the anterior group than the posterior group (70.1 years vs 65.0 years). The two groups showed a comparable improvement of JOA functional score after surgery (12.8 vs 11.9)with a similar follow-up period (3.02 years vs 3.04 years).
These data suggest that electrophysiological documentation of this condition plays an important role in anterior surgical intervention,particularly in elder patients who tend to have clinically silent cord compression at multiple levels on MRI. Anterior decompression, followed by fusion at a single optimal level, when compared with multilevel laminoplasty, is less invasive with lower incidence of postoperative axial symptoms inherent in posterior surgeries.

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We present a case of spinal cord infarction with acute spinal cord oedema treated by laminoplasty. A 44-year-old man presented with numbness in the left arm. The patient reported neck pain, which had begun the previous day followed by numbness in the upper left arm on the day of presentation. The sensory disturbance was precipitate and muscle weakness in the left lower limb was noted. The results of laboratory tests, including CBC, chemistry, coagulation, bleeding time, and CSF test, were within normal limits at the time of presentation. Physical examination showed weakness of the triceps brachii and brachioradial muscles, sensory disturbance in the left hand, and bladder dysfunction. T2 weighted MRI in the horizontal plane showed oedematous tissues in the cervical spinal cord with intermingled regions of high and low signal intensity. The patient was hospitalized immediately with a diagnosis of spinal cord infarction.
Solu-medrol^® (methylprednisolone) was started to stabilize swollen tissues. However, because of severe pain that could not be managed even with morphine, deterioration of muscle paralysis, and sensory disturbance, the patient underwent laminoplasty for C3 to C7 using the Hirabayashi method on day 1 of hospitalization. The patient was followed up postoperatively and after discharge. The patient has been well. He returned to work a year after treatment with minimal residual numbness in the left arm, and has mostly recovered his muscle strength. This operation resulted in almost complete amelioration of muscle paralysis one year later. This observation indicated that decompression by laminoplasty is an invaluable treatment for spinal cord infarction.

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We studied the surgical outcome in 21 cases of simultaneous cervical and lumbar surgery for combined symptomatic cervical spondylotic myelopathy (CSM) and lumbar canal stenosis (LCS). All patients underwent open-door laminoplasty for CSM and laminectomy for LCS. There were 13 men and 8 women with a mean age of 70 years (range, 49 to 84 years)and a mean follow-up period of 4 years (range, 18 to 113 months). The mean JOA score (scoring system of Japanese Orthopaedic Association for cervical myelopathy) was 7.4 points (range, 4-11) before surgery and improved to 12.6 points (range,7-16) after surgery. The mean recovery rate was 54.1%. There were no cases of neurological deterioration after surgery. Simultaneous cervical and lumbar posterior decompression was useful for combined symptomatic CSM and LCS in these cases.

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The authors assessed clinical outcome and health-related quality of life (HRQOL) in patients who have undergone cervical decompression. The study involved a prospective cohort of 10 surgically treated patients (eight men and two women, aged: 51-82 years) with cervical compression myelopathy. The clinical state and HRQOL of the patients were assessed by the scoring system of the Japanese Orthopaedic Association (JOA score) and the MOS 36-item short form health survey (SF-36) before treatment and after 6 months after surgery. The results of both instruments were compared. JOA score showed that clinical state improved after surgery (preoperative score: 10.5±3.4, postoperative score: 14.0±3.0). Three SF-36 categories (VT, SF, and MH) improved after surgery. However, neither the mental nor the physical summary component of the SF-36 score demonstrated improvement. No significant correlation was observed between the improvements in JOA and SF-36 scores. These results suggest that the objective (doctor-oriented) outcome evaluated by the JOA is not correlated to the HRQOL.

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We report a case of osteonecrosis-like lesion of the medial femoral condyle after arthroscopic partial medial meniscectomy. The patient was 34-year-old man who complained of pain on the medial side of the right knee after a rear-end automobile collision in 2002. Physical examination showed a normal range of motion of the knee. McMurray’s test was positive medially, and he had tenderness of the medial joint line. MRI showed a horizontal tear of the posterior horn of the medial meniscus.
The patient requested conservative treatment. However, medial pain of the right knee continued. Arthroscopic medial partial meniscectomy was performed 5 months after injury. Although symptoms diminished temporarily after surgery. He complained of recurrent knee pain 5 weeks after surgery. Radiographs and MRI showed osteonecrosis-like lesion of the medial femoral condyle. The patient underwent conservative treatment by bracing. At 12 months after surgery, the symptoms had resolved and the lesion had disappeared. Several authors have reported osteonecrosis of the femoral condyle after arthroscopic meniscectomy. This case is also considered to be rare, because the lesion was in a younger patient, and the postoperative course by conservative treatment was good.

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We recently performed total knee arthroplasty (TKA) in a case of which severe genu varum had developed following supracondylar femoral fracture.
A 74-year-old woman in 1991, and sustained a supracondylar fracture of the right femur was treated conservatively at a bonesetting clinic. As the knee pain had intensified since 1999, she consulted our hospital in October 2001. Preoperatively, the FTA was 210 degrees, the range of motion (ROM) of the knee was from 15 degrees in extension to 110 degrees in flexion, and the JOA score was 40. In July 2003, TKA was performed, without corrective osteotomy. The prosthesis used was an LCS Universal RP^® (Depuy). Postoperatively, FTA (177 degrees), knee ROM (from 0 degrees in extension to 120 degrees in flexion) and JOA score (80) was improved. As the LCS prosthesis for TKA is designed to determine the rotational alignment of distal femur on the basis of the plane of tibial osteotomy, it was useful in the present case of femoral condylar deformity.

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Deep vein thrombosis and pulmonary embolism remain among the most severe complications after total knee arthroplasty (TKA) despite the various methods taken to prevent them. TKA without a tourniquet is one of the preventive methods. In this study, we investigated the volume of blood loss in TKA without a tourniquet in 30 cases treated by TKA from May 2003 to July 2004. The patients were 5 men and 25 women, with an average age of 74 years (range, 62 to 84 years). Seventeen of the patients had hypertension (HT). Preoperative autologous donation was 800 ml by each patient, and cell saver was used during surgery. Total actual blood loss was the sum of blood loss during and after surgery. The estimated blood loss was calculated from change of hemoglobin (Hb).
None of the cases were complicated by pulmonary embolism during the follow-up period of 4-19 months (mean 10.5 months). Average actual blood loss was 1,409 ml, and the mean estimated blood loss was 1,725 ml. There was no significant correlation between the two volumes. There was no significant correlation in the volume of blood loss between with and without hypertension. None of the patients required transfusion in excess of their autologous donation. We thought that TKA without a tourniquet might be a useful method in terms of prevention of pulmonary embolism, but it is important to reduce total blood loss during surgery.

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Ten consecutive unicompartmental knee arthroplasties (UKA) in 10 patients (mean age 78.9 years, range 69-89 years) were studied retrospectively. Eight knees were diagnosed with medial osteoarthritis, and two had osteonecrosis of the medial femoral condyle. The mean follow up period was 8.4 months (range 2-17 months). M/G^® Unicompartmental Knee System (Zimmer, Inc. Warsaw, IN, USA) were used for all patients. The mean JOA score improved from 56 points to 92.5 points at the final follow-up. The mean preoperative range of motion (ROM) was 133.5 degrees, and no reductions were observed postoperatively. Radiographically, preoperative varus alignments (mean FTA 182.3 degree) were improved to the normal range of alignment (mean FTA 174.7 degree). There were no surgical complications. The amount of bleeding at surgery and duration of hospital stay were much less in UKA than in similar cases of TKA. These findings suggest that the less invasive UKA provided early recovery and good function. We concluded that UKA was quite useful, especially for these aged patients with unicompartmental osteoarthritis or necrosis.

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MIPO (minimally invasive plate osteosynthesis) for distal femoral fractures was applied in 15 patients (5 men and 10 women, ages 16-89 years) with 16 fractures. There were 5 A-type and 11 C-type fractures according to the AO classification. All fractures healed without needing primary or secondary bone grafts. There were no infections or refractures. There were 3 cases in which the femonotibial angle (FTA) increased after operation.
An emphasis on maintenance of the soft tissue envelope around fractures has improved efficiency in increasing osseous healing and decreasing infection.
In cases which have osteoporosis or major bone defect of the medial side, we must take notice of increasing varus deformity after operation. In these cases, we recommend the use of the locking plate system.

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Hip fractures are very common in the elderly and most of them are treated operatively because of severe comorbidity. The purpose of this study was to evaluate retrospectively the prognosis of patients who were treated nonoperatively.
303 patients were treated for hip fractures at our institution between January 2001 and December 2003, of them 41 cases (13.5%) were treated nonoperatively (5 men and 36 women). The mean age of the patients was 87 years (range, 58-98 years). The average follow-up period was 11.9 months (range, 3 days-36 months).
The 41 patients were treated nonoperatively because of severe comorbidity (44%), severe gait disturbance before injury (17%), complications after admission (15%), dementia (15%), or wishes of the patient and their family (10%). Cardiovascular disease was the most common comorbid illness that contraindicated operative treatment of the fracture. The mean period until patients were allowed bed-to-chair transfer with assistance was 14.1 days (range, 2-40 days). None of the 41 patients could walk at final observation, although most of them could move in a wheelchair. The rate of mortality was 12% at 3 months, 32% at 6 months, and 39% at 12 months. There was a significant difference in mortality between patients who could sit on a chair by two weeks (30%) and those who could not (62%).

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The purpose of this retrospective study was to evaluate rotational instability of the basal neck fracture of femur using Gamma nailing. Twenty-six cases (1 man, 25 women) of basal neck fracture of femur, treated by Gamma nail from 1992 to 2004, were investigated. The mean age was 81.8 years (range, 66-95 years). The mean follow up period was 23.8 months (range, 2-96 months).
Five cases had rotational instability (2 cases of “cut out”, 3 cases of rotational malunion) on radiographic images. These cases were characterized by fracture with large displacement before surgery, and with surgical failure (insufficient length of lag screw insertion, malposition of lag screw, rotational fixation).
When we treat basal neck fracture of femur with large displacement by Gamma nail, we need to keep good alignment and to insert the lag screw accurately. The surgical technique requires much skill. We do not recommend the Gamma nail for this type of fracture.

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A 62-year-old man, had a history of non-union of right femoral fracture sustained about 30 years ago. The fracture was cured after several operative treatments. In August, 2003 he felt suddenly pain in his thigh and was unable to walk. Radiographic examination revealed a refracture at the old femoral fracture site. An operation was performed using the Huckstep nail on August 21, 2003, and he had begun to walk. However, he complained that it became difficult to walk again after sudden onset of thigh pain on April 17, 2004. At that time, the breakage of the Huckstep nail was confirmed by radiographic examination. An interlocking nail fixation and bone graft using the fibula was performed. Both mechanical and biological conditions could have caused non-union of the fracture. Stress shielding at the fracture, caused by too rigid initial fixation of the fracture by multiple screws and damaged tissue surrounding the fracture caused by several operations might have inhibited the fracture healing process. It was considered that non-union of the fracture induced the fatigue fracture of the nail.

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Internal fixation by use of cannulated cancellous screw is a common orthopaedic procedure. Between January 2002 and September 2003, we treated three cases of subtrochanteric fracture following cannulated cancellous hip screw fixation for femoral neck fracture. The patients were women between 78 and 80-years-old. All three fractures occurred within 6 weeks of surgery. One fracture occurred at the site of the distal screws,one occurred after falling,the other occurred spontaneously while walking. Re-osteosynthesis was required in two cases using an intramedullary hip nail system after all screws were removed. Although the cause of these subtrochanteric fractures is unclear, several factors are thought to be operative. Two of three our patients who sustained subtrochenteric fracture while walking showed severe osteoporosis. Because bone density has been found to correlate with fracture stability, we assessed the degree of bone mineral density (BMD). In most of such cases with osteoporosis, we believe the degree of osteoporosis should be taken into consideration, when selecting among alternative methods of treatment.

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Avulsion fractures of the ischial tuberosity are sometimes appeared in athletes in sports such as sprinting, long jumping, or hurdling. We here report a case of avulsion fracture of the right ischial tuberosity.
A 13-year-old boy presented with right buttock pain and gait disturbance, which had occurred suddenly during a 100 m sprint race. At the first examination, he held his right knee in the flexion position and complained of tenderness at the right ischial area. Plain radiographs showed an avulsion fragment of the right ischial tuberosity separated from the pelvis by 3 cm.We performed an operation in which the fractured fragment was fixed using three cancellous screws. He could start walking under partial weight bearing at 3 weeks, and then jogging at 3 months after the operation.
There have been diverse opinions on the treatment of this type of fracture. As conservative treatment sometimes might delay the return to sports due to residual pain at the fracture site,we selected surgical intervention in this case because the fragment was separated by more than 2 cm.

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