We reported a case of arthroscopic debridement of a ganglion cyst causing suprascapular nerve paralysis. A 65-year-old man complained about continuous weakness of his right arm for ten months. Following magnetic resonance imaging (MRI) that showed ganglion at right suprascapular notch, an arthroscopy revealed a juxtacapsular ganglion cyst and degenerative tear of the glenoid labrum. Arthroscopic debridement was performed. After a postoperative period of three months strength of the right arm improved without recurrence of any experienced symptoms.

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The purpose of this study was to evaluate short term outcomes and 6 months postoperative T2 magnetic resonance imaging (MRI-T2) findings after arthroscopic full-thickness rotator cuff repair (ARCR). We evaluated 17 shoulders of 16 patients (8 men, 8 women, mean age 60.6 years), 10 right and 7 left shoulders, followed-up for more than 6 months after surgery. The mean follow-up period was 12 months. During arthroscopic surgery 6 small, 7 medium and 4 large tears were repaired. The mean JOA and UCLA scores showed good clinical results after ARCR with an improvement from 61 to 93 points and 11.8 to 31.1 points, respectively. Postoperatively, MRI revealed in 4 of 17 (23.5%) shoulders a recurrent defect and the 4 re-torn cuffs included 2 medium and 2 large tears. However, significant differences in clinical results were not observed among the patients with repaired or re-torn cuffs. We believe that improvement of function and reduction of pain were obtained in patients with re-torn cuffs.

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We reported about fixation with volar locking plate (VLP) in several cases of unstable distal radius fractures with satisfying surgical results. We evaluated 10 cases (3 men, 7 women, mean age 62) for perioperative aspects with a focus on postoperative adaptation to the treatment. All cases experienced bone fractures between April and June 2006. Periods from injury to operation stretched from 3-97 days. Examined bone fractures by AO-classification were : A 2 : 4 wrist, A 3 : 1 wrist, B 2 : 2 wrists, B 3 : 1 wrist, C 2 : 1 wrist, C 3 : 1 wrist. All cases received treatment with VLP. External fixations were applied for 12-31 days. Results showed that VLP enabled early exercise, subchondral support and strong inner fixation. Advantages of this technique are that the treatment can be positively applied to inner and outer joint bone fractures, with a wide adaptation range.

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The purpose of this study was to examine clinical outcomes and operative pitfalls of six cases of total hip arthroplasty (THA) surgery after failed transtrochanteric rotational osteotomy (TRO) for avascular necrosis of the femoral head. Five were men and two were women. The average age of the patients at the time of conversion to THA was 40 years (range, 21-60 years). Postoperative Japanese Orthopaedic Association (JOA) scores showed very satisfactory improvement compared to preoperative scores (mean score 40.7/78.5 points, respectively). Compared to the primary THA procedure, the mean operation time of THA after the failed TRO was significantly longer and the average of blood loss was also significantly greater. Postoperative complications were observed in only one hip. The broach should be inserted carefully to avoid retroversion. It is important to completely remove the impingement of the osteophyte. Because in THA after TRO many pitfalls are existing, these points should be taken into preoperative and postoperative consideration.

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Posterior lumbar interbody fusion (PLIF) is considered to be a suitable operative procedure for degenerative spondylolisthesis. However, PLIF is known as a procedure with many side effects; among them these related to the extensive invasion of paravertebral muscles (PVM) are the most remarkable. In order to overcome this problem with the aim being the prompt recovery of patients, we have recently conducted the MIS-TLIF (minimally invasive surgery-transforaminal lumbar interbody fusion), which is associated with less PVM insult. The procedure enables patients to rise, walk, leave the hospital, and return to their job promptly. MIS-TLIF is the combination of PLIF procedure using a percutaneous pedicle screw and rod system, CD Horizon Sextant, a bilateral decompression and a transforaminal interbody fusion by hemi mini-open approach using microendoscope or microscope. We reported comparative short-term outcomes after MIS-TLIF and conventional PLIF. MIS-TLIF technique was associated with longer surgical procedure. However, bed rest length and admission were shorter when compared with the conventional PLIF procedure. Concerning efficiencies of JOA score about low back pain differences were absent. There was a reduction in the low back pain on day 3 after MIS-TLIF procedure comparing to the preoperative period when evaluated through the VAS score. The MIS-TLIF is a less invasive procedure, which is associated with a reduction of the low back pain in the postoperative period that contributes to shorten the length of bed rest and admission. MIS-TLIF technique is a less insulting procedure for the treatment of degenerative spondylolisthesis.

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Many surgical techniques have been reported for the treatment of malalignment of patella. Over recent years, as the medial patellofemoral ligament (MPFL) has been shown to be the primary restraint to lateral patellar translation, MPFL reconstruction has become a common procedure. The purpose of this study was to investigate the short term results of 8 cases (4 men, 4 women, mean age 22.8 years), who underwent MPFL reconstruction in our hospital using hamstring tendons. Mean follow-up period was 1.7 years. The mean Kujala score improved from preoperative 55.6 points to postoperative 95.5 points, with no occurrence of patella apprehension. Furthermore, patellofemoral alignment improved after surgery in all cases. Based on these results, we concluded that MPFL reconstruction is useful for the treatment of patella malalignment.

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We reported a case of total hip arthroplasty (THA) for an irradiated hip. The patient was 65 years old woman with right coxalgia. At age 60, total hysterectomy surgery, for womb malignant melanoma, was performed at our department. This enforced external radiotherapy at an irradiation level of 48.5Gy. After treatment blood tests did not reveal any complications and tumor markers were negative, but right hip joint mobility was limited. At her first examination before THA, end stage coxarthrosis was diagnosed. Radiography and computerized tomography (CT) revealed protrusio acetabuli. During the five months period to surgery, the patient received conservative treatment without retrogression. Cement THA surgery using a Kerboull cross plate was then performed, because postoperative loosening of acetabular is often observed after cementless and cement THA procedure. Preoperative Japanese Orthopaedic Association (JOA) score was 15 points compared to postoperative score of 85 points. We recommend reinforcement of the acetabulum by a Kerboull cross plate in THA surgery for irradiated hip.

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From 1974 to 2005, we treated 520 hips in 471 patients with developmental dysplasia of the hip (DDH). Among these, 101 hips in 89 patients (18.9%) were diagnosed as DDH when they were older than six months. In addition, 43 patients were diagnosed after they had begun to walk. In the 1970’s the rate of DDH diagnosis after six-month-old patients was 30.3%. From the 1980’s to the 1990’s this rate decreased, but increased again to 24.3% after 2000. We compared gender, family history of DDH, affected side and treatment method (conservative treatment or operation) between patients diagnosed before six months old and after six months old. No significant differences were found except for treatment method. 22.4% of DDH patients diagnosed before six months old were treated by surgery, compared to 69.3% of patients diagnosed older than 6 months. In conclusion it became clear that the rate of DDH diagnosis at an older age has increased in recent years, so we argue that it is important to improve the accuracy of the medical examination for DDH.

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We reported two cases suffering snapping of PIP joint of the little fingers with pain. Radiographs revealed swan-neck deformity, osteoarthritis and ulnar instability of the PIP joints. In case of the first patient, a 42-year-old woman, osteotomy of the basal phalanx was performed to correct ulnar deviation of the PIP joint. However, the swan-neck deformity worsened three months after surgery. In order to revise the outcome of surgery, we performed osteotomy again followed by sublimis sling method using radial flexer digitorum superficialis tendon. In the case of second patient, only the sublimes sling method was used. In the case the first patient, correction of deformity, relief from pain and snapping of the PIP joint was improved seven months after the first surgery, although she finally shows loss of 30 dgree of flexion range of motion. However, the second patient has no loss of flexion range of motion two month after the surgery. We considered sublimis sling method using radial flexer digitorum superficialis tendon might be a good treatment modality to control hyper-extension and ulnar-instabirity of the PIP joint due to chronic radial collateral ligament injury.

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A degloving injury of the right middle finger tip was successfully treated using a bag-type negative pressure dressing (BNPD). The patient was a 5-year-old girl who injured her right middle finger with a fruit sorting machine. Injury was classified as zone II degloving injury, accompany with distal phalanx exposure.
After adequate debridement, using clean techniques, the wounds were covered with a hydrophilic polyurethane sponge. A drainage tube was placed on top of the sponge, and the whole region was covered with a film dressing. Then the hand was placed in a commercially available, gas sterilized, sealable bag. The mouth of the sealed bag was fixed to the forearm with film dressing to ensure a tight seal. The tube was connected to an aspirator and kept at negative pressure -15 to -17 kPa during rest periods. During therapeutic exercise of the fingers, aspiration was stopped and the negative pressure was reduced to enable the fingers to move freely.
Thirty-four days after starting the treatment, adequate granulation and wound regression were achieved and the BNPD was terminated. One week after termination of BNPD, the wound was almost epithelialized. At the last follow-up, 34 weeks after the injury, TAM was 100% in the middle finger and the regeneration of the nail was satisfactory.
The BNPD method allows an early rehabilitation and motion of the affected finger resulting in a reduction of joint and scar contracture. For that reason, the BNPD should be considered as a feasible treatment for the finger tip injury instead of the aluminum foil method, and the artificial dermis.

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We reported 11 cases of non-traumatic posterior interosseous nerve paralysis, 6 males and 5 females, respectively.
Patient’s age ranged from 19-72 years with a mean of 44.8 years. Posterior interosseous nerve was surgically explored in all patients. Nerve entrapment occurred in 5 patients, in 4 of them it happened at the supinator, called arcade of Frohse. In another patient symptoms were caused by a space occupying lesion that was finally diagnosed as a fibromatosis of bursal wall. In addition, nerve constriction was observed in 5 patients at the level of the posterior interosseous nerve trunk. External neurolysis was performed in all patients. Recovery from paralysis was observed between months 2-9 with a mean of 5.1 months after surgery. This result was satisfactory in our opinion, because we could perform surgery in all patients in a period of time relatively short following paralysis, 1-6 months with a mean of 4.2 months, respectively.

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Large skin defect is often treated by the skin graft. However it is a technically difficult method. We reported two cases of large skin defect of the foot which were treated using a conservative approach, the film-dressing therapy. The therapy was simple, and consisted of washing and dressing the wound with a film. Wound healing was achieved in few months without any sensory disturbance. The method is technically easy and lack of cosmetic problems. Based on the current results we recommend this technique for large skin defects.

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We report a rare case of fracture of bilateral pedicles following osteoporotic vertebral compression fracture. A 59-year-old woman complained about pain in her back, right buttock and right leg. Radiography revealed non-union of the vertebral body following L2 compression fracture. Further, myelogram showed incomplete block at L2 vertebral upper portion, and computerized tomography myelography (CT-M) bilateral L2 pedicle fractures; a dynamic radiograph in her extention position showed a reduction of the non-union site. Follow up examinations were performed at two weeks and three months after the procedure, afterwards once per two months. Posterolateral fusion (PLF) using autologous bone graft with pedicle screws through the fractured pedicles was performed at the extended position.
Eight months after surgery, plain CT indicated bone union in the PLF and pedicle fractures to be healed. Ten months after surgery, the Japanese Orthopaedic Association (JOA) score improved by 66.7% and the correction loss of L2 vertebra had finally reached down to 26.7%. At the end of the follow-up period, her leg pain was gone and she was able to walk without any supports. We believe that in this particular case, stresses may have been concentrated on bilateral pedicles in vertebral pseudoarthrosis during lumbar motion and led to pedicle fractures. To the best of the authors’knowledge, this was the first report of pedicle fractures following vertebral pseudoarthrosis.

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The objective of our study was to verify diagnostic accuracy of sitting and supine position radiography (S-S radiography) for early detection of fresh vertebral fractures in the elderly. To detect vertebral fractures mobility, lateral radiographs in sitting and supine position were performed on elderly patients (17 men, 77 women, mean age 80.3 years) complaining of acute trunk pain without a neurologic deficit. We studied the S-S radiography at the first clinical examination and additional magnetic resonance images (MRI) to diagnose fresh vertebral fractures. MRI detected 102 fresh vertebral fractures between T4 and L5 in 75 patients (15 men, 60 women, mean age 79.5 years). A correct diagnosis of incident fractures based on the S-S radiography was made in 90.7% of patients. Early detection of fresh fractures based on the S-S radiography in those vertebral fractures with fresh fracture based on MRI was made in 76.5% of all vertebral fractures. Diagnoses of fresh fracture based on Xp in those vertebral fractures with previous fracture based on MRI did not occur. We concluded that the S-S radiography at the first clinical examination was effective for early detection of fresh fractures in the elderly.

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We reported a series of five patients (2 men, 3 women), aged 44 to 67 years (mean age 61), who were diagnosed with elastofibroma dorsi, rare benign soft tumors located at the inferior pole of the scapula. Three lesions were unilateral and two were bilateral. All patients were referred from other clinics and diagnosed at the time with a large, unspecified tumor of the back. Two of the patients complained of pain and clunking of the scapula on shoulder abduction. All patients underwent excision of the tumor. Preoperative magnetic resonance imaging revealed concordance with the histopathological diagnosis. In the case of three patients postoperative complication of hematoma formation occurred. We believe, presumptive diagnosis is possible by careful clinical examination using magnetic resonance imaging (MRI). Because postoperative hematoma is unexpectedly frequent and symptomatic, only excisional biopsy is necessary for histopathological diagnosis and radical resection should be avoided.

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We report a case of infantile digital fibromatosis observed by electron microscopy. A four year-old boy was admitted to our department with a swelling on the second toe of his right foot, which first occurred at age three. Closer examination revealed a 1×1cm sized firm, red nodule in the lateral aspect of the toe. Magnetic resonance imaging (MRI) showed a soft tissue mass with low signal intensity on T1(-weighted) images, and iso signal intensity to the muscle on T2 (-weighted) images. A marginal resection was performed. The excised lesion was small firm mass that had white cut surface. Histological examination showed several cytoplasmic inclusion bodies in the spindle-shape tumor cells. Electron microscopy revealed that the inclusion bodies showed characteristics of actin filament. At follow-up examinations 10 months after surgery, no recurrence of the tumor was seen. Infantile digital fibromatosis is a fibromatosis is usually observed in feet of children less than 1 year old. Our electron microscopic study indicated that this tumor has a myofibroblastic origin.

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Several procedures are available for the reconstruction of massive bone defects following resection of malignant tumors. Recently, the new techniques of extracorporeally-irradiated bone autograft and vascularized bone graft were reported. However, the complication rate after surgery appears to be higher than expected. Combined use of extracorporeally-irradiated bone and vascularized bone would seem to be the ideal graft process for reconstruction because of the cumulative advantagesarising from this approach. Five patients (14-57 years, mean age 32.4) with a malignant tibial tumor were treated surgically with a combination of vascularized bone graft and extracorporeally-irradiated autograft. In 4 patients, the vascularized bone graft were successful without vascular complication. The mean period until the start of full weight bearing was 9 months (range 8-10) and the MTS score was classified as good to excellent with a mean score of 94 points (range 87-100). No local recurrences arising from the irradiated bones were detected. In one case, the vascularized scapula graft transplanted was totally necrotic due to venous thrombus. Combined use of free vascularized bone graft and extracorporeally-irradiated autograft proved to be a reliable procedure for the reconstruction of massive bone defects following resection of a malignant tumor.This procedure is best suited for intercalary defects of the tibia.

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We evaluated the postoperative X-ray of the femoral trochanteric fracture using Proximal Femoral Nail Antirotation (PFNA), which is a new implant for patients with proximal femoral fracture made by AO/ASIF group. From April 2004 to May 2006, 25 patients, 5 men and 20 women, were treated for femoral trochanteric fracture using PFNA procedure. The mean age was 84 years (69-98 years). Twenty five fractures were classified using AO/ASIF classification, 10 as 31A1, 14 as 31A2, and 1 as 31A3, respectively.
Tip-apex distance (TAD) average was 21±4 millimeters. As evaluated according to the zones in the femoral head, PFNA blade were most frequently placed in the center-center zone (23 of 25 cases). No cases of cutout were observed. Three months after operation sliding length of PFNA blade average was 3.1±4.0 millimeters. There was no statistical relationship between fracture classification, TAD, blade position, and sliding length of PFNA blade. In two cases the sliding length was over 10 millimeters. In these cases some gap of fracture site remained. In order to reduce the excessive sliding of PFNA blade it is necessary to reduce the gap to a minimum.

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This study evaluates the clinical results of osteosynthesis on femoral trochanteric fractures. Sixteen cases (5 men, 11 women, mean age 84.9 years) were treated with proximal femoral nail antirotation (PFNA) from May 2005 to March 2006. The mean period from injury to surgery was 4.3 days (range 0 to 8 days) and the mean follow-up period was 5.2 months (range 3 to 13 months). Using the AO classification, two fractures were classified as 31-A1 and 14 fractures as 31-A2. All cases resulted in bone union. There were no postoperative incidents of varus deformity, neck rotation, infection or severe impairment of walking ability. We conclude that the proximal femoral nail antirotation produces very satisfying results for internal fixation of unstable femoral trochanteric fractures.

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We reported about two cases of hemorrhagic shock for open pelvic fracture patients, who were successfully treated with intra aortic balloon occlusion (IABO). In the first case, a 69-year-old man was run over by a train and transferred to our emergency and critical care center with an open wound around anus. His blood pressure was 130/55-mmHg and pulse was 90/min. AO classification of the pelvic fracture was 61-C1. The second case was of an 18-year-old man who suffered injuries from a motor vehicle accident. On arrival, an open wound around the perineal area was examined. The patient’s blood pressure was 72/43-mmHg and pulse 110/min. AO classification of the pelvic fracture was 61-C2. Because neither patient responded to fluid administration and emergency transfusion and status of shock continued, a catheter for intra-aortic balloon occlusion was inserted. This procedure stabilized the patients’ blood pressure and operations were performed. In both cases descending aorta was partially and intermittently shut off. Total interruption time of descending aorta for case 1 and case 2 was 10 and 20 minutes, respectively. IABO is a secure method for arresting bleeding below the abdomen and effective for emergency treatment of open pelvic fractures with hemorrhagic shock.

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Pre and postoperative antibiotic therapies in surgery are associated with reduce incidences of wound infection. However, because of side effects, long term prescription of the antibiotics should be avoided. In order to clarify effectiveness of antimicrobial prophylaxis (AMP) in orthopaedic surgery, we surveyed it institution.
One hundred seventy two patients, 89 males and 83 females, with a mean age of 51 years, who underwent surgery between November 2005 and June 2006 at our institution were investigated. Operations consisted of total knee and hip joint arthroplasty (34 patients), spinal decompression (47 patients) and arthroscopic surgery including ligament reconstruction of knee, meniscus injury, synovectomy, and shoulder surgery (91 patients). Antibiotic type, administration period, method of AMP, and surgical site infection (SSI) incidence were investigated. Cefazolin was the most commonly administrated antibiotic (98.2%). Mean administration period of AMP was 2.6, 1.3 and 1.4 days for joint arthroplasty, spinal decompression, and arthroscopic surgery, respectively. In 31 of 45 patients surgical procedure was longer than 3 hours. There patients received an additional dosage of antibiotic. Twenty one patients (29%) did not receive any antibiotic in the postoperative period. The incidence of SSI was 1.2% (2/172). Infections were superficial. Overall the administration period of AMP was short in our institution. In cases of joint arthroplasty the administration period was shorter than proposed in the guidelines. In case of spinal decompression and arthroscopic surgery one day administration on the operative day was considered sufficient for AMP. Further studies are required to determine the optimal AMP method in the near future.

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Total knee arthroplasties were performed in 1348 rheumatoid arthritis patients at Dohgo Spa Hospital between April 1984 and December 2005. Of those, 13 knees (0.96%), of 12 patients (3 knees of 3 men and 10 knees of 9 women) were treated for an infection that had developed after total knee arthroplasty. We identified 3 acute, 4 delay and 6 late infections on the basis of the clinical presentation described by Fizgerarald et al. As for clinical symptons, all patients complained about persistent pain, but only 6 cases (46%) had developed fever.
It was valuable to examine the knee infection they elevated higher C-reactive protein than elavating white blood cell count. All patients were treated with a suction-irrigation system and antibiotics. Eight knees (62%) were receptive to prosthesis by treatment with the suction-irrigation system only. The organism involved included eight cases of Staphylococcus aureus, two cases of Methicillin-Resistannt Staphylococcus aureus (MRSA) and one case of Pseudomonas aeruginosa. Treatment in the case of the two infected knees caused by MRSA failed and the prosthesis was removed. Two knees with one-stage revision and one knee with two-stage revision had no signs of reinfection.

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Revision of infected total hip arthroplasty has had variable success and can be performed in single or double-stage procedures using antibiotics to treat the infections. From April to July 2006 we have treated a total of 5 patients suffering from infected total hip arthroplasty using the Prostalac hip system at Anderson Orthopaedic Research Institute. Several advantages are associated with the Prostalac hip system like, effective treatment of sepsis, reduction of patient morbidity and rehabilitation from prolonged immobility. Furthermore, it permits a less complicated approach to placement of the final arthroplasty components. The Prostalac hip is comprised of a cobalt chrome alloy core femoral component, a cobalt chrome alloy modular femoral head, a one-piece polyethylene acetabular component, a PMMA stem centering device and antibiotic-loaded bone cement. It has been designed to remain in situ for approximately three months after which a second surgery is performed for implantation of a permanent THA prosthesis. Considering the design characteristics of this device stress associated with full weight bearing should be avoided during the three month implantation period. We had the good results for all treated cases; unfortunately this system has not been approved in Japan.

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Revision anterior cruciate ligament (ACL) reconstruction surgery has become increasingly common. A 21-year-old woman was performed primary ACL reconstruction with bone-patella tendon-bone (BTB) on the left knee at 17 year. After ACL reconstruction, she sometimes felt instability and complained about giving way on the reconstructed knee. She developed pain from 18 year. No limitation of motion was showen but positive anterior drawer test, pivot shift test and McMurray test on the physical examination at 21 year. We performed revision ACL reconstruction, which was preserved primary graft and augmented with hamstrings tendon and medial meniscus was repaired. At 14 months after operation, she has no complain subjectively and no rotatory and antero-postarior instability has restrained. We believe this technique offers a reasonable approach to revision ACL surgery in the properly indicated patients, especially for the rotatory istability.

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For mono-compartmental osteoarthritis, we perform focal dome osteotomy distal to the tibial tuberosity using the Ilizarov apparatus. In this paper, we introduce a unique osteotomy technique. Before surgery, we designed a malalignment test to identify the source of the mechanical axis deviation and the center of rotaion of angulation (CORA). After the lower leg is fixed with the Ilizarov apparatus a Rancho Cube is attached to a rod connecting the proximal ring at the level of the CORA. A distal hole in the Rancho Cube is used as a drill guide. Next, the tibia is drilled through the hole of the Rancho Cube around the CORA. Circular osteotomy is accomplished by connecting the multiple drill holes with a small chisel. Using this technique it is possible to cut the bone around the CORA and preserve soft tissue around the osteotomy site. Acute correction is performed until the mechanical axis passes through the Fujisawa point. The advantages of the technique we introduced are high adjustability of the bone ends, large bone-to-bone contact, high primary stability, rapid bone healing and complete correction without translation.

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Postoperative autologous transfusion of filtered shed blood (SBT) is a simple and inexpensive method to avoid allogeneic blood transfusion, and has been widely used in total knee arthroplasty (TKA). In the present report, we used a postoperative wound drainage and return system with filter in one patient who underwent bilateral serial TKA. Postoperative complications, plasma D-dimer (DD) and hemoglobin values were evaluated. A 72 year old woman who was suffering from rheumatoid arthritis received first left side TKA operation, blood transfusion was not required during the procedure. Five months later, she received a right TKA and postoperative SBT. No evident clinical complications were observed after both procedures. Hemoglobin values showed minimal differences in both postoperative courses when evaluated one week after the surgery. Interestingly, the DD values measured during postoperative day 1, were higher following the 2nd TKA comparing to the 1st TKA, 56.6μg/ml and 4.2μg/ml, respectively. The DD value reflects the degree of second fibrinolytic activity, and we speculated there may be a lot of micro-coagulation clots in the filtered shed blood. For that reason DD values have to be carefully interpreted particularly during the immediate post operative period, because coagulation-fibrinolytic activity may be greatly influenced by SBT.

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We reported the mid-term results of 15 knees in 10 patients with ostheoarthritis treated by NexGen^® LPS-Flex total knee arthroplasty (TKA). Patients received clinical and radiological evaluation. Three males and 7 females with a mean age of 76.2 years were followed up for a period of 48 to 65 months (mean follow up 54.4 months). Preoperative mean flexion angle improved after the procedure from 130.1 to 138.0. In addition, mean preoperative range of motion increased from 130.7 to 137.0, after surgery. The mean Japanese Orthopedic Association knee rating score improved from 50.7 to 91.7 points. Clinical complications were not observed. There was no radiographic evidence of loosening or sinking. Correlation between the body mass index/postoperative flexion angle, and preoperative/postoperative flexion angle were statistically significant.
The use of LPS-Flex in our mid-term evaluation is associated with an improvement of flexion accompanied with good clinical outcome.

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We performed medial unicompartmental knee arthroplasties (UKA) using minimally invasive surgical technique (MIS) in 23 patients from 2002 to 2006. The MG Uni UKA system (13 knees), and Zimmer Uni UKA system (10 knees) were used in the procedure. Osteoarthritis (OA) was diagnosed in fifteen knees, and osteonecrosis (ON) of femoral condyle in 8 knees respectively. The patients mean age was 77.4 years (66-85), and the mean follow up period 16.9 months (6-50). The mean operation time was reduced from 116 min to 107 min since 2005. The bleeding was minimal. Mean preoperative hemoglobin dropped from 12.5 g/dl to 11.7 g/dl the day after surgical procedure. Further more no blood transfusion was required. The mean preoperative range of motion was 135 and 134 degrees at the latest review. The mean JOA score improved from 52 to 89 points. Mean gait stability was achieved at day 11.2 (4-25). In conclusion, rapid recovery and minimal invasiveness makes this procedure (MIS-UKA) an excellent therapeutic option for older patient suffering from OA and ON.

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We reviewed 9 cases (4 men, 5 women, mean 49.9 years) who underwent revision surgery after Microendoscopic Discectomy (MED). Primary causes of revision were residuum in four, relapse in two and instability in three patients. Residuum and relapse were treated by the Love method in five cases and in one case by osteoplastic discectomy. Cases of instability were all treated by anterior lumbar interbody fusion. In all cases, the residual lumbar disc herniation migrated. Preoperative and postoperative hernia disc level was at L5/S in four revision cases. These results suggest that more attention to migrated lumbar disc herniation and lumbar disc herniation at L5/S disc level is necessary during surgery.

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We reported a case of scoliosis complicated with syringomyelia caused by Chiari malformation. The patient was an 11-year-old girl with scoliosis. She had been asymptomatic and had no past history until then. Radiographs revealed a 69° Cobb’s angle of scoliosis from Th4 to Th11. Syringomyelia and Chiari malformation were diagnosed by magnetic resonance imaging (MRI). The patient showed subtle neurological abnormalities such as sensory disturbance, muscle weakness of fingers, absence of superficial abdominal reflexes and hyporeflexia of the legs. Foramen magnum decompression, C1 laminoplasty and duraplasty with preservation of the arachnoid membrane were performed. Postoperatively, the size of the fistula and sensory disturbance had decreased. However, the Cobb’s angle progressed from 69° to 112° during six months after surgery. A posterior spinal correction and fusion from Th3 to L1 was performed. To avoid the risk of potential development of neurological problems due to distraction force in the spinal cord, we corrected the spinal deformity by rod rotation maneuver using Cotrel-Dubousset (CD) system. The Cobb’s angle of scoliosis changed to 37°. We believe in cases of atypical scoliotic curves, neurological examination and MRI are important means to check for the existence of Chiari malfoemation and sylingomyelia.

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Two cases of cervical intradural meningioma located anterior from the spinal cord were successfully resected by hemilaminectomy. Sensory evoked potential (SEP) was monitored through the operation. Since we approached from postero-lateral direction, the margin between spinal cord and tumor was easily identified. Resection was safely performed because of the flatness of the cord. In one case the arising site of the tumor from the dura was resected and patched with an artificial dura. In the other case the arising site was burned by bipolar cautery because of the existence of a venous plexus in that site. Preoperative symptoms, numbness and spasticity of extremities disappeared in both cases after surgery. Follow-up period up to 1 year revealed no evidence of tumor recurrence. In addition, neurological symptoms were absent. Our results suggest that the posterior approach hemilaminectomy with SEP monitoring is a less invasive and safe method for intradural cervical meningioma arising from the anterior site of the dura.

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Kurokawa’s procedure is associated with a satisfactory clinical outcome. However, excessive loss of cervical lordosis often occurred. A total of 31 patients were treated with Kurokawa’s procedure until February 2005. From March 2005 another 28 patients were operated using our technique which consisted in preservation of posterior elements. Our procedure enables us to preserve the C2 insertion of semispinalis cervics and, re-attachment of spinous process and extensor musculature from C3 to C7. Patients were clinically evaluated using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy and postoperative axial pain. Radiologic evaluation of cervical alignment and cervical range of motion (the difference between lordotic angle at maximum extension and at maximum flexion) performed pre and postoperatively. The mean follow-up period was 36 and 8 months, respectively for Kurokawa’s and our procedure. Although, there were not significant differences between Kurokawa’s and our procedure when comparing the recovery rate through the JOA score, the decreasing rate of cervical range of motion, and the rate of postoperative axial pain. However, the average postoperative lordotic angle increased 1.8 degrees in our procedure while in Kurokawa’s procedure it decreased 4.1 degrees, respectively. Preservation of the C2 insertion of semispinalis cervics as dynamic stabilizer and posterior ligamentous complex as static stabilizer in our procedure, lead to an effective cervical alignment.

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The purpose of this study was to elucidate the factors influencing bony fusion rate in atlantoaxial- or occipito-cervical fixations using wires and/or rods in patients with rheumatoid arthritis (RA). Thirty-two RA patients who underwent modified Gallie fixation (n=8) or occipito-cervical fixations using Ransford loop with sublaminal wiring (n=24) were evaluated. Follow-up average duration was 3.8 years. Classes and duration of RA, Ranawat’s score, type of cervical lesion, bony fusion, and X-ray measurements including atlas-dens interval (ADI) and space available for spinal cord (SAC) were retrospectively investigated. Bony fusion was confirmed in 23 cases (72%, fused group) and absent in 9 (28%, non-fused group). When the preoperative measurements between the groups were compared, preoperative ADI in neck flexion was significantly smaller in fused than non-fused group (7.2±3.6, 11.4±2.2mm), respectively. Cut-off value of preoperative ADI in neck flexion for estimated bony fusion was calculated as 9mm. However, even in fused group preoperative SAC in neck extension was larger than postoperative SAC (17.3±3.9, 15.4±3.8), respectively; suggesting that bony fusion had occurred during mild progression of atlantoaxial subluxation. Atlantoaxial- or occipito-cervical fixations without screw reinforcement in patients with rheumatoid arthritis yield satisfactory results when 1) preoperative ADI in neck flexion is equal or less than 9mm, 2) preoperative SAC in neck extension is affordable for another 2mm subluxation, and 3) a postoperative halo-vest fixation is used.

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We experienced two cases of Transforaminal Lumbar Interbody Fusion (TLIF) for lateral nerve root compression. The first case was a 58-year-old woman who suffered from lumbago and severe right leg pain. Clinical neurological findings following a MRI suggested right L5 radiculopathy. The MRI revealed a convexity of the right lateral margin of the disc and foraminal stenosis at L5/S1. TLIF procedure was performed on the right side after the diagnosis was confirmed through right L5 radiculography and anesthetic nerve root block. The second case was a 48-year-old man who complained of severe pain in the left thigh. He had already undergone lumbar discectomy at the left L4/5 twice. Clinical neurological post MRI findings suggested left L4 radiculopathy. The MRI revealed left lateral disc herniation at L4/5. TLIF procedure was performed on the left side after the diagnosis was confirmed through left L4 radiculography and anesthetic nerve root block. The clinical outcome after surgery in both cases was satisfactory. During TLIF procedure complete surgical decompression of the nerve root was performed by total resection of the facet joint. In addition lumbar interbody fusion could be treated during one surgical procedure.

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