We introduce our strategy for safe screw insertion in the cervical and upper thoracic spine and its clinical results. We employed lateral mass screws for C1, 3, 4, 5, and 6 and pedicle screws for C2 and 7, and the thoracic level. When the C2 pedicle was thinner than 3.5mm, we used C2 laminar screws. We did not use Magerl-type transarticular screws or facet screws. A total of 128 screws were inserted from the occipital bone to the Th3 vertebra in 16 cases. There were 6 cases of cervical myelopathy, 4 cases of RA and others. Clinical complications were reviewed and appropriate insertion was evaluated using 3D-CT. There were no major complications including spinal cord or nerve root injury, or damage to the vertebral artery. Among the 128 screws, 123 (96.0%) were confirmed to be accurately inserted by 3D-CT. For lateral mass screw insertion by the Roy-Camille technique and C2 laminar screw insertion, all screws were inserted at the appropriate sites (100%) without any complications. All five screws that were inappropriately inserted were pedicle screws. Among a total of 51 pedicle screws, 5 showed minor breaches of the wall at C7, T1 and T3, yielding a 90% success rate for pedicle screws as a whole. There was one case of C2-PS loosening. All cases showed solid fusion, and there was no case of infection. We conclude that our strategy using a combination of pedicle, lateral mass and laminar screws is safe and reliable.

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Thirteen patients with cervical degenerative disorders were treated by laminoplasty combined with pedicle screw fixation. The mean improvement rate was 43.1%. Five screws out of 59 were dislocated from the pedicles, two in the transverse foramen and three in the spinal canal. However, neither neurological deterioration nor vertebral artery injury occurred. Loss of correction of cervical lordosis occurred in only one case. Although rigid internal fixation and decompression were obtained by this procedure, the surgical techniques for insertion of screws correctly into the pedicles were too difficult because the pedicles were excessively sclerotic and hypertrophic.

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Pyogenic spondylitis frequently occurs in aged or morbid patients, and the clinical features are often atypical. In this study, 24 cases were examined. The average patient age was 64.1 years. The cases were reviewed with regard to basic disease, mode of development, clinical features and treatment results. Twenty-three (96%) of the patients had underlying diseases such as diabetus mellitus, liver cirrhosis and cancer. Twenty-one cases developed acutely, and 3 cases were subacute or chronic. Fourteen of the patients had first consulted other departments or clinics. Six patients did not have high fever, and bacteria were not detected in 16. Although 22 cases (92%) were diagnosed by pathological findings, 2 were diagnosed as metastatic bone tumor or osteoporotic vertebral fracture. Twenty-one cases were treated by conservative therapy, while 3 needed surgery. The periods of therapy ranged from one to 11 months, with an average of 4.5 months.

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Between June 2007 and January 1998, we operated on 21 patients (13 men, 8 women, mean age 57 years) for sciatic pain caused caused by lateral lumbar disc herniation. In most cases, lateral fenestration under microscopic observation was done via the paraspinal approach of Wiltse.
We evaluated the morphology of the herniation with reference to the localization classification of Sannohe. Comparison of the localization classifications obtained by MRI with the operative findings, yielded an agreement rate of 57.1%. Furthermore, examination of the escape direction of the herniation showed that this occurred, craniad migration in 7 patients and at the intervertebral disc level in 14 patients. In patients with herniation directed cranially, the rate of agreement between the MRI localization classification and operative findings was 42.9%, whereas in those with herniation escape to the intervertebral disc level, the rate of agreement was 64.3%.
In cases of herniation directed cranially, we think that a new classification focusing on the relationship with the lateral part of the pars interarticularis is necessary.

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We report our experiences with minimally invasive plate osteosynthesis (MIPO) for distal tibial fractures (AO types 43A-C) from January 2005. There were 9 men and 1 woman with a mean age of 52.9 years. The mean follow-up was 9.2 months. We used a Narrow LC-LCP in 2 cases and an LCP Distal Tibia Plate in 8 cases. In all cases, the fractures were united both clinically and radiologically at a mean of 4.3 months after the procedures. There was no deep infection, loss of reduction, or implant failure. According to Burwell’s criteria, the radiographic results were anatomical in 8 cases and poor in 2. Objective results were good in 8 cases and poor in 2. Subjective results were good in 8 cases and poor in 2. In the MIPO technique, it may be difficult to obtain anatomical reduction because the fracture site cannot be observed directly. As we performed reduction onto the plate using a cortical screw in 4 cases of residual axial malalignment after closed reduction, anatomical reduction was obtained. For concomitant fibular fractures, we used a K-wire in 7 cases and obtained good union. The mean period of full weight-bearing was 9.2 weeks, which was shorter than in other series. We consider that earlier mobilization is allowed because of the good angular stability of LCP.

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Fracture of an ossified Achilles tendon is rare. This report describes one such case.
The patient was a 47-year-old man who suffered pain at the back of the ankle after falling down some steps. Fracture of an ossified Achilles tendon was diagnosed from radiographs. We repaired the injury using an anchoring system, and after the operation the patient used a short leg cast for 6 weeks.
The clinical result was good, and the patient had no complaints after 11 months of follow up.

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The Taylor Spatial Frame (TSF) is a new external fixator that consists of two rings and six struts. Compared with the Ilizarov external fixator, the TSF allows easy correction of lower limb deformities, and since 2005, we have used the TSF for this purpose. In the present study, we evaluated the effectiveness of the TSF for the treatment of deformities in 3 children (4 tibiae). There were 2 male patients and 1 female patient (aged 12, 13 and 16 years respectively), and their diagnoses were hypophosphatemic rickets, idiopathic external tibial torsion, and secondary genu recurvatum (with avascular necrosis of the femoral head after slipped capital femoral epiphysis). The length gain averaged 2.5cm (range 2.0 to 3.1cm), the mean external fixation index was 53.0 days/cm (range 41.0 to 67.5 days/cm), and the mean corrected angle was 31.5 degrees (range 20 to 40 degrees). Complications included one fracture of the lengthening site and one case of transient peroneal nerve palsy. There were no cases of pin tract infection. In all cases, we achieved accurate corrections as planned before surgery. We believe that the TSF is a very useful and accurate external fixator for correction of lower limb deformities, especially complex multiplanar deformities.

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The purpose of this study was to evaluate the results of reconstruction of the anteromedial bundle alone of the anterior cruciate ligament, while retaining the posterolateral bundle, using bone-patellar tendon-bone between 2006 and 2007. Three male patients were followed up for 8 to 12 months (mean : 10.7 months) after surgery. The mean age was 24.7 years (range : 18 to 35 years). There were two complications : medial collateral ligament and medial meniscus injuries.
The range of knee motion was full, and the Lachman, anterior drawer and pivot shift tests were negative in all patients. The KT-2000 side-to-side difference was -0.5mm (range : -1.5 to +0.5mm). The complications were improved. The reconstructed anterior cruciate ligament was clearly observed and showed good tension by magnetic resonance imaging in all patients.
The authors think that reconstruction of the anteromedial bundle alone of the anterior cruciate ligament while retaining the posterolateral bundle using bone-patellar tendon-bone is a good procedure.

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We have examined 83 cases of pain around the knee among 355 long-distance runners visiting our hospital in the last three years. The causes of the pain in 70% of cases were patellar chondromalacia, Hoffa disease and iliotibial band friction syndrome. In addition, stress fracture of the tibia or femur tended to be easily overlooked as the cause of the pain. To ensure early return to running, it is necessary to make a correct diagnosis and give appropriate instructions about exercise.

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High tibial osteotomy (HTO) is often performed on knees with osteoarthritis of the medial compartment. Cartilage regeneration can often be confirmed after HTO, as a result of decreased stress on load-bearing cartilage. The purpose of this study was to evaluate the clinical outcome and factors influencing cartilage regeneration at second-look arthroscopy.
Nineteen knees with osteoarthritis were examined by second-look arthroscopy 13 months after HTO. Twelve knees had partial fibrocartilage coverage on the medial joint surface (cartilage regeneration +), and seven had no fibrocartilage coverage (cartilage regeneration −). A significant difference in the clinical outcome score was seen between the cartilage regeneration + and − groups (P<0.01).
Age, femorotibial angle (FTA) at second look, BMI and preoperative arthroscopic osteochondral grade had no influence on cartilage regeneration. Ten of 12 knees subjected to HTO with drilling had cartilage regeneration whereas 5 of 7 knees subjected to HTO without drilling had no cartilage regeneration. Thus the drilling procedure had some influence on cartilage regeneration.
In conclusion, cartilage regeneration improves the articular surface and the clinical outcome score, and one of the factors influencing cartilage regeneration is drilling.

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The purpose of this study was to address the usefulness of medical checks for detecting elbow injuries in child and adolescent baseball players. We carried out the medical checks in the field in 2006, and osteochondrosis of the humeral capitellum was diagnosed in 7 players. These players 1) had played baseball for more than 3 years, 2) were either pitchers or catchers, 3) had a history of elbow pain, and 4) had limited range of motion in the elbow. We investigated the percentage of each stage in these players in comparison with other outpatients. The primary stage was evident in 71.4% of the field group and 16.7% of the outpatient group. These results suggest that medical checks in the field are useful for early detection of elbow injuries.
It is important to determine the history of playing baseball, the defense position, elbow pain and limitation of range of motion to facilitate early detection.

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We report two cases of capitellar fracture, one with malunion and the other with elbow dislocation. The first patient was a 69-year-old woman with malunion of a capitellar fracture causing pain and limiting the range of motion of the right elbow. She had fallen onto her left hand 7 months before her first visit. Osteotomy of the malunited fragment, anatomical restoration, and fixation of the fragment with DTJ screws were performed. At 13 months after surgery, her elbow pain was reduced, and flexion had improved from 120°to 130°, and her JOA score had recovered from 70 points to 91 points. The second patient was a 75-year-old woman who had fallen down steep stairs suffered a capitellar fracture with elbow dislocation and bilateral radius distal end fracture. The capitellar fragment was reduced and fixed with DTJ screws. At 10 months after surgery, she had slight pain, a range of elbow motion of -15°to 120°, and her JOA score had recovered to 76 points.
We consider that anatomical reduction and fixation of the capitellar fragment with a DTJ screw might be a good method for treating cases of capitellar fracture with malunion or dislocation.

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Thirty-seven cases of the distal radius fracture have been treated with a novel intramedullary nailing system of MICRONAIL, since October 2006. We reported the operative procedures, indications, limitations and outcome of this system, which had both stability and lowinvasiveness. Twenty-two cases were classified as type A and seventeen as type C, in the AO classification.
All cases showed good bone union finally. They were excellent or good cases in Saito and Cooney classification. Eight cases had transient disorder of radial sensory nerve after surgery, but they all recovered at the final inestigation. In one case, breakage of the internal fixation occurred two weeks after surgery, necessitating reoperation.
We were convinced that this nailing system was a promising method of treatment for the distal radius fractures and could be of great benefit to patients, allowing quick recovery.

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The S-ROM^®-A stem is a modular cementless hip implant with a modular proximal sleeve that mates with a fluted stem. The various sleeve and stem lengths, and proximal body types, can be configured into many combinations. Independence of the sleeve and stem permits correction of the excessive anteversion found in certain types of severe dysplasia in primary total hip arthroplasty (THA). We evaluated 18 severely dysplastic hips treated by THA using an S-ROM^®-A stem between July 2005 and October 2007. Group I class was evident in 4 hips, group II class in 10 hips, and group III class in 4 hips according to Crowe’s classification. To determine the accuracy of the implant position, we calculated the change in the leg length, the anteversion of the acetabular and femoral neck, and femoral offset before and after the operation. We found that the S-ROM^®-A stem offered a large range of femoral offset, length, and version options that could be used independently or in combination to recreate normal osseous anatomy and a well-tensioned soft tissue envelope, thus enhancing hip stability after THA for severely dysplastic hips.

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Generally, for fracture of the proximal humerus, osteosynthesis is performed via a deltoid-pectoral approach, in spite of the risk of adhesion of soft tissue. We have tried minimally invasive surgery for this type of fracture via a deltoid-split approach with non-contact bridge plates. The series consisted of 17 patients, 14 females and 3 males, with a mean age of 71.5 years.
We obtained bone union with good recovery of range of motion (mean elevation 122 degrees) in all cases with initial treatment. Axillary nerve palsy occurred in only one case, but subsequently this was completely resolved. While a deltoid-split approach must be considered as a feasible technique for minimally invasive surgery for fracture of the proximal humerus, the possibility of axillary nerve injury must be borne in mind.

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We present a case of malignant giant cell tumor of bone (GCT) that developed after surgery alone. Malignancy develops in approximately 1-2% of patients with giant cell tumors of bone, and is classified as either primary or secondary. Primary malignant GCT is extremely rare, and secondary malignant GCT typically occurs after radiotherapy, but can rarely occurs without radiotherapy. A 27-year-old male with GCT of bone in the left distal femur was treated by curettage and autologous bone grafting. One year later, the tumor recurred and reoperation was performed. Two years after the second surgery, malignant change and pulmonary metastasis occurred. Despite chemotherapy, the patient died one year after development of malignant GCT. This patient was younger than is usual for cases of this type, and the period between recurrences was shorter than usual. Clinicians should be mindful about malignant transformation in cases with giant cell tumor of bone showing repeated recurrence.

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We report two case of lumbar fusion for multiple spondylolithesis.
The patients were women aged 54 and 70 years who complained of leg or buttock pain in addition to lower back pain. All lytic defects were bilateral and located at L4 and L5. We performed removal of the L4 floating lamina and ragged edge at L4 and L5, translateral or posterior lumbar interbody fusion (TLIF or PLIF) and direct repair and bone grafting of the L5 pars defect. Postoperatively, computed tomography (CT) was performed at the latest follow-up to assess the healing of the bone defects.
Lumbosacral fusion is the most common operation for multiple-level spondylolithesis, and has been proven to be effective for lumbar spinal disorders such as pseudoarthritis, loosening of screws, or adjacent segment degeneration. In our patients, no fusion at L5-S was carried out. The clinical result was good, but careful follow-up of these cases will be necessary. Direct repair of multiple-level spondylolysis using a pedicle screw laminar hook and autogenous bone graft is useful if the slip and disc degeneration is intermediate grade at the L5-S level.

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We report two cases of osteonecrosis of the femoral medial condyle treated using high tibial osteotomy (HTO) together with mosaicplasty.
Because both patients were comparatively young and the affected area had shown no improvement with conservative treatment, we performed mosaicplasty using HTO together with open wedge. Valgus correction of about 11 degrees and 10 degrees was obtained in each FTA, and there was no correction loss observed at the time of the last follow-up. However in one case, although the condition of the graft appeared good by MRI, partial necrosis was present, suggesting the need for careful long-term follow-up.

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The use of the KYOCERA Alumina Bearing Surface Cup (ABS Cup) with a ceramic-on-ceramic bearing surface was stopped because of problems with the device.
We report two cases of failure of total hip arthroplasty (THA) involving ABS cup breakage.
In the first case, the patient, a 39-year-old man, had femoral head necrosis, and underwent a left THA with the ABS cup. Fracture of the alumina inlay occurred two years after the operation without trauma. The patient underwent revision surgery and fracture was found to have occurred mainly on the peripheral portion of the inlay. In the second case, the patient, a 69-year-old woman, had bilateral osteoarthritis of the hip, and underwent bilateral THA with the ABS cup. Seven years after surgery, the ABS liner dissociated from the metal shell. At revision surgery, the alumina inlay was found not to have a fracture, and the polyethylene rotation prevention mechanism had failed.
Patients who have undergone THA with the same system should be observed meticulously throughout the clinical course.

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We report an adult case of pyogenic arthritis of the hip. A 74-year-old woman was admitted to our hospital because of fever and increasing right hip pain. She was scheduled to undergo right total hip arthroplasty (THA) because of rheumatoid arthritis. There was no history of joint puncture or trauma. The patient’s body temperature was 38.2°C and movement of her right hip was restricted because of severe pain. The white blood cell count was 9100/μl and CRP was 13.4mg/dl. Plain radiography showed narrowing of the joint space in the right hip, and magnetic resonance imaging showed right hip effusion. One day after admission, aspiration of the right hip joint was performed, and culture of the aspirate grew α-Streptococcus. The patient therefore received intravenous antibiotics. Five days after admission, debridement, irrigation and the Girdlestone procedure were performed on the right hip. After surgery, intravenous antibiotics were continued for 10 days. The body temperature and other clinical indicators of inflammation gradually improved, and the patient was discharged 19 days after surgery. As Indium-111 scintigraphy at 5 months after surgery showed no signs of infection, THA of the right hip was performed. Six months after THA, the patient has no problems with the treated hip.
Adult cases of pyogenic arthritis without a history of joint puncture or trauma are rare. However, as the prognosis of such cases is sometimes very poor, joint puncture must be performed immediately and adequate treatment should be instituted whenever such cases are suspected.

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