We treated a case of hand trauma associated with marrow exposure, using a bag-type negative pressure dressing together with an atomized basic fibroblast growth factor (bFGF) preparation.
The patient was a 79-year-old man, who had a defect of the skin, soft tissue and dorsal part of the bone of finger IV, with marrow exposure. We started a bag-type negative pressure treatment together with an atomized bFGF preparation, observing the surface of the wound once a day. Therapeutic exercise was done to prevent any joint contracture. Excellent granulation was evident on the 25th day, and this was subsequently covered by a skin graft. Currently, the state of the skin is excellent, and the patient has no obstacle to daily living activity.

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In the present study, we investigated the surgical outcomes of 21 elderly patients aged ≥75 years among 79 patients (men, n=50; women, n=29; mean age, 67.6 years) who underwent microendoscopic laminectomy for lumbar spinal stenosis between March 2007 and April 2008.
Subjects comprised 10 men and 11 women with a mean age of 79.1 years (range, 75-92 years) who presented with stenosis between one or two intervertebral levels. Decompressions were performed at intervertebral levels L3-4 (n=1), L4-5 (n=14), L3-4 and L4-5 (n=4), L4-5 and L5-S1 (n=1), and L4-5 with decompression of L5 spondylolysis (n=1).
Postoperative therapy comprised standing and walking initiated the day after surgery.
Length of surgery, blood loss, intra and postoperative complications, presence or absence of significant anamnesis, and improvement rates for JOA score were investigated.
The results showed that the mean length of surgery was 115 minutes per one intervertebral level. Mean blood loss was 51 g and no intra or immediate postoperative complications, including deliria, were observed. One patient developed pneumonia during the postoperative course. Anamnesis included hypertension (n=13), heart disease including angina pectoris or valvular disease (n=7) and previous cancer surgery (n=3). Mean JOA score improved from 13.3 points preoperatively to 23.5 points postoperatively; the mean improvement rate was 63.3%.
Although length of surgery is an issue, microendoscopic laminectomy is believed to be a useful method for treating lumbar spinal stenosis in elderly patients as blood loss is low and it is effective with regard to postoperative therapy.

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Twelve patients (7 males, 5 females) with thoracolumbar burst fracture were treated with posterior instrumentation (one above, one below) and vertebroplasty using hydroxyapatite grafting between June 2005 and January 2008. The modified Frankel classification score was D0 in 10 patients and E in 2 before surgery, E in all at the final follow-up point.
We evaluated the kyphotic angle and parcentage ratio of vertebral collapse preoperatively, postoperatively and at the final follow-up point. The mean kyphotic angle was 14.1 degree preoperatively, 6.3 degrees postoperatively, and 10.8 degree at the final follow-up point. The mean correction loss was 4.5 degrees. The mean percentage ratio of vertebral collapse was 64.7% preoperatively, 83.3% postoperatively, and 73.2% at the final follow-up point. The mean correction loss was 10.1%. Patients with a load sharing classification score of 6 points tended to have a large correction loss.
We considered that this surgical procedure was useful, although there was some correction loss.

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Osteoporotic compression fractures cause back pain and kyphosis. These fractures are usually treated conservatively and heal without neurological deficit in most cases. In a few cases, however, late-onset paraparesis can result from delayed vertebral body collapse, and this requires surgical treatment.
We present the clinical results obtained in 6 patients who underwent vertebroplasty using calcium phosphate cement (CPC) for late-onset paraparesis due to osteoporotic vertebral collapse. The preoperative neurologic status was incomplete paralysis in all patients. The average age was 82 (79∼90) years, and the average follow-up period was 24 (12∼34) months. The affected verebral level was T12 in 5 patients and L 1 in one.
The average operation time was 78 minutes, and the average total blood loss was 20ml.
Neurological deficits were ameliorated in all patients, and back pain was improved significantly. There were no postoperative complications.
The factors responsible for neurological deficits due to osteoporotic vertebral collapse were retropulsed bony fragments from the collapsed vertebral body into the spinal canal and kyphosis with instability. After CPC vertebroplasty, the local kyphosis was markedly corrected and spinal stability was restored. This type of surgery could be a good choice for treating late-onset paraparesis after osteoporotic vertebral collapse caused by local angular kyphosis and instability, rather than spinal cord compression of retropulsed bony fragments.

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We carried out posterior correction using the pedicle subtraction osteotomy (PSO) method for two cases of osteoporotic vertebral fractures with delayed paraparesis. After laminectomy of the affected vertebra, decompression and anterior interbody fusion by pedicle subtraction osteotomy, a protruding cage was inserted. Then solid posterior correction fixation was conducted by placing pedicle screws combined with claw hooks at two or three vertebrae above and below. We mixed the patient's autologous bone with artificial bone using a bone mill and carried out bone transplantation in and outside the protruding cage and around the screw and rod at the back.
Up to this point, three months after surgery on average, there has been no trouble such as loosening of the instrumentation or back out. The local posterior curvature angle was 20 degrees before surgery, but was improved to 6 degrees after surgery. Hardly any post-surgery correction loss was observed. Before surgery, the patients could not walk. However, after surgery, the pain in the lower limb and back were alleviated, and the patients can now walk.
Even though this is a short-term result, it can be said that utilization of a claw hook was effective for maintaining the corrected position after posterior correction surgery by the pedicle subtraction osteotomy method.

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There are many clinical reports about the treatment of lateral discoid meniscus, and recently partial meniscectomy and subtotal/total meniscectomy have been the most commonly selected surgical procedures. However, few studies have compared the use of different surgical procedures on the basis of preoperative factors. In the present study, therefore, we evaluated whether there are any differences in preoperative factors between the use of partial and subtotal/total meniscectomy. Between April 2003 and August 2008, we performed arthroscopic surgery on 62 knees with symptomatic lateral discoid meniscus. The patients were divided into two groups according to the surgical procedure employed : a partial meniscectomy group and subtotal/total meniscectomy group. The partial meniscectomy group comprised 34 patients (mean age at surgery 29.5 years) and the subtotal/total meniscectomy group comprised 28 patients (mean age 23.1 years). We evaluated four preoperative factors : 1) presence of extension disturbance, 2) presence of click or pain in the friction rotation test, 3) L/M ratio (ratio of lateral and medial joint space length on Rosenberg view X-ray), and 4) MRI findings. There were significant differences in the presence of extension disturbance, L/M ratio and preoperative MRI findings. In addition, it was possible to predict the surgical procedure preoperatively using a combination of preoperative factors. We conclude that preoperative factors are useful for selection of the surgical strategy for lateral discoid meniscus.

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In revision total knee arthroplasty, there are often several problems, including extensor mechanism disruption, intraoperative fracture, infection or delayed wound healing. We report a 76-year-old woman who sustained both tibial and fibular fractures after total knee arthroplasty (TKA). She was undergone revision TKA with the shoelace skin closure technique. She had severe swelling, fracture blisters, and ulcers because of many complications such as diabetes mellitus, liver cirrhosis and anemia. At revision TKA, we made an additional skin incision on the medial side of the knee joint for the shoelace technique to avoid any compartment syndrome including skin trouble. The additional incision was tightened and completely closed on postoperative day 8. We suggest that this option would be a good one in TKA when primary skin closure is difficult because of soft tissue damage.

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Dislocation of sternoclaviclar joint is rare. We reported two cases of traumatic posterior dislocation of sternoclaviclur joint.
The first patient was a 17-years-old man who sustained his left shoulder by the collision played soccer and collided with other player. Immediately he noticed his left chest pain and motor disturbance of left shoulder joint. CT showed posterior dislocation of left sternoclavicular joint, and it had pressed the trachea. A vessel ultrasonography showed compressed left subclavian vein. We performed manual reduction under general anesthesia and repaired ligaments. The second patient was a 35-years-old man. He fell running at the athletic meet, and hit hard on his left shoulder. We made the diagnosis of posterior dislocation of left sternoclaviclar joint with a CT. We performed open reduction and internal fixation sternoclaviclar joint with a K-wire. It is necessary to take care about the damage of mediastinum organs.

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We describe two cases of glenoid fracture associated with traumatic anterior dislocation of the shoulder that were treated using the Bristow procedure. The patients were both women, aged 60 and 70 years. Both had anteroinferior glenoid fractures involving two thirds of the glenoid length, being type 1 by the Ideberg classification and causing dislocation of the shoulder. Although reduction was possible in both cases, redislocation occurred readily. We therefore undertook screw fixation of the displaced fragment via an anterior approach using the Bristow procedure. This operation stabilized the shoulder of each patient tightly, and there was no redislocation or displaced fragment after surgery.
Although there have been some reports of conservative treatment for this type of fracture, we consider that cases showing marked instability require surgery. Because accurate reduction and rigid fixation of the fragment were necessary, we selected open surgery with the Bristow procedure rather than arthroscopic screw fixation, because the former was easier to accomplish.
In conclusion, we consider this procedure useful for treatment of glenoid fracture associated with traumatic anterior dislocation of the shoulder.

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We report two cases of rotationally displaced unicondylar fracture of the basal phalanx. The first patient was an 18-year-old man with a unicondylar fracture of the right litte finger in which the fragment was supinately displaced. The fracture, sustained when catching a softball two days before the first visit, caused pain and limited the range of motion of the finger. Open reduction and internal fixation with two Kirschner wires were performed. Good reduction was obtained and early active motion was started. Six months after the operation, extension of the PIP joint was -20°, and flexion was 105°. The second patient was a 70-year-old man with a unicondylar fracture of the right index finger in which the fragment was pronately displaced. He had injured the finger when using a sanding machine, and visited us soon afterwards. An open wound was present on the dorsal aspect of the PIP joint. We inserted a small elevator into the wound and reduced the fragment. The fragment was stable, and early active motion was started. Seven months after the operation, extension of the PIP joint was -20°, and flexion was 90°.
We consider that lateral and rotational stress imposed at the same time cause rotationally displaced unicondylar fracture of the basal phalanx. To obtain better extension of the PIP joint, passive motion should be started early.

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We report the clinical outcome of surgical treatment for distal radius fracture using external fixation. During the period 2004-2007, 15 patients (5 men and 10 women) with a mean age of 58.0 years (range, 39-75 years) were enrolled in this study. The average follow-up period was 2 years 6 months (range: 3 months to 4 years 7 months).
All of the fractures were of the unstable type. X-ray evaluation was performed with ulnar plus variance (UV), volar tilt (VT) and radial inclination (RI). The clinical outcome was evaluated in terms of the Cooney score and Saito's point system. The postoperative VT and RI were markedly improved in comparison with the preoperative values. However, UV shortening deformity gradually regressed to the preoperative state. Clincal evaluation was excellent or good at 56.3% in terms of the Cooney score, and 100% by Saito's point system. Almost all of the patients expressed satisfaction, but the Cooney score was not always good. We consider that external fixation is useful not only for cases of open fracture or marked soft tissue swelling around the wrist joint, but also for severe fracture at the joint surface, and that it is also effective when used with a locking plate, depending on the circumstances.

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We report a case of necrotizing fasciitis in the thigh, which was treated successfully without amputation of the leg. The patient was a 52-year-old woman who presented with right thigh pain, swelling and redness. We diagnosed necrotizing fasciitis of the thigh complicated by endotoxin shock and acute renal failure, thereby systemic management was performed. We carried out surgical debridement for the necrotizing fasciitis at the 3rd week of hospitalization, and then performed surgical free skin grafting at the 13th week. The wound healed without recurrence. At the 18th week of hospitalization, the patient was able to walk using one stick, and was discharged from hospital. Endotoxin adsorption (PMX) and continuous hemodiafiltration (CHDF) were very effective for this case in an acute stage. For the treatment of necrotizing fasciitis, surgical debridement, use of adequate antibiotics, and systemic management are important.

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This case report is the first clinical trial of non-invasive thermal ablation using magnetic resonance-guided focused ultrasound (MRgFUS) for the palliation of painful bone metastasis.
A 60-year-old woman suffering from painful bone metastasis at the ilio-sacral joint had been treated with external beam radiation and radiofrequency ablation. MRgFUS treatment for the bone metastasis was conducted using a focused ultrasound phased array system (ExAblate^® 2000, InSightec Ltd.), integrated with a magnetic resonance imaging (MRI) scanner (GE 3.0-T MRI). During the treatment, the site of each sonication and the temperature elevation in the tissue adjacent to the targeted bone were monitored in real time. The Efficacy of MRgFUS was evaluated using a numeric rating scale (NRS), the brief pain inventory (BPI), and medication level questionnaires before treatment, 3 days, 2 weeks, 1 month, and 3 months after treatment. The total length of the treatment was 147 min. Sonication was done 15 times, with an average sonication energy of 441.3 J. The NRS score of the metastatic lesion decreased from 7 to 0 two months after treatment. The BPI score showed that pain did not interfere with the patient's activities of daily life 3 months after treatment. No treatment-related adverse events occured.
These clinical results indicate that MRgFUS may be useful non-invasive palliative treatment for the patients with bone metastases in the future.

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We described a case of spinal cord infarction with sudden onset of paralysis. The patient was a 80-year-old male with a history of rectal cancer, colon cancer and abdominal aortic aneurysm. He developed sudden intense backache and weakness in both legs. In the Th8 conus medullaris, T2-weighted MR imaging showed a high-intensity signal. We diagnosed spinal cord infarction, and started steroid pulse therapy, which resulted in partial recovery.
Spinal cord infarction is a condition that develops rapidly, with a prodrome of backache, dissociated sensory disturbance and urination disorder, without any compressive spinal cord lesion. This case was diagnosed on the basis of the above symptom and findings of MRI scan. We consider that spinal cord infarction should be considered in patients who develop unexpected intensive backache and flaccid palsy.

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We experienced a case of idiopathic thoracic spinal cord herniation, which is a relatively rare condition caused by dropping of the spinal cord into a dura mater defect. Recently, with the development of imaging techniques, case reports of idiopathic spinal cord herniation have been increasing. The patient was 54-year-old woman, who suffered from anterior chest pain, back pain and sensory disturbance extending from the right abdomen to the right leg. We performed MRI and CT myelography, we found sharp deviation of the spinal cord to the ventral side at the Th4/5 level, with a double dura mater at the same level. The final diagnosis was spinal cord herniation. Some reports have suggested that the neurological symptoms of spinal cord herniation are progressive, and that natural recovery cannot be expected. Therefore we performed surgery to widen the dural defect. After surgery, the neurological symptoms were improved, and no recurrence was evident at the final follow-up examination.

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Generally, postoperative therapy for ankle fracture requires several weeks without weight-bearing. Therefore, surgery for ankle fracture necessitates long hospitalization, resulting in delayed rehabilitation. Consequently, we have changed our postoperative standard regimen from several weeks of non-weight-bearing to full immediate weight-bearing with an ankle supporter one day after the operation. As a result, the patients have benefited from shorter hospitalization and regained the ability to walk earlier.
We conclude that postoperative early weight-bearing for ankle fractures shortens the period of restriction of daily living activity.

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We reviewed five cases of tarsal tunnel syndrome treated surgically in our department. The patients comprised 3 females and 1 male (1 female underwent neurolysis in both feet) and ranged in age from 9 to 82 years with a mean of 45.6 years. The etiology was a ganglion in 3 cases, a bony prominence due to talocalcaneal coalition in 3, and injury in one. Clinical outcomes after surgery were excellent except for one patient who had tarsal tunnel syndrome for five years.
The causes of tarsal tunnel syndrome are various, and include tumor, talocalcaneal coalition, injury, malalignment of the foot, or idiopathic. Magnetic resonance imaging, computed tomography, and electrophysiological evaluation are useful for detecting the cause and the entrapment points responsible for tarsal tunnel syndrome. The outcome of surgical treatment was usually good. Wide exposure of the affected nerve and careful neurolysis are recommended, because tarsal tunnel syndrome has various causes and entrapment points.

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We report a case of multiple fractures in an ipsilateral lower extremity that presented treatment difficulties resulting from delayed femoral union, skin necrosis, and MRSA infection. The patient was 28-year-old woman with a trochanteric fracture of the left femur (AO classification 31-A1), a shaft fracture of the left femur (AO classification 32-A3), open fractures of the left tibia and fibula (AO classification tibia 42-A3 and fibula 42-A2), and dislocation of the right 4th toe MP joint, all as a result of a traffic accident.
On the day of admission, a surgical procedure was performed, which included debridement and external fixation for the open fractures of the left tibia and fibula. Five days after the first operation, osteosynthesis of the left femoral shaft fracture was carried out using a Gamma 3 long trochanteric nail, but the distal locking screw could not be inserted because of obesity and swelling of the left thigh. Thereafter, MRSA infection and skin necrosis occurred at the open wound associated with the left tibia and fibula. After these skin problems had been resolved, insertion of an intramedullary nail for the tibia fracture and plate fixation for the fibula fracture were performed at 5 months after injury. A period of about 8.5 months was required before the patient was able to walk with full weight-bearing.
There were several reasons why this case took such a long time to treat, and these included the double fracture of the femur, a situation referred to as “floating knee”, soft tissue damage and the surgical technique employed.

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The purpose of this study was to evaluate the clinical results of surgical treatment for distal femoral fractures in elderly patients. We treated eleven patients (2 men, 9 women, mean age 79 years) between 2005 and 2008. A locking compression plate was applied in eight cases, a femoral nail in two, and screw fixation in one. In six cases, the lengths of these implants were limited for post operations of proximal femoral fractures. The mean follow-up period was 5 months. One case of non-union required a second operation. Finally, all of the patients achieved bone union. The radiological measurements including Lindahl's angle and Condyle shift were investigated at the last follow-up. The mean postoperative Neer score was 64 points (range 41 to 78 points). In two cases, good results were not obtained because of postoperative complications. There were no significant differences between the radiographic evaluation and the Neer score.
We conclude that proper choice of implants and prevention of postoperative medical complications are desirable for good operative results in elderly patients with distal femoral fractures.

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Seventeen cases of distal fracture of the tibia were treated by intramedullary nailing between April 2005 and March 2008. The patients comprised 4 women and 13 men, with a mean age of 46 years.
All the fractures were united, and the clinical results were satisfactory.
Intramedullary nailing for distal fracture of the tibia is useful because it is less invasive to soft tissues and the blood supply of the bone. However, this treatment is not necessarily indicated for all fractures.

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The targeter system is a new plating device for treatment of proximal part fracture of the tibia. We have treated 18 consecutive cases with this plating system. The series comprised 7 women and 9 men with a mean age of 63 years. All the fractures were united, and the clinical results were satisfactory. The targeter system is a useful and less invasive treatment for proximal part fracture of the tibia.

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Achilles tendon rupture is rarely associated with an avulsion fracture of the calcaneus. We present a 55-year-old male who sustained a rare form of Achilles tendon rupture ; diagonal rupture from the proximal deep layer to the distal surface, accompanied with the avulsed bone fragment. We repaired the injured superficial and deep layers using an anchor system and Tsuge sutures respectively. This surgical technique provided strong repair and allowed earlier rehabilitation. At the six-month follow-up, the patient achieved almost preinjury functional use of the affected limb without any complaints.
The Achilles tendon is contiguous with both the gastrocnemius and soleus muscles. The mechanism of injury in this case was thought to be contraction of the gastrocnemius muscle, comprising a superficial layer, which resulted in avulsion fracture of the calcaneus when the knee was extended. This would have increased the repetitive strain on the soleus muscle, which might then have caused rupture of the deep layer of the Achilles tendon.

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We performed arthroscopic surgery and examined the clinical results one year after the procedure in 32 patients (32 knees) older than 40 years of age in whom meniscus tear had been doubtful at the time of preoperative diagnosis, and for which conservative therapy had not been successful. The cases that preoperative extension restrictions remained after surgery was significantly low of postoperative JOA score, because it was considered that an element of the OA was strong. In contrast, the proportion of patients who underwent partial meniscectomy for lateral meniscus tear and discoid meniscus tended to be high, possibly due to removal of mechanical stress. If partial meniscectomy were possible for ICRS grade 4 in which the cartilage damage was considerable, a significant improvement from the preoperative situation was suggested after one postoperative year.

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We report a rare case of cervical epidural abscess caused by Aspergillus infection. An 82-years-old male presented with complete left hemiplegia in the upper and lower limbs. Cervical MRI demonstrated a mass compressing the cervical spinal cord from the left side. The mass showed high intensity in the T2 WI and low intensity in the T1 WI, and its surface was enhanced by GD. The laboratory data revealed no evidence of an inflammatory response, such as WBC or CRP elevation, but β-D glucan was positive. Further examination showed a positive response for Aspergillus antigen and antibody. Therefore we made a diagnosis of epidural abscess caused by Aspergillus, and started intravenous administration of fungicide. Two months later, the abscess had disappeared and the hemiplegia had improved.
This was considered to be a rare case of epidural abscess caused by Aspergillus. Cases like this showing a minimal inflammatory response require examination for fungal antigens to allow early diagnosis and treatment.

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Plough fracture, a burst fracture of the atlas with C1-C2 dislocation, is a very rare and unstable form of fracture. Here we describe a case of this injury that was treated by C1-C2 posterior instrumentation.
An 81-year-old man was involved in a motor accident and admitted to our hospital. He had a scalp laceration in the frontal region. Neurological examination revealed Frankel C paralysis and hypesthesia below C3. A cervical X-ray film showed fracture of the atlas, and T2-weighted MRI showed a high-intensity area in the spinal cord at C1-C2. CT showed bilateral vertical fracture of the anterior arch, a fracture of the posterior arch, and C1-C2 dislocation. The C1-occiput joint remained intact. No fracture of the axis was evident.
Gardner traction was performed for 7 days, followed by C1-C2 posterior fusion with a screw and rod system. CT scan 3 months after surgery showed adequate fusion of C1-C2, and plain radiography showed no instability. By this time, the patient’s neurological deficit had improved, and he was able to use a wheelchair.
Plough fracture is a rare and unstable type of fracture that can be treated by posterior C1-C2 fusion with a screw and rod system. This technique was safe in the patient case, and reliable stability was obtained.

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We carried out a retrospective case-controlled study of alignment and clinical results of C2 dome laminectomy for myelopathy in ossification of the posterior longitudinal ligament (OPLL). While resection of the C2 lamina is reported to lead to kyphosis after laminectomy, laminoplasty can reportedly inhibit this kyphosis. We studied 18 patients with myelopathy in OPLL for whom C2 dome laminectomy was added to open-door laminoplasty. The follow-up period averaged 35.6 months. Outcome was assessed in terms of the Cobb angle between C2 and C7, and the Japanese Orthopedic Association (JOA) motor function scores for the upper and lower extremities for cervical myelopathy. The C2-C7 angle averaged 10.2° before surgery, and decreased to 7.1° after surgery. The JOA score averaged 10.9 before surgery, and increased to 13.5 after surgery. These results were not worse than those for patients undergoing laminoplasty only. We concluded that the clinical results of C2 dome laminectomy were good, although careful follow-up of these cases will be necessary.

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The purpose of this study was to investigate the clinical results of reconstruction using a free vascularized fibular graft.
Between 1991 and 2007, 22 patients (16 male and 6 female, aged 3 to 74 years) with osteomyelitis, mandibular tumor, long bone tumor and congenital pseudoarthrosis were treated with vascularized fibular grafts. The mean length of the graft was 15cm (range, 9 to 22cm). Ten grafts were used in the lower limb, one in the upper limb, and eleven in the jaw.
Complications occurred in 6/22 patients of whom 5 required a second operation. Postoperative thrombosis at vascular anastomoses necessitated reexploration in 3 patients.
The mean period required for radiographically evident bone union was 9.3 months. The union rate was 100% (10/10) in the lower and upper limbs, and 73% (8/11) in the jaw.

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