Postural sway during one-leg standing with eyes closed on the affected leg following anterior cruciate ligament (ACL) reconstruction was quantified and compared to that on the contralateral normal leg, and that on the leg of normal control group. We examined 19 patients (11 males, 8 females) with ACL reconstruction using hamstring-tendons (postoperative period: average of 21 (12-68) months) and 10 healthy normal volunteers (8 males, 2 females). Using the postural sway meter, we measured environmental area and locus length per unit area. There is no statistical difference in environmental area and in locus length per unit area among 3 groups. Postural sway in the knee more than 1 year after ACL reconstruction was equal to those in control group.

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Objective. Various types of spinal reconstructive surgery have been performed for osteoporotic vertebral fracture associated with delayed neurological deficit (DND). However, patients with this spinal disorder are often older and have multiple medical comorbidities. Major/minor perioperative complications can sometimes be problematic. We analyzed the pathogenesis and mechanism of DND, and investigated the usefulness of percutaneous vertebroplasty (PVP) for osteoporotic vertebral fractures associated with DND.
Methods. Sixteen patients (average age 76 years ; range 61-91 years) with DND underwent PVP with polymethyl methacrylate. To investigate the pathogenesis and mechanism of DND, local kyphotic angle, vertebral instability, and rate of involvement of the posterior wall of the pseudoarthrotic vertebral bodies were assessed. As a control, the same parameters were studied in patients without DND who underwent PVP, and the results were compared with the DND group. The average follow-up period was 29 months (range 6-63 months). PVP outcome was evaluated using the modified Frankel classification and visual analogue scale (VAS).
Results. Fourteen patients showed one grade of neurological recovery on the modified Frankel classification upon discharge from hospital (mean 16.7 days after PVP), and their gait ability had improved to D2 grade at the final follow-up. Average kyphosis angle was corrected from 21.7 to 11.2 degrees (p<0.0001), and vertebral instability was also improved from 12.5 to 4.1 degrees (p<0.0015).
Conclusions. The main cause of DND is kyphotic deformity and vertebral instability. PVP improves kyphotic deformity and vertebral instability, and is a useful, less invasive surgical procedure for osteoporotic vertebral fracture associated with DND in the elderly.

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Meniscal cysts are uncommon, especially in children. We report a case of lateral discoid meniscus with meniscal cyst in a four-year-old boy. The patient was referred to our department because of limited range of motion in the right knee without any apparent cause. He had slight soft tissue swelling on the anterolateral side and 20 degrees of knee extension limitation. Physical examination showed no tenderness over the anterolateral joint line or disappearing sign. The McMurray test was negative and ligamentous instability was not evident. Magnetic resonance imaging (MRI) showed lateral discoid meniscus with a 13×7-mm meniscal cyst. MRI also showed a high-intensity area through the lateral meniscus body in the T2-weighed image, which was connected to the meniscal cyst. At arthroscopy, a 15-mm longitudinal tear of the complete type in the lateral discoid meniscus was repaired with two FasT-Fix^®. We performed both arthroscopic partial meniscectomy and open cystectomy through a small anteromedial incision. After a postoperative period of seven months, there was no evidence of cyst recurrence. We consider that this case of meniscal cyst in a young patient is an interesting one from the viewpoint of etiology.

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The formation of meniscal cysts is usually related to meniscal tears. Several authors have reported surgical treatments for meniscal cysts, such as arthroscopic decompression, partial menisectomy, and open cystectomy. However, there have been no previous reports of treatment for meniscal cyst accompanied by meniscal flap tear in a young athlete.
We report a case of lateral meniscal cyst arising from the middle segment of a flap-torn meniscus in a 19-year-old football player. The patient experienced pain and local swelling lateral to the left knee. MR images showed a radial tear of the lateral meniscus and a small lesion resembling a lateral meniscal cyst. Non-operative treatment was performed for 4 months, but the knee pain and local swelling persisted. In addition, MR images suggested expansion of the meniscal tear and cyst. Arthroscopic meniscal suturing was therefore carried out using both the inside-out and all-inside techniques for repair of the flap tear and reduction of the meniscal cyst. The FasT-Fix meniscal repair system (Smith and Nephew) was used for stabilizing the radial tear with a horizontal mattress suture. The Lysholm knee scores were 64 preoperatively and 94 at the 4-month follow-up point after surgery.

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We report a case of articular cartilage defect in a medial femoral condyle with anterior cruciate ligament (ACL) rupture that was repairable by ACL reconstruction and drilling.
The patient, a 41-year-old woman, presented with left knee pain. Fifteen years earlier, she had suffered left knee MCL rupture, which had been treated by suturation at a local hospital. She had felt pain and instability in the left knee from about one year prior to consultation at our hospital. Physical examination of the left knee revealed ROM 0∼145°, Lachman test (+), anterior drawer test (+), N test (+), and valgus stress test (−). MRI of the left knee demonstrated ACL rupture and medial meniscus injury. After one month, ACL reconstruction was performed. Arthroscopic examination revealed an articular cartilage defect in the medial femoral condyle and ACL rupture. The ACL was reconstructed using bone-patella tendon-bone, and then drilling was performed to the articular cartilage defect in the medial femoral condyle. After 14 months, the sensation of giving way was resolved, the ROM of the left knee was almost full, allowing removal of the interference screw and arthroscopic examination. The area of the articular cartilage defect in the medial femoral condyle was found to be covered with the tissue like fibrocartilage-like tissue, and the synovial covering of the reconstructed ACL was slightly poor, although there were no problem with tension or volume.
ACL reconstruction and drilling were effective for this case of articular cartilage defect in the medial femoral condyle.

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The purpose of this study was to clarify the short-term results of TKA with wedge-type metal augmentation for knees with bone defects of the medial tibial condyle (4 OA and 1 RA) treated in 2008. Five patients (1 man and 4 women) were followed up for 4 to 10 months (mean : 7.6 months) after surgery. The mean age was 76.6 years (range : 70 to 83 years). NexGen LPS-Flex-type TKA with an extension stem was used for all patients.
JOA score was improved from 35.0 before surgery to 75.5 after surgery in OA patients, and from 41 to 85 in RA patient. The knee extension was improved from −22° to −7° and the knee flexion was improved from 108° to 130°. On radiography, FTA was improved from 202° to 175°.α angle was 95.5°,β angle was 89.1°,γ angle was 0.6°, and δ angle was 86.5° after surgery.
Good short-term results were obtained using TKA with wedge-type metal augmentation for knees with bone defects of the medial tibial condyle.

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Mobile bearing total knee prostheses have a potential for bearing dislocation or spinout. Surgeons must understand the etiology and management of this unusual complication. Prior reports have identified bearing dislocations as an important complication surgical technique and surgeon experience being important associated factors. We have observed an unusual case of dislocation of a posterior-stabilized rotating-platform total knee arthroplasty, which had both a cam-post mechanism and a rotating platform. The patient, a 79-year-old woman with knee osteoarthritis and lumbar canal stenosis underwent primary total knee arthroplasty using a mobile bearing prosthesis. Six weeks after the operation, she sustained a complete dislocation of the PFCΣ RP-F prosthesis. We tried closed reduction without anesthesia. The causes of posterior dislocation are multifactorial. Potential contributory factors may include component malposition, extensor mechanism and patella dysfunction, prosthesis design and an increased flexion gap. Posterior translation of the tibia “drives” the rotation while the knee is in flexion. Muscle weakness of the quadriceps was present, as a result of lumbar canal stenosis. After surgery (laminectomy), the quadriceps deficiency was ameliorated. Surgical error in soft tissue balancing is the cause in the majority of cases with failure to achieve correct balance, particularly the flexion gap.

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A locking compression plate (LCP) offers angular stability and better fixation of osteoporotic bone. We report three cases of periprosthetic femoral fracture that were treated with a LCP distal femur (LCP-DF) between January and April 2008. All the patients were women, with a mean age of 79 (range, 68-94) years. There were two supracondylar femoral fractures (AO classification 33-A1 and A3) above a total knee arthroplasty. One patient had undergone ipsilateral total hip arthroplasty. There was one femoral shaft fracture (AO classification 32-A1, Vancouver type C) after bipolar hip arthoplasty. The mean duration of follow-up was 5.7 months. All fractures healed with good alignment, and there was no loss of reduction or implant failure. All patients returned to their previous level of mobility. Our results show that fixation of periprosthetic femoral fractures with LCP-DF provides satisfactory results.

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Metal-on-metal total hip arthroplasty (THA) is characterized by low wear and a wide range of motion. We performed metal-on-metal THA with limitations in young males with alcoholic avascular necrosis of the femoral head, and studied the short-term outcome of the procedure. Five patients were treated during the period from September 2007 to July 2008. All of the patients were males engaged in manual labor. The average age at the time of surgery was 39 years, and the average postoperative follow-up period was 5.2 months. The average period until return to work was 57 days, and no particular postoperative complications were observed. With regard to postoperative range of motion, more than 100 degrees of flexion was obtained. The average Japanese Orthopaedic Association hip score, which was 42 points before surgery, improved significantly to 93 points after surgery. In particular, pain was disappeared completely, and it was possible for the patients to return to heavy manual labor. As metal-on-metal THA might be involved with some problems, such as the metal ion concentration, its application to patients with renal dysfunction or gravida should be limited.

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Cement removal during revision total hip arthroplasty, especially removal of the distal cement plug in the intramedullary canal, can be a tedious, time-consuming process. The usual methods for removing cement include high-speed drills, chisels, saws, and reamers, which are often associated with fracture and perforation of the femoral shaft. Recently, ultrasonically driven tools have been becoming available for revision hip surgery. In two cases of aseptic loosening of the cemented femoral stem, we used this device for removal of cement from the intramedullary canal without femoral cortical windows or trochanteric osteotomy. There were no intraoperative femoral fractures or inadvertent femoral perforations during cement removal, and the cemented femoral stems were revised to noncemented implants. Ultrasonically driven tools are able to reduce the incidence of perforation, the time for cement removal, and also intraoperative blood loss. These tools are useful for surgeons who are not expert in removing cement during revision surgery.

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Purpose : The purpose of this study was to assess the effectiveness of wearing elastic stockings for preventing deep-vein thrombosis (DVT) after artificial leg joint replacement.
Subjects and Methods : Eighty-nine cases of total hip arthroplasty (THA) and 115 cases of total knee arthroplasty (TKA) conducted at the authors' hospital between July 2006 and October 2007, and for which data were available, were included in the study. The THA group comprised 79 females and 10 males, and the TKA group comprised 103 females and 12 males. The average age of the THA group was 68.4 (43-85) yr, and that of the TKA group was 74.0 (42-89) yr, at the time of surgery.
One week after surgery, screening tests were conducted using leg vein echography, to check whether or not DVT had occurred. In addition, the subjects were classified into a “no-stockings group” composed of patients who did not wear any elastic stockings after surgery, and a “stockings group” composed of patients who wore stockings for two weeks after surgery, and the incidences of DVT in the two groups were compared and evaluated.
Results : The incidence of DVT in the THA group as a whole after surgery was 10 out of 89 cases (11.2%), and that in the TKA group as a whole was 5 out of 115 cases (4.3%).
The DVT incidence in the THA group after surgery was 5 out of 38 cases (13.2%) for the no-stockings group, and 5 out of 51 cases (9.8%) for the stockings group. On the other hand, the DVT incidence in the TKA group after surgery was 4 out of 61 cases (6.6%) for the no-stockings group, and 1 out of 54 cases (1.9%) for the stockings group.
For statistical analysis, the χ² test was conducted, assuming that the significance level was 5. As a result, there was no significant difference in DVT incidence between the no-stockings group and the stockings group for both THA group and TKA. However, when patients wore stockings, the incidence of DVT decreased from 13.2% to 9.8% in the THA group, and from 6.6% to 1.9% in the TKA group.
Discussion and Summary : For both the THA and TKA groups, the wearing of stockings had no statistically significant effect on post-surgical DVT incidence, but did reduce the incidence of DVT to some degree especially in the TKA group.

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The aim of this study was to follow up and assess QOL after THA. Fifty-six patients with coxarthritis were divided into three groups; group A comprising 26 unilateral coxarthritis patients, group B comprising 13 bilateral coxarthritis patients who underwent unilateral THA, and group C comprising 17 bilateral coxarthritis patients who underwent bilateral THA. Outcomes at 1,3, and 6 months after THA were measured with SF-36. In Groups A and C, SF-36 scores gradually improved at any point, while no improvement of the SF-36 scores were observed in group B. Group B scored significantly lower on all subscales of the SF-36 at 6 months than groups A and C. Our results suggest that patients with bilateral coxarthritis cannot expect much improvement of QOL after initial THA.

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We experienced a case of synovial osteochondromatosis of the hip joint. The patient, a 46-year-old woman, had been suffering from coxalgia and limited hip motion, especially flexion and internal rotation, for about one year. Roentgenography and CTscan showed many calcified masses in the right hip joint. T2-weighted MRI showed many nodular lesions. Synovial osteochondromatosis was suspected and surgery was performed using the Ganz approach with anterior dislocation of the hip. We found 24 cartilaginous masses in the hip joint, but no nodular lesions within the synovium. Microscopic examination confirmed that the masses were cartilaginous. The case was therefore diagnosed as synovial osteochondromatosis of the hip joint. At 6 months after the operation, the patient had no pain in the hip and walked without a limp. Range of motion of the hip was improved, and there was no longer any flexion contracture. The Ganz approach is useful when wide examination of the hip joint is necessary.

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Cases of a fracture of the hydroxyapatite (HA)-coated stem in patients who underwent total hip arthroplasty have occasionally been reported. This article describes a case of stem fracture seen in a 61-year-old female patient more than 11 years after cementless bipolar head prostheses performed at this hospital. The patient had idiopathic avascular necrosis of the right femoral head, and at the age of 48, she underwent cementless bipolar head prosthesis using a titanium, HA-coated MCF stem (Kyocera Corporation, Kyoto, Japan). The stem was successfully implanted, and the postoperative clinical progress was uneventful. Eleven years and 10 months after operation, the patient had acute weakness of the right hip when she stood up, resulting in gait disturbance. Hip radiography revealed a fracture of the basal portion of the stem neck, and a revision hip arthroplasty was performed. Analysis showed that the fracture developed from the site of a rectangular notch serving as a gripper made at the stem neck. Therefore, the fracture might be caused by stress concentration at the rectangular part and the resultant metal fatigue. Implants with such design may be associated with breakage even a long time after bipolar head prostheseis.

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The purpose of this retrospective study was to evaluate mortality after surgical therapy in very elderly patients over 90 years of age with hip fractures. We included 41 patients (6 males and 35 females) with mean age of 93 years who were treated surgically for neck or trochanteric fractures of the femur. We investigated walking ability before injury and after surgery, survival rate, and physical status before surgery using the classification of the American Society of Anesthesiologists (ASA) . Before injury, 36 patients (87.8%) had been able to walk with or without assistive devices, but at 4 months after surgery only 15 patients (36.6%) were able to do so. Survival rate was 88.6% at 4 months and 75.6% at 1 year after surgery.
Seven patients who were classified as ASA class I before surgery were all alive at 1 year after surgery. There was a significant difference in walking ability after surgery between the survivors and non-survivors. We considered that preservation of walking activity after surgery was important for improving the survival rate of very elderly patients with fractures of the femoral neck or trochanter.

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The purpose of this study was to evaluate early functional recovery after arthroscopic rotator cuff repair (ARCR). Forty patients with full-thickness rotator cuff tears underwent ARCR and were followed up for one year postoperatively. There were 17 men and 23 women with a mean age of 66.4 years (range 38 to 84 years). The patients were evaluated in terms of the Japanese Orthopaedic Association (JOA) shoulder score at 3, 6 and 12 months after surgery. The JOA score improved significantly from the third months after surgery. Recovery progressed until 12 months after surgery. The mean preoperative JOA score of 68.8 points had improved to 95.4 points by the time of the latest follow-up. The pain score showed a progression curve similar to that of the total JOA score. The function score was improved after 6 months. The range of motion was improved after 6 months for active forward flexion, and only after 12 months for both internal and external rotation. In this series, ARCR gave good clinical results at 12 months after surgery. Rapid pain reduction after ARCR with a lower morbidity may contribute to rapid return of function.

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Since 2005, we have used a knotless anchor for arthroscopic Bankart repair. The purpose of this study was to clarify the outcome of this operative method.
Ten patients with traumatic anterior shoulder instability (7 males and 3 females) were followed up for more than six months. The mean age at surgery was 23.5 years. (range 16-28 years). Clinical outcome was evaluated on the basis of the recurrence ratio, Rowe score, and range of shoulder motion (external rotation at the side position). As no cases of recurrence were observed, the recurrence ratio was 0%. The average postoperative Rowe score for the cases as a whole was 91.5 points. The average loss of external rotation at the side position was 12.5 degrees, compared with the other arm at the side position. All of the patients’ courses were satisfactory.
The knotless anchor appeared to be a useful device for arthroscopic Bankart repair in these cases.

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Various surgical techniques for spinal metastases have been described. Although curative surgery such as total en bloc spondylectomy for spinal metastases has been advocated, such an aggressive approach is not always justified in patients predicted to have short survival. For patients with limited life expectancy, palliative surgery such as posterior decompression with stabilization is often selected. Recently, many authors have reported an excision technique employing an ultrasonic osteotome. We have performed posterolateral circumspinal decompression with an ultrasonic osteotome, and anterior vertebral reconstruction using cement augmentation and posterior fusion for four patients with thoracolumbar spinal metastases. Pain relief and improvement of paresis were obtained in all cases. This technique is relatively safe and less invasive for short-term palliation.

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Malignant fibrous histiocytoma (MFH) and dermatofibrosarcoma protuberans (DFSP) grow in an infiltrative fashion and have a high risk of local recurrence. Major loss of function is likely to occur in surgical resection of these tumors in the forearm because of the infiltrative nature of the tumor and the anatomical complexity of the forearm. We report three cases of these conditions (2 MFH and 1 DFSP) those were treated surgically with a wide marginal resection and reconstruction using an anterolateral thigh flap. Six or more muscles in all cases and the distal ulna in two cases were resected with the tumor. Functional reconstruction was performed by muscle transfer in 2 cases and a fascia lata graft in 1 case. Skin and soft-tissue defects were covered with an anterolateral thigh flap in all cases. Postoperative complications were partial necrosis of the flap in one case and dislocation of the radial head in one patient whose distal half of the ulna was resected. One patient developed lymph node metastasis and underwent surgery. At the last follow-up, all patients were free of local recurrence. Functional results in these patients were an ISOLS score of 70-80% and a DASH score of 30-35 points. An adequately wide procedure and reconstruction with an anterolateral thigh flap are able to achieve good local control and limb salvage with acceptable limb function.

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Clinical results of treatment for spinal cord tumors over the last 5 years were retrospectively evaluated. Thirty-one of the total of 33 cases were treated surgically. Surgical therapy was not applicable for the remaining two cases because lung cancer was found during preoperative examinations in one case, and in the other, an intramedullary tumor was found to be located in the upper cervical spine.
Among the 31 cases treated surgically, the Frankel grade was improved or unchanged in 29, whereas it deteriorated in two. Schwannoma was the most common pathological type of tumor. The tumor was intradural and extramedullary in 63.7% of cases and located at the thoracic vertebral level in 45.4%.

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We report two cases of open ankle fracture with deficits of the bone and cartilage. In the first case, a 25-year-old man fell from his motorcycle and was transferred to our emergency and critical care center. His right foot had been partially amputated at the ankle. The posterior tibial artery was ruptured at the injury site, and so the classification of the open fracture was Gustilo IIIC. We performed emergency reconstruction of the posterior tibial artery and internal fixation with K-wires, and covered the skin deficit using artificial cutis. On the 4^th day after injury, we performed skin grafting and reconstruction of the ankle joint using a bone block from ilium, resulting in a non-union partial arthrodesis of the ankle joint. At 22 months after the operation, the patient had slight pain in the ankle joint, but was able to return to work. In the second case, a 50-year-old man suffered from injuries in a motor vehicle accident. On arrival, the patient had a wide open wound around the lateral ankle and foot area with deficits of the soft tissues and bones. We performed emergency irrigation and internal fixation with K-wires, and covered the skin deficit with artificial cutis. On the 11^th day after injury, we performed arthrodesis of the ankle joint and free transplantation of an antero-lateral thigh flap. At 5 months after the operation, bone union was achieved and the patient was able to walk without pain using one crutch. For severe open ankle fractures with massive deficits of the bone and cartilage, it is important to stabilize the joint, and arthrodesis of the ankle joint should be considered at an early stage.

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We used Locking compression plate (LCP) for distal femoral fractures in 13 patients (4 men and 9 women, aged 24-87 years) .Using the AO classification, 6 fractures were classified as type A, 1 as type B, and 6 as type C. The Minimally Invasive Plate Osteosynthesis (MIPO) technique was applied in 11 patients. The fractures were caused by falls in 5 patients, falls from a height in 4, traffic accidents in 3, and sports injury in 1. Of the 13 patients, 1 had an open fracture (Gustilo Type IIIA) and 1 had postoperative TKA. The mean period from injury to surgery was 6 days (range,1-16 days). The average follow-up period was 12 months (range,3-25 months).
Bone union was obtained in all cases, and no case showed significant correction loss after surgery. However, comminution and defects of the medial bone cortex may cause delayed union or non-union. It seems important to consider whether medial plate fixation is necessary.

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A 60-year-old man who took a blood test for suspected gout was referred to our hospital because the data showed a high serum level of alkaline phosphatase (ALP) at 2059 U/l. The bone-specific ALP (BAP) level was 318 U/l and the serum NTX level was also high, exceeding 80nmol BCE/L. Bone scintigraphy demonstrated abnormal accumulation in many bones, and the corresponding X-ray images demonstrated bone resorption and bone formation in the same locations. The left humerus in particular was bent and enlarged.
Alendronate was started at 70mg twice a week, and the ALP level declined to 186 U/l and BAP to 17.6nmol BCE/L 7months later. Because laboratory data were stable at 11months, we reduced the dose of alendronate to 35mg twice a week. Restoration of the bone cortex and trabecular bone was observed by X-ray one year later.
In the present case, safe and effective control was obtained using only half the dosage of alendronate recommended by the American FDA. We intend to adjust the dosage of alendronate according to symptoms and changes in laboratory data.

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Peripheral arterial disease (PAD) is an important manifestation of systemic atherosclerosis, and prompts many patients to consult orthopedics departments. The prevalence of PAD treated in our clinic was examined. I studied 197 patients with intermittent claudication (IMC), numbness of the lower limbs and cold sensation by measuring the ankle brachial pressure index (ABI).
Defining an ABI of 0.9 or less as PAD, 12 (6.1%) of 197 patients and 6 (13%) of 47 patients with IMC were diagnosed as having PAD. Three of 90 patients with lumbar spinal canal stenosis (LCS) had PAD.
It is thought that orthopedic surgeons should always take blood vessel characteristics and mental change caused by PAD into consideration in patients presenting with IMC.

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We evaluated 22 foots of 20 patients (10 males and 10 females) undergoing surgical treatment for calcaneal fractures between January 2005 and January 2008. The average age of the patients was 55.0 years. The mean follow-up period was 12.8 months. The types of fractures were evaluated according to the Essex-Lopresti classification. Our surgical approach was via an Ollier lateral transverse skin incision, and all cases were treated by open reduction and fixation with Kirschner wires. Bone defects were treated by implantation of calcium phosphate cement. X-ray assessment was made using the Böhler angle, and clinical assessment was done on the basis of the Maxfield score. The average Böhler angle improved from 4.3 degrees (minimum -8 degrees, maximum 25 degrees) preoperatively to 22.5 degrees (minimum 8 degrees, maximum 40 degrees) postoperatively, and was not confirmed in the final check-up. Excellent results were obtained in 11 patients, and good results in 9. We conclude that this treatment is useful and generally yields good outcomes.

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High tibial osteotomy (HTO) is an established technique for treating medial osteoarhrosis and osteonecrosis of the knee. We performed opening-wedge HTO in 7 patients from March 2007 to April 2008. The mean age of the patients was 62.3 years (range 51-66 yr). The medial osteotomy site was fixed with a DynaFix VS osteotomy plate followed by grafting with porous 60%β-tricalcium phosphate (TCP).
The limb was not immobilized with a knee brace postoperatively and full weight bearing was allowed from the fourth week in principle, those lateral tibial plateau fractures were occurred in two patients during the surgery. The mean preoperative and postoperative femorotibial angle was 181.6 degrees and 170.7 degrees, respectivery. The mean JOA score improved from 57.7 to 77.1 points. There was no pseudoarthrosis or loss of correction.
Opening wedge HTO avoids fibro-osteotomy, lateral muscle detachment and leg shortening. The correction can be adapted intraoperatively based on an X-ray image of the whole lower extremity. Rigid fixation with the use of a medial DynaFix plete and 60%β-TCP allows early full weight bearing and discharge within four to five weeks after surgery. This is an effective, simple, precise, and less invasive procedure for busy middle-aged patients with medial gonarthrosis.

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Sixty-four patients with cervical myelopathy underwent spinous process-splitting laminoplasty. In terms of recovery rate, there were no significant differences between patients showing a high T2 without a low T1 signal and those showing no change, when compared using the JOA scoring system for cervical myelopathy. However, the recovery rate in patients showing a high T2 with a low T1 signal was significantly lower than that in patients showing a high T2 without a low T1 signal. Patients showing regression of the change in intramedullary signal intensity had a significantly better outcome in terms of recovery rate than patients without regression. The intramedullary signal changes in cervical myelopathy generally indicate myelomalacia and cord gliosis. The stages of myelomalacia can be divided into early, intermediate and late stages. In the early stage, a high T2 signal indicates reversible changes such as cord edema, inflammation, vascular ischemia, or demyelination. In the intermediate stage, cystic necrosis occurs gradually as the lesion progresses, a low T1 change appears, and in the last stage irreversible pathological changes occur, such as cavitation, a decrease of cellular density, and motor neuron loss. Thus, a high T2 signal change does not indicate a poor prognosis, and reflects a broad spectrum of spinal cord reparative potential. However, a low T1 change indicates a poor prognosis.

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We report our strategy for safe screw insertion in the cervical spine and its clinical results. Since 2006, we have been using the Roy-Camille lateral mass screw technique for C3,4,5, and 6. One hundred and eleven lateral mass screws were inserted in 25 patients using this technique between January 2006 and August 2008. Clinical complications were reviewed and screw position was evaluated using multi-detective 3D-CT. We encountered no major complications, including spinal cord or nerve root injury, damage to the vertebral artery, or superficial or deep infection. Among the 111 screws, all were confirmed by multi-detector 3D-CT to accurately inserted.
In Japan, pedicle screws have been used because of their biomechanical strength. On the other hand, it is known that the technique for lateral mass screws is safer than that for pedicle screws. Based on the present data, we are able to conclude that the Roy-Camille technique is safer and more reliable for cervical posterior reconstruction surgery.

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Guyon canal syndrome is a well known entrapment syndrome of the ulnar nerve at the wrist joint level. Soft tissue tumors much as ganglions have been reported as the main cause. We experienced a rare case of Guyon canal syndrome, caused by a deep branch of the ulnar artery. The case was a 75 year-old female. She complained of discomfort feeling at the palmo-ulnar area of the left ring and little fingers. We suspected the Guyon canal syndrome from the physical findings, and the examination of the conduction velocity of the ulnar nerve. We could not detect, however, any cause for it from MRI. We performed therefore, an operative exploration into the Guyon Canal. Then we found a branch of the ulnar artery running deeply over the palmer side of the ulnar nerve. And we noted also a pseudoneuroma lying on the ulnar nerve at just proximal to the crossing point of the arterial branch. We diagnosed that this arterial branch was causing the entrapment of the ulnar nerve. So we cut it out with electro-coagulation.
We do not know why such a deep arterial branch, possibly an anatomical anomaly, can cause compression to the ulnar nerve for the first time at the age of 75. However, it is important that we should keep in mind that such an arterial branch also could cause the Guyon Canal Syndrome.

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Osteochondritis dissecans (OCD) of the humeral capitellum is most commonly seen in children who engage in overhead throwing sports, especially baseball. We report three cases of lateral-type of elbow OCD at the advanced stage treated with an osteochondral graft from the patello-femoral joint. The patients were 3 boys (all baseball players) with a mean age of 14 years (range, 13 to 15 yr). The mean follow-up period after surgery was 11.3 months. The average Japanese Orthopaedic Score (elbow) improved from 72.3 points (range, 70 to 75) to 96.3 points (range, 96 to 100) postoperatively. All 3 boys were able to return to baseball activity, including throwing. However, one patient who was found to have already developed osteoarthritis at surgery, and who resumed throwing activity early, had some difficulty with throwing. When treating elbow OCD, we think it is necessary to preserve the cartilage as far as possible, but in cases at the advanced stage when the cartilage cannot be retained, this method can be effective.

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From April 2006, we have performed lymphaticovenous anastomosis (LVA) using indocyanine green fluorescence lymphography, and found that the untied stay suture method (USSM) is effective for vessels with diameters of 0.3-0.5mm or below. We applied the USSM for replantation of infantile zone 1 after fingertip amputation and obtained good results. Here we report this technique.
Two patients who underwent replantation of zone 1 after complete fingertip amputation using the USSM from August 2007 were studied. The USSM used for anastomosis of blood microvessels 0.3-0.5mm or less in diameter in fingertip replantation differed from that used in LVA. The 1^st and 2^nd stay sutures were placed but untied, and then the 3^rd and 4^th sutures were placed and tied, followed by tying of the two stay sutures. Both of the replanted fingertips survived, and good fingertip shape and good nail regrowth were obtained.
The USSM of placing the 1^st stay suture untied, then placing the 2^nd stay suture, and thereafter tying both stay sutures is especially effective for LVA with diameters of 0.3-0.5mm or below, in which the lymphatic wall is thin and transparent lymph flow into the vein. However, for anastomosis of blood microvessels 0.3-0.5mm in diameter or less, as in replantation of amputated fingertips, the method in which the 1^st and 2^nd stay sutures remain untied until after the 3^rd and 4^th (5^th, 6^th) sutures are placed and tied is an easier technique.

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Since April 2006, we have performed lymphaticovenous anastomosis (LVA) using indocyanine green fluorescence lymphography (FL-ICG). The use of FL-ICG in LVA allowed more precise identification of lymphatics and anastomosis to veins. We report the usefulness of this method for treatment of male lymphedema of the lower limbs.
Among the patients who underwent LVA since we introduced FL-ICG, 6 male patients (7 limbs) with lower-limb lymphedema who were followed postoperatively for 6 months or longer were included in the present study.
Indocyanine green (ICG) was injected intracutaneously at several points on the lower extremity, and the dye distribution was observed using a special infrared camera (Photo Dynamic Eye). ICG is taken up into the lymphatics and its spread along with the lymph flow can be monitored. When a lymphatic vessel was visualized by linear flow of ICG, an incision was made at the site and the lymphatic was searched and identified using an operating microscope, and then anatomosed to the cutaneous vein.
Among a total of 7 limbs, 4 were evaluated as excellent, 3 as good, 0 as fair and 0 as poor.
In conventional LVA, identification of the lymphatics depends greatly on the experience of the surgeon. However, the use of FL-ICG allows more accurate identification of the lymphatics and confirmation of lymph flow after anastomosis.

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