Giant cell tumor (GCT) of the sacrum is rare and difficult to treat, although several treatment modalities have been reported. Here we report a patient with sacral GCT who underwent selective intra-arterial embolization.
The patient, a 23-year-old woman, had been treated with curettage alone at a local hospital. However, 4 months after surgery, MRI showed recurrence of the tumor, and the patient was referred to our hospital for further treatment.
After discussion with her and her family, they accepted intra-arterial embolization of the tumor vessels. Embolization using a temporary embolic agent reduced the size of the tumor and the level of serum acid phosphatase (ACP). However, both the tumor size and the level of ACP increased a few months after the procedure. Therefore, embolization was performed using an embolic agent consisting of spherical particles. MRI showed a marked reduction of tumor size 1 month after the last embolization, and the level of serum ACP also fell to less than the standard value.
Embolization using a spherical-particulate embolic agent can be an effective treatment for sacral GCT.

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We report a case of recurrence of an aneurysmal bone cyst (ABC) which developed in the right proximal ulna of a 9-year-old girl. Radiography revealed a radiolucent lesion with a bulging, thin cortex, septa, and a ground-glass appearance. Magnetic resonance imaging revealed that the tumor, measuring 73×30mm, was located in the proximal ulna near the physis, and contained septa and a fluid-fluid level. The tumor was subsequently diagnosed as an ABC by open biopsy, and was treated by surgical curettage and packing with artificial bone. However, the tumor recurred 4 months after surgery. First, the recurrent tumor was subjected to wide curettage, then absolute ethanol was injected into the cyst, followed by packing with artificial bone. The post-reoperative course was uneventful without recurrence. ABCs show a high rate of recurrence. Many arise near open physes or articular cartilage in skeletally immature patients. The risk of recurrence is highest in pediatric patients with juxtaphyseal lesions. In the present case, concern about possible damage to the physis and thin cortex discouraged us from curetting the tumor aggressively. Preservation of the physis remains a high priority of treatment, and adjuvant therapy, such as injection of absolute ethanol, application of liquid nitrogen, or argon laser cautery, should be combined with curettage whenever possible.

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We have been treating femoral neck fractures using cannulated cancellous screws, in accordance with individual cases. The clinical results of 43 patients treated between 2003 and 2009 were reviewed retrospectively, with the aim of clarifying any problems with our therapeutic algorithm.
The mean age of the patients at surgery was 70.0 (range 27-96) years ; 31 patients had a non-displaced fracture and 12 had a displaced fracture. Patients aged less than 65 years (group U) mostly had displaced fractures, whereas patients aged 65 years or more (group O) mostly had non-displaced fractures. All patients were followed radiographically for a mean period of 19.0 (range 6-58) months.
There were no cases of non-union in the non-displaced fracture group, and 4 cases of non-union in the displaced fracture group.
The patients in whom operative reduction was good had a 94.9% union rate, but those in whom reduction was poor had a 50.0% union rate.
Although we were relatively satisfied with these results, we conclude that the type of fracture and reduction during surgery need to be given sufficient consideration.

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We report two cases with old femoral neck fracture. One patient was an 80-year-old woman who had fallen down 6 months previously. The other patient was an 88-year-old man who had fallen down 4 months previously. Both patients had severe flexion contracture in their hip joints, and X-rays examinations showed severe old femoral neck fractures. Surgery was performed using bipolar hemiarthroplasty. This procedure was chosen in consideration of the patients' age and the presence of several risk factors related to their general condition. As the contracture was severe in the first case, we performed release of the soft tissues, especially in the area of the rectus femoris. After surgery, both patients regained full extension of their hip joints, and were able to start standing and walking exercise one week after the operation. Their ADL scores were obviously improved in comparison with those before surgery. We think that the release of soft tissue is useful in order to improve the contracture of the hip joint with old femoral neck fracture.

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We evaluated the clinical results of the proximal femoral nail anti-rotation (PFNA) for proximal femoral fractures.
Sixty-eight patients (16 men and 48 women, mean age 79.8 years) were treated with PFNA between November 2006 and May 2009. All cases were classified using the AO classification : 31 as A1, 24 as A2, 9 as A3, and 4 as B2.
The average tip-apex distance (TAD) was 15.0 mm. At the latest follow-up, the average sliding length of the PFNA blade was 4.9 mm. In 10 cases (of excessive sliding), the sliding length was over 10 mm.
There was no severe impairment of walking ability. All cases showed bone union without head rotation or neck varus deformity. There were no postoperative episodes of cut-out, infection, or deep venous thrombosis.
There was no relationship between TAD, AO classification, and excessive sliding of the PFNA blade. We evaluated trochantric fracture using Utsunomiya’s classification, which divides cases into the intramedullary type and the extramedullary type. In the present cases, the average length of the PFNA blade was 6.2 mm [7 cases (26.9%)] for the intramedullary type and 3.6 mm [2 cases (5.1%)] for the extramedullary type. The intramedullary type showed greater sliding than the extramedullary type.
We concluded that the PFNA procedure gave very satisfying results for internal fixation of hip fracture, and that Utsunomiya’s classification was useful for prediction of excessive postoperative sliding.

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Avascular necrosis of the femoral head (ANFH) after intertrochanteric fracture is uncommon. We reported a 93-year-old woman sustained this unusual complication. Internal fixation was performed, using a compression hip screw. Four months after surgery the patient was able to walk with the aid of a cane, was discharged from the hospital. However, at 6 months after surgery, she complained her hip pain without any cause. We diagnosed ANFN on the basis of radiological findings, and performed bipolar hip hemi-arthroplasty. The possible etiology of the complication was damage to the vascular supply (posterosuperior retinacular artery and/or deep branch of the medial circumflex femoral artery) of the femoral head. The possible risk factors for such vascular damage are a proximal intertrochanteric fracture line similar to the basal neck fracture, fractures with displacement of the fragments, fractures with comminution, and excessive external rotation of the limb in fixation. This case may be caused by what fracture lime is similar to basal neck fracture and external rotation of the limb.

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We investigated the outcome of surgical treatment for fracture of the proximal femur in 141 patients (39 males and 102 females, mean age 82.0 years), focusing on mortality and walking ability before and after surgery.
The cumulative survival rate was 85.1% at 14.2 months after surgery. Eighty-five (60.2%) of the 141 subjects were able to regain the same level of walking ability, whereas 35 (24.8%) showed a decrease of walking ability.
We also investigated the factors responsible for decreased survival and walking ability. Advanced age and an extended perioperative period (over 5 days) were found to be significant factors (t<0.05). It is therefore important to perform surgery promptly after fracture of the proximal femur.

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Open fractures of the calcaneus are rare and difficult to treat. The frequent incidence of complications, such as skin necrosis and deep infection, creates a high risk of unsatisfactory results, as we have reported previously.
We propose the new strategic protocol for open calcaneal fractures that includes a combination of antibiotic beads and Vacuum-Assisted Closure (VAC) therapy for the wound as an initial treatment.
Only three cases have been treated using the new protocol, but none of them developed deep infection or major skin problems. Recent studies of open calcaneal fractures have reported infection rates ranging from 11% to 31%. At our hospital the infection rate for open calcaneal fractures has been 43%. Combination therapy with antibiotic beads and VAC has advantages for wound management, especially on the medial side of the calcaneus.

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We investigated preoperative percentage vital capacity (%VC) and forced vital capacity in 1 second (FEV1%) in 75 patients with cervical spondylotic myelopathy (CSM) and 41 patients with lumbar canal stenosis (LCS) as a control group. In 32 CSM patients, postoperative spirometry was performed. In CSM patients we also compared %VC between those with upper cervical lesions and the others. The upper cervical lesion group had high intramedullary signal intensity changes and the other group had no signal changes on T2-weighted MRI on the cranial side from the C4/5 level. In terms of FEV1%, there were no significant differences between the CSM group and the LCS group. However, the %VC in the CSM group was significantly lower than that in LCS. The %VC in the CSM group improved slightly after surgery. The %VC in the upper cervical lesion group was lower than that in the other CSM patients, but there were no significant differences between the two groups. The spinal segments of the main inspiratory muscles are present in the cervical spinal cord, and those of the main expiratory muscles are located in the thoracic spinal cord. We considered that the preoperative decrease of %VC in CSM was due to weakness of the respiratory muscles. Respiratory dysfunction is considered to be one form of impairment in CSM.

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Retro-odontoid pseudotumor is an inflammatory mass most frequently associated with rheumatoid arthritis and dialysis. Recently, some case reports of retro-odontoid pseudotumor without instability have been published. Here we describe a 63-year-old man who was admitted to our hospital with numbness of the left upper extremity and walking disturbance. MRI showed a large retro-odontoid pseudotumor and severe compression of the spinal cord at the C1 level. The patient underwent C1 laminectomy, posterior occipital-C2 fusion and tumor resection via a transdural approach. Postoperative MRI showed that the retro-odontoid pseudotumor had been partially removed, but this was enough to obtain sufficient decompression of the spinal cord. Neurological symptoms were markedly improved after surgery.

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Objectives: To measure the size of the working space (WS) and the inclination angle of the tubular retractor (TR) in microendoscopic discectomy (MED) for lumbar disc herniation.
Methods: Forty-five patients were evaluated; L4/5 was affected in 23 patients, L5/S in 21, and L5/6 in one. WS and the inclination angle of the TR were measured using the axial CT image and a plastic template for the TR, both of the actual size. When measuring the WS, the medial one-fourth of the facet joint line was determined, assuming a partial facet resection. To secure access to the edge of the lateral recess, the medial-upper edge of the template was kept on the one-fourth line.
Results: The average WS was 10.7±2.7mm for the patients overall, 9.4±2.1 in L4/5, and 12.0±1.7 in L5/S. The average inclination angle of the TR was 7.9±1.7° for the patients overall, 7.0±1.5° in L4/5, and 8.9±1.2° in L5/S. Each parameter in L4/5 was significantly smaller than that in L5/S. The correlation between the WS and the operation time was significant. Five L4/5 cases had a WS smaller than 8mm, in which a standard rongeur was used with some difficulty.
Conclusion: Preoperative evaluation of the working space gives time to prepare additional surgical instruments, or offers a better opportunity for avoiding difficult cases during the learning period.

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We describe about antimicrobial prophylaxis (AMP) for lumbar spine surgery without instrumentation.
We evaluated 180 patients (119 males, 61 females) who had undergone the lumbar spine surgery without instrumentation. They were divided into two groups: group A, who were given AMP for two days after surgery, and group B, who were given AMP on the day of surgery. Cefazolin sodium was used for AMP.
WBC, CRP, body temperature and the incidence of surgical site infection (SSI) were evaluated.
The CRP level increased from 0.23mg/dl before surgery to 1.24mg/dl one week after surgery in group A, and similarly increased from 0.29mg/dl to 1.23mg/dl in group B.
WBC increased from 7,068/μl to 7,950/μl in group A, and decreased from 7,175/μl to 7,064/μl in group B. Body temperature increased from 35.9°C to 36.1°C in group A, and from 35.8°C to 36.2°C in group B. There was one case of SSI, in group A. None of the examined.
Parameters showed any significant difference between the groups.
These results suggest that administration of AMP on the day of surgery provides sufficient prophylaxis for lumbar spinal surgery.

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Deep venous thrombosis (DVT) is one complication that is likely to occur after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Its importance as a life-threatening complication is now widely recognized, and the need for countermeasures to prevent VTE has been emphasized. Here we reported the incidence of DVT using ultrasonography, D-dimer and the heparin-induced thrombocytopenia (HIT) antibody measurement in 47 patients undergoing TKA and THA.
The incidence of DVT was 14.9% in this series, and all cases involved TKA.
Postoperative D-dimer value was related to the period of Enokisaparin administration. The detection rate of HIT antibody was 19.1%. In all cases, there was no notable decrease in the platelet count.
It was possible to prevent DVT to some degree in this series. However, it is necessary to be aware that administration of Enokisaparin can induce thrombocytopenia.

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Unlike distal deep vein thrombosis, proximal deep vein thrombosis carries a high risk of pulmonary embolism. Of 595 consecutive patients undergoing total knee arthroplasty between August 2007 and July 2009, proximal deep vein thrombosis was identified in three (0.5%) using venous compression ultrasonography. The patients were all females, and ranged in age from 70 to 72 years. They were kept at rest in bed after detection of the proximal deep vein thrombosis, and administered anti-coagulation and dissolution drugs. We observed the proximal deep vein thrombosis once a week using venous compression ultrasonography, and when the thrombosis had disappeared or was reduced, ambulation was allowed. As a result, we were able to prevent pulmonary embolism in these three patients.

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We report a case of valgus knee deformity with patellar dislocation caused by infantile septic arthritis. The patient, a boy, had a congenital heart malformation. He had developed infantile septic arthritis of the knee joint at 1 month of age, and the distal lateral epiphysis of the femur had been affected. At 6 years of age, valgus deformity appeared, and therefore we performed deformity correction and leg lengthening with an Ilizarov fixator. However, the deformity recurred and the patella became dislocated laterally 3 years after initial surgery. In a second operation, we performed osteotomy at two sites of the femur. Distally, we corrected the valgus deformity and reduced the patella by changing the rotation of the femur and overlapping the medial soft tissue. Proximally, we corrected the retroversion and performed lengthening on a gradual basis. In the left leg, the preoperative mLDFA was 110° and the postoperative mLDFA was improved to 90°. As the deformity will likely relapse because of the patientｾs age, we plan to achieve realignment again by corrective surgery.

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The purpose of this study was to evaluated the clinical outcomes of osteochondral autografting with high tibial osteotomy (HTO) in 5 female patients with idiopathic osteonecrosis of the knee. The mean patient age was 65.8 years (range, 60 to 72 years) and the average follow-up period was 30.6 months (range, 12 to 53 months). The mean preoperative JOA score of 67.0 points improved to 93.0 points postoperatively. Varus deformity of the lower extremity was improved from a mean FTA of 179.8 degrees preoperatively to 170.4 degrees postoperatively. Second-look arthroscopy demonstrated excellent cartilage repair in 4 of the 5 knees. Osteochondral autografting with HTO is one of the possible options for manegement of idiopathic osteonecrosis of the knee in elderly patients.

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The development of the locking plate has allowed considerable progress in the treatment of fractures, but few studies have evaluated its usefulness for the treatment of aseptic non-union. We have treated 15 cases of aseptic non-union of long bones in the lower limb (femur : 5, tibia : 10, including 3 periprosthetic non-unions) using locking plates. The initial treatments were external fixation in 1 case, intramedullary nailing in 2, conventional plating in 5, locking plating in 4, and use of a cast only in 3. Nine cases were hypertrophic non-unions and 5 were atrophic non-unions. Union was achieved in all cases, although one case showed correction loss and 5 showed delayed union. These results were quite good, and allowed us to conclude that the locking plate is useful for the treatment of aseptic non-union of bones in the lower limb. Because the degree of bone defect and deformity differs in individual cases, detailed preoperative planning and choice of an appropriate operative technique are needed to achieve good results.

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Hip dislocation is mostly caused by high-energy injury, and only rarely by athletic injury. Here we report a 17-year-old boy who suffered hip dislocation while sprinting. When he suddenly stopped after the sprint burst, posterior dislocation of the hip and anterior wall fracture of the acetabulum occurred. The hip is generally displaced posteriorly with the hip flexed, adducted, and internally rotated. Posterior wall fracture of the acetabulum sometimes occurs when the hip is less flexed. Although some authors have reported posterior dislocation with posterior wall fracture, there has been no previous report of posterior dislocation with anterior wall fracture. In the present case, the femoral neck might have impinged against the anterior acetabulum wall with the hip flexed, adducted, and internally rotated. In this position, an axial load would have been added to the hip joint, resulting in posterior dislocation and anterior wall fracture. We examined the hip joint by MRI in 5 months after the injury, and no osteonecrosis of the femoral head was evident. Careful follow-up will be necessary because hip dislocation often results in osteonecrosis even in cases of low-energy injury.

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We report the clinical results for10 cases of periprosthetic fracture after Hip Arthroplasty between April 2005 and March 2009.
On the basis of the Vancouver system, 7 cases were classified as Type B1, 1 case as Type B2, and 1 case as Type C.
Type B1 cases were treated with a cable plate system, wiring only, locking compression plate and conservative treatment respectively. Type B2 cases were treated with revision arthroplasty or wiring. The type C case was treated with a plate. We evaluated the JOA score, bone union, the period until full weight- bearing, operation time, intraoperative blood loss and complications.
All fractures healed with complete union. The mean JOA score was 69.6 preoperatively and 56.0 postoperatively. The mean period for the callus formation was 6.8 weeks. The mean period until full weight bearing was 8.6 weeks. The mean operation time was 180 minutes,and the mean blood loss was 359 ml.
We considered that the locking compression plate is useful for Vancouver types B1 and Type C. A bone graft should be considered for Vancouver types B2 and 3.

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Fourteen cases of partial intraarticular femoral condylar fracture were treated using lag screws and buttress plating. The average patient age at the time of surgery was 55.9 years (range, 25 to 84 years). The follow-up period ranged from 4 to 16 months. Using the AO/OTA classsification system, 2 fractures were classified as type B1, 8 as type B2, and 4 as type B3.
The mean range of motion at final follow-up was -2.5 to 131.1 degrees. The mean Neer score was 92.1 points, 12 cases being classed as excellent, and 2 as satisfactory. Buttress plating appears to be an appropriate technique for treatment of partial intraarticular femoral condylar fractures, especially in elderly patients.

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The purpose of this study was to evaluate the functional and radiological outcome of proximal humeral fractures treated by minimally invasive plate osteosynthesis (MIPO) via an anterolateral acromial approach, which was recently reported as an alternative to open reduction and internal fixation via a deltopectoral approach.
In 2008, five patients (4 males and 1 female, mean age 62.6 years) were considered to be candidates for MIPO, and we treated them with a proximal humeral internal locking system (PHILOS). At the final follow-up (mean 8.9 months after surgery), the average shoulder flexion was 144 degrees, shoulder abduction 126 degrees, and JOA score 87.6. One patient had delayed union, which resulted in varus deformity postoperatively.
Reduction and internal fixation of proximal humeral fractures can be achieved using MIPO employing the same incision as that with an intramedullary nail, without invasion of the rotator cuff. However, because of the risk of axillary nerve injury, an inferomedial screw cannot always be applied to prevent varus deformity. Therefore we conclude that adaptation for MIPO should only be considered in patients whose age makes them unsuitable for use of an intramedullary nail, and in whom medial support can be obtained easily.

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The purpose of this study was to assess screw penetration of the humeral head after locking plate fixation of proximal humeral fractures.
The 14 patients, with an average age of 61.8 years, underwent locking plate fixation for proximal humeral fractures, and were followed up for an average one year. The types of proximal humeral fractures by Neer's classification were 2-part fractures in 2 cases, 3-part fractures in 8 cases, and 4-part fractures in 4 cases. Screw penetration of the humeral head was observed in four cases. The fracture type in all 4 cases was the 4-part fracture. A bony defect of the glenoid was suspected in two of these four cases on radiography. Removal of the implants was performed in 3 cases. In one case, screw penetration on the articular surface of the humeral head and damage of the articular cartilage on the inferior glenoid were observed during arthroscopic capsular release. Bone damage to the glenoid was not suspected in this case before arthroscopy. The average range of motion of the shoulder joint was 93 degrees in flexion and 19 degrees in external rotation in the cases of screw penetration, compared with 103 degrees in flexion and 54 degrees in external rotation in the cases without screw penetration.
The results of this study indicate that careful observation of the screw penetration and glenoid damage is required after locking plate fixation for 4-part fractures.

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We report the treatment of little leaguer's shoulder (LLS), which is a condition of the throwing shoulder resulting from over-use. From September 2009, 8 patients with LLS (7 to 14 years old) were investigated with regard to details of the initial physical examination, physical therapy and the question to the physical therapist (PT) and athletic trainer. Heel-buttock distance, straight leg raising angle, hip internal rotation angle, and Hara's test (a combined abduction test, horizontal flexion test, elbow extension test, elbow push test) were investigated. Tightness of the hamstrings, reduced range of motion at the hip and gleno-humeral joint, and weakness of the muscle at the shoulder and trunk were observed. At the end of treatment, in almost all cases, tightness, range of joint motion and muscle power were all improved. Physical therapy was initially focused on the lower leg, hip joint and trunk. Treatment of LLS involved a ban on throwing, and stretching of the shoulder, trunk, and lower extremity.

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We report seven cases of knot impingement and acromial erosion associated with rotator cuff repair. Between June 2007 and April 2009, we operated on 73 cases of rotator cuff tear using a suture anchor with the double row technique (Twin Fix, Fastin RC and Panalok Loop RC). Among 48 patients who underwent 3D-CT, 33 (68.8%) were found to have acromial erosion due to knot impingement. We operated again on 7 patients (1 man and 7 women) with a mean age of 66.2 years (range 49 to 76 years). With regard to size, the rotator cuff tears comprised one on the bursal side, 2 small tears, 3 medium tears and one large tear. Four cases were not associated with pain and had almost a full range of motion, and 3 cases were associated with some pain and contracture. A knot of thread projected from rotator cuff and the acromion were scraped off the surface with the image of the arhroscope. All threads and knots projected from rotator cuff were removed. After surgery, 3 patients who had pain and contracture showed an improved range of motion and reduced pain.

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We report the use of a navigation system for spinal surgery, with details of its utilities and problems. Between April 2004 and June 2009, we treated 28 cases using a navigation system. The average patient age at the time of surgery was 49 years (range 10 to 86 years). Cervical spine surgery was undertaken in 16 cases, and thoracolumbar spine surgery in 12. The diagnoses were RA (3 cases), kyphosis (6 cases), spondylolisthesis (2 cases), trauma (10 cases), and others (5 cases). All patients had marked bone destruction or bone deformity.
The mean operation time was 268 minutes for cervical surgery and 238 minutes for thoracolumbar surgery, and the mean blood loss was 282 ml and 279 ml, respectively. We used 81 cervical screws in 13 cases, and 68 thoracolumbar screws in 12 cases. Seventy-eight of the 81 cervical screws were graded in Group 1, and 3 were graded in Grade 2. Two of the 68 thoracolumbar screws were graded in each of A-1, A-2, and A-3, respectively, and 1 was graded in C-2. Many of the misplaced screws showed lateral perforation, perhaps due to spinal rotation when placing the screws by pushing the entry point of the spinal column.
We were able to insert the screws safely using the navigation system. Especially for cases with marked deformity, we were able to control the screws with careful preoperative planning.

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Background : Improved treatment of spinal deformities is increasingly dependent on better fixation. Significant postoperative complications often occur following thoracolumbar fixation, particularly in long-segment constructs, and include loss of fixation, lumbar lordosis, and pseudarthrosis. We reduced a complication associated with a posterior implant by using a pedicle screw and claw hook.
Method : A validated 3-dimensional, non-linear finite element model of an intact L1-S1 segment was modified to simulate posterior fusion with instrumentation with a pedicle screw and/or claw hook. The posterior instrumentation represented a simulation of the conditions present immediately after surgery.
Results : Segment motion decreased with the addition of the claw hook during all motion. The pull-out strength of the pedicle screw with the addition of the claw hook was reduced in flexion. Maximum stress on the rod was increased by addition of the claw hook.
Conclusion : A reasonable combination of pedicle screw and/or claw hook fixation may be logical for reducing the incidence of pullout and for maintenance of spinal alignment. The biggest concern with the use of claw hook fixation is that extra fusion is necessary, and that instrument failure might occur.

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The purpose of this study was to evaluate the clinical results of surgical treatment for unstable midshaft clavicular fractures using locking compression plate (LCP).
We treated twenty-eight patients (21 men, 7 women, mean age 47 years) between December 2003 and November 2009. The mean duration of follow-up was 10 months. Finally, all of the patients achieved bone union. The mean time of bone union was 14 weeks (9-26 weeks). The complications were loosening of locking screw in three cases and back out of plate in two cases.
Our results show that fixation of unstable midshaft clavicular fractures with LCP provides satisfactory results. However, there was a limit in fixation of locking screw in superior position of LCP. Therefore, according to the case it is necessary to limit briskness to some degree until the bone union.

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We examined the results of surgical treatment for distal femur fractures in our hospital from January 2005 to June 2009. There were 26 patients, 21 of whom were treated with a locking plate (LP; 19 with a MIPO approach) and 5 with an intramedullary nail (IN). We evaluated surgical time, use of bone grafts, timing of callus formation, femoral angle, ROM of the knee, and complications. No differences in the results were evident between LP and IN for any of the items, but delayed union was evident in 2 cases treated by LP. In the latter cases, delayed union appeared to have resulted from an inappropriate start to weight-bearing or the presence of a medial cortical gap. When selecting LP, it seems necessary to achieve medial cortical contact as soon as possible. In the case of comminuted fractures, bone grafting and a double plate should be considered.

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Recently, many reports have concluded that osteosynthesis for pilon fracture with Locking Compression Plate (LCP) yields good clinical results. We had also treated 24 cases of type C pilon fractures using LCP. Our series included 7 females and 17 males, with a mean age of 57.2 years.
Bone union was obtained with good recovery of the range of motion (mean dorsal/palmar flexion 15/50 degrees) with initial treatment in most cases, although one case required arthrodesis because of post-traumatic arthritis and ankle pain. Angular stability achieved with LCP gives more rigid fracture fixation and decreases the number of cases requiring bone-grafting or external fixation after definitive surgery. However, pilon fracture still requires orthopaedic surgeons to apply optimal soft tissue management, and minimally invasive anatomical reduction of the ankle joint. Otherwise, unacceptable clinical results may occur, such as skin necrosis, deep infection, and post-traumatic arthritis.

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Choosing a correct combined cup and stem anteversion in total hip arthroplasty (THA) will yield a maximized, stable range of motion and will reduce the risk for dislocation. From August 2008, we have established a safe zone of combined anteversion of 30° to 50° and performed THA on 33 hips using Stryker Navigation's CT-Hip system. The aim of this study was to investigate the accuracy of the cup and stem positions. The evaluation of implant position has been performed on postoperative CT, with the aid of CT-based planning software. Combined anteversion was 37.9±6.2° (standard deviation) (range, 24-52°). Femoral stem anteversion was 20.6±7.1° (10-33°) and cup anteversion was 17.3±4.8° (7-26°). The combined anteversion with computer navigation was within the safe zone of 30 to 50 for 29 of 33 (88%) hips. The results of this study indicate that the combined anteversion technique using computer navigation for THA is a reliable method.

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We examined the cup inclination and anteversion in MIS-THA, according to three approaches, in 303 patients treated over a two-year period from 2007 in our hospital. Among the joints treated, the Mini-one approach was used for 109, the OCM approach for 162, and the Hardinge approach for 32. All operations were performed with the patient in the decubitus position. The cup anteversion was measured by Lewinnek's method.
In the OCM approach, cup anteversion was intentionally increased, probably because of pelvic tilting during surgery. The OCM approach has the potential to minimize the degree of surgical invasion, pain, recovery time and hip dislocations. However, attention is necessary with regard to cup placement.

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The present study examined the short-term results of CentPillar cementless total hip arthroplasty (THA) using the GB HA and TMZF HA stems. We treated 31 patients during the period between January 2005 and June 2009. The average age of the patients at the time of surgery was 54 years, and the average postoperative follow-up period was 13 months. Early stem subsidence after surgery was significantly less frequent for the TMZF HA stem than for the GB HA stem. In particular, early stem subsidence was detected in cases of varus or valgus stem alignment. The change in stem alignment after surgery using the TMZF HA stem was smaller than that for the GB HA stem. There was no significant difference in the stem-occupation rate in the canal between the two stem types. The average Japanese Orthopaedic Association hip score improved significantly after surgery with both types of stem. The CentPillar TMZF HA stem achieved initial stability of the proximal femur as a result of smaller stem subsidence by coating the PureFix HA with plasma spray.

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We investigated 14 patients (15 hips) undergoing total hip arthroplasty (THA) for rheumatoid arthritis (RA) and rheumatic disease from October 2005 to December 2008. The subjects were 11 patients with RA, one patient with RA who had a neck fracture of femur, one patient with systemic lupus erythematosus, one patient with periarteritis nodosa, and one patient with aortitis syndrome. The mean age at surgery was 68 years (51-81 years). The average follow-up period was 2.1 years (8 months-3.8 years).
15 hips were treated with a Dorr cortical bone subtype, type A (all cementless THA), 10 hips with Dorr type B (2 cemented, 3 hybrid and 5 cementless THA), and 4 hips with Dorr type C (all hybrid THA). Neither cemented nor cementless cups showed migration or loosening by Moore's estimation. All cementless stems were bony stable by Engh's estimation. One case treated with a cemented stem showed an increase of the radiolucent line. The average point score of the Japanese Orthopaedic Association (JOA) scoring system improved from 33.5 to 77.7, but the activity of 20％ of the patients had declined at the latest follow-up.
Both hybrid and cementless THA showed good short-term results, but clinically the level of activity declined in patients who suffered major joint involvement and/or had steroid induced depression.

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Extensor tendon ruptures in the hands of patients with rheumatoid arthritis are treated by tendon transfer and/or tendon grafting. Various methods of reconstruction are performed on the rheumatoid wrist joints after synovectomy. One of these is the Sauve-Kapandji procedure, which is used to form a shelf with the excised ulnar head and a partial wrist arthrodesis after ulnar head excision. However, there are some associated problems, such as instability at the edge of the ulna and ulnar drift deformity of the carpal bones after ulnar head excision. The latter problem cannot be prevented by the Sauve-Kapandji procedure, and the wrist joint may be stiff after partial wrist arthrodesis.We report the results of our series, and discuss the indications for reconstruction. [Object and method] We examined its 11 sample 12 hands that had been experienced between April, 2006 and June, 2009. After ulnar head excision we did synovectomy, and used the Sauve-Kapandji procedure or a partial wrist arthrodesis together with the case where it has misgivings about the instability of the wrist joint after operation. [Result] Most hands regained the progress function, and were able to keep the winding function. The joint with the pain hardly was kept though the movable region limitation was left in the wrist joint as a result of the operation. For some cases, limitation of movable region remained after a partial wrist arthrodesis. Therefore, it is necessary to note us for the selection of method of operating.

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Subcutaneous tendon ruptures in patients with rheumatoid arthritis almost always affect the extensor tendon, and flexor tendon rupture is infrequent. We experienced a rare case of multi-flexor tendon rupture in a 71-year-old female patient with rheumatoid arthritis, who presented with inability to flex her left middle finger, ring finger and little finger. She had been receiving treatment for rheumatoid arthritis for 17 years, and had been unable to flex the DIP joint of the left middle finger for many years. However, the inability to flex the DIP joint and PIP joint of the left ring finger and little finger had developed 2 weeks before presentation. Surgical exploration revealed FDP(III, IV, V) and the FDS (IV, V) rupture at the center of the palm. No bone spur was found within the carpal canal, and we considered that the tendon ruptures had been caused by direct invasion of the tendon by tenosynovitis. We sutured the FDP(V) to the FDP(IV), and the end of the FDP(IV) to the FDS. Tenodesis of the FDP(III) and arthrodesis of the DIP joint of the middle finger were then performed. The patient started ROM exercise with tape fixation of the middle finger, ring finger and little finger as soon as possible after the operation.
In this condition, it is important to perform suturing to a strong tendon, and to start exercise as soon as possible in order to prevent articular contracture.

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The sternoclavicular joint (SCJ) is a rare site for infection. We report a case of septic arthritis of the SCJ.
A 66-year-old diabetic man complained of pain in the anterior left neck. Redness and swelling were evident in the area of the left SCJ. The white cell count was 18,290/µl and the CRP level was 33.24mg/dl. Magnetic resonance imaging (MRI) showed inflammatory swelling around the left SCJ. An aspirate obtained by CT-guided needle puncture grew Staphylococcus aureus. Consevative therapy ineffective, and MRI about two weeks later showed osteomyelitis of the left clavicle and destruction of the left SCJ. Curettage and irrigation were performed, but the CRP level remained high. Therefore, we performed curettage under continuous irrigation, and filled the bone defect with cement beads. Four weeks later, we removed of the cement beads and covered the bone defect with the ipsilateral pectoralis major muscle.
Early diagnosis and therapy for septic arthritis of the SCJ is important. MRI is useful for early diagnosis and a correct choice of treatment. Furthermore, debridement with cement beads and coverage of the bone defect with the ipsilateral pectoralis major muscle aids complete recovery.

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