Arthroscopic treatment has been widely performed for tears of the lateral discoid meniscus. However, this frequently results in total meniscectomy in cases of degenerative peripheral tear. We performed meniscal suturing of residual peripheral tears after subtotal meniscectomy to preserve the function of the meniscus.
Methods : We treated 15 knees of 15 patients (4 males and 11 females) with symptomatic lateral discoid meniscus tears. The mean age of the patients at surgery was 18.7 years (range, 7 to 37 years), and the mean follow-up period was 2.7 years (range, 12 to 65 months). We retrospectively compared the clinical results and the incidence rate of osteochondritis dissecans (OCD) in the peripheral repair group with those in the subtotal meniscectoy group. Clinical results were assessed on the basis of the Japanese Orthopaedic Association (JOA) score.
Results : Eight patients underwent arthroscopic partial meniscectomy alone. In the remaining 7 patients with degenerative peripheral tears, meniscal repair was performed after subtotal meniscectomy to avoid total meniscectomy. All of the patients had excellent JOA scores at the final follow-up point. None of them required additional surgery for re-tear. The incidence of OCD was 14% in the partial meniscectomy group, whereas OCD was not found in the peripheral repair group.
Conclusion : Our results demonstrate the short-term efficacy of arthroscopic partial meniscectomy in conjunction with peripheral repair in cases of degenerative peripheral tear of lateral discoid meniscus.

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In Japan, the ratio of the elderly population has been increasing. We investigated the clinical features of elderly patients with cervical spinal cord injury. We treated 71 patients with cervical spinal cord injury between 2000 and 2009, of whom 24 (19 men and 5 women) aged 70 years or more were classified as elderly. The mean age of such elderly patients was 78.3 years. The number of non-elderly patients was 47 (39 men and 8 women), with a mean age of 52.9 years. Between the elderly and the non-elderly patients, the causes of spinal cord injury and ratios of conservative treatment differed significantly. Although significant differences were not evident, the elderly patients had certain features, such as a low proportion of patients receiving massive steroid doses, cervical bone injury, and staying at home after discharge from hospital. Knowledge of the clinical features of elderly patients with cervical spinal cord injury appears to be very important and helpful for treatment planning.

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For treatment of cervical spondylotic myelopathy (CSM), various posterior decompression procedures can be adopted, such as Z-shaped laminoplasty, expansive open-door laminoplasty, and spinous process-splitting laminectomy. We have conducted expansive open-door laminoplasty as the first treatment of choice in 168 CSM patients since 2001, even in the presence of spondylolisthesis. However, some researchers have described postoperative instability in such cases with regard to the angle of cervical lordosis, range of motion, and slippage angle of the cervical spine, although little has been reported regarding the slippage distance of the cervical spine after surgery. In this study, we evaluated 6 patients showing CSM with a slippage distance of 3.5mm or greater on X-ray images, treated by expansive open-door laminoplasty without internal fixation devices, who were followed -up for more than 5years (range: 5yr 9mo to 9yr). Their severe slippage distance before surgery (3.9±0.4mm) had not worsened at the final follow-up (3.6±0.8mm) (p=0.17). Other aspects were significantly reduced, including the slippage angle, range of motion of the cervical spine, and dynamic antero-posterior diameter of the cervical spinal canal. Expansive open-door laminoplasty is considered effective for surgical management of patients with CSM, even when accompanied by spondylolisthesis.

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Congenital defects of the posterior arch of the atlas are very rare. In this study, we investigated seven patients with congenital defects of the posterior arch of the atlas. The mean patient age was 47.5 years (range, 16 to 64 yr). All patients complained of neck pain. According to the classification of Currarino, four cases were classified as Type A, two as Type B, and 1 as Type E. The symptoms in the Type A and Type B patients subsided after conservative treatment. The Type E case (complete defect) showed myelopathy due to atlanto-axial instability caused by co-existing os-odontoideum, and the patient underwent posterior occipito-C4 fixation with pedicle screws. After the operation, the neck pain disappeared and the symptoms of the myelopathy improved. Most cases of congenital defects of the posterior arch of the atlas are found incidentally by roentgenographic or computed tomographic examinations for neck pain. We suggest that congenital defects of the posterior arch of the atlas be considered in differential diagnosis of patients with neck pain.

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We report the use of a navigation system for upper cervical fusion with details of its utilities and problems. Between March 2005 and July 2010, we treated 49 cases (including 2 multiple operation cases) using this system. From March 2005 to March 2009, CT-based navigation was used, and for the latter period Iso-C 3D navigation was employed. The average patient age at the time of surgery was 63 years. There were 18 trauma patients and 31 non-trauma patients. Transarticular screw fixation (the so-called Magerl technique) was applied for 26 cases, C1 lateral mass screw and cervical pedicle screw fixation for 7 cases, and occipital screw fixation for 6 cases. The deviation of the inserted screw after surgery assessed by CT scan and complications of upper cervical fusion were investigated.
We experienced one case of transarticular screw deviation in high-riding VA patients, avoiding VA injury. Exclusion criteria for transarticular screw fixation should be established in order to avoid VA injury. One complication of posterior fusion was non-union, seen in 2 cases. No neurological deterioration occurred. In cases of non-union, we used C1 lateral mass screw fixation in patients with rheumatoid arthritis (RA). In conclusion, the use of transarticular screws and a navigation system is the first choice for upper cervical fixation.

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We report a case of periprosthetic fracture of the femur after total hip arthroplasty (THA). The patient was a 77-year-old woman who had undergone THA at the age of 50 for osteoarthritis of the hip. Six years ago, implant loosening had been pointed out. Pain appeared when the hip was twisted three days ago, and walking became difficult. Radiograph showed an oblique periprosthetic fracture of the femur and bone defects of the proximal femur. The diagnosis was Vancouver classification type B3. Open reduction internal fixation with a LCP reconstruction plate 4.5/5.0 and revision THA with a cemented long stem were performed. At the end of the follow-up period of seven months, no implant failure had occurred. LCP, periprosthetic screws and a cable system were useful for fixation of the periprosthetic fracture. However, it may be difficult to obtain a good long-term result when stem revision for Vancouver type B3 is performed with only bone cement.

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We report three cases of periprosthetic femoral fracture that were treated with a locking compression plate-distal femur (LCP-DF) and LCP cable system between March and June 2010. One was a femoral shaft fracture after total hip arthoplasty, and the others were femoral shaft fractures after bipolar hip arthoplasty. The patients ranged in age from 84-88 years with a mean of 83.5 years. All had been injured in falls. All of the cases were type B1 by the Vancouver classification. Surgery was performed within a week, and all patients were relieved of pain and transferred to a wheelchair from the first postoperative day. In two cases, bone union was obtained after three months. There was no correction loss or implant failure. One patient died of a malignant tumor before the fracture had become united.
We consider that a LCP cable system is useful for treatment of periprosthetic femoral fractures.

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We report a case of femoral head necrosis after surgery for trochanteric fracture. The patient was an 85-year-old man who had sustained the fracture in a fall. We performed osteosynthesis for the fracture. Left coxalgia occurred 8 months later. At 9 months after the operation, collapse of the femoral head was observed. Bipolar head arthroplasty was performed 14 months postoperatively. Pathological examination of the femoral head indicated osteonecrosis. Other reports have suggested that the causes of osteonecrosis are initial high-energy trauma combined with basal neck fracture and iatrogenic damage to the blood supply of the femoral head. High-energy trauma with fracture displacement that had disrupted the blood supply to the femoral head may have been the major factor contributing to the femoral head necrosis in the present case.

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Transcatheter arterial embolization (TAE) was performed in 12 patients with pelvic fractures and pelvic extravasations (CT-extra) evident by enhanced CT. Three of the patients were men and 9 were women, with an average age of 56.9 years. The injury severity score ranged between 25 and 51 points. The following 3 points were evaluated : 1. TAE loading completion time from the start of treatment, 2. Arteries embolized, 3. Systolic blood pressure before and after TAE, 4. Complications of TAE. The average period required for TAE was 183 min. The mean systolic blood pressure prior to and after TAE was 76 mmHg and 117 mmHg, respectively.
As complications, kidney failure and ED occurred in one patient. Although TAE was effective for achieving acute hemodynamic stability, there have been many previous reports of TAE-specific complications. Therefore TAE for pelvic fractures should be performed with meticulous care.

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We report our experience with a 56-year-old female patient who made good progress after fixation of two implants, an intramedullary nail and a locking compression plate (LCP) for a segmental fracture of the femur. She had been struck by a car when riding a motorcycle, and was brought to the hospital by ambulance. She had a segmental fracture (AO classification 32-B2, 33-A3) of the femur combined with fractures of the right calcaneal bone, ankle, lateral malleolus, and foot. Wire traction was applied, and we performed open reduction inter-fixation with an intramedullary nail and a LCP on the distal femur 12 days after injury. We used a cable system and a periprosthetic screw on the LCP for the intermediate part of the bone chip. Synostosis was obtained in four months after surgery, and the patient is making satisfactory progress. An intramedullary nail is considered to be the first choice for fixation of segmental fracture of the femur. However, in the present case, we chose to use a plate together with an intramedullary nail, because the condyle part of the bone chip was small, and we expected that fixation with an intramedullary nail would be inadequate. A LCP, cable system and periprosthetic screw were useful for fixation to the bone chip bearing an inserted intramedullary nail.

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Recently the incidence of high-energy trauma in the elderly due to traffic accidents seems to have been increasing. In our hospital, we often treat cases of trauma to the limbs and pelvic area caused by traffic accidents. Among these cases, we selected 18 cases of fracture in individuals aged 65 years old or more, involving the scapular arch, spine, pelvis, and lower limbs that had been sustained in car or motorcycle accidents. We examined the ages of the patients, the areas of injury, the Injury Severity Scores(ISSs), the methods of orthopedic treatment, and the clinical results.
The average patient age was 73.9 years. The area of injury was the lower leg in most cases, followed in order by the pelvis and the femur. Amalgamation damage, head injury accounted for the majority.
The average ISS was 19.5. The ISS was obviously high in fatal cases, and in cases having amalgamated head injury. All 3 inoperable cases that were ultimately fatal involved head injury. In patients who survived, early operative intervention achieved excellent results.
Pelvic fractures occurred at high frequency, affecting 10 cases. As the reported mortality rate of pelvic fractures is high in the elderly, in our hospital we actively perform transcatheter arterial embolization (TAE) and bone fixation at as early a stage as possible.
In elderly patients with high-energy trauma, the presence of head injury seems to be associated with an unfavorable outcome. For many cases of pelvic fracture, it is important to actively perform TAE and early fracture stabilization.

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This study was conducted to verify the clinical outcomes after treatment of fracture of the hamate hook in baseball players. Nine male baseball players, who underwent resection of the hamate hook with a J-shaped skin incision from the ulnar midlateral area of the palm to the palmar side of the wrist, were included in this study. In one patient, palmaris longus tenden grafting was added because of a partial tear of the flexor digitorum profundus of the little finger. The mean patient age at the time of surgery was 19.2 years (range: 14 to 56 years), and the mean follow-up period was 3.6 months (range: 1 to 7 months). Except for the one patient with tendon grafting, eight patients made a full return to baseball in mean about 5.3 weeks. As a postoperative complication, there was numbness of the ulnar nerve area in one patient for only a short period. None of the patients had any pain in the treated hand at the time of the final examination. In cases of hamate hook fracture in baseball players, excision of the hook is useful for early return to the sport.

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Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy. However, there is no consensus regarding the most appropriate timing for surgery. Here we report the results of electrophysiological examinations conducted before treatment and the changes in symptoms after treatment for CTS. We studied 90 patients (118 hands) with CTS who were diagnosed at our hospital between 2001 and 2010. We divided the patients into two groups : one group with sequelae, and the other without. We calculated the average of CMAP terminal latency for the abductor polis brevis (APB) and the difference of CMAP terminal latency between the 2nd lumbiric and 2nd palmar interosseus. Interestingly, between the patients without sequelae after surgery and with sequelae after conservative treatment, these averages were approximate. If surgery is performed when the terminal latency is under these averages, then an excellent outcome can be expected.

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Ten cases of rupture of the extensor pollicis longus (EPL) tendon have been encountered between April 2004 and March 2010. Seven cases were fixed with a volar locking plate, six underwent surgical tendon transfer, and four received conservative therapy.
We studied the fracture type, the interval from fracture until rupture of the EPL tendon, and the clinical outcome.
Dislocation was within 2 mm in six cases and exceeded 2 mm in four. Outcome was considered excellent in three cases and good in three by the Riddell classification. In six weeks, three cases showed dislocation within 2 mm and three exceeding 2 mm.
Our experience suggests that we should have the compartment open during surgery and we should reconstruct the sliding floor in cases with a dorsal roof fragment.

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Osteochondrosis of the humeral trochlea with osteochondritis dissecans of the humeral capitellum is comparatively rare. We report a 15-year-old male table tennis player who developed repetitive right elbow pain. Computed tomography showed two lesions of the subchondral bone in the right humeral capitellum and trochlea. Arthroscopic surgery was performed, and the postoperative course was satisfactory. We considered the trochlear lesion to be osteochondrosis, whereas that of the capitellum was osteochondritis dissecans, based on the chronological course revealed by computed tomography. The reasons for the delay in diagnosis were inadequate physical examinations and unclear radiological findings. Our findings indicate that osteochondrosis of the humeral capitellum or trochlea should be considered in the differential diagnosis of this type of case.

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We report two cases of osteochondritis dissecans (OCD) in identical twin male badminton players. The younger brother presented at the age of 15 years complaining of a two-year history of right knee pain during sports activity. Physical examination showed a positive result in the patella grinding test, but no range of motion limitation. Plain radiography showed that the lateral femoral groove had irregularity and a radiolucent region, and a diagnosis of OCD was made on the basis of magnetic resonance imaging (MRI). Arthroscopy demonstrated softening of the OCD lesion and partial cracking of the cartilage. The OCD lesion was fixed using bone strips. Five months after surgery, MRI demonstrated almost total disappearance of the lesion, and the patient returned to his original sports activity. The elder brother presented at the age of 16 years with a three-month history of left knee pain during sports. Physical examination revealed only mild tenderness of the patellofemoral joint. Plain radiography and MRI showed OCD in the lateral femoral groove, and arthroscopy demonstrated the lesion but no cracking of the cartilage. As had been the case for the younger brother, surgery was performed using bone strips. Because the lesion appeared to show good remodeling into normal bone on MRI at three months after surgery, the patient returned to his original level of sport. Although familial incidence of OCD is not unusual, cases in identical twins are very rare. The similarities of both site and onset timing of these OCD lesions suggest that some genetic factor may contribute to the cause of OCD other than overloading due to repetitive and strong sports activity. Also, our clinical results indicate that fixation with bone strips is a useful therapeutic option for OCD in the femoral groove to facilitate a prompt return to sports activity.

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We report the clinical results of anatomically oriented anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone graft (BTB). This technique is intended to mimic the two bundles of the normal ACL, based on the concept of twin tunnel ACL reconstruction. The attached bone plug is introduced into a rectangular femoral socket via a halfway rectangular tibial tunnel in order for the anterior portion of the graft to function as the anteromedial bundle (AMB) and its posterior portion to behave as the posterolateral bundle (PLB). Between July 2007 and December 2009, 47 patients (26 men and 21 women) underwent ACL reconstruction. The mean patient age was 29.0 years (range, 14 to 54 years) and the average follow-up period was 13.8 months (range, 6 to 27 months). Pivot shift test gave a slightly positive result in 5 patients, and the anterior drawer test gave a slightly positive result in 4 patients. The mean KT-2000 side-to-side difference was 0.65 mm (range, -4.0 to +5.0 mm). The mean Lysholm score was 95.4 (range, 85 to 100). Slight rotation instability remained after ACL reconstruction, but fresh meniscal injury was negligible in all cases. The clinical results of anatomically oriented ACL reconstruction with a BTB were good.

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We used a laser beam to determine the location of the femoral tunnel during ACL reconstruction. Location of the correct anatomical site is necessary in order to perform intra-articular drilling in the tibia. With this technique, a laser pointer is set at the tibial guide, which reflects the laser beam and illuminates the point where the femoral bone tunnel should be made. This is the first report of the use of a laser-guided technique for arthroscopic surgery.
Using postoperative 3D-CT, we evaluated double-bundle ACL reconstruction of 38 joints in terms of the location of the bone tunnel in the femur and tibia, and examined antero-posterior instability with a KT-1000 before and after the operation. It was possible to create the bone tunnel at the correct anatomical site of the AMB and PLB in both the femur and tibia. Our method is useful for creation of a bone tunnel at the correct anatomical site of the ACL.

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We evaluated 6 patients who underwent MIS-TKA using a lateral approach for valgus knee. There were 4 women (5 knees) and 2 men (2 knees) with a mean age of 71 years. The preoperative diagnoses were osteoarthritis in 3 knees, rheumatoid arthritis in 1 knee, and valgus knee after high tibial osteotomy in 3 knees. The mean JOA score and FTA improved from 48 points and 159 degrees preoperatively, to 80 points and 176 degrees respectively, after a mean follow-up of 16 months. One postoperative complication was mild varus knee deformity due to subsidence of the tibial component in the RA knee at 3 months after surgery. The minimally invasive lateral approach is a useful procedure for the treatment of valgus knee deformity in patients undergoing total knee arthroplasty.

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The purpose of this study was to evaluate the clinical results of total knee arthroplasty in elderly patients. We treated 31 patients older than 80 years (6 men and 25 women) between January 2008 and December 2009. The mean follow-up period was 13 months. We investigated operation time, blood loss, postoperative complications, range of motion, the Japanese Orthopaedic Association (JOA) score and walking ability.
The most frequent postoperative complication was delirium (4 cases). None of the postoperative complications were severe. The average knee extension was improved from
-11.1° to -3°, and the average JOA score was improved from 47.8 to 74.8. Finally, all of the patients were able to walk with or without assistive devices.
This group comprising patients older than 80 years was compared with a group aged 70-79 years (43 patients) treated during the same period. At the final investigation, the average JOA score in the latter group was higher than the score in the former group.
We conclude that TKA is a useful procedure for relieving pain and improving function in not only younger generation, but elderly patients.

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We report a patient who was treated with a pedicled latissimus dorsi myocutaneous flap for lack of skin and loss of elbow flexion after resection of a soft tissue sarcoma in the upper limb. The patient, a 71-year-old man, had a tumor in the distal part of the left upper limb. MRI imaging showed that the tumor was located deeply, and a needle biopsy revealed a diagnosis of myxofibrosarcoma. At the time of surgery, the tumor measured 9x6x6 cm and the patient complained of local pain and slight disturbance of the range of elbow flexion. We performed wide tumor resection and sacrificed all of the biceps, part of the brachialis and brachioradialis, and the musculocutaneous nerve. After tumor resection, to cover the skin defect and allow recovery of elbow flexion, we performed functional reconstruction using a pedicled latissimus dorsi musculocutaneous flap. At the last follow-up, one year after the operation, the patient was free of local recurrence and distant metastasis. The functional result was an ISOLS score of 86.7%. It has been reported that a pedicled latissimus dorsi myocutaneous flap is useful for covering a wide range of skin defects and for restoration of elbow flexion. A pedicled latissimus dorsi myocutaneous flap has an advantage in that the patient is able to flex the elbow using the flap in the early period after reconstruction surgery. In the present case, postoperative function was as good as in other reports, and we were able to confirm the early activity of the myocutaneous flap by needle EMG.

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We report a case of desmoid tumor originating from the peroneal nerve. The patient was an 18-year-old man who had been aware of pain in his left leg for 2 years. The pain had gradually increased, and he had also noticed paresthesia of left leg and a dropped foot 1 year later, and therefore consulted us. CT and MRI showed a 13x8-cm tumor on his buttock. This was diagnosed as desmoid tumor by open biopsy, and resection was performed. The tumor was resected en bloc with the peroneal nerve. Pathological examination revealed that the desmoid tumor had originated from the peroneal nerve. Currently, the dropped foot and paresthesia still remain, but the tumor has not recurred after two years of follow-up. However, careful long-term observation will be necessary.

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A 14-year-old boy with hemophilia A presented at our pediatric outpatient department because of pain of unknown cause in the left femoral region, which had subsequently developed into severe pain in the left inguinal region.
Upon admission, severe pain was evident upon flexion of the left hip and knees. Lower limb muscle force could not be measured, as the patient was unable to perform active movement. Paresthesia and hypesthesia were evident in the left anterior femur, and CT scan identified a hematoma in the left iliopsoas muscle.
Bed rest and supplementation of factor VIII were prescribed. Due to severe pain, inability to ambulate, and advanced neural disorder, a thrombectomy was performed on the second day of admission. Subsequently, pain upon extension of the left hip joint and paresthesia in the anterior femur decreased. At 7 months after the procedure, the sensory sluggishness had improved, the MMT score recovering to 4 in the left iliopsoas muscle and 4 in the quadriceps femoris muscle.
Iiliopsoas hematoma is a known complication of hemophilia. For a hemophiliac patient with accompanying femoral nerve paralysis due to iliopsoas hematoma, conservative treatment is generally chosen. However, early thrombectomy with sufficient supplementation of coagulation factors is desirable to avoid irreversible damage to the nerve if the pain is severe and accompanied by advanced paralysis.

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We report a case of extensive foot degloving injury including the plantar area, which was reconstructed with a free anterolateral thigh flap.
A 9-year-old boy was run over by a car on his way to school on foot, and sustained a degloving injury to his right leg. There was an open right tibial shaft fracture, right toe DIP disarticulation, and a sock-form degloving injury which extended from the distal leg to the toes. With external skeletal fixation, a full-thickness skin graft was performed for the distal leg and dorsal foot using exfoliated skin, and the plantar area was covered by artificial dermis in an emergency operation. Internal fixation of the tibia was performed with Ender nailing two weeks later. After one further week, we performed reconstructive surgery for the plantar area using a contralateral free anterolateral thigh flap. As equinus contracture developed, closed mobilization and external skeletal fixation of the ankle joint in a neutral position were performed four weeks after grafting of the free flap.
The patient became able to walk independently 5 months after initial surgery. At 13 months after surgery, ankle dorsiflexion and plantar flexion were 5 degrees and 60 degrees, respectively, showing a good postoperative course of bone union. Neither ulceration nor dyskeratosis was observed in the plantar area, except for a partial epidermolysis.
A free skin flap is used for extended soft tissue damage, whereas a medial plantar flap is considered to be the first option for reconstruction of the weight-bearing part of the foot sole. An anterolateral thigh flap is also useful, in addition to a latissimus dorsi flap and a scapular flap.

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Deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) are important complications in orthopedics. There is high risk of DVT or PTE in patients with hip fractures before surgery, but reports of such cases have been scarce.
We examined the incidence of preoperative DVT in 113 patients with hip fractures (34 males and 79 females, mean age 82 years). Computed tomography (CT) with contrast medium was used for diagnosis. The period from injury to CT was recorded, and D-dimer was assayed.
The incidence of DVT was 7.1% (8/113 patients). The average period from injury to CT was 3 days (from 0 to 20 days), and the average D-dimer level was 35.5μg/ml (from 0.9 to 289.0μg/ml) in the patients with DVT. There was no evident relationship between preoperative DVT and D-dimer level.
The results of this study indicate that preoperative DVT is not rare in patients with hip fracture, and that close attention must be paid to possible DVT from the time of injury.

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Background: The validity of fondaparinux and enoxaparin has been reported in the prevention of deep vein thronbosis and pulmonary embolism (DVT/PE) after total knee arthroplasty (TKA). We compared the effectiveness of early administration of these two drugs after TKA.
Methods: We studied 32 patients who underwent TKA in the period between May 2009 and May 2010. The operations were performed under general anesthesia and femoral nerve block, using an air tourniquet, and using cements for implant fixation. The patients were divided in two groups, use of 2.5mg fondaparinux once daily (Fa group), and use of 2000IU of enoxaparin twice daily (Ex group). The initial dose was administered between 12 and 21 hours after surgery and continued for 14 days. We compared the incidence of DVT/PE, bleeding complications, D dimer level, and hemoglobin (Hb) loss.
Results: DVT/PE occurred in 6 patients (38%) in the Fa group, and 3 (19%) in the Ex group. Bleeding complications occurred in none of the Fa group and 4 (25%) in the Ex group. There were no significant differences in D dimer level and Hb loss.
Conclusion: Our results indicate that enoxaparin decreases the incidence of DVT/PE compared with fondaparinux, but increases the bleeding complications.

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