Purpose : In cases of fracture of the distal end of the humerus in the elderly, dislocation and/or non-union of the joint tend to occur due to fragility of the bones, which makes conventional fixation treatment difficult. Our institution has been employing an ONI trascondylar plate for fractures in patients 70 years and older, and here we evaluated the clinical usefulness of the plate.
Materials and Methods : We evaluated 7 elbows of 7 patients (3 men and 4 women) who were treated surgically between June 2005 and August 2008 (mean age at surgery : 80 years, range : 72-85 years). The mean follow-up period after surgery was 11.7 months (range : 2-55 months). AO classification of the fracture type was A2 in 5 patients, A3 in 1 patient, and C2 in 1 patient.
Results : The mean postoperative external fixation period was 2.7 weeks (range : 2-4 weeks). Favorable treatment outcome means were obtained, with an elbow motion range of 118 degrees (range : 95-140 degrees) at flexion and -20 degrees (range : -30 to -5 degrees) at extension, and a Japanese Orthopaedic Association (JOA) score of 90.3 points (range : 78-96 points) at final observation. One patient with a C2 fracture type had non-fusion of the bone.
Conclusion : An ONI trascondylar plate is considered effective for treatment of distal-end humerus fracture in elderly patients, although an internal plate is considered necessary for AO classification type C fracture.

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We describe a case of recurrent and intractable giant cell tumor of the tendon sheath (GCTTS). The patient was 40-year-old woman who had suffered tumors in the left middle finger for 20 years, and had undergone surgical excision of the lesions on two occasions. At the time of consultation, diffuse tumors were evident at the proximal interphalangeal (PIP)-metacarpal phalangeal (MP) joint of the left middle finger. At surgery, we found that the tumor extended to the dorsal side of the PIP and the MP joint. The tumor and the tendon sheath were resected, and no recurrence has since been observed for two years. As the tumor showed a complex anatomical form, the previous excisions might have been insufficient. We consider that GCTTS should be subjected to long-term follow-up because of its high recurrence rate, and also the long period until recurrence.

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Habitual patellar dislocation is treated by surgical procedures such as proximal-realignment and distal realignment; however, it is difficult to cure this condition using either of these methods alone. Here we describe mobile-bearing total knee arthroplasty (TKA) for a case of severe knee osteoarthritis complicated by habitual patellar dislocation since childhood, for which good results were obtained without the need for any additional procedures.
The patient was an 82-year-old woman with severe pain in the left knee. During the initial examination, the range of motion of the left knee joint was －10° of extension to 140° of flexion, and the Japanese Orthopaedic Association (JOA) score for knee osteoarthritis was 40 points. Preoperative radiographs demonstrated a varus deformity in the left lower extremity with a femorotibial angle (FTA) of 188°, the axial view showed luxation of the patella.
We performed TKA using a mobile-bearing implant. Intraoperative findings revealed that the central articular surface of the distal femur had disappeared, and that the patellar articular surface was concave and dome-shaped. The lateral patellofemoral ligament was released; this procedure was identical to that performed in conventional TKA.
Postoperative radiographs showed good alignment, with a FTA of 172°. In the axial view, the patella was located in a reduced position at any angle of knee joint flexion.
The postoperative range of motion of the left knee joint was 0° of extension to 130° of flexion. The patient was able to walk without the support of a T-shaped cane.
There are many surgical treatments for habitual patellar dislocation. The appropriate treatment is selected according to the type and seriousness of the dislocation and the age of the patient.
From the findings of the present case, we believe that in a case of knee osteoarthritis complicated by habitual patellar dislocation, surgery performed using a mobile-bearing implant would eliminate the necessity of performing additional proximal realignment and distal realignment.

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Arthroscopic meniscal repair has been a common treatment for meniscal tears, and several techniques including all-inside, inside-out, and outside-in meniscal suturing are currently available. The FasT-Fix meniscal repair system (Smith and Nephew) is one of the major devices currently used for all-inside meniscal repairs.
Methods : We treated 21 knees of 21 patients (16 males and 5 females). The mean age of the patients at surgery was 23 years (range, 12 to 43 years), and the mean follow-up period was 7.2 months (range, 3 to 12 months). All meniscal tears treated by all-inside meniscal repair with the FasT-Fix suture device were evaluated retrospectively. There were 16 red-red zone tears, 8 red-white zone tears, and 1 white-white zone tear, including 6 bucket handle tears. Clinical results were assessed on the basis of the Lysholm knee score.
Results : The postoperative Lysholm scores were improved significantly (average: 75 before surgery and 97 after surgery). No case of postoperative extra- or intra-articular complication was encountered.

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We report the use of occipitoaxial fixation for recurrence of a foramen magnum tumor. A 72-year-old man underwent total resection of a foramen magnum schwannoma via a lateral approach. However, 32 months later, he was hospitalized with severe headache and paralysis of the right upper extremity. MRI showed recurrence of the tumor at the same level. The paralysis progressed and led to respiratory pentaplegia. We performed occipitoaxial pedicle screw fixation and tumor resection. At 19 months after re-operation there was no recurrence of the tumor and radiography revealed occipitoaxial bone union. The advantage of a lateral approach is that it gives good exposure of a tumor located at the anterior foramen magnum, there is no need for retraction of the spinal cord, and no risk of cerebrospinal fluid leakage or infection that often occurs when the anterior approach is used. The use of posterior cervical fixation for cervical spinal tumors is controversial. Here we performed posterior fixation in order to resect the facet joint at C2/3 to obtain good exposure for prevention of excessive bleeding from the extradural venous plexus.

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We evaluated the clinical results of microendoscopic surgery for lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LCS) in 44 patients (including 7 hemodialysis or renal transplantation patients), who were followed up to determine the degree of improvement in the JOA score, along with data obtained using a visual analog scale (VAS), the Roland-Morris Disability Questionnaire (RDQ), and the Self-Rating Depression Scale (SDS). The mean scores for the JOA, VAS, RDQ and SDS improved in patients who were not receiving hemodialysis, whereas hemodialysis or renal transplantation patients showed deterioration in the mean VAS for lower back pain and the RDQ. We investigated the instability of the lumbar spine using X-ray and magnetic resonance imaging (MRI), and found no significant deterioration. In this study, the relationship between lower back pain and instability of the lumbar spine was unclear, but we conclude that the long-term outcome of hemodialysis or renal transplantation patients requires more careful attention.

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The term “hangman's fracture,” describing traumatic spondylolisthesis of the axis, has been used since the original description in 1965 by Schneider et al. This retrospective study included 7 consecutive patients with hangman's fracture. There were 6 males and one female with a mean age of 51.7 years at surgery. The average follow-up period was 38.3 months (range 10-105 months). The cause of injury was a road traffic accident in 3 patients, a fall from height in 2 patients, sport in one patient, and other cause in the remaining patient. All the patients showed solid union with no implant failure. There were no neurological complications. Radiological evaluations showed an average angulation of 8.4 degrees and translation averaging 2.5 millimeters before surgery. The residual deformity after surgery averaged 1.0 degrees of angulation and 1.3 millimeters of translation. The average final residual deformity was 3.1 degrees of angulation and 1.3 millimeters of translation. Operative treatment of hangman's fracture achieved good clinical and radiological outcomes in this series.

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Dislocation fracture of the lumbosacral spine is a relatively rare lesion. Here we report two cases of this injury in patients with multiple trauma. Case 1 : A 38-year-old man who was injured when a heavy load fell onto his back. Radiographs demonstrated anterior displacement of the fifth vertebra with bilateral facet dislocation and left inferior facet fracture. Four days after the injury, the patient underwent posterior lumbar interbody fusion (PLIF). At the five-month follow-up, the patient was able to walk with a crutch, but right coxalgia persisted. Case 2 : A 39-year-old man who fell from a height of about 8 m. Radiographs showed bilateral-facet fracture dislocation. A posterior lumbar interbody fusion was performed on the day after injury. At the one-year follow-up point, the patient was able to walk alone and had returned to work at a construction site. For dislocation fracture of the lumbosacral spine, surgical treatment for reduction, stabilization, and interbody fusion has been recommended by several authors. We performed PLIF for two such cases, and obtained good short-term results.

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We treated 5 patients with femoral neck fracture using a conical stem combined with modular necks of different length and inclination (Modulus System, Lima Co. Italia) a between July and May 2010. The mean age at the time of surgery was 81 years, and the mean follow-up period was 113 days.
Walking ability was maintained in 3 of 5 patients post operatively. The first two cases showed more than 3mm sinking of the stem, but continuous sinking was not found after one month post operation. There was no relationship between stem sinking and the cortical index or canal flare index. Postoperative CT demonstrated a relationship of between the stem anteversion and the neck anteversion of the unaffected side. The use of a modularity stem was effective in reducing the risk of dislocation and the tension of the hip joint during operation.

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While bisphosphonates have been shown to decrease the risk of vertebral and femoral neck fractures in osteoporotic patients, recent reports have associated long-term use of bisphosphonate with low-energy diaphyseal femoral fracture.
This article describes a 68-year-old woman who presented with low-energy right femur fracture. She had been taking alendronate for treatment of steroid osteoporosis for 5 years and had a contralateral diaphyseal stress fracture at the time of the initial fracture. The stress fracture did not heal, and 1 year and 3 months later, she suffered sequential contralateral femoral fracture.
Several reports have recommended temporary or permanent discontinuation of bisphosphonate in such patients. However, the benefit of bisphosphonate for treatment of osteoporosis cannot be neglected.
As there is little likelihood that stress fracture can be cured, we recommend that prophylactic fixation should be considered if such a fracture is found in the contralateral limb.

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The purpose of this study is to evaluate the clinical results of treatment for proximal tibia fractures using a locking plate. We treated 11 patients (6 men and 5 women, mean age 69 years) between 2007 and 2009. The mean follow-up period was 11 months. The fracture type by the AO classification was 41-B2 in 2 cases, 41-B3 in 4 cases, 41-C2 in 1 case, and 41-C3 in 4 cases. The fractures united in all patients. When evaluated according to the Hohl and Luck criteria, functional results were excellent in 5 cases, good in 5, and fair in 1, and the anatomical results were excellent in 3 cases, good in 7, and fair in 1. In the latter (fair) case, reduction of the articular surface was poor during the operation. The articular surface step-off in this case was 4 mm after the operation. We conclude that a locking plate is useful for treatment of proximal tibia fractures, and that reduction of the articular surface is important for obtaining a good outcome.

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We investigated the clinical and radiological outcomes of 16 patients (male 13, female 3) with tibial shaft fractures that were treated using intramedullary nails between February 2008 and January 2010. The patients ranged in age from 15-75 years with a mean of 44.3 years. According to the AO classification, 3 cases were A1, 3 were A3, 2 were B1, 4 were B2, 1 was B3, 2 were C1 and 1 was C2. There were 5 open fractures. According to Gustiloʼs classification, 3 cases were typeⅠand 2 were typeⅡ. All patients were relieved of pain, and no clinical complications were observed. Bone union had occurred in 15 patients, but there was one case of delayed union which required bone graft five months after intramedullary nail fixation. We believe that reduction of the fracture and a correct surgical technique are important. We recommend that the guide pin should be inserted in the center of the distal fragment across the epiphyseal scar under fluoroscopy.

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Pain of the metacarpophalangeal (MP) joint is a common complaint, and most cases respond to conservative treatment. We have experienced three cases of MP joint injury that did not respond to conservative therapy and required surgery. The patients felt swelling and tenderness of the MP joint, and the range of joint motion was limited due to pain. All of the injuries had been caused by minor indirect trauma. The condition was difficult to diagnose from radiographs and MRI, but dye leakage was evident on arthrography of the MP joint in all cases. We diagnosed capsular rupture of the MP joint and performed debridment of the scar tissue with repair of the joint capsule. After surgery, all the patients were free of pain. Arthrography is effective for diagnosis of capsular rupture of the MP joint, and the present cases show that good results can be obtained with surgical therapy.

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Background: Wrist arthroscopy has been used successfully with many modifications and improvements, although distal radioulnar joint (DRUJ) arthroscopy is still uncommon. Here we studied the usefulness of DRUJ arthroscopy.
Patients and Methods: A total of 34 patients with ulnar-sided wrist pain who underwent both radiocarpal joint and DRUJ arthroscopy were studied retrospectively. The preoperative diagnoses included 24 cases of TFCC injury, 5 cases of ulnar head subluxation, 4 cases of ulnocarpal abutment syndrome, and 1 case of synovitis. Arthroscopic findings, the rate of visible foveal attachment, and the relationship between arthroscopic findings and pain were investigated.
Results: Arthroscopic findings of the DRUJ were normal in 10 cases, synovitis in 16, foveal tear in 9, disk tear in 5, and free body in 1. The total number of foveal tears was 13, although 4 could not be confirmed by arthroscopy. The fovea was visualized in 26 cases (76%). In 17 of 24 cases (71%), abnormality of the DRUJ was considered to have been the cause of ulnar-sided wrist pain.
Discussion: Although DRUJ arthroscopy is technically difficult, it is mandatory for the diagnosis and treatment of ulnar-sided wrist pain.

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Cases of simple injury to the medial meniscus without ligament damage are rarer in youths than injuries to the lateral meniscus. Here we report a case of simple injury to the medial meniscus that occurred bilaterally over a short time period in a 16-year-old male school baseball player, who initially suffered right knee pain upon sudden extension of the joint and became unable to walk. Arthrocele and restricted range of motion were confirmed, and blood without lipid droplets was sampled via aspiration. A simple bucket-handle tear of the medial meniscus was confirmed on MRI, and meniscus repair surgery performed. Ten months later, the patient suffered a similar tear in the contralateral medial meniscus via a similar mechanism of injury, and meniscus repair surgery was also performed. At 3 months postoperatively, the patient had no pain during motion and no re-tear.
Simple meniscus injuries are generally due to degenerative tears in the elderly or discoid meniscus injury. In young athletes, stress from inverted alignment of the legs and repetitious knee-in/toe-out movements during sport are likely contributory, and therefore leg posture safety training for such sports is recommended.

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Objective : To consider the additional effects of glucosamine hydrochloride on osteoarthritis of the knee (knee OA).
Subjects/Methods : The subjects were 20 middle-aged and elderly female patients with knee OA (mean age 73.1 years) undergoing conservative treatment, and a small-scale clinical test was conducted for three months.
The subjects were divided into a 750-mg (G750) group and a 1,500-mg (G1500) group according to the amount of glucosamine used, and evaluations of local findings, pain index (VAS : visual analog scale), questionnaire (JKOM : Japanese Knee Osteoarthritis Measure) and markers of bone and cartilage metabolism (COMP, CTX-2, C2C, hyaluronic acid, NTX, osteocalcin) were made once a month after the start of the test.
Results : The characteristics of the subjects in the G750 group were : mean age 74.8 yr, K-L grade II 2 knees, III 17 knees, and those in the G1500 group were : mean age 71.3 yr, K-L grade II 5 knees, III 12 knees. There were no significant differences between the groups. There was no significant change in local findings resulting from the use of glucosamine hydrochloride in either of the groups. The JKOM values improved significantly, compared to the values before use, for the items “stiffness/pain in the knee” and“condition of daily life”at three months in the G750 group (P=0.008) and after one month in the G1500 group (P=0.015). The VAS values were improved significantly, compared to the values before use, only in the G1500 group after two months (P=0.012). No significant change was seen in the markers of bone and cartilage metabolism in either group.
Conclusion : From the results of this small-scale study, additional effects of pain alleviation were seen by additional use of glucosamine in the conventional conservative treatment of knee OA.

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Soft tissue balance is one of the key factors affecting the clinical results of total knee arthroplasty (TKA). The purpose of this study was to evaluate the short-term results of total knee arthroplasty using a VANGUARD RP High-Flex knee system and soft tissue balance assessment using a tensor device and clinical transepicondylar axis. We carried out 47 TKAs in 37 patients (11 knees in 10 men and 36 knees in 27 women;mean patient age 74.3 years). The preoperative diagnosis was osteoarthritis in 41 cases, rheumatoid arthritis in 5, and osteonecrosis of the knee in 1.
The patients were evaluated postoperatively for change in range of motion (ROM), knee rating score, and also by radiographic analysis. The mean active preoperative knee extension was -10.2 degrees, and the mean active preoperative knee flexion was 114.2. Post-operatively, the range of knee extension was increased, and the knee rating score was improved from 60 to 85. None of the patients showed any problems with component angles on plain radiographs (α, β, γ and ∂ angles).
In this study, satisfactory early results were achieved for TKA with the VANGUARD RP High-Flex knee system. Our results suggest that EQUI-FLEX^TM and the clinical transepicondylar axis are useful for achieving good balance.

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The present study examined the clinical results of arthroscopic treatment for pyogenic arthritis of the knee. Between 2003 and 2010, 8 patients (8 knees) with pyogenic arthritis were treated by arthroscopic debridement. The patients comprised 4 males and 4 females, with a mean age of 63.2 years. The causes of infection were intra-articular infection in 5 knees and unknown in 3. The mean follow-up period was 12.5 months. Staphylococcus aureus was cultured in 3 knees and Streptococcus pneumoniae in 3. The other 2 patients had negative aspirate cultures. After arthroscopic debridement, all the knees were treated by irrigation.
None of the cases showed failure of initial treatment and required revision surgery. The functional results according to Ballard's evaluation were good in 6 knees, fair in 1 and poor in 1. Irrigation was initially performed in all knees. We believe that irrigation is indicated for patients in whom an early diagnosis can be established, and that early diagnosis and treatment are important.

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We report two cases of posterior shoulder instability due to playing baseball.
Case 1 : A 16-year-old boy experienced pain in the right shoulder when throwing a ball sidearm, in spite of usually pitching overhand. After the injury, he frequently felt shoulder pain during pitching. Jerk test demonstrated instability of the right shoulder. At six months after the injury, surgery was performed. Posterior capsular elongation was evident, and we performed arthroscopic capsulolabral plication without suture anchors. At three months after the operation, the patient was free of pain, and the jerk test gave a slightly positive result. Case 2 : An 18-year-old male felt left pain when swinging a bat during baseball practice. After the injury, he frequently felt pain during pitching and in daily life. Jerk test demonstrated instability of the left shoulder. At 4 years after the injury, surgery was performed, and this revealed a labral lesion in the posterior portion of the glenoid with posterior capsular elongation. We performed arthroscopic capsulolabral repair with suture anchors. At one year after the operation, the patient was free of pain during pitching and in daily life. Jerk test gave a negative result. These cases demonstrate that arthroscopic posterior capsulolabral plication and repair are useful for treatment of posterior shoulder instability.

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We present an arthroscopic technique for partial-thickness rotator cuff tears involving simultaneous arthroscopy and bursoscopy (DA technique). The surgical technique is described, and its benefits are discussed.
Eleven patients with partial-thickness rotator cuff tears were treated with the DA technique. There were 6 articular side tears and 5 bursal side tears. Mean age at the time of surgery was 67.5 years. For articular-side partial tears, the DA technique was introduced after routine diagnostic arthroscopy and acromioplasty. With visualization of both the intra-articular and subacromial sides, a suture anchor was passed through the remaining intact tendon, and inserted into the bone at the articular margin. Two spinal needles were passed through the full-thickness layer medial to the articular side tear in the same manner. Anchor sutures were relayed with PDS, which was introduced into the articular side through the spinal needles, and bought back into the subacromial space. Sutures were finally tied in the subacromial space. For bursal side tears, a suture anchors was inserted with subacrmoial bursoscopy. The DA technique was then applied, and sutures were placed at the appropriate location and tied securely with double vision.
The mean operation time was 144.9 min and there were no intraoperative complications. The mean JOA score for the seven patients after a minimum 6-month follow-up was improved from 68.3 to 90.3 points.
Transtendon repair for partial articular side tears is technically demanding, but this DA technique is safe and secure, with no blind processes.

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We present a new patch graft procedure using the quadriceps tendon (QT). The surgical procedures are described in detail and our preliminary results reported.
QT patch grafting was performed in 12 patients with an average age at operation of 68.3 years (range 45-82 years). Cuff repairability was evaluated by standard arthroscopic examinations. Subacromial decompression was done as needed. The size of the defect was measured, and the QT was harvested just above the patellar insertion. The QT patch was fixed to the torn edge of the cuff medially, and to the greater tuberosity with suture anchors laterally.
The mean operation time was 175.6 min (range 142-240 min). The mean JOA score was improved from 68.5 points preoperatively to 88.3 points postoperatively. Postoperative MRI showed 4 typeI cases, 7 typeII cases, and 1 typeV case according to Sugaya's classification.
A QT graft is thicker than the fascia lata, which is commonly used as patch material, and is expected to work as a depressor of the humeral head.

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We conducted a review of patients with rheumatoid arthritis who were able to discontinue treatment with biologic agents after achieving clinical remission. For assessment of the effect of biologic agents, the improvement ratio of MMP-3 was evaluated, as well as DAS28. The MMP-3 improvement ratio is calculated as the MMP-3 value after induction of biologic agents devided by the MMP-3 value just before starting biologic agents. The MMP-3 improvement ratio showed a very close correlation with the improvement of DAS28, and its decrease sensitively paralleled the amelioration of clinical symptoms, even after DAS28 had reached the remission level and no decrease was demonstrated. All of the patients were judged to no longer require biologic agents when DAS28 had fallen below 1.8 and the MMP-3 improvement ratio had fallen below 0.4 continuously for more than six months. All of the patients maintained tight disease control after discontinuation. The present findings suggest that MMP-3 is a very useful index for evaluation of rheumatoid arthritis control, and that its improvement ratio can be used to judge whether biologic agents can be dincontinued.

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We reported three cases of leg ulcer in patients with rheumatoid arthritis (RA) treated with low doses of methotrexate (MTX).
General conditions of all patients were stable and the activities of RA were well controlled. The ulcerations were induced by trauma or surgical intervention, however, there was no sign of cutaneous vasculitis. Skin ulcerations had been refractory to conserve therapy for over 5 months (Cases 1 and 2). After discontinuation of MTX, all cases were resolved successfully within 4 weeks.
It is considered that the toxicity of MTX probably delayed wound healing even at a low dose.

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Community-based screening for osteoporosis is vital for early prevention of low bone mineral density and minimizing the risk factor of fragility fracture among elderly and peri- and postmenopausal women. We investigated 602 women aged 30 years or older (mean age 61.2±9.1; range 33-81 years) who underwent screening for osteoporosis in Saijo, Ehime, Japan between 2000 and 2001. We evaluated the relationship between self-administered questionnaire responses and the findings of quantitative ultrasound (QUS) of calcaneous bone for all subjects. The self-administrated questionnaire included 23 items inquiring about exercise habits, milk consumption, emmenia, or parameters associated with actual skeletal status.
Bone mass showed a gradual decrease with each advancing age decade in all subjects. Additionally, bone mass was intimately related to history of fracture, history of osteoporosis, presence or absence of lower back pain, and some of the items related to actual skeletal status.
In conclusion, screening for osteoporosis using the QUS examination is valid for assessing osteoporosis and actual skeletal status in community-dwelling female residents.

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The reported incidence of deep venous thrombosis (DVT) in patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA) and hip fracture surgery is 40-60%, and data indicate that about 32% of patients die after developing symptomatic pulmonary thromboembolism (PTE). We performed revision-THA on a patient with alcoholic liver cirrhosis who had developed osteolysis after femoral head replacement at another hospital 15 years previously. The operation, taking 90 minutes, had involved only cup replacement via the posterior approach, and the intraoperative blood loss had been about 1300 ml. The patient started walking exercise on the following day, and was able to walk independently with a walker in the ward at seven days after surgery. The D-dimer level at one week after surgery was 16.8μg/ml, and angiographic computed tomography (CT) showed DVT in the anterior tibial veins of the affected leg and PTE in both inferior lobar branches of the pulmonary artery. We started anticoagulant therapy, and inserted an inferior vena cava filter on the following day. An angiographic CT reexamination one week later showed that the DVT was reduced and PTE had disappeared. This case did not require postoperative anticoagulant drugs because of the patient's bleeding tendency due to hepatic cirrhosis. Careful attention was required in this case, because asymptomatic PTE occurred despite the patient's bleeding tendency and early rehabilitation after the operation.

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