The purpose of this study was to examine the correlation between lumbosacral spinal instability and pelvic inclination in patients with osteoarthritis of the hip.One hundred patients (9 males and 91 females, mean age 66) treated by total hip arthroplasty were investigated. The lumbosacral spinal instability was found in 43patients (43%).In the affected individuals, flexion contracture of the hip joint and pelvic anteversion occurred, but lumbar lordorsis and sagittal alignment did not change. The percentages of Crowe classification types Ⅲ and Ⅳ in the patients with lumbosacral spinal instability were significantly higher than those in the patients with no instability. Our results suggest that lumbar lordosis compensates for lumbosacral instability during the correction of sagittal alignment.

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Hybrid total knee arthroplasty (TKA) with an uncemented femoral component and a cemented tibial and patellar component has been performed to avoid the problems associated with uncemented fixation. We assessed the clinical results and radiographic features of 56 hybrid cruciate retaining TKAs with an average follow-up of 27 months. The mean age at surgery was 75 years. Range of motion and JOA score were evaluated clinically. The Knee Society roentgenographic evaluation system was used for radiological assessment.
The mean JOA score improved from 59.2 points preoperatively to 81.7 points postoperatively. One knee was revised due to septic loosening of the tibial component. No revisions were performed for aseptic loosening of the femoral component. The component position and alignment were approximately as planned preoperatively and were maintained until the final follow-up. An initial gap around the femoral component was noted in 11 knees (19.6%) and remained in 6 knees (10.6%) at the final follow-up. Radiolucent lines were noted in 23 knees (41.1%) on the medial side of the tibia. All radiolucent lines were less than 2 mm in width and showed no progression.
Hybrid TKA provides good results in selected cases. A longer follow-up is required to determine the advantages of hybrid TKA in terms of clinical outcome.

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We report two patients who developed osteonecrosis in the contralateral compartment after initial unicompartmental knee arthroplasty (UKA). The first patient was a 77-year-old woman with lateral compartment osteoarthritis of the left knee. She underwent lateral UKA and then 4 years and 2 months later, severe knee pain suddenly occurred due to osteonecrosis of the medial femoral condyle accompanied by collapse of the articular surface. We performed UKA in the medial compartment, and the symptom disappeared. The second patient was a 79-year-old man with medial compartment osteoarthritis of the left knee. He was treated with UKA, and after discharge he continued to use lateral wedge arch support on the basis of his own judgment. One month later, however, lateral knee pain occurred and progressed rapidly. Because severe collapse of the lateral femoral condyle was observed, we performed additional UKA in the lateral compartment.
The symptom disappeared without any decrease in the range of motion. We think that osteonecrosis in the contralatelal compartment may occur as a complication after UKA because of the postoperative increase in loading due to changes in leg alignment. Our results suggest that additional UKA is a useful therapeutic option for this complication as it is not surgically invasive and yields excellent postoperative knee function.

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Background : A multidisciplinary approach has been shown to be effective for treatment of intractable pain. However, few hospitals in Japan have established liaison clinics for such patients. We investigated the short-term results of a liaison clinic for patients with intractable chronic pain.
Methods : This study included 32 outpatients (11 males, 21 females) with intractable chronic pain who visited to our hospital between April 2012 and June 2012. At the baseline, patients completed a self-reported questionnaire and provided demographic and clinical information. Experts in various fields (anesthesia, orthopaedic surgery, psychiatry, physical therapy, and nursing) examined the patients and attended the conference once a week. At the conference we discussed the physical, psychological, and social problem of the patients and decided on courses of treatment. The degree of catastrophizing was measured using the Pain Catastrophizing Scale (PCS). Psychological co-morbidity was evaluated using the Hospital Anxiety Depression Scale (HADS) , and functional disability was measured using both the Pain Disability Assessment Scale (PDAS) and the Oswestry Disability Index (ODI). Clinical severity was assessed using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ).
Results : After a follow-up period of three months, there was no significant change in the scores for the PDAS, HADS for depression, ODI or JOACMEQ. Both PCS and HADS for anxiety were significantly decreased after three months of treatment. Lumbar function assessed by the JOABPEQ was significantly improved after three months of treatment.
Conclusions : This liaison clinic for patients with intractable chronic pain was able to improve the patients' lumbar function and anxiety.

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We report the results of surgical treatment for patellar lower pole fracture with patella baja employing the modified Mclaughlin procedure using a cable wire.
Because patellar lower pole fracture is associated with a small distalis bone chip, fixation using a wire circlage may be insufficient. Also, as patella baja results in quadriceps femoris muscle atrophy, surgery may become difficult because of flexural limitation.
We report a 78-year-old man who suffered a fall and a patellar lower pole fracture manifested by hyperflexion of the right knee. There was right tibial tubercle avulsion next after excision of a right femoral region liposarcoma, and patella baja was evident. The K-wire implant from the distalis side was difficult for a flexural limit, and the distalis bone chip was small, and fixation by the wire circlage was insufficient.Therefore we performed osteosynthesis through the patella and tibial tubercle, and synostosis and a good result was obtained by the Mclaughlin procedure using a cable wire.
However, when we employ the modified Mclaughlin procedure for patellar lower pole fracture, we need to insert a screw to the tibial tubercle and remove the implants early if there is the risk of cut-out after operation for bone fragility of the tibia and the patella.

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We report a case of pes anserinus syndrome after unicompartmental knee arthroplasty (UKA). The patient, a 79-year-old woman, had undergone UKA on right side for osteoarthritis of the knee. Three weeks after the operation, she complained of snapping symptoms in the medial part of the right knee, which had not been evident before the operation. X-ray and CT examinations suggested that the problem had been elicited by popping of the semitendinosus and gracilis over osteophytes in the joint, which had not been sufficiently dissected during surgery. As conservative treatment for eight months after UKA failed to relieve the symptoms, resection of the osteophytes was undertaken. Postoperatively, the snapping symptoms disappeared and the patient currently remains symptom-free. This was a rare case of snapping knee caused by improvement of knee alignment and range of motion, and the presence of osteophytes that had not been problematic before UKA.

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Total knee arthroplasty (TKA) for patients with severe varus deformity has become common operation in Japan because of the rapid aging of the population. Treatment of severe malalignment, instability and bone defects is important. Here we report the clinical results of total knee arthroplasty for 23 knees with severe varus deformity. We defined a severe varus knee femorotibial angle (FTA) as one exceeding 195 degrees. The average observation period was 64 months. Autologous bone graft was performed for 3 knees, and augmentation and long tibia stem was used for 3 knees. We used SF-36 for clinical evaluation. Image assessment was based on the standing HKA (Hip-Knee-Ankle) angle, and the Knee Society TKA roentgenographic evaluation and scoring system. The mean SF-36 score improved from 47.6 points to 63.7 points after TKA. The standing mean HKA angle was 204° (range 197° to 215°) before surgery and was corrected to 185° (range 176° to 195°). The post-operative standing HKA angle was classified as following 3 groups : HKA≧184°, 184°>HKA≧177°, HKA≦176°. A clear zone appeared in zone1 on tibia APX-ray in 4 knees belonging to the HKA≧184° group. Our 23 knees achieved good results, and careful postoperative observation is still necessary especially in the varus group.

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Total knee arthroplasty (TKA) following high tibial osteotomy (HTO) is a challenging operation due to deformation of the proximal tibia and an altered soft tissue balance. We have experienced 3 patients required early revision TKA because of loosening of a tibial component. The purpose of this study was to clarify the cause of early loosening of the tibial component in TKA following HTO.
Thirteen patients who underwent TKA following HTO were included in this study. Three cases with early loosening of the tibial component were retrospectively compared with 10 controls without loosening. There were no significant differences in preoperative deformity of the proximal tibia, surgical procedures, and postoperative component fixation angles between the groups. All cases with early loosening of the tibial component were used minimally invasive surgery (MIS) tibial component, whereas no loosening was found in conventional components.
It has been reported that some tibial components for MIS TKA are beneficial for avoiding interference with the lateral cortex. However, we have experienced 3 patients required early revision TKA because of loosening of a MIS tibial component. It is concluded that early loosening might be caused by insufficient fixation resulting from the design of the MIS component itself.

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We report the short-term results of hip arthroplasty using a cementless cup with bulk structural autogenous grafts from the femoral head in 12 joints. The mean follow-up time was 3.5 years. The mean JOA score increased from 44 points preoperatively to 86 points at the time of final follow-up. Radiographic analysis showed bone union of the bone graft in all cases.

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Iliopectineal bursitis is a rare disease associated with various hip disorders. We report a case of impaired blood flow due to iliopectineal bursitis in a patient with osteoarthritis of the hip.
An 85-year-old man was admitted to our hospital because of right leg pain and edema. Radiographic findings showed osteoarthritis of the right hip. Ultrasound imaging of the hip revealed right iliopectineal bursitis compressing the right femoral vein. Aspiration of the iliopectineal bursitis was performed and its size was reduced for a while, but relapse soon occurred. Total hip arthroplasty (THA) and partial bursectomy were indicated for the painful bursitis.
In cases of impaired blood flow due to iliopectineal bursitis, aspiration of the bursitis is associated with risks of recurrence and deep vein thrombosis. Treatments for hip disease such as THA and bursectomy should be considered in cases of severe iliopectineal bursitis with vessel compression.

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Leg pain in children, described as“growing pains”, is a frequent clinical presentation. Growing pains include pain late in the day, pain not specifically related to joints, and intermittent manifestation with symptom-free intervals. Physical examination, laboratory tests, and roentgenography show no abnormality. There is no single diagnostic test or criteria for growing pains. Therefore I have proposed new diagnostic criteria which incorporate four conditions as follows : leg-pain less than eight hours in duration, no complaints at visiting hospital, no abnormal findings of physical examination, and normal roentgenograms. If these four conditions can be satisfied, then a clinical diagnosis of growing pains can be made. A retrospective study based on these criteria covering a period of one year demonstrated that the sensitivity of the criteria was 93% and the specificity was 94%. A prospective study covering another year demonstrated the sensitivity of 92% and the specificity of 83%. These new criteria are useful for diagnosis of growing pains.

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We report five cases of rickets presenting initially at a department of orthopaedic surgery with a chief complaint of bowleg. Two cases were nutritional rickets and three were hypophosphatemic rickets. The patients comprised two males and three females with an average age of two years and three months. In all cases, X-ray examination of the legs showed the typical signs of rickets such as cupping, flaring and fraying at the metaphysis. The average femorotibial angle (FTA) was 198.3 degrees (192-210 degrees). Three cases were treated by administration of vitamin D under the supervision of a pediatrician.
Nutritional rickets has recently been increasing because of vitamin D deficiency in the diet resulting from absence of milk or eggs in individuals with food allergy. Ultraviolet phobia can also result in vitamin D deficiency due to disturbance of vitamin D metabolism. In patients presenting with bowleg, rickets may be considered. X-ray findings such as cupping, fraying and flaring are typical signs of rickets and useful for diagnosis.

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The present study was conducted to compare the diagnostic accuracy of magnetic resonance imaging (MRI) and ultrasonography (US) for detecting rotator cuff tears. A total of 42 cases for which shoulder arthroscopic surgery was performed were examined preoperatively using MRI and US. Subscapularis tendon tears were identified by MRI with a sensitivity, specificity and accuracy of 72.2%, 95.8% and 85.7%, respectively, and by US with corresponding values of 61.1%, 95.8% and 81.0%, respectively. Supraspinatus tendon tears were identified by MRI with a sensitivity, specificity and accuracy of 97.1%, 87.5% and 95.2%, respectively, and by US with corresponding values of 91.2%, 100% and 92.9%, respectively. No significant differences were observed between the MRI and US for all evaluations. Our results suggest that US is useful for diagnosis of supraspinatus tendon tears, and equally as useful as MRI. On the other hand, both methods were not sufficient for diagnosis of subscapularis tendon tears. In conclusion, US may be helpful as a screening examination for detection of a rotator cuff tear. However, if the findings are negative, then the possibility of a subscapularis tendon tear should be considered.

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The purpose of this study was to investigate clinical outcomes after arthroscopic superior capsular reconstruction (ASCR) for irreparable rotator cuff tear. A consecutive series of 12 shoulders (5 males and 7 females, average age : 70 years) between 2009 and 2012 was evaluated on the basis of preoperative and postoperative factors (JOA score, range of motion (ROM), magnetic resonance imaging (MRI) etc.) at an average of 17.4 months after surgery. The JOA score increased from 52 points preoperatively to 79 points postoperatively. Postoperative ROM in flexion (143°) and abduction (107°) was significantly higher than preoperative ROM (flexion 115°, abduction78°). Among 11 shoulders for which postoperative MRI was possible 12 months after surgery, 8 cases were type 1-3 and 3 were type 5 according to Sugaya's classification. When treating an irreparable rotator cuff tear, it is often difficult to maintain the integrity of the repair because of fatty degeneration and muscle atrophy. ASCR is considered capable of improving superior glenohumeral stability and shoulder joint function in patients with irreparable rotator cuff tear.

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An 83-year-old male presented two years after developing pain in the right shoulder joint without apparent cause. Shoulder hemarthrosis was confirmed by arthrocentesis at a local clinic. Although hemorrhagic synovial fluid was aspirated by arthrocentesis several times, the hemarthrosis recurred repeatedly and the patient was referred to our institution. Physical examination demonstrated swelling of the right shoulder joint and a significantly restricted range of motion. Blood tests showed no coagulation abnormalities. Plain X-ray showed degenerative changes in the glenohumeral joint. MRI indicated joint effusion, proliferation of the synovium, and a massive rotator cuff tear. After preoperative transarterial embolization for control of hemorrhage, shoulder arthroscopy was performed, and this revealed proliferation of the enlarged synovium, and absence of cartilages in the humeral head and glenoid. Synovectomy was performed as far as possible. Pathological examination demonstrated chronic synovitis, but no abnormal synovial cells were found. One year postoperatively, no hemarthrosis has been evident and the pain has been relieved, although range of motion is still restricted. Non-traumatic shoulder hemarthrosis is relatively rare. The present case was diagnosed to be shoulder hemarthrosis associated with cuff tear arthropathy, based on imaging and pathologic findings. Embolization and arthroscopic synovectomy achieved a favorable treatment outcome.

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A 58-year-old woman suffered a coronal shear fracture at the distal end of the humerus. Olecranon osteotomy was used for repair. The fracture surfaces were freshened, and the fragment was fixed to the humerus with two screws, which were seated below the articular surface. At 2 weeks, gentle active motion was allowed to minimize any adhesion formation. The duration of follow-up at the most recent physical examination was 20 months. The range of elbow motion was from -5 to 140 degrees, and the patient had no pain. She obtained union of the fracture and a good functional result, with a JOA score of 96. She was pleased with the surgical result. Olecranon osteotomy is useful for treatment of coronal shear fracture at the distal end of the humerus.

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Desmoplastic fibroma (DF) is an extremely rare locally aggressive bone tumor. We report a case of multiple recurrence of a DF that developed in the right distal radius of an 11-year-old boy who had fallen from a slide and landed on his right hand. He sustained a fracture of the right distal radius, and intrafocal pinning from the dorsal side was performed at a nearby hospital. Six weeks after surgery, bone union was completed. However, during 10 months after surgery, his wrist gradually swelled and he visited our hospital. Radiography revealed a radiolucent lesion with expansive, well-defined, marginal sclerosis. Computed tomography and magnetic resonance imaging revealed that the tumor, measuring 40x30x27mm, was located in the distal radius, had destroyed the volar cortex, and extended into the soft tissue. The tumor was subsequently diagnosed as a DF by needle biopsy, and was treated by marginal excision, surgical curettage, and packing with artificial bone and an iliac bone autograft. However, the tumor recurred and had to be excised 3 times after the first operation. We observed the natural history of the tumor after the fourth recurrence because there was no loss of motor function and no symptoms.
DFs show a high rate of recurrence. It was difficult to extensively resect the tumor in the present case because of associated anatomical problems and potential loss of function after surgery, and the age of the patient discouraged us from using chemotherapy or radiation therapy. Preservation of motor function remains a high treatment priority, and a multidisciplinary approach involving chemotherapy, radiotherapy, and medication should be used in combination with wide resection whenever possible.

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A 12-year-old boy fell while playing football, injuring his left knee joint. About 4 months later, he visited our hospital because the knee joint had suddenly “locked”, making extension impossible.
On examination, the range of motion was -60 degrees of extension, and 145 degrees of flexion without any sign of inflammation or fluid retention.
CT and MRI views of the knee joint revealed a bone tumor (exostosis) at the medio-proximal site of the tibia.
Suspecting this tumor to be the cause of the locked knee, we immediately performed surgical exploration of the knee joint, and noted a bone tumor with a hook-shaped cartilaginous cap on the top, arising from the attachment of the pes anserinus, and also noted that the tendons in the pes anserinus had been partially injured.
These findings revealed that the mechanism responsible for knee locking had been trapping of the tendons in the pes anserinus by the bone tumor. We therefore excised and removed the bone tumor.
After surgery, the patient recovered well, regaining the full range of knee joint motion.
We are confident that surgical excision of this type of bone exostosis may be the first choice of treatment for some cases of locked knee.

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Spinal cord tumor is divided into three types in its location ; intramedullary tumor, intradural extramedullary tumor, and extradural tumor. Dumbbell tumor has been known as a special type of spinal cord tumor which has both a component within the canal and a component in the paravertebral space linked by tumor traversing the neural exit foramen. We examined six cases of spinal cord dumbbell tumor which were treated surgically. We investigated these cases about pathological diagnosis, spinal level of tumor origin, Toyama classification of dumbbell tumor, surgical approach and recovery rates with Japan Orthopaedic Association scoring system(JOA score). We observed one cavernous hemangioma, one granular cell tumor and four schwannomas. Of six cases, one was origined in the cervical spine, four were in the thoracic, and one was in the lumbar. Based on Toyama classification, typeⅢb was found in three cases. TypeⅡa, Ⅱc and Ⅲa was found in one case respectively. Three cases of type Ⅲb were performed surgery with posterior and anterior approach and other three cases with posterior approach. The average recovery rate of the six cases was 60.5% using the Hirabayashi method. All cases showed neither the progress of the spinal deformity, nor neurological deficit, nor recurrence during follow-up period.

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We describe six patients with retroodontoid pseudotumor and cervical myelopathy treated by surgery. Two patients had rheumatoid arthritis and two had previously undergone cervical laminoplasty. Occipitocervical posterior fusion and laminectomy of the atlas were performed in all patients, and this led to pseudotumor regression and neurological improvement in all cases. One hundred and one patients underwent spinous process-splitting cervical laminoplasty and were followed up for over one year at our hospital. In eleven patients, retroodontoid pseudotumor progressed, and in three patients the spinal cord was compressed. In these patients, long-term mechanical stress on the occipitoaxis through a decrease of ROM in the middle and lower cervical spine was thought to have been responsible for progression of the pseudotumor.

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A 73-year-old woman fell backward from a standing position onto a chair 50cm in height.
During the week after injury, her back pain gradually increased without any neurologic symptom. MRI showed a Th11 vertebral fracture and she was admitted to our hospital. Computed tomography (CT) revealed a fracture line that extended from the Th11 vertebra to the Th9 spinous process, with ossification of the anterior longitudinal ligament (OALL) from Th6 to L1, thus satisfying the criteria for diffuse idiopathic skeletal hyperostosis (DISH). There was no deficit in the vertebral wall, or any compression of the spinal cord. Three weeks after the injury, we performed balloon kyphoplasty because 1) conservative treatment for this 3-column injury with DISH would have required a long period of bed rest and carried a high risk of non-union, 2) there was minimal bone loss in the vertebral body, and 3) delayed anterior cement dislocation would have been less likely due to massive OALL. On the first postoperative day, the patient's back pain was relieved and she started walking with a hard brace. Two months after the operation, the brace was successfully removed because bone union had been confirmed by CT. Although vertebral fractures with DISH often require instrumentation surgery, BKP can be a good choice in carefully selected patients.

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The purpose of this study was to evaluate the results of surgical treatments for distal clavicular fractures using an acromioclavicular plate. We treated 14 cases of distal clavicular fracture. According to the Craig-Takubo classification, one fracture was Type Ⅱa, five were Type Ⅱb, six were Type V, and one was Type IV. Operations were performed under general anesthesia using an acromioclavicular plate. After surgery, all shoulders were fixed with a sling for one week, and shoulder use under 90 degrees of flexion and abduction was allowed until removal of the plate. In all cases except for one, the acromioclavicular plate was removed within 6 months, and patients performed shoulder exercise on their own. The average period until removal of the acromioclavicular plate was 5.4 months. Bone union was obtained in a cases. There were no cases of refracture after plate removal, and no cut-out of the plate hook at the acromion. The average range of shoulder motion was 170 degrees in flexion and 58 degrees in extended motion. We observed a bone defect at the acromion, which had been created by the hook of the acromioclavicular plate, but this became unclear within 3 months after plate removal. Problems associated with the acromioclavicular plate included limited shoulder motion until plate removal, and persistence of the bone hole in the acromion for several months. The acromioclavicular plate might be a useful internal fixator because of its strong fixation and simplicity of application.

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Femoral nerve block is generally performed via peripheral nerve block for postoperative analgesia after internal fixation for femoral trochanteric fracture.
We describe 20 such cases, for which only femoral nerve block was used in ten, and femoral nerve block and sciatic nerve block by the parasacral approach in the other ten, at random, after internal fixation of trochanteric fractures using short femoral nails.
There were no differences among three patients who received diclofenac suppositories within 12 hours after the operation.
In elderly patients with femoral trochanteric fracture, sciatic nerve block is unnecessary, and femoral nerve block alone is sufficient.
However, in younger patients, discretion is required with regard to the form of analgesia used.

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Proximal femoral fractures in children are not so common, and therefore previous reports of this fracture are scarce, with some inconsistent results and complications.
Generally, most of such fractures in children reunite promptly themselves, but proximal femoral fractures in children have a high risk of complications, such as faulty union, malunion, vascular necrosis etc. at the fracture site.
Recently, we experienced a case of proximal femoral fracture (TypeⅢ, according to the Delbet-Colona classification) in a 12-year-old boy.
This patient was immediately treated by surgical reduction and internal fixation with 2 hook-pins under general anesthesia. Post-operative recovery was good and uneventful.
Now, at 8 months after the operation, the patient has recovered well, is able to play baseball without any pain, and has no complications so far.

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Stress fractures of the lateral malleolus of the ankle joint are rare. Almost all cases are treated conservatively, for example with a casting and/or protected weight-bearing. We report a case of stress fracture of the lateral malleolus of the ankle joint for which correction osteotomy was needed. The patient, a 41-year-old woman, complained of pain in her right ankle after she had starting jogging one month previously. X-ray and CT examinations revealed a distal fibula fracture. X-ray showed a sclerotic change valgus angulation deformity, which seemed to put the malleolus at risk of stress fracture.Therefore, we performed surgical correction.

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