We report an 83-year-old female patient who developed pyogenic arthritis of both knee joints almost synchronously. She initially complained of right knee pain and became unable to walk. Pus was drained by arthrocentesis, and Streptococcus agalactiae was detected. MRI scan showed no evidence of osteomyelitis. Arthroscopic debridement and closed suction-irrigation were performed, and an antimicrobial agent was administered. On the same day the patient complained of left knee pain. Similarly, pus was drained by arthrocentesis and the same bacterium was detected. We treated this episode in the same way, and CT scan demonstrated no antecedent infection.
There are very few reports of pyogenic arthritis developing at almost at the same time in both knee joints. With regard to the pathogenetic mechanism in this case, we consider that bilateral infection arose hematogenously from an asymptomatic antecedent infection resulting from the process of healing of a patellar fracture and resulting weakened resistance.

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Postoperative pain of unknown origin can be a reason for revision of unicompartmental knee arthroplasty (UKA). We report a case of persistent knee pain after mobile UKA that was resolved by revision to fixed UKA. The patient, an 85-year-old woman, had undergone mobile UKA because of medial-type osteoarthritis in her left knee seven years previously. However, even after surgery, anterior knee pain had persisted despite of conservative treatment. Although neither loosening of the implant nor degenerative change in the unresurfaced area had been observed, revision arthroplasty was undertaken at the patientʼs request. During the revision operation, we found severe impingement of the mobile-bearing insert with fibrous tissue that had been produced in the anterior uncovered area of the medial femoral condyle, and carefully removed the mobile UKA implants, followed by successful revision to fixed UKA. Soon after the revision surgery, the patientʼs pain disappeared, and she recovered well without loss of range of knee motion. It should be noted that mobile UKA may cause anterior bearing impingement due to loss of implant coverage of the femoral condyle, especially when a single peg-type femoral component is placed in a flexion position, and that the conversion of mobile to fixed UKA can be a useful and less invasive therapeutic option for the treatment of anterior mobile bearing impingement after mobile UKA.

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We describe the outcome of 16 Miller-Galante unicompartmental knee arthroplasties (MG-Uni) carried out for osteoarthritis and osteonecrosis of the medial compartment. These operations were undertaken more than ten years ago at Niihama Kyoritsu Hospital by a single surgeon. The mean patient age at operation was 78.6 years (66-86 years). All the knees had an intact anterior cruciate ligament, full-thickness cartilage in the lateral compartment, and correctable varus deformity.
Two patients were transferred to another hospital, and 7 patients died. The mean time from surgery to death was 7.8 years (3 to 11). Six patients are alive and the mean time since surgery is 11.3 years (10 to 17 years). The mean age of the remaining patients is 88.5 years (77 to 94 years) and they are free from gonalgia. At the final radiographic evaluation, one knee had incomplete tibial radiolucency and two knees had slight polyethylene abrasion. Signs of a slight progression of osteoarthritis in the lateral component have been noted in two knees. No component shows evidence of loosening or alignment change.

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It has been reported that patients feel a degree of dissatisfaction after total knee arthroplasty (TKA) because of a sensation of instability during knee flexion. The ATTUNE^TM Total Knee System (DePuy) has been newly developed to stabilize and reproduce smooth motion during knee kinematics. This system offers many sizes of implants and inserts according to individual patient variations. We evaluated the kinematics of this type of knee implant with small variations of the inserts using an intraoperative navigation system. ATTUNE^TM TKA was performed in 3 knees with osteoarthritis. These TKAs were evaluated for knee kinematics, especially flexion/extension gap (FEG), anterior-posterior translation (APT), and axial rotation (AR), using an imageless navigation system (Kolibri). In the cruciate retaining (CR) type, no medial pivot motion was observed, and thus the kinematics showed a bicondylar roll-back pattern when the joint gap was tight. However, a medial pivot and decreased bicondylar roll-back pattern was shown when the joint gap was reduced with a 1-mm thinner insert to regulate the appropriate ligament balancing, even in the same knee. In the posterior stabilized (PS) type, the knee kinematics showed a small APT and AR, and moreover, FEG was even throughout the whole range of motion.

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In total knee arthroplasty (TKA), it is technically challenging to manage bone defects on the medial tibial plateau associated with severe varus deformity. Treatments for bone defects include cement filling, bone autografts, and metal augments. Suitable options were selected depending on the size of the defects and patient age. Stem extension was added for all the cases to improve initial fixation. We assessed the clinical and radiologic effects on the addition of stem extension to the tibial component in 10 knees with proximal tibial bone defect.
Four knees with bone defects of less than 5 mm were managed by cement filling. For bone defects larger than 5 mm, 3 patients under 65 years old were treated with autologous bone grafts, and 3 patients over 65 years old had metal augmentations.
The mean JOA score improved from 48.3 points preoperatively to 75.7 points postoperatively. The range of motion and femorotibial angle also improved postoperatively. The implanted positions of the femoral and tibial components were maintained on radiographs at the final follow-up. Although localized radiolucent lines were noted in 4 knees (40.0%) on the medial side of tibia, they was no progressive loosening of the bone-cement interface requiring revision surgery.
The use of stem extensions in patients with bone defects is helpful for secure fixation of the tibial component. Long-term study is required to evaluate the stress shielding effect of the long stem on tibial bone loss and implant survival.

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One of the common problems of total hip arthroplasty (THA) for hip dysplasia is insufficient acetabular bone coverage. We have performed reaming bone grafting (RBG) for acetabular bone defects localized at the superolateral to superior acetabular ridge (outer type). The objective of this study was to evaluate the short-term results of RBG for the outer type.
Eight hips in 8 patients who underwent outer-type RBG for primary THA between January 2012 and January 2013 were included. In 7 of these hips, the bone grafts showed bony incorporation. Only in one hip was the bone graft completely absorbed. The graft survival rate was 87.5%.
RBG is not technically difficult, and makes it easier to achieve bony incorporation than bulky bone grafting. However, in a few cases, the bone grafts are absorbed. One of the most important factors that predicts a good result is initial fixation to obtain rigid cup stability. If the indications are properly chosen, RBG is one of the most useful methods for recovery of acetabular bone stock.

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The purpose of this study was to examine changes in pelvic inclination and spino-pelvic alignment about the pelvic tilt in individuals with severe posterior pelvic inclination after total hip arthroplasty. We treated six patients with severe posterior pelvic inclination (6 males, mean age 75 years), to create a pelvic inclination of 35 degrees in the upright position.
We evaluated the pelvic inclination angle (PIA), anterior pelvic plane (APP), length from the C7 plumb line to the hip axis (C7-HA), and compared the preoperative state with that at one year postoperatively.
Postoperatively, we classified the patients into two groups : three with posterior pelvic inclination, and three with anterior pelvic inclination.
Changes in each of the parameters (posterior pelvic inclination groups/anterior pelvic inclination groups) included PIA in the decubitus position 8.2°/1.3°, PIA in the upright position 4.0°/-6.2°, APP-0.4°/8.0°, and C7-HA-18.8mm/-40.1mm.
In the posterior pelvic inclination groups, lumbar lordosis decreased and C7-HA moved backwards. In the other groups, C7-HA moved forward.
We expected that posterior pelvic inclination would become more severe after THA. However, posterior pelvic inclination did not change in half of the patients. Thus we found that postoperative pelvic inclination does not change greatly.

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Jehovah's Witnesses refuse blood transfusions on the basis of their religious belief. We report our experience with total hip arthroplasty without blood transfusion in a Jehovah's Witness.
The patient was a 70-year-old woman who had been receiving treatment for rheumatoid arthritis for 34 year and had been taking anti-platelet agents for atrial fibrillation and hypertension. Plain radiographs revealed severe erosions (Larsen Grade 4) in the right hip. We used a cemented femoral component and reamed the acetabulum gently to minimize any bleeding, while performing intraoperative blood-salvaging autotransfusion.
We carried out hybrid total hip arthroplasty with a cementless acetabular component and a cemented femoral component. The operation time was 62 minutes, intraoperative blood loss was 50ml, and postoperative blood loss was 90ml. The preoperative hemoglobin level was 9.9g/dl, and the lowest hemoglobin level was 6.8g/dl after surgery. At the final follow-up, the patient was able to walk with a T-shaped walking stick, and her Japanese Orthopaedics Association score (right/left) was 80 points/81 points on.
We considered that the use of a cemented femoral component and gentle reaming of the acetabulum were factors that reduced bleeding during total hip arthroplasty.

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The purpose of this study was to compare the timing and rate of postoperative re-tear of arthroscopic rotator cuff repair with double-row repair (DR group) and suture bridge repair (SB group).
Seventy-two patients who had undergone arthroscopic rotator cuff repair with a minimum follow-up period of 12 months were enrolled in this study. The patients were divided into two groups according to the repair technique employed. There were 38 shoulders in the DR group (average age 66.7 years) and 34 shoulders in the SB group (average age 67.3 years). Clinical outcomes were evaluated by the JOA score. MRI was carried out just before starting active range of motion exercise, 6 and 12 months postoperatively. Re-tear patterns were evaluated as well as repair integrity on MRI.
The average size of the tear was 18.5 mm in the DR group and 22.1 mm in the SB group. The postoperative JOA score was significantly improved in both groups, but no significant differences were found between the two groups. At the latest follow-up, re-tear was noted in 8 shoulders (21.1%) in the DR group and 7 (20.6%) in the SB group, which was not significantly different. Early re-tear before the initiation of active exercise was found in only 2 shoulders in the DR group. With regard to the re-tear pattern, medial failure was more common in the SB group but the difference was not significant.
The SB technique did not improve the structural integrity of the repaired tendon. In this study, a large percentage of postoperative re-tears occurred after active exercise. Gentle protective rehabilitation would be needed to improve healing of the repaired cuff.

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We evaluated the clinical results of treatment for distal radius fracture with a palmar locking plate in 65 patients (17 men and 48 women). The average patient age at the time of surgery was 67.5 years, and the average follow-up period was 7.3 months. We used a P-plate (Meira Inc.) in all case. Fracture was classified using the AO classification. Type A included 46 cases, type B5 cases, and type C14 cases. We measured the radial inclination, ulnar variance, palmar tilt, and step of the articular side, and used the Mayo Wrist Score to evaluate the results. There was no large correction loss, and the Mayo Wrist Score was considered to be almost excellent. This result suggests that the P-plate has wide adaptation for the treatment of distal radius fracture.

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Fibro-osseous pseudotumor of the digit (FOPD), or heterotopic ossification closely related to myositis ossificans, occurs in the subcutaneous tissues of the digits. This tumor often appears as a painful and localized swelling in the soft tissues of the fingers.
We experienced a case of FOPD, without pain, in a 38-year-old man. who had been aware of a mass in his left index finger for the previous one year. No other symptoms were associated with the mass. Although we considered this tumor to be a kind of giant cell tumor, X-ray examination demonstrated calcification inside the tumor. We excised the tumor, and diagnosed it as a FOPD by histological examination.

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We evaluated the outcome of conservative treatment for SRE (skeletal related events) of the spine. Fifty-eight patients (32 men and 26 women, mean age 68 years) were treated at our institution between August 2012 and September 2013. The site of the primary tumor was the lung in 20 patients, breast in 11, prostate in 9, and other sites in 18. Instability of the spine was evaluated using the Spine Instability Neoplastic Score (SINS). Early mobilization was performed based on the stability of the spine estimated by SINS. Pain (Numerical Rating Scale (NRS)), imaging studies of the vertebral body, SINS, and ADL (Barthel Index (BI)) were evaluated at the start and at 1, 2, 3, 4, 6 months. NRS improved over time and in the imaging studies, bone formation was gradually observed in almost all cases after three months. SINS improved over time and about 90% of the patients were considered stable after three months. Although mean BI was 71 initially, it gradually improved and at the time of the last observation the mean BI was 82. Our data suggest that early mobilisation is safe and efficient for selected patients who have received conservative treatment for SRE (skeletal related events) of the spine.

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We recently encountered a rare case of intramedullary tumor of the thoracic spinal cord with large extramedullary lesions. The patient, a 70-year-old male, had experienced numbness of both lower extremities and spastic paresis with gait disturbance. Magnetic resonance imaging demonstrated a mass at Th2 that showed isointensity on T1-and hyperintensity on T2-weighted images. The lesion showed strong intramedullary enhancement, and extramedullary extension with a“snowman-like”shape. The associated spinal cord swelling was manifested as a high-intensity area on T2-weighted images. At surgery, a dark red extramedullary tumor was dissected and excised en bloc, and it was unclear whether this tumor was connected to the intramedullary tumor. Subsequently, the intramedullary tumor was revealed under the pia mater, and this was dissected from the spinal cord and excised en bloc. The histological features of the tumor were consistent with capillary hemangioma. Capillary hemangioma of the spinal cord is rare, but can be surgically removed and cured without adjuvant therapy. Magnetic resonance imaging appears useful for differential diagnosis.

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Objectives : Assessment of the accuracy and angle of cortical bone trajectory (CBT) screw implantation before and after introduction of preoperative three-dimensional (3D)-simulation.
Methods : Forty-eight screws (24 L4 screws and 24 L5 screws) used in 13 operations for lumbar decompression and fusion performed at our institution were analyzed using postoperative CT. Twenty-four screws used before and after the introduction of 3D-simulation (initial group and later group, respectively) were compared for 1) the number of deviations (Neoʼs criteria), 2) the laterally oriented angle on the axial plane, and 3) the cranially oriented angle on the sagittal plane.
Results : Three out of 24 screws in the initial group deviated medially (grade 1 : one screw, grade 2 : two screws) without clinical symptoms. In the later group, all 24 screws were properly inserted. The laterally oriented angle and cranially oriented angle at the L4 level in the initial group were 17.1°and 31.8°, respectively, whereas those in the later group were 14.5°and 30.6°, respectively. The corresponding angles at the L5 level in the initial group were 13.6°and 30.6°, respectively, and those in the later group were 15.3°and 28.3°, respectively.
Discussion : In conventional pedicle screw implantation, it is easy to correct the insertion point or angle using fluoroscopy. However, in CBT screw implantation, since a screw is inserted obliquely from both the sagittal and axial planes, the correct lateral orientation and screw entry point are difficult to determine from intraoperative fluoroscopy alone. Therefore, it is important to confirm not only the screw angles but also the insertion point and screw size in preoperative 3D-simulation in order to insert the CBT screws properly.

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We performed posterior spinal fusion with cortical bone trajectory screws (CBTs) in 5 patients (4 females, 1 male). The average age of the patients at surgery was 78 (range 65 to 89) years, and the average postoperative follow-up period was 12 (range 7 to 16) months. The average Japanese Orthopaedic Association Score was improved from 9.6 points preoperatively to 21.8 points postoperatively, although one patient developed MRSA infection after surgery. Postoperative computed tomography scanning revealed 4 cases of screw loosening in 2 patients. There were no other complications such as screw backout, fractures of the lamina around the screws, or nerve root injuries. The CBTs were designed to primarily utilize cortical bone of the lamina and pedicle, and to be placed in the medial to lateral direction as compared to conventional pedicle screws, which utilize cancellous bone in the pedicle and vertebrae by screw placement in a lateral to medial direction. The CBTs have pullout and toggle characteristics equivalent to those of conventional pedicle screws. The entry point on the lamina is located more medial by CBTs than by conventional pedicle screws. Therefore, wide exposure is unnecessary for placement of CBTs, thus minimizing surgical damage to the back muscles. Additional long-term follow-up will be needed to clarify the advantages or disadvantages associated with CBTs.

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The aim of this study was to investigate the relationship between prolongation of the cauda equina conduction time (CECT) by magnetic stimulation and the functional classification of neurogenic intermittent claudication due to lumbar spinal stenosis (LSS). The study subjects were 96 LSS patients who underwent spine surgery. LSS can be classified into three types : nerve root type, cauda equina type and mixed type. The mean CECT was 3.98 ms in the nerve root type, 5.68 ms in the cauda equina type and 5.05 ms in the mixed type. The differences between the types were significant. Among the three types, the claudication distance showed no significant difference with abnormal prolongation of CECT. For clinical assessment, the postoperative JOA score was significantly improved in all types, in comparison to the preoperative JOA score. In the nerve root type, CECT was not prolonged. In the cauda equina type, however, CECT was prolonged. CECT is useful for evaluation of cauda equina damage.

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Plain radiography in a sitting-supine position is useful for diagnosing acute osteoporotic vertebral fractures. However, its use for diagnosing pathological fractures due to metastatic spinal tumors has not been reported. Here we investigated morphologic changes in metastatic vertebral fractures using plain radiography with the patients in a sitting-supine position.
We performed radiographic analysis of 62 patients with metastatic spinal tumors, who were diagnosed by computed tomography, magnetic resonance imaging, and/or positron emission tomography. We obtained anteroposterior and lateral radiographs, and then compared sitting and supine radiographs to evaluate the presence of an unstable metastatic vertebral body.
There were 65 pathological fractures in 41 patients, and 27 unstable metastatic vertebral bodies in 24 patients. Instability was recognizable in 7 vertebral bodies only in anteroposterior radiographs. Twenty-two patients (91.7%) had pain on movement of the spine due to unstable collapsed vertebral bodies, of whom 8 (47.1%) had stable collapse, and 7 (33.3%) non-collapse.
Evaluation of metastatic vertebral body instability using this approach probably helps to determine the plan of treatment for metastatic spinal tumors.

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There are many difficulties in the treatment of fractures of the distal clavicle. Most of such fractures are intraarticular fractures, so the optimal treatment is anatomical reduction and internal fixation. Some surgeons use plate screws for achieving stability of the distal fragment. However, as screw fixation is sometimes weak, there is a need to insert many screws into the distal fragment, and treatment with tension band wires is performed. As we cannot use a clavicle plate, a tension band wire and strengthen cerclage wire. If good fixation stability is established early, ROM training can be inintiated, allowing good results and an early return to society.

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The purpose of this study was to evaluate the clinical results obtained with intramedullary fixation in comparison with plate fixation for midshaft clavicular fractures.
We treated 19 patients (including two, who had undergone only removal of implants) between October 2007 and July 2013. The mean age at surgery was 44.0 years.
Eight patients were treated by intramedullary fixation, and eleven by plate fixation. The mean period until bone union and implant removal was shorter in the intramedullary fixation group than in the plate fixation group. No significant inter-group difference was detected in the mean ratio of clavicle shortening. There was one case of refracture after implant removal in the plate fixation group, and one case of clavicle shortening in the intramedullary fixation group. In conclusion, it is important to select the most appropriate treatment method according to the form of fracture.

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We report the results of surgery for trochanteric fracture using a long nail in our hospital. Between April 2009 and March 2013, 22 patients with trochanteric fracture were treated by using a long nail. We were able to follow up 18 of these 22 patients (5 males and 13 females). The average age was 79 years (47-94 years). There were no complications before or after surgery, and the average surgery time was 78 minutes (50-165 minutes). Tip apex distance (TAD) was average 4.4 mm (2∼9 mm), and the average telescoping was 6.5 mm (0∼17 mm). Bone union was achieved in all cases except for two that could not be followed up sufficiently. Use a long nail for trochanteric fracture AO clarification A3 and A2 cases that the fracture line extend to subtrochanter, we obtained a good result without complications. As use of a long nail is associated with problems such as a long operation time and significant invasion, it is necessary to select its indications carefully.

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The standard treatment for femoral shaft fractures in preschool children is casting or traction. In this report, we present a case of femoral shaft fracture in a preschool child treated with the elastic nailing technique. The patient was a 4-year-old boy with a history of pervasive developmental disorder. He was brought to our hospital by ambulance after falling out of a second-story window at his house. He suffered severe head injury and a right femoral shaft fracture. We performed emergency surgery and treated the right femoral fracture by elastic nailing with a 2.4-mm Kirschner wire under general anesthesia. He started gait training at 4 weeks after surgery. Three months after surgery, we performed cranioplasty and removed the Kirschner wire from the right femur under general anesthesia. He had no leg length discrepancy or gait abnormality at 10 months after surgery. In this case, considering the benefit of patient management in an intensive care unit, we performed elastic nailing for the femoral shaft fracture. As a result, the patientʼs general condition improved rapidly and he started gait training at an early date. In conclusion, we recommend using elastic nailing for femoral shaft fractures in preschool children with head injury.

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For patients with pelvic fracture, it has become the usual practice to choose the model of damage control according to the individual situation. However, the timing of radical surgery has received little attention. We examined the timing of radical surgery, postoperative complications and changes in platelet count, CRP and albumin levels in blood of patients with pelvic fracture. The platelet count increased within an average of 2.4 days, and the CRP level peaked within an average of 3.7 days. The albumin level increased within an average of 4.9 days. Surgery was performed within an average of 8.9 days.
Pape et al. I expected a peak of the SIRS with level of L-6. Matsuoka et al. expected a peak of the SIRS with platelet count and CRP. A albumin and CRP are acute-phase proteins. Therefore decrease of CRP and increase of albumin appear, inflammation calmed down, and it is the timing called of window of opportunity.
In this series, increase of albumin and the decrease of CRP appear on day 5-10 after injury, and we perfomed surgery 8.9 days.

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Treatment of talus fractures with dislocation is challenging. We report three such cases (talar neck fracture 2 cases, talar body fracture 1 case). In all patients, urgent open reductions and fixations were performed under general anesthesia. The patients were followed up for an average of 8.7 months (range 6-10 months) after injury. All of the fractures healed anatomically without malunion. Post-traumatic arthritis and avascular necrosis were not observed. Urgent reduction of the fracture dislocation and fixation may minimize complications and provide good clinical outcomes.

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[Objective] We report a case of open rupture of lateral collateral ligament of the ankle joint. [Case] A 13-year-old girl sustained an open deformity of the right ankle when she fell down from some steps and sprained her right ankle. She had no previous episode of sprain in her right ankle. She had two open injuries and her right ankle showed varus deformity. Radiological examination revealed medial malleolus hypoplasia and subcutaneous emphysema. At surgery, the anterior tibiotalar joint capsule and anterior talofibular ligament were found to be ruptured. The calcaneofibular ligament was detached from its associated periosteum. The articular facets of the tibia and talus were both intact. The treatment consisted of wound irrigation, debridement, reduction and suture of the capsule and ligaments followed by immobilization with a short leg cast. Three weeks after the operation, the patient started walking with partial weight-bearing and was able to walk without any aid at six weeks. At the final follow-up, she had achieved good functional and radiographic results. [Conclusions] Capsular suturing and ligament repair can achieve a good functional outcome with a short immobilization time, even in cases of medial malleolar hypoplasia.

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Introduction : Calcific myonecrosis is a rare type of calcified lesion, which can occur more than 10 years after a physical injury. Compartment syndrome is suggested to be the underlying cause. We report four cases of calcific myonecrosis arising in the leg.
Patients and methods : Between 1991 and 2013, four patients presented with expanding masses in the lower limbs more than 20 years after sustaining trauma. All of the patients were males, ranging in age from 51 to 66 years (mean 56 years).
Results : Three patients underwent excision and one was treated conservatively. Three patients had no complications after surgery, such as infection and local recurrence. In the patient who was treated conservatively, the mass did not become enlarged, and was still painless after 2 years of follow-up.
Conclusion : Although calcific myonecrosis is not commonly encountered, it can be diagnosed on the basis of its specific clinical course and imaging. In confirmed cases of calcific myonecrosis, simple observation may be feasible and surgical intervention should be avoided because of the high rate of postoperative complication.

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