A follow-up study was performed in 16 patients over 75 years old who had undergone 18 Charnley type total hip arthroplasty (THA) procedures. Fourteen patients were osteoarthritic, including six with rapidly destructive coxopathy and two with avascular necrosis of the femoral head. Three patients died, and the other 13 cases were investigated both clinically and radiologically. The postoperative follow-up period ranged from 3 years to 9 years 8 months (mean: 5 years 6 months).
Although these elderly patients had various preoperative complications, mean hip score improved from 39.9 to 79.7 points postoperatively, and QOL and ADL in these patients improved dramatically. Radiological study confirmed that osteoporosis in the elderly has little relationship with loosening of hip prostheses. In elderly patients, THA may be indicated even if the postoperative life expectancy is not extremely long.

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We report a result in treatment for 9 cases of fracture of ipsilateral fumer following total hip arthroplasty (THA).
Mean age at primary THA operation was 56 years old and mean time from the THA to the fracture was 8 years and 8 months. According to the Johanssons classification, they were divided into one case of type I, III and 7 cases of type II. The injuries were frequently due to slight trauma in the cases with stem loosening combined with the fragility of the thin femoral cortex. Open reduction and/or rereplacement was required in most of the cases, but bone fusion was obtained.

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Recently much more attention has been paid to autologous blood transfusion in elective orthopaedic surgery because of problems associated with homologous blood transfusion such as isoimmunization, graft versus host disease, and various kinds of viral infections.
Since 1989, we have used the predeposit autologous blood transfusion by the modified leap-frog method. Since October 1993, we have used recombinant human erythropoietin. We evaluated 58 patients, mainly who were to undergo elective hip surgery. Erythropoietin was applied to 14 of those 58 patients during the predeposit procedure.
As a result, only 5 of 58 patients needed homologous blood transfusion. In patients treated with erythropoietin, the progress of anemia after autologus blood being taken was significantly less than in the nontreated. No side effects were encountered in this study.
Thus, we conclude that autologous blood transfusion stored as liquid blood is safe and useful for elective orthopaedic surgery, and that the erythropoietin definitely increases the amount of predeposit and enhances recovery from the anemia.

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Intraoperative salvage blood transfusion was performed in 38 hip replacements (salvage group) and was compared to 32 hip replacements without salvage blood transfusion (non-salvage group). The amount of bleeding showed no difference between the salvage and non-salvage groups. An average of 489ml were salvaged and 320ml of homologous blood were transfused in the salvage group, while 1131ml of homologous blood were transfused in the non-salvage group. The amount of homologous blood transfusion of the salvage group was significantly less than that of the non salvage group. In 14 cases of the salvage group, additional homologous blood transfusion was not used (SS group), while in the rest 24 cases was used (SA group). There was no RA patient in the SS group, while there were 5 RAs in the SA group. The operation time was shorter in the SS group. Also we noticed that the amount of operative bleeding was significantly less in the SS group. The preoperative Hb was significantly higher in the SS group. Our data suggest that homologous blood transfusion can be avoided by using salvage blood transfusion in non RA hip replacement in a patient with Hb higher than 11.2mg/dl and operative bleeding of less than 1100ml.

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Bursitis calcarea of the hip joint is a relatively common condition. But it is sometimes misdiagnosed as osteoarthritis and infection. We report 2 cases in the bursa iliopectinea (group 1), and 2 cases in the bursa trochanterica m. glutei (group 2). Group 1 experienced a more sudden onset and less range of motion than group 2.
Nonsteroidal anti-inflammatory drugs decrease symptoms. However, some reports described a recurrence of pain when the calcium deposit remained. Aspiration of the calcium is the easy and less-invasive treatment, and may shorten the duration of these conditions.
This is a first report of the analysis about the calcium deposit in the hip joint. The macroscopic specimens resembled a milky emulsion, and X-ray diffraction showed a poorly crystallized hydroxyapatite similar to a shoulder lesion.

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Spontaneous osteonecrosis of the knee occurs with sharp pain, showing charactaristic radiographic images of femoral medial condyle. We have chosen high tibial osteotomy (HTO) for this disease. In this report, we comparatively assessed the therapeutic result of HTO for spontaneous osteonecrosis of the knee and that for osteoarthritis of the knee (OA).
Fourteen osteonecrosis patients(14 knees) who underwent HTO between October 1982 and October 1993 were enrolled in the study. All were spontaneous cases occurring in the femoral medial condyle. Radiographic changes of the necrotic area, variations in femorotibial angle and those at Mikulicz-line passing point on frontal X-rays of the bilateral lower limbs in a standing position at the preoperative and final examinations were investigated. Furthermore, changes in clinical results shown by a three-university tentative assessment plan were also reviewed. Ten patients (10 knees) followed for over a year were compared with HTO-performed 162 patients for medial knee OA followed for over a year. The necrotic area disappeared in half of the patients, and was unchanged in the other half. The osteonecrosis group showed better clinical results than the OA group. Recently, total or unicompartmental knee arthroplasty has been increasingly performed. We, however, recomfirmed, despite the small number of subjects, that HTO was the first-choice surgical technique for spontaneous osteonecrosis of the knee.

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Total knee arthroplasty was performed in 40 knees of 34 patients. The series contained 15 cases with rheumatoid arthritis and 25 with osteoarthritis. The postoperative follow-up was done at 6-66 months (mean 26 months).
JOA score improved from a mean of 54.7 points preoperatively to 76.2 points postoperatively.
The mean of the range of motion (ROM) decreased from 116° preoperatively to 104° postoperatively.
We studied the factors influencing in the postoperative ROM. The results were found to correlate with preoperative ROM, but not with angle of components, patella height and depth, change of joint line and tibial component position.

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Two-stage reimplantations were performed for eleven infected joint arthroplasties (total hip replacement: 6 cases, femoral head replacement: 3 cases and total knee replacement: 2 cases) and were evaluated after an average follow up of 53 months.
While the recurrences of infection were noted in 4 of 5 cemented revision cases, no recurrence was seen in 6 non-cemented revision cases.
Our results suggest that early extraction of the infected implant and two-stage reimplantation with non-cement are reliable procedures for the management of infected prothesis.

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Infection after implant arthroplasty is a most serious complication. For diagnosing postoperative infection, we measured pre-and postoperative white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and fever in 64 cases of total hip arthroplasty (THA), 20 cases of bipolar endoprosthesis (EP) and 61 cases of total knee arthroplasty (TKA) for osteoarthritis (OA) or rheumatoid arthritis (RA). All cases were uncomplicated after surgery.
In 55 OA-THA·EP cases, WBC was normalized one week after surgery, while the CRP value was 3.08±2.67mg/dl after one week, then decreased gradually. ESR changed about one week after the change in CRP. Fever above 37C° was not observed after one week. The changes in WBC, CRP and ESR in 34 OA-TKA were the same as those in OA-THA·EP. In 29 RA-THA cases, CRP was 85±68% of the preoperative value one week after surgery, a minimal value after two weeks and then increased gradually to the preoperative level. ESR was 76±30mm as the maximal value one week after surgery and was minimal after three weeks, then increased gradually. In 27 RA-TKA cases, the course of changes was the same as that RA-THA.
We conclude that uneventful recovery after implant arthroplasty is indicated as followed; one week after surgery, the CRP value is under 6.0mg/dl in OA or 150% of preoperative level in RA and fever above 37C° is not observed.

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We performed a retrospective study of 89 total knee replacements in which post-operative suction drainage was used (in 73 knees) and not used (in 16 knees) from 1989 to 1994. Comparison of these 2 groups revealed no statistically significant difference in the rate of wound infection, the amount of time needed to return to preoperative levels of erythrocyte sedimentation ratio, or in the postoperative range of motion. However, the amount of time needed to return to pre-operative levels of C-reactive protein was longer in the drained group (P=0.01). And there was a greater decrease in the drained group of homoglobins and hematocrit than in the non-drained group (P=0.001).
We conculded that suction drainage on total knee replacement surgery is meaningless.

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We compared our cases with a nationwide epidemiological survey of spinal cord injuries in Japan from January 1990 to December 1992. We had 16 cases of cervical spine injury due to diving accidents which constituted 3% of all injuries and 54% of sports injuries. The average age of them was 24.1 years, ranging from 12 to 41 years. The nationwide epidemological survey included 114 cases of diving accidents which constituted 1% of all injuries and 22% of sports injuries. The average age of them was 22.1 years, ranging from 10 to 55 years.
Since the greater part of both cases had severe clinical symptom, it was difficult to recover from the palsy and return to social life. And so we think that a wide educational program is essential in order to reduce the number of diving accidents.

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The neurological function of 100 patients who had undergone surgical treatment for cervical spondylotic myelopathy was reviewed in order to compare the validity of the revised Japanese Orthopaedic Association scoring systems for cervical myelopathy (“17-2”and“100”systems) to the original“17”scoring system. Each category in the“17-2”and“17”systems was also estimated as the proportion to 17 points. The scores in total as well as each category showed a highly significant correlation between the two systems. The motor function score in the upper extremities as well as the total score was significantly lower in the“17-2”system compared to the“17”system, because of the detailed evaluation of the shoulder and elbow function in the new system. Scores estimated from the“17”and“17-2”systems were significantly lower than the“100”system in total as well as motor and sensory functions. The recovery rates calculated based on the“17”and“17-2”systems were significantly correlated with differences less than 2%. The minimum transverse area of the spinal cord on T1-weighted MR images showed a high correlation with the score and recovery rate evaluated by any of the three scoring systems.

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The clinical outcomes in 34 patients following laminoplasty for cervical myelopathy were assessed whether they are related or not to the findings of magnetic resonance imaging at the most stenotic level of the spinal cord. The morphologic parameters measured were not correlated with the clinical improvement evaluated with the JOA score. Twenty patients showed a high-intesnity signal within the spinal cord on T2-weighted sagittal images, and they had a significantly poorer improvement. Nine patients who showed normal intramedullary structure on postoperative axial MR images (gradient echo) had a tendency of better results. As far as the patient who had a postoperative improvement rate of less than 50% were concerned, the clinical improvement was not related to the presence of the increased signal intensity of the spinal cord on MR imaging

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Fifteen patients with cervical spondylotic myelopathy(CSM) were studied retrospectively. They were selected out of 33 patients with CSM who were operated during the last 3 years. Selection criteria was the patients who demonstrated both a high signal intensity area(HIA) on T2-weighted MR image and a distinct change in the waveform of spilal cord evoked potentials (SCEPs) suggesting a spinal conduction block. Those changes were highly correlated with a location in the spinal cord.
In all but one patient, the intervertebral level of the conduction block coincided with that of HIA. The HIA within the cord was, therefore, considered to reflect the level of the myelopathic condition in most patients with CSM. In only one exceptional patient, conduction block was revealed at the C4-C5 level, whereas the HIA on MRI was seen at the C5-6 level. The discrepancy can be explained that the HIA in this patient was localized in the gray matter of the spinal cord, which was suggested by the "snake-eyes" appearance on the additional axial T2-weighted MR images of the C5-6 level, while the nervous systems tested by the SCEP were the posterior and posterolateral funiculi of the spinal cord.

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This article reports our experience using the AO cervical spine locking plate for anterior cervical spinal fusion. Six cases of this series underwent this surgical treatment for degenerative diseases or traumatic lesions. Fusion, stability and alignment of the cervical spine was achieved in all patients. There was no significant complications. The state of spinal cord and neighboring disk could be assessed with MRI. Although the number of patients was small and the follow-up period was short, this method was considered to be useful.

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Nine rheumatoid patients who suffered from severe neck-occipital pain with cervical myelopathy were operated by using a Luque's segmental spinal instrumentation (modified U-shaped rod). Five of the patients had mutilating disease. Occipital-upper thoracic fusion and decompressive laminectomy were carried out for the five mutilating patients who had upper cervical lesions along with severe subaxial subluxation and instability. Neck-occipital pain and cervical myelopathy were improved after surgery in all the five mutilating patients. However, in one case, postoperative instability was appeared on the upper thoracic level just below the fusion level. Occipital-upper cervical fusion was carried out for the four non mutilating patients who had vertical subluxation or irreducible atlanto-axial subluxation. In three of those cases, laminoplasty was performed below the fusion level. Neck-occipital pain was improved in all the four cased after surgery. However, in two cases with occipital-C3 fusion, mild instability on the fusion site remained postoperatively.

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In this paper, we report a patient with malignant soft tissue tumor who had undergone above-the-knee amputation following development of post-operative Methicillin-resistant Staphylococcus aureus (MRSA) infection.
The patient was a 55-year-old man with synovial sarcoma of the left thigh. After preoperative chemotherapy combined with thermotherapy and radiation therapy, wide local excision of the tumor was performed. One month post-operatively, he suffered a pathological fracture of his left femur, and internal fixation with an intramedullary nail was performed. Immediately after the second operation, marked swelling of the wound and a high grade fever developed. MRSA was detected in the wound discharge. After 10 weeks of daily irrigation and adequate antibiotic infusion, MRSA disappeared on culture testing. However, development of acute arterial embolism of the artificial graft necessitated above-the-knee amputation. In the resected specimen, MRSA was detected in the medullary cavity.
These findings suggest that establishment of criteria for isolation of patients with MRSA infection is necessary.

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Nine hemodialysis patiens (3 men and 6 women) with femoral neck fractures (10 hips) were evaluated clinically and radiologically. The average period of hemodialysis treatment was 11.5 years. The average age at injury was 64 years old. The average follow-up time was 2 years and 8 months. Three hips (Garden stage I or II) were treated conservatively, and prosthetic replacements were performed in 7 cases (Garden stage III or IV).
We studied the relationships between the cause of injury and types of prosthesis, and presence or absence of bone cyst in the femoral neck. All of the cases with bone cyst in the femoral neck or head suffered spontaneous fracture and the other patients without cysts were injured by falling down. In the 3 cases treated with non-cemented prosthetic replacement, 2 showed loosening radiologically. Clinical results were good in 9 hips and poor in 1 of the non-cemented replacements. It is advisable to use bone cement for prosthetic replacement of the unstable femoral neck fractures in hemodialysis patients if the patient's general condition does not contraindicate surgery.

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The Gamma Nail is a new device for treatment of the intertrochanteric fracture of the femur. The device became popular in Japan after development of the Asiatic Gamma Nail. However some complications have been reported; cut out of lag screw, fracture of femur shaft and varus deformity. We have used this device since November, 1992, and varus deformity was seen in several early cases. We think that varus deformity is caused by the adducted position of injured leg during surgery which is fixed to facilitate reaming.
Since May, 1993, we have attempted to prevent varus deformity by doing over-traction for the injured leg. As a result, varus deformity did not occur with this device and all patients could walk by themselves.
So we conclude over-traction appears to be a very useful method to prevent varus deformity in these kinds of cases.

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We treated a 53-year-old man with fracture of intercondylar eminence of the tibia. He had non-displaced(Type I) fracture at the first examination and was treated by long leg cast. But 4 weeks later it was found that the fracture was displaced, which suggests that non-displaced fracture of intercondylar eminence may displace later. We recommand primary arthroscopic fixation for Type I fractures of the intercondylar eminence of the tibia, because it is hard to reduce the fragment arthroscopically once it is displaced.
This paper describes a new technique of arthroscopically reduction and internal fixation for the fracture of intercondylar eminence of the tibia.

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Sleeve fracture of the patella is uncommon type of fracture in children.
We report a case of simultaneous sleeve fractures of bilateral patellas.
The case was a 12-year-old boy. He experienced sudden, severe pain in his knees when he was going to jump on his both legs. Physical examination revealed swollen bilateral knees.
Tenderness was located over the inferior pole of his patellas.
A lateral radiograph showed patella alta and an avulsion fracture at lower pole of the patella.
At surgery, an unique procedure in suturing the displaced cartilages with 3-0 DEXON was performed for adequate reduction. The fracture was fixed with tension band wiring. Three months after surgery, he resumed full range of motion without pain.

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We treated a case of localized nodular synovitis (LNS) in the knee joint under arthroscopy. This case was 30 year old male, who visited our hospital because of pain and mass of right knee joint. We performed arthroscopy and pedunculated tumor was found at medial synovia. It was resected completely and it was diagnosed as LNS.
Previously LNS was regarded as a part of pigmented villonodular synovitis (PVS). However it should be treated as another entire of disease as it's clinical cause in differ from the PVS.

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Seven patients with extra-abdominal desmoid tumors were treated at our department between 1972 to 1994. Two of them were men, and five were women. Five had their first operation at our department and two were recurrent cases after operation at other hospitals. Local recurrence was observed in one patient with intralesional excision (1/1), and one of three with marginal excision (1/3), however, it was not observed in three patients with wide excision (0/3). Musculocutaneus flap such as latissimus dorsi flap could be an useful reconstructive method for patients who had major muscle resection with impairment. We must research the therapeutic effect of adjuvant therapy for the extra-abdominal desmoid.

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Twenty-four cases of giant cell tumor of bone were treated surgically, including curettage, curettage with bone grafting, curettage with cement packing, wide resection and amputation. Local recurrence or metastasis occurred in eleven cases (ten cases with curettage and bone grafting surgery, and one with curettage and cement packing method). In the case of surgical treatment for giant cell tumor of bone, we would like to recommend the complete curettage with cement packing to maintain the function of joints and limbs when giant cell tumors with stage 1 or 2 invade the subchondral bone, and recommend the reconstruction surgery after wide resection with stage 3.

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Additional wide resection was carried out in eight patients in whom the malignant soft tissue tumors were inadequately excised at another hospital. The patients were divided into two groups: the first group included four patients having local recurrence at the time of admission to our hospital. The second group included the remaining four patients who admitted to our hospital without signs of local recurrence. The histological examination showed two cases of leiomyosarcoma and two cases of liposarcoma in the first group, and one case of malignant fibrous histiocytoma and three case of liposarcoma in the second group. Two patients of the first group were operated after twenty three and thirty two months after first operation. All the patients of the secone group were operated within one or two months since the first operation. In these two patients, the wide excisional defects were reconstructed by using vascularized skin flaps. In one of these patients, intraoperative radiation was carried out. All the patients had uneventful postoperative course. The function of the limbs in all patients were excellent.

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One hundred and seven patients with bone and soft tissue tumors in the upper extremities, including shoulder girdles were surgically treated between 1982 and 1994. These included 41 benign bone tumors, 55 benign soft tissue tumors, 2 malignant bone tumors and 9 soft tissue sarcomas. However it is reasonable and enough treatment for benign turors, that curettage and/or bone graft or simple resection were performed, it is relatively difficult to preserve function of the upper extremities for the surgical treatment of bone and soft tissue sarcomas.
Out of 107 cases, two local recurrences in the benign soft tissue tumors and five metastases in the bone and soft tissue sarcomas, were observed after surgery.

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Three patients with metastatic cancer in the proximal femur treated with bipolar hip prosthesis replacement after complete resection of the tumor were reported. The primary sites of tumor of these patients were larynx, breast and liver, respectively, and these tumors were found to metastasize extensively to another sites of bodies in addition to the femur. Resection of the proximal femur tumor and bipolar hip prosthesis replacement relieved all patients from the pain completely and two of three patients from difficulty in walking. Although the operation may not have beneficial effect on survival, the procedure reported here would be expected to improve the quality of life of the patient with extensive metastatic cancer.

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Two cases of radial head fractures combined with osteochondral fractures of the capitellum were studied. In the case of a 22 years old male, multi X-ray views, tomography and CT were useful for the diagnosis of the osteochondral fracture of the capitellum (Kocher-Lorenz type) and the radial head fracture (Mason type 3). The radial head was fixed with Herbert screws and the osteochondral fracture of the capitellum was fixed with four #24 wires. Two weeks after the operation, ROM exercise was started with CPM. Five months after the operation, elbow function was almost excellent except a slight limitation of extension. In case 2 (59 years old male), X-ray examination clarified the radial head fracture but did not prove the osteochondral fracture of the capitellum but it was confirmed during the operation. The operation was performed by the same way as in case 1. The radial head fracture was fixed with Herbert screws and the osteochondral fracture of the capitellum was fixed with one #30 wire. Multiple X-ray views, tomography and CT are necessary for an accurate diagnosis of osteochondral fractures of the capitellum. A popular treatment of the osteochondral fracture of the capitellum is resection, but wide chondral defect may advance OA changes and elbow instability. If accurate reduction and proper fixation are possible, internal fixation is advisable. Wire fixation has some merit. The elbow joint movement is not restricted because the wire is buried slightly beneath the articular surface and can be removed without the joint being reentered.

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Metastatic carcinoma to the limb muscles is extremely rare. We report a case of posterior interosseous nerve palsy due to intramuscular metastasis of lung carcinoma.
The patient was a seventy-seven years old female. She consulted our clinic because of progressing motor disturbance of left fingers accompanied with painful and tender mass in the dorsal site of left forearm.
We excised a 2x2cm mass tightly adhered to the supinator and posteror interosseous nerve. The tumor was histologically diagnosed as a metastatic squamous cell carcinoma from lung.
This is the first example of posterior interosseous nerve palsy caused by metastatic carcinoma to skeletal muscle.

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We have administered intravenous infusions of Heparin (2500-5000 IU) by the single-shot method, in cases of arterial obstruction after digit replantation. There were seven patients (six men, one woman) with an age of 17-51 years (average, 36 years). Amputated levels were zone I in three fingers, zone II in one and zone III in three. We injected Heparin using our single-shot method 1 to 9 times (average: 3.6 times), over 1 to 6 days (average: 3 days) postoperatively. Five fingers completely survived, while one finger only partially survived. We did not encounter any serious complication. Intravenous infusion of Heparin using this method was effective for cases involving arterial obstruction after digit replantation.

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We evaluated the long-term results of the treatment for seventeen patients with Colles' fractures. Follow-up period ranged from 6 to 18 years (mean 10 years). Of the 17 patients, one was a man and 16 were women and their ages varied from 37 to 74 years (mean 60 years). The fracture type of the all cases was Gartland group I. The function of the wrist joint was assessed by Gartland and Werley system and the radiographic evaluation was made by Kawashima's criteria. Although the range of motion (ROM) of the wrist joint was limited in 4 patients, total function of the joint showed good or excellent in all cases. In all 4 patients with limited ROM, the radiographic findings showed poor initial reducion.

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We report the results of treatment of the fractures at the distal part of proximal phalanx of index finger in two patients, middle finger in two patients, little finger in one patient. These included 4 males and 1 female ranging in age from 2 to 33 years (average age 13 years). Two rotational supracondylar fractures and one unilateral condylar fracture were also treated with manual reduction and percutaneous pinning. An intra-articular comminuted fracture of proximal interphalangeal (PIP) joint was treated with open reduction and internal fixation using K-wires, and the metaphyseal fracture was immobilized without reduction.
Postoperatively, four patients developed lateral angulation deformity of the fingers ranging from 5 to 18 degree. This deformity usually did not prevent full range of motion. The degree of deformity was unchanged even in children. The case with intra-articular comminuted fracture suffered limitation of range of motion of PIP joint.
Our results indicate that anatomical reduction is essential for preventing the malunion.

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We reviewed the results of arthroscopic examination with or without arthroscopic surgery in 14 patients with painful wrist disorders. The condition followed traumatic Triangular fibrocartilage complex (TFCC) injury in 6 patients, Rheumatoid arthritis (RA) in 2 patients, Kienböck disease in 2 patients, ulnocarpal abutment syndrome in 2 patients, calcified arthritis with pseudoarthrosis of the scaphoid bone in one patient, and 6th compartment syndrome in one patient. There were 7 males and 7 females. The average age of the patients was 39.2 years (rang: 12-66 years). The average follow-up period was 10.1 months (range: 2-46 months). Class 1A type of TFCC injury was the best indication for arthroscopic resection. We believe that for successful arthroscopic synovectomy in RA wrist, the double approach (dorsal and volar approach) procedure is the best approach. The arthroscopic examination was useful for evaluation of the articular lesion in abutment syndrome and Kienböck disease. In addition, sixth compartment syndrome would be excluded arthroscopically from the other wrist disorders with intra-articular lesion.

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Arthroscopic reconstruction of the anterior cruciate ligament (ACL) has the advantage of less morbidity and more detailed observation of the knee joint than conventional open procedures. In this paper, endoscopic technique for ACL reconstruction using patellar tendon autograft is reported.
The problems of endoscopic technique are breakage of femoral cortex, breakage of patellar tendon graft, breakage of guide pin, injury of posterior cruciate ligament, and residual bone tips inside the joint. We describe the solusions of these problems.
1. To avoid the breakage of femoral cortex, it is necessary to check the position of the femoral guide wire in the X-P.
2. To avoid the breakage of patellar tendon graft, we insert the femoral screw coverd with the Penrose drain.
3. To avoid the breakbge of guide pin, we insert the femoral guide wire at 90° knee flexion, and insert the femoral screw at more than 120° knee flexion.
4. To prevent the injury of posterior cruciate ligament, the femoral guide wire should be placed around the “eleven o'clock” in the right knee, and around the “one o'clock” in the left knee.
5. To prevent the residual bone tips inside the joint, it is necessary to irrigate the joint sufficiently.

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Since 1986, twenty-seven ankle arthroscopic surgeries have been performed and we evaluated the results of 16 ankles of 14 patients who were treated by arthroscopic surgery alone. The patients were 4 men and 10 women with an average of 49 years (range, 14-76 years). The diagnosis was osteoarthritis in 6 ankles, old ligamentous injury in 5, rheumatoid arthritis in 3, and fracture of the talus in 2. Arthroscopic treatment was resection of the meniscoids and soft tissue impingements, debridement of osteochondral lesions, and removal of loose bodies. The Japanese Orthopaedic Association (JOA) score was used to clinically evaluate the results. There was a marked improvement in pain at final review, with an average score of 15.3 compared with an average of 6.3 preoperatively (p<0.001).
The chronic ankle pain due to soft tissue impingements can be safely and effectively treated by operative ankle arthroscopy.

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The authors have experienced elbow arthroscopic surgery on the twelve elbows, in eleven patients. The diagnoses included four loose bodies, four onteoarthritis, two onteochondritis dissecans and one rheumatoid arthritis. We performed synovectomy in ten cases, removal of the free body in nine cases and debridement in six cases, with as average postoperative follow up period of twenty seven months. We performed elbow arthroscopic surgery in a lateral position with sufficient traction. Pain diminished in 92% of patients and the range of motion improved in 67%. There were no complications. It was considered that operative elbow arthroscopy was an effective measure because of the minimal invasion and short hospitalization.

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The present study was carried out to evaluate the postoperative curative result of arthroscopic partial excision, one of the treatment techniques for injury of triangular fibrocartilage complex (TFCC) tissues in the wrist joint. The indications for this technique are reported. Of 55 patients who underwent arthroscopic examinations during the past 5 years, 24 had suffered from injury of TFCC tissues, 18 of whom underwent arthroscopic partial excision and were selected for this study. Pain, range of motion in the wrist joint, grip strength and roentgenographic finding were evaluated through direct physical examinations. Traumatic rupture was noted in 13 patients (average age; 27 years) and degenerative rupture in 5 (average age; 40 years). The curative result for traumatic rupture was excellent in 10 cases, good in 1 and poor in 2. The result for degenerative rupture was excellent in 1 case and poor in 4. When the pationts were graded according to Palmer's classification, of 11 patients who had excellent results, 6 were classified as Class 1D, 3 as Class 1A, 1 as Class 1B and 1 as Class 2C. Ulnar variant was positive in 10 patients, neutral in 6, and negative in 2. Average ulnar variant was positive in 10 patients, neutral in 6, and negative in 2. Average ulnar variance was 0.6mm in 11 patients who had excellent results and 2.5mm in 6 patients who had poor results.
It is considered that the arthroscopic partial excision was effective in patients classified as Class 1D and 1A and other methods of treatment should be applied to patients showing ulnar variance of more than 2.5mm.

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We evaluated the relationship between straight leg raising test (SLRT) and operative findings in 25 patients with lumbar disc herniation. The operative findings we evaluated in this study were as follows; the type of herniation, the location of the herniation, the nerve root of involvement, and the wet weight of herniotomized disc.
The positive SLRT angles were higher in order: sequestration>protrusion>subligamentous extrusion>transligamentous extrusion, intraforaminal>central>centro-lateral>posterolateral, and L4 root>L5 root>S1 root. But no correlations were found in the relationship between positive SLRT angles and the type of herniation, the location of the herniation, or the nerve root of involvement. On the other hand, a correlation was found between the wet weight of herniotomized discs and positive SLRT angles.
In conclusion, the more closely to the root the herniated disc existed, the less the positive SLRT angle might be. Once the herniated disc was sequestered, positive SLRT angle increased.

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We analyzed the results percutaneous nucleotomy that was performed on 16 patients with lumbar disc herniation following ineffective conservative treatment. Twelve patients were males and three were females. Their ages at nucleotomy ranged from 16 to 39 years (mean, 22 years). The level of the disc involved was L4/5 in 12 patients and L5/S1(L6) in 4. Subjective symptoms and objective signs evaluated by Japanese Orthopaedic Association (JOA) scores were compared before and after the surgery. The mean improvement in the score was 59.4%. The improvement of 75 to 100% was seen in 9 patients, 50 to 74% in 2, 25 to 49% in 2, and less than 24% in 3. Greater improvement was found in patients with a puncture from the affected side in comparison with that normal side, indicating that the former was a preferred approach for nucleotomy. The 2 patients with the poorest improvement rate later underwent the surgical procedures and were found to have the subligamentous extrusion type. Extirpation scars were visualized in these patients by magnetic resonance imaging after percutaneous nucleotomy.

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We report three cases of lumbar disc herniation with bladder and rectal dysfunction. We performed surgical decompression for all three cases as soon as possible, but duration of symptoms of progressive dysfunction before surgery in each case was three or four days. The patient who had the most serious preoperative dysfunction had unsatisfactory results. In that case, the patient had completely lost anal sphincter tone, and had complete urinary retention before surgery. Another patient who anal sphincter weakness and incomplete urinary retention had satisfactory results. The third patient who had anal sphincter weakness and complete urinary retention also had satisfactory results.
We think that because the prognosis of patient with lumbar disc herniation with bladder and rectal dysfunction depends on preoperative dysfunction, it is important to perform surgery before complete dysfunction develops.

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From April 1991 to March 1994, we experienced 17 cases of lateral lumbal disc herniation. Of 17 cases, 11 were intraforaminal lumbal disc herniation (LDH), 5 were intra & extra-foraminal LDH and 1 was extraforaminal LDH. Surgical treatment was performed in 13 cases and in 7 cases they were operated on using lateral fenestration. The merit of this procedure is that decompression can be achieved with minimal resection of the facet joint without spinal fusion and the addition of medial fenestration is possible.

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Lumbar radiographs of 1, 296 patients (819 females, 477 males) were reviewed over a two year period. Patient ages ranged from 40 to 96, with a mean of 62.5. Measures were taken of lumbar scoliosis, using the Cobb method, lumbar lordosis and osteoporosis.
Degenerative lumbar scoliosis (DLS) in patients over 40 years, defined as having a measurement greater than 10 degrees on Cobb's angle, was observed in 234 cases (175 females, 59 males; age range 40∼96, mean 69.5).
Results indicate that DLS is more likely to occur in females than in males-with the frequency increasing with age; that the convexity of the curve is dominant to the left side; and occurences of lumbar lordosis are fewer among patients diagnosed with DLS. The risk of lateral slipping increases with an increase in Cobb's angle.

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Fourty-five patients with lumbar spinal canal stenosis (LSCS), who had laminectomies performed on them, were reviewed. There were 21 men and 24 women whose ages ranged from 43 years to 79 years (average 61.2 years).
We examined correlations between views of magnetic resonance imaging (MRI) and operative results. We measured the size of thecal sac at the most stenotic level and classified forms of cauda equina as normal, partial grouping, total grouping and an unclear type from an axial view. Operative results were evaluated by the JOA score and Hirabayashi's improvement rate.
There were no correlations between the size of the thecal sac and the operative results.
Each type classified before operation had no differences in operative results compared with other types, but we recognized that only the normal type classified after operation had excellent operative results statistically.

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Low lumbar fractures are relatively rare and no fixed treatment for them has been reported in the literature. Seven patients with low lumbar fractures (L3-L5) were treated surgically at Kawasaki Medical School Hospital discussed in this report. Follow-up ranged from 5 months to 122 months with an average of 62.3 months. Surgically, the anterior approach was employed in two cases, a transpedicular approach was used with achievement of good results and complete improvement of symptoms. Our results suggest that short rigid instrumentation is useful in accomplishing shorter fusion and restoring lumbar lordosis, which prevent persistent complaints of back pain.

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Pyoderma gangrenosum is a non-infections chronic disease of unknown etiology which forms pustules and ulcers.
It is a relatively rare disease firstly described by Brunsting et al. in 1930. In Japan, more than 300 cases have been reported in the dermatology field since 1958. Although some cases of pyoderma gangrenosum associated with chronic arthritis and rheumatoid arthritis have been reported, the disease has occurred very rarely in orthopaedic field.
This paper reports a patient with pyoderma gangrenosum after asterior interbody fusion for lumbar spondylolisthesis, in whom steroid therapy was markedly effective to cure the affection.

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To evaluate the effects of a muscle reluxant, Tizanidine, on intramuscular pressure of the paraspinal muscules, 16 patients with lumbosacral diseases (at the mean age of 60 years, range 30 to 74) were examined. Tizanidine was orally administered at a dose of 2mg. Intramuscular pressure was measured before and 30 minutes after administration using slit catheter transducer technique during lying (supine and prone). standing (neutral, flexion and extension) and walking.
In lying positions and walking, the mean intramuscular pressures after administration were significantly lower (p<0.05) than those before administration. During standing, intramuscular pressures decreased after administration although it was not statistically significant.
The patterns of intramuscular pressure during walking were classified into following five types: stable, unstable, waxing, waning and miscellaneous. The stable pattenrs was observed in six patients before administration and in nine patients after, and three patients with waxing pattern before administration presented either stable or waning pattern after intake of Tizanidine.
In conclusion, Tizanidine decrease the pressure in the paraspinal muscles in lying positions and walking. It also may improve the patters of the pressure of patients with lumbosacral diseases during walking.

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The treatment of bone fragility and deformity of osteogenesis imperfecta is unsatisfactory because we have no available curative therapy.
From 1985 to 1994, we attempted to treat surgically 5 of 10 patients with osteogenesis imperfecta. Among these 5 patients, 3 were men and 2 were women (one type I B, one type III, one type IV A, and two type IV B by Sillence classification).
Three patients (one type I B and two type IV B) were treated by surgical correction with Bailey-Dubow extensible intramedurally rod. One patient (type III) was treated conservatively as he could not walk preoperatively. One patient (type IV A) transferred to another hospital after short follow-up period.
These three operative cases were classified according to Hoffer and Bullock as grade I (one patient), grade III (two patients), and grade V (one patient).

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To investigate the effects of serum markers on metabolic activities associated with both the formation and the resorption of bone, a biochemical study of the serum carboxyterminal propeptide of type I procollagen (P I CP) and the cross-linked carboxyterminal telopeptide of type I collagen (I CTP) was performed for disorders of bone metabolism. Serum P I CP and I CTP statistically increased in patients with the chronic renal failure, in who experienced hypercarcemia due to secondary hyperparathyroidism associated with a malignant tumor, bone metastasis, and Basedow's disease as compared with the normal group. Our results suggest that serum P I CP and I CTP may be useful as indicators of bone metabolic activities.

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Pycnodysostosis is a relatively rare disease characterized by systemic osteosclerosis and susceptibility to bone fracture. We performed intramedullary nail fixation in 2 patiants with fracture of long bone, and obtained good results.
Patient 1: A 17-year-old male suddenly had severe pain in the left leg during a running high jump in physical training at school on November 11, 1991. X-ray examination showed fracture of the left fibula and tibia with an open wound (about 1 cm) on the anterior surface of the left leg. After immediate, washing and debridement, wire traction was initiated and intramedullary nail fixation was performed, on November 26.
Patient 2: A 43-year-old female underwent internal fixation using a D. C. plate due to left femoral subtrochanteric fracture in 1981, and nail removal in 1983. Intramedullary nail fixation was made due to fracture of the right femur in 1987. On November 29, 1989, she fell down in the bathroom and visited our hospital because of pain in the left thigh. Re-fracture was found at the same site of the left femur, intramedullary nail protruded at the proximal site in the right femur, with bone fusion failure. On December 15, 1989, horizontal type intramedullary nail fixation in the bilateral femurs was performed, and complete fusion was gained.
Intramedullary nail fixation for pycnodysostosis allows motions of the joint in the early stage, and complications such as joint contracture can be prevented. In addition, horizontal fixation enhances fixation force, and we do not remove nails because of possible re-fracture.

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Intercostal neuralgia caused by thoracic radiculopathy is difficult to diagnose unless accompanied by myelopathy. As compared with cervical or lumbar radiculopathy, neurological findings are rarely observed except sensory loss. Diagnosis of thoracic spinal legion without recognition of intercostal neuralgia is most difficult. We report two cases of spinal tumor whose initial symptoms were chest pain only. In case 1 (46-year-old, female), she complained of right linear chest pain, and was first diagnosed as intercostal neuralgia, but its cause remained unknown. In case 2 (36-yearold, male), his complaint was nocturnal pain of right chest without apparent margin. He first took various examinations of internal medicine including Holter ECG, abdominal echogram, CT and GIF. Both cases were finally diagnosed as spinal tumor by Magnetic Resonance Imaging (MRI). The former was small (6mm in diameter) arachnoid cyst which selectively compressed right 9th thoracic nerve root. The latter was schwannoma arised from axillar portion of 6th nerve root, which located dorsal aspect of spinal column at Th4 level and severely compressed spinal cord. In both cases pain disappeared after surgical removal of the tumor. MRI was quite successful to make diagnosis in both cases.

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