Four knees from three patients had metal-backed patellar component failure after Miller-Galante type I total knee arthroplasty (M-G I TKA). The failure led to considerable wear of the femoral component and to metal-induced synovitis metallosis. A metal-backed patellar component from one knee without metallosis was replaced with an allpolyethylene patella component. Three knees with metallosis were replased from a M-G I femoral component, metal-backed patellar component and worn tibial surface to a M-G II femoral component, all polyethylene patella component and M-G II tibial surface.
The factors of failure were from the patient (activity, weight, range of motion etc.), surgical technique (lateral release etc.), and patellar implant design (the use of metal back, the depth of groove etc.).
Metal-backed patellar component failure is a serious complication of TKA and will increase in number. Absorbed metal ion may damage human body. We conclude that revision should be perfomed as soon as metallosis occurs.

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Knee joint radiographs from 250 joints with primary osteoarthritis (OA) and 48 with articular chondrocalcinosis (CC), aged 65 or older, were compared.
Presence of femoral cortical erosion (FCE) in OA and CC, relation to CC and patello-femoral osteoarthritis (PF-OA), position of the patella and the femur during extension of the knee (patello-femoral distance) and configuration of the patella (attrition rate and T-angle) were evaluated.
We found FCE in 9 joints (19%) with CC, but none with OA. Knees showing FCE in CC had higher mean PF-OA grade, and the upper end of their patella almost touched the femur during extension of the knee. There was a tendency that the patella with larger attrition rates had smaller T-angles, and that the patella showing FCE was in a so-called “patella wrapped around the femur” configuration.
We concluded that local mechanical factors played an important role in the FCE formation in CC associated with PF-OA.

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Two cases of knee arthritis were experienced. A 22-year-old woman complained of a swelling in the left knee since childhood. X-ray examination revealed narrowing of the femoro-tibial joint space.
There was no immunological abnormality. Since pathological findigs of left knee synovium showed infiltration of neutrophils, we treated her condition as infectious arthritis by antibiotics but was not effective. After considering clinical course of arthritis in several joints, she was diagnosed to have rheumatoid arthritis. She was treated with steroid and gold.
The second case was of a 24-year-old man who complained of pain and swelling in his right knee. He was also treated by antibiotics which did not cure his arthritis. After considering all clinical and pathological findings including lymph follicles and synovial proliferation like villi, he was diagnosed to have rheumatoid arthritis. He was treated with ateroid.
These cases indicate that pathological and clinical findings are very important for diagnosis of knee arthritis.

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A case of popliteal aneurysm presenting with symptom of acute common peroneal nerve palsy is reported. A 63-year-old man was diagnosed as having a right popliteal artery aneurysm by conventional angiography and MRI. This patient was treated with excision of the aneurysm, and reconstruction was made using an artificial vessel.

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A series of 17 knees in 16 patients, ages ranging from 52 to 77 years (mean, 66 years), with early or moderate osteoarthritis of the knee, were treated by arthroscopic debridement. All patients were followed up for at least 12 months after surgery. The average JOA score improved from 68 to 89 points.
We concluded that arthroscopic debridement is a good surgical procedure for the early osteoarthritis of the knee.

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There have been different methods of high tibial osteotomy (HTO) for osteoarthritis of the knee. We developed an osteotomy drill guide block and angle correction measurement device to achieve accurate dome-shaped osteotomy and obtain the desired correction angle. Osteotomy was performed by percutaneous drillings. Since 1991, we have perormed percutaneous HTO in 54 cases (9 men, 45 women).
The mean follow up period was 21 months. The Japanese Orthopaedic Association (JOA) score was used to clinically evaluate the results. The average postoperative score was 80, while the average preoperative score was 60, demonstrating the improvement. The preoperative femoro-tibial angle (FTA) was 184 degrees and the postoperative FTA was 168 degrees. There were no patients who showed serious peroneal nerve palsy.
Our procedure has the advantage of being easy to perform as well as being less invasive because the ostotomy is performed by percutaneous drillings. It was considered that percutaneous HTO with an Orthofix external fixator allows early movement and maintains an accurate correction angle.

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High tibial osteotomy (HTO) is an excellent treatment for osteoarthritis of the knee. However, due to a prolonged life span recurrence ta the varus deformation and destruction of lateral joint sometimes require TKA in patients after HTO. We compared the status of 9 knees in 7 patients who underwent HTO and the problems encountered during surgery before and after the subsequent TKA.
Comparison of the status before and after the surgery: FTA was improved from the mean 177.2° to 173°, ROM from 5°-112°to 3°-106°, and JOA score from an average of 66 points to 80 points.
Patellar inversion sometimes caused trouble at the time of TKA. Attention should be paid to the adjustment of ligament balance and decrease in bone stock due to osteotomy (at the time of HTO and TKA).
The lateral shift of the tibia at the time of HTO requires careful positioning of tibial component.

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We evaluated the clinical results of 43 total knee arthroplasties with anatomical modified knee (AMK) prosthesis in 28 patients. Twenty-two knees of 15 patients had osteoarthritis and 21 knees of 13 patients had rheumatoid arthritis.
The mean age at the time of operation was 68.2 years, and mean duration of the follow-up was 4 years. There were 6 male (7 knees) and 22 female (36 knees) patients.
The mean Japanese Orthopaedic Association score was 42 points preoperatively, 75.3 points in the early period after the operation, and 72.9 points at the latest follow-up. The radiographic appearance of the hips improved postoperatively. Femoral tibial angle improved from mean of 186.7 degrees preoperatively to a mean of 174.0 degrees postoperatively. The mean A angle changed from 95.2 degrees to 97.6 degrees, and the C angle changed from 86.8 degrees to 88.6 degrees. The mean patella tilt angle improved from 8.5 degrees to 7.9 degrees.
Radiolucent lines on the radiographs appeard in 8 knees (18.6%).
We got a good result by using AMK proshtesis.

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Postoperative results more than five years of cemented total knee replacement were reviewed clinically and radiologically and compared between 31 knees 21 patients with rheumatoid arthritis (RA) and 30 knees 21 patients with Osteoarthritis (OA). Average follow-up periods were 97.3 months in RA, and 86.6 months in OA. Kinematic total condylar type in 49 knees and Total condylar type in 8 knees were mainly used prostheses. Scores of other items except range of motion according to JOA score system increased significantly after surgery. Total arc at the time of follow-up was well correlated with preoperative one. Survival rates were calculated by defining loosening, late infection and revision surgery as end point of TKR.
Cumulative survival rates at ten years were 91.2% in RA and 100% in OA. Radiolucent zones, which mainly appeared at tibial bone-cement interface, were observed in 16.1% of RA knees and 16.7% of OA knees.
The overall results of cemented TKR suggested to be stable and durable for more than 10 years in both RA and OA knees.

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We report a relatively rare case of fracture-dislocation of Lisfranc's and Chopart's joints with some discussions.
The patient was a 55-year-old man who was driving a small van and collided with a shed. His right foot was pinned between the seat and the front of the car. On presentation, closed reduction was attempted under lumber anesthesia, but was unsuccessful. At 11 days after injury, the swelling had subsided and infection of the sutured lacerations had resolved, so open reduction was carried out under lumbar anesthesia. The medial and lateral longitudinal incisions of the right foot were made, after which the fracture-dislocation was reduced as completely as possible and fixed with Kirschner wires. A non-weight-bearing short leg cast was applied for 6 weeks after surgery, and the patient subsequently wore a plantar plate for partial weight-bearing walking. The wires were removed on 9 weeks after operation when bone union appeared to have been achieved.
The fracture-dislocations were visualized on preoperative three-dimensional CT scans, but it was impossible to assess deformation of the tarsal and metatarsal bones. Coronal CT scans of Chopart's joint performed before and after surgery delineated the transverse arch of the foot. Concomitant use of three-dimensional lateral plain XP, which is capable of showing the medial longitudinal arch, made it possible to evaluate the displacement associated with the fractures, the severity of dislocations, and the improvement after reduction.

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Injuries of the Lisfranc joint are not common, and the results of treatment are often unsatisfactory.
We operated on seven patients (6 male and 1 female) with Lisfranc's fracture-dislocation from 1992 to 1996. Average age was 41 years, ranging from 27 to 56 years. Three cases were caused by traffic accident, three cases by compression, and one by a fall (almost all were high-energy injuries). Five cases were open fractures, two of which were classified as Type III under Gustilo's classification.
In all cases, open reduction and internal fixation were performed. The anatomical position of the forefoot after reduction improved in almost all cases, but in the cases with severe soft tissue injuries it was difficult to have a good function.
We concluded that in treatment of Lisfranc's fracture-dislocation we should consider not only the correct reduction of the fracture, but repair of soft tissue as well.

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Dislocation of the Chopart joint is uncommon and only a few reports have appeared in the literature. We report rare case of medioplanter fracture-dislocation of the Chopart joint. The patient was a 19-year-old man, who was injured in a traffic accident. Radiologically, there was a medioplanter dislocation of the Chopart joint accompanied by a fracture of the navicularbone and calcaneus. Reduction was done by the manual closed method under direct traction of the forefoot. The clinical course was favorable and the patient returned to his post.

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We evaluated the result of nine feet of seven patients who underwent V-osteotomy of the head of the first metatarsal bone according to the Austin procedure for treatment of hallux valgus with a mean of twenty-four month follow-up (range, eight months to fifty months).
The average hallux valgus angle was corrected from 28.0±6.5° to 11.7±8.0° and intermetatarsal 1-2 angle from 14.9±4.3° to 10.1±1.9° postoperatively. However, the average hallux valugus angle was developed to 22.3±13.9°. In five of nine feet, the preoperative hallux valgus angle was over 25°. Hallux valgus deformity recurred on four feet in this group. We concluded that the Austin procedure should not be used for a the hallux valgus with a preoperative angle of over 25°.

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Fourteen Achilles tendons of fourteen patients who underwent percutaneous suture for acute subcutaneous rupture were followed clinically for five months to eight years and nine months (with a mean of three years and seven months).
All patients were successfully repaired using a percutaneous suturing repair technique. No re-rupture has occurred. Patients showed a 96% recovery of the uninjured contralateral side in planter flexion power. No patient lost ankle motion postoperatively. Two patients complained of postperative sensory disturbance associated with neuropathy of the sural nerve. Three were no infections, skin necrosis, suture extrusions or painful scar formations.
We concluded that percutaneous suture with care to the sural nerve is a good surgical procedure for repairing acute Achilles tendon ruptures.

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From 1992 to 1996, a bipolar endoprosthesis has been utilized in forty elderly patients with fractures of the hip in the femoral neck. Thirty-two cases were reviewed and observed for more than six months. In twenty-six patiens, an uncemented Modular Austin Moore Hip (Zimmer) was used, In the remaining six patients, a cemented prosthesis was applied. The clinical results were evaluated by walking ability and thigh pain. Postoperative thigh pain was experienced in 73% of the patients using the uncemented prosthesis. These patients had outside mobility ability. Postoperative roentgenological analysis was conducted on thirteen patients. The following was observed:
1. sinking of the stem in excess of 3mm in seven hips
2. intramedullary bone formation at the stem tip in six hips
3. cortical hypertrophy in three hips
4. thickening of the cortex at the femoral neck in five hips
Statistically, there was no connection between thigh pain and bone chage.

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We treated 16 cases of the femoral shaft fractures by closed interlocking nailing. The average age of the patients was 39 years (range, 12 to 86 years). Grosse-Kempf nails were most frequently used. One delayed union occurred in a 65-year-old woman who sustained a segmental fracture of the femur and was treated by closed interlocking nailing (static lock). We considered that this delayed union was owing to a small gap (5mm) remained at the proximal transverse fracture site. Dynamization was performed at 4 months after the initial operation and union is appeared to be progressing at present. The remaining 15 fractures united uneventfully without any deformity, shortening and infection. We conclude that closed interlocking nailing is one of the best methods for the femoral shaft fractures.

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We surgically treated 14 tibial condyle fractures between 1991 and 1995. Patients included 9 males and 5 females between 35 and 83 years old, with a mean age of 63.8 years. The follow-up period was between 4 and 52 months with a mean of 21.6 months. According to Hohl's classification, there were 3, 1, 1 and 9 cases belonging to type B, C, D and F, respectively including 3 open fractures. According to the evaluation of Hohl & Luck, the outcome was excellent in 6 cases, good in 6 cases, fair in one case and poor in one case. Outcome was fair and poor in the type F cases. These cases had a large depression before the operation, which remained postoperatively. We stress the importance of anatomical reduction of the joint surface.

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Between 1982 and 1996, 44 patients with 57 fractures were treated with external fixation and subsequent internal fixation. The fractures were maintained in external fixation for an average of 47.1 days, after which the fixator was removed and internal fixation was done during the same procedure in cases without pin-tract infection. Four of the 57 fractures, 7.0%, subsequently developed deep infections after intramedullary nailing. we concluded that since the possibility exists of a pin-site infection developing during external fixation, a fixator should be used with caution even if internal fixation, especially with an intramedullary nail, is done with no active infection more than three weeks after the external fixator is removed.

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A follow-up study was performed on 22 patients with iliac crest prosthesis made from a glass ceramic containing apatite and wollastonite. These patients had undergone surgery to treat iliac crest defects involving the removal of the tricortical iliac bone between November 1993 and July 1996. Patients included 12 males and 10 females ranging in age from 43 to 73 years (average, 60). Clinical and radiological examinations were perfomed. Nineteen patients (86%) suffered no tenderness 18 patients (82%) showed bone formation. Only two patients suffered from dislodgment of the prosthesis. There were no cases of infection or pathological reactions at the reconstruction site. We therefore conclude that iliac crest prosthesis made from apatite/wollastonite glass ceramic are useful for reconstruction of the iliac crest defect.

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We measured the CE angle, Sharp angle, acetabular roof obliquity and acetabular cover ratio of the femoral head of 62 males and 216 females.
The CE angle was 37±7.2 degrees (mean±SD), the Sharp angle was 36±5.5 degrees, the acetabular roof obliquity was 5.6±5.7 degrees. These values are similar to those of a Caucasian. The anterior acetabular cover ratio was 52±14 percent, the posterior acetabular cover ratio was 79±12 percent.
The CE angle correlated very closely with the posterior acetabular cover ratio. With increasing age, the posterior acetabular cover ratio tended to increase. We assumed that the reason was that the pelvis tilted to the posterior with increasing age.

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From 1988 to 1996, we treated femoral neck fractures in 3 children. In this fracture, complications were frequent and included avascular necrosis, non-union, disturbed growth at the upper end of the femur.
There were 2 males and 1 female ranging in age from 3 to 9 years, with average of 6.0. The average follow-up period was 14 months (range: 12-15 months). An undisplaced fracture was treated conservatively, and two displaced fractures were treated operatively.
Bone union was achieved in all. Clinically, there was no problem at follow-up time. Avascular necrosis didn't occur in our cases. Adequate primary internal fixation was necessary for this fracture.

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Twelve congenital dislocations of the hip in 12 patients were reviewed. Follow-up period ranged from 5 years to 13 years (average 8 years). The radiological assessment was based on Smith's ratio and Severin's classification. Accoding to Smith's ratio, all of the hips had lateral displacement and superior displacement. According to Severin's classification, 7 hips were evaluated as group I a, 4 hips as group II a, one hip as group IV a.

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The purpose of this study was to evaluate the factors which may influence survival rate of replantation. We have performed replantation of 47 amputated digits from 1991 to 1996. Patients included 19 men and 10 women, ranging from 18 to 64 years of age, with a mean of 45.1 years. Survival rate was 78% in 27 completely amputated digits and 80% in 20 incompletely amputated digits and overall average rate of survival rate was 79%. We reviewed all replanted digits with regard to factors which influenced survival rate. The age, ischemic time, amputated level didn't influence the survival rate. The survival rate of multiple amputated digits was inferior to that of single amputated digit. The survival rate of avulsion type was inferior to that of clean-cut type, local crushed type and diffuse crushed type. In the correlation between the number of anastomosed vessels and the survival rate, it shows low rate of survival by anastomosis of 1 artery and 1 vein. In order to increase the survival rate of replantation, we recommend that arterial anastomosis is 2 arteries and venous anastomosis is more than 2 veins.

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This study was carried out to evaluate clinical results and radiological changes of the rheumatoid wrist treated by Sauvé-Kapandji procedure or Darrach procedure with radio-carpal limited fusion.
Fourteen wrist joints in 11 patients (2 males and 9 females) were selected in this study, with a mean follow-up period of 4 years and 4 months (range, 3 months-9 years and 4 months). Mean age at operation was 52.0 years old (range, 29-78 years old). Ten wrists had undergone Sauvé-Kapandji procedure, and 4 wrists had undergone Darrach procedure with radio-carpal limited fusion. All wrists had also undergone synovectomy. We compared with two group by postoperative clinical results and radiological changes.
Postoperative wrist pain disappeared in a 12 joints during 14 joints in both procedures. Postoperative synovitis recurred in joint with Sauvé-Kapandji procedure. There was no postoperative weakness of the grip power. Postoperative range of dorsal-palmar flexion and radial-ulnar flexion of the wrist joint decreased in both procedures, while that of supination-pronation of forearm were maintained fairly good. Carpal height ratio decreased after operation, while ulnar carpal shift ratio, radial rotation angle and palmar carpal subluxation ratio did not change. Both procedures released from wrist pain and would have an advantageous effect on the postoperative developmental deformity of the rheumatoid wrist.

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The clinical results were compared between total wrist fusion and limited wrist fusion in 8 patients involving 5 post-traumatic arthrosis, 1 necrosis of capitate, 1 Volkmann's contracture and 1 replanted forearm. Ages at the time of operation ranged from 16 to 64 years old with an average of 41.3 years old. Follow-up periods ranged from 9 to 144 months and averaged 56 months. In patients with partial wrist fusion, the postoperative ROM of dorsi-palmar flexion or radio-ulnar deviation decreased nearly half of the preoperative ROM. Seven of 8 wists pain disappeared postoperatively, and the remaining 1 scapho-trapezium-trapezoid fusion for scaphid non-union developped painful arthritis followed by total wrist fusion. The overall activity of daily life in partial wrist fusion was superior than in total wrist fusion.
Partial wrist fusion would maintain the functional ROM of the wrist joint, while total wrist fusion would solve the intractable wrist pain with successful correction of the wrist deformity.

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A 67-year-old male sustained a fracture and dislocation of the right radial head with ipsilateral distal radioulnar dislocation in a traffic accident. Six days after immediate reduction and immobilization with a long arm plaster splint, open reduction of the fracture was performed and fixed with Herbert screws, supplemented by proximal and distal radioulnar transfixations with two K-wires in supination and long arm casting. Four weeks after surgery, the K-wires were removed and an active ROM exercise was started. Six months after surgery, he showed 135°of flexion, -12°of extension, and a full range of supination and pronation without pain.
Fracture, or fracture and dislocation of the radial head accompanied by distal radioulnar dislocation, which is quite rare, has been called Essex-Lopresti fracture since he reported two cases in 1951, following the earliest report made by Curr and Coe in 1946. Only 18 cases have been reported. All the cases in which the distal radioulnar dislocation had been overlooked or the radial head had been resected showed poor results. In any cases of radial head fracture, careful attention should be paid to the distal radioulnar joint. For treatment, restoration of the radial length by either open reduction and internal fixation or prosthetic replacement is extremely important. Resection of the radial head should never be done.

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This is a report on the clinical results of distal radial fractures with prompt reduction using percutaneous pinning. Forty-three patients were involved in a follow-up study which included physical and radiological examinations conducted over a period ranging from 2 to 87 months, the average period being 37.3 months. There were only a few patients who complained of lasting postoperative pain during exercise or who had any significant impairment during ordinary daily activities. None of the subjects of the study had any pinning-related complications. The technique appeared to be satisfactory on both the subjective level and on the level of the objective evidence. This method is easy to perform, maintains tight fixation, and allows for early finger motion. This leads to the conclusion that percutaneous pinning is one useful method for the treatment of distal radial fractures.

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We have performed percutaneous LASER disc discectomy for 34 patients with 56 lumbar herniated discs. Its indication is 1) resistant with conservative treatment, 2) leg sign is evident 3) protruded disc on MRI imaging is recognized. Operative procedures are as follows: first, stick the pilot needle into the disc under imaging with prone position. The diameter of the needle is enlarged with canula. Finally, a 2.5mm cannula is inserted and from that portal, Nd-YAG LASER was radiated through light fiver cable. Its' energy is 40W and is raditated until no resistance on the probe is felt. Preoperative and postoperative JOA lumbar score was used for evaluasion. Is all cases, postoperative JOA score was superior than that in preoperative period. Patients were satisfied to know successful results with minimal invasive operation in local anesthesia. Therefore, we conclude that PLDD is the safe, low invasive and effective treatment for lumbar protruded disc herniation, and its effect is more evident younger patients.

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A 12-year-old boy had lumbago and a left leg pain, presenting an antalgic gait. The lumbar X-ray film showed L₅ spondylolisthesis of 100% slip. After evaluating the state of the cauda equina by myelograms and MRI, we tried reduction by traction, but in vain due to a severe pain. Therefore, we performed such an operation as follows. First, by the posterior approach, we sufficiently released both L₅ and S₁ nerve roots and set pedicular screws. Although we, after that, accomplished the anterior release by almost complete transection of anterior longtudinal ligament, we additionally had to do partial spondylectomy to achieve reduction. Then, we did anterior interbody fusion, and fixed pedicular screws with rods. He is now able to enjoy a normal school life one year after surgery. We think that not only the posterior-and-anterior combined approach but also partial spondylectomy shall be considered for the reduction of severe spondylolisthesis.

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We report a case of lumbar compression fracture due to post-pregnancy osteoporosis. The patient was a 24-year-old female, who complained slight low back pain after her first delivery.
About two months after the delivery, an attack of low back pain occured. Plain X-ray showed fracture (compression type) of the L2 vertebral body. Double energy X-ray absorptiometry (DEXA) showed a reduction of bone mineral density (BMD) to 0.692g/cm².
The patient was treated with four weeks bed rest followed by bracing and rehabilitation. She refrained from nursing her baby, and calcium, vitamin D, and hormonal agents were administered. She recovered uneventfully and four months later, BMD had increased to 0.802g/cm² on DEXA.
The cause of her fracture might have been bone demineralization due to pregnancy, child birth and nursing her baby. Another reason was the small volume of her peak bone mass which may have been due to other aspects of her life style.

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In recent years, cervical foraminotomy under a surgical microscope has been performed in the treatment of cervical radiculopathy. The purpose of this study is to reveal the relation between cervical nerve roots and their surrouding structures using eight sets of cadaveric cervical spines. The cervical intervertebral foramen had a tubular structure with its entrance being the narrowest, while the nerve root sheath had a funnel-like shape with the branching site being the largest. In the foramen, the C4/5 disc located anteriorly to the C5 nerve root, while the C5/6 and C6/7 discs at the axillar portion of the C6 and C7 nerve roots, respectively. On the other hand, the C8 nerve root was separated from the C7/T1 disc in the foramen. The intrathecal C6 and 7 nerve rootlets passed behind the two successive discs to reach their respective intervertebral foramen. In the procedure of foraminotomy, it seems essential to have an adequate knowledge regarding the minute anatomy of the cervical intervertebral foramina.

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This report is based on our clinical results of 31 patients who were treated with automated percutaneous nucleotomy (PN) for cervical disc herniation. Their main complaints were radiculo-neuralgia resistant to conservative treatments.
The average improvement rate of JOA scores for all types of cervical disc herniation treated by PN was 81.2%, while the average improvement rate of the pain scores was 70.6% (out of a possible 6 points). It was found that they had no complications and comparatively slight decrease on cervical range of motion. PN may be the substitution for former operative treatments of cervical disc herniation patient if the problem is a pain caused by soft disc herniation and the patient is not paralyzed.
We have categorized discography findings for cervical disc herniations into subligamentous extrusion type herniations and epidural leak type. Categorized in this way, the former had a better average improvement rate of JOA scores and of the pain scores than the latter. Also, we distinguished those who had reoccurring pain at discography from those who did not. Categorized in this way, the former had a better average improvement rate of JOA scores and significantly better average improvement rate of the pain scores than the latter.
We conclude from the above-mentioned facts that better results on PN for cervical disc herniation can be acquired if PN is used for those who have reoccurring pain at discography and whose discography findings are not epidural leak type.

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For evaluation of the results of treatment of cervical spondylotic radiculopathy, we reviewed 30 patients with conservative treatment and 32 patients with anterior interbody fusion. The average age of conservative group was 48.9 years of age and that of operative group was 49.0. The average period of follow up in conservative group was 1 year and 7 months and that in operative group was 5 years and 6 months. The results of treatment were evaluated by Manabe's criteria. The score of conservative group after admission was 2.4 points and that of operative group was 2.1. The score of conservative group at the time of follow up was 4.8 points and that of operative group was 5.8. Most of the conservative group remained some symptoms, but their activities of daily life were good. All of the operative group obtained very good results and they returned to their occupation. We suggested that anterior interbody fusion was useful in selected cases of cervical spondylotic radiculopathy.

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Twenty consecutive patients surgically treated for cervical spondylotic radiculopathy were studied retrospectively. These cases were divided into two groups according to their predominant symptoms, group I with prominent radicular pain (n=9) and group II characterized by significant upper limb weakness (n=11). Although both groups showed marked clinical improvements following anterior decompression and fusion, the results were less favorable in group II than in group I because of the residual weakness.
Preoperative neurological examination revealed that the distribution of the upper limb weakness in group II patients was not limited to muscles innervated from one spinal cord segment, but had a tendency to involve distal muscles. In contrast, sensory deficits tended to be of a focal distribution rather than diffuse. Radiographically, preoperative MRI demonstrated that spinal cord compression was more common in group II than in group I. These findings suggested that the complexity of the clinical picture in some radiculopathies was related to the confusing association of spinal cord involvement.

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A consecutive series of 168 patients with cervical radicular symptoms were treated by microcervical foraminotomy. A hundred forty-nine of these patients followed up over 12 months (average 43 months) were included in this study.
The outcome was satisfactory in 63 of 74 (85%) radiculopathy patients, and in 54 of 75 (72%) myeloradiculopathy patients. The rate of the satisfactory outcome was higher for cervical disc herniation (76 out of 81 [94%]) than for other cervical degenerative diseases (51 out of 68 [75%]), including spondylosis in 54, ossification of the posterior longitudinal ligament in 15 and ossification of the yellow ligament in 2.
As compared to the anterior decompression surgery, the microsurgical posterior decompression enabled the patients to return to the previous daily activities earlier with the surgical result being almost equal to the previous reports of anterior procedures.
Our posterior procedure would be best indicated for the patient with cervical disc herniation located laterally or the patient with cervical myeloradiculopathy.

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Two cases of localized pigmented villonodular synovitis (PVS) in the talocrural joints of a 36 and a 27 year old women are presented. In one case, synovial invasion into the fibula was seen intraoperatively, and total synovectomy and curettage was performed. 7 years postoperatively, osteoarthritis in one ankle progresses without local recurrence. In the other case, erosion of articularcartilage was seen, and total synovectomy was performed.
Because of invasion into the bone, it is important to diagnose PVS early and proceed with treatment.

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We treated seven cases (5 males and 2 females) of osteoid osteoma, and examined their preoperative radiological findings and surgical results. The mean age of patients was 16 years (range 9-25 years). The location of tumor was intracortical area of femur in 6 cases and intramedullary area of tibia in 1 cace. Resection of nidus and iliac bone graft were performed in 6 cases and resection of nidus alone in 1 case. There was no local recurrence and preoperative rest pain and nocturnal pain in all cases disappeared after operation.
On preoperative computed tomography, identification of nidus was possible in all cases, but on preoperative radiogram, small nidus less than 5mm in 3 cases were not demonstrated. We examined pre- and post-operative MRI in 3 cases. The intramedullary high intensity area adjacent to the intracortical nidus on preoperative T2-weighted image was diminished after operation in all 3 cases.
The mechanism of intramedullary edematous change adjacent to the cortical nidus is still unknown. However, the postoperative MRI findings in the present study suggest that production of prostaglandins in the nidus, as Greco reported in 1991, or cytokines, such as interleukins may be associated with the pathogenesis of osteoid osteoma.

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Osteoblastoma is an uncommon, solitary, benign, vascular, bone and osteoid-producing tumor that is rich in osteoblasts and most often involves long bones of the extremities and vertebrae.
Recently, we have diagnosed and treated an agressive osteoblastoma of the fifth cervical vertebrae in a 55-year-old woman. Osteoblastoma usually occurs in posterior elements of the spine. This is an extreamely rare case as the tumor was in the entire vertebrae. According to Dorfman and Weiss, this shows atypical cytologic features that correlate with a tendency for local recurrence. Therefore, it is important to perform radical surgery for the treatment of agressive osteoblastoma. In this case, it was necessary to leave a small part of tumor because of the anatomical character of the spine. It is considered the tumor's progress must be carefully monitored.

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We report six cases of metastasic spinal tumor who were operated by Luque SSI (segmental spinal instrumentation) with bone cement fixation. There were five males and one female with a mean age of 64.3 years (range 59-71 years). There were two cases of prostate cancer, and one each of lung cancer, thyroid cancer, malignant lymphoma and of unknown cause. There was major metastasis in Th3 in two cases, and in Th2, Th4, Th7 and Th8, respectively, in each of the remaining four cases. All patients had paraplegia (Frankel grade C in four cases and B in two cases). We operated by posterior decompression and instrumentation (Luque SSI) in all cases. In four cases, anterior decompression from posterolateral approach by using CUSA was done. The range of fixation was set at above and below two or three levels from decompression area in all cases. Lower cervical fixation was performed in four cases. Postoperatively, radiation therapy was tried for all cases. The mean follow up period was 14 months (range 5-31 months). Five cases recovered on Frankel grading scale, four cases showed good result on pain grading scale and five cases showed recovery on ADL grading scale. Although, there was one minor instrumentation failure such as cutting of sublaminal wiring, stability of fixation site was maintained until final follow up in all cases. This study shows that the Luque SSI with bone cement fixation is a good method for management of metastatic spinal tumors, especially for fixation of cervical spine in cases with upper thoracic spinal metastasis, because it is difficult to use the hook and screw systems in such cases.

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We report a case of pyogenic spondylitis of diffuse lumbar spine vith involvement of the posterior element. The patient was a 74-year-old female who had severe pain around the lower back, which occurred following urologic disease with diabetes mellitus. MRI findings showed the abnormal signal intensity in L2, L3, L5 vertebral body and L3, L4 spinous process. Although we suspected metastatic disease, we could not eliminate the need for biopsy, which revealed the diagnosis as osteomyelitis. Even if MRI findings showed metastatic disease, clinical course and laboratory studies should be evaluated and diagnostic biopsy should be considered as a diagnostic possibility.

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1. 極めてまれな化膿性肩鎖関節炎の1例を報告した.
2. MRSAを起炎菌とするIVHカテーテル感染からの血行性播種により発症したものと考えられた.
3. 肩鎖関節切除により感染は沈静化し, 良好な肩関節機能が温存できた.

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A 20-year-old female broke her right femoral shaft, right patella, and bilateral distal radius in a traffic accident. Osteosynthesis was performed on her right femur and right patella using an intramedullary rod and a tension band wiring. Four weeks after the operation, the myositis ossificans was detected in the right quadriceps muscle at the fracture site. Despite the limitations on exercise of the knee joint and icing of the thigh around the ossification lesion, progression of ossification was observed on X-ray. Disodium Etidronate (EHDP, 400mg/day) was administered for 8 weeks continually. The ossification area was reduced after EHDP administration and bone union at the fracture site was completed without delay. Basal on this experience, we concluded that bone union in patients with fractures is not disturbed by the EHDP administration at the usual dose for the treatment of osteoporosis (200mg/day).

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We have reported a case of using rib-latissimus dorsi osteomusculocutaneus flap in reconstruction of chest wall defects caused by osteonecrosis due to radiation.
The patient was a 68-year-old female who was admitted with myasthenia gravis. Twenty-seven years ago she was treated by cobalt irradiation. After the initial irradiation, radionecrosis developed in her sternum and the overlying soft tissues. Several sequestrectomies were required, therefore, she was referred to our department for reconstruction of the chest wall. CT examination revealed the extent of radionecrosis in her sternum. There was extensive loss of soft tissues. A latissimus dorsi compound myocutaneus flap, containing rib was then marked out. After the opertion, minor wound complication occured, but other postoperative complications including respiratory insufficiency was not seen with rib-latissimus dorsi osteomusculocutaneus flap.
In conclusion rib-latissimus dorsi osteomusculocutaneus flap seems to be a dependable method for chest wall reconstruction.

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We had seven patients (six males, one female) with acute complete dislocation of the acromioclavicular joint. They were all treated using Rowe's procedure. The average age was 46.1 years old (range: 13-81 years), and the average follow-up period was 13.9 months (range: 5-27 years). The results were evaluated using Kawabe's score, and were rated as excellent in three patients, good in three, and fair in one. There was a low degree of in pain, high range of motion, and ADL, but no appreciable improvement in deformity. These results show that Rowe's procedure is useful patients such as elderly persons, or athletes who desire a minimal period for treatment.

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Posterior dislocation of the shoulder is uncommon, accounting for 0.9-3.8% of shoulder dislocations. Those associated with fractures are less common. We report one case of posterior dislocation of the shoulder associated with fracture through the neck of the humerus.
The patient was a 49-year-old female who sustained a posterior dislocation of the shoulder associated with neck fracture of the humerus in a traffic accident. Open reduction was performed, and the dislocated Numeral head was reduced and fixed with A-O screws. The follow-up period was 18 months. The postoperative JOA score was 87 points. The radiographs showed no evidence of avascular necrosis.
We emphasize the importance of CT scans in making the diagnosis of a posterior dislocation of the shoulder associated with fracture of the humerus.

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We evaluated glenohumeral range of motion and laxity in 550 high school baseball players and investigated the relationship between those characteristics and shoulder pain. The results revealed that all players exhibited a consistently greater degree of external rotation and a corresponding lesser degree of internal rotation in the dominant shoulder. However, there were no statistically significant correlation between ROM and incidence of shoulder pain. Shoulder laxity was evaluated with the Load & Shift test and the sulcus sign. Overall, 41% of the dominant shoulders exhibited laxity. Among those shoulders, there were 34% of the dominant shoulders with anterior laxity, 21% with inferior laxity, 20% with posterior laxity. The players who has laxity in their shoulders experienced early detection of shoulder laxity and a corrective training program should be considered to prevent shoulder pain.

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A retrospective study of six patients with cauda equina tumors is presented. Initial symptoms among our paitents were leg pain or low back pain. Pain was the most prominent clinical manifestation. In spite of the patient's subjective complaint, few objective neurological defects were observed. It is often difficult to establish a diagnosis in the early phase. The features of cauda equina tumor pain differ from pain due to disc herniation. The correct diagnosis was confirmed by myelogram in two patients and by MRI in four patients. The average interval until MRI diagnosis was 4.5 months, while that until diagnosis by myelogram was 12.5 months. MRI was useful for diagnosing cauda equina tumor. The physician should suspect cauda equina tumor if the patient complains of progressing or non responsive leg or lumbar pain.

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Plural myxopapillary ependymomas of the filum terminale are rare and only a few cases were reported previously. This report illustrates two myxopapillary ependymomas of the filum terminale in two cases, a 15-year-old girl and a 5-year-old boy. In both cases, MRI demonstrated intradural tumors in the upper lumbar spine and the sacrum. At surgery, the encapsulated tumors were connected the filum terminale, and invasion to the surrounding tissue was not evident. Piecemeal total removal was achieved and the posterior elements of vertebra was reconstructed. Histological examination reveal that both tumors in each case had similar histological presentation as myxopapillary ependymoma and the filum terminale between the tumors had myxomatous changes. In both cases, clinical course was uneventful. No evidence of recurrence and dissemination was also detected. And no remarkable neurological deficit was observed at follow-up. From the facts that the encapsulated appearance and myxomatous changes in filum terminale, it is suggested that each tumor may arise from different original site.

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Three cases of anterior spinal artery syndrome are presented. They included one man and two women, the age at onset of the symptom were 51, 47 and 51 years. The clinical course, neurological status, and MR imaging findings were studied from the onset to the chronic phase. One women showed Frankel A palsy throughout her clinical course. The other woman recovered from B to C and the man recovered from C to D. Dissociated sensory loss occurred in all cases. A linear high signal intensity area on T2 images was observed in all cases, and this area become more clearly defined in the anterior parts of spinal cord in the chronic phase. T1 images showed no signal change in two cases and a high signal area in one case. The region of the spinal cord which showed acute signal changes become atrophic on T1 images in the chronic phase.

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In case of constitutional disease of bone, spinal deformation may occur in the young days, leading to neuropathy. We reported a case of constitutional disease of bone, suffering from spinal bony ankylosis, and leading to spinal pseudoarthrosis after having the 10th and 11th thoracic vertebrae fractured by compression without apparent history of trauma. The spinal pseudoarthrosis might be attributed to the chronic stress concentration on the area fractured by compression. We applied anterior and posterior fusions using instruments and obtained good union.

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