We followed up six cases of resistant or recurrent congenital club foot, corrected by medial release operation, (Mc Cauley's method). Period for following up varied from two years and one month to nine months after operation. The eldest patient at operation was eight years and the youngest two years and four months of age. Correction in a plaster boot should be completed just postoperatively or within one to two weeks after operation. Operative elongation of tendo achillis was performed six weeks after the first operation in cases of incomplete correction of equinus deformity. Simultaneous elongation of Achilles tendon by medial release operatien should be indicated in cases of high grade equinus deformity.
1. We report a man, 42 years of age, whose trunk seems to be too short comparing with his lower extremities. 2. Clinical pictures show undescended testis with eunuchoidism that endocrine examinations revealed hypothyreoidism and adrenocortical hypofunction. 3. By radiographical examinations, epiphyseal cartilage of long bones of extremities remain ununited for 42 years and flat vertebral bodies with osteoporosis are presented.
Dysostosis craniofacialis is a rare and peculiar disease which was first reported by Crouzon in 1912. The condition is characterized by acrocephaly, exophthalmus, dysplasia of maxillar bone, etc. A case of Crouzon's disease was reported. The case was 13 year-old boy and his mother noted already deformity of his head 6 months after birth. At the age of one exophthalmus and visual disturbance appeared. Since 2 or 3 years of age he has had occasional headache and vomiting. According to Crouzon the disease is hereditary but present case had no heredity. The clinical symptoms was tower shaped head, exophthalmus, maxillar hypoplasia which resulted in malocclusion of the jaw, depression of the nasal base, and protrusion of lower lip, and marked disturbance of sight that aggravated mental retardation. In roentogenography of the skull pronounced digital impressions and deformity of the pituitary fossa were observed. Visual disturbance was due to the atrophy of the optic nerve. Pressure of the cerebrospinal fluid was higher than normal. Except elevation of activity of serum alkaline-phosphatase we found no abnormality in blood and urine. The disease is said to be caused by premature closure of cranial sutures, especially coronary and lambda sutures, though the cause of the closure in early stage is not yet cleared. As to the treatment the operative procedure should be carried out as early as possible, which is partial resection of the skull for decompression of the brain. Our case seemed to be too late for the surgical treatment.
We experienced 2 patients of osteoarthrosis alkaputonurica from one family tree. They are sisters. There are another two patients, father and brother, who were already dead and were supposed to have alkeputonuria from their clinical histories. Present patients have ochronosis in the auricles and sclerae. First clinical manifestation was low back pain and stiffness of the lumbar spine, radiating pain to the lower extremities and pain in the knee joint have gradually developed. Radiologic examination demonstrates degenerative changes and wafers-like changes of the intervertebral discs and so-called bamboo spine was partially observed. In analysis of serum protein α1 and α2 globulin increased and there was also increases of the calcium levels in the serum. The family tree indicates prepotent type of heredity.
In the extirpation of the intramedullary spinal cord tumor, the secondary push-out method by Elsberg was carried out so far. A 28 year old man with ulnar nerve schwannoma in the distal aspect of left upper arm was carried out the extirpation. Since the demarcation between the tumor and nerve fibers was not clear and the primary extirpation was afraid likely the nerve injury, the incision of epineurium was only performed and the wound was closed temporarily. At the reoperation after one week, the tumor was localized and pushed out medially. And then this tumor was extirpated easily without injury of healthy nerve fibers. The postoperative course was uneventful, and the shooting pain radiating from the medial side of upper arm to the left 4th and 5th fingers was disappeared completely after surgery. There were not the functional disturbance of the hand and fingers. It is noted that the secondary push-out method by Elsberg is able to apply for the tumor extirpation of peripheral nerve. Otherway, it was also reported a case of the great intramedullary tumor (lipoma) extirpating with this method.
A case of monostotic fibrous dysplasia which had onset at the age of three and had repeated treatments and relapses was reported. A girl was struck on her leg at the age of three and X-ray examination revealed bony lesion of the right tibia. She was diagnosed osteitis fibrosa and treated by curettage and bone graft. At the age of five she was told relapse of the disease. However, it was left untreated, as she had no subjective complaints. At 9 years old she had swelling and tenderness on her right leg and visited our clinic. Under the diagnosis of monostotic fibrous dysplasia of the right tibia curettage, osteotomy and bone grafting were performed. In consequence the symptoms disappeared. At the age of twelve when she was re-examined recurrent bony involvement again appeared at the distal site of the tibia where bone grafting was previously done. Curettage and bone grafting was again performed. At 37th day following operation, no subjective complaint is present. Each of the repeated operations resulted in satisfactory union of the grafted bone. However, at the peripheral portion of transplantion relapses of the disease were observed at the some time following each operation. Sufficient curettage and bone grafting should be considered. Bone graft was excised from the contralateral side of the fibula at each operation. Excised portion of the fibula showed excellent bony regeneration. Therefore, at each operation the graft was able to be taken from the same site of the fibula. A present, it shows also good process of regeneration following the last operation.
Case: 78-year-old woman. She was aware of a spontaneous tender swelling of the first metatarsal part of the right foot since June '62. The tumor had been incompletely incised or excised six times during the last four years, but within about six months local recurrence has repeated. At the time of her first appearance at our clinic (21st June '66), the tumor was as large as child's fist, and X-ray photograph of the right foot showed the remarkable bone destruction of the first, second and third metatarsus. Clinically it was diagnosed synovial sarcoma. Her right lower leg was amputated according to Syme's method (29th June '66). The patient remains well four months later, and chest X-ray photograph revealed no signs of lung metastasis.
The case was a woman aged 60 with liposarcoma in the soft tissue of posterior proximal portion of the left thigh. At first the tumor was clinically diagnosed a sort of benign soft tissue tumor. Excision of tumor was performed, but recurrence was observed at operation site. Post-operative irradiation had no effect with recurrence of the tumor. Therefore, amputation of the left thigh was done. However, it gradually became hard and the patient complained of severe pain. Grossly, it was lobulated and dark brown. Pathologically, it was undifferentiated myxoid type according to Stout. Liposarcoma of this type is difficult to distinguish microscopically, therefore, it is often dianosed incorrectly fibrosarcoma, rhabdomyosarcoma, etc.
Twenty-seven cases of cancer patients with bone metastases which resulted in the first manifestation were recognized at the National Cancer Center Hospital of Japan, from March 23rd, 1962 to December 28th, 1965. Among them 10 cases have primary site in bronchus, unknown in 7 cases, 5 in kidney 3 in prostate, 1 in thyroid, 1 in liver, and remaining 7 cases were not diagnosed their primary site with any of the clinical and cytological examination and autopsy. 4 cases, in which primary lesions were each of bronchus, kidney, prostate and liver, were demonstrated as the very interesting cases with regards to the diagnosis and treatment of the primary lesions and their bone metastases. Especially, in case of the bone metastasis of cancer of kidney radical nephrectomy was postulated to be performed if possible, despite of the evidence of wide-spread bone metastasis.
Some cases of low back pain are resistant to various conservative treatments. For such cases we have tried the epidural injection of dectan-suspension, and report the results of fifty cases. The effect of the treatment is evaluated in five grades: complete cure, remarkable improvement, improvement, no change, and change for the worse. The data thus obtained is examined from three points of view, that is, in relation to the kind of disease, the periods since the onset of the disease, and the frequency of injections. The conclusion is that a complete cure or remarkable improvement is often observed in the cases of sciatic pain, that the earlier the treatment is given, the greater the effect is, and that the injections seems to be limited to five or six. This method seems to be very helpful in confirming operative indication for intervertebral disc protrusion.
Two cases of spondylolisthesis, a 63 year-old male and 61 year-old female, with marked spondylotic changes were reported. Progressive sensory and motor disturbances appeared in their legs and their walk was very unstable. The male patient had a dysfunction of the bladder and rectum as well. According to the clinical, electromyographical and roentgenological examinations, the causes of their paralysis were thought to be a pressure on the nerve roots and cauda equina. Laminectomy for the female patient and laminectomy with spinal fusion for the male patient were performed with satisfactory recoveries.
In order to re-educate the spinal cord bladder, it is important to realize which type the cord bladder belongs to, either automatic or autonomous. The more correct information is obtained from cystometry, as a direct method, for differentiation between them. Anal reflex, ice water test, and the testicles squeezing test were done as simple clinical tests, comparing with the results of cystometry. Presence of anal reflex was well coincident with the automatic bladder, but there are some exceptional cases. Ice water test was not satisfactory for differentiation of bladder type, because the test was positive only in severe hypertonic bladder. The testicles squeezing test was always negative in the complete paraplegic cases with the lesion over the lower third of Th. segment level. However, the test was negative in many complete paraplegic cases with the lesion below L1 segment level. So, further studies are required on it's clinical significance. It was observed by cystometry of automatic bladder that contraction of detrusor muscle (increase in pressure) was not developed by the trigger action for micturition, such as percussion, massage and so forth. Therefore, it is speculated that the opening at the internal urethral orifice is primarily significant for micturition of paraplegia.
By using “Quadrilateral Socket” at the top of weight bearing brace instead of the lumbal corset, we could have following advantages. 1) Improvement of gait Hip joint is not fixed, so patients need not swing pelvis. Gait pattern looks closer to normal gait, furthermore, we can expect increasing of blood flow of bones. 2) Improvement of sitting position Patients can flex hips, so sit very easily. 3) 10-20% lighter than the lumbal corset types Problems are that we need prosthetic techniques in fabrication and still the price is cheeper nearly 20% according to the Japanese Welfare Law for Disabled.
In our hospital, 22 cases of Kienböck's disease were treated during 1958 to 1965. This series was discussed clinically and radiographically. The time of follow-up varies from 6 months to 5 years. Variation of the age, sex and site of these patients was same as other reports. In the conservative treatment, bone drilling and bone grafts good results were obtained only for the pain, but not for the restoration of the wrist joint motion.
Three cases of pigmented nodular tenosynovitis which located at the fingers were reported. The first case was considered to have relationship to a trauma. The second case had familial hypercholesteremia. In this case pigmented nodes were discovered at the both hand, elbow and lower limbs. All three cases was associated with hypercholesteremia which was considered to play an important role for the essential factor of the disease.
The so-called key-punchers disorders have chiefly orthopedic symptoms associated with some of ophthalmological and psychiatric symptoms and are not always peculiar to key-punchers. We have conducted a periodic physical examination for key-punchers once or twice a year, which has proved considerably effective. The items of the examination include a neurological test for tension sign, Adson's test, Morley's test, Tinel's sign, and checking tenderness, pain in motion and mass of the flexor tendons in the finger joint regions. An x-ray examination of the cervical spine is usually done with six radiographs taken antero-posteriorly, laterally, obliquely and with the cervical spine bending forward and backward. C. M. I. is employed for a mental test and Y-G test for a character test. Thus, the subjects are examined both physically and mentally. As the result, tension sign are positive in 52%, Adson's test 17%, Morley's test 38%, Tinel's sign 12.5%, flexion test 5.6%. As mentioned above, a relatively high incidence of positive reaction is noted in the neurological test. The subjects who are considered to be a neurotic by the Fukamachi's Judge show a higher incidence of positive neurological test.
Fourteen cases of habitual and recurrent dislocation of the shoulder joint were collected in the last ten years; sexual incidence was expressed either sex as 7 in male and 7 in female and the age varied from 12 to 37 years. 12 cases of them are anterior dislocation, the other 2 cases, posterior. 8 cases of the former were treated surgically with Oudard procedure (technique of Zinnaka). Follow up examination shows satisfactory results. One of the latter was operated with Nicola procedure. There is no recurrence of luxation for 4 years after operation.
Nine patients with posterior fracture-dislocation of the hip were reviewed after a post therapeutic period varying from seven months to eight years, and examined personally in an attempt to evaluate their functional results. Using criteria advocated by Stewart and Milford, the results were rated as excellent in four, good in one, fair in two, and poor in two patients. In those remained dislocated for more than one month no good result was obtained. Regardless of the type of treatment or dislocation, there was no satisfactory result in the cases which had elapsed more than five years after injury. This unsatisfactory results were principally due to avascular necrosis of femoral head or traumatic arthritis of hip. It cannot be overemphasized that too optimistic policy in treating traumatic dislocation of hip must be discarded.
Two cases of osteochondromatosis have been presented. Roentgenograms of the cases showed many calcified loose bodies in the joint and atrophy of bone. Loose bodies were attached by pedicles to the synovial membrane which was in the form of a papillary fold. The articular surface was normal. In the pathological study, the peripheral layer of the loose bodies was generally fibrous connective tissue, in which some part of the synovial membrane remained. Its interior was composed of fibrous, hyaline cartilage. The central areas showed new bone-like formation and degeneration of the cartilage cells. The etiology of osteochondromatosis is unknown. Several theories have been advanced in an attempt to account for the metaplasia of the synovial membrane. In one case of the subject there was a history of trauma of the right hip joint, in the other case the patient had suffered from chronic arthritis of the left knee joint. In addition to its predisposition toward neoplasma, osteochondromatosis may develop after trauma or chronic arthritis.
Intertrochanteric osteotomy for 33 cases of osteoarthritis and subluxation of the hip joint was performed at our clinic from July, 1956 to December, 1965. Methods of the operation were displacement osteotomy in 17 cases, displacement varus osteotomy in 10, displacement valgus osteotomy in one and varus osteotomy in 5. The results in 26 cases from one to 5 years after the operation were obtained as followings: 1. In majority of the cases, pain in the hip disappeared or diminished, and 76 per cent of 26 cases was satisfied with the results of the operation. 2. The range of motion of the hip did not mostly improve, and in some cases it decreased slightly. 3. Radiological findings were improved in 62 per cent of 26 cases. 4. Although varus osteotomy for congenital subluxation of young adults was excellent, it was discouraging for osteoarthritis of the dislocated hip. 5. Effect of the osteotomy seemed mostly to last long.
In present study dried animal and human bones were used, since there are so many factors as medullary bleeding which hinder adhesion of bone in vivo. Using TOM/100E type universal strain gage, tensile and bending strength were determined in each material. Aron αA was employed, because it has a rapid set time and is simple in procedure. Prior to applying the adhesive it is the most difficult preparation to grind bone horizontally so as to obtain the complete contact between the both bony surfaces. The results showed that the adhesive was relatively strong to tensile strength, but bending strength was extremely low which was less than 1/20 of tensile strength. If dimension of the bony surface becomes twice, the set time of the adhesive duplicates proportionally. Chemical osteosynthesis is considered to have severe problem as weakness for bending strenghth.
In the leg and foot fracture associated with open wound healing may be delayed because of soft tissue loss and damaged local circulation, non-union and osteomyelitis may result. Cross-leg pedicle flap is most useful in treating oppen wound and also it may promote bone union. This paper expresses follow-up studies of 23 patients applied cross-leg flap. Most of them are progressing favorably, but delayed cases combined bone infection are prolonged healing.
Two cases of fractures of the neck of talus associated with complete displacement of the body were reported with presentation of postoperative detail. Case 1. A 50 year-old male treated with an oprative reduction immediately after trauma, was studied by two series of intraosseous venographies 8 and 10 months following the operation. Case 2. A 7 year-old male with an operative reduction done one month following trauma, was similarly studied by transosseous phlebographies 3 and 6 months after the operation. In both cases, the process of consolidation of the talus fractures was ascertained by means of the intraosseous venography. Both patients have had a favorable postoperative course without undue complication and were allowed to walk without help of crutches. The transosseous venography seems to be of great value for evaluating revascularisation of fractured talus.
Combined cases of os calsis fracture and compression fracture of vertebra are not uncommon. In fact, eight out of twenty-two cases (36%) of os calsis fractures we have recently treated fall under this category. Recent employment of canvas traction in the treatment of compression fracture of vertebra has also made operative techniques for os calsis fractures easier to apply. However, in view of prognosis, we are faced with a dilemma that the discontinuance of his therapy at an early stage tends to cause re-crushing of recuperating vertebral body, whereas prolonged application may result in atrophy of foot bones, thus lowering working ability. Results of the above eight cases involved, including two incorrect diagnoses, have been: one:good four:fair three:poor. We shall now try to make investigations into the causes of poor results in the hope of contributing somewhat to the treatment of these cases.
We experienced one patient with insensitivity to pain which caused pathologic fractures and deformity of the extremities. The patient, nine years old girl, has clinical manifestations of insensitivity to pain, which are described in the literatures, as corneal opacity, no response to painfull stimula, scarred tongue, deformity of joint etc. From her clinical history pathologic fractures have easily occurred with no subjective complaint. In this case congenital leucopathia is also observed. It is difficult to prove insensitivity to pain.
The trial which positively conducts osteotomy and lengthens the shortened leg, has been reported much, but the cases over 40 years old have never been found among them. We tried to lengthen the lower leg with 46 years old patient who had been complaining of severe rolling of body when he walk, because of both hip joints tuberculosis resulted in ankylosis and shortening of a leg. The tibia was cut transversely, subperiosteally, leaving periosteum as it was, and it was lengthened one milimeter a day using Katayama-Hirakawa's Apparatus. Now, one year and seven months tollowing the operation, though slight bending of tibia and sensory disturbance in peroneal nerve region are noticed, walking and balance of body have been remarkably improved. The patient is satisfied to be able to walk very easily.