J'ai travaillé pendant dix mois à la Clinique Chirurgicale Orthopédique et Réparatrice, Centre de Traumatologie d'Hôpital Cochin sous la direction du Professeur Merle d'Aubigné comme un boursier technique de Gouvernement Français. Dans mon stage j'ai appris beaucoup de choses de la chirurgie orthopédique de la France. Parmi eux, les méthodes opératoires que j'ai l'intention de pratiquer avec beaucoup d'intéret chez nous sont comme les suivantes. 1) Greffe inter-tibio-péronière du traitement des pseudarthroses graves de jambe. (M, d'Aubigne) 2) Ostéotomie de varisation en plan oblique. (méthode de Merle d'Aubigné) 3) Arthrodèse de la hanche. (Merle d'Aubidné) 4) Prothèse total de la hanche. (Merle d'Aubigné) 5) Technique d'égalisation du fémur en un temps du traitement des inégalités de longueur des membres inférieurs. (Merle d'Aubigné) 6) Résection partielle des os long dans cas de la tumeur. (Merle d'Aubigné) 7) Opération de mobilisation du raideur du genou. (R, et J. Judet) 8) Butée ostéoplastique de la hanche. (R. et J. Judet) 9) Opération du traitement des luxation récidivantes de l'épaule. (M. Latarjet)
A boy, two years and nine months old, was examined because of abnormal gait with stiffness of the right knee. The child was born two weeks earlier than the expected terminal. Bougie was used at delivery because of mother's toxemia. The boy's weight was 4100 gram at birth. His development was normal and there was no history of injury or inflammation after birth. His mother noticed of a limitation of flexion in his right knee, when the baby started walking after fifteen months. On examination, the boy was healthy in general, but the range of flexion was from 180 degree to 155 degree in his right knee. Further forced flexion caused to increase the physiological lumbarlordosis and painless tenseness in his quadriceps muscle. No shortening of the leg or muscle atrophy of the thigh region was noticed. His hip and knee was normal on radiogram. Surgical treatment was initiated, as symptomatic therapy was ineffective. Anteromedial incision of the right thigh was made, followed by an incision of the quadriceps muscle. By the modified Putti's method, both tendo m. recti femoris and tendo m. vastus medialis were lengthened by 2.5 cm. The treated lesion was immobilized in a plaster in the position of extension of the hip joint and 110 degree flexion of the knee joint. The plaster was removed off at the eighteenth day following operation. The result of the operation was good and the gait became normal, none of disturbances were observed in his daily life.
The term “rickets” or “osteomalacia” may be only significant of a syndrome just as rheumatism, in which the excess of osteoid seam is formed by disturbed calcium deposition to newly formed bone. It is absolutely important to differentiate the type of rickets, as the treatment and the prognosis in each type is different one another. There are some processes in diagnosis as follows. 1) As for history, present illness and clinical signs, some characteristics are found in relation to the aetiology. The diagnosis is commonly done by x-ray findings and determinations of calcium, inorganic phosphorus and alkaline phosphatase activity in the serum. 2) In x-ray findings, changes which represent secondary hyperparathyroidism may develop in some types of rickets, especially in glomerular osteodystrophy. In addition, some marked radiological findings may also be shown in idiopathic hypophosphatemic osteomalacia. These findings, however, can not be useful in distinguishing the types. 3) The histological changes such as excess of osteoid, bone resorption, fibrosis and new bone formation, as well as much retained calcium following to calcium infusion can make sure of the diagnosis. 4) The most significant information of type differentiation is given from the biochemical findings and the functional tests of the related organs. 5) Existence of secondary hyperparathyroidism can be confirmed from calcium infusion and EDTA disodium calcium infusion tests. 6) As the biochemical determination does not demonstrate significant difference between Vitamin D deficient rickets and hypophosphatemic rickets, the observation of response to treatments is definite in those cases.
The repair of wide gaps in peripheral nerve injuries is the vexing problem. For this purpose many attempts have been made in the past by nerve homografts with no success. It is most important to reduce a immune foreign body reaction in nerve homografting. Marmor reported irradiated nerve homografting with success in dogs. Our Co60 irradiated homografting summarised as below. Thirty adult rabbits were used in this study. The tibial nerve grafts were excised and frozen immediately by dry ice, and stored at -20°C until irradiation. The grafts were irradiated by Co60 with 200×104 roentgen equivalent physicals in a frozen state and stored in a freezer. A two centimeter irradiated nerve was implanted intramuscularly. At one week after operation, non-irradiated implant was involved in a inflammatory cellular reaction, but no reaction about the irradiated one was observed. At two or three weeks there was no reaction around the irradiated implant. By contrast, marked fibrous tissue proliferation and destruction were observed about non-irradiated one. The irradiated nerve homografts were implanted between a gap of 3.5-4 centimeters of the tibial nerve. The grafts were sutured through the nerve sheath. Electromyograms showed Fibrillation Voltage at 1st or 2nd week after operation, low complex NMU Voltage at 15th week, normal NMU Voltage or High Amplitude NMU Voltage at 20th week in the case of good recovery. But in this case Fibrillation Voltage was observed in some area. Each graft was explored surgically. The Bodian strain was employed. Schwann cells proliferation about the plant and axis cylinder were visible. No cellular infiltration had occurred.
Previously we reported an experimental electro-physiologic study of ulnar neuritis to decide the cause, the indication of operative treatment and the chance for operation. In addition to the investigation, lesions resembling ulnar neuritis seen in the nerve compression syndromes were induced in rabbits, and the vascularity of this experimental lesions was examined angiographically. Material; normal and gently compressed confricted sciatic nerves with Vinyl-tube of mature rabbits. Method; This research was studied in detail by injecting a micro-suspension of barium sulphate into the rabbits' aortae of various levels and then displaying the injected vessels by microradiography of the nerve. Consequently, the slight angiographic findings were obtained by injecting the rabbits' arcus aortae of which aorta thoracica had been ligated. This fact suggests that the axonal vessels are the other important factor to the nutrition of rabbits' sciatic nerves and the early operation for the ulnar neuritis may be recommended.
Peripheral nerve tumor is one of the diseases liable to be overlooked in the usual clinic. Recently we have had four successive cases of peripheral nerve tumor. One of them was at the right plexus brachialis and the others were at the sciatic nerve and its ramification. As the results of histological examination, they were all found to be Schwannoma.
A case of the extradural cauda equina tumor demonstrating the bony involvement of the fifth lumbar vertebra and a dumb bell shape was reported. A man, thirty-three years old, had the low back pain and the radiating pain to the left lower extremity. In 1958, he complained of the above symptoms after the lumbar contusion due to the traffic accident. At Jan. 25, 1966, when admitted, he showed the left sciatica and the numbness on his left lower extremity, and his radiograms showed the widening of the spinal canal and the destruction of the fifth lumbar vertebra, and the filling defect due to pressure from the left side in the myelogram. The dumb bell shaped tumor was removed from the left side of the vertebral body (L5) extradurally and proved the neurinoma histologically.
A interesting case of extradural hemangioma was reported. A man, age of 27, admitted with disturbance of gait and general exhaustion in August, 1965. Myelogram revealed extradural tumor. A hemorrhagic, elastic and soft tumor was excised fully between 6th to 9th thoracic spine. Histologically it was cavernous hemangioma.
Two cases of fatigue fracture were reported. One of them was of a rib fracture caused by pingpong and the other was in the left tibia by hard training of marathon. Case 1. 29 years old, male. He had sudden pain on the right side breast during playing pingpong and visited department of internal medicine. He was admitted and treated under diagnosis of right exsudative pleurisy. After discharge from hospital, he visited department of orthopedics for closer examination. Then, the old fracture of right 6th rib was found in the roentgenogram. But the fracture had already appeared in the some roentgenograms taken during his admission. Case 2. 17 years old, male, high school student. He had pain at the proximal part of the left lower leg after everyday's hard training of marathon, and visited a surgeon. He was treated as osteomyelitis of the left tibia. Later, he visited our clinic and in the series of roentgenograms, periostal reaction and thickening were proved in the postero-medial cortex of the proximal third of the left tibia. He was diagnosed in our clinic fatigue fracture of the left tibia and applied a below the knee plaster cast for 2 months. And the fracture healed completely. The cause of the fatigue fracture of the rib by pingpong was discussed.
A male, thirty-seven years of age, sustained an injury on his left shoulder by a cut tree falling accidentally on him. He suffered from an acute pain and swelling on his left shoulder at that time but no medical treatment was given. One week later he returned his work. About five months later, there developed a painful stiffness on the left acromioclavicular oint. About eight months after the accident he visited our hospital. By radiographic inspection no luxation was observed, but there was seen an transluscent area about 8mm long at the outer end of the left clavicle. Blood tests showed no abnormal readings. The outer end of the left clavicle was excised about 6.0mm long. Four weeks after operation the patient was free from all percepitible symptoms. Histologically it demonstrates that the marrow cavities are filled with a fibrous tissue and numerous capillaries.
From the clinical as well as histological viewpoint, various types of mycosis fungoides have been reported, and was classified in reticuloendotheliosis or lymphoma, such as leukemia, reticulum cell sarcoma and Hodgkin's disease. As the entity is not obvious, it is rather difficult to make a exact diagnosis of the disease. The reports of the lesions involved visceral organs are not rare. In reviewing literatures, no involvement of the bone marrow by the disease had reported. We have come across a case of Vidal-Brocq type of mycosis fungoides. The patient, a 47-year-old farmer, was admitted to our clinic in March, 1965 and died in June, 1965. On autopsy the same histological findings was observed in the medullary cavity of the right femur as in the skin.
Out of 218 cadavera for autopsy, 16 (7.30%) defective neural arches of the 5th lumbar vertebra were found, of which 12 neural arches in 6 cadavera were examined histologically with serial sections. The results obtained were mainly as follows: 1. In osseous parts of the defective neural arches, it was found that bone trabeculae were scanty and atrophied, bone marrows were enlarged and changed in fibrosis and Havers's canals were also enlarged. Lacunar resorption was seen in the bone trabeculae near the defected area which was bordered with calcified plate. 2. The defected areas were occupied by connective tissues and fibrous cartilages mixed with hyaline cartilages. In peripheral part of the defected areas, proliferation and scaring of the connective tissues were seen, and in central part of them, fissures and vesicular degeneration were prevalent. Isolated bone particles, calcified tissues and cartilage islands were seen in some of the defected areas. 3. Inferior articular cartilage of the defective vertebrae was noticed to be more degenerated than superior articular cartilage.
In our hospital, cervical interbody fusion has been performed on 23 patients of cervical discopathy (including cervical spondylosis and cervical trauma) during the last 8 months. Discussing the cases, we noticed it to be very difficult to diagnose exactly the symptomatic level of cervical disc for reason of its miscellaneous neurologic symptoms due to multiple degenerative lesions, inspite of many diagnostic procedures. Therefore, we should not neglect that the involved disc exists even in the asymptomatic level except the level diagnosed through the systematic examination. In conclusion, it is recommended that the spinal fusion should be performed even in the suspected level adjacent to the symptomatic disc. It is reported that the pathogenesis of neuropathy in cervical spondylosis is the compression due to instability of the cervical spine or the posterior protrusion of its vertebral ridge and disc. We should remove these pathogenic causes. In some cases, we encounter the difficulties in the complete removal of osteophytes encroaching upon the nerve roots or the spinal cord by Cloward's method. Recently, we have obtained the good results by the modified Robinson's method that aligns the local kyphotic curvature of the cervical spine and eliminates the compression upon the nerve roots and the spinal cord by means of the insertion of the wedgeshaped bone plug into the intervertebral space.
Six poliomyelitic feet with cavus deformity corrected by fusion of the first metatarsocuneiform joint were reviewed. Postoperative period is too short to draw final conclusion concerning persistent end result, but this procedure proved to be safer, less traumatic, and effective in correcting the deformity. In some instances, however, additional procedures including the fusion of naviculocuneiform joint and tenoplasty in the sense of reinforcing or replacing the weak posterior tibial muscle were found to be necessary in the prevention of planus deformity.
Eleven patients of Coxa vara et magna following congenital dislocation of the hip joint and Perthes disease etc, were operated in our clinic from January, 1963 to April, 1966. Their chief complaints were pain in the hip joint and limp. Operation was performed with trochanter-plasty in combination with shelf operation or various types of intertrochanteric osteotomy, including adduction, abduction, detorsion and displacement osteotomy. The combined reconstructive procedures were indicated to improve the changes of acetabulum, femoral head and neck, which were different in each case. Following operation, shape of the hip joint was improved and pain on walking was relieved markedly, but limp has been improved not so evidently as expected. The authors think that our operative procedures are encouraging, but the treatment for Coxa vara et magna remains unsolved yet.
Five cases of calcium deposits in the menisci of the knee out of 5440 cases complaining of the pain of the knee joint in our clinic were characterized roentgenographically and symptomatically. One of these five cases was noted ossification of meniscus roentgenologically and histologically. Another one case revealed multiple calcification occurring in fibrocartilage disc and hyaline cartilage surfaces (elbow, hand, symphysis, hip and hand). The clinical evidence of these calcification was often very acute and resemble a septic arthritis, and called as “pseudogout” or “chondrocalcinosis articularis”. Otherwise, five menisci of 136 menisci removing from the knee joints of 34 cadavera revealed the finding of the spotted or linear calcification.
Cortical drilling or myelotomy was done on 8 patients who had severe pain for a long time and had not responded to conservative therapy such as aspyrin and intra-articular steroid hormone injections. Although these were followed up for only a short period, results of this procedure were satisfactory. Nine joints were relieved from joint pain immediately after the operation. Two of three patients who were followed up over six months had no pain and the other had recurrence of pain, Of two cases which had poor results, one had severe hydrops of the knees. The other is the patient who had had avascular necrosis of the femoral head before femoral cortical drilling for degenerative arthritis and arthrodesis was done. Partial relief of pain was seen in one case which had a 168° flexion contracture of the knee.
Recently fifteen cases, twenty-two joints, of neurogenic arthrosis have been experienced. Eighty per cent of them were older than fifty years of age, and the youngest was twelve years old boy. Five patients were male and ten were female. Six patients complained of mild or moderate pain in affected joints, but nine had no pain. Abnormal findings in the roentgenogram were observed in eleven knee joints (50%), three ankle joints, two lumbosacral joints, two hip joints, two shoulder joints and two elbow joints. Etiologically eleven cases (73.3%) were caused by tabes dorsalis, and the others were by syringomyelia, poliomyelitis, peripheral neuritis and unknown. In roentgenographic findings of the knee joints, there were noted lateral subluxation of tibial articular surface, periosteal thickness and marked bony changes, which were erosion or multiplication, at medial articular border of tibia and lateral articular border of femur in all cases. Analyzing dynamic actions in neurogenic arthrosis of knee joints on the bases of these findings, we assumed that erosion and multiplication of the bones were easily occurred at medial tibial condyle and lateral femoral condyle.
There are many difficulties in the treatment of fractures and dislocations of the talus. We experienced to treat the fracture of the talus with posterior dislocation of the body. We tried to reduce the rotated posterior fragment by Böhler's manoeuver without success. Then, reduction was performed by operation and two fragments were fixed with a Kirschner wire and a staple. In reducing the posterior fragment pushing the distal end of the posterior fragment backward was successful. After twelve weeks immobilization in plaster cast, the talus has been protected by ishial weight-bearing apparatus below the hip joint. At forteen months after the operation, the result is excellent.
In 1954, Kinmonth & Taylor demonstrated lymphatic system by intralymphatic injection of contrast material. The large number of studies were accumlated to this method experimentally and clinically. It is commonly proved that the lymphography is useful to diagnose a lymphatic metastasis. We performed lymphography in five cases which were Fibrous dysplasia, Haemoangioma, Fibroma, Myxofibrosarcoma and Osteosarcoma. The results are presented here. 1) A lymph node of benign tumor maintains normal size and architectual pattern (Fibrous dysplasia), or increases in node size and number without abnormal pattern (Haemoangioma and recidivation of Fibroma). 2) A case of recidivative Myxofibrosarcoma after 60Co therapy, reveals peripheral filling defects of lymph node and stagnation of afferent vessels by lymphography, but histologically fibrosis and atrophy are observed without lymph node metastasis. 3) A case of Osteosarcoma, 71 years old man, in spite of abnormal pattern by lymphography, demonstrats no lymph node metastasis histologically. Following the report by Malamos, a lymph node of old age reveals fatty degeneration and fibrosis, resulting a abnormal lymphatic pattern. 4) It is reported that the reactions of lymph node following lymphography are slight. By microradiography we observed a considerable number of defects which were filled by contrast material in lymph node and concluded that lymphography affected lymph node deeply morphologically.
A case of the giant osteoid osteoma is a 20-years old male who had complained of low back pain, especially at night for about last 6 months. Rentgenogram showed an osteolytic lesion in the pars interarticularis of the 3rd lumbar vertebra. The lesion has not conventional nidus formation (Jaffe.), without any definite demarcation from the surrounding structures. After the surgical removal, he relieved his complaint. Recovery and postoperative course was very satisfactory. After curettage, the specimens were franular and gritty. On microscopic examination, highly vascularized osteogenic connective tissue and osteoid tissue were observed, and also the trabeculae of newly formed osseous tissue and the proliferation of osteoblast were recognized in them. Clinically and rentgenologically our case is different in biological behaviour from conventional osteoid osteoma (Jaffe. Lichtenstein.) and belongs to the giant osteoid osteoma (Dahlin. and Johnson.)
We have recently seen one case of an uncommon bone tumor that was first reported by Jaffe in 1958 and called desmoplastic fibroma. The details of our case are following. A sixteen-years old male, college student, was admitted to Kumamoto University Hospital in April 1965, complaining of swelling in the distal end of left forearm which had begun two years ago. There was no history of trauma. When examined, the patient appeared to be good in general health. Local examination revealed the large tumor at the distal end of radius with slight tenderness, but no fluctuation or redness. The dorsiflexion and volar flexion of left wrist joint were limited passively, but there was no paresis of finger. The physical examination of chest and abdomen revealed no abnormality. Laboratory data: haemoglobin 15.6g/dl; red blood cells 509×104; white blood cells 6, 000. Chemical studies: serum calcium 10.0mg/dl: serum phosphorus 4.0mg/dl: serum alkaline phosphatase 5.8 Bodansky units, serum acid phosphatase 3.6 King and Armstrong unit. When the lesion was surgically exposed, a rubbery, whitish tumor was found that in general peeled out easily. Microscopically this tumor consisted of abundant, rich collagenous intracellular material in which there is a relatively small number of small consistently similar fibroblasts of benign appearance. The patient was without evidence of reccurrence one year after operation.
The reported incidence of Hodgkin's disease in bone varies widely from 10.7% to 34.0%, and radiographic evidence may be found antemortem in approximately fifteen per cent of all cases of Hodgkin's disease. Three cases with bone lesions were found among eighteen patients of Hodgkin's disease in our hospital in recent four years. The first case was a boy, seven years of age, with several nodules in the left neck and involement of the first lumbar spine, which resulted in a wedge-shaped deformity by the collapes of the body. This case were treated by Endoxan and Trenimon, following by irradiation. Relief of the pain and arrest of the bone destruction were obtained. The next case was a woman, twenty-six years of age, with enlargement of several supraclavicular lymph-nodes and later destructive involvement of the fifth thoracal spine. Chemical controls produced some remissions and regressions of the adenopathy, even though temporarily. The another case was a man, twenty-seven years of age, with adenopathy of the left neck and involvement of the right 9th rib. Treatment of the patient, by several chemotherapeutic agents (Endoxan, Vincristine, 6MP, etc.) and local irradiation of the bone lesion, were proved to be respond in some degree, but the patient resulted in death.