Department of Orthopedic Sasebo Municipal Hospital In orthopedic department of Sasebo municipal hospital, we had 101 cases of congenital torticollis during 84 months from April 1962 to March 1969. There were 85 cases available from our questionnaire or result obtained from direct examination. According to our study, we found that the cases of 59 boys and 42 girls, there were 56 cases of right torticollis and 45 cases of left region. There were 35 cases of normal delivery, 5 cases of caesarean operation and 10 cases of other obstetrical operations. Concerning complication, out of 10 cases, there were 6 cases of congenital dislocation of hip joints, pes valgus, cerebral palsy and ventriculal septal defect. 11 familiar cases were shown on our study. The most interesting cases were mirror-imaged identical twins ans brothers. We report these cases that are seldom found in the literature.
In congenital dislocation of the hip, twenty hips were followed up for two years or more after open reduction. Among them, only seven hips (35%) had satisfactory results radiologically and functionally. In this experience, it was found that the factors influencing the result were age at surgery, surgical technique, surgical trauma to the greater trochanter, and adaptation of hip. Especially, postoperative contructure of the hip and osteochondritis were seemed important factors. In conclusion, early complete reduction and good movement were necessary to obtain good result. For these purposes, not only so called open reduction involving excision of limbus, teres ligament, and fibro-fatty tissue in the joint, but also varus-derotation osteotomy, pelvic osteotomy, or shelf operation may be add if necessary.
Thirteen cases of congenital dislocation of 15 hips treated with another operations after initial one were followed. An average age of the patients at the time of the first operation, was 9 years and 6 months. The operations were 3 Colonna's capsular arthroplasties, 2 acetabuloplasties following closed reduction, 6 subtrochanteric or intertrochanteric osteotomies, 3 acetabuloplasties and 1 Campbell, s myotomy. The second operations were carried out on an average of 5 years and 9 months after the first one, The second or third operations were 5 acetabuloplasties, 7 subtrochanteric or intertrochanteric osteotomies, 1 Colonna's capsular arthroplasty, 1 trochanterplasty, 1 derotation osteotomy with trochanterplasty and acetabuloplasty, 1 subtrochanteric osteotomy with acetabuloplasty and 1 arthrodesis, The indications were made to relief pain in 14 hips, to restore the anatomical relation between the head and the socket in 2 hips and also the limping in 1 hip. Functional results obtained were normal in 1 hip, restored in 8 hips, unchanged in 4 hips and deteriorated in 4 hips at the average lapse of 4 years and 3 months after the final operation. X-rays of representative cases were shown with discussion.
Recently we had an opportunity to find two sisters cases of multiple epiphyseal dysplasia. Case 1, The patient was a 44-year-old housewife who compained pain in the hip joint and difficulty with walking. Her height was 119cm, and the distance between the extended fingertips of both arms was 125cm. Her fingers and toes were shorter than normal. Motor disturbances of hip joints, especially restricted adduction, abduction and flexion were noted. Radiographic study revealed flattening of the head of the femur and humerus, coxa vara and flattening of the condyles of the knee joint. Case 2, The patient was an elder sister of case 1, 57-year-old housewife who complained pain in the hipjoint, toc. Her height was 131cm, and the distance between the extended fingertips of both arms was 125cm. Osteoarthritic changes were seen in the both hip, shoulder, elbow, wrist, knee and ankle joints. We consider that this cases satisfies the criteria of Fairbank's triad.
We have found an unusual case of osteo-onychodysplasia associated with flat vertebral body and osteoarthritis of hip. The patient was a 19-year old female who complained pain in the hip joint. She was a short girl of 138cm. The physical examination revealed dystrophy of the nails, adiadochkinesis, flat vertebral bodies, dysplasia and motor disturbance of the knee-, elbow- and hip-joints, and other anomalies including lateral displacement of the patella and the presence of the iliac horn. This case satisfies the all four criteria of osteo-onychodysplasia, in addition to the symptoms of chondro-osteodystrophy, a very rare case worthy to be reported.
Recently, an extremely interesting case of melorheostosis was encountered at the Kagoshima prefectual Hospital for crippled children. A review of the world literature failed to disclose similar marked progression of the disease. Therefore this case is of sufficient interest to warrant a report. The diagnosis is made from its characteristic roentgen appearance. The charcteristic appearance resembling was flowing down the side of a candle is present in the streaked, sclerotic thickening on one side of the long bones of the limb. The condition was first described in 1922 by Leni and joanny. The patient was a boy of seven years old. He was first seen in May 1968, at the age of seven, because of Pes calcaneus in the left limb, and the condition was found incidentally on roentgengrams. Roentgenograms showed that in the left ilium, extending from the acetabulum upward, there was an irregular area of markedly increased density. The head of the femur the tibia, the fibula, and the tarsal bones, demonstrated similar sclerotic areas. Abnormalities of the soft tissues of the affected limb, was found, including scleroderma. Etiology and pathogenesis of Melorheostosis are unknown.
The patient is a 4 years old boy. His parent noticed the valgus deformities of the feet and the lameness when he was 2 years old. His mother has been also noticed the laxity of the joints and the velvetiness of the skin. At our clinic, we pointed out spinal deformity and lateral mobility of the knee. On examination, hyperelasticity in all over the body, especially in extremity, and hypermobility in all joint were admitted, but no scar tissue following to incurable wound which is characteristic to Ehlers-Danlos syndrome because of fragility of skin. Rentgenographical findings showed thoraco-lumbar kyphoscoliosis and both coxa valga, but no luxation of the hips. Laboratory findings was not abnormal. Histologically, connective tissue around blood vessels was sparse and elstic fibers were reduced or crowded.
Pulmonary disease associated with rheumatoid arthritis or collagen diseases were noted recently in Japan. Three cases with rheumatoid pneumonitis were reported while the patients with rheumatoid arthritis was treated in our clinic. They were patients with definite or classical rheumatoid arthritis, and had a cough, dyspnea, shortness of breath and sense of a vise. The Co-relation between the stage and the appearance of rheumatoid pneumonitis was not clear. The chest film revealed the fibrosing pneumonitis or diffuse interstitial fibrosis with a strand or nodular shadow. Respiratory examination revealed low function. The treatment using corticosteroid was successful for the rheumatoid pneumonitis.
In early rheumatoid arthritis, the hip joint is rarely affected. The hip joint is involved in severe classical rheumatoid arthritis and is similar to osteoarthritis roentgenographically in those cases. On the hip joint, in the early stage of classical rheumatoid arthritis roentogenographically general narrowing of the joint space and bone atrophy are characteristic. On the other hand, irregular narrowing of the joint space, new formation of bone cystes and spicular formation are beginning in the early stage at the weight bearing part. It is worthwhile to be followed up that oteoarthritic changes were noticed at the early stage of rheumatoid arthrits in a few cases treated with intra-articular injection of steroids into the hip joints.
The patient is 26 years old male who has been easy to suffer from wounds and burns on his extremity since his childhood. In 14 years old, he was suffered from incurable ulcer at the tip of his rt. 1st, toe. Same sort of ulcers grew on the toes of his both feet and the sole of it. foot recurrently. They had sometimes got well after the efection of some bone fragment. On Examination, sensory and trophic disturbances were admitted on his extremity. Rentogenographic findings showed destruction, absorption or disappearing of phalangeal, metatarsal and tarsal bones. We consider the cause of such mutilating changes of the bones is attributedrecurrent to be sensory, trophic disturbances and recurrent wounds accompanying infections. The basic disease of the patient may be syringomyely or such similar disease.
1) A vary of the subchondral venous congestion are almost agree with grade of degenerative change in the knee. In severe osteoarthritis, periosteal collateral vessels is defective. 2) After operation of intra-articular surgery and high tibial osteotomy, venous congestion is reduced and collateral vessels is increased. 3) In clinical investigation, operation was most effective for relief of pain and inactivity of the knees were improved. 4) In operative procedure of the knee, it is suggested that intraosseous circulation is accelerated.
Recentry, facial injuries are increasing in the frequency with the escalation in the number of automobile accidents. So called blowout fracture is the fracture of the orbital floor, which is caused by a sudden increase of the intraorbital pressure resulting from the application of a traumatic force to the periorbital soft tissues. In this paper, the clinical findings, and diagnosis, therapies of the blowout fractures about 14 cases are presented.
Neurologic complications of fracture of the pelvis are an entity rarely discussed and likely to be undiagnosed because of being obscured by the associated severe bony and soft tissue injury and because of a lack of awareness of the possibility of nerve demage. We encounted 5 cases of nerve injury as a result of fracture of the pelvis at the Kumamoto Rosai Hospital over the year 1968 to 1969. Classifying fractures of the pelvis in our cases, 2 cases had Malgaigne's fractures and one case separation of the symphysis pubis with fractures of the pubic rami and the ischium. Other two cases had fracture from the ilium to the acetabulum and fracture of the pubic rami and the ischium. All fracture of our cases correspondingly severe with the pelvic ring continuity brocken anteriorly or posteriorly. Although it is difficult to explain accurate level of the lesion in our cases, perhaps the lesion is thought to be due to damage at the plexus level. Especially the lumbosacral trunk was involved in all of our cases. The nerve damage was incomplete. All of the cases were treated with the conservative methods. The prognosis of this injury is comparatively good, although there may be weakness in the leg and hypesthesia in the foot. But the functional results of all cases are good, two cases returning to heavy work.
We present the fracture-dislocation of the hip joint in our clinc. 1) Fourteen cases (in our clinic) were all male. 2) Twelve these cases were produced owing to the motor car accidents and most of them were made by dash bord injuries. 3) According to the classification by Thompson, Type II are most popular. 4) It is very important to catch correct diagnosis for therapy and if the case have acetablar rim fracture, postero-obligue view is necessary. 5) Four of fourteen cases were accompanied with sciatic nerve injury 6) We made operative reduction with screw for five cases of the acetablar rim fracture. 7) According to the classification of prognosis by Thompson, Type IV and V are not so good but Type II and III show good result. The reasons of bad result often owe to arthrosis deformans of the hip.
Recently, the fracture associated with important head injury is going to increase owing to augumentation of the traffic accident, so-called “traffic war” in our district. At the point of orthopaedic treatment, it is more difficult than the other fracture: for example, especially the time of the operation and post-operative cure included rehabilitation. The clinical findings and the operative treatment of our 6 cases are presented respectively is this report.
The technique of tarsal V-osteotomy for the treatment of pes cavus deformity that was described by L. E. Japas in 1968 was reviewed. Our cases were poliomylitis 2 and cerebral palsy I, and their types of feet were anterior pes cavus deformity. Six weeks after operation, plaster cast was removed for roentogenographic examination. At this time, healing after V-osteotomy had occured and weightbearing was permitted. Cavus deformity of feet was almost completely corrected and did not show shortening of the length of feet as seen in the conventional operation. Any complication was not been found.
Femoral arteriovenous fistula (AVF) was performed and closed after a month in the dogs. Follow up studies were carried out on blood flow, blood pressure, angiogram, diameter of blood vessel and cardio-thoracic rate (CTR). The results obtained were mainly as follows: 1. Increased blood flow of femoral artery decreased considerably and blood pressure increased after closure of AVF. 2. Dilated proximal femoral artery recovered during three or four weeks after closure of AVF. 3. Increased CTR recovered within four weeks after closure of AVF. 4. Increased collateral vessels decreased after closure of AVF.
Three men of sixth decade, who had hypesthesia and paresthesia at the ulnar nerve distributions and atrophy of the hand muscles were reported. Everyone had evident osteoarthritis in the lower cervical vertebrae and in the right elbow joint. Though osteophytic formation at the ulnar side of the trochlea was similar grade in three men, only one had paresis of the right ulnar nerve due to campression by the osteophyte. In one of remains, surgical exposure of the right ulnar nerve showed dislocation of this nerve onto the tip of the medial epicondyle and slight cicatrical constriction at the proximal level of the epicondyle. The last one had the history that diagnosed as delayed neuritis of the right ulnar nerve and treated with no improvement. His symptomes and signs seemed to be those of due to peripheral lesion and oblique roentgenograms revealed no narrowed intervertebral canal between the seventh cervical vertebra and first thracal vertebra. But in lower part of the pectral major muscle there exist slight muscle atrophy. Electromyography showed polyphasic motor unit voltages and giant oscillations in this portion. Moreover, myelogram revealed defect of the nerve root contour of the eighth cervical nerve. After surgery, decompression of this nerve root was performed, immediate sensory improvement was obtained.
Abnormal callus formation around the hip joint were observed roentgenologically in paralysed extremities with injury of the spinal cord, and recognised 35 percent of callus formation among about 100 cases. Neurogenic arthrosis have been experienced in the roentgenogram in some cases: diffuse destraction and productive change in Bone. In these cases, resection of capsule and bone near the hip joint and covering the operative defect with the total thigh flap for the hip disarticulation, were performed. However, some difficult problems have been found.
Owing to the development of the chemotherapy, the conservative treatment of spinal tuberculosis has been effective. 1) A follow-up study showed that many cases had been cured with the conservative treatment for two to three years, but there were a considerable number of cases which had been treated more than five years. 2) The number and type of the surgery we have done, is as following: a) Posterior spinal fusion…76 b) Debridement by posterior approach…65 c) Debridement by anterior approach…23 d) Anterior spinal fusion…22 3) The clinical opservation revealed that most cases had been cured with surgical treatmant for one to three years and the cases cured with surgery for more than five years had been much less than that with conservative treatment. 4) As for the surgical procedure, anterior spinal fusion is thought to be most excellent procedure.
There are few reports on tuberculous tenosynovitis, but probably many sergeons encounter with the disease. We treated four cases of tuberculous tenosynovitis of the hand. Case 1. 35 aged male; Patient has had suffered from swelling and pain in the left middle finger for a year. He received curattage and removal of granulation tissues from the synovial tendon sheath. Tuberculous bacilli cultured from the specimen. Case 2. 21 aged male; Patient was injured in the left hand at the sea, followed by swelling and pain in the dorsum of the hand. He had curattage eight times for two years. Case 3. 59 aged male; He has had swelling and pain over the volar surface of the left forearm for one and half year. Many rice bodies were found at surgery in the tendon sheath. Case 4. 43 aged female; She has noted swelling and pain in the right ring finger for a year. At operation watery seropurulent fluid was found in the flexor tendon sheath of the ring finger. Frequently the correct diagnosis is not made for many months or even years because of the slow developement of the symptomes. The presence of a chronic dough-like sausageshaped swelling over the flexor or extesor tendons is practically always due to tuberculosis, and if rice bodies can be demonstrated the diagnosis is practically certain. The operative treatment with anti tuberculous drags are considerate the best.
This paper presents five cases of tuberculous tenosynovitis with special reference to them; four are males and one female. Lesion was located in the extensor tendon of wrist in two cases. These series contain two cases diagnosed as carpal tunnel syndrom and tumor at the early stadium. In all cases excision of tendon sheath was performed with vigorous anti-tuberculous therapy. Post operative clinical courses are satisfactory in all cases. Diagnosis was established by histological examination in four cases and by bacteriological examination in one case.
Pigmented villonodular synovitis, tenosynovitis, and bursitis are well known and not unknown. The etiology of this disease is unknown. Jaffe, Lichtenstein (1941) concluded that the lesion is an inflammatory response to some unknown agent and that the disease is not a true tumor or neoplasm. Prior to this time, this disease was known by varions names, including xanthoma, xanthogranuloma, giant-cell tumor, myeloplaxoma and benign polymorphocellular tumor of the synovial membrane etc. Microscoically, this desease is characterized by hyperplasia and proliferation of synovial-lining cells and undifferentiated connective-tissue cells of the synovial membrane with formation of large number of polyhedral or spindleshaped stromal calls. These cells may contain abundant lipid, hemosiderin, or both and multinuclear giant cells are common. A case of pigmented villonodular synovitis in the left ankle was reported in this paper. A nineteen year-old female was first seen on December 1968, with a complaint of pain and swelling in the left ankle. There was no history of injury. Two months before admission, the pain, which was present with use, but not at rest. There was a good, painless range of motion. Roentgenograms revealed no pathological findings. A diagnosis of bursitis in the left ankle was made. At operation on December 28, 1968, an irregular, nodular, yellowish, brown, soft tumor was encountered which extended from ankle joint into the Chopart-joint. A synovectomy, as comlete as possible, was performed, The microscopic diagnosis was pigented villonodular Synovitis.
An electron microscopic study has been made on an extra-abdominal desmoid tumor with several recurrence on the gastrocnemius muscle region of the right leg in a 24-year-old female. The tumor mass removed from the patient, of hard rubber-like consistency, was infant head-sized, white or yellow in colour, and the demarcation line was obscure. This tumor, histologically, presented an appearance of fibroma with a marked proliferation of the connective tissue. Electron microscopically, this tumor was composed of slender ficroblastlike cells and abundant collagen fibers. The cytoplasm of the fibroblast-like cells was filled with dilated cisternae of the roughsurfaced endopiasmic reticulum involving dense filamentous material, well-developed Golgi complex, and a great number of lysosomes. An extremely complexed shape of the tumor cell-nucleus with invagination or indentation was observed, and intranuclear inclusions surrounded by well difined double nuclear membranes were also frequently found in the nuclei. Another point of interest is that the collagen fibrils with an axial repeating structure of about 700 Å were seen in the matrix of the cell, sometimes surrounded by unit membranes. Mature collagen fibrils in the cell have been scarcely reported except in the case of sarcoma cells.
A male, aged 31 years, was admitted with complaint of swelling on outer aspect of his for two years. On physical examination, the swelling was remarkable, rounded and hard, and ulceration was found on its top. The gluteal and adjacent muscles became thin and atrophic. Radiograph revealed a voluminous cystic mass in proximal part of the femur which expanded eccentricall, showing thin layer of the cortex and coarse trabeculae in it. The femoral head and neck were completely destroyed. Under clinical diagnosis of aneurysmal bone cyst, disarticulation of the hip was performed and the stump was covered with the medial flap containing the adductor muscles. The excised tumor was measured about 24×13×12cm oval in size. The appearance of the cut surfaces of it was darkish red, encapsulated with the thin bony shell, and had many cavities of various sizes Histologically, fibrous tissues infiltrated with lymphocytes were found which were dotted with multinucleated giant cells and hemosiderine deposits. In another areas of the same specimens, many irregular cavities separated by fissues and lined with endothelial on their inner surfaces, so called benign vascular channels, were found. Three months after the operation, the patient is in good clinical conditions.
Case 1. Age: 40. Sex: Female. The patient complained of pain in the left shoulder and radiating pain to the left upper arm for two months before admission. Chest x-ray showed an expanding lesion of the left 1st rib. Resection was carried out July 24-1969. The resection specimen microscopically revealed at fibrous dysplasia of bone. Case 2. Age: 59. Sex: Male. The patient first noticed pain in the left shoulder on December 1968, and the pain gradually increased in intensity, radiating to the left upper arm. He was admitted to Nagasaki Atomic Bomb Hospital June 25-1969. Chest x-ray showed an osteolytic lesion of the left 1st rib. Surgical resection of the tumor was carried out July 10-1969. Section of the tumor mass revealed metastatic adenocarcinoma.
A case of plasmocytoma of the lumbar spine verified by necropsy is reported. A male aged sixty-four years had distructive lesion of the lumbar spine (L1, L2) with paraplegia in the early stage. A mass in the abdomen was palpable, proved to be extended from lumbar lesion on autopsy. Necropsy showed very rare dual tumor, Glioblastoma Multiforme with plasma cell infiltration in the left temporal lobe. There was no marked plasma cell infiltration on the other organs and no remarkable amyloidosis. The Tumor was a γ-A Myeloma. This is a relatively rare case of Myeloma metastatic to the nervous system.