It is said that the causative factor of spina bifida is due to the disturbance of growth of the neural tube. Spina bifida is classified to two types, one is spina bifida occulta which is due to abscence of laminae and pedicles without sac-formation, the other is spina bifida cystica which is reserved for conditions in which a sac of dura mater and arachnoid protrudes through a cleft in the vertebrae. Now we experienced two cases of spina bifida occulta associated with epidermal cyst which is relatively rare as the tumor of the spinal region. Case 1. Male aged 4 years. Chief complaints are tumor formation at the lumbosacral region and deformity of bilateral feet. At the age of 3 years, the patient visited our clinic and was diagnosed spina bifida cystica with congenital club foot. After treatment of congenital club foot, plastic operation of spina bifida was performed. Fatty tumorous mass coming from subdural region was found and sac containing liquor or nerve root was not proved. The conditions after operation were not improved. Case 2. Female aged 30 years. Chief complaints are movement disturbance of right leg with hypaesthesia or anaesthesia of bitlateral lower legs. Disturbance of urinary bladder and rectum is not recognized. X-ray photo showed the defect of laminae at sacrum. At plastic operation, tumorous mass was found at the lumbar region and was resected but nothing resembling meningocele or sac containing liquor or nerve root were found. The conditions afer operation are improved especially in gait and sensory disturbance in left lower leg.
A 48 year old woman. Her early complaint was difficulty in walking. One year previously the patient first complained low back pain. These complaints increased gradually, being accompanied by sensory disturbances of the lower extremities. Two months later she felt clumsiness in the legs and gradually became incapable of standing. On X-ray and surgical findings broad ossification of the posterior longitudinal ligament were observed mainly in the thoracic and also in the lumbar region being accompanied by those of other spinal ligaments, such as anterior and interspinous ligament, as well as ligamenta flava.
We report the four cases of the spinal cord tumor which we have experienced recently. Case 1. female … aged fifty was a neurinoma occured in the canda equina. Case 2. female … aged thiry five was a epidermal cyst occured in the nineth thoracic vertebral region. Case 3. male … aged fifty seven intramedullary astrocytoma which occured in the region of the fourth thoracic vertebrae. Case 4. female … aged eighteen was a meningioma occured in the extradural space of the fourth and fifth thoracic vertebrae. In the case 1. 2. 4. tumors were operatively almost completely resected, but in the case 3. unable to resect. Consequently in the former, symptom (sensory and motor disturbance) has obviously improved and deminished, but in the latter not improved and deteriorated.
Vascular diseases of the spinal cord are rare when compared with cerebro-vascular diseases. Two cases of anterior spinal artery syndrome were reported. The initial symptome was pain at the level corresponding to the lesion. Temporal profile was characterized by abrupt onset and rapid evolution, the syndrome being completed in hours or days; a partial recovery occurred in a period of weeks or months. And also, in five autopsy cases of the spinal cord injury, no changes of the anterior spinal artery could be recognized.
This paper reports an autopsy case of a patient who died of complication of pneumonia four months after cervical spinal cord injury. The X-ray photograph of cervical vertebra was normal before his death and there was an anesthesia below the level of C4. At Autopsy, tears of intervertebral disc were observed between the vertebral body C3 and C4, and also between C5 and C6. At these points, intervertebral discs were prominent toward cervical spinal cord which was compressed and flattened. According to the histological examination, deviation and degeneration of sensory nurve fiber were seen in the central side from the injured part and deviation and degenertion of motoric nurve were seen in the peripheral side.
Anterior cervical fusion has been performed on the patients suffering with the cervical osteochondrosis and cervical injury such as whiplash injury in our clinic. All patients were operated on according to Robinson's or Cloward's method. Badicular symptoms had been found in all patients and the spinal cord compression symptoms in 23 patients before surgery. Anterior interbody fusion was carried out at the C4-5-6 levels in 9 patients, the C5-6-7 in 8 patients and the C5-6 in 4 patients etc. Ninety-two percent of the patients showed the improvement of Barré syndrome. In Barré syndrome the relationship between the results of the operative treatment and the level of cervical fusion was not clear.
As the operative procedure for lumbar spondylolysis, spinal fusion is generally performed, however, this method has weak points of the influence to the neighboring intervertebral disc and the limitation of the spinal movement. It is considered that spinal fusion should be performed for the case with discogenic intervertebral instability and the laminal instability, on the other hand, bone graft in the separated part of the lamina for the case with only the laminal instability. On the basis of this consideration, for 4 cases, we performed bone graft in the separated part of the lamina by bone plugs and transient fixation of the lamina and spinous processes by a metal spike-plate. All the cases had good ossification and normal movement of the lumbar spine, and were released from the lumbosacralgia.
The total of operations for lumbal disc lesion in the last nine years is brought up to 193 cases (146 male and 47 female). These operations are composed of 25 cases of laminectomy, 122 cases of Love's method and 46 cases of anterior fusion. We have carried the anterior fusion out for salvage operation against poor result cases owing to posterior approach, severe disc degeneration, so-called unstable vertebrae and pseudolisthesis and so on. We make it a rule to be based on extraperitoneal route, except 3 cases of transperitoneal route. We have 3 cases of vascular lesion, thrombophlebitis and transplantated bone dislocation as complication of this procedure.
(1) By the use of drain with a vaccum bottle (Redon's drain), quantity of post-operative bleeding in orthopedic operations of 323 patients (352 operations) were observed. (2) In total average the post operative bleeding indicated 23.1 per cent of blood loss during surgery. Especially the quantity of post-operative bleeding in hip joint and lumbar spine operation more increased. (3) The quantity of post operative bleeding in 21 reoperative cases increased 59 per cent more than that in first operation. (4) This method observation was of use easily to determine quantity of blood and solution transfusion in post operation.
A 31 years old male, who had been playing golf for 6 months, felt severe pain in his neck and back right after his tee shot. X-ray showed fracture of the 7th cervical spinous process. He was admitted and the fragment was removed surgically. Four months later, he resumed playing golf, and two weeks after his starting exercise, he felt same pain in his neck after his swing. X-ray revealed 6th cervical spinous process fracture. The fragment was removed and post-operative course is satisfactory. Significance of this case are 1. No figure of fatigue fracture at the 6th cervical spinous process was evident. 2. This type of fracture might be misdiagnosed as simple neck and back pain. 3. Patient's particular swing form, pulling his chin to chest, might be one of the causes of the fracture.
Fifteen cases with so called Galeazzi facture were seen and treated in our department and Kyushu Rosai Hospital for last ten years. These cases were reviewed clinically and radiologically for further evaluation of the treatment. From the radiological point of view, two types of this fracture were pointed out according to the site of fracture of radius. One is the classical type, fracture of distal one third of the shaft of radius with dislocation of the distal radio-ulnar joint, and the other, fracture of proximal one third of the shaft of radius with the dislocation. Eleven cases were classified as the classical type, and four cases as the second type. Follow-up result for the classical type revealed that immediate open redution with fixation of fracture of radius with a plate and screws gives the best result and that closed reduction ends up with poor result in most cases. Arthrography for the radio-ulnar joint could contribute to make a diagnosis for rupture of the articular disc and dislocation of the joint.
1. The studies on bending strength of rabbit tibia was performed using our invented instrument. 2. The bending strength after osteosynthesis to the fractured tibia was gradully increased up to seven to nine weeks after surgery, and decreased thereafter because of the cancellation of the bone cortex. 3. According to above result the bone union is expected in seven to nine weeks after osteosynthesis. 4. After removal of the plate which inserted for internal bone fixation, in seven weeks the bone bending strength increased gradually thereafter.
A case of interarticular horizontal dislocation of the patella in a 27-year-old male was reported. The dislocation was occurred when falling down in a brook. Aftor closed reduction was failed, open reduction was carried out on the following day of the injury. The quadriceps tendon was not ruptured, the patella detached from the quadriceps apparatus and cranial part of the patella was interposed between the articular surfaces. The patella was pulled out and reduced to the original site without fixation to the quadriceps tendon. After 5 months, the knee joint was in a full function.
Fracture of the articular surface of the patella is uncommon. This paper reports a case of this rare fracture which we encountered lately. The patient was a 13 year old girl student who was admitted to our department on February 19, 1971. According to the patient's statement, she stood up on her tiptoes and twisted her left knee in the classroom for writing on a blackboard. Suddenly she had severe pain in her left knee and could not walk thereafter. In the physical examination, the knee showed tenderness, marked swelling with ballotement of the patella, pain in flexion, and limited range of motion. Roentgenographic studies of the knee showed a bone fragment between the patella and the medial condyle of the femur as well as partial defect of the articular surface of the patella. The excision of the fragment was done on the 12th hospital day and the fracture of the patella was confirmed. The limitation of the range of motion was gradually decreased postoperatively, and became almost normal on the 48th postoperative day. The pain and tenderness of the knee disappeared as well.
Five cases of so-called tangential osteochondral fracture of the knee joint, of which the fracture lines were tangential to joint surface of the femoral condyle, were presented. This type of fracture is frequently overlooked and become easily to be chronic. While the majority of reported cases were caused by sport, four of our 5 cases were caused by severe traumas except one. Two fresh cases were treated by open reduction and the other three by extirpation of the fragment with excellent or satisfactory results.
During 1956 to 1969, 40 patients have received treatment for fracture of the lower end of the femur at the Nagasaki Rosai Hospital. Of these, 20 patients were followed, and their follow-up studies reported. In the 20 patients, 5 cases were treated by closed treatment, and 15 were operated on. The results obtained are excellet in 9 cases, good in 3, fair in 2, and poor in 6.
During past few years, the operation was performed on 22 cases with fracture of the distal femur. Patients were 17 males and 5 females, aged from 5 to 60 years. Methods of internal fixation of the fracture were as follows. 1) 7 cases were perfrormed with blade plate fixation, including 3 cases fixed with tibia bolt simultaneously. 2) 4 cases were fixed with plate, including 2 cases with tibia bolt fixation. 3) 3 cases were fixed with only tibia bolt. 4) 3 cases were fixed with only screws. 5) 3 cases were fixed with dual intramedullary nails. 6) 2 cases were perfrormed in other methods. In comparing with these operation methods, dual intramedullary nailing resulted excellent in stability. It's easy to remove the nails, but the indication of the method will be restricted in number. Technique of the intramedullary nailing is rather difficult. The crossed scrow fixation cloud be obtained good stability only when used thick one. T fracture of the condyle should be fixed with blade plate and tibia bolt. Operation was performed in early stage, revealed better result than in late stage. Anatomical reduction and firm fixation are important for early exercise to move.
We have experienced the five cases of the tibial plateau fracture in early half year. Case 1. lateral condylus tibiae and eminentia fracture, 2. completely unstable fracture, 3. crush fracture of lateral condylus, 4. local crush fracture, 5. split fracture of bilateral condylus. Case 2. 4. 5. were achieved with closed method, but after 2 months case 2. was achieved open reduction, bacause its calcification had been poor. Case 1. 3. were performed by open reduction and internal fixation and immediate mobilization of the knee. We have only 5 cases and had not followed longer than a half year, so this report should not be considered result study of fractures of the tibial plateau. Charles and other many writers have reported, “It is important that fracture of the tibial plateau are treated by surgical reconstruction and by immediate mobilization of the knee.” Our results of open reduction are agreed with its tenet, and those ranged between excellent and good of Hohl and Luck's grade.
Ten cases of arterial injury associated with fracture of the lower extremity for the past 12 years were reviewed. Eight cases were caused by traffic and the remaining two by industrial accidents. Two cases were femoral, five tibial and three both fractures, and the injured arteries were three femoral, five popliteal and two tibial arteries, being adjacent to the fracture sites. Although surgical repair of arterial injury has come recently to be successfully applied for its acute stage, diagnosis and initial treatment were easily delayed and our cases had showed already the distal ischemic necroses at admission. Except one case with a false aneurysm of the posterior tibial artery, amputations were finally performed for other nine cases.
Seventy cases of juxta-articular fracture in the knee, seen in our outpatient clinic from January, 1960 to December, 1970 were reviewed by correspondence and examination. Eighty eight fractures in seventy cases except fracture of the patella as follows: twenty-one fracture sites in supracondyle femur, eleven in the condyle with joint surface, four only in the condyle, twelve in the intercondylar tubercle area of the tibia, thirteen in the condyle of tibia with joint surface, four only in the condyle, fourteen in proximal a third of the tibia and nine in the head of fibula. Age of the patients ranged between four to sixty-six. However, this type of fracture is more common in male paients from second decade to fourth decade. Follow-up results were reviewed from a point of view of deformity, pain, instability, and range of motion of the knee joint. Fractures in tibia remained in wide range of motion in the knee joint, but that in distal end of the femur of the adult, even only in a condyle, in poor result in range of motion. Conservative treatment, such as traction, etc, revealed better result than operative management. It is cosidered that generally speaking, operative treatment was selectively done in severe cases with dislocation of fracture fragment, and surgical maneuvering might add injuries in the soft tissues around the joint. Six cases out of twelve with the intercondylar tubercle fracture were revealed non-union but remained in wide range of motion unless associated with other complication.
Follow up investigation on the fracture of knee was performed in 70 patients that were treated from 1955 through 1970 in our clinic. On the fracture of the knee except for patella, 16 cases were non-operatively and 23 cases were operatively treated. Ten cases out of 23 cases with operative management were applied to the K-U compression blade plate. It was clarified that the operative treatment with early movement and no plaster fixation gave the excellent result both anatomically (radiologically) and functionally. Regarding these point, it was proved that the K-U compression blade plate was one of the most excellent ideal tools. On the fracture of the patella, 31 patient were treated in our clinic. Some of them were excellently trated using the wire acording to the Pauwels' method. The fracture of the knee inclusive of patella should be treated according to not only anatomical but also functional standpoint, and especially in order to obtain the functional reduction, it might be necessary the useful rehabilitation planning.
114 fractures about the knee joint treated in our clinic during the years 1961-1970 were analysed. Of these fractures, twenty were distal femoral fractures (nine treated by operation), forty-four were proximal tibial fractures (twelve treated by operation), and fifty were patellar fractures (twenty-two treated by operation). As for the range of knee mortion, generally the cases treated conservatively were better than the surgical. Only the fourteen patients of fifty who were sustained of the patellar fractures were traceable. Two years was regarded as the shortest time after injury, ten years was the longest follow up; the average was four years. The followed patients had all normal function of the knee except two patients who were resected the patella, and no degenerative joint change was found.
The follow up result of 33 cases lower femur end fracture was reported and the difference between open reduction and closed reduction was compaired. The result was following. 1) The Range of Motion 2) Amako's Criteria with regard to the function of the knee joint, the jnjury of the supra patellar poach must be most carefully treated.