A man aged twenty complained of increasing pain and swelling in the left thigh of one year duration. The pain was severe at night. On examination there was palpable sclerotic swelling over the posterior and lateral aspect of the mid-shaft of the femur. A radiograph showed a fusiform enlargement of the mid-shaft of the femur with dense cortical thickening and sclerosis around a small cavity of an osteoid osteoma. At operation the lesion was excised from the femur in a block of bone. Histological examination confirmed the diagnosis of osteoid osteoma. Since operation the patient has remained free from symptoms.
Fifteen cases of cancer patients with skeletal metastasis as the initial sign were reported. Among them, 5 cases have their primary site in bronchus, 2 in Prostate, 2 in liver and 1 in stomach respectively. And in remaining 3 cases, we could not find their primary site in spite of the clinical, cytogical and autoptical examination. Bicides, We are now examining their primary site in 2 cases. We also reported 2 cases of the skeletal metastasis of hepatom which were diagnosed by necropsy.
Recently, we had an opportunity to perform the wide block resection of the affected bone in three cases of chondrosarcoma originated in the scapula and pelvis. In these three cases, it was found that the histological findings were well differentiated. Concernning to the case originating in the scapula, we succeeded in the total resection of the tumor including the sourounding muscles. There are no evidence of local recurrence and shoulder joint retains moderate range in motion. Concernning to the case originating in the pubis and ischium proliferating of the tumor in the pelvic cavity and adhesion to the intra-pelvic organs were remarkably seen. And, it was thought that total resection of the tumor was difficult. So that, post-operative Tele-Cobalt irradiation therapy is now being performed. Cocernning to the case originating in the iliac bone, the iliac wing was resected including the affected area. And, we could recognize several cartilage foci on the cut surface. It is suggested that the tumor is a secondary chondrosarcoma caused by the malignant change of the cartilage foci. So that, it is thought we should look out for malignant change of the remainning cartilage foci.
In 1943, Inclan described three cases which had large, calcific masses in the region of major joints. In 1899, Duret published the original account of this disease for the first time. Our case, sixty aged woman complained of a lump in the posterior part of the left shoulder in Feburary, 1970. Characteristic findings of this disease are large, painless, calcfied masses in juxta-articular sites predominantly on extensor surfaces, particularly around the elbow and hips. There is no elevation of the serum calcium or phosphorus and no associated renal disease in this disease. There is evidence of familial or racial predisposition.
We have recently experienced an intersting case of giant cacinosis cutis. The patient, a 12 year-old boy, noticed tumor to each of the posterior cubital region and the left gluteal region. He said he has received a blow on his cubital and gluteal regions one month before. Tumor was cystic, fluctuant and fixed. When punctured exploratory, creamy material exuded slowly. His physical examination does not show any abnormality, except fo the high value of alkaline phosphatase (24.4 K-A unit). We removed this tumor completely with difficulty. His post-operative function is normal in every way.
A new design of the dorsal flap for Syndactyly operation resuled in the change of the position of suture line in interdigital space. This design of the flap improved the follow-up results of the operation.
Congenital dislocation of head of radius without associated synostosis between radius and ulna is very rare. Recently we had two cases of this condition. Case 1; 16 year old boy had deformity and feeling of fatigue around the right elbow joint. He has full range of motion of the joint. However there are clicking noises in the movement at the 90° extension and the 65° flexion of the joint. He has no history of injury to the elbow. Radiographic examination of it showed anterior dislocation of the head of the radius with dome shaping on its upper surface. Case 2; The mother of this 1 year and 10 month old boy noticed clicking noise in the left elbow when moved. He has no restriction of the joint motion. X-rays showed anterior dislocation of the head of the radius.
A twelve years-old girl was sent to our clinic. She had sarcoma-like findings after the fracture of right humerus, and congenital dislocation of bilateral radial heads. Her serum alkaline phosphatase showed high level. Microscopically the tissue surrounding the fracture site seemed to be reactive callus formation, containing giant cells and enchondral ossification. She was treated with corticosteroid, but excessive callus did not cease to grow. Her father had similar past history i. e. repeated fractures and hyperplastic callus after the fracture. Her aunt also had fracture of right fibula followed by tumor formation at the age of ten years old. Resection of the fibula and surrounding tumor was performed. Microscopic diagnosis by pathologist was chondrosarcoma, but she is now alive fifteen years after the operation. Other roentogenological findings of this family are thin cortex and radiolucent zone at the metaphysis of long bone in childhood.
The purpose of this paper is to report the late results of congenital pseudarthrosis of the tibia. There are eight patients diagnosed congenital pseudarthrosis of the tibia, and six of them were followed up. Four of them were treated by intramedullary nail or onlay graft, and had bone-union, while other two were amputated. Experience have shown as following. 1. The dormity of anterior bowing is apt to relape during skeletal growth regardless the treatment. 2. In two cases, there are compensatory elongation of the thigh of affected limb. 3. Amputations were done in the case of chronic osteomyelitis and the case of very large bone defect. 4. The success of osteosynthesis is influenced by the patient's age. 5. The best treatment is that the intramedullary nail is used to protect the deformty during infancy, and the osteosynthesis is attempted during childhood.
Osteogenesis imperfecta has been reported more than 400 cases in Japan. But family cases are rare. Osteogenesis imperfecta is characterized by fragility of bone, deafness, blue scierotics and laxity of joints. We have experienced six cases in one family that consist of a mother, four sons and a granddaughter. Our cases have suffered from fracture from several to about 16 times. Blue scierotics was noticed in two cases of the family. Deafness was noticed in five cases except a granddaughter. Recurrent dislocation of shoulder was noticed in three cases of the family. Dwarfing was watched in all cases. Varus deformities of the femurs are dominant. Scoliosis of the vertebral bodies was in one case, hyperlordosis is in two cases, and kyphosis is in one case. But deformity and functional disturbances of upper extremity were within normal limits in all cases. Serum level of alkaline phosphatase was sightly elevated in one case.
It is shown by many authors that the determining of the process of the skeletal maturity was useful for a indicator of body maturity. Certain stage are given to the maturity process of the distal epiphyses of radius, ulna, carpals, metacarpals and proximal phalanges. The divided each stage is numbered and each number represents the skeletal score, and skeletal age is determined by those score. Seventy-nine cerebral palsied children ranging in age from two years to eighteen years are investigated. We made comparison of skeletal age and chronological age between cerebral palsy and normals. There was retardation of skeletal age in 46% distal epiphyses of radius and ulna, 58% of carpals, 59% of metacarpals and 44% of phalanges.
Our adjustable ischial weight-bearing brace consist of an air bag at the anterior wall of plastic quadrilateral socket, fixed knee joint, and Patten bottom with wide foot plate and rocker bottom. The brace revealed easy donning, satisfactoric suspension, reliable non-weight bearing to the lower extremity, and increased comfortness to wear. This brace may be an excellent ready to use stock brace for any patient who indicates ambulation without weight bearing on the lower extremity. Adjustable patella tendon bearing short leg brace was made according to the same idea as mentioned above. This short leg brace showed some problems concerning the socket size and shape. Further investigation will be necessary for determine adequate size of air bag and the place to attach it, and proper air pressure in it.
We have reported the end-result of 23 cases of the spinal cord tumor which were operated on our clinic from 1960 to 1969. The result was as follow: Exeellent: 5, Good: 1, Fair: 7, Unchanged: 5, Worse: 1, Death: 4. 14 cases were neurinoma. We have reported 6 interesting cases from these cases. Case I which had 4 neurinomas into the different spinal cord. Case II which had 6 neurinomas in the different nerves include the spinal cord neurinoma. Case III which had disc henna and spinal cord tumor. Case IV haemoangioma which could not take out. Case V cholesteatoma. Case VI which had spinal cord cancer without spinal bone metastase. We have found the good result in the operated cases of spinal cord tumor within a half year from leg complaint had appeared.
The present study is a review of the cases of 25 patients who allowed to enter this hospital for further evaluation and diagnosed Scalenus Syndrome from '68 Nov. to '70 Oct. We classified under the following three type; vascular type, neurological type and combined type. 1. In angiography, the stenosis or obstruction was observed in vascular type, but, no stenosis was observed in neurological type. 2. In motor and sensory nerve action potential the delay of velocity motor nerves and sensory nerves could not be observed, but the amplitude of sensory nerves decreased in 2 cases with neurological and combined type. 3. The autonomic nerve system test was showed abnormality in 8 cases of 10. 4. Allen test was of no value as diagnostic test. Adson test was seen in 50% patients positive and Halstead test was 70% positive.
Some cases of spinal cord compression syndrome at the cervical osteochondrosis are difficult enough to distinguisch from the other diseases. Case I: Muscle atrophy of the left hand is remarkable, but none of subjective and objective symptome in the right hand. Case II: Only muscle atrophy of the right schoulder is noted, but none symptome of the both lower extrimities. Case III and IV: ataxic gait is remarkable with sensory disturbance. Case V: ataxic gait is remarkable without sensory disturbance. We supposed that Case I and II were caused by lesion of the one side anterior column, and that case III and IV were caused by lesion of the bilateral posterior column chiefly rather than lateral corticospinal tract, and that case V by bilateral spinocerebellar tract.
We prefer lumbar discography rather than myelography or epidurography in the routin radiologic investigation of intervertebral disc disease. This paper is based on the discographic study of 36 discus, 16 cases of spondylolysis and spondylolisthesis. Discogram were graded (I to V) for the evaluation. The results are summerized as follows: 1) The degree of the degeneration of the disc is proportionate to the resistance of the disc to injektion and the respans of pain of the patient. 2) The average degree of degeneration of the affected disc is 2.5 in spondylolysis and 4.5 in spondylolisthesis. 3) In spondylolysis hight degree of degeneration shows after fourth decades. 4) In spondylolisthesis hight degree of degeneration shows in all cases and combined others disc.
The new type of injection needle for localizing nerve block was presented. This needle consists of Tefloncoating except for the top, and conected remote controled injection plastic tube, included wire terminal which is conected to the electrical stimulation equipment. The injection is done under control of electrical puls stimulation which points exact pheripheral nerve localization. The diluted phenol block (2-5%) for 274 spastic cases were done, the effect has continued for 3 to 6 months, A. D. L. is much improved after the block. The regional nerve block by this needle is easy and reduced the dosage of anesthetic agents. The clinical application of this needle may be useful and practical.
Image Intensifiers have been widely used for orthopaedic examinations and operations, but they are too expensive to use in the smaller hospitals. Therefore, we devised a simplified X-ray fluoroscope and operation table which is cheap in price and is relatively satisfactory in orthopaedic use.
One-hundred and nineteen post-traumatic neuromas, in thirtyseven patients, were treated by intralesional injection of a solution of triamcinolone acetonide with one percent lidocaine chloride. The tenderness or paresthesia of forty-two neuromas were eliminated after a single injection. Of the forty-eight neuromas was decreased on the twice injections. The symptoms of eight neuromas failed to respond to triamcinolone injection therapy. Why the triamcinolone injections failed in eight cases is not clear, but these failures may reflect the technical limitation of procedure and failure of the drug to reach the precise location of neuromas. Therapy was less successful for the deeper and the larger neuromas of the arm and the leg. It suggest that, in the successful cases, the mechanism of relief of the neuroma tenderness is local softening and flattening of scar at the exact neuroma site. These findings suggest that a trial of this technique prior to surgical treatment on the limbs is given a fair things.
The present study was done to observe the articular cartilage of femoral head and is based on eleven hip-arthrograms in ten children who were diagnosed as having Perthes disease. We devided our arthrograms into three types by observing the epiphyseal center and the articular cartilage of femoral head, and analysed them by calculating the ratio of the height of femoral head to the transverse diametor, as an expression of sphericity.
In orthopedic department of Nagasaki Atomic Bomb Casualty Hospital, we had three cases of Palindromic rheumatism, and observed during five years from November 1966 to October 1970. Case 1, The patient was a 43-year-old housewife, case 2, the patient was a 38-year-old man and case 3 was a housewife aged 30. They were, similarly, complained pain attacks of fingers joint, toe joint, ankle joint and knee joint. The attacks lasted a few hours or a few days and then disapeared and yet after each attack the affected joint became “completely well every time”. The swellings were ascribed either to intraarticular effusions or to nonpitting edema of periarticular tissues or to both. They were generally but not always painful, pain being moderette to agonizing. The affected joints were generally associated with red or cyanotic discoloration of the skin and with a subjective sensation of local heat. In all cases, the concentration of the blood uric acid was remained within a normal limit and the persistently negative roentgenograms. We report these cases that are seldom found in the literature.
Destructive changes in the acromial end of the clavicles have been reported in 11 patients with advanced rheumatoid arthritis by Alpert (1961). We wish to report a similar case which has recently come to our notice. The patient was a 37-year-old male with a three year history of rheumatoid arhtritis. The main radiographic findings were tapering of the acromial end of right clavicle and widening of the acromioclavicular joint space. Two remnants of non-osteolysed bone were seen between the acromion and the end of clavicle. The shoulder joint was not affected. Roentgen examination of another joints were within normal limits. This clavicular lesion must be distinguished from bone destruction caused by hyperparathyroidism, post-traumatic osteolysis, tuberculosis and acro-osteolysis.
Radiological changes in the cervical spine were investigated among eighty two patients with classical or definite rheumatoid arthritis. Sixty six cases out of eighty two (80.5%) complained of the subjective symptoms such as pain in the neck and so forth. Thirty four cases out of eighty two (41.5%) were found the objective finding such as limitation of neck rotation and flexion sideway. There are no abnormal neurological signs in this series. Radiological change of the cervical spine, in the strict sense, were found in sixty five cases of this series (79.3%). Radiological changes in the atlanto-axial joints, especially anterior subluxation of the atlas on the axis were more commonly observed among the group of the patients with those clinical symptoms. Rheumatoid changes in the synovial atlanto-axial joint were also confirmed in a autopsy case with classical rheumatoid arthritis which had expired of pulmonary tuberculosis.
Case: Thirty-eight year old male. Veteran fisherman. He had usually used the right shoulder in a position of the external rotation and abduction. On 24-Oct. -1969, when he lifted up about 50kg fish-box backward, sharp lancinating pain had suddenly come in his right shoulder and radiated to the biceps region of the upper arm. He was admitted to a hospital and diagnosed shoulderluxation. Some treatment was done but symptom became no change. So he was admitted to our hospital on 18-May-1970, about six months after the onset. The clinical feature was tenderness on anterior aspect of the right shoulder and tumor of the biceps muscle with light medianus palsy. The site of rupture was the the supra-glenoid tuberosity. Histological finding of the site of the ruptured tendon showed the fat degeneration. Medianus nerve was compressed by the scar of the biceps tendon and muscle. Tendon-transfer was done by using the tendon of the semi-tendinous muscle. Four months after the operation, the shoulder function was very good, and he returned to the usual occupation.
This report concerned to the primary fracture healing after K-U Compression plate fixation. We have had 270 clinical cases of fracture and treated with K-U compression plate. X-ray examinations showed that the majority of the cases were healed without accompaning the callus formation. Experimental studies of the above method were done using rabbits. Studies of X-ray, CMR, histology, microangiography, and tetracycline labelling were done every week after K-U compression plate fixation. Bony union was better on the case of intact periosteum than the injured one.
This study is based on a series of 46 patients with 47 trochanteric fractures in all, of whom 27 patients (28 fractures) were treated by open reduction and internal fixation, and remaining 19 were treated by closed mehods of treatment. The following results were obtained. 1) Of the 46 patients studied, 26 were male and 20 female, and 42.8per cent of all patients were between 71 and 92 years of age. 2) Of the 47 trochanteric fractures studied, 30 were unstable fracture. 3) The mortality rate among patients treated by operative methods has been reduced as compared with that treated by nonoperative methods. 4) Coxa vara deformity following open reduction and internal fixation of the trochanteric fractures develops in 39.4per cent, nonunion and protrusion of the nail into the acetabulum in 7.1per cent respectively. Moreover the majority of those complications was observed in the unstable trochanteric fractures. 5) The authors concluded that, placing the hip in the valgus position, then rigid internal fixation by so-called dual plating with the nail-plate and a buttress plate is useful as one of the manegements of preventing coxa vara deformity following operation in some cases of the unstable trochanteric fractures.
After Examining 48 cases of cmminuted fractures from 1963 to 1970 (comminuted fractures of femur 22, comminuted fractures of crura 26), the results of their treatments, term of hospitalization and the motion of knee joints are as follow: 1. Many reoperative cases are found in the earlier operating group. 2. Among the early operated cases, except 2 or 3, patients were required shorter term of hospitalization and showed better motricity of knee joints. 3. Only one infectious case was found among early operated group. 4. More improvement in the metal stuffs for fixation and the prevention of serum hepatitis are desired.
The cause of non-union and delayed union of fractures had been investigated befor several decades and the treatment of these fractures have been a thorough knowledge by orthopedists. But up to date many of these patients have been consulted at the orthopedic clinic, Yamaguchi Labour Hospital. During the past ten years (1960-1969), eighty seven patients with non-union and delayed union of fractures of the long bones (the clavicle, the humerus, the antebrachial bones, the femur, the crural bones) were treated by the operative technique at our clinic. Here, owing to know the tendancy of the cause and the treatment of these fractures for the last ten years we followed up these patients.
We have employed the A. O. I. compression plate on the treatment of 6 fresh fractures, 7 pseudarthrosis and 3 osteotomies. As this compression plate is very rigid at the point of the fixation, the post-operative plaster cast is not necessary and so joint contractures have not been in all cases. The primary fracture-healing take place without roentgenological callus formation as up to the present. Temporarily, the enlargement of the fracthre gap has been seen in a few casses, but we could obtain the direct bony bridging of the fracture gap in all cases afterwards.
Two cases of the infant with subluxation of the second vertebra on the third were reported not associated with any neurological defecit. Twenty month old baby girl was admitted to our department with the complaint of strict limitation of neck movement. X-ray revealed four millimeter of dislocation of the second vertebra on the third in anterior flexion. Treated with halter traction and a neck brace. Seven month old baby girl appeared to our department with the complaint of limitation of neck move ment after violent insertion of a single tube for her stomach. X-ray revealed minimal dislocation of the second vertebra on the third.
50 cases which had been treated in our clinic for the last 3 years were analyzed from miscellaneous angles. 1. As traumatic mechanism to the cervical spine, axial compression, hyperflexionn, hyperextension, whiplash, rotation and “unknown” are listed. 2. As factors causing myelopathy to the cervical cord, dislocation, fracture, intervertebral sliding, angulation, posterior spur, ossification of the posterior longitudinal ligament, anomaly developmental stenosis and “unknown” are listed. 3. Relationships between these mechanism and factors were discussed. The spinal cord surounded by the narrow spinal (congenital or acquired) has tendency to be involved even by slight forces. 4. Traumatic cervical myelopathy was classified into 5 types due to parts of transverse cord lesions. i. e. anterrior, posterior, central, Brown-Sequard and transverse type. 5. Most of transverse type with severe paralysis changed into posterior and central type with slight paralysis in the last examination. This means that traumatic myelopathy is caused by both damage and circulatory disturbance of the spinaal cord.
Experiences in the surgical treatment of 128 decubitus ulcers (65 ischial ulcers, 54 sacral ulcers and 13 trochanteric ulcers) in patients with paraplegia has been presented. The principles in the surgical treatment of decubitus ulcers are as follows: excision of the ulcer, scar, bursa and bony prominence, use of a rotated flap of muscle and fascia to cover bony stump and to fill dead space and coverage with a large regional pedicle flap of skin and fat. Success rate in ischial ulcers was 80 per cent. Sacral and trochanteric ulcers were more difficult to treat successfully.
The results of operative treatment for osteoarthritis of the hip were evaluated on 62 hips in 53 cases (10 males and 43 females), 11 cases being primary and 42 secondary in nature. The operative methods employed were displacement osteotomy in 26 cases, displacement-varus osteotomy in 15, displacement-valgus osteotomy in 8, shelf operation in 7, arthrodesis in 4 and prosthesis operation in one, and the follow-up period was on an average of 3 years and 2 months. Thirty eight out of 44 unilateral cases satisfied with the operation, and in the majority of them the clinical results coincidented with the final X-ray findings, especially, 95% of 20 cases showed excellent improvement of the X-ray findings satisfied with the operation. Five cases out of 9 bilateral cases, of which 4 cases showed the excellent improvement of X-ray findings, satisfied with the operation.
From may 1970, 391 babies were born at National Kokura Hospital, New Kokura Hospital and Syu Hospital, and tested by Barlow's methode from birth to age 7 days. This test was positive in the 11 babies (2.8%). The babies (male 2, female 9) were treated in a sponge rubber abduction splint (35cm×20cm×1.5cm). We want follow up this treatment.
Acetabular development in the congenital dysplasia and dislocation of the hip was discussed by measurement of the acetabular angle, which were treated at Nagasaki University Hospital during the period from 1964 to 1968. Conclusions were as follow. 1. In the cases of dysplasia and dislocation treated by Pavlik method (97 cases, 103 hips) acetabular development was good, if the treatments were begun within 5 monthes after birth. 2. In the cases of dislocation treated by plaster cast fixation (56 cases, 63 hips), degree of improvemet of the acetabular angle was not satisfactory in 82%. In these unsatisfactory cases, inverted limbus were found in 92% by arthrogram of the hip, but when manual reductions were done, these limbus have been pressed against acetabular roof by femoral head. 3. In the cases which were surgically reduced with limbectomy, none of all cases had good acetabular development. 4. It is thought that factors influencing the acetabular development are age of initital treatment, concentricity of the femoral head and shape of the limbus.
In the six-year-period from 1953 to 1959, 262 patients with the congenital dislocation or subluxation of the hips were seen at our outpatient clinic. The routine treatments in these years were to attempt manual reduction and to immobilize the dislocated hip in a frog-leg plaster during three or four months, after which gradual mobilization was allowed. Based on the analysis of the radiographic and clinical data of these cases, osteochondritis in the congenital dislocation of the hips was examined. The results are as follows: 1. Thirty percent of the cases showed similar findings to those of Legg-Perthes disease. 2. It was in two cases apparently that immobilization of the normal hips in the frogleg position had caused the vascular damage to the femoral epiphysis. 3. Males and females were equally affected. 4. Occurrence of the osteochondritis increased correlating to the age at the initial treatment. 5. In cases of which the femoral epiphysis had failed to appear before nine months of age, more frequent occurrence of the osteochondritis was revealed. 6. Cases incompletely reduced showed the poor healing tendency of the osteochondritis.
On 813 in-patients with congenital dislocation of the hip or it's residual disorders treated in our clinic during the last nineteen years (1952-1970), evolution of the treatments (conservative 440, operative 373 cases) were annually analysed. Conservatively, the treated cases for early infants period have increased lately: Cases less than one year of age were 4% of total ones during the early three years (1952-1954) and 35% during the last three years (1968-1970). Up to now, so-called Lorenz methods have been used chiefly for inpatients, however, the number of cases has decreased and these are giving place to Pavlik's bandage methods for out-patients. Surgically, though Colonna capsular arthroplasties were performed in 90% of 58 cases before 1965, nothing but 2 cases after 1966. While 93% of 73 open reductions of hips were actively applied after 1962 and 77% of 95 osteotomies against residual disturbances for the last seven years (1964-1970). Only shelf operations (167 hips) were used constantly through the reviewed periods.
From July 1969 to October 1970, we have endeavored to set up criteria for an adequate treatment of the congenital dislocation of hip at our hospital. Recently, we had an opportunity to give a brief account of the observations on the treatment of fourty joints which were not treated and diagnosed as congenital dislocation of hip. Our observations centered around the infants. The infants below 1 year old were treated by Pavlik's method as a standard treatment. Most of them have shown satisfactory development of the hip joints, but in several cases the standard treatment was considered not to be sufficint. As an additional treatment, the plater cast fixation was performed in two of these cases and the detortion-osteotomy was performed in the remainning cases. The infants over 1 year old were treated by over head traction method as a standard treatment and subsequently the closed or open reduction and maintenance of the reduced hip with plaster cast. Our attempt centered around the minimizing the duration of the plaster cast fixation and the permission of the movement in some range. Concernning to the infants over two years old, it was suggested that the Salter's operation shoud be taken into consideration.
During the past three years, 157 babies with congenital dislocation of the hip were treated with Pavlik's bandage, including 93 dislocations, 53 subluxations and 11 hypoplasias of the acetabular roof. The reduction was failed in 14 cases out of 93 cases of dislocation. One hundred and forty nine hips in 112 cases, including 68 dislocations, 60 subluxations and 20 hypoplasias, were followed from 6 to 45 months after the treatment. The results showed that the anatomical healing was obtained in 138 hips (93%) and epiphysitis of the femoral head occurred in 11 hips. Observing 68 hips of dislocation, the anatomical healing was obtained in 60 hips (88%) and the results were inclined to become to be worse with the increase of age at the initial treatment.
129 hips in 88 children (47 unilateral hips and 82 bilateral hips), treated in our clinic from October 1962 to Descember 1968, were reexamined. It consist of 43 dislocated hips, 55 sub-dislocated hips, and 31 dysplasic hips according initial classification. Duration of treatment with this brace was largely four to six months. The age distribution were 2y 6m to 8y (average 3 year old) at the time of this examination. Majority of the hips showed exellent funcion. However acetabular angle was 25 degrees or more in 27.1% of the cases and C-E angle was 14 degrees or below in 38.0%. 46.5% showed 90 Y-coordinate-index or above which mean lateral displacement of the head of femur according Dr. Iino. There were 28 hips which showed tendency of lateral displacement at the time of initial examination. 18 hips (64.3%) of them still showed lateral displacement at the time of this investigation. The number of deformed femur head was 12 at the time of initial investigation and 4 at the recent examination.
It is reported that by the functional treatment with Pavlik-bandage in C. H. D osteochondritis detormities are decreasing. But, actually, in our out-patient clinic, these osteo-chondritis deformities in femoral head due to manual reduction and retention by plaster cast are seen frequently. Moreover, often, reduction failures by Pavlik-bandage in our and another clinic are observed too. This may mean that functional treatment is not still popular and is not used exactly. We started functional treatment from this year generally for dislocated hip below 1 year to study effective reduction technic and to achieve best results, 19 dislocated hips have been treated by September in 1970. All cases are below 7 monthes. Reduction failures were seen in 3 hips. As for reduction failure in these 3 hips, we had obvious reason why we failed to reduce. The point of Pavlik-bandage treatment is to flex the suffered hip fully. This portion changes dislocation-promoting vector in extended hip, to dislocation-reducing vector by full flexion In this position, femoral head slips down to hinter accetabulum rand, and according to hip abduction comes to below accefabulum, and is reduced by extending movement. In our failure-cases, hips had been holded rather a little extended position. So upper posterior accetabular rand had been pressed inwardly by femoral head and in one case interposition had deen formed by application of Pavlik-bandage, in bad position. Band was not effective and not strong enough to hold full flexed position. Every time, we must take care to check bandage and condition of suffered hip exactly.
Since the frequency of the deformation of the femoral head has been becreased with the use of Pavlik's band, the lateralisation of the femoral head has been closed up recently. In our clinic the lateralisation was observed in 21% of 83 cases on which Pavlik's band had been applied. Among them the trochanter press band was appied on 5 cases, and Lange's apparatus 7 cases to improve the symptoms. Among them who had been treated with Pavlik's band or with plasters for the congenital dislocation of the hip, the derotation osteotomy was operated on 14 cases of the subluxation.
In our clinic subtrochanteric osteotomy is performed in children aged about two years with congenital residual subluxation of the hip. The osteotomy allows changes in the neck-shaft angle, the torsion and the anteversion. The direction of the osteotomy runs obliquely from the frontal surface of the femur distally posteriorly, and then two procedures are done according to the femoral head-neck deformity. In the valgus deformity the femur is cut in a position of internal rotation. Thereafter the distal fragment is outward rotated and adducted. The osteotomized site is fixed with a plate and four screws. Correction of anteversion deformity is achieved by both adduction and external rotation of the distal fragment after the osteotomy. The authors must emphasize retroflexion of the femoral head and neck accompanied with the latter procedure. To ensure a physical remolding of the femoral head and neck, apophysis is not injured and the plate is removed three or four monthes after the surgical treatment. Postoperative immobilisation is kept with indirect extention (2Kgm) for about three weeks.
Detorsions varus osteotomy is one of the most important treatments of congenital dislocation of hip. Many techniques have been trying even now, but this operation needs the skilled operator and long operative time. And in some cases, uncomfortable result may be present after operation. Now we devise and favor a means of this operation, which is not lost time and obtain easier expected angle. Deciding corrective angle, we place our clinical views with roentgenograms. We use a few triangle metals and chart at operation. The triangle metals class from 5 degrees to 90 degrees. The chart list a length of bone wedge's base at varus osteotomy and a distance of distal femoral lateral rotation at detorsion osteotomy, by measuring diameter of osteotomy part on roentgenogram.
Twenty-one Innoninate Osteotomies have been done since January 1968 in our clinics. Clinical materials in this series consist of thirteen congenitally dislocated hips, seven subluxated hips and one spastic dislocated hip of hemiplegic child. Of these, eight were done as the primory treatment, and thirteen were done as the secondary treatment. They are sixteen girls and two boys aged seventeen months to ten years, at operation Unilateral dislocation 9 cases (9 hips) Bilateral dislocation 2 cases (4 hips) Unilateral subluxation 4 cases (4 hips) Bilateral subluxation 2 cases (3 hips) Unilateral dislocation with spastic hemiplegia 1 cases (1 hips)
Pemberton's procedure has been performed in 4 cases of unilateral and one bilateral case of congenital dislocation of the hip. 1) In the experimental study of skeletal specimen, Salter's procedure, the anterior roof of the acetabulum is shifted over the femoral head more than pemberton's, but the posterior and medial portion of the socket is covered of the femoral head in Pemberton's procedure rather than Salter's. 2) In cases with marked anteversion, derotation osteotomy should first be performed, and I think, a loosely capsule should be performed capsuloplasty in a high dislocation. 3) Results of the pericapsular osteotomy were most satisfactory between ages of two and eight.
The results of 50 shelf operations to 45 patients were followed up. The average of their age was 10 years and 1 month, and the average period of observation was 6 years and 4 months. The method of shelf operation was mostly followed after Jinnaka's method. Functional capacity of the hips and X-ray findings were evaluated in each case. The majority of the cases showed good functional hips without limb or pain in walking. Younger the age at surgery revealed better results. the oldest case who was 48 years old at the time of surgery showed poor functional result. Improvement of CE angle and Acetabular angle were detected, however as far as concerning X-ray findings, generally the result of surgery was poor. As a whole, 80% of the cases showed functional improvement more or less, and 6% showed bad result.
57 cases with congenital dislocation of the hip joint after varusosteotomy were reviewed especially from the following points as below: 1) Indication for surgery 2) osteotomyangle 3) Meterial and method of fixation 4) Injuries of the epiphysis 5) Insufficient medial displacement of the distal fragment 6) A care for residual subluxation. It war stressed that the factors for deformity of the hip joint should be treated from the general aspect of the whole hip joint.