A girl aged 9 years had polyostotic fibrous dysplasias, pigmentations at the left breast and upper extremity, and precocious puberty as well. Laboratory tests revealed a marked increase of serum alkaline phosphatase and dysfunctions of the pituitary and ovary.
A 25-year-old female complained of dullness and pain in the left humeral region. Roentgenograms showed a left unilateral type of polyostotic fibrous dysplasia. A section of the left humerus revealed multilocular cyst filled with bloody clots and the surrounding medullary cavity was filled with gray gritty tissues. Histnlogically, fibrous bone, cellular fibrous tissues and blood vessels were found in the latter, and endothelium-like cell in the former wall.
Recently we experienced a case of Paget's disease with cauda equina lesion. Case: A woman aged 27 admitted to our clinic due to gait disturbance and numbness of the legs. Roentgenogram reveales sponlylolisthsis between the 4th and 5th lumbar vertebrae and severe destruction of the 5th lumbar vertebrae, so-called “ivory vertebrae”. Myelogram showed a complete block at the lower border of the L4. Total laminectony was performed on April 26, 1977. Histological examination revealed that osteoblasts and osteoclasts ranged alongthe thick bony trabeculae, and the fibrous stromas had hypervascularization.
Elephantiasis neuromatosa is an uncommon disease characterized by large, grotesque tumorous skin hypertrophy. Recentry we experienced a case of this disease. Case: N. Y. 12-year-old girl. At birth she had a large pigmentation in the left thigh, which grew up gradually with skin hypertrophy like an elephant's skin. A tumor in the left inguinal region was noticed at 5 or 6 years old. Her mother has also many neurofibromas and a large pendulous tumor. Pathological examinations of the tumor and the skin revealed a typical plexiform neurofibroma.
Case 1 A girl, ten years old, had pain and swelling in her right arm. Roentgenograms revealed marked destruction of the right humerus, medullary cavity was destroyed as like as so called “hole within hole”, cortex was distinctly thinned and partially broken and moderate periosteal new bone formation was recognized. These findings were quite mimic to Ewing's sarcoma, but examinations such as angiogram, blood examination, open biopsy showed no malignant findings. Her course of illness was very good and almost healed without any specific treatment. Case 2 A girl, two and one-third years old, walked with a limp. X ray findings of her left femur were almost as like as case 1. But diagnosis of Hand-Schüller-Christian disease was made easily because of her general findings. They were exophthalmus, diffuse papular eruption, enlargement of the liver and right external ear canal occulsion by the granulation tissue. After curettage of the bone, chemotherapy and steroid treatment were used, her course was good and recently examination showed no subjective findings. Case 3 A boy, seven years old, had pain in his left arm. X ray findings showed well defined oval rarefaction in the middle part of the left humerus. Medullary cavity was expanded from inside, cortex was thinned but little periosteal new bone formation was presented. These findings simulated to solitaly bone cyst. But we diagnosed this case for histiocytosis X, because the lesion was not located in the distal or proximal part of the long bone and bone destruction and formation were mixedly noted at the same time, and the diagnosis was proved histologically. He had gained full recovery after curettage and bone graft.
Benign chondroblastoma was separated from the category of Giant Cell Tumor by H. L. Jaffe and L. Lichtenstein in 1942. Since then, we can find many reports about Benign Chondroblastoma in the domestic and the foreign. This time we could have a chance to treat this tumor which was arising from the patella. Judging from many reports, it was very rare to find Benign Chondroblastoma in the patella. We laid importance on histological findings of this case to diagnose this tumor as Cystic Benign Chondroblastoma. Still more, we tried to compare statistically Japanese cases with foreign cases.
Two cases of unusual cystic lesion are reported. Case 1 A 20-year-old female was seen by authors with tenderness around her right hip. Roentgenogram of her right hip revealed an unusual cystic lesion of great trochanter. At this surgery, the lesion consisted of only cavity. There was no fluid in the cavity and this cavity was not lined by a thin menbran. Histological examination of excised wall showed only bone trabeculae. Case 2 A 22-year-old female was seen by authors with pain on walking. Roentgenogram revealed an unusual cystic lesion of ilium. Macroscopic and micro scopic findings were the same as case 1. There was no organisms in the cavity. The authors could not diagnose these lesions as bone cyst, and the authors consider that the selesions are distinct entity.
A patient, 39-year-old male, first had noticed a small subcutaneous tumor in his calf in 1970. This tumor had been resected twice on May and June in 1976. But the tumor showed a local recurrence and metastases to the regional lymphnodes, which were also removed after the administration of ADR. A distant soft part metastasis, noticed on his back on February in 1977, became small by the effect of chemotherapy with ADR. Histologically, the tumor cells with blunt-ended nuclei in the interlacing cords were high gradely anaplastic. The mitotic rate was elevated (1-5/HPF). Reticulin was usually present and a majority of the fibrosis was parallel with the long axis of the tumor cells.
Sixteen cases of metastatic disease of the spine were treated in last seven years. Two cases of the fibro-sarcoma and the breast cancer lived longer than the other. Almost of the other cases died within one year, after the pain on the neck, the back and lumbar area was noted. In many cases one or two months before death, E. S. R. make peaks, after that they decreased the rates.
We applied Computerized Tomography (CT) as a method of pre-operation examination of bone and soft tissue tumors. The EMI general purpose scanner (CT 5005-7) provides matrix of 320×320 in a section of 13mm width. CT was a very useful pre-operation examination, because it exposed more correctly localization of tumor in 3 out of 4 cases than only a ordinary method. CT could not exposed a minute change of soft tissue. Contrast enhansment was seen in a case of osteosarcoma of the femur.
Forty-four patients with osteosarcoma had had a poor prognosis with five-year survival rate of 15.3%. Recently, nine patients have been treated with adriamycin 0.8mg/kg daily for three days, repeated until 600mg/kg. They have survived from one month to 30 months with an average of 12 months after operation. Five of nine patients have had pulmonary metastasis. Thereafter, multidrug cyclic chemotherapy with vincristine, methotrexate with citrovorum factor rescue and adriamycin has been initiated in them. Three of five patients have had 2, 3 and 4 courses respectively. There was recog nized a transient shrinkage of tumor mass in size from one month to two months at chest roentgenogram.
Histopathologic findings on electrical injury of excised specimens from a six-year-old boy were described. Deep tissue necrosis was extremely marked and it was associated with vascular alteration. Coagulation necrosis of the vessels walls together with thrombogenesis was one of the most important changes in the present case.
Presented case is Avulsion fracture of iliac crest and it is uncommon. Only 8 cases have been reported in the Japanese literatures. The patient is a 15-year-old boy. He had the severe pain of right hip just at Judo. This case was treated by operative reduction and then immobilization for four weeks. At surgery anterior superior iliac spine was normal. Excellent prognosis was revealed.
A case of fatigue fracture in the left tibia was presented. He was 13 years old boy, complaning of pain and swelling in the left leg. The rotatotomographic picture showed the formation of periosteal and endosteal callus. The biopsy was performed for the purpose of the differential diagnosis from osteosarcoma. The histological findings revealed marked enlargement of Haversian canals and numerous resorption cavities, that is, cancellization in the cortical bone. In addition, the formation of cartilaginous tissue was slightly recognized the cleft of fracture. In the periosteal callus, lamina could not be recognized, and the formation of fibrous, immature bone trabeculae were found.
Case 1 A twelve-year-old male sustained a severe open fracture of the femur by traffic accident. A mid-thigh amputation was performed and he became toxic after two days. Extremely foul discharges developed and gas was detected on X-ray. Open disarticulation of the hip and hyperbaric oxygen therapy with energic chemotherapy were successfully performed. Case 2 A forty-nine-year-old farmer was treated by osteosynthesis and primary closure for dirty open fracture of the fibula sustained in the field. He was transfered to our hospital on the following day because of severe gas gangrene of the lower leg and toxicemia. Hyperbaric oxygen therapy and careful débridement were performed, and he was recovered without amputation.
Post-traumatic contracture of the proximal interphalangeal joints is frequently seen in our clinic, but its treatment is not so easy. The authors analyzed the results of 15 cases treated surgically and reported their own operative method.
The method of external skeletal fixations popularized since the device of the external fixation equipment of Judet or Hoffmann being available, and is gaining its definite place in osteosynthesis. We had experience with the method of A-O external fixation, about which few reports have been discripted yet, in the treatment of 15 cases as follows; 2 cases of the ankle fractures, 6 cases of the comminuted tibial fractures, one case of the knee arthrodesis, one case of the ankle arthrodesis and 5 cases combined with high tibial osteotomy. Our result has shown that this method is more efficient than that of Judet or Hoffmann.
Various methods of internal fixation for femoral neck fracture have been reported since Smith-Petersen's nail. Each of them has not only positive but also negative points. Recently, we have used Deyerle's device consisting of several pins and side plate in 9 patients. As a rule, full weight bearing is permitted immediately after operation. Pseudoarthrosis developed in one case, and aseptic necrosis of the femoral head in another. These 9 cases will be reviewed and the advantages or disadvantagest of his method will be discussed.
Intramedullary condylo-cephalic nail fixation (C-C nailing) was indicated for surgical repair of nineteen trochanteric fractures of the femur, including one case of pathological fracture due to metastasis from the breast cancer. There were three men and sixteen women. The age range was from fifty-three to one hundred and one years, with an average of seventy-seven years. Of the nineteen patients in this series, nine were operated according Küntscher's method, ten were done according Ender's method, among which there was no respectable difference regarding the end result. C-C nailing has several advantages with respect to a operating time, a blood-loss and early rehabilitation. The patients were able to sit on the bed about three days postoperatively and walk about a month after the operation. As a complication of this procedure, a) peroneal paralysis, b) thrombophlebitis and c) local hematoma were observed in several cases in our series.
Seventy-four injured menisci of sixty-nine cases were operated in our clinic from 1955 through 1977. In 66 unilateral cases two had lateral and medial meniscus injuries in the same knee, and three had the single meniscectomies of the both knees. The ratio of the injured lateral memisci to the medial ones was 5:2, but except for discoid menisci its ratio was 2:3. The ages of the onset ranged from 6 years to 56 years; semilunar type chiefly concentrated in 1-3 decades and, discoid type in teen-agers. One third of the cases were injured by sports and the other one third had not any history of trauma. Except for snapping, main symptoms were muscular atrophy, click, tenderness on the joint space, and the disturbance of the motion.
Eighty-four cases of clavicle fracture have been treated at our hospital and one related hospital since 1972. Out of 43 cases which were followed up over 1 year, 36 cases were treated conservatively and 7 cases were operated on. Lateral fracture from the lig. coracoclavicular should be operated as a first choice in over 15 year old's patient. The operated cases have the best result but fest fixation by medullary K-wire or plate is necessary in operation.
Nachuntersucht sind 244 Unterarmschaftfrakturen von 161 Patienten. Es ergibt folgende Ergebnisse: 1) Operativ behandelte Ulna und Radiusbrueche, ausschliesslich versorgt mit Metalplatten erzielten durchaus befriedigendes Ergebnis. 2) Bei der Osteosynthese sind exakte Reposition und einwandfreie Fixation unentbehrlich. 3) Gegenwaertig verfuegbare Metalplatten fuer Unterarmknochen sind meistens nicht nur voluminoes zu gross, sodern auch zu robust konstruiert. 4) Frakturen im Bereich der distalen Unterarmgegend (Distalende nicht im Begriff) werden ueberwiegend bei jungeren Patienten beobachtet. Mehrzahl davon gehoeren zu der Gruenholzfraktur 5) Bei der distalen Unterarmbruechen kommt es im Lauf der Zeit nicht selten eine volare Konvexdeformitaet vor. Gegen diese Verformung besteht es noch keine gute Loesung.
30 cases out of 1969 patients with the ossification of the posterior lougitudinal ligament in the cervical spine were found in X-ray cervical spine in Okinawa. The classification is, 17 cases of the continued type, 9 of the segmented type, 2 of the mixed type and 2 of the others. The incidence of the level of the maximal ossification were located in C5, C4, C6 and C3. Narrowing of the cervical canal in sagittal diameter due to the ossification was 34 per cent in average.
A survey was made to investigate the relation of 120 cases of ossification of posterior longitudinal ligament in the cervical spine to their age, sex and daily and occupational environment. Average age was 57.5±10.2 in male and 51.6±8.5 in female. The patients of fifth and sixth decades are larger in number than other decades. Their occupations were mostly light labors, who were asked for the sitting position for a long time. Past histories of diabetes mellitus were not numerous in relation to the control group.
Radiologic findings of old 100 people (mean age 77 years) on a home for the aged showed 17 cases of Ankylosing Hyperostosis (AH) which had 11 cases of Hahn's groove. AH in our hospital was 26 cases which showed OPLL (11 cases) and Hahn's groove (16 cases). As above described, the high frequency of Hahn's groove (27 cases, 62.8%) in 43 patients with AH examined was observed. This findings suggests rich blood suply of the vertebral body and that the ligaments of spine is a source of connective and vascular tissue which favors the progression of ossifying reaction.
Clinical and X-ray courses in 54 cases of O. P. L. L. were followed-up for the last ten years. 1) Out of 21 cases of continuous or mixed type, the ossifications were revealed to increase in 7 cases (43%), of which the physical findings and symptoms were getting worse in 440. 2) An increasing of ossifications and a serious aggravation of symptoms were not observed on the cases of segmental or prolapse type.
In our clinic, 178 cases have been diagnosed as ossification of posterior longitudinal ligament. We investigated 58 of 123 cases conservatively treated or not treated. As for the 58 cases, this report details the clinical progression, the development of the ossification, the type of ossification and, in addition, provides the frequency of ossified yellow ligament. Follow-up was conducted from 1 year to 17 years 1 month (mean 3 years 4 months).
Sporadic ossification of posterior longitudinal ligament of all spines is rarely reported. Recently the authors experienced such a case as follows. Fifty year old female has had numbness and tight sensation in her both legs and visited our hospital. Clinical examinations disclosed hyperactive tendon reflexes, and pathological reflexes in the bilateral lower extremities and hypesthesia of the left leg in the L5 area and belows. In X-ray pictures ossification of the posterior longitudinal ligament was found at the levels of C4-C6, Th5-Th9 and all lumbar spines. After laminectomy of Th4-Th9 and L4 spines the spasticities of both lower extremities disappeared, leaving somewhat exaggerated tendon reflexes.
Clinical finding, diagnostic key points, factors influencing the prognosis of O. P. L. L. were discussed. For the treatment of O. P. L. L. of the thoracic spine, Laminectomy had been performed upon 6 patients (4 female, 2 male). The result was good in 3 cases and not much improved in other cases. In laminectomy, we would emphasize next two points. One is wide and extensive laminectomy, and another is keeping the thoracic spine at extension position during and after the operation to relieve the compression of the spinal cord.
Several cases with ossification of the posterior longitudinal ligament at the cervical spine have recently been reported to be associated with ossification of either the posterior longitudinal ligament, the yellow ligaments or both at the thoracic spine. The problem that arises from these is which the main lesion for myelopathy is, cervical or thoracic. This is to report our own experiences of 13 cases which were felt somewhat difficult to determine the main lesion. Careful neurological examinations in the upper and the lower limbs were the most valuable for the diagnosis. When the upper limbs are severely affected or nearly same as the lower limbs are, the main lesion is, in high possibility, located at cervical region. If the lower limbs are more severely affected than the upper limbs, thoracic region could be the main lesion. Cervical laminectomy showed satisfactory results. Whereas thoracic laminectomy did not bring good results, anterior body fusion of the thoracic spine brought better results in thoracic myelopathy due to ossified posterior longitudinal ligament. However, good results were obtained by thoracic laminectomy in cases with thoracic myelopathy due to ossified yellow ligaments.
25 cases out of about 270 cervical cord injuries are found in our clinic. Ossification patterns can be divided in to hyperostotic type (17 cases) and spondylotic type (8 cases) clinically. Inducing force is weaker than other cervical cord injury. Injuried level is often at disc level especially in spondylotic type. Prognosis is related to inducing force, ossification type and narrowing rate. Histology shows compressed and degenerated cord. So, we have not done the early decompressive laminectomy because of further damage to fragile cord by operation. But, we think that anterior spinal fusion is sometime indicated. Anterior spinal fusion should be done in the cases with myelographic interruption at the disc level.
Extensive laminectomy plus bilateral partial facetectomy for ossification of posterior longitudinal ligament in cervical spine had been performed on 24 cases. Operative levels had been determined by gas myelogram. Gas myelogram was done by two needle oxygen method. The results of operative treatments are classified as excellent 1 case, good 9 cases, fair 10 cases and poor 4 cases.
We studied 42 cases with ossification of posterior longitudinal ligament of cervical spine. The instability or narrowing of cervical disk and formation of osteophyte are found in many cases. Cloward's anterior spinal fusion is effective in many cases. We must take notice of the interveriebral disk in the patients who have ossification of cervical posterior longitudinal ligament.
50 operative cases treated by interbody fusion without excising the ossified mass and 30 non-operative cases treated conservatively were analyzed neurologically and radiologically to make clear the effects of intervertebral stabilization and fusion on the myelopathic symptoms of this condition, comparing with the corelation between the intervertebral mobility and immobility in the narrow canal. It was stressed that the cervical cord compressed and strangulated by the static factor of the narrow canal, increasing by the dynamic factor of the movements of the cervical spine would be mechanically and ischemically damaged and subsequently produce symptoms and functional disabilities. In conclusion, spontaneous and operative stabilization of the cervical disk space with unbalanced mobility acts effectively to the improvement of the cervical cord function.
The operative results and technique of 18 cases with cervical spondylotic myelopathy are described. The operative technique which we had underwent since in 1968 is subtotal resection of the affected vertebral body and most of the patients in this series had functionally excellent results. The technique for posterior longitudinal ligament calcification is described in details.
42 patients with cervical myelopathy due to ossification of the posterior longitudinal ligament have been treated in our clinic since 1953. There were 34 males and and 8 females, and 21 cases in the segmental type of ossification, 6 in the continued type and 15 in the mixed type. Anterior approach was done in 17 cases to remove the ossification and poserior approach was taken in 19 cases. In 2 cases posterior approach was performed after the vertebral bodies were fused. There is no difference in the results between the anterior approach and the posterior approach. Dynamic roentgenogram is useful for determination of the indication. There are two types of the cases with movable or non-movable intervertebral space in which myelographic filling defect was seen during flexing the cervical spine. The anterior approach is indicated in the movable type. Either the anterior approach or the posterior approach is taken in the non-movable type.
Sixteen cases of radiculopathy and myelopathy due to ossification of the posterior longitudinal ligament (OPLL) were subjected to surgical treatment and the results obtained were examined. Surgical procedures were anterior fusion in 6, both excision of OPLL and anterior fusion in 3 and laminectomy in 7. Results of surgery were excellent in 5, satisfactory in 5, unsatisfactory in 3 and failure in 3. The investigation was performed on one autopsy case. The microangiograms of the spinal cord demonstrated the rarefied capillary network in the greymatter and abnormal arrangement of the intrinsic arteries.