Tumoral calcinosis has been rarely reported in Japan. We found a twelve-year-old female patient with a right elbow lesion of this disease. So we have furnished a case and have given consideration to the clinical and pathological findings of this disease.
Five patients in whom squamous cell carcinoma (SCC) of the lower extremity had been diagnosed were treated and followed up in the last 11/2 years. In two patients SCC was found in osteomyelitic foci, one in a crual ulcer, two in chronic ulcer induced from the common squamous cell carcinoma. Above-knee amputations, a partial resection, a below-knee amputation and a syme amputation were performed respectively. In one patient metastasis of the regional lymph nodes was found in four months after operation.
Ulcers occur frequently over the inner side of the ankle and lower third of the leg which are conventionally called “ulcer areas”. Most are the stasis ulcers which are caused by chronic venous insufficiency. Recently we had an opportunity to treat a case of the statis ulcer. This stasis ulcer is due to the post-thrombotic syndrome. Symptoms of this syndrome consist of local edema, pain, pigmentation, varicose veins, stasis dermatitis, stasis cellulitis, as well as chronic ulceration. Simple wound management or skin grafting are not adequet to prevent recurrence of this condition. Conservative treatment, elevation of the extremity and elastic compression from toes to knee, should be attempted initially. If conservative regimen fails, stripping of superficial varicose veins and ligation of the dilated communicating veins are recommended. Malnutrition of the skin due to poor venous return may be the cause of the chronic leg ulcers.
26 year old male was injured in his lower lim by the traffic accident. Then he lost his right lower limb at thigh. In his left foot malunited fracture was seen especially in metatarsal bone. He complained severe pain in his heel on walking. There was hyperkeratotic skin at heel and callosity in the MP joint of big toe. As we could not cover the heel after resecting involved skin by cross leg method, the patient was indicated for vascularized free groin flap. The operation was done under continuous epidural anesthesia. Operation time was 4 hours 20 minutes. Bllod loss was 120g. 8 days after operation, venous congestion was recognized at the center of the flap, the cause of which we guessed due to smoking, although we said him not to smoke. 2 weeks after operation, all of the flap survived. The callosity of the big toe diminished gradually. He complained no pain in his left foot.
The pedicle flap skin graft has several problems in its fixation between donor and reciepient side after grafting. The tortion, the tention, the flexion and the infection of the grafted pedicle flap including the wound are considered to be important. It is very difficult to check these points in gypsum bandage after grafting which is Commonly used. Hoffmann's external osteotaxis was applied to this skin graft to resolve these problems. This methode suggested us to be very easy to check problem points. This Technique was applied to 6 cross leg, 3 cross finger and 5 abdominal flap cases.
Infants often take an asymmetrical posture and muscle tone, that is, one sided flattening of the skull, postural scoliosis, limitation of abduction of the flexed hip, pelvic obliquity and so on. In this study, we described the significance of the these oblique posture in infancy and the techniques of their handlings. In order to prevent the occurrance of deformity of the skull, new-born babies should be put into the side position for the first four months. After that they should be kept in the prone position. When an oblique posture was noticed in infants, we advised their mothers to do some handlings which were based on the righting and balance reactions: for example, oblique suspension.
100 paralytic feet are examined through plain X-ray films and podometer. Data are analysed with principle component analysis. Three factors of deformation are extracted. They are plantal—dorsal flexion of a talus, calcaneus and total foot respectively. Varus—valgus deformity depends on the balance of the first and second factor of deformity. Calculating the factor scores, we can express a deformed foot as a point of three dimensional Cathesian coordinate system in which each axis stands for factor of deformity.
The dynamic balance mechanisms in four normal subjects were studied by unstable board which inclined in a sinusoidal form of 0.3-4Hz. Subjects on the static sensograph (Sanei 1GO1) placed on the board were inclined antero-posteriorly or right-left. Then we got magnetic recordings of fluctuation of the center of gravity. The antero-posterior or right-left fluctuations were filtrated in the frequency of the board movements by the active filter. Lissajous's figure of right-left (abscissa) and antero-posterior fluctuation (ordinate) during right-left inclining showed the diagonal pattern from right upper to left under, but during anteroposteriorly inclining showed only the antero-posterior component. These suggested that the dynamic control of not only right-left but also antero-posterior fluctuation played the important role to balance upright standing during right-left inclining. But, as human being standing bipedally would have lateral stability, the antero-posterior control would be revealed dominantly during antero-posteriorly inclining. Furthermore, Lissajous's figure of movements of inclined board and right-left, or antero-posterior fluctuation suggested that the dynamic control of the standing posture below 1Hz was different from above 1Hz.
EMG obtained from muscles of lower extrimities of the normal subjects on the sinusoidally (0.3-4.0Hz) inclining board showed many complixities. So, we get Lessojous's figure of EMG and the movements of the board. Superimposed Lessajous's figures will reveal averaged patterns of EMG activities. Experiments are done in two manners of right to left to right inclination (rolling) and anterior to posterior to anterior inclination (pitching). The EMG activities of m. vastus lateralis (VL) and m. tibialis anterior (TA) increased during inclining posteriorly in 1Hz. suggesting to prevent the center of gravity moving posteriorly. Above 1Hz, the EMG activities of VL and TA seems to reveal to move the center of gravity anteriorly, being inhibited by hamstrings (HAM) and m. gastrocunemius (GS). But on rolling, EMG of HAM and TA operated during inclining below 1Hz right and left respectively, suggest to privent the center of gravity moving anteriorly and posteriorly respectively. Above 1Hz, EMG activity of right VL, right and left HAM and left TA would act to move the center of gravity posteriorly and left VL and right TA anteriorly. These suggest that the standiy posture would be stabilizted by the fluctuations of the center of gravity due to EMG activities.
Eleven patients of scoliosis associated with neurofibromatosis were investigated. A sharply angulated right curve involving five vertebrae or fewer was the most common. Kyphosis was associated in nine of the eleven patients. Dystrophic osseous changes in the axial skeleton characteristic of neurofibromatous scoliosis were noted in all of the patients. The wedging of the apical vertebra at the time of detection was noted markedly. But the progression of the wedging was not distinct and not related to the progression of the curve. The structural changes of the compensatory curve in the neurofibromatous scoliosis were not so severe as in the idiopathic scoliosis. Brace treatment was unsuccessful. Operative treatment appeared necessary.
Radiographic examinations were done in 61 cases who had lumbar scoliosis due to disc degeneration. 1) Frequency of them were 12.4% of all the patients (508 cases) who visited Kyushu University hospital for their back pain from Jan. '76 to June '76. 2) They were classified 2 groups. The one had severe disc degenerations and osteoarthritic changes, the other didn't have them. 3) Structural curves tend to be seen in the older patients. The older patients had higher degrees of curve than the younger patients. 4) In many of them, the degrees of curve was within 15 degrees. The higher the deeree of the curve, the more frequent retrolisthesis and lateral slipping were recognized.
We made an experiment on electrical stimulation to the intercostal muscles in human patients with scoliosis. The results were analyzed after about nine months. In many cases, flexibility of the scoliotic curve increased. And the increased flexibility of curvature may increase the effect of brace correction.
An extensive school screening program for scoliosis needs to establish the early treatment program. Since 1963, an underarm brace “Active Corrective Brace” has been used in 396 cases with idiopathic scoliosis. Follow-up study revealed that 21 percent of the final average percentage of correction was successfully obtained. The brace should be indicated for the cases with flexible curves of 20-40 degrees. This brace program can allow development of the postural reflexs and activation of the trunk muscles to correct the curves and also be cosmetically and structurally acceptable to the children so that the trertment will continue untill complete skeletal maturity.
Sixty patients with the conservative treatment of the idiopathic scoliosis were clinically evaluated. The one group (30 cases) was treated with the modified Milwaukee brace and the other group (30 cases) was applied with Active corrective brace during over six months. The satisfactory results in Active corrective brace group were obtained in patients with flexible curves about 30 degrees, especially in the cases with thoraco-lumbar curve. It was necessary not only to apply the corrective casting in early stage but also to use the home traction in many cases with rigid curves over 40 degrees in our bracing treatment.
Nineteen patients was operated on hypotensive anesthesia. Twelve cases was scoliosis, three was spinal cord injury in thoracolumbar region and four was other spinal disease. Age was ranged from eleven to forty (mean twenty five). Hypotension was maintained by use of trimethaphan camphor sulfonate. It poseses sympathetic ganglion blocker. In a retrospective study comparing normotensive and hypotensive anesthesia, the average blood loss was remarkably reduced in Harrington instrumentation and posterior spinal fusion for scoliosis. Ischemia of the surgical wound was achieved by hypotension and operative procedure was easily and strictly performed on posterior spinal surgery. None of complication was noted.
A 11-year-old female had complained of swelling and pain of left humerus after inversion. Roentgenograms revealed pathological fracture and an enlarged cystic lesion in the humerus head. We followed up the healing of fracture with sling for 8 weeks, and the patient entered our hospital on the purpuse of treatment of the cyst. We made bone biopsy for diagnosis of cyst, and it was diagnosed as solitary bone cyst. But on the operation the cyst contained bloody fluid. The cyst was curetted and grafted with bone tips collected from her iliac bone. Finally, it was diagnosed as aneurysmal bone cyst.
A case of benign chondroblastoma was reported. A 12 year-old girl visited our clinic because of her right knee pain. She felt knee pain when she was running the day before. Radiographic examination revealed radiolucent defect with thin slightly sclerotic margin and pathologic fracture of the right patella. She was treated with curretting and autogenous bone-graft. The radiogram showed no abnormality 15 months after the operation. Histologic examination of the tumor was done and answer of the pathologist was giant cell tumor. The tumor was re-examined in Fukuoka university, because the macroscopic finding of the tumor was not thought giant cell tumor. The result of the reexamination was benign chondroblastoma.
We experienced a case of benign osteoblastoma involving the lamina of the cervical spine. The patient, a 14 year old male, was admitted because of limitation of neck movement and a tumor in the nuchal region. X-ray and CT scan revealed an abnormal shadow at the region of lamina of C6. But the vertebral body, lamina and spinous process were normal. Complete removal of the tumor without laminectomy was done. The histological examination showed it was a benign osteoblastoma.
A recent study concluded that lateral bending, rotation and flexion-extension at the upper cervical level were not well controlled by any of the conventional orthoses (occipito-mandibular orthoses). Our orthoses (occipito-zygomatic orthoses) is designed to controll movements of the upper cervical spine. A subzygomatic pad is changed for mandibular support in the orthoses and subzygomatic pad is widened to nose. Occipital pad is also widened to bilateral and parietal. There is no complication by pressuse on the sub-zygomatic soft tissues in our experience.
50 patients with cervical spondylotic myelopathy with multiple disc levels of compression were treated by laminectomy or three-level anterior body fusion. Of those followed for more than one year, 28 patients were treated by laminectomy and 13 patients by three-level fusion. 4 patients with laminectomy and 2 patients with three-level fusion subsequently required anterior body fusions and laminectomies respectively due to further advances of the symptoms. Satisfactory results were obtained in more than six seventh of all but re-operation cases.
Several methods of surgery have been reported on osteoplastic enlargement of the cervical canal, though the indication of this surgery is not clear. Recently, we performed this surgery upon seven patients of cervical myelopathy due to ossification of the longitudinal ligament or cervical disc lesion, and the results were evaluated postoperatively. Four of them showed Excellent or Good result postoperatively. With the short-term follow-up and small number of patients of this surgery, it is hard to draw conclusion from these results concerning indication of the surgery, but a better result seems to be obtained in developmental cervical canal stenosis with cervical disc lesion. Further follow up will be needed.
This is to report two cases of cervical disc herniation in which their neurological signs were recognised mainly in the lower limbs, showing similar symptoms to thoracic myelopathy. Case I is a 40 year-old female, and Case II is a 50 year-old male. They felt numbness of the right lower limb at onset, which gradually increased and was accompanied by motor disturbance of the left lower limb. Deep tendon reflex of the lower limbs was hyperactive in both cases. Sensory disturbance was noticed below the level of Th6 in case I and below the level of Th4 in case II. No symptoms and signs in the upper limbs except positive Hoffman's reflex in the left hand were recognised. X-ray showed slight narrowing of the disc space at C5-C6. Myelograms demonstrated a filling defect of contrast medium around the level of C5-C6. Surgical exploration through anterior approach confirmed cervical disc herniation, and good results were obtained after the surgery.
By using of the selective arteriography of the spinal cord, we have examined 40 cases of disorder of the thoracic and thoraco-lumbar region. In the thoracic and thoraco-lumbar regions the level of origin of the artery of Adam-Kiewicz is recognised. A-P X-ray films are taken to demonstrate any findings of the ascending and descending artery of the spinal arteries. The superior radiculo-medullary artery is difficult to be visualized at the upper thoracic region. Our study confirmed that selective arteriography is useful to evaluate the local conditions of disorver of thoracic and thoraco-lumbar region.
Fifty six patients of juvenile disc herniations have been investigated concerning the provoking cause, disc lesion level, physical signs and treatment etc comparing with adult disc lesions. The results are as follows; 1) History of direct or indirect trauma as a provoking cause is not so frequent as anticipated. 2) Objective findings dominate in children in spite of the minor complaints. 3) The most frequent disc lesion is L4-5 intervertebral disc as adult disc herniation. 4) Judging from the discogram, disc degeneration is mild and protrusio type in most of cases. 5) End results of operative treatment are gratifying both in our cases and in those of others.
We have been always at a loss which operation to select when young adult had multiple disc lesion. Usually it has been sele: ted anterior and posterior approach appro priately. But it is difficult to select which operation to take. We have experianced three cases which have disc degeneration with disc herniation in L4-5 and only disc degeneration in L3-4, L5 SI. In these three cases we performed anterior interbody fusion only to L4-5 and results are good.
About 200 cases of posterolateral lumbar-spine fusion were performed in our hospital from 1972 to 1979 in which 115 cases were examined during the period of more than three years. Among these, 83 cases (112 intervertebral spaces) were followed up and compared with single and multiple posterolateral lumbar-spine fusion which were mainly assessed by roentogenographic and clinical results. The incidence of solid fusion was high, 84.3% (intervertebral spaces, 88.4%). For one level fusion the incidence was 94.6% and for multiple levels the incidence showed 63.0% (intervertebral spaces, 82.1%) solid fusions. For disc lesions we had solid fusion in 93.3% (intervertebral spaces, 95.0%) but for spondylolysis and spondylolisthesis in 75.0% (intervertebral spaces, 81.0%). In our cases there were no clear correlations between clinical and roentgenographic results. It is suggested that cross unilateral lumbar-spine fusion is effective in the cases which need multiple spine fusions.
In our clinic, 48 patients were surgically treated and 23 patients were conservatively treated for lumber canal stenosis. Forty-eight patients operated were reported according to the new international classifications. The results in operative cases revealed “good” in 25 cases (52%), “fair” in 12 cases (25%), “poor” in 11 cases (23%) and that in conservative cases was worse than operative cases. We emphasized the importance of carring not only out an adequate decompressive surgery, but also performing the long term follow-up and treating in accordance with individual patient clinical problems.
24 cases of lumbar spinal stenosis (15 pseudospondylolisthetic, 4 spondylolisthetic and 5 spondylotic stenosis) were treated by laminectomy followed by fusion for the past 5 years (1974 to 1978). Majority of the cases were middle aged and were engaged in manual labor. All cases but one had cauda equina claudication. Myelograms showed a complete block in 14 cases out of 23 cases. Good results were obtained except one case with cervical spondylotic myelopathy.
Our patients with osteosarcoma are divided into 3 groups according to the method of treatment. Group 1: In the 18 years between 1955 and 1972, immediate surgery with or without chemotherapy was performed in 26 patients. Five-year survival rate of group 1 was 19%. Group 2: In the 6 years between 1973 and 1978, 10 patients with osteosarcoma received intraarterial continous infusion of drug. All patients underwent delayed surgery following intraarterial continous infusion. It seems that result of group 2 is better than that of group 1. Group 3: Since 1978, 1 patient with osteosarcoma receives high dose of methotrexate following surgery.
Prognosis of osteosarcoma was studied on 45 cases for the past 21 years: 1. The 5-year-survival rate was 22 % in 39 cases observed over 5 years. 2. Since 1968, the systemic medication of preoperative chemotherapy, irradiation of 6, 000 to 9, 000 rads followed by amputation was employed. Consequently, 5-year-survival rate raised to 35%, in 20 cases. 3. The preoperative irradiation followed by amputation was effective, and more effective with chemotherapy. 4. The prognosis of cases with destruction beyond the epiphyseal plate was mostly poor. 5. Long term chemotherapy was considered to be effective for preventing the pulmonary metastasis.
Forty-seven patients with osteosarcoma were classified into five groups by chemotherapeutic regimen. The first group (included ten patients) was treated with nitromin, azan and sarkomycin before 1960, the second group (twelve patients) with mitomycin C from 1961 to 1970, the third group (eight patients) with VAMT from 1971 to 1974, the fourth group (eight patients) with adriamycin from 1975 to 1977, and finally the fifth group (four patients) with adriamycin and methotrexate since 1978. The first showed 0% of five-year cumulative survival rate, the second 24.9%, the third 12.5%, and the fourth 37.5%. Twelve patients with systemic chemotherapy since 1975 had 49.6% of five-year cumulative survival rate, and the other thirty-five patients before 1974 with non-systemic chemotherapy had 11.4%.
Amputation for two cases and wide resection for a case of Osteosarcoma who were decreased tumor growth by preoperative intermittent arterial infusion of high dose adriamycin is described. It may be effective to prevention against pulmonary metastasis that high dose adriamycin infusion into the central vein or pulmonary artery.
Between 1964 and 1974, 105 patients with osteosarcoma were admitted to our clinic, in which 75 patients were operated radiclly and 65 of them were followed up for five to ten years. A five years survival was of all cases was 24%. Systemic adjuvant chemotherapy for patients with osteosarcoma has been given in our clinic since 1963. Comparison the rerults of the group treated before and after 1963 showed a marked difference (16% and 28%). Though the result of the group treated after 1975 cannot evaluate because of the shortage of the follow up, a better result will be expected.
14 cases of osteosarcoma of the lower limb have been treated in our clinic since 1955. There are ten males and four females, ranging of age in 3 years old to 44 years old (average 18.8 years old). The lesion is at the femur in 8 cases and at the tibia in 6 cases. Our regime of treatment can be divided into three category, that is, radical operation following chemotherapy in 3 cases from 1955 to 1958, arterial perfusion following radical operation with radiation therapy in 4 cases from 1959 to 1968 and arterial perfusion followng raidical operation with chemotherapy in 7 cases from 1969 to 1979. Only 3 cases survived over 5 years. Relation between regime of treatment and the results was studied in this paper. Best results were obtained in the last group.
Isolation perfusion chemotherapy for osteosarcoma in the extremities has been performed on 111 cases since 1960 in our department. Our therapeutic regimen consisted of perfusion chemotherapy and amputation in the first group of 17 cases between 1960 an 1964, perfusion chemotherapy, amputation and bronchial arterial infusion in the second group of 48 cases between 1965 and 1972, and perfusion chemotherapy, amputation and systemic administration of adriamycin in the third group of 19 cases between 1973 and 1978. Five years survival rate of the first group is 38.0% and that of the second group is 35.1%. Four years survival rate of the third group is 59.8%. Recently we have performed perfusion chemotherapy, amputation and systemic administration of vincristine, high dose methotrexate with citroforum factor rescue and adriamycin in the treatment of osteosarcoma.
41 cases of osteosarcoma were treated in our department in 2 decades from 1960 to 1979. The surgical treatment and radiation therapy were primarily used in 8 case detected in 5 years from 1960 to 1964, the chemotherapy being applied in combination. The results were poor, the 5-year survival rate being only 12.5%. 25 cases were treated in 10 years from 1965 to 1974. Only 10 of them were subjected to the pre-operative intra-arterial infusion. The 5-year survival rate was 40% and 26% for these 10 cases and the rest 15 cases who had not undergone any pre-operative intra-arterial infusion, showing a favorable effect of pre-operative intra-arterial infusion. 8 cases were treated in 5 years from 1975 to 1979, 7 of them being subjected to the pre-operative intra-arterial infusion. The multi-drug chemotherapy was used in these 8 cases, who made favorable progress. Our latest therapeutic approach lays main emphasis on the pre- and post-operative chemotherapy. Namely, patients are hospitalized in short duration at intervals for chemotherapy while they are examined in the outpatient clinic for progress when they are released from the hospital. If any sign of pulmonary metastasis is detected, the patient is strongly persuaded to undergo the lobectomy.