We performed eight modified Bristow, two Putti-Platt and one Bankart procedures for recurrent anterior dislocation of the shoulder between 1975 and 1981. Redislocation didn't occur in any cases. In the cases of the modified Bristow procedure, break or spontaneous removal of the screw was not found. But the limitation of external rotation was larger than other reports. Two patients complained of pain in the scapular region and the pain disappeared after removal of the screw.
Neck-shoulder-arm pain may be produced various disorders, especially cervical spinal disorders including spondylosis and tumor or thoracic outlet syndrome. The pain due to the lesions in the costoclavicular region was resulted from compression or constriction to the brachial plexus. Non-traumatic inflammatory and tumorous diseases causing the pain are listed in Table 1. It was stressed that these diseases should be always in mind and early diagnosed because delayed diagnosis might lead to miserable results.
Although the vascular complications of the thoracic outlet syndrome are most infrequent, their presence may cause severe ischemic symptoms in the upper extremity. This is to report our recent experience of three cases with evident vascular complications. These patients had coldness, pain, weakness and colour change in the affected hand. In two cases of these patients had fingertip ulcerration. On physical examination radial and brachial pulses were absent in three cases, and the axillary pulse was absent in one case. Three patients had demonstrable bony abnormalities on plain radiography of the thoracic outlet, such as cervical rib, abnormal first rib and clavicular deformity following clavicular fracture. Angiography had considerable value in this condition. Complete obstruction was found at the subclavian artery in one case and other cases had incomplete obstruction at the subclavian artery with brachial arterial occlusions. We performed surgical treatments for these patients. Excellent results were obtained in two cases and insufficient improvement in one.
We use neurography of the brachial plexus as a method of diagnosis of thoracic outlet syndrome (T. O. S.). A mixture of 10cc of saline, 10cc of venografin and 10cc of 1per cent lidoeaine is introduced at one shot by supraclavicular approach, and films are taken on A-P views in several positions of the affected arm. In normal cases the dye fills out the brachial plexus area, but in cases of T. O. S. it shows narrow and thin through the scalenus triangle or the costoclavicular area. In this study, we find out the difference between normal neurogram and abnormal one of T. O. S., and the difference between pre-ope, neurogram and post-ope. in cases of T. O. S.
A 6-year-old boy without rheumatic sign and symptome was presented with a painless subcutaneous nodule on dorsum of the left foot. The nodule was yellow-brown in colour and aproximately 2cm in diameter, and was lobulated into several nodules of 2 and 4mm. Histology demonstrated a central fibrinoid necrosis sorrounded by palisading histiocytes and chronic inflammatory cells, which indicated to be essentially identical with rheumatic nodule.
Two cases of microgeodic disease are reported herein. Case 1, A 9-year-old boy visited our hospital for the pain and swelling of his right index finger. Radiological examination revealed a small, rounded cystic change with perifocal sclerosis in the middle phalanx. The antibiotic drugs were given as a suspected case of osteomyelitis for two months. After that the pain swelling decreased. However, considering that there were few inflammatory signs and symptoms in clinical and laboratory findings and the course of the disease in this case was different from that of typical osteomyelitis, this case should be diagnosed microgeodic disease. Case 2, 7-year-old boy was seen on account of the swelling and local heat of his left index finger. X-ray picture showed the atrophy of the trabeculae of middle phalanx. Under the diagnosis of the microgeodic disease the course of disease was observed without medication. A month leter, swelling and pain disappear. But two months after onset he visited our clinic with the deformity of the index finger. Radiologically a fracture of the middle phalanx was seen, which was treated by splint fixation. This is probably the first report of the microgeodic disease combined with a pathological fracture.
Two cases of sterno-costo-clavicular hyperostosis were reported. A 52-year-old male had a episode of remission and deterioration of the symptoms. The specimens of the effected tissues showed the histological changes of a chronic osteomyelitis. Culture of the specimens were positive for anaerobic bacteria. In addition, the value of serum antibody level for propionibacterium granulosum were up to 256. Another case was a 41-year-old female who had a marked swelling and pain on her lift anterior chest. There was a possible relationship between a deterioration of the symptoms and that of eczema of the fingers and menstrual cycle.
Five cases of cervical spinal cord injury associated with ossification of the posterior longitudinal ligament were reported. All cases were male patients, and the ages ranged from 48 to 64 years, with an average of 56. 2 years. Tetraplegia occured in all cases, while no or slight complaints were noticed in their necks to the injury. All cases were treated by skull traction as a method of first choice. Anterior fusion was needed for two cases because of respiratory caused by fracture d-slocation of the C5 in one case and spondylotic myelopathy which developed after healing of the spinal injury in another case. All cases improved but one.
Two cases of cervical spinal cord tumor resected after anterior subtotal spondylectomy were reported. The operative field exposed through this anterior approach was better than expected. In this paper, the advantages of the anterior approach for cervical spinal cord tumor were stressed, and it's operative indications and technical notes were discussed.
Cerebral somatosensory evoked potentials (SEP) to the median nerve stimulation were recorded in 42 patients with traumatic cervical cord lesion and 29 patients with cervical myelopathy. In patients with traumatic lesion, early components of SEP were often not recognized or their latency was prolonged, if they were present, when they compared with those found in patients with myelopathy. These findings suggest that there exists a different mechansim regarding to the obstruction of spinal cord conduction between those two groups of patients. SEP at the early stage may prove usefulness for early judgment of incomplete spinal lesion.
3 cases with spinal lipomas were reported. Each case was classified to extradural, intradural and maldevelopmental lipoma. A 40-year-old man with extradural lipoma showed transverse spinal cord lesion syndrome within one month after the onset of numbness in the thigh and had complete recovery after the total excision. A 20-year-old man with intradural lipoma had long duration of involvement and developed to be spastic paralysis inspite of 4 times operations. An another 58-year-old female with maldevelopmental lipoma had the trouble of the trophic ulceration in her right heel, incontinentia urinae and sensory deficite in the foot and saddle area which developed gradually during past 30 years. After subtotal excision the trophic ulceration healed speedy but the neurological status was unchanged. We stressed that the spinal cord lipoma should be taken into account the classification in connection with location of the tumor which had close relation with clinical course.
48 cases of spinal cord tumors which had been treated surgically in our clinic were able to be followed up for 5.7 years (average) and the clinical results and the X-ray findings were reviewed. Intradural extramedurally tumors were in 34 cases, intramedurally in 8 and extradural in 6. Results are as follows: 1) “Excellent” + “good” are 86.2% in intradural extramedurally tumors, and 100% in extradural tumors, but all cases of intramedurally tumors are under “fair”. 2) Post operative results are influenced by those factors as follows; i) nature of the tumor, ii) localization of the tumor, iii) interval from onset to operation, iv) size of the tumor, v) total resection of the tumor, vi) post operative bony changes of the spine. 3) Post operative deformities of the spine are found in 35% in X-ray examination and 3 of them are performed anterior body fusion for correction of swan neck deformity of the cervical spine.
A 26-year-old male was referred to our department with a complaint of complete urinary retention. He did not complaint of low back pain or limb pain, but had slight numbness in the medial side of his left foot. Myelography and discography were performed, and he was diagnosed as lumbar disc herniation at L3-4 and L4-5. Laminectomy was done after 26 days of appearance of urinary retention. The herniated discs were located at midline, and at the level of L3-4 adhesion to dura mater was found. After removal of protruded discs his bladder function returned to almost normal.
One hundred twenty two patients with lumber disc herniation all diagnosed at the surgical exposure and treated with extripation of nucleos pulposus were analysed. Patients were divided into two groups according to the operative findings; those with prolapsed hernia, those with protruded hernia. The latter is divided into two groups, those with fragmental hernia, those with non-fragmental hernia. In the group with prolapsed hernia, neurological deficift were dominat, whereas in the group with protruded hernia, symptoms of root irritation, for example, Lasegue's sign, lumbar scolisis and lumber stiffness etc. were dominant. Patients with protruded hernia are younger than those with prolapsed disc hernia.
The operation of fixation of the articular column with Zielke instrument transversing the pedicle and anchored within the vertebral body is described in detail. It gives sufficiently stable fixation in cases which have instability of the thoracic or lumbar spine and, are recommended laminectomy. 10 cases which are contained lumbar spinal canal stenosis, degenerative spondylolisthsis and spinal fracture, are presented in this series.
Twenty-five patients with lumbar spine lesion were operated by anterior spinal fusion using Zielke instrumetation. There were eleven patients with lumbar injury and fourteen patients with lumbar disease. The purpose of this surgical procedure was gotten early ambulation and aquisition of sure bone union afforded by solid fusion of instrument from immediately after the operation. All caces were gotton solid fusion and were not noticed non-union.
From 1978 to 1981, we have performed peridurography in ninety-six cases. In this study, we compared its finding with myelographical and surgical findings. Of ninety-six cases, fifty six were intervertebral disc herniation, sixteen were lumbar canal stenosis, fourteen were lumbar spondylolisthesis, five were lumbar pseudolisthesis, two were caudal tumor and one was lumbar degenerative arthritis. The findings of peridurography correlated to clinical and surgical findings as well as myelography. In peridurography, root findings are quite valuable. In the case the myelography shows block lesion, we consider that peridurography should be performed to clarify the root and caudal lesion which cannot detect by conventional myelogram. We concluded that peridurography is one of the most useful and convenient method in the diagnosis of low back lesion.
We experienced a very rare case of idiopathic scoliosis with calcification of annulus fibrosus. A 8 years old girl. She was diagnosed idiopathic scoliosis at three years old and had 35 degrees lumber curve with annulus fibrosus calcification. When she was seven years old, the lumbar curve was 100 degrees. So we operated the scoliosis by Harrington rod instrumentation without fusion, and corrected 77 degrees. At the same time, we resected a part of anterior longitudinal ligament with intervertebral disc material between Th10 and Th11 and examined. In soft X-ray, calcification was found in annulus fibrosus. Light microscopically, anterior longitudinal ligament was normal but annulus fibrosus was calcified.
In two hundred and eighty patients with low back pain and low extremity pain that were treated with ceiropractic therapy, approximately ninety percent of the localized causes are occupied with cervical spines and pelves. Anatomy of sciatic, piriformis and buckle bone in outlet of pelvis was investigated on the thirty places on fifteen corpses. It was made clear by ceiropractic therapy that approximately ninety percent of localized causes on low back pain and knee-joint pain are occupied with the cervical spines and pelves at the detouched place from pains. From now on, diagnosis and treatment of pains and numbness will be advanced greatly by logical explanations of ceiropractic therapy.
Patients suffering from cervical spondylotic radiculopathy or myelopathy who were treated conservatively in our clinic were subjected in order to determine the prognosis of this disease. Twenty-seven cases were followed up for a year to 15 years (avelage: 6 years 11 months in radiculopathy, 6 years 9 months in myelopathy). The results were as follows. 1) Radiculopathy (18 cases): Subjective symptoms of 14 patients had improved and 8 patients (45%) of them had completely releaved. 2) Myelopathy (9 cases): Most of the cases especially in type III myelopathy of our classification had become progressively worse at the time of the follow-up study. The results suggested that the conservative treatment were effective in radiculopathy except progressively deteriorating cases and most of the cases with myelopathy especially in type III should be treated surgically as early as possible.
The purposes of surgical treatment for the fracture dislocations of cervical spine are the stabilization of cervical spine and the expectation of the recovery of neurological functions. We prefer the anterior spinal fusion for these cases after pre-operative reduction of cervical spine achieved by means of skull traction. However, in unstable fracture dislocations it is very difficalt to mantain the reduced position. We employ the H plate to fix such unstable cases for early rehabilitation. 5 cases fused with H plate could be out of bed immediately after operation and the results of spinal fusion are excellent.
It is necessary for orthopedic surgeons to differentiate this type of malignant tumor from cervical spondylosis or other benign disorders producing brachial neuralgia. This report is to describe our recent experience of one case of typical “Pancoast tumor”. A 52 year-old captain was referred to our clinic with severe pain of his right shoulder girdle radiating to the ulnar side of the right upper limb. He had been treated as cervical spondylosis or periarthritis of the shoulder in several clinics for four years, however, the pain had been getting worse gradually. X-ray examination in our clinic revealed slight bone destruction around the second and third costvertebral junctions. Accompaning with other characteristic symptoms, signs and findings, biopsy under bronchoscopy confirmed to be adenocarcinoma at the right pulmonary apical region. Radiation therapy and chemotherapy were given, and the pain have decreased to some extent so far.
The cases with chronic renal failure (CRF) have many problems in surgical treatment, especially, management of fluid, elctrolyte, acid-base balance, anemia, bleeding tendency, infection of a sugical wound, and so on. We experienced three patients with CRF required operative treatment for spine and spinal cord disorders; 1) spinal cord tumor, being on maintenance hemodialysis for 7 years, 2) cervical spondylosis with CRF due to hypertention, 3) atlanto-axial dislocation with CRF due to renal calculi. Even if those who require operative treatments have severe CRF, operation can be performed through sufficient pre- and post-operative management in co-operation with anesthesiologist and specialist on renal disorders.
Although etiology of idiopathic scoliosis is unknown, we designed to investigate thermography of back in idiopathic scoliosis and discuss its usefulness. Thermographic examination was performed in 142 children. 19 children had straight spines, 24 had functional curves and 99 sustained idiopathic scoliosis. We compared their thermographies and X-ray films of them. We showed criteria of the thermography. We suggested that in screening of spinal deformity thermographic observation was useful and it gave us functional factor in scoliosis.
The equilibrium function tests were performed to the two hundred twenty three patients with idiopathic scoliosis. The results were as follows; 1) Abnormality of standing on one-leg test was 27.4% and abnormality of Mann's test was 38.1%. Abnormality of both tests was 14.8%. 2) There were no correlation between abnormality of equilibrium function tests and sex, age, curve angle of scoliosis. 3) The coincidence rate of curve convex side and the side of the test abnormality was 40%. However, the coincidence rate of curve convex side and the side of both tests abnormality was only 2.8%.
Goldenhar's syndrome (oculo-auriculo-vertebral dysplasia) is a rare congenital malformation and consists of epibulbar dermoids and anomalies of the external ear and vertebra. We report a 4 years old girl with Goldenhar's syndrome who has congenital malformation of skull, ear, hart, vertebra and facial nerve palsy. She was treated with excision of a hemivertebra with non-incarcerated type because her thoracolumbar courve increased from 38° to 57° during two years. Ten days after the operation, a corrective under arm cast was applied. Good correction has been obtained with the procedure.
Thirty-five patients (60 hips) were operated for the correction of hip deformities in cerebral palsy. Twenty-three patients (41 hips) out of them were mainly corrected by division or recession of the iliopsoas tendon. Twelve patients (19 hips) were mainly corrected by lenghenning of the psoas tendon. The latter method was more efficient than the former in terms of the preservation of hip flexors.
Thrombosis of the superior sagittal sinus (SSS) and right popliteal artery of a Japanese female with systemic lupus erythemantosus (SLE) is described. She had longstanding intracranial hypertension (ICH) and chronics headaches. Results of coagulation studies were normal, and the SSS thrombosis in this patient may have been due to thrombo phlebitis. Carotid angiography should be performed in cases of SLE with ICH, because the therapeutic regimen selected depends directly on the cause of the ICH.
When fibrinogen coagulates to form fibrin the interlacing fibers of the resultant clot become adhesive. In vivo this make the onset of wound healing. Since 1970, the welding effect of fibrin clots was re-investigated. Before the clinical application, biomechanical examinations, which would investigate the tensile strength of welded nerve or tendon, showed significant strength for glueing nerve anastomoses. Also histological examinations indicated excellent nerve regeneration in the distal nerve segment. Some clinical cases, which were treated with clotting substances, were reported.
We described our designed method of dressing for skin grafting on three cases out of the many. Among the cases, it is hard to guarantee a perfect take because it often fails. We have used this method and have had good constant results.
The first rib fractures are uncommon, and to our knowlege the stress fractures of the first rib has not been so much reported previously. We report a first rib fracture caused by the continuous stress due to the heavy responsible cough. Case report; 36 years old, female, nurse P. I; She has gotten the cough suddenly, and so has been insomnia. After one month she complained the back and right shoulder pain. Left first and right seventh rib fractures were found on the X-ray. They healed without pain after six months. The cause of the cough was diagnosed as the conversion reaction by a psychosomatic physician.
A case of a 12-year-old boy with bone necrosis in the distal metaphysic of the right femur is reported. He was admitted to our hospital with chief complaint of pain in the right knee. Roentgenograms of the right distal metaphysis of the femur revealed irregulary mixed lesion of the sclerotic and lytic shadow. Angiography showed no malignant finding. The biopsy was performed for the purpose of the histological diagnosis. Microscopic examination revealed necrosis of cancellous bone with diffuse granulation tissue surrounding it. As he had no episode suspected cause of bone necrosis, we diagnosed this case as idiopathic bone necrosis.
Aseptic necrosis of the talus following trauma is common, but there are few reports about nontraumatic necrosis of the talus and its etiology is not known, either. In this study four cases of nontraumatic necrosis of the talus are reported, one having no related disorder, one suffering from osteoarthritis of left ankle joint and having had intra-articular corticosterold injection, and two suffering from rheumatoid arthritis and having had corticosteroid therapy for a long time.
Acute effect of postural change on human subcutaneous tissue blood flow in the hand region was studied in normal subjects using the hydrogen washout technique, a system which allows repeated determinations of blood flow rate. Changing from the supine to the upright position caused decrease of the subcutaneous tissue blood flow in the hand region by approximately 46 per cent. Lowering an arm below heart level reduced that subcutaneous tissue blood flow in the hand region. The subcutaneous tissue blood flow was also found to be reduced in the hand region by raising an arm above heart level. These findings have important implications in the postoperative mangements following hand surgery.
A 52-year-old female patient has been affected by a slightly painful tumor in the right hypothener region since 8 years. The tumor was measured as 10×10mm, not tender. And there was a continuous murmur on the tumor. However, angiogram did not show any prominent vascular changes. Surgical extirpation was done, and the tumor which was macroscopically soft and bluepink mass encapsulated with smooth covering membrance was arised from the ulnar artery. Soon after the extirpation of the tumor with a part of the ulnar artery, mlcrovascular anastomosls was practiced. Histological study showed “angioleiomyoma”. The case was reported and discussed in this paper.
We experienced two consecutive cases of 4-5 metacapal fusion among 11 menbers of two families that are related to the mother side. About the deformity of metacarpal fusion, there are reports by Lerch, and Holmes Homes previously. The patients we treated surgically were a seven-year-old boy and a 13-year-old boy, the former had the deformity in the right hand, and the later had it in both hands. We made a comparison with normal hands in the ratio of the length of their little fingers.
Eleven cases of the collateral ligament injuries of the fingers treated in our clinic for the past three years were followed up. The averaged follow up period was about 10 months (2.5 months-21 months). Four patients with over 25 degrees of instability on stress x-ray film were treated operatively and anothers 7 patients with minor degrees of instability were treated conservatively. The results with conservative means in chronic injuries were not so good as with operative one. In these patient, pain on motion, unilateral swelling and sharply localized tenderness had persisted untill follow-up time.
We have treated surgically 15 cases of spontaneous ruptures of tendones in the hand in the past 15 years. There were eleven females and four males. The average age was 52 years with a range from 16 to 71 year. Genesis were RA (4 cases), fracture (3 cases), OA (3 cases): (Madelung's deformity, radioulnar dislocation, Kienböck's disease), contusion (1 case) and 4 of unknown causes. Flexor tendon injuries were 2 cases. (contusion: M-T junction, unknown: insertion). Other cases were extensor tendon injuries and ruptured portion were wrist joint. Tendon transfer was done principally. Darrach's operation and synovectomy etc. was performed according to necessity.
Two cases of intraarticular fracture of metacarpals are reported, which were treated by internal fixation with K-wires combined with direct traction, and got good results clinically and radiologically. The first case was 13 years old boy, whose fracture was in the 3rd MP joint, and the second, 26 years old man, in 5th CM joint. In these cases, satisfactory reduction and rigid fixation were not accomplished by cross wire fixation due to comminuted fractures. So the treatment was completed by direct traction using a special apparatus which I designed. Using this apparatus we can assure that the distraction force acts only on the fractured joint and besides in a continuous way. As a result the alignment of the fragment is kept and the movement of the neighbour joints is made possible. From these view points, it seems that this apparatus is useful for the treatment of unstable intraarticular fracture of the metacarpals.
The lunatomalacia (kienböck disease) is similar to the old fractures of the carpal scaphoid in clinical features. Now, we carried out the follow-up studies of 8 lunatomalacias and 5 scaphoid fractures, which were operatively treated in our clinic since 1974 till 1981. The surgical procedure is mainly the shortening of the radius as for lunatomalacia, and the bone grafting (Russe) as for scaphoid fractures. The result of the broken scaphoid is better than that of the lunatomalacia. And we did the siortening radius on the one case of the old scaphoid fracture, too. The result of this interesting case is excellent.
A little device sometimes brings good results in hand surgery. Some of our new devices are presented. 1. Old unreduced dislocations of distal radioulnar joint. Bunnell and Liebolt stabilized the joint by free tendon, however good results were not obtained. Using sublimis tendon as a dynamic stabilizer, we obtained a good result. 2. Nonunions of the scaphoid. Bone graft by Russe's method is commonly accepted. However in two cases because of small proximal fragment or radiocarpal osteoarthritis, we performed transposition of free tendon in defect of resected proximal scaphold and obtained good results. 3. End to end suture of tendons. Tendon suture techniques were developed recently on the basis of intratendinous circulation. However in practice, incongruity or rotational malposition was often observed at anastomosis. So, we apply stay-sutures of 7/0 nylon bilaterally, then performed Tsuge's tendon suture. This simple device needs no additional stitches and makes the suture much easier.
The patient reported here was a 14-year-old female who had numerous surgical treatments for the lesions in her left tibia. Initial diagnosis at the age of 21/2 years was fibrous dysplasia. However, histological findings of curetted materials from the lesions were compatible with Ossifying fibroma which Kempson described in 1961. It was our impression that aggressive surcal inrervention should be deferred until bone growth approaches to maturity.