We tried to fix the bone graft of rabbits with fibrin glue and to examine the radiological and histological changes at 1, 3 and 5 weeks. The operation was performed in 12 rabbits. We had no finding as to obstruction of wound healing and immunological reaction. Fibrin Glue namely seems to be a safe and useful adhesive. On the other hand, we did not find fibrin glue to have osteogenetic potency we had expected at this experiment. Fibrin glue was thought to act at early stage of wound healing.
We have experienced a case of idiopathic bone infarction of the left distal femur. The patient, a 55-years-old femle caddy, has been suffering from severe pain at the buttock and the pain from thigh to toe during two months. She had the same episode two years ago, but the pain became free within a month. At first we suspected that the pain was caused by lumbar spinal canal stenosis. In the course of treatment pain was limited at the left knee and there was an osteosclerotic lesion at the distal metaphysis of the left femur on x-ray films. There were no inflammatory signs in the clinical, laboratory and histopathological data. Finally we have found that the pain was caused by the lesion. By the past history, clinical course, signs and histopathological findings, the lesion was diagnosed as idiopathic bone infarction.
A case suspected of eosinophilic granuloma of the left proximal tibial end was repoted. Eosinophilic granuloma is the most benign variant of histiocytosis X and may have spontaneous regression during course. When it occurs in infancy, it is important to differentiate from Letterer-Siwe syndrome, congenital generalized fibromatosis and metastatic neuroblastoma. Our case was a one-month-old girl whose left lower limb was noticed to be less active than the right one at ten days after birth. The roentgenographic appearance of the left proximal tibial end showed cystic osteolysis of spongiosa, periosteal new bone formation and partial cortical defect. About two months later, these findings disappeared without therapy and then there are no sing of reccurence or new focus.
We present a case of solitary enchondroma originatiog from the left femoral neck in a 7-year-old girl which seems to be rare. We measured bilateral femoral scores in order to follow postoperative course. Before the operation there were remarkable differences between the right and left femoral scores, but 4 weeks and 6 weeks after the operation the differences decreased rapidly. During these periods the patients was on the bed and weight bearing was not permitted. The reasons why the differences decreased so rapidly are not obscure, but we think about the following reasons; (1) removal of the tumor, (2) the effect of drilling, and (3) the effect of bone graft.
Giant cell tumors which are typically present with large areas of bone destruction produce particularly difficult therapeutic problems for the orthopaedic surgeon. This is to report on two cases with this tumor in which relatively successful results were obtained by surgical treatment. One case was a 24-year-old woman who was in the thirty-fourth weeks of pregnancy. She felt pain in the right elbow joint. Radiological and histological examinations with the open biopsy revealed a feature of giant cell tumor occurring in the humerus. Wide resection of the tumor was performed after child birth. As recurrence of tumor was not evident upon radiological examination during the six months period following surgery, we performed Coonrad II total elbow arthroplasty. She regained a pain free elbow with a relatively good range of motion at five months after the operation. The other case was a 39-year-old man who complained of the right shoulder joint pain without known trauma. Bone radiographs showed a cystic tumor in the humerus head with proximal humeral fracture. The angiogram showed a feature of giant cell tumor occurring in the humeral head. This case was treated by curettage and cryosurgery. After the operation, he was fixed with zero-position cast brace. Bony union was achieved successfully with no recurrence of the tumor six months after the operation.
Thorough curettage with methyl-metacrylate cementation is presented in a series of 5 cases with a follow-up time between 7 and 55 months. The advantages of this method are full and early mobility and stability. It is suggested that the heat generation could be an advantage of the method. Two of the tumors were situated in the distal femur, two in the proximal tibia and one in the distal radius. Of our five cases, favourable results have been obtained in four cases, but local recurrence and lung metastasis have been found in one case in the distal radius, which is malignant giant cell tumor.
Clinicopathologic study on seven cases of osteofibrous dysplasia was performed. The mean age of the patients at the time of first examination was 6.4 years and all of them had an intracortical, eccentric lesion in the anterior aspect of the shaft of the tibia. Six of them underwent an excision or an en-block resection and five of the six patients recurred, being accompanied by pathologic fractures and/or pseudarthrosis, the results of operation were not satisfactory. Meanwhile, one case who was treated conservatively with a PTB brace showed relatively satisfactory results. The patients under the age of ten years might not have to be operated. Although the histologic finding of osteoid rimmed by osteoblasts is typical in this condition, we had four cases showing this finding which could not be diagnosed clinically as osteofibrous dysplasia. The histologic feature of osteoblastic rimming is, therefore, not necessarily characteristic to osteofibrous dysplasia. In osteofibrous dysplasia the number of osteoclasts around osteoid is larger and collagen fibers in the stroma are less abundant than those in fibrous dysplasia, which may be related to the aggressive potentiality of the disease.
Telangiectatic osteosarcoma is one of relatively rare bone tumors. Recently we experienced such a case, and reported here. A fifty-four-year-old woman was admitted on January, 1984, with the complaint of the right lower extrimity pain and paralysis. She had an elastic hard tumor sized 10cm in diameter in the right gluteal region. We observed a osteolytic and destructive lesion in the right sacrum and the extension into the surrounding soft tissues of the tumor in roentgenogram and CT scans, First time, biopsy was carried out and diagnosis of giant cell tumor of bone was made by histological findings. Tumor resections were performed twice. At first time, this tumor was diagnosed as aneurysmal bone cyst. And at second time, this tumor was finaly diagnosed as telangiectatic osteosarcoma.
We experienced a patient of ATL, who showed various radiographic changes of the phalangeal bones on his early onset. A 26-year-old man visited our hospital because of joint pain of bilateral knees and fingers. Remarkable radiographic change was found on his phalangeal bones. After 4 weeks he showed lymphnode swelling and hepatosplenomegaly. Smear of peripheral blood showed convoluted lymphoblastic cells with T-cell markers. He was treated with multi-agent chemotherapy for ALT. After 19 weeks, his radiograph showed normal findings. After 23 weeks, he showed hypercalcemia, and high level of ALP, and of LDH, but no radiographic change was found.
We reported a patient with a huge chondrosarcoma of the scapula combined with a large lung abscess. The patient was a 61-year-old man who had resection of the left lobe 34 years before under a diagnosis of tuberculosis. He had also pitting edema of the left upper arm. P-A view of his chest X-P showed a large mass at the left scapula region and another mass at the left lower lung region. The left lower region mass was not diagnosed before operation by surgeons and anesthesiologists. After forequarter amputation, a biopsy was performed for the mass of left lung and showed a large lung abscess with 1000ml of cold pus.
Prompt cytological diagnosis was carried out on 45 cases of bone tumors. Cytocolour stain (Merck; Szczepanik modification of Papanicolaou stain) and Hemacolour stain (Merck) were used for cytological diagnosis. Cytocolour stain requires only 3 minutes for completion of stain and Hemacolour stain 15 seconds. In 31 cases of malignant bone tumors, 25 cases were diagnosed malignant but one case diagnosed benign (false negative). In 14 cases of benign bone tumors, 8 cases were diagnosed benign but 2 cases diagnosed malignant (false positive). These prompt stains were useful for cytological diagnosis of bone tumor on the point of time and accuracy.
A retrospective study of 97 cases of fine needle aspiration of bone and soft part tumors performed at the National Fukuoka Central Hospital between August 1977 and September 1985 showed an overall accuracy of 74.2% in the diagnosis of malignancy. The main reason of true negative was the lack of the aspirated material and the existence of well differentiated soft part sarcomas which were judged as Papanicolaou class III. 93.9% of the cases with class IV and V were malignant. The lack of the aspirated material in the malignant tumors was noted in 10.1%. Differentiation between metastatic cancer, malignant lymphoma and sarcoma was not so difficult. Further diagnosis for histological type by the cytology depends upon the knowledge of histological details of sarcoma. We believe that cytological confirmation of malignancy by fine needle aspiration is a useful method for the treatment of malignant bone and soft part tumors.
Lymphatic dissemination of soft tissue sarcoma is an infrequent occurrence. From published cases, one can establish the incidence of regional lymph node metastases in soft tissue sarcomas as between 2% and 45%, depending upon histology, location, and stage of disease. Records of 97 patients of our institutes with a diagnosis of soft tissue sarcoma were reviewed to estimate a clinical importance of prophylactic dissection of regional lymph nodes. Only nine patients had evidence of sarcoma metastaic to draining lymph nodes. Of these patients, four were synovial sarcoma, three rhabdomyosarcoma, and two epithelioid sarcoma. Three of four patients with synovial sarcoma and all three with rhabdomyosarcoma had involvement of inguinal or axillar lymph nodes. Prophylactic removal of draining lymph node areas in most patients with sarcomas does not appear to be worthwhile with the possible exception of synovial sarcoma, epithelioid sarcoma, and rhabdomyosarcoma, although the possibility of direct invasion by the primary or recurrent tumors do exist.
A case of angiomatoid malignant fibrous histiocytoma was presented. The tumor was unlike other variants of malignant fibrous histiocytoma because of prominent cystic change, haemorrhage and occurring in young adult. Our case was a 17-year-old boy who had been suffered from pyrexia and general fatigue. He was admitted to the medical ward in our hospital. The laboratory findings revealed only severe anemia, but the cause of pyrexia was not found. The patient was refered to us, orthopedists, with complainning of the soft part tumor of his right thigh. The pathologic examination by the biopsy showed malignant findings, then the tumor was removed widely with whole belly of the long adductor muscle. The tumor showed haemorrhagic cyst-like space with psuedocapsule macroscopically and the tumor was diagnosed microscopically as the angiomatoid malignant fibrous histiocytoma. His complaints and anemia were rapidly recovered after the operation. He has been followed for about five months, and no metastatic lesion and no local recurrence were found yet.
A case of A-V malformation in the lower leg, which had been suspected of malignant tumor because of unusual symptoms, was reported. The patient was a girl aged sixteen with a painful lump in her calf. The characteristic clinical features of A-V malformation such as gigantism of the limb, skin ulceration, dilated varicose veins and cardiac failures were not revealed. Surgical excision of the angiomatous tissue, which existed in the soleus muscle, was carried out. Histological diagnosis of the excised tissue was A-V malformation. Because of localized type, satisfactory surgical result was obtained.
A case of recurrent calcific periarthritis involving multiple sites was reported. She was a 26-year-old woman and suffered from this disease for ten years. Calcium deposits were detected in joint capsule histologically. These deposits consisted of Ca and P (Ca/P molar ratio was 1.7/1).
Clinical study was performed on 24 cases of conservatively treated pseudogout from 1972 to 1985. 11 cases and 13 cases were “definite” and “probable” by McCarty diagnostic criteria. The over-all clinical results were as follows: 1) Associated diseases; hypertension, senile cataract, gonarthrosis, diabetes mellitus, generalized osteoarthropathy, gout, rheumatoid arthritis. 2) Microscopic examination of calcium pyrophosphate crystal and roentgenogram of articular chondrocalcinosis are important for diagnosis. 3) Septic, rheumatoid, and gouty arthritis are the main considerations in the differential diagnosis of the aged acute arthritis.
20 case with severe acute inflammatory arthritides were evaluated on the initial differential diagnosis. Final diagnoses of these 20 cases were suppurative arthritis (12 cases), crystal deposition disease (including highly suspected cases) (6 cases), unknown etiology (2 cases), and one case which showed difficulty in differentiation between supputative arthritis and crystal deposition disease. Whether findings of any diagnostic value may exist or not was discussed on the early diagnosis of these 20 cases. Clinical manifestations showed no difference between 9 cases with suppurative arthritides (excluding 3 infant cases) and 6 cases with crystal deposition disease. White cell counts were abnormally high in many cases with the former. CRP showed no difference. ESR elevation was noted in the latter group. Mean age was 66 in the former and 70 in the letter. Incidence of crystal induced arthritis was none under the age of 70. However, approximately half of the cases over 70 years old were showed crystal induced arthritis. Microscopic examination of synovial fluid and of gram-stained preparation are at-most important in the early differential diagnosis of acute arthritides. Crystal deposition disease is established if crystals were recognized and suppurative arthritis is evident if bacteria were found in the synovial fluid. Caution should be made because complications by both are not infrequent. Considering the above mentioned discussion, the treatment schedule may be as follows. In cases of over 70 years old with acute arthritis, irrigation is the only option and antibiotics may be reserved for 24hrs. In cases under 60 years and in infants in particular, antibiotic prescription and distension-irrigation should be done as rapidly as possible.
Serum uric acid values in outpatients (male 416 cases, female 393 cases) were measured, and the following results were obtained: 1) The hyperuricemia were found in 26.3 per cent of male patients, and were found in 6.1 per cent of female patients. 2) The mean value of serum uric acid was 5.5mg/dl in male, and was 4.5mg/dl in female. 3) The complaints of lumbago and back-pain, without trauma, were found more in patients of hyperuricemia than in patients of non-hyperuricemia.
We have treated 3 cases of Polymyalgia Rheumatica in the past 4 years in our hospital. All patients were treated by steroid in low doses, but one patient with temporal arteritis was not controlable by the low dose steroid teraphy. HLA-DR locus typing was performed in all patient. The types were DR2, DR4, DRW9, and two DRW12.
A single intravenous dose of 2g of Ceftizoxime was administerd prophylactically to 31 patients undergoing total hip replacement and prosthesis. In the serum, blood of bone marrow, and cancellous bone, half-life of the antibiotic were 1.32, 1.12, and 1.65 hours respectively; the mean concentrations in one hour were 69.26, 58.70, and 12.54 micrograms per ml or gram respectively. Ceftizoxime showed very good concentration in bone.
Concentrations of cefoperazone (CPZ) in the bone marrow blood and the cancellous bone were investigated by one shot intravenous injection of CPZ (2g) prior to surgery. Concentration in the bone marrow blood was highly elevated (156μg/ml) immediately after injection of CPZ and time dependently decreased, however the concentration was always higher than that in the serum. CPZ was also found in the cancellous bone 1-2 hours after injection with peak level of 27.7μg/ml. It was suggested that the effective dose of CPZ in the bone marrow blood and the cancellous bone was obtained at least 3 hours after injection considered for MIC80 value of CPZ.
We would like to report 5 cases of so-called “Cortical Abscess”. The onset was insidious and inflammatory sings were mild. All patients were male, and four of them were ranged from 12 to 15 years old and one was 33 years old. The lesions were all in the diaphyseal corticis of long bones, 3 in the femur and 2 in the tibia. Surgical intervention was performed for definitive diagnosis and therapeutic aid followed by antibiotic therapy. Recurrences were seen in 2 cases requiring surgery. Staph. aureus was cultured from operative specimens in 3 cases and cultures were nagative in 2 cases. Differential diagnosis from tumorous conditions such as osteoid osteoma, Ewing sarcoma, osteosarcoma and histiocytoma is mandatory. Three phase bone imaging study is currently carried out by using 99mTc-MDP and appears extremely beneficial to make the diagnosis of early stage of osteomyelitis to be differentiated from cellulitis and non-inflamatory masses.
Seven patients with chronic osteomyelitis were treated at our clinic by temporary implantation of gentamicin-PMMA beads between 1982 and 1985. The age ranged from 22 to 71 (average: 49) and the length of follow-up averaged 17 months. Origins of osteomyelitis were post-traumatic in 5 cases and hematogenous in 2. Localizations were 3 femurs, 3 tibias and 1 humerus. Operative procedure was sequestrectomy and temporary implantation of gentamicin-PMMA beads (SEPTOPAL Chains) into the osteomyelitic cavity. Successful results were obtained in 6 patients who had no sign of recurrence. As many publicications reported the possibility of recurrence after long symptoms-free intervals, the fateful course of chronic osteomyelitis may not be altered by this modality. However it has many therapeutic efficacy and advantages in comparison to conventional treatments of osteomyelitis.
We have experienced eight cases of primary osteomyelitis. In acute osteomyelitis, it was difficult to diagnose due to little local sign in the early stage. The clinical diagnosis should be made in children with tenderness and positive blood culture. Brodie type was made a wrong diagnosis as bone cyst. It is important to differentiate it from tumor.
Forty-nine patients who were hospitalized in Nagasaki University between February, 1977 and July, 1985, were examined in order to know the trend about the bacterial infections of bones and joints. Most of the bacillus in 37 cases of osteomyelitis and in 12 cases of pyogenic arthritis were staphylococcus aureus. There was a tendency of increase of the subacute and chronic types of osteomyelitis, and the pyogenic arthritis which was followed by puncture of the knee joint. Our results suggested that while diagnosing the osteomyelitis, the recognition of the existence of the subacute osteomyelitis is very important, and that we must pay more attention to prevent the iatrogenic infection.
Tow cases, which might have been opportunistic infection in the early post-operative state, are reported in this paper. Case 1, a 60-year-old male, developed spticemia on the 22nd day after a synovectomy for suppurative arthritis of the left knee. He had a 13 years history of steroid medication following pituitary adenoma resection. Case 2, a 60-year-old, female, developed pueumonia 4 days after T. K. R.. The bacillus involved was strongly suspected to be a Legionella pneumophila. This patient's basic disease was rheumatoid arthritis. These two cases had similarities of situation, for example their general condition before the onset of infection and antibiotic medication after the operationo; these infections took a similar course. The number of aged patients who have complications following operations for basic diseases has been increasing in the orthopaedic field. We must always, therefore, pay attention to the possibility of the opportunistic infection in the management of such cases.
Candida arthritis has been uncommon. But recently, with the increased use of antibiotics, immunosuppressive agents, intra-venous catheterization and intra-articular steroid injection, they probably occur much more frquentry than recognized. A review of the literature yields 33 documented cases. We have had two experiences of Candida albicans arthritis. Case 1 was an 84-year-old male. His right knee was involved following repeated intra-articular steroid injection. Case 2 was a 63-year-old male. He had sustained fracture-dislocation of left hip joint and abdominal abscess by traffic accident. A year later, his left hip joint was involved follwing prolonged use of antibiotics and dranage. Candida organisms were identified in the synovium in both cases. Both cases were treated by synovectomy and arthrodesis.
Three cases of gas gangrene were reported in this paper. Gas gangrene developed in two after open fracture in the lower limb and the OTHER one after closed femoral fracture in the patient with severe diabetes mellitus. The latter is thought to be rare and only one case has been reported in the literature. All the patients were in toxic stage when they were referred to us. Therefore, disarticulation of the hip was done in all the case with combination therapies of antitoxic serum and antibiotics, which resulted in a good recovery.
Breathing oxygen under high pressure increases the concentration of oxygen in the blood and improves hypoxia situation. So HBO is applied to many diseases. In orthopaedics HBO is used in gas gangrene known to be anaerobic infection. We utilized HBO in soft tissue infection (including aerobic infections) adjunctive to surgical treatment and antibiotics therapy. The results were good. If gas formation is found in the wound, HBO should be done as soon as possible. However, in the cases of aerobic soft tissue infections, main therapy is surgical treatment with antibiotics therapy, and HBO is adjunctive therapy.
A 42-year-old male visited our department because of swelling and limitation of ROM on his right shoulder. At the consultation, soft tissue tumor or subacromial bursitis were suspected. The soft tissue tumor was eliminated by further examination including CT-scan, echo and angiography upon hospitalization. During the operation, many rice bodies and a large necrotic mass were recognized. Histological findings of the above tissue didn't deny the possibility of tuberculous lesion. The diagnosis of tuberculous bursitis, which is very rare, was made according to the above findings and positive tuberculous reaction of his skin. After the operation, anti-tuberculosis medication was begun. Four months later, his symptoms had decreased remarkably.
A 64-year-old man complained of pain in his left ankle. For five months, he was treated for it as gout in another hospital. His left ankle was swollen, and roentgenogram revealed erosion on the articular surface of the fibula, narrow joint space, and slight osteoporosis. Tuberculous arhtritis was suspected from the present illness and the roentgenogram. Synovectomy of the left ankle and extirpation of the cyst were performed. From the operative findings, we concluded that it was tuberculosis, which was proven histologically later, and the chemotherapy was started on the fifth postoperative day. Despite the chemotherapy, a sinus tract on the wound did not close, so curettage and arthrodesis of the ankle were performed four months after the first operation. The postoperative course had been satisfactory for five months. Recently, tuberculosis has decreased in number, which often results in delay in time of diagnosis. Chemotherapy has improved treatment of tuberculosis and surgery has become elective in most cases. So, even performing biopsy positively, a correct diagnosis should be made early enough to avoid unnecessary joint destruction.
We have treated a case of tuberculosis of the ankle, which could not be correctly diagnosed for 2 years. A 34-year-old male visited Nagasaki Univ. Hospital because of continued pain some time after a spain of the ankle. After operation, pain and swelling still continued, and moreover, a fistula developed in the ankle. For 2 years after the operation, the ankle lesion was treated as an infection caused by staphylococcus epidermidis. On reflection we believe that tuberculosis of the ankle should have been suspected in the early period of his treatment because of his symptoms and the course of his disease.
In this paper we reported a female infant with spinal tuberculosis who developed motor disturbance of her both lower extremities at 11-month-old. On admission she couldn't move her lower extremities at all and her knee and ankle jerks were exaggerated with ankle clonus on the both sides. We made a diagnosis of spinal tuberculosis from hematological examination and the findings of her X-ray pictures, tomsgrams and CT. We began to treat with administration of Rifampicin and INH. The laboratory findings were normalized after one month and neurological abnormalities were completely recovered after three months of treatment. However, by the reasons of that there is no history of tuberculosis in the patient and her family, her mantoux reaction was negative, and the period between the beginning of treatment and normalization of laboratory findings was short, there were some difficulties in differential diagnosis between spinal tuberculosis and pyogenic osteomyelitis.
Many procedures have been devised for recurrent anterior dislocation of the shoulder. In our hospitals, the Oudard-Jinnaka has been the most frequently performed operation since 1937. The present report is that of our experience with the procedure. From 1953 to 1985, we did a total of thirty-eight Oudard-Jinnaka procedures for the anterior instability excluding the multidirectional instability and the recurrent anterior subluxation. A follow-up was undertaken of thirty patients. The age of the patients ranged from sixteen to thirty-eight years and averaged twenty-three years at the time of the operation. Twenty-three procedures were done in male patients and 7, in female. They were followed for one to thirty-two years. The average follow-up was eleven years. Five of the thirty patients redislocated their shoulders from four months to nineteen years after operation. They had no recurrences during the ensuing years. Redislocation occurred in one of twenty-three patients in whom the bone graft was longer than 3cm as indicated in the manual. In shoulders in which the bone graft was shorter than 2.5cm, the incidence of redislocation was significantly increased.
Posterior dislocation of the shoulder is rare and easily overlooked. The incidence reported previously is about 1.5 to 3.8 per cent of all shoulder dislocations. Some clinical findings and an axillar radiogram will establish the diagnosis. But, severe swelling and resricted motion in the early days after injury prevent us from making the correct diagnosis. We have experienced a case of chronic posterior dislocation which had been operated on with McLaughlin's method nine weeks after injury. Clinical course was very favorable.
Ultrasonic examination was performed on 11 cases of Legg-Calve-Perthes disease (LCPD). The cartilaginous femoral head, the nucleus, the iliac bone and the limbus were visualized by ultrasonography. In LCPD the deformity of the cartilaginous femoral head and the fragmentation of the nucleus can be demonstrated. We developed “echo-index” which is a new method for measurement of ultrasonographic results of LCPD. The results of echo-index is well correlated with those of caput-index by Jonsäter. We presented the ultrasonographs of 4 cases of LCPD comparing the results of arthrography. Ultrasonic examination is non-invasive and we think that it is very useful for the evaluation for LCPD.
We studied radiologically the hip joints of the cerebral palsy children. We measured alpha angle, anteversion angle, neck-shaft angle and CE angle in 50 patients. The results were as follows: 1) Dislocated or subluxated hips were found in 20 percents of 100 hips. 2) Alpha angle and anteversion angle in non-ambulatory group were more increased than in ambulatory group. 3) CE angle in non-ambulatory group was more decreased than in ambulatory group.
It is proposed that hip dislocation in cerebral palsy occurs with muscle imbalance about the hip. Selective muscle releases-psoas tenotomy, adductor myotomy, hamstring tenotomy-have been performed for the treatment of hip dislocation in cerebral palsy. In this report, we showed two interestings cases of cerebral palsy which suggested that hamstrings' hypertonicity led the lateralization and elevation of the femoral head. On the other hand, we experienced a rare hip dislocation in Moyamoya disease which was reduced by derotative varus osteotomy without hamstring tenotomy. From these results, we concluded that hip dislocation in Moyamoya disease might occur by a different mechanism from that in cerebral palsy.
Genu recurvatum due to posterior release of the hamstrings will often disturb the ambulation in children with cerebral palsy. We consider that the main factor of genu recurvatum is caused by the spasticity of the rectus femoris muscle. From 1984 to 1985, distal release operations of the rectus femoris were performed on eleven cases of spastic paralysis and three cases of athetosis. Ten of the fourteen patients showed improvement in gait or sitting or both post-operatively. The spasticity of the rectus femoris was effectively released by our operation and the insufficiency of the quadriceps femoris has not been observed in all operated cases.
We presented the follow-up study of fifteen hips of thirteen patients of CDH treated surgically. The follow-up period was 3.8 years in average. Open reduction was performed in two hips, open reduction with derotation varus osteotomy in five and open reduction with femoral shortening in eight. Saltor or Chiari operation was added in four. The postoperative results were excellent on the whole showing less deformity of the femoral head and a good stabilization of the hip. We stress that each factor obstructing a stable reduction should be evaluated and removed at surgery and, if overriding dislocation of the femoral head, decompression of femoral shortening is important to prevent necrosis of the femoral head.
Femoral lengthening operations in the pertrochanteric region with distal transfer of greater trochanter were performed on two hips of coxa vara and plana, seven hips of coxa vara with acetabular dysplasia which were combined simultaneously with Chiari pelvic osteotomy. All cases had leg length discrepancies over 20mm, and were diagnosed as preosteoarthritis or initial stage of coxoarthrosis. The patients consisted of one male and eight females, an average age being 15-year-old. Ninomiya described that limping and Trendelenburg sign would not disappear by distal transfer of the greater trochanter alone in the cases having leg length discrepancies over 20 or 30mm. Operations were performed since 1980. Preoperative mean discrepancy was 26mm. Eight patients showed Trendelenburg sign preoperatively and postoperative mean lengthening of the femur was 17.1mm. Trendelenburg sign almost disappeared in seven cases. Preoperative mean score of osteoarthritis of the hip joint based on the J. O. A. criteria was 80.3 points which were improved to 89.2 point postoperatively.
In order to clarify the significance of the constructional abnormalities of the hip joint on the progress of secondary coxarthrosis, we examined X-ray pictures of 91 cases with some morphological abnormalities on their bilateral hips. Furthermore, side of the hip joint which induced pain earlier and stronger was investigated. Following results were obtained: 1) The most correlative factors which induced pain earlier were abnormal acetabular roof angle and CE angle. 2) Disorder of hip congruity may influence the development of the secondary osteoarthritis of the hip.
To know the haemodynamics of the osteoarthritis of the hip, intraosseous venographies of the proxymal femur were performed in 58 hips of 45 patients. The picture of the veins obtained by intraosseous venography was examined with paticular attention to the visualization of superior retinacular vein (S. R. V.), inferior retinacular vein (I. R. V.), gluteal vein (G. V.), medial circumflex vein (M. C. V.), lateral circumflex vein (M. C. V.), and flow into diaphysis. (FID). As the stage of the disease progressed, incidence of the visualization of S. R. V., I. R. V. and G. V. decreased and that of F. I. D. increased. These findings suggest that disturbance of venous circulation has occurred in relation to the radiological abnormalities such as sclerotic change and cyst formation of the femoral head. Another cause of the occurrence of F. I. D. may be the proxymal displacement of the femoral head.
In Japan, there are many cases of secondary osteoarthritis of the hip caused by CDH or dysplasia of acetabular roof. Seven patients (eight hips) with secondary osteoarthritis were treated by transposition osteotomy of the acetabulum. Clinically, satisfactory results were achieved in six hips. Arthrogram is useful for the prediction of postoperative hip congruity.
Twenty-seven cases with 30 hips of advanced coxarthrosis treated by valgus extension osteotomy (Bombelli) and valgus flexion osteotomy were investigated. Clinically, arevition of pain was notable. Roentugenologically, disappearance of bone sclerosis and pseudocyst made the trabecular structure normal. Joint space became remarkably wide and remodelled as a new joint. Some effects could be obtained as determined as a biomechanical analysis. However, capital drop may be considered to be a new femoral head adapting to a new acetabulum, formed as the result of biological restoration. In order to promote the remodelling of the hip joint using the capital drop most efficiently, the valgus flexion osteotomy seems to be more rational than the valgus extension osteotomy.
A herniation of the capsule in the hip caused by articular effusion is very rare. A 72-year-old man who had osteoarthritis of the left hip noticed left inguinal mass for the last 4 or 5 years. The mass was gradually getting larger in size and gait pain annoyed him. On admission, the left hip showed limitation of motion, particularly in flexion, extension, and abduction. Surgical excision was carried out. The mass was noted to be anterior herniation of the capsule and to compress the femoral nerve and vessels. It was similar to iliopsoas bursa, but CT-scan, macroscopic examination and histologic study revealed that it was not likely to the bursa. Removal of the capsule relieved his complaints, but subsequently a half year later, THR was performed.
On seventeen hips, we performed the measurement of bone marrow pressure and the intramedullary venography in the proximal femur to study the haemodynamics of the medullary circulation. In case of bone necrosis, the baseline pressure was above 30mmHg, or the pressure elevation by stress test was more than 10mmHg above the baseline at five minutes after the injection of 5ml of normal saline.
The follow-up data of the hip endoprosthesis for femoral neck fracture evaluated by the questionarie were previously reported on this journal. In the data, twenty-three out of thirty-two patients had some disability as well as pain. Seven patients could be reviewed. The high degree of distal migration occurred in five cases. The proximal migration occurred in one case whose neck was too long. We consider that the adjustment of the length of the neck is important in the surgical technique.
Of the 130 patiants (148 hips) who had a total hip replacement at our clinic during the years from 1971 to 1984, 84 hips were evaluated by questionaire and roentogenograms. The type of prosthesis was Mckee-Farrar in 1971-1976, Charnley-Müller in 1976-1980 and Trapezoidal-28 in 1980-1984. The incidence of the migration of the acetabular component was 11per cent in Mackee-Farrar, 10per cent in Charnley-Müller and 22per cent in Trapezoidal-28. The incidence of the sinking of the femord component was 22per cent in Mackee-Farrar, 52per cent in Charnley-Müller and 50per cent in Trapezoidal-28. Eight cases were needed revision surgery. The acetabular component revisions were seven and the femoral compoment revision was only one.