Calcifying aponeurotic fibroma is a rarely seen benign soft part tumor. Throughout the world, from 70 to 80 cases have been reported and in Japan there have been only 6 cases since Keasbey reported the first one in 1953. Recently we experienced such a case which is reported here. A 5 -year-old girl visited our hospital with the complaint of a tumor in the area of the left ankle joint after learning of calcification of the area by X-ray at a hospital in her neighborhood. She had an elastic hard tumor, the size of the head of the little finger, in the anterior distal lateral malleolus of her left foot. The surface was smooth, the margin unclear, and adhesion to skin, mobility, redness and local heat was not found. In the operative findings, the tumor was about 4.0×2.0×1.5cm in size, yellow-white, elastic soft and adhered tightly to the periosteum of fibula, anterior talo-fibular ligament, anterior tibio-fibular ligament and the capsule of ankle joint. These adhesions were invasive. In the pathological findings, the tumor mainly consisted of spindle cells like fibroblasts, and these cells were of an interlaced pattern. Focal calcification was present and pathological diagnosis was calcifying aponeurotic fibroma.
One hundred and fifty-six free skin flap transfers have been performed for reconstruction of the extremities in recent decade at our clinic. There were 56 dorsal foot flaps, 52 peroneal flaps, 16 latissimus dorsi musculocutaneous flaps, 15 groin flaps, 8 medial leg flaps, 7 scapular flaps, one fillet flap, and one medial thigh flap. 95 flaps have been used for reconstruction of the upper extremity, and 61 for the lower extremity. From review of our experience of clinical cases, our selection of the free flap in reconstruction of the extremities is as follow. For covering of skin defect, latissimus dorsi musculocutaneous flap is useful for large defect. Scapular flap, groin flap, and medial leg flap were useful for middle and small defect. If the composite tissue transfer (bone, nerve, nail, etc) is also required, peroneal flap, dorsal foot flap, and latissimus dorsi. musculocutaneous flap are useful according to the needs of recipient site. For thumb reconstruction and sensory reconstrction of the finger, dorsal foot flap will be used.
The reconstruction of injured fingers is often difficult when the bone, nerve and vessel of fingers are exposed. For the reconstruction of such fingers we have used a Venous skin graft obtained from the arm. This method was performed on 8 cases. The flap survived in all 8 cases. The largest flap of the 8 cases is an 8.0cm×3.0cm in size. For 2 coses we have covered the skin defect of two fingers with a Venous skin graft. The grafted skin was rich in elasticity and flexibility.
We acertained the sural nerve was nourished by the cutaneous branches of the peroneal artery or the muscular perforating branch of the posterior tibial artery and developed the new free vascularized sural nerve graft. Twenty-one clinical cases including four brachial plexuses, six median nerves, four ulnar nerves, five digital nerves and two radial nerves were reconstructed with this technique. Their graft length was between 6 and 30cm. Most of the grafts were sected and folded on itself without damage to the blood supply of the nerve and used in the fashion of cable graft. Their follow-up period ranges from 2 to 32 months. An early and sufficient functional recovery is obtained though the final extent of recovery in half of our cases could require several months. Compared with the other vascularized nerve graft and conventional nerve graft, our method has many advantages: 1) A “cable graft” can be designed on itself without damage to blood supply of the nerve, 2) Survival of the nerve can be reasoned by the accompanying flap and the flap can close the skin defect simultaneously, 3) An early and certain functional recovery can be obtained in the poorly conditioned cases.
Intramuscular ganglion is extremely rare. There are few reports in the medical literature written in English and Japanese. We experienced a case of ganglion in the Articular Genss Muscle. The patient, a 49-year-old man, was found to have a swelling in the proximal side of the right patella. The mass was soft and non-tender. Arthrography revealed compression in the proximal side of the quadriceps bursa. The computed tomography revealed cystic lesion with illdefined border and perifocal low density. We made a diagnosis of atypical ganglion by histologic examination.
Recently, some cases that was diagnosed as internal derangements of the knee were confounded with the symptoms caused by instability of the proximal tibiofibular joint. We experienced 2 cases of instability of the proximal tibiofibular joint, which were diagnosed by drawing the fibular head anteriorly and treated operatively.
We reported a case of idiopathic unilateral external torsion of the tibia. The patient was an 18 years old female, a nurse student, and complained of gait disturbance with severe pain over the anterior surface of the right leg. Tibial torsion angles were demonstrated by C. T. showing 51 degrees on the right and 38 degrees on the left. Symptoms and signs were improved after derotation osteotomy at the high tibial portion.
Fourteen patients of patello-femoral joint disorder were treated by anteromedial displacement taxing our ingenuity. This procedure isolates the tibial tuberosity as a pedicle by adding the reed osteotomy and simultaneously displaces it anteriorly and medially. In this method, the bone graft is not necessary and the patients can begin the early rehabilitation. This paper reports the results of the procedure in 14 patients with 16 knees. The results of this procedure is evaluated by symptoms and roentgenographs and it is proved that this procedure is useful for the patello-femoral joint disorder associated with malalignment.
From July 1983 to August 1986, arthroscopic lateral release was performed in sixteen patients (sixteen Rnees) of subluxation syndfrome of the patella. Their mean age at the time of operation was 20.1 years with a range from 12 to 20 years. Eight patients had osteochondral fracture of the patellar medial facet. Fragments of all patients were removed arthroscopically. Fifteen patients were available for follow up. The follow up interval ranged from three months to three years and four months (mean, 12.7 months). Roentgenographycal results were satisfactory in all patients, but clinical results were unsatisfactory in two patients (follow up interval of one patient was seven months and another was eight months). These patients were unable to play sports at the time of follow up. Arthroscopic findings of these patients showed more remarkable changes of chondromalacia patellae than those of other patients, and physiological findings showed remarkable genu valgum, and roentgenographycal findings showed remarkable dysplasia of the patellar groove.
Since March 1983 till August 1984, we have done the laterl retinacular release for subluxation syndrome of the patella in 22 cases. The mean age was 18 years (from 10yrs. to 26yrs.). The tilting angle and the lateral shift of the patella in their skyline view were distinctly improved (p<0.01 significantly). According to the Ficat's criteria, the results at one year after the surgery were excellent in 55% of the cases and good in 45%. At two years after surgery, the results were excellent in 49%, good in 39% and fair in 12%. The resucts became worse between one and two years after operation. The all fair cases had large Q-angle (over 25 degrees), general joint laxity and patella alta.
The medial collateral ligament (MCL) is commonly injured and not so difficult to diagnose. 75 patients were diagnosed in the past five years at Kyushu Rosai Hospital. The rupture ends were interestingly displaced into the center of the knee joint in 2 cases of 75 cases. One case showed avulsion fracture in the intercondylar space on X-ray film, and was misdiagnosed as avulsion fracture of the cruciate ligaments, because both cruciate ligaments were injured in this area. Another case showed that rupture end existed among the medial femoral condyle and medial meniscus on the arthroscopic examination, and was misdiagnosed as tear end of the middle-posterior segment of the medial meniscus. Preconception is dangerous even in the diagnosis of the MCL and carefull examination is necessary.
15 cases of both (medial and lateral) meniscal injuries were encountered in the last two years. 14 cases were accompanied with anterior cruciate ligament injuries (ACL) which was 17.7% of ACL injuries in the same period, and one case with medial collateral ligament injury. Most frequent initial sport was volleyball, and most frequent combination of tear types of both menisci was longitudinal tear of middle-posterior segment of medial and lateral menisci. Extension of the tear was developed with period from initial injury, but even single trauma could cause both menisci injuries, of which is taken account. Partial menisectomy as arthroscopic surgery was mostly done for the treatment of the meniscal tear.
Open surgery for reconstruction of anterior cruciate ligament (ACL) such as Insall method required large incision and long period of post-operative immobilization. Arthroscopic surgery has many advantages in comparison with open surgery such as small incision, minimmum scar formation, preventing muscle damage and so on. Our technique for ACL reconstruction under X-ray control is reported. Initially, arthroscopic meniscectomy and/or meniscal suture are done. Then 3cm skin incisions are made on lateral femoral condyle and anterior of the tibia. After exposure of the cortex, 1.5mm Kirshner wires are inserted under X-ray image. The isometric points for ACL reconstruction are just posterior and superior region of the femoral attachment and anterior medial site of the tibial attachment. Following these Kirshner wires, stepped bone tunnels are made using 5mm and 8mm reamers. Then the Leeds-Keio's artificial ligament is passed carefully and fixed with bone plugs and staples. If necessary, extra-articular reconstruction is done. After a week of immobilization, the device of continuous passive motion is applied and three weeks later, partial weight bearing is permitted using the Lenox-Hill brace. Although the follow-up period is short as long as 4 months, range of motion and stability are better with our present method than our previous open method.
A total knee replacement was performed on a patient suffering from pain with rheumatoid arthritis. This knee had been done of arthroplasty using interposing chromicized fascia lata (J-K Membrane). Macroscopic and microscopic findings were studied. This paper reports these findings in the knee joint which had been passed for ten years with J-K membrane.
We reported the experience of continuous passive motion in postoperative rehabilitation of total knee replacement on 9 RA patients (14 knees) and 6 OA patients (7 knees). We applied continuous passive motion on these patients from the first day to the 14th day after the operation. Comparing results of experimental patients with control (3 RA and 5 OA patients) were as follows. Compared with control, excellent range of motion in operated knees was obtained early after operation and it was maintained during follow-up period in both RA and OA patients. Postoperative bleeding was not increased on experimental patients. In conclusion, continuous passive motion is a valuable procedure for early rehabilitation of total knee replacement.
The course of the repair of the rotator cuff rupture has not been fully clarified experimentally in comparison with that of other tendons. Revascularization and remodelling of surgically made canine rotator cuff rupture were studied microangiographically. Twenty-four shoulders of twelve adult mongrel dogs were used. The study was divided into two groups: group I. Resection of the supraspinatus tendon. group II. Tendon suturing to bone after cuff resection. The dogs were killed at regular intervals and specimens including the cuff and the greater tuberosity were obtained and observed microangiographically. Microangiographic studies were also performed in six shoulders of three non-operaed dogs to clarify the normal distribution of the blood vessels in the rotator cuff. In normal canine rotator cuff, three main arteries contributed the arterial supply of the supraspinatus tendon; the suprascapular artery, the cranial circumflex humeral artery and the caudal circumflex Numeral artery. The supraspinatus tendon insertion was relatively hypovascular in its intratendinous portion. In group I, wide scar tissue formed in the gap was hypervascular and the vascular pattern was entirely different from that of normal supraspinatus tendon at twenty-four weeks. In group II, tendo-osseous junction underwent a process of progressive reconstruction, though proliferation of blood vessels still remained at twenty-four weeks.
The movement of the shoulder complex was once aptly described by Codman as the “scapulohumeral rhythm”. The aim of our study was to demonstrate this rhythm by using fluoroscopy and a computer. The subjects were asked to elevate their arms smoothly in approximately 3 seconds and 5 seconds in front of the fluoroscopy with and without load. The X-ray was irradiated perpendicullarly to the scapular plane. Movements were calculated using the computer. During abduction in the scapular plane, the ratio of scapular movements to humeral movements was about 0.38. The scapulohumeral rhythm was divided into three stages, and the first stage was thought as the setting phase. The movements of the instant center of the humerus were in a small area during elevation. This result suggested that the movement of the glenohumeral joint was almost rotational. The movements of the instant center of the scapula were in a relatively large area during the motion.
The tracking movement of shoulder joint in the saggital and the scapular plane was analysed by electromyogram, which was led from the upper trapezius, rhomboideus, middle deltoideus and pectoralis major, and the waves recorded on data recorder were analysed by computer. The subjects were evaluated an average of 78 months after pectoralis major transfer for shoulder instability. The purpose of this study was to determine the influence of this operation on the muscles surrounding the shoulder joint and on the tracking movement of the shoulder joint. The subjects showed a tendency to move the operated shoulder joint more quickly than that on the unoperated side. The gain of pectralis major muscle on operated side is significantly higher than that on unoperated side. (p<0.05) It is considered that this increase of action potential should be useful for scapula stability because scapula abduction is improved after this operation.
The authors reviewed 42 cases with the inferior shoulder instability seen at the Kumamoto University Hospital and associated Hospital between September 1985 and October 1986. There were 28 cases with bilateral inferior shoulder instability. The most of cases with moderate inferior shoulder instability had motion pain in the shoulder joint as a chief complaint, and those with severe inferior shoulder instability had numbness and weakness in the upper extremities. The cases with the apprehension or history of shoulder dislocation had multidirectional instability of the shoulder. At first, all of the cases were treated with muscle strengthening exercise of rotator muscle conservatively. On two cases, Neer's anterior capsular shift was performed.
A review of thirty cases of the modified Bristow procedure for recurrent anterior shoulder dislocation is presented. The follow-up ranged from 6 months to 12 years and 2 months, with a mean of 3 years and 5 months. In our series there were no redislocations. 93% did not complain of pain and 70% had no difficulty in a daily living. All patients were subjectively satisfied with the procedure. The patients were asked to grade their results from 0 to 10 points and the average results, as graded by the patients, was 9.3 points. Three patients were not capable of returning to sports after the operation because they feared having a recurrence. The Mean loss of external rotation was 8.6 degrees. Roentgenograms at follow-up revealed that two had non-union of the bone block, two had loosened screws and two had broken screws.
Fifteen shoulders with recurrent anterior dislocation were treated with a modified Bristow procedure. The average length of follow-up was four years and seven months. All patients were satisfied with the results, although one had a displaced screw from the coracoid process. There were no readislocations. The average loss of external rotation was 12 degrees. The modified Bristow procedure is an effective method of treating recurrent anterior dislocation of the shoulder.
A case of the thoracic outlet syndrome treated with the brace elevating the scapula is reported. A 25-year-old woman felt neck and shoulder pain radiating down the right arm without causes three years ago. The symptoms increased progressively. Exercises to strengthen the shoulder suspension muscle were not effective. The symptoms were exacerbated by passive downward traction of the arm and relieved by passive upward movement. The symptoms were improved by the brace of elevating the scapula. I think this brace management may be used as one method of the conservative treatments of the thoracic outlet syndrome.
The patients with thoracic outlet syndrome have numbness of the upper limbs, stiff shoulder, pain on the neck and pain on the back, whose brachial plexuses and/or subclavian vessels are compressed at the thoracic outlet. However, etiology and diagnosis of the thoracic outlet syndrome are not certain yet. We performed first rib resections by transaxillary approach on five patients with thoracic outlet syndrome, and obtained good results. We think that this operation is not only safe and relatively easy but also excellent in its good results.
Odontoid fracture of the dens is notorious for the difficulty of the accurate reposition and the rigid immobilization. There is the high rate of non-union in case of non-surgical management. We have experienced the case of old dense fracture (Anderson type II) and treated satisfactorily with Fronto-Occipito-Zygomatic brace (FOZY brace). FOZY brace is effective for the upper cervical support in comparing with other cervical orthoses.
A case of lateral dislocation of atlanto-axial joint is reported. This case was a 65 years old man who had had severe pain in posterior neck and occipital lesion. Radiographs showed lateral dislocation of atlanto-axial joint. This patient was xero positive and there were erosions in atlanto-axial joints, which suggested that the cause of lateral dislocation was RA. Complete relief was obtained immediately after posterior fusion by Mcgraw's method and he has been assymptomatic 7 weeks postoperatively. Anterior dislocation of atlanto-axial joint is very common. Posterior, upward and rotatory dislocation of atlanto-axial joint are sometimes seen. But lateral dislocation of atlantoaxial joint is very rare. We could not find the report of lateral dislocation of atlanto-axial joint caused by RA.
To define the changes of the cervical spine of RA, 98 patients of RA were studied according to its clinical symptoms, Lansbury index, ADI, Stage and the duration of disease. 87 of the patients were women and 15 men. These ages ranged from 27 to 75 years old, with an average of 54.9 years old. The duration of disease varied from 10 months to 37 years (average, 12 years and 8 months). Of 98 patients, atlanto-axial subluxation developed in 21 (21.4%) and disc space narrowing in 19 (19.4%). Nuchal pain was a common finding in the patients and found in 74 (75.5%). But they had not always correlation with symptoms and cervical changes. In 30 patients who had cervical involvement, there was no symptoms about cervical region. The cervical involvements increased in the patients whose duration of disease was more than 13 years and/or with Lansbury index more than 45 per cent. And it may be necessary to check the cervical spine in such patients unless they had no symptoms about cervical spine.
The plasma concentrations of estrogen (estrone, estradiol and estriol) were measured in 34 OPLL cases, aged 37-74yr and 30 non-OPLL cases, aged 37-74yr, using radioimmunoassav mpthnd. The mean concentrations of estrone in OPLL cases and non-OPLL cases were 65.1pg/ml and 72.6pg/ml. The mean concentrations of estradiol in OPLL cases and non-OPLL cases were 27.0pg/ml and 22.4pg/ml. The concentrations of estrone and estradiol were not significantly different between OPLL cases and non-OPLL cases. The concentration of total estrogen was significantly higher in OPLL cases and non-OPLL cases than in healthy younger men. The high plasma concentration of estrogen in OPLL cases was due to aging.
The yellow ligaments of the thoraco-lumbar spines of the ten autopsied cadavers were investigated histopathologically and rentgenographically by making sagittal and transverse specimens of the spines, to clarify the mechanism of the ossification of the yellow ligament (OYL). Rentgenographic findings revealed that OYLs including minimal ossification were recognized in 98% of the yellow ligament. The ossification tended to become larger in accordance with the cadavers' age. Histologically, small ossification sites at the insertion of the ligament on the inferior surface of the upper lamina, which could not be detected rentgenographically, were demonstrated in some cases. Moreover, four corners of the sagittally sectioned yellow ligament, namely, ventral and dorsal margins of the ligament attached to the inferior and superior surfaces of the laminae were the predominant ossified areas. These findings suggest that the ossification is due to the distraction stress suffered by the yellow ligament.
The purpose of this paper is to evaluate roentgenologic changes of ankylosing ing hyperostosis of the spine (AH) and speculate the factors developing AH. In this report, 22 patients with spinal injury were studied. All patients were males. The mean age of these patient at the final follow-up was 58 years with a range from 34 to 79 years. The patients were divided into two groups; one group of ossification of the anterior longitudinal ligament of the spine (OALL) and the other of non-ossification of the anterior longitudinal ligament o f the spine (non-OALL). Each group was composed of 11 patients. There was no difference in the background between two groups. Roentgenologic changes were evaluated by comparing two groups with regard to three points; the height of intervertebral discs, the degree of kyphosis and lordosis, and the degree of spodylolisthesis. The main results found in this long term follow-up study were as follows: 1) In the cervical spine, OALL group has narrowing of the intervertebral discs more commonly than non-OALL group. 2) In the thoracic and lumbar spines, non-OALL group has more narrowing of the intervertebral discs than OALL group. 3) OALL group has tendency to increase the degree of thoracic kyphosis and decrease that of lumbar lordosis. 4) There is no significant difference in the degree of spondylolisthesis between two groups. According to these results, we think that the important factor in the development of AH is not only diffuse ossifying diathesis but the local biomechanical factor.
The purpose of this paper is to describe the relation between ossification of the posterior longitudinal ligament in the cervical spine (OPLL) and ankylosing hyperostosis of the spine (AH). The radiograms of 10 patients who had AH with OPLL comprised the material for this study. The mean age of this group of patients was 64 years with a range from 49 to 81 years. There were 9 males and one female. Duration of follow-up study varied from 51 months to 128 months, the average being 87 months. The main results found in this study were as follows; 1) Of the 10 patients studied, two advance in the stage of AH and all 10 pateients had growing of ossification of anterior longitudinal ligament in the spine. 2) Common type of OPLL with AH was cotinuous type in Seki's classification. 3) Five patients (50%) had growing of OPLL and advance in the stage of AH in cervical spine. Generally, these patients had the early stage. Four patients advanced from the first stage to the second stage and one patient advanced from the second stage to the third stage. In cosideration of these results, it is important to pay attention to radiographic changes of the first stage of AH-predical nucleus and the changes along the anterior surface of vertebral bodies-to anticipate growing of OPLL.
Post-operative long-term results of thoracic myelopathy due to ossification of the posterior longitudinal ligament (thoracic OPLL) were studied. There were nineteen cases consisting of 3 males and 16 females. Their ages ranged from 41 to 74 years old (average; 52 years old) at the time of operation. The follow-up periods were more than 6 months and up to 11 years (average; 4 years and 2 months). The overall results were not satisfactory comparing with those of cervical OPLL; that is, excellent and good results were obtained in 53% of the cases at the time of discharge, and in 47% at the time of follow-up study. Based on our follow-up results we propose that the choice of operative procedure of thoracic OPLL is following; that is, anterior approach must be selected at first in principle, and laminectomy may be selected if OPLL exists more extensively. Further, if there is some mobility of the spine in the area of laminectomy, posterior fusion may be necessary using bone grafts or instruments.
Ninety-four patients with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine who had been treated operatively were evaluated clinically and radiologically. Anterior fusion, laminectomy, cervical enlargement surgery was carried out on 33 cases, 18 cases, 43 cases respectively. Radiological progression of OPLL was seen in 36% of anterior fusion, 100% of laminectomy, 81% of enlargement. In the postoperative evaluation, anterior fusion was found to be effective in 64%, laminectomy 61%, and enlargement 70%. There was no obvious correlation between post-operative result and progression of OPLL after operation.
The degenerative spondylosis of the thoracic spine tends to be neglected because the disease usually has light symptoms. This 39-year-old male case complained of severe back pain on right rotation of the trunk. We succeeded in treating the patient by originally designed seatbelt-type apparatus which prevents him to rotate to the right. We also discussed some differences between this patient and the other with ankylosing hyperostosis of spine (Forestier's disease) in this report.
Three cases of vertebral myeloma treated surgically were presented. All cases were male and ages ranged from 48 to 73 years (average, 59 years). One case had a focus in the cervical column and others in the thoracolumbar columns. On the former case, extraction and anterior fusion with ceramic spacer was performed. On the latter two cases, extraction and posterior fusion with Harrinton rod, wire and bone cement, was performed. Although the follow-up term is not so long, prognosis is good.
We report eight cases of spinal tumor treated with spinal instrumentation. This method is usefull in the point of its stabilization and supporting of the spine. We reconstructed spinal deformity which has been destructed by spinal tumor. In the result, the instrumentation surgery reduced the pain and the paresis, and enabled early rehabilitaion.
We have been using spinal instrumentation across the unfused vertebrae in the treatment of thoracolumbar fractures. But it was hoped that only injured level was internally immobilized and fused. Three cases of thoracolumbar spinal injuries were treated by anterior decompression and fusion combined with posterior transpedicular. Zielke fixation between injured levels: the first lumbar bursting fracture, the second lumbar bursting fracture, and fracture-dislocation of the twelfth thoracic spine on the first lumbar spine. Transpedicular instrumentation with anterior strut graft gave sufficient stabilization to the unstable spinal segment.
Twenty-four patients with spinal disorders were treated by Luque's segmental spinal instrumentation. We used this method for the purpose of increasing stability and reducing the period of postoperative bed rest. This surgery was performed on four cases with spinal fracture, four cases with metastatic spinal tumor, two cases with unstable spine, four cases with spondylolytic spondylolisthesis and ten cases with degenerative spondylolisthesis. The patients with the fractured spine were allowed to sit on the bed on the first postoperative day, and other cases on the seventh postoperative day. The patients were allowed to sit and walk with the William's flexion brace. We recognized two complications. One was pain of the sacral region which was noticed in some cases, and another was a wire breakage seen only in one case.
Automatic Analytic System of scoliosis that employed TV camera, A/D changing apparatus and personal computer, was applied clinically. The results were previously reported by Okamoto. The character of Automatic Analytic System is the following. (1) It analyzes automatically the back deformity of scoliosis by personal computer, and prints out the results. (2) The time for analysis is about thirty seconds for each person. (3) It can screen the spinal deformity without X-rays and contact, objectively, correctly, and directly. (4) It can be carried easily for the light weight. (5) Many analytic apparatuses are not needed in a prefecture, if the system has been perfected. This time we carried out the medical examination of scoliosis at the primary and lower secondary schools in the city of Isahaya by means of the Automatic Analytic System. In seventeen cases screened that had more than 15° of Cobb angle in the thoracic C curve type, the correlation coefficient between the Cobb angle and the difference between the right back pitch and left one at standing was 0.75, which is a pretty good correlation. As a result of this medical examination, we saw that this Automatic Analytic System of scoliosis is excellent in the medical survey at school.
We presented a 17 years old woman who had congenital kyphoscoliosis with spastic paralysis that was influenced in the degree by psychosomatic disorder. We diagnosed initially that the spastic paralysis was caused by compression of spinal cord due to tight film terminale, but eventually, we found that the development of paralysis was influenced mainly by psychosomatic disorder.
Spinal evoked potentials (SEPs) were monitored during scoliosis surgery in 11 patients. Epidural bipolar stimulating and recording electrodes were placed caudal and rostral to the site of surgery, respectively. In one case of scoliosis, with overdistraction of the vertebral axis, monitoring SEPs were reduced in amplitude with the delay of latency. These findings were correlated postoperatively with neurological deficits. Continuous recording of SEPs are stable and reproducible monitoring techniqu and make it possible to predict the neurological prognosis intraoperatively.
Scoliosis in cerebral palsy caused by spasticity and unbalanced muscle tension is frequently seen and the incidence has been reported from 6.5 to 38 per cent, which is higher than in the general population, and to be highest in non-ambulatory patients. This deformity may progress to cause pain, an impairment of cardiopulmonary function, loss of sitting and standing balance, or a combination of these difficulties with subsequent deterioration of functional abilities. For such spinal deformities, spine fusion and instrumentations have been mainly performed. However, these procedures limit rotatory movement of the spine which is necessary for ADL. Therefore, we performed muscle release operation for scoliosis in cerebral palsy on five cases. Although the scoliosis deformity was not satisfactorily corrected by our procedure, there was no progression of scoliosis and clinical symptoms such as stability of sitting and standing balance, and pain relief, have improved.
Two cases of Sacral Agenesis, which is a rare deformation and is included in Caudal Regression Syndrome, were reported. The first case, 7 years old girl, has short trunk, tiny underdeveloped pelvis, dorsal prominence of the lowest vertebra and telescoping back which seems to be caused by spino-pelvic instability and flexible lumbar scoliosis. The second case, 4 years old girl, also has a short trunk, severe contracture of the lower extremities and progressive congenital scoliosis.
Fibrous cortical defect is known as a non-neoplastic bone lesion which is characterized by the radiolucent appearance radiographically, and frequently occurred in the metaphysis of a long bone. This disease is self-limiting without any complaint. In this paper, We presented two cases of fibrous cortical defect which showed unusual clinical course. One was a fifteen-year-old girl who had a lesion in the distal metaphysis of the right femur. The other was a twelve-year-old boy who had a lesion in the proximal metaphysis of the left tibia. Both complained of the pain on exersion. We observed over a half year but the pain continued and the lesion persisted radiographically. Finally, the operation was performed and the symptom disappeared.
Two cases of cerebral palsy with fragmentation of the distal pole of the patella were presented. They were a 7-year-old girl and an 11-year-old boy. The former complained of right knee joint pain but the latter did no pain. They had severe spasticity in the legs and knee flexion contracture. Excessive tension in quadriceps mechanism appeared to cause the lesions. Hamstring release was done in both cases, resulting in the bony fusion postoperatively. Knee joint pain disappeared in the female case.
Between 1956 and 1986, ninty-five patients in myogenic torticollis were treated by open tenotomy. The ages of 15 cases of them were over ten years old. Five cases underwent tenotomy at both distal and proximal ends of sternocleidomastoideus muscle and ten cases at distal end only. We used three types of post-operative immobilization: cast in eleven cases, halo brace in three cases and collar brace in one. We concluded that the halo brace was indicated for the myogenic torticollis which was complicated in cervical scoliosis in high-teen-agers. Especially the halo brace was of great advantage to traction for the scoliosis rather than cast immobilization. Complications of the halo brace was concerned with pinning, but this trouble was solved by technique of pinning. For low-teen-agers we made a new type of collar brace for the purpose of early mobilization.
Forty-one patients with quadriceps contracture involving 49 limbs due to repeated intramuscular injections were treated between 1976 and 1985. Adequate follow-up studies were obtained from 37 patients (45 limbs). The operations were performed following the muscle belly approach which includes transverse division of rectus and scarred portion of vasti. The result was generally excellent. In all cases, the angle of knee flexion on prone position became better than 60° and all cases except 2 gained better than 130° of knee flexion in supine position. To prevent large dimple of thigh, we divided rectus in two steps at some distance.
There is little place for the conservative treatment of the slipped upper femoral epiphysis but the gidelines for the surgical treatment are divided on the issue because of high incidence of the serious complications. Our principle of the management for this condition is proposed based on the analysis of 5 cases. (1) 5 cases were treated by two stage procedure. At first pinning in situ was done for preventing further slipping and when the mobility of the hip joint was restricted secondary osteotomy was performed for improvement of the range of motion. (2) Southwick's subtrochanteric osteotomy is recommended for cases with slipping less than 50 degrees and Sugioka's anterior rotational osteotomy, for cases with slipping greater than 50 degrees. (3) Periodical follow-up is thought to be more reasonable than prophylactic pinning for asymptomatic opposite hip.
A radiolodical study about the growth of the acetabulum was carried out on 42 children with Perthes' like change of the femoral head after the conservative treatment of CDH. The growth pattern was constructed statistically with the regression curve of α angle (from 1 to 7 years old), Sharp angle (from 7 to 20 years old) and the ratio between the depth and the length of the acetabulum (from 7 to 20 years old). In Perthes' like change group, the growth pattern shows the deterioration o f a angle from 5 to 7 years old and the shallow acetabulum. The deformity of the femoral head due to Perthes' like change produces a powerful effect on the growth of the acetabulum.
We performed a radiological measurement to know the defferencies of the growth of the acetabulum between Pavlik harness and Lorenz's method. α-angle, Sharp angle and the ratio between the depth and the length of the acetabulum were measured in serial X-ray pictures of 74 hips by Lorenz's method and of 45 hips by Pavlik harness. There was the continuous growth close to the control group in the Pavlik harness group but there was the deterioration of the growth from 5 to 7 years old in Lorenz group. The most characteristic change of the growth pattern occurred at 5 or 15 years old. The deterioration of the growth in Lorenz's group may be due to the damage of growth cartilage around the acetabulum during the period of treatment.