We treated three cases of osteomyelitis of the foot in children at the same time. They were one girl and two boys. Osteomyelitis of the foot was relatively rare in our department and literature. Many authors reported that osteomyelitis of the foot in children was diagnosed as an inflammation of the soft tissue at first. Our cases were diagnosed as osteochondrosis of the calcaneus, phlegmone or tendinitis of the achilles tendon by other doctors. They were referred to us because of their continuous tolerable pain at night and inflammatory signs. The X-ray findings were recognized at least ten days after onset. Concerning the treatment, they got the good results by the conservative treatment. In conclusion, it is necessary to suspect osteomyelitis if the inflammatory signs of the foot and tolerable pain are noticed.
In the recent 4 years, 8 cases of hematogenous osteomyelitis, 6 males and 2 femles, were seen at our hospital. Their ages ranged from 6 to 65 years with an avarage of 27.9. Of the 8 cases, 7 had involvement of both flat and short bones. The most frequently involved bones were calcaneus in three patients aged less than 10 years, and lumbar vertebrae in two patients aged more than 60 years. Although 6 cases were the acute form, each one of the humerus and mandibula were subacute and chronic form. The blood culture was positive in 4 of 8 cases (St. aureus in 3 cases, Salmonella in a case of the rib). An average of 31 days after the onset of symptoms, demonstarable radiographical findings were revealed. A case of bilateral acute hematogenous osteomyelitis was reported.
Septic arthritis has been decreasing gradually, but the bones and joints are often destructed, which affects the growth of these organs. In 9 years from July, 1979 to Aug., 1988 11 patients with juvenile septic arthritis (7 males and 4 females) have consulted our Department. Involved joints were as follows: 4 hip joints, 6 knee joints and 1 foot joint. Eight of these joints were hematogenous, 2 were trauma and 1 was iatrogenic. The causal bacteria was verified in the bacteria culture from joint fluid in 8 cases. All of these cases had staph. aureus, and in 1 case of the other three, staph. epidermidis was proved by intraoperative cultivation of synovial tissue. Four patients were treated by capsulectomy, 3 of them being accompanied with closed irrigation, and the other 7 patients were treated by puncture and drainage.
Candida arthritis is rare. But recently, it has been seen increasingly because of prolonged antibiotic treatment and intra-articular steroid therapy. We reported two cases (64 and 63 years old women) of knee arthritis by Candida, both of which had undergone intra-articular therapy. In one of them, Candida parapsilosis was cultured from the synovial fluid and synovium specimen. Candida organisms were identified in the synovium by PAS and Grocoot staining. Synovectomy and Amphotericin B treatment were administered.
Twenty-four cases of monoarticular joint disease were diagnosed as non-classified monoarthritis at our hospital. These patients underwent labolatory examinations and open biopsy, and were followed from 1 month to 6 years and 7 months (mean, 1 Year and 11 months). Four patients were diagnosed as having rheumatoid arthritis, 2 in infectious arthritis, 1 in tuberculous arthritis and 1 with localized nodular synovitis. The remaining patients' diagnosis was non-specific arthritis.
Over the past 7 years we have treated three cases of bone and joint tuberculosis. They were proved to be tuberculous infection of the 10th and 11th thoracic vertebrae, olecranon and ankle joint. Tuberculosis should be considered in the differential diagnosis of unexplained chronic arthritis and osteomyelitis. Therapy should include excision of involved bone and soft tissues and appropriate chemotherapy.
Spontaneous rupture of the tendon during long-term systemic administration of steroids is rare and it is found only sporadically at the Achilles tendon. We report two cases of spontaneous rupture of the tendon during long-term systemic steroid therapy. One of the patients who was administered steroids for systemic lupus erythematosus developed rupture of the Achilles tendon, and the other treated for polyneuritis showed rupture of the tendon of the long head of the biceps brachii muscle. These two cases are considered to show that rupture of the tendon occurred due to degeneration and weakness of tendon tissue during long-term systemic steroid therapy.
Radiographic studies of the lower cervical spine in rheumatoid arthritis (RA) were performed to investigate the influence of the fusion of the upper cervical spine upon the lower. Twenty of 54 patients treated operatively were examined. Fourteen cases with atlanto-axial anterior subluxation were treated with McGraw's procedure and 6 cases with atlanto-axial vertical subluxation were treated with occipito-atlanto-axial fusion. Normal subjects of control were 50 patients who were diagnosed as classical RA and treated conservatively. In each case, narrowing of intervertebral space without osteophyte, end-plate erosion, facet erosion, collapse of vertebral body and anterior subluxation were investigated from four roentgenograms (anteroposterior, lateral including neutral, flexion and extension). Collapse and anterior subluxation were more frequently by seen in cases of occipito-atlanto-axial fusion than in cases of McGraw's procedure and non-operative treatment. This result suggests that the fixation of occipitoatloid joint adds great force to the lower cervical spine.
One hundred shoulders of 50 patients were examined about their roentgenograms and the clinical evaluation with Shoulder Evaluation Sheet (J. O. A. score) in spite of the presence or absence of clinical symptoms. Twenty-eight patients had complaints of 44 shoulders. Roentgenographic examination was carried out by means of bicipital groove projevtion as well as A-P and axillary projection. The results were as follows. 1) It was suggested that roentgenographic changes proceeded in order of items of our roentgenographic examination. 2) The primary roentgenographic change was found out at the portion of the bicipital groove by bicipital groove projection before clinical appearance of clinical symptoms. 3) Our roentgenographic evaluation's score reflected the results of J. O. A. score.
Roentgenographic examination was carried out in 181 knees of 91 patients with rheumatoid arthritis. 14 cases (37%) of RA patients over 60 and 14 cases (42%) of the patients whose disease durations were over 10 years were the grade IV or V of Larsen's method. We judged that these cases had operative indication and did TKR to 18 joints (9%) out of them. Judging from the narrowing of the femoral-tibial joint space, 65% of the cases showed normal alignment, 31% medial narrowing alignment, and 4% lateral narrowing alignment.
Wrist synovectomy (with or without resection of the distal ulna) was performed in 8 cases with monoarticular rheumatoid arthritis affected in the wrist joint. 5 cases (3 female and 2 male) were followed and their mean age was 50 years old. At follow-up after a mean observation time of 26 months, all cases had complete pain relief, but the range of motion was not improved in pronation and in volar flexion. Four cases had morning stiffness preoperatively and it disappeared in all cases. The CRP test was various in each case. The radiographic findings showed progression in all cases. Rheumatoid arthritis developed in the course of the follow-up periods in 3 cases. To diagnose the RA, synovial histology should show the characteristic histological changes in synovial membrane as follows; 1) villous hypertrophy; 2) infiltration of chronic inflammatory cells; 3) tendency to form “lymphoid nodules”; 4) deposition of compact fibrin; and 5) foci of cell necrosis. And 4 cases had 3 or more findings of the above-mentioned. The diagnosis of the monoarticular rheumatoid arthritis is difficult in early stage. Wrist synovectomy and synovial histology is very effective for the diagnosis and treatment of this disease.
Understanding of the rheumatic patient condition in a busy orthopedic clinic is not so easy. We tried to classify the RA patients into 5 groups in order to understand the patient's clinical condition easily: 1) initial condition, 2) incomplete remission, 3) complete remission, 4) inflammed condition, and 5) burned-out condition. Then we made preliminary criteria for the conditions by estimating the items which indicate their inflammatory states.
We experienced the dexamethason palmitate (D-PAL) therapy for 21 patients of Rheumatic Arthritis (RA) and evaluated its usefulness and the side effect. In the single injection group, the localized anti-inflamatory effect was found, while the general effect was expectedly noted in the repetitional injection group although the drug control of RA was comparatively decreased. The good results were particulary obtained in stage I II, class 1 2 of RA. We considered that the efficiency of D-PAL repetitional injections was expected both in the interval therapy for a few months until the effect of induction drug therapy appeared, and in the maintenance therapy for the condition such as class 3, 4 of RA.
We treated 20 patients diagnosed under the new ARA criteria for rheumatoid arthritis (RA) with Bucillamine 100mg-300mg/day. There was an improvement rate of 85%. Effectiveness was especially marked in early RA patients but it was seen also progressed RA patients, and it was seen in about eight weeks after administration. The drug was effective in patients who had changed over from injectable gold salts, Dpenicillamine and Auranofin. It's side effects were seen in 30% of the patients, but severe ones were not seen in our cases. Among remission inducing agents, this drug was one that could be administered early.
Thirty-two Salter innominate osteotomies that were performed in thirty-one patients, 4 boys and 27 girls, between 1974 and 1988 were roentgenologically reviewed. On the plane A-P radiograph the α-angle and the center-edge angle of Wiberg were measured pre- and postoperatively. The preoperative complications were as follows: the acetabular dysplasia (32 hips); the subluxation (11 hips); the lateralization (12 hips); and the dislocated hip (9 hips). At late review, twenty-one hips (20 patients) were assessed by the Severin's criteria. Fifteen of twenty-one hips (71%) were rated as group I or II. In six unsatisfactory hips, the radiological results especially the CE angles were not improved remarkablly. Main purpose of this procedure was to gain the acetabular coverage of the femoral head, however, it was thought to be one of the important factors influencing the end results to increase the CE angle, in other words to sink the femoral head into the joint. We combined the open reduction with this osteotomy to make the femoral head in good position for 11 hips with concomitant subluxation. Thirteen of eighteen hips that developed avascular necrosis preoperatively were followed for at least 5 years, and 8 of 13 hips got the satisfactory results. Though it was difficult to predict their prognosis, the Slater's osteotomy might be useful for these heads because of improvement of the containment.
Biomechanical effects of the Chiari pelvic osteotomy were evaluated using two dimentional computer simulation by Kawai's Rigid Body Spring Model. These results were compared with clinical outcomes. 176 patients who had Chiari pelvic osteotomy in our clinic were available for this study. Their abduction power of the hip was measured by Cybex and that was analyzed using the simulation. The results were as follows. 1) The abduction power of the hip was decreased temporally after the operation, but was gradually increased to the preoperative level in 6 to 9 months. 2) In the younger patients, the abduction power was restored in early period. 3) The vector direction of the abductor muscles were changed medially with hip abduction by the simulation.
In order to know the haemodynamics of the proximal femur in osteoarthritis of the hip, intramedullary pressure (IMP) of the metaphysis was measured. For the 40 cases (61 hips) of osteoarthritis of the hip, the correlation between IMP and radiological findings was discussed, and the correlation between IMP and visualization of extraosseous veins in intramedullary venography (IMV) was also examined. As the radiological changes of osteoarthritis progressed, IMP was elevated. In the cases which had no visualization of extraosseous veins in IMV, high IMP was observed. According to the above findings, elevation of the IMP in osteoarthritis of the hip may be due to the disturbance of the venous circulation of the proximal femur.
The results of trochanteric varus osteotomy were reviewed 2 years and 2 months to 12 years and 1 month (mean, 5 years and 7 months) after operation. We evaluated the results according to the J. O. A. 's score and radiographic findings. Clinically, 12 cases (92.6%) showed good or excellent results. The clinical results had relation to the enlargement of joint space and continuous Shenton's lines, but little relation to CE angles.
The purpose of this study is to clarify the effect of OMNIFIT system in hip prosthesis. Twenty-two hip joints of 21 cases treated by prosthesis operations with OMNIFIT system were evaluated by postoperative results and roentgenograms. The age range was from 52 to 94 years old with an average of 75 years old. The follow-up term ranged from 6 months to 47 months with an average of 25 months. According to the JOA score, 16 patients showed good results. Other 5 cases showed bad results due to complications, such as senile dementia, rheumatoid arthritis, and parkinsonism. Changes of roentgenographic findings, such as sinking of the stem, sclerotic changes of the acetabula, and osteoporotic changes, gave no influence on the postoperative results. Range of motion between the inner and outer heads showed a marked decrease especially in the cases which had reaming of the acetabula. The Sharp angle of the outer head showed a marked decrease especially within a month after operations. Range of motion between the inner and outer heads showed significant relationship with the Sharp angle. Varus position of the outer head is good for mobility between the inner and outer head. OMNIFIT system was thought to be an effective prosthesis.
Up to July, 1988 one hundred eleven patients (124 hips) with coxarthrosis were treated by bipolar endoprosthetic replacement. Of them thirty patients (32 hips) required additional acetabuloplasty with bone graft from the acetabular dysplasia. In this paper an idea of bone grafting using the excised autogenous femoral head-neck block is reported. Reviewing the cases CE angle of the bipolar head before acetabuloplasty was average 13.4 degrees (range: -20-40 degrees) and the angle improved to average 54.1 degrees after bone grafting. To evaluate the influence of excessive bone coverage on the hip motion the cases were divided into the groups at intervals of 10 degrees increase of CE angle from 40 degrees. There was no significant restriction of flexion and abduction of the hip joint by increasing bone coverage of the bipolar head.
Allograft was used on a patient who was diagnosed as rheumatoid arthritis with severe acetabular protrusion. The acetabular deficiency was reconstructed with the allograft in bipolar hip arthroplasty. We employed a freezed femoral head as the allograft. Roentgenographically, bone trabeculae were passing the graft-acetabular junction in medio-inferior region. Bone scans showed increased activity in the allograft near the host-donor junction at an early stage and maintain high activity up to date. Partial incorporation and high radioactivity suggest that this allograft will be incorporated completely at the early date.
147 total hip replacements (THR) were performed for past 16 years. Müller prostheses were used in 88 cases, Charnley prostheses in 59 cases. 10 cases of dislocations occurred in Charnley prostheses for early complications. We suggest that they might have been caused by the weakness of defence of anterior soft tissues. Müller's surgical approach made such weakness.
104 total hip replacements were performed for 87 patients since 1973. 60 hips in 47 patients could be evaluated. The cases consist of six males and forty-one females. The mean age was 57 years old (range, 42-73) and the duration of follow-up ranged from 5 years to 15 years (average, 9 years). In the follow-up study, operated hips were evaluated using the JOA score. Radiological examination was performed using postoperative radiological evaluation scale of Kawauchi et al. Results showed that preoperative total average score of 39 points was improved to 72.3 points postoperatively with marked improvement mainly in relief of pain. Revision was done in two cases (2%). Infection and another complications were not noted.
Ankylosis of the hip restricts patient's activities of daily life and causes pain in the contralateral hip, lower back and knees. We performed 4 total hip replacements in 3 patients who received malpositioned arthrodeses for osteoarthritis (27-year-old and 56-year-old women) and tuberculosis (54-year-old man), and in a patient of malpositioned spontaneous ankylosis for tuberculosis (64-year-old man). At an average follow-up period of 5.7 years, all of them showed improved activities of daily life and relief of their preoperative pain in the associated joints with good muscle power about the hips.
A very rare case of recurrent anterior dislocation of the hip with neurofibromatosis was reported. A man aged forty-one years sustained anterior dislocation of his right hip when he fell posteriorly while working in the field fifteen years ago. The dislocated hip was reduced under general anesthesia. Two years ago he fell while working, and sustained same dislocation of his right hip. Third dislocation occurred when he tried to stand up, and forth dislocation occurred when he was swimming. Radiographs demonstrated an elogation of the right femur, and increase in the neck-shaft angle, but no remarkable change was seen in the acetabulum and femoral head. At operation, we recognized tear of the anterior capsule and softening of the capsule and capsular ligament. We performed capsular plication and intertrochanteric varus-derotation osteotomy. During a year after the operation, no further redislocation occurred.
Six patients (7 hips) were treated for slipped capital femoral epiphysis. Three of 4 patients (5 hips) who had a mild slip were treated by in situ pinning, and one patient (2 hips) underwent hormonotherapy for hypothyroidism without surgical operation. One patient with moderate slip was treated by trochanteric osteotomy, and open reduction was carried out on one patient with severe slip. All the patients at an average follow up of 3 years and 3 months were evaluated clinically and radiologically, and satisfactory results were achieved without complications such as avascular necrosis, chondrolysis or osteoarthritis.
A follow-up study of the eighteen hips with previous episode of Legg-Calve-Perthes disease aged over eighteen years old was carried out. There were close relationship between hip pain and acetabular roof angle in X-ray findings. It could be concluded that the acetabular roof angle is an important factor to predict the prognosis of Legg-Calve-Perthes disease.
In this study, forty-four cases (forty-six hips) of Perthes' disease treated by varus osteotomy from 1975 to 1985 were studied radiologically to investigate the incidence of the “Head at risk” signs and the correlation between the signs and the prognosis of this disease. The radiological result of the femoral head was evaluated by Mose's criteria after a minimum follow-up period of three years after diagnosis. Among the five of “Head at risk” signs, “Gage's sign”, “Calcification lateral to the epiphysis”, and “Diffuse metaphyseal change” were seen in nine, ten, and ten hips, respectively out of forty-six hips. Other two signs were undetectable because of varus ostetomy. The cases with no risk signs proved to have good radiological results. There was an increasing incidence of a poor radiological result with an increasing number of the risk signs. “Diffuse metaphyseal change” had a high risk for the poor result.
Avascular necrosis of the femoral head is frequently observed in growing spontaneously hypertensive rats (SHR), which resembles the pathological findings of Perthes' disease in man. In the incidence of Perthes' disease, it is known that the femoral heads of boys are affected more often than those of girls. The purpose of this study is to observe the difference of the incidence between male SHR and female. In male SHR, the number of the necrosis at the age of 6, 9, 12, 15 and 20 weeks (14 femoral heads of 7 SHR in each age group) was 0, 1, 1, 9 and 7, respectively. Moreover, the retardation of the ossification in the femoral head was also seen frequently. On the other hand, the necrosis in female SHR was seen only in 4 of 70 femoral heads. The similarity of the femoral head lesions in SHR and Perthes' disease is discussed in this papper.
HLA typing was examined in four patients with avascular necrosis of the femoral head which occurred in two families. One family is brothers who are habitual drinkers and another is brothers by a different mother who suffered from SLE with steroid therapy. Former disclosed the same pattern of HLA typing. Common HLA type in four patients are CW 3 and DR 9. The role of immunological factors in idiopathic avascular necrosis of the femoral head is discussed in this paper.
Hematological changes after fracture in 112 patients excluding the concomitant visceral lesions and the diseases in the past history were investigated during two months after fracture. Male patients numbered 49 and female 63, and the ages on an average of 59.3 years ranged from 16 to 95 years. Fractures of the proximal femur were 52, the femoral shaft 9, the lower leg 24 and multiple fractures 27. Results were as follows: 1) Anemia was remarkable in the patients with multiple fractures including pelvic fracture and in the aged patients with extracapsular fracture of the femoral neck or subtrochanteric fracture of the femur. 2) In aged patients, important hematological changes were anemia and hypoproteinemia. 3) Several cases showed transient abnormal findings of hepatic or renal function. 4) In the patients with closed fracture, laboratory data revealed the values under 2+ of Creactive protein.
The effects of spinal anesthesia with 0.5% Marcaine® (0.5% bupivacaine) was studied in 107 lower extremity surgeries. In Marcaine spinal anesthesia group, other anesthetic agents and vasopressors were not significantly less often used than in Carbocaine® (mepivacaine) epidural anesthesia group. In hip, lower leg and foot surgeries, analgesic duration was significantly longer in the former group than in the latter group. Cephalad spread was greater in the latter group than in the former group. We conclude that 0.5% Marcaine spinal anesthesia is as safe and useful for the lower extremity surgery as Carbocaine epidural anesthesia, especially for elderly and hip surgery.
We treated 11 patients with complicated femoral and tibial fractures by a dynamic axial fixator. Four patients had multiple injuries, three had severe complications and four had open fractures. The average healing time was 7.8 months. Pin complication occurred in four patients. In no case was the infection severe enough to require removal of the fixation device. This method was easy to use and effective. Patients found the lightweight, smooth, single bar to be quite acceptable in their daily activities.
This study was designed to address to improve the durability of the external fixation of pelvic fractures. 4mm and 5mm Hoffman Pins, 5mm Ace Fischer Pin, 6mm Ace Hip Pin and Miami Pelvic Screw were screwed in different places of the iliac crest and measured pull out strength. 5mm Ace Fischer Pins which were seated in anterior part of the ilium and which were penetrated in anterior part of the cortex of the ilium were loaded three times at the tip of the pins and then resulting loosning was investigated. We investigated if a drill guid would help to screw pins into the ilium not penetrating the cortex of the ilium. The posterior and mid regions of the ilium had weaker bone for screw fixation than the anterior region. Thread length and configuration had the most dramatic effect on pullout strength. The pins seated within the ilium had better durability than the pins penetrated the cortex of the ilium. A drill guide helped to screw into the ilium not penetrating the cortex of the ilium.
We treated twenty-seven ipsilateral fractures of the femur and tibia from 1970 through 1988. All the fractures except one tibial fracture and two amputations were, in the most cases, treated surgically with plates. Nineteen patients were examined in person. According to the criteria for assessment of end results by Karlström and Olerud, the patients were graded as excellent, good, fair and poor. Excellent results were achieved in eight patients, good in six, fair in one and poor in four. We found that plates were especially useful regarding prevention of shortening and deformity. Poor results were more associated with severity of fractures and concomitant soft tissue injury, such as nerve injury, than the type of fractures.
Eleven cases of reoperated femoral shaft fractures using intramedullary nailing method were reviewed. The results showed excellent bone union in all the cases after an avarage of 11.1 months postoperatively. The ages of the patients ranged from seventeen to fifty-nine (average, 36.1) and all were male. Primary operations had been carried out by plates and screws in ten cases and by Küntscher Intramedullary nail in one. Nine Kúntscher and two Grosse and Kempf intramedullary nails were used for the final operations. We would prefer intramedullary nails, especially using closed method, to plate fixation because the former preserves blood supply to the fracture site. Grosse and Kempf nail which has transverse locking screws prevents shortening and rotational deformity of the fragments and this has widen the indication of the original Kúntscher nail.
Twenty-two femoral shaft fractures in 22 patients were treated by intramedullary nailing, 14 patients were operated with Küntscher nail and 8 patients were with Ender nails. According to the winquest and Hansen classification, these fractures were classified in Type II or in Type III. The period when full-weight bearing was permitted was earlier in patients who was operated with Küntscher nail than in Ender nails. However, the time of bone union in cases operated with Ender nails was the same as in cases with Küntscher nails. The cases which showed radio-lucent zone at the distal points of Küntscher nails were shorter in period of bone union than others without radio-lucent zone. These results suggested that elastic fixation was better than rigid fixation in operative teratment for femoral shaft fractures by closed intramedullary nailing.
Ten cases (7 male and 3 female ) of severely comminuted fractures of the femoral shaft were mainly treated by K-U plate. The follow-up period was 20 months in an average ranging from 5 months to 58 months. The fractures were classified into 3 types in order of seventies of comminution, and evaluated as our operative methods. Union was obtained in all cases. Slight Lower limb-length discrepancy was noted, however there was no case of limping.
We report the incidence of pressure sores in elderly patients operated on for femoral neck fracture. Pressure sores were found in 52 patients (47%). Most of the sores were in wemen aged 75 or more. A total of 81 pressure sores were seen in 52 patients and the commonest sites were sacrum and buttocks. Pressure sores developed preoperatively in 54% of the patients and in 46% within 1 week after operation and later. Relation was found between pressure sores and low albuminemia. The prevention of pressure sores in elderly patients with femoral neck fracture should be paid.
Fifty cases of intertrochanteric fracture were treated operatively. Nineteen cases were treated using Ender's intramedullary nails and 31 cases using compression hip screws. Those fractures fixed with Ender's nails tended to develop varus deformity, pain at the insertion area of the nails and distal migration of the nails at the knee. Each fracture was classified according to classification of Evans. Good results were obtained in 64% of stable type and 73.3% of unstable type using compression hip screws, and in 33.3% of stable type and 20% of unstable type useing Ender's nails.
The follow-up study of 84 cases over the age of 65 years old with femoral neck fracture was undertaken. These cases were 27 intracapsular and 57 extracapusular fractures. They were from 65 to 95 years old (average, 78 years), and followed for 0.5 to 5 years (average, 3.7 years). At the time of this study 17 cases had been already died because of heart disease and etc. Nineteen cases recovered to the almost same level as preinjury. Results of intracapsular fracture were better than that of extracapsular. It was thought that improvement of technical procedures and rehabilitation at home was important.
Osteosynthes is by percutaneus intramedullary nailing using multiple pinning of K-wires or rush pins were performed for six patients above 65 years old who sustained distal femoral fracture. Four of them acquired good and early bony union. Two of them acquired good range of motion of the knee. Advantages of these methods for old patients are as follows. First, the invasion of these methods is little for the femoral condyles that are fragile due to osteoporosis. Second, the invasion of these methods for muscles around the knee joint is little. Third, it is easy even for old patients to acquire early bony union, because there is no invasion on the periosteal membrane by these methods. Forth, required time for these operations is short and bleeding is a little. Therefore, these methods are very useful for distal femoral fracture for old patients whose range of activity is less than that of young people.
Two cases with microfracture of the medial tibial condyle were reported. The fracture was supposed to be a stress fracture. Gonalgia reduced by using a pair of cruthes in several weeks. Differential diagnosis from pes anserinus bursitis and aseptic necrosis of femoral condyle was important because of a lack of the X-ray signs in a initial stage.
Intraarticular fractures of the knee have proved difficult to manage because of the variation of the fractures and accompanying soft tissue injuries. Controversy between surgical and conservative therapy has existed for decades. To choose the appropriate method of treatment, the fractures must be thoroughly evaluated. We performed the arthroscopic managment on 12 cases of all 23 intraarticular fractures of the knee since Nov. 1984. Arthroscopy is a low-risk procedure that allows accurate definition of the fracture and assessment of the concomitant soft tissue damages. In addition, by utilizing arthroscopic visualization, reduction and stabilization of the fractures can be accomplished percutaneously or with a very limited incision.
For the last ten years, 70 patients with the fracture of patella were treated in our hospital. Of these, follow-up study was carried out in 27 cases. Twelve patients were treated conservatively and 15 operated on. Enlargement of the involved patella was noted as well as shortening of the patellar tendon in most cases. Clinical result was generally better in conservative group. This is considered to be attributable to the less damage of the patello-femoral joint in conservative group than operative group.
Two cases of Salter-Harris Type II separation of the epiphyseal cartilage plate were treated at our hospital. Case 1. A 6-year-old boy fell from a swing and injured his left knee. Radiographs showed a Type II fracture of the distal femoral epiphysis with anterior displacement. Manipulative reduction was attemped and immobilization was applied with a plaster cast to the flexed leg. Case 2. A 13-year-old boy injured his right ankle while playing Judo. Radiographs showed a Type II fracture of the distal tibial epiphysis with posterior displacement, together with a spiral fracture of the lower fibula. Manipulative reduction was attempted and a plaster cast immobilization was applied. These two cases were treated conservatively with satisfactory results.
Thirteen cases of the fractures in the upper end of the tibia were reported. Thease cases were classified by Hohl's classification: undisplaced type, 2 cases; split type, 2 cases, split depression type, 3 cases; and comminuted type, 6 cases. Four cases of undisplaced type and split type were treated conservatively and 9 cases of split depression type and comminuted type were operated. The results were estimated by the criteria of Hohl and Luck: excellent in 7 cases, good in 3 cases, fair in 1 case and poor in 2 cases. The conclusion was following: 1. the stable internal fixation made early mobilization possible, 2. the short-term cast and early mobilization made good results, 3. primary repair of ligamentous or meniscal injury made good results, 4. the degree of depression of the tibial condyle must be controlled within 5mm in depth, which made good results.
In order to rehabilitate patients as early as possible after the operative reduction of tibial plateau fractures, we developed and applied a knee brace which was possible to give corrective force in the direction of varus or valgus at the knee joint. As a result, the improvement of therapeutic evaluation for the above mentioned fractures was obtained.
To examine important factors in the range of motion of the knee after fractures including the knee: supracondylar and condylar fractures of the femur and tibial condylar fractures, ranges of motion finally obtained after operations in 77 cases were investigated. Five factors which seemed to affect the range of motion were selected and analized statistically: the site of the fracture, the period of post-operative immobilization, the method of internal fixation, the period between injury and operation, and the age of patients. Analysis by Quantification 1 showed that the most important factor affecting the final range of motion was the site of fracture, and the period of post-operative immobilization followed. It appears that in the femur intra- and extra-articular tissues are easier to adhesion. So to avoid the contracture after operation, motion exercise should be started as early as possible if the fracture was well fixed.
Three cases of compartment syndrome of the leg were reported. Intracompartmental pressures were measured by needle manometer method. Pressure and clinical findings were used as indications for decompressive fasciotomy. So in all cases with a pressure of forty milimeters of mercury or more, decompressive fasciotomy was done. Except one case, good results were obtained. Elevated tissue pressure in the osteofascial compartment of extremities may cause loss of function or necrosis of the enclosed nerve and muscle. The early diagnosis and treatment of a compartment syndrome requires that the extremities at risk be examined frequentry.