Since 1984 spherical acetabular osteotomy was performed on 231 patients (270 hips) with acetabular dysplasia, some of whom showed early or progressive degenerative changes with the CE angle of 10° or less. The 45 hips (43 patients) were followed for an average of 3 years and 10 months. The age of the patients at the time of operation ranged from 13 to 61 years (average, 27.4 years). The clinical and radiological results were as satisfactory in the progressive degenerative group as in the early degenerative group; there was no significant difference of the outcome among procedures of type I, II and III in the spherical acetabular osteotomy.
We measured isometric muscle force of the hip abductor to evaluate the influences of the surgery to the hip. Measurement was done on eleven patients with osteoarthritic hip treated by rotational acetabular osteotomy, using a new device of our own design pre- and postoperatively. The force was measured at four different degree in adduction-abduction position such as fifteen degrees in adduction, neutral, fifteen and thirty degrees in abduction. An abduction force was evaluated on maximum value and durability. Maximum value within six months after operation shwed less than that of preoperative one at any position, and they recovered to preoperative values over six months after operation at fifteen degrees adducted and neutral position. On the other hand at fifteen degrees and thirty degrees abducted posotion did not. Durability was increased within six months after operation, and then the variation between each position became small over six months after operation.
We evaluated the clinical and radiogical results of 46 hips diagnosed as pre and early osteoarthritis treated by Chiari pelvic osteotomy. The average follow-up period was 6 years 7 months. Satisfactory results were provided in 29 hips (63.0%). Poor results showed in cases with 1) inadequate medial displacement of the femoral head, 2) lower height (<5mm adove from acetabular ridge) of the osteotomy, 3) postoperative lateral migration of the femoral head. Lateral migration of the femoral head was found frequently in cases with lower height of the osteotomy.
From 1977 to 1989, 35 Bombelli's valgus-extension osteotomies were performed for secondary osteoarthritis of the hip in 30 patients. All patients returned for personal examination, interview and X-ray assessment. The average follow-up period was 7.8 years (range, 1.2 to 12.8). The average of the patients was 43.2 years (range, 28 to 65). At the latest evaluation 83.3% of the patients were good or excellent on the subjective evaluation of JOA score. It would appear that age itself cannot be held as an absolute contraindication to osteotomy. Better results were obtained in the patients with the large capital drop and no osteoporosis.
In 1969 Nishio devised transtrochanteric curved varus osteotomy in the treatment of subluxation of the hip. We performed this procedure on 50 hips in 46 patients from 1976 through 1987 at our hospital. We studied 34 hips in 30 patients in these patients which were followed for more than 2 years. Radiological results showed that 19 hips were good. 12 hips were poor and other 3 hips had little change. Poor group in radiological results did not remark improvement of pain score in clinical results. 3 hips showed femoral head necrosis and another 3 hips showed lateral subluxation of the head. This procedure has been useful to early stage of osteoarthritis with subluxation of the hip, especially unilateral type.
Since 1982 the bipolar hemiarthroplasty has been performed for the primary surgery of the coxarthrosis. One hundred twenty-four patients (144 hips) were available for follow-up assessment. Mean follow-up interval was 3 years 11 months (range, 1 to 8 years 4 months). The prostheses used were Bateman UPF for 49 hips and collarless, microstructured Omnif it hip system for 95 hips. Radiologically, migration of the outer head was observed 6.9% superiorly and 7.8% centrally. Subsidence of the stem was 5.5%. Omnifit prosthesis was more stable than Bateman UPF. Clinically, good-to-excellent result was obtained in 76.6%. The JOA hip rating score improved 84.7 points after surgery from the preoperative average 47.4. No deterioration of the results during follow-up intervals was observed. Pain relief was remarkable and consequently it influenced on improvement of gait ability and ADL. The intermediate follow-up study suggests a role for the bipolar hemiarthroplasty in the primary surgical treatment of coxarthrosis.
From 1976 to 1990, 17 hip arthrodeses have been performed for severe osteoarthritis at the National Misasa Onsen Hospital. The age of the patients ranged from 32 to 55 years at the time of the operation. Follow-up period was 4 months to 13 years (average, 3 years and 6 months). In the follow-up study, operated hips were evaluated using the JOA score. Results showed that preoperative total average score of 53.2 points (range, 32 to 68) was improved to 66.6 points (range, 50 to 76) postoperatively. Especially, pain score changed for the better from 15.3 points to 37.1. Nonunion rate was 17.6 per cent. We come to the conclusion that even recently, hip arthrodesis is one of the useful operation for severe osteoarthritis in the middle age.
Fibrin glue is used widely in Japan as tissue sealant, adhessive and hemostatic agent. But it is prepared commercially from pooled human blood, so there is some risk of transmission of hepatitis B, acqired immune deficiency disease, and other blood-transmission disease. We described a cryoprecipitation technique for preparation of fibrin glue from patient's own blood. This technique enables the glue to be made in large quantities with no greater risk of disease transmission. We report on our method preparing fibrinogen from single-donor fresh-frozen plasma (FFP). We have found that the cryoprecipitation glue is useful in reducing post-operative bleeding in hip surgery and that it seems to affect osteogenesis.
The cases of seventeen patients who had spherical acetabular osteotomy mainly were reviewed to evaluate the efficacy of recombinant human erythropoietin (EPO) in autologous blood predeposit, compared with the control group of nineteen patients. Autologous blood predeposit was performed by leap-frog method, and EPO was intravenously administered two times a week from a week before the first phlebotomy to the operation. The mean age of the EPO group was 44.6 years and the control group 34.4 yeras. The mean amount of autologous blood predeposit and perioperative blood loss of each group were 1447g, 1368g and 1507g, 1114g. The rate of reduction of the blood hemoglobin concentration of the EPO group was significantly less than that of the control group (P<0.001), and no side effect appeared. And in the patients of the EPO group the rate of reduction of blood hemoglobin concentration was related to the serum iron and the serum ferritin. In conclusion, EPO is effective to the autologous blood predeposit before elective operations with enough iron supply.
The cause of osteochondritis dissecans of the hip is unknown. We examined the etiology based on the analysis of 6 cases, aged 11 to 25 years. Of these 6 cases, five patients had history of LCC and one had dysplasia. All X-ray revealed a dysplasia, deformity of the femoral head and a lesion in the weight bearing area. The patients made favorable progress after the spherical acetabular osteotomy in expectation of reparing the lesion. Therefore, osteochondritis dissecans seems to be caused by the disturbance of the healing biomechanism, because the overloaded forces are concentrated on an affected area of the femoral head adding to a vasucular disturbance and a repeated minor trauma.
In this paper, we report two cases of osteochondromatosis of the hip joint which is regarded as a fairly rare condition. The first case was a 51-year-old womam, in whom osteochondromatosis had accompanied to bilateral osteochondromatosis of the hip in one side of her hip joints. Total hip replacement was performed for the painful hip of the contra-lateral side, however, no surgery was carried out for the involved side because of little subjective symptoms. The second case was a 13-year-old boy, in whom osteochondral free bodies were revealed to increase in size and number radiologically in the hip with the residual deformity of the femoral head due to the congenital dislocation of the hip he had had in his childhood. In the latter case, as mamy as 200 intra-articular free bodies were removed surgically, some of which being burned into the articular surface or having caused the partial articular defects of the hip joint, which implied the probable secondary osteoarthritis in future. Based on these findings it is suggested that the surgical removal of free bodies should be carried out in the early stage of this condition especially in young patients.
In particularly revision and dislocated hip arthroplasty, wide operative exposure for total hip replacement is necessary to promote the accurate and the safe positioning of the implant. In such 20 cases we have used the technique of sliding trochanteric osteotomy reported by Glassman et al. We gained satisfactory results in postoperative X-ray findings (good positioning of the implant), clinically good results and less complications from the osteotomy of the greater trochanter using this method.
We studied a group of 22 patients (7 males and 15 females) which consist of 20 cases of femoral neck fracture and 2 cases of idiopathic femoral head necrosis, treated by J-2 type prosthesis during 1984-1990. Age distribution of these cases were 45 to 92 years old (mean: 75.4 years), and were followed from 2 months to 6 years and 7 months (mean: 2 years and 6 months). Postoperative OA hip score of the Japanese Orthopaedic Association (J. O. A. Score) was 80.1 points on an average. Rsults were discussed to J. O. A. score, ability of transfer, bone atrophy, thinness or thickness of cortical bone, central migration, sinking and pathology of one death case.
21 patients (30 hips) were treated with Harris/Galante porous total hip system without bone cement from 1986 to 1990 at Fukuoka Yniversity. 18 poor study cases were evealuated retrospectively according to the Japanese Orthopaedic Association's scoring system and roentgenograms. It should be selected out of adequate implants by fixation at first. It's important to use exact operative technique whether the total hip is cementless or not.
The influence of anterior pelvic inclination on osteoarthritis (OA) of the hip joint was investigated. At first, we examined cadaver pelvises radiologically which had various pelvic inclination angles, and confirmed the correlation between the pelvic inclination and the numerical value of radiological measurement. 275 OA of the hip were classified into three groups according to this numerical value. In group 3, which included the cases with the least pelvic inclination, the incidence of OA not due to either acetabular dysplasia or femoral head deformity was higher than the other groups. Furthermore, OA which had destructed the femoral head was observed in 38.8% of the cases in group 3. It was concluded that the pelvic inclination may affect the pathogenesis of OA in the hip joint.
Deformities of the hip in cerebral palsy are caused by imbalance of muscle power. The flexion-internal rotation combined adduction deformity is common and causes the crouched position, scissors gait and furthermore hip subluxation. To correct this deformity we tried modified Barr's operation combined with muscle release or osteotomy of the femoral neck. We have found this procedure has the effect of reenforcing the power of abduction and it is beneficial to treat the hip disorder in cerebral palsy.
We report the experience of femoral lengthening with lowering of the greater trochanter in two cases. Femoral lengthening was performed by callus distraction using Orthofix. One case was a 13-year-old male, the other was an 18-year-old female. They had histories of CDH. Preoperative symptoms were limping, scoliosis and leg length discrepancy. Radiographically, coxa vara deformity and high greater trochanter were seen. Leg length discrepancy before operation were 42mm in both cases. 45mm and 35mm lengthening was gained postoperatively. Limping and scoliosis were improved 10 months postoperatively. Femoral lengthening by callus distraction with lowering of the greater trochanter was a satisfactory procedure for coxa vara deformity with leg length discrepancy.
We reported that the concentration of plasma somatomedin-C was significantly lower than the normal value. The follow-up study of the somatomedin-C in 20 patients and the stature and bone age in 16 patients with Perthes' disease was made. The follow-up term was from 1 year and 1 month to 2 years and 4 months in the concentration of somatomedin-C and it's term in stature and bone age was 1 year and 4 months to 3 years. It was suggested that the concentration of somatomedin-C in Perthes' disease was transiently low at initial time. In addition to this, there was a tendency to recover gradually the short stature and the retardation of bone age.
A variety of factors have been thought to be in the etiolgy of rheumatoid arthritis (RA). Several studies looking for genetics, psychological problems, immune mechanism and possibly infectious etilogy have been conducted. In this report, we review these factors of RA by the questionnaire for 538 RA patients receiving treatment in our hospital. In the questionnaire, 433 (83.4%) answered that they had some factors at the onset of RA, main of which being overwork, moisture, food, infection etc. 158 (30.5%) had intrafamilial accummlation, 21 of 403 (5.2%) had ATLA antibody and 124 of 174 (72.1%) had HLA-DR4 antigen. In age of onset, patients with intrafamilial accumulation and patients with infectious etiology tend to show the younger onset and patients with ATLA antibody tend to show the older onset. In its clinical course, patients without any etiological factors tend to have better prognosis than the others.
Substance p (SP), which is localized in the peripheral and central terminals of the afferent nerve fibers, has recently been implcated as acting aneurogenic, inflammatory role in experimental arthritis. The purpose of this study was to investigate the existence of the SP-immunoreactive nerves and cells in rheumatoid synoviun, using immunohistochemistry. We found the SP-immunoreactive cells in rheumatoid synovium, but could not find it in the osteoarthritic synovium. Many SP-reactive cells were localized in the subsynovial lining area, and were observed around blood vessels. It could be considered that SP plays an important role in rheumatoid inflamation.
The most frequent radiological change seen in the cervical spine in rheumatoid arthritis (RA) is atlantoaxial subluxation (AAS). The special importance of AAS lies in the fact that the change can increase the instability of the spine, which often leads to non-traumatic dislocations that sometimes cause severe neurological disturbance. Neurological manifestations, however, often are absent, even in patients with severe AAS. Radiological measurements were made to define the relationship between radiological changes and neurological symptoms. The interval between the anterior surface of the dens and posterior aspect of the anterior arch of the atlas in flexion (minimal diameter) and the interval between the posterior surface of the dens and the anterior surface of the posterior arch in extension (maximal diameter) were measured. Then instability index (I. I.) was calculated as max. d.- min. d./max. d.×100 (%). 39 patients with AAS were classified into two groups. Group 1 in which the patients had no neurological symptoms or tingling only in their hands included 30 patients; Group 2 in which the patients had neurological abnormalities such as hyperreflexia, pathological reflex, sensory deficits, muscle weakness and gait disturbance included 9 patients. The I. I. of the cases with neurological symptoms was significantly larger than those of cases without neurological symptoms. Minimal diameter was also reliable in the development of neurological symptoms.
Rheumatoid involvement of the cervical spine is considered relatively frequent, but there are relatively few references in the literature about the involvement of the thoracic and lumbar spine in the course of rheumatoid arthritis. Radiological Study of the lumbar spine in 68 patients with rheumatoid arthritis showed that: 1. Osteoporosis was seen in 47 patients (69.1%) and compression fractures in 18 patients (26.5%). 2. Osteoporosis and compression fractures were frequent in the RA patient who was older than 60-year-old female and more than Class 2 in Stage III and IV. 3. Incomplete paralysis occurred in 4 cases of compression fractures and one of them seemed related to rheumatoid involvement.
We reported a case which caused the tendon rupture of the patella in about one month after total knee replacement (TKR). The patient, a sixty-nine-year-old female, has been treated for Reumatoid Arthritis at our hospital. Pain of her right Knee had gradually increased and the apparent deformity of her right knee joint was recognized on X-ray, so that TKR of her right knee was performed. According to our schedule, the physical therapy was begun in two days after TKR. She felt pain at anterior portion of her right knee with crepitation in about four weeks after TKR, and couldn't extend her right knee. We found the high riding patella on X-ray and diagnosed as the tendon rupture of the patella. In about five weeks after TKR, the tendon repair was performed. Now, the patient walks with no complaints.
Two patients with rheumatoid arthritis who sustained femoral neck fractures without a history of significant trauma following total knee arthroplasties are reported. As we could diagnose at the early stage of the fracture, one patient was treated conservatively. But another patient was obliged to be treated with femoral head arthroplasty. Because initial radiographic findings are minimal, Identification may be difficult. Bone sicintigraphy and MRI are useful method for diagnosis. It is important that evaluation of rheumatoid patients with persistent hip pain following joint reconstruction requires a high degree of clinical suspicion and close follw-up.
We examined bone mineral density (BMD) by QDR 1000 of Hologic company in 86 patients (13 males and 73 females) with rheumatoid arthritis. We discussed the relationship between the BMD and the factors that are under influence of rheumatoid arthritis. The results were as follows. 1. It is recongnized that BMD of patients with rheumatoid arthritis is less than that of normal females in the fifties and the sixties. 2. There is no relationship between the BMD and the age (except in females in the fifties and the sixties), morbid term, strength power, stage class grouping, presence of steroid dose. 3. It is unclear that rheumatoid arthritis is under influence of general osteoporosis.
Twenty-one children with twenty-three duplicated thumbs who were surgically treated were studied. On five rudimentary thumbs, simple ablation was done and the results were all good. The postoperative condition of the six thumbs on which transfer of the abductor pollicis brevis was done were assessed. In two thumbs which were operated on below one year of age, the opposition was poor. But in four thumbs over one year of age, the opposition was good. Interphalangeal joints of five thumbs were stabilized with a K-wire for three weeks or less, and in the four of them the motion of the interphalangeal joints were restricted. On the other hand, in only two of the eighteen thumbs without any stabilization of the interphalangeal joint, the motion of the interphalangeal joints were restricted. Angular deformity of the proximal phalanx occurred in two thumbs as a result of physeal growth disturbance. One of them had been operated on at seven months of age and the other eight months. We conclude that (1) the rudimentary type of the duplicated thumb can be treated surgically in the early infant, and (2) the other types of duplicated thumb should be treated surgically over one year of age to avoid the technical failures such as injury to the growh plate, incorrect transfer of the abductor pollicis brevis.
Palmar fracture dislocation of the PIP joint is uncommon injury, though dorsal fracture dislocation is common. We reported two cases of this injury which occurred, when they took great power on the finger tip. Case 1 was a 62-year-old woman. She sustained a palmar fracture dislocation of the PIP joint of the right ring finger when she fell down. Case 2 was an 18-year-old woman. She sustained this injury of the left ring finger when she caught the basketball. X-ray photographs of these patients showed palmar dislocation of the middle phalanx with dorsal base fracture fragment. The fracture fragment was fixed with mini cortex screw. Case 1 was immobilized in a splint for five weeks. Case 2 was immobilized for three weeks. They had a pain free and acquired almost full ROM.
Thirty-seven fractures of the phalanges and metacarpals of the hand were treated by percutaneal intramedullary fixation with two kirschner wires. The kirschner wires were slightly bowed, and they were introduced from the bilateral cortex near the proximal joint. They were crossed each other in the medullary canal and the tips of them were placed at the subchondral bone of the distal fragment. The firm fixation and noninvasive techniqe allowed early range-of-motion exercise so that was the fanctional recovery of the hand quick. We recommend this method not only for the fractures of the phalanges and metacarpals of the hand but also for the metatarsal bones.
Volar Barton's fracture is an unusual injury. We have treated five cases of volar Barton's fracture at fresh injury. Four cases were treated by open reduction and internal fixation with A-O small T plate. One case had been treated by conservative therapy with cast, but the carpal bone was translocated to volar side lately and proximal carpal instability was caused. So radiocarpal limited arthrodesis was added. Clinical results were evaluated by the Sarmiento system. Three of four cases treated by open reduction and internal fixation were excellent, and one case was good. One case treated by cast was poor, because pain, ROM limitation and loss of grip power had, remained. After arthrodesis the symptoms were improved, and the result became fair. In the case with carpal instability, the instability was caused by the deformity of articular surface of distal radius and the disruption of radiocarpal ligament. In other cases the anatomical reduction was obtained and carpal instability did not develop.
The objective of this investigation was to estimate the motion of the finger while one finger joint was fixed. We studied the joint of the right index finger with electrogoniometers on eight volunteers. In the beginning the subjects performed 1Hz cyclic flexion and extension of the index finger without resistance. Following this test, the DIP joint was fixed at 0 and 45 degrees flexion, and the subjects performed finger motion. In the same way, the tests were carried out with the PIP and MP joints fixation. The movement of the three joints were recorded in the Pen Recorder and the Data Recorder. Result: In the PIP 0 degree fixation, the range of the DIP flexion was less than that of no resistance. When the PIP joint was fixed at 45 degrees flexion, the subjects moved their DIP joint to flexion more easily. In the DIP 45 degrees fixation, the movement to extension of the PIP joint was more difficult than that in the DIP non-fixation. We refer to the oblique retinacular ligament for the factor that correlates the movement of the DIP and PIP joints. The MP joint, however, showed independent movement while other joint was fixed.
We experienced treating 7 cases with the latissimus dorsi flap to restore the upper limb. The operation was performed in 4 cases to restore elbowflexion, 1 case to restore elbow extension, and 1 case to restore finger extension. The 7 cases were used as the musculcocutaneous flap. All of these cases survived completely. After the operation active flexion of the elbow in 4 cases with elbow flexion reconstruction was measured between 100° and 130°, and active extension between -10 and -35°. In the case with restoration of elbow extension, the range of motion after the operation was between -5° of extension and 125° of flexion. In the case with restoration of the finger extension, the pinch power after operation was stronger then it was before operation. I think that latissimus dorsi flap is the best musculocutaneous flap for the reconstruction of the elbow and the finger.
Compression neurapraxias of the brachial plexus secondary to nonunion of the clavicle is rare. We experienced treating such a case. The patients was a 66-year-old man who had been injured in the traffic accident. He was treated conservatively, but clavicle became nonunion and neurovascular compression developed gradually. Five months after surgery, clinical results were favourable and the patient was engaged in farming.
In recent orthopedic literature, it has been stated that fractures through an open proximal clavicular epiphyseal plate have been misdiagnosed as dislocations of the proximal end of the clavicle, in patients younger than 25 years of ago. Two cases of epiphyseal separation of the medial end of the clavicle are presented. Case 1: 6-year-old girl. Chronic antero-superior displaced type. The epiphisis of the medial end of the clacicle ossified and appeared on X-ray films. At about three months after the injury, open reduction by a modified Burrow's method was performed and a modified Desault sling applyed for sixweeks postoperatively. The prognosis was excellent at three years after the operation. Case 2: 9-year-old boy. Acute posterior displaced type. The medial end of the right clavicle was displaced posterioly and appeared on a 40-degree cepharic tilt X-rey films taken by Rockwood's method. At six days after the injury, because of the unsuccssful closed reduction, open reduction, maintained by a Kirschner wire, was performed. And the figure-eight dressing was applyed for about three weeks postoperatively. The prognosis was excellent at four months after the operation.
Proximal humeral fractures in children may develop the axial rotational deformity or the growth disturbance of the upper humeri. In this study, the functional result of 7 cases with this fracture was investigated clinically and radiologically. All patients injured at the age of between 6 and 14 years were treated conservatively in six with zero-position casting or traction, in the other one with abduction pillow. In each case, shoulder functions such as pain, range of motion and abductor muscle power were examined clinically, and the humeral length discrepancy (HLD) and the neck-shaft angle of the humeri were measured radiologically. As the result, the shoulder function at the average of 6 years after injury showed no significant insufficiency compared with the sound side. Radiological examination revealed that the HLD was less than 9mm in all cases and the neck-shaft angle improved with age. From these results, it is suggested that the treatment of this fracture was good.
Out of 59 humeral shaft fractures in patients, 27 fractures were treated by Ender nailing, the Ender nails were inserted from the proximal or the distal humerus, or from both sides. No infection, mal-union or non-union occurred but one case of postoperative radial nerve palsy which was followed by reconstructive intervention. Backing out of the nail developed in 5 cases, requiring early removal of the nail. Bony union occurred in all cases who underwent immediate closed pinning, and the excellent and satisfactory clinical results were obtained in 90% of the cases.
Non-unions in 2 children and 3 adults were treated by osteosynthesis in combination with bone grafting. The bone graft was taken from the projecting radial condyle and fixation of the non-union was done by K-wire in the former, and bone graft from the ulnar condyle resected for releasing the ulnar nerve and by plating in the latter. The results in chidren were exellent despite of some fish-tail deformities and growth acceleration of the humeral condyle. The adult patients were rapidly relieved of their pain, but some restri ctions of ROM remained, and corrective osteotomy of the humerus was thought to be preferably performed at the same time.
Post-traumatic radioulnar synostosis is infrequent, especially following an isolated ulnar shaft fracture, it is very rare. The patient was a 48-year-old man, who was injured by taffic accident. 6 months after intramedullary fixation of the right ulna, he complained of restriction of active or passive forearm rotation. An examination showed that his forearm was fixed in neutral position. 10 months after the osteosynthesis, we treated him surgically with excision of the synostosis, encircling of raw surface of ulna by a silastic sheet and transplantation of free fat. At present, 10 months after the operation, he has gained an active range of motion of 40° pronation and 45° supination. He was graded excellent by Vince and Miller's evaluation, but we should follow him up because of a new bone formation of the synostosis.
From 1981 to 1990. 25 cases of cubital tunnel syndrome were treated by the modified King's procedure, that is medial epicondylectomy with external neurolysis of the ulnar nerve. The ages of the patients at the time of surgery ranged from 14 to 64 years (average, 44.4 years). The follow-up term was 7 months to 10 years and 6 months (average, 3 years and 3 months) after surgery. Using Ikuta's scoring system, excellent results were obtained in 3, good in 7, fair in 11, and poor in 2 elbows. The results were dependent on the duration of their symptoms and the age at the time of surgery. Therefore early diagnosis and treatment is important for cubital tunnel syndrome.
A case of intraneural lipofibroma of the digital nerve is described. The patient was a twenty-three-year-old male who had noticed a soft mass in his right palm and middle finger one month ago. The mass increased in size, but he was asymptomatic and there was no loss of function. At surgery, enlarged sausage-shaped, gray-yellow digital nerve was found. Total resection of the mass was impossible because it surrounded the funiculus. Partial resection of the mass was done. Microscopically, the mass consists of fibrofatty tissue that has surrounded and infiltrated nerve trunk and has grown along the epineurium and perineunium.
With serial stimulation of the ulnar nerve at the elbow the compound action potential and sensory nerve action potential were recorded using “inching techique” in 10 normal subjects and 15 patients with the cubital tunnel syndrome. The motor axons and sensory axons normally showed a predictable latency change of 0.13 to 0.24ms/cm and 0.14 to 0.21ms/cm as the stimulus site was moved proximally in 1cm increments. Preoperatively in 13 of the 15 patients abnormal conduction was sharply localized from 1cm proximal to the medial epicondyle to 3cm distal. Then intraoperative inching technique performed in 9 patients. The findings were as follows. 1) Conduction abnormalities corresponded to the compressive lesions and localized. 2) Preoperative conduction abnormalities corresponded to intraoperative ones.
Association with urethritis, which is caused by several microorganisms including gonococcus, is recently thought to be important for a diagnosis of Reiter's syndrome, although the syndrome has been classically described as the combination of nongonococcal urethritis, arthritis and conjunctivitis. A 35-year-old man was affected by gonococcal urethritis two weeks before his complaint of lrft knee and right second toe pain. He had also balantitis, mucous membrane erosion, heel pain and weight loss. Moreover, HLA-B 27 was positive in his blood cell, and no bacteriae was detected in the blood or synovial fluid. According to the symptoms and findings, Reiter's syndrome was mostly suspected for this case. The diagnosis of this syndrome is difficult since history of bacterial urethritis is apt to miss to hear from patients with arthritis. Careful history taking seemed to be significant for the accurate diagnosis.
Seven wrist arthroplasties with Swanson's flexible hinge implant were done in five patients with rheumatoid arthritis. We followed them up postoperatively for an average of 6.3 years (range, 3-10 years). AT first postoperative year, pain was significantly decreased, range of motion and grip strength were incresed, and stability was acquired. But at long-term follow-up, 7 implant fractures were found, severe pain appeared in 4 wrists, and 6 wrists were unstable. Pain and instability showed tendency to increse after implant fracture. We thought that the cause of implant fractute is stress at implant caused by excessive wrist motion.
11 patients with rheumatoid arthritis were admitted to our hospital for femoral neck fracture. They were compared with those without rheumatoid arthritis about injury mechanism, fracture type, and results of treatment. The results were as follows. 1. There were three spontaneous fractures in rheumatoid group. 2. There was tendency to be injured by mild trauma and to show severe displacement of fracture in rheumatoid group. 3. Bone union was achieved by osteosynthesis even in rheumatoid group.
The coracohumeral ligament (C-H lig.) is a kind of capsular ligament that originates from the lateral base of the coracoid process, separates anteriorly and posteriorly, and inserts into the greater and lesser tuberosities. This ligament restrains the external rotation and the abduction of the shoulder joint. The rotator interal (RI) is the space between the superior border of the subscapularis and the adjacent supraspinatus tendon. It is formed by thin, elastic, and membranous tissues. We have studied the pathogenesis of the contracted shoulder by the autopsy. We have recognized that the degeneration of the C-H lig. and the RI is the main pathology of the contracted shoulder as Ozaki described. We operated on 4 cases of the idiopathic contracted shoulder by resecting the C-H lig. and the scar tissue of the RI. All of them have got good functional results.
We treated two cases with septic arthritis of the shoulder joint. Synovectomy and continuous irrigation-suction treatment was carried out using arthroscopy. Passive ROM excercise was started just after operation. Our procedures were so effective that they had good function without contracture. We confirmed that the early treatment with the use of arthroscopy is very useful for the septic arthritis.
Idiopathic humerus varus is a very rare desease. In this condition, well known are the limitation of the shoulder movement and the shortening of the humerus. For this reason an operative treatment is often indicated. The most popular procedure for this condition is corrective osteotomy. Our experience with two cases suggested the procedure to be good to treat the idiopathic humerus varus. The first case was corrected at the neck by an osteotomy. The patient could abduct to 115 degrees (20 degrees improved). The second case which showed 16mm of shortening of the humerus was elongated at the proximal humerus, and could elevate to 150 degrees (70 degrees improved). After these experiences, the third case diagnosed as the idiopathic humerus varus was operated on with a corrective osteotomy and elongation of the proximal humerus. The abduction range after surgery was 140 degrees (60 degrees improved). To treat the idiopatic humerus varus, these combined procedures may yield good results.
22 cases of complete dislocation of the acromioclavicular joint (Allman' grade III) treated by Dewar procedure was reviewed. The post-operative duration ranged from 12 months to 61 with an average of 37 months. Post-operative results were evaluated on the base of shoulder evaluation by the Jpn. Orthop. Assoc. The average of total point was 96.7 (100 to 87 points). We discussed about the Dewar procedure, too.
It is not easy to maintain anatomical restoration conservatively for acromioclavicular separation. We have reported previously that reconstruction of acromioclavicular or coracoclavicular ligament offers superior result to the simple transfixation of acromioclavicular joint by the Kirschner wires. Nine patients treated by modified Weaver procedure were reviewed and were compared to the five patients by modified Dewar procedure and a patient by modified Neviaser procedure. At review, a functional result of the shoulder including pain, range of motion, muscle weakness and activity of daily living was evaluated . A radiographic result was also evaluated. The displacement less than 50% of the width of clavicle was rated as good restoration. Seven patients were satisfactory in the functional assessment, but the good restoration was maintained only in four patients. The fact that the poor restoration doesn't always lead to poor function, encourages conservative treatments. The fifteen patients who had been treated operatively, were assigned into good restoration group (8) and poor restoration group (7). Functional assesment was significantly (p<0.05) higher in good restoration group. We concluded the operative procedure which can maintain good restoration to be the better treatment. On that standpoint of view, the transfer of coracoacromial ligament as a substitute for coracoclavicular ligament seems to be insufficient for the acromioclavicular separation.
From 1988 through 1990, 9 patients with ruptured coracoclavicular ligaments were treated with a metal wire method as an initial fixation between the coracoid process and the distal end of the clavicle after primary suture, reconstruction of the coraco-clavicular ligaments (modified Weaver or modified Dewar method) or osteosynthesis of fractured clavicle. Six of these patients had dislocation of acromioclavicular joint (Tossy grade 3) and the others had the fracture of the distal end of the clavicle (Neer type 2). The average age at the time of operation was 42.2 years old (from 24 to 57 years old). The removal of wire was done within 6 monthes after operation. The length of follow-up averaged 11 months. These patients were evaluated postoperatively by physical examination, radiography and Kawabe's criteria. The results were graded excellent in 8 cases and good in 1 case by Kawabe's criteria. All cases had relief of pain and full active range during shoulder motion. There was no case of redislocation of A-C joint or non-united clavicle, though the breakage of wire was found in 2 cases. Therefore, the metal wire method as an initial fixation was useful for surgical treatment of ruptured coracoclavicular ligaments.