High tibial osteotomy (HTO) for osteoarthritis of the knee is an established surgical procedure currently in widespread use. Wiht the intention of properly correcting bone deformint by as simple a technique of HTO as possible we have been performed Barrel-Vault osteotomy (Dome) using a guide and chisel of our own make. In view, however, of a fact that delayed union was not infrequent after operation by our procedure, it was felt necessary to investigate into the cause of this complication (possible causative factors included age, body weight, correct angle, technical skill and height of osteotomy plane). A total of 165 patients (186 joints) who had an HTO performed by the procedure during the period from January 1986 through October 1989 were analyzed in this retrospective study. This series comprised 11 male (12 joints) and 154 female (174 joints) and their age at operation ranged from 45 to 77 years, averaging 64.2. Delayed union was spoken of when more than 12 weeks were required until bone union was accomplished and accounted for 35 (19%) of the entire patients. Results: There was noted a tendency for delayed union to occur in a larger proportion of patients above 70 years of age. The incidence of delayed union also increased as the body weight of correct angle increased, although no significant correlation was noted for either of these factors. Both technical skill and height of osteotomy plane were recogized to play an important causative role in delayed union. Thus, poor technical skill was associated with delayed union in 65% of cases, while delayed union was seen in 6%, 32% and 43%, respectively, of osteotomies done in optimal, too high and too low planes. These results point to the importance of performing an HTO at a properly selected level.
To predict the onset age of secondary osteoarthritis of the hip joint due to subluxation and acetabuar dysplasia, we reviewed radiographs of 145 hip joints with pre-arthritis or in the early ptages of osteoarthritis. Twelve conventional X-ray parameters were measured, as was a new parameter of congruency of the joint, the DAHC (Discrepancy of the Acetabuar-Head Curvature). Correla-tion coefficients between these X-ray parameters and the onset age were calculated. Asthe DAHC and Sharp's angle had the highest correlation with the onset age, webelieve these parameters to be useful in the prediction of the onset age of osteoarthritis of the hip.
Forty-seven patients (50 hips) with osteoarthrosis were treated with valgus osteotomy. The mean follow-up period was 4 years and 10 months. According to the JOA score, the preoperative scores (mean, 53.3 points) improved postoperatively (mean, 84 points). For the best result it is necessary that the incongruity be improved by a valgus osteotomy and the weight-bearing area be enlarged by a shelf operation.
We performed Chiari's medial displacement osteotomy combined with transtrochanteric osteotomy for secondary osteoarthritis of the hip with dysplasia. We discussed the clinical effect of 13 joints performed Chiari's osteotomy combined with varus osteotomy and 12 joints performed Chiari's osteotomy with valgus osteotomy in over 3 years. Results are as follows. 1. Clinical estimation is good for long term except 1 case. 2. Fine new acetabulum is formed in the joint after Chiari's osteotomy at less than 6mm height from the edge of the acetabulum. 3. The femoral head displaced medially by an average of 7.7mm. 4. The acetabular bone cysts decreased in size or disappeared in 11 joints out of 13 joints, which may have occurred clue to dispersion of dynamic load and biological effect aquired by the osteotomy.
Twenty-four hips with revised cemented total hip replacement (THR) were reviewed for analizing problems of the revision surgery for non-septic loosening of cemented THR. Clinical complications such as deep infection, dislocation and femoral shaft fracture were found in four one, and one hip after the revision surgery. Four patients had trochanteric complication. Radilogically, clear zones developed early at the stem side. Revised hips with long stems were associated with poorly packed cement condition. The result of this study suggested the more risk of the various troubles at the cemented stem of revised THR. We recentry use the cementless stems combined with auto or allo bone graft for revision surgery.
201 hips with the Harris-Galante Porous (HGP) system and 41 hips with Hybrid system were compared both clinically and radiographically. According to the radiogram taken at follow-up, radiopaque lines around the stem, which is called “clear zones”, were frequently seen in zone 4, 10, 11 or 12. It was likely that the patients did not have thigh pain when these clear zones appeared exclusively in zone 4, 10, 11, or 12. On the other hand, however, the patients seemed to have thigh pain when the clear zones also appeared in other areas and zone 4, 10, 11, or 12. Thirty-six patients (23%) with osteoarthritis who had HGP system complained of thigh pain. In the group with Hybrid system, only two patients (6%) had thigh pain. However, this thigh pain in the HGP group had a tendancy to disappear gradually and remained in only two patients (6%). Sinking and micromovement of the stem may be one of the causes of the thigh pain. An optimal method for fixation of the femoral component has not been established. The results obtained from our short-term follow-up showed that smaller number of patients had thigh pain in the group of HGP system in comparison with previous reports. However, long-term follow-up study may be still necessary to draw some definite conclusion upon this matter.
We reviewed 30 patients who had had a dual bearing type prosthesis between January 1987 and July 1990. The cases consisted of 4 males and 26 females. The age range from 55 to 77 years old with an average of 66 years old. They were evaluated over a pevicd of between one and three years and six months postoperatively by questionnaire and roentgenograms. According to the J. O. A. hip score, the preoperative score had improved postoperatively by a mean, of 49.8 points to a mean, of 83.8 points. Roentgenographically, central migration was observed in 10 hips (27.7%) and sinking of the stem in 10 hips (27.7%).
We had performed dual bearing type endoprosthesis combined with acetabular bone graft for coxarthrosis with acetabular dysplasia on 38 hips for last 11 years, 3 hips being revision, and reviewed them. The clinical results showed that preoperative total average score of 44.1 points was improved to 81.4 points postoperatively, especially in pain, by Japanese Orthopaedic Association Hip Score System, but they were not interrelated to superior migration. As measured from the serial roentgenograms after the operation, superior migration mostly began during weight-bearing period. The progress of additional superior migration of the endoprosthesis was noticed in 12 of 21 hips (57.1%) over two years after the operation. CE angle after reaming before bone grafting interrelated with superior migration in CE angle plus group.
Bipolar arthroplasty with acetabuloplasty was performed on 63 hips with marked dysplasia. Radiological evaluation of the acetabulum was done by measurement of Sharp's angle and the Acetabular-Head index (AHI) before and after operation, and migration of the outer-head component was discussed. Pre-operatively. Sharp's angle was on av. 49.3° and the AHI 44.1%. After reaming the acetabulum, they were on av. 53.9° and 53.4%, respectively. Migration of the outer-head was recognized in 46.8% of the cases more than one-year past the postoperative time in which the heads migrated beyond the critical level (5mm superiorly, 2mm laterally or medially) were superiorly in 10 heads, laterally in 8 and medially in 5. Although there were no statistical correlations between migration and Sharp's angle or the AHI, a tendency to migrate superiorly was observed in those cases with a steep acetabulum (Sharp's angle>50°) and a marked deficiency of the head-covering (AHI<50%). Generally, migration of the outer-head does not influence the clinical results, but one case is still pending revision surgery as there is a yearly decrease in its clinical score caused by a marked superomedial migration.
Bipolar hip arthoroplasty with acetabular reaming for advanced hip osteoarthritis was performed on 25 hips. 19 hips among this series had displastic acetabula and had been treated with autologous bone graft without any screws and pins. The patients had been operated on at 40-76 years of age (average, 52.3 years of age) and had been followed for one year and six months to six years (average, three years and three months) postoperatively. The mean JOA score was improved from preoperative 49.6 to postoperative 86.7. The improvement of pain score was especially remarkable, and an increase of hip ROM was acceptable. X-ray measurement made 1 year postoperatively showed that 76% of the patients had proximal migration, but roentgenogram taken three years postoperatively showed the extent of these migration tended to stop with the appearance of osteosclerotic zone in the circumference of outer head. No distal migration was seen.
we have treated 42 osteoarthritic (OA) and 21 rheumatoid arthritic (RA) hips (mean age: 61) with bipolar arthroplasty (OMNIFIT: 57, OMNIFLEX: 6). In cases with severe bone defects (OA: 13, RA: 12) bone grafting was added to the acetabula. Patients were followed-up for an average of 31 months. Radiological and clinical findings were evaluated for this study. Outer head migration was detected in 46 cases, which stopped within 2 years except for 6 RA cases with bone defects. Stem sinking occured in 46 cases, which stopped within 2 years except for 3 cases. There was no significant correlation between the stem sinking and the canal fit index which were measured immediately after surgery at the levels of the middle and distal stems. No relationship was found between thigh pain and the radiological findings which were characterized by either a radiolucent or sclerotic zone at the distal end of the stem. Special caution should be paid to these RA cases with bone defects who indicate the need for a bipolar arthroplasty. A proximal press fit may be more important than a middle or distal fit in order to prevent stem sinking. Radiological changes at the distal end of the stems may not be the cause of the thigh pain.
Dual bearing hip arthroplasty was performed on patients with rheumatoid arthritis from 1980 to 1990 in our department. 35 patients with 54 hips were evaluated radiologically, by measuring the central and upper migration of the prosthesis. The follow-up period was from 12 to 104 months (average-37 months). Mostly, the migration stopped about one year after surgery with the appearance of sclerosing areas in a new acetabulum. However, in some cases with acetabular protrusion or bone atrophy preoperatively, the migration progressed continuously. A cup-shaped bone graft using an extracted femoral head was considered to be a valuable procedure for restoring the disrupted acetabulum.
Avascular necrosis of the femoral head was treated with vascularized bone graft fn 7 adults (9 hips). They were followed clinically for 8-50 months (mean, 35 months). Their preoperative stages were classified. Radiographically, 7 hips were at stage II and 2 were at stage III. To compare the clinical results and preoperative Magnetic Resonance Imaging, T1 weighted images were classified into 3 patterns according to the modified Totty's classification. 6 hips were classified into band like pattern and 3 inhomogenous pattern. 6 hips showed good results. All of them were at stage II band like pattern. On the other hand, 3 hips showed poor results. On of them was at stage II and inhomogenous pattern. The other 2 were at stage III and inhomogenous pattern. This suggests that this operation should be offered to the hip with stage II and band like pattern on MRI.
From 1976 to 1991 at the Yamaguchi Central Hospital, there were 28 patients, aged 25 to 79 years, who underwent the Judets procedure for displaced femoral neck fractures. 18 patients were followed up and follow-up averaged 54 months. Nine patients showed radiographic evidence of late segmental collapse despite fracture union. Although our series is small, the rate of union was 94% and the rate of late segmental collapse was 50%. These results are worse than those achieved by several authors using internal fixation alone or in combination with autogenous bone graft.
We will report on the characteristic features of pulmonary embolism (5 cases) and deep vein thrombosis (2 cases), especially on the prodromal symptoms. The onset time was about 2 weeks after operation in 4 out of 5 pulmonary embolism cases, which corresponded to the starting time of the rehabilitation. A non-infectious, unknown fever and tachycardia were seen just before their onset in 6 out of the total 7 cases. They were considered to be important prodromal symptoms of pulmonary embolism and deep vein thrombosis.
Twelve patients with cervical spondylotic amyotrophy were followed at least a year after the operation. All patients were men and the follow-up time ranged from 1 to 12 years (average, 7 years and 3 onths). Eight patients had exellent or good functional results of the shoulder joint, which were related to the time from onset to operation and the muscle power (MMT of shoulder abduction). The presence of electromyographic abnormalities in the opposite side did not show the poor results. Anterior decompression is mainly indicated but posterior decompression is also considered for the patient with long tract sign. The mutiple muscle transfer was done in one patient, who was not expected good recovery by decompression of spinal cord or spinal root and the result was satistactory.
In these days, expansive laminoplasty is the most popular operation as posterior decompression surgery for patients of cervical spondylotic myelopathy. In 1974, expansive laminoplasty was started in our clinic. In this report, the authors described the postoperative results and radiographic observations on 43 cases (expansive laminoplasty in 25 cases and laminectomy in 18 cases) who were followed for more than 1 year. We compared expansive laminoplasty with laminectomy, in respect to postoperative results and radiographic observations, in order to examine whether it had more advantage.
144 patients with cervical myelopathy, due to spondylosis and occification of posterior longitudinal ligament, were surgically treated and followed from 10 to 30 years (mean, 16 years). In 90 patients (62%), good result was maintained for a short-term follow-up to a long-term. In 40 cases (28%), late decline of operative results occurred as long as 1 to 5 or 6 years after improvement and plateau. And 11 cases of these deteriorated. The decline was mainly caused by benign prostatic hypertrophy, degenerative joint disease, fracture of femoral neck, apoplexy and cerebral arteriosclerosis. The deterioration of cervical myelopathy was observed only in 5 cases, of which 4 cases were caused by degenerative change of adjacent intervertebral joint on anterior body fusion and one was caused by increase of kyphosis of cervical spine after laminectomy.
A review of 17 patients who had undergone anterior cervical disectomy and fusion was performed to analyze the change of the neighbouring disks. Their ages renged from 43 to 65 years old (average; 49 yeras old) at the time of operation. The follow-up period ranged from more than 8 years to 27 years (average; 14 years). The number of fused inter-vertebrae were 1 in 5 cases, 2 in 6 cases, 3 in 4 cases, and 4 in 2 cases. Of 17 cases, 14 cases have radiographic changes on the neibouring disks of fused vertebrae. There were narrowing in 8 cases, olisthesis in 8 cases, and fusion in 2 cases. 2 cases had non-union in the previously fused vertebrae. These changes were influened by the factors including the number, portion, and alignment of the fused vertebrae.
We will report on twenty-eight case studies of patients with recurrent cervical myelopathy who underwent reoperations between 1980 and 1991. They consisted of 19 patients with cervical spondylotic myelopathy and 9 patients with OPLL. At first operation, 26 patients had anterior fusions, and 2 patients had laminectomies. Of the 26 anterior fusion qroup, anterior fusions at the adjacent intervertebral level were performed on 8 patients, expansive laminoplasties on 15 patients, and laminectomies on 3 patients. Anterior fusions were performed on the 2 laminectomy patients. The causative factors of the reoperations were as follows: -14 patients (50%) had a cord compression at the ajacent level, 4 had canal stenosis, 4 had insufficient decompression, 3 had a progression of the OPLL, 2 had a kyphotic deformity, and had a traffic accident. In our follow-up studies over an average of 2 years and 9 months, excellent and good results were obtained in 11 patients (39%), poor in 10, unchanged in 5, and worse in 2. From these results, we conclude that the operative procedures and levels of cervical myelopahy should be decided after an accurate neurological and image evaluation of the affected levels.
The fact that a congenital union of the cervical spine tends to cause hypermobility and/or herniation of an adjacent level has been well documented. On the other hand, this same tendency in anterior interbody fusion is usually considered only postoperatively. We investigated 11 cases of congenital union and 4 cases of adjacent recurrent disc herniation after interbody fusion by measuring the range of motion roentgenologically. Results: All the cases with a congenital union of the C2/3 had normal stability at the C3/4. In these cases with both a congenital union and interbody fusion below the C4 level, hypermobility was encountered immediately above the fused segment.
24 patients with cervical disc herniation were treated operatively and examined using superconducting 1.5 Tesla magnetic resonance imaging before and after their operations. 10 (41.7%) of the 24 cases showed lesions of a high intensity area (H. I. A.) in the spinal cord on the sagittal Fast scan images before surgery. We could not confirm whether there being a H. I. A. or not, related with the factors of age, the duration of symptoms, the JOA score prior to operation, and the rate of improvement. In 4 cases there remained slight lesions of the H. I. A. 1 case was stationary, and in 5 cases the symptoms had disappeared. The last group's results were better than the other two.
The clinical results of cervical disc herniation treated with conservative therapy were evaluated in 16 patients. They consisted of 10 patients with myelopathy and 6 with radiculopathy. Eight patients were males and the others were females, and their ages varied from 28 to 58 years. The factors influenced their prognosis, such as age, duration of symptoms, severity of symptoms on admission, diameter of canal, and the disc herniation to canal ratio on CT discogra phy were examined. Results were as follows; 1) All of the patients with radiculopathy were satisfied with the results. And 8 of 10 patients with myelopathy improved after conservative therapy. 2) Age, duration of symptoms, severity of symptoms on admission, and diameter of the canal dian't influenced the prognosis of myelopathy treated with conservative therapy. 3) If the herniation occupied more than 40% of the canal diameter, we could not achieved satisfactory results with conser vative therapy.
We reported a rare case of severe OPLL in an adult case of vitamin-D resistant rickets. The case was 56-year-old female. We started 50-150 thousand units of vitamin-D treatment about 16 years ago. About 2 years before operation, she was complaint of gait disturbance and dysuria. X-ray examination showed a severe OPLL from C1 to Th2 (max. stenosis 79%, C1, 2). We performed a surgery of canal-expansive laminoplasty and suboccipital craniectomy.
Seventy years old male was operated for the ossification of posterior longitudinal ligament with cervical myelopathy. The laminoplasty was performed from C1 to T1. His post operative course was smooth and there was nothing paticular with out minimized thoracic breathing. On post-operative sixthday, he showed good neurological recovery but suddenly developed apnea with CO2-narcosis. After two weeks of respiratory care, vital capacity was gained by 800cc. Post-operative three months later vital capacity recovered normal range. The CO2-narcosis was considered to be dueto bilateral fourth cervical nerve palsy caused by posterior displacement of the spinal cord and the merve roots traction after posterior decompression.
Two cases of cervical myelopathy caused by the calcification of yellow ligament are presented. Case 1 was a 64-year-old man who complained of numbness of the extremities and gate disturbance. Radiographs showed round shaped calcification in the spinal canal between the C4/5 and the C6/7. En-block laminectomy was performed. The results of X-ray diffractions revealed mainly hydroxyapatite. Case 2 was an 80-year-old woman who complained of hypesthesia of the extremities. A myelogram showed an incomplete block at the C5/6 level and en-block laminectomy was performed. Microanalysis of the calcification consisted of hydroxyapatite and Ca-pyrophosphate mixed.
Nakamura Method is an evaluating system of motor function for patients with cervical myelopathy. It consists of five items. The authors examined reliability of the Nakamura Method in 34 patients with cervical myelopathy. The authors conclude that the Nakamura Method is a valuable evaluating system.
We studied incidence of neck symptoms in 186 patients who had surgery of cervical spine. There are three types of complaints which are shoulder discomfort, dullness and pain. 24% of laminectomy cases complained continuous shoulder discomfort. 13% of laminoplasty cases complained continuous pain. A fewer patients who had anterior spinal fusion complained than posterior decompression. Laminectomy was done in the patients who had poor ROM of cervical spine, so diminished ROM may be the cause of shoulder discomfort. ROM after laminoplasty is not so bad, so we guess that good motion of cervical spine will cause pain after surgery. We have to keep in mind neck symptoms after spinal surgery in order to get better QOL.
The results of the brace treatment with under-arm were studied in 10 patients with idiopathic scoliosis, who were braces for an average of 26 months from 6 to 17 years. The mean curvature was 31.7 degrees and the average correction at end results was 25 degrees. There was a significant difference between the final correction and the best correction in brace, between the final and the initial correction. 3 cases who showed progression in the brace, were over 16 years old at the initial stage.
A new method for idiopathic scoliosis, using transpedicular screws in the lower curve and Harrington distraction rod is reported in this paper. Two patients with S-shaped spinal curves and one with a single thoraco-lumbar curve were treated by this procedure. The curves were evaluated by Cobb angle, apical vertebral rotation, and lumbar lordosis. The correction of Cobb angles and rotational deformities were satisfactory in all three cases. The two with S-shaped curves obtained physiologic thoraco-lumbar and lumbar lordosis. This new method is indicated for those patients with an S-shaped curve.
In 1983, Neer et al in the article entitled “Cuff-tear Arthropathy” reported 26 patients that shared the character-istic clinical and radiological features. We reported 2 cases that shared several of the clinical and radiological features as the cases reported by Neer. 2 cases visited our hospital with complain of bloody joint effusion. We performed arthroscopic synovectomy on these cases and got good results.
We hava examined shoulder joint disorders in physical college student swimmers. We have obtained some conclusions as below. 1. 50% of the swimmers were demonstrated to have swimmers' shoulder. Most of them were free style swimmers. 2. Swimmers' shoulder showed significant limitation of shoulder external rotation (p<0.05) when compared with non-swimmers' shoulder group. 3. 63% in the swimmers' shoulder qroup had shown improvement from pain by stretching exercise and muscle strengthening exercise especially to shoulder external rotation muscles.
MRI is one of the most popular diagnostic method in the spinal surgery. Recently MRI has been used as a diagnostic tool for the diseases in bone and joint. However, there are a few reports about the findings of MRI in the disorders of the shoulder joint. In this study, we evaluated the availability on diagnosis with MRI in the shoulder joint disorders. There were 16 cases (7 males, 9 female) in our study. The mean age was 47.7 years old. Our cases consisted of 10 cases with rotator cuff tear and 6 cases with impingement syndrome. All of the cases were carried out arthrograpy and/or bursography. And we examined the T1 weighted, T2 weighted sagittal plane and T1 weighted axial plane of MRI, too. We compared the findings of MRI with the findings of arthrography and bursography, and further more, in some cases with the findings of operation. In the cases with small rotato cuff tear, T2 weighted sagital plane of MRI demonstrated increased signal in the leion. In the case with massive cuff tear, T1 and T2 sagital plane showed upward displacement of the humeral head and T1 axial plane demonstrated disappeared infraspinatus muscle. In only one case we could not detect cuff tear with MRI. In the cases with impingement syndrome, T1 sagittal plane showed increased signal in the lesion. There were no significant abnormal findings in two of 6 cases. Comparing the findings of MRI with the findings of arthrograhy and/or bursography, these of MRI are not prominent than those of others. But, MRI is safer and less invasive than the other. In the near future, we will be able to diagnose the shoulder joint disorders only with MRI.
From 1982 to 1991, we have treated 26 cases of axillary scar contracture, caused by burns, including 1 cases of electrical burn. We classified the axillary contractures into two types. I. A wed formation on the anterior and/or posterior axillary line. II. A scar contracture of the entire axillary region. For type I. we used local flaps, especially the 5-flap technique. For type II. free skin grafts were our first choice. But when the axilly region was deeply injured, as in electrical burns, flaps (myocutaneous or fascio-cutaneous) were needed for the reconstruction.
From 1976 to 1990, conservative and operative procedures were performed in the treatment of 155 cases of fractures of the proximal humerus, and 78 cases were followed-up during that time. The average followup period was 7 years. We classified these fractures according to Neer's 4 part classi-fication. The conser-vative treatment resvlts were almost acceptable. But some of group 1 (minimal displacement) and group 4 (fracture fo the greater tuberosity) complained of disability due to impingement syndrome after conservative treatment. Accordingly, the young patients in group 4 had to undevgo operative procedures, after which we emphasized the importance of rotator cuff exercises as an aftertreatment for group 1 and group 4. The old patients accepted contracture of the shoulder joint, but the young patients did not. When the prosthetic replacement was performed 1 month or more after the injury, the results were poor due to a muscle weakness and/or contracture of the soft tissues.
There are several methods of internal fixation for displaced proximal humeral fracture, and hookplate fixation seems to be a useful treatment for this fracture. We have treated 13 cases (7 males, 6 females) by hookplate fixation for displaced proximal humeral fracture. The follow-up period averaged 2 years and 3 months. Good results were noted for elderly cases who had severe osteoporosis. There was no case of necrosis of the humeral head and psuedoarthrosis.
We retrospectively reviewed cases of 23 of 35 patients who underwent operative treatment for distal clavicular fractures in Fukuoka Orthopedic Hospital. The average age was 32.5 years. There were 17 males and 6 females. In 20 cases osteosynthesis was done, and in 3 cases resection of distal part of the clavicle was performed. 19 cases out of 20 treated by ostesynthesis made satisfactory results. Only one of tree cases that had delayed union received limited range of motion. There was no case of nonunion.
Fractures of the clavicle are chiefly managed conservatively. The methods are grossly divided into the plaster cast and the clavicular band fixation. We seldom use the former because of its troublesome maneuver and the patient's discomfort. The clavicular band, now obtainable commercially, however had two major unavoidable dissatisfactions. Continuous stability to maintain the position of reduction is uncertain and vascular and neurological complications caused by the shoulder strap at the axillar portion are often encountered. The author has designed a new model of clavicular band which prevents these unacceptable points. The model consists of a vertical bar, shoulder straps and a horizontal elastic chest belt which is set to the lower part of the bar. The bar is put on the spine and the horizontal elastic belt is wrapped around the chest, holding the bar in its proper position. The shoulder straps run from the anterior humeral heads down to the side of the chest, apart from the axillar groove, crossing at the lowest part of the bar and are fixed in front of the chest onto the chest belt. Continuous maintainance of the reduced position of the clavicular fracture is satisfactory and the patient does not encounter discomfort, thus preventing complications.
Treatment of acromioclavicular dislocation is controversial. We treated 6 cases of complete acromioclavicular dislocation by the Rowe procedure. 5 cases were fresh ones and 1 case was chronic. The technige is as follows. A skin incision is made in line with the clavicle and the joint, directly down to the bone, turning back one layer of the trapezius and the deltoid, the periosteum and the capsule. Next, only 1cm of the clavicle should be removed. Care should be taken to rongeur off the superior cortex of the clavicle smoothly. Dislocation of the joint is reducted and a K-wire may be transfixed to it. Last, the repair is carried out by overlapping, in one layer, the periosteum, the capsule, and the muscle. As an aftertreatment, gentle motion is encouraged 1 week after the operation, the K-wire should be removed between 3-5 weeks. Work or sport may be possible by 5-8 weeks. The results of the treatment were evaluated by Kawabe's score. The 5 fresh cases were excellent and reduction of the dislocation were seen in their roentgenograms. The chronic case was fair because of mild pain, dullness and deformity.
The fracture-dislocation of the proximal humerus is uncommon desease and is associated with great therapeutic problems. The purpose of this study is to report the incidences and the results of it's treatments. From 1980 to 1990, 36 patients had consulted our hospitals with displaced 2 part (18 pts.), 3 part (6 pts.), 4 part (9 pts.) and articular surface (3 pts.). 29 patients were followed up from one to eleven years with an average of 5.3 years after the treatment and evaluated in accordance with the criteria proposed by the Japan Orthopaedic Association (JOA score). The average age at injury of females (40.6 years) was statistically higher than that of males (64.7 years). The patients with 2 part were commonly found between 40 and 70 years old. The patients with 4 part or articular surface were found below 40 years or above 60 years old. These specific incidence of the fractured type were thought that this fracture-dislocation was produced by the injury force and the strength of patient's bone mineral content. Eleven patients with 2 part treated coservatively had 97 points of average JOA score and four patients treated operatively had 85 points. The patients with 3 part treated conservatively had good score than that with 3 and 4 part and articular surface which were treated operatively. Also avascular necrosis of the head was observed in patients with 3 and 4 part treated operatively and the score were 69 and 75 points respectively. In four patients, the humeral heads were resected and the average score was 52 points. These results suggest that the conservative treatment is recommended for the patients with 2 part and the prostretic replacement is indicated for the patients with 4 part.
We have experienced a case of giant cell tumor of tendon seath of the knee joint in a 43-year-old man who man was admitted to our hospital because of his knee joint pain. Preoperative diagnosis of this case was injury of lateral meniscus. However, we could find it to be an intra-articular tumor by arthroscopy. The tumor was removed and proved to be giant cell tumor of tendon seath. His symptom disappeared after operation.
Although ganglions of meniscus are frequent, a ganglion of the posterior cruciate ligament is very uncommon. A patient, a 34-year-old man, was admitted to our hospital with complaints of a giving way and knee pain. On arthrogram, we found a reddish brown cystic mass in the intercondylar notch. Microscopic examination confirmed the diagnosis of a ganglion.
In 15 cases of Osgood-Schlatter's disease, namely total of 18 knees, the excision of bone fragments and plasty of tibial tuberosity were carried out and the results of the these operations were studied. Pain in 16 out of 18 knees (89%) was gone permanently, and the remaining two knees (11%) had signs of slight pain with exercising. All cases returned to sports in early stage. An average period of starting sports after operation was 1.6 monthes. When the isolated fragment is recognized and simptoms continue with conservative treatment, and if they wish to resume sports activity again, an operative treatment is recommended.
We have operated on 23 knees with patellar malalignment syndromes over the past two and a half years, using the proximal realignment (Insall) method. We carried out a retrosupective study of 20 of these knees and discussed the principals and our results of this study. The results are as follows:- 1. This procedure is useful for patellar malalignment syndrome. 2. It is also useful for chondromalacia patella and dislocation of the patella. 3. Patelloplasty was also needed for a severely damaged chondral bone.
The subject of this investigation was 23 cases with 26 knees in which male was 6 cases and 6 knees, and female 17 cases, 20 knees. The age at operation ranged from 9 years and 10 months to 55 years and 10 months old (average 21 years and 10 months old). All cases passed over 10 months after the operation. The results of the operation were divided into “satisfactory”, “unsatisfactory” and “undivided” groups. The numbers of each group were respectively 20 cases 23 knees (88.5%), 2 cases 2 knees (7.7%), and 1 cases 1 knee (3.8%). Regardless with a variety of subjective complaints, objective and the radiological findings were relatively successful. Therefore, this operative method was demonstrated to be effective for the syndrome of patellar subluxation.
Pathological findings of plain X-rays and arthrography were investigated to realize the causes of lateral asteoarthrosis of the knee. The number of lateral osteoarthrosis cases was 22 knees of 18 patients. 14 cases were women. 12 cases were on the right side, 2 cases on the left and 4 cases on both sides. 10 of 17 lateral menisci were found to be of the discoid type. In 9 knees which were classfied in the advanced stage (Stages III, and IV), 5 knees had seriously torn lateral discoid meniscus. Torn lateral discoid meniscus was supposed to be one of the important causes of lateral osteoarthrosis of the knee.
There are many conservative treatments for osteoarthritis of the knee joint. We stressed that the muscle exercise of the lower extremities is one of the most significant treatment. The exercises we recommend are the straight leg raising and the abducting the hip joint. These exercises provides the stability of the knee joint and makes the functional axis of the lower extremity vertcal during walking. We proved the efficacy of these exercises for osteoarthritis of the knee joint by control study.
123 patients were treated with a lateral wedged insole for their gonarthrosis between 1986 and 1990. Of these cases, 47 knees had high tibial interlocking wedge osteotomy and 2 knees had total knee replacement (TKR). They were followed-up for a period of more than three months. They were assessed using an original questionnaire and roentgenograms. 81% of the patients had conservative treatment and 55% of the patients treated with osteotomy and TKR had satisfactory results using a wedged insole. But, we could not guess at the effectiveness of the wedged insole by assessing their roentgenograms.
Arthroscopic debridement was carried out in 45 medial osteoarthritic knees of 41 patients. There were 13 men and 28 women, and the mean age was 62.3 years old ranging from 46 to 78 years old. The average follow-up term was 26.0 months ranging form 7 to 69 months. The results were evaluated by Japanese Orthopaedic Assosiation score for osteoarthritic knee. Thirty-eight knees of 45 knees were improved (82.9%) and 39 patients of 41 patients were satisfied with the result of surgery. Two patients with medial compartnent ulcer (Grade III) were not improved. There was no statistical significance between improved group and non-improved group in terms of the following factors: age, obesity, follow-up term, duration, operative method, X-P Grade, standing FTA, meniscal status and type of pain. Good results can be predicted in the case of the Grade I or II, but a clear prediction of prognosis has not been established for the Grade III (ulcer) or more advanced Grade.
The changes of the leg alignment and the joint space were evaluated in 46 osteoarthrotic knees before and after barrel-vault osteotomy. Lateral opening angles (α-angle), tibial angles, passing points of Mikulicz's mechanical line (M-line) and femoro-tibial angles (FTA) in each standing and supine position were measured on pre- and post-operative X-ray. Postoperative mean values or degrees of tibial angle, M-line and FTA were 81.7°, lateral 38.2% and 165.6° respectively. Preoperative α-angles were 2.9° in supine position and 6.1° in standing position. The mean postoperative α-angle in standing position was 2.6°, which was similar to the preoperative one in supine position. These results suggest that the correct angle in barrel-vault osteotomy had better be determined on the preoperative A-P view X-ray in supine position.