Thirty-seven patients undergoing hemodialysis were examined for the presence of spinal disease. Lateral vertebral radiographs were helpful. Vertebral erosion was the most evident features in cervical spine. Nineteen patients (51.4%) had vertebral erosion. Five patients (13.5%) showed disc-space narrowing with vertebral erosion which was diagnozed as destructive spondyloarthropathy (DSA). In thoracic and lumbar spine, osteoarthritis was the most evident features. Blood chemistry such as BUN, CRE, ALP, and Ca, was not important for vertebral changes. Patients under longer-termed hemodialysis tend to have abnormalities in the spine on X-ray. Frequently, the patients with with hemodialysis complaint neck pain. But X-ray findings were not well correlated with stage of symptom. It is necessary to observe X-ray findings frequently in spine, especially cervical spine, because of such reason.
Destructive Spondyloarthropathy (DSA) in longterm hemodialysisi patients has been on the increase. We had two patients with DSA of the lumbar spine, whose daily rou tine activities were highly restricted because of severe low back pain, and intermittent claudication respectively. We performed operations using the posterior lumbar interbody fusion method with the Steffee VSP system, and got excellent results. There are some difficulties in performing the interbody fusion method in long-term hemodialysis patients because of renal osteodystrophy which causes its collapse of nonunion. We emphasize the importance of a firm internal fixation and long-term external immobilization.
β2-Microglobulin (β2-MG) derived amyloidosis has become a major concern in long-term hemodialysis patients. Clinical symptomatology is largely restricted to the articular and periarticular sites and in rare cases systemic manifestations have been described. We will present a long-term hemodialysis patient who developed tarsal tunnel syndrome due to a solid tumor, causing numbness and pain in his right foot and toes. Removal of the tumor and pathological examination demonstrated amyloid that was positive to β2-MG by specific antibody testing.
Carpal tunnel syndrome (CTS) is well known to occur in patients on hemodialysis. We have treated 20 cases (29 wrists) during the last four years. We analysed clinical symptoms, sings, surgical results and pathological findings. We found numbness or hypesthesia in all cases and spontaneous pain of fingers in 24 cases (83%). Surgical decompression of the median nerve by sectioning of the transverse carpal ligament was done in all cases. At the operation, we found thickening of the transverse carpal ligament. Amyloid deposits was found in the transverse carpal ligament as pathological findings. We consider that thickening of the transverse carpal tunnel ligament by amiloid deposits is the main factor of the cause of CTS.
Complications of long-term hemodialysis in the hands were reviewed. They included carpal tunnel syndrome (C. T. S.) in 31, snapping finger in 8, and mallet finger in 5 patients. The patients with C. T. S. had 10 years dialysis history on an average. Moreover, it is interesting to note that the development of this particular condition is dependent upon the patients age at the time of starting hemodialysis: the younger the patients, the later the development of C. T. S.. We had 2 cases of recurrence. The patients with snapping finger were treated surgically with good results. The surgical treatment was applied in one case of mallet finger, and the other were treated conservatively.
Ten dialysis patients with evidence of R. O. D. were studied on X-ray, chemical finding and bone histology. AL-P, P. T. H. increased in most patients with evidence of R. O. D. but estradiol decreased. In bone histology, four cases were osteitis fibrosa, four sclerotic type and one mixed type. Patients with evidence of osteitis fibrosa was younger than those with other type. It is suggested that the development of R. O. D. is correlated with secondary hyperparathyroidism and other endocrine function.
A number of 341 patients who are under Haemodialysis (HD) in Nagasaki City were interviewed in person by a single observer with the use of sequence questioning concerning the bone and joint complaints complicated with HD such as pain at rest (PR) as well as in motion (PM), restricted range of motion (ROM) of joints, carpal tunnel syndrome (CTS) and pathological fracture (PF). The number of affected patients with PR, PM, restricted ROM and CTS were 127 (37.2%), 150 (44.0%), 61 (17.9%) and 86 (25.2%) respectively. The joints involved with PR and PM in order of frequency were the shoulder, knee and low back, and the common joints with restricted ROM were the knee, shoulder and fingers in this order, more than half of which were bilaterally. Twenty-six (7.2%) patients had PF and the most common sites of which were rib and metatarsal bone. The incidence of all these complications revealed that the age of patient was not significant, however, the trends appeared to correlate with the duration of HD.
Clinical and radiological evaluations were carried out on 17 hemodialysis patients who were treated by total parathyroidectomy with forearm autograft (PTX). The average follow-up period was 3.6 years. Clinical symptoms such as pain and itching had improved within 7 days after the PTX. In radiological findings, subperiosteal resorption of the phalanges and cranium had also improved within 6 months after the PTX, but the rugger jersey appearances of vertebral body had not improved. According to the histomorphometric analysis of the iliac bone biopsy, these 17 cases were classified into the following three types: mild type (3 cases), osteitis fibrosa type (12 cases) and mixed type (2 cases). In the mixed type, the improvement was less than in the others. The aluminum stain was done on 11 of the 17 cases, and it was positive in 7 cases.
We retrospectively analyzed the records of 253 patients undergoing hemodialysis, who had been operatively treated at our institutions from 1980 to 1991. The most common orthopaedic ptoblem was carpal tunnel syndrome in 198 of the 253 patients. There was no benefit from carpal tunnel release in 4 of 13 patients with both bilateral carpal tunnel syndrome and destructive spondyloarthtopathy. These results are poor in comparison with those in our previous study, which demonstrated no benefit from the same operative procedure in only 2 out of 45 patients with isolated carpal tunnel syndrome. Depositions of beta-2-microglobulin amyloid were demonstrated in specimens of the affected sites in patients with carpal tunnel syndrome, destructive spondyloarthropathy, and cystic bone lesions.
X-ray examinations were performed on 239 hemodialyzed patients to detect abnormal findings of the Spine. Destructive Spondylarthropathy (DSA) was observed in 21 cases (8.8%); 9 males (6.7%) and 12 females (11.5%), and largely found in the cervical vertebrae. Rugger jersey spine was observed in 26 cases (10.9%); 16 males (11.9%) and 10 females (9.6%). The rate of DSA and Rugger jersey spine was markedly high in cases with long periods of hemodialysis. A high incidence of ossification of the posterior longiludinal ligament in the cervical spine was observed in a total of 18 cases (7.5%); 13 males (9.6%) and 5 females (4.8%). Our study showed radiographic findings of the spine in hemodialyzed patients to be extremely varied.
Forty-six cases of lumbar disc herniation treated by posterior nucleotomy without bone fusion were reviewed. These cases consisted of 28 males and 18 females. The age range was from 14 to 72 with an average of 41 years. The mean follow-up period was 5 years and 4 months. The average improvement rate by the J. O. A. score was 80.6 percent. The improvement rate of S. L. R. was high, but the improvement rate of lumbago was low. On roentgenograms, there was a tendency for an advancing disc space to narrow, which revealed disc degeneration, but no significant correlation was recognized between the rate of improvement and the roentgenographical changes.
We reviewed the roentgenographic results of forty-seven cases of lumbar disc herniation treated by a Simple disc excision (Love's operation) with and without PL-fusion at Miyazaki Medical College from 1982 to 1990. While there was a tendency for the disc space narrowing in both methods, the results were better in the Simple disc excision+PL-fusion than in the Simple disc excision only. We concluded that a PL-fusion should be available for patients with instability in the lumbar vertebra.
Percutaneous discectomy has been advocated as an alternative to conventional surgery for the treatment of lumbar disc herniation. The purpose of this study is to assess the clinical results in patients operated for bilevel lumbar disc herniation. The subjects were 261 patients who had percutaneous discectomy since April in 1989. Fifty-one patients had multiple disc herniations and in them, 12 cases who had radiculopathy due to two disc lesions were operated for both lesions. They consisted of eight males and four females aged 17-40 years (mean, 26.3 years) and were followed up for 8-20 months (mean, 14 months) after operation. The intervertebral levels involved were L1-2 and L2-3 in one, L3-4 and L4-5 in three, L4-5 and L5-S1 in eight. Five patients had two levels done simultaneously and seven patients underwent additional operation. The postoperative results were evaluated according to Macnab's criteria. The results were excellent in seven, good in four and poor in one. Percutaneous discectomy seems to be an excellent procedure for treating two disc levels.
Since 1985, operative treatment was performed in 23 patients of under 18 years old with lumbar disc herniation. 14 cases were treated by herniotomy and 9 cases by percutaneous nucleotomy (PN). We compaired the results of these treatments. The cases treated by herniotomy showed better results the other. The cuses of failed PN were disc with separated end-plate, L5/S1 herniation and extruded herniation.
In order to explore the significance of high signal intensity on MRI of lumbar disc herniation, comparision was made between high and low signal groups of herniation in terms of clinical data, operative and histopathological findings. In 5 of 16 cases, MRI (T2-weighted) demonstrated high signal herniation and 4 of these 5 cases were accompanied by the rupture of the posterior longitudinal ligament (PLL). In 11 cases with low signal intensity, 10 were not accompanied by the rupture of the PLL. There was no significant difference in clinical and histopathological findings between both groups, except for the duration of symptoms and the incidence of vascular infiltration. These findings suggest that high signal intensity on MRI of lumbar disc herniation may be related to the rupture of the PLL followed by the release of herniation from high pressure and increase of water contents.
The coronal MRI was performed on 23 paients with lumbar disc herniation. Normal lumbosacral nerve roots were well depicted by T1 weighted coronal images. The coronal images demonstrated that a nerve root had deviated laterally by hernial mass. The images had similar diagnostic values to myelography. The coronal MRI was a useful diagnostic method for lumbar disc herniation.
A 64-year-old man who had suffered from syphilis twenty years before complained of numbness and weakness on his left lower extremity in May 1988. He was made a diagnosis of lumbar canal stenosis and treated with laminectomy from L3 to L5. After surgery, his symptom was improved. But he recomplained of lightening pain on his right lower extremity and gait distubance in December 1989. The diagnosis of charcot spine was made by the characteristic X-p findings and his past history. He underwent posterolateral fusion with pedicular screw system (Steffee) from L3 to L5. Solid union is not achieved but clinical result is good.
We reported one case of L3, L4, L5 spondylolysis. Cotrel-Dubousset pedicle screw fixation combined with bilateral posterolateral fusion was followed by Gills operation. Pedicle screw fixation is useful for stabilization of bone graft used in the case of multilevel instability or correction of spondylolisthesis.
Eleven cases of lumbar lesions which showed “drop foot” were evaluated. They included 8 cases of lumbar disc hernia and 3 cases of lumbar spinal canal stenosis, and all patients were surgically terated. Patients showing strongly positive straight leg raising test or patients who had “drop foot” after disappearing of leg pain, gained less outcome. Operative treatment should be performed before irreversible change of nerve tissue occurs.
The purpose of this paper is to evaluate the weight of various factors which influence the level diagnosis of lumbar disc herniation. The subjects were 415 patients who had been operated for lumbar disc herniation (L3-4, L4-5 and L5-S1). We performed the method of quantification theory type 2 and discriminant analysis (2 groups and 3 groups). Correct discrimination rates of the level diagnosis were examined with 2 parameters for every level. Following results were obtained. 1. The factors which influence the level diagnosis were, in order of weight, PTR and sensory of medial side of the lower leg on L4, 1st toe dorsiflexion power and sensory of medial side of the foot on L5, and ATR and sensory of lateral side of the foot on S1 respectively. 2. Correct discrimination rates of the level diagnosis were 87-96% when both symptoms were found, and 76-90% when either symptom was found.
Compound muscle action potentials (CMAPs) were recorded in tibialis anterior, extensor digitorum brevis and abductor hallucis elicited by stimulation of the cauda equina. We examined twenty patients with intermittent claudication due to lumbar canal stenosis. For the purpose of analyzing the alteration on the cauda equina propergation, we recorded the CMAPs before walking and immediately after onset of the intermittent claudication, and then continuously recorded them every few seconds. In all patients the latency of CMAPs showed no changes after walking stress. But in fifteen patients of twenty the amplitude decreased by various degrees immediately after walking stress and gardually made recovery to the control. The decreased amplitude of CMAPs was reflected the impairment of the motor axons. We conclude that the temporary conduction block of the cauda equina and/or lumbar nerve root occurs in the imtermittent claudicaion of the lumbar canal stenosis.
The purpose of this paper is to describe the double roots involvement at the single intervertebral disc level. Of 69 cases morphologically dianosed as being abnormal at the L4/5 disc level, we compared 38 cases of lumbar disc herniation diagnosed as single root involvement by nerve root infiltration (NRI) with 17 cases of lumbar canal stenosis diagnosed as double roots involvement by NRI. As a result, neurologically both absent or diminished response in ankle jerk and sensory disturbance at S1 root area were noticed in 4 (11%) of 38 cases in lumbar disc herniation, and these cases were suggested to have the double roots involvement (L5+S1 root involvement) at the single level of L4/5 disc.
In order to investigate the changes of myelographic findings after posterior lumbar surgery, iotrolan myelography was performed in 73 cases of lumbar disc herniation and 25 cases of lumbar spinal stenosis. Postoperative myelography was performed 4 weeks after surgery. In the cases of disc herniation, the findings of cauda equina shifting and double shadow of dural tube were well improved, but the finding of nerve root sleeve defect was poorly improved. In the cases of spinal stenosis, the findings of dural tube stenosis and block were well improved, but the finding of nerve root sleeve defect was poorly improved. It is suspected that the myelographic findings which were due to extradural mechanical compression are well improved, but that the finding of the root sleeve defect which was due to that mechanical compression and adhesion in and around the root sleeve is poorly improved. The improvement of root sleeve defect was observed in 38% of disc herniation and 24% of spinal stenosis. And many of these cases showed good clinical results.
The radiological features of ante-position type instability (AP group), as defined by Knutsson, were studied in 74 cases and compared with 55 cases of degenerative spondylolisthesis (DS group), and 58 cases of lumbar disc lesion (DL group) which excluded the AP group, the DS group, Spondylolysis and Spondylolisthesis. 88% of the AP group and 94% of the DS group were female. The age distribution was almost the same in both the AP group and the DS group and predominant in those over fifty. Anterior slips occured at L4 level in 93% of the AP group and 67% of the DS group. Severe facet joint degeneration was more predominant in the DS group (92%) than in the AP group (81%). The frequency of M type and W type lamina was more predomiant in the DS group (78%) than in the AP group (29%) and DL group (L4:23%), whereas the pedicle-facet angle was almost the same in both the DS group and the AP group. In conclusion, there are several similar radiological features in both the DS group and the AP group, but there are some differences, too. Thus, we consider the AP group to be a slight different group from the DS group.
A homologous blood transfusion introduces the risk of disease transmission and immune reactions. An autologous blood transfusion eliminates these risks. Since 1984, we have used autologous transfusions in spinal surgery, this study reviews our experiences with autologous transfusions excluding frozen autologous blood transfusions. This series consisted of twenty patients who had spinal surgery. Autologous transfusions could be achieved by intraoperative blood salvage using a cell saver and predeposited blood. In 90 percent of the patients, operations were performed using only autologous blood trasfusions. In two cases homologous blood was required for the transfusions. There were no complications in the autologous blood transfusions. The use of instrumentation (pedicle screwing) and a long spinal fusion were some of the factors which increased the intraoperative blood loss. This suggests that instrumentation surgery, and a long spinal fusion are indicated for autologous blood transfusions.
Autotransfusion avoids the risk of disease transmission, isoimmunization, and the graft-versus-host disease that is seen with an homologous blood transfusion. In our hospital, thoraco-lumbar surgery, which is expected to have much blood loss, has been performed with venesection and an intraoperative autotransfusion method by Cell Saver 4 since 1989. Venesection was performed 2.12 times on an average for each case and the volume was 785g. The average ratio of intraoperative autotransfusion to total blood loss was 37.9%. Only one of the 5 cases which bled more than 3000g of total blood loss did not necessitate any homologous blood, but the other 4 cases did. With our method of autotransfusion, the limitation of total blood loss is suspected to be about 3000g.
A review of 35 cases aged fifteen years or younger with traumatic vertebral column and spinal cord injuries is presented here. There were twenty-one cervical, twelve thoracic and two lumbar spinal injuries. Cases of atlantaxial injuries are more common than in adults. Radiographic and clinical features of the lower cervical spine are the same as those of adults. All of the spinal cord injuries without radiographic abnormalities (SCIWORA) occurred in cerviao-thoracic lesions. In these cases, neurological recovery was poor. Paralytic scoliosis occurred in all cases with upper thoracic spinal injuries. Traumatic syringomyelia was found in one case with a thoracic cord injury.
We studied the effects of conservastive treatment, especially of drugs, in 124 patients with spinal spasticities. Paresthesia and clumbsiness in postoperative state were partially resolved in 60% of cases. Medical therapy was not very effective in only way, but significantly useful in the introduction of rehabilitation.
Twenty-seven percutaneous trephine biopsy of the spine were performed under fluoroscopic guidance without complications. The distance from the midline, the angle of insertion, between the trephine and the frontal plane, and the depth of trephine penetration are calculated on preoperative CT scans. We concluded that closed trephine biopsy of the spine can be performed safely when the proposed technique is used.
This report describes a 53-year-old male with polyostotic fibrous dysplasia of the thoracic and lumbar spine. He had back pain in the lumbar spine for 1 month and had no evidence of any endocrine abnormality. Plain radiographs of the spine demonstrated lytic lesions from the first to the fifth lumbar spine. Computed tomogram and Magnetic Resonance Image were very useful to evaluate the expanse of the lesions. Biopsy findings confirmed the diagnosis of fibrous dysplasia.
We experiensed 3 cases of giant neurofibromas which grew initially outside the spinal canal and invaded inside thereafter. Cases 1 and 2 were plexiform neurofibroma associated with neurofibromatosis and Case 3 was solitary neurofibroma. All three cases had no neurological deficits. Case 1 was found accidentally by radiological examination of the chest. A biopsy was done. No further treatment was done because of a lack of symptoms. Case 2 visited our clinic with lower back pains and destruction of the right sacroiliac joint was found. Partial resection of the tumor was performed because the tumor had invaded the plexus and the surrounding tissues. At present, 2 years after surgery, she is wearing a brace and has no problems in her daily routines. In case 3, there was a huge neurofibroma on the right side of the 10th thoracic spine, the lamina of which had been destructed by the tumor. The tumor was encapsulated and a radical resection was performed. Although, all three cases showed invasions of a neurofbroma in the spinal canal, the prognoses of cases 1 and 2 were different from case 3 because even though a neurologicl deficit did not occur initially and the nature of the tumor was less agressive, spinal cord damage might occur in the future requiring reconstruction of the bony structure.
We reported on two cases of Malignant Lymphoma in the spinal epidur al space. Case 1 was a 49-year-old man and case 2 was an 82-year-old wo man. Both cases had a neurological deficit without any evidence of systemic lymphoma. Laminectmy was performed in both cases and the tumors were removed and proved to be Malignant Lymphoma, the diffuse small cell type, pathologically. Postoperatively, radiotherapy and chemotherapy were administered and led to the improvement of the neurological symptoms.
The surgical treatment by the direct anterior approach to the upper thoracic spine is seldom necessary, but it may be technically difficult because of the vital structures in the region. We report one case with the spinal cord tumor at the lower cervical and upper thoracic region, treated by the sternum splitting approach and the free vascularized fibular graft. The case is a 67-year-old female, presented with gradually progressive weakness of lower extremities and retension of urine. MRI examination revealed the spinal cord tumor at the ventral C6-Th2 region. The tumor was resected anteriorly using the sternum splitting approach and the reconstruction of the vertebral defect was performed by the free vascularized fibular graft, 7.5cm in length. Histological examination showed meningioma. There was a good neurological recovery and no complication. Hodgson et al reported a 40% mortality rate with this sternum splitting approach in 1960, but the recent Japanease reports have showed no serious complications. We guess that the sternum splitting approach can be performed relatively in safety with a careful respiratory management.
Paralysis of the ipsilateral arm and contralateral leg was first described by Wallenberg in 1901 as “hemiplegia cruciata”. At the level of upper cervical spinal cord, the fibers for upper limp and lower limb cross the midline at the different levels. Hemiplegia cruciata is produced by involvement of the crossed arm and uncrossed leg fibers of the pyramidal tract at the level of the decussation of the pyramid. Etiology has been reported to be hemorrhage, occlusion of the anterior spinal artery and trauma such as fracture of the odontoid process, but hardly due to spinal cord tumor. It has been said that extramedullary tumor at this level is very difficult to be diagnosed because of varied and strange symptoms. So early diagnosis is important to understand the anatomy of this level.
The extradural meningeal cyst is an entity which was defined by Schlezinger in 1898. We will report on a 40-year-old female with an extradural meningeal cyst. She had lower back pain, pain in her left lower extremities and numbness in her lower leg. Radiographical examinations revealed a widening of the spinal canal, between the 1st sacral spine and the 4th sacral spine. A CT scan demonstrated a soft tissue density mass in the spinal canal, between the 5th lumbar spine and the 1st sacral spine. An MRI showed a cystic lesion in the spinal canal, between the 1st sacral spine and the 3rd sacral spine. The patient was treated with laminectomy and a local excision. The cyst existed from the upper border of the 1st sacral spine to the 4th sacral spine. The postoperative course was uneventful, and there were no further symptoms.
Spinal intradural metastasis originating from outside the neural axis is extremely rare. We therefore will report a case of metastasis to the cauda equina from lung carcinoma. The clinical course may be so rapid and poor that operative treatment should be considered after careful clinical evaluations.
We reported a case of spontaneous spinal epidural hematoma which was diagnosed by MRI. A 37-year-old man had acute and severe back pain which radiated toward his legs. 4 hours later he developed weakness of both legs. On admission (3 days later) he showed flaccid paralysis and urinary incontinence. MRI demonstrasted an epidural posterior mass (Th9-Th11) which compressed the spinak cord anteriorly 5 days later laminectomy was performed and revealed the hematoma at posterior epidural space. Histopathological diagnosis was A-V malformation. At follow-up 1 months after surgery MRI showed the presence of mass lesion in the same position. At follow-up 4 months after surgery the mass was diminshed but he had no improvement in neurological recovery. We think MRI is the first choice for the diagnosis and the follow-up method of spinal epidural hematoma.
Spinal cord lesions are not detectable on roentgenograms and computed tomography (CT) scans. Magnetic resonance imaging (MRI) is able to make soft-tissue lesions visible. MRI was performed on 12 patients with an acute spinal injury using T1-and T2-weighted images. There were 8 males and 4 females. Intramedullary lesions were found in 3 of the 12 patients, these MRIs demonstrated a low signal intensity on the T1-weighted image. On the T2-weighted image, intramedullary lesions were found in 6 of the 12 patients, and these MRIs demonstrated a high signal intensity. In 4 of the 12 patients, MRI demonstrated an increased signal intensity in the disc space and adjacent soft-tissues, these findings suggested a hematoma. The MRI demonstrated intramedullary and extramedullary soft-tissue lesions and was useful in establishing a diagnosis and in choosing the appropriate therapy.
Gadolinium-DTPA was administered prospectively to 35 patients who presented themselues for magnetic resonance images (MRI) about 2 weeks after a cervical cord injury. Three types of enhancement MRI signal patterns were seen in assoication with cord injuries. Type R, seen in nine of the patients, demonstrated a rim enhancement consistent with complete quadriplegia. Type S, seen in thirteen of the patients, demonstrated a spot enhancement consistent with incomplete quadriplegia. Type N, seen in thirteen of the patints, demonstrated no enhancement cosistent with incomplete quadriplegia. This report indicates a distinct correlation between the patterns the spinal cord injury as identified by the enhancement MRI and the neurologic recovery.
Magnetic resonance imaging was performed on 28 patients with chronic spianl cord injury. Low intensity area on T1-weighted sagittal view was frequently observed at the level of injured spine, and its width and extent have close corrrelation with the grade of paralysis and reduction of the spine.
MRI of 15 thoracic OPLL (8 males, 7 females) and 12 lumbar OPLL (9 males, 3 females) patients were reviewed. It has been reported that MRI of OPLL was low signal epidural lesion. But in this study, almost 80% of thoracic OPLL and 50% of lumbar OPLL had some extent of middle or high signal intensity areas within the ossifications on MRI. Especially in continious and mixed type of thoracic OPLL, high or middle signal intensity areas within the ossification showed broad band appearance. In addition, in thoracic and lumbar OPLL, there was no hypertrophy of posterior longitudinal ligament and the morphology of disks was not so various as that in cervical OPLL.
We studied the distance between the roots-exit point of the dural sac and internal portion of the dorsal root ganglion, and the ratio of proximal migration of the dorsal root ganglion with MR coronal imagings among three groups (pre-growth spurt, growth spurt, post growth-spurt group). The first thing is longer, and the last is higher with ages, but there is no significant difference between 3 aged groups.
The purpose of this paper is to report the good results of callus distraction (Callotasis) for congenital short fingers and to evaluate the merit and demerit about this technique. Callotasis was performed at 5 metacarpal bones of 2 patients, and their age at the time of operation was 10 and 16 years old. We used two kinds of lengthening, one is Hoffmann and another is Orthofix. The bone was distracted at the rate of 0.25 to 0.5mm daily after the waiting period for 3 weeks. The schieved elongation varied from 7 to 13mm (average 11.2mm). The rate of elongation was 21 to 38% (ave. 32.8%). The healing index ranged form 70 to 130 (ave. 104. 18). During the distraction, some complication were observed; deformity of bone, pin tract infection and extension contracture of MP joint. The great merit of this technique is not to need bone graft and to be able to get the large elongation.
Tibial Hemimelia is very rare. The treatment is difficult, because the deformity of the leg is severe with flexion contracture of the knee and club foot. And the shortening of the leg is noticed in born, and the leg length discrepancy is increased with growth. The results of treatment of 3 legs in 2 children with tibial hemimelia are presented. At first, we had done arthroplasty of the knee and ankle by Brown techunique, or Putti technique, without amputation of the leg. Their leg length discrepancy and at increased gradually with growth. At 7 years old, and at 8 years old, we had lengthened their legs by Callotasis with Orthofix. Amount of lengthening was 5.3cm and 8.0cm vespectively. After these procedures, they were able to walk vigorously with small orthosis.
The long term follow-up of 10 patients with congenital pseudoarthrosis of the tibia treated by vascularized bone graft are reported here. 7 patients were female, and 3 were male. All were classified initially as Boyd's Type 2 pseudoarthrosis. The age at clinical presentation ranged from birth to 6 years old. 7 patients had had 11 previous surgeries prior to vascularised bone grafting, the unions having failed, they were refered to us. The age at vascularized bone grafting ranged from 2 to 13 years. 8 patients had a vascularized fibula graft (VFG) to fill a defect ranging from 6 to 13cm in size. Two patients, one who was a first case of vascularized bone graft, and the the other who had a defect of the contralateral fibula caused by a previous surgery, had a vascularized rib hraft (VRG). All the patients except two showed a primary bone union within four months. One VFG and one VRG failed to unite at the proximal junction with the tibia. The VRG nonunion united after receiving a conventional bone graft, but the VFG one failed to unite. As the family refused any further surgery, this case was classified as a failure and continues to wear a brace. The follow-up was from 5 to 12 years. 8 spontaneous fractures were seen in 4 patients who had been succesfully treated with conventional bone grafts. Two patients received osteotomies to correct angulation deformities. The leg length discrepancy ranged from 1 to 6cm and averaged 3.8cm. Patients with VRG tended to develop angulation deformities. Inspite of several complications, vascularised fibular grafting may be the most reliable technique in achieving bone union in congenital pseudoarthrosis of the tibia.
32 cases of congenital club foot operated with postero-medial release were followed up. Preoperatively lateral tibio-calcaneal angle and lateral tolocalcaneal angle were related to MTR angle and the index of MEARY's method significantly (p<0.05-0.001). Therefore, we can suppose the prognosis of the deformity of the foot preoperatively.
Sixty images using magnetic resonance imaging (MRI) in sixteen patients (16hips) with Legg-Calvé-Perthes disease were evaluated over a mean period of 1 year and 10 months. In the initial stage, MRI could demonstrate the necrotic changes of the capital femoral epiphysis as the low intensity area on T1, T2-weighted imageprior to the radiological changes. The early images in this stage presented the low intensity zone in the upper subchondral bone and this dark zone widespreaded in the epiphysis. In the fragmentation stage, the repair tissues were characterised by high signal intensity on T2 weighted images. In the reparation stage, the signal intensity gradually increased on T1-weighted images and decreased on T2-weighted images according to the bone marrow maturity.
Thirty-one magnetic resonance studies were performed on 12 dislocated hips before and after treatment. T1-weighted image showed excellent view of the articular cartilage of the actebulum and the head, the pulvinar and the secodary ossification center. The labrum was clearly demonstated on T2-weighted image. The shape of the labrum could be divided into three types, the everted, hypertrophied and inverted labrum. The hip with one of former two types was easy to reduce the dislocated head by the Pavlik harness. The children with last type of the labrum had critical history of treatment. The shape of these labrums was confirmed by arthrographic studies. After surgery all labrums obtained a good congruity with the head and the thorn sign was pesented on weighted image. By using appropriate choice of pulse sequence, TR, TE, MRI was a useful imaging modality for assessment of the clinically important soft tissues and cartilaginous structures of the infantile dislocated hip.
We report a rare case of a synovial sarcoma which occurred in the forearm. A 17-year-old woman complained of tenderness at the dorsal side of the forearm in 1985. In 1990, she recognized a painful tumor and underwent the excisional biopsy. The diagnosis was the synovial sarcoma, and the wide excision, a complete en bloc removal of the extensor in the forearm, was carried out and free gracilis muscle transplantation was performed for the functional reconstruction of the extensor. 8 months after the operation, the range of motion of the wrist was 40° in palmarflexion and 50° in dorsiflexion. The power was roughly evaluated as 4 of MMT. Now both recurrence and metastasis are not recognized.