A rarc case of septic arthritis due to streptocccus sanguis II in an immunocompro miscd host is described. This case was successfully treated with arthroscopic lavage and antibiotics. According to a review of the literature, FMOX and CZON are recommended before identification of the organism.
Necrotizing fasciitis is a relatively uncommon but serious disease, indicated by progressive infection causing extensive necrosis of the fascia. We have had 10 cases of necrotizing fasciitis at our hospital during the last ten years in six men and four women, ranging in age from 4 to 78 years. The upper extremities were the sites of involvement in three cases and lower extremities in seven. Seven patients had associated chronic disease such as diabetes mellitus and liver dysfunction. Causative organisms were Streptococcus in four cases. Staphylococcus aureus in two, vibrio vulnificus in one and Klebsiella in one. The mortality rate was 10% (1 of 10). The presence of chronic debilitating diseases may contribute to the onset of necrotizing fasciitis, but in our cases the relatiom between the severity and prognosis of necrotizing fasciitis was not recognized. Early diagnosis, local therapy (surgical debridement) and systemic therapy are important in the Treatment of necrotizing fasciitis.
Methicillin resistant Staphylococcus aureus (MRSA) infections are becoming more prevalent and are more difficult to eradicate. We treated nine patients who had bone or joint infections caused by MRSA. Eight patients were successfully treated by longterm therapy. There were an average of 2.5 surgical procedures per patient. Emphasis should be placed on the interruption of transmission of MRSA within the hospital.
We studied the function and complications of the affected limbs after limb salvage procedures in 31 patients with malignant bone tumors. Limb salvage procedures consisted of high-dose fractionated external radiotherapy, wide resection with or without reconstruction for osteoarticular defects by bone graft and prosthetic replacement, and intraoperative radiotherapy. Function was evaluated according to Enneking's criteria. Excellent results were achieved in 6 patients and good results in 15. Fair and poor results were seen in the 2 patients who underwent extensive muscle resection at surgery, and also in the other 8 patients with postoperative complications, such as non-union and fracture of grafted bone, loosening of prosthetic replacement, and deep infection. Moreover, high-dose fractionated external radiotherapy frequently gave rise to severe radiation side effects in the soft tissue. Because the limb salvage procedure using intraoperative radiotherapy preserved the stability of nearby joints and considerably reduced radiation side effects, it appears to offer the best treatment in terms of the postoperative function of the affected limbs.
Limb salvage operation was performed in five cases of malignant bone tumors of the lower extremity. All cases were reconstructed using a Kotz prosthesis and the postoperative function was evaluated according to Enneking's criteria. As a result, three cases were rated as fair and two cases were rated as poor. The main reason for the unsatisfactory results was insufficiency in muscle strength for knee extension. Regarding complications, there were three cases of skin necrosis, one case of local recurrence and two cases of lung metastasis.
Limb saving by prosthesis is a standard method of surgery for treatment of malignant bone tumors. We have had experience of 12 cases with a follow-up 12-72 months. The functional results according to the MSTS evaluation system were good in 6 cases and fair in 6. In each parameter, muscle strength was evaluated as poor in almost all patients with proximal Pemoral and tibial lesions. These results sugges that inprouenent is heeded in the reconstruction and attachment of hip abductors and patellar ligament.
Functional results of limb-sparing procedures performed for patients with malignant bone tumors were reviewed. These tumors included metastatic bone tumors in 50 patients, chondrosarcoma in 10 patients, and osteosarcoma in 7 patients. Cases of metastatic bone tumors localized intracompartmentally achieved satisfactory results in pain relief and functional activity by en block tumor resection followed by reconstruction. Patients with tumors around the shoulder continued to have a functional shoulder disability post-operatively. However, elbow and finger functions were retained, and functional ability of the upper extremity was rated as good. In pelvic tumors, good functional results were seen after resections in which femoro-sacral continuity was maintained or reconstructed. Prosthetic implants in the treatment of tumors in the hip lesion lead to a relatively good result.
Limb-salvage operations in the treatment of malignant bone tumors were analyzed with particular attention given to functional results. This atudy evaluates twelve patients (8 males, 4 females). The location of the primary tumor was the humerus in 3 patients, femur in seven and tibia in three. Histological diagnosis included conventional osteosarcoma in 7, chondrosarcoma in 3 and malignant fibrous histiocytom (MFH) in 2. Using Enneking's criteria surgical stage was evaluated as I A in one, I B 4 and II B in 7. Curative wide excision or wide excision was applied in all cases. At an average thirty six-month follow-up, no patients showed any evidence of local recurrence and complication. However, four patients had lung metastases, three of them dying from this diseaes. Postoperative function was analyzed according to Enneking's functional criteria. The over-all rating was good in one and fair in 2 for the upper extremity; excellent in 2, good in 6 and fair in one for the lower extremity. Good results in ADL were obtained in both the upper and lower extremity except for arthrodesis of the knee joint. Limb-salvage operation in malignant bone tumor is justified from both an oncological and a functional standpoint.
Nineteen patients with malignant bone tumors treated by limbsalvage procedures were evaluated. Histological diagnoses were chondrosarcoma (6), osteosarcoma (6), malignant fibrous histiocytoma (2), Ewing's sarcoma (2) and giant cell tumor (3). The surgical stages were: Stage I B (6), Stage II A (2), Stage II B (9) and Stage III (2). Fourteen patients were treated by preoperative and/or postoperative intra-arterial chemotherapy. The operative procedures were tumor resection alone (5) and reconstruction with bone graft (3), bone cement (2), prosthetic Numeral head (1), total shoulder arthroplasty (2) and total knee arthroplasty (5). One patient required no surgery, following complete response with intra-arterial high-dose adriamycin. The most common complication of patients with marginal (5) or intra-lesional surgical margin (2) was local recurrence (36%). Functional evaluations were excellent (7), good (10), fair (2) and poor (3). Metastasis was 47%, death 42% and disease free survival 58% with a mean follow-up of 55 months. Careful preoperative selection and attention to limb salvage procedures are important for a successful outcome.
Functional results following wide excision of malignant bone tumors are not necessarily satisfactory, since reconstructive procedures for large bone and soft tissue defects are not yet established. So far, limb salvage surgery has been indicated for 12 cases of locally aggressive or malignant bone tumors. In upper extremities, including two shoulder and one wrist joints, arthroplasty with endoprosthesis or vascularized fibular graft (FVFG) were performed. The results were scored as good using Enneking's criteria, and the procedure has been stable for a long period. On the other hand, reconstruction in lower extremities was complicated in two cases due to prosthetic problems around the knee. However, a breakage of the tibial component was successfully salvaged by revision two years after surgery, and a loosening of the femoral component was asymptomatic until the patient's death. Both of these cases were evaluated as good. The results of two cases, in which FVFG was applied, were stable and satisfactory. The remaining cases of endoprosthetic replacement only have a follow-up of less than one year. Development of a prosthesis satisfactory for long-term use is mandatory to achieve truly long lasting functional reconstruction.
Functional results in patients with malignant bone tumors of upper and lower limbs were evaluated according to the Musculoskeletal Tumor Society System Classification. In the group receiving prosthetic surgery the rating was as follow: excellent 4, good 15, fair 4, and poor 2. The evaluation of the arthrodesis group was:, good 11, fair 2, and poor 2. No excellent cases were identified. Reconstructing resected lesions using a total knee device or proximal femoral prosthesis in older patients or in metastatic iesions, achieves good short term results. An arthrodesed knee is a stable painless condition that allows for almost unlimited activity. The disadvantage is the inability to bend the knee, which interferes with sitting and may be cosmetically undesirable.
An Implantable injection port was utilized in the intra-arterial chemotherapy of 4 cases with malignant bone orsoft tissue tumor. No patients had complications during the perod of chemotherapy. The drug delivery system using the implantabl injection port provided a more comfortable method of therapy gdministr atron for patients with malignancy.
Chemotherapy for sarcoma was associated with some side effects of renal hypofunction; For instance an increase in serum creatinine and urine nitrogen concentration, tetany due to hypocalcemia and magnesemia and delayed excretion of several drugs including anticancer medications. These side effects were seen in four patients following chemotherapy for osteosarcoma and malignant fibrous histiocytoma (MFH). Cisplatin (CDDP) which was found to be the most toxic agent was administrated to all patients. Highdose methotrexate (HD-MTX) with citrovorum factor (CF) rescue and ifosfamide were added for treatment of osteosarcoma. Ifosfamide was also added for MFH. Despite adequate hydration a temporary decrease of creatinine clearance occured which took one to several weeks to recover. Transfusion of serum protein and red blood cells improved the recovery of renal function. Tetany attacks which were prevented by continuous infusion of Ca and Mg tended to happen when renal function was beginning to decrease. Repeated CDDP administration caused irreversible renal hypofunction and delayed excretion of serum MTX after HD-MTX chemotherapy in two cases. Careful monitoring of serum MTX and administration of CF prevented severe side effects due to MTX. It is important to pay careful attention to renal toxicity and delayed excretion of several drugs in intensive chemotherapy for sarcoma.
Ifosfamide (IFM), an attractive drug for treatment of malignant bone and soft tissue tumors, has hemorrhagic cystitis as the dose limiting factor. Mesna (2-mercaptoethanosulfonate) protects against hemorrhagic cystitis caused by oxazaphoshorine compounds, and high dose administration of IMF with Mesna has been reported in the USA and Europe to be highly effective in the treatment of sarcoma. In Japan a phase two clinical study of Mesna is now underway, but we are not able to use Mesna in our institute. Hemorrhagic cystitis occurred in 5 patients administered a single dose of IMF without Mesna. We then tried continuous administration of ifosfamide to the same patients for three to 7 days to prevent hemorrhagic cystitis. Our study showed that the continuous administration of 1.6gr/M2/day IMF is the limiting dose for preventing hemorrhagic cystitis.
Secretion of matrix metalloproteinase (MMP) from human osteosarcoma cells was affected by culture conditions. Analyzing the conditioned medium using SDS-polyacrylamide gel electrophoresis (SDS-PAGE), the cells were shown to secrete MMP-2 with an Mr of 72 KDa. When the cells were ireated with interleukin-1 (IL-1) they secreted MMP-3 with an Mr of 57 KDa. When cultured in a type I collagen-coated or a gelatin-coated dish, MMP-1 was detected in both culture mediums, although more was found the gelatin coated dish. Analysis by SDS-PAGE containing gelatin, revealed gelatinolytic activities with an Mr of 72 KDa and 66 KDa in the conditioned medium from cells in the standard dish. When heated with IL-1, these achuihes covered a wide spectrum. Gelatinolytic activities were most detected in the type 1 collagen-coated dish. Considering the differences seen in MMPs and gelatinolytic activities, secretion of MMPs appears to be modulated by in vivo factovs.
There are many problems concerned with the management of giant cell tumors (GCT) of the sacrum. Three cases of sacral GCT were treated by curettage, followed by irradiation or chemotherapy. Reconstruction involving sacro-iliac fusion was done in two cases. Two patients were able to walk without support, while the other needed a crutch. Complications included amenorrhea in two patients due to irradiation, skin erosion in one, foot drop in one, and bladder dysfunction in one. Post-operative irradiation was considered one therapy for managing sacral GCT.
Metastatic bone tumors were treated by reimplantation of the resected bone after autoclaving, with filling of the defects caused by tumor resection using fresh autogenous bone grafts. Case 1. A 67-year-old woman with lung cancer had a lytic lesion in the right lesser trochanter. At operation, the proximal quarter of the right femur was excised and autoclaved. A long-stem prosthesis was then inserted through the autoclaved bone and the remainder of the femur. She was able to walk with a cane for 14 months after the operation until her death from metastatic brain tumor. Case 2. A 56-year-old man with a Grawitz tumor had a metastatic lesion in the diaphysis of the left femur. The lesion was resected, the bone autoclaved, and then returned to its bed. A Küntcher nail was used for internal fixation. Case 3. A 37-year-old woman with breastt cancer had a metastatic tumor in the left supra-acetabular ilium. She was treated with an autoclaved bone graft to the ilium and THR was also performed for reconstruction. The mean follow-up period was 11 months. All patients were able to walk with canes, and had no infection or local recurrence. Several authors have reported on the advantages of autoclaved bone grafts for treating primary bone tumors. Our results suggest that autoclaved bone grafts are an attractive limb salvage procedure for metastatic as well as primary bone tumors.
Hydroxyapatite (HA) was implanted in bone defects after curettage of benign bone tumors, including among others seven solitary bone cysts, and six giant cell tumors. Seventeen patients ranging in age from 6-69 years, had 18 implantations. Ten cases were only implanted by HA for small lesions or for lesions in children. Eight cases had both HA and autograft inplantations for large lesions affecting pathological fractures or weight-bearing lesions. Postoperative courses were satisfactory and complete healing was achieved in all cases with only one complication. The duration of follow-up ranged from 2-30 months (mean: 13 months). HA is therefore very useful for filling up bone defects after curettage of benign bone tumors from the point of biological safety, bone formation, availability and ease of use.
Thirty-nine patients with benign bone tumors in the lower leg (tibia and fibula) were surgically treated from 1980 to 1991. These included 13 osteochondromas, 8 nonossifing fibromas, 5 fibrous dysplasias, 5 intra-osseous ganglia, 3 giant cell tumors of bone and one ossifing fibroma, osteoblastoma, aneurysmal bone cyst, desmoid fibroma, osteoid osteoma respectively. Twelve cases were only treated by tumor resection with the rest receiving bone grafting, cement packing or hydroxyapatite packing simultaneously. Thirty-six cases achieved good results, but there were three recurrences within ten years after surgery.
We reviewed three cases of histologically confirmed benign chondroblastoma around the knee joint and discussed problems in diagnosis and prognosis. Case 1: 17-year-old boy, complaining of right knee pain. X-ray pictures showed a translucent area with perifocal sclerosis in the medial condyle of the distal femur. 2 years after curettage and bone graft, there is on problem clinically and radiologically. Case 2: 19-yer-old boy. At the time of his first episode of knee pain during sport activities, radiograms showed on evidence of any abnormality. Two years later knee pain and motion disturbances increased. On X-ray examination, there was a 5×6cm radiolucent area in the distal femoral epiphysis invading the articular surface. Seven years after curettage and bone graft, he had knee pain and osteoarthritic changes radiologically. Case 3: 13-year-old girl, complaining of knee pain and motion disturbances with meniscal signs. Plain X-ray film showed no abnormalities, however, MRI demonstrated an abnormal mass in the proximal tibial epiphysis in T1-weighted view, reaching to the articular surface and growth plate. Six months after curettage and bone graft, the knee pain and motion disturbances had disappeared. Examination of these cases of chondroblastoma around the knee joint, suggested three inportant aspects. (1) Tumor mass spreading to the articular surface may cause clinical findings of a meniscal lesion such as locking and McMurray sign. (2) X-ray pictures at an early stage may not identify the existance of femoral problems, and MRI is the most useful method for early diagnosis. (3) Tumor invasion on to the articular cartilage and growth plate may lead to osteoarthritis and growth disturbances.
A series of 92 cases of cartilagenous exostosis were reviewed in regard to problems of heredity, malignant transformation, and surgical techniques for malformation of the forehand. Of 92 cases, 57 solitary were and 35 multiple. Most patients at first consultation were in their second decade. Prevalent lesions were the wrist and knee regions. Heredity, which appeared to be autosomal dominant, was found in six patients among 35 cases with multiple lesions. Malignant transformation was found in only two cases. Malformation of the forearm seemed to be treated well by lengthening of the ulna.
Subungual exostosis is a relatively rare benign bone tumor occurring on the distal phalanx. We experienced eight cases (four male, four female) between 1978 and 1991. The mean age of patients at the time of diagnosis was 21 years (range, 10 to 51). No patients had any history of trauma. Histologically, four cases were diagnosed as osteochondroma-type, and three exostosis-type. No recurrences and nail deformities were noted.
Ossifying fibroma of the tibia distinguished from fibrous dysplasia is a recognized clinicopathological entity reported by Kempson et al. Four cases each of ossifying fibroma and fibrous dysplasia arising in the tibia are presented, comparing the radiological features and histological appearance of the tumors. Radiologically, ossifying fibromas revealed intracortical osteolytic lesions clearly marginated by abundant bony sclerosis. X-rays of fibrous dysplasia revealed typical ground glass appearance with an increase in diaphyseal width seen in all cases. Histological findings seen in ossifying fibromas were osteoid bone rimmed by osteoblasts. In comparison fibrous dysplasias revealed more abundant fibrous tissue and osteoid bone only scarcely rimmed by osteoblasts. Therefore ossifying fibromas can be distinguished from fibrous dysplasia both radiologically and histologically. Also clinically ossifying fibromas were distinguishable due to the high recurrence rate after curettage and bone graft.
An osteoid osteoma in a 19-year-old female was diagnosed with Magnetic Resonance Imaging (MRI). She had an obstinate pain at day-break for 1 year. On physical examination her Lasègue's sign was positive. MRI was performed to discover any lumbar disc herniation, and demonstrated a tumor in the left vertebral arch of the third lumbar spine. The tumor had high signal intensity with a very low signal in the center on the T2-weighted image. The MRI findicgs showed the nidus of the osteoid osteoma.
From 1983 an operative procedure with adjuvant chemotherapy has been used in the treatment of 31 patients with soft tissue sarcoma. Subjects comprised 17 males and 14 females, ranging in age from 9 to 76 years. The sarcomas were histologically classified into 3 graded, 11 cases in grade I, 9 in grade II and 11 in grade III. The average duration of follow-up was 25 months, ranging from 5 to 73 months. The survival rate, (including 5 cases with distant metastases) was 61%. Factors affecting treatment outcome included histological grade, size and primary site of the tumor, and the extent of invasion. Despite achievement of local control by curative procedures, metastases appeared in 7 of the 26 cases, who had no signs of metastases before beginning treatment. There was no difference in survival rate between two groups with or without chemotherapy.
Eleven cases of soft tissue sarcomas arising in the thigh, particularly in the frontal or popliteal area, were estimated to be adherent to major large vessels by angiogram, CT, and/or MRI. Eight cases were tightly adherent to femoral vessels, and two to popliteal ones. Of these cases, seven underwent combined resection of tumor and affected vessels, followed by reconstruction with artificial vessels in five, and autogeneous saphenous vein graft in one. One case with femoral vein resection had no reconstruction. The popliteal fossa and femoral triangles are anatomicd spaces, but it is not feasible to resect large tumors safely or curatively without combined resection of these vessels. Therefore, in these areas, we recommend combined resection fo tumor and major vessels as the preferred management, at least in high grade lesions.
We studied the relation between tumor size and prognosis in soft tissue sarcomas of the extremities in 43 patients. Soft tissue sarcomas over 10cm in diameter of 26 patients were located in the lower extremities (poximal thigh: 19 patients), and of those 13 patients had a local recurrence. In the 17 patients whose sarcomas were less than 10cm, 13 patients were resected with inadequate margin, and 5 had a local recurrence. The 5 and 10-year survival rate of the patients with the tumors over 10cm was lower than those with ones less than 10cm. The prognosis was poor in the 18 patients with a local recurrence. This indicates that local control of soft tissue sarcomas is important for improving their prognosis.
We presented a case of a 52-year-old woman who had an extensive malignant soft tissue tumor (MFH) in her left buttock treated with modified hemipelvectomy. This procedure allowed the large operative defect to be covered by a myocutaneous flap of the quadriceps femoris muscle and overlying skin and subcutaneous tissue. In addition, the upper part of the iliac wing was conserved. No wound problems were observed one month postoperatively and she was fitted with a Canadian prosthesis. This procedure provides a counterpressure for the external prosthesis, and a vascularized anterior musculo-cutaneous thigh flap decreases the risk of skin necrosis and wound problems.
Since the opening of Oita Medical College Hospital ten years ago, in 1981, 187 patients with bone or soft tissue tumors have been seen in our Orthopedic Division. Among eleven patients with osteosarcoma, three patients were diagnosed as having a periosteal osteosarcoma, low grade central osteosarcoma and extraskeletal osteosarcoma, respectively. Eight patients with conventional osteosarcoma were treated and four were still alived with no evidence of disease recurrence.
A clinical study was made of 4 glomus tumors in the knee treated between 1977 and 1991. Patients comprised 2 men and two women, ranging in age from 33 to 64 years. Time between onset and treatment ranged from 1-10 years. The most characteristic symptom of the glomus tumor is tenderness or pain of varying degrees. All 4 patients had either pain or tenderness with one exhibiting pain on touch and servere tenderness, and one had paroxysms associated with a change in the temperature, especially cold temperatures. Surgical excision was performed on all patients, with all symptoms relieved post-operatively. Histopathological examination showed that, 3 of the glomus tumors were of the vascula tvne and one was solid.
We examined the hip joints of 116 newborns, as a neonatal screening program, and five infants by ultrasonography from February to August 1991. The five infants included one postpurulently pathological hip dislocation (PHD), one acetabular dysplasia (AD), two congenital hip dislocations (CHD), and one juvenile rheumatic arthritis (JRA). Graf's method was used for all of them except the JRA infant. In the PHD infant, intracapsular scar formation could be visualized on a ultrasonogram, and was confirmed by operation. In two CHD and one AD infants, ultrasonography showed hip maturation, followed simultaneously by roentgenography. Diagnosis was difficult in the JRA case, because cardiac sonography showed intracardial effusion, whle the only symptom was monocoxalgia and ultrasonography couldn't demonstrate intracapsular effusion of the hip. Ultrasonography should be used as a neonatal screening procedure and a primary diagnostic tool because it is noninvasive and easily available.
We evaluated a group of children with spinal palsy to determine the incidence and sequellae of hip inatability. Eight children with spinal palsy occuring before the age of thirteen years were followed for a mean of 10.5 years (range 2-17 years). One child had spastic cervical spinal palsy and the others had flaccid thoracic spinal palsy. All patients had complete palsy and were non-ambulatory. Radiographic determination of instability was made using Reimers' migration percentage. Five of these pstients (63%) developed subluxation in unilateral hips and they were all flaccid. Pelvic obliquity, scoliosis and hip contracture were present in all patients with subluxated hips. At final follow-up, none of the patients with subluxated hips, who were all nonambulatory, had physical problems related to the hip disesse.
The inbalance of muscles surrounding the hip in myelomeningocele patients causes an unstable hip. We performed posterolateral iliopsoas/psoas transfer in 19 unstable hips of 14 patients, all with level three Sharrard neurological deficits. Their progress was followed for more than three years after surgery. At follow-up, 12 hips were well contained, 4 hips were subluxated, and 3 hips dislocated. In many cases, CE angle was increased after surgery, but in cases with highly dysplastic hips, acetabular dysplasia remained after only iliopsoas transfer was carried out. We recommend psoas transfer combined with pelvic osteotomy for patient with a highly dysplastic acetabulum.
we reviewed 52 cases (66 hips) of Charnley low friction arthroplasties which were followed for 10 to 20 years (average 12.4 years). Age at operation ranged from 33 to 77 years (average 54.9). The average pre-operative and post operative JOA scores were 44.3 and 75.7 points respectively. The rate of revision surgery was 6% at 10 years and 35% at 15 years after primary total hip replacement. During this period of follow-up, problems such as deep infection (3 hips), dislocation (3 hips), femoral shaft fracture without loosening (2 hip), with loosening (1 hip), breakage of the stem (2 hips), breakage of the socket (2 hips) were found. Potential failure and reoperation were needed in 14 patient, ten years after primary surgery due to mechanical causes. Of these 14 cases, five were stem components, eignt socket components and one involved both components. Causes of potential failure of the operation included over reaming of the acetabulum, varus position of the stem, existence of the pilot hole and aggressive granulomatous lesions of femoral bone. In this follow-up series, patient age and socket angle were not associated factors. Over reaming of the acetabulum was the principal cause of loosening, thereby resulting in poor results ten years after surgery.
We reviewed 25 patients (26 hips) who had received a Charnley low-friction arthroplasty dunring the period 1974 to 1981. Average age of the patients was 58.5 years, and clinically the average JOA score was 78.3, at the time of last follow-up which was an average 11.5 years after surgery. Radiologic assessment of the socket (using Charnley's method) and the stem (Nagaya's method) at the time of last follow-up showed 11.5% of the hips to be Grade 4 (of the socket) and 7.7% were Grade 4 (of the stem). The survivorship rate (Kaplan-Meier method) was 91.0% in the socket and 96.2% in the stem. The average rate of socket wear was 0.10mm per year. Revisions were performed in one stem 7 years after surgery and another, socket and stem, 14 years after surgery.
The results of 111 Charnley and Charnley-Müller total hip replacements were reevaluated a minimum of ten years postoperatively. Data was available on 65 cases, 46 of which were by personal examination and 19 by questionnaire. Twenty cases required revision surgery. Reasons for this were, the loosening of the femoral component in ten cases, loosening of both the femoral and acetabular component in four, recurrent dislocaction in one, and fracture of the femoral shaft in three. There was a significantly higher incidence of revislon suragery in patients who had a Charnley-Müller prosthesis and who were younger than sixty years of age. Roentgenographic loosening of the femoral component was recognized in all revised hips. In non-revised hips, loosening of the femoral component was seen in 39.3%, while loosening of the acetabular component was only 14.3%. Valgus, more than 50 degrees, of the socket and poor packing of cement of the femoral component significantly influenced the incidence of loosening, whereas body weight and status of the contralateral hip were not shown to influence loosening. Since loosening of the femoral component seems unavoidable with revision surgery necessary in sone patients, we advocate using a cementless prosthesis to preserve bone stock allowing revision to be performed without difficulty.
110 Müller total hip replacements (THR) were performed in 90 patients between July, 1974 and April, 1980. Twenty-one patients with 26 arthroplasties had been revised for various reasons. Seventeen patients had died and 20 patients were lost to follow-up. The remaining 32 patients with 38 arthroplasties were reviewed minimum of ten-years post-operatively. The average JOA score was 66 points (range, 51 to 94). Follow-up radiographs showed a 57.9 per cent incidence of loosening of the acetabular component and a 15.8 per cent incidence of the femoral component according to Nagaya's x-ray assessment.
Seventy-one total hip replacements in 65 patients were performed in our elinic between 1973 and 1981. Fifteen these patients had died from causes unrelated to the arthroplasty and another 18 patients had been lost to follow-up. After excluding one Charnley arthroplasty case, there remained 31 patients who had 35 Charnley-Müller THR were followed up. Revision surgery was performed on 5 hips (14.3%), because of loosening in three, infection in one, fracture of the femoral shaft in one case. The average score on the JOA hip-rating scale increased from 51.7 points preoperatively to 78.1 postoperatively. Five years after surgery, the average score increased to 78.7, but at the time of last follow-up (mean: 13 years 9 months) it had decreased to 68.9. Good results continued five years after surgery. X-ray evidence of loosening was seen in 29.4% of the acetabular component and 11.8% of the femoral component. In spite of the low hip score and loosening seen on X-ray, the majority of patients were satisfised with the result of their THR. The signifcant difference between good and poor cases can not be explained by age, weight, original disease, occupation or X-ray finding.
From 1976 to 1981, 43 total hip replacements had been perfomed in 35 patients in our clinic. Of these, we were able to follow 17 joints in 13 patients for more than 10 years. Clinical assessment using the JOA hip score and radiological assessment using Nagaya's method were carried out pre and post-operatively. The incidence of a clear zone was 80% on the acetabular side and 82% on the femoral side. The rate of loosening of stage III and IV was 42% on the acetabular side and 53% on the femoral side. The revision rate was 29%. The average JOA hip score at 5 years was 84 points, decreasing to 75 points at 10 years. JOA hip score results were comparatively better than that of X-ray findings.
We clinically and radiographically evaluated 116 total hip replacements with an average follow-up period of 12.8 years. According to the J. O. A. hip score, 42 hips were excellent, 16 hips were good, 20 hips were fair and 24 hips were poor. Fourteen hips required revision surgery. Thirty sockets (25.9%) and seven stems (6.0%) showed loosening, with both componnents loose in ten hips (8.6%). Satisfactory (excellent, good, fair) results were achieved in 76.5% of hips. However, radiographical loosening occurred in 40.5% of hips.
Two cases of idiopathic transient osteoporosis of the hip were examined by MRI, which showed a low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image at the affected femoral head. As symptoms improved signal intensity normalized. One patient was also examined by DPX which showed a low value bone mineral density at the affected area. This also gradually normalized as symptoms improved. MRI and DPX were both useful methods for diagnosis and follow-up of idiopathic transient ostepoprosis of the hip.
Osteochondritis dissecans (OCD) of the hip is a relatively rare condition which is usually treated conservatively although there have been a few reports of surgical treatment for this condition. We report two cases of OCD. Who were treated surgically. OCD developed in the first case as a late complication of congenital dislocation of the hip, and in the second, following Perthes disease. In the first case, a 15 year-old female, a small fragment was observed at the lateral part of the femoral head away from the weight bearing area and was excised leaving a defect of the cortical margin. In the second case, a 32 year-old female, two segmented large fragments were seen at the center of the weight bearing area of the femoral head and were fixed onto underlying bone with several cortical bone pegs. Radiologically, the cortical defect of the femoral head had remodelled to a smooth contour 12 years after excision and the fixed large fragments had established complete bone union 2 years post-operatively. Clinical results of these surgical treatments showed that not only was there good improvenent in the restricted range of motion of the involved hips but pain was also diminished. The overall good results in these two patients indicates that surgical therapy should be considered in OCD of the hip.
The results of open reduction of the severely slipped capital femoral epiphysis are reviewed for 6 hips. All cases of acute on chronic slip achieved good clinical and radiological results. We feel that a safe anatomical reconstruction by open reduction of the epiphysis is the best way to avoid hip deformity in adolescence and prevent the development of osteoarthritis of the hip in later life. The greater incidence of avascular necrosis is probably due to damage to the blood supply of the head at the time of the acute slip or kinking of the vessels before replacement. Accordingly we have tried selective angiography of the femoral medial circumflex artery to improve treatment and postoperative rehabilitation.
This study was designed to identify the change in radiological shape of the pelvic cavity caused by sagittal pelvic inclination and to learn the correlation between inclination and progression of osteo-arthritis (OA) of the hip joint. As a preliminary study, antero-posterior (AP) and lateral radiographs of 10 bleached pelves were taken simultaneously in seven different sagittal tilt angles. The degree of sagittal tilt of the pelvis (A) was then compared to the longitudinal: transverse axis length (L/T) ratio of the radiological shape of the pelvic cavity in AP radiographs. This study revealed a linear relationship between the two parameters that led to the equation: A=-67.0°×L/T+55.7° in males and A=-69.0°×L/T+61.6° in females. Using this the sagittal pelvic tilt can be calculated from the radiological shape of the pelvic cavity. Applying this equation to pelvic radiographs of 212 patients; 52 normal hips and 160 with OA hip of varying severity, pelvic tilt was calculated to investigate whether it relates to the aging of the patient or involves progression of OA. There was a significant correlation between age and pelvic tilt angles of patients in both normal and OA hip groups; the pelvis tended to incline posteriorly with increasing age. Further studies are required to elucidate the participation of the pelvic inclination on progression of OA of the hip.
This study analyzed clinical, radiological, and histological features of rapidly destructive coxarthrosis (RDC). Nine cases, most of whom were elderly females, were studied. Clinical examination revealed that 5 cases had some immunological abnormalities and 6 cases had minor trauma at onset. Radiologically, all casess demonstrated osteoporosis in the femoral head. Histological results showed osteonecrosis of trabecular bone in the femoral head and synovitis.
We clinically and roentgenologically reviewed 14 patients who had unilateral curved varus osteotomy following Chiari's osteotomy and 11 patients (12 joints) who had curved varus osteotany performad following the shelf operation. All operations had been performed a minimum of three years preuvously. Results were as follows: 1. Clinical evaluation using the Japan Orthopedic Association's criteria was excellent in both groups. 2. Shortening of the leg length following curved varus osteotomy was 4.7mm on average (Range: 0-10mm). 3. The collodiaphyseal angle of the femur decreased from 152 to 121 degrees on average. 4. The distal femoral bones shifted 6.3mm laterally average (except 3 Joints).
Seventeen patients with severe coxarthrosis were treated by THR (cemented Harris type) with a mean follow-up period of five years and eleven months. The JOA score of 35.4 points to improved from a preoperative mean a postoperative mean of 77.4. Radiographic evaluation of the THR resulted in a mean score of 1.41 points. The average angle of inclination of the acetabular component was 29.4°, with a CE angle of 61.8°, indicating that the acetabular componednt was positioned as planned. By using clear indications, and accurate operative technique we achieved satisfactory results in all our patients treated with THR.
We attempted to surgically treat collateral ligament injuries, especially if the patient was a teenager. In our experiments, the calcaneofibular ligament often ruptured at the end of the calcaneus side, on the anterior talofibular ligament and the calcaneofibular ligament injury. The calcaneofibular ligament is sometimes accidentally pulled out under the inferior peroneal retinaculum. In such cases, peroneal tenosynovitis may occur after anatomical repair of the calcaneofibular ligaments. We believed that the anterior talofibular ligament was the most important stabilizer of the ankle joint, so therefore transferred the calcaneofibular ligament to the capsule where the anterior talofibular ligament was attached, in order to provide reinforce nent. Six patents were in the study, and compared to two other groups; One in which the calcaneofibular ligament was intact, another in which the calcaneofibular ligament was neglected. No remarkable difference was seen among the three groups, but the instability improved more in the group in which we transferred the calcaneofibular ligament. These results indicate that this operative technique is useful for treatment of ankle ligamentous injuries.
Twenty-eight patients treated nonoperatively for injuries to the lateral ankle ligaments were seen at follow-up after 11-76 months (mean 2.9 years). Residual symptoms were present in 50 per cent, mainly in the form of functional instability, and recurrent sprains had occurred in 36 per cent. Sports performance level was down in 60 per cent of patients who had functional instabiliby. Reccurrent sprains related to the angle of anterior axis and low joint surface of the tibia, and were unrelated to the degree of primary talar tilt and anterior talar displacement.
Six elderly patients with degenerative painful ankle joints were operated on with arthrodesis of the talo-fibular joint. Average age at operation was 61 years. As well as conventional operation methods, with or without tibial sliding bone grafting, the medial and lateral malleoli were fixed firmly to the talus by loop wiring. Bony fusion of ankle joints was achieved in 8 to 12 weeks post-operatively, with solid, stable and painless ankles obtained in all patients. Clinical outcome was excellent, even allowing Japanese-style sitting. The authors emphasize that arthrodesis remains a method of choice for the treatment of the painful degenerative ankle joint.