When treating the slipped capital femoral epiphysis, it is important to evaluate the head-shaft angle and the direction of the slipped femoral head. We have made laser lithography models of the slipped capital femoral epiphysis to recognize the exact shape of the hip joint. In this report we demonstrate using two cases the advantage of using this method in the treatment of this disease. Case 1: Y. O., an eleven-year-old boy with a chronic slipped capital femoral epiphysis. His head shaft angle was 55-degrees. We employed transtrochanteric rotational osteotomy of the femoral head. Case 2: an eleven-year-old boy with an acute episode of this disease. His headshaft angle was 30-degrees after traction. The epiphysis was fixed with two canulated pins. We demonstrated the advantage of this method in performing an osteotomy or in situ pinning. When carrying out an osteotomy, we could decide the degree of rotation and direction by using the laser lithography models. This method was useful when carrying out in situ pinning because it allowed us to evaluate the position and direction of pins.
We reviewed the results of 13 intertrochanteric varus or valgus osteotomies performed for secondary osteoarthritis of the hip. We treated them using the modified Ueno method. The average age of patients with varus or valgus osteotomy at operation was 40.5 years and they were followed up for an average of 68 months. The mean postoperative J. O. A. score of patients with varus or valgus osteotomies was 84.5 points. At the latest evaluation 85% of the patients were judged as good or excellent according to the J. O. A. score. Two patients with varus osteotomies achieved poor results. The causes of the poor results were pre-operative indications and surgical technique. We found that valgus osteotomy with acetabuloplasty was effective even for treating severe degenerative changed arthritis (advanced stage) of the hip.
We compared the short-term post-operative results of rotational acetabular osteotomy (group of RAO) and Chiari pelvic osteotomy with Transtrochanteric curved varus osteotomy (group of Chiari varus) in the treatment of the osteoarthritic hip joint. Assessment was made at 4 weeks, 12 weeks, 6 months and 1 year after surgery to compare the influence of operative technigue on, ROM, MMT, time to start walking hospitalisation, JOA score and radiographic evaluation. In regard to the amount of blood loss the Chiari varus group was superior to the RAO group. Regarding MMT, time to start walking hospitalisation and radiographic evaluation the RAO group was superior to the Chiari varus group.
A retrospective study was performed on 8 hips in 6 consecutive patients with avascular necrosis of the femoral head. Avascular necrosis of the femoral head was induced by alcohol abuse in 1 hip, trauma in 3 hips, and steroid intake in 4 hips. Each patient was treated by Sugioka's transtrochanteric rotational osteotomy of the femoral head. In 5 of the 8 hips, varus osteotomy of the femur was simultaneously performed at the time of transtrochanteric rotational osteotomy. With an average follow-up of 1 year after Sugioka's transtrochanteric rotational osteotomy, seven hips showed good or excellent results. The remaining one patient had postoperative hip pain, although collapse of the affected area was not demonstrated on the recent radiographs.
Twenty-eight patients with coxarthropathy treated by arthrodesis were evaluated radiologically (position of the fused hip and changes in adjacent joints) and clinically (pain, gait and ADL). Mean follow-up period was seven years and eight months. Average postoperative hip position was 21 degrees in flextion and 2 degrees in abduction. There was no significant influence of the fused position of the hip on the adjacent joints. Twenty-six patients (93%) who demonstrated complete fusion gained significant improvement in pain and gait, and were able to return to their jobs. Hip arthrodesis provides an attractive alternative method for selected young individuals with severe hip disease.
We designed a new method. to assess the three dimensional “combined” range of motion (ROM) of the hip joint. With this method, ROM is expressed by the movement of the distal end of the femur on the sphere, whose center is the femoral head, with a radius of the length of the femur. In this report, we measured the ROM of 37 abnormal hip joints (21 osteoarthritis, 9 osteonecrosis, 3 slipped femoral epiphysis, 4 progressive pseudo reumatoid dysplasia) with this method. Abducti on in flexion tended to be limited in the early stage of osteoarthritis and osteo necrosis. Abduction and adduction were severely limited in progressive pseudo reumatoid dysplasia.
This report concerns a rare case of piriformis syndrome caused by synovial osteochondromatosis of the hip. The patient involved was a 67-year-old female who visited our hospital complaining of left hip joint and buttock pain. On examination she had a positive sign of Pace and sign of Freiburg. The findings on straight-leg-raising and all other radicular provocation testing were negative. Preoperative MRI suggested that the obturatorius externus muscle and its surrounding region were inflammatory. Injection of a local anesthesic at the site of a trigger-point over the muscle temporarily alleviated the symptoms. Based on the above findings we diagnosed the patient as having piriformis syndrome and performed surgery. The sciatic nerve was found in its normal anatomical location and the nerve itself appeared normal. However, a part of the nerve was flattened. An incision was mede in the piriformis muscle. The hip joint capsule was swollen and we incised the capsule. Many intraarticular free bodies were removed from the hip joint. We concluded that bulging resulting from osteochondromatosis of the hip caused the piriformis syndrome. After surgery, clinical symptoms disappeared.
Between 1993 and 1994, twenty-six hip arthroplasties were performed on 25 patients using the Impact Modular Hip System. This system maintains the entire femoral neck by allowing the resection to be made at the head/neck junction. By saving the femoral neck, minimal bone is removed. It also permits the entire implant to rest within the neck region where it can obtain unsurpassed rotational stability and transfer physiological load along the trabecular path. Preoperative diagnosis was osteoarthritis of the hip in 19 hips, avascular necrosis of the femoral head in 2, and miscellaneous in 5. The JOA hip score averaged 56.5 points before surgery. The average age of the patients at the time of surgery was 62.5 years, ranging from 42 to 85 years. Postoperatively, there were no major complications such as postoperative infection or dislocation. All patients were followed for more than 4 months (mean 10.4 months). The JOA hip score averaged 89.4 points after surgery. More than 80% of the hips were rated as having an excellent or good result and there were no poor results.
We studied changes in the femoral shaft after femoral endoprosthetic replacement from the viewpoint of bone remodeling. We evaluated 39 hips followed-up for 6 months to 6 years and 1 month. The width of bone, medulla and cortex were measured at the end level of the stem on each radiograph taken after surgery and after over 6 months. Changes were classified into 6 types of bone remodeling according to Iwasaki's classification. The types (TYPE I, IV) in which the cortex was thickening were frequently detected as having an unstable stem. Stress and minor mobility of the stem-end due to ustability may have caused bone remodeling which controled resorption of bone in the endosteum and promoted formation of bone in the periosteum. Thin cortex and enlarge-ment of the medullary cavity in type V was caused by aging and osteoporosis. It was assumed that this change in bone remodeing coutribute to progression of the unstable stem and sinking of the stem in the femoral shaft.
We performed cementless total hip arthroplasty (THA) with bone grafting for acetabular dysplasia in 30 hips since 1988 and reviewed these radiographically. The average period of follow-up was 4 years (range 1.2-6 years). The average age at operation was 53 years (from 33 to 77). The grafted bone was united in all cases and the mean resorption rate was 12.0% at the time of final observation. In 25 hips (83%), a reactive line at the interface between the socket and acetabular grafted bone was observed. The types of radiographic fixation were classified according to Ehgh et al.'s criteria as follows; optimum fixation in 23 hips, suboptimum fixation in 5, and unstable in 2. In cases in which the area of the socket covered by acetabular host bone was large, there was a high incidence (88%) of optimum fixation. These results suggest that adequate ingrowth of bone is difficult to obtain between the socket and grafted bone in cementless THA.
From 1983 to 1984, we performed 6 total hip arthroplasties in 6 patients. Of these, we were able to follow 5 joints in 5 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 rate of loosening of stage III and IV was 40% on the acetabular side and 60% on the femoral side. The average JOA hip score at 5 years was 74 points, decreasing to 71 points at 10 years. JOA hip score results were comparatively better than that of X-ray findings.
Twenty-seven patients (27 hips) received revision of total hip arthroplasties from 1985 in our hospital. Seventeen of these cases which could be followed for over six months were evaluated using the JOA score and roentgenologic criteria. All cases showed over 70 points on the JOA sore. According to the roentgenologic criteria, results are as follows; 1) Twenty-five % of the revision with cement showed Grade III and Stage III (Charnley's and Nagaya's criteria). 2) Forty % of the cup components and 10% of the stem components of the cementless revision proved to be unstable. 3) Four cementless cases were unstable at first, but proved to be stable at the follow up. Roentgenologic assessment is more sensitive than clinical evaluation to examine the result of the revision hip arthroplasties.
To investigate magnetic resonance (MR) imaging of anterior cruciate ligament (ACL) tears, the authors retrospectively reviewed 39 MR imaging examinations in 39 patients. We classified the MR imaging patterns of the torn ACL into four types. Torn ACL appears as a homogeneous iso-intensity mass on Type I images; as a continuous thin and waving low-intensity band with or without high-signal-intensity spots on the Type II images; as a disrupted band with a high-signal-intensity area on Type III images and as an absence of the ACL on Type IV images. We also report secondary lesions on MR imaging findings associated with tears of the ACL, posterior cruciate ligament index and bone bruising, in our patients.
Most of the examinations for diagnosing recurrent anterior shoulder dislocation are invasive, however MRI is non-inasive, and is widely used recently. Pre-operative MRI of 20 patients (15 males 5 females) with recurrent anterior dislocation of the shoulder were investigated. All cases underwent arthroscopic examination followed by modified Bristow's operation. SET 1 and MPGRT2* weighted images were obtained in the horizontal and scapular coronal planes of the shoulder (signa 1.5 Tesla MRI). We evaluated MRI findings on the Hill-Sachs lesion and Bankart lesion and then compared these with arthroscopic and operative findings. MRI showed 14 with Hill-Sachs lesions, and 6 without it. However arthroscopic examination revealed 12 out of 14 Hill-Sachs lesions, in 2 cases the lesions could not be clearly observed, and in cases without Hill-Sachs lesions, 2 cases had false negative findings on arthroscopy. The sensitivity of MRI in the diagnosis of Hill-Sachs lesions was 86% and the specificity was 100%. Regarding the Bankart lesion, MRI showed 18 positive and 2 negative cases. However, at surgery 17 had Bankart lesions and 3 cases did not have the lesion. Which means one false positive case was diagnosed by MRI. The sensitivity of MRI in the diagnosis of Bankart lesions was 100% and the specificity was 67%. We divided the Bankart lesion cases into three groups; defect of labrum, avulsion or tear of labrum and honey Bankart. From MRI findings there were 9, 7, and 2 cases respectively. Defect of the labrum and honey Bankart coincided with operative findings. However, in the avulsion or tear group, 4 showed avulsion or tear, 2 had defect of the labrum and the remaining one showed no abnormality.
MRI is very useful for diagnosis of rotator cuff tears. In this study, we compared MRI findings with operative findings. 43 patients who underwent MRI investigation before operation were chosen for this study. There were 40 males and 3 females, ranging in age from 30 to 77 years (mean: 53.8 years at the time of surgery). MRI was performed with a 1.5T superconductive system with shoulder surface coil. MPGR T2*-weighted images were performed in the coronal oblique plane and sagittal oblique plane. The size of the tear was measured in both planes. Out of 43 patients, the operative findings confirmed complete tears in 36 patients and partial tears in 7 patients. On the other hand, MRI showed complete tears in 34 patients, partial tears in 8 patients and tendinitis in one patient. MRI demonstrated 91.7% sensitivity, 85.7% specificity and 90.7% accuracy in the diagnosis of complete tears. Linear regression analysis showed an excellent correlation between MRI assessment and the size of the complete tear at operation on both planes (r=0.70, 0.89). However, in 4 cases MRI was misinterpreted which may have been due to the very tiny size of the tear. MRI provided very useful pre-operative information regarding the size and site of rotator cuff tears.
The capability of magnetic resonance imaging (MRI) to visualize degenerative changes of the hip was retrospectively investigated in 38 hips of 27 patients. Comparative assessment was made between changes of MRI and histological findings. Subchondral cysts produced low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in the early stage of degeneration, while those in the advanced stage of degeneration caused low signal intensity on both T1-and T2-images. At the end stage of degeneration, subchondral cysts showed the same signal patterns as those in the early stage of degeneration. Osteophytes of the acetabular roof demonstrated low signal intensity on both T1-and T2-weighted images, whereas capital drop of the femoral head caused a high signal intensity on both T1-and T2-images. Histological study showed thickened trabeculae in the osteophytes of the acetabular roof and proliferation of fatty tissue in the area of the capital drop of the femoral head. Hyaline cartilage of the joint showed an intermediate signal intensity on T1-weighted images. The intermediate signal intensity deteriorated in proportion with the progression of degeneration.
In 85 patients with anterior cruciate ligament (ACL) rupture, we examined bone bruises retrospectively using magnetic resonance imaging (MRI). In 53 patients who underwent arthroscopy, the bone bruises were compared with the cartilage lesions. Depending on the time from their ligamentous injury to the performance of MRI, the patients were divided into three groups: the acute group (less than 1 months, n=29), the subacute group (between 1 and 12 months, n=29), and the chronic group (12 months or more, n=27). The detection rate of bone bruises by MRI was significantly higher in the acute group than in the other groups (p<0.0001). Bone bruises were always detected in the same locations of the lateral compartment of the knee joint. In four patients who observed bone bruises in the first MRI and underwent follow-up MRI 3-6 months later, bone bruises had disappeared in the follow-up MRI. In the acute group, bone bruises in the lateral femoral condyle were often found to be accompanied by cartilaginous injuries. In the subacute and chronic groups, the rate of degeneration of these cartilaginous lasions had progressed.
Improvement of quality of life (QOL) of patients with rheumatoid arthritis (RA) is very important. There are many scales to assess QOL, but we have had no specific Japanese individual QOL measurement. MIZU is a specific Japanese individual QOL measurement scale which was developed by the Ministry of Health and Welfare in 1994. This study was designed to explore the QOL in 40 patients with RA using Version 2 of the Arthritis Impact Measurement Scale (AIMS2) and MIZU, and the correlation between AIMS2 and MIZU. AIMS2 is a revised and expanded version of the original Arthritis Impact Measurement Scales Health Status Questionnaire in 1992. MIZU correlated highly with AIMS2 (r=0.67, p<0.01). It takes approximately 12.5 minutes to complete MIZU which is a very short time compared with AIMS2. We conclude that MIZU is a conventional and useful Measurement Scale to evaluate QOL of patients with RA. But we did not refer to its reliability and its validity in this study. We think that these aspects should be inveshgated in a further study.
Clinical correlations with IgG-rheumatoid factor (IgG-RF) were evaluated in 41 patients with rheumatoid arthritis (RA). The patients with positive IgG-RF with disease duration of less than two years showed increased levels in ESR, C-reactive protein, serum IgG concentrations and Lansbury's index, but they had neither extra-articular disorders nor vascular damage. However, four of eight patients with positive IgG-RF with disease duration of over five years had extra-articular disorders and vascular damage (especially interstitial pneumonia). In one early RA patient with positive IgG-RF who showed decreased levels of ESR and C-reactive protein and serum IgG concentrations, a high titer of IgG-RF was revealed over six months and joint damage progressed. In conclusion, we suggested that measurment of IgG-RF is useful in the clinical evaluation of rheumatoid arthritis associated with extra-articular disorders, vascular damage, and joint damage progression.
73 patients with classical RA were studied according to their roentgenographic joint changes. 63 of the patients were women and 10 men ranging in age from 30 to 85 years, with an average of 57 years. The duration of disease varied from 2 years to 38 years (average, 11 years and 7 months). Effects on joits were influenced by all anatomical features. In regard to antinuclear antibodies, the homogeneous type was most frequently detected and two cases had detection of anti-centromere antibodies.
The Sauvé-Kapandji procedure was used in wrist synovectomy in 20 patients (25 hands) with rheumatoid arthritis. Subjects comprised 15 women and 5 men, with age at the time of surgery ranging from 21 to 74 years (average 46.7 years). They were evaluated from 1 to 12 years (average 3.4 years) after the operation. One case suffered from ossification at the pseudarthrosis site and three exhibited click at the distal end of the ulna. The hand grip strength was higher at the final evaluation than preoperative value. Post operative range of wrist dorsi flexion was reduced compared with the preoperative score. However, supination values were significantly improved after the operation. Radial rotation, ulnar drift, ulnar shift, and carpal height ratio were measured roentgenologically showing no significant change within the follow-up period. We concluded that the Sauvé-Kapandji operation is a valuable procedure for wrist synovectomy in patients with rheumatoid arthritis.
Tendon rupture in rheumatoid arthritis is ceused by invasion of rheumatoid granulation into the tendon structure, mechanical pressure on it by anatomical irregularities and emaciation due to tenosynovitis. We experienced two cases of subcutaneous rupture of flexor pollicis longus in the rheumatoid hand. The first case was a 72-year-old woman and the second was a 60-year-old woman, with substantial functional loss of her thumb. They were treated with synovectomy and tendon grafting using the palmans longus tendon. Hand function in the first case is not adequate, while the second case has good function. Tension of the grafted tendon and abnormities of adjacent arthroses were reasons for the poor result in first case.
The effects of estrogen replacement therapy on bone mineral density (BMD) and the incidence of low back pain in post-oophorectomized women were evaluated. BMD of the lumbar spine was measured using dual energy absorptiometry (Lunar DPX) in 23 patients who had developed artificial menopause due to oophorectomy. The average age of patients was 44.8 year-old. 17 patients had been treated with estrogen replacement therapy. Lumbar BMD of 23 healthy women (average age: 46.6 years) was measured and served as a control group. There were no significant differences in lumbar BMD between the estrogen treated group and control group. Lumbar BMD in the estrogen non-treated group was significantly lower than in the estrogen treated group and control group (p<0.05). Incidence of low back pain was significantly lower in the estrogen treated group than in the estrogen non-treated group (p<0.05). We concluded that estrogen replacement therapy significantly decreases bone loss and prevents an increase in the incidence of low back pain.
Occassionally we meet patients who have received inadequate treatment. In our hospital, patients are first examined 1st year or 2nd year trainees, therefore we investigated the features of missed fractures and how to diminish the number of these and how to salvage the patients. From January 1993 to July 1994, 8, 490 patients with trauma came to the emergency center in our hospital. Among these patients, 169 people were questioned as possible missed fractures or inadequate treatment and were re-evaluated. The following results were found: 1. Elbow fractures were missed frequently. 2. The features of missed fractures were minimal displacement, small fragments, unclear fracture lines. 3. Inexperience of examination and ability of reading films. 4. Orthopaedic specialists and radiologists read the films; staff call the patients who were doubtful about missing fracture. 5. It is necessary to have feedback for trainees.
Twenty-six cases with displaced fractures of the distal end of the clavicle (Neer type II) were treated surgically. All cases except one had almost full range of motion at the shoulder joint. Three cases treated with kirschner wiring or tension band wiring had loosening of the wire. Three cases treated with Bosworth's method had loosening of screws. All cases achieved bone union. If the patient is old and the distal fragment is comminuted, it is better to use a combination of several methods for internal fixation.
We have previously reported internal fixation of the middle third of the clavicle using a cancellous cannulated screw. However we have found some disadvantages associated with this, and have therefore developed a new improved cannulated clavicle screw. The main difference in this screw is that there are pitches on both sided of the screw to prevent shortening of the fractured clavicule.
Twelve patients with humeral shaft fractures repaired by intramedullary fixation were evaluated retrospectively We report on our experience of intramedullary fixation for humeral shaft fractures. The mean age of patients studied was 49 years (ranging from 19 to 73 years). Mean follow-up period after surgery was 20 months ranging from 9 to 45 months. We used Ender nails in 10 cases and Rush pins in 2 cases. We preferred to use the distal rather than proximal approach, because painful adhesive capsulitis of the shoulder occurred more often with the latter. We also used a functional brace after surgery. Post-operative clinical results were good in all cases, especially in those with the distal approach. In conclusion, intramedullary fixation using the distal approach for treatment of humeral shaft fractures is useful and allows early mobilization.
Three patients with missed Monteggia fractures were treated by corrective of the ulna. Results were evaluated using the JOA elbow elbow evaluation sheet, and rated as excellent in two, and poor in one. The poor case was a 14-year-old male. The period from injury until operation was one year and three months, and post-operative redislocation of the radial head occurred. Four months after surgery, he was treated by resection of the radial head. Preoperative X-ray films revealed osteoarthrosis, but if we tried to lengthen the ulna by osteotomy to correct the deformity sufficiently dislocation of the radial head may be un avoidable. We emphasize that there should be complete resection of scar tissue in the radiohumeral joint and stability of the radial head at the radiohumeral joint should be confirmed during surgery.
Arteriovenous malformation (AVM) is classified as either congenital or traumatic (acquired) in origin. Most cases are congenital, with traumatic AVM relatively rare in Japan. About 30 traumatic AVM cases have been reported in the literature, only 5 (16.7%) of these cases were caused by blunt trauma. We surgically treated a blunttraumatic AVM of the forearm which existed in the flexor pollicis longus muscle and obtained a satisfactory surgical result.
In order to clarify limitations assouated with remodeling of angulated distal forearm fractures in children, twenty children who were treated for completely distal diaphyseal forearm fractures were clinically and radiographically reexamined. The median age at time of fracture was 8.6 years (range, four to twelve years old). The median follow-up time was 12.5 months (range, one to 67 months). For the radiographical evaluation, radial angulation and dorsal tilt were measured at the time of postreduction, healing and follow-up examination. In this study, it is suggested that the possibility of remodeling after distal forearm fractures is 16° of radial angulation and -30° of dorsal tilt in children younger than 11 years of age.
Twenty-eight elderly patients underwent central venous catheterization via the external jugular (EJ) vein before surgery. Plain chest X-P provided the position of the tip of catheter, and via the image of the catheter on film the confluent angle of the EJ vein into the subclavian vein was measured. The catheter was successfully positioned into the central vein of twenty-six patients (93.1%), excepting two patients who were found to have malpositioned tip entry. This success rate was much higher than any other previous reports. No complications accompanied the catheterization, such as accidental pneumothorax and carotid puncture. This data shows that our catheterization maneuver is safe and reliable. The confluent angle of the EJ vein into the subclavian vein ranged from 33 to 136 degrees, and the mean value was 78.6±29.5 degrees. The angles of eleven patients (37.9%) were more than 90 degrees, which means those EJ veins flowed into the subclavian vein from the brachial side. This data suggests that the lower success rate of this route via the EJ vein, compared with via the subclavian vein, was attributed to this anatomical variation.
Femoral neck fractures in young adults are generally said to have a poor prognosis because of high energy trauma. We investigated twelve patients (twelve fractures) less than 51 years of age. Patient's age age ranged from 18 to 50 years(mean 31.7 years), and there were 10 males and 2 females. The mean follow-up period was 4.7 years. Fracture type is Garden stage III; 1 fracture, Evans type 1 group A; 4, group B; 1, group D; 2, type 2; 1, and subtrochanteric fracture; 1 fracture. The clinical assement consisted of physical exarmination using the JOA hip score and radiographs. Bone union was achieved in all patients. No patient had necrosis of the femoral head. The average JOA hip score was 95.1 points (range; 83 to 100). We concluded that in this study the clinical results were most influenced by the complications and the type of fractures.
We have previously reported the usefulness of the Gamma Nail for Peritrochanteric femur fracture but have since noticed some problems. The device has been used clinically since September 1992 in a total of 41 patients, 26 patients of whom had the lag screw placed in the lower part of the head of the femur. These 26 patients were evaluated radiographicalk. Cases in which the Nail could only be inserted distally, and therefore the proximal end of the Nail projected out of the greater trochanter, despite the lag screw being placed in a good position. As a result, we considered that it was necessary to make the Nail shorter at the proximal end, as well as narrower at the distal part from the lesser trochanter to allow the lag screw to be inserted at a smaller angle.
We report on our treatment of 31 cases of fracture-dislocation of the hip, seen in our hospital between January 1984 and August 1994. There was no difference in results achieved following conservative treatment between whether the injury happened to the weight-bearing dome or not. Injury of the weight-bearing dome was associated with outbreak of osteoarthritis of the hip in those receiving surgical treatment.
We monitored the amount of radiation received by surgeons and assistants during surgery carried out with fluoroscopic assistance. The radiation was monitored with the use of MYDOSE MINIX PDM107 made by Aloka Co. Over a one year period from 20, 8, 1992 to 19, 8, 1993, a study was undertaken to evaluate exposure of the groin level to radiation with or without use of the lead apron during 106 operation. (Group-1) In another group radiation was monitored at the breast and groin level outside of the lead apron during 39 operations. (Group-2) In Group-1 the average exposure per person during one year was 46.0μSV and the average exposure for each procedure was 1.68μSV. The use of the lead apron affirmed its protective value; the average radiation dose at the groin level out-side of the apron was 9.11μSV, the measured dose beneath the apron 0.61μSV. The average dose of exposure to the head, breast at groin level outside of the lead apron, were 7.68μSV, 16.24μSV, 32.04μSV respectively. This study and review of the literature indicate that the total amount of radiation exposure during surgery done with fluoroscopic control remains well within maximum exposure limits.
We report on 176 femoral shaft fractures in 172 patients who were treated surgically. The series included 27 open fractures and 111 communited fractures. Intramedullary nailing was used in 127 femora (92 Interlocking nails and 35 Nolocking nails), Ender nailing in 43, and other procedures in 6. The union rate was 99.4%. Complications included one infection (0.6%). Shortening of more than two centimeters occured in 7 patients (4.0%) and malunion of more than 15 degrees was noted in 3 patients (1.7%). The best clinical results were found in patients treated with interlocking nails.
We report two cases of supracondylar fractures of the femur who were treated with total knee prosthesis and interlocking intramedullary nailing. A 69-year-old woman, who had suffered from rheumatoid arthritis, had difficulty in walking due to bilateral knee pain. We advised total knee replacement (T. K. R.). After that she suffered a supracondylar fracture of the right femur. At the same time that we performed T. K. R., we treated her with retrograde insertion of an interlocking intramedullary nail from the intracondylar femoral notch. A 67-year-old woman suffered a supracondylar fracture of the femur following T. K. R. twice before. She was twice treated with condylar tube plate but still developed another supracondylar fracture we performed retrograde insertion of an interlocking intramedullary nail.
Four cases with fractures of the distal end of the femur were treated by osteosynthesis using the Intramedullary Supracondylar Nail. In all cases, satisfactory results were obtained. This method provided stable fixation which allowed early range of motion of the knee joint, and relatively early weight bearing.
To clarify the factors affecting clinical results, 21 cases of tibial plateau fractures treated operatively in our hospital were reviewed. Mean post-surgical period of immobilization was 11.4 days, and the range of motion (ROM) of the knees recovered on average to 133.9 degrees flexion. In 16 cases a continuous passive motion system was used. In this group, a better range of motion was acquired than in the manually exercised group. Clinical results were evaluated according to the criteria proposed by Hohl and Luck. Every case achieved a good to excellent result. There was no correlation between age and final ROM, nor type of fracture and final ROM. On the other hand, longer immobilization periods tend to delay recovery of the ROM.
To document problems of operative treatment, we evaluated postoperative results of 30 patients with tibial plateau fractures. Patients included 17 males and 13 females, with a mean age of 49 years, ranging from 17 to 78. The average follow-up period was 15 months, ranging from 6 to 54 months. Following the principle of Hohl, there were 4 minimally displaced fractures, one with local depression, 9 with split depression, 3 with total depression, and 13 comminuted fractures. These patients were treated by open reduction and internal fixation with a cannulated cancellous screw, with a plate, or with a tibia bolt. According to the evaluation of Hohl & Luck, excellent and good results were achieved in 83%. Fair and poor results were seen in the split depression group or in the comminuted fracture group. These cases had a depression of more than 5mm in depth, located from the central to posterior region of the weight bearing area, except 2 miserable comminuted fractures. We think anatomical reduction of joint surfaces is most important, as mentioned by other investigators. However, it is difficult to verify posterior joint surfaces in common surgical approaches. We must take care to remember this point during open reduction.
Fifteen tibial fractures were treated by the Russell-Taylor interlocking nail system. Ages of patients ranged from 14 to 77 years with an average of 39 years. Fractures were classified according to AO as A2 in 5 cases, A3 in 3 cases, B2 in 4 cases, B3 in 1 case and C3 in 2 cases. The average time to union was 107.3 days (range: 59-225 days). The average time to full weight bearing gait was 46.9 days (range: 21-92 days). The R-T nail was found to function well in these patients. There were no infections, no malunions and no cases of nonunion. The present study suggested that the R-T nail is suitable for surgical treatment of tibial shaft fractures.
We studied the association between the type of external fixator and subsequent bone union achieved. During 1988-1994 we treated 15 cases (19 bones) of bone injury requiring an external fixator. These 15 cases were divided into a fracture group (11 cases, 13 bones), an osteomyelitis group, and a pseudoarthrosis group (5 cases, 6 bone). The type of external fixator used included orthofix, Ace-Fischer, Hoffmann, Mono-tube. Results for the fracture group were orthofix 6 cases, Ace-Fischer 3 cases, Hoffmann 3 cases, Mono-tube 1 case. Results for osteomyelitis; pseudoarthrosis group were orthofix 4 cases, Ace-Fischer 1 case, Hoffmann 1 case. Transverse fractures, and oblique fractures had an effect on primary bone union in the orthofix. Comminuted fractures had an effect on primary bone union in Ace-Fischer. Osteomyelitis, pseudoarthrosis had an effect on primary bone union in dynamization. External fixators are effective for helping bone union following fracture, osteomyelitis and pseudoarthrosis.
We reported a case of the large fibular defect caused by osteomyelitis of fibula of a 20 years old male. He was hospitalized with the fractures of tibia and fibula in another hospital because of traffic accident. He was treated by osteosynthesis of tibia and fibula but suffered the large defect of the distal fibula (8cm long) with the equinovarus deformity due to osteomyelitis. We lengthened the fibula and then corrected the equinovarus deformity but was difficult to reduct the anterior dislocation of talus because of the narrowness of the ankle joint. So it can be thought that correction of the deformitry should be considered first before lengthening the fibula.
Forty-three patients with malleolar fractures of the ankle were treated surgically. Fractures were classified into SER type, SA type, PER type, PA type as defined by Lauge-Hansen. The clinical results according to Burwell were good in 36 cases, fair in 5 cases, poor in 2 cases. Anatomical reduction significantly affected the clinical results.
For the treatment of calcaneal fractures, determination of the disruption of the posterior subtalar joint is important. Sanders proposed a new classification for calcaneal fractures based on CT findings in 1993. In this study, we evaluated the pre-operative cisruption and clinical results of 19 cases treated in our hospital prospectively, according to this classification. These cases were classified into 8 categories, 3 type I, 3 type IIA, 3 type IIB, 3 type IIC, 3 type IIIAB, 3 IIIAC and one type IIIBC. Those cases with minimal displacement tended to achieve excellent results. We recommend that the disruption of the posterior subtalar joint in calcaneal fractures should be determined based on CT findings.
Results of operative treatment with open reduction and internal fixation through the lateral approach established by Sclamberg, for calcaneal fractures was evaluated. Seven patients with calcaneal fractures (male 6, female 1, average age: 54 years, average observation period: 15 months) were treated surgically in our hospital since 1990. Types of fracture according to classification of Essex Lopresti were II-B (5) and II-E (2). To evaluate the roentgenological results, the critical angle and the CALCIS score were used. Moreover, clinical assessment was made using the score of Maxfield et al. The clinical angle and the CALCIS score improved from 36.5° to 14.9° and from 7.7 to 5.1 points, respectively. As a clinical assessment, ‘excellent’ and ‘very good’ were observed in 4 and 3 patients respectively. In addition, patients with greater improvement in their critical angle tended to have better clinical scores. We concluded that this procedure is a relatively easy technique and provides better results for intra-articular fractures of the calcaneus.
To investigate the mechanism causing calcaneal fractures, we reproduced the fracture using an experimental model. A specimen foot was obtained from a patient after a Syme amputation, and the soft tissue except for the intraosseous ligaments were removed. We hypothesized that the collision of the talus with the calcaneus when the ankle was inverted cause the calcaneal fracture. The tales was fixed to the calcaneus in extension-pronation-abduction position with Kirschner wires. The specimen was then put on a floor upside down. A ten kg-weight was dropped onto the heel from an 80cm height. Roentgenographic and CT findings revealed the fracture line observed in the specimen to be joint depression type III according to the classification by Essex-Lopresti, and type IIA by Sanders. In this experiment, we have succeeded in reproducing similar calcaneal fractures observed in clinical cases. We conclude that the injury of the subtalar joint contributes to cause a peculiar fracture line seen in this fracture, when the hindfoot is in inverted position.
The results of enbloc excision with bone graft in three cases of tibial osteofibrous dysplasia are reported. Two children were recurrent cases following previous treatment at another hospital with simple curettage and bone graft while they were under ten years of age. In all three cases, the tumor was resected with a semiwide margin, and the bone defect was reconstructed with a vascularized or conventional fibula graft. There was uneventful healing, and solid bone union was obtained without any disability in the lower extremity. In conclusion, enbloc resection combined with fibula grafting can eradicate this locally aggressive bone tumor, although longer follow-up should be continued.
We report on our experience of surgical treatment of a dysplasia epiphysealis hemimelica case. The patient was a 2 year 8 month old boy. On physical examination a nut sized, painless bony hard mass was palpable on the medial aspect of the right knee, which showed a valgus deformity. His right foot was planovalgus anad the head of the talus was palpable. A full range of motion was present at the knee joint, but plantar flexion of the right ankle was limited. The plain x-ray showed some accessory calcification centers on the inner aspect of the epiphysis of the femoral medial condyle, distal tibia, talus and navicular. We performed surgical treatment using excision of the mass for correcting the valgus deformity of the knee. Four months after operation, there was no reccurence of the valgus deformity. We review the literature and discuss the surgical treatment of this condition.