Radiological shape of the pelvic cavity reflects pelvic inclination. We investigated changes in the pelvic inclination of THRs (81 cases, 72 females and 9 males) in both the standing and decubitus positions. Ages ranged from 31 to 81 years (average; 65.4 years). Roentgenographic findings were measured using Doiguchi's approximate equation. In almost all cases the inclination was to the posterior with older aged patients even more prone to posterior inclination. It is important to evaluate roentgenographic findings not only in the decubitus position but also in the standing position.
The bipolar endoprosthesis (Hastings hip) operations performed in 41 hips between 1985 to 1990 were retrospectively reviewed. There were 31 cases of femoral neck fractures, 5 cases of aseptic necrosis of the femoral head and 5 cases of osteoarthritis. The mean age at surgery was 77.0 years (ranging from 65 to 87). The follow up period was 3.2 to 9.3 years postoperatively (mean 5.6 years). Preoperative complications were seen in 68.3% and the survival rate was significantly lower in such cases. The average JOA score was 81.0, while in osteoarthritic cases this was 74.6 showing a statistical difference between these two groups (p<0.05). The rate of survival, analysed according to Kaplan-Meier's method shows that the cumulative population was 91.2% after five years, declining to 80.2% ten years postoperatively. The Hastings hip system is more simple, reliable and cheaper than other bipolar prosthesis systems. We consider that the Hastings hip is a good choice for elderly patients with a femoral neck fracture.
Due to local bone loss, re-attachment of the greater trochanter is often difficult in revision total hip arthroplasty and pseudoarthrosis of the greater trochanter. We use the Dall-Miles cable grip system (DMCGS) for trochanteric fixation in 17 hips (ten hips with revision, five hips with T. H. R. and two hips with pseudoarthrosis of the greater trochanter). Post-operatively, the trochanter failed to unite in two hips, caused by failure of the position of the cable grip. In all other cases, good radiological and clinical results were achieved. Better results are obtained using the DMCGS in cases of trochanteric bone loss following hip surgery using trochanteric osteotomy.
From 1987 to 1993, 76 primary total hip arthroplasties (THA) with cementless porous-coated hip prostheses were performed in our hospital. Of these, dislocation after THA occurred in only 4 hips (5.3%). Many reports show that the factors which seem to influence dislocation after THA are acetabular cup position, femoral neck length, head size and position of the femoral head. We investigated the relationship between these factors and dislocation after THA. There was no significant difference between the presence or absence of dislocation after THA and these factors. This study suggested that the factors that were most likely to influence dislocation after THA were acetabular cup malposition and soft tissue weakness or imbalance.
Radiographic assessment was done to investigate outer head migration after bipolar arthroplasty in 44 osteoarthritic hips (35 patients). Bone graft was performed on the lateral edge of the acetabulum using resected femoral heads in 19 cases who had dysplastic acetabulae. There was a significant correlation at six months between CE angle and medial migration (r=-0.43, p<0.05). This indicates that the outer head placed with a smaller CE angle tends to move more medially. Reaming depth toward the acetabular fossa affected superior migration of the outer head. The mean superior migration of the outer head in the deeper reaming group (>6mm) is significantly greater than that in the shallower reaming group (<5mm). Thickness of the grafted bone correlated strongly with superior migration at 12 months (r=0.93, coefficient for slope=0.85). This result shows that the grafted bone did not act as a brake on the superior migration of the outer head.
Synovial osteochondromatosis (SOC) rarely occurs in the hip joint (4.8% reportedly). Three cases of SOC including an atypical variety are presented. In case one (32 year-old female), multiple loose bodies were revealed by the arthrogram, and extirpation of the free bodies and partial synovectomy were performed. Seven years postoperatively, osteoarthrosis is suspected. In case two (63 year-old female), erosion of the femoral neck and a synovial tumor were observed by MRI. The invasive chondroma originating from the synovia was confirmed as SOC by biopsy. Total synovectomy and bipolar endoprosthetic replacement were performed, and the patient was rated at ninety three points according to the JOA scoring system eleven months postoperatively. In case three (40 year-old female), enlargement of the femoral head with osteoarthrosis was observed with loose bodies. Total synovectomy and bipolar endoprosthetic replacement was performed, and the patient was rated as having ninety points by JOA scoring. Milgram proposed synovectomy in phase I for patients such as case one, or only extirpation of loose bodies in phase II for cases two and three. However, endoprosthetic replacement was indicated for advanced osteoarthrosis or for erosion of the femoral neck for the treatment of SOC, while synovectomy should be limited in SOC of the Hip joint.
Vascularized pedicle iliac bone grafts were performed on 13 hips (10 cases; 7 males, 3 females, mean 32.4 years) with avascular necrosis of the femoral head (ANF) and followed up 13.6±4.5 months after surgery. Seven hips showed no sinking after weight bearing, while 6 hips showed 1 to 5mm post-operative sinking. Among 6 stage 2 ANF caseo induced by steroids, 3 SLE hips advanced to stage 3 or 4 postoperatively, while only 1 hip advanced to stage 3 among 5 non-steroid induced stage 2 ANF hips. The average JOA hip score for 7 hips with less than 2mm sinking of the femoral head was 89.3, in comparison to 62.3 for 6 hips with sinking of 2mm or more.
From 1988 to 1992, 91 cases of high tibial osteotomy were performed using four types of internal fixation methods. Group A, consisted of 14 cases fixed by stapling. Group B, consisted of 24 cases fixed by plating located on the lateral side of the tibia. Group C, consisted of 17 cases fixed by lateral side plating in combination with medial side stapling. Group D, consisted of 36 cases, fixed by medial side plating in combination with lateral side stapling. Postoperative changes in the tibial-plateau-tibial-shaft-angle (TPTS) were measured. Decrease in TPTS of more than 2 degrees, was 28% in group A, 46% in group B, 47% in group C, and 0% in group D. This result indicates that medial side plating in combination with lateral side stapling should be recommended for internal fixation of high tibial osteotomy.
This study investigated the post-operation period required for lesions to become stable on radiographs following high tibial osteotomy for osteonecrosis of the medial femoral condyle. Eleven knees were studied regarding the lesion size on pre-operative radiographs and at three months and one year follow-up. Cases were classified into two groups according to post-operative changes. The radiographic lesion expanded in three cases (group A) and reduced in eight case (group B). In group A, expansion of the lesion were seen until 3 months post-operatively. In group B, lesion reduction was very slow and many cases occurred during three month to one year post-operative period. Most lesions did not change in size on radiographs one year after post-operatively.
we performed tibial condyle valgus osteotomy for 14 knees with severe medial osteoarthritis, and investigated 9 of these patients from 1992. Cases were evaluated in regard to their femoro-tibial angle, Mikulicz line and JOA score. Almost all patients achieved good results, and it was suggested that the operation indicated for treatment of severe medial osteoarthritis was High Tibial Osteotomy.
We performed a statistical analysis of patients who had interlocking wedge osteotomy for osteoarthritis of the knee in Kyushu University during 1980 to 88. Follow-up of patients was greater than five years and arthroscopic findings at the time of surgery were also evaluated. The result of the osteotomy was excellent with the JOA score increasing from sixty to eighty-six. Arthroscopic findings at surgery did not influence the result. Age at the time of operation, preoperative JOA score, post-operative mechanical axis, pain at follow-up and follow-up period did influence the result statistically.
Clinical results and treatment of open fractures of the lower legs were evaluated. Thirteen open fractures (in twelve patients) from 1991 to 1993 were treated at our hospital. None of the factures developed osteomyelitis. Only one patient who had a fracture of the fibula developed the complication of a deep infection in the fracture area. Recovery in the range of motion of eight fractures classified as Gustilo's Type III was inferior to the other cases. In the present series an external fixator was used in six fractures. Five of these fractures needed secondary skin grafts which were successful under the condition of the presence of the external fixator. In addition open fractures of the lower legs with soft tissue damage requires stable fixation to promote healing and decrease morbidity. The external fixator provides rapid and stable fixation, thus it is a feasible treatment for open fracture of the lower legs.
We studied the clinical results of skin grafts performed in 19 patients with soft tissue injuries of the lower limbs. In 15 cases, skin grafts were required in the below knee area. Split thickness skin grafts were performed in 13 cases, including six mesh skin grafts. Four full-thickness skin grafts, four pedicle flaps, and two peroneal island flaps were performed. They were classified into five categories according to the accompanying musclo-skeletal injuries, 3 cases without musclo-skeletal injuries, 3 cases with muscular injury, 2 cases with vascular injuries, 2 cases with closed fractures, and 8 cases with open fractures. In those with severe open fractures, grafting was required repeatedly to cover the large skin defects. Skin defects accompanying open fractures should be covered as early as possible to avoid infection, and minimize the functional deficit.
18 flaps including 9 free vascularized flaps and 9 pedicle flaps were used to cover traumatic skin defects of the lower extremity. All patients were male ranging in age from 3 to 64 years (mean 31 years). 9 vascularized flaps comprised latissimus dorsi flaps (4), lateral upper arm flaps (2), medial plantar flaps (2) and one groin flap. 9 pedicle flaps were made up of 2 medial plantar flaps, one gastrocnemius flap, one soleus flap and 5 other different flaps. 17 flaps survived completely. A reversed fasciosubcutaneous flap developed partial necrosis and required skin grafting. 2 free and 2 pedicle medial plantar flaps were used to cover the weight bearing area without developing a skin ulcer. Free flaps could cover any part of the lower extremity. Pedicle gastrocnemius flaps could cover the anterior aspect of the knee and proximal 1/2 of the tibia. Soleus flap could cover the middle 1/3 of the tibia. However, few pedicle flaps were able to cover large skin defects at the distal 1/3 of the tibia, where free flaps are indicated. Reversed flaps may not be reliable in traumatic skin defects with fracture because of the high incidence of vascular injury.
Twenty open fractures or dislocations (19 patients) were treated using flap reconstruction. The persent study included 14 open tibial fractures (type II: n=3, type IIIA: n=1, type IIIB: n=10), 2 open femoral fractures (type IIIB: n=1, type IIIC: n=1), 2 open knee dislocations (IIIC), an open ankle dislocation (IIIB), and an open calcaneal dislocation associated with metatarsal fractures (IIIB). Flap reconstructive procedure were performed as follows, including the initial procedure and salvage procedures; free flap: n=5, local random pattern flap: n=9, local axial pattern flap: n=3, and pedicle muscle flap: n=9. Both the free flap and the local axial pattern flaps showed a 100% survival rate in all cases. On the other hand, the rates of distal necrosis in the local random pattern flaps and pedicle flaps were 33% and 63%, respectively. There were six deep infections in our study. In conclusion, we should carefully select the method of flap reconstruction for treating skin defects associated with severe fractures of the lower extremities in particular checking for unstable vascularity. It is also important, for protection from infection, to provide well-balanced soft-tissue management combined with bone fixation method.
25 cases of lower limb crush injuries with severe skin defects, including 13 cases of the leg and 12 cases of the foot, were investigated postoperatively. Patients comprised 21 males and 4 females with an average age of 26 years. Various free flaps were performed in 21 cases, although most cases utifized latissimus dorsi MC flaps and scapular flaps. In addition free vascularizad bon grafts were performed in two cases with large bony defects. In our study, Latissimus dorsi MC flaps were suitable for reconstructing severe skin defects with other soft tissue defects and scapular flaps were useful in the reconstruction of the foot or the lower limb of a child.
We treated 14 cases of traumatic skin defects of the lower extremity. seven cases were treated with mesh skin graft, 5 cases with Peroneal flap, 1 case with a Sural flap, and 1 case with an instep island flap. Many cases of wide skin defects need reconstruction of both bone and soft tissue.
Since May 1981, we have performed 25 cases cf Peroneal vascular island flap, 9 cases of free peroneal flap, 8 cases of free scapular flap, 9 cases of free groin flap and 5 cases of free latissimus dorsi flap. Our first selection for treating wide skin defects of the leg and foot is the peroneal vascular island flap which covers the exposed bone, vessels and nerves. In regard to free flaps, our first choice is to use a scapular flap. The advantages of this flap are that the subcutaneous fat is thin, the branch of the circumflex scapular artery can be easily located, the vascular pedicle is long and vessel diameter is 1.2 to 2.0mm. In cases with wide skin defects from the knee to ankle joint we use a latissimus dorsi flap.
In total knee arthroplasty (TKA), measurements during pre-operative planning or in intra-operative decision-making dictate a mismatch in the size between the femoral and tibial components. This is because most total knee systems are designed to fit a Caucasian population. We evaluated the mismatch rate of 50 knees in which TKA was performed from 1991 to 1994 and compared the ratio of medial-lateral to anterior-posterior dimensions (aspect ratio) of the distal femur and the proximal tibia in these 50 cases as well as 9 templates of a total knee system. The femoral aspect ratio was significantly less in the templates than in achial cases and this in formation may be useful developing future Asian sized knee prostheses.
The short-term results of 46 knees in 37 patients treated by LCS total knee systems were evaluated clinically and radiologically. The models used were the Rotating Platform type in 22 knees and the Meniscal Bearing type in 24 knees. Using the criteria described by three universities, the average clinical score after operation achieved by the Rotating Platform type was 88.9 points and 86.4 points for the Meniscal Bearing type. Component placement angle was good and follow-up revealed that the components remained in place. We found radiolucent lines in 69.6% and subsidence in 21.7% of the cases, but no further worsening was observed. The motion of the meniscal insert during bending fell into three groups; forward shift, backward shift and no shift. The range of motion was significantly wider in the backward shift group (flexion: average 132°), but there was no difference among the three groups in regard to clinical results.
We performed bilateral TKA in 10 patients with gonoarthrosis. Patients were classified into two groups; those living in a residence, and those hospitalized. Clinical results and post-operative ADL scores were then compared between the two groups. The presence of any cardiovascular disease was found to be strongly associated with poorer clinical outcome in both groups. According to the JOA score, very good results were achieved in both groups, and most patients were very satisfied. However improvement in knee expansion was more restricted in the hospitalized group. In regard to ADL, leave hospital, some patients were able to use public transport, and with the aid of a western style toilet rather than a Japanese style one were able to self-toilet themselves. In general, as long as 100 degrees of flexion were achieved, patients could maintain their ADL.
We have experienced two patients who developed dysfunction in another joint after TKA. The first case was a 76-year-old woman with bilateral knee osteoarthritis who suffered bilateral femoral neck fractures 6 months after bilateral TKA. The second case was a 71-year-old woman with rheumatoid arthritis who suffered advanced destruction of her left hip joint 16 months after bilateral TKA. These cases suggested problems such as preoperative evaluation, postoperative management, operative order, and operative interval.
Two surgical cases of os odontoideum in spondyloepiphyseal dysplasia (SED) tarda were reported. The first case was a 34-year-old male suffering from intractable neck pain with bilateral numbness in his hands due to myelopathy. The radiogram demonstrated atlantoaxial subluxation and invagination of the posterior arch of C1 into the foramen magnum. CT-myelogram showed the spinal cord to be compressed between the posterior arch of C1 and the base of the odontoid process. The second case was a 28-year-old male who developed tetraplesia after falling down. His radiogram demonstrated posterolateral atlantoaxial subluxation. In both cases, the posterior arch of C1 was located close to the foramen magnum and was unable to be reduced downward. Both cases required occipitocervical fusion using a fan-like rod. We experienced two cases of SED congenita with similar radiological findings to SED tarda. Narrowing of the atlanto-occipital interval and loss of motion were also seen in SED congenita experienced previously. Their finding may be characteristic of case with os odontoideum in SED. The first case achieved a good recovery after surgery, however, the second case remained tetraplegic.
We analysed three RA patients who had their cervical spinal lesions treated by posterior fusion with unsatisfactory results. All cases were classified as stage 4. Severe neck pain recurred in all three patients and neurological symptoms developed in one of them. Neck pain was improved with a cervical brace in two patients but in the patient with nerological symptoms the neck pain and symptoms increased in severity. The most important factor for good long-term results following posterior spinal fusion for cervical lesions in RA is to achieve stabilization with union of the bone graft.
This study reports five cases with rheumatoid arthritis requiring salvage surgery after posterior atlantoaxial fusion. Patients were divided into two groups, the first group included two nonunion and one malunion of atlantoaxial fusion and the second group included two who develope subaxial subluxation. In the first group, one case of nonunion could be again treated by atlantoaxial fusion after removing the primary grafted bone and reduction of subluxation. But the other nonunion case, and the patient with malunion needed occipitocervical fusion to be performed because their subluxation could not be reduced. After surgery, occipitocervical pain disappeared in all cases of the first group, but myelopathy persisted in the two cases treated with occipitocervical fusion. In the second group, MRI revealed severe compression of the spinal cord at subaxial level in both cases. They were treated with anterior decompression and fusion followed by posterior decompression and fusion. Regardless of the spinal cord decompression shown on MRI one case with a long history of myelopathy prior to surgery did not recover remarkably. For improvement of myelopathy and preservation of the atlantooccipital joint, it is important to closely observe and treat the loss of correction as early as possible.
We report fifteen cases treated with a 4-pad halovest (Levtech Halo) consisting of four independently adjustable pads. Patients included two hangman's fractures, five dense fractures, three cases with atlanto-axial instability, four metastatic tumors and one pyogenic spondylitis. Nine patients underwent surgery. One patient experienced pin loosening. One patient with metastatic tumor developed a pressure sore which healed without removing the halovest. A 62-year-old femal with a round back and pigeon chest complained of discomfort with the halovest which was improved by remodeling the sternal pad and interscapular pad using a heat gun. Lateral cervical spine x-rays of seven patients were taken in the upright and supine positions while wearing the halovest. Mean intervertebral motion ranged from 2.4 to 4.3 degrees. Motion restriction with the 4-pad halovest is equal to, or better than, results with standard vests used in previous studies. This halovest has the following advantages, comfort, pad adjustability, ease of washing, avoidance of excess sweating and pressure sores.
The usefulness of a one-stage surgical treatment with an anterior and posterior approach has been reported. We have surgically treated patients with spinal injuries using this one-stage technique, and report the clinical results. Eight patients, 7 males and 1 female, with a mean age of 50 years were treated types of injury included 7 fracture-dislocations and 1 burst fracture. Neurological findings at the first visit included complete paralysis in 3 cases, incomplete paralysis in 3 cases and no paralysis in 2 cases (According to Frankels classification, A in 3 cases, C in 1 case, D in 2 cases and E in 2 cases). Our method of surgical treatment involved first reduction, decompression and internal fixation using instruments in a posterior approach and then decompression and bone grafting using the anterior approach. Results of neurological findings showed that no cases worsened and 5 of 6 cases improved except one classified as an E type. Union of grafted bone was obtained in all cases. There were no post-operative complications except one case who was reoperated for displacement of the grafted bone and had a severe respiratory disorder. Improvement in the neurological findings were satisfactory and it was concluded that the one-stage anterior-posterior approach was beneficial for neurological recovery.
We used the CDI claw technique for treating delayed neurologic deficits following vertebral fractures in 2 osteoporotic patients. Neurologic deficits improved using posterior fusion without decompression. It was suggested that the neurologic deficit was mainly due to instability. Posterior long fusion without bone grafting may possibly produce late complications, so patients should be chosen carefully.
Sixteen cases of unstable thoracolumbar spinal fractures were treated early using short fixation with a pedicular screw system. During an average of two years follow-up neurological improvement was shown in II cases, according to Frankel's grading. Dislocation was repositioned well, and remained stable, but the kyphotic angle was reduced on average by 7.8° at follow-up. Three major causes for the loss of the kyphotic angle include breakage or bending of the screw, vertebral settling, and rod-screw loosening. Some authors suggest that pain is caused by the loss of the kyphotic angle. Fortunately, no postoperative severe pain or neurological damage occurred in any of our sases. Other techniques should be added to the short fixation and pedicular screw system, to retain the kyphotic angle.
We reviewed clinical and radiological results of five patients with lower lumbar burst fractures treated by pedicle screws. All patients achieved successful union of the fracture with good alignment and improved their neurological deficits as well as reducing their low back pain. Posterior decompression with reduction of the prolapsed fracture fragment in the spinal canal was useful for treating patients who underwent surgery within four weeks from the time of injury. It may be possible to preserve the lower disc segment in Dennis type B fractures by using posterolateral fusion of the upper disc segment only. To achieve earlier mobility, and reduce the period of bed-rest required, anterior strut grafting may be needed in patients with a burst fracture whose spinal bodies and upper and lower discs are severely destroyed including those with Dennis type D fractures.
This study analysed the problems assciated with measuring the pressure distribution on the sole during walking. Subjects comprised 7 normal adult males and the pressure distribution was measured on their soles by changing the distance (0, 20, 30, 40, 50, 60, 70, 80CM) between the two recording plates (ANIMA G-4800). The ratio of the maximum pressure of the left foot was about 50% at both 50 and 60cm between the two recording plates. We concluded that the most suitable distances between recording plates for measuring pressure distribution on the sole were 50cm and 60cm.
Traumatic posterior dislocation of the glenohumeral joint is rare compared with anterior dislocation. We have experienced four traumatic posterior dislocations of the shoulder joint from 1984 to 1993. Three cases were injured in traffic accidents and one in a fall. Diagnosis of two cases was delayed by misreading of the anteroposterior X-ray views with along combined fractures. However the two other cases were immediately diagnosed by an axillary X-ray view and successfully treated by closed reduction. We conclude that axillary X-ray views are an important addition to clinical findings to make the diagnosis of a posterior dislocation of the glenohumeral joint.
Gadopentate (Gd)-enhanced magentic resonance (MR) imaging for diagnosis of periarthritis of the shoulder joint is reported. Thirty-seven patients (39 shoulders) with periarthritis of the shoulder were examined by means of MR imaging with T1- and T2-weighted sequences. T1-weighted images were again obtained following intravenous administration of Gd dimeglumine in the 11 shoulders. Five normal volunteers and three patients with recurrent anterior shoulder dislocation were compared with the above patients. We assessed the signal intensity of the subacromial bursa, the supraspinatus tendon, the axillary portion in the gleno-humeral joint, the tendon sheath of the long head of the biceps and the humeral head. In the Gd-T1 weighted images, the area of the subacromial bursa revealed high signal intensity in patients with periarthritis of the shoulder compared with normal volunteers and patients with recurrent anterior shoulder dislocation. The authors conclude that Gd MR imaging is useful for illustrating the pathology associated with periarthritis of the shoulder.
This study determined changes in shoulder function associated with increasing age. We studied the range of motion, inferior instability and intra-articular pressure of the shoulder according to patient's age. We examined 50 normal shoulders by elevating them from 60 degrees to 150 degrees in 30 degree increments in both the coronary and sagittal plans, and measured their range of motion from the most internally rotated to the most externally rotated position. We measured inferior instability of 35 shoulders and intra-articular pressure of 11 shoulders. When age and degree of elevation were high, range of motion of the shoulder was decreased. Inferior instability was independent of age. When an increased volume of normal saline was injected intra-articularly the shoulder, the intra-articular pressure was higher. We concluded that the capacity of the shoulder capsule in younger subjects was larger than in the old.
We report on the postoperative assessment of 287 arthrographic findings, including 21 with subscapular tendon injuries. Two hundred and seventeen were male (207 cases), 70 were female (66 cases), with an average age of 52.6 years. Five arthrogram projections were assessed: antero-posterior view in both the external and internal rotated positions axillary lateral view, scapular lateral view and bicipital groove view. Our cirteris for diagnosing a subscapular tendon tear was the extreavasatin of dye into the subcoracoid burase and intravasation of dye into tye subscapular tendon. Sensitivity was 14% and specificity 98% in the antero-poster view, 80% and 92% in the axillary view, 43% and 66% in the scapular lateral view, 85% and 97% in bicipital groove view. These results showed that axillary and bicipital groove views are useful in diagnosing subscapular tendon injuries.
Results of nonoperative management of 18 patients with full-thickness tears of the rotator cuff proven by arthrographic examination are reported. Average age at first examination was 62.8 years. Patients were evaluated at an average of 2.1 years and 6.2 years. All patients were reviewed by questionnaire. Patients were evaluated according to their JOA score with the mean total score improving with time. Pain, ADL, elevation, internal rotation scores were all improved. At the first follow up, muscle strength was worse but at the last evaluation mean muscle strength score was higher than the one on the first examination. Conservative treatment produces satisfactory results when it is given to patients with a reasonable JOA score on first examination.
We reconstructed large bony defects of the humerus using a fibula head graft in four cases. In one of the four patients the large bony humeral defect was caused by osteomyelitis of the humerus, while the other three were due to parosseal osteosarcomas of the humerus. Free vascularized proximal fibula grafting was performed in three cases. In the other case a proximal fibula graft using the fibula head was performed. The mean follow-up period was 4·5 years. All cases were evaluated according to their JOA score and the was functionally evaluated reconstructive procedure following surgical treatment of the musculoskeletal tumor according to Enneking. In two patients under 40 years of age both the JOA score and % Rating of Enneking's evaluation were significantly higher than in patients aged over 40 years. We concluded that a free vascularized fibula graft is a very useful procedure for treating large bony defects of the humerus.
Shoulder arthrodesis is the most often proposed method for treatment of patients with root avulsion because of limitation of muscles for reconstruction. Although the patient achieves stable joint by this method, this joint becomes very inconvenient in a crowded place. From 1980, in nine patients with flail shoulder, we performed shoulder joint reconstruction using a muscle transfer. Prior to this operation, intercostal nerve transfer had been carried out as elbow flexoplasty in all patients. This paper presents the operative method and results of the muscle transfer. Operative method: With the patient in a lateral decubitus position, the shoulder is approached through a T-shaped incision. The flap is mobilized freely enough to expose the spine of the scapula, the lateral 5cm of clavicle, the acromion and the deltoid muscle. The scapular spine is cut at the base of the acromion and the upper fiber of trapezius with the acromion is freed from the clavicle and scapular spine. The superior angle of the scapula is cut at its base and the levator scapula with the angle is fixed to the lateral part of the scapular spine with a wire. The arm is then abducted to a right angle and the acromion with trapezius is fixed to the humerus as distally as possible. The transferred acromion is fixed by two or three screws. Postoperatively the arm is immobilized in a shoulder spica at 90 degrees of abduction for four to six weeks. Results: At follow-up an average of 34 months after surgery, the mean active elevation angle was 46±16 degrees. The power of elbow flexors was increased to 3 or 4 by MMT due to the increase in stability of the shoulder joint. This operative method may take the place of shoulder arthrodesis for patients with root avulsion as a shoulder reconstructive operation.
Middle aged athletes in Japan were studied to evaluate changes in their hematological indices. Ninety-two male and twelve female athletes (average age, male: 53.3 years, female 43.8 years) were examined for blood characteristics at the world veterans championship athletic meeting. Sixty-five male and nine female marathon runners all showed elevation of creatine kinase (CK) and HDL-Cholesterol before competition (CK, male: 220.3IU/L, female: 135.3IU/L, HDL-Cholesterol, male: 80.7mg/dl, female: 83.5mg/dl). Twenty-three of twenty-five male marathon runners showed a significant increase of CK (580IU/L), LDH (626.4IU/L), WBC (10940.9/mm) and GOT (38.5IU/L) after the competition. In conclusion, it was shown that long distance training in middle aged athletes caused elevation of HDL-Cholesterol and CK.
Stress fractures are a common sporting injury particularly seen among adolescents. This is a case report about stress fractures seen in players of a high school baseball team and tennis team. 131 players consulted us since 1992. We found 13 stress fractures in 12 players (tennis: 8, baseball: 5). In regard to the fracture site, 5 tennis players and one baseball player had a fracture of the tibiae; 2 tennis players and 2 baseball players involved the metatarsi. One baseball player's fracture was of the ribs; one tennis player had a fracture of the hallux sesamoid and one of the calcaneus. Four regular players of tennis and one regular player of baseball were included. Regular tennis players tended to suffer more stress fractures of the tibiae. Remodeling of pitching form is also supposed to cause baseball players' stress fractuers in the first grade. Early checkup and treatment are needed for those players who develop symptoms of stress fractures.
A freshly torn lateral ligament of the ankle often requires surgical therapy. Operative treatment is usually selected if radiographic examination performed with the heel held under adduction stress reveals a tilting angle (TT) of the talus greater than 10 degrees. This study compared the results of surgical and conservative therapies and we hoped that our findings would help to clarify the limitations of conservative therapy. Subjects included those whose talus was tilted over 10 degrees with the heel fully inverted. Torn lateral ligaments were conservatively treated in 214 patients at our hospital. The mean difference in TT between the right and left ankles was 7.96 degrees in these patients. The difference in treatment results between patients with a TT of over 10 degrees and those under 10 degrees was statistically significant. The difference in treat ment results between patients undergoing surgical and conservative therapies in patients with a TT of less than 10 degrees was not statistically significant.
Sporting injuries commonly cause strain and/or contusion of muscles, the treatment of which is generally RICE (Rest, Ice, Compression and Elevation) acute stage and an early sporting rehabilitation program. Surgery for such injuries is rarely indicated. In our hospital, surgical treatment (removal of hematoma and suture of torn muscles) was performed in 3 out of 54 cases with sporting injuries within a one yearperiod. These 3 cases had severe symptoms (gait disturbance and intractable motion pain) and large intramuscular hematoma shown on MRI. All three cases had a complete recovery postoperatively, allowing the to return to full sporting activities.
We evaluated knee flexor and extensor strength and functional performance of high-school basketball players of the 1993 national champion teams. Ten males and ten females (mean age, 16.9 years and 16.8 years, respectively), who had no previous knee injuries, were examined. Muscle strensth was assessed by measuring peak torque during concentric, eccentric, and isometric muscle actions using a MYORET isokinetic testing device. Muscle strength per body weight of the male players was always greater than that of the female players. However, when isokinetic muscle strength was divided by isometric muscle strength for standardization, the eccentric quadriceps strength of female players became greater than that of the males. It was suggested that female players can utilize their eccentric quadriceps muscle action for bounce motion before jumping-up and for shock absorption at landing. On the other hand, the eccentric quadriceps contraction causes an anterior-drawing force onto tieir tibial tubercles at the time of landing, and this might be a possible cause of non-contact type ACL injuries which frequently occur in female basketball players.
Thirty-three cases of acute closed rupture of the Achilles tendon were treated by percutaneous repair from 1988 through 1993. Subjects consisted of 20 males and 13 females with a mean age of 40 years. The follow-up period was a mean 38.3 months. The ruptured Achilles tendon occurred as a sports injury in 32 cases, including volleyball 16, badminton 6, running 4 and others 6. Mean operative time was 22 minutes. Mean duration of cast immobilization after surgery was 40 days. Full weight-bearing gait was started at a mean of 57.9 days. Regarding postoperative range of motion, the mean angle of dorsiflexion was 14.0 degrees and 51.4 degrees of plantarflexion. Compared with the intact site, both types of flexion decreased but all cases regained normal ADL. Three cases reruptured and 5 cases developed nerve injuries as a postoperative complication. In 66.7% of males, sporting activity returned to the preoperative level, but many females tended to become less active in sports following the injury. We concluded that this method achieved excellent results but attention should be paid for nerve injury and postoperative rehabilitation.
We report six patients who were treated with reconstruction of their medial collateral ligament using a palmaris longus tendon graft. There were 2 baseball players, 2 judo players, one rugby player and Javelin thrower. Sport-related injury of the medial collateral ligament occurs most commonly in baseball pitchers. This study assessed the results of reconstruction of the medial collateral ligament in the throwing athlete and described our method of reconstruction of the medial collateral ligament.
We experienced 3 cases of subluxation of the peroneal tendon during the last six years. All subjects were injured during sporting activities. Surgical treatment was performed in 3 cases (modified Kelly's operation). After five weeks immobilization with a plaster-cast, partial weight-bearing was allowed. After a mean of four months post-operatively, patients all returned to full sporting activities. All patients achieved excellent results and returned to their preoperative athletic level.
We report four cases five toes with hallux sesamoid lesions which were treated using sesamoidectomy. In this report, the surgical technique for such disorders and the differentiation between osteonecrosis and fracture of the sesamoids are discussed. All toes had the same histological findings consisting of necrotic bone and fibrocartilaginous material making it difficult to discriminate histologically between osteonecrosis and fracture. We used clinical criteria to diagnose sesamoid fracture in which subjects recalled any strenuous activity or minor trauma due to sesamoid pain. Finally two fractures and three osteonecroses were diagnosed, treated and followed. At surgery we recommend a medial midline incision and plantar approach to the sesamoid without a medial capsular incision as this method may help to prevent hallux deformity and reduce the abutting of the digital nerve by the sesamoid.
Nineteen primary uncemented total hip arthroplasties (THAs) were performed in 15 patients with rheumatoid arthritis. Average age was 57.7 years. Four hips had an acetabular component placed with cement (Hybrid). The follow up period averaged 25.2 months (range, 6 to 61 months). Clinical evaluation based on the Japanese Orthopedic Association (JOA) score indicated significant improvement from preoperative to the most recent follow-up examination for pain. No hips required revision surgery. There was no evidence of roentgenographical failure; however, 68% of femoral and 73% of acetabular components had minor radiopaque lines and 53% of femoral components had cortical thinning in zones 2 and 6, and 74% of femoral components showed cortical atrophy in zones 1 and 7. No hips had femoral component subsidence, or acetabular component migration. Complications included only two dislocations. No deep sepsis occurred. These short term results suggest that cementless THA may be successful in rheumatoid hips. Clinical outcome is similar to that seen in our cemented THA paients, with a similar follow-up period. However, a longer follow-up study is necessary for a true evaluation of the efficacy of cementless THA in rheumatoid patients.
The results of multiple joint replacement for 62 rheumatoid arthritis patients are reported. Subjects were followed up for an average of 37 months. In 52 patients, walking ability improved or was maintained but in 5 patients it worsened and 5 patients had died. Factors which worsened the patient's walking ability were rheumatic disorders of the foot, ankle, and cervical spine and compression fractures of the thoracolumbar spine due to osteoporosis. Extra care must be given for these factors after multiple joint replacement in rheumatoid arthritis patients.
A 51-year-old female presented with hip pain of 6 months duration and a rapidly destructive appearance of the femoral head radiographically. The patient had no clinical or laboratory evidence of sepsis or neurogenic disease. Femoral head replacement was performed. We describe the clinical, radiographic, and pathologic findings of this case which suggested rapid destructive coxarthrosis.