We report a case in which endosteal bone erosion was found to have developed three years after hip prosthetic surgery was performed. Radiography showed that the bone erosipn was present all around the femoral stem. The histological speciment showed focal aggregates of macrophages and gaint cells with high density polyethylene wear debris suggestig that the development of bone erosion may occur due to the interaction between foreign bodies and macrophages.
We experienced one case of recurrent dislocation of the inner femoral head caused by wear of the bearing insert. The subject a 51 year-old woman with coxarthrosis had received bipolar hip prostheses with a self-centering mechanism approximately seven years earlier. She had been relatively young at the time of her first operation, was engaged in agriculture and enjoyed an active life after this operation. Seven years rater, she developed intermittent severe pain in her hip joint and was occasionally unable to walk. Examination revealed extreme varus alignment of the outer head and a radiolucent zone on the acetabular side. During surgery, we found fixed varus of the outer head, granulation of 3 to 4 millimeters on the acetabulum, and manifest wearing of all inner HDP liner, but failuer of the leaflet was not seen. This suggested that the wear occurred due to impingement of the stem neck with the outer head fixed in varus over giving concentric rotation. In conclusion, we should be care-ful about treating cases showing progressive varus of the head even when the prevailing bipolar hip pros-thesis with self-centering mechanism was been used.
We reviewed bilateral total hip replacements (by JIAT) performed for treating bilateral coxarthrosis. During the ten year 16 patients were operated on by JIAT. Subjects included two males and 14 females whose ages at the time of operation ranged from 44 to 75 years (mean 62.7 years). Follow up of the joint operated on was 6.6 years on average, and 4.6 years for the second joint. Patients were chinically evaluated according to the Japanese Orhtopaedic Association's (JOA) hip score, and radiologecilly using spike angle and stem sinking. In addition, we investigated the relationship between stem sinking and leg length discrepancy. Total JOA hip score of the first operated side improved from 42.6 preoperatively 82.8 at follow-up. Also, the total score of the second side improved from 38.5 preoperatively to 84.0 at follow-up. Clinically, the postoperative course was good. There were no significant differences in spike angle between the first operated side and the second side. But, in regard to stem sinking on the first operated side, there was a larger amount of sinking in the period prior to the second side operation (leg length descrepancy=19mm) compared with the other period (leg length discrepancy=0mm).
Twenty three patients were treated by THA (cemented MX-1). There were fifteen cases of severe coxarthrosis, six cases of RA and two cases of aseptic necrosis of the femoral head. The mean follow-up period was four years and nine months. The avarage JOA score was 33.6 points preoperatively, compared with 79.7 points postoperatively. The improvement in the JOA score averaged 46.1 points. Radiologic evaluation of THA resulted in a mean score of -4.2 points.
Thirteen hips in 12 patients with adolescent slipped capital femoral epophysis (SCFE) were reviewed to examine the radiological changes which occurred after pinning using the in situ method. The duration of follow-up was more than 2 years. No hips showed further slipping after pinning was performed using one of three methods such as long neck screw (LNS), Kirschner wire and cannulated cancellous screw (CCS). Twelve of the hips had show complete epiphyseal chosure within a mean period of 11.8 months after operation. In the radiological course of epiphyseal closure, it was commonly seen that a focal narrowing with sclerosis of the proximal femoral growth plate appeared at the posterior portion shortly after pinning. This narrowing then proceeded toward the anterior portion, leading to complete epiphyseal closure. There were no severe complications such as avascular necrosis. chondrolysis and degenerative changes of the hip. However, residual short neck deformity as well as buried screw heads inside the cortex were seen in this series, especially following multiple CCS pinning. Contralateral slipping of the epiphysis was observed in one of the four patients who had not had prophylacitic pinning.
One hundred and eighty-eight patients with back pain and sciatica caused by degenerative lumbar disorders were studied prospectivevy after decompression and spinal fusion with spinal instrumentation. One hundred and twenty-two of the 188 patients underwent decomression and posterolateral fusion using a Knodt distraction rod (Knodt group). The 66 remmaining patients were treated by decompression and posterolateral fusion with the Diapason transpedicle screw syistem (Diapason group). At follow-up, 70% of both groups had achieved good results. The fusion rate was 92.6% in the Knodt group and 98.5% in the Diapason group. The wound infection rate was 2.5% in the Knodt group and 4.5% in the Diapason group. Neurologic deficit rate was 10.7% in the Knod group and 1.5% in the Diapason group. Most of these complications resolved. We velieve that the Diapason system provides excellent fixation and can be applied safely without significantly increasing the complication rate.
We retrospectively analyzed the incidence and variety of associated complications in 54 patients who underwent lumber spinal fusion using transpedicular screw fixation systems. The average operative time was 3 hours 28 minutes with an average blood loss of 376 grams for one level fusion. Intraoperatively fracture of the pedicle during screw insertion occurred in 5.6% of cases. The neural infury rate was 3.7%. Post operative complications included 7.7% screw breakage, 1.9% AW-GC spacer breakage, 1.9% nut loosening and 9.6% screw loosening. Final results included 9.6% pseudoarthrosis and 9.6% delayed union. In all of these unsuccessful union cases the graft bone collapsed and the “disc height” became narrow in the post operative period. We believe that the AW-GC spacer offers mechanical advantages compared with iliac bone strut grafts alone.
We reviewed 143 cases treated consecutively using the Pedicular Screw System for thoracic and lumbar spinal disorders. The purpose of the study was to clarify the rate of complications associated with the Padicular Screw System when used to treat spinal disoreds. The rate of infection and neurological deterioration were both 0.7%. Screw breakages were 5.6%, althaugh in traumatic lesions this increased to 13.3%. For these cases, we used the posterior bone graft technique alone. We recommend the use of fluoroscopy for appropriate screw insertion and the use of anterior bone graft techniques for decreasing the incidence of screw breakages.
We performed a study to evaluate the complication ratio associated with spinal instrumentation surgery for non-deformity or non-tumor patients. One transient cervical myelopathy, one infecion with MRSA and one pedicle fracture were observed. Six cases (8%) had instrument problems, 3 wire breakages and 3 dislodgements of the screw or the rod. It is considered that the most important factor for avoiding complications when performing instrumentation surgery is to select a familiar method. Furthermore, as there was no direct injury to large vessels or nerves by the screw, pedicular screwing was considered to be a safe method.
Many types of spinal instrumentation have been developed and are widely used for treating a range of spinal disorders such as injuries, tumors and degenerative disease. However varions complicatios have been found to arise after the use of these instruments. We investigated the cause of operative and post-operative complications associated with the use of spinal instruments (Kaneda device 14, Harrington 5, A-O pedicular screw 15, Diapason 4, compact CD3, Spine system 1) in 41 patients (27 meals, 14 females). 5 cases showed loosening of the nut, and 4 cases had hook deviation when using the Kaneda device. One case of screw penetration, one case of increasing kyphosis, one case of screw breakage, one case of MRSA infection, 3 cases of projection of the posterior edge of the screw causing pain were seen with the A-O system. One case of screw breakage was seen with the Spine system and there was one pedicular fracture associated with Diapason. Both patients with broken screws started sports or their job 4 or 5 weeks postoperatively. The patient who had screw penetration had been taking steroids for sarcoidosis for 13 years. Osteoporosis was found in the patient with increasing kyphosis. The abnormal position of the pedicular screw was not seen in post-poerative roentgenograms in three cases. We conclude that the cause of pedicular fracture is due to operative technique, the cause of screw penetration is due to operative indication, the cause of screw breakage is due to early activity by the patients, projection of the posterior screw edge is due to instrumental structure, and MRSA infection is due to sterility of the opertation.
We reviewed 27 cases who underwent Cotrel-Dubousset Instrumentation (CDI) for lumbar degenerative disorders and studied the major complications encountered. Intra-operative complications experienced were pedicular fractures in 2 cases, post-operative complications were local infection, non-union of the grafted bone, instrument failure, and decubitus at the screw head in 1, 4, 6, and 1 case, respectively. To avoid these complications, it is important to restrict the indication for using instrumentation in lumbar degenerative disorders and to develop good surgical techniques.
A New method of performing a dihedral trochanteric osteotomy was designed to overcome osteotomy nounion and trochanteric bursitis secondary to wire breakage. The osteotomy was performed in two-steps with a side-cutting power saw and was started distal to the abductor tubercle. The first step of the osteotomy was done in an oblique direction similar to the usual fashion and stopped en route from the abductor tubercle to the femoral neck. Next, the blade of a side-cutting power saw was inserted between the capsule of the hip joint and the tendons of the gluteal muscles. The second step of the osteotomy was performed in a vertical direction from the tip of the greater trochanter until it reached the site of the first osteotomy. A v-shaped osteotomy of the greater trochanter was compleated with the apex of the osteotomy medical and the trochanteric fragment was retracted proximally. After operative procedures to the acetabulum were done, the trochanteric fragment was reduced into the original position and fixed with a single screw. The results of the first 24 hips in 23 patients were prospectively studied. At operation, reduction and fixation of the trochanter to its bed were easily performed because of the dihedral osteotomy. This method was found neither to prolong the operation time nor to increase blood loss. In all hips, osseous union of the greater trochanter was obtained and there was no trochanteric bursitis. The advantages of this type of osteotomy are obvious. Not only is rotation resisted but anatomical replacement of the trochanter is made easier, and the surface area of the osteotomy is increased.
A retrospective study of 24 patients who had had a total hip replacement and 16 patients who had had an acetabular osteotomy showed that there were few clinical differences between the patients who had used suction drainage for 3 hours postoperatively and those who had used for 48 hours. We can conclude that minimal drainage time did not cause any deleterious effects on the postoperative clinical course.
From 1983 to 1994, Chiari pelvic osteotomies were performed in 881 hips for treatment of secondary coxarthrosis with dysplasia. 435 hips (397 patients) were the subjects of this study. There were 40 male and 357 female patients with an average age at the time of operation of 36 years, ranging from 13 to 64 years. Incidence of migration after only Chlari's procedure had been performed increased significantly in the advanced and terminal stages. Incidence of migration in subjects treated with the combined procedure which included valgus osteotomy was high, 71 hips out of 136 (52.2%). But the incidence was less in patients with a combined varus osteotomy; 6 hips out of 42 (14.3%). However, clinical results were not related to the degree of migration. Our results indicate that mild migration of the femoral head is an adaptation of the newly formed acetabulum.
Transposition osteotomy of the acetabulum has been performed since 1956 and is a circumacetabular osteotomy for the dysplastic hip. Of 178 procedures, carried out for osteoarthritis in dysplastic hips, some of which were performed by Nishio himself, we were able to review 102 hips after 2 to 17 years (mean 5.7 years). The clinical result, evaluated according to the Japanese Orthopaedic Association hip score, was exellent (over 90) in 42%, good (80-89) in 26%, fair (65-79) in 23% and poor (less than 65) in 9%. The results depended on the stage of the disease, that is, the more advanced the stage, the poorer the result. No cases have undergone secondary total hip arthroplasty to date. Adequate medialization, as well as good lateral and anterior coverage, was significantly related to achieving good results. An early stage of osteoarthritis in severely dysplastic hips is thought to be the best indication for this procedure.
We repart a case of osteochondral fracture of the talus with rupture of the anterior talo-fibular and calcaneo-fibular ligaments, treated by using an absorbed pin. The subject was a 30 year-old man who was injured while playing tennis. Plain X-ray showed a partially detached fragment which we diagnosed as a Berndt classification stage 2. Three days after the injury we operated by using 2 absorbed pins and ruptured ligaments. AT the time of surgery the fragment was found to be completely detached, so we revised the diagnosis to a Berndt stage 3. The patient was immobilized in a cast for 4 weeks after which he started active excise of the angle. Weight bearing of 10kg was allowed form the 6th week after surgery and increased by 10kg each week. Good results were achieved using this treatment.
Eight men and 8 women with or without sprain were analysed using subtalar stress films and ankle stress filsms We measured the anterior displacement of the calcaneus compared with the talus using two different methods. The amount of anterior displacement of the calcaneus measured by ankle stress films related to the displacement shown by subtalar stress films. Therefore I concluded that it was possible to evaluate sub talar instability using ankle stress films.
This study analysed whether in version of the posterior foot was related to the medial arch in the Windlass action. Subjects comprised 10 normal adult males. Roentgenogram were taken in a siting position, adding passive dorsiflexion. Calcaneo-first metatarsal angle (Hibbs angle) was measured on the lateral view of the foot, Tibio-calcaneal angle (TB-C angle) and Ankle mortice-heel contact angle (A-H angle) were measured on the posterior roentgenogram of the foot according to Cobeys method. We then compared the Hibbs angle, TB-C angle and A-H angle with the control group. When the toes were dorsiflexed Hibbs angle was significantly lower than in the Control group when all the toes except the fifth toe were dorsiflexed and the medial arch off the foot was elevated. However no significat differences were seen between the Control group and the TB-C angle and A-H angle in the Windlass action. We concluded that there was no inversion of the posterior foot in the Windlass action.
We experienced two cases of extradural arachnoid cysts in the thoracolumbar region. Case 1: A 13-year-old female suffered from low back pain and progressive weakness of her lower limbs. MRI and myelogram showed a cystic lesion located in the posterior part of the spinal canal which was compressing the spinal cord at the Th12-L3 level. Cine MRI revealed turbulence in the cyst and spinal fluid flow between the subarachnoid space and cyst. We confirmed that the extradural arachnoid cyst communicated with the subarachnoid space. After extirpation of the cyst and closure of the communicating fissure, complete motor recovery was seen and the patient's low back pain disappeared. Case 2: A 65-year-old female suffered from low back pain and was unable to walk due to palsy of her lower limbs. Although an arachnoid cyst at the Th11-L2 level was suspected from MRI and myelogram, neither turbulence in the cyst nor communication flow was seen in tine MRI. Fluid aspiration improved the palsy of her lower limbs, however MRI taken 3 days later revealed accumulation of fluid and the palsy exacerbated after 3 weeks. Surgery was performed, at which time it was found that the arachnoid cyst communicated with the subarachnoid space. The cyst was extirpated and the connecting pedicle ligated. Complete motor recovery was seen 3 months after surgery.
We report on a case of a 26-year-old female with lumbago and right sciatica due to a sacral nerve root cyst. We also review the literature. Sacral nerve root cysts are described in the literature both clinically and pathologically, but failure to evaluate the different characteristics of these cysts has led to a confusion in etiology and terminology. We consider that MR Imaging is useful in diagnosis, and surgery is usually recommended for large cysts which due to their mass effect may cause symptoms.
Spinal cord meningioma accompanied by ossification is considered to be rare. Ossification was noted in 3 of the 7 patients with spinal cord meningioma encountered at our department during the past 20 year. All lesions were of the psammomatous type and showed plate-like ossification of 4×2, 7×5, 15×10mm. The lesion of ossification was adhered to the meningeal side of the tumor in all 3 cases but was located in the tumor parenchyma in 1. However, no ossification caused directly by fusion of psammomatous lesion was observed. The lesion could be visualized by CT (direct tumor sign) only in the case in which ossification extended over more then 10 mm. Direct tumor sign are considered to contribute to the diagnosis of meningioma and determination of its site. Ossification was suspected to have been caused by metaplasia due to stimulation of the meninges by the tumor.
The schwannoma is the most commomly occurring spinal tumor, but bone destruction caused by schwannoma is rarely reported. We experienced a giant schwannoma which caused bone destruction in the sacral region and report on the diagnosis and treatment of this case. The patient an 83 year-old female who deueloped sacral pain in March 1993. The sacral tumor was discoverd by CT at another hospital in September 1994. She was diagnosed as hawing a schwannoma by biopsy, so was adnitted to our hospital for sutgery. MRI had identhed that the tumor was about 5cm and was located in S1 and S2, but it had not progressed to Note to author. What do you mean by kotubankuu. Do you mean. We extracted the tumor mass by using a posterior appvoach.
Twenty patients with intradural extramedullary tumors were treated sutgically in our hospital from 1979 to 1994. Five of twenty patients had recurrent tumors and required reoperation. Histology of the recurrent tumors diagnosed three cases to be neurinoma and two cases were meningioma. The recurrence rate was 23% for neurinoma and 33% for menigioma. The main cause of recurrence was incomplete resection of the tumor at the primary operation. In two cases of recurrent neurinoma, multipletumors were found at the second operation. We need to consider Neurofibromatosis 2 when diagnosing multiple tumors in the central nervous system.
A 67-year old female, with a relatively uncommon multiple neurilemmoma, exhibited symptoms of cauda equina compression. Because of the relative mobility of the cauda equina and wide space in the canal, tumors arising in the cauda equina usually produce less symptoms than any other spinal tumors. Lumbago and leg pain were the predominant initial symptoms. Gd-DTPA enhanced MRI was considered to be valuable examination for the early diagnosis of cauda equina tumors. Six months after the operation, in spite of resection of one root, the patient showed no evidence of any postoperative neurological defect.
Seventeen patients with 19 symptomatic discoid latetal menisci were reviewed at an average follow-up of 46 months. Their average age at surgery was 22.3 years and 11 patients (13 Knees) were less than twenty years old. All knees were treated with arthroscopic total or subtotal meniscectomy. We evaluated arthroscopic findings of cartilage at surgery, clinical results, radiological changes, and musle atrophy of the quadriceps postoperatively. 8 knees (42.1%) had excellent clinical results, 11 (57.9%) had good results. There were no fair or poor results. Cartilaginous damage or irregularity were seen arthroscopically in the lateral compartment of 7 knees at surgery and 14 knees revealed some radiological changes postoperatively. However there was no correlation between clinical results and arthroscopic or radiological findings. Clinical results were influenced by age and postoperative musle atrophy.
Low density single-contrast arthrography of forty knees thirty eight patents were evaluated. The author read each arthrogram with the name blinded, and then compared this with the findings at arthroscopy. No meniscal tears were diagnosed on 40 out of 43 normal menisci, meniscal injuries were also diagnosed in 31 out of 37 cases of meniscal injury by low density single-contrast arthrograpy. The authors regard arthrography as having high diagnostic value.
Of the TKR (total knee replacement) cases we experienced in this department up tp 1995, 2 (1.5%) were complicated with an MRSA infection. In both cases, curettage of the lesion and continuous irrigation were conducted immediately arter the infection was diagnosed. In one case which demomstrated loosening of the implants, removal of the implants and artrodesis were necessary. However, we succeeded in suppressing the early infection and retaining the implants in the other case in which loosening did not occur. Factors accelerationg infection were assumed to be insufficient contral of the reticular gland which was the site of wire traction in the tibial tubercle and plural surgery duting the same hospitalization period in Case 1 and decreased defence function against local infection attributable to frequent steroid injections and marked anemia and hypoproteinemia after surgery in Case 2. The advantage of povidone odine is that it demonstrates action against bacteria including MRSA as wellas fungi and viruses of and it does not acquire bacterial resistance. Its toxicity in bone, cartilage and soft tissue is negligible. Compared with other disinfectants, its bacterididal action is strong and it inexpensive. We conchided that 0.1% povidone iodine solution was effective when utilized in continuous irrigation.
Ganglion arising from the oblique popliteal ligament is extremely rare. We experienced a case in which MRI was useful in diagnosising this problem. The patient was a forty one-year-old male complaining of popliteal pain when standing. MRI revealed a globular mass adjacent to the posterior cruciate ligament. The mass showed uniformly low intensity in T1, and high ihtensity in T2. We tried to remove the mass using the posterior approach. The root of the mass was arising from the oblique popliteal ligament. The mass had a fibrous capsule and was filled with filled withe mucus peculiar to that of ganglion. after removal of the mass, the patient's symptoms improved completely.
We report 20 cases of unstable spine, who were operated on using a new spinal instrument made of titanium alloy; the SPINE System. There were eleven trauma cases, four tumor cases, and one case each of spondylolytic spondylolisthesis, degenerative spondylolisthesis, spondylolysis, lumber disc degeneration and disc herniation. In eighteen cases, a transpedicular system was used. In one case with chordoma of the axis, cervical posterior fusion implant was applied, and the hook rod for spondylolysis was used in one case. The follow-up period ranged from five months to eighteen months, with a mean of eleven months. The kyphotic change increased above 5 degrees in two cases out of eleven trauma cases. In three cases out of eighteen cases, transpedicular screws were found to be broken during follow-up. MRI investigation was carried out in eight cases after surgery. MRI revealed acceptable images. This type of instrumentation has some advantages and may be recommended in the treatment of unstable spine.
A total of 50 patients with an unstable lumbar disorder underwent posterolateral fusion using spinal instrumentation between 1984 and 1993. We investigated the clinical results for any correlation with the radiograms. Subjects comprised 22 males and 28 females, with an average age of 48 years. Disorders consisted of 17 patients with degenerative spondylolisghesis, 5 with spondylolysis or spondylolytic spondylolisthesis, 5 with lumbar canal stenosis, 4 with lumber disc herniation, 9 with a multiply operated back and 10 with fractures. Four kinds of spinal instrumentations were used; Harrington or Luque rod in 15 patients, Knodt rod in 8 and pedicular screw system in 31. Bony fusion was obtained in all patients except one. Complications occurred in 9 patients with an instrument failure involving either rod loosening or breakage of the screw or hook. Clinical results were excellent in 11, good in 14, fair in 11 and unchanges in 14. The clinical condition did not collelate with instrument failure. However, we concluded that instrument surgery should only be performed for the severely unstable spine.
We investigated the pathological changes and alterations in intradiscal pressure after an experimental intradiscal injection in the mature rabbit. Thirty intervertebral discs in 6 rabbits were used as controls, and normal pressures were measured. Chymopapain, 10% sodium chloride, or betamethasone were injected separately into 5 intervertebral discs of 9 rabbits. Rabbits were sacrificed at 1 week, 4 weeks, and at 12 weeks after the intradiscal drug injection. The intradiscal pressure changed depending on the degree of disc degeneration and if there was any regeneration. The chymopapain-injected intradiscal pressure decreased significantly at 4 weeks compared with the pressure at 1 week and at 12 weeks (p<0.05, p<0.01 respectively). The intradiscal pressure of the 10% sodium chloride-injected discs decreased at 4 weeks, but by 12 weeks the pressure had recovered to the same level as fourd in the cotrols. Necrotic nucleus pulposus was seen histopathologically at 1 week after chymopapain injection, and at 1 week after the 10% sodium chloride injection. At 12 weeks, there intervertebral discs had regenerated with chondrocytes different from in the normal nucleus pulposus. The pressure of the betamethasone-injected discs was unchanged throughout the 12 weeks with only slight histological changes.
Bladder dysfunction is rare, but needs urgent diagnosis and surgical treatment. At our hospital 129 cases were operated on for lumbar disc herniation over a period of two years (1993-1994) and subjects fell into two groups. Group A patients (125 cases) did not have bladder dysfunction, and Group B patients (4 cases) did. In Group B risk factors assouated with bladder dysfunction were obesity, history of lumbar ache, giant prolapsed herniation and acute worsening. Group B cases were operated on within 2 weeks (fastest 16 hours, longest 9 days since symptons occurred). Bladder dysfunction improved in all group B patients after sargery. Those operated upon sooner gained better recovery of bladder dysfunction except case 1 who had their operation the quickest, but had a poorer recovery for compared to the others. Case 1 had their prolapse at the disc between L3 and L4. The upper lumbar vertebral canal is narrow than lower, so it seems that symptoms occur more severely there. We evaluated bladder dysfunction using urinary velocity which the patient recorded. Urinary velocity was determined having patients record volume of urine over 24 hours as well as the time from start to finish of each urination.
From 1978 to 1994, we operated on 595 cases of lumbar disc herniation using Love's method alone or in addition to another type of (postero-lateral fusion or other instruments). We report on our analysis of 25 of these 595 cases who reguied reoperation. The average interval between the first and second operaton was 4.8 years. In regard to patients age, those in the re-operated group tended to be more in the 20-39 year old group. In regard to the level of disc herniation, the number of re-operated cases with problems at L4/5 and L5/S1 were similar. In addition, 17 of the re-operated cases were located at the same level as their first operation. In regard to types of herniation (according to Yanagida's classification), there were no diffrences in the numbers of re-operated cases among the 4 types. If fixation was performed at the first operation, there was less likelihood of those cases requiring reoperation compared to non-fixated cases. The amount of nucleus resected at the first operation had no connection with the duration between the first operation and reoperation. In conclusion, there was no relationship between reoperation and disc level of herniation, types of herniation, and amount of nucleus resected. However, fixation at the first operation affected numbers requiring reoperation in this study.
We report a case of the Far-Out Syndrome that occurred in a female patient with isthemic spondylolisthesis and a 30% slip. This syndrome was described as alar transverse process impingment of the L5 spinal nerve by Wiltse in 1984. The patient's chief complaint was bilateral leg pain and we were not able to visualize an abnormal lesion in the spinal canal with myelography, CTM or MRI. At surgery, it was necessary for L5 spinal nerve decompression to be carried out far enough laterally. L5 spinal root block is a important diagnostic tool in this syndrome.
The authors report three cases of symptomatic severe (more than 50%) spondylolisthesis. Two cases were grade III sondylolisthesis, and one case was spondyloptosis. First case (%slip: 50) was treated by in situ posterolateral fusion (PLF) without instrumentation. Second case (%slip: 100) was treated by both posterior lumbar interbody fusion (PLIF) and PLF with pedicle scerw, The Last case (%slip: 65), which showed a neurological deficit, was reduced with a pedicle screw and fixed by PLIF and PLF. A pseudoarthrosis developed in the first case, but progression of the slip did not occur. The other two cases had solid fusion and symptoms completely resolved. No neurological complications were observed in this series. We concluded one stage PLIF and PLF with pedicle screw system was a suitable procedure for severe spondylolisthesis.
Even when patients with lumbar spinal instability are of advanced aged, we need to consider lumbar spinal fusion according to their activities of daily livng. Operative results and problems of posterior lumbar interbody fusion (PLIF) are investigated in patients over 65 years old. Twenty patients underwent PLIF with Steffee VSP. Ten patients were male and ten female. Their ages ranged from 65 to 83 years with an average of 71.8 years. There were eleven patients with degenerative spondylolisthesis, four with spondylolytic spondylolisthesis and five with lumbar canal stenosis. The follow-up periods ranged from six months to 3.5 years with an average of 1.5 years. Clinical results were evaluated according to the JOA (Japanese Orthopedic Association) score. Small collapse of the grafted bone was seen in seven patients, however, all patients successfully gained intervertebral bony union. The average JOA score was 14.0 points preoperatively, and this improved to 22.8 points postoperatively. The average ratio of improvement was 60.5%. Applications of PLIF for single disc lesions brought better clinical results than those for multiple disc lesions. We concluded that PLIF is a very effective method for complete decompression of spinal roots and rigid intervertebral bony union even in advanced aged patients.
This study investigaed operative results of the lumbar canal stenosis in elderly patients over 75 years (range; 75 to 84). Thirty-four patients were classified as degenerative type and 14 patients were classified as degenerative spondylolisthesis type. Laminectomy was performed for 39 cases, fenestration for 8 cases and Luque's S. S. I for 1 case. There were no severe complications. Clinical results were evaluated by a JOA score, the recovery rate was determined by Hirabayashi's method and the activity of walking clasified into four groups. The pre-operative mean score was 10.4 points and the mean recovery rate was 72.0%. Excellent results in which they could fully walk was found in 26 patients, good with walking within a short distance in 6 patients, fair only with walking in the house in 14 and poor without walking in 2 patients. A second operation was performed in 2 cases but there were no sass in which symptoms occurred due to instability after dicompression without fusion. We recommed that elderly patients showing signs of Lumbar canal stenosis should be operated on before clinical features worsen.
We carried out a urodynamic study pre and post-operatively in nine patients who had neurogenic bladder caused by lumbar spinal disease and investigated their transition and prognosis. The study involved five male and four female patients ranging in age from 37 to 72 years, average age 63 years. They consisted of six lumbar spinal canal stenosis, and one case each of lumbar disc herniation, epidural abscess and epidural tumor. Six patients recovered but three did not. Three patients in the recovered group had no urinary symptoms and the other three had only mild symptoms such as difficulty of urination or a sense oresidual urine. On the other hand, the patients in the non-recovery group suffered from severe symptoms, such as anuresis. However the duration of urinary symptoms in the recovered group was longer than in the non-recovery group. From this study, we concluded that conditions for recovery of the neurogenic bladder include both the possibility of urination even if compensated by abdominal presssure and for the patient to have a moderate remaining sense of the urinary bladder.
We shudied the radiographic findings in 15 cases of the classical rheumatoid arthritic shoulder (29 shoulders). These shoulders were classified into two groups according to symphomatology: 18 had symptomatic shoulders and 11 were non-symptomatic. Injection of local anesthetic was done into the acromioclavicular joint, the subacromial bursa, and the glenohumeral joint. Radiographs were graded according to the Larsen classification. Clinical symptoms and radiologic appearance are often poor indicators of the source of pain in the shoulder joint complex in patients with rheumatoid arthritis. About 30% of the shoulder were relieved of pain by acromioclavicular joint injection.
We report on the epidemiology of Rheumatoid Arthritis in Tusima island. (1) There were 128 RA patients (male 27, female 101) with a prevalence of 0.36%. The annual incidence in Tusima island is 0.025%. (2) About 25% of RA patients were are older than 70 years of age.
Miller-Galante typeII total knee replacement (TKR) has been performed in our department since March 1991. We report our evaluation of TKR performed for rheumatoid arthritis particularly looking at bilateral TKR carried out at the same time (B-TKR). B-TKR is compared to unilateral TKR and gradual bilateral TKR in this report. We found that B-TKR has the advantages of decreasing the patient's physical, mental and economic burden. However, it increases the surgical and anesthetic burden.
32 patients with rheumatoid arthritis (RA) undergoing arthroplasy were treated with intravenous recombinant human erythropoietin (EPO) in order to donate autologous blood. The patients received 6000 units of EPO and 40mg of iron 3 times a week and autologous blood was collected after erythropoiesis. All cases except one were able to avoid homologous blood transfusion during or after operation. Since responses to EPO were extremely different among these patients, we investigated the factors, including serum cytokine levels, which influenced on the patient's response to EPO. The response correlated negatively with initial erythrocyte sedimentation rate, serum CRP levels and serum TNF-α levels. There was no relation between the response to EPO and IL-1β or IL-6 levels. These results suggest that the response to EPO depends on activity of RA and also indicate that TNF-α, one of the most important cytokines in RA, is the major inhibitor of erythropoiesis in RA patients.
Popliteal cysts in rheumatoid arthritis are rarely reported in Japan, and in particular giant calf cysts are very rare. We report two cases of giant calf cysts, in which the patients presented with calf pain and weakness in rheumatoid arthritis. Arthrography was the most useful diagnostic tool for identifying calf cysts. Both cases received surgical treatment, and had a good post-operative recovery.
Inflammatory arthritic conditions affecting the rheumatoid knee joint may be complicated by the development of popliteal cysts. We describe 4 RA patients who presented with ruptured cysts. Patients were 2 males and 2 females. All were outpatients and their ages at the time of rupture ranged from 43 to 61 years. Duration of RA ranged from 7 to 31 years. They presented with acute pain and swelling around the knee in accordance with increasing inflammatory indices. All patients were treated conservatively at the begining. One patient's is popliteal complaint improved following an intra-articular corticosteroid injection. The other patients remained symptomatic and underwent surgery. One patient with a markedly degenerated knee joint underwent total knee arthroplasty. We performed cystectomy and anterior synovectomy on the other 2 patients. There were no relapses of popliteal cysts in any patients. It is important to treat ruptured popliteal cysts in RA to control synovitis. If resistant to nonsurgical treatment, cystectomy with further anterior synovectomy should be performed.
Two hundred and forty patients were treated for fractures of the proximal femur at this hospital over an 8 year period (between 1987 and 1994). Subjects ranged in age from 52-98 years, (mean age, 80.3 years). The authors assessed the patients ADL both before injury and at discharge. The average ADL score before injury and at discharge was 8.1 and 6.9 points, respectively. The ADL score was the same before injury and at discharge in 96 of the 240 patients (40.0%). However, the ADL score decreased in 135 of the 240 patients (56.3%).
This study evaluated the results of surgery for patients with intracapsular fractures of femoral neck. Subjects consisted of 12 fractures (12 patients) with an average age of 50.4 years who were followed up for 6 months to 4 years 2 months (mean 2 years 7 months). We classified these fractures according to Garden's staging. All cases except one achieved bony union and there were no cases with late segmental collapse. We conclude that osteosynthesis, when adequately indicated for intracapsular fractures of the femoral neck, achieves good results.
Clinical examinations were performed on 21 patients over 90 years old treated operatively for femoral trochanteric fractures. At the latest follow-up, 10 patients were alive, and 6 of 10 were able to walk. Eleven patients were dead, most of whom died due to pneumonia, which was on important post operative complication. The older the patients are, the more complications and higher surgical risks they have. Early surgical therapy produces a good prognosis with early post-operative rehabilitation. There are few hospitals and welfare facilities for very elderly patients near our hospital, so it is necessary for us to confer with welfare agencies for their entrance.
One complication of Ender nailing when used for peritrochanteric fractures of the proxmal femur is an outbreak of gonalgia. We analysed the cause of gonalgia, and considered ways of overcoming this problem. Subjects included twenty-three cases (five males, eighteen females) ranging in age from 58-95 years (mean 80 years), whom we treated from April 1992 to December 1993. Gonalgia was seen in twelve cases (52.2%). There was a correlation between gonalgia and projection of the pin on the medial epicondyle. Projection of the pin was due to operating technique, such as poor dispersion of the pin in the femoral head, the inserted position not fitting correctly and poor support on the medial epicondyle. To avoid these problems it is important that pin projection is avoided by studying the anatomical form of each case, by selecting a correctly fitting nail and by deciding on the bending position and angle of the pin.
We report the results of surgical treatment of 51 trochanteric fractures of the femur using the Compression Hip Screw. The average age of patients at the time of surgery was 76.0 years (range, 24-91 years). Average follow up period after surgery was 11.3 months (range, 3-46 months). According to the classification of Evans, 25 cases were stable and 26 cases were unstable. The results of treatment were as follows; (1) After the fracture, 11 patients became wheelchair bound and one patient became bedridden. (2) Radiographic findings showed that the fracture line disappeared by 18.4 weeks post-operatively and the mean decrease in the collodiaphyseal angle was 3.5° and the mean shortening of the femoral neck was 3.8mm. (3) Local complications were observed in 4 cases; coxa vara deformity in one, cut-out in one, and local pain in two.
我々がC. H. S. で治療した大腿骨頸部外側骨折50例のうち不良例は4例だった. うち3例を症例報告しその原因について検討をくわえた. いずれの症例でも, 内後方の骨皮質の連続性が保たれておらず荷重に対する支持性が十分でなく, ラグスクリューは安定した内固定が得られる位置へ挿入されていなかった. 大腿骨頸部外側骨折をC. H. S. をもちいて治療する場合, 正確な整復のもとに安定した内固定が得られる位置ヘラグスクリューを挿入することが重要とおもわれる.