From 1986 to 1995, 256 patients who had an ACL injury were operated on in our hospital. We investigated ACL injury mechanism in these patients. We examined the relationship between the position of the knee joint and the derection of force when the ACL was torn. Valgus stress to the knee and external rotation of the tibia on the femur was thought to be the most common injury mechanism. Forty-four patients with an acute complete ACL tear were examined by Magnetic Resonance Imaging (MRI). Among them, 64% showed signs of “bone bruise” located at both the lateral femoral terminal sulcus and the postero-lateral part of the tibial plateau. These findings suggest that the common injury mechanism of the ACL involves severe anterior subluxation with impact of the posterior part of the tibia on to the femur. Particularly in a non-contact type of ACL injury, we think that contraction of the quadriceps exerts an anterior drawing force onto the tibial tubercle when the patient lands from a jump. This was thought to be the cause of the anterior tibial dislocation tibia, even if the tibia was rotated externally.
Between October 1991 and May 1995, we treated 151 patients with knee ligament injuries; 130 patients (86per cent) had an isolated injury, 21 patients (14per cent) had an assosiated injury with an other ligament. The average age of patients at the time of surgery was 26.5 years (16 to 57 years). All patients were followed for more than 7 months (mean 25.6 months). Our present approach for treating patients with an acute combined injury includes primary repair of all damaged structures. The anterior cruciate ligament can be reconstructed later using autogenous graft harvested from the central third of the patellar ligament. Most injuries of the posterior cruciate ligament can be treated non-operatively. The decision regarding subsequent reconstruction of the cruciate ligament depends on the patient's age, activity level, demands, and desires. Reconstruction should only be undertaken after the injured knee has been fully rehabilitated. Postoperatively, there were no major complications such as postoperative stiffness of instability.
Sixty patients, with anterior cruciate ligament (ACL) reconstruction using the iliotibial tract, had their overall knee function assessed at least 2 years postoperatively using the one-leg hop test. For comparison, 30 physically active healthy volunteers with normal knees (15 men and 15 women) and 30 patients with chronic ACL-deficient knees (15 men and 15 women) were also examined. The hop index in the ACL-reconstructed group was significantly improved compared to that of ACL-deficient group, and almost reached the same level as the healthy volunteers. In the ACL-reconstructed group, the hop index gave a good reflection of subjective knee function (IKDC score) and sports level. The results indicated that the one-leg hop test is a useful method for quantitatively evaluating the function of ACL-reconstructed knees.
Measurement of knee muscle strength and instability is important for diagnosing and estimating the surgical results for knee cruciate ligament injury. When knee muscle strength and instability is estimated, the side difference is usually ignored. The muscle power of the weak side is about 90% compared with that of strong side. This difference in knee muscle strength between the weak and strong side is statistically meaningful. Regarding knee instability, 10% of normal knees show more than a 2mm side difference. When knee muscle strength and instability is estimated, the side difference must also be taken into consideration.
We studied image diagnosis for assessing the effects of preoperative treatment of osteosarcoma in 20 patients. Image diagnosis included X-ray, CT, MRI, angiography and bone scintigraphy which were carried out immediately before and after preoperative treatment in every patient. Histological effects by preoperative treatment were graded according to tumor necrosis, and the histological examination revealed partial response (PR) in 5 patients, no change (NC) in 10 and progressive disease (PD) in 5. No patient showed a complete response (CR). The valuable diagnostic indicators relating to the histological effects were as follows; decrease of tumor volume in MRI, disappearance of neovascularity in angiography, and marked decrease of 99Tc-MDP uptake in bone scintigraphy. X-ray and CT were not useful for evaluating the histological effects. All the findings in MRI, angiography and bone scintigraphy were observed only in the PR patients. In the NC patients, MRI and angiography displayed the findings, however, bone scintigraphy did not. The PD patients did not show any of the findings. These results indicate that the grade of the histological effects by preoperative treatment could be evaluated by MRI, angiography and bone scintigraphy.
We reviewed 18 patients with cubitus varus deformity who were treated by interlocking wedge osteotomy in Kyushu University Hospital between 1986 and 1994. Subjects comprised 13 males and 5 females with an average age at injury of 4.9 years and at operation of 12.6 years. The average follow-up period was 37 months. We evaluated the pre- and post-operative carrying angle (CA), range of motion (ROM) of the elbow, and limitation of external rotation of the shoulder. The mean CA was improved from 21.1 degrees of varus to 9.7 degrees of valgus, and was almost equivalent to 9.6 degrees of valgus on the uninjured side. The mean ROM of elbow flexion increased from 125.4 degrees to 134.9 degrees, and over-extension decreased from 13.4 to 9.2 degrees. In comparison with the uninjured side, the mean limitation of external rotation of the shoulder decreased from 11.0 degrees to 5.7 degrees. All cases achieved bone union. This procedure is recommended for its rigid fixation and good bone union due to a wide bone contact area, and also for its three dimensional correction.
We describe the evaluation of intra-arterial chemotherapy response for bone and soft-tissue high grade sarcoma. Subjects included 41 with 22 bone and 19 with soft-tissue sarcoma. Surgical stage was I-B (1), II-B (36) and III (4). Pre-operative intra-arterial chemotherapy was performed on 17 patients, pre- and post-operative on 11, and post-operative on 13. Limb salvage procedures were performed on 32 patients (78%) and primary amputation on 9. Over all disease free survival at 10 year follow-up was 54% (bone tumors) and 61% (soft-tissue tumor). 17 patients had CDF, 5 patients NED, 3 patients AWD and 16 patients DOD at a median follow-up period of 31 months (6-202). The prognosis was correlated with the evaluation of change in tumor size, pain and imaging findings, but did not correlate with the change in histopathology and serum alkalinephosphatase.
We examined the effect and assessment of neoadjuvant chemotherapy for 21 spindle cell soft tissue sarcomas treated at our institute from 1982 to 1994. Evaluation of effectiveness of the preoperative chemotherapy was performed by thermogram, 67Ga citrate scintigram, CT scanning and angiogram, and the tumor necrotic rate (≥40%). The 5-year overall survival rate was 69.3%, and the histological assessment according to the tumor necrotic rate mainly corresponded to the prognosis of these patients in comparison with the graphical assessment. Graphical assessment which agrees with histological assessment may be useful for valuating chemotherapeutic efficacy.
Thirty-seven patients who had a corrective osteotomy for cubitus varus were reviewed. The age at injury ranged 1 to 9 years. Twelve cases were below 3 years of age. Primary fractures were supracondylar fracture of the humerus in 27, diacondylar fracture including physeal lesions in 7, lateral condylar fracture in 1, unknown in 2. Physeal lesions tended to result in severe deformity. Thirty-two patients were operated on while they were of school age. Closing wedge osteotomy were done in 31 cases, dome osteotomy in 2, curved wedge osteotomy which is a combined procedure of the above two techniques in 3 and others in 1. Closing wedge osteotomy should be the first choice of correction, providing adequate correction with a simple procedure and firm fixation. However, in some cases with more than 30 degrees of correction angle the prominence of the lateral condyle remained and patients complained of cosmetic dissatisfaction. As post operative remodelling of bone is uncertain, prominence of the bone may be corrected at the time of surgery. Thus, we recommend the curved wedge osteotomy in cases who need correction of the varus more than 30 degrees.
We studied the results of corrective osteotomy for post traumatic cubitus varus deformity in 24 patients. Simple closed wedge osteotomy was performed in 17 cases, and two-dimensional wedge osteotomy in 3 cases. The mean carrying angle was —19.5 degrees pre-operatively and 3.9 degrees at follow-up. The lateral condylar prominence tended to be less obvious at follow-up. The loss of correction during skeletal growth was found in 2 cases, probably due to the existence of physeal injuries.
Between 1982 and 1994, corrective osteotomies for cubitus varus after supracondylar fracture were done in 10 patients (male 8, female 2). The average age at the time of surgery was 16 years (range 4 to 44 years) and the interval between injury and the osteotomy averaged 12 years (range 1 to 36 years). Follow up ranged from 7 months to 13 years (mean 4 years and 7 months in children, one year and 4 months in adult). A simple closing wedge osteotomy was done without respecting rotational deformity. The angle of the wedge was determined by adding the varus angle of the affected side and the carrying angle of contralateral side. Surgical results were evaluated using three categories (Function, ROM, Deformity) according to the JOA score. Rotational deformity after surgery was evaluated using Yamamoto's method. In 7 children, wedge osteotomies (averaged 33°) were done for varus deformity (averaged 28°). Immediately after surgery, satisfactory valgus (averaged 6°) was achieved, however, correction loss (averaged 5°) was seen within 3 months. Correction loss didn't progress after 3 months. In 3 adults, one case who received plate fixation showed primary bone healing in cubitus rectus, however, two cases whose osteotomy was fixed by K-wires and tension band wiring developed delayed union resulting in correction loss. The patient who received plate fixation as a second surgery showed 5° varus deformity, while the other resulted in union with 13° varus. Internal rotational deformity averaging 10° was seen in children and 8° in adult. Internal rotational deformity to this degree did not affect the functional result. 9 of 10 patients were satisfied with the results especially in appearance. One patient who developed malunion was not satisfied.
We have been treating cubitus varus deformity by a wedge osteotomy since 1966. We investigated the results of osteotomy of 22 elbows in 21 patients. Of these 22 elbows, the varus deformity resulted from supracondylar fracture in 7, diacondylar fracture in 13 and unclear in 2. The average age at the time of surgery was 10.9 years (5 to 23 years). The follow-up period ranged from 1 to 17 years (average; 5.8 years). Carrying angle just after operation in 7 supracondylar fracture cases, irrespective of age, did not vary during final follow-up. However, of 13 diacondylar fracture cases, a decrease in their corrected angle was observed in 6 cases whose ages were under 11 years at the time of surgery. Tilting angle (TA) was seen to be slightly improved post-operatively. There was a positive correlation between TA and flexion angle of the elbow at follow-up. Humeral torsion was measured by ultrasound in 8 patients, consequently the distal end of the operated humerus was seen more internally rotated compared with the healthy side. From above results, it can be suggested that the corrective osteotomy for cubitus varus deformity resulting from diacondylar fracture should be performed during early teens. TA correction is advised in patients associated with limitation of the elbow flexion. Also it is necessary to correct the axillar deformity to obtain better anatomical correction.
We reviewed the patellofemoral problems of patients who received Mark 3 type total knee arthroplasty (TKA). There were 99 knee joints including 39 osteoarthrosis (OA) and 60 rheumatoid arthritis (RA) patients. Radiograms of all knees were reviewed. In 45 knee joints, clinical examination and radiological measurement were done and JOA scores before and after surgery were compared. The lateral shift ratio was calculated and the thickness of the patella was measured from the skyline view. There were two patella fractures. One fracture might be attributed to strenuous work as a farmer, and the other might be due to severe osteoporosis with ankylosis in the contralateral knee. Neither patella dislocation nor broken patella component were seen these 99 knees. Anterior knee pain appeared in only two out of 45 knees. Mean JOA score improved after TKA both in OA (preop. 44, post op. 71) and in RA knees (preop. 33, post op. 72). All 45 knees showed lateral shift of the patella. However, this did not indicate a poor result. There was no correlation between JOA score and the lateral shift ratio nor between JOA score and thickness of the patella.
The design of the Ortholoc Total Knee System has changed 4 times since 1984. In this study, biomechanical studies which supported the design change are summarized. In 1989, the Ortholoc 3 was developed. The most important part of the design of this femoral component was the recessed patellar groove. In 1990, a biomechanical study was performed to get a large flexion angle for Japanese patients and the posterior flange of the femoral component was shortened. Other designs and operative techniques are established. However, antomical variation of the lower extremity has not been considered in the biomechanical studies. Clinically, a preoperative evaluation of each patient is important to minimize failures.
Fifty-seven knees in 41 patients with medial osteoarthritis treated by high tibial osteotomy (HTO) were clinically reviewed. Average age of patients was 66.7 years. Patients were evaluated from 5 to 15 years postoperatively (mean, 8.5 years). Clinical results were satisfactory in 85% of the knees at the five year follow-up evaluation and in 81% at last follow-up evaluation. Two knees required TKA after 11 and 12 years. The femorotibial angle (FTA) at one year and last follow-up significantly correlated with the last clinical score and improvement score. FTA one year after surgery was one of the main factors that influenced long term results. The mean FTA immediately after surgery was 168.4° in patients who had an excellent improvement score. The change of FTA after surgery was minimum in patients who were corrected to nearly 170°. Clinical results were satisfactory even in the elderly over 70 years old.
Seven knees with medial osteoarthrosis, in which tibial osteotomy was performed with hemicallotasis over a year previously, were evaluated clinically and radiographically. The average age of patients was 63 years and average follow-up period was 14 months. Femorotibial angle changed from 181 to 167 degrees. JOA knee score improved to 93 postoperatively from 59 points. Hemicallotasis is a method for correcting varus deformity of the proximal tibia. In this method, however, upper displacement of the fibular head occurs and that is a unresolved problem.
We reviewed thirty-two patients (38 knees) who had undergone high tibial osteotomy (interlocking wedge osteotomy). Thirty-eight osteoarthritic knees were evaluated by arthroscopy, before osteotomy and an average of 18.8 months after osteotomy. We graded the arthroscopic findings of the articular surface and the meniscus according to Fujisawa's classification. We observed fibrous tissue growing over the ulcerated area in the medial compartment. In most patients the articular surface of the lateral compartment was unchanged but fibrillation was seen a quarter cases. Fibrillation was also seen on the lateral meniscus in a quarter of cases, but they had no symptoms.
Two cases of pyogenic spondylitis of the cervical spine are reported. One case was operated on for destructive cervical spine and another for treating the patient's neurological symptoms. Magnetic resonance imaging was useful for making an early diagnosis of this lesion and for evaluating the effects of treatment.
A 67-year-old woman who had respiratory deficiency caused by pulmonary tuberculosis complained of numbness of bilateral lower limbs. Radiographic findings showed an antero-lateral defect and marginal sclerosis of Th12 and L1. CT scan and DSA indicated an aneurysm adjacent to the paraspinal tuberculous abscess. The patient didn't desire surgical treatment of the aneurysm and she died 6 years later due to aneurysmal rupture.
We report 6 cases of post-traumatic syringomyelia. The mean age at the time of injury was 33.5 years ranging from 18 to 60 years. The paralysis was complete in 5, and incomplete in one case. Their vertebral fractures were treated surgically except for one case. The duration from injury to diagnosis of syringomyelia ranged from 1.25 to 29 years (mean 7.7 years). The intial symptoms were numbness and/or pain, but 2 cases had no symptoms. All cases showed multi-cystic syringomyelia expanding both rostrally and caudally on MR imaging. 4 patients were treated surgically becase of progression of their symptoms. Laminectomy was performed in 3 cases at the thoracic region, and hemi-open laminoplasty in 2 in the cervical region. They underwent syringo-subarachnoid shunting (one required reoperation due to malfunction of the syringo-peritoneal shunting. Postoperative MR imaging showed the disappearence of the syrinx in one case, significant decrease in 2, and very slight decrease in one. The patients obtained improvement of symptoms, but the case who required reoperation showed poor recovery of muscle atrophy.
We report the successful use of tekmiron thread instead of wire for atlanto-axial subluxation in two cases. The atlanto-axial instability was caused by rheumatoid arthritis in one, and by an old dens fracture in the other. Bony union was acquired within four months after surgery, and the atlanto-axial subluxation disappeared radiographically in both cases. We recommend the use of tekmiron thread for atlanto-axial fixation.
The relationship between clinical symptoms and AAS, VS in rheumatoid arthritis were investigated. AAS/VS was reported in 29 of 63 RA patients. The sensitivity of the clinical symptoms (headache, neck pain, cervical noise, shoulder stiffness, neurological deficits) was low due to the existence of asymptomatic AAS/VS. Therefore, we concluded that clinical symptoms were not useful for diagnosing AAS/VS in RA patients, and we should be aware of the existence of asymptomatically progressive cervical change in RA.
We report three cases of anomalies of the craniovertebral junction with myelopathy. Case 1 was a 28-year-old man who complained of muscle weakness of his right upper limb and gait disturbance. He was diagnosed as having basilar impression, atlantoaxial dislocation and hyperplasia of the dens with spondyloepiphyseal dysplasia. Case 2 was a 15-year-old woman who complained of gait disturbance. She was diagnosed as having ossiculum terminal and atlanto-axial dislocation with Down's Syndrome. Case 3 was a 67-year-old man who complained of limb numbness and gait disturbance. He was diagnosed as having atlanto-occipital fusion, basilar impression and atlanto-axial dislocation with spongilosis. All patients had surgical treatment with improvement in their cord symptoms.
Transcranial Magnetic stimulation can elicit a muscle response (MEP) from the target muscle with a voluntary contraction. MEPs were recorded from nineteen patients with cervical myelopathy due to single level compressin of the spinal cord. Central motor conductino time (CMCT) was also measured by subtracting the peripheral conduction time from the onset latencies of the MEPs. These methods were performed in biceps brachii (BB) muscles and abductor digit minimi muscles (ADM). The CMCT of BB and ADM were delayed in the cases with cord compression at C1/2 level. The CMCT of ADM was markedly delayed compared to that of BB in the cases with cord compression at C3/4 level. The CMCT of only the ADM was delayed in the cases with cord compression at C4/5 and C5/6 levels. These results showed that comparison of the CMCT between the BB and the ADM is useful in the clinical diagnosis of the level of cervical myelopathy.
We recorded late responses from APB and EDB during voluntary contraction with supramaximal electrical stimulation in both normal controls and patients with cervical spondylosis. Late responses which were detected in the silent period had two components in controls. Onset latencies of the first component were 25.3±1.5ms at wrist stimulation. Onset latencies of the second component (voluntary potential, VP) were 48.9±2.2ms at wrist stimulation. Latencies at the end of the silent period were 93.9±7.9ms for wrist stimulation, 77.3±7.4ms for elbow stimulation. Latencies of both components and at the end of the silent period for elbow stimulation were shorter than those for wrist stimulation. These results show that afferent impulses generate both components and the end of silent period. Origin of the first component was alphamotoneuron from its latency. First component should be F wave. Origin of second component of upper limb was unkown. Onset latencies of F waves were 46.2±4.0ms for ankle stimulation. Onset latencies of second component were 69.7±4.4ms for ankle stimulation. Origin of second component in lower limb was not cortex from its latency. In cervical spondylosis VPs could not be elicited in spastic hands.
In recent years, many authors have reported that an extruded lumbar intervertebral disc was absorbed through phagocytosis and dehydration. However, absorption of an extruded cervical intervertebral disc has rarely been repoted. We have investigated the follow-up MRI of all 24 patients with cervical disc herniation seen between 1991 and 1995. Of these, 8 patients with radiculopathy and 7 with myelopathy had been treated nonoperatively, and a further 9 patients with severe myelopathy had undergone expansive laminoplasty. In follow-up MRI, a reduction in the size of the extruded disc was seen in 5 of the 15 nonoperative patients and in 8 of the 9 operative patients. The 9 operative patients showed a mean recovery rate of 68.4±15.2% (range from 44 to 90%) according to their JOA score. In the nonoperative group, recovery of symptoms was seen in all 5 patients with reduction, and in only 4 of 10 patients with nonreduction. The initial MRI of the 5 patients with reduction was taken between 2 and 7 weeks (mean 4 weeks) after onset, and between 1 month and 14 years (mean 13 months, not including the one at 14 years) after onset in the 10 patients with nonreduction. The initial MRI of the 9 operative patients was taken between 1 month and 6 years (mean 14 months after onset). The pathomechanism for disc reduction was concluded to have been the same as for lumbar disc herniation in the nonoperative patients. However, the pathomechnism in the operative patients was inconclusive and was likely to be different from that in the nonoperative patients.
A total of 47 patients with cervical myelopathy underwent double door laminoplasty. We examined the radiological changes and their local symptoms for any potential correlationship. The 47 patients involved 31 males and 16 females, with an average age of 61 years. Cervical back muscle area was measured by computed tomography. Local symptoms remained in 7 patients after the operation. These local symptoms did not correlate with ligament deviation nor the CT measurements of back muscle area.
We reviewed 8 patients in whom the Cervical Spine Locking Plate was aplied for degenerative cervical spine disease. Morscher introduced a system to prevent migration and loosening of screws by using a cross-split screw head that can be locked into the plate. The secondary advantage of this system is that it eliminates the need for posterior cortex purchase and there by decreases the risk of spinal cord injury. Subjects comprised 5 men and 3 women with a mean age of 56 years. Five were cervical spondylosis and 3 ossification of the posterior longitudinal ligament. Hardware lossening occurred in one Rheumatoid Arthritis Patent but a fusions healed in a good position. CSLA provides immediate stable fixation with minimal complications. Its use should be considered in the surgical treatment of patients requiring multilevel anterior cervical arthrodesis of degenerative cervical spine disease.
We evaluated cervical alignment of cerebral palsy (CP) patients using a biomechanical method. Patient's ages ranged from 10 to 31 years with an average of 20 years. There were 18 men and 10 women. “A” values (the index of the degree of malalignment) of CP patients were significantly higher than those of normal men. In addition, sagittal rotation between two vertebrae increased at the upper cervical disc level. Imbalance leading to muscle strain in CP patients seemed to be an important factor that proceeds the buckling of the cervical alignment.
We operated on 6 long-term hemodialysis patients cervical spondylomyelopathy two patients had cevical canal stenosis, and the other had destructive spondyloarthropathy. Activity of daily living of all patients was highly restricted because of gait disturbance, upper extremity paresthesia and muscle weakness. We performed laminoplasty in 2 patients, anterior spinal fusion with spinal process wiring in 4 patients, and examinated the cause of the cervical spondylomyelopathy.
We report two cases of acute spinal epidural hematoma with spontaneous resolution. Case 1: A 71-year-old woman experienced sudden onset of neck pain. On admission, neurological examination showed left hemiplegia. MRI revealed hematoma compressing her spinal cord from C4 to C6. Her symptoms recovered after 16 hours and almost complete recovery was achieved 3 days after the onset. MRI showed that her hematoma disappeared on the 21th day after onset. Case 2: A 63-year-old woman was admitted to our hospital for acute onset of severe backpain and paraplegia below L1. Her paraplegia recovered gradually about 3 hours after onset, and there was no recurence of paraplegia. The hematoma appeared from Th11 to L1 on MRI and disappeared on the 60th day after onset. MRI is useful for detecting acute spinal epidural hematoma safely and accurately. Conservative management may be appropriate in these instances in which early neurological recovery occuris.
The standard treatment for spinal epidural hematoma has been prompt surgical evacuation. Emergency decompression for spinal epidural hematoma was also emphasized in our previous report. We now report four cases with natural resolution and recovery. We conclude that concervative management of spinal epidural hematoma may be apppropriate in instances in which there is minimal neurologic findings or early and sustained neurological recovery confirmed by radiological resolution of the lesion.
Spinal crod infarction is rare in comparison with cerebral infarction. The onset is rapid and it is difficult to diagnose decisively. We report on the clinical course of a patient with spinal cord infarction and detail the and serial MR imaging from acute to chronic phase. The patient, a 47-year-old female, had suddenly developed paraplegia. She remained alert but had flaccid palsy of the lower limb, hypaesthesia, and numb sensation of the lower limb. We could not find any abnormal finding on myelography. MR impaging showed a high intensity signal in the anterior area of her spinal cord from 7th to 12th thoracic spinal cord on T2W-Imaging at 56 hours after the onset. There was a clear high intensity area in the anterior area of spinal cord from 7th to 12th thoracic segments on T2W-Imaging after 23days. According to the acute onset and the high intensity area seen in anterior area of the spinal cord on T2 W-Imaging, we diagnosed anterior spinal artery infarction.
Commonly, the prognosis of CSM accompanied by myelomalacia is not good, and the pathology remains to be clarifed. We report one case of myelomalacia in a 61 year old male. February 1991, he deveisped weakness of his right lower extremity and numbness of left lower extremity. Symptoms progressed slowly. July 1993, he was not able to walk without support, and had disturbed fine finger movement. Neurological examination revealed incomplete tetraplegia below C6. Preoperative MRI show an intramedually lesion in which was of low intersity on T1 images and high intersity in T2 and Gd enhanced images. We diagnosised CSM accompanied by myelomalacia, and cervical laminoplasty (C2-C6) was performed. The patient began to recover, but three months later, progressed to paresis. On MRI, the cord was swollen, and the intramedually lesion imaged by T2 was enlarged. We report progression of the degeneration of the intramedually CSM lesion accompanied by myelomalacia.
A 66-year-old woman presented with symptoms of sudden onset of numbness, muscular weakness of bilateral lower extremities and urinary retention. Within 30 minutes after onset, she had complete flaccid paraplegia, and was transferred to the municipal hospital. MRI 5 days after onset revealed a swollen spinal cord and a low intensity area on T1 weighted sagittal images, and high intensity area on T2 weighted images in the anterior part of the cord below L1. MRI 3 weeks after onset, showed a high intensity area in the anterior part of the cord on T1 weighted images and the cord was thinner than in the earlier images. After admission, motor recovery was seen, and she could walk with a cane eight months after onset, but there was no recovery of dissociated sensory loss below L1 on both sides, and urinary ratention.
We carried out a survey of lower extremity injuries in runners living in Saiki city and its environs. The mean age of subjects was 38.8 years, the mean number of years running 13 years, and mean monthly mileage 224km. We obtained information by means of questionnaires, measuring alignment in the lower extremity and muscular strength. 23 runners had experience of running injuries and many had hsd Achilles tendinitis. Injured runners differed significantly from noninjured runners in that they were more likely to have run more miles per week, run at a faster pace, and been running for more years. With respect to malalignment of the lower extremity 8 runners demonstrated genu varum and 5 runners flat foot. No specific malalignment correlated with any specific injury. There was no statistical difference in muscular strength between injured runners and noninjured runners. There may be a positive association between running injury and training errors.
Stress fracture of the rib is comparatively rare. We experienced three cases of stress fracture of the rib in high school baseball players. Case 1 and 3 were pitchers and had an 8th rib fracture on the dominant side. Case 2 was a third baseman who developed a second rib fracture on the dominant side. Diagnosis was based on a history of increased training, and bone scintigraphy which was a very useful examination for early stage diagnosis. Early diagnosis and treatment are necessary for those players who develop symptoms of stress fracture.
We experienced a case of a 34 year-old man who ruptured his pectoralis major due to bench press exercise. Operation was performed three months after injury resulting in satisfactory functional repair but the patient was not satisfied with the cosmetic. Rupture of the pectoralis major is a rare illness with only about 100 reports found so far. In many of these reports, surgery achieved good results for complete rupture cases. However, there were fewer reports on old cases, but many of those available showed that the operation achieved good functional results, but there were not so many good cosmetic results.
We experinced a rare case of osteochondromatosis in the subacromial bursa. The patient was a 65-year-old man who complained of left shoulder pain, touchable mass lesion and slightly limited of range of shoulder motion. Roentgenograms and arthrography showed several calcified or ossified mass lesions in the extraarticular region. He was treated with a surgical procedure that consisted of anterior acromioplasty, removal of the mass lesion and resection of the subacromial bursa. Histologic examination showed this case might be a different etiology from the typical synovial osteochondromatosis.
A case of recurrent anterior dislocation of the shoulder in the aged is presented. An 88-year-old female dislocated her right shoulder, and then had approximately another 5 times dislocations since. X-ray revealed posterolateral notch and MRI revealed rotator cuff tear. After Öudard-Iwahara·Yamamoto modified procedure, she had no complaints, and no recurrence was noted until 3.5 years after the operation. Based on our experience, Öudard-Iwahara·Yamamoto modified procedure is recommended in the elderly person.
We describe the results of using the Bankart repair with a soft-tissue attachment device, the Mitek G II anchor in 5 consective cases (3 males and 2 females, ranging in age from 23 to 43 years) for traumatic recurrent anterior instability of the shoulder. Follow up period ranged from 8 months to 2 years 7 months. The average surgical time was 25 minutes more in the Mitek G II anchor group than in the transosseous suture group. The surgical outcome was satisfactory in 5 cases. No metal-related complication occurred in this series. We concluded that the Mitek G II anchor was a useful attachment device for cases treated with a Bankart repair.
Diagnosis of subscapularis tendon rupture is difficult because it can frequently be reduced and specific symptoms are few. Recently, there have been many reports on the effectiveness of MRI to diagnose rupture of the subscapularis tendon. We found MRI to be very effective for confirming rupture as reported, although we only experienced two examples. We report on the arthrography, MRI, and surgical findings in these cases. Amalgamating RSD immediately after the operation improve the symptoms of one case limitation in the ROM in the other case did not improve although the pain disappeared in both cases after operating. We also report on our method of rebuilding the damage to the rotater interval which amalgamates with rupture of the subscapularis tendon. We believe that restoration of the rotater cuff interval is very important for successful treatment of this disease.
We surgically treated 6 patients with rotator interval lesions. Our diagnosis required (1) existence of shoulder pain, (and night pain), (2) existence of motion pain or limitation of range of motion, (3) tenderness of the rotator interval, (4) rotator cuff (supra spinatus tendon and subscapular tendon) are not torn, (5) arthrographic findings suggest a rotator interval lesion. Surgical procedure; coraco-acromial ligament is resected and coraco-humeral ligament is retracted, rotator interval is sutured side to side. Patients were evaluated acording to their JOA score. Mean preoperative JOA score was 65.5 and postoperative JOA score was 96.3.
Forty-five patients who had surgery to repair a full thickness rotator cuff tear (45 shoulders) were followed for an average of 35.5 months (range, 6 to 72). Thirty were men and 15 women. The average age of the patients was 56 years (range, 31 to 67 years). After anterior acromioplasty, tendon to bone repair was accomplished in 37 shoulders, tendon to tendon repair in three, and repair with Teflon felt in five. It was necessary to transfer the subscapularis in three shoulders and to advance supraspinatus in one shoulder. Generally patients were placed in abduction braces to hold the shoulder in 60° to 90° flexion and abduction after the operation. Patients received passive ROM (range of motion) exercises to the shoulder for the initial 4 to 6 weeks. This therapy was followed by active assisted ROM and finally by active ROM as strength was regained. Using JOA score, excellent or good results were achieved in 93% of the patients with small or medium tears (5cm≥, N=29). However, excellent or good results were achieved in 70% of large or massive tears (5cm<, N=16).
From 1980, we have operated on rotator cuff tear patients with the same operative method namely, tendon to bone suture, lateral acromioplasty and coraco-acromial ligament resection. 16 out of 36 patients with a post operative period of more than 10 years were evaluated according to their JOA score. The mean age of the subjects was 65 years at follow-up and they were followed up for an average period of 12 years. They were evaluated before surgery and at an average period of five years after surgery. However, they were evaluated according to Wolfgang's criteria before surgery because of the absence of the JOA score at that time. As Wolfgang's criteria (x) and JOA (y) score correlate (y=3.1x+37.3, r=0.92), the preoperative score were converted into JOA score. The average JOA scores were 66.3, 94.3 and 94.7 before surgery, at five years and at 12 years after surgery, respectively. There was no significant differernce between follow-up at five and 12 years after surgery concerning the total and each item of the JOA score. From our study, it can be concluded that five years of follow-up is enough for patients operated on for rotator cuff tear.
We reviewed the results of 18 cases of posttraumatic shoulder contracture which had required surgical therapy. Before 1990 we performed closed manipulation for all cases. Since 1990 we have used surgical manipulation for those cases whose disorder resulted from fracture or dislocation of the shoulder, and we have performed arthroscopic manipulation for other cases of contracture. In the surgical manipulation, anterior acromioplasty, releasing of the coracoacromial ligament, the coraco-humeral ligament and the joint capsule are performed. In two cases we also performed partial tenotomy of the pectoralis major muscle or osteotomy of the greater tuberosity of the humerus. In the arthroscopic manipulation, inflammatory synovium in the joint capsule and the subacromial bursa were resected and release of the coraco-humeral ligament was performed. After that, the shoulder joints were manipulated manually. ROM, pain, ADL, complication and recovery period after procedures were assessed. Results: ROM was improved 44° in flexion, 51° in abduction, 18° in external rotation.
Between 1988 and 1994, we performed hemi (HA) and total shoulder arthroplasties (TSA) on ten shoulders. We evaluated the results of these TSA and HA procedures for nine cases of rheumatoid arthritis and one fracture of the humeral neck. The results of these ten cases were successful or acceptable in a short-term follow up study (1 year-6 years 8 months, mean 3yrs and 4 months). At follow-up, all shoulders were free from pain. The average range of active flexion, active abduction and active external rotation improved in HA. But the range of motion did not improve in TSA. Of the four shoulders, two had complications with an anterior dislocation and a posterior dislocation. And three of the patients (75 percent) had radiolucent lines at the glenoid-cement junction. However none of these were symptomatic and there was no loosening of the glenoid component. In one case with a rotator cuff tear, the articular surface of the glenoid showed a gradual destructive change in HA, but the patient had no pain and gained a good ROM. Though HA and TSA are effective for pain relief, HA is better than TSA for improving the patients ROM and ADL.
5 elbow joints of 3 cadavers were dissected to investigate the anatomical characteristics of the lateral collateral ligament. We could identify the existence of the posterior fiber of the lateral collateral ligament in all cadavers. The anterior fiber of the lateral collateral ligament ran from the lateral epicondyle to the annular ligament. The posterior fiber originated from the lateral epicondyle and inserted into the crest of the supinator of the ulna. We concluded that meticulous dissection was needed to identify the posterior fiber of the lateral collateral ligament and the posterior fiber had the important function of keeping the elbow stable.
Intramedullary nailing surgery using Herbert screws was performed in 6 patients with a 1/3 fracture of the clavicle. Excellent synostosis was observed in every patient, without malunion of the bone. The patients started excursion training in the early phase of recovery, and gained excellent excursion field. It was thought that intramedullary nailing surgery using Herbert screws could become a promising therapy in the future for patients with a 1/3 fracture of the clavicle.