There are few studies about corticosteroid-induced osteoporosis in children. This study investigated the effects of corticosteroid therapy on clinical features such as bone mineral density, back pain and pathological fractures in pubertal children. Bone mineral density of the lumbar spine and total body were measured using DEXA in eight patients treated with prednisone. All patients were female ranging in age from 10-15 years. Remarkable bone loss was evident in their lumbar spine. The mean L2-4 Z score was -3.38SD. Total body bone mineral density slightly decreased. The mean total body Z score was -1.00SD. The patients with a lower bone mass in the lumbar spine tended to experience low back pain. Two patients suffered from pathological fractures due to osteopenia; one with L1 and L2 compression fractures and the other with a 4th metatarsal fracture of right foot. Corticosteroids reduce bone mineral and have and effect on various organs in multiple ways, making the treatment for osteoporosis complicated and difficult. A substantial protocol for corticosteroid-induced osteoporosis in childhood needs to be established, not only to prevent back pain or fractures but also to ensure normal growth.
The effect of vitamin K2 on bone mass of osteoporotic middle-aged female rats induced by ovariectomy was studied. OVX or Sham operations were performed at day 0. Vitamin K2 (Note to Author Please confirm which dose of vit K2 was given) was orally administered for 7 or 14 weeks and the rat was then sacrificed. After resecting the proximal tibias, X-ray pictures were taken and the bone area of each proximal tibial metaphysis was measured by computer. In experiment 1, in which vitamin K2 was given during the whole experimental period of 7 or 14 weeks, vitamin K2 did not inhibit the decrease in bone mass induced by ovariectomy. In experiment 2, in which no drug was administered for the first seven weeks, followed by vitamin K2 administration for the second 7 week period, vitamin K2 did not inhibit the decrease in bone mass. In conclusion, vitamin K2 did not influence the bone mass of the osteoporotic rats induced by ovariectomy.
We treated twelve patients who had previously received DMARDs to no effect with Mizoribine (100mg-150mg) for one year. We then evaluated their clinical findings (Lansbury index) and laboratory data (CRP, RAHA). Mizoribine was effective in 5 patients (41%) and ineffective in 7 patients (59%). The effective group showed an improvement in their Lansbury index four months after starting the treatment (P<0.01). One patient began to feel anacatesthesia after five months and stopped the medication. One week after stopping their symptoms improved. There were no statistical differrences regarding age, morbidity year, class, stage, combination rate of PSL and Mizoribine dose between the effective and ineffective group, although the effective group had a tendency to use Mizoribine more early than the ineffective group. Drug indications note that Mizoribine should be used if DMARDs are ineffective, but it can be administered earlies than this effective, but it can be used more early.
We report the results of a trial assessing additive combination therapy using Auranofin in patients with Rheumatoid Arthritis (RA). Subjects included 23 RA patients who had been treated with a disease-modifying antirheumatic drug (DMARD) effectively but incompletely. Auranofin was added aiming at complete remission. Three cases with adverse reactions such as diarrhea and itching were reported. Lansbury index demonstrated a significant improvement, decreasing from an average of 48% prior to administration to 34% at three months. There was also a significant improvement in laboratory findings such as ESR and CRP. It appears that additive combination therapy using Auranofin is effective in this patient population, at least for up to three months.
Fifty-three patients with rheumatoid arthritis were evaluated for the effect of combination DMARD therapy. Various combinations of DMARDs for the treatment of active RA were used, although in this study about 80% of RA patients were treated using combination DMARD therapy with salazosulfapyridine(SASP). The combination therapy with SASP was maintained for more than 2 years in 12 patients (21.8%). During the first 6 months of combination therapy 50.9% (28/55) of the patients had an overall favorable response. The incidence of side effects was 23.6% (13/55), but this was almost the same as that reported for single DMARD therapy. The results revealed that combination DMARD therapy with SASP is an effective therapy to use before changing from one DMARD to another.
I report on incubated leucocyte infusion therapy for RA patients. Cultured leucocytes are obtained from healthy human leucocytes which are cultivated for 48 hours being added with 5% RPMI-1640. The cultured leucocytes consist of Three types of cells: one, an activated Omikoshi-cell, the other, non-omikoshi cell. The patient has to be medicated once every 4 weeks, and this is repeated 6 times, comprising 1 course. After initial medication, this course has to be repeated once every 2 to 4 months depending on the patient's recovery. The healing rate is 100% for patients with stage I and II RA. The main problem associated with this therapy is its high cost, 50, 000yen (approx. $500) for every dosage, and incubated leucocytes have to be infused within 24 hours.
We performed anterior interbody fusion in 17 patients with cervical myelopathy because of cord compression at one intervertebral level. In all cases, radiographic examination showed cervical disc herniation, and 9 patients had associated spondylotic changes, and 3 patients had ossification of the posterior longitudinal ligament (OPLL) Since favorable response was not achieved in 2 patients after the initial operation, we additionally performed expansive laminoplasty. Both of these cases were accompanied by cervical canal stenosis. In this report, the authors describe their postoperative results and reconsider the indications for anterior interbody fusion.
We reviewed 11 patients who required re-operations for cervical spondylotic myelopathy. These Subjects were separated into two groups according to their clinical conditions. Group 1 included patients who required re-operation because of conditions related to their initial condition or initial surgery. Group 2 included patients who required re-operation because of an added clinical condition. After secondary surgery, Group 2 achieved better clinical results than Group 1. We recommend that we teach patients about their expected clinical course after surgery and in patients with a narrow spinal canal we recommend the use of combined operations.
Circulatory function is an important prognostic factor for the surgical results of cervical myelopathy. However it is difficult to measure spinal cord blood flow (SCBF) during surgery, therefore until now no investigator has reported such results in human subjects. we measured SCBF during laminoplasty of cervical spine using laser-doppler flowmetry to investigate the relationship between surgical results and SCBF. Eight cases with cervical spondylotic myelopathy and four cases with cervical myelopathy due to OPLL were examined. Surgical results were evaluated using the JOA score and Hirabayashi method. The average Hirabayashi score in cases with an inceasing SCBF during elevation of lamina was 79.4% and that in cases with a decreasing SCBF was 32.9% which was statistically significant. Measurement of SCBF using laser-doppler flowmetry during laminoplasty of the cervical spine is useful for the evaluation of surgical results.
Cervical laminoplasty (Hattori's method) has been applied to patients with cervical myelopathy since 1971. A 53-year-old man, operated upon with this method 11 years ago, visited our clinic with paraplegia on July, 1995. Laminectomy were done and the enlarged laminae were examined for X-ray and histological evaluation. Z-sharped laminae achieved hard union, and new bone formation was mainly seen at dorsal side of the laminae. Histologically, thin scar tissue was formed slightly on the durai side. It can be confirmed flom this case that cervical laminoplasty fulfilled the function of the spinal canal with structural bone covering the spinal cord, and obtained moderate limitation of range of motion, with less scar formation around the dura mater.
We retrospectively evaluated the surgical results of cervical spondylotic amyotrophy in 39 patients (34 men and 5 women) who had been managed between 1973 and 1995. The average age at the time of surgery was 51.2 years (range, 33 to 82 years). Subjects showed muscle atrophy at the shoulder girdle (17 patients), at the forearm and hand (12 patients), and throughout the whole upper extremity (10 patients). Activities of daily living were preoperatively impaired by the muscle weakness. Neurological findings revealed 27 myelopathies and 12 radiculopathies. Anterior interbody fusion (Robinson-Smith) was performed in 35 patients (60 intervertebral discs) and expansive laminoplasty (Hirabayashi) was performed in 4 patients. The average duration of follow-up was 64 months (range, 6 to 164 months). The activities of daily living improved in 31 patients (79%), but in eight patients (21%) they were still impaired. The eight patients preoperatively had all showed myelopathy. In cases of developmental spinal canal stenosis (under 12mm of the sagittal diameter), multiple segmental (over three intervertebral discs) lesions, and generally narrow subarachnoid space, anterior interbody fusion gave poor results. In such cases we recommend the expansive laminoplasty.
To clarify the role of mechanical factors in the pathogenesis of the ossification of the posterior longitudinal ligament (OPLL), we investigated the cervical posture of 32 patients with OPLL and 18 patients with cervical spondylotic myelopathy (CSM) in their daily life. All patients were examined directly in our hospital. Patients with OPLL maintained their carvical spine in the anterior flexed position significantly longer than patients with CSM. We concluded that mechanical factors are important aspects in the pathogenesis of OPLL.
The Zucker fatty rat is used as an animal model to study ectopic ossification. The morbidity of OPLL in this adult rat is 23.8%. To evaluate the relationship between aging and the incidence of OPLL, we investigated the morbidity in elderly Zucker fatty rats and observed the localization of BMP-receptors in the ossification tissue by immunostaining. Four of 5 Zucker fatty rats had OPLL in their cervical spine, but only one of 4 control rats had OPLL. As the enchondral ossification site, the expression of BMPR-IA was strong while that of BMPR-II was weak. The expression of BMPR-IB was not detected. In the normal posterior longitudinal ligament of the Zucker fatty rat, We could only detect the expression of BMPR-IA, but in the control rat we could not defect any of these receptors. We concluded that Zuckerfatty rat is a useful animal model for evaluating OPLL because it has a hereditary disposition and the morbidity of OPLL increases with age.
In 1990 Rousselin et al. reported pseudotumor of the periodontoid soft tissue mass in patients on long-term hemodyalysis. Our study of the upper cervical spine was performed using magnetic resonance imaging and X-ray in 20 patients (15 males and 5 females). The mean age of subjects was 53 years (ranging from 35 to 78 years). They were treated with long-term hemodialysis for a mean of 9 years (ranging from 4 to 24 years). Plain radiography demonstrated vertical atlantoaxial subluxation in two, and one showed a fracture of the odontoid process. The other showed an irregular feature of the atlantoaxial joint. Pseudotumor of the periodontoid soft tissue was observed in 5 cases (25%) by MRI. The mean duration of dialysis in patients with pseudotumor was 17.7 years, and that in patients without it was 7.4 years. The duration of dialysis in the pseudotumor group was significantly older than that in the non pseudotumor group (P<0.01). There was no significant difference in β2 microglobulin between the 2 groups. In T1-weighted MRI sequences, the signal intensity of the soft tissue mass was lower or equal than that of the spinal cord. In T2-Weighted sequences, the abnormal masses exhibited low intensity in 4 patients, and of high intensity in one patient. These Pseudotumor are suggestive of β2 microglobulin amyloidosis. MRI appeared to be very useful for the demonstration of the periodontoid soft tissue mass.
Extreme lumbar disc herniation (ELLDH) is one of the diagnotic difficulties of nerve root impingement in the hidden zone. We have surgically treated thirteen patients with ELLDH, and report on their diagnosis and the surgical approach used. Subjects comprised 13 patients, (11 male, 2 female) ranging in age at surgery from 25 to 68 years (mean 46.3 years). The locations of disc hernia were intraforaminal (IF, 7 cases), and extraforaminal (EF, 6 cases). Myelography was of no value in the diagnosis of EF but implied the level of the herniated disc in IF. Discography and radiculography were more valuable for diagnotic establishment of IF. Cross sections of CTM and MRI supplied very important findings of EF. Regarding surgical procedure, the cases of IF were treated by unroofing (six cases) and hemilaminectomy (one cases), three cases of EF have been recently treated by osteoplastic hemilaminectomy without fusion instead of facet destructive procedure which was used earlier. Accuracy of preoperactive diagnosis and appropriate selection of surgical approach are needed for ELLDH.
This study evaluated the instability of the lumbar spine after osteoplastic hemilaminectomy. Twelve patients with extraforaminal intervertebral disc herniation of the lumbar spine were studied, (these subjects represented 7% of the total number of subjects with lumbar disc herniation). Subjects were 8 males and 4 females with a mean age of 50 years ranging from 20 to 70 years. The duration of follow-up varied from 4 months to 58 months, with a mean of 2 years. 11 patients underwent osteoplastic hemilaminectomy and one patient had an osteoplastic bilaterallaminectomy. Subjects were evaluated radiologically with regard to bone union, range of motion, osteoarthritis of the facet joint and clinical results. The main findings were as follows: 1. The results at the time of final follow-up were excellent in 58%, good in 33%. 2. The bone union rate at the spinous process was 100%. There was 78% of the osteoplastic laminectomy in bone union at the lamina in osteotomy. 3. ROM at the level of the disc herniation decreased about 12% postoperatively. 4. 60% of the osteoplastic laminectomy (3 of 5 cases) were due to osteoarthritis of the facet joint. 5. There were no cases of instability. These results show that the osteoplastic hemilaminectomy is an excellent surgical technique for patients with extraforaminal intervertebral disc herniation of the lumbar spine. This paper also introduces a new technique for osteoplastic hemilaminectomy using a stainless steel thread wire. This offered the following advantages, compared with an osteotomy using a chisel. 1. There is no cracking and no warped bone when performing an osteotomy of the spinous process. 2. There is sharp cutting line of the cortex at the side of the canal when performing an osteotomy of the lamina. 3. The direction of the cutting is the opposite in osteotomy using the chisel. This means in a direction away from the nerve. Therefore, there is less possibility of nerve root injury. 4. There is less cutting loss.
We present a series of 30 patients who were diagnosed as having extraforaminal lumbar disc herniations and underwent osteoplastic hemilaminectomy. Subjects included 20 male and 10 female patients, with an average age of 51 years. Regarding the level of the herniation, fifteen were at the L5-S level, nine at the L4-5 level, six at the L3-4 level and one at the L2-3 level. The follow-up period varied between 11 months and 104 months, with an average of 54.7 months. The results were as follows. The mean JOA score was 27.5 at the last follow-up, compared to 12.4 pre-operatively. Complete union was achieved in all osteotomy cases. No patient suffered spinal instability postoperatively. An advantage of osteoplastic hemilaminectomy is that it allows a comprehensive view of the nerve root canal throughout the intraforaminal and extraforaminal zones and preserves posterior structures such as the facet joint and pars interarticularis.
We experienced two cases of synovial osteochondromatosis of the hip. Case 1, a 12-year old boy complained of limitation in his right hip motion. Roentgenograms showed many small calcified or ossified particles in the right hip joint. We performed synovectomy, and found the hip joint to be filled with more than two hundred calcified loose bodies. Range of motion of the hip recovered after surgery. Microscopic examination, revealed the synovium to have an osseous and cartilaginous lesion. Case 2, a 24-year-old man complained of right coxalgia and limitation of right hip motion since he was 20 years old. Roentgenograms showed right hip joint space narrowing and osteoporosis. Hip tuberculosis or pigmented villonodular synovitis was Suspected. However, gadolinium (Gd) enhanced MRI with fat suppression showed enhanced hypertrophic synovium and no enhanced nodular lesion in the synovium. Therefore, this case was diagnosed as synovial oeteochondromatosis of the hip joint. Synovectomy revealed hypertrophy of the synovium, and osteochondromatosis were seen matted within the synovium. There were no loose bodies in the joint space. However, this case achieved only a small improvement in his range of motion post-operatively. Microscopic examination, the synovium had many cartilaginous lesions, but there was few ossiferous lesion. We consider that Gd enhanced MRI with fat suppression is useful for the early diagnosis of synovial osteochondromatosis that has not been ossified.
We observed the histological deformities in the rat hip joint caused by mechanical loading using an original intra-corporeal method. This was done to investigate the pathogenesis of disorders in the proximal femoral epiphysis such as slipped capital femoral epiphysis and Perthes' disease which usually deform the femoral head architecture. Under a compressive loading force of 3 Kilogram, the articular cartilage was depressed at the lateral part of both the femoral head and acetabulum in Wister rats from 9 weeks of age. Plump chondrocytes became spindle shape and the osseous nucleus sank into the growth plate. The growth plate decreased in thickness and the cellular column was distorted in that region, Deformity of the growth plate was more prominent in the lateral rather than the medial part. The above findings lessened with progression of age. Our new method is useful for understanding histological damage to the hip joint caused by mechanical loading.
Weakness of the hip abductor muscles caused by wide surgical dissection may produce a Trendelenburg gait postoperatively, and increase disability of the postoperative hip. We investigate the dissection-effect of the gluteus medius muscle to its blood flow using an in vivo animal model. Sixteen hips of 8 adult rabbits were used. Blood flow was measured using the hydrogen washout technique. After the control blood flow rate was determined, the origin of the gluteus medius muscle was dissected from the iliac crest in the proximal-distal direction in 10 hips. Blood flow of the gluteus medius muscle was measured every one-third of the dissection. In the other 6 hips, the greater trochanter was osteotomised and the gluteus medius muscle dissected from the ilium in the distal-proximal direction. Blood flow of the gluteus medius muscle was measured every one-third of the dissection. Results showed that the blood flow was decreased significantly from control value after dissection of the proximal or distal two-thirds of the gluteus medius musie from its origin. It is suggested that minimum damage to the mid-portion of the gluteus medius muslcle is important to reduce the incidence of postoperative complications.
Absorbable FIXSORB SCREWS are made from poly-L-lactic acid. We used these screws for internal fixation when performing Transposition Osteotomy of the Acetabulum (TOA) in 8 hips instead of using Kirschner wires or screws which are made of titanium. At an average follow-up of fourteen weeks, there were no displacements of the osteotomized fragment or foreign body reaction in all our patients. Although the period of postoperative follow-up is short, we believe that these absorbable screws seem to be a useful internal fixation device for TOA.
We performed rotational acetabular osteotomy (RAO) in 9 middle aged patients. All subjects were women with advanced osteoarthritis (OA) of the hip and congruity of the hip improved in abduction. The age at surgery ranged from 47 to 58 years, with a mean of 50.6 years and the follow-up period averaged 4 years and 8 months. We compared CE angle and JOA hip score before and after surgery. All patients improved both in CE angle and JOA score. The mean CE angle improved from -1.7 degrees to 40.2 degrees. The mean JOA score improved from 66 to 90.7 points. Two of three bilateral patients showed progression of the degenerative changes in their contralateral hip after surgery. In one remaining patient, the contralateral hip required, total hip arthroplasty. The indications for RAO in middle aged patients with advanced degenerative arthritis of the hip have been controversial. Our findings suggest that satisfactory results can be obtained when hip congruity improves in abduction. In bilateral cases, early surgery of the contralateral hip may prevent progression of OA of the contralateral hip.
We report the follow-up results in 22 cases of unilateral total hip arthroplasty in patihents with bilateral osteoarthritis. 1. Pain of sixteen unoperated hips (73%) improved after one year of implantation 2. Radiological findings improved in 14 hips (64%) with recovery of hip joint space. 3. Patients with bilateral osteoartheritis improved. and radiological roof osteophyte and end stage osteoartheritis
We designed a device to measure the leg length discrepancy during total hip arthroplasty (THA), and then performed a randomised prospective study to determine the efficacy of the device between June 1993 and August 1995. Thirty-four hip arthroplasties were performed on 34 patients using the Impact Modular Hip System. The mean age of the patients was 62.5 years ranging from 51 to 81 years. These patients were divided into 2 groups of 17 patients each. In Group I, we performed usual THA without using the device. In Group II, the device was used for measuring the length of the two points between the iliac bone and the greater trochanter. Leg length discrepancy before and after THA was determined by measuring the length from the ischial tuberosity to the lesser trochanter on the full-view lower extremity roentgenogram. The mean leg length discrepancy in Group I was within 1cm, while that in Group II was more than 1cm. No statistical differences were found in surgical time and operative blood loss between the two groups.
We reviewed 16 cementless total hip arthroplasties (THAs) (in 14 patients) in which 9 hips had the Harris/Galante Porous System (H/G) and 7 hips had the Harris/Galante MultiLock Prosthesis (MultiLock). We evaluated these cases clinically and radiographically. The mean age of patients at surgery was 53.7 years, ranging from 45 to 67 years. All patients were diagnosed preoperatively as having osteoarthritis and were followed for more than 6 months (mean of H/G 75 months and mean of MultiLock 15 months). The average preoperative JOA score increased (range 58.1 to 83.7 points by H/G and range 59.4 to 87.1 points by MultiLock). In 9 hips (56%) there were radiolucent lines, but there was no evidens of loosening of the femoral component. A longer followup study is necessary for an evaluation of the relationship between the cementless THA and thigh pain.
From 1991 to 1994, we performed 31 cementless total hip arthroplasties in 30 patients. Of these we were able to follow 15 joints in 15 patients for more than one year. From these 15 total hip arthroplasties, we assessed roentgenologic criteria on the stem side. According to the assessment, there were two “unstable” stems and it seemed important to get cancellous condensation in the proximal femur.
we reviewd radiographs and JOA scores of seven patients in whom an Osteonics total hip replacement (THR) had dislocated (6 posteriorly; 1 anteriorly) and compared the orientation of the acetabular cup, limb length discrepancy, change in limb length and ROM score component in JOA score with 13 patients who had a THR that had not dislocated. There was no difference between the posterior dislocation group and no dislocation group. We consider that post-operative education for prevention of dislocation of the prosthesis is important because of the narrow ROM of the prothesis.
Antibiotic-impregnated bone cement beads have been popularized for the treatment of chronic osteomyelitis. Many surgeons have used aminoglycoside-impregnated beads, because aminoglycosides are heat-stable during polymerization of PMMA and have a broad antibacterial spectrum. Unfortunately, aminoglycosides are not very effective against methicillin-resistant staphylococcus aureus (MRSA) infections. Cement beads have not been impregnated with vancomycin because of its heat-liability. With vancomycin-impregnated beads (VCM-beads), we were successful in treating a 58 year-old man, who had an MRSA infection after THR. The local concentration of vancomycin was 85.23μg/ml at 24 hours after surgery, 9.34μg/ml at 7 days, 3.69μg/ml at 14 days. These values were well above the minimum inhibitory concentration (MIC, 1.56μg/ml). The serum concentration of vancomycin reached the peak (2.96μg/ml) 4 hours after surgery. This peak value was under the safety limit, and the serum concentration of vancomycin was undetectable after 4 days. From this study, VCM-beads were proved to be effective for deep MRSA infection and local concentration of vancomycin beads was well above the MIC at least 2 weeks after insertion.
We report our experience of revision surgery for 4 socket failure after AML type cementless total hip replacement. Case 1; A right THR was performed in March 1990, in a 61-year-old woman suffered from avascular necrosis. The prosthesis was dislocated 3 times post-operatively and it was replaced under general anesthesia. After the 3rd dislocation, the inner head migrated lateral-superiority and metallosis was suspected. Revision of the socket was performed. Intra-operatively, we recognized polyethylene wear and failure but no metallosis findings were found, so we revised the inner head and the polyethylene liner. Case 2; A left (March, 1990) THR and a right THR (with bone graft) (April, 1990) were performed in a 55-year-old woman for rapidly destructive coxopathy. 1 year and 5 months after the operation, the grafted bone was collapsed and the socket was migrated lateral-superiority at the right side. We recognized contact of the metal back with the inner head in X-P in May, 1995 so we performed socket revision in June. Intra-operatively, we recognized severe metallosis and wear of polyethylene and the metal back was replaced with cement, inner head and polyethylene liner. Trauma and grafted bone collapse are suspected as the cause on the above 2 examples, but a weak point in the construction of the polyethylene liner of AML type total hip replacement must be also taken under consideration.
Congenital dislocation of the hip with arthrogryposis multiplex congenita is more difficult to treat than developmental dislocation of the hip by either nonsurgical or surgical means. We treated 5 patients (7hips) surgically from 1980 to 1995. The average age at the time of surgery was approximately 2 years, except for 1 patient who was operated on when aged 7 years. Four patients (6hips) were treated by open reduction (O. R.), derotation-varus osteotomy (D. V. O), and shelf operation or pelvic osteotomy. One patient (1hip) was treated by O. R. and D. V. O. Reduction was relatively successful in all patients, with no recurrence of dislocation. Range of motion of the hip could be maintained by aggressive and continuous motion exercise which was commenced 4 weeks after surgery with the removal of the hip spica cast.
Radiographically, we have frequently noted spiny bifida occulta of posterior lumbar and/or sacral spine in anteroposterior views of the pelvis in Perthes' patients. We reviewed the relation between Spina bifida occulta and Perthes' disease. A high incidence of 80% of spina bifida occulta was shown in 230 Perthes' patients whose age at diagnosis ranged from 2-16 years and averaged 7.4 years. Fusion of the posterior elements progressed with growth; whereas at follow-up 94% of 125 patients before 14 years were unfused and 48% of 58 patients aged over 15 years were fused. Growth retardation due to delayed general skeletal maturity in Parthes' patients exists in the posterior lumbosacral area.
In cerebral spastic tetraplegia or diplegia, 13 knees with fragmentation of the lower pole of the patella were compared with 58 knees without fragmentation on lateral roentgenograms. A ratio of the longitudinal patellar length to the maximal length transversing it may be used as a parameter of fragmentation. The limit of such a ratio without fragmentation was 2.5. It is considered that the ratio should be measured regularly in children walking with spastic lower extremities and that treatment of their abnormal posture is necessary to maintain walking ability before the ratio approaches 2.5.
We report a 3-year-old girl with permanent dislocation of the patella due to distal femoral epiphyseolysis in the perinatal period. This distal femoral epiphyseolysis may have occurred from a trial of external cephalic version. Radiogram showed genu valgum in the right knee when aged two months. Presently, the patient has a permanent lateral dislocation of the patella. The etiology of patellar dislocation is discussed.
We report a case of ossification of the patellar tendon in a high school baseball player. The patient is a 16-year-old boy started to play baseball when 7-years-old. He had been feeling pain in his right knee for 4 years prior to presentation. On examination, a hard mass was palpable on the lateral aspect of the right patellar tendon. Radiographs, CT and MRI, showed bone-like shadow on the patellar tendon, but laboratory data were normal. Surgery revealed ossification of the patellar tendon. Pathological investigation revealed this to be bone tissue. The ossification may have been due to abnormal repair of patellar tendonitis.
Sixteen normal knees and 14 knees with patellofemoral osteoarthritis (PF-OA) were evaluated. In each knee, a line was drawn on the skin according to the contour of the tibial tubercle and the patellar ligament, and a wire was placed on the skin so that it matched the width of the patellar tendon. An axial view radiograph was taken at 30° of knee flexion with the Merchant technique. On the radiograph, a line was drawn between the highest point of the medial and lateral condyle (C line). A perpendicular was drawn from the central point of the marking to the C line and the point of intersection was defined as TT point. Another perpendicular was drawn from the lowest point of the sulcus to the C line and the point of intersection was defined as the S point. The length of the C line, the distance between the highest point of the lateral condyle and the TT point (TT-LC distance), and the distance between the TT point and the S point (TT-S distance) were measured. The distance between the medial and lateral condyles was identical between the normal (41.0mm±3.3mm) and the PF-OA group (42.1mm±5.0mm). However, the TT-LC distance was 8.5mm±7.2mm in the normal group and 1.8mm±8.8mm in the PF-OA group (p=0.0276) and the TT-S distance was 16.3mm±7.4mm in the normal group and 23.4mm±6.6mm in the PF-OA group (p=0.0098). This new radiography technique can be used for screening to evaluate patellofemoral disorders.
Twelve parameters of the knee were evaluated using computed tomography to analyze possible etiological mechanisms leading to patello-femoral arthritis (PF-OA). Sixteen normal knees and 14 knees with PF-OA were tested. CT scans were taken at the level of the femoral epicondyles, the tibial tubercle and the malleoli of the ankle joint at full extension and 30° of flexion. The slices were superimposed and three parameters; tibial tubercle rotation angle (TT angle), malleolar line rotation angle (ML angle) and tibial tubercle and lateral condyle angle (TT-LC angle) were measured with the central point of the medial and lateral epicondyle line as the fiducial point. Differences in each parameter between full extension and 30° of flexion were also evaluated as dynamic factors. Three other parameters, Lateral condyle rotation angle (LC angle), Lateral and medial condyle angle (LC-MC angle) and Lateral condyle and patellar groove angle (LC-S) were also measured to evaluate the anatomical configuration. The position of the tibial tubercle at full extension relative to the femoral condyle was almost the same in both groups. The results, however, demonstrated that, in the PF-OA knee, the tibial tubercle stayed more lateral compared with the normal knee at 30° of flexion. It is obvious that the tibial tubercle exists laterally in knee flexion and the patella impinges against the lateral femoral condyle in knee flexion, which will cause PF-OA.
We report our results of arthroscopy which was used to treat 34 sport players in one year. Patients are 21 males and 13 females with an average age of 21.5 years. Fifteen of these cases had meniscal tears with ACL tear. Reconstruction was performed for complete ACL tear and no treatment was performed for partial ACL tear. Suture was performed for indication cases and meniscectomy performed for others. In these subjects, 7 cases of meniscal tear with partial ACL tear were investigated postoperatively. Only meniscal suture were performed for these 7 cases and all cases returned to sport without problems. We recommend suture of meniscus as a knee stabilizer, for cases of partial ACL tear.
A Prospective study was performed to evaluate the role of microfibrillar collagen hemostat (Avitene) in the blood loss of total knee arthroplasty (TKA). Of 103 TKAs (93 patients) with osteoarthritic knees studied to analyze blood loss, 41 TKAs used avitene on the cut tibial surfaces and 62 TKAs did not. TKAs in the avitene group demonstrated an average 429ml in suction drainage, whereas those in the non-avitene group averaged 440ml. An average calculated total blood loss was 1039ml in the avitene group and 1088ml in the non-avitene group. Avitene did not statistically decrease blood loss.
The results of 6 total knee arthroplasties (MG-I one joint, MG-II five joints) after high tibial osteotomy (HTO) were reviewed. The average age was 70.6 years (range, 61-82 years). The mean period from HTO to TKA was 95 months (range, 25-204 months). The average follow-up period after TKA was 17.5 months (range, 6-24 months). It was difficult to dislocate the patella from the femoral groove and retract it to the lateral aspect, so we osteotomized the tibial tuberosity in 4 cases. As the bone axis shifted to the medial side of the proximal tibia, it was difficult to mount a tibial component. In the patient treated with MG-I, the postoperative range of motion was -10-110 degrees, and the JOA score was 80 points. In patients using MG-II, the average postoperative range of motion was -1.0-96.0 degrees, and the average postoperative JOA score was 77.5 points (range, 70-80 points). There was no signifficant difference between these cases and other TKA cases.
Miller-Galante TKA (MG: 1989-1990 and MG II: 1991-1995) with or without patellar resurfacing were reviewed retrospectively in 51 knees. 8 MG and 37 MG II were included in the final study group. All patients had a diagnosis of osteoarthritis. In the group treated by resurfacing, there was patellar subluxation in 2 knees (15.4%) and mild peripatellar pain in 2 knees (15.4%). In the group that had not had resurfacing, there was patellar subluxation in 1 knee (4.2%) and mild peripatellar pain in 2 knees (8.4%). There were no significant complications (osteonecrosis, fracture, loosening and failure of components, and chronic severe pain) and no revisions in both groups. On the basis of our findings, we recommended that the patellar surface was retained.
From May 1987 to November 1990, We performed 28 Miller-Galante Total Knee Arthroplasties in patents with osteoarthritis or rheumatoid arthritis, wear of patellar component was seen in 3 knees and revision surgery was performed in these three cases. We evaluated 22 knees including revision cases with femorotibial angle, percent of patellar cutting, tilting angle and lateral shift. We considered that wear of the patella component was caused by a low percentage of patellar cutting and a tendency for lateral shift. The Harris Osteotomy Blade and Metal Cutting Blade are very useful for removing components of Miller-Galante Total Knee Arthroplasty.
We experienced a relatively rare case of tuberculosis of the hand. Diagnosis of bone and joint tuberculosis is difficult today because the number of patients is low and especially if the patient has suffered from rheumatoid arthritis, the diagnosis become more difficult. In addition if the patient has been treated with steroids, future management will be difficult, making it hard to care for such patients.
Atypical mycobacterium infection of the joint is a rare condition. It is often misdiagnosed and treated unsatisfactorily, therefore arthritis persists and results in joint destruction. We report on a case with prolonged wrist swelling and joint destruction. The patient was first suspected of having tuberculosis with an atypical mycobacterium infection, therefore his joint fluid was cultured on Ogawa medium. Results led to a positive diagnosis and we gave preoperative chemotherapy before surgery.
Flexor tendon synovitis in patients with rheumatoid arthritis commonly presents with a carpal tunnel syndrome and a trigger finger. Triggering at the wrist joint is an uncommon feature in this disease. In this case there was a rheumatoid nodule at the wrist joint. The passage of the nodule from the proximal side of the transverse carpal ligament to the distal end, when the fingers were extended, caused a trigger wrist with a click. On surgical exploration, an oval shaped mass arising from the flexor digitorum superficialis tendon of the middle finger was excised, and the transverse carpal ligament was also released. Postoperatively the patient had no further symptoms.
[Purpose] The aim of this study was to clarify the influence of hypertonic wrist and elbow muscles in stroke patients. [Materials and Methods] Subjects comprised 28 stroke patients, (10 males and 18 females), ranging in age from 43 to 88 years, with a mean age of 68.9 years. Plain postero-anterior and lateral roentgenograms were taken of wrists and elbows bilaterally. [Results and Conclusions] (1) There were many plus variant wrists in the stroke patients. (2) The mean values of Radial Inclination, and L. U. I. in the affected side were more than those in the contralateral side. The C. U. D. R. on the affected side was less than that of the contralateral side. (3) Osteophytes of the elbow joint proliferated in the olecranon fossa, and even in the capitulum humeri.
We used three types of opponens hand orthoses for patients with median nerve palsy. Conventional short opponens hand orthosis is a static type and has some problems with ADL. Therefore, we made two new types of dynamic opponens hand othoses, and compared them to the conventional static device. One of the dynamic opponens hand othoses is a three jaw chuck pinch type and the other is glove type opponens othosis. Our results showed that the glove type opponens hand othosis was the most functionally useful.
We treated 6 cases of Kienböck's disease with revascularization for 2 cases, replacement arthroplasty using bone cored tendon ball for 3 cases and bone graft for 1 case. The age at surgery ranged from 30 to 56 years, with an average of 40 years. The follow-up periods ranged from 6 months to 9.5 years, with an average of 4.5 years. The preoperative stage classification described by Lichtman et al was stage II for 1 case, stage III a for 3 cases, and stage III b for 2 cases. Clinical results according to Lichtman's criteria were evaluated as satisfactory in 3 cases and unsatisfactory in 3 cases. The period before returning to work ranged from 2 months to 6.5 months, with an average of 5 months. Carpal height ratio (CHR) decreased in 3 cases with replacement arthroplasty using bone cored tendon ball. Osteoarthritis appeared in 2 cases with replacement arthroplasty using bone cored tendon ball. MRI suggested existence of normal marrow in cored bone and improvement of viability of lunate bone with revascularization. In conclusion, surgical treatment for Kienböck's disease should be selected after considering the patient's age, occupation, and stage of disease and it may be an effective treatment.
Osteochondromatosis in the wrist is infrequent, and very rare in the radiocarpal joint, especially in the triangular fibrocartilage complex (TFCC) region. This is a case report of a 38-year-old woman with synovial osteochondromatosis in the radiocarpal joint. MRI showed TFCC, and the synovial sheath of the Extensor carpi ulnaris (ECU) was involved with osteochondromatosis. At surgery excision of osteochondral bodies, partial resection of the TFCC, and synovectomy were indicated. The TFCC was reconstructed with the extensor carpi ulnaris tendon. At 8 months's follow-up, the patient was asymptomatic with full range of motion in the affected wrist.
Since September 1994, we have performed wrist arthroscopic treatment in 17 patients for ulnar wrist pain associated with Triangular Fibrocartilage Complex tears. The age at surgery ranges from 17 to 50 years (average 30.5 years). Follow-up averaged 10.4 months. Post-Arthroscopy diagnoses were Palmer I-A; 3 cases, I-B; 1 case, I-D; 1 case, II-C; 10 cases, II-E; 2 cases. 5 cases with traumatic tears achieved excellent or good results, but 2 cases with degenerative perforations required ulnar shortening or Sauvé-kapandji procedures.