Biligiani and Morrison studied the relationship between the shape of the acromion and rotator cuff lesions. They reported that most rotator cuff lesions were observed in patients with a hooked acromion and identified the importance of acromion morphology as one of the extrinsic causes of rotator cuff lesions. The aim of this study is to investigate the relationship between the morphology of the acromion obtained at surgery with that of pre-operative MR imaging. Thirty-nine patients with an average age of 57 years were operated on and pre-operative MR imaging was carried out in all cases. The acromion which was obtained during the surgery by lateral acromioplasty was sliced into 100μ thicknesses and it was classified as flat (type 1), smoothly curved (type 2) or hooked (type 3). To determine the acromial shape by pre-operative MR imaging, the sagittal oblique gradient echo images were obtained and classified into the same classification according to the appearance on the image obtained 4mm lateral to the acromioclavicular joint. In twelve specimens which showed type 1, five acromions were determined as type 1, four acromions were determined as type 2 and three acromions were determined as type 3 by MR imaging. In 16 specimens which showed type 2 acromion, eleven cases were determined as type 2 by MR imaging. Eleven specimens were classified as type 3 acromion and seven of them were determined as type 3 by MR imaging. The sensitivity, specificity and accuracy of MR imaging were 58.0%, 79.1% and 72.6% respectively. The low sensitivity suggests that the oblique sagittal MR imaging depends on the site and plane chosen. Therefore in our study, there was a difference between the acromial type seen in MR imaging and that of the specimens.
MRI is very useful for the diagnosis of the rotator cuff tear. However, in case of partial tears it is sometimes controvertible. In this study, we studied the accuracy of MRI in the diagnosis of partial tears. 67 patients who underwent MRI investigation before operation were chosen for this study. There were 61 males and 6 females, ranging from 30 to 80 years (mean: 54.8 years at the time of operation). MRI was performed with 1.5T superconductive system with shoulder surface coil. MPGR T2*-weighted images were performed in the coronal oblique and sagittal oblique planes. complete tears were diagnosed when full thickness high intensity was observed in the rotator cuff, whereas with partial high intensity of the rotator cuff, was considered as partial tears. MRI demonstrated 77.8% sensitivity, 91.4% specificity and 89.6% accuracy in the diagnosis of partial tear. In 8 cases MRI had misinterpretation. In MPGR T2*-weighted images, not only the partial tears but the degenerative changes also show high intensity of the rotator cuff. Therefore, it is difficult to differentiate and maybe this is the reason of misinterpretations of partial tears by MRI. MRI provided with useful pre-operative informations of partial tears of the rotator cuff. However, in few cases it is hard to differentiate for the degenerative changes of the rotator cuff.
We report two cases of sonographically guided aspiration of ganglion cyst causing suprascapular nerve paralysis. The age at treatment of the two patients was 38 and 32 years old. In both cases, clinical examination revealed wasting of infraspinatus muscle and weakness of external rotation of the shoulder. Electromyographic studies revealed denervation of the infraspinatus muscle. In both cases the cyst was found by MR imaging and by ultrasonography imaging in the suprascapular notch. The cysts were drained under sonographic guidance using a special probe for aspiration and a long needle. After aspiration both patients had no shoulder pain and recovered muscle power. No recurrence of the cyst has been found at follow-ups of 3 months and 13 months respechvely. Sonographically guided aspiration of ganglion cyst is a good teatment because it is less invasive, although it does have the possibility of relapse. We recommend that this treatment should be tried prior to surgery.
We report a rare case of deltoid muscle contracture in an adult. The patient was a 40 year old female who visited our hospital complaining of pain and motion disturbance of both shoulder joints. She had received multiple intramuscular injections for migraine treatment for 5 years. Clinical examination revealed winging of the scapula and fibrous bands were seen in the intermediate part of the deltoid muscles. Strength of the deltoid muscles was normal. Adduction, external rotation and horizontal flexion of the shoulders were restricted, -25 degrees, 35 degrees, 90 degrees, respectively. Fibrous bands showed high echo images within low echo areas on ultrasonography and a low intensity area on MRI. In September 1995, surgery was performed on her right shoulder. The deltoid fascia and subcutaneous tissue were thoroughly and widely released. After resection of fibrous bands at the midpart of the deltoid muscle, range of abduction was improved during surgery. She is now able to touch the opposite shoulder with her right hand. No adductive disturbance was seen. The patient was satisfied with the surgical results and we plan on operating on her left shoulder.
The shoulder joint is a relatively rare site for loose bodies of the synovium. In this study we present two cases with loose bodies in the bursa around the shoulder joint. Case 1: A 42-year-old male who had swelling and discomfort with limitation of motion of the right shoulder. Roentgenogram and CT scan showed destruction of the acromion and retention of fluid on the subacrominal brrsa. Operative findings revealed numerous loose bodies. A definite diagnosis of tuberculous bursitis was revealed by histological examination due to the presence of granulation and caseous necrosis. Case 2: An 88-year-old female had been suffering from right shoulder pain for 7 years. Roentgenogram showed numerous radiodense bodies in the right shoulder joint. CT scan and MRI also revealed the same findings. Numerous loose bodies removed from the shoulder were found to be a combination of cartilage and bony tissue. Histologically, this case was diagnosed as synovial osteochondromatosis. In both cases, the lesion was treated by removal of the loose bodies and a partial synovectomy with satisfactory results. From this study, it can be concluded that in cases with loose bodies around the joints, the final diagnosis can be made after histological examination.
We have treated shoulder arthralgia in chronic dialysis patients by arthroscopic débridement (AD) in the following cases: patients whose shoulder arthralgia was severe at rest, caused impairment in sleeping and caused severe shoulder arthralgia during dialysis. AD was performed on 21 shoulders of 17 patients. The ages of the patients ranged from 39 to 78 years (mean: 57.9). The period from the start of dialysis to surgery ranged from 10 to 21 years (mean: 16). The postoperative duration of follow-up ranged from 3 to 28 months (mean: 15). The clinical results was assessed according to their JOA (Japan Orthpaedic) score. Arthroscopy and bursoscopy in all cases distinctively showed proliferation of feather like synovial villi. Microscopy revealed amyloid deposits above the cartilage surface and in synovial villi. After AD, the pain during dialysis and nocturnal pain desappeared completely in 19 shoulders of 15 patients. The longest postoperative lasting effect has been observed for 28 months. The average JOA score for all cases was remarkably improved in pain by AD. Arthroscopic debridement for shoulder arthralgia in dialytic patients achieved satisfactory results.
We have used a continuous passive motion device (CPM Armciser™) for treating 26 shoulder joint diseases in our clinic. Nine patients with rotator cuff tear had CPM applied prior to surgery and re-applied after removal of the abduction brace at about 6 weeks post-operatively. Seven with frozen shoulder had CPM used before and immediately after surgery. We found several difficulties associated with the use of CPM. Fitting of the patient's arm to the CPM is poor and a lot of time is required to fix the patient's upper extremity to the CPM properly. Improvements in the CPM which we used are required to make it easy and safe to use.
We conducted a clinical study in 19 patients who underwent surgical management for malignant pelvic tumors. Treatment included wide resection, hemipelvectomy and intraoperative radiotherapy (IORT) in 3, 8 and 8 patients, respectively. IORT was applied for aged patients or those in a poor general condition. Local recurrence did not occur in any of the patients who underwent wide resection or hemipelvectomy. Using TORT, curative local control was also achieved in 5 of 8 patients. Modifying the IORT could improve the clinical value for malignant pelvic tumors.
We reviewed the clinical results of 51 cases with pelvic tumors. There were 19 patients with benign tumors and 32 patients with malignant tumors including 9 patients with metastatic tumors. Benign lesions were treated by resection or curettage with or without bone grafting. Local control was achieved in all patients except for 1 with a giant cell tumor of the bone. Surgical treatments were performed in 14 patients with malignant lesions, and surgical margins were intralesional or marginal in 6 patients and wide in 8 patients. Local recurrences occured in 7 patients. The survival rate was significantly higher in the group which had wide surgical margins. Reconstructions were done in 4 patients with periacetabular tumors. Procedures of reconstruction were iliofemoral pseudarthrosis in 2 patients, iliofemoral arthrodesis in 1 patient and autoclaved bone graft in 1 patient. Infection occured in 1 patient treated with an autoclaved bone graft but good functional results were obtained in the remaining 3 patients.
There are many problems to be resolved in the treatment of pelvic bone tumors, induding a high recurrence rate, postoperative infection, difficulty of reconstruction and postoperative functional disability. We experienced 10 cases of primary malignant pelvic bone tumors, (five cases of sacral chordomas, two chondrosarcomas, one osteosarcoma, one Ewing's sarcoma and one PNET). Sacral amputations were performed in all five cases of chordomas, and two cases recurred. The case with an osteosarcoma of the iliac bone was treated by wide resection and pre-and postoperative chemotherapy, and at the latest follow-up has no evidence of the disease. Two cases of chondrosarcomas were treated by intralesional resection, one of which recurred with the patient subsequently dying. The cases of Ewing's sarcoma and PNET were treated conservatively by chemotherapy and radiotherapy, with one still alive and healthy. Severe postoperative complications were noted among eight operative cases. Local recurrence is one of the major problems. As the surgical stumps of the two recurrent chordomas were both negative histopathologically, skip lesions may exist. Deep infection is another major complication. Three cases were infected with or without skin necrosis after surgery. Surgery was needed to treat the infection in two cases.
Twenty-five consecutive patients with chordoma, chondrosarcoma, malignant lymphoma, myeloma, osteosarcoma, malignant fibrous histiocytoma, malignant schwannoma, fibrosarcoma, synovial sarcoma, rhabdomyosarcoma, liposarcoma, undifferentiated sarcoma in the pelvis were treated. Ten local recurrences (48%) occurred among twenty-one patients who had local tumor resected. Eight distant metastases (42%) occurred among the nineteen patients with localized disease at presentation. The ten-year overall survival was 32%. Patients with pelvic bone and soft tissue sarcoma continue to have a poor prognosis with standard treatment. In addition to a significant risk of local failure, these patients are at high risk for systemic relapse. Preoperative and/or postoperative intraarterial chemotherapy was useful for local tumor control in patients with pelvic sarcomas.
Nine Patients with malignant bone tumors in the pelvis were reviewed. These tumors included chondrosarcoma in 5 cases and osteosarcoma in 4 cases. Seven out of 9 cases were treated by surgical techniques, although 2 with osteosarcoma were unoperated because of uncontrollable extension of the tumor. Cases with a tumor localized to the pubits, ishium, or innominate bone were successfully operated without reconstructing the resected areas. In cases with tumors extending to the sacrum, it was not easy to get the safety margin, and recurrence was seen in many cases. Sacro-iliac desis was successfully obtained in all 4 cases in which we tried using iliac or fibular grafts. Recurred chondrosarcoma showed extensive growth and we therefore, should try to resect the tumors with safety margin in the first operation by using supplementary techniques such as hyperthermia or chemotheray under a high-pressure-oxygen treatment.
We report 8 cases of pyogenic spondylitis (4 male, 4 female) who were treated in our hospital between 1988 and 1995. The age of the patients at first presentation to our hospital ranged from 4 to 70 years, (mean 49.2 years). The lesions involved the thoracic spine in one patient and lumber or sacral spine in seven patients. Two patients were conservatively treated and six patients underwent surgical treatment. We investigated clinical findings, hematological results, radiographs, and MRI of these patients before the onset of treatment. Four patients were of acute onset and the rest were chronic. Four patients suffered from other general diseases such as diabetes mellitus, liver cirrhosis, kidney dysfunction etc. Increase in CRP and ESR were observed in seven patients. MRI showed a decrease in intensity on T1-weighted images and an increase in intensity on T2-weighted images in all patients. In 5 patients, MRI was taken after injecting Gd-DTPA, all of whom showed clear enhancement. The diagnosis of pyogenic spondylitis was confirmed by inflammatory findings in the hematological investigations and the response to antibiotics. Moreover, MRI was very useful for confirmation of the diagnosis.
Eight cases of infectious spondylitis were treated in our hospital from 1993 to 1996. We evaluated 6 cases with pyogenic spondylitis and 2 cases with tuberculous spondylitis using MR imaging. All two cases with tuberculous spondylitis revealed rim enhancement on MRI after Gd-DTPA. Four of 6 cases with pyogenic spondylitis had rim enhancement on Gd-DTPA. Our results show that rim enhancement on Gd-DTPA is not useful for differentiating between pyogenic spondylitis and tuberculous spondylitis.
43 cases of pyogenic spondylitis were analysed. Cervical spine was involved in three cases, thoracic spine in 12, and lumbar spine in 28. According to clinical classification described by Guri, 18 cases were acute (41.9%), 9 were subacute, and 16 were the insidious form (37.2%). The causative organism was detected in 15 cases, and Stapylococcus aureus was present in 7 cases (46.7%). The causative organism was detected by blood culture in 10 cases, vertebral biopsy in 3, and tissue culture obtained by operation in 2 cases. Blood culture was useful in the acute form. Histological findings of vertebral biopsy were divided into 3 patterns following acute inflammation in 8 cases, chronic inflammation in 2, and connective tissue formation (non-specific findings) in 9. It is very important to consider the clinical course and blood inflammatory findings in order to make a correct diagnosis when the histology shows only non-specific findings.
We reviewed 28 patients with pyogenic vertebral osteomyelitis treated in Kyushu Rosai Hospital between 1988 and 1995, Subjects were evaluated according to their radiographic and MR imaging findings as well as laboratory markers of inflammation. The mean age of patients was 57.6 years (15 to 75 years) and mean period of follow-up was 27.3 months (range, 3 to 77 months). In 21 patients, the onset of disease was acute, in 5 subacute and in 2 mild. There were man cases in which signs of inflammation and vertebral or disk abscess decreased on MR imaging when CRP improved. However there were others cases in which normalization of CRP was associated with worsening of inflammation and abscess. We concluded that MR imaging is useful for follow up of patients with pyogenic vertebral osteomyelitis.
We report on 13 patients (9 males, 4 females) with pyogenic osteomyelitis of the spine treated since 1987 to 1995. Femaels ages ranged from 48 to 75 years (mean 54 years). Impaired regions were the cervical spine in 3 patients, thoracic spine in 2 and lumbo-sacral spine in 9. Seven patients suffered from complications, of whom 5 had diabetes mellitus. The follow-up periods ranged from 4 months to 7.5 years (mean, 1 year and 8 months). Main symptoms included febrile illness of varying intensity and back pain. Leukocytes did not remarkably increase, while ESR Increased, Ranging from 10 to 154mm/hr, mean 95.5mm/hr and CRP ranged from 1+ to 6+, mean 4+. Radiological changes in the spine mainly included narrowing of the disc space and collapse of the vertebral bodies. In general, we treated pyogenic osteomyelitis of the spine conservatively with antibiotics and bed rest. However surgery was needed for 9 Patients, because of abscess, neurological symptoms and resistance to conservative treatment. Nine patients recovered without any sequellae, 3 patients recovered with some neurological symptoms and one Patient died.
Thirty five cases of pyogenic spondylitis were treated in our hospital from 1984 to 1995. Twenty five of these cases were treated conservatively and ten cases surgically. With conservative treatment, we had good clinical results but there was residual pain and nonunion on X-ray. We recommend surgical treatment at an early stage in cases with neurological deficits and resistance to conservative treatment.
11 cases with pyogenic cervical osteomyelitis were followed. 9 cases were operated on and 2 cases were treated by nonoperative methods. Clinical results were good in 9 cases. Two cases had sever neurological problems at follow up inspite of receiving emergency surgery. These cases had initially severe paralysis (Frankel A or B). Age, sex, DM and the duration from initial symptoms to operation had no influence on clinical results. We believe that initial neurological severity influenced final results.
Infectious disease of the spine needs early diagnosis and definite treatment. Development of magnetic resonance (MR) imaging has made it possible to depict the infectious lesions. MRI seems to be superior to other morphological diagnostic methods for showing the lesions. We studied 19 consecutive cases diagnosed by MR imaging. Early changes of the spine and soft tissue were diagnosed by MRI correctly in cases of acute onset. Degenerative disc disease made diagnosis difficult in some cases. High signal intensity of the disc on T2 weighted images, and serial axial images showed the lesions. Ga-enhanced MR imaging was also helpful to distinguish infectious from degenerative disc lesions. MR imaging is useful for the diagnosis of infectious spinal disease. In regard to treatment, MR imaging was helpful in deciding on the effectiveness of antibiotics but was not useful for deciding on the duration of antibiotics.
We studied 23 cases (17 males, 6 females) with suppurative spondylitis to find out the characteristics which affect the clinical course. Two cervical cases and 11 thoracoo-lumbar cases recuperated with intravenous antibiotics, however, four cervical cases and six thoraco-lumbar cases needed surgery after antibiotic administration. Thoraco-lumbar cases aged under 14 years could be treated conservatively. The surgical cases revealed the following characteristics: palsy due to kyphotic deformity of the cervical spine, and long-standing (>8 weeks)/recurrent inflammation in the thoraco-lumbar spine despite antibiotic admimistration. Regarding the area of osteolysis shown on radiographs and high intensity areas in MR images, significant differences were not seen between conservatively and surgically treated cases at any spinal level. High intensity area in T2 weighted images extended to the whole body of the cervical spine.
Twenty-nine patients with a diagnosis of tuberculous spondylitis were reviewed regarding clinical features, radiographic findings and surgical outcome. 14 (48%) patients were aged in their fifties and sixties. Neurologic complications had occurred in 9 (31%) patients, 8 of whom could not walk. In five patients, the neurologic deficit almost recovered to normal. On radiographic evaluation, bony destruction over the half of the vertebral body was apparent in 29 (88%), but bony bridge and sclerotic changes in the involved vertebrae were not present in non-treated cases at admission. Tomography can be useful for detection of subtle changes in the vertebral body. We operated on 29 cases (33 lesions), of which 18 lesions were treated by curretage and anterior spinal fusion, 14 received ahterior spinal fusion and posterior instrumentation combined, one received only posterior fusion with instrumentation. All cases with anterior spinal fusion and bone graft achieved stable union with satisfactory results.
One hundred thirty seven patients with spinal infection were treated in our department between 1956 and 1995. Sixty five were male and 72 female, with a mean age of 42.6 years (range, five to 76). The patients were divided into four groups: those admitted between 1956 and 1965 (group 1); between 1966 and 1975 (group 2); between 1976 and 1985 (group 3); and between 1986 and 1995 (group 4). The patients were evaluated by a review of the records. Seventy-nine of the cases were in group 1, 20 in group 2, 16 in group 3, and 22 in group 4. 77.3% of the patients in group 4 were more than 50 years old, while the patient age distribution in group 1 peaked during the third and fourth decades. The percentage of the patients with tuberculous spondylitis significantly decreased to 13.6% in group 4, although it was about 90% in group 1 and 2. Compromised hosts, such as patients with liver cirrhosis or malignant tumor, increased to 27.3% in group 4. Moreover, iatrogenic infection after instrumentation, percutaneous discectomy, or discography occurred in five cases, of which four were in group 4. In the recent 10 years, persons over 50 years old were more susceptible to spinal infection. Tuberculous spondylitis decreased to 13.6% of all spinal infections, while compromised hosts and patients with iatrogenic infection showed increases.
Diagnosis and treatment of 24 pyogenic spondylitis and 5 tuberculous spondylitis cases were examined. Twenty two patients underwent needle biopsies for spinal infection and correct useful in the diagnosis of spinal infection. Three of the 11 operated patients were treated by instruments, and their clinical results were excellent. However, we considered that instrumentation surgery for spinal infection should be performed only when a rigid fixation was necessary.
We report the long-term results of 49 patients diagnosed with tuberculous spondylitis, who were treated surgically. Subjects included 16 males and 33 females, 12 to 80 years-old (average age 54.7 years). The period of follow up was 3 months to 17 years (average 6.8 years). Neurological de ficits were recognized in 24 patients (49%). We perfomed anterior fusion in 41 patients, posterior fusion with instrument ation in 4, costotransversectomy in 2, posterior, curettage in 2. Generally, we performed radical resection of spinal focus and bone grafting using the anterior approach for the patients with tuberculous spondylitis. We added posterior fusion with instrumentation for 6 patients who did not achieve bone union after anterior fusion. We achieved bone union in all patients finally. Improvement in gait ability was good in almost aupatients, but in 4 patiens who had complications gait ability renamed poor.
Hemangiopericytoma is a vascular neoplasm consisting of capillaries outlined by an intact basement membrane that separates the endothelial cells of the capillaries from the spindle-shaped tumor cells in the extravascular area. These neoplasms are found in soft tissue but have rarely been shown to involve the spinal canal. This is a report of two such cases.
This is a case report of cervical fracture associated with ankylosing spondylitis. The patient was a 52-year-old man with a 20-year-history of ankylosing spondylitis who presented with a cervical fracture after falling down on the ground. Plain X-ray film showed the fracture to be at the C6/7 disk level although he suffered from only mild myelopathy. After Glisson traction, the angular deformity at at the fracture site was repositioned and anterior spinal fusion was performed. After the operation, the patient's neurological symptoms resolved. Post-operatively he started sitting up in bed in propped up position using a SOMI brace. It was believed that this case escaped complete spinal cord injury and maintained an intact spinal canal.
A 29-year-old man was involved in a motorcycle versus automobile accident. On admission to our hospital he had paresthesia and slight loss of motor power in both upper limbs and was found to be paraplegic with complete sensory and motor loss below Th6. His injury was classified as a Frankel type A. Radiographs of the spine showed a burst fracture of C4 and vertebral body fractures at Th4-9 with maximun lateral dislocation at Th6/7. Posterior fusion at Th2-10 with a Luque and a Harrington rod was done about 4 weeks after the initial injury. Anterior fusion at C4-5 was done 10 days after initial operation. Eight months after surgery, he recovered to Frankel type D and could walk using a long leg cast. In patients with quadriplegia, proper treatment is dependent on early diagnosis of the primary lesion. Although it is uncommon, the second or third leveles of injuries are not recognized. Therefore, it is recommended that total spinal radiographs should be taken as soon as possible.
We studied 34 cases with both symptomatic degenerative disc lesions and spondyloporosis accompained by vetebral fracture and deformities, to investigate the influence these factors have on each other. All patents were female, with a mean of 77.2 years. The average follow-up period was 4 years 11 months. Slips such as degenerative spondylolisthesis, posterior slip, isthmic spondylolisthesis was proven in 23 cases. The vertebral fractures were located from T8 to L4, with most seen from T11 to L1 levels. 26 cases had sciatic symptoms. Tenderness was reported in all cases at lower lumbar levels (disc lesion level), in 25 cases it was also shown at the level of the vertebral fractures. In 4 cases, sciatic symptoms developed after the vertebral fractures were found at another levels. Intractable Knee joint disability was also documented in 16 cases.
We performed corrective surgeries on 5 patients with dystrophic spinal deformity. All subjects had such a rigid curve that circumferential dissection and osteotomy of the vertebrae were required for correction. Two cases needed a second operation due to a rapid increase in the nonfused curve caudal to the operated area just after the first operation. Therefore, it is considered that to correct the deformity in neurofibromatosis, circumferential dissection and osteotomy are necessary and during a growing period total long fusion may be necessary to maintain the correction.
We performed vascularized rib grafts for anterior fusion of the thoracolumbar spine in 3 cases. Case 1: A 23-year-old female with an extradural abscess at the Th3-6 level. A 5cm vascularized graft obtained from the 6th rib was used for fusion from Th3 to Th6. Radiographically, bony fusion was observed two months after operation. Case 2: A51-year-old female with spinal tuberculosis at the Th7-11 level. A 7cm vascularized graft obtained from the 8th rib was used for fusion from Th7 to Th12. Radiographically, bony fusion was observed three months after the operation. Case 3: A50-year-old male with spinal tuberculosis at the Th9-L5 level. A 15cm vascularized graft obtained from the 9th rib was used for fusion from Th9 to L4. Although bony fusion was not observed at three months after the operation, correction of kyphosis was maintained. Vascularized rib grafts appear to be an easy method for anterior fusind of thoracolumbar spine and a useful treatment for cases with destruction involving multiple vertebral bodies and marked kyphosis.
We performed a clinical and radiological study of the prognosis of unoperated RA patients with cervical myelopathy. 16 patients with neural finding (Ranawat IIIA or IIIB) were investigated. The average age of subjects was 69.5 (60-77) years the average duration of disease was 14 years. Radiological involvement of the cervical spine at the beginning of this study was as follows: AAS 3 cases, AAS+VS 9 cases, VS, VS+SS, SS 1 cases, unknown 1 case. 2 years and 7 months after the onset of myelopathy, 6 cases showed the deterioration in their neurological findings and 5 cases were dead. The causes of death were gastrointestinal disease, heart failure and malignant lymphoma. The survival rate of unoperated patients with myelopathy was no more than 50.6% at 5 years after the onset of myelopathy.
A case of idiopathic chondrolysis of the hip in an adolescent Japanese girl is reported. She was initially treated with nonweight bearing, skin traction and physical therapy, however hip motion was gradually impaired. The hip was then placed in a continuous passive motion machine with wire traction for 2 months and the function of the hip improved. It is considered that continuous passive motion with skeletal traction may be efficacious against idiopathic condrolysis of the hip.
Recently, incomplete inguinal hernias have been reported as a cause of incurable groin pain in young athletes. In 1993, Hackney proposed that such injuries be called sports hernia. We experienced 16 patients with 19 sports hernias. Subjects were all soccer player at senior high school in Saga city ranging in age from 16 to 18 years, who complained of groin pain when performing full exercises. Most patients had tender points at the anulus inguinalis superficialis; at the lateral edge of the adductor longus tendon and at the anterior superior iliac spine. Pain was caused when performing hip adduction under resistance. Patients also had a sensory disturbance in the region of the ilioinguinalis nerve. We used ultrason ography and MRI under abdominal pressure to diagnose the presence of a sports hernia, and whether this was complicated by inflammation of symphysis pubis. All patients were treated with surgical repair of the inguinal hernia, and became pain-free, however 5 patients with the added complication of inflammation of the symphysis pubis still had motion pain. We propose that the mechanism causing this groin pain involves an exertional entrapment neuropathy around the annulus inguinalis as radial tunnel syndrome.
Seven hips in 7 patients with Perthes' disease, all boys who were 9 and older at the age of onset of symptoms and were treated by subtrochanteric varus osteotomy, were reviewed clinically and radiographically after the age of bony maturity to examine the results of this procedure. The severity of the disease of the 7 hips comprised grade II: 5 hips and III: 2 hips according to Catterall's classification. However, the radiographic results at follow-up according to Stulberg's classification reported the following, class II: 2 hips, III: 2 hips and IV: 3 hips. Clinical results were good with a mean JOA hip score of 93 at follow-up, and a mean age of 21.4 years. However, there were 2 patients in their mid twenties who complained of hip pain at motion, both of whom had residual hip deformity of Stulberg class IV accompanied by a low Acetabular Head Index (AHI) and Acetabular Edge Angle (AEA) at the age of bony maturity.
Release surgery of soft tissues including the iliopsoas, adductor muscle of the hip, hamstring and Achilles' tendon has been performed for subluxation in patients with cerebral palsy. This retrospective study evaluated 47 hips in 31 patients with cerebral palsy. Results were analyzed a mean of four years after procedures with assessment of their locomotion, migration percentage, sharp angle and center edge angle. Locomotion improved in 24 (71%) of the 31 cases. Postoperatively 19 patients night-time bracing, had a significantly improved migration percentage, and center edge angle. This treatment is useful for treating hip subluxation in spastic cerebral palsy patients.
We treated 100 hips with developmental dysplasia of the hip using the Pavlik harness. Due to reduction failure in 7 cases we then performed open reduction. Six of these cases were followed-up until at least 6 years of age. Five were treated using an anterior approach and one was treated using a medial approach. The age at surgery ranged from 6 to 12 months, and the age at follow-up ranged from 9 years 3 months to 17 years 2 months. According to Severin's classification, 3 hips belonged to group I, 1 hip to group II, 1 hip to group III and 1 hip to group IV. We defined grou I and II as good, and group III and IV as poor. All hips developed coxa magna. Two hips, 1 in group II and 1 in group III, developed coxa valga and then displayed a decrease in the center edge angle. The group III hip developed such severe coxa valga that derotation-varus femoral osteotomy was necessary. The poor results of the group IV hip were mainly due to a failure to adequately gain or maintain the reduced position.
Transtrochanteric rotational osteotomy of the femoral head was carried out on three cases of posttraumatic osteonecrosis. Injuries of the hip joint were femoral neck fracture on two cases, and central dislocation with acetabular fracture on one case. The age of the each patient was 16, 20, 12 years old at the trauma, and 18, 22, 13 years old at the osteotomy. Findings of the osteonecrosis of the femoral head appeared at 12, 9, and 10 months after the trauma on each case. Preoperative classification of femoral head necrosis according to Sugioka was grade II in every patients. Intact area of the femoral head on the lateral view of the preoperative roentgenogram was about one third or more on each case. Ratio of transposed intact articular surface of the femoral head after the osteotomy to the acetabular weight bearing area was 100% on each case. Postoperative follow-up period is 51, 39, and 22 months on each case. Progressive collapse of the femoral head has not yet seen. The assessment score of hip joint function in Japanese Orthopaedic Association is 88, 88, and 90 on each case.
Transtrochanteric rotational osteotomy was performed on 10 hips and vascularized pedicled: liac bone grafts were performed on six hips with avascular necrosis of the femoral head (ANF). The average age at surgery was 37.2 years (ranging from 20 to 65 years). The follow up period was 1 to 17 years postoperatively (average 5.4 years). The basic diseases of ANF were idiopathic in eight hips, steroid-induced in five hips and alcohol in three hips. 12 hips were classified as Stage II and 4 hips were stage III. Type I-B was five hips, type I-C was nine hips, type II was one hip and type III was one hips. The JOA hip score improved from 60.8 to 77.1 postoperatively in the transtrochanteric rotational osteotomy group and from 60.2 to 79.7 in the vascularized pedicled iliac bone graft group. The result of transtrochanteric rotational osteotomy was favourable, especially in type I-B hips. The result obtained using the vascularized pedicled iliac bone graft was usually satisfactory but variable.
Although rotational acetabular osteotomy (RAO) is a good procedure for treating the dysplastic hip, there are some reports of unfortunate results caused by inadequate indications and operative mistakes in RAO. It is necessary for prevention of such problems to adhere to the adequate indications and make the exact surgical plan. We have used laser lithography models of the treatment of slipped capital femoral epiphysis. In consideration of this experience we made laser lithography models of the dysplastic hip to perform a simulated surgery and preoperatively plan in RAO. We were able to correctly perform this operation using this simulated surgery in RAO.
Forty-four cases of non-cemented hip prosthesis in 41 patients with femoral neck fracture, 2 patients with osteoarthritis and 1 patient with avascular necrosis were analysed with parficular reference to roentgenographic findings more than three years after surgery. The mean age at surgery was 70.3 years, and they were followed up for an average of 54 months. Results revealed that 71% of Bateman narrow stem type, 12% of modified type and 10% of OMNIFIT showed unfixed prosthesis. This result suggests that prosthesis occuping much of the medulla shoud be used for the surgery.
We studied femoral bone changes in 22 hips of 20 patients who had received an uncemented hip prosthesis. In 17 hips of 16 patients an anatomic hip prosthesis (A group) was used and in 5 hips of 4 patients the Harris/Galante hip prosthesis (H group) was used. The average age of A group was 65.6 years and that of H group was 68.8 years. The average follow-up period of A group was 2.7 years and that H group was 5.8 years. No A gruop patients had thigh pain but 4 H group patients reported thigh pain. The radiological findings of A group were stable; the fixation in the porous region was good. In H group there were 2 patients who had evidence of roentogenographical failure; subsidece and nonfixation in the porous region.
A biomechanical study was done to determine the safe range for cup abduction and cup anteversion and to compare range of motion when the neck and the inner-head of the hip prosthesis were altered. The results of this study showed that the safe range for cup abduction and cup anteversion that would allow physiologic range of motion without impingement was 50°-60° abduction and 10°-20° anteversion. It was also found that the smaller neck and the larger inner-head were better for expansion of the range of motion.
During a seven-year period, 63 total hip replacements were performed in osteoarthritis patients; Seven dislocations occurred. Three hips had one dislocation, while the remaining 4 dislocated more than once. Six dislocations were posterior and one, anterior. Open reduction was done in one, revision was required in 4. The angle and the height of the acetabular component of the roentgenograms were not significant between the control group and the dislocated group. The leg length (mean) in the surgery of the dislocated group was 9.5mm longer than that of the control group (p<0.01).
Chipped allograft bone tissue has been used for bone loss around prosthetic stems in revision hip arthroplasty. The purpose of this study was to investigate the consolidation of the grafted allograft bone around the stem. The graft was judged to be consolidated when the bone trabecular pattern appeared around the stem radiographically. Six cases were investigated. In all cases bone consolidation was observed after 16 to 30 months (average: 21.7 months). No significant loosening or sinking was observed. This study showed the use of an allograft for bone loss around prosthetic stems is useful in order to cover the bone loss or defect in revision arthroplasty of hip joints.
Acute progressive necrosis of subcutaneous tissue is characteristic of nccrotizing fasciitis. This infection, frequently accompanied by fever, shock and DIC, is potentially fatal. We report a case who survived a toxic shock-Like syndrome assouated with necrotizing fasciitis of the thigh. The patient was a 54-year-old woman who visited our hospital because of severe left thigh pain and general fatigue. In spite of antibiotics, swelling and bullae formation rapidly progressed with hypotension, renal insufficiency and thrombocytepenia. CT showed a layered highdensity area in the subcutaneous tissue. Surgical debridement was performed on the second day of admission. Histology revealed diffuse necrosis of superficial fascia with massive infiltration of polymorp-honuclear cells. Group A streptococci were cultured from the debris. The wound was left open and sequential washing was performed in combination with administration of ABPC. The patient's general condition and local findings were all almost recovered by the 7th day of admission.
The authors encountered a rare case of necrotizing myositis in the upper extremity due to invasive Group A Streptococcal infection. This is the first such case reported in Tokushima. The patient was forty-three year old male who came to our hospital for pain of the right upper extremity and fever. His general condition suddenly worsened, followed by septic shock (Toxic shock-Like Syn-drome). Internal medication was administered and surgical treatment conducted for six months with good results. The present case demonstrates the importance of early diagnosis and the need for internal medication and surgery.
We report a very rare case of non-clostridial gas gangrene in a child with otitis media. The patient was a 2 year 10 month old girl who had several episodes of common cold and otitis media in a 4 month period. She was admitted to our hospital with high fever, swelling of the left thigh, and was unable to walk. Her growth retardation and malnutrition seemed to indicate parental neglect. X-ray films of the left thigh revealed a gas shadow. We diagnosed her as having gas gangrene. Fusobacterium necrophorum was cultured from her ear discharge and pus from posterior thigh. She was successfully treated with emergency debridement, drainage and administration of systemic antibiotics.
Four cases of gas gangrene with trunk involvment experienced at the Tottori University Hospital over past 15 years are reviewed in this report. All cases were transferred from other hospitals and developed gas gangrene to the trunk on admission to our hospital. Gas gangrene developed after severe injury to the lower extremity in cases 1 and 2, case 3 after open pelvic fracture, and case 4 caused by rectofistula. Patients were treated with surgical management, antibiotics and hyperbaric oxygen therapy. Cases. 1, 2 and 3 also received extensive debridement and amputation or dislocation. Subsequently all three of these cases survied. However case 4, in which open drainage and colostomy were performed died after 5 weeks. Extensive surgical management such as amputation or disarticulation should be performed in cases with wide gangrenous involvement to ensure their survival.