A 47 year-old woman suffered from gait disturbance due to back pain and muscle weakness. Laboratory data showed serum hypophosphatemia, elevated alraline phosphatase, normal level of ionized calcium. She had family or past history of any significant disorders. Therefore, we initially treated her as adult onset osteomalacia. 19 years later (aged 68 years), she complained of a buttock tumor. Excision of the tumor was carried out with histological diagnosis confrming a glomus tumor. After removal of the tumor, the above symptoms disappeared and the laboratory data rehirned to the normal range 8 months later.
The relationship between calcaneal bone mineral density (BMD) and body size was examined in 495 persons (101 men, 394 women) aged 20 years or more. Calcaneal BMD was estimated by single-energy X-ray absorptiometry. Body height and weight were also recorded as indices of body size. Calcaneal BMD decreased with increased age from 40 years or more in both sexes, and the extent of the decrease in women was greater than that in men. Multiple linear regression analyses of calcaneal BMD on age, height and weight disclosed that calcaneal BMD was related significantly to weight only in men, but with both height and weight in women.
Bone density of the calcaneus, lumbar vertebrae, femoral neck was measured and the correlation between age, body height and body weight assessed. Evaluation of the calcaneal bone density was examined. Subjects comprised 42 cases, all female, ranging in age from 22 to 66 years (mean, 49.3 years). For all cases, bone density of calcaneal, lumbar vertebrae, femoral neck was measured using DEXA of Lunar company. The calcaneal bone density was measured in the area containing calcaneal side cortical bone. Significant correlations were recognized between calcaneus and weight, calcaneus and age, calcaneus and neck of femur, calcaneus and lumbar vertebrae. Significant correlation wasnot recognized between calcaneus and height. The coefficient of variation of calcaneal bone density was 0.398%. In regard to calcaneus bone density, there was a correlation with the other measurement locus. Measurements of BMD using DEXA were shown to be useful, but it is necessary to consider the infwence of weight.
The bone mineral loss in rheumatoid arthritis (RA), which occurs not in the juxta-articular region but generalized, is well recognized. However the pathogenesis of generalized bone loss in RA is not clear. In this study, we investigated factors which may influence it, so we measured bone mineral density at the lumbar spine more than 2 times over 12 months with dual energy X-ray absorptiometry (DEXA). Measurements were performed for 29 females and 36 age-matched female controls. There was a difference in Z-score with controls. In longitudinal study, bone loss was significantly greater in early disease.
We present a case of multiple metastatic calcinosis surrounding the joints in a 58 year-old male, who had been on hemodialysis since 1988. He was referred to our hospital in 1995 complaining of pain in a right knee mass. On examination, a large and elastic hard mass was palpable surrounding his right knee joint, with diffuse tenderness, and similar masses were seen surrounding other joints (bilateral shoulder, left hip, bilateral fingers). Serum calcium level was within normal range, but serum phosphorus level was high and under poor control. In the following period, his right knee mass ruptured expelling bloody fluid. The mass showed acute inflammation clinically and on blood examination. After admission, we surgically removed as much of the mass as possible. The histopathological diagnosis was metastatic calcinosis cutis. 6 months after the operation, he had no symptoms with full range of motion (ROM) in his right knee joint. We concluded that surgical resection is necessary for large calcinosis when it induces limitation of ROM, acute inflammation, or other complications.
Adductional defomity of congenital club foot almost always originates in the Chopart joint, and rarely originates in the Lisfranc joint. We performed metatarsal osteotomy to treat aductional defomity in the Lisfranc joint of four patients with congenital clubfoot. We adopted the “Lowe angle” for evalution of the adductional defomity in the Lisfranc joint. Before surgery the average Lowe angle was sixty degrees and after surgery it was seventy-nine degrees. The average follow up period from the metatarsal osteotomy was seven years (range, 5-11 years) and the average Lowe angle at final follow up was ninety degrees. The operative evaluations of the four cases were all good. We have experienced a case with fatigue fractures of the fourth metatarsal bones on both feet, caused by the adductional deformity in the Lisfranc joints of congenital clubfoot. Metatarsal osteotomy needs a comparatively simple technique. We recommend this operation in order to achieve not only good foot aligrmment but also good function.
We reviewed the results of 32 equinus feet of 21 patients with cerebral palsy who were treated with selective posterior release between 1991 and 1996. The mean age at surgery was 14.1 years and the postoperative follow-up period averaged 32.5 months. In addition to the selective posterior release, 24 feet of 14 patients received plantar release, and 7 patients with severe equinus deformities received Achilles tendon lengthening using White's method. Four feet of two patients showed recurrence (recurrence rate, 12.5%). Locomotion was improved in eight patients, unchanged in 13 patients, and worse in none. No patients newly developed a crouching posture after surgery. Selective posterior release and plantar release are sufficent procedures for correction of equinus deformity caused by cerebral palsy.
Radiological assessment was performed in cases with osteoarthritis (OA) of the ankle joints without definite origin, for example, trauma, infection etc. Among 25 OA cases unkown origin, 17 cases belonging to 8 males and 9 females ranging in age from 51 to 71 years (mean: 59.9yrs) were inversion types, 8 cases belonging to 2 males and 6 females ranging from 51 to 75 years (mean: 63.6yrs) were eversion types. Radiological mesurements were performed as follows, the basic line was drawn on the longitudinal axis of the distal third of the tibia, and the angle between this line and the mortise called ∠TAS on A-P view, called ∠TLS on lateral view, inclination of the articulus medio-malleoli on A-P view called ∠TMM. Measurements of normal material were parformed in 20 cases in the same manner. In normal material, ∠TAS was 89.2±3.0, ∠TLS was 81.2±4.1, ∠TMM was 23.8±5.9. In inverted OA, 86.6±3.5, 78.1±3.6, 78.1±3.6. In everted OA, 86.9±3.2, 76.1±3.8, 33.5±13.4. There were significant differences (p<0.05) in ∠TAS, ∠TLS, ∠TMM between normal and OA, but were not significant between inversion and eversion types. The positions of the Mikulicz line at the knee and ankle joints were measured in the two types. It was 30.4±7.9% from the medial edge of the knee in inversion type, 28.5% in eversion type, 22.2±28.5% from medial edge of ankle in inversion type, 63.0±23.4% in eversion type. There were no significant differences between the two types at knee, but there were significant differences (p<0.05) at the ankle joint. To clarify the reasons leading to the development of OA of unkown origin, it is suggested that the shape and range of motion of the subtalar joint, and instability of ankle be evaluated including dynamic assessment.
Ingrowing nails have been described as painful, often chronic and affecting work and leisure. We present a review of our results in treating ingrowing toenails for a two-year period. During this time span, 38 phenol cauterizations were performed on 30 ingrowing patients. In these patients, no ingrown nails recurred, although two nail deformities were noted. Almost all patients obtained relief from pain and infection, and 93% of them were satisfied with this procedure. A low recurrence rate and little postoperative pain were achieved by this procedure for ingrowing toenails.
There are many previous reports on the tuberculosis of various joints so far. However, reports on the tuberculosis of the elbow joint are very few. Recently, we experienced a case of tuberculosis of the elbow and describe the method of diagnosis and treatment. A 79-year-old man visited our hospital in June 1996 with a massive swelling and limited ROM of the right elbow joint. He had been suffering from right elbow joint pain since 1993. He noticed swelling around the joint and limitaion of the right elbow joint from April, 1996. We suspected tuberculosis of the elbow because he had a history of tuberculosis of the right greater trochanter. Mantoux test was strongly positive. Fluid from his olecranon bursa was punctured for Polymerase chain reaction (PCR), which revealed Mycobacterium tuberculosis. Microscopical examination also confirmed the same diagnosis. Therefore, instantly antitubercular drugs were administered and also currettage and synovectomy of his right elbow joint were performed. 3 months after the operation, pain and swelling of his right elbow joint decreased markedly and ROM also increased to a certain extent. From this study it can be concluded that PCR is useful in the early diagnosis of osteoarticular tuberculosis.
A 10 year-old complained of spiking fever and bilateral knee arthritis associated with hydroarthrosis and limited flexion of the knees. On admission in May 1996, blood examination showed, WBC-6600/mm3, CRP-3.1mg/dl, ESR-27mm/hr, CH50-49U/ml and ASO-234-IU/ml. Negative Rheumatoid factor and no change in the knee and wrist X-rays caused difficulty in the diagnosis of juvenile rheumatoid arthritis or septic arthritis. Treatment with arthroscopic synovectomy of the knee reduced the idiopathic hydroarthrosis. The diagnosis of juvenile rheumatoid arthritis was made according to the arthroscopic findings and pathology of the synovitis. After withdrawal of DMARD (Tiopronin 200mg/day) and NSAID (Diclofenac 50mg/day), the knees showed a significant functional improvement and inflammatory findings continuously disappeared. Knee arthroscopy is an easily available examination which gives important information on the diagnosis of juvenile rheumatoid arthritis. Arthroscopic synovectomy was a valuable treatment for the highly active synovitis found in juvenile rheumatoid arthritic knees.
The diagnostic and prognostic significance of antinuclear antibodies in rheumatoid arthritis is discussed. 109 patients with classical or definite RA (95 female, 14 male) were studied. Patients ranged in age from 23 to 87 years, with an average of 59 years. The duration of disease varied from 3 years to 53 years (average, 12.5 years). Positive detection of antinuclear antibodies was 55% (over×40) with homogeneous types most frequently detected (63%) followed by nucleolar types (14%) and speckled types (7%). Detection of anti-centromere antibodies was positive in three cases in this series. 10 of 14 seronegative RA in this series were positive for antinuclear antibodies, and all of these patients were in the subset of cases with least erossive disease. This study suggests that many RA patients may have other collagen diseases.
Bucillamine has been used to treat rheumatoid arthritis. Agranulocytosis is a rare but life threatening side effect of bucillamine. We report a patient with RA who developed agranulocytosis after administration of bucillamine. A 53 year-old female suffering from RA had been treated with NSAIDs and 2.5mg of prednisolone for nine years. We began bucillamine 200mg daily after she showed exacerbation of general arthritis. Her arthritis responded well to bucillamine. However, she developed agranulocytosis at 36 days and died by septic shock 45 days after administration of bucillamine. From this patient and the literature review, we suggest that when starting bucillamine, white blood cell should be counted weekly, at least for 6 weeks.
Poly-L-Lactic acid screws were applied for internal fixation when performing a Rotation Acetabular Osteotomy in 6 Hip joints (PLLA group). A comparison group had a K-wire applied in 21 Hip joints (K-wire group). We reviewed the surgical time, bleeding volume during and after surgery, and could not find any significant difference between the PLLA and K-wire groups. Strength and complications such as bone resorption and inflammation around the screws were abo similar.
We studied the clinical and radiological results of Rotational Acetabular Osteotomy (RAO) in 15 female patients over 40 years of age. 13 cases were treated with a single RAO, one case also received a varus osteotomy and in addition one other case received a valgus osteotomy. The mean age at the time of surgery was 45.8 years (range, 41 to 56 years). The mean duration of follow-up was 1.4 years (range, 0.5 to 3.3 years). Most cases achieved excellent results, and it was suggested that RAO is indicated for patients over 40 years of age, and those who have achieved congruity in abduction and have a round head.
Three cases of an unusual, poorly recognized destructive hip arthropathy with radiographic findings of rapid severe joint destruction are presented. Case 1: An 81 year-old female presented with hip pain of 3 months duration and radiographs showed a rapidly destructive appearance of the femoral head. The patient had no clinical or laboratory evidence of sepsis or neurogenic disease. Case 2: A 55 year-old female presented with hip pain of 7 months duration. Radiographic findings developed into sudden destruction of the joint during an ordinary course of secondary osteoarthritis. Case 3: A 55 year-old female who had been treated with oral medications for nearly thirty years for schizophrenia, was injured in a fall. She complained of right coxalgia, but fracture of the femoral neck was not diagnosed by anteroposterior X-ray in the local orthopedic clinic. The pain didn't improve and she visited our hospital 2 months after the injury. Radiographs showed abnormal bone absorption of the femoral neck. The pathomechanism of rapidly destructive coxarthrosis (RDC) has not been clarified. However our cases support the features of RDC previously described in the literature. We should regard RDC as a special type of a syndrome causing hip joint destruction rather than one disease.
We report one case of idiopathic transient osteoporosis of the hip which was examined by MRI. A 31 year-old woman who suffered from right hip pain while pregnant is described. MRI showed low signal intensity in the affected femoral head on T1-weighted images and high signal intensity on T2-weighted images. After regression of the hip pain, the signal intensity normalized. MRI was a useful method for diagnosis and follow-up of idiopathic transient osteoporosis of the hip.
Synovial osteochondromatosis is a benign disease of synovial tissue, most commonly affecting the knee and elbow joint, and is rarely found in the hip joint. We report two cases of synovial osteochondromatosis of the hip joint. In both patients, motion of the affected hip joint was not greatly restricted. Roentgenography of the affected hip joint revealed expansion of the joint cavity. Arthrogrphy of the involved hip joint showed a honeycomb shadow. Definite diagnosis was made on the arthrographic findings in both cases. We performed arthrotomy, taking care not to dislocate the femoral head because of the potential hazard of femoral head necrosis. Many loose bodies and synovial tissue were removed in both cases. Postoperatively, both patients did well.
We performed a prospective randomised controlled trial of the A-V Impulse System for reduction of lower limb swelling in 22 patients undergoing hip joint surgery. The A-V Impulse System was used 2 or 6 hours for 7 days. Before surgery, and on the 3rd and 7th postoperative day, we measured the thigh and calf circumferences of both legs. In the 6 hours group, there was a mean relative reduction of postoperative swelling of the thigh by 1.71cm and of the calf by 2.13cm. In the 2 hours group, there was a mean relative reduction of postoperative swelling of the thigh by 0.58cm and of the calf by 0.02cm. The A-V Impulse System appears to be an effective method of reducing postoperative leg swelling.
We report on our storage of autologous blood in the out-patient setting. Subjects comprised 23 cases who planned alloarthroplasty, ranging in age from 42 to 82 years, with a mean of 64.5 years. These patients were divided into 2 groups, 17 patients had osteoarthritis (Group OA) and 6 patients had rheumatoid arthritis (Group RA). For comparison, we used 30 cases who deposited blood before surgery on an inpatient basis. All subjects were women. The storage of autologous blood was done according to our standards and we combined chalybeate with erythropoietin. Changes in Hb, Hct and the progress ion of anemia were examined. There was no difference between Group OA and the in-patients, but Group RA had a slower recovery of anemia than in-patients (p<0.05). We consider that patients with no pre-existing complications can successfully use out-patient autologous blood storage.
We know that a fifth to a third of patients with cementless THA complain of thigh pain. In order to obtain an initial fixation, to prevent loosening of the stem and consequently to protect against thigh pain, we used a very small quantity of cement at the distal end of the stem. We report our results in twelve female patients with osteoarthritic hips operated on with the cementless THA. Our method was as follows: just before putting the stem into the femoral bone we inserted a minute quantity of cement, the average weight of which was 0.85g, into her pulp chamber, and then we set up the stem. Post operative rehabilitation was practiced the same as for cementless THA. The result was that thigh pain appeared in only one patient (5.9%), and in their X-rays after surgery we found five hips with a radio lucent line at Zone 1, but except for one case the width was below 1mm. We report our experiment study and believe that our method is effective for preventing thigh pain after cementless THA.
The results of hemiarthroplasty for 18 hemodialysis patients are reported. There were 17 cases of femoral neck fractures and 1 case of aseptic necrosis of the femoral head. Subjects were followed-up for an average of 25 months. A retrospective analysis of the outcomes in 18 patients showed a return to the preinjury ambulatory status in 33per cent. 6 patients had died. In 2 patients loosening of the stem was observed.
This paper evaluated the utility of HATCP coated femoral head prostetic replacement. This prosthesis has been used in 24 cases of femoral neck fracture and 2 cases with necrosis of the femoral head since 1995 in our department. All patients started partial weight bearing from 1 week postoperatively. Short-term follow-up (mean: 1 year 2 months) was carried out. Subjects included 24 cases 7 male and 17 female ranging from 51 years to 89 years (mean: 80). The averege postoperative JOA hip score was 83 points. No patients developed thigh pain, limping gait or the Trendelenburg sign. Regarding the radiological results, there were radiolucent lines around the prosthesis in 4 cases. However no radiolucent line was found around the HATCP coated stem and sinking did not appear. The short-term clinical results were good and we found osteoconduction in 72% of patients around the HATCP coated stem 6 months after surgery.
Thirty two hips in 30 patients with Charnley THR of more than 20 years follow-up were examined at an average follow-up period of 22.6 years. Patients consisted of 6 males and 24 females with underlying disease comprising 28 cases of osteoarthritis and 4 avascular necrosis. Fourteen with original THR were further evaluated both clinically by JOA hip score and rediologically on findings such as clear-zone, socket migration, stem sinking. Revision surgery had been done in 9 hips (28%), five of which were needed because of prosthetic loosening.The result of JOA hip score of the 14 with original THR ranged from 35 to 97 points with an average of 70 points. A radiological socket clear-zone of more than 3mm was observed in 7 hips (50%), stem clear-zone in 4 hips (29%), socket migration of more than 5mm in 3 hips (21%), stem sinking in one hip (7%). There was no significant radiological findings correlating to the clinical result of JOA hip score.
Ten revision operations of femoral endoprostheses and total hip arthroplasties were carried out in our clinic. Three endoprostheses were replaced with endoprostheses. Five endoprostheses were replaced with total hip arthroplasties. Two total hip arthroplasties were replaced with total hip arthroplasties. Four cases were caused by pyogenic infection one of which was a mycotic infection. Six other cases were caused by mechanical loosening or dislocation. We classified these ten patients into infectious group and non-infectious group, and compared the two groups. We examined clinical and radiological findings after a mean follow-up period of 2.6 years (in infectious group) and of 7.3 years (in non-infectious group). We considered that sufficient bone autograft and sufficient cementing are effective measures to guard against failure of revision surgery.
We studied radiologically the growth of hip joints in 4 children who have been using an ishial weight-bearing brace or external prosthesis. They underwent surgery for osteosarcoma in the distal femurs and proximal tibiae before the age of 10 years. Two children received amputation at the proximal thigh and the remaining 2 children underwent a limb salvage procedure. After closure of growth plates in all children, the radiological findings around the affected hip joints such as narrow joint spaces, smaller femoral heads, decrease of bone trabeculae and long proximal femurs were observed in comparison with those of the contralateral side. Among those findings, the decrease of bone trabeculae and long proximal femurs were more indicative that the use of an ishial weight-bearing brace or external prosthesis had influenced the growth of the hip joint.
We report on the clinical result of congenital dislocation of the hip treated with the Pavlik harness in 10 males and 78 females. Reduction was obtained in 67 cases (76%). The reduction rate was 65% in cases whose α angle were less than 40 degrees, 56% in cases whose Yamamuro distance “a” was less than 6mm, and 58% in cases whose Yamamuro distance “b” was more tnan 12mm. 17 cases were followed for more than five years. Four cases were rated as excellent, seven cases as good, four cases as fair and two cases as a failure. Use of the Pavlik harness seems to be a favourable treatment for congenital dislocation of the hip but it is important to remember its limitations.
This study reports the outcomes of 4 different methods for approaching the elbow joint. 20 elbows of 20 patients were operated on for treatment of primary osteoarthrosis of the elbow joint. The approach methods were as follows; 7 Kashiwagi, 7 Anterior, 5 Anterior-posterior and 1 Tsuge. There were 27 males and 3 females ranging in age from 32 to 66 years with an average of 49.3 years. The average follow-up period was 5 years 1 month (range: 7 months to 13 years 1 month). Pre and postoperative (at final follow-up) JOA scores, osteoarthritic changes in radiogram were investigated and their relation ship with the follow-up period analysed. Regardless of the approach methods, the average JOA score improved from 62.9 points to 84.9 points after surgery. There was no significant difference among all the methods described above. In the Kashiwagi approach there is a disadvantage in reaching the anterior part of the elbow, therefore, for the last 15 years we prefer to use the anterior approach because of its wide range of exposure. However, in case of osteophytes in the olecranon fossa, the posterior approach can be added and a satisfactory result obtained. In elbows with severe deformity due to osteophytes, the Tsuge method can be considered.
During the three years from 1993 to 1996, 8 comminuted intra-articular fractures of the elbow were treated operatively, and followed up for a mean period of 12.4 months. There were 6 cases of olecranon fractures and 2 cases of distal end of the humerus fractures, in patients aged from 32 to 77 years (average age 52.8 years). Functional results were judged independently according to the Japan Orthopaedic Assosiation (JOA score). Internal fixation with tension band wiring, additional thin Kirschner wires and/or Herbert screws, absorbable pins, canulated screws with or without bone grafts, provided sufficient stability to allow for early functional treatment in 7 cases and led to union of the difficult fractures in all cases. Three patients required surgical mobilization, with final satisfactory outcome. Two patients developed heterotopic ossification. Mean motion of the elbow joint was 118 for flexion-extension. The average JOA score for all elbows was 93.0 points (range: 87-100 points) at the time of follow-up examination. The ultimate clinical and radiologic results obviously depend on the quality of the anatomic restoration of the joint surface.
We evaluated 12 patients with Monteggia fractures treated at the University of Occupational and Environmental Health, between 1979 to 1996. Nine of the 12 cases had missed and malunited Monteggia fractures, with dislocated radial heads. We were able to reduce the dislocated radial heads more easily in the three newer cases compared to those cases with old injuries. In regard to the older cases, good results were achieved in those treated by ulna osteotomy with over-correction of the angular deformity and elongation of the bone. Reconstruction of the annular ligament alone was not sufficient for optimal heatment.
Fourteen patients with fractures of the humeral capitellum were treated at the Chugoku Rosai Hospital during a sixteen year period. Eight patients were available for follow up assessment. Conservative treatment was carried out in only one patient. Open reduction and internal fixation were performed in seven patients. Eight patients were assessed for reduction in range of motion, instability and pain. Downgrading because of a reduced range of motion was recorded in six patients. Type II was frequently seen due to indirect fractures in younger patients. In elderly patients Type IQ was frequently seen because of direct fractures. The differences in types was responsible for differences in treatment results.
We have developed two types of technical aids for standing up. Commercially made walkers were utilized for making these aids. The first type is a device for standing up and transfer, the other is for standing up and ambulation. The good stability and reliability provided by these two devices during standing up gave the patients confidence. As a result, the patients could stand up independently and then, they could transfer to a wheel chair or ambulate with the walker smoothly. These technical aids seem useful for patients with difficulty in standing up.
Footprints of 16 patients with rheumatoid arthritis (32 feet) and 12 normal subjects (24 feet) were recorded using a pressure distribution measurement system (ANIMA MP-4800) during gait and static double standing. 14 feet of 32 rheumatoid feet had callus plantar forefoot. Arch index was calculated from the recorded foot print images. In rheumatoid feet with callus, the difference between arch index during gait and arch index while standing is significantly decreased compared with that of normal subjects. These results suggest that flexibility of the arch is decreased in rheumaoid feet with callus formation.
Twenty-one patients with lumbar canal stenosis were treated with intravenous Prostaglandin E1 (PGE 1). 8 cases were judged by patients to be satisfactory, but PGE 1 was not effective in 13 cases. All patients had Myelography and CT imaging before the treatment. In order to evaluate any correlation between the canal dimension and the effectiveness of PGE 1, we reviewed the computed tomography scans. A significant difference was found between the effectiveness of PGE 1 in the group with root tunnel stenosis compared to the group with no root tunnel stenosis. It was suggested that the autonomic nerve system arround the root had something to do with the effectiveness of PGE 1 for lumbar canal stenosis.
We treated 10 patients with lumbar spinal canal stenosis with intravenous Argatroban. Doses were 20mg/day for two weeks and all patients were hospitalized. Four cases were very good and 3 cases had good results according to the JOA score. No cases worsened. Side effects were transient hypotention in one case although there was no need to stop treatment. We concluded that Argatroban was effective for treating lumbar spinal canal stenosis.
Ten patients with lumbar spinal stenosis and 10 healthy men had their leg blood flow measured using a Laser Doppler flowmeter. After walking until developing intermittent claudication, leg blood flow increased in the patient group and decreased in the control group after walking for 5 minutes. There was a statistically significant change between the two groups. After cycling with an ergometer for 5 minutes, leg blood flow showed the same tendency in the two groups as after walking, but without statistical significance. These results suggest that there is a paripheral circulatory disturbance in patients with lumbar spinal stenosis.
This study evaluated the usefulness of MRI in the diagnosis of intra and extraforaminal lumbar nerve root compression, which is difficult to diagnose by myelogram. We retrospectively analyzed 14 patients with intra and extraforaminal lumbar disc herniation and 7 patients with lumbar foraminal encroachment between July 1993 and June 1996. Parasagittal and axial images in T2WI were analyzed. Decrease of fat tissue around the nerve root was reported in 92.9% of cases with in lumbar disc herniation and 100% in foraminal encroachment. Enhanced MRI was useful for identifying nerve root compression caused by lumbar disc herniation which we couldn't diagnose by parasagittal and axial MRI.
Is MRI useful in diagnosing nerve root constriction in lumbar canal stenosis? Lumbar spine MRIs were reviewed in a young control group (Group 1) and a surgically treated older group (Group 2). (Conclusions) (1) In group 1 T1 axial images at the disc level show the lateral recess and foramen as a thin open area of high signal intensity. This area is called an “eye” aperture. The “Eye” sits between the posterior aspect of the disc and the anterior aspect of the articular process. (2) The “Eyes” are closed in no cases of group 1 and 43% of group 2 from all checked nerve roots on MRI. The posterior aspect of the disc contacts the anterior aspect of the facet joint to a varying extent. We call this phenomenon the “Closed eye sign”. (3) 74% of the nerve roots with a positive “Closed eye sign” checked in surgery showed obvious macroscopic constriction (71% of L4 roots and 91% of L5 roots). (4) The positive “Closed eye sign” indicates definite narrowness of the nerve root channel and is useful in diagnosing lateral type lumbar canal stenosis.
We analyzed fifteen cases which showed spontaneous regression of lumbar disc herniation on MR imaging. Their characteristic clinical pictures were as follows; patients complained of acute onset of severe leg pain, the pain decreased within several weeks, but numbness and/or muscle weakness remained in some cases. Types of herniation were sequestration in 7 cases, extrusion in 8 cases. Gd-DTPA enhanced MRI were performed in 12 cases, and eleven of them showed the finding of a “wrapped disc” that was enhanced around the herniated mass. The herniated mass demonstrated high intensity on T2 weighted images in the course of spontaneous regression.
We performed serial MRIs after Gd-DTPA injection in 30 patients with lumbar disc herniation, and their findings were classified into the following 3 groups. Group A: no enhancement, Group B: partial enhancement, Group C: circulatory enhancement (socalled wrap-around disc). Axial area of the herniated mass in MRI and pain of the lower limbs were continuously evaluated. Decrease in lower limb pain correlated closely with reduction in the herniated mass. Regression of the herniated mass in group C occurred within two or three months, and leg pain in group C was reduced by half within two months. On the other hand, in patients with a large central herniation, reduction of the herniated mass and decrease in leg pain were hardly recognized. It is considered that enhanced MRI is useful for predicting the natural history of the lumbar herniated disc.
Surgical findings in lumbar disc hernia were compared to pre-operative MRI, CTM and Myelogram findings. Ninety-one cases were studied using Love's method. The accuracy of hernia diagnosis in MRI was 59.3%, 41.2% in CTM, and 35.2% in Myelogram. At the L5/S1 disc level, the accuracy of hernia diagnosis by CTM and Myelogram was decreased. MRI was useful for the diagnosis and cure of lumbar disc herniation.
Posterior epidural migration of lumbar disc herniation (PEMLDH) is rare. Four new cases of this condition are reported, in addition to the 59 previously documented cases. It has been reported that the incidence of PEMLDH ranges from 0.46 to 3.8 percent of surgically treated lumbar disc herniation. More than 40 per cent of the herniation were observed at L1-2 to L3-4 levels. Although the mechanism is not well known, age-related disc degenerations could play a role as a predisposing factor. MRI is most useful for diagnosis of this condition. The clinical symptoms of PEMLDH are more severe and frequently linked to neural damage of the cauda equina, therefore prompt surgical treatment may be necessary.
We reviewed the results of operative treatment in 32 patients with lumbar disc herniation in adolesence. During 1991-1996 we operated on 18 patients (13 men, 5 women, mean age at surgery, 16.4 years) with percutaneous discectomy (PD); 14 patients (10 men, 4 women, mean 15.5 years) with open discectomy. The post operative results, were excellent or good in 11 of 18 patients (61.1%) with PD, and in 13 of 14 patients (92.5%) with open disectomy, respectively. The average period of recovery to playing sports was 1.75 months with PD, 2.90 months with open disectomy. One of the important things in surgical treatment of lumbar disk herniation in adolesence is the period of recovery to full sporthing activities. In this study, it is suggested that PD is the most useful treatment for lumbar disk herniation in adolesence.
The occurrence of endometriosis as a soft tissue tumor in orthopaedics is rare. We present a patient who had endometriosis in the inguinal subcutaneous region. A thirty four-year-old woman noticed a bean-sized tumor in the right inguinal region in 1982. The tumor responded to antibiotics. A bean-size painful tumor was again noticed in the same region in 1993. The mass and the pain were more prominent just after menses. Rediographs were normal. A subcutaneous soft tissue tumor with a 2.5cm in diameter could be seen on computed tomographic scans. On MRI the tumor was segmented, not enhanced with contrast medium, and demonstrated, moderate to high intensity on T1-weighted images and high intensity on T2-weighted images. Histological examination of the biopsy specimen revealed endometrial glands and stroma. We diagnosed endometriosis of the inguinal region and resected widely. Six months after the operation, the patient was asymptomatic and had resumed all of her usual activities. Several cases involving endometriosis have been reported in Japanese orthopaedic articles, so it is important to remember endometriosis in the differential diagnosis of soft tissue tumors.
We report a case of fibromatosis which was located in the right forearm. A 62 year-old male had disrupted extension of both ring and little fingers with wrist extension. The ulnar portion of the flexor digitorum profundus muscle was involved by tumor. We achieved a good recovery of finger function by performing a simple marginal tumor resection.
It is well known that Werner's syndrome is often associated with a high frequency of malignant tumors. A case of Werner's syndrome associated with malignant fibrous histiocytoma of the right forearm is reported, with a review of the literature. The patient presented with, because of bilateral cataracts at the age of 28 years, and diagnosed as having Werner's syndrome. He was first admitted to our hospital in July, 1994 complaining of pain in his right forearm for the post two years. At examination a 5.5×5.0×1.5cm and a 1.0×1.0×1.0cm tumor were seen on the dorsal of his right forearm. The tumors adhered to surounding tissues. He was biopsied, and the histologic diagnosis was malignant fibrous histiocytoma. The patient refused radical surgical treatment and chemotherapy. He died of pulmonary metastasis in December, 1994. The authors emphasized the importance of checking for malignant tumors when examining patients with Werner's syndrome.
A Clear Cell Sarcoma (C. C. S.) producing melanin pigments similar to malignant melanoma (M. M.) was first described by Enzinger in 1965, even though C. C. S. is deeply located, arising from structures such as tendons. We report on a 21 year-old male referred to us with a right swollen heel revealing radiographic osteolytic destruction in the calcaneus. Histologically the tumor was characterized by pale-staining tumor cells arranged in nests. Hemosideroid granules were identified as melanin by Fontana-Masson staining and positive HMB-45. Vimentin, S-100 and N. S. E. were positive, while keratin, E. M. A. were negative. A syme amputation was performed, preserving the anterior planter flap to cover the heel followed by a 5cm lengthening of the tibia. Metastases to the popliteal lymph node was found two months post operatively, and the patient died with diffuse lymph node and lung metastases. Prognosis of this C. C. S. case was poor even after chemo-immuno therapy.
From 190 patients with soft tissue sarcoma, 30 patients with extrapulmonary metastases were studied. The lung was a site of metastases in 72 patients, lymph node in 5, bone in 5, muscle in 6, subcutaneous soft tissue in 8, visceral organs in 2, and retroperitoneal cavity in 2 patients. Primary tumors arising in the distal portion of an extremity tended to metastasize to subcutaneous tissue. On the other hand, large tumors arising in the proximal site of the thigh tended to metastasize to visceral organs. Tumors morphologically resembling carcinomas, such as synovial sarcoma and epithelioid sarcoma developed lymph node metastases. Clear cell sarcoma, and alveolar soft tissue sarcoma somewhat resembling malignant melanoma or renal cell carcinoma, in which brain metastasis is frequently seen, developed brain metastasis. Survival was not influenced by metastatic site. Pattern of metastases seems to be dependent on the primary site and histologic type. Morphological similarities between synovial sarcoma, epithelioid sarcoma, CCS, ASPS and epithelial tumors explain the similarity of the metastatic sites.
A retrospective clinical review of 50 patients with bone and soft extremity tissue sarcomas from 1987 to 1995, managed by 33 wide local resections (limb salvage) and 17 amputations or disarticulations, was performed to evaluate local tumor control. The mean follow-up period was 38.7 months. Overall survival at five years was 80% for the resection group and 50% for the amputation group for bone sarcomas, 71.1% for the resection group and 47.1% for the amputation group for soft tissue sarcomas. Three patients had local recurrence (6.0%). There were no local recurrences after amputation but three (9.1%) after wide resection. Problems concerning the surgical wound was one of the most frequent complications in wide local resection and the average duration of wound healing after resection was longer than that after amputation.
We report the case of a 19 year-old woman with solitary involvement of the ninth thoracic vertebral body and development of neurologic deficits. Trephine biopsy under CT examination was performed, and eosinophilic granuloma was proven histologically. We treated conservatively and neurologic deficits improved rapidly after biopsy. Complete reversal of the neurologic deficits and the features of vertebral body healing on MRI and CT appearances were reported.