A 29-year-old man lost consciousness briefly after falling from a height. Initial examination revealed complete quadriplegia, with normal strength in trapezius and at the C5 sensory level. Cranial nerves were intact. Cervical spine X-ray demonstrated a fracture dislocation of C4, and he underwent C4-5 posterior wiring and fusion. Postoperatively he became unresponsive and two days later, experienced locked-in syndrome. Vertebral angiography demonstrated complete occlusion of the right vertebral artery 2cm proximal to the fracture site, and the mid one-third portion of basilar artery was completely obstructed. We concluded that the thrombus of the vertebral artery caused the thromboembolism of the basilar artery and pontine-infarction during surgery.
In recent years cases of delayed myelopathy following spinal compression fracture in elderly cases with osteoporosis have posed a therapeutic problem. During the past three years we have experienced 5 such cases who underwent surgical treatment in our department. All subjects were females with severe osteoporosis and a BMD of 0.395-0.527g/cm2. Their ages ranged from 62 to 88 years with 2 cases developing after trauma and 3 cases developing without remarkable trauma. Posterior vertebral body collapsed into the vertebral canal due to increased kyphosis and intervertebral necrosis leading to spinal cord compression. The mean preoperative angle of kyphosis was 29.2°, and this improved postoperatively to a mean of 12.8°. Excluding one case, improvement in both Frankel's classification and JOA score was observed within a short period after surgery to permit gait with the assistance of a cane. Since a number of points need to be clarified with regard to the type of compression fracture which leads to delayed vertebral collapse and to development of neurological symptoms, it is considered advisable to prevent delayed vertebral collapse as much as possible.
We report two cases of fractures of adjacent lower vertebrae after posterior spinal decompression and fusion with instrumentation for treatment of vertebral burst fractures in osteoporotic patients. Case 1. A 72-Year old man was admitted with lumbago and gait disturbance. Burst fractures at Th9, 11, 12 were identified by X-ray. This was treated by posterior decompression at Th10-L1 and fusion with insturumentation at Th8, Th10-L1, L2, Acute low back pain occurred after 3 months. X-ray showed a compression fracture at L3. After resting quietly for 4 weeks, the symptoms diminished. Case 2. A 74-year old woman was admitted with lumbago and gait disturbance. Burst fracture at Th7, 8 was identified on X-ray, and treated by posterior decompression at Th6-L9 and fusion with instrumentationa at Th5, 6-Th9, 10. Acute lumbago and bilateral lower limb pain occurred after six months. X-ray revealed a burst fracture at L1, which was treated by posterior decompression at L1 and fusion with instrumentation at Th11, 12-L2, 3. In this paper, we report these two cases in addition to our review of the literature.
We report a case of atlanto-axial subluxation in a patient with cerebral palsy. A 15-year-old man complained of progressive gait disturbance. Roentgenography demonstrated os odontoideum and instability of the atlanto-axial joint, an increased atlanto-dental interval of 5mm and decreased space available for the spinal cord of 7mm. He underwent posterior internal fixation using the Brooks and Magerl method. Roentgenography 16 months after the operation demonstrated good bone union and no instability at the atlanto-axial joint. In this case, atlanto-axial subluxation was considered because of incompetence of the odontoid process and the transverse atlantal ligament.
Clinical outcomes and magnetic resonance imaging (MRI) findings were evaluated for patients with syringomyelia associated with Arnold-Chiari malformation type I after syrinx-subarachnoid shunting. Subjects included four patients, 1 male and 3 females, with a mean age at surgery of 42.5 years and a mean follow up period of 1.9 years. Following laminoplasty or fenestration, myelotomy was performed at the dorsal root entry zone (DREZ) of the cord. The cavity was drained by insertion of a shunt tube (diameter 1.2-1.4mm) at the DREZ into the cephalic side for a distance of 2-3cm. Neurological deterioration improved in 3 of the 4 patients at the final observation. MRI disclosed a remarkable deflation of the syrinx in 3 patients at follow up. We did not encounter major complications such as neurological deficits. The results of the current study suggest that syrinx-subarachnoid shunting is useful and safe for the treatment of syringomyelia associated with Arnold-Chiari malformation type I.
We report a case of thoracic disc herniation sequestrated to the dorsal epidural space. The patient was a 31 year old male who had muscle weakness around his left hip and hypesthesia extending from his left abdomen to left foot. Myelography, CT myelography, and MRI showed Thoracic 7-8 herniation. Posterior approach was selected for surgery and the sequestrated hernia was removed.
We report a case of infarction of the cones medullaris. The patient, a 62-year-old woman, had sudden numbness of her left lower extremity. In the conus medullaris, MR imaging showed a low intensity signal on T1 W-imaging and a high signal one on T2 W-imaging. The lesion and the cauda equina were enhanced on Gd-DTPA enhanced T1 W-imaging after 6 days.
Finite element analysis was performed to identify the stress distribution in a compressive model of the cervical spinal cord. The finite element model included material properties of white matter and grey matter. Stress and strain distribution results indicate that there were high stresses in the compressing area. This is not likely to be the case. On the assumption that grey matter is slightly less rigid than white matter, high stress concentrated on anterior column, posterior column and antero-lateral column. And a high strain concentrated on the grey matter. This suggests that the difference between white and grey matter and their unique form are important factors in cervical spondylotic myelopathy.
Forty patients with cervical myelopathy due to spondylosis (CSM, n=20) and ossification of the posterior longitudial ligament (OPLL, n=20) underwent cervical laminoplasty using the modified Ito's method. The mean age at surgery was 64.1 years and the mean follow-up period was 37.6 months. Clinical results were evaluated using the Japanese Orthopaedic Association (JOA) score and the recovery rate was calculated according to Hirabayashi's method. The preoperative JOA score of CSM improved from 8.9 to 12.8 postoperatively and that of the OPLL group from 11.7 to 15.1. The average recovery rate was 48.0% in CSM and 59.3% in OPLL. Cervical alignment was classified into kyphosis (contains S and reverse S) and non-kyphosis (lordosis and straight). The average recovery rate of kyphosis was 43.5% in CSM and 32.0% in OPLL, while that for non-kyphosis was 50.0% in CSM and 67.5% in OPLL. There was no significant difference between the recovery rate of kyphotic OPLL and non kyphotic OPLL.
A comparative study was performed in patients with cervical myelopathy due ro one or two segmental spondylosis to compare surgical results achieved using the posterior method with anterior methods. Fifty eight patients were evaluated. Thirty patients were treated by laminoplasty and twenty-eight received anterior decompression and arthrodesis using the Cloward technique. With regard to several prognostic factors, including the age at surgery, duration of symptoms, and severity of preoperative myelopathy, there were no significant differences between the two groups. Neurological improvement was assessed acording to Hirabayashi's recovery rate. The mean recovery rate was 63.3% for laminoplasty and 64.3% for anterior decompression and fusion. The difference between the two groups in the recovery rate was not statistically significant.The incidence of postoperative complications was lower after laminoplasty than those after anterior methods had been used. The results of the current study suggest that laminoplasty is a useful method for surgical treatment of cervical myelopathy and radiculomyelopathy due to one or two segmental spondylosis.
The torsion dystonia is a rare disorder resembling athetosis characterized by abnormal involuntary movements and postures produced by muscle spasm. In patients with athetosis, cervical radiculopathy or myelopathy often occurs during adult life. However, we experienced a patient who had cervical radiculomyelopathy associated with torsion dystonia. In 1996, a 54 years old female visited our hospital due to gait disturbance and pain in the right upper extremity associated with involuntary movements of her head and neck. Her symptoms first appeared at the age of four, which gradually aggravated and she was diagnosed as idiopathic torsion dystonia by neurologist. Neurological examination showed cervical radiculomyelopathy. Radiographs and imaging investigations revealed instability, degenerative changes and compression of spinal cord at the C3/4 level. Initially, we followed Matsuo's method by releasing selective muscles to minimize the involuntary movements. As a second step, two months later, anterior body fusion at C3/4 level was carried out. Her cervical spine was immobilized with halo vest for 6 weeks without any inconvenience. Bone union was achieved by 6 months postoperatively and her symptoms were decreased. In cervical radiculomyelopathy associated with abnormal involuntary movement, cervical fusion operation following selective muscle release is an effective surgical option.
We evaluated the clinical status and MRI findings of patients with cervical myelopathy due to OPLL before and after surgery. This study consisted of 25 cases (male 15, female 10) who received cervical laminoplasty. The transverse area of the spinal cord at the maximum cord compression level was measured and we compared the transverse area with surgical outcome. The clinical results were evaluated according to the Japanese Orthpaedic Association (JOA) score. Recovery after surgery was evaluated using the formula suggested by Hirabayashi et al. There were no statistically significant differences between the increase of the transverse area and surgical outcome. Patients who showed intramedullary signal intensity in the T2 weighted MR image at the maximum cord compression level pre-and postoperatively had poor recovery of neurological symptoms.
This study evaluated the relationship beween spinal canal anteroposterior diameter, canal-body ratio and height. Subjects consisted of 50 patients with cervical spondvlotic myelopathy, and a control group of 50 healthy male volunteers. The anteroposterior dimensions of the vertebral bodies and spinal canal were assessed on lateral roentgenograms, using a target distance of 150cm. The width of the canal was measured between the midpoint of the posterior cortex of the vertebral body to the closest point on the spinolaminar line. The width of the vetebral body was measured at its center. Results revealed that the spinal canal anteroposterior diameter was narrower in the cervical spondylotic myelopathy group compared to the control group. In contrast there was no significant difference between the 2 groups in regard to vertebral body anteroposterior diameter. A correlation between anteroposterior dimensions of the vertebral bodies and spinal canal height was recognized in the control group. However, no correlation between canal-body ratio with body height was seen in either group. A significant difference in canal-body ratio was seen between the control group and cervicl spondylotic myelopathy group (p<0.01). We consider that the canal-body ratio is an effective determination method for cervical canal stenosis.
Circulatory factors are important in achieving a good outcome following surgical treatment of cervical myelopathy. However, it is difficult to measure spinal cord blood flow (SCBF) during surgery. We measured SCBF, before and after decompression of the cervical spine, in posterior median lesions by using laser-doppler flometry. We evaluated the relationship between surgical result and the change of SCBF after decompression, and compared SCBF with morphological changes in the spinal cord on magnetic resonance imaging (MRI) before and after surgery. Subjects comprised 13 patients with cervical spondylotic myelopathy and 15 patients with cervical myelopathy due to ossification of the posterior longitudinal ligament. The average SCBF before deconpression was 32.2ml/min/100g and after decompression, 19.2ml/min/100g, revealing that SCBF decreased in most cases after decompression. The change of SCBF after decompression affected the improvement of neurological deficits at follow up. There was no relationship between the change of SCBF and the morphological change of the cord on MRI. Measurement of SCBF using laser-doppler flometry during decompression of the cervical spine is useful for predicting the surgical result.
Many activities of daily living (ADL) require dorsiflexion of the neck. We assessed the impact of changes in neck dorsi-flexion on dietary activitiy. We measured the angles of neck dorsiflexion produced by various postures and containers used during drinking. The dorsiflexion angle is defined as the angle made between the 2nd and 7th cervical vertebrae and is expressed as the difference between the respective angle measurement and that of matural upright posture. Concerning the effect of posture, sitting on a chair is most suitable for patients with neck spondylosis, and, in case of the Japanese life style, it is preferable to sit on a folding chair. Sitting cross-legged is a parhcularly bad posture in this regard. As to the type of containes, cups which we developed were the best, followed by cone shaped glasses. The worst container tested was a car. Therefore, cervical spondylosis patients should avoid drinking beverages directly from a can.
We reviewed 78 patients after surgical decompression for lumbar spinal canal stenosis. The average follow-up was two years four months. Two groups of patients were compared: the control group consisting of those aged si less than 70 years, and an elderly group in which patients were si more than 70 years. In regard to JOA score, both groups improved by 7.5 points after surgery. 84.1% of old patients had an excellent or good result.
We analyzed 47 patients with degenerative lumbar canal stenosis treated by posterior decompressive surgery. The average age at the time of surgery was 57.5 years. The average duration of follow-up was ten years and one month. The patients were subdivided into 4 groups. Ten patients were without spondylolisthesis and underwent decompression with fusion (Group I-a). Twenty three were without spondylolisthesis and underwent decompression without fusion (Group I-b). Eleven patients had spondylolisthesis and underwent decompression with fusion (Group II-a). Three patients had spondylolisthesis and underwent decompression without fusion (Group II-b). Surgical outcome was evaluated on the basis of the JOA score. The mean JOA scores after surgery were 21.0 in Group I-a, 19.8 in Group I-b, 22.3 in Group II-a, and 16.0 in Group II-b. There was no significance in the JOA score between with and without fusion. We therefore suggest that simultaneous fusion is not necessary with laminectomy of the lumbar spine in patients who have degenerative lumbar canal stenosis, especially for those without spondylolisthesis.
This study investigated the operative results and factors involved in multiply operated back cases (M. O. B.). 639 cases of Lumbar canal stenosis were surgically treated over a 5 year period, 32 of whon (4.9%) were M. O. B.. Average improvememt rate according to the J. O. A. score using Hirabayashi's method was 52.0%. Many factors are involved with M. O. B.. The prinapal factors were instability at the affected level and insufficient decompression of lateral recess. It is relatively easy to resect adhesions in new stenotic damage, with an improvement rate was 53.7%. However, when the stenosis is long-term, with scar formation or compression on the dura and nerve root it is very difficult to release the nerve. In these cases, the improvementrate was 20-30%. For the prevention of M. O. B., adequate decompression and accurate fusion are necessary at the first operation.
We prospectively investigated and compared the results from wire fixation and those from pedicle screw fixation for an unstable lumbar spine. Between April 1992 and July 1996, we surgically managed 44 cases of unstable lumbar spine using either wire fixation or pedicle screw fixation. Wire fixation was employed for 22 patients (11 male and 11 female, with a mean age at surgery of 51.1 years), and pedicle screw fixation was employed for 22 patients (8 male and 14 female, with a mean age at surgery of 57.1 years). The results showed no difference in % slip, slip-angle, frequency of bone union, or in frequency of instrument failure between those that had received wire fixation and those that had received pedicle screw fixation. In those with lumbar spondylolisthesis, the operative results were excellent or good in only 7 (53.8%) of 12 cases treated with wire fixation and in 13 (81.6%) of the 16 treated with pedicle screw fixation. In those with lumbar disc herniation or lumbar canal stenosis, there was no significant difference in the results between those that had been treated with wire fixation and those that had been treated with pedicle screw fixation. We concluded from these short term results that wire fixation was sufficient for an unstable spine with lumbar disc herniation or lumbar canal stenosis, while pedicle screw fixation was better than wire fixation for an unstable spine with lumbar spondylolisthesis.
Lumbar disk herniation associated with posterior vertebral apophyseal avulsion is unusual and was first considered to occur only in adolescents. Now it is clearly demonstrated that posterior vertebral apophyseal avulsion may also occur in adults in which the ring apophysis is completely ossified and joined to the vertebral body. We described two adults cases with low back pain and leg pain. In both cases traumatic episodes were not conspicuous. Radiographs and CT scan demonstrated characteristic bony fragments at the vertebra posteriorly bulging into the spinal canal. One case was operated on by laminotomy, discectomy and removal of bony fragments. The other case was first operated on by laminotomy and foraminotomy, but his symptoms persisted necessitating a second operation of discectomy and removal of bony fragments.
Percutanoeus discectomy (PD) has been utilized in our institution for treating lumbar disc hernia since 1990. The post-operative course of PD is known to be unclear. This paper reports the outcome after PD observed in a regional hospital. Thirty seven cases, who underwent PD over 7 years (1990 to 1997), were studied, with a mean follow up period of 18 months (6 months to 68 months). This included 25 males and 10 females, with mean age of 23 years (range, 15 to 46). The preoperative and postoperative symptoms were compared, usiong the JOA score and Hirabayashi's scoring system. The JOA score was singificantly improved; scores were 9.0 preoperatively, and 12.4 after PD. Symptoms of 25 patients improved by more than 40% according to Hirabayashi's scoring system. Ten patients improved less then 40% and 8 cases had additional surgery after PD. PD is an effective treatment of choice for lumbar disc herniation, but limited to localized lesions within a disc level hernia as well as within the posterior longitudinal ligament.
In genecal MRI is a useful diagnostic tool for non-invasively assessing general body components. However, we report a case of lumbar disc herniation which was incorrectly diagnosed by MRI as a spinal tumor. The subject was a 69 year old male. His chief complaint was pain in his left thigh. At surgery a large sequestrated disc fragment was easily removed from the dura mater. We then correlated MRI findings with operative findings and found that a large sequestrated disc fragment on the dura mater was reported by MRI as a spinal tumor mass.
Two patients with dysplastic spondylolisthesis were treated by two-weeks preoperative traction and posterior lumbar inter body fusion using the Steffee VSP system. Both patients were relieved of their symptoms, and solid interbody fusion was obtained and loss of correction was not observed at one year after surgeny. Posterior lumbar interbody fusion using the Steffee VSP system is a useful method for treaing dysplastic spondylolisthesis.
To study the features of abnormal movements of the separated neural arch, we measured the angle between the upper-line, of the verlebral body and the upper line of the spinous process under functional X-ray (V-S angle). This paper reports on the assessment of the VS-angle in 43 cases of spondylolysis and 46 cases of spondylolisthesis. The degree of movement of the separated neural arch, varied individnally. special tendancy was found in either group except the subgroup with 3 degrees of movement of the separated neural arch was more dominant in spondylolysis than spondylolisthesis. The degree of movement of the separated neural arch, was not correlated with aging, movement of disc or disc narrowness.
Three cases of intraspinal canal cysts of the lumbar spine were treated surgically. All cases were male, with a mean age at the time of surgery of 27.0 years (range, 20 to 40 years). All patients presented with radicular pain and significant motor deficit. The levels of the intraspinal cysts were at (L4/5) in 2 cases and (L3/4) in one case. The clinical history and findings on physical examination, plane radiography, myelography, CT-myelography, discography, CT-discography and MRI with and without enhance were reviewed. Discography and CT-discography was carried out in 2 cases, showing communication between intraspinal canal cysts and the intervertebral disc. Histological findings of a cyst showed granulation tissue and a degenerative intervertebral disc. We propose that the intraspinal canal cysts were associated with mechanical pressure on a slightly degenerated intervertebral disc and absorbed sequestrated lumbar disc herniation.
We experienced a rare case of intramedullary cavernous hemangioma of the cervical cord. A 43 year-old male had been injured in a traffic accident, receiving a C6 dislocation fracture. He was sent to our hospital complaining of numbness of his left arm. MRI revealed an intramedurally tumor of the cervical spine. We planned an initial A. S. F. of C 6/7 followed by tumorectomy later. His symptoms worsened, so we resected the tumor under a microscope and monitored the outcome. The pathologic diagnosis was a cavernous hemangioma. He has a disturbance of fine finger movement, but can walk well.
Neurinoma is the most common spinal cord tumor. However neurinoma with large cystic changes are rare. We experienced two cases of this condition in the lumbar spine: A 53-year-old male suffering from low back pain and bilateral buttock and thigh numbness; and a 40-year-old female complaining of low back and left lower limb pain and pollakisuria. The MR images of both cases showed an intradural tumor with large cystic change, which represented low signal in T1-weighted images and high signal in T2-weighted images. In the contrast MR images of case 2 the cyst wall was clearly enhanced with Gd-DTPA. Both tumors were removed surgically and pathologically diagnosed as Antoni-B type neurinoma. No evidence of any postoperative neurological defect was shown. Contrast-enhaced MR images should be taken to differentiate between a cystic neurinoma and an arachnoidal cyst.
A case of extraskeletal myxoid chondrosarcoma is reported. A 42-year-old man presented to our clinic for local excision of tumor arising in the right brachial plexus. His tumor was diagnosed as a neurinoma by CT and MRI findings. We performed excision of the tumor but adhesion to the brachial plexus made this very difficult, and it was not possible to excise all of the tumor perfectly. Histopathological examination showed that the tumor was composed of many nodules in which tumor cells were arranged in cords or strands in the abundant myxoid matrix. Histological diagnosis was an extraskeletal myxoid chondrosarcoma. The CT and MRI findings of extraskeletal myxoid chondrosarcoma are the same as neurinoma making it difficult to preoperatively diagnose extraskeletal myxoid chondrosarcoma.
Anterior cruciate ligament (ACL) reconstruction in older patients will occur more often as patients live longer and play sports more. We investigated 13 patients with the Lysholm score, aged over 40-years-old after ACL reconstraction. The patients were seven male and six female, with an average age of 47 years. The mean Lysholm score was 92.8 points. Preoperatively twelve of thirteen patient played sports and postoperatively nine of twelve patients (75%) continued playing. As ACL reconstruction for young patients is valuable, the operation for older patients is also of value.
Forty-six patients with tumors of the cauda equina were treated with minimum exposure and reconstruction of the posterior components. 29 men and 17 women (age, 10-74 years) were treated between April 1981 and May 1997. The tumors included schwannoma (32 patients), lipoma (5 patients), ependymoma (2 patients), and others (7 patients). Laminoplasty was perfomed in 32 patients. Ten of the 32 patients used a Threadwire saw. Semicircumferential decompression was perfomed in 5 patients. Laminectomy and partial laminectomy was performed in the remaining patient. The follow-up period ranged from one month to sixteen years. Three patients included multiple neurofibromas with Von Recklinghausen disease, malignant schwannoma and tethered cord syndrome relapsed. Three patients developed a significant postoperative deficit. One patient malignant schwannoma who had multiple surgery for developed anesthesia in the foot. Two patients with large tumors (dermoid cyst and ependymoma) developed bowel or bladder dysfunction. Good alignment with no instability of the lumbar spine was obtained for all patients.
We have performed 30 Total Hip Arthroplasties in 28 cases since 1992. We were able to follow 26 cases and 28 hips (cemented; 13 cases 14 hips, uncemented 13 cases, 14 hips). The mean length of follow-up was 28.9 months (range, 13 to 52 months). Femoral side radiographic assessment showed good fixation and stability in all cemented THAs, and 12 Bone ingrown and 2 Bone ingrowth suspected in uncemented THAs, when Engh's Fixation/Stability Score was adjusted. The mean postoperative JOA score was 76.1 for the cemented group and 79.1 for the uncemented group. The pain score was superior in the cemented group to the uncemented group, and the walking and activity score were superior in the uncemented group to the cemented group. Thigh pain was detected in 5 hips (4 cases) for the uncemented group (35.8 per cent), and in 2 hips for the cemented group (14.3 per cent), although the result was not statically significant. There seem to be some cases which develop thigh pain in the uncemented THAs, although rigidly fixed bone ingowth is recognized on the radiographs, probably due to uneven load transfer from the prosthesis to the bone.
Twenty five hips involving 25 patients with Harris-Galante cementless THA were examined with a mean follow-up period of 6.5 years. They were evaluated both clinically and radiologically. The result of the JOA hip score ranged from 64 to 97 points with an average of 86 points, and thigh pain was observed in 7 hips. Radiological findings such as socket migration, osteolysis, loosening were not observed in the acetabular component. Stem sinking was seen in 2 hips, one of which showed definite loosening. Focal osteolysis occurred at zone 1 and 7 in one hip, while cortical hypertrophy was seen in 6 hips (24%) and occurred mainly in zone 2 and 6. Reactive line which indicates linear ossification around the components was observed in the socket of 8 hips (32%) and the stem of 25 hips (100%). The reactive line around the stem occurred with more than 90% of incidence at zone 1 and 4, showing a low incidence at zone 7 which contains a porous coating of the stem.
We examined the clinical and radiographic results of femoral head replacement. We studied a group of 46 patients, 47 joints (18 males and 28 females) consisting of 35 cases of femoral medial neck fracture, 10 cases of avascular necrosis of the femoral head and 2 cases of coxarthrosis. They were treated by femoral head replacement during 1977-1996 and were typed as follows: Austin-Moore (5 cases), Harris-Galante (2 cases), Omnifit (4 cases), Omniflex (6 cases) and HA-TCP (30 cases). Age distribution of these cases were 18 to 89 years (mean: 67.9 years), and they were followed from 1 year to 19 years and 9 months (mean: 4 years and 7 months). The mean postoperative JOA score was 80.0 points (Moore: 76.6, H/G: 75, Omnifit: 76, Omniflex: 75.5, HA-TCP: 81). Radiographically, loosening was frequently seen in all patients except HA-TCP type.
We radiographically examined the cementing grade in the cases using the medullary-plug cementing technique of femoral stem in Total Hip Arthroplasty (THA). Among patients with coxarthrosis who received THA in our department from 1979, 9 patients (10 hips) were treated with no medullary-plug. Their age at the time of surgery ranged from 56 to 76 years with a mean of 67.4 years. Another group who were treated with a medullary plug comprised 12 patients (13 hips) aged between 58 and 82 years with a mean of 67.5 years. Results were judged radiographically according to cementing grade and loosening. Use of the medullary plug cementing technique decreased the rate of aseptic loosening of the femoral stem of THA in this short-term follow-up study.
We present a case with dissociation of the polyethylene liner after total hip arthroplasty. In 1986, a 64-year-old woman with osteoarthrosis was treated with cementless total hip arthroplasty. She remained almost free of symptoms for ten years after the operation. In 1996, dissociation of the polyethylene liner from the metal shell occurred after the patient fell down. This dissociation was due to failure of the liner-locking mechanism. At revision, severe metallosis, which mainly consisted of titanium, was found around the hip joint. The metal shell, which was well fixed to the bone, was removed with curved osteotomes. After reaming of the acetabulum, a new acatabular component was implanted. Postoperative course was good.
In a series of 278 total hip arthroplasties, fifteen dislocations occurred. There were 4 men and 11 women; their average age was 68 years (range, 45 to 80 years). The diagnosis before hip replacement was osteoarthritis in 9 patients, rheumatoid arthritis in 4, and revision for failed femoral prostheses. Six dislocations were anterior and seven were posterior. The mean cup abduction angle was 44.9 degrees (32-58) and anteversion was 11.3 degrees (1-33). There was no statistical difference between the dislocated hips and the control group with respect to abduction or anteversion of hip prosthetic components. Seven hips had previous surgery and ten dislocation were considered to be caused by soft tissue imbalance. Muscular imbalance rather than malposition of the components was the major factor determining dislocation.
We microscopically investigated the periprosthetic tissue reaction to wear debris arising from the metal on metal total hip replacements (THR) and compared our findings with that occurring in polyethylene cases. McKee-Farrar prostheses were revised in 4 cases 13 to 20 years after first insertion, providing the opportunity to investigate the accumulated granulation tissues around the prostheses. Much less volumetric, and over all smaller diameter wear particles were observed in the metal on metal THR, cases which caused milder and less intense tissue histiocytic reactions, particu-larly multinucleated giant cells, compared to that in the metal of polyethylene cases. Interleukin-1 and -6, which play an important role in osteolysis were also seen much less in the metal of metal THR.
Seventeen hips in sixteen patients who had osteonecrosis of the femoral head were treated using the transtrochanteric rotational osteotomy. One deep infection and two postoperative intertrochanteric fractures occurred and they were managed with salvage operations such as arthrodesis and femoral endoprosthesis. Out of the remaining fourteen hips, eight had neither hip pain nor progressive collapse of the femoral head. The other six hips, four of which showed progressive collapse, had moderate or severe pain. Preoperative intact area ratio of the posterior part of the femoral head on a lateral X-ray and postoperative intact area ratio of the weight-bearing part on an anteroposterior X-ray were found to be significantly associated with postoperative collapse of the femoral head.
Transtrochanteric rotational osteotomy was performed on 22 hips in 17 patients with osteonecrosis of the femoral head. Ten were male and seven female, with a mean age at surgery 36.3 years (ranging from 17 to 66 years). Follow-up periods ranged from two to 7.8 years (average 4.7 years). Osteonecrosis was induced by steroid drugs in 11 hips and non-steroids 11 hips (six idiopathic, four alcohol abuse and one trauma). Postoperative progressive collapse occurred in three steroid group hips and two hips of the non steroid group, which were chiefly dependent on the small ratio of transposed intact articular surface to the weight-bearing area. Postoperative complication was subcapital fracture in two hips in the steroid group which were cases of systemic lupus erythematosus with bilateral operated hips. In the non-steroid group two hips developed subcapital fractures or varus deformity of the osteotomy site, due to insufficiency of fixation of the osteotomy site.
Valgus intertrochanteric osteotomy is an effective treatment for osteoarthritis of the hip in younger patients. However, the disadvantage of this osteotomy is the difficult stem insertion at the time of subsequent total hip arthroplasty. Sugioka designed transtrochanteric valgus osteotomy to overcome this disadvantage. The purpose of the present study was to report the short-term results after operateion. The results of the first 10 hips in patients were prospectively studied with a minimum of 6-months follow-up. All patients had a long history of hip pain. The average age at the time of operation was 45.7 years. All patients had a flexion arc of at least 80 degrees and at least 20 degrees of passive adducion. Preoperative radiographs of the patients showed an elliptical deformity of the femoral head associated with a well-developed infermedial osteophyte and improved congruence of the articular surfaces was demonstrated in full adduction. Operatve corrections averaged 19 degrees of valgus and 6 degrees of extension. Bone union of both the femoral and trochanteric osteotomies was obtained in all hips. Hip pain was relieved in all except one hip.
We reviewed the long-term results of 34 transtrochanteric curved varus osteotomies that had been performed for advanced subluxated osteoarthrosis of the hip. Subjects conprised one male (two hips) and twenty-four female patients (thirty-two hips); the mean age at the time of the operation was 44 years (range, 31 to 53 years). The average duration of follow-up was 14.4 years (range, 10 to 20 years). All hips were evaluated preoperatively and at the time of the latest follow-up according to the Japanese Orthopaedic Association (JOA) clinical hip scoring system. Measurement of acetabular roof obliquity and center-edge (CE) angle was made on the preoperative radiographs and the influence of acetabular coverage on the clinical results was studied. The average JOA clinical score improved from 60.7 points preoperatively to 76.4 points. Most of the improvement in the score was due to pain relief. Fifteen of 34 (44%) had a good or excellent result, and nineteen hips (56%) had a fair or poor result. Five hips (three patients) failed and a total hip replacement was performed. Clinical results correlated well with the extent of preoperative acetabular coverage. The hips with less than 30 degrees of acetabular roof obliquity on the preoperative radiographs achieved better results than those with more than 30 degrees of obliquity. The hips with more than 0 degrees of CE angle also gained better results than those with a CE angle of less than 0 degrees.
Surgical treatment of secondary osteoarthritis is controversial. We evaluated clinical results of the shelf operation and discussed the indications. Clinical examination was carried out on twentyone hips in nineteen patients. Fifteen patients had only shelf operations and six had combined interochanteric osteotomies. The average follow-up was eight years four months. The mean center edge angle improved from 7.0°to 39.5°. The mean acetabular head index improved from 56.5% to 90.5%. The preoperative mean Japanease Orthopedic Association (JOA) hip score was 65.2 and postoperatively this increased to 85.5. Only one patient had total hip arthroplasty at last follow-up. We believe the shelf operation may be taken into consideration for treatment of secondary osteoarthritis.
We report the clinical and radiographic results of Chiari pelvic osteotomy in 9 hips. The average age of patients at the fine of surgery was 37.6years and they were followed up for an average of 79 months. We utilized the Japanese Orthopedic Association (JOA) score for clinical evaluation and CE angle, Sharp angle, AHI. The mean postoperative JOA score of patients with Chiari pelvic osteotomy was 81 points. One patients achieved a poor results which was due to an incorrect preoperative indication. We found that valgus osteotomy with Chiari pelvic osteotomy was effective even for treating advanced hip stages.
Rotational acetabular osteotomy provides excellent congruity at the site of the osteotomy and good coverage of the femoral head. However, necrosis of the transferred acetabulum has been reported after this procedure. The purpose of this study was to evaluate the effects of rotational acetabular osteotomy on the blood flow rate of the osteotomized acetabulum. Eleven hips of ten adult mongrel dogs were utilized. Blood flow rate was determined using the hydrogen washout technique. The platinum electrode was inserted into the acetabulum after minimum dissection. Then, the blood flow rate of the acetabulum was measured after each of the following procedures; intact; stripping off the gluteal muscles from the acetabulum; circumacetabular osteotomy. The blood flow rate of the acetabulum was significantly decreased from the control value after stripping of the gluteal muscles from the acetabulum. The addition of circumacetabular osteotomy caused a complete arrest of blood flow in the acetabulum. These results indicate that the acetabulum receives blood flow from the gluteal muscles and the bone marrow in an animal model. Hip joint capsule does not seem to have any role in supplying the nutritional pathways to the acetabulum.
The Bernese periacetabular osteotomy described by Ganz et al restores the position and acetabular coverage of the dysplastic hip to nearly normal, but it has several disadvantages due to the asphericity of the osteotomy surfaces. Because this osteotomy is a series of straight cuts, incongruity at the site of the osteotomy and anterior displacement of the hip joint may occur in patients who need an extensive acetabular reorientation. We designed a curved periacetabluar osteotomy to improve these drawbacks. The direct anterior approach described by Murphy et al is used with the patient supine. The triple osteotomy is done with a specially curved osteotome, designed to approximately correspond to the circumferential curvature of the acetabulum. Except for the use of the osteotome, an incomplete cut of the ischium and a complete cut of the pubis are performed in the similr manner as those of the Bernese periacetabular osteotomy. The first step in osteotomy of the ilium is to score the inner table of the pelvis with a power drill. A C-shaped osteotomy line is started proximal to the anteroinferior iliac spine and ended in the distal part of the quadriilateral surface. The actual osteotomy along the scored line is done with the osteotome being directed proximally in the supraacetabular portion, posteriorly in the proximal part of the quadrilateral surface, and distally in the distal part of the quadrilateral surface. Then, the acetabular fragment can be redirected and is fixed with two or three screws. The posterior column of the acetabulum is kept intact. The results of the first 24 hips in 24 patients were prospectively studied with a minimum of 6-month follow-up. All hips had residual hip dysplasias. At operation, the osteotomized acetabular fragment was rotated without difficulty and was medialized as necessary. The averge lateral center-edge angle was 6 degrees preoperatively, compared with 29 degrees postoperatively. The average anterior center-edge angle was 8 degrees preoperatively, compared with 26 degrees postoperatively. Bone union and relief of pain were obtained in all hips.
We report our experience using the modified transgluteal approach to the hip which is described in the literature. Between 1994 and 1996, we examined 43 people (48 hips), 13men and 30 women, with a mean age 59 years (range, 18 to 83 years). The approach is exposure of the hip by osteotomy of the anterior part of the greater trochanter and the whole of the gluteus medius and minimus and the vastus lateralis are attached to the osteotomised fragment. We studied the evidence of this approach. Continity was preserved along the gluteus medius and minimus and the vastus lateralis in all cases and the power of the abductor muscles were preserved. Complications included displacement of the osteotomised fragment and heterotopic calcification.
We report a case of osteoid osteoma of the femoral neck causing arthritis of the hip joint. The patient was an 18-year-old boy, who complained of limping and severe hip pain with limited range of motion. There was no abnormal radiological findings on his first visit to the doctor, immediately after the onset of pain. At our investigation one year after the onset of pain, radiograph showed sclerosis at the proximal femoral neck. MRI showed low intensity on T1WI and high intensity on T2WI in the femoal neck and high intensity on T2WI in the hip joint space. Bone scintiscan demonstrated an abnormal integration in the left hip joint. Tomography and computerized tomography revealed a nidus surrounded by a sclerotic lesion in the cortex of the left femoral neck. There was no infectious sign in laboratory data. Curettage and iliac bone graft were performed. The diagnosis of osteoid osteoma was confirmed by histology. Hip pain and limping disappeared after surgery, although, limited range of motion of the hip remained due to patient's lack of cooperation with rehabilitation. Osteoid osteoma causing hip arthritis was rare. Purulent arthritis, bone tumor and pigmented villonodular synovitis should be considered as a differential diagnosis.
Eleven cases with epiphyseal injuries of the distal tibia in children were treated by percutaneous pin fixation. In all cases, satisfactory results were obtained without deformity and growth disturbance of the ankle. Percutaneous pin was fixation was an easy and effective treatment for epiphyseal injuries of the distal tibia which required closed reduction.
Fourteen cases with fractures of the neck of the talus were treated surgicaliy. They were classified into group I (2cases), II (8cases) and group III (4cases) according to Hawkins classification. All cases achieved bone union. There was no case with osteonerosis. Using the criteria for assessment described by Hawkins, excellent results were achieved in 7 cases and good in 7. Anatomical reduction with internal fixation following immediate reduction of the dislocation are important for good treatment results.
We report the surgical treatment of post-traumatic talipes equinus deformity. 17 feet out of 17 cases with post-traumatic equinus deformity, 12 males and 5 females ranging in age from 7 to 62 years (mean age: 32 years), were operated from 1978 to 1997 in our hospital. Soft part release operation was done in 10 feet, and bony operation in 7 feet. All cases were plant igrad after operation. However, arch supports were needed for treatment of residual equinus deformity in five patients. One patient with severe open fracture of the femur complained of shortening of the lower limb. Equinus deformity can be a cause of metatarsalgia and loss of stability on standing. We recommend the relese operation in combination with rotation flap for treatment of the deformity. However, osteotomy of the tarsal bone and fusion of the ankle were necesary in some cases. Evalution of the foot, such as the condition of the skin, muscle, bone and nerve, was vey important for deciding whether to use surgical treatment.