We present 2 cases of neuropathic spinal arthropathy treated by spinal fusion. 1 case involved a 39-year-old female with a history of congenital insensitivity to pain and a neuropathic spine who suffered progressive neurological compromise secondary to the L4-5 lesion. Radiograph revealed spondylolisthesis at L4 with severe destructive changes at L5. She underwent laminectomy at L3-5 with posterior spinal fusion using titanium instrumentation and a bone graft from L4 to the sacrum. Although follow-up radiograph confirmed progressive instability in the screw and rod, her motor loss and sensory disturbance gradually improved after the operation. The other case involved a 53-year-old male with complete T12 paraplegia due to traffic accident 25 years ago. At that time skeletal injuries to the spine included burst fractures in T12 and L1. The spine has decompressed and later fused posteriorly from T12 to L1 after the injury. Follow-up radiographs confirmed disc space narrowing, facet arthropathy, and destruction in the vertebral body with severe instability at L4-5. Recently he underwent posterior spinal fusion using ISOLA stainless instrumentation with a bone graft from L2 to the iliac bone. Postoperative radiographs showed good maintenance of the position and alignment of the instrumentation with no progression of arthropathy. We concluded that successful arthrodesis was achieved not only by rigid fusion using instrumentation but also by sufficient postoperative bracing.
Difficulties are often encountered in the determination of the decompression levels of mult: intervertebral stenosis. We conducted a study on multilevel decompression in 117 cases with lumbar spinal canal stenosis. Each case was classified according to the type of neurogenic intermittent claudication. The range of decompression levels was determined in intraoperative findings. For the radicular type where the SNRB is effective only in one-level, signs of compression were found in 50% of the additional decompression cases. On the other hand, 29% of the effective multi-vertebral decompression cases had levels without compression. A total of 70% of the caudal type and the mixed type cases showed multi-vertebral compression, wheress 30% had levels with fewer signs of compression. In the radicular type cases it was questioned whether decompression should be applied at the level where the SNRB is vague and at the severe stenotic level on the image where the SNRB is ineffective. In the caudal and the mixed type case, it is necessary to rely on image diagnosis because of the lack of precise diagnosis of the level responsible for caude equina symptoms. In the intra operative findings, we found that further limiting the levels to be decompressed is highly recomended for each type. It is however considered risky to limitlevels of decompression while many other issues remain unsoived. Needless to say, curring in one operation is advisable.
Since 1987, we have operated on 59 patient by laminectomy for lumbar spine, of which 37 patients were followed up and evaluated. The mean age of the patients at surgery was 71 years, ranging from 60 to 83 years. The average preoperative JOA increased (range: 15 to 24 points). Improrement was however not seen in spondylolisthesis patients. A longer follow-up shonld be necessary for lumbar spondylolisthesis.
This study investigated the operative results of the lumbosacral radiculopathy of lumbar canal stenosis. 24 cases were treated by surgery 9 cases received fenestration, 8 cases also received wide laminectomy, and in addition 7 cases received lumbar segmental fusion by instrumentation. The mean age at the time of surgery was 69.8 years (ragne; 56 to 81 years). The mean duration of follow-up was 23 months (range; 12 to 31 months). The clinical results were evaluated by the JOA score, and the recovery rate was determined by Hirabayashi's method, and by the recovery ratio of radiculopathy symptoms, pain and dysesthesia of the lower extremities. The preoperative mean JOA score was 14.5 points, which changed to 20.5 points at the final check, and the mean recovery rate was 42.7%. The recovery ratio of radiculopathy pain shows a tendency to decrease as the number of decompressed intervertebral segments increase.
This study reviewed the results of the conservative treatment and operative treatment for lumbar canal stenosis. 161 patients with lumbar canal stenosis were inrestigated in this study. 101 cases were degenerative canal stenosis and 60 were degenerative spondylolisthesis. The average age at admission was 66.9 years and the average follow-up period was 1 year and 9 months. We evaluated their JOA score and findings of myelogram and CTM at the time of admission. The JOA score and findings of myelogram of degenerative spondylolisthesis were severer than those of degenerative canal stenosis. All cases undergoing conservative treatment showed only radicular symptoms. Operations were performed in all the patients with cauda equina syndrome. Degenerative canal stenosis cases with radicular symptoms, showed correlation between the JOA score and prognosis. In the same cases, the distance of the bilateral articular prosess and the anteroposterior diameter of the lateral recess measured by CTM correlated with prognosis.
A new classification for vertebral compression fractures caused by osteoporosis is proposed in this study. The patients were classified into two groups; type I and type II according to the findings of the posterior wall of the vertebral body detected by MR imaging. The duration of back pain was investigated in each group and statistical analysis was performed by the Wilcoxon regressin method. p<0.001 was considerd significantly different.
10 females with vertebral fracture and kyphosis deformity due to osteoporosis were retrospectively studied following operative treatment. Their average age was 68 years (46 to 77 years) at the time of operation. The average follow-up was 10 months. All patients had neurological disorder (4: thoracic myelopathy, 5: cauda equina syndrome, 1: myelopathy and cauda eguina syndrome) while 6 had non-ambulatory paraparesis. They were treated by posterior instrumentation and spinal fusion, and an additional anterior decompression followed by A-W glass ceramic strut graft in 5 with spinal canal encroachment of fracture fragments. Urinary disturbance in 6 patients disappeared, intermittent claudication in 3 disappeared (2) or improved (1), and low back pain in 10 disappeared (4) or improved (6). The 6 non-ambulatory cases were able to walk with support except for a rheumatoid arthritis patient. Instrumentation was useful in relieving back pain with early mobilization. The correction rate of kyphosis was, however, 50% for insufficiently balanced spine, showing no correlation with the improvement of clinical symptoms. Use of hooks instead of screws for secure anchorage in the bone, supplemental spinal osteotomy for greater correction, and more precise instrumentation for well-balanced spine are required.
We report 3 cases of Paraplesia caused by osteoporotic vertebral compression fracture and OYL. All 3 were female patients over 70 years old with severe osteoporosis. Vertebral compression fractures occured at the thoraco-lumbal junction and OYL existed in the next intervertebral space. Radiographic evaluation showed spinal cord compression caused by posterior OYL. The patients were treated surgically with posterior decompression and fusion using a Luque rod or transpedicular screw system. We evaluated the clinical symptoms using the JOA score and Hirabayashi method. Excent for 1 patient whose postoperative JOA score could not be evaluated due to dementia, the percentage of clinical recovery of the other 2 patients was 17% and 88%. We thus concluded that intervertebral fusion should be carried out for osteoporotic patients.
We operatively treated 18 cases of delayed paraplegia after osteoporotic vertebral fracture in the past 11 years, They included 9 cases (2 males, 7 females) operated by the anterior method (using Kaeda device) and 9 cases (2 males, 7 females) operated by posterior method (using the Luque rod). Their ages ranged from 59 to 78 years (average; 68.9 years). 2 cases of RA and 2 cases of diabetes were included. There was no difference in neurological deficits and daily activities between the anterior and posterior methods. The anterior method is however suitable especially for the relief of pain, and the posterior method for decreasing invasion.
We report a case of pustulotic arthro-osteitis. Arthro-osteitis is a rare condition in palmoplantar pustulosis (PPP). A 60-year-old woman was admitted to our hospital with persistent low back pain and limitation of the lumbar flexion and extension. Diagnosed with PPP, surgical treatment by anterior spinal fusion was performed. She recovered well, and bone union is good today.
Disturbance of the shoulder joint results from the uncoordinated movement of the shoulder girdle muscle and contracture of these shoulder muscles. The purpose of this study is to evaluate patients with birth palsy who were treated surgically to improve the shoulder function. 9 shoulders of 9 patients with birth palsy were operated on. The average age at surgery was 12.8 years (range; 4 months to 12 years). The follow-up period was 4 months to 12 years with the average of 4 years 11 months. The reconstructions of shoulder functions were performed by muscle transfer in 7 patients and rotation osteotomy of the humerus in 2 patients. Muscle transfer operation was performed in patients who desired more elevation of the arm. Rotational osteotomy of the humerus was also performed on those who had reasonable elevation but with the arm in the internal rotation position due to muscle contracture. We transferred m. latissimus dorsi in 1 patient out of the 7 patients, m. pectoralis major and m. latissimus dorsi in 1 patient, m. trapezius and m. levator scapulae in 1 patient, and m. trapezius, m. levator scapulae and m. latissimus dorsi in 4 patients out of the 7. The range of motion of the shoulder joint was investigated pre and post operatively. The average preoperative flexion, abduction, and external rotation angles were 74.4°, 72.8° and 3.3°. At the final follow-up these improved to 106.7°, 95.6° and 16.1° respectively. In this series, most of the patients were satisfied with the results.
This study reports the outcomes of surgical treatments for congenital elevation and hypoplasia of the scapula. 6 shoulders of 5 patients with congenital elevation (1 Sprengel's deformity, 1 Noonan syndrome bilateral, 3 Klippel-Feil syndrome) and 1 patient with congenital hypoplasia of the scapula were treated surgically. They were followed-up for 2 months to 17 years 3 months (average: 7 years 4 months). There were 2 males and 4 females and their ages ranged from 3 to 15 years (average: 6 years 5 months). For the congenital elevation of the scapula, the König method was carried on 3 shoulders (in 1 case, Z-plasty was added for the webbed neck), and the Woodward method on 1 shoulder. The patient with the Noonan syndrome was operated on by osteotomy with release in 2 shoulders. In this bilateral case, for the weakness of the shoulder abductor, pectoralis major muscle transfer was added during reoperation. The congenital hypoplasia was treated with pectoralis major muscle transfer only. The range of motion of the shoulder and downward displacement of the inferior angle of the scapula were investigated in these patients. The average shoulder abduction angle improved from 99.2° to 140° at the final follow-up. The average downward displacement of the scapula was 6.2mm (-11mm to 26mm). Patients with Sprengel's deformity showed better results functionally and cosmetically compared to those with underlying diseases such as Klippel-Feil and Noonan syndrome. Patients with muscle hypoplasia around the shoulder girdle were treated with pectoralis major muscle transfer, and satisfactory functional improvement was observed, From these results, good results may be obtained for shoulder girdle muscle hypoplasia by pectoralis major muscle transfer to improve scapular abduction.
Not only long thoracic nerve palsy but also accessory nerve palsy cause winging of the scapula. We treated 9 patients with thoracic nerve palsy and 8 patients with accessory nerve palsy. Winging of the scapula was accentuated by forward flexion of the arm in long thoracic nerve palsy, and by lateral flexion of the arm in accessory nerve palsy. The majority of patients with long thoracic nerve palsy was caused by neuralgic amyotrophy. All of these patients were treated by conservative treatment. Functional recovery was good and operative treatment was not necessary. Accessory nerve palsy was mainly caused by the iatrogenic, e. g. radical neck dissection or lymph node biopsy. 4 patients were treated by conservative treatment, while the remaining 4 patients were treated by operative treatment. 3 of these patients showed improvement.
We report 6 patients with entrapment of the infraspinatus branch of the suprascapular nerve and discuss the diagnosis, pathology, treatment, and outcome over a mean follow-up period of 5 years. Each patient presented shoulder pain and weakness. EMG disclosed denervation and motor unit loss restricted to the infraspinatus muscle, with the supraspinatus muscle remaining normal. 2 patients were seen to have spaceoccupying lesions at the spinoglenoid notch by MRI, and ganglia were confirmed and removed surgically in 3 patients. Good results were seen in 3, but 1 required reoperation because of recurrence. We performed neurolysis and shaving of the spinoglenoid notch on a patient without ganglia. The other 2 patients without ganglia were treated conservatively. Our patients required 1 to 2 years to recover from paralysis of the infraspinatus muscle. Suprascapular neuropathy at the spinoglenoid notch should be included in the differential diagnosis of patients presenting shoulder pain and weakness.
We performed glenoid osteotomy on a weight-bearing shoulder with posterior subluxation. The patient was a 44-year-old paraplegia male. He complained of disability and pain in his right shoulder after starting plaining tennis. His shoulder pain subsided after a local anesthetic injection at the gleno-Numeral joint, Plain X-ray films showed osteophyte in the Numeral head and osteosclerotic change in the glenoid. Arthrogram did not reveal typical findings of rotator cuff tear. CT indicated a narrowing of the posterior joint space and posterior subluxation of the humeral head. We performed posterior open-wedge glenoid osteotomy and posterior capsular shift. The follow-up period was 18 months. He no longer complained of disability and pain even though he has playing tennis, and pushing up his body with his arm. The range of motion of his shoulder improved 5 degrees in external rotation, and at the fifth lumbar vertebra in internal rotation. CT showed excellent congruency of the gleno-Numeral joint. The J. O. A score was 88 points in the postoperative state, and 55 points in the preoperative state, and he satisfied with his shoulder function.
The shoulder joint is the most unstable joint in the human body. The direction of instability is mostly anterior, and posterior instability is rare. From 1979 to 1997, we operated on 16 posterior subluxation patients at our hospital. In this paper, we report the results of the surgical treatments for these patients. There were 10 males and 6 females with a mean age of 17 years (range; 13 to 29 years). The average follow-up period was 7 years 9 months (range; 4 months to 18 years 8 months). 8 patients were also associated with inferior subluxation. 1 patient had general joint laxity. In the first 4 cases, we followed Scott's original method and tightening of posterior capsule. However, due to some complications, Namely cicatricial scar and/or pain of the posterior glenoid site, the remaining 12 patients were operated on by the modified Scott's procedure. All the patients were evaluated by the shoulder evaluation score of the Japanese Orthopedic Association. The pre-operative average JOA score was 74. 8 points, which improved to 93. 8 points at the final follow-up. Recurrence was observed in 2 cases, of which had general joint laxity. All excent these two patients showed no difficulties in ADL and sports activities. From this study it can be suggested that satisfactory results can be obtained in patients with posterior subluxation by the modified Scott's method.
Introduction: In orthopedic surgery, it is important to prevent infections, and antibiotics are used for this aim. The concentration of antibiotics must exceed MIC in the venous blood and bone marrow. In this study, we measured the concentration of isepamicin of the venous blood and bone marrow. Subjects and methods: The subjects consisted of 4 males and 2 females who underwent reconstruction of the rotator cuff. Their ages ranged from 40 to 65 (average is 56.7 years old). We administend 400mg of Isepamicin for 30 minutes and extracted the venous blood and bone narrow immediately after, 30 minutes, and 60 minutes later. The blood of the bone narrow was extracted from the surgical neck of the humerous during the operation, separated the venous blood and bone marrow at a rate of 3000/min for 10 minutes, and measured the blood plasma. Results: The concentration of Isepamicin was higher than MIC in both the venous blood and bone marrow. Side effects of Isepamicin were found in all cases. Conclusions: Isepamicin is an effective antibtic agent for orthopedic surgery.
Few orthopaedic surgeons take care to decrease postoperative pain. We compared postoperative pain in 42 patients receiving continuous subcutaneous administration of Buprenorphine with 12 non-receiving patients. We administered Buprenorphine to the 42 patients for 2 days at 0.013mg/hr, and we also administered NSAIDs, Pentazosin or Morphine to patients who required it. In general anesthetic patients, there was a significant decrease in pain 6 to 12 hours after operation, but in lumbar anesthetic patients, there was no remarkable difference between the two groups. 92% of the non-receiving patients (11/12) of Buprenorphine used painkillers to decrese postoperative pain, but only 33% patients (14/42) used something in addition to Buprenorphine. Continuous subcutaneous administration of Buprenorphine is useful for decresing postoperative pain in orthopaedical operations, particularly for general anesthesia.
Few studies describe the interrelation between the thoracic outlet syndrome (TOS) and whiplash injury. A prospective study was carried out to determine the pathogenic significance of trauma or injury to the upper body in the development of neurovascular compression at the thoracic outlet. 29 cases of cervical strain injuries (N-group), 30 cases of probable TOS with positive Morley-test alone (PT-group), and 52 patients of definite TOS with further positive Roos & wright stress test (T-group) were compared on sex, age, weight, symptom, various clinical and radiographic findings, The PT-and T-groups had more elderly patients with headache, arm numbness, lumbago, and shoulder stiffness. The history from the onset of accident, duration of symptom, and treatment indicated significant difference in the TOS patients. Radiography of TOS cases also showed a higher percentage of neck-lengh/height ratio, and demonstrated the midbottom line of T1 vertebral body at the lowest part of the cervical spine. The presence of persons susceptible to traumatic TOS should be well-understood through correct initial treatment for patients with trauma.
We investigated the anti-inflammatory effects of static magnetic fields (SMF) on the whole-body of adjutant-induced arthritis (AA) in rats. SMF could increase rat tail skin temperatures and calories in the chronic stage as well as the acute stage of AA in rats through enhanced blood flow. These results suggest that SMF plays an important role in AA as an inhibitor of inflammation in the chronic stage, which indicates ischemic conditions with lower temperature relative to normal conditions, but as a promoter of inflammation in acute stages with higher temperature relative to normal conditions.
Posterior upper cervical fusion in 13 patients with atlanto-axial subluxation caused by rheumatoid spondylitis (9 atlanto-axial anterior subluxation, 4 vertical subluxation) was assessed with magnetic resonance imaging. 9 patients were treated by C1-C2 posterior fusion and 4 patients by occipital-upper cervical fusion. MRI was performed both before and after surgery. The operative results were most and least favorable in 12 patients in whom the cord indentation present before surgery disappeared after surgery, and only 1 patient in whom indentation persisted unchanged by T1-weight imaging. In T1-weight imaging after GD-DTPA was injected intravenously showing the inflamation of the synovial joints, 12 out of 13 patients showed ehhancement before surgery, and 6 patients showed persistence after surgery. In T2-weighted imaging, 4 of these patients showed high signal intensity in the spinal cord, and 3 showed unchanged persistence postoperatively.
Renal insufficiency is a serious symptom in patients with Rheumatoid Arthritis (RA), and it occurs from various causes. We report 2 cases of Total Knee Arthroplasty (TKA) in patients with RA who have advanced renal insufficiency. Case 1 was a 70 year-old man suffering from RA for 40 years. Renal insufficiency appeared 2 years ago. The pre-operative renal function was BUN: 83.4mg/dl, Cr.: 5.47mg/dl, 24Ccr.: 11.3L/day. Operation was performed on the right TKA for 45 minutes. The amount of bleeding was 40ml. Case 2 was a 50 year-old woman suffering from RA for 10 years. Renal insufficiency appeared 1 year ago. The pre-operative renal function was BUN: 64.0mg/dl, Cr.: 3.43mg/dl, 24Ccr.: 19.0L/day. Operation was performed on the left TKA for 26 minutes. The amount of bleeding was 30ml. The 2 cases showed no post-operative renal dysfunction, and improved quality of life after surgery.
Fractures of the distal radius associated with the dislocation of the distal radioulnar joint are called Galeazzi fractures. In children, the disruption of the distal ulnar physis rarely occurs in place of the dislocation of the distal radioulnar joint. These cases are called Galeazzi equivalents. We report a case of a very rare irreducible Galeazzi equivalent. A 14-year-old boy fell down and injured his right wrist. X-ray showed that the fracture pattern of the distal radius was greenstick with volar angulation (apex dorsal). The distal ulnar physis was disrupted (Salter-Harris type II) and the proximal metaphyseal fragment displaced dorsally, but the distal radioulnar joint was intact. Closed reduction of the distal ulna failed and open reduction was carried out through a dorso-ulnar approach. It was revealed that the interposition of the extensor carpi ulnaris (ECU) and tendon of the extensor digitiquinti (EDQ) between the fragments hindered the reduction. After removing the interposed soft tissues, the fracture was reduced easily and could be fixed stably with a single Kirschner wire. Neither growth arrest nor loss of range of motion occured at 5 months after operation.
Clinical results of metacarpal and metatarsal bone lengthening carried out on 15 bones in 13 patients by the Callot, asis procedure are reported. This procedure is simple and easy-to-perform, but treatment sometimes require a long time. The mean age of the cases was 23.3 years (range: 11 to 59 years). The lengthening rate ranged from 21 to 90% (mean: 41.4%). 5 bones had incomplete callus formation. 4 of them were first metacarpal bone, probably coused by the damage of the periostea, due to old age and/or less blood supply compared with other metacarpal bones.
Subcutaneous rupture of the flexor tendons in the hand other than rheumatoid arthritis is rare. We report a case who was suffered from subcutaneous rupture of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) to the little finger associated with nonunion of the hook of the hamate. The patient was a 63-year-old man. He suddenly noticed pain in his palm and difficulty in flexing his little finger during golf. He could not remember any episodes of trauma or injury that might have caused hamate fracture. His radiogram revealed nonunion of the hook of the hamate. Intraoperative findings revealed rupture of the FDS and FDP at the hamate nonunion. We removed a fragment of the hamate. Because of the myostatic contracture of the FDP, the proximal end of FDS was sutured to the distal end of the FDP with the modified Kessler method. Passive range of motion exercise was began 2 weeks after surgery. 2 years after surgery, he gained TAM of 200 degrees which classified as excel-lent after the Buck-Gramckos' criteria.
The treatment of scaphoid nonunion poses a challenging clinical problem. This problem is particularly substantial in the case of associated dorsal intercalated segmental instability collapse (DISI), radiocarpal degenerative changes, and poor scaphoid bone quality. We herein report two cases of symptomatic scaphoid nonunion, degenerative arthritis between the distal scaphoid fragment and radial styloid, with midcarpal degenerative changes treated by excision of the distal scaphoid fragment. Both patients had pain relief, and improved range of motion and grip strength. Carpal collapse and DISI deformity remained unchanged, at least in our short period of follow-up. The operation which is simple and requires a short period of immobilization can be considered a surgical option for scaphoid nonunion with degenerative arthritis.
We performed finger reconstruction by the toe-to-finger transfer on 15 cases. 6 cases were reconstructed for small finger amputation. We utilized a third toe-to-finger transfer for the reconstruction. Informed consent is an important fector. 8 case were finger reconstruction for the multiple digits (more than 3 digits), for which we have used a II toe-to-finger transfers were used. 5 of these cases had undergone amputation at the metacarpal level. The total active motion of these 5 cases was 40° on average. As for the full range of motion of the thumb, all 5 cases were able to pinch well. Improved finger function was seen, but prostheses is required for ehhancement of cosmesls.
Leri-Weill syndrome is a hereditary disorder transmitted as an autosomal dominant trait. Appearing in the form of mesomelic dwarfism, it consists of mild shortness of stature and Madelung deformity of the wrist. We here in report the results of surgical treatment on 3 patients (4 wrists). All cases were female affected bilaterally, and their ages at operation were 9, 25 and 31. 2 adult patients complained of pain and deformity in the right wrist, and a skeletally immature girl complained of deformity of the bilateral wrists. Dorsal dislocation of the distal ulna was observed in all patients. Radiograph revealed excessive ulnar and volar angulation of the distal articular surface of the radius in all patients. The mean radial inclination was 56.3° (45-60°), and volar tilt was 32.8° (20-43°). Radius opening wedge osteotomy and iliac bone graft were performed to correct radial inclination and volar tilt in 2 adults. Fixation was achieved with the A-O plate and tension band wiring in each. Wedge osteotomy (radial closing and ulnar opening) was performed in the bilateral wrists of the girl fixed with the tension band wiring. The follow-up period ranged from 1 to 4 years. The prominence of the ulnar head diminished and correction of the radius was preserved in 2 adults. The girl however showed progressive loss of correction in the bilateral wrists with growth.
10 years ago, a 47 year old woman suffering from quadriplegia for 30 years sustained bilateral elbow neuropathic arthropathy, and thus syringo-peritoneal shunting for syringomyelia, and relief of the elbow from load by the use of an electrically-powered wheel chair were carried out. 10 years later, review of the woman revealed almost no aggravation of quadriplegia and elbow arthropathy. A 69 year old man suffering from quadriplegia for 29 years sustained bilateral elbow neuropathic arthropathy with syringomyelia, and thus synovectomy, debridement, and closure of the fistula followed by bracing were carried out for the left worse elbow. 3 months after surgery, no inflammation nor remarkable effusion was seen.
Diagnosis of reflex sympathetic dystrophy (RSD) is not always easy in daily practice because of its complex features at each phase. The clinical diagnosis is currently apt to be abused in various institutions, especially in orthopaedic clinics. This situation prompted us to examine retrospectively the validity of diagnosis and efficacy of treatment in patients suffering from RSD. The subjects were 31 patients diagnosid as RSD in various institutions, and were referred to the Orthopaedic and Pain Clinic in Kurume University Hospital from April, 1988 to August, 1997. These patients were retrogradely re-evaluated by orthopedists and pain-clinic staffs with reference to the fiagnostic classification of the Gibbon's RSD score. Therapeutic efficacy was surveyed by questionnaires, including degree f patient satisfaction in daily activities. 24 patients were satisfied with the RSD criteria, and the remaining 7 patients were not. As for therapeutic efficacy, a high degree of patient satisfaction was obtained in patients first stage RSD. On the other hand, therapeutic efficacy was not remarkable in those with second and third stage RSD. From these results, we concluded that early diagnosis and treatment are particularly important and that additional psychological assistance is inevitable in patients with advanced stage RSD.
As previously reported, MRI is found to be useful in the evaluation of meniscal and cruciate ligament injuries. But at our institute, however, due to frequent in consistencies between MRI and arthroscopic findings, we investigated problem knees by MRI and compared the findings with those using arthroscopy subsequently performed. 28 cases with medial and lateral meniscus, and 31 cases with anterior and posterior crucial ligament were examined. The field strength of MRI was 1.0 Tesla, and images were meared by the T2 weighted gradient echo method. Sensitivity for medial meniscus, lateral meniscus, anterior cruciate ligament, and posterior cruciate ligament was 60, 38, 33, and 20 percent respectively, specificity was 78, 90, 91, and 89 percent respectively, and accuracy was 75, 75, 74, and 77 percent respectively. These values are lower compared with other reports. Diagnoses of meniscal and cruciate ligament injuries from magnetic resonance imaging of the knee at our institute are not confidential. For improvement, the scanning and imaging methods, must be changed and a new sophisticated MRI scanner is desirable.
This study was designed to realize changes in the tibial tunnel regarded as the enlargement of the bone tunnel after anterior cruciate ligament reconstruction by bone-patellar tendon-bone autograft. The changes in the geometry of the tibial tunnel were measured radiographically during the immediate postoperative period, the period that sclerotic change occurred, and at around 1 year after surgery in 34 knees. At the level of the joint line, we measured the inner diameter of the tibial tunnel and the outer diameter that included the sclerotic region at the margin of the tunnel. We also measured the position of the tibial tunnel at AP and lateral view. Only 2 out of 34 knees showed an enlargement of the inner diameter greater than or equal to 2mm in width. In the other 32 knees, the main change was the thickening of the sclerotic region, ranging from 1.5 to 5mm, at the margin of bone tunnel. No significant relationship was seen between the thickening of the sclerosis and the position of tibial tunnel. These results suggest the possibility that the thickening of the sclerotic region may be regarded as the enlargement of the tibial tunnel.
Histological evaluations were performed on 13 patients who underwent anterior cruciate ligament (ACL) reconstruction using rolled-iliotibial tract autografts. At the time of the second-look operations after more than 18 months of interval from the reconstructions, tissues were biopsied from the anterior central surface of the reconstructed-ACL in the knee position of 60° flexion. The crimp period (CPD) of each specimens showing structure-spescific features were measured under polarized light after staining with hematoxylin and eosin. The number of fibroblasts per 1mm2 was also counted. Magnetic resonance imaging (MRI) examinations were carried out on the reconstructed-ACLs performed with 0.5 Tesla whole body system (Philips, Gyroscan), and the intensity in the area of the biopsy was evaluated by T1-weighted images. The correlations between the CPD and number of fibroblasts, arthroscopic findings, and the intensity of magnetic resonance imaging (MRI) in the area of the biopsy were evaluated. Correlation was found between the CPD and number of fibroblasts and between the CPD and arthroscopic findings, while no correlation was observed between the CPD and MRI intensity.
We reviewed 21 patients, and 22 knees operated on because of the rupture ofthe posterior cruciate ligament (PCL). The clinical outcome was evaluated using the Lysholm score. All 21 patients had undergone magnetic resonance imaging (MRI). According to MRI findings, knees were divided into three groups; high, iso, and low intensities. The evaluation of BTB (bone patella tendon bone) by MRI tended to change from high intensity to low intensity. The average Lysholm score of the low intensity group (93.6points) was higher than the score of the high intensity group (87.0points). The intensity of the reconstructed PCL on MRI correlated with the clinical results.
15 TKAs observed more than 4 years were examined for changes in the patellar position with the time. The patellar height and patellar tilt were measured by preoperative roentgenograms and postoperative roentgenograms at 4 weeks and more than 4 years, The range of motion (ROM) of the knee was compared with the measured value. 15 TKAs were classified into 2 groups by the ROM. 8 TKAs with ROM greater than preoperation were group A and 7 TKAs with ROM less than preoperation were group B. The average index of the patellar height in group B was 0.99 prior to operation, 1.01 at 4 weeks after operation, 0.83 at more than 4 years. Each was 1.001, 1.06, 0.97 respectively in group A. The patellar height showed a temporary high average after operation, but showed low at more than 4 years. The average tilting angle in group B was 5.9° prior to operation, 9.7° at four weeks, 9.3° at more than 4 years. Each 3.3°, 5.2°, and 6.0° respectively in group A.
40 primary uncemeneted total knee arthroplasties (MG II) were performed in 32 patients with osteoarthritis. The average age was 73.0 years at the time of surgery. The follow-up period was an average of 5.6 years (range; 5 to 6.6 years). Clinical evaluations based on the Japanese Orthopedic Association score indicated significant improvements from preoperative to the most recent follow-upexamination. There was no evidence of rentogenographic failure in the femoraland tibial component. None of the knees required revision surgery. The flexion angle at the last follow-up correlated well with the last clinical score, especially in the ability of stairs. The clinical score of patients with flexionangle over 110° was significantly better than that under 110°. These mid-term results of uncemented MG II TKAs proved satisfactory in osteoarthritis. However, a longer follow-up period is necessary for problems related to the patellarcomponent even in MG II TKAs, because mal-alignment of the patella-femoral jointhas been observed in 4 knees.
We measured the muscle torque of active knee motion for 50 knees in 42 cases who underwent total knee arthroplasty at the Yamaguchi Rousai Hospital, In this study, we used CYBEX 6000 and measured the muscle torque prior to operation, and 3 months, 6 months, 1 year, and 2 years after operation. The recovery of the extension and flexion torque of the knee began soon after the operation, and 3 months later their average torque was already superior to the one before operation. The recovery of the torque continued until 2 years after operation and their average torque was nearly equal to that of the controls. We found three factors which influenced the recovery of the torque, namely preoperative torque, the difference in diseases, suffered, and surgical method. Cases showing better preoperative torque tended to have a better postoperative torque, while casessuffering from rheumatoid arthritis showed better torque recovery than osteoarthritis copses within 3 months after operations. In cases on which the subvastus approach was performed, the postoperative torque tended to recover earlier than those by the medial parapatellar approach.
We reviewed 21 knees of 14 patients who underwent unicompartmental knee arthroplasty (UKA) for gonarthrosis in the medial compornent between 1992 and 1996. The mean age at surgery was 64 years with the postoperative follow-up period averaged at 32 months. Good clinical results were obtained and the average JOA score improved from 58 to 88 points. However the femorotibial angle (FTA) tended to increase gradually, despite the degree of corrected FTA (average 176). Patients requiring revision or with steep increase of FTA showed obesity, high performance ADL, or injury in the anterior cruciate ligament. In conclusion, UKA may have an indication only for elderly patients with low daily activity.
We developed a new index to quantify the position of the tibial tuberosity in the anteroposterior direction relative to the patellar groove of the femur in degrees (angles), based on the lateral radiograph of the knee. This index is the angle TT between a tangent to the patellar groove, which is parallel to the central line of the tibial shaft and the line from the most anterior point of the tibial tuberosity to the point of the contact between the tangent and the patellar groove. The angle TT increased linearly with knee flexion and the mean value was 6° at 30° of knee flexion, and 22° at 90° of knee flexion. The correlation was 0.826. With this index, the position of the tibial tuberosity in knees with Osgood-Schlatter disease was expressed 6° anteriorly compared with that in normal knees.
Tibial tubercle transfer is often performed for patella maltracking. In this procedure, the periosteum of both sides of the tibia is stripped off along the tibial tubercle and then the bilateral cortices are transected. It is however likely to disturb blood supply to the tibial tubercle. We have, therefore, devised a new procedure in which the periosteum of the medial side of the proximal tibia is left intact when tibial tubercle transfer is performed. The purpose of this study is to investigate the blood supply to the tibial tubercle in an animal model using a hydrogen washout technique. 10 mongrel dogs weighing 10.0 to 19.1kg were used. Blood flow was measured using a hydrogen washout technique. Before the surgical procedure, the control blood flow rate of the tibial tubercle averaged 19.2ml/minute per 100g of tissue. The blood flow rate did not significantly decrease after dissection of the periosteum on the lateral side of the tibia alone (p> 0.05). After the tibial tubercle osteotomy, the blood flow rate averaged 11.2ml/minute per 100g of tissue, which is a 26% decrease as compared with the value after dissection of the periosteum on the lateral side of the tibia alone (p<0.05). The blood flow rate significantly decreased to 3.4ml/minute per 100g of tissue after distal periosteal dissection (p<0.05). The addition of medial periosteal dissection caused a complete arrest of the blood flow in 11 out of 12 knees, which is a 99% decrease as compared with the value after distal periosteal dissection (p<0.05).
In 21 patients (25 torn menisci), we retrospectively examined abnormal intensity area around the torn site using Magnetic Resonance Imaging (MRI) and correlated with histrogical findings. Abnormal high or iso intensity changes were revealed in 21 of 25 torn menisci by MRI. Hitologic abnormalities (e. g. mucoid degeneration and cleavage of collagen bundles) correlated well with these intensity changes on MRI.
we examined the causes of reinjuries in repaired meniscus of three cases more than one year after repairing. Case 1 was a 60-year-old male who had a medial meniscus peripheral tear and PCL injury. 21 months after repairing we underwent a partial meniscectomy. The removed meniscus had a degenerative change and we concluded that the reinjury causes were from the PCL injury and degeneration in the meniscus. Case 2 was 20-year-old male with an initial medial meniscal injury from playing baseball. Partial meniscectomy was done 17 months after the initial operation. The torn region was covered by an avascular tissue like a synovial membrane, and so we conculuded that the cause was from incomplete healing of the repaired meniscus. Case 3, a 16-year-old was reinjured 15 months after ACL reconstruction and a medial meniscus suture. The removed meniscus did not have a degenerative change. We conculuded that the meniscal tear of case 3 was a traumatic injury with no relation to the initial repair.
Radiological evaluation was performed in cases with osteonecrosis of the medial femoral condyle (ON). The subjects were 32 knees of 32 cases (5 males and females) with an average age of 65 years (46-77 years). We examined the femoral angle, tibial angle, and posterior slope by plain X-ray film, and compared with the angles of the osteoarthritis of the knee (OA). The tibial angle of the ON is smaller than the angle of the OA (p<0.01). No statistical significance was found for femoral angle and posterior slope Varus deformity of ON is lower than OA.
we measured the bone mineral density (BMD) of the calcaneus of treated legs by single X-ray absorptiometry in 28 patients after treatment with non-weight bearing for more than 2 weeks. 6 out of the 28 patients had more than 30% lossof BMD compared with untreated side even after 6 months of treatment. 2 of the 6 experienced problems during treatment; one pseudoarthrosis of the tibia, and another communited fracture of the tarus treated with long term non-weight bearing. However, no severe bone loss of the calcaneus was found in the other 4 patients, and these were associated with non-localized pain of the foot. 4 patients with severe bone loss without treatment problems showed a tendency of the risk of osteoporosis (female, old age, post menopause) and low BMD compared with the same age group with leg treatment. The relation of bone loss of the foot and continuous pain of the foot after treatment is suspected. Further investigation is essential to determine the clinical significance of bone loss after treatment of fractures.
we investigated the correlation between various measuring methods of bone mineral density (lumbar dual X-ray absorptiometry (DXA), forearm DXA, calcaneus single X-ray absorptiometry (SXA), and calcaneus ultrasound densitometry (USD)), and compared the results of screening for osteoporosis. 20 healthy females ages 20 to 69 were selected for this study. The measurement of the bone mineral density was carried out using lumbar DXA (DPX-α, Lunar), forearm DXA (DPX-α, Lunar), calcaneus SXA (SXA 2000, Dove Medical Systems), and calcaneus USD (A-1000 PLUS, Lunar) for each subject. The correlation coefficient of lumbar DXA vs forearm DXA, calcaneus SXA, and calcaneus USD was 0.605, 0.787, 0.624 respectively in all subjects. Those of the lumbar DXA<1 subjects were 0.459, 0.533, 0.257 respectively. The correlation coefficient of forearm DXA vs calcaneus SXA and calcaneus USD was 0.742 and 0.642 respectively, and that of calcaneus SXA vs calcaneus USD was 0.804 in all subjects. Detective ability of osteopenia was highest in calcaneus SXA followed by forearm DXA and calcaneus USD by receiver operating characteristic analysis based on lumbar DXA. The sensitivity of the screening for osteoporosis of forearm DXA, calcaneus SXA, and calcaneus USD based on lumbar DXA was 50%, 78%, and 22% respectively; that of lumbar DXA, calcaneus SXA, and calcaneus USD based on forearm DXA was 47%, 79%, and 42% respectively; that of lumbar DXA, forearm DXA, and calcaneus USD based on calcaneus SXA was 54%, 58%, and 38% respectively; and that of lumbar DXA, forearm DXA, and calcaneus SXA based on calcaneus USD was 33%, 67%, and 83% respectively.
We studied the effects of stopping treatments of osteoporosis. 36 osteoporosis patients were divided two groups. Group A (9 patients) did not receive treatments after receiving treatment for a few years, and group B (27 patients) continued treatments during the follow-up period. The average age of group A was 71.5 years and group B was 75.9 years at the start of treatment. The average change in heights for three years was -4.4cm in group A and -2.2cm in group B. The average BMD change rate for three years was -4.7% in group A and +0.8% in group B. The patients in group B showed reduced new lumbar spine fractures, as compared with group A (118 v. s 278 fractures per 1000 persons-years). It is thus important to continue treatment for osteoporosis.
The timing for excision of heterotopic ossification (HO) is controversial. Generally, the presence of maturity of HO is important and surgical excision is decided according to radiographic appearance, alkalin phosphatase, bone scanes. We expenenced 1 case with HO in the hip joint following cerebro-vascular disease, whose hip joint was ankylosed. HO was considerd immature because of the high alkalen-phosphatase level, but excision was performed 7 months after stroke. 10 months after surgery, now, patial recurrence is found, however, his hip joint maintains a relative good range of motion and he is satisfied. We think that early surgical excision before the maturity of HO is useful for preventing infra-articular ankylosis.
Over a 5 year period (1992-1997), we treated 13 hip joints in 11 patients who had been undergoing hemodialysis for chronic renal failure. The average follow-up period was 3.1 years. The mean post-operative JOA score was 70.9 points. We classified 8 cases of femoral neck fracture into 2 groups; a trauma group and a group with no history of significant trauma. 5 out of 8 cases showed large bone cysts in the femoral neck and head. 4 out of 5 cases (large bone cysts in the femoral neck and head) had no trauma, and we performed prosthetic hemiarthroplasty in these cases. Treatment by curettage and bone grafting of the cysts of the femoral neck was assumed to be difficult. Conseguently when we discovered cystic lesions in the femoral neck and head of patients who had been undergoing hemodialysis, we followed up their subsequent history and performed prosthetic hemiarthroplasty after fracture.
We found that osteonecrosis of the femoral head occurred in growing Wistar rats (WRs) when they were made to stand up during feeding. To observe the behavior of WRs and the histology of their femoral heads, 32 5-week-old male WRs were fed in a high cage (27 cm in height), and then 10, 10, and 12 WRs were killed at 9, 12, 15 weeks respectively. The total standing time in a day was around 2 hours at 6 weeks, and it decreased gradually as the WRs grew. Histological examination disclosed osteonecrosis in 3 femoral heads (15%) at 12 weeks and 8 femoral heads (33%) at 15 weeks. Histological abnormalities in the growth plate of the lateral portion, where the nutrient vessels penetrated into the femoral heads from the lateral, were found in 4 femoral heads (20%) at 12 weeks and 8 femoral heads (33%) at 15 weeks. However, there were no osteonecrosis nor other abnormal findings in the femoral heads at 9 weeks. These results suggest that osteonecrosis resulted from repeated mechanical stress from standing.