It is important to give weight control advice to obese female with gonarthritis to prevent ischemic heat diseases as well as in the conservative treatment of gonarthritis. In our study, we compared the changes of blood sugar and lipid metabolism by comparing the result before, right after, and one hour after bicycle rowing exercise with the load shift lever set to load I and load II. We compared the results for six female patients. Three hours after their breakfast, we asked them to contine the bicycle rowing exercise for ten minutes three times, with an interval of five minutes in between. Comparison of the results for load I and load II showed no difference in the blood pressure, heart rate, blood sugar, T-cho, and HDL-cho. We however found an obvious increase in the blood density of FFA for load II. We realized that even the aged can increase their FFA by raising the load shift level one level higher. The bicycle rowing exercise did not produce any effects on the heart rate.
Meniscal cysts of the knee are rare, but methods of treatment have been evolving. We treated 23 patients with 24 meniscal cysts by arthroscopic partial meniscectomy and cyst decompression. Their average age was 30 years (range, 18-72 years). Each patient had tenderness over the joint line and 14 knees (60%) had palpable mass. There were 24 cases of meniscal cysts, with 1 patient having a bilateral cyst. 9 cysts involved the lateral meniscus and 15 cysts involved the medial. All cases had a meniscal tear; most of the tears were horizontal. The treatment were successful in all cases, with no recurrence after an average follow-up of 6.7 months.
Single incision endoscopic anterior cruciate ligament (ACL) reconstruction has been widely performed in recent years. This procedure has been advocated to further reduce the morbidity of ACL reconstruction. This article describes our modified ACL reconstruction method by Rosenberg using multistrand hamstring tendons. The end of the hamsting tendons are sutured together to form a looped-strands to avoid stress shielding. We connected each end of the looped-graft in series with Telos artifical ligament. The artifical ligament portion of the hybrid-substitutes were firmly secured to the femur by Endo Button and to the tibia by double stapling technique. Eighteen ACL reconstructions were followed-up for more than one year after our procedure and showed good stability and ROM.
The purpose of this study is to report the arthroscopic and bursoscopic findings in shoulder stiffness and to determine the efficacy of arthroscopic capsular release and its effect on the time course for this disease. 40 patients (23 females, 17 males, 40 shoulders) with a mean age of 55.5 (38 to 69) years were evaluated at a mean follow-up of 60 (6 to 84) months. All patients failed to show improvement with conservative measures within a mean period of 7.5 (3 to 24) months. 30 of the stiff shoulders were classified as idiopathic frozen shoulder. 4 developed after significant traumatic events and 4 after prolonged immobilization. 2 patients were diabetic. We performed arthroscopic capsular release and synovial debridement for all patients and subacromial decompression for the patients suspected of subacromial impingement by bursoscopy. Intraarticular findings (n=40) were vascular synovitis (100%), adhesion between biceps tendon and rotator cuff (15%), incomplete rotator cuff tears (13%) and labral lesions (8%). There were no cartilaginous lesions. Intrabursal findings (n=20) were vascular synovitis (95%), incomplete rotator cuff tears (45%), subacromial erosion (35%) and fibrous band (10%). The mean postoperative active motion was Flex.=168.0 (+85.2), E. R.=53.4 (+45.6) and I. R.=Th10 (+7 segments). The mean JOA shoulder score improved to 93.0 (+38.8). Gains in the motion and JOA shoulder score were all statistically significant (p<0.05). The mean duration of formal rehabilitation with a CPM was 4 (3 to 11) weeks. The mean time to achieve painless final motion was 12 (3 to 16) weeks. Regardless of etiology, all patients manifested extremely similar intraarticular findings, but subacromial impingement was suspected in one third of the patients by bursoscopy. Through the management of refractory shoulder stiffness in this study, final painless motion was achieved within a mean of 12 weeks.
We reviewed 34 patients with 36 rotator cuff tears of the shoulder at an average of 10.5 months after arthroscopically-assisted mini-open repair. There were 12 women and 22 men whose average age was 64.5 years. The results were obtained using the JOA score. The average pre- and post-operative scores were 71.8 and 94.9 respectively (p<0.0001). The mean postoperative scores improved for each of the subcategories of pain, function, and range of motion (p<0.0001).
This study was performed to assess the influence of anatomical variations on the correction angle (COA) in high tibial osteotomy (HTO). We assessed anteroposterior radiographs of the supine lower extremity in 100 knees (22 males and 78 females) with medial osteoarthritis. The mean age was 68 years (50-82). We determined the COA in HTO in a way that allows the mechanical axis to pass through the central point of the lateral tibial plateau. On each radiograph, the bowing angle of the femoral shaft (BTS), femorotibial angle (FTA), ratio of femoral length to tibial length (FTR), and 8 additional parameters were measured, after which the COA was calculated. The range of FTR meant that the range of tibial length was greater than 56mm. 56mm changed the COA by approximatery 1.0°. The COA based on the mechanical axis is therefore consistently reliable, regardless of anatomical variations.
We carried out analysis of the tibial plateau using 20 resection specimens from total knee arthroplasty to obtain basic morphologic data on size and shape. Unmagnified copies of the specimens were produced. For the anteroposterior axis, a line was drawn from the midpoint of the medial and lateral intercondylar tubercles to the insertion of the posterior cruciate ligament. The mediolateral axis was drawn perpendicular to the anteroposterior axis and measured as the mediolateral distance. The anteroposterior distances at the midpoint, and points 10%, 20%, 30% and 40% from it, were measured. Two tibial component shapes (one symmetric and the other asymmetric) were also templated to determine the fit of the components. The ratio of the medial anteroposterior distance/mediolateral distance at each point was significantly larger than that of the lateral anteroposterior distance/mediolateral distance. The fit was significantly better for the asymmetric than for the symmetric component. These data suggest that the shape of the tibial resected surface in Japanese individuals is also asymmetric.
We examined the clinical and radiographic results of total knee arhtroplasties (TKAs). 22 TKAs were performed in 19 patients (15 females and 4 males) consisting of 13 cases of osteoarthritis and 6 cases of rheumatoid arthritis. The average age at the time of surgery was 63.0 years. The follow-up period averaged 6.3 years (range; 5 to 10 years). They were typed as follows: PCA modular (10 cases), Kinemax (1 case) and MG II (11 cases). The Japanese Orthopedic Association (JOA) score improved from a preoperative average of 59.5 points to the average at the mid term of 76.3 points. 1 knee required revision surgery due to the loosening of the femoral and tibial components after 7 years.
Out of 251 total knee artroplasties performed at our institution between 1986 and 1997, 9 were followed by revision. The reasons for revision were all patellar component failure of Miller-Galante Total Knee Arthroplasty (MG I TKA). Total knee artroplasty with patellar component failure always has some femoral component wear making it necessary to revise not only the patella component but also the femoral component. Although it was very diffcult to remove the patellar plate from the bone due to strong bone ingrowth, the airtome and metal cutter were very useful for removing the patellar plate.
Wear particles are currently one of the major probrems of Total Knee Arthroplasty (TKA). We experienced a rare case of massive osteolysis in the posterior femoral condyles of the stable cementless TKA, which was caused by HDP and metal wear particles 5 years after operation. This made the revision TKA more difficult at the late stage of massive osteolysis. Regular radiographic review of TKA is thus recommended.
We reported a case of epidural varix with neurological symptoms. The patient was a 36 years old male who had muscle weakness and hypesthesia around his left leg. Myelography, CT myelography, and MRI showed L3/4 varix. Posterior approach was selected for surgery and the sequestrated varix was removed.
The purpose of this study is to estimate the effects of the drip infusion therapy with argatroban and its sustenance. 14 patients who had failed conservative treatment were administered argatroban (20mg/day) for 2 weeks. 12 patients showed some improvements in their symptoms following this treatment. No patients worsened. The mean JOA score significantly improved from 12.9 points to 19.4 points. Most subjective symptoms showed significant improvement, but not objective symptoms. 5 patients had continuous improvements for more than a mean of 17.8 months, but 4 patients showed recurrence after a mean follow-up of 3.7 months. These results suggest that drip infusion therapy with argatroban is recommended for lumbar spinal canal stenosis.
Percutaneous discectomy (PD) has been conducted in our institution for lumbar disc herniation since 1990. The post-operative course of PD is unclear. This paper reports the unsatisfactory results after PD observed in a regional hospital. 39 cases who underwent PD over a period of 8 years (1990 to 1998), were studied, and 10 showed unsatisfactory results after PD. This included 5 males and 5 females, with mean age of 23.6 years (16 to 35) after a mean follow up period of 19 months (6 months to 29 months). 10 patients showed no improvement and 8 cases underwent additional surgery after PD. Comparing the 2 PD operative methods, manual discectomy on 18 cases resulted in 4 unsatisfactory results and mechanical discectomy on 21 cases in 6. PD is the effective treatment of choice for lumbar disc herniation, but is limited to localized lesions within a disc level hernia as well as within the posterior longitudinal ligament.
26 cases with lateral lumbar disc herniation were surgically treated. Of these, 18 were male and 8 were female ranging in age from 19 to 77 years old (mean; 53.2 years old). The level of lateral lumbar disc herniation was L3/4 in 7, L4/5 in 13, and L5/S1 in 6 cases. All patients complained of severe pain in the lower extremities. Facetectomy with posterolateral fusion was performed in 9 cases, osteoplastic hemilaminectomy in 13 cases, and lateral fenestration in 4 cases (disc herniation was removed in all). The results were as follows. The mean JOA score was 12.9/15 in the last follow-up, compared to 5.6/15 pre-operatively. Excellent and good results were achieved in all cases.
10 patients underwent surgery for migrated nucleus pulposus throughout the intraspinal and intraforaminal zones. 8 patients underwent osteoplastic hemilaminectomy and 2 patients underwent osteoplastic bilateral laminectomy using threadwire saw. The average patient age was 61 years in the 8 male and 2 female patients involved. The follow-up period varied between 2 and 35 months, with an average of 11 months. The location of migrated nucleus pulposus was confirmed by magnetic resonance imaging and disco-enhanced CT. The L4-5 disc was the most commonly herniated level (50%), followed by L3-4 (40%), L5-S1 (10%). Selective nerve root block was performed to determine the root responsible. The roots responsible were L3 in 2 patients, L4 in 3 patients, L5 in 1 patient, and L4+L5 in 4 patients. Postoperative results were as follows. Leg pain had recurred in all patients. The mean JOA was 13.5, compared to 7.3 pre-operatively. This surgical exposure provides excellent visualization and preserves posterior structures.
The purpose of this study is to evaluate the clinical outcome of osteoplastic laminectomy applied to space occupying lesions in the spinal canal. Osteoplastic laminectomy was performed in 14 patients, of which 4 were diagnosed with spinal cord tumor, 3 with cauda equina tumor, 3 with lumbar disc herniation, 1 with extradural arachnoid cyst, 1 with extradural granulation, 1 with arterio-venous malformation, and 1 with L3 burst fracture. Operative procedures were 1) osteotomy of the bilateral interarticular parts and spinous processes using a threadwire saw, 2) removal of the lamina, 3) resection of the intracanal lesion, and 4) fixation of the posterior element with lag screws. The average recovery rate of the clinical score was 29% in 2 cases of thoracic myelopathy, and 67% in 12 cases of lumbar symptoms. The lesions expanding up to 107% of the longitudinal diameter or 123% of the lateral diameter in the spinal canal could be resected under an excellent visual field. Oblique radiographs of the lag screws showed that congruity of the osteotomy site strongly correlated (p=0.03) to positioning all threads in the anterior part. The screw tips in L5 were loosened because of osteoporosis and the lowest mobile segment.
To study the usefulness of posterior fusion using pedicle screws, 32 patients (average age at surgery 37.2 years, average follow-up 29 months) with lumbar disc degenerative disease except olisthesis, lysis, and spinal canal stenosis were reviewed. All patients were divided into 4 groups: 14 with neural compression (NC) without previous lumbar surgery (PLS) (Group 1), 5 with no NC without PLS (Group 2), 9 with NC with PLS (Group 3), 4 with no NC with PLS (Group 4). JOA score and reinstatement for physical work were evaluated in these groups. The recovery rate of low back pain score ranged from 50% to 66%. The recovery rate of leg symptom score was higher in Group 1 than in Group 3 and Group 4. 14 out of 17 patients (82%) who had physical work returned to the same work afterr operation: the reinstatement rate was 100% in Group 1 and Group 3, 60% in Group 2, and 50% in Group 4. The height of the disc adjacent to fusion and loadotic angle of fusion area were analyzed in lateral radiographs to compare PLIF with PLF. There were no significant differences between the 2 procedures. More than 5mm of loadosis was lost at follow-up in 2 out of 4 patients who had underwent two-level PLF.
In this paper, we report the clinical results of surgical treatment for lumbar degenerative diseases of aged patients (older than 65 years). In particular, we compared the cases using instrumentation and the cases that did not. 77 cases, who were treated surgically over 5 years (1993 to 1997), were studied, with a mean follow-up period of 2.5 years. This included 38 males and 39 females, with mean age of 70 years. 21 cases were treated with instrumentation, and 56 cases. The preoperative and postoperative symptoms were compared using the JOA score and Hirabayashi's scoring system. Cases using instrumentation showed improvement of the average JOA score from 7.5 points preoperatively to 12.4 points. The average improvement rate was 67.2%. In cases that did not use instrumentation, the average JOA score improved form 7.6 points preoperatively to 11.5 points, and the average improvement rate was 51.3%. We believe instrumentation surgery is useful for treating lumbar degenerative diseases of aged patients.
The radiological features of the severe loss of the disc height of the lumbar spine with reference to reduced movement were studied in 85 cases of L5/S1 disc resorption (average 57 years old) and compared with 108 cases (average 45 years old) of lumbar disc lesion. The degree of movement of the disc was measured from the lateral view of the extension and flexion radiographs. The average range of movement was 7.05 degrees in the L5/S1 disc resorption group (DS) and 8.9 degrees in the control group (DLG). Slight reduction of movement was seen but there were no statistical correlation between the two. In isthmic spondylolisthesis cases and retro-spondylolisthesis cases of the DS group, reduction of movement was not proved. On the contrary, considerable reduction of movement was demonstrated for degenerative spondylolisthesis. Movement below 4 degrees was more frequent in the DS group (28%) than the DL group (18%). It proved to be more frequent for degenerative spondylolisthesis than other groups in DS group. In conclusion, the existence of severe loss of disc height showed no correlation with the reduction of movement, but the reduction of movement was more predominart in degenerative spondylolisthesis than other spondylolisthesis.
The external fixation system is used for the treatment of fracture, limb lengthening, deformity corrections, etc. Some complications are however seem, of which one especially serious one is pin track infection. In order to reduce pin track infection, we develop a new postoperative dressing method details of which and the infection rate are reported in the following. Since use of the external fixation system from 1995, postoperative pin site care has been performed basically by cleaning the affected part twice a week, then the pins and the skin around the pin sites were disinfected with hibitane pledget while removing secreta and eschar. After disinfecting the affected limb and the entire external fixator using hibitane spray, and filling with univalve gauze, the affected area and the external fixation system were convered with a sponge pad at the same time, and made airtight with bandages. Pin track infection was observed in 1 out of 24 cases (4.2%), which had a open femoral shaft fracture. Results show that above method helps prevent pin track infection.
Methicillin-resistant staphylococcus aureus (MRSA) infections have become a major therapeutic concern in the orthopaedic field. MRSA is resistant to most types of antibiotics, making it very difficult to treat. Between November 1995 and February 1998, MRSA infection of a joint or bone was found in 10 cases at our hospital. The mean age of the patients was 63 years, with age ranging from 13 to 91 years. The patients included 5 acute osteomyelitis, 2 chronic osteomyelitis and 3 pyogenic arthritis. 9 of these cases had been treated surgically. We treated 6 cases using closed continuous irrigation, another using the Papineau technique, and another using curettage at the focus. Another case of a 91-year-old man required amputation because of acute exacerbation of chronic osteomyelitis in the tibia. 7 cases were successfully treated, but 2 cases of an immunocompromised host showed recurrence and are still undergoing treatment. In our experience, we consider radical debridement, sequestrectomy and resection of scarred and infected bone and soft tissue to be the best therapeutic approach, while appropriate antibiotics therapy and/or closed continuous irrigation are also required.
We reported a case of Brodie's abscess which developed unusual patterns with penetration of the epiphyseal plate of the distal tibia. A thirteen-year-old boy was referred to our hospital complaining of mild pain and swelling of the left ankle. The roentgenography of the left tibia disclosed a radio-lucent lesion which was surrounded by a clear osteosclerotic margin. The lesion existed in the metaphysis and epiphysis with penetration of the epiphyseal plate of the distal tibia. The C-reactive protein value and erythrocyte sedimentation rate were normal. The diagnosis was made by a needle biopsy of the lesion with aspiration of pus. The bacteriological examination revealed staphylococcus aureus. Surgery with curettage and bone graft including the epiphyseal plate resulted in it healing and no deformity nor limb length-discrepancy was recognized.
Fifteen patients with pyogenic arthritis of the knee were treated by open arthrotomy and early passive motion. All patients healed without subsequent operations. Of these patients, two had excellent results, eleven had good results, and two had fair results according to the modified Ballard's evaluation method. This is a useful and simple method for treating pyogenic arthritis of the knee.
Tuberculosis of pubis is uncommon. We report two cases of tuberculosis of pubis. Case 1. A 60-year old man was admitted with left groin pain and claudication. Case 2. A 77-year old woman was admitted with pain of the symphysis pubis. Both cases were treated with curettage and postoperative chemotherapy. Although bone grafting was not carried out in these cases, good resuts were gained. MRI and CT were useful for the detection of abscess and for follow-up.
Despite the progress of antibiotics, the management of osteomyelitis involving composite bone and soft tissue defects remains a major problem for surgeons. We performed a free composite serratus anterior and rib flap for a case of osteomyelitis of calcaneus. The flap has survived in its entirety. The patient was able to walk without any assistance three months after the operation, and bony union was achieved eight months after operation. He did not complain of any inconvenience in using his upper arm although scapular winging was noted, and returned to his original job as a cook four months after operation. Free composite serratus anterior and rib flap is useful for one-stage reconstruction of extensive composite bone and soft tissue defects.
We report a case of tendinitis of the tibialis posterior with talipes equinovarus. A 13 year-old boy complained of right ankle pain and gait disturbance walking long distances. His right ankle indicated talipes equinovarus and the range of motion of the ankle joint was limited because of the pain. Radiographs demonstrated no anomaly, while MR imaging revealed the swelling of the tendon of the tibialis posterior and fluid in its sheath. We performed no treatment without rest. After a month he could walk with no pain and has shown no relapse of the symptoms to date.
4 patients with acute rupture of the Achilles tendon were managed with use of an early active mobilization protocol in combination with a new suture technique (6 strand modified Kessler core suture and hemi-circumferential cross stitch suture). This protocol eliminated postoperative immobilization with cast. The patients were aged 23 to 28 years and all practiced recreational sports. At follow-up, ranging from 4 to 10 months, ankle mobility was more or less normal and there were no reruptures. All the patients were able to resume jogging within 4 months. These results demonstrate the advantage of not using postoperative immobilization and beginning functional rehabilitation immediately.
An unusual case of idiopathic hallux varus is reported in this paper. A 63 year-old woman presented with hallux varus deformity accompanied with pain and showed no evidence of underlying inflammatory disease nor history of trauma. This case had 42 degrees of the pre-operative varus deformity. Muscle release and reconstruction without osteotomy resulted in good alignment of the great toe and the patient was cured of gait disturbance with pain.
We report a rare case of neuropathic arthropathy (Charcot joint) in the subtalar joint due to familial amyloidotic polyneuropathy (FAP). A 49-year-old female from Arao city presented in November 1996 with swelling of her right foot. There was no history of injury. She had been diagnosed as FAP in 1990. Her grandmother, father, and elder brother had also suffered from FAP. Neurologically, superficial sensation, position sense and vibration sense were decreased in the calf and below. Swelling, redness, and local heat were seen around her right ankle. No tenderness and pain on motion was observed. On plain roentgenography, intra-articular fracture of the talus and calcaneus were observed. One year later, the roentgenography demonstrated subchondral sclerosis and collapse of the subtalar joint with heterotopic ossification. To the best of our knowledge, there are few reports on Charcot sutalar joint due to FAP.
We performed a total ankle arthroplasty (TAA) for a patient with secondary osteoarthritis of the ankle joint. There were several problems with the surgical technique on performing TAA such as choice of adequate implant, determining the exact osteotomy line and cementing technique.We think these problems pose as one of the most important factors in improving long term results after TAA.
Between 1992 and 1997, in competitive athletes, we performed surgical repairs for acute tears of the lateral collateral ligaments of the ankle and Evans procedure for chronic lateral instability of the ankle. On 51 cases (51 ankle joints), we could perform postoperative evaluation of sports activity based on replies given by indivisual patients to a questionnaire. The 51 cases consisted of 26 patients classified as the acute group and 25 patients classified as the chronic group. In the former, 2 patients did not return to their preinjury sports level and in the latter, 9 did not. This result correlates with incomplete rehabilitation. We concluded that primary operative repair produces satisfactory results, and that the Evans procedure needs adequate rehabilitation, such as peroneal muscle strengthening and tilt-board exercise.
We followed up on 7 cases of ruptures of the lateral ligament of the ankle joint treated by Glas' procedure. Clinically, the results of the Seligson's scale were excellent except for 2 cases with OA changes in the pre-operative period. Radio logically, the mean of the talar-tilt-angle improved from 14.6° to 3.4° in the post-operative period, and no ossification of the periosteum was seenin all cases.
We treated 15 cases of ankle joint trauma with arthroscope. Patients ranged in age from 13 to 63 years, with a mean of 36.2 years. They comprised of 3 with osteochondritis dissecans of the talus, 2 with ligamennt injuries, 2 with old avulsion fractures of the lateral malleolus, and 8 with malleolar fractures. Osteochondritis dissecans of the talus were treated with fragement excisios, curettage and transmalleolar or percutaneous drilling of the crater. No complications were seen in all cases such as neurological and arterial damage. Ankle arthroscopy is useful in the diagnosis and treatment of ankle joint trauma.
59 patients with fresh fractures of the middle third of the clavicle were treated surgically from August 1992 to December 1997. The surgical technique by intra-medullary nailing with a cannulated cancellous screw (CCS) was mainly performed. The age of the patients at surgery ranged from 14 to 83 years old (average age: 40 years old). They consisted of 44 males and 15 females, 32 right side and 27 left side. In the beginning, 10 patients were operated with K-wires. From December 1993, for the purpose of protecting against the K-wire and improving the fixation, intramedullary nailing surgery using CCS was performed on 46 patients. 3 patients were operated with 1/3 tubular plates because of the narrow intramedullary space for CCS. 34 patients who were operated with CCS with only a 1cm skin incision at an average time of 33 minutes. In this way, intramedulary nailing surgery using CCS was performed with small skin incision, short operation time and moderately good fixation. CCS was however dissatisfactory at the rotational fixation and 1 patient resulted in pseudoarthrosis.
Most proximal humeral fractures could be treated by conservative treatment, and only a few patients were treated by operation. In this study, we discuss 20 patients, 14 with 2-part and 6 with 3-part fracture. The JOA score was 82.0 point, and major complications were seen in one patient.
We reviewed 25 patients who underwent conservative treatment for proximal humerous fracture. Their average age was 69.2 years, ranging from 34 to 91 years.The follow-up period ranged from 1 month to 41 months, the mean of which was 9 months. Typing was done according to the Neer clssification and clinical assesment according to the Japanese Orthopaedic Association Scoring System (JOA score). Typing was minimal displacement in 8, Group III-2part in 7, Group IV-2part in 2, Group IV-3part in 6, Group V 3part in 1, and Group VI-3part in 1. 24 patients showed union of the fractures, which 1 case had no union. The average range of motion was 113.6 degrees flexion, 50.8 degrees externalrotation, and 68.4 degrees internal-rotation. The average JOA score was 77.8. Conservative treatment for proximal humerous fracture is considered to be very useful for elderly patients.
Proximal epiphyseal injuries of the humerus are comparatively rare in children. We experienced eleven cases in the past ten years, for which we investigated the length of both humerus and the functional disorders of four patients at the final follow-up. The epiphyseal injury of all eleven patients were type II Salter-Harris, and the grade of displacement of four patients was Neer-Horowitz grade II, three were grade III (N-H), and four were grade IV (N-H). We measured the neck-shaft angle of the humerus radiologically for nine patients. The neck-shaft angle improved in observable periods. In children, epiphyseal injuries display marked remodeling, so functional prognosis is good. In the four patients the we checked, all had no functional disorders, but all had limb-length inequality radiologically. We consider moderate reduction to be necessary for the prevention of limb-length inequality.
Percutaneous intramedullary fixation is reliable method for treating unstable diaphyseal, metaphyseal and epiphyseal forearm fractures in children. Since 1988, we have treated 31 diaphyseal and metaphyseal forearm fractures (20 cases) with this method, penetrating through the physis from epiphysis. The mean age at injuries was 8.8 years (range 3-15 years) and mean follow-up period was 2 years 7 months (range 6 months-7 years 7 months). K-wires were removed 9.8 weeks on average (range 3-40 weeks) after the operation. All fractures healed, except 1, in which fracture recurred and was healed by re-percutaneous intramedullary fixation. There were no cases with arm length discrepancies or deformities due to growth disturbance. In 1 case, there was a very small-sized osseous bridge-liked shadow in the physis, and in 2 cases, there was a very small ossification in the physis, which seemed to be a trace of K-wire penetration. There was however no evidence of physeal arrest in these 3 cases. We conclude that penetrating the epiphyseal line with the K-wire for a short period does not cause growth arrest.
We encountered 3 cases of Galeazzi fracture, which is found very rarely among children. There were 2 fresh cases and 1 obsolete case. The patients were injured when they were 10 to 15 years old, and the injury occurred when the patients fell down while they were playing sports in all cases. The fracture site was radius at 1/3 distal point, and dolsal dislocation was found at the distal end of the ulna. Avulsion fracture of the styloid process of the ulna was noted in 1 case. 1 case was treated by conservative therapy and 2 cases were managed surgically, for which satisfactory results were obtained.
We reported a case of radial head dislocation, the pathology of which we could determine by MRI images. A 12 year old boy, who had had no traumatic history of his right elbow, was introduced to our hospital due to the flexion disturbance of his right elbow. Pre-operative MRI images showed the soft tissue at radio-capittelar joint. So we estimated it annular ligament. In the annular ligament existing in the radio-capittelar joint which was seen on MRI images. We performed only reduction of the annular ligament and radial head without reconstruction of the ligament. MRI was useful in understanding the pathology of this case, and it may be a dislocation caused by “pulled elbow” during his childhood.
Dislocation of the radial head is usually associated with the fracture of the ulna (Monteggia's fracture), and isolated dislocation of the radial head is rare. In 1994, Lincoln reported 5 cases of traumatic dislocations of the radial head associated with ulnar bowing. After his report, clinical entity of “ulnar bowing” gained widespread interest. We experienced 5 cases of dislocation of the radial haed associated with ulnar bowing. 3 cases were boys and 2 were girls, and their ages ranged from 5 to 11 years old. All their plain X-rays showed “ulnar bowing”, and their maximum ulnar bow ranged 3.5 to 11.0mm. The dislocations of the radial head were closely reduced in 3 fresh cases. In 2 cases with less ulnar bowing (4.0 and 4.5mm), the reduction of the radial head was accomplished without reduction of ulnar bowing. On the other hand, in 1 case with ulnar bowing of 11mm, ulnar bowing was reduced without the reduction of the radial head. As ulnar bowing reduced, the reduction of the dislocation of the radial head was achieved. After reduction of the radial head, 5mm of ulnar bowing remained. In 2 cases with old dislocation of the radial head with ulnar bowing, no closed reduction could be obtained, and open reduction with reconstruction of the annular lifgaments was performed. In all cases, full range of motion was more or less obtained, and re-dislocation of radial head did not occur. We recommend the reduction of ulnar bowing firstly for patients with dislocation of the radial head accompanied with ulnar bowing of more than 5mm. For patients with ulnar bowing less than 5mm, the reduction of the dislocation of the radial head should be reduced first.
We treated three cases of long standing Barton fractures. All cases were men, aged 40 to 54. There were two volar Barton fractures and one dorsal Barton fracture. The period from injury to operation time was 2.5 to 5 months. The operative technique is as follows, Reduction of subluxated radiocarpal joint by distraction using extenal fixation, osteotomy, and rigid internal fixation. External fixation was continued or 5 to 8 weeks. Clinical results were excellent in two cases and fair in one as evaluated by the Green & O'brien system (1978). In conclusion, the important points of the operation were to perform redution of the subluxated radiocarpal joint, to protect the fragile fracture fragment by the distraction of the external fixation and to use rigid internal fixation.
This paper reports a case of scapholunate dissociation, a popular group of traumatic carpal instability. The patient was a 29-year-old male who had fallen on his arm outstretched from his motorcycle. In spite of cast fixation for 2 weeks at another doctor, the wrist pain persisted for several weeks. We therefore performed ligamentous reconstruction of the scapholunate interosseous ligament with a tendon slip from extensor carpi radialis longus. 6 months after the operation, the patient has increased hand grip power with no wrist pain. Generally speaking, scapholunate dissociation is accompanied by both dorsiflexed lunate and voralflexed scaphoid. In this case, however, there was dorsiflexed intercalated segment instability deformity (DISI), but no rotary subluxation of the scaphoid (RSS), i. e., radiolunate angle and scapholunate angle were increased, but the radioscaphoid angle was within normal limit. In such cases, the dorsal capsulodesis (Blatt's method) may have little effects on the correction of DISI. The authors recommend that preoperative kinematic analysis be performed on the affected wrist.
Radial osteotomy has been recommended for stages II and III-a of Kienböck's disease because of it's load decreasing effect on the lunate. Recently usefullness of this procedure in the tratment of advanced stage Kienböck's disease has been demonstrated clinically by several authors. In contrast, the effects of this procedure on the biomechanics of the degenerative arthritis of wrist advanced Kienböck's disease are unclear. In this study, we studied 17 patients with stage III and IV Kienböck's disease to analyse the precise radiographic consequence of radial wedge osteotomy for progressive stage Kienböck's disease. 12 patients who underwent the radial closing wedge osteotomy and 5 patients who underwent radial shortening osteotomy for the treatment of advanced Kienböck's disease were reviewed clinically and radiographically. There were 7 males and 10 females, whose average age was 51 years. 5 were stage III-a, 10 were III-b and 2 were stage IV. The average follow-up period was 2 years and 3 months. The following measurements were made for radiographic assessment: the angle of radial inclination, ulnar variance, carpal height ratio, Ståhl index, radio-lunate angle, radio-scaphoid angle, scapho-lunate angle, carpal-ulnar distance ratio, lunate covering ratio, and ring to proximal pole distance. The radial inclination decreased from 26.8° to 15.7 in the wedge osteotomy group. The ulnar variance increased 2mm in the radial shorening group. The carpal height ratio decreased from 0.509 to 0.504 and Ståhl index increased from 36% to 37%, both without statistical significance (p<0.01) in the wedge osteotomy group. In addition, the radio-scaphoid angle increased significantly (p<0.01) in the wedge osteotomy group. The increased lunate covering ratio is believed to increase the area of distribution of the axial load through the lunate by increasing the contact area with the radius. In addition, the increased radio-scaphoid angle is believed to correct the radio-carpal malalignment in patients with advanced stage Kienböck's disease. The satisfactory clinical outcome of radial closing wedge osteotomy is believed to be due to both these effects on carpal alignment.
Two cases of forearm tissue defects were treated by free vascularized musculocutaneous flap or free vascularized muscle flap transplantation. Case 1 who received a press injury and had an infection in the left forearm suffered complete median nerve palsy. Free vascularized rectus abdominis flap (9×12cm) was transplanted following debriedement of infected tissue. Thirteen months later, this patient has returned to his original job. Case 2 received two operations against soft tissue sarcoma in the right forearm before she visited our hospital. Tissue defect following wide recection of synovial sarcoma in the right forearm was reconstructed by free vascularized latissimus dorsi musculocutaneous flap (24×15cm). The right hand of this patient is useful with a simple elbow orthosis seven months after the last operation.
The suspensionplasty procedure is a simple method in which the base of the first metacarpal is suspended at approximately its normal level and then stabilized by reconstruction of a strong intermetacarpal ligament. We assessed 5 thumbs in 5 patients (2 male, 3 female). Patients ranged inage from 55 to 80 years (mean 66 years), follow-ups were 10-15 months (mean 12.5 months). Patients were classified according to the Eaton classification as follows; stage IV in all thumbs. In this pepar, we discuss the method of tendon suspensionplasty (Thompson method).
In this paper, we report three cases of the fracture of the hamate hook during golf. Two cases injured their right hands and one the left. Two cases were right handed and one case made right shots with left hand. One case was treated by the excision of the hamate hook for paralysis of the superficial branch of the ulnar nerve. The other cases were treated conservatively. The causes of the fracture are assumed to be the direct force at the grip end, imbalance at the muscler and ligamentous extension force inserted in the hamate hook.
We evaluated 45 cases of post-traumatic contractures, 42 PIP and 3 MP joints, treated by the dynamic skeletal traction apparatus (Nakashima external fixator). This apparatus offers the advantage of stretching shortened collateral ligaments and articular capsule by traction, and of mobilizing the stiff joint during active ROM exercise. All the cases showed improvement of ROM. The average total active ROM increased from 31.6° to 65.8°. Only 3 patients had motion pain after the treatment among 23 patients who complained of pre-operative motion pain. It is suggested that this apparatus is very useful for the treatment of the post-traumatic contracture as well as intra-articular fracture.
Three handred and fifty-four trigger fingers in 292 patients treated initially by percutaneus A-1 pulley release technique from July 1996 to May 1998 were reviewed retrospectively. There were 255 (87.3%) females, 37 (12.7%) males, with a mean age of 52.4 (range 36-84 years). The Thumb was most frequently involved (159 digits), followed by middle finger (96), index finger (66), ring finger (30), and little finger (3). They consisted of 242 (262 digits) idiopathic patients, 36 (74) hemodialysis, and 14 (18) rheumatoid arthritis. Of the 354 trigger fingers, 339 (95.8%) had complete resolusion of triggering with the disappearance of snapping after percutaneus release. Reoperations (percutaneus or open surgery) were required in 12 (3.4%) fingers 9 for residual snapping after release, 2 for uneven movement with pain by the tendon nobule and incompletely released A-1 pulley, 1 for the narrow between the thick tendontheath and tendon nodule. At reoperation, residual snapping and uneven movement were considered to be caused by incompletely release in 6 fingers, hypertrophy of the tenosynovium in 3, snapping in A-2 pulley in 2, and adhesion between the deep and superficial flexor tendons in 1. Pain over 4 weeks after surgery was found in 19 fingers, and Metacarpo-phalangeal joint flexion iontracture like “Dupuy treins contrcture” occured in 3, but no infection and no neuro-vascular injury were seen. We reccommend this technique for outpatients with trigger fingers, because of its safety, simplicity, few complication, and patient's satisfaction with high successful rate.