We report our experience in the management of 6 patients with thoracic disc herniation using the postero-lateral approach. Costo-transversectomy in 5 patients, and transverse-arthropediclectomy in 1 were performed. One patient showed no improvement after disectomy using the costotransversectomy approach, while the others had good clinical conditions. Poor results were seen in a patient with a large central hard mass. Because the field of view is limited to central herniations and manipulation of the spinal cord involves considerable risks, lateral approach is indicated for large central hard masses. It is important to assess the level, location, consistency of disc herniation, general condition of the patient, and surgical experience when choosing the surgical approach.
Upper lumbar disc herniation (ULDH) often found in the elderly is relatively rare. We report 7 cases of ULDH (4 discs at L2/3, 3 discs at L3/4) and compared them with 18 cases of general adult population under 40 years old as a control. The mean age of ULDH was 56.8 years and that of the control 40 years. Pre-JOA score of ULDH was lower than that of the control lesion.
We performed 425 lumber disk herniations surgeries between April 1993 and March 1998. Twenty-three were of the upper lumber disk herniations (L1-2, L2-3, L3-4). We analyzed these patients according to their clinical symptoms, radiological findings and surgical results. Preoperative signs and symptoms were highly variable, and the incidence of cauda equina syndrome was relatively high in our series (57%). We believe these symptoms to have close relations with the charactaristics of the posterior longitudinal ligament and type of herniated nucleus polposus in the upper lumbar spine.
We experienced 2 cases of lumbar disc herniation extruded to the dorsal epidural space. Case one; A 51-years-old male developed intense lumbar pain, right lower leg pain and weakness. The lesion appeared as an egg-like filling defect in the L3 body of the vertebra from the border by L4 in myelogram. The lesion occupied a large part of the spinal canal in contrast CT. Lumbar spinal MRI showed iso signal with T1 and low signal with T2. Case two; A 33-years-old female had developed lumbar and buttock pain. In myelogram, the lesion compressed the epidural space at L5/s1 level from the right. In CT, though the CT number of the lesion was water-density, we had to make the differential diagnosis of the lumbar spinal lesion to be native of hernia. Lumbar spinal MRI showed iso signal with T1, and low and high signal with T2. Two cases were diagnosed with sequestrated hernia in operation findings and pathology findings. It is sometimes difficult to differentiate between hernia to dorsal epidural space and spinal canal inner tumor. sequestrated hernia changes its brightness grade on MRI with progress. Understanding of the brightness grade on MRI with progress of sequestrated hernia is especially effective to distinguish between the hernia and epidural tumor, and also useful to observe spontaneous resorption of the hernia.
Percutaneous laser nucleotomy (PLN) has recently been utilized for many medical faculties of lumbar disc herniation. The post-operative course of PLN is known to be unclear. This paper reports the results of operational treatments for lumbar disc herniation, which were performed by PLN but ineffective in other hospitals. The subjects consisted of 6 cases (5 males and 1 female, aged 21-52 years). Their preoperative and postoperative symptoms were compared, using the JOA score and the Hirabayashi's scoring system; we examined the possible cause of ineffective PLN from preoperatives test and operational findings. The JOA score was significantly improved, and the improvement rate according to Hirabayashi's scoring system was above 80% for all these cases. Lumbar disc herniation descending down from the disc level was observed in 5 of these 6 cases and was regarded as partly responsible for ineffective PLN.
During the past 6 years, 32 cases of lumbar disc herniation treated by posterior approach for over 70 years old were clinically studied. All patients have been followed for more than one year. These studies investigated the clinical symptoms, X-ray findings, and operative results compared with 23 patients aged 20 to 39 who were treated by posterior approach for lumbar disc herniation in 1997. Common clinical symptoms were severe leg pain and motor disturbance in lower extremity. Preoperative X-rays suggest that the lower lumbar spine tends to be stable due to degenerative changes, and the upper lumbar unstable on the contrary making the unstable upper lumbar a potential risk factor of the involved levels. The averaged preoperative JOA score was 11.8 points and the post operative JOA score was 23.1. The Hirabayashi's average recovery rate was 66.2%. The recovery rate was as good as that of the 23 patients aged 20 to 39. In most cases, postoperative diagnosis is combined stenosis. From these findings, laminectomy or partial laminectomy causing possible posterior decompression is necessary for lumbar disc herniation in elderly patients.
21 patients who underwent spinal fusion using pedicle screws for lumbar canal stenosis were reviewed. There were 11 males and 10 females. The mean age at surgery was 61 years and the mean follow-up period was 28 months. Degenerative spondylolisthesis was found in 18 patients and degenerative lumbar canal stenosis with antero-posterior instability in 3 patients. The improvement rate of JOA score was 73% and bony union rate was 95%. Low back pain was improved in 12 (63%) out of 19 patients, and intermittent claudication in 17 (81%) out of 21 patients. Leg symptom, however, remained in 14 (70%) out of 20 patients. Numbness mainly deteriorated the leg symptoms. Instrumentation and bone graft were added in the segments adjacent to fusion for 2 patients: a 64-year-old female showing pedicle screws pull-out and graft bone collapse due to osteoporosis, and a 69-year-old male developing new scoliosis on the adjacent segment which had been decompressed without fusion. Attention should be paid to using pedicle screws for osteoporotic patients and to decompression without fusion for segments adjacent to fusion.
Seventy-two patients were treated with posterior lumbar interbody fusion (PLIF) by total facetectomy (TF), using intervertebral spacer (i. e. AW glassceramic, hydroxyapatite), for lumbar degenerative disorders. Patients were followed clinically and radiographically from four months to over two years. Fusion was achieved in 95.8% of the cases, and good clinical improvement was shown in the JOA score for most patients. Especially, spinal fusion by PLIF was useful in relieving low back pain. PLIF by TF provides wide decompression, prevents iliac pain caused by picked bone and offers spinal surgeons numerous advanteges for the treatment of lumbar diseases. Use of the intervertebral spacer also provides good support and good filling-up for bone graft.
Lumbosacral and pelvic alignment is important in the treatment of degenerative lumbar spines. In this study, we measured the dynamic radiography of lumbosacral and pelvic alignments in 26 patients with degenerative lumbar deformity, and compared motion of lordosis angle and sacral inclination, pelvic angle, sacral transration. Sacral inclination, pelvic angle and sacral transration were also correlated. These dynamic radiography parameters are useful in the treat ment of degenerative lumbar deformity.
The biomechanical stability of the lumbar spine after lamino-facetectomy and the restoration of the resected lamina was investigated using fresh-frozen human cadaveric lumbar spine specimens. Six pure moments of flexion-extension, right-left bending and right-left axial rotation were applied and intervertebral rotations were recorded. The neutral zone (NZ) and range of motion (ROM) under three conditions of intact, lamino-facetectomy and after the restoration of the resected lamina were analyzed statistically to determine comparative biomechanical instability. NZ results showed no changes in any direction, with respect to the intact behavior, after the two procedures. The flexion/extension ROM increased significantly after the lamino-facetectomy, but not after the restoration of the resected lamina. The axial rotation ROM increased remarkably after the lamino-facetectomy and the increased ROM was not reduced completely by the restoration of the resected lamina. We concluded that the spinous process prevents hyperextensive instability of the lumbar spine and it is important to preserve the spinous process as well as facet joints in the decompressive surgeries of the lumbar spine.
Degenerative lumbosacral kyphosis occurs due to lower lumbar disc degeneration. Patients with this deformity indicate marked loss of lumbosacral balance. This disalignment disturbs walking and standing ability markedly. Conservative treatment including brace treatment for this deformity is difficult due to the loss of lumbosacral balance. Surgical treatment had been performed by use of the Isola-Galveston method from only a posterior approach. This procedure was performed to obtain correction and fusion at degenerated discs. Patients operated on by this procedure gained relative relief of symptoms, but loss of correction occurred in the fused area. No correction of the lumbopelvic alignment, measured by the pelvic angle offered by Jackson, seemed to be a major factor of this results. We changed the operative procedure to gain correction of the pelvic angle and more lumbar lordosis. Posterior transverse wedge osteotomy in the L4 region by the modified eggshell procedure and posterior shortening with spinal instrumentation started from 1997. Three patients were operated on by this method. The Isola-Galveston method was used in one case and the Jackson lumbopelvic fixation method with the Liberty system in another two cases. The fusion area was from L1 to sacrum. After the operation, the pelvic angle was corrected to under 30 degrees and lumbar lordosis over 30 degrees and maintained during follow up. There was no loss of correction and instrumentation failure. Symptoms related to malposture improved markedly in all patients.
Spinal operations were performed on 4 cases with Amyotrophic Lateral Sclerosis (ALS), in which 3 cases were wrongly diagnosed with cervical spondylotic myelopathy, 1 with L4 degenarative spodylolisthsis, and 1 with L1/2 disc herniation. (In 1 case, operation was performed two times for cervical lesion and lumbar lesion.) The chief complaint of all cases with obvious sensory disturbance, were muscle weakness, dullness, and numbness of the extremity. Sensory disturbance and MRI/CTM showed spinal compression slightly presenting spondylotic degenerative change were misdiagnosed. We must be careful in the evaluation of cases who have simultaneously spondylotic degenerative lesion and ALS. In all cases, post-operational symptoms were worse than pre-operational itself. We believe that the operation deteriorated the neurological states progressively and gave no benefit. In conclusion, spinal disease, with ALS or those for which ALS cannot be ruled out should not be operated.
Spontaneous epidural spinal hematoma is a relative condition which suddenly develops symptoms of spinal cord compression and needs appropriate surgical treatment immediately. We report one case of acute spinal epidural hematoma with spontaneous resolution. A 58-year-old woman experienced suddan on backpain and gait disturbance from muscle weakness. She had history of hypertention therapy. On admission, neurological examination showed paraplegia below T5. MRI showed mass lesion from C2 to C3, and CT after myerography revealed hematoma compressing her spinal cord. She was treated non-operatively. Her paraplegia recovered after 21 hours and complete recovery was more or less achieved 7 days after the onset. There was no recurrence of paraplegia. But MRI shows hematoma which is low-intensity on T1-weighted image and high-intensity on T2-weighted image exists 4 months after onset. In the case of acute spontaneous spinal epidural hematoma in which neurological deterioration is followed by early and sustained recovery, non-operative therapy may be considers.
A case of lumbar epidural hematoma is reported. The patient was a fifty-seven years old woman. Her complaint started with lumbago. After three weeks from the onset, thigh pain and numbness appeared. An epidural mass was detected at L4/5 by MR imaging, myelogram and CTM. In MRI imaging, the mass showed low intensity in T1, high intensity in T2 and ringed enhancement effect with Gadolinium. The mass was considered as a synovial cyst or a ganglion by MRI, but histological diagnosis was organizing hematoma. The mass was a subacute hematoma. The intensity of hematoma in MRI is said to be changing with time, thus it is difficult to diagnose epidural hematoma.
Spinal epidural hematoma (SEH) is relatively rare, and the classical clinical condition is acute onset with back pain, followed by symptoms of nerve root or spinal cord compression. We report two cases of spontaneous spinal epidural hematoma (two males). One was cervicothoracic hematoma on the ventral side of the spinal cord, the other was cervical hemotoma on the dorsal side. Magnetic resonance imaging (MRI) showed a high intensity lesion with T1-weighted and T2-weighted imagings. Operative decompression was performed for these cases. Because the cases were operated soon after the diagnosis, greater neurological recovery was obtained. The critical factors for recovery after SEH are the operative interval and preoperative neurological deficits. Rapid diagnosis and emergency surgical treatment are very important for patients in SEH.
To clarify the natural course of degenerative spondylolisthesis, the progression of disk slippage and clinical symptoms were studied in 35 patients with more than 10 years of follow-up. Progressive slippage was observed in 12 patients (34%). No progression of slippage was noted in patients exhibiting restabilization signs on X-ray film. There was no correlation between the clinical symptoms and progression of slippage. Surgical intervention should be done with the knowledge of the natural course of this disease.
The purpose of this study was to prospectivly evaluate the outcome of a decompressive procedure for degenerative spondylolisthesis without fusion designed to preserve facet joints. The “Semi circumferential decompression” technique that allows resecting the yellow ligament “en bloc” through the operating microscope and fine air drills (1.5-2mm). Eighty two concecutive patients were studied prospectively between Feb 1992 and Feb 1997. The average age of the patients was 67.6 years (range 49-85). Range of follow up was 12 months-62 months (mean 28 months). The overall clinical results were graded by JOA score as good to excellent (70%) fair (13%) and poor (17%). Four cases required reoperation. The surgical procedure decompression without fusion is not widely accepted at the moment, if the posterior structure was not violated with meticulous decompression technique under surgical microscope making spinal fusion rarely required.
On surgical treatment for degenerative spondylolisthesis of the lumbar spine, we performed the operation according to pathological conditions in each patient. Decompression and fusion was done in all patients. Indications of reduction with spinal instrumentation were as follow; kyphotic alignment, increasing slip rate over 5% in motion picture. We operated on 33 cases, from April 1988 to October 1977. 12 cases, mean age at the operation was 59 years old, were operated on by reduction and fusion. 21 cases, mean age at the operation was 68 years old, were operated on by decompression and fusion in situ. Bony union was obtained in all cases except without reduction. Improvement from preoperative symptoms was marked in cases with reduction. Cases without reduction showed decreased disc height in slipped level within 3 months after the operation. Our indication for reduction and fusion seemed to have justfication. Further indications for reduction and fusion may be needed in surgical treatment for spondylolisthesis.
Recently asymptomatical cervical cord compression has been proposed in elderly patients especially by magnetic resonance images (MRI). We determined symptomatic levels in compressive cervical myelopathy by evoked spinal cord potentials (ESCPs) recorded epidurally and compared the results with radiologic findings. 7 patients over sixty-five years old with compressive cervical myelopathy were studied. ESCPs following median nerve (MN-ESCPs) and transcranial magnetic stimulation (TCM-ESCPs) were recorded pre-operatively from the epidural space. Symptomatic compression was limited to one (n=4) or two (n=3) disc levels and anterior interbody fusion showed good results. The specificity between the symptomatic levels determined by electrophysiological assesment and high intensity change in the spinal crod on T2-weighted MRI was 92% and that of abnormal findings on myelography was 95%. We considered that high intensity change in the spinal cord on T2-weighted MRI and abnormal findings on myelography were very useful for level diagnosis.
The purpose of this study is to clarify a reliable assessment index of compressed spinal cords in MRI diagnosis. Seventeen patients with cervical spondylotic myelopathy were examined with magnetic resonance imaging and evoked spinal cord potentials (ESCPs) before surgery. Spinal cord transverse area and compression ratio (central and 1/4-lateral anteroposterior diameter divided by transverse diameter) were measured on T1-weighted axial imaging, having abnormality in ESCPs, as indicators of spinal cord morphology. The correlation between these dimensions and electropthysiolosical findings were investigated. The mean preoperative transverse area of the spinal cord was 47±13mm2. The mean preoperative central compression ratio of the spinal cord was 34±4%. The mean preoperative 1/4 lateral compression ratio of the spinal cord was 27±5%. A correlation (ρ=0.65, P<0.01) was observed between the 1/4-lateral compression ratio of the spinal cord and amplitude ratio of TCE-ESOP. The preoperative 1/4-lateral compression ratio of the spinal cord was assumed to reflect the degree of functional involvement of the corticospinal tracts. In the assessment of compressed spinal cords, 1/4 lateral compression ratio can serve as a more reliable index than others.
We use intraoperative spinal cord monitoring in laminoplasty using the Threadwire saw (T-saw). We experienced change of amplitude in 5 cases (3 in Cervical spondylotic myelopathy, 2 in cervical ossification of the posterior longitudinal ligament). Somatosensory evoked potential was used in 3 cases and spinal cord evoked potential in 2. The change of the amplitude occured during inserting the T-saw in four cases and during use in one. In 3 cases, the amplitude recovered at the end of the surgery. There were 3 cases of postoperative neurological deficit. While laminoplasty using T-saw has been generalized for the surgery of cervical spine, there are some cases in which operative procedures cause neural injury. It is important to exercise more care in each procedure to avoid spinal cord damage.
We experienced a case of atlanto-axial subluxation associated with hypoplasia of the atlas. A 57 years old man was admitted to our hospital in July 1998, complaining of continuous headache. He had no family and past history of any significant disorders, but experienced head confusion a month ago. On examination, he did not have sensory disturbance, pathological reflex and hyperreflex except headache. In X-ray, atlanto-dental interval was 6mm (flexion position) and 2mm (extension position). In addition, space available for the spinal cord was 11mm. But there was no spinal stenosis between C2 and C7. In this paper, we focused on the size of the atlas of this case, and discussed it.
This paper presents the clinical results of patients with posterior approaches for cervical spondylotic myejopathy (CSM) more than 10 years after surgery. There were 42 males and 14 females with ages ranging from 39 to 79 years old (average 55 years). The duration of follow-up ranged from 10 years to 35 years (average 17 years). Operative procedures consisted of 36 laminoplasties and 20 conventional laminectomies. At the time of discharge, 40 patients (71%) were excellent of good. At the time of the follow-up (average of 17 years), there were 28 patients (48%) in these categories. The best clinical results were obtained 1 year after surgery. After that the clinical results deteriorated gradually. Deterioration was usually seen from 3 to 7 years post operatively. In the clinical results, laminoplasty was better than laminectomy. In the laminoplasty, spinal canal has been maintained to be enlarged. And postoperative malalignment was rare and postoperative ROM of neck was 60% of preoperative. Conventional laminectomy occurred postoperative malalignment due to destruction of posterior parts of the cervical spine. Laminoplasty was very useful at the point of postoperative malalignment. However laminectomy still remains the preferable option in certain elderly patients with limited ROM of the neck and need quick operation.
A retrospective clinical and radiographic analysis was perfomed on 5 patients who were treated with lateral mass plate. The average patients age was 46.8 years (range, 22-78 years), and the average follow-up period was 10 months (range, 3-20 months). Three patients with dislocation and fracture of the cervical spine were treated with posterior plate without bone graft, and with decompression and anterior plate with iliac crest bone graft. One patient with C456 body fracture and C345 lamina fracture was treated with posterior plate with bone graft. One patient with cervical myelopathy with athetosis was treated with long posterior plate (C2-T1) with bone graft. After surgery, the patient's neck was protected with a soft collar while in bed, and a philadelphia collar was worn when ambulating for the first month, then a neck collar for Next two months. Solid arthrodesis was achieved in all. No patients experienced neurological deterioration. However, some loosening screws and some malpositioned screws were found by the CT scans and X-ray, due to poor operative technique. Although there was no clinical symptom, one patient underwent additional operative procedure to replace two screws. We conclude that lateral mass plating is a good method for cervical spine stabilization if we are able to master the surgical technique well.
The features and treatment of pyogenic spndilitis have recently been changing with the increase of elder people and immunocompromised hosts. We analyzed prospectively 13 patients who had pyogenic spondilitis. We treated 7 patients by conservative treatment and 6 patients by operative treatment. The mean age of our cases was 59y/o. The 8 patients (53%) were immunocompromised hosts. For the latest 2 cases, we treated by minimally invasive spine surgery because of their poor conditions. One had the curettage of two discs and washout of the huge epidural abcess from the posterior approach. The other had disc curettage of T5/6 using VATS. (Video Associated Thoracic Surgery) At the last follow-up, the recurrence of spondilitis occurred in only one patient. We emphasize that minimal invasive treatment of pyogenic spondilitis is useful for immunocompromised hosts and elder patients.
Atypical mycobacterium infection of spine is very rare. It is often misdiagnosal and treated unsatisfactory. We report a case of spondylitis due to atypical mycobacterium. A man, seventy years old, had a 1-month history of back pain and right buttock pain. He has abscess discharging pus on right buttock. Radiographs of the thoracic spine were suggestive of inflammatory disease such as pyogenic or tuberculous, with destrucion of the T10 and T11 vertebral bodies. Laboratory findings included a white blood cell count of 10, 600, erythrocyte sedimentation rate of 125mm per hour and C reactive protein of 13.7mg/dl. We found E. coil and Staphylococcus milleri from the culture of the buttock's abscess. We diagnosed the patient as pyogenic spondylitis, and we gave him antibiotic drugs. Spondylitis persisted and resulted in more destruction of vertebral body. After 2 months, we performed anterior intervertebral fusion with iliac bone graft. We found mycobacterium kansasii from the culture of granulation sent at operation. After the operation, we gave him antitubercular drugs, but he has had numbness of lower fegs and spasticity. Laboratory findings have suggested mild inflammation, indicating the weed for careful observation. It is important to discriminate spondylitis cannd by atypical mycobacterium from pyogenic or tuberculous spondylitis.
Tuberculosis of the cervical spine is uncommon to arise in the whole apine. We report a case of tuberculous cervical spondylitis with Barré-Liéou syndrome. The case was a 61 year old female, who complained of mild muscle weakness and strong dizziness at motion, headache, nausea, so called Barré-Liéou syndrome. MRI showed rim enhancement of the retropharyngeal soft tissue and peridural abscess. We therefore performed the operation of curretage and anterior spinal body fusion by use of autogenous fibula bone, adding the chemotherapy of INH, RFP and SM. She gradually recovered from Barré-Liéou syndrome. The origin of Barré-Liéou syndrome in this case was unsidered the source of the irritation of the vertebral nerve by tuberculous abscess.
We experienced 11 femoral neck fractures treated with closed reduction and hook-pin fixation. The man: woman ratio was 7:4 and mean patient age was 65 (42-81) years. The mean follow up range was 197 (24-275) days. The undisplaced: displaced fracture ratio was 4:7. Postoperative partial weight bearing was started from a week with patients of undisplaced fracture, and from 2 to 3 weeks with patients of displaced fracture. 9 patients healed without early complications. A patient did not achieve union 6 months after internal fixation. The hook-pin fixation of femoral neck fracture is a stable and simple procedure, and good postoperative results can especially be expected for undisplaced fractures.
We present 2 cases of ipsilateral fractures of the hip and femoral shaft. Both cases were caused by road traffic accidents resalting in multiple injuries. The ware radiograph showed only femoral shaft fracture in the first diagnosis. After surgery for femoral shaft fracture with interlocking nailing, ipsilateral fracture of the hip was found in the post-operation radiogragh. As the ipsilateral facture of the hip and femoral shaft is caused by high energy trauma and the patient usually suffers multiple injuries, diagnosis of hip fracture is frequently misdiagnoled. Fractures of the femoral neck may sometimes also be associated with technical errors during closed nailing of the femoral shaft. We recommend use of the routine hip radiograph when high energy trauma and care are required in the placement of the entry hole for intermedullary nailing.
A twenty one-year old man was hit by a car and his left hip joint was dislocated posteriorly. After manual reduction, a small bone fragment was found between the joint space. Arthroscopic removal of the fragment was carried out successfully. The osteochondral fragment was 4cm long, 1cm wide, and 0.5cm thick, and derived from the posterior rim of the acetabulum. Full weight-bearing was permitted one week after the operation, and his hip function was recovered completely at a follow-up of four months post-operatively. Arthroscopic surgery proved to be less invasive and more useful than open surgery for the extraction of free bodies in the hip joint.
We report two patieuts with osteophytes on the femoral head resulting in the locking of the hip joint, for which surgical resection of the osteophytes resulted in resolution of symptoms. In case 1, examination of the femoral head before Chiari pelvic osteotomy revealed sharp osteophytes on the anterior, medial, and inferior surfaces of the femoral head, all of which were subsequently resected. For case 2, locking occurring after Chiari pelvic osteotomy was resolved by surgically dislocating the hip joint using the Ganz's trochanter frip approach, and resetting the osteophytes. Incarceration of the limbus was previously considered to be the most common cause of hip joint locking. However osteophytes on the femoral head, as seen in our patients, should also be considered as a possible cause of locking when magnetic resonance imaging and arthroscopy fail to identify a cause.
Fourteen cases with dislocated fractures of the hip joint were treated surgically. They were classiffied into type II (3 cases), III (3 cases), IV (3 cases) and type V (5 cases) according to the Thompson and Epstein classification. All cases achieved bone union. There were in 3 cases with osteonecrosis of the femoral head. Using the criteria for assessment described by Thompson and Epstein, excellent results were achieved in 5 cases, good in 7, and fair in 2. Anatomical reduction with internal fixation following earlier reduction of the dislocation are important for good treatment results.
We present the results of 42 total hip arthroplasties using Osteonics femoral components with a mean follow-up period of 25 months (range, 12 to 60 months). Femoral components with arc deposition (AD) have been evaluated in 14 patients, while those with hydroxyapatite (HA) coating in 28 patients. The clinical results of both femoral components were excellent. The average Japan Orthopaedic Association hip score increased from 44 prior to the operation to 90 at the time of the last follow-up. All radiographs of both groups were measured to examine the presence of reactive line, cancellous condensation and subsidence. The reactive line occurred in 2 hips (14%) of the AD group at zones I and VII which contain a porous coating of the stem, but none in the HA group after 1 to 2 years. Cancellous condensation occurred in the HA group, more than the AD group, significantly at zone II. Our radiological results show that the HA coating can provide durable implant fixation.
We performed clinical and radiological studies in 36 hip prosthesis with a zirconia ceramic head and in 30 with a metal head from 1989 to 1997. The average postoperative JOA score and reduction of the diameter of the polyethylene were not significantly different between the two groups. A longer follow-up study is necessary to achieve the desired effects of hip prosthesis with a zirconia ceramic head.
We evaluated the results of the rotational acetabular osteotomy using an allogeneic heat-treated or freeze-dired bone graft clinically and radiographically. The average age of the patients at the time of the osteotomy was thirty one years old. The average duration of follow-up was two years. We preserved the power of abduction of the hip joint without stripping procedure of gluteus medius. There are no obvious absoaption or collapsing of the grafted bone radiographically. The results of the rotational acetabular osteotomy using an allogeneic bone graft is better as compared with the rotational acetabular osteotomy using an autogenous bone graft. We reported the utility of heat-treated or freeze-dried bone graft at the time of the rotational acetabular osteotomy.
The tibial bone mineral density (BMD) was measured in 10 patients who had undergone hip joint surgery, including 5 pelvic osteotomies (4 rotational acetabular osteotomies and 1 Chiary pelvic osteotomy) and 5 hip replacements (3 total hip arthroplasties and 2 bipolar arthroplasties. Periods of non weight bearing after surgery in all patients were almost the same (56-69 days). The BMD of the tibia on the surgically treated side was measured by periferal quantitative computed tomography (pQCT) system, which provide three different BMD values of the travecular BMD in the distal portion(D50), total BMD in the distal portion (D100) and diaphysis (P100). The measurements were obtaind preoperatively, and at several time points postoperatively, basically 2 weeks, and 1, 2, 3, 6, 9, 12, 15, 18 months. Bone loss was seen in all patients after hip operation, while decreasing pattern did not differ between the pelvic osteotomy group and hip replacement group. Bone loss rate was negatively correlated with BMD in tibia obtained preoperatively in all patients (D50: R=0.58, P=0.026, D100: R=0.89, P=0.0067, M100: R=0.64, P=0.019). The bone loss rate after hip operation was not influenced by the operation method but by preoperative BMD in the tibia. In patients with low BMD bone loss would have been accelerated after hip operation and strength of the bone decreased.
Hip radiographs were examined in forty patients with rheumatoid arthritis who had total hip arthroplasties. The patients' ages ranged from 37 to 83 years. Radiological appearances of hip involvement was calssified into five types as described by Lowe et al. Radiographic evaluation showed that protrusio acetabuli and loss of joint space were seen in 45% and 28%, respectively. Types of hip involvement correlated with the serum level of CRP and type of joint destruction (LES, MES, MUD), but not with disease duration, maintenance dose of corticosteroids and JOA score. 70% of the patients with protrusio acetabuli were MUD type and most with loss of joint space were LES or MES type.
We performed autologous bone graft and cement-less total knee arthroplasty (TKA) to the knee lesion with the rheumatoid arthritis (RA) that has advanced defect in tibial plateau. Case 1 was a 66 year-old woman and ver chief complaint was right gonalgia. The lateral rear of the tibial plateau cansed advanced bone defect of the cystoma. The operation filled up the cancerous bone at the affected refin sufficiently. Case 2 was a 56 year-old woman and ver chief complaint was dvsbasia and left gonalgia. The tibia was dislocated in the front and saw bone defect in the tibial plateau rear. We inserted the cortical bone part of a resected bone fragment to the rear and made a wall, and filled up the cancerous bone at the affected refin defect department sufficiently. Good results can be obtained with sufficient bone graft and TKA of the knee lesion in the tibial highlands. The 3D-computed tomography was very useful to grasp the conditions of the bone defect.
To assess the synovial proliferation in rheumatoid knee joints, a new method by means of MRI was designed. Coronal slices of fat-suppressed Gd-enhanced MRI were divided into 5mm widths laterally. In each area, high intensity synovial membrane was scored as no membrane (0), partial (1), and full (2). Calculating these scores, synovial proliferation of the knee joint was assessed in 7 knees (RA and operated, 3; RA and not operaed 3; non-RA, 1). All three knee joints operated on with TKR had high scores, and the non-RA had a low score. By using this method, synovial proliferation of RA knee join was assessed more objectively.
In knee with patellofemoral disorder, MRI was taken both at full extension and at 30° of knee flexion. Images at the level of the femoral epicondyle and at the level of tibial articular surface were superimposed, and three parameters were measured to analyze the rotational and anteroposterior positions of the patellar tendon. First, the trans-epicondylar line was drawn and the central point was defined as Point C. The angle between the line (Line PT) from the central point of the patellar tendon to Point C and the epicondylar line was defined as Angle PT. The angle between the line from the most anterior point of the lateral condyle to Point C and Line PT was defined as Angle LC-PT. Next, a circle was drawn so that the trans-epicondylar line was the diameter of the circle. The ratio of the distance PT relative to the length of the radius of the circle was defined Ratio PT. Angle PT and Angle LC-PT demonstrate rotational angle of the patellar tendon relative to the epicondylar line. Ratio PT demonstrates anteroposteior position of the patellar tendon. In case of excessive lateral pressure syndrome, the patellar tendon located postero-laterally at 30° of flexion compared to the normal knees. In one case of patellofemoral arthritis, the patellar tendon located antero-laterally at 30°of flexion. This technique was usuful in the analysis of the mechanism of the patellofemoral disorder.
The short-term results of 62 knees in 55 patients with osteoarthritis treated by Prolix total knee arthroplasty were evaluated clinically and radiologically. The average age was 74.0 years (range; 60-89 years) at the time of surgery. The follow-up period was an average of 21 months (range: 6-38 months). The mean JOA knee rating score improved from 46.1 to 74.8 points. The mean FTA improved from 186.1° to 172.0°. The mean range of motion went from 101.8° preoperatively to 99.3° postoperatively. There were no significant complications (infection, DVT), patellofemoral disorders, and loosening or sinking radiographically. The short term results of the Prolix system were good.
Radiographic increase in the size of femoral and tibial bone tunnels has been observed, but etiology and clinical significance of these changes remain unknown. The purpose of this study is to compare the amount and shape of the femoral and tibial tunnel expansion following iliotibial tract (ITT) autograft and hamstring tendon (HS) autograft ACL reconstruction. We also investigated the relationship between bone tunnel enlargement and clinical results. Forty patients (20ITT, 20HS) were retrospectively reviewed for tunnel measurements. AP and lateral plain X-rays were obtained in each patient at 8 to 14 (mean 12) months postoperatively. The width of the femoral bone tunnel increased in 60% of ITT and in 30% of HS group. On the other hand, that of the tibial increased in 25% of ITT and in 20% of HS group. Tunnel expansion rate and degree was greater in the ITT than in the HS group. And, the shape of tunnel expansion differed from the ITT to the HS group. No correlation was seen between tunnel enlargement and clinical outcomes, such as stability, range of motion, and knee score.
We reviewed 31 patients treated by meniscal suture from 1994 to 1998. They consisted 19 males and 12 females with a mean age of 19.1 years (range: 10-34 years). The average follow-up period was 9.6 months (range; 1 to 36 months). We evaluated factors about the return to sports activity after meniscal repair. The important factors are sex (female), age (after 30 years), ligament insuf-ficiency, and type of sports (requiring jumping). The rehabilitation method shoud be considered to shorten the return period to sports activity.
Complete tear of rotator cuff at a young age is rare because it is usually based on degenerative changes of the rotator cuff. The treatment for young patients tends to be conservative with the diagnosis of impingement syndrome without complete tear of the rotator cuff. Also simple shoulder sprain may be diagnosed without further examination. In our case, the 36 year old patient sufferd from shoulder pain after he injured his right shoulder. Before he consulted our hospital, he was treated conservatively from his physical findings without further examination. We executed an MRI and arthrography which allowed us to diagnose the complete tear of the rotator cuff. We subsequently executed rotator cuff repair.
We compared gradient echo T2_??_ weighted images and fast spin echo T2 weighted images in the MRI diagnosis of rotator cuff tears 19 patients who underwent both MR images and shoulder surgery were studied. The standard of reference for the diagnosis of rotator cuff disorder was the surgery reports. The number of full-thickness tears and partial-thickness tears were 16 and 3 respectively. The interpretation of both MRI were in accord with that of surgery reports except 2 cases. One bursal partial-thickness tear was missed on T2_??_ but was correctly identified on T2. One small full-thickness tear was missed on T2 but was correctly identified on T2_??_. The size of full-thickness tears correlated well with the length of high intensity on both MR imaging films. But the high intensity area revealing a tear was significantly wider on T2_??_ than those on T2 with resulting the degeneration showing high intensity on T2_??_.
We investigated the usefullness of ultrasonography (US) for rotator cuff tears. During the last nine years (1990-1998), we perfomed US on 101 patients (102 shoulders) who had undergone shoulder US prior to surgery and arthroscopy. Their ages ranged from 32 to 83 years, with a mean age of 56.7 years. Toshiba SONOLAYER SSA-270A (7.5MHz, 1990-93), Yokokawa RT-2000 (7.5MHz, 1993-96) and Yokokawa ROGIQ700MR (10MHz, 1996-98) were used. We diagnosed a full thickness rotator cuff tear by finding nonvisualization, defect, thinning (<4mm), and a Partial thickess tear by finding partial defect and thinning. At surgery, full thickness tears were comfirmed surgically in 84 shoulders, and partial thickness tears in 14 shoulders. US compared to surgical findings yielded an accuracy of 91.8 per cent in the detection of full thickness tears, and an accuracy of 61.5per cent in partial thickness tears. US was useful in screening of tears and degeneration of the rotator cuff, but discrimination between a partial thickness tear and small full thickness tear was difficult.
Arthroscopic subacromial decompression (ASD) was carried out on 12 cases of shoulder impingement syndrome; 8 males and 4 females ranging in age from 30 to 72 years (average age; 56.6 years). Rotator cuff tears were seen completely in 6 cases, partially in 2 cases, and without 4 cases. The mean time following surgery was 5.3 months, ranging from 3 months to 12 months. At follow-up all cases were examined by a JOA shoulder score and disapperance of impingement sign. The mean score was 60 points before surgery, improving 86 points during follow-up, which was a significant demonstration of pain relief. Postoperatively 3 cases showed remaining impingement sign. Its causes were dysfuction of the rotator cuff due to complete large tear, shortage of subacromial decompression and remaining calcified deposits. It is essential to evaluate the rotator cuff function before surgery and decide the suitable decompression area during surgery.
We studied the pathological diagnosis of the synovium of the subacromial bursa of 30 patients with shoulder impingement syndrome without rotator cuff tear. The diagnosis consisted of three types, i. e. chronic synovitis (73.3%), degeneration (16.7%) and fibrosis (20%). The results of a group with friction finding observed arthroscopically at the undersurface of the coracoacromial arch were more or less the same as one of another group without the finding. In deciding the surgical indication to the shoulder impingement syndrome of intact rotator cuff tear, clinical findings are very important.
Suprasucaplar nerve palsy (SNP) is a rare entity, but it must be differentiated from various shoulder disabilities. Six operated cases of SNP were reported. All cases complained of shoulder pain and revealed weakness of the external rotation power. Five cases were caused by a ganglion and one by an abnormal band. Electromyographic study demonstrated nurogenic pattern In five cases, and low frequency pattern in one. Diagnosis was performed by physical examination, electlomyography, ultrasonography, and magnetic resonace imaging. All cases showed excellent results, and recurrence was not observed.
Gross anatomical study of the inferior transverse scapular ligament was carried out in 119 cadaveric shoulders. The ligament was present in 116 shoulders (97.5%) and absent in 3 shoulders (2.5%). Thickness of the inferior transverse scapular ligament was various and was classified by its appearance in four groups: absent, thin membranous, fascia-like thick membranous or thick ligamentous band. A thin membranous ligament was seen in 31 shoulders (26%), a fascia-like ligament in 46 shoulders (38.7%), a thick membranous ligament in 14 shoulders (11.8%) and a thick ligamentous band in 25 shoulders (21%), respectively. The space under the ligament also varied.