A case of aphalangic hand was reconstructed by nonvascularized toe proximal phalanx transfers to the augment length and to improve the function and appearance. As Goldberg and Watson recommended, an eight month-old boy underwent operation of toe proximal phalanx transfers which included intact epiphysis, periosteum and lateral collateral ligaments. Since the extensor and flexor tendons made a loop at the metacarpal head, it was incised longitudinary, and toe phalanx was inserted into this space. Lateral collateral ligaments were then sutured to the extensor and flexor tendons. Six months after operation, there has been no sign of bone absorption in the transplanted proximal toe phalanxes. This patient is now able to use his hands without any inconvenience in daily life. Past attempts at inserting bone grafts from various donor sites resulted in bone absorption. Even using proximal toe phalanx transfers without collateral ligaments resulted in the absorption of all toe phalanxes (Radocha et al.). For better functional results and to avoid bone absorption, suture of the lateral callateral ligaments to the recipient tendons should therefore be included in operations.
Snapping wrist is a rare and unique condition. Two cases are reported. Case 1: A 64-year-old female had an eight-month history of snapping phenomenon on the flexion of the right ring and little fingers. She also complained of pain at her right wrist. On examination, there was a hard mass in the palmar side of her right wrist. When the carpal tunnel was explored at operation, a 1.0cm×2.0cm white tumor was found, arising from the synovial tissue around the profundus tendon to the ring finger. The tumor was removed, and triggering completely disappeared after the surgery. The histological diagnosis was fibroma of the tendon sheath. Case 2: A 12-year-old female had a three-year history of snapping at the wrist induced by right wrist motion. She also suffered from pain and swelling of her right wrist. In this case, snapping was caused by wrist on supination-dorsoradial flexion. Radiograph was interpreted as negative. She was treated with conservative medication and was warned against wrist motion to induce snapping. Two weeks after the first examination, swelling and pain were relieved but we lost follow-up on her progress.
We introduced a new surgical option (synovectomy only of flexor tendons without carpal tunnel release) for idiopathic carpal tunnel syndrome in 11 patients, for which open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR) are popular surgical treatments. Our technique aims to decrease carpal tunnel content, but OCTR and ECTR aim to increase carpal tunnel volume. In this study, carpal tunnel pressures, clinical evaluations, electrophysiological evaluations and duration to return to work were investigated. A pressure transducer has been substituted for the median nerve in the tunnel to register sizable pressure when tension was applied to the flexor digitorum tendon (FDS and FDP) during active power grip. The operation was ended after sufficient decompression was acquired. Our technique showed were or less the same decompression effects as ECTR. All patients showed clinical and electrophysiological improvements after operation and were able to return to work earlier. No complications were seen. However, this is a short term result, so further consecutive study may need to be considered.
The treatment of advanced stages of Kienböck's disease (stage III-B and IV according to Lichtman's classification) consists of several methods. We performed radial closing wedge osteotomy for eleven patients with advanced stages of Kienböck's disease from 1990 to 1998. Seven patients were followed up for more than 6 months. All patients were female with an average age of 50.1 years. Five were stage III-B and 2 were stage IV. All patients underwent radial wedge osteotomy. The average follow-up was 3.5 years. Pain in the wrist, grip strength and wrist range of motion were assessed preand post operatively and Nakamura's scoring system was applied as postoperative clinical status. The following measurements were made pre-and postoperatively for radiographic assessment: the carpal height ratio, Ståhl's index, carpal-ulnar distance ratio, lunate covering ratio, radio-lunate angle, scapho-lunate angle, and radio-scaphoid angle. All patients were relieved from pain of the wrist and returned to their original jobs. Grip strength improved from 54% to 95% of the opposite wrist. Wrist motion also improved, with the flexion-extion arc, from 60% to 83% of the opposite side. Clinical results were good in 4, fair in 2 and poor in 1 patients using the Nakamura's scoring system. The carpal height ratio and Ståhl'S index decreased from 0.48 to 0.45 and from 33% to 27%, respectively, both without statistical significance. The carpal-ulnar distance ratio and the lunate covering ratio increased significantly (p<0.002), from 0.29 to 0.39 and from 68% to 84%, respectively. In addition, the radio-scaphoid angle was improved from 75.1° to 67.1° with statistical significance (p<0.01). Furthermore, the improvement of the radio-scaphoid angle and Nakamura's postoperative clinical score correlated significantly (p<0.001). Our study demonstrates that radial closing wedge osteotomy offers the advantage of improving not only wrist symptoms but also scaphoid rotation in patients with advanced Kienböck's disease.
We report a case of extensor tendon rupture secondary to untreated Kienböck disease (Lichtman stage IV). Dorsal deviated fragment of the collapsed lunate is thought to cause attritional rupture of extensor digitorum of index finger and extensor indicis proprius. Resection of the dorsal fragment and tendon graft using palmaris longus tendon was performed with satisfactory results.
We treated 5 fresh cases with lunate and perilunate dislocation consisting of 2 cases with palmar lunate dislocation and 3 cases with dorsal perilunate dislocation. All of the cases were males, ranging from 21 to 60 years old. Manual reduction was succeeded in 2 out of 5 cases, consequently 1 of the 2 cases was fixed with percutaneous pinning. The other 4 cases were treated with open reduction, ligamentous suture, and osteosynthesis. One case with manual reduction and percutaneous pinning showed a slight scapholunate dissociation postoperatively 3 years, but no significant clinical symptoms. Four of 5 cases were over 85 points on the clinical evaluation by Green and O'brien, one case being 50 points. We concluded the following; 1. Early reduction and ligamentous repair produces relative good results in this injury. 2. Wrist contracture, especially limitation of the dorsal flexion, results from not only severity of the ligamentous disruption in this trauma but also excessive tension in ligamentous suture and extended immobilization.
Seven hands of 7 patients with thumb polydactyly underwent surgery were followed-up. The mean age of the patients at operation was 8 months (range; 3-15 months). According to Wassel's classification, 1 patient was Type II, 4 were Type IV, 1 was Type V and 1 was Type VII. Radial hypoplastic thumb was resected in all patients. Angulation of the phalanx and matacarpal bone was treated with osteotomy in 3 patients. The average follow-up period was 7 years and 2 months (range; 7 months-15 years). According to Tada's evaluation, 5 hands were evaluated as good, 2 hands were fair, and none was poor. As a subjective evaluation, patients and their parents were satisfied with the results in 6 patients (86%).
Two important fractures of the trapeziometacarpal joint are Bennett's fracture and Rolando's fracture. There are many treatments for these fractures, amongst which closed reduction and percutaneous pinning have become the treatment of choice for these fractures these days. We report on our treatment with an external fixator in 7 cases of Bennett's fracture and Rolando's fracture between 1995 and 1998. Four cases are Bennett's fractures and 3 cases are Rolando's. All cases could be followed, and the follow-up period varied from 6 months to 2 years. The policy of our department has been towards the reconstruction of the articular surface with closed reduction applying external fixator. If the fracture is not reducible, an open reduction is recommended. Clinical results were assessed using Saito's demerit point system for Bennett's fracture and roentgenographic findings were analysed. There were 6 excellent, 1 good, and no fair or poor. Roentgenographically, there was only 1 case with shortening of the metacarpal shaft. By using an external fixator, reduction can be maintained without difficulty.
During the period from January 1996 to October 1998, 40 fingers of 37 cases of finger tip injury were treated conservatively using occlusive dressing. In the earlier half of this period until April 1997, 20 fingers of 19 cases were treated with gentamicin ointment mixed with PGE1 (2μg/g). Their mean age was 45 years (ranging from 2 to 64 years). In the second half, 20 fingers of 18 cases were treated with gentamicin ointment only. Their mean age was 44 years (ranging from 20 to 65 years). In each treatment, we first performed sufficient irrigation, débridement, hemostasis, and resection of any protruded bone. At several days later, we applied the respective ointment and covered this by sterilized aluminium foil as occlusive dressing. Then once a week as required, we reirrigated the wound with osvan and changed the sterilized aluminium foil. The duration until regeneration of new skin in the earlier group with PGE1 ointment was 24.3±11.0 (8-55) days, and that in the late group with gentamicin-only ointment was 25.6±11.2 (11-54) days. There was no significant difference.
We studied the results of treatment using spacers of cement with antibiotics for an infected hip joint in 11 cases, during the period from September 1994 to October 1998. Five cases were male and 6 were female. Their mean age was 65 years, with age ranging from 26 to 80 years. The infected hip joints involved coxitis purulenta in 3 cases, an infected prosthesis in 7 cases, and an infected girdlestone in 1 case. The mean follow-up period was 1.6 years, ranging from 5 days to 4.1 years. At first, we removed the prosthesis or resected the femoral head, and performed curettage. Next, we inserted spacers made from cement with antibiotics, modeled on a unipolar prosthesis. Seven cases (63.6%) responded, while the other 4 cases (36.4%) did not respond. A new prosthesis could be replaced in 5 cases. The mean follow-up period after replacing the prosthesis was 2 years, with range from 1 month to 3.9 years. These 5 replacements have not relapsed. We have concluded that this treatment was effective.
We report six cases of iliopsoas abscess. Three patients had diabetes mellitus. All cases were treated conservatively with antibiotic therapy, and rest on the bed. Four out of six were carried out with echo-guided percutaneous drainage. We achieved successful results in all cases. Echo-guided percutaneous drainage could be the treatment of first choice for iliopsoas abscess.
We treated 9 children with acute osteomyelitis between October 1992 and October 1998. The sites of osteomyelitis were femur in 4 cases, tibia in 3 cases, humerus in 1 case, and radius in 1 case. The age at onset was from 1 month to 13 years g months. After diagnostic aspiration and/or blood culture, we treated all cases at first by administering intravenous antibiotics. Two cases were cured by conservative methods, and we operated on 7 cases in which the presence of an abscess was confirmed by aspiration or the symptoms persisted after the administration of sufficient antibiotics. All cases were cured uneventfully. We conclude that we should surgically treat cases with acute osteomyelitis with confirmed abscess by aspiration or symptoms do not improve immediately after the administration of antibiotics.
A 38-year-old nurse who accidentally pierced her right ring finger with a needle stained with BCG vaccine was admitted to our hospital, complaining of chronic swelling of the finger. Macroscopic findings during surgery and pathological examination revealed that the tenosynovitis was caused by tuberculosis.
We report two cases of osteochondritis dissecans of the multiple lesions in both knees. The first case was a 14-year-old boy who had left knee pain. On physical, radiographic, and MRI examinations, he was diagnosed with lateral discoid meniscus injury and osteochondritis dissecans of the femoral medial condyle in the left knee, and three osteochondritis dissecans lesions in both femoral condyles and lateral patellofemoral groove in the right knee. Because of the lack of symptons in his right knee, he underwent subtotal menisectomy of discoid and multiple drilling of the femoral medial condyle lesion in the left side as arthroscopic treatment. After three months for nonweight bearing protection of the left knee, he experienced right knee pain. On arthroscopic examination, he underwent bone grafting and internal fixation only to the right femoral medial condyle lesion. The second case was a 10-year-old boy who suffered from night pain of the left knee. On radiographic and MRI findings, he had multiple osteochondritis dissecans lesions of both knees. The lesions were lateral tibial condyle and patellar central ridge in the right knee, and femoral medial condyle, lateral tibial condyle, and patellar central ridge in the left knee. He underwent artroscopic drilling to some lesions with cartilaginous softening in both knees.
We have treated 13 patients with meniscal cyst. The lateral meniscus was involved in 9, and the medial meniscus in 4. Although recent reports suggest that all meniscal cysts are assosiated with meniscal tear, meniscal tear was not found in four patients in this series. We treated partial meniscectomy and cyst decompression in 4 patients, partial meniscectomy alone in 3, and partial meniscectomy and open cystectomy or cyst puncture in 2. In addition, one patient had open cystectomy and another without meniscal tear had arthroscopic cyst decompression. In conclusion, the case who had meniscal cyst in assosiation with a meniscal tear showed arthroscopic partial meniscectomy and cyst decompression. When a meniscal tear is not observed arthroscopically, Arthroscopic cyst decompression is recommended instead of open cystectomy when meniscal tears are not observed arthroscopically.
A case of tenosynovial giant cell tumor (TGCT) in the left intercondylar notch was reported. This tumor has been rarely reported until now. A-41-year-old man with left gonalgia showed limited range of motion and hemarthrosis. Although there are slight differences histologically between TGCT and localized pigmented villonodular synovitis (PVS), multinucleated giant cells and no foamy cells were present in this case, which is characteristic of TGCT. Careful follow-up is needed because of possible local recurence or invasion.
We present two cases of intrathoracic meningocele associated with von Recklinghausen's disease. Both cases had typical multiple skin lesion of this disease. CASE 1. A 57-year-old female visited our hospital with nausea in April 1994. Although chest X-ray film revealed a tumor in the left mediastinum, she suffered no respiratory disturbance. She was admitted to our hospital with dyspnea on February 1998. Chest X-ray film revealed a massive left pleural effusion, and a tumor approximately 10cm in diameter appeared after drainage. CT-myelography and MRI showed intrathoracic meningocele. The tumor was resected completely by thoracotomy and laminectomy. CASE 2. A 32-year-old female visited our hospital with scoliosis 13 years ago. She had been asymptomatic, but a follow-up radiograph revealed enlargement of the tumor from 3cm to 6cm in diameter over 6 years. CT scan and MRI showed the tumor communicating with the dural sac. The tumor was resected by thoracoscopic surgery. Their operative course was uneventful. The thoracoscopic resection was minimally invasive. We consider thoracoscopic surgery useful, but indication should be determined according to the size and position of the tumor.
We present four cases of primary spinal tumor in adolescents. Two patients had aneurysmal bone cyst, and two osteoblastoma. These tumors were found in the thoracic spine in one patient, and lumbar spine in 3. The patients consisted of four men, and their average age was 19 years old. Following resection of their tumors, spinal instrumentation was used in two patients because of massive destructive change in the lumbar spine. Average duration of the follow-up was 9 months. Although there has been no recurrence in all cases, further observation is necessary.
In the past 10 years from 1989 to 1998, we treated surgically four cases of cervical dumbbell tumor. Two patients were male and two were female, and their mean age was 52 years (range; 50 to 57). The mean duration of follow-up was 2 years and 5 months (range; 6 months to 6 years). According to Eden's classification, three cases belonged to type II, and one case to type III. Three patients underwent hemifacetectomy without facet fusion, and one anterior spinal fusion. In pathological examination, three were neurinoma and one was solitary fibrous tumor. The clinical results were evaluated by the JOA score, and the radiological results were evaluated by lordortic angle, range of motion, rotational angle, and degree of slip of cervical spine. As a result, the JOA score improved and no instability and malalignment of cervical spine was seen in all cases. Good results were thus obtained in a short term after operation.
Current evaluation equipments of spinal cord injuries such as ASIA and Frankel classification provide better neurological understanding of patients, but not always express their functional assessment. To improve this problem, Ueta reported a new classification for spinal cord injuries; modified Frankel classification 1998. We investigated the relationship between Ueta's classification and ADL by functional independence measurement. 44 patients consisting of 38 males and 6 females with a mean age of 54.8 years (range: 16 to 86 years) were available for evaluation. It was concluded that Ueta's classification is useful for the categorization of acute central cervical cord injuries in the acute phase as well as for the evaluation of neurological disorders and functional assessment in the chronic phase.
The purpose of this study was to determine whether MR imaging is useful to predict the collapsing rate of fractured thoracolumbar spine. We treated 18 patients (male; 4, female; 14) who exhibited thoracic or lumbar vertebral body fractures (22 vertebral fractures: compression fracture 17, burst fracture; 22). The age of the patients ranged from 68 to 78 years (average; 70 years). All patients received a body cast or hard orthosis. The collapsing rate of the fractured vertebra and kyphotic angle of the adjacent segments were measured with pre-treatment and post-treatment lateral radiography. MRI was performed in all patients during treatment. The kyphotic angle changed from 14.9° to 16°. The collapsing rate of the anterior vertebral height changed from 76.2% to 71.2%, that of the middle vertebral height from 75.3% to 65.3% and that of the posterior vertebral height from 95.0% to 93.6%. The collapsing rate of the middle vertebral height before treatment was correlated to the kyphotic angle after treatment. The low signal intensity area of the fractured vertebra on T1 weighted imaging was not correlated with the radiological collapsing rate. MR imaging did not predict the collapsing rate of the fractured vertebra.
A retrospective review of six patients treated nonoperatively for severe burst fractures of the lumbar spines with mild neurological deficits was performed. In five patients considered to have good functional outcome; kyphotic deformity averaged 10 at injury (-14 to 21) and 3.6 at follow-up (-6-15), and spinal canal compromise averaged 54.4% at injury (46.9-62.0) and 34.1% at follow-up (22.2-42.4). One patient with laminar fracture had a mild back pain, requiring surgery. Nonoperative treatment should be considered an alternative in the treatment of severe burst fractures of the lumbar spine with mild neurological deficit and normal posterior column.
Therapeutic effect of short fusion within two vertebrae using pedicle screws for thoraco-lumbar spinal injuries was investigated. The patients comprised 16 males and 6 females, aged from 17 to 65 years (mean age: 37 years). Types of injuries were burst fracture in 15 cases, dislocation fracture in 5 and seat belt fracture in 2. Rigid fixation was performed in 14 cases, and semi-rigid fixation in 8 cases. Reduction of bone fragment in the spinal canal was attempted by driving-in in 11 subjects and by lordotic-distraction in 3 subjects. Although dislocation was favorably reduced, kyphotic correction suffered loss of more than 10 degrees in half of all the patients. Bone fragment in the spinal canal was relatively well reduced, as revealed by CT. There was no evident relationship between kyphotic deformity and back pain. Since kyphotic deformity to some degree is clinically acceptable, short fusion using pedicle screws is considered useful.
Operative cases in thoraco-lumbar fracture-dislocations were investigated. Nine males underwent surgical reduction, decompression and posterior instrumentations using ISOLA in 7 patients and VSP in 2 from June 1993 to July 1998. The age at the surgery ranged from 24 to 49 years old (average 33 years old) and follow-up period from 4 months to 65 months (average 17 months). The dislocated vertebrae ranged from T9 to L2 and 3.4 vertebrae on average were included into fusion area. Four patients underwent urgent operations and 5 patients elected operations. The duration of bed rest averaged 2 weeks. Six patients represented complete paraplesia preoperatively and no one improved postoperatively. Three patients with incomplete paraparesis improved completely (2 patients D→E, 1 patient B→E). After surgery the mean kyphotic angle before, justafter, at follow-up were 12°, 0°, and 4° respectively. Therefore good reduction was achieved and the correction loss was small. Three patients complained of persistent girdle pain of the torso but there was no relation with the correction loss of the kyphosis after surgery.
Postoperative results were evaluated in 9 patients (5 males and 4 females) with ossification of spinal ligaments in the cervical and thoracic spine. The mean follow-up period was 14.2 months. The age at the time of operation ranged from 45 to 79 years with a mean of 58.2 years. Cervical laminoplasty and thoracic laminectomy were performed on 9 patients, simultaneously or additionally. The mean recovery rate using Hirabayashi's method was 51.6%. In the simultaneous decompression group, the operative result was better. The operative result of the extensive ossification group was worse than that of localized group. We consider simultaneous decompression to be effective in patients with ossification of spinal ligaments in both the cervical and thoracic spines, and whose spinal cord is compressed at multiple levels.
We report the effectiveness of instrumentation for aggravated thoracic myelopathy after laminectomy for ossification of the posterior longitudinal ligament (OPLL) and ossification of the yellow ligament (OYL). A 44-year-old woman with thoracic OPLL and OYL underwent laminectomy of T7-T11 at another hospital showed aggravation of myelopathy: muscle weakness and sensory loss developed in the sitting position, which however improved in the supine position. Radiological analysis showed that the kyphotic angle of T6-T12 was 6 degrees in the sitting position but it increased to 18 degrees in the supine position. Therefore posterior element defect due to laminectomy as well as obesity seemed to aggravate myelopathy. We corrected kyphosis using ISOLA and the kyphotic angle decreased corrected to 9 degrees. She became ambulatory with a cane after the surgery. Three months later we added anterior decompression and fusion of T7 to T9, and she could walk without any support. We recommend addition of posterior instrumentation after laminectomy in such obese patients with thoracic OPLL.
A malignant tumor of the thigh sometimes needs amputation of the sciatic nerve. Well understandings of soft tissue neoplasms have made it possible to perform limb saving procedure in carefully selected cases. We performed a limb saving operation for patients involving sciatic nerve. In an effort to determine the results of this procedure, the functions of the lower extremities were assessed in 9 patients. In 9 cases it was found by imaging studies that the sciatic nerve and vessels were located near the tumor mass. Eight patients had a local resection associated with the amputation of the sciatic nerve, and one underwent splitting of the nerve sheath. The function of the lower extremities has been assessed regularly by Enneking's evaluation system. All patients who had an amputation of the nerve had 50 to 70% function, although one exception of nerve sheath splitting gained 96%. An almost normal gait was seen in the latter patient, the other 8 patients showed major gait disturbances because of the lack of active knee flection and extension of the ankle. In contrast, patients who had amputation or disarticulation gained about 70% functional score. In this aspect the local procedure does not produce results nearly as functional as a prosthesis. Therefore, in carefully selected patients, amputation is superior to a spared limb with sciatic nerve palsy in our opinion.
The frequency of the synovial sarcoma is about 10% among malignant soft tissue tumors and usually it develops near the joint of the extremities. We present a case of synovial sarcoma in this report. A 55 years old male found a tumor in his left leg 15 years before initial appearance. Pain of the affected leg developed 8 years before. Because of increasing severity of the pain, he visited a nearby clinic. He was referred to us because of abnormal findings on the x-ray film of his left foot. A hard tumor could be palpable in his affected leg, and calcification could be found on the x-ray film. The tumor was diagnosed as synovial sarcoma by the enucleation examination.
We report a case of dedifferentiated leiomyosarcoma. The patient was a 56 year-old man. The tumor was local recurrence in the right greater pectoral muscle after radiotherapy and chemotherapy. Tumor showed typical moderately leiomyosarcoma with dedifferentiated component. This component was revealed as pleomorphic malignant fibrous histiocytoma as a result of immunohistochemistry. These results indicated dedifferentiated components derive from loose muscle features due to dedifferentiation. We diagnosed this case as dedifferentiated leiomyosarcoma.
In this study, we report a rare case of an aneurysm of a persistent sciatic artery. A 71-year-old woman had a 10-month history of right thigh growing mass and pain in her right lower extremity. When she visited our hospital, an elastic hard and nonpulsatile mass was seen at the right thigh and was 18×10cm in size. She had no traumatic history. Computed tomography demonstrated a well-defined mass indicating low density. Magnetic resonance imaging showed an abnormal shadow, indicating low signal intensity in both T1 and T2 weighted images. Surgical excision revealed that the sciatic nerve was adhered to the nonpulsatile mass. The pathological diagnosis was atherosclerotic aneurysm filled with thromboses. Persistent sciatic artery is a very rare embryological anomaly. We believe that the clinical course of our case fulfills an aneurysm of a persistent sciatic artery. However, preoperative diagnosis was very difficult.
Amyloidosis rarely occurs without underlying disease: multiple myeloma, chronic inflammation, and long-term haemodialysis. The occurrence of soft-tissue tumors with amyloid deposition is extremely rare. As yet there is no report regarding soft tissue tumors with amyloid deposition without any underlying disease. We report a case of alocalized amyloidosis in the right infrapateller bursa in a plasterer with a tumor history of 13 years. A 66-year-old man visited our clinic on January 29, 1997, complaining of a large painful mass (85×65×45mm)on the right tuberculum tibiae while working in a knelt down position. Extirpation of the mass was performed on March 4, 1997. A microscopic examination revealed an amyloid deposition localized in the tumor. A demonstration of birefringence double refraction with Congo-red stain was indispensable for this pathological diagnosis.
We report a case of intramuscular myxoma occurring in the adductor brevis. A sixty-year-old man was referred to our hospital with a large soft tissue mass in the left thigh detected by abdominal CT. MR-imaging disclosed a large mass that was homogenous hypointense with respect to the adjacent muscle on T1-weighed image and hyperintense on T2-weighed image. The mass showed remarkable irregular postcontrast enhancement. We removed the tumor completely after the final diagnosis of intramuscular myxoma by open biopsy. Intramuscular myxomas are benign lesions both clinically and histologically, but may cause confusion in preoperative roentgenographic diagnosis if these are identified with unusual expression.
Angiomyoma (vascular leiomyoma) mainly occurs in the lower leg, and it is a painful tumor. We report a rare case of angiomyoma arising from the deep soft tissue of the foot. A 81 year-old woman had a 3-month history of right foot nodule. When she visited our hospital, the tumor was seen at the planta pedis and was 5×3cm in size. X-ray showed marked calcification in the tumor. Computed tomography showed a intramuscular mass indicating low density. Magnetic resonance imaging showed an abnormal shadow, indicating low and high signal intensities in T1 and T2 weighted images, respectively. Surgical excision of the tumor was performed. The tumor was circumscribed and white-gray nodule, and calcium flecks were visible. Microscopic examination of the tumor showed the lesion was composed of a well-demarcated nodule of smooth muscle tissue punctured with thin-walled vessels.
The radiographical assessment in 24 cases with endoprosthetic reconstruction after resection of bone and soft tissue tumors was reported according to the Rizzoli grading system and International Symposium of Limb Salvage (ISOLS) system. In roentgenographic changes, we made a comparison between Kotz modular femur and tibia reconstruction system (KMFTR) and Howmedica modular resection system (HMRS). The type of prosthesis did not significantly affect the pattern of bone remodelling and diaphyseal anchorage. On the ISOLS grading, the interface between the stem and bone was Fair or Poor in 20% at KMFTR and in 7% at HMRS. In addition, the average time of clear radiolucent line occurrence was later at HMRS than at KMFTR (KMFTR: 9.0 months, HMRS: 19.2 months). There was, however, no statistical significance in these results. HMRS was improved to address the problem of stress shielding. But our radiological results showed that it is not yet clear whether HMRS is the optimum prosthesis. Further experimental and clinical data are needed in order to improve results.
Mega-dose chemotherapy and peripheral blood stem cell transplantation was performed on a case of Ewing's sarcoma of the pelvis. A 13-year-old male was admitted with fever and left buttock pain. Tumor was found to occupy the left wing of the ileum on CT. The tumor demonstrated small round cells with positive PAS staining cytologically. After radiotherapy and normal-dose chemotherapy, he received megadose chemotherapy consisting of carboplatin, etoposide and ifosfamide and stored peripheral blood stem cells were transplanted. Rapid hematological recovery was observed with few complications. He had been well for 2 months until the tumor relapsed in the same area.
Giant-cell tumor is predominantly a benign condition, but it can evolve into a malignant tumor or metastasize to the lung. Transformation of benign giant-cell tumor into sarcoma is relatively common after radiation therapy. We report here a case of a patient who had local recurrence seven years after marginal resection and radiation therapy for a giant-cell tumor of the sacrum. One years after initial operation, the patient returned to us because of a lump in the lower abdomen, and re-resection of the tumor and radiation therapy (50Gy) were performed. Microscopic examination showed the typical feature of benign giant-cell tumor. Seven years after the radiation therapy, low back pain developed gradually and a computerized tomography showed a huge tumor of the pelvic space. Histological features of the tumor indicated malignant transformation into fibrosarcoma.
Management of pulmonary metastases in bone and soft tissue sarcomas remains a major clinical problems. This study was designed to compare the final lung and serum concentration of doxorubicin and cisplatin by an isolated lung perfusion (ILP) model and a pulmonary venous interruption (PVI) model compared with systemic administration in the rat. Cisplatin levels in the lung were 6.2μg/g in the group with 3mg/kg cisplatin perfusion, and 2.6μg/g in the PVI group, versus 1.98μg/g in the intravenous group. Doxorubicin levels in the lung were 75.3μg/g in the ILP group with 0.8mg/kg doxorubicin, and 29.7μg/g in the PVI group, versus 24.8μg/g in the intravenous group. Based on the results, one patient with metastatic leiomyosarcoma to the lung underwent PVI method with 150mg cisplatin during the surgical therapy without side effects and complications. It is concluded that those models have important pharmacokinetic advantages and anticipate an increased treatment response for pulmonary metastatic sarcomas as compared with systemic administration.
Intraosseous epidermoid cysts in the distal phalanx of the finger are rare. We report a case of a 14-year-old girl complaining of swelling, and local tenderness of her left middle finger. Roentgenogram showed a radiolucent lesion with thinning and loss of the cortex and a fragment probably due to pathological fracture. She did not have a definite history of trauma to her finger. We therefore assumed that this cyst originated from the dysembryoplasia. We surgically treated it with excision and bone grafting, and obtained satisfactory surgical results without recurrence.
The lesions of eosinophilic granuroma are usually associated with the femur, spine, and pelvic. Only 3 cases have been reported in the hand to our knowledge. We treated eosinophilic granuroma of the 1st metacarpal shaft in a 1-year and 11-months old boy with biopsy and curretage. There has been no evidence of recurrence of the lesion during follow-up. Although this condition is rare, when lytic and cortical destruction are observed in infantile hand without inflammatory findings, eosinophilic granuroma shoud be considerd.
We report a case of Ewing's sarcoma treated by free auto-fibular grafts. A 13-year-old girl experienced pain in her left leg. A plain radiograph showed thickened cortex over almost the entire tibia. The light microscopic features of a biopsy sample were those of a small round cell tumor. The patient received combined intensive multidrug chemotherapy before surgery. Local wide resection with reconstruction using a free auto-fibular bone graft and a intramedullary nail was performed. Plain radio-graph made one month after grafting showed fusion of the fibula. The patient was able to walk without any support in daily life 12 months after surgery.
We studied ten patients with residual coxa vara deformity treated surgically by distal advancement of the greater trochanter and femur lengthening by callotasis in late severe Perthes' disease. Patients who had residual coxa vara deformity complained gluteal muscle pain and dullness, and gluteus medius gait. The average operation age was 13.4 years old. The average articulo-trochanteric distance (ATD) was 2.6mm, and leg length discrepancy was 18.4mm. Callotasis was performed 27.1mm. Finally, the average ATD improved 26mm, and leg length discrepancy improved 2.8mm. Their complaints and limping disappeared completely.
The usefulness of arthro-MRI with direct injection of Gd-DTPA into the hip joint cavity principally for discrimination of limbus rupture was examined for 33 joints of 25 patients. In 26 joints, contrast in the periphery of the limbus was clearer than on T1 and T2-weighted images, and in 12 joints limbus rupture which was not apparent on T1 and T2-weighted images was clearly depicted. In comparison to T1 and T2-weighted images, arthro-MRI yielded more information about the acetable, bone head cartilage surface, articular limbus and intraosseous cysts, bursa, and intra-articular free bodies. Arthro-MRI enables discrimination between rupture and degeneration of the joint limbus, which is difficult using T1 and T2-weighted images, and is therefore useful for diagnosis of diseases of the limbus.
In this study, we investigated the results of bipolar endoprosthesis of the acetabular side in the avascular necrosis of the head. We selected 31 joints of 23 cases who had been operated on for more than 3 years ago. The motive was, idiopathic 16 joints, alcohol 6 joints, steroid 5 joints and after fracture of the femoral neck 5 joints. Acetabular reaming was done in 6 cases, 7 joints. We investigated (1)proximal migration of the outer head, (2) existence of the roof osteophyte and (3) existence of osteolysis with the passing year's X ray. (1) Proximal migration was seen in 4 joints (12.9%), in the 3 joints, acetabular reaming was done. (2) Roof osteophyte was seen in the 6 joints that was not seen in the proximal migration. Bipolar endoprosthesis is elective for the avascular necrosis of the femoral head. We concluded that acetabular migration is the factor the bad results and that roof osteophyte contributes to the stability of the outer head.
We investigated the operative results of 26 patients (34 hips) treated by hemiarthroplasty (Prosthesis)or total hip arthroplasty (THA) for avascular necrosis of the femoral head (ANF) classified according to the etiology. Clinical results using JOA hip score averaged 79.7 points in prosthesis and 91.2 points in THA after surgery. There was no correlation between them. On X-ray findings, the rate of loosening was shown for 23.1% of prosthesisind-ucedusing of steroid and 30.0% of prosthesis induced alcohol drinking. There was no loosening in THA. It is important to prevent loosening in prosthesis in ANF induced-steroid and induced-drinking.
We report a case of pigmented villonodular synovitis (PVS) occurring in the hip joint. Case: A 54-year-old female had increasing right hip pain and swelling for over eight years. We found a slightly decreasing Range of Motion (ROM). Roentgenograph showed narrowed joint space and multiple cystic changes on the acetabulum, femoral head and neck. The lesion appeared with low intensity with T1 and T2 MRI, and showed very low intensity with T2* MRI. We diagnosed PVS by biopsy and performed only synovectomy without damaging the blood vessels around the right hip joint. She has had no reccurrence and has maintained good function of the right hip joint for seven months.
We carried out a study on the prophylaxis of postoperative pulmonary embolism (PE). We used heparin after operation in high risk PE patients, but four patients developed PE. We concluded that appropriate plophylaxis is necessary to prevent PE.
Hypochondroplasia is a type of short-limbed dwarfism, but we have not encountered any neurological problems related to a narrowed spinal canal. We have recently experienced a case report of paraplegia in hypochondroplasia due to ossification of yellow ligament. The patient was a 49-year-old female complaining of gait disturbance. She showed short-limbed dwarfism, but had a normal face, fingers and toes. X-ray demonstrated ossification of the yellow ligament from Th4 to Th10, for which wide laminectomy was performed. Spinal canal stenosis in achondroplasia is caused by early fusion of vertebral body and lamina, but neurological complication is related to other spinal disorders, such as degenerative changes. Hypochondroplasia in the most severe type demonstrates the same symptoms.
We operated on 62 elderly cases (over 65 years of age) with trochanteric fracture of the femur during 1987-1996, in which 19 cases were with Ender nails and 43 cases with compression hip screws (CHS). According to Evans' classification, 24 cases were stable and 38 cases were unstable. The follow-up period was 3 months to 10 years (mean; 9.3 months). Post-operative changes of fracture parts (collodiaphyseal angle, shortening of the femoral neck, antversion, and retroversion) in the x-ray pictures were larger in Ender nail group than the compression hip screw group. Thus, use of CHS is recommended for unstable type fractures.
Postoperative results of gamma nailing for peritrochanteric fracture were studied on 48 cases with an average age of 74.9 years from 1994 to 1998. The postoperative complication, seen in four (8.3%) cases with an average age of 84 years, was superior cutting out by the lag screw. Our clinical result was worse compared with other reports. The purpose of this study is the evaluation of the cause of cutting out, and the follow-up of these cases. Gamma nails were inserted at incorrect positions in three cases, and in the other case, the gamma nail was inserted at the correct position but she fell down again after the operation. Even if the lag screw is at correct position, elderly patients or those with severe osteoporosis require close attention and long follow-up.