We examined 83 patients who had undergone both MRI and arthroscopy. The respective sensitivities, specificities, and accuracies of MRI of the knee were 94.6%, 76.1%, and 85.5% for medial meniscal tears, 80.0%, 82.8%, and 84.3% for lateral meniscal tears, 100%, 97.1%, and 97.6% for anterior cruciate ligament injuries, and 100%, 98.7%, and 98.8% for posterior cruciate ligament injuries. The reasons for inconsistencies between MRI and arthroscopic findings were suggested as follows; 1) a time lag between MRI and arthroscopy, 2) possibilites of lateral meniscal injuries in lateral infrapatellar approach, 3) variability of meniscal tears near the capsule, 4) difficulty of diagnosis of lateral meniscal tears at the posterior forms near the hiatus popliteus tendon.
We present two cases of osteochondritis dissecans of the lateral femoral condyle after the meniscectomy of the discoid lateral meniscus. The first case was a 13-year-old boy who underwent subtotal excision of the right discoid lateral meniscus two years ago. The second case was a 8-year-old girl who underwent subtotal excision of the right discoid lateral meniscus three years ago. In both cases, radiographs showed obvious translucent lesion on the posterior part of the lateral femoral condyle. Arthroscopy showed that there was early separation of the lesion by palpation with a probe in the first case, but no evident softness and swelling of the articular surface in the second case. At surgery, arthroscopic fixation with absorbable pins (PDS) were performed for both cases. At four months after the arthroscopic fixation, radiographs showed good union in both cases and there were no clinical symptoms. Arthroscopic fixation for osteochondritis dissecans of the knee is minimally invasive and effective to ensure the healing of lesions.
Osteochondritis dissecans (OCD) of the knee joint usually occurs on the lateral aspect of the medial femoral condyle or the so called “classical site”. However, it rarely occurs on the lateral femoral condyle. We report 5 cases of 7 knees of OCD on the lateral femoral condyle associated with discoid lateral meniscus. The OCD lesion existed in the posterior portion of the lateral femoral condyle. Existence of the discoid meniscus subjected the lateral femoral condyle to repeated stresses by its thickness and morphology around 45 degrees of knee flexion. This abnormal load may pose as the main cause of OCD of the lateral femoral condyle.
Meniscal cysts of the medial menisci of both knees are extremely rare. Here we report an operative case for this disorder. Case: 18 year-old-male, member of the Self-Defense Force. The patient has no history of trauma. He has been aware of pain in the medial aspect of the knees (left>right) since he was 13 years old. He entered the Self-Defense Force at 18 years old and visited our department for intolerable pain during training. Physical findings observed were; the tenderness from median to posterior aspect of the medial joint spaces and the positive McMurray sign in the knees. Magnetic resonance imaging (MRI) revealed well demarcated, iso-intensity like that of muscle in the T1 weighted image and high in the T2 weighted image, polycystic mass in the medial menisci with longitudinal and horizontal tears in the posterior horn of both knees. November 1997, an arthroscopic decompression of the cyst and partial menisectomy were performed. There was a leaking of mucous fluid from the tear portion in the left knee, however, no leaking was observed in the right. At present, 16 months have passed after the operation, the bilateral gonalgia disappeared and the patient satisfaction is high. The cysts in both knees disappeared in the MRI study and an excellent postoperative result was obtained.
The rupture of the patellar tendon is a rare injury. We report two cases of the subcutaneous rupture of the patellar tendon in recreational athletes. One patient was a 26 years old man. He was injured while playing baseball. Another patient was a 35 years old man. He was injured while playing volleyball. The patients underwent operative debridement and primary repair of the ruptured patellar tendon using nonabsorbable sutures passed through the patella and tibial tubercle drilled holes until two weeks after injury. At operation, the ruptured patellar tendon was always considerably frayed, resembling the ends of a mop. Postoperatively, patients were immobilized for three to four weeks in a cylinder cast. After removal of the cast, full active flexion exercise was begun. At final follow-up, patients had no complaints and exhibited normal range of motion and quadriceps strength.
In most cases, the Trendelenburg sign is positive when there is a weakness in the abductor muscles resulting in the weakness of the hip, as in neurological disorders and or hip disorders. In 1997, Vasudevan P. N. et. al. reported that the medial deviation of the mechanical axis of the leg may cause a positive Trendelenburg sign. They said that if the hip is abducted in compensation for a varus deformity below the hip, the trochanter rotates proximally, thus effectively shortening and weakening the abductor muscles. From this we can deduce that the Trendelenburg sign can be detected if there is a medial shift of the mechanical axis of the leg because of the deformity of the femur and tibia with primary osteoarthritis of the knee. We selected 15 patients, studying a total of 30 legs. No neurological or hip disorders were presented in all participants. We conducted Trendelenburg sign tests and manual muscle tests (MMT) of the hip abductor muscles, while studying their knee complaints and plane X-rays. 7 legs had no complaints of the knee, showed negative Trendelenburg sign, and had normal (5) MMT scores. The other 23 legs had knee complaints and showed osteoarthritis on their X-rays. The Trendelenburg sign was present in the legs of 21 of the 23 patients. The MMT score was also good (4) in all of these legs. These results suggest that the Trendelenburg sign may be positive in the medial shift of the mechanical axis of the les with primary osteoarthritis of a particular knee with problematic symptoms.
35 patients with medial osteoarthritis of the knee underwent at random either a dome osteotomy (Dome) or hemicallotasis open-wedge osteotomy (Hemi). At one year after the operation, we compared the radiographic changes in the patellar tendon length, tibial plateau angle, and lateral shift of the proximal tibial plateau with respect to the tibial axis between the Dome group consisting of 20 knees of 18 patients and the Hemi group consisting of 19 knees of 17 patients. No significant differences were seen in the age, gender, femorotibial angle before and after the operation, and correction angle between the two groups. In the Dome group, the patellar tendon length became shorter, and the tibial plateau angle decreased significantly than that in the Hemi group without any changes. The degree in the lateral shift of the proximal tibial plateau in the Dome group was significant greater than the Hemi group. The results in this study showed that hemicallotasis open-wedge osteotomy shows little technical difficulties in the subsequent total knee arthroplasty seen after the dome operation, because there are no changes in the patellar tendon length and less deformity of the proximal tibial with respect to the tibial axis postoperatively. These slight changes are considered an advantage of this method.
Six Patients (8 limbs) with severe osteoarthritis of the knee were treated by tibial condyle valgus osteotomy (TCVO). The medial joint space of the knee had disappeared or Miklicz's line was seen to pass through the medial side from the medial edge of the tibia in these patients. The patients age ranged from 54 years to 81 years. The follow-up periods were from 2 years to 6 years. The average score of these patients (JOA score) improved from 45 points to 85 points after surgery. We concluded that symptoms improved due to the decrease in the load of the medial joint of knee was and the recovery of the stability of the knee joint by TCVO.
We report long-term results (over 10 years) of total knee arthroplasty (TKA) for the treatment of osteoarthritis (OA) and rheumatoid arthritis (RA). Twenty-three patients (OA; 10 patients, RA 13 patients) with 36 knees were examined. Clinical results were evaluated using the Knee Function Scoring System developed by three universities. Radiographs were evaluated for the loosening and sinking of TKA. Post-operative complications were evaluated in 79 knees of 49 patients. The function score significantly improved from 41 to 73 points in patients with OA and from 40 to 63 points in patients with RA. In both OA and RA knees, the extension of the knee joint improved after surgery and was maintained at follow-up. Positive correlation was found between the knee flexion angle before surgery and that at follow-up. In radiographic evaluation, only 1 sinking was found in OA, whereas, 2 loosening and 4 sinking were found in RA. Postoperative complications were 1 infection in OA, whereas, 7 aseptic loosening, 2 infections, and 1 posterior dislocation were seen in RA, indicating better functional recovery with less complication can be expected in OA patients than in RA patients. Better flexion of the knee joint can also be expected if TKA is performed before contracture of the knee joints develops.
We evaluated the clinical and radiographic results of total knee arthroplasty in 17 patients using the Duracon System. 13 knees of 10 patients had osteoarthrosis and 8 knees of 7 patients had rheumatoid arthritis. The mean age at the time of operation was 68.3 years. The mean follow-up period was 5.0 years. The mean JOA score improved from 42 to 77 points in the OA group and from 41 to 76 points in the RA group. The mean extension changed from -17° to -4° in the OA group and from -6° to -1° in the RA group. Obvious loosening was not confirmed on the radiographs.
This study was designed to assess the significance of the reinifusion system for unwashed, filtered shed blood (CBC II: ConstaVac Blood Conservation System II, Stryker) after total knee arthroplasty (TKA). Forty-nine cases were evaluated. Forty-four cases were managed only with CBC II, while 5 were managed with both CBC II and the preoperative autologous blood donation. Fifty-two % of the blood loss after surgery was collected and transfused on an average. Five cases who were managed only with CBC II had homologous transfusion, however, 2 of the 5 cases were transfused because of the postoperative complications (apoplexy and intestinal bleeding) more than 2 days after surgery. No major complications caused by the use of CBC II were recognized. It is a beneficial method to use CBC II after TKA in order to avoid homologous transfusion.
Deep infection after Total Knee Arthroplasty (TKA) is one of the worst complication, therefore it is important to prevent infectious artificial joints. If the C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are elevated before surgery, we always hesitate to perform the opetation. We investigated 12 patients, 18 joints with inflammatory reactions who under went TKA before surgery. Before surgery, the CRP ranged from 0.5 to 13.0 (average 4.0) and ESR 27 to 134mm/hr (average 73.2). TKA was performed because infection of the knee joint could not be proven by joint fluid culture and synovial biopsy. After an average of 5.8 years (from 6 month to 12 years) from the surgery, fortunately there have been no patients with deep infection.
We have developed a new concept which enables precise patella resection. A K-wire is inserted through the patella so that the wire is perpendicular to the anterior surface, after which resection is performed perpendicular to the wire. Nine fresh frozen cadaver patella specimens were used. First, the circumference of the anterior surface was marked because the anterior surface was convex in shape. After the thickness of each patella was measured, a K-wire was inserted through the patella perpendicular to the marked plane using a specially designed cutting guide. The guide had a concave surface which matched the anterior surface of the patella. The wire was then inserted through the cutting drill, and resection was performed creating a patella 15mm in thickness. The thickness of the resected patella and the angle of the cut surface relative to the marked plane were both measured. The value of the angle was positive when the angle was open superiorly in the sagittal plane and laterally in the coronal plane. The thickness of the patella was 23.8±3.5mm and 15.3±0.4mm before and after the resection, respectively. The angle of the cut surface was-0.7°±2.2° (-3.5 to 3.5°) in the sagittal plane and 0.2°±2.9° (-4 to 5°) in the coronal plane. The angle was larger in four specimens with poor bone quality.
Supracondylar fracture of the femur after total knee replacement is an uncommon complication and treatment is often difficult. We experienced three cases in which Ender nails were used for internal fixation to treat this type of fracture. In the two patients had osteopenia, no evident surgical encroachment of the anterior femoral cortex was seen. Use of Ender nails enables the fracture to be fixed for any prostheses shape. Internal fixation allows comparatively early range-of-motion exercises at the knee without the need for long bed rest and extensive surgical exposure. We thus concluded that this technique is useful for treating this type of fracture.
We successfully treated six distal femoral fractures with Intramedullary Supracondylar Nail (IMSN) In two men and four women with a mean age of 77.2 years (range of 66 to 88 years). According to AO classification, they were classified into type A2 (2 cases), type C1 (1 case), and type C2 (3 cases) respectively. All cases were treated with the closed technique. For the type C cases, we inserted a thin guide wire and fixed the intracondylar with a cannulated screw before inserting a thick IMSN. A follow-up study was conducted on all patients for a mean period of 19 months (range of 8 to 30 months). All fractures healed within 3 months (range of 2 to 5 months) without bone grafting. There were no implant failures and severe complications. The average knee range of motion was 105 degrees. Clinical results were evaluated according to Neer's criteria: Excellent=2; Satisfactory=3; Unsatisfactory=1. The IMSN easily provides rigid internal fixation for early range of motion exercise with minimal invasion.
Fractures of the distal femur were studied in twenty patients treated at Hamanomachi General Hospital, consisting of eight males and twelve females with a mean age of 59.3 years (range, 13 to 83 years). The average duration of follow-up study was 1.5 years (range; 0.4 to 9.5 years). All patients were classified according to the AO/ASIF classification and Kuwano's criteria was used for the assessment of the results. There were twelve cases of type A, three of type B, and five of type C. Type A: Closed treatment consisting of skeletal traction or a plaster cast was performed on four patients. Internal fixation was used in eight patients: Kirschner wires (K-wire) in one, Zickel nail in five, Intramedullary Supracondylar nail (IMSC nail) in one, and May anatomical bone plate in one. Results were excellent in six, good in four, and fair in two. Perfect anatomical reduction was not necessary, while correction of the axial alignment, length and rotation were necessary. Closed treatment or intramedullary fixation is thought to be preferable. Type B: Open reduction and internal fixation were performed on all patients using K-wire, Herbert screw or cannulated screw with good to excellent results. An accurate anatomical reduction of the joint surface and early motion exercise is essential. Type C: Internal fixation was performed in four patients: K-wire or Tibia bolts in three, and IMSC nail in one with excellent results. Closed treatment was done on one patient who had hemophilic arthropathy with fair result. Open anatomical reduction of the joint surface and internal fixation are thought to be preferable. And early motion exercise is necessary. We conclude that selecting the appropriate treatment for each case is important.
We evaluated the results of surgical treatment performed for patellar fractures in forty three patients. Twenty seven patients were men, and sixteen were women. The mean age of the patients was forty eight years (range; 15 to 84). The cause of injuries were slip in twenty patients, traffic accident in fifteen, fall in six and others in two. Twenty seven patients were fixed with double circumferential wiring (DCW), six were fixed with tension band wiring (TBW), seven were fixed with DCW and TBW, and four with others. Clinical results were assessed according to the scale of Watanabe. Bone union was achieved in all cases. Twenty three patients showed excellent results, seventeen good, and three fair. Eighteen patients had muscle weakness of the quadriceps.
We reviewed 28 cases of tension band wiring for the fracture of the patella, in which subcutaneous wiring was used in 21 cases. There were 11 males and 17 females with an average age of 58 years old (20-80). They were classified into 17 transverse, 6 three-parts, 4 comminuted, and 1 vertical fracture. The evaluation of the treatment, before the removal of the wire, was performed based on Watanabe's score. All patients showed satisfactory results, with 22 evaluated as excellent, 5 as good, and 1 as fair.
Fractures of the tibial plateau often associate ligamentous and meniscal injuries. MR imaging is useful for evaluating not only the extent of the fracture depression or displacement but also associated soft-tissue injuries. We compared the findings of MR imaging with those of arthroscopy in thirteen patients with fractures of the tibial plateau. In this series, 8 (61.5%) lateral meniscal tears, 2 (15.4%) anterior cruciate ligamentous tears and 1 (7.7%) posterior cruciate ligamentous tears were seen at arthroscopy. The sensitivity for lateral meniscal tears was significantly less than for other tears. 75% of lateral meniscal tears were peripheral tears. Peripheral tears of the lateral meniscus are especially difficult to detect on MR imaging. In conclusion, special attention should be given to peripheral tears of the lateral meniscus in fractures of the tibial plateau. Even if MR imaging do not show lateral meniscal tears, arthroscopy is recommended.
From April 1992 to December 1998, osteosynthesis and prosthetic procedures were performed on 352 cases of femoral neck fractures and clinical examinations were performed on 30 cases (8.5%) over 90 years old. The 30 cases (2 males and 28 females) whose age ranged from 90 to 99 years (mean, 92.1 years) were followed up 2 weeks to 6.5 years (mean, 2.25 years) after surgery. One patient died 2 weeks after surgery, but 22 patients (84.6%) lived over 1 year after surgery and 17 patients (56.7%) were alive at the latest follow-up. Twenty one patients (70%) regained the ability to walk by the time of their discharge. In spite of early post-operative rehabilitation, the activities of daily living (ADL) at discharge were lower than that before injury due to senile dementia, celebral infarction, hemiplegia, or a major complication. In our cases osteosynthesis procedures for intracapsular femoral neck fractures produced a good prognosis and may better than prosthetic procedures in some cases.
A retrospective analysis was performed investigating 103 patients aged over 65 years who have been operated on for femoral neck fractures. Twenty nine patients had died at a mean of 11 months after surgery. Ambulatory status was influenced by the time interval between injury and surgery, dementia, and environment. Ambulatory status was not influenced by the operative method and age. It was 79% of the patients regained preoperative ambulation. They had no dementia and under went surgery within 3 days of injury.
Seventeen cases with intra-articular displaced fracture of the calcaneus were treated surgically using the plate. They were classified into type II-C (3 cases), II-E (8 cases), and II-F (6 cases) according to Essex-Lopresti's classification. All cases achieved bone union. Using the criteria for assessment described by Maxfield, excellent results were achieved in 9 cases. very good in 7 and fair in 1. Open reduction and internal fixation is a useful method for treating intra-articular displaced fracture of the calcaneus.
We reviewed the clinical results of 43 fractures of the ankle treated by open reduction and internal fixation from 1995 to 1997. The average age was 41.6 years (range: 15 to 85 years) and follow-up period was 18 months (range: 8 to 156 months). The fractures were grouped into four types according to Lauge-Hansen classification. There were no relationship between clinical results and types of fractures. But poor reduction after surgical treatment and large displacement of the initial degree caused poor clinical results. In addition, delayed surgical treatment also produced the some results
We studied the clinical results of the joined external fixation for plafond fractures. Between 1996 and 1998, we treated 14 ankle injuries with external fixation. And plafond fractures were 11. Postoperative results were evaluated using Burwell's criteria and Ovadia's radiological assessment. The clinical results were good in 6, fair in 3, and poor in 2. The radiological assessment were 6 anatomical, and 5 fair. The joined external fixation was useful for correcting the dislocation between the tibia and talus at the operation. It was useful for improving joint mobility and protecting muscle weakness at rehabilitation.
We treated 8 children with femoral shaft fractures. Their ages at fracture were 2 years 5 months to 15 years 3 cases were treated conservatively and 5 cases by antegrade intramedullary nailing. (Three with Küntscher nail, one with Ender nail and the other one with Kirschner wire) All cases achieved bone union. Children treated by intramedullary nailing had shorter duration of admission. Intramedullary nailing is a useful method for femoral shaft fractures, especially for cases difficult to treat conservatively.
We examind the femoral shaft fractures in children with external fixation devices in an effort to prevent malunion, speed up early recovery and discharge. The researchers followed up on 8 patients with 9 femoral fractures for a 6 month period after removal of the external fixators. Patient ages ranged from 3 years old to 10 years old with a mean age of 6.9 years oid. Six were male and two were female. All procedures were performed under general anesthesia. The technique involved is used to reduce fractures as much as possible, end to end, on the traction table and fix it with an external fixation device. No other external fixation devices were employed postoperatively. The weight bearing time began when the patient was relieved of pain. The time ranged from 5 weeks to 13 weeks with a mean time of 9.6 weeks. In all cases, except for the one case in which the fixator had been removed as mentioned above, the bending was within 5°, which is a good reduction position. In addition, all the cases had no limitations in the excursion of knee and hip. Leg length discrepancy was within 5mm in all cases. The use of external fixation devices in the management of femoral shaft fractures in children ensures fine reduction position/alignment and early ROM, and is therefore considered as an effective method.
We observed the healing process of ruptured Achilles tendons in a series of examinations using magnetic resonance imaging. The Achilles tendons are co-joined in two shapes in the incipient stage. One is the dumbbell shape and the other is the spindle shape. The tendon tended to co-join in the dumbbell shape in the conservatively treated group, while it tended to co-join in the spindle shape in the surgically treated group. The ruptured part tended to co-join in the spindle shape when it was narrow (less than 4mm), and in the dumbbell shape when wide (more than 5mm). The diameters from the anterior to posterior sides enlarged in the process for both shapes, and no significant difference was seen between the two shapes. No significant difference was also seen between the two for the healing time of the ruptured part. Regardless of the above finding, it is impossible to deny that surgical treatment promotes earlier healing of the ruptured part than conservative treatment, according to the relationship between the size of the ruptured part and co-joining shape.
We prospectively treated 19 Achilles tendon ruptures with combined percutaneous and open surgery. The repair was performed with Kessler-Tajima two knots suture of No. 2 nonabsorbable polyfilament. After below knee splinting for 1 week, patients began ambulation in a walking cast. Tree weeks after surgery, the cast was removed, after which ROM exercise and full weightbearing was allowed in a hinged orthosis. Six weeks after surgery, use of the orthosis was discontinued. In the follow-up 3 years and 2 months later, all the tendons had healed completely and there were no wound complications nor reruptures.
‹Purpose› The diagnosis and treatment of shoulder problems depend upon konwledge of the anatomy. The purpose of the present study was to determine the prevalence and characteristics of glenohumeral ligament complex (GHLC) in traumatic anterior instability of the shoulder. ‹Materials and methods› Control group: 44 cadavers (17 females, 27 males; mean age at the time of death, 74.1 years). The cadavers were dissected and 84 shoulders were examined. Traumatic anterior instability (TAI) group: 22 patients (1 female, 21 males; mean age, 20.3 years). We examined 22 shoulders arthroscopically. The prevalence of SGHL, MGHL and IGHL was investigated. GHLC was assigned to one of four anatomical categories: type 1 has 3 distinct ligaments; type 2 has 3 ligaments and a foramen between a narrow MGHL and a normal IGHL; type 3 has 2 ligaments and no MGHL; type 4 has no ligament pattern. ‹Results› SGHL was present in 94.0% of the control group and 90.9% of the TAI group. MGHL was present in 63.1% and 68.2%. IGHL was present in 90.5% and 90.9%. GHLC were categorized as follows: type 1 (38.1% in the control group and 27.3% in the TAI group); type 2 (17.9% and 36.3%); type 3 (35.7% and 27.3%); type 4 (8.3% and 9.1%). ‹Conclusion› This study suggests that a narrow MGHL (GHLC type 2) is predisposed to traumatic anterior instability.
Recurrent anterior dislocation of the shoulder generally occurs in youths, and is rarely seen in the aged. Here we present two cases of recurrent anterior dislocation of the shoulder in the aged. Case 1. A 79-year-old female fell and dislocated her right shoulder for the first time. Despite adequate manual reduction and splinting for four weeks, recurrent dislocation has occurred several times since then. CT demonstrated anterior subluxation with a posterolateral notch. Surgical treatment was performed using the modified Bristow procedure, and subscapularis has disappeared. She has had no dislocation since surgery. Case 2. An 84-year-old female fell and dislocated her right shoulder for the first time. Since then, recurrent dislocations have occurred easily. CT and MRI revealed a posterolateral notch. The modified Bristow procedure was performed. She has had no dislocation, and has had a stable mobile shoulder since surgery. Weakness of the anterior elements including subscapularis in Case 1, and enlargement of the posterolateral notch due to osteoporosis in Case 2 should be considered as a leading cause of recurrent anterior dislocation. Conservative treatment was not effective, and surgical treatment was indicated to prevent recurrent dislocation and to regain the range of motion of the shoulder for daily life activities.
We report a case of the locked posterior dislocation of the right Shoulder with chronic humeral head fracture. Locked posterior dislocation of the Shoulder is a rare condition in shoulder dislocations. A 61 year-old man experienced right shoulder pain and limited of the right shoulder elevation and external rotation. TIA attack had caused the dislocation in this patient. He visited our hospital 4 weeks after injury. CT scan is very useful for the diagnosis of the posterior dislocation of the shoulder. He had an impression defect that involved 45 per cent of the articular surface. Diagnosed with the posterior dislocation fracture of the right shoulder, surgical treatment by open reposition to the shoulder, osteosynthesis to the humeral head fragment, and bone graft to the bone defect were performed. 5 months after surgery, recovery has been good.
24 Shoulders of 12 patients with Rheumatoid Arthritis were examined with plain X ray (A-P view) and ultrasonography (US). The anterior, superior and posterior aspects of the shoulder were scanned in the transverse plane. Findings of the US were compared with those of X ray according to Larsen's classification. Even in early stages of Larsen's classification in which X-ray could not detect remarkable changes, effusion, atrophy of the rotator cuff, were detected by US. In more moderate stages, the ratio of detecting the findings of atrophy of the rotator cuff, rotator cuff tear, atrophy of limbs and erosion increased in US scanning. These results suggest that US is useful for evaluating the conditions of the shoulder joint in RA.
It is difficult to objectively diagnose certain painful conditions of the shoulder such as impingement syndrome. Magnetic resonance imaging and arthroscopy of shoulder impingement syndrome excluding rotator cuff tear were evaluated in 40 patients. Patients who underwent magnetic resonance imaging before arthroscopy were reviewed after the operation. The high intensity area of T2* weighted images in subacromial bursa and rotator cuff tendon was checked as a sign of subacromial impingement. The high intensity area of T2* weighted images in the subacromial bursa and rotator cuff tendon was 80 and 17.5 per cent in the whole group. When the whole group was classified according to arthroscopic findings, the high intensity area of T2* weighted images in the subacromial bursa and rotator cuff tendon were 74 and 22 per cent in the group of significant subacromial frayed findings, 90 and 10 per cent in the group of rotator cuff tendon frayed findings without significant subacromial fraying, 100 and 0 per cent in the group of thickend coracoacromial ligament.
Treatment regimens for frozen shoulder vary. These include joint distension which is performed in conjunction with the arthrography of the shoulder. Distension arthrography was performed in 19 cases from April 1997 to March 1998, of which nine cases (4 men, 5 women) were available for this study. One case underwent surgical manipulation after joint distension. One case was admitted for surgery but joint distension on the day of admission was so effective that she discharged without surgery. The average JOA score was 55.4 before this procedure and 84.1 at the time of follow-up. As the treatment for frozen shoulder, we recommend this procedure before surgery.
Reconstructive musculoskeletal surgery is important for preventing infections. Usually, antibiotics are used for this aim. The concentration of antibiotics must exceed MIC in the venous blood and bone marrow. In this study, we measured the concentration of Isepamicin of venous blood and bone marrow. The subjects consisted of 8 males and 1 female who underwent reconstruction of the rotator cuff. Their ages ranged from 36 to 66 years (average 54.6). Four hundred mg of Isepamicin was administered intravenously during 60 minutes. Their venous blood and bone marrow were taken immediately after the admistration, 30 minutes later, and 60 minutes later. The blood of the bone marrow was extracted from the bony sulcus made on the humeral head during the operation. The serum of the venous blood and bone marrow was measured to determine the concentration of the Isepamicin. There were no statistical significance between the Isepamicin concentrations of venous blood and bone marrow. They were higher than MIC to prevent infections in both venous blood and bone marrow. No side effects of Isepamicin were found in all cases. The shift to the bone marrow of Isepamicin administered intravenously was excellent.
We treated 6 cases of vertebral osteomyelitis in this past 3 years. The characteristics are as follows; all cases were over 50 years old, 5 cases had other complications (diabetes melitis, etc), 3 cases were of the subacute type. The faster the CRP improved, the better was the prognosis. A sign of healing in MRI findings is a decrease in the low signal intensity area in sagittal T1-weighted images.
We treated two cases of lumbosacral pyogenic spondylitis. Because their sacra were infected, it was impossible to place the screws in the S1 pedicles. We aimed at early mobilization and prevention of pseudoarthrosis, and used the spinal instrumentation with iliac screws for lumbosacral fixation. Both two cases were able to walk within one week after surgery, and bone union completed in five months.
External fixation is often used for open fractured or infected long bone. However, That for infected spines has not been reported untilnow. We have used percutaneous external fixation for pyogenic spondylosis with severe instability of the spine and epidural abscess. A 74-year-old man had severe pain of both legs. He was not able to walk. MRI showed bony destruction of the L3 and L4 vertebras and epidural abscess formation at the level of Th8 to L1. Xp showed severe instability of the lumbar spine. External fixation and anterior interbody fusion were performed and good results were achievel Spinal instrumentation for pyogenic spondylosis is now the standerd method. However implants have never been used for infected long bone. And if operations are needed, external fixation is used. Likewise external fixation is a good method for pyogenic spondylosis.
We report a rare case of candida vertebral osteomyelitis at the multi level lesion. A-58-year old man had complained of low back pain and fever elevation, one month later after abdominal surgery. The findings on plain radiographs and tomograms showed narrowing of the disc space at the Th12/L1, L4/5 and L5/6 levels. MRI showed abnormal signal intensity in the region of the Th12-L1 and L4-6 vertebral bodies. The needle biopsy of the spine grew candida tropicalis. He was managed conservatively with antifungal agents and bed rest. The symptoms reduced gradually. The treatment was successful with no recurrence after follow-up of 10 months.
Recently, infections caused by Candida are increasing due to the increase in the compromised host. In this paper, we report a difficult case of Candida spondylitis. A 61 years old man had high fever and liver dysfunction. He underwent liver biopsy in the internal medicine division. He also underwent laparoscopic operation for removing the hematoma in surgery. Afterward CT showed abscess in iliopsoas and epidural, around lumbar vertebral. We performed needle biopsy. The cultures were positive for Candida albicans. Chemotherapy performed during ESR became normal after 4 weeks. Then spondylitis recurred. Chemotherapy had no effects this time. We operated with anterior decompression and bone grafts. Chemotherapy stopped after ESR became normal 12 weeks later Spondylitis has not recurred even now. Generally chemotherapy continues after WBC, CRP and ESR become normal for 3 to 4 weeks. But difficult cases of Candida spondylitis need longer term chemotherapy.
Twenty-one cases of Achilles tendon rupture were treated non-surgically from 1988 to 1998. The patients were treated with below-knee plaster cast for 4 weeks. Full weight bearing and active motion exercise of the ankle were allowed right after removal of the cast, and short-leg splint was used for one week. Two re-ruptures occurred when the patients fell within 2 days after removal of the cast. The other 19 patients were satisfied with their treatment and result. They do not feel pain on walking, nor weakness of the affected limb. There was no arthrofibrosis. All patients returned to their previous levels of recreational activities. The results of this study suggent that short leg casting with immediate full weight bearing is effective for the treatment of Achilles tendon rupture. Early weightbearing possibly enhances tendon healing because collagen is reported to respond to loading and muscle vascularity increases with weightbearing. Also, 4 weeks of immobilization was short enough to avoid arthrofibrosis. Non-surgical treatment with immediate weight bearing can be the choice treatment for Achilles tendon ruptures in non-competitive athletes.
Old ruptures of the Achilles tendon are hardly repaired by end to end sutures. We report two cases of that kind of injury using peroneus brevis tendon. Two cases sustained neglected rupture of the Achilles tendon by misdiagnosis. Peroneus brevis tendon is long enough to cover the defects of a ruptured tendon. Both case 1 as well as case 2 were in good condition after the reconstruction of the Achilles tendon. We concluded that this method is most effective for old rupures of the Achilles tendon.
The patient was a 28-year-old male, a riot police, whose injury had been caused by the eccentric contraction of the pectoralis major muscle during arrest training. At first he was treated conservatively, but two months later he felt pain in his left pectoralis major muscle and the concavity of that was marked We reconstructed the pectoralis major muscle six months after the injury, and then repaired the rupture with iliotibial band. After 4 months, he did not return to work but regained muscle strength and range of motion gradually. In our case, we used the iliotibial band in consideration of age, activity, and strength of the ligament. It serves as one of the effective ways for the rupture of pectoralis major muscle.
Three cases of accessory nerve injury after excision of the neck tumor were reported. Characteristic complains of these patients are shoulder pain, atrophy of the trapezius, and weakness of shoulder abduction. A 59-year-old female visited our hospital 7 months after excision of the right neck lipoma. She noticed pain, atrophy, weakness and inability to horizontally abduct the shoulder. Intraoperatively, the accessory nerve was found to be buried in the scar. Neurolysis was performed because muscle twitch was elicited by electrostimulation. She could horizontally abduct the shoulder 3 weeks after neurolysis and complete recovery was seen after 3 years and 3 months. A 27-year-old male was referred to our hospital, 2 months after excision of the right neck lymphnode. Intraoperative findings revealed a neuroma in-continuity of the accessory nerve. 7 months after resection of the neuroma and epineural repair, complete recovery was seen. A 36-year-old male visited our hospital, 2 months after excision of the right neck lymphnode. The accessory nerve was buried in the scar and one of three funiculi was tied. Resection of neuroma and funicular repair were performed in the funiculus and neurolysis was carried out in the other. Six months after surgery, muscle strength was recovered, but trapezius atrophy remained.
Three patients with elbow contracture with the cubital tunnel syndrome were successfully treated with resection of the osteophyte and neurolysis through posteromedial approach. The patients were a 32-year-old bodybuilder, 50-year-old softball player of the National Athletic Meet and 43-year-old wiring worker who had been a baseball pitcher for 11 years. All three patients were male, and characteristics of their symptoms were elbow contracture with pain on maximum flexion and extension with ulnar nerve palsy. Osteophytes of the elbow joint were considered the main cause of both the contracture and cubital tunnel syndrome. Resection of osteophytes at the medial, anterior, and posterior aspects of the elbow joint and decompression of the ulnar nerve were performed through posteromedial approach. A small lateral incision was required to remove free bodies or an osteophyte hanging over capitellum humeri in two patients. The mean preoperative range of motion (extension of -22.7 degrees and flexion of 95.0 degrees) improved after the surgery (extension of -13.7 degrees and flexion of 114.3 degrees). The preoperative symptoms including ulnar nerve palsy were relieved. The level of performance in sports improved in two patients, and activities in daily living markedly improved in all.
We successfully treated recurrent and persistent carpal tunnel syndromes with neurolysis and palmaris brevis turnover flap with hypothenar fat. A 53-year-old female received carpal tunnel release 19 months ago. Night pain and paresthesia were once resolved after surgery, however, symptoms recurred after 9 months. On examination, Tinel sign along the operative scar and positive Phalen test were found. Two-point discrimination of the thumb was 8mm but motor weakness was not found and terminal latency was within the normal range. Intraoperative findings revealed that the median nerve migrated volarly and adhered to the dorsal aspect of the sectioned flexor retinaculum. After the index surgery, night pain resolved immediately and only slight numbness remained at 18 months after surgery. A 67-year-old female received carpal tunnel release 12 months ago. Pain in the palm started, and night pain and paresthesia worsened after surgery. On examination, we found Tinel sign along the operative scar, positive Phalen test, weakness in thumb abduction and mild delay in terminal latency. Operative findings were volar migration of the median nerve surrounded by the scar tissue. After the index surgery, night pain disappeared immediately and she has been symptom-free for 16 months.
41 limbs in 34 patients with entrapment neuropathy of the common peroneal nerve were operated on in our department. Among these, 11 limbs in 7 cases were diagnosed as having osteoarthritis, and 11 limbs in 11 case as lumbar disc herniation before our diagnosis. The causes of these misdiagnoses were investigated with medical care records. The causes of misdiagnoses as lumbar disc herniations were as follows: paresthesia from the lateral aspect of the leg to the dorsal aspect of the foot as the patient complaint, misunderstanding of the symptoms from the extension and compression of the common peroneal nerve as a positive SLRT (straight leg raising test), relying on image studies without precise examination of the physical findings, and no consideration of the entrapment neuropathy as a differential diagnosis. The causes of misdiagnoses as knee joint disorders were as follows: gonalgia as the patient complaint, diagnosis relying on image studies without precise examination of the physical findings, and no consideration of the entrapment neuropathy as a differential diagnosis. In the diagnosis of lumbar spinal and knee joint disorders, the entrapment neuropathy of the common peroneal nerve should be considered as a differential diagnosis.
Simultaneous fracture of the scaphoid and trapezium is very rare and this combination of fractures has been reported only occasionally. We reviewed a 19-year-old man with radial tuberosity fracture of the trapezium (type 2A according to the classification of Walker et. al.) and incomplete fracture through the waist of the scaphoid (type A2 according to Herbert). The mechanism of this combination fracture is controversial. Our patient's motorcycle collided into a car from the left side causing the handlebar to forcefully swing clockwise. The shearing force of the handlebar was exerted on the base of the first metacarpal through the first web space at the ulnar flexion position of the wrist, resulting in radial tuberosity fracture. This force was transmitted to the scaphoid and at the same time the scaphoid was hyperextended forcefully and injured. We performed open anatomical reduction of the articular surface of the trapezium and percutaneous fixation with a Herbert-Whipple screw for the scaphoid fracture. The patient achieved early functional recovery with this procedure.
The spontaneous rupture of the finger extensor tendon due to Madelung's deformity is rare. We report a rare case of attritional finger extensor tendon rupture due to Madelung's deformity. A 64-year-old woman visited our hospital and complained of the disability to extend her right ring and little fingers. X-ray showed classical Madelung's deformity in her bilateral wrists. Attritional rupture of extensor digitorum communis (EDC) tendons of the ring and litter fingers was suspected. At operation, the EDC tendons of the ring and little fingers and extensor digiti minimus (EDM) tendon were completely ruptured. The EDC tendon of the middle finger was partially ruptured. The ulnar head was dorsally dislocated. The Sauvé-Kapandji procedure was performed, and then the distal end of ring and little EDC tendons was sutured to the middle EDC tendon, which was augmented by palmaris longus tendon graft. The cause of extensor tendon rupture was considered to be attrition by the dislocated ulnar head.