Some cases with abnormal alignment of the cervical spine due to congenital abnormality or RA require reconstruction of the cervical spine by not only decompression but also posterior fusion using some instrumentation. The authors have been operating on such cases using Olerud Cervical. The purpose of this study is to estimate the advantages and the problems of this system. Investigation were carried out on the patients suffering from upper cervical spine (with middle and lower C-spine) diseases that are treated by this system. There were 12 cases altogether; 4 RA, 3 congenital abnormality, 3 trauma and 2 tumor. These cases were examined for reducted alignment, symptoms, and complications (infection etc.) in the post operative state. Most of the cases had good results, but severe infection ocurred in one case.
The purpose of this paper is to compare radiological changes after cervical laminoplasty and laminectomy. The subjects were 78 patients with myelopathy caused by the cervical spondylosis or the ossification of the posterior longitudinal ligament in the cervical spine. 61 cases were treated using Z-shaped laminoplasty (Hattori's Method) and 16 using laminectomy. The average age at the time of surgery was 57, and the average follow-up period was 11 years and 2 months. The functional results were evaluated according to the Japanese Orthopaedic Association's scoring system. At the time of follow-up, the average recovery rate was 63% in the laminoplasty group, and 32% in the laminectomy group. In the laminoplasty group, the abnormality of alignment was greatly reduced in frequency and degree compared with the laminectomy group. The recovery rate was poor in patients with postoperative changes in the type of cervical spine curvature developed. Laminoplasty is considered to be superior to laminectomy in maintaining cervical alignment and preventing postoperative spinal deformities.
We reviewed 177 patients with cervical compression myelopathy who underwent decompression of the cervical spinal cord from 1986 to 1999. 11 patients (6.2%) developed postoperative C5 nerve palsy. Intraoperative electrophysiological examination was performed on 4 patients with postoperative nerve palsy, and identified symptomatic cord levels were at the C4-5 or multiple level including C4-5. Significant motor loss of the deltoid and biceps muscle is therefore predicted to occur with C5 nerve root disorder in patients with myelopathy at the C4-5 disc level. In other words, myotome of the deltoid and biceps of patients with myelopathy at the C4-5 disc level are main at C5 due to irjury of the C6 spinal cord segment. Nerve palsy is thus significant when C5 nerve disorder occurs in such patients.
The effects of the occipito-axial angle on the development of subaxial lesion after occipitocervical fusion are discussed. Twenty-seven patients without rheumatoid arthritis who underwent occipitocervical fusion for irreducible atlantoaxial dislocation were reviewed with an average 4.1 year follow-up. No significant relationship was seen between the abnormal range of the occipito-axial angle, and development of subaxial subluxation was not apparent. The effects of mechanical stress after occipitocervical fusion on the subaxial region were not significant in patients without rheumatoid arthritis.
Level diagnosis of cervical ossification of the posterior longitudinal ligament (OPLL) is difficult because cervical OPLL usually lnvolves multilevel lesions. The purpose of this study is to determine the injury level of the cervical OPLL by electrophysiological methods. We recorded evoked spinal cord potentials (ESOPs) including spinal cord, transcutaneous and transcranial stimulation from 17 OPLL patients at pre-or intra-operation. The injury level was 94.1% for single -and double-level lesions and 87% for motion segments. These results suggest that most cervical OPLLS can be treated by level one or two levels anterior fusion.
Atlanto-axial subluxation is often associated with rheumatoid arthritis. Previously we reported a comparatively high frequency of abnormal mobility of the cervical vertebra in OPLL patients. In this study, 35 OPLL patients who received surgical treatment were examined radiographically. Atlanto-axial subluxation, occipito-atlanto abnormal mobility (0/C1 abnormal mobility), and atlanto-axial abnormal mobility (C1/C2 abnormal mobility) were examined before and after surgery, using the parameters of ADI, Bull's angle, and Fujiwara's C1/C2 angle. Only one patient presented atlanto-axial subluxation before surgery, and another patient exhibited post-operative atlanto-axial subluxation. Before surgery, 9 patients presented 0/C1 abnormal mobility, and 13 patients after surgery. 15 patients showed no change after surgery. The patients with 0/C1 abnormal mobility showed significant decrease in lower cervical mobility statistically. We believe these data are important in the assessment of the abnormal mobility of the upper cervical spine in OPLL. Some problems such as neck pain and tethering effect, are experienced after laminoplasty. We will examine the relation between these problems and upper cervical abnormal mobility.
In the past 3 years, we have encountered 8 subjects surgically treated for cervical myelopathy with calcification of the ligamentum flavum. We analyzed the patients' data with regard to clinical symptoms, X-ray findings, and surgical results. In X-ray findings, they were compared with 30 subjects aged 60 to 75 as the control group without neurological deficit. Common clinical symptoms were sensory and motor disturbance, and numbness in the upper extremity. Preoperative X-rays suggested that the range of motion of the cervical spine tended to increase at the level at which the ligamentum flavum calcified, compared with the same level of the control group. In 6 subjects, the Hirabayashis' recovery rate was more than 60%, but in 2 subjects whose preoperative JOA score was less than 10 points, the recovery rate was poor. In this study, calcification of the ligamentum flavum of cervical spine is considered to be caused by the dynamic factor of the cervical spine.
A patient, who developed methicillin resistant staphylococcus aureus (MRSA) infection after posterior instrumentation and anterior spinal fusion, was treated with curettage, closed irrigation, and intravenous Vancomycin (VCM) administration without removal of instrumentation. A 69-year-old male with DM developed suppurative spondylitis of Th 9 and 10, and developed incomplete paraparesis with vesico-rectal disturbance. Posterior instrumentation from Th 8 to Th 11 was performed using ISOLA system, which followed anterior decompression and spinal fusion with ribs. The patient developed MRSA infection with high fever and massive pus discharge from the back wound 2 weeks after surgery. Debridement, closed irrigation, and intravenous VCM administration were performed wiothout removal of the posterior instrumentation. The serum concentration of VCM was monitored keeping its peak level below 40μg/ml and its trough level below 10μg/ml. After 3 weeks of irrigation and 6 weeks of intravenous administration of VCM, the MRSA infection subsided. Neither renal damage, nor hearing impairment was seen at that time. Two years after surgery, recurrence of infection was not apparent, and solid spinal fusion was obtained. MRSA infection after spinal instrumentation was successfully treated by keeping the spinal instrument immobilized. The intravenous administration of VCM with monitoring of the serum concentration probably reduces its side effects.
Reports of the pyogenic spondylitis of the upper cervical spine are rare. Furthermore, treatment of pyogenic spondylitis of the thoracic and lumbar spine is generally conservertive, but treatment of the cervical spine requires frequent operation. We surgically the treated pyogenic spondylitis of the upper cervical spine with headache, neck pain, and neurological symptoms. Operation was found to improve the patient's symptoms.
We experienced one case of pulmonary embolism in a patient after spinal surgery over the past two years. The patient was a 51-years-old man who had experienced deep vein thrombosis in the past. He under went anterior spinal fusion for C6/7 disc hernia. 5 days after the operation, he suddenly experienced respiratory difficulty. Though his consciousness was clear, and his vital signs were stable, even after 3L pure oxygen supplied, his arterial saturation rate was low at 74%. We supplied 10L oxygen, used an Ambu bag, kept his venous line, and injected lactolingel, His chest pain was relieved and his arterial saturation rate improved to 95%. To investigate the cause, we examined his arterial blood gas, ECG, and chest X-p, and suspecting pulmonary embolism, we consulted cardiologists. In the UCG, the right ventricle hed apparently enlarged, and angiography showed that his right pulmonary artery the patient restricted by 80% due to thrombosis. We diagnosed as having pulmonary embolism, attempted cardiac cathetelization, and injected urokinase, the thrombosis was reduced by 1/3, and the patient survived.
In the past 3 years, we have encountered 31 aged patients who underwent salvage surgery for degenerative lumbar disease. 11 of these patients underwent posterolateral fusion (PLF) of the vertebrae during the initial surgery. We analyzed their date with regard to clinical symptoms, postoperative results, and the main pathological factors of salvage surgery. The main pathological factor was insufficient decompression at the affected level in 19 cases. On the other hand, in only 3 cases that underwent PLF during the initial surgery, it was canal stenosis of the upper level after fusion. Based on these investigations, it can be concluded that sufficient decompression and adequate posterolateral fusion should be achieved during the initial surgery.
We reviewed 14 patients over 80 years of age after surgical decompression for lumbar canal stenosis. The average age at the time of surgery was 83.6 years. The average duration of follow-up was a year and eleven months. Another group of 45 patients aged 70 was compared as the control group. The clinical result was evaluated on the basis of the JOA score. The mean JOA scores of the group of over 80 was 12.9 points before surgery and 18.7 points after surgery. The JOA score improvement rate was 36.8%. These dates were low compared to the other group. But 93% of over showed excellent or good results.
For the past 5 years, 16 patients over 80 years old with degenerative lumbar canal stenosis were surgically treated. The operative method was wide laminectomy. Of these, in 2 cases with unstable spine, postelolateral fusion were added. The mean age at surgery was 82.5 years. (the range being from 80 to 90), and the mean postoperative period was 34 months. The clinical results were evaluated retrospectively with the Japanese Orthopedic Association low back pain rating score (JOA score). The JOA score was 8.3 preoperatively and 20.2 postoperatively (rate of improvement: 57.1%) on average. Especially for gait capability and leg pain good recovery has been obtained. The average time of operation was 57 minutes and amount of bleeding was 157g. The operation results were satisfactory in 72% patients. If preoperative general complication is under control, wide laminectomy is an effective method for aged patient.
We report two cases of spinal epidural hematoma treated conservatively. In both cases, complete recovery was achieved and hematoma disappeared on MRI. In spinal epidural hematoma, neurological deterioration is followed by careful observation alone, and conservative treatment should be considered.
We report three cases of lumbar intraspinal synovial cyst-Casel, A 58-year-old male was admitted to our hospital because of severe right sciatica. MRI of spine revealed that a low intensity cystic mass in T1 weighted image was located dorsally at the level of the fourth-fifth lumbar vertebral bodies. The cyst was removed with L4/5 medial facetectomy. His sciatica was cured after surgery. Case 2, A 56-year-old male was admitted to our hospital with lumbar intraspinal cyst at the L4/5 on MRI. The cyst was removed microscopically. His sciatic pain disappeared after surgery. Case 3, A 81-year-old female had intermittent cludication with left sciatica. She was admitted to our hospital with intraspinal cyst at the L2/3 on MRI. The cyst was removed. Her pain of the sciatica disappeared. Pathological examination revealed synovial cysts at three cases.
Intraspinal canal cysts of the lumbar spine were named “discal cysts” by Toyama in recent years. We are reporting a case of multiple discal cysts of the lumbar spine. The patient was a 24-year-old man. His complaint started with low back pain and left thigh pain. On admission, neurological examination suggested the left L5 radiculopathy. The cysts were detected at bilateral L4/5 by Magnetic Resonance Imaging (MRI), Discogram and CT-discogram (CTD). In MRI, the cysts showed low intensity with T1-weighted imaging, high intensity with T2-weighted imaging, and ringed enhancement effect with Gadolinium. In the Discogram and CTD, the cysts were connected with the intervetebral disc. Upon operation, we found that the cyst was dark red, very fragile, and adhered to the L5 nerve root and intervertebral vein. The cyst contained blood of a pinkish color. There was no herniation. In the histological findings, there were mostly fibrous tissues and partially with hemosiderin in the cyst wall. It is considered that the base of the discal cyst was associated with mechanical pressure on a slightly degenerated intervertebral disc. The mechanical pressure causes the peridural membrane to tear off the intervertebral body, inducing rupture of the anterior internal plexus, which results in hematoma and cyst.
This paper reports an 8-year-old girl with a calcified intervertebral disc at C4-5. She presented with a 4-day history of neck pain and limited of neck motion. There was no history of inflammation or injury. Neurological examination was normal. Radiographs of the cervical spine showed calcification of the C4-5 intervertebral disc. She was treated with nonsteroid anti-inflammatory agents, and her physical activities were restricted. Her pain disappeared 2 weeks later, and she recovered normal neck motion. When examined 10 months later, she was asymptomatic and normal upon physical examination. Follow-up radiographs showed a reduction of the calcification.
Atlanto-axial rotatory fixation is often seen in childhood. We experienced two difficult cases of children's atlanto-axial rotatory fixation. The first case was a 9-year-old girl who developed torticollis after experiencing pain in the right side of her neck and a fever. 3 months later, she visited our hospital and was admitted. CT scan revealed atlanto-axial rotatory fixation. She was put on neck traction for 3 weeks (Grisson type), but reduction was not complete. The treatment was therefor change to skull traction. Her deformity was corrected. However torticollis recurred, and she was put on Halo-vest for 3 months. The second case was a 6-year-old girl who had been treated with Juvenile Rheumatoid Arthritis since she was 5. She generally developed neck pain. Subsequently trismus and torticollis appeared before 3 months before she visited our hospital. Atlanto-axial rotatory fixation was confirmed in CT scan and plain radiograph. Torticollis was corrected easily by skull traction, but deformity recurred soon after. Neck deformity improved by increasing aspirin dosage, however torticollis remained slightly.
We studied 18 cases of idiopathic scolisis who had been surgically treated with the TSRH hook and rod system. The curve magnitudes and spinal balances in the standing radiographs were evaluated before and after surgery. The results were generally good except for the decompensation problem in the King type II curves. The TSRH hook and rod system is a good modality for the surgical treatment of scoliosis.
The results of thirty-one consecutive primary total hip arthroplasties using the anatomic locking hip system were reviewed after a minimum of five years. Their pre-operative JOA score of 41 points improved to 88 points post-operatively. One performed revision surgery. The survival rate at five years from the operation was 0.97. Proximal femoral bone atrophy appeared in twenty-five hips (83%), but the revision case showed no bone atrophy. It is not clear whether the proximal femoral bone atrophy correlated with the stability of the femoral component. The cementing technique in the revised case was grade C. We considered this was the most important cause for loosening. The width of the clear zone of another two hips showed more than 2mm. These two cases finally showed stem loosening, but did not undergo surgery.
The follow-up study of bioceram type cemented total hip arthroplasty performed using size 28mm alumina head with HDP-socket between September 1982 and September 1992 was reviewed. Twenty-four hips of 20 patients consisting of 18 women and 2 men were available for study. Their ages ranged from 36 to 84 years, with a mean age of 54.7 years. The post-operative average time was 12.7 years. The diagnosis at the time of surgery was OA of the hip for 18 cases, one rheumatoid arthritis, and one revision of acetabular central migration by bipolar cup. Clinical results were evaluated by the JOA score and radiological evaluation by Charnley's method for the acetabular side and Nagaya's method for femoral component. The clinical JOA score of 40.5 points improved to 81 point post operatively. At the 8th year of follow-up, the clinical JOA score changed to 73 points. Radiologically, 18 hips, or 75% of the cases showed good results after the 8th year. The mean wear rate of the cups against the alumina head was 0.12mm per year and not as good as other prosthetics.
We conducted radiological examination on the femoral bone in 45 hips of 41 patients who received cemented hip prostheses. In 28 hips, the first generation technique was used. In 13 hips the Bateman stem (B-1 group) was used, in 15 hips, the Perfecta stem (P-1 group) was used. And in 17 hips second generation technique was used (Perfecta stem, P-2 group). The average follow-up period of group B-1 was 7.6 years, that of group P-1 was 4.4 years, and that of group P-2 was 2.6 years. The results were judged radiographically according to the cementing grade. Use of the centralizer was effective for adequate cement mantle because it decreases the rate of stem-mulposition. The results also suggest the importance of canal flare type and canal-stem filling.
Complete congenital dislocation of the hip is one of the most challenging reconstructions in hip arthroplasty. The distorted anatomy in this hip include a high hip center, a small femoral canal, leg length discrepancy, soft tissue contractures, and increased anteversion of the femoral neckshaft angle. Therefore, total hip arthroplasty in CDH has been associated with higher failure and complication rates. We report a case of total hip arthroplasty using subtrochanteric femoral shortening via transverse osteotomy unilateral high-riding congenital dislocation of the hip. This shortening technique was used with non-cemented components, reinforced with bicortical autograft struts and cables. Noncemented acetabular reconstruction was performed at the level of the true acetabulum without bone grafting. The time to union of the osteotomy site was 4 months. JOA scores improved from 52 points preoperatively to 76 points at the latest follow-up at 6 months after surgery.
Bone defect is a serious problem in revision arthroplasty. Allograft serves as a solution for restoring bone defects. This paper describes the incidence of allograft for acetabular revisions in our department and examines the clinical outcomes. Between 1992 and 1999, 72 acetabular revisions were performed. Forty-eight (67%) revisions were with bone grafts, and, in 36 grafts, allogenic bones were used. In cases with allografts that had at least one-year follow-up after operation (mean follow-up period: 3.8 years), there were no re-revisions or cases in which radiographical loosening was observed.
We perfomed cementless total hip arthroplasty (THA) with block bone grafting for acetabular dysplasia in 24 hips since 1988 and reviewed radiographic findings for them. The average period of follow-up was 8.1 years (range 5.2 to 11.4 years). The average age at operation was 58.5 years (range 38 to 69). The types of radiographic fixation were classified according to the criteria of Engh et al as follows: optimum fixation in 17 hips, suboptimum fixation in 5 hips, and unstable fixation in 2 hips. Although the area of the cup covered by graft bone was less than 30%, 2 hips were unstable. These results suggest that not only cup coverage ratio but other factors may affect fixation.
We performed conversion of ankylosed hips to total hip arthroplasty (THA) for 4 patients during the period between September, 1999 and February 2000. Their ages ranged from 50 to 65 years and the duration of fusion prior to THA ranged from 17 to 51 years. The patients consists of two men and two women. The causes of ankylosis were tuberculous arthritis (two patients) and osteoarthritis (two patients). In our cases, the indications for conversion to THA were disabling pain in the low back and knee, and disability of ADL. Relief of preoperative pain vas obtained in all patients, and their gait improved. All patients were satisfied with the results of conversion to THA.
We report a case of slipped capital femoral epiphysis, for which were uncertain whether removal of titanium canulated cancellous screws was appropriate. A twelve-year-old boy visited our clinic complaining of left coxalgia after a fall. Plain radiography showed left acute slipped capital femoral epiphysis. Internal fixation was performed with canulated cancellous screws made of titanium alloy (Ti-6Al-4V). 22 months after the operation, removal of the screws was attempted. However removal was stopped because of breakage of the screws and instruments for removal. After several days, removal of the screws was attempted again, the bone around the screws was reamed and the screws were removed. Screws made of titanium alloy have good biocompatibility to bone. Failure of the removal after internal fixation of slipped capital femoral epiphysis has been reported. Stainless steel screws have low biocompatibility to bone and should be used in cases like this.
Cobalt, chromium, nickel, and molybdenum concentrations in the serum of a patient were measured. The patient underwent bilateral hip replacement with Mckee-Farrar prosthesis 26 years ago. Roentogenographic examination in March 1986 showed loosening of his right acetabular component; however, he did not experience any pain in his right hip at that time and refused revision surgery. He was satisfied with his hips and worked as a public servant until he retired in 1993. He visited our clinic complaining of occasional posterior thigh pain on. September 8, 1999, up on which metal ion concentrations were measured. His liver functions showed slight abnormality, but he appeared to be in good health. X-ray films of the patient showed slightly widened bone absorption around the right acetabular component compared to 1986. Cobalt, nickel, and molybdenum concentrations were in the normal range. Chromium concentration had slightly increased, however, the risk of chromium contamination during venopuncture using a steel needle had to be taken into consideration. On December 20, 1999 he visited our clinic again complaining of right hip pain. The pain was diagnosed as entrapment neuropathy of the obturator nerve and was treated with a nerve block. He was satisfied with the results and refused revision surgery again. His liver function on that day was normal.
We carried out our accelerated rehabilitation program after Transpositional Acetabular Osteotomy (TAO) for 17 dysplastic hips in 17 patients from November 1998 to December 1999. The mean age at the time of surgery was 36 years and the mean length of follow-up was 10.3 months. Before the operation, the mean acetabular-head index was 56.7% and the mean center-edge angle was 6.6°. Postoperatively, they were 85.7% and 36.0°, respectively. The use of a wheel chair was started at 6.4 days, gait with double crutch at 15.1 days, and gait with single crutch at 22.1 days after surgery on average. The mean hospital stay after surgery was 34.4 days. One patient experienced nonunion complication of the greater trochanter with breakage of the wire. The outcome of the questionnaire showed that 75% of the patients were satisfied with our rehabilitation program. Transpositional Acetabular Osteotomy (TAO) was reported by Nishio in 1956. We made several improvements on this technique, which erabled accelerated rehabilitation.
We examined 142 cases of ACL injuries, and investigated the prevalence, location, classification, and sequelae of the bone bruises on MRI. Bone bruises were seen on 91.3% of acute ACL injury cases. Among all cases, bone bruises were mostly located on the lateral notch of the femur and the postero-lateral of the tibia. We believe that the bruises were related to the posture of the leg at the time of injury. A large number of reticular type bone bruises were detected in cases with acute injury and the geographic type in cases with subacute injury. Geographic type I tended to remain longer on the image, indicating different evaluation results from others. There for careful observation and follow up are therefore essential to geographic type I.
The tendon-like tissue regeneration at the portion of harvested semitendinosus tendon (ST) is observed in some knees underwent ACL reconstruction using hamstring tendons. The purpose of this study is to investigate the effect of regenerated tissue on the postoperative knee flexor strength. 20 consecutive patients whose injured ACL were reconstructed using hamstring tendons were divided into two subgroups, depending on the regeneration of the tendon relief and MRI findings at a follow-up time of more than 2 years. The regeneration group consisted of 14 patients with apparent tendon-like tissue in the ST harvested portion, while the non-regeneration group consisted of the remaining 6 patients without any such tissue. All patients were evaluated by the isokinetic maximum torque of the knee flexor strength using Cybex II and the flexion lag. The maximum torques of the regeneration and non-regeneration groups were 93.4±10.2% and 93.2±11.2%, respectively, showing no significant differences. Conversely, the flexion lag in the regeneration group was 3.2±2.0 degrees, while significantly lower than 8.0±2.2 degrees in the non-regeneration one. Our results suggest the possibility that the regenerated tendon-like tissue might act as well as normal ST.
We investigated the natural history of dislocation of the patella with conservative treatment. This study group was composed of nine women (twelve knees) and four men (four knees) with a median age of 11.8 years (range 4 to 16.3) at the time of primary dislocation of the patella. The treatment for the first episode of dislocation was plaster cast in nine cases and elastic bandage in two cases. Five cases were not treated. In twelve cases, there was at least one recurrent dislocation, and in seven of these twelve cases, dislocation recurred frequently. All cases of recurrent dislocation eventually underwent operation.
In this report, we describ our surgical technique of arthroscopy assisted medial retinaculum repair and lateral retinaculum release for patellar dislocation. Following the arthroscopic evaluation for osteochondral fracture, we identified the medial retunaculum defect. In all cases, the medial retinaculum was found to be torn off from the medial margin of the patella. After making a bone tunnel just lateral of the medial margin of the patella by a 2mm Kirshner's wire, a thread holder with absorbable thread was passed through the drill hole into the knee joint. A nylon loop was inserted below the retinaculum defect. After the thread was passed through the loop and taken out of the skin, a needle with another end of the thread was passed through subcutaneously from the same skin hole. After the lateral retinaculum was released, the thread was tied under the arthoscope. The same procedure was repeated several times. Five patients (range; 11 to 24 years) were treated with this surgical technique. There were no recurrences of patellar dislocation.
In this report, we describ our surgical technique of arthroscopic internal fixation for the avulsion fracture of the anterior cruciate ligament using cannulated screws. Four patients (range; 21 to 46 years) were treated with this surgical technique. One case was type I with raputure of the PCL and tear of the medial and lateral miniscus. Two cases were isolated type II, and one case was type III A with tearing of medial meniscus. Patients were encouraged to perform range of motion and muscle strength exercises and walk using DonJoy brace from the third day after surgery. The cannulated screws were removed after confirmation of bone union. All cases gained full range of motion, and they showed no sign of the knee instability. This method is technically easy and provides rigid fixation which allows early rehabilitation.
Twenty-five patients with Achilles tendon rupture were treated in our hospital from April 1997 to November 1999. A modified Savage core suture and modified cross-stitch peripheral suture were applied to all of them. They were evaluated clinically and the diameter of the Achilles tendon was measured by ultrasonograph. Partial weight bearing without a splint began at 8.5 days after the operation. Major complications such as suture failure or reccurent tendon rupture were not encountered. Muscle strength was maintained in all cases. The thickness of the Achilles tendon was not significant compared to previous reports including non-surgical treatment. Our treatment method allowed weight bearing without a splint early enough to maintain muscle strength.
Ankle sprains are very common injuries in sports. In this study, we investigated 1824 cases of ankle sprains. About half of the cases visited other clinics or hospitals before visiting ours. The reasons were persistent ankle symptoms, including pain, gait disturbance and continuous swelling etc.. Forty cases were uncommon injuries of the syndesmosis sprains. Twenty-six cases were recent and the remaining fourteen cases were old. All the old cases were diagnosed as the lateral ligment injury. The recent cases were divided into three groups. They were treated and evaluated by our criteria. Treatment included taping, casting and brace after casting. The results were excellent or good. Old cases could not be classified into the stage but treated identically to the recent cases. The results were good. We concluded that syndesmosis sprain require a longer recovery period than other types, but, exact treatment shows good results.
Our report concerns twelve cases with chronic injuries of the malleolus caused by traction injuries during sports. All the cases showed slight tenderness, swelling, and limping. Radiograph showed accessory ossification center and MRI demonstrated avulsion fracture of the apophlyseal cartilage and fragmentation of the accessory center. In this series we attempted the treatment suggested by Ogden. All the cases were treated with cast fixation, following one month rest from the sports. Two cases used braces after cast fixation. Excluding one case, all of the cases showed good results.
Although, ulnar wrist pain is experienced in many diseases, such as trauma, tenosynovitis, Guyon's canal syndrome, hypothner hammer syndrome, TFCC injury, DRUJ disorder, and ulnocarpal abutment syndrome, osteoarthritis of the pisotriquetral joint is rare. We report two cases of the osteoarthritis of the pisotriquetral joint. The main symptom of these cases was ulnar wrist pain. Ulno-carpal abutment syndrome was associated in one case, and Guyon's canal syndrome in the other. As conservative treatment was not effective, surgical treatment was performed. Excision of the pisiform provided complete relief from the ulnar wrist pain.
A 19-year-old woman with a deformednail on her little finger for 10 years after trauma is reported. As a severe deformity from infection around the nail occurred frequently, we performed a free vascularized nail graft in order to reconstruct her nail. The third toe was chosen as a donor site, and the nail matrix and plate were sacrificed with two veins attached to the flap. Free skin graft was performed for the donor site. After the nail matrix and plate of the recipient site was resected, the flap were fixed and the two veins of the flap was anastomosed to a digital artery and a vein respectively. No complication due to the arterio-venous shunt after surgery was evident. The nail plate never fell off and the clinical result was excellent. Though arterio-venous anastomosis is not physiological, the venous flap is now recognized as an effective treatment. The procedure described in this paper is considered to be beneficial for cases in which nail reconstruction is necessary.
The occuvance of Dupuytren's contracture is believed to be high in Northern Europe, but rare in Japan. We investigated the incidence and factor, related to Dupuytre's contracture at our hospital and a retirement home. A total number of 414 people (203 men and 211 women) were examined. Their ages ranged from 50 to 95, and averaged 69.8 years. The disease was detected in 50 cases (12%) overall; 39 men (19%) and 11 women (5%). 16 cases were bilaterally affected and 34 unilaterally. Cancerning the severity of the disease, 90% of the cases were in stage 0 of Meyerding's classification. The incidence of the disease in the cases with diabetes mellitus, chronic alcoholism, or liver cirrhosis was higher on the whole.
One hundred twenty-nine median nerves of 105 cases were reviewed for variations during operations to treat carpal tunnel syndrome. The variations in the course of the motor branches (Poisel. 1974) were the extraligamentous type in 122 hands (94.6%), the subligamentous type in 2 hands (1.6%), and the transligamentous type in 5 hands (3.9%). Accessory branches were found in 10 hands (7.8%), a high division of the median nerve in 4 hands (3.1%) and median artery in 4 hands (3.1%). In 123 (95.3%) of 129 hands, the recurrent baranch arose from the radial aspect of the median nerve, in 3 hands (2.2%) from the central-radial aspect, in 3 hands (2.2%) from the central aspect, and in no hands from the ulnar side. To avoid the injuryy of the motor branches during operation of the carpal tunnel syndrome, special attention must be paid to the variation of the recurrent branch.
Five cases of elbow joint contracture following fracture-dislocation were mobilized. Operations were performed 3 to 17 months after injury (mean: 12.4 months). The first three cases were operated through postero-lateral incision only. Medial incision was added to the last two cases. Forty-eight hours after operation, patients were encouraged to receive early ROM exercise with the CPM unit. The average ROM of the elbow joint before the operation was -43.4 degrees (extension) and 101 degrees (flexion). ROM became -25 degrees (extension) and 123 degrees (flexion) one month after operation and -14 degrees (extension) and 135.6 degrees (flexion) at the final examination. Expecially after operation through medial and postero-lateral incisions, full extension of elbow joints was gained eventually. We found that early ROM exercise with CPM unit and throught mobilization by medial and postern-lateral incisions were effective to improving limited ROM in stiff elbows follwing fracture-deslocation.
Osteochondritis dissecans of the Numeral capitellum is not uncommon in boys who have played baseball rigorously from a very young age. We report the surgical results of the lateral closing wedge osteotomy of the humerus first reported by Yoshizu. All 9 boys complained of elbow pain on throwing and batting, tenderness on lateral humeral condyle, and limited elbow motion. They needed to stop playing baseball or reduce their activity because of the pain. Separated (7) or freed (2) fragments from the capitellum were seen by radiogram in all boys. These boys were observed under conservative treatment for at least one month. The age at surgery ranged from 13 to 16 (mean; 14.8) years old. An osteotomy was performed to remove laterally based wedge bones which had a peak located at the junction between the capitellum and trochlea, and a peak angle was 10 degrees. In 7 of 9 boys, cancellous bones were grafted, and in 5 of the 9 boys, bone pegs were inserted to fix the fragments. The follow-up ranged from 9 to 105 months (mean 38 months). After the surgery, the pain was reduced or disappeared in all boys. The mean range of motion of the elbow joint did not change significantly after the surgery. Six to 8 months after the surgery, eight of the boys could play baseball as well as they could before developing the problem.
We report three cases of the reconstruction for skin defects of the ankle. (Case 1) A 54-year-old woman. Skin defects of the posterior ankle were found. We performed reconstruction using the lateral calcaneal island flap. (Case 2) A 45-year-old women. Skin defects of the medial ankle were found. We performed reconstruction using the medial plantar fasiocutaneous island flap. (Case 3) A 63-year-old man. Skin defects of the anteriole ankle were found. We performed reconstruction using the latissimus dorsi myocutaneous flap.
We reviewed the outcome of a new radical operation of seventeen congenitally dislocated hips in fifteen children, and six residual subluxation of the hips in six children. The follow-up duration ranged from one year and one month to ten years and seven months. The mean age at the time of operation was eleven months (range; nine months to twenty five months). The acetabular angle, the center-edge angle of Wiberg and the distance “a” “b” of Yamamuro were measured on the roentogenograms before the open reduction and at the time of final follow-up. The mean ace tabular angle before operation was 38° and 31° at the time of follow-up. The mean center-edge angle was improved from -42° to 14°, the mean distance “a” from 2mm to 9mm, and the mean distance “b” from 17mm to 9mm. No avascular necrosis of the femoral head occurred after this operation. Two secondary operations were performed for the residual acetabular dysplasia of the hips. This operation involves two important procedures unlike other approaches. One is circumferential capsulotomy and dividing the piriformis to pull down the femoral head in front of the acetabulum. Another procedure is the resection of the whole transverse ligament to open the acetabular entrance to sink the head into the acetabulum deeply. This procedure reffered to as the wide exposure method, is useful for troublesome dislocated hips.
We reviewed the results of 35 hip arthrographies for patients with cerebralpalsy. The mean age at hip arthrography was five years and three months. The average duration of follow-up was 27.6 months. In all cases, iliopsoas intramuscular tenotomy, adductor muscles release, and humstrigs elongation were performed. In hip arthrography, inverted limbus was recognized in one case, whose postoperative results were poor. The pattern of limbus and ligamentum teres, and the width of medial pooling did not show the differences in the postoperative acetabular head index (AHI) and center edge angle (CE angle). The postoperative results were good when the depth of acetabulum was more than 35%.
Five patients with osteogenesis imperfecta underwent multiple osteotomies and intramedullary rodding with 18 Bailey rods for lower extremity deformities. The average age at insertion of the first rod was 6.2 years and average follow-up was 6.1 years. Only one fracture had occured in a bone after correct placement of a rod, causing the rod components to disarticulate. There were a total of 18 complications following insertion of the Bailey rods, for an overall complication rate of 61%. Tibial rods were more prone to complications than femoral. 14 of the 18 complications required reoperations, during which five tibial rods required one or two rod reinsertions. Although the Bailey rods appear to be effective for preventing fractures and deformities of lower limbe in skeletally immature osteogenesis imperfecta patients, a new intramedullary rod system is necessary to overcome many of the problems assosciated with Bailey rods.
We performed correction of varus and extention deformities of the femur due to Ollier disease using the Ilizarov method. The patient was a 9-year-old-boy, who underwent angular deformity correction and lengthening of the femur using the Orthofix unilateral fixator when he was 7 years old. We measured the %mechanical axis (%MA), deformity angle of AP, and lateral view on X-ray. Before the correction, the %MA was-13.6% and the angles of the deformities were 24 degrees varus and 25 degrees extension. We performed an open osteotomy and angular correction gradually using the Ilizarov apparatus for 118 days. The result wave satisfactory: the %MA improved to 74.6% and the angle of correction on the lowor limb exceeded by 3 degrees. As the Ilizarov system is bulky, intensive physical therapy proved more difficult than the unilateral system. It was however effective for correcting the three dimensional angular deformity close to the joint in older children.
Giant cell tumors (GCT) are primary benign tumors, which arise from long bone epiphysis commonly. We report a rare case of GCT that occurred in the calcaneus. A 22-year-old woman was suffered from developing pain and swelling in the right lateral heel. On physical examination, hard mass with tenderness was palpated in the lateral calcaneus lesion. Results from laboratory tests were within normal limits. Plain radiography revealed osteolytic lesion in the calcaneus, and lateral cortex was disrupted. CT showed a mass lesion in the calcaneus, and periosteal reaction was not found. On MR imaging, bone tumor of the calcaneus was identified. The lesion was low-and iso-intense on T1-weighted sequence and inhomogeneous on T2-weighted imaged images. After administration of Gd-DTPA, inhomogeneous enhancement was seen in the tumor. The pathologic diagnosis was GCT of bone. The tumor was reseated, and cryosurgery utilizing nitrogen liquid was added, in order to remove tumor cells completely. Allo-bone graft was performed, and bone defect of the calcaneus was occupied with grafted bone. There was no evidence of recurrence 4 months following surgery.