[Objective] It snowed in January 2001 for the first time in 34 years in Sasebo City, Nagasaki Prefecture. We collected snow-related injury cases in the district, which had little experience with snowfall, to help residents avoid injuries. [Methods] A questionnaire survey was performed in hospitals and offices of physicians belonging to the Sasebo Association of Orthopedists, and statistics of injury, age, sex, injury mechanism, and therapy were obtained from patients with snow-related injuries who visited the hospitals and physicians between January 15 and 17 in 2001. [Results] The survey was performed on 115 patients of 30 facilities, and results were as follows: Fracture of the distal radius, 31; compression fracture of the thoracic and lumber vertebras, 4; fracture of the proximal humerus, 2; other fracture, 1; sprain, 28; bruise, 29; and gall, 3. [Discussion] Fracture of the distal radius accounted for 27% of overall cases (56% of all fracture cases). The incidence of fracture of the distal radius without complication in healthy people was high among snow-related injuries in this district, and there was no case of fracture of the femoral neck. Warning middle-aged people to walk carefully when snowing is necessary.
We have reviewed the clinical results of an ultrasound device for refractory fracture in Kagoshima prefecture. Twenty nine patients with nonunion, eleven with delayed union, and two with hip arthrodesis were treated with ultrasound device. Bone union was achieved in 69% of the patients with nonunion and 91% of the patients with delayed union. The untrasound device is useful for the treatment of intractable fracture, however, the success rate of bone union was not as high as previously reported.
Between December 1999 and June 2001, two young adults with Ewing's sarcoma of bone and one adult with primitive neuroectodermal tumor of subcutaneous tissue were treated at our hospital. The patients were treated with multimodal approach including intensified chemotherapy, radiotherapy, and aggressive surgical treatment. Residual viable cells observed in the postoperative microscopic sections suggest that macroscopically complete tumor resection is essential for this tumor even if other non-invasive therapies are quite effective.
In this study, we report a rare case of chondrosarcoma with multiple bone metastases withouot pulmonary involvement. A 47-year-old man underwent wide excision for chondrosarcoma of the right seventh rib. After a 51 month excellent control period of the primary tumor, a second tumor of the left scapula was identified. Subsequently additional metastases were noted in the right femur and right ilium. All bony involvement, scapula, femur and ilium were resected with a wide margin and bone defect of the right femur was reconstructed with autoclaved bone graft. Microscopical examination showed that all specimens of the right seventh rib, left scapula, right femur and right ilium are of the same histologic type without change in the histologic grade. The patient is still alive, and to date has had no evidence of lung metastasis.
Giant cell tumors (GCTs) of the sacrum are a difficult clinical problem. Three patients with huge sacral GCTs were therefore treated with extra beam radiation therapy. Case 1 was a 32-year-old man with a tumor below S2. Case 2 was a 30-year-old woman with a tumor below S1 on the right side, and Case 3 was a 19-year-old man with a tumor below S1. Using a linear accelerator, they were treated with megavoltage X-ray at doses of 40Gy in 20 fractions according to embolization, 50Gy in 25 fractions, and 65Gy in 32 fractions, respectively. They are alive and free of tumors at an average follow-up of 80 months (range: 13-192 months). No radiation-induced sarcomatous transformations of controlled tumors, especially in Case 1 with a follow-up of 192 months, were noted. Wide excision (total sacrectomy) is associated with high morbidity and pelvic/spinal instability. Curettage with or without supplemental radiotherapy is associated with a high recurrence rate. These data suggest that giant cell tumor of the bone can be will controlled by radiation therapy. Complications are minimal, and normal function can be preserved in the treated areas. Megavoltage irradiation should be considered in treating local diseass not easily controlled by surgery in the axial skeleton.
In this study, we report the diagnostic utility of diffusion-weighted MR images in hemangioma. Diffusion-weighted echo-planar imaging was performed on five patients with hemangioma. The apparent diffusion coefficient (ADC) was determined from images. The average ADC of five hemangiomas was 1.740±0.048. Two cases suspected of hemangiomas by conventional MRI showed far different values of ADC (one was 2.56 in angiolipoma, another was 1.20 in desmoid tumor) on diffusion weighted images. We could therefore differentiate these two cases as hemangiomas. Diffusion-weighted imaging is a useful tool in the differential diagnosis of soft tissue tumors such as hemangiomas.
Intraneural hemangioma is an extremely rare condition. To our knowledge, only one case of hemangioma within the common peroneal nerve has been reported. We present an additional case. A 48-year-old male was seen on May 20, 1999 complaining of severe left knee pain and paresthesia on the lateral aspect of the left lower leg and dorsum of the foot. Physical examination revealed swelling and marked tenderness of the left common peroneal nerve in the lateral proximal region of the popliteal fossa. A Tinel's sign along the nerve in the popliteal fossa was present. Hypesthesia over the peroneal nerve distribution and a weakness of the toe extensor was present. He was diagnosed as compression syndrome of the common peroneal nerve. After failed conservative treatment with vitaminn B1, 12 and antiinflammatory drugs, surgical decompression was carried out. At surgery, in the proximal region of the popliteal fossa, a dark red mass of about 2cm surrounding the common peroneal nerve was noted, and distal to this tumor another three smaller bluish masses on the nerve were also noted. Decompression of the nerve by opening the epineurium and incision of aponeurotic part of the biceps muscle were carried out, because dissection of the tumor without injury to the nerve was considered imposssible. Postoperative course was uneventful. However after five months, disabling pain recurred and second operation was carried out. Intrafascicular dissection of the tomor was intended but bleeding from the cavities of the tumor prevented further dissection, and ligation of the nutrient vessels of the nerve near the tumor was carried out. After deflation of the pneumatic tourniquet, the size of the tumor was reduced and blood supply of the nerve was seen to be normal. Five months after the second operation, the patient had no pain and no sensory disturbance.
We report a case of chondroma on the popliteal region. A 37 year-old man presented a soft mass on the popliteal fossa. The mass was located on the left popliteal fossa measuring 6×4×3cm. MRI revealed low intensity on T1 weighted images and high intensity lesion on T2* weighted inages. The tumor was located between the semimembranosus and medial head of gastrocnemius muscles. All specimens showed typical characteristics of chondrocytes and hyaline cartilage. Histopathological diagnosis was Chondroma. After resection of the tumor, whitish tumors the size of a grain of rice were found in the left knee joint. The origin of the tumor was thought to be synovial chondromatosis or paraarticular chondroma.
A case of malignant schwannoma arising in the cauda equina is presented. The patient was a 4-year-old boy who began to experience pain in the left popliteal fossa without a clear cause. Spinal neoplasm was suspected after MRI and urinary dysfunction deteriorated. We performed immediate tumor resection. The space occupying lesion in the lumbar canal was diagnosed as malignant schwannoma of cauda equina histologically. Though he underwent chemotherapy after surgery, the tumor recurred seven months later. Adjuvant radiation therapy was performed, and although the size of the lesion reduced in MRI, additional metastatic lesion was found in the thoracic spine and brain. Although malignant schwannoma of cauda equina is very rare in childhood, spine surgeons should pay attention to this pathology because of the difficulty involved in treating it.
We experienced a patient with synovial osteochondromatosis in the hip joint. The case was a 29-year-old woman who has been suffering from coxalgia and limited hip motion, especially flexion and internal rotation since she was 26. Roentgenograms showed a calcified mass in the right hip joint. Arthrography showed a large mass in the right hip joint cavity. CT-scan showed the mass size to be 4×3×2cm. Gdenhanced MRI with fat suppression showed enhanced hypertrophic synovium and no enhanced nodular lesion. We suspected synovial osteochondromatosis, osteochondritis dissecans, or chondrosarcoma. We performed synovectomy, and found only one large mass in the hip joint. There was no nodular lesion within the synovium. Microscopic examination revealed a cartilaginous mass with calcification in the central portions and surface layering of synovium. The case was therefore diagnosed as synovial osteochondromatosis of the hip joint.
In order to examine the effectiveness of running loading therapy for bone mineral density (BMD), we comparatively evaluated measuring methods by computed X-ray absorptiometry (CXD) and assayed urinary deoxypyridinoline (Dpd) for ovariectomized (OVX) rats. Continuous running loading therapy for OVX rats was found to suppress a decrease in mean BMD, and significanfly increase bone metabolic marker compared to normal rats. These results suggest that the assessments of urinary Dpd as well as CXD for osteoporosis diagnosis are reliable and suitable methods.
We have been using double spike plate (DSP) fixation for bi-socket ACL reconstruction since February 2000. In the first 15 cases, a total of 100N were applied for graft tension at the time of fixation when the knee was bent at 80 degrees. We evaluated whether this setting was “over-tightening” taking the patients' symptoms into consideration. Five patients complained of stiffening in their knee, despite finally regaining full ROM. Side-to-side anterior laxity differences were evaluated as not tight (Max: -0.5mm). However, the duration until regaining full ROM was significantly longer than other patients (p=0.0011). For bi-socket ACL reconstruction using DSP fixation, our fixation setting was critical in considering the patients' symptoms although it led to acceptable anterior stability.
We performed multivariate analyses on individual factors such as gender, age, preoperative anterior knee laxity, presence of resection of the posterior part of meniscus, and presence of genu recurvatum that may affect anterior knee laxity after anterior cruciate ligament (ACL) reconstruction using the hamstring tendons. Thirty-four males and forty females were included in this study except for patients with multiple ligament injuries of the knee, bilateral or revision ACL reconstruction. All patients underwent identical surgery and were treated with the same postoperative management. Their anterior knee laxity was measured using a KT-1000 arthrometer under manual maximum force before and one year after the reconstruction. The results showed that the regression coefficient was 0.432 and there was significant correlation between postoperative anterior laxity and gender, preoperative anterior laxity, resection of the posterior part of meniscus, and genu recurvatum. From these results, we concluded that it is important to plan graft selection, surgical technique, and postoperative management for each patient to achieve better postoperative anterior knee laxity.
We investigated the effects of both the preoperative quadriceps muscle strength and activity level on the recovery of quadriceps strength after anterior cruciate ligament (ACL) reconstruction using hamstring tendons. Thirty-two males and thirty-four females were included in this study except for patients with multiple ligament injuries of the knee, bilateral or revision ACL reconstruction. All patients were measured for the isokinetic peak torque of their uninvolved and involved quadriceps muscle strength using the cybex machine before and one year after the reconstruction. The results showed that the higher the involved/uninvolved ratio of the quadriceps peak torque and the higher the activity level before operation, the better the recovery of strength in the involved quadriceps muscle at one year after operation. These results indicate that it is important for patients with lower activity level, particularly below recreational level, to strengthen their quadriceps under the guidance of aggressive muscle training preoperatively, and increase rehabilitation motivation postoperatively.
We have performed 181 anterior cruciate ligament (ACL) reconstructions using hamstrings from 1997 to 2001 in our hospital. The purpose of this study was to clarify the cause of graft failure of reconstructed ACL. There were 4 patients (2.2%) with recurrent instability due to graft failure. All patients were male, and their mean age was 18.8 years at primary ACL reconstruction. We used four-strand graft of semitendinosus tendon in these patients, and isometry was less than 4mm at surgery. We measured the position of the tibial tunnel on postoperative lateral X-ray. Inadequate anterior positions were observed in 2 patients. Before re-rupture, the KT-2000 arthrometer showed the average side-to-side difference to be 2.7mm. High intensity signal on magnetic resonance imaging (MRI) was observed within the reconstructed ACL graft in 3 patients. Three patients had minor injury less than 1 year after surgery. The main causes of graft failure were considered to be graft impingement and failure of graft incorporation. Graft impingement can be avoided by properly positioning the bone tunnel and performing adequate notchplasty. The cause of failure of graft incorporation was not clarified clinically. It is necessary to carefully examine patients who suffer minor injury less than 1 year or show high intensity on MRI after reconstruction.
We investigated the morphology of the C2 isthmus for the placement of transarticular screws using human cadaveric vertebrae and 3D-CT, for safe screwing of C1-2 fixation in an identical manner to the Magerl technique. We measured the width of the C2 isthmus, optimum screw insertion angle, and optimum length of the screw. There were significant differences in the measured values among the cadaveric vertebrae and each side (right and left). The measured values of human cadaveric vertebrae correlated precisely with those of 3D-CT. The safe screw passage area between spinal canal and vertebral artery is severely limitted. The Magerl technique is commonly performed under anteroposterior and lateral view images. Some have pointed out that this technique is difficult because it requires a high degree of skill. These results demonstrate that preoperatively reconstructed 3D-CT is relatively valuable for safe screw fixation by the Magerl technique.
In recent years, atlanto-axial transarticular screw fixation performed as described by Magerl for atlanto-axial subluxation has been popular because of its excellent biomechanical stability. However, there is a risk of vertebral artery injury with placement of transarticular screws. Twelve patients (age range: 18 to 72 years, mean: 60 years) underwent surgery as described by Magerl & Brooks for reducible atlanto-axial subluxation. Four were men and eight were women. Computed tomography (CT) was performed after surgery. We evaluated the position of the transarticular screw by means of sagittal reconstruction CT images. There was no screw that deviated from the C2 isthmus and had been placed incorrectly in the spinal canal. One screw (4.2%) passed through the C2 isthmus and bordered on the foramen of the transverse process. The screw angle measured between a line through the axis of the screw and the mid-sagittal line was -3-13 degrees. The screw length projected out of the C1 lateral mass was -3.6-10.8mm. There was no complication such as vertebral artery injury during screw insertion. Because of translational or rotational atlanto-axial subluxation, presurgical computed tomographic scans with sagittal reconstruction may provide information necessary to perform transarticular screw fixation safely.
We evaluated the use of two kinds of Tekmiron in the treatment of 8 rheumatoid patients with atlanto-axial subluxation, thread (7 cases) and tape (1 case). Bony union between atlas and axis could not be achieved in the first case, in which only the McGraw method was used. However, seven cases achieved posterior union. We performed the Magerl method and McGraw or Brooks method on 6 cases, and Brooks method on one. Our evaluations about Tekmiron were as follows: 1) It is more flexible than wire. 2) We can perform sublamina wiring using it more safely than wire. 3) There is less risk of compression to the dura and the spinal cord at the sublamina after operation when using it instead of wire. 4) It has no artifact on MRI or CT, while wire does. 5) Tekmiron threads pose the same risk as wires, cutting off osteoporotic bone or graft bone during tieing. 6) Tekmiron tapes are superior to threads in fixation to the graft bone, because tapes are much wider than threads. In other words, tape has less risk of causing fracture in tieing. 7) As this material is slippery, it is difficult to tie it strongly. It therefore becomes loose, requiring surgeons to tie it skillfully or specially, using biobond or special tie technique for example. 8) Recent development of the tighting-gun makes tieing easy and steady. These results show that Tekmiron tape with tighting-gun is more useful than wire.
To determine which laminoplasy should be selected for the treatment of cervical myelopathy due to narrowed canal and multisegmental spondylosis, surgical results, surgical morbidity, postoperative complications, and postoperative cervical alignment of open-door laminoplasty and those of French-window laminoplasty were compared. This retrospective study consisted of 50 patients with cervical multisegmental spondylotic myelopathy who were treated surgically and followed up more than 2 years after surgery. Twenty-five patients underwent open-door laminoplasty, and remaining 25 underwent French-window laminoplasty. The mean preoperative JOA score was 9.8 points in the open-door group and 8.4 points in the French-window group. The mean postoperative JOA score was 13.3 points in the open-door group and 12.4 points in the French-window group. There was no significant difference in the mean preoperative and postoperative JOA score between the two groups. Postoperative transient paralysis of the nerve root occurred in one patient in the open-door group and 3 in the French-window group. The postoperative range of flexion-extension motion significantly decreased in the French-window group than the open-door group. No development of the malalignment of the cervical spine or segmental spinal instability was observed in either group after surgery.
A 53-year-old male was admitted on suspicion of spondylitis and underwent antibiotic therapy. On the day following admission, low back pain decreased, but he experienced neck and shoulder pain and numbness in the left upper extremity. On the third day, when cervical spine was extended slightly on evacuation, he experienced sudden back pain. Neurological examination at that time revealed complete paraplegia. Anesthesia and motor paralysis below C7 was noticed. The symptoms were in the category of Frankel A. We found the spinal canal to be relatively narrow and disc herniation at the C6/7 level. He underwent steroid therapy in large quantities and lamimoplasty from C3 to C7. Intraoperatively, it was found that the cervical vertebrae were slightly unstable at the C6/7 level. Postoperatively, symptoms of paralysis improved to the Frankel D.
We experienced 6 patients with paralysis due to cervical mechanical compression last year at our hospital. One patient had multiple sclerosis. He displayed sudden symptoms which improved and deteriorated. He also showed high T2 lesion in MRI. Another patient sustained spinal infarction. She also suddenly caused symptoms and showed high T1 and T2 lesion in spinal MRI. One patient had alcholic neuropathy. We believe that these diseases can be differentiated by physical examination, MRI, and various other examinations.
Spinal cord herniation is a rare cause of neurological symptoms. We report a case of a 72-year-old woman presented with myelopathy of the lower right extremity and sensory disturbance of the lower left extremety. Three years earlies the subject experienced weakness in the right leg and numbness in the left leg. The patient did not have a history of injury or spine surgery. The symptoms worsened until examination by the authors three years, later by MRI, myelography, and CT scan. MRI scan well revealed spinal cord anterior deviation at the Th5 level. In operation, dura membrane defect, duplicated dura, and spinal cord herniation were observed. Laminectomy and dural fixation with artificial dura were performed. After operation, the patient's complaints gradually decreased.
Dynamic MR myelography for lumbar canal stenosis is said to be very difficult, because patient space in MRI is so small that the flexion or extension position cannot be obtained. We constructed special devices for these positions. This paper introduces these devices and discusses some cases.
We previously measured and evaluated sagittal spinal alignment (SSA) and concluded that maintenance of lumbar lordosis is important for the elderly. Here we further investigated the relationship between SSA and the activities of daily life (ADL) of elderly individuals. We evaluated the range of motion (ROM) of hips and knees, osteoporotic changes of vertebral bodies and gait. The group with lumbar kyphosis had better ROM of hip flexion than that with lordosis. However, there was no difference in hip extension between the two groups. Gait was better in the lumbar lordosis group. We concluded that the crouched position of patients in the kyphosis group was not due to hip contracture but to compensation for imbalance. Despite this compensation, the ability to walk was not completely corrected. These observations imply that maintenance of lumbar lordosis of the elderly is crucial to the maintenance of their ADL.
We evaluated subchondral low signal intense abnormality on T1-weighted MRI in the osteoarthritis (OA) and osteonecrosis (ON) of the knee after tibial Condyle valgus osteotomy (TCVO). Subjects consisted of 11 OA patients, aged 71 on average (range: 66-79) and 3 ON patients, aged 59 on average (range: 46-72). The MRI follow-up period was 18 months (range: 12-25) in the OA group and 17 months (range: 12-24) in the ON group. Clinical improvement was observed in all patients. Except for one patient in the OA group, T1-weighted MRI showed low signal intense area in the medial compartment of the knee. At follow-up, the MRI evaluation revealed a decrease in the low signal intense areas in 9 of the 10 OA patients and in 2 of the 3 ON patients. These results suggest that bone remodelling of the subchondral lesion can be expected after decompression and stabilizing surgery, TCVO.
41 discoid lateral menisci (DLM) in 34 adults over 20 years of age were operated arthroscopically from 1994 to 2000. They complained of knee pain, lack of extension, hydrarthrosis, etc. 29 knees (71%) were not associated with specific injuries, and in 30 knees (73%) more than 4 weeks had passed since the symptoms occurred. Excluding 9 worn menisci in 6 patients, DLM were classified as incomplete (69%) or complete (31%). Evaluation of articular cartilage was rated on the basis of the Fujisawa classification system, and there were more degenative changes on the lateral compartment than the medial. 19 knees (46%) underwent total menisectomy, 10 knees (24%) subtotal menisectomy, and 12 knees (29%) partial menisectomy. From preoperative radiographs of 34 DLM in 28 patients, 18 DLM (52%) were diagnosed as osteoarthritis. 26 DLM in 14 patients were surveyed by interview or telephone. The average duration of follow-up was 40.3 months (8-82 months). Evaluation of clinical results was rated on the basis of the modified Amako classification system postoperatively, and 22 knees (72%) had either A (excellent) or B (good) ratings. Though we investigated the factors for unsatisfactory clinical results, degeneration of cartilage on the lateral seemed to reflect clinical results.
We experienced 2 patients with osteochondral defects of the medial femoral condyle who underwent autogenous osteochondral graft. In the first case, surgery was performed for osteonecrosis with two large osteochondral pegs transfer. The second case was treated using the mosaicplasty technique for osteochondritis dissecans. Grafts were taken from the non-weightbearing edges of the femoral condyles at the level of the patellofemoral joint. The secondary examination after surgery revealed that the lesions treated by autogenous grafts were covered with cartilage-like tissue. The duration of follow-up was 4 years in the first case and 1.5 in the second respectively. No clinical symptoms were seen. These results suggest that autogenous osteochondral bone graft seems to be a useful method in the treatment of osteochondral bone defect of the knee, although additional follow-up is required.
We reviewed the results of limb salvage treatment in four children (five extremities) who had congenital fibular hemimelia and were managed between 1981 and 2001. The age at the time of the first visit ranged from eight days after birth to nine years and eight months, and the follow-up period ranged from two years and ten months to nineteen years. Three extremities showed complete absence of fibula, and two showed proximal absence with distal anlage. Posterior release of the ankle was performed on four extremities to correct the pes equinus deformity. Tibial lengthening was performed on three extremities, and was repeated on two extremities. However, common complications were seen such as medial bending deformities of the tibia and lengthening difficulties because of excessive tightness of soft tissues. Three children showed good ambulation with or without AFO and one showed poor walking at final follow-up. We think this form of treatment is an attractive alternative to early amputation.
Sports athletes often suffer lumbar disc herniation and occasionally are obliged to give up sports because of this disorder. In this paper, we presented the postoperative athletic ability of athletes with lumbar disc herniation. Twenty-two patients (15 male, 7 female) whose sports activity level was competent in national meets were studied. They consisted of 3 judo, 3 volleyball, 3 soccer, 2 rugby, 2 baseball players, etc. Nineteen patients were treated by percutaneous discectomy and the remaining 3 underwent laminotomy and discectomy (Love's method). Eight patients resumed their original sports activity and 8 showed a lower level of recovery. The authors conclude that percutaneous discectomy can be recommended as an excellent surgery for athletes suffering from lumbar disc herniation.
This paper reports a 27 and 20-year-old male with stress fracture of the femoral neck. They presented a several-day history of coxalgia and claudication, and they had histories of sports-injury caused by running. Alignment of the lower extremity was normal. Radiographs showed a consolidation area in the inferior side of the femoral neck (compression type fracture). MRI showed “linear pattern” in both T1 and T2 images. They were treated with nonsteroid anti-inflammatory agents, and physical activities were prohibited. Coxalgia disappeared 3 months later, and they recovered normal hip motion and gait. In summary, our cases showed that detailed history-taking and MRI are useful in diagnosis, and that the type of fracture is an important factor in deciding treatment.
We investigated cortical motor neuron excitability in patients with total brachial plexus injuries. The cortical motor neuron excitabilities were evaluated by the amplitude of spinal evoked potentials (SCEPs) following unilateral transcranial magnetic stimulation (TMS). Several components of SCEPs were recorded following TMS. The amplitude of these components were similar by right and left cortex stimulation in control subjects. In patients with brachial plexus injury, the amplitude of SCEPs following TMS was similarly recorded by right or left cortex stimulation. These results suggested that cortical motor neuron excitability is preserved in the early stages of peripheral nerve injury.
We have been attempting superearly ambulation after cervical laminoplasty and thoracolumbar laminectomy since July 1998. The aim of this report is to evaluate this postoperative treatment. The average recovery rate of JOA score did not differ from the conventional rehabilitation group. The course of postoperative rehabilitation was shorter than conventional rehabilitation. The cervical laminoplasty group did not complain of postoperative neck pain and showed no complications. Postoperative activity restrictions after cervical laminoplasty and thoracolumbar laminectomy may not be necessary.
This report describes purulent arthritis of the shoulder with an uncharacteristic onset and discussion about the etiology of purulent arthritis. A 48 year old female suffered from chronic left shoulder pain and therefore underwent an old wives remedy (bee therapy) at the end of 2000. After the therapy, she noticed mild shoulder warmth and pain. 4 weeks after the therapy the warmth and pain increased rapidly, prompting her to consult our clinic. On physical examination, local heat and swelling were recognized on her left shoulder, and she could not move her shoulder because of her severe pain. Physical and labolatory findings were consistent with purulent arthritis. We executed irrigation and de'bridement of her left shoulder after the diagnosis of purulent arthritis of the shoulder.
We report a case of pyogenic osteomyelitis that was difficult to distinguish from metastatic tumor in the thoracic vertebral bone. A sixty-seven-year-old man was referred to us with the chief complaint of back pain. Magnetic resonance imaging demonstrated abnormal signal intensity of the Th11 vertebral body and lamina without disc space narrowing. From radiographic findings and the clinical absence of fever, we suspected metastatic tumor, and performed operation. Histopathological examination of the focus demonstrated granulation tissue with lymphocyte and neutrophilic lymphocyte. The patient was successfully treated with intravenous antibiotics.
In a previous case, fixing the distal locking screw of the femoral interlocking nail from the side caused the drill bit to break off and become lodged in the marrow cavity. From this experience, we have been using K-wire to make screw holes to prevent breakage of drill bits since 1998. When screws were inserted with this method in 23 cases, no breaking of drill bits or K-wires was observed, and the two screws could easily be inserted in all cases. Compared to the conventional method, this method requires relatively complicated procedures. However, there was no significant difference in the operation and fluoroscopy. Considering the need to extract the broken drill bit after using the conventional method, this method was concluded to be extremely useful.
We report a case of a 16-year-old man with late kyphosis after hyperflexion sprain. He first visited our hospital 3 weeks after suffering hyperflexion sprain while exercising on a mat. The chief clinical symptom was posterior neck pain, and no neurologic impairment was seen. At first, he was immobilized with a cervical collar, but radiographs showed late instability that progressed gradually. We therefore performed posterior wiring and fusion from C2 to C3. From the sixth week after operation, radiograph showed progressive kyphotic angulation from C3 to C5, so we performed traction by Halo vest after anterior release from C3 to C5, and anterior fusion from C3 to C5 in a two-stage procedure. Radiographic evidence showed bony fusion, and no deterioration of instability was seen after operation.
No detaild study has been performed to assess the difference in cement volume between the lateral and medial condyles. In this study, the area of the cement layer was measured by means of NIH image and the difference in the cement volume between the condyles was quantitatively investigated. Bone quality change one year after TKA was also inquired. The results showed that more cement was significantly inserted into the lateral tibial condyle than the medial condyle in cemented total knee arthroplasty, and bone quality along the medial edge of the medial tibial condyle was found to have deteriorated at sgort-team follow-up after total knee arthroplasty.
Osteolysis is recognized far less frequently in the follow-up of TKA rather than THA for the following reasons: the size of wear particle in TKA is larger than in THA; the particle in TKA is too large to be phagocitized; and the cellular response is much less reactive. Another reason is the joint capsule of the knee is more extensive than one of the hips. There are also many bursae around the knee joint compared to hip joint. We report two cases of severe osteolysis after TKA, adjacent to the tibial and femoral components. One case was a 66-year-old female who had pain and swelling since an operation (13 years ago). Radiographs showed massive osteolytic defect at the tibial and femoral side. However the tibial and femoral components were well-fixed. We therefore exchanged only the polyethylene insert. The other case was a 73-year-old female who underwent TKA 16 years ago. Severe pain developed, and a large osteolytic lesion was noticed in the distal femur and the proximal tibia surrounding the screw. The tibial and femoral components were unstable, and we performed total revision arthroplasty. When a patient complains of pain with osteolysis evident in radiograph, the only cause would be synovitis or synovitis with loosening. If the prosthetic component is stable, curettage of the granulation tissue, synovectomy, and isolated component exchange are considered. There operation methods should especially be considered for elderly persons, and high risk patients to avoid further complications. Patients should also be observed after prosthetic surgery symptomatically and radiographically to perform these surgeries.
Pulmonary embolism (PE) due to deep vein thrombosis (DVT) remains the most serious complication in acute spinal cord injury (SCI). The incidence of PE has been reported as relatively low in Japan, however it can be lethal if it occurs. We experienced two similar cases of fatal PE after SCI. Case 1 was a 44-year-old male with BMI of 29.4. He was treated for schizophrenia on an out-patient basis. He attempted suicide by leaping from a height and suffered polytrauma including bursting fracture of the third lumbar vertebra, for which posterior lateral fixation of the spine was performed. Seventeen days after surgery, he fell into cardiopulmonary arrest due to suspected PE and died in spite of aggressive cardiopulmonary resuscitation. Case 2 was a 34-year-old male with BMI of 35.5. He had a very similar history of mental disorder, mechanisms of injury and surgical procedures as case 1. He suddenly collapsed on the 27th postoperative day and was diagnosed as massive PE by arteriography. Thrombolytic therapy and catheter-tip embolectomy were immediately performed without success. For these two ceses, anticoagulation was not instituted. There are several factors that predisposed these patients to PE; trauma, obesity and postsurgical status for spine fracture. Prevention of DVT is the key strategy against PE. Therefore, Preventive measures including routine use of anticoagulants or placement of filter devices for these high-risk group patients should be considered.
We performed cervical spine fusion with axis plate system for cervical fracture dislocation beginning October 1999. In this study 7 patients with cervical fracture dislocation were reviewed in clinical investigation. Five patients were male and 2 were female. The mean age was 53 years (range: 22-75). We treated these patients with lateral mass screw for C3 to C5, and pedicle screw for C6 to C7 after decompression. All cases were treated with bone grafts. The range of follow-up was 5 to 11 months. Clinical results were evaluated using the Frankel classification. Six patients improved, and the other patient did not suffer from any complications. No patient experienced injury of instrument.
Between January 1998 and June 2000, 62 patients had been treated with continuous epidural injections for low-back and leg pain. The clinical results were evaluated by the Japanese Orthopedic Association (JOA) score. The average JOA score improved significantly from 10.3 to 18.8 points. Only 13 patients (20.1%) were underwent surgical operation. One patient had a complication of epidural abscesses. We conclude that this method was useful for the patients with low-back and leg pain, and moreover, both patients and doctors can have times to think about treatments.
Fracture of the tarsal navicular body is an uncommon and complex injury of the midfoot. We reviewed the clinical results of 6 fractures of the tarsal navicular from 1990 to 1999. There were 5 males and one female with an average age of 37.5 years. Follow-up period was 19 months. Three cases were treated conservatively, and the other 3 underwent surgery. All cases achieved bone union. There were 2 cases of necrosis, 3 cases of malunion, and 4 cases of osteoarthritis.
We report the incidence and risk factors of heterotopic ossification after noncemented ceramic total hip arthroplasty. All of the operations were performed by one surgeon using the same operative approach and type of fixation. The patients were allowed to walk using two crutches and full weight-bearing usually on the 7th postoperative day. They were discharged on the 26th postoperative day on average, using one cane. In contrast, heterotopic ossification was evident in 12.2% of the hips, and the major risk factor was hypertrophic type described by Bombelli. Accelarated rehabilitation did not affect the incidence of heterotopic ossification.
We reviewed five cases of ipsilateral fractures of the femoral neck and shaft treated at our hospital since 1997. They were all males. Their ages ranged from 23 to 66 years (average: 39.6 years). All injuries resulted from high energy trauma. There were four intracapsular femoral neck fractures and one extracapsular fracture. There were no open fractures. All patients were treated with reconstruction nail. The average follow-up was 22 months. At follow-up, all patients had achieved good results and all fractures were followed to union. There was no case of avascular necrosis of the femoral head. Ipsilateral fractures of the femoral neck and shaft should be stabilized by internal fixation as early as possible. The reconstruction nail is useful for providing superior stabilization with a single implant.
We treated 12 cases of open patella fractures. The ages of the patients (10 men and 2 women) ranged from 19 to 67 years and averaged 30.5 years. All patients were injured by direct contact; 7 by traffic accident, 2 by falling, and 1 by falling down 1. Transverse 8, Vertical 3, Comminuted 1 in By classification of patella fracture, there were 8 transverse, 3 vertical, and 1 comminuted. All open patella fractures were treated operatively (Zuggurtung: 7, screws: 2, irrigation only: 3). Infection and non-union were not seen after surgery, but 1 elderly woman showed limited range of motion.
The Dias-Tachdjian classification is a common method for classifying the physeal injuries of the ankle in children. But this classification has certain drabacks. The mechanism of the position of foot trauma is complicated. It is difficult to distinguish supination plantar flexion from supination external rotation stage 1. Although the mechanism of Tillaux fracture and Triplane fracture is supination external rotation, they are classified as others. We studied 34 patients with epiphyseal injuries of the ankle in children and investigated the advantages and drawbacks of the Dias classification. The purpose of this study is to apply Lauge-Hannsen classification to physeal injuries of the ankle in children.
Orecranon stress fracture is comparatively rare, and it is reported as a growth period baseball elbow failure. We experienced a three year natural progress of olecranon stress fracure in a 14-year-old boy. Thought it was difficult to differentiate whether this case was stress fracture or epiphyseal closing disorder caused by traction action of the triceps brachii musle during pitching, we diagnosed it as olecranon stress fracture due to difference in the position of the epiphyseal line of the olecranon.
Case 1. A 22 year old male fractured his lower leg when landing on a baseball court. On that day after the diagnosis of open lower leg fracture we executed osteosynthesis with an interlocking nail (Gustilo type II, A0 type A3). Case 2. A 37 year old female fractured her lower leg when falling on a badminton court. On that day we executed irrigation and debridement after the diagnosis of lower leg open fracture (Gustilo type II, A0 type A1). 17 days after the first operation we executed plate osteosynthesis. Discussion. In a gymnasium players occasionally lose their balances. To prevent falling to the court, a strong force between the sole of their sports shoes and the court may be transmitted to the bone causing fracture. This report describes 2 cases of an open fracture of the lower leg due to indirect forces, and a discussion about the generation of indirect forces from the interaction of the sole of a sports shoe with the gymnasium floor.
A 30-year-old man presented with a history of mono-arthritis at the IP joint of his left great toe accompanied with conjunctivitis and balanitis circinata, following enthesopathy at multiple sites. He had Achilles tendon rupture near insertion at the calcaneal bone, when he slipped on a grass slope. The tendon rupture end appeared swollen and denatured in reconstruction surgery. Histologically, numerous neovascularizations were seen in the tendon fiber and loss of staining of the collagen fiber with inflammatory cells, suggesting prolonged inflammation at the Achilles tendon near the insertion site weakened the strength of the Achilles tendon, leading to rupture with minor trauma. Sulphasalazine and low-dose predonizolone were not effective for this patient. But, interestingly, bucillamine was effective for decreasing symptoms due to multiple enthesopathy with decreased serum level of c-reactive protein.
Alkaptonuria is a rare inborn metabolic disorder in which ochronotic pigment is deposited in the connective tissue and cartilage. Ochronotic arthropathy is the consequence of longstanding alkaptonuria and leads to progressive joint disability. In this paper, we mainly report a case of a 48-year-old man with severe ochronotic arthropathy involving the shoulders.