Pulmonary embolism is a serious complication of surgical intervention. We here report a 68-year-old woman with cervical myelopathy who suffered pulmonary embolism just after intubation before cervical laminoplasty. While receiving cervical laminoplasty, her blood pressure suddenly dropped after intubation in general anesthesia. An immediate CT revealed bilateral pulmonary embolism. She was successfully treated by the anticoagulants and thrombolytic agents. Retrospectively she showed many risk factors of pulmonary embolism, such as long duration in bed, obesity, and deep venous thrombosis. Although pulmonary embolism rarely occurs, careful attention should be paid to this disease especially in the patients with many risk factors.
We report three cases with amalgamation of pulmonary thromboembolism after operation. Screening before operation for the deep vein thrombosis which causes pulmonary thromboembolism was important. In this study deep vein thrombosis was screened by ultrasonography, but pulmonary thromboembolism was not experienced. We therefore concluded that screening for deep vein thrombosis by ultrasonography is useful for patients with a high risk of developing this disease.
Lower limb orthopedic surgery involves great risks of deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE). We experienced six cases of DVT and PTE in a year. [Cases] The six cases consisted of femoral neck fracture (2 cases), femoral supracondylar fracture (1 case), arthroscopic surgery for meniscus disorder (1 case), TKA (1 case), and THA (1 case). All were cured by anti-coagulation and thrombolysis therapy. [Discussion] We have been using D-dimmer as a screening test since November 2001 because it allows us to arrest symptomless DVT and PTE. The D-dimmer test is also useful for determining early treatment and avoiding massive PTE.
The relation between DVT (deep venous thrombosis)and plasma markers for coagulation and fibrinolysis was examined in 33 cases after TKA (total knee arthroplasty). FDP(fibrin degradation products), D-D(D-dimer), and TAT(thrombin-antithrombin III complex)were measured preoperatively and postoperatively on days 1, 4, 7, 14. DVT was diagnosed by ultrasonography in all cases and by vonography when D-D rese over 10 μg/mL. DVT was recognized at 30%, but no PTE (pulmonary thromboembolism) was found. In the comparison of DVT and non-DVT, although individual specificity is wide for postoperative fluctuation of these plasma markers, FDP and D-D significantly increased in DVT on postoperative days 4, 7, and 14 but TAT increased on the first postoperative day. Though it was thought to be a preceding value, it had no significance. DVT may be suspected when D-D rises and when it is prolonged. The reference value of D-D in diagnosis of DVT is 10 μg/mL.
Risk management in the medical world has become critical and many trials are reported. Our hospital renewed our risk management committee in Junuary 2002, and has since been working on the risk management using online system. The online system allows hospital staff to access information on problems quickly. At the same time, we worked on profecting privacy. Our risk management system, committee activity and online user interface method are discussed in this paper.
Morphologic changes of the bicipital groove following cuff repair were studied. Thirty-nine cuff repairs were performed at our institute. Tenodesis of the long head of the biceps was performed in 12 shoulders, and not in the remaining 27. The duration of the average follow-up was 24.4 months. Morphologic changes of teh bicipital groove were recognized in 10 out of 12 shoulders that underwent tenodesis. Especcially in all cases with decortication or drilling of the bicipital groove, teh morphologic change was distinct. The changes were found in 9 out of 27 whose biceps tendon was not fixed and massive rotator cuff tears were recognized in these cases during the surgeries. These morphologic changes revealed a trend of lower clinical results. Especially in cases without the tenodesis, clinical results of groove deformity cases were statistically lower than those of the non-deformity cases.
The purpose of this study was to evaluate the results of arthroscopic Bankart repair using anchors in selected patients. Thirty-two patients (F/M=8/24, mean age=20) with unidirectional anterior-inferior instability, an isolated anterior detachment of the glenohumeral ligament complex, underwent arthroscopical repair. They did not have large anterior glenoid defect or Hill-Sachs lesion. Twenty-eight patients were excellent, and four good by Rowe's grading system with a mean follow-up period of 36 months. The recurrence rate was 3%. The mean loss of elevation was 1°, and external rotation was 4°at the arm site and 2°in 90° abduction. This operation for the selected patients restored stability of the shoulder and led to favorable outcome equivalent to open surgery. It was useful for overhead or contact athletes.
Many hemiplegic patients suffer from subluxation of the shoulder joint and show severe damage to rotator cuff and humerus. There were 12 hemiplegic patients with pain and subluxation of the shoulder. Application of triangular sling did not prevent subluxation. Radiological examination revealed some flexion and abduction (45 degrees abduction in the scapular plane) reduced not only subluxation but also pain in 11 patients. Pain remained in one patient whose shoulder was not reduced by flexion and abduction. The use of pillow, slings or other ways to keep the shoulder in some flexion and abduction was effective in reducing the subluxated shoulder joint.
Spontaneous hemorrhage in shoulder joint is rare. We experienced a patient with spontaneous hemorrhage in the bilateral shoulder joint. The case was a 61-year old woman who suffered from bilateral shoulder pain, especially in motion. She also complained of spontaneous bilateral shoulder pain, when the hemorrhage from her shoulder joint did not occur. We performed arthroscopic synovectomy, which revealed a small cuff-tear in the right side scope. No cuff-tear was found in the left side. No osteoblastic or osteolytic changes were also found at both sides. Synovium was extremely multiplied at both bursal sides. Specimens showed atypical synovitis. Diagnosis was spontaneous hemorrhage to the exclusion of PVS, hemangioma, aneurysm, and varix. Several authors have described that spontaneous hemorrhage occur in the shoulder joint associate with massive cuff-tears. In this case, we only found a small cuff-tear in the right side and not in the left. Her pain alleviated during a period from surgery to the final follow-up.
11 cases with fractures of the proximal end of the humerus were treated by osteosynthesis using the polarus nail. All cases achieved bone union. All cases were evaluated. The JOA score was 86, the average flexion angle was 140.5°, and abduction was 131.6°. This method is useful for the treatment of the fracture of the proximal end of the humerus, even in cases of dislocation, displaced fragments, or osteoporosis.
We report the treatment for proximal humeral fractures of elderly patients using the intramedullary nail. From January 1997 to September 2002, we treated 29 cases by intramedullary fixation using the Ace humeral nail and TARGONPH. The patients consisted of 6 males and 23 females with a mean age of 77.9 years (range:65 to 97 years). According to the Neer's classification, all fractures were classified as 2-part fracture (20 cases) or 3-part fracture (9 cases). Their pain decreased early and they could start rehabilitation one day after operation. All achieved bone union and showed good results. Intramedullary nail is considered a useful operative method for proximal humeral fracture in elderly patients because it provides sufficient fixation.
Prosthetic replacement is recommended for four-part fracture-dislocation of the proximal humerus, especially in elderly patients because the surrounding soft tissues do not attach easily to the humeral head. We report a which underwent open reduction and internal fixation for four-part fracture-dislocation of the proximal humerus according to Neer's classification. The case was a 83-year-old male injured in slipping. During the surgery, upon removal of the humeral head, no apparent rotator cuff tears were not seen. Internal fixation was performed with a plate and screws. Bone union was recognized on the pain X-ray and CT images, and there were no signs and symptoms of avascular necrosis of the humerus head eight months after the operation. These results suggest that avascular necrosis does not cause tearing of the totator cuff, even in elderly patients.
We have treated midshaft clavicle fractures operatively by closed reduction and percutaneous pinning fixation. However, we have experienced Kirschner wire retrograde displacements in some cases that were fixed by single Kirschner wore. In such cases, we there foreused double Kirschner wires for the fixation and inserted them intramedullary into the clavicle with bending to prevent displacement. We consider percutaneous pinning fixation by double Kirschner wires a useful operative technique.
A 14-year-old visited our hospital, complaining of hemarthrosis of the right knee. The hemarthrosis was caused by kick motion while playing soccer. He had painful restriction of extension and tenderness on the lateral side of the infrapatellar area. MRI demonstrated a well circumscribed lesion with hypointense signal on both T1-and T2-weighted images in front of the ACL. Arthroscopy revealed a nodular mass arising from the patellar fat pad, and the lesion was resected arthroscopically. Pathological findings confirmed the diagnosis of localized nodular synovitis (LNS). The preexisting LNS was thought to have been injured by the hyperextension of the knee during kicking, resulting in hemarthrosis and locking symptom.
We experienced 3 cases of meniscocapsular separation associated with medial collateral ligament injury of the knee. The degree of medial collateral ligament injury was I to II. All cases were treated by functional brace. We found MCL deep layer injuries by MR images in all cases, but no signs of meniscocapsular separation were found. For the medial meniscal hypermobility revealed by arthroscopy, we reconstructed the medial meniscus and symptoms disappeared in all cases after the operation. The diagnosis for meniscocapsular separation is difficult in stress X-P, arthrography and MRI, thus requiring careful examination of medial collateral ligament injuries of the knee.
We performed an original double osteotomy technique in 10 osteoarthritis knee and one osteonecrosis knee, in which transverse osteotomy from the medial aspect of the proximal tibia to the proximal tibiofibulal joint were added to tibial condyle valgus osteotomy and fixed with an open wedge osteotomy plate. All cases had good results and could return to their jobs. Adequate adaptation of both compartments of the knee and alignment of the lower limb were achieved independently with this technique.
Fibrodysplasia Ossificans Progressiva (FOP) is a severe, comparatively rare disease, characterized by the progressive heterotopic ossification of the muscle, tendon, ligament, and facsia. There is no known effective therapy for this desease. In this syudy, we report two cases of FOP. One of the patients was a 7-year-old boy, suffering from multiple masses on neck and back, and congenital bilateral hallux valgus. We diagnosed him as FOP from his clinical findings. Due to aggravation of the multiple masses, oral etidronate therapy was begun in March 2001. After the therapy, no worsening symptom was observed. Another patient was a 6-year-old boy, complaining of congenital bilateral hallux valgus. Within a couple of years, multiple masses became evident on his neck and back, for which FOP was diagnosed. In this case we did not start etidronate therapy because of no large progression of the masses. The results of this study suggest that etidronate therapy may be helpful for the treatment of FOP.
We reviewed 11 cases (5 boys and 6 girls) of atlantoaxial rotatory fixation (AARF). The mean age of the patients was 6.0 years (range : 4 to 8 years) and the mean duration between symptom onset and first consultation was 5.3 days (range : 0 to 13 days). Of the patients, 10 were treated with cervical collar fixation. In these 10 patients, 2 had undergone manipulative reduction under general anesthesia because of relatively longer duration of disorder and elder age. The other one patient who was injured in a motor vehicle accident underwent manipulation and was subsequently fixed with a halo-vest. Our clinical results suggest that earlier reduction and appropriate fixation are more beneficial in patients with AARF.
Calcification of the cervical intervertebral disc is considered a comparatively rare disease in Japan. We report a 7 year-old-boy with a calcified intervertebral disc at C3-4. He complained of neck pain and had limited neck motion at the time of the first medical examination, as well as a history of upper respiratory infection. Neurological examination was slightly hyperreflex. Blood examination was WBC 9800 CRP1.0 mycoplasma antibody 320. Radiographs of the cervical spine showed calcification of the C3-4 and flattening deformity of the adjacent vertebral body of the C4. CT showed calcification of the intervertebral disc at the C3-4 and in the left front of the C4 vertebral body. With conservative treatment, his pain disappeared two days later, and he recovered normal neck motion. Three months later, radiographs showed a reduction of the calcification but flattening deformity of the adjacent vertebral body renained.
The indication of surgical treatment for idiopathic scoliosis showing a Cobb angle of more than 45 degrees after skeletal maturity is controversial. We investigated the clinical course of 20 patients with idiopathic scoliosis who had been treated conservatively showing a Cobb angle of more than 45 degrees at the time of skeletal maturity. At the final follow-up, the Cobb angle had increased in 8 out of 20 patients. The Cobb angle had progressed in patients with single curve or severe rotation of the vertebrae even after skeletal maturity. A few patients complained of low back pain and cosmetic discontent. The progression of deformity should be observed in patients showing idiopathic scoliosis with single curve or severe rotation of the vertebrae even after skeletal maturity.
We studied 84 patients with neurinoma and 21 patients with meningioma who could be observed for more than 2 years after surgery and have the clinical results analyzed. Generally, the main cause of recurrence is thought to be incomplete resection of the tumor in the first operation. In this study, all cases reguiring reoperation had dumbbell tumors.Thus we observed prognosis of dumbbell type neurinomas with MRI. Some of the residual tumors outside the spinal canal after surgery did not recur. Only 5 out of 17 cases of meningioma completely resected without removal of dura mater could be observed on prognosis with MRI in this study. There was no recurrence in all of these cases.
Ten women (age : 42 to 82) with spinal menigiomas were treated surgically between January 1989 and July 2001. All menigiomas were intradural-extramedullary. Histopathological subtypes were meningotheliomatous in four cases (cervical level in two cases and thoracic level in two cases) and psammomatous in six cases (thoracic level). MRI revealed dural tail sign in four cases and CT revealed direct tumor sign (calcification or ossification) in four cases (psammomatous type). Surgical results were excellent except for one recurrence case. Cell counts in the celebro-spinal fluid significantly correlated with the prognosis. (Pearson's correlation coefficient ; P<0.05)
We treated a very case of atlanto-axial subluxation associated with dumbbell tumors. The case was a 67-year-old female. She had complained of upper extremity numbness sinse 1997 and atlanto -axial subluxation was suspected. In May 2001, myelopathy had radically progressed and she could not walk. MRI revealed dumbbell tumors at the level of C1. She also sufferd from severe weakness of both upper and lower extremities, severe hypesthesia, hyper deep tendon reflex and neurogenic bladder. AAD was 10mm in flexion, but reduced by cervical traction. In August 2001, we resected the tumors by C1 hemilaminectomy and peformed C1-2 fusion with the Magerl and Brooks method all at once. Histopathologic examination showed schwannoma. Eight months after surgery, the patient can walk with a crutch. The Tomogram showed fusion of the graft and no recurrence of the tumors was seen on MRI. Atlanto-axial instability is caused by trauma, inframmation, etc. We suspect this case to be 1) an amalgamation of idiopathic AAS and a tumor or 2) secondary AAS due to dumbbell tumor. Tumors occupying the cervical canal may lead to the degeneration and tear of the transverse ligament, causing secondary AAS.
Idiopathic herniation of the spinal cord is a rare desease. We report two cases of thoracic idiopathic spinal cord herniation in a 64-year-old woman and a 63-year-old woman showing thoracic myelopathy. MRI and CTM were useful for diagnosing this disorder. After repairing the herniation, neurologic deficients improved in both patients.
We reviewed the clinical results of 28 patients (9 females and 19 males) with spinal or paraspinal tumor-like lesions who underwent biopsy from January 1999 to July 2002. Their mean age was 67 (range : 16 to 87) years. The biopsy site was thoracic lesion in 8 patients and lumbar lesion in the remaining 20. Twenty-six patients had undergone percutaneous biopsy with a trephine needle (19 via transpedicular approach, and the other 7 via posterolateral approach) under image intensification in 23 of these patients and CT image in the remaining 3. The remaining 2 had undergone open biopsy. Three of the patients who received percutaneous biopsy required re-biopsy. No complication was not seen in any patient. Pathological examinations confirmed metastasis in 12 patients, primary bone tumor in 3, lymphoma in 4, benign soft part tumor in 1, infection in 1, and normal tissue in 7.
The present study presents a case of fibrous dysplasia of the lumbar spine. The patient was a 17-year-old boy. Beginning in March 2001, he began to experience lumbar pain and numbness in the right leg with no apparent cause. On initial examination, plain X-ray, CT, and MRI confirmed a Schmorl's node in the upper margin of the second lumbar vertebra. The patient was closely followed, but seven months later, a kyphotic deformation of the lumbar spine was detected, and plain X-ray and MRI showed more advanced destruction of the second lumbar vertebra. As a result, the patient was admitted to undergo thorough testing. Bone scintigraphy and Ga sintigraphy revealed an abnormal lesion in the second lumbar vertebra and right rib. Chest X-ray showed a swollen lesion exhibiting a ground-glass appearance in the right rib. Bone biopsy of the body of the second lumbar vertebra confirmed fibrous dysplasia. Due to the rib lesion, the patient was diagnosed as having polyostotic fibrous dysplasia. Because the fibrous dysplasia of the second lumbar vertebra increased the risk of fracture and neuropathy, after subtotal extirpation of the body of the second lumbar vertebra, L1/2 and L2/3 anterior lumbar spinal fusion was performed. The patient's postoperative course was uneventful, and on discharge, the patient was able to walk unaided. In this patient, fibrous dysplasia, which is an extremely rare condition, was initially difficult to diagnose.
We investigated the outcome of cervical cord injury patients treated with conventional rehabilitation in our hospital. For the purpose of this study, we employed FIM score and ASIA motor score as the indices of patient's functional recovery. These indices were expressed as the difference in each score obtained before and after inpatient rehabilitation. Fifty-two cervical cord injury patients were chosen for the subjects (mean age : 47.9, the majority of the patients distributed between teen age and sixty). The main causes of their injury were falling to the ground, downfalling, and traffic accidents. The mean increments of FIM score and ASIA motor score were 14.3 and 3.1 respectively in the completely paralyzed patients. On the other hand, the incompletely paralyzed patients showed 23.4 in FIM score and 12.1 in ASIA motor score, and these were significantly greater than those of the completely paralyzed patients (p<0.05). On the basis of these results, we concluded that conventional rehabilitation may provide functional recovery which facilitates daily living. Contrary to these results, neither complication of cervical fractures nor surgical treatment showed correlation with functional gaining in any of the patients.
We present two cases of radiculopathy caused by the degenerative change of foraminal lesion on the hinge side several years after open-door laminoplasty.The two patients were a 69-year-old male and a 62-year-old male. They complained of disability of elevation of shoulder and flexion of elbow six years and three years after open-door laminoplasty, respectively. The radiculopathy was considered to be mainly caused by compression of nerve roots due to deformity and hypertrophy of facet joint on the hinge side, combined with posterior spur or spondylolisthesis. We performed posterior foraminotomy and obtained good results in both patients. Posterior foraminotomy is useful for the treatment of cervical radiculopathy caused by hypertrophy of facet joints after open-door laminoplasty.
We studied elderly patients over 70 years old who underwent laminoplasty for cervical spondylotic myelopathy. Operations were performed on 21 patients over 70 years old at the time of operation from 1995 at the Kumamoto City Hospital. These patients were reviewed and compared with patients below 69 years old in this study. Clinical results were evaluated by the Japanese Orthopaedic Association scoring system. The operative results of patients over 70 were not significantly different from those of patients below 69. But we found that the recovery of the lower motor function of elderly patients was apparently worse than that of younger patients statistically.
Since October 1999, we have been using anterior plate for anterior fixation in the cervical spine. The clinical results of a group using a plate for anterior fixation for degenerative disorders (50 cases) and a group that did not (50 cases) were compared. No significant differences were seen between the two groups in terms of operation time, a quantity of operative hemorrhage, and clinical results. There was a tendency for delay in fusion time by shortening the postoperative time in bed. The group using a plate showed correlation between delay in fusion time and postoperative time in bed and the group that did not use the plate indicated good fusion. In addition, better alignment of the whole cervical vertebrae and fixed vertebral body could be maintained more easily with the use of the plate.
Though pharyngeal oedema occurs after anterior cervical fusion comes to some degree, urgent intubation is rarely needed. Conventionally, extubation is determined by measuring the retropharyngeal distance at C3-C4 just after operation and side X-p is filmed after operation up to the third day. Steroid is then used as needed. Keishibukuryougan is increasingly used for the purpose of enhancing improvement of patients who received anterior cervical fusion during this one year and this agent has proved useful for this purpose.
A 43-year-old male was suffering from low back pain and numbness of bilateral feet for several months. After lifting a heavy load, low back pain worsened and difficulty in walking appeared. Motor weakness and sensory disturbance in both legs, and difficulty in urination were seen. Computed tomography showed calcification not only in the disc space between the 11th and 12th thoracic spine but also in the anterior aspect of the spinal canal. MRI revealed extreme spinal cord compression by the anterior mass. Operation was performed by anterior approach and a semi-total corpectomy of the 12th thoracic spine was performed. Brown fluid with small calcareous grain was flushed out after incision of the posterior longitudinal ligament. Once compressed dura bulged gradually after resection of the posterior longitudinal ligament. Spinal fusion from the 11th thoracic to the first lumbar spine was done with a hydroxyapatite block, rib grafts, and Kaneda SR system. Analysis of the fluid revealed constituent elements to be calcium phosphate (27%) and calcium carbonate (22%). The pathological specimen showed degenerated and calcified ligament. Four months after surgery, back pain and neurological deficit were improved.
We treated cases of lumbar disc herniation with MED between May 2000 and October 2002. We used MED in 15 cases, that is 4% of 370 lumbar vertebrae operated cases in a year, 16% of hernia cases. Our indication was outside hernia in the spinal canal with protrusion/extrusion of 4/5 and 5/S level. We attempted MED in 30 cases (male/female ratio : 17/13) and their average age was 41 years (16 to 64 years). Five cases were switched to the traditional Love method because of dura injury. Fifteen cases were L4/5 level hernia, and 15 cases were L5/S level. They included 17 cases of subligamentous extrusion and 13 cases of transligamentous extrusion. The average operation time was 98 minutes (59 to 157 minutes), and the average blood loss was 50.8ml (0 to 220ml). After operation, wound pain improved in 5 days, and fever up also improved in 3 days. Only 6 cases used analgesic agents. In most cases of MED operation, the value of WBC fell with in the normal range in 3 days and that of CRP in 7 days. The JOA score improved from 12 to 25 points, and the average recovery ratio was 77%.
Twenty-seven hips with Legg-Calve-Perthes disease were studied to evaluate head at risk signs by magnetic resonance imaging (MRI). The mean age at the first presentation was 6 years ranging from 3 years to 10 years, and the mean follow-up period was 48 months, ranging from 23 months to 96 months. There were 25 hips with lateral subluxation, 5 with calcification, 15 with metaphyseal cyst, 9 with Gage's sign, and 7 with horizontal growth plate. Lateral subluxation resulted from enlargement of the articular cartilage on MRI. Calcification existed in the enlarged lateral articular cartilage on MRI. The defect in the lateral part of the epiphysis on the radiographs called Gage's sign showed intermediate intensity on T1-weighted image and high signal intensity on T2-weighted image, suggesting that Gage's sign represents reparation at an early stage. The metaphyseal cyst presented various signal intensity on MRI, and it was thought that metaphyseal cyst involved growth plate influenced prognosis. The growth plates were not horizontal on MRI.
We reviewed the results of sugical treatment in three children with congenital deficiency of the fibula. The age at the time of surgery ranged from two to thirteen, and the follow-up period ranged from seven to ten years. They were each classified Type I A, Type I B, and Type II according to the classification of Achterman and Kalamchi. Two patients who had a stable hip and a plantigrade foot underwent langthening of the tibia or the femur and tibia, and one patient who had congenital anomalies of the foot underwent Syme amputation. All of them needed further corrective surgery. But at the final follow-up, all patients were satisfied with their daily life, and had no pain and limping. We suggest that estimation of foot deformity is essential for the surgical treatment of congenital deficiency of the fibula and various management methods should be designed for leg lengthening.
We report a case of congenital pseudarthrosis of the tibia. A 1-year 2-month old boy was admitted to our hospital with congenital pseudarthrosis of the tibia. He presented right leg deformity with anterolateral bowing. His mother and grandmother were given a diagnosis of neurofibromatosis 1, and he himself had numerous café-au-lait spots. He was treated by excision of the pseudarthrosis and segmental bone transport at 1 year 8 months old, but could not achieve union at the distal docking site. He then underwent autogenous-iliac bonegraft at 2 years 8 months old, but could not obtain union at the distal tibia. When he was 4 years 9 months old, he underwent grafting of the ipsilateral fibula to the tibia as described by Goldberg et al. in 1988. After the operation, due to valgus deformity after fracturing the transplanted fibula, an intramedullary rod was inserted. Solid union and hypertrophy of the graft was achieved at 6 years old. Residual deformities include tibial angulation and leg length discrepancy, but he has been able to walk with a long leg brace without any complaints.
We treated 13 patients with sacral decubitus using V-Y advancement flap. They consisted of 7 males and 6 females, and the average age was 81 years (range: 65 to 93). Their decubitus was infected with MRSA, Pseudomonas, etc. We treated them with antibiotics. But because the decubitus remained the same or become wider, we performed operation. Seven of the 13 sacral decubitus healed primarily, six healed secondarily by conservative treatment and 4 developed minor recurrence. None had recurrence. As V-Y advancement flap is simpler and easier, it is useful for treating sacral decubitus.
We evaluated the results of treatment for fracture using the sonic accelerated fracture healing system (SAFHS). We treated 36 bones in 30 patients. The patients consisted of 20 males and 10 females. The age of the patients ranged from 20 to 82 years, and the average age was 46.2. The rate of bone union was 61.1%. We believe that pseudoarthrosis and unstable fixation reguire additional operation.
We present our experience of consecutive patients of 70 years or older who underwent surgical treatment for distal femoral fracture (AO types A and C) from 1992 to 2001 in our department. In total, nine female patients with an average age of 80.2 years were followed up for more than four months. There were four type-A1, one type-A2, one type-A3, one type-C1, and two type-C2 fractures according to AO classification. Patients were divided into a simple group (AO type A1 and C1) and a comminuted group (AO type A2, A3 and C2). Three patients were treated with May anatomical plates, three with Zickel supracondylar nails, and three with intramedullary supracondylar (IMSC) nails. All fractures united in an average duration of 11.0 weeks. The operating time averaged 69 minutes in the simple group and 119 minutes in the comminuted group. After Wilde modification of the Neer scoring system, two patients were excellent and three were moderate in the simple group, while all patients except one two could not walk before injury were moderate in the comminuted group.
Seventeen cases of patellar comminuted fracture were treated with tension band wiring using cannulated screws. In all cases, bone union was achived, and satisfactory results were obtained. This method can be applied to almost all types of patellar fractures.
Early knee joint movement is reguired in the medical treatment of patella fractures. We performed percutaneous cannulated screw fixation for patella fracture on 15 knees of 15 patients. The mean age of patients was 66.8 years (range ; 16 to 87 years). The mean follow-up time was 15 months. Bone union was achieved in all cases. All of the patients showed satisfactory results, experiencing no skin damages by screws.
We performed radiographic investigation on 18 fractures of pronation-external rotation injury of the ankle. The 18 fractures were separated into two groups, : nine fractures were treated with trans-syndesmotic screw after open reduction and internal fixation ; nine fractures were treated without trans-syndesmotic screw. The width of the syndesmosis, the width of the medial mortise, and the height of the fibullar fracture were measured on the mortise roentgenograms in all 18 fractures at the time of injury, post-operation, and follow-up. As the widths of the syndesmosis and the medial mortise, and the height of the fibular fracture were more extensive than cases in general, supplemental trans-syndesmotic fixation was performed. There were no significant difference between the two groups on the width of the syndesmosis and the medial mortise at the time of follow-up. The trans-syndesmotic screw was useful for severe pronation-external rotation fracture of the ankle, however we must avoid unnecessary trans-syndesmotic fixation after inadequate reduction of the fibular fracture.
We reviewed the clinical outcomes of 17 children (12 males, 17 females) with femoral shaft fractures from 1993 to 2001. Their age ranged from 0 to 14 years (average age : 7.8 years). We treated 12 patients with traction and casting, 4 patients with external fixation, and 1 patient with pinning. At an average follow-up of 23 months (6 to 67), we measured remodeling of the femoral shaft and amount of femoral overgrowth. We found that the angular deformities were corrected slowly and slightly at the fracture site, and overgrowth took place in those between 4 and 10 years of age.
We have treated femoral shaft fractures using the interlocking intramedullary nailing system since 1992. We investigated factors contributing to radiological results in 70 femora of 66 patients with femoral shaft fracture. As a result, 68 femora of 64 patients eventually achieved bone union in an average of 245 days (23 to 1029 days) after the first surgery. Eight femora of eight cases reguired reoperation. Static locking, age, and the degree of comminution were significantly correlated with radiological results, as were age and degree of comminution were significantly correlated.
Pelvis inclines to the posterior in the standing position. We investigated factors which influence the change of pelvic inclination from the decubitus to the standing position. The subjects consisted of 129 coxarthrosis hips of 79 patients. We investigated the change of pelvic inclination angle from the decubitus to the standing position and the following factors : age, sex, stage, pelvic inclination angle in the decubitus and standing positions, and Sharp angle. The change of pelvic inclination angle increased in groups with high age, posterior inclination in the decubitus and standing positions, and normal Sharp angle. We speculate that coxarthrosis in elderly patients without dysplasia is caused by increased pelvic inclination angle in the standing position.
It is important to determine the coxarthrosis stage to evaluate joint space of the hip. The standing position reflects the influence of weight-bearing on the hip joint more clearly than the prone position. We experienced some cases of coxarthrosis whose stage in X-ray in the prone position changed in the standing position. We examined 77 hips of 50 patients with coxarthrosis, and classified then into the four stages according to only the narrowing of joint space in anterposterior X-ray of the hip : early-stage (41 hips), early phase of advanced-stage (11 hips), and late phase advanced-stage (25 hips). Terminal-stage was excluded. Thirteen hips (15.6%) moved to the progressive stage : 1 hips (2.4%) in early-stage, 3 hips (27.3%) in early phase advanced-stage, and 8 hips (32.0%) in late phase advanced-stage. In conclusion, as the coxarthrosis stage can change in the standing position, we need to pay attention to determining the coxarthrosis stage especially in advanced-stage cases.
We studied the results of 25 rotational acetabular osteotomies (RAO) for advanced osteoarthritis of the hip. All patients were female. The average age at operation was 43 years (range : 30 to 55 years). The average duration of follow-up was 3.2 years (range : 1 to 7.3 years). The CE angle, AC angle, and AHI significantly improved in all patients after surgery. At the time of follow-up, the average Japanese Orthopaedic Association hip score improved from 64 to 89. Five joints showed progression of degenerative changes. These patients indicated advanced osteoarthritis also in the opposite hip. No patient had secondary total hip arthroplasty (THA). We conclude that RAO can improve the advanced osteoarthritis of the hip and delay the indication for THA.
We reviewed the results of bipolar endoprosthesis performed on 62 hip joints in 50 patients. The mean follow-up period was 12.5 years (range : 10 to 15.5 years). The original disease was osteoarthritis in 46, rheumatoid arthritis in 7, and osteonecrosis of the femoral head in 9 joints. The average JOA score was 74.3 points in the latest follow-up examination, compared with 46.1 points preoperatively. Radiologically, osteolysis was found on the acetabular side in 15 joints (24.2%), and on the femoral side in 10 joints (16.1%). Progressive migration of the outer head was found in 31 joints (50.0%). Revision surgery had to be performed on 7 joints. The results of the present study suggest that bipolar endoprosthesis should not be used for osteoarthritis and rheumatoid arthritis hip.
We present the results of 45 total hip arthroplasties using anatomic medullary locking prosthesis with a mean follow-up period of 7.3 years (range ; 5 to 10 years). The average Japan Orthopaedic Association hip score increased from 48 points prior to the operation to 92 points at the last follow-up. All radiographs were examined for the acetabular cup position and the presence of radiolucency and loosening. The results of this study showed that lateral placement of the uncemented acetabular cup may result in a higher rate of loosening of the femoral component.
Total hip arthroplasty with HA-TCP coated acetabular cup and stem was performed on 11 patients (11 hips) with rheumatoid arthritis. Follow-up was conducted for more than one year, and JOA hip score was examined at the time of follow-up and pre-operation. X-ray examination was performed postoperatively for migration or rotation of the cup and surrounding radiolucent lines at the time of follow-up and immediately after operation. The fixation/stability score of the stem was examined at the time of follow-up. At follow up, the median JOA hip score was 79 points (range : 70 to 96 points). In postoperative X-ray examination, the rotation angle increased 4 degrees in only one cup but the cup fixed after one year. Radiolucent lines were sometimes seen in the lateral zone of the AP view at follow-up, especially for collaps type and protruded type undergoing considerable bone graft. This proves that the clinical results of the HA-TCP coated cup and stem for rheumatoid arthritis were good for a short-term, but we should pay attention to radiolucent lines at the cup and provide long follow-up.