The sternoclavicular joint (SCJ) is an unusual site for infection. We report a case of pyogenic arthritis of the SCJ. A 79-year-old man who was diabetic complained of pain and swelling in the left SCJ. Magnetic resonance imaging (MRI) showed arthritis of the SCJ and abcesses around the SCJ. A needle aspiration of the abcess grew Staphylococcus aureus. He underwent drainage and antibiotic therapy at another hospital, but the inflammation of the SCJ did not improve. MRI about a month later after the beginning of the treatment showed osteomyelitis of the left clavicle, so he was referred to our hospital. He was not pyrexial, white cell count was normal, CRP was 5.65 mg/dl, and ESR was 58 mm/l st h. Plain SCJ X-rays were unremarkable, but MRI and bone scintigraphy showed arthritis and osteomyelitis. He underwent a debridement with an ipsilateral pectoralis major muscle covering the bony defect. After the debridment, there is no recurrence. When there is evidence of infection beyond the SCJ such as myelitis, aggressive surgical therapy is necessary.
We reported a case of rheumatoid subacromial bursitis containing considerable rice bodies. A sixty-year-old woman was diagnosed as rheumatoid arthritis (RA) eight years ago. She complained of pain and swelling in her left shoulder for five years. On examination, remarkable swelling was observed on the anterior and posterior parts of the shoulder. T2-weighted MRI demonstrated multiple nodules with low intensity in effusion of the subacromial bursa (SAB). Gadolinium-enhanced MRI showed high intensity border of SAB and no enhanced nodular lesion. The SAB was resected surgically. More than one thousand rice bodies were found in the resected SAB. No bacterial infection including tubercle bacillus was found. Pathological diagnosis was chronic inflammation caused by RA. The postoperative course was uneventful.
To investigate lumbar spinal lesions in rheumatoid arthritis (RA), we examined the lumbar spine of patients with RA radiologically. Forty-six RA patients suffering from low back pain were included (7 males and 39 females). Some abnormal findings were obtained in 42 patients (91%). There were disc narrowing in 28 patients (61%), bone spur in 21 patients (46%), erosion of the terminal plate of the vertebra in 19 patients (41%), compression fracture of the vertebra in 17 patients (37%), spondylolishthesis in 13 patients (28%), and destruction of the vertebra in 3 patients (7%). These findings suggest that the low back pain in patients with RA are caused by age-related degeneration and/or inflammatory changes associated with RA.
We report the radiological and clinical features of SAPHO syndrome. Case 1 was a 51-year-old woman who had been suffering from palmoplantar pustulosis and painful osteitis of the left clavicle and lumbar spine for one year. Initial MRI T2 weighted images of the lumbar spine showed high intensity, and a later MRI showed low intensity. Bone biopsy showed nonspecific inflammatory infiltration with lymphocytes and plasma cells. Case 2 was a 48-year-old man suffering from palmoplantar pustulosis and right hip pain since he was 27 years old. Roentgenograph showed osteolytic lesion on the iliac side of the right sacroiliac joint. MRI showed low intensity on T1 weighted images and high intensity on T2 weighted images. An open biopsy showed no evidence of malignancy or microorganisms. They were diagnosed as SAPHO syndrome, and treated with nonsteroidal anti-inflammatory drugs.
Background: In this study, we attempted to determine the connection between throwing injuries, especially to the shoulder or elbow, and the amount of pitching practice, in high-school pitchers. Methods: We distributed questionnaires to 67 high-school baseball pitchers and had them answer questions on the following: their sports career, past sport-related injuries, the amount of baseball practice per day and per week, the number of throws per day, and the number of non-throwing day per week. Using an unpaired T-test, we looked for statistical relationships between throwing injuries and the above factors. Results: Of the 67 cases that answered our questionnaire, 53 (79.1%) answered that they had suffered sports-related injuries in their careers. Of these, 48 (71.6%) had suffered throwing injuries to the shoulder or elbow. Our examination showed that 34 pitchers (50.7%) currently had derangement of the shoulder or elbow, and the questionnaires showed that these pitchers had spent much more time practicing throwing in elementary school and junior high school than those without these problems. Conclusion: Excessive throwing practice in elementary school and junior high school may lead to derangement of the shoulder or elbow.
We present a rare case of multiple osteochondromata after total body irradiation in a bone marrow recipient. The patient was a 9-year-old boy. He had been given 13.2 Gy of total body irradiation (TBI) before allogeneic bone marrow transplantation (BMT) at the age of one because of acute lymphoblastic leukemia (ALL). He did not have a family history of hereditary multiple osteochondromatosis. Osteochondromata presented at the left clavicle, bilateral scapulae, right distal femur, and right proximal tibia. The lesions of the left clavicle and bilateral scapulae were excised. Histological features of resected specimens were those of osteochondroma, showing no evidence of malignant transformation. Although radiation is recognized to be a cause of osteochondroma, reports of TBI are rare. TBI should be considered as one of the causes of multiple osteochondromata.
In this study, we report a very rare case of giant cell tumor (GCT) of the tendon sheath and vascular leiomyoma in the same finger. The patient was a 39-year-old man. On his first visit to our hospital, he conplained of pain in an elastic hard mass which was palpable at the left index-finger tip. Plain radiograph showed bone destruction of the distal and middle phalanges. We performed en bloc resection of the tumor. The results of post-operative histological examination indicated GCT of the tendon sheath. Seven months after the surgery, a new lesion was identified on the more proximal side of the same index-finger. Plain radiograph revealed pressure erosion at the proximal phalanx. We suspected reccurrence of the GCT of the tendon sheath, and performed excision of the tumor. To our surprise, the pathological diagnosis was not GCT of the tendon sheath, but vascular leiomyoma. This means that, histologically, a comparatively different soft tissue tumor had grown at the same finger. To our knowledge, double mesenchymal tumor is very rare, and no case of double mesenchymal tumor arising in the same finger has been reported before.
We treated a giant liposarcoma in the buttock. The case was a 44-year-old male. He became aware of the mass in his buttock in 1996. The mass increased rapidly from 2000 and finally an ulcer developed on the huge mass. He therefore visited our hospital in June 2002 for the first time. He presented a giant tumor in his right buttock and posterior thigh. We resected the tumor on July 24. The size of the tumor was 43×26×15 cm and the weight was 10.1 kg. The pathology was dedifferentiated liposarcoma. Giant liposarcoma is reported in many cases, but most occur in the retroperitoneal space. The liposarcoma in our case was very big as those that occur in limbs.
We report a case of insufficiency fracture in the left hip joint, in which giant tumoral calcinosis occurred during hemodialysis. The patient was a 36-year-old male on chronic maintanance hemodialysis for 11 years. He experienced left thigh pain upon awaking. Roentgenograms showed a calcified mass in the bilateral hip joint and right shoulder joint. Laboratory tests including intact parathyroid hormone (i-PTH) level were normal, except for increases in serum calcium and phosphorus. MRI showed that T1 low intensity and T2 high intensity areas around the hip joint subcutaneous and intramuscle. We performed osteosynthesis with ender nailing, and biopsy of a part of the fracture, and calcinosis in the left hip joint. Microscopic examination revealed calcareous deposits limited by bands of fibrous connective tissue and giant cell. Eel calcitomin puls therapy was given after every hemodialysis. Three months later, after right shoulder calcinosis was decreased on X-ray.
The methods of limb-salvage operations for malignant bone tumors are diverse. For proximal humerus, limb-salvage is better than amputation as functional disturbances are serious. We report a case of limb-salvage operation with extensive resection and reconstruction using scapular bone flap for the osteosarcoma of the right proximal humerus. The case was a 20-year-old man. He was operated after neoadjuvant chemotherapy in August 2001. The operation consisted of extensive resection (glenoid-humeral shaft bone with around soft tissues resection), reconstruction that returned back the glenoid-humeral shaft bone treated with the Pasteur method and in-lay grafted with scapular bone flap, and lattismus dorsi musclocutaneous flap addition. He had postoperative infection with MRSA and P. aeruginosa but recovered by medication using only antibiotics and local irrigation. Adjuvant chemotherapy was completed in July 2002. One year after operation, he had only shoulder dysfunction in his right upper extremity with no local recurrence and metastasis. We recommend scapular bone flap for the osteosarcoma of the right proximal humerus to allow some blood flow of the flap without defects in other sites.
Autopsied cases of bone metastasis in carcinoma and sarcoma were reviewed. Autopsy reports registered in the Tottori University Hospital during 1989 to 2000 were used. The subjects included 244 men and 121 women. The average age of the patients was 64 years in an age range of 10 to 92 years. There were 85 cases of bone metastasis. In 32 cases, bone metastasis had already been detected by clinical investigations before autopsy. Others were detected at autopsy for the first time. The frequency of occult bone metastasis in esophageal cancer, pancreatic cancer, lung cancer, and colon cancer was high. Metastatic lesions were most commonly detected at the lumbar vertebrae. This study indicates that occult bone metastasis exists at a comparatively high level.
We report the diagnostic utility of diffusion-weighted MR images in primary soft tissue tumors. Diffusion-weighted echo-planar imaging was performed in seventy-seven patients with primary soft tissue tumors (benign: 37 cases, malignant: 40 cases). The apparent diffusion coefficient (ADC) was determined from each image. The average ADC of benign cases was 1.53±0.26, and that of malignant soft tissue tumors was 1.31±0.63. In addition, except for three giant cell tumors of soft parts and 11 myxoid type sarcoma cases, ADC of benign soft tissue tumors was 1.58±0.19, and that of malignant soft tissue tumors was 0.94±0.19. This malignant soft tissue tumor ADC valve was significantly lower than that of the benign tumor group (p<0.0001). This indicates that diffusion-weighted imaging is useful in the differential diagnosis of primary soft tissue tumors.
The aim of this study was to evaluate the efficacy of Doppler ultrasonography (US) with very high frequency transducers on assessing soft-tissue masses. We performed sonographic evaluation with an ATL HDI-5000 equipped with a 12.5-MHz linear transducer. Images were obtained in 70 patients admitted to our hospital. We applied Sono-CT as a new variation of compound sonography. Sono-CT provides compound images by combining the images obtained by electronically directing the transducer to scan from multiple angles. In this study, we found that US was able to depict softest tissue masses in detail. All tumors were shown as hypoechoic masses, except lipoma. Particularly, US was useful to diagnose certain neural or fatty tumors, and it was proven to help modality the most in the diagnosis of glomus tumors, since its vascularity can easily be detected using this device. In addition, US was not hampered by metal-induced artifacts. Moreover power (color) Doppler imaging was a valuable adjunct in differentiating malignant tumors from benign ones. US offers many advantages in the assessment of soft-tissue masses. This examination is thought to be sensitive, widely available, noninvasive, and less expensive.
Significance of posterior clearance during modified ligament dependent cut procedure in total knee arthroplasty was assessed in 62 cases. The posterior clearance consisted of release of the posterior cruciate ligament, release of the posterior capsule, excision of posterior osteophytes, and excision of posterior condyle which was not covered with the posterior flange of the femoral component. Posterior clearance significantly improved the maximum flexion angle, relieved extension disturbance, and provided proper joint gap after ligament release. No major complications were found. Posterior clearance is a significant technique to achieve maximum flexion angle during total knee arthroplasty.
We report a case of windswept deformity. Windswept deformity is characterized by varus and valgus deformity in the knees. A 77-year-old female had been suffering from gonalgia and deformity. She had no abnormal laboratory data but had a habit of sitting on her legs with her right knee valgus and left varus. Watanabe insisted that sitting on legs with the right knee valgus and left knee varus is a cause of this deformity. So we gathered information on sitting posture by conducting a questionnaire survey on 300 subjects (100 young females, 100 elderly women without osteoarthrosis in their knees, and 100 elderly women with osteoarthrosis in their bilateral knees). Most of these subjects presented the same results regardless of age and osteoarthrosis, indicating that many women are thought to sit in the same position for a long time. Sitting habit is considered not to be a cause but a risk or worsening factor. In this case, the patient was treated by bilateral TKA. Histological examination showed degeneration and fibrosis. We considered gonarthrosis to cause this deformity. By bilateral TKA, her legs became straight and she gained walking ability without pain. Satisfactory results were achieved in a short term.
Sixty-seven knees in 46 patients with the Miller-Galante II knee prosthesis were evaluated after a follow-up period of 9.1 years (range: 6.3 to 11.4 years). The average age of the patients at the time of surgery was 69.7 years (range: 48 to 82 years). The primary diagnoses were osteoarthritis in 56 knees (40 patients) and rheumatoid arthritis in 11 knees (6 patients). One knee arthroplasty failed because of osteolysis beneath the posterior femoral flange. The JOA score and radiographs were obtained in the remaining 66 knees in 45 patients. The average JOA score was 81.6 points for osteoarthritis and 83.2 points for rheumatoid arthritis in the final follow-up. There was no significant difference in the tibiofemoral angle, the relative position of components, patellar tilt, and lateral shift at four weeks after surgery and in the latest follow-up. Patellar component wear, typically seen in the Miller-Galante I prosthesis, was not observed. Survival curve showed 99% survival at 10 years for all knees. The Miller-Galante II knee prosthesis provided excellent clinical results in the intermediate follow-up. However, in the uncemented 38 knees, the incidences of osteolysis and radiolucent lines of tibial components were significantly higher than those of cemented 28 knees.
From December 1991 to April 1995, 70 consecutive New Jersey low-contact stress (LCS) total knee arthroplasties (TKAs) were performed. Twenty two TKAs were done using rotating platform tibial component, and 48 were done using meniscal bearing tibial component. Two patients sustained bearing insert failure at eight years after primary TKA. Subluxation of tibiofemoral articulation occurred in one case, secondary to increased polyethylene wear and ligamentous instability. It was corrected easily by the insertion of a thicker bearing. The other case had patellar bearing breakage with delamination, but patellofemoral maltracking was not seen. The polyethylene of the patellar component was changed, improving the condition of both patients with relief of pain. Component failure, especially polyethylene wear and breakage were found to occur frequently.
We treated five patients with five infected total knee arthroplasties for 10 years. We reviewed onset time of infection, organism, surgery for the affected knee, and timing of reimplantation. The average onset time was 23 months (range: 2 to 84 months). Cultures grew Staphylococcus epidermidis in three knees, Staphylococcus aureus in one knee, and Klebsiella pneumoniae in one knee. Only one joint was cured by continuous drainage. Knee arthrodesis was conducted on one joint, and 2-stage reimplantation on three joints. But one joint was resulted in knee arthrodesis. The average timing of reimplantation was 5.6 months (range: 4 to 8 months).
The clinical results of ankle arthrodesis are reviewed. From April 1990 to April 2002, we performed ankle arthrodesis on seven patients. Operations were performed on five patients with rheumatoid arthritis and two patients with osteoarthritis. All arthrodeses were performed by the transfibular approach. The mean follow-up period was 3.8 years. Clinical evaluation was assessed using the Japanese Orthopaedic Assosiation (JOA) scoring system. Both pain and gait scores after the operation markedly improved, and all patients were satisfied with the results. There was no nonunion case. Ankle arthrodesis with transfibular approach is an effective operation in patients with rheumatoid arthritis or osteoarthritis.
We examined the symptoms of the lower extremities of patients at our Sanatorium for Leprosy. Of 660 patients, 37.4% had drop foot and 25.4% showed foot deformity. Amputation was carried out on 20.3% of the patients. Neuropathy occurred in 48.3%. The most serious symptom in Leprosy is damage to the peripheral nerves. Patients who suffered from nerve damage have foot deformity. Loss of sensory increases the risk of local trauma and delay in discovering wounds. Leprosy patients also have difficulty in reacting to protect their wounds, leading to the tending of aggravation.
Magnetic resonance imaging (MRI) is now more widely used in the initial diagnosis of pyogenic vertebral osteomyelitis. This article reports on the use of MRI in the initial diagnosis of 18 cases of pyogenic vertebral osteomyelitis, as well as follow-up MRI in 12 cases. We reviewed the clinical findings and MRI results in pyogenic vertebral osteomyelitis. It is suggested that MRI is useful as a means of following course and efficacy of treatment.
We reviewed 36 patients who had been diagnosed as pyogenic spondylitis in our department between 1987 and 2002. All patients were treated conservatively at first by the administration of intravenous antibiotics and the bed rest with orthobrace. Twenty-six patients were treated by this conservative therapy alone (conservative group), and the remaining 10 were obliged to undergo operative therapy (operative group) because of the poor reaction to chemotherapy (6 cases) and the appearance of neurological deterioration (4 cases). In the conservative group, clinical results were good in 23 patients and poor in 3 patients suffering general complications including diabetes mellitus, rheumatoid arthritis and gastric cancer. In the surgical group, neurological deficits remained in 2 patients. Although the application of spinal instrumentation for osteomyelitis surgery is still controversial, it is considered to be a good modality for cases whose inflammatory signs become negative.
The difference in prognosis due to difference in treatment methods for vertebral compression fractures caused by osteoporosis is discussed in this study. The patients were divided into two groups: early treatment group and late treatment group. It was found that early treatment prevents kyphotic deformity and nonunion. It is important to assess the damage area on MRI, ensure appropriate recumbency, and provide exercise in the sitting position after wearing thoraco-lumbar orthosis, which led to a clear difference between both groups in terms of lumbago improvement (p<0.05, statistical analysis was performed by the chi-square test of independence).
Operative treatment of delayed myelopathy after osteoporotic vertebral compression fracture was studied for general condition, nerve compression, type of fracture, and area of MRI Gd. Treatment of fracture was selected depending on the antero and posterior heights of vertebrae. Operative methods included spine shortening or Kaneda when the posterior hight of vertebrae was greater than the antero hight, whereas vertebroplasty, PLF, and Kaneda was selected when the two equivalent.
Twelve Monteggia fractures were treated from 1996 to 2002 in our hospital. We evaluated their clinical results for this fracture. The subjects were all male. The average age of injury was 17.5 years. There were 8 children (under 15 years) and 4 adults (over 16 years). The mechanism of action of this fracture was 5 traffic accidents, 4 falls, and 3 others. Using the Bado classification, 6 were Type I , 3 Type II , and 3 Type III. There was no Type IV. There were 3 open fractures, 1 delayed union, and no nonunion. We attempted manual reduction in some children without anesthesia, but could not reduce completely. Consequently, we had to perform reduction again and immobilization later under anesthesia. The first operation was carried out 0.7 days (0 to 5 days) after injury. The most popular operation is osteosynthesis with kirschner wire. Many cases achieved excellent results, and 2 patients had poor. One had multiple trauma and internal medicine disease, and the other had flexor muscles hard injury.
Four cases with femoral neck fracture were treated by osteosynthesis combined with valgus osteotomy of the femur using compression hip screw. Three cases were old fractures and one case was pseudoarthrosis. In all cases, the hip pain decreased early in the postoperative period, and bone union was achieved. Valgus osteotomy of the femur is an effective method for old fracture and pseudoarthrosis, and compression hip screw provides stable fixation which allows early rehabilitation. Because of these reasons, this method is useful for old fractures and pseudoarthrosis of the femoral neck.
Between January 1997 and June 2002, 50 cases of femoral trochanteric fractures were treated with a proximal femoral nail (PFN), and 50 cases with a Gamma nail. This study evaluated the effectiveness of these fixation devices. There were no significant differences in the mean age, sex, fracture types according to Evans classification and the pre-injury walking ability between the two groups. We clinically and radiographically evaluated the two groups. More than 70 percent of the patients regained walking ability post operatively. Local complications included: three fractures the around the tip of the nail in the Gamma group and one in the PFN group, and five cases of Coxa vara deformity in the Gamma group. However, there was no incidence of cut-out in either group. These devices provide satisfactory results in the treatment of such fractures. However, we conclude that the PFN is a more useful device than the Gamma nail because femoral neck screw positioning is critical.
From January 1996 to January 2002, we operated on 18 cases of subtrochanteric fractures of the femur, using the ¥-nail on 8 cases, CHY-nail on 5 cases, IMHS on 4 cases, and Gamma nail on 1 case. In this study, we evaluated the post-operative results of the ambulation status and alteration in X-rays. Eleven (69%) of the 16 patients who could walk before injury regained the ability to walk. In 15 patients (83%), bone union was obtained. Two cases of delayed union developed nail fracture. It is necessary to consider dynamization for delayed union. If good reduction can not be achieved, we should expose the broken bone location and reduce it.
From 1990 to 1998, 11 Miller-Galante Unicompartmental Knee Arthroplasties were evaluated clinically and radiographically on cases followed up for more than one year. The mean age was 71.6 years, and mean follow-up period was 2.9 years. All patients had underwent medial compartmental replacements, with 7 osteoarthritis and 4 osteonecrosis. The mean JOA score improved from 56.8 preoperatively to 87.3 at the final follow-up period. The mean range of motion improved from 125.1° to 127.5°. Partial radiolucent lines were noted in about 7 femoral components and 5 tibial components. No components were thought to be clinically loose in the latest follow-up evaluation. Unicompartmental knee arthroplasty allows good-excellent early results with appropriate patient selection and requires careful longer term follow-up evaluation.
We report a rare case of traumatic dislocation of the hip in a child. The patient was a 1-year-old girl injured in a traffic accident. The patient had posterior dislocation of her right hip. Two hours after the injury, closed reduction was performed. She was kept in skin traction for 2 weeks and had post treatment of non-weight bearing for 8 weeks. Six months after the injury, normal ranges of motions were obtained on the hip joint and she had no complains. X-ray showed no abnormal findings.
We report a case of sleeve fracture of the upper pole of the patella after medial meniscal repair. A sixteen-year-old boy presented a history of medial meniscal repair. He fell down the stairs, and landed on his knees, after which he could not walk with sudden pain in the left knee. Local examination showed severe effusion and localized tenderness on the upper pole of the patella. He was unable to extend the knee actively. Aspiration produced blood-stained fluid containing fat globules. Lateral radiograph showed avulsion of the upper pole of the patella. Surgical treatment was performed. The avulsed patella fragment of the upper pole included a sleeve of cartilage. The patella, its cartilage sleeve, and the extensor retinaculum were repaired. Three days later, he started passive knee flexion. Now he has regained/recovered full range of movements and is able to extend his knee completely. Patients with fracture of this type usually have a history of trauma or operation around the knee. It was concluded that the mechanism of the injury is inherent weakness at the growth plate of the patella during rapid growth in adolescence, combined with the detrimental effect of immobilization, with the quadriceps contracting against resistance. Accurate reduction and fixation are considered important to present development of the patella magna and persistence of anterior knee pain.
Many surgical techniques have been reported for the treatment of patellofemoral instability. The authors performed follow-up evaluations in 40 knees (6 males, 34 females) for recurrent dislocation of the patella after Elmsli-Trillat procedure. The mean age of the patients at the surgery was 21.1 years (range: 13 to 42 years). An average follow-up of 69 months (range: 24—113 months) was examined. We evaluated all patients using the Fulkerson's functional knee scores, Q angle, and evaluated the period of the time from primary dislocation to primary operation, and the number of times of dislocation. Radiographs were taken before and after surgery in tangential projections. The average Fulkerson's functional knee score improved significantly from 41.5±14.6 before operation to 86.4±8.2 at follow-up (p<0.0001). The average Q angle improved significantly from 23.8±3.0 before operation to 5.0±3.6 at follow-up (p<0.0001). The average tilting angle improved significantly from 26.6±10.0 before operation to 15.6±4.3 at follow-up (p<0.0001). The average congruence angle improved significantly from 27.7±13.3 before operation to —9.1±9.3 at follow-up (p<0.0001). The average sulcus angle was 147.7±10.8 before operation. The 40 knees were divided into two groups according to long-term outcome; excellent or very good or good (32), or fair or poor (8). The mean age at the time of surgery for patients with good resutls was 19.8±4.7 years and for those with poor results was 27.4±7.5 years (p<0.05). The mean length of time between the first dislocation and surgery for patients with good results was 84.0±52.7 months and for those with poor results was 176.5±112.0 months (p<0.05). The mean number of times dislocation for patients with good results was 6.7±2.5 times and for those with poor results was 10.8±3.5 times (p<0.05). The mean number of Carter-index for those patients with good results was 3.8±0.5 and for those with poor results 4.7±0.4 (p<0.05). Our study suggests that the Elmsli-Trillat procedure prevents recurring dislocation. The main cause of deterioration in the clinical results was aggravation of patellofemoral joint pain.
The iliopsoas bursa is the largest bursa in the human body. Iliopsoas bursitis causes enlargement of the bursa and may lead to hip pain, groin mass, femoral nerve palsy, or compression of the femoral vein. We reported a case with the iliopsoas bursitis complicating old congenital dislocation of the hip. As not much yet known about the iliopsoas bursitis, it is sometimes misdiagnosed as abcess, inguinal hernia, aneurism, tumor, etc. Treatment is mainly conservative, but surgical treatment may be indicated in case of heavy groin pain or the compression and obstruction of adjacent structures.
We report a case of traumatic dislocation of the hip in a child. A three-year-old boy fell down, and his right knee was hit on the ground. Just after the accident, he could not move his right leg because of severe pain in his right hip. When he came to our hospital, he kept his right hip in a flexion, internal rotation and adduction position. A hard mass was palpable in the right gluteal region. The X-ray findings showed right hip posterior dislocation without fracture and no congenital skeletal dysplasia of the hip was seen. Four hours after his injury, he received closed reduction under general anesthesia, followed by skin traction in the abduction position of his right hip. Ten days after reduction, MRI and CT showed that there was no fracture and cartilage damage. He felt no hip pain and started to walk on full weight bearing. Nine months after the incident, MRI showed no significant abnormal findings such as bone necrosis and dysplasia of the hip, and the patient had no complaints of problems in daily life.
Myxoid liposarcoma is thought to be insensitive to chemotherapy. This time, we applied a new chemotherapy to some cases of myxoid liposarcoma, and found that the treatment is very effective. The results were as follows: Case 1 was a 41-year-old female treated with three courses of systemic chemotherapy with IFM, ADM, CDDP (IAP therapy). (IFM 2g/m 2, ADR 20mg/m 2, CDDP 20mg/m 2 was administered for three days in succession, and stopped for the next two weeks. This series consists of one course of full dose of IAP therapy.) Case 2 was a 51-year-old female treated with three courses of IAP therapy with 2/3 dose, and with five courses with 1/3 dose. Case 3 was a 28-year-old male treated with two courses of IAP therapy with a full dose, combined with 45Gy radiotherapy. One case showed CR, and two showed PR. These results indicate that IAP therapy is effective for myxoid liposarcoma.
In total hip arthroplasty (THA), the rolling motion of the patient in both the forward and backward directions can easily occur particulary using the posterolateral approach, making it difficult to place the acetabular cup in a suitable angle. We devised a three-dimensional goniometer which consists of three goniometers to assess multi-directional pelvic motion during THA. The purpose of this study is to assess the pelvic motion during THA with posterolateral approach using our device. This prospective study involved 26 THAs in 25 cases. Each patient was placed in a lateral decubitus position on the operating table. A Steinmann-pin was inserted into the illium on the operated side. Our device was attached to the Steinmann-pin. Using this device, we measured the tilt angle of the pelvis in the horizontal plane, frontal plane, and sagittal plane before dislocation and at the time of cup placement. The changes of the tilting angle of each plane were analyzed in the three-dimensional directions. In the horizontal plane, the pelvis tilted forward, averaging 14.35 degrees. In the frontal plane, the pelvis tilted toward the caudal, averaging 0.08 degrees. In the sagittal plane, the pelvis tilted backward averaging 3.96 degrees. Pelvic motion primarily occurred when the Hohman-retractor was used for acetabular exposure.
We report a 60 -year-old female with fibrous dysplasia of the twelfth thoracic spine. She presented middle back pain and anterior chest numbness of the T12 dermatome region. X-ray views showed sclerotic changes in the left pedicle of the T12 vertebra. Computerized axial tomogram demonstrated calcification spots within the radiolucent area accompanied by perifocal sclerotic bony changes in the left pedicle of the T12 vertebra. Bone scintigram showed increased uptake in the left pedicle of the T12 vertebra. Based on radiographic evaluation, chondrosarcoma was diagnosed and she underwent total en bloc spondylectomy of T12. Histopathologic diagnosis of the resected specimen was fibrous dysplasia. Because monostotic fibrous dysplasia of the thoracic spine is rare, it is difficult to establish a diagnosis by radiographic evaluation alone. We radiographically misdiagnosed the lesion. We recommend interoperative or preoperative histological exploration before or during surgery.
Most patients with thoracic outlet syndrome (TOS) have sloping shoulders or military posture. TOS patients with both postural characteristics demonstrate severe chronic symptoms. In our clinical experiences over the past 10 years, we have diagnosed TOS by identifying the lateral margin of the clavicula radiologically, because the position of the clavicula in the TOS lesion is related to the pathogensis. All patients underwent radiological evaluation of the cervical spine by identifying the metal marker on the anterior margin of the lateral site of the bilateral claviculas, after obtaining the correct lateral view of C7 at sitting. Seventeen normal subjects showed the anterior shift of the marker from the C7-T1 disc level. In 37 patients with unilateral TOS symptoms, the symptomatic side revealed posterior shift from the C7-T1 vertebra, while the asymptomatic side showed anterior shift in normal vertebrae. On 50 patients with bilateral TOS symptoms, most demonstrated posterior shift from the C7-T1 vertebra, and the results were compatible with the symptomatic side with unilateral TOS. The postural characteristics of TOS could be confirmed in our radiological evaluation.
Three patients with advanced osteoarthritis of the knee joint (OA) were treated by tibial condylar valgus osteotomy (TCVO). The first case of TCVO underwent resection of the anterior cruciate ligament to correct the alignment of the lower extremity. From this experience, we thought that the double osteotomy (reversed Y-shaped osteotomy) of the proximal tibia was needed for the treatment of the advanced OA in a few cases. The second case was the most severe OA case. The alignment of the lower extremity and stability of the knee joint were improved by TCVO and this case could walk after surgery. The tibia of the last case was fractured at the time of surgical correction because the lateral joint space of the knee joint was narrow. This case was treated by the double osteotomy (reversed Y osteotomy) accidentally. The conclusion was that the double osteotomy is rarely needed to treat advanced OA with narrow lateral joint space.
We studied the relation between a radial tear of the posterior horn of the medial meniscus and osteonecrosis of the knee. Thirty-eight knees of 37 patients were diagnosed as medial meniscus tear and received arthroscopic knee surgery. We divided them into two groups: knees having radial tear of the posterior horn of the medial meniscus (posterior horn group) and knees containing radial tear except for posterior horn, horizontal tear, degenerative tear, and flap tear of the medial meniscus (non-posterior horn group). The posterior horn group consisted of 14 knees (average age: 65.1 years old) and the non-posterior horn group consisted of 24 knees (average age: 59.6 years old). All cases underwent MRI before arthroscopy. MRI findings were classified into three types (typical osteonecrosis, small osteonecrosis, and non-osteonecrosis). In the posterior horn group, typical osteonecrosis were five knees and small osteonecrosis were five knees, while in the non-posterior horn group only three knees were small osteonecrosis. These findings suggest the relevance between radial tear of the posterior horn of the medial meniscus and osteonecrosis of the knee (Mann-Whitney test p<0.01). The etiology of spontaneous osteonecrosis of the knee joint is unknown, however one etiology could be the radial tear of the posterior horn of the medial meniscus.
Osteochondoritis dissecans occurs mostly in the juvenile form. The differentiation between adult form and juvenile form is uncertain. We report a case of osteochondoritis dissecans in the knee in the adult form. A 41-year-old carpenter presented left knee pain and visited our hospital. Linearly increased signal intensity between the fragment and donor sites was seen on MRI T2*weighted sagittal images. 12mm×18mm bony fragmentation had occurred, resulting in creater lesion on the medial femoral condyle. A Kirchner wire was driven through the defect of the articular cartilage arthoscopically by drilling. Six months after operation, he was able to return to his previous occupational and recreational activities. But further follow-up is needed after the operation.
We report a 76 -year-old woman with rheumatoid arthritis for 20 years, who gradually experienced dull pain in her leg thigh and general fatigue. She was gaven medicine at a near by hospital. But due to worsening conditions, she was introduced to our hospital. On the same day she visited our hospital, she reguired relaxation and debridement. Bacteriological examination showed the existence of group A Streptococci in the lesion, and we diagnosed this case as toxic shock like syndrome. Treatment with high-dose penicillin, clindamycin, and globulin were effective. After one month, she underwent skin graft from another thigh. After three months, she was able to walk for herself and was discharged. We considered it is important to diagnose her illness as Group A Streptococcus Infection.
We investigated 6 hips of 5 patients who were treated for slipped capital femoral epiphysis with cannulated screws. The age at operation was 11 to 13 (mean: 12.1 years). The duration of follow-up was 17 to 56 months (mean: 34 months). Physical closure after operation was observed at 22 to 40 months (mean: 29 months). We removed the screws in 5 of the 6 hips. The results were evaluated using the radiographic measurements of posterior tilt angle (PTA) and Jones' classification for remodeling of the capital femoral epiphysis. There were no severe complications such as avascular necrosis, chondrolysis, and osteoarthritis. The improvement of PTA was 0 to 21 degrees (mean: 10.3 degrees). Four hips were type A and two were type B by Jones' classification. We can conclude that in situ pinning is useful for slipped capital femoral epiphysis.
In this study, we report a very rare case of malignant peripheral nerve sheath tumor (MPNST) arising in the finger tip. A 78 -year-old woman complained of right ring-finger pain and soft tissue mass. We underwent open biopsy of the tumor, and found that the tumor had spread toward the proximal along the digital nerve. The case was diagnosed as MPNST in addition to the histological results. Because of the malignancy, wide excision was performed including ring-finger amputation from the base of the fourth metacarpal bone. No recurrence and metastasis were found for eleven months after surgery. To our knowledge, malignant tumor in the finger is very rare, and no case of MPNST arising in the finger has been reported.
Between September 1995 and March 1998, mid-term results of 66 knees in 55 patients with osteoarthritis treated by Profix (Smith and Nephew, Inc, Memphis, TN) total knee arthroplasty were evaluated clinically and radiologically. All cases were cementless femurs and tibial components were implanted. The average age was 74.1 years (range; 60 to 89 years) at the time of surgery. The follow-up period was an average of 5 years and 10 months (range; 5 to 7 years). The mean JOA knee rating score improved from 46.4 to 73.7 points. The mean extension was —12.2° preoperatively and increased to a mean of —2.3°. The mean FTA improved from 186° to 171° postoperatively. The mean flexion went from 117.5° preoperatively to a mean of 101.5° postoperatively. The mean FTA improved from 186° to 171° postoperatively. There was no loosening or sinking radiographically. On the tibial side, radiolucent lines were noted in 15 knees (22.7%). On the femoral side, radiolucent lines were noted in 7 knees (10.7%). There were no radiolucent lines of more than 2mm in thickness. There was no statistically significant correlation between the occurrence of radiolucent lines and postoperative clinical resuits. Considering loosening and infection, survival rate was 0 %. The Profix system provided excellent and predictable mid-term clinical results in the current series of patients. Total knee arthroplasty with cementless technique was a reliable and effective means of treating osteoarthritis.
We report clinical results of total knee arthroplasty in 22 knees with severe varus deformity. The mean follow-up period was 5.4 years. We define severe varus knee femorotibial angle (FTA) as over 195 degrees. Severe varus knees were classified into the bone defect type and fixed varus type. Medial tibial bone defect is the main cause of varus deformity in the bone defect type. Altough, the fixed varus type reveals large laxity of the lateral supporting structure, it is difficult to correct varus deformity by valgus stress because of severe medial soft tissue contracture. We evaluated clinical results using the Knee Society Score. The knee score improved from 38.6 points to 76.6 points after TKA. The Function score also improved from 40.7 to 80.9. The mean standing FTA was 198.8° (range 195° to 209°) before surgery and corrected to 176.1° (range: 167° to 188°). Four knees, however, was over 180°. Although slight varus instability was observed on stress Xray, it had no significant effects on clinical results.
Fractures of the proximal forearm in young children present problems in management and in the indications for operative treatment. We studied 15 fractures of the forearm treated operatively (13 children) and nonoperatively (2 children). All fractures were not open types. The average age was 10.4 years (range : 3 to 14) and mean follow-up period was 2 years 6 months (range : 6 months to 4 years 5 months). Union was achieved in 14 children and 1 was pseudoarthrosis. The final range of movement was a greater loss of pronation than supination. There was no limitation of function in any patient.
Ipsilateral distal femoral fracture after postoperative femoral neck fracture is a rare complication and treatment is often difficult. We treated three cases in which retrograde supracondylar intramedullary nails were used for internal fixation. The patients consisted of three females with ages ranging from 75 to 89. Two patients underwent hemiarthroplasty and another underwent Gamma nailing. According to AO classification, they were classified into A1 (2 cases) and C1 (1 case), respectively. All patients tended to fall down easily after postoperative femoral neck fracture. Consequently all fractures healed within four months. The average knee range of motion was —10 to 93 degrees. Clinical results were evaluated according to Neer's criteria. All cases were ranked as unsatisfactory. In generally, walking ability tended to deteriorate because multiple fractures occurred ipsilatelly. One case developed secondary femoral fracture at the mid shaft postoperatively, because of jamming between the distal tip of the cement and proximal tip of the intramedullay nail. Use of retrograde supracondylar intramedullary nail is effective for this type of fracture, but we have to be careful about the length of the intramedullary nail before surgical planning. As rigid fixation is difficult for the osteoporotic bone, post operative treatment is also important.
We operatively treated 8 cases of discopathy, which did not respond to long-term conservative therapy. The mean term of conservative therapy was 4.08 years. Because of low back pain, all patients experience disability in their daily life. The clinical results were evaluated by the JOA score, and the recovery rate was determined by Hirabayashi's method. The preoperative mean JOA score was 9.8 points, which changed to 24.5 points, and mean recovery rate was 73.8%. All patients had undergone magnetic resonance imaging (MRI) and discography. Discography is an indispensable examination to check the symptomatic level(s). We think that careful review of medical history is the most important factor in determining indication for operation.
Six patients with spinal arachnoid cyst were treated at the Ryukyu University Hospital from 1990 to 2001. We evaluated the operative results retrospectively. The mean age of these six patients was 48 years (range : 13 to 72 years). They were consisted of one male and five females. All cysts occurred at the dorsal side of the spinal cord. Three cases had extradural arachnoid cyst, and the other three had intradural arachnoid cyst. All patients underwent surgery for cyst excision. For extradural arachnoid cyst, we recognized a stalk between the cyst wall and dura in all cases. Total excision was performed on two cases with tying of the stalk. Partial excision was performed in one case because of adhesion. For intradural arachnoid cyst, one case was treated with laminoplasty and total resection of the cyst, the other two cases were treated with laminectomy and partial cyst wall resection. After surgery, three cases of extradural arachnoid cyst and one case of intradural cyst treated with total resection showed no recurrence and recovered satisfactory. Whereas, the other two cases of intradural arachnoid cyst treated with partial cyst wall resection showed recurrence of cyst and one became worse at follow-up.