Minimal invasive surgery has revolutionized all areas of surgery. The use of endoscopes permits surgical maneuvers to be performed through small incisions. In this report, we present a video-assisted endoscopic surgery for a variety of spinal indications. Thoracoscopy was used to release complex spinal curvatures for the reduction of scoliosis and to resect spinal cord tumors developing into the thorax. Laparoscopic retroperitoneal techniques were used for anterior arthrodesis to restore spinal segmental stability in patients with spinal fracture. In addition, the posterior approach was used for lumbar discectomy for the treatment of disc herniation using endoscopic techniques. In conclusion, endoscopic spinal surgery is designed for conventional operations involving extensive anatomic dissections performed via small incisions. These procedures yield shorter recovery times and less morbidity.
Various methods are available for the surgical treatment of supracondylar fracture of the femur in elderly patients at surgical institutions. In elderly patients, osteoporotic changes of the femur, especially in the condyle, makes complete treatment difficult. If internal fixation does not provide static stabilization of the fracture, external fixation is required additionally. We use the Kirschner wire for imtramedurally nailing using the Ender nail etc. External fixation is initially performed to treat supracondylar fracture of the femur in elderly patients (over 70) capable only of lower grade activity in daily life. In the recent five years, 20 patients with supracondylar fracture of the femur were treated surgically. Ten were treated using the K-wire imtramedullary nail. All achieved bone union finally and loss of activity in daily life was minimum. The clinical outcome was considered satisfactory. Our method provides better management for elderly patients with osteoporosis and lower grade activity, because it requires little costs and less surgical invasion.
Patellar tendon rupture rarely occurs in adults without systemic diseases. We report two cases of fresh patellar tendon rupture treated with augmentation using the Leeds-Keio artificial ligament. The remnants of the ruptured tendon were preserved. The artificial ligament was passed transversely through the distal end of the quadriceps tendon along the proximal margin of the patella and it crossed itself in front of the patella in a cross shape. Both ends of the implant were passed through a transverse tunnel drilled through the tibial tuberosity. CPM exercise was begun on the second day after surgery. Active knee extension was permitted at three weeks postoperatively. The advantages of this method are there is no need for immobilization and that rehabilitation is much quicker.
Ruptured Achilles tendon has been treated by the percutaneous repair method since 1995 at our hospital. This report discusses the treatment results and MRI study. The subjects were 56 cases (27 males, 29 females), whose average age was 44.6 (range: 27 to 61). Five patients were followed up on MRI by their consent. After three months from operation, average dorsal flexion was 16.4 degrees. On MRI, after one month, the Achilles tendon showed the dumbbell type. After three months, all cases showed the spindle type. Conservative treatment is the established method but this method provides fasten results. A possible reason may be percutaneous repair can draw end to end more than conservative treatment, and comparative early bearing and training of ankle motion provides good range of ankle dorsal flexion.
Traumatic dislocations of the hip joint are high energy and uncommon injuries. Traumatic anterior dislocation accounts for about 10% of all hip dislocations and is classified into superior and inferior types. We experienced 3 cases of superior type anterior hip dislocation. The average age was 33 years and the follow-up period ranged from 3 to 12 months, averaging 7 months. Secondary osteoarthritis and avascular necrosis (AVN) of the femoral head are reported as complications of anterior hip dislocation. The prevalence of AVN may be higher when reduction is delayed for more than 24 hours. All our patients took early reduction, averaging 2.5 hours, post injury one open reduction and the others closed reduction. Good ROM was achieved and pain disappeared. No arthritis and AVN of the femoral head were seen. After reduction, all our cases were inhibited with weight bearing for more than 3 weeks. All achieved good clinical results, but further follow-up is required.
Traumatic dislocation and fracture-dislocation of the hip is an absolute orthopedic emergency. Early recognition and prompt, stable reduction is the essence of successful management. Four cases of traumatic dislocation and fracture-dislocation of the hip were treated during 1999-2001. The patients ranged in age from 22 to 66 years, and were followed for a mean period of 1.6 years after surgery. Traumatic dislocation and fracture-dislocation of the hip were classified according to the Thompson & Epstein classification; 1 in Type I, 0 in Type II, 1 in Type III, and 2 in Type IV. Three patients were treated with open reduction within six hours.-One patient was treated with closed reduction within six hours and internal fixation two days after injury. JOA hip score and Thompson & Epstein classification were used for clinical assessment. Thompson & Epstein classification were one Excellent, two Good and one Poor. One patient (Type IV) developed posttraumatic osteoarthritis.
Destructive spondyloarthropathy (DSA) in patients on hemodialysis due to chronic renal failure was first reported by Kuntz et al. in 1984. As far as we know, there are few reports on surgical treatment for lumbar lesion. We here report two patients with DSA of the lumbar spine treated successfully. Both patients had gait disturbance because of severe pain, whose X-ray of the lumbar spine showed narrowing of the disc space between L4 and L5 and instability of the vertebral body. We performed posterolateral fusion combined with posterior lumbar interbody fusion. Rigid fusion seems to be an optimal surgical option for these patients. However, it is often difficult because of the poor general conditions of the patients. It is very important to select the appropriate operative method according to the patients conditions.
In RA cases requiring fixation, wire cannot be passed if the bone is weak. We experienced two cases of cutout and looseness of wire with the occipital after occipito-cervical posterior fusion for RA. We performed re-fixation using the Tekmilon cable system instead of wire. By positioning the bar hole of the occipital at the caudal of the inion, good fixability was obtained. These results suggest that the Tekmilon cable system applies stress dispersively, and that cutout of wire does not occur easily. This allows operations to be carried out comparatively safely.
Ishemic heart disease including myocardial infarction is one of the most serious perioperative complications. We experienced two cases of ischemic heart disease due to abrupt arrhythmia after spinal surgery. One case showed ventricular fibrillation soon after surgery and the other showed atrial premature contraction two days after surgery on electrocardiogram. Although they did not present any abnormal findings on routine preoperative examinations (chest x-ray radiograph, electrocardiogram, and echocardiogram), constriction of the coronary artery was indicated by postoperative angiography. They were treated by coronary artery bypass graft and completely recovered without after-effects. Patients with spinal disorders seldom display symptoms of myocardial ischemia because of reduced daily activities in terms of motor dysfunction. On the other hand, positional changes under unstable cardiovascular dynamics during surgery may have possibility to induce the ischemic responses of heart muscles. In other words, it is extremely difficult to make the accurate diagnosis of myocardial ischemia preoperatively and is critical once it occurrs. We should bear in mind that asymptomatic myocardial ischemic patients who do not show any abnormal findings in usual preoperative screening do exist when attempting spinal surgery.
We report a case of anterior decompression and fusion by the sternum splitting approach for upper thoracic spinal kyphotic deformity caused by tuberculous spondylitis. The patient was a 65-year-old male. He suffered from tuberculous spondylitis at 9 years of age and underwent posterior fusion at that time. He has been suffering from lower limb paresis and weakness since one year ago, and these symptoms are deteriorating gradually. MRI examination showed severe anterior compression of the spinal cord due to kyphosis at the T2-4 level. We performed anterior decompression and fusion by the sternum splitting approach with thoracoscopy, and successfully obtained good results. Although anterior decompression and fusion by the sternum splitting approach has been reported as technically difficult because of dangerous anatomical problems involved, such as major vessels, and depth of surgical approach, these disadvantages were somewhat resolved by using thoracoscopy. We concluded that sternum splitting approach assisted with thoracoscopy is useful for the upper thoracic anterior approach.
Objective: The aim of this study was to determine whether leg length discrepancy after developmental dysplasia of the hip affects lumbar degenerative changes or not. Method: The subjects were eight women who had leg length discrepancy more than 3cm due to developmental dysplasia of the hip or supportive arthritis of the hip in their childhood, ranging in age from 43 to 78 years. We investigated sagittal and coronal alignment and degenerative changes of the thoracolumbar spine on plane X-ray film, and according to the JOA score except I-B and I-C and contracture of the hip. Results: X-ray film of the lumbar vertebrae showed mild degenerative deformity and scoliosis in all patients. The size of osteophytes was larger and the number was more on the concave side than convex side. Five subjects had extension contracture of the hip. The mean JOA score was 18.4 (ranging from 16 to 22). There was no significant difference in the I-A score between the patients and control group. Conclusion: Leg length discrepancy more than 3 cm after developmental dysplasia of the hip was found to have no significant effects on lumbar degenerative changes and low back pain.
We studied 16 patients with lumbar or thoracolumbar idiopathic scoliosis treated with anterior spinal fusion alone. Four patients were men and 12 were women. The average age at the time of operation was 16.1 years, and the average follow-up time was 65 months. Preoperatively, the mean Cobb angle of the major curve was 60 degrees, which improved to 22.8 degrees after operation. The mean recovery rate of the Cobb angle was 63%. There were 7 patients in whom instrumentations ended one vertebra above the lowest end vertebra (Group A), whereas there were 9 patients in whom lowest end vertebras were involved in the instrumented areas (Group B). Postoperatively, the mean instrumented disc angle just below the lowest instrumented vertebra of the patients in group A was sigificantly greater than that of the patients in group B. Furthermore, in group A, frequency of posterior slip of the lowest instrumented vertebra was significantly greater than that in group B. These results suggest that there exists potential risk of disc degeneration just below the lowest instrumented vertebra when the lowest end vertebra is not involved in the fusion area.
Large curves between 50 and 80 degrees progress after skeletal maturity in untrated idiopathic scoliosis. In patients treated surgically for idiopathic scoliosis, curves sometime progress after removal of spinal instrumentation. Twenty-seven patients were evaluated to quantitate curve progression after removal of spinal instrumentation and identify factors leading to curve progression. Curve progressed in nine out of the twenty-seven patients. Curve progression is related to only curve magnitude, and not to correction rate, interval between operation and removal of spinal instrumentation, age, Rissers sign, type of scoliosis (adolescent, juvenile, infantile) , and spinal balance.
We report a case of 12th thoracic vertebral fracture with late neuropathy that was treated conservatively. A 69-year-old man fell from a roof and suffered severe back pain. He was admitted to the hospital of his family physician. After one month, his back pain did not improve, and he was referred to our hospital. The fracture was diagnosed on a radiograph. Ten days later, dorsiflexion of the bilateral ankle was weakening, and MRI indicated that the fractured vertebral body was compressing the spinal cord. Neuropathy due to the fracture was diagnosed and a body cast was applied. After casting, his pain diminished and muscle strength of his ankle gradually recovered. After two months of casting, he was discharged on foot with a hard brace.
We report a patient with a necrotizing fasciitis whose life could be saved by amputation of the upper limb. A 57-year-old man had watery diarrhea and right ring finger pain without a definite trauma. He visited other hospital. But two days later, he had severe pain, swelling, and blood circulation loss at the finger. The patient was therefore transferred to our hospital. Within a few hours, skin lesion aggravated, and spread to his right shoulder and around the trunk. Necrotizing fasciitis was diagnosed and his upper right limb was amputated. Streptococcus pyogenes was cultured in his blood. Intravenous antibiotics, including penicillin G and clindamycin, were added just after operation. About two months after operation, his general conditions improved.
We treated a comparatively rare case of septic arthritis of the knee joint followed by common cold in an infant, caused by β-lactamase-negative ampicillin-resistant H. influenzae (BLNAR). The patient was 9 months of age. Knee joint arthritis symptoms appeared following common cold and middle ear infection. We detected H. influenzae from the fluid of the knee joint, and from the effusion of the middle ear and throat. The results of bacteriological tests indicated BLNAR. It was treated by surgical drainage and antibiotics injection. BLNAR is rapidly increasing in recent years. BLNAR can therefore be suspected when infantile septic arthritis especially following common cold. In this case, it is very important to detect the joint fluid by bacteriological tests and carefully select the antibiotics to use without residual disability.
It is well known that cervical spondylosis in athetoid cerebral palsy results from abnormal muscle tension. However there is no information on low back pain in athetoid cerebral palsy. Sixty-one athetoid cerebral palsy workers were investigated by questionnaire. Forty-one (67.2%) athetoid cerebral palsy workers had low back pain in daily life. X-ray examination was performed on 29 athetoid cerebral palsy workers. Lumbar spondylolyses were shown in 17 (58.6%). Endplate lesions of the lumbar vertebral body were found in 91 vertebras (53.5%). There were no significant differences between age and occurrence of low back pain or spondylolyses. These results suggest that abnormal athetoid mortion is related to the occurrence of the spondylolyses.
We experienced a 22-year-old man who had bilateral hip dislocations due to spastic quadriplegia. At age seven and ten, he underwent selective soft tissue release with subluxation of the hips, but failed to obtain reduction. He was admitted to our institution because he could not tolerate hip pain any more. Both hips were kept in adduction and internal rotation position on wheelchair. He could not move without severe hip pain which disrupted daily activities. X-ray finding showed bilateral hip dislocations and degenerative changes of the femoral head. For reasons that there were degenerative changes of the femoral head, a long time had passed after dislocation, and presence of severe pain, we selected proximal femoral resection-interposition arthroplasty for the hip dislocations. We operated on his left hip first, then his right hip three months later. Skin traction was not possible for his left hip after the first operation because of low back pain. So we used an external fixation to keep distance of his right hip joint and removed it after eight weeks. Five months after the operations, X-ray showed a few heterotopic bones and proximal migration of the femur but he was able to sit with no difficulty or pain.
Between 1974 and 2002, eleven patients (1 male and 10 females) received a delayed diagnosis of congenital dislocation of the hip (CDH) 7 to 44 months (the average age 17 months) after birth. Four patients had not walked yet, and 7 patients had started walking at an average of 13.7 months after birth. Difficulty in walking was noticed in 7 patients. There were not limitations of hip joint abduction or asymmetry of thigh folds in half of the patients. It was concluded that other methods such as ultrasound screening were necessary to prevent overlooking CDH, since some patients with CDH were lacking of typical clinical signs.
A case of bilateral 4th brachymetatarsia treated by callotasis is reported. A 14-year-old girl visited our department because her bilateral 4th toes were naturally short and hypoplastic. X-ray showed that bilateral 4th metatarsals were as short as 15 mm. Because of cosmetic problems, she required corrective surgery. The middle parts of the bilateral 4th metatarsal were explored and small external fixation devices for distraction were applied. Osteotomy was performed while preserving the periosteum. Distraction of 0.25 mm per day commenced at 3.5 weeks after surgery. As good callus formation was recognized on serial X-rays, the value of lengthening was increased up to 0.5 mm per day at 10 weeks after surgery. Distraction was discontinued when the 4th metatarsals appeared long enough. The external device was removed at 14 weeks after surgery. No complications occurred and clinical results were excellent. Callotasis is considered to be a beneficial procedure for the treatment of brachymetatarsia.
We performed bloody therapy for a complicated tarsal tunnel syndrome case of comparatively rare congenital tarsal bone fusion symptoms, and obtained good results. The patient was a 34-year-old firefighter complaining chiefly of numbness of the sole and pain. He underwent conservative treatment at another hospital, and the symptoms improved at one time. However, symptoms aggravated again after skiing and operations were reguired. The operation ablated release of tarsal tunnel and adhesion department. Spontaneous pain disappeared three days after operation and numbness one week after. He achieved full load gait, and there was rarely pain in gait. Physical compression by ski boots is thought to aggravate symptoms.
Fracture-dislocation of the ankle with the fibula fixed behind the tibia (Bosworth fracture-dislocation) is rare. We report a case of Bosworth fracture-dislocation. The patient was a 26-year-old man. He injured his left ankle while falling down the stairs. He underwent open reduction and internal fixation three days after injury. One year after operation, he had no disabilities in daily activities, but range of motion of his ankle was limited to 10 degrees in dorsiflexion and plantal-flxation respectively. CT is useful for diagnosing Bosworth fracture-dislocation, but it is the most important to recognize the entity of this fracture-dislocation.
Bosworth fracture-dislocation is a rare fracture-dislocation of the ankle joint with the proximal part of the fibula entrapped behind the tibia. The patients foot displays severe external rotation. For this case, we attempted close reduction, but because it failed, open reduction was performed using syndesmotic screws. X-rays do reveal characteristics of this dislocation, but it is often overlooked in examination, resulting in inappropriate treatment and disastrous outcome. This report discusses a case of Bosworth fracture-dislocation experienced and related studies.
We performed glenoid osteotomy on a weight-bearing shoulder with posterior subluxation. The patient was a 44-year-old paraplegia male. He complained of disability and pain in his right shoulder after starting playing tennis. His shoulder pain subsided after a local anesthetic injection at the gleno-humeral joint. Plain X-ray films showed osteophyte in the humeral head and osteosclerotic change in the glenoid. Arthrogram did not indicate rotator cuff tear. CT indicated narrowing of the posterior joint space and posterior subluxation of the humeral head. We performed posterior open-wedge glenoid osteotomy and capsular shift. The follow-up period was 7 years. He did not complain of disability and pain even during tennis. CT showed excellent congruency of the gleno-humeral joint. J.O.A score was 88 points seven years after operation and 55 points in preoperatively and he was satisfied with his shoulder function.
Since 2000, we have performed ultrasonography (US) on 57 shoulders of patients who underwent shoulder US prior to surgery and arthoroscopy. We investigated the type (size) of rotator cuff tear from US findings. Aloca SSD-650CL (7.5 MHz prove) was used for this study. We determined complete tear in findings with defects, thinning, nonvisualization, and low echo area in full layer, and partial tear in findings with partial defects, low echo area, and heterogeneous internal echo pattern. The correspondence ratio of US findings to those in surgery resulted in an accurancy of 81.6% for complete tears, but the correspondence ratio for each type was 40.4%. For medium and large tears, we diagnosed the type of cuff tear from the findings of US, lower grade than finding in surgery. It was difficult to discriminate small tears from partial tears, but examination of US was found to be useful for determining the method of surgery.
The purpose of this study was to determine the prevalence of cuff tear and acromioclavicular joint (ACJ) osteoarthrosis by magnetic resonance imaging (MRI) evaluation in symptomatic shoulders. MRI was performed on 124 shoulders in 115 patients whose age ranged from 16 to 83 years (average: 58.0 years). There were 74 men (79 shoulders) and 41 women (45 shoulders). The patients were divided into three groups according to age; A group (10 shoulders: 16-29 years), B group (43 shoulders: 30-59 years), and C group (71 shoulders: 60-83 years). Rotator cuff tears and ACJ osteoarthrosis were graded on scales 0 to 3 (normal, increased signal intensity, incomplete, complete), and 1 to 4 (none, mild, moderate, severe), respectively. There was a significant difference in the severity of the cuff tears and the ACJ osteoarthrosis with respect to age. 20% of the shoulders were graded incomplete or complete cuff tears in group A, 88% in group B, and 93% in group C. No shoulders were graded moderate or severe ACJ changes in group A, 63% in group B, and 93% in group C. There was a definite correlation between the cuff tears and ACJ osteoarthrosis. MRI of the symptomatic shoulders indicated well correlation between the rotator cuff tears and ACJ osteoarthrosis.
The ranges of bone lesion and synovial membrane lesion in RA hip joints were examined using MRI, and compared with histopathologic images. T1 emphasized images are able to indicate the range of the lesions rich in blood circulation of the synovial membrane, and low in blood circulation in territories with signals that show tendency of blood distributor around synovial membrane lesion. These results suggest that T1 emphasized images conbined with the usual T1 emphasized image provide useful information for determining the remedy for RA.
Synovial cyst is a relative disease. We report a synovial cyst with literature. The cyst reduced remarkably after arthrography. A 45-year-old woman had been suffering back pain and left leg pain for seven months, and was unable to stand or walk. MRI indicated a tumor in the left side between L5 and S1, and arthrography was performed to remove the synovial cysts. After arthrography, pain of the left leg reduced remarkably and the cystic component was found to have disappeared in MRI. No lumbar pain nor left leg pain recurred. Way of curing synovial cysts include resting, use of instruments, steroid injection, and operation to remove a part of the vertebral arch, and removal of the synovial cysts. In this case, the wall of the cysts broke when the needle of the arthrography was injected, and the components of the cyst leaked out. In the removal of synovial cysts, arthrography is sometimes useful for diagnosis and curing.
We report four cases of femoral shaft fracture after operative treatment for femoral neck fracture. All cases were women aged 68 to 91 years. They were studied from January 1999 to June 2001. Three femoral shaft fractures occurred three months after operation for femoral neck fracture and were treated using the long gamma nail. One femoral shaft fracture occurred four months after operation and was treated using the intramedullary nail. Two cases were treated using the gamma nail without distal locking screw for the femoral neck fracture, one using the gamma nail with distal locking screw, and the remaining one using the compression hip screw and canulated cancellous hip screw. In all cases, postoperative femur shaft fracture occurred in an early stage. Treatment for this fracture needs to be selected in consideration of union of the femur neck fracture. The long gamma nail and intramedullary nail were found to be useful for secondary femoral shaft fracture.
Re-operation for osteosynthesis with long gamma nail is a valid therapy for femoral shaft fracture after osteosynthesis with PFN. We experienced a case in which the implant broke 10 months after the second operation. Compression on the fracture location may have been slight because of strong intramedullary fixation, and may have caused pseudoarthrosis of the femoral shaft, eventually leading to the breaking of the implant. An alternative method to treat pseudoarthrosis is to modify the design of implants or dynamization. However, dynamization requires caution in ensuring against breaking of the cortex of the femoral bone by the nail itself. Therefore the nail must be modified to suit the bone.
Dislodgement of the polyethylene liner is an increasingly common complication following total hip arthroplasty. We present three cases of dislodgement of the polyethylene liner after total hip arthroplasty using the Harris-Galante porous acetabular component. At the revision surgery, some tines of the metal shell were broken and the grasping points of the polyethylene liner were severely damaged. Metallosis around the joint was also observed. These dislodgements are considered to have been caused by the failure of the liner-locking mechanism. In each case, postoperative course was good. These results indicate the need to recognize the importance of early treatment for postoperative mechanical failure.
We have experienced a case of posterolateral rotatory instability (PLRI) in post-traumatic cubitus varus. The patient was a 35-year-old male with apprehension of his left elbow. He had a history of fracture of the humerus at age nine months. He was treated using a plaster cast, but it slipped off after one week. He had not received any treatment since then. Unstableness of his left elbow has been noticed since five years old. On his visit to our clinic, the range of motion of his left elbow was 5 to 135 degrees. He presented deformity of the left elbow which was 5 degrees cubitus varus and 20 degrees internal rotation. Radiogram showed ulnar deviation of the olecranon, hypertrophy of the radial head, and enlarged curvature of the trochlea notch. He showed not only 20 degrees varus instability but also posteolateral rotatory instability. Correction osteotomy of the humerus and reconstruction of the lateral ulna collateral ligament with use of a palmaris longus tendon were performed. Three years postoperatively, there has been no recurrence of apprehension and lateral instability.
Five cases of stage IIIB or IV Kienböcks disease were treated by scaphocapitate arthrodesis and tendon ball implantation. Three were male and two female, with age at operation ranging from 36 years to 64 years with an average of 50 years. Four patients were categorized according to Lichtmans criteria as being in stage IIIB and one in IV. The follow-up period ranged from four months to three years. Postoperative wrist pain decreased in all. Grip strength improved from an average of 12.3kg to 22.6kg. The postoperative range of motion of the wrist joint increased from 49.8° to 64.0°.
Injection study using contrast medium and lidocaine was performed on the 16 middle fingers of normal volunteers to evaluate correctness of injection techniques. We used two different single injections at the palmophalangeal crease; subcutaneous and transthecal. Agent location was evaluated by roentgen studies. The success rate of the subcutaneous injection was 100%. With the transthecal injection, we found agents inside and outside the tendon sheath in all cases. Success rate was therefore 0 %. Since the transthecal digital block was first introduced by Chiu in 1990, many authors have described the anesthetic effect as satisfactory. But the transthecal digital block technique presents considerable concern. The mechanism of the single injection transthecal digital block was concluded as unclear in this study.
We surgically treated six patients with decubitus ulcers with gluteus maximus myocutaneous flap. The six cases comprised of three men and three women ranging in age from 47 to 89 years (mean: 60 years). Four had sacral decubitus ulcers and two had sciatic decubitus ulcers. Lesions ranged in size from 6 × 4 cm to 16×12 cm and all were evaluated as Shea type IV. Surgical treatment produced gratifying results, completely curing the ducubitus ulcers in all six patients. Of these six patients, five were treated with gluteus maximus myocutaneous flap combining Dufourmentel flap and the remaining one by gluteus maximus myocutaneous flap only because the flap could not be transferred sufficiently to cover the decubitus ulcer. In general, this method seems to be technically safe.
Acute spinal subdural hematoma is a very rare cause of spinal cord compression. When it does occur, it may have disastrous consequence. The formation of acute spinal subdural hematoma may result from iatrogenic causes such as spinal puncture or epidural anesthesia in association with coagulation of abnormalities. Because of spinal emergency, the accuracy of diagnosis and time interval between the onset of symptoms and surgical evacuation are very important, and the therapeutic outcomes are determined by these factors. We report a case of an elderly male with a history of liver cirrhosis who developed spinal subdural hematoma. The patient complained of sudden severe back pain and flaccid paraplegia with sensory deficit. Although the surgical evacuation was performed five hours after the symptoms first appeared, there were no remarkable improvements in neurological conditions after surgical evacuation.
We retrospectively reviewed seven patients who had undergone a fascial patch repair of massive rotator cuff tears to evaluate efficacy of this surgery between August 2000 and November 2002. The mean age of the seven patients (six males, one female) was 56.7 years (47 to 74 years). Four patients recalled traumatic event. The average duration of time between the onset of symptoms and surgical repair was 25 months. All patients were evaluated before and after surgery based on their JOA score (pain, function [muscle strength and activities of daily living], range of motion, maximum 80 points). The average preoperative JOA score was 39.8 points, and average postoperative score was 66.1 points. There was a significant decrease in pain and significant increases in muscle strength, ability to perform daily activities, and range of motion. Fascial patch repair of massive rotator cuff tears should provide patients pain relief as well as satisfactory functions and range of motion.
"Whiplash" is a common injury in clinical management, but occasionally patients do not respond to conventional treatment, and become worse instead. We have noted that these severe symptoms represent the classic features of thoracic outlet syndrome (TOS) in the past 10 years. Sixty-four patients were reviewed as neurogenic traumatic TOS (T-group), and 17 patients as TOS associated with cervical disc disease (CT-group) . During treatment, we in itially provided all T-group cases with an explanation of traumatic TOS. Therapeutic muscle toning exercise or use of shoulder-girdle and cervical spine pillow are highly desirable. Use of medication or neck colar, and certain injections are also recommended for CT group cases. Anterior cervical fusion was performed on six patients with CT suffering neck or arm pain related to cervical radiculopathy. All six cases of disc injury displayed chronic residual symptoms after anterior fusion, and underwent additional therapies over an average of 548 days. The long period of convalescence, financial loss through disability, and inevitable medical-legal complications make TTOS one of the most prevalent and important posttraumatic problems faced by medical professionals.
Although anterior spinal decompression and fusion (ASF) serves as the established surgical method for cervical spondylotic myelopathy and cervical disc herniation, there are some cases requiring re-operation because of disorders in adjacent segments over long-term. At our institution thirty-six cases underwent laminoplasty after ASF. Twenty-five cases of them were caused by disorders in the adjacent segments. The risk factors of these disorders in the adjacent segments of ASF evaluated were number of segments of fusion, diameter of spinal canal, presence of stenosis except for fusion segments in the first operation, pre-operative Japanese Orthopaedic Association cervical myelopathy score, pre and post operative cervical alignment. There were no significant differences in all subjects. Although ASF has a high risk of re-operation compared with posterior surgery in the first operation, it also has certain merits. Posterior surgery is not considered superior to anterior surgery only in terms of lower rate of re-operation. We could not identify the risk factors of disorders in the adjacent segments of ASF in this study.
The subject was a 51-year old woman. Extraction was enforced for left L5/S1 extraforaminal lumber disc herniation on October 30, 2001. Remission and the postoperative course of symptoms were excellent. Tumescence, hyposensitivity of lower left thigh, numbness, and low temperature appeared around December 2001, and dropfoot also recurred. She was hospitalized in our department for close examination on May 23, 2002 due to aggravation of symptoms. Tumescence of dysesthesia below both the dominant lower left thigh and lower left thigh, tone changes, and low temperature were seen. On hospitalization, muscle weakness was eminent and gait difficulty was found. No clear dyschromatopsia congenitia information could be obtained in MRI and EMG study. Skin temperature problems, vasomotor disturbance, and Sudecks atrophy were found and treated with original and other medications for the CRPS type II (causalgia RSD) diagnosed. Ketamine drip, epidural block, and lumbar sympathetic ganglia block were performed although the therapeutic effect was slight, The treatment was carried out through cooperation between the departments of this hospital, pain clinic, etc. The patients symptoms alleviated, he was able to walk again and leave the hospital. It has been reported that in some rare cases, treatment is very difficult due mainly to the amalgamating CRPS of the intervertebral disc affected by lumbar vertebra herniation. This report discusses a case of CRPS amalgamating with a very rare intervertebral disc of the lumbar vertebra outside herniation. The case is discussed taking into consideration other related references.
We report a case of allergic reaction to metal after osteosynthesis by titanium implants. A 20-year-old man injured his right upper limb in a traffic accident. Ten days after the accident, internal titanium plate (Mathys's narrow LC-DCP plate) fixation of his humerus shaft fracture was performed and his radius and ulna shaft fracture were fixed by intramedullary nail (Century Medicals TRUE/FLEX rod system). Three months after the operation, redness, papules and erosion appeared around his right upper arm surgical wound. His condition did not improve, so he visited our hospital one and a half years after the operation asking for removal of the titanium implants. In this case, he had no medical history of allergy. We removed the titanium implants and four months later, although there was still slight discoloration, redness and papules disappeared. There was also an increase in eosinophils, suggesting that his allergic reaction was caused by the titanium implants.
We report the postoperative outcomes of treatment for open femoral shaft fractures including Gustilo type III a fracture, with primary fixation using an intramedullary nail within the golden hour. Ten fractures were treated by primary fixation using intramedullary nails. The average patient age at injury was 26.1 years (range: 11 to 62 years). The average follow-up was 26.1 months (range: 17 to 48 months). Fracture were classified as Gustilo type I : 2 cases, Type II : 6 cases, type III a : 2 cases. AO classification showed type A: 2 cases, type B: 7 cases, type C: 1 case. Treatment progressed smoothly without problems and 7 achieved union. Pseudarthrosis occurred in 2 fractures, and union was achieved by exchange of nail and bone transplantation. One Gustilo type III a fracture developed an infection. Though the causal relation between infection and response to operation in Gustilo classification and reaming was not clear for this case, primary fixation should be performed at the least when reaming is necessary.
We performed THA on 48 patients with osteoarthritis using a cup insert with 20 degrees hood and 26 mm femoral head, to prevent hip dislocation. We turned posterior the cup insert about 60 degrees on the plane on which the cup was placed. Good results were obtained, and the average JOA score was 82, up 35 points. No dislocation occurred. This method may be effective for preventing hip dislocation after THA.
Surgical site infection (SSI) is the most common postoperative complication. We used one bioclean room 3 times daily, and perfoming joint replacement over 300 times per year. However, we have never experienced a case of deep SSI. The present study was conducted in order to investigate the air cleanliness of a bioclean room in our institution, and the risk factor of SSI during an operation. Airborne particle and microorganism measurement were performed in order to assess the degree of air cleanliness. Air samples were collected during 16 elective hip and knee arthroplasties which were performed at our institution. Our result, clearly revealed that there were no problems regarding the air cleanliness of a bioclean room at our institution. However, a marked increase in the number of airborne microoganisms was observed in proportion to staff movement. Therefore, the risk factor for SSI was the movement of the staff. We concluded that the proper education of all staff was the most important factor in the prevention of SSI.
Various diseases are known to cause metatarsal sesamoid, and there are very few reports on osteomyelitis. This report discusses a case of osteomyelitis of metatarsal sesamoid experienced, taking available references into consideration.
We reviewed sixteen patients with malignant soft-tissue sarcoma of the subcutis. Of the patients in the current study, seven were male and nine were female. All were treated between 1990 and 2002. The mean follow-up was 2.51 years. Twelve (75%) of the patients underwent operation at another hospital before being referred to us. Eight (67%) of these twelve patients who had received marginal excision at another hospital had microscopic residual tumor on repeated excision. We followed a treatment strategy that consisted of excision with the goal of obtaining wide margins. Three (18.8%) patients developed local recurrences and three (18.8%) distant metastases. Eleven (68.7%) of the sixteen patients remained disease-free, two (12.5%) had no evidence of disease, and three (18.8%) died. Three patients with DOD were rarely extraskeletal osteosarcoma, large size tumors (≥ 5 cm) that were fibrosarcoma, and MFH. The overall five-year survival rate of the patients was 71%. Our results show that histology and size are important prognostic factors in soft tissue sarcoma of the subcutis.
We observed four patients on whom bone allograft sterilized with ethylene oxide gas was used intraoperatively to fill bone defects after curettage. Average age was 16.7 years. They consisted of two males and two females. Two had single bone cyst, one giant cell tumor, and one chondroblastoma. All cases showed swelling and redness around their wound, and discharge from an early period after surgery. Although postoperative infection was suspected, all cultivation was found to be bacteria free. There was no elevation in C-reactive protein from the second week after surgery. Three cases underwent surgical treatment. A case receiving conservative treatment with immunosuppressant agent showed good results of gradual wound healing. We suggest inflammation was induced by residual ethylene oxide of the freeze-dried bone.
We examined the clinical results of surgical treatment for tarsal tunnel syndrome. During the period from April 1986 to August 2002, we treated 81 feet in 62 patients including 11 feet in 6 recurrent cases. Twenty-five feet were left, 26 were right and 15 were bilateral. There were 26 males and 36 females. The average age was 50.2 years (range: 13 to 79 years). Evaluation was performed at a mean follow-up of 27.8 months (range: 1 to 177 months) after the operation. Causes of the tarsal tunnel syndrome were fascia cruris in 6 feet, flexor retinaculum in 30 feet, level of abductor hallucis muscle in 81 feet, tendonitis or tenosynovitis in 7 feet, ganglion or tumors in 7 feet, deformity of bone or joints, varix in 5 feet, and muscle anomaly in 1 foot. Recurrent cases were caused by scar or adhesion of the tibial nerve except for a recurrence case of ganglion. Results were excellent in 78 feet and poor in 3 feet. We believe that careful hemostasis is important for the surgical treatment of tarsal tunnel syndrome to prevent or minimize scar formation or adhesion around the operative nerve.
We report 39 patients with pyogenic spondylitis who were treated from 1987 to 2001. Their age ranged from 18 to 84 years (mean:60.3 years). The follow-up period ranged from one month to 35 months (mean:9.5 months). Seventeen patients suffered from complications, of whom 6 had diabetes mellitus, 3 had liver cirrhosis and 3 had rheumatoid arthritis. The most common pathogen was methicillin-sensitive Staphylococus aureus (MSSA, 6 cases) and methicillin-resistant Staphylococcus (MRSA, 3 cases). Ten cases had complications of the spinal epidural abscess. Thirty-eight cases were diagnosed MRI and scintigraphy. One case could not be diagnosed either by MRI or by scintigraphy at an early stage. Fifteen of these cases were treated conservatively and 24 were treated surgically, because of abscess with meningitis, neurological deficit and resistance to conservative treatment. Two out of the 10 cases of spinal epidural abscess sustained residual pain, and one showed residual neurological deficit. Fales-negative MRI results in diagnosis at early stages of pyogenic spondylitis should be noticed. Surgical treatment at an early stage is recommended for cases with these complications and/or spinal epidural abscess.
Forearm contracture, especially pronation contracture, has been noted after fractures of the forearm, inflammation, osteoarthritis of the wrist and elbow, and spastic paralysis. Although various procedures, such as the Steindler method, Tubby-Denisch method, and osteotomy of the forearm, are recommended for these contractures, progress is not simple but complicated. We report a case of release of the pronator teres muscle and excision of the proximal interosseous membrane for contracture of the forearm due to burn. A 28 year-old male sustained burns over 60% of his body in a traffic accident at 22. Skin graft was performed for his body over ten times, and his right upper limb was amputed. He indicated severe loss of supination after the skin grafts, neurolysis of the median nerve, and opponens plasty. Release of the pronator teres muscle and excision of the proximal interosseous membrane were performed. The operation increased supination from 20 degrees to 80 degrees. He maintained good range of motion after the operation and returned to his previous job.