Lumbar disc lesion in a narrow sense is lumbago with leg pain due to severe disc degeneration and loss of function, and does not include disc herniation. The MRI findings and clinical symptoms of lumbar disc lesion in patients with history of thirty years illness were examined. The clinical symptoms of the lumbar disc lesion were mainly difficulty of postual change and gait. MRI findings showed moderate and diffuse findings (Grade 2 and 3 of Gipson's classification). The difference between MRI findings and histology of intervertebral disc was slight.
Five years ago, we started treating patients with OPLL by anterior spinal cord decompression through posterior approach for the first time. In the four persons treated for OPLL etc. so far, the kyphotic angles of the concerned region have been appreciated at present.
We present a case of lateral herniation (intraforaminal herniation) which we have trouble in making diagnosis because there is no degenerative change on the responsible disc level. The patient is 47 years old female. April 20th 2003,she felt severe left hip pain and couldn't move. There was a tumor like mass which surround L3 root on MRI. As a result of operation, the tumor like mass turned out not to be tumor but to be lateral disc herniation. We thought it to be a tumor, because there was no degenerative change on L3/4 disc level, so discography and CT discography was not performed. We have second thought that we must perform discography and CT discography case by case.
Between June, 1994 and July, 2003, a total of 370 patients underwent lumbar discectomy for herniated nucleus pulposus. Twenty-two patients (5.9%) were diagnosed as having extraforaminal lumbar disc herniation (ELDH). The average age at the time of surgery was 55.4 years. The level was L2/3 in one case, L3/4 in five cases, L4/5 in nine cases, and L5/S1 in seven cases. Myelography was normal in 14 cases and abnormal in eight cases. However, ELDH was not diagnosed. In only one out of 17 cases, ELDH could not be detected on magnetic resonance imaging (MRI). Selective nerve root block was performed in 16 cases. Pain was reproduced and clinical symptoms improved transiently by nerve root block in all cases. Accurate diagnosis of ELDH was achieved with CT-discography (CTD) in 12 out of 12 cases (100%). Myelography is basically of no value as a diagnostic technique for ELDH. MRI more or less clearly demonstrates the pathology, but present certain cases as false normal. Selective nerve root block is useful for diagnosis at the pathological level. CTD is an excellent diagnostic technique for ELDH, but in order to identify ELDH, it has to be performed whenever myelography is normal or equivocal. In all cases, we performed resection of herniated discs following lateral fenestration. Clinical symptoms improved in all cases after surgery. Accurate preoperative diagnosis estimated by CTD is crucial in order to obtain satisfactory operative results.
We reviewed 17 patients (15 males and 2 females) who had undergone re-operations for degenerative lumbar disease. They were operated for lumbar disc herniation (LDH) in 12, lumbar spinal canal stenosis (LSCS) in 4, and destructive spondyloarthropathy (DSA) in 1. Among the LDH cases, seven were re-operated for recurrence of LDH, and five for postoperative lumbar spinal stenosis. Their symptoms were due to degenerative changes, and additional herniotomy or laminectomy was done with good results. One was combined with root injury during operation. Re-operation proved insufficient for scar formation. In LSCS cases, recurrence of symptoms was due to insufficient decompression as a result of a too narrow laminotomy in the transverse or caudocranial direction. Additional laminectomy and lumbar fusion provided good results. In the DSA case, one of the reasons for incomplete union was insufficient range of spinal fusion. Additional lumbar fusion provided good results.
Magnetic resonance imaging (MRI) is useful for the diagnosis of lumbar radiculopathy. However, because some cases present false normal or equivocal results, and several problems are also encountered in diagnosis, it is difficult to detect small herniated disc material, lateral lumbar canal stenosis, and disc hernia with lumbar canal stenosis on MRI. In order to achieve accurate diagnosis, it is first necessary to carefully read slices of the foramen with regard to asymmetry on parasagittal images. Secondly, other diagnostic radiologic studies (myelography, discography, computed tomography, etc) have to be performed whenever lumbar radiculopathy proves unequivocal. Myelography reveals nerve root compression, shortening, and enlargement, and in order to identify pathological nerve root, selective nerve root block should be performed. Plain computed tomography (CT) always clearly demonstrates the pathology, and CT is especially useful for bone material. CT-discography can more readily and accurately identify the enhanced herniated disc material. These radiologic studies, suggest that CT-discography is most useful for accurate diagnosis.
Twenty-eight total knee arthroplasties for the treatment of osteoarthritis were performed with NexGen LPS-Flex knee prosthesis in 28 patients (Flex group) who had 120 degrees or more knee flexion before operation, and were evaluated for range of motion and tibial rotation at 90 degrees of knee flexion and maximum knee flexion at one year postoperatively. These results were retrospectively compared with the one-year postoperative results of a group of 41 NexGen LPS total knee arthroplasties in 34 patients (LPS group), who had osteoarthritis and 120 degrees or more knee flexion before operation. The average preoperative and postoperative extension was–10±9.1, –1.1±3.1 degrees in the LPS group and –9.9±8.0, –1.4±2.3 degrees in the Flex group respectively. The average preoperative and postoperative flexions were 133.1±10.4, 125.8±10.7 degrees in the LPS group and 135.8±7.4, 133.6±8.2 degrees in the Flex group respectively. The postoperative flexion in the Flex group was higher than that in the LPS group. Compared with the LPS group, tibial internal rotation of 90 degrees of flexion and maximum knee flexion were more frequent and larger in the Flex group.
We report nine cases of osteoarthritis of the hip treated with Japanese Orthopaedics Hip Prosthesis (JOHP) and followed up for one year or more. All patients were female. The average age at operation was 66.3 years (range:62 to 75 years). The average duration of follow-up was 3.5 years (range:1 to 5.7 years). We discussed the results by Japanese Orthopaedic Association (JOA) hip score and radiologically. The average JOA hip score improved from 33 to 82. Especially, pain improved. Radiologically, sinking of the stem was found only in one case, but pain remained. In the other eight cases, no sinking and loosening were found. The results indicate that the JOHP is a useful system for Japanese with acetabular dysplasia, because the form of the cup is not semispherical.
Fifty-seven primary cementless total hip arthroplasties (THAs) were performed in 48 patients with rheumatoid arthritis. The average length of follow-up was 2.4 years (range; 1.1 to 4.4 years). The average age of these 48 patients at the time of surgery was 56.9 years (range; 36 to 78 years). In all patients Kyocera Per Fix HA prosthesis was used. Clinical evaluation based on the JOA score indicated significant improvement from 36.8 points preoperatively to 67.4 points postoperatively. Three patients (5%) complained of thigh pain. There was no evidence of roentgenographic failure such as femoral component subsidence, loosening or osteolysis. Spot welds contacting the porous surfaces were observed in 52 hips (91%). None of the hips showed radiolucent lines adjacent to the porous-surfaced portion of the stems. All femoral components showed bone ingrown fixation. These findings suggest that cementless stem may be successful in rheumatoid patients.
Twenty-six cases of osteoarthritis of the hip joint were treated by total hip arthroplasty together with bone graft using bioabsorbable screws. The follow-up term was over three years in all cases. All cases except one achieved bone union, and had no problems associated with bioabsorbable screws. Only one case of cemented socket showed collapse of the grafted bone and was revised. Bioabsorbable screws are safe and useful for bone graft in total hip arthroplasty in place of metal screws.
The purpose of present study is to report the short-term results of revision total hip arthroplasty (revision THA) without cement. Thirty-four hips of 33 patients who underwent revision THA from September 1998 to August 2002 and who could be followed up for one year or more were enrolled in the study. There were six men seven hips and 27 female 27 hips, and mean age was 73 years. In AAOS classification, Type 2 was eight hips and Type 3 was 26 hips. The average full weight bearing time was 8 days. Only one hip was movement of acetabular component and required re-operation. Initial fixation in acetabular enabled early full weight bearing and early social rehabilitation.
We report two cases of metallosis following total hip arthroplasty (THA). Case 1 was a 57-year-old female, operated for left coxarthrosis by THA with bone-grafting acetabuloplasty with a bipolar endoprosthesis. Sapphire screws were used for grafted bone fixation. Three years after the operation, gradual migration of the outer head occurred and fracture of the screws was observed. Eight years later, radiographs showed severe metallosis of the surrounding tissue. As she had many general disorders, she was observed conservatively. Case 2 was a 57-year-old female with severe right coxarthrosis, operated in the same way as the case 1.4 years after the operation, a big mass was found in the inguinal resion. Radiographs showed migration of the outer head and severe metallosis. In the revision, the mass was found to be black granulaion tissue enveloped by thin membrane. The inner head had warned out severely. Detailed examination, including scanning electron micrograph and energy-dispersive x-ray analysis, revealed that, many rough edged ceramic particles originating from the fractured ceramic screws had become embedded in the inner surface of the polyethylene bearing insert. These ceramic fragments had entered the prosthetic joint space during joint movement, thereafter causing continuous abrasion of the metal head.
Purpose: The purpose of this study was to evaluate the outcome of rotator cuff tears repaired arthroscopically. Methods: Twenty patients underwent arthroscopical rotator cuff repair since 2002. The mean follow-up period was 7.5 months. (range: 3M to 16M) Shoulder functions were assessed before operation and after operation by means of JOA shoulder scoring system. Results: Nine patients had small tears, five had medium tears, two had large tears and four had partial tears. The average score was 58.2 points, before operation and 88.4 points after operation. Conclusions: Arthroscopic rotator cuff repair provides good results.
Many studies have reported the effects of cimetidine on calcific shoulder tendinitis. We investigated 18 additional tests. Eighteen subjects were tested by our clinic from August 2002 to October 2003.There were 16 females and two males. (age 31 to 76, average 52.8) Cimetidine 400mg+etodolac 400mg were given orally every day to all the subjects. Of these, 17 subjects were injected with local anesthetic and dexamethasone 2mg. Plain X-rays show decreased calcified opacity in 12 cases. Four cases cases were considered ineffective possibly because of medical history.
The purpose of this study was to investigate the clinical results of total shoulder arthroplasty in patients with osteoarthritis of the shoulder. In 2001 and 2002, five shoulders in four patients with osteoarthritis of the shoulder without cuff tear underwent shoulder arthroplasty. Their average age was 79 years (range: 72 to 88 years). All the cases were female. We used modular Neer in all cases with bone cement both on glenoid components and humeral stems. The follow-up period averaged 20 months (range : 14 to 32 months). All the cases were investigated using the Japanese Orthopaedic Association shoulder score. The total and pain scores and post operative range of motion of the sholder improved in all cases. No radiological loosening of both components was found the final evaluation.
We report a patient who was reexamined arthroscopically after the modified Bristow procedure. The patient was a 28 years old man. Three years three months previously, he had been treated for recurrent dislocation of the shoulder which had bone defects on the glenoid with the modified Bristow procedure. Because he developed pain of the right shoulder, the shoulder was examined arthroscopically. Arthroscopic findings showed the conjoin tendon and screw used for fixation to be intra-articular and that the bone defect on the glenoid had restored well. The articular side of the transferred coracoid was covered by chondroid tissue though it histologically showed fibrocartilage. The modified Bristow procedure was shown to be an excellent therapy for recurrent dislocation of the shoulder with bone defects on the glenoids.
We present a case of a ring-shaped lateral meniscus in combination with anterior cruciate ligament (ACL) rupture. A 20-year-old man was admitted to our hospital for the purpose of the ACL reconstruction of his right knee. He had a history of valgus stress injury during a badminton game seven months ago. Physical examinations showed anterior instability of the knee, but there were no signs suggesting tear of the lateral meniscus. Magnetic resonance imaging revealed tear of ACL and a fragment-like meniscus structure of the lateral meniscus in the intercondylar notch. Arthroscopic examination showed a ring-shaped lateral meniscus in addition to the ACL tear. The intercondylar portion of the lateral meniscus was well attached to the intercondylar notch. The rest of the lateral meniscus was normal with an intact rim and had a smooth margin.
This paper presents a six-year-old boy with midsubstantial rupture of the anterior cruciate ligament (ACL). ACL injuries are rare in children younger than eight years. The outcome of non-operative treatment, primary ACL repair and extra-articular reconstruction is unsatisfactory. Transphyseal reconstructive surgery in patients who is not near skeletal maturity can result in leg-length discrepancy and angular deformity. For patients who are near skeletal maturity, transphyseal ACL reconstruction is performed at the appropriate skeletal age. For patients who do not meet the skeletal age requirements for transphyseal reconstruction, modification of sports and activity is the preferred treatment.
To assess the results of high tibial osteotomy after accelerated rehabilitation, high tibial osteotomy using blade staple was performed. Between November 2002 and June 2003, eight patients underwent high tibial osteotomy for medial osteoarthritis of the knee. They consisted of one man and seven women with a mean age of 65 years (range : 53 to 72 years). The patients were allowed passive range of motion one day after, and partial weight bearing one week after osteotomy. Five patients were allowed full weight bearing four weeks later and four patients three weeks later. Hospitalization duration was decreased with full weight bearing four weeks after osteotomy, but full weight bearing after three weeks did not decrease duration because of loss of collection with loosening of the blade staple. To decrease hospitalization duration, it is important to perform full weight bearing four weeks after high tibial osteotomy with blade staple.
We report a case of bone destruction of distal clavicle in a long-term dialysis patient. The patient was a 21-year-old male who had been undergoing dialysis for 16 years, developing abnormal mass of the right distal clavicle. Plain shoulder X-rays showed massive soft tissue calcification associated with osteolysis of the distal clavicle, suggesting dystrophic calcification due to renal osteodystrophy. T1-weighted MRI demonstrated mass lesion iso intensity, and T2-weighted MRI showed the low intensity area with small foci of high intensity. Focal curettage was performed suspecting local infection. Pathological diagnosis was hyperparathyroidism. Close inspection of systematic bone X-rays revealed ectopic calcification on the bilateral hip joint and very generalized loss of bone density, with relative increase in the density of the vertebral end-plates, which is the so called 'rugger jersey appearance'. Careful follow-up is necessary to examine systematic bone lesions in long-term dialysis patients.
The patient was a 61-year-old woman. She consulted a first hospital because of knee pain. She was introduced to our institution for close examination due to insufficient fracture of the tibia, atrophic change in her whole bone, and higher serum alkaline phosphatase. She showed low BMD (0.662g/cm², 55% of YAM), high biochemical markers, high excretion of urine calcium and slight increase of serum high sensitive PTH. Suspecting dysfunction of the parathyroid, more examinations were performed. Detecting goiter by the neck US and increase in serum thyroid hormone, hyperthyroidism was diagnosed. We treated her by medication first, which improved the better thyroid function and recovered more bone mass.
Blount's disease is bowleg seen in children caused by disturbed ossification of the proximal metaphysis and medial epiphysis of the tibia. In early stages, this disease often responds well to conservative treatment and prognosis is good. In advanced cases, invasive treatment is indicated, but residual varus deformity, relapse of deformity, unequal leg length, etc. are not uncommon, requiring multiple operations treatment difficult. We recently encountered three cases of Blount's disease. Two were treated by the conventional method, and one invasively by the Illizarov procedure. These experiences are reported in this paper. The two cases treated with the conventional method required multiple operations, but the final outcome evaluated radiographically and clinically was more or less satisfactory. For the case treated with the Ilizarov procedure, three-dimensional correction of varus deformity, internal torsion, and shortened leg was achieved during a single operation. The postoperative course of this case has been favorable, although the follow-up period is short. Different methods of treatment for this disease, especially the conventional invasive procedure and the Ilizarov procedure, were compared.
Rheumatoid arthritis commonly affects the thumb and fingers. Although deformity does not require surgical intervention unless pain is present or a functional deficit exists, tendon rupture may restrict daily activities. We assessed the pattern of subcutaneous extensor or flexor tendon rupture, surgical procedures, and outcome. Fourteen hands in 12 patients (two males and 10 females) were investigated. The average age was 65 years (range : 42 to 84 years). Subcutaneous extensor tendon rupture mainly existed on the ulnar side due to tenosynovitis and subluxation of the ulna head. On the other hand, flexor tendon rupture occurred from the radial to middle side. One case included the flexor pollicis longus and superficialis and profundus tendon to the index finger due to osteophyte of the lunate. The other case included the flexor digitorum superficialis of the middle and ring fingers caused by severe tenosynovitis. Combined operations with synovectomy, tendon transfer or tendon graft and Sauve-Kapandji's procedure were performed. Slight extension deficit was residual, but no obvious disturbance was recognized.
The clinical results of Sauvé-Kapandji procedure for reconstruction of rheumatoid patients were reviewed. From April 1995 to November 2002, we performed Sauvé-Kapandji procedure on 25 rheumatoid patients. The mean follow-up period was 3.5 years (range : 0.6 to 7.8 years). Clinical and X-ray evaluation were assessed. Wrist pain after the operation markedly improved in all patients. Overall patients were satisfied with the functional results of this procedure. There was no nonunion case. Alignment of distal radioulnar joint improved postoperatively. Sauvé-Kapandji procedure is there fore an effective procedure for patients with rheumatoid arthritis.
We investigated 11 patients who underwent surgical treatment for rheumatoid spondylitis of the lumbar spine. Instruments were used in all cases. Improvement was noted in all cases, but there were one pseudoarthrosis, two new vertebral fractures, and two disc space narrowing of the adjacent segment. Immediate and excellent symptomatic improvement can be expected for rheumatoid spondylitis by spine reconstruction composed of sufficient decompression from behind and with the use of some instruments. However, complications by new vertebral fractures and disorder of the adjacent segment in later periods occur in some cases.
We investigated the clinical course of 48 rheumatoid arthritis (RA) patients with amyloidosis who had undergone operation of the joint or cervical spine. The patients consisted of three males and 45 females with a mean age of 40 years. Sixteen patients (34%) had been operated at more than three joints. Eleven patients (23%) had been operated at the cervical spine, and 17 patients (35%) died. The mean period from the time of diagnosis of amyloidisis to death was 2.3 years(range : 2 months to 7 years). Operation-plants must be developed very carefully for amyloidosis. Pre-operative assessment for RA including amyloidosis and inflannatory control are important.
Since the introduction of the clinical path in 1998, our department has conducted various reviews in accordance with CDCs measures for preventing postoperative infections while verifying clinical results as to the duration, administration method, and types of antimicrobial drugs. In this study we investigated changes in the incidence of SSI (CDC) after a shift from postoperative 2-day administration (day of surgery to2nd postoperative day) to postoperative 1-day administration (day of surgery to 1nd postoperative day). Occurrence of SSI was found in one case (0.4%) in the postoperative 1-day administration group (281 cases) against three cases (0.929%) in the postoperative 2-day administration group. The results of the present investigation suggest that postoperative administration of antimicrobial drugs is safe even when the duration of administration is shortened from two to one day after surgery.
We studied physical and blood findings at admission as the prognosis prediction after proximal femoral fracture operation. We compared physical and blood findings at admission between a group regaining walking ability and a group failing to regain walking ability. The cases were females above sixty-five years of age who were able to walk before injury. Ninety-seven cases were investigated between October 2001 and March 2003. There was a statistical difference between the two groups in serum albumin, corpuscular hemoglobin and ages. There was no statistical difference between the two groups in serum protein, C-reactive protein, creatinine clearance, Body Mass Index, O² saturation of artery, and weight. Serum albumin and corpuscular hemoglobin are nutrition assessment indexes. Poor nutritional status is considered a risk factor for proximal femoral fracture.
The Gamma nail is used for the treatment of trochanteric and subtrochanteric fractures because it pravides the theoretical advantage of a load-sharing femoral component. We report the postoperative results of DYAX-A (titanium gamma nail) for trochanteric and subtrochanteric fractures in 24 cases from October 2002 to July 2003 and results of comparison between reamed nailing and unreamed nailing. We found no difference in blood loss, postoperative patients' mobility, and fracture union. But operating time were shorter in the unreamed nailing cases,in which the one step conical reamer was used. The unreamed procedure is useful, especially when shorter operative time and less blood loss is desired. There were few operative and postoperative complications, but cut-out occurred in one case. To avoid cut-out, it is necessary to master the appropriate surgical techniques and insert the lag screw in an appropriate position.
We treated 424 cases of intertrochanteric fractures using the Gamma nail between April 1996 and March 2003. All of the cases were able to walk at the time of the injury. We investigated their postoperative walking ability and conducted multivariate studies from the results, we concluded that early operation using the gamma nail and early rehabilitation helps to prevent loss of walking ability after intertrochanteric fractures.
We studied the results of osteosynthesis of 55 femoral neck fractures in elderly people. Two cases of re-fracture were excluded from analysis, and the remaining 53 cases were divided into two groups. One consisting of patients who underwent hemi-arthroplasty after osteosynthesis (re-op group, 9 cases), and the other which did not (non-re-op group, 44 cases). Unstable fractures showed a higher rate of re-operation than that of stable fractures. The Garden alignment index (GAI) of the lateral view was significantly lower in the re-op group than in the non-re-op group (P<0.05). The interval between the day of injury to operation was significantly longer in the re-op group than in the non-re-op group (P<0.05). These date suggested that we should take into consideration not only Garden classification, but the GAI of the lateral view of X-ray in deciding operative indications, and perform osteosynthesis as soon as possible.
Eight occult fractures of the proximal femur were experienced over the past 30 months. All cases were female. Apparent fracture was not observed on plain X-ray film but was revealed by MR imaging. The incidence of occult fracture of the proximal femur was 5% out of all proximal femoral fractures at our hospital. The mean age at the time of injury was 77.0 years. (33 to 93 years). The mean follow-up period was 3.7 months. (1 to 14 months). Three cases underwent internal fixation, since they were recognized to be complete fracture by MR imaging. The CHS system was used for two cases and CCHS for one case. Since most of the occult fractures were revealed to be incompletely damaged, most were treated conservatively. However, since there were a few cases of occult fractures which were completely damaged as our MR imaging study showed, great case must be taken to investigate whether the occult fracture is incomplete or complete to diminish further damage of the fracture site.
Six cases of distal tibial fracture were treated surgically using two plates. They were classified into C1 (2 cases), C2 (2 cases), C3 (one case) and pseudoarthrosis (one case) according to the AO classification. In all cases, bone union was achieved, and satisfactory results were obtained. This method is useful for distal tibial fractures with comminuted anterior wall.
Ten open tibial fractures were treated with the Ilizarov external fixator. According to the Gustilo classification, two were Grade II, four Grade III a, three Grade III b, and one Grade III c. Bone union was achieved in all the cases without malalignment and deep infection. The external fixation time was 118 days on average. Four cases had pin track infection, and two required debridement with removal of the pins. Three cases were delayed union, and bone chipping was performed. The Ilizarov external fixator is a useful device for the management of open tibial fractures.
A consecutive series of 19 patients (19 hips) with dysplastic hip were treaded at the Kumamoto Orthopaedic Hospital with curved periacetabular osteotomy, described by Naito et al., and followed up for a minimum of six months (average, 13 months). There were one male and 18 females. The average age at the time of operation was 40 years. The average acetabular head index was 96.6% postoperatively, compared with 68.3% preoperatively. The average Japanese Orthopaedic Society Hip Score improved from 70.5 points preoperatively to 90.7 points postoperatively. Eighteen out of the 19 patients were very satisfied with this procedure. There were no major complications, except in six patients who experienced sensory disturbance in the area of lateral femoral cutaneous nerve, which disappeared after several months.
The gait of five patients with unilateral hip ankylosis was analyzed in terms of distribution of foot pressure, stance phase rate (stance phase/gait cycle), step length, and foot angle. There was no relation between leg length discrepancy and talipes equinus. The ankylosing side was significantly shorter than the normal side for stance phase duration. There was no significant difference between the ankylosing side and normal side for step length.Interrelation was seen between the foot angle and external rotation angle of the ankylosing hip.
We treated an 81-year-old female who had femoral fracture with osteomyelitis by MRSA. She underwent osteosynthesis of the femoral neck fracture in 2000. Two years after the operation, her thigh became infected, for which she underwent operations such as removal of prosthesis, continuous irrigation, and plugging of PMMA cement beads with VCM. Unfortunately, she suffered a femoral fracture again. We performed osteosynthesis using the gamma-nail and grafted calcium phosphate cement (Biopex) with VCM to the bone defect, and obtained good results Biopex is useful for grafting to the bone defect when osteosynthesis is required for the treatment of fractures with osteomyelitis by MRSA.
Case 1 was a 47-year-old man who complained of a right foot pain. X-ray and CT showed gas formation in the fifth right toe. Case 2 was a 62-year-old woman who complained of right femoral pain. X-ray and CT showed gas formation in the right femur. These patients had severe diabetes mellitus. Culture revealed the presence of corynebacterium and peptostreptococcus, but not clostridium. These patients were treated with surgical management, antibiotics and skin graft, without hyperbaric oxygen therapy. An antibiotic regimen consisting of penicillin was used initially for both patients. Nonclostridial gas gangrene is extremely rare but is life threatening. Aggressive treatment including surgical management and intravenous antibiotics with or without hyperbaric oxygen therapy must be initiated immediately to minimize morbidity and mortality.
We report two Brodie's abscess located in the metaphysis of the long bone which penetrated the growth plate. In the one case, a 14-year-old girl, the abscess extended in the distal metaphysis and epiphysis of her right femur. Her epiphyseal cartilage had already ossified on radiography, and curetting was performed over the growth plate leaving the drainage tube in the dead space. In the other case, a 13-year-old girl, the abscess spread from the distal metaphysis to the epiphysis of her right tibia. In this case the epiphyseal cartilage still existed, so we curatted only the metaphyseal lesion from apprehension of growth disturbance. Both cases were observed for over six months, during which time experience any symptoms in daily life nor did growth disturbance of the bone progress.
A 68-year-old man presented with about a week history of purpura on the extremities follwing fever elevation. He exhibited painful swelling of the right sternoclavicular joint. Leukocyte count was 13200 /μl and CRP was 17.02 mg/dl. ESR was 119 mm/hr. X-rays showed a lytic change in the medial end of the right clavicle and hyperostosis in the medial end of clavicle. CT revealed that the medial end of clavicle, the first rib, and a portion of the sternum were eroded. MRI and bone scintigraphy showed arthritis and osteomyelitis. Open biosy indicated Gram positive rod. He underwent a debridement with the pectoralis major muscle covering the bony defect. Operateve findings revealed lytic change of the cortical bone, and abnormal granulation in the bone marrow. When there is evidence of infection beyond a joint, such as myelitis, an aggressive surgical therapy is necessary.
A 68-year old man had been suffering low back pain and a slight fever for two months. He also had hemorrhoid fistulae and used to puncture them using a needle. Pain on both lower extremities started one month later and he had occasional fever around 38 C. When he visited our hospital, he was slightly febrile (37.8 C) and drowsy. He also presented clinical symptoms of meningeal irritation, as well as pollakisuria and hyperreflexia of the patella and Achilles tendon reflex. Sensory disturbance distal to inguinal band was also seen. The Japan Orthopedic Association (JOA) score for lumbar lesion was 8/29. WBC was 12100/ml, CRP was 12.3mg/dl, and ESR was 71mm/1h in blood exams. MRI revealed a mass in isointesity on T1, high intensity on T2 posterior to the 5th vertebral body, suggesting subdural abscess. Emergency incision and drainage were performed. Surgery revealed adhesion between the cauda equina and arachnoid and cauda equina encased abscess. After irrigation and placement of the draining catheter, the wound was closed and antibiotics were administered. Metithiline sensitive staphylococcus aureus was identified from the abscess. After drainage and administration of AB-PC, clinical symptoms and blood test values improved, except for the episode of high fever with skin rush due to allergy to AB-PC. At 10 months after surgery, his JOA score improved to 26/29 and the values of blood test values were within the normal range.
We treated four patients with infected total hip arthroplasties for 16 years. We reviewed onset time of infection, organism, and the timing of reimplantation. Cultures grew staphylococcus epidermidis in two hips, MRSA in one hip, and enterococcus faecium in one hip. Three joints acutely infected were cured by continuous drainage and could retain prosthesis, and 2 - stage reimplantation on one joint that was infected late. Debridement with retention of the prosthesis is a potentially successful treatment for early postoperative infections and should not be attempted in patients with chronic infection.
We retrospectively reviewed 76 patients who had undergone anterior cervical discectomy and interbody fusion without plate instrumentation. They consisted of 62 males and 14 females and were follwed up for an average of 23.1 months (3-48 months). Dynamic roentgenograms taken after surgery were reviewed and final decision was made based on flexion-extension roentgenograms and disappearance of clear zone between a vertebra and bone graft. The overall union rate was 92% (70 of 76patients) and mean time to union was 5.8 months. Solid arthrodesis was achieved in 94% of patients with one-level fusion (48 of 51patients) , 88% of those with two-level fusion (21 of 24 patients), and 100% of those with three-level fusion (1 of 1patient). Pseudoarthrosis with motion was noted in 6 patients. Anterior cervical discectomy and interbody fusion without plate instrumentation results in acceptable fusion rates for not only single-level but also multi-level fusion.
A particular case of the bilateral C5 palsy resulting after operation for cervical spondylotic amyotrophy is reported here. An 89-year-old female suffered from muscle weakness in the left shoulder girdle. In primary physical examination, manual muscle testing (MMT) of the ipsilateral trapezius muscle and biceps muscle were both 0(zero). Aslightly long tract sign was also pointed out, but there was no sensory disorder. X-ray findings demonstrated a narrow spinal canal from the C3 to C7 level. Magnetic resonance imaging (MRI) revealed that the left anterolateral element compressed the spinal cord severely at C4/5 and moderately at C3/4. Anterior interbody fusion at C3/4 and en-block laminoplasty from C4-7 were therefore performed. Although muscle weakness more or less recovered once postoperatively, subsequent bilateral C5 palsy (MMT 1) was indentified. After ten months of follw-up without any additional treatment, the palsy recovered spontaneously to MMT 4. It has been suggested that postoperative C5 palsy tends to occur after posterior decompression of severe anterior C4/5 compression. In the treatment of cervical spondylotic amyotrophy, especially when severe C4/5 compression is suspected, simultaneous foraminotomy should be necessary for preventing anxious postoperative C5 palsy.
(Objective) Complications that arise follwing anterior fusion of the cervical spine using a plate are an important clinical issue. We therefore monitored patients who underwent anterior fusion at our hospital and investigated complications associated with this surgery. (Subjects) Subjects were 126 patients (86 male, 40 female ; age range 17-78 years, mean age 52.5) who underwent anterior fusion of the cervical spine using a plate between November 1993 and June 2003. The duration of postoperative follow-up ranged from 0.5 to 80 months (mean : 15.8 months). The breakdown of the 126 patients was as follws : disk herniation (n=60), spondylotic myelopathy (n=27), dislocation fracture (n=18), vertebral body fracture (n=6), spondylotic radiculopathy (n=5), neoplasm (n=2), metastatic neoplasm (n=2), and others (n=6). The CSLP (AO) plate was used in 121 patients, PEAK plate in three patients, and Caspar plate in two patients. (Results) The following six complications were documented : postoperative screw damage (n=3), plate damage (n=2), discomfort in swallowing (n=2) and loosened screw (n=1). However, no plate-related complications were observed during surgery.