We reported three cases of coracoacromial arch failure and superior humeral dislocation in natural history following massive rotator cuff tear. They consisted of a 71-year-old male, 84-year-old female, and 72-year-old male with tenderness of the shoulder, hydrarthrosis, restriction of ROM, and or impression in the area in front of the acromion. Their X-ray, CT showed superior humeral dislocation and destruction of the acromion in the diagnostic imaging. There is no effective treatment for this disease. We report the role of coracoacromial ligament and the pathology of coracoacromial arch failure in natural history following massive rotator cuff tear.
Recurrent anterior dislocation of the shoulder is rarely seen in elderly patients. We have experienced three cases of this disease with different real nature. All cases had rotater cuff tear, and two cases had Bankart lesion. Case 1 : A 74-year-old female had severe instability with massive rotater cuff tear and large bony Bankart lesion. Surgical treatment was consisting of fixation of the anterior fragment of the glenoid and arthroscopic rotater cuff repair (ARCR). Case 2 : A 52-year-old female fell and dislocated her shoulder with Bankart lesion and cuff tear four years ago. Only the cuff tear was repaired. Recurrent dislocation of the shoulder occurred without trauma in recent years. Bankart repair and ARCR were performed on this case. Case3 : A 69-year-old female fell and dislocated her shoulder with massive rotater cuff tear without Bankart lesion. Recurrent anterior dislocation of the shoulder occurred several times a week. Surgical treatment was performed using ARCR. This disease is caused by the combination of rotater cuff tear and Bankart lesion in the elderly. It is necessary to maintain satisfactory results by treating both injuries if the need arises.
We experienced three cases of eosinophilic granuloma with chemotherapy. Two cases (Case 1 and 3) had single-system multi-site lesion. Case 1 had the lesion in the right thigh and skull. Case 3 had the lesion in the right pelvis, skull, and left 2th rib. We treated them with chemotherapy (JLSG-02) after biopsy. One case (Case 2) had single-site lesion in the pelvis. We followed him conservatively for one month after biopsy, but the symptoms remained the same. We treated him with chemotherapy (JLSG-02), after which, the lesion tended to decrease. There are some opinions on eosinophilic granuloma but no consensus. We have had experience of chemotherapy for multi-site and intractable single-site lesions. The clinical outcomes were good.
We report a case of McCune-Albright syndrome complicating pituitary adenoma and fibrous dysplasia. The patient was a 17-year-old man. He experienced left thigh pain when he played volley-ball. Left femoral neck fracture was diagnosed by X-ray. There was multiple fibrous dysplasia in the left femoral neck. The fracture was treated by compression hip screw and canulated cancellous hip screw. Union of the femoral neck fracture was poor.
Metastatic tumor of the femur may cause veduced QOL. At our department we usually conduct surgical treatment actively, if vital prognosis is expected in severa months and general condition is good to some extent. Intrameduallay nail with bone cement is performed on the metastatic bone tumor from the trochanter to diaphysis of the femur. This report describes a study on surgical treatment with favorable results.
We reported a 32-year old man, who was referred to our hospital because of recurrence of a primary bone tumor in the right humerus. The patient underwent the initial marginal excision surgery of the tumor at the former hospital, and it recurrently appeared about 2 years after the initial surgery. We diagnosed the tumor as parosteal osteosarcoma after diagnostic work-ups. Wide marginal resection of the tumor at diaphysis of right humerus was conducted. After the pasteurization, the bone was re-implanted and a humeral nail was used for osteosynthesis. Twelve months after the surgery, no local recurrence and no metastatic lesions of the tumor were observed. In addition, functionality and range of motion of the right shoulder were preserved. Following surgery, the patient did not experience any difficulties during normal activities.
We reviewed 80 operated cases of delayed neurological disorder after osteoporotic vertebral fracture. They were divided into two groups by the suffered level: A-group, spinal cord level (T10-L1) and B-group, cauda equina level (L2-L5). We performed anterior surgery on 23 cases and posterior surgery on 57 cases. There were no significant differences in the recovery of paraparesis and ambulant ability between the anterior and posterior surgeries, but anterior surgery provided more pain relief and posterior surgery was less invasive. The A-group with anterior compression and instability showed good indication for anterior surgery and B-group with posterior compression and instability for posterior surgery, but in the intermediate cases, posterior surgery seemed to be better especially for elderly patients with some complications. In the follow-up of these patients, we experienced new fracture of other vertebra in 44% for anterior surgery and 23% for posterior surgery by an average of 16.5 months. The progressive natural course of new vertebral fractures or kyphosis of the spine for these patients with severe osteoporosis will require adequate surgery considering the long period of time after the first surgery.
We evaluated the effectiveness of transpedicular injection of bioactive calcium phosphate cement (CPC) or hydroxyapatite block (HA block) into the vertebral body for the repair of osteoporotic vertebral fracture. We used HA block in one case and in the other three cases, HA block or CPC with postero-lateral fusion using a pedicle screw. Clinical evaluation was carried out according to the Frankel grading and neurological improvement was seen in all cases. The kyphotic angle improved from 27.3 degrees before surgery to 2.5 degrees after surgery, but correction loss occurred 11.3 degrees at final follow-up of an average of 17 months after surgery. Transpedicular injection of bioactive CPC or HA block into the vertebral body using a pedicle screw is useful for repairing osteoporotic vertebral fracture.
In this study we retrospectively reviewed nine cases in which posterior spinal shortening with spinous process wiring was used to treat an osteoporotic vertebral fracture. The average age at surgery was 76 (64-85) years. T12 was collapsed in two patients, T12 and L1 in three, L1 in two, L2 in one, and L3 in one. All patients complained of neurological deficit. Five were unable to walk, and the other four were unable to walk without a cane. The average follow-up period was 17 months after surgery. Local kyphosis was 26.6 degrees preoperatively, 8.9 degrees postoperatively, and 21.4 degrees at the most recent follow-up examination. There were two cases of postoperative complication : one of intervertebral pseudoarthrosis, and the other deep wound infection. All patients obtained significant relief from neurological deficit ; three could walk without a cane, and the other six with a cane.
This study was conducted on five patients (3 males, 2 females) who underwent vertebroplasty with calcium phosphate cement in the treatment of osteoporotic vertebral fracture. The short term results of this surgery was very good for pain relief. Patients were able to walk after two post-operative days. We consider this to be a relatively less invasive surgical method for patients of advanced age.
Sixty-three patients with delayed neurologic deficit due to post-traumatic osteoporotic burst fractutes underwent various kinds of operative methods. Anterior decompression and fusion was performed on eleven patients, posterior decompression and fusion on twenty-five patients, posterior fusion on six patients, posterior spinal shortening on five patients, and vertebroplasty on sixteen patients. Neurologic deficit recovered in all groups but posterior decompression and fusion provided the best results statistically. Posterior spinal shortening improved the correction rate of kyphosis, which did not differ significantly in other groups. Postoperative back pain was less in all patients even though kyphosis remained. Posterior fusion and vertebroplasty provided less blood loss and shorter operative time than other groups. We recommend posterior fusion with vertebroplasty in the absence of posterior compression of the spinal cord. Anterior decompression / fusion or posterior spinal shortening is recommended over surgery for this disease.
We studied the results of total hip arthroplasty using the Kyocera PerFix HA P+ stem compared with normal stem. The average age at operation was 61 years (range: 40 to 79 years). The average duration of follow-up was 1.7 years (range: 1 to 4.2 years). The PerFix HA P+ stem was used in 16 hips, and normal stem in 29 hips. The canal filling rate of the proximal stem region was higher in the P+ stem compared with the normal stem. There were no differences in the improvement of the JOA score, canal flare index of the femur, incidence of spot welds, reactive lines, and stress shielding between the two stem groups. These results suggest that the PerFix HA P+ stem improves the canal filling rate of the proximal stem region, which may decrease the stress shielding for long term follow-up.
Total hip arthroplasty (THA) for high positioned dislocated hips was performed on 13 patients. 10 woman and three men. The mean patient age was 59.6 years (range; 44 to 84). Attempts were made to correct the leg-length discrepancy to an appropriate length in each case. The mean lengthening was 43 mm (range; 30 to 65 mm). One patient complained of sural cutaneous nerve palsy due to overlengthening of the femur, and two patients complained of numbness in the femur nerve area. We consider that the appropriate leg-lengthening to be within 50 mm.
A 63-year-old woman had been suffering from right hip pain for 15 years. She was diagnosed as osteoarthritis of the right hip three years ago. She had noticed pain, swelling of the right lower extremity and a right inguinal mass for two months. When she visited our hospital, the mass in her right groin was palpable and the right lower extremity was remarkably swollen. The mass was elastic, hard, smooth and immobile. She didn't show any infectious symptoms. Erythrocyte sedimentation rate was 20mm/1h and other blood tests were within normal range. Plain radiographs revealed dysplasia of the bilateral hips and moderate degenerative arthritis of the right hip. MRI revealed a 4.0 × 4.0 cm well-defined mass in isointensity on T1, high intensity on T2 anterior and medial to the hip joint and represented the mass that communicated with the right hip, suggesting iliopsoas bursitis. CT revealed a mass that was enhanced slightly with the displacement of femoral vessels medially. Iliopsoas bursitis was diagnosed and she was treated conservatively. Due to granual aggravation of symptoms, needle biopsy was performed to determine malignancy of the tumor two months later. Pathologically no malignancy was confirmed and the mass was resected surgically. The pathological diagnosis of iliopsoas bursitis was made. After the surgery, clinical symptoms improved remarkably.
This report documents insidious subcapital fracture of the femur with alcaptonuria in a 56-year-old-man. He had undergone total hip arthroplasty (THA) in the right side at the age of 53 years, and tenorraphy after Achilles tendon rupture in the right side at 56 years. On his first visit to our hospital, black pigmentation in the auricle and eye ball, and black urine were noted. He revisited our hospital for granual aggravation of left hip pain. Radiographs of the left hip showed displaced subcapital fracture of the femur. During THA, the femoral head and acetabulum were blackish. Histological examination demonstrated brownish pigmentation in the whole femoral head with scattering pieces of the cartilage. In addition to sharing force, accumulation of homogentisic acid in the bone and cartilage in the proximal femur were thought to have caused the subcapital fracture in this case.
This study was undertaken to assess the factors affecting the postoperative range of motion after total knee arthroplasty (TKA). From November 2000 to March 2003, 68 TKA (The Fundation Total Knee System) surgeries were performed on 64 patients. Of these, 33 joints in 32 patients with osteoarthritis were observed as the subjects of this study. The patients were divided into two groups according to the postoperative range of motion (ROM). The average follow-up period was 34 months (range : 18 to 46 months). The good group, defined as having more than 120 degrees range of motion consisted of 20 knees in 19 patients. The poor group with 90 degrees or less consisted of 13 knees in 13 patients. Each group was examined preoperatively, and operatively for factors relating to range of motion after TKA. The results of this study indicated that the factors affecting ROM were preoperative range of flexion and ROM, heights of postoperative joint line, and preoperative and postoperative patellar height.
A study of the relationship between stair-climbing and posterior laxity of knee was performed in 37 patients with osteoarthritis after 44 MG II total knee arthroplasties. Evaluation of ascending and descending stairs was performed using gentle stairs (16 cm-high) and steep stairs (first step : 34-cm high, second step : 23 cm-high) whose heights were the same as two-step bus stairs. Lateral radiograph at 90 degrees of the involved knee in the spine position was taken. The tibilfemoral contact point was identified on the radiograph. The distance from the posterior edge of the tibial component to the tibiofemoral contact point was measured and expressed as a percentage of the total width of the tibial component. The contact-point ratio was used to quantify the posterior laxity. The percentage of patients capable of ascending and descending the gentle stairs and steep stairs in the manner of one foot / stair was 57 and 27 % respectively. The main reason for inability to ascend/descend the gentle and steep stairs in a reciprocal manner was muscle weakness and a resultant feeling of insecurity. The manner of going up and down the gentle and steep stairs was related to the posterior laxity of the knee.
Total knee arthroplasty (TKA) is associated with significant postoperative pain. This subset of patients have an increased risk of venous thrombosis and, are therefore prescribed perioperative prophylactic anti-coagulant drugs, which may increase the risk of catheter removal with epidural analgesia. New strategies for the treatment of postoperative pain are thus required. The technique for the fascia iliaca compartment block was first described by Dalens. This is a interesting technique, particularly when a peripheral nerve stimulator is not available. We evaluated the clinical course of 37 consecutive patients undergoing TKA under spinal and epidural anesthesia. Sixteen patients received the fascia iliaca compartment block (Group 1). The other 21 patients did not as a control group (Group 2). Patients with the fascia iliaca compartment block required a third less postoperative analgesic requirements than the control group in a 4-hour postoperative period (p<0.02). In conclusion, the fascia iliaca compartment block technique is easy, safe and reliable in managing postoperative pain in TKA patients.
Femoral condyle fractures following total knee arthroplasty are difficult to manage, because they are periprosthetic and occur in an elderly population. Three female patients with this fracture with an average age of 81.3 years (range ; 76 to 91 years) treated operatively using a plate system were studied. The average period of follow-up was 23 months (range ; 8 to 43 months). The three fractures were 33-A1, 33-C2 and 33-A1 combined with 32-B1 according to the AO classification. All cases achieved complete bone union, but one case of 33-C2 fracture showed malunion of twenty degree anterior convex angulation. One case of 33-A1 fracture operated with LCP (locking compression plate) was allowed early range of motion exercise and full weight bearing.
We studied the clinical results of intramedullary nailing together with cerclage wiring for long oblique and spiral femoral shaft fractures in aged patients. Between 1999 and 2004, we treated nine fractures. Of which six fractures were proximal shafts, two were middle third shafts and one was distal shaft. The average operating time was 191 minutes for the proximal and middle shaft fractures and 165 minutes for the distal shaft fracture. The average intraoperative bleeding was 1073 ml for the proximal shaft and middle shaft fractures and 180 ml for the distal shaft fracture using tourniquet. All nine cases could start walking exercise under weight-bearing early after the operation due to strong fixation. Before injury, seven cases could walk ; as a result of the surgical treatment, six could walk. Intramedullary nailing together with cerclage wiring imposes heavy operative stress, but provides very good results for bone union and walking ability.
We report two cases of non-union of the femoral shaft fracture after intramedullary nailing. Both cases were treated surgically using re-nailing and decortication. In both cases, bone union was achieved, and satisfactory results were obtained.
We performed osteochondral grafting with mosaicplasty on a patient diagnosed with ankle sprain in spite of osteochondral lesion of the talar dome. A 14-year-old boy sprained his left ankle during a volleuball practice game when he landed on the floor after spiking the ball and his ankle was forced to a varus position. He was diagnosed with ankle sprain and only prescribed compresses. But because of persistent ankle pain at sports, he consulted our hospital six months after injury. The X-ray films showed osteochondral lesion (Berndt and Harty's classification Stage III ) at the antero-lateral part of the talus. Although we performed a preliminary arthroscopic survey of the ankle and osteochondralsynthesis (PDS pin) for the lesion in combination with autograft transplantation six months after injury, it resulted in nonuinon. We performed osteochondral graft with mosaicplasty on the lesion two years after the first operation and gained good results after the re-operation. When traumatic osteochondral lesion of the talus is diagnosed, it is important to differentiate it from ankle sprain. Osteochondral graft with mosaicplasty seems useful in salvage treatment for osteochondral lesion.
A 5-year-old boy was caught in a landslide and sustained injuries including with severe floating knee fracture and Hawkins Type I talus neck fracture. Other fractures were subtrochanteric part of the femur, tibia, fibula, and ankle dislocation fracture. Distal diaphisis of the tibia showed Gustilo Type III a open fracture, for which we performed operative treatment. Other fractures including the talus were treated conservatively. The injured leg was fixed with a long hip spica casting for eight weeks. After eight weeks, Hawkins sign was seen in the talus and considerable callus formations at each fracture site. We started weight bearing. Twelve weeks after the accident, all fracture sites healed, and 16 months after the accident, he had no limited range of motion in his hip, knee, and ankle. He also had no motion pain at each joint. X-ray pictures showed complete union and no avascular necrosis of the talus.
Operative therapy was performed on 11 intra-articular fractures of the calcaneus by means of extended lateral approach with calcaneal plate. Preoperatively, all cases were evaluated by Sanders classification. Clinical evaluation was performed by Maxfield score, and nine out of all 11 cases achieved excellent or good results. Pre-and postoperative changes in radiographic findings were studied. Improvement of the Bhler angle was not necessarily reflected in the clinical results, but on the other hand, improvement of the width index and intra-articular displacement was reflected. This method is considered to be an effective treatment for intra-articular calcaneal fractures.
Dislocations of the peroneal tendon and posterior tibial tendon are comparatively rare disorders. They tend to become habitual and require caution. For the dislocation of the peroneal tendon, the Das de procedure is widely accepted since it incurs minimal sacrifice of other structures. Here we report our modified Das de procedure for tighter fixation of the peroneal or flexor retinaculum. With this procedure, the peroneal or flexor retinaculum is incised at the anterior attachment, the bursa is refreshed, then the retinaculum itself is sutured. We treated 14 patients with this procedure from October 1997 to April 2004 and report the clinical results here. The pationts consisted of nine males and five females with a mean age of 20 years (14 to 35 years), and mean follow-up period of six months (0.5 to 28 months). Thirteen patients had peroneal tendon dislocation (11 patients tore their superior peroneal tendon and two tore the inferior one) and one had posterior tibial tendons dislocation. Symptoms more or less reduced in all cases, but only one patient had redislocation. Often injuries of the ankle joint without fracture are treated as sprains. It is therefore difficult to distinguish whether the tear is of the superior or inferior peroneal tendon in the dislocation of peroneal tendon, and diagnosis and therapy play important roles for this injury.
We report a case of medial plantar nerve injury as a complication of acupuncture needle. A 19-year-old woman complaining of medial right foot pain was treated by acupuncture for medial foot pain. A month after the treatment, the patient suffered from both hypesthesia and paresthesia. Radiological examination revealed a single needle in the right foot. After removal of the needle, clinical course was satisfactory, and hypesthesia and paresthesia improved.
Giant cell tumors (GCT) of hand bones are uncommon and reported more biologically aggressive than those elsewhere. A 17-year-old man with GCT in the right second metacarpal is presented. Physical examination of the dorsal hand showed a mild tenderness with moderate swelling but no erythema. Results from laboratory tests were within normal limits. Radiographs showed an osteolytic lesion in the bone of the metacarpal. CT revealed a mass lesion in the second metacarpal, and evidence of destruction of the volar cortex was present. MR imaging demonstrated a mass lesion in the metacarpal, which was iso intense on T1-weighted and slightly high intense on T2- weighted images. The lesion was obviously enhanced by Gd-DTPA and the cortex was thinned but there was no definite evidence of extraskeletal extension. A complete curettage of the lesion and bone graft was performed through a dorsal approach. The pathological findings were compatible for bone GCT. There was no evidence of local recurrence or metastatic disease two years after surgery.
Two cases of unusual hand tumor causing severe pain in the hand are presented in this study. [Case 1] A 24-year-old man was seen initially with a two month history of pain over the palmar aspect of his thumb. There was no history of trauma or an antecedent event related to the onset of symptoms. Neither neurological deficits nor tumor mass was observed. However, bumping the thumb produced severe pain. Surgical exploration of the thumb demonstrated a tumor fixed to the digital nerve. The mass measured 1 × 1.5mm, consisted of white tissue with well-defined margins and was excised under the operating microscope. Microscopic examination revealed segments of clusters of pacinian corpuscle, and the pathological diagnosis was pacinian neuroma. [Case 2] A 76-year-old woman noticed a eight month history of pain under the nail of her thumb finger. There was no antecedent trauma. She underwent surgical treatment for the tumor. Histology showed nerve bundle separated abundant fibro-fatty tissue. Pathological diagnosis was lipofibromatous hamartoma (neural lipofibroma). Postoperatively, the patients were both free from symptoms. Although Pacinian neuroma and lipofibromatous hamartoma are unusual source of digital pain, they should be kept in mind when approaching any hand tumor.
We treated 29 cases of proximal humeral fractures by intramedullary nail (Targon PH) from July 2002 to October 2004. The patients consisted of seven males and 22 females with a mean age of 76.5 years (range : 54 to 92 years) and a mean follow-up period of 233 days (range : 22 to 561 days). According to the Neer's classification, all fractures were classified as 2-part fracture (12 cases), 3-part fracture (16 cases), and 4-part fracture (1 case). Targon PH provides strong dipping for 3-part and 4-part fractures, and good early stage dipping for osteoporosis cases. Because it provides stable fixed force, p ostoperative treatment can be started, thus improving pain and function from an early stage. So we can expect pain and early improvement of a function.
The purpose of this study is to evaluate the results of surgical treatment using the clavicle hook plate. Between June 2003 and July 2004, nine patients (eight men and one woman), with a mean age of 45 years (20 to 60) were treated using this plate. Six had distal claviclar fracture (Neer type II) and three had AC dislocation. The patients were evaluated after a mean follow up of eight months (4 to 12) using the Japan Orthopaedic Association shoulder score. As the plate was not removed in six patients, we evaluated pain, function, and range of motion. The average JOA score was 77.2 points (65 to 80). Clinical results were satisfactory, but the hook of the plate was found to have migrated to the acromion in all patients on X-ray.
To our knowledge, there are no Japanese reports that patients with acromioclavicular dislocation were treated using clavicular hook plates (AO Clavicle Hook Plate®). Five male patients, aged from 18 to 59 years, with acute acromioclavicular dislocation (Tossy type 3) were treated with the temporary fixation devices. The devices were removed 54 to 133 days after the operation. The mean follow-up period was 7.4 ±4.3 months. Its results were evaluated according to Kawabe's scoring system. The system showed excellent in 4 patients and poor in the remaining one. One developed wound infection before removal of the device. The infection was improved with administration of antibiotics and removal of the device. Another patient had night pain. Subluxations were found in 3 patients. Despite these complications, no functional disorders of shoulder joints were found on ADL. This device is useful to treat acute acromioclavicular dislocation.
Partial or complete aplasia of the posterior arch of the atlas is a rare anomaly. The purpose of this paper is to illustrate radiological findings and review literature on congenital defects of the posterior arch of the atlas. Case 1 : A 20-year-old woman diagnosed with abnormality of the posterior arch of the atlas was referred for further diagnostic follow-up in this hospital. She complained of nonspecific neck pain and headache, but neurological examination results were normal. Roentgenograms and CT scans revealed absence of the posterior arch of the atlas except for the posterior tubercle. Case 2 : A 20-year-old woman underwent medical check-up for cubital pain and numbness. Routine lateral view of cervical X-rays showed abnormality of the posterior arch of the atlas. There was partial defect of posterior arch of the atlas in 3D-CT. The posterior arch of the atlas became gradually thin in the axial view of CT. As a result, the posterior atlantodens interval remained wide. The symptoms of both subsided quickly with conservative treatment. In recent studies, bony gaps in the posterior arch are bridged by loose connective tissue rather than cartilage, suggesting that the anomaly is a result of defective development of the cartilage rather than disturbance of ossification per se.
Spondylolysis of the cervical spine is a rare condition, with less than 100 cases described worldwide. We present such a case of spondylolysis of the cervical spine. The patient exhibited only neck pain, but no neurological symptoms. Radiograph revealed bifida of C6 and spondylolysis of C6. He was treated conservatively and the neck pain disappeared.
We report a case of intraspinal synovial cyst with lumber spondylolysis. A healthy 17-year-old man suffered low back pain in combination with dysethesia of the left lower limb. Radiographs and CT of the lumber spine demonstrated bilateral L5 spondylolysis. However, the facet joints were devoid of degenerative changes. MRI showed development of a cystic legion compressing the thecal sac at the L4-5 level. Laminectomy was performed and the cyst was resected. It lay posterior to the nerve roots and its base was related to the L4-5 facet joint. Histologically, a cyst wall of fibrous tissue with synovial lining cells and evidence of inflammation with granulation tissue were seen. The patient's symptoms disappeared completely after surgery. Hypermobility of the facet joint is apparently a predisposing factor of cyst formation.
We reviewed the clinical presentations, radiological studies, and operative and histologic findings in five patients with lumbar intraspinal synovial cysts treated surgically. The mean age at operation was 51.6 years, and the mean follow-up period was 16 months. All patients presented with radiculopathy and one with cauda equina syndrome. Ring enhancement was characteristic to diagnosis by magnetic resonance imaging. Most of the lumbar intraspinal synovial cysts were associated with significantly degenerated facet joints. Surgical decompression and resection of the synovial cysts were successful for relieving symptoms completely.
We investigated the surgical results of 11 hemodialysis patients with lumber disease from 1999 to 2004. The mean age was 65.1 years [54 to 76 years]. The mean duration of hemodiaylsis was 11 years 7 months (1 year 8 months to 22 years 11 months).Six patients were diagnosed with lumber canal stenosis, two with destructive spondyloarthropathy (DSA), two with lumber disc herniation, and one with spondylolisthesis. Six patients were treated by laminectomy or laminoplasty, four were treated by posterolateral fusion (PLF) with pedicle screw fixation, and one by anterior interbody fusion. The operation results were excellent in four patients, good in two, fair in two, and two patients died due to complications. Complications included two infections, two loosening of the pedicle screw among four PLF patients, one death after operation due to postoperative hemorrhage. As operations for hemodialysis are often accompanied by many complications, cooperation with hemodialysis medical specialists and anesthesiologists and adeguate informed consent from patients and family members are important.
Three cases of spontaneous spinal epidural hematoma were treated conservatively. Each case was diagnosed by MRI. At the time of diagnosis, spontaneous neurological recovery had already started in each patient and they were therefore all treated conservatively. In each case, the size of the hematoma rapidly reduced on the follow-up MRI. Conservative treatment is safe in some cases of spinal epidural hematoma cases if neurological recovery starts early.
Hypertrophic pachymeningitis is a rare disorder that causes intracranial or spinal thickening of the dura mater. We report three cases of hypertrophic pachymeningitis. All these patients presented symptoms such as back pain, paraparesis, and bladder-bowel disturbance. The cases of hypertrophic pachymeningitis include infections such as tuberculosis, fungal and meningococcal meningitis, and autoimmune diseases such as rheumatoid arthritis, Wegener's granulomatosis, and sarcoidosis. Serologic test results for RA factor were positive in two patients, and no arthritis was found. One patient was diagnosed as meningitis, which was considered to be a field disease. MRI scan revealed marked dural thickening with circumference. It was hypointense on both T1 and T2WI, and contrast enhancement was prominent. All patients were successively cured by steroid therapy. The patients showed initially good response to steroid therapy, but in one patient, symptoms recurred when the steroid dosage was reduced. Laminectomy and markedly thickened dura compression were performed, and the cord was noted. This was partially excised for the purpose of curing and diagnosis. Echo proved useful for the diagnosis of hypertrophic pachymeningitis.
We reviewed seven hemodialysis patients who required spinal surgery. All were male with an average age of 59 years. They consisted of four cervical and three lumbar spinal diseases. The duration of hemodialysis ranged from four years and eight months to 26 years and 9 months, with a mean of 18 years and 5 months. Two cases of cervical destructive spondyloarthropathy underwent posterior spinal fusion with laminoplasty. One case of cervical myelopathy and one of epidural calcification were underwent laminoplasty alone. Three cases of lumbar diseases primarily underwent only decompression procedures. The clinical results of all cases improved soon after surgery, However, the condition of one cervical case without fusion and two lumbar cases deteriorated with time. One lumbar case which received additional instrumented fusion surgery died on the day following the surgery due to presumable heart attack. From this study, decompression surgery combined with spinal fusion is thought to be the profered treatment when attempting spinal surgery on hemodialysis patients. However, we should consider not only spinal pathology but also general conditions of the patient due to the presence of asymptomatic myocardial ischemic lesions that did not show any abnormal findings in the usual preoperative screening.
A study was conducted on the clinical features of hand-arm vibration syndrome. The subjects consisted of 69 patients who were medically examined from January 1997 to 2004. They were evaluated for patient age, time and period of using vibrater, clinical symptoms, physical findings, complications, medical history, and X-ray examination. The evaluation results were mean age of 65.2 years, mean vibrater using time of 9832 hours, and mean period of vibrater use of 24.4 years. Clinical symptoms included finger and antebrachium numbness (100%), stiffening (98.6%), cold feeling (95.7%), pain (92.8%), palm sweating (92.8%), and insomnia (92.8%). Physical findings were imperception (100%), palm sweating and sleeping disturbance (92.8%), and intermittent claudication / lower limb numbness (18.8%). Raynaud's phenomenon was found in five patients (7.2%). Complications included hearing loss (92.8%), peumoconiosis (24.6%), and malignant disease (4.3%). Peripheral circulatory disorder, peripheral neuropathy, and motility were jeen in all patients. Intractability of perceptual disorder was the most common problem. Dysgraphia was 92.8%. Sleep electroencephalogram wave was normal while the most abnormal aspect was the pattern and course of each sleeping stage. According to literature, autonomic nerve dysrhythmia is connected with the central nervous system in some ways. In terms of work-related disorders, vibration disorder was found in 23.2% of abnormal X-ray findings. Previous studies indicated that there is no relation ships between clinical symptoms and X-ray findings. Image diagnosis is therefore very important.
Von Willebrand disease (vWD) is the most common inherited bleeding disorder. Despite an increasing understanding of the pathophysiology of vWD, diagnosis of vWD is frequently difficult because of the uncertainly over the relationship between laboratory assays and function in vivo. The case was a 34-year old man whose medical history did not indicate previous bleeding. He played baseball and broke his knee in september. 2004. A nearby doctor performed osteosynthesis upon diagnosis of left intercondylar eminence fracture of the tibia. Swelling, fistula with clotting, and left knee pain continued two months after surgery. He had been given an antibiotic for the treatment of subcutaneous abscess at the previous hospital, but left knee pain and subcutaneous hematoma lingered in greater and lesser degrees. In the initial diagnosis, we observed that range-of-motion was restricted in the left knee joint, and an X-ray examination showed Sudeck's bone atrophy. The left knee was nontender or swollen and the patellar ballottement was not demonstrable. MRI examinations indicated cystic lesions and fistula not extending to the joint capsule. After surgery to drain hematoma, postoperative bleeding continued. The coagulation screen was isolated prolonged APTT. The bleeding time was not prolonged, and titers of vW factor and factor VIII decreased. A haemtologist diagnosed his case as vWD and administered desmopressin intravenously. The effects were immediate. APTT is a frequently used screening test. Each laboratory should determine its own reference range and be aware of the variable sensitivity of APTT to reduce levels of clotting factors. Surgical procedures on patients with vWD require good liaison between an experienced haematologist and the surgical/anaesthetic team.
In this study, we report a very rare case of mucinous cystadenocarcinoma with huge metastatic lesion on the thigh. A 73-year-old man was admitted to our hospital complaining of a huge mass on his right thigh. Magnetic resonance imaging showed a cystic lesion. We performed open biopsy of the tumor twice, but could not detect any viable neoplastic cells. We then performed en bloc resection of the tumor. Myxomatous tumor extended invasively in the intramusclar region. The results of post-operative histological examination indicated mucinous adenocarcinoma. Because this patient had underwent excision of the appendical tumor in 1993, we investigated the specimens of both the appendix and thigh. Pathological report revealed metastatic mucinous cystadenocarcinoma consistent with the previously resected primary appendix cancer. To our knowledge, no case of mucinous cystadenocarcinoma with skeletal muscle metastasis has ever been reported.
A case of multiple schwannoma is reported. A 19-year-old female presented multiple mass in the right femur, right brachium, left palm, right hilum renalis and cauda equina. Head MR imaging showed bilateral vestibular schwannoma. Histopathological diagnosis of all tumors except the tumor in right hilum renalis and vestibular schwannoma showed the same pattern of Antoni A tissue and Antoni B tissue as schwannoma. Thus this case was diagnosed as neurofibromatosis type 2. There does not appear to be any malignant transformation of neurofibromatosis type 2-related schwannomas. But because of the critical location of many of these tumors in the cranium or spinal cord, patients may succumb to the space-occupying effects of their tumors, and should be carefully observed for a long period.
Fibrosarcoma may occur at any age but is the most common at 30 to 55 years of age. We experienced two cases of fibrosarcoma occurring in childhood. One patient was a 10-year-old girl, suffering from a slowly enlarging mass in the right iliac. We diagnosed her as fibrosarcoma from pathologic findings at biopsy. We excised it with a wide margin of normal tissue. There was no recurrence identified on MRI seventeen months following the surgery. The other patient was a 8-year-old girl, who underwent excision of a right shoulder mass marginally in another hospital and was diagnosed as low grade myxofibrosarcoma. We excised it with a 3 cm margin. There was no recurrence identified on MRI 11 months following the surgery. Fibrosarcomas are rare in children, and there are only a few reports on the effects of radiation and chemotherapy. We need to continue careful follow-up.
We report two cases of malignant lymphoma reguiring surgical treatment. In one case, we resected the tumor widely because chemotherapy and radiation were not effective. In the other case, fearing pathological fracture, proximal femoral bone prosthesis was performed, followed by chemotherapy. Generally radiation or chemotherapy is selected for malignant lymphoma as the treatment of first choice. However operative treatment is considered effective for quality of life is some cases.
We evaluated the toxicity and feasibility of chemotherapy for patients with soft tissue sarcomas. A total of 13 patients were treated in our department from 1998 to 2003. The median age of the patients was 42.6 years. The patients were treated with a combination of IFO + ADM + CDDP (11 courses), IFO + EPI (10 courses), or IFO + ADM (43 courses), or IFO (6 courses). Toxicities were assessed according to the National Cancer Institute-common toxicity criteria. Hematologic toxicities were anemia (29% grade 3 and 4), leukopenia (99%), neutoropenia (100%) and thrombopenia (13%). Nonhematologic toxicities were mainly nausea or vomiting (grade 1 and 2). All courses were completed despite the occurrence of these toxicities. Chemotherapy using high-dose IFO and ADM proved feasible with intense supportive treatment in adult soft tissue sarcomas.
In this study, we report a rare case of leiomyosarcoma with osteoclast-like giant cells occurring in the hand. A 58-year-old man underwent excision of the right palmar tumor in another hospital, and the pathological diagnosis was giant cell tumor (GCT) of the tendon sheath. Because the tumor recurred twice, he visited our hospital. We suspected recurrence of the GCT of the tendon sheath, and performed excision of the tumor. Pathologically, the tumor was composed of fascicles of spindle cells, showing typical features of smooth-muscle differentiation, as well as marked nuclear pleomorphism and high mitotic figures with some atypical mitoses. In order to differetiate other tumors with osteoclast-like giant cells, we performed immunohistchemical examination. Immunohistochemically, many tumor cells tested positive for desmin, muscle specific actin, and α-smooth muscle actin. Eventually we diagnosed this tumor as leiomyosarcoma with osteoclast-like giant cells. Initially this case was thought to be malignant transformation of the GCT of the tendon sheath, but after careful revision of the slides and immunohistochemical examination, diagnosis was changed to leiomyosarcoma with osteoclast-like giant cells.
We experienced three cases of posterior dislocation of the elbow joint with associated fracture of the coronoid process, which was type IIB fracture according to the Regan and Morrey classification. The patients were all male and their ages were 15, 17, and 27 years. The fragment that was detached from the coronoid process was less than 30 percent. Immediately after closed reduction under local anesthesia, we examined elbow instability at flexion of 30 degrees, and confirmed that the injured joint was stable in all cases. All fracture-dislocations were treated by immobilization of the elbow in a plaster cast for four weeks. After an average follow-up of 10 months, all patients were satisfactory with no pain or instability. Range of motion of the elbow joint was full, and the JOA score was 100 points in all three patients.
Two cases of osteochondritis dissecans (OCD) developing radial head dislocation are presented in this study. The first case was a 13-year-old male who started playing baseball at nine years of age. He experienced a right elbow pain at 12 years. He had been treated conservatively for a year. Pain had relieved, however, severe pain and locking in the elbow occurred. Plain X-ray film showed OCD and radial head dislocation. The right radial head had widened and looked longer than left one. Firstly, the detached osteochondral free body was removed and wedge osteotomy was accomplished in the lateral humeral condyle. Reduction of the radial head was observed but pain in the radio-humeral joint still continued. Thereafter, radial shortening by approximately seven millimeters was performed. Pain was relieved perfectly and he now plays volleyball without any problems in his elbow. The second case was a 14-year-old male started playing baseball at 10 years of age. He experienced right elbow pain at 13 years. He underwent an operation to reattach the free osteochondral part. The reattached fragment was not reunited. Radial dislocation developed during this post-operative period. Since elbow pain persisted and elbow range of motion was increasingly limited, wedge osteotomy was perforned on the lateral humeral condyle. Reduction of the radial head was observed and elbow pain subsided. MRI-imaging revealed that OCD was located in the anterior capitulum in both cases. In this condition, radial head dislocation nay occur, conplicating treatment. Great care must be taken to ersure that the radial head of OCD patients does not develop secondary deformity in the elbow joints in adolescents.
[Introduction] We report 2 patients with RA in whom a Coonrad-Morrey artificial elbow joint was used by cutting the ulnar stem during surgery. [Subjects and methods] Patient l was a 43-year-old female who had undergone fixation with a restraint type Mckee artificial elbow joint in the left arm at the age of 18 years. Marked loosening of the implant was observed by plain radiography, and the stem tip performed the lateral humerus. In this patient, the skeleton was sma11 due to the effects of JRA, and the medullary cavity was very small. Patient 2 was a 70-year old female. The patient contracted RA at the age of 54 years. Surgical treatment was requireb because of aggravation of pain and high restriction of excursion. The patient was of small stature, and the medullary cavity was small. In these patients, we performed surgery using a Coonrad-Morrey artificial elbow joint with the thinnest stem that we could obtain. Although we used the thinnest X-small stem, reaming of the partial cortex was required in Patient l. Since the ulnar stem was long, its cutting during surgery was required in both patients. [Conclusion] Development of smaller artificial elbow joints suitable for Japanese patients is necessary.