A retrospective analysis was performed on eight patients (four women and four men) who underwent TLIF between June 2003 and June 2005. The approach involved unilateral laminectomy and inferior facetectomy at the level of fusion. Interbody fusion was achieved from this unilateral approach by performing diskectomy, arthrodesis, and insertion of one titanium cage packed with autologous bone. Initial symptoms were a combination of low back pain and radiculopathy. The average age of the patients was 53.6 years and the average follow-up time was 15 months. All patients had single-level TLIF (L/5 or L5/S1). The mean operating time was 255 minutes and mean blood loss was 205g. In all patients, low back pain and radiculopathy were improved. One complication, radiculopathy by bone graft, was seen in eight patients. The Japanese Orthopedic Association (JOA) score improved from 20/29 to 25/29. TLIF is a reliable and safe technique for interbody support that can be performed with excellent clinical outcome.
We evaluated treatment for lumbar spinal stenosis by Rolland-Morris disability questionnaire (RDQ), VAS, and modified JOA score (m-JOA). The subjects were 29 patients (average 68 years), consisting of 20 patients who underwent surgical operation and 9 patients who received conservative therapy. We evaluated RDQ, VAS and m-JOA at 0 week, 2 weeks, 1 month, 3 months, 6 months after treatment. RDQ, VAS, m-JOA were gradually recovered after treatment. Operated cases were more recovered than conservative cases. RDQ was useful for the evaluation of treatment not only for lumbar disc herniation, but also lumbar spina stenosis.
Recently we performed lumbar laminoplasty by the midline spinous splitting approach as an operation method for lumbar spinal canal stenosis in order to preserve posterior support tissue, especially the paravertebral muscle and facet. We investigated and compared lumbar laminoplasty by the midline spinous splitting approach and conventional operation method concerning operation time and blood loss. Between October 2002 and July 2004, 21 patients underwent the conventional operation, and the number of decompression lamina was 56 levels, where 16 were male and 5 were female (mean 2.7 levels per patient). After July 2004, 13 patients underwent lumbar laminoplasty by the midline spinous splitting approach, and the number of decompression lamina was 30 levels, where 9 were male and 4 were female (mean 2.3 levels per patient). The operation time of the conventional operation method for one level was 58.3 minutes on average, and blood loss was 89.8g. That of lumbar laminoplasty by the midline spinous splitting approach for one level was 52.4 minutes on average, and blood loss was 58.3g.
Sacroiliitis is important for the diagnosis of ankylosing spondylitis (AS), however, it is hard to identify radiographic abnormality of the spine in the early stage of the illness. We compared radiographic changes in the lumbar vertebrae with changes in the sacroiliac joint. We reviewed 19 patients (15 men, 4 women) diagnosed with AS at our hospital. Their mean age at first examination by the doctor was 35.2 years. On their first visit, five were grade 2 sacroiliitis, five were grade 3 and nine were grade 4. Squaring of the vertebral body, syndesmophyte, and shiny corner were seen in grade 2 and grade 3. Discal calcification and discal ballooning were seen in grade 4. Sacroiliitis was grade 4 in all patients with bamboo spine. It was noted that careful attention should be paid to radiographic changes of the lumbar vertebrae in the early stage of AS.
We experienced a rare case of a 54-year-old male with a burst fracture of the axis body (C-2). The mechanism of this lesion was thought to be application of a vertical downward force and bending force to the dense. On arrival, he had severe pain on his neck and neurological deficit on his left upper extremity. Plain radiography and CT scan showed a burst fracture of the axis body classified as type 2 according to Benzel's classification. He was treated with direct traction for the first six weeks and halo-vest fixation for the next four weeks. We kept his neck in an extension position opposing the mechanism of injury. Three months later, reduction and bone union were obtained. Eleven months after injury, he had no neck pain and neurological symptoms, and the motion range of the cervical spine was not restricted. The fragments were united by conservative therapy. Our case suggested that the mechanism of this fracture was axial downward force with flexion position.
Motor function can be improved in patients with ossification of the posterior longitudinal ligaments (OPLL) with operative treatment, but numbness of the extremities is complained with long term follow-up surgery. The anthors investigated the improvement of numbness from the standpoint of patients. Thirty-five patients with OPLL who underwent surgery at different hospitals were reviewed by a questionnaire survey. The mean postoperative follow-up period was 10 years and 3 months. The postoperative improvement of numbness and the relation between the JOA score and improvement of numbness were investigated. The rate of improvement in the JOA score was 52%, but numbness disappeared postoperatively only in four patients. Some patients were not satisfied with their operative results because of intractable numbness. The surgical outcome of patients with OPLL should be evaluated giving consideration to the improvement of numbness.
The results of treatment in patients with symptomatic facet cyst are reviewed. Six patients with neurogenic sign were treated. All cysts were associated with facet joint osteoarthritis. The connection between cyst and facet joint was revealed with arthrography. Four patients were treated conservatively and acquired neurogenic recovery. On the follow-up MR images, one cyst decreased in size, one cyst remained unchanged, and one cyst disappeared. Two patients were treated with cyst excision in surgical treatment. The symptoms disappeared. Histological findings showed that the cystic wall was composed of fibrous connective tissues including hemosiderin, but without synovial lining cell. No recurrence was found on the follow-up MR images.
Nine cases of medial malleolar fracture were treated surgically using plate. They were classified into SA stage II (6 cases), SER stage IV (one case), PA stage II (one case), PD stage II (one case) according to the Lauge-Hansen classification. All cases achieved good bone union. No implant-related complications were observed. Plate osteosynthesis can provide stable fixation for medial malleolar fractures caused by compression force or sharing force.
We investigated 19 patients (13 males and 6 females) who had undergone major lower extremity amputation caused by arteriosclerosis (ASO), diabetes mellitus (DM), and chronic renal failure (CRF) from January 2001 through March 2005. The average age of the patients was 77.7 years. The average follow-up period was 10.1 months. We conducted an investigation into basic disease (ASO, DM, CRF), high cutting rank, surgical site infection, and prognosis. For the case that merged many basics diseases, survival rate was low regardless of a high cutting rank for one year, and surgical site infection worsened this rate.
From 1998 to 2004, 15 feet in 14 patients underwent the Hammond procedure alone or Hammond procedure with lateral soft tissue release to correct hallux valgus deformities. The average patient age at the time of the operation was 50.3 years, and the average follow-up was 7.6 months. The average preoperative hallux valgus angle was 34.6°, and the average intermetatarsal angle was 15.1°. After surgery, the feet were corrected to an average hallux valgus angle of 14.7°, and the average intermetatarsal angle was 7.7°. The results were also graded according to the Japanese Orthopaedic Association (JOA) score and Glynn's assessment. This modification of the Hammond procedure can serve as an effective means of managing severe hallux valgus deformities.
We evaluated 24 patients undergoing surgical treatment between 1997 and 2004. The subjects consisted of 11 males and 13 females. The average age was 40.1 years. Fracture types were evaluated by AO classification in our study. We also examined the ROM of shoulder and elbow in terms of the average period for bone union. We estimated the degree of varus-valgus angulation at the most recent follow-up in patients for whom anteroposterior radiographs were taken, and the degree of anterior posterior angulation in patients for whom lateral radiographs were taken. The average period for bone union was 16.4 weeks. The ROM of shoulder was found to decrease in patients operated using the antegrade interlocking nail. Both varus-valgus angulation and anterior posterior angulation did not exceed 11°. The surgical method should be considered taking into account fracture type, complication, and post-surgical functions.
The author experienced relief operation for the earthquake and tsunami disaster in Sumatra Indonesia in March 20005. The author participated in both the chronic and acute phases of international disaster relief operation, and reports the activities of international disaster relief operation and the differences in medical support for disaster depending on the phase. The importance of the "3T of disaster medicine: triage and treatment, and transportation" was verified.
Fracture of the distal radius is very common, especially in elder people. Loss of reduction of the fracture often develop into symptomatic malunion or nonunion. Three cases of malunion following Colles's fracture, one case of nonunion following Smith's fracture, and one case of nonunion following Colles's farcture are reported in this study. All cases were female and mean age was 75.2 years at the time of operation. All patients underwent collective open-wedge osteotomy, and bone graft (harvested from ulna) according to Sauve-Kapandji's or Darrach procedure. The mean follow-up period was nine months. Functional and radiological outcomes improved in all cases.
Thumb carpometacarpal osteoarthritis is one of the most common problems in hand surgery practice. This common disease produces pain, aggravation of insufficient motion, joint instability, swelling, tenderness and crepitus, resulting in significant disability in daily living. Various surgical procedures have been developed such as simple trapeziectomy, arthrodesis, ligament reconstruction tendon arthroplasy, and implant arthroplasty. The goal is to perform the best operation in order to restore strength, range of motion, and painless function. We performed Watson's procedure on 11 patients. This technique is a modification of the Burton's procedure, which is based on three components: suspension of the thumb metacarpal on the flexor carpi radialis tendon through dorso-radial to palmarulnar insertion, maintenance of the cortical bridge at the base of the metacarpal, and interposition of a tight collagenous (tendon) arthroplasty. All patients acquired satisfactory pain relief, pinch power, grip strength, and range of motion.
Recently, guidelines for the usage of antibiotics are being revised. Administration of antibiotics under careful obserbation is recommended even in patients with known history of allergy. In this paper, we report a case of serious ADR, TEN by oral antibiotics. To avoid this terrible complcation, it is essential to investigate past history carefully.
In 132 patients (mean age 61.1 years) with unilateral hip disease who underwent total hip arthroplasty (THA) from March 2003 to July 2004, gait was analyzed preoperatively and six months after unilateral THA. All patients were tested during "free" walking along a 5-m walkway in which a ground reaction force plate (gait scan 8000; Nitta, Inc.) was installed. The assessed parameters were single and double support duration, cadence, gait speed, and differences between the two legs in single support duration. The assessed parameters improved significantly after surgery. There were some patients in whom differences between the two legs in single support duration were still observed at six months. Differences between the two legs in single support duration were correlated with the age and preoperative limb length discrepancy at six months after surgery. Multivariate analysis showed that clinical data associated with differences between the two legs in single support duration was preoperative limb length discrepancy (p=0.001). The results indicate that the preoperative limb length discrepancy affects characterization of the functional restitution of patients after surgery.
We experienced a case of subchondral insufficiency fracture of the femoral head with osteogenesis imperfecta (OI). A 64-year-old woman experienced sudden pain in her left hip. Initial X-ray of her hip did not show any fracture line, but two months later, MRI showed subchondral insufficiency fracture of her left femoral head. She had hearing disorder and blue sclera. She was classified as osteogenesis imperfecta Type-1. We treated her with oral bisphosphonate and non-weight-bearing. Eight months after the treatment, she had no pain and could walk with a cane. On the X-ray, there was slight collapse of the femoral head, but there was no osteoarthritis of the hip. These treatments were useful for this patient.
Conservative treatments are usually successful in many cases of calcific tendonitis of the shoulder. Surgical treatments are performed on patients who failed to respond to conservative treatments. The purpose of this study is to clarify the effects of surgical treatment. Six cases of surgical procedure were followed up. The four cases were open procedures and the last two underwent arthroscopical operation. Manipulations were required in two cases for contractures. Rotator cuff sutures were performed on four cases of more than 10 mm defect. Acromioplasty was added in a case of subarcomional impingement. Calcific deposits disappeared in all cases but a open case. In open cases, the mean preoperative and post operative JOA scores were 68 and 96 points respectively. In arthroscopic cases, they were 63 and 97 points respectively. Surgical treatment with additional procedures such as manipulation, rotator cuff suture and acromioplasty, are effective for patients resisting conservative treatments.
Usefulness of the anteroposterior (AP) view radiograph of the knee in deep flexion was assessed. In this method, the thigh of the subject was placed on a specially designed device so that the lower leg hung and the knee flexion angle was 120 degrees. The direction of the X-ray beam was set parallel to the tibial plateau, and the cassette was placed proximal to the knee joint. AP radiograph in deep flexion and the so called epicondylar view radiograph at 90 degrees knee flexion were taken in 10 normal male subjects with and without 1.5kg loading. On the radiographs, distal femoral condyles and tibial plateaus were clearly visible. The effect of 1.5kg loading on the joint gap distance was smaller in deep flexion. With these radiographs on deep knee flexion, knee joint gap can be evaluated before and after total knee arthroplasty.
We report a case of dysfunction following reconstruction of the knee extensor mechanism using artificial ligament. Three years ago, a 49-year-old man sustained an injury of the patella fracture of the left knee in a traumatic event. Since then, he had not been able to walk without crutches or extend his left knee completely. Plain radiograph showed two divided bony fragments of the patella and that the periarticular bone had changed atrophically. The distance between the two fragments was approximately 7cm. The knee extensor apparatus recontruction was performed using the Leeds-Keio artificial ligament, which was fixed to the tibia with double staples. The rehabilitation program was controlled strictly. Eighteen weeks after the operation, no extension lag was found and he could walk by himself. At 28 weeks after the operation, however, he had not been able to extend the operated knee on his own and the extension lag increased to 20°suddenly. On examination at 47 weeks after operation, the MRI showed loosening of the artificial ligament resulting from weak fixation due to the tibial atrophy. Although the knee extensor apparatus recontruction using artificial ligament is a good method, results for this case were poor. We concluded that it is necessary to reinforce the fixation of the artificial ligament in such bone atrophy cases by the addition of another augmentation.
Meniscal cysts of the knee are rare. Recent reports suggest that most meniscal cysts are associated with meniscal tear and that they are treated by arthroscopic partial meniscectomy with cyst decompression. This paper presents a 34-year-old woman with symptomatic medial meniscal cyst sustaining a meniscal tear at arthroscopy. We performed an arthroscopic partial meniscectomy but we could not find the opening of the track to the cyst. So open cyst resection was performed to maximize the stabilizing effects of the meniscus and load bearing effects of the knee.
Discoid medial meniscus is a rare finding. We report a case of bilateral discoid medial menisci. A 24-year-old student had a 7-year history of both knees complaints with no specific acute injury. There were 10° extension lags in both knees and the radiographs showed widening of the medial joint space. Magnetic resonance imaging revealed bilateral complete type discoid medial menisci with horizontal tears. His right knee was treated successfully by the excision of the torn central anomalous discoid portion of the meniscus using the arthroscopic technique.
We retrospectively reviewed the results for seven patients who were less than twelve years old with eight discoid lateral menisci. The average age at the time of operation was 8.1 years, and the average duration of follow-up was 9.3 months. The state of meniscus and cartilage was evaluated with Watanabe's classification and Fujisawa's classification. The clinical results were rated according to the Japanese Orthopedic Association (JOA) Score for Meniscus Injuries. The mechanism of injury was not clear in all cases. The diagnosis of complete lateral discoid meniscus was confirmed in seven cases (88%) and the degeneration of cartilage was slight. Subtotal meniscectomy was required in the complete type (seven cases) due to prevalence of horizontal tear and hypermobility. The average JOA score at initial presentation was 50 points, and it remarkably improved to an average of 96 points at postoperative recent follow-up examination.
We report the abnormality of the meniscus in family. Case 1 was a ten-year-old boy who complained of pain and locking of the right knee. On magnetic resonance imaging of the bilateral knee, there was a high intensity area on the posterior portion of the bilateral lateral meniscus. In arthroscopic findings, the medial meniscus of the right knee had abnormality of attachment on the anterior portion. The bilateral lateral meniscus comprised of two parts which were completly separated and duplicated at the midportion. The anterior part was connected to the capsule and the posterior part to the cartilage surface of the tibia plateau at the midportion. The medial meniscus of the left knee had two layers on the anterior portion (double-layers medial meniscus). Case 2 was a seven-year-old girl who was the sister of case 1. She complained of pain of the right knee, and instability of the bilateral patella. On magnetic resonance imaging of the right knee, there was a high intensity area on the posterior portion. In arthroscopic findings, the shape of the bilateral lateral meniscus was almost the same as case 1. We could not find literature on this abnormality of the lateral meniscus in family.
With the progress of the fixing material used for high tibial osteotomy, long hospitalization duration is becoming shorter. Since January 2005, we have been using LCP as the fixing material for high tibial osteotomy to shorten hospitalization duration and examine usefulness of LCP. Our department had been using blade staple and the Surfix lock plate system for high tibial osteotomy until 2004. Between January 2005 and April 2005, nine patients underwent high tibial osteotomy using LCP. They consisted of nine women with a mean age of 68 years (range: 56 to 76). We compared the result of the blade staple and Surfix lock plate system with these of LCP in terms of hospitalization duration. The average hospitalization duration of cases using LCP was 50 days (range: 36 to 69), there was no cases of delay of bone adhesion, and no cases with of decreased correction angle. The results of obtaining LCP and the Surfix lock plate system were essentially equal. The duration of hospital stay can be obviously shortened than the staple method.
Good results from High Tibial Osteotomy have been reported in numerous papers on medial compartmental osteoarthritis of the knee. But the delayed start of weight bearing or delayed discharge from hospital remains a problem. We developed a new operating procedure for high tibial osteotomy to resolve this problem. The most characteristic point of this new procedure is not to resect but impact and collapse the wedged cancellous bone of the proximal tibia at the time of closed osteotomy. The Giebel plate is inserted at the beginning and the SURFIX locking plate is used later for internal fixation material. Five male and seven female patients were treated by the newly developed method. Their mean age was 62.4 years and the mean duration from the operation was 8.1 months. The mean period of starting full weight bearing was 3.7 weeks and the duration of hospital stay was 7.1 weeks, which were both shorter than those of interlocking wedge osteotomy. The mean knee score of the Japanese Orthopaedic Association changed from 67 to 83.5 after the treatment. There were no marked complications except three cases of skin irritation caused by the head of the Giebel plate, which were reduced with removal of the plate.
We studied factors contributing to residual deformity in patients with Perthes' disease who underwent additional surgery for residual deformity including a high trochanter and femoral shortening after Perthes' disease. We studied 34 hips. The mean age at the onset of Perthes' disease was 6.5 years, and the mean age at the time of additional surgery was 13.9 years. Additional surgery included: distal transfer of the greater trochanter in 13 hips, combined femoral lengthening and distal transfer of the greater trochanter in 20 hips, and femoral valgus osteotomy in one hip. According to the Catterall classification, 13 hips were in group 3, and 21 hips were in group 4. Major risk factors included lateral subluxation and metaphyseal cysts of head at risk signs, which were present in 94% of patients, respectively. When the final clinical results were evaluated according to the Stulberg classification, 6 hips were in class II, 24 hips were in class III, and 4 hips were in class IV. Residual deformity tended to occur in cases which were classified as group 3 and 4 according to the Catterall classification, and in which lateral subluxation or metaphyseal cyst were present, requiring additional surgery of the femur.
We evaluated the short-term results of the treatment of femoral neck fractures using the Hansson pin. Twelve patients (two males and 10 females, mean age: 74.5) were included in this study. The fractures were classified according to Garden. Stage I and II constituted undisplaced (nine patients) and stage III and IV displaced fractures (three patients). The clinical evaluation was based on the fracture union rate, walking ability, and complications (osteonecrosis, redisplacement). In addition, the Garden alignment index and pin position were measured radiographically. Nine patients healed without complications. Three patients did not achieve bony union. Complications consisted of osteonecrosis of the femoral head in one case, and redisplacement in two cases. Poor fracture reduction and malposition of the pin are associated with redisplacement of fracture.
Pseudopathologic fracture of the femoral neck, first reported by Pope in 1981, is a fracture which shows radiolucency in the superolateral subcapital region of the femoral neck that mimics the features of a pathologic fracture. Our purpose was to determine the prevalence of this phenomenon in Japanese patients. Between January 2000 and January 2005, 148 femoral neck fractures were treated in our hospital. Radiographs and medical records were reviewed. Twenty four (16%) of the 148 fractures showed radiolucency in the superolateral subcapital region (pseudopathologic fracture). These included two (6%) out of 33 Garden stage I fractures, none out of 22 Garden stage II fractures, 15 (27%) out of 55 Garden stage III fractures, and seven (18%) out of 38 Garden stage IV fractures. These incidences in each Garden stage were relatively similar to those reported previously, with an exception that no case of stage I with pseudopathologic fracture was found. The mechanisms which cause radiolucency are discussed. Understanding of the appearance of subcapital hip fractures mimicking pathologic fractures and knowledge of the cause of such findings are important for prescribing appropriate treatment and avoiding lengthy, costly laboratory and radiographic workup.