A network for hip fractures was constructed by eight health care institutes in Kumamoto city to treat patients with proximal femoral fractures from surgery through rehabilitation sequentially. The network established an electric critical path (CP) connecting the surgical hospitals and rehabilitation institutes. Network members share patient information on the critical path at a secure website. Sixty-five patients (14 males, 51 females) who applied for the CP from April 2004 to May 2005 underwent operations with osteosynthesis (OS) or hemiarthroplasty (HA) for hip fractures at surgical hospitals, then transferred to the rehabilitation institutes, and were finally discharged. The mean age was 82.4 years (range 54 to 101 years). We evaluated the whole length of hospital stay after surgery and the recovery rates of gait ability comparing before injury and at the time of discharge from the rehabilitation institutes. The length of hospital stay was 90.2 days on OS and 67.2 on HA. The recovery rates of gait ability were 34.1% on OS and 52.4% on HA. We checked variance from our CP, and develop the CP for improving the quality of local healthcare networks.
The purpose of this study was to examine the correlation between preoperative complications and hospital expenses in femoral intertrochanteric fractures. We studies 34 patients who were hospitalized and operatad on in our hospital. The hospital expenses of patients who had preoparative complications were higher. The difference between those with and without the complications was almost 120,000 yen. But treatment expenses for the complications were less than expected. We found that hospital expenses increased in proportion to the duration of hospitalization, indicationg that increase in hospital expenses is not due to the cost of the treatment for complications but rather for the extended duration of hospitalization. We concluded that shortening the duration of hospitalization is an adequate means of reducing hospital expenses.
The purpose of the present study is to report a new method for treating unstable intertrochanteric fractures using DHS (dynamic hip screw), TP (trochanter stabilizing plate), CCS (cannulated cancellous screw), and β-TCP (β-tricalcium phosphate). We particularly report the effectiveness of β-TCP for medial bone defects at the femoral neck. Twenty-five subjects were treated by the new method from May 2004 to December 2004 and compared with twenty-one subjects, treated by the conventional method without β-TCP, from April 2003 to April 2004. The average neck shortening was 6.0 mm in the new method group, compared with 9.6 mm in the conventional method group. The results of the investigation suggest that β-TCP prevents neck shortening in unstable intertrochanteric fractures.
We experienced two cases of fat embolism syndrome with femoral shaft fracture. Case 1. An 18-year-old boy who was injured in a traffic accident, showed disturbance of consciousness and suffered shock by fat embolism syndrome a day after the injury. Diagnosis was performed by MRI, and he was treated with edaravone and sodium ozagrel. The symptoms completely disappered and no relapse was seen. Case 2. A 73 year-old man who was injured in a car accident showed dyspnea and disturbance of consciousness two days after the injury. Chest X ray films revealed snow storm appearance, and he suffered shock by fat embolism syndrome. He was treated with steroid and sivelestat sodium hydrate. His symptoms completely disappered and no relapse was seen.
We report a case of sciatic nerve palsy caused by cast compression. The patient was a 12 years old boy. He sustained a femoral shaft fracture while playing soccer. He underwent percutaneous pinning and spica casting at some other hospital. After the operation, he lost his lower leg sensation and could not move his ankle and toe. Six days after the primary operation, we operated on his femur with the removal of pins, open reduction, and plate fixation. After this operation, his lower leg sensation and motor power gradually recovered. And 18 months later, his sciatic nerve function recovered 90%.
We report a case of pseudoaneurysm of the profunda femoris artery following an internal fixation of a femoral neck fracture. An 81-year-old woman fell and was admitted to our hospital complaining of pain of her right thigh. X-ray showed an intertrochanteric fracture of her right femur. It was fixed with a compression hip screw. After the operation, she went into shocked, anemia progressed, and atrial fibrillation occurred. Her right thigh was swollen but peripheral pulses were palpable. Blood transfusions were administered. Her blood pressure recovered, but anemia and atrial fibrillation did not improve. Swelling of her right thigh progressed. On the seventh post operative day, Ultrasonography was performed and a color doppler echogram showed a pseudoaneurysm of 4 cm in diameter in her right thigh. Angiography revealed an extravasation from a branch of her profunda femoris artery. The injured artery was embolized with coils successfully. Anemia and atrial fibrillation improved. A possible cause of the pseudoaneurysm way have been arterial injury by the drill. Greater care is necessary in the use of drills to prevent vascular injury.
We compared the microarchitecture of the femoral head in femoral neck fractures treated for 3.5 months with alendronate versus women treated as control. The bone volume, trabecular thickness, trabecular number, and trabucular spacing in specimens from one case treated with alendronate and six controlls were measured. The two-dimensional histomorphometry, bone volume fraction, trabecular thickness, and trabecular number were significantly greater in the alendronate specimens: 22.7±0.7% vs 13.7±6.5% (p=0.0285), 226.3±98.7μm vs 149.2±40.8μm (p=0.0007), and 4.2±1.2 No/mm vs 2.7±0.9 No/mm (p=0.004); and trabecular spacing was significantry smaller; 438.9±143.1μm vs 1216.97±452.43μm (p=0.0004). Alendronate not only increases bone volume but also improved microarchitecture.
We present a case of posterior spinal fusion with vertebroplasty in the treatment of thoracic vertebral fracture with delayed palsy. The case was a 73-year-old female diagnosed as thoracic vertebral fracture of Th11 with delayed palsy. She gradually developed gait disturbance and bladder-bowel disturbance. MRI revealed burst fracture of Th11 and compression of the spinal cord. She was operatively treated with posterior spinal fusion with vertebroplasty using hydroxyapatite and showed a good course at follow-up six months later.
We experienced two cases of wide-range spinal epidural abscess after an epidural block. In one case, the abscess spread from Th8/9 to C3/4, and in the other the abscess spread from L5 to Th2/3. We performed emergency operation on both cases but paralysis remained. In the treatment of spinal epidural abscess, early diagnosis and the timing of the operation are important because paralysis can deteriorate suddenly and the abscess may spread.
We studied 31 pateients with pyogenic spondylitis who were treated at our hospital from 1996 to 2004. They consisted of 17 male and 14 female patients ranging in age from 37 to 76 years (mean: 63 years). The follow-up period ranged from six to 26 months (mean: 13 months). Sixteen cases were treated conservatively with antibiotics and brace, and 15 cases surgically. Twenty patients (64.5%) had an impaired immune system secondary to diabetes mellitus, cancer, renal or hepatic failure. The infection in 18 patients (58.4%) was caused by organisms. The source of the infection was confirmed in seven (22.6%) with the urinary tract being the most frequent source. MRI is very sensitive and often quite specific for spinal infection. But it is difficult to evaluate the healing phase of chronic pyogenic spondylitis.
Elastofibroma is relatively rare, benign, slow-growing, fibroproliferative tumor that is localized mainly in the subscapular region. The usual clinical presentation of the tumor is elderly patients complaining of shoulder pain or discomfort and mechanical obstruction to arm movement. On the other hand, many cases have been reported where the patient feels no discomfort and only lumps are observed for a long time. We diagnosed and operated on a case of elastofibroma dorsi accompanied by severe back pain, and examined the tumor pathologically. Some authors suggest that when elastofibroma is revealed using CT or MRI and the patient has no discomfort, further aggressive treatment is not required. However, some elastofibromas clinically resemble malignant tumors of the back. We therefore recommend that all elastofibromas be excised and examined pathologically.
Ewings sarcoma of the right femur diaphysis of a 13-year-old man was treated by en bloc resection, intraoperative extracorporeal irradiation, and reimplantation with intramedullary nailing. With many advantages including complete sterilization of tumor cells, precise anatomic adaptation of the size and shape, no risk of disease transmission, possible restoration of ligaments and joint capsules, and absence of immunologic response, intraoperative extracorporeal irradiation and reimplantation is an easy and convenient reconstructive surgical procedure after the en bloc resection of the malignant bone tumors. In this case, a single dose of 50 Gy was delivered to the bone extracorporeally. Tumor recurrence and distant metastasis were not found, and joint mobility and muscle strengthening of the right lower extremity was good at one-year follow-up examination. However callus formation was poor at the proximal part of the osteosynthesis on the X-ray. Uptake of the bone scintigraphy was found on the grafted bone, which implicated recovery of blood supply ten months following the surgery. In this case, careful observation of the clinical course is needed for the present time.
There are several procedures for the reconstruction of bony defects after the resection of osteosarcoma. It is more common recently to reconstruct with prosthesis than with arthrodesis around the knee joint, which is the most common site of osteosarcoma. However, prosthetic reconstruction is acompanied by serious complications such as infection, loosening, and destruction of tissue. We here report a case of osteosarcoma expanding to the femoral epiphysis treated by the concomitant use of liquid nitrogen-treated autograft and vascularized fibula graft. A16-year-old girl was referred to our hospital with pain of the right thigh. X-ray and MR imaging showed extension of tumor from the femoral dyaphysis to the epiphysis. Histologic study of the tumor resulted in a diagnosis of conventional osteosarcoma. Following pre-operative chemotherapy, she underwent resection of tumor. For the reconstruction of the large bony defect after resection, we used liquid nitrogen-treated autograft and vascularized fibula graft. Prognosis has been good without severe complications such as infection, local recurrence, and contracture of the knee joint. The range of motion of the knee joint is −10° to 110°. This type of hybrid reconstruction may provide good result because the vascularized fibra graft allows abundant blood supply. These results suggest that our procedure for reconstruction of bony defects after the resection of osteosarcoma around the knee joint can be a useful method for functional joint reconstruction.
The leading cause of death in our country has been cancer since 1981. The total number of deaths from cancer reached 304,286, with a mortality rate of 241.5 per 100,000, accounting for 31.0% of all deaths in 2002. According to an estimate prepared by the Foundation for Promotion of Cancer Research (2003), it is expected that 890,000 people will contract cancer each year. Bones are located next to the lungs and liver, and bone is a favorite site for cancer metastasis. Bone metastasis is found in 25 to 50% of terminal cancer patients, and it is thought that 70000 to 150000 terminal-stage cancer patients are presently suffering from bone metastasis. Maintaining the QOL of these patients is an urgent concern in order to help them live fulfilling lives. The authors therefore apply medical technology to identify bone metastasis molecular target proteins using proteomics in order to facilitate low cost early diagnosis and prevention of bone metastasis.
Brown tumor is a focal bone lesion caused by primary or secondary hyperparathyroidism. We describe a case of brown tumor presenting bone cyst-like shadow on X-ray at the right radius and tibia associated with primary hyperparathyroidism, in a 34-year-old woman with general fatigue and bone pain of the right forearm and leg. The diagnosis was suggested by radiological and biochenmical findings. The excision of a parathyroid adenoma normalized the metabolic status, but the bone lesions had not improved at the follow-up 12 months after parathyroidectomy. Therefore, surgical resection of the only tibia bone lesion was performed and the radius bone lesion was observed conservatively to confirm the identification of development into bone cyst-like brown tumor. Radiological findings of the tibia bone lesion and right leg pain improved, but the radius bone lesion did not change and the right forearm pain remained. We propose that additional surgical treatment should be performed for bone lesions after parathyroidectomy in bone cyst-like brown tumors with symptoms.
Bipedalism is the hallmark of the family Hominidae. It is thought that the development of bipedal locomotion in Homo sapiens was accompanied by physical immobility of the lumbar spine, leading to lower back pain. The Bone and Joint Decade, which was proposed by the World Health Organisation (WHO), is a worldwide movement extolling the importance of the motor organs in maintaining physical health. Motor organmanaged movement activates the brain and nervous system, and plays an important role in maintaining both circulatory and metabolic health. The purpose of our study was to clarify the causes of lower back pain by analyzing the effects of bipedalism on changes in gene and protein expression in the intervertebral lumbar discs. This was achieved by investigating thses processes in a standing mouse model and approximating the results to the human environment. We are confident that our research will help to furter elucidate the causes of lower back pain.
We investigated the radiologic features of 156 patients who underwent total hip or knee arthroplasy for the treatment of rheumatoid arthritis. We observed scoliosis, spondylolisthesis, disc space narrowing without little osteophyte, end-plate erosion, osteoporosis, and vertebral collapse. These findings seem to be characteristic features of rheumatoid arthritis.
Sarcoidosis is granulomatous multisysytem disorder, and commonly involves pulmonary hilar lymph nodes, eyes, lung, and skin. Nodular muscular sarcoidosis is rare and often confused with soft tissue tumor or systemic inflammatory disorders. We experienced a case of nodular muscular sarcoidosis of the right calf in a 71-year-old female. In this patient, calf mass was the initial manifestation without pain or muscle atrophy. The serum level of the angiotensin-converting enzyme (ACE) was within normal range. MRI is useful in evaluating the extent and distribution of muscle involvement. Axial MRI showed a ster-shaped central structure of decreased signal intensity, a "dark star sign". Coronal and sagittal MRI showed an inner stripe of decreased signal intensity and outer stripes of increased signal intensity, a "three stripes" sign. We detected increased uptake of Gallium scintigraphy in the muscular nodule. Biopsy was performed on the right lateral head of the gastrocnemius muscle. Histological examination showed Langhans type giant cells and epithelioid cells without caseous necrosis. Nodular muscular sarcoidosis was diagnosed. MRI, Gallium scintigraphy, and biopsy were useful for diagnosis.
Meningioma is a common benign tumor that accounts for about 25% of spinal neoplasms, rarely it is possible to detect see the presence of a mass shadow indicating calcification on X-ray in spinal meningioma. In this paper, we report a case in which we detected a calcification mass in spinal meningioma by simple X-ray with literature. A 73-year-old woman had low back pain and right calf pain in July 2003. She also noticed progressive muscle weakness below the anterior tibiolis. By a X-ray, we found the presence of a mass shadow indicating considerable calcification and spondylolisthesis at the level of the L4 vertebrae. We performed laminectomy from Th12 to L2 and from L4 to L5, and tumor resection. Histologically we diagnosed psammomatous meningioma, in terms of many variable-shaped psammomatous bodies against S-100 positive.
Pulmonary embolism (PE) associated with total knee arthroplasty is often reported, but that associated with unicompartmental knee arthroplasty (UKA) is very rare. A case on which we performed UKA developed PE despite of low such risk. We consider that the causes include localized higher pressure to the femur by the tourniquet and weight of the leg, which was supported at the femur by a leg hanger.
Neoplasia occurring in the sinus tract is a well known complication of chronic osteomyelitis. Squamous cell carcinoma, fibrosarcoma, myeloma, and malignant lymphoma have been reported. We report a rare case of malignant lymphoma arising from osteomyelitis. The patient was a 59-year-old male. At 15 years-of age, he had open fracture in the distal end of the right femur, and had suffered from chronic osteomyelitis since then. On March 2004, he had swelling, redness and pain around the right knee. He underwent antibiotic therapy, but it was not effective. Xp, CT, and MRI revealed osteolytic lesions in the distal end of the femur and swelling soft tumor in the vicinity. A part of the soft tumor was excised by open biopsy, and histological diagnosis was malignant lymphoma. At internal medicine department in our hospital, chemotherapy (R-CHOP therapy: 6cycles) and radiation therapy (total: 40Gy) were done. After four months, MRI indicated that soft tumor had disappeared.
We report a case on which we performed prosthetic knee replacement. She fell down and broke her prosthesis. The cause of prosthesis damage was related to its characteristics. We obtained satisfactory results soon after the operation.
Supracondylar fracture of the femur is one of the severe complications after TKA. It is usually treated by plate and screws, intramedullary rods, revision TKA or external fixator, but its results are not adequate for bone union, range of motion and other functions. Recently it is treated by the retrograded intramedullary supracondylar nail and the result is reported as excellent. We operated on two cases of this fracture (one is PS type component and the other is CR type) of this using nail by minimum incision and invasion through the patellar tendon. We carefully reamed the entrance point and forced it into the bone marrow manually without drilling. After rehabilitation, they regained good functions close to the preinjury conditions. We therefore think that this is a useful and safer surgical method for this type of fracture for both PS and CR TKA components.
The lock plate is a new surgical instrument for fractures. In this study, we compared the duration of hospitalization for high tibial osteotomy using the lock plate and that using the blade staple (the latter performed between November 2002 and June 2003) at our hospital. Between January 2004 and September 2004, 15 patients underwent high tibial osteotomy using the lock plate for medial osteoarthritis of the knee. They consisted of one man and 14 woman with a mean age of 67 years (range: 54 to 80 years). The patients were allowed passive range of motion and full weight bearing two days after osteotomy. Osteotomy using lock plate decreased the duration of hospitalization 84 days to 52 days. High tibial osteotomy using lock plate requires information on its unique systems.
We present a case of a 13-year-old boy with osteochondritis dissecans of the talus, in whom favorable outcomes were obtained by osteochondral autograft transplantation. He underwent arthroscopic fixation of the osteochondral lesions of the talus using polydioxanone pins, but came our hospital due to nonunion. Since pain in the ankle persisted, plain radiography and magnetic resonance imaging were performed. The results suggested stage 3 osteochondritis dissecans of the talus, according to the four-stage classification of Berndt and Hatty. We performed osteochondral autograft transplantation. At the time of writing this report 12 months postoparatively), the patient had experienced no pain and range of motion was not limited. In addition, radiolucency of the talus was restored.
To clarify which factors influence the results of operative treatment of ankle malleolar fracture, the outcome was assessed clinically and radiographically in 76 joints of 76 patients who consisted of 49 males and 27 females with an average age of 36 years. After an average follow-up of 11.3 months, clinical and radiographic results were evaluated according to Burwells clinical and radiographic criteria. Clinical results were good in 63 joints, fair and poor in 13 joints. Postoperative reduction was anatomical in 65 joints, fair and poor in 11 joints. There were no significant differences between clinically good and fair/poor groups with regard to sex, age, fracture type according to the Lauge-Hansen classification, number of malleolar fractures, and injury-operation interval. However, clinical results were significantly lower in patients injured by traffic accidents compared to other causes such as fall and sport injury. Although there was a tendency for anatomical reduction to be obtained in patients with good clinical results, it was not significant in this study.
Repetitive trauma to the hypothenar region may cause hypothenar hammer syndrome (HHS) characterized by inadequate circulation to the ulnar digits. We experienced a rare case of HHS caused by single trauma. A 13-year-old boy complained of numbness and cyanosis to three ulnar 3 digits after hitting the left hypothenar region on the floor when trying to receive a ball during volleyball game. Thermograms revealed low temperature of the three ulnar digits and angiograms showed occlusion of the ulnar artery whose superficial branch had little connection with the radial artery. We found a pseudo-aneurysm of the ulnar artery at the Guyon canal during surgery and an interpositional vein graft was performed after resection. After surgery his symptoms and signs disappeared and he could play volleyball again.
We present four cases of sarcoidosis with destructive arthropathy. Acute transient polyarthritis, chronic arthritis and tenosynovitis may occur in patients with sarcoidosis, however, such bone changes are relatively rare. Plain roentgenograms of the four cases exhibited osteolytic or sclerotic appearance in some joints except for the operated joint. One case showed positive correlation between laboratory data (CRP/ESR) and actual disease activity, while the other three cases did not. Histopathologic specimens showed chronic synovitis, lymphocyte aggregates, synovial hypertrophy, hyperplasia, and accumulations of fibrin-like material. None of the four cases exhibited non-caseating epitheloid granuloma. It is known that sarcoidosis may be accompanied with symptoms of autoimmune diseases in some cases. Some unknown factor may play an important role in systemic osteoarthritis in sarcoidosis.
We performed treatment for distal radius fracture using the Bone Grow External Fixator (BGF, MES co.) which combines non-bridging type external fixation with electrical stimulation. 7 fractures (three males and four females) were treated with the BGF. The age ranged from 32 to 76 years (average; 59.3 years). We removed the BGF four to six weeks after recognizing bone union on X-ray. As the BGF is of the non-bridging type, it allows range of motion exercise at an early stage and prevents loss of radius length after removal. However this method by itself is not adequate for severe osteoporotic cases and comminuted fractures. For these cases we obtained satisfactory results by using with β-TCP, minimum open reduction and internal fixation. We need more cases to evaluate utility of electrical stimulation.
The purpose of this study was to evaluate interrelation among knee muscle force, foot grip power, toe grasp ability, and single-legged balance. The evaluation was carried out on 21 university handball club members (11 male, 10 female, mean age 22.1 years). Concentric and eccentric muscle torques of knee flexors and extensors were measured using a Kin/Com dynamometer. Foot grip power was measured using a hand grip dynamomenter. Toe grip ability was evaluated to rotate the axis of a special device using toes as fast as possible. The movement of lower limbs on monopodal stance was recorded using a triaxial accelerometer attached firmly to the skin on both knees. Maximal amplitude of acceleration was used as a parameter for postural sway. We analyzed functional correlation using a Spearman rank correlation coefficient and ANCOVA for the right and left legs separately. As a result, single legged balance was found to correlate significantly with toe grip ability. The toe grip ability of the left foot showed no relationship with knee muscle power nor foot grip power, however relationship with balance failure and difficulty to perform rock, paper, and scissor movement was seen to some extent.
Twelve cases of pyogenic osteomyelitis were treated with antibiotic impregnated bone paste between September 2003 and October 2004. The average age was 57.2 years (19 to 78 years) at the time of surgery. The mean follow-up period was 8.1 months (two to 12 months). Among these cases, seven had diabetes mellitus, one had erythroderma exfoliativa, and the remaining four had no history. The cultured bacteria were methicillin resistant staphylococcus aureus (MRSA) in seven cases, mixed organism in two cases, and pseudomonas aeruginosa, methicillin sensitive staphylococcus aureus (MSSA) in one case respectively. All cases were cured with no evidence of the reccurence. We concluded that antibiotic impregnated bone paste provides satisfactory results in treatment of pyogenic osteomyelitis.
We investigated 24 patients with skeletal tuberculosis in the past 20 years. The age range was from 24 to 86 years (average: 57.2 years). Half of the patients (12 cases) were tuberculous spondylitis. Of nine cases excluding the tuberculous spondylitis cases, three were tenosynovitis and two were psoitis. There was no tuberculous arthritis of the hip and knee joint. Tuberculin reaction was considered to be useful for screening inspection in the diagnosis of skeletal tuberculosis because it was positive in 70% of these patients. If swelling without heat or redness that does not react to antibiotics is seen, tuberculosis should be suspected.
A case of osteoblastic intra-spinal meningioma is reported. A 71-year-old woman presented with severe low back pain. Plain roentgenogram of the lumber spine showed sclerotic lesion in the spinal canal at the level of the thoracolumbar transitional zone. CAT scan demonstrated high density area at the lesion. MR images showed a round mass lesion, by which the spinal cord was compressed laterally. There was no muscle atrophy and sensory disturbance. Neither bladder nor rectal dysfunction was seen. The lesion was surgically removed. Histological examination showed numerous psammoma bodies and mature bone which consisted of bone marrow and spicules, which was consistent with osteoblastic meningioma. The patients postoperative course was not problematic. Calcification such as psammoma body is sometimes found especially in spinal cord meningioma but ossification of the meningeal tumor is rarely observed. There are several theories of ossification in intraspinal meningiomas. The ossification in this case was probably a metaplasia of the stroma cells to the osteoblasts.