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Masato Tomita, Noriaki Miyata, Yoshihiro Nozaki, Makoto Osaki
2012 Volume 61 Issue 4 Pages
605-607
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We reported a case of the reconstruction of Achilles tendon after resection of the malignant soft tissue tumor in the calf muscles with Bard mesh®. The case was a 37-year-old man. He noticed a mass in the left calf muscles. He visited a nearby hospital and was introduced to our outpatient clinic due to suspected malignancy. With biopsy, we diagnosed his tumor as synovial sarcoma. After neo-adjuvant chemotherapy, we performed operation. In the operation, the Achilles tendon was resected 3 cm apart from both proximal and distal ends of the tumor. After that we reconstructed the Achilles tendon with Bard mesh ®. One and a half years after the operation, he could walk well without any support, and move his ankle joint smoothly. Bard mesh® is a very useful artificial material for reconstruction after surgery of malignant soft tissue tumor.
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Koji Murakami, Ryohei Yokoyama, Takashi Hatano, Ken-ichi Nishiyama
2012 Volume 61 Issue 4 Pages
608-611
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Intraarticular lipoma (lipoma arborescens) is a rare condition characterized by villous or papillary appearance and covered with synovial membrane. This condition most commonly affects the knee joint and rarely other joints. We report a rare case of lipoma arborescens of the shoulder joint. The patient was a 60-year-old female with a two-week history of pain and swelling in her left shoulder. Physical examination revealed an elastic, palpable mass measuring 5×5 cm with mild pain on push at the anterior aspect of the left shoulder joint. On MRI, the sharply-demarcated tumor was located in the subdeltoid bursa, showing high but slightly inhomogeneous signal on T1- and T2 weighted images. At surgery the lesion was located within the subdeltoid bursa and papillary on appearance. Histologically, the lesion consisted of the proliferation of mature adipose cells with villous structure and admixed with blood vessels, fibrous tissues and chronic inflammatory infiltrates. These features were consistent with those of lipoma arborescens.
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Satoshi Hisanaga, Hiro Sato, Kiyoshi Oka, Toshitake Yakushiji, Hiroshi ...
2012 Volume 61 Issue 4 Pages
612-617
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Superficial acral fibromyxoma (SAFM) is a rare benign soft tissue tumor with a predilection for finger tips and toes of adults, uncommonly involving the underlying bone in some cases. We report a rare case of SAFM eroding the distal phalanx. A 58-year-old male presented with continued swelling and pain of the right index finger after an operation of an ingrown nail ten years ago. The nail plate changed to the shape of a spoon causing elevation of the nail bed, cansing the skin of the nail to fold, bulge, and become cornified. Plain radiographs revealed erosion of the distal phalanx. Magnetic resonance imaging revealed that the tumor arising in the dermis extended into the underlying bone. An excisional biopsy was performed, however the lesion of the nail fold was left partially without excising in order to close the operation wound. The pathological diagnosis was SAFM. At three years after the surgery, the residual lesion has not been growing.
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Koji Fujieda, Yasunari Oniki, Eiichi Nakamura, Hiroaki Nishioka, Azusa ...
2012 Volume 61 Issue 4 Pages
618-622
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report a case of a lateral parameniscal cyst combined with a pericruciate meniscal cyst. A 24-year-old woman was referred to another clinic with a complaint of catching her left knee a year ago. Magnetic resonance imaging (MRI) of the left knee showed a horizontal tear of the anterior horn of the lateral meniscus and a meniscal cyst adjacent to the meniscus. However, the procedure was not performed because symptoms were moderate. One month ago, she visited our hospital because her left knee could not extend fully. Her left knee revealed a loss of extension of 10° and local tenderness on all fours with lateral joint space. Knee radiographs were normal. MRI showed that the expanded parameniscal cyst and intrarticular cystic lesion abutted the anterior cruciate ligament (ACL). We performed partial lateral menisectomy and removed the cystic lesion by arthroscopy. The lesion was diagnosed as pericruciate meniscal cyst arising secondarily to the parameniscal cyst. The pericruciate meniscal cyst was suspected to have originated from the meniscal horizontal tear like the parameniscal cyst.
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Yoshiaki Fukutoku, Yasutaka Tashiro, Akio Sakamoto, Shuichi Matsuda, K ...
2012 Volume 61 Issue 4 Pages
623-626
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Suprapatellar synovial plica with complete septum is a relatively rare disease, but it sometimes causes anterior knee pain, suprapatellar swelling, and flexion disorder in young people. We report three cases of this disease, in which the suprapatellar bursa and knee joint were completely separated by the septum. All cases were young or middle aged female and they had anterior knee pain and swelling which were localized in suprapatellar pouch. Two of them had limited range of motion under 90°. T2-weighted MRI revealed synovial plica, seen as bands of low signal intensity within the high-signal intensity joint fluid in all cases. Rest and injection therapy were not effective. However arthroscopic synovectomy and resection of the septum successfully cured their symptoms and no recurrence was observed.
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Fuyuki Tominaga, Toshihiro Ohdera, Eiji Yoshimoto
2012 Volume 61 Issue 4 Pages
627-630
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Recently, good clinical outcomes of unicompartmental knee arthroplasty (UKA) are reported for elderly patients. The purpose of this study is to investigate sports activities following UKA. We surveyed 145 cases, 167 knees (25 males, 120 females), treated with M/G Uni or Zimmer Uni in our hospital between February 2000 and August 2010. The mean follow-up was 43.4 months (range; 12-117 months). There were 123 knees with osteoarthritis and 44 knees with osteonecrosis. Age at operation ranged from 50 to 92 years old (average 75.8 years old). We compared postoperative sports activities with clinical and radiographic outcomes. Thirty-five patients (24.1%) enjoyed sports activities after surgery, and all of them were low-impact sports. There was a significant relationship between participation in sports, JOA score, and gender.
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Takuma Inoue, Itaru Furuichi, Masakazu Murata, Kenji Ogawa, Noboru Mor ...
2012 Volume 61 Issue 4 Pages
631-634
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Revision total knee arthroplasty may be difficult especially in case accompanied by bone defect due to rheumatoid arthritis, infection, or slack of joint. In such cases, condylar knee constraint may be chosen for stability. The short-term results of cases using constrained condylar knee replacements by revision knee arthroplasty performed at our hospital are reported. The cases were nine knees who underwent revision total knee arthroplasty between May 2005 and February 2011. The average age at operation was 70.3 years old (52 to 84 years old) and the underlying diseases were six rheumatoid arthritis and two gonarthrosis. Revision was performed due to infection in four knees, slack after total knee arthroplasty in four knees, and femur condylar fractures in one knee. NexGen LCCK was used in all the cases. The JOA score of seven knees with rheumatoid arthritis before operation was 35.3 points on average (10 to 56 points). The postoperative JOA score was 62.6 points on average (56 to 75). The JOA score of two knee with gonarthrosis before operation was 32.5 points on average (25 to 40). The postoperative JOA score was 52.5 points on average (45 to 60), indicating postoperative improvement in all cases.
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Noboru Moriguchi, Itaru Furuichi, Masakazu Murata, Kenji Ogawa, Takuma ...
2012 Volume 61 Issue 4 Pages
635-639
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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In this study, the results of total knee arthroplasty (TKA) were reviewed for more than three years after surgery using Genesis II. The subjects were patients who had underwent TKA between 2006 and 2008 using Genesis II (Smith & Nephew). Sixty-seven joints were observed. They consisted of 46 joints with knee osteoarthritis (OA) and 21 joints with rheumatoid arthritis (RA). The average age at surgery was 73.5 years. Of the 46 OA joints, PS type joints were used for 42 and CR for four. PS type joints were used for all 21 RA joints. The patella was replaced in all patients except four. The results were evaluated according to the JOA score, Barthel Index, range of motion of knee, X-rays, and complieations found. The average JOA score improved from 53 points before surgery to 79 points and the average Barthel Index from 70 to 97 points. The range of motion improved from -14-112 degrees before surgery to 0-122 degrees. Implants were placed at angles of α 97, β 90, γ 3, and δ 86. The mean FTA was 181 degrees before surgery, and 174 degrees at the last observation. Postoperative complications were delayed wound healing in three joints with OA, progressive valgus in two joints, infection in two joints, and delayed wound healing in one RA joint. The postoperative rasults of the patients in this study were generally good because they were short-term results. Follow-up over a longer term in required.
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Shuichi Eto, Tomoki Takahashi, Manabu Taguchi, Yoichi Hayashida, Hirok ...
2012 Volume 61 Issue 4 Pages
640-643
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Patellofemoral pain, crepitus, and locking after total knee arthroplasty (TKA) are reported as patellar clunk syndrome (PCS). We report one case of PCS after posterior stabilized TKA. A 70-year-old man with degenerative arthritis of his left knee was treated with left TKA one month after arthroscopic synovectomy. Three months later, he noticed painful catching, grinding of the patellar when moving his knee from flexed to extended position. Arthroscopic debridement of the symptomatic patellofemoral nodule was perfomed one year after TKA, and all symptoms disappeared after operation. Many of the factors associated with an increased incidence of post operative PCS were seen in this case, such as previous surgery of the knee, increased postoperative knee flexion, failure to totally cover the patellar during resurfacing with uncovered patellar bone exposed, and peripatella synovium.
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Michiko Uchiyama, Takafumi Torigoshi, Kazushige Maeda, Kunihiko Okano, ...
2012 Volume 61 Issue 4 Pages
644-647
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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This study aimed to evaluate the effects of continuous femoral nerve blocks (CFNB) on pain after total knee arthroplasty (TKA). We investigated 40 patients (7 males, 33 females) who received CFNB after TKA between November 2010 and August 2011 at our institution and 40 patients (11 males, 29 females) who didnot receive CFNB after TKA as the control group. We measured the number of analgerics used, ROM, D-dimer level, and incident rate of deep vein trombosis (DVT). The CFNB group used an average of 1.03 analgesics for 48 hours, while the control group used 1.93 analgesics. The mean active flexion knee seven days after TKA was 87.8 in the CFNB group, and 81.4 in the control group. The D-dimer level one week after TKA was 10.1μg/ml in the CFNB group, and 14.7μg/ml in the control group. The incident rate of DVT was 0 % in the CFNB group and 12.5% in the control group. The number of analgesics used and D-dimer level one week after TKA showed a significant difference, confirming that CFBN is effective for pain after TKA.
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Fumitake Kamegawa, Hidetoshi Onoue, Hitoshi Shirachi, Makoto Sakurai, ...
2012 Volume 61 Issue 4 Pages
648-650
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Treatments for tibial plateau fractures at thin soft tissue areas in elderly persons are accompanied by high risks of complications due to the wide deployment range required. We report two cases of elderly patients with tibial plateau fracture treated using the Ilizarov external fixation. Case 1 was a 73-year-old male with right tibial plateau compound fracture (Schatzker type V). Debridement was performed on the same day the fracture was sustained. Ilizarov external fixation was performed 13 days after the trauma and partial weight bearing was started six weeks after surgery. The external fixation was removed 14 weeks after surgery. Case 2 was an 84-year-old male with right tibial plateau fracture (Schatzker type V). Ilizarov external fixation was performed six days after trauma. Partial weight bearing was started four weeks after surgery, and external fixation was removed 12 weeks after surgery. Bone coalescence was achieved in both cases without major complications, and both were able to walk on their own at discharge.
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Hisato Tanaka, Takaki Kasahara, Kanako Kodama
2012 Volume 61 Issue 4 Pages
651-654
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report the results of using the cross-band separated type orthosis to treat 36 patients with vertebral fractures for a period of 18 months between January 2010 and June 2011 at our hospital. The patients consisted of nine males and 27 females. Their mean age was 81.6 years, and the mean observation period was 5.8 months. The cross-band separated type orthosis can be divided into the cross band part for supporting the superior limb girdle and the soft lumbosacral section for supporting the side pillar and posterior strut. The rear strut of the cross band section is passed through the rear side of the para-midline lumbosacral orthosis, allowing it to be used as a traditional lumbosacral corset while maintaining the original functions.
The average percentage of wedge deformity was 76.8% in the first visit, decreasing to 65.4% in the last observation. The average decrease in wedge deformity was 14.8%. The kyphotic angle worsened by 4.36 degrees on average. Pain improved in 77%, and cleft formation was seen only in one case. Because of the extensive use of mesh, the orthosis is compatible for many patients, even providing strong support for patients with severe spinal curvature.
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Koichiro Toyoda, Eiichi Shiigi, Ryutaro Kuriyama, Takenori Fujisawa, T ...
2012 Volume 61 Issue 4 Pages
655-657
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We conducted a retrospective study on high-dose acetaminophen for lumbar disease. Twenty-four patients (11 males, 13 females, average age 67 years) were placed on high-dose acetaminophen (>2,000 mg/day × 3-4 times) for 2.5 months. Numeric rating scale changed from 8.3 (pre-dose) to 2.8 (post-dose). Efficacy was seen in 65% of the patients while the remaining 35% had to change drug and use combined block therapy. Elevation of AST and ALT was found in 21%. An above five-fold elevation of ALT was seen only in one patients, but ALT decreased after the drugs were discontinued. High-dose acetaminophen is a first choice drug for lumbar disease.
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Takamitsu Tokioka, Hideyuki Doi
2012 Volume 61 Issue 4 Pages
658-662
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Eight cases of postoperative epidural hematoma (PEH) were seen out of 1512 posterior spinal surgeries, and the incidence was 0.53%. In the period before blood pressure control with nicardipine hydrochloride was started, five cases of PEH were accompanied with blood hypertension over 160 mmHg. In the later period after blood pressure control was begun, two cases were suffered PEH due to bleeding, although they were treated conservatively. Blood pressure control with nicardipine hydrochloride after surgery is considered useful to prevent PEH, but emergency surgeries for patients using anticoagulants have potential risks of PEH even though postoperative blood pressure is controlled well.
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Masahiko Abematsu, Kosei Ijiri, Naoya Kawabata, Masahito Nagata, Ayumi ...
2012 Volume 61 Issue 4 Pages
663-664
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Dural repair using polyglycolic acid mesh and fibrin glue is a common method for preventing cerebral spinal fluid leakage after spinal surgery. In case of large close spinal fluid leakage, reoperation is needed. Since 2009, we have been treating spinal fluid leakage after spinal surgery using fascia, polyglycolic acid mesh, and fibrin glue. In this article, we report the method and results of use after surgery.
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Fujio Nakazawa
2012 Volume 61 Issue 4 Pages
665-668
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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A 5-year-old boy suffered low back pain after swinging a golf club for pleasure. At first we diagnosed him as lumbar (L) 4/5 disc herniation (LDH). But after four months from the onset, the herniated nucleus was absorbed and signs of inflammation were observed at the L4, 5 spinal bodies in magnetic resonance imaging (MRI). We told the patient and his family that it was not LDH but spondylodiscitis. After a year, the signs of inflammation in the spinal bodies remained, but symptoms disappeared and the patient returned to his usual lifestyle. The case took a long time to diagnose but prognosis was good. MRI was useful for diagnosing and evaluating the progress of spondylodiscitis.
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Kosei Miyazaki, Naoshi Kikuchi, Sanshiro Inoue, Yugo Takano, Kazuya Yo ...
2012 Volume 61 Issue 4 Pages
669-673
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Atypical mycobacterium infection of the spine is very rare. We report two cases of infectious spondylitis caused by atypical mycobacteria. Case 1: A 49-year-old man was born with partial IFN-γ receptor 1 deficiency. At age thirty, he had multiple osteomyelitis and pathological rib fracture. M. avium was found at biopsy and he was treated and cured by antituberculosis therapy. On admission, MRI suggested infectious spondylitis with destruction of the Th11/12 disc. We suspected infectious spondylitis caused by M. avium, and antituberculosis therapy (isoniazid, rifampin, ethambutol and pyrazinamide) was started. After three years, infectious spondylitis was cured. Case 2: A 90-year-old woman with a one-year history of back pain. MRI and CT showed non-union of the vertebral body at L2, and a rim-enhancing mass was observed in the iliopsoas muscle. She was moved to our hospital, and biopsy was performed by CT guide. M. intracellulare was found by PCR and combination therapy (clarithromycin, ethambutol, and rifabutin) was started. After six months, She experienced a gradual increase in back pain, and MRI showed an enlarged rim-enhancing mass. It is important to determine if spondylitis is caused by atypical mycobacterid or tuberculous spondylitis.
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Kiyoshi Sada, Tadashi Tomonaga, Takashi Iioka, So Morooka
2012 Volume 61 Issue 4 Pages
674-678
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Ten patients (5 males and 5 females age range; 60-84, mean age; 72.2 years) with pyogenic spondylitis were treated by percutaneous suction aspiration and drainage between June 2002 and June 2010 at the Department of Orthopaedic Surgery, Nagasaki City Hospital. We lay the patients in the lateral recumbent position and made a small incision with local anesthesia. We used Myer's imshrument to perform percutaneous suction aspiration and washed out the intervertebral space. We inserted an aspiration tube for drainage and epidural tube for continuous irrigation or injection of antibiotics. Lumbago and imflammatory reaction improved in all ten patients. The average number of days of hospitalization was 60.9 days. We consider percutaneous suction aspiration and drainage to be effective for pyogenic spondylitis because the bacteria can be identified and improvement of lumbago is greater due to low invasion.
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Takuya Ikuta, Mitsuru Sakaguchi
2012 Volume 61 Issue 4 Pages
679-682
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We evaluated the clinical and radiographic results of total hip arthroplasty in 212 cases using Exeter type system. We followed them for a period of more than one year (average 4.6 years).
In all cases, the mean JOA score improved from 49.2 to 81.0 points. The survival rate of the femoral component due to aseptic loosening as the endpoint was 99%, and that due to other causes as the endpoint was 98.6%. Our findings show that the Exeter stem implanted by proper cementing technique provides excellent middle-term results.
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Junichi Kamizono, Yasuhiro Ishido, Motoyuki Tanaka, Riichiro Yoshii, H ...
2012 Volume 61 Issue 4 Pages
683-687
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Loss of femoral bone stock presents a significant challenge in hip revision surgery. We report a case whose massive bone defect of the femur was reconstructed with a megaprosthesis combined with impaction bone grafting. A 76-year-old woman underwent bipolar hemiarthroplasty for femoral neck fracture 25 years ago. Two years later, she underwent revision surgery with long stem for periprosthetic femoral fracture. But bone union failed. Sinking of the stem and bone defect of the femur progressed gradually. In 2010 she came to our hospital suffering from impending fracture of the lateral condyle of the femur caused by the sinking of the stem. The femur was shorter than the unaffected side by 13 cm. CT demonstrated complete absence of the proximal femur. To achieve adequate fixation of the stem, distal medullary canal was reconstructed with circumferential metal mesh and impacted bone grafts, and proximal canal was reconstructed with a megaprosthesis. This method may be useful for massive and circumferential bone defects of the proximal femur.
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Atsunori Tokushige, Takashi Imagama, Akihito Sakka, Toshihiro Seki, To ...
2012 Volume 61 Issue 4 Pages
688-691
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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The purpose of this study was to investigate the removal methods of well-fixed cementless femoral components and their problems. Between April 2008 and August 2011, six well-fixed cementless stem ware removed because of breakago of the stem or infection. Four stems were proximal fixation stems and two ware Zweymuller stems. Extended trochanteric osteotomy was performed on two of the proximal fixation stems. The other four stems were removed using an osteotome. Trochanteric fracture occurred in one case in which the stem was removed using the osteotome. Revision THA was performed on two cases with breakage of the stem and one case with infection. The results of this study indicated that collared proximal fixation stems should be removed by extended trochanteric osteotomy, while Zweymuller stems are relatively easy to remove with an osteotome.
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Satoshi Kido, Soichiro Nakano, Junichi Arima, Takayuki Tanaka, Hiroshi ...
2012 Volume 61 Issue 4 Pages
692-696
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report the clinical and radiographic outcome of patients after revision surgery with cementless femoral components at our hospital. From 1998 to 2009, fifteen hips of 14 patients who underwent revision surgeries of femoral components and could be followed up for one year or more were enrolled in this study. There were two men in two hips, and 12 females in 13 hips, and their mean age at surgery was 68.3 years old. The mean follow-up duration was 5.1 years. According to the Paprosky classification, two hips were classified as type I, 11 hips as type II, and two hips as type IIIA. There were no cases of type IIIB or IV. The JOA hip score improved from 57.0 points to 78.7 at the final follow-up. Stem subsidence over 3 mm and stress shielding were seen in one and six hips, respectively. According to the criteria of Engh et al., 14 hips were classified with bone-ingrowth fixation, and one with stable fibrous fixation. There were no hips with unstable stem nor cases with serious complications after the revision surgeries.
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Katsuhiko Murakami, Katsutoshi Sunami
2012 Volume 61 Issue 4 Pages
697-699
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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The infection at surgical sites is a major problem in surgical patients. It was found that sutures play a role in surgical site infection. Due to the importance of suture, suture coated with Triclosan was developed. Triclosan is a broad-spectrum antiseptic and has been used for over 30 years. It has antimicrobial activity against S. aureus, S. epidermidis, MRSA, MRSE, Vancomycin resistant Enterococcus fecalis, Psedomonas aeruginosa and E.coli. Polyglactin 910 (Vicryl), a commonly used suture, is coated with Triclosan and is sold under the trade name of Vicryl Plus. Vicryl Plus has been used in veterinary practice and was found to be effective in prevention of surgical site infection. However, there were reports on tissue reaction caused by Vicryl and Vicryl Plus.These reactions happened rarely and equally between Vicryl and Vicryl Plus, suggesting that it was not caused by Triclosan but probably resulted from a contamination.
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Katsunori Yazawa, Makoto Miyazaki, Kazuaki Fukuda, Kosuke Numata, Tets ...
2012 Volume 61 Issue 4 Pages
700-703
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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A 62-year-old man complained of swelling of the left upper limb and left shoulder pain without obvious causes. After clinical observation for four days, swelling became worse and he visited our hospital again. In physical examination, swelling of the left upper limb was seen. D-dimer rose slightly in laboratory data. Venous ultrasound examination showed venous thrombosis the in left subclavian vein and left internal jugular vein. He was hospitalized and started on anti-coagulation therapy. Three weeks after the start of treatment, he was discharged due to diminished D-dimer. After three months, thrombosis diminished in venous ultrasound examination, and anticoagulation was discontinued. Subclavian deep venous thrombosis is a very serious disease which causes upper limb swelling, and early stage treatment is needed to prevent serious complications.
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Yasuhiro Ohmori, Seiya Jingushi, Tsutomu Kawano, Keita Miyanishi, Taka ...
2012 Volume 61 Issue 4 Pages
704-706
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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The effects of low molecular weight heparin or enoxaparin to prevent postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE) were evaluated retrospectively in primary total hip arthroplasty (THA) cases. The enoxaparin treatment was carried out on 238 patients undergoing primary THA between June 2009 and July 2011. The average age of the patients was 67 years old. The patients received 2000 IU of enoxaparin injected subcutaneously once or twice per day until day 7 to 10 after surgery. When the serum D-dimer level was over 10 μg/mL on day 7, enhanced CT scan was carried out to investigate DVT or PE. The frequency of DVT or PE in discontinued cases due to side effects was investigated retrospectively. There was no symptomatic PE. Fifty-four cases (22.7%) had enhanced CT and six developed DVT, of whom three also developed PE. One case had PE without DVT. Forty cases discontinued the treatment (16.8%), due to hemorrhage in 34 cases (14.3%), and due to liver dysfunction in five cases (2.1%).
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Yukihiro Furue, Hiroaki Tamura, Ikufumi Nagayoshi, Tatsuo Motoyama, Ma ...
2012 Volume 61 Issue 4 Pages
707-710
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report two junior high school baseball pitchers treated with osteosynthesis of the avulsed fragment of the humeral medial epicondyle. Both pitchers experienced severe pain in the medial elbow after throwing the ball only once and could not continue to pitch. Roentgenographic study revealed avulsed fragment of the medial epicondyle of the humerus. Osteosynthesis was performed, and as a result, they achieved union of avulsed fragment and were able to pitch again after the treatment. Treatment for little leaguer's elbow is still controversial. Because the growth plate has not closed in this age group, conservative methods are applied for fragmentation. But in junior high school pitchers, as the growth plate is going to close or has closed in the age group, we think osteosynthesis is one treatment option.
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Tatsuya Sakai, Itaru Furuichi, Masakazu Murata, Kenji Ogawa, Takuma In ...
2012 Volume 61 Issue 4 Pages
711-714
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report the clinical results of surgically treating distal humerus fractures. From January 2007 to April 2011, we treated nine cases consisting of two males and seven females whose average age was 71.0 years old. According to the AO/ASIF classification, there were one C1, two C2, and six C3 fractures. We treated four cases with tension band wiring (TBW) and screws, three cases with LCP distal humerus plate (LCP), and two cases with total elbow arthroplasty (TEA). They were then reviewed in terms of time to bone union, clinical results (range of motion and Jupiter's classification) and postoperative complications. The time to bone union was 6.0 months (3 to 12 months) on average. The flexion angle of the elbow was 122 degrees (90 to 140 degrees), and the extension angle of elbow was -30 degrees (-40 to -10 degrees) on the average after the operation. The results were excellent in one case, good in seven cases, and fair in one case according to Jupiter's classification. Complications included one of nonunion, one infection with MRSA, and two olecranon failures after ulnar osteotomy. These were reoperated and cured. When treating distal humerus fractures, it is important to ensure rigid fixations to enable early stage rehabilitation and to select the treatment methods in this disease, taking into account age, ADL, and complications. TEA is required depending on the situation.
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Shojiro Ishibashi, Naoyuki Kuga, Hiroshi Hagihara
2012 Volume 61 Issue 4 Pages
715-718
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Osteoporotic distal humerus fracture, which is known to be difficult to treat, is challenging to the orthopaedic surgeon. We treated 21 distal humerus fractures between 2003 and 2011, with a mean age of 80 years, using the ONI plate in 10 cases and the locking compression plate in nine cases. The fractures were classified into 13 extra-articular, three simple articular, and five multifragmentary articular fractures. One nonunion and nine cases of complications including superficial infection, ulnar nerve palsy, heterotopic ossification, etc occurred. Rates of nonunion and complications in extra-articular, simple articular, and multifragmentary articular fractures were 0%, 0%, 20%, and 23%, 67%, 60%, respectively. At the last follow-up, the mean range of motion of the elbow in the three groups were 100, 82, and 71 degrees, respectively, indicating no significant difference between the implants. Both the ONI plate and locking compression plate provided excellent results for extra-articular and simple articular fractures, however, treatments for multifragmentary articular fractures had a high rate of complications.
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Yasujiro Tsutsumi, Yoshihisa Anraku, Katsuhiko Kunitake, Masanori Yasu ...
2012 Volume 61 Issue 4 Pages
719-723
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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The purpose of this study was to evaluate the modified operative technique using the PHILOS Plate System for displaced fractures of the greater tuberosity of the proximal part of the humerus. The initial results of eight patients treated with this method are reported. The patients consisted of four males and four females. Their mean age was 53 (26-74) years old. The average duration from trauma to surgery was 8.8 (3-20) days. The average duration of follow-up was 7 (3-18) months. Osteosynthesis was performed using a Proximal Humerus Internal Locking System (PHILOS; Synthes, Germany). Firstl, the plate was cut in half, the proximal half of the plate was used and all shoulders received the additive fiber-cerclage of the rotator cuff after plate fixation. The functional and radiological outcomes were evaluated. According to Neer's classification, there were three cases of type IV and five cases of type VI. All cases achieved bony union. The mean postoperative JOA shoulder scores averaged 96.4 points, and there was no subacromial impingement or complications. This internal fixation method may provide more secure fixation for comminuted fractures of the greater tubercle of the humerus especially in weak bones.
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Koichiro Sakimura, Shinichi Nakahara, Yusuke Nakazoe, Masao Eto
2012 Volume 61 Issue 4 Pages
724-727
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We reviewed the clinical outcome of minimally invasive plate osteosynthesis (MIPO)technique in displaced proximal humeral fractures. The thirteen cases consisted of three men and ten women, whose mean age was 71.5 years. Fracture type by the AO classification was one A2, two A3, five B1, and five B2. All cases were treated with indirect reduction and locking plate fixation through a deltoid-splitting approach proximally and small incision distally. Nonunion and implant failures were not found in any case. At the final follow-up, the mean active range of motion was 135° for shoulder flexion, and the mean JOA score was 85 points. The MIPO technique for proximal humeral fractures can minimize soft tissue damage and devascularization of fracture fragments, but has the risk of damaging the axillary nerve.
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Takahiro Yara, Yukio Abe, Yasuhiro Yamaoka, Koji Yoshida, Daisuke Naka ...
2012 Volume 61 Issue 4 Pages
728-731
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Clavicle fracture is common, but fracture of both proximal and distal ends is a very rare injury. We report one such case. A 44-years-old man fell while walking, and he sastained proximal and distal clavicle fracture. We treated this patient at our hospital using the Scorpion plate for both proximal and distal fractures. This plate can fix fragments with one screw and two hooks. The Scorpion plate shoued good retentivity and bone fixation characteristics.
Excellent union of bone was achieved in this case at follow-up. These results indicate that the Scorpion plate is a useful device for the fracture of both proximal and distal ends.
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Yusuke Nakazoe, Koichiro Sakimura, Kohei Kawaguchi, Shinichi Nakahara, ...
2012 Volume 61 Issue 4 Pages
732-736
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Epiphyseal plate injury of the medial end of the clavicle is a rare injury. We report two cases. The cases involved a 15-year-old boy and a 16-year-old boy each sustaining injury to the medial clavicle while playing. Radiographs and computed tomography confirmed the posterior displacement of the medial clavicle. Because closed reductions were unsuccessful, open reduction and internal fixation using an absorbable screw and suture were performed. The prognoses were excellent at three months after the operations. It is impossible to differentiate epiphyseal plate injury of the medial end of the clavicle from sternoclavicular dislocation by clinical symptoms and imaging findings. For most epiphyseal plate injuries of the clavicle that have been reported definitive diagnosis could be obtained daring operation. Since there is a risk of mediastinum internal-organ damage, we recommend reduction and fixation in an early stage.
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Shinichi Nakahara, Masao Eto, Yusuke Nakazoe, Koichiro Sakimura
2012 Volume 61 Issue 4 Pages
737-742
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Recently there have been some reports of subacromial erosion (SE) after arthroscopic rotator cuff repair (ARCR). It is hypothesized that SE is caused by knot impingement. We classified SE by MRI T2WI sagittal findings. Grade 0: No appearance of SE. Grade 1: Depth of SE is less than half the thickness of the acromion. Grade 2: Depth of SE is more than half the thickness of the acromion. We treated 95 cases by ARCR and 21 cases by open rotator cuff repair (ORCR, McLaughlin method only). There were 62 cases of Grade 0, 21 cases of Grade 1, and 12 cases of Grade 2 among ARCR. There were no cases with SE among ORCR. Generally, the bone shape is investigated by CT, but it is useful to evaluate SE by MRI because no other tests such as CT are required, and patients are not exposed to radiation.
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Tasuku Kiyuna, Hiroshi Yamaguchi, Hiroshi Arakaki, Hiroshi Chinen, Yas ...
2012 Volume 61 Issue 4 Pages
743-745
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Unreducible chronic anterior dislocation of the shoulder is rarely reported. We report a case of an 84-year-old female requiring humeral head prosthesis and Latarjet procedure.
Four months ago, she fell and dislocated her right shoulder. At that time, dislocation was reduced and her arm was fixed with a triangular sling. However, she decided to take the sling off, after which she suffered, dislocation repeatedly in four months. Finally, she sustained unreducible chronic anterior dislocation of the right shoulder and was referred to our hospital. On physical examination, she could not move her arm because of shoulder pain, and her JOA score was only 16 points. Radiographs and CT scans showed anterior dislocation of the shoulder, Hill-Sachs lesion, and bony Bankart lesion. MRI showed rotator cuff tear. Hemiarthroplasty, Latarjet procedure, and rotator cuff repair were performed. Her arm was fixed with an abduction pillow for eight weeks after surgery. Rehabilitation program was started at two weeks after the operation. Seven months after surgery, she did not complain of any pain, and active range of motion improved. No obvious redislocation was found on radiographs, and her JOA score also improved to 63 points.
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Hiroyuki Kitahara, Yoshihiro Yabe, Tsuyoshi Miyaji, Keiichi Tsuda, Syu ...
2012 Volume 61 Issue 4 Pages
746-750
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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The case pertains to a 70-year-old male that experienced a second re-tearing following a repair of the rotator cuff. A second repair of the rotator cuff was carried out but the rotator cuff did not fuse with the bone. Such a rotator cuff repair was considered to be difficult, therefore CTA head hemiarthroplasty was carried out with the purpose of eliminating pain and improving the shoulder joint functions. The pain, range of motion, and retention of the upper limb also improved following surgery, and a good grade was obtained with no problems upon engaging in activities of daily living. It is believed that the ability to repair the rotator cuff declines in elderly patients due to the normal degeneration of the rotator cuff. CTA head hemiarthroplasty is thus suggested to be one effective treatment methods in elderly patients if there is strong degeneration of the rotator cuff or a re-tearing of the rotator cuff.
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Takashi Toma, Hiroshi Yamaguchi, Tomohiro Moriyama, Yasunari Ikema, Fu ...
2012 Volume 61 Issue 4 Pages
751-753
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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There have been few reports of rapidly collapsed idiopathic humeral head necrosis. We report a case of an 80-year-old female with humeral head replacement. Four months ago, she had felt right shoulder pain with no inducer. Conservative treatment was performed at a nearby orthopedic clinic. However, the pain did not improve, and she was referred to our hospital. On physical examination, she could not move her arm because of pain. Radiographs and CT scans showed collapse of the humeral head, and MRI showed rotator cuff tear. Japanese Orthopaedic Association (JOA) shoulder function score was only 21. Differential diagnosis, such as infection, rheumatoid arthritis, Charcot joint, history of oral steroid use, and smoking history were investigated by joint fluid culture, blood test, and previous history. Idiopathic humeral head necrosis was strongly suspected, and humeral head replacement was performed. Pathological examination provided a definitive diagnosis of idiopathic humeral head necrosis. Eighteen months after surgery, she did not complain of any pain, and active range of motion had improved. Her JOA score also improved to 83.
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Hitoshi Arimura, Junji Ide, Yasunari Oniki, Hiroshi Mizuta
2012 Volume 61 Issue 4 Pages
754-757
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We reported a rare case of the intratendinous tear of the supraspinatus tendon in a young athlete. A 16-year-old, right-handed girl who was a high school Judo player presented with a history of traumatic right shoulder pain. The pain was exacerbated with overhead motion. The patient had mild limitation of range of motion with normal strength but positive impingement signs. Although there were no abnormal findings in plain radiograph, MRI on T2WI and STIR showed a horizontal high intensity area in the distal supraspinatus tendon and a possible intratendinous rotator cuff tear. In shoulder arthroscopy, the lateral aspect of the rotator cuff insertion was found to be a soft area when probed and incised, allowing access to the intratendinous rotator cuff tear. The intratendinous tear was repaired with three horizontal sutures after debridement. At follow-up four months later, the patient had alveaoly returned to practicing Judo.
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Hirota Kohama, Hiroshi Yamaguchi, Kenji Horikiri, Chojo Futenma, Fumin ...
2012 Volume 61 Issue 4 Pages
758-760
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report a rare case of synovial osteochondromatosis of the shoulder. The patient was an 18-year-old male who complained of left shoulder pain.
Four years ago, he fell and injured his left shoulder in a high jump competition. Radiological examination revealed no fractures. His shoulder pain improved with time, but three months before being referred to our hospital, he suddenly noticed left shoulder pain without any cause. X-ray, CT and MRI showed multiple calcified loose bodies in the left shoulder joint. The active forward elevation was 120 degrees, and internal rotation was at level L5. His JOA score was 62 points. Arthroscopic removal of loose bodies and synovectomy were performed. Pathological findings revealed the loose bodies to be synovial osteochondromatosis. Nine months after surgery, he has no pain with improvement in range of motion. His JOA score also improved to 98 points. Radiogram showed no signs of recurrence.
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Daisuke Noda, Takashi Ishinishi
2012 Volume 61 Issue 4 Pages
761-764
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Open traumatic rupture of the tibialis anterior tendon is rare injury. Open rupture can be diagnosed early relatively easily, so primary tendon repair is the main treatment. When diagnosed late, conservative treatment may be preferred in some rare cases for elderly patients, However because causervative treatwent decreases ankle joint motion, claw toes and flat foot with arthrosis may occur. For this veason surgical repair such as end-to-end tendon repair and tendon reconstruction should be considered in patients who can walk. We report a case of open traumatic rupture of the tibialis anterior tendon treated by primary tendon repair including Savage method as a core suture and cross-stitch method, who obtained excellent results with and full loading from an early stage.
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Hirokazu Takai, Tomoki Takahashi, Shuichi Eto, Seiko Takai, Youichi Ha ...
2012 Volume 61 Issue 4 Pages
765-768
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Herein, we present 5 elderly female patients, aged 74-84, having calcaneus fractures operated on utilizing artificial bone grafts. Artificial bone was grafted onto the calcaneus bone. Open reduction and internal fixation (ORIF) with Kirschner wire required small lateral incisions. We removed the wires and permitted partial weight bearing at 4 weeks post surgery. Full weight bearing was permitted at 8 weeks post surgery. Böhler angles of the Calcaneus (pre-surgery, post-surgery and at the last follow-up) were calculated. Four patients were Joint Depression Type, and one was Tongue Type. Utilizing Essex-Lopresti classification, average Böhler angles were as follows: 6.2° (before); 28° (after); and, 27° (last follow-up). Böhler angles did not change over time post surgery. Artificial bone grafts onto the calcaneus bone with one small lateral incision in ORIF, for elderly patients with osteoporosis, seems to be extremely beneficial.
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Mikio Terahara, Ryuichiro Kikuno, Ryo Motokishita, Setsuro Komiya
2012 Volume 61 Issue 4 Pages
769-774
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Forged composites of unsintered hydroxyapatite/poly-L-lactide (F-u-HA/PLLA) composite devices which have high strength and are bioactive and bioabsorbable are was frequently used in orthopedic surgery such as fracture repair, osteotomy, and bone graft. It has been reported that bioabsorbable plate (Super-Fixsorb® MX40 mesh) has strength almost equal to metallic bone fixation devices. We present two patients who underwent fracture repair for metatarsal bone and lateral malleolus fractrure using bioabsorbable plate (Super-Fixsorb® MX40 mesh).
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Yuichiro Nishino, Takashi Miyamoto, Tatsuya Fukushima, Kenji Taguchi, ...
2012 Volume 61 Issue 4 Pages
775-778
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Open total talus dislocation is relatively rare but the choice of treatment is controversial. We experienced three male cases of open total talus dislocation, between November 2009 and August 2011, whose mean age was 40.5 years. Average follow-up was 14.5 months. The mechanisms of injury included motor-vehicle collision (two patients), and fall from a height (one). We performed open reduction and used external fixator on the same day. Infection and osteoarthritis occurred in two patients but all patients acquired independent gait without avascular necrosis. Sufficient informed consent about possible complications was needed.
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Takeshi Utsunomiya, Sanshiro Inoue, Kazuya Yokota, Yugo Takano, Kosei ...
2012 Volume 61 Issue 4 Pages
779-784
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We performed a retrospective study on 14 patients (10 men and 4 women) with the Lisfranc joint fracture-dislocation (LFD) treated at the Miyazaki Prefectural Miyazaki Hospital between 2006 and 2011. The mean age was 54.1 years, with the age range of 11 to 88 years. Ten patients suffured from high energy injuries. The average length of follow-up was 7.67 months (range; 3 to 17 months). Patient outcome was assessed with use of the Japanese Society for Surgery of the Foot standard rating system. We attempted to determine statistically what factors affected the clinical result of the LFD. Major determinants of good clinical results were younger age and anatomical reduction. The patients showed poor clinical results with leg injuries on the same side of the LFD. We concluded that stable anatomical reduction and relevant treatment of complications are important for LFDs.
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Takuya Akamine, Goichiro Yoshida, Dai Takata
2012 Volume 61 Issue 4 Pages
785-787
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Dual energy X-ray bone absorptiometry (DXA) analysis and blood examination were carried out on college sports women (n=19, average 19.8±1.0 years) and general women (n=10, average 22.5±2.1 years). Several findings were obtained as follows. (1)Lean body mass was higher and % fat was lower significantly (p<0.001, p<0.01) in female long distance athletes compared with general women. (2) Bone mineral density on lumbar spine (L
2-L
4) and tibia shaft was higher significantly (p<0.05, p<0.05) in female Judo participants compared with general women. (3) Bone mineral density on tibia shaft was lower significantly (p<0.05) in female swimmers compared with general women. (4) Blood estradiol was low in 47% of the female college sports women. But they did not show the tendency towards lack of bone mineral content.
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Osei Tsuji, Misao Urakado, Eiichi Koyanagi, Michio Shinohara, Masayosh ...
2012 Volume 61 Issue 4 Pages
788-792
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Bone metabolism markers play an important role in evaluating the therapeutic effects of osteoporosis treatment. TRACP-5b (tartrate-resistant acid phosphatase 5b) has been considered a reliable bone metabolism marker since it is not susceptible to diurnal and day-to-day variation, and is unaffected by renal dysfunction. Also TRACP-5b has higher sensitivity to change in its blood level during osteoporosis treatment than other bone resorption markers. In our research however, some differences were found in TRACP-5b values between the analytical laboratories. We came to the conclusion that this interlaboratory variation is caused by the differences in handling the analytical samples, i.e., the time for exposure to the room temperature and the frequency of freezing and thawing. TRACP-5b is an acid phosphatase, so its activity may be sensitive to pH, temperature and exposure time. Therefore, more careful handling of TRACP-5b samples at each analytical laboratory is crucial for achieving more accurate analysis and reducing interlaboratory variation on this marker.
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Go Miake, Yasuo Noguchi, Shunsuke Hotokezaka, Takao Mae, Kosuke Sasaki ...
2012 Volume 61 Issue 4 Pages
793-794
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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The number of fractures of osteoporosis patients is increasing. Fractures caused by osteoporosis reduire drug therapy. We conducted on investigation on how to treat osteoporosis in proximal femoral hip fracture patients. We examined the percentage of pre- and post- injury osteoporotic treatments for 560 proximal femoral hip fracture patients treated in our hospital from April 2007 till July 2011. The percentage of pre-injury osteoporosis drug treatment was 14.3% (80/560); specifically, 18 patients out of 70 (25.7%) had a history of proximal hip fracture, on the other side, and 62 patients out of 490 (12.7%) did not. Thirty-three patients out of 158 (20.9%) had a history of taking osteoporosis drugs after they left our hospital. Present treatments using antiosteoporotic drugs for proximal hip fracture are insufficient for preventing additional fractures.
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Kenichi Seo, Shinji Tomari, Yasumasa Ito, Tatsuya Yufu, Takahiro Yasuh ...
2012 Volume 61 Issue 4 Pages
795-798
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report a case of atypical femoral fracture during long-term bisphosphonate therapy. A 77-year-old woman taking alendronate for six years fell in her house. She was unable to stand up and was taken to our hospital. X-ray showed left femoral shaft fracture and periosteal reaction of the lateral cortex of right femur. We perfomed osteosynthesis with intramedullary nail. Postoperative course was good, but one year and ten months after the operation, she fell again. X-ray showed right femoral shaft fracture. She continued taking alendronate until this time. She underwent osteosynthesis with intramedullary nail at another hospital. Bilateral femoral fractures achieved bone union smoothly without delayed healing. There have been recent reports linking bisphosphonate and a specific pattern of femur fractures. The effectiveness of bisphosphonate is not doubtful, but we should watch out for the potential development of excessive suppression of bone turnover during long-term bisphosphonate therapy and be aware of the possibility of atypical femoral fracture.
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Toshinobu Umeki, Yasushi Momota
2012 Volume 61 Issue 4 Pages
799-802
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Recently, atypical femoral fractures associated with bisphosphonates (BP) are often reported, but similar fractures are also known to occur without the use of BPs. The relationship between atypical femoral fracture and BP is unknown, so we conducted a retrospective study to clarify this relationship. We evaluated 20 patients (6 males and 14 females) with femoral shaft fracture from January 2006 to May 2011 excluding children, grouping them into the transverse or short oblique fracture group and spiral or long oblique fractures group. We studied age, cause, and BP usage before injury. The transverse or short oblique fracture group consisted of nine patients while the spiral or long oblique fracture group consisted of 11 patients. It was found that four patients in the transverse or short oblique fracture group had been using BP before injury. The results of this study suggest a relationship between femoral transverse or short oblique fracture and BP, but other factors seem to be involved in these fractures.
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Fumie Kyushima, Kenshiro Ikebe, Kiminori Sakamoto
2012 Volume 61 Issue 4 Pages
803-806
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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We report seven cases of distal femur fractures in non-ambulatory children from April 2008 to August 2011 without apparent injury. The underlying diseases were cerebral palsy, spina bifida, and Duchenne's dystrophy.
We found that the cases shared some common features, so we investigated the risk factors of the fracture. Most cases showed lower body weight, and many cases had some kind of fracture or underwent osseous surgery before sustaining the fracture. Feeding disorders, lower level of activities of daily living (ADL), limited communication abilities, and contractures of the knee joint were associated with the frequency of this fracture. Antiepileptic treatment was also a risk factor.
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Riichiro Yoshii, Motoyuki Tanaka, Junichi Kamizono, Hironori Kakoi, Sa ...
2012 Volume 61 Issue 4 Pages
807-810
Published: September 25, 2012
Released on J-STAGE: November 27, 2012
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Antithrombin (AT) III deficiency is an autosomal dominant genetic disease which increases the risks of thrombosis by 10 to 20 times compared to healthy persons. In patients with AT III deficiency, thrombosis is induced by moderate factors such as injury, surgery, and pregnancy. We report the case of a 7-year-old girl who needed corrective surgery for pes equinus. We planned measures to prevent thrombosis in the perioperative period. Aimming to keep the active AT III level above 80%, we administered heparin during surgery. We continued to administer AT III reagent and heparin for one week after surgery. From week 1 to 5 after surgery while the patient leg was fixed, we examined the active AT III level every day to determine the AT III reagent dose. As a result, we were able to prevent thrombosis by the strict control of AT III levels and by the use heparin.
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