Aims

Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Aims

Rotational acetabular osteotomy (RAO) has been reported to be effective in improving symptoms and preventing osteoarthritis (OA) progression in patients with mild to severe develomental dysplasia of the hip (DDH). However, some patients develop secondary OA even when the preoperative joint space is normal; determining who will progress to OA is difficult. We evaluated whether the preoperative cartilage condition may predict OA progression following surgery using T2 mapping MRI.

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Introduction

Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis. However, it is a still big problem that there is a possibility of death in pulmonary embolism (PE) after TKA. We previously reported that there was more incidence of asymptomatic PE than estimated in general by detail examinations. But it was difficult to whom we decided to perform additional examinations except the patients with some doubtful symptoms. Therefore, we investigated detail of PE patients after primary TKA to find out anything key point in PE.

Purpose

Leg length discrepancy after total hip arthroplasty (THA) sometimes causes significant patient dissatisfaction. In consideration of the leg length after THA, leg length discrepancy is often measured using anteroposterior (AP) pelvic radiography. However, some cases have discrepancies in femoral and tibial lengths, and we believe that in some cases, true leg length differences should be taken into consideration in total leg length measurement. We report the lengths of the lower limb, femur, and tibia measured using the preoperative standing AP full-leg radiographs of the patients who underwent THA.

Aims

The aims of this study were to evaluate the long-term outcome of surgery for bone or soft-tissue metastases from renal cell carcinoma (RCC) and to determine factors that affect prognosis.

Aims

Although we often encounter patients with an aortic aneurysm who also have diffuse idiopathic skeletal hyperostosis (DISH), there are no reports to date of an association between these two conditions and the pathogenesis of DISH remains unknown. This study therefore evaluated the prevalence of DISH in patients with a thoracic aortic aneurysm (AA).

Pedicle screw (PS) insertion has been critised for its risk of serious injury to neurovascular structures. Although computed tomography (CT)-based navigation has been developed to avoid such complications, perforation remains an issue, even with the aid of additional guidance. We clarify screw perforation rate and direction in 359 consecutive patients treated using CT-based PS insertion and present important considerations for more accurate screw placement.

The medical records of 359 consecutive patients who underwent PS insertion involving C2-L5 using a CT-based navigation system were reviewed. Postoperative CT images were analysed to evaluate the accuracy of screw placement. We investigated both rate and direction of screw perforation according to vertebral level.

Of the 3413 PS that were inserted, 3.0% (104/3413) were judged as Grade 3 (more than 4mm) perforations. Allover perforation rates by vertebral level were shown in Table 1. The rate of these perforations was 5.0% for C2, 7.8% for C3–5, 3.9% for C6–7, 3.4% for T1–4, 3.5% for T5–8, 1.4% for T9–12, and 1.7% for L1–5. We also analysed the odds ratio (OR) for screw perforation in vertebrae accounting for the effects of age and disease. Multivariate analysis identified that PS insertions at C3–5 (OR 4.9, 95% CI 2.2–10.9; p<0.001) were significantly associated with Grade 3 screw perforation as compared with that of L1–5.

Even with CT-based navigation, careful insertion of PS is needed in the middle cervical spine because of a significantly higher perforation rate as compared with the lumbar region.

For figures and tables, please contact authors directly.

Background

We occasionally come across cortical atrophy of the femur with cemented collarless polished triple-taper stem, a short time after the operation. This study aimed to estimate the radiographs of cemented collarless polished triple-taper stem taken at three, six, twelve, and twenty-four months after the initial operation.

Introduction

Hip-Spine syndrome has various clinical aspects. For example, schoolchild with severe congenital dislocation of the hip have unfavorable standing posture and disadvantageous motions in ADL. Hip-Spine syndrome is closely related closely as the adjacent lumbar vertebrae and the hip joint. Furthermore, not only the pelvis and the lumbar spine, but also the neck position might influence on the maximum hip flexion angle. In this study, we examined the maximum hip flexion angle and pelvic movement angle by observing the lumbar spine, the pelvis and the neck in three different positions.

Objectives

Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh.

Aim

The aim of this study is to evaluate the effect of three-dimensional (3D) simulation with 3D planning software ZedKnee® (ZK) in total knee arthroplasty (TKA).

Introduction

In the previous study regarding the relationship among maximum hip flexion, the pelvis, and the lumbar vertebrae on the sagittal plane, we have found in X-rays that the lumbo lordotic angle (LLA) and the sacral slope angle (SSA) have a large impact on hip flexion angle. We examined hip flexion angles to the various height of the objects (half round plastic tube) placed under the subject's lower back and compared the passive hip flexion angles in the supine position between younger and middle age groups.

Background

Continuous epidural anesthesia or femoral nerve block has decreased postoperative pain after total knee arthroplasty to some extent. Although the established efficacy of these pain relief method, some adverse events such as hematoma or muscle weakness are still problematic. Intraoperative local infiltration of analgesia (LIA) has accepted as a promising pain control method after total knee arthroplasty. The safety and efficacy of LIA has been reported, although there are still limited evidence about the effect of LIA on quadriceps function and recovery of range of motion in early post-operative phase. The purpose of this study is to compare the quadriceps function and range of motion after TKA between the LIA with continuous epidural anesthesia and continuous epidural anesthesia alone.

Purpose

Posterior pelvis tilt (PPT) would affect lumbar lordosis and lead to hip flexion, which causes difficulties walking and standing in patients with hip disorders. Hip flexion movement associated with PPT is well known. We investigated the effect of the angle of hip flexion without the movement of PPT in the supine position.

Direct anterior approach (DAA) is one of the best way to the hip joint for prevention of post-operative dislocation. We have applied this method as minimum invasive surgery (MIS) to more than two hundred developmental dysplastic hip of Japanese patients in total hip arthroplasty (THA) and there is no post-operative dislocation within three years of last observation carried forward (LOCF). The reason of this benefit is derived from the accuracy of cup positioning and keeping good muscle balance. But the learning curve is very important and some technical pitfalls are there in this approach. We have chosen thirty four patients that the duration of operating time more than one and half hours and loss of blood more than five hundred gram in hour series. The most important factors of the difficulties are the combinations of shortening of femoral neck, especially Perthes like deformity of developmental deformities of the hip joint (DDH) and widening of pelvic bone for the reason of insufficiency working spaces and the difficulties of broaching insertion (8/34). The second factor is the contracture of hip and knee joints combinations for the difficulties of lift up the proximal femur as broaching stem (3/34). The obesity, Body Mass Index (BMI) above thirty is not the reason of difficulties of women in our series. DAA can be extended to Smith-Petersen approach and very useful technique for primary THA in Japanese dysplastic hip patients.

The Dall approach is a modified anterolateral approach with osteotomy of the anterior part of the greater trochanter. This approach relatively preserves the soft tissue tension during total hip arthroplasty (THA). We insert the stem and select a ball neck size so as to have a stable hip which will not dislocate easily during the trial reduction. The aim of this study is to evaluate the adequacy of this method, to measure leg length discrepancy and offset discrepancy at postoperative radiographs. We selected patients for inclusion in this study from those who have more than a 120 degree of affected hip flection angle, the opposite hip is almost normal with a low leg length discrepancy (primary OA, osteonecrosis, Crowe 1 secondary OA, femoral neck fracture). All THA were performed with cement fixation using an alignment guide to ensure accurate acetabular positioning. The ball head's diameter used were all 26mm. From September 2011 to October 2013, 22 patients met inclusion criteria among 103 THA. The mean age for 22 subjects was 66.6±12 years. The mean flexion angle of preoperative hip joints was 127.2±6.1 degrees. The cup inclination was 43.8° ± 3.5°. Anteversion was 11.8°±6°. The mean preoperative leg length discrepancy was 5.8mm±6.3mm. The mean postoperative leg length discrepancy was 0.7±3.5mm. The mean postoperative offset discrepancy was 0.7±6.6mm. There were no dislocations in this series of 103 cases. Discussion. Dislocation and leg length discrepancies are major complications following a total hip arthroplasty. A good range of motion of the preoperative hip joint is considered a high risk dislocation factor. The Dall approach with minimal release of soft tissue related to a tension of hip joint offers maximal stability and the ability to accurately restore leg length.

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour.

Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs.

The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery.

Cite this article: Bone Joint J 2014;96-B:1693–8.

Objectives

In order to ensure safety of the cell-based therapy for bone regeneration, we examined in vivo biodistribution of locally or systemically transplanted osteoblast-like cells generated from bone marrow (BM) derived mononuclear cells.

Total knee arthroplasty (TKA) provides good results even for severe knee osteoarthritis (OA) patients. However, patients often suffer from post-operative pain and have long rehabilitation periods. In recent years, utilization of unicompartmental knee arthroplasty (UKA) has increased in an effort to decrease pain and shorten recovery compared to TKA. Moreover, the long-term results of the UKA have improved. Many surgeons now wonder whether TKA or UKA is better for patients with isolated medial knee OA. In Japan, the government has public insurance system and patients are able to receive the joint replacement surgery inexpensively. This study was conducted to compare the cost the public insurance and the patients co-payment for TKA and UKA.

We investigated a series of thirty TKAs and fifteen UKAs performed in Fussa Hospital (Tokyo, Japan) from July 2012 to April 2013. Data from two TKAs' were excluded since the patients had comorbidities (asthma and severe DM) that extended their hospitalizations. Patients were discharged from the hospital if they were able to go up and down the stairs or were able to conduct routine activities of daily living.

Total payments the hospital received averaged $19600 (S.D. $1600) for a TKA and $15200 (S.D. $1300) for a UKA. Patients paied averaged of $690 (S.D. $370) for a TKA and $470 (S.D. $170) for a UKA (Figure 1). The surgical fee was $3769 for both TKA and UKA, and was uniform thoughout Japan. The implant price averaged $6200 (S.D. $300) for TKA and $3900 (S.D. $200) for UKA, where prices were also determined by the government. Hospitalization averaged 28 days (S.D. 7 days) for TKA and 21 days (S.D. 6 days) for UKA. For both TKA and UKA, the total cost and the number of days in hospital were highly correlated (R = 0.92 and R = 0.96, respectively). A linear cost model suggests the TKA cost was $210 times days of hospitalization plus $13100 and the UKA cost was $220 times days of hospitalization plus $10000. Patients' payments were not correlated to the days of hospitalization (R = 0.22 and R = 0.45, respectively).

TKA and UKA are performed all over the world now and the number of the surgeries increases each year. Althouth each country has a different insurance system, many countries face an increasing and problematic economic burden for both patients and insurance organization (either public or private company). This study showed UKA is less expensive than TKA by $4400, an advantage that might complement the traditional view that UKA is less invasive and often has fewer complications for treating isolating medical compartment OA. For Japanese system, patients pay relatively little out-of pocket despite long hospitalization, and length of stay has a direct and significant effect on total cost for TKA and UKA

This multicentre prospective clinical trial aimed to determine whether early administration of alendronate (ALN) delays fracture healing after surgical treatment of fractures of the distal radius. The study population comprised 80 patients (four men and 76 women) with a mean age of 70 years (52 to 86) with acute fragility fractures of the distal radius requiring open reduction and internal fixation with a volar locking plate and screws. Two groups of 40 patients each were randomly allocated either to receive once weekly oral ALN administration (35 mg) within a few days after surgery and continued for six months, or oral ALN administration delayed until four months after surgery. Postero-anterior and lateral radiographs of the affected wrist were taken monthly for six months after surgery. No differences between groups was observed with regard to gender (p = 1.0), age (p = 0.916), fracture classification (p = 0.274) or bone mineral density measured at the spine (p = 0.714). The radiographs were assessed by three independent assessors. There were no significant differences in the mean time to complete cortical bridging observed between the ALN group (3.5 months (se 0.16)) and the no-ALN group (3.1 months (se 0.15)) (p = 0.068). All the fractures healed in the both groups by the last follow-up. Improvement of the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, grip strength, wrist range of movement, and tenderness over the fracture site did not differ between the groups over the six-month period. Based on our results, early administration of ALN after surgery for distal radius fracture did not appear to delay fracture healing times either radiologically or clinically.

Cite this article: Bone Joint J 2013;95-B:1544–50.

The ratio of the incidence of trochanteric to cervical fractures increased with age in the elderly female population, but the reason for this fact remain unclear.

The purposes of this study were to investigate whether or not there are specificities of the local distribution of mechanical properties at the trochanteric region of the elderly female using a scanning acoustic microscope (SAM). Human proximal femurs were harvested from seven female cadavers (67–88 years) and proximal femur was coronally sectioned into halves across the center of neck. The surface of the coronal section was polished in order to achieve flat surfaces of smoothness well below the surface resolution in scanning with SAM. Bone tissue density and elastic modulus were calculated from the acquired SAM data. Mechanical properties were measured at the lateral and medial trochanter. Cortical bone tissue of the lateral trochanter had significantly lower elastic modulus than that of the medial trochanter in the all specimen over 70s(p<0.05). Trabecular bone tissue of proximal region of the lateral trochanter had significantly lower elastic modulus than that of distal region in all 80s specimens (p<0.05). Decrease of the elastic modulus of cortical bone in the lateral trochanter and low value of the elastic modulus of trabecular bone in the proximal region of the lateral trochanter may be related to the increase of the ratio of trochanteric to cervical fractures with age in the elderly female population.

Background

We occasionally came across cortical atrophy of femurs with cemented collarless polished triple-taper stem in a short term period. This study aimed to estimate radiographs of cemented collarless polished triple-taper stem taken 6 months after the initial operation.

Purpose

Surgical site infection (SSI) is an infrequent but serious complication of total joint arthroplasty (TJA). Orthopaedic SSI causes substantial morbidity, prolonging the hospital stay by a median of 2 weeks, doubling the rates of rehospitalization, and more than tripling overall healthcare costs. Colonization with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) is known to be associated with an increased risk of subsequent SSI. Carriers are two to nine times more likely to acquire S. aureus SSIs than non-carriers. Screening of the nose and throat for MRSA colonization and preoperative patient decolonization have been shown to decrease the incidence of subsequent MRSA infection. The aim of this study was to investigate the association between the results of MRSA colonization screening and the incidence of SSI in our hospital.

Introduction

Correction and arthrodesis for cervical kyphosis associated with atetoid cerebral palsy has been considered to be difficult because of their involuntary neck movements and severe deformity. The aim of this study is to evaluate the surgical outcome of midline T-saw laminoplasty and posterior arthrodesis using pedicle screws.

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients.

The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92.

We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years.

Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both Open Reduction and Internal Fixation (ORIF) and Total Elbow Arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome.

This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA.

All procedures were performed by two experienced Consultant Surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs.

Both groups of patients were similar with respect to fracture configuration, age, sex, co-morbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months.

At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united.

This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications.

A special surgical technique and consideration is necessary in the total hip arthroplasty for dysplastic osteoarthritis after Kalamchi and MacEwen Type III or IV deformity (so called “Perthes-like-deformity”). There have been few reports concerning the total hip arthroplasty for “Perthes-like-deformity”. We evaluated the clinical and radiological outcome of 52 uncemented hip arthroplasties for the lesion.

We have performed 106 hips of uncemented total hip arthroplasty for dysplastic osteoarthritis after Kalamchi and MacEwen Type III or IV deformity. Among them, 52 hips of 47 patients (11 males and 41 females) were evaluated with minimum of three years follow-up. The average age at the surgery was 52 (28 to 65). The average follow-up period was 4.8 (3 to 8.1) years. Against the developmental dysplasia or dislocation, 29 hips of 26 patients had been treated by casting or surgery in infancy. Thirteen hips of 11 patients had no previous treatment before the arthroplasty. Spongiosa metal cup (GHE: ESKA implants, Lübeck, Germany) was used for 33 hips of 28 patients and Zweymüller type cup (Allo-classic cup: Zimmer Inc., Warsaw, IN, Bicon cup: Smith & Nephew Orthopedics AG, Rotkreuz, Switzerland) for 19 hips of 19 patients. Spongiosa Metal stem (GHE: ESKA implants) was used for 23 hips of 19 patients and Zweymüller type stem (Alloclassic stem: Zimmer Inc., SL stem: Smith & Nephew Orthopedics AG) for 29 hips of 28 patients. The average operative time was 108 (53 to 233) minutes. The average blood loss during the surgery was 731(150 to 1749) milliliters. The adductor tendon release was added in 28 hips of 26 patients against the severe contracture. The patients were evaluated clinically (pre-surgical history, hip score, leg length discrepancy, Trendelenburg sign, and gait function) and radiologically (ATD before the surgery, alignment, and stability of implants). Average ATD before the surgery was −2.2 (−28 to 17) millimeters. The average leg length discrepancy was 1.9 (0 to 7) centimeters before the surgery and was improved to 0.1 (0 to 1) centimeters after the surgery. The average hip score was 54 (23 to 80) before the surgery and was improved to 90 (69 to 100) after the surgery. At the final follow-up, Trendelenburg sign was positive in 14 hips of 14 patients (26.9%) and the limping was not obvious in 38 hips of 33 patients (73.1%). All implants were stable at the final follow-up.

“Perthes-like-deformity” often has the severe deformity. It has a shortening or an absence of the neck and an excessive antetorsion of the femur. When it has the coxa magna, the acetabulum is shallow, has the narrow anteroposterior diameter, and has the thin wall like the osteophyte. It is frequently accompanied by shortening of leg and contracture, as the lesion arises from the development disorders. Thus, the total hip arthroplasty, especially uncemented one, is complicated. However, the satisfactory result can be obtained by careful consideration and surgical procedure such as a provision against the bleeding and the soft tissue release.

Introduction: Since 2004, in addition to the original curved varus osteotomy for osteonecrosis of the femoral head, we have intentionally performed anterior or posterior rotation without incising the articular capsule to obtain a more extensive viable area in the loaded portion. We investigated the extent of viable area on the loaded portion after this modified operation.

Materials and Methods: Subjects included 11 patients (13 joints: anterior, 12 joints; posterior, 1 joint) who underwent a modified curved varus osteotomy and anterior or posterior rotation. We investigated the percent of viable area in the preoperative vs. the postoperative weighted portion. In addition, we measured the extent of viable area in the loaded portion when the extent of curved varus osteotomy without rotation was performed based on a schematic drawing.

Results: In this study, the combination of transtrochanteric curved varus osteotomy and anterior or posterior rotation significantly increased the percent viable area from 66% to 85%.

Discussion: The extent of postoperative viable area on the loaded portion might have been increased more than in the original procedure.

Total elbow arthroplasty (TEA), as a primary procedure and open reduction and internal fixation (ORIF) have been used to treat complex intra-articular distal humeral fractures in elderly patients. The failure rate after ORIF is high and TEA has often been used as a salvage procedure. Although satisfactory results have been reported after TEA as a primary procedure, there are no publications reporting the results of TEA after failed internal fixation (FIF). In this study we compared the results of patients that had TEA after FIF with those that had had primary arthroplasty (PA). We reviewed the results of 9 consecutive patients who had FIF with 12 patients who had PA. All the operations were performed by one surgeon using the same technique and same prosthesis. Both groups of patients were similar with respect to ages, sex, co-morbidity and hand dominance. The mean follow-up for both groups of patients was 5 years. At final review, patients who had had FIF had a mean Mayo score of 68 and a range of flexion/extension of 90 degrees, there was 1 infection and 1 case of loosening. The PA group had a mean Mayo score of 88 and a range of flexion/extension of 96 degrees, there were no cases of infection or loosening. This study shows the results of TEA are satisfactory either as a PA or after FIF, however the results after PA are significantly better than after FIF.

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. All had a minimum of 5 years follow-up. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed for at least 5 years.

Introduction: To investigate the presence or absence of osteonecrosis of femoral head (ONFH) in patients undergoing massive corticosteroid therapy, we have performed magnetic resonance imaging (MRI) early after administration. In some patients, MRI revealed an increase in hip fluid. In this study, we evaluated retention of hip fluid early after massive steroid therapy by MRI.

Materials and Methods: The subjects were 14 patients (28 joints) in whom oral administration of prednisolone at an initial dose of 40 mg/day or more or pulse therapy was performed. They consisted of 3 men (6 joints) and 11 women (22 joints). Ages ranged from 17 to 72 years, with a mean of 38.2 years. We evaluated retention of hip fluid in T2-weighted MRI images or T2 fat-suppressed images within 3 months after massive steroid therapy according to the joint fluid grading established by Mitchell et al and evaluated volume of hip fluid by integrating an area (by using Mac scope ver 2.58).

Results: Average volume of all joints was 7.18 cm³. Eleven joints were evaluated as Grade 1, in which a small amount of joint fluid is noted, and their average volume was 3.98 cm³. Fifteen joints were evaluated as Grade 2, in which retention involves the entire femoral neck, and their average volume was 8.96 cm³. Two joints were evaluated as Grade 3, in which marked retention involves the excavation of the cupsula articularis, and their average volume was 11.45 cm³. No joint was evaluated as Grade 0, in which no joint fluid is detected.

Discussion: The pathogenesis of corticosteroid-related ONFH is multifactorial; various hypotheses have been proposed, suggesting the involvement of arteriosclerosis, thrombosis, fat embolization, vascular endothelial disorder, venous return disorder, enhanced blood coagulation, fibrinolytic abnormalities, and bone tissue apoptosis. However the detailed mechanism remains to be clarified. In this survey, when regarding Grade 2 or higher joints as showing a significant increase in hip fluid, the increase was noted in 17 joints (60.7%). We understood objectively by an increase in hip fluid by estimating its volume. An increase in hip fluid early after massive steroid therapy may persistently increase intraarticular pressure, affecting influx of nutrient vessels in the femoral neck or venous return, which is considered to be a tamponade effect. This may be an etiological factor involved in ONFH.

Assess the outcome of plating of lateral end clavicle fractures. Lateral end clavicle fractures can be treated both conservatively and surgically. Different surgical methods are available to stabilize lateral end clavicle fractures. We treated 15 lateral end clavicle fractures with plate fixations (4 AO ‘T’ plate and 11 ACUMED lateral clavicle plate) from September 2002 to December 2005. There were 12 males and 3 females and the mean age was 33.12 year (range 23–61). 3 were done for non-union and 13 for acute fractures. 2 non-unions were treated with AO ‘T’ plate and 1 with ACUMED lateral clavicle plate. 1 patient with non-union had bone grafting at the time of the procedure. Acute fractures were stabilized with in 3 weeks from the time of the injury. All fractures were Type 2 according to Neer classification of lateral end clavicle fractures. The cause of the injury was, simple fall (3), fall from pushbike (3), assault (3), sports/skate-board (3), and RTA (3). The senior author operated on all patients. The arm was immobilized in a sling for six weeks post operatively. The follow up ranged between 5 months to 36 months All but one fracture healed. 1 ‘T’ and 1 ACUMED plate was removed 7 months after the index procedure after fracture consolidation. There was no superficial or deep infection. Patients were assessed clinically with Constant and DASH scores; patient satisfaction with the procedure was also recorded and union assessed radiologically.. Lateral end clavicle fractures pose a challenge due to the small size of the distal fragment. In our experience plating of these fractures give satisfactory results. Oblique fracture patterns result in better fixation and union rates. The plate design and advantages of the ACUMED contoured distal clavicle plates are further discussed in the paper.

Crush injury is one of the categories of nerve injury, which is often encountered in the clinical field. There is no doubt that crushed nerves, which have anatomical continuity, regenerate spontaneously and somehow reinnervate their target tissues, such as muscle and skin. However, the longer it takes to reinnervate the target tissues, the more profoundly the atrophy of these target tissues progresses, resulting in a poor outcome. Clinically, it is therefore crucial to accelerate nerve regeneration if excellent results are to be achieved. Hepatocyte growth factor (HGF) is well known to be involved in many biological functions, such as organ regeneration and angiogenesis, and to exert neurotrophic effects on motor, sensory, and parasympathetic neurons. This raised hopes that HGF protein might be useful for the clinical treatment of nervous system disorders. However, administration of HGF as a recombinant protein is still beset by a number of problems, such as a short serum half-life and poor access to the central nervous system by the systemic route because of the presence of the blood-brain barrier. These problems can be major obstacles to the therapeutic use of such factors, and this has highlighted the need to develop innovative therapeutic strategies for more efficient delivery into the nervous system. Gene transfer into the nervous system has enormous therapeutic potential for a wide variety of disorders. It appears to have advantages over the administration of single or multiple bolus doses of a recombinant protein because gene transfer can achieve an optimally high, local concentration within the nervous system. Recently, two different strategies have been reported. Firstly gene transfer by local intraneural injection and secondly gene transfer via retrograde axonal transport. In crush injury, it is well known that some axons in the crushed nerve can remain intact. It is from this evidence that the idea of performing gene transfer via retrograde axonal transport arose. In this study, we gave repeated intramuscular injections of the human HGF gene, using nonviral HVJ (Hemagglutinating Virus of Japan) liposome method, to examine whether transfection of the rat nervous system with this gene is able to exert neurotrophic effects facilitating recovery of a crushed nerve. The expression of HGF protein and HGF mRNA indicated that gene transfer into the nervous system did occur via retrograde axonal transport. At 4 weeks after crush, electrophysiological examination of the crushed nerve showed a significantly shorter mean latency and a significantly greater mean maximum M-wave amplitude with repeated injections of HGF gene. Furthermore, histological findings showed that the mean diameter of the axons, the axon number and the axon population were significantly larger in the group with repeated injections of HGF gene. The above results show that repeated human HGF gene transfer into the rat nervous system is able to promote crushed-nerve recovery, both electrophysiologically and histologically, and suggest that HGF gene transfer has potential for the treatment of crushed nerve.

We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain.

Introduction: We evaluated antero-posterior instability of the hip with osteonecrosis immediately after anterior rotational osteotomy using Dynamic CT and investigated the relationship between the instability and the developing marginal osteophyte of the femoral head postoperatively.

Materials and Methods Twenty-three hips in 21 patients with non-traumatic osteonecrosis undergoing anterior rotational osteotomy were studied. There were 19 men and 2 women with a mean age of 39 years at operation. All patients were followed up for more than 2 years (mean: 4). The etiologic factors were steroid administration in 10, alcoholic abuse in 12, and both in 1. According to the staging system by the Japanese Ministry of Health, Labor, and Welfare, there were 11 hips in stage 3a (collapse less than 3 mm), 9 in 3b (collapse 3 mm or greater), and 3 in stage 4. Dynamic CT, taken in both neutral and 45 degrees flexion positions, studied the antero-posterior shift of the femoral head. In addition, we analyzed marginal osteophytes with more than 2 mm in size on follow-up A-P radiographs.

Results: Seven hips (30%) with 5 hips in stage 3b and 2 hips in stage 4 showed instability. Marginal osteophytes were shown in 8 hips including all of 7 hips with the instability. However, these hips had no joint narrowing.

Conclusions: From these results, hip instability immediately after anterior rotational osteotomy occurs in cases with an extensive necrotic lesion and marked collapse preoperatively. Developing marginal osteophytes may prevent the instability.

Introduction: In cases of small and middle size osteonecrosis on conventional antero-posterior (AP) radiographs, we studied the extent of the lesion on AP radiographs at the 45 degrees flexion position for lesions of the anterior area of the femoral head.

Materials and Methods: Classification of Japanese organizing committee was applied for the extent of the lesion on joint surface. Type A lesions occupy the medial one-third or less; Type B, the medial two-thirds or less; Type C-1 occupies more than the medial two-thirds; and Type C-2 extends laterally to the acetabular edge at the neutral position on conventional AP radiographs. Thirty-three hips (25 patients) with small or middle size lesions (Type A;11, Type B;22) were studied. On AP radiographs taken at the 45 degrees flexion position, the extent of the lesion was studied in 33 hips.

Results: Seven of 11 hips of Type A on neutral position showed Type A lesions. For the remaining 4 hips, 2 were Type B, 2 were on Type C-1 at 45 degrees flexion position. For 22 hips with Type B on neutral position, 6 were Type B, 12 were Type C-1, 4 were Type C-2 found at the 45 degrees flexion position.

Discussion: AP radiographs at the 45 degrees flexion position revealed more extensive necrotic area in cases of small and middle size lesions comparing with the neutral position. This finding may be related to progression of the disease.

Introduction: We investigated the necrotic area and its shrinkage on stage 1 femoral head necrosis with band pattern low intensity on MRI.

Materials and Methods: Eleven femoral heads (6 patients) with a history of steroid treatment were studied. In heads, band pattern was detected by MRI. The mean age was 40 years.

The location of the lesion shown by the band pattern low intensity was determined by Japanese investigation committee as follows. Type A lesion occupies the medial one-third or less; Type B occupies the medial two-thirds or less; Type C-1 occupies more than the medial two-thirds; and Type C-2 extends laterally to the acetabular edge at the neutral position. Types were observed on initial and final MRIs. The mean follow up was 4 years and 3 months. For the repair patterns, the direction was observed in the anterior and posterior slices of MRIs.

Results: Initial MRIs showed types were Types A, B, C-1, and C-2 in 3, 3, 3, and 2 femoral heads, respectively. At the final observation, no band pattern was noted on the weight-bearing surface in 3 Type-A femoral heads. The femoral head surface was repaired, and the lesion was present only in the non-weight-bearing region. In all of the 3 Type-B femoral heads and 5 Type-C1 and -C-2 femoral heads, the lesion shrank to Type A. The articular surface was covered with normal intensity area from the posterior direction in all femoral heads

Discussion: We believe that the repair occurred during the disease process in stage 1 necrosis.

Objective: The reported incidences of traumatic and iatropathic nerve injuries with supracondylar fractures in children are 12–16% and 6% respectively, with the majority recovering spontaneously. We performed a retrospective review of lesions referred to our tertiary unit to determine the incidence of surgical intervention.

Methods: Between 1997 and 2002, 37 neuropathies (associated with 32 supracondylar fractures) in 19 males and 13 females with an average age of 7.9 years were referred for further management. 8 fractures were classified as Gartland grade 2 and 24 as grade 3. All fractures were closed, with 2 treated non-operatively, 20 by closed reduction and percutaneous pinning and 10 by open reduction and internal fixation at the referring hospitals.

Results: The ulnar nerve was the most frequently injured (51.4%), followed by median (27%) and radial (21.6%) nerve palsies. 14 (37.8%) neuropathies were related to the fracture, while 23 (62.2%) were iatropathic. 10 patients (31.3%) required operative exploration while 3 (9.4%) were listed for surgery but were cancelled as they were recovering. Nerve grafting was used in 4 of the 10 operated cases, the donor nerve being the medial cutaneous nerve of the forearm in 3 and the superficial radial nerve in one. 26 patients (81.3%) had excellent outcomes, 5 (15.6%) good and 1 (3.1%) fair.

Conclusion: Although most had excellent outcomes, surgical exploration was required for nearly a third of the cases referred to our unit. This is in contrast to the current literature, which suggests that the majority of supracondylar neuropathies recover spontaneously.

Introduction: Traumatic and iatropathic nerve injuries complicate 6–16% of paediatric supracondylar extension fractures of the humerus. The majority recover spontaneously. This retrospective review of lesions referred to our tertiary unit determined the incidence of surgical intervention.

Methods: Between 1997–2002, 37 neuropathies (32 fractures) in 19 males and 13 females (mean age 7.9yrs) were referred for further management. 8 fractures were Gartland grade 2 and 24 grade 3. All fractures were closed. Two were originally treated non-operatively, 20 by closed reduction and percutaneous pinning and 10 by open reduction and internal fixation.

Results: The ulnar nerve was most frequently injured (19, 51.4%), followed by median (10, 27%) and radial (8, 21.6%) nerve palsies. 14 (37.8%) neuropathies were fracture-related but 23 (62.2%) were treatment-related. 10 patients (31.3%) required operative exploration. Three (9.4%) were listed for surgery but cancelled due to nerve recovery. Nerve grafting using either the forearm medial cutaneous nerve or the superficial radial nerve was necessary in 4 of 10 operated cases. 26 patients (81.3%) had excellent outcomes, 5 (15.6%) good and 1 (3.1%) fair.

Discussion: In contrast to current literature suggesting that 86 to 100% of supracondylar associated neuropathies recover spontaneously within 2 to 3 months, surgical exploration was required in over 30% of cases.

Introduction: To determine the aetiology of peripheral nerve injuries presenting to a specialist centre, identify the management strategies employed and discuss the functional outcome achieved.

Methods: Retrospective review of all children referred to this hospital between 1996–2003 with an acquired nerve injury. Obstetrical brachial plexus palsy was excluded.

Results: 100 nerve injuries (94 patients) were identified. The mean age was 9.9yrs (0.5–16yrs). 81 injuries involved the upper limb, 19 the lower limb. Most were due to low energy trauma and associated with fractures or their surgical management. 16% presented with autonomic sympathetic dysfunction, 10% with neuropathic pain. 43 patients underwent at least one surgical procedure. The operation was classified diagnostic in 5 (no surgically remediable lesion identified), therapeutic in 33 (surgical procedure could be expected to aid recovery) and reconstructive in 5 (no improvement in nerve function could be achieved; functional improvement achieved by other means). Excellent functional outcome only occurred in conservatively treated cases and in some treated by neurolysis. Nerve grafts and direct repairs were associated with good outcomes. Delayed surgery was associated with fair outcomes.

Discussion: Peripheral nerve injuries in children as in adults require careful, prompt attention to obtain the best outcome. Iatropathic injuries must be acknowledged.

This study reports on postoperative changes of intra and epidural space of both degenerative lumbar spinal canal stenosis(DLSCS) and degenerative spondylolisthesis(DO)on MRI. 48cases(DLSCS:20cases, DO:28cases)were investigated in this study. All cases performed bilateral wide fenestration.

The average age of these patients was 65 years and average follow-up period was 60 months. The average improvement ratio(%) of JOA score was 68% at the last follow-up. Symptomes had deteriorated in 8 cases, according to an increase in the volume of the postlaminectomy membrane, at the last follow-up. There were 8 cases(29%)in DO. showing an increase of % slip on X-ray at the last follow-up, accompanied with both a slight decreasing of the cross-sectional area(CSA)of dural sac and a slight deterioration of clinical results.

Discussion: Symptomes in around 17% of the cases deteriorated, and there were three factors on MRI ; a poor expansion of the dural sac, a grouping of the cauda equina, and a decrease in the CSA of the dural sac.

Antibiotic-impregnated polymethylmethacrylate beads, which are used to deliver antibiotic directly to infected sites in the musculoskeletal system has been evaluated most widely. The disadvantages include reduced biocompatibility with bone, short duration of drug release, very low release rate and thermal damage to the antibiotics. For solving this problem, we developed the antibiotic-impregnated calcium hydroxyapatite ceramic implant (HA) as a new drug delivery system. This study is to evaluate the clinical results of the antibiotic-impregnated HA used for the treatment of infected total hip and knee arthroplasty. Twenty-two patients with infected arthroplasty treated antibiotic-impregnated HA were evaluated. There were 5 men and 17 women with a median age of 65 (range, 54–86 years). The study included 14 hips and 8 knees. The duration from the initial arthroplasty to the detection of the infection was 16 years at the longest (median of 2 years and 2 months). The most common microorganism was Staphylococcus aureus, presented in 13 patients. Antibiotic most frequently impregnated was Vancomycin. In five patients, debridement without removal of the prosthesis was performed with antibiotic-impregnated HA implanted in surrounding bone. In another three patients, one-stage revision was performed with antibiotic-impregnated HA. In fourteen patients, antibiotic-impregnated HA was used to fill the dead space after removal of the prosthesis (two-stage revision was performed in 9 patients). No patients developed evidence of recurrent infection at an average follow-up of 18.7 months. Antibiotic-impregnated HA is an excellent drug delivery system for the infected total hip and knee arthroplasty.

We have reviewed 20 patients stage-IIIB and stage-IV Kienböck’s disease in order to examine the efficacy of two forms of radial osteotomy, namely radial wedge osteotomy and radial shortening. Lateral closing wedge osteotomies and radial shortenings were carried out on 11 and nine patients, respectively. There were no preoperative differences with respect to age, gender, and radiological stage.

After a mean follow-up of 29 months, all patients, in both groups, had either a good or an excellent outcome. After the lateral closing wedge osteotomy, the radioscaphoid angle significantly increased and the St̊hl index significantly decreased. Progression of the degenerative changes at the radioscaphoid joint was found in two patients in this group. By contrast, there were no significant changes in any radiological parameters after radial shortening. Both procedures gave acceptable clinical results in stage-IIIB and stage-IV Kienböck’s disease.

The results and complications of 104 vascularised fibular grafts in 102 patients are presented. Bony union was ultimately achieved in 97 patients, with primary union in 84 (84%). The mean time to union was 15.5 weeks (8 to 40). In 13 patients, primary union was achieved at one end of the fibula and secondary union at the other end. In these patients, the mean time to union was 31.1 weeks (24 to 40). Five patients failed to achieve union, with a resultant pseudarthrosis (3 patients) or amputation (2 patients).

There were various complications. Immediate thrombosis occurred in 14 cases. In two of 23 patients with osteomyelitis, infection recurred at two and six months after surgery, respectively. Both patients had active osteomyelitis less than one month before the operation. Bony infection occurred in a patient with a synovial sarcoma of the forearm one year after surgery. In 15 patients, 19 fractures of the fibular graft occurred after bony union, all except one within one year after union. In patients in whom an external fixator had been used, fracture occurred soon after its removal. Union was difficult to achieve in cases of congenital pseudarthrosis of the tibia. Appropriate alignment of the fibular graft is an important factor in preventing stress fracture. The vascularised fibula should be protected during the first year after union.

Postoperative complications at the donor site included transient palsy of the superficial peroneal nerve in three patients, contracture of flexor hallucis longus in two and valgus deformity of the ankle in three.

Vascularised fibular grafts are useful in the reconstruction of massive bony defects. We believe that meticulous preoperative planning, including choosing which vessels to select in the recipient and the type of fixation devices to use, and care in the introduction of the vascularised fibula, can improve the results and prevent complications.

Nine children sustained a second fracture of the distal humerus after union of an ipsilateral supracondylar fracture which had healed with cubitus varus. There were eight boys and one girl with a mean age of five years (1 to 8) at the time of the second fracture which occurred at a mean of 1.5 years after the first. In all patients, the second fracture was an epiphyseal injury of the distal humerus, either associated with a fracture of the lateral metaphysis below the site of the previous supracondylar fracture, or a fracture-separation of the entire distal humeral epiphysis. This suggests that the physis and epiphysis tend to be more subject to injury than the metaphysis of the distal humerus in children who have had a previous supracondylar fracture with varus malunion.

We report two new radiographic projections for evaluating avulsion fractures at the lateral malleolus. We used seven freshly amputated legs with simulated avulsion fractures and radiopaque markers to assess their value.

The projections allow accurate assessment of the displacement of fragments without superimposition, and also show whether they affect the anterior talofibular or the calcaneofibular ligament or both.

We have developed a method of measuring anterior displacement of the calcaneus on the talus in instability of the subtalar joint and have used the technique to demonstrate anterior instability in 50 patients (72 feet) showing a positive drawer sign. The angle of the posterior facet of the talus was also measured to assess the bony configuration. Our patients with subtalar joint instability could be divided into three categories. The first group had a history of trauma leading to ankle instability (26 cases), the second showed generalised joint laxity (10 cases) and the third were young females with a history of chronic stress on the foot and a poor bony block (14 cases). Satisfactory results were obtained by treating the instability with a brace or by reconstruction of the interosseous talocalcaneal ligament.

We report the case of a 19-year-old man with inguinal lymphadenopathy caused by metallic debris from the loosening of a prosthesis inserted after tumour resection. Large amounts of wear debris may be released from such massive replacements, and surgeons should be aware of the range of possible adverse effects.