[Show abstract][Hide abstract] ABSTRACT: Conventionally, posterior C1-C2 fusion has been performed using a sublaminar wiring technique with a structural bone graft. Subsequent advent of newer fixation devices, such as the C1 lateral mass screw and C1 hook, has achieved more solid fixation with improved surgical outcome; however, in these fixation systems, the protruding end of the metal implant above the level of the atlas may result in a complication due to contact with the surrounding structures.
Two men and two women whose ages at the time of surgery ranged from 14 to 72 years. A supralaminar hook was used as a fixation device for C1 in two cases, whereas a lateral mass screw (Tan's method) and an atlas claw hook were employed for one each of the remaining 2 cases. We retrospectively reviewed the clinical features and postoperative course of these patients using the clinical records. Moreover, we measured the protruding height of the instrument above the atlas as well as the Redlund-Johnell (R-J) value on postoperative radiographs. All patients complained of crepitus and/or pain on neck extension. Erosion in the occipital bone was detected on multiplanar reconstruction computed tomography (MPR-CT), whereas plain radiographs failed to reveal the bony change. In those cases, protruding instruments used for C1 fixation contacted the occipital bone resulting in an erosive change at the impingement point. We removed the implant in all four cases after confirmation of solid bony union.
Two of the four patients complained of occipital crepitus alone without pain. The management options for this condition may be controversial; however, progression of bony erosion may result in perforation of the occipital bone. This may possibly be associated with the serious complication of cerebrospinal fluid leakage. Considering this potential sequela, we removed the implants from all our reported cases after confirmation of solid bony union.
We treated four cases that developed erosion in the occipital bone after posterior spinal instrumentation was performed for upper cervical lesions including C1. MPR-CT was useful in detecting the erosive changes in the occipital bone.
[Show abstract][Hide abstract] ABSTRACT: Study design:
A retrospective case review.
To assess the clinical and radiographic outcomes and identify the predictive factors associated with poor clinical outcomes after lumbar spinous process-splitting laminectomy (LSPSL) for lumbar spinal stenosis (LSS).
Overview of literature:
LSPSL is an effective surgical treatment for LSS. Special care should be taken in patients with degenerative lumbar scoliosis (DLS).
A consecutive retrospective case review of patients undergoing LSPSL for LSS with a minimum 2-year follow-up was performed. Mild DLS and mild degenerative spondylolisthesis (DS) were included in the study. The Japanese Orthopedic Association (JOA) score and recovery rate were reviewed. Poor clinical outcome was defined as a recovery rate <50% using Hirabayashi's method.
A total of 52 patients (mean age, 72 years) met the inclusion criteria and had a mean follow-up of 2.6 years (range, 2-4.5 years). The preoperative diagnosis was LSS in 19, DS in 19, and DLS in 14 cases. The mean JOA score significantly increased from 14.6 to 23.2 at the final follow-up. The overall mean recovery rate was 60.1%. Thirteen patients (25%) were assigned to the poor outcome group. A higher rate of pre-existing DLS was observed in the poor outcome (poor) group (good, 15%; poor, 62%; p=0.003) than in the good outcome (good) group. None of the patient factors examined were associated with a poor outcome. A progression of slippage ≥5 mm was found in 8 of 24 patients (33%) in the DS group. A progression of curvature ≥5° was found in 5 of 14 patients (36%) in the DLS group. The progression of scoliosis and slippage did not influence the clinical outcome.
The clinical and radiographic outcomes of LSPSL for LSS were favorable. Pre-existing DLS was significantly associated with poor clinical outcome.
Asian spine journal 10/2015; 9(5):705. DOI:10.4184/asj.2015.9.5.705
[Show abstract][Hide abstract] ABSTRACT: Descriptive case report.To report a rare case of post-traumatic torticollis by odontoid fracture in a patient with diffuse idiopathic skeletal hyperostosis (DISH).Cervical fractures in DISH can result from minor trauma, and a delay in presentation often prevents their timely diagnosis. Cervical fractures in patients with spinal DISH usually occur in extension injuries, and almost always occur in the lower cervical spine. Reports of odontoid fractures with torticollis in patients with spinal DISH are rare.A 73-year-old man with DISH presented with severe neck pain and a cervical deformity presenting as torticollis without neurological deficits. He gave a history of a fall while riding a bicycle at a low speed 3 months ago. X-ray showed torticollis in the right side, and computed tomography (CT) showed a type-II odontoid fracture and subluxation at the C1-2 level.We performed a staged treatment because this patient had severe neck pain associated with a chronic course. Initially, the fracture dislocation was reduced under general anesthesia and was stabilized with a halo vest. We then performed posterior occipitocervical in situ fusion after confirming the correction of the cervical deformity by CT. The patient showed significant amelioration of neck symptoms postoperatively, and bony fusion was achieved 1 year after surgery.For post-traumatic torticollis due to an odontoid fracture, plain CT is useful for diagnosis and posterior occipitocervical in situ fusion following correction and immobilization with a halo vest is a safe and an effective treatment.
Medicine 09/2015; 94(36):e1478. DOI:10.1097/MD.0000000000001478 · 5.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Descriptive case report.To report a case of a diffuse idiopathic skeletal hyperostosis (DISH) patient with both massive ossification of the anterior longitudinal ligament (OALL) leading to severe dysphagia as well as ossification of the posterior longitudinal ligament (OPLL) causing mild cervical myelopathy, warranting not only an anterior approach but also a posterior one.Although DISH can cause massive OALL in the cervical spine, severe dysphagia resulting from DISH is a rare occurrence. OALLs are frequently associated with OPLL. Treatment for a DISH patient with OPLL in setting of OALL-caused dysphagia is largely unknown.A 70-year-old man presented with severe dysphagia with mild cervical myelopathy. Neurological examination showed mild spastic paralysis and hyper reflex in his lower extremities. Plane radiographs and computed tomography of the cervical spine revealed a discontinuous massive OALL at C4-5 and continuous type OPLL at C2-6. Magnetic resonance imaging revealed pronounced spinal cord compression due to OPLL at C4-5. Esophagram demonstrated extrinsic compression secondary to OALL at C4-5.We performed posterior decompressive laminectomy with posterior lateral mass screw fixation, as well as both resection of OALL and interbody fusion at C4-5 by the anterior approach. We performed posterior decompressive laminectomy with posterior lateral mass screw fixation, as well as both resection of OALL and interbody fusion at C4-5 by the anterior approach. Severe dysphagia markedly improved without any complications.We considered that this patient not only required osteophytectomy and fusion by the anterior approach but also required decompression and spinal fusion by the posterior approach to prevent both deterioration of cervical myelopathy and recurrence of OALL after surgery.
Medicine 08/2015; 94(32):e1295. DOI:10.1097/MD.0000000000001295 · 5.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to evaluate the preoperative radiographs with cases of developmental dysplasia of the hip (DDH) leading to rotational acetabular osteotomy (RAO) or curved peri-ace-tabular osteotomy (CPO), and examine the frequency of femoroacetabular impingement (FAI) related bone morphology in the acetabulum and femoral head-neck junction. Twenty-four hips with hip dyaplasia who underwent CPO or RAO were included in this study. Six hips had grade 0 and eighteen hips had grade 1 OA according to the Tönnis classification. We excluded patients with moderate and severe hip osteoarthritis and major femoral head deformities. Preoperative radio-graph was evaluated on sharp angle, center-edge angle, alpha angle, crossover sign and posterior wall sign. Crossover signs were revealed in 7 hips (29.2%); posterior wall signs were revealed in 16 hips (66.7%); and cam-type deformities with an alpha angle of ≥50. 5˚ere observed in 19 hips (79.2%) in preoperative evaluation. As determined using the Tönnis scale, no progression of os-teoarthritis was found in 16 of the 24 hips; there was a one-grade progression in 8 hips. Among the 8 hips, either positive cross-over sign or posterior sign in acetabulum, and an alpha angle of ≥50. 5˚n femur were observed in six hips with progression of osteoarthritis. The presence of cam-type deformity and acetabular retroversion in patients who underwent RAO or CPO was relatively high in preoperative radiographs, and caution should be employed during surgery in patients with DDH. There is a possibility of secondary FAI due to excessive forward coverage of the bone fragments after RAO and CPO.
Open Journal of Orthopedics 05/2015; 5(5):126-134. DOI:10.4236/ojo.2015.55017
[Show abstract][Hide abstract] ABSTRACT: In total hip arthroplasty (THA), combined anteversion (CA) is used as a parameter for assessment of overall prosthetic alignment. The purpose of this study was to comparatively examine the CA value in patients who underwent primary THA using the image-free navigation system either with a cup-first or stem-first technique.
Eighty-three hips undergoing primary THA using the OrthoPilot® image-free navigation system (B. Braun-Aesculap, Tuttlingen, Germany) were included in this study. The patient population was divided into two groups depending on the procedure used: cup-first technique and stem-first technique. In the cup-first group, inclination and anteversion (AV) angles were targeted at 35-45° and 15-25°, respectively, while stem antetorsion (AT) was determined for each patient based on the amount of individual native femoral AT angle. In the stem-first group, the femur was prepared first with the target angle corresponding to the native femoral AT and the cup AV was decided considering the CA calculated with Widmer's formula (aiming at the optimal Widmer's CA of 37.3°).
Better consistency in Widmer's CA values was attained in the stem-first group as indicated by the smaller SD values. In the assessment of overall alignment, Widmer's CA values were within the satisfactory range (37 ± 5°) in 41.9 and 92.3 % of the subjects in the cup-first group and the stem-first group, respectively.
The stem-first technique with image-free navigated THA could effectively achieve accurate and consistent control of the CA value and thus is expected to improve the surgical outcome.
International Orthopaedics 05/2015; DOI:10.1007/s00264-015-2784-9 · 2.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The level of vascular endothelial growth inhibitor (VEGI) has been reported to be negatively associated with neovascularization in malignant tumors. The soluble form of VEGI is a potent anti-angiogenic factor due to its effects in inhibiting endothelial cell proliferation. This inhibition is mediated by death receptor 3 (DR3), which contains a death domain in its cytoplasmic tail capable of inducing apoptosis that can be subsequently blocked by decoy receptor 3 (DcR3). We investigated the effects of sodium valproate (VPA) and trichostatin A (TSA), histone deacetylase inhibitors, on the expression of VEGI and its related receptors in human osteosarcoma (OS) cell lines and human microvascular endothelial (HMVE) cells. Consequently, treatment with VPA and TSA increased the VEGI and DR3 expression levels without inducing DcR3 production in the OS cell lines. In contrast, the effect on the HMVE cells was limited, with no evidence of growth inhibition or an increase in the DR3 and DcR3 expression. However, VPA-induced soluble VEGI in the OS cell culture medium markedly inhibited the vascular tube formation of HMVE cells, while VEGI overexpression resulted in enhanced OS cell death. Taken together, the HDAC inhibitor has anti-angiogenesis and antitumor activities that mediate soluble VEGI/DR3-induced apoptosis via both autocrine and paracrine pathways. This study indicates that the HDAC inhibitor may be exploited as a therapeutic strategy modulating the soluble VEGI/DR3 pathway in osteosarcoma patients.
International Journal of Oncology 03/2015; 46(5). DOI:10.3892/ijo.2015.2924 · 3.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Most unilateral pedicle stress fractures occur on the contralateral side of patients with unilateral spondylolysis. However, there are few reports of unilateral pedicle stress fractures in patients with bilateral spondylolysis and spondylolisthesis. We report a unique case of unilateral pedicle stress fracture in a long-term hemodialysis patient with isthmic spondylolisthesis. A 65-year-old man who had undergone hemodialysis presented with lower back pain that had persisted for several years. The patient experienced severe right lower extremity pain with no history of trauma. Computed tomography revealed unilateral pedicle fracture with bilateral L5 spondylolysis and spondylolisthesis with progression of scoliosis. The patient underwent Gill laminectomy of L5 with pedicle screw fixation at L4-S1 and interbody fusion at L5-S1. The patient’s leg pain ceased immediately, and he began walking without leg pain. In our present patient, development of scoliosis caused by destructive spondyloarthropathy may have contributed to a unilateral pedicle fracture.
[Show abstract][Hide abstract] ABSTRACT: Aims
Navicular fracture is still challenging disorder to treat because there is a risk of nonunion, avascular necrosis and symptomatic osteoarthritis.
Patients (Methods and results)
A 40-year-old woman with an ununited fracture of the tarsal navicular bone was treated with localized naviculocuneiform arthrodesis (arthrodesis of the navicular, the middle cuneiform, and the lateral cuneiform). Fusion with the navicular, the middle cuneiform, and the lateral cuneiform as well as union of fracture of the navicular was confirmed on the radiographs.
Localized naviculocuneiform arthrodesis using a locked plating system is one of the options to treat nonunion of the navicular bone.
Journal of Orthopaedics 12/2014; 11(4). DOI:10.1016/j.jor.2014.08.006
[Show abstract][Hide abstract] ABSTRACT: Object:
Laminoplasty is the preferred operation for most patients with cervical myelopathy due to multilevel ossification of the posterior longitudinal ligament (OPLL). Recent studies have demonstrated several significant risk factors for poor clinical outcomes after laminoplasty, including older age, lower preoperative Japanese Orthopaedic Association (JOA) score, postoperative change in cervical alignment, cervical kyphosis, and high occupying ratio of the OPLL (that is, the ratio of the greatest anteroposterior thickness of the OPLL to the anteroposterior diameter of the spinal canal at the same level on a lateral image). However, the impact of dynamic factors on clinical outcomes is unclear. The purpose of this study is to assess the impact of dynamic factors on the clinical outcome after laminoplasty for cervical myelopathy due to OPLL.
A consecutive series of patients who underwent laminoplasty for cervical myelopathy due to OPLL between 2003 and 2009 was retrospectively reviewed. The indication for laminoplasty at the authors' hospital included preoperative straight or lordotic alignment of the cervical spine and an occupying ratio of OPLL less than 60%. The JOA score and recovery rate were used to evaluate clinical outcomes. A poor clinical outcome was defined as a recovery rate of less than 50%. Patient factors examined along with outcome included age, preoperative JOA score, preoperative somatosensory evoked potentials, preoperative motor evoked potentials, body mass index, and presence of high intensity on MRI. Radiographic measures included the preoperative C2-7 lordotic angle, preoperative C2-7 range of motion (ROM), preoperative segmental ROM at the level of myelopathy, and the occupying ratio of OPLL.
There were 45 patients (33 males and 12 females). The mean follow-up period was 4 years (range 2-6.8 years). The mean patient age was 66.9 years (range 50-85 years). The mean JOA score significantly increased from 9.1 before surgery to 13.1 at the final follow-up. The mean recovery rate was 51.2%. Nineteen patients (42%) had a recovery rate of less than 50%. Patient factors were not associated with surgical outcomes. Only the preoperative C2-7 ROM was significantly greater in the poor surgical outcome group (23.1° vs 14.1°). Receiver operating characteristic curve analysis showed that the optimal preoperative C2-7 ROM cutoff was 20°. Logistic regression analysis revealed that patients with a preoperative C2-7 ROM of greater than 20° had a 4.6 times higher risk (p = 0.021) of a poor clinical outcome, indicating that dynamic factors may have an impact on the surgical outcome of laminoplasty.
Fusion surgery may be a useful strategy in patients with preoperative hypermobility of the cervical spine.
[Show abstract][Hide abstract] ABSTRACT: Introduction
Chondral fracture of the knee is relatively rare and the optimal treatment option for this injury is still controversial. In this report, we present the case of a patient with this injury who was treated surgically using the bone peg fixation procedure. There has been no literature reporting the use of this technique for fixation of a detached chondral fragment.
The patient was a 14-year-old Japanese boy who sustained a knee injury while kicking a soccer ball. Although routine radiographs showed no abnormality, magnetic resonance imaging showed a large full-thickness chondral defect in the weight-bearing portion of his lateral femoral condyle and a detached chondral fragment in the anterior region. The size of the defect (fragment) was 2cm by 1.5cm. At surgery, the chondral fragment was fixed with eight cortical bone pegs that were harvested from the anteromedial aspect of his tibia.
The postoperative magnetic resonance imaging at 4 months and the second-look arthroscopy at 12 months revealed apparent healing of the fragment. In the final follow-up examination at 26 months, a physical examination showed no swelling with recovery of full range of motion, and he could play soccer at the pre-injury level with no complaint. Based on the clinical course of this patient, it is thought that bone peg fixation can be a valuable option for fixation of a large chondral fracture of the knee.
Journal of Medical Case Reports 09/2014; 8(1):316. DOI:10.1186/1752-1947-8-316
[Show abstract][Hide abstract] ABSTRACT: The authors report a case of adhesive arachnoiditis (AA) and arachnoid cyst successfully treated by subarachnoid to subarachnoid bypass (S-S bypass). Arachnoid cysts or syringes sometimes compress the spinal cord and cause compressive myelopathy that requires surgical treatment. However, surgical treatment for AA is challenging. A 57-year-old woman developed leg pain and gait disturbance. A dorsal arachnoid cyst compressed the spinal cord at T7-9, the spinal cord was swollen, and a small syrinx was present at T9-10. An S-S bypass was performed from T6-7 to T11-12. The patient's gait disturbance resolved immediately after surgery. Two years later, a small arachnoid cyst developed. However, there was no neurological deterioration. The myelopathy associated with thoracic spinal AA, subarachnoid cyst, and syrinx improved after S-S bypass.
[Show abstract][Hide abstract] ABSTRACT: Background:
Soft tissues of the shoulder undergoes substantial stresses due to humeral head movement, and this may contribute to throwing shoulder injuries in baseball pitchers. Prevention and management of throwing shoulder injuries critically rely on reduction of shear force at the shoulder joint. However, the amount and direction of the force applied to the shoulder during the throwing motion have not been clarified. The purpose of this study was to analyze forces applied to the shoulder during a baseball pitch.
We performed biomechanical analysis of 213 baseball pitchers of various ages and skill levels. Throwing motion was analyzed with a 3-dimensional motion capture system. The Euler angle sequence was adopted to describe angular values of the upper arm relative to the trunk for shoulder rotation, and inverse dynamics was used to estimate the resultant joint forces at the shoulder.
There was a significant relation between horizontal abduction/adduction angle and resultant anterior/posterior force at the point of maximum external rotation (MER) (r = -0.63, P < .01), whereby increased horizontal abduction was associated with increased resultant anterior force. There was a significant but weak correlation between abduction/adduction angle and superior/inferior force at MER (r = 0.24, P < .01). Comparison among the groups with variable ages and skill levels showed larger horizontal abduction and smaller external rotation angles at MER in the adult amateur player group, whereas normalized compression force and internal rotation torque values at MER were smaller in the junior high school- and elementary school-aged groups.
These results suggest that excessive horizontal abduction at MER increases anterior shear force in the shoulder and may lead to shoulder injuries. Focusing on reducing horizontal abduction at MER in the throwing motion may be key to preventing and managing shoulder injuries in baseball pitchers.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 06/2014; 23(12). DOI:10.1016/j.jse.2014.03.005 · 2.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a rare case of posterior interosseous nerve (PIN) paralysis in a tennis player. The PIN, a 2 cm section from a bifurcation point of the radial nerve, presented increased stiffness in the surgical findings and treated with free sural nerve grafting after excision of the degenerative portion of the PIN. We speculate that PIN paralysis associated with hourglass-like constriction can be caused and exacerbated by repetitive forearm pronation and supination in playing tennis.
Journal of Orthopaedics 06/2014; 11(2). DOI:10.1016/j.jor.2014.04.017
[Show abstract][Hide abstract] ABSTRACT: Periosteal chondrosarcoma is an extremely rare low-grade malignant cartilaginous tumor arising from the external bone surface. Diagnosis of periosteal chondrosarcomas may be challenging, since this condition closely resembles periosteal chondromas. It has been reported that positron emission tomography (PET) is useful in distinguishing benign from malignant cartilaginous tumors using a maximum standardized uptake value (SUVmax) cut-off of 2.0 or 2.3. This report presents the case of a 40-year-old female with an 18-month history of a tender mass in the left distal femur. Radiological findings demonstrated periosteal buttressing. Magnetic resonance imaging (MRI) revealed a chondrogenic tumor of 3 cm in size developing from the external bone surface. It was difficult to differentiate periosteal chondrosarcoma from periosteal chondroma on the basis of size and the radiological and MRI findings. PET/computed tomography (CT) revealed abnormal linear uptake with an SUVmax of 2.7, indicating a malignant tumor. A diagnosis of periosteal chondrosarcoma was made, and wide resection was performed. Tumor histology was consistent with grade II chondrosarcoma. PET/CT is thus useful in differentiating periosteal chondrosarcoma from periosteal chondroma.