Katsumi Takase

Lunate excision, capitate osteotomy, and intercarpal arthrodesis for advanced Kienböck disease. Long-term follow-up.

Background: Kienböck disease is caused by aseptic necrosis of the lunate. In the advanced stages of the disease, carpal collapse, joint incongruity, and osteoarthritis develop. We performed lunate excision, capitate osteotomy, and intercarpal arthrodesis (the modified procedure of Graner et al.) on fifteen patients with stage-IIIB or IV Kienböck disease. This report is a review of the findings in these patients. Methods: The subjects ranged in age from twenty-six to fifty-four years (mean, 39.2 years) at the time of surgery. We evaluated the results more than five years postoperatively (range, sixty-two to 145 months postoperatively; mean, 79.3 months postoperatively). Therapeutic results were evaluated according to the scoring system of Evans et al. Results: Pain disappeared after surgery in most patients. Others had a reduction in the intensity of the pain to a mild level. The grip strength on the affected side had recovered to about 80% of that on the unaffected side twelve months after surgery. The long-term results were graded as good in eleven of the patients, as fair in two, and as poor in two. Postoperative radiographs showed that the carpal bone parameters (carpal height index and radioscaphoid angle) had improved. Radiographic osteoarthritic changes occurred in all of the patients; however, except for moderate limitation of the range of motion at the wrist joint, these findings did not affect the level of pain, grip strength, or activities of daily living. Conclusions: Lunate excision followed by capitate osteotomy and intercarpal arthrodesis (the modified procedure of Graner et al.) is a reliable form of treatment for advanced Kienböck disease, with favorable results for at least five years postoperatively.

The radiographic study in the relationship of the glenohumeral joint

Accurate reproduction of anatomic relationship is important in non‐constrained prosthetic arthroplasty. The accurate lateral glenohumeral offset, which indicates a parameter of the lever arm of the deltoid and supraspinatus muscles, is one of the most important elements in achieving the efficient shoulder functions after prosthetic reconstruction. However, to our knowledge, there has been no detailed study on the influence of minute changes in the neck shaft angle, within the normal range, on lateral glenohumeral offset. In this study, we evaluated the relationship between the neck shaft angle and various geometric measurement values in the glenohumeral joint.

Clinical pathology and therapeutic results of neurilemmoma in the upper extremity

Purpose. To evaluate the clinical pathology and postoperative outcomes of patients with neurilemmoma in the upper extremity who underwent tumour enucleation, and the correlation factors for neurological deficits apart from enucleation of nerve fascicles. Methods. Magnetic resonance imaging was used to evaluate the state of lesions of the patients with upper-extremity neurilemmoma who underwent tumour enucleation. To find out the correlation factors for neurological deficits, the patients were then divided into 2 groups based on their recovery period—group A (shorter than 6 months) and group B (at 6 months or longer). Duration of the illness, the affected nerve, and the size and histological type of the tumour were then compared between the 2 groups. Results. Of the 20 patients who underwent tumour enucleation for neurilemmoma in the upper extremity, 19 had a single nerve affected and one had multiple lesions involving two nerves. The tumours in 6 patients were of Antoni A type histology and in the remaining 14 patients were of a mixed type. Antoni B type alone was not observed. 15 patients showed postoperative neurological deficits. No neurological deficits were observed in 5 patients. Neurological deficits were fully recovered in all patients except the one with a lesion in the digital nerve. Apart from enucleation of nerve fascicles, the period required for the recovery of neurological deficits was correlated to the duration of the illness (p=0.04) and the histological type of the tumour (p=0.03). Conclusion. Most of the patients with neurilemmoma (95%) had a single nerve affected. A majority of patients (70%) had the mixed type of Antoni A and Antoni B histology; Antoni B type alone was not observed. Neurological deficits were observed in 75% of patients. In patients with neurilemmoma developing in the upper extremity, the period required for recovery from postoperative neurological deficits was short when the duration of illness was short and when Antoni A type histology was present.

Intraarticular lesions in traumatic anterior shoulder instability: a study based on the results of diagnostic imaging.

Background Diagnostics of intraarticular lesions is important in the treatment of traumatic anterior shoulder instability. Patients and methods We studied 30 patients: 26 men and 4 women. For all patients preoperative examinations involved arthrography, CT arthrography, MR arthrography, and 3D-CT. Results The articular capsule adhered to the margin of the glenoid in only 3 cases. In the remaining 27 patients, the joint capsule was detached, showing medial translation. Hill-Sachs lesions were present in 24 cases. Bankart lesions were detected in all cases, and they extended over 2–5 h. Osseous Bankart lesions were detected in 13 cases. MR arthrography revealed the articular labrum in all cases, but AIGHL in only 16 cases. Bankart lesions were found in all cases. When the patients were divided according to the frequency of dislocation, there was a correlation between both distance of the detached joint capsule and visualization of AIGHL and the frequency of dislocation. Interpretation From this study, the frequency of dislocation was higher in the patients with severe detachment of the joint capsule, in whom AIGHL could not be visualized by MR arthrography.   ▪

A combined fracture of the greater and lesser tuberosity with head shaft continuity in the proximal humerus

We treated a combined fracture of the greater and lesser tuberosity with head shaft continuity in the proximal humerus. This case is impossible to classify in three of the classifications, the Neer classification, AO Müller classification, or Jakob classification. However, this case has been described as fracture types in two different categories in the Codman classification. Based on our experience with this case, we concluded that both the plain radiographs and the CT scans were necessary to make a correct diagnosis and classify the fractures of the proximal humerus.

Changes in surgical procedures for acromioclavicular joint dislocation over the past 30 years.

Generally, surgical treatment is recommended for Rockwood type 5 traumatic acromioclavicular joint dislocations. Since 1980, the authors have performed the modified Dewar procedure, the modified Cadenat procedure, and anatomical reconstruction of the coracoclavicular ligaments for this injury. The goal of this study was to determine the ideal surgical procedure for acromioclavicular joint dislocations by comparing these 3 procedures. The modified Dewar procedure was performed on 55 patients (Dewar group), the modified Cadenat procedure was performed on 73 patients (Cadenat group), and anatomical reconstruction of the coracoclavicular ligaments was performed on 11 patients (reconstruction group). According to the UCLA scoring system, therapeutic results averaged 27.3 points in the Dewar group, 28.2 in the Cadenat group, and 28.4 in the reconstruction group. The incidence of residual subluxation or dislocation in the acromioclavicular joint was evaluated at final radiographic follow-up. Subluxation occurred in 21 patients in the Dewar group, 18 in the Cadenat group, and 3 in the reconstruction group. Dislocation occurred in 3 patients in the Dewar group. Osteoarthritic changes in the acromioclavicular joint occurred in 20 patients in the Dewar group, 9 in the Cadenat group, and 1 in the reconstruction group. The modified Cadenat procedure can provide satisfactory therapeutic results and avoid postoperative failure or loss of reduction compared with the modified Dewar procedure. However, the modified Cadenat procedure does not anatomically restore the coracoclavicular ligaments. Anatomic restoration of both coracoclavicular ligaments can best restore acromioclavicular joint function.

Osteoid Osteoma of the Great Toe

Osteoid osteoma is a relatively common osteoblastic lesion of benign skeletal neoplasms and occurs most commonly in the cortex of long bones, especially the femur and the tibia. Radiological characteristics are a nidus that appears as a small, relatively radiolucent zone within an area of extensive reactive sclerosis. Clinically, the lesion presents with increasing pain, is worse at night, and is relived by nonsteroidal anti-inflammatory drugs (NSAIDs). Osteoid osteomas involving the phalanges of the toes are uncommon, and its accurate preoperative diagnosis is difficult due to the unique clinical and radiological features. The features in the phalanx of the toe are soft tissue swelling and a nidus frequently located in the cancellous without osteosclerosis. This article presents a case of a 22-year-old man with osteoid osteoma in his distal phalanx of the hallux. A needle biopsy of his great toe revealed a small number of bacteria, so he was initially treated for osteomyelitis but with unsatisfactory results. The particular characteristics of clinical and imaging findings supported a diagnosis of osteoid osteoma in the distal phalanx of the hallux. After surgical removal of the tumor, his symptoms resolved. The pathological examination confirmed the suspected diagnosis. In a patient with chronic foot pain that changes to become nocturnal and disappears with NSAID administration, it is important to include osteoid osteoma as a differential diagnosis. A detailed assessment of both clinical and radiological features can lead to the correct diagnosis, which must be confirmed with histopathological examination to ensure adequate excision.

Chronic posterior dislocation of the glenohumeral joint complicated by a fractured proximal humerus: a case report.

A 41-year-old right-handed woman was involved in a traffic accident and landed on the right arm while the right shoulder was in flexion. She experienced pain and severe impairment of right shoulder motion immediately following the accident. She was misdiagnosed with a fractured proximal humerus with no displacement and was treated conservatively by immobilisation. There was inadequate recovery in range of motion and gradual development of severe pain. Two years and 4 months after the injury, the patient presented to our hospital where a diagnosis of chronic posterior fracture dislocation of the shoulder with split articular surface of the humeral head was made. A humeral head replacement without resection of the greater tuberosity or the coracoid process was performed. Postoperative recovery was uneventful. The patient returned to work as a cook one year later. At 20-month follow-up, the patient had no pain, and her shoulder range of motion was forward flexion 160 degrees, abduction 140 degrees, external rotation 40 degrees, and internal rotation L3.

Histological and ultrastructural changes in the undersurface of the acromion with subacromial impingement

Background We examined histological changes in the undersurface of the acromion in patients with symptoms of subacromial impingement, in order to clarify whether or not these changes are the main cause of rotator cuff tear. Methods We studied 39 shoulders. The undersurface of the acromion and the coracoacromial ligament were examined by light microscopy and transmission electron microscopy. Results The distinct four-layer structure seen in the undersurface of the acromion of normal subjects was not found in any of our patients. In patients with full-thickness cuff tear, the extent of the tear had a greater association with the degree of degeneration in the undersurface of the acromion than age or the duration of illness. There was little association between structural changes in the coracoacromial ligament and the extent of or the presence of full-thickness cuff tear, or the duration of illness, but there was a strong association with patient age. Interpretation The histological changes in the undersurface of the acromion in patients without cuff tear were merely minute changes compared to those in patients with full-thickness cuff tear. We conclude that the advanced degenerative changes in the undersurface of the acromion result from full-thickness cuff tear.

Risk of Motion Loss With Combined Bankart and SLAP Repairs

We have performed arthroscopic Bankart procedures using absorbable or metallic suture anchors for traumatic anterior shoulder instability for over a decade. This article describes the frequency, pathology, and therapeutic results of patients treated for superior labrum anterior and posterior (SLAP) lesions concomitant with Bankart lesions. Twenty patients (Group A) had a mean age of 33.8 years at the time of surgery. On arthroscopic findings, SLAP lesions were classified type 2 in 15 patients and type 4 in 5, based on Snyders criteria. In addition, intra-articular free bodies were present in 2 SLAP lesions, and a capsular tear was present in 1. We performed debridement (Group A1) or reattachment (Group A2) to the superior glenoid edge of these lesions, considering whether they communicated to Bankart lesions. The therapeutic results were evaluated according to the Japanese Orthopaedic Association (JOA) score and Japan Shoulder Society (JSS) shoulder instability score. Mean JOA and JSS shoulder instability scores were 95.1 and 90.8 points, respectively. All Group A patients remained pain free, and no instability recurred in any patient. Meanwhile, mean JSS shoulder instability function and range of motion scores were 18.9 and 15.1 points, respectively, in Group A1, and 17.5 and 10.1 points, respectively, in Group A2. A significant correlation in range of motion was observed in Groups A1 and A2 (P=.04). Regarding postoperative limitation in external rotation with the arm at the side, the difference in range from that on the healthy side was 9.8 degrees in Group A (7.0 degrees in Group A1 and 12.6 degrees in Group A2). When SLAP lesions communicated to Bankart lesions, we had satisfactory results without SLAP repair; therefore, unnecessary repairs for the concomitant pathology should be avoided, and different postoperative care should be performed for patients with Bankart repair with reattachment of a SLAP lesion.