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広範囲腱板断裂の2症例に広背筋移行術を施行し長期経過を知ることができたので報告する．症例1 60歳男性 建築業 重量物を持ち上げようとして右肩に軋音．疼痛と挙上困難出現．挙上50°，外旋－20°，内旋Th 8，JOA score 40点．広背筋移行術施行．7週間の外転固定．術後9年の現在，挙上140°，外旋20°，内旋Th 9，JOA scoreは72点である．症例2 50歳男性 左官 6年前に右肩広範囲腱板断裂に対して腱移植，棘上筋前進法施行．術後6年で疼痛挙上困難が再発．再断裂を生じる．挙上55°，外旋30°，内旋L1，JOA score 55点．広背筋移行術施行し5週間の外転固定．術後9年，関節症性変化の進行を認めるも挙上140°，外旋50°，内旋L1，JOA scoreは81.5点である．本術式は侵襲が大きいが，一次修復不可能な広範囲腱板断裂で肩挙上能力の回復を希望する者に対しては試みてしかるべき手術と考える．

Several studies have demonstrated that inflammation in the subacromial bursa is an important component in the pathogenesis of impingement syndrome. We have demonstrated in a previous study that many inflammatory cytokines, including stromal cell-derived factor 1 (SDF-1, CXCL12), are increased in the subacromial bursa [Blaine et al. 2005. J Shoulder Elbow Surg 14(Suppl 1):84S-89S]. SDF-1 is a potent chemotactic and angiogenic factor that stimulates recruitment of inflammatory cells. In the current study, we proposed that the resident cells in subacromial bursal tissue produce SDF-1, which can play a role in the inflammatory reponse of bursal tissue, and that this chemokine can be regulated by steroid (dexamethasone) and nonsteroidal anti-inflammatory medications (NSAIDs). Twenty-two subacromial bursa tissues (18 bursitis and 4 normal bursa) were obtained intraoperatively from patients during shoulder surgery and analyzed using the cDNA Array technique in accordance with an IRB approved protocol. cDNA array results were confirmed with real-time reverse transcription-polymerase chain reaction (RT-PCR). Bursal cells (from 4 normal bursa, 3 bursitis) and two normal bone marrow with whole tissue explants were cultured for one passage. Cell culture supernatants were collected and SDF-1 protein was detected with enzyme-linked immunosorbent assay (ELISA). Cultured bursal cells were treated with a COX-2 inhibitor and dexamethasone, and cells was harvested at 1-day and 4-day intervals. SDF-1 expression was evaluated by real-time RT-PCR and ELISA. cDNA Array analysis demonstrated that the gene expression of SDF-1 was increased in patients with subacromial bursitis compared to controls (p < 0.05). Real-time RT-PCR also revealed that the mRNA expression of SDF-1 in bursitis tissue is increased 10-fold over control tissue. While the normal bursal cells produced negligible amounts of SDF-1 protein, cultured cells derived from bursitis lesion released as much SDF-1 protein (235 pg/100,000 cells) as normal bone marrow stromal cells (283 pg/100,000 cells) as measured by ELISA. The addition of a COX-2 inhibitor and dexamethasone to bursitis cell lines led to decreased SDF-1 expression levels compared to untreated bursitis cell lines. These studies demonstrate that there is a significant elevation of SDF-1 expression in the subacromial bursa of patients with rotator cuff disease. Furthermore, this chemokine can be downregulated by COX-2 inhibitors and steroids. These results provide biologic evidence for the use of steroid and NSAIDs in the treatment of subacromial bursitis. In the future, targeted inhibition of molecules such as SDF-1 in the subacromial bursa may present a therapeutic strategy that may avoid the side effects of these other (steroid and NSAID) medications.

To clarify the role of calpain in the receptor activator of NF-kappaB ligand (RANKL)-supported osteoclastogenesis, RANKL-induced calpain activation was examined by using murine RAW 264.7 cells and bone marrow-derived monocyte/macrophage progenitors. We found that calpain activity increased in response to RANKL in both cell types based on alpha-spectrinolysis and that mu-calpain, rather than m-calpain, was activated during RANKL-supported osteoclastogenesis in RAW 264.7 cells. Overexpression of mu-calpain clearly augmented RANKL-supported osteoclastogenesis in RAW 264.7 cells, thereby implicating its pivotal role in this process. Cell-permeable calpain inhibitors, including calpastatin and calpeptin, were sufficient to suppress RANKL-supported osteoclastogenesis based on decreased expression of the osteoclastogenic marker, matrix metalloproteinase 9, and the generation of tartrate-resistant acid phosphatase-positive multinucleated cells in both cell types. Calpain inhibitors suppressed NF-kappaB activation via inhibition of the cleavage of inhibitor of NF-kappaB(IkappaBalpha)in RAW 264.7 cells. Taken together, our findings suggest that mu-calpain is essential to the regulation of RANKL-supported osteoclastogenesis via NF-kappaB activation.

We devised a special instrument to assess intraoperative pelvic motion and used this device to measure intraoperative pelvic motion in three dimensions. A total of 100 total hip arthroplasties (THAs) were performed using this device. Two approaches were utilized: 52 THAs were performed with the posterolateral approach and the remaining 48 with the translateral approach. The average angle of pelvic tilt in the THAs with the translateral approach was less than that with the posterolateral approach. The average internal rotation angle was 1.75 degrees with the translateral approach and 14.25 degrees with the posterolateral approach. With the posterolateral approach, the internal rotation of the pelvis frequently occurred during retraction of the femur using a Hohmann's retractor placed at the anterior rim of the acetablum, with flexion and internal rotation of the affected hip.

Surgical neck fracture of the humerus is a common injury in elderly people and usually successfully unites following adequate conservative or surgical treatments. Thus, the nonunion of the proximal humerus is not very common, but is difficult to treat once it develops.We present a case of surgical neck nonunion of the left humerus for which prosthetic replasement was performed. Although she was unable to hold anything in her left arm or elevate left shoulder due to a severe pain before prosthetic replacement, she could hold a one kg dumbbell five months after the operation without pain.

Posterolateral reconstruction of the posterior capsule, piriformis tendon, and external rotators in total hip arthroplasty improves the stability of the hip joint. This study was performed to evaluate the effect of this reconstruction on range of motion (ROM) and circumferential muscle strength. We selected 58 limbs of 29 patients. Posterolateral reconstruction was performed in 13 patients (reconstruction group). Posterolateral reconstruction was not performed in 16 patients (nonreconstruction group). No significant differences were seen in preoperative and postoperative ROM between the 2 groups. The reconstruction group had significantly higher abduction muscle strength (P

The purpose of the present study is to report the mid-term results of modified Sugioka transtrochanteric valgus ostetomy (TVO) for the treatment of secondary osteoarthritis. The lateral displacement of the greater trochanter was simultaneously performed. Fourteen TVOs were performed in 14 patients with unilateral osteoarthritis of the hip from 1993. We assessed 8 hips in 8 patients in this study. The mean age of the patients at the time of surgery was 46.4 years (41 to 55 years). The average follow-up was 3.9 years (2.4-7.2years). The patients were evaluated for radiographic changes of the joint space, roof osteophyte, weight bearing surface of acetabulum, AHI, abductor lever arm, capital drop, bone cyst in the acetabulum or femoral head as well as clinical results using JOA score. The mean JOA score improved from 57.4 to 76.3. The widening of joint space, lengthening of weight bearing surface of acetabulum were seen in seven hips. The length of the abductor lever arm after surgery was not proportional to the JOA score at the latest follow-up. In one patient, total hip arthroplasty was required after 2.2 years. This procedure is considered useful for the treatment of osteoarthritis in dysplastic hips.

Arthroscopic synovectomy can be useful for management of inflammatory conditions, but total synovectomy is difficult using current techniques. Traditional open synovectomy requires dislocation of the femoral head from the acctabulum, with the inherent risk of avascular necrosis and prolonged rehabilitation period. The purpose of this report of two cases is to describe the indication of arthroscopic surgery for the treatment of the synovial chondromatosis of the hip joint.

We investigate the short-term results of immediate weight bearing after cementless THA. One hundred and seven hips of 102 patients were included in this study. Three different types of prosthesis were used. Patients were allowed full weight bearing three days after THA. Clinical and radiographical findings were observed for six months after surgery. Subsidence of the femoral prosthesis was observed in three hips. Two did not sustain injury. No other complications were observed. These three types of prosthesis had good initial stability for postoperative immediate weight bearing, and bone ingrowth may lead to the prosthesis.

The Purpose of this paper is to evaluate an arthroscopic examination on posterior superior glenoid impingement in 11 cases of throwing athletes. Under arthroscopy, with the arm placed in external rotation and 90° abduction, impingement was found between the posterosuperior border of the glenoid and the undersurface of the cuff (arthroscopic internal impingement test).This test supports the belief that internal impingement occurs in overhead throwing athletes.

We reported two cases of soft tissue tumor whose diagnosis was difficult to determine as whether malignant or benign in preoperative examinations.1 case was a 70-year-old female. 2 painless soft tissue masses 10cm and 3cm in diameter were found in her left inguinal region. Magnetic resonance imaging (MRI) demonstrated clear border without adhesion to the surrounding tissues. No typical tumor atain was obtained on angiogram. Although a needle biopsy demonstrated no evidence of malignancy, postoperative diagnosis was malignant lymphoma, non-Hodgkin myxoid cell type.The other case was a 53-years-old male. A painless soft tissue mass 5cm in diameter was found in his left axillary region, MRI demonstrated clear border without adhesion to the surrounding tissues. Gadolinium enhanced images demonstrated low to high intensity specles, which suggested neurilemoma. The biopsy specimen showed neurological cells and no evidence of malignancy. Post operative diagnosis was benign neurilemoma.We concluded that preoperative image examinations for example MRI provides considerable reference for surgical location, which was however insufficient for histological diagnosis, and a study on the false-negative of the histology by needle biopsy was necessary for preoperative diagnosis. Laboratory data is also important for cases of malignant lymphoma prior to operation.

A sixty-year-old man was seen complaining of discomfort and swelling without pain in his left shoulder. On examination slight restriction of motion was found, but the muscle strength of left upper extremity was within normal limits. The only positive result from the laboratory studies was elevation of the level of rheumatoid factor. Tuberculin test was found to be strongly positive. Thickening of the wall of subacromial bursa and a large number of rice bodies suspended in the fluid were observed by echo gram, MRI and bursography.The subacromial bursa was resected surgically. After the operation, medical treatment for tuberculosis was started. Symptoms and abnormal data recovered to normal six months after operation. Pathological study of the tissue showed granuloma with caseous necrosis and multi-uncleated giant cells. Tuberculous bacteria was detected from the cultivation of the tissue. The diagnosis of tuberculosis of the subacromial bursa was thus confiremed.We suggest that early surgical treatment is necessary to avoid invasion of the infected lesion to surrounding tissues.

We report the successful results of semi-rigid fusion for a thoracic vertebral fracture-dislocation in rheumatoid arthritis (RA). The patient was a 52-year-old woman who was diagnosed as rheumatoid arthritis when she was 13 years old. She underwent posterior fusion of O-C4 for basilar impression, and C6-T3 for the sublaxation of C7-T1 at 36 and 46. After these two operative procedures, she had severe thoracic vertebral fracture-dislocation caused by minor trauma when she was 52. We performed semi-solid fusion for the affected spine using the braided polyester cable (Nespron®). Nine months after the operation when bony fusion was achieved in the affected spine, she had no back pain and needed no brace.

We reviewed 9 patients in which 9 shoulders were operated on because of internal impingement. The mean age of the patients at operation was 20.3 years (range; 16 to 28 years). All patients had undergone arthroscopic internal impingement test, followed by arthroscopic debridement. The clinical outcome was expressed using JOA score and JOA score for athletics. All postoperative JOA scores and athletic JOA scores were higher than preoperative scores. The average follow-up period was 11 months (range; 9 to 16 months). 8 cases were able to start playing baseball again, but the ninth case was not.

Over a three year period (1994-1996), we performed 18 carpal tunnel releases in long-term hemodialysis patients. Six of these patients were a second carpal tunnel release group, with their symptoms recurring 1 to 8 years (mean: 4.3 years) after their first carpal tunnel release. In this study we reviewed the difference between the first carpal tunnel release group and the recurrent group.Although, there was no significant difference between the two groups in regard to preoperative objective symptoms and the number of distal motor latencies, complications appeared to be a prominent feature in the recurrent group.Microscopic examination showed amyloid depositions in the membranous tissue surrounding the median nerve in the recurrent group and this may cause the recurrence of symptoms.We conclude that it is necessary to follow patients after re-operation because factors which prevent recurrence are still unclear.

Rotational acetabular osteotomies are performed to correct dysplastic hips in young adults. However, there is a potential risk of intrapelvic vascular injury. To define the relation of these vascular structures to the bone around the acetabulum, we measured the distance and direction from the anteroinferior iliac spine to the external iliac artery and from the base of the superior pubic ramus to the obturator artery in 34 cadaveric hemipelves (17 male, 17 female; 19 left, 15 right). The distance to the external iliac artery was significantly shorter in females (average 31.7 mm) than in males (average 38.2 mm); and the distance to the intrapelvic entry portal of the obturator canal, through which the obturator artery passes, was significantly shorter in females (average 27.2 mm) than in males (average 33.4 mm). In addition, the external iliac artery was located significantly more ventral and closer to the anteroinferior iliac spine in right hemipelves than in left hemipelves. The intrapelvic entry portal of the obturator canal was located more caudodorsal to the base of the superior pubic ramus in females than in males. Care should thus be taken during surgery in light of our findings.

The purpose of this study was to evaluate the efficacy of two intermittent pneumatic compression devices as prophylaxis against intravascular coagulation and leg swelling following total hip arthroplasty. We studied 121 patients by assessing thrombogenesis using the D-dimer level before and after total hip arthroplasty. In addition, the patients' postoperative swelling was evaluated by measuring the thigh and lower leg circumference. Altogether, 58 patients were assigned to the calf-thigh pneumatic compression group, and the other 63 were assigned to the plantar compression group; the two pneumatic compression devices were compared to evaluate which was more effective for reducing thrombogenesis. At 7 days postoperatively, the mean D-dimer levels of the calf-thigh compression group and the plantar compression group were 8.86 and 9.26 microg/ml, respectively. There was no significant difference ( P = 0.697) between the two groups. However, the increased ratio of the circumference of the thigh, which was compared after arthroplasty, averaged 1.22% in the calf-thigh compression group and 3.19% in the plantar compression group, which was significantly different ( P0.01). Calf-thigh pneumatic compression was found to be more effective than plantar compression for reducing thigh swelling during the early postoperative stage.

We evaluated 60 limbs, including 34 primary total hip arthroplasties in 30 patients (mean age, 56 years) at a minimum of 2 years postoperatively. Femoral offset ratio (%FO) was calculated by dividing the femoral offset by the distance between the centers of the bilateral femoral heads on radiographs. The tilt angle of the pelvis by the Trendelenburg test was measured using the magnetic sensor system. In the limbs having a negative Trendelenburg sign after reconstruction, the %FO averaged 20.1% (range, 14.7% to 24.7%), and the tilt angle of the pelvis averaged +0.8 degrees (range, -1.0 degrees to +5.0 degrees ). The tilt angle of the pelvis correlated positively with %FO (P=.0160, r=0.407). The reconstructed hip joint position is crucial to improve hip abductor function.

We have used arthroscopy in the treatment of synovial chondromatosis of the hip joint. Two patients complained of pain of the hip joint that was aggravated by weight bearing. On admission, range of motion of the affected hip joints was slightly restricted. At hip arthroscopy, osteochondral loose bodies were removed from the joint and partial synovectomy was performed. Histologic examination revealed synovial chondromatosis. Pain relief was obtained in both patients postoperatively.