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Summary Objective Progestins are commonly prescribed for hormone replacement therapy (HRT) and contraception. However, the effects of progestins on bone metabolism remain unclear and are often controversial. Design and patients This study was conducted to test the hypothesis that progestins with no significant glucocorticoid activity may be a better choice for HRT to achieve increased beneficial effects on bone metabolism than progestins with strong glucocorticoid activity. A total of 104 postmenopausal women aged 50–75 years with osteoporosis were allocated randomly to three groups: (1) conjugated oestrogen plus medroxyprogesterone acetate (HRT-MPA, with significant glucocorticoid activity); (2) conjugated oestrogen plus norethisterone (HRT-NET, with no significant glucocorticoid activity); and (3) control (no treatment). Measurements Vertebral X-rays and bone mineral density (BMD) at distal 1/3 radius were assessed at baseline and every 6 months during the 2-year study period, along with markers of bone turnover. The occurrence of new nonvertebral fractures was identified by X-ray. Results After the 2-year treatment, mean BMD changes relative to baseline in the HRT-MPA, HRT-NET and control groups were 1·6%, 2·3% and –1·9%, respectively. In addition, the rate of increase in HRT-NET was significantly greater than that in HRT-MPA (P = 0·019). The incidence of new fractures during the 2-year treatment in the control group was 26% (9/34). HRT-NET treatment significantly inhibited the occurrence of new fractures (RR 0·14, 95% CI 0·02–0·93, P = 0·04), while HRT-MPA treatment failed to show a statistically significant reduction (RR 0·41, 95% CI 0·14–1·24, P = 0·11). Both HRT-MPA and HRT-NET treatments significantly decreased serum osteocalcin levels by 29·4% and 23·5%, respectively, after 6 months of treatment, with the decrease in HRT-MPA being significantly greater than that in HRT-NET (P = 0·042). Conclusions These findings suggest that progestins with no significant glucocorticoid activity may be a better choice for HRT, resulting in increased beneficial effects on bone metabolism compared with progestins with strong glucocorticoid activity.

An avulsion fracture of the tibial tubercle is a common injury in traffic accident. If the fracture is closed, then a comparatively good prognosis can be expected through reinforcement of the bone via osteosynthesis and the use of artificial ligaments. In this case, an open wound was observed in the tibial tubercle, and the wound was so polluted that the healing process was significantly delayed. It was therefore difficult to provide simultaneous surgical treatment and so three operations were required to perform the reconstruction of the extensor mechanism. The reconstruction of extensor mechanism and the frame fixation between the patella and tibia was performed. Six months after the injury, the patient was able to walk without aid, had a range of movement from 5 degrees to 130 degrees , and did not show any indications of ADL disorder. Using this method of frame fixation between the patella and tibia proved to be an effective technique for the reconstruction of the open knee extension mechanism injury.

当院関連病院で治療した，大腿骨近位部骨折を伴う90歳以上の骨粗鬆症患者の機能予後および生命予後について検討した．対象は1996年から1998年までの3年間に入院治療を行った48例（男性7例，女性41例）であり，全例に観血的手術が行われた．生命予後に有意な影響を与える因子として，術前全身状態，受傷前歩行能力，術前合併症数，椎体骨折数，骨折タイプ，術式が挙げられ，術前全身状態が悪く，受傷前歩行能力が低く，術前合併症数や椎体骨折数が多く，内側骨折，人工骨頭例で生命予後が劣っていた．機能予後に有意な影響を与える因子として，術前全身状態，術前後の痴呆が挙げられ，痴呆の重い症例ほど術後の歩行再獲得率は劣っていた．超高齢者の大腿骨近位部骨折の治療は，単に骨折部を治療するだけではなく，骨粗鬆症，痴呆などを含む全身状態が大きく関与しており，これらに対する多方面からの総合的アプローチが必要である．

UNLABELLED This study was done to assess the long-term functional outcome of very elderly patients with hip fractures, to determine whether bone mineral density and prevalent vertebral fractures could affect mortality and ambulatory status, and to examine which patient characteristics reported in the literature are predictive of patient mortality and ambulatory status. Seventy-four patients 90 years and older with hip fractures were analyzed and followed up for at least 4 years or until death. The mean age of the patients was 92.8 years and all were treated surgically. Walking ability before injury was better than at discharge; walking ability decreased during the first year after discharge, but thereafter reached a plateau. The predictors of survival were the preoperative American Society of Anesthesiologists score, walking ability, fracture type, type of surgery, and the number of prevalent vertebral fractures on admission. Dementia and the number of prevalent vertebral fractures were predictors of the recovery of walking ability. Type of surgery and fracture type are collinear variables, and because it is difficult to separate the effects of one versus the other, additional well-designed, randomized studies on the effect of the type of surgery and fracture type on outcome are needed. LEVEL OF EVIDENCE Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Study Design. A prospective study of 22 patients with the syndrome of acute central cervical spinal cord injury with motor and sensory impairment involving only upper extremities (ACCSCI-U) was done from admission to the 2-year follow-up. Objectives. To evaluate the course of neurologic function and to identify predictors of a good neurologic recovery in patients with ACCSCI-U. Summary of Background Data. Little is known regarding the time-course profile of neurologic and functional recovery and the prognostic factors for neurologic recovery in patients with ACCSCI-U. Methods. Between 1997 and 1998, 22 new cases of ACCSCI-U were identified (15 men and 7 women) with a mean age of 45.9 years (range, 13-75 years). They were all treated nonsurgically. Neurologic impairment, as evaluated by the American Spinal Injury Association (ASIA) motor and sensory scores, was assessed on patient arrival at the emergency department and followed prospectively at intervals from admission to the 2-year follow-up. The magnetic resonance imaging (MRI) studies were performed acutely (1 hours to 2 days after injury), subacutely (3-21 days after injury), and chronically (3-9 months after injury). Logistic regression analysis was used to identify the variables that were associated with neurologic improvement. Results. No patient sustained cervical fractures. The mean sagittal diameter of the cervical spinal canals (14.8 mm) was smaller than that of normal subjects in Japan. Of these 22 patients, seven (32%) had radiologic evidence of developmental cervical canal stenosis and two (9%) had evidence of ossification of posterior longitudinal ligament. Thirteen (59%) had cervical spondylosis: of these, four (31%) had cervical stenosis. Nonsurgical treatment resulted in nearly full neurologic recovery within approximately 6 weeks after the injury. None of the patients went on to need surgery. Their average ASIA score of motor, light touch sensation, and pin sensation was increased from 82.2, 104.5, and 104.3 at admission to 99.3, 111.2, and 111.0, respectively, at 2 years after injury. Logistic regression analysis revealed that the best predictor associated with a better neurologic recovery of motor, light touch sensation, and pin sensation was the absence of MRI findings of abnormal signal intensity in the spinal cord, with an odds ratio of 64 (P < 0.006), 13 (P < 0.04),and 15 (P < 0.03], respectively. The results also revealed that percent deficit improvement became significant at 1 week after injury to predict neurologic recovery at 2-year follow-up points. Conclusions. In patients with ACCSCI-U, a favorable neurologic prognosis can be predicted following nonsurgical treatment. Most recovery occurred by 6 weeks, and patients with severe initial neurologic damage and old age had poorer recovery. Touch and pin sensation recoverect at the same rate, whereas motor recovered more quickly. The absence of abnormal MRI signal intensity in the spinal cord and a good early neurologic improvement were the significant predictors of long-term improvement in neurologic function.

Previous experiments have demonstrated that bone cell populations derived from explants of lumbar vertebral bone of adult female rats contain osteoprogenitors that require dexamethasone (Dex) or progesterone (Prog) to proliferate and differentiate into fully differentiated bone-forming osteoblasts. We now show that the Prog-dependent population cannot be detected in male rats after sexual maturation, but is present in prepubertal rats of both sexes and can be induced in adult male-derived populations by culturing the explants in medium containing 17beta-estradiol (10(-9)-10(-8) M). This suggested that the Prog- and Dex-dependent osteoprogenitors in adult female-derived populations were probably distinct populations and that the survival of the Prog-dependent osteoprogenitors and/or their ability to proliferate are dependent on the presence of estrogen. We then proceeded to prove this by using replica plating. When one of the paired colonies duplicated was cultured in medium containing Dex (10(-8) M) and the other in medium containing Prog (10(-5) M), 5.0% of duplicates formed bone in Prog only, 11.1% formed bone in Dex only, and 3.4% formed bone in both Prog and Dex. In all cases the size of the bone-forming colonies in Dex-treated cultures was larger than that in Prog-treated cultures, indicating that the effects of Dex on osteoprogenitor proliferation are greater than those of Prog. The results demonstrate the existence of three classes ofosteoprogenitors in adult female rat-derived bone cell populations: a class responding to Dex only, a class responding to Prog only, and a class responding to both Dex and Prog. The results also indicate that the effects of Prog are not mediated by Prog binding to the glucocorticoid receptor and imply that Prog plays an important role in maintaining bone mass through regulating the class of osteoprogenitors responsive to Prog.

We have shown previously that progesterone (Prog) and dexamethasone (Dex) stimulate osteoprogenitor proliferation and differentiation in cell populations derived from adult rat vertebrae and in primary cultures of fetal rat calvariae. In these two in vitro systems, osteoprogenitors can be identified by the appearance of colonies of differentiated osteoblasts producing bone (bone nodule formation). Culture conditions supporting proliferation and differentiation of osteoprogenitors include a requirement for the presence of serum in the culture media. Our major interest in the present study was to investigate whether Prog- and Dex-mediated osteoprogenitor proliferation and differentiation was observed to the same degree in different lots of fetal bovine serum (FBS). In addition, we wanted to investigate whether osteoprogenitors present in cell populations derived from fetal calvarial bone and those present in populations derived from adult vertebral bone would respond similarly under the different culture conditions. We found that, in populations derived from adult rat vertebrae, the effects of the serum component of the culture medium on the number of bone nodules induced by Prog and on the dose-dependency of the Prog effect were striking: in culture media containing the most effective serum the number of bone nodules was 22-fold higher than that in the least effective serum. In addition, Prog responses were detectable at 10(-5) M only in some sera but were significant at 10(-7) M in others. The effect of Dex in the adult rat vertebrae-derived populations was much less dependent on the serum used: the number of bone nodules in culture media containing the most effective serum was only 1.3 times greater than that in media containing the least effective serum. In cell populations derived from fetal calvariae, the serum dependence of the Prog response was less pronounced: a 4.3-fold increase over control was observed in the most effective serum, and a 2.4-fold increase in the least effective serum. No effects of the serum component of the culture medium on the Dex response were detectable. Thus, Prog-induced bone nodule formation appears to be strongly dependent on the particular type of FBS used for osteoprogenitors present in bone cell populations derived from adult rat vertebrae but much less so in populations obtained from fetal rat calvariae. Preliminary experiments suggest that the estrogen content of the culture media may be one of the determinants regulating Prog responsiveness of the osteoprogenitors. Dex-induced proliferation and differentiation of osteoprogenitors in bone cell populations derived from both adult rat vertebrae and fetal rat calvariae, on the other hand, did not appear to be strongly dependent on factor(s) present in the FBS component of the culture medium.

Subcutaneous rheumatoid nodules occur commonly in advanced cases of rheumatoid arthritis and are the most common extra-articular lesion of this disease. We present a case of a very unusual giant rheumatoid nodule that developed on the lateral side of a knee. The case was devoid of systemic symptoms of arthritis and the lesion was limited to a rheumatoid nodule. The nodule was successfully treated by surgical excision. However, other new nodules developed in her hand. Her clinical course has not been satisfactory.

Among the elderly, hip fracture is the most common outcome of osteoporosis. The main aim of this study was to investigate the clinical characteristics, treatment, complications, long-term outcome and mortality of elderly hip fracture patients, aged 90 years and over. MATERIAL AND METHODS: We retrospectively analyzed 44 patients admitted between 1994 and 1998 with femoral neck or trochanteric fracture. The age of the patients ranged between 90 and 99 years and all 44 patients were surgically managed with one exception who died during the preoperative hospitalization. Hemiarthroplasty was most often used for medial (subcapital and transcervical) fractures. Internal fixation with either Ender nails or a compression hip-screw with a plate was used for lateral (per-, inter- and sub- trochanteric) fractures. RESULTS AND CONCLUSIONS: Most fractures (98%) were due to low energy trauma. Overall, mortality was 29.6% during the first year, being higher in patients with greater severity of pre-existing medical illness and in patients with difficulty in walking before the operation. In addition, if hemiarthroplasty was performed, the rate of death was higher. Rehabilitation was difficult if the patient had severe dementia or had difficulty in walking before the operation.

The purpose of this study is to clarify the usefullness of intraoperative spinal sonography (IOSS) for spinal diseases.Our IOSS procedure is as follows; 1) After laminectomy or laminoplaty, water is properly applied over the dura surface, 2) The probe used for IOSS is the 7.5MHz Toshiba probe, 3) Scanning of acurate sagittal and axial images.More information the spinal cord can be obtained using IOSS than MRI imaging in some cases. IOSS provides an excellent visualization of the spinal cord and anterior surface of the spinal canal. This method is therefore quite useful for monitoring the decompression of the spinal cord in cervical myelopathy and OPLL. We can also observe the position and extent of syrinx and evaluate the shunt, as well as observe the size of syrinx which changes with breathing in the case of syringomyelia. IOSS may play a significant role for solving the extending mechanism of syrinx.TOSS has thus been concluded as being extremely useful for reconfirming the decompression of the spinal cord during real-time operations. This method also allows evaluation of dynamic spinal cord motion in various kinds of spinal diseases.

Vitamin K2 has been approved for the treatment of osteoporosis in Japan since 1995. Vitamin K2 treatment in osteoporosis has been shown to inhibit the occurrence of new bone fractures and to maintain BMD. The uniqueness of the prevention of bone fractures by vitamin K2 is that there has been no direct evidence of the relationship between increase of BMD and a decrease in the occurrence of bone fractures. A recent systematic review of seven Japanese randomized controlled trials by Cockayne has also shown that supplementation with phytonadione (Vitamin K1) and menaquinone (Vitamin K2) , particularly menaquinone-4, is associated with increased BMD and reduced fracture incidence. To confirm these results, a larger well design RCT using fractures as the primary endpoint is clearly needed.

Progestins are commonly prescribed for hormone replacement therapy (HRT) and contraception. However, the effects of progestins on bone metabolism remain unclear and are often controversial.This study was conducted to test the hypothesis that progestins with no significant glucocorticoid activity may be a better choice for HRT to achieve increased beneficial effects on bone metabolism than progestins with strong glucocorticoid activity. A total of 104 postmenopausal women aged 50-75 years with osteoporosis were allocated randomly to three groups: (1) conjugated oestrogen plus medroxyprogesterone acetate (HRT-MPA, with significant glucocorticoid activity); (2) conjugated oestrogen plus norethisterone (HRT-NET, with no significant glucocorticoid activity); and (3) control (no treatment).Vertebral X-rays and bone mineral density (BMD) at distal 1/3 radius were assessed at baseline and every 6 months during the 2-year study period, along with markers of bone turnover. The occurrence of new nonvertebral fractures was identified by X-ray.After the 2-year treatment, mean BMD changes relative to baseline in the HRT-MPA, HRT-NET and control groups were 1.6%, 2.3% and -1.9%, respectively. In addition, the rate of increase in HRT-NET was significantly greater than that in HRT-MPA (P = 0.019). The incidence of new fractures during the 2-year treatment in the control group was 26% (9/34). HRT-NET treatment significantly inhibited the occurrence of new fractures (RR 0.14, 95% CI 0.02-0.93, P = 0.04), while HRT-MPA treatment failed to show a statistically significant reduction (RR 0.41, 95% CI 0.14-1.24, P = 0.11). Both HRT-MPA and HRT-NET treatments significantly decreased serum osteocalcin levels by 29.4% and 23.5%, respectively, after 6 months of treatment, with the decrease in HRT-MPA being significantly greater than that in HRT-NET (P = 0.042).These findings suggest that progestins with no significant glucocorticoid activity may be a better choice for HRT, resulting in increased beneficial effects on bone metabolism compared with progestins with strong glucocorticoid activity.

The human skeleton accumulates bone up to approximately age 30, after which bone is gradually lost. Although estrogen replacement therapy prevents postmenopausal bone loss, it is not certain that estrogen deficiency alone is responsible for the decrease in bone mass. Progesterone deficiency could also be a factor, and progesterone replacement therapy has been shown to prevent postmenopausal bone loss associated with ovarian dysfunction. This article reviews what is known about bone remodeling and bone loss as a function of age and gender, discusses evidence from studies in rats that progesterone plays an important role in regulating bone formation, and suggests directions for future studies in predicting the success or failure of implant therapy based on the number and kinds of osteoprogenitor cells present.

For refractory post-total knee arthroplasty infections, resection arthroplasty combined with muscle grafting has been conducted to control the infection while preserving the infected limb. Resection arthroplasty was conducted on 9 patients (10 knees) with post-total knee arthroplasty refractory infection. All infections were brought under control. Seven patients were pain free, and mild pain persisted in 2 after walking and during locomotion. The average range of knee motion was 67 degrees. The mean discrepancy in leg length was 5.2 cm. There was no recurrence of infection in any patient. The function of each knee was accepted. Resection arthroplasty combined with muscle transfer is an effective method if the individuals desire to preserve the affected limbs for religious or cosmetic reasons and wish to regain the ability to move their knees.

Juvenile rheumatoid arthritis (JRA) is a relatively uncommon condition. The damage to the cartilaginous tissue is often irreversible and responsible for much of the morbidity. Timely diagnosis and appropriate aggressive treatment of patients improve quality of life and outcome. A reported case of JRA is presented in which limping associated with flexion contraction of the knee developed without any systemic symptoms. Magnetic resonance imaging and arthroscopic examination were helpful with early diagnosis. Aspirin was effective. There have been no recurrence to date.

Recently, the incidence of osteoporosis and its related fracture are increasing as the aging of population has been progressing in most developed countries, becoming a serious medical and social problem. Among osteoporosis-related fractures, especially, hip fracture might have a marked influence on survival prognosis as well as a restriction of patient's daily activity and the bed-ridden status. Thus, clinical significance of hip fracture has been increasing, but particularly in the extreme elderly, it is difficult to manage patients in most cases because of the peculiarity due to their extreme old age. For example, hip fracture in the extreme elderly is characterized as follows: (1) It occurs easily with a slight external force. (2) It often associates various complications. (3) Its physical differences among individuals are considerably large. (4) Rehabilitation after surgery is difficult in many cases because of complicated dementia. and (5) It is difficult for the patients to live independently at home. This article reviews the literature on survival prognoses and functional results in the extreme elderly with hip fracture. The data from the literature indicate that in the extreme elderly, preoperative general condition, walking ability, type of fracture, and the type of surgery are likely to be the significant predictors of survival prognosis, whereas the degree of dementia seems to be the significant predictor of the recovery of walking ability.

We investigated the effects of the sex hormone progesterone (Prog) and the synthetic glucocorticoid dexamethasone (Dex) on proliferation and differentiation of progenitor cells of osteogenic, adipocytic, and hemopoietic lineages in cell populations derived from explants of adult female rat lumbar vertebrae. The cell populations were obtained by culturing bone explants in plasma clots immersed in α-minimum essential medium plus 10% fetal calf serum (standard medium) and then subculturing the outgrowth cells in standard medium plus 50 μg/ml of ascorbic acid, 5 mM β-glycerophosphate, and with or without Prog or Dex. On day 6 of culture, these populations were analyzed for cAMP responses to parathyroid hormone (PTH), prostaglandin E2 (PGE2), and isoproterenol (IPT). Increases in intracellular cAMP were seen in response to PTH, PGE2, and IPT, and culturing in medium containing Prog increased these responses. At various time periods between days 4–27 of culture, the cultures were evaluated for the presence of bone nodules, alkaline phosphatase (AP)-positive colonies, adipocytes, monocytes, and macrophages. Prog and Dex increased the number of bone nodules and AP-positive colonies. The effect of Prog on bone nodule formation was smaller than that of Dex. In addition, the effect of Dex on bone nodule formation was evident after 10 days of culture, while the Prog-induced effects became significant at days 16–20 of culture. Both hormones also increased the number of Sudan IV-positive colonies (adipocytes), certain types of α-naphthyl butyrate esterase (α-NBE)-positive colonies (monocytes, macrophages, and T-lymphocytes), and ED2-positive colonies (macrophages). Prog-treated cultures contained more colonies of small spindle-shaped α-NBE-positive cells and fewer colonies of small round α-NBE-positive cells when compared with Dex-treated cultures. These data indicate that cell populations derived from adult rat lumbar vertebrae contain, among others, osteoprogenitors and progenitors for adipocytes and macrophages that are stimulated to proliferate and differentiate by Prog and Dex. The data also suggest that the effects of Prog and Dex differ qualitatively and quantitatively. (J Bone Miner Res 1996;11:921–930)

In a study of the osteogenesis capability of the human posterior longitudinal ligament of the spine, ligament cells were isolated and cultured. The effect of bone-seeking hormones, such as parathyroid hormone (PTH), calcitonin (CT), prostaglandin E2 (PGE2), and 1,25-dihydroxycholecalciferol [1,25-(OH)2D3], on the ligament cells was investigated with respect to DNA synthesis, adenosine-3',5'-cyclic monophosphate (cAMP) levels, alkaline phosphatase (ALP) activity, and acid phosphatase (ACP) activity. Cell lines obtained from nonossified sites in patients with ossification of the posterior longitudinal ligament of the spine (OPLL) were found to have several different phenotypic characteristics for osteoblasts: high ALP activity, PTH- and PGE2-stimulated increases in cAMP, and responses to both CT and 1,25-(OH)2D3. It is clear that proliferation and differentiation in such ligament cells are controlled by various types of bone-seeking hormones, and it was suggested that many cells with osteoblast-like characteristics are present. These results are considered important with respect to the etiology of OPLL, and an experimental system using cultured ligament cells appears to be useful in research on OPLL.

We observed the formation of subwavelength periodic strained layers associated with nanovoids in the cross section of femtosecond laser-irradiated lines written inside 4H-SiC single crystals. Both conventional and high-voltage transmission electron microscopies were carried out for microstructural analyses. The cross section of the irradiated lines consists of four to six groups of fine periodic structures. Each group is composed of strained layers with a typical spacing of 150 or 300 nm. The layers extend along the irradiated lines, aligned parallel to the electric field of the laser light. Tiny voids approximately 20 nm in diameter are found in the layers.

Because of our interesting in the good hitocompatibility of Al2O3 filler, as a new imimplant material, we performed an experiment on rats and rabbits to determine what kind of clinical application could be made. These results were presented at the 3rd. Orthopaedic Ceramic Implants Meeting in 1983.In this paper, we will report on 8 clinical cases counducted using results from previous experiments as a base.(Case) Eight clinical cases include 3 cases of bone cyst, 2 cases of giant cell tumor, 2 cases of benign chondroblastoma and a case of osteomyelitis. Follow up period is from 6 months to 2 years 11 months, average 1 year 5 months.(Result) From results of our experiments, we found that a ratio of 1 to 1 mixture of Al2O3 filler and autobone produced the best results when implanted to the site of bone lesion. This was the method used in our clinical cases. Radiographically, implant lesions became homogenous at 2 months to 12 months after surgery, average 4 months. These cases have no recurrence and good clinical course.

The pathogenesis of OPLL is not well understood. We have been studying its morphological and radiographical features.We carried out histological investigations on 8 surgical materials and 1 autopsy case. They all were prepared for study with hematoxyline eosine, stain, and 2 of them with double tetracycline bone labeling were prepared with undecalcified ground section with Villanueva bone stain.Degenerative change of the ligament, increasing numbers of vessels and appearance of cartilage cells could be seen at upper, lower and vertebral or disc side of all types of OPLL, especially in the continuous type.Undecalcified section showed that osteoid could be seen much at the edge of OPLL except canal side. On fluoromicroscopic findings, tetracycline bone labels could be seen much at the same side where osteoid existed, but especially at disc lebel.Bone formation must be accelerated at the edge of OPLL.

Segmental instability often occurs at the level adjacent to intervertebral fusion after surgery. The cause is mainly due to disc degeneration at the level, however, the facet joint might play a role as one of the main structural components of a segmental motor segment.This report is to elucidate the relation between segmental instability and the facet joint. Angles of inclination of the facet joints are measured as a indicator for this study.The subjects are 26 cases with cervical spondylotic myelopathy who have had anterior interbody fusion in our clinic. There are 15 males and 11 females, and the average age is 50 years old. The average follow-up period after surgery is 6 years.Before surgery various angles of inclination of the facet joint were observed, but at the time of follow-up they tended to be nearly same showing decreased angles at the lower surface of the joint and increased angles at the upper surface, which produces so-called posterior widening of the joint space.This results suggest that facet inclination might be secondary reaction to segmental instability of the level.

Twent-three patients with progressive cervical spondylotic myelopathy were surgically treated and their post-operative courses were observed in detail during the time of their hospitalization. According to an evaluation of the post-operative results by questionaires, twenty cases (86.9%) improved within four weeks. While motor and sensory disturbance tended to improve within one week following surgery, tendon-reflexes remained still abnomal until about 8 weeks later. Moreover the results by means of anterior and posterior approaches are discussed.

We observed thoracic ligamentum flavums which had been surgically removed, by use of a scanning electron microscope and transmission electron microscope. They were from 8 cases of ossification of thoracic ligamentum flavums and 9 cases of spinal canal stenosis or spinal tumors with no other ossification in roentgenograms for the control. These specimens were further observed by Toluidine blue staining and Van Gieson staining. In the case of ossification of the thoracic ligamentum flavum, close to the site of ossification, various degenerative changes were observed such as wavy pattern of elastic fibres, increase of chollagen fibres, irregular patterns, and appearance of oval and rosen-shaped granular particles. Nearer the site of ossification, appearance of chondrocyte and calcification of marix were observed. At the site of ossification, Haversian systems with osteogenecity were observed. These findings could show that ossification of thoracic ligamentum flavum may be the result of a course of endochondral ossification. We discuss more about the course of ossification from the viewpoint of degeneration of ligaments.

The leg consisted of a tight skin envelope directly covering bone and musculotendinous structures. Soft tissue defects in this area were difficult to repair because of the poor blood supply to the skin and the limitations imposed in designing reliable flaps. Several kinds of new reconstructive procedures for coverage of the leg were introduced.11 patients were treated with different flap transfers for soft tissue defects of the leg, between 1980 and 1983 at the Yamaguchi University School of Medicine.There were 5 free flaps, 4 pedicle skin flaps and 2 muscle flaps. All patients were male and their ages ranged between 20 and 65 year-old. Types of the free flaps used included free latissimus dorsi (2), free groin flap (2), and free peroneal flap (1), The pedicle flaps consisted dorsalis pedis flap (1), peroneal flap (1), bipedicle gastrocnemius M-C flap (1) and cross leg fasciocutaneous flap (1). The muscle flaps used the peroneus longs, brevis and the abductor hallucis (1), and the gastrocnemius (1). All flaps survived and any sequelae of the skin and tibia bone did not occur.The authors emphasized the superiority of the free latissimus dorsi, free peroneal flap, pedicle peroneal flap and cross leg fasciocut aneous flap for coverage of soft tissue defect of the leg.