This study was performed in order to understand the reasons why the metastasis of malignancy into the disc is rare in contrast to the commonly seen vertebral metastasis. By histopathologic studies of 14 vertebral columns with vertebral metastases of various malignant tumors and 616 disc specimens, the authors found three pathways for an intravertebral tumor to invade into the adjacent disc: 1) direct infiltration from the rim of the vertebral body not covered by the cartilagenous plate, 2) infiltration from the side of the vertebral body close to the vertebral corner, through the subspace beneath the longitudinal ligament, and 3) hematogenous invasion via small vessels in the subspace beneath the longitudinal ligament. The authors concluded that the cartilagenous plate between the vertebral body and the disc as well as high intradiscal pressure would be acting as a barrier against tumor invasion from the vertebral body into the disc, and suggests that gradual increase of capillaries in the disc with age may enhance hematogenous invasion into the disc in rare occasions.
The clinical results of 26 digits (18 patients) lengthened by distraction callotasis were evaluated and the factors which influenced healing were analysed. There were 14 men and four women, with a mean age of 39 years. All digits had suffered traumatic amputation. There were eight thumbs and 18 fingers. The level of the site of the osteotomy was at the proximal metaphysis in ten, the middle diaphysis in 13 and the distal metaphysis in three. Although the proposed length was achieved in 23 of the 26 digits, five required additional bone grafts. The rate of healing was 96 days/cm in the digits without complications such as callus fracture or poor callus formation, and 158 days/cm in those with complications. Lengthening at the proximal metaphysis gave a better result than at the diaphysis or distal metaphysis.
The clinical results and complications of the vascularized fibular graft for the reconstruction of various long bone defects were reviewed in 60 cases. Bony reconstruction was achieved in 57 of the 60 cases; however, various postoperative complications occurred in 54 percent of the cases. One case of arterial thrombosis of an anastomosed vessel and nine cases of venous congestion of the monitoring flap occurred in the early postoperative periods. The authors managed the nine cases of venous congestion of the flap conservatively, and all flaps survived. Partial necrosis of the flap was noted in eight of these nine cases, but additional surgical intervention was required in only four cases. Treatment included a gastrocnemius musculocutaneous flap in one case and a full-thickness skin graft in three cases. The vascularized fibula survived and bony fusion was achieved in all of these cases. The one case of arterial thrombosis resulted in graft failure due to a delay in the decision to perform a thrombectomy. Graft fracture occurred in 13 cases as the mechanical stress to the graft increased. In two cases of femoral reconstruction, graft fracture occurred during dynamization of the graft, despite the use of an Ilizarov external fixator. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibular grafting offers the patient a great deal of benefit; however, this graft has a concomitant high risk of complications. Great attention to detail must be paid to prevent postoperative complications.
The results of extension block Kirschner wire fixation for the treatment of mallet fractures of the distal phalanx were retrospectively assessed in 65 consecutive patients. The indications for this technique were the presence of a large bone fragment, and palmar subluxation or the loss of joint congruity of the distal interphalangeal joint. Using the Wehbé and Scheider classification there were 27 type IB, 19 type IIB, 17 type IA, and 2 type IIA fractures. According to the Crawford rating system there were 46% excellent, 32% good, 20% fair and 2% poor results. We believe that this technique, when properly applied, produces satisfactory results.
Six hundred surgical cases of lumber intervertebral disc herniation were evaluated histologically for the presence of blood vessels. These patients ranged in age from 12 to 77 years. Blood vessels were observed in 57 of 101 cases of complete prolapse type of herniated disc (56.4%), 12 of 32 cases of incomplete prolepse type of herniated disc (37.5%), and 53 of 467 cases of protrusion type of intervertebral disc herniation (11.3%). The presence of blood vessels in intervertebral discs was also investigated in postmortem specimens. Blood vessels were observed in 293 of 616 intervertebral discs (T10-L5), in individuals older than 40 years of age from 100 postmortem spines. The specimen age range was 16–89 years. Most of the blood vessels seen in the extruded tissue, exposed to the epidural space in cases of complete and incomplete prolapse type of herniation, are thought to have been newly formed after herniation occurred, As Invasion of the intervertebral disc by blood vessels was found to occur with the advance of age, it is possible that such blood vessels become extruded with the intervertebral disc tissue. The intervertebral disc may herniate posterilorly in three basic patterns. The first pattern Is "protrusion type of herniated disc," in protrusion hernia type there is abnormal posterior bulging of the anulus fibrosus. The disc pathology is predominantly nucleus pulposus, and the peripheral layer of the aulus fibrosus remains attached to the vertebral body bony rim, however. In the second pattern, "incomplete prolapse type of herniated disc," the peripheral anulus fibrosus has become detached from a portion of the vertebral body rim, exposing disc tissue to the epidural space, This tissue is still in continuity with the disc, however. There are no free fragments of disc tissue, and as such, this is considered an incomplete prolapse type of hernlation. The third pattern is "complete prolase type of herniated disc," in which the peripheral anulus fibrosus has become detached from a portion of the posterior vertebral body rim, exposing disc tissue to the epidural space. In this pattern there is free disc tissue that is no longer in continuity with the disc. This is considered extruded tissue. Free specimens of extruded tissue, removed as independent pieces, are found during surgery for complete prolapse type of herniated disc. Frequently most of this tissue is composed of anulus fibrosus. Small blood vessels accompanied by loose fibrous tissue are sometimes observed in the marginal reglons of these free extruded pleces of anulus. The origin of these small blood vessels is unclear. It is possible that pre-existing blood vessels with in the intervertebral disc became extruded together with the herniated tissue, or that newly formed blood vessels after herniation occurred. But blood vessels are not usually observed in the intervertebral disc. If the origin of blood vessels was the intervertebral disc, then their presence with the extruded tissue would provide histologic evidence as to the origin of the herniation. Namely, there is an opinion that blood vessels in the extruded tissue of complete and incomplete prolapse type of herniations are thought to be characteristic of these patients of hernlations, but this study has mentioned that blood vessels could be seen in protrusion type of herniated disc also, and blood vessels in the extruded tissue in cases of prolapse type of hernlations are thought to have been extruded with the intervertebral disc tissue, to have newly formed after hernlation occurred. This study has investigated the significance of these small blood vessels.
Brachial plexus palsy at birth remains a serious problem. Although most cases resolve during the first few months by spontaneous regeneration, several operations have been used to correct the residual deformity. In the present study we describe the results of the latissimus dorsi and teres major tendons transfer on to the rotator cuff to improve shoulder function. Six patients were included in the study: three girls and three boys; four right shoulders, and two left. The types of palsy were four Erb's palsy (C5, C6) and two C5-C7 palsy. The median age at the time of operation was 11 years and 1 month and the median follow-up period was 54.2 months. Median preoperative passive external rotation was 51 degrees, and active abduction 67 degrees. Median postoperative active external rotation was 72 degrees, and postoperative active abduction 109 degrees. This procedure increased the ranges of external rotation and abduction, and provided considerable improvement in shoulder function.
From 1984 to 1999, the authors treated 64 cases of fracture of the scaphoid in children. Causes of injury were sports (n = 27), punching game machines or fighting (n = 22), and traffic accident or other trauma (n = 15). Most (46 cases) were nonunion cases. Eighteen cases were acute. Cast immobilization was performed in 10 acute cases and two nonunion cases. Screw fixation was performed in 52 cases, including 35 cases of bone graft. In 10 of these operated cases, freehand screw insertion was used. Ultimately, good bony fusion was achieved in all cases, but in two nonunion cases a secondary bone graft was necessary. Functional results in all cases were acceptable. A major problem is that children are not brought to clinics immediately after injury, so the percentage of nonunion is high.
