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1.  En-bloc resection of thoracic calcified meningioma with inner dural layer in recapping T-saw laminoplasty: a case report 
BMC Surgery  2015;15:82.
Background
In the treatment of spinal cord tumors, complete tumor resection with complete reconstruction of the spine represents the ideal goal. However, for the treatment of heavily calcified spinal meningioma, en-bloc resection of the tumor together with the involved dura at the tumor base through laminectomy is quite difficult. Conventional laminectomy is not wide enough to allow full exposure of such tumors, and postoperative dural defects can cause serious complications.
Case presentation
A 58-year-old Japanese woman presented with a 3-month history of progressive muscle weakness and numbness of the lower extremities. Magnetic resonance imaging (MRI) and computed tomography showed a calcified spinal cord tumor with dural tail sign at the T10-T11 level, severely compressing the spinal cord anterolaterally. The patient underwent en-bloc resection of the tumor with the inner layer of the dura and preservation of the outer layer of the dura through recapping T-saw laminoplasty of T10-T11, including bilateral facet joints. The tumor was histologically diagnosed as meningioma. Postoperatively, the patient achieved complete recovery of neurological functions. Bone union after laminoplasty was obtained within 6 months. Follow-up MRI at 5 years postoperatively demonstrated no recurrence of the tumor.
Conclusion
Resection of spinal meningioma with only the inner layer of dura can minimize postoperative complications, including spinal fluid leakage. Recapping T-saw laminoplasty provides extensive exposure for tumor removal. The combination of these techniques may offer an ideal surgical option for complete resection of spinal meningioma with complete preservation of the posterior spinal elements.
doi:10.1186/s12893-015-0066-5
PMCID: PMC4491201  PMID: 26141600
Bone union; Dural layer; Recapping laminoplasty; Spinal meningioma; T-saw
2.  Short-Term Results of Transforaminal Lumbar Interbody Fusion Using Pedicle Screw with Cortical Bone Trajectory Compared with Conventional Trajectory 
Asian Spine Journal  2015;9(3):440-448.
Study Design
Case-control study.
Purpose
To evaluate clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) performed with cortical bone trajectory (CBT) pedicle screw insertion with those of TLIF using 'conventional' or percutaneous pedicle screw insertion.
Overview of Literature
CBT is a new trajectory for pedicle screw insertion in the lumbar spine; clinical and radiological results of TLIF using pedicle screws inserted with CBT are unclear.
Methods
In total, 26 patients (11 males, 15 females) were enrolled in this retrospective study and divided into three groups: TLIF with pedicle screw insertion by conventional minimally invasive methods via the Wiltse approach (M-TLIF, n=10), TLIF with percutaneous pedicle screw insertion (P-TLIF, n=6), and TLIF with pedicle screw insertion with CBT (CBT-TLIF, n=10). Surgical results and preand postoperative radiological findings were evaluated and compared.
Results
Intraoperative blood loss was significantly less with CBT-TLIF (p=0.03) than with M-TLIF. Postoperative lordotic angles did not differ significantly among the three groups. Complete fusions were obtained in 10 of 12 levels (83%) with M-TLIF, in seven levels (100%) with P-TLIF, and in 10 of 11 levels (91%) with CBT-TLIF. On postoperative computed tomography, correct positioning was seen in 84.1% of M-TLIF screws, 88.5% of P-TLIF screws, and 90% of CBT-TLIF screws.
Conclusions
CBT-TLIF resulted in less blood loss and a shorter operative duration than M-TLIF or P-TLIF. Postoperative rates of bone union, maintenance of lordotic angles, and accuracy of pedicle screw positions were similar among the three groups.
doi:10.4184/asj.2015.9.3.440
PMCID: PMC4472594  PMID: 26097661
Transforaminal lumbar interbody fusion; Cortical bone trajectory; Conventional trajectory; Percutaneous insertion; Computed tomography
3.  Combined Effect of a Locking Plate and Teriparatide for Incomplete Atypical Femoral Fracture: Two Case Reports of Curved Femurs 
Case Reports in Orthopedics  2015;2015:213614.
In surgical treatment for atypical femoral fractures (AFFs), reconstruction nail fixation is recommended for both complete and incomplete fractures. Although it has been reported that AFF is affected by many factors, The ASBMR Task Force 2013 Revised Case Definition of AFFs states that a curved femur is often seen in Asian patients. It is sometimes difficult to insert a nail into a femur in incomplete AFF patients with severely curved femurs. We report two incomplete bisphosphonate-related AFF patients with marked femoral curvatures treated by locking plates and teriparatide, showing early bone unions and favorable long-term outcomes.
doi:10.1155/2015/213614
PMCID: PMC4460197  PMID: 26101679
4.  Vertebral osteomyelitis and epidural abscess caused by gas gangrene presenting with complete paraplegia: a case report 
Introduction
Gas gangrene is most often caused by Clostridium perfringens infection. Gas gangrene is a medical emergency that develops suddenly. The mortality rate is higher with trunk involvement than with involvement of the extremities, which carries a better prognosis. With respect to vertebral involvement, there are few reports in the literature. The purpose of this paper is to report a very rare case of vertebral osteomyelitis caused by gas gangrene.
Case presentation
A 78-year-old Japanese woman with diabetes mellitus was admitted to our hospital with the chief complaints of back pain, dysuria, and complete paralysis of both legs. A computed tomography scan showed soft tissue swelling anterolaterally at intervertebral disc level T11/12 and a gas-containing epidural abscess that compressed her spinal cord. Cultures later grew Clostridium perfringens and Escherichia coli. Hemilaminectomy was done from T10 to T12, and an epidural abscess was removed. She went on to have fusion surgery 6 weeks after the initial operation and subsequently experienced complete pain relief. She was discharged 2 months later, at which time she was able to walk with a cane. Examination 18 months after surgery showed normal gait without a cane.
Conclusions
Discitis caused by gas gangrene infection was successfully treated by immediate debridement and subsequent fusion surgery.
doi:10.1186/s13256-015-0567-y
PMCID: PMC4403783  PMID: 25888739
Clostridium perfringens; Debridement; Epidural abscess; Fusion surgery; Gas gangrene; Vertebral osteomyelitis
5.  Remote cerebellar hemorrhage following thoracic spinal surgery of an intradural extramedullary tumor: a case report 
Introduction
Remote cerebellar hemorrhage is a rare complication of spinal surgery. Although loss of cerebrospinal fluid seems to play an important role in the pathogenesis of this complication, the detailed mechanism of remote cerebellar hemorrhage after spinal surgery remains unclear. We report the case of a patient with remote cerebellar hemorrhage following thoracic spinal surgery of an intradural extramedullary tumor and discuss this entity with reference to the literature.
Case presentation
A 57-year-old Japanese woman presented to our hospital with back pain, dysuria, and numbness of both legs. A neurological examination was performed, and imaging was performed with ordinary radiography, magnetic resonance imaging, and computed tomography. Her magnetic resonance imaging scan showed an intradural extramedullary tumor at the T3 level. A tumor resection and T1-T5 pedicle screw fixation were performed. Twelve hours after spinal surgery, she complained of unexpected dizziness, nausea, and vomiting. A total of 850mL of serosanguineous fluid had been drained at that time, and drainage was stopped. An urgent brain computed tomography scan showed a cerebellar hemorrhage. She was treated conservatively, and was able to leave hospital six weeks after the initial operation, without any neurological deficits except for slight ataxia.
Conclusions
Remote cerebellar hemorrhage has to be suspected when unexpected neurological signs occur after spinal surgery. If an excessive amount of cerebrospinal fluid drains from the drainage tube after spinal surgery, drainage should be stopped.
doi:10.1186/s13256-015-0541-8
PMCID: PMC4378378  PMID: 25889850
Postoperative complication; Intradural extramedullary tumor; Remote cerebellar hemorrhage; Spinal surgery; Thoracic spine; Neurological signs
6.  Arthroscopic Quadriceps Tendon Repair: Two Case Reports 
Case Reports in Orthopedics  2015;2015:937581.
Recently, although some studies of open repair of the tendon of the quadriceps femoris have been published, there have been no reports in the literature on primary arthroscopic repair. In our present study, we present two cases of quadriceps tendon injury arthroscopically repaired with excellent results. Case 1 involved a 68-year-old man who was injured while shifting his weight to prevent a fall. MRI showed complete rupture at the insertion of the patella of the quadriceps tendon. The rupture was arthroscopically repaired using both suture anchor and pull-out suture fixation methods via bone tunnels (hereafter, pull-out fixation). Two years after surgery, retearing was not observed on MRI and both Japan Orthopedic Association (JOA) Knee and Lysholm scores had recovered to 100. Case 2 involved a 50-year-old man who was also injured when shifting his weight to prevent a fall. MRI showed incomplete superficial rupture at the insertion of the patella of the quadriceps tendon. The rupture was arthroscopically repaired using pull-out fixation of six strand sutures. One year after surgery, MRI revealed a healed tendon and his JOA and Lysholm scores were 95 and 100, respectively. Thus, arthroscopic repair may be a useful surgical method for repairing quadriceps tendon injury.
doi:10.1155/2015/937581
PMCID: PMC4359866  PMID: 25815224
9.  Japanese 2011 nationwide survey on complications from spine surgery 
Background
The Japanese Society for Spine Surgery and Related Research (JSSR) previously carried out two nationwide surveys in 1994 and 2001 on complications from spine and spinal cord surgery. More than 10 years have now elapsed since 2001. Rapidly ageing populations have major impacts on society, particularly in the medical field. The purpose of this study was therefore to examine the present situation for spine surgery in Japan.
Methods
The JSSR research team prepared a computerized questionnaire made up of two categories in order to capture clinicopathological information and surgical information. A recordable optical disc for data storage was sent to surgeons who were certified for spine surgery by JSSR. The data was analyzed.
Results
The JSSR carried out a nationwide survey of complications of 31,380 patients. Patients aged 60 years or older comprised 63.1 % of the overall cohort. This was considerably higher than observed in previous surveys. Degenerative spinal diseases increased 79.7 %. With regard to surgical approach, the incidence of anterior surgery has decreased, while that of posterior surgery has increased compared to the earlier surveys (both p < 0.05). Spinal instrumentation was applied in 30.2 % cases, compared to 27.0 and 34.0 % cases in the 1994 and 2001 surveys, respectively. Intraoperative and postoperative complications were reported in 10.4 % and were slightly increased compared to 8.6 % in the earlier surveys (both p < 0.05). Diseases associated with a high incidence of complication included intramedullary tumor (29.3 %) and primary malignant tumor (22.0 %). The highest incidence of complication was dural tear (2.1 %), followed by neurological complication (1.4 %).
doi:10.1007/s00776-014-0656-6
PMCID: PMC4302221  PMID: 25477013
10.  Comparison between Bilateral C2 Pedicle Screwing and Unilateral C2 Pedicle Screwing, Combined with Contralateral C2 Laminar Screwing, for Atlantoaxial Posterior Fixation 
Asian Spine Journal  2014;8(6):777-785.
Study Design
A retrospective study.
Purpose
To compare clinical and radiological outcomes between bilateral C2 pedicle screwing (C2PS) and unilateral C2PS, combined with contralateral C2 laminar screwing (LS), for posterior atlantoaxial fixation.
Overview of Literature
Posterior fixation with C1 lateral mass screwing (C1LMS) and C2PS (C1LMS-C2PS method) is an accepted procedure for rigid atlantoaxial stabilization. However, conventional bilateral C2PS is not always allowed in this method due to anatomical variations of C2 pedicles and/or asymmetry of the vertebral artery. Although unilateral C2PS plus contralateral LS (C2PS+LS) is an alternative in such cases, the efficacy of this procedure has not been evaluated in controlled studies (i.e., with bilateral C2PS as a control).
Methods
Clinical and radiological records of patients who underwent the C1LMS-C2PS method, using unilateral C2PS+LS (n=9), and those treated using conventional bilateral C2PS (n=10) were compared, with a minimum two years follow-up.
Results
Postoperative complications related to the unilateral C2PS+LS technique included one case of spontaneous spinous process fracture of C2. A C1 anterior arch fracture occurred after a fall in one patient, who underwent bilateral C2PS and C1 laminectomy. No significant differences were seen between the groups in reduction of neck pain after surgery or improvement of neurological status, as evaluated using the Japanese Orthopaedic Association score. A delayed union occurred in one patient each of the groups, with the final fusion rate being 100% in both groups.
Conclusions
Clinical and radiological outcomes of unilateral C2PS+LS were comparable with those of the bilateral C2PS fixation technique for the C1LMS-C2PS method.
doi:10.4184/asj.2014.8.6.777
PMCID: PMC4278983  PMID: 25558320
Cervical spine; Atlantoaxial instability; Laminar screw; Pedicle screw
11.  Comparison of activities of daily living after osteoporotic hip fracture surgery in patients admitted from home and from geriatric health service facilities 
With the population and proportion of the elderly increasing each year, difficulties with postoperative treatment outcomes after osteoporotic hip fracture are increasing. This study focused on activities of daily living (ADL) in patients who underwent surgery for hip fracture through an investigation of living arrangements, the presence of dementia, and other complications of aging. Information from 99 patients who lived either at home or in geriatric health service facilities was collected for this trial. Most patients were over 65 years of age and female, and about half of them had dementia. The postoperative ADL score (focusing on patients’ walking ability) was significant for those living at home than for those living in facilities. In addition, patients with dementia were divided into the following two categories: an early-rising group, comprising patients who were able to use a wheelchair within 48 hours of their operation; and a late-rising group, who did not start using a wheelchair until more than 48 hours after surgery. The ADL scores for the two groups were compared. Although the preoperative ADL scores were not significantly different between the two groups, postoperative ADL scores were significantly higher in the early-rising group than in the late-rising group, especially in patients who had undergone hemiarthroplasty. These data suggest that ADL in dementia patients following hip fracture depends on the surgical procedure performed and whether they are late or early risers after surgery.
doi:10.2147/CIA.S69244
PMCID: PMC4218892  PMID: 25378917
delirium; dementia; rehabilitation; elderly
12.  Syncope caused by congenital anomaly at the craniovertebral junction: a case report 
Introduction
Anomalies in the craniovertebral junction may be a rare cause of syncope. The mechanisms of syncope related to craniovertebral junction anomaly remain unknown.
We present an extremely rare case with anomaly in the craniovertebral junction and syncope, and discuss the mechanism of the syncope.
Case presentation
A 10-year-old Japanese boy with a congenital anomaly in the craniovertebral junction presented with recurrent syncope. A physical examination showed generalized hyperreflexia, but motor and sensory examinations were normal. Computed tomography and magnetic resonance imaging showed basilar invagination and spinal cord compression at his craniovertebral junction. Three-dimensional computed tomography angiography revealed an anomalous course of his bilateral vertebral arteries, both of which showed a persistent first intersegmental artery that entered the spinal canal at the caudal portion of the C1 posterior arch. In this case, the arteries were nearly pinched between the C1 posterior arch and the pars interarticularis of the C2. C1 laminectomy and occiput-cervical fusion (O-C2) was performed using an instrumentation system. After surgery, the syncope was not observed.
Conclusions
Syncope can be related to compression of extracranial arteries within the neck. In this case, transient brain ischemia caused by the anomalous course of vertebral arteries that were pinched between the C1 posterior arch and the pars interarticularis of C2 in cervical motion was the suspected cause of the syncope.
doi:10.1186/1752-1947-8-330
PMCID: PMC4196201  PMID: 25296768
Craniovertebral junction; Syncope; Vertebral artery
13.  Gossypiboma 19 years after laminectomy mimicking a malignant spinal tumour: a case report 
Introduction
Gossypiboma is rare and mostly asymptomatic in chronic cases. It can be confused with other soft tissue masses.
Case presentation
Our patient was an 87-year-old Japanese man with a history of surgery for a lumbar lesion causing lumbar canal stenosis 19 years earlier. Computed tomography showed a soft tissue mass with osteolysis and periosteal thickening of the vertebral lamina. On magnetic resonance imaging, the mass showed heterogeneous signal intensity on T2-weighted imaging, suggesting a malignancy. At the time of biopsy, small pieces of retained surgical sponge were collected. Surgical treatment was performed to excise the soft tissue tumour.
Conclusions
Gossypiboma should be included in the differential diagnosis of soft tissue masses in the paraspinal region in patients with a history of previous spinal surgery.
doi:10.1186/1752-1947-8-311
PMCID: PMC4177374  PMID: 25236490
Foreign body; Gossypiboma; Laminectomy; Malignant spinal tumour; Retained surgical sponge; Spinal surgery
14.  Successful treatment of nonunion with an Ilizarov ring fixator after ankle fracture for Charcot arthropathy: a case report 
BMC Research Notes  2014;7:503.
Background
Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial.
Case presentation
A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications.
Conclusion
In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires.
doi:10.1186/1756-0500-7-503
PMCID: PMC4127037  PMID: 25103697
Ilizarov ring fixator; Ankle fracture; Charcot arthropathy; Nonunion; Diabetes
15.  Pathological fracture of the femur in Alagille syndrome that was treated with low-intensity pulsed ultrasound stimulation and an Ilizarov ring fixator: a case report 
Background
Alagille syndrome is a multisystem disorder, which is characterized by hypoplasia of the intrahepatic bile ducts, malformations of the cardiovascular system, eyes, and vertebral column, and abnormal facies. Several of the characteristics of Alagille syndrome may result in an especially high risk of fracture. The majority of patients suffer from chronic cholestasis, which can have a variety of adverse effects on bone metabolism. In Alagille syndrome, fractures primarily occur in the lower limb long bones in the absence of significant trauma.
Case presentation
A 9-year-old Japanese girl with Alagille syndrome was admitted to our institution with marked hyperbilirubinemia and a pathological fracture of the femur. She had been diagnosed with biliary atresia at the age of 1 month and treated with surgical bile duct reconstruction, vitamins D and K, and ursodeoxycholic acid. However, her liver dysfunction and hyperbilirubinemia worsened. The pathological fracture of the femur was treated with low-intensity pulsed ultrasound stimulation (LIPUS) and an Ilizarov ring fixator. Seventy-four days after surgery, the patient had anatomically and functionally recovered. There was no leg-length discrepancy and no angular malalignment of the lower extremities as measured clinically and radiographically. The range of motion of the hip, knee, and ankle of the patient’s operative leg matched the range of motion in the nonoperative leg.
Conclusion
To the best of our knowledge, there are no reports on use of the Ilizarov frame and LIPUS in diaphyseal femoral fractures in Alagille syndrome. This case report provides evidence that this procedure is successful for managing such diaphyseal fractures in Alagille syndrome.
doi:10.1186/1471-2474-15-225
PMCID: PMC4109381  PMID: 25004954
Alagille syndrome; Low-intensity pulsed ultrasound stimulation (LIPUS); Ilizarov ring fixator
16.  The Relationship between Osteoporosis and Osteoarthritis of the Knee: A Report of 2 Cases with Suspected Osteonecrosis 
Case Reports in Orthopedics  2014;2014:514058.
Knee specimens of two osteoporotic patients who underwent unilateral knee arthroplasty for suspected osteonecrosis of the knee were examined histologically. Preoperative findings of magnetic resonance images in both patients were consistent with the diagnosis of osteonecrosis of the medial femoral condyles, although plain X-rays showed minimal degenerative changes. In both patients, preoperative bone mineral densities of the femoral condyle and proximal tibia of the affected side were lower than those of the unaffected side. Pathological examination of the resected femoral condyle and proximal tibia showed almost intact joint cartilage, healing of the collapsed subchondral bone, and significant trabecular bone loss. Histologically, no evidence of osteonecrosis, including empty lacunae of the trabecular bone, was observed. These findings indicated that subchondral bone collapse caused by osteoporosis, but not osteonecrosis, initiated the osteoarthritic change of the affected knee. This report emphasizes that there may be cases of progressive local osteoarthritis caused by fracture of subchondral bone because of osteoporosis.
doi:10.1155/2014/514058
PMCID: PMC4090430  PMID: 25045564
17.  Combined effect of teriparatide and low-intensity pulsed ultrasound for nonunion: a case report 
BMC Research Notes  2014;7:317.
Background
Low-intensity pulsed ultrasound is a pain-free therapy performed daily at home by the patient and has been shown to promote fracture healing. Teriparatide is a parathyroid hormone preparation that activates osteoblastic bone formation and is also reported to be effective in promoting bony union.
Case presentation
We report the case of a 56-year-old Japanese male with a femoral shaft fracture who underwent intramedullary osteosynthesis nailing initially. He had no radiologic or clinical sign of healing 3 months later and low-intensity pulsed ultrasound was initiated at that time. He was reassessed in another 3 months, with evidence of mild bone consolidation but the fracture gap persisted. Subsequent treatment with human parathyroid hormone was initiated in combination with low-intensity pulsed ultrasound. Full fracture healing was present 6 months after beginning the combination low-intensity pulsed ultrasound and teriparatide. It is hypothesized that the potential additive effects of low-intensity pulsed ultrasound and teriparatide therapy ultimately triggered sufficient bone formation to support osseous union.
Conclusion
The case reported herein is a femoral shaft atrophic nonunion in which traditional interventions failed. Successful fracture healing was finally achieved with low-intensity pulsed ultrasound and teriparatide therapy. This is the first reported case of diaphyseal nonunion with deterioration of bone quality in long bones resolved with teriparatide and low-intensity pulsed ultrasound.
doi:10.1186/1756-0500-7-317
PMCID: PMC4059730  PMID: 24886079
Teriparatide; Low-intensity pulsed ultrasound (LIPUS); Nonunion; Bone quality
18.  Congenital lumbar spinal stenosis with ossification of the ligamentum flavum in achondroplasia: a case report 
Introduction
Achondroplasia is a genetic disorder of bone growth. Congenital spinal stenosis is a well-known complication of this disease, but, to the best of our knowledge, no cases involving combined stenosis with congenital lumbar spinal stenosis and ossification of the ligamentum flavum in achondroplasia have been reported previously. In this report, we describe a case of a patient with congenital spinal stenosis with achondroplasia combined with ossification of the ligamentum flavum at the lumbar spine, which we treated with decompressive surgery.
Case presentation
A 75-year-old Japanese woman with achondroplasia was unable to walk due to a neurological deficit of the lower extremities caused by congenital spinal stenosis that resulted from achondroplasia and ossification of the ligamentum flavum at the lumbar spine. Congenital spinal stenosis was observed from L1 to L5, and ossification of the ligamentum flavum was identified from L1/2 to L3/4. A decompressive laminectomy from L1 to L5 and removal of the ossification of the ligamentum flavum were performed. The patient’s neurological symptoms improved after surgery. She could walk with T-cane at the time of her four-year follow-up examination.
Conclusion
In this report, we describe what is, to the best of our knowledge, the first known published case of ossification of the ligamentum flavum in congenital spinal stenosis associated with achondroplasia at the lumbar spine. Although resection of the ossification of the ligamentum flavum at the congenital spinal stenosis at the lumbar spine was technically difficult because of congenital narrowing of the spinal canal, thickening of the lamina and adhesion of the ossified ligamentum flavum, a wide laminectomy and resection of the ossification of the ligamentum flavum resulted in acceptable improvement of the patient’s neurological symptoms.
doi:10.1186/1752-1947-8-88
PMCID: PMC3973881  PMID: 24597928
Achondroplasia; Lumbar spinal stenosis; Ossification of the ligamentum flavum
19.  Anterior Hip Subluxation due to Lumbar Degenerative Kyphosis and Posterior Pelvic Tilt 
Case Reports in Orthopedics  2014;2014:806157.
Nontraumatic anterior subluxation and dislocation of the hip joint are extremely rare. A 58-year-old woman presented to our outpatient clinic with left hip pain with a duration of 15 years. There was no history of trauma or other diseases. Her hip pain usually occurred only on walking and not at rest. Physical examinations demonstrated no tenderness in the hip joint. The range of motion of both hip joints was almost normal. Laxity of other joints was not observed. The bone mineral density of the lumbar spine and proximal femur confirmed a diagnosis of osteoporosis. A plain radiograph showed osteoarthritic changes of the hip joints, severe posterior pelvic tilt, and superior displacement of both femoral heads, especially in a standing position. Three-dimensional computed tomography (3DCT) revealed anterior subluxation of both femoral heads. Seven years after the initial visit, both hip joints showed progression to severe osteoarthritis. Although the exact cause remains unclear, lumbar kyphosis, posterior pelvic tilt, and a decrease in acetabular coverage may have influenced the current case. We should be aware of these factors when we examine patients with hip osteoarthritis.
doi:10.1155/2014/806157
PMCID: PMC3926232  PMID: 24592346
20.  Surgical treatment and intraoperative spinal cord monitoring in scoliosis associated with chronic inflammatory demyelinating polyneuropathy: A case report 
Upsala Journal of Medical Sciences  2013;118(2):134-137.
There has been only one reported case of neuromuscular scoliosis following chronic inflammatory demyelinating polyneuropathy (CIDP). However, no cases of scoliosis that were treated with surgery secondary to CIDP have been previously described. A 16-year-old boy with CIDP was consultant due to the progression of scoliosis with the coronal curve of 86° from T8 to T12. Posterior correction and fusion with segmental pedicle screws were performed under intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials. Although the latency period was prolonged and amplitude was low, the potential remained stable. Coronal curve was corrected from 86° to 34° without neurological complications. We here describe scoliosis associated with CIDP, which was successfully treated with surgery under intraoperative spinal cord monitoring.
doi:10.3109/03009734.2012.757682
PMCID: PMC3633329  PMID: 23311940
Chronic inflammatory demyelinating polyneuropathy; intraoperative spinal cord monitoring; scoliosis; transcranial electric motor-evoked potentials
21.  Trigger Finger Appearing as Gradually Increasing Digital Nerve Disorder after Surgical Treatment 
Case Reports in Orthopedics  2013;2013:542965.
Trigger finger is a common disease, and operative treatments are often applied for it. Digital nerve injury is one of the complications of this surgical treatment, and paresthesia and sensory disturbance occur early after the operation. This paper presents a case of trigger finger appearing gradually as increasing digital nerve disorder after surgical treatment. In the second surgery, scar tissue covered the palmar MP joint where the A1 pulley had existed before, and palmar digital neurovascular tissue of the ulnar side was found on the inside of the scar. The ulnar digital nerve showed swelling like a neuroma, and bilateral digital nerves existed nearer to the center of the flexor pollicis longus tendon than normal digital nerves. Even when we operate on trigger finger by open release, we should create an appropriate surgical space for observation and be careful of digital nerve injury.
doi:10.1155/2013/542965
PMCID: PMC3619667  PMID: 23634312
22.  Posteriorly migrated thoracic disc herniation: a case report 
Introduction
Posterior epidural migration of thoracic disc herniation is extremely rare but may occur in the same manner as in the lumbar spine.
Case presentation
A 53-year-old Japanese man experienced sudden onset of incomplete paraplegia after lifting a heavy object. Magnetic resonance imaging revealed a posterior epidural mass compressing the spinal cord at the T9-T10 level. The patient underwent emergency surgery consisting of laminectomy at T9-T10 with right medial facetectomy, removal of the mass lesion, and posterior instrumented fusion. Histological examination of the mass lesion yielded findings consistent with sequestered disc material. His symptoms resolved, and he was able to resume walking without a cane 4 weeks after surgery.
Conclusions
Pre-operative diagnosis of posterior epidural migration of herniated thoracic disc based on magnetic resonance imaging alone may be overlooked, given the rarity of this pathology. However, this entity should be considered among the differential diagnoses for an enhancing posterior thoracic extradural mass.
doi:10.1186/1752-1947-7-41
PMCID: PMC3582544  PMID: 23402642
Intervertebral disc herniation; Posterior migration; Thoracic spine
23.  Symptomatic cervical disc herniation in teenagers: two case reports 
Introduction
The development of a symptomatic herniated cervical disc before the age of 20 is extremely rare. Sporadically reported cases of patients with cervical disc herniation under the age of 20 usually have had underlying disease.
Case presentation
Case 1: A 19-year-old Asian man visited our clinic and presented with progressive pain in his upper left scapula and weakness of the left deltoid and biceps brachii muscles. C5 radiculopathy by soft disc herniation at C4-C5 without calcification was diagnosed. Microsurgical posterior foraminotomy was performed and he recovered completely eight weeks after the surgery.
Case 2: A 15-year-old Asian man presented with difficulty in lifting his arm and neck pain on the right side. Neurological examination showed weakness of the right deltoid and biceps brachii muscles. A magnetic resonance imaging scan demonstrated a herniated intervertebral disc in the right C4-C5 foramen. The patient was treated conservatively and put under observation only, and had completely recovered eight weeks after admission.
Conclusion
Although extremely rare, symptomatic cervical disc herniations may occur even in the younger population under the age of 20 without any trauma or underlying disease. Favorable outcomes can be achieved by conventional treatments for cervical disc herniation.
doi:10.1186/1752-1947-7-42
PMCID: PMC3599747  PMID: 23402661
24.  Massive Deposition and Accumulation of Hydroxyapatite Crystal after Total Hip Arthroplasty: A Case Report 
Case Reports in Orthopedics  2013;2013:305180.
We presented a case in which massive hydroxyapatite accumulation was observed around the artificial hip joint. A 66-year-old female showed a massive accumulation of fluid in and around the hip joint, and milk-like aspirate was obtained. Her aspirate culture was negative, and sediment analysis by X-ray diffraction showed that its component was hydroxyapatite. Since pain was mild, the patient was treated conservatively. To our knowledge, this is the first case in which liquid hydroxyapatite (milk of calcium) was accumulated around the artificial hip joint.
doi:10.1155/2013/305180
PMCID: PMC3580907  PMID: 23476851
25.  Amelioration of pregnancy-associated osteoporosis after treatment with vitamin K2: a report of four patients 
Upsala Journal of Medical Sciences  2012;117(3):336-341.
We demonstrate for the first time therapeutic effects of vitamin K2 (menatetrenone) on pregnancy-associated osteoporosis with multiple vertebral fractures in four cases. Due to its safety, vitamin K2 presents itself as a treatment option for women with pregnancy-associated osteoporosis. Desirably, future controlled studies should verify these findings.
doi:10.3109/03009734.2012.676573
PMCID: PMC3410294  PMID: 22746299
Pregnancy-associated osteoporosis; vertebral fracture; vitamin K2

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