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There is a phenomenon in which the tendon appears to increase the length after rotator cuff repair. However, it is unclear in which cases tendon lengthening occurs and how the degree of lengthening affects the surgical outcome. This study aimed to evaluate pre- and postoperative musculotendinous junction (MTJ) and tendon length on magnetic resonance imaging (MRI) and assess the postoperative tendon lengthening and its impact on postoperative outcomes.We reviewed 109 patients with good repair integrity after arthroscopic rotator cuff repair. Patients whose supraspinatus tendons were simply pulled out laterally without any additional procedures were included. They underwent serial MRI before surgery and at 3, 6, and 24 months after surgery. The location of the MTJ in relation to the line of the glenoid fossa and the supraspinatus tendon length were measured. Clinical evaluation was conducted 2 years after surgery, including the range of shoulder motion, shoulder strength index (affected/unaffected strength), Constant score, University of California, Los Angeles (UCLA) score, and pain numeric rating scale (NRS). The characteristics of the preoperative tendon, change in tendon length over time, amount of the lateral shift of MTJ location and tendon length, and impact of tendon lengthening on postoperative clinical outcomes were analyzed.The preoperative tendon retraction significantly correlated with the MTJ location (r = -0.75; p0.0001) and preoperative tendon length (r = -0.46; p0.0001). Tendon length at 3, 6, and 24 months after surgery was significantly longer than those before surgery (26.7 ± 5.8 mm, 27.9 ± 6.6 mm, 28.5 ± 5.6 mm, and 21.5 ± 5.1 mm, respectively). From before surgery to 24 months after surgery, the MTJ location moved 8.4 ± 8.6 mm laterally and the tendon length increased 7.0 ± 6.1 mm. A significant and weak negative correlation was found between tendon lengthening and the abduction strength index (r = -0.22; p = 0.03); however, no significant correlation with pain, range of shoulder motion, external rotation strength index, Constant score, and UCLA score was found. Multiple linear regression analysis also showed that tendon lengthening was only associated with the abduction strength index (standardized coefficient = -0.20, p = 0.03).Tendon lengthening and lateral shift of MTJ location were observed after arthroscopic rotator cuff repair, and they correlated with preoperative tendon retraction. Although the amount of tendon lengthening had negative weak correlation with abduction strength index, it did not affect other postoperative outcomes.

The characteristics of foot structure in adolescents and adults are different, affecting sports performance and leading to the progression of foot and lower extremity disorders.This study aimed to investigate the relationship between the intrinsic foot muscles (IFM) and plantar fascia morphology and the repetitive rebound jumping and jump landing ability in adolescent athletes.A total of 60 adolescent athletes (35 boys and 25 girls) participated in this study. B-mode ultrasonography was used to obtain images of the IFM and plantar fascia morphology [thickness and cross-sectional area (CSA) of the abductor hallucis (AbH), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and thickness of the plantar fascia]. The repetitive rebound jump performance was evaluated using the Optojump™ system. Participants were instructed to jump five times continuously with one leg, jumping as high as possible with minimal ground contact time. The jump landing was assessed by measuring the dynamic posture stability index (DPSI) using forward one-legged jump landings.The thickness and CSA of the AbH and FDB were positively correlated with the jump height and reactive jump index. The DPSI score was significantly correlated with the thickness of the AbH, but not with other IFMs or plantar fascia. In the multiple regression analysis, only the thickness of the FDB was associated with the jump height and reactive jump index, indicating that FDB thickness might facilitate adolescent athletes to jump higher with minimal contact time in repetitive rebounding movements.The IFM (especially FDB) should be focused on when examining sports performance in adolescent athletes.

Background Arthroscopic Bankart repair (ABR) yields good results in young athletes with anterior shoulder instability. However, the treatment for overhead athletes is challenging because recovery of range of motion is necessary for return to play and repeated shoulder motion may lead to recurrent instability. The aim of this study was to investigate the clinical outcomes and return to sports after ABR on the dominant shoulder in overhead athletes. Methods This study included 24 competitive level overhead athletes who underwent ABR on their dominant shoulders. The mean age at surgery was 17.6 years, and the mean follow-up was 39.7 months. The range of bilateral shoulder motion, the Rowe score, the Japanese Shoulder Society Shoulder Instability Score (JSS-SIS), and the Japanese Shoulder Society Shoulder Sports Score (JSS-SSS) were evaluated before the surgery and at the final visit. Recurrent instability, the final level of return to sports, and the duration before returning to sports were confirmed, as well as the pre-, intra- and postoperative factors, which prohibited complete return to play. Results There were no cases of recurrent instability. The Rowe score, JSS-SIS, JSS-SSS, and the range of flexion, abduction, internal rotation significantly improved postoperatively. Fifteen athletes (62.5%) returned to the same or superior levels without any complaint in their shoulders. The mean duration needed for a complete return was 13.3 months. The postoperative external rotation deficit in abduction was larger in the athletes who returned incompletely than those who returned completely, 7.8° and 2.3°, respectively. Conclusions ABR is a reliable surgery for preventing recurrent instability in overhead athletes, however the rate of a complete return to preinjury level was low and a long duration was needed for complete return to play. The postoperative external rotation may be necessary for a complete return to overhead sports. Level of evidence Level IV: Retrospective Case Series.

Surgical planning of posterior referencing total knee arthroplasty (TKA) using computed tomography (CT) might lead to over-rotation of the femoral component because CT could not detect cartilage thickness of the posterior femoral condyle. The purpose of this study was to examine the rotational alignment difference of the femoral component between magnetic resonance imaging (MRI) and CT.For elderly varus osteoarthritic patients, 66 varus osteoarthritic knee patients that underwent primary TKA were selected. Twenty-seven young patients who underwent primary anterior cruciate ligament reconstruction were selected as control. After the transepicondylar axis (CEA), the surgical epicondylar axis (SEA) and the posterior femoral condylar line (PCL) were drawn on CT and on MRI at the same angles as CT. Then, the practical PCL was drawn on MRI considering the cartilage thickness (the cartilage PCL). The angle between the SEA and the cartilage PCL (the cartilage posterior condylar angle (PCA)) was measured as preoperative planning. To investigate the accuracy of preoperative MRI measurement, the cartilage thickness on posterior femoral condyles was directly measured during TKA.The cartilage PCA for varus osteoarthritic patients averaged 1.3 ± 1.3°. The cartilage PCA was 1.8 ± 1.0° significantly smaller than the bone PCA (the PCA measured on CT). Meanwhile, the cartilage PCA was 0.2 ± 0.4° significantly larger than the bone PCA in young people. The preoperative angle measurement on MRI strongly correlated with the direct measurement of cartilage thickness during TKA.There was 1.8° of divergence between MRI and CT in varus osteoarthritic patients due to cartilage degeneration of the medial femoral condyle. Cartilage assessment using MRI was useful for femoral component rotational alignment.

The subtalar joint has a possible compensatory mechanism for supramalleolar deformities; the failure of this mechanism causes the progression of ankle osteoarthritis. However, the reason for this failure has not been fully elucidated. This study aimed to evaluate the characteristics of the morphologic changes in the subtalar joint in varus ankle osteoarthritis using computed tomography. The study included 30 patients with severe osteoarthritis (modified Kellgren-Lawrence classification grade ≥ 3; mean age: 68.5 years) and 30 patients without- or with early osteoarthritis (grade 0-1; mean age: 43.0 years) as the control group. The location of cysts, osteophyte formation in the subtalar joint, and thickness of the subchondral bone plate were evaluated. In the osteoarthritis group, cyst formation was observed on the posterolateral side of the posterior facet of the calcaneus in 6 cases (20%) and of the talus in 7 cases (23.3%). Osteophyte formation was observed in the talus in 21 cases (70.0%) and in the calcaneus in 29 cases (96.6%). Osteophyte formation was observed on the posterior or lateral side of the posterior facet, and osteophyte contact between the talus and calcaneus was observed. The subchondral bone plate of the posterior medial side of the posterior facet of the talus was significantly thicker in the osteoarthritis group. The subtalar joint is less affected in severe varus ankle osteoarthritis containing a thickened subchondral bone plate in the posteromedial aspect of the posterior talar facet.

Background: Magnetic resonance imaging (MRI) is widely used to diagnose subscapularis tendon tears; however, it is difficult to assess the anterosuperior aspect of these tears. Radial-sequence MRI can reveal the fiber components of the anterosuperior aspect, from perpendicular, by overcoming the partial volume effect. We aimed to classify the insertion of subscapularis tendon tears on radial-sequence MRI and determine the effectiveness of radial-sequence MRI for subscapularis tendon tear assessments. Methods: We retrospectively investigated 196 patients (mean age, 66.7 ± 9.0 years; 118 men, 78 women) who underwent 1.5 T MRI before arthroscopic rotator cuff repair. Radial-sequence MRI findings of the anterosuperior aspect insertion of the subscapularis tendon were classified into five grades, and intraoperative findings compared with preoperative conventional MRI and radial-sequence MRI. We calculated sensitivity, specificity, accuracy, and positive and negative predictive values. Interobserver and intraobserver reliability for radial-sequence MRI classification was calculated using kappa (κ). Results: Conventional MRI sensitivity of subscapularis tendon tears was 45.3%; specificity, 95.8%; accuracy, 82.1%; positive predictive value, 80.0%; and negative predictive value, 82.5%. Radial-sequence MRI sensitivity was 92.5%; specificity, 88.1%; accuracy, 89.3%; positive predictive value, 74.2%; and negative predictive value, 96.9%. Sensitivity (P

Background Vascular disorders in throwing athletes can occur from the thoracic outlet to the fingertips. The occurrence of these disorders around the shoulder is well known, and treatment options have been established for them. However, the occurrence of vascular pathology in the digital arteries in elite baseball pitchers is unclear, and treatment options have not yet been established. We hypothesized that asymptomatic professional baseball pitchers often have existing pathological changes in their digital blood flow; therefore, we quantitatively measured the blood flow in the index finger using ultrasonography and compared the results to those of non-baseball players. Methods Seven asymptomatic professional baseball pitchers (pitcher group) and 11 healthy volunteers (control group) were included. The flow velocity, flow volume and vessel resistance index of the ulnar digital artery of the index finger were measured just distal to the proximal interphalangeal joint using pulsed wave Doppler in two positions: 1) with the proximal interphalangeal (PIP) joint relaxed (10–15° flexed) and 2) with the PIP joint passively extended (0–5°). Results The mean flow velocity and flow volume were lower in the extended position than in the relaxed position in both groups. In the dominant hand, which was the throwing hand in the pitcher group, the mean flow velocity and the flow volume in the relaxed position were significantly lower in the pitcher group than in the control group. The vessel resistance index in the relaxed position of the dominant hand was significantly higher in the pitcher group than in the control group. In the nondominant hand, there was no significant difference in any parameter between the two groups. Conclusions Asymptomatic professional baseball pitchers may have a pathological change in digital blood flow in the throwing hand. As treatment options for this condition have not yet been established, it is of utmost importance to carry out periodic examination and prevention before the condition progresses to the symptomatic end stage.

Motion analysis can be used to evaluate functional recovery after anterior cruciate ligament (ACL) reconstruction; however, the biomechanics parameters of the lower limb that are specifically altered in ACL-reconstructed knees compared to the contralateral side are not well understood. This retrospective study aimed to compare side-to-side differences in lower limb biomechanics during the first 100 milliseconds (ms) after initial contact in a single-leg forward landing task.Using three-dimensional motion analysis, lower joint kinematic and kinetic variables were measured 8-10 months postoperatively in 22 patients who had undergone ACL reconstruction. We determined side-to-side differences in lower limb biomechanics over the 100-ms timeframe after landing, and receiver operating characteristic (ROC) curve analyses were performed to calculate the area under the curve (AUC) for parameters showing significant side-to-side differences.During the 100-ms timeframe after landing, 58 kinematic and kinetic items showed significant side-to-side differences. Side-to-side differences in lower limb biomechanics over the 40-ms timeframe after landing existed. The ROC curve analysis identified 11 items with AUC values ≥ 0.70, including hip flexion, abduction moment, and knee joint power, and their AUC values were not significantly different.Hip flexion/abduction moment and knee power after GRF max could be used as outcomes for assessing functional recovery in patients who have undergone ACL reconstruction.

Background Right- and left-side throwers in baseball may have different shoulder conditions and throwing biomechanics. This study aimed to compare the passive range of motion, humeral torsion, and clinical findings between right- and left-handed throwers who sustained throwing shoulder injuries and confirm the differences in the characteristics between throwing sides. Methods A total of 52 pitchers diagnosed with throwing shoulder injuries were included in this study: 27 patients were right-side throwers (R group), and 25 were left-side throwers (L group). We measured the bilateral passive external and internal rotation angles in abduction position (ABIR) and total arc at their first visit. To assess posterior shoulder tightness, the internal rotation angles in forward flexion (FIR), and the abduction angle (AA) and horizontal flexion angle (HFA) without scapula motion were measured. The bilateral humeral torsion angles were also measured using ultrasonography. These values were compared between the participants' throwing and non-throwing sides and between the R and L groups' throwing sides. Furthermore, several physical findings in the shoulders were assessed, and the positive ratio was compared between the R and L groups. Results On comparing the throwing and non-throwing sides, the R group had significantly greater external rotation angles in the abduction position and humeral torsion angle, and smaller ABIR, total arc, FIR, AA, and HFA in the throwing side, while the L group showed no significant differences, except for a smaller ABIR and larger HFA in the throwing side. On comparing the throwing side between the R and L groups, the R group had a smaller FIR, AA, and FHA than the L group. Regarding the physical findings, the posterior jerk test, Kim test, anterior and posterior drawer sign, sulcus sign, and scapular winging in the L group were significantly more positive than in the R group. Conclusion The range of motion and humeral torsions differed between the left- and right-side throwers, as did the pathology between their throwing sides. Clinicians should consider the possibility that the pathological condition differs between left- and right-side throwers.

Medial malleolar osteotomy has been widely performed for posteromedial osteochondral lesions of the talus (OLT) to expose the lesion. In osteochondral fragment fixation, bioabsorbable pins should be inserted as perpendicular as possible to obtain the rigid fixation. However, the exposure of the lesion may depend on the osteotomy angle, which affects the pin insertion angles. This study aimed to analyze the relationship between pin insertion and osteotomy angles in the medial malleolar osteotomy.Twenty-four ankles of 23 patients were included. The malleolar bisector angle which was calculated from radiographs and actual osteotomy angles were measured on radiographs, and the pin insertion and osteotomy angles were measured using MRI. The intersection angle was defined by the tangential line of the tibial plafond and medial malleolar articular facet, and the bisector of this angle was defined as the malleolar bisector angle. The relationship between pin insertion and osteotomy angles was analyzed.There was no significant difference between the actual osteotomy (55.7° ± 6.6°) and malleolar bisector angles (57.4° ± 4.3°) on the radiograph. There was a significant correlation between pin insertion and osteotomy angles (rs = 0.601). The pin insertion angle (54.3° ± 5.9°) in the lower actual osteotomy angle than the malleolar bisector angle was smaller than those in the higher actual osteotomy angle (63.4° ± 8.2°).This study showed the osteotomy angle affected pin insertion angle. The osteotomy angle should not be smaller than the malleolar bisector angle at medial malleolar osteotomy to insert pins as perpendicular as possible for fixation of posteromedial OLTs.

During anterior cruciate ligament (ACL) reconstruction, even when a posterior wall of the femoral bone tunnel is identified, computed tomography (CT) occasionally demonstrates a breach of the posterior femoral cortex of the femoral bone tunnel, i.e., posterior wall blowout, after ACL reconstruction (posterior wall blowout-like phenomenon). This study aimed to investigate the influence of the posterior wall blowout-like phenomenon on clinical outcomes after ACL reconstruction using hamstring tendon.A total of 105 patients who underwent CT examination two weeks after ACL reconstruction were enrolled. A cortical suspension device was used for femoral side fixation in all cases. Posterior wall was identified in all cases during the surgery. The side-to-side difference in anterior knee laxity, pivot shift test, Lysholm knee score, the International Knee Documentation Committee (IKDC) subjective form, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were evaluated one year after the surgery. A second CT examination was performed 6-12 months after the surgery, if a posterior wall blowout-like phenomenon was identified in the first CT examination.Two weeks after the surgery, 16 of the 105 patients showed a posterior wall blowout-like phenomenon. Twelve of the 16 cases demonstrated a regenerated posterior femoral cortex of the femoral bone tunnel on their second CT images. There were no significant differences between the posterior wall blowout-like phenomenon group and the normal posterior wall group in terms of a side-to-side difference in anterior knee laxity (0.4 ± 1.5 mm and 0.1 ± 1.6 mm, respectively), pivot shift test, Lysholm knee score, IKDC score, and KOOS at one year after surgery. The length and diameter of the femoral bone tunnel were not significantly different between the two groups.Posterior wall blowout-like phenomenon after ACL reconstruction using a cortical suspension device did not negatively influence clinical outcomes.III - retrospective comparative clinical study.

Background Lateral ankle ligament repair for chronic lateral ankle instability is common, and arthroscopic repair of the anterior talofibular ligament (ATFL) has been widely performed. However, it is desirable to repair of calcaneofibular ligament (CFL) combined with arthroscopic ATFL repair to obtain good long term clinical outcomes. Repairing CFL through small skin incision, there is the possibility to interfere with ATFL and CFL anchors because of close attachment of ATFL and CFL at fibula. The purpose of this study is to determine the safety anchor insertion angles for ATFL and CFL on CT images and to achieve ATFL and CFL repair with minimally invasive technique. Methods Fifty ankles in 50 patients were included in this study. On a sagittal CT image, the anchor drill hole angles for ATFL and CFL were measured to avoid interference with these anchors. Then, arthroscopic ATFL repair combined with CFL repair was performed on 15 patients according to the safety insertion angles obtained by CT. CFL repair was performed through 1.5 cm length of accessory anterolateral portal. Clinical outcome was evaluated using the Japanese Society for the Surgery of the Foot (JSSF) ankle hindfoot scale and the Karlsson score before surgery and at final follow-up. Results On the CT image, the mean angles between the ATFL drill hole and anterior border of the fibula was 59.4 ± 6.5°, and those between the longitudinal axis of the fibula and ATFL drill hole, and the CFL drill hole were 34.6 ± 5.0°, and 15.1 ± 5.7°, respectively. Postoperative CT after arthroscopic ATFL repair combined with CFL repair showed that no interference with 2 anchors, and JSSF scale and the Karlsson score were significantly improved from preoperative to final follow-up. Conclusions This study showed how safety ATFL and CFL anchor insertion angles comprise a minimally invasive anatomical repair technique.

Arthroscopic ankle arthrodesis (AAA) has advantages of being less invasive and achieving a high bone union rate. However, there are still some nonunion or delayed union cases, especially those of high-grade deformity. During AAA, curettage of the subchondral bone using an abrader burr provides bone debris, and there is the possibility of bone debris being used as autograft to improve bone union. The purpose of this study is to analyze bone debris histologically, and the effect of its implantation on bone union of AAA. Bone debris from 6 patients was collected during AAA. Bone debris/atelocollagen composite was made and cultured for 4 weeks. Histological analyses were performed before and after culture. Twenty-six patients with AAA were divided into 2 groups with or without bone debris implantation, and the time to union after surgery was evaluated. In histological analysis of bone debris/atelocollagen composite, bone debris contained bone, cartilage and synovium fragment at time 0. After 4 weeks of culture, osteocalcin positive cells migrated and proliferated in the gel. Ki67 positive cells significantly increased after culture. In clinical cases, time to union was significantly shorter in the bone debris group (9.3 ± 1.3 weeks) than that in the control (12.4 ± 3.1 weeks). This study showed that bone debris contained the osteochonductive and osteoinductive properties, and there is the potential for its implantation into the ankle joint to improve bone union in ankle arthrodesis.

Recent reports have described midterm natural courses of osteochondral lesion of the talus (OLT) and lack of progression of ankle osteoarthritis (OA) in adult patients. The relationship between the OLT managed with nonoperative treatment and development of OA in children remains unknown. We report the long-term course of medial OLT in a 12-year-old female who was treated nonoperatively for 10 years. Radiographically, no osteoarthritic changes were observed at the first examination. She initially returned to her basketball club after nonoperative treatment. Although daily activities were not restricted, limitation of recreational activities began to appear at 4 years of follow-up. Subsequently, plain radiographs revealed bone absorption around the osteochondral fragment and osteophyte formation at the medial gutter, then ankle OA was advanced at the final follow-up.

Femoral offset and anteversion have been reported to affect the incidence of dislocation following bipolar hemiarthroplasty, although the magnitudes of contributions of the femoral offset and stem anteversion on dislocation, both singly and in combination is not fully understood.Using the CT data of 61 patients (61 hips), including 30 male and 31 female who underwent bipolar hemiarthroplasty, three-dimensional dynamic motion analysis was performed using a modular implant that enabled adjustment of femoral offset and stem anteversion independently. The pattern of impingement and relationship between femoral offset/stem anteversion and range of motion were evaluated using the software.We found that a higher femoral offset and stem anteversion correlate with a greater range of motion of flexion and internal rotation. Furthermore, an increased femoral offset has a great effect on increasing range of motion of flexion than stem anteversion, and increased both femoral offset and stem anteversion have fewer effect on the flexion, whereas increasing stem anteversion has a great impact on internal rotation than offset, especially in the case with lower femoral anteversion. However, a higher stem anteversion decrease the range of motion of external rotation, whereas a higher femoral offset leads to an increased range of motion of external rotation.We demonstrated that both a higher femoral offset and stem anteversion substantially affected the range of motion in flexion, internal rotation and external rotation. However, these are not independent, but rather mutually confounding, the surgeons should consider retaining femoral/anterior offset in bipolar hemiarthroplasty.

Background Percutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. Methods We retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport. Results There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15–43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED. Conclusions PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports.

Background Joint-preserving procedures should be considered as much as possible for hip disorders in pediatric and young patients. However, in patients with extensive osteonecrosis (ON) of the femoral head combined with severe collapse and advanced secondary osteoarthritis (OA), the optimal procedure has not been elucidated. This retrospective study aimed to investigate the postoperative outcomes of 11 patients who underwent transtrochanteric rotational osteotomy (TRO) alone or with a combination treatment for various hip disorders in young patients and to evaluate the usefulness of TRO. Methods Eleven patients (11 hips) with a mean age at operation of 22 years were included. The mean follow-up duration was 9.4 years. Preoperative diagnosis was secondary OA in 6 patients (pigmented villonodular synovitis, 2; after rotational acetabular osteotomy, 1; pyogenic arthritis, 1; femoroacetabular impingement, 1; acetabular dysplasia, 1) and ON in 5 patients (slipped capital femoral epiphysis, 4; femoral neck fracture, 1). Combination treatment was performed in 2 patients with distraction arthroplasty and in 6 patients with intra-articular procedures (mosaicplasty, 1; drilling, 1; microfracture, 4; cam resection, 1). Clinical evaluation was performed by using the Merle d’Aubigne and Postel score (MDPS). Joint congruency and progression of osteoarthritic change in all cases, and progression of collapse in the ON patients were evaluated radiographically. Results The mean MDPS improved from 10.3 to 14.2 in the OA patients and from 9.4 to 14.8 in the ON patients. The OA grade was maintained or improved in 10 hips (91%). Progressive collapse was prevented in all ON patients, and good remodeling was demonstrated. Conclusion Even in the highly degenerative cases, TRO enabled repair and prevention of the progression of OA. This procedure might be a useful salvage operation for treating secondary OA and ON of the hip even if the clinical condition is advanced, especially in young patients.

Background We performed arthroscopic rotator cuff repair (ARCR) combined with miniopen supraspinatus and infraspinatus muscle advancement for massive rotator cuff tears (RCTs) to decrease tension at the repair site with the goal of reduction of the failure rate. We evaluated the clinical outcomes and failure rate after this procedure. Methods This study included 47 patients diagnosed with chronic massive RCTs between October 2010 and March 2015. Of these patients, 21 underwent transosseous equivalent (TOE) ARCR only (control group), and 26 underwent TOE ARCR with muscle advancement (study group). We evaluated shoulder clinical outcomes at preoperative and postoperative assessments and also measured muscle strength and the acromiohumeral interval (AHI) at the same time in both groups. Failure rates were calculated in both groups by evaluating the cuff integrity with postoperative magnetic resonance imaging. Results Although there was statistically significant improvement for the mean clinical scores in the both groups, there were no significant differences between the 2 groups. The postoperative abduction muscle strength and AHI were significantly higher in the study group (46.3 ± 20.6 N and 9.4 ± 2.9 mm; P = .04) than in the control group (34.6 ± 20.0 N and 7.7 ± 3.0 mm; P = .04). The failure rates were significantly lower in the study group than in the control group (23.1% and 52.4%; P = .03). Conclusion The TOE ARCR with muscle advancement can achieve significantly better abduction muscle strength, wider AHI, and lower failure rates for massive RCTs than the normal TOE ARCR.

Arthroscopic repair of the lateral ankle ligament using the anchor system has been increasingly reported. We treated a 39-year-old woman who suffered from pain and instability in her left ankle joint. She was diagnosed with chronic ankle instability and an osteochondral lesion of the talar dome. For this patient, arthroscopic repair of the anterior talofibular ligament (ATFL) was performed. Standard anteromedial and anterolateral portals were placed, and excision of the osteochondral fragment and microfracture were performed. Then, an accessory anterolateral (AAL) portal was placed. No. 2 nylon sutures were inserted into the ATFL remnant through the AAL portal. Two bone tunnels were created at the footprint of the fibula attachment toward the posterior edge of the lateral malleolus using a passing pin, and nylon sutures anchored in the ATFL were retrieved toward the posterior fibula. The foot was held in neutral position with eversion, and nylon sutures were tied at the posterior fibula. At 1 year after surgery, the Japanese Society for Surgery of the Foot scale was improved from the preoperative value of 48 points to a postoperative value of 100 points. Stress radiography showed no difference of talar tilt angle between the involved and noninvolved ankles. Joint position sense was also improved at 3 and 6 months after surgery. This arthroscopic repair of the ATFL using the pull-out technique enabled achievement of an improved clinical score and stability of the ankle and proprioception, and there was no concern about complications of the anchor system.

Background Dynamic external fixation is a useful treatment option for unstable fracture-dislocations of the proximal interphalangeal (PIP) joint, because it simultaneously reduces axial pressure load on the joint surface, maintains congruent joint reduction, and permits early joint motion. However, most current devices are large, hindering finger movement, and unstable. To address these problems, we developed a dynamic external finger fixator, named the Micro Ortho Fixator®. The purpose of this study was to review the results of using the new external finger fixator to treat unstable fracture-dislocations of the PIP joint. Materials and methods Nine patients who sustained unstable fracture-dislocation injuries of the PIP joint were treated with the Micro Ortho Fixator®. Seven fractures were accompanied by depressed bony fragments at the base of the middle phalanx. All patients were evaluated for pain and range of PIP motion at the final follow-up. Radiographs of the affected fingers were evaluated for PIP congruity and reduction. The mean follow-up duration was 11.1 months (range: 6–33 months). Results At the final follow-up, pain averaged 0.3 (range: 0–2) on the Numeric Pain Rating Scale, and the total arc of motion at the PIP joint averaged 91.2° (range: 50–110°). All fractures had healed, and the intra-articular step-off improved from 1.9 mm (SD: 1.0) before surgery to 0.2 mm (SD: 0.4) at the final follow-up. The patients who sustained sports injuries returned to competition after an average of 3.5 months (range: 2.5–4 months). Conclusion The external fixator is compact and facilitates range-of-motion (ROM) exercises, has high stability, and achieves good joint congruity and an ROM equivalent to the healthy joint of the patient. Study design/Level of evidence Therapeutic/IV.

Background There is little description of the effect of cup position on the hip range of motion in total hip arthroplasty. The purpose is to evaluate the effect of cup medialization/lateralization with a compensatory increase/decrease in femoral offset on the hip range of motion, and whether the bone morphology of the anterior inferior iliac spine affects hip range of motion in total hip arthroplasty. Methods Using the CT data of 100 patients (male; 30, female; 70), 3D-dynamic motion analysis was performed in four scenarios with cup medialization/lateralization with the same/decreased global offset. We calculated the range of motion before component impingement and bony impingement in flexion, internal rotation and external rotation using the software. Furthermore, we measured bony morphological features of anterior inferior iliac spine, and we analyzed the correlations among them. Findings We found that the cup medialization with the same stem offset had negative effects on hip range of motion in flexion and internal rotation due to bony impingement, whereas cup medialization caused external rotation to significantly decrease with the same global offset. On the other hand, cup lateralization with the same global offset had negative effects on flexion and internal rotation, whereas external rotation increased. Furthermore, there were negative correlations among flexion and laterally large and steep anterior inferior iliac spine. Interpretation Our results demonstrated that the advantage of cup medialization can depend on the individual anatomy such as bony morphology of anterior inferior iliac spine in flexion.

Osteoarthritis (OA) is common age-associated disease, and associated with joint pain, mobility limitations and compromised overall quality of life. OA treatment is currently limited to pain management and joint arthroplasty at end stage disease. Oxidative damage to cartilage extracellular matrix and cells is an important mechanism in joint aging and OA pathogenesis. Evidence from in vitro and in vivo models of OA suggests that pharmaceuticals and natural compounds with antioxidant properties reduce expression of mediators of OA pathogenesis and OA severity in animal models. Among the signaling pathways that control cellular protective mechanisms against oxygen radical damage is heme oxygenase-1 (HO-1). We recently report HO-1 reduced OA severity in a mouse model. This led to the hypothesis that compounds that increase HO-1 expression have therapeutic potential in OA. Carnosic acid (CA), a natural diterpene with oxidant activity, is prevents cartilage degeneration though induction of HO-1. CA induced HO-1 and miR-140 expression in human articular chondrocytes, and cartilage degeneration was attenuated by CA treatment. Induced HO-1 by CA was in part associated with downregulation via miR-140 binding to 3’UTR of BTB and CNC homology 1 (BACH1). These findings suggest that CA attenuates cartilage degradation through HO-1 upregulation and has potential as a supplement for OA prevention.

Background Osteochondral lesions of the talus (OLT) are recognized as being commonly associated with trauma. However, the etiology of OLT remains unclear. In the case of a posteromedial lesion of OLT (medial OLT), the deep layer of the deltoid ligament is located close to the medial OLT, and this relationship between a medial lesion and deltoid ligament could be a risk factor for medial OLT. The purpose of this study is to investigate the unique anatomic feature of the deep deltoid attachment to the talus in patients with medial OLT compared with patients with non-medial OLT. Methods Forty ankles with medial OLT and 40 ankles without medial OLT were retrospectively reviewed in this study. On the coronal images of MRI, the attachment of deltoid ligament was measured. The continuity of the osteochondral fragment and its bed was evaluated on MRI and arthroscopic findings. Results Coronal MRI images showed that the attachment of the deep deltoid ligament to the medial OLT was broader and located more proximally than in non-medial OLT. The continuity of fibers from the insertion site of deltoid ligament to the talus to the osteochondral fragment was observed (76.7%). In the arthroscopic findings, the osteochondral fragment was obviously connected to the talus at the medial site in 85.2% of feet. Conclusions The location of the deep deltoid ligament attachment to the medial OLT was more proximal and there was the possibility of these anatomic feature might contribute to the pathogenesis of medial OLT.

Background The purpose of this study was to evaluate bone tunnel changes following anterior cruciate ligament (ACL) reconstruction during the early postoperative period using computed tomography (CT), and to understand the impact of postoperative immobilization on these changes. Methods Twenty patients who underwent double-bundle ACL reconstruction using hamstring tendon autografts were included. We subcategorized patients into two groups: patients who underwent isolated ACL reconstruction and had three days of knee immobilization (Group A, n = 10); and patients with concomitant meniscus injuries who underwent ACL reconstruction and meniscus repair simultaneously (Group B, n = 10) had their knees immobilized for two weeks after surgery. Bone tunnel enlargement was evaluated using CT imaging at one to three days, two weeks, one month, three months and six months after surgery. The cross-sectional area of the femoral and tibial tunnels was measured, and enlargement rate was calculated. The tunnel center location at two weeks after surgery was also evaluated. Results The mean cross-sectional area adjacent to the joint space of the femoral and tibial tunnels significantly increased immediately after surgery, especially in the first month (P 0.01). There was no significant difference in tunnel enlargement rate between group A and B. Tunnel center location changed even in the first two weeks. Conclusions Bone tunnel enlargement following double-bundle ACL reconstruction occurred at an earlier time point after surgery than anticipated. Postoperative immobilization could not prevent bone tunnel enlargement, but might prevent tunnel migration.

Background The purpose of this study was to evaluate the relationship of fatty infiltration in rotator cuff muscles and shoulder strength in rotator cuff tears and these changes during nonsurgical treatment. Methods Fifty-three shoulders from 47 patients (mean age: 69.9 years) diagnosed with rotator cuff tears by magnetic resonance imaging (MRI) were treated nonsurgically. The degrees of fatty infiltration in supraspinatus (SSP) and infraspinatus (ISP) muscles were graded by the modified Goutallier classification (grade 0–1, grade 2–3, or grade 4). The isometric strength of the abductors (Abd) and external rotators (ER) were examined with a hand dynamometer. We analyzed the correlation of the modified Goutallier classification in SSP and ISP muscles with the strength of Abd and ER at initial visit. In addition, MRI and strength tests were repeated after 24 ± 6 months, and changes in fatty infiltration and strength were examined. Results Fatty infiltration of SSP and ISP muscles had a negative correlation with the strengths of Abd and ER at initial visit, respectively. Six of 45 shoulders (SSP grade: 0–3) and 7 of 43 shoulders (ISP grade: 0–3) had progression of fatty infiltration. Predictive factor of a progression of fatty infiltration during follow-up was decreased initial strength of Abd. There was no significant change in the strength of Abd, and the strength of ER showed significant improvement between the initial and post-treatment measurements. Even in the subgroup that had progression of fatty infiltration at follow-up, the strength of Abd and ER did not decrease significantly. Conclusions Although fatty infiltration of the rotator cuff muscles exhibited a negative correlation with muscle strength, fatty infiltration and muscle weakness did not progress at the same rate.

Importance Several studies have shown a statistically significant decrease in proprioceptive function in anterior cruciate ligament (ACL)-deficient knees. The effects of ACL reconstruction on knee proprioception have continued to be a matter of debate. Objective The main aim of this review was to verify whether there is impaired proprioceptive function of the lower extremity in subjects with ACL reconstruction when compared with uninjured external controls. Evidence review A comprehensive search was performed using PubMed and Scopus to search for relevant studies on knee proprioception after ACL reconstruction on 10 September 2016. The studies that used only a patient's contralateral leg as a control were excluded. A modified Cochrane Methods Group on Screening and Diagnostic Tests Methodology was used to grade the quality of the studies. Findings A total of 11 studies involving 213 patients and 204 controls were included. In the threshold to detect passive motion measurement, five of the six studies showed no significant differences between the ACL-reconstructed knees and the uninjured external control knees. In the joint position sense measurement, only one of six studies showed that ACL-reconstructed knees had significantly lower proprioceptive function than those of uninjured external control knees. Conclusions and relevance This review demonstrated that there was no evidence of impaired proprioceptive function in subjects with ACL reconstruction when compared with the uninjured external controls. Higher quality studies and homogenisation on clinical assessment are needed to perform a more definitive analysis in the future. Level of evidence III, systematic review of level II and III studies

Highlights • EES involving the ulnar nerve is uncommon and extremely rare. • EES in the ulnar nerve may mimic benign soft tissue tumor. • Despite its rarity, high index of suspicion is advisable due to malignant nature. • Wide excision and reconstruction is needed for EES involving ulnar nerve., Introduction Extraskeletal Ewing sarcoma (EES) of the extremity is uncommon, and only a small number of reported cases have been devoted to the upper-extremity. Presentation of case A 65-year-old woman presented with a recurrent EES, a highly malignant tumor, involving the ulnar nerve at the right elbow region which was initially suspected as a benign soft tissue tumor, schwannoma, thus marginal excision had been performed. Due to its malignant behaviour, we treated the recurrent lesion with wide excision and reconstruction combined with chemotherapy. Histological evaluation revealed a monotonous small round cells appearance. Discussion EES of the extremity involving the ulnar nerve is fairly uncommon. The tumor was often smaller in the adult than in the child population which was consistent with the present case, thus may mimic a benign tumor. Because of the overlapping histopathological features of EES with other tumors, other investigations such as immunohistochemistry and cytogenetic studies must be performed to allow definitive diagnosis. The result of our study was negative for the EWSR1-FLI-1 and CIC-DUX4 fusion gene, however, other less frequent translocations could be found in this case which does not exclude the diagnosis of Ewing sarcoma family. Conclusion Few cases of EES involving the ulnar nerve have been previously reported. The correct diagnosis of EES involving the ulnar nerve has become particularly important in order to enable the initiation of comprehensive management that have the potential to reduce disease progression and the avoidance of improper and potentially harmful surgical therapy.

Backgound Despite the fact that femoral impingement against the anterior inferior iliac spine (AIIS) is increasingly recognized, there is no description of morphologic features of the AIIS in hip dysplasia and their effect on hip range of motion (ROM) in total hip arthroplasty (THA). The purpose is to evaluate the bone morphology of the AIIS in hip dysplasia and whether its morphology affects hip ROM in THA. Methods Computed tomography–based simulation software was used to create 3-dimensional bone models and perform virtual simulations. Using the computed tomographic data of 85 patients (male: n = 25, female: n = 60, mean age: 60.9) with hip osteoarthritis due to dysplasia, we measured the straight, vertical, and horizontal distances between the anteroinferior edge of the AIIS and the center of rotation in sagittal and axial views. The anterior and lateral versions of the AIIS were also measured. We calculated the ROM of flexion (Flex), and internal rotation (Int-R) in THA in the software, and analyzed the correlations among them. Results The AIIS prominence is bigger and extends more anteriorly and laterally in males than in females. Furthermore, the taller the patient, the more the AIIS extends anteriorly and laterally. We found that Flex and Int-R decreased inversely proportional to the size and lateral version of the AIIS. Conclusion Our results demonstrated that the AIIS bone morphology substantially affects the ROM of Flex and Int-R especially in patients with laterally large AIIS bony anatomy in THA. Furthermore, our result indicates that the morphologic features of AIIS in hip dysplasia may be different between males and females.

Background Cerebrospinal fluid (CSF) leakage is a hazardous complication after spine surgeries. Although most CSF leakages occur because of intraoperative dural tears, there are several reports that delayed CSF leakage occurred with undetected dural tears during surgery, which is known as occult dural tears (ODT). In this paper, we investigate ODT resulting in delayed CSF leakage following spinal surgery in our institute. Methods A retrospective review was conducted of 12,346 consecutive patients who underwent spinal surgery in order to identify ODT cases that underwent revision surgery. Results Among the 12,346 patient, 6 patients (0.049%) underwent revision surgery due to ODT resulting in delayed CSF leakage. In all surgeries, no dural tears were detected during primary surgery. However, 5 patients complained of headaches, 5 patients had CSF leakage through the skin and/or pseudomeningocele and 3 patients complained of nausea. The period between primary surgery and the diagnosis of ODT was an average of 2.7 days (range 1-4 days) after surgery. In revision surgeries, dural tears were found in all cases, although, at the time of primary surgery, there were no apparent dural tears. Direct dural suturing was performed in 5 cases and dural patching using fascia was performed in one case. In all cases, fibrin glue was used. The symptoms of all cases got better after surgery. Conclusions Although the incidence of delayed CSF leakage due to occult dural tears was not high, caution is necessary when patients complain of headaches or nausea after spine surgery.

We treated a 39-year-old female who had experienced destruction of her ankle joint owing to rheumatoid arthritis. This relatively young patient wished to avoid ankle fusion and joint replacement. Therefore, distraction arthroplasty with arthroscopic microfracture was performed to improve her symptoms and preserve motion. A microfracture procedure specifically for cartilage defects of the tibial plafond and talar dome was performed with the arthroscope, after which a hinged external fixator was applied to distract the ankle joint. The ankle joint space was enlarged by the external device and joint movement allowed. After 3 months, removal of the external device and repeat arthroscopy revealed newly formed fibrocartilage on the surfaces of both the tibia and the talus. At 2 years after the surgery, a radiograph showed that the joint space enlargement of the ankle had been maintained. The American Orthopaedic Foot and Ankle Society score improved from 37 points preoperatively to 82 points at 2 years postoperatively. Our findings suggest that good clinical results can be achieved with distraction arthroplasty and arthroscopic microfracture in a relatively young patient with rheumatoid arthritis.

Functional MRI (fMRI) studies have been used to investigate how the brain processes noxious stimuli in osteoarthritis (OA) and to identify the cortical location of pain perception. However, no consensus has been reached regarding brain activity associated with pain-induced conditions in OA patients. We examined cerebral responses using intra-epidermal electrical stimulation of the . knee in knee OA patients. To replicate the pain of knee OA in terms of predictability, acute pain generated by electrical stimulation was provided simultaneously with displayed images in this study. We used fMRI to identify differences in response between healthy subjects and knee OA patients and explored the modulating cortico-subcortical and cortico-cortical pathways using psychophysiological interaction (PPI) analysis. Our results show that chronic pain results in a different brain activation profile in the DLPFC and the pain matrix in knee OA patients. Abnormal brain connectivity between the DLPFC and the pain matrix is induced by chronic pain in knee OA patients.

No definite consensus has been reached regarding the optimal technique for graft fixation to the femur in an anterior cruciate ligament reconstruction. The purpose of this study was to evaluate the mechanical strength of two cortical suspension devices which were the TightRope (TR), a new adjustable-length loop device, and the EndoButton (EB), a well-established fixed-length loop device.The devices were tested under cyclic and pull-to-failure loading conditions in both an isolated device setup and a specimen setup using porcine femora and bovine flexor tendons. In particular, we examined the influence of tendon and device lengths, whereby the total length of the bone tunnel was fixed to 35 mm and an effective length of tendon in the bone tunnel was adjusted.In the isolated device testing, the EB showed significantly higher ultimate tensile strength than the TR. The displacement after preloading for the EB was statistically lower than that for the TR, and retained a significant difference after the cyclic load. In contrast, specimen testing showed no statistical difference in the displacement among the EB group and TR groups.This study indicated that the EB provides greater mechanical strength than the TR. An important new finding was the measurement of initial displacement from the initiation of fixation until loading began using 50 N of tension. In isolated device testing, the TR induced significantly more displacement than the EB during preloading, which could reflect the TR loop's stretching capacity until a certain amount of tension is applied.

Introduction Posterior cruciate ligament (PCL) reconstruction using the remnant preserving technique may contribute to improved postoperative posterior stability, graft healing, and proprioception recovery. Although there have been several reports on remnant preserving PCL reconstruction, no study has yet evaluated the proprioceptive functions before and after PCL reconstruction with remnant preservation. The purpose of this study is to retrospectively evaluate the clinical outcomes and proprioceptive function after isolated single-bundle PCL reconstruction with remnant preservation for chronic PCL injuries. Hypothesis Isolated single-bundle PCL reconstruction with remnant preservation surgery for chronic PCL injuries provides satisfactory clinical outcomes and good recovery of the proprioceptive function. Methods Nineteen patients who had undergone isolated single-bundle PCL reconstruction with remnant preservation for chronic PCL injuries were followed up for more than 2 years. The posterior laxity was measured by the gravity sag view, stress radiography and the KT-2000 knee arthrometer. The proprioceptive function was defined as the threshold to detect passive motion (TTDPM). Results The average Lysholm score significantly improved from 63.7 ± 13.2 preoperatively to 94.4 ± 4.6 at final follow-up. The postoperative posterior laxity significantly improved. Regarding TTDPM, there were no significant differences between the preoperative score and the score at every given time point, regardless of the starting angles and the moving directions of the knees. Conclusions The proprioceptive function, defined as TTDPM, is maintained after single-bundle PCL reconstruction with remnant preservation, and the postoperative clinical scores and posterior laxity significantly improve. Level of evidence Level IV, therapeutic case series.

Background Osteochondral lesions of the talar dome (OLT) involve the articular cartilage and subchondral bone. The subchondral bone plate (SBP) plays a crucial role in cartilage metabolism, and its disruption no longer maintains cartilage homeostasis. Computed tomography (CT) can provide more precise information on subchondral bone. CT image prediction of the histological findings on OLT will be useful to determine the most appropriate therapeutic strategy. We hypothesized that the clarification of the relationship between CT image of subchondral bone and histological findings of articular cartilage in osteochondral fragment will predict the cartilage degeneration in OLT. The purpose of this study is to evaluate the unique features of the CT findings that relate to the condition of the articular cartilage in OLT. Methods Thirty ankles in 29 patients, who had OLT with an osteochondral fragment were retrospectively reviewed. At surgery, the osteochondral fragment of 19 ankles could be preserved (preservation group) by fixation or drilling, and in the remaining 10 ankles the osteochondral fragment was removed (excision group). Preoperative CT findings were compared between the 2 groups. Biopsies of the osteochondral fragment from 13 ankles were performed. The relationship between the CT and histological findings were evaluated. Results The area of lesion in the preservation group was significantly larger than that in the excision group. The CT images of the lesion showed the rate of absorption of the SBP in the preservation group to be lower than that in the excision group. As for the lesion bed absorption, it was higher in the preservation group than in the excision group. In the excision group, all cases showed bed sclerosis while bed sclerosis was observed in 42.1% of cases in the preservation group. The specimens with disruption of the subchondral bone plate exhibited cartilage degeneration and abundant chondrocyte cloning. OLT with absorption of the SBP on CT showed severe cartilage degeneration, while the remaining SBP on CT showed low-grade cartilage degeneration. Conclusions This study shows the features of preoperative CT and histological findings in OLT with osteochondral fragments. The condition of the subchondral bone plate affects the cartilage degeneration. CT findings provide important information for the determination of surgical treatment.

BACKGROUND CONTEXT Expansive laminoplasty for cervical myelopathy preserves posterior structures to prevent postoperative development of instability and cervical kyphosis. It requires successful reconstruction of the laminae of the vertebral arches, as sinking or non-union of the expanded laminae may induce neurological regression, segmental motor paralysis, and postoperative axial pain. Novel hybrid hydroxyapatite (HA) spacers with interconnected porous calcium hydroxyapatite ceramic (IP-CHA) and solid ceramic with sufficient biocompatibility and mechanical strength were developed as an artificial bone substitute. PURPOSE To evaluate the usefulness and bone bonding rate of hybrid HA spacers in expansive laminoplasty. STUDY DESIGN/SETTING Expansive cervical laminoplasties with novel HA spacers composed of IP-CHA and solid ceramic were prospectively performed in cervical myelopathy patients. PATIENT SAMPLE Expansive open-door laminoplasties were performed in 146 cervical myelopathy patients: 450 hybrid HA spacers and 41 autogenous bone spacers harvested from the spinous processes were grafted into the opened side of each lamina. OUTCOME MEASURES Neurological conditions were assessed using the scoring system developed by the Japanese Orthopaedic Association (JOA), and functional improvements in the JOA scores were determined from the recovery rate (RR). METHODS The patients were followed up using computerized tomography (CT), and bonding rates for hybrid HA and autogenous spacers, bone fusion rates of the hinges of the laminae, and complications associated with the implants were examined. RESULTS Clinical symptoms significantly improved in all patients, and no major complications related to the procedure occurred. The hybrid HA spacers showed sufficient bone bonding on postoperative CT scans. The hinges fused completely in over 95% patients within 1 year. Only 4 spacers (0.9%) showed lamina sinking, and most expanded laminae maintained their positions without sinking or floating throughout the follow-up. CONCLUSIONS The hybrid HA spacers contributed to high bone fusion rates of the spacers and hinges of the laminae, and there were no complications associated with their use. Cervical laminoplasty with these spacers is safe and simple, yields sufficient fixation strength, and ensures sufficient bone bonding in the immediate postoperative period. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.