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Foot impairment in rheumatoid arthritis (RA) may exacerbate sarcopenia from physical inactivity because of foot pain while walking. The present study aimed to investigate the prevalence of sarcopenia in patients with RA-associated foot impairment, and whether treatment with a foot orthosis improved physical activity and muscle quantity.Thirty-two patients with RA were diagnosed as sarcopenic or nonsarcopenic, and the prevalence of sarcopenia was determined. Eleven patients with sarcopenia were treated with a foot orthosis. The following parameters were compared between baseline and after 6 months of treatment: physical activity (walking, moderate-intensity activity, and vigorous-intensity activity), foot pain while walking, Health Assessment Questionnaire (HAQ) score, and body composition parameters, including muscle quantity.Sarcopenia was present in 25/32 patients (78.1%). The use of a foot orthosis improved walking activity (Patients with RA-associated foot impairment had a high rate of sarcopenia. Treatment with a foot orthosis increases light-intensity physical activity such as walking, but does not enhance moderate-to-vigorous-intensity activities or increase muscle quantity.

BackgroundAlthough drug therapy for rheumatoid arthritis (RA) has recently improved, treating patients with established disease, whose hands have three major deformities (thumb deformity, finger deformities, and ulnar drift), remains a challenge. The underlying complex pathophysiology makes understanding these deformities difficult, and comprehensive assessment methods require accumulated skill with long learning curves. We aimed to establish a simpler composite method to understand the pathophysiology of and alterations in the hand deformities of patients with RA.MethodsWe established a rheumatoid hand cohort in 2004 and clinically evaluated 134 hands (67 patients). We repeated the evaluations in 2009 (100 hands of 52 patients) and 2015 (63 hands of 37 patients) after case exclusion. Thumb deformities, finger deformities (swan-neck and boutonnière deformity), and ulnar drift were semi-quantitated and entered as parameters into a two-step cross-sectional cluster analysis for the data in 2004. The parameters in each cluster were plotted at each evaluation point. Two-way analysis of covariance was used to examine whether differences existed between evaluation points and clusters of deformity parameters.ResultsFive clusters most appropriately described hand deformity: (i) cluster 1, minimal deformity; (ii) cluster 2, type 1 thumb deformity; (iii) cluster 3, thumb deformity and severe boutonnière deformity; (iv) cluster 4, type 2 or 3 thumb deformity and severe ulnar drift; and (v) cluster 5, thumb deformity and severe swan-neck deformity. Clusters 1 and 2 had higher function than cluster 5, and cluster 3 had moderate function. Clusters 1–4 had similar disease duration but showed different paths of deformity progression from disease onset. Clusters 1 and 2 represented conservative deformity parameters and clusters 3, 4, and 5 represented progressive deformity parameters. Over time, thumb deformity evolved into other types of deformities and swan-neck deformity worsened significantly.ConclusionsOur comprehensive analysis identified five deformity patterns and a progressive course in the rheumatoid hand. Knowledge of the characteristics of progressive deformity parameters may allow rheumatologists to more easily implement practical interventions and determine functional prognosis.

To examine the recurrence of deformity after silicone implant arthroplasty combined with resection arthroplasty for severe forefoot deformity in patients with rheumatoid arthritis.We reviewed the long-term results of this procedure for 27 feet in 15 patients. Their average age and disease duration at the time of operation were 58.6 years and 17.5 years, respectively, and the average follow-up period was 10.3 years.An improved hallux valgus angle (45.3° preoperatively, 23.6° 6 months after operation) was maintained. By contrast, deformity and dislocation of lesser toe had recurred at the final follow-up; the angle between the proximal phalanx and the metatarsal of the second toe improved 13.4° with recurrence of 22.5°, the angle between the proximal phalanx and ground surface improved 22.4° with recurrence of 34.5. Furthermore, claw toe deformity at the final follow-up was significantly worse in the group whose hallux valgus deformity was observed 6 months after operation.This procedure could maintain the alignment of the first metatarsophalangeal joint, but the recurrence of claw toe deformity is a problem and the relation between the first toe and the lesser toe is an important consideration.

Background The recent classifications for posterior tibial tendon dysfunction (PTTD) stage II are based on forefoot deformity, but there is still no consensus regarding a detailed explanation of the clinical condition. The purposes of this study were to clarify the clinical condition of flatfoot deformity using three-dimensional (3D) computed tomography (CT) imaging under loading on both healthy and flat feet and to compare 3D movement of the forefoot in response to load. Methods Ten volunteers and 10 PTTD stage II patients with symptomatic flatfoot deformity were examined. CT scans of 20 healthy and 20 flat feet were performed under non-loading and full weight-bearing conditions. Images of the tibia and foot arch bones (talus, calcaneus, navicular, and first and fifth metatarsal bones) were reconstructed into 3D models. Rotations of individual tarsal bone or metatarsal bone were described by the Eulerian angles. Results Compared with healthy feet, flat feet experienced plantarflexion of the fifth metatarsal bone relative to the first metatarsal bone under loading conditions. We defined this phenomenon as synonymous with forefoot varus on the coronal plane. Conclusions The results of this study have clarified part of the clinical condition of the forefoot in flatfoot deformity and may have applications in basic research of the staging advancement and substage classification of PTTD.

To establish a new assessment tool for ulnar drift (UD) in rheumatoid arthritis (RA).We established an observational cohort of 67 patients (134 rheumatoid hands) beginning in 2004. Fifty-two patients (100 hands) had follow-up in 2009 and 37 patients (63 hands) completed follow-up in 2015. UD was evaluated with the Fearnley classification and our scoring method, which assesses four parameters of the metacarpophalangeal joint. Cluster analysis using UD parameters divided hands into groups. Changes in UD over time, correlation of the Fearnley stage and cluster with a functional assessment, and reliability of the parameters were analyzed.UD increased and worsened over time according to the trend test. A dendrogram indicated five clusters would be appropriate. Both the Fearnley classification and cluster were associated with function; however, our method related to function more linearly (R-squared: 0.42). We found one type of hand in which bone destruction precedes the joint dislocation and one type in which joint dislocation progresses with little deviation during UD progression.Our UD evaluation appeared to be simple and related to function. Additionally, it enables dividing UD hands into five stages. Thus, our assessment should be beneficial compared to the Fearnley classification in considering treatments of UD.

Insoles are frequently used in orthotic therapy as the standard conservative treatment for symptomatic flatfoot deformity to rebuild the arch and stabilize the foot. However, the effectiveness of therapeutic insoles remains unclear. In this study, we assessed the effectiveness of therapeutic insoles for flatfoot deformity using subject-based three-dimensional (3D) computed tomography (CT) models by evaluating the load responses of the bones in the medial longitudinal arch in vivo in 3D.We studied eight individuals (16 feet) with mild flatfoot deformity. CT scans were performed on both feet under non-loaded and full-body-loaded conditions, first with accessory insoles and then with therapeutic insoles under the same conditions. Three-dimensional CT models were constructed for the tibia and the tarsal and metatarsal bones of the medial longitudinal arch (i.e., first metatarsal bone, cuneiforms, navicular, talus, and calcaneus). The rotational angles between the tarsal bones were calculated under loading with accessory insoles or therapeutic insoles and compared.Compared with the accessory insoles, the therapeutic insoles significantly suppressed the eversion of the talocalcaneal joint.This is the first study to precisely verify the usefulness of therapeutic insoles (arch support and inner wedges) in vivo.

Aim The aim of the present study was to investigate the influence of anti-tumor necrosis factor (anti-TNF) agents on gait function in patients with rheumatoid arthritis (RA). Methods Nine subjects with RA who were being treated with anti-TNF agents, participated in this study. A motion capture system was utilized, and data from the force plate and captured three dimensional motions were analyzed.Gait evaluation was performed before and 5.8 ± 2.6 months after introducing the anti-TNF agent. Stride, gait velocity and joint moments were calculated. In addition, an index of balancing weight of the lower extremities was determined. Results Stride length averaged 45.8 cm at baseline and 53.1 cm at the time of follow-up, and gait velocity averaged 0.9 m/s at baseline and 1.1 m/s at the time of follow-up. At heal contact, the joint moment of hip extension increased from 0.37 to 0.49, while ankle joint dorsiflexion moment increased from 0.08 to 0.13. During mid-stance, knee joint extension moment decreased from 0.16 to 0.06. At toe-off, hip joint flexion moment increased from 0.60 to 0.80, and ankle joint dorsiflexion moment increased from 0.80 to 1.05. The index of balancing weight of the lower extremities increased from 19.6 to 20.9 N. Conclusion The induction of anti-TNF therapies improved alterations in shock absorption in the early stance phase, balancing weight of the lower extremities in mid-stance, and increased push-off power in the later stance phase.

Background:The objective of this study was to evaluate the bone rotation of each joint in the hindfoot and compare the load response in healthy feet with that in flatfeet by analyzing the reconstructive three-dimensional (3D) CT image data during weightbearing.Methods:CT scans of 21 healthy feet and 21 feet with flatfoot deformity were taken in non-load condition followed by full-body weightbearing load condition. The images of the hindfoot bones were reconstructed into 3D models. The volume merge method in three planes was used to calculate the position of the talus relative to the tibia in the tibiotalar joint, the navicular relative to the talus in talonavicular joint, and the calcaneus relative to the talus in the talocalcaneal joint.Results:The talar position difference to the load response relative to the tibia in the tibiotalar joint in a flatfoot was 1.7 degrees more plantarflexed in comparison to that in a healthy foot ( p = 0.031). The navicular position difference to the load response relative to the talus in the talonavicular joint was 2.3 degrees more everted ( p = 0.0034). The calcaneal position difference to the load response relative to the talus in the talocalcaneal joint was 1.1 degrees more dorsiflexed ( p = 0.0060) and 1.7 degrees more everted ( p = 0.0018).Conclusion:Referring to previous cadaver study, regarding not only the cadaveric foot, but also the live foot, joint instability occurred in the hindfoot with load in patients with flatfoot.Clinical Relevance:The method used in this study might be applied to clinical analysis of foot diseases such as the staging of flatfoot and to biomechanical analysis to evaluate the effects of foot surgery in the future. Level of Evidence: III

Mycoplasma fermentans has been suspected as one of the causative pathogenic microorganisms of rheumatoid arthritis (RA) however, the pathogenic mechanism is still unclear. We, previously, reported that glycolipid-antigens (GGPL-I and III) are the major antigens of M. fermentans. Monoclonal antibody against the GGPL-III could detect the existence of the GGPL-III antigens in synovial tissues from RA patients. GGPL-III antigens were detected in 38.1% (32/84) of RA patient's tissues, but not in osteoarthritis (OA) and normal synovial tissues. Immunoelectron microscopy revealed that a part of GGPL-III antigens are located at endoplasmic reticulum. GGPL-III significantly induced TNF-alpha and IL-6 production from peripheral blood mononulear cells, and also proliferation of synovial fibroblasts. Further study is necessary to prove that M. fermentans is a causative microorganism of RA; however, the new mechanisms of disease pathogenesis provides hope for the development of effective and safe immunotherapeutic strategies based on the lipid-antigen, GGPL-III, in the near future.

In this study, we investigated the usefulness of contrast-enhanced MRI with maximum intensity projection (MIP) as a convenient tool for detecting early rheumatoid arthritis (RA). A total of 21 patients with undiagnosed arthritis of the hands at the initial visit were enrolled in a prospective study over a 1-year period. The number of swollen joints found during physical examination at this first visit, the results of serological tests and the number of synovitis joints diagnosed on MIP images were compared between the RA group and non-RA group. Of the 21 patients, 17 (81%) from the initial study who were followed up for an additional 1 year entered this study. Of these, 5 met the conditions for diagnosis of RA during follow-up, and 12 did not. MIP images were used to review the arthritis of RA patients, and a significant difference was found in the number of synovitis inflammations detected with MIP images when compared with findings after physical examinations. The two criteria of positive CARF and/or anti-CCP antibody and symmetrical synovitis in bilateral hands on MIP images allowed the prediction of RA with 100% sensitivity and 75% specificity. Thus, MIP is a useful tool for making early diagnosis of RA because it yields clear visualization even with just one image.

Upper cervical involvement is common in patients with rheumatoid arthritis (RA). Anterior atlanto-axial subluxation (aAAS) sometimes occurs at an early stage of the disease. We hypothesized that not only antero-posterior instability but lateral instability may occur with atlanto-axial involvement in RA. To prove this hypothesis, we evaluated the lateral instability of the atlanto-axial joint in RA, using dynamic open-mouth view radiographs. Thirty RA patients and a control group of 22 non-RA outpatients were enrolled in this study. The patients underwent lateral view radiographs of the cervical spine during flexion and extension, and antero-posterior (AP) open-mouth views during maximum right and left bending of the neck. The anterior atlanto-dental interval (AADI) was measured to evaluate antero-posterior instability of the atlanto-axial joint, and atlanto-dental lateral shift (ADLS) was defined to evaluate dynamic lateral instability. In the RA group, AADI averaged 3.2 mm in flexion, and in eight patients, it exceeded 3 mm in flexion (aAAS). In the control group, the AADI averaged 1.0 mm in flexion. The ADLS in the RA group averaged 14.8%, and this was significantly greater than in the control group, in which it averaged 6.1%. The ADLS averaged 20.6% in the RA subgroup with aAAS, and 12.7% in the RA subgroup without aAAS. In both subgroups, the ADLS was significantly greater than that of the control group. In this study, dynamic lateral instability of the atlanto-axial joint in RA was demonstrated. The results suggest that an evaluation of the dynamic lateral instability of the atlanto-axial joint can be useful for early diagnosis of atlanto-axial lesions in RA.

As treatment for subluxation due to rheumatoid arthritis (RA), rehabilitation by hand therapy is one option, but the number of therapist is not sufficient. Therefore, a device for rehabilitation of thumb metacarpophalangeal (MP) joint subluxation has been developed. To improve the device, it is necessary to measure in close proximity to the actual rehabilitation. Therefore, the authors tried to measure two kinds of rehabilitation by using motion capture and a contact force sensor. To measure rehabilitation movements, three markers were attached to the metacarpal bone, six markers were attached to each side of the interphalangeal (IP) joint, MP joint and proximal phalanx of the right thumb of the subjects, and a finger model was created by these markers. Further, three markers were placed on the left index of the therapist, and force direction was calculated by these markers. Measurement was conducted on healthy subjects, Rehabilitation was performed by the person who is not a therapist, but received the guidance of the doctor who is coauthor. As a result, the authors could measure rehabilitation by hand therapy, force, point of action and displacement. The results suggest that rehabilitation with traction twice as efficient as that without traction. Furthermore, it was found that rehabilitation is possible with calculated force, and the force is reproducible by the actuator in the device.

We report a case of carpal tunnel syndrome caused by volar dislocation of the lunate in a patient with rheumatoid arthritis. A 74-year-old woman complained of numbness in her fingers. Carpal tunnel syndrome was diagnosed, and carpal tunnel release was performed. However, the symptoms recurred. Three-dimensional computed tomography and magnetic resonance imaging revealed volar dislocation of the lunate and synovitis around the distal radioulnar joint, respectively. Resection of the lunate and the Sauvé-Kapandji procedure were effective.

Although epidemiological studies on epiphyseal injury have been reported, such studies have not been made systematically in Japan. In this study, we examined the incidence of epiphyseal injury in paediatric patients treated at five general hospitals and three private clinics. We treated the patients with limb injuries between January 1992 and December 1997, and reviewed them at least 18 months after the original injuries. The original radiograms and the completed case records were classified according to age and sex of the injured children, site of the fracture, type of treatment, and its complications. Epiphyseal injuries accounted for 17.9% of all paediatric fractures. The most frequently injured epiphysis was the phalanges of hands, 21.9% of all physeal injuries. Salter-Harris type I accounted for 28.6% of physeal injuries; type II (60.9%) revealed the largest number of cases in this study, compared with type III (6.7%) and type IV (3.7%). Type V was not recognized. Most physeal injuries were treated conservatively. Either weight-bearing joints or elbow joints were treated surgically. Complications of physeal injuries were seen in seven cases. Five cases involved the upper limb, and the other two cases involve the lower limb. Although deformity or malfunction caused by physeal injuries was remained, only one case needed a corrective osteotomy. Other six cases revealed a fair prognosis.

Spontaneous flexor tendon rupture is an unusual complication of systemic lupus erythematosus (SLE) and has not previously been reported. While tendon ruptures in association with SLE have been focused on the previous studies, upper extremity tendon ruptures are infrequently reported in the literature. Here, we present an uncommon case of spontaneous flexor tendon rupture of the ring and little fingers in a patient with SLE and discuss the mechanism of injury and its surgical treatment.

Treatments for rheumatoid arthritis (RA) have improved since methotrexate and biological agents were approved; however, few longitudinal analyses have tracked joint destruction, deformity progression, or functional impairments that directly affect the activities of daily living. Due to the consequences of functional impairments, we conducted this study to glean more information regarding deformity progression over time.This study enrolled 134 hands in 67 RA patients with hand deformities in 2004. After 5 years, 100 hands in 52 patients were eligible for the final assessment. Analyses consisted of morphological and radiographical evaluations of deformities, functional evaluations by questionnaires and the modified Kapandji index, and activity evaluations.In this period, the type I deformity (Nalebuff and Millender, Orthop Clin North Am 6(3):753-63, 1975) was the most common thumb deformity. Swan-neck and boutonnière finger deformities also progressed. At the 5-year follow-up, questionnaire score worsened, when disease activity was high.Our study showed that there was a marked progression in hand deformities in RA patients over a 5-year period. In order to assist RA patients in performing the activities of daily living, medical and rehabilitative interventions should target the restoration of functional loss through joint destruction as well as the prevention of disease progression.

Background The acquisition of flatfoot by an adult is thought to primarily be caused by posterior tibial tendon dysfunction, although some other causes, such as congenital flexible flatfoot or an accessory navicular, may also be responsible. The objective of this study was to evaluate the bone rotation of each joint in the medial longitudinal arch (MLA) and compare the response in healthy feet with that in flat feet by analyzing the reconstructive three-dimensional (3D) CT image data during weightbearing. Methods CT scans of 20 healthy feet and 24 feet with flatfoot deformity were taken in non-load condition followed by full-body weightbearing condition. Images of the tibia and MLA bones (first metatarsal bone, cuneiforms, navicular, talus, and calcaneus) were reconstructed into 3D models. The volume merge method in three planes was used to calculate the bone-to-bone relative rotations. Findings Under loading conditions, the flatfoot dorsiflexed more in the first tarsometatarsal joint, and everted more in the talonavicular and talocalcaneal joints compared with the healthy foot. The total relative rotation was larger in the flatfoot compared with the healthy foot only in the first tarsometatarsal joint. Interpretation Supporting the MLA in the sagittal direction and the subtalar joint in the coronal direction may be useful for treating flatfoot deformity. The first tarsometatarsal joint may play an important role in diagnosing or treating flatfoot deformity.

We present a rare case of spontaneous tendon rupture of the extensor digitorum communis (EDC) in a patient with systemic lupus erythematosus (SLE). Inflammation in SLE presents as periarthritis, which may develop into Jaccoud’s arthropathy. We bridged the ruptured tendon of the EDC (III) at the metacarpophalangeal (MP) joint of this patient with a tendon graft. This case demonstrates that this portion of the MP joint can be a site of tendon rupture of fingers in SLE patients.

It is difficult to evaluate the kinematics of flat foot from 2D images, and no definitive methods have so far been established to diagnose flat foot. This study evaluated hindfoot kinetics through the progression of posterior tibial tendon dysfunction (PTTD) in patients with stages II and III PTTD flat foot compared with those in normal patients under dorsiflexion and plantarflexion conditions using 3D computed tomography (CT) reconstruction images.CT images were taken of 26 normal and 32 flat feet in neutral, plantarflexion, and dorsiflexion positions of the ankle joint, from which 3D virtual models were made of each hindfoot bone. The 3D bone motion of these models was calculated using volume merge methods in three major planes.Tibiotalar-joint motion in ankle-joint plantarflexion became less plantarflexed (normal -41.2°, stage II -33.5°, stage III -25.3°) and less adducted (normal -13.9°, stage II -10.7°, stage III -5.6°) as the stage progressed. Talocalcaneal-joint motion in stage III became more plantarflexed (normal -0.8°, stage II -3.0°, stage III -8.7°) and more adducted (normal -0.3°, stage II -4.7°, stage III -10.3°) as the stage progressed. Talonavicular-joint motion in stage III became more plantarflexed (normal -7.2°, stage II -7.6°, stage III -14.9°) and more adducted (normal 1.0°, stage II -7.3°, stage III -17.9°) as the stage progressed.Tibiotalar-joint plantarflexion decreased and talocalcaneal and talonavicular-joint adduction increased in the maximal ankle-joint plantarflexion in stage II in comparison with normal cases. Tibiotalar-joint plantarflexion and adduction were decreased and of the talocalcaneal and talonavicular joints increased in stage III in comparison with stage II cases.

Study design A case-series study. Objectives To measure the 3-dimensional (3D) morphology and kinematics of the craniovertebral junction (CVJ) using a 3D computed tomography (CT) model; to reveal abnormal patterns and the relationships between pathology and kinematics. Summary of background data Evaluations using radiography, 2-dimensional (2D) CT and magnetic resonance imaging have limitations because of the complex 3D structure of the CVJ. Methods Twenty-four rheumatoid arthritis patients (21 females, 3 males) with cervical involvement underwent CT scanning of the cervical spine from the basilar process of the occipital bone to the first thoracic vertebra in neutral and flexed positions. The 3D morphology of the occipital condyle, atlas, and axis were classified based on the type of deformity observed. Periodontoid lesions (continuous bony lesions between the atlas and the odontoid process) were also noted. The 3D kinematics in the atlanto-occipital and atlantoaxial joints were evaluated using the volume merge method. Results Deformities in the atlanto-occipital joints appeared more frequently than those in the atlantoaxial joints. The most common instability pattern was flexural rotation during flexion at the CVJ. The direction of translational motions during flexion was posterior in the atlanto-occipital joint and anterior and caudal in the atlantoaxial joint. Conclusion The results suggest that bilateral occipital condyle deformation, unilateral and bilateral mass collapse, and periodontoid lesions may affect flexion/extension rotational instability in the atlantoaxial joint. In addition, unilateral occipital condyle deformation and atlantoaxial joint stability may affect sagittal translational instability to the posterior side in the atlanto-occipital joint. The noninvasive 3D CT imaging technique employed here would be useful for predicting the prognosis of patients with rheumatoid deformities at the CVJ.

Background: Knowledge of normal bone motion of the foot is important for understanding the gait as well as for various pathologies; however, the pattern of 3D motion is not completely understood. The aim of this study was to quantify the in vivo motion of the tibiotalar joint, talocalcaneal joint, and talonavicular joint in normal adult feet using a noninvasive (e.g., nonsurgical) measurement technique. Materials and Methods: CT images were taken of both feet of ten normal young adults (six males, four females) in neutral, plantarflexion, and dorsiflexion positions of the ankle joint, from which 3D virtual models were made of each mid-hind foot bones. The 3D bone motion of these models was calculated using volume merge methods in three major planes. These data were used to analyze the relationship between the motion of the ankle joint and each other joint. Results: Tibiotalar rotation was observed in dorsiflexion, abduction, and eversion during maximal dorsiflexion of the ankle joint. Talocalcaneal and talonavicular rotation was very small because the ankle joint motion was limited to the sagittal plane. Tibiotalar rotation was also observed in plantarflexion and adduction during maximal plantarflexion of the ankle joint, and talocalcaneal rotation was very small. Talonavicular rotation was observed in plantarflexion and inversion. The motion of the x-axis and the z-axis of tibiotalar joint, and the x-axis and the y-axis of the talonavicular and talocalcaneal joint were associated with the ankle motion. Conclusion: Bone motion could be easily and accurately calculated using volume merge methods more effectively than it could with other methods. Clinical Relevance: The data elucidates the baseline segmental motion for comparison with symptomatic subjects which could help us to better understand pathokinematics of various foot and ankle pathologies.

The purpose of the current study is to establish the dynamic close-mouth view radiograph method. Seven healthy volunteers were enrolled. Dynamic open-mouth and close-mouth view radiographs were obtained. The odontoid lateral mass interval and the dynamic atlantodental lateral shift (ADLS) were measured. The ADLS was 9.4+/-5.3% by the close-mouth view, showing a significantly greater percentage than that of 5.3+/-4.0% by the open-mouth view. The dynamic close-mouth view can be useful for diagnosis of atlantoaxial lateral instability.

Recently, for a recurrent patellar dislocation, medial patellofemoral ligament (MPFL) reconstruction has come to be commonly performed, yet the precise in vivo MPFL biomechanics still remains to be clarified. The purpose of this study was to analyze the length change pattern of MPFL in vivo. The subjects were comprised of ten male and ten female healthy volunteers. The length of the MPFL was measured using an open-MRI both from a leg extended position and a highly knee-flexed position in order to analyze the length change pattern of the MPFL. The MPFL length for men and women resulted in an average of 52 ± 3 mm and 43 ± 2 mm at the knee extended position, respectively. The length change pattern of the MPFL presented a slight change at up to a flexion angle of 60° and a decrease at over 60°. In terms of morphology, the fiber bundle of the MPFL experienced linear tension at a knee flexion angle of 60°. We determined that the MPFL length in vivo exhibited a specific length change pattern. MPFL mainly contributes to the medial constraint of a patella with a knee flexion of 0° to 60°, wherein it is expected to have the strongest strain at 60°. However, more studies are needed to obtain a better understanding of cases with a history of patellar dislocation.

In 1992, the authors developed a non-weightbearing unilateral ambulatory hip abduction brace, which was named the new pogo-stick brace for unilateral Legg-Calve -Perthes' disease. The hip abduction angle of the new pogo-stick brace was adjustable 45 degrees . The advantage of this brace was that even in the sitting position, the hip abduction angle was maintained. Twenty patients were treated with unilateral LCPD using the new pogo-stick brace. In the Catterall classification, one patient was classified as group 2, 17 as group 3, two as group 4. In Herring classification, one patient was classified as group A, 17 as group B, two as group C. Ultrasonography was performed to determine containment of the hip joints, and the abduction angle of the new pogo-stick brace was adjusted to get better containment, every 2 months. Mose's and acetabular head index methods were used for radiographic evaluation, and classified into good, fair and poor groups both at the primary healing and at the final follow-up. Total evaluation was defined as worse group between Mose's method and acetabular head index method. The average time from onset of disease to the primary healing was 25 months. The average bracing period was 21 months. The average follow-up period was 94 months. At the final follow-up appointment, patients who were classified into good and fair groups were 85% in Mose's method, 95% in acetabular head index method, 85% in total evaluation. In Stulberg classification, the total number of patients who were classified into classes I and II was 85%. The outcome of the new pogo-stick brace was not worse than that of any other treatment method, and was better than that of other unilateral ambulatory braces.

The anterior band of the inferior glenohumeral ligament is the most important restraint for preventing traumatic anterior glenohumeral instability. The condition of this ligament markedly affects the results of arthroscopic Bankart repair. We compared non-arthrographic magnetic resonance imaging (MRI) in abduction and external rotation and arthroscopic findings of the ligament in 51 shoulders with traumatic anterior glenohumeral instability. The condition of the ligament was evaluated based on the presence of a thick low-signal band between the anterior labrum and the head of the humerus in all magnetic resonance images obtained from the 3- to 5-o'clock position of the glenoid rim (right shoulder). The sensitivity and specificity of the MRI evaluation were 94% and 82%, respectively. MRI in abduction and external rotation is fairly useful for predicting the condition of the ligament in advance of invasive measures (ie, arthroscopy).

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, debridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40 degrees C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7 ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and debridement, may be one of the options for treating septic arthritis of an infant's shoulder.

Rheumatoid arthritis (RA) is characterized by massive synovial proliferation, angiogenesis, subintimal infiltration of inflammatory cells and the production of cytokines such as TNF-α and IL-6. Allograft inflammatory factor-1 (AIF-1) has been identified in chronic rejection of rat cardiac allografts as well as tissue inflammation in various autoimmune diseases. AIF-1 is thought to play an important role in chronic immune inflammatory processes, especially those involving macrophages. In the current work, we examined the expression of AIF-1 in synovial tissues and measured AIF-1 in synovial fluid (SF) derived from patients with either RA or osteoarthritis (OA). We also examined the proliferation of synovial cells and induction of IL-6 following AIF-1 stimulation. Immunohistochemical staining showed that AIF-1 was strongly expressed in infiltrating mononuclear cells and synovial fibroblasts in RA compared with OA. Western blot analysis and semiquantitative RT-PCR analysis demonstrated that synovial expression of AIF-1 in RA was significantly greater than the expression in OA. AIF-1 induced the proliferation of cultured synovial cells in a dose-dependent manner and increased the IL-6 production of synovial fibroblasts and PBMC. The levels of AIF-1 protein were higher in synovial fluid from patients with RA compared with patients with OA (p < 0.05). Furthermore, the concentration of AIF-1 significantly correlated with the IL-6 concentration (r = 0.618, p < 0.01). These findings suggest that AIF-1 is closely associated with the pathogenesis of RA and is a novel member of the cytokine network involved in the immunological processes underlying RA.