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Background: Recovering normal hindfoot alignment and correcting deformity of the ankle joint following total ankle arthroplasty (TAA) in osteoarthritis (OA) is essential for improving clinical outcomes and increasing long-term survival. We aim to evaluate hindfoot alignment following standard TAA compared to TAA with a total talar prosthesis (“combined TAA”) in varus-type OA patients. Methods: This retrospective study was conducted between 2010 and 2022. We included 27 patients (30 feet) who underwent standard TAA and 19 patients (22 feet) who underwent combined TAA. Hindfoot alignment at the subtalar joint was measured by weightbearing subtalar radiographic view before and after surgery. Results: In the standard TAA, the angle between the tibial shaft axis and the articular surface of the talar dome joint (TTS) changed from 75 to 87 degrees ( P

Background: With the increase in life expectancy, the prevalence of ankle osteoarthritis (OA) is also expected to increase in the future. Functional disability and diminished quality of life associated with end-stage ankle OA are comparable to those associated with end-stage hip or knee OA. However, there are few reports on the natural history and progression of patients with ankle OA. Hence, this study aimed to evaluate the risk factors for progression in patients with varus ankle OA. Methods: We evaluated 68 ankles from 58 patients diagnosed with varus ankle OA using radiography performed at intervals over at least 60 months. The mean follow-up period was 99 ± 40 months. Narrowing of the joint space and increasing osteophyte formation were defined as ankle OA progression. Multivariate analysis was performed using logistic regression to predict the odds of progression; the model included 2 clinical variables and 7 radiographic variables. Results: Of the 68 ankles, 39 (57%) progressed. In multivariable logistic regression analyses, patient’s age (odds ratio [OR] 0.92, 95% CI 0.85-0.99, P

Abstract We report two cases of Schloffer tumor that required resection after radical colon cancer surgery because of suspected lymph node recurrence on contrast‐enhanced (CE) CT and 18F‐FDG‐PET/CT. Case1 is a 69‐year‐old man with sigmoid colon cancer pStage IIA, and case2 is a 61‐year‐old man with descending colon cancer pStage IIIB.

Abstract Background Varus ankle osteoarthritis is classified using only weightbearing anteroposterior ankle radiographs; however, sagittal ankle alignment may also affect the position and extent of joint space obliteration. We hypothesized that the sagittal alignment of the ankle may also affect the position and extent of joint space obliteration visible on the coronal section; therefore, we identified the sites of joint space obliteration in patients with stage 3 varus ankle osteoarthritis for comparison with the sites observed on simulated weightbearing computed tomography and investigated the effects of anterior and posterior ankle subluxation. Methods Simulated weightbearing computed tomography scans of 83 ft with varus ankle osteoarthritis (26 stage 3a, 57 stage 3b) were performed to check for joint space obliteration in the ankle. Further classification as exhibiting either anterior, posterior, or no subluxation on weightbearing lateral radiographs was performed. Results Anterior, posterior, and no subluxation was seen in 5, 9, and 12 ankles among the 26 classified as stage 3a, respectively, and in 22, 12, and 23 ankles among the 57 classified as stage 3b, respectively. The mean tibial lateral surface angle on weightbearing lateral radiographs in stage 3a ankles was 75.6, 83.3, and 80.3 degrees in the anterior, posterior, and no subluxation groups, respectively; and 75.5, 86.6, and 82.7 degrees in stage 3b ankles (p

Background: A previous study on 2-dimensional evaluation of the subtalar joint functioning in varus ankle osteoarthritis concluded that varus deformity was compensated for by the subtalar joint during early stages but not in the advanced stages. Although compensatory function is expected both along the axial and coronal planes, compensatory function in all 3 dimensions (3D) remains unevaluated. This study evaluated the 3D-compensatory function of a varus subtalar joint using Globally Optimal Iterative Closest Points (Go-ICP), a 3D-shape registration algorithm, after 3D-bone shape reconstruction using computed tomography. Methods: This study included 22 ankles: 4 stage 2 ankles, 5 stage 3a ankles, 6 stage 3b ankles, and 4 stage 4 ankles, categorized according to the Takakura-Tanaka classification. As the control group, 3 ankles without prior ankle injuries and disorders and 4 stage 2 ankles were included. One control ankle was used as a reference. Relative values compared with the reference ankle were evaluated in each group using Go-ICP. Each axis was set so that dorsiflexion, valgus, and abduction were positive on the X axis, Y axis, and Z axis, respectively. Results: Rotation angles of the talus (Rotation T) and calcaneus (Rotation C) on the Y axis in the control and stage 3b were −7.6, −28, −2.1, and −13 degrees, respectively, indicating significant differences. Value of Rotation T-Rotation C (Rotation T-C) represents compensatory function of the subtalar joint. In all ankles, there was a correlation between Rotation T and Rotation T-C on the Y axis and Z axis ( P < .01, r = 0.84; P < .01, r = −0.84, respectively). There was a correlation between Rotation T values on the on Y and Z axes ( P = .01, r = 0.53). Conclusion: In varus ankle osteoarthritis, the talus had varus deformity with adduction. Compensatory function in the coronal plane persisted, even in the advanced stages; however, it was not sufficiently maintained in stage 3b. Furthermore, compensatory function in the axial plane was relatively sustained. Level of Evidence: Level III, retrospective comparative study.

In this study, we investigated the human capacity to generate randomness in decision-making processes using the rock-paper-scissors (RPS) game. The randomness of the time series was evaluated using the time-series data of RPS moves made by 500 subjects who played 50 consecutive RPS games. The indices used for evaluation were the Lempel–Ziv complexity and a determinism index obtained from a recurrence plot, and these indicators represent the complexity and determinism of the time series, respectively. The acquired human RPS time-series data were compared to a pseudorandom RPS sequence generated by the Mersenne Twister and the RPS time series generated by the RPS game’s strategy learned using the human RPS time series acquired via genetic programming. The results exhibited clear differences in randomness among the pseudorandom number series, the human-generated series, and the AI-generated series.

Background: The impact of varus ankle osteoarthritis (OA) on the distal tibial fibular syndesmosis is poorly described. This study aimed to investigate the possible relationship between the condition of the distal tibial fibular syndesmosis and the degree of the varus deformity using weightbearing simulated computed tomography (CT), in patients with varus ankle OA. Methods: This retrospective comparative study included 155 varus ankles, divided into 4 Takakura-Tanaka groups (stage 2, 3a, 3b, and 4). A control group comprised 35 ankles without prior ankle disorders. The angles between the tibial shaft and the articular surface of the tibial plafond on the anteroposterior view (TAS), and articular surfaces of the tibial plafond and talar dome (TTW) were measured from weightbearing ankle radiographs. The varus angle of the ankle (VA) was defined as 90 – TAS + TTW. On the CT axial view, 1 cm proximal to the tibial plafond, the area of the syndesmosis (“CT-area”) and the distance between the fibula and the tibia (CT-FCS) were measured. Results: The CT area in stages 2, 3a, 3b, 4, and control group were 99, 79, 77, 103, and 97 mm 2 , respectively. The CT-FCS were 3.5, 3.1, 2.9, 4.3, and 3.9 mm, respectively. In all 155 OA ankles, CT area and CT-FCS were negatively correlated with the VA (correlation coefficient r = –0.38, P < .01; and r = 0.38, P < .01, respectively). Both CT area and CT-FCS were significantly smaller in stages 3a and 3b than in the control group ( P < .01). Conclusion: There may be a relationship between the narrowing of the syndesmosis and the varus deformity in patients with varus ankle OA, especially in stages 3a and 3b. Clinical Relevance: Clinicians should be aware of the impact of varus ankle arthritis on the distal tibial fibular syndesmosis when operatively treating varus ankle OA. For some patients, the isolated treatment for the tibiotalar joint may be insufficient, and treatment for the syndesmosis as well as tibiotalar joint may be needed. Level of Evidence: Level III, retrospective case control study.

Hypercalcemia is a common electrolyte abnormality in malignancy and is largely caused by activation of parathyroid hormone (PTH) pathways. We report the case of a 76-year-old man with hypercalcemia primarily owing to 1,25-dihydroxyvitamin D3 overproduction from a high-grade fetal lung adenocarcinoma. Histologically, the tumor itself and tumor-adjacent macrophages were positive for the CYP27B1 protein, a key enzyme that generates 1,25-dihydroxyvitamin D3. Suppression was observed in serum PTH and PTH-related hormone levels, suggesting hypercalcemia is independent of the PTH pathway. Serum calcium level returned to normal after surgical resection of the lung cancer, supporting extrarenal overproduction of 1,25-dihydroxyvitamin D3 elicited by the tumors is the cause of hypercalcemia in this patient.

Background:. The rate of revision surgery for total ankle arthroplasty (TAA) is higher than for hip and knee arthroplasties. Tibiotalocalcaneal arthrodesis is widely used; however, it requires a large allograft. Thus, the use of a customized total talar prosthesis in combination with the tibial component of TAA (combined TAA) may be an effective strategy for talar component subsidence. This study aimed to evaluate the clinical and radiographic effectiveness of the combined TAA in such revision cases. Methods:. Between 2000 and 2015, 10 patients (10 women; 10 ankles) were treated using the combined TAA for revision after standard TAA or combined procedures that included the use of a talar body prosthesis. In 6 patients, the tibial component was concurrently replaced. The median follow-up period was 49 months (interquartile range [IQR], 24.5 to 90 months). The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score, a numerical rating scale (NRS) pain score, passive range of motion of the ankle, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at final postoperative follow-up. Results:. The median NRS pain score improved significantly, from 7 (IQR, 6.25 to 8.75) to 2 (IQR, 1 to 3). The median JSSF ankle-hindfoot scale total score improved significantly, from 64 (IQR, 56.25 to 71.5) to 88.5 (IQR, 79.75 to 96). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20 to 27.5) to 35 (IQR, 30 to 40), and the median function score improved from 34 (IQR, 26.5 to 37) to 43.5 (IQR, 39.75 to 46). The median range of motion improved from 29° (IQR, 25.5° to 35°) to 35° (IQR, 31.25° to 43.75°). No significant difference in osteophyte formation was found. Degenerative changes in the adjacent joint were found only in the talonavicular joint. Conclusions:. The combined TAA, used in revision for postoperative complications after standard TAA or combined procedures including the use of a talar body prosthesis, was associated with improved objective JSSF ankle-hindfoot scale scores, subjective pain assessment, and range of motion in the ankle. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract Background Combined small cell lung carcinoma (SCLC) is defined as SCLC combined with elements of non-small cell lung carcinoma (NSCLC), accounting for approximately 30% of cases of SCLC. However, combined SCLC and giant cell carcinoma (GC) is very rare. Case presentation A 50-year-old woman with a 45 pack-year smoking history was referred to our hospital for further investigation of an abnormal left hilar shadow. Chest computed tomography (CT) revealed a 28-mm solid pulmonary nodule in the left lower lobe and an enlarged left hilar lymph node adjacent to the left main pulmonary artery. CT-guided biopsy of the pulmonary nodule led to the diagnosis of high-grade neuroendocrine carcinoma. The preoperative clinical stage was defined as cT1bN1M0. Thus, the patient underwent left lower lobectomy with ND2a-2 lymph node dissection via thoracotomy. Pathological investigation revealed a 22-mm tumor and dense sheet-like growth of small tumor cells with scant cytoplasm and finely granular nuclear chromatin. Moreover, there was a sheet-like growth of bizarre, highly pleomorphic mono- or occasionally multinucleated giant cells, accounting for approximately 40% of the tumor. Both the small and giant cell components were thyroid transcription factor-1-positive and p40-negative and exhibited neuroendocrine differentiation, as indicated by positivity for synaptophysin and CD56 and negativity for chromogranin A. While the small cell component was E-cadherin-positive and vimentin-negative, the giant cell component was E-cadherin-negative and vimentin-positive, indicating an epithelial-to-mesenchymal transition. Only the small cell component was found within the mediastinal and hilar lymph nodes. The final pathological diagnosis was combined SCLC and GC, pT1bN2M0, and pStage IIIA. The patient received adjuvant chemotherapy with 4 cycles of cisplatin and irinotecan. No sign of recurrence has been noted for 1 year after the surgery. Conclusions This is the first detailed report of a unique case with combined SCLC and GC. The coexistence of SCLC and GC in the presented case might indicate several possibilities: (1) GC may arise from SCLC via epithelial-to-mesenchymal transition, (2) SCLC may arise from GC through phenotypic conversion, and (3) SCLC and GC may have derived from a common neuroendocrine origin. Further investigation is necessary to reveal the underlying pathological process.

Insertional Achilles tendinopathy (IAT) is caused by traction force of the tendon. The effectiveness of the suture bridge technique in correcting it is unknown. We examined the moment arm in patients with IAT before and after surgery using the suture bridge technique, in comparison to that of healthy individuals. We hypothesized that the suture bridge method influences the moment arm length. An IAT group comprising 10 feet belonging to 8 patients requiring surgical treatment for IAT were followed up postoperatively and compared with a control group comprising 15 feet of 15 healthy individuals with no ankle complaints or history of trauma or surgery. The ratio of the moment arm (MA) length/foot length was found to be statistically significant between the control group, the IAT group preoperatively and the IAT group postoperatively (p < 0.01). Despite no significant difference in the force between the control and preoperative IAT groups, a significantly higher force to the Achilles tendon was observed in the IAT group postoperatively compared to the other groups (p < 0.05). This study demonstrates that a long moment arm may be one of the causes of IAT, and the suture bridge technique may reduce the Achilles tendon moment arm.

Category: Ankle Arthritis Introduction/Purpose: In the patients with the varus type ankle arthritis, the stage of disease was classified according to the narrowing of tibiotalar joint using the weight-bearing ankle radiography. By the Takakura-Tanaka classification, the stage 4 ankle arthritis indicates more than half of the joint space was disappeared in the tibiotalar joint. Inclination of the surface of tibiotalar joint in the patients with stage 4 ranges from neutral to severely varus, that may confuse the etiology of staged ankle arthritis. The purpose of this study was clarifying the etiology of the stage 4 ankle arthritis combined with evaluating the syndesmotic instability using the weight-bearing simulated computed tomography(CT). Methods: Forty nine ankles with stage 4 varus type ankle arthritis were investigated. A weight-bearing simulated CT scan was taken in the neutral position of the ankle with a 300 N pressure from plantar side. In the axial view of the CT at 1 cm proximal to the tibial plafond, the distance between the fibula and the tibia was measured as the fibular clear space (FCS-CT). In the anteroposterior view of the weight-bearing radiography of the ankle, the angle between the tibial shaft and the joint surface of the distal end of the tibia was measured as the tibial anterior surface angle(TAS-Xp). The Pearson correlation coefficient was obtained to identify the correlations between the FCS-CT and the TAS-Xp. P values

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis (AA) has been applied for end-stage ankle arthritis. On the other hand, low tibial osteotomy has been applied for mild to moderate ankle arthritis, however distal tibial oblique osteotomy (DTOO) has come to be applied for end-stage arthritis and clinical results were reported to be favorable. The purpose of this study was to compare clinical outcomes after AA and DTOO. Methods: From 2011 to 2014, 37 patients with stage 3b ankle arthritis were treated surgically. In these patients, 25 whose talar tilting angle (TTW) was over 10 degrees with minimum follow-up of 1 year were investigated in this study. Seventeen patients were treated by AA and 8 were treated by DTOO. Clinical outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale before surgery and at the latest follow up. The patient-based evaluation was performed at the latest follow up using Self-administered evaluation questionnaire (SAFE-Q). TTW and range of motion (ROM) of the ankle were also evaluated before surgery and at the latest follow up. In addition, rate of bony union and complications were investigated. Results: The average ages at the surgery were 60(41-77) years old in the AA group and 66(49-75) in the DTOO group. The average follow up periods were 32(15-49) months in the AA group and 29(13-52) in the DTOO group. Scores of the JSSF scale significantly improved at the latest follow up in both groups. In comparison between two groups, “Social functioning” and “General Health and Well-being” scores in SAFE-Q were significantly higher in the AA group than in the DTOO group. In contrast, ROM was higher in the DTOO group than in the AA group. There were no significant differences in TTW, bony union rate and complications. Conclusion: Ankle arthrodesis spoils the joint motion, however it restores stability and activity of the daily living, that leads to the higher levels of social functioning, general health and well-being.

Category: Sports Introduction/Purpose: The pathogenesis of fifth metatarsal stress fractures remains uncertain. We hypothesized that physical characteristics and environmental factors, which have received limited attention in the literature thus far, might be involved in the development of such fractures. To test our hypothesis, we performed a medical checkup and a survey of the living environment of athletes in college soccer teams, and subsequently, we investigated the existence of fifth metatarsal stress fractures, and examined the differences between the injury group and the non-injury group. Methods: The survey and measurements were conducted in 273 male athletes from the same college soccer team between 2005 and 2013. A medical checkup, comprising assessment of stature, body weight, body mass index, arch height ratio, toe-grip strength, quadriceps angle, leg-heel angle, functional reach test, one-leg standing time with eyes closed, straight leg raise test, finger-floor distance, heel-to-buttock distance, ankle joint range of motion, and general joint laxity test, and a questionnaire survey were performed once a year. A survey was conducted at the time of injury that resulted in fifth metatarsal stress fractures. The study participants were separated into an injury group and a non-injury group, depending on whether they had a fifth metatarsal stress fracture. The measurement items and survey items were compared, and the association between the presence or absence of injury and the measurement items was analyzed. Results: Toe-grip strength was significantly weaker in the injury group, compared with the non-injury group, suggesting that a weak toe-grip is associated with fifth metatarsal stress fracture (p < 0.05). In addition, injury on the non-dominant leg was more frequent in the fifth metatarsal stress fracture injury group (p < 0.05). Between-group comparisons of the other items showed no statistically significant differences. Conclusion: The association between weak toe-grip strength and fifth metatarsal fracture suggests that a weak toe-grip may lead to an increase in the load applied onto the lateral side of the foot; this may cause mechanical stress on the bone. In addition, the effect of the non-dominant leg on the fifth metatarsal bone may need to be studied further.

Category: Ankle Introduction/Purpose: With the recent remarkable progresses in image diagnosis using magnetic resonance imaging (MRI), it could be possible to evaluate articular cartilage in detail. T1ρ mapping by MRI has recently drawn attention as a noninvasive cartilage evaluation method. While its validity has been proven, there are no reports describing T1ρ mapping for the ankle; therefore, in this present study, T1ρ values of the articular cartilage surfaces of the talar dome were measured in healthy individuals. Methods: The study sample comprised 10 ankles from 10 healthy volunteers (4 male and 6 female), with a mean age of 32.2 years. Images taken using a 3.0 T MRI device, manufactured by Philips, were processed using the PRIDE software (Philips, Inc.) and analyzed using Image J, a specialized analysis software. Evaluations were performed using slices in the coronal plane from the trochlear ridge of the talus and slices 10 mm anterior and posterior of the ridge. Each slice was divided into three equal parts including the medial, central, and lateral areas of cartilage on the articular surface of the trochlea tali, to totally yield 9 regions of interests where T1ρ values (ms) were measured. Furthermore, values were measured thrice for each region in each volunteer, and the mean was calculated. Results: T1ρ values for the medial, central, and lateral regions were 31.0 ± 6.4 ms, 31.2 ±7 .2 ms, and 32.2 ± 6.9 ms, respectively for the anterior talus; 24.2 ± 4.2 ms, 21.7 ± 5.6 ms, and 25.1 ± 5.5 ms, respectively for the trochlear ridge of the talus; and 33.8 ± 4.8 ms, 31.9 ± 4.5 ms, and 35.1 ± 4.8 ms, respectively for the posterior talus. T1ρ values were significantly lower in the anterior and posterior areas of the talar dome than in the trochlear ridge of the talus (p < 0.05). Conclusion: Proteoglycan content of articular cartilage in the talar dome was determined to be low in the anterior and posterior areas, that reveals load application might be concentrate on these areas.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is a popular surgical treatment for the patients with end-stage ankle arthritis. Along with development of the implant, indication for TAA has been extended to the severe deformity due to osteoarthritis or rheumatoid arthritis. However, a certain rate of complication after TAA is still remaining. The main reasons for failed TAA are the complications of talar component such as aseptic loosening or subsidence. We developed artificial talar prosthesis and indicated for the patient with idiopathic necrosis of the talus. This time we applied this new implant combined with tibial component of the TAA for the patient with end-stage ankle arthritis having severe collapse of the talus. The purpose of this study is to evaluate the outcomes of TAA with artificial talus. Methods: 【Materials】Thirteen patients (13 ankles) treated by TAA with artificial talus since 2007 to 2014 were investigated. The mean duration of follow-up was 35 months (range; 12 to 66 months). Twelve patients (12 ankles) were suffering from osteoarthritis of the ankle, and 1 was from rheumatoid arthritis. The mean age at the surgery was 71 year-old(range; 61 to 81 year-old). 【Methods】Clinical outcomes were evaluated by Visual Analog Scale (VAS) scores. Functional outcomes were assessed by scoring system produced by the Japanese Society for Surgery of the Foot (JSSF ankle-hindfoot scale) before surgery and at the final follow- up. Results: Postoperative VAS was improved from 8.9 to 2.3. Postoperative JSSF scale were improved from 41 to 87. There were no case that required the revision surgery due to implant failure or deep infection. Conclusion: The ankle has small joint surface compared with other weight-bearing joints, that causes the complications of talar component. For the patients with severe deformity or osteonecrosis of the talus, indications of TAA should be applied carefully. Patients of end-stage ankle arthritis with poor bone stock in the talus may have been unsatisfied with use of previous implant models of TAA. The artificial talus could be a possible option to solve this problem. In the current study, TAA with artificial talus remained favorable clinical and functional results for the patient with severe deformity or poor bone stock in the talus.