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Background: The calcaneal enthesis, an osseous footprint where the Achilles tendon seamlessly integrates with the bone, represents a complex interface crucial for effective force transmission. Bone adapts to mechanical stress and remodels based on the applied internal and external forces. This study explores the relationship between the elasticity of the Achilles tendon enthesis and the bone microstructure in the calcaneal crescent. Methods: In total, 19 calcaneal-enthesis sections, harvested from 10 fresh-frozen human cadaveric foot-ankle specimens (73.8 ± 6.0 years old, seven female), were used in this study. Indentation tests were performed at the enthesis region, and Hayes’ elastic modulus was calculated for each specimen. Micro-CT scanning was performed at 50-micron voxel size to assess trabecular bone microstructure within six regions of interest (ROIs) and the cortical bone thickness along the calcaneal crescent. Results: Significant Spearman correlations were observed between the enthesis elastic modulus and trabecular bone thickness in the distal entheseal (ROI 3) and proximal plantar (ROI 4) regions (R = 0.786 and 0.518, respectively). Conclusion: This study highlights the potential impacts of Achilles tendon enthesis on calcaneal bone microstructure, which was pronounced in the distal calcaneal enthesis, suggesting regional differences in load transfer mechanism that require further investigation.

Abstract This study aimed to determine the efficacy of using both the postero-anterior and oblique image intensifier views intra-operatively and late start of post-operative partial weight-bearing (PWB) in reducing the incidence of delayed union in the ischium at one year after curved periacetabular osteotomy. We evaluated computed tomography images to clarify the incidence of delayed union at the osteotomy sites at one year post-operatively for 117 hips in 104 patients. Fifty-eight hips in 54 patients with use of both the postero-anterior and oblique image intensifier views intra-operatively and late start of post-operative PWB were assigned to the oblique view and late PWB group (OL group) and 59 hips in 50 patients with use of only the postero-anterior image intensifier view intra-operatively and early start of post-operative PWB were assigned to the control group (C group). In univariate analyses, the incidence of delayed union in the ischium at one year post-operatively was significantly lower in the OL group (3.5%) than in the C group (22%). Use of both the postero-anterior and oblique image intensifier views during curved periacetabular osteotomy and late start of PWB were effective for reducing delayed union of the ischium at one year post-operatively.

Study Design A retrospective cohort study. Purpose To investigate the outcomes of balloon kyphoplasty (BKP) for vertebral compression fractures (VCFs) at the distal end or adjacent vertebra of the fused segments in patients with diffuse idiopathic skeletal hyperostosis (DISH). Overview of Literature Vertebral fractures in the midportion of the fused segments in patients with DISH are generally unstable; thus, immobilization is recommended. However, VCFs classified as type A in the AO classification are observed at the distal end and adjacent vertebra of the fused segments, and treatment strategies for VCFs associated with DISH remain controversial. Methods The outcomes of 72 patients who underwent BKP for VCFs between 2015 and 2021 were retrospectively investigated. Patients with DISH were assigned to group D (n=21), whereas those without DISH were assigned to group ND (n=51). Back pain, incidence of subsequent adjacent fractures, reoperation rates, and local kyphosis were statistically analyzed. Results VCFs in group D occurred at the distal end or adjacent vertebra of the fused segments, and no fractures occurred in the midportion of the fused segment. Back pain improved in both groups, with no significant differences between them. Subsequent adjacent fractures were observed in three of the 21 patients in group D and 11 of the 51 patients in group ND, with no significant difference between them. Reoperation was performed in one patient each in groups D and ND, with no significant difference between the groups. Postoperatively, local kyphosis progressed significantly in group D. Conclusions Although local kyphosis is more advanced in patients with DISH, BKP is effective for VCFs at the distal end or adjacent vertebra of the fused segments and may be useful in older patients with high complication rates.

Objectives This study documents the time elapsed from the diagnosis of osteonecrosis of the femoral head (ONFH) to surgery, exploring the factors that influence ONFH severity.Design Retrospective observational study of a nationwide database.Setting The Kaplan-Meier method with log-rank tests was applied to examine the period from definitive diagnosis of ONFH to surgery using any surgery as the end point. For bilateral cases, the date of the first surgery was the endpoint.Participants This study included 2074 ONFH cases registered in 34 university hospitals and highly specialised hospitals of the multicentre sentinel monitoring system of the Japanese Investigation Committee between 1997 and 2018.Main outcome measure The primary outcome was the time from diagnosis to surgery. The secondary outcome was the proportion of subjects remaining without surgery at 3, 6 and 9 months, and at 1, 2 and 5 years after diagnosis.Results The median time to surgery was 9 months (IQR 4–22 months) after diagnosis of ONFH. The time to surgery was significantly shorter in the alcohol alone group and the combined corticosteroid and alcohol group than in the corticosteroid alone group (p=0.018 and p

Introduction: Older adults with cervical spinal cord injury (CSCI) often have a poor prognosis due to the high number of complications, decreased motivation to rehabilitation, and poor response to treatment. This study aimed to investigate the characteristics of CSCI in Japanese older adults and examined the factors influencing their discharge home. Methods: In this retrospective cohort study, we extracted data on consecutive cases with CSCI between 2005 and 2020 from the study hospital's database. Patients over 65 years old who were admitted to the hospital within 14 days of injury were selected. A univariate analysis was performed between the home discharge and out-of-home discharge groups. In addition, binary logistic regression analysis of admission findings and patient background was performed to examine independent factors influencing home discharge. Results: Of the 219 patients included, 90 (41.1%) were eventually discharged to home. Comparing home discharge and out-of-home discharge groups revealed significant differences in age at injury, length of hospital stay, neurological level of injury (NLI), percentage of American Spinal Injury Association (ASIA) Impairment Scale (AIS: A), percentage of living alone, ASIA motor score (AMS), and Spinal Cord Independence Measure (SCIM) at initial visit and discharge. Binary logistic regression analysis revealed that old age (over 75 years old) at injury (odds ratio [OR]: 0.31, 95% CI: 0.16-0.60, P

Intramedullary nails are an effective treatment for common femoral trochanteric fractures. However, one of their complications is implant breakage due to poor reduction and nonunion after surgery. We herein report a case of a 54-year-old man who underwent total hip arthroplasty for nonunion after internal fixation of a femoral trochanteric fracture. The femoral trochanteric fracture was treated by internal fixation using the Trigen InterTAN nail. The patient developed symptoms of hip pain 6 months after internal fixation. Nine months after internal fixation, hip radiographs and computed tomography scans showed breakage of only the compression screw. During total hip arthroplasty, we were unable to remove the lag screw and compression screw before the femoral head dislocation because no gap was present between the two screws. Thus, we removed these screws with the femoral head after dislocation of the femoral head. The removed nail was partially damaged at the lag screw hole. This change was retrospectively observed on the preoperative computed tomography scan. Three months after total hip arthroplasty, the patient was able to walk unaided and the hip pain had resolved. If only the compression screw is completely broken after internal fixation with the Trigen InterTAN nail, both the lag screw and compression screw will be difficult to remove with preservation of the femoral head. We effectively managed such a case by not only revision internal fixation but also total hip arthroplasty.

Abstract Background Soft tissue has an important role in stabilizing the hinge point of medial closed wedge distal femoral osteotomy (MCWDFO). However, there are conflicting data on the soft tissue anatomy around the hinge point of MCWDFO and, therefore, further anatomical data are needed. The purposes of the study were to: 1) anatomically analyze the soft tissue around the hinge point of MCWDFO; 2) radiologically define the appropriate hinge point to prevent an unstable hinge fracture based on the result of the anatomical analysis; and 3) histologically analyze the soft tissue based on the result of the anatomical analysis. Methods In 20 cadaveric knees, the capsule attachment of the distal lateral side of the femur was marked with a radiopaque ball bearing. A digital planning tool was used to calculate the area of the marked capsule attachment around the ideal hinge point of MCWDFO on radiographs. The soft tissue around the hinge point was histologically examined and the periosteal thickness was measured and visualized graphically. The graph and radiograph were overlayed using image editing software, and the appropriate hinge position was determined based on the periosteal thickness. Results As a result, the periosteal thickness of the distal lateral femur tended to rapidly decrease from the metaphyseal region toward the diaphyseal region. The overlayed graph and radiograph revealed that the periosteal thickness changed in the region corresponding to the apex of the turning point of the femoral metaphysis in all cases. Conclusions In conclusion, the periosteum might support the hinge of MCWDFO within the area surrounded by the apex of the turning point of the femoral metaphysis and the upper border of the posterior part of the lateral femoral condyle.

Abstract This study aimed to investigate the influence of bone marrow edema (BME) for the assessment of the boundaries of necrotic lesions using unenhanced and contrast-enhanced (CE) magnetic resonance (MR) images in patients with osteonecrosis of the femoral head (ONFH). We retrospectively reviewed 72 consecutive hips in 55 patients of ONFH that were Association Research Circulation Osseous (ARCO) stage III or higher and underwent both unenhanced and contrast-enhanced MR imaging between January 2005 and February 2016. The degree of extension of BMEs, and the boundaries of the necrotic lesions were compared using unenhanced and CE MR images on both mid coronal and mid oblique-axial slices. Forty-two percent of the coronal T1 images, 40% of the coronal fat-saturated T2 images, and 48% of the oblique-axial T1 images showed differences in the boundaries of necrotic lesion, by comparison with those of CET1-weighted MR images. The boundaries of necrotic lesions were clearly detected in all hips on CE coronal slices and 97% of all hips on CE oblique-axial slices. The BME grade in the difference group was significantly higher than in the non-difference group on the coronal plane (P = 0.0058). There were significant differences between the BME grade and duration from the onset of hip pain to MR imaging examination. Multivariate analyses revealed that the duration from the onset to MR imaging examination in both coronal (P = 0.0008) and oblique-axial slices (P = 0.0143) were independently associated with differences in the boundary of necrotic lesion between T1 and CET1-weighted MR images. Our findings suggest that unenhanced MR image may be insufficient for a precise assessment of the boundaries of the necrotic lesions for ONFH cases in the early phase of subchondral collapse due to the diffuse BME.

Abstract Background The femoral anteversion angle is an important factor in performing surgery in the proximal part of the femur. Predicting the femoral anteversion angle based on the morphology of the proximal femur is clinically useful. The purpose of this study was to investigate whether an anatomical landmark can be used to predict the femoral anteversion angle intraoperatively. Materials and methods We analysed CT data obtained from 100 hips in 69 patients with osteonecrosis of the femoral head with no more than 2 mm collapse and no evidence of osteoarthritic changes. The measured variables were the femoral anteversion angle, the femoral neck-shaft angle, and the AW angle (defined as the angle between the femoral shaft axis and the tangential line of the anterior wall of the greater trochanter). The correlations between variables were also investigated. Multiple regression analysis by the forced input method was performed for the degree of femoral anteversion angle, using sex and the AW angle as explanatory variables. Results On CT, the mean femoral anteversion angle was 14.8° ± 10.8°, the mean AW angle was 17.5° ± 8.0°, and the mean femoral neck-shaft angle was 127.3° ± 5.4°. There was a positive correlation between the femoral anteversion angle and the AW angle. The approximation equations based on the multiple regression analysis were as follows: male femoral anteversion angle = AW angle × 0.7 − 0.7 and female femoral anteversion angle = AW angle × 0.7 + 4.3. Conclusions Femoral anteversion angle can be predicted based on the AW angle of the greater trochanter.

Background/Objective: Beta-tricalcium phosphate (β-TCP) is often used as a gap filler in open-wedge high tibial osteotomy (OWHTO). The aim of the present study was to investigate the effects of using β-TCP with different porosities on bone remodelling after OWHTO.Methods: We evaluated 29 knees in 26 patients that underwent OWHTO using β-TCP with porosities of 60% and 75% (combined group). A further 30 knees in 28 patients that underwent OWHTO using β-TCP with 60% porosity alone were allocated as a control group. In the combined group, a β-TCP block with 75% porosity was inserted into the gap at the cancellous bone site and a β-TCP block with 60% porosity was inserted into the medial cortical bone side. In the control group, a β-TCP block with 60% porosity was inserted into the osteotomy gap. The bone remodelling phases of the inserted β-TCP blocks were evaluated on standard anteroposterior radiographs using the modified van Hemert classification at 3 and 6 months post-operatively. Results: The rate of satisfactory bone remodelling at the cancellous bone sites was 86.2% (25/29) in the combined group and 0% (0/30) in the control group at 3 months post-operatively (p

Background: Some researchers have stated that magnetic resonance imaging (MRI) is useful for assessing the coracoacromial ligament (CAL) at the acromial undersurface. However, few studies have investigated the reliability and clinical significance of MRI findings for the CAL at the acromial undersurface. The purpose of this study was to determine the association between CAL thickness at the acromial undersurface and rotator cuff tear size. Methods: The CAL thickness at the acromial undersurface was evaluated in 182 patients with rotator cuff tears (mean age: 64.9 ± 8.4 years) using a 3.0-Tesla MRI system. The association between CAL thickness at the acromial undersurface and rotator cuff tear size determined by the DeOrio and Cofield classification (partial; small: 3 cm) was analyzed statistically. The intraobserver and interobserver reliabilities for MRI measurements of CAL thickness at the acromial undersurface were determined by calculation of intraclass correlation coefficients and their 95% confidence intervals. Results: The mean CAL thickness at the acromial undersurface was 2.7 ± 1.4 mm (range: 0-6.5 mm). Increasing rotator cuff tear size was significantly associated with decreasing CAL thickness at the acromial undersurface (P = .004). The intraobserver and interobserver intraclass correlation coefficients for CAL thickness at the acromial undersurface were almost perfect (0.98 and 0.91, respectively). Conclusion: The present study clarified that (1) MRI was a reliable tool for evaluation of CAL thickness at the acromial undersurface and (2) increasing rotator cuff tear size was significantly associated with decreasing CAL thickness at the acromial undersurface. These findings may assist toward understanding the progressive pathology in rotator cuff disease.

Background: Patients scheduled for metal implant surgery in some facilities in Japan undergo preoperative metal patch testing (MPT). However, few studies have reported the impact of MPT results on scheduled surgery; therefore, the value of preoperative MPT remains unknown. Material and methods: In analysis 1,the preoperative MPT results requested by orthopedic surgeons from 4 institutions from 2014 to 2018 were retrospectively analyzed. In analysis 2, the medical records of all patients who underwent total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty/reverse shoulder arthroplasty between 2014 and 2018 were collected. The number of patients who underwent MPT and their surgical results were analyzed. Results: In analysis 1, MPT was performed on 72 patients during the study period. The overall MPT positivity rate was 26.4% for the entire cohort in analysis 1. In 4 out of 19 MPT-positive cases, the results of MPT changed the treatment plan to use alternative materials or cancel the surgery. In analysis 2, 1087 patients underwent total hip arthroplasty, total knee arthroplasty, and TSA/RSA; only 16 patients underwent MPT. Aseptic loosening occurred postoperatively in 3 patients (0.3%), none of whom had a history of allergy, and none underwent preoperative MPT. Conclusion: Metal allergy did not appear to be directly involved in aseptic loosening to any large or meaningful degree in our patient cohort. Only 1.5% of the patients underwent preoperative MPT; therefore, our results suggest this testing had limited benefit or utility. Further studies are needed to determine whether MPT is necessary in preparation for joint replacement.

Abstract Background Discriminating traumatic rotator cuff tears (RCTs) from degenerative RCTs is sometimes difficult in elderly patients because the prevalence of asymptomatic RCTs increases with age. Little intraoperative information is available on the characteristics of traumatic and degenerative RCTs in elderly patients. The purpose of this study was to compare the arthroscopic findings and histological changes of the coracoacromial ligament (CAL) between traumatic and degenerative RCTs in elderly patients. Methods Forty-two shoulders of 42 patients aged ≥ 65 years underwent arthroscopic rotator cuff repair. Nineteen patients had traumatic full-thickness RCTs (Group T), and 23 had degenerative full-thickness RCTs (Group D). The quality of the rotator cuff tissue and the condition of the long head of the biceps were examined. The grade of CAL was evaluated both arthroscopically and histologically. The stiffness of the musculotendinous unit was calculated by measuring the force and displacement using a tensiometer. The arthroscopic and histological findings of the two groups were compared. Results Although the mean tendon displacement was comparable, the stiffness was different between Group T and Group D (0.56 ± 0.31 and 1.09 ± 0.67 N/mm, respectively; p

Dislocation after total knee arthroplasty (TKA) is a rare complication, and few cases of anterior dislocation have been reported. Furthermore, there are no reports of early postoperative dislocation. A 72-year-old woman who had previously undergone resection of the posterior thigh muscle group for liposarcoma of the thigh underwent TKA for knee osteoarthritis. However, anterior dislocation was observed at 1 week postoperatively. We considered that the cause of the early anterior dislocation was previous resection of the posterior soft tissues of the knee joint. This case is a rare report of early anterior postoperative dislocation after TKA.

Lymphoproliferative disorders (LPDs) are serious complications associated with rheumatoid arthritis (RA) treatment that mostly occur during methotrexate (MTX) treatment. Cessation of MTX may induce regression of LPDs but is often followed by a flare of RA. Here, we describe two patients with RA flares after the discontinuation of MTX due to LPDs and sarilumab was useful for the treatment of RA without a relapse of LPDs. Patient 1 was an 84-year-old woman, who developed an LPD in the pharyngeal region after 7 years of MTX treatment. Discontinuation of MTX induced regression of LPD but RA flared within 6 months. Administration of sarilumab, in addition to salazosulfapyridine and prednisolone, reduced the RA activity without LPD relapse. Patient 2 was a 76-year-old man, who developed LPD in the pharyngeal region after 5 years of MTX treatment. Discontinuation of MTX induced regression of LPD, but soon RA flared. Although treatment with tocilizumab (TCZ) was effective in controlling RA, it flared again after 2 years. TCZ was switched to sarilumab and RA was in remission. LPD did not recur during these periods.

Purpose In modern total knee arthroplasty (TKA), flexion and extension gaps between the femur and tibia are equilibrated before implanting the final components. Uncontrolled intraoperative posterior tibial translation (PTT) could cause an artifactual widening of the flexion gap, which could lead surgeons to alter the femoral component size. We designed an intraoperative posterior sagging control device to prevent intraoperative PTT. In this study, we investigated whether the use of this device could prevent artifactual widening of the flexion gap. Methods Twenty-five patients, 21 women and four men, aged 74.2 years, were enrolled in this prospective study. All patients underwent postero-stabilized TKA using a navigation system. Intraoperative PTT, flexion and extension gaps with or without using the posterior sagging control device were measured with navigation system. These measurements were compared with or without the posterior sagging control device and after the final implantation also. Results There were significant differences between the measurements performed with or without the posterior sagging control device when compared to the post-implantation measurements. The use of the device reduced the number of patients with a >3 mm increase in flexion gap from 7 (28%) to 1 (4%). Conclusion This study suggests that the posterior sagging control device prevents PTT and artificial flexion gap widening. This could prevent an unnecessary increase in component size.

Purpose To evaluate clinical outcomes between hybrid closed wedge high tibial osteotomy (HCWHTO) and total knee arthroplasty (TKA) for advanced medial compartmental osteoarthritis of the knee (advanced knee OA). Methods In more than grade 3 OA based on the Kellgren-Lawrence classification, when patients’ age was less than 60 years or activity level was more than level 5 based on the UCLA activity score, 22 knees (18 patients) underwent HCWHTO. The other 22 knees (18 patients) that underwent TKA were evaluated retrospectively. Muscle strength was evaluated preoperatively and at 1 year postoperatively. The visual analogue scale (VAS) and Japanese version of the Knee injury and Osteoarthritis Outcome Score (J-KOOS) were used to evaluate clinical outcomes preoperatively and at a mean 66-months follow-up. Results All postoperative muscle strength measures improved to preoperative equivalent levels in the HCWHTO group; they were significantly higher in the HCWHTO group than in the TKA group ( p < .05). The VAS score and total J-KOOS significantly improved in both groups (HCWHTO, p = .001; TKA, p = .040); there were no significant differences in the scores between the groups at the final follow-up. Hybrid closed wedge HTO significantly improved the activities of daily living and sport/recreation scores, whereas TKA did not at the final follow-up. Conclusions In advanced knee OA, HCWHTO led to improved muscle strength, and its midterm clinical outcomes were equivalent to those of TKA. To postpone or even to avoid TKA, HCWHTO is considered an appropriate treatment for young and high-activity patients with advanced knee OA. Level of Evidence Therapeutic Level III

Purpose The purpose of this study was to evaluate sequential patellar height changes as well as the factors leading to these changes after medial open-wedge high tibial osteotomy (MOWHTO). Methods The study cohort constituted 37 knees from 36 patients who underwent MOWHTO for varus knee. The Caton–Deschamps index (CDI) for patellar height was measured preoperatively and at 2 weeks and 3, 6, and 12 months postoperatively. The factors related to sequential changes in patellar height were evaluated. Results Significant differences were observed between preoperative CDI and postoperative CDI at all time points ( p < .05). Two-week postoperative CDI and postoperative CDI at 3,6,12-months was also significantly different ( p < .05). The only significant factor for the change in patellar height between preoperative CDI and postoperative CDI at 2-weeks and 12-months was the change in the Δ medial proximal tibial angle (ΔMPTA) (postoperative MPTA–preoperative MPTA). We could not identify the factor that affected the change in patellar height change from 2-weeks postoperatively. Conclusion The change in patellar height continued sequentially until at least 3 months postoperatively. ΔMPTA was associated with the change in patellar height at 2 weeks postoperatively compared with preoperatively; however, no factors associated with the change in patellar height from 2 weeks postoperatively to 3, 6, and 12-months postoperatively were identified.

Abstract Introduction Avascular necrosis of the femoral capital epiphysis is the most serious complication after traumatic dislocation of the hip in children. This case report discusses the localization and revascularization of the necrotic femoral head following rarely experienced traumatic open anterior hip dislocation in children. Case presentation Our patient was an 11-year-old Japanese boy who had open anterior hip dislocation sustained in a traffic accident. Reduction of the hip joint was performed in an emergency operation, and he was evaluated using serial gadolinium-enhanced magnetic resonance imaging. T1-weighted magnetic resonance images showed two bands with low signal intensity in the femoral capital epiphysis on coronal and oblique axial planes, indicating the existence of avascular osteonecrosis of the femoral head. We observed gadolinium enhancement in the central region of the epiphysis, where the area between the two bands with low signal intensity was located. Serial assessment with enhanced magnetic resonance images during a non-weight-bearing period of 1.5 years after injury showed revascularization starting from the central region and converging toward the peripheral region. Although the patient had leg-length discrepancy due to the early epiphyseal closure, non-weight-bearing treatment for the avascular osteonecrosis of the femoral head achieved a favorable outcome without any hip joint dysfunction, pain, or sign of secondary osteoarthritic change within 4.5 years after injury. Conclusion We confirmed the revascularization process of the necrotic lesion in the femoral capital epiphysis in an 11-year-old boy using serial gadolinium-enhanced magnetic resonance imaging. Conservative non-weight-bearing treatment achieved a favorable outcome.

Abstract Background The purpose of this study was to investigate the relationship between the bone length available for coracoid transfer without coracoclavicular ligament injury and the distance from the coracoid tip to the attachments of the coracoacromial ligament or pectoralis minor. We hypothesized that cadaver height and the soft tissue attachments on the coracoid process were predictive factors for sufficient bone length for coracoid transfer. Methods This study included 28 shoulders from Japanese cadavers: 19 male and 9 female. The distance from the coracoid tip to the distal attachment of the coracoclavicular ligament and the anterior and posterior margins of the coracoacromial ligament or pectoralis minor on the coracoid process were measured. Results The mean available length for coracoid transfer was 24.8 ± 3.4 mm. There was a significant difference in length between male and female subjects, being 26.0 ± 2.9 mm and 22.2 ± 3.0 mm, respectively (p = 0.004). High positive correlations were found between the length of the coracoid transfer and cadaver’s height (r = 0.48, p = 0.009) and the distance from the coracoid tip to the anterior coracoacromial ligament attachment (r = 0.63, p < 0.001). The receiver operating characteristic curve area under the curve for cadaver height was 0.72 while that for distance from coracoid tip to anterior coracoacromial ligament was 0.88 when predicted for a sufficient length for coracoid transfer > 25 mm. Conclusions Our findings will aid surgeons in preoperative planning and performing of osteotomy of the coracoid safely by predicting the available length of coracoid bone graft.

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Lisfranc ligament is a strong interosseous ligament located between the medial cuneiform (C1) and base of the second metatarsal (M2). Lisfranc injuries occur in approximately 0.2% of all fractures and are often overlooked or misdiagnosed. Weightbearing radiograph of the foot has been used as a diagnostic method for Lisfranc injuries; however, there is no study to evaluate the reliability of the measurement techniques on weightbearing radiographs. While several measurement techniques on weightbearing radiograph have been proposed for evaluating Lisfranc injuries, it remains unclear which measurement is the most reliable. This study aimed to evaluate the intra- and inter-observer reliability of the measurement techniques using weightbearing radiographs. Methods: Seventeen patients who were diagnosed with Lisfranc injuries using weightbearing radiographs and were treated with open reduction and internal fixation in our hospital between January 2013 and April 2019 were included in this study. Patients with multiple fractures were excluded. Four observers were selected, of which two were orthopedic specialists with more than six years of experience, while the remaining two were orthopedic surgeons with less than five years of experience. Observers evaluated the intra- and inter-observer reliability of the five measurement points on weightbearing radiographs on the affected and unaffected sides. The measurement points included the proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 and C1- the medial cuneiform (C2). Results: The proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 of The affected sides were wider than those of the unaffected sides with significant difference (p

This report describes clinical and radiographic characteristics of two pediatric patients with a presumptive diagnosis of subchondral fracture of the femoral head made based on their clinical course and imaging findings. An 8-year-old boy and an 8-year-old girl had subchondral fracture in the femoral head without osteonecrosis, which was verified by contrast-enhanced magnetic resonance imaging. Although complete disappearance of the fracture line was confirmed in the boy, the girl had a residual femoral head deformity after conservative treatment. Subchondral fracture of the femoral head should be included in the differential diagnosis of pediatric hip pain.

Objective. To report a rare case of an acute attack of calcium pyrophosphate dihydrate (CPPD) deposition disease in a patient with lumbar spondylolytic spondylolisthesis, which demonstrated widespread lesion with neurological deficit. Methods. An 86-year-old woman presented with high fever and bilateral neurological deficit of the lower extremities. Results. CRP was elevated (20.9 mg/dl). Plain radiographs and computed tomography images showed bilateral L4 spondylolytic spondylolisthesis. Sagittal magnetic resonance (MR) images revealed effusion at the L3-4 interspinous space, and a gadolinium- (GD-) enhanced epidural mass was observed at the level of L4 vertebral body. Axial MR images showed an intra- or epidural lesion at L2-3. Moreover, epidural GD-enhanced masses compressed the dural sac in the shape of a cross at the L3-4 and L4-5 segments. The patient was suspected of having pyogenic arthritis of the lumbar spine in initial diagnosis. A total of 1.2 ml of fluid with a murky, pus-like synovial effusion was aspirated from the L3-4 interspinous space under the fluoroscopic image. Smear speculum of synovial fluid tested negative for bacteria and fungi; however, a number of crystals were seen. Based on the result of smear speculum, we suspected the pathology as crystal deposition disease. Based on polarized light microscopy, which revealed monocle or triclinic intracellular crystals with a positive birefringence, the patient was diagnosed with pseudogout of the lumbar spine. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered by intravenous drip injection for 3 days, and local and systemic inflammatory signs, as well as neurological deficits, dramatically improved. Conclusions. We encountered the rare case of an acute attack of pseudogout with the wide lesion in the lumbar spondylolytic spondylolisthesis. Multiple culture of the effusion provided a definitive diagnosis, which allowed for appropriate, minimally invasive treatment for 8 weeks of NSAID administration that provided the satisfactory recovery from the symptoms.

Abstract Background This study investigated the risk factors for postoperative complications requiring revision surgery within 3 years after transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH). Methods We reviewed 127 patients (147 hips) who underwent TRO (anterior or posterior rotational osteotomy) for ONFH between January 2002 and December 2014. Two patients were lost to follow-up, and five patients with progression of femoral head collapse requiring a salvage procedure such as total hip arthroplasty within 3 years after TRO were excluded. The better hip in patients treated bilaterally was also excluded (n = 20) to avoid duplication of patient demographics, leaving 120 hips (120 patients) for the analysis. We reviewed the medical records of each patient to screen for postoperative complications that required revision surgery within 3 years after surgery, recording the patient’s age, sex, body mass index, surgical side, condition of the contralateral hip, previous alcohol intake, previous alcohol abuse, previous corticosteroid use, perioperative corticosteroid use, smoking status, preoperative stage and type of ONFH, preoperative activity level, and preoperative and final follow-up Japanese Orthopaedic Association scores. Differences between cases with and without complications were analyzed. Results Eleven (9.2%) cases showed postoperative complications that required revision surgery. The most common complication was deep infection (n = 5), followed by nonunion of the greater trochanter (n = 3), nonunion of the intertrochanteric osteotomy site (n = 2), and femoral head fracture (n = 1). The multivariate analysis showed an independent association between previous alcohol abuse and postoperative complications (odds ratio, 13.5). Conclusion A correlation might exist between alcohol abuse and complications following a TRO procedure.

Category: Ankle, Arthroscopy Introduction/Purpose: Ankle sprain commonly occurs in sports activities and most patients are successfully managed with conservative treatment. An incidence of 10–30% of patients will fail conservative treatment and result in chronic lateral ankle instability (CLAI) that may require surgical treatment. Recently, several systematic reviews reported that arthroscopic lateral ankle ligament repair for CLAI are provided good clinical results. However, the pathologic condition of the lateral ankle ligament after anatomical repair has not been clarified. Previous investigations have reported that ligament signal intensity using MRI has a strong negative linear relationship with material biomechanical strength properties. The purpose of this study was to report the clinical outcome and evaluation of the anterior talofibular ligament (ATFL) using MRI after arthroscopic lateral ankle ligament repair. Methods: We retrospectively reviewed 40 patients (40 ankles) who underwent arthroscopic lateral ankle ligament repair for CLAI. The average age at the time of surgery was 28 years (range 12–66 years). The average follow-up was 13 months (range 12– 18 months). Clinical outcomes were assessed preoperatively and 12 months postoperatively using Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale and Self-Administered Foot Evaluation Questionnaire (SAFE-Q). The ATFL was evaluated using 3.0-T MRI at the preoperatively, six months postoperatively and 12 months postoperatively. The ATFL characteristics classified into the following categories: nonvisualization of the ligament, discontinuity, a wavy or curved contour, or high signal intensity within the ligament. Results: The mean JSSF score increased from 72 preoperatively to 95 at 12 months postoperatively. The preoperative MRI findings of the ATFL were categorized as discontinuity (11 ankles), a wavy or curved contour (14 ankles), or high signal intensity within the ligament (22 ankles). The all ATFL findings at the six months postoperatively had straight band extending from the talus to the fibular malleolus, and nine of 40 ankles had high signal intensity within the ligament. The ATFL findings at the 12 months postoperatively revealed residual high signal intensity within the ligament in six of nine ankles. A comparison of the postoperative ATFL with high signal intensity and with low signal intensity group, there were no significant difference in postoperative clinical outcomes between the groups. Conclusion: This study demonstrated that arthroscopic lateral ankle ligament repair was an effective procedure for the treatment of CLAI and restored the condition of ATFL.

Category: Ankle, Arthroscopy Introduction/Purpose: Osteochondral talar lesions (OCL) are infrequent in children, and little is known about the treatment and clinical outcome of these defects. Clinicians normally first attempt nonoperative treatment of these lesions, but if such treatment fails, surgical many treatments including retrograde drilling (RD), are attempted. RD is usually reserved for large OCLs with intact overlying cartilage. Good clinical outcomes have been reported in RD. However, the clinical outcomes of RD for OCL in children remains unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of RD in skeletally immature children. Methods: From January 2015 to April 2018, RD was performed on eight feet with OCL in six consecutive patients in skeletally immature children. Arthroscopic lateral ankle ligament repair was also performed in one of the eight feet, and one foot was excluded; therefore, we studied seven feet in five patients. The patients comprised three boys and two girls with a mean age at surgery of 11 (range, 9–12) years. All patients were followed for a minimum of 6 months postoperatively, the average follow-up was 19.1 (range, 8–39) months. All patients were grade 0, determined according to a modified Pritsch classification system. All patients were evaluated for Japanese Society for Surgery of the Foot (JSSF) scale and radiographic outcomes at preoperatively and postoperatively final follow up. Results: The average JSSF scale improved from 79.4 points (range, 69–90 points) to 100 points in all feet at final follow-up (p

Category: Ankle, Sports Introduction/Purpose: The arthroscopic bone marrow stimulation (ABMS) promotes repaired tissue healing of the osteochondral defect. Recently, T2 mapping has been used to evaluate the repair of cartilage tissue; however, the prognostic worth of T2 values after ABMS has not yet been clarified. Several articles have reported that the subchondral condition affects the articular cartilage condition, and subchondral bone edema (SBE) is reportedly associated with inferior outcome after ABMS. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS. The purpose of the present study was to investigate the relationship between SBC/SBE and T2 values of repaired tissue on MRI after ABMS. We hypothesized that the presence of SBC/SBE would affect the characteristics of the repaired tissue after ABMS. Methods: We prospectively enrolled 18 patients (18 ankles) scheduled to undergo treatment with ABMS for OLT. The patients were six males and 12 females (age, 29.3 ± 22.1 years; lesion length, 10.8 ± 3.0 mm; lesion area, 59.7 ± 26.0 mm2). Repair tissue was assessed using a 3 T MRI unit, and T2 maps were calculated. Patients were divided into two groups for investigating effect of the SBE: those with SBE and those without SBE based on MRI performed pre-ABMS and 1 year post-ABMS. We investigated the relationship between T2 value and SBE presence. For investigating the relationship between SBC and T2 value, the patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. Clinical results were assessed using JSSF scale. Results: There were no significant differences in mean T2 values and JSSF score before ABMS between those with SBE versus those without SBE (T2 values, P = 0.5; JSSF score, P = 0.9). At 1 year post-ABMS, there was no significant difference between groups in T2 value (P = 0.8), but the JSSF score was significantly lower in the SBE group (P = 0.02). No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values, P=0.7 / JSSF scale score, P=0.25).Lesion length/area were correlated with T2 values of repaired tissue (length: r = 0.50, P = 0.005; area: r = 0.29, P = 0.04). Conclusion: The presence of pre- and/or post-ABMS SBE does not affect the T2 values of repaired tissue after ABMS for OLT. The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, post-ABMS SBE was associated with poorer clinical outcome. Larger lesion size is correlated with poorer condition of repaired tissue.

Purpose: The purpose of this study was to clarify the indication for opening wedge high tibial osteotomy (OWHTO) in terms of lower limb alignment to achieve satisfactory clinical results. Methods: Ninety-two patients (98 knees) with medial compartment knee osteoarthritis were investigated in this study. The average follow-up period was 34 months (range, 24–68 months). The average age of the patients at the time of surgery was 63 years (range, 41–77 years). Results: The patients were divided into the following two groups according to the preoperative femorotibial angle (FTA) on anteroposterior full-length radiographs of the lower limbs while weight bearing: 29 knees with a preoperative FTA of ≥185° were defined as those with severe varus (S group), and the remaining 69 knees with a preoperative FTA of 175° were defined as undercorrected. The Lysholm score was used to assess the clinical results. The average postoperative FTA was 175.7° ± 4.1° in the S group and 174.6° ± 3.1° in the M group ( p = 0.013). Significantly, more undercorrected knees were observed in the S than M group ( p = 0.00035). The postoperative Lysholm score was 85.6 ± 8.5 in the S group and 88.5 ± 5.7 in the M group at the last follow-up ( p = 0.0033). Conclusion: Based on these results, we recommend that a preoperative FTA of

Category: Ankle Arthritis Introduction/Purpose: Arthroscopic ankle arthrodesis (AAA) is a good clinical outcome, because the arthroscopic method has been deemed to have shorter union time, less blood loss, less morbidity, shorter hospital stays, and more rapid mobilization. However, it is unclear about the relationship between progression of adjacent-joint arthritis and clinical outcome at long-term follow-up. The purpose of this study was to investigate the relationship between AAA and adjacent-joint arthritis at 2 years postoperatively. Methods: We evaluated 17 feet of 17 patients at a minimum of two years after surgery that were able to be followed, from among 59 feet in 55 patients with ankle osteoarthritis who underwent AAA between January 2006 and April 2015. The mean age was 66.1 ± 8.1 (range, 57-79) years, and postoperative follow-up was performed at a mean of 4.5 ± 2.3 (range, 2-10) years after surgery. The radiographic evaluation examined a union rate of the ankle, and a progression of adjacent-joint osteoarthritis (OA) change. We examined the relationship between the presence of adjacent-joint OA and Japanese Society for Surgery of the Foot (JSSF) score before surgery and last follow up. Additionally, we examined the relationship between the presence of adjacent-joint OA and Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at last follow up. Results: JSSF score was improved to 56.9 points before surgery and 89.2 points last follow up, and the union rates was 17 feet of 17 feet (100%). At the last follow-up, radiographic signs of developed or progressing arthritis were observed in ten feet at subtalar joint (58.8%) and in three patients at talonavicular joint (17.6%). The postoperative JSSF scale regarding the presence or absence of the adjacent joint OA, there were no significant differences (89.3 ± 6.0 points in the absence group and 89.2 ± 6.1 points in the presence group). Postoperative SAFE-Q was not significantly different, pain and pain-related physical functioning and daily living, social functioning, shoe-related, and general health and well-being. Conclusion: There was no significant difference in the JSSF score of presence or absence of the adjacent-joint OA before surgery and at the final follow-up. Additionally, there was no significant difference in the SAFE-Q of presence or absence of the adjacent-joint OA at the final follow-up. The adjacent-joint OA was progressed after AAA, however clinical outcome was relatively maintained.

Category: Arthroscopy Introduction/Purpose: The arthroscopic bone marrow stimulation (ABMS) technique is the first-line procedure for the treatment of osteochondral lesions of the talus (OLT). Recently, T2 mapping was used to evaluate repair cartilage tissue, but the prognostic factors for T2 values after ABMS have never been clarified. Some patients have OLT with sclerotic changes in the subchondral bone, and several articles have suggested that the subchondral bone condition affects the condition of the articular cartilage. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS.The purpose of this study was to investigate the relationship between subchondral bone sclerotic changes and repair tissue T2 values on MRI after ABMS. Methods: Twenty ankles in 20 patients treated with ABMS for OLT were evaluated. The patients included 7 males and 13 females (age, 30.52±21.44 years, lesion length 10.4±3.0mm, lesion area 55.7±26.5mm2). Repair tissue was assessed using a 3T MRI unit, and T2 maps were calculated at the one-year post-ABMS follow up. The patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. We investigated the relationship between T2 values and SBC. Clinical results were measured using the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale. Results: No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values; 48.2±3.3ms vs. 50.1±2.9ms, P=0.7 / JSSF scale score; 89.4±5.8 points vs. 93.3±8.2 points, P=0.25). Lesion length was correlated with the T2 values of repair tissue (Length; r=0.3 P=0.01). Age and BMI were not significantly correlated with T2 values of the repair tissue. Conclusion: The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, we believe that lesion size affected the condition of the repair tissue.

Background:. Subchondral insufficiency fracture of the femoral head (SIF) occurs infrequently in young adults. As the collapsed SIF lesion is usually located at the anterior portion of the femoral head, young adults with SIF are considered to be candidates for transtrochanteric anterior rotational osteotomy, similar to patients with osteonecrosis of the femoral head (ON). In the present study, we assessed the clinical and radiographic results of anterior rotational osteotomy for the treatment of SIF as compared with ON. Methods:. We retrospectively reviewed 28 consecutive patients who underwent anterior rotational osteotomy for the treatment of unilateral SIF (7 patients) or unilateral ON (21 patients). The mean duration of follow-up was 3.7 years (range, 2.0 to 6.2 years). Clinical and radiographic assessments were performed with use of the Harris hip score (HHS), sequential radiographs, and single-photon emission computed tomography/computed tomography (SPECT/CT) with 99mTc-hydroxymethylene diphosphonate performed 5 weeks after surgery. Results:. The mean HHS (and standard deviation) in the SIF group improved significantly from 51.6 ± 11.7 preoperatively to 91.9 ± 7.1 at 1 year after surgery and to 96.9 ± 3.8 at the time of the latest follow-up (p = 0.0010 and 0.0002, respectively). Similarly, the mean HHS in the ON group improved significantly from 52.4 ± 13.7 preoperatively to 80.7 ± 10.0 at 1 year after surgery and to 88.2 ± 12.6 at the time of the latest follow-up (p < 0.0001 for both). The HHS was significantly higher in the SIF group than in the ON group at 1 year after surgery (p = 0.019), but there was no significant difference between the groups at the time of the latest follow-up (p = 0.10). A postoperative intact ratio (calculated as the intact area of the femoral head divided by the weight-bearing area of the acetabulum on an anteroposterior radiograph) of >80% was achieved in association with smaller femoral neck-shaft varus angles in the SIF group (10.0° ± 4.2°) as compared with the ON group (15.3° ± 8.2°). Postoperative progression of collapse at the anteriorly rotated subchondral lesion was observed in 5 patients (23.8%) in the ON group but no patients in the SIF group. SPECT/CT images showed that rate of increased tracer uptake at the collapsed lesions in the SIF group was significantly higher than that in the ON group (p < 0.0001). Conclusions:. The present study suggested that the absence of progression of collapse and a sufficient postoperative intact ratio without the need for marked varus realignment may be associated with favorable results following anterior rotational osteotomy for the treatment of SIF in young adults. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Para-acetabular insufficiency fractures are rare and exceedingly difficult to diagnose without a high index of suspicion, since the images mimic those of bone tumors. We herein present the case of a 55-year-old woman who suffered from hip pain with subacute onset. She had undergone a hysterectomy-ovariectomy due to endometriosis when she was 41 years old. Her bone mineral density was normal due to supplemental treatment with female hormones. About 3 months after onset, she was referred to our institute with a diagnosis of pelvic bone tumor. Plain radiographs and computed tomography showed irregular osteosclerosis in the para-acetabulum. Bone scintigraphy demonstrated uptake in the para-acetabulum. Magnetic resonance imaging showed abnormal signal with low-signal intensity on T1-weighted images and high-signal intensity on T2-weighted images throughout the entire hemipelvic bone. Since the pain continued for more than 3 months, open biopsy was undertaken and the lesion was found to be non-neoplastic. Six months after onset, the pain disappeared. The clinical course suggested a diagnosis of insufficiency fracture in the para-acetabulum. Para-acetabular insufficiency fractures should always be considered in cases of hip pain, even in patients with prolonged symptoms.

Alkaptonuria is a very rare disorder in which homogentisic acid accumulates due to a deficiency in the activity of homogentisic acid 1,2 dioxygenase. This deficiency results in deposition of a yellowish– brown pigment in connective tissue. Such deposition is termed ’ochronosis’ and leads to deterioration in the formation and structure of proteoglycans in hyaline cartilage. These actions lead to fragmentation and rapid destructive arthritis. Often, ochronotic arthritis appears at 40–60 years of age, and many patients are treated symptomatically. Here, we report two patients (three ankles) with ochronotic arthritis who were treated with ankle arthrodesis. In all cases, the postoperative clinical score improved, but the time needed for fusion was prolonged and symptomatic subtalar arthropathy developed in the early postoperative period. [ABSTRACT FROM AUTHOR]