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Background: Open-wedge High Tibial Osteotomy (HTO) is an effective treatment for Osteoarthritis (OA) of the knee; however, postoperative changes due to HTO can make subsequent Total Knee Arthroplasty (TKA) technically difficult and can affect long-term survival. Case Report: Medio-lateral stability along with balanced flexion and extension gaps provides a good functional outcome. A 71-year-old man underwent TKA conversion after open-wedge HTO 12 years earlier; the conversion was performed due to arthritic deterioration in the knee. Medial instability was noted because of poor ligament balancing. The residual medial instability was managed with a knee brace due to the unavailability of the constrained prosthesis. Management of persistent mediolateral instability persisting after soft tissue release and balancing ideally requires varus-valgus constraint. Conclusion: TKA conversion after open-wedge HTO requires a special technique and careful preparation before surgery.

Untreated leg length discrepancy can cause spontaneous osteonecrosis of the knee, which is associated with subchondral insufficiency fractures of the knee and progression or onset of osteoarthritis of the knee. Spontaneous osteonecrosis of the knee can be secondary to cartilage loss or additional subchondral changes. A 40-year-old female underwent opening-wedge high tibial osteotomy and osteochondral grafting for osteonecrosis of the femoral medial condyle and osteoarthritis of the knee caused by leg length discrepancy after a traffic accident. High tibial osteotomy and cartilage restoration are often considered for the treatment of knee osteonecrosis with cartilage damage in younger patients.

Complications after arthroscopic meniscal suture repair have been reported. Migration of a meniscal repair implant mimicking meniscal injury is rare. A 28-year-old female had undergone Anterior Cruciate Ligament (ACL) reconstruction at another hospital 12 years ago . The remaining instability after ACL reconstruction resulted in medial meniscal damage, wear and narrowing in the posterior third. The H-fix that was used in the meniscal repair became detached, exposing the inside of the knee joint. Meniscal repair is a successful procedure in conjunction with ACL reconstruction. However, when knee instability after ACL reconstruction remains, the choice of meniscal repair implants may lead to potential complications even after long-term clinical follow-up.

Chondral injury after arthroscopic meniscal suture repair is rare. We present a case of chondral injury due to the migration of suture after meniscal repair. The aberrant suture that remained temporarily at the medial tibiofemoral joint may have led to the chondral lesion of the femoral medial condyle and the tibial medial plateau at the weight-bearing portion.

Background: The trapeziometacarpal joint is the second most common site of osteoarthritis in the hand and the most frequent one to require surgery. Arthrodesis of the trapeziometacarpal joint is recognized as one of the valuable technique but unfortunately there has been wide variation in the union rate. The purpose of this study was to evaluate a new arthrodesis technique involving a cross-shaped bone graft and locking plate fixation. Methods: Eleven male patients diagnosed as Eaton’s stage III osteoarthritis of the trapeziometacarpal join were treated in our institute. The mean patient age was 62 years (range 50 to 80 years). At the day after surgery, physical therapy was started and free use of the hand was permitted. Results: Patients showed radiographic evidence of trapeziometacarpal joint union after an average postoperative period of 8.3 weeks (range 6–12 weeks). The VAS pain score significantly decreased from 7.2 points preoperatively to 0.4 points after surgery. Mean side pinch strength increased significantly from 3.8 kg (53% compared to unaffected side) prior to surgery to 6.2 kg (86%). The DASH score improved from 38.6 (range 34.1–43.2) preoperatively to 17.0 (6.8–22.7) postoperatively. Conclusions: These data suggested that our technique is a successful procedure for the trapeziometacarpal joint arthrodesis. Cross-shaped bone grafts have the advantages of restoring thumb length and providing internal stabilization, especially for rotational force. No complications arose at the bone harvest site of the iliac crest. The procedure seems to be technically demanding, particularly for adapting the bone graft to perfectly match the shape of the defect.

Background Several different triangular fibrocartilage complex (TFCC) tear patterns have been classified through the use of wrist arthroscopy. A tear of the dorsal aspect of the TFCC has been previously reported, but it is not included in Palmer original classification. Our purpose was to describe this type of tear pattern along with the clinical presentation. Methods An isolated dorsal TFCC tear was encountered in seven wrists of six patients (three men and three women; average age was 31 years). All patients were evaluated by physical exam, X-ray, plain axial computed tomography with pronation, neutral and supination position, magnetic resonance imaging (MRI) with coronal, sagittal, and axial section and arthroscopy. Results The clinical findings varied and included the following: tenderness at the dorsoulnar aspect of the wrist was positive in all wrists, fovea sign was positive in five wrists, and tenderness at the dorsal aspect of the distal radioulnar joint was present in one wrist. Pain with forearm rotation was positive in all wrists. The ulnar head ballottement test induced pain in all wrists, whereas dorsal instability of the ulnar head was present in one wrist with this test. The ulnocarpal stress test was positive in five wrists. Axial and sagittal images on MRI revealed the dorsal tear in five wrists. All wrists were treated with an arthroscopic capsular repair. The final functional outcome at an average follow-up of 16.1 months was four excellent and one good wrist according to the modified Mayo wrist score. Conclusions The aim of this article is to describe our experiences with tears involving the dorsal aspect of the TFCC, which may be misdiagnosed if the surgeon is not cognizant of this injury. Type of study/level of evidence Diagnostic/level IV

Background Evaluation of knee and lower limb function alone is not sufficient to assess gait. For accurate assessment of gait abnormality, gait oscillation should also be measured. The goal of this analysis was to assess the influence of the knee joint on gait oscillation during gait and stair-stepping in patients with osteoarthritis of the knee. Methods In 33 patients diagnosed with knee osteoarthritis and 33 healthy adults as the control group, we examined acceleration (anterior and lateral directions) and gait barycentric factors (single-support phase and ratio of center of gravity maximum values) during gait and stair-stepping. Results Acceleration in the anterior direction in the sacral region was greater in healthy adults than in osteoarthritis (OA) patients during gait and stair-down. Acceleration in the anterior direction in the dorsal vertebral region was greater in OA patients than in healthy adults during (up and down) stair-stepping. Acceleration in the lateral direction in the sacral region was greater in healthy adults than in OA patients during stair-up. Acceleration in the lateral direction in the dorsal vertebral region was greater in OA patients than in healthy adults during stair-stepping. The single-support phase was close to 1 for gait and stair-stepping in healthy adults and OA patients. The single-support time was largely the same for gait and stair-stepping in healthy adults. On the other hand, the single-support time was longer for stair-stepping than for gait in OA patients. The ratio of the center of gravity maximum values was greater for the sacral region than for the dorsal vertebral region. There was a significant difference in the stair-stepping ratio of the center of gravity maximum values between healthy adults and OA patients for the sacral region. Conclusion We considered that knee OA influenced acceleration in the anterior and lateral direction in the dorsal vertebral and the ratio of the center of gravity maximum values on gait oscillation.

Background:Pigmented villonodular synovitis (PVNS) is a rare disorder around the ankle joint. The optimal treatment for diffuse-type PVNS is still controversial because of the high incidence of recurrence. We present the clinical features of our patients and review the current diagnostic and treatment modalities.Methods:Five patients with PVNS located around the ankle were surgically treated. In three patients, diffuse PVNS arose from the ankle joint, and in the other two it arose from the calcaneocuboid and intercuneiform joints. The average follow-up time after surgery was 2.9 years (range, 2–4.6 years).Results:The average time between onset of pain and diagnosis of PVNS was 6.4 years (range, 4–10 years). Arthrotomic tumor resection was performed in all of the patients. In the three patients with ankle joint PVNS, both medial and lateral approaches were used. One patient experienced mild infection at the surgical site, but this healed conservatively. No tumor recurrences had occurred after minimum follow-up of 2 years, although mild pain persisted in the three patients with ankle PVNS.Conclusions:Diagnosis of diffuse PVNS is frequently delayed due to vague symptoms and variable growth patterns. Orthopedic clinicians should be aware of the existence of this lesion, and it should be suspected in patients with persistent ankle swelling. To prevent tumor recurrence, accurate evaluation of tumor location and careful operative planning are mandatory. A combined surgical approach involving medial and lateral incision is necessary to expose the entire joint cavity.

Idiopathic avascular necrosis of the scaphoid, or Preiser disease, is a rare condition. Both the etiology and the pathology are still not well understood. We here present 2 cases with this disease and discuss the recommended treatment according to the stage of disease progression and by reference to previous studies in the literature. Similar to Kienböck disease, the recommended treatment should be selected according to the degree of disease progression. We believe that vascularized bone graft should be restricted to Herbert stage I or II cases with no evidence of radiocarpal arthritis or carpal instability. Our first case showed excellent revascularization following vascularized bone graft, as revealed by magnetic resonance image findings. The presence of arthrosis of the radiocarpal or mid-carpal joints is an indication for scaphoid excision with midcarpal fusion or proximal row carpectomy.

The origin of the peroneal intraneural ganglion and the outcome of treatment are still controversial. We report here three cases with peroneal intraneural ganglion and discuss the appropriate treatment. In our cases, 58-, 62-, and 65-year-old patients were operated on with extraneural decompression and epineurotomy within 4 months after onset of drop foot. Two cases demonstrated intraneural ganglion connecting to the articular branch and traversing to the deep and common peroneal nerve. At the 1-year follow-up, paralyzed peroneal nerve could be recovered in all patients even with residual ganglion. We propose correct early diagnosis, simple exoneural dissection, and atraumatic epineurotomy for the successful treatment of peroneal intraneural ganglion. Disruption of the stalk in the articular branch is a key point to prevent recurrence. For early diagnosis, clinicians should be aware of the existence of this rare lesion.

We demonstrate various patterns of traumatic triangular fibrocartilage complex (TFCC) tears including some atypical that cannot be categorized under Palmer's classification. TFCC traumatic tears in 173 wrists were examined arthroscopically or macroscopically and divided into disk tears (subdivided into four types: slit tear, flap tear, horizontal tear and tear within the distal radioulnar joint) and peripheral tears (subdivided into six types: ulnocarpal ligament tear, dorsal tear, radial tear, ulnar styloid tear, foveal tear and distal radioulnar ligament tear). Combinations of these types were found in 32 wrists. Wrist arthroscopy revealed various traumatic TFCC tears that do not come under Palmer's classification; therefore establishment of a new classification for traumatic TFCC tears seems to be warranted.

Wrist arthroscopy has been successfully used with many modifications and improvements. However, distal radioulnar joint (DRUJ) arthroscopy is still uncommon. We experienced 2 cases of ulnar-sided wrist pain due to isolated triangular fibrocartilage complex (TFCC) disk tear within the DRUJ. DRUJ arthroscopy in these cases showed horizontal tear and fibrillation of TFCC disk without TFCC tear at the radiocarpal joint. Foveal attachment was intact in both cases. These were treated with debridement, which relieved pain after surgery and achieved good functional recovery. Although DRUJ arthroscopy is technically difficult, it is mandatory for making a diagnosis and treating ulnar-sided wrist pain.

The goal of this study was to compute the dynamic neck loads during simulated high-speed bilateral facet dislocation and investigate the injury mechanism.Ten osteoligamentous functional spinal units (C3/4, n = 4; C5/6, n = 3; C7/T1, n = 3) were prepared with muscle force replication, motion tracking flags, and a 3.3-kg mass rigidly attached to the upper vertebra. Frontal impacts of increasing severity were applied to the lower vertebra until dislocation was achieved. Inverse dynamics was used to calculate the dynamic neck loads during dislocation. Average peak impact acceleration required to cause dislocation ranged between 7.6 and 11.6 g. This resulted in dynamic neck loads applied at average peak rates of 906 Nm/s for flexion moment, 8017 N/ for anterior shear, and 8100 N/s for axial compression. To determine the temporal event patterns, the average occurrence times of the load and motion peaks were statistically compared (P0.05).Among average peak loads, axial compression of 233.6 N was first to occur followed by anterior shear force of 73.1 N and flexion moment of 30.7 Nm. Among average peak motions, axial separation of 5.3 mm was first to occur followed by flexion rotation of 63.1 degrees and anterior shear of 21.5 mm. Subsequently, average peak posterior shear force of 110.3 N was observed as the upper facet became locked in the intervertebral foramina. Average peak axial compression of 6.6 mm occurred significantly later than all preceding events.During bilateral facet dislocation, the main loads included flexion moment and forces of axial compression and anterior shear. These loads caused flexion rotation, facet separation, and anterior translation of the upper facet relative to the lower. The present data help elucidate the injury mechanism of cervical facet dislocation.

Background. Marked hyperplasia of the parathyroid gland (PTG) is a characteristic feature of severe hyperparathyroidism in patients under chronic haemodialysis treatment. Percutaneous ethanol injection therapy (PEIT) is now becoming popular in Japan as a treatment option for secondary hyperparathyroidism (SHPT) and its cost is covered by the National Health Insurance (NHI) System. The Japanese Society for Parathyroid Intervention surveyed its membership in 2004 to revise the guidelines for the use of PEIT. Methods. The project was approved by the Executive Committee of the Society, and the primary questionnaire was addressed to 3268 centres (departments) affiliated with the Japanese Society for Dialysis Therapy. A follow-up questionnaire was sent to all the centres that responded. Results. Although the number of centres to which the questionnaire was sent in 2004 was 3268, compared with 2653 in 1998, the number of responses decreased from 1425 (53.7%) in 1998 to 962 (29.4%) in 2004. To the question of whether the centre performed PEIT, 114 (11.9%) answered 'Yes' and 848 (88.1%) answered 'No' in 2004. It was an increase from 1998 when only 83 (5.8%) of 1425 centres answered 'Yes'. In the 1998 survey, 612 patients underwent PEIT at 74 centres, and in 2004, 2098 patients underwent PEIT at 111 centres. Conclusions. PEIT may become the frequently performed treatment for SHPT patients who become resistant to medical therapy. However, the same problems as in 1998 remain unsolved; that is, recurrent nerve paralysis, difficulty of post-PEIT PTx and lack of evidence showing the long-term effectiveness of PEIT.

【目的】大腿骨頚部内側骨折に対する骨接合術後成績不良例について検討を行った．【対象】2004年1月～2007年5月の間，当院にて骨接合術を行った24例のうち，成績不良例は3例であった．症例1，89歳女性，Garden II型．受傷5日でハンソンピンにて骨接合術施行したが，術後2カ月で骨頭扁平化が出現し6カ月で完全に骨頭が圧潰した．症例2，58歳男性，透析患者．6カ月前から誘引なく右股関節痛が出現．Garden III型でありハンソンピンによる骨接合術を施行．偽関節となり術後7カ月で人工骨頭挿入術を施行した．症例3，76歳女性，Garden III型の内側骨折に外側骨折を合併．CHSにて骨接合術施行したが，術後3カ月半でラグスクリューが脱転し，抜釘・人工骨頭挿入術を施行した．【結語】今後，大腿骨頭壊死の予測，透析患者や外側骨折を合併した症例に対する術式選択が課題である．

STUDY DESIGN An in vitro human cadaveric biomechanical study. OBJECTIVES To quantify effects on operated and other levels, including adjacent levels, due to CHARITE disc implantations versus simulated fusions, using follower load and the new hybrid test method in flexion-extension and bilateral torsion. SUMMARY OF BACKGROUND DATA Spinal fusion has been associated with long-term accelerated degeneration at adjacent levels. As opposed to the fusion, artificial discs are designed to preserve motion and diminish the adjacent-level effects. METHODS Five fresh human cadaveric lumbar specimens (T12-S1) underwent multidirectional testing in flexion-extension and bilateral torsion with 400 N follower load. Intact specimen total ranges of motion were determined with +/-10 Nm unconstrained pure moments. The intact range of motion was used as input for the hybrid tests of 5 constructs: 1) CHARITE disc at L5-S1; 2) fusion at L5-S1; 3) CHARITE discs at L4-L5 and L5-S1; 4) CHARITE disc at L4-L5 and fusion at L5-S1; and 5) 2-level fusion at L4-L5-S1. Using repeated-measures single factor analysis of variance and Bonferroni statistical tests (P < 0.05), intervertebral motion redistribution of each construct was compared with the intact. RESULTS In flexion-extension, 1-level CHARITE disc preserved motion at the operated and other levels, while 2-level CHARITE showed some amount of other-level effects. In contrast, 1- and 2-level fusions increased other-level motions (average, 21.0% and 61.9%, respectively). In torsion, both 1- and 2-level discs preserved motions at all levels. The 2-level simulated fusion increased motions at proximal levels (22.9%), while the 1-level fusion produced no significant changes. CONCLUSIONS In general, CHARITE discs preserved operated- and other-level motions. Fusion simulations affected motion redistribution at other levels, including adjacent levels.

Elongation-induced vertebral artery (VA) injury has been hypothesized to occur during nonphysiological coupled head motions during automobile impacts. Although previous work has investigated VA elongation during head-turned and head-forward rear impacts, no studies have performed similar investigations for frontal or side impacts.The present study quantified dynamic VA elongations during simulated frontal and side automotive collisions, and compared these data with corresponding physiological limits.In vitro biomechanical study of dynamic VA elongation during simulated impacts.A biofidelic whole cervical spine model with muscle force replication and surrogate head underwent simulated frontal impacts (n=6) of 4, 6, 8, and 10 g or left side impacts (n=6) of 3.5, 5, 6.5, and 8 g.Average (SD) maximum physiological VA elongation was 7.1 (3.2) mm, measured during intact flexibility testing. Average peak dynamic elongation of right VA during left side impact, up to 17.4 (2.6) mm, was significantly greater (p.05) than physiological beginning at 6.5 g, whereas the highest average peak VA elongation during frontal impact was 2.5 (2.4) mm, which did not exceed the physiological limit. Side impact, as compared with frontal impact, caused earlier occurrence of average peak VA elongation, 113.8 (13.5) ms versus 155.0 (46.2) ms, and higher average peak VA elongation rate, 608.8 (99.0) mm/s versus 130.0 (62.9) mm/s.Elongation-induced VA injury is more likely to occur during side impact as compared with frontal impact.

Cortical abnormalities at the distal postero-medial femoral metaphysis may be relatively common. We reviewed the plain radiographs of 197 knees in 130 children aged between 5 and 12 years to investigate the incidence of distal femoral cortical irregularities (DFCI) and their association with symptoms. An adductor magnus lesion was found in 15% of cases, with an even number of irregular and cystic lesions. A medial gastrocnemius lesion was found in 5% of cases, but no association was found between symptoms and the lesion. Overall, lesions were found in 25% of cases aged 5 to 9 years, but in only 13% of cases aged 12 and 13 years. Boys showed a higher incidence of both adductor magnus and medial gastrocnemius lesions. DFCI is a benign, self-limited entity and a relatively common radiologic finding. Regardless of whether or not symptoms are present, imaging findings should be carefully interpreted to avoid unnecessary diagnostic and invasive therapeutic procedures.

STUDY DESIGN Determination of alar, transverse, and apical ligament strains during simulated head-turned rear impact. OBJECTIVES To quantify the alar, transverse, and apical ligament strains during head-turned rear impacts of increasing severity, to compare peak strains with baseline values, and to investigate injury mechanisms. SUMMARY OF BACKGROUND DATA Clinical and epidemiologic studies have documented upper cervical spine ligament injury due to severe whiplash trauma. There are no previous biomechanical studies investigating injury mechanisms during head-turned rear impacts. METHODS Whole cervical spine specimens (C0-T1) with surrogate head and muscle force replication were used to simulate head-turned rear impacts of 3.5, 5, 6.5, and 8 g horizontal accelerations of the T1 vertebra. The peak ligament strains during impact were compared (P < 0.05) to baseline values, obtained during a noninjurious 2 g acceleration. RESULTS The highest right and left alar ligament average peak strains were 41.1% and 40.8%, respectively. The highest transverse and apical ligament average strain peaks were 17% and 21.3%, respectively. There were no significant increases in the average peak ligament strains at any impact acceleration compared with baseline. CONCLUSIONS The alar, transverse, and apical ligaments are not at risk for injury due to head-turned rear impacts up to 8 g. The upper cervical spine symptomatology reported by whiplash patients may, therefore, be explained by other factors, including severe whiplash trauma in excess of 8 g peak acceleration and/or other impact types, e.g., offset, rollover, and multiple collisions.

Elongation-induced vertebral artery injury has been hypothesized to occur during non-physiological coupled axial rotation and extension of head. No studies have quantified dynamic vertebral artery elongation during head-turned rear impacts. Therefore, we evaluated effect of rotated head posture vs. forward head posture at the time of impact on dynamic vertebral artery elongation during simulated rear impacts.A whole cervical spine model with surrogate head and muscle force replication underwent either simulated head-turned (n = 6) or head-forward (n = 6) rear impacts of 3.5, 5, 6.5 and 8 g. Continuous dynamic vertebral artery elongation was recorded using custom transducer and compared to physiological values obtained during intact flexibility testing.Average (SD) peak dynamic vertebral artery elongation of up to 30.5 (2.6) mm during head-turned rear-impact significantly exceeded (P0.05) the physiological beginning at 5 g. Highest peak elongation of 5.8 (2.1) mm during head-forward rear impact did not exceed physiological limit. Head-turned rear impact caused earlier occurrence of average peak vertebral artery elongation, 84.5 (4.2) ms vs. 161.0 (43.8) ms, and higher average peak vertebral artery elongation rate, 1336.7 (74.5) mm/s vs. 211.5 (97.4) mm/s, as compared to head-forward rear impact.Elongation-induced vertebral artery injury is more likely to occur in those with rotated head posture at the time of rear impact, as compared to head-forward.

Head-turned whole cervical spine model was stabilized with muscle force replication and subjected to simulated rear impacts of increasing severity. Multiplanar flexibility testing evaluated any resulting injury.To identify and quantify cervical spine soft tissue injury and injury threshold acceleration for head-turned rear impact, and to compare these data with previously published head-forward rear and frontal impact results.Epidemiologically and clinically, head-turned rear impact is associated with increased injury severity and symptom duration, as compared to forward facing. To our knowledge, no biomechanical data exist to explain this finding.Six human cervical spine specimens (C0-T1) with head-turned and muscle force replication were rear impacted at 3.5, 5, 6.5, and 8 g, and flexibility tests were performed before and after each impact. Soft tissue injury was defined as a significant increase (P0.05) in intervertebral flexibility above baseline. Injury threshold was the lowest T1 horizontal peak acceleration that caused the injury.The injury threshold acceleration was 5 g with injury occurring in extension or axial rotation at C3-C4 through C7-T1, excluding C6-C7. Following 8 g, 3-plane injury occurred in extension and axial rotation at C5-C6, while 2-plane injury occurred at C7-T1.Head-turned rear impact caused significantly greater injury at C0-C1 and C5-C6, as compared to head-forward rear and frontal impacts, and resulted in multiplanar injuries at C5-C6 and C7-T1.

Intervertebral Neck Injury Criterion (IV-NIC) is based on the hypothesis that dynamic three-dimensional intervertebral motion beyond physiological limits may cause multiplanar injury of cervical spine soft tissues. Goals of this study, using a biofidelic whole human cervical spine model with muscle force replication and surrogate head in simulated side impacts, were to correlate IV-NIC with multiplanar injury and determine IV-NIC injury threshold for each intervertebral level.Using a bench-top apparatus, side impacts were simulated at 3.5, 5, 6.5, and 8 g horizontal accelerations of the T1 vertebra. Pre- and post-impact flexibility testing in three-motion planes measured the soft tissue injury, i.e., significant increase (p0.05) in neutral zone (NZ) or range of motion (RoM) at any intervertebral level, above corresponding physiological limit.IV-NIC in left lateral bending correlated well with total lateral bending RoM (R = 0.61, P0.001) and NZ (R = 0.55, P0.001). Additionally, the same IV-NIC correlated well with left axial rotation RoM (R = 0.50, P0.001). IV-NIC injury thresholds (95% confidence limits) varied among intervertebral levels and ranged between 1.5 (0.6-2.4) at C3-C4 and 4.0 (2.4-5.7) at C7-T1. IV-NIC injury threshold times were attained beginning at 84.5 ms following impact.Present results suggest that IV-NIC is an effective tool for determining multiplanar soft tissue neck injuries by identifying the intervertebral level, mode, time, and severity of injury.

Automotive collision simulations have been performed using either incremental or single trauma. In single trauma, a single impact is performed, while in incremental trauma, a series of impacts of increasing severity are executed. Equivalency of incremental and single trauma for soft tissue injury severity due to the final impact has not been established. Thus, the purpose of the present study was to investigate whether incremental and single trauma produced similar cervical spine subfailure injury severity due to simulated frontal impacts.Porcine cervical spine specimens (C2-T1) of the incremental trauma group were subjected to five frontal impacts (2, 3.5, 5, 6.5, 8 g), while single trauma specimens were subjected to a single impact (8 g). Flexibility tests were performed on specimens while intact and following each impact. Intact and post 8 g flexibility parameters were compared within incremental and single trauma groups and between groups.No significant differences (P0.05) were found between incremental and single trauma groups when either intact or post 8 g flexibility parameters were compared. Significant increases in flexibility parameters from intact to post 8 g were observed in both groups, indicating soft tissue injury.Incremental and single trauma produced equivalent subfailure cervical spine injury in simulated impacts, for the experimental conditions studied. This study may facilitate greater use of the incremental trauma protocol in future experimental designs.

We report a case of paradoxical extension phenomenon of the little finger, so called "lumbrical plus deformity" due to repetitive trauma to the ulnar side of the palm. The adhesion between the flexor digitorum profundus tendon and the lumbrical muscle was the cause of this phenomenon. The lumbrical muscle release was sufficient to solve this rare problem.

Vascularized bone graft (VBG) is a form of vascularized bone marrow transplant in which the bone marrow is surgically grafted with its microenvironment intact. Due to the preservation of cellular viability, VBG have significant advantages over non-vascularized bone grafts. Free vascularized fibula grafts have superior material properties and tolerate infection. Bone healing can be accomplished in a shorter period, even in an irradiated bed. In addition to these properties, VBG has other biological advantages that are not always familiar to oncological surgeons. Hypertrophic change can be divided into reactive and adaptive hypertrophy. Early hypertrophy is associated with donor-derived cells, whereas later remodeling is associated with recipient-derived cells. VBG has significant advantages in enhancing neo-revascularization of necrotic bone. We reviewed VBG from a novel viewpoint that stems from our basic research.

A 38-year-old woman presented with a very large synovial chondromatosis arising from the interphalangeal joint of the thumb. The tumor surrounded the interphalangeal joint and its size was approximately 3 cm. The range of motion was almost fused. Plain radiographs showed an extra-osseous tumor shadow with calcifications. The patient had no local recurrence at one year of follow-up after marginal resection of the tumor and synovectomy. Because this case showed no osteoarthritic changes, it can be classified as primary synovial chondromatosis with a tumor-like nature. Based on the clinical course and pathological report, our synovial chondromatosis case can be classified as Milgram stage 3. Our case report is unique in three respects: i) origin from the interphalangeal joint of the thumb, ii) a single lump of mass and iii) extremely large size. To our knowledge, a similar type of synovial chondromatosis has not been previously reported in the English literature.

Intraosseous lipoma remains a poorly-characterized tumor. In paticular, the natural course of intracalcaneus lipoma after conservative treatment and the appropriate surgical modalities are still quite controversial.We reviewed six symptomatic patients who underwent curettage of intracalcaneus lipoma followed by grafting of α- or β-tricalcium phosphate. An endoscopically-assisted technique was used in one case.All patients experienced heel pain that increased acutely after minor trauma. Heel pain disappeared soon after surgery in five cases. One patient experienced short-term mild chronic regional pain syndrome for short term. β-tricalcium phosphate was completely resorbed and remodeled after transplantation.Surgical treatment is indicated for cases that are: i) symptomatic, ii) larger than the critical size, and iii) prone to pathological fracture. Curettage of intracalcaneus lipoma involving an endoscopically-assisted technique and filling of the defect with β-tricalcium phosphate is a feasible method and is minimally-invasive for the patient.

Summary Although the deltoid muscle has been assumed to be an essential shoulder muscle, the full extent of postoperative functions of the upper extremity following its complete resection due to sarcoma has not been thoroughly investigated. In this study, we review patients who underwent wide resection for sarcoma in the deltoid muscle, followed by functional reconstruction using pedicled latissimus dorsi (LD) muscle transfer. Four patients with sarcoma arising in the deltoid muscle were reviewed. Tumor resection with a wide surgical margin resulted in loss of the entire deltoid muscle together with the axillary nerve. For reconstruction, the ipsilateral pedicled LD muscle was transferred on its neurovascular pedicle for use as a functional substitute. One case had local recurrence and the transferred LD myocutaneous flap was resected. There were no serious complications after the operation, and all flaps survived perfectly. Wound healing at both the recipient and donor sites was uneventful. Active abduction of the shoulder joint was >160° in all patients. The muscle manual test of shoulder flexion was good to normal and abduction was fair to good. Musculoskeletal Tumor Society scores were excellent in all cases and the average score was 92% (range, 87–93%). Our results suggest that removal of the entire deltoid muscle resulted in a slight impairment of function. Pedicled LD musculocutaneous flaps are useful for covering the defect that results from resection of the deltoid muscle and they contribute additional function to the affected shoulder.

【目的】三角線維軟骨（TFCC）の損傷は手関節尺側部痛の原因として確立されているが，実際はTFCC損傷が存在しても必ずしも疼痛を生じるものではない．今回，その損傷形態と疼痛との関連性について検討した．【対象】TFCC損傷疼痛群は尺骨突き上げがなくTFCCのみ治療を行い症状の軽快した27例28関節，非疼痛群は尺骨遠位（茎状突起を含む）の骨折を伴わない橈骨遠位端骨折において鏡視下手術の際TFCC損傷を確認し，その後全く尺側部痛を生じなかった18例18関節とした．損傷形態の分類はPalmer分類及びオリジナルの分類を使用した．【結果】疼痛群：1A: 15，1B: 9，1C: 3，水平断裂: 4，背側部断裂: 5，尺骨小窩断裂: 4，複合損傷11，非疼痛群：1A: 10，1B: 3，複合: 1，大断裂: 6であった．【考察】以上より，1）1A断裂の疼痛への関与は断裂形態だけでは説明ができない，2）周辺部損傷は疼痛の原因となる危険性が高い，3）大断裂は疼痛を生じない，と推察した．

A new β-tricalcium phosphate with uniform triple superpore structure, SuperPore(®) (HOYA, Tokyo, Japan), has been in clinical use since 2010. As far as we are aware of, there have been no reported clinical studies using this material. We report on the first clinical cases of benign bone tumor filled with SuperPore(®).We retrospectively evaluated the results for 34 benign bone tumors treated by curettage followed by implantation of the highly purified β-tricalcium phosphates Osferion(®) (Olympus, Tokyo, Japan) or SuperPore(®).After a mean follow-up of 12 months, none of the patients experienced local recurrence of the tumor or any adverse effects from the filling materials. Radiographically, complete resorption of the material and bone remodeling were achieved in 32 cases. In 17 selected cases with a small bone tumor, the mean period for complete resorption of the filling material was 21 weeks in the Osferion(®) group and 15 weeks in the SuperPore(®) group, with the latter showing a trend for better outcomes.SuperPore(®) is a safe and reliable filling substitute for defects following curettage of small bone tumors. Both SuperPore(®) and Osferion(®) gave satisfactory results with good biocompatibility and fast resorption characteristics.

Sarcomas in the forearm and hand are very rare, accounting for less than 1% of all upper-limb tumors and clinical outcomes after surgery and adjuvant therapies are uncertain. The forearm and hand present specific challenges due to their unique anatomical structures. There is little soft tissue and each compartment is narrow, such important structures exist in close proximity. Anatomic constraints make it difficult to achieve wide surgical margins. Although sarcomas often metastasize to the lung, the overall survival rate is excellent. Wide marginal resection during initial surgery is the most predictive factor for tumor control. The role of reconstructive surgery following wide excision for sarcoma of the forearm and hand is even more important than elsewhere in the body because excision is likely to cause bone, tendon and nerve defects, leading to severe functional deficits. Multiple options exist for bony and soft tissue reconstruction of the upper limb, with the choice dependent upon tumor type, wound characteristics, surgeon preference and the patients' functional requirements. Success should be measured not just by stable wound coverage but also by preservation of patient's health, limb cosmesis, sensation and function. Careful preoperative planning with consideration of all the possible resected structures should improve patient outcomes.

For tumors that are located beside the main peripheral nerve, combined wide resection of both the tumor and peripheral nerve is mandatory. We here present an interesting case with synovial sarcoma of the wrist. An 8 cm of ulnar nerve defect was reconstructed by vascularized, folded sural nerve graft with the peroneal flap, whereas an 8 cm of distal ulna was reconstructed using extracorporeally irradiated osteochondral autograft. Our case showed excellent nerve regeneration. Extracorporeal irradiated osteochondral graft was a good option for reconstruction of the distal ulna. This procedure should be indicated for the reconstruction of non-weight-bearing joints. These kinds of reconstruction have been addressed in only a few cases of oncological reconstruction.

Digital glomus tumour is a rare neoplasm. Surgical excision is the only known curative treatment but the best approach for subungual glomus tumours is still controversial. A total of 12 patients with subungual glomus tumour were reviewed. There were 11 female patients and one male patient, with a mean age of 48.6 years. Surgical procedures were performed using an operative microscope and tumours were excised using the lateral subperiosteal approach. In all, 10 patients were satisfied with the outcome from the lateral operative approach because they were able to use the affected hand for kitchen work shortly after the treatment. One case presented residual tumour and underwent re-operation. No tumour recurrences and nail deformity were detected after excision with the lateral approach. The lateral subperiosteal approach was safe and reliable for the subungual glomus tumour and allowed full access to any glomus tumours. Microscopy allows careful visualisation of the tumour. It is important that surgeons accurately locate tumours to achieve complete excision.

We report here the unique case of 60-year-old man with severe ulnar nerve palsy caused by synovial chondromatosis arising from the pisotriquetral joint. At operation, the tumor entrapped the ulnar nerve proximal to the Guyon canal so that it was severely paralyzed. The ulnar neurovascular bundle could be separated safely under the microscope. To our knowledge, this type of severe neuropathy has not been reported before. Although synovial chondromatosis associated with peripheral nerve neuropathy is extremely rare, we should be aware of the existence of this type of compression neuropathy in the upper limb.

Distal radius fracture (DRF) is one of the most common traumatic events for the hand surgeon to treat. Numerous surgical procedures have been described for this fracture (Ruch et al., 2004); however, the ideal method of surgical management is still controversial. The latest development of a volar locking plate fixation markedly changed the treatment of DRF (Chen & Jupiter, 2007; Chung et al., 2006). Volar locking plate fixation creates a more rigid mechanical construct and allows early rehabilitation that can be initiated with the goal of an improved functional outcome; therefore, volar locking plate fixation currently has widespread popularity, even for dorsally displaced intraarticular fracture (Orbay & Fernandez, 2002; Willis et al., 2006). The functional outcome of the treatment of DRF is considered to be affected by extraarticular alignment, anatomical reduction of the articular surface, intraarticular soft tissue injuries and postoperative complications. Wrist arthroscopy is currently recognized as an important adjunctive procedure in the management of DRF (Doi et al., 1999; Freeland & Geissler, 2000; Ruch et al., 2004). This is because arthroscopically assisted reduction and internal fixation of DRF cause minimal surgical intervention and provide not only excellent visualization of the joint surface for anatomical restoration of articular fragments but evaluate and treat intraarticular soft tissue injuries. Although it is better used in conjunction with percutaneous pinning and external fixation, wrist arthroscopy becomes problematic when plate fixation is performed because vertical traction has to be both applied and released during surgery; therefore, a plate presetting arthroscopic reduction technique (PART) using a volar locking plate has been developed, that can simplify the combination of plating and arthroscopy (Abe et al., 2008). PART can also be performed with minimal skin incision and is less invasive. This chapter will describe the procedure of PART and its effectiveness for the treatment of DRF.

Direct numerical simulation (DNS) of supercritical CO2 turbulent channel flow has been performed to investigate the heat transfer mechanism of supercritical fluid. Due to effects of the mean density variation in the wall normal direction, mean velocity in the cooling region becomes high compared with that in the heating region. The mean width between high- and low-speed streaks near the wall decreases in the cooling region. From the turbulent kinetic energy budget, it is found that compressibility effects related with pressure fluctuation and dilatation of velocity fluctuation can be ignored even for supercritical condition. However, the effect of density fluctuation on turbulent kinetic energy cannot be ignored. In the cooling region, low kinematic viscosity and high thermal conductivity in the low speed streaks modify fine scale structure and turbulent transport of temperature, which results in high Nusselt number in the cooling condition of the supercritical CO2.

Nackenverletzungen, welche wahrend Autounfallen auftreten, konnen zu chronischen Symptomen, inklusive Nacken- und Schulterschmerzen, Muskelkater, Kopfschmerzen, Schwindel, verschwommenem Sehen und Gedachtnisverlust fuhren [11,31]. Die geschatzten jahrlichen Sozialausgaben belaufen sich auf 10 Milliarden Dollar in den USA und 10 Milliarden Euro in Europa [2, 12, 46]. Von Weichteilverletzungen der Halswirbelsaule wurde bei allen Kollisionsrichtungen berichtet, jedoch ist der Heckaufprall mit dem hochsten Risiko der Weichteilverletzung verbunden.

This reports tha development of bioactive glass ceramic particles and evaluates their use inclinical applications. 1. The subjects of the evaluation were 13 impacted teeth, 17 intramaxillary cysts (not including radicular cysts), and 7 atrophic mandibular alveolar ridges. 2. The results were classified into effective, slightly effective, ineffective, and harmful, a very high proportion, 33 or 89.3%,were judged effective or slightly effective. 3. None were evaluated to be harmful, showing the safety of the present material. Among the ineffective cases there were open wounds due to infection, leakage of the supplied material, and fistulation. In cases where inflammation had not disappeared at the supply there were cases where the particles had to be completely removed due to infection, It was determined the that this was not due to the material, but possidly due to the surgical procedures, as there were no further complications in the tretment. 4. From the results reported here, the bioactive glass ceramic material here was found to be useful in the articial bone needed after atrophic mandibular alveolar ridge surgery.

BACKGROUND: Side impact may cause neck and upper extremity pain, paresthesias, and impaired neck motion. No studies have quantified the cervical spine mechanical instability and injury threshold acceleration due to side impact. The goals of the present study were to identify and quantify cervical spine soft tissue injury and the injury threshold acceleration for side impact, and to compare these results with previous findings. METHODS: Six human cervical spine specimens (C0-T1) underwent 3.5, 5, 6.5, and 8 g impacts. Pre- and postimpact flexibility tests were performed. Soft tissue injury was defined as a significant increase (p < 0.05) in the average intervertebral flexibility above the baseline 2 g impact. The injury threshold was the lowest T1 horizontal peak acceleration that caused the injury. RESULTS: The injury threshold acceleration was 6.5 g, with injuries occurring at C4-C5 through C7-T1 in flexion, axial rotation, or left lateral bending. After 8 g, three-plane injury was observed at C4-C5 and C6-C7, whereas two-plane injury occurred at C3-C4 in flexion and left lateral bending and at C5-C6 and C7-T1 in axial rotation and left lateral bending. CONCLUSIONS: Side impact caused multiplanar injuries at C3-C4 through C7-T1 and significantly greater injury at C6-C7, as compared with head-forward rear impact. Language: en

STUDY DESIGN An in vitro biomechanical study. OBJECTIVES The objectives were to: quantify dynamic canal pinch diameter (CPD) narrowing during simulated bilateral facet dislocation of a cervical functional spinal unit model with muscle force replication, determine if peak dynamic CPD narrowing exceeded that observed post-trauma, and evaluate dynamic cord compression. SUMMARY OF BACKGROUND DATA Previous biomechanical models are limited to quasi-static loading or manual ligament transection. No studies have comprehensively analyzed dynamic CPD narrowing during simulated dislocation. METHODS Bilateral facet dislocation was simulated using 10 cervical functional spinal units (C3-C4: n = 4; C5-C6: n = 3; C7-T1: n = 3) with muscle force replication by frontal impact of the lower vertebra. Rigid body transformation of kinematic data recorded optically was used to compute the CPD in neutral posture (before dislocation), during dynamic impact (peak during dislocation), and post-impact (flexion rotation = 0(0) degrees ). Peak dynamic impact and post-impact CPD narrowing were statistically compared. RESULTS Average peak dynamic impact CPD narrowing significantly exceeded (P < 0.05) post-impact narrowing and occurred as early as 71.0 ms following impact. The greatest dynamic impact narrowing of 7.2 mm was observed at C3-C4, followed by 6.4 mm at C5-C6, and 5.1 mm at C7-T1, with average occurrence times ranging between 71.0 ms at C7-T1 and 97.0 ms at C5-C6. CONCLUSION Extrapolation of the present results indicated dynamic spinal cord compression of up to 88% in those with stenotic canals and 35% in those with normal canal diameters. These results are consistent with the wide range of neurologic injury severity observed clinically due to bilateral facet dislocation.

Previous clinical studies have identified the cervical facet joint, including the capsular ligaments, as sources of pain in whiplash patients. The goal of this study was to determine whether whiplash caused increased capsular ligament laxity by applying quasi-static loading to whiplash-exposed and control capsular ligaments.A total of 66 capsular ligament specimens (C2/3 to C7/T1) were prepared from 12 cervical spines (6 whiplash-exposed and 6 control). The whiplash-exposed spines had been previously rear impacted at a maximum peak T1 horizontal acceleration of 8 g. Capsular ligaments were elongated at 1mm/s in increments of 0.05 mm until a tensile force of 5 N was achieved and subsequently returned to neutral position. Four pre-conditioning cycles were performed and data from the load phase of the fifth cycle were used for subsequent analyses. Ligament elongation was computed at tensile forces of 0, 0.25, 0.5, 0.75, 1.0, 2.5, and 5.0 N. Two factor, non-repeated measures ANOVA (P0.05) was performed to determine significant differences in the average ligament elongation at tensile forces of 0 and 5 N between the whiplash-exposed and control groups and between spinal levels.Average elongation of the whiplash-exposed capsular ligaments was significantly greater than that of the control ligaments at tensile forces of 0 and 5 N. No significant differences between spinal levels were observed.Capsular ligament injuries, in the form of increased laxity, may be one component perpetuating chronic pain and clinical instability in whiplash patients.

Direct numerical simulation (DNS) of supercritical CO2 turbulent channel flow is performed to investigate the heat transfer mechanism of supercritical fluid. In the present DNS, full compressible Navier-Stokes equations and Peng-Robison state equation are solved. Due to effects of the mean density variation in the wall normal direction, mean velocity in the cooling region becomes high compared with that in the heating region. The mean width between high- and low-speed streaks near the wall decreases in the cooling region, which means that turbulence in the cooling region is enhanced and lots of fine scale eddies are created due to the local high Reynolds number effects. From the turbulent kinetic energy budget, it is found that compressibility effects related with pressure fluctuation and dilatation of velocity fluctuation can be ignored even for supercritical condition. However, the effect of density fluctuation on turbulent kinetic energy cannot be ignored. In the cooling region, low kinematic viscosity and high thermal conductivity in the low speed streaks modify fine scale structure and turbulent transport of temperature, which results in high Nusselt number in the cooling condition of the supercritical CO2 .Copyright © 2007 by ASME