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Purpose To compare clinical and radiographic outcomes of using a variable-angle volar locking plate (VAVLP) with those of using a fixed-angle volar locking plate (FAVLP) for treating unstable intra-articular fractures of the distal radius . Methods One hundred twenty patients with unstable intra-articular fractures of the distal radius were randomized to open reduction and internal fixation with a VAVLP (n = 60) or an FAVLP (n = 60). Supplementary methods (eg., Kirschner wire fixation) were required in 4 patients with a VAVLP and 9 with an FAVLP. Clinical outcomes were evaluated at 6 weeks, 3 months, 6 months, and 1 year after surgery. Posteroanterior and lateral radiographs were used to measure standard radiographic parameters before surgery, in the immediate postoperative period , and at 1 year. Plate prominence and articular congruity were quantified using computed tomography at 6 months. Results There were no significant differences in any clinical outcome between the groups at any follow-up time. Volar tilt was significantly greater in patients treated with a FAVLP in the immediate postoperative period (8° vs 6°) and at 1 year (8° vs 5°). Although significant differences were not found in articular gap or stepoff between the 2 plates, the distal and volar prominence of the VAVLP was significantly greater than that of the FAVLP at 6 months. Significantly more patients treated with a VAVLP had a complication (38% vs 19%). However, most secondary surgeries were performed for hardware removal, and no patients from either group had complex regional pain syndrome or tendon rupture . Conclusions Patients with intra-articular distal radius fractures can expect good functional and radiographic outcomes with VAVLP or FAVLP fixation. The VAVLP may be more prone to technical errors, leading to complications, whereas the FAVLP is more likely to require supplementary fixation. Type of study/level of evidence Therapeutic I

Purpose: To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach. Methods: We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores. Results: We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score. Conclusions: An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure. Level of Evidence: IV, therapeutic case series.

Background: Osteochondritis dissecans of the humeral capitellum (capitellar OCD) is a common injury among adolescent throwing athletes. Some younger patients with incomplete maturity of the epiphysis and early-stage capitellar OCD are good candidates for nonoperative treatment. However, during initial examination, predicting the need for surgical treatment in patients with capitellar OCD is difficult. Purpose: To perform multivariate ordered logistic regression analysis of data obtained from patients’ medical records and images on initial examination and identify the predictors of unsuccessful nonoperative management of capitellar OCD. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: This study included 245 elbows with capitellar OCD (all male; mean age, 14 years [range, 10-27 years]). Patients were divided into 3 groups comprising 148 elbows requiring an immediate operation on initial examination, 48 requiring nonsurgical treatment, and 49 requiring an operation after nonoperative management. Baseline data and radiographic parameters, such as lesion location, lesion size, modified Minami classification, radial head size, skeletal age difference between both elbows on initial examination, lesion size on computed tomography, and staging on magnetic resonance imaging, were retrospectively reviewed. Univariate and multivariate ordered logistic regression analyses of spontaneous healing of the lesion were conducted. Results: Univariate logistic regression analysis showed that radial head enlargement and skeletal age difference were significantly associated with spontaneous healing. In multivariate ordered logistic regression analysis, radial head enlargement (anteroposterior and lateral) and skeletal age difference were significant predictors of lack of spontaneous healing (odds ratio [OR], 2.76, P =.025; OR, 7.92, P =.026; and OR, 1.84, P =.0089, respectively). Conclusion: To predict spontaneous healing in the moderate stage, plain radiographs would be important to evaluate radiocapitellar congruity and skeletal age. This study showed that preoperative radiographic findings of radial head enlargement and advanced skeletal age of the throwing side compared with that of the nonthrowing side were predictors of advanced-stage capitellar OCD. Despite several limitations, the statistical significance and correlations herein provide important information on preoperative surgical planning to surgeons.

Background First-rib stress fracture is considered a potential cause of nonspecific atraumatic chronic shoulder pain in adolescent athletes. However, the etiology in throwing athletes with first-rib fracture is still unknown. The purpose of this retrospective study was to investigate the characteristic clinical features and radiographic findings of overhead throwing athletes with first-rib fracture. Methods Twenty-four first-rib stress fractures in 23 players were studied retrospectively. Clinical features, including age, initial symptom, sports, pain-related activity, diagnostic method, treatment method, and final follow-up, were reviewed. Results The following characteristic clinical features were identified: mean age of 16.8 years (range, 13 to 25 years), 19 dominant arm injuries and 5 non-dominant arm injuries, and an acute increase in pain while swinging the bat or pitching the ball. Sixteen fractures presented with posterior shoulder or upper thoracic back pain. At a mean time of 7.5 months after the initiation of conservative treatment, 17 healing fractures (71%) and 7 nonunion fractures (29%) among throwing athletes with first-rib stress fracture were identified. On image analysis, first-rib stress fractures were classified into 3 types depending on the direction and location of fracture lines: groove, intrascalene, and posterior types. Three symptomatic patients underwent first-rib resection due to thoracic outlet syndrome. On average, 46% of the first rib was visible on the shoulder radiographs and 97% was visible on the cervical spine radiographs. The Cohen kappa coefficient for the above percentages was 0.87 and the percent agreement was 89.4% for the shoulder, and the Cohen kappa coefficient was 0.80 and the percent agreement was 99.0% for the cervical spine. Conclusions First-rib stress fracture should be considered when adolescent overhead throwing athletes have acute-onset posterior shoulder pain while swinging the bat or pitching the ball. Anteroposterior radiography of the cervical spine is available for initial diagnosis. Although 71% of the patients healed at a mean follow-up of 7.5 months with conservative treatment, some patients may have symptoms consistent with thoracic outlet syndrome. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Previous studies have shown that the shoulder internal rotation elbow flexion (SIREF) test, which is a modified elbow flexion (EF) test, has significantly higher sensitivity than the EF test in patients with cubital tunnel syndrome (CubTS). Here, we hypothesized that this increase in sensitivity was due to increase in the ulnar nerve strain around the elbow introduced by the additional shoulder position. Methods Ulnar nerve strain at the elbow was intraoperatively measured at both the EF test and SIREF test positions in 20 patients with CubTS before simple decompression. Statistical analysis was performed with the Wilcoxon signed rank test at a confidence level of 99% ( P Results Mean ulnar nerve strain in the EF test position was 18.9% ± 12.1%, whereas that in the SIREF test position was 24.7% ± 14.0%. Ulnar nerve strain was higher in the SIREF than in the EF test position in all cases, and the difference was significant (mean, 5.8% ± 0.9%; 95% confidence interval, 3.90%-7.73%). Conclusion This study indicated that increased sensitivity in the SIREF test compared with the EF test was due to the increase in ulnar nerve strain around the elbow. To the best of our knowledge, this is the first study showing that shoulder position changes the ulnar nerve strain around the elbow in living patients with CubTS.

Osteoid osteoma of the distal phalanx is very rare. We describe a case of osteoid osteoma of the distal phalanx of the ring finger with clubbed finger deformity that improved after tumour removal. A 50-year-old left-handed man presented with a history of right ring finger pain without any trauma. The distal phalanx of the ring finger had tender, redness, and a clubbed finger deformity. Plain radiography indicated a circular radiolucent area in the centre of the lesion. Computed tomography and gadolinium enhanced magnetic resonance imaging indicated presence of a nidus. The lesion was removed via the transungual approach. Histopathological examination confirmed the presence of an osteoid osteoma. His pain was immediately relieved after surgery. At the 2-year followup, he had no pain and the clubbed finger deformity had improved. In cases where clubbed finger deformity involves only one finger, the possibility of chronic osteomyelitis or osteoid osteoma should be considered.

Recent reports have suggested that fascicular constriction located proximal to the elbow may be the primary aetiology of spontaneous anterior interosseous nerve palsy (sAINP), and recommended interfascicular neurolysis ranging from the proximal forearm to distal upper arm (wide incision surgery: WIS) for its treatment. On the basis of these reports, it was hypothesised that, if the aetiology of sAINP was fascicular constriction, neurolysis limited proximal to the elbow (minimal incision surgery: MIS) should have similar results to those of WIS. Twenty-five surgically treated sAINP cases were retrospectively evaluated. The mean age of onset was 42.8 years, the mean preoperative period was 5.3 months, and mean follow-up period after operation was 31 months. Eleven patients underwent MIS, while 14 underwent WIS according to the patient's intention (intention-to-treat). Twenty-one patients had fascicular constriction, and no entrapment neuropathy was seen in this series. At the latest follow-up, 82% of the patients had British Medical Research Council grade of ≥4 in flexor-pollicis-longus, while 80% had grade of ≥4 in flexor-digitorum-profundus-of-the-index-finger. There were no significant differences between the results of either group. These result suggested that the aetiology of sAINP may not be external compression, but fascicular constriction, and MIS may be its favourable surgical treatment.

We report a case of distal radius fracture after a Sauve-Kapandji procedure combined with synovectomy and tendon transfer in a rheumatoid arthritis patient. This case shared several unusual features that were also seen in a previously reported case. Based on these features, we discuss favorable surgical treatment for the rheumatoid wrist with extensor tendon rupture, and also the optimal treatment for distal radius fracture after such procedures.

We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients < 50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases > 50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p < 0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is < 50 years of age, and the pre-operative delay is < seven months. If the patient is > 50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with tendon transfer as the primary surgical procedure.

Background: A variety of osteotomies has been proposed to correct posttraumatic cubitus varus deformity as well as any associated hyperextension and/or rotational deformities. However, lateral closing-wedge osteotomy and step-cut osteotomy, both of which have been used extensively with satisfactory outcomes, correct only in the coronal plane. To date, no direct comparison has been made between three-dimensional and simple coronal plane osteotomies. Methods: Between 1983 and 2007, we treated eighty-six elbows with a posttraumatic varus deformity. We classified patients who underwent three-dimensional osteotomies as Group I and those who underwent simple coronal plane osteotomies as Group II, and we compared the outcomes between the groups. Clinical evaluation included an assessment of the carrying angle and measurement of the passive range of motion before surgery and at the time of the final follow-up. To evaluate the remodeling capacity of the bone to recover elbow flexion in Group II, we assessed the range of motion before surgery and at the time of the final follow-up in patients who were less than ten years old and those who were more than ten years old. Results: There was no significant difference between the groups with regard to the carrying angle or the elbow range of motion, either before surgery or at the time of the final follow-up. However, Group I had more significant loss of correction (p = 0.018). In Group II, elbow motion reached the physiological range by the time of the final follow-up in patients who were less than ten years old. Conclusions: For osteotomies to correct cubitus varus deformity, correction of internal rotation is not needed. With a three-dimensional osteotomy, it is difficult to maintain correction and to acquire the planned carrying angle because of the small area of bone contact. It is necessary to correct hyperextension in patients older than ten years of age, as after that age bone remodeling is not expected to increase elbow flexion. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

A 74-year-old woman diagnosed with Churg-Strauss syndrome (CSS) complained of difficulty in flexing her left thumb and index finger. Electromyography demonstrated isolated anterior interosseous nerve (AIN) palsy, with no other peripheral neuropathy. We diagnosed this case as spontaneous AIN palsy complicated with CSS, the first case of this kind. Surgical treatment should be considered if no sign of recovery is seen within six months of onset.

Whereas osteochondroma is a common benign bone tumor in adolescence, it is rarely observed in elderly patients. It is unknown why osteochondromas, which usually develop during skeletal growth, rarely develop in elderly patients. The authors report 3 cases of symptomatic spinal osteochondroma in elderly patients and discuss the possible reasons for the onset of the enlargement of osteochondromas in elderly patients. Clinical history, radiographs, MR images, and CT myelography studies were obtained in each patient and are described. A review of the relevant literature is also presented. In the first case, the cervical osteochondroma caused spinal canal compression and occipital nerve irritation. It was totally excised, which successfully relieved the pain and allowed the patient to return to normal neurological function. In the second case, total removal of the tumor was effective in alleviating clinical symptoms. In the last case, ablation of the articular facet joint partially relieved the patient's lower-back pain. In the first 2 cases, the patients suffered from psoriasis and associated psoriatic arthritis and in the last case, the patient suffered from HIV-associated psoriatic arthritis. The psoriatic arthritis was characterized as asymmetric chronic multiple-joint arthritis and was HLA B27 positive. The pathology of psoriatic arthritis was the accelerating bone turnover and ankylosis. Symptomatic osteochondroma of the spine in elderly patients is extremely rare since it typically develops during skeletal growth. In this report, the authors show that pathological accelerating bone turnover such as psoriatic arthritis may be a possible mechanism for the onset of the enlargement of osteochondromas in elderly patients. The age of the patients in this report suggests that growth of the osteochondroma continues after skeletal development.

Isolated volar dislocation of the fifth carpometacarpal joint is a very rare injury. We present two cases of isolated volar dislocation of the fifth carpometacarpal joint treated successfully with percutaneous skeletal fixation.

To describe the magnetic resonance (MR) imaging findings of denervation and reinnervation of skeletal muscles in rats.The posterior tibial nerve was transected in 48 rats (nerve section group) and was repaired just after transection in another 48 rats (nerve repair group). At 2, 4, 6, and 8 weeks after surgery, changes in the area and signal intensity of the gastrocnemius muscle on T1- and T2-weighted MR images in vivo (four rats in each group) and T1s and T2s were analyzed in vitro in both groups (20 rats each) and compared with electromyographic findings. Water volume content and extracellular fluid space of the muscle in vitro were also examined in both groups (24 rats each). Four rats were used as controls for in vitro analysis.At T2-weighted MR imaging, the muscle showed continuously high signal intensity in the nerve section group. In the nerve repair group, the signal intensity was high until 4 weeks, when it recovered. Increases in signal intensity on T2-weighted MR images and T2s were seen in the nerve section group throughout the study period. In the nerve repair group, increased signal intensity on T2-weighted MR images was noted at 2 and 4 weeks and significantly returned to normal at 6 weeks (P.014), just after the detection of the M wave at electromyography. T2 increased at 2 weeks, then decreased significantly at 4 weeks (P =.012). Extracellular fluid space significantly increased in the nerve section group at all measurement times and in the nerve repair group at 2 and 4 weeks, then it decreased after 6 weeks (P.003), which is parallel to the change in signal intensity on T2-weighted MR images, although there was little change in total water volume content in either group.Changes in signal intensity on T2-weighted MR images that are related to denervation may result from an increase of extracellular fluid space. MR imaging clearly demonstrates that changes in rat skeletal muscle are reversed when the nerve heals and reinnervation proceeds.

Summary: A healthy 49-year-old female complaining of progressive hemiplegia of the left side consulted the Emergency Department. Neurological examinations and non-contrast computed tomography of the brain showed no evidence of hemorrhage. Acute ischemic stroke was diagnosed, and intravenous recombinant tissue-type plasminogen activator was administered under the guidelines of the National Institute of Neurological Disorders. After starting the treatment, the patient developed progressive quadriplegia and pain in the back of her neck. Cervical magnetic resonance imaging showed a vast epidural hematoma. The patient underwent emergency decompression surgery and removal of the hematoma by spine surgeons. Intraoperative epidural bleeding was observed on the left side at the C3-C4 level. Postoperatively, the patient showed significant improvement, becoming neurologically intact and functional by the 14-month follow-up. Importantly, this case illustrates that a cervical epidural hematoma can present as hemiplegia, which can be misdiagnosed as a cerebrovascular accident in neurology emergency rooms.

Neurological symptoms of herniated nerve fibers resulting from limited perineurial injury from sharp materials such as needles have become a recent topic in clinical practice. However, the mechanism of this disorder, which is known as a perineurial window, has not been clarified. To investigate the mechanism of nerve damage in the perineurial window, we designed small (1-mm length) and large (5-mm length) perineurial windows using tibial nerves of Wistar rats. In the 1-mm group, a marked hernia of the endoneurial contents developed soon and decreased in size with time, but protrusion of nerve fibers was still observed after 12 weeks. Nerve fibers in both the herniated portion and under the edge of the window were damaged. Even after 12 weeks, regeneration of the nerve fibers and the perineurium was incomplete. In contrast, in the 5-mm group, the initial endoneurial edema was remarkable, but herniated nerve fibers were not seen after 12 weeks. Neurological impairment in the 5-mm group was marked in the early stage but rapidly recovered. The repair of the perineurium and nerve fibers in the 1-mm group was slower than in the 5-mm group. Persistent neurological symptoms in the perineurial window appeared to be more closely associated with entrapment of nerve fibers at the window edge rather than with disruption of endoneurial homeostasis.

Cancer polyarthritis is a very rare condition. Here, we present a case of cancer polyarthritis, who also had mononeuritis simplex as a manifestation of paraneoplastic neuralgic syndrome. A 71-year-old man, who initially presented symmetrical polyarthritis and unilateral posterior interosseous nerve palsy, was subsequently diagnosed to have gastric cancer. Total gastrectomy was performed, and his polyarthritis and the palsy simultaneously disappeared within 2 weeks after the resection. His gastric cancer was found to be metastasized to his liver 16 months after the total gastrectomy; however, the polyarthritis and the palsy did not recurrent throughout his course. The polyarthritis in this case was diagnosed as a cancer polyarthritis from its features. On the other hand, the isolated posterior interosseous nerve palsy in this case met the diagnostic criteria for paraneoplastic neurological syndrome. This case was also unique in that the manifestations of paraneoplastic syndromes did not recur even after the metastasis of the primary cancer, suggesting that some specific clones in the cancer were responsive to the manifestations of paraneoplastic syndromes. Our case suggested that relapse of the manifestations of paraneoplastic syndromes may not always herald the recurrence of primary or metastatic tumour, and other tumour markers and signs should be periodically followed to search for the recurrence of the tumours.

Here we presented the first case of pacifier type thumb duplication. A newborn Japanese girl with no family history had a duplicated thumb on her left hand. The duplicated thumb showed a very large, oedematous soft-tissue nubbin in its appearance and was resected on the fifth day after birth. X-ray showed hypoplastic phalanx bone, suggesting type II polydactyly. Histology of the resected thumb showed enormous oedema in its connective tissue with cartilaginous and neural elements. This case was quite similar to literary reported cases of pacifier polydactyly in post-axial polydactyly, and its pathological condition seemed to be distinctly different from floating type or rudimentary type thumb duplication. We considered this type of thumb duplication as pacifier type thumb duplication, rather than floating or rudimentary type, in order to understand its underlying pathophysiology and to avoid confusion in further discussions.

There are many risks of iatrogenic peripheral-nerve injuries during routine medical procedures. These injuries may occur during venipuncture for drawing blood, endoscopic treatments, punctures of joints or ganglions, various kinds of surgical procedures, and in numerous other situations. It is important to create a "Manual" of such accidents or incidents. In case an accident occurs, both the medical staff and the injured patient should receive adequate support to avoid any anxiety. The doctor must examine the person's injury carefully, and must judge its severity as soon as possible. The doctor must also offer the patient a prompt explanation about their injury and its proper care or treatment. This explanation must be easy to understand. This step can reduce patient anxiety and even prevent the early stages of complex regional pain syndrome (CRPS). One of my therapeutic strategies for treating early-stage CRPS is to use prednisolone for a short period for the treatment of strong pain and serious edema; the other approach is to do administer a warm-cold alternating bath with range-of-motion (ROM) exercise. Creation of manuals and education of staff to quickly respond to such situations is extremely essential.

The functional anatomy of the interosseous membrane (IOM) of the forearm was studied in 15 fresh frozen cadavers. The IOM consisted of three components: the tendinous part; the membranous part; and the dorsal oblique accessory cord. The tendinous part was a thick and strong complex of three to ten bundles which run from the proximal one third of the radius to the distal quarter of the ulna. The membranous part was recognised as a soft and thin structure, adjacent proximal and distal to the tendinous part. The dorsal oblique cord was found as a single cord on the dorsal side of the IOM from the proximal quarter of the ulna to the middle region of the radius. This cord was distinct from the oblique cord, which existed on the palmar side of the forearm separated from the IOM. The IOM was flat in the neutral position, while it flexed along the rotation axis in pronation and supination. Since the prominence of the curvature in the IOM was almost in the same direction as the fibres of the tendinous part, the tendinous part demonstrated only bending, similar to partial bending of an elastic board. The bending position was changed with the forearm position and the tightened bundles in the tendinous part were altered during rotation.

We now report newly developed three-dimensional magnetic resonance imaging (3D-MRI) system which is based on semiautomatic tissue extraction from the axial MR images utilizing the fuzzy reasoning calculation method and 3D-image reconstruction with surface rendering. We also studied normal in vivo dynamic changes of the interosseous membrane (IOM) of forearm during rotation using this 3D-MRI. Serial axial MRI of right forearms of five healthy volunteers was obtained in five rotational positions, and extraction and 3D-reconstruction of the radius, ulna, and IOM was made using the system. Extraction results were well with the fuzzy reasoning method. 3D-MRI of the radius and ulna, IOM were reconstructed from these images respectively, and their 3D-shapes were almost identical to the anatomic shape. 3D-MRI showed there were wavy deformities on the IOM in pronation position in the all five subjects and dorsiflexion on the most dorsal portion of the IOM at maximum supination in three forearms. In neutral position, the IOM of all five volunteers was almost flat. From anatomic orientation, these dynamic changes of the IOM mainly occurred at the membranous portion, which is soft, thin, and elastic. Otherwise, the tendinous portion which is a thick and strong complex of 5 to 10 bundles run from proximal one third of the radius to distal one fourth of the ulna, demonstrated minimal dynamic changes on the 3D-MRI. Therefore, the tendinous portion is considered to be taut during rotation to provide stability between the radius and the ulna, while the membranous portion is easy to deform and allowing smooth rotation. Furthermore, because of wide-use, our 3D-MRI system is useful for in vivo analysis of soft tissue kinesiology in normal and abnormal musculoskeletal systems.

We describe two patients with SAPHO (synovitis-acne-pustulosis-hyperostosis-ostitis) syndrome who presented some of the classic features of Behcet's disease. The first case is a man diagnosed as SAPHO at 74 years old. His major complaint is pain and swelling of the bilateral sterno-clavicular region for more than 14 years. Another conspicuous complication was bilateral glaucoma and episodes of iritis were recognized during the follow-up period. The second case is a 65-year-old woman, who first consulted us with right knee pain. As she had a past history of palmoplantar pustulosis and anterior chest pain, her sterile knee arthritis was diagnosed as SAPHO. She also had been suffering from recurrent oral aphthous ulceration since 6 months before visiting our hospital. Considering the clinical courses of our two cases and a review of five previously reported cases, these conditions may imply that classic features of Behcet's disease are minor complications of SAPHO syndrome. Human leukocyte antigen typing and frequent association of sacroiliitis in our cases and in the review of the literature for SAPHO syndrome with some of the classic features of Behcet's disease may indicate this condition to be a closely related disease with seronegative spondylo-arthritis.

We report a bit-rate transparent optical burst switching (OBS) router prototype using a fast 5 times 5 PLZT [(Pb,La)(Zr,Ti)O3 ] optical matrix switch. Dynamic switching in a two-wavelength, 2 times 2 OBS switch is demonstrated. Contention resolution using a tunable Mach-Zehnder interferometer wavelength converter for both 40- and 10-Gb/s bursts is demonstrated for the first time. Error-free operation was achieved for both bit rates under the same settings, as required in autonomous networks

A 55-year-old woman with incomplete spontaneous posterior interosseous nerve (PIN) palsy underwent interfascicular neurolysis and tendon transfer, 17 years after its onset. After one year, her nerve function partially recovered electrophysiologically. This case suggests that incomplete spontaneous PIN palsy may recover by interfascicular neurolysis, even with a long preoperative delay.

We observed the healing process under rigid external fixation after Salter-Harris type-1 or type-2 physeal separation at the proximal tibia in immature rabbits. Metaphyseal vessels grew across the gap with little delay; the site of separation then came to lie in the metaphysis and was bridged by endochondral ossification. Union was achieved within two days in all rabbits. Progression of endochondral ossification repaired the separated physis, thus showing ‘primary healing of physeal separation’. This depends on accurate reduction and stable fixation to allow the survival of vessels across the gap.

In magnetic resonance imaging of peripheral nerve palsy, changes of signal intensity are often found in paralyzed muscles. The purpose of this report is to clarify the relation between magnetic resonance imaging findings and clinical examination in suprascapular nerve palsy. The subjects were 12 patients with suprascapular nerve palsy who underwent magnetic resonance imaging examinations. In 9 of 12 cases ganglion cysts were found at the spinoglenoid notches. On T1-weighted images the signal intensity of infraspinatus muscle was high in four cases but normal in the supraspinatus muscle in all cases. On T2-weighted images the signal intensity of infraspinatus muscle was high in six cases, and that for supraspinatus muscle was high in one case. In two cases the high intensity of palsied muscles became normal after the palsy recovered. Magnetic resonance imaging is a useful examination of peripheral nerve palsy not only for the detection of ganglion cysts but also for assessing the stage of paralysis.

We examined radiographs of the elbows of the pitching arms of 79 professional baseball pitchers (mean age, 25.1 years; mean duration of professional career, 4.7 years) and noted the frequency and size of spurs, bone fragments, and intra-articular loose bodies according to site. The influence of duration of professional baseball career on these osteoarthritic changes was also investigated. The olecranon tip was the most frequent site of spurs (62/79; 78.5%), and fragmentation of the spur was detected in 17 joints. The frequency of spurs was also high at the medial margin of the olecranon, the tip of the coronoid process, the medial margin of the sigmoid notch, the medial margin of the trochlea and the olecranon fossa. In 38 subjects, spurs were observed at the distal portion of the radial notch of the ulna. However, few pitchers had osteoarthritic changes in the humeral capitellum or radial head. Intra-articular loose bodies were detected in 4 of 79 joints (5.1%), and bone fragments were present below the medial humeral epicondyle in 25 of 79 joints (31.6%). Osteoarthritic changes in the elbow joint appeared to be attributable mainly to traction stress and impingement associated with extension and valgus strain. Significant osteoarthritic changes were often found in professional pitchers whose careers exceeded 5 years.

We used magnetic resonance (MR) myelography in ten patients with injuries to the brachial plexus and compared the findings with those obtained by conventional myelography and postmyelographic CT (CTM). In the presence of complete nerve-root avulsion (seven cases), a post-traumatic meningocele was detected by MR myelography. In injuries to the upper roots (three cases) MR myelography showed abnormal findings with a high signal intensity in the nerve root, obliteration of the damaged nerve root, or enlargement and obliteration of the root sleeve. No pseudomeningoceles were detected in these upper-root injuries by MR myelography and CTM. The overall accuracy of detection of damaged nerve roots or root sleeves was better with MR myelography than with conventional myelography and was similar to that of CTM. MR myelography is non-invasive, relatively quick, requires no contrast medium, provides imaging in multiple projections, and is comparable in diagnostic ability to the more invasive, time-consuming techniques of conventional myelography and CTM.

Extraneural pressure in the cubital tunnel is considered to be a major pathophysiological factor for cubital tunnel syndrome. Thus, it has been hypothesised that the higher extraneural pressure in the cubital tunnel should result in a more severe stage of cubital tunnel syndrome. Extraneural pressures in cubital tunnel at elbow maximum flexion of 41 patients with cubital tunnel syndrome were evaluated, and compared with their preoperative disease severity using McGowan's classification and Dellon's staging. Mean extraneural pressure was significantly higher in maximum elbow flexion than in maximum elbow extension (p < 0.001). However, no significant relation was seen between the severity of cubital tunnel syndrome and the extraneural pressure induced by maximum elbow flexion (McGowan's classification: p = 0.62; Dellon's staging: p = 0.92). The results suggested that the progression of disease severity of cubital tunnel syndrome may not be explained simply by dynamic pressure in the cubital tunnel, and other causative factors should also be contributing to the progression.

A new technique for increasing weak flexion force of the elbow in patients with brachial plexus injuries is reported. The concept of this procedure is to increase the moment arm of the biceps brachii muscle by moving the point of action distally. Advancement of the insertion of the biceps brachii muscle was performed with an anterior approach to the radius. The biceps tendon was stripped off the radius at its insertion. A hole was dug into the radius 2 cm distal to the original insertion. The biceps tendon was then reattached to the drill holes made in the distal edge of the initial hole with the elbow in 30 degrees of flexion. After immobilization in 70 degrees of flexion for 5 weeks, range-of-motion exercises were initiated. This procedure was applied in six cases of brachial plexus injury. Flexion force at the elbow was increased, and the initial motion of elbow flexion has become very smooth in all patients. Consequently the activities of daily living are easier to perform. This procedure is simple and involves no functional or tissue sacrifice.

Simple decompression of the ulnar nerve at the elbow has not been shown to reduce nerve strain in cadavers. In this study, ulnar nerve strain at the elbow was measured intraoperatively in 11 patients with cubital tunnel syndrome, before and after simple decompression. Statistical analysis was performed using a paired Student’s t-test. Mean ulnar nerve strain before and after simple decompression was 30.5% (range 9% to 69%) and 5.5% (range −2% to 11%), respectively; this difference was statistically significant ( p < 0.01) with a statistical power of 96%. Simple decompression reduced ulnar nerve strain in all patients by an average of 24.5%. Our results suggest that the pathophysiology of cubital tunnel syndrome may be multifactorial, being neither a simple compression neuropathy nor a simple traction neuropathy, and simple decompression may be a favourable surgical procedure for cubital tunnel syndrome in terms of decompression and reduction of strain in the ulnar nerve.

There is no definition for fascicular constrictions of the spontaneous anterior interosseous nerve palsy (sAINP) and spontaneous posterior interosseous nerve palsy (sPINP). One surgeon has evaluated his findings in our 32 patients of sAINP/sPINP using either photographs or video tapes and proposed a definition. All patients had interfascicular neurolysis, and 87 case reports of "fascicular constriction" were also evaluated. Fascicular constriction was defined as every instance of thinning in the fascicle regardless to its extent. Thinning as a result of extrinsic compression was excluded. The fascicular constrictions were divided into four types: recessed, recessed-bulging, rotation, and rotation-bulging constriction. Two independent surgeons went through our findings to verify their repeatability. The relation between the fascicular constrictions and age at the onset of palsy was evaluated using Student's t test. We found 54 fascicular constrictions, with many variations. However, they could all be categorised by our method. The repeatability among the independent authors was 96%. The age at the onset of palsy was significantly younger in rotation-bulging than in rotation constriction (p = 0.0003). Our definition of describing fascicular constrictions was accurate, and should help to provide consensus in describing these palsies.

A flexibly configurable radio access network architecture is expected to provide low-cost mobile broadband services. The radio access network architecture has changed drastically thanks to the evolution in optical fiber communication technologies. This paper describes optical transport technologies that contribute to the efficient deployment of broadband radio access systems.

We review recent advances in WDM-PON technologies to realize economical system implementation, and also discuss cost-effective solutions and potential areas of application.

A case is described of compression of the motor branch of the median nerve caused by an anomalous thenar muscle.

This paper presents a packet filtering mechanism by using packet delay distribution estimation for improving the clock stability of time synchronization with IEEE 1588. We study a packet delay distribution estimation method by using a dedicated probing packet, and discuss the applicability of the estimation method for the clock control mechanism in IEEE 1588 slave nodes. Numerical simulations show that the packet delay distribution estimation method is effective for packet filtering in heavily congested networks.

Shoulder internal rotation enhances symptom provocation attributed to cubital tunnel syndrome. We present a modified elbow flexion test--the shoulder internal rotation elbow flexion test--for diagnosing cubital tunnel syndrome.Fifty-five ulnar nerves in cubital tunnel syndrome patients and 123 ulnar nerves in controls were examined with 5 seconds each of elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests before and after treatment (surgery in 18; conservative in others). For the shoulder internal rotation elbow flexion test position, 90° abduction, maximum internal rotation, and 10° flexion of the shoulder were combined with the elbow flexion test position. The test was considered positive if any symptom for cubital tunnel syndrome developed5 seconds. Influence of the shoulder internal rotation elbow flexion test was evaluated by nerve conduction studies in 10 cubital tunnel syndrome nerves and 7 control nerves.The sensitivities/specificities of the 5-second elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests were 25%/100%, 58%/100%, and 87%/98%, respectively. Sensitivity differences between the shoulder internal rotation elbow flexion test and the other two tests were significant. Shoulder internal rotation elbow flexion test results and cubital tunnel syndrome symptoms were significantly correlated. Influence of the shoulder internal rotation elbow flexion test on the ulnar nerve was seen in 8 of 10 cubital tunnel syndrome nerves but not in controls.The 5-second shoulder internal rotation elbow flexion test is specific, easy and quick provocative test for diagnosing cubital tunnel syndrome.

This paper presents a master redundancy technique for improving the availability of synchronization in IEEE 1588. We propose a novel best master clock (BMC) algorithm to take account of link congestion between master and slave nodes. To determine the priority of master nodes, a BMC algorithm with a simple link congestion estimation based on a modified IEEE 1588 message sequence is used. The effectiveness of the proposed master redundancy technique is demonstrated by numerical simulation.

We propose and demonstrate a failed ONU detecting method by controlling ONUs to periodically transmit with MPCP frames of commercially available EPON. Proposed method can specify failed ONUs even when disturbing lights are higher by 18 dB than normal ONUs.

Purpose To compare the shoulder internal rotation test—a new, provocative test—with the elbow flexion test in the diagnosis of cubital tunnel syndrome (CubTS). Methods Twenty-five patients with CubTS were examined before and after surgery with 10 seconds each of the elbow flexion and shoulder internal rotation tests. Fifty-four asymptomatic individuals and 14 neuropathy patients with a diagnosis other than CubTS were also examined as control cases. For the shoulder internal rotation test, the patient's upper extremity was kept at 90° abduction, maximum internal rotation, and 10° flexion at the shoulder, with 90° elbow flexion and neutral position of the forearm and wrist, with finger extension. Test results were considered positive if any slight symptom attributable to CubTS occurred within 10 seconds. Extraneural pressure inside the cubital tunnel was intraoperatively measured with the positions of both the elbow flexion and shoulder internal rotation tests, in 15 of the CubTS cases. Statistical analyses were performed using Student's t -test with a confidence level of 95%. Results The preoperative sensitivity in CubTS cases was 80% in the 10-second shoulder internal rotation test and 36% in the 10-second elbow flexion test, and these differences were significant. None of the control cases had positive results in either test. All the CubTS cases improved with surgery; after surgery, neither test provoked symptoms in any surgical patient. The extraneural pressure increased in both provocative positions with no significant difference. Conclusions Positive results for the 10-second shoulder internal rotation test were more sensitive than that for the elbow flexion test of the same duration and seemed specific to CubTS. Type of study/level of evidence Diagnostic III.

The elbow flexion test is a standard, provocative diagnostic test for cubital tunnel syndrome (CubTS). The purpose of this study was to investigate the association between the elbow flexion test and the degree of extraneural pressure in the cubital tunnel of CubTS patients.Extraneural pressure on the ulnar nerve in the cubital tunnel was evaluated using 0.7-mm thickness catheter during surgery of 25 CubTS cases and compared with the results of preoperative elbow flexion testing. Statistic analysis was performed using Student's t-test with a confidence level of 95% (p.05).Forty-eight percent of the patients were positive for the elbow flexion test. Mean extraneural pressure was significantly higher in maximum elbow flexion than in maximum elbow extension (p.001). No significant association was seen between the result of 45 seconds of the elbow flexion test and the extraneural pressure in the cubital tunnel induced by maximum elbow flexion (p = .45).Our results suggested that the mechanism of provocation of symptoms of CubTS by the elbow flexion could not be explained simply by dynamic pressure in the cubital tunnel, and other pathophysiological factors could also be contributing.Diagnostic III.