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Background: The initial ultimate load for graft fixation is one of the essential factors in the reconstruction of lateral ankle ligaments. Several anchoring devices have been developed to fix the substitute ligament into the bone. A fair comparison of these fixation methods warrant a reproducible examination system. The purpose of this study was to make an experimental animal model and to compare the initial ultimate loads of 3 graft fixation methods, including the use of EndoButton (EB), interference screw (IFS), and a novel socket anchoring (SA) technique. Methods: Porcine calcaneus bones and 5-mm-wide split bovine Achilles tendons were used as fixation bases and graft materials, respectively. Both ends were firmly sutured side-by-side, using the circumferential ligation technique as a double-strand substitute that was 45 mm in length. Porcine calcanei with similar characteristics to adult human calcanei were mounted on a tensile testing machine, and substitutes were fixed into bones using the 3 fixation methods. A polyester tape was passed through the tendon loop and connected to a crosshead jig of the testing machine. The initial ultimate loads were measured in 15 specimens for each fixation method to simulate a lateral ankle ligament (LAL) injury. Results: The ultimate loads (ULs) were 223.6 ± 52.7 N for EB, 229.7 ± 39.7 N for SA, and 208.8 ± 65.3 N for IFS. No statistically significant difference was observed among the 3 groups ( P = .571). All failures occurred at the bone–ligament substitute interface. Conclusion: The initial ULs in all 3 fixation methods were sufficient for clinical usage. These values were larger than the UL of the anterior talofibular ligament; however, these were smaller than the UL of the calcaneofibular ligament. Clinical Relevance: In an experimental animal model, ULs for SA, EB, and IFS techniques showed no significant difference. All failures were observed in the fixation site of the calcaneus and were overwhelmingly related to suture fixation failure.

BACKGROUND: Some patients with end-stage osteoarthritis of the knee remain unsatisfied after total knee arthroplasty (TKA). We postulated that to increase satisfaction, self-efficacy (SE) for physical activity should receive more attention in rehabilitative intervention, alongside the management of patient expectations, pain, and function. OBJECTIVE: We examined the relative impact of Physical Activity SE on Health-Related Quality of Life (HRQOL) alongside other factors such as pain and physical function which are well-addressed by current interventions. METHODS: One hundred and six first-TKA recipients (15 Male/91 Female, age 73.6 ± 7.2) were evaluated at 3 and 6 months post-operatively using the Medical Outcomes Study 36-Item Health Survey (SF-36v2) for HRQOL, knee extension strength measurement, Timed Up and Go test (TUG), One Leg Standing time test (OLS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain and function, and an instrument for measuring Physical Activity SE among the frail elderly in Japan. RESULTS: Significant improvement over pre-operative values was found at 3 and 6 months in TUG, OLS, WOMAC Pain and Function, and the 8 subscales of the SF-36v2. Factors found to significantly impact SF-36v2 subscale scores at 6 months post-operatively were found to be knee pain, knee function, and SE for physical activity. CONCLUSION: These results support our postulation that interventions to improve SE for physical activity could have comparable impact alongside interventions for knee pain and knee function, on the advancement of HRQOL among TKA recipients.

The direct lateral approach to the subtalar joint through the IFT portal provides safe and speedy access to reach the posterior aspect of the subtalar joint and the ankle joint. This viewing portal allows for excellent visualization that extend from the posteromedial corner to the lateral joint space and anterolateral corner of the subtalar joint. Two working portals comprising of the posterolateral and sinus tarsi portals are safely made to enable visualization from the IFT portal. These portals are also useful to observe the CFL and interosseous talocalcaneal ligament.

BackgroundThere are few reports on the detailed biomechanics of the deltoid ligament, and no studies have measured the biomechanics of each ligamentous band because of the difficulty in inserting sensors into the narrow ligaments. This study aimed to measure the strain pattern of the deltoid ligament bands directly using a Miniaturization Ligament Performance Probe (MLPP) system.MethodsThe MLPP was sutured into the ligamentous bands of the deltoid ligament in 6 fresh-frozen lower extremity cadaveric specimens. The strain was measured using a round metal disk (clock) fixed on the plantar aspect of the foot. The ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N-m force was applied to the ankle and subtalar joint complex. Then the clock was rotated every 30° to measure the strain of each ligamentous band at each endpoint.ResultsThe tibionavicular ligament (TNL) began to tense at 10° plantar flexion, and the tension becomes stronger as the angle increased; the TNL worked most effectively in plantar flex-abduction. The tibiospring ligament (TSL) began to tense gradually at 15° plantar flexion, and the tension became stronger as the angle increased. The TSL worked most effectively in abduction. The tibiocalcaneal ligament (TCL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased. The TCL worked most effectively in pronation (dorsiflexion-abduction). The superficial posterior tibiotalar ligament (SPTTL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased, with the SPTTL working most effectively in dorsiflexion.ConclusionOur results show the biomechanical function of the superficial deltoid ligament and may contribute to determining which ligament is damaged during assessment in the clinical setting.

Background Inversion ankle sprains, or lateral ankle sprains, often result in symptomatic lateral ankle instability, and some patients need lateral ankle ligament reconstruction to reduce pain, improve function, and prevent subsequent injuries. Although anatomically reconstructed ligaments should behave in a biomechanically normal manner, previous studies have not measured the strain patterns of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) after anatomical reconstruction. This study aimed to measure the strain patterns of normal and reconstructed ATFL and CFLs using the miniaturization ligament performance probe (MLPP) system. Methods The MLPP was sutured into the ligamentous bands of the ATFLs and CTLs of three freshly frozen cadaveric lower-extremity specimens. Each ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N m force was applied to the ankle and subtalar joint complex. Results The normal and reconstructed ATFLs exhibited maximal strain (100) during supination in three-dimensional motion. Although the normal ATFLs were not strained during pronation, the reconstructed ATFLs demonstrated relative strain values of 16–36. During the axial motion, the normal ATFLs started to gradually tense at 0° plantar flexion, with the strain increasing as the plantar flexion angle increased, to a maximal value (100) at 30° plantar flexion; the reconstructed ATFLs showed similar strain patterns. Further, the normal CFLs exhibited maximal strain (100) during plantar flexion-abduction and relative strain values of 30–52 during dorsiflexion in three-dimensional motion. The reconstructed CFLs exhibited the most strain during dorsiflexion-adduction and demonstrated relative strain values of 29–62 during plantar flexion-abduction. During the axial motion, the normal CFLs started to gradually tense at 20° plantar flexion and 5° dorsiflexion. Conclusion Our results showed that the strain patterns of reconstructed ATFLs and CFLs are not similar to those of normal ATFLs and CFLs.

Biomechanics of the subtalar joint are complex. The calcaneofibular ligament has been seen as the most important stabilizer.

Background Corrective surgery for adult spinal deformity has recently been increasingly performed because of aging populations and advances in minimally invasive surgery. Low bone mineral density is a major contributor to proximal junctional kyphosis after spinal long fusion. Assessment for low bone mineral density ideally involves both dual energy X-ray absorptiometry and identification of pre-existing vertebral fractures, the latter, requiring only standard equipment, being performed more frequently. We therefore aimed to examine the impact of pre-existing vertebral fractures on the incidence of type 2 proximal junctional kyphosis, including proximal junctional fracture and failure, after corrective surgery for adult spinal deformity. Methods We performed a retrospective, single institution study of 106 women aged over 50 years who had undergone corrective long spinal fusion for severely symptomatic spinal deformity from 2014 to 2017. We allocated them to three groups (with and without pre-existing vertebral fractures and with severe [Grades 2–3 according to Genant et al.‘s classification] preexisting vertebral fractures) and used propensity score matching to minimize bias. The primary outcome was postoperative proximal junctional fracture and the secondary outcome proximal junctional kyphosis/failure. Results The primary and secondary endpoints were achieved significantly more often in the 28 patients with than in the 78 without preexisting vertebral fractures (total 41). The former group was also significantly older and had greater pelvic tilt and fewer fused segments than those without vertebral fractures. After propensity score matching, the incidences of the endpoints did not differ with pre-existing vertebral fracture status; however, patients with severe vertebral fractures more frequently had proximal junctional fractures postoperatively. Postoperative improvements in health-related quality of life scores did not differ with pre-existing vertebral fracture status. Conclusions Severe pre-existing vertebral fractures are a risk factor for proximal junctional fracture after correction of adult spinal deformity.

Following ankle sprains, some patients complain of their ankles "giving way," characterized by functional instability with no positive findings in traditional stress tests. The calcaneofibular ligament (CFL) may contribute to the stabilization of the subtalar and talocrural joints, and some functional instability may be due to CFL insufficiency. We aimed to clarify and quantitatively assess CFL insufficiency with three-dimensional stress computer tomography (CT) using the Pronation-External Rotation Stress Test (PERST).Ten patients who tested positive under PERST and underwent an isolated CFL reconstruction were included. Using a custom-made loading jig, we used the Supination-Internal Rotation Stress Test (SIRST) and PERST to assess the function of anterior talofibular ligament (ATFL) and CFL, respectively. 3D-CT in neutral position was used as a baseline, and we quantified the distance between the origin and insertion of the CFL and ATFL at 2 years pre- and postoperatively.Postoperative scores improved in all patients with no giving way symptoms. The preoperative length of the CFL increased by 14.0% from baseline under PERST, while the postoperative length only increased by 2.0% and was significantly restricted (P .01). The pre- and postoperative length of ATFL was increased by 7.5% and 9.0% from baseline under SIRST, respectively, with no significant difference (P = .41). The clinical function improved with significantly less change in distance between the origin and insertion under PERST and showed no difference under SIRST.The 3D-CT stress test may be useful for quantifying pre- and postoperative CFL function. CFL insufficiency is one of the main causes of subtalar joint instability; therefore, measuring the distance between the origin and insertion of the CFL could provide the means to quantify the instability of the subtalar joint.

[Purpose] The purpose of this study was to identify the factors influencing change in life-space mobility after total knee arthroplasty (TKA) in patients with severe knee osteoarthritis (knee OA). [Participants and Methods] Overall, 58 primary unilateral TKA recipients (9 males and 49 females; age ± SD 74.6 ± 6.5 years) were enrolled. We evaluated Life-Space Assessment (LSA) scores, knee extensor strength, Timed Up and Go test (TUG), one-leg standing time (OLS), Western Ontario and McMaster Universities osteoarthritis Index, and physical activity self-efficacy (SE) before surgery and at 3 months post-operation. [Results] Life space mobility significantly expanded 3 months after surgery compared with preoperative baseline. Preoperatively, walking SE and knee extensor muscle strength on the operative side were found to have strong correlation with LSA scores, while stairs SE and knee extensor muscle strength of the operative side were correlated at 3 months post-operation. [Conclusion] These findings suggest that to expand the life-space mobility of TKA recipients, it is important to enhance self-efficacy for general physical activity in addition to strengthening the quadriceps muscles.

Background Measuring the strain patterns of ligaments at various joint positions informs our understanding of their function. However, few studies have examined the biomechanical properties of ankle ligaments; further, the tensile properties of each ligament, during motion, have not been described. This limitation exists because current biomechanical sensors are too big to insert within the ankle. The present study aimed to validate a novel miniaturized ligament performance probe (MLPP) system for measuring the strain patterns of the anterior talofibular ligament (ATFL) during ankle motion. Methods Six fresh-frozen, through-the-knee, lower extremity, cadaveric specimens were used to conduct this study. An MLPP system, comprising a commercially available strain gauge (force probe), amplifier unit, display unit, and logger, was sutured into the midsubstance of the ATFL fibers. To measure tensile forces, a round, metal disk (a “clock”, 150 mm in diameter) was affixed to the plantar aspect of each foot. With a 1.2-Nm load applied to the ankle and subtalar joint complex, the ankle was manually moved from 15° dorsiflexion to 30° plantar flexion. The clock was rotated in 30° increments to measure the ATFL strain detected at each endpoint by the miniature force probe. Individual strain data were aligned with the neutral (0) position value; the maximum value was 100. Results Throughout the motion required to shift from 15° dorsiflexion to 30° plantar flexion, the ATFL tensed near 20° (plantar flexion), and the strain increased as the plantar flexion angle increased. The ATFL was maximally tensioned at the 2 and 3 o’clock (inversion) positions (96.0 ± 5.8 and 96.3 ± 5.7) and declined sharply towards the 7 o’clock position (12.4 ± 16.8). Within the elastic range of the ATFL (the range within which it can return to its original shape and length), the tensile force was proportional to the strain, in all specimens. Conclusion The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns.

Background Fusion surgeries for scoliosis patients are believed to deteriorate sports performance; in particular, forward roll should deteriorate, but no literature is available to substantiate this claim. Hypothesis The extent of postoperative deterioration can vary according to surgery type or curve type. Patients and methods Idiopathic scoliosis patients between 10 and 29 years of age who underwent correction and fusion surgeries at our hospital were included in this study. Forward roll was recorded on video preoperatively and 1-year postoperatively. Performances were evaluated twice on a 10-point scale by two blinded examiners. Preoperative and 1-year postoperative upright spinal radiographs were analyzed for the Lenke classification, number of fused vertebrae, upper and lower instrumented vertebrae, major curve Cobb angle, thoracic kyphosis, lumbar lordosis, and surgical procedures. Results The average age was 16 years. Curve types according to the Lenke classification were: 15, type 1; 5, type 2; 14, type 5; 2, type 6. The mean number of fused vertebrae was 6.9 (3.2 for anterior surgeries and 9.3 for posterior surgeries). The mean preoperative assessment of forward roll was 9.6 points, and the 1-year postoperative assessment was lower at 8.8 points. Cluster analysis classified patients into 3 groups: long fusion with marked performance deterioration (C1), long fusion with minimal deterioration (C2), and short fusion with minimal deterioration (C3). The upper and lower instrumented vertebrae in C1 were more distal than those in C2. Conclusion Patients with thoracic curves were classified into two groups, and patients who underwent surgeries with more distal upper and lower instrumented vertebra levels exhibited lower postoperative performance. However, patients with Lenke 5 curves who underwent anterior surgery showed better preoperative performance than other patients who underwent posterior surgery, showing minimal postoperative deterioration. Level of evidence III; therapeutic study.

Background Fusion surgeries for scoliosis patients are believed to deteriorate sports performance; in particular, forward roll should deteriorate, but no literature is available to substantiate this claim. Hypothesis The extent of postoperative deterioration can vary according to surgery type or curve type. Patients and methods Idiopathic scoliosis patients between 10 and 29 years of age who underwent correction and fusion surgeries at our hospital were included in this study. Forward roll was recorded on video preoperatively and 1-year postoperatively. Performances were evaluated twice on a 10-point scale by two blinded examiners. Preoperative and 1-year postoperative upright spinal radiographs were analyzed for the Lenke classification, number of fused vertebrae, upper and lower instrumented vertebrae, major curve Cobb angle, thoracic kyphosis, lumbar lordosis, and surgical procedures. Results The average age was 16 years. Curve types according to the Lenke classification were: 15, type 1; 5, type 2; 14, type 5; 2, type 6. The mean number of fused vertebrae was 6.9 (3.2 for anterior surgeries and 9.3 for posterior surgeries). The mean preoperative assessment of forward roll was 9.6 points, and the 1-year postoperative assessment was lower at 8.8 points. Cluster analysis classified patients into 3 groups: long fusion with marked performance deterioration (C1), long fusion with minimal deterioration (C2), and short fusion with minimal deterioration (C3). The upper and lower instrumented vertebrae in C1 were more distal than those in C2. Conclusion Patients with thoracic curves were classified into two groups, and patients who underwent surgeries with more distal upper and lower instrumented vertebra levels exhibited lower postoperative performance. However, patients with Lenke 5 curves who underwent anterior surgery showed better preoperative performance than other patients who underwent posterior surgery, showing minimal postoperative deterioration. Level of evidence III;Therapeutic Study.

The graft on flap method, a useful option for the restoration of fresh fingertip amputation, was applied to the reconstruction of the short fingertip stumps resulting from the initial amputated stump plasties. As a modification, a nail bed graft from the big toe and a small cubic iliac bone graft were substituted for the lost tissues normally reduced as a composite graft in fresh cases. Upon follow-up ranging from 1 to 8 years, the grafted bone was found to have been resorpted in all cases. For the reconstruction of short fingertip stumps after the initial amputated stump plasties, acceptable results have not yet been achieved using the graft on flap method.

Category: Arthroscopy; Hindfoot Introduction/Purpose: As a minimally invasive surgical option for posterior ankle/subtalar pathologies, the prone hindfoot endoscopy (a.k.a. Van-Dijk’s method) has been becoming the ‘gold standard’ technique. While this technique holds advantage regarding good orientation and safety handling of posteromedial pathologies, it limits access to the anterolateral part, therefore inconvenient when simultaneously dealing with anterior and posterior pathologies. Recently, we have introduced a novel ‘infra- fibula-tip (IFT)’ portal, which permits wide access to the posterior talocalcaneal joint (PTCJ), from anterolateral to posteromedial, with a patient positioned in supine or semi-lateral. The present study reviewed clinical outcomes of a case series of arthroscopic hindfoot mobilization using this new surgical technique, so as to document its clinical utility. Methods: The sequence of surgical procedures is as follows; - Create an IFT portal, from a small incision immediately distal to the fibular tip, through the peroneal tendon sheath (anterior to the tendons, but posterior to the calcanofibular ligament), toward the posterior porch of PTCJ. - Inserting a 30-deg 2.7mm scope to the posterior porch, and broadly observing posterior intraarticular findings. - Gently moving the scope to the anterolateral porch, and broadly observing anterolateral intraarticular findings. - Creating an anterolateral (AL) portal under arthroscopic guidance. - Creating a PL portal at immediately lateral to the Achilles tendon, with guidance of a blunt rod inserted from the AL portal (gently advanced posteriorly through the lateral recess and penetrated the rod toward subcutis). - Executing posterior procedures from the PL portal, while observing from the IFT portal. Executing anterolateral procedures working from the AL portal, while observing from the IFT portal. Results: A total of 7 cases underwent the procedure of interest to date. Subtalar osteoarthritis (OA) occurred in all, with accessory anterolateral talar facet (AALTF) impingement in 3. Ankle OA occurred in 3, with anterior bony impingement in 2. Preceding pathologies included peri-ankle intraarticular fractures (4), talocalcaneal coalition (2), and neurogenic varus foot (1). Mobilization procedures included lateral-to-posterior PTCJ debridement (7), coalition release (2), AALTF removal (3), sinus debridement (2), posterior ankle capsule release (2), anterior ankle debridement (2), talonavicular debridement (1), and Achilles tendon lengthening (1). The surgery duration ranged from 65 to 245 minutes. Postoperatively, of 4 cases followed more than 6 months, remarkable motion improvement (10 degrees or more) occurred in 3, and every case reported symptom relief. Conclusion: The IFT portal accesses the middle of the PTCJ, with a short skin-to-joint distance, allowing flexible exploration of both the posterior and anterior porches. Posteriorly, ability of direct intraarticular access (without extraarticular shaving) reduces surgical invasion, as well as the risk of potential neurovasucular injury. Anteriorly, it helps secure good triangulation for handling sinus pathologies. Since subtalar arthroscopy using the IFT portal is doable in a supine or semi-lateral position, anterior ankle arthroscopy could be simultaneously executed. Arthroscopic hindfoot mobilization using this technique appears to be efficient for dealing with ankle/subtalar contracture due to combined anterior and posterior pathologies.

Electromyographic biofeedback (EMG-BF) therapy provides information on the state of contraction of the targeted muscles and relaxation of their antagonists, which can facilitate early active range of motion (RoM) after elbow surgery. Our aim in this study was to calculate the minimum detectable change (MDC) during EMG-BF therapy, initiated in the early postoperative period after elbow surgery.This study is an observational case series. EMG-BF of muscle contraction and relaxation was provided during active elbow flexion and extension exercises. Patients completed 3 sets of 10 trials each of flexion and extension over 4 weeks. The total range of flexion-extension motion and scores on the Japanese Society for Surgery of the Hand version of the disability of the arm, shoulder, and hand questionnaire and the Japanese version of the Patient-Rated Elbow Evaluation were obtained at baseline and weekly during the 4-week intervention period. A prediction formula was developed from the time-series data obtained during the intervention period, using the least-squares method. The estimated value was calculated by removing the slope from the prediction formula and adding the initial scores to residuals between the measured scores and predicted scores individually. Systematic error, MDC at the 95th percentile cutoff (MDC95), repeatability of the measures, and the change from the baseline to each time-point of intervention were assessed.The MDC95 was obtained for all 3 outcome measures and the range of values was as follows: RoM, 8.3° to 22.5°; Japanese version of the Patient-Rated Elbow Evaluation score, 17.6 to 30.6 points; and disability of the arm, shoulder, and hand questionnaire subscale: disability and symptoms score, 14.2 to 22.9 points.The efficacy of EMG-BF after elbow surgery was reflected in earlier initiation of elbow RoM after surgery and improvement in patient-reported upper limb function scores. The calculated MDC95 cut-offs could be used as reference values to assess the therapeutic effects of EMG-BF in individuals.

Background Spinal sagittal malalignment is managed by long spinal fusion including the pelvis, which reduces lumbar spine range of motion and impairs the activities of daily living. This study aimed to evaluate the changes in activities of daily living after long spinal fusion in adults with spinal deformity, and clarify the improvement or deterioration in the specific activities of daily living postoperatively. Methods We retrospectively reviewed 40 adults who underwent long spinal fusion in a single institution between 2014 and 2016 (female/male, 39/1; mean age, 68.5 years; range, 52–79 years). Each patient undertook three self-assessed health-related quality of life measures preoperatively and again at 2-years postoperatively: Oswestry Disability Index (ODI), Scoliosis Research Society (SRS)-22 questionnaire, and Japanese Orthopaedic Association back pain evaluation questionnaire (JOABPEQ). Radiographic outcomes were measured preoperatively and at 2 years postoperatively. Results Total ODI and all SRS-22 domains were improved at 2 years postoperatively. The JOABPEQ scores were also improved in all domains, except lumbar function. The change in pelvic incidence minus lumbar lordosis correlated with improvements in total ODI, SRS-22 function, and self-image scores. At 2 years postoperatively, satisfaction was correlated with total ODI, all SRS-22 domains, and the JOABPEQ pain domain. Subclass analysis of the JOABPEQ lumbar function domain at 2 years postoperatively revealed that 65% of patients had difficulty ‘putting on socks or stockings’, 42% had great difficulty ‘bending forward, kneeling, or stooping’, 32% reported improvement in ‘sit to stand’, and 32% reported deterioration in ‘putting on socks or stockings’ after surgery compared with before surgery. The JOABPEQ lumbar function domain was not correlated with the SRS-22 satisfaction domain. Conclusions Despite restricting lumbar function, spinopelvic fusion improves health-related quality of life. Surgeons and patients should discuss potential changes and limitations in the activities of daily living after long spinal fusion including the pelvis.

It is commonly accepted that wide en bloc resection followed by reconstruction is essential in progressive lesions (Campanacci grade III) for local control of possible recurrence. However, specific grade III can be downgraded and treated with intralesional curettage to preserve better wrist function, without increasing the recurrency rates. In this report, Grade III giant cell tumor of the distal radius was successfully treated using vascularized osseous graft from the inner lip of the iliac bone in addition to downgrading strategy.

Asymptomatic pisotriquetral arthroses caused ruptures of the flexor digitorum profundus tendon of the little finger in 2 elderly patients. Ruptures occurred with unnoticeable onset, and bilateral ruptures separately occurred with interval of several years in one patient. The tendon was ruptured in zone IV with perforation of the gliding floor through which the degenerative pisiform was visible. The gliding floor was repaired followed with excision of the pisiform, and the ruptured tendon was then transferred to the profundus tendon of the ring finger. Asymptomatic pisotriquetral arthrosis in old age can be an aspect of the pathological background of flexor tendon ruptures of the little finger that occur unnoticed.

The purpose of this study was to compare the characteristics of scoliosis in Prader-Willi syndrome (PWS) patients versus idiopathic scoliosis (IS).We identified 193 PWS patients. Scoliosis was found in 58 PWS patients, 39 of whom were treated with GH. Fifty-five IS patients were consecutively selected from an outpatient clinic. We investigated 113 patients (58 PWS group, 55 IS group) followed for a minimum of 2 years. The mean age was 17.9 and 16.1 years, respectively. Deformity was measured using Lenke classification, Cobb angle, thoracic kyphosis at T2-5 and T5-12, lumbar lordosis at T12-S1, and sagittal alignment at the C7 plumb line. BMI was also recorded.According to the Lenke system, patients were classified as (PWS group/IS group): Type 1 (8/26), Type 2 (1/4), Type 3 (3/15), Type 4 (1/0), Type 5 (32/8), and Type 6 (13/2). The average Cobb angles were 32.6° in the PWS and 35.4° in the IS. No significant differences were found for the thoracic kyphosis (T2-5, T5-12), lumbar lordosis (T12-S1) or C7 plumb line between the two groups. BMI was increased in the PWS group not treated previously with GH as compared with the IS group and the PWS group with GH.Most PWS patients presented with lumbar or thoracolumbar curves (Type 5, 6), whereas IS patients typically had thoracic scoliosis (Type 1, 2, 3).

Background: Screw fixation used in modified Kidner procedures to treat persistent symptomatic accessory navicular in adult cases is often challenging in adolescent cases with a small accessory fragment. The present study aimed to document the clinical effect of a suture anchor stabilization technique applicable to such cases where osteosynthesis is considered an ideal outcome. Methods: Consecutive clinical cases who received this surgical treatment from 2009 to 2016 were retrospectively reviewed. The focus of interest included radiographic union of the accessory bone, changes in symptoms evaluated using a validated clinical outcome scale introduced by the Japanese Society for Surgery of the Foot, and changes in the medial arch bony alignment measured in lateral weight-bearing plain radiographs. Results: Twenty-two feet in 15 individuals (11 females and 4 males, age at surgery 10–16 years) were identified. In 14 feet (64%), radiographic bone union was confirmed within 8 weeks postoperatively. At the final follow-up ranging 12–51 months postoperation, the clinical scores have significantly improved ( p < 0.001) to 96 ± 5.71 (mean ± standard deviation, range 87–100), from 54 preoperatively. Radiographic measurements revealed significant postoperative increase of the sagittal talar tilt angle ( p < 0.001, increment 4 ± 3°, range 0–11) and the talo-first metatarsal angle ( p < 0.001, increment 5 ± 4°, range 0–12). No significant changes were identified in the calcaneal pitch angle, first metatarsal tilt angle, calcaneo-navicular angle, and the navicular height. Conclusion: Despite the modest bone union rate, the clinical outcomes suggest distinct symptom-relieving effect, at least in the short- to midterm, while the radiographic measurements suggest positive biomechanical effects. The present suture-anchor stabilization concept appears to be a promising treatment option for persistent symptomatic accessory navicular in adolescent cases.

Patients with Prader-Willi syndrome (PWS) have fragile bones. Osteoporosis is a major concern in scoliosis surgery. Our aim was to investigate bone mineral density (BMD) in PWS patients and to verify the efficacy of and scoliosis deterioration with growth hormone (GH) administration for osteoporosis.We followed 148 PWS patients who underwent lumbar spine (L2-4) BMD testing. Sixty-four patients had scoliosis, and 84 were non-scoliosis patients. Patients were treated with GH (0.245 mg/kg/week) until they reached a skeletal age of 17 years for males and 15 years for females. We also evaluated the effect of GH treatment on BMD in 101 patients (60 males, 41 females) undergoing BMD testing more than twice. The mean patient age was 5.4 years. The mean duration of GH administration was 54 months.Mean lumbar BMD was 0.567 g/cm(2). Fifty patients (33.8%) had osteoporosis and 41 (27.7%) had osteopenia. There was no significant difference in mean BMD between patients with scoliosis (0.598 g/cm(2)) and without scoliosis (0.548 g/cm(2)). GH treatment caused a significant increase in Z score (pre-GH: mean -2.28 vs. post-GH: mean -1.53, P0.001). There was no statistical difference in the prevalence of scoliosis between the GH treatment group (45/112, 40.1%) and non-treatment group (19/36, 52.8%).Among patients with PWS, 61.5% had low BMDs. GH administration significantly improved the lumbar BMD (Z score). There were no statistically significant differences in the prevalence of scoliosis among patients who received GH treatment compared to patients who did not.

Category: Ankle Arthritis Introduction/Purpose: Abnormal tibial plafond geometry, varus deformity and insufficient talar anterior coverage in particular, is well recognized as congenital factors predisposing ankles to osteoarthritis (OA), both primarily and after lateral ligament injury. Presumably, abnormal geometry of the gutter articulations (for the medial and lateral malleoli) also increases a risk of ankle OA, though this concept has not been well addressed to date. The talar side-wall surfaces, which appears to be less affected by degenerative deformity in ankle OA, may leave the congenital characteristics of the gutter articulation geometry. To identify a type of ankles at higher risk of OA development in this context, the present study explored characteristics of the talar side-wall geometry in OA ankles. Methods: Clinical CT images, from 21 moderate to advanced OA ankles without critical preceding pathologies and from 29 age- matched non-OA ankles, were subjected to 3-D morphometric evaluation of the talar dome side-wall geometry. Using a DICOM viewer (AquariusNET®, TeraRecon, Foster City, CA, USA), a local coordinate system for each ankle was manually established using talar landmarks. Then, on a transverse section at 3-5 mm distal to the superior aspect of the talar trochlea, the angle between the medial and lateral side-wall tangential lines (regressed from five cortical surface reference points for each) was measured as the “anterior opening angle.” Similarly, the “inferior opening angle” was measured on a mid-coronal section. Differences between groups were statistically tested using a t-test, with the significant level of p set at 0.05. Results: The anterior opening angle was significantly larger (p = 0.006) in the OA ankles (mean +/- SD: 11.9 +/- 6.0 degrees) than in the non-OA ankles (8.5 +/- 3.2). The inferior opening angle was also significantly larger (p = 0.007) in the OA ankles (30.7 +/- 11.1) than in the non-OA ankles (25.2 +/- 5.5). Defining the range of mean +/- 2SD as “normal” (Figure), 13 out of 21 (62%) OA ankles had both or either abnormally large anterior and/or inferior opening of the talar side-wall surfaces. Conclusion: Anterior and inferior opening trapezoidal shapes are common characteristic of the talar dome geometry. It is also well recognized that the degrees of opening substantially vary across individuals. The present study documented frequent occurrence of excessive anterior and/or inferior opening in OA ankles. Assuming that these abnormalities are inherent characteristics rather than results of degeneration, excessive anterior and inferior openings of the talar dome side-walls could be pathogenetical factors that increase a risk of ankle OA. Clinically, when ankles with excessive anterior and/or inferior opening talar dome side-walls would have ligament insufficiency, surgical repair or reconstruction should be considered to minimize a risk of future OA development.

To gain a better understanding of the precise anatomy of the lateral ligaments of the ankle through a systematic review of published cadaveric studies in order to improve anatomical minimally invasive surgery (MIS) for treatment of chronic ankle instability (CAI). A systematic review of the literature was performed using the PubMed, EMBASE, Cochrane databases and Web of Science on June 2015 with the two search concepts: “lateral ligament of the ankle” and “anatomy”. Anatomical studies that reported gross anatomy of the anterior talar fibular ligament (ATFL) and calcaneal fibular ligament (CFL) in English were included to assess the morphology and origins and insertions of the ligaments. All records found in the literature search were screened by title and abstract. Potentially relevant articles were selected for full-text review. Each of the identified articles was reviewed and included in qualitative synthesis. The following data were abstracted from the included articles: authors, date of publication, sample size, mean age, the length and the width of the each ligament, number of bundle of the ATFL and the location and the footprint of the origins and insertions for the ATFL and CFL. Sixteen studies were identified indicating the length of the ATFL and CFL was 12–24.8 and 18.5–35.8 mm, respectively, while the width was 5–11.1 and 4.6–7.6 mm, respectively. Fibular origins of the ATFL and CFL were located on the anterior border of distal fibula at a distance of 10–13.8 and 5.3–8.5 mm proximal to the tip of the fibula, respectively. The talar insertion of the ATFL was located 14.2–18.1 mm to the subtalar joint or 11.3–14.8 mm to the anterolateral corner of the talar body. The calcaneal insertion of the CFL was located 12.1–13 mm to the subtalar joint or 13.2–27.1 mm to the peroneal tubercle on the lateral wall of calcaneus. Systematic review of the literature of the research for the ATFL and CFL has identified the morphology of the ligaments and their location of origins and insertions. This is the best available data about the ATFL and CFL which will facilitate more precise anatomical MIS for treatment of CAI. Systematic review, Level IV.

Many complications have been reported to occur with surgery for scoliosis in Prader-Willi Syndrome (PWS). However, growth hormone (GH) treatment has contributed to improvements in height, body composition, bone density and breathing functions in PWS patients. The purpose of this study was to investigate patients who underwent surgery for scoliosis in PWS.There were 136 PWS patients being followed-up by the Pediatrics Department of our hospital. Among these, we investigated nine patients who had undergone surgery. Their mean age was 11 years. The mean follow-up period was 6 years 10 months.The mean body mass index was 22.5 kg/m(2). GH therapy was administered to eight patients. Brace treatment was performed in two patients. Spinal correction and fusion were performed in six patients, and the growing rod method was performed in three patients. Necessary reoperations were performed in two patients. For the total 11 surgeries in the nine patients, the mean blood loss was 397 ml and the mean operation time was 4 h and 20 min. The mean Cobb angles were 76.0 degrees preoperatively and 35.8 degrees at follow-up. Regarding complications, one patient experienced early dislodgment of the hook and one patient experienced a superior wound infection.There were no severe complications such as deep infections or neurovascular damage. A few obese patients underwent surgery, but there were no dangerous complications. Overall, we consider that GH treatment before surgery may reduce postoperative complications. The growing rod method was effective for PWS patients who resisted brace treatment owing to mental retardation.

〔目的〕人工膝関節全置換術（TKA）による回復過程を検討するために，身体機能および健康関連QOL（HRQOL）を調査した．〔対象〕TKA術後リハを実施した変形性膝関節症患者40膝とした．〔方法〕身体機能評価にはTimed Up and Go test（TUG），膝伸展筋力，開眼片脚起立時間を測定し，HRQOL評価には準WOMACとSF-36を用いた．〔結果〕身体機能の全項目において術後3ヶ月で有意に改善した．準WOMACの痛みとSF-36の身体機能，体の痛み，全体的健康感，社会生活機能は術後1ヶ月で有意に改善し，さらに術後3ヶ月で準WOMACの機能も有意に改善した．開眼片脚起立時間を除く身体機能とHRQOLの全項目は，変化量と初期値との間に有意な負の相関を認めた．〔結語〕TKAによりHRQOLは術後1ヶ月で改善し，術後3ヶ月では身体機能が改善することが示唆された．

This study describes pseudoarthrosis of the proximal phalanx of the little finger and its successful treatment using a free vascularized genicular osseous-periosteal flap. Since this thin and pliable flap can be harvested as a small vascularized unit, it is ideal for the treatment of phalangeal pseudoarthrosis.

Background context The prevalence of scoliosis in Prader-Willi syndrome (PWS) is high; however, the prevalence of PWS is rare, with one person in 10,000 to 20,000 affected. The etiology and characteristics of scoliosis associated with PWS remain unidentified. In addition, it is believed that the speedup of growth associated with growth hormone (GH) supplement treatment may influence the deterioration of scoliosis in PWS. Purpose To investigate scoliosis in Japanese patients with PWS. Study design Retrospective observational study. Patient sample We investigated 101 patients (67 men, 34 women) who were followed up from November 2002 to January 2008. All patients were diagnosed using fluorescence in situ hybridization or the methylation test. Of the 101 patients, 80 had an inherited deletion of chromosome 15q11–13 (deletion) and 21 patients had no deletion, including those with uniparental disomy. Outcome measures 1) Prevalence of scoliosis; 2) association of scoliosis with GH treatments; 3) association of scoliosis with genotype; 4) clarification of PWS scoliosis characteristics; and 5) analysis of severe PWS scoliosis patients (Cobb angle greater than 40°). Scoliosis for our study was defined as scoliosis with a Cobb angle greater than 10°. Methods To investigate PWS-associated scoliosis, we used spinal X-ray examinations. The pattern of scoliosis was classified into three types: primary single lumbar or thoracolumbar curve (Type 1), double curve (Type 2), and primary single thoracic curve (Type 3). For statistical analysis, chi-square tests for the distribution of patients were used (p Results 1) Scoliosis was found in 38.6% (39/101) of patients with PWS. 2) There was no statistical difference in the prevalence of scoliosis between the GH treatment group (32.8%) and the GH nontreatment group (group with no GH treatments) (46.5%) (p=.16, chi-square test). 3) There was no statistical difference in the prevalence of scoliosis between the deletion group (38.8%) and the nondeletion group (38.1%) (p=.84, chi-square test). 4) Scoliosis was classified into three types, according to single or double curve scoliosis and position of scoliosis. The prevalence of these groups was 61.5% for Type 1 (primary single lumbar and thoracolumbar curve), 48.7% for lumbar curve convex on the left side, 28.2% for Type 2 (double curve), and 10.3% for Type 3 (primary single thoracic curve). 5) Severe scoliosis was found in nine patients (8.9%, 9/101). Type 2 was found in 66.7% (6/9) of patients with severe scoliosis. During the follow-up period, two patients changed from Type 1 to Type 2. Conclusions Scoliosis in PWS can be classified into three types. A lumbar curve convex on the left side was found in most patients. In addition, severe deterioration of scoliosis was found in Type 2 patients. Therefore we recommend careful, ongoing observations for patients showing double curve tendencies.

von Recklinghausen's disease (neurofibromatosis type I) is a chromosomal dominant hereditary disease, characterized by cafe-au-lait spots of the skin and multiple neurofibroma. Importantly, the neurofibroma arising in the oral and maxillofacial region is known to result in a jaw deformity. We report a case of facial asymmetry which may have been due to the neurofibroma of von Recklinghausen's disease and the repeated surgical intervention for it. The patient was a 20-year-old male. He had repeatedly undergone surgical extirpation of a tumor in the left parotid gland region since he was 3 years old. In the present findings, his face was asymmetric and his dental arch was narrow because of the mandibular deviation and the soft tissue mass in the left mandibular region. Radiographic examinations revealed a bone defect at the mandibular angle and atrophy of the left ramus. To improve these problems, distraction osteogenesis to expand the dental arches, and two-jaw surgery and iliac bone graft to restore the skeletal asymmetry were performed. Upon follow-up one year later, skeletal relapse was not noted.

Purpose Oblique triangular flaps often need extensive advancement for fingertip coverage. The purpose of this report is to retrospectively investigate the relationship between sensory recovery and advancement distance of oblique triangular flaps. Methods Fourteen consecutive fingertip amputations in 11 patients were treated with oblique triangular flaps between 2005 and 2006. These cases had been regularly followed up (range, 14–21 months) until sensory recovery of the fingertip covered with the flap reached a plateau, and then final sensory condition was evaluated with the Semmes-Weinstein monofilament test and a moving 2-point discrimination test, in addition to evaluation of existence of dysesthesia. Results Dysesthesia existed in 7 fingers, and there was an associated a significant difference between a flap advancement distance of more than 12 mm and a flap advancement distance of less than 12 mm. In an objective evaluation of whether the 2.83 monofilament (0.086 g) could be recognized in the Semmes-Weinstein test, there was also an associated significant difference between a flap advancement distance of more than 12 mm and a flap advancement distance of less than 12 mm. Conclusions Good sensory recovery occurred in cases with less than 12 mm flap advancement. In cases where the flap was advanced more than 12 mm, sensory disturbance of the fingertip occurred and did not subside. Type of study/level of evidence Prognostic II.

Mucosa-associated lymphoid tissue (MALT) lymphoma is an extranodal low-grade lymphoma found mainly in the gastrointestinal tract. However, it rarely occurs in the oral cavity. A case of MALT lymphoma arising in the minor salivary glands of the buccal region is reported. A 21-year-old woman was referred to our department because of a swelling in the left buccal mucosa. Clinically, the mass was elastic hard and painless, but did not adhere to the skin or oral mucosa. After resection of the mass, it was diagnosed to be a malignant lymphoma arising in the buccal gland. The lymphoma was classified as MALT type on the basis of histopathological and immunohistochemical findings. Further evaluation suggested that the patient might have Sjogren's syndrome. An association of the MALT lymphoma with Sjogren's syndrome was suggested. Six months after treatment, there was no evidence of recurrence.

Using pathological and immunohistochemical approaches, we investigated whether lingual injection of B16 cells spontaneously induces cervical lymph node metastasis and whether the extent of tumor lymphangiogenesis is related to the incidence of lymph node metastasis during the local progression of a tumor. Primary tumors developed into unilateral (phase I), separated (phase II), and fused (phase III) patterns. The rate of cervical lymph node metastasis increased in both phases II and III. Intratumoral lymphatic vessel density (LVD) was significantly higher in phase III, whereas increase in peritumoral LVD started in phase II. In this study, we demonstrate the development of cervical lymph node metastasis induced by the progression of melanoma in the tongue, and provide unique evidence that an increased LVD may heighten the risk of lymph node metastasis. In particular, the peritumoral vessels may play an important role in the propensity for early metastatic spread to regional lymph nodes.

Study design A retrospective minimum 20-year follow-up study using 4 standard self-administered questionnaires, one of which, the SRS-22 was also administered to control groups. Objective To evaluate long-term postoperative pain and other clinical outcomes of scoliosis correction and fusion surgery with Harrington instrumentation using Moe square-ended rods for better preservation of sagittal alignment. Summary of background data Only a few long-term outcome studies have used standardized and validated self-administered tools, and no studies have established SRS-22 control data within their own population. There is no previous minimum 20-year follow-up evaluation after correction surgery preserving thoracic kyphosis and lumbar lordosis. Methods Of 86 consecutive patients who underwent instrumentation surgery for scoliosis by a single surgeon, 61 patients participated using Japanese Orthopaedic Association, Roland-Morris Disability Questionnaire, Oswestry Disability Index, and Scoliosis Research Society (SRS-22) questionnaires and 51 patients were included in this study. Results were analyzed for pain and other clinical outcomes. A total of 771 hospital employees were sent SRS-22 questionnaires. A total of 763 responded, resulting in 2 control groups composed of nonscoliosis and untreated mild scoliosis controls of the same culture and language as the long-term follow-up group. Results The prevalence of continuous low back pain was about 15%. Average Japanese Orthopaedic Association, Oswestry Disability Index, and Roland-Morris Disability Questionnaire scores at follow-up were 25 points, 7.3%, and 1.6, respectively. The average SRS-22 scores were 4.2 (function), 4.3 (pain), 3.7 (self-image), and 3.9 (mental health) for the postoperative follow-up group compared with 4.5 (function), 4.3 (pain), 3.5 (self-image), and 3.5 (mental health) for the nonscoliosis controls. Conclusion Improved preservation of normal sagittal alignment resulted in a prevalence of low back pain comparable with the age-matched general population. Moreover, SRS-22 results for self-image and mental health were positive compared with the controls, possibly reflecting the surgeon's emphases on mental health and management of patient expectations. Level of evidence 4.

Background Lenke 5C type adolescent idiopathic scoliosis (AIS) with a Cobb angle of over 30 degrees has high risk of progression. The need for corrective surgeries for degenerative lumbar scoliosis has been increasing these days and some of those cases are pre-existing type scoliosis. However, it is said to be difficult to differentiate pre-existing type scoliosis from de novo type scoliosis. The purpose of this study is to analyze the relevant X ray metrics of degenerative lumbar scoliosis and to discover differences between pre-existing and de novo type scoliosis. Methods Of 54 consecutive patients who were diagnosed as candidates for corrective surgery for left convex thoracolumbar / lumbar scoliosis since December 2008, 19 patients over age 50 were included in this study. The average age was 60 years old (50-80 years old). All patients were female. Coronal and sagittal parameters were contrasted between two groups divided according to the existence of scoliosis in their adolescence; clear (AIS) and unclear (de novo). Results Eleven were AIS, and 8 were de novo. The average age was 54.0 years old for AIS and 67.4 for de novo (p

Background: Ankle ligament injuries and instability are commonly observed. Knowledge of the relationship between the foot position and tensile forces of the ankle ligaments could be useful for treatment of ankle ligament disorders. The aim of this study was to measure the tensile forces of the ankle ligaments at the end points of passive circumferential rotating motion of the ankle and subtalar joint complex in various foot positions. Methods: Ligament tensile forces of the anterior talofibular (ATF), calcaneofibular (CF), posterior talofibular (PTF), and tibiocalcaneal (TC) ligaments were measured simultaneously in eight cadaver specimens, with a force probe in each ligament in a custom-made ankle ligament testing device. Weights of 0.5 kg and 1 kg were applied to the foot through a loading arm to provide axial compression and a bending moment to the foot and ankle. The position of the loading arm was changed circumferentially in 10-degree increments. Results: Maximal tensile force in the ATF ligament was observed in supination with plantarflexion (108 ± 62.8 N at 0.5 kg and 130 ± 39.1 N at 1 kg). The maximal tensile force in the CF ligament was observed in pronation with plantarflexion (68 ± 48.6 N at 0.5 kg and 135 ± 92.9 N at 1 kg). The maximal tensile force in the PTF ligament was observed in dorsiflexion (131 ± 80.1 N at 0.5 kg and 109 ± 36.3 N at 1 kg). The maximal tensile force of the TC ligament was observed in pronation with plantarflexion (49.0 ± 80.1 N at 0.5 kg and 67.4 ± 69.6 N at 1 kg). Relatively high magnitudes of tensile force were observed in the ankle ligaments, and the peak forces were related to the anatomic position of individual ligaments. Conclusions: The ATF ligament has an important role in the supination position in plantarflexion, CF and TC ligaments also are important for pronation in plantarflexion, and the PTF is an important stabilizer in dorsiflexion. This study provides baseline information for further research related to ligament instability and reconstruction operations.

Objective: To evaluate the accuracy of repositioning of the maxilla by Le Fort I osteotomy with emphasis on maxillary backward transference. Materials and Methods: Thirty patients with jaw deformity who underwent Le Fort I osteotomy were enrolled in the study. The patients were divided into 3 groups: backward transference group, in whom both molar regions were moved >2 mm in the posterior direction; forward transference group, in whom both molar regions were moved >2 mm in the anterior direction; and minor transference group, in whom both molar regions were moved

Two cases of successful reconstruction of massive defects around the knee with multiple-island combined flaps based on the subscapular axis are reported. Both defects resulted from aggressive debridement for acute osteomyelitis after open fixation of high-energy fractures around the knee. In Case 1, a four-island combined flap consisting of the scapular flap, the lattissimus dorsi muscle flap, the serratus anterior muscle flap, and the scapular osseous flap, based on the same subscapular axis, was used. Partial bone transport using the Ilizarov apparatus was added as reinforcement of arthrodesis. In Case 2, a five-island combined flap, consisting of the scapular, parascapular flap, the lattissimus dorsi muscle flap, the serratus anterior fascial flap, and the scapular osseous flap, was used. Consequent ankylosis of the knee joint afforded the patient painless full weight bearing without secondary arthrodesis. Multiple-island combined flaps based on the subscapular axis can provide three-dimensional reconstruction of destructive knee defects.

Subcutaneous granuloma annulare is a benign inflammatory disorder consisting of deep dermal or subcutaneous nodules, and frequently occurring in the extremities and scalp in children. The occurrence of aggregated multiple nodules in a digit is quite atypical. This is a report of an eight-year-old girl who presented with increasingly asymptomatic multiple nodules on her middle finger over a period of six months. Definitive diagnosis of subcutaneous granuloma annulare was achieved with surgical biopsy and no aggressive growth subsequently and showed a tendency toward spontaneous resolution.

A 59-year-old woman noticed a swelling and redness in the buccal and palatal mucosa 12h after setting of a temporary crown (TEK) made of self-curing resin at a dental clinic. When she came to our hospital, the edema and redness in the buccal and palatal mucosa around the right upper molar were seen. The TEK had already been removed at the clinic. We suspected an allergy to TEK, and performed a patch test to the chemicals of the resin. The only liquid component of resin showed a positive reaction. Topical glucocorticoid ointment was applied, and the symptoms almost subsided 3 days later.

The invasion of oral squamous cell carcinoma (SCC) cells into the mandibular bone is a common clinical problem. It has been reported that BHY cells, a human oral SCC cell line, are capable of invading mandibular bone of nude mice. These results led us to examine possible mechanisms of osteoclastogenesis induced by BHY cells using in vitro culture systems. When BHY cells were cocultured with mouse bone marrow cells (BMCs), only few osteoclasts were formed, even though BHY cells express the receptor activator of NF-kappaB ligand (RANKL). However, adding BHY cells to a coculture of mouse primary osteoblasts (POBs) and BMCs markedly induced osteoclastogenesis in the absence of osteotropic factors. Furthermore, another oral SCC cell line, HSC-2, which does not express RANKL, also induced osteoclastogenesis in our cocultures. These effects were significantly, but not completely, inhibited by adding osteoprotegerin (OPG). In addition, we also found that TNFalpha released from these cells partially contributes to osteoclastogenesis via a RANKL-independent mechanism. Adding BHY or HSC-2 cells suppressed mouse OPG mRNA expression and protein production by POBs in cocultures of POBs and human oral SCC cells. This finding is consistent with the result that BHY cells and HSC-2 cells did not enhance osteoclastogenesis in cocultures of BMCs and POBs from OPG-deficient mice. Immunohistochemical analysis showed a reduction of OPG expression in osteolytic lesions as compared to normal lesions from oral SCC patients. Therefore, oral SCC-induced suppression of OPG expression in POBs appears critical for osteoclastogenesis, rather than expression of RANKL in SCC cells.

A 40-year-old woman presented with a six-month history of synovial chondromatosis of the metacarpophalangeal joint of the right ring finger, which was resected through both dorsal and volar incisions. To our knowledge there have been only 17 reported cases of articular synovial chondromatosis of the digital joint so far. We present a case affecting the metacarpophalangeal joint with a review of scattered information found in other 17 reports.

Salivary duct carcinoma is characterised by aggressive behaviour, with a high risk of local recurrence, and regional and distant metastasis. This report describes a patient with salivary duct carcinoma that originated in the minor salivary glands of the mucosa over the maxilla. Microscopically, vascular invasion varied from 4 to 5 per 10 high-power fields, and immunohistochemical staining with E26 transformation specific-1 was demonstrated in the tumour cells. Ki67 positivity was also revealed in 52% of the specimens examined. These results suggest that salivary duct carcinoma is a highly aggressive malignant salivary gland tumour due to proliferative cell activity, angiogenesis, and vascular invasion.

A convenient method for condylar reconstruction through vertical ramus sliding osteotomy after condylectomy of the mandible is described. The method utilises the submandibular approach enabling a modification of the intracapsular temporomandibular joint arthroplasty and avoidance of excessive exposure of the temporomandibular joint capsule. This appears to prevent mandibular dysfunction postoperatively while maintaining the restored vertical dimension of the ramus.