A Case of Impaired Upper Esophageal Sphincter Opening Due to Sarcopenic Dysphagia Successfully Treated With Balloon Dilatation.

A case of an 84-year-old man diagnosed with "probable sarcopenic dysphagia" using the sarcopenic dysphagia diagnostic algorithm is presented. The patient demonstrated improved upper esophageal sphincter (UES) passage by the immediate effect of balloon dilatation. He had suffered a myocardial infarction and was unable to eat orally for approximately a month, presenting with sarcopenia and severe dysphagia, as indicated by the Food Intake LEVEL Scale (FILS) score of 1. Videofluoroscopic examination of swallowing study at 67 hospital days revealed impaired UES opening, with food bolus unable to pass through the UES. After confirming the loss of the gag reflex, we performed balloon dilatation, resulting in improved UES passage. With swallowing rehabilitation using balloon dilatation and appropriate nutritional therapy, the patient progressed to full oral intake and achieved FILS score of 8. This case suggests the effectiveness of combined nutritional therapy and swallowing rehabilitation with balloon dilatation in managing sarcopenic dysphagia. In addition, balloon dilatation could be applied for patients with sarcopenic dysphagia presenting impaired UES opening.

Efficacy and Safety of "Vacuum Swallowing" Based on a Strong Negative Esophageal Pressure in Healthy Individuals.

Vacuum swallowing is a unique method for improving the pharyngeal passage of a bolus by creating subatmospheric negative pressure in the esophagus. However, whether healthy individuals and other patients with dysphagia can reproduce vacuum swallowing remains unclear. Therefore, this study aimed to assess whether healthy individuals verified using high-resolution manometry (HRM) could reproduce vacuum swallowing and evaluate its safety using a swallowing and breathing monitoring system (SBMS). Two healthy individuals who mastered vacuum swallowing taught this method to 12 healthy individuals, who performed normal and vacuum swallowing with 5 mL of water five times each. The minimum esophageal pressure and the maximum pressure of the lower esophageal sphincter (LES) were evaluated during each swallow using the HRM. Additionally, respiratory-swallowing coordination was evaluated using the SBMS. Ten individuals reproduced vacuum swallowing, and a total of 50 vacuum swallows were analyzed. The minimum esophageal pressure (-15.0 ± 4.9 vs. -46.6 ± 16.7 mmHg; P < 0.001) was significantly lower, and the maximum pressure of the LES (25.4 ± 37.7 vs. 159.5 ± 83.6 mmHg; P < 0.001) was significantly higher during vacuum swallowing. The frequencies of the I-SW and SW-I patterns in vacuum swallowing were 38.9% and 0%, respectively, using the SBMS. Vacuum swallowing could be reproduced safely in healthy participants with instruction. Therefore, instructing exhalation before and after vacuum swallowing is recommended to prevent aspiration.

Mechanism of the Immediate Effect of Balloon Dilation Therapy in Spinal Muscular Atrophy With Dysphagia: A High-Resolution Manometric Study.

Balloon dilation therapy (BDT) is used to treat pharyngeal dysphagia in patients with impaired upper esophageal sphincter (UES) relaxation due to cricopharyngeal dysfunction. However, the mechanism underlying this immediate effect remains unclear. Here, we present a case in which we investigated the immediate effects of BDT on UES dysfunction using high-resolution manometry (HRM). A 67-year-old man was diagnosed with spinal muscular atrophy (SMA). He gradually developed dysphagia, and a gastrostomy was performed. Despite continuing oral intake of supplemental nutrition, the patient developed dysphagia. Videofluoroscopic (VF) examination of swallowing revealed pharyngeal residue, while HRM showed weak pharyngeal contractility and impaired UES opening. BDT was performed to address the UES dysfunction. Immediately following BDT, VF demonstrated improved pharyngeal bolus passage. As for the UES function during swallowing, HRM revealed that the UES relaxation duration was significantly longer and the UES nadir pressure was significantly decreased. The patient continued the BDT before oral intake. HRM revealed immediate and prolonged UES opening with decreased UES pressure during swallowing as an immediate effect of BDT. This suggests that these findings represent the mechanisms underlying dysphagia in this patient with SMA. BDT resulted in an immediate improvement in UES function, potentially leading to dysphagia improvement. BDT should be combined with conventional rehabilitation for impaired UES opening. However, further studies are needed to confirm the long-term effectiveness of BDT for dysphagia due to SMA.

Use of Pinching Nose Maneuver in a Patient With Severe Dysphagia Caused by Pseudobulbar Palsy.

Swallowing disorders resulting from pseudobulbar palsy are characterized by deficiencies in the oral preparatory and oral stages of the swallowing process. In certain cases, obstruction can occur when the tongue base comes into contact with the palate, impeding the intraoral bolus flow into the pharyngeal cavity. In this report, we discuss a case of severe pseudobulbar palsy, in which an intraoral bolus flowed into the pharyngeal cavity with pinching the nose. A 78-year-old man with a history of recurrent cerebral infarction was evaluated. The patient had severe dysphagia and cognitive impairment due to pseudobulbar palsy. A videofluoroscopic examination of swallowing (VF) was conducted while the patient was in a reclined position. In the oral cavity, when the bolus reached the posterior tongue section, the flow was hindered by the functional obstruction caused by the tongue base pressing against the palate. Despite the clinician's instructions to swallow, the patient was unable to comply due to the severity of his cognitive impairment. To alleviate this obstruction, the clinician pinched the patient's nose. This action opened the fauces, facilitating breathing and relieving the functional obstruction. Subsequently, the bolus flowed into the pharyngeal cavity and successfully flowed into the esophagus while swallowing. This maneuver was named the "pinching nose maneuver" (PNM). The PNM, as described here, can serve as a technique to improve the movement of an intraoral bolus into the pharyngeal cavity in patients with cognitive dysfunction.

A Case of a Patient With Spinal Muscular Atrophy With Dysphagia Who Acquired Vacuum Swallowing.

We present a case of acquired vacuum swallowing in a patient with spinal muscular atrophy associated with dysphagia. A 67-year-old male presented with spinal muscular atrophy. Even though he was able to eat orally, he required a long time to eat and faced difficulty while swallowing saliva, resulting in frequent spitting. Instructions regarding vacuum swallowing to eliminate pharyngeal residue were provided, and a reduction in meal duration and improved saliva swallowing were observed. High-resolution manometry revealed a significant increase in pharyngeal contractile integral and a significant decrease in esophageal pressure with vacuum swallowing, which enabled the passage of a bolus through the pharynx compared with non-vacuum swallowing. Furthermore, an increase in the lower esophageal sphincter pressure, reflecting diaphragmatic contraction, was also observed. Therefore, this case report elucidates that a patient with neuromuscular disorders could acquire vacuum swallowing with proper instructions.

Shoot gravitropism and organ straightening cooperate to arrive at a mechanically favorable shape in Arabidopsis.

Gravitropism is the plant organ bending in response to gravity, while a straightening mechanism prevents bending beyond the gravitropic set-point angle. The promotion and prevention of bending occur simultaneously around the inflorescence stem tip. How these two opposing forces work together and what part of the stem they affect are unknown. To understand the mechanical forces involved, we rotated wild type and organ-straightening-deficient mutant (myosin xif xik) Arabidopsis plants to a horizontal position to initiate bending. The mutant stems started to bend before the wild-type stems, which led us to hypothesize that the force preventing bending was weaker in mutant. We modeled the wild-type and mutant stems as elastic rods, and evaluated two parameters: an organ-angle-dependent gravitropic-responsive parameter (ß) and an organ-curvature-dependent proprioceptive-responsive parameter (γ). Our model showed that these two parameters were lower in mutant than in wild type, implying that, unexpectedly, both promotion and prevention of bending are weak in mutant. Subsequently, finite element method simulations revealed that the compressive stress in the middle of the stem was significantly lower in wild type than in mutant. The results of this study show that myosin-XIk-and-XIf-dependent organ straightening adjusts the stress distribution to achieve a mechanically favorable shape.

Food appearance affects reward-related brain activity in healthy adults: a functional magnetic resonance imaging study.

A good appearance of food increases appetite. A new food product called iEat® resembles the appearance and softness of familiar foods. Previous studies have reported that iEat® foods increase appetite. However, the neuronal substrates underlying the increase in appetite following the observation of iEat® foods remain unknown. In the present study, the brain activity of 20 healthy adults during the visual presentation of iEat® and pureed foods and non-food objects was examined using functional magnetic resonance imaging. Compared with pureed foods and non-food objects, iEat® foods showed significantly greater activation in regions of the brain reward system, such as the amygdala, ventral striatum and orbital frontal cortex. In addition, individual differences in the activity of the left amygdala were positively correlated with subjective appetite ratings. These results suggest that the good appearance of foods, such as iEat® foods, may be useful for stimulating the appetite of patients with poor appetite.

Cough-Inducing Method Using a Tartaric Acid Nebulizer for Patients with Silent Aspiration.

The tartaric acid nebulizer is a well-known cough test to evaluate cough function. This study aimed to evaluate the effectiveness of a cough-inducing method using tartaric acid (CiTA). Patients with dysphagia examined by videofluoroscopic examination of swallowing (VF) at a single institution from May 2017 to August 2017 were included in this retrospective observational study. Although undergoing VF, patients who had aspirated without reflexively coughing or who had coughed insufficiently, were instructed to cough voluntarily. Patients who could not cough voluntarily or had expectorated insufficiently underwent the CiTA method. The rate of cough induction and the effectiveness of expectoration using the CiTA method were evaluated. One hundred fifty-four patients (mean age 69.2 ± 16.8 years) were evaluated. Eighty-seven patients aspirated during VF. Of those patients, 15 were able to expectorate via the cough reflex, 18 were able to expectorate with a voluntary cough, and 12 required suctioning for removal of aspirated material. The remaining 42 patients underwent the CiTA method. Thirty-eight patients (90.4%) could reflexively cough, and 30 (71.4%) could expectorate the aspirated material. This novel method, CiTA, was effective for cough induction in patients with dysphagia, especially for those with silent aspiration.

[A Case of Surgical Resection for Solitary Lymph Node Metastasis of Hepatocellular Carcinoma].

A 77-year-old man has undergone 5 times of transcatheter arterial chemoembolization(TACE)and 5 times of radiofrequency ablation(RFA)for hepatocellular carcinoma(HCC)since 2015. In February 2019, serum tumor marker levels extremely increased and CT scan showed a 40 mm mass in hepatoduodenal ligament. Imaging study revealed that intrahepatic lesions of HCC were well controlled and the mass was diagnosed as solitary lymph node metastasis of HCC. We performed surgical resection of the lymph node. The patient discharged 8 days after the surgery. Histopathologicaly, the tumor was diagnosed as lymph node metastasis of HCC. The patient remains free from recurrence 14 months after surgery.

Morphological divergence in the curvature of human femoral diaphyses: Tracing the central mass distributions of cross-sections.

The diaphysis of the human femoral bone has a physiological anterior curvature; additionally, there is a curvature to the medial side or lateral side. In addition to compression stress from gravity during standing, walking, and running, these bones are continuously exposed to complex stresses from the traction forces of the various strong muscles attached to them. The femoral diaphysis is subjected to these mechanical stresses, and the direction and size of its curvature are defined according to Wolff's law and the mechanostat theory of Frost. The purpose of this study was to quantitatively evaluate the curvature of the femoral diaphysis in Japanese skeletons by determining the curve connecting the central mass distributions (CMD) of cross-sectional images. A total of 90 right femora (46 males and 44 females) were randomly selected from modern Japanese skeletal specimens. Full-length images of these bones were acquired using a clinical computed tomography scanner. The range between the lower end of the lesser trochanter and the adductor tubercle of each femur was divided at regular intervals to obtain ten planes, and nine levels were analyzed. The CMD curve was determined by connecting the CMDs of each of the nine cross-sections. First, the CMD of a cross-section in each of the nine slices was calculated, and the nine trajectories were superimposed from above. Then, by converting the shape of the entire CMD curve to superimpose the coordinates of the endpoint on the starting point, a closed arc representing the curvature of the femur was determined. For both males and females, the patterns varied from mostly medial to largely lateral curvature. The size of the curvature also varied for individuals. By analyzing only the coordinates of the vertex of the CMD curve of each femoral bone, the outlines of the diaphyseal curvatures could be recognized. The femora were thereby divided into two groups: medial bending and lateral bending. Considering males and females together, the number in the lateral-curvature group (n = 51) was larger than that in the medial-curvature group (n = 39). Moreover, the average age of the lateral-curvature group was significantly higher than that of the medial-curvature group (p < 0.05). In males, with an increase in the cortical bone proportion of the cross-sectional area, the anterior vertex of diaphyseal bending tended to be more prominent. This cortical proportion was significantly higher in the medial-curvature groups than in the lateral-curvature group (p < 0.01). The phenomena observed in this study may be related to pathophysiologies such as atypical fractures of the femur and osteoarthritis of the knee joints.

[A Case of Cecal Cancer Directly Invading the Duodenum with a Mobile Cecum].

A 70-year-old man showing positive results for a fecal occult blood test was admitted to a local hospital. He was suspected of double cancer in the cecum and duodenum. While performing ileocolic and segmental duodenal resections, he was diagnosed with cecal cancer invading the duodenum, following which he underwent surgical intervention. The tumor directly invaded the duodenum because of the mobile cecum. This case of duodenal invasion by cecal cancer is atypical.

Gross anatomical investigation of the muscular head between the vastus lateralis and intermedius in the Japanese population: a cadaver study.

Unlike the general understanding of the quadriceps femoris, the existence of a new muscular head between the vastus lateralis and the vastus intermedius was reported, and named the tensor of the vastus intermedius in the Swedish population. The purpose of this study was to investigate the presence and form of the muscular head in the Japanese population and to clarify its structure by gross anatomical approaches. A total of 35 thighs of 20 Japanese cadavers were investigated. We searched for the muscular head and classified it into four types. In addition, nerve fiber analysis was performed for each classification type. Regarding classification, 11% were the independent type, 29% were the common type, 37% were the vastus lateralis type, and 23% were the vastus intermedius type. Based on nerve fiber analysis, in the common type, the muscular head was under dual nerve supply from the vastus lateralis and intermedius. The other three types were innervated only by nerves from the vastus lateralis. The target muscular head may always be present in Japanese. The nerves from the vastus lateralis were always distributed in the target muscular head based on nerve fiber analysis; therefore, this muscular head may be most closely related to the vastus lateralis. The name of this muscular head should be "the accessory head of the vastus lateralis" rather than "the tensor of the vastus intermedius."

Reduced cortical bone thickness increases stress and strain in the female femoral diaphysis analyzed by a CT-based finite element method: Implications for the anatomical background of fatigue fracture of the femur.

The incidence of hip fractures is increasing in Japan and is high among women older than 70 years. While osteoporosis has been identified as one of the causative factors of fracture, atypical femoral fracture has emerged as a potential complication of bisphosphonate therapy. Atypical femoral fracture is prevalent among Asian women and has been attributed to morphological parameters. Age-related decreases in the morphological parameters of the femoral diaphysis, such as cortical bone thickness, cortical cross-sectional area, and the cortical index, were reported in Japanese women prior to bisphosphonate drugs being approved for treatment. Thus, in the present study, the relationships between biomechanical and morphological parameters were analyzed using a CT-based finite element method. Finite element models were constructed from 44 femurs of Japanese women aged 31-87 years using CT data. Loading conditions were set as the single-leg configuration and biomechanical parameters, maximum and minimum principal stresses, Drucker-Prager equivalent stress, maximum and minimum strains, and strain energy density were calculated in 7 zones from the subtrochanteric region to distal diaphysis. Pearson's correlation coefficient test was performed to investigate relationships with morphological parameters. While absolute stresses gradually decreased from the subtrochanteric region to distal diaphysis, absolute strains markedly declined in the proximal diaphysis and were maintained at the same levels as those in the distal regions. All types of stresses and minimum principal strain in the femoral diaphysis scored higher absolute values in the high-risk group (≥70 years, n = 28) than in the low-risk group (<70 years, n = 16) (p < 0.05). The distribution patterns of equivalent stress and strain energy density were similar to that of Young's modulus, except for the region of the linea aspera. All biomechanical parameters correlated with morphological parameters and correlation efficiencies, with the reciprocal of cortical bone thickness showing the strongest correlation. The present results demonstrated that biomechanical parameters may be predicted by calculating the cortical bone thickness of femurs not treated with bisphosphonates. Furthermore, strain appeared to be repressed at a low level despite differences in stress intensities among the regions by bone remodeling. This remodeling is considered to be regulated by Wolff's law driven by equivalent stress and strain energy densities from the proximal to distal femur. The present results will promote further investigations on the contribution of morphological parameters in the femoral diaphysis to the onset of atypical femoral fracture.

Sex-based differences in human sacroiliac joint shape: a three-dimensional morphological analysis of the iliac auricular surface of modern Japanese macerated bones.

The human pelvis is one of the skeletons where sex differences are expressed, but few detailed studies have been conducted on sex-related differences in the sacroiliac joint morphology. Therefore, we conducted a three-dimensional morphological analysis evaluation of the sacroiliac joints to clarify the sex-related difference of the joint's morphology. Right-side macerated innominate bones of Japanese males (n = 100) and females (n = 70) whose ages at death were recorded were included in the study. Three-dimensional images were created from the subjects' iliac auricular surface images, and 16 measurement parameters were acquired on the basis of 11 defined measurement points. All measurement parameters were compared between the male and female groups. The values of the measurement parameters indicating the size of the iliac auricular surface were significantly larger in the male group than in the female group. In addition, the angle between the short and long arms of the auricular surface was larger in the male group. Furthermore, on the basis of the corrected values of the physical disparity, the long arm dimension of the iliac auricular surface was larger in the male group, while the short arm dimension was larger in the female group. The sex-based differences in the iliac auricular surface morphology that were confirmed in this study may reflect the sex-based differences in the sacroiliac joint function. The findings of this study may contribute to the elucidation of the pathophysiology of the sacroiliac joint dysfunction that frequently occurs in women.

[A Case of Advanced Adenosquamous Carcinoma of Pancreas with Conversion Surgery after Chemoradiotherapy Followed by Systemic Chemotherapy].

A man in his 60s with upper abdominal discomfort was referred to our hospital. CT scan revealed the 40 mm tumor in the body and tail of pancreas invading stomach wall. Solid soft tissue contact was also observed around celiac artery(CA)and common hepatic artery(CHA). EUS-FNA from pancreatic mass showed suspicion of adenosquamous carcinoma. We diagnosed it as pancreatic adenosquamous carcinoma, cT4N0M0, cStage Ⅲ. The patient received radiotherapy(46.8 Gy/26 Fr in total)combined with S-1. Although the primary lesion showed shrinkage, solid soft tissue around CA and CHA deteriorated. We judged the tumor unresectable, and the patient received systemic chemotherapy using gemcitabine(GEM). After 6 courses of GEM, solid soft tissue around CA and CHA almost disappeared. Based on these results, we performed distal pancreatectomy and partial gastrectomy 8 months after the initiation of the treatment. Pathological results showed adenosquamous carcinoma of the pancreas with Grade 2 response to the preoperative treatment. Although the tumor invaded into the gastric wall, R0 resection was achieved. The patient is alive with no recurrence a year and 4 months after the initiation of treatment and 8 months after resection.

Morphological profile of atypical femoral fractures: age-related changes to the cross-sectional geometry of the diaphysis.

The use of bisphosphonates for osteoporosis patients has markedly decreased the incidence of femoral neck or trochanteric fractures. However, anti-osteoporosis drugs have been reported to increase the incidence of atypical femoral fractures, which involve stress fractures in the subtrochanteric region or the proximal diaphysis. In this study, the morphological characteristics of the cortical bone in human femoral diaphysis samples were analyzed from individuals who lived before bisphosphonate drugs were available in Japan. A total of 90 right femoral bones were arbitrarily selected (46 males and 44 females) from modern Japanese skeletal specimens. Full-length images of these femurs were acquired using a computed tomography scanner. An image processing method for binarization was used to calculate the threshold values of individual bones for determining their contours. The range between the lower end of the lesser trochanter and the adductor tubercle of each femur was divided at regular intervals to obtain 10 planes. The mean value of cortical bone thickness, periosteal border length, and the cortical cross-sectional area was evaluated for all planes. Moreover, the ratio of the area of the cortical bone to the total area of cross-section at the mid-diaphysis was calculated. A comparison between males and females demonstrated that most females had lower cortical bone area ratios at the mid-diaphysis. The femoral outer shape did not differ markedly according to age or sex; however, substantial individual differences were observed in the shape of the inner surface of the cortical bone. The cortical bone thickness and the cross-sectional area decreased with age in the femoral diaphysis; furthermore, in females, the decrease was higher for the former than for the latter. This may be due to a compensatory increase in the circumference of the femoral diaphysis. In addition, in about half of the subjects there was a discrepancy between the region with maximal value of the cortical bone thickness and that of the total cross-sectional area. Biological responses to mechanical stresses to the femoral diaphysis are thought not to be uniform. Bisphosphonates inhibit bone resorption and may promote non-physiological bone remodeling. Thus, a nonhomogeneous decrease in cortical thickness may be related to the fracture occurrence in the femoral diaphysis in some cases. Thus, long-term administration of bisphosphonates in patients with morphological vulnerability in the femoral cortical bones may increase the occurrence of atypical femoral fractures.

Investigating interindividual variations in cortical bone quality: analysis of the morphotypes of secondary osteons and their population densities in the human femoral diaphysis.

Osteons are the primary sites of cortical bone lesions. However, many aspects of osteon microstructure remain poorly understood. This study aimed to explores interindividual differences in the osteon morphotype distributions in the human femoral diaphysis by evaluating the secondary osteon distributions in samples from human femurs. Two anonymized bone fragments from two modern Japanese femurs were examined. Twelve continuous transverse femoral diaphysis specimens were prepared from each fragment. Imaging examinations were conducted using a circularly polarized light microscope, and cross-sectional images were rendered using graphical synthesis software. Osteons in the images were identified as either bright-type osteons, dark-type osteons, or an others type. The two femurs were compared, and the secondary osteon morphotype distributions in different regions of their cross-sections were analyzed. When the two femurs were compared, significant differences in osteon density were observed in some regions and cross-sections. The dark-type osteon presence was strongest in the anterior and posterior regions of the femurs. The analytical method used in this study was found to be able to evaluate osteon microstructure. The results suggest that examining additional specimens and analyzing the biomechanical underpinnings of interindividual differences in osteon distribution patterns may help to improve our understanding of osteon microstructure.

An Ancient Skeleton with Multiple Osteoblastic Bone Lesions Containing a Scapular Sunburst Appearance from a 5th-6th Century Grave Excavated in Oita, Japan.

A human skeleton of a middle-aged adult male was found in a 5th-6th century Kinoue-Kodo stone coffin excavated from the southwest marginal region of the Oita plains, northeast Kyushu, Japan. The skeleton was buried respectfully in the ancient tomb, and red pigment was applied to his face after death. We report herein findings from computed tomography imaging of the skeleton and discuss the multiple osteoblastic lesions identified in the humerus, scapula, clavicle, vertebra, pelvic bones, and skull of this individual. These lesions comprised cortical bone thickening with periosteal reaction localized to the surface and osteosclerotic changes mainly observed in the trabecular structure of cancellous bone. In particular, a typical sunburst pattern was also noted on the left scapula as another characteristic lesion found in this case. By differential diagnosis, the disease suffered by this individual was most likely to be metastatic bone tumors, especially of prostate cancer. This person may have survived until many bone metastases had developed throughout his whole body.

Diversity in intracortical remodeling in the human femoral bone: A novel view point with the morphological analysis of secondary osteons.

INTRODUCTION: In humans, intracortical bone remodeling is performed by a basic multicellular unit (BMU) composed of osteoclasts and osteoblasts penetrating through cortical bones. As a result, secondary osteons and their boundaries, cement lines, can be observed on the transverse section. There have been few reports mention whether there is diversity within a single individual and on the relevance to bone remodeling. The purpose of this study is to investigate the morphological diversity of secondary osteons in human femoral bone and to examine the relationship with bone remodeling. MATERIAL AND METHODS: First of all, we developed an original method to get the cross-sectional images of the cortical bones around the whole circumference for the purpose of evaluating the morphology of the secondary osteon exhaustively. Then, a total of ten cross-sectional slices from one right human femoral bone of male were prepared and stained with this method. The osteon population density and complexity of cement lines in osteons were evaluated in detail. RESULTS: Within this femoral bone, the osteon population density was significantly higher in the periosteal side and in the posterior area. Conversely, the cement line density and the osteon complexity were higher in the endosteal side; the proportion of complexed osteon significantly increased from the periosteal side toward the endosteal side. DISCUSSION: The results suggested that there were diversities in osteon population densities and osteon morphological pattern within one human femoral bone. It seemed that the BMUs ran to avoid the existing regions of osteon in the periosteal sides and to overlap the existing osteon in the endosteal sides. This seemed to be one of the novel viewpoints in the morphological analysis of secondary osteons. It might be better for the orthopedic surgeons to be aware that the osteon distribution in the cortical bone is not uniform.

Anatomical study of the articular branches innervated the hip and knee joint with reference to mechanism of referral pain in hip joint disease patients.

INTRODUCTION: Referred pain in the anterior knee joint is the most common symptom in hip disease patients. The development of referred pain is considered to be related to dichotomizing peripheral sensory fibers. However, no gross anatomical findings identify any dichotomizing fibers innervating both the hip and knee joints. We dissected the femoral and obturator nerves in human cadavers to investigate the distribution of the articular branches in the hip and knee joints. Fourteen embalmed left lower limbs from 14 Japanese adult cadavers (five from females, nine from males, average age 73.8 ± 14.1 years) were observed macroscopically. The articular branches of the femoral and obturator nerves were dissected at the anterior margin of the groin toward the thigh region. After dissections of the articular nerves of the hip joints, the femoral and obturator nerves were exposed from proximally to distally to identify the articular nerves of the knee joints. The branching pattern of the articular branches in the hip and knee joints was recorded. In six of 14 limbs (42.9%), the femoral nerve supplied articular branches to the anteromedial aspect of both the hip and knee joints. These articular branches were derived from the same bundle of femoral nerve. These gross anatomical findings suggested that dichotomizing peripheral sensory fibers innervate the hip and knee joints and these could relate to the referred pain confirmed in the anterior knee joints of patients with hip disease. Clin. Anat. 31:705-709, 2018. © 2018 Wiley Periodicals, Inc.