Long-term outcomes of Kudo type-5 unlinked surface-replacing total elbow arthroplasty for rheumatoid arthritis: a 15-year average follow-up study.

BACKGROUND: Total elbow arthroplasty (TEA) has been used for various conditions including rheumatoid arthritis (RA). While the Kudo TEA has been associated with favorable short-term outcomes, there is limited information on the longer term outcomes of this device. The aim of this study was to investigate the average 15-year outcome of Kudo type-5 TEA in patients with RA. METHODS: For this retrospective cohort study, we reviewed 29 elbows in 28 patients (Larsen grade III, n = 8; IV, n = 19; V, n = 2) with RA who underwent Kudo type-5 TEA between 1999 and 2010. The patients were followed up for a mean of 15 (range: 10-21) years. We investigated the survival with setting revision/removal as the endpoints. The risk factors for revision/loosening were assessed. RESULTS: There was a significant improvement in elbow flexion after Kudo TEA. Preoperative and postoperative Mayo Elbow Performance Score improved significantly from 60.3 to 94.7. Complications included intraoperative medial humeral epicondyle fracture (n = 2), postoperative dislocations (n = 4), deep infections (n = 1), and persistent ulnar nerve neuropathy (n = 1). Aseptic loosening was observed in 7 elbows (24.1%; humerus, n = 3; ulna, n = 3; both sides, n = 1). The causes of the 5 revisions were postoperative dislocation (n = 1), deep infection (n = 1), aseptic loosening of the humerus (n = 2), and aseptic loosening of the ulna (n = 1). All 5 elbows underwent revision of the ulnar component (n = 2) or the linked TEA (n = 3). The survival rate was 81% at 15 years after surgery with setting revision/removal as the endpoints. A deviation of ulnar component insertion angle of over 5° in any plane was associated with more revision compared to those with accurately placed implants. CONCLUSION: The Kudo type-5 elbow showed good results for up to 15 years of follow-up. However, excessive deviation of insertion angle of the ulnar component (over 5°) was associated with more revision. Due to the small sample size, robust statistical analysis of risk factors for postoperative complications or revision could not be performed, and further research is warranted to resolve this limitation.

Distal junctional failure after corrective surgery without pelvic fixation for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture.

BACKGROUND: Thoracolumbar junctional kyphosis (TLJK) due to osteoporotic vertebral fracture (OVF) negatively impacts patients' quality of life. The necessity of pelvic fixation in corrective surgery for TLJK due to OVF remains controversial. This study aimed to: 1) evaluate the surgical outcomes of major corrective surgery for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture, and 2) identify the risk factors for distal junctional failure to identify potential candidates for pelvic fixation. METHODS: Patients who underwent surgical correction (fixed TLJK>40°, OVF located at T11-L2, the lowermost instrumented vertebra at or above L5) were included. Sagittal vertical axis, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis (L1-S1), local kyphosis, and lower lumbar lordosis (L4-S1) were assessed. Proximal and distal junctional kyphosis (P/DJK) and failures (P/DJF) were evaluated. Pre/postoperative spinopelvic parameters were compared between DJF and non-DJF patients. RESULTS: Thirty-one patients (mean age: 72.3 ± 7.9 years) were included. PJK was observed in five patients (16.1%), while DJK in 11 (35.5%). Twelve cases (38.7%) were categorized as failure. Among the patients with PJK, there was only one patient (20%) categorized as PJF and required an additional surgery. Contrary, all of eleven patients with DJK were categorized as DJF, among whom six (54.5%) required additional surgery for pelvic fixation. In comparisons between DJF and non-DJF patients, there was no significant difference in pre/postoperative LK (pre/post, p = 0.725, p = 0.950). However, statistically significant differences were observed in the following preoperative alignment parameters: SVA (p = 0.014), LL (p = 0.001), LLL (p = 0.006), PT (p = 0.003), and PI-LL (p < 0.001). CONCLUSIONS: Spinopelvic parameters, which represent the compensatory function of lumbar hyperlordosis and pelvic retroversion, have notable impacts on surgical outcomes in correction surgery for TLJK due to OVF. Surgeons should consider each patient's compensatory function when choosing a surgical approach.

High-degree posterior rotational osteotomy for extensive collapsed femoral head osteonecrosis in teenagers: remodeling and results with a mean of 10-year follow-up.

INTRODUCTION: This study evaluated the effectiveness of high-degree posterior rotational osteotomy for teenagers with extensively collapsed femoral head osteonecrosis. MATERIALS AND METHODS: We reviewed 40 hips in 35 patients with severely collapsed femoral head osteonecrosis treated by this procedure with a mean follow-up period of 9.7 years (range 5-25 years). Thirteen hips had a history of steroid administration. Nine had slipped capital femoral epiphysis. Nine had femoral neck fracture. Two had traumatic dislocation and fracture. Seven had no apparent risk factors. The mean age of the patients (18 women and 17 men) was 14.8 years. All femoral heads were extensively collapsed below the acetabular roof, and 20 hips showed preoperative joint space narrowing (ARCO stage 4). Lateral radiographs of the femoral head revealed extensive lesions from the posterior to anterior portion. The mean degree of posterior rotation was 118° with intentional varus positioning [mean: 19° (range 10-30)]. The pre- and postoperative extent of the viable area of the femoral head was assessed using conventional anteroposterior radiographs and 45-degree flexion radiography. Further collapse, joint space narrowing, femoral head morphology, and congruency with the acetabulum based on the Stulberg classification were assessed using conventional anteroposterior radiographs. The clinical assessment was conducted using the Merle d'Aubigné hip scores at the last follow-up. RESULTS: The viable area of the femoral head on the loaded portion was seen during a short period after operations. The necrotic lesions were gradually improved postoperatively. The mean extent of viable bone below the acetabular roof was 48% at less than 6 months after surgery and 92% at the final follow-up. The mean extent on 45° flexion radiography was 54% at less than 6 months after surgery and 89% at the final follow-up. Further collapse was prevented in 38 hips (95%). In 19 of 20 hips with preoperative narrowing of the joint space, the joint space was first improved, but narrowing progressively observed in 9 of 40 hips at the final follow-up. Thirty-four hips had excellent or good clinical outcomes, whereas 6 had fair or poor outcomes. CONCLUSIONS: We concluded that this procedure is effective at delaying the progression of degeneration if adequate area of viable bone can be moved under the loaded portion of the acetabulum in teenagers with severe femoral head osteonecrosis.

Type V Tibial Tubercle Avulsion Fracture with Suspected Complication of Anterior Cruciate Ligament Injury: A Case Report.

Background and Objectives: Type V tibial tubercle avulsion fractures are extremely rare; therefore, information on them remains limited. Furthermore, although these fractures are intra-articular, to the best of our knowledge, there are no reports on their assessment via magnetic resonance imaging (MRI) or arthroscopy. Accordingly, this is the first report to describe the case of a patient undergoing detailed evaluation via MRI and arthroscopy. Case Presentation: A 13-year-old male adolescent athlete jumped while playing basketball, experienced discomfort and pain at the front of his knee, and fell down. He was transported to the emergency room by ambulance after he was unable to walk. The radiographic examination revealed a Type Ⅴ tibial tubercle avulsion fracture that was displaced. In addition, an MRI scan revealed a fracture line extending to the attachment of the anterior cruciate ligament (ACL); moreover, high MRI intensity and swelling due to ACL were observed, suggesting an ACL injury. On day 4 of the injury, open reduction and internal fixation were performed. Furthermore, 4 months after surgery, bone fusion was confirmed, and metal removal was performed. Simultaneously, an MRI scan obtained at the time of injury revealed findings suggestive of ACL injury; therefore, an arthroscopy was performed. Notably, no parenchymal ACL injury was observed, and the meniscus was intact. The patient returned to sports 6 months postoperatively. Conclusion: Type V tibial tubercle avulsion fractures are known to be extremely rare. Based on our report, we suggest that MRI should be performed without hesitation if intra-articular injury is suspected.

Atypical femoral fracture mimicking lumbar radiculopathy in two patients taking bisphosphonate long-term: A case report.

BACKGROUND: Atypical femoral fracture (AFF) is a rare complication in patients with osteoporosis undergoing long-term bisphosphonate therapy. The most common symptom of incomplete AFF is nonspecific thigh pain, which is often difficult to distinguish from other causes. CASE PRESENTATION: We present two cases of AFF misdiagnosed as lumbar radiculopathy. Both patients visited our hospital for thigh pain, and in both cases the findings of lumbar spine magnetic resonance imaging showed substantial nerve compression. These patients had been treated for lumbar radiculopathy, but localized symptoms became conspicuous and femoral radiographs revealed complete AFF. The initial radiographs were reviewed retrospectively and revealed slight lateral cortical thickening in the affected femur, denoting a missed incomplete AFF. Internal fixation with intramedullary nails was performed. CONCLUSIONS: AFF may mimic lumbar radiculopathy. Therefore, clinicians should consider AFF as a differential diagnosis in older patients with lumbar canal stenosis who are undergoing long-term bisphosphonate therapy and present with thigh pain.

Comparison of pedicle screw placement accuracy between two types of imaging support (Artis Zeego versus two-dimensional fluoroscopy): a cross-sectional observational study.

BACKGROUND: The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. Artis Zeego is an emerging intraoperative imaging technique that can provide conventional two-dimensional fluoroscopic images and rapid three-dimensional fluoroscopic computed tomography reconstruction imaging. The aim of this study is to compare the insertion accuracies of PS placement using Artis Zeego and conventional 2D X-ray fluoroscopy. METHODS: In this study, we retrospectively reviewed the postoperative images of thoracolumbar fusion patients who underwent surgery using pedicle screws between 2013 and 2018. Pedicle screw malplacement was assessed using a four-grade classification by Rao et al. Misplacement rates were compared between pedicle screws assisted with Artis Zeego and two-dimensional fluoroscopy. RESULTS: A total of 1107 pedicle screws in 153 patients were inserted using Artis Zeego, and 427 pedicle screws in 80 patients were inserted using fluoroscopy. The overall perforation rate was 4.2% (46 perforations of 1106 pedicle screws) in the Artis Zeego group and 7.7% (33 perforations of 427 pedicle screws) in the fluoroscopy group. In the Artis Zeego group, 43 (3.9%) screws were classified as grade 1, and three (0.3%) screws were classified as grade 2. In the fluoroscopy group, 21 (4.9%) screws were classified as grade 1, 10 (2.3%) screws were classified as grade 2, and 2 (0.5%) screws were classified as grade 3. The use of Artis Zeego was associated with a significantly lower screw malplacement rate than was the use of fluoroscopy (p < 0.001). CONCLUSIONS: Our results demonstrated that pedicle screw placement with Artis Zeego was associated with a lower malplacement rate than was conventional two-dimensional fluoroscopy. No severe malplacement was observed in the Artis Zeego group. Thus, Artis Zeego could be a good option for improving pedicle screw accuracy.

Radiological features of cervical spine in dropped head syndrome: a matched case-control study.

PURPOSE: Dropped head syndrome (DHS) is presumably caused by focal myopathy in the cervical posterior muscles; however, distinguishable radiological features of the cervical spine in DHS remain unidentified. This study investigated the radiological features of the cervical spine in dropped head syndrome. METHODS: The records of DHS patients and age- and sex-matched cervical spondylotic myelopathy (CSM) patients were reviewed. Cervical spinal parameters (C2-7, C2-4, and C5-7 angles) were assessed on lateral cervical spine radiographs. Quantitative radiographic evaluation of cervical spine degeneration was performed using the cervical degenerative index (CDI), which consists of four elements: disk space narrowing (DSN), endplate sclerosis, osteophyte formation, and listhesis. RESULTS: Forty-one DHS patients were included. Statistically significant differences were noted between the upper and lower cervical spine in the sagittal angle parameters on the neutral, flexion, and extension radiographs in DHS group, whereas no significant differences were observed in CSM group. CDI comparison showed significantly higher scores of DSN in C3/4, C4/5, C5/6, and C6/7; sclerosis in C5/6 and C6/7; and osteophyte formation in C4/5, C5/6, and C6/7 in DHS group than in CSM group. Comparison of listhesis scores revealed significant differences in the upper levels of the cervical spine (C2/3, C3/4, and C4/5) between two groups. CONCLUSION: Our results demonstrated that the characteristic radiological features in the cervical spine of DHS include lower-level dominant severe degenerative change and upper-level dominant spondylolisthesis. These findings suggest that degenerative changes in the cervical spine may also play a role in the onset and progression of DHS.

Wide-Awake Approach for Flexor Digitorum Superficialis Tendon Transfer Followed by Early Active Mobilization.

Background The standard clinical practice to treat closed ruptures of the flexor digitorum profundus (FDP) tendons includes free tendon grafting; however, it is not suitable when the muscle amplitude of the ruptured FDP is not sufficient. We report outcomes of six patients who underwent flexor digitorum superficialis (FDS) tendon transfer of the ring finger using the wide-awake approach to repair the closed rupture of the FDP tendon of the little finger in zone 3 or 4. Methods The patients were identified by reviewing our institutional billing records from January 2012 to October 2019 for the International Classification of Disease 10 code M66.3 that describes the diagnosis as "spontaneous rupture of flexor tendons." Results The patients comprised two men and four women with an average age of 72.2 years (standard deviation [SD], 8.4 years). All patients were hospitalized after surgery to undergo early active mobilization. The average total active motion at the final evaluation was 201.8° (range: 85-248°). According to Strickland's criteria, outcomes were excellent for two, good for three, and poor for one patient. No patients complained about the ring finger. Conclusion These results suggest that FDS tendon transfer is recommended when the muscle amplitude of the ruptured FDP is insufficient. We believe that the wide-awake approach and early active mobilization may contribute to satisfactory outcomes.

Controlling nutritional status score predicts postoperative complications after hip fracture surgery.

BACKGROUND: Controlling Nutritional Status (CONUT) score is calculated using laboratory values, including serum albumin, total cholesterol concentration, and total lymphocyte count; it is reportedly valuable for making nutritional assessments. One advantage of CONUT score over other nutritional assessments is that it can be calculated retrospectively using only objective laboratory values. Studies demonstrated that CONUT score was a useful tool for predicting prognosis and complications in various surgical conditions. Nevertheless, few studies utilized the score as a potential predictive marker for postoperative complications among hip fracture patients. The purpose of this study was to determine the association between CONUT score and postoperative complications in hip fracture patients. METHODS: We retrospectively reviewed 211 elderly patients who underwent hip fracture surgery at a single institution from 2013 to 2018. CONUT score was calculated using preoperative routine laboratory tests for serum albumin, total cholesterol concentration, and total lymphocyte count. As potential confounders, we extracted data such as patient age, sex, fracture type, and general conditions/comorbidities, as defined by the American Society of Anesthesiologists Physical Status (ASA-PS) classification and the Charlson Comorbidity Index (CCI). Postoperative complications were defined as a Clavien-Dindo classification of 1 or more. Simple and multivaribale logistic regression analyses were performed to assess the incidence of postoperative complications as the outcome measures. RESULTS: The mean age [IQR] was 86 [80-90], and 80.1% of the reviewed patients were female. Based on the CONUT scores, 78.7% of hip fracture patients were classified as malnourished; 18% experienced postoperative complications. Simple analyses revealed significant risk factors for postoperative complications, including age, the ASA-PS, the CCI, and the CONUT score. Multivariable analysis found that CONUT score was the independent risk factor for postoperative complications (odd ratio = 1.21, 95% confidence interval = 1.01-1.45, p = 0.04). CONCLUSIONS: Preoperative CONUT scores are independently associated with the incidence of postoperative complications. CONUT score can be used for risk assessment in hip fracture patients to predict early postoperative complications.

Chronic dysphagia caused by Laryngo-vertebral Synostosis after anterior fusion for cervical spine trauma: a case report.

BACKGROUND: Anterior cervical spine surgery is often associated with postoperative dysphagia, but chronic dysphagia caused by laryngo-vertebral synostosis is extremely rare. We report a case of chronic dysphagia caused by synostosis between the cricoid cartilage and cervical spine after anterior surgery for cervical spine trauma. CASE PRESENTATIONS: We present a case of a 39-year-old man who had sustained complex spine trauma at C5-6 associated with complete spinal cord injury at the age of 22; the patient presented with a 5-year history of chronic dysphagia. Computed tomography demonstrated posterior shift of the esophagus as well as calcification of the cricoid cartilage and its fusion to the right anterior tubercle of the C5 vertebra. A barium swallow study demonstrated significant barium aspiration into the airway and no laryngeal elevation. The patient underwent resection of the bony bridge and omohyoid muscle flap insertion. His symptoms ameliorated after surgery. CONCLUSION: Synostosis between the cricoid cartilage and cervical spine may occur associated with cervical spine trauma and causes chronic dysphagia. Resection of the fused part can improve dysphagia caused by this rare condition and omohyoid muscle flap might be a good option to prevent recurrence.

Impact of Spinopelvic sagittal alignment on the surgical outcomes of dropped head syndrome: a multi-center study.

BACKGROUND: Most of the previous studies about the surgical treatment of dropped head syndrome (DHS) are small case series, and their primary outcome measures were cervical alignment parameters. Therefore, little is known about the associations between pre- and postoperative global sagittal alignment in the whole spine and the clinical outcomes of the surgical treatment of DHS. In this study, we investigated the surgical outcomes of DHS, including correction of cervical and global spinal sagittal alignment. METHODS: This study was a retrospective observational study. Fifteen patients with DHS who had undergone correction surgery were enrolled. Surgical outcomes, including complications and implant failures, were investigated. We assessed cervical alignment parameters as well as spinopelvic global alignment parameters, including pelvic incidence (PI), lumbar lordosis (LL), and C7-sacral sagittal vertical axis (SVA). We examined the changes in these parameters using pre- and posoperative whole spine lateral radiographs. The parameters were compared between the failure and nonfailure groups. RESULTS: Recurrence of sagittal imbalance and horizontal gaze difficulty was observed in 6 cases (40%). In all, 3 cases (20%) exhibited a distal junctional failure and required multiple surgeries with extension of fusion. Of all the radiographic parameters compared between the failure and nonfailure groups, significant differences were only observed in pre and postoperative SVA and PI-LL. CONCLUSIONS: Our results suggest that the global sagittal alignment parameters, including PI-LL and SVA, were different between the patients with failure and non failure, and these parameters might have notable impacts on surgical outcomes. Surgeons should consider PI-LL and SVA while determining the surgical course for patients with DHS.

Lateral lumbar interbody fusion in revision surgery for restenosis after posterior decompression.

OBJECTIVE: The purpose of this study was to compare the clinical results of revision interbody fusion surgery between lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) with propensity score (PS) adjustments and to investigate the efficacy of indirect decompression with LLIF in previously decompressed segments on the basis of radiological assessment. METHODS: A retrospective study of patients who underwent revision surgery for recurrence of neurological symptoms after posterior decompression surgery was performed. Postoperative complications and operative factors were evaluated and compared between LLIF and PLIF/TLIF. Moreover, postoperative improvement in cross-sectional areas (CSAs) in the spinal canal and intervertebral foramen was evaluated in LLIF cases. RESULTS: A total of 56 patients (21 and 35 cases of LLIF and PLIF/TLIF, respectively) were included. In the univariate analysis, the LLIF group had significantly more endplate injuries (p = 0.03) and neurological deficits (p = 0.042), whereas the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), surgical site infections (SSIs) (p = 0.02), and estimated blood loss (EBL) (p < 0.001). After PS adjustments, the LLIF group still showed significantly more endplate injuries (p = 0.03), and the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), EBL (p < 0.001), and operating time (p = 0.04). The PLIF/TLIF group showed a trend toward a higher incidence of SSI (p = 0.10). There was no statistically significant difference regarding improvement in the Japanese Orthopaedic Association scores between the 2 surgical procedures (p = 0.77). The CSAs in the spinal canal and foramen were both significantly improved (p < 0.001). CONCLUSIONS: LLIF is a safe, effective, and less invasive procedure with acceptable complication rates for revision surgery for previously decompressed segments. Therefore, LLIF can be an alternative to PLIF/TLIF for restenosis after posterior decompression surgery.

Frequent mutations of genes encoding vacuolar H+ -ATPase components in granular cell tumors.

Granular cell tumors (GCTs) are rare mesenchymal tumors that exhibit a characteristic morphology and a finely granular cytoplasm. The genetic alterations responsible for GCT tumorigenesis had been unknown until recently, when loss-of-function mutations of ATP6AP1 and ATP6AP2 were described. Thus, we performed whole-exome sequencing, RNA sequencing, and targeted sequencing of 51 GCT samples. From these genomic analyses, we identified mutations in genes encoding vacuolar H+ -ATPase (V-ATPase) components, including ATP6AP1 and ATP6AP2, in 33 (65%) GCTs. ATP6AP1 and ATP6AP2 mutations were found in 23 (45%) and 2 (4%) samples, respectively, and all were truncating or splice site mutations. In addition, seven other genes encoding V-ATPase components were also mutated, and three mutations in ATP6V0C occurred on the same amino acid (isoleucine 136). These V-ATPase component gene mutations were mutually exclusive, with one exception. These results suggest that V-ATPase function is impaired in GCTs not only by loss-of-function mutations of ATP6AP1 and ATP6AP2 but also through mutations of other subunits. Our findings provide additional support for the hypothesis that V-ATPase dysfunction promotes GCT tumorigenesis.

Development of nomograms for prognostication of patients with primary soft tissue sarcomas of the trunk and extremity: report from the Bone and Soft Tissue Tumor Registry in Japan.

BACKGROUND: The use of nomograms for prognostication of individual cancer patients has been recommended in order to facilitate precision medicine. However, models for patients with soft tissue sarcomas (STSs) are limited because of the rarity and heterogeneity of such cancers. In addition, no model has been developed on the basis of an Asian cohort. Here, we attempted to develop and internally validate nomograms for patients with localized STSs of the trunk and extremity. METHODS: This study retrospectively extracted 2827 patients with primary trunk and extremity STSs after definitive surgery using the Bone and Soft Tissue Tumor Registry, which is a nationwide sarcoma database in Japan. We developed three nomograms predicting the probability of local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS) and disease-specific survival (DSS) at 2 years after surgery, using the Cox multivariate model. The nomograms were internally validated for discrimination and calibration using bootstrap resampling and assessed for their clinical applicability by decision curve analysis (DCA). RESULTS: Local recurrence, distant metastasis and disease-specific death occurred in 241 patients (8.5%), 554 patients (19.6%) and 230 patients (8.1%), respectively. Histological diagnosis, grade and tumor size strongly influenced all three endpoints. The nomograms predicted accurately the probability of LRFS, DMFS and DSS (concordance index: 0.73, 0.70 and 0.75, respectively). DCA demonstrated that our nomograms had clinical applicability. CONCLUSION: We have developed the first nomograms for STSs based on an Asian cohort. These nomograms allowed accurate prediction of LRFS, DMFS and DSS at 2 years after definitive surgery, and can be used as a guide by clinicians for appropriate follow-up and counseling of patients.

Recurrent femoral shaft fractures in a child with gnathodiaphyseal dysplasia: a case report.

BACKGROUND: Gnathodiaphyseal dysplasia (GDD) is an extremely rare autosomal dominant disease characterized by cemento-osseous lesions in the jawbones, bone fragility, and diaphyseal sclerosis of the tubular bones. Patients with GDD are prone to sustain fractures by minor accidents. Although over 80 cases have been reported, detailed information about the orthopedic treatment of the fractures is limited. CASE PRESENTATION: A 9-year-old Japanese girl with a known history of GDD presented with pain and deformity in the left thigh after a minor fall. She had a displaced transverse fracture in the mid-shaft of the left femur and underwent a closed reduction and external fixation. In the 25th week after the initial surgery, she had another fracture in the left femur at one of the half-pin insertion sites. She underwent an external fixation again. After this operation, the patient sustained another refracture at the same fracture site and one supracondylar fracture at the distant site of the femur. The supracondylar fracture occurred without any triggering activity before beginning a weight-bearing exercise. The supracondylar fracture was successfully treated conservatively, but she sustained two more diaphyseal fractures at half-pin insertion sites one after another. She eventually underwent a revision surgery with a flexible intramedullary nail. At 3 months postoperatively, the fracture was healed and the patient maintained her ambulatory status without further refracture. CONCLUSIONS: Patients with GDD might have narrower safety ranges of biomechanical and physiological drawbacks, which are considered to be acceptable in ordinary cases. The choice of treatment should be aimed at minimizing these negative effects. We recommend intramedullary devise as the first-choice implant for the treatment of isolated femoral shaft fracture in GDD patients in this age group.

Shoulder and elbow pain in junior high school baseball players: Results of a nationwide survey.

BACKGROUND: Despite proposals and guidelines to prevent baseball injuries in young players by societies and organizations, many shoulder and elbow injuries continue to occur among junior high school baseball players. In order to investigate the training conditions of junior high school baseball players and the risk factors for shoulder and elbow pain in the players, we conducted a questionnaire survey among junior high school baseball players throughout the country. METHODS: The questionnaire survey was conducted among junior high school baseball players in September 2016. RESULTS: A total of 11,134 junior high school baseball players belonging to 495 teams responded to the survey. Among these, 4004 players trained every day of the week and 1151 players played baseball games every month with no off-season. Among 9752 players who did not have shoulder and/or elbow pain in the spring and summer of 2015, 19.2% of players experienced elbow pain over the course of one year, 13.6% of players experienced shoulder pain, and 28.0% complained of shoulder and/or elbow pain. The frequency of elbow pain was more than that of shoulder pain. At risk for shoulder pain were pitchers and catchers and second-year students, while risk factors for elbow pain were playing pitcher and catcher positions, pitching or throwing ≥300 balls per week, playing ≥10 games on average per month and being left-handed. CONCLUSION: Risk factors for shoulder pain were different from those for elbow pain. To prevent elbow pain, coaches should pay attention to pitchers and catchers and left-handed players and not allow players to pitch or throw ≥300 full-power balls per week or participate in ≥10 games per month. They should also pay attention to pitchers and catchers and second-year students to prevent shoulder pain. It is important for coaches to train multiple pitchers and catchers.

[Clinical features and diagnosis of lumbar fractures caused by pregnancy- and lactation-associated osteoporosis.]

Pregnancy- and lactation-associated osteoporosis is a rare disease. Although researchers have reported a few cases, there are no established diagnostic criteria for pregnancy- and lactation-associated osteoporosis. However, a diagnosis can be easily obtained by an accurate medical interview, physical examination, imaging studies, and laboratory data, including bone mineral density measurement. This disease should be suspected when a woman presents with severe back pain in the late stages of pregnancy or the early postpartum period. An accurate and prompt diagnosis helps with appropriate treatment and prevents the progression of the disease.

[Fracture management and current concepts related to pregnancy-associated osteoporosis.]

Pregnancy-associated osteoporosis is a rare condition characterized by a transient but significant reduction in bone mineral density. To date, the underlying pathophysiological mechanisms remain unclear. Related symptoms include severe back or hip pain secondary to vertebral fractures and/or transient osteoporosis of the hip, which typically occur during the third trimester or during lactation. Although most women are managed conservatively, a few women need surgery. Prompt diagnosis and appropriate treatment is important not only for pain control, but also to improve the woman's future quality of life.

Chronic Kirschsteiniothelia infection superimposed on a pre-existing non-infectious bursitis of the ankle: the first case report of human infection.

BACKGROUND: Kirschsteiniothelia is a saprophytic fungus that is abundantly present in the environment. To date, there have been no reports of human infection caused by this fungus. We report a case of Kirschsteiniothelia infection superimposed on a pre-existing non-infectious bursitis of the ankle. CASE PRESENTATION: An 81-year-old immunocompetent female local farmer noticed the presence of a nodule on her right ankle 5 years before her first visit to our hospital. A cystic mass of approximately 45 mm × 30 mm was present at the tip of the right lateral malleolus. Culture of the aspirated fluid revealed visibly black colonies and characteristic blackish hyphae; nucleotide sequence of the internal transcribed spacer region was determined and compared in a GenBank database. The results indicated Kirschsteiniothelia infection. CONCLUSIONS: We described the first case of Kirschsteiniothelia infection manifested as ankle bursitis. The disease seemed to be localized and systemic antibiotics had not been used in this case. However, continued observation is needed because of the possibility of disease progression with the pathogen.

Quadrant Analysis of Quantitative Computed Tomography Scans of the Femoral Neck Reveals Superior Region-Specific Weakness in Young and Middle-Aged Men With Type 1 Diabetes Mellitus.

We have previously shown that the intertrochanter of young and middle-aged patients with type 1 diabetes mellitus (T1DM) showed higher buckling ratio (an index of cortical instability) and lower volumetric bone mineral density (vBMD). However, we have not yet reported the detailed findings regarding the mechanical and density properties of the femoral neck. Therefore, we present a subanalysis of our previous study with the aim of further evaluating the middle third of the femoral neck via quadrant quantitative computed tomography in young and middle-aged patients with T1DM. Bone parameters in 4 anatomical quadrants (superoanterior [SA], inferoanterior [IA], inferoposterior [IP], and superoposterior [SP]) were cross-sectionally evaluated in 17 male T1DM patients and 18 sex-matched healthy controls aged between 18 and 49 yr using quadrant quantitative computed tomography analysis. Patients with T1DM had a thinner cortical thickness in the SP quadrant and a significantly lower cortical vBMD in the SA quadrant than the controls. The serum insulin-like growth factor-1 values in patients with T1DM were positively correlated with the average cortical thickness in the SA quadrant and the average trabecular vBMD in the SP quadrant of the femoral neck. The cortical thickness in controls was negatively correlated with age in the SP and IP quadrants. The cortical thickness in patients with T1DM showed no correlation with age in all quadrants. The fragility of the femoral neck was remarkable in the superior region of patients with T1DM. Insulin-like growth factor-1 may play an important role in superior cortical thinning and in lowering cortical vBMD. Furthermore, in young and middle-aged men with T1DM, the structure of the femoral neck exhibits similar changes as those observed with aging.