The Effect of γ Phosphate Modified Deoxynucleotide Substrates on PCR Activity and Fidelity.

Controlling PCR fidelity is an important issue for molecular biology and high-fidelity PCR is essential for gene cloning. In general, fidelity control is achieved by protein engineering of polymerases. In contrast, only a few studies have reported controlling fidelity using chemically modified nucleotide substrates. In this report, we synthesized nucleotide substrates possessing a modification on Pγ and evaluated the effect of this modification on PCR fidelity. One of the substrates, nucleotide tetraphosphate, caused a modest decrease in Taq DNA polymerase activity and the effect on PCR fidelity was dependent on the type of mutation. The use of deoxyadenosine tetraphosphate enhanced the A : T→G : C mutation dramatically, which is common when using Taq polymerase. Conversely, deoxyguanosine tetraphosphate (dG4P) suppressed this mutation but increased the G : C→A : T mutation during PCR. Using an excess amount of dG4P suppressed both mutations successfully and total fidelity was improved.

Age-specific incidence of joint disease in paediatric patients with haemophilia: A single-centre real-world outcome based on consecutive US examination.

INTRODUCTION: Joint health is one of the most important factors contributing to a healthy life in patients with haemophilia. Recent study revealed that starting early prophylaxis was not enough to prevent joint disease in most paediatric patients with haemophilia. AIM: In this study, we aimed to determine the age-specific incidence of acute joint disease during childhood at single haemophilia treatment centre (HTC). METHOD: The joint health in 48 patients was evaluated based on consecutive US testing for 5 years at annual multidisciplinary comprehensive care. RESULTS: During the study period, 23 patients (47.9%) had no joint disease since the initial examination, whereas 13 patients (27.0%) showed development from negative to positive findings. The incidence of joint disease increased with age: 0% in preschool, 5.3% in elementary school, 14.3% in junior high school and 35% beyond high school age. Among the 13 patients who developed joint disease, two experienced acquired synovitis that resolved during the follow-up period. Statistical analysis revealed that the patients who routinely underwent follow-up by the HTC exhibited a significantly lower incidence of joint disease than did those followed up at other institutions (p < .001). CONCLUSION: These results indicated that close check-up, including routine joint examination using US as well as frequent assessment of pharmacokinetic profile at the HTC, might play an important role in avoiding joint disease among paediatric patients with haemophilia.

Dynamic ultrasound reveals the specific behavior of the medial meniscus extrusion in patients with knee osteoarthritis.

BACKGROUND: In the dynamic condition, knee osteoarthritis (OA) usually presents with pain. In the weight-bearing condition, a medial meniscus extrusion (MME) may cause severe symptoms and pathological progression. However, the correlation between a dynamic MME and pain has not been elucidated. Now, an MME can be evaluated under dynamic conditions and reflect the characteristics of symptomatic knee OA. This study investigated MMEs during walking and their correlation with knee pain. METHODS: Thirty-two symptomatic patients with knee OA (mean age, 60.5 ± 9.9 years) were enrolled in this study. The medial meniscus was evaluated using ultrasonograms during walking, and in the static supine and unipedal standing positions, as dynamic and static conditions, respectively. The ΔMME (the difference between the maximum and minimum MMEs) was obtained in each condition. The intensity of the knee pain during walking was measured by the visual analog scale (VAS). RESULTS: The ΔMME in the dynamic condition was significantly higher than that in the static condition (P < 0.01). There was a significant correlation between VAS and ΔMME only in the dynamic condition. CONCLUSIONS: The dynamic evaluation is a valid tool for understanding the mechanisms of knee pain and the behavior of the medial meniscus in symptomatic knee OA.

A case of severe COVID-19 with pulmonary thromboembolism related to heparin-induced thrombocytopenia during prophylactic anticoagulation therapy.

A 53-year-old male Japanese patient with COVID-19 was admitted to our hospital after his respiratory condition worsened on day 9 of the disease. With the diagnosis of severe COVID-19, treatment with remdesivir, dexamethasone, and unfractionated heparin was started for the prevention of thrombosis. Although the patient's respiratory status data improved after treatment, severe respiratory failure persisted. Thrombocytopenia and D-dimer elevation were observed on day 8 after heparin therapy initiation. Heparin-induced thrombocytopenia (HIT) antibody measured by immunological assay was positive, and contrast computed tomography showed pulmonary artery thrombus. The patient was diagnosed with HIT because the pre-test probability score (4Ts score) for HIT was 7 points. Heparin was changed to apixaban, a direct oral anticoagulant, which resulted in a reduction of the pulmonary thrombus and improvement of the respiratory failure. In patients with COVID-19, anticoagulant therapy with heparin requires careful monitoring of thrombocytopenia and elevated D-dimer as possible complications related to HIT. (151/250 words).

Arthroscopic mobilization for metacarpophalangeal joint extension contracture.

BACKGROUND: As a first-line surgical treatment for treating metacarpophalangeal (MCP) joint extension contractures, mobilization surgery with open dorsal approach has been indicated. However, this procedure has the possibility to result in postoperative recurrence over the course of time because its invasive open dorsal approach has a negative impact on the postoperative gliding of the extensor mechanism. We report the preliminarily outcomes of patients who underwent a minimally invasive arthroscopic mobilization to alter and enhance their existing surgical strategy in place of MCP joint extension contractures. METHODS: This retrospective study included seven patients with 13 MCP joint extension contractures who had received an arthroscopic release of the bilateral collateral ligament and/or dorsal capsule of affected MCP joint. The extension contractures were caused by long-time immobilization with inadequate extended position of the MCP joint after either hand and wrist fractures, extensor tendon injury, or peripheral nerve palsy. All patients received sufficient exercise under the supervision of a physical therapist for more than 3 months before surgery. However, physical therapy did not improve the MCP joint extension contractures. We measured the active and passive flexion angles preoperatively at 1 and 6 months after surgery. The passive flexion angle was also measured after arthroscopic mobilization on the operation table. Surgery-related complications regarding nerve, vessel, skin, and tendon were also assessed. RESULTS: In all patients, significant improvements were observed in both the active and passive flexion angles 1 month after surgery, and continued to improve 6 months after surgery. Two out of 13 metacarpophalangeal joints developed blisters on the dorsal side of the joint, but conservatively recovered. CONCLUSIONS: Based on the positive improvements observed in our patients, we conclude that this minimally invasive arthroscopic technique has the potential to alter and enhance the surgical treatment strategy for MCP joint extension contractures.

Ultrasonographic digital blood flow measurement in professional baseball pitchers - A quantitative and comparative study with non-throwers.

BACKGROUND: Vascular disorders in throwing athletes can occur from the thoracic outlet to the fingertips. The occurrence of these disorders around the shoulder is well known, and treatment options have been established for them. However, the occurrence of vascular pathology in the digital arteries in elite baseball pitchers is unclear, and treatment options have not yet been established. We hypothesized that asymptomatic professional baseball pitchers often have existing pathological changes in their digital blood flow; therefore, we quantitatively measured the blood flow in the index finger using ultrasonography and compared the results to those of non-baseball players. METHODS: Seven asymptomatic professional baseball pitchers (pitcher group) and 11 healthy volunteers (control group) were included. The flow velocity, flow volume and vessel resistance index of the ulnar digital artery of the index finger were measured just distal to the proximal interphalangeal joint using pulsed wave Doppler in two positions: 1) with the proximal interphalangeal (PIP) joint relaxed (10-15° flexed) and 2) with the PIP joint passively extended (0-5°). RESULTS: The mean flow velocity and flow volume were lower in the extended position than in the relaxed position in both groups. In the dominant hand, which was the throwing hand in the pitcher group, the mean flow velocity and the flow volume in the relaxed position were significantly lower in the pitcher group than in the control group. The vessel resistance index in the relaxed position of the dominant hand was significantly higher in the pitcher group than in the control group. In the nondominant hand, there was no significant difference in any parameter between the two groups. CONCLUSIONS: Asymptomatic professional baseball pitchers may have a pathological change in digital blood flow in the throwing hand. As treatment options for this condition have not yet been established, it is of utmost importance to carry out periodic examination and prevention before the condition progresses to the symptomatic end stage.

Development of sheet-enhanced technique (Set) method for matrix-assisted laser desorption/ionization imaging mass spectrometry.

RATIONALE: The key to successful experiments in matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) is to apply the matrix uniformly to the sample. With the development of automated equipment, uniform matrix application has made great progress while the sample preparation required to acquire a better image becomes complicated. METHODS: The approach is to apply the matrix uniformly to tape and adhere it to the tissue section. We call this the sheet-enhanced technique (Set) method. RESULTS: The Set method promotes ionization of biomolecules as well as the spray method. This procedure does not require the preparation and application of a matrix solution for each experiment, dramatically reducing the time and effort of matrix deposition. CONCLUSIONS: In the present study, we have developed the Set method as a new matrix application method. The method promotes ionization of biomolecules as well as the spray method for MALDI-IMS.

Monitoring Vascular Compromise Using Ultrasound After Free Tissue Transfer.

OBJECTIVES: To report the clinical utility of high-resolution ultrasound (US) for monitoring vascular compromise after free tissue transfer. METHODS: Fifty-two tissue transfers in the extremities were included in this study. Blood flow around the anastomotic pedicle and subcutaneous tissue of the grafted flap was monitored with pulsed color and power Doppler US whenever the conventional monitoring method, comprising the bedside assessment of the temperature, capillary refill, and flap color, showed abnormalities until 1 week after reconstruction. RESULTS: All flaps were indicated for US monitoring, with 44 flaps showing Doppler signals in each position, even though conventional flap monitoring showed an abnormality. Forty of the 44 flaps showed no flap failure, whereas the remaining 4 flaps developed partial necrosis. Abnormal US findings were noted in 8 of the 52 flaps. Ultrasound revealed interruption of venous blood flow around the anastomotic pedicle in 6 of 8 flaps. Emergent exploration revealed venous occlusion at the anastomotic pedicle, similar to the US finding. In 2 of the 8 flaps, US showed no blood flow to either the anastomotic pedicle or subcutaneous tissue. Emergent exploration revealed arterial occlusion at the anastomotic pedicle. Seven of the 8 reexplored flaps were salvaged after revision surgery with complete flap survival. Partial flap survival was noted in 1 case, but complete flap failure was avoided. CONCLUSIONS: Ultrasound is a useful adjunct that enables a direct assessment of perfusion in grafted tissues, which may reduce unnecessary exploration when conventional flap monitoring shows an abnormality.

Joint distraction and early mobilization using a new dynamic external finger fixator for the treatment of fracture-dislocations of the proximal interphalangeal joint.

BACKGROUND: Dynamic external fixation is a useful treatment option for unstable fracture-dislocations of the proximal interphalangeal (PIP) joint, because it simultaneously reduces axial pressure load on the joint surface, maintains congruent joint reduction, and permits early joint motion. However, most current devices are large, hindering finger movement, and unstable. To address these problems, we developed a dynamic external finger fixator, named the Micro Ortho Fixator®. The purpose of this study was to review the results of using the new external finger fixator to treat unstable fracture-dislocations of the PIP joint. MATERIALS AND METHODS: Nine patients who sustained unstable fracture-dislocation injuries of the PIP joint were treated with the Micro Ortho Fixator®. Seven fractures were accompanied by depressed bony fragments at the base of the middle phalanx. All patients were evaluated for pain and range of PIP motion at the final follow-up. Radiographs of the affected fingers were evaluated for PIP congruity and reduction. The mean follow-up duration was 11.1 months (range: 6-33 months). RESULTS: At the final follow-up, pain averaged 0.3 (range: 0-2) on the Numeric Pain Rating Scale, and the total arc of motion at the PIP joint averaged 91.2° (range: 50-110°). All fractures had healed, and the intra-articular step-off improved from 1.9 mm (SD: 1.0) before surgery to 0.2 mm (SD: 0.4) at the final follow-up. The patients who sustained sports injuries returned to competition after an average of 3.5 months (range: 2.5-4 months). CONCLUSION: The external fixator is compact and facilitates range-of-motion (ROM) exercises, has high stability, and achieves good joint congruity and an ROM equivalent to the healthy joint of the patient. STUDY DESIGN/LEVEL OF EVIDENCE: Therapeutic/IV.

Comparison of sonography and MRI in the evaluation of stability of capitellar osteochondritis dissecans.

PURPOSE: To compare the diagnostic accuracies of ultrasonography (US) and magnetic resonance imaging (MRI) with intraoperative capitellar osteochondritis dissecans (COCD) fragment stability findings. METHODS: Patients whose International Cartilage Repair Society (ICRS) osteochondritis dissecans (OCD) classifications were I/II (stable) or III (unstable) were included. Patients underwent preoperative US and MRI. On US, lesions were evaluated as unstable when irregular contours of the chondral surface were observed. On MRI, lesions were evaluated as unstable when articular bone irregularity, a T2 high signal intensity interface, or a high signal intensity line through the articular cartilage was observed. Using the surgical assessment as the gold standard, accuracies of fragment stability diagnoses were calculated for US and MRI. RESULTS: Thirty-four patients with OCD classifications of I/II (stable) or III (unstable) were included. Twenty-four patients (stable: 12, unstable: 12) underwent preoperative US; 22 (stable: 11, unstable: 11) underwent preoperative MRI. Preoperative US and MRI stability assessments correctly matched intraoperative fragment findings in 23 of 24 patients and 16 of 22 patients, respectively. US criteria in this study achieved superior accuracy compared with MRI criteria (96% vs. 73%; P < .05). CONCLUSION: US was a useful tool for evaluating fragment instability in COCD.

Correlation between "hourglass-like fascicular constriction" and idiopathic anterior interosseous nerve palsy.

INTRODUCTION: In recent operative cases of anterior interosseous nerve palsy (AINP), hourglass-like fascicular constrictions have been reported. We prospectively investigated the ultrasonographic history of these lesions to better understand the role of this lesion in AINP. METHODS: Seven patients who were diagnosed with idiopathic AINP based on classic clinical findings and had hourglass-like fascicular constrictions found on ultrasonography were included. All but 1 patient selected surgery, and we followed up all patients clinically and with ultrasonography. RESULTS: In the 5 patients treated surgically in whom paralysis recovered to a level greater than M4, postoperative ultrasonography revealed less constriction. The other patient experienced little recovery after surgery, and the severe constriction remained. In a conservatively treated patient, the paralysis recovered completely, and upon ultrasonography, the constriction had lessened. CONCLUSIONS: Although the mechanism is still unknown, hourglass-like fascicular constriction lessened with relief of motor weakness both in operatively and conservatively treated patients. Muscle Nerve 55: 508-512, 2017.

Novel sluggish speed signs on ultrasound is indicative of hemangiomas.

Background Hemangiomas are sometimes difficult to diagnose with current techniques. Sluggish speed signs (SSS) are a phenomenon that: (i) cannot be depicted as Doppler flow on Doppler ultrasound; (ii) can be observed as fluid movements on Doppler ultrasound; and (iii) cannot be depicted as waveforms on pulse Doppler mode. We hypothesized that SSS could be diagnostic indicators for hemangiomas. Purpose To evaluate whether ultrasound findings, in particular those relating to SSS, are a reliable tool for detecting hemangiomas compared to magnetic resonance imaging (MRI) and the gold standard for hemangioma diagnosis: pathological examination by biopsy or after surgical resection. Material and Methods Totally, 105 patients (mean age, 44.9 years) with soft-tissue tumors underwent MRI and ultrasound examination before biopsy or tumor resection. Ultrasound findings were compared with MRI as well as pathological findings, which were used as reference. Results Hemangiomas were identified in 16 (6.25%) of the 105 patients. On MRI, flow voids showed sensitivity and specificity values of 81.3% and 96.6%, respectively. On ultrasound examination, SSS was the only finding to show equally high sensitivity (93.8%) and specificity (96.6%) for diagnosing hemangiomas. There was no significant difference in the diagnostic capabilities between these two parameters ( P = 0.479). Conclusion SSS showed a high sensitivity and specificity for diagnosing hemangiomas and therefore are useful diagnostic tools to supplement MRI.

Temporary meniscus extrusion is caused by cumulative stress from uphill and downhill tasks in healthy volunteers.

Purpose: Excessive mechanical stress accumulates and causes knee injury. Meniscal extrusion is a key factor in detecting the reaction to cumulative mechanical stress. The accumulation of stress strongly depends on environmental conditions such as flat ground or uphill/downhill, and accumulates in knee compartments; only a few studies have reported the effects of different environments on lateral and medial meniscus extrusion. This study aimed to investigate the effects of cumulative uphill/downhill stress on the meniscal extrusion in each compartment. Methods: A total of 30 healthy volunteers with 30 affected knees were involved in this cohort study (mean age, 22.0 ± 1.1 years; men, n = 14). The participants were divided into flat-walking, uphill/downhill-walking, and uphill/downhill-jogging groups and their numbers of steps taken were recorded during the effort. Moreover, medial and lateral meniscal extrusions during walking were evaluated using ultrasound three times, before and after efforts (T1) and (T2), and one day after efforts (T3), respectively. Results: In the flat-walking group, no significant differences were observed between the follow-up periods. Conversely, in the uphill/downhill-walking and jogging groups, the medial meniscus extrusion at T2 was significantly higher than that at T1. Conversely, the medial meniscus extrusion at T3 was significantly lower than that at T2. By contrast, the lateral meniscus did not show any difference between the follow-up periods in any group. Conclusion: Temporary extrusion of the meniscus occurred after uphill/downhill tasks in healthy volunteers, and its reaction was observed only in the medial meniscus.

Morphological Changes in the Infrapatellar Fat Pad During Walking Detected by Dynamic Ultrasound in Healthy Volunteers.

Aim This study aimed to verify specific morphological changes in the infrapatellar fat pad (IFP) during walking in healthy young participants. Methods A total of 17 healthy young participants (mean age, 22.8 ± 0.9 years) were recruited in this cross-sectional study. The IFP was evaluated using ultrasonography in three conditions: supine, standing, and walking. The IFP value was described as the thickness of the distal section of the IFP. Additionally, in the walking condition, the IFP was captured in video mode on ultrasonography, and its dynamics were recorded. The waveform of the IFP was produced using the sequence of the IFP thickness on each image. The morphological change of IFP (ΔIFP) was calculated in the IFP waveform and was shown as the difference in IFP thickness between the maximum and minimum at the beginning of the early stance phase. Moreover, kinematics and kinetic data were evaluated using a three-dimensional motion system, and the knee flexion angle (KFA) and knee flexion moment (KFM) were obtained. Results The thickness of the IFP during walking was significantly greater than that during the supine and standing conditions (p < 0.001 for both). The IFP waveform during walking showed a gradual increase during the stance phase and a decrease during the swing phase of the gait cycle. ΔIFP was 1.35 ± 0.42 mm and significantly correlated with the KFM (r = 0.59, p = 0.007). Conclusions Dynamic ultrasonography revealed a specific morphological change in the IFP during walking, which correlated with the KFM.

Medial meniscus extrusion during gait is associated with decrease in knee rotation in early-stage knee osteoarthritis.

BACKGROUND: In patients with medial knee osteoarthritis (OA), medial meniscus extrusion during gait is aggravated by mechanical stress, such as knee adduction moment (KAM). Conversely, the decrease in the range of knee rotation during stance phase is also one of the important issues in early knee OA, whereas the correlation between medial meniscus extrusion and knee rotation during gait are unclear. RESEARCH QUESTION: To investigate the correlation between increase in medial meniscus extrusion and range of knee rotation during gait in patients with early- and late-stage of knee OA. METHODS: Forty patients with medial knee OA were enrolled and divided into early- and late-OA group by Kellgren-Lawrence grading scale. During gait tasks, the extent of medial meniscus extrusion was measured using ultrasonography and kinetic/kinematic data were measured using three-dimensional motion analysis system. The correlation between medial meniscus extrusion and the range of knee rotation or KAM were evaluated in the overall, early-, and late- OA groups. RESULTS: A significant negative correlation was observed between an increase in medial meniscus extrusion and range of knee rotation angle in early-OA group only. However, an increase in medial meniscus extrusion significantly correlated with the second KAM peak in the overall and early-OA groups. SIGNIFICANCE: The decrease in range of knee rotation during stance phase may be associated with the increase in medial meniscus extrusion during gait in patients with early knee OA.

Very rapid DNA-templated reaction for efficient signal amplification and its steady-state kinetic analysis of the turnover cycle.

Oligonucleotide-templated reactions are powerful tools for the detection of nucleic acid sequences. One of the major scientific challenges associated with this technique is the rational design of non-enzyme-mediated catalytic templated reactions capable of multiple turnovers that provide high levels of signal amplification. Herein, we report the development of a nucleophilic aromatic substitution reaction-triggered fluorescent probe. The probe underwent a rapid templated reaction without any of the undesired background reactions. The fluorogenic reaction conducted in the presence of a template provided a 223-fold increase in fluorescence after 30 s compared with the nontemplated reaction. The probe provided an efficient level of signal amplification that ultimately enabled particularly sensitive levels of detection. Assuming a simple model for the templated reactions, it was possible to estimate the rate constants of the chemical reaction in the presence and in the absence of the template. From these kinetic analyses, it was possible to confirm that an efficient turnover cycle had been achieved, on the basis of the dramatic enhancement in the rate of the chemical reaction considered to be the rate-determining step. With maximized turnover efficiency, it was demonstrated that the probe could offer a high turnover number of 1500 times to enable sensitive levels of detection with a detection limit of 0.5 pM in the catalytic templated reactions.

Effects of metacarpophalangeal joint position and finger joint movement speed on lumbrical muscle activity.

OBJECTIVES: The effect of metacarpophalangeal joint position and finger joint movement speed on lumbrical muscle activity remains unproven and was examined in this study. MATERIAL AND METHODS: Twenty-four healthy adults performed flexion-extension movements of the index finger in different metacarpophalangeal joint positions (extension or flexion) and movement speeds (60, 120, 240, and 360 beats per minute). The activities of the first lumbrical, first dorsal interosseous, and extensor digitorum muscles were evaluated using surface electromyography, and compared with those during finger joint extension. RESULTS: The metacarpophalangeal joint positions affected only lumbrical muscle activity, which was greater during extension. Further, finger movement speed affected the lumbrical and extensor digitorum muscle activities, which increased with increasing movement speeds. CONCLUSION: The present study suggests that position and movement speed can influence the lumbrical muscle activity during metacarpophalangeal joint extension. These findings may help expound lumbrical function and develop suitable strategies for inducing lumbrical muscle activity.

Measurement of the lumbrical muscle activity of the hand using electromyography supported by the ultrasound imaging technique with string navigation.

Although placing surface electrodes on small muscles by palpation is difficult, ultrasound guidance may enable electrode placement on the small muscles. This study aimed to examine whether ultrasound guidance is helpful for placement of electrodes on a small muscle, such as the hand lumbrical muscle. Twelve dominant hands of 12 healthy right-handed adults were included in this study. The first lumbrical muscle belly of the hands was identified using ultrasound guidance with a string navigation technique for placing surface electrodes. This technique was designed to identify the location of the center of the muscle belly under ultrasound imaging using a string. After the electrodes were placed on the muscle belly using this technique, the surface electromyographic signals of the first lumbrical, first dorsal interosseous, and adductor pollicis muscles were recorded. The activity of the lumbrical muscle could be separately measured of the first dorsal interosseous and adductor pollicis muscles. This technique has the potential to enable surface electromyography of small muscles for which placement of surface electrodes by palpation is challenging.

Effect of limb alignment correction on medial meniscus extrusion under loading condition in high tibial osteotomy.

Background: This study aimed to investigate the effect of high tibial osteotomy (HTO) on medial meniscus extrusion (MME) and the association between the changes in limb alignment and MME under weight-bearing (WB) conditions after HTO. Methods: We included 17 patients with knee osteoarthritis (OA) who underwent HTO. MME was evaluated using ultrasonography in supine and unipedal standing positions. Knee alignment was evaluated radiographically using WB, whole-leg radiographs with the hip-knee-ankle angle (HKAA), percentage of the mechanical axis (%MA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA). All measurements were performed serially at four time points: preoperative and 3, 6, and 12 months postoperative. Clinical outcomes were assessed by knee injury and osteoarthrosis outcome score (KOOS) and visual analogue scale (VAS) value for pain. Results: Mean MME in the WB position was significantly greater than that in the supine position in the preoperative condition; however, MME in both supine and WB positions was significantly lowered postoperatively. The ΔMME, difference of MME between supine and WB positions, was significantly lowered postoperatively and maintained for up to 1 year. MME change in the WB position between preop and postoperative conditions was significantly correlated with change in HKAA and %MA at 1 year postoperative. KOOS and VAS score were significantly improved after HTO. Conclusions: HTO correcting varus alignment can decrease MME in WB position and minimise the change in MME between supine and WB positions. The changes in MME after HTO were correlated with changes in the mechanical alignments.