Employment of color Doppler echocardiographic video clips in a cardiac auscultation class with a cardiology patient simulator: discrepancy between students' satisfaction and learning.

BACKGROUND: We have provided fourth-year medical students with a three-hour cardiac auscultation class using a cardiology patient simulator since 2010. The test results of 2010-2012 revealed that as compared with aortic stenosis murmur, students correctly identified murmurs of other valvular diseases less often. We investigated whether employment of color Doppler echocardiographic video clips would improve proficiency in identifying murmurs of aortic regurgitation and mitral regurgitation, and whether students' favorable responses to a questionnaire were associated with improved proficiency. METHODS: A total of 250 fourth-year medical students were divided into groups of 7-9 students in 2014 and 2015. Each group attended a three-hour cardiac auscultation class comprising a mini-lecture, facilitated training, two different auscultation tests (the second test being closer to clinical setting than the first) and a questionnaire. We provided each student with color Doppler echocardiographic videos of aortic regurgitation and mitral regurgitation using a tablet computer, which they freely referred to before and after listening to corresponding murmurs. The test results were compared with those in 2010-2012. The students had already completed the course of cardiovascular medicine, comprising lectures including those of physical examination, echocardiography, and valvular heart diseases, before participating in this auscultation training class. RESULTS: Most students indicated that the videos were useful or somewhat useful regarding aortic regurgitation (86.3%) and mitral regurgitation (85.7%). The accuracy rates were 78.4% (81.2% in 2010-2012) in aortic regurgitation and 76.0% (77.8%) in mitral regurgitation in the first test, and 83.3% (71.4%) in aortic regurgitation and 77.1% (77.6%) in mitral regurgitation in the second test, showing no significant differences as compared to 2010-2012. Overall accuracy rate of all heart sounds and murmurs in the first test and that of second/third/fourth sounds in the first and second tests were significantly lower in 2014-2015 than in 2010-2012. CONCLUSIONS: Referring to color Doppler echocardiographic video clips in the way employed in the present study, which most students regarded as useful, did not improve their proficiency in identifying the two important regurgitant murmurs, revealing a discrepancy between students' satisfaction and learning. Video clips synchronized with their corresponding murmurs may contribute toward improving students' proficiency.

A Medical Record Peer-Review System to Evaluate Residents' Clinical Competence: Criterion Validity Analysis.

In contrast to input evaluation (education delivered at school) and output evaluation (students' capability at graduation), the methods of outcome evaluation (performance after graduation) of medical education have not been sufficiently established. To establish a method to measure the quality of patient care and conduct outcome evaluation, we have been developing a peer review system of medical records. Here, we undertook a pilot study to evaluate the criterion validity of our system by using "evaluation by program directors (supervisors in the hospitals)" as a criterion standard. We selected 13 senior residents from three teaching hospitals. Five reviewers (general internists working in other hospitals) visited the hospitals independently and evaluated five patients' records for each resident based on the previously established sheet comprising 15 items. Independently, program directors of the senior residents evaluated their clinical performance using an evaluation sheet comprising ten items. Pearson's analysis revealed statistically significant correlation coefficients in three pairs of assessments including clinical reasoning (r = 0.5848, P = 0.0358). Bootstrap analysis revealed statistically significant correlation coefficients in additional 5 pairs including history taking (r = 0.509, 95% confidence interval: 0.034-0.847). In contrast, the correlation coefficients were low in some items: r = 0.132 (-0.393-0.639) for physical examination and r = 0.089 (-0.847-0.472) for attitude toward patients. To the best of our knowledge, this is the first study, albeit a pilot one, that investigates the criterion validity of medical record evaluations conducted by comparing the assessments of medical records with those by program directors.

Questionnaire-Based Development of an Educational Program of Traditional Japanese Kampo Medicine.

Traditional Japanese Kampo medicine has been widely used in clinical practice in Japan. Though it is a compulsory subject in Japanese medical schools, a standard educational program in Kampo medicine does not exist. Tohoku University has incorporated Kampo medicine into clinical education via didactic lectures since 2003; however, student evaluations have been lower for Kampo than for all other clinical specialties. We administered a questionnaire about a Kampo medicine course for fifth-year students from 2009 to 2012 and developed an educational program based on feedback obtained. The questionnaire consisted of nine questions (a clear training plan; opportunities for learning, practice, and patient contact; acquisition of medical knowledge and physical examination; learning professionalism; understanding the specialty; overall assessment) that were rated on a 5-point Likert scale along with open-ended questions about the course's strengths and weaknesses. The students responded to the questionnaire after clinical practice in Kampo medicine and other clinical specialty courses. Scores for Kampo medicine and the average of other clinical specialties were compared. All 389 students who participated in Kampo clinical practice answered the questionnaire. In 2009, scores for Kampo medicine for nine questions were lower than for the average of the other clinical specialties. After curriculum reformation involving hands-on training in 2012, all scores except "opportunities to learn about clinical cases" and "opportunities to practice involvement" were higher than the average of all other clinical specialties. In conclusion, we have successfully developed a Kampo medicine educational program for our university through this survey study.

Development of a peer review system using patient records for outcome evaluation of medical education: reliability analysis.

In addition to input evaluation (education delivered at school) and output evaluation (students' capability at graduation), the methods for outcome evaluation (performance after graduation) of medical education need to be established. One approach is a review of medical records, which, however, has been met with difficulties because of poor inter-rater reliability. Here, we attempted to develop a peer review system of medical records with high inter-rater reliability. We randomly selected 112 patients (and finally selected 110 after removing two ineligible patients) who visited (and were hospitalized in) one of the four general hospitals in the Tohoku region of Japan between 2008 and 2012. Four reviewers, who were well-trained general internists from outside the Tohoku region, visited the hospitals independently and evaluated outpatient medical records based on an evaluation sheet that consisted of 14 items (3-point scale) for record keeping and 15 items (5-point scale) for quality of care. The mean total score was 84.1 ± 7.7. Cronbach's alpha for these items was 0.798. Single measure and average measure intraclass correlations for the reviewers were 0.733 (95% confidence interval: 0.720-0.745) and 0.917 (95% confidence interval: 0.912-0.921), respectively. An exploratory factor analysis revealed six factors: history taking, physical examination, clinical reasoning, management and outcome, rhetoric, and patient relationship. In conclusion, we have developed a peer review system of medical records with high inter-rater reliability, which may enable us, with further validity analysis, to measure quality of patient care as an outcome evaluation of medical education in the future.

Feasibility and effectiveness of cardiac auscultation training with a cardiology patient simulator for first-year medical students.

BACKGROUND: The effectiveness of cardiac auscultation training with a cardiology patient simulator for medical students is still unclear. Starting such training earlier may help students improve their proficiency. We investigated whether cardiac auscultation training using a simulator for first-year students is feasible and effective. METHODS: A total of 43 first-year medical students (5-12 in each year, 2015-2019) participated in three 1.5-hour extra-curricular classes comprising mini-lectures, facilitated training, two different auscultation tests (the second test closer to clinical setting than the first), and a questionnaire. The test results were compared with those of 556 fourth-year medical students who participated in a compulsory 3-hour cardiac auscultation class in 2016-2019. RESULTS: The accuracy rate of all heart sounds and murmurs was higher in the first-year students than in the fourth-year students in both the first (85.8 vs. 79.4 %, p = 0.001) and second (71.3 vs. 61.2 %, p = 0.02) tests. That of second/third/fourth sounds was also higher in the first-year students than in the fourth-year students in both the first (86.0 vs. 79.7 %, p = 0.01) and second (70.9 vs. 53.9 %, p = 0.002) tests. The accuracy rate of murmurs was higher in the first-year students than in the fourth-year students in the first test (85.5 vs. 78.9 %, p = 0.04), but not in the second test (72.1 vs. 75.7 %, p = 0.58). All the first-year students and 65 % of them agreed that they had received sufficient knowledge and built sufficient skills, respectively. All the first-year students and 93 % of them agreed that they were satisfied with the program, and that the program was suitable for first-year students, respectively. CONCLUSIONS: Although training time was different between the two groups and it is possible that only motivated first-year students participated in the program, these results suggest that our cardiac auscultation training is feasible and effective for first-year medical students.

Ethylene/polar monomer copolymerization behavior of bis(phenoxy-imine)Ti complexes: formation of polar monomer copolymers.

Bis(phenoxy-imine) Ti complexes bearing a phenyl group ortho to the phenoxy-O can mediate the copolymerization of ethylene and 5-hexene-1-yl-acetate though they are group 4 transition metal catalysts.

Variation in effectiveness of a cardiac auscultation training class with a cardiology patient simulator among heart sounds and murmurs.

BACKGROUND: Effectiveness of simulation-based education in cardiac auscultation training is controversial, and may vary among a variety of heart sounds and murmurs. We investigated whether a single auscultation training class using a cardiology patient simulator for medical students provides competence required for clinical clerkship, and whether students' proficiency after the training differs among heart sounds and murmurs. METHODS: A total of 324 fourth-year medical students (93-117/year for 3 years) were divided into groups of 6-8 students; each group participated in a three-hour training session using a cardiology patient simulator. After a mini-lecture and facilitated training, each student took two different tests. In the first test, they tried to identify three sounds of Category A (non-split, respiratory split, and abnormally wide split S2s) in random order, after being informed that they were from Category A. They then did the same with sounds of Category B (S3, S4, and S3+S4) and Category C (four heart murmurs). In the second test, they tried to identify only one from each of the three categories in random order without any category information. RESULTS: The overall accuracy rate declined from 80.4% in the first test to 62.0% in the second test (p<0.0001). The accuracy rate of all the heart murmurs was similar in the first (81.3%) and second tests (77.5%). That of all the heart sounds (S2/S3/S4) decreased from 79.9% to 54.3% in the second test (p<0.0001). The individual accuracy rate decreased in the second test as compared with the first test in all three S2s, S3, and S3+S4 (p<0.0001). CONCLUSIONS: Medical students may be less likely to correctly identify S2/S3/S4 as compared with heart murmurs in a situation close to clinical setting even immediately after training. We may have to consider such a characteristic of students when we provide them with cardiac auscultation training.

Arthroscopic and open synovectomy of the elbow in rheumatoid arthritis.

BACKGROUND: Synovectomy has been advocated for early treatment of the rheumatoid elbow. It has not been determined whether arthroscopic or open synovectomy is better and whether a preoperative arc of flexion of >90 degrees is an important prognostic factor. METHODS: Arthroscopic or open synovectomy was performed in fifty-eight elbows in fifty-three patients with rheumatoid arthritis and radiographic changes in the joint of Larsen grade 2 or less. Clinical symptoms, recurrent synovitis, postoperative complications, and radiographic changes were assessed ten to eighteen years (average, thirteen years) postoperatively. RESULTS: Eleven (48%) of twenty-three elbows in which arthroscopic synovectomy had been performed and sixteen (70%) of twenty-three elbows in which open synovectomy had been performed were mildly or not painful at the latest follow-up evaluation. However, no significant difference was detected between the overall clinical results of arthroscopic synovectomy and those of open synovectomy. In elbows with a preoperative arc of flexion of <90 degrees , the clinical results of the two procedures were comparable. In elbows with a preoperative arc of flexion of <90 degrees , arthroscopic synovectomy provided significantly (p < 0.05) better function than open surgery after mid-term follow-up, and motion and function continued to be better in those patients at the most recent follow-up evaluation. Recurrent synovitis was observed in six elbows that had arthroscopic synovectomy and in three that had open synovectomy, and the Larsen grade increased in both groups. Three elbows with a preoperative arc of flexion of <90 degrees underwent a total elbow arthroplasty to treat ankylosis after open synovectomy. Surgical complications were uncommon and not severe. CONCLUSIONS: Arthroscopic synovectomy of the elbow is a reliable procedure. One of the most favorable indications for either arthroscopic or open synovectomy is a preoperative arc of elbow flexion of >/=90 degrees in patients with early rheumatoid arthritis.

Volume of a wash and the other conditions for maximum therapeutic effect of arthroscopic lavage in rheumatoid knees.

The objective of this study was to determine the appropriate volume of saline to obtain a beneficial effect of arthroscopic lavage and the prognostic factors related to the clinical effect in a refractory rheumatoid knee. Arthroscopic lavage or arthrocentesis was performed in a random manner in 142 patients with relapsing rheumatoid arthritis. All patients were followed up for 24 months. Intra-articular lavage with 5 l (p < 0.01) or 3 l (p < 0.05) of saline gave better clinical results than did arthrocentesis. There was no significant difference between the cumulative incidence of recurrence of knee synovitis in patients who underwent arthrocentesis and that in patients who underwent lavage with 1 l of saline. Cox regression analysis showed that patients with knee arthritis of more than 6 months in duration and with Larsen grade II or less were more responsive to lavage with 5 or 3 l of saline. The duration of the effect of lavage with 3 l of saline was increased 2.9-fold (p = 0.04) by injection of both steroids and high molecular weight hyaluronan. No bleeding or infectious complications occurred after those procedures. Arthroscopic lavage with 5 l of saline is safe and has good therapeutic effects for rheumatoid knees with mild destruction in which arthritis has persisted for more than 6 months. Lavage with 3 l of saline is recommended when intra-articular injection of corticosteroid and high molecular weight hyaluronan is performed after lavage.

Number of papers published in English from the nursing departments of 42 national universities in Japan in the past ten years.

BACKGROUND: In Japan, the departments of nursing were established by 2004, and graduate school programs for master's degree were established by 2008, in 42 national universities. With these changes, a more academic mission has been pursued, and the need for writing papers in English has increased. AIM: To investigate the numbers of papers published in English from the nursing departments of national universities in Japan over the past ten years. METHODS: The lists of teachers who have nursing licenses in the departments of nursing in the 42 national universities (n=2292) were obtained from the Japan Association of Nursing Programs in Universities. The number of papers published in English by these teachers from 2004 to 2013 was counted using the SCOPUS database. RESULTS: The average number of total papers, in which at least one of the authors was a nursing teacher, and first-authored papers, in which the first author was a nursing teacher, were 211.4 and 69.9 per year, respectively; both increased approximately two-fold during the past ten years. The means and standard deviations of the number of total papers and first-authored papers were 50.3±63.8 (range: 1-382) and 18.3±23.4 (range: 0-147) according to universities, and 1.39±5.84 (range: 0-140) and 0.33±1.28 (range: 0-21) according to teachers, respectively. When journals with the highest number of papers were analyzed, 12 of the top 20 (total papers) and 12 of the top 16 (first-authored papers) were in journals whose editorial offices are in Japan. CONCLUSION: The number of papers published in English has increased over the past ten years, varied markedly depending on the universities and teachers, and many papers were published in Japanese journals. To our knowledge, this is the first report anywhere to determine the average number of nursing papers "per teacher" in a specific population.

Debridement arthroplasty for primary osteoarthritis of the elbow. Surgical technique.

BACKGROUND: Formal and more aggressive debridement procedures have been described for the treatment of advanced primary osteoarthritis of the elbow. However, the literature contains little information on the results of long-term follow-up. The purpose of this study was to evaluate outcomes at an average of ten years after debridement arthroplasties performed through a posteromedial approach. METHODS: Thirty-three elbows with primary osteoarthritis in thirty-two patients treated with debridement arthroplasty were available for clinical follow-up evaluation. Through a posteromedial approach, the flexor-pronator muscle origin was reflected from the medial epicondyle and the joint was opened, preserving the anterior oblique bundle of the medial collateral ligament. The ulnar nerve was decompressed in all patients. Osteophytes were removed from the anterior, medial, and posterior sides of the elbow joint. In nine elbows, osteophytes from the lateral compartment were removed through an additional lateral approach. The mean age at the time of the operation was fifty years. The mean duration of follow-up was 121 months, and nineteen elbows were followed for more than ten years. RESULTS: The mean preoperative limitation of extension of 31 degrees was reduced to 24 degrees , and the mean preoperative flexion of 101 degrees improved to 118 degrees (p < 0.001). The mean arc of movement improved by 24 degrees . The mean Japanese Orthopaedic Association elbow score was 83 points at the latest follow-up evaluation compared with 60 points preoperatively (p < 0.001). Of twenty-five patients who had performed heavy manual work, nineteen (76%) returned to their previous job or an equivalent job. At the latest examination of the nineteen elbows followed for more than ten years, the limitation of extension was found to have increased by 7 degrees compared with the limitation noted at one year (p < 0.009); the mean arc of flexion had remained the same. Three elbows required a reoperation. Overall, 85% of the elbows were satisfactory to the patients. CONCLUSIONS: Debridement arthroplasty through a posteromedial approach can provide stable and reliable long-term results with regard to relief of pain, gains in range of motion, and the patient's ability to return to his or her previous occupation. In our series, a modest loss of extension was observed at ten years, whereas the arc of flexion remained consistent.

Labral shape after arthroscopic Bankart repair: comparisons between the anchor and Caspari methods.

PURPOSE: Morphological changes after repair of the glenoid labrum were examined using fresh cadavers and clinical cases to compare the anchor and Caspari methods. TYPE OF STUDY: Cadaveric and case series. METHODS: The depth of the glenoid concavity after Bankart repair was measured in 4 shoulders from 2 fresh cadavers. We made positive models of the glenoid cavity with gypsum and measured the distance from the lateral-most extent of the anterior labrum to the medial extent of the glenoid cavity. We also compared the depth of glenoid concavity in clinical cases between the anchor and Caspari methods using air computed tomography arthrography and magnetic resonance imaging. RESULTS: We determined the effective depth as the distance from the lateral-most extent of the anterior labrum to the medial extent of the glenoid cavity. The effective depth in fresh cadaver experiments after the anchor method showed substantial differences at the superior and middle levels of the glenoid labrum compared with the Caspari method. Mean effective depths in clinical cases were 5.8 mm (range, 4.2 to 6.8 mm) after the anchor method and 3.5 mm (range, 2.0 to 5.0 mm) after the Caspari method. Effective depth following the anchor method was significantly greater than that of the Caspari method. CONCLUSIONS: During repair of Bankart lesions for traumatic anterior instability of the shoulder, effective depth was higher following use of the anchor method than with the Caspari method. CLINICAL RELEVANCE: Understanding the shape of the anterior labrum and glenoid concavity after use of the anchor and Caspari methods may help to improve the surgical technique and clinical results of arthroscopic Bankart repair.

Adenovirus-mediated in vivo B7-1 gene transfer induces anti-tumor immunity against pre-established primary tumor and pulmonary metastasis of rat osteosarcoma.

We have previously reported that an osteosarcoma vaccine generated by ex vivo transfection of B7-1 cDNA induces protective as well as curative immunity against B7-1-negative parental osteosarcoma. Because establishment of human osteosarcoma cell lines, which is a prerequisite for ex vivo gene transfer, is rarely successful, we, in the present study, investigated the therapeutic efficacy of adenovirus-mediated in vivo B7-1 gene transfer to pre-established primary tumor as well as pulmonary metastasis of osteosarcoma. Adenovirus-mediated rat B7-1 gene transfer induced (a) expression of B7-1 molecules in osteosarcoma cells by both in vitro and in vivo infection procedures, (b) curative immunity against pre-established primary osteosarcoma and, subsequently, hosts gained protection against additional challenge of parental B7-1-negative osteosarcoma cells, (c) systemic immunity against pre-established pulmonary metastasis, and (d) activation of regional lymph node CD4(+) T cells, expansion of dendritic cells and natural killer cells and the secretion of interferon-gamma. These findings collectively support the therapeutic value of adenovirus-mediated in vivo gene transfer on osteosarcoma, which is of greater simplicity than cell-based B7-1 vaccine, and represent an attractive strategy for therapy of patients with metastatic osteosarcama who acquired resistance to current therapeutic protocols.

Combined gene therapy with adenovirus vectors containing CTLA4Ig and CD40Ig prolongs survival of composite tissue allografts in rat model.

BACKGROUND: The blockade of costimulatory signal pathway by anti-CD40 ligand antibody or cytotoxic T lymphocyte antigen 4 immunoglobulin (CTLA4Ig) prolongs allograft survival in various vascularized organ transplantations. Because of the short half life of these agents, repeated administration of proteins is required to achieve significant graft survival. Furthermore, there is limited information regarding the effect of cosimulatory blockade on the survival of composite tissue allografts. Therefore, we examined the effect of adenovirus-mediated gene transfer of CTLA4Ig or CD40Ig gene or both in composite tissue allotransplantation. METHODS: The hind limbs removed from male ACI rats (RT1 ) were transplanted into female Lewis rats (RT1 ) heterotopically. The recombinant adenovirus carrying CTLA4Ig (AxCTLA4Ig) or CD40Ig (AxCD40Ig) was intravenously administered after limb transplantation. RESULTS: Limb allograft survival was significantly prolonged by either AxCTLA4Ig or AxCD40Ig treatment at 1 x 10 plaque forming unit (mean survival time [MST] of 39.4+/-6.0 and 13.0+/-2.9, respectively) compared with the adenovirus vector containing beta-galactosidase-treated group (MST of 4.8+/-0.8). Combination of AxCTLA4Ig and AxCD40Ig led to significant prolongation of graft survival (MST of 49.2+/-6.6). Serum levels of CD40Ig were higher in rats treated with combination therapy than those treated with AxCD40Ig alone, whereas the serum levels of CTLA4Ig in rats treated with AxCTLA4Ig alone and AxCTLA4Ig and AxCD40Ig combined were very similar. CONCLUSION: This study indicates that an adenovirus-mediated gene therapy of CTLA4Ig or CD40Ig has a therapeutic potential for preventing rejection in composite tissue transplantation. Furthermore, a combination therapy of AxCTLA4Ig and AxCD40Ig was even more effective in preventing acute rejection and prolonging the survival of allografted limbs without apparent complication.

Living ethylene/norbornene copolymerisation catalyzed by titanium complexes having two pyrrolide-imine chelate ligands.

Ethylene/norbornene copolymerisation behaviour of titanium complexes with two pyrrolide-imine chelate ligands is described.

In vivo immunogenicity of osteosarcoma cells that express B7-1a, an alternatively spliced form of B7-1.

BACKGROUND: B7 family members play a central costimulatory role in T cell activation. We have previously identified B7-1a, an alternatively spliced form of B7-1. The function of B7-1a in induction of anti-tumor immunity remains uncertain. MATERIALS AND METHODS: The cDNAs of murine B7-1, B7-1a and B7-2 were introduced into a murine osteosarcoma cell line, LM8. The ability of B7 transfectants to elicit in vivo anti-tumor immunity was comparatively analyzed with respect to tumorigenecity, pulmonary metastasis and survival time. RESULTS: LM8 cells expressing B7-1, B7-1a, or B7-2 all elicited immunological responses in immunocompetent C3H/He mice. Notably, the anti-tumor effects were most obvious in mice inoculated with B7-1a-transfected LM8 cells. Such a difference among B7-transfectants became indistinguishable in immunodeficient nude mice. CONCLUSION: These findings indicate that B7-1a serves as a more efficacious costimulatory molecule than B7-1 or B7-2 in the induction and maintenance of anti-tumor immune responses against a poorly immunogenic osteosarcoma cell line.

Débridement arthroplasty for primary osteoarthritis of the elbow.

BACKGROUND: Formal and more aggressive débridement procedures have been described for the treatment of advanced primary osteoarthritis of the elbow. However, the literature contains little information on the results of long-term follow-up. The purpose of this study was to evaluate outcomes at an average of ten years after débridement arthroplasties performed through a posteromedial approach. METHODS: Thirty-three elbows with primary osteoarthritis in thirty-two patients treated with débridement arthroplasty were available for clinical follow-up evaluation. Through a posteromedial approach, the flexor-pronator muscle origin was reflected from the medial epicondyle and the joint was opened, preserving the anterior oblique bundle of the medial collateral ligament. The ulnar nerve was decompressed in all patients. Osteophytes were removed from the anterior, medial, and posterior sides of the elbow joint. In nine elbows, osteophytes from the lateral compartment were removed through an additional lateral approach. The mean age at the time of the operation was fifty years. The mean duration of follow-up was 121 months, and nineteen elbows were followed for more than ten years. RESULTS: The mean preoperative limitation of extension of 31 degrees was reduced to 24 degrees, and the mean preoperative flexion of 101 degrees improved to 118 degrees (p < 0.001). The mean arc of movement improved by 24 degrees. The mean Japanese Orthopaedic Association elbow score was 83 points at the latest follow-up evaluation compared with 60 points preoperatively (p < 0.001). Of twenty-five patients who had performed heavy manual work, nineteen (76%) returned to their previous job or an equivalent job. At the latest examination of the nineteen elbows followed for more than ten years, the limitation of extension was found to have increased by 7 degrees compared with the limitation noted at one year (p < 0.009); the mean arc of flexion had remained the same. Three elbows required a reoperation. Overall, 85% of the elbows were satisfactory to the patients. CONCLUSIONS: Débridement arthroplasty through a posteromedial approach can provide stable and reliable long-term results with regard to relief of pain, gains in range of motion, and the patient's ability to return to his or her previous occupation. In our series, a modest loss of extension was observed at ten years, whereas the arc of flexion remained consistent.

Usefulness of bioabsorbable thread pins after resection arthroplasty for rheumatoid forefoot reconstruction.

BACKGROUND: Bioabsorbable thread pin has been used for internal fixation of bone. The results of resection arthroplasty of the lesser metatarsophalangeal (MTP) joints using internal intramedullary fixation with bioabsorbable pins have not been reported. METHODS: Resection arthroplasty of the MTP joints of the lesser toes with poly-L-lactic acid (PLLA) thread pins or Kirschner wires was performed at random in reconstruction of the 87 rheumatoid forefeet (62 patients) with a grommet-protected silicone-rubber implant insertion of the first MTP joint. Clinical symptoms, the state of radiographic changes, and complications were assessed 5-10 years (average, 7.7 years) postoperatively. RESULTS: The mean American Orthopaedic Foot and Ankle Society clinical scores at the preoperative and latest points were 31 and 91, respectively, in the operated patients with PLLA pins, while the mean scores were 32 and 82, respectively, in the operated patients with Kirschner wires. The lesser toes treated by bioabsorbable pins did not become rigid, although they were stable. Recurrent dorsal subluxation of the lesser MTP joints was visible on radiographs in three of the 46 feet with PLLA pins, while two feet had three dislocated MTP joints and one subluxated MTP joint postoperatively and recurrent dorsal subluxation of the lesser MTP joints was visible in four of the 41 feet with Kirschner wires. The postoperative hallux valgus did not progress to the preoperative level during the follow-up period in both groups. Two of the 46 feet with PLLA pins and two of the 41 feet with Kirschner wires had radiographic evidence of silicone synovitis without pathological fracture. Three patients with Kirschner wires had wire-track infection, and one patient had severe circulation disturbance of the corrected lesser toes necessitating wire removal. CONCLUSIONS: A new trial of internal fixation with bioabsorbable pins may lead to the establishment of a safe method for enhancing stability of the lesser toes after resection arthroplasty of the lesser MTP joints.

The lateral collateral ligament complex and related muscles act as a dynamic stabilizer as well as a static supporting structure at the elbow joint: an anatomical and experimental study.

Among 71 osteoligamentous elbow joint specimens from Japanese subjects, 66% of the lateral ulnar collateral ligaments (LUCLs) were in an incomplete form, such as a fibrous intermuscular septum lying between the anconeus, supinator and extensors, and terminated on the annular ligament. The 'typical' complete ligament, extending from the lateral epicondyle and over the radial collateral ligament (RCL) to the crista spinatoris, appeared in only 20% of the elbows examined. This observation suggests that, in Japanese subjects, the LUCL is not usually a simple ligamentous static stabilizer, but acts as a dynamic stabilizer, together with its related muscles. In addition, when the elbow was flexed by more than 90 degrees, the distance between the lateral epicondyle and the radial head became almost 1.5 mm larger than the distance from the epicondyle to the annular ligament. We therefore consider that, in the overflexed position, the radial head moves slightly distal while the length of the RCL remains almost constant. This morphometrical observation suggests that the annular ligament needs to be supported by the LUCL-muscle complex from the distal side, as well as by the RCL from the proximal side. This extended definition of the lateral collateral ligament complex and its associated muscular function is discussed.