The ICHI-FIXATOR® system, a novel wire-connected external fixator, demonstrates efficacy in managing intra-articular fractures involving the proximal phalanx of the big toe.

Proximal phalanx fractures of the big toe involving angulation or dislocation of the articular surface require repositioning and fixation. We treated a patient with such a fracture using a novel wire-connected external fixator, the ICHI-FIXATOR® system. A 45-year-old male sustained an injury when slipping down the stairs and impacting his left big toe. Plain radiography and computed tomography revealed a proximal phalangeal fracture of the left big toe with dislocation of the articular surface and comminution. The surgical intervention was performed using 1.1-mm diameter C-wires and an external fixator. The patient regained ambulation and resumed work immediately after surgery. Four weeks postoperatively, all wires were removed on an outpatient basis. Eight months postoperatively, the patient experienced no pain during strenuous activities or exercises. This novel wire-connected external fixator provides reliable and secure fixation, facilitating a prompt return to normal daily activities. This technique may be an effective option for managing toe fractures.

Difficulty in Early Diagnosis of Bilateral Posterior Fracture-dislocation of the Shoulder Caused by an Electric Shock in a Walk-in Patient: A Case Report.

Introduction: Bilateral posterior fracture-dislocation of the shoulder is a very rare injury that is commonly missed. Almost 70% of bilateral posterior dislocations are due to convulsive seizures, with electric shocks accounting for < 5% of bilateral posterior shoulder dislocations. Case Report: The case of a walk-in patient, a 52-year-old man, with bilateral posterior fracture-dislocation of the shoulder caused by an electric shock is reported. Although he was initially admitted to the emergency department for observation of the potential complications of an electric shock, such as fatal arrhythmia and rhabdomyolysis, he subsequently consulted an orthopedic surgeon 4 days after the event due to persistent bilateral shoulder pain and was diagnosed using X-ray and computed tomography with bilateral posterior fracture-dislocation of the shoulder. Following open reduction and internal fixation 7 days after the injury, the upper limbs were fixed with shoulder braces at a slightly flexed and abducted position with neutral rotation for 3 weeks postoperatively followed by range of motion exercises. Twelve months after surgery, he had a Constant shoulder score of 94, an American Shoulder and Elbow Surgeon score of 100, and no shoulder re-dislocation or humeral head necrosis. Conclusion: In this walk-in patient, the diagnosis of bilateral posterior fracture-dislocation of the shoulder caused by an electric shock was delayed. We believe that understanding the mechanism of this type of injury will facilitate its early diagnosis.

Factors Associated with Return to Sport After Anterior Cruciate Ligament Reconstruction: A Focus on Athletes Who Desire Preinjury Level of Sport.

INTRODUCTION: In most previous studies investigating return to preinjury level of sport (RTPS) after anterior cruciate ligament reconstruction (ACLR), whether patients continue aiming for RTPS not only before but also after ACLR was unclear because environmental and social factors were not considered. Herein, we aimed to evaluate factors associated with RTPS among athletes who desired to achieve RTPS even after ACLR, excluding patients who no longer desire this goal owing to environmental and social factors. METHODS: Ninety-two patients who underwent primary double-bundle ACLR with a minimum 2-year follow-up and desired to achieve RTPS before surgery were retrospectively enrolled. Twelve (13%) patients who no longer desired to achieve RTPS after ACLR owing to environmental and social factors were excluded. Sixty-nine patients were included in the final cohort. At the final follow-up, the patients were split into two groups: those who achieved (R group) or did not achieve (N group) RTPS based on patient self-assessment. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Lysholm scores were also determined. The anterior tibial translation in the Lachman test and acceleration and external rotational angular velocity (ERAV) in the pivot shift test were measured at the hardware removal operation. RESULTS: Significant differences were observed for preinjury level of sports between the groups (p < 0.05). The rate of RTPS in competitive athletes was lower than that in recreational athletes (20/46: 43% vs. 16/22: 73%; p =.037). Lysholm score, KOOS symptom, pain, and quality of life showed higher values in the R group than in the N group (p < 0.050). Acceleration was significantly lower in the R group than in the N group (p = 0.028). CONCLUSION: Competitive level of sports is a risk factor for failure to achieve RTPS. The postoperative functional outcomes in the group that achieved RTPS showed more favorable results. These results provide important information to enable the surgeons to consider the appropriate surgical plan for competitive athletes who desire to achieve RTPS after ACLR.

Factors Associated With Residual Pivot Shift After ACL Reconstruction: A Quantitative Evaluation of the Pivot-Shift Test Preoperatively and at Minimum 12-Month Follow-up.

Background: Postoperative residual rotatory laxity remains despite improvement in surgical techniques for anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose: To evaluate factors associated with residual pivot shift after ACLR by quantitative measurement of the pivot shift before and after surgery. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 97 patients who underwent primary double-bundle ACLR between June 2016 and March 2021 and underwent surgery to remove staples, with at least 12 months of follow-up evaluation, were enrolled. Quantitative measurements were performed under general anesthesia immediately before ACLR (preoperatively), after temporary fixation of the ACL graft (intraoperatively), and immediately before staple removal (postoperatively). The laxity of pivot shift was assessed using inertial sensors to measure acceleration and external rotational angular velocity (ERAV). Descriptive data were assessed for associations with postoperative acceleration and ERAV in a univariate analysis. A multiple linear regression analysis was performed to identify factors associated with postoperative acceleration and ERAV. Results: Anterior tibial translation, acceleration, and ERAV increased from intra- to postoperatively (P < .05). Factors significantly associated with postoperative acceleration were age (ß = -0.238; P = .021), lateral posterior tibial slope (PTS) (ß = 0.194; P = .048), and preoperative acceleration (ß = 0.261; P = .008). Factors significantly affecting postoperative ERAV were age (ß = -0.222; P = .029), ramp lesions (ß = 0.212; P = .027), and preoperative ERAV (ß = 0.323; P = .001). Conclusion: Greater preoperative laxity in the pivot shift was the factor having the most significant association with residual pivot shift after ACLR using quantitative measurements under general anesthesia. Younger age, higher lateral PTS, and concomitant ramp lesions were significant predictors of residual pivot shift. These findings can help pre- and intraoperative decision-making regarding whether an anterolateral structure augmentation should be added.

Nontuberculous mycobacteriosis oligoarthritis of the right hand misdiagnosed as rheumatoid arthritis: A case report.

Infection with Mycobacterium marinum has several different clinical presentations. Most commonly, it appears as a solitary papulonodular lesion on an extremity. A rare presentation of osteoarticular M. marinum involving multiple small joints and tenosynovitis of the hand, which was misdiagnosed as rheumatoid arthritis, is reported. The patient was initially treated for seronegative rheumatoid arthritis but failed to respond to methotrexate. Magnetic resonance imaging showed arthritis and tenosynovitis. Subsequently, synovial biopsy led to histological and microbiological diagnosis. Antimycobacterial treatment should be started promptly in such cases. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.

An Analysis of the Femoral Drilling Angle to Avoid Tunnel Collision during Double-Bundle Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction on the Knee.

Concomitant anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has been reported as an effective technique for providing rotational control of the knee. However, the intraoperative risk of collision with an ACL tunnel during the drilling for the femoral ALL tunnel has been described. The purpose of this study was to investigate the various femoral drilling procedures to avoid tunnel collisions during combined double-bundle ACL and ALL reconstruction. Nine cadaveric knees were used in this study. ACL drilling was performed through the anteromedial portal to footprints of the posterolateral bundle at 120° (PL120) and 135° (PL135) knee flexion and the anteromedial bundle at 120° (AM120) and 135° (AM135) knee flexion. ALL drilling was performed at 0° (Cor0-ALL) and 30° (Cor30-ALL) coronal angles using a Kirschner wire (K-wire). The distance between the ALL footprint and ACL K-wire outlets, axial angles of ALL K-wires colliding with ACL K-wires, and distances from the ALL footprint to the collision point were measured. From these values, the safe zone, defined as the range of axial angles in which no collisions or penetrations occurred, was identified by simulation of tunnels utilized for reconstruction grafts in each drilling procedure. The point-to-point distance from the ALL footprint to the K-wire outlet was significantly greater in the AM120 than the AM135 (13.5 ± 3.1, 10.8 ± 3.2 mm; p = 0.048) and in the PL135 than the PL120 (18.3 ± 5.5, 16.1 ± 6.5 mm; p = 0.005) conditions, respectively. During an ACL drilling combination of PL135/AM120, a safe zone of > 45° in Cor30-ALL was identified. With a narrow safe zone during the PL135/AM120 combination only, the risk of femoral tunnel collisions in combined double-bundle ACL and ALL reconstruction is high. AM drilling at 120° and PL drilling at > 135° knee flexion, combined with ALL drilling at 30° coronal angle and > 45° axial angle, may reduce this risk.

The Janus kinase inhibitor (baricitinib) suppresses the rheumatoid arthritis active marker gliostatin/thymidine phosphorylase in human fibroblast-like synoviocytes.

Gliostatin/thymidine phosphorylase (GLS/TP) is known to have angiogenic and arthritogenic activities in the pathogenesis of rheumatoid arthritis (RA). The novel oral Janus kinase (JAK) inhibitor baricitinib has demonstrated high efficacy in RA. However, the effect of baricitinib on fibroblast-like synoviocytes (FLSs), a key component of invasive synovitis, has not been still elucidated. This study investigated whether GLS/TP production could be regulated by JAK/signal transducers and activators of transcription (STAT) signaling in FLSs derived from patients with RA. FLSs were cultured and stimulated by interferon (IFN)γ in the presence of baricitinib. Expression levels of GLS/TP were determined using reverse transcription-polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA), and immunocytochemistry. Phosphorylation of STAT proteins was investigated by Western blot. In cultured FLSs, GLS/TP mRNA and protein levels were significantly induced by treatment with IFNγ and these inductions were suppressed by baricitinib treatment. Baricitinib inhibited IFNγ-induced STAT1 phosphorylation, while JAK/STAT activation played a pivotal role in IFNγ-mediated GLS/TP upregulation in RA. These results suggested that baricitinib suppressed IFNγ-induced GLS/TP expression by inhibiting JAK/STAT signaling, resulting in the attenuation of neovascularization, synovial inflammation, and cartilage destruction.

Diagnosis of medial meniscal ramp lesion is difficult by pre-operative magnetic resonance imaging evaluation and needs a methodical arthroscopic exploration.

BACKGROUND: Meniscal ramp lesion (RL) is the peripheral lesion of the posterior horn of the medial meniscus (PHMM) associated with anterior cruciate ligament (ACL) tear. The purpose of this study was to evaluate the accuracy of pre-operative magnetic resonance imaging (MRI) evaluation in diagnosing RL and to identify whether the difficulty in diagnosis differs depending on the location of RL. METHODS: ACL-injured patients undergoing ACL reconstruction from January 2017 to January 2019 were enrolled. A methodical arthroscopic exploration to identify RL was conducted intra-operatively using three steps, namely, the anterior visualization step, the inter-condylar visualization step, and the posteromedial step. The location of the RLs was evaluated and classified into two types as follows: Red-red zone (RR) - a meniscal tear of the red-red zone of the PHMM. Menisco-capsular junction (MCJ) - a lesion at the menisco-capsular junction of the PHMM, which is more peripheral than RR. Furthermore, the accuracy of 1.5-T MRI evaluation to diagnose RL by two testers using sagittal proton-density fat-saturated images was calculated. RESULTS: Of the 81 patients enrolled, 11 had RL: 5 cases each were at the MCJ and RR, and 1 case was at both locations. The sensitivity of MRI for detecting RL was 27.3-45.5%, whereas the specificity was 84.3-95.7% in total. The sensitivity of MRI in detecting RL at the RR and MCJ was 40.0-80.0%, 0-20.0%, respectively. The intra-observer reliability of the MRI evaluation was moderate (κ coefficient: 0.40-0.46), while the inter-observer reliability was fair to moderate (κ coefficient: 0.27-0.41). CONCLUSIONS: A low sensitivity of the MRI in detecting RL at the MCJ was observed, and the reliability of the MRI evaluation for diagnosis of RL was not high. Therefore, methodical arthroscopic exploration is essential to diagnose RL even when it is not suspected on pre-operative MRI.

Anterolateral ligament reconstruction in addition to primary double-bundle anterior cruciate ligament reconstruction for grade 3 pivot shift improves residual knee instability during surgery.

PURPOSE: High-grade pivot shift in the anterior cruciate ligament (ACL) injured knee is a risk factor for postoperative residual pivot shift. Procedures in addition to ACL reconstruction such as anterolateral ligament (ALL) reconstruction have been performed for patients with a high-risk of residual pivot shift. The aim of this study was to investigate the effect of the addition of ALL reconstruction to primary double-bundle ACL reconstruction in patients with preoperative high-grade pivot shift to improve stability as evaluated by quantitative measurement. METHODS: Patients with ACL injuries who showed preoperative grade 3 subjective pivot shift and who underwent primary double-bundle ACL reconstruction combined with ALL reconstructions were retrospectively enrolled. Anterior tibial translation (ATT) in the Lachman test, and acceleration and external rotational angular velocity (ERAV) in the pivot shift were measured as quantitative values. Quantitative values before surgical intervention for ACL-injured knees (ACLD) and uninjured contralateral knees (intact), after temporary fixation of the isolated ACL grafts (ACLR), and subsequently after temporary fixation of both ACL and ALL grafts (ACLR + ALLR) were measured with the patient under general anaesthesia. RESULTS: In total, 18 patients were included. The ATT was lower in ACLR and ACLR + ALLR than in intact (P = .008 and .005), while there was no significant difference between ACLR and ACLR + ALLR (P > .05). The acceleration of ACLR + ALLR was lower than that for ACLR (P = .008), while there was no significant difference between intact and ACLR or ACLR + ALLR (P > .05). The ERAV of ACLR was higher than that of intact (P < .001), while that of ACLR + ALLR was lower than that of ACLR (P < 0.001), and there was no significant difference in ERAV between intact and ACLR + ALLR (P > 0.05). CONCLUSION: According to quantitative assessment of the pivot shift, the addition of ALL reconstruction to primary double-bundle ACL reconstruction improved residual knee instability and restored knee stability during surgery. Combination of ALL reconstruction with primary double-bundle ACL reconstruction was effective for patients with ACL injuries exhibiting a preoperative grade 3 subjective pivot shift. LEVEL OF EVIDENCE: IV.

Preoperative Knee Instability Affects Residual Instability as Evaluated by Quantitative Pivot-Shift Measurements During Double-Bundle ACL Reconstruction.

BACKGROUND: The pivot-shift test is an important indicator of functional outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR). Preoperative instability as indicated by the pivot-shift test is associated with residual instability after ACLR. Few studies have used quantitative means to evaluate the pivot shift after ACLR. PURPOSE: To investigate the relationship between preoperative and residual instability and to identify the risk factors for residual instability by using quantitative measurements of the pivot shift. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 91 patients undergoing primary double-bundle ACLR were retrospectively enrolled. Quantitative measurements of instability for ACL-deficient knees (ACLD) and uninjured contralateral knees (intact) preoperatively, as well as ACLR knees intraoperatively, were performed under general anesthesia using the pivot-shift test, with inertial sensors to measure acceleration and external rotational (ER) angular velocity. The ratios of intact to ACLD (ACLD/I) and intact to ACLR (ACLR/I) were measured. Patients who showed an ACLR/I of >1 were classified into the residual instability group, and those with an ACLR/I of ≤1 were classified into the noninstability group. Regarding demographic, surgical, and quantitative measurement factors, between-group comparisons and multivariate logistic regression were conducted for predictors of residual instability. Receiver operating characteristic curves were used to evaluate the correlations between ACLD/I and ACLR/I and the cutoff value of ACLD/I in predicting residual instability. RESULTS: The predictive factors for intraoperative residual instability included female sex (odds ratio [OR], 0.3 [95% CI, 0.1-0.9]; P = .034) and ACLD/I for acceleration (OR, 1.6 [95% CI, 1.2-2.1]; P < .001), and ACLD/I for ER angular velocity (OR, 1.9 [95% CI, 1.2-3.1]; P = .013). Correlations between ACLD/I and ACLR/I were moderate with respect to both acceleration (r = 0.435; P < .001) and ER angular velocity (r = 0.533; P < .001). The cutoff points for ACLD/I were 4.9 for acceleration (sensitivity, 65.1%; specificity, 85.7%; area under the curve [AUC], 0.76) and 2.4 for ER angular velocity (sensitivity, 80.0%; specificity, 50.0%; AUC, 0.74). CONCLUSION: Greater preoperative instability was a risk factor for residual instability as measured intraoperatively by a quantitatively evaluation in the pivot shift during ACL reconstruction. Quantitative measurements of instability during the pivot shift mechanism under general anesthesia may enable surgeons to predict postoperative residual instability.

Anterolateral ligament reconstruction as an augmented procedure for double-bundle anterior cruciate ligament reconstruction restores rotational stability: Quantitative evaluation of the pivot shift test using an inertial sensor.

PURPOSE: The purpose of this study was to investigate the biomechanical function of the anterolateral structures (ALS) of the knee regarding rotational stability, and to attempt to verify the effectiveness of anterolateral ligament (ALL) reconstruction concomitant with double-bundle anterior cruciate ligament (ACL) reconstruction by quantifying the pivot shift test (PST) using an inertial sensor. METHODS: Six knees of the fresh-frozen cadavers were evaluated during the following phases: (1) [Intact]; (2) ACL-deficient [ACL-D]; (3) ACL-reconstructed [ACL-R]; (4) ACL-reconstructed + ALS-deficient [ACL-R + ALS-D]; and (5) combined ACL and ALL reconstructed [ACL-R + ALL-R]. We evaluated knee rotational instability during each phase using the PST. We used an inertial sensor to calculate tibial external rotational angular velocity (ERAV) and tibial acceleration. Data were analyzed using repeated-measures analysis of variance; statistical significance was accepted as P < 0.05. RESULTS: Relative to [Intact], [ACL-D] caused a significant increase in ERAV and acceleration. However, there was no difference in these parameters between [ACL-R] and [Intact]. [ACL-R + ALS-D] increased ERAV significantly compared with [ACL-R], and there was a significant difference between ERAV during [ACL-R + ALS-D] and [Intact]. However, ERAV was significantly reduced during [ACL-R + ALL-R] compared with [ACL-R + ALS-D], and there was no significant difference in ERAV or acceleration between [ACL-R + ALL-R] and [Intact]. CONCLUSIONS: ALS controlled rotational instability in cooperation with the ACL in a cadaveric model. In cases of combined injury of ACL and ALS, concomitant ACL and ALL reconstruction may restore knee stability comparable with the intact state.

Comparison of quantitative evaluation between cutaneous and transosseous inertial sensors in anterior cruciate ligament deficient knee: A cadaveric study.

BACKGROUND: Recently several authors have reported on the quantitative evaluation of the pivot-shift test using cutaneous fixation of inertial sensors. Before utilizing this sensor for clinical studies, it is necessary to evaluate the accuracy of cutaneous sensor in assessing rotational knee instability. To evaluate the accuracy of inertial sensors, we compared cutaneous and transosseous sensors in the quantitative assessment of rotational knee instability in a cadaveric setting, in order to demonstrate their clinical applicability. METHODS: Eight freshly frozen human cadaveric knees were used in this study. Inertial sensors were fixed on the tibial tuberosity and directly fixed to the distal tibia bone. A single examiner performed the pivot shift test from flexion to extension on the intact knees and ACL deficient knees. The peak overall magnitude of acceleration and the maximum rotational angular velocity in the tibial superoinferior axis was repeatedly measured with the inertial sensor during the pivot shift test. Correlations between cutaneous and transosseous inertial sensors were evaluated, as well as statistical analysis for differences between ACL intact and ACL deficient knees. RESULTS: Acceleration and angular velocity measured with the cutaneous sensor demonstrated a strong positive correlation with the transosseous sensor (r = 0.86 and r = 0.83). Comparison between cutaneous and transosseous sensor indicated significant difference for the peak overall magnitude of acceleration (cutaneous: 10.3 ± 5.2 m/s2, transosseous: 14.3 ± 7.6 m/s2, P < 0.01) and for the maximum internal rotation angular velocity (cutaneous: 189.5 ± 99.6 deg/s, transosseous: 225.1 ± 103.3 deg/s, P < 0.05), but no significant difference for the maximum external rotation angular velocity (cutaneous: 176.1 ± 87.3 deg/s, transosseous: 195.9 ± 106.2 deg/s, N.S). CONCLUSIONS: There is a positive correlation between cutaneous and transosseous inertial sensors. Therefore, this study indicated that the cutaneous inertial sensors could be used clinically for quantifying rotational knee instability, irrespective of the location of utilization.