Midterm Outcomes After Total Knee Arthroplasty With Lateral Approach for Valgus Knee Deformity in Patients With Rheumatoid Arthritis.

Background Valgus knee deformity is often seen in rheumatoid arthritis (RA) cases. Usually, the medial approach has been often utilized for total knee arthroplasty (TKA), even in valgus deformity cases; however, the medial approach is feared to induce further instability in the medial side because it could further break the soft tissue structure, including medial collateral ligament (MCL) and medial patellofemoral ligament (MPFL). Consequently, loosening of the implant, recurrence of valgus knee deformity, and pain due to instability might be induced in the early period after surgery. In this study, a lateral approach for TKA against valgus deformity in RA cases was utilized to avoid further damage on the medial side. Methods Eleven valgus knees in 10 patients with RA (mean age, 61.1 years; mean follow-up, 33.1 months) underwent primary TKA with the lateral approach. Iliotibial band (ITB) dissection and/or peroneal nerve release were performed if necessary. Radiological and clinical investigations were evaluated pre- and postoperatively. Results The average operating time was 106 minutes, which was no longer compared with the time after the medial approach described previously. The extension angle was significantly improved from -15.0 ± 10.2 to -5.5 ± 4.2 degrees (P = 0.03), while the flexion angle showed no significant change (from 111.8 ± 15.9 to 115.0 ± 13.2 degrees). The hip-knee-ankle angle (HKA) was also significantly corrected from -9 ± 4.9 to 0.4 ± 1.7 degrees (P < 0.001). The 2011 Knee Score System (KSS) scores were significantly improved from 6.9 ± 3.4 to 21.5 ± 2.9 (P < 0.001) in symptoms, from 15.6 ± 2.7 to 31.1 ± 4.1 (P < 0.001) in satisfaction, and from 31.5 to 59.5 (P < 0.01) in activity. Conclusion Midterm outcomes after lateral approach TKA were good, and knee alignment was significantly improved. The lateral approach TKA for valgus deformity in patients with RA was not complicated and difficult because it required no additional operating time compared with the medial approach. From the perspective of preventing further damage to the soft tissue structure on the medial side, the lateral approach was meaningful for valgus deformity in patients with RA.

Detection of dural defect localization using four-dimensional dynamic computed tomography myelography for patients with superficial siderosis.

BACKGROUND: There are cases of superficial siderosis (SS) with spinal ventral fluid-filled collection in the spinal canal (VFCC). In our previous study, the balanced steady-state free precession sequence magnetic resonance imaging is useful in identifying the location of dural defects. However, because of its narrow scan area and long scan time, it cannot easily detect the defect location in some patients with small dural defect. In this study, we applied four-dimensional dynamic computed tomography (4DCT) imaging, including time-axis imaging, to myelography using the latest CT imaging equipment, which can perform short-time continuous imaging, to identify the dural defect site. METHODS: Twenty SS patients with VFCC (9 males, 11 females; mean age 61.6 years) underwent 4DCT myelography (4D-CTM). A 192-row helical CT (SOMATOM Force, SIEMENS) with high-speed scanning capability was used to obtain 9-11 scans per minute at low dose while flowing contrast medium into the subarachnoid space. Then, contrast leakage sites were identified. RESULTS: The contrast leakage sites could be identified in all 20 cases: C7/Th1, 2 cases; Th1/2, 5 cases; Th2/3, 9 cases; Th3/4, 1 case; Th5/6, 1 case; Th7/8, 1 case; and Th8/9, 1 case. Eighteen cases underwent surgical operation, and actual dural defects were confirmed at the contrast leakage sites. The mean ± standard deviation of leakage time from contrast agent injection was 19.0±9.2 s. CONCLUSIONS: 4D-CTM can be used to reliably identify the location of spinal fluid leakage. In SS cases, dural defects could be visualized in an average of 19 seconds.

Comparison of Postoperative Complications and Outcomes in Anterior Cervical Spine Surgery: Ossification of the Posterior Longitudinal Ligament Versus Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To compare the frequency of complications and outcomes between patients with ossification of the posterior longitudinal ligament (OPLL) of the cervical spine and those with cervical spondylotic myelopathy (CSM) who underwent anterior surgery. SUMMARY OF BACKGROUND DATA: Anterior cervical spine surgery for OPLL is an effective surgical procedure; however, it is complex and technically demanding compared with the procedure for CSM. Few reports have compared postoperative complications and clinical outcomes after anterior surgeries between the 2 pathologies. METHODS: Among 1434 patients who underwent anterior cervical spine surgery at 3 spine centers within the same spine research group from January 2011 to March 2021, 333 patients with OPLL and 488 patients with CSM were retrospectively evaluated. Demographics, postoperative complications, and outcomes were reviewed by analyzing medical records. In-hospital and postdischarge postoperative complications were investigated. Postoperative outcomes were evaluated 1 year after the surgery using the Japanese Orthopaedic Association score. RESULTS: Patients with OPLL had more comorbid diabetes mellitus preoperatively than patients with CSM ( P <0.001). Anterior cervical corpectomies were more often performed in patients with OPLL than in those with CSM (73.3% and 14.5%). In-hospital complications, such as reoperation, cerebrospinal fluid leak, C5 palsy, graft complications, hoarseness, and upper airway complications, occurred significantly more often in patients with OPLL. Complications after discharge, such as complications of the graft bone/cage and hoarseness, were significantly more common in patients with OPLL. The recovery rate of the Japanese Orthopaedic Association score 1 year postoperatively was similar between patients with OPLL and those with CSM. CONCLUSION: The present study demonstrated that complications, both in-hospital and after discharge following anterior spine surgery, occurred more frequently in patients with OPLL than in those with CSM.

Assessing ulnar neuropathy at the elbow using magnetoneurography.

OBJECTIVE: To measure neuromagnetic fields of ulnar neuropathy patients at the elbow after electrical stimulation and evaluate ulnar nerve function at the elbow with high spatial resolution. METHODS: A superconducting quantum interference device magnetometer system recorded neuromagnetic fields of the ulnar nerve at the elbow after electrical stimulation at the wrist in 16 limbs of 16 healthy volunteers and 21 limbs of 20 patients with ulnar neuropathy at the elbow. After artifact removal, neuromagnetic field signals were processed into current distributions, which were superimposed onto X-ray images for visualization. RESULTS: Based on the results in healthy volunteers, conduction velocity of 30 m/s or 50% attenuation in current amplitude was set as the reference value for conduction disturbance. Of the 21 patient limbs, 15 were measurable and lesion sites were detected, whereas 6 limbs were unmeasurable due to weak neuromagnetic field signals. Seven limbs were deemed normal by nerve conduction study, but 5 showed conduction disturbances on magnetoneurography. CONCLUSIONS: Measuring the magnetic field after nerve stimulation enabled visualization of neurophysiological activity in patients with ulnar neuropathy at the elbow and evaluation of conduction disturbances. SIGNIFICANCE: Magnetoneurography may be useful for assessing lesion sites in patients with ulnar neuropathy at the elbow.

Nationwide survey of patients with multisystem proteinopathy in Japan.

OBJECTIVE: Multisystem proteinopathy (MSP) is an inherited disorder in which protein aggregates with TAR DNA-binding protein of 43 kDa form in multiple organs. Mutations in VCP, HNRNPA2B1, HNRNPA1, SQSTM1, MATR3, and ANXA11 are causative for MSP. This study aimed to conduct a nationwide epidemiological survey based on the diagnostic criteria established by the Japan MSP study group. METHODS: We conducted a nationwide epidemiological survey by administering primary and secondary questionnaires among 6235 specialists of the Japanese Society of Neurology. RESULTS: In the primary survey, 47 patients with MSP were identified. In the secondary survey of 27 patients, inclusion body myopathy was the most common initial symptom (74.1%), followed by motor neuron disease (11.1%), frontotemporal dementia (FTD, 7.4%), and Paget's disease of bone (PDB, 7.4%), with no cases of parkinsonism. Inclusion body myopathy occurred most frequently during the entire course of the disease (81.5%), followed by motor neuron disease (25.9%), PDB (18.5%), FTD (14.8%), and parkinsonism (3.7%). Laboratory findings showed a high frequency of elevated serum creatine kinase levels and abnormalities on needle electromyography, muscle histology, brain magnetic resonance imaging, and perfusion single-photon emission computed tomography. INTERPRETATION: The low frequency of FTD and PDB may suggest that FTD and PDB may be widely underdiagnosed and undertreated in clinical practice.

Reverse V-shaped osteotomy for ankylosing rocker-bottom foot deformity in patients with rheumatoid arthritis. A report of 3 cases.

This study evaluated reverse V-shaped osteotomy for ankylosing rocker-bottom foot deformity in patients with rheumatoid arthritis. We experienced 3 feet: rheumatoid rocker-bottom deformities with painful and/or infectious bony prominence towards the bottom of the foot, treated with a reverse V-shaped osteotomy in the mid-hindfoot. In all three cases, significant correction was achieved with restoration of the medial longitudinal arch, and improvement in clinical scores was confirmed. Reverse V-shaped osteotomy has the potential to be a useful and definitive procedure for ankylosing rocker-bottom deformity in patients with rheumatoid arthritis.

Factors associated with the time required for CRP normalization in pyogenic spondylitis: A retrospective observational study.

Background: Treatment for pyogenic spondylitis tends to be prolonged; however, few studies have examined the factors associated with the time required for infection control. Therefore, we analyzed a consecutive cohort of patients to identify factors associated with the time required to control infection in pyogenic spondylitis. This study aimed to clarify the factors linked to the duration necessary for achieving infection control in cases of pyogenic spondylitis, using C-reactive protein (CRP) normalization as an indicator. Methods: In this retrospective observational study, we investigated 108 patients diagnosed with pyogenic spondylitis. We evaluated the number of days from the first visit to CRP normalization; for cases wherein CRP did not normalize, the number of days to the date of final blood sampling was evaluated. In the present study, infection control in pyogenic spondylitis was defined as a CRP falling within the normal range (≤0.14 mg/dL). We performed univariate and multivariate Cox regression analyses to identify various factors associated with the time required for CRP normalization in pyogenic spondylitis. Results: The mean time required for CRP normalization was 148 days. Univariate Cox regression analysis showed that the serum creatinine level, estimated glomerular filtration rate (eGFR), lymphocyte percentage, neutrophil percentage, CRP level, CRP-albumin ratio, and neutrophil-to-lymphocyte ratio were significantly associated with the time required to control infection. Multivariate Cox regression analysis showed that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were the independent factors associated with a longer infection control time. Conclusions: We found that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were significantly associated with a longer time for CRP normalization in pyogenic spondylitis. These findings may help identify patients with pyogenic spondylitis who are at a high risk for an extended infection control period.

Early full weight-bearing and gait exercise after cemented total ankle arthroplasty with modified antero-lateral approach.

BACKGROUND: According to the conventional postoperative procedure after total ankle arthroplasty (TAA) against end-stage osteoarthritis (OA) and rheumatoid arthritis (RA), mobilization and weight-bearing is currently started after completion of wound healing. Recently, early mobilization for dorsiflexion after TAA with modified antero-lateral approach was reported to be feasible and safe. To investigate the further possibility of expediting rehabilitation, this study evaluated the feasibility and safety of early full weight-bearing and gait exercise after cemented TAA utilizing a modified antero-lateral approach. MATERIALS AND METHODS: This retrospective, observational study investigated 23 consecutive ankles (OA: 14 ankles, RA: 9 ankles) that had received cemented TAA with a modified antero-lateral approach. These ankles were divided into three groups [1. conventional postoperative protocol: 8 ankles, 2. early dorsiflexion protocol: 7 ankles, 3. early dorsiflexion+full weight-bearing protocol: 8 ankles]. In group 3, after early dorsiflexion mobilization (day 3), full weight-bearing/gait exercise was started from 7 days after surgery (10 days after if malleolar osteotomy was added). Postoperative wound complications were observed and recorded. Number of days for hospitalization was also evaluated. Range of motion (ROM) of dorsiflexion/plantar flexion was measured. Patients also completed a self-administered foot evaluation questionnaire (SAFE-Q) and the scale of Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot score preoperatively and at final follow-up. RESULTS: No postoperative complications related to wound healing were observed even after early full weight-bearing and gait exercise. Days for hospitalization was significantly shortened in early full weight-bearing and gait exercise group (group 3) from 35-38 days to 24 days. ROM for both dorsiflexion and plantar flexion significantly increased in group 3, furthermore all indices of SAFE-Q score also showed stronger significant improvement in group 3. JSSF score improved significantly after TAA in all groups. CONCLUSION: Within this small number of cases, early full weight-bearing and gait exercise from 7 days after cemented TAA was feasible and safe with the modified antero-lateral approach. Combination of early dorsiflexion mobilization and weight-bearing/gait exercise contributed to shortening the hospitalization day, and improving ROM for both dorsiflexion and plantar flexion after surgery. Innovations in postoperative procedures for rehabilitation after TAA can be expected.

Safety and effectiveness of risedronate in Paget's disease of bone: postmarketing surveillance study in Japan.

INTRODUCTION: We conducted an all-case postmarketing surveillance study between 2008 and 2017 to evaluate the safety and effectiveness of risedronate for Paget's disease of bone (PDB) in Japan. MATERIAL AND METHODS: This study registered all patients who received once-daily risedronate 17.5 mg for the treatment of PDB and collected data over a 48-week follow-up period per treatment cycle for each patient. RESULTS: The safety analysis set included 184 patients (mean age, 63.7 years), 81 (44.0%) of whom previously received a bisphosphonate. Of them, 41 (22.3%) experienced 72 adverse drug reactions (ADRs), and 8 (4.3%) experienced 14 serious ADRs. Common ADRs included gastrointestinal disorders (20 patients, 10.9%) and hypocalcemia (6 patients, 3.3%). The effectiveness analysis set included 182 patients, 124 of whom completed only one treatment cycle and 58 of whom completed multiple treatment cycles. The proportions of patients who normalized serum alkaline phosphatase (ALP) concentration were 71.1% (113/159 patients) and 67.3% (33/49 patients) for the first and second treatment cycles, respectively. The relapse rate according to ALP levels after the end of treatment for the first cycle was 5.0% (95% confidence interval [CI] = 2.1-11.5) at 24 weeks and 12.9% (95% CI = 7.5-21.7) at 40 weeks. Regarding pain relief, the achievement rates were 70.0% (49/70 patients) and 30.8% (4/13 patients) for the first and second treatment cycles, respectively. CONCLUSION: To conclude, risedronate 17.5 mg/day is safe and effective for treating patients with PDB in daily practice.

Frequency and pathogenesis of periprosthetic atypical femoral fractures associated with total knee arthroplasty: A multicenter prospective study with complementary histopathological and biomechanical analysis.

INTRODUCTION: Although the diagnostic criteria for atypical femoral fracture (AFF) exclude periprosthetic fractures, reports of periprosthetic femoral fractures with characteristics of AFF are rapidly increasing. In this study, we investigated the frequency and pathogenesis of periprosthetic AFF associated with total knee arthroplasty (TKA) based on a theory of AFF subtypes that divides AFFs into two main types: fragility stress fractures of the bowed femoral shaft in the mid-shaft and "typical" subtrochanteric AFFs due to suppression of bone turnover (e.g., by bisphosphonates). PATIENTS AND METHODS: This multicenter prospective study of AFFs was conducted from 2015 through 2022. Clinical, pathological, and morphological characteristics were investigated in patients with periprosthetic AFFs associated only with non-stem TKA. Then, biomechanical investigation of the periprosthetic AFF was performed by computer tomography-based finite element analysis (CT/FEA) using two models with different load axes to examine how the correction of lower limb alignment by TKA influences the tensile stress distribution of the femur and the location of the AFF. RESULTS: Four of 61 AFFs (6.6%) were identified to be periprosthetic AFF (1 mid-shaft; 3 subtrochanteric). Periprosthetic AFFs had characteristics including mechanical stress due to bowing deformity and potentially suppressed bone turnover due to long-term exposure to specific drugs (e.g., bisphosphonates and glucocorticoids). Although 2 periprosthetic AFFs appeared to involve a bowed femur, one with both of the aforementioned characteristics occurred in the subtrochanteric region, which would be an unusual site for a bowed AFF, and it was demonstrated histologically to have biological activity at the fracture site, suggesting a stress fracture. Furthermore, CT/FEA revealed that tensile stress distribution changed proximally as load axis was shifted laterally according to correction of lower limb alignment by TKA. CONCLUSION: Orthopedic surgeons should recognize the presence of TKA-associated periprosthetic AFF caused by various factors including specific drugs, bowing deformity, and lower limb alignment. X-rays of the full-length femurs should be checked regularly after TKA, especially in patients with bowed femurs or long-term exposure to specific drugs.

Quick Transposition of ReBOSSIS-J® to the Host Bone Trabeculae Within One Month After Supplementing to the Harvest Site on the Calcaneus for Autologous Bone Grafting in a Rheumatoid Arthritis Case.

We present the case of a patient with rheumatoid arthritis who underwent talonavicular joint fusion using an autologous calcaneal bone graft. At the same time, the bony defect at the harvest site was supplemented with ReBOSSIS-J® [70% ß-TCP and 30% poly(L-lactide-co-glycolide)](ORTHOREBIRTH Co. Ltd., Kanagawa, Japan), a synthetic bioresorbable bone void filler for the repair of bony defects with handling characteristics similar to a cotton ball. Material resorption and new bone formation had already started one week postoperatively. Transposition to host bone trabeculae was almost completed by 26 days postoperatively. Very rapid reactive graft resorption, repair with new bone formation, and subsequently, most of the transformation to host bone trabeculae were confirmed. ReBOSSIS-J® appears feasible to contribute to early heel weight-bearing exercise after foot or ankle surgery. In addition, preventing the fracture at the harvesting site of the calcaneal bone graft can also be expected.

Impact of Preoperative Motor Status for the Positive Predictive Value of Transcranial Motor-Evoked Potentials Alerts in Thoracic Spine Surgery: A Prospective Multicenter Study by the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research.

STUDY DESIGN: Prospective multicenter study. OBJECTIVE: To investigate the validity of transcranial motor-evoked potentials (Tc-MEP) in thoracic spine surgery and evaluate the impact of specific factors associated with positive predictive value (PPV). METHODS: One thousand hundred and fifty-six cases of thoracic spine surgeries were examined by comparing patient backgrounds, disease type, preoperative motor status, and Tc-MEP alert timing. Tc-MEP alerts were defined as an amplitude decrease of more than 70% from the baseline waveform. Factors were compared according to preoperative motor status and the result of Tc-MEP alerts. Factors that showed significant differences were identified by univariate and multivariate analysis. RESULTS: Overall sensitivity was 91.9% and specificity was 88.4%. The PPV was significantly higher in the preoperative motor deficits group than in the preoperative no-motor deficits group for both high-risk (60.3% vs 38.3%) and non-high-risk surgery groups (35.1% vs 12.8%). In multivariate logistic analysis, the significant factors associated with true positive were surgical maneuvers related to ossification of the posterior longitudinal ligament (odds ratio = 11.88; 95% CI: 3.17-44.55), resection of intradural intramedullary spinal cord tumor (odds ratio = 8.83; 95% CI: 2.89-27), preoperative motor deficit (odds ratio = 3.46; 95% CI: 1.64-7.3) and resection of intradural extramedullary spinal cord tumor (odds ratio = 3.0; 95% CI: 1.16-7.8). The significant factor associated with false positive was non-attributable alerts (odds ratio = .28; 95% CI: .09-.85). CONCLUSION: Surgeons are strongly encouraged to use Tc-MEP in patients with preoperative motor deficits, regardless of whether they are undergoing high-risk spine surgery or not. Knowledge of PPV characteristics will greatly assist in effective Tc-MEP enforcement and minimize neurological complications with appropriate interventions.

Angioleiomyoma mimicking a swollen bursa on first metatarsophalangeal joint accompanying with hallux valgus deformity.

We present a case of a patient who underwent a modified scarf osteotomy and tumour excision based on a preoperative diagnosis of hallux valgus deformity and accompanying bursitis. Subsequent histopathological examination revealed that the tumour was an angioleiomyoma. While tumours around the first metatarsophalangeal (MTP) joint are typically associated with gouty nodules, infections, or swollen bursa (bursitis) in patients with hallux valgus deformity, the occurrence of soft tissue tumours in this area is rare. Moreover, angioleiomyoma is an even rarer form of soft tissue tumour and is seldom suspected prior to resection. To our knowledge, there have been no reports of angioleiomyoma arising in the first MTP joint. However, it is important to consider the possibility of an atypical tumour in cases where soft tissue masses are present, even in patients with hallux valgus deformity, and to perform at least imaging tests such as ultrasound and magnetic resonance imaging before surgery. This prospect should always be kept in mind.

The lower Osteotomy Level is Associated With Decreased Revision Surgery Due to Mechanical Complications After Three-Column Osteotomy in Patients With Adult Spinal Deformity: A Multi-Institutional Retrospective Study.

STUDY DESIGN: A multi-institutional retrospective study. OBJECTIVES: To investigate risk factors of mechanical failure in three-column osteotomy (3COs) in patients with adult spinal deformity (ASD), focusing on the osteotomy level. METHODS: We retrospectively reviewed 111 patients with ASD who underwent 3COs with at least 2 years of follow-up. Radiographic parameters, clinical data on early and late postoperative complications were collected. Surgical outcomes were compared between the low-level osteotomy group and the high-level osteotomy group: osteotomy level of L3 or lower group (LO group, n = 60) and osteotomy of L2 or higher group (HO group, n = 51). RESULTS: Of the 111 patients, 25 needed revision surgery for mechanical complication (mechanical failure). A lower t-score (odds ratio [OR] .39 P = .002) and being in the HO group (OR 4.54, P = .03) were independently associated with mechanical failure. In the analysis divided by the osteotomy level (LO and HO), no difference in early complications or neurological complications was found between the two groups. The rates of overall mechanical complications, rod failure, and mechanical failure were significantly higher in the HO group than in the LO group. After propensity score matching, mechanical complications and failures were still significantly more observed in the HO group than in the LO group (P = .01 and .029, respectively). CONCLUSIONS: A lower t-score and osteotomy of L2 or higher were associated with increased risks of mechanical failure. Lower osteotomy was associated with better correction of sagittal balance and a lower rate of mechanical complications.

Simultaneous Visualization of the Thoracic Duct and Blood Vessels Using MRI: A Comparison Between Balanced Turbo-field-echo and Spin-echo.

OBJECTIVE: Magnetic resonance thoracic ductography (MRTD), concomitant with blood vessel imaging, provides useful anatomical information. The purpose of this study was to assess the visibility of the thoracic duct and blood vessels simultaneously by MRTD using balanced turbo-field-echo (bTFE) and turbo spin-echo (TSE). METHODS: MRTDs concomitant with blood vessel imaging on bTFE and TSE were obtained for 10 healthy volunteers with a 1.5T-magnetic resonance unit. Visibility of the thoracic duct, blood vessels in the thoracic region; motion artifacts; and overall image quality were scored by two radiologists using three-to-five-point scales; those were compared between bTFE and TSE. RESULTS: The thoracic duct was generally well-visualized on MRTD sequences. The upper part of the thoracic duct was better visualized on TSE than on bTFE (p < 0.05). The blood vessels were well visualized on bTFE and TSE; the bilateral subclavian arteries and the right subclavian veins were better visualized on TSE than on bTFE (all p < 0.05). Motion artifacts and overall image quality were better on TSE than on bTFE (p = 0.0039 and 0.0020, respectively). CONCLUSION: MRTD concomitant with blood vessel imaging on TSE has better visibility of the thoracic duct and blood vessels than bTFE.

Computed diffusion-weighted imaging with a low-apparent diffusion coefficient-pixel cut-off technique for breast cancer detection.

OBJECTIVE: This study aimed to compare the image quality and diagnostic performance of computed diffusion-weighted imaging (DWI) with low-apparent diffusion coefficient (ADC)-pixel cut-off technique (cDWI cut-off) and actual measured DWI (mDWI). METHODS: Eighty-seven consecutive patients with malignant breast lesions and 72 with negative breast lesions who underwent breast MRI were retrospectively evaluated. Computed DWI with high b-values of 800, 1200, and 1500 s/mm2 and ADC cut-off thresholds of none, 0, 0.3, and 0.6 (×10-3 mm2/s) were generated from DWI with two b-values (0 and 800 s/mm2). To identify the optimal conditions, two radiologists evaluated the fat suppression and lesion reduction failure using a cut-off technique. The contrast between breast cancer and glandular tissue was evaluated using region of interest analysis. Three other board-certified radiologists independently assessed the optimised cDWI cut-off and mDWI data sets. Diagnostic performance was evaluated using receiver operating characteristic (ROC) analysis. RESULTS: When an ADC cut-off threshold of 0.3 or 0.6 (× 10-3 mm2/s) was applied, fat suppression improved significantly (p < .05). The contrast of the cDWI cut-off with a b-value of 1200 or 1500 s/mm2 was better than the mDWI (p < .01). The ROC area under the curve for breast cancer detection was 0.837 for the mDWI and 0.909 for the cDWI cut-off (p < .01). CONCLUSION: The cDWI cut-off provided better diagnostic performance than mDWI for breast cancer detection. ADVANCES IN KNOWLEDGE: Using the low-ADC-pixel cut-off technique, computed DWI can improve diagnostic performance by increasing contrast and eliminating un-suppressed fat signals.

Early Resection of the Tibialis Anterior Tendon for Tendon Exposure After Total Ankle Arthroplasty to Prevent Deep Infection: A Report of Three Cases in Patients With Rheumatoid Arthritis.

Exposure of the tibialis anterior (TA) tendon with wound dehiscence after total ankle arthroplasty (TAA) with the anterior approach is a problematic complication, especially in rheumatoid arthritis (RA) patients. Once the TA tendon is exposed, the duration of wound healing is prolonged, and it could be a risk factor for deep infection. Thus, early resection of the TA tendon was evaluated for tendon exposure with wound dehiscence after TAA in RA patients. In this case report, three rheumatoid ankles that showed wound dehiscence with exposure of the TA tendon after TAA with the anterior approach are presented. Early resection of the TA tendon and debridement under local anesthesia were performed within two days after wound dehiscence. In all cases, wound healing was completed within two weeks after the treatment. Drop foot was not seen in any patients, and there was no difference between the pre and postoperative (1 year after TAA) range of dorsiflexion. Muscle strength for ankle dorsiflexion was also maintained. In conclusion, early resection of the TA tendon appears to be a useful option for undesirable tendon exposure with wound dehiscence to prevent deep infection and prolonged wound healing after total ankle arthroplasty in RA patients.

Effect of vitamin D deficiency on surgical outcomes of degenerative cervical myelopathy.

Background: Due to its association with bone metabolic status and muscle strength/mass, vitamin D deficiency has the potential to affect neurological symptom recovery after surgery for degenerative cervical myelopathy (DCM). However, few studies have investigated the effects of vitamin D deficiency (serum 25(OH)D <20 ng/mL) on surgical outcomes in DCM patients. Herein, we investigated the prevalence of vitamin D deficiency in patients with DCM, and determined whether vitamin D deficiency affects surgical outcomes for DCM. Methods: In this retrospective observational study we assessed the recovery rate 1 year after surgery in 91 patients diagnosed with DCM who underwent surgery. First, we analyzed the correlation between vitamin D levels and various background factors. Then, patients were divided into 2 groups according to vitamin D sufficiency, and univariate analysis was performed on vitamin D and surgical outcomes. Finally, Spearman correlation analyses were performed to identify factors correlated with recovery rate after surgery for DCM. Results: The average Japanese Orthopedic Association score for the assessment of cervical myelopathy (C-JOA score) improved postoperatively. Age was positively correlated with vitamin D levels, and parathyroid hormone levels were negatively correlated with vitamin D levels. Among the 91 patients, 79.1% of patients were diagnosed with vitamin D deficiency. No significant differences in recovery rate were found between the vitamin D-deficient and vitamin D-sufficient groups. Finally, the Spearman correlation analysis showed a positive correlation between the preoperative C-JOA motor dysfunction score in the lower extremities and the recovery rate, while age demonstrated a negative correlation with recovery rate. Conclusions: No association was found between vitamin D deficiency and clinical outcomes after surgery for DCM. The results of this study do not support the need to normalize vitamin D levels for achieving neurological improvements in patients with DCM.

Early mobilization of dorsiflexion from 3 days after cemented total ankle arthroplasty with modified antero-lateral approach.

BACKGROUND: According to the conventional postoperative procedure after total ankle arthroplasty (TAA), mobilization is currently started after completion of wound healing. To investigate the possibility of expediting rehabilitation, this study evaluated the feasibility and safety of early mobilization of dorsiflexion after cemented TAA utilizing a modified antero-lateral approach. MATERIALS AND METHODS: This retrospective, observational study investigated 14 consecutive ankles that had received cemented TAA. Mobilization of dorsiflexion was started from 3 days after surgery. Postoperative wound complications including blister formation, eschar formation, wound dehiscence, peri-incisional decreased sensation were observed and recorded. Range of motion (ROM) of dorsiflexion/plantar flexion was measured. Patients also completed a self-administered foot evaluation questionnaire (SAFE-Q) and the scale of Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot score preoperatively and at final follow-up. RESULTS: No postoperative complications related to wound healing were observed. ROM for dorsiflexion, SAFE-Q score, and JSSF score improved significantly after TAA. CONCLUSION: Within this small number of cases, early mobilization of dorsiflexion from 3 days after cemented TAA was feasible and safe with the modified antero-lateral approach. Innovations in postoperative procedures for rehabilitation after TAA can be expected.