Morphology of the Radial Attachment of the Radioulnar Ligament and Surrounding Landmarks.

PURPOSE: The triangular fibrocartilage complex (TFCC) is composed of dorsal and palmar radioulnar ligaments (RULs). A common injury pattern of the RUL is the avulsion of the ulnar insertion, which can be treated by arthroscopic or open repair. Although the general method of TFCC reconstruction is a tendon graft with a bone tunnel, detailed information regarding the radial attachment of the RUL is unclear. This study aimed to clarify the morphology of the radial attachments of the palmar radioulnar ligament (PRUL), dorsal radioulnar ligament (DRUL), and short radiolunate ligament (SRL) using three-dimensional imaging. METHODS: A total of 29 upper limbs (16 formalin-fixed and 13 embalmed by Thiel's embalming method) of Japanese cadavers were used. After gross observation, we marked the attachments of the PRUL, DRUL, and SRL using 0.7-mm diameter pins. We created three-dimensional images of the radius, outlining the PRUL, DRUL, and SRL attachments. The software application calculated the centers of the PRUL and DRUL attachments. RESULTS: The PRUL attachment was horizontally shaped. The center of the PRUL was 1.5 mm proximal and 5.8 mm radial to the tip of the palmar pyramid formed by the palmar cortex and the radioulnar and radiocarpal joint surfaces. The DRUL attachment was vertically shaped. The center of the DRUL was 2.0 mm proximal and 1.7 mm radial from the tip of the dorsal pyramid formed by the dorsal cortex and the radioulnar and radiocarpal joint surfaces. The length of the SRL was 9.2 mm. The SRL and PRUL were strongly conjoined. CONCLUSIONS: The anatomical center on the RUL attachment of the radius can be determined from osseous landmarks. CLINICAL RELEVANCE: The findings of this study contribute to the understanding of RUL attachment to the distal radius and may assist surgeons in performing anatomical reconstruction of TFCC.

The knee position at tourniquet inflation does not affect the gap balancing during total knee arthroplasty.

INTRODUCTION: The relationship between gap balancing and clinical outcome of total knee arthroplasty (TKA) has been researched. Tourniquet is widely used by most surgeons; however, there are little quantitative data about the gap depending on the tourniquet usage. We aimed to investigate whether the knee position at tourniquet inflation affected the gap measurement intra-operatively. METHODS: TKA was performed for 104 knees and the tourniquet was inflated with the knee at full flexion and extension. The gap was measured in each static knee flexion status (0°, 30°, 45°, 60°, 90°, 120°, and in full flexion) using a tensor. We measured the gap twice; under the tourniquet inflation and release. The gap difference at each static knee flexion status was calculated by subtracting the gap under release from that under inflation. RESULTS: When the tourniquet was inflated with the knee at full flexion, the mean gap differences were < 1 mm and < 1° in each static knee flexion status. When the tourniquet was inflated with the knee at full extension, the mean gap differences were < 1 mm and < 1°, respectively. All values of the gap difference were minimum, and were not affected by the tourniquet, whether the knee position at the tourniquet inflation was flexed or extended. CONCLUSIONS: We postulated that the knee position at tourniquet inflation would affect the gap, which was refuted by our results. This shows that we can measure the gap without considering the knee position at tourniquet inflation.

A tensor with a flat surface overestimates midflexion laxity in total knee arthroplasty: Comparison between a tensor with a flat-shaped surface and a tensor with an insert-shaped surface.

BACKGROUND: Soft tissue balance is important for the success of total knee arthroplasty (TKA). Various types of tensors have been developed for the precise measurement of a gap. We hypothesized that the surface shape of the tensor that contacted the TKA component affected the gap measurement. This study aimed to compare the gaps obtained with flat and insert-shaped surface tensors. METHODS: Two senior surgeons performed 95 TKAs (Vanguard-PS:55 knees; Persona-PS:40 knees). The joint gap was measured in each static knee flexion status (0°, 30°, 45°, 60°, 90°, 120°, and full flexion). We compared the gaps measured with a flat surface tensor and an insert-shape surface tensor. We defined a significant change as a gap difference of >1 mm with a statistical significance. RESULTS: In Vanguard-PS, significant changes were observed at 30° and 45°. In Persona-PS, significant changes were observed at 30°, 45°, and 60°. In both implants, gaps measured with the flat tensor were larger than those measured with the insert tensor at approximately midflexion, and the significant changes disappeared in higher flexion position over midflexion. CONCLUSIONS: The surface shape of the tensor affected the measurement of midflexion laxity in TKA. When measuring the gap with a flat tensor, the midflexion laxity was overestimated. A tensor with an insert-shaped surface should be used to measure the gap in TKA.

Accuracy of tibial component placement in unicompartmental knee arthroplasty performed using an accelerometer-based portable navigation system.

PURPOSE: There is a need for new devices to improve the accuracy of implantation in unicompartmental knee arthroplasties (UKAs). The accelerometer-based portable navigation system is expected to improve this accuracy. This study aimed to compare the accuracy of UKAs performed by the portable navigation system with that of the conventional method, and to investigate whether the portable navigation system can complement the surgeon's experience. METHODS: The study comprised of 80 Oxford UKAs. Knees were divided into two groups based on the method of tibial osteotomy: the conventional group (37 UKAs performed by an experienced surgeon using the extra-medullary guide) and the portable navigation group (43 UKAs performed by 2 unaccustomed surgeons using the navigation system). The absolute error from the target angle on the coronal and sagittal plane was measured on whole lower leg X-ray. The incidence of outliers (> 3°) was compared between the groups using Fisher's exact probability test. RESULTS: The incidences of outliers on the coronal plane were 41.0% (15 of 37 knees) in the conventional group and 9.3% (4 of 43 knees) in the portable navigation group (p < 0.0001). The incidences of outliers on the sagittal plane were 13.5% (5 of 37 knees) in the conventional group and 14.0% (6 of 43 knees) in the portable navigation group (p = 0.3772). CONCLUSION: This is the first report on the usefulness of an accelerometer-based portable navigation system in UKA. The use of this system improves the accuracy of implantation of the tibial component beyond the experience of the surgeon. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Intraoperative manipulation for flexion contracture during total knee arthroplasty.

BACKGROUND: Joint gap unbalancing during total knee arthroplasty (TKA) induces flexion contracture. Flexion contracture is one of the most serious complications of TKA. When flexion contracture is found during surgery, intraoperative manipulation is often empirically performed. We evaluated the effects of intraoperative manipulation on joint gap and postoperative flexion contracture. MATERIALS AND METHODS: TKA was performed for 136 knees. Intraoperative manipulation was performed for flexion contracture in 61 knees. Joint gap changes before and after manipulation were measured at six positions from extension to 120° of flexion. Manipulation was not performed for 75 knees. The extension angle was measured radiographically immediately after surgery, at 3 months, and 6 months postoperatively. Extension angles with manipulation and without manipulation were compared. RESULTS: Joint gap changes (mm) before and after manipulation were 0.1, 0.0, -0.2, -0.3, -0.1, and -0.3 at 0°, 30°, 45°, 60°, 90°, and 120° of flexion, respectively, indicating that manipulation could not change joint gaps significantly. Extension angles (°) with and without manipulation were -4.0 ± 4.6 and -3.8 ± 3.9 immediately after surgery, -5.3 ± 6.7 and -5.5 ± 6.2 at 3 months postoperatively, and -2.7 ± 6.0 and -3.8 ± 5.8 at 6 months postoperatively. No statistically significant difference existed between the values with or without manipulation during all periods. CONCLUSION: Intraoperative manipulation does not enlarge the gap or resolve postoperative flexion contracture. Developing the new surgical technique is required to achieve perfect balance at TKA.

Changes in postoperative extension angle after total knee arthroplasty: Effect of polyethylene insert thickness.

BACKGROUND: Flexion contracture is a serious complication after total knee arthroplasty (TKA). Polyethylene insert (PE) thicker than the extension gap during surgery causes flexion contracture. The purpose of this study was to identify the changes over time in postoperative extension angle and the correlation between extension gap and PE thickness. METHODS: Overall, 127 knees were analyzed to evaluate the changes in extension angle over time. "Gap difference" was defined as the distance obtained by subtracting the extension gap from the PE thickness. Patients were divided into four groups according to gap difference (0-3 or greater mm). We evaluated the correlation of gap difference and changes in postoperative extension angle over time. RESULTS: The extension angles of all knees were -4.2 ± 3.9 (deg. mean ± s.d.) at surgery, -5.9 ± 5.7 at 3 months, -3.4 ± 5.4 at 6 months, and -1.3 ± 5.4 at 2 years. Gap difference was negatively correlated with the extension angle at surgery and at 2 years (r = 0.40, r = 0.36). The extension angles at 2 years in each group (groups 0, 1, 2, 3 or greater) were 2.0°±4.7°, -0.8°±5.3°, -3.4°±5.3°, -4.0°±4.1° (p < 0.05), respectively. CONCLUSIONS: The extension angle became worse at 3 months compared to that at surgery (p = 0.01) and then improved until 2 years. The correlation between gap difference and extension angle was maintained at 2 years, and thicker PE caused flexion contracture even after 2 years. Hence, PE selection considering the extension gap is important.

Using Accelerometer-Based Portable Navigation to Perform Accurate Total Knee Arthroplasty Bone Resection in Asian Patients.

Implant alignment is an important factor affecting clinical results associated with total knee arthroplasty (TKA). No report exists showing the utility of an accelerometer-based portable navigation system among patients with marked femoral bowing. The aim of this study was to evaluate the accuracy of a portable navigation system for implant alignment in Asian patients with marked femoral bowing. The authors evaluated 142 consecutive TKAs performed for primary osteoarthritis since July 2013. A portable navigation system was used in 67 knees, and a conventional jig was used in 75 knees. The authors measured the mechanical axis and femoral/tibial component alignments on long-leg radiographs obtained 2 weeks after TKA. In addition, coronal bowing of the lower limb was evaluated. The results were analyzed in the general and marked femoral bowing subgroups. There were no significant differences between the 2 groups for demographic data. The rates of femoral component outliers in the coronal plane for the navigation system and conventional technique were 1.5% and 13.3% (P=.01), respectively. Marked femoral bowing was observed in 73 knees. In the subgroup of patients with marked femoral bowing, femoral coronal alignment and its outliers were more accurate in the navigation group (0%) than in the conventional group (16.2%) (P=.025). This is the first report to show the utility of an accelerometer-based portable navigation system for accurate prosthetic alignment among Asian patients with marked femoral bowing. The navigation system decreased outliers in coronal alignment of the femur, even in cases of marked femoral bowing, but did not increase complications. [Orthopedics. 2017; 40(3):e465-e472.].

The effect of tourniquets on patellofemoral joint congruity during total knee arthroplasty.

BACKGROUND: Incongruity of the patellofemoral joint after total knee arthroplasty (TKA) causes anterior knee pain. Intraoperative congruity tests are necessary to avoid unnecessary lateral retinacular release, and the usage of tourniquets may influence these results. The purpose of this study was to examine the effect of tourniquets on patellofemoral joint congruity during TKA. MATERIALS AND METHODS: Two hundreds and seventeen knees were examined after TKA. Skyline radiographs at 60° and 90° flexion were taken immediately after wound closure before and after tourniquet deflation to compare changes in patellar tilt angle. RESULTS: In the patellar tilt angle at 60° flexion, lateral tilt was observed in 18 knees. Tourniquet deflation changed the patellar tilt angle by a mean -0.7° ± 1.2° (p = 0.030). Medial tilt was observed in 10 knees. Tourniquet deflation changed the patellar tilt angle by 0.9° ± 0.7° (p = 0.004). Tourniquet deflation improved the degree of lateral and medial patellar tilt. In the patellar tilt angle at 90° flexion, lateral tilt was observed in 118 knees. Tourniquet deflation changed the patellar tilt angle by a mean -1.1° ± 1.2° (p < 0.001). Medial tilt was observed in 71 knees. Tourniquet deflation changed the patellar tilt angle by 0.5° ± 1.0° (p < 0.001). Tourniquet deflation improved the degree of lateral and medial patellar tilt. CONCLUSIONS: Tourniquet deflation improved patellofemoral congruity in a statistically significant way, but only to a small extent, indicating low clinical significance. Therefore, intraoperative congruity tests performed with tourniquets in place are reliable.

Identification of Cyclopropylacetyl-(R)-carnitine, a Unique Chemical Marker of the Fatally Toxic Mushroom Russula subnigricans.

A toxic mushroom, Russula subnigricans, causes fatal poisoning by mistaken ingestion. In spite of the potent bioactivity, the responsible toxin had not been identified for about 50 years since its first documentation. Recently, we isolated an unstable toxin and determined the structure. The slow elucidation was partly due to the instability of the toxin and also due to misidentification of R. subnigricans for similar mushrooms. To discriminate genuine Russula subnigricans from similar unidentified Russula species, we searched for a unique chemical marker contained in the mushroom. Cyclopropylacetyl-(R)-carnitine specific to R. subnigricans was identified as a novel compound whose (1)H-NMR signals appearing in the upfield region were easily recognizable among the complicated signals of the crude extract.

Osteoarthritis hip joints in Japan: involvement of acetabular dysplasia.

BACKGROUND: We conducted a nationwide epidemiologic study regarding hip osteoarthritis (OA) in Japan, and a previous report found these patients to be unique in comparison to Caucasians. This report focused on the data regarding each hip joint, and the involvement of acetabular dysplasia with hip OA was analyzed. METHODS: Seven hundred twenty OA hips were examined. Sixty-five joints with osteonecrosis of the femoral head and 215 non-OA contralateral joints of the unilateral patients were examined as controls. The revised system of stage classification for hip OA of the Japanese Orthopedic Association (JOA) was used according to the reproducibility in order to ensure reliable data from the multiple institutions. The acetabular dysplasia indexes were also chosen according to the reproducibility and measured in the radiograph of bilateral hip joints. The clinical score was assessed using the JOA scoring system. The relative risk of the grade of acetabular dysplasia indexes for hip OA was calculated as the odds ratio and the 95% confidence interval. RESULTS: The stage of the OA joints deteriorated with increasing age. The clinical scores also decreased. The grade of the acetabular dysplasia indexes of the OA joints was significantly higher than that of the control joints. Each index of acetabular dysplasia demonstrated significantly increased odds ratios for hip OA. Among the OA joints, the deterioration of the OA stage was found to be significantly associated with an increasing grade of acetabular dysplasia. The odds ratio for OA deterioration in the acetabular dysplasia index was also obtained. The joints of females tended to have a higher grade and prevalence of acetabular dysplasia than those of males. CONCLUSIONS: These findings confirmed a high prevalence of acetabular dysplasia in hip OA joints in Japan. Acetabular dysplasia was one of the most important factors associated with hip OA.

Elevation of the femur in THA through a direct anterior approach: cadaver and clinical studies.

BACKGROUND: The direct anterior approach in THA is an intermuscular approach that requires no muscle detachment. However, it is difficult to elevate the proximal femur for access to the femoral canal. QUESTIONS/PURPOSES: We asked (1) which part of the capsule should be released to allow effective elevation of the proximal femur; (2) whether the release of the internal obturator tendon allows elevation; and (3) whether hip hyperextension reduces the ability to elevate the femur. METHODS: We conducted a cadaver study and a clinical study. In the first study, the elevation of the proximal femur was measured in 6 hips in 3 cadavers after excision of the anterior capsule, after the release of the superior capsule or the posterior capsule, after the release of the superior and posterior capsule, and after the release of the internal obturator tendon under traction of 70 N. Each hip was positioned at 0°, 15°, and 25° hyperextension. In the second study of 39 patients, the posterior capsule was released after the superior capsule in the first 13 hips, and the superior capsule was released after the posterior capsule in the next 26 hips. The elevation achieved for each hip was measured as in the cadaver study. RESULTS: In our cadaver study, hip elevation increased after superior capsule release but not after release of the internal obturator tendon. After superior capsule release, the ability to elevate the femur was not diminished by hip hyperextension. In our clinical study, elevation increased after superior capsule release. CONCLUSIONS: Superior capsule release was most effective of all releases for elevating the proximal femur in the direct anterior approach.

Analysis of interobserver reliability for radiographic staging of coxarthrosis and indexes of acetabular dysplasia: a preliminary study.

BACKGROUND: We are planning a multicenter survey on coxarthrosis and acetabular dysplasia in Japan. To collect reliable data, we performed a preliminary study to elucidate the observer agreement on assessment items. METHODS: We collected radiographs of hip joints in eight patients with various findings of coxarthrosis. Twelve registered orthopedic specialists evaluated them regarding the roentgenographic stage of coxarthrosis and five indexes of acetabular dysplasia (acetabular angle, center-edge angle, acetabular roof obliquity, acetabular head quotient, approximate acetabular quotient). To assess observer agreement, we calculated the value of the kappa statistic for stages and the coefficient of variation for the indexes. The same 12 specialists then assessed the coxarthritis stage on the same radiographs 1 month after the first evaluation based on our own descriptions of the roentgenographic stages. RESULTS: For the first evaluation of the roentgenographic stage, the value of the kappa statistic was 0.448; and for the second evaluation it was 0.600. The results of the coefficient of variation for the indexes of acetabular dysplasia, ranked in ascending order, were as follows: acetabular angle, acetabular head quotient, acetabular roof obliquity, center-edge angle, approximate acetabular quotient. CONCLUSIONS: For the upcoming multicenter survey, clear descriptions of the stages of coxarthrosis and selection of appropriate indexes can be helpful for collecting dependable results.

Toxic isolectins from the mushroom Boletus venenatus.

Ingestion of the toxic mushroom Boletus venenatus causes a severe gastrointestinal syndrome, such as nausea, repetitive vomiting, diarrhea, and stomachache. A family of isolectins (B. venenatus lectins, BVLs) was isolated as the toxic principles from the mushroom by successive 80% ammonium sulfate-precipitation, Super Q anion-exchange chromatography, and TSK-gel G3000SW gel filtration. Although BVLs showed a single band on SDS-PAGE, they were further divided into eight isolectins (BVL-1 to -8) by BioAssist Q anion-exchange chromatography. All the isolectins showed lectin activity and had very similar molecular weights as detected by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS) analysis. Among them, BVL-1 and -3 were further characterized with their complete amino acid sequences of 99 amino acids determined and found to be identical to each other. In the hemagglutination inhibition assay, both proteins failed to bind to any mono- or oligo-saccharides tested and showed the same sugar-binding specificity to glycoproteins. Among the glycoproteins examined, asialo-fetuin was the strongest inhibitor. The sugar-binding specificity of each isolectin was also analyzed by using frontal affinity chromatography and surface plasmon resonance analysis, indicating that they recognized N-linked sugar chains, especially Galbeta1-->4GlcNAcbeta1-->4Manbeta1-->4GlcNAcbeta1-->4GlcNAc (Type II) residues in N-linked sugar chains. BVLs ingestion resulted in fatal toxicity in mice upon intraperitoneal administration and caused diarrhea upon oral administration in rats.

Identification of the toxic trigger in mushroom poisoning.

We have isolated the small, highly strained carboxylic acid cycloprop-2-ene carboxylic acid from the Asian toxic mushroom Russula subnigricans. This compound is responsible for fatal rhabdomyolysis, a new type of mushroom poisoning that is indicated by an increase in serum creatine phosphokinase activity in mice. We found that polymerization of the compound at high concentrations via ene reaction abolishes its toxicity.

Intra- and intersurgeon variability in image-free navigation system for THA.

In image-free navigation systems, cup orientation is determined in the pelvic coordinate by registration of bony landmarks. While the value of navigation relates primarily to the reliability and accuracy of cup placement, the reliability of registration plays a role in cup placement. We therefore examined intra- and intersurgeon variability in registration and the distance between registration points in each bony landmark. Thirty-seven THAs were performed in the lateral position and 15 THAs in the supine position. The cup was fixed using a navigation system. The registration was repeated two more times by operator and assistant, and the intra- and intersurgeon variability of cup abduction angle and anteversion was analyzed by ICC (intraclass correlation coefficients). In 25 hips, the distance between intrasurgeon registration points and between intersurgeon registration points in each landmark were calculated. The ICC in the lateral position ranged between 0.59 and 0.81, and between 0.85 and 0.95 in the supine position. The ICCs of cup abduction angle for the intra- and intersurgeon variability were 0.92 and 0.95 for the supine position and 0.65 and 0.59 for the lateral position. Those of anteversion were 0.93, 0.85, and 0.81, 0.72, respectively. The variability in locating the ASIS in the lateral position was greater than that in the supine position. The variability of registration points depended on bony landmarks and patient position but the range of variability we found would not likely result in a large variability in cup placement.

Factors influencing the stability of stems fixed with impaction graft in vitro.

Mechanical stability of the stem is believed to be an important factor in successful impaction grafting in revision THA. We asked whether particle size, femoral bone deficiencies, stem design, graft composition, and impaction technique influenced the initial stability of the stem in vitro using model femora and human bone particles. Bone particles made with a reciprocating blade-type bone mill contained larger particles with a broader size distribution than those made by a rotating drum-type bone mill and had higher stiffness on compression testing. The stiffness on torsional testing decreased as the degree of proximal-medial segmental deficiencies increased. The stiffness and maximum torque in a stem with a rectangular cross section and wide anteroposterior surface were higher in torsional tests. Adding hydroxyapatite granules to the bone particles increased the torsional stability. To facilitate compact bone particles, we developed a spacer between the guidewire and modified femoral packers. This spacer facilitated compacting bone particles from the middle up to the proximal and the technique increased the amount of impacted bone particles at the middle of the stem and also improved the initial stability of the stem. Stem design and degree of deficiencies influenced stiffness in the torsional test and the addition of hydroxyapatite granules enhanced torsional stiffness.

Status of navigated total hip arthroplasty in dysplastic osteoarthritis.

This article describes the results of 41 total hip arthroplasties (THAs) carried out using a new image-free hip navigation system. For the study, registration landmarks (tear drop, posterior rim, and inner wall of the acetabulum) were added to the hip navigation system OrthoPilot (B. Braun Aesculap, Tuttlingen, Germany). The reamer center was indicated in reference to these landmarks, and final cup angle was indicated as the radiologic angle. Forty-one total THAs to treat dysplastic osteoarthritis of the hip were performed. The difference between reamer center and cup center was 4.1 +/- 3.0 mm. The difference in cup abduction angle between navigation and radiography was 6.4 degrees +/- 5.1 degrees and of anteversion was 5.9 degrees +/- 5.0 degrees. Our preliminary clinical results showed adequate accuracy.

Bolevenine, a toxic protein from the Japanese toadstool Boletus venenatus.

A toxic protein, called bolevenine, was isolated from the toxic mushroom Boletus venenatus based on its lethal effects on mice. On SDS-PAGE, in either the presence or absence of 2-mercaptoethanol, this protein showed a single band of approximately 12 kDa. In contrast, based on gel filtration and MALDI-TOFMS, its relative molecular mass was estimated to be approximately 30 kDa and approximately 33 kDa, respectively, indicating that the protein consists of three identical subunits. This toxin exhibited its lethal activity following injection at 10mg/kg into mice. The N-terminal amino acid sequence was determined up to 18, and found to be similar to the previously reported bolesatine, a toxic compound isolated from Boletus satanas.