Atraumatic Spontaneous Achilles Tendon Rupture in Patients Receiving Oral Corticosteroids Treated With the Modified Side-Locking Loop Suture Technique.

Atraumatic spontaneous Achilles tendon ruptures sometimes occur in patients receiving oral corticosteroids. In general, these cases are treated surgically; however, delayed postoperative management can lead to impaired activities of daily living. The modified side-locking loop suture (SLLS) technique is a useful suture method for safe and early active mobilization. Three cases of spontaneous Achilles tendon ruptures were treated with the modified SLLS technique with good clinical results. The modified SLLS technique is a useful method with a short rehabilitation period for treating atraumatic spontaneous Achilles tendon rupture in patients undergoing corticosteroid therapy.

Brain Activity Changes in Somatosensory and Emotion-Related Areas With Medial Patellofemoral Ligament Deficiency.

BACKGROUND: Patellar instability with medial patellofemoral ligament (MPFL) deficiency is a common sports injury among young people. Although nonoperative and surgical treatment can provide stability of the patella, patients often have anxiety related to the knee. We speculate that neural dysfunction may be related to anxiety in these patients; however, the mechanism in the brain that generates this anxiety remains unknown. QUESTIONS/PURPOSES: (1) How does brain activity in patients with MPFL deficiency change in the areas related to somatic sensation against lateral shift of the patella? (2) How does patella instability, which can lead to continuous fear or apprehension for dislocation, influence brain activity in the areas related to emotion? METHODS: Nineteen patients with MPFL deficiency underwent surgical reconstruction in our hospital from April 2012 to March 2014. Excluding seven patients with osteochondral lesions, 12 patients (five males and seven females; mean age, 20 years) with MPFL deficiency were sequentially included in this study. Eleven control subjects (four males and seven females; mean age, 23 years) were recruited from medical students who had no history of knee injury. Diagnosis of the MPFL deficiency was made with MR images, which confirmed the rupture, and by proving the instability with a custom-made biomechanical device. Brain activity during passive lateral stress to the patella was assessed by functional MRI. Functional and anatomic images were analyzed using statistical parametric mapping. Differences in functional MRI outcome measures from the detected activated brain regions between the patients with MPFL deficiency and controls were assessed using t tests. RESULTS: Intergroup analysis showed less activity in several sensorimotor cortical areas, including the contralateral primary somatosensory areas (% signal change for MPFL group 0.49% versus 1.1% for the control group; p < 0.001), thalamus (0.2% versus 0.41% for the MPFL versus control, respectively; p < 0.001), ipsilateral thalamus (0.02% versus 0.27% for the MPFL versus control, respectively; p < 0.001), and ipsilateral cerebellum (0.82% versus 1.25% for the MPFL versus control, respectively; p < 0.001) in the MPFL deficiency group than in the control group. In contrast, the MPFL deficiency group showed more activity in several areas, including the contralateral primary motor area (1.06% versus 0.6% for the MPFL versus control, respectively; p < 0.001), supplementary motor area (0.89% versus 0.52% for the MPFL versus control, respectively; p < 0.001), prefrontal cortex (1.09% versus 1.09% for the MPFL versus control, respectively; p < 0.001), inferior parietal lobule (0.89% versus 0.62% for the MPFL versus control, respectively; p < 0.001), anterior cingulate cortex (0.84% versus 0.08% for the MPFL versus control, respectively; p < 0.001), visual cortex (0.86% versus 0.14% for the MPFL versus control, respectively; p < 0.001), vermis (1.18% versus 0.37% for the MPFL versus control, respectively; p < 0.001), and ipsilateral prefrontal cortex (1.1% versus 0.75% for the MPFL versus control, respectively; p < 0.001) than did the control group. CONCLUSIONS: Less activity in the contralateral somatosensory cortical areas suggested that MPFL deficiency may lead to diminished somatic sensation against lateral shift of the patella. In contrast, increased activity in the anterior cingulate cortex, prefrontal cortex, and inferior parietal lobule may indicate anxiety or fear resulting from patellar instability, which is recognized as an aversion similar to that toward chronic pain. CLINICAL RELEVANCE: This study suggests that specific brain-area activity is increased in patients with MPFL deficiency relative to that in controls. Further longitudinal research to assess brain activity and proprioception between patients pre- and postreconstructive knee surgery may reveal more regarding how patella instability is related to brain function. We hope that based on such research, a neural approach to improve patella-instability-related brain function can be developed.

A genome-wide association study identifies a locus associated with knee extension strength in older Japanese individuals.

Sarcopenia is a common skeletal muscle disease in older people. Lower limb muscle strength is a good predictive value for sarcopenia; however, little is known about its genetic components. Here, we conducted a genome-wide association study (GWAS) for knee extension strength in a total of 3452 Japanese aged 60 years or older from two independent cohorts. We identified a significant locus, rs10749438 which is an intronic variant in TACC2 (transforming acidic coiled-coil-containing 2) (P = 4.2 × 10-8). TACC2, encoding a cytoskeleton-related protein, is highly expressed in skeletal muscle, and is reported as a target of myotonic dystrophy 1-associated splicing alterations. These suggest that changes in TACC2 expression are associated with variations in muscle strength in older people. The association was consistently observed in young and middle-aged subjects. Our findings would shed light on genetic components of lower limb muscle strength and indicate TACC2 as a potential therapeutic target for sarcopenia.

A "sandwich" method of reconstruction of the medial patellofemoral ligament using a titanium interference screw for patellar instability in skeletally immature patients.

BACKGROUND: No standard surgical procedure for medial patellofemoral ligament (MPFL) reconstruction exists in skeletally immature patients with patellar instability. This study aimed to evaluate the clinical effectiveness of a novel reconstruction technique for the MPFL in patients with patellar instability because of non-closure of the epiphyseal line. METHODS: The "sandwich" method was fixation of the patella between a double-stranded semitendinosus tendon through the posterior third of the femoral insertion of the medial collateral ligament (MCL) as a pulley with a titanium interference screw in a single patellar tunnel. Five knees in five patients were studied: four with recurrent and one with habitual patellar dislocations. Subjects underwent MPFL reconstruction with or without lateral release. Patients were evaluated using pre-operative and post-operative physical and radiographic examinations, including apprehension testing, assessment of tilting and congruence angles, medial and lateral shift ratios under stress measured using X-ray imaging, and Kujala and Lysholm scores. RESULTS: No patient experienced recurrent post-operative episodes of dislocation or subluxation. By the final follow-up, patellar apprehension had disappeared in all patients. In addition, all patients showed significant improvement in the following: tilting angle, congruence angle, lateral shift ratio, Kujala score, and Lysholm score. CONCLUSIONS: The MPFL reconstruction methods, using a double-stranded semitendinosus autograft and sparing the femoral physeal line in non-closure of the epiphyseal line, provide acceptable short-term results for the treatment of patellar instability.

Sporadically occurred bilateral osteochondritis dissecans on the trochlea of the femur: case report.

We report the case of a 13-year-old boy with bilateral osteochondritis dissecans in the lateral femoral trochlea of the knees. They were classified as grade 4 in the right knee and grade 1 in the left knee on the basis of the Nelson classification within 1 year after first consultation. In the right knee, the fragment was surgically fixed, but the left knee healed with conservative treatment. This case indicates the possibility that osteochondritis dissecans of the lateral femoral trochlea may develop bilaterally at different times and present at different stages. The case shows the importance of early diagnosis and appropriate treatment on the basis of the stage.

Dose-response relationship between sports activity and musculoskeletal pain in adolescents.

Physical activity has multiple health benefits but may also increase the risk of developing musculoskeletal pain (MSP). However, the relationship between physical activity and MSP has not been well characterized. This study examined the dose-response relationship between sports activity and MSP among adolescents. Two school-based serial surveys were conducted 1 year apart in adolescents aged 12 to 18 years in Unnan, Japan. Self-administered questionnaires were completed by 2403 students. Associations between time spent in organized sports activity and MSP were analyzed cross-sectionally (n = 2403) and longitudinally (n = 374, students free of pain and in seventh or 10th grade at baseline) with repeated-measures Poisson regression and restricted cubic splines, with adjustment for potential confounders. The prevalence of overall pain, defined as having pain recently at least several times a week in at least one part of the body, was 27.4%. In the cross-sectional analysis, sports activity was significantly associated with pain prevalence. Each additional 1 h/wk of sports activity was associated with a 3% higher probability of having pain (prevalence ratio = 1.03, 95% confidence interval = 1.02-1.04). Similar trends were found across causes (traumatic and nontraumatic pain) and anatomic locations (upper limbs, lower back, and lower limbs). In longitudinal analysis, the risk ratio for developing pain at 1-year follow-up per 1 h/wk increase in baseline sports activity was 1.03 (95% confidence interval = 1.02-1.05). Spline models indicated a linear association (P < 0.001) but not a nonlinear association (P ≥ 0.45). The more the adolescents played sports, the more likely they were to have and develop pain.

Clinical outcomes of revision meniscal repair: a case series.

BACKGROUND: Meniscal preservation results in better clinical outcomes than meniscectomy; however, no studies have evaluated the results of revision meniscal repair. HYPOTHESIS: Revision meniscal repair can achieve good clinical outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study participants were 16 patients with symptomatic meniscal retears of a total of 96 patients who underwent primary arthroscopic meniscal repair. Fifteen of these 16 patients underwent revision meniscal repair. The mean age at revision was 27 years, and the mean duration between the primary operation and revision was 27 months. Eight patients had degenerative changes of the meniscus at revision. Clinical outcomes were assessed using the Lysholm score and the Tegner sports activity score, and image assessment was performed using magnetic resonance imaging. RESULTS: Five patients had re-retears of a resutured meniscus, and the mean duration between revision and the re-retear was 25 months (range, 8-68 months). The mean follow-up of patients without re-retears was 41 months (range, 24-74 months), and the mean Lysholm score in those without re-retears significantly improved from 81.4 points (range, 73-89 points) at pre-revision to 97.4 points (range, 90-100 points) at the final survey (P = .0001). Degenerative changes of the meniscus at the revision site were observed in all 5 patients with re-retears but in only 3 of the 10 patients without re-retears. CONCLUSION: Revision meniscal repair should be considered in the setting of a retorn meniscus without degenerative changes.

A comparison of patient-reported outcomes and arthroscopic findings between drilling and autologous osteochondral grafting for the treatment of articular cartilage defects combined with anterior cruciate ligament injury.

BACKGROUND: To compare the patient-reported outcomes and arthroscopic findings between drilling and autologous osteochondral grafting (AOG) for the treatment of articular cartilage defects combined with anterior cruciate ligament (ACL) injuries. METHODS: The subjects were 40 patients who had articular cartilage defects in the weight-bearing part of the medial and lateral femur condyle combined with ACL injuries that were treated by drilling (20 patients) or AOG (20 patients) at the same time as ACL reconstruction was performed. In the drilling group patients, lesions were penetrated with multiple 1.2-mm Kirschner wires, and in the AOG group patients, grafts were made to cartilage defects from one to three osteochondral pegs harvested from the less-weight-bearing periphery of the articular surface of the femoral condyle. The patient-reported outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective knee examination score. Second-look arthroscopy was performed to evaluate the repaired cartilage macroscopically. RESULTS: The median follow-up duration was 25 (range, 12-42) months. The IKDC scores were significantly improved from 64.4 to 95.4 points in the drilling group and from 52.3 to 94.3 points in the AOG group, with no difference between the two groups, although there was a difference in the repaired cartilage findings of arthroscopy. CONCLUSION: In this study, no differences in IKDC scores were found in patients with a concomitant ACL rupture and an osteochondral lesion treated by drilling or AOG at a minimum follow-up of 1year, regardless of the differences at arthroscopic grading of the ICRS classification. LEVEL OF EVIDENCE: Case-control study (LEVEL III).

Late malignant transformation of giant cell tumor of bone 41 years after primary surgery.

Giant cell tumor of bone is an uncommon benign tumor that frequently recurs locally. Spontaneous malignant transformation of conventional giant cell tumor of bone is rare and usually occurs with irradiation.This article describes a case of malignant transformation of a giant cell tumor 41 years after initial curettage and subsequent resection. A 68-year-old man presented with a 6-month history of left hip pain. He had been diagnosed 41 years previously with giant cell tumor in the left femoral neck treated by simple curettage and bone grafting, followed by resection of the femoral head 1 year later for local recurrence. On presentation, radiographs revealed a destructive lesion in the left proximal femur. Incisional biopsy revealed recurrence of giant cell tumor with suspected malignant transformation. The patient underwent en bloc resection of the proximal femur with adequately wide margins and reconstruction of the hip joint with a prosthesis. Pathological findings showed malignant transformation of a giant cell tumor to osteosarcoma and leiomyosarcoma. No recurrence or metastasis developed during 2-year follow-up. Benign local recurrences usually arise in the first 3 postoperative years, whereas malignant transformation tends to take longer than 3 years. To the authors' knowledge, the 41-year interval from primary surgery to diagnosis of malignancy for the current patient is the longest interval reported among cases in which patients received no radiation therapy.

Mortality in patients with hip fracture aged over 90 years: a report from a progressively aging island.

INTRODUCTION: In our aging society, hip fractures are common in elderly patients, especially those aged above 90 years. Improving mortality rates after this injury is an important part of medical management for the elderly. This study assessed mortality rates after hip fracture in patients aged ≥90 years and examined factors that contribute to mortality. METHOD: Between April 2003 and March 2009, 186 patients aged ≥65 years were studied. Of these, 50 patients were aged ≥90 years. Walking ability before injury and at discharge, preoperative physical status, number of comorbidities, postoperative survival, sex, fracture type, and patients' residential status were investigated. RESULTS: One-year mortality was higher in patients aged ≥90 years (24%) than in younger patients (10%) (p=0.01). Moreover, older patients were less likely to retain walking ability at discharge, and poor postoperative ambulatory levels were associated with increased mortality. Preoperative physical status according to the grading system of the American Society of Anesthesiologists (ASA) did not differ between the two age groups. Poor ASA grade was associated with mortality in the entire population, but this association was not significant in the older group. Although older patients had a higher number of trochanteric fractures, fracture type and mortality did not significantly correlate with age. CONCLUSION: Acceptable outcomes of hip fracture surgery can be achieved in very old patients. In addition, postoperative ambulatory level may be a predictor of mortality.

Sequential multiple insufficiency fractures around knee over 6 months in a patient with primary osteoporosis.

In this report, we describe a case of multiple insufficiency fractures occurring over 6 months in the bilateral knees of an individual with primary osteoporosis. An 87-year-old woman complained of spontaneous pain in her right knee. A plain X-ray did not show any lesions at the time; however, 2 weeks later, a slightly displaced supracondylar fracture was observed. The fracture was treated with a long leg cast for 6 weeks. The patient was able to walk with a walker 12 weeks after the injury, but her right thigh muscles had atrophied. Four months after the first injury, she suffered left knee pain. Magnetic resonance imaging (MRI) showed an undisplaced supracondylar fracture of the left femur. After undergoing the same treatment as for the previous fracture for 8 weeks, she complained of pain in the proximal tibia, and a fracture in the lateral tibial plateau was observed by MRI. No malignancy or endocrine disorders were found by imaging or laboratory studies. Her bone mineral density was found to be low, and she was diagnosed with multiple insufficiency fractures due to primary osteoporosis. The work overload on the healthy side induced by muscle weakness on the affected side may have caused the subsequent insufficiency fractures on the healthy side. These findings suggest that one should pay attention to and treat lower limb muscle atrophy when managing insufficiency fractures of the lower limbs.

A case of symptomatic tumoral calcinosis on the great toe and review of the literature.

A 67-year-old woman with no specific medical history showed a hard mass on her great toe for several years. The lesion was elastic, round, and had good mobility. An X-ray showed the lesion to be a calcified "chicken wire" lesion; CT and MRI findings indicated it as a benign subcutaneous calcified tumor. Therefore, a resection biopsy was performed. The mass was a 20 x 20 mm calcified tumor diagnosed as tumoral calcinosis. Pathological findings showed that the calcified lesion lay in fibrous connective tissue and characteristic cells were seen around the calcification site. In this case, the lesion was mature and surgical resection was successful. The patient showed no symptoms or recurrence 3 years after the surgery.