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1.  Comparison of the Thickness of Pulley and Flexor Tendon Between in Neutral and in Flexed Positions of Trigger Finger 
This study aims to compare the morphology of the A1 pulley and flexor tendons in idiopathic trigger finger of digits other than the thumb between in neutral position and in the position with the interphalangeal joints full flexed and with the metacarpophalangeal (MP) joint 0° extended (hook grip position).
A total of 48 affected digits and 48 contralateral normal digits from 48 patients who initially diagnosed with idiopathic trigger finger were studied sonographically. Sonographic analysis was focused on the A1 pulley and flexor tendons at the level of the MP joint in the transverse plane. We measured the anterior-posterior thickness of A1 pulley and the sum of the flexor digitorum superficialis and profundus tendons, and also measured the maximum radialulnar width of the flexor tendon in neutral and hook grip positions, respectively. Each measurement was compared between in neutral and in hook grip positions, and also between the affected and contralateral normal digits in each position.
In all the digits, the anterior-posterior thickness of flexor tendons significantly increased in hook grip position as compared with in neutral position, whereas radial-ulnar width significantly decreased. Both the A1 pulley and flexor tendons were thicker in the affected digits as compared with contralateral normal digits.
The thickness of flexor tendons was significantly increased anteroposteriorly in hook grip position as compared with in neutral position. In trigger finger, A1 pulley and flexor tendon were thickened, and mismatch between the volume of the flexor tendon sheath and the tendons, especially in anterior-posterior direction, might be a cause of repetitive triggering.
PMCID: PMC4814722  PMID: 27099639
A1 pulley; flexor tendon; hook grip; metacarpophalangeal joint; trigger finger; ultrasonography
2.  Preoperative Periarticular Knee Bone Mineral Density in Osteoarthritic Patients Undergoing TKA 
The Open Orthopaedics Journal  2016;10:396-403.
Preoperative periarticular bone quality is affected by joint loading. The purpose of this study was to determine the periarticular bone mineral density of the knee joint of patients undergoing total knee arthroplasty, and whether the location of the load-bearing axis correlates with the measured bone mineral density.
Materials and Methods:
The bone mineral densities of the medial and lateral femoral condyles and the medial and lateral tibial condyles were analyzed in consecutive 116 osteoarthritic patients (130 knees) by dual energy x-ray absorptiometry.
The median bone mineral density values in the condyles were 1.138 in femoral medial, 0.767 in femoral lateral, 1.056 in tibial medial, and 0.714 in tibial lateral. The medial condyles showed significantly higher bone mineral densities than the lateral condyles in both the femur and tibia. In addition, the femoral medial showed significantly higher bone mineral density levels than the tibial medial, and the femoral lateral condyle had higher bone mineral density levels than the tibial lateral. The bone mineral density Medial/Lateral ratio was significantly negatively correlated with the location (tibial medial edge 0%, lateral edge 100%) of the load-bearing axis in the femur and tibia.
Preoperative bone mineral density values may provide against the changes in bone mineral density after total knee arthroplasty by reflecting the correlation with joint loading axis. These results help explain why total knee arthroplasty has such good long-term clinical outcomes with a low frequency of component loosening and periarticular fractures despite a high degree of postoperative bone loss.
PMCID: PMC4995525  PMID: 27583058
Dual energy x-ray absorptiometry; Knee; Load-bearing axis; Osteoarthritis; Preoperative bone mineral density; Total knee arthroplasty
3.  Sonographic swelling of pronator quadratus muscle in patients with occult bone injury 
BMC Medical Imaging  2015;15:9.
The disarranged fat stripe of the pronator quadratus muscle (PQ) on radiographs (the PQ sign) is reported to be predictive of subtle bone fractures. This study aimed to report the results of magnetic resonance imaging (MRI) study in the patients in whom bone injury was not radiographically detected around the wrist joint, and the PQ was sonographically swollen following acute trauma.
We evaluated sonographically the PQ of 55 patients who showed normal radiographs following acute trauma. The sonographic appearance of the PQ was checked on both longitudinal and transverse images. On the longitudinal image, the probe was positioned along the flexor carpi radialis tendon. For the transverse image, we adopted the image of the same level in which the PQ of the unaffected hand showed maximal thickness. The PQ was considered to be swollen with disproportionate hyperechogenicity and/or thickening compared with the unaffected side at least in one of the two images. Of the 55 patients, 25 patients whose PQ was considered to be swollen underwent MRI study. PQ thickness in millimeters was retrospectively measured on longitudinal and transverse sonographic images.
Twenty-three patients (92.0%) had occult bone injury, and two adult patients (8.0%) showed only wrist joint effusion on MRI. Among these 23, the distal radius was the most frequent location of the occult bone injury (20 patients; 9 [36.0%] with an occult fracture line and 11 [44.0%] with bone bruising). In longitudinal image, the mean value of the PQ thickness of affected hands was 6.2 (3.7–9.6 mm; standard deviation [SD], 1.5) and that of unaffected hands was 4.5 (2.3–6.7 mm; SD, 1.2), respectively. In transverse image, that of dominant and nondominant hands was 7.6 (4.6–13.2 mm; SD, 2.0) and 5.5 (3.6–7.5 mm; SD, 1.1), respectively. The mean difference in PQ thickness between affected and unaffected hands was 1.7 (0.1–5.0 mm; SD, 1.1) in longitudinal image and 2.0 (0.3–6.8 mm; SD, 1.7) in transverse image.
Sonographic swelling of the PQ might be indicative of occult bone injury in patients with normal radiographs following acute trauma.
PMCID: PMC4374529  PMID: 25880205
Ultrasonography; Pronator quadratus; Occult bone injury; Wrist joint
4.  Retention of the posterior cruciate ligament does not affect femoral rotational alignment in TKA using a gap-balance technique 
Previous studies have evaluated the ability of the gap technique to achieve accurate rotational placement in both posterior cruciate ligament (PCL)-retaining and PCL-substituting total knee arthroplasty (TKA). The purpose of the present study was to determine (1) the accuracy of this technique in degrees and (2) whether retention of the PCL affects the rotational alignment of the femoral component relative to the transepicondylar axis during TKA. The hypothesis of this study was that retention of the PCL does not affect the femoral rotational alignment in TKA using a gap-balancing technique because both procedures are reported to have good long-term clinical outcomes.
The femoral rotation angle (FRA) relative to the transepicondylar axis was examined in 206 patients who underwent primary TKA using either PCL-retaining (104 knees) or PCL-substituting (102 knees) prostheses to determine the effect of PCL retention on FRA. Quantitative three-dimensional computed tomography was used to assess the FRA in both groups. All values are expressed as median (25th percentile, 75th percentile).
Postoperative FRA in the PCL-retaining group was −1.1° (−2.8°, 2.2°) and in the PCL-substituting group was −0.1° (−2.5°, 2.8°). The groups were not statistically different. One outlier was found in the PCL-retaining group, and none was found in the PCL-substituting group.
The gap technique reliably allows accurate rotational alignment of the femoral component during TKA despite the retention of the PCL.
Level of evidence
Therapeutic study, Level II.
PMCID: PMC4237913  PMID: 25119053
PCL retention; Femoral rotational alignment; TKA; Gap-balance technique
5.  Characteristics and significance of fever during 4 weeks after primary total knee arthroplasty 
Most previous studies on postoperative fever (POF; ≥38 °C) after total knee arthroplasty (TKA) have reported findings from only the immediate postoperative days (PODs). The hypothesis of the current study is that 4 weeks of follow-up may reveal differences in the characteristics of POF and fever-related factors between a normal inflammatory response and an early acute infection-related response.
A total of 400 consecutive TKAs (314 patients) were retrospectively investigated. Patients were stratified into those who developed an early acute periprosthetic infection that required subsequent surgical treatment (STG; n = 5 TKAs) and those who did not (non-STG; n = 395 TKAs).
Among the 400 knees, 149 (37 %) developed POF, with most reaching a maximum temperature (MT) on POD 0. In 13 TKA patients who had POF with a peak daily temperature ≥38 °C during postoperative weeks 2–4, the causes of POF were respiratory and urinary tract infections (n = 5 for each), superficial infection (n = 2), and periprosthetic infection (n = 1). The STG and non-STG differed significantly with regard to the rate of POF (p = 0.0205) and MT (p = 0.0003), including MTs less than 38 °C, during postoperative weeks 2–4. All five STG patients had elevated C-reactive protein levels and local symptomatic findings before the additional surgery.
The occurrence of POF and MT along with elevated C-reactive protein and local symptomatic findings at 2–4 weeks postoperatively may indicate the need for a positive fever workup to recognize early acute periprosthetic infection.
PMCID: PMC3990857  PMID: 24522863
Total knee arthroplasty; Postoperative fever; Maximum temperature; Periprosthetic infection
6.  Anteroposterior Translation Does Not Correlate With Knee Flexion After Total Knee Arthroplasty 
Stiffness after a TKA can cause patient dissatisfaction and diminished function, therefore it is important to characterize predictors of ROM after TKA. Studies of AP translation in conscious individuals disagree whether AP translation affects maximum knee flexion angle after implantation of a highly congruent sphere and trough geometry PCL-substituting prosthesis in a TKA.
We investigated whether AP translation correlated with maximum knee flexion angle (1) in patients who were awake, and (2) who were under anesthesia (to minimize the effects of voluntary muscle contraction) in a TKA with implantation of a PCL-substituting mobile-bearing prosthesis.
AP translation was examined under both conditions in 34 primary TKAs. Measurements under anesthesia were performed when the patients were having anesthesia for a contralateral TKA. Awake measurements were made within 4 days of that anesthetic session in patients who had no residual sedative effects. The average postoperative interval for the index TKA flexion measurements was 23 months (range, 6–114 months). AP translation was evaluated at 75° flexion using an arthrometer.
There was no correlation between postoperative maximum knee flexion and AP translation at 75° during consciousness. There was no correlation between postoperative maximum knee flexion and AP translation under anesthesia.
AP translation at 75° flexion did not correlate with postoperative maximum knee flexion in either awake or anesthetized patients during a TKA with implantation of a posterior cruciate-substituting prosthesis.
Level of Evidence
Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3890185  PMID: 24005980
7.  Posterior Condylar Offset Does Not Correlate With Knee Flexion After TKA 
Studies of medial and lateral femoral posterior condylar offset have disagreed on whether posterior condylar offset affects maximum knee flexion angle after TKA.
We asked whether posterior condylar offset was correlated with knee flexion angle 1 year after surgery in (1) a PCL-retaining meniscal-bearing TKA implant, or in (2) a PCL-substituting mobile-bearing TKA implant.
Knee flexion angle was examined preoperatively and 12 months postoperatively in 170 patients who underwent primary TKAs to clarify the effect of PCL-retaining (85 knees) and PCL-substituting (85 knees) prostheses on knee flexion angle. A quasirandomized design was used; patients were assigned to receive one or the other implant using chart numbers. A quantitative three-dimensional technique with CT was used to examine individual changes in medial and lateral posterior condylar offsets.
In PCL-retaining meniscal-bearing knees, there were no significant correlations between posterior condylar offset and knee flexion at 1 year. In these knees, the mean (± SD) postoperative differences in medial and lateral posterior condylar offsets were 0.0 ± 3.6 mm and 3.8 ± 3.6 mm, respectively. The postoperative change in maximum knee flexion angle was −5° ± 15°. In PCL-substituting rotating-platform knees, similarly, there were no significant correlations between posterior condylar offset and knee flexion 1 year after surgery. In these knees, the mean postoperative differences in medial and lateral posterior condylar offsets were −0.5 ± 3.3 mm and 3.3 ± 4.2 mm, respectively. The postoperative change in maximum knee flexion angle was −2° ± 18°.
Differences in individual posterior condylar offset with current PCL-retaining or PCL-substituting prostheses did not correlate with changes in knee flexion 1 year after TKA. We should recognize that correctly identifying which condyle affects the results of the TKA may be difficult with conventional radiographic techniques.
Level of Evidence
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3734430  PMID: 23609812
8.  Safety and efficacy of a new tourniquet system 
BMC Surgery  2012;12:17.
In upper limb surgery, the pneumatic tourniquet is an essential tool to provide a clean, bloodless surgical field, improving visualization of anatomical structures and preventing iatrogenic failure. Optimal inflation pressure to accomplish these objects without injuring normal tissue and inducing complications is not yet established. Use of the minimum tourniquet pressure necessary to produce a bloodless surgical field is preferable in order to prevent injury to normal tissue. Various methods have been implemented in an effort to lower effective cuff pressure. The purpose of this study is to report clinical experience with a new tourniquet system in which pressure is synchronized with systolic blood pressure (SBP) using a vital information monitor.
We routinely used the tourniquet system in 120 consecutive upper limb surgeries performed under general anaesthesia in our operating room instead of our clinic. Cuff pressure was automatically regulated to additional 100 mmHg based on the SBP and was renewed every 2.5 minutes intervals.
An excellent bloodless field was obtained in 119 cases, with the exception of one case of a 44-year-old woman who underwent internal screw fixation of metacarpal fracture. No complications, such as compartment syndrome, deep vein disorder, skin disorder, paresis, or nerve damage, occurred during or after surgery.
This new tourniquet system, synchronized with SBP, can be varied to correspond with sharp rises or drops in SBP to supply adequate pressure. The system reduces labor needed to deflate and re-inflate to achieve different pressures. It also seemed to contribute to the safety in upper limb surgery, in spite of rare unexpected oozing mid-surgery, by reducing tissue pressure.
PMCID: PMC3465201  PMID: 22894765
Tourniquet; Upper limb surgery; Systolic blood pressure; Autoregulation
9.  Clinical use of a new tourniquet system for foot and ankle surgery 
International Orthopaedics  2009;34(3):355-359.
This study reports the results of the clinical use of a new tourniquet system for surgery of foot and ankle that can determine tourniquet pressure in synchrony with systolic blood pressure (SBP). We prospectively applied additional pressure of 100 mmHg based on the SBP recorded before the skin incision in 100 consecutive procedures. There were 34 open reduction internal fixation procedures, 26 lateral colateral ligament repair or reconstruction, 16 Achilles tendon repairs, nine arthroscopic procedures such as removal of loose body or accessory bone and synovectomy, seven corrective osteotomy and eight others such as removal of tumour, ankle fusion, and bone graft. The average initial tourniquet pressure was 211 mmHg. The average maximum SBP change during surgery was 28 mmHg. All cases maintained an excellent operative field without measurable bleeding and there were no postoperative complications. Fifty-five cases had a lower intra-operative SBP than the initial value. Since a tourniquet should be applied at the lowest pressure possible for maintaining a bloodless surgical field, the new system appears to be practical and reasonable, as compared to conventional tourniquets, which maintain the initial pressure.
PMCID: PMC2899285  PMID: 19455329
10.  Preoperative laxity in osteoarthritis patients undergoing total knee arthroplasty 
International Orthopaedics  2007;33(1):105-109.
A preoperative quantitative evaluation of soft tissues is helpful for planning total knee arthroplasty, in addition to the conventional clinical examinations involved in moving the knee manually. We evaluated preoperative coronal laxity with osteoarthritis in patients undergoing total knee arthroplasty by applying a force of 150 N with an arthrometer. We examined a consecutive series of 120 knees in 102 patients. The median laxity was 0° in abduction and 8° in adduction. The femorotibial angle on non-weight-bearing standard anteroposterior radiographs was 180° and correlated with both abduction (r = −0.244, p = 0.007) and adduction (r = 0.205, p = 0.025) laxity. The results of a regression analysis suggested that the femorotibial angle is helpful for estimating both laxities. Considering the many reports on how to obtain well-balanced soft tissues, stress radiographs might help to improve the preoperative planning for gaining the optimal laxity deemed appropriate by surgeons.
PMCID: PMC2899222  PMID: 17938923

Results 1-10 (10)