Introduction: Numerous studies have reported that refractory lateral epicondylitis of the humerus is an intra-articular lesion. In this study, we investigated the pathology of refractory cases based on the operative findings.

Methods: A modified Nirschl procedure was performed in 23 elbows of 21 patients with refractory lateral epicondylitis of the humerus that had proven resistant to conservative treatment for at least 6 months, and the pathology of the refractory cases and the clinical results were examined based on the operative findings.

Results: All the elbows had abnormalities at the origin of the extensor carpi radialis brevis (ECRB) tendon, and the tendon was ruptured or showed a partial defect in 8 (35%) elbows. On the other hand, the intra-articular findings included only abnormalities in the synovial folds in 1 elbow, abnormalities in the articular cartilage in 2 elbows, and tension of the annular ligament in 8 elbows, none of which was likely to be involved in the pathology of the lateral epicondylitis. In regard to the clinical results, the mean Japanese Orthopaedic Association-Japan Elbow Society (JOA-JES) score improved markedly from 24.8 before surgery to 95.8 after surgery, and the postoperative outcome of the elbow was graded as “excellent” in 78% of cases according to Nirschl's grading system, indicating that excellent results can be obtained by the modified Nirschl procedure.

Discussion: Lateral epicondylitis of the humerus, which is considered to be the cause of the lateral elbow pain syndrome, has been classified into the following two types of lesions: extra-articular lesions of the ECRB tendon, and intra-articular lesions, such as lesions of the synovial folds and annular ligament.

Conclusion: Our findings, based on the operative findings, revealed that the pathology in most refractory cases of lateral epicondylitis of the humerus is an extra-articular lesion of the ECRB tendon at its origin.

Objectives: Observation of the dynamics of the shoulder joint inside the scapulohumeral joint capsule during shoulder elevation by ultrasonography.

Subjects and Methods: The study was conducted in 20 healthy adults (10 men and 10 women) aged 32.3 ± 5.6 years old. During maximum external rotation of the shoulder joint, the scapular plane was passively elevated, and ultrasound images of the glenoid cavity rim and humeral head were obtained, accompanied by measurement of the angle of elevation at which the spherical part of the humeral head could be confirmed. In addition, the angle of elevation was changed to 100, 120 and 140 degrees and the distance from the glenoid cavity rim to the bone head surface was normalized to the height, to obtain the glenoid cavity rim-humeral head distance (hereinafter simply called “the distance” in the text). Differences in “the distance” depending on the angle of elevation were analyzed.

Results: The spherical part of the humeral head was confirmed at an elevation angle of 73.8 ± 4.1 degrees. “The distance” increased significantly as the angle of elevation increased (p < 0.01).

Discussion: During shoulder elevation, the humeral head rotates within the joint capsule, becoming directed downwards as a result. This movement, combined with the large radius of curvature of the humeral head, probably resulted in the increase of “the distance” as the angle of shoulder elevation increased.

Conclusions: Using measurement of “the distance” at varying angles of elevation of the shoulder as an indicator, we observed the dynamics inside the shoulder joint capsule.

Background and Objective: A campaign to spread sports rhythm training at all public elementary schools in Yokohama City was undertaken, and the effects of this training in improving the exercise capabilities of the school children and preventing injury during physical exercises were evaluated. Methods: A brochure and DVD explaining the exercise program were prepared and distributed, and the instructors, qualified by the Yokohama Sports Association, visited the desiring elementary schools to provide guidance. Thereafter, interviews were conducted at each elementary school and a questionnaire survey was conducted at the schools who participated in the program. Results: The program was provided on 591 occasions in total, involving a total of approximately 65,000 participants. The program was known to 81% of all schools in the area and 36% of all the schools continued implementing the program. One of the major reasons given for inability to continue implementing the program was “have no chance for implementation.” When asked about the impressions of teachers, 84% opined that the program was “effective for improving the physical strength of the children,” and said that the school nurse office visit rate had decreased markedly at schools which continued implementing the program for 6 months or longer. Discussion: It would seem desirable to continue with the instructor visits to elementary schools and the investigation, accompanied by verification of the evidence of effectiveness of this program. Conclusions: Sports rhythm training seems to be a valid method for improving the exercise capabilities of children and preventing injuries during physical exercises.

OBJECTIVES: We introduce a newly developed patient-reported outcome (PRO) index for chronic low back pain, named modified Health Assessment Questionnaire for Chronic Low Back Pain (mHAQ-CLBP).

METHODS: The mHAQ-CLBP represents mainly a modification of the Health Assessment Questionnaire and consists of eight questions regarding activities of daily living (ADL): (1) dressing and grooming (2) arising from bed (3) eating (4) walking (5) personal hygiene (6) reach (7) grip, and (8) common daily activities. In addition, there are five more questions regarding instrumental ADL (IADL), namely (9) cooking (10) cleaning (11) washing (12) hobbies, and (13) night pain. The response to each question was scored by the subject on a graded scale of 0 (possible, with no difficulty) to 3 (impossible), and the average score was calculated and adopted as the mHAQ-CLBP score.

 Patients with chronic low back pain were assessed by the mHAQ-CLBP, and simultaneously by the visual analog scale for pain (PS-VAS) and the EuroQOL 5-dimensions (EQ-5D), at the baseline and at more than three months after the baseline. The correlations among these indices were statistically evaluated by multivariate linear regression analysis.

RESULTS: A total of 101 patients who could be followed up for more than three months were recruited for this study. The mHAQ-CLBP score was 0.851 at the baseline and improved to 0.742 at the end of the observation period, although the change was not statistically significant. The mHAQ-CLBP score was correlated significantly with the score on the PS-VAS and the EQ-5D, within an error margin of 0.1%.

DISCUSSION: Our results suggest that the score on the mHAQ-CLBP well reflects the severity of low back pain, and is correlated with the quality of life.

CONCLUSIONS: mHAQ-CLBP is a convenient and appropriate PRO index for objective evaluation of the ADL, IADL, and quality of life in patients with chronic low back pain.

Purpose: Although cementless implant components are commonly used in total knee arthroplasty (TKA), cemented implant fixation is required in osteoporotic patients. We examined the use of x-ray quantitative computed tomography (QCT) to assess the bone mineral density (BMD) of the proximal tibia to determine the optimal type of fixation for TKA in individual patients.

Materials and Methods: In patients undergoing TKA between June 2017 and September 2018, QCT of the proximal tibia and BMD measurement of the spine and proximal femur were performed. Cementless fixation was performed in 110 knees and cemented fixation was performed in 15 knees of the patients.

Results: The mean CT value of the proximal tibia was 75.5. The CT value showed correlations with BMD of the spine and proximal femur, with correlation coefficients of 0.61 and 0.69, respectively. The mean CT value of the proximal tibia was 80.5 in patients with cementless fixation and 39.4 in those with cemented fixation.

Discussion: The CT value of the proximal tibia correlated with the BMD of the proximal femur.

Conclusion: QCT is a suitable method to evaluate local BMD in the proximal tibia and to determine a good implant fixation method.

Purpose: The purpose of this study was to evaluate the usefulness of Nordic poles (NP) as a walking aid.

Method: Subjects were divided into two groups based on their usage of NPs: a group that used NPs only during exercise and a group that used NPs for daily walking, and their walking abilities were compared during walking without (independent walking) and with (Nordic walking, NW) the aid of NPs.

Result: The group using NPs for daily walking walked faster during NW than during independent walking.

Discussion: Use of NPs is expected to improve the walking ability of patients with reduced walking ability.

Conclusion: The findings of the study suggest that NP could be one of the useful walking aids.

Exercise guidance was provided at medical institutions to elementary and junior high school students who were unable to squat with closed legs. The exercise guidance provided according to an exercise prescription eventually enabled half of the students, regardless of sex and age, to squat with closed legs. Students who became able to squat were found at each of the three steps (Steps 1 to 3) of the exercise program. Provision of exercise guidance is effective to enable students to acquire the ability to squat with closed legs.

Objective: We encountered 5 cases of stress fractures of the first rib.

Patients and Methods: All patients were male, and the mean age was 15.4 years. The mean time to hospital visit after onset was 13.4 days. Diagnosis was made by plain radiography and computed tomography (CT) imaging.

Results: The patients received conservative therapy with low-intensity pulsed ultrasound and returned to play after an average of 6.9 weeks of treatment.

Discussion: It is considered important for clinicians to bear in mind the possibility of stress fractures when treating patients presenting with scapular and back pain.

Conclusion: We have reported the clinical courses of patients with stress fractures until they resumed their sports activities.

In 29 patients with the mean age 79.4 ± 3.1 years, in whom effect of intra-articular injections of hyaluronic acid (hereinafter referred to as HA) attenuated osteoarthritis of the knee (hereinafter referred to has OA), the improvement of the Lequesne index of severity and visual analogue scale (VAS) score were compared at 6 months between patients who did (debridement group, n = 12) or did not agree (control, n = 17) to undergo arthroscopic debridement. The debridement group showed significant improvements of the severity index (p = 0.012) and VAS scores (p = 0.029) as compared to the control group.

The Japanese Clinical Orthopaedic Association (JCOA) has been conducting an annual questionnaire survey of medical institutions belonging to the JCOA to determine the results of school medical screening for locomotive organ health of students since fiscal year 2016. Herein, I report the results of the survey for fiscal year 2019. Four thousand two hundred cases of locomotive organ disorders were identified. Scoliosis accounted for the majority of the diagnoses, and other diagnoses included Osgood-Schlatter disease, lumbar spondylolysis, disc herniation, and little league elbow. After the diagnosis, 0.1% of the students underwent surgery and 2.8% were referred to other specialists.

【Objective】We investigated the treatment of extra-articular distal radius fractures in adult.

【Materials and Methods】The x-rays findings and the clinical results at the final observation were compared between forty conservative cases and thirty nine surgical cases using the volar locking plate.

【Results】The x-rays findings and the clinical results at the final observation were significantly better in the surgical group.

【Discussion】The conservative group also had good clinical results, but the surgical group was significantly better.

【Conclusion】The x-rays findings and the clinical results at the final observation were better in the surgical group.

We encountered a case of Galeazzi fracture-dislocation, and interposition of the extensor carpi ulnaris (ECU) tendon made the dislocation irreducible. Although similar cases have been reported in Galeazzi-equivalent lesions, the pathogenesis in those cases is different from that in the present case. In the present case, if the dislocation of the ulnar head could be stably reduced by removing the interposing ECU tendon, osteosynthesis of the fractured ulnar styloid process is not necessarily required.

I report my experience of 29 cases of toe fractures that were fixed externally using Aquaplast for finger splints. Since the fixtures were small, all the patients were able to wear shoes even after the fixation. Although there were 2 cases of delayed union and 1 case of pseudarthrosis, bone union was eventually achieved in 28 cases. I think that this method is particularly useful in environments where people spend a lot of time barefoot, like in Japan.

I report the effects of the Hokkaido Eastern Iburi Earthquake and the subsequent blackout that occurred in the early morning of September 6, 2018, based on the results of a questionnaire survey of the members of the Hokkaido Society of Clinical Orthopaedic Association.

Although direct damage from the earthquake was small, damage from the blackout, including suspension of business, was extensive.

This event underscores the importance of measures to be taken against power outages according to the scale of a medical institution.

We explored a muscle strength measurement method that could be used in elderly patients with knee osteoarthritis and useful in daily practice. In patients scheduled for knee arthroplasty, we performed isokinetic muscle strength measurement on 133 knees in 116 patients, and isometric muscle strength measurement on 43 knees in 37 patients. The maximal muscle strength determined by the isokinetic measurement method was 32.3° for extension and 39.5° for flexion, with failure of the strength measurement in 11.3% cases. On the other hand, with the isometric measurement method, the maximal muscle strength determined was 60° for extension and 30° for flexion. No significant difference in the maximal muscle strength was observed between 45° and 60° extension and between 45° and 30° flexion in the isometric measurement method. Thus, isometric measurement at 45°, which allows reliable strength measurement, appears to be useful.

We enrolled 28 subjects with biphalangeal fractures of the fourth or fifth toe who had been followed up until the achievement of bone union in this study. The time to bone union was 1.6 to 12 months, and the subjects were divided into the following two groups for comparison: a patient group in which bone union was achieved in less than 4 months (bone union group, n = 20), and a patient group in which it took longer than 4 months to achieve bone union (delayed union group, n = 8). There was no significant difference in the mean age, gender distribution, laterality (right or left side) distribution, fractured toe, or fracture sites between the two groups. However, the duration of splint application was significantly shorter in the delayed union group as compared to that in the bone union group.

Purpose: We performed this study to examine the changes in the profile of outpatient rehabilitation users at our hospital. Subjects and methods: The number of new users and their care level at the start of use between January 2015 and December 2019 were tabulated. Results: The number of new users was 140, and their care level at the start of use was “requiring support” in 92 users (66%) and “requiring long-term care” in 48 users (34%). Conclusion: The demand for short-time outpatient rehabilitation is mainly accounted for by people who “requiring support,” suggesting that the number of users is likely to increase in the future.

We applied the Tsume-flat series® to 190 great toes with ingrown/incurvated nails and examined the types of wires in this study. The results showed that only Tsume-cap® could be used to treat ingrown nails, while both Tsume-flat® and Tsume-cap® could be used to treat incurvated nails. The treatment period was longer for incurvated nails, and wire replacement/change were required. The Tsume-flat series® is broadly applicable for nail conditions, including ingrown and incurvated nails, and is an extremely useful tool in clinical practice, if the Tsume-flat® and Tsume-cap® are used as appropriate.

We retrospectively evaluated the postoperative outcomes of patients who underwent fixation by either the Tension Band Wiring (hereinafter referred to as “TB”) method or the Cannulated Cancellous Screw (hereinafter referred to as “CCS”) fixation method for fractures of the medial malleolus. Analysis of the pseudoarthrosis rate in cases of medial malleolus fracture based on the Herscovici classification showed that the pseudoarthrosis rate was higher in the subgroup of the TB group with type D fractures, on the other hand, there was no significant difference between the groups that underwent fixation by the TB and CCS methods. No cases of pseudarthrosis cases were observed among the patients with type B fractures in either the TB or the CCS group. These findings suggest that a surgical procedure other than the TB method could be used for cases with type D fractures, especially those with proximal fracture lines, and that either surgical procedure could, however, be used for patients with type B fractures to obtain good outcomes.

I encountered two cases of pseudarthrosis of the pubis/ischium that were difficult to treat. Case 1 was a 33-year-old female patient diagnosed as having juvenile rheumatoid arthritis (JRA) when she was 16 years old and had been treated with biological and other agents since. The patient developed a fissured fracture of the right ischium in June 2017, and in August 2018, she was detected as having pseudarthrosis of the bilateral ischia and pubis. Case 2 was a 91-year-old female patient who presented to our hospital with bilateral thigh pain on May 7, 2019. She was diagnosed as having a fracture of the left pubis, and gradually, over time, developed pseudarthrosis of the bilateral ischia and pubis. The patient was started on 20 μg/day of teriparatide, which resulted in good bone union.

The Tsume-flat series® were used for 66 weeks in a 78-year-old woman who had undergone phenol cauterization on both edges of the left hallux 20 years earlier, that had resulted in narrowing and inward curving of the nail plate. The patient was treated with Tsume-pla for 11 weeks and Tsume-cap® for 10 weeks, followed by application of Tsume-flat® for 45 weeks, while being kept under follow-up. Sixty-six weeks later, inward curving nail was corrected, and the nail continued to grow smoothly. During the treatment, the nail was clipped 7 times. Application of Tsume-pla appears to be highly useful for painless treatment of nail conditions such as in the patient reported herein.