We report three cases of anterior shoulder dislocation including anterior glenoid rim facture treated by arthroscopic Bankart repair. The patients were two men and one woman with a mean age of 46 years (range, 24 to 61 yr). The mean standby period from injury to surgery was 14.7 days, and the mean follow-up period after surgery was 4.7 months. The fractured glenoid rim bones were attached to the anteroinferior glenohumeral ligament. The displaced fragments were repositioned anatomically and directly through the fragment to the glenoid rim with suturing of its ligament. Suture fixation was performed by the dual suture method with biodegradable anchors. One case required a simultaneous arthroscopic rotator cuff repair. CT examination confirmed bone union in all cases, and no recurrence of the shoulder dislocations was observed. An excellent range of shoulder motion was obtained in the short-term follow-up period. The mean Japanese Orthopaedic Association (JOA) shoulder score was 91 points. The modified arthroscopic Bankart repair gave good clinical results for anterior glenoid rim fracture.

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Histiocytic sarcoma is a rare hematopoietic malignancy with a poor prognosis. We report a 31-year-old woman who developed histiocytic sarcoma in the lower extremity. An open biopsy was required because a definitive diagnosis could not be made on the basis of a core-needle biopsy specimen. The diagnosis of histiocytic sarcoma was established using immunohistochemistry. No metastatic lesion was detected by PET-CT, and wide resection based on the procedure for a malignant soft tissue tumor was performed without neo-adjuvant chemotherapy. However, adjuvant radiotherapy was performed because there are few reports of histiocytic sarcoma being treated using surgery alone. During 35 months of follow-up, neither local recurrence nor distant metastasis has been observed. Our experience suggests that if a solitary lesion of histiocytic sarcoma can be resected with a sufficient margin, chemotherapy may be unnecessary.

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Background : The indications for hip arthroscopy continue to evolve. This study investigated the results of arthroscopic surgery for symptomatic hip joint diseases.
Patients and methods : Nine patients were included in this study. The etiology was femoroacetabular impingement in 3 hips, dysplasia in 2 hips, ossification of the labrum in 1 hip, Perthes disease in 1 hip, labrum tear in 1 hip, and septic arthritis of the hip in 1 hip. Chondral lesions were classified using the International Cartilage Research Society classification system.
Results : Labral debridement for degenerative tear or ossification was performed in 6 hips and labral repair was performed for 2 hips. Femoral head-neck osteoplasty was performed for 6 hips. Microfracture was performed for 1 dysplastic hip with grade 4 chondral lesions. The mean Japanese Orthopaedic Association hip score was improved from 58 points preoperatively to 81 points at follow-up. However, pain remained in 3 hips that had grade 3 or 4 chondral lesions.
Conclusion : Hip arthroscopy is a useful surgical technique for hip joint diseases. However, its indications for dysplastic cases require circumspection.

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The purpose of this study was to evaluate the clinical results of bipolar hemiarthroplasty using the direct anterior approach (DAA) in 34 patients (6 men and 28 women, mean age 76.5 years, treated between 2008 and 2011). The mean follow-up period was 11 months. For comparison, we used a group of 30 patients (7 men and 23 women, mean age 76.4 years, treated between 2007 and 2008) in whom the anterolateral approach had been used.
Intraoperative complications included a greater trochanter fracture in 2 cases and a proximal femur vertical crack in 1 case. Operation time and intraoperative blood loss showed no significant differences between the DAA and anterolateral approach. Time until recovery of walking ability was significantly shorter in the DAA group than in the anterolateral approach group. We conclude that the DAA is useful for prompter recovery of walking ability.

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From July 2009, we started spinal micro-endoscopic surgery to reduce the degree of surgical invasion. The reduced invasiveness of spinal endoscopy is considered especially valuable in surgery for lumbar canal stenosis (LCS). We evaluated spinal micro-endoscopic surgery for LCS in comparison with laminectomy performed in 2008.
We treated 18 patients (14 men and 4 women) with LCS using spinal micro-endoscopy in comparison with 44 patients (21 men and 23 women) who underwent LCS with laminectomy operations. In either group, the mean age was 71 years. The mean operation time per level was 163 min in the endoscopy group and 49 min in the laminectomy group. The mean amount of intraoperative blood loss per level was 38 g in the endoscopy group and 77 g in the laminectomy group. The mean period from surgery to the start of walking was 1.2 day in the endoscopy group and 1.9 day in the laminectomy group. Spinal endoscopic surgery for LCS is less invasive, but requires a much longer operation time. We perform spinal endoscopic surgery only for patients with ASA physical status 1 or 2.

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We report a case of intratendinous ganglion arising from the extensor tendon of the ring finger. The patient, a 57-year-old woman, was awared of the mass on the dorsum of the right hand two years ago. She consulted our hospital due to pain and enlargement of the mass. The findings of MRI suggested a ganglion, a giant cell tumor of the tendon sheath, or tenosynovitis. Surgical exploration revealed a gelatinous lobulated mass associated with a tear of the extensor tendon of the ring finger, and this was diagnosed as a ganglion. After 1 year and 4 months of follow-up, neither recurrence not tendon rupture has been observed. Intratendinous ganglion is rare, and to our knowledge only 38 cases have been reported previously. The majority (24 cases) arose from an extensor tendon of the hand, and were located in the distal portion of the extensor retinaculum, suggesting that repeated irritation of this area might give rise to mucoid degeneration. This was likely the case in the present patient in view of her occupation (personal computer user) and the lesion location.

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Soft tissue chondroma is a rare benign soft part tumor. We describe a 47-year-old man, who presented with swelling of the proximal interphalangeal joint (PIP joint) of the right index finger. As blood examination revealed no abnormality, he was treated conservatively. However, the swelling increased, and was associated with pain and disturbance of excursion. There was calcification within the tumor, and a scalloping on the phalanx of the index finger, prompting us to suspect synovial osteochondromatosis or chondrosarcoma. The tumor was excised and found to have many miliary calcifications extending from the articular capsule of the PIP joint. Pathologically, we diagnosed it as soft tissue chondromatosis. There has been no recurrence after 21 weeks of follow-up.

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The aim of surgical treatment for metastatic bone tumors is not to cure the disease but rather to improve the quality of life by relieving pain and maintaining ambulatory function for as long as possible in the patient's remaining years.
Between 2005 and 2011, 7 patients with pathological fractures of the femur were treated surgically at our hospital. All of the patients were stabilized with intramedullary nailing. Two moribund patients did not undergo surgery. The patients who underwent surgical treatment of their pathologic fractures achieved better functional outcome and better pain control.

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Prognostication is an important part of treatment decision-making for patients with metastatic spinal tumors. In this study, we analyzed retrospectively the relationship between outcome in 56 patients (29 males and 27 females) with metastatic spinal tumors treated at our hospital and their expected prognoses in terms of prognostication scores (Tokuhashi score and Katagiri score). Twenty patients underwent palliative surgery including decompression or fusion with instrumentation. Forty-three and 36 patients received radiotherapy and chemotherapy, respectively. All patients with a Tokuhashi score of more than 12 points (predicted life expectancy>12 months) survived for more than 12 months after initial diagnosis. Meanwhile, 20 of 33 patients with a Tokuhashi score of less than 8 points (predicted life expectancy<6 months) survived for more than 12 months, contrary to expectation. These cases included patients with lung and renal cancer who achieved remission with gefitinib and sunitinib malate. Recently, as newly developed anticancer drugs have improved the long-term survival of cancer patients, it is necessary to develop a new prognostication score that takes into account the effects of chemotherapy for those with metastatic spinal tumors.

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We investigated calcification of the peripheral joints and the transverse ligament of the atlas (TLA) in five patients with calcification of the ligamentum flavum (CLF) who underwent cervical decompressive surgery. We also investigated calcification of the TLA and the cervical ligamentum flavum in patients who had calcification in the peripheral joints and also a control group without such calcification. The control group was matched to the peripheral calcification group by age and sex. Calcification of the peripheral joints and the TLA was seen in all five of the patients who underwent surgery. Calcification of the TLA was present in 71 (79%) of the 90 patients in the peripheral calcification group and in none (0%) of the 90 patients in the control group. Calcification of the cervical ligamentum flavum was present in 31 (34%) of the 90 patients with peripheral calcification and in none (0%) of the 90 control. This study demonstrated a relationship between calcification of the peripheral joints, CLF, and calcification of the TLA. Some authors have performed decompressive laminectomy or laminoplasty only at the affected levels. However, we performed cervical laminoplasty from C3 to C7 to prevent compression of the spinal cord by de novo calcification at the unaffected levels.

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Atlantoaxial rotatory fixation (AARF) can occasionally occur after trauma or pharyngeal infection in children, causing torticollis, limited neck motion, and neck pain. The mechanism responsible for AARF is not fully understood, but may be due to the immature joint structure seen in children. The causes of irreducible subluxation or recurrence are muscle spasm and ligamentocapsular contractures, synovial fringes, and deformity of the superior facet of the axis. We have experienced a pediatric case of AARF that was resistant to conservative treatment. The patient, a 7-year-old girl, had been infected with mumps and developed torticollis a month before presentation. She had been seen at a local clinic and diagnosed as having AARF, which was then treated conservatively without any response. She was therefore brought to our hospital to undergo Glisson traction. As torticollis still remained, we performed closed manipulation under general anesthesia. 3D CT showed a C2 facet deformity. One month after halo fixation, remodeling of the C2 facet deformity was observed. Two months after halo fixation, the remodeling had advanced and the appearance had begun to resemble that on the normal side, and therefore we removed the halo vest and installed a Philadelphia collar. One month later, we removed the Philadelphia collar, and since then (one year later) the torticollis has not recurred.

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Glenoid fractures are uncommon. Here we describe three such cases that were treated surgically. All of the patients were male; one had been injured in a fall, and the other two had additional clavicle fractures resulting from traffic accidents. All of the cases were classified as Ideberg Type V. The surgery was performed with the patients in the lateral decubitus position. In two cases the shoulder was abducted and a posterior approach with arthroscopic assistance was employed. Early rehabilitation was started after surgery, and shoulder function recovered quickly in all cases. Good results were obtained in the short term. A posterior approach with the shoulder abducted and using arthroscopic assistance is very useful for osteosynthesis of glenoid fractures.

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The present study investigated the clinical results of internal fixation of proximal humeral fractures using the Polarus humeral nail. Between September 2004 and September 2009, 34 shoulders of 34 patients (25 females, 9 males) underwent intramedullary fixation using the Polarus humeral nail. The mean patient age was 67 years, and the average period of follow-up was 27 months (range 12-77 months). According to the AO classification, 19 fractures were type A, 11 were type B, 2 were type C, and 2 were unclassifiable. We checked the radiographic results, JOA score and the range of shoulder motion,and investigated the relationships between these parameters and the incidence of complications. Bone union was obtained in 33 shoulders. Arthrotic changes were seen in 2 shoulders, but these did not worsen the clinical outcome. The average JOA score was 81 points(45-100). The average range of shoulder motion was 136 degrees for flexion, 39 degrees for external rotation, and L2 for internal rotation. Complications included infection, screw back-out, varus deformity, and osteonecrosis. Although the clinical and radiological outcomes of proximal humeral fractures after repair with the Polarus humeral nail were mostly satisfactory, it is important to prevent any potentially deleterious complications.

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Although greater tuberosity fracture of the humerus is treated conservatively in many cases, surgery is chosen when the fragment displacement is large and non-union or subacromial impingement is expected. There have been few reports of treatment for obsolete greater tuberosity fracture. Here we report a case of arthroscopic fixation for obsolete greater tuberosity fracture using a suture bridging technique.
A 66-year-old man who had been injured in a fall was diagnosed as having dislocation of the left shoulder and greater tuberosity fracture. He was recommended to undergo surgery, but rejected this option, and was referred to our hospital 5 months after the injury. At the time of consultation, the patient had difficulty elevating his left arm, and had severe pain on motion. We diagnosed obsolete left greater tuberosity fracture on the basis of CT scans and MR images. At 6 months after injury, arthroscopic fixation surgery was performed using a suture bridging technique.
At 1 year after the operation, the patient was free of motion pain and was able to elevate his left arm. X-ray and CT images showed good bone union.
We conclude that an arthroscopic suture bridging technique is useful for obsolete and displaced greater tuberosity fracture of the humerus.

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An 18-year-old male, suffered a sprain injury of the right small finger during a basketball game. He visited our hospital because of pain and inability to move the small finger.
On inspection, the injured finger showed a boutonniere-like deformity, making the patient unable to extend the PIP joint passively against resistance.
X-ray examination demonstrated no fracture, but an ulnar stress view showed gross instability of the joint. Therefore, we suspected an injury of the radial collateral ligament combined with central slip rupture at the PIP joint of the right finger, and performed surgery immediately.
The operative findings revealed that the central slip was not torn, but the radial collateral ligament was avulsed from its attachment at the middle phalanx, and the stump of the avulsed ligament was caught between the radial lateral band and the central slip of the extensor tendon.
We pulled back the entrapped ligament stump, allowing free extension of the PIP joint.
We then repaired the torn radial collateral ligament, returning it to its original attachment to the middle phalanx, using a small bone anchor. We started range of motion exercises of the small finger actively on the day after the operation. A buddy tape was also attached between the small finger and the ring finger up until the 7th week, and this remained in place at all times except during motion exercise.
At the final evaluation, the patient had recovered a full ROM with no pain, regaining all of his original activities, including basketball.
This was a very rare case, because most of the collateral ligaments of the PIP joints are severed at their proximal attachment. We consider that a boutonniere-like deformity, as we seen here, may occur in the following manner. If the PIP joint receives stress force from a lateral direction when in a slightly flexed position, the distal attachment of the collateral ligament will be torn and the ipsilateral condyle will protrude temporarily between the lateral band and the central slip of the extensor tendon. Then, on repositioning of the PIP joint, the torn stump of the ligament will be left between the lateral band and the central slip of the extensor tendon.

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An 88-year-old man presented with a history of swelling on the dorsal side of the hand without systemic illness. No skin lesions were present. Although he denied any specific injury, he reported that he had been stung on the hand by a bee one year previously. MR imaging with and without gadolinium enhancement showed marked extensor tenosynovitis but no bone erosions. Radiographs of the chest and hand revealed no abnormality. The patient subsequently underwent complete extensor tenosynovectomy of the hand. During surgery, the extensor digitorum communis IV and V tendons were found to be ruptured. Reconstruction of the extensor tendons using the palmaris longus tendon was performed. Pathological examination showed non-caseating granulomas with epithelioid cells, and Mycobacterium intracellulare was identified on culture. The patient was treated with rifampicin, ethambutol and clarithromycin for six months, and at the 12-month follow-up had achieved satisfactory extension of the finger with complete resolution of the soft tissue swelling of the hand.

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We performed proximal row carpectomy (PRC) and dorsal capsule interposition combined with the Sauve-Kapandji (S-K) procedure in 2 patients with severely damaged wrist joints.
One case was diagnosed as the terminal stage of Kienbock disease, complicated by a subcutaneous laceration of the deep flexor tendon of the index finger at the level of the segmented lunate, which was volarly dislocated.
The other case was thought to be advanced renal arthropathy, complicated by subcutaneous lacerations of the extensor tendons of the ring and little fingers at the level of the badly degenerated DRUJ.
In case 1, we performed flexor tenodesis of the DIP joint of the index finger, along with PRC and dorsal capsule interposition combined with the S-K procedure. In case 2, we performed extensor tendon transfer using the extensor indicis proprius tendon, along with PRC and dorsal capsule interposition combined with the S-K procedure.
Both patients were satisfied with the results, and they returned to normal activities without pain.
PRC was originally indicated for the remaining articular cartilage of the proximal capitate and lunate fossa. However, we performed PRC for wrists with severe damage and almost total loss of the cartilage, with interpositioning of the dorsal joint capsule, combined with the S-K procedure. Therefore, we consider that this procedure is an excellent rescue method for severely damaged wrist joints.

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When treating distal humerus shaft fracture, an intramedullary nail is inserted into the lateral humeral condyle. The purpose of this study was to evaluate the clinical results of treatment for distal humerus shaft fracture using an intramedullary nail. We treated 9 patients (3 men and 6 women, mean age 80 years) between 2006 and 2011. The fracture type by the AO classification was 12-A2 in 2 cases, 12-B1 in 2, 12-B3 in 2, 12-C2 in one, and two cases were unclassifiable non-unions. Bone union was achieved in all patients, but was delayed in 3. All patients were relieved of pain, and no clinical complications were observed. We believe that fracture stabilization and an appropriate surgical technique are important. We recommend insertion of an intramedullary nail in to the lateral humeral condyle for stabilization of distal humerus shaft fracture.

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Few studies have attempted to compare the results of surgery among microscopic discectomy using a tubular retractor (MD), microendoscopic discectomy (MED) and Love's method using a microscope (micro-Love) for patients with lumbar disc herniation (LDH). In this study, the surgical outcomes of MD and MED were reviewed and compared with those for the micro-Love method. The subjects comprised 53 patients with LDH, among whom 8 underwent MD, 22 underwent MED, and 23 underwent the micro-Love methods. The operation time in the MED group was significantly longer than that in the other groups. However, there were no significant differences in recovery rate in terms of JOA score and blood loss among the three groups. These surgical methods seem to be as equally useful for the treatment of patients with LDH if surgeons become proficient in the use of each of them.

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This study was performed to investigate the surgical results of the minimally invasive lumbar interbody fusion technique (group M) in comparison with the traditional open technique (group O) for one-level fusion, focusing on the period from surgery until discharge. Twenty-four patients (group M : 12 cases, group O : 12 cases) who had received neither anticoagulants nor antiplatelet drugs were studied. Surgical time, blood loss, usage of NSAIDs, hospital stay, and JOA score were compared between the two groups. Statistical evaluation showed that perioperative blood loss was markedly and significantly (P<0.01) decreased in group M. Although the operation time in group M was longer (284 min) than in group O (258 min), group M had a shorter hospital stay and received a smaller amount of NSAIDs. There was no significant difference in JOA score between the two groups. We suggest that the benefits associated with minimally invasive spine surgery techniques are lower perioperative blood loss, decreased pain, and a shorter hospital stay, but that this approach requires a learning curve for surgeons in the initial phase.

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Tramadol hydrochloride/acetaminophen is a combination drug containing tramadol hydrochloride 37.5 mg and acetaminophen 325 mg. To evaluate the effect of this tramadol hydrochloride/acetaminophen combination (Tramcet®) on pain in patients with spinal disease, we tested 40 consecutive patients who had been receiving NSAIDs for more than one month without any effective pain relief. The patients received four Tramcet® tablets as a daily dose. After 4 weeks, 92% of the patients obtained pain relief and 92% of them showed improved activity of daily living. Nausea and vomiting has been reported to be the main side effect of Tramcet®. When we applied metoclopramide for the first three days together with Tramcet®, the incidence of nausea or vomiting was 16%, whereas Tramcet® alone elicited nausea in 57% of the patients. When we compared the effect of Tramcet® on patients with and without neuralgia, the effects were the same.
Tramadol hydrochloride/acetaminophen was thus shown to be effective for pain relief in patients unresponsive to NSAIDs, showing a lower risk of serious adverse events such as gastric ulcer or impairment of renal function.

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We reviewed two patients who underwent total knee arthroplasty after developing septic arthritis of the knee. The first patient was a 68-year-old woman who complained of right knee pain and swelling. At the first visit, pus was drained by arthrocentesis, and Staphylococcus aureus was detected. We performed arthroscopic debridement and closed suction-irrigation for 16 days. Thereafter, there was no recurrence of the septic arthritis. One year after the operation, total knee arthroplasty was performed. Ten years after the arthroplasty operation, knee joint function remains good.
The second patient was a 74-year-old woman who complained of left knee pain and swelling. At the first visit, pus was drained by arthrocentesis and methicillin-resistant Staphylococcus aureus was detected. For initial surgery, we performed arthroscopic debridement and closed suction-irrigation for 17 days. Thereafter, septic arthritis recurred, and therefore we performed a second operation for open debridement and closed suction-irrigation for 13 days again. This resolved the septic arthritis, and one year later, total knee arthroplasty was performed. Four months and two weeks after the arthroplasty surgery, knee joint function remains good.
We have reviewed two patients who underwent total knee arthroplasty after treatment of septic arthritis of the knee, and achieved good results.

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We compared the clinical results of simultaneous bilateral total knee Arthroplasty (TKA) and unilateral TKA. Between January 2005 and May 2011 we performed 29 simultaneous bilateral TKAs and 65 unilateral TKAs. We found a low incidence of serious complications and no significant difference in clinical results, operation time, amount of bleeding or quantity of transfused blood between the two procedures. We consider that simultaneous bilateral TKA is a more useful method because the recovery period after treatment is shortened.

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We report a case of arthroscopic repair of anterior cruciate ligament (ACL) injury in an adolescent with open physes. The patient was an 11-year-old boy who had been injured by hyperextension of the knee while playing soccer. The Lachman test and anterior drawer sign (ADS) were positive at initial consultation. CT and MRI confirmed a tibial eminence avulsion fracture and partial injury of the ACL. Arthroscopic primary suturing was performed. A tibial eminence avulsion fracture (6mmx6mm) and partial tear of the postolateral bundle (PL) were evident, and the patient underwent arthroscopic pull-out suture fixation using No.2 Fiberwire® for the avulsion fracture, without drilling the proximal tibial physes, and suturing of the PL remnant using 3 No.2 Vycril®, respectively. At the final follow-up evaluation 2 years after the operation, physical examination showed a negative Lachman test, ADS and pivot-shift test without any complications, and the boy returned to the previous sport. Arthroscopic repair is one of the operative procedures available for tibial eminence avulsion fracture or ACL tear at the femoral attachment in adolescents with open physes.

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We retrospectively studied 16 knees in 16 patients who had undergone meniscal repair surgery for solitary lateral meniscal tear, excluding discoid meniscus and concurrent ligament injuries. The purpose of this study was to evaluate the causes of the injury, clinical symptoms, preoperative MR imaging findings, intraoperative findings, and postoperative clinical results in these cases.
The etiology of the tear was sports-related trauma in 9, standing motion from a squatting position in 5, and no obvious cause in 2. The clinical symptoms were knee pain and locking in 14, and catching and discomfort in 2.
Tears had occurred in the peripheral region of the posterolateral corner or popliteomeniscal fascicle of the lateral meniscus in all cases.
Surgery was performed using the Inside-out technique in 4 cases, the All-inside technique in 2, and both in 9. Up to now, none of the cases have recurred.
The mechanism responsible for solitary meniscal tear is considered to be repeat impingement of the lateral meniscus. Since it is difficult to diagnose such a tear only by MRI, each case has to be judged on the basis of clinical symptoms, clinical course and MRI findings.
As repeat damage to the lateral meniscus can be a cause of tears, attention must be paid to the risk of re-tear, and long-term observation is advisable.

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Introduction : Quadriceps tendon rupture is a relatively rare lesion. Here we report two cases of this injury that required surgical repair.
Cases : Case 1 : A 58-year-old man with a history of renal transplantation sprained his left knee when coming downstairs. His knee had swollen, and he was unable to extend it. He came to our hospital one month after injury. On the basis of clinical evaluations, X-ray and magnetic resonance imaging, we diagnosed a quadriceps tendon rupture, and performed surgery. We repaired the tendon rupture by suturing the tendon to the patella using pull-out of the ethibond suture through the drill hole. In addition, we added augmentation using the semitendinosus tendon. Two weeks after the operation, the patient started range of motion exercise. Four weeks after the operation, he started weight-bearing. Case 2 : A 68-year-old man without a history of major illness sprained his right knee while descending a slope. He suffered severe pain and difficulty with movement of the right knee. On the basis of clinical evaluations, X-ray and magnetic resonance imaging, we diagnosed a quadriceps tendon rupture. Eight days after injury, surgery was performed using a procedure similar to that for case 1, followed by a similar course of rehabilitation.
Results : In both cases, six months after surgery, the range of knee motion was satisfactory, without extension lag.

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Here we introduce the Insight System, which allows an appropriate femoral position to be maintained during surgery. Total knee arthroplasty (TKA) is usually performed by two surgeons. The knee joint is approached via the mid-vastus, and the Insight System is fixed on the femur. We can then change the position of the knee easily using a foot switch.
At our hospital, we performed TKA using the Insight System (Scorpio NRG PS type for 49 knees, and Scorpio TS for one knee) in 45 patients (50 knees) with an average age of 76.2 yr. At the final follow-up (from 8 months to 5.5 years after surgery), the average knee flexion angle was 123 degrees, the average knee extension was -4.3 degrees, and the JOA score was 85.7 points. In the final X-ray component positions, the average α angle was 96.5 degrees, the average β angle was 89.5 degrees, the average γ angle was 2.3 degrees, and the average δ angle was 84.5 degrees. The average operation time was 117 min (range 90 to 150 min). The complications in this series were two fractures of the femoral medial condyle and one case of deep infection.
We were able to perform the operations stably using the Insight System, and this is considered to be a useful instrument at the institutions concerned.

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