Medial patellofemoral ligament (MPFL) reconstruction is performed for recurrent patellar dislocation, and good results have been reported. Here we describe MPFL reconstruction for recurrent dislocation after realignment for bilateral recurrent patellar dislocation in a 25-year-old female patient with kabuki make-up syndrome. Four years previously, distal realignment surgery had been performed for bilateral recurrent patellar dislocation. However, patellar dislocations of the bilateral knee were persistent, and therefore MPFL reconstruction surgery was performed. No patellar dislocation has been observed for two years since the procedure.

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We designed a caliper positioned parallel to the femoral axis during total hip arthroplasty, and evaluated its accuracy in comparison with the straight caliper employed previously. At the same time, we evaluated the degree of femoral offset.
The correlation between the limb length measured intraoperatively and that measured by radiography was improved by use of the new caliper (p < 0.01, r = 0.83), but the correlation with femoral offset was not so high. Although measurement of the limb length parallel to the femoral axis is accurate, but not for that of the degree of femoral offset. To measure femoral offset correctly, it is necessary to reproduce the pre-and post-measurement abduction positions.

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Traumatic atlantoaxial dislocation is comparatively rare. We present a case of atlantoaxial rotatory dislocation fracture in a 53-year-old male, who had fallen down stairs under the influence of alcohol and struck his posterior neck region. He was transferred to our emergency department. At initial examination he was alert and neurologically normal, but his head was fixed in the cock robin position. Cervical CT showed atlantoaxial rotator dislocation with left C2 superior articular process fracture. Glisson's traction was performed initially, followed by skeletal traction. Because dislocation remained, manual reduction was performed under general anesthesia. Thereafter, we applied a halo-vest for one month, followed by use of a Philadelphia collar. Four months after trauma, there is no limitation in the range of neck motion.

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In patients with variable changes in pelvic inclination, total hip arthroplasty (THA) is required for accurate cup installation to prevent dislocation. Here we reported the use of THA for hip ankylosis due to juvenile idiopathic arthritis (JIA) and variable pelvic inclination with changes in posture. The patient was a 55-year-old woman, who had received medical treatment for JIA until the age of 14 year. She had been examined two years previously for bilateral leg pain and gait disturbance. Clinically, the lumbar spine had degenerative changes and the left hip joint was ankylosed at a 50-degree -flexed position, causing severe lordosis of the pelvis and lumbar spine and more severe lordosis during changes in posture. We treated the lumbar spine by laminectomy, and then THA was performed under a navigation system. Postoperatively, the patient was relieved of her symptoms and her ambulatory ability was improved. Anteversion of the pelvis with changes in posture remains, but the large femoral head has ensured that no dislocation has occurred up to the present.
In cases of variable pelvic inclination due to changes in posture, use of a navigation system is useful intraoperatively for accurate cup installation, and a large femoral head matches any postoperative changes in pelvic inclination.

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It is sometimes difficult to achieve rigid internal fixation and early shoulder ROM recovery in patients with distal clavicle fracture. We have developed an anatomical locking distal clavicle plate (NOW-J) through which a maximum of ten screws can be inserted to the distal fragment. We investigated the clinical results of obtained with the NOW-J plate for treatment of distal clavicle fractures. Ten patients (8 men and 2 women, mean age 54.9 years) were included in the study. The fracture types according to the Craig classification were Type I in 3 cases, Type IIA in 3 cases, Type IIB in 2 cases, and Type V in 2 cases. All the patients started postoperative rehabilitation on the day after the surgery. Bone union without displacement was achieved in all patients within 3 months after surgery. Shoulder elevation of 150° was achieved within 3 weeks after surgery in 9 cases. We conclude that the NOW-J is a useful plate for treatment of distal clavicle fracture because of the rigid fixation it provides. Further study is needed to clarify whether the NOW-J can be applied to more unstable fractures, distal comminuted fractures, and osteoporotic fractures.

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Transportation of patients to hospital by ambulance from the mountainous area of Kochi prefecture has been reported to take about twice as long as the national average. Possible reasons are that 85% of the area is mountainous, the transportation network in Kochi is poor, highly advanced medical institutions are concentrated in the central part of the prefecture, and there is a shortage of doctors. To overcome this problem, we have been operating a helicopter emergency medical service (HEMS). The aim of the HEMS is not only rapid transportation of patients to hospital, but also delivery of medical staff who can initiate critical care immediately at the scene.
Here we examined the role and problems of helicopter transportation in regional medicine. We reviewed 314 patients with orthopedics conditions among trauma cases transported by helicopter between March 2005 and August 2011. The main causes of injury were traffic accidents (100 cases, 38.8%), falls from a height (87 cases, 27.7%) and falls due to slipping (39 cases, 12.4%). One hundred thirty-nine cases required emergency surgery. Ninety-five patients were transported from rural hospitals and 37 patients from clinics. Helicopter transportation ensures that initial treatment can be started immediately and patients can be transported safely and quickly to highly advanced medical institutions. We consider that helicopter transportation is useful for minimizing preventable trauma death and disability, and can reduce differences in regional medicine availability. However, helicopter transportation has various problems such as flight difficulty at night or in bad weather, and effective maintenance of the system will be necessary in future.

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Introduction : Congenital hallux valgus is a rare condition. However, many cases have been reported as a feature of fibrodysplasia ossificans progressiva (FOP).
Patient : A 5-month-old male infant.
Chief complaint : Bilateral hallux valgus deformity.
Presentation : Bilateral hallux valgus had been evident at birth, and the patient was referred to our hospital from his referring physician at 5 months of age. Medical and family history : No remarkable findings.
Treatment : We treated the patient with an orthopedic appliance, but no improvement in the deformity was showed. At the age of 1 year and 5 months, FOP was diagnosed by genetic analysis. Currently, the patient is 1 year and 8 months old, and there has been no change in the bilateral hallux valgus deformity. No mass on the back has yet appeared.
Discussion : A shortened great toe and hallux valgus are frequently found in patients with FOP. The first step when encountering patients with congenital hallux valgus is to make a genetic diagnosis. If this reveals FOP, treatment must be conservative, and neither operation nor biopsy is indicated. If genetic diagnosis is negative, a search for other congenital diseases must be made. In any event, conservative treatment is the first choice.

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Sports injury due to excessive practice or a high number of games is a problem in childhood competitive sports. However, there have been few nationwide investigations of injury during the growth phase, especially in school-age children. We carried out an unsigned questionnaire survey to investigate sports injuries in young players who participated in nationwide schools table tennis competitions, focusing on consultation with medical institutions. The rate of consultation with medical institutions, such as hospitals, was low for sport injuries in schoolchildren. There is a need to have a sense of urgency about this, and to reconsider what orthopedic surgeons should do in connection with sports-related medical examinations in future. It is important for orthopedic surgeons to be well versed in sports medical examination, and to be able to offer rehabilitation and conditioning with a view to a return to sport, placing emphasis on not only diagnosis and medical treatment, but also injury prevention.

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Plain X-ray images and 2-dimensional templates have previously been used for preoperative planning of total hip arthroplasty (THA). Recently, planning using CT images and 3-dimensional templates, aiming at higher accuracy, has occasionally been reported. The objective of this study was to investigate the usefulness of 3-dimensional templates for preoperative THA planning. Fifteen hips in 15 patients who underwent initial THA between April and September 2012 were investigated. The implant size determined by both 2- and 3-dimensional preoperative planning was compared with the size of the implant actually used in surgery, and the concordance rate was investigated. The concordance rate was analyzed statistically using the chi-squared test. The rate of complete concordance afforded by 2-dimensional preoperative planning (2D) cups was 40% (6 of 15 patients), whereas that for 3-dimensional preoperative planning (3D) cups was 67% (10/15). The rates of complete concordance for 2D and 3D stems were 27% (4/15) and 40% (6/15), respectively. The concordance rates for 2D cups and stems tended to be higher, but were not significantly different from those of 2D cups and stems. When cases one -size larger or smaller were included in the concordance rate, the rates for cups and stems were 93% (14/15) for both 2D and 3D. No significant difference was noted in the size concordance rate between 2D and 3D templates for preoperative THA planning. However, preoperative 3D planning has several advantageous features, and we intend to continue our investigation.

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The use of digital templates is increasing with the spread of electronic medical records in Japan. We used a digital template (PC Group) for bipolar hip prosthesis in patients with femoral neck fracture, and compared the accuracy of digital templating with the conventional on-lay template (H Group). Through the entire study period, the H group was superior to the PC group in accuracy of both stem size and outer head size. However, beyond 3 months, the accuracy was almost the same between the two groups in terms of size. In the first 3 months, the H group was apparently superior to the PC group. It was thought that experience was necessary for accurate digital templating. The stem size in the PC group tended to exceed the actual size of both the outer head and stem compared with the H group. As size tends to be extended with a digital template, caution is considered necessary. A digital template is convenient, needs no paper, can be used for arthroplasty, fractures of the extremities, and various other orthpaedic operations, but is a little expensive and takes time to master. The digital template has reliability equal to that of a conventional template, and is considered to be useful.

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For diagnosis of FAI (femoroacetabular impingement), it is useful to obtain not only a static image but also a dynamic image, as FAI is affected by dynamic factors in the hip joint. We assessed the usefulness of ROM (range of motion) simulation using 3D CT for diagnosis of FAI in a 34-year-old man with thigh pain and a decreased range of hip joint motion. He had a history of fracture of the femoral shaft. Plain X-ray demonstrated the pistol grip deformity and the formation of a bump at the anterior head-neck junction. ROM simulation using 3D CT revealed that impingement occurred between the femur and the edge of the acetabulum at 65 degrees of hip flexion, compared with 100 degrees in the contralateral hip joint. We carried out surgical dislocation and resected the bone spur at the edge of the acetabulum and the bump at the anterior head-neck junction, and performed osteochondroplasty. Postoperatively, the patient was relieved of thigh pain and achieved a wide range of hip motion. ROM simulation showed impingement at 90 degrees of hip flexion. ROM simulation using 3D CT is useful for diagnosis of FAI and treatment planning.

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Bipolar hemiarthroplasty systems are currently widely used for the treatment of femoral neck fractures. A dislocation of the inner head in bipolar hip prosthesis with a self-centering system is a rare complication. Here we describe disassembly of a bipolar prosthesis in an elderly patient. An 86-year-old woman suffered a fall, and dislocated the inner head with a self-centering bipolar hip prosthesis. No structural damage was detected in the implant at re-exploration, and no technical difficulty was encountered during either procedure. The mechanism of disassembly was considered to have been impingement between the outer head and the acetabulum while the hip was forced into flexion, adduction, and internal rotation.

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The purpose of this study was to evaluate the clinical results of total hip arthroplasty for salvage of failed trochanteric fracture fixation. We treated six patients (1 man, 5 women, mean age 79 years). The mean interval from fracture fixation to arthroplasty was 24 months. The mean duration of follow-up was 16 months. Cementless standard stem was used in 3 patients, modular stem in one patient, and cemented stem in 2 patients. Mean JOA score improved from 32 preoperatively to 81 (P<0.01). There was no intra, postoperative femoral fracture, dislocation, and venous thromboembolism. Computed tomography was useful for the surgical planning. Total hip arthroplasty for salvage of failed trochanteric fracture fixation was technically more difficult. It is necessary to perform the preoperative surgical planning in detail.

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In our daily lives, the kneeling movement is very important, especially for individuals in Japan. Total knee arthroplasty (TKA) is an effective procedure for significantly relieving knee pain and improving ambulatory ability, however, many patients are not able to kneel after TKA surgery. We began to perform minimally invasive (MIS)-TKA in September 2010, and we found that not few patients were able to kneel after surgery. Therefore, we have examined the factors which contribute to increased kneeling ability after MIS-TKA with regard to surgical procedure, muscle recovery or range of knee motion.
The present study included 35 knees of 26 patients who underwent TKA in our department between November 2009 and July 2012. TKA revision patients were excluded from this study. To determine which method would be more effective in enabling the patient to kneel after surgery, the subjects were divided into two groups a MIS group and a conventional TKA group and analyzed statistically.
Fifteen knees were treated by conventional TKA, and twenty by MIS-TKA. Kneeling was possible after surgery for 4 knees treated conventionally and 14 knees treated using MIS-TKA. There was a significant difference in kneeling action between the two groups (p<0.05).
MIS-TKA is a technique in which the patella is not everted. It has been reported that everting the patella significantly reduces patellar blood flow. We conclude that not everting the patella in MIS-TKA is one of the factors that facilitate a kneeling action after surgery.

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The present study was conducted to evaluate the femoral and tibial tunnel positions created by the transtibial and outside-in techniques, and to assess the difference in clinical outcome between the two techniques after anterior cruciate ligament (ACL) reconstruction.
The study included 45 patients who underwent ACL reconstruction using either the transtibial (n=15) or outside-in (n=30) technique. Computed tomography scans of the treated knees were performed two weeks after surgery, and three-dimensional surface models were then produced. The positions of the femoral tunnels were measured by the quadrant method. Tibial tunnel aperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau.
The clinical outcomes were measured in terms of range of motion, the Lachman test, pivot shift test, KT-2000 arthrometry, and Lysholm score at 6 months after surgery.
On the femoral side, outside-in technique can create tunnels more accurately at the anatomic ACL footprint center than the transtibial technique.
On the tibial side, the bone tunnel positions for the transtibial and outside-in techniques were both significantly closer to the tunnel position that was indicated by data from previous studies.
There were no significant differences between the two groups in any of the physical parameters determined, or the Lysholm score.
The outside-in technique showed more accurate positioning of the femoral tunnels than the transtibial technique. It was difficult to create two femoral tunnels using the transtibial technique because the positions of the femoral tunnels are defined by the direction of the tibial tunnel. The present findings suggest that the outside-in technique is useful because it can create accurate positioning of the femoral tunnels independently.

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We report two rare cases of complete discoid medial meniscus in the knee. Case 1 : a 28-year-old man presented with a ten-year history of left knee pain without any history of injury. On physical examination, he had no swelling or loss of motion. Case 2 : a 29-year-old woman complained of localized pain in her right knee since childhood, without any history of injury. A few days earlier, she had noticed progressively increasing pain in the affected knee, and upon presentation the knee was locked and swollen. In both cases, radiographic views showed no specific abnormalities.T2-weighted magnetic resonance imaging (MRI) of both knees revealed bilateral medial discoid meniscus with a high-intensity area in the form of horizontal tears. Arthroscopic surgery was performed on both knees, and this confirmed the tears seen on MRI. At 10 years and 6 months after surgery in both cases, neither of the patients has symptoms or loss of motion. In these cases, it was assumed that partial meniscectomy was an appropriate surgical method for treatment of complete discoid medial meniscus.

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This report describes the use of arthroscopic fixation for five cases of tibial eminence fracture.
All the patients were male (average age 20.0 yr), and classified as Meyers-McKeever type 2 by X-ray imaging and computed tomography (CT). Displaced fragments were reduced arthroscopically, fixed with Ethibond sutures by the pull-out method in two cases, and fixed with cannulated cancellous screws in three cases. At ten days after surgery, range of motion (ROM) exercise and weight-bearing were started with an anterior cruciate ligament brace. Postoperative results were evaluated by X-ray, CT, MRI imaging, Lysholm score, and Kneelax arthrometer. At one year after surgery, bone union had been achieved all cases; the average Lysholm score was 98.6, and the knee-lax translation was 0.71 mm. None of the patients showed ROM limitation, anterior instability, or rotational instability. We have used pull-out fixation with Ethibond suture for small fragments, and screw fixation for large fragments. Both methods can be performed arthroscopically. In this series, all the cases were fixed with these two methods, and showed good postoperative outcomes.

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After arthrolysis of a stiff knee joint, it is often difficult to maintain intraoperative range of motion (ROM) because of pain in postoperative rehabilitation. Therefore, appropriate analgesia is important for rehabilitation. Previously we reported the efficacy of local infusion analgesia (LINFA) using an intra-articular double lumen catheter after total knee arthroplasty. The purpose of this study was to document the effect of our LINFA for patients with stiff knees. We present a case series study, in which 4 patients were treated for arthrofibrosis of the knee after pyogenic arthritis. The disease duration ranged from 5 to 22 weeks, preoperative ROM was 80-100 degrees, and the minimum follow-up period was 6 months. All patients underwent arthroscopic arthrolysis of the stiff knee, followed by placement of an indwelling double-lumen catheter. For LINFA, bolus injection of 10 mL of 0.75% ropivacaine was performed through the smaller tube of the double- lumen catheter. The larger tube for suction drainage was clamped for 1 h following injection of the analgesic. Immediately after the injection, ROM excercise was performed at least twice a day. Intraoperative ROM was 125-145 degrees, and the ROM at final follow-up was 130-150 degrees. There were no serious adverse effects such as infection, nerve injury, or skin trouble. Our results show that LINFA for arthrolysis of the knee joint is a safe and efficient method of treatment.

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Our tentative criterion for application of micro-endoscopic surgery for lumbar degenerative spondylolisthesis with neurological symptoms has been <20% slippage. We investigated the 1-year postoperative results of 25 patients treated in this way (21 men and 4 women; mean age 68.4 years). Preoperative X-ray examination demonstrated that 8 patients showed no change of slippage during forward and backward bending, and these patients were classified as a stable group. The mean slippage in this group was 12.5%, and it had not changed at the 1-year follow-up point. The remaining 17 patients showing slippage change were classified as an unstable group in whom slippage in the middle position was 8.4±1.3° preoperatively and 9.2±1.3° at the 1-year follow-up point. The mean improvement ratio for the JOA score was 59.9% in the stable group and 47.0% in the unstable group. No patients needed additional surgery due to an increase of slippage or deterioration of symptoms. Micro-endoscopic surgery is able to cope with lumbar degenerative spondylolisthesis with slippage of <20%.

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Purpose: To evaluate the functional and radiographic results of a scaphoid excision and four-corner fusion using headless compression screws on scapholunate advanced collapse (SLAC) wrist and scaphoid nonunion advanced collapse (SNAC) wrist.
Subjects and Methods: Three patients, with a mean age of 53.7 (range, 43-62) years, were treated for SLAC wrist (2 cases), SNAC wrist (1 cases). Four-corner fusion was achieved with an Acutrak® screw (one wrist) and a Twinfix® screw (2 wrists). The average follow-up time was 6.7 (range, 5-10) months. We evaluated the wrist range of motion (ROM), grip strength, visual analog scale (VAS), and modified Mayo wrist score. Radiographs were evaluated for union, carpal hight ratio (CHR) and radio-lunate angle (RLA).
Results: Average wrist ROM flexion/extension was 38°/40°after surgery and 48°/30° before surgery. The mean postoperative grip strength improved to 25.2kg, compared with 14.1kg before surgery. The average postoperative VAS was 5mm, an improvement over the preoperative average of 78mm. The postoperative mean modified Mayo wrist score was 57, which was better than the preoperative score of 22. Union had occurred in all wrists by an average 10 weeks. The postoperative mean CHR averaged 0.52, compared with the preoperative values of 0.50. Average RLA was -10° postoperatively, compared to -17° preoperatively.
Conclusion: Four-corner fusion using headless compression screws is an effective method allowing early ROM exercise and improvement of VAS, grip strength, and modified Mayo wrist score.

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To clarify the motion of the first metacarpal bone (1^st MC) of the trapezium (Tz), the author took 3D-CT images of his own thumb in six positions : neutral, flexion, extension, adduction, abduction and opposition. Based on these images, these six positions were reconstructed using bone models of the 1^st MC and the Tz. In the neutral position, the axis of the 1^st MC was on the perpendicular axis of the Tz. The axis of the 1^st MC was flexed at 16°, adducted 10° and pronated 5° in flexion, extended 9°, abducted 5° and pronated 9° in extension, flexed 9°, adducted 40° and supinated 16° in adduction, flexed 0°, abducted 10° and pronated 11° in abduction, and flexed 15°, abducted 10° and pronated 30° in opposition. The main contacts of the Tz and 1^st MC were both central to volar in flexion, both radial in extension, radial and ulnar in adduction, both radial in abduction, and volar and radiovolar in opposition. Three-dimensional analysis of the position of the 1^st MC on the Tz in these six positions allowed the main contact areas of the Tz and 1^st MC to be deduced.

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To develop a new staging system for osteoarthritis (OA) of the carpometacarpal joint of the thumb (CMJT), we obtained three-dimensional computed tomographic images of 19 thumbs with OA of the CMJT. These cases were divided into three groups at the early, progressive, and terminal stages. In the early stage, the trapezium (Tz) and the first metacarpal bone retained their normal anatomical relationship and were in contact with the subchondral bones. In the progressive stage, the surface of the Tz became grooved, and the first metacarpal bone (1^st MC) was subdislocated dorsally along the groove. In the terminal stage, the 1^st MC had sunk into the Tz and become fixed in a flexed and pronated position.
One of the 19 thumbs was at the early stage, nine were at the progressive stage, and nine were at the terminal stage. With this staging system, the features of the stages clearly differ from one another, making it easier to choose the best clinical treatment.

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Subcutaneous rupture of the flexor digitorum profundus (FDP) tendon of the small finger at the wrist joint is rare. Reports about this tendon rupture have appeared occasionally in the literature. In all of the reports, tendon suture, graft, or transfer was selected as the treatment. We performed tenodesis of the DIP joint for this lesion in two cases. The first patient was unable to flex the DIP joint of his little finger after a bowling game, and he was anxious to return to work as soon as possible after the operation. The second patient injured his little finger during a golf tournament. As he was a top amateur golf player, he also hoped to return to playing golf early. Therefore we selected tenodesis for reconstruction of the flexor tendon rupture, anticipating that the recovery period would be short. Both patients were well satisfied. In fact, the second patient was able to win victories in six golf tournaments within three months after the operation. We consider that flexor tenodesis is the treatment of choice for patients desiring an early return to daily life.

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We report a case of rupture of the flexor pollicis longus (FPL) associated with radius distal fracture. A 67-year-old woman fell and landed on her right hand when she was exercising. She sustained a fracture of her right distal radius, displaced to the dorsal side. One day after the injury, open reduction and internal fixation using a volar plate were performed. During a week after surgery, her right wrist was immobilized with a plaster splint. When the splint was removed, she was unable to flex the interphalangeal (IP) joint of her right thumb. Rupture of the FPL was diagnosed. Two weeks after surgery, we performed end-to-end suturing of the FPL, which was ruptured near the fracture site. The bilateral edges of the rupture were sharp.
Rupture of the FPL associated with radius distal fracture is a very rare complication, although some reports have described it after malunion of a distal radius fracture repaired by internal fixation using a volar plate.

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No outstanding fixation method for subtrochanteric fractures of the femur has been available. In recent years, intramedullary fixation with a long femoral nail has yielded good clinical results. However, the long proximal femoral nail system requires accurate fluoroscopic techniques for distal screw insertion.
We have been treating femoral subtrochanteric fractures with the IPT Long Nail System® (230 mm), a device that enables a surgeon to insert the distal screw without a fluoroscope. Here we report our initial experience with the IPT Long Nail System® for treatment of femoral subtrochanteric fractures.
Between November 2010 and March 2012, we operated on 14 patients (5 males and 9 females) with femoral subtrochanteric fractures using the IPT Long Nail System® (230 mm). Their mean age was 80.8 years (range, 45-90 years). The average follow-up period was 11 months (range, 9-18 months). The average operation time was 81.5 min (range, 35-130 min), and the average bleeding volume was 192 ml (range, 50-650 ml). Before injury, the patients' activities of daily living (ADLs) were : walking unaided 8 patients, walking with a cane 3 patients, and wheelchair 3 patients. Bone union was obtained in 11 patients, and after surgery all were able to regain their previous ADL abilities.
As surgery with the IPT Long Nail System® (230mm) is easy, patients suffer less surgery-related stress. We agree with previous authors that the 230-mm nail length is satisfactory for treating femoral subtrochanteric fractures.

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Bisphosphonate therapy decreases the risk of vertebral and proximal femoral fractures in patients with osteoporosis. However, recent reports have associated long-term bisphosphonate therapy with atypical femoral fractures. We report two cases of atypical femoral fracture in patients receiving bisphosphonate therapy. One patient had ipsilateral femoral pain before fracture, and the other did not. Both patients showed cortical thickening, short oblique orientation, medial spikes, minimal trauma, and absence of comminution. The association between bisphosphonate therapy and the occurrence of atypical fractures of the femur is highly likely. However, the incidence rate was very low. The need for continued bisphosphonate therapy should be carefully reassessed.

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We report cases of reoperation for fractures in our hospital. Between March 2005 and December 2011, 962 patients underwent surgery for fractures and the patients were followedup for at least three months. Seventeen patients (mean age 82.3 years) underwent reoperation (2 males and 15 females; upper extremities 2, lower extremities 15). The average period from primary surgery to reoperation was 27 years. Complications included refractures, non-union, and osteonecrosis. The reasons for reoperation were technical error and bone fragility. For better outcome, it is important to not only acquire proficiency in surgical techniques, but also to ensure that patients are given drug therapy for osteoporosis if necessary.

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Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue sarcoma that is considered low-grade. We have treated two cases of EMC.
Case 1: A 46-year-old man with EMC on the left upper arm. We opted for marginal excision and added radiotherapy. Chemotherapy was performed for pulmonary metastasis. After ten years and there is no evidence of local recurrence or metastasis.
Case 2: A 65-year-old man with EMC on the left thigh. There was neither local recurrence nor metastasis six months after surgery with wide excision.
The clinical behavior of EMC is considered to be that of a low-grade sarcoma, based on the first description of the tumor by Enzinger and Shiraki, who reported that only 4 out of 34 patients died of the disease within a short-term follow-up period (median 3.5 years). Later, in 1992, Saleh et al. followed up ten patients with EMC over a long period and concluded that EMC is a persistent and finally devastating tumor with a high potential for local recurrence and distant metastasis, despite showing an indolent long-term course. We must consider the possibility of recurrence and metastasis after long-term progression of EMC, and therefore prudent follow-up is required.

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We report a 64-year-old woman who was referred to our institution for treatment after X-ray images showed an osteolytic lesion in the right distal femur at a local clinic. She had first felt pain in the right knee about one year previously, and nine months later she visited the local clinic when her pain worsened. She had no notable medical history. Incisional biopsy indicated malignancy, although the diagnosis was not definitive. Wide excision of the tumor lesion and artificial joint replacement of the right knee were performed. Pathological examination proved that the removed tissue specimen was osteosarcoma, and therefore, cisplatin and adriamycin were administered as postoperative chemotherapy. No recurrence was noted eight months after surgery. While reports of primary osteosarcoma in elderly patients have been increasing, it remains a rare tumor. Special attention is important in the diagnosis of osteosarcoma, as delay may result in deterioration of the condition and a poorer prognosis.

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Solitary bone cyst (SBC), a tumor-like lesion, is not rare. The treatment remains undecided, and various approaches (such as conservative, steroid injection, curettage with bone grafting, and curettage with cannulation) have been reported. As the pathogenesis of SBC of the calcaneus differs from that of SBC of long bones, the treatment needs to be altered accordingly.
We have treated 22 patients with SBC between 2003 and 2012. The locations of the lesions were the humerus in 2 cases, femur in 8, tibia in 1, fibula in 1, calcaneus in 6, iliac bone in 3, and pubic bone in 1. We surgically treated 10 of the 22 cases.
Lesions in the calcaneus were treated by curettage with bone grafting, and the patients have made satisfactory progress without recurrence.
Lesions in long bones tend to recur when in the active phase. The cannulated hydroxyapatite pin is recommended because of its higher success rate. We treated such cases using curettage plus cannulation, but recurrence was common.

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The origin of peroneal intraneural ganglion and the outcome of treatment are still controversial. Here we report three cases of peroneal intraneural ganglion and discuss the appropriate treatment. The patients, aged 58, 62, and 65 years, underwent surgery with extra neural decompression and epineurotomy within 19 months after onset of drop foot. After 1 year of follow-up, peroneal nerve paralysis had recovered in all patients, even in those with residual ganglion. For successful treatment of peroneal intraneural ganglion, we propose that correct early diagnosis, simple exoneural dissection and atraumatic epineurotomy are effective. For early diagnosis, clinicians should always be mindful of the possibility of this rare lesion.

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We report a case of patellar tendon rupture in a patient with osteogenesis imperfecta. The patient was a 37-year-old man who suffered a patellar tendon rupture by missing a step on the stairs. X-ray examination demonstrated patella alta, and discontinuity of the patellar tendon was noted on MRI. The patient was diagnosed with osteogenesis imperfecta (Sillence type 1A) by the presence of a blue sclera, a history of achilles tendon rupture and femoral diaphyseal fracture, and a low value of serum intact type 1 collagen N-propeptide (P1NP). The ruptured tendon was repaired using Ethibond suture, and augmented using the Leeds-Keio artificial ligament. There has been no re-rupture during one year of follow-up, and the patient has satisfactory knee function.

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Ankle arthrodesis is the most common method for cure of destructive ankle lesions. However, total ankle arthroplasty (TAA) is an operation that should be considered as a method for maintaining or improving the range of motion (ROM).
We report our experience with the use of FINE TAA for six ankles in 2 patients with OA and 3 with RA. The average preoperative JOA score was 34 points, and this was improved to 72 points after the operation. However, one OA patient experienced loosening of the artificial joint.
Our experience suggests that surgical indications should be considered carefully. The high obesity example more than 75kg of the activity was out of adaptation.

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We have investigated the importance of patient global assessment with visual analogue scale (Pt-VAS) in Boolean evaluation as an index of disease activity remission in patients with rheumatoid arthritis (RA). Among 298 RA patients referred to our institution, Boolean evaluation indicated that among 4408 treatment opportunities, remission was evident in 2052, whereas Pt-VAS indicated remission for all four components on 1618 occasions. Pt-VAS demonstrated a significantly close correlation with the patient's clinical situation, in particular the Pain Score and health assessment questionnaire (HAQ). As Pt-VAS increased, there was a gradual reduction of sensitivity and an increase of specificity for the group in which tender joint count (TJC), swollen joint count (SJC), and C-reactive protein (CRP) were within 1. With regard to sensitivity, all measurements demonstrated more than 90% simplified disease activity index (SDAI) remission, but within 10 mm the specificity was less than 50%. Up to 30 mm, both sensitivity and specificity were more than 90%, while within 20 mm specificity was almost 80%. Therefore, we conclude that in Boolean evaluation of remission, Pt-VAS might be acceptable within 20 mm.

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We evaluated 9 patients who underwent TEA using the DOH total elbow system. There were 8 women and 1 man with a mean age of 68 years. All 9 patients were diagnosed as having rheumatoid arthritis; 6 had painful stiffness and 3 had painful instability.
We used non-constrained-type DOH total elbow system with cemented components. Four patients who had wrist pain underwent the Darrach procedure additionally.
The modified Mayo Elbow Performance Score (mMEPS) was used for clinical evaluation. After a mean follow-up of 15 months, the mMEPS improved from 48 to 86 points, and elbow flexion from 107 to 129 degrees. There was no dislocation or radiological evident loosening.
Two patients were complicated with incomplete ulnar nerve palsy, which was resolved within 1 year. One patient sustained an ulnar fracture distal to the ulnar component at 7 months after surgery. She treated with a cast, and healing was achieved.
We experienced 1 patient who sustained a fracture of the medial epicondyle of the humerus before TEA. This required additional pinning fixation, and clinical evaluation confirmed improvement.
In conclusion, TEA is considered a good technique for rheumatoid arthritis patients with painful elbow.

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We report a case of right shoulder contracture with ectopic ossification of the coracoclavicular ligament after distal end fracture of the clavicle. This male patient had struck his right shoulder and fractured the distal end of the right clavicle. The fracture was treated conservatively, and the bone healed six weeks after injury. However, the patient returned four and a half months later with contracture of the right shoulder. As two months of rehabilitation facilitated no improvement, resection of the ossified coracoclavicular ligament and manipulation were performed. The range of motion of the right shoulder returned to almost normal, and this condition was retained at six months after surgery. Although a good short-term result was obtained by resection of the ossified coracoclavicular ligament in this case, further monitoring for re-ossification will be necessary.

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Purpose and Objective : We report 4 cases of reoperation for contracture, pain and osteoarthritis after arthroscopic Bankart repair for recurrent shoulder dislocation. These cases were evaluated for part of the position and ratio of suture exposure, and ROM before and after reoperation.
Results : There were 4 of 5 (80%) exposure at the 5 : 00 position on the articular capsule, 4 of four (100%) at 4 : 00, 2 of four (50%) at 3 : 00, 0 of four (0%) at 2 : 00, and the sutures were removed. After reoperation, all the patients showed improvement of ROM and pain relief.
Conclusion : For prevention of osteoarthritis, it is important not to bear too much strain on the articular capsule suture, and not to tie a knot in the intraarticular region.

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Objective: The purpose of this study was to investigate and clarify the characteristics of lumbar disc herniation (LDH) in younger patients.
Patients and Methods: The case group comprised 50 patients under 20 years of age who underwent microscopic discectomy, microendoscopic discectomy, and bilateral fenestration and discectomy. The control group comprised 50 patients age between 30 and 60 years who were treated by microscopic discectomy. The average ages of the case group and the control group were 17.9 years and 44.5 years, respectively, and the average follow-up periods were 6.3 months and 7.7 months, respectively.
Results: Compared with the control group, most of the patients in the case group had subligamentous-type herniation (84%); transligamentous and sequestrated herniation was relatively rare. The preoperative Japanese Orthopedic Association score (JOA score) for the case group was significantly less than that for the control group in terms of lumbago and straight-leg raising (SLR). The average JOA score increased by 6.4 points postoperatively in the case group and 5.3 points in the control group.
Conclusions: Clinically, younger LDH patients tend to have lumbago and severely positive SLR in comparison with adult patients. As most of the herniations in younger patients are the subligamentous type, if conservative therapy is unsuccessful, operative treatment should be considered.

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