Reproduction of forearm rotation dynamic using intensity-based biplane 2D-3D registration matching method.

This study aimed to reproduce and analyse the in vivo dynamic rotational motion of the forearm and to clarify forearm motion involvement and the anatomical function of the interosseous membrane (IOM). The dynamic forearm rotational motion of the radius and ulna was analysed in vivo using a novel image-matching method based on fluoroscopic and computed tomography images for intensity-based biplane two-dimensional-three-dimensional registration. Twenty upper limbs from 10 healthy volunteers were included in this study. The mean range of forearm rotation was 150 ± 26° for dominant hands and 151 ± 18° for non-dominant hands, with no significant difference observed between the two. The radius was most proximal to the maximum pronation relative to the ulna, moved distally toward 60% of the rotation range from maximum pronation, and again proximally toward supination. The mean axial translation of the radius relative to the ulna during forearm rotation was 1.8 ± 0.8 and 1.8 ± 0.9 mm for dominant and non-dominant hands, respectively. The lengths of the IOM components, excluding the central band (CB), changed rotation. The transverse CB length was maximal at approximately 50% of the rotation range from maximum pronation. Summarily, this study describes a detailed method for evaluating in vivo dynamic forearm motion and provides valuable insights into forearm kinematics and IOM function.

[TWO CASES OF ALLERGIC VULVOVAGINITIS DIAGNOSED BY DIRECT MICROSCOPIC URINE SEDIMENT EXAMINATION].

Cedar pollen is known as a typical allergen that causes various allergic symptoms in the nasal mucosa, conjunctiva, and skin. However, inflammation of the vulvar mucosa due to sensitization to cedar pollen is not well-known. We experienced two cases in which the detection of cedar pollen during microscopic urine sediment examination led to the diagnosis of allergic vulvovaginitis caused by cedar pollen. The cases involved a 4-year-old girl and a 10-year-old girl. In both cases, the patients presented with chief complaints of pruritis in the vulva and insomnia due to frequent urination during the season of cedar pollen dissemination. Both patients were afebrile. No inflammatory skin changes such as erythema, swelling, or non-purulent discharge from mucous membranes of the vulva were observed. Microscopic urine sediment examination revealed large amounts of shed cedar pollen. The patients' conditions improved after treatment with oral antihistamines and instruction to dry their underwear indoors. Follow-up blood tests revealed high levels of specific anti-IgE antibodies to cedar pollen, thus confirming a diagnosis of allergic vulvovaginitis due to cedar pollen. Cedar pollen can cause allergic vulvovaginitis. Microscopic urine sediment examination is useful, and when combined with specific IgE antibody testing, leads to an appropriate diagnosis. This disease should also be considered in patients with complaints of vulvar discomfort during the season of cedar pollen dissemination.

Risk factors for insufficient ultrasound-guided supraclavicular brachial plexus block.

PURPOSE: Ultrasound-guided supraclavicular brachial plexus block (SCBPB) is performed by surgeons for upper limb anesthesia; however, certain patients need additional local anesthesia. This study aimed to identify risk factors for additional local anesthetic injection requirements. METHODS: In total, 269 patients receiving ultrasound-guided SCBPB were enrolled. Patient age, sex, body mass index, anesthetic drug dose, surgeon expertise (hand surgeon or resident), tourniquet time, comorbidities (diabetes mellitus and mental disorders), and preoperative blood pressure representing anxiety were compared between the additional local anesthesia and no additional local anesthesia groups matched for background using propensity scores. Receiver operating characteristic analysis was performed to determine risk factor cut-off values with the highest predictive potential. RESULTS: Of 269 patients, 41 (15.2%) required additional intraoperative local anesthesia. Among surgical sites, elbow surgery showed the highest prevalence of the need for additional local anesthesia (17/41, 41%). A high body mass index and high systolic blood pressure before surgery were identified as risk factors for additional intraoperative local anesthesia requirement. Furthermore, systolic blood pressure > 170 mmHg (area under the curve, 0.66) predicted the need for intraoperative local anesthesia with 36% sensitivity, 89% specificity, 37.5% positive predictive value, and 88.6% negative predictive value. The median systolic blood pressure was significantly greater in patients requiring additional local anesthesia than in those not requiring it [151 (139-171) mmHg vs. 145 (127-155) mmHg; P = 0.026]. CONCLUSION: Elbow surgery, obesity, and high systolic blood pressure (> 170 mmHg) before surgery are predictive of additional intraoperative local anesthesia requirement. LEVEL OF EVIDENCE: Prognostic Level III.

Development of Atypical Ulnar Fracture is Associated with Bisphosphonate Therapy and Severe Spinal Deformity: A Case Report.

Atypical ulna fracture (AUF) is relatively rare and is known to be associated with prolonged bisphosphonate (BP) use. The developmental mechanism remains unclear. We report a patient with an AUF associated with BP and severe spinal deformity. The patient was an 85-year-old woman receiving oral alendronate for 8 years without vitamin D supplementation. During regular kitchen work, she needed left upper limb support. She presented with atraumatic pain over the ulna. Radiographs revealed a transverse fracture in the proximal ulna and ulna bowing deformity. Whole-spine standing radiographs showed severe degenerative kyphoscoliosis. The skin induration with pigmentation on her left elbow that suggested prolonged overload and during standing work, coincided exactly with fracture location. This report suggests that 'direct stress', with persistent local overload on the proximal ulna, is one of the developmental mechanisms of AUF, in addition to persistent suppression of bone remodelling by prolonged BP use and vitamin D deficiency. Level of Evidence: Level V (Therapeutic).

Relationship between distal radius fracture severity and 25-hydroxyvitamin-D level among perimenopausal and postmenopausal women.

AIMS: Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency. METHODS: This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared. RESULTS: The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities. CONCLUSION: Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D3 supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study. Cite this article: Bone Jt Open 2022;3(3):261-267.

Arthroscopic Triangular Fibrocartilage Complex Reconstruction Using a Palmaris Longus Tendon Graft.

Patients suffer from persistent ulnar wrist pain and distal radioulnar joint instability because of chronic triangular fibrocartilage complex (TFCC) foveal tear are treated with TFCC reconstruction. We performed an arthroscopic TFCC reconstruction using a palmaris longus tendon graft that provided a minimally invasive procedure. After confirming the TFCC foveal tear and stability between the TFCC remnant and radius, the bone tunnel was made in the ulna from the ulnar shaft to ulnar fovea. The position of the bone tunnel was checked by fluorography and arthroscopy. Curved bendable 18-gauge needles into which 3-0 nylon sutures were inserted in a loop shape were passed through the tunnel from the ulnar side, and both volar-side and dorsal-side TFCC remnants were penetrated. The nylon suture was extracted from the arthroscopic 4/5 portal, and the palmaris longus tendon graft was introduced into the joint. The graft was passed through the TFCC remnant and ulnar bone tunnel from the arthroscopic portal and fixed to the ulna using an interference screw. This procedure was indicated for TFCC foveal tears with intact radial-side TFCC remnants. If the radial-side tear and instability between the TFCC and radius coexist, this technique is contraindicated, and stabilization of both the radial and ulnar sides of the TFCC should be considered. This arthroscopic technique does not violate the distal radioulnar joint capsule, extensor carpi ulnaris tendon, or tendon sheath. In addition, it helps to stabilize the ulnar carpal complex.

Comparison of the Orientation Angles of Volar Locking Plate Distal Ulnar Locking Screw for Distal Radius Fractures.

PURPOSE: This study aimed to measure the angles between the screw and plate in 16 commercially available volar locking plates (VLPs) to determine the fixable intra-articular fragment size. METHODS: Ulnar orientation angles (axial plane) and elevation angles (sagittal plane) between the distal ulnar screw and plate were measured for 14 fixed-angle VLPs and 2 variable-angle VLPs. Each VLP was simulated by 2 surgeons to sit distally and ulnarly in 10 normal distal radius models. The distance between the screw and distal/ulnar end of the distal radius on both the volar and dorsal sides, designated as the longitudinal/lateral distance, was measured to identify the fixable size of the 2 intra-articular fragments: volar lunate fragment and dorsoulnar fragment. Relationships between the ulnar orientation angle and dorsal-side lateral length as well as the elevation angle and dorsal-side longitudinal distance were analyzed. RESULTS: The ulnar orientation and elevation angles ranged from 6.5° to 16.9° and -5.8° to 34.3°, respectively, for fixed-angle VLPs and -12.5° to 32.2° and 3.1° to 42.1°, respectively, for variable-angle VLPs. The minimal longitudinal distances on the volar side with the fixed- and variable-angle VLPs were 4.3-10.9 mm and 5.8-5.9 mm, respectively. On the dorsal side, the lateral distance negatively correlated with the ulnar orientation angle (R = -0.74), and the longitudinal distance negatively correlated with the elevation angle (R = -0.89). CONCLUSIONS: The Depuy Synthes variable-angle VLP provides an advantage for fixating small intra-articular fragments. For fixed-angle VLPs, the Mizuho VLP provides an advantage for fixating small volar lunate fragments. A narrow dorsoulnar fragment can be fixated using a plate with a large ulnar orientation angle, such as the Zimmer Biomet or Mizuho VLP. CLINICAL RELEVANCE: The ability of each individual commercially available plate to capture specific intra-articular fragments should be known.

Tolerability of the first infusion of once-yearly zoledronic acid within one to two weeks after hip fracture surgery.

OBJECTIVE: Once-yearly infusions of zoledronic acid (ZA) 5 mg may be optimal for secondary fracture prevention after hip fracture (HF), but there are crucial side effects of ZA. This study assessed the tolerability of the first infusion of once-yearly ZA within one to two weeks after HF surgery and to identify risk factors for acute-phase reactions (APRs) and the decrease in serum calcium (Ca) concentration. METHODS: We analyzed 84 patients (average age: 83 years, 18 men and 66 women) who met the inclusion criteria. The patients underwent the first infusion of ZA one to two weeks after HF surgery and received antipyretic analgesics and active vitamin D analog. RESULTS: APRs occurred in ten patients (11.9%) and all these patients had pyrexia (>37.5 °C) and/or other symptoms. The asymptomatic hypocalcemia (serum Ca < 8.3 mg/dL) incidence was 6.0% at 7 days after ZA infusion. Compared with female patients without APRs, female patients with APRs had significantly higher levels of serum 25-dihydroxyvitamin D at baseline and serum C-reactive protein on the day ZA was administered (day 0). Multiple linear regression analyses showed that serum level of tartrate-resistant acid phosphatase-5b were significantly associated with an absolute decrease in serum corrected Ca from day 0 to day 7. CONCLUSIONS: The first infusion of ZA within one to two weeks after HF surgery was well tolerated with the combined use of antipyretic analgesics and active vitamin D analog. Higher inflammatory condition after surgery which is more likely sensitized by ZA administration may increase the risk of APRs, and high bone turnover may increase hypocalcemia risk.

Comparing the locking screw direction of three locking plates for lateral clavicle fractures: a simulation study.

BACKGROUND: The locking plate is a useful treatment for lateral clavicle fractures, however, there are limits to the fragment size that can be fixed. The current study aimed to measure the screw angles of three locking plates for lateral clavicle fractures. In addition, to assess the number of screws that can be inserted in different fragment sizes, to elucidate the size limits for locking plate fixation. METHODS: The following three locking plates were analyzed: the distal clavicle plate [Acumed, LLC, Oregon, the USA], the LCP clavicle plate lateral extension [Depuy Synthes, LLC, PA, the USA], and the HAI clavicle plate [HOMS Engineering, Inc., Nagano, Japan]. We measured the angles between the most medial and lateral locking screws in the coronal plane and between the most anterior and posterior locking screws in the sagittal plane. A computer simulation was used to position the plates as laterally as possible in ten normal three-dimensional clavicle models. Lateral fragment sizes of 10, 15, 20, 25, and 30 mm were simulated in the acromioclavicular joint, and the number of screws that could be inserted in the lateral fragment was assessed. Subsequently, the area covered by the locking screws on the inferior surface of the clavicle was measured. RESULTS: The distal clavicle plate had relatively large screw angles (20° in the coronal plane and 32° in the sagittal plane). The LCP clavicle lateral extension had a large angle (38°) in the sagittal plane. However, the maximum angle of the HAI clavicle plate was 13° in either plane. The distal clavicle plate allowed most screws to be inserted in each size of bone fragment. For all locking plates, all screws could be inserted in 25 mm fragments. The screws of distal clavicle plate covered the largest area on the inferior surface of the clavicle. CONCLUSIONS: Screw angles and the numbers of screws that could be inserted in the lateral fragment differed among products. Other augmented fixation procedures should be considered for fractures with fragment sizes < 25 mm that cannot be fixed with a sufficient number of screws.

Quantitative Analysis for the Change in Lengths of the Radius and Ulna in Missed Bado Type I Monteggia Fracture.

BACKGROUND: In missed Monteggia fracture (MMF) cases, ulnar angulation and lengthening by osteotomy are required to reduce the dislocated radial head. This study aimed to clarify the abnormal discrepancy in length between the radius and ulna in MMF. We tested the hypothesis that the increase in the abnormal discrepancy in length between the radius and ulna relates with the duration of radial head dislocation. METHODS: In total, 24 patients with MMF were studied and classified into 2 groups, according to the duration of radial head dislocation, including the early group (n=9, within 3 y) and the long-standing group (n=15, older than 3 y). The lengths of the radius (Lr) and ulna (Lu) were measured. The difference in length between the ulna and radius (DL=Lu-Lr) was calculated on both the affected (DLaff) and normal (DLnor) sides. DLnor-DLaff, which represented an abnormal discrepancy in both bones, was analyzed for correlation with the duration of radial head dislocation and the age at initial injury. RESULTS: The affected and normal sides had no differences in the Lr of both the groups and in the Lu of the early group. However, in the long-standing group, Lu was significantly smaller in the affected side than in the normal side (P=0.001). In the long-standing group, DLaff was significantly smaller, owing to decreased length of the ulna, than DLnor (P=0.003). The DLnor-DLaff was positively correlated with the duration of radial head dislocation and was negatively correlated with the age at injury. CONCLUSIONS: In chronic MMF cases, the length of the ulna was shorter in the affected side than in the normal side. Therefore, ulnar lengthening is necessary to resolve this abnormal discrepancy and reduce the radial head. Because excessive ulnar lengthening has risks of postoperative complications, one of the surgical options is gradual ulnar lengthening or shortening osteotomy of the radius. LEVEL OF EVIDENCE: Level III-Prognosis study.

Regional Distribution of Articular Cartilage Thickness in the Elbow Joint: A 3-Dimensional Study in Elderly Humans.

During elbow procedures, reconstruction of the joint (including the articular cartilage) is important in order to restore elbow function; however, the regional distribution of elbow cartilage is not completely understood. The purpose of the present study was to investigate the 3-dimensional (3-D) distribution patterns of cartilage thickness of elbow bones (including the distal part of the humerus, proximal part of the ulna, and radial head) in order to elucidate the morphological relationship among them. METHODS: Two 3-D surface models were created with use of a laser scanner: (1) a cartilage-bone model based on 20 elderly cadaveric elbows exhibiting normal cartilaginous conditions and (2) a bone model that was created after dissolving the cartilage. The 2 models were superimposed, and cartilage thickness was measured as the interval distance on the articular surface. Measurements were made at categorized anatomical points of the individual bones, and 3-D distributions on the entire articular surface were analyzed. The spatial relationship among individual bones was also assessed. RESULTS: In the distal part of the humerus, the cartilage was thickest in the intermediate region between the capitellum and the trochlea (mean [and standard deviation], 1.27 ± 0.17 mm); in the proximal part of the ulna, it was thickest at the anterolateral edge of the coronoid (2.20 ± 0.39 mm) and the anteroproximal edge of the proximal sigmoid notch (2.49 ± 0.55 mm); and in the radial head, it was thickest at the articular zone on the rim circumference within the dish (1.10 ± 0.17 mm) and on the proximal circumference around the side (1.02 ± 0.17 mm) (p < 0.001 for all). These thicker cartilage regions gathered on the joint center, facing each other. CONCLUSIONS: The present study demonstrated regional variations in elbow cartilage thickness. The combined findings in individual bones showed "cartilage gathering" at the center of the elbow joint, which we believe to be a novel anatomical finding. CLINICAL RELEVANCE: An enhanced understanding of elbow cartilage geometry will provide additional insights into elbow procedures in elderly individuals, such as hemiarthroplasties, in which anatomical contours could help to restore normal joint function and improve postoperative outcomes.

Validation of the registration accuracy of navigation-assisted arthroscopic débridement for elbow osteoarthritis.

BACKGROUND: The identification and precise removal of bony impingement lesions during arthroscopic débridement arthroplasty for elbow osteoarthritis is technically difficult. Surgical navigation systems, combined with preoperative 3-dimensional (3D) assessment of bony impingements, can provide real-time tracking of the surgical instruments and impingement lesions. This study aims to determine the registration accuracy of the navigation system for the humerus and ulna during elbow arthroscopy. METHODS: We tested the registration procedure using resin bone models of 3 actual patients with elbow osteoarthritis. We digitized bone surface points using navigation pointers under arthroscopy. We initially performed paired-point registration, digitizing 6 preset anatomical landmarks, and then refined the initial alignment with surface matching registration, digitizing 30 points. The registration accuracy for each trial was evaluated as the mean target registration error in each reference marker. Three observers repeated the registration procedure 5 times each with the 3 specimens (total, 45 trials). The median of the registration accuracy was evaluated in total (45 trials) as the accuracy of the registration procedure. The differences in the registration accuracy among the 3 observers (median of 15 trials) were also examined. RESULTS: The total registration accuracies were 0.96 mm for the humerus and 0.85 mm for the ulna. No significant differences were found in the registration accuracy for the humerus and ulna among the 3 observers. CONCLUSIONS: This arthroscopic-assisted registration procedure is sufficiently feasible and accurate for application of the navigation system to arthroscopic débridement arthroplasty in clinical settings.

Three-Dimensional In Vivo Analysis of Malunited Distal Radius Fractures With Restricted Forearm Rotation.

Malunited distal radius fractures (DRFs) occasionally restrict forearm rotation, but the underlying pathology remains unclear. We aimed to elucidate the mechanism of rotational restriction by retrospective analysis of 23 patients with unilateral malunited DRFs who presented restricted forearm rotation. We conducted computed tomography during forearm rotation on both sides. Three-dimensional (3D) bone surface models of the forearm were created, and 3D deformity of the distal radius, translation of the distal radius relative to the ulna, distal radioulnar joint (DRUJ) contact area, and estimated path length (EPL) of distal radioulnar ligaments (DRUL) during forearm rotation were evaluated. In total, 18 patients had dorsal angular deformities (DA group) and five had volar angular deformities (VA group). In the DA group, the closest point between the distal radius and ulna on DRUJ was displaced to the volar side during supination and pronation (p < 0.001); DRUJ contact area was not significantly different between the DA and normal groups. In bone-ligament model simulation, the EPL of dorsal DRUL was longer in the DA group than in the normal group (p < 0.001); opposite phenomena were observed in the VA group. In the DA group, translation of the distal radius in a volar direction relative to the ulna during pronation was impaired presumably due to dorsal DRUL tightness. Anatomical normal reduction of the distal radius by corrective osteotomy may improve forearm rotation by improving triangular fibrocartilage complex tightness and normalizing translation of the distal radius relative to the ulna. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1881-1891, 2019.

Analysis of forearm rotational motion using biplane fluoroscopic intensity-based 2D-3D matching.

Measuring three-dimensional (3D) forearm rotational motion is difficult. We aimed to develop and validate a new method for analyzing 3D forearm rotational motion. We proposed biplane fluoroscopic intensity-based 2D-3D matching, which employs automatic registration processing using the evolutionary optimization strategy. Biplane fluoroscopy was conducted for forearm rotation at 12.5 frames per second along with computed tomography (CT) at one static position. An arm phantom was embedded with eight stainless steel spheres (diameter, 1.5 mm), and forearm rotational motion measurements using the proposed method were compared with those using radiostereometric analysis, which is considered the ground truth. As for the time resolution analysis, we measured radiohumeral joint motion in a patient with posterolateral rotatory instability and compared the 2D-3D matching method with the simulated multiple CT method, which uses CTs at multiple positions and interpolates between the positions. Rotation errors of the radius and ulna between these two methods were 0.31 ±â€¯0.35° and 0.32 ±â€¯0.33°, respectively, translation errors were 0.43 ±â€¯0.35 mm and 0.29 ±â€¯0.25 mm, respectively. Although the 2D-3D method could detect joint dislocation, the multiple CT method could not detect quick motion during joint dislocation. The proposed method enabled high temporal- and spatial-resolution motion analyses with low radiation exposure. Moreover, it enabled the detection of a sudden motion, such as joint dislocation, and may contribute to 3D motion analysis, including joint dislocation, which currently cannot be analyzed using conventional methods.

In Vivo Three-Dimensional Analysis of Malunited Forearm Diaphyseal Fractures with Forearm Rotational Restriction.

BACKGROUND: The aim of this study was to clarify the mechanisms of rotational restriction in malunited forearm diaphyseal fractures. METHODS: We retrospectively analyzed the cases of 18 patients with malunited forearm diaphyseal fractures and rotational restriction. All patients underwent bilateral computed tomography (CT) of the forearm in maximum supination, pronation, and neutral positions. From these images, we created 3-dimensional (3-D) bone surface models. We quantified the 3-D deformities, identified instances of osseous impingement between the radius and the ulna during forearm rotation, calculated the path length of the central band (CB) of the interosseous membrane, and measured forearm range of motion. RESULTS: Sixteen patients had extension deformity of the radius (the RE group) and 2 had flexion deformity (the RF group). In the RE group, extension deformity of the radius and valgus deformity of the ulna had significant negative correlation with pronation range of motion (R = -0.50, p = 0.046) and supination range of motion (R = -0.63, p = 0.027), respectively. Osseous impingement was mainly observed during pronation (15 of 16 patients). The CB path with the largest changes in length originated from the distal CB attachment area of the radius and ran toward the proximal area of the ulna (the transverse CB). The transverse CB significantly increased in length in supination compared with that in pronation (p < 0.001). Therefore, tightness of the transverse CB appeared to cause supination restriction in the RE group. In the RF group, osseous impingement caused supination restriction. The greatest increases in the transverse CB length were observed in pronation in the RF group, which appeared to cause pronation restriction. CONCLUSIONS: In the RE group, pronation restriction was associated with osseous impingement that was due to extension deformity of the radius, and supination restriction was associated with CB tightness that was due to valgus deformity of the ulna. In the RF group, our results suggested that pronation restriction was caused by CB tightness and that supination restriction was caused by osseous impingement. CLINICAL RELEVANCE: Three-dimensional corrective osteotomy for extension deformity of the radius in malunited forearm diaphyseal fractures would improve rotational restriction by relieving osseous impingement during pronation and CB tightness during supination.

Physeal bar resection using a patient-specific guide with intramedullary endoscopic assistance for partial physeal arrest of the distal radius.

The partial physeal arrest of the distal radius could result in progressive deformities and functional problems of the wrist. Despite being the most preferred surgical intervention, physeal bar resection (Langenskiöld procedure) is technically demanding. This manuscript aims to illustrate the technical tricks and present an illustrative case of premature physeal arrest of the distal radius managed with a novel method for the Langenskiöld procedure, involving complete removal of the bar using a patient-specific guide in combination with an intramedullary endoscopy technique that facilitated direct observation.

Three-dimensional kinematics of the lunate, hamate, capitate and triquetrum with type 1 or 2 lunate morphology.

The purpose of this study was to investigate the differences in three-dimensional carpal kinematics between type 1 and 2 lunates. We studied 15 instances of wrist flexion to extension (nine type 1, six type 2), 13 of radial to ulnar deviation (seven type 1, six type 2), and 12 of dart-throwing motion (six each of type 1 and 2) in 25 normal participants based on imaging with computerized tomography. Mean proximal translation of the distal articular midpoint of the triquetrum relative to type 2 lunates during wrist radioulnar deviation was 2.9 mm (standard deviation (SD) 0.7), which was significantly greater than for type 1 lunates, 1.6 mm (SD 0.6). The hamate contacted the lunate in ulnar deviation and ulnar flexion of wrists with type 2 lunates but not with type 1. We conclude that the four-corner kinematics of the wrist joint are different between type 1 and 2 lunates.

[The influences of narcissism on the justifiability evaluation of anger expression].

In this study, we examined the relationship between the level of narcissism and justifiability evaluation of anger expression. Participants, 313 students, were asked to rate the justifiability of a variety of anger expressions by them as suffering victims, and answer the Narcissistic Personality Inventory-Short Version (NPI-S). Results indicated that the higher the sense of superiority and competence, which was an aspect of personality, the more justifiable they felt their unilateral expression of anger was. In contrast, the higher the need for attention and praise, another aspect, the less justifiable they felt their unilateral expression was. It was suggested, however, that individuals who had higher need for attention and praise tended to appraise suffering situations as severer, indicating that they would potentially evaluate anger expression as more justifiable. The results suggested that narcissism directly and indirectly involved in the justifiability evaluation of anger expression.

Relation of the tendency to feel anger and postanger reappraisals.

The present study was designed to identify defensive reappraisals by analyzing their relations to changes in an interpersonal situation following expression of anger and reappraisals as well as to identify the characteristics of people who use defensive reappraisals. Japanese undergraduate students (N= 229) responded to a questionnaire on how they express anger in daily life. Analysis indicated the group who reported a lower tendency to feel anger (the Low group) reported reappraisals such that Damage to Self was less severe, and Instigator's Responsibility was smaller than that for the group who reported a higher tendency (the High group), which suggested that people who tend to feel less anger use reappraisals to reduce their anger after expression more than those who tend to feel more anger. Moreover, the amount of variance in Reappraisals accounted for by Changes in Interpersonal Situation was small in the Low group (R2=.06) compared to that for the High group (R2=.48), so people who tend to feel less anger seem to use defensive reappraisals.