Comparison of Visibility and Risk of Neurovascular Tissue Injury Between Portals in Needle Arthroscopy of the Anterior Ankle Joint: A Cadaveric Study.

Background: For needle arthroscopy with 0° viewing, the visible range of intra-articular structures and the difference between portals remain unknown, as do the risks for neurovascular tissue at each portal. Purpose: To clarify the visibility and safety of needle arthroscopy. Study Design: Descriptive laboratory study. Methods: Ten cadaveric ankle specimens were used. A needle arthroscope with a 1.9-mm diameter was inserted from 4 portals (anteromedial [AM], anterolateral [AL], medial midline [MM], and anterocentral [AC]). Visibility was assessed using a 15-point ankle arthroscopy checklist. In addition, the ankles were dissected to measure the distance between each portal and neurovascular tissues. The visibility of the ankle joint was compared between portals. Results: The success rate of visibility in the deltoid ligament and the tip of the medial malleolus was 100% from the AM, MM, and AC portals and 10% from the AL portal, with significant differences between the portals (P < .01). The visibility success rates in the origin of the anterior talofibular ligament and the tip of the lateral malleolus were 20% for the AM portal, 90% for the MM and AC portals, and 100% for the AL portal, with significant differences between the portals (P < .01). All other points of the ankle joint were visualized from all the portals with a 100% success rate. The AC portal was in contact with the anterior neurovascular bundle in 4 of the 10 specimens. Conclusion: When needle arthroscopy was performed from the AM or AL portal, the site opposite to the portal in the ankle joint was difficult to visualize. Conversely, most points of the ankle joint could be visualized from the MM and AC portals. Care should be taken when creating an AC portal because of its proximity to the anterior neurovascular bundle. Clinical Relevance: The present study provides information regarding which portal should be selected to perform needle arthroscopy in the ankle joint, which will be beneficial for management of ankle injuries.

Preoperative radiologic predictors of successful soft tissue release surgery for hip subluxation among cerebral palsy patients: A STROBE compliant study.

Paralytic hip subluxation is a common problem in children with cerebral palsy. Although surgical procedures such as soft tissue release and osteotomy have been advocated for its prevention, the exact indications of such procedures remain unclear. We attempted to evaluate preoperative radiographic parameters and identify prognostic factors in children with cerebral palsy. We retrospectively investigated 43 hips in 27 children with cerebral palsy who had undergone soft tissue release surgery for hip subluxation. We evaluated the age at the time of surgery and the radiographic parameters such as the center-edge angle (CEA), the migration percentage (MP), and the acetabular index (AI) at 3 time points: preoperation, 1 year after surgery, and at final follow-up. The outcome measure was determined by the MP value at final follow-up. Student t test was used to compare the quantitative variables between 2 groups (good vs poor outcome). Then the multiple regression analysis was applied to determine the prognostic factors upon soft tissue release surgery. Children with good outcome exhibited higher CEA (average value of -1.43° vs -13.2° in those with poor outcome), lower MP (53.9% vs 71.3%), and lower AI (28.1° vs 35.3°). Upon multiple regression analysis, we found that the age at the time of surgery, preoperative CEA, and preoperative MP did not appear to be independent prognostic factors. The only independent factor that affected prognosis after soft tissue release surgery was the preoperative AI. The preoperative AI values <34° were associated with the good outcome with specificity of 87% and sensitivity of 60% according to the receiver operating characteristic curve analysis. These findings indicate that the outcome of soft tissue release surgery can be predicted by the preoperative AI value.

Reproducibility of acquiring ultrasonographic infant hip images by the Graf method after an infant hip ultrasound training course.

PURPOSE: The objective screening of infant hips using ultrasonography (Graf method) is gaining favor in the diagnosis of developmental dysplasia of the hip in Japan. However, the accuracy of the Graf method is dependent on the examiner's experience and technique. The purpose of this study was to investigate the reproducibility of acquiring ultrasonic hip images and their evaluation after examiners attended an infant hip ultrasound training course. MATERIALS AND METHODS: Ultrasonic images of 70 hips of 35 newborns who were screened by ultrasonography using the Graf method, were evaluated. The images were acquired by two inexperienced examiners who attended the training course. The inter- and intra-examiner measurement errors as well as reproducibility were calculated based on the images obtained. RESULTS: The intra-examiner measurement error in the acquired images of the same hip was minor. The inter-examiner measurement error was also small. The intra- and inter-examiner agreements of the Graf classification were high. The intra-examiner reproducibility of the acquired ultrasonic images was substantial, and the inter-examiner reproducibility was almost perfect. CONCLUSIONS: Our results demonstrated that inexperienced examiners could obtain ultrasonic infant hip joint images with minor differences and high reproducibility after the training course. Our findings raise the possibility of extending the infant hip ultrasound course in Japan.

MRI appearance in the early stage of Legg-Calvé-Perthes disease to predict lateral pillar classification: A retrospective analysis of the labral horizontalization.

BACKGROUND: The Herring lateral pillar classification is widely used for the classification of Legg-Calvé-Perthes disease, but is not applied at the early stage of Legg-Calvé-Perthes disease because it is typically applied at the late fragmentation stage. The purpose of this study was to investigate the correlation between the early appearance on magnetic resonance imaging of the acetabular labrum and lateral pillar involvement in Legg-Calvé-Perthes disease. METHODS: Non-contrast magnetic resonance images of 26 hips in 25 children with early-stage Legg-Calvé-Perthes disease were retrospectively reviewed. The extent of labral horizontalization was quantitatively evaluated with a new method, the labral angle, on T2*-weighted magnetic resonance images. A small labral angle indicates strong labral horizontalization. Calculation of the teardrop distance and acetabular head index on radiographs was modified for application to magnetic resonance imaging, and the extent of cartilaginous lateral subluxation (cartilaginous tear drop distance) and cartilaginous lateral extrusion (cartilaginous acetabular head index) were evaluated. The outcome measure was the lateral pillar classification. RESULTS: There were statistically significant correlations between the labral angle and the cartilaginous tear drop distance (p = 0.002, ɤ = -0.58) and the cartilaginous acetabular head index (p < 0.001, ɤ = 0.65) on magnetic resonance images. The labral angle was small in order of groups C, B, and A, and there were significant differences between groups A and C (p < 0.001) and B and C (p = 0.006). CONCLUSION: Greater labral horizontalization observed on magnetic resonance imaging at the early stage of Legg-Calvé-Perthes disease correlated with strong cartilaginous lateral subluxation and extrusion, and with increased lateral pillar collapse at the maximum fragmentation stage. Our finding suggests that a quantitative evaluation of labral horizontalization using magnetic resonance imaging in the early-stage of Legg-Calvé-Perthes disease can predict the later lateral pillar classification.

Flatfoot in the contralateral foot in patients with unilateral idiopathic clubfoot treated using the foot abduction brace.

While the foot abduction brace (FAB) plays an important role in the Ponseti method, the true function of the FAB in the treatment of idiopathic clubfoot remains unknown. In our clinical experience, we have noted that many patients with unilateral idiopathic clubfoot developed significant flatfoot in the contralateral foot during brace treatment. The purpose of this study was to investigate the natural history of the contralateral foot development during and after brace wear. We also discuss the effect of the FAB on the contralateral foot.We retrospectively reviewed 21 contralateral feet of 21 patients with unilateral idiopathic clubfoot who were treated using the Ponseti method and were conservatively followed up until the FAB was taken off (6 years of age or older). We evaluated flatfoot indicators of the contralateral foot on standing radiographs during and after brace wear and compared them against the normal reference ranges. We also evaluated the changes in the flatfoot indicators of the contralateral foot during and after brace wear.Although there was a significant difference in the flatfoot indicators between the contralateral foot and normal reference ranges during brace wear, there was no significant difference in the flatfoot indicators after brace wear. While there was no significant improvement in flatfoot indicators of the contralateral foot during brace wear, there was a significant improvement or a trend to improve after brace wear. There was no significant correlation between the contralateral flatfoot and original joint laxity.Significant flatfoot deformity was observed in the contralateral foot during brace wear. The contralateral flatfoot persisted during brace wear and improved to within normal reference ranges after brace wear. Our findings suggest that the FAB may influence the development of the contralateral foot, leading to the flatfoot.

Magnetic resonance imaging evaluation of the labrum to predict acetabular development in developmental dysplasia of the hip: A STROBE compliant study.

Recently, more attention has been paid to the role of the acetabular labrum. Therefore, we designed a retrospective cohort study of patients with residual hip dysplasia (RHD) who underwent magnetic resonance imaging (MRI). The objective of this study was to investigate an association between the MRI appearance of the labrum before school age and the natural history of RHD.We retrospectively investigated 45 hips of 40 patients who underwent MRI at about 3 and 4 years of age for RHD and were conservatively followed up with until 6 years of age or older. We evaluated the extent of eversion with a new method that measures the ß angle (MRI ß angle) using landmarks of the Graf method on MRI T2*-weighted images. The outcome measure was the Severin classification at the final follow-up. We compared the radiographic and MRI parameters at approximately 3 and 4 years of age between the good and poor outcome groups. The Student t test or one-way analysis of variance was used to compare the quantitative variables between groups. The Chi-square test was used to perform a ratio comparison.Although there was a significant difference in the center-edge (CE) angle, there was no significant difference in the acetabular index and the ratio of the presence of femoral head necrosis and the break in Shenton line between the good and poor groups. The MRI ß angle was significantly greater in the poor outcome group than in the normal and good outcome groups. The cut-off value of the MRI ß angle to differentiate the good and poor outcome groups was 65°, and its specificity and sensitivity were 92% and 53%, respectively.There was labral eversion on MRI scans in patients with RHD. Acetabular development before adolescence was poorer with greater labral eversion on MRI scans. The specificity for poor acetabular development was high when the MRI ß angle was 65° or more. The MRI ß angle has the potential to predict acetabular development.

Morphometric analysis of the peroneal tubercle using a three-dimensional computed tomography model.

BACKGROUND: The peroneal tubercle is a small bony ridge located on the lateral wall on the calcaneus immediately inferior to the lateral malleolus and separates the peroneus brevis and peroneus longus tendons. The size and configuration of the peroneal tubercle has been implicated in the pathogenesis of peroneal tendon tears and tenosynovitis and is the increasing object of clinical interest. However, the morphology of the tubercle is difficult to assess with precision. METHODS: We utilized a new method to evaluate the three-dimensional (3D) geometry of 46 calcanei from 34 consecutive patients; average patient age was 48.0 years who underwent lower extremity computed tomography (CT) for clinical treatment of non-peroneal tubercle-related conditions. The 3D geometries of calcanei were reconstructed by using the computer software to calculate the surface 3D models. To measure the size of the peroneal tubercle, we virtually excised it from the 3D calcaneus model and made a precise measurement of the height. RESULTS: Peroneal tubercles with measured heights of 1mm or more were detected in 65% of the feet, with an average tubercle height of 2.59mm. Peroneal tubercles were larger and more frequent in middle-aged or older than younger patients.

The changes of gap junctions between pituitary folliculo-stellate cells during the postnatal development of Zucker fatty and lean rats.

We investigated the effect of leptin on the postnatal development of gap junctions between folliculo-stellate cells by using Zucker fatty (fa/fa) rats that have defects of the functional leptin receptor. Male Zucker fatty rats (fa/fa) and male Zucker lean rats (+/+) were used at each of the following postnatal ages: 20, 30, 40, 50, 60, 70, 80, 90 days, and 1 year. On one of the aforementioned dates, the anterior pituitary glands were prepared for observation by transmission electron microscopy. We quantified the number of follicles and gap junctions, and calculated the rate of occurrence as the ratio of the number of gap junctions existing between folliculo-stellate cells per intersected follicular profile. In Zucker lean male rats, the number of gap junctions remained relatively constant from days 50 to 90 (0.44 ± 0.02 to 0.49 ± 0.03), and was similar in 1 year old rats (0.47 ± 0.03). These data were statistically higher compared to Zucker fatty male rats. In Zucker fatty male rats, very few gap junctions were observed in 30-day-old rats (0.04 ± 0.01: mean ± SE). This disruption of gap junction formation persisted, and the number of gap junctions remained constant and showed a low level from days 40 to 90 (0.11 ± 0.02 to 0.17 ± 0.02); this finding was similar in 1-year-old rats (0.17 ± 0.02). These observations indicate that the effect of leptin over the gap junction formation within the anterior pituitary glands was directly mediated by interaction with the functional leptin receptor present on the folliculo-stellate cells.

Intercellular communications within the rat anterior pituitary. XVI: postnatal changes of distribution of S-100 protein positive cells, connexin 43 and LH-RH positive sites in the pars tuberalis of the rat pituitary gland. An immunohistochemical and electron microscopic study.

The architecture of luteinizing hormone-releasing hormone (LH-RH) nerve ends and the S-100 protein containing folliculo-stellate cells forming gap junctions in the pars tuberalis is basically important in understanding the regulation of the hormone producing mechanism of anterior pituitary glands. In this study, intact male rats 5-60 days old were prepared for immunohistochemistry and electron microscopy. From immunostained sections, the S-100 containing cells in pars tuberalis were first detected on day 30 and increased in number to day 60; this was parallel to the immunohistochemical staining of gap junction protein, connexin 43. LH-RH positive sites were clearly observed on just behind the optic chiasm and on the root of pituitary stalk on day 30. On day 60, the width of layer increased, while follicles and gap junctions were frequently observed between agranular cells in 10 or more layers of pars tuberalis. In the present study, we investigated the sexual maturation of the anterior pituitary glands through the postnatal development of S-100 positive cells, connexin 43 and LH-RH nerves. It is suggested that the folliculo-stellate cell system including the LH-RH neurons in the pars tuberalis participates in the control of LH secretion along with the portal vein system.

The Pavlik harness in the treatment of developmentally dislocated hips: results of Japanese multicenter studies in 1994 and 2008.

BACKGROUND: It has already been more than 50 years since the Pavlik harness was introduced in Japan, and today the Pavlik harness is widely recognized as the standard initial treatment modality for developmental dysplasia of the hip. We performed a multicenter nationwide questionnaire study concerning the results of Pavlik harness treatment twice in 1994 and 2008. METHODS: In 1994 and in 2008, we sent questionnaires to 12 institutes in Japan specializing mainly in pediatric orthopedics. We compare the results of these two studies and discuss differences in reduction rates, incidence of avascular necrosis in the femoral epiphysis and the percentage of joints with acceptable morphology (Severin grade I + II/total) at skeletal maturity. We statistically assessed these results to see whether there were changes in the treatment outcomes over this 14-year period. RESULTS: Reduction of the dislocated hips was obtained by the Pavlik harness in 80.2% (1990/2481 hips; 1994) and 81.9% (1248/1523 hips; 2008). The incidences of avascular necrosis of the proximal femoral epiphysis in the dysplastic hips were 14.3% (119/835 hips; 1994) and 11.5% (76/663 hips; 2008). The type of avascular necrosis in hips from the 2008 study was determined according to the classification of Kalamchi and MacEwen: 24/69 hips (34.8%) were classified as group I; 20/69 hips (29.0%) as group II; 11/69 hips (15.9%) as group Ill; 14/69 hips (20.3%) as group IV. The percentages of hips with acceptable outcomes at skeletal maturity discerned from Severin X-ray changes (grade I + II/total) were 72.3% (604/835 hips; 1994) and 77.7% (488/628 hips; 2008). CONCLUSION: Reduction rates and the incidence of avascular necrosis in 2008 were statistically similar to the results in 1994. The rate of acceptable outcome (Severin grade I + II/total) in 2008 was statistically higher than that of 1994.

Involvement of the adrenal glands and testis in gap junction formation via testosterone within the male rat anterior pituitary gland.

We investigated the influence of testicular and adrenal androgens on the presence of gap junctions between folliculo-stellate cells in the anterior pituitary glands of 60-day-old Wistar-Imamichi strain male rats. The animals were separated into six groups: Group A served as the controls and had free access to a normal diet and water, Group B was given a normal diet and 0.9% NaCl for their drinking water as the controls of adrenalectomized groups, Group C was castrated, Group D was adrenalectomized, Group E was both castrated and adrenalectomized, and Group F was also both castrated and adrenalectomized. In addition, the animals of Group F were administered a dose of testosterone that is known to produce high physiological levels of the hormones in plasma. Five rats from each group were sacrificed 1, 2, 3, 4, 5, 6, and 7 days after their respective operation, and the anterior pituitary glands were removed and prepared for observation by transmission electron microscopy. We quantified the number of follicles and gap junctions and calculated the rate of occurrence as the ratio of the number of gap junctions existing between folliculo-stellate cells per intersected follicle profile. Simultaneous removal of adrenal glands with castration resulted in a significantly decrease in the number of gap junctions, whereas the administration of testosterone to these rats compensated for this change. These observations indicate that the preservation of gap junctions between folliculo-stellate cells is mainly dependent on androgens from both the testes and adrenal glands in adult male rats.

MRI findings in residual hip dysplasia.

BACKGROUND: Residual subluxation of the hip is a major problem in pediatric orthopaedics. Corrective surgery by Salter innominate osteotomy is performed for residual subluxation before school age. Common indications for corrective surgery are determined based on the clinical condition, x-ray images, and arthrographic images. However, the surgical indications vary among institutions. Thus, further information that can predict acetabular growth with certainty is needed for precise decision- making. This study focused on signal intensity changes on magnetic resonance (MR) images within the weight-bearing portion of the acetabulum to determine whether these signal intensity changes could predict acetabular growth. METHODS: Thirty-six patients who showed residual subluxation after reduction of developmental dysplasia of the hip and whose MRIs were taken when they were around 3 years old were studied. Corrective surgery was performed in 14 patients, whereas the remaining 22 patients were followed conservatively. The presence of a high-signal intensity area (HSIA) within the weight-bearing portion of the acetabular cartilage on T2-weighted MR coronal section images was investigated, and the correlation between HSIA presence and acetabular growth was examined. RESULTS: All patients who underwent corrective surgery showed an HSIA within the weight-bearing portion of the acetabular cartilage on T2-weighted MR images before surgery. After surgery, all patients showed HSIA disappearance or decrease. In patients who were followed conservatively, HSIA-positive patients had poor acetabular growth, whereas HSIA-negative patients had favorable acetabular growth. CONCLUSIONS: HSIAs in the acetabular cartilage may be caused by an extraordinary stress load from the femoral head. The presence of HSIA on MRI may prevent acetabular growth. HSIA on MRI appears to be a significant decision-making tool for corrective surgery.

[Bone disease with pain. Legg-Calvé-Perthes' disease (LCPD)].

Legg-Calvé-Perthes disease (LCPD) is a relatively common disease in pediatric hip disorder. Now the disease is categorized into osteochondrosis. This disease was firstly reported by Legg A.T. (USA) , Calvé J. (France) , and Perthes G.C. (Germany) in 1910. Since then its pathophysiology, clinical and imaging findings, and natural history have been researched, but the true etiology remains unknown, and effective treatment methods for some types of this disease are not constituted. In this issue, its pathophysiology, clinical symptoms, peculiar features of the imaging modalities, and currently acceptable treatments were addressed.