Younger age, hyperextended knee, concomitant meniscectomy and large prerevision anterior tibial translation are associated with graft failure after the revision anterior cruciate ligament reconstruction.

Purpose: Graft failure following revision anterior cruciate ligament (ACL) reconstruction is higher than after primary ACL reconstruction. However, data regarding revision surgery is scarce. We aimed to evaluate the associated factors for failure after revision ACL reconstruction. Methods: Fifty-four patients (mean age: 24.7 ± 10.0 years) who underwent revision ACL reconstruction at our hospital with ≥1 year follow-up were retrospectively examined. Patients were divided into Group F (graft failure) and Group N (no graft failure) groups. Univariate analysis was conducted to identify factors associated with graft failure. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal thresholds for differentiating between the two groups. Results: Graft failure was observed in 7 of 54 patients (13.0%). In the univariate analysis, significant differences were observed for age at the initial surgery (Group F: 15.6 ± 1.5, Group N: 20.9 ± 8.1), age at the revision surgery (Group F: 18.0 ± 2.8, Group N: 25.7 ± 10.3), presence of hyperextended knee (Group F: 85.7%, Group N: 14.9%), concomitant meniscectomy (Group F: 42.9%, Group N: 14.9%), prerevision space for the ACL (sACL) (Group F: 7.2 ± 3.4 mm, Group N: 13.4 ± 4.7 mm) and preoperative anterior tibial translation (ATT) (Group F: 5.0 ± 1.4 mm, Group N: 2.7 ± 3.1 m). ROC analysis of preoperative sACL and preoperative ATT on one-leg standing plain radiograph showed that cutoff values of 6.9 and 4.2 mm were the optimal thresholds, respectively. Conclusion: Younger patients with a hyperextended knee, concomitant meniscectomy, small sACL and large ATT before revision ACL reconstruction are predisposed to graft failure. Level of Evidence: Level IV.

Postoperative Gait Performance Following Pertrochanteric Fractures Is Influenced by the Preoperative Condition of the Gluteal Muscles.

Introduction Amid an increasing number of patients with pertrochanteric fractures, early prediction of postoperative gait potential could reduce unnecessary rehabilitation and hospitalization. The relationship between preoperative gluteal muscle condition and postoperative gait outcomes remains unclear. The gluteal muscles are crucial for mobility, and their cross-sectional area (CSA) and fatty infiltration are indicators of physical function. Preoperative computed tomography (CT) provides quantitative data on muscle CSA and density, measured in Hounsfield Units (HU). This study aimed to identify which preoperative muscle index, CSA, BMI-adjusted CSA, or muscle density, best predicts postoperative gait ability. We hypothesized that a higher adjusted CSA and muscle density in the gluteus muscles would be associated with superior gait performance. Materials and methods Preoperative assessments included radiographs and CT scans. Patients under 75, with less than four weeks of follow-up, prior contralateral hip surgery, prefracture immobility, male patients, high-energy trauma, or conditions impairing physical performance were excluded. Gait performance was evaluated four weeks postoperatively, classifying patients into two groups: the 'parallel bar group,' requiring parallel bars, and the 'walker group,' walking independently. Patients underwent CM nailing. Preoperative CT scans measured the CSA and muscle density of the gluteus maximus and medius. Measurements were taken from the non-injured side to avoid interference from the fracture. Muscle borders were manually traced, and the CSA and muscle density in HU were calculated. Results Out of 81 patients, 49 met the inclusion criteria (mean age: 87). The patients were divided into the 'parallel bar group' (n=19) and the 'walker group' (n=30) based on postoperative gait performance. No significant differences in age, weight, height, or fracture laterality were observed between groups. The mean (and standard deviation (SD)) of CSA for the gluteus maximus in the 'parallel bar group'/in the 'walker group' was 2211.8 ± 469.8 mm²/2440.0 ± 586.2 mm², respectively (p=0.15), and for the gluteus medius, it was 1751.7 ± 415.2mm²/1869.1 ± 448.3mm², respectively (p=0.36). The mean (and SD) muscle density for the gluteus maximus in the 'parallel bar group'/in the 'walker group' was 13.6 ± 12.7 HU / 20.6 ± 13.0 HU (p=0.07), and for the gluteus medius, it was 25.2 ± 8.4 HU/31.8 ± 10.1 HU, respectively (p=0.02). The ROC curve identified a 30.9 HU cut-off for gluteus medius density, with sensitivity and specificity of 60.7% and 78.9%. The mean (and SD) of BMI-adjusted CSA for the gluteus maximus in the 'parallel bar group'/ in the 'walker group' was 116.4 ± 26.8 m²/106 kg/124.3 ± 29.2 m²/106 kg, respectively (p=0.35), and for the gluteus medius, it was 93.3 ± 27.2 m²/106 kg/95.4 ± 21.3m²/106kg, respectively (p=0.78). Conclusion This study analyzed preoperative CT images of women aged 75 and older with pertrochanteric fractures, comparing gluteal muscle CSA and density with postoperative walking ability. The gluteus medius density was significantly higher in the superior gait group, with a cut-off value of 30.9 HU. However, no significant differences were found in the gluteus maximus density, CSA, or BMI-adjusted CSA. These findings partially support the hypothesis, emphasizing the importance of muscle evaluation in predicting postoperative gait performance.

Human uncultured adipose-derived stromal vascular fraction shows therapeutic potential against osteoarthritis in immunodeficient rats via direct effects of transplanted M2 macrophages.

BACKGROUND: The uncultured adipose-derived stromal vascular fraction (SVF), consisting of adipose-derived stromal cells (ADSCs), M2 macrophages (M2Φ) and others, has shown therapeutic potential against osteoarthritis (OA), however, the mechanisms underlying its therapeutic effects remain unclear. Therefore, this study investigated the effects of the SVF on OA in a human-immunodeficient rat xenotransplantation model. METHODS: OA model was induced in the knees of female immunodeficient rats by destabilization of the medial meniscus. Immediately after the surgery, human SVF (1 × 105), ADSCs (1 × 104), or phosphate buffered saline as a control group were transplanted into the knees. At 4 and 8 weeks postoperatively, OA progression and synovitis were analyzed by macroscopic and histological analyses, and the expression of collagen II, SOX9, MMP-13, ADAMTS-5, F4/80, CD86 (M1), CD163 (M2), and human nuclear antigen (hNA) were evaluated immunohistochemically. In vitro, flow cytometry was performed to collect CD163-positive cells as M2Φ from the SVF. Chondrocyte pellets (1 × 105) were co-cultured with SVF (1 × 105), M2Φ (1 × 104), and ADSCs (1 × 104) or alone as a control group, and the pellet size was compared. TGF-ß, IL-10 and MMP-13 concentrations in the medium were evaluated using enzyme-linked immunosorbent assay. RESULTS: In comparison with the control and ADSC groups, the SVF group showed significantly slower OA progression and less synovitis with higher expression of collagen II and SOX9, lower expression of MMP-13 and ADAMTS-5, and lower F4/80 and M1/M2 ratio in the synovium. Only the SVF group showed partial expression of hNA-, CD163-, and F4/80-positive cells in the rat synovium. In vitro, the SVF, M2Φ, ADSC and control groups, in that order, showed larger pellet sizes, higher TGF-ß and IL-10, and lower MMP-13 concentrations. CONCLUSIONS: The M2Φ in the transplanted SVF directly affected recipient tissue, enhancing the secretion of growth factors and chondrocyte-protecting cytokines, and partially improving chondrocytes and joint homeostasis. These findings indicate that the SVF is as an effective option for regenerative therapy for OA, with mechanisms different from those of ADSCs.

Rotating Hinge Knee Arthroplasty for Charcot Joints of the Knees in Patients With Charcot-Marie-Tooth Disease: A Report of Two Cases.

We report two cases wherein rotating hinge knee (RHK) arthroplasty was performed for Charcot joints that developed secondary to Charcot-Marie-Tooth disease (CMT).  Case 1 was of a 74-year-old woman with CMT. She presented with muscle weakness and sensory disturbances of the distal lower limbs, deformity, and significant medial instability of the bilateral knees. She was then diagnosed with Charcot joints of the knees secondary to CMT, which were treated with RHK arthroplasty. Five years postoperatively, there was no instability, and she was able to stand unassisted without pain. Case 2 was a 90-year-old woman with CMT who presented with muscle weakness and sensory disturbances of the distal lower limbs, deformity, and significant medial instability of the bilateral knees. She was then diagnosed with Charcot joints of the knees secondary to CMT, which were also treated with RHK arthroplasty. One year postoperatively, there was no instability, and she was able to walk smoothly using a walker. These clinical cases indicate that RHK arthroplasty can be a good therapeutic option for Charcot joints of the knees in patients with CMT.

Goal Orientation and Desire for Approval Were Associated With Sports Injuries Among Young Japanese Athletes.

Introduction: This study aimed to clarify the relationship between psychological factors (goal orientation and desire for approval from others) and the severity of sports injuries experienced by young Japanese athletes. Methods: A total of 560 young Japanese athletes (328 males and 232 females) aged 18-24 years completed an online survey in 2022-2023. A web questionnaire was used to investigate participants' task and ego orientations, desire for approval from others (e.g., coaches and friends/families), and history of injury. The samples were then split into 3 groups on the basis of the rest duration due to the injury: noninjury group (0 days), mild-to-moderate injury group (1-27 days), and severe injury group (>28 days). Spearman's test examined a correlation between task and ego orientation scores among all samples. The Mann-Whitney U test was used to compare the scores between the severe injury and noninjury groups. Result: A significant positive correlation was found between task and ego orientation scores from all samples (ρ=0.27, p<0.001). The severe injury group had significantly higher task orientation scores and desire for approval scores than the noninjury group (ρ=0.001, p<0.001). Conclusions: Japanese young athletes with high task orientation and approval desire may be at risk of severe sports injuries requiring >4 weeks to return to sports. The goal orientation profiles should be interpreted with caution. Future research should examine contextual effects such as the perceived motivational climate, in addition to the goal orientation profiles.

Morphological analysis of the distal femur as a surgical reference in biplane distal femoral osteotomy.

Distal femoral osteotomy (DFO) is performed alone or with high tibial osteotomy (HTO) for patients with osteoarthritis and distal femur deformities. DFO is technically demanding, particularly when creating an anterior flange. Herein, we examined the morphological characteristics of the distal femur based on the cortical shape as a surgical reference for biplanar DFO. Computed tomography images of 50 valgus and 50 varus knees of patients who underwent biplanar DFO or total knee arthroplasty were analyzed. Axial slices at the initial level of the transverse osteotomy in the DFO and slices 10 mm proximal and 10 mm distal to that level were selected. The medial and lateral cortical angles and heights (MCLA, LCLA, MCH, and LCH) were measured on axial slices. Statistical comparisons were performed between the medial and lateral cortices and valgus and varus knees. MCLA and MCH were significantly smaller and lower, respectively, than LCLA and LCH (P < 0.01). The MCLA and MCH of varus knees were significantly smaller and lower, respectively, than those of valgus knees (P < 0.01). Surgeons should carefully observe morphological differences in the distal femur cortex, distinguishing between medial and lateral knees and varus and valgus knees during the creation of the anterior flange in the DFO.

Patellofemoral instability part 1 (When to operate and soft tissue procedures): State of the art.

Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence. Stratifying the risk of recurrence includes evaluating risk factors such as age, trochlear dysplasia, contralateral dislocation, and patellar height. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint. Reconstruction of the medial patellofemoral ligament is the most frequent way of addressing the medial soft tissues in patients with patellofemoral instability. Meanwhile, lateral tightness can be achieved by lateral retinaculum lengthening or release. Approaching patellofemoral instability in a patient-specific approach, combined with a shared decision-making process with the patient/family, will guide surgeons to the deliver optimal care for the patellar instability patient.

Setting hinge position distal to the proximal margin of the distal lateral femur reduces the maximum principal strains of the hinge area and risk of hinge fractures.

Purpose: The optimal hinge position to prevent hinge fractures in medial closing wedge distal femoral osteotomy (MCWDFO) based on the biomechanical background has not yet been well examined. This study aimed to examine the appropriate hinge position in MCWDFO using finite element (FE) analysis to prevent hinge fractures. Methods: Computer-aided design (CAD) models were created using composite replicate femurs. FE models of the MCWDFO with a 5° wedge were created with three different hinge positions: (A) 5 mm proximal to the proximal margin of the lateral epicondylar region, (B) proximal margin level and (C) 5 mm distal to the proximal margin level. The maximum and minimum principal strains in the cortical bone were calculated for each model. To validate the FE analysis, biomechanical tests were performed using composite replicate femurs with the same hinge position models as those in the FE analysis. Results: In the FE analysis, the maximum principal strains were in the order of Models A > B > C. The highest value of maximum principal strain was observed in the area proximal to the hinge. In the biomechanical test, hinge fractures occurred in the area proximal to the hinge in Models A and B, whereas the gap closed completely without hinge fractures in Model C. Fractures occurred in an area similar to where the highest maximal principal strain was observed in the FE analysis. Conclusion: Distal to the proximal margin of the lateral epicondylar region is an appropriate hinge position in MCWDFO to prevent hinge fractures. Level of Evidence: Level V.

Association Between Psychological Readiness to Return to Sports at 3 Months Postoperatively and Risk of Second ACL Injury.

Background: Psychological readiness to return to sports (RTS) has been associated with second anterior cruciate ligament (ACL) injury. However, this relationship is controversial because covariates such as anatomic and knee function characteristics have not been adequately considered. Purpose/Hypothesis: To investigate whether psychological readiness in the early postoperative period can predict the occurrence of a second ACL injury within 24 months after primary ACL reconstruction (ACLR) using propensity score analysis. It was hypothesized that patients with high ACL-RSI after injury (ACL-RSI) scores at 3 months postoperatively would have a second ACL injury within the projected postoperative period. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 169 patients who underwent primary ACLR using hamstring tendon autografts between November 2017 and July 2021 and also underwent knee functional assessments at 3 months postoperatively. The ACL-RSI scale was used to assess psychological readiness for RTS. A second ACL injury was defined if ipsilateral or contralateral ACL injury was confirmed by examination within 24 months postoperatively. Based on a previous study showing that 65 was the highest cutoff value for the ACL-RSI score for RTS, we classified patients into 2 groups: those with high ACL-RSI scores (≥65; group H) and those with low ACL-RSI scores (<65; group L). We generated 1-to-1 matched pairs using propensity score analysis and used log-rank testing to compare the rate of second ACL injury between the 2 groups. Results: More patients returned to any sports activities within 12 months in group H than in group L (90% vs 73%; P = .03). A second ACL injury within 24 months postoperatively was identified in 7% of patients (13/169). The rate of second ACL injury was significantly higher in group H than in group L (17.6% vs 3.4%; P = .001). In 43 matched pairs extracted using propensity scoring, the rate of second ACL injury was also higher in group H than in group L (18.6% vs 4.7%; P = .04). Conclusion: Patients with a higher ACL-RSI score at 3 months exhibited a significantly higher incidence of second ACL injury within 24 months after primary ACLR.

Injuries to both anterolateral ligament and Kaplan fiber of the iliotibial band do not increase preoperative pivot-shift phenomenon in ACL injury.

Background: To assess the incidence of anterolateral ligament (ALL) and Kaplan fiber of the iliotibial band (KF) injuries in patients with acute anterior cruciate ligament (ACL) injury on magnetic resonance imaging (MRI), and to investigate the association between these injuries and the magnitude of preoperative pivot-shift test. Method: One-hundred and five patients with primary ACL injury were retrospectively reviewed. ALL injury and KF injury were assessed by preoperative MRI, and subjects were allocated into four groups: Group A, neither injury; Group B, only ALL injury; Group C, only KF injury; Group D, simultaneous ALL and KF injuries. Before ACL reconstruction, tibial acceleration during the pivot-shift test was measured by an electromagnetic measurement system, and manual grading was recorded according to the International Knee Documentation Committee (IKDC) guideline. Results: In MRI, the ALL was identified in 104 patients (99.1%) and KF in 99 patients (94.3%). ALL and KF injuries were observed in 43 patients (43.9%) and 23 patients (23.5%), respectively. Patient distribution to each group was as follows; Group A: 43 patients (43.9%), Group B: 32 patients (32.7%), Group C: 12 patients (12.2%), Group D: 11 patients (11.2%). No significant differences were observed in tibial acceleration, and manual grading among the four groups. Conclusion: Simultaneous injury to both ALL and KF was uncommon, and preoperative pivot-shift phenomenon did not increase even in those patients. The finding suggests that the role of ALL and KF in controlling anterolateral rotatory knee laxity may be less evident in the clinical setting compared to a biomechanical test setting.

Influence of Distal Reference Point of the Tibial Mechanical Axis on the Ankle and Hindlimb Alignment Change after Total Knee Arthroplasty.

The alignment philosophy in total knee arthroplasty (TKA) has tended to shift from the gold standard of mechanically aligned technique to personalized alignment, such as the kinematically aligned (KA) technique. However, the influences of different surgical techniques on lower limb alignment relative to the ground are not fully investigated. This study investigated the influence of the ankle and hindlimb alignment change after mechanically aligned TKA and KA-TKA. The varus osteoarthritic patients who underwent TKAs were divided into a mechanically aligned TKA group (group M, n = 50) and a KA-TKA group (group K, n = 50). Radiographic parameters (hip-knee-calcaneus [HKC] angle, hip-knee-ankle [HKA] angle, talar tilt angle [TTA], and tibiocalcaneal angle [TCA]) were investigated using full-length standing radiographs. The deviation angle (ΔTA; angle between the tibial mechanical axis [TMA] and the ground tibial mechanical axis [gTMA]) and the change of ΔTA (cΔTA) were also assessed. These parameters were compared between the two groups, along with the correlation between the preoperative HKA angle and other parameters. ΔTA, TTA, and TCA showed no differences between the groups pre- and postoperatively, and no significant changes were observed postoperatively. The preoperative HKA angle showed a significant negative correlation with cΔTA in both groups (group M: r = -0.33, p = 0.02; group K: r = -0.29, p = 0.04) although no correlation was observed the with preoperative TTA and TCA. Despite no change in ΔTA after surgery, the preoperative varus deformity was associated with a change in the deviation between gTMA and TMA after surgery. A severely varus knee may be inappropriate for ground KA-TKA.

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning.

BACKGROUND: Postoperative rotator cuff retear after arthroscopic rotator cuff repair (ARCR) is still a major problem. Various risk factors such as age, gender, and tear size have been reported. Recently, magnetic resonance imaging-based stump classification was reported as an index of rotator cuff fragility. Although stump type 3 is reported to have a high retear rate, there are few reports on the risk of postoperative retear based on this classification. Machine learning (ML), an artificial intelligence technique, allows for more flexible predictive models than conventional statistical methods and has been applied to predict clinical outcomes. In this study, we used ML to predict postoperative retear risk after ARCR. METHODS: The retrospective case-control study included 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. Patients who initially presented with retears and traumatic tears were excluded. In study participants, after the initial tear repair, rotator cuff retears were diagnosed by magnetic resonance imaging; Sugaya classification types IV and V were defined as re-tears. Age, gender, stump classification, tear size, Goutallier classification, presence of diabetes, and hyperlipidemia were used for ML parameters to predict the risk of retear. Using Python's Scikit-learn as an ML library, five different AI models (logistic regression, random forest, AdaBoost, CatBoost, LightGBM) were trained on the existing data, and the prediction models were applied to the test dataset. The performance of these ML models was measured by the area under the receiver operating characteristic curve. Additionally, key features affecting retear were evaluated. RESULTS: The area under the receiver operating characteristic curve for logistic regression was 0.78, random forest 0.82, AdaBoost 0.78, CatBoost 0.83, and LightGBM 0.87, respectively for each model. LightGBM showed the highest score. The important factors for model prediction were age, stump classification, and tear size. CONCLUSIONS: The ML classifier model predicted retears after ARCR with high accuracy, and the AI model showed that the most important characteristics affecting retears were age and imaging findings, including stump classification. This model may be able to predict postoperative rotator cuff retears based on clinical features.

Knee Osteotomy Decreases Joint Inflammation Based on Synovial Histology and Synovial Fluid Analysis.

PURPOSE: To examine the biological changes in the joints of patients with knee osteoarthritis (OA) before and after around-knee osteotomy (AKO), focusing on synovial fluid (SF) and synovial pathological changes. METHODS: Patients who underwent AKO for medial compartment knee OA between 2019 and 2021 were examined. SF and synovium were obtained at the time of AKO and plate removal after bone union (mean, 16.8 months [range: 11-38 months] postoperatively). SF volume and interleukin (IL)-6 concentrations in SF were assayed using enzyme-linked immunosorbent assay. Synovitis was assessed histologically using a semiquantitative scoring system. Macrophage infiltration was assessed by immunohistochemistry using a semiquantitative score for F4/80 expression. The M1/M2 ratio was calculated using percentage of cells positive for CD80 and CD163. The expression of proinflammatory cytokines was assessed by the percentage of IL-1ß- and IL-6-positive cells. The number of vascular endothelial growth factor-positive luminal structures was counted to assess angiogenesis. The change in each parameter was compared before and after AKO using the Wilcoxon matched-pairs signed-rank test. RESULTS: Twenty-four knees of 21 patients were included. SF volume and IL-6 concentration significantly decreased postoperatively (12.6 ± 2.1 mL vs 4.2 ± 0.6 mL; P < .0001 and 50.5 ± 8.6 pg/mL vs 20.7 ± 3.8 pg/mL; P = .0001, respectively). A significant reduction in synovitis score (P = .0001), macrophage infiltration (P < .0003), M1/M2 ratio (P < .0007), angiogenesis (P < .0001), and the percentage of IL-1ß- and IL-6-positive cells in the intima (P < .008 and P < .002, respectively) was found after AKO. CONCLUSIONS: SF volume and IL-6 concentrations in the SF decreased and inflammatory synovium pathology improved after AKO. In addition to biomechanical changes, the biological environment of the joint can be improved after AKO. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.

Inter-observer Agreement and Reproducibility of Pertrochanteric Fracture Classification Using Plain Radiograph Versus Computed Tomogram Images: A Study of 523 Patients.

Background A precise preoperative imaging classification system for pertrochanteric fractures is imperative due to the reported unreliability of the current classification system, which relies solely on plain radiographs. This study aims to achieve two primary objectives: (i) elucidate the reproducibility of pertrochanteric fracture evaluation based on the Revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Classification, comparing plain radiographs and computed tomography (CT) scan images, and (ii) investigate the consistency of fracture classification between both imaging modalities. Methods A total of 523 patients (112 males and 411 females, mean age 85 years) who had both preoperative plain radiographic and three-dimensional CT images were enrolled in this study. Following the Revised AO/OTA Classification, three individual observers initially classified the fractures in plain radiograph images as either Stable (A1) or Unstable (A2). Subsequently, they further categorized them into five sub-categories (A1.1, A1.2, A1.3, A2.2, and A2.3). The same classification system was applied to the CT scan images. Inter-observer agreement and consistency of fracture classification between plain radiographs and CT scan images were assessed. Results The inter-observer agreement for fractures classified as stable or unstable using only plain radiographs was found to be fair among the three observers, with a mean κ of 0.397 (95% CI: 0.316-0.478). However, inter-observer agreement improved significantly when using CT scans, with a mean κ of 0.590 (95% CI: 0.518-0.662). Our results demonstrated a consistency level between two graphical modalities ranging from fair to moderate, with κ values of 0.581, 0.383, and 0.335, respectively. It's worth noting that plain radiographic classification occasionally resulted in underestimations, with each observer identifying 16.1%, 34.0%, and 37.9%, respectively, of cases as A1 in plain radiographs that were classified as A2 in CT scans. Conclusions This study reveals a moderate to substantial level of inter-observer agreement for fracture classification when using CT scan images, in contrast to plain radiographs. Fracture evaluation relying solely on plain radiographs sometimes underestimates fracture classification and exhibits less consistency compared to using CT scan images.

Intra-articular site-specific distribution of advanced glycation end products in the shoulder of patients with diabetes mellitus having rotator cuff tears.

BACKGROUND: Advanced glycation end products (AGEs) are compounds formed due to aging and diabetes mellitus (DM). They activate NADPH oxidase (NOX) by binding to their receptors, thereby increasing the production of reactive oxygen species (ROS), which cause oxidative stress. In this study, we investigated the effects of AGEs on the tissues of the shoulder joint (such as rotator cuff synovium, and capsule) in patients with DM having rotator cuff tears. METHODS: This study included eight patients with DM who underwent surgical treatment for rotator cuff tears with contracture. The rotator cuff, synovium, and joint capsule were harvested at the time of surgery and evaluated by hematoxylin-eosin staining. Furthermore, immunostaining was used for evaluating AGEs and receptor for AGEs (RAGE), cell activity, ROS, and apoptosis. Quantitative real-time polymerase chain reaction (qPCR) was employed for the cellular evaluation of NOX, interleukins, RAGE, and collagen. RESULTS: The AGEs and RAGE staining as well as the ratio of ROS and apoptosis were in the following order: rotator cuff > joint capsule > synovium. In contrast, the cellular activity was significantly higher in the synovium than in the other regions. The type I collagen expression (as shown by qPCR) as well as the RAGE and NOX expressions were as follows: rotator cuff > joint capsule > synovium. Conversely, the expression of inflammatory cytokines (i.e., IL-6 and IL-1ß) was higher in the synovium than in the other regions. CONCLUSIONS: Our study is among the first to evaluate the effects of AGEs on each tissue of the shoulder joint in patients with DM having rotator cuff tears and contractures. The accumulation of AGEs in each tissue of the shoulder joint could reveal the locations affected by DM, which can lead to a better understanding of the pathophysiology of DM-related shoulder diseases.

Clinical and Radiological Comparison of Single and Double Intra-articular Injection of Adipose-Derived Stromal Vascular Fraction for Knee Osteoarthritis.

The aim of the article is to compare the clinical and radiological outcomes between single and double stromal vascular fraction (SVF) cell injections in patients with knee osteoarthritis (OA). We included 54 patients treated for varus knee OA with intra-articular SVF cell injection. They were divided into two groups: those who received one injection and those who received two. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, knee range of motion, and knee muscle force were assessed at baseline and 3, 6, 12, and 24 months after the first injection. The preoperative hip-knee-ankle (HKA) angle was evaluated using plain radiographs, and T2 mapping values were assessed. The total WOMAC score improved significantly in the single injection group from 3 to 24 months, but the total WOMAC score in the double injection group improved significantly at 24 months. The T2 mapping values in both the groups improved, with a significant difference at 12 months. The preoperative mean HKA angle and the correlation coefficients between the HKA angle and the total WOMAC score and between the HKA angle and the T2 mapping value of the medial femur were significant. In conclusion, double injections may provide more satisfactory treatment outcomes in patients with severe varus knee alignment. This clinical trial is registered in the Japanese Ministry of Health, Labour and Welfare (URL: https://saiseiiryo.mhlw.go.jp/published_plan/index/2) with the registration name "Cell transplantation therapy for osteoarthritis using autologous subcutaneous adipose tissue-derived regenerative (stem) cells (ADRCs)," and the registration number was "PB5160012."

Heterogeneous Cells as well as Adipose-Derived Stromal Cells in Stromal Vascular Fraction Contribute to Enhance Anabolic and Inhibit Catabolic Factors in Osteoarthritis.

The stromal-vascular fraction (SVF), comprising heterogeneous cell populations and adipose-derived stromal cells (ADSCs), has therapeutic potential against osteoarthritis (OA); however, the underlying mechanism remains elusive. This study aimed to investigate the therapeutic effects of heterogeneous cells in rabbit SVF on rabbit chondrocytes. Rabbit SVF and ADSCs were autografted into knees at OA onset. The SVF (1 × 105) and low-dose ADSCs (lADSC; 1 × 104) groups adjusted for their stromal cell content were compared. Animals were euthanized 8 and 12 weeks after OA onset for macroscopic and histological analyses of OA progression and synovitis. Immunohistochemical and real-time polymerase chain reaction assessments were conducted. In vitro, immune-fluorescent double staining was performed for SVF to stain macrophages with F4/80, CD86(M1), and CD163(M2). OA progression was markedly suppressed, and synovitis was reduced in the SVF groups (OARSI histological score 8 W: 6.8 ± 0.75 vs. 3.8 ± 0.75, p = 0.001; 12 W: 8.8 ± 0.4 vs. 5.4 ± 0.49, p = 0.0002). The SVF groups had higher expression of collagen II and SOX9 in cartilage and TGF-ß and IL-10 in the synovium, lower expression of MMP-13, and lower macrophage M1/M2 ratio than the lADSC groups. Immunofluorescent double staining revealed a markedly higher number of M2 than that of M1 macrophages in the SVF. The therapeutic effects of SVF on chondrocytes were superior than those of lADSCs, with enhanced anabolic and inhibited catabolic factors. Heterogeneous cells, mainly M2 macrophages in the SVF, enhanced growth factor secretion and chondrocyte-protective cytokines, thus benefiting chondrocytes and knee joint homeostasis. Overall, the SVF is a safe, relatively simple, and a useful treatment option for OA.

Accuracy comparison of cup positioning during total hip arthroplasty using Hip Align and AR-Hip in the supine position.

INTRODUCTION: The aim of this study is to compare the accuracy of acetabular cup positioning between the accelerometer-based navigation system and the augmented reality-based navigation system during THA in the supine position. MATERIALS AND METHODS: This retrospective study included 66 patients (70 hips) who underwent THA using two types of portable navigation system, Hip Align or AR-Hip, in the spine position. The absolute difference between the intraoperative navigation record and postoperative measurement using computed tomography data was evaluated. Preoperative clinical factors that decreased the accuracy of cup positioning by ≥ 3° were analyzed via multiple logistic regression analyses. RESULTS: The average absolute error of inclination was 2.8 ± 2.6° in Hip Align and 2.7 ± 1.8° in AR-Hip, and absolute anteversion error was 2.5 ± 2.0° in Hip Align and 2.6 ± 2.2° in AR-Hip, and there was no significantly different between the two navigation systems. There was a significant association between the absolute measurement error (≥ 3°) of cup inclination and patients' BMI in the Hip Align group [odds ratio (OR) 1.350; 95% confidence interval (CI) 1.035-1.760; p = 0.027], but not in the AR-Hip group. CONCLUSIONS: The accuracy of the acetabular cup positioning between the Hip Align and AR-Hip showed no difference during THA in the spine position. The high BMI could have negative influence on the accuracy of cup positioning in THA using Hip Align, thus AR-Hip could be designable for obesity patients.

Combining age, sex, body mass index, sport level, and preoperative quadriceps strength improves the predictive ability of quadriceps strength recovery after anterior cruciate ligament reconstruction.

PURPOSE: This study compared the predictive ability of each independent predictor with that of a combination of predictors for quadriceps strength recovery one year after anterior cruciate ligament (ACL) reconstruction. METHODS: Patients who underwent primary ACL reconstruction using hamstring autografts were enrolled. Quadriceps strength, hamstring strength, and anterior tibial translation were measured, and the limb symmetry index (LSI) of the quadriceps and the hamstrings was calculated preoperatively and one year after surgery. Patients were classified into two groups according to the LSI of the quadriceps strength at one year postoperatively (≥ 80% or < 80%). Multivariate logistic regression analysis identified the independent predictors of quadriceps strength recovery, and the cut-off value was calculated using the receiver operating characteristic curve. A model assessing predictive ability of the combination of independent predictors was created, and the area under the curve (AUC) for each independent predictor was calculated by using the receiver-operating characteristic curves and the DeLong method. RESULTS: Of the 646 patients, 414 (64.1%) had an LSI of at least 80% for quadriceps strength one year after surgery, and 232 patients (35.9%) had an LSI of < 80%. Age, sex, body mass index (BMI), preinjury sport level, and LSI of preoperative quadriceps strength were independently associated with quadriceps strength recovery one year after ACL reconstruction. The cut-off values were age: 22.5 years; sex: female; BMI: 24.3 kg/m2; preinjury sport level: no sport; and LSI of preoperative quadriceps strength: 63.3%. The AUC of the model assessing the predictive ability of the combination of age, sex, BMI, preinjury sport level, and LSI of preoperative quadriceps strength was significantly higher (0.73) than that of similar factors of preoperative quadriceps strength (AUC: 0.63, 0.53, 0.56, 0.61, and 0.68, p < 0.01, respectively). CONCLUSION: The combination of age, sex, BMI, preinjury sport level, and LSI of preoperative quadriceps strength had a superior predictive ability for quadriceps strength recovery at one year after ACL reconstruction than these predictors alone. Multiple factors, including patient characteristics and preoperative quadriceps strength, should be considered when planning rehabilitation programs to improve quadriceps strength recovery after ACL reconstruction. LEVEL OF EVIDENCE: III.