Return-to-play outcomes after full-endoscopic spine surgery under local anesthesia in professional baseball players: Comparison by timing of surgery.

BACKGROUND: Full-endoscopic spine surgery via a transforaminal approach (TF-FESS) is minimally invasive and could help athletes quickly return to play. When treating professional athletes, we have to consider their season schedule. In this study, we investigated the characteristics of Japanese professional baseball players who underwent TF-FESS and examine how the timing of surgery influenced their postoperative course. METHODS: Ten players who underwent TF-FESS (discectomy, foraminoplasty, or thermal annuloplasty according to their diagnosis) under local anesthesia were analyzed. Multilevel surgeries were performed at the same time in patients with lesions at multiple levels. The patients were divided into three groups according to timing of surgery (pre/during/post-season). Time to complete return to play and duration of official game loss were compared between the three groups. RESULTS: All players (100 %) could return to their original level of professional play after FESS surgery. Seven of the 10 patients underwent two-level surgery. The mean time until complete return to play was 4.6 months (range, 2-8 months) and the mean duration of game loss was 1.5 months (range, 0-4 months). The mean duration of game loss was shorter in the post-season group than in the other groups (0.9 vs 2,4 months), and 4 of 6 patients in the post-season group did not miss any games. CONCLUSIONS: TF-FESS is a good technique for achieving a quick return to play in professional baseball players. In particular, surgery performed during the post-season could allow players to return to play after adequate rehabilitation with no game loss.

Impact of Structural Abnormalities in Left Ventricle and Left Atrium on Clinical Outcomes in Heart Failure with Preserved Ejection Fraction.

Two key echocardiographic parameters, left ventricular mass index (LVMI) and left atrial volume index (LAVI), are important in assessing structural myocardial changes in heart failure (HF) with preserved ejection fraction (HFpEF). However, the differences in clinical characteristics and outcomes among groups classified by LVMI and LAVI values are unclear.We examined the data of 960 patients with HFpEF hospitalized due to acute decompensated HF from the PURSUIT-HFpEF registry, a prospective, multicenter observational study. Four groups were classified according to the cut-off values of LVMI and LAVI [LVMI = 95 g/m2 (female), 115 g/m2 (male) and LAVI = 34 mL/m2]. Clinical endpoints were the composite of HF readmission and all-cause death. Study endpoints among the 4 groups were evaluated. The composite endpoint occurred in 364 patients (37.9%). Median follow-up duration was 445 days. Kaplan-Meier analysis revealed significant differences in the composite endpoint among the 4 groups (P < 0.001). Cox proportional hazards analysis demonstrated that patients with increased LAVI alone were at significantly higher risk of HF readmission and the composite endpoints than those with increased LVMI alone (P = 0.030 and P = 0.024, respectively). Age, male gender, systolic blood pressure at discharge, atrial fibrillation (AF) hemoglobin, renal function, and LAVI were significant determinants of LVMI and female gender, AF, hemoglobin, and LVMI were significant determinants of LAVI.In HFpEF patients, increased LAVI alone was more strongly associated with HF readmission and the composite of HF readmission and all-cause death than those with increased LVMI alone.

Usefulness of the 2-year iodine-123 metaiodobenzylguanidine-based risk model for post-discharge risk stratification of patients with acute decompensated heart failure.

PURPOSE: A four-parameter risk model that included cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters was recently developed for prediction of 2-year cardiac mortality risk in patients with chronic heart failure. We sought to validate the ability of this risk model to predict post-discharge clinical outcomes in patients with acute decompensated heart failure (ADHF) and to compare its prognostic value with that of the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores. METHODS: We studied 407 consecutive patients who were admitted for ADHF and survived to discharge, with definitive 2-year outcomes (death or survival). Cardiac MIBG imaging was performed just before discharge. The 2-year cardiac mortality risk was calculated using four parameters, namely age, left ventricular ejection fraction, New York Heart Association functional class, and cardiac MIBG heart-to-mediastinum ratio on delayed images. Patients were stratified into three groups based on the 2-year cardiac mortality risk: low- (< 4%), intermediate- (4-12%), and high-risk (> 12%) groups. The ADHERE and GWTG-HF risk scores were also calculated. RESULTS: There was a significant difference in the incidence of cardiac death among the three groups stratified using the 2-year cardiac mortality risk model (p < 0.0001). The 2-year cardiac mortality risk model had a higher C-statistic (0.732) for the prediction of cardiac mortality than the ADHERE and GWTG-HF risk scores. CONCLUSION: The 2-year MIBG-based cardiac mortality risk model is useful for predicting post-discharge clinical outcomes in patients with ADHF. TRIAL REGISTRATION NUMBER: UMIN000015246, 25 September 2014.

Prognostic Impact of Echocardiographic Diastolic Dysfunction on Outcomes in Patients With Heart Failure With Preserved Ejection Fraction　- Insights From the PURSUIT-HFpEF Registry.

BACKGROUND: Although diastolic dysfunction is important pathophysiology in heart failure with preserved ejection fraction (HFpEF), its prognostic impact in HFpEF patients, including those with atrial fibrillation (AF), remains to be elucidated.Methods and Results:We included the data for 863 patients (321 patients with AF) registered in a prospective multicenter observational study of patients with HFpEF. Patients were divided into 3 groups according to the 2016 ASE/EACVI recommendations. The primary endpoint was a composite of all-cause death or HF rehospitalization. Median age was 83 years, and 55.5% were female. 196 (22.7%) were classified with normal diastolic function (ND), 253 (29.3%) with indeterminate (ID) and 414 (48.0%) with diastolic dysfunction (DD). The primary endpoint occurred more frequently in patients with DD than in those with ND or ID (log-rank P<0.001 for DD vs. ND, and log-rank P=0.007 for DD vs. ID, respectively). Taking ND as the reference, multivariable Cox regression analysis revealed that DD (hazard ratio (HR): 1.57, 95% confidence interval (CI):1.06-2.32, P=0.024) was independently associated with the composite endpoint, whereas ID (HR: 1.28, 95% CI: 0.84-1.95, P=0.255) was not. DD was associated with the composite endpoint in both patients with and without AF. CONCLUSIONS: HFpEF patients classified with DD using the 2016 ASE/EACVI recommendations had worse clinical outcomes than those with ND or ID. DD may be considered a prognostic marker in patients with HFpEF regardless of AF.

Prognostic relevance of elevated plasma osmolality on admission in acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry.

BACKGROUND: Complicated pathophysiology makes it difficult to identify the prognosis of heart failure with preserved ejection fraction (HFpEF). While plasma osmolality has been reported to have prognostic importance, mainly in heart failure with reduced ejection fraction (HFrEF), its prognostic meaning for HFpEF has not been elucidated. METHODS: We prospectively studied 960 patients in PURSUIT-HFpEF, a multicenter observational study of acute decompensated HFpEF inpatients. We divided patients into three groups according to the quantile values of plasma osmolality on admission. During a follow-up averaging 366 days, we examined the primary composite endpoint of cardiac mortality or heart failure re-admission using Kaplan-Meier curve analysis and Cox proportional hazard testing. RESULTS: 216 (22.5%) patients reached the primary endpoint. Kaplan-Meier curve analysis revealed that the highest quantile of plasma osmolality on admission (higher than 300.3 mOsm/kg) was significantly associated with adverse outcomes (Log-rank P = 0.0095). Univariable analysis in the Cox proportional hazard model also revealed significantly higher rates of adverse outcomes in the higher plasma osmolality on admission (hazard ratio [HR] 7.29; 95% confidence interval [CI] 2.25-23.92, P = 0.0009). Multivariable analysis in the Cox proportional hazard model also showed that higher plasma osmolality on admission was significantly associated with adverse outcomes (HR 5.47; 95% CI 1.46-21.56, P = 0.0113) independently from other confounding factors such as age, gender, comorbid of atrial fibrillation, hypertension history, diabetes, anemia, malnutrition, E/e', and N-terminal pro-B-type natriuretic peptide elevation. CONCLUSIONS: Higher plasma osmolality on admission was prognostically important for acute decompensated HFpEF inpatients.

Underweight Is Associated with Poor Prognosis in Heart Failure with Preserved Ejection Fraction.

The obesity paradox states higher body mass index (BMI) is associated with better outcomes than normal weight in patients with heart failure with preserved ejection fraction (HFpEF). However, underweight was defined by BMI < 18.5 kg/m2, and results have been inconclusive, in part due to small number of participants. The number of underweight patients with HFpEF is higher in Asian than in Western countries. In this study, we aim to determine the prognostic impact of underweight in patients with HFpEF in Asian population.We enrolled 846 consecutive patients from the PURSUIT-HFpEF registry. We then divided them into three groups by BMI, namely, underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 23), and overweight (23 ≤ BMI). The underweight group consisted of 187 patients (22%). Over a mean follow-up of 407 days, 105 deaths were reported as all-cause mortality. On multivariable Cox analysis, the underweight group was determined to be significantly associated with higher risk of all-cause mortality than the normal and overweight groups (Hazard ratios [HR]: 2.33; 95% confidence intervals [CI]: 1.45-3.75, P < 0.001; HR: 3.54; 95% CI: 1.99-6.29, P < 0.001, respectively), after adjustment for age, sex, vital signs, and comorbidities.Underweight is a useful predictor of poor prognosis in patients with HFpEF in Asian population.

Prediction of sudden cardiac death in chronic heart failure patients with reduced ejection fraction by ADMIRE-HF risk score and early repolarization pattern.

BACKGROUND: AdreView myocardial imaging for risk evaluation in heart failure (ADMIRE-HF) risk score is a novel risk score to predict serious arrhythmic risk in chronic heart failure patients with reduced ejection fraction (HFrEF). Moreover, early repolarization pattern (ERP) has been shown to be associated with an increased risk of sudden cardiac death (SCD) in HFrEF patients. We sought to investigate the prognostic value of combining ADMIRE-HF risk score and ERP to predict SCD in HFrEF patients. METHODS: We studied 90 HFrEF outpatients with LVEF< 40% in our prospective cohort study. In cardiac MIBG imaging, the heart-to-mediastinum (H/M) ratio was measured on the delayed planar image. ADMIRE-HF risk score was derived from the sum of the point values of LVEF, H/M ratio, and systolic blood pressure. We also assessed ERP on the standard electrocardiogram. RESULTS: During a median follow-up of 7.5(4.5-12.0) years, 22 patients had SCD. At multivariate Cox analysis, ADMIRE-HF risk score and ERP were independently associated with SCD. Patients with both intermediate/high ADMIRE-HF score and ERP had a higher SCD risk than those with either and none of them. CONCLUSION: The combination of ADMIRE-HF risk score and ERP would provide the incremental prognostic information for predicting SCD in HFrEF patients.

Prediction of sudden cardiac death in patients with chronic heart failure by regional washout rate in cardiac MIBG SPECT imaging.

BACKGROUND: The sympathetic nervous system provides an important trigger for major arrhythmic events through regional heterogeneity of sympathetic activity, which could be evaluated by SPECT imaging as the regional MIBG washout rate (WR). There is little information available on the prognostic value of regional WR in SPECT imaging for the prediction of sudden cardiac death (SCD) in patients with chronic heart failure (CHF). METHODS: We studied 73 CHF outpatients with LVEF < 40%. At study entry, the regional WR was measured in 17 segments on the polar map. We defined abnormal regional WR as both the regional WR range (maximum - minimum regional WR) and maximum regional WR > mean value + 2SD obtained in 15 normal controls. RESULTS: During a mean follow-up of 7.5 ± 4.1 years, 15 of 73 patients had SCD. The abnormal regional WR and abnormal global WR on planar images were significantly and independently associated with SCD. Patients with both the abnormal regional WR and global WR had a significantly higher risk of SCD than those with none of these criteria. CONCLUSIONS: The analysis of regional MIBG WR on SPECT imaging provides additional prognostic value to global WR on planar images for SCD prediction in CHF patients.

Serial Change in Serum Chloride During Hospitalization Could Predict Heart Failure Death in Acute Decompensated Heart Failure Patients.

BACKGROUND: Although hyponatremia predicts morbidity and mortality in acute decompensated heart failure (ADHF), hypochloremia is also independently associated with poor prognosis in ADHF. Little is known, however, about the prognostic value of serial change in serum chloride during hospitalization in ADHF patients.Methods and Results:We prospectively studied 208 ADHF survivors after discharge and divided them into 4 groups according to serum chloride on admission and at discharge: (1) persistent hypochloremia group (n=12), hypochloremia both on admission and at discharge; (2) progressive hypochloremia group (n=42), development of hypochloremia after admission; (3) improved hypochloremia group (n=14), hypochloremia only on admission; and (4) no hypochloremia group, no hypochloremia during hospitalization (n=140). During a mean follow-up period of 1.86±0.76 years, 20 of 208 patients had heart failure death (HFD). In a model adjusted for hyponatremia, hypochloremia both on admission and at discharge was still significantly associated with HFD. Hyponatremia, however, was not significantly associated with HFD after adjustment for hypochloremia. Patients with persistent hypochloremia (HR, 9.13; 95% CI: 2.56-32.55) and with progressive hypochloremia (HR, 4.65; 95% CI: 1.61-13.4) had a significantly greater risk of HFD than those without hypochloremia during hospitalization. CONCLUSIONS: Both persistent hypochloremia and progressive hypochloremia during hospitalization are associated with HFD in ADHF patients.

Rationale and Design of the Multicenter Trial on Japan Working Group on the Effects of Angiotensin Receptor Blockers Selection (Azilsartan vs. Candesartan) on Diastolic Function in the Patients Suffering from Heart Failure with Preserved Ejection Fraction: J-TASTE Trial.

BACKGROUND: Previous studies suggest that the pathophysiology of heart failure with preserved ejection fraction (HFpEF) is characterized not only by high ventricular stiffness, but also by vascular stiffness. Azilsartan has higher vascular affinity compared with other angiotensin II receptor blockers (ARBs), which were proven to have no beneficial effects on clinical outcomes in patients with HFpEF in earlier clinical trials. We aimed to test the hypothesis that azilsartan may improve left ventricular diastolic function in HFpEF patients with hypertension in this trial. METHODS: The Effects of Angiotensin Receptor Blockers on Diastolic Function in Patients Suffering from Heart Failure with Preserved Ejection Fraction: J-TASTE trial is a multicenter, randomized, open-labeled, and assessor(s)-blinded, active controlled using candesartan, parallel-group clinical trial, to compare changes in left ventricular (LV) diastolic dysfunction between HFpEF patients with hypertension who have received candesartan or azilsartan for 48 weeks. The primary endpoint is the change in early diastolic wave height/early diastolic mitral annulus velocity (E/e') assessed by echocardiography from the baseline to the end of the study (48 weeks). A total of 190 patients will be recruited into the study. CONCLUSIONS: The design of the J-TASTE trial will provide data on whether differences between the effects of the two tested drugs on LV diastolic function exist in HFpEF patients with hypertension and will improve understanding of the pathophysiological role of vascular stiffness on diastolic function.

Clinical Outcome of Arthroscopic Treatment for Posteromedial Elbow Impingement in Adolescent Baseball Players.

PURPOSE: To evaluate the clinical outcomes of arthroscopic treatment in adolescent baseball players with posteromedial elbow impingement. METHODS: This retrospective study evaluated the clinical outcome of arthroscopic treatment for posteromedial elbow impingement in adolescent baseball players. Patients were eligible for participation if they had undergone surgery at least 2 years earlier and excluded if they had arthritis, loose bodies, osteochondritis dissecans, ulnar collateral ligament tear, flexor/pronator injuries or medial epicondylitis, or nerve problems. Patients were also excluded if they had undergone prior elbow surgery, were younger than 13 years, or were older than 19 years. Arthroscopic treatment included debridement of posteromedial synovitis, fragment removal, and olecranon spur excision. At a mean follow-up of 26.7 (range 24-42) months, patients were evaluated based on a questionnaire, examination, and the previously reported elbow outcome score. RESULTS: This retrospective study involved 15 male patients, comprising 6 pitchers, 3 catchers, and 6 fielders, of mean age 15.7 (range 14-17) years. Mean time from onset of symptoms to surgery was 4.9 (range 3-18) months. Intraoperative findings included posteromedial synovitis and olecranon spurs in all patients and fragments in 10. The elbow outcome score was considered excellent in 11 patients and good in 2, with a mean score of 92 points (maximum 100 points). The mean postoperative range of motion at the elbow was 5° to 139.7° of flexion. All patients were able to return to their previous level of play after an average of 3.4 (range 2.5-4.5) months. No patient developed medial instability that later required reconstructive surgery. CONCLUSIONS: Arthroscopic debridement, excision of the olecranon spur, and removal of fragments yield reliable subjective and objective results and allow a return to baseball in adolescent patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Tolvaptan Reduces the Risk of Worsening Renal Function in Patients With Acute Decompensated Heart Failure and Preserved Left Ventricular Ejection Fraction　- Prospective Randomized Controlled Study.

BACKGROUND: Although the mainstay of treatment for acute decompensated heart failure (ADHF) is decongestion by diuretic therapy, it is often associated with worsening renal function (WRF). The effect of tolvaptan, a selective V2 receptor antagonist, on WRF in ADHF patients with preserved left ventricular ejection fraction (LVEF) is unknown.Methods and Results:We enrolled 50 consecutive ADHF patients whose LVEF on admission was ≥45%. Patients were randomly assigned to either tolvaptan add-on (n=26) or conventional diuretic therapy (n=24). The primary endpoint was the incidence of WRF, defined as an increase in serum creatinine (Cr) ≥0.3 mg/dL or 50% above baseline within 48 h of randomization. There was no significant difference between the 2 groups in the change in body weight or the total urine volume during 48 h. However, the change in Cr (∆Cr) at 24 and 48 h after randomization and the incidence of WRF (12% vs. 42%, P=0.0236) were significantly lower, and the fractional excretion of urea (FEUN) at 24 and 48 h after randomization was significantly higher in the tolvaptan group. There was an inverse correlation between ∆Cr and FEUN at 48 h after randomization. CONCLUSIONS: Tolvaptan can alleviate congestion with a significantly lower risk of WRF in ADHF patients with preserved LVEF, presumably through maintenance of renal perfusion.

Eplerenone might affect atrial fibrosis in patients with hypertension.

BACKGROUND: Eplerenone is reported to reduce the development of atrial fibrillation (AF). The aim of this study was to clarify the mechanism of eplerenone for AF prevention from the viewpoint of P wave morphology, which is reported to correlate with atrial fibrosis. METHODS: Thirty-five patients with hypertension, who were randomized to receive eplerenone (n = 16) or amlodipine (n = 19) for 1 year, were evaluated. P wave signal-averaged electrocardiography was recorded at baseline and 1 year after entry, and P wave duration (Ad) and P wave dispersion (P-disp) were obtained. Serum levels of intact procollagen type I N-terminal propeptide (PINP) and N-terminal procollagen-III peptide (PIIIP) were also measured. RESULTS: There were no significant differences in baseline clinical characteristics including Ad, P-disp, and the decrease in blood pressure at 1-year follow-up between the two groups. Ad and P-disp (mean ± standard deviation) significantly increased in patients on amlodipine after 1 year (140 ± 21 ms to 139 ± 19 ms vs 132 ± 10 ms to 136 ± 12 ms, P < 0.01 and 14 ± 7 ms to 9 ± 4 ms vs 12 ± 5 to 16 ± 8, P < 0.01, respectively). PINP was significantly more decreased in patients with eplerenone than amlodipine (56.6 ± 30.4 µg/mL to 46.6 ± 19.4 µg/mL vs 41.5 ± 16.2 µg/L to 48.7 ± 21.3 µg/L, P < 0.01). Percent changes of Ad, P-disp, PINP, and PIIIP were significantly smaller in patients with eplerenone than amlodipine (0.0 ± 4.7% vs 3.2 ± 4.4%, P < 0.05, - 28.6 ± 31.0% vs 46.3 ± 73.0%, P < 0.01, - 5.6 ± 38.1% vs 22.7 ± 42.7%, P < 0.05, and - 9.2 ± 25.1% vs 7.4 ± 19.0%, P < 0.05, respectively). CONCLUSIONS: Eplerenone reduced the increase of Ad and P-disp with a decrease of PINP and PIIIP, which might translate into reduction of atrial fibrosis. This study showed that eplerenone may be useful as upstream therapy for AF in patients with hypertension.

The CHADS2 score predicts ischemic stroke in chronic heart failure patients without atrial fibrillation: comparison to other stroke risk scores.

The CHADS2 score is useful in stratifying the risk of ischemic stroke or transient ischemic attack (TIA) in patients with non-valvular atrial fibrillation (AF). However, it remains unclear whether the CHADS2 score could predict stroke or TIA in chronic heart failure (CHF) patients without AF. Recently, the new stroke risk score was proposed from 2 contemporary heart failure trials. We evaluated the prognostic power of the CHADS2 score for stroke or TIA in CHF patients without AF in comparison to the "stroke risk score". We retrospectively studied 127 CHF patients [left ventricular ejection fraction (LVEF) <40 %] without AF, who had been enrolled in our previous prospective cohort study. The primary endpoint was the incidence of stroke or TIA. The mean baseline CHADS2 score was 2.1 ± 1.0. During the follow-up period of 8.4 ± 5.1 years, stroke or TIA occurred in 21 of 127 patients. At multivariate Cox analysis, CHADS2 score (C-index 0.794), but not "stroke risk score" (C-index 0.625), was significantly and independently associated with stroke or TIA. The incidence of stroke or TIA appeared to increase in relation to the CHADS2 score [low (=1), 0 per 100 person-years; intermediate (=2), 1.6 per 100 person-years; high (≥3), 4.7 per 100 person-years; p = 0.04]. CHADS2 score could stratify the risk of ischemic stroke in CHF patients with the absence of AF, with greater prognostic power than the "stroke risk score".

Incidence and clinical features of sacral insufficiency fracture in the emergency department.

INTRODUCTION: A sacral insufficiency fracture (SIF) often manifests as low back pain or sciatica in the absence of any antecedent trauma. These fractures may be missed because of lack of appropriate imaging. The purpose of this study was to clarify the incidence and clinical features of SIF as well as the characteristic findings on magnetic resonance imaging (MRI) of the lumbar spine. MATERIALS AND METHODS: The study participants comprised 250 patients (132 male, 118 female; mean age 58.6years) with pelvic trauma. SIF was identified on computed tomography or MRI. The incidence, initial symptoms, and time delay between the first visit and an accurate diagnosis of SIF were recorded. RESULTS: We detected 11 cases of SIF. Initial symptoms of SIF were low back pain (36.4%), gluteal pain (63.6%), and coxalgia (18.2%). Two patients complained of both low back pain and gluteal pain. The mean delay between the first visit and an accurate diagnosis of SIF was 23.9days. This time interval was significantly longer than in patients with other types of pelvic fracture. Four patients underwent MRI targeting the lumbar spine to investigate their symptoms. In all 4 patients, the signal intensity on T1-weighted and fat-suppressed images of the second sacral segment was low and high, respectively. CONCLUSION: This study demonstrates that accurate diagnosis of SIF may be delayed because of difficulties in detecting this type of fracture on plain X-ray and the non-specific nature of the presenting complaints. Emergency physicians should keep SIF in mind when investigating patients who complain of low back pain or gluteal pain. Findings at the second sacral segment on MRI targeting the lumbar spine may aid early diagnosis of this type of pelvic fracture.

Two-year follow-up study of subchondral surface irregularities of the capitellum on ultrasonography in baseball players under the age of 10 years.

OBJECTIVE: To determine whether subchondral surface irregularities of the capitellum on ultrasonography in baseball players under the age of 10 years are indicative of early osteochondritis dissecans (OCD) of the capitellum. MATERIALS AND METHODS: A total of 321 players aged 6-9 years underwent ultrasonographic examination, and the findings for the subchondral bone of the capitellum on the throwing side were graded as 0, 1a, 1b, 2, or 3. Subjects classified as grade 1a or 1b showed irregularities of the subchondral bone surface and were investigated radiographically for OCD. All players continued to throw and were re-examined by ultrasonography after 1 and 2 years. RESULTS: At the first examination, 11/321 (3.4%) had irregularities at the subchondral surface of the capitellum [grade 1a in 7/321 (2.2%); grade 1b in 4/321 (1.2%)]. The seven players with grade 1a showed no evidence of OCD or Panner's disease on radiography and were reclassified as grade 0 at the 2-year follow-up. All four players with grade 1b were reclassified as grade 0 at follow-up 1 and 2 years later. CONCLUSION: Subchondral bone surface irregularities of the capitellum on ultrasonography in children under the age of 10 years may not be indicative of disease, but rather represent variation of ossification during normal development.

Influence of Medial Collateral Ligament Release for Internal Rotation of Tibia in Posterior-Stabilized Total Knee Arthroplasty: A Cadaveric Study.

BACKGROUND: Previous studies suggested that changes in kinematics in total knee arthroplasty (TKA) affected satisfaction level. The aim of this cadaveric study was to evaluate the effect of medial collateral ligament (MCL) release by multiple needle puncture on knee rotational kinematics in posterior-stabilized TKA. METHODS: Six fresh, frozen cadaveric knees were included in this study. All TKA procedures were performed with an image-free navigation system using a 10-mm polyethylene insert. Tibial internal rotation was assessed to evaluate intraoperative knee kinematics. Multiple needle puncturing was performed 5, 10, and 15 times for the hard portion of the MCL at 90° knee flexion. Kinematic analysis was performed after every 5 punctures. After performing 15 punctures, a 14-mm polyethylene insert was inserted, and kinematic analysis was performed. RESULTS: The tibial internal rotation angle at maximum knee flexion without multiple needle puncturing was significantly larger (9.42°) than that after 15 punctures (3°). Negative correlation (Pearson r = -0.715, P < .001) between tibial internal rotation angle at maximum knee flexion and frequency of puncture was observed. The tibial internal rotation angle with a 14-mm insert was significantly larger (7.25°) compared with the angle after 15 punctures. CONCLUSION: Tibial internal rotation during knee flexion was reduced by extensive MCL release using multiple needle puncturing and was recovered by increasing of medial tightness. From the point of view of knee kinematics, medial tightness should be allowed to maintain the internal rotation angle of the tibia during knee flexion which might lead to patient satisfaction.

Variations in the obturator artery around the obturator foramen assessed by three-dimensional computed tomographic angiography and prevention of vascular-related complications in rotational acetabular osteotomy.

PURPOSE: The aims of this study were (1) to evaluate the anatomical variations and locations of the obturator artery at the obturator foramen using computed tomographic (CT) angiography images and (2) to evaluate the pubic osteotomy site in rotational acetabular osteotomy using postoperative CT images in order to assess the relationship between the obturator artery and the pubic osteotomy site. METHODS: We examined a total of 196 hips in 98 consecutive Japanese patients for aim (1), and 38 consecutive patients who underwent rotational acetabular osteotomy for aim (2). RESULTS: The prevalence of arterial anastomosis of the obturator artery (corona mortis) was 14.3 %, with the obturator artery being located closer to the superior pubic ramus and the osteotomy site in these subjects. CONCLUSIONS: Extensive care should be taken during rotational acetabular osteotomy in patients showing variations of the obturator artery with corona mortis.

Risk Stratification for Ventricular Tachyarrhythmias by Ambulatory Electrocardiogram-Based Frequency Domain T-Wave Alternans.

BACKGROUND: Ambulatory electrocardiogram (ECG)-based T-wave alternans (TWA) quantified by the modified moving average method (MMA) can be used to identify patients at risk for sudden cardiac death. However, there is no information available on ambulatory ECG-based TWA as quantified by the frequency domain (FD) method to identify patients with an implantable cardioverter defibrillator (ICD) who are at high risk for ventricular tachyarrhythmias. Further, there are few data regarding the comparison of clinical utility of FD-TWA with MMA-TWA, heart rate variability (HRV), and heart rate turbulence (HRT). METHODS AND RESULTS: In 41 patients with ICD, of whom 14 patients had a past history of at least one appropriate ICD discharge, FD-TWA, MMA-TWA, HRV, and HRT were analyzed from 24-hour Holter ECG monitoring recordings. Only positive results of FD-TWA and abnormal HRV (standard deviation of all normal-to-normal intervals ≤111 ms) were significantly more frequently observed in patients with than without appropriate ICD discharge. Patients with FD-TWA positive had a significantly higher risk of appropriate ICD discharge than those with FD-TWA negative (50% vs 16%; odds ratio, 5.3 [95% confidence interval, 1.2-23.7], P = 0.02). When FD-TWA and HRV were combined, the specificity (93% vs 59%, P = 0.003) and predictive accuracy (83% vs 66%, P = 0.07) for the identification of patients with appropriate ICD discharge were greater than those for FD-TWA only. CONCLUSION: The ambulatory ECG-based FD-TWA might be useful to detect patients with ICD who are at high risk for ventricular tachyarrhythmias, and the combination of FD-TWA and HRV might improve the ability to detect such high-risk patients.