Outcomes of cruciate-retaining total knee arthroplasty for osteoarthritis with severe varus deformity.

BACKGROUND: Varus deformity is common in osteoarthritic knee. The purpose of this study was to investigate the clinical and radiographic outcomes after cruciate-retaining (CR) total knee arthroplasty (TKA) for severely varus osteoarthritic knees and compare them to those of mildly to moderately deformed osteoarthritic knees. METHODS: Eight hundred ninety-four subjects were undergone CR TKA, 137 had severe varus deformity (group 1), and 757 had mild-to-moderate deformity (group 2) of the lower limb preoperatively. Pre- and postoperative outcomes were compared between two groups clinically and radiographically. RESULTS: Mean follow-up period was 54.7 ± 28.9 months. Mean age was 77.8 ± 6.7 years in group 1 and 74.5 ± 7.4 years in group 2 (p < 0.001). Preoperative hip-knee-ankle angle (HKAA) was - 17.7°±2.9° in group 1 and - 6.3° ± 5.1° in group 2 (p < 0.001). Preoperative range of motion (ROM) was 127.7° ± 15.2° in group 1 and 130.8 °± 9.6° in group 2 (p = 0.019). Preoperative Knee Society scores and WOMAC score were not significantly different between two groups. Postoperative HKAA was - 0.4° ± 2.3° in group 1 and 0.6 ° ± 2.0° in group 2 (p < 0.001). Postoperative ROM, Knee Society scores, and WOMAC score were not significantly different between two groups. CONCLUSIONS: CR TKA showed results in subjects with severe varus deformities comparable to those without severe varus deformities. Whether the degree of preoperative varus deformity of the lower limb should be considered when deciding to perform CR-type or PS-type TKA requires further discussion. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Preclinical assessment of thrombin-preconditioned human Wharton's jelly-derived mesenchymal stem cells for neonatal hypoxic-ischaemic brain injury.

Hypoxic-ischaemic encephalopathy (HIE) is a type of brain injury affecting approximately 1 million newborn babies per year worldwide, the only treatment for which is therapeutic hypothermia. Thrombin-preconditioned mesenchymal stem cells (MSCs) exert neuroprotective effects by enriching cargo contents and boosting exosome biogenesis, thus showing promise as a new therapeutic strategy for HIE. This study was conducted to evaluate the tissue distribution and potential toxicity of thrombin-preconditioned human Wharton's jelly-derived mesenchymal stem cells (th-hWJMSCs) in animal models before the initiation of clinical trials. We investigated the biodistribution, tumorigenicity and general toxicity of th-hWJMSCs. MSCs were administered the maximum feasible dose (1 × 105 cells/10 µL/head) once, or at lower doses into the cerebral ventricle. To support the clinical use of th-hWJMSCs for treating brain injury, preclinical safety studies were conducted in newborn Sprague-Dawley rats and BALB/c nude mice. In addition, growth parameters were evaluated to assess the impact of th-hWJMSCs on the growth of newborn babies. Our results suggest that th-hWJMSCs are non-toxic and non-tumorigenic in rodent models, survive for up to 7 days in the brain and hold potential for HIE therapy.

Subacute dermal toxicity of perfluoroalkyl carboxylic acids: comparison with different carbon-chain lengths in human skin equivalents and systemic effects of perfluoroheptanoic acid in Sprague Dawley rats.

Perfluoroalkyl and polyfluoroalkyl substances (PFASs) are used in various fields but raise concerns regarding human health and environmental consequences. Among PFASs, perfluorooctanoic acid (PFOA) and short-chain perfluoroalkyl carboxylic acids (SC PFCAs) are detectable in skin-contact consumer products and have dermal absorption potential. Here, we investigated the effects of dermal exposure to PFOA and SC PFCAs using in vitro and in vivo models. Human skin equivalents were topically treated with 0.25 mM and 2.5 mM PFOA and SC PFCAs (perfluoropentanoic acid, PFPeA; perfluorohexanoic acid, PFHxA; and perfluoroheptanoic acid, PFHpA) for 6 days, and cell viability, interleukin (IL)-1α, oxidative stress markers (malondialdehyde, MDA; and 8-hydroxydeoxyguanosine, 8-OHdG), and histopathology were examined. MDA levels were significantly higher in the PFASs groups than in controls. Compared with SC PFCAs, 2.5 mM PFOA caused more IL-1α (p < 0.001) release, decreased skin thickness and microscopic abnormalities. To evaluate systemic effects, Sprague Dawley (SD) rats were dermally treated with 250 and 1000 mg/kg PFHpA for 2 weeks and clinical and anatomic pathology were assessed. At 1000 mg/kg, 83% of the rats died, with severe ulcerative dermatitis at the application site. Adverse PFHpA-treated systemic changes were observed in the kidney, liver and testes, and histopathologic lesions such as renal tubular necrosis, hepatocellular necrosis, and germ cell degeneration were seen at 250 and 1000 mg/kg. Our study suggests that SC PFCAs have fewer effects on the skin than PFOA, but SC PFCAs can have adverse effects on major organs with systemic exposure at high concentrations.

Comparative adherence to weekly oral and quarterly intravenous bisphosphonates among patients with limited heath literacy who sustained distal radius fractures.

Individuals with limited health literacy (HL) are less likely to obtain preventive care. We designed a study to compare adherence to weekly oral and quarterly intravenous bisphosphonates among patients with low HL. The study enrolled a total of 432 female patients who presented with a distal radius fracture caused by low-energy trauma. Participant HL was measured using the Newest Vital Sign tool, and patients were randomized to weekly oral or quarterly intravenous bisphosphonate groups. Subjects in the intravenous bisphosphonate group received intravenous injections of 3 mg ibandronate every 3 months, and those in the oral bisphosphonate group self-administered 70 mg alendronate orally once each week for 12 months. The adherence to weekly oral or quarterly intravenous bisphosphonates was analyzed by HL level. The rate of adherence to quarterly intravenous bisphosphonates was significantly higher than that for weekly oral bisphosphonates in patients with inadequate HL (73 vs. 46%, p = 0.001), whereas no significant differences were observed between HL groups in adherence to intravenous bisphosphonate. Conversely, the rate of adherence to orally administered bisphosphonates was significantly lower in patients with inadequate HL than in those with appropriate HL (46 vs. 65%, p = 0.005). After controlling for confounding variables, inadequate HL, the presence of comorbidities, and weekly oral bisphosphonates were associated with a higher likelihood of nonadherence to osteoporosis treatment. Thus patients with limited health literacy can achieve rates of adherence to quarterly intravenous bisphosphonates, as opposed to weekly oral bisphosphonates, similar to rates among patients with appropriate literacy.

Patients With Limited Health Literacy Have Similar Preferences but Different Perceptions in Surgical Decision-making for Carpal Tunnel Release.

BACKGROUND: Health literacy is the ability to obtain, process, and understand health information needed to make appropriate health decisions. The proper comprehension by patients regarding a given disease, its treatment, and the physician's instructions plays an important role in shared decision-making. Studies have disagreed over the degree to which differences in health literacy affect patients' preferences for shared decision-making; we therefore sought to evaluate this in the context of shared decision-making about carpal tunnel release. QUESTIONS/PURPOSES: (1) Do patients with limited health literacy have different preferences of shared decision-making for carpal tunnel release than those with greater levels of health literacy? (2) How do patients with limited health literacy retrospectively perceive their role in shared decision-making after carpal tunnel release? METHODS: Over a 32-month period, one surgeon surgically treated 149 patients for carpal tunnel syndrome. Patients were eligible if they had cognitive and language function to provide informed consent and complete a self-reported questionnaire and were not eligible if they had nerve entrapment other than carpal tunnel release or had workers compensation issues; based on those, 140 (94%) were approached for study. Of those, seven (5%) were lost to followup before 6 months, leaving 133 for analysis here. Their mean age was 55 years (range, 31-76 years), and 83% (111 of 133) were women. Thirty-three percent (44 of 133) of patients had less than a high school education. Health literacy was measured according to the Newest Vital Sign during the initial visit, and a score of ≤ 3 was considered limited health literacy. Forty-four percent of patients had limited health literacy. The Control Preferences Scale was used for patients to indicate their preferred role in surgical decision-making preoperatively and to assess their perceived level of involvement postoperatively. Bivariate and multivariable analyses were performed to determine whether patients' clinical, demographic, and health literacy factors accounted for the preoperative preferences and postoperative assessments of their role in shared decision-making. A total of 133 patients would provide 94% power for a medium effect size for linear regression with five main predictors. RESULTS: We found no differences between patients with lower levels of health literacy and those with greater health literacy in terms of preferences of shared decision-making for carpal tunnel release (3.0 ± 1.6 versus 2.7 ± 1.4; mean difference, 0.3; 95% confidence interval, -0.2 to 0.8; p = 0.25). A history of surgical procedures (coefficient = -0.32, p < 0.01) and a lower Disabilities of the Arm, Shoulder and Hand score (coefficient = 0.17, p = 0.02) were independently associated with a preference for an active role in shared decision-making. However, patients with limited health literacy (coefficient = -0.31, p = 0.01) and an absence of a caregiver (coefficient = -0.28, p = 0.03) perceived a more passive role in actual decision-making. CONCLUSIONS: Physicians should be aware of the discrepancy between preferences and perceptions of shared decision-making among patients with limited health literacy, and physicians should consider providing a decision aid tailored to basic levels of health literacy to help patients achieve their preferred role in decision-making. LEVEL OF EVIDENCE: Level II, prognostic study.

Factors influencing functional outcome of proximal interphalangeal joint collateral ligament injury when treated with buddy strapping and exercise.

STUDY DESIGN: Prospective cohort. INTRODUCTION AND PURPOSE: This study evaluates the factors influencing treatment outcomes of proximal interphalangeal (PIP) joint collateral ligament injuries when treated with buddy strapping. METHODS: Sixty-seven patients treated with buddy strapping for a PIP joint injury were enrolled. The finger range of motion (ROM), grip strength, and a Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score were assessed at 3 and 6 months after the initial injury. The factors that were assessed for their influence on the functional outcomes included age, sex, hand dominance, affected finger, type of injury, injury severity, time to treatment, the duration of buddy strapping, and exercise training. RESULTS: Buddy strapping for PIP joint injuries led to satisfactory results with 77% recovery of grip strength, 84% recovery in ROM, and mean QuickDASH scores of 14 at 6 months. A decrease in grip strength was associated with an increase in age and injury severity at 6 months, and these 2 factors accounted for 22% of the variance in the grip strength. A decrease in ROM was associated with the delayed treatment, which accounted for 18% of the variance in ROM at 6 months. An increased disability was associated with delayed treatment, female gender, and radial digit injury at 3 months, and these 3 factors accounted for 37% of the variance in disability. At 6 months, only the delayed treatment remained an associated factor, which accounted for 20% variance in disability. DISCUSSION AND CONCLUSIONS: PIP collateral ligament injuries had very good outcomes with buddy strapping. However, delayed treatment was significantly associated with poor functional outcomes in terms of the ROM and disability. An increase in age and injury severity were associated with lower grip strength up to 6 months, whereas a female gender and radial digit injury were associated with an increased disability up to 3 months. LEVEL OF EVIDENCE: 2.

Remnant-preserving and re-tensioning technique to cover the graft in anterior cruciate ligament reconstruction.

PURPOSE: This study set out to assess the clinical and radiographic outcomes and the extent of synovial coverage on second-look arthroscopy of anterior cruciate ligament (ACL) reconstruction using a remnant-preserving and re-tensioning technique to easily cover the graft with a remnant. METHODS: Forty-three subjects with ACL rupture underwent remnant-preserving and re-tensioning ACL reconstruction using a free tendon Achilles allograft between 2011 and 2013. The clinical outcomes were assessed by Lysholm knee score, Lachman stress test, pivot shift test, International Knee Documentation Committee (IKDC) classification, and Tegner Activity Scale score. Side-to-side difference (SSD) was assessed on stress radiographs. The extent of synovialization was evaluated on second-look arthroscopy. RESULTS: The mean Lysholm score was 54 ± 11 before surgery and 94 ± 5 at the last follow-up (p < 0.001). On Lachman stress test, 42 subjects had grade 0 or 1 on the Lachman stress test, and 42 had grade 0 or 1 on the pivot shift test. Forty-one subjects had IKDC classification A or B; two were classified as C or D. The median Tegner Activity Scale score was 6.5 (range 5-9) before injury and 6 (range 4-8) at the last follow-up (p = 0.048). Mean SSD on stress radiographs was 9.9 ± 2.6 mm preoperatively and 1.0 ± 1.7 mm at the last follow-up (p < 0.001). In the assessment of the extent of synovial coverage of the graft, 39 subjects were in group 1 (>75 %) for synovial coverage of the graft, three were in group 2 (50-75 %), and one was in group 4 (≤25 %). CONCLUSIONS: The remnant-preserving and re-tensioning technique resulted in satisfying short-term results clinically and radiologically and good synovial coverage on second-look arthroscopy. LEVEL OF EVIDENCE: Case series, Level IV.

Multiple looping technique for tibial fixation in posterior cruciate ligament reconstruction using free tendon Achilles allograft.

PURPOSE: This study was conducted to evaluate case series outcomes of a new tibial fixation technique using a free tendon graft during posterior cruciate ligament (PCL) reconstruction which is less affected by tibial metaphysis bone density. METHODS: Thirty-two subjects underwent single-bundle PCL reconstruction using a free tendon Achilles allograft. The graft was looped to be double stranded. The free ends of the graft were fixed to the femoral side using suture washer, and the looped end was fixed to the tibial side using the multiple looping technique. Range of motion of the knee and side-to-side difference were assessed at the last follow-up. The Lysholm Knee score was evaluated preoperatively and at the last follow-up. The Tegner Activity Scale score was evaluated before injury and at the last follow-up. RESULTS: Twenty-eight subjects were followed up for at least 18 months. Mean follow-up was 27.7 ± 4.8 months. All subjects showed normal range of motion at the last follow-up. The mean side-to-side difference was 10.4 ± 2.8 mm preoperatively and 2.3 ± 1.8 mm at the last follow-up (p < 0.001). The mean Lysholm Knee score was 58 ± 9 preoperatively and 91 ± 5 at the last follow-up (p < 0.001). The median Tegner Activity Scale score was 7 (range 5-9) before injury and 6 (range 4-8) at the last follow-up (p = 0.001). CONCLUSIONS: The multiple looping technique for tibial fixation resulted in satisfactory outcomes from single-bundle PCL reconstruction without any significant complications. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Low Median Nerve Palsy as Initial Manifestation of Churg-Strauss Syndrome.

Anterior interosseous nerve (AIN) syndrome is typically characterized by forearm pain and partial or complete dysfunction of the AIN-innervated muscles. Although the exact etiology and pathophysiology of the disorder remain unclear, AIN syndrome is increasingly thought to be an inflammatory condition of the nerve rather than a compressive neuropathy because the symptoms often resolve spontaneously following prolonged observation. However, peripheral neuropathy can be 1 of the first symptoms of systemic vasculitis that needs early systemic immunotherapy to prevent extensive nerve damage. Churg-Strauss syndrome (CSS; eosinophilic granulomatosis with polyangiitis) is 1 type of primary systemic vasculitis that frequently damages the peripheral nervous system. CSS-associated neuropathy usually involves nerves of the lower limb, and few studies have reported on the involvement of the upper limb alone. We report on a rare case of low median nerve palsy as the initial manifestation of CSS. The patient recovered well with early steroid treatment for primary systemic vasculitis.

Focal Eosinophilic Myositis of the Hand Presenting as a Refractory Pyogenic Infection.

Eosinophilic myositis is a rare disorder in which eosinophils infiltrate muscle and supporting connective tissue structures. The disorder can be localized or diffuse, and it may be associated with various systemic features resembling autoimmune disease. Focal eosinophilic myositis is the most limited form of eosinophilic myositis, for which muscle involvement is generally limited to the lower extremity. We report on a rare case of focal eosinophilic myositis of the interosseous muscles of the hand, which presented as a refractory, pyogenic hand infection.

Effect of Metabolic Syndrome on the Outcome of Corticosteroid Injection for Trigger Finger: Matched Case-Control Study.

PURPOSE: To compare the efficacy of corticosteroid injections in treating trigger finger in patients with and without metabolic syndrome (MS). METHODS: Fifty-one patients with trigger finger and MS were matched for age and sex with 52 control patients without MS. All patients were treated with a single corticosteroid injection. The response to treatment, including objective triggering, tenderness at the A1 pulley, and Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH) were assessed at 6, 12, and 24 weeks' follow-up. Before the 24-week evaluation, 7 in the MS group and 10 in the control group were lost to follow-up. RESULTS: Prior to treatment, patients with MS had Quinnell grades and initial mean QuickDASH scores similar to those in the control group. The proportion of treatment failure for the MS group (49%) was significantly higher than that of control group (19%) after 6 months' follow-up. Unresolved triggering was more prevalent in patients in the MS group at the 12- and 24-week follow-ups. Local tenderness was more persistent in the MS group than in the control group throughout the 24 weeks of follow-up. After 24 weeks of follow-up, 14 patients (27%) in the MS group and 6 (12%) in the control group underwent surgical release. QuickDASH scores of the MS group were worse than those of the control group at the 12- and 24-week follow-ups. CONCLUSIONS: Trigger finger patients with MS are at risk of poorer functional outcomes and treatment failure after a single corticosteroid injection than age- and sex-matched controls. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Effects of health literacy on treatment outcome and satisfaction in patients with mallet finger injury.

STUDY DESIGN: Prospective cohort. INTRODUCTION: Patient comprehension of their injury, its treatment, and health care provider's instructions plays an important role in health management and recovery from trauma. PURPOSE OF THE STUDY: This study investigates the effects of health literacy (the ability to obtain, process, and understand health information needed to make appropriate health decisions) on treatment outcomes and satisfaction in patients with mallet finger injuries. METHODS: A total of 72 patients who had been treated with an orthosis for an acute mallet finger injury were enrolled in this prospective study. Health literacy was measured according to the newest vital sign during the initial visit, and adherence according to the treatment protocol was rated at week 7 when orthotic intervention was ceased. At 6 months, a follow-up visit was conducted to assess the extensor lag, treatment satisfaction, and disability (through the Quick Disabilities of the Arm, Shoulder, and Hand score). Bivariate and multivariable analyses were performed to determine whether patient demographics, injury characteristics, and health literacy factors accounted for following outcomes: extensor lag, satisfaction, and disability. RESULTS: The newest vital sign scores were moderately correlated with patient adherence and age. Extensor lag was associated with an increase in age, poor adherence, and low health literacy, and these 3 factors accounted for 28% of the variation in the extensor lag. A greater disability was associated with poor adherence, which accounted for 12% of the variance in disability. Lower treatment satisfaction was associated with low health literacy and poor adherence, and these 2 factors accounted for 21% of the variation in treatment satisfaction. DISCUSSION AND CONCLUSIONS: Limited health literacy was associated with poor adherence in orthosis care for mallet finger injuries and led to poorer treatment outcomes in terms of extensor lag and treatment satisfaction. LEVEL OF EVIDENCE: 2B.

To What Degree Do Pain-coping Strategies Affect Joint Stiffness and Functional Outcomes in Patients with Hand Fractures?

BACKGROUND: Patients with hand fractures often have pain, swelling, and stiffness in the joints of the hand, which may lead them to protect their hands, resulting in more stiffness and in delayed recovery. However, the effects of pain-coping strategies and catastrophization (the tendency to expect the worst to occur when pain is present, an approach that can be thought of as the opposite of "coping") on functional recovery after hand fractures have not been investigated in depth. QUESTIONS/PURPOSES: Are preoperative catastrophization and anxiety in patients with hand fractures associated with (1) decreased grip strength; (2) decreased range of motion; and (3) increased disability at 3 and 6 months after surgical treatment for a hand fracture? Secondarily, we asked if there are other patient and injury factors that are associated with these outcomes at 3 and 6 months. METHODS: A total of 93 patients with surgically treated hand fractures were enrolled in this prospective study. Preoperative assessments measured coping strategies evaluated by measuring catastrophic thinking with the Pain Catastrophizing Scale and pain anxiety with the Pain Anxiety Symptom Scale. At 3 and 6 months postoperatively, grip strength, total active range of motion, and disability (Quick Disabilities of the Arm, Shoulder, and Hand score) were assessed. Bivariate and multivariate analyses were performed to identify patient demographic, injury, and coping skills factors that accounted for outcomes of strength, motion, and disability. RESULTS: Decreased grip strength was associated with catastrophic thinking (beta = -1.29 [95% confidence interval, -1.67 to -0.89], partial R(2) = 11%, p < 0.001) and anxiety (beta = -0.83 [-1.16 to -0.50], partial R(2) = 7%, p = 0.007) at 3 months, but by 6 months, only anxiety (beta = -0.74 [-1.04 to -0.44], partial R(2) = 7%, p = 0.010) remained an important factor. Decreased total active range of motion was associated with pain catastrophizing (beta = -0.63 [-0.90 to -0.36], partial R(2) = 6 %, p = 0.024) and anxiety (beta = -0.28 [-0.42 to -0.14], partial R(2) = 3%, p = 0.035) at 3 months but not at 6 months. Similarly, increased disability was associated with pain catastrophizing (beta = 1.09 [1.39-0.79], partial R(2) = 12%, p < 0.001) and anxiety (beta = 0.93 [1.21-0.65], partial R(2) = 11%, p = 0.001) at 3 months; these factors failed to be associated for 6-month outcomes. CONCLUSIONS: Preoperative poor coping skills as measured by high catastrophization and anxiety were associated with a weaker grip strength, decreased range of motion, and increased disability after surgical treatment for a hand fracture at 3 months. However, poor coping skills did not show persistent effects beyond 6 months. More research may be needed to show interventions to improve coping skills will enhance treatment outcome in patients after acute hand fractures. LEVEL OF EVIDENCE: Level III, prognostic study.

A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures.

PURPOSE: To compare surgical outcomes of volar locking plates (VP) and external fixation (EF) (with or without intra-focal fixation) for AO-type C2 and C3 fractures of the distal radius. METHODS: From an initial group of 92 patients with AO-type C2 and C3 distal radius fractures who were enrolled in a prospective, randomized study comparing volar plate fixation with external fixation (with or without intra-focal fixation), 74 patients were studied. The researchers evaluated functional assessments (wrist range of motion, grip strength, and Michigan Hand Questionnaire) at each patient visit and measured radiographic assessment (radial inclination, volar tilt, ulnar variance, and articular congruity) at 12 months. RESULTS: The grip strength of the VP group was significantly greater than that of the EF group at 3 and 6 months. The range of motion was significantly greater in the VP group than in the EF group at 3 months. There were no significant differences in the range of motion and grip strength between the 2 groups at 12 months. The Michigan Hand Questionnaire score was higher in the VP group than in the EF group at 3 months but was same at 12 months. There was no significant difference between groups with respect to volar tilt or radial inclination. The VP group showed superior radiologic outcomes in terms of the ulnar variance. One patient in the VP group and 3 in the EF group had an intra-articular stepoff deformity greater than 2 mm. This difference did not reach statistical significance. CONCLUSIONS: These results for functional recovery after distal radius surgery offer insight into treatment decisions and interpretations of treatment outcomes for patients with comminuted intra-articular distal radius fractures.

Effects of Metabolic Syndrome on the Outcome of Carpal Tunnel Release: A Matched Case-Control Study.

PURPOSE: To compare outcomes of carpal tunnel release in patients with or without metabolic syndrome. METHODS: In a prospective consecutive series, 35 patients with metabolic syndrome and surgically treated carpal tunnel syndrome (CTS) were age- and sex- matched with 37 control patients without metabolic syndrome. Grip, pinch strength, perception of touch with Semmes-Weinstein monofilament, and Boston Carpal Tunnel Questionnaires (BCTQ) were assessed preoperatively and at 3, 6, and 12 months postoperatively. RESULTS: Patients with metabolic syndrome had more severe electrophysiologic grade of CTS than those without metabolic syndrome, but the 2 groups had similar preoperative grip/pinch strength and BCTQ scores. The BCTQ symptom score for the metabolic syndrome group was significantly greater than that of the control group at 3 months, and the BCTQ function score of the metabolic syndrome group was significantly greater than that of the control group at 3 and 6 months' follow-up. However, there was no significant difference in BCTQ symptom or functional scores between groups at 12 months' follow-up. There was no significant difference in grip strength between groups through 12 months' follow-up whereas the pinch strength of the control group was significantly greater than that of the metabolic syndrome group at 12 months' follow-up. Semmes-Weinstein monofilament test results were significantly greater in the control group than in the metabolic syndrome group at 3 and 6 months' follow-up but were similar at 12 months. CONCLUSIONS: Patients with CTS and metabolic syndrome have delayed functional recovery after carpal tunnel release, but noteworthy improvements in symptom severity and hand function are similar to those in patients without metabolic syndrome 1 year after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Femorotibial relationship changes as the posture changes from patellae-forward stance to preferred toe-out stance.

BACKGROUND: Full-length standing anteroposterior radiograph is a standard protocol to evaluate the lower limb alignment in frontal plane. However, most people tend to stand or walk with feet pointing outward. The purpose of this study is to assess the femorotibial relationship as the posture changes from patellae-forward stance for the conventional technique of a full-length standing anteroposterior radiograph to a toe-out quiet stance using a fluoroscope. METHODS: Femoral and tibial rotation and femorotibial rotation were measured in 60 healthy lower limbs using fluoroscopy during postural change from patellae-forward stance to toe-out quiet stance. RESULTS: The average toe-out angle was 21.4°. The average femoral, tibial, and femorotibial rotations during postural change were 6.1°, 4.0°, and 2.1°, respectively (p = 0.000). The correlation coefficient for femoral and tibial rotation was 0.747 (p = 0.000). The correlation coefficient for femoral and femorotibial rotation was 0.670 (p = 0.000), and for tibial and femorotibial rotation was 0.006 (p = 0.962). The correlation between toe-out angle and femorotibial rotation was statistically significant (r (2) = 0.096, p = 0.016). The correlations between toe-out angle and femoral rotation, and between toe-out angle and tibial rotation were not statistically significant (r (2) = 0.047, p = 0.095, and r (2) = 0.000, p = 0.9, respectively). CONCLUSIONS: The subject's posture significantly affects the femorotibial relationship. When a subject changes posture from a patellae-forward stance to a toe-out quiet stance, the femur rotates internally on the tibia. LEVEL OF EVIDENCE: Diagnostic, level II.

Transcriptional changes of gibberellin oxidase genes in grapevines with or without gibberellin application during inflorescence development.

The concept that gibberellin (GA) application on seeded grapevines induces seedlessness has been known for decades in viticulture. GA was applied to inflorescence clusters of seeded diploid grapevine cultivar 'Tamnara' (Vitis spp.) at 14 days before full bloom (DBF). Morphological and molecular effects of GA application were examined on the induction of parthenocarpic fruit development. With GA application, ovaries were enlarged and pollen tube growth was completely inhibited. Vitis GA oxidase enzymes, key determinants for GA level, were characterized through phylogenetic analysis with Arabidopsis GA oxidase enzymes. Five VvGA 20-oxidase (VvGA20ox), three VvGA 3-oxidase (VvGA3ox), and nine VvGA 2-oxidase (VvGA2ox) family proteins, and one VvGA methyltransferase (VvGAMT) and one Vitis cytochrome P450 714A1 proteins were identified, and their expression patterns were analyzed during inflorescence development from 14 DBF to 5 days after full bloom (DAF). VvGA2ox1, VvGA20ox3, and VvGA3ox2 were the most abundantly expressed genes in each gene family at 7, 5, and 2 DBF, respectively. Following GA application at 14 DBF inducing seedlessness, GA catabolic genes such as VvGAMT2, VvGA2ox3, and VvGA2ox4 were up-regulated at 12 DBF, full bloom, and 5 DAF, respectively. Conversely, most GA biosynthetic genes, VvGA20oxs and VvGA3oxs, were down-regulated at near full bloom, and the timing of their peak expression was changed. These results suggest that GA application at pre-bloom changes the GA biosynthesis into GA catabolic pathway at near full bloom by altering the transcription level and timing of GA oxidase genes during grapevine inflorescence development.

Factors delaying recovery after volar plate fixation of distal radius fractures.

PURPOSE: To evaluate the factors influencing delayed functional recovery in patients with a distal radius fracture treated by volar plate fixation. METHODS: A total of 122 patients with a distal radius fracture treated by volar locking plate were enrolled. The wrist range of motion, grip strength, and functional outcome by the Michigan hand score were assessed 3, 6, and 12 months after surgery. The factors assessed for their influence on delayed functional recovery include age, sex, bone mineral density (BMD), hand dominance, the type of fracture, the energy of trauma, the time to surgery, and the duration of immobilization. A multivariate regression analysis was conducted to identify independent predictors of delayed functional recovery in terms of the Michigan hand score. RESULTS: There was a significant decrease in the wrist range of motion in patients with a high-energy trauma, severe type fracture, or increase in duration of immobilization at month 3, whereas only a severe fracture type was associated with a decreased range of motion after 6 and 12 months. An increase in age, a decrease in BMD, and high-energy trauma reduced grip strength at months 3 and 6, whereas only an increase in age and a decrease in BMD reduced grip strength at month 12. According to the multivariate regression analysis, severe type fracture and high-energy trauma reduced functional outcomes at months 3 and 6. Conversely, at month 12, an increase in age and a decrease in BMD reduced functional outcome. CONCLUSIONS: An increase in age and a decrease in BMD were important risk factors influencing delayed functional recovery up to 12 months after distal radius fracture surgery, whereas fracture severity and high-energy trauma were associated with decreased functional outcomes up to 6 months after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.