Comparison of functional outcomes between single-radius and multi-radius femoral components in primary total knee arthroplasty: a meta-analysis of randomized controlled trials.

PURPOSE: Our purpose in the current meta-analysis was to compare the functional outcomes in patients who have received single-radius (SR) or multi-radius (MR) femoral components in randomized controlled trials (RCTs) for primary total knee arthroplasty (TKA). The hypothesis was that there would be no statistically significant difference between two groups in terms of functional outcomes. MATERIALS AND METHODS: We searched the international electronic databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to February 2020 for RCTs that compared functional outcomes of SR and MR femoral component designs after primary TKA. We performed a meta-analysis of nine RCTs using the Knee Society Score for the knee (KSS-knee), KSS-function, Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), degree of knee flexion, extension, and complications, including postoperative infection and revision surgery. RESULTS: The meta-analysis revealed no statistically significant differences in all the analyzed variables, including KSS-knee, KSS-function, KOOS, OKS, knee flexion, and knee extension. For postoperative complications, no statistically significant differences were detected for femoral component designs in postoperative infection or incidence of revision surgery between the two groups. CONCLUSIONS: The current meta-analysis of RCTs did not show any statistically significant differences between SR and MR femoral component designs in terms of postoperative functional outcomes. Evaluated outcomes included functional outcome scores, degree of knee flexion, extension, and complications. However, because of the limited clinical evidence of this study owing to the heterogeneity between the included RCTs, a careful approach should be made in order not to arrive at definite conclusions.

Ursolic acid inhibits pigmentation by increasing melanosomal autophagy in B16F1 cells.

Melanosomes are specialized membrane-bound organelles that are involved in melanin synthesis. Unlike melanosome biogenesis, the melanosome degradation pathway is poorly understood. Among the cellular processes, autophagy controls degradation of intracellular components by cooperating with lysosomes. In this study, we showed that ursolic acid inhibits skin pigmentation by promoting melanosomal autophagy, or melanophagy, in melanocytes. We found that B16F1 cells treated with ursolic acid suppressed alpha-melanocyte stimulating hormone (α-MSH) stimulated increase in melanin content and activated autophagy. In addition, we found that treatment with ursolic acid promotes melanosomal degradation, and bafilomycin A1 inhibition of autophagosome-lysosome fusion blocked the removal of melanosomes in α-MSH-stimulated B16F1 cells. Furthermore, depletion of the autophagy-related gene 5 (ATG5) resulted in significant suppression of ursolic acid-mediated anti-pigmentation activity and autophagy in α-MSH-treated B16F1 cells. Taken together, our results suggest that ursolic acid inhibits skin pigmentation by increasing melanosomal degradation in melanocytes.

Outcome Differences of Remnant- Preserving versus Non-Preserving Methods in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Meta-analysis with Subgroup analysis.

PURPOSE: To analyze differences in clinical outcomes of arthroscopic anterior cruciate ligament reconstruction between remnant-preserving and non-preserving methods. METHODS: International electronical databases PubMed, Embase, and the Cochrane central database from January 1966 to December 2017 were searched for randomized controlled trials (RCTs) and observational studies that compared differences of clinical outcomes of ACL reconstruction with and without remnant preservation. A meta-analysis of these studies was performed to compare clinical outcomes. Subgroup analyses were conducted to evaluate the role of methodological quality in primary meta-analysis estimates. RESULTS: Five RCTs and six observational studies were included in this meta-analysis and subgroup analysis. The remnant-preserving method in arthroscopic ACL reconstruction showed a statistically significant difference compared to the non-preserving method regarding arthrometric evaluation (side-to-side difference). Lachman test, Lysholm scores, and IKDC subjective scores showed statistically minor difference in meta-analysis, but showed no significant difference in subgroup analysis. Remained parameters including pivot shift test, IKDC grades, incidence of cyclops lesion showed no statistically differences in meta-analysis or subgroup analysis. CONCLUSIONS: This meta-analysis with subgroup analysis showed that arthroscopic remnant-preserving ACL reconstruction provided statistically significant but limited clinical relevance in terms of arthrometric evaluation. Results of Lachman test, Lysholm scores, and IKDC subjective scores demonstrated statistically minor differences.

Comparison of medial and lateral tibial tunnel in pullout repair of posterior root tear of medial meniscus: Radiologic, clinical, and arthroscopic outcomes.

PURPOSE: Medial meniscus posterior root tear (MMPRT) should be repaired to the correct position as possible to maintain hoop tension of the meniscus. In this study, we propose a comparison of the outcome between the medial tunnel and the lateral tunnel in the pullout suture technique using the tibial tunnel for anatomical repair of posterior root tear of medial meniscus. METHODS: From April 2010, of patients who underwent pullout suture, 51 cases (24 medial tunnel group (MTG) and 27 lateral tunnel group (LTG)) were able to follow-up with second look arthroscopy. Original Coronal Ratio of Root Attachment (CRORA) was defined as the ratio of the distance from the medial edge of the tibial plateau to the root attach site divided by the entire tibial medial-lateral width on preoperative computed tomography. Error between postoperative CRORA and original CRORA was calculated. We compared this error, clinical outcome, and arthroscopic finding between MTG and LTG. RESULTS: The mean error ratio of postoperative CRORA divided by original CRORA was 0.86 ± 0.11 in MTG, which was significantly (p = 0.001) lower than that (1.02 ± 0.06) in LTG. The mean value of the root attach point in the MTG with a post/original CRORA value of 0.86 ± 0.11 means statistically significant medialization after the operation. There was no statistically significant difference in changes of International Knee Documentation Committee (IKDC) and Lysholom score between MTG and LTG. The difference between the two groups of arthritis progression was not statistically significant. CONCLUSION: In patients with MMPRT, CRORA may provide a basis for coronal assessment of root repair position before and after surgery, and lateral tibial tunnel technique can help anatomical repair by reducing technical error due to guide pin slip medially compared to medial tibial tunnel technique.

Pectoralis major tendon transfer for recurrent anterior shoulder dislocation after primary surgery in an elderly patient: A case report.

RATIONALE: Adequate stability of traumatic anterior shoulder dislocation without any obvious damage to the anterior capsulolabral structure in elderly patients can be achieved by treating the associated rotator cuff injuries. However, in case of recurrent shoulder dislocation despite rotator cuff repair, the repaired rotator cuff may be weakened or reruptured and is often impossible to repair again. Therefore, the role of the rotator cuff as a shoulder stabilizer cannot be expected. Even if the anterior joint capsule is left, it is too weak to imbrication either. An additional anterior structural reconstruction that can replace the rotator cuff and capsule is needed to prevent recurrence. PATIENT CONCERNS: A 59-year-old man visited our clinic because of traumatic anterior dislocation of the right shoulder combined with anterior-superior rotator cuff tear. Because there was no obvious anterior capsulolabral injury, he underwent arthroscopic rotator cuff repair only. Postoperative rehabilitation was maintained; however, anterior shoulder dislocation recurred 10 months postoperatively. DIAGNOSIS: Physical examination revealed anterior instability in abduction and external rotation of the shoulder joint. Magnetic resonance imaging suggested retear of the repaired anterior-superior rotator cuff and Hill-Sachs lesion of the humeral head. INTERVENTIONS: Diagnostic arthroscopy was performed. The reruptured rotator cuff seemed impossible to repair; thus, arthroscopic remplissage procedure was performed for engaging the Hill-Sachs lesion. In addition, open pectoralis major tendon transfer for anterior stabilization was performed via the deltopectoral approach. OUTCOMES: At the 12-month follow-up, the patient showed good clinical outcomes, including internal rotation of the shoulder joint without recurrent instability. LESSON: Recurrent anterior shoulder dislocation after primary surgery in the elderly may be a challenging situation for surgeons. In patients with irreparable anterior rotator cuff tear and for whom reconstruction of the anterior glenoid is not indicated, pectoralis major tendon transfer is a good treatment option for satisfactory clinical outcomes without recurrence.

Discoid Medial Meniscus Tear, with a Literature Review of Treatments.

The present study reports our experience of treating four cases of symptomatic discoid medial meniscus, three of which were bilateral. We performed partial meniscectomy with a four-portal technique using a knife leaving a 6 mm peripheral margin after confirmation of magnetic resonance imaging findings. Clinical results were assessed at the end of 2-year follow-up using the Knee Injury and Osteoarthritis Outcome Score and a visual analogue scale. We obtained satisfactory clinical results without recurrence of the symptoms in all cases.

Pelvic artery embolization in the management of pelvic arterial bleeding following midurethral sling surgery for stress urinary incontinence.

The transobturator tape (TOT) method is the recent minimally invasive midurethral sling surgery. The TOT method was invented to reduce complication rate of surgical technique for female stress urinary incontinence. Pelvic bleeding following TOT procedure, although extremely rare, could be occurred. We presented three cases which treat pelvic arterial bleeding after midurethral sling (TOT and tension-free vaginal tape Secur) surgery via pelvic artery embolization. Therefore we report our cases with brief review of the literature.

Alterations in uterine hemodynamics caused by uterine fibroids and their impact on in vitro fertilization outcomes.

OBJECTIVE: To investigate the impact of fibroids on the blood flow of the uterine and subendometrial arteries and in vitro fertilization (IVF) outcomes. METHODS: In this study, we analyzed 86 IVF/intracytoplasmic sperm injection (ICSI) cycles in which a gonadotropin-releasing hormone antagonist protocol was used for controlled ovarian stimulation between January 2008 and March 2009. The subjects comprised 86 infertile women with (fibroid group, n=43) or without (control group, n=43) uterine fibroids. RESULTS: Patient characteristics were similar between the fibroid and control groups. The IVF/ICSI outcomes in patients with fibroids were similar to those of patients in the control group. The resistance index (RI) and pulsatile index (PI) of the uterine and subendometrial arteries on the day of embryo transfer were also comparable between the two groups. IVF outcomes and uterine hemodynamics in patients with multiple (≥2) fibroids were similar to those of patients with a single fibroid. However, clinical pregnancy and implantation rates were significantly lower in patients with fibroids who experienced uterine cavity distortion than in patients with fibroids who had a normal uterine cavity (both p<0.05). The RI and PI of the subendometrial artery were significantly higher on the day of embryo transfer in patients with fibroids who experienced uterine cavity distortion than in patients with fibroids who had a normal uterine cavity (both p<0.05). CONCLUSION: Fibroids which distorting the uterine cavity might impair the subendometrial artery blood flow clinical pregnancy rate and embryo implantation rate in infertile patients undergoing IVF. Otherwise, IVF outcomes were not influenced by the presence of uterine fibroids.

Hyperreflective foveal lesion observed with optical coherence tomography in cases of epiretinal membranes with a firm foveal attachment.

PURPOSE: To report the optical coherence tomography (OCT) findings of the firmly attached foveal area and to investigate the functional results and predictive values in correlation to the degree of firmness of the foveal adherence of the epiretinal membrane (ERM). METHODS: We retrospectively reviewed the medical records regarding 167 eyes of 166 patients who underwent vitrectomy for the removal of the ERM between January 2009 and December 2012. We evaluated the degree of foveal attachment in all the patients based on the surgical video and reviewed the OCT images. The main and secondary outcome measures were OCT findings including the presence and the size of a highly reflective lesion, visual acuity, and the mean duration of the ERM before surgery. RESULTS: An abnormal highly reflective lesion was observed beneath the ERM in the foveal area. We termed this type of finding a "hyperreflective foveal lesion" (HFL). This HFL was present in 22 of 23 eyes (95.7%) with a firm foveal attachment (FFA) and in 2 of 144 eyes (1.4%) without an FFA (P < 0.001). The HFL showed a sensitivity of 96%, specificity of 99%, positive predictive value of 92%, and negative predictive value of 99%, as a predictor of FFA. The mean duration of the ERM before surgery was significantly longer in the group with an FFA than in the group without an FFA (P = 0.029). Regarding the degree of firmness of the adherence in the eyes with an FFA, the group with a greater degree of firmness had a larger HFL as observed with OCT before surgery (P < 0.05). The visual acuity in patients with an FFA was significantly lower than that in patients without an FFA after surgery (P = 0.031). CONCLUSION: Visual acuity after surgery was significantly lower in patients with an FFA. The presence of an HFL in the OCT demonstrated a high predictive value for firmness of the foveal attachment. The size of an HFL in the OCT was associated with the degree of firmness and allowed us to predict inner and outer retinal damages after surgery.

A pulled sutures technique for bony Bankart lesion.

In an attempt to present a new surgical technique for arthroscopic bony Bankart fixation, the authors developed the pulled sutures technique. In executing the new method, the authors first passed several non-absorbable sutures through labroligamentous tissue with displaced articular fragment by mimicking transglenoid suture technique. Aimed at achieving a safe and stable fixation, using a knotless anchor rather than transglenoid suture, was deployed. Overall, this pulled sutures technique was shown to be effective with the result of direct reduction, stable, and safe fixation for bony Bankart's lesion.

ARP101 inhibits α-MSH-stimulated melanogenesis by regulation of autophagy in melanocytes.

Autophagy is a cooperative process between autophagosomes and lysosomes that degrades cellular organelles. Although autophagy regulates the turnover of cellular components, its role in melanogenesis is not clearly established. Previously, we reported that ARP101 induces autophagy in various cancer cells. Here, we show that ARP101 inhibits melanogenesis by regulation of autophagy. ARP101 inhibited α-MSH-stimulated melanin synthesis and suppressed the expression of tyrosinase and TRP1 in immortalized mouse melanocytes. ARP101 also induced autophagy in melanocytes. Knockdown of ATG5 reduced both anti-melanogenic activity and autophagy mediated by ARP101 in α-MSH treated melanocytes. Electron microscopy analysis further revealed that autophagosomes engulf melanin or melanosome in α-MSH and ARP101-treated cells. Collectively, our results suggest that ARP101 inhibits α-MSH-stimulated melanogenesis through the activation of autophagy in melanocytes.

Autophagy mediates anti-melanogenic activity of 3'-ODI in B16F1 melanoma cells.

Autophagy is a cellular degradation process for cellular aggregates and unneeded cellular compartments including damaged mitochondria, ER, and peroxisomes. Melanosome is cellular organelle that is the cellular site of generation, storage and transports of melanin in melanocytes. Despite potential importance of autophagy, the role of autophagy in melanogenesis and melanosome autophagy are largely unknown. In here, we identified 3'-hydroxydaidzein (3'-ODI) as an autophagy inducer from a phytochemical library screening. Treatment with 3'-ODI significantly reduced α-MSH-mediated melanogenesis but efficiently increased autophagy both in melanoma cells and melanocytes. Furthermore, inhibition of autophagy significantly reduced the anti-melanogenic effects of 3'-ODI in α-MSH-stimulated melanoma cells. Taken together, these results suggest that autophagy mediates anti-melanogenic activity of 3'-ODI.

Cathepsin B in eutopic and ectopic endometrial tissues of patients with endometriosis.

This study was performed to investigate the expression of cathepsin B mRNA and protein in eutopic and ectopic endometrial tissues of patients with endometriosis and in normal endometrial tissues and to clarify the association between the cathepsin B expression and endometriosis. A total of 40 women with histologically confirmed endometriosis were recruited for study group. For controls, 20 women undergoing operative treatment for uterine myoma, cervical intraepithelial neoplasia (CIN) or benign gynecologic conditions other than endometriosis were recruited. Eutopic endometrial tissues of both groups and ectopic endometrial tissue of study group were collected during the operations. We employed real time reverse transcriptase - polymerase chain reaction (RT-PCR) to quantify mRNA levels of cathepsin B in these tissues. Then, we performed western blot analysis to measure the protein levels of cathepsin B. The expressions of cathepsin B mRNA and protein were significantly higher in both eutopic and ectopic endometrial tissues of women with endometriosis than in endometrial tissues of controls. These data suggest that the higher expression of cathepsin B in the endometrial tissues might be associated with the development of endometriosis. In addition, eutopic endometrium itself with higher expression cathepsin B may play a pivotal role in the histogenesis of endometriosis.

Partial tetrasomy of chromosome 22q11.1 resulting from a supernumerary isodicentric marker chromosome in a boy with cat-eye syndrome.

The 22q11 region has been implicated in chromosomal rearrangements that result in altered gene dosage, leading to three different congenital malformation syndromes: DiGeorge syndrome, cat-eye syndrome (CES), and der(22) syndrome. Although DiGeorge syndrome is a common genomic disorder on 22q11, CES is quite rare, and there has been no report of Korean CES cases with molecular cytogenetic confirmation. In this study, we present the phenotypic and genetic characteristics of a 3-month-old boy with CES. Clinical findings included micropthalmia, multiple colobomata, and renal and genital anomalies. Cytogenetic analyses showed the presence of a supernumerary marker chromosome, which was identified as a bisatellited and isodicentric chromosome derived from an acrocentric chromosome. The results of array comparative genomic hybridization and fluorescence in situ hybridization studies confirmed the karyotype as 47,XY,+mar.ish idic(22)(q11.1) (D22S43+).arr 22q11.1(15,500,000-15,900,000)x4, resulting in a partial tetrasomy of 22q11.1. To the best of our knowledge, this is the first report in Korea of CES confirmed by cytogenetic and molecular cytogenetic analyses.

Serous retinal detachment following combined photodynamic therapy and intravitreal bevacizumab injection.

We report a case of serous retinal detachment following combined photodynamic therapy (PDT) and intravitreal bevacizumab injection in subfoveal choroidal neovascularization (CNV). A 53-year-old woman was diagnosed with subfoveal CNV secondary to age-related macular degeneration (AMD) and treated with combined PDT and intravitreal bevacizumab injection. One day after treatment, the patient experienced a sudden decline of vision and optical coherence tomography (OCT) showed serous retinal detachment involving the macula. She was managed conservatively with an oral steroid beginning on the second day of the combined treatment and the subretinal fluid started to decrease one week following the initiation of steroids. This case suggests that combined PDT and intravitreal injection of bevacizumab can be associated with serous retinal detachment. Additional studies are needed to establish the safety and complications following this treatment regimen.

Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft.

PURPOSE: The purpose of this study was to analyze the clinical results of anterior cruciate ligament (ACL) reconstruction with the remnant-preserving technique by use of a hamstring graft and looped sutures according to the amount of the tibial remnant of the ACL. METHODS: Sixteen subjects had undergone ACL reconstruction with the remnant-preserving technique by use of 4 strands of a hamstring tendon and a looped suture technique and were followed up for at least 12 months. The mean follow-up was 35.1 months. At the last follow-up examination, the patients were evaluated with the International Knee Documentation Committee scale and Hospital for Special Surgery score as subjective tests; stress radiographs, Lachman test, and anterior drawer test by use of the KT-2000 arthrometer (MEDmetric, San Diego, CA) as objective tests; and single-legged hop test, reproduction of passive positioning, threshold to detection of passive motion, and single-limb standing test as functional tests. On the basis of the extent of ACL remnant, patients were then divided into 2 groups. Group I comprised patients with more than 20%, and group II comprised those with less than 20%. For each of the 2 groups, a statistical comparison of the final results was made. RESULTS: The mean Hospital for Special Surgery score improved from 65.8 (preoperatively) to 95.2 (at last follow-up). Functional evaluation revealed that the difference was not significant in terms of mechanical stability, but a significant difference was detected in functional outcome and proprioception. Regarding the threshold to detection of passive motion at 30 degrees (P = .030) and reproduction of passive positioning at 15 degrees (P = .032) and 30 degrees (P = .024), group I (> 20%) showed better results than group II (< 20%). CONCLUSIONS: We confirmed that the remnant-preserving technique described showed good proprioceptive and functional outcomes with statistical significance. Therefore it may be expected that the more the tibial remnant is kept intact, the better the preservation of proprioceptive function will be. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Retinal artery occlusion in a healthy pregnant patient.

PURPOSE: We report a case of branch retinal artery occlusion (BRAO) in a healthy pregnant woman. METHODS: A 29-year-old pregnant woman presented with decreased vision in her left eye. She had a pale retina with macular edema consistent with BRAO. An extensive workup was performed to determine an etiologic factor. All test results were within normal limits except for her factor VIII activity. Her visual acuity improved from finger counting to 20/30 over 2 months without any treatment. RESULTS: This case suggests that BRAO can occur in healthy patients without any systemic or ocular disorders. CONCLUSIONS: BRAO can occur in healthy patients without any systemic or ocular disorders, despite an extensile evaluation.

Burst-shot infrared digital photography to determine scotopic pupil diameter.

PURPOSE: To evaluate the usefulness of infrared digital photography for determining scotopic pupil size by comparing infrared digital photography with a Colvard pupillometer (Oasis Medical). SETTING: Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea. METHODS: Scotopic pupil size in 50 eyes of 25 healthy individuals was measured with a Colvard pupillometer and a digital camera (DSC-F828) using infrared burst shots after 5 minutes of dark adaptation. Measurements were performed by 2 independent examiners (E1 and E2). The digital photograph images were read using the ruler function of Adobe Photoshop 7.0 by 2 independent readers (R1 and R2). Agreement and repeatability were analyzed using the comparison method described by Bland and Altman. RESULTS: The mean scotopic pupil diameter measured using the Colvard pupillometer was 6.69 mm +/- 0.78 (SD) (E1) and 6.70 +/- 0.71 mm (E2). The mean scotopic pupil diameter measured from the digital photograph images was 6.67 +/- 0.75 mm (E1) and 6.66 +/- 0.78 mm (E2). The mean difference between E1 and E2 with both devices was small; however, the result with the infrared digital camera was marginally smaller than with the Colvard pupillometer. The limits of agreement were -0.01 +/- 0.70 mm with the Colvard pupillometer and 0.01 +/- 0.20 mm with the digital photograph image. The digital photograph image showed better agreement. The coefficient of interrater repeatability was smaller for the digital photograph image (0.39) than for the Colvard pupillometer (0.70). CONCLUSIONS: Scotopic pupil measurement using an infrared digital camera with a burst shot had good agreement with the Colvard pupillometer and better repeatability. The infrared digital camera is less expensive, and pupil unrest can be overcome by taking serial images.

Arthroscopic anterior cruciate ligament reconstruction with the tibial-remnant preserving technique using a hamstring graft.

We propose that the tibial remnant of the anterior cruciate ligament (ACL) is able to enhance the revascularization and cellular proliferation of the graft, to preserve proprioceptive function, and to be able to acquire anatomic placement of the graft without roof impingement. Therefore, it seems reasonable to assume that preserving the tibial remnant as much as possible as a source of reinnervation, if technically possible without causing impingement, would be of potential benefit to the patient. Our surgical technique was developed to maximize the preservation of the tibial remnant. The distally attached semitendinosus and gracilis tendons are harvested using the tendon stripper. After satisfactory placement of 2 guide pins convergently, a closed-end socket in the lateral femoral condyle is created using an adequately sized curved curette. For anatomic placement of the graft, the tibial tunnel should be positioned within the boundaries of the normal ACL tibial remnant. The reamer must be advanced very carefully to minimize injury to the residual remnant at the intra-articular margin of the tibial tunnel. Penetration should stop at the base of the stump. The folded grafts are then pulled intra-articularly through the tibial tunnel, the tibial remnant, and the femoral socket by pulling sutures under arthroscopic visualization. The ACL tibial remnant is compacted by the tendon passage. The graft is secured proximally by tying sutures in the lateral femoral condyle and distally at the tibia with double staples by a belt-buckle method. The advantages of our technique include maximal preservation of the tibial remnant, no roof impingement caused by intrasynovial anatomic placement of the graft, the simplicity of the procedure, the minimal need for hardware or special instruments, the economic benefit, and the potential prevention of tibial tunnel enlargement by preventing synovial fluid leakage.

Arthroscopic retrieval of a very rare penetrating foreign body of the knee.

We report the very rare case of an 8-year-old boy who accidentally fell on the ground, causing the lead of a pencil to penetrate his left knee joint cavity. After radiographic diagnosis, the pencil was removed by a physician at a private clinic and the boy was referred to our department for further evaluation. We performed arthroscopic retrieval of the pencil lead through standard arthroscopic portals without an accessory portal. Postoperatively, the patient had a quick recovery without problematic sequelae.