A Case of an Splenic Artery Aneurysm and Focal Nodular Hyperplasia Associated with an Abdominal Vascular Abnormality of Hereditary Hemorrhagic Telangiectasia.

In October 2021, a 51-year-old woman developed a skin rash. Abdominal computed tomography revealed a large splenic artery aneurysm and an intrahepatic portovenous shunt. As her splenic artery aneurysm was at risk of rupture, she was referred to the Kindai University Hospital and underwent coiling surgery. In October 2023, approximately two years after she had been initially referred, contrast-enhanced ultrasound revealed findings suggestive of focal nodular hyperplasia. No reports have confirmed the occurrence of liver masses in patients with hereditary hemorrhagic telangiectasia, which is considered to be an interesting finding when investigating the mechanism of tumor development.

Does vacuum phenomenon at non-fused discs affect the postoperative course after transforaminal lumbar interbody fusion in patients showing a positive value of difference in lumbar lordosis?

INTRODUCTION: Preoperative difference in lumbar lordosis (DiLL) was associated with surgical outcomes after single-level transforaminal lumbar interbody fusion (TLIF). Patients with DiLL>0 (DiLL (+)) tended to show worse clinical outcomes and postoperative greater restoration of lumbar lordosis (LL). However, some patients with DiLL (+) showed relatively good outcomes and no postoperative LL restration. This study aimed to elucidate whether the lumbar intervertebral disc vacuum phenomenon (VP) influences clinical course after single-level TLIF in patients with DiLL (+) and DiLL (-). METHODS: Patients with lumbar spinal stenosis and degenerative spondylolisthesis treated with single-level TLIF were included. Pre- and postoperative LL were measured, and postoperative LL improvement was calculated. Preoperative DiLL was calculated as preoperative supine LL minus standing LL. Severity of VP at the non-fused discs (SVP (non-FS)) was evaluated using preoperative reconstructed computed tomography imaging. Clinical outcomes were assessed using the Oswestry disability index, visual analogue scale (VAS; low back pain (LBP), lower-extremity pain, numbness, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Patients were stratified by the median preoperative SVP (non-FS) score into severe and mild VP groups in patients with DiLL (+) or DiLL (-), and their surgical outcomes were compared. RESULTS: Overall, 89 patients were included. In patients with DiLL (+) (n = 37), patients with severe VP showed worse clinical outcomes, particulary for LBP and DiLL (+) patients with mild VP showed greater LL improvement (6.5° ± 10.0°). In patients with DiLL(-) (n = 52), patients with severe VP showed worse clinical outcomes, particularly for LBP and no differences in preoperative, postoperative, and improvement of LL were observed between two groups. CONCLUSION: Patients with DiLL (+) and DiLL (-) showed different clinical courses depending on VP severity at the non-fused discs after single-level TLIF.

Arthroscopic Hip Capsular Repair Improves Patient-Reported Outcome Measures and Is Associated With a Decreased Risk of Revision Surgery and Conversion to Total Hip Arthroplasty.

Purpose: To perform a systematic review to assess the effect of capsular repair compared with nonrepair on patient-reported outcome measures (PROMs) and conversion to total hip arthroplasty (THA) after hip arthroscopy in patients with femoroacetabular impingement syndrome. Methods: We initially searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PubMed databases, as well as ongoing clinical trials (https://clinicaltrials.gov), on December 15, 2022. The eligibility criteria were randomized controlled trials (Level Ⅰ) and prospective comparative studies (Level II) of patients who underwent capsular repair and nonrepair via hip arthroscopy with a minimum follow-up period of 2 years. We registered this protocol a priori on PROSPERO (identification No. CRD42021239306). We assessed the risk of bias using the Methodological Index for Non-randomized Studies (MINORS) appraisal tool. Results: This review included 5 studies with a total of 639 patients (270 with capsular repair [average age, 35.4 years; 41% female patients] and 369 with nonrepair [average age, 37.3 years; 38% female patients]). In the included studies, surgical procedures consisting of labral repair and pincer or cam osteoplasty were performed via hip arthroscopy. The modified Harris Hip Score was measured in all the included studies, and the standardized mean difference in PROMs for capsular repair versus nonrepair in the included studies was 0.42 (95% confidence interval [CI], 0.20 to 0.63). A sensitivity analysis of randomized controlled trials achieved consistent results (standardized mean difference in PROMs, 0.31; 95% CI, 0.02 to 0.60). Capsular repair was not associated with a reduction in revision surgery (risk difference, -0.02; 95% CI, -0.06 to 0.03; 26 of 270 patients with capsular repair vs 42 of 369 with nonrepair) but was associated with a reduction in conversion to THA (risk difference, -0.05; 95% CI -0.09 to -0.01; 12 of 270 patients with capsular repair vs 38 of 369 with nonrepair). The average Methodological Index for Non-randomized Studies (MINORS) score in the included studies was 20. Conclusions: Patients who undergo capsular repair in conjunction with other arthroscopic hip preservation techniques have better PROMs and a lower incidence of THA conversion. Level of Evidence: Level II, systematic review of Level I and II investigations.

The influence of COVID-19 epidemic on the number of orthopaedic surgeries in Japan.

BACKGROUND: There is limited data on the impact of COVID-19 epidemic on the number of orthopaedic surgeries in Japan. METHODS: We conducted a nationwide hospital survey asking for the monthly number of orthopaedic surgeries performed at each facility from January 2019 to June 2021. Those facilities that had performed at least 100 surgeries in 2019 were included for analyses. The facilities were further grouped by prefecture and by hospital characteristics. A brief health economic evaluation was also performed. Risk ratios were compared using univariate analyses with P < 0.05 considered statistically significant. RESULTS: Questionnaire was sent to 1988 hospitals with 1671 hospitals (84%) responding. The survey data indicated a total number of orthopaedic surgeries decreased in 2020 compared to 2019 (1,061,541 vs 1,119,955 P < 0.01), and also for the first six months of 2021 compared to the same period in 2019 (530,388 vs 550,378 P < 0.01). In 2020, over 50% of all facilities in nearly all of the prefectures saw a decline in surgical procedures. The risk of incurring more than a 25% decease in the number of surgeries was significantly higher in 2020 for class I designated medical institutions compared to those that were not designated for any types of infectious diseases among the institutions with a tertiary emergency medical center in 2020 (crude risk ratio 2.9: 95% CI 1.2-7.4, p = 0.02) and in 2021 (crude risk ratio 4.7: 95% CI 1 0.9-12.1, p < 0.01). The estimated total nationwide decrease of revenue were in the range of approximately ¥29.2 to ¥116.8 billion per year for orthopaedic surgeries alone. CONCLUSION: There was a statistically significant decrease in the number of orthopaedic surgeries in Japan. The magnitude of the decline varied by prefectures and hospital characteristics, with the greater impact imposed on medical institutions with higher classification functions. The estimated immediate health economic impact was sizable.

Efficacy and Safety of Beta-Tricalcium Phosphate/Polylactic-Co-Glycolic Acid for Implantation of Bone Defects.

INTRODUCTION: Bone defects are often observed after surgery for fractures and bone tumors. Their treatment is technically difficult and sometimes results in negative clinical and economic outcomes. To repair bone defects, a bone graft is implanted by selecting a transplant material from an autologous or artificial bone. Each method has its advantages and disadvantages. Compared to the gold standard of autologous bone graft, bone graft substitutes are not limited by the amount of harvested graft and avoid complications at the donor site. ORB-03 is a new cotton-like bone graft substitute composed of beta-tricalcium phosphate (ß-TCP) and a bioabsorbable polymer, polylactic-co-glycolic acid (PLGA). ORB-03 is easy to mold and can fill various bone defect shapes, and its three-dimensional microfiber scaffold can enhance the differentiation of osteoblasts and promote osteogenesis. We investigated the efficacy, ease of handling, and safety of ORB-03 as a bone graft substitute. A multicenter, open-label, single-group study was conducted at six institutions. METHODS: Between July 2018 and August 2019, 60 patients with bone defects caused by fracture, benign tumors, or an iliac donor site from bone harvesting were enrolled in this study; 54 patients were finally included for the safety analysis and 48 patients for the image analysis. During surgery, ORB-03 was mixed with the patient's blood and molded into a bone defect. To evaluate the efficacy of ORB-03, radiography and computed tomography (CT) were performed at intervals until 24 weeks after surgery. RESULTS: The effective rate and its accurate bilateral 95% confidence interval (CI) were calculated based on the efficacy criteria at 24 weeks postoperatively. The ease with which ORB-03 could be handled in surgery was evaluated. Adverse events that occurred after surgery were evaluated, and those associated with ORB-03 were examined. Bone fusion was good in all cases, and the radiography and CT effective rates were 100.0% and 91.5%, respectively. Handling was easy in all cases. There were four adverse events, none of which were clinically problematic. CONCLUSIONS: ORB-03 was found to be easy to handle, safe, and effective as a bone graft substitute for bone defects.

Effect of Preoperative Severity and Location of Lumbar Intervertebral Disc Vacuum Phenomenon on Surgical Outcomes After Single-Level Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: This study aimed to examine whether preoperative severity and location of lumbar intervertebral disc vacuum phenomenon (VP) influence surgical outcomes after single-level transforaminal lumbar interbody fusion. METHODS: We included 106 patients (age, 67.4 ± 10.4 years; 51 male/55 female) with lumbar degenerative diseases, who were treated with single-level transforaminal lumbar interbody fusion. Severity of VP (SVP) score was measured preoperatively. SVP score at fused disc was used as SVP (FS) score and at nonfused discs was used as SVP (non-FS) score. Surgical outcomes were assessed using the Oswestry Disability Index (ODI) and visual analog scale (VAS; low back pain (LBP), lower extremity pain, numbness, LBP in motion, in standing, and in sitting). The patients were divided into severe VP (FS or non-FS) and mild VP (FS or non-FS) groups, and surgical outcomes were compared between the 2 groups. Correlations between each SVP score and surgical outcomes were analyzed. RESULTS: There were no differences in surgical outcomes between the severe VP (FS) and mild VP (FS) groups. Postoperative ODI, VAS score for LBP, lower extremity pain, numbness, and LBP in standing were significantly worse in the severe VP (non-FS) group than in the mild VP (non-FS) group. SVP (non-FS) scores significantly correlated with postoperative ODI, VAS score for LBP, lower extremity pain, numbness, and LBP in standing; however, SVP (FS) scores did not correlate with any surgical outcomes. CONCLUSIONS: Preoperative SVP at fused disc is not associated with surgical outcomes; however, SVP at nonfused discs is correlated with clinical outcomes.

The Medial Tibial Plateau Can Be Used as a Direct Anatomical Reference for the Posterior Tibial Slope in Medial Unicompartmental Knee Arthroplasty.

There has been no consensus about how to determine the individual posterior tibial slope (PTS) intraoperatively. The purpose of this study was to investigate whether the tibial plateau could be used as a reference for reproducing individual PTS during medial unicompartmental knee arthroplasty (UKA). Preoperative computed tomography (CT) data from 48 lower limbs for medial UKA were imported into a three-dimensional planning software. Digitally reconstructed radiographs were created from the CT data as the lateral knee plain radiographs and the radiographic PTS angle was measured. Then, the PTS angles on the medial one-quarter and the center of the MTP (» and ½ MTP, respectively), and that on the medial tibial eminence (TE) were measured on the sagittal multiplanar reconstruction image. Finally, 20 lateral knee radiographs with an arthroscopic probe placed on the » and the ½ MTP were obtained intraoperatively, and the angle between the axis of the probe and the tangent line of the plateau was measured. The mean radiographic PTS angle was 7.9 ± 3.0 degrees (range: 1.7-13.6 degrees). The mean PTS angles on the » MTP, the ½ MTP, and the TE were 8.1 ± 3.0 degrees (1.2-13.4 degrees), 9.1 ± 3.0 degrees (1.4-14.7 degrees), and 9.9 ± 3.1 degrees (3.1-15.7 degrees), respectively. The PTS angles on the » MTP and the ½ MTP were strongly correlated with the radiographic PTS angle (r =0.87 and 0.80, respectively, p < 0.001). A statistically significant difference was observed between the mean angle of the radiographic PTS and the PTS on the TE (p < 0.01). The mean angle between the axis of the probe and the tangent line of the tibial plateau was -0.4 ± 0.9 degrees (-2.3-1.3 degrees) on the » MTP and -0.1 ± 0.7 degrees (-1.5-1.2 degrees) on the ½ MTP, respectively. An area from the medial one-quarter to the center of the MTP could be used as an anatomical reference for the individual PTS.

Lateral shift of the femoral condyle after total knee arthroplasty: simulation using 2D-templates of the medial pivot design on knee radiographs of young Japanese patients.

BACKGROUND: Total knee arthroplasty (TKA) is an established surgical treatment for advanced knee osteoarthritis by which patients can expect improvement of knee pain and function. Although many surgeons have investigated limb alignment after TKA, changes in coronal positional relation between the femur and tibia are not known well. METHODS: Radiographs of 105 knees of young Japanese patients between 20 and 49 years-old (60 men and 45 women) without osteoarthritic changes who received arthroscopic surgeries at our hospital were used in this study. Using 2D-templates of the medial pivot design (the FINE total knee), we simulated TKA on a SYNAPSE-PACS software. First, the femoral component was placed in normal knee alignment and then was merged to the medial concave of the insert where the tibial component was placed in neutral alignment. The length of the mediolateral shift of the femoral component was measured as an estimate of lateral shift of the femoral condyle, of which association with radiographic parameters including the femorotibial angle (FTA), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) was analyzed. Subjects were classified into three groups according to the femoral component size that was chosen in simulation of TKA, and the lateral shift of the femoral condyle was compared between groups. RESULTS: The estimated mean lateral shift of the femoral condyle was 5.99 ± 1.98 mm and was greater in males than females (p < 0.05). Also, it was most highly correlated with the medial proximal tibial angle (MPTA) (r = - 0.553, p < 0.01). A group receiving larger component sizes significantly shifted more laterally compared with a group receiving smaller component sizes (p < 0.01). CONCLUSIONS: These results suggest that the coronal positional relation between the femur and tibia is altered and subsequent ligament imbalance may occur after mechanically aligned TKA using the medial pivot design.

Comparison of pain and discomfort in supine and lateral positions after surgery for lumbar degenerative disease: A prospective randomized controlled study.

INTRODUCTION: To compare postoperative pain and discomfort between supine and lateral positions after lumbar surgery, a prospective randomized controlled study was performed. METHODS: Forty-three patients with lumbar degenerative disease, treated by decompression (n = 23) or fusion surgery (n = 20), were randomly assigned to be placed in either the supine (supine group: n = 21) or lateral (lateral group: n = 22) position postoperatively, and asked to maintain their position until a day after the surgery. Postoperative back pain and discomfort (visual analog scale [VAS], 0-100 mm) and the number of patients who could maintain their position were examined. RESULTS: The VAS scores for back pain (supine: 64.9 ± 22.0, lateral: 55.7 ± 21.4) showed no significant difference between the positions. However, the supine group showed significantly more severe discomfort (75.6 ± 15.7) than the lateral group (64.9 ± 15.7, p = 0.039). Significantly fewer patients maintained their position in the supine group (28.2%) than in the lateral group (68.2%; p = 0.022). Among patients who underwent fusion surgery, significantly fewer patients maintained their position in the supine group (10.0%) than those in the lateral group (60.0%, p = 0.029). CONCLUSION: Postoperative discomfort was significantly reduced in the lateral position than in the supine position; thus, the lateral position is more suitable after lumbar surgery in terms of postoperative discomfort.

Unexpectedly rapid decrease in the size of a spinal epidural abscess after percutaneous posterior pedicle screw fixation without decompression surgery: a case report.

INTRODUCTION: Spondylodiscitis accompanying spinal epidural abscess is often treated with decompression surgery when there are neurological symptoms. We report a case of spondylodiscitis accompanying spinal epidural abscess with severe lower extremity pain that was successfully treated with percutaneous posterior pedicle screw fixation without decompression surgery. CASE PRESENTATION: A 53-year-old man was admitted to our hospital with severe low back pain (LBP), lower extremity pain and numbness, and fever. Lumbar magnetic resonance imaging (MRI) revealed spondylodiscitis at L2-L3 and a small epidural abscess located ventrally in the spinal canal. Initially, the patient was treated conservatively with empirical antibiotics. However, the lower extremity symptoms worsened and the epidural abscess expanded cranially to the T12 level. Percutaneous pedicle screw fixation without decompression was performed thirty-three days after admission. Postoperatively, the LBP and lower extremity pain dramatically improved. A postoperative MRI performed one week post-operatively showed an unexpectedly rapid decrease in the size of the epidural abscess, although no decompression surgery was performed. Two months after surgery, the epidural abscess completely disappeared. At the final follow-up (five years postoperatively), no recurrence of epidural abscess was observed, and the patient had no symptoms or disturbance of activities of daily living. DISCUSSION: This surgical strategy should be carefully selected for patients with spondylodiscitis with accompanying spinal epidural abscess who have lower extremity symptoms. The stabilising effect of pedicle screw fixation may be advantageous for controlling spinal infections. Percutaneous posterior pedicle screw fixation without decompression is an optional treatment for spondylodiscitis accompanying spinal epidural abscess.

Time-Dependent Change in Cartilage Repair Tissue Evaluated by Magnetic Resonance Imaging up to 2 years after Atelocollagen-Assisted Autologous Cartilage Transplantation: Data from the CaTCh Study.

OBJECTIVE: To elucidate the time course of magnetic resonance imaging (MRI)-based morphological and qualitative outcomes after an atelocollagen-assisted autologous chondrocyte implantation (ACI) and to analyze the correlation between arthroscopic and MRI-based assessment. DESIGN: We included ACI recipients from a multicenter registration study (CaTCh [Cartilage Treatment in Chiba] study). Morphological (3-dimensional magnetic resonance observation of cartilage repair tissue: 3D-MOCART, MOCART2.0) and qualitative assessment (T2- and T1rho-mapping) by MRI were conducted at 6, 12, and 24 months post-implantation. Global T2 and T1rho indices (T2 and T1rho in repair tissue divided by T2 and T1rho in normal cartilage) were calculated. Arthroscopic second-look assessment was performed in 4 and 15 knees at 12 and 24 months post-implantation, respectively. RESULTS: The 3D-MOCART over 12 months witnessed significant patient improvement, but some presented subchondral bone degeneration as early as 6 months. The MOCART2.0 improved from 57.5 to 71.3 between 6 and 24 months (P = 0.02). The global T2 index decreased from 1.7 to 1.2 between 6 and 24 months (P < 0.001). The global T1rho index decreased from 1.5 to 1.3 between 6 and 24 months (P = 0.004). Normal or nearly normal ICRS-CRA (cartilage repair assessment scale developed by the International Cartilage Repair Society) grades were achieved in 86% and 93% of the lesions at 12 and 24 months, respectively. Better ICRS-CRA grade corresponded to better MOCART2.0, with no trend in the T2 and T1rho values. CONCLUSIONS: Atelocollagen-assisted ACI improved the MRI-based morphological and qualitative outcomes until 24 months post-surgery, and normal or nearly normal grades were achieved in most lesions by arthroscopic assessment. MRI assessment may be an alternative to arthroscopic assessment.

Postoperative loss of correction after combined posterior and anterior spinal fusion surgeries in a lumbar burst fracture patient with Class II obesity.

Background: When treating thoracolumbar fractures with severe cranial endplate injury but no or slight caudal endplate injury, it is debatable whether anterior fusion should be performed only for the injured cranial level, or for both cranial and caudal levels. We report an unexpected postoperative correction loss after combined multilevel posterior and single-level anterior fusion surgery in a patient with obesity. Case Description: A 28-year-old male with Class II obesity was brought to the emergency room with an L1 burst fracture with spinal canal involvement. Cranial endplate injury was severe, whereas caudal endplate injury was mild. The first surgery with 1-above 1-below posterior fixation failed to achieve sufficient stability; thus, additional surgeries (3-above 3-below posterior fixation and single-level T12-L1 anterior fusion) were performed. Postoperatively, the local kyphosis angle (LKA) between T12 and L2 was 22° in the lateral lying position and 29° in the standing position. Twenty-one-month post surgery, bony fusion between T12 and L1 was observed, and the LKA was 28° in both the lateral lying and standing positions. After posterior implants were removed 24 months after the surgery, significant correction loss both at the T12-L1 segment (6°) and L1-L2 segment (6°) occurred, and LKA was 40° at the final follow-up. Conclusion: In this patient, an intense axial load due to excessive body weight was at least one of the causes of postoperative correction loss. Postural differences in LKA may be useful to evaluate the stability of thoracolumbar fractures after fusion surgery and to predict postoperative correction loss.

Brain Diseases and Fall-Related Surgery in Older Persons.

BACKGROUND: It is known that age-related brain symptoms (gait difficulty and dementia) increase the likelihood of fall-related surgery. In contrast, it is not known which types of brain disease underlie such symptoms most. OBJECTIVE: The aim of this study was to correlate brain diseases with the types of surgeries performed at our hospital for patients who had fallen. METHODS: This was a retrospective study at a multifaculty university hospital in Japan, with a 12-month recruiting period, a follow-up period of 3.0 ± 2.5 weeks, and ≥1×/week visits. We assembled a neurogeriatric team to diagnose brain diseases with the use of brain imaging to the extent possible and correlated the diagnoses with types of fall-related surgery. RESULTS: Fall-related surgery was conducted by the orthopedics (OP) and neurosurgery (NS) faculties (total n = 124) at a ratio of about 2 to 1. The underlying brain diseases differed by faculty; for OP, surgery was most commonly performed in patients with a combination of white matter disease (WMD) and Alzheimer's disease (AD) (79%) followed by dementia with Lewy bodies. In contrast, for NS, the most common surgery was for patients with alcoholism (50%) followed by a combination of WMD and AD. CONCLUSION: Fall-related surgery was performed by the OP and NS faculties at a 2 to 1 ratio. The major underlying brain diseases were a combination of WMD and AD (79%) for OP and alcoholism (50%) for NS.

Effects of the difference between lumbar lordosis in the supine and standing positions on the clinical outcomes of decompression surgery for lumbar spinal stenosis.

OBJECTIVE: The authors sought to evaluate the relationship between the difference in lumbar lordosis (DiLL) in the preoperative supine and standing positions and spinal sagittal alignment in patients with lumbar spinal stenosis (LSS) and to determine whether this difference affects the clinical outcome of laminectomy. METHODS: Sixty patients who underwent single-level unilateral laminectomy for bilateral decompression of LSS were evaluated. Spinopelvic parameters in the supine and standing positions were measured preoperatively and at 3 months and 2 years postoperatively. DiLL between the supine and standing positions was determined as follows: DiLL = supine LL - standing LL. On the basis of this determination patients were then categorized into DiLL(+) and DiLL(-) groups. The relationship between DiLL and preoperative spinopelvic parameters was evaluated using Pearson's correlation coefficient. In addition, clinical outcomes such as visual analog scale (VAS) and Oswestry Disability Index (ODI) scores between the two groups were measured, and their relationship to DiLL was evaluated using two-group comparison and multivariate analysis. RESULTS: There were 31 patients in the DiLL(+) group and 29 in the DiLL(-) group. DiLL was not associated with supine LL but was strongly correlated with standing LL and pelvic incidence (PI) - LL (PI - LL). In the preoperative spinopelvic alignment, LL and SS in the standing position were significantly smaller in the DiLL(+) group than in the DiLL(-) group, and PI - LL was significantly higher in the DiLL(+) group than in the DiLL(-) group. There was no difference in the clinical outcomes 3 months postoperatively, but low-back pain, especially in the sitting position, was significantly higher in the DiLL(+) group 2 years postoperatively. DiLL was associated with low-back pain in the sitting position, which was likely to persist in the DiLL(+) group postoperatively. CONCLUSIONS: We evaluated the relationship between DiLL and spinal sagittal alignment and the influence of DiLL on postoperative outcomes in patients with LSS. DiLL was strongly correlated with PI - LL, and in the DiLL(+) group, postoperative low-back pain relapsed. DiLL can be useful as a new spinal alignment evaluation method that supports the conventional spinal sagittal alignment evaluation.

Influence of Age on Signal Intensity of Magnetic Resonance Imaging and Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction: Comparisons Among Different Age Groups.

BACKGROUND: Thus far, the clinical results of anterior cruciate ligament (ACL) reconstruction have been observed to be comparable between young and older patients. In contrast, age-related changes in the structural and mechanical properties of tendons used for autografts have been described. However, age-related changes associated with graft maturation remain poorly understood. HYPOTHESES: The hypotheses of this study were that (1) clinical outcomes after ACL reconstruction would be comparable between younger and relatively older patients and (2) younger patients would show lower signal intensity changes on magnetic resonance imaging scans indicative of graft maturation that would be better than that in relatively older patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively evaluated 236 patients who underwent double-bundle ACL reconstruction via the outside-in technique using hamstring autograft between January 2012 and December 2015. The patients were categorized by age into 3 groups: <20 years old, 20 to 39 years old, and ≥40 years old. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) score, Tegner activity scale, Lysholm score, and objective assessment of joint laxity 24 months after surgery. In addition, graft maturation was evaluated using magnetic resonance imaging-derived measures of the signal intensity ratio (SIR) at 3, 6, 12, and 24 months postoperatively. Clinical outcomes and graft maturation were compared among the 3 groups. RESULTS: The SIR of both bundles increased from 3 months to 12 months and decreased by 24 months, showing the same tendency in all groups. No significant difference was found in the SIR among the 3 groups at any time point (P > .05). The IKDC score was significantly lower in the ≥40-year group than in the <20-year group (P < .01). In contrast, no significant differences were noted in other clinical outcomes. CONCLUSION: Patients aged ≥40 years exhibited lower IKDC scores compared with younger patients, although the results of graft maturation were comparable.

Sweat-gland carcinoma with neuroendocrine differentiation (SCAND): a clinicopathologic study of 13 cases with genetic analysis.

Low-grade neuroendocrine carcinoma of the skin (LGNECS) was proposed in 2017 as a new primary cutaneous neoplasm with neuroendocrine differentiation; however, it is not yet well known due to its rarity. Herein, we perform a detailed clinicopathologic analysis of 13 cases as well as panel DNA sequencing in three cases. The study included 12 males and 1 female with a median age of 71 (43-85) years. All lesions occurred on the ventral trunk. The mean tumor size was 2.2 (0.8-11.0) cm. The histopathology resembled that of well-differentiated neuroendocrine tumors (NETs) in other organs, but intraepidermal pagetoid spreading was seen in 8 (61.5%) cases and stromal mucin deposits in 4 (30.8%). Immunoreactivity for CK7, CK19, EMA, BerEP4, CEA, chromogranin A, synaptophysin, INSM1, GCDFP15, GATA3, ER, and bcl-2 were present in varying degrees in all tested cases. PTEN c.165-1G>A splice site mutation was detected by panel sequencing in one case, and GATA3 P409fs*99 and SETD2 R1708fs*4 in another case. Lymph node metastasis was seen significantly in cases with tumor size >2.0 cm [8/8 (100%) vs. 1/5 (20%)]. All three cases with size >3.0 cm were in unresectable advanced-stage [3/3 (100%) vs. 1/10 (10%)], and two of the three patients succumbed to the disease. The two cases of death revealed mild nuclear atypia (mitosis: 1/10 HPFs) and moderate nuclear atypia (2/10 HPFs). Thus, tumor size would be a better prognostic factor than nuclear atypia, mitotic count, and Ki67 index, unlike in NETs. These clinicopathologic and immunohistochemical features would represent the characteristics as skin adnexal tumors with apocrine/eccrine differentiation rather than NETs; therefore, we rename it as sweat-gland carcinoma with neuroendocrine differentiation (SCAND).

Predictors of Spontaneous Restoration of Lumbar Lordosis after Single-Level Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Diseases.

INTRODUCTION: Preoperative factors that predict postoperative restoration of lumbar lordosis (LL) are not well understood. To investigate whether preoperative postural correction of LL, sagittal malalignment, or lumbar flexibility are associated with the postoperative restoration of LL in patients treated with a single-level transforaminal lumbar interbody fusion (TLIF), a retrospective cohort study was conducted. METHODS: We enrolled 104 patients (mean age: 67.5±10.7 years old; 47 men and 57 women) with lumbar degenerative diseases treated with a single-level TLIF. The pre- and postoperative LL were examined using lateral radiographs in the standing position and computed tomography (CT) images in the supine position. The correlation between postoperative LL restoration and preoperative postural correction of LL (difference in LL between the standing and supine positions: D-LL), sagittal imbalance (pelvic incidence minus LL: PI-LL), and lumbar flexibility (difference in LL between the flexion and extension postures) were analyzed. Patients were divided into two groups according to the D-LL (D-LL≥0° and D-LL<0°). The rates of postoperative LL restoration (postoperative LL-preoperative LL in standing) were compared between the two groups. RESULTS: Multiple regression analysis performed after adjustment for age, gender, body mass index, and cage angle revealed that postoperative LL restoration was significantly correlated with D-LL (p<0.001), but not with PI-LL, and lumbar flexibility. Patients with a preoperative D-LL≥0° showed a significantly greater increase of LL after TLIF (7.1°±11.2°) than those with D-LL<0° (1.4°±6.6°) (p=0.003). CONCLUSIONS: A preoperative evaluation of a lateral radiograph or CT taken in the supine position is useful in predicting postoperative improvement of sagittal alignment. Postoperative improvement of sagittal spinopelvic alignment would be expected when LL is corrected in the supine position preoperatively. Surgeons should pay attention to the postural correction of LL when performing short-segment fusion surgery for lumbar degenerative disease with sagittal malalignment.

Rapidly progressive osteoarthritis in the medial patellar facet due to lateral femoral placement after medial unicompartmental knee arthroplasty. A case report.

INTRODUCTION AND IMPORTANCE: Factors that affect patellofemoral (PF) osteoarthritis (OA) after unicompartmental knee arthroplasty (UKA) remain unclear. We report a case in which the lateral placement of the femoral component resulted in rapidly progressive OA in the medial patellar facet. CASE PRESENTATION: The patient was an 84-year-old woman who had increased pain in the left knee due to varus knee OA for 1 year and underwent medial UKA. One month after the surgery, the patient complained of limited knee flexion of 90° with anterior knee pain, and around 7-mm lateral placement of the femoral component was observed on a postoperative radiograph and computed tomography scan. Six months after the surgery, rapidly progressive OA with subchondral bone depression in the medial facet was observed and this has been ongoing till the last follow-up of 3 years. The knee flexion is limited 105° now, and the patient complains of quadriceps weakness with anterior knee pain when stair-climbing and standing up from a chair. CLINICAL DISCUSSION: Lateral placement of the femoral component in medial UKA may cause progressive PF OA with limited knee flexion and anterior knee pain, which could be attributed to impingement between the femoral component and the medial patellar facet. CONCLUSION: Surgeons should be careful regarding the lateral placement to prevent symptomatic PF OA from occurring after medial UKA.

Computed Tomographic Assessment of Age- and Gender-Specific Sagittal Lumbopelvic Alignment in a Japanese Population.

INTRODUCTION: Previous studies have reported differences in lumbopelvic alignment between standing and supine positions. Computed tomography (CT) images taken in the supine position are often used for clinical studies in addition to standing radiographs, although not frequently. Our study aims to clarify normative values of CT-evaluated lumbopelvic parameters and the characteristics of age- and gender-related lumbopelvic alignment in the supine position. METHODS: Patients undergoing CT scans of abdominal or lumbar regions for reasons other than low back disorders were included (n=581). Sagittal multiplanar reconstruction CT images were obtained, and lumbar lordosis (LL), L5-S1 angle, and sacral slope (SS) were measured. Mean values of the parameters in patients aged 59 years and under, 60-69, 70-79, and 80 and over, and in males and females, were calculated. Age- and gender-related differences in these parameters were statistically analyzed. RESULTS: Among the four age groups, patients 80 years and over showed significantly lower LL and SS than patients aged 70-79. Females 80 years and over showed significantly lower LL and SS than all other age groups, but those in males did not. The comparison between males and females showed no significant differences in LL and SS; however, the L5-S1 angle was significantly higher in males than in females. In patients 80 years and over, females showed significantly lower LL and SS than in males. CONCLUSIONS: This study provides normative CT-evaluated lumbopelvic parameters, such as LL, L5-S1 angle, and SS, which will be utilized for comparisons in future studies. The present study first revealed that pelvic retroversion and lumbar kyphosis occur in elderly females in the supine position, which raised a possibility that age-related decrease of LL and SS in females occurs at an older age in the supine position than in the standing position.