Relationship Between Revision Rate, Osteoarthritis, and Obesity for ACL Reconstruction: A Nationwide Retrospective Cohort Study.

Background: The long-term goal of anterior cruciate ligament (ACL) reconstruction is to prevent secondary osteoarthritis due to instability. Obesity itself is also a risk factor for osteoarthritis and shows an increase in its incidence, but little is known about the relationship between obesity and the outcome of ACL reconstruction. Purpose/Hypothesis: This study aimed to determine the relationship between the outcome of ACL reconstruction and obesity. It was hypothesized that obesity would be associated with the revision rate of ACL reconstruction and additional surgical treatment for osteoarthritis in patients who undergo ACL reconstruction. Study design: Cohort study; Level of evidence, 3. Methods: Claims and health screening data of the National Health Insurance Service were used to analyze patients who underwent ACL reconstruction between January 1, 2003, and December 31, 2021. The association between obesity and risk of revision ACL reconstruction and additional surgical treatment for osteoarthritis or meniscal lesion was analyzed. Body mass index (BMI) was used to classify patients as underweight (BMI, <18.5), normal weight (BMI, 18.5-24.9), overweight (BMI, 25.0-29.9), obese (BMI, 30.0-39.9), or morbidly obese (BMI, ≥40.0). Multivariable Cox proportional hazards model analysis was conducted. Results: A total of 56,734 patients were included. Of them, 311 (0.5%) patients were underweight, 26,613 (46.9%) were normal weight, 24,372 (43.0%) were overweight, 5324 (9.4%) were obese, and 114 (0.2%) patients were morbidly obese. The underweight group showed a significantly lower risk of revision ACL reconstruction than the normal weight group (hazard ratio [HR], 0.54; 95% CI, 0.31-0.93; P = .0273). However, the overweight, obese, and morbidly obese groups had no significant difference from the normal weight group. The risk of high tibial osteotomy (HTO) or total knee arthroplasty (TKA) was significantly high for the overweight (HR, 1.93; 95% CI, 1.70-2.19; P < .0001) and obese (HR, 2.71; 95% CI, 2.23-3.30; P < .0001) groups. Subgroup analysis performed in patients ≥40 years of age for the risk of HTO showed a significant increased risk in the overweight group (HR, 1.889; 95% CI, 1.56-2.29; P < .0001) and obese group (HR, 2.78; 95% CI, 2.10-3.69; P < .0001). Subgroup analysis performed in patients ≥50 years of age for the risk of TKA also showed a significant increased risk in the overweight group (HR, 2.03; 95% CI, 1.67-2.47; P < .0001) and obese group (HR, 2.53; 95% CI, 1.83-3.50; P < .0001). After adjusting for meniscal injury at index surgery by multivariate regression analysis, 1.87- and 2.75-fold increased risks of HTO were identified for the overweight and obese groups, respectively, for patients aged >40 years. For patients aged >50 years, 2.02-fold and 2.52-fold increased risks of TKA were observed for the overweight and obese groups, respectively. The risk of additional surgery due to the meniscal lesion was high for the overweight (HR, 1.09; 95% CI, 1.03-1.15; P = .002) and obese (HR, 1.10; 95% CI, 1.01-1.21; P = .0351) groups, while no significant difference was found for the underweight and morbidly obese groups. Conclusion: This study highlights that obesity does not increase the revision rate of ACL reconstruction. However, the risk of additional surgical treatment for osteoarthritis and meniscal lesions increased as BMI increased. Further investigation is needed to determine the efficacy of ACL reconstruction for preventing osteoarthritis in obese patients.

Graft choice to decrease the revision rate of anterior cruciate ligament reconstruction: a nationwide retrospective cohort study.

There are many graft choices for anterior cruciate ligament (ACL) reconstruction, including autografts and allografts. The choice of graft has been identified as a significant factor affecting the outcome of ACL reconstruction. This study aimed to determine whether allograft or autograft is better for avoiding revisional ACL reconstruction. The National Health Insurance Service-Health screening database analyzed 146,122 patients who underwent ACL reconstruction surgery from Jan. 1, 2002, to Dec. 31, 2021. The study was conducted in two groups, autograft or allograft, and the rates of revision ACL reconstruction between the two groups were compared. Propensity score matching and multivariable Cox Proportional Hazard model analysis were used. The significant predictors for complications (p < 0.05) were as follows. The total of patients with ACL reconstruction was 146,122. Allograft was used in 121,148 patients, and autograft was used in 24,974 patients. 9.2% of the allograft group and 8.7% of the autograft group underwent revision ACL reconstruction. (P < .0001) 70.0% & 63.6% of patients underwent revision surgery within 1 year in the allograft & autograft groups, respectively. In summary, using autograft in primary ACL reconstruction is helpful in lowering the rate of revision surgery.

Efficacy of pulse oximetry for early diagnosis of pulmonary embolism after total knee arthroplasty.

INTRODUCTION: Early diagnosis and aggressive treatment of pulmonary embolism (PE) are crucial for preventing severe complications after total knee arthroplasty (TKA). This study aimed to examine the efficacy of measuring oxygen saturation (SpO2) using a pulse oximeter for early diagnosis of PE after total knee arthroplasty (TKA). MATERIALS AND METHODS: We consecutively examined 1645 patients who underwent TKA between January 2015 and November 2019. Postoperative SpO2 was measured with a pulse oximeter, which was stopped if SpO2 was maintained at ≥ 95% until postoperative day 2 (POD2). To diagnose PE, computed tomographic pulmonary angiography (CTPA) was performed for specific indications, including persistently low SpO2 < 95% (group 1), sudden decrease in SpO2 (group 2), and decrease in SpO2 after POD3 with presenting symptoms (group 3). Also, we divided the patients into unilateral, simultaneous and sequential TKA groups and compared the results with specific statistical techniques. RESULTS: Of the 1645 patients who underwent TKA, there were 20 patients with PE (1.2%), and symptomatic PE was observed in only 4 patients (0.24%). CTPA was performed in 58 (3.5%) patients, of whom 20 were diagnosed with PE. In groups 1 (n = 34), 2 (n = 21), and 3 (n = 3), CTPA was performed 2.4, 2.6, and 8.3 days after TKA, respectively, and 12, 8, and 0 patients were diagnosed with PE, respectively. Of the 782, 416, and 447 unilateral, simultaneous, and sequential (done in same admission with interval 1 or 2 weeks) patients with TKA, 38, 18, and 2 received CTPA, and 13, 6, and 1 were diagnosed with PE, respectively. All patients diagnosed with PE have persistently low SpO2 < 95% (group 1), or sudden decrease in SpO2 (group 2) until POD2. Of the patients diagnosed with PE, SpO2 decreased without the presentation of symptoms in 16 patients (11 and 5 from groups 1 and 2, respectively) and with the presentation of symptoms, such as mild dyspnea and chest discomfort, in 4 patients (1 and 3 from groups 1 and 2, respectively). CONCLUSIONS: Measuring SpO2 using a pulse oximeter until POD2 was an effective method for early diagnosis of PE after TKA. No case of morbidity or mortality was observed after early diagnosis with early stage CTPA and management of PE. We recommend measuring SpO2 with a pulse oximeter for early diagnosing of PE in TKA.

Joint Replacement Surgery in Patients with Rheumatoid Arthritis in South Korea: Analysis of a Large National Database.

Background: We aimed to investigate the current trend of joint replacement surgery incidence in patients with rheumatoid arthritis (RA) in South Korea and to compare the incidence of joint replacement surgery in each affected joint. Methods: We performed this big data analysis to investigate the current trend of joint replacement surgery incidence in patients with RA in South Korea and to compare the incidence of joint replacement surgery in each affected joint. This retrospective study was based on data from the Korea National Health Insurance claims database. Results: The prevalence of RA increased every year (0.13% in 2008, 0.25% in 2016). The number of newly diagnosed patients increased from 29,184 in 2010 to 38,347 in 2016. The incidence rate of joint replacement surgery in patients with RA increased from 0.72% in 2010 to 4.03% in 2016. The knee (68.3%) was the most commonly replaced joint. The relative risk (RR) of additional joint replacement surgery was highest for the shoulder joint (RR,1.454; 95% confidence interval, 0.763-2.771). The median time from diagnosis to surgery was the shortest in the elbow joint (379 days) and the longest in the shoulder joint (955 days). The median time for each joint was short in order of the elbows, ankles, hips, knees, and shoulders (p < 0.01). Conclusions: The most frequently and initially replaced joints were different, but the prevalence and incidence of RA, as well as those of joint replacement surgery, have recently increased in South Korea. Joint replacement surgery in RA was the highest for the knee joint. The median time from diagnosis to surgery was shortest for the elbow, followed by the ankle, hip, knee, and shoulder. Regardless of whether patients are symptomatic, evaluation of large joints such as the knee, elbow, ankle, and hip should be considered from an early stage.

Basic Strategies of Augmentation Mammoplasty in Patients with Tendencies of Pectus Excavatum and Carinatum.

BACKGROUND: In this era of growing popularity of cosmetic surgeries, more women of various chest wall shapes are likely to receive augmentation mammoplasty. Pectus excavatum (PE) and pectus carinatum (PC) are the two most common chest wall deformities, and many asymptomatic patients visit the clinic. In this study, we presented various strategies for successfully performing breast augmentation in PE and PC patients without long-term complications such as symmastia. METHODS: From January of 2019 to December of 2021, a total of 132 patients with tendencies of PE and PC received augmentation mammoplasty in our institute. We retrospectively reviewed data on demographics, surgical procedure, outcomes, and complications. RESULTS: Among the 132 cases, 71.21% were done via inframammary approach, and 28.79% via transaxillary approach. The mean implant volume was 337.25 ± 51.46 ml, and the mean follow-up period was 16.48 ± 6.74 months. The Likert scale of outcome satisfaction scored 9.13 ± 0.48. No symmastia occurred. CONCLUSION: We presented our basic strategies of breast surgery in patients with various chest wall anomalies. Augmentation mammoplasty can benefit PE and PC patients physically as well as psychologically, to carry out healthy positive lives. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Periareolar Augmentation Mastopexy: Finding the Aesthetic Level of Breast Lifting.

Background: Ptosis and volume atrophy of the breasts are common symptoms for various ages of women and may induce a considerable amount of stress in daily life. Periareolar augmentation mastopexy is an effective procedure for such conditions, and planning the new nipple position is very important. Aim: To provide a simple, straightforward planning and walkthrough of this operation in a journey to find the ideal level of breast lifting for natural upper fullness. Materials and methods: From January 2019 to December 2021, a total of 193 patients with volume deflation and ptosis of the breast received periareolar augmentation mastopexy in our institute. We retrospectively reviewed data on demographics, surgical procedures, outcomes, and complications. Results: All operations were done with periareolar incisions, and the mean follow-up period was 29.48 ± 9.11 months. The Likert scale of outcome satisfaction scored 9.02 ± 0.61. Complications were minimal, and no symmastia or bottoming out occurred. Conclusion: We present our basic strategies of periareolar augmentation mastopexy with a slight modification of the design. We believe that lifting the nipple to 3-4 cm above the inframammary fold (IMF) (making the top of the areola about 5-6 cm above the IMF) yields satisfactory aesthetic results.

Platelet-to-White Blood Cell Ratio: A Feasible Biomarker for Pyogenic Liver Abscess.

The platelet-to-white blood cell ratio (PWR) has been reported to predict the severity of patients with various diseases. However, no previous studies have assessed the use of the PWR as a prognostic marker for pyogenic liver abscesses (PLA). This observational retrospective study was performed between January 2008 and December 2017, including 833 patients with PLA from multiple centers. The enrolled patients, on average, had a PWR of 17.05, and 416 patients had a PWR lower than 17.05. A total of 260 patients (31.2%) with PLA showed complications of metastatic infection, pleural effusion and abscess rupture. A low PWR level was identified as a strong risk factor for metastatic infection and pleural effusion. The low PWR group also had a longer hospital stay. In the multivariate analysis, old age, anemia, albumin and CRP levels and unidentified pathogens were significant factors for low PWR levels. A low PWR, old age, male sex, abscess size, albumin, ALP and unidentified causative pathogens showed significant associations with a hospital stay longer than 28 days. As a result, PLA patients presenting with a low PWR were shown to have more complications and a poor prognosis. Considering its cost-effectiveness, PWR could be a novel biomarker used to predict a prognosis of PLA.

Incidence and risk factors analysis for mortality after total knee arthroplasty based on a large national database in Korea.

This study aimed to analyze the rates and risk factors of postoperative mortality among 560,954 patients who underwent total knee arthroplasty (TKA) in Korea. The National Health Insurance Service-Health Screening database was used to analyze 560,954 patients who underwent TKA between 2005 and 2018. In-hospital, ninety-day, and one-year postoperative mortality, and their association with patient's demographic factors and various comorbidities (ie., cerebrovascular disease, congestive heart failure, and myocardial infarction) were assessed. In-hospital, ninety-day and one-year mortality rates after TKA were similar from 2005 to 2018. The risk of in-hospital mortality increased with comorbidities like cerebrovascular disease (hazard ratio [HR] = 1.401; 95% confidence interval [CI] = 1.064-1.844), congestive heart failure (HR = 2.004; 95% CI = 1.394 to 2.881), myocardial infarction (HR = 2.111; 95% CI = 1.115 to 3.998), and renal disease (HR = 2.641; 95% CI = 1.348-5.173). These co-morbidities were also independent predictors of ninety-day and one-year mortality. Male sex and old age were independent predictors for ninety-day and one-year mortality. And malignancy was risk factor for one-year mortality. The common preoperative risk factors for mortality in all periods were male sex, old age, cerebrovascular disease, congestive heart failure, myocardial infarction, and renal disease. Malignancy was identified as risk factor for one-year mortality. Patients with these comorbidities should be provided better perioperative care.

The Effect of Cartilage Lesion in the Lateral Compartment of the Knee on the Surgical Outcome of Medial Open-Wedge High Tibial Osteotomy.

The aim of this study was to identify the effect of cartilage lesion in the lateral compartment of the knee on the surgical outcome of medial open-wedge high tibial osteotomy (MOWHTO). A total of 172 consecutive patients who underwent MOWHTO were evaluated retrospectively. Among the patients who underwent second-look arthroscopic assessment, 30 patients with lateral compartment cartilage lesion (group 1: ≥ grade 2 cartilage lesion according to the International Cartilage Repair Society [ICRS] grading system) and 64 patients with normal or near-normal lateral compartment cartilage (group 2: grade 0 or 1 cartilage lesion according to the ICRS grading system) were included in the analysis. Each patient was evaluated for the following variables: clinical scores, radiographic osteoarthritis grade, and comparative measurement under arthroscopy. All clinical scores were similar between the two groups preoperatively and at the time of second-look operation. Group 1 showed a significantly higher osteoarthritis grade in the lateral compartment of the knee on the 30 degree flexed posteroanterior view according to the International Knee Documentation Committee grading system preoperatively (p = 0.005) and at the time of second-look operation (p = 0.002). In regard to the comparative measurement under arthroscopy, the size of cartilage lesion on the medial compartment decreased by time in both groups (p = 0.000), whereas the size of cartilage lesion on the lateral compartment increased by time in both groups (p = 0.004). However, the degree of change in the cartilage lesion size in each compartment of the knee over time did not significantly differ between the two groups. Regarding the cartilage lesion grade in the lateral compartment, there was no statistically significant difference in the frequency of deterioration between the two groups. As a result, the presence of cartilage lesion of ICRS grade 2 or 3 in the lateral compartment of the knee, either subtle or not detected during the preoperative evaluation, would not affect the surgical outcome of MOWHTO. This is a Level IV, therapeutic case series study.

Radiographic Prognostic Factors Relevant to Surgical Outcomes of Arthroscopic Partial Medial Meniscectomy in Elderly Patients with Mild Osteoarthritis.

The aim of this study was to investigate radiographic factors relevant to predict surgical outcomes of arthroscopic partial meniscectomy (APM) in elderly patients with mild osteoarthritis (Kellgren-Lawrence grades 1 and 2). Data of 172 consecutive patients aged >70 years who underwent arthroscopic meniscal surgery were reviewed retrospectively. The patients who met the inclusion criteria were classified into two groups based on the minimal clinically important difference value of the Lysholm knee scoring scale comparing the score of the last visit with that of the preoperative period: group 1 (with clinically significant improvement) and group 2 (without clinically important change). Radiographic factors assessed on X-ray and magnetic resonance images were evaluated using bivariate and logistic regression analyses. A total of 73 patients were included in this study. Bivariate analysis revealed that the extent of meniscus extrusion (p = 0.031), meniscus extrusion ratio (p = 0.001), and grade of meniscus degeneration (p = 0.019) were significantly different between the groups. Multivariate logistic regression analysis showed that the meniscus extrusion ratio was the most important independent predictive factor for surgical outcomes with clinically important changes (coefficient = 0.159, p = 0.009). On receiver operating characteristic (ROC) curve analysis, the cutoff point of the meniscus extrusion ratio discriminating the two groups was 34.2% (sensitivity: 79.3%; specificity: 68.6%; accuracy: 72.6%). Meniscus extrusion ratio was the most relevant predictive factor for discriminating patients with clinically important change. Meniscus extrusion ratio, with the cutoff point of 34.2%, could serve as a guide to determine whether to perform APM in elderly patients with mild osteoarthritis. This is a Level IV, therapeutic case series study.

Environmental risk factors and comorbidities of primary biliary cholangitis in Korea: a case-control study.

BACKGROUND/AIMS: The risk factors for the development of primary biliary cholangitis (PBC) is unclear. This study aimed to investigate the risk factors associated with PBC in Korea through a questionnaire survey. METHODS: Consecutively enrolled 103 PBC patients from six referral hospitals and 100 age- and sex-matched community controls participated in this study. A standardized questionnaire survey including demographics, lifestyle, individual and familial medical history and reproductive history was prospectively collected and analyzed. RESULTS: The PBC patients had a mean age of 58.3 years and a female proportion of 86.4%. The age- and sex-matched controls had a similar educational level and economic status to the PBC patients. Among the lifestyle factors, the multivariable analysis showed smoking including both first-hand and second-hand (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.06 to 3.93), history of autoimmune diseases (OR, 2.46; 95% CI, 1.06 to 6.35), and family history of PBC (OR, 17.76; 95% CI, 1.77 to 2,418.74) were significantly associated with PBC, whereas alcohol intake was negatively associated with PBC. Among reproductive factors, the number of induced abortions was significantly associated with PBC, while the number of full-term deliveries was negatively associated with PBC. CONCLUSION: A family history of PBC, accompanying autoimmune diseases, and smoking were significantly associated with PBC. More induced abortions and less full-term deliveries were associated with PBC in women. In contrast, mild to moderate alcohol intake was negatively associated with PBC. Further studies are warranted to validate the results of this study and to search for clues about the pathogenesis of PBC.

Does desflurane need more irrigating-pump pressure for the visibility in arthroscopic shoulder surgery than sevoflurane?

BACKGROUND: In arthroscopic shoulder surgery, a mechanical fluid-irrigation system is used to wash out blood from the joint. If used at high pressure, it can cause side effects such as fluid extravasation, leading to airway obstruction after surgery. Desflurane is prone to increasing sympathetic nerve activity and plasma catecholamine release more than another inhalation anesthetics. The objective of this study was to determine whether desflurane could increase in the irrigation pump pressure than sevoflurane in shoulder arthroscopy. METHODS: Patients were randomized into a sevoflurane group (group S) and a desflurane group (group D). Each included 20 patients. For group S, sevoflurane 1.2 MAC and intravenous remifentanil were administered for anesthesia maintenance. Group D received desflurane 1.2 MAC and intravenous remifentanil. Starting at 20 mmHg of pump pressure, the surgeon estimated the visibility of the surgical field (grade I-IV). After that, the pressure was freely adjusted by the surgeon to obtain clear vision with the arthroscope during the surgery. RESULTS: The maximum pressure of the mechanical water pump was higher in group D than group S (54.0 ± 6.8 mmHg vs. 48.9 ± 5.7 mmHg, P = 0.017), but the difference was not statistically significant at a significance level of 0.01. The arthroscopic visibility at the surgical site did not differ significantly between the two groups (P = 0.284). CONCLUSIONS: When desflurane is used in arthroscopic shoulder surgery, it does not require more pressure from the irrigating-fluid pump to secure a clear vision of the surgical site, compared to sevoflurane.

Vascular Calcification in Patients Undergoing Total Knee Arthroplasty: Frequency and Effects on the Surgery.

BACKGROUD: This study aims to investigate the frequency of distal femoral and popliteal arterial calcification and to evaluate the intraoperative and postoperative effects of arterial calcification in patients undergoing total knee arthroplasty using a tourniquet. METHODS: The records of 5,438 patients who had undergone primary total knee arthroplasty between January 2003 and January 2017 were retrospectively reviewed. We examined the preoperative radiographs of the knee from all patients for calcifications of the femoral and popliteal arteries. Vascular calcification was identified on preoperative radiographs in 223 cases. Intraoperative and postoperative complications were investigated among these patients. Postoperative complications were analyzed from the time of surgery to the last follow-up (minimum 1-year follow-up). RESULTS: Vascular calcification of the arteries around the knee was found in 223 cases (4.1%). The mean patient age was 70.6 years in the non-calcification group and 73.8 years in the calcification group (p > 0.05). The calcification group was classified into medial, intimal, or mixed subgroups according to the morphology of calcification on preoperative radiographs. The medial type included 46 cases (20.6%); intimal type, 161 cases (72.2%); and mixed type, 16 cases (2.7%). There was no statistically significant difference in demographic and surgical data among the three groups. There were intraoperative complications in two cases in the medial type group, both of which involved tourniquet failure. There was also a postoperative complication in one case in the medial type group, which involved wound dehiscence at 2 weeks postoperatively. No other postoperative complications were identified during 1-year follow-up. CONCLUSIONS: Despite the presence of calcifications in the arteries around the knee, total knee arthroplasty (using a tourniquet) can be performed without serious complications.

What can the radiological parameters of superior migration of the humeral head tell us about the reparability of massive rotator cuff tears?

OBJECTIVE: The interrelation and clinical utility of the parameters for superior migration of the humeral head, such as the acromiohumeral interval (AHI), inferior glenohumeral distance (IGHD), and upward migration index (UMI), in the management of massive rotator cuff tears are not clear. The objectives of this study were to identify the relation between AHI, IGHD, and UMI when measured with radiography and MRI and to determine whether superior migration can predict the irreparability of massive rotator cuff tears. METHODS: We retrospectively reviewed the files of 64 consecutive patients who underwent arthroscopic partial or complete repair for massive rotator cuff tears at our institution between August 2015 and August 2018. We recorded both radiography and MRI measurements of AHI, IGHD, and UMI, and further the tangent sign, fatty infiltration of the rotator cuff muscles, and the Patte grade. We performed correlation assessments and multiple logistic regression analysis to identify potential predictors of the reparability of massive rotator cuff tears. RESULTS: Thirty-five patients had partially reparable and 29 had completely reparable tears. Parameters measured with either radiography or MRI were highly correlated with each other. The radiographic measurements showed a moderate or low correlation with the MRI measurements. All parameters of superior migration of the humeral head on radiography and MRI, the tangent sign, fatty infiltration of the infraspinatus muscle, and the Patte grade showed significant differences between patients with partially and completely repaired tears. Among these, the independent predictors for irreparability was Patte grade = 3. CONCLUSION: The AHI, IGHD, and UMI were highly correlated when measured with either radiography or MRI, but not when comparing their radiographic with their MRI values. Furthermore, they were not independent indicators of reparability in massive rotator cuff tears.

Osteochondral Fracture of Posterior Aspect of Lateral Femoral Condyle After Lateral Patella Dislocation: A Case Report.

CASE: A healthy 15-year-old girl presented with osteochondral fracture at the posterior aspect of the lateral femoral condyle (LFC) associated with a right patellar dislocation after a noncontact injury. The patient remained asymptomatic 18 months after the arthroscopically assisted reduction and internal fixation of the osteochondral fracture using bioabsorbable pins and was able to eventually resume her usual activities of daily living. CONCLUSIONS: This is the first report of an osteochondral fracture at the posterior aspect of the LFC after an acute patellar dislocation, successfully treated with arthroscopically assisted reduction and internal fixation using bioabsorbable pins. This rare injury and unique mechanism of injury have been discussed.

The effect of medial open wedge high tibial osteotomy on the patellofemoral joint: comparative analysis according to the preexisting cartilage status.

BACKGROUND: Although it has been known that medial open wedge high tibial osteotomy (MOWHTO) would adversely affect the patellofemoral joint, no previous study examined the surgical outcome of MOWHTO according to the preexisting cartilage status of the patellofemoral joint. The aim of this study was to investigate the effect of MOWHTO on the patellofemoral joint with regard to objective and subjective aspects according to the preexisting cartilage status. METHODS: Ninety-two patients who underwent MOWHTO and a following second-look arthroscopic assessment were included in this study. The patients were divided into two groups according to the preexisting cartilage status of the patellofemoral joint: group 1 (International Cartilage Repair Society [ICRS] grade 2 or 3) and group 2 (ICRS grade 0 or 1). Comparative analysis was performed regarding clinical scores, radiographic parameters, and arthroscopic measurements between the two groups. RESULTS: Clinical outcomes showed overall improvement from baseline to the time of second-look operation, with no significant difference between the two groups at each time point. There were no significant differences in radiographic parameters between the two groups. Radiographic grade of patellofemoral osteoarthritis in both groups showed a tendency to progress, without statistical significance. In arthroscopic assessment, the size of the cartilage lesion on the patellofemoral joint increased with time in both groups (P = 0.003), but the degree of change over time between the two groups was not statistically significant. Consistently, there was no significant difference in the frequency of progression of cartilage lesion grade in the patellofemoral joint between the two groups. CONCLUSIONS: MOWHTO would contribute to osteoarthritis progression of the patellofemoral joint regardless of the preexisting cartilage status, without an association with clinical outcomes in short-term follow-up.

Effect of a Formulation Containing Low-Dose Sodium Deoxycholate on Local Fat Reduction.

BACKGROUND: Synthetic deoxycholic acid (DCA) has been approved as an injectable drug for the nonsurgical reduction of submental fat. OBJECTIVE: In this study, we evaluated the fat-reducing effects of a new formula containing a low dose of DCA and fat dissolution by topical application of DCA. METHODS: Sodium deoxycholate (99.1% pure) and the new formulation containing 10% DCA were injected or topically applied to the dorsa of obese mice (induced by a high-fat diet). The rate of change in body weight was evaluated, together with comparisons of micro-computed tomography images, body composition measurements, and histology findings. RESULTS: The results showed that the new formula containing low-dose DCA was as effective as the older high-dose formulation with respect to the rate of change in body weight and reductions in subcutaneous fat pad area, body fat weight, and the thickness of the subcutaneous fat layer. Furthermore, topical application of the high-dose, but not the low-dose, formulation yielded promising effects. CONCLUSIONS: The development of a better protocol for the high-dose preparation, including dose optimization and application methods that minimize the adverse effects of DCA, merits further study. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors - www.springer.com/00266 .

Role of biomarkers as predictors of acute kidney injury and mortality in decompensated cirrhosis.

Evidence suggests that novel biomarkers predict acute kidney injury (AKI) development and outcome earlier than serum creatinine. The aim of this study was to determine the incidence and prognosis of AKI in decompensated cirrhotic patients, and also assess the usefulness of plasma cystatin C, urine neutrophil gelatinase associated lipocalin (NGAL), tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) in early prediction of AKI and mortality. Single-center, prospective observational study enrolling decompensated cirrhotic patients without AKI at the time of admission. Of 111 patients with decompensated cirrhosis, 45 (40.5%) developed AKI while hospitalized. Even with 53.3% being transient (stage 1), mortality was significantly higher in AKI than non-AKI patients (46.5% vs. 25%, p = 0.02). Plasma cystatin C and urine NGAL, but not urine [TIMP-2]·[IGFBP7] at the time of admission were found to be independent early predictors of AKI. Substitution of cystatin C for creatinine significantly improved the model for end-stage liver disease (MELD) score accuracy for mortality prediction. The incidence of AKI is high and is associated with high mortality in decompensated cirrhotic patients. Plasma cystatin C and urine NGAL are useful for early detection of AKI. MELD-cystatin C, rather than original MELD, improves predictive accuracy of mortality.

The preliminary report about the modified supramalleolar tibial osteotomy for asymmetric ankle osteoarthritis.

OBJECTIVE: Supramalleolar tibial osteotomy (SMO) for asymmetric ankle osteoarthritis (OA) is known to lead to satisfactory. Here, authors present a preliminary report on SMO surgical treatment in patients with asymmetric ankle arthritis. MATERIALS AND METHODS: We reviewed cases of asymmetric ankle OA treated by modified SMO between January 2011 and October 2015. Clinical assessment was performed with the use of the ankle and hindfoot score of the American Orthopedic Foot and Ankle Society (AOFAS), foot function index, and visual analogue scale (VAS). Patient satisfaction with surgery and postoperative subjective symptoms were examined. Radiographic evaluation included preoperative and postoperative tibial anterior surface angle (TAS angle), talar tilt angle (TT angle), and tibial lateral surface angle (TLS angle). Takakura stage was measured. RESULTS: The average follow-up period was 46.3 months. The AOFAS score was 55.7 ± 6.03 preoperatively and 76.0 ± 4.73 postoperatively. Foot function index was 60.7 ± 8.78 preoperatively and 30.8 ± 7.59 postoperatively. VAS was 7.2 ± 0.53 before surgery and 1.9 ± 0.85 after surgery. Clinical evaluations showed statistically significant improvement. The majority of patients reported satisfactory results in the subjective satisfaction evaluation. TAS angle was 84.6 ± 1.82 preoperatively and 94.0 ± 2.79 postoperatively. TLS angle was 78.8 ± 2.11 preoperatively and 81.8 ± 1.80 postoperatively. TT angle was 3.6 ± 1.26 before surgery and 2.1 ± 0.79 after surgery. Thirteen cases showed radiographic improvement of Takakura stage. Complications were not observed. CONCLUSION: Modified SMO is a useful procedure that provides for the union and stability of osteotomy with the advantages of the existing SMO and can be performed without bone graft.

Effect of Sarcopenia on Postoperative Mortality in Osteoporotic Hip Fracture Patients.

BACKGROUND: Few studies have investigated the effects of sarcopenia on postoperative outcomes including mortality rates following surgery for osteoporotic hip fractures. The purpose of the present study was to determine the prevalence of sarcopenia and the relationship between sarcopenia and 1- and 5-year mortality rates in a consecutive series of patients with osteoporotic hip fractures. METHODS: Among patients who underwent hip surgery for osteoporotic hip fractures, this study included 91 patients subjected to abdominal computed tomography within 1 year of hip surgery. We defined sarcopenia using sex-specific cut-off points for the skeletal muscle index at the level of the third lumbar vertebra. All patients were divided into 2 groups according to the presence or absence of sarcopenia and the 1- and 5-year mortality rates were compared. To confirm factors affecting mortality in addition to sarcopenia, we examined patient age, sex, American Society of Anesthesiologists grade, location of fracture, type of surgery, and bone mineral density. RESULTS: The 1- and 5-year mortality rates were 20.9% and 67.2%, respectively. Among the 45 patients with sarcopenia, the 1- and 5-year mortality rates were 22.2% and 82.7%, respectively. Of the 46 patients without sarcopenia, the 1- and 5-year mortality rates were 19.6% and 52.7%, respectively. Results of the Kaplan-Meier analysis showed that sarcopenia did not affect the 1-year mortality rate (P=0.793), but had a significant effect on the 5-year mortality rate (P=0.028). Both perioperative sarcopenia (P=0.018) and osteoporosis (P=0.000) affected the 5-year mortality rate. CONCLUSIONS: Sarcopenia increases the risk of 5-year mortality in patients with osteoporotic hip fractures.