Modulating the mesenchymal stromal cell microenvironment alters exosome RNA content and ligament healing capacity.

Although mesenchymal stromal cell (MSC) based therapies hold promise in regenerative medicine, their clinical application remains challenging due to issues such as immunocompatibility. MSC-derived exosomes are a promising off-the-shelf therapy for promoting wound healing in a cell-free manner. However, the potential to customize the content of MSC-exosomes, and understanding how such modifications influence exosome effects on tissue regeneration remain underexplored. In this study, we used an in vitro system to compare the priming of human MSCs by 2 inflammatory inducers TNF-α and CRX-527 (a highly potent synthetic TLR4 agonist that can be used as a vaccine adjuvant or to induce anti-tumor immunity) on exosome molecular cargo, as well as on an in vivo rat ligament injury model to validate exosome potency. Different microenvironmental stimuli used to prime MSCs in vitro affected their exosomal microRNAs and mRNAs, influencing ligament healing. Exosomes derived from untreated MSCs significantly enhance the mechanical properties of healing ligaments, in contrast to those obtained from MSCs primed with inflammation-inducers, which not only fail to provide any improvement but also potentially deteriorate the mechanical properties. Additionally, a link was identified between altered exosomal microRNA levels and expression changes in microRNA targets in ligaments. These findings elucidate the nuanced interplay between MSCs, their exosomes, and tissue regeneration.

Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block.

PURPOSE: To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery. MATERIALS AND METHODS: A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines. RESULTS: CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events. CONCLUSIONS: Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.

SIRT1 as a potential therapeutic target in pelvic organ prolapse due to protective effects against oxidative stress and cellular senescence in human uterosacral ligament fibroblasts.

INTRODUCTION: The pathogenesis of pelvic organ prolapse (POP), an age-related disease, has not been fully elucidated. Therapeutic targets of POP are limited. Silencing information regulator 2 related enzyme 1 (SIRT1), a gene considered capable of regulating oxidative stress and cellular senescence, has been widely demonstrated involved in aging and age-related diseases. The present study aimed to explore the role of SIRT1 in POP in vivo and in vitro. METHODS: Expression levels of SIRT1 in uterosacral ligament (USL) tissues from patients with or without POP were measured using immunohistochemical assays. SRT1720, a SIRT1 agonist, was used to upregulate SIRT1, and hydrogen peroxide (H2O2) was used to establish an oxidative stress model in human uterosacral ligament fibroblasts (hUSLFs). The effects of SIRT1 on cell viability, apoptosis, senescence, and reactive oxygen species (ROS) levels were detected, respectively. Western blot assays were used to examine expression levels of apoptosis- and senescence-associated biomarkers. Unpaired Student's t test, Mann-Whitney U test, χ2 test, and one-way ANOVA were performed for determining statistically significant differences. RESULTS: Compared to the control group, expression levels of SIRT1 were downregulated in USL tissues and hUSLFs from patients with POP, and associated with stage (p < 0.05). hUSLFs of patients with POP had lower growth rates (p < 0.0001) than those of the control group, which were improved by upregulating SIRT1 (p < 0.05). The senescent proportion was higher in the POP group than the control group (43.63 ± 10.62% vs. 4.84 ± 5.32%, p < 0.0001), which could be reduced by upregulating SIRT1 (p < 0.0001). High ROS levels in the POP group were also alleviated by SRT1720. H2O2 exposure increased ROS levels, inhibited proliferation, and triggered apoptosis and senescence in hUSLFs of patients without POP in a concentration-dependent manner. Further, these damages were alleviated by pretreatment with SRT1720. CONCLUSIONS: SIRT1 is downregulated in patients with POP, and the development of SIRT1 activators or agonists may have applications in the treatment and prevention of POP through antioxidative stress and antisenescence effects.

The female urethral closure mechanism during physical stress.

The closure of the urethra under the condition of stress is the result of a reflex contraction of the urethral rhabdosphincter and pelvic floor muscles. This is likely induced by activity of the abdominal muscles due to a sudden increase in abdominal pressure. This reflex contraction with an increase of urethral pressure occurs a few milliseconds before an increase in intraabdominal pressure. The urethral pressure increase during stress is only possible with fixation of the urethra by the pubourethral ligaments (PUL), facilitating urethral kinking. The highest and most important increase in pressure and resistance occurs in the distal urethra due to this kinking of the urethra.

Spontaneous tendon or ligament ruptures in patients undergoing dialysis: First pediatric case report and literature review.

Spontaneous tendon or ligament ruptures are quite rare and mostly associated with chronic systemic diseases such as diabetes mellitus, systemic lupus erythematosus, rheumatoid arthritis, and chronic kidney disease (CKD). In this study, we present the first documented case of a spontaneous rupture of the medial patellofemoral ligament (MPFL) in a pediatric patient. The patient was undergoing long-term peritoneal dialysis (PD) and had a history of severe secondary hyperparathyroidism. Additionally, we discussed spontaneous tendon and ligament ruptures associated with CKD or dialysis through a comprehensive literature review. This case report highlights the importance of recognizing that spontaneous tendon or ligament injuries are not exclusive to adults; children with CKD can also be affected. Several factors including poor parathyroid hormone (PTH) and metabolic acidosis control, prolonged CKD duration and presence of malnutrition play role in the pathogenesis. Early diagnosis is crucial as it allows for timely surgical intervention and leads to a favorable functional recovery.

Lax Uterosacral Ligament and Urge Urinary Incontinence: MRI Findings in Symptomatic Patients Versus Healthy Volunteers.

INTRODUCTION AND HYPOTHESIS: The objective was to explore the association between urge urinary incontinence (UUI) and lax uterosacral ligaments (USL) using MRI. METHODS: Sixty-seven female participants were recruited prospectively: 41 continent volunteers (control group) and 26 patients with UUI. Static proton density- and T2-weighted turbo spin echo sequences of MR images were used. A radiologist employed a standardized grid system to record structural observations of the USLs on sequentially numbered axial MR images and then applied a four-point grading scale to assess ligament visibility. MR images were interpreted by a radiologist and a urologist, and then validated by an expert radiologist. RESULTS: The comparison between the mean length of uterosacral ligaments in the control and UUI groups was highly statistically significant (p < 0.001). The mean length of the right USL was 38 ± 11 mm, and the left USL was 35 ± 12 mm in the UUI group. In the control group, the mean length of the USL was 22 ± 9 mm on the right side and 18 ± 9 mm on the left side, along their craniocaudal extent. The highest inter-observer agreement was on the level of origin and insertion (image numbers), whereas the lowest agreement was on the anatomical site of origin and insertion of the USL in both the control and UUI groups. CONCLUSIONS: The average length of USLs in patients with UUI is significantly longer than that in healthy continent women, indicating laxity. Our findings support the relationship between the laxity of the USL and UUI symptoms and have therapeutic implications.

Intraoperative Fluorescent Ureter Visualization for Transvaginal High Uterosacral Ligament Suspension for Severe Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: We aimed to demonstrate the feasibility of ureteral navigation using intra-ureteric indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during transvaginal high uterosacral ligament suspension for prolapse repair to reduce the risk of iatrogenic ureteral injury. METHODS: A cystoscope was inserted into the bladder, the tip of a 6-F open-end ureteral catheter was inserted into the ureteral orifices, and ICG was instilled into the ureters. The ureteral path was then clearly identified using NIRF imaging. Sutures were safely placed in the uterosacral ligaments at the level of the ischial spine, taking advantage of direct ureteral visualization. RESULTS: At the end of the procedure, diagnostic cystoscopy was performed to confirm ureteral patency. No intraoperative or postoperative complications were observed. CONCLUSIONS: Intra-ureteric ICG-NIRF imaging represents a simple, inexpensive, and reproducible trick for intraoperative ureteral detection, and could reassure surgeons during difficult operations, for instance, in the case of severe prolapse and/or when ureteral course abnormalities are expected.

A Randomised Trial on the Effects of the Addition of Uterosacral Ligament Plication to Pectopexy Operation on Anatomical Restoration and Female Sexual Functions.

INTRODUCTION AND HYPOTHESIS: The objective was to determine whether the addition of uterosacral ligament plication to pectopexy for pelvic organ prolapse increases anatomical improvement and female sexual functioning. METHODS: This is a prospective randomised study. Forty patients who underwent laparoscopic pectopexy (LP) and laparoscopic pectopexy with uterosacral ligament plication (LPUSL) were included in the study. A total of 38 patients were evaluated in the study. Patients were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system and the patients who had symptomatic apical prolapse POP-Q ≥ II were included in the study. Patients were evaluated preoperatively and postoperatively at the 3rd, 6th and 12th month, with respect to anatomical changes as well as sexual function. RESULTS: A statistically significant difference was found when the preoperative C points was compared with the C points postoperatively, at 3rd, 6th and 12th months in both the LP and LPUSL groups (p < 0.001). Additionally, there were statistically significant difference between the LP and LPUSL groups in terms of C and Aa points at the 6th and 12th postoperative months in favour of the LPUSL group (p = 0.007, p = 0.005 respectively). There was also a statistically significant difference when Ba points were compared between the two groups at the 12th postoperative month, in favour of the LPUSL group (p = 0.002). There were no statistically significant differences between the groups with respect to the variables of the Female Sexual Function Index. Additionally, all parameters were significantly better in both groups at the 3rd and 12th months than the preoperative values in post hoc analysis; only desire also had a significant improvement between the 3rd and 12th months in the LPUSL group in post hoc analysis. CONCLUSION: Pectopexy operation seems to be a successful surgical approach as an alternative to sacrocolpopexy. The addition of uterosacral ligament plication to pectopexy operation improves the anatomical restoration more drastically than with LP on its own. Moreover, either LP or LPUSL has improved the majority of sexual function indices.

The Outcomes of the Manchester Procedure Versus Sacrospinous Ligament Hysteropexy for Uterine Prolapse: A Study of the British Society of Urogynaecology Database.

INTRODUCTION: The Manchester procedure (MP) and sacrospinous ligament hysteropexy (SSHP) have long been established as effective conservative surgeries for treating uterine prolapse. However, there have been limited studies on outcomes comparing these two techniques. METHODOLOGY: This was a prospective cohort study of the British Society of Urogynaecology database between February 2007 and 2023 of MP and SSHP outcomes from 90 centres in the UK. The primary outcome was the Patient Global Impression of Improvement (PGI-I). The other outcomes compared were the absence of pelvic organ prolapse beyond the hymen in any compartment evaluated by the Pelvic Organ Prolapse Quantification (POP-Q), complications, and the incidence of reported symptomatic prolapse within 1 year after the operation. RESULTS: There were 718 women who underwent MP and 2,384 who had SSHP. The PGI-I score was significantly better in the MP group (p value <0.001). The rates of symptomatic prolapse within 1 year (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.18-0.69; p value 0.001), recurrence of prolapse beyond the hymen (OR 0.13, 95% CI 0.03-0.53; p value 0.001) and apical recurrence (OR 0.09, 95% CI 0.01-0.65; p value 0.003) during follow-up examination were lower in the MP group. The combined peri-operative and post-operative complications reported in both groups were comparatively similar. CONCLUSION: The symptom improvement was better and recurrence was lower with the MP than with SSHP at short-term follow-up.

Impact of Mannitol Bladder Distension in the Intraoperative Detection of Ureteral Kinking During Pelvic Floor Surgery.

INTRODUCTION AND HYPOTHESIS: Ureteral injuries are the most feared complications of gynecological surgery and therefore intraoperative recognition is of the utmost importance. Intraoperative cystoscopy represents the diagnostics of choice to investigate ureteral patency thanks to the direct visualization of ureteral flows after administration of infusion mediums. In this study, we aimed to compare the diagnostic performance of saline versus mannitol intraoperative cystoscopy in terms of false negatives in a large cohort of patients. METHODS: We retrospectively analyzed data of patients who underwent vaginal hysterectomy and high uterosacral ligament suspension for POP. Patients were divided in two groups based on the use of saline or mannitol medium for intraoperative cystoscopy. Postoperative daily control of serum creatinine was performed until discharge, as well as urinary tract imaging, in symptomatic patients. RESULTS: A total of 925 patients underwent vaginal hysterectomy followed by high USL suspension for POP. Saline and mannitol medium were used in 545 patients and 380 patients respectively. Postoperative ureteral injuries were identified in 12 patients, specifically in 2% of the saline group and in 0.3% of the mannitol group. CONCLUSIONS: The use of mannitol instead of saline as a bladder distension medium was able to significantly reduce the occurrence of postoperative ureteral sequelae.

Effect of Vaginal Microecological Alterations on Female Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the correlation between endogenous vaginal microecological alterations and female pelvic organ prolapse (POP). METHODS: Patients who underwent vaginal hysterectomy were retrospectively analyzed as the POP group (n = 30) and the non-POP group (n = 30). The vaginal microbial metabolites and enzyme levels were tested using the dry chemoenzymatic method. The mRNA and protein expression were tested using real-time quantitative PCR and immunohistochemistry. SPSS version 25.0 and GraphPad Prism 8.0 were performed for statistical analysis. RESULTS: Compared with the non-POP group, the vaginal pH, H2O2 positivity and leukocyte esterase positivity were higher in patients with POP (all p < 0.05). Further analysis showed that patients with pelvic organ prolapse quantification (POP-Q) stage IV had higher rates of vaginal pH, H2O2 positivity and leukocyte esterase positivity than those with POP-Q stage III. Additionally, the mRNA expression of decorin (DCN), transforming growth factor beta 1 (TGF-ß1), and matrix metalloproteinase-3 (MMP-3) in uterosacral ligament tissues were higher, whereas collagen I and III were lower. Similarly, the positive expression of MMP-3 in uterosacral ligament tissue was significantly upregulated in the POP group compared with the non-POP group (p = 0.035), whereas collagen I (p = 0.004) and collagen III (p = 0.019) in uterosacral ligament tissue were significantly downregulated in the POP group. Correlation analysis revealed that there was a significant correlation between vaginal microecology and collagen metabolism. In addition, MMP-3 correlated negatively with collagen I and collagen III (p = 0.002, r = -0.533; p = 0.002, r = -0.534 respectively), whereas collagen I correlated positively with collagen III (p = 0.001, r = 0.578). CONCLUSIONS: Vaginal microecological dysbiosis affects the occurrence of female POP, which could be considered a novel therapeutic option.

Laparoscopic Versus Vaginal Uterosacral Ligament Suspension in Women With Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of the Literature.

OBJECTIVE: Uterosacral ligament suspension (USLS) is one of the most frequently used operations for the restoration of apical support in women with uterovaginal prolapse. However, existing studies are inconclusive as to whether and which surgical access route is superior. The aim of the present meta-analysis is tentatively to compare the efficiency and the postoperative complications of laparoscopic USLS (L-USLS) and vaginal USLS (V-USLS), highlighting that current evidence remains inconclusive regarding the superiority of either surgical access route. DATA SOURCES: We performed a systematic literature review of 5 major databases (Medline, Scopus, Google Scholar Cochrane Central Register of Controlled Trials and Clinicaltrials.gov) from inception till April 2023. METHODS OF STUDY SELECTION: No language restrictions were applied. All comparative studies that compared L-USLS and V-USLS for the management of women with uterovaginal prolapse were included. TABULATION, INTEGRATION, AND RESULTS: Data from 6 retrospective cohort studies on 856 patients were extracted and analyzed. The methodological quality of the included studies was assessed using the risk of bias in nonrandomized studies of interventions tool and ranged between moderate to serious. The pooled results suggest that L-USLS was associated with a potentially decreased incidence of ureteral compromise (odds ratio [OR], 0.19; 95% confidence interval [CI] 0.04-0.89; p = .04) and seemingly lower objective (OR 0.47; 95% CI 0.23-0.97; p = .04) and subjective recurrence rates (OR 0.46; 95% CI 0.23-0.92; p = .03). There were no significant differences between the rates of postoperative pain from USLS sutures, postoperative pelvic hematomas, the suture exposure/granulation tissue formation, and the prolapse recurrence retreatment among the 2 groups. CONCLUSION: The present meta-analysis indicates that L-USLS is possibly associated with significantly fewer ureteral compromise rates and decreased subjective and objective recurrences rates compared to V-USLS. Nevertheless, given the limitations in data quality and heterogeneity of the included studies, these findings should be interpreted with caution. Large-scale randomized studies are essential to more definitively determine the relative merits of the laparoscopic versus vaginal approach.

Minimally Invasive Sacrohysteropexy Versus Vaginal Hysterectomy With Uterosacral Ligament Suspension for Pelvic Organ Prolapse: A Prospective Randomized Non-Inferiority Trial.

STUDY OBJECTIVE: To investigate whether minimally invasive Sacrohysteropexy (SH) is non-inferior to vaginal hysterectomy (VH) with uterosacral ligament suspension (USLS) in women with symptomatic uterovaginal prolapse. DESIGN: Prospective, randomized, non-inferiority study. SETTING: Tertiary university-based hospital. PATIENTS: A total of 146 patients with uterovaginal prolapse between July 2016 and August 2019. INTERVENTIONS: Patients were randomly assigned in a 1:1 ratio to either laparoscopic or robotic SH surgery or VH with USLS surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was prolapse recurrence at 1 year after surgery, defined as prolapse ≥ stage 2 evaluated using the pelvic organ prolapse quantification system, bothersome vaginal bulge symptoms, or retreatment for prolapse. The secondary outcomes included operation time, estimated blood loss, hospital stay, operation-related complications, pain intensity, quality of life, and activities of daily living. Of 146 women who underwent randomization, 73 in the SH group and 73 in the VH with USLS group were analyzed. SH was non-inferior for recurrence compared with VH with USLS (16.4% vs 15.8%, 95% confidence interval: -13.0% to 14.2%). Operating duration and transvaginal length were significantly longer in the SH group, while there were no significant differences in the estimated blood loss, length of hospital stay, or postoperative complication rates. Although perioperative pain intensity was greater from 1 week to 1 month in the SH group, the quality of life and activities of daily living did not differ between the groups throughout postoperative year 1. CONCLUSION: Laparoscopic or robotic SH was non-inferior to VH with USLS for the recurrence of pelvic organ prolapse at the 1-year follow-up.

Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy.

STUDY OBJECTIVE: To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DESIGN: A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SETTING: Tertiary center for urogynecology. PATIENTS: Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse. INTERVENTIONS: Comparison analysis of estimated long-term costs was performed. MEASUREMENTS AND MAIN RESULTS: Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. CONCLUSION: The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

An Apparatus for Measuring Combined Shear-Tensile Loading in Fibrous Tissues Ex Vivo.

Soft tissues such as tendon and ligament undergo a combination of shear and tensile loading in vivo due to their boundary conditions at muscle and/or bone. Current experimental protocols are limited to pure tensile loading, biaxial loading, or simple shear, and thus may not fully characterize the mechanics of these tissues under physiological loading scenarios. Our objective was to create an experimental protocol to determine the shear modulus of fibrous tissues at different tensile loads. We assembled a four-actuator experimental system that facilitated shear deformation to be superimposed on a tissue subjected to an axial preload. We measured shear modulus in axially loaded electrospun nanofiber scaffolds with either randomly oriented or aligned fibers. We found that shear modulus in the nanofiber phantoms was shear-strain stiffening and dependent on both the axial load (p < 0.001) and fiber alignment (p < 0.001) of the scaffold. The proposed system can enhance our understanding of microstructure and functional mechanics in soft tissues, while also providing a platform to investigate the behavior of electrospun scaffolds for tissue regeneration. Our experimental protocol for determining loaded shear modulus would be further useful as a method to gauge tissue mechanics under loading conditions that are more representative of physiological loads applied to tendon and ligament.

Residual Strain and Joint Pressurization Maintain Collagen Tension for On-Joint Lumbar Facet Capsular Ligaments.

Modeling the lumbar facet capsular ligament's (FCL) mechanical behavior under various physiological motions has often been a challenge due to limited knowledge about the on-joint in situ ligament state arising from attachment to the bone or other internal loads. Building on prior work, this study presents an enhanced computational model of the lumbar facet capsular ligament by incorporating residual strain and joint pressurization strain, factors neglected in prior models. Further, the model can predict strain and stress distribution across the ligament under various spinal motions, highlighting the influence of the ligament's attachment to the bone, internal synovial fluid pressurization, and distribution of collagen fiber alignment on the overall mechanical response of the ligament. Joint space inflation was found to influence the total observed stress and strain fields, both at rest and during motion. A significant portion of the ligament was found to be in tension, even in the absence of external load. Additionally, the model's ability to account for residual strain offers a more realistic portrayal of the collagen fibers and elastin matrix's role in ligament mechanics. We conclude that (1) computational models of the lumbar facet capsular ligament should not assume that the ligament is unloaded when the joint is in its neutral position, and (2) the ligament is nearly always in tension, which may be important in terms of its long-term growth and remodeling.

Demonstration of transverse ligament on 3D SPACE MRI in whiplash-associated disorder and nontraumatic conditions.

PURPOSE: This study aims to delineate the three-dimensional (3D) SPACE MRI findings of the transverse ligament (TL) in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group. METHODS: A retrospective analysis was performed on cervical spine MRI scans obtained from 46 patients with WAD and 62 nontraumatic individuals. Clinical features, including the WAD grade and stage, were recorded. The TL's morphological grade and the symmetricity of the lateral atlantodental interval was assessed using axial 3D T2-SPACE images. The morphological grading was evaluated using a four-point scale: 0 = homogeneously low signal intensity with normal thickness, 1 = high signal intensity with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures. Additionally, the number of cervical levels exhibiting degeneration was documented. RESULTS: When comparing the WAD and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3) and the number of degenerated cervical levels. Logistic regression analysis revealed that high-grade TL changes and a lower number of degenerative levels independently predicted the presence of WAD. Within the WAD group, the subset of patients with high-grade TL changes demonstrated a significantly higher mean age than the low-grade group (grade 0 or 1). CONCLUSION: High-grade morphological changes in the TL can be detected in patients with WAD through the use of 3D SPACE sequences. Clinical relevance statement 3D SPACE MRI could serve as an instrumental tool in the assessment of TL among patients with WAD. Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning.

Venous reconstruction using a round ligament-covered prosthetic vascular graft in right­lobe living­donor liver transplantation: a technical report.

PURPOSE: To evaluate the short term-outcomes of venous reconstruction using a round ligament-covered prosthetic vascular graft and assess its effectiveness in the prevention of prosthetic vascular graft migration in right­lobe living donor liver transplantation (LDLT). METHODS AND RESULTS: Thirty patients underwent reconstruction of the middle hepatic vein (MHV) tributaries during right lobe LDLT between January, 2021 and October, 2022. These patients were divided into the autologous vascular graft group (A group, n = 24) and the round ligament-covered prosthetic vascular graft group (RP group, n = 6). The computed tomography (CT) density ratio of the drainage area in the posterior segment of patent grafts was significantly higher in the RP group than in the A group (0.91 vs. 1.06, p = 0.0025). However, the patency rates of reconstructed MHV tributaries in the A and RP groups were 61% and 67%, respectively, with no significant difference between the groups (p = 0.72). Prosthetic vascular graft migration did not occur in the RP group. CONCLUSION: Venous reconstruction using round ligament-covered prosthetic vascular grafts is a feasible and simple method to prevent prosthetic vascular graft migration in right-lobe LDLT.

Ten-year results from the UK National Ligament Registry: Patient characteristics and factors predicting nonresponders for completion of outcome scores.

PURPOSE: The aim of this study was to report the demographic and mechanism of injury data in the UK National Ligament Registry (NLR) at 10 years and determine factors leading to poor compliance with completion of Patient-Reported Outcome Scores (PROMs). METHODS: A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR) were included. Patient demographics, mechanism of injury and patient compliance with completing PROMs were analysed. Patient characteristics were further analysed in relation to compliance with completing the different PROMs at the predefined time points. Patients were identified as nonresponders if they had not completed either 1- or 2-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: A total of 17,492 patients were included in this study. The average age for patients undergoing ACLR between 2013 and 2022 was 29.4 (SD, 10.3). Seventy percent were men and 30% women. Football was the most common activity associated with an ACL injury. Patient compliance with recording PROMs was 55% preoperatively and 37%, 32% and 24% at 1-, 2- and 5-year postoperative follow-up, respectively. Nonresponders represented 54% of eligible patients. Multivariate analyses showed that sex, age, smoking, time interval between injury and surgery and low socioeconomic status were associated with low compliance with postoperative PROM completion (p < 0.001). CONCLUSION: This study reports the demographic characteristics for patients on the NLR since 2013. Male sex, young age, increased waiting time between injury and surgery, smoking and lower socioeconomic class were predictors of low compliance with completion of postoperative PROMs on the UK NLR. Understanding the factors that affect patient compliance with PROMs improves our ability to provide targeted interventions and information to specific patient populations with the aim of enhancing inclusiveness and representation of population in the registry. LEVEL OF EVIDENCE: Level III.

Mid-term outcomes of laparoscopic vaginal stump­round (Kakinuma method) and stump­uterosacral (Shull method) ligament fixation for pelvic organ prolapse: A retrospective comparative study

BACKGROUND: Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) using mesh are popular approaches for treating pelvic organ prolapse (POP). However, it is not uncommon that native tissue repair (NTR) should be presented as an option to patients who are expected to have extensive intraperitoneal adhesion or patients for whom LSC or RSC is difficult owing to various risk factors. Laparoscopic vaginal stump-uterosacral ligament fixation (Shull method) has been introduced as a method for NTR in case of POP. However, effective repair using this surgical procedure may not be possible in severe POPs. To solve the problems of the Shull method, we devised the laparoscopic vaginal stump-round ligament fixation (Kakinuma method) in which the vaginal stump is fixed to the uterine round ligament, a histologically strong tissue positioned anatomically higher than the uterosacral ligament. This study aimed to retrospectively and clinically compare the two methods. METHODS: Of the 78 patients who underwent surgery for POP between January 2017 and June 2022 and postoperative follow-up for at least a year, 40 patients who underwent the Shull method (Shull group) and 38 who underwent the Kakinuma method (Kakinuma group) were retrospectively analyzed. RESULTS: No significant differences were observed between the two groups in patient background variables such as mean age, parity, body mass index, and POP-Q stage. The mean operative duration and mean blood loss in the Shull group were 140.5 ± 31.7 min and 91.3 ± 96.3 ml, respectively, whereas the respective values in the Kakinuma group were 112.2 ± 25.3 min and 31.4 ± 47.7 ml, respectively. Thus, compared with the Shull group, the operative duration was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.003) in the Kakinuma group. Recurrence was observed in six patients (15.0%) in the Shull group and two patients (5.3%) in the Kakinuma group. Hence, compared with the Shull group, recurrence was significantly less in the Kakinuma group (P = 0.015). No patients experienced perioperative complications in either group. CONCLUSIONS: The results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.