RECAM-J 2023-Validation and development of the Japanese version of RECAM for the diagnosis of drug-induced liver injury.

AIM: The diagnosis of drug-induced liver injury (DILI) is challenging. We modified the revised electronic version of the Roussel Uclaf Causality Assessment Method (RUCAM) for the diagnosis of DILI (RECAM), the scoring system developed in US and Spanish cohorts in 2022, and developed RECAM-J 2023 to align with the clinical practice in Japan. In the current study, we introduce RECAM-J 2023 and verify its performance in the context of Japanese patients with DILI. METHODS: After translation of RECAM into Japanese, modifications were made to develop RECAM-J 2023 without any alteration to the scores. To examine the validity and performance of RECAM-J 2023, clinical information on DILI and non-DILI cases in Japan were retrospectively collected. The diagnosis of DILI was made by expert's decision. Then we scored each case using RECAM-J 2023, and calculated area under curve (AUC) values for identification for DILI. RESULTS: We collected data from 538 DILI and 128 non-DILI cases. The sum of highly probable (HP) and probable (PR) cases categorized by RECAM-J 2023 were only 206 (38%) in DILI cases. As the primary cause of low scores was the deduction with missing hepatitis virus markers, which is unlikely to be an issue in prospective applications, we rescored without these deductions. At this time, the sum of HP and PR was raised to 421 (78%). The AUCs of RECAM-J 2023 without deductions were 0.70 and 0.88 for identifying at least HP, and at least PR, respectively. CONCLUSION: RECAM-J 2023, when prospectively used without any missing hepatitis virus markers, provides acceptable performance for identifying at least PR DILI cases in Japanese daily clinical practice.

Accurate tibial tunnel position in transtibial pullout repair for medial meniscus posterior root tears delays the progression of medial joint space narrowing.

PURPOSE: This study aimed to evaluate the association between the progression of medial joint space (MJS) narrowing, medial meniscus extrusion (MME) and clinical scores and the tibial tunnel position in pullout repairs for medial meniscus posterior root tears (MMPRTs). METHODS: This retrospective study examined 54 patients. Changes in MJS (ΔMJS), MME (ΔMME) and clinical scores and their relationship with the tibial tunnel position were evaluated using correlation coefficients. The distance from the anatomical to technical attachment position in the tibial tunnel position was measured in the anterior and medial directions, and the direct distance was measured using the Pythagorean theorem. RESULTS: The mean ΔMJS and ΔMME were 0.6 ± 0.8 and 1.3 ± 1.3 mm, respectively, and the mean anterior, medial and direct distances were 1.4 ± 2.3, 2.2 ± 1.7 and 3.4 ± 1.7 mm, respectively. ΔMJS had a significant positive correlation with the medial (r = 0.580, p < 0.001) and direct (r = 0.559, p < 0.001) distances, while ΔMME had a significant positive correlation with direct distance (r = 0.295, p = 0.030). Several clinical scores were significantly negatively correlated with these distances. CONCLUSION: In transtibial pullout repair for MMPRTs, accurate tibial tunnel position delayed the progression of MJS narrowing and MME, leading to improved clinical outcomes. The progression of MJS narrowing was associated with the mediolateral direction of the tibial tunnel position, while the clinical scores were associated with the anteroposterior direction of the tibial tunnel position. These findings indicate the need to orient the tip of the guide in a more posterolateral direction when creating the tibial tunnel. LEVEL OF EVIDENCE: Level IV.

Spleen stiffness in patients with chronic liver disease evaluated by 2-D shear wave elastography with ultrasound multiparametric imaging.

BACKGROUND: The novel 2-D shear wave elastography (2D-SWE) can measure two ultrasound parameters: shear wave dispersion (SWD) and shear wave speed (SWS). We investigated the ability of 2D-SWE in measuring spleen stiffness using ultrasound multiparametric imaging. METHODS: This cross-sectional study included patients with chronic liver disease who underwent esophagogastroduodenoscopy and ultrasonographic examinations of the spleen between September 2018 and December 2021. In total, 157 patients were enrolled in this study: 81 and 67 patients were included in the pilot set for hepatic venous pressure gradient (HVPG) measurements and validation cohort without HVPG measurements, respectively. To confirm reproducibility between the two examiners, an additional 30 patients were enrolled. RESULTS: The Bland-Altman plots revealed no significant bias in the SWD as measured by two examiners. The splenic SWS (r = 0.752) and SWD (r = 0.444) were correlated with the HVPG. Regarding high-risk varices, as per the Youden index, the cut-off value for splenic SWS was 3.30 m/s, with a sensitivity of 85.7%, specificity of 92.5%, positive predictive value of 85.7%, and negative predictive value of 92.4% in the pilot set. In the validation set, good diagnostic performance by the splenic SWS was observed. However, SWD did not perform as well as SWS. CONCLUSIONS: The splenic SWS, measured using ultrasound multiparametric imaging, was closely correlated with the HVPG. Thus, SWS is a useful predictive marker for high-risk varices.

Increased quadriceps muscle strength after medial meniscus posterior root repair is associated with decreased medial meniscus extrusion progression.

BACKGROUND: This study aimed to assess quadriceps muscle strength after medial meniscus (MM) posterior root repair and determine its relationship with clinical scores and MM extrusion (MME). METHODS: Thirty patients who underwent pullout repair for MM posterior root tear and were evaluated for quadriceps muscle strength preoperatively and at 1 year postoperatively were included in this study. Quadriceps muscle strength was measured using the Locomo Scan-II instrument (ALCARE, Tokyo, Japan). MME and clinical scores (i.e., Knee Injury and Osteoarthritis Outcome Score [KOOS], International Knee Documentation Committee score, Lysholm score, Tegner score, and visual analog scale pain score) were evaluated preoperatively and at 1 year postoperatively, and second-look arthroscopy was performed at 1 year postoperatively. Wilcoxon's signed-rank test was used to compare each measure pre- and postoperatively. Pearson's correlation coefficient was used to assess the correlation with quadriceps muscle strength values. Multiple regression analysis was performed to identify factors associated with the change in MME (ΔMME). RESULTS: Second-look arthroscopy confirmed continuity of the posterior root in all patients. The quadriceps muscle strength measured at 1 year postoperatively (355.1 ± 116.2 N) indicated significant improvement relative to the quadriceps muscle strength measured preoperatively (271.9 ± 97.4 N, p < 0.001). The MME at 1 year postoperatively (4.59 ± 1.24 mm) had progressed significantly relative to the MME preoperatively (3.63 ± 1.01 mm, p < 0.001). The clinical scores at 1 year postoperatively were improved significantly relative to the scores preoperatively (p < 0.001). The postoperative quadriceps muscle strength was correlated with ΔMME (correlation coefficient = -0.398, p = 0.030), and the change in quadriceps muscle strength was correlated with the KOOS-Quality of Life (correlation coefficient = 0.430, p = 0.018). Multiple regression analysis showed that the postoperative quadriceps muscle strength had a significant effect on ΔMME even when the body mass index and time from injury to surgery were included. CONCLUSIONS: After MM posterior root repair, patients with greater quadriceps muscle strength showed less MME progression. In addition, patients with greater improvement in quadriceps muscle strength had better clinical scores; therefore, continued rehabilitation aimed at improving quadriceps muscle strength after MM posterior root repair is recommended. LEVEL OF EVIDENCE: IV.

Associations among Preoperative Malnutrition, Muscle Loss, and Postoperative Walking Ability in Intertrochanteric Fractures: A Retrospective Study.

Sarcopenia and malnutrition are increasing in older adults and are reported risk factors for functional impairment after hip fracture surgery. This study aimed to investigate the associations between skeletal muscle mass loss, malnutrition, and postoperative walking ability in patients with hip fracture. We retrospectively reviewed patients who underwent intertrochanteric fracture surgery at our institute. The psoas muscle index, controlling nutritional status score, and functional ambulation category (FAC) were used to evaluate skeletal muscle mass, nutritional status, and walking ability, respectively. Six months after surgery, walking ability was assessed as either "gait disturbance" or "independent gait". Multivariate binomial logistic regression analysis, with skeletal muscle mass, nutritional status, and other factors, was used to predict the risk of being assigned to the gait disturbance group. This study included 95 patients (mean age, 85.2 years; 70 women). Sixty-six patients had low skeletal muscle mass, 35 suffered from malnutrition, and 28 had both. Malnutrition and low skeletal muscle mass were significantly associated with postoperative gait disturbance (FAC < 3). Preoperative low skeletal muscle mass and malnutrition were risk factors for postoperative poor walking ability. Further preventive interventions focusing on skeletal muscle mass and nutritional status are required.

Steep posterior slope of the medial tibial plateau and anterior cruciate ligament degeneration contribute to medial meniscus posterior root tears in young patients.

PURPOSE: Medial meniscus posterior root tears (MMPRTs) occur most frequently in middle-aged and older adults. However, this serious condition can also occur in younger patients. The purpose of this study was to compare anterior cruciate ligament (ACL) degeneration and sagittal medial tibial slope in young adults with and without MMPRT. METHODS: Eighteen healthy volunteers, 18 young patients (20-49 years of age), and 30 middle-aged and older patients (50-70 years of age) with MMPRT repair were included in the study. Sex, body mass index (BMI), femorotibial angle, ACL degeneration, and medial tibial slope angle were compared among the groups. ACL degeneration and medial tibial slope angle were assessed using magnetic resonance imaging. RESULTS: In the healthy volunteer group, the young patient group, and the older patient group, the medial tibial slopes were 3.5° ± 1.4°, 6.1° ± 2.7°, and 7.2° ± 1.9°, respectively, and the ACL degeneration rates were 5.6%, 38.9%, and 43.3%, respectively. Young patients with MMPRT had significantly steeper medial tibial slopes and ACL degeneration compared to those of the healthy volunteers (P < 0.05). The parameters of young patients were similar to those of older patients with MMPRT. In the multivariate logistic regression analysis, BMI, medial tibial slope, and ACL degeneration were significantly associated with MMPRT in young patients. CONCLUSION: BMI, steep medial tibial slope, and ACL degeneration contribute to MMPRT development in younger patients. LEVEL OF EVIDENCE: Level III.

The stability of repaired meniscal root can affect postoperative cartilage status following medial meniscus posterior root repair.

BACKGROUND: Transtibial pullout repair yields beneficial clinical outcomes in patients with medial meniscus (MM) posterior root tear. However, the relationship between repaired meniscal root healing status and postoperative clinical outcomes remains unclear. We aimed to evaluate changes in articular cartilage damage and clinical scores after pullout repair using two simple stitches (TSS). METHODS: Thirty-three patients who underwent pullout repair using TSS were assessed. Healing status was assessed by a semi-quantitative second-look arthroscopic scoring system comprising three evaluation criteria (width of bridging tissues, stability of the repaired root, and synovial coverage), 1 year postoperatively. MM medial extrusion (MMME) and cartilage damage were assessed preoperatively and 1 year postoperatively. The medial compartment was divided into 8 zones (A-H) for comparison of preoperative and 1-year postoperative cartilage damage. Clinical outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome score, Lysholm score, International Knee Documentation Committee scores, and visual analogue scale pain score. RESULTS: Although cartilage damage did not aggravate significantly in most medial compartment areas, MMME progressed at 1 year postoperatively. No statistical differences were observed in cartilage damage between the central-to-medial area of the medial femoral condyle and the medial tibial plateau area at 1 year postoperatively. Regarding semi-quantitative healing scores, the stability score was significantly correlated with the International Cartilage Repair Society grade at 1 year postoperatively. All 1-year and 2-year clinical scores significantly improved compared with the preoperative scores. CONCLUSION: Regarding TSS repair, stability of repaired meniscal root negatively correlated with cartilage damage in the medial compartment loading area. All 1-year and 2-year clinical scores significantly improved than those of the preoperative scores. Achieving MM stability is crucial for suppressing cartilage degeneration. LEVEL OF EVIDENCE: IV case series study.

Epidemiological features of acute medial meniscus posterior root tears.

PURPOSE: Untreated or overlooked medial meniscus posterior root tears (MMPRTs) induce sequential knee joint degradation. We evaluated epidemiological features of acute MMPRT for its early detection and accurate diagnosis. METHODS: Among 330 MMPRT patients from 2018 to 2020, those who underwent arthroscopic pullout repairs were enrolled. Patients who underwent non-operative treatment or knee arthroplasty, those with a cruciate ligament-deficient knee or advanced osteoarthritis of the knee, and those with insufficient data were excluded. Finally, we retrospectively evaluated data from 234 MMPRTs (female: 79.9%, complete tears: 92.7%, mean age: 65 years). Welch's t-test and Chi-squared test were used for pairwise comparisons. Spearman's rank correlation analysis was performed between age at surgery and body mass index (BMI). Multivariable logistic regression analysis with stepwise backward elimination was applied to the values as risk factors for painful popping events. RESULTS: In both sexes, there were significant differences in height, weight, and BMI. In all patients, there was a significant negative correlation between BMI and age (ρ = - 0.36, p < 0.001). The BMI cutoff value of 27.7 kg/m2 had a 79.2% sensitivity and a 76.9% specificity for detecting MMPRT patients aged < 50 years. A painful popping event was confirmed in 187 knees (79.9%), and the frequency was significantly reduced in partial tears as compared to complete tears (odds ratio: 0.080, p < 0.001). CONCLUSION: Higher BMI was associated with a significantly younger age of MMPRT onset. Partial MMPRTs had a low frequency of painful popping events (43.8%).

Medial meniscus posterior root repair influences sagittal length and coronal inclination of the anterior cruciate ligament: a retrospective study.

PURPOSE: Medial meniscus (MM) posterior root tears (PRTs) lead to abnormal kinematic changes in the knee and may induce pathological external rotation of the tibia during knee flexion. This study aimed to investigate changes in the length and inclination of the anterior cruciate ligament (ACL) after MM posterior root repair using magnetic resonance imaging (MRI). METHODS: This retrospective study included 44 patients who underwent MM posterior root repair between 2016 and 2019. Clinical outcomes were evaluated before and after surgery. MRI examinations were performed at 10°/90° of knee flexion preoperatively and 3 months postoperatively. The ACL length, proximal angle, and distal angle were determined using the sagittal view. MM extrusion and ACL inclination angle were determined using the coronal view. RESULTS: Clinical outcomes significantly improved 1 year after surgery. The postoperative ACL length (29.7 ± 2.4 mm) and proximal angle (47.0 ± 7.4°) at 90° of knee flexion decreased relative to the preoperative values (31.5 ± 2.3 mm and 51.8 ± 8.7°, P < 0.01). The postoperative ACL inclination (64.9 ± 5.6°) at 10° of knee flexion decreased relative to the preoperative value (69.7 ± 5.6°, P < 0.01). CONCLUSION: Pathologically-stretched linear ACL at 90° of knee flexion and a steep ACL inclination at 10° of knee flexion could be reduced after MM posterior root repair. This suggests that pullout repair could restore MM function as a secondary stabilizer, thereby preventing meniscal and cartilage degeneration.

Comparison of posterior root remnant cells and horn cells of the medial meniscus.

PURPOSE/AIM OF THE STUDY: Previous studies have noted distinctions between medial meniscus posterior root and horn cells. However, the characteristics of root remnant cells have not been explored in detail. The purpose of this study was to evaluate the gene expression levels, proliferation, and resistance to mechanical stress of remnant and horn cells. MATERIALS AND METHODS: Medial meniscus tissue samples were obtained from patients who underwent total or uni-compartmental knee arthroplasty. Cellular morphology, sry-type HMG box 9, type II collagen, and chondromodulin-I gene expression levels were analyzed. Collagen synthesis was assessed by immunofluorescence staining. Proliferation analysis after 4 h-cyclic tensile strain was performed. RESULTS: Horn cells displayed triangular morphology, whereas root remnant cells appeared fibroblast-like. sry-type HMG box 9 mRNA expression levels were similar in both cells, but type II collagen and chondromodulin-I mRNA expressions were observed only in horn cells. The ratio of type II collagen-positive cells in horn cells was about 10-fold higher than that in root remnant cells, whereas the ratio of sry-type HMG box 9-positive cells was similar. A significant increase in proliferation was observed in root remnant cells compared to that in horn cells. Further, under cyclic tensile strain, the survival rate was higher in root remnant cells than in horn cells. CONCLUSIONS: Medial meniscus root remnant cells showed higher proliferation and resistant properties to cyclic tensile strain than horn cells and showed no chondromodulin-I expression. Preserving the medial meniscus posterior root remnant during pullout repair surgery might maintain mechanical stress-resistant tissue and support healing.

The impact of the surgical Apgar score on oncological outcomes in patients with colorectal cancer: a propensity score-matched study.

BACKGROUND: The surgical Apgar score (SAS) predicts postoperative complications (POCs) following gastrointestinal surgery. Recently, the SAS was reported to be a predictor of not only POCs but also prognosis. However, the impact of the SAS on oncological outcomes in patients with colorectal cancer (CRC) has not been fully examined. The present study therefore explored the oncological significance of the SAS in patients with CRC, using a propensity score matching (PSM) method. METHODS: We retrospectively analyzed 639 patients who underwent radical surgery for CRC. The SAS was calculated based on three intraoperative parameters: estimated blood loss, lowest mean arterial pressure, and lowest heart rate. All patients were classified into 2 groups based on the SAS (≤6 and >6). The association of the SAS with the recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) was analyzed. RESULTS: After PSM, each group included 156 patients. Univariate analyses revealed that a lower SAS (≤6) was significantly associated with a worse OS and CSS. A multivariate analysis revealed that the age ≥75 years old, ASA-Physical Status ≥3, SAS ≤6, histologically undifferentiated tumor type, and an advanced pStage were independent factors for the OS, and open surgery, a SAS ≤6, histologically undifferentiated tumor type and advanced pStage were independent factors for the CSS. CONCLUSIONS: A lower SAS (≤6) was an independent prognostic factor for not only the OS but also the CSS in patients with CRC, suggesting that the SAS might be a useful biomarker predicting oncological outcomes in patients with CRC.

Large flexion contracture angle predicts tight extension gap during navigational posterior stabilized-type total knee arthroplasty with the pre-cut technique: a retrospective study.

BACKGROUND: This study aimed to determine the predictors of tight extension gap (EG) compared with the flexion gap (FG) during navigational posterior stabilized-type total knee arthroplasty using the pre-cut technique. METHODS: Nineteen patients with tight EG (defined as FG-EG ≥2 mm after pre-cut; group T) and 84 patients with an approximately equal gap (defined as FG-EG = 0-1 mm after pre-cut; group E) were enrolled. Medial tibial slope angle, hip knee ankle angle, flexion contracture angle, and active maximum flexion angle were compared between the two groups. RESULTS: The multivariate logistic regression model indicated that the probability of tight EG increased with flexion contracture angle (odds ratio, 1.13; 95% confidence interval 1.05-1.20; P ≤ 0.001). According to the receiver operating characteristic analysis, the flexion contracture angle cut-off value associated with tight EG was 15.0° (sensitivity, 85%; specificity, 78%). CONCLUSION: This study demonstrated that a large flexion contracture angle (cut-off 15.0°) was associated with tight EG after pre-cut osteotomy during posterior stabilized-type total knee arthroplasty. Awareness of this risk factor may help improve preoperative predictability of tight EGs and preparedness for additional procedures, such as soft tissue release or capsulotomy, to correct them. LEVEL OF EVIDENCE: Level III.

Grade of Subchondral Insufficiency Fracture of the Knee and the Presence of a Posterior Shiny-Corner Lesion are Correlated with Duration of Medial Meniscus Posterior Root Tear in Women.

Bone marrow edema (BME) after meniscus injury and risk factors for subchondral insufficiency fracture of the knee (SIFK) have been reported. However, their association with medial meniscus posterior root tear (MMPRT) remains unknown. We investigated the association of BME volume (BME-V), posterior shinycorner lesion (PSCL), and SIFK with MMPRT to examine the correlations between BME-V and medial meniscus extrusion (MME), PSCL and duration from injury to the time of magnetic resonance imaging (duration), and SIFK and duration. Twenty-nine patients who underwent surgery for MMPRT were included (mean age, 59.2; range, 39-84). The presence of PSCL, femoral BME-V (cm3), and SIFK grade (1-4) were evaluated. Preoperative factors, such as MME (mm) and duration (weeks), were investigated using multivariate linear/ logistic regression analyses. Multivariate linear regression analysis revealed duration as a significant factor for high-grade SIFK (p<0.01). Multivariate logistic regression analysis revealed duration as a significant factor for the presence of PSCL (odds ratio=0.94, p<0.05). A long duration of MMPRT leads to severe MME and highgrade SIFK (3 and 4), often resulting in knee arthroplasty. Early diagnosis of MMPRT and pullout repair can prevent severe MME and high-grade SIFK.

Postoperative external tibial rotation is correlated with inferior meniscal healing following pullout repair of a medial meniscus posterior root tear.

PURPOSE: The purpose of this study was to evaluate the influence of tibial rotation on the postoperative healing status of the medial meniscus (MM) following pullout repair of the MM posterior root tear (MMPRT). METHODS: Ninety-one patients (68 women and 23 men; mean age 63.3 ± 8.8 years) who had undergone transtibial pullout repair of MMPRT were enrolled in the study. The tibial external rotation angle (ERA) in each patient was measured postoperatively using computed tomography in the extended knee position. The meniscal healing status following transtibial pullout repair was assessed by second-look arthroscopy (mean postoperative period 12 months) using a previously published scoring system (range 0-10). The association between the ERA and the meniscal healing score was investigated using univariate linear regression models. The ERA cut-off for improved meniscal healing score (≥ 7) was determined using receiver-operating characteristic analysis. RESULTS: The ERA and the meniscal healing score were significantly associated, confirming that increased ERAs were correlated with worse meniscal healing status (R = - 0.28; P < 0.001). The optimum ERA cut-off value was 0.5°, with a sensitivity of 68% and a specificity of 63%. The mean meniscal healing scores were 7.3 and 6.2 among patients with ERAs < 0.5° and those with ERAs ≥ 0.5°, respectively (P < 0.001). CONCLUSION: This study demonstrated that the ERA was significantly correlated with the postoperative meniscal healing status. Postoperative tibial rotation could be one of the factors affecting postoperative outcomes of pullout repair of MMPRT. Controlling the tibial rotation may possibly improve meniscal healing. LEVEL OF EVIDENCE: III.

A newly-developed guide can create tibial tunnel at an optimal position during medial meniscus posterior root repairs.

BACKGROUND: During transtibial pullout repair of medial meniscus (MM) posterior root tears (MMPRTs), accurate tibial tunnel creation within the anatomic MM posterior root attachment seems critical. This study aimed to evaluate the tibial tunnel position created by a newly-developed Precision guide during pullout repair of MMPRTs. METHODS: In 40 patients who underwent transtibial pullout repairs, the tibial tunnel was created using the Unicorn Meniscal Root (UMR) (n = 20) or Precision guide (n = 20). Three-dimensional computed tomography images of the tibial surface were evaluated postoperatively, using Tsukada's measurement method. The expected anatomic center of the MM posterior root attachment was defined as the center of three tangential lines corresponding to anatomic bony landmarks. The expected anatomic center (AC) and the tibial tunnel center (TC) were evaluated using the percentage-based posterolateral location on the tibial surface. The difference in the mediolateral and anteroposterior percentage distance between the AC and TC was calculated, as was the absolute distance between the AC and TC. RESULTS: The mean AC was located 77.4% posterior and 40.1% lateral. The mean TC was similar in the UMR and Precision guide groups. There was no significant difference in the mediolateral percentage distance (UMR 3.9% vs. Precision 3.6%, p = 0.405), but a significant difference was observed in the anteroposterior percentage distance (UMR 3.5% vs. Precision 2.6%, p = 0.031). The mean absolute distance between the AC and TC was 3.9 mm and 3.5 mm (UMR and Precision guide groups, respectively) (p = 0.364). CONCLUSIONS: The new Precision guide can create tibial tunnel in an optimal and stable position during pullout repair of MMPRTs.

Semi-quantitative arthroscopic scoring system is related to clinical outcomes in patients after medial meniscus posterior root repair.

BACKGROUND: Different methods are available to assess the healing status of repaired root for medial meniscus posterior root tears (MMPRT) using second-look arthroscopy. However, few studies are comparing them or validating their usefulness. Therefore, it was hypothesized that the semi-quantitative arthroscopic score might correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. METHODS: Data of 61 patients who underwent MMPRT pullout repair and second-look arthroscopy were retrospectively evaluated. The semi-quantitative arthroscopic scoring system was divided into three evaluation criteria: scores from 0 to 10 points include the width of the bridging tissue, stability of the repaired root, and synovial coverage. The qualitative evaluation was classified into 4 status; complete healing, lax healing, scar tissue healing, and failed healing according to the stability and mobility of the repaired root. Multivariate linear regression analyses were used to identify predictors of 1-year postoperative clinical outcomes, including Knee Injury and Osteoarthritis Outcome, Lysholm, or International Knee Documentation Committee scores. Spearman's correlation analysis was used to analyze the correlation between second-look arthroscopic score/qualitative evaluation and 1-year postoperative clinical outcomes. In addition, the optimal cutoff point of semi-quantitative arthroscopic score was determined by receiver operating characteristic (ROC) curve. The Mann-Whitney U test was used to compare clinical outcomes between patients with semi-quantitative arthroscopic scores ≥8 and scores <8. RESULTS: All clinical scores significantly improved at 1 year postoperatively. A good correlation was observed between the semi-quantitative score and clinical scores, but none between qualitative evaluation and clinical scores. The optimal cutoff point of semi-quantitative second-look arthroscopic score was 8 points. Significantly, better clinical outcomes were observed in patients with semi-quantitative scores ≥8 points. CONCLUSIONS: All 1-year postoperative clinical scores were significantly improved. The semi-quantitative arthroscopic scores correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. LEVEL OF EVIDENCE: IV case series study.

Medial meniscus posterior root repairs: A comparison among three surgical techniques in short-term clinical outcomes and arthroscopic meniscal healing scores.

BACKGROUND: Medial meniscus (MM) posterior root repairs lead to favorable clinical outcomes in patients with MM posterior root tears (MMPRTs). However, there are few comparative studies in evaluating the superiority among several pullout repair techniques such as modified Mason-Allen suture, simple stitch, and concomitant posteromedial pullout repair. We hypothesized that an additional pullout suture at the MM posteromedial part would have clinical advantages in transtibial pullout repairs of the MMPRTs. The aim of this study was to compare the clinical usefulness among several types of pullout repair techniques in patients with MMPRTs. METHODS: Eighty-three patients who underwent arthroscopic pullout repairs of the MMPRTs were investigated. Patients were divided into three groups using different pullout repair techniques: a modified Mason-Allen suture using FasT-Fix all-inside meniscal repair device (F-MMA, n = 28), two simple stitches (TSS, n = 30), and TSS concomitant with posteromedial pullout repair using all-inside meniscal repair device (TSS-PM, n = 25). Postoperative clinical outcomes and semi-quantitative arthroscopic meniscal healing scores (0-10 points) were evaluated at second-look arthroscopies. RESULTS: No significant differences among the three groups were observed in patient demographics and preoperative clinical scores, except for preoperative Lysholm scores. At second-look arthroscopies, there were no significant differences among the three techniques in postoperative clinical outcomes and meniscal healing scores. CONCLUSIONS: This study demonstrated that the TSS-PM pullout repair technique did not show better scores in postoperative clinical outcomes and meniscal healings compared with the F-MMA and TSS techniques. Our results suggest that the concomitant posteromedial pullout suture may have no clinical advantage in the conventional pullout repairs for the patients with MMPRTs.

[Synchronous Double Primary Non-B, and Non-C Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma-A Case Report].

A 78-year-old man without hepatitis virus B or C underwent right hemi-hepatectomy and lymph node dissection for a tumor 5 cm in diameter located in the hepatic hilum of the posterior segment of the liver with portal vein thrombi extending into the main portal trunk and a tumor 1.5 cm in diameter in the peripheral side of segment 5 of the liver. Histopathologically, the former was diagnosed as intrahepatic cholangiocarcinoma and the latter as hepatocellular carcinoma(HCC). Five months after the surgery, intrahepatic and lymph node metastases were diagnosed based on computed tomography(CT); therefore, chemotherapy with S-1 for 3 months and gemcitabine and cisplatin(GC)for 5 months was administered, after which the metastatic lesions were not detected. Nineteen months after the surgery, partial resection of segment 2 of the liver was performed for a tumor 3 cm in diameter, which was diagnosed as HCC histopathologically. Two years after the second surgery, 2 recurrent nodules in the liver in segments 3 and 4 were detected on CT. Platinum-based hepatic arterial infusion chemotherapy(HAIC)and transcatheter arterial chemoembolization(TACE)were performed, and chemotherapy with GC was then administered for 7 months. For a new tumor detected in segment 1 in the liver, TACE was performed 17 months after initial HAIC. Seventy-four months after the initial surgery, 5 new nodules less than 1 cm in diameter were detected, and chemotherapy with sorafenib was administered for 5 months, after which the patient died of coronavirus disease 2019.

A posterior shiny-corner lesion of the tibia is observed in the early phase after medial meniscus posterior root tear.

BACKGROUNDS: Medial meniscus (MM) posterior root tear (PRT) results in joint overloading and degenerative changes in the knee, and pullout repair is recommended to prevent subsequent osteoarthritis. Diagnosing MMPRT is sometimes difficult, especially in the case of an incomplete tear. A posterior shiny-corner lesion (PSCL) is reported to be useful for diagnosis, although the association between MMPRT and PSCL is unknown. This study aimed to investigate the properties of PSCL, such as the location, volume, and duration from injury to the time of MRI (duration). We hypothesized that PSCL is observed in the early phase after the MMPRT onset. METHODS: T2-weighted fat-suppression magnetic resonance imaging (MRI) was obtained from 55 patients with MMPRT preoperatively. The prevalence of the PSCL; giraffe neck, cleft, and ghost signs; severe MM extrusion (> 3 mm); and the PSCL volume were evaluated. The PSCL lesion elliptical volume (mm3) was calculated by measuring the anteroposterior, transverse, and craniocaudal dimensions. RESULTS: PSCL was observed in 34 (62%) cases. The mean volume of the PSCL was 102.0 mm3. A significantly shorter duration was observed in the PSCL-positive group (5.6 weeks) than that in the PSCL-negative group (40.9 weeks, P < 0.01), although no significant correlation was observed between the PSCL volume and duration. The sensitivity for the MMPRT was 90.5% when the cut-off duration value was 3 weeks and 81.8% when the cut-off value was 8 weeks. CONCLUSIONS: MRI examination may detect PSCL if it is performed early following MMPRT onset. Detecting PSCL may be useful in diagnosing MMPRT with high sensitivity.

Transtibial pullout repair techniques using two simple stitches for medial meniscus posterior root tear can prevent the progression of medial meniscus extrusion and obtain successful outcomes.

PURPOSE: Transtibial pullout repairs using two simple stitches (TSS) and a combination of TSS with posteromedial pullout repair (TSS + PMP) using an all-inside meniscal repair device have been reported previously for the treatment of medial meniscus (MM) posterior root tears. This study aimed to investigate the postoperative clinical outcomes of these techniques including MM extrusion (MME). METHODS: Fifty-two patients who underwent transtibial pullout repair were investigated and divided into TSS (n = 27) and TSS + PMP (n = 25) groups. The clinical outcomes were assessed using the Lysholm knee score and Knee Injury and Osteoarthritis Outcome Score 1 year postoperatively and compared between two groups. MME was measured using magnetic resonance imaging at 1 year postoperatively and compared between two groups. RESULTS: A significant improvement in each clinical score was observed in both groups, and no significant difference was seen in clinical outcomes. Moreover, no significant difference in postoperative MME was observed in both groups (TSS and TSS + PMP: 3.5 mm and 3.8 mm, respectively). Though no significant progression of MME was observed in TSS group, a significant progression of it was observed in TSS + PMP group postoperatively. CONCLUSIONS: This study demonstrated that both techniques improved clinical outcomes in the short-term postoperative period. However, MME was progressed significantly in TSS + PMP group 1 year postoperatively, which indicated that PMP might not be a useful additional procedure for reducing the postoperative MME.