Clinical and radiological results of high tibial of osteotomy over the age of 65 are comparable to that of under 55 at minimum 2-year follow-up: a propensity score matched analysis.

PURPOSE: The results of medial open-wedge high tibial osteotomy (MOWHTO) according to age is inconclusive. This study aimed to compare the clinical outcomes and failure of MOWHTO in patients < 55 years and > 65 years. METHODS: Consecutive patients who underwent MOWHTO from July 2009 to August 2020 were retrospectively analyzed. 205 patients were considered for analysis. A 1-to-1 propensity score matched analysis to assess clinical outcomes scores including International Knee Documentation Committee (IKDC) subjective score and Lysholm score, radiologic outcomes, complication, and Total Knee Arthroplasty (TKA) conversion between patients > 65 years and patients < 55 years was performed. Radiologic outcomes included Hip-Knee-Ankle (HKA) angle, Weight Bearing Line ratio (WBLR), posterior tibial slope (PTS), and Insall-Salvati (IS) ratio before and after surgery. RESULTS: The follow-up period was 50.4 months in patients > 65 years and 55.3 months in patients < 55 years. There was no significant difference in the preoperative and postoperative HKA angle, WBLR, PTS, IS ratio, IKDC score and Lysholm score between the two groups. The arthroscopic evaluation of cartilage did not show any statistically significant differences between the two groups. Regarding Minimal clinically important differences (MCID), in the 26% of the older group exceeded MCID of IKDC score; 45% of the older group exceeded MCID of Lysholm score. In the younger group, 24% exceeded MCID of IKDC score and 35% exceeded MCID of Lysholm score. In older group, there were 7 (11.3%) cases of TKA conversion while no TKA conversion was recorded in the younger group. (P = 0.007) The average time to TKA conversion was 67 months. (42 months to 90 months) Kaplan-Meier analysis revealed that the survival rate was 95.2% at 4 years in the older group. CONCLUSION: Similar clinical results were obtained in patients over 65 years of age that were eligible for MOWHTO at minimum 2-year follow-up as in patients under 55 years of age. MOWHTO may be a viable option in older patients if proper indications are met. However, the risk of TKA conversion must be considered preoperatively and discussed with patients. STUDY DESIGN: Cohort study; Level of evidence, 3.

Quantitative Analysis and Molecular Docking Simulation of Flavonols from Eruca sativa Mill. and Their Effect on Skin Barrier Function.

Eruca sativa is a commonly used edible plant in Italian cuisine. E. sativa 70% ethanol extract (ES) was fractionated with five organic solvents, including n-hexane (EHex), chloroform (ECHCl3), ethyl acetate (EEA), n-butyl alcohol (EBuOH), and water (EDW). Ethyl acetate fraction (EEA) had the highest antioxidant activity, which was correlated with the total polyphenol and flavonoid content. ES and EEA acted as PPAR-α ligands by PPAR-α competitive binding assay. EEA significantly increased cornified envelope formation as a keratinocyte terminal differentiation marker in HaCaT cells. Further, it significantly reduced nitric oxide and pro-inflammatory cytokines (IL-6 and TNF-α) in lipopolysaccharide-stimulated RAW 264.7 cells. The main flavonol forms detected in high amounts from EEA are mono-and di-glycoside of each aglycone. The main flavonol form of EEA is the mono-glycoside of each aglycone detected, and the most abundant flavonol mono-glycoside is kaempferol 3-glucoside 7.4%, followed by quercetin-3-glucoside 2.3% and isorhamnetin 3-glucoside 1.4%. Flavonol mono-glycosides were shown to be a potent PPAR-α ligand using molecular docking simulation and showed the inhibition of nitric oxide. These results suggest that the flavonol composition of E. sativa is suitable for use in improving skin barrier function and inflammation in skin disorders, such as atopic dermatitis.

Reliability of the TT-TG Index Versus TT-TG Distance on MRI: Morphometric Analyses in Asian Children and Adolescents.

Background: The tibial tuberosity-trochlear groove (TT-TG) distance measured on magnetic resonance imaging (MRI) is commonly used to decide the treatment for patellar instability; however, the patient's joint size is not considered in this measurement. The TT-TG index has been proposed as a knee size-adjusted measurement for tibial tuberosity location. Purpose: To evaluate the reliability of the TT-TG index compared with the TT-TG distance by analyzing variations in measurement according to age and sex in a pediatric Asian population. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 698 knee MRI scans were collected in patients between 4 and 18 years of age who did not have any patellofemoral problems. Patient age, sex, height, and weight were recorded. The scans were divided into 5 groups according to patient age (4-6 years, 46 scans; 7-9 years, 56 scans; 10-12 years, 122 scans; 13-15 years, 185 scans; and 16-18 years, 289 scans); MRI scans were also divided by sex (497 male, 201 female). Three independent observers measured the TT-TG distance and TT-TG index on each scan, and age- and sex-based differences in the measurements were evaluated after adjusting for body mass index (BMI). The reliability of the measurements was calculated with the intraclass correlation coefficient (ICC). Results: Good to excellent inter- and intraobserver agreement was found for TT-TG distance (ICC, 0.74) and TT-TG index (ICC, 0.88). The TT-TG distance was significantly different among the groups and increased with age, while variations in the TT-TG index were minimal between age groups and sexes. This finding was also consistent after compensating for the effect of BMI. Conclusion: The TT-TG distance changed with age, while the TT-TG index was relatively constant. Therefore, the TT-TG index may be more reliable and effective for diagnosing and planning treatment, especially in children and adolescents.

Lipoma with osteocartilaginous metaplasia in infrapatellar fat pad: A case report and review of literature.

RATIONALE: Lipomas are tumors composed of mature adipocytes, originating from the mesoderm, and are the most common soft tissue tumor. According to the World Health Organization classification of human soft tissue and bone tumors, there are 14 types of benign tumors, including mature adipose tissue. Osteolipoma is known as the rarest subtype of lipoma. PATIENT CONCERNS: A 63-year-old female presented to our hospital for the evaluation and treatment of a palpable mass with pain in the right knee. DIAGNOSIS: The diagnosis was confirmed as lipoma with osteocartilaginous metaplasia. INTERVENTIONS: Surgical removal of the tumor was performed. OUTCOMES: The main symptoms improved immediately after the surgery and recovered without any complications or recurrence until 2 years after surgery. LESSONS: Lipoma with osteochondral degeneration is a rare variant of lipoma and it is important to differentiate it from other malignant tumors. Pathological confirmation should be performed after marginal resection of the mass.

Clinical Results after Design Modification of Lospa Total Knee Arthroplasty System: Comparison between Posterior-Stabilized (PS) and PS Plus Types.

Background: Lospa posterior-stabilized (PS) Plus type is a modified version of Lospa PS, in which the polyethylene insert shape is modified to reinforce stability and prevent patella-post impingement compared to Lospa PS. However, studies comparing the clinical and radiographic results of the two designs have not been reported yet. This study aimed to compare the clinical results of total knee arthroplasty (TKA) using the existing PS type and the modified Lospa PS Plus type. Methods: A retrospective study was performed on 558 knees of 342 patients who underwent TKA using the Lospa PS or PS Plus types and were followed up for at least 2 years. Cases were divided into two groups according to the implant used: 212 cases in the PS group and 346 cases in the PS Plus group. For clinical outcome assessment, knee range of motion (ROM), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Knee Society Score (KSS) were recorded before surgery and at the 2-year follow-up. Radiographic outcomes were evaluated according to the American Knee Society method. The incidence of postoperative complications and survival rates were compared between the two groups. Results: Both groups showed significant clinical improvement after surgery. The average KSS significantly improved from 53.4 points in the PS group and 52.3 points in the PS Plus group preoperatively to 91.3 points and 93.2 points after surgery, respectively (p < 0.001). The average WOMAC score improved from 50.4 points in the PS group and 52.3 points in the PS Plus group before surgery to 15.6 points and 14.8 points after surgery, respectively (p < 0.001). There was no significant difference between the two groups in ROM, the alignment of the lower limbs, and the implant position after surgery. The complication rates were also similar between the groups (p = 0.167). Conclusions: The Lospa PS Plus model is a modified design that improves the post structure from the previous PS type. Compared to the PS type, the PS Plus type showed similar statistical results at 2-year follow-up and good clinical results. The short-term average survival rate was over 98%, showing promising results.

Magnetic Resonance Imaging of Patellofemoral Morphometry Reveals Age and Gender Variations in the Knees of Children and Adolescents.

BACKGROUND: The morphology and alignment of the patellofemoral joint are crucial risk factors for patellar instability, and the incidence of acute primary patellar dislocation is the highest in women in their second decade of life. The purpose of the study was to analyze age and gender variations of the patellofemoral joint using magnetic resonance imaging (MRI). METHODS: A total of 852 patients aged between 4 and 18 years with a history of knee MRI examinations were screened for eligibility and 663 patients (470 males, 193 females) were included. Patients were divided into groups according to age and sex. The age group was divided into five groups (Group 1, 4-6 years; Group 2, 7-9 years; Group 3, 10-12 years; Group 4, 13-15 years; and Group 5, 16-18 years). Three orthopaedic surgeons measured MRI parameters reflecting the patellofemoral morphology (sulcus angle, lateral trochlear inclination, trochlear facet symmetry, and femoral depth) and alignment (tibial tuberosity-trochlear groove distance, percent sulcus location, and percent tibia tuberosity location). RESULTS: Parameters including tibial tuberosity-trochlear groove distance, sulcus angle, percent tibial tuberosity location, trochlear facet symmetry, and femoral depth showed significant differences between the age groups (p < 0.05). The sulcus angle decreased fin Group 2, and the femoral depth showed an increasing trend with aging in male patients. However, the sulcus angle in females decreased first and then increased in Group 3 as the inflection point. The femoral depth showed an opposite pattern. CONCLUSIONS: Patellofemoral morphometry showed age and gender variation. Notably, the sulcus angle and femoral depth were significantly different between males and females and changed according to the development. These findings may reflect the sex difference and peak incidence of the patellar instability risk. Understanding the morphological changes and differences of the patellofemoral joint may facilitate the diagnosis of patellofemoral pathologies.

Incidence and Factors Affecting the Occurrence of Lateral Hinge Fracture After Medial Opening-Wedge High Tibial Osteotomy.

BACKGROUND: Few clinical studies have reported the predictors of lateral hinge fracture (LHF) after medial opening-wedge high tibial osteotomy (MOWHTO). PURPOSE/HYPOTHESIS: The purpose was to compare the incidence of LHF on plain radiographs versus computed tomography (CT) scans and to investigate the factors related to the development of LHF after MOWHTO. We hypothesized that (1) a higher LHF detection rate would be seen on CT scans versus plain radiographs and (2) LHF incidence would be related to opening gap width and hinge position. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 97 MOWHTO cases were included. The presence and types of LHF were determined from plain radiographs and CT scans. Radiographic parameters were measured on plain radiographs taken 6 weeks postoperatively. Anterior and posterior opening gap widths, coronal and sagittal osteotomy slopes, and fibular height were calculated from CT scans. The wedge-hinge relationship and the zone of hinge position were assessed, and the patient and radiographic factors related to LHF occurrence were evaluated. RESULTS: Seventeen LHF cases (20.5%) were detected on plain radiographs, while significantly more (37 cases; 44.6%) were found on CT scans (P = .001). Based on Takeuchi classification, 28 LHF cases were considered type 1, 7 were type 2, and 2 were type 3. Logistic regression analysis revealed that opening gap width (odds ratio, 1.615; 95% confidence interval, 1.232-2.118; P = .001) and posterior opening gap width (odds ratio, 3.731; 95% confidence interval, 1.642-4.351; P = .008,) differed significantly between patients with versus without LHF. Other patient and radiographic factors were not significantly related to LHF occurrence. Receiver operating characteristic curve analysis identified the opening gap width cutoff values for LHF as 11.0 mm (area under the curve, 0.81; sensitivity, 78.4%; specificity, 73.9%). CONCLUSION: The incidence of LHF after MOWHTO can be underestimated on plain radiographs compared with CT scans. Only large opening gap width, especially posterior gap width, was found to have a statistically significant relationship with occurrence of LHF. Therefore, special caution for possible LHF may be needed if a large correction is planned.

Application of Three-Dimensional Computed Tomography Improved the Interrater Reliability of the AO/OTA Classification Decision in a Patellar Fracture.

We investigated whether interrater reliabilities of the AO/OTA classification of patellar fracture change with the imaging modalities applied, including plain radiography and two- and three-dimensional (2-D and 3-D) computed tomography (CT). Seven orthopedic specialists and four orthopedic residents completed a survey of 50 patellar fractures to classify the fractures according to the AO/OTA classification for patellar fractures. Initially, the survey was conducted using plain radiography only, then with 2-D CT introduced three weeks later and 3-D CT introduced six weeks later. Fleiss' Kappa coefficients were calculated to determine interrater reliability. The overall interrater reliability of the AO/OTA classifications was 0.40 (95% CI, 0.38-0.42) with plain radiography only and 0.43 (95% CI, 0.41-0.45) with the addition of 2-D CT. With the addition of 3-D CT, the reliability was significantly improved to 0.54 (95% CI, 0.52-0.56). In specialists, interrater reliability of the classifications was moderate with all three imaging modalities. With the use of 3-D CT, interrater reliability of the classification was 0.53 (95% CI, 0.50-0.56), which was significantly higher than that with the use of 2-D CT (κ = 0.45; 95% CI, 0.42-0.48). In residents, interrater reliability of the classification was 0.30 (95% CI, 0.24-0.36) with plain radiography. The reliability improved to 0.49 (95% CI, 0.43-0.56) with the addition of 2-D CT, which was significantly higher than that with plain radiography only. The use of 3-D CT imaging improved interrater reliability of the classification. Therefore, surgeons, especially residents, may benefit from using 3-D CT imaging for classifying and planning the treatment of patellar fractures.

Factors related to the early outcome of medial open wedge high tibial osteotomy: coronal limb alignment affects more than cartilage degeneration state.

INTRODUCTION: This study aimed to identify possible factors influencing the early outcome after medial open wedge high tibial osteotomy (MOWHTO). MATERIALS AND METHODS: A total of 87 MOWHTO cases with a minimum of 2-year follow-up and second-look arthroscopic results available were enrolled. The cartilage degeneration state was evaluated by the International Cartilage Repair Society (ICRS) grading. Radiographic parameters including the hip-knee-ankle axis (HKA), medial proximal tibia angle (MPTA), posterior tibial slope, patellar height, mechanical lateral distal femoral angle (LDFA), joint line convergence angle (JLCA), joint line obliquity (JLO), and weight-bearing line ratio (WBLR) were measured. The pre-operative arthritic change was evaluated by Kellgren-Lawrence (KL) classification. According to the post-operative HKA, knees were divided into three (Under/Optimal/Over-correction) subgroups. Subjective International Knee Documentation Committee (IKDC) scores were evaluated and factors related to post-operative IKDC scores were analyzed. RESULTS: The pre-operative HKA (P = 0.002), post-operative HKA (P = 0.007), pre-operative MPTA (P = 0.011), and pre-operative WBLR (P = 0.031) were significantly related to the post-operative IKDC score. Cartilage degeneration states evaluated from first and second-look arthroscopy were not associated with post-operative IKDC score. Subgroup analysis revealed that the Under-correction group had significantly lower post-operative IKDC scores compared to the Optimal and Over-correction group (P = 0.012 and P = 0.030, respectively). CONCLUSION: Our result suggests that a sub-optimal correction of coronal limb alignment negatively affects the early outcome of MOWHTO. On the other hand, the effect of the degree of cartilage degeneration was not significant.

Patellar fractures in elderly patients: a multicenter computed tomography-based analysis.

INTRODUCTION: This study aimed to demonstrate the characteristics of patellar fractures and evaluate clinical outcomes in elderly patients. PATIENTS AND METHODS: Medical records of patients aged ≥ 60 years who presented with patellar fractures were retrospectively reviewed from an institutionally approved multicenter (five institutions) orthopedic database. Patient characteristics and fracture patterns were identified, and the clinical outcomes were investigated. We compared differences according to the injury mechanism (low- vs. high-energy). RESULTS: A total of 202 patients [mean age, 69.4 years (range, 60-88 years); male, 89, female, 113] were included in this study. The mean follow-up period was 14.8 months (range 6-58 months), and 75% of the fractures were from low-energy injuries. According to the AO /OTA classification, the most common type was type C (136 cases, 67.3%; 33 cases, C1; 23, C2; and 80, C3), followed by type A (39 cases), type B (26 cases), and unclassified (1 case). The unclassified case was an intra-articular marginal impaction without cortical breakage. Computed tomography (CT) revealed that of the cases, 66.8% had an inferior pole involvement; 80.7%, a comminuted fragment; and 10.4%, an impacted fracture. A total of 166 fractures (82.2%) were treated surgically. The mean union time and range of motion were 13.1 weeks and 123.8° (range 30-150°), respectively. The Lysholm score was 82.1 ± 12.0, with 65.7% of the cases having excellent or good function. The complication rate was 12.4% (24 cases), including ten, four, two, and five cases of infection, fixation failure, nonunion, malunion, and pin migration, respectively. The reoperation rate was 26.4%. CONCLUSION: Patellar fractures in the elderly were mostly from low-energy injuries, and types C3 and A1 were the most common. CT images demonstrated high rates of an inferior pole involvement and comminution. The complication and reoperation rates were relatively high.

[The effect of whole body vibration by sonic waves on mood, the autonomic nervous system, and brain function in elderly].

AIM: The purpose of this study was to clarify the effect of sonic wave vibration (SWV) on mood, the autonomic-nervous system, brain function and cognitive function in elderly people. METHODS: We randomly assigned 24 late-stage elderly people (M 88.0±5.0 yrs) into a SWV group and a control group. The SWV group conducted 10 minutes of SWV per day, 5 days a week for 8 consecutive weeks. For evaluation purposes, we analyzed the moods with TDMS, heart rate variability (HRV), resting energy expenditure (REE), and brain activation during the Stroop test using near-infrared spectroscopy (NIRS). RESULTS: The stability level and pleasure level of mood increased significantly immediately after SWV. Simultaneously, the levels of the parasympathetic nervous system index of HRV significantly increased while the levels of the sympathetic nervous system index significantly decreased. REE also significantly increased. These results suggest that SWV has a relaxation effect as well as increasing the energy expenditure for elderly people. After intervention, Stroop B's execution time significantly decreased suggesting an improvement in the processing speed. The NIRS revealed that SWV may therefore activate the frontal lobe function. CONCLUSIONS: These results suggest that SWV may have a positive effect on mood, the autonomic nervous system, cognitive function and brain functions, and thus such treatment may be useful for elderly people.

Effectiveness of iron supplementation in the perioperative management of total knee arthroplasty: a systematic review.

INTRODUCTION/PURPOSE: The purpose of this systematic review was to evaluate the effect of iron supplementation during total knee arthroplasty (TKA): (1) Is the iron supplementation necessary during TKA? (2) When is the optimal timing of iron supplementation? (3) Which is better, between orally and intravenously administered iron supplementation? And (4) What is the optimal dose of iron supplementation? MATERIALS AND METHODS: A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data about study design, total number of cases enrolled, iron administration method, timing, and dose were extracted. Change in hemoglobin and transfusion rates were extracted to evaluate the effectiveness of iron supplementation. RESULTS: Eleven studies were included in the final analysis. Most of studies reported that hemoglobin change between iron and control group did not show any difference. Only one study reported that iron supplementation could reduce the decrease in hemoglobin. However, transfusion rate showed a decrease in the iron supplementation group compared with the control group. There was no clear consensus on the optimum timing and dose of iron supplementation and intravenously administered iron was more effective than orally administered iron, especially in anemic patients. CONCLUSION: Iron supplementation is not clear as a way to raise hemoglobin levels after TKA, but an effective treatment for lowering transfusion rate, especially in patients with anemia. We could not determine the optimal timing and dose of the iron. Intravenously administered iron was similar to, or better than, orally administered iron for improving hemoglobin levels and transfusion rate.

Effect of preoperative vitamin D deficiency on functional outcomes after high tibial osteotomy: a retrospective case control study.

BACKGROUND: This study aimed to evaluate the effects of vitamin D deficiency on the functional outcomes following a high tibial osteotomy (HTO). METHODS: Clinical data of 209 patients (327 knees) who underwent HTO done by a single surgeon were retrospectively registered for the study. Ninety-four patients (94 knees) who underwent HTO were analyzed. Patients were assigned into two groups according to their preoperative serum vitamin D levels (D- Deficiency and S- Sufficient); < 20 ng/ml (group D, N = 48) and ≥ 20 ng/ml (group S, N = 46) respectively. A subjective form of International Knee Documentation Committee (IKDC) score, mechanical alignment, and cartilage status before and 1 year following HTO were studied between groups. RESULTS: The mean postoperative IKDC score was significantly higher in group S (p = 0.012). Moreover, the difference of IKDC score between pre- and post- HTO was also significantly higher in group S (p = 0.006). Preoperative vitamin D level and IKDC score did not show a significant correlation. Serum vitamin D level was found to be moderately correlated to postoperative IKDC score (r = 0.342 and, p = 0.001). A moderately positive correlation between serum vitamin D level and improvement of IKDC score following osteotomy was appreciated (r = 0.381 and, p < 0.001). CONCLUSION: Patients with vitamin D deficiency had less satisfactory functional outcomes within 1 year from HTO surgery. Our results suggest that preoperative serum vitamin D level is one of the factors affecting the outcome after HTO. We recommended analyzing serum vitamin D levels as part of the routine workup in patients undergoing HTO.

Changes in patellar fracture characteristics: A multicenter retrospective analysis of 1596 patellar fracture cases between 2003 and 2017.

PURPOSE: This study aimed to investigate the characteristics of patellar fracture and the changes in these characteristics over time in Korea. METHODS: A total of 1596 patients with patellar fractures who visited 5 university hospitals from 2003 to 2017 were included in the analysis. The demographic characteristics of the patients, including age, sex, body mass index, and fracture characteristics, including the fracture classification, injury mechanism, fixation method, and postoperative complication rate, were analyzed through a review of the medical records and plain radiographs. RESULTS: There were 988 (61.9%) male patients and 608 (38.1%) female patients. The mean age was 51.3 (range, 3-97) years for the study group, 47.6 (range, 8-94) years for male patients, and 57.3 (range, 3-97) years for female patients. Increasing trends in the proportion of patients aged ≥60 years and in the proportion of female patients were observed during the study period (p = 0.002 and p < 0.001, respectively). The fixation method also changed significantly during the study period, with decrease of the tension band wiring and increase of the combined method (p < 0.001). The incidence of high-energy injuries and more complex types of fracture was higher in male patients than in female patients (p < 0.001 and p < 0.001, respectively). Patients aged ≥60 years with patellar fractures showed a higher percentage of low-energy injuries and higher postoperative complication rates than younger patients (p < 0.001 and p = 0.002, respectively). CONCLUSIONS: Patellar fractures in the female and elderly populations are increasing. Moreover, elderly patients with patellar fractures had a higher postoperative complication rate and also a higher percentage of low-energy injury than younger patients. Therefore, patellar fractures in the elderly population should be considered fragility fractures, and further studies are warranted to suggest a specific treatment plan for fragility patellar fractures.

Impact of two- and three-dimensional computed tomography use on intraobserver and interobserver reliabilities of pilon fracture classification and treatment recommendation.

BACKGROUND: Two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) have been increasingly used in various intra-articular fractures including pilon fracture. However, no study has investigated intraobserver and interobserver reliabilities of pilon fracture classification using 3D CT images. HYPOTHESIS: (1) Intraobserver and interobserver agreements of fracture classifications and treatment recommendations will improve by using 2D CT images compared to using plain radiographs only; (2) agreements will improve by adding 3D CT images compared to adding 2D CT images; and (3) agreements of orthopedic residents rather than specialists will be influenced more by imaging modality. MATERIALS AND METHODS: Ten orthopedic specialists and 10 residents completed a survey to classify the fractures according to the Rüedi-Allgöwer and AO/OTA classifications and to select treatment options using 25 pilon fracture images. The survey was conducted using plain radiographs, with 2D and 3D CT images introduced 3 and 6weeks later, respectively. Kappa coefficients were calculated to determine reliabilities. RESULTS: Intraobserver reliabilities for fracture classifications in specialists significantly improved by using 2D images compared to using plain radiographs only. Addition of 3D CT did not significantly improve intraobserver reliabilities compared to those with 2D CT. Use of 2D CT images significantly improved overall interobserver agreement of both classifications, with the improvement being greater for residents. Use of 3D CT images did not improve the interobserver reliability of both classifications. Overall interobserver reliabilities for treatment recommendations did not significantly differ according to the imaging modality. However, interobserver agreement among residents significantly improved from slight agreement using radiographs only to fair agreement using 2D CT images. DISCUSSION: Intraobserver and interobserver reliabilities of pilon fracture classification and treatment recommendations did not improve between using 3D and 2D CT. Using 2D CT images improved the intraobserver and interobserver reliabilities of the fracture classifications in specialists and the interobserver reliabilities of the fracture classifications and the treatment recommendations in residents. LEVEL OF EVIDENCE: IV, case control study.

A Switch of an Idea: Simultaneous High Tibial Osteotomy and Lateral Meniscal Allograft Transplantation.

High tibial osteotomy (HTO) has been regarded as an effective treatment modality for isolated medial compartment knee osteoarthritis (OA) with varus deformity. However, management for relatively young active patients with both varus-aligned medial compartment knee OA and symptomatic irreparable lateral meniscus tear can be challenging. In this situation, correction of varus alignment by HTO and restoring the function of the lateral meniscus by meniscal allograft transplantation (MAT) can be a possible solution. We present the clinical result and technical considerations for a case of varus-aligned medial compartment OA combined with lateral meniscus tear treated by simultaneously performed medial open wedge HTO and lateral MAT.

A Case of Herpes Zoster Presented with Lower Limb Paresis.

Herpes zoster is a common viral disorder that typically shows characteristic painful skin lesion. Motor neuropathy rarely complicates herpes zoster infection, and it may be overlooked without suspicion. Here, we report a case of a herpes zoster patient who presented with sciatica and paresis, but without the typical skin lesion. The patient was initially misdiagnosed as having other disorders including trauma or spine lesion. Electrodiagnostic study and magnetic resonance imaging (MRI) helped to make an accurate diagnosis and localize the motor nerve involvement of herpes zoster.

Intra-articular Large Ossicle Associated to Osgood-Schlatter Disease.

Osgood-Schlatter disease (OSD) is known as a self-limiting condition but surgical excision of the ossicles may be required in adults resistant to conservative treatments. The ossicle associated to OSD is generally small and located outside the joint near the tibial tubercle; however, large or intra-articular ossicle has been reported rarely. Here, we report an unusual case of OSD with a separated, large-sized ossicle that protruded into the knee joint and treated by arthroscopy-assisted excision of the ossicle.

The effects of graft shrinkage and extrusion on early clinical outcomes after meniscal allograft transplantation.

BACKGROUND: Graft shrinkage or radial extrusion is a reported complication after meniscus allograft transplantation (MAT). Whether shrinkage or extrusion progress after surgery and whether they are associated with the clinical outcome of MAT remain debatable. In this study, graft shrinkage and extrusion were measured in the coronal and sagittal planes using serial postoperative magnetic resonance imaging (MRI). The purpose of this study was to evaluate if graft shrinkage or extrusion is correlated to the clinical outcome of MAT. METHODS: MRIs acquired at 3 and 12 months postoperatively in 30 patients (21 men and 9 women) who underwent MAT (6 medial and 24 lateral menisci) from 2010 to 2016 were analyzed. Two orthopedic surgeons and two musculoskeletal specialized radiologists each performed the MRI measurements. Allograft shrinkage was measured by the width and thickness of the graft at the coronal and sagittal planes. To determine the graft extrusion, distances between the proximal tibia cartilage margin and the extruded graft margin were measured in both coronal (either lateral or medial) and sagittal (both anterior and posterior) plane and relative percentage of extrusion (RPE) were calculated. Subjective International Knee Documentation Committee (IKDC) scores at 12 months were evaluated as a clinical outcome measurement, and correlations between shrinkage or extrusion of allograft and IKDC score were analyzed. RESULTS: In the coronal plane, radial RPE averaged 43.6% at postoperative 3 months, but there was no significant progression of extrusion at 12 months (average 42.0%) (P = 0.728). In the sagittal plane, there were no significant progressions of anterior and posterior RPE (P = 0.487 and 0.166, respectively) between postoperative 3 and 12 months. Shrinkage was calculated by multiplying the width and height of the three sections and summing these values. There was no significant progression of shrinkage between postoperative 3 and 12 months (P = 0.150). RPE in the radial (R = 0.147, P = 0.525), anterior (R = 0.249, P = 0.264), and posterior (R = 0.230, P = 0.315) directions and shrinkage (R = 0.176, P = 0.435) were not correlated to IKDC score at postoperative 12 months. CONCLUSIONS: In the coronal and sagittal planes, extrusion and shrinkage did not progress from 3 months to 1 year. Extrusion and shrinkage had no correlation with early clinical outcomes. This finding suggests that graft extrusion or shrinkage may be not a great concern especially in early postoperative period of MAT, and multiple, serial MRI may be not necessary.

Meniscal Tissue Engineering Using Aligned Collagen Fibrous Scaffolds: Comparison of Different Human Cell Sources.

Hydrogel and electrospun scaffold materials support cell attachment and neotissue development and can be tuned to structurally and mechanically resemble native extracellular matrix by altering either electrospun fiber or hydrogel properties. In this study, we examined meniscus tissue generation from different human cell sources including meniscus cells derived from vascular and avascular regions, human bone marrow-derived mesenchymal stem cells, synovial cells, and cells from the infrapatellar fat pad (IPFP). All cells were seeded onto aligned electrospun collagen type I scaffolds and were optionally encapsulated in a tricomponent hydrogel. Single or multilayered constructs were generated and cultivated in defined medium with selected growth factors for 2 weeks. Cell viability, cell morphology, and gene-expression profiles were monitored using confocal microscopy, scanning electron microscopy, and quantitative polymerase chain reaction (qPCR), respectively. Multilayered constructs were examined with histology, immunohistochemistry, qPCR, and for tensile mechanical properties. For all cell types, TGFß1 and TGFß3 treatment increased COL1A1, COMP, Tenascin C (TNC), and Scleraxis (SCX) gene expression and deposition of collagen type I protein. IPFP cells generated meniscus-like tissues with higher meniscogenic gene expression, mechanical properties, and better cell distribution compared to other cell types studied. We show proof of concept that electrospun collagen scaffolds support neotissue formation and IPFP cells have potential for use in cell-based meniscus regeneration strategies.