Clinical Outcomes of Modified Suture Buttons for Tibial Side Fixation in Anterior Cruciate Ligament Reconstruction: A Retrospective Comparative Study.

Introduction Restoring knee joint stability and resuming sports activities are important objectives of anterior cruciate ligament (ACL) reconstruction. The maintenance of anterior knee stability after ACL reconstruction is contingent on graft tension. Various devices and techniques have been used to achieve robust tibial graft tendon fixation, and their advantages and disadvantages are established. However, a gold standard has not been established. Therefore, we aimed to determine whether anterior knee joint stability and clinical outcomes of graft tendon fixation could be improved using a recently modified suture button (MSB) compared with using an adjustable suspensory fixator (ASF) at 1 year after double-bundle ACL reconstruction. Methods This study retrospectively analyzed postoperative data derived from 79 patients at a single center between January 2016 and December 2021. The patients were assigned to groups that underwent double-bundle ACL reconstruction with tibial fixation using an MSB (n = 30) that maintains tension while tying sutures, or an ASF (n = 49). We then compared complications, clinical outcomes and knee joint stability at 1 year postoperatively. Rates of postoperative infection, graft rupture, implant removal and residual anterior knee laxity (AKL) were compared between the groups using chi-square tests. Patient-reported outcome measures (PROM) based on Forgot Joint Score-12, Knee Injury and Osteoarthritis Outcome, and Lysholm Knee scores were compared using Mann-Whitney U tests. Results One patient in the MSB group developed postoperative infection. Rates of graft rupture and implant removal in the MSB and ASF groups were 3.3% and 4.1%, and 3.6% and 10.2%, respectively. None of the PROMs differed between the groups. The proportions of postoperative AKL were 3.6% and 14.9% in the MSB and ASF groups, respectively. A trend towards lower postoperative AKL in the MSB group did not reach statistical significance (p = 0.25). Conclusions The incidence of AKL at a year after ACL reconstruction using the MSB was 3%. Postoperative AKL and clinical outcomes were comparable between the MSB and ASF groups. A low AKL rate and positive postoperative outcomes indicated that MSB could be an option for tibial-side fixation in ACL reconstruction.

Incisura tangent method to determine the transsyndesmotic axis for syndesmotic fixation.

BACKGROUND: Clamping along the transsyndesmotic (TS) axis decreases the risk of malreduction when reducing syndesmotic diastasis. We aimed to measure the difference between the TS axis and the axis determined by the newly proposed fluoroscopic incisura tangent (IT) method. The measurements were compared to those between the TS axis and those based on the center-center (CC) and talar dome lateral (TL) methods. METHODS: We analyzed computed tomographic images of 43 normal ankles. The IT view was simulated using a digitally reconstructed radiograph, in which the anterior and posterior fibular incisura tubercles overlapped on the internally rotated anteroposterior view. The interaxis angle between the TS and the axes determined by the IT method was measured on the axial computed tomographic image corresponding to the radiographic image. The same procedure was repeated using the CC and TL methods. The measured values were compared between the three methods using a one-factor analysis of variance. Furthermore, the measurements of the anteverted and retroverted incisurae were compared for each fluoroscopic method. RESULTS: The mean interaxis angles between the TS were - 0.5 degrees, 6.3 degrees, and - 1.8 degrees for the IT, CC, and TL methods, respectively, with a significantly larger value for the CC method than for the IT and TL methods (P < .001). No significant difference was found in the interaxis angle in the anteverted (-0.1 degrees) and retroverted (-1.0 degrees) incisurae when using the IT method (P = .15). The angles in the retroverted incisurae were larger than those of the anteverted incisurae for the CC and TL methods. CONCLUSION: The fluoroscopic IT method accurately estimated the TS axis. The interaxis angles were consistent, regardless of the incisura anatomy. The fluoroscopic method can be used to clamp and fix the syndesmosis along the TS axis. LEVEL OF EVIDENCE: Ⅳ.

Validity of the Center-Center Method for the Syndesmotic Fixation Axis Compared to the Transsyndesmotic Axis.

BACKGROUND: Placement of clamp forceps along the transsyndesmotic (TS) axis reduces the risk of iatrogenic syndesmotic malreduction during ankle fracture surgery with tibiofibular diastasis. This study aimed to measure the difference between the TS axis and the axis determined by an intraoperative fluoroscopic technique using the center-center (CC) method. We also compared the values obtained when the CC method was performed at different heights from the tibial plafond. METHODS: We evaluated the computed tomography scans of 150 patients with normal syndesmosis. The CC method was simulated using digitally reconstructed radiographs. The TS and CC axes were projected onto an axial computed tomographic image linked to digitally reconstructed radiography. The angle between the two axes (interaxis angle) and the distance between the intersection of these axes and the medial tibial cortex (interaxis distance) were measured. The procedures were performed 0, 10, and 20 mm proximal to the tibial plafond, and the measurements were compared among the different heights using a 1-way repeated-measures analysis of variance. RESULTS: The TS axis was found to be externally rotated to the CC axis, with an interaxis angle of 8.5 degrees (SD, 6.8 degrees). The interaxis angle increased from 1.9 degrees at a height of 0 mm to a greater angle at higher heights (P < .001). The overall interaxis distance was 7.7 (SD, 6.3) mm, increasing from 2.0 mm at a height of 0 mm to a greater distance at higher heights (P < .001). CONCLUSION: The TS axis was externally rotated relative to the CC axis, and the difference between the 2 axes was greater when the CC method was performed on the higher heights from the tibial plafond. To clamp the syndesmosis along the TS axis, the CC method should be applied close to the ankle joint. LEVEL OF EVIDENCE: Level IV, case series.

Readability and quality of online patient resources regarding knee osteoarthritis and lumbar spinal stenosis in Japan.

BACKGROUND: This study aimed to quantify the readability and quality of online patient resources on knee osteoarthritis and lumbar spinal stenosis in Japan. METHODS: Three search engines (Google, Yahoo, and Bing) were searched for the terms knee osteoarthritis and lumbar spinal stenosis. The first 30 websites of each search were screened. Duplicate websites and those unrelated to the searched diseases were excluded. The remaining 125 websites (62 on knee osteoarthritis, 63 on lumbar spinal stenosis) were analyzed. The text readability was assessed using two web-based programs (Obi-3 and Readability Research Lab) and lexical density. Website quality was evaluated using the DISCERN score, Clear Communication Index, and Journal of American Medical Association benchmark criteria. RESULTS: Readability scores were high, indicating that the texts were difficult to understand. Only 24 (19%) and six (5%) websites were classified as average difficulty readability according to Obi-3 and Readability Research Lab, respectively. The overall quality of information was low, with only four (3%) being rated as having sufficient quality based on the Clear Communication Index and Journal of American Medical Association benchmark criteria. None of the websites satisfied the DISCERN quality criteria. CONCLUSIONS: Patient information on Japanese websites regarding knee osteoarthritis and lumbar spinal stenosis were difficult to understand. Moreover, the quality of the websites was insufficient. Orthopaedic surgeons should contribute to the creation of high-quality easy-to-read websites to facilitate patient-physician communication.

High-intensity focused ultrasound ablation assisted using color Doppler imaging for the treatment of hepatocellular carcinomas.

PURPOSE: We evaluated the usefulness of color Doppler flow imaging to compensate for the inadequate resolution of the ultrasound (US) monitoring during high-intensity focused ultrasound (HIFU) for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: US-guided HIFU ablation assisted using color Doppler flow imaging was performed in 11 patients with small HCC (<3 lesions, <3 cm in diameter). The HIFU system (Chongqing Haifu Tech) was used under US guidance. Color Doppler sonographic studies were performed using an HIFU 6150S US imaging unit system and a 2.7-MHz electronic convex probe. RESULTS: The color Doppler images were used because of the influence of multi-reflections and the emergence of hyperecho. In 1 of the 11 patients, multi-reflections were responsible for the poor visualization of the tumor. In 10 cases, the tumor was poorly visualized because of the emergence of a hyperecho. In these cases, the ability to identify the original tumor location on the monitor by referencing the color Doppler images of the portal vein and the hepatic vein was very useful. HIFU treatments were successfully performed in all 11 patients with the assistance of color Doppler imaging. CONCLUSION: Color Doppler imaging is useful for the treatment of HCC using HIFU, compensating for the occasionally poor visualization provided by B-mode conventional US imaging.

US-CT 3D dual imaging by mutual display of the same sections for depicting minor changes in hepatocellular carcinoma.

The purpose of this study was to evaluate the usefulness of ultrasound-computed tomography (US-CT) 3D dual imaging for the detection of small extranodular growths of hepatocellular carcinoma (HCC). The clinical and pathological profiles of 10 patients with single nodular type HCC with extranodular growth (extranodular growth) who underwent a hepatectomy were evaluated using two-dimensional (2D) ultrasonography (US), three-dimensional (3D) US, 3D computed tomography (CT) and 3D US-CT dual images. Raw 3D data was converted to DICOM (Digital Imaging and Communication in Medicine) data using Echo to CT (Toshiba Medical Systems Corp., Tokyo, Japan), and the 3D DICOM data was directly transferred to the image analysis system (ZioM900, ZIOSOFT Inc., Tokyo, Japan). By inputting the angle number (x, y, z) of the 3D CT volume data into the ZioM900, multiplanar reconstruction (MPR) images of the 3D CT data were displayed in a manner such that they resembled the conventional US images. Eleven extranodular growths were detected pathologically in 10 cases. 2D US was capable of depicting only 2 of the 11 extranodular growths. 3D CT was capable of depicting 4 of the 11 extranodular growths. On the other hand, 3D US was capable of depicting 10 of the 11 extranodular growths, and 3D US-CT dual images, which enable the dual analysis of the CT and US planes, revealed all 11 extranodular growths. In conclusion, US-CT 3D dual imaging may be useful for the detection of small extranodular growths.

Evaluation of pancreatic intraepithelial neoplasia and mucin expression in normal pancreata.

BACKGROUND/PURPOSE: It has been suggested that pancreatic ductal adenocarcinoma (PDAC) and pancreatic intraepithelial neoplasia (PanIN) are closely related, but several reports indicate PanIN lesions can also be found in normal pancreata (normal PanINs). We examined differences in mucin expression between normal PanIN lesions and PanINs in PDACs (PDAC PanINs). METHODS: We examined 54 autopsied normal pancreata and eight autopsied PDACs for PanIN lesions; graded the pancreata specimens as PanIN-1A (non-papillary hyperplasia), PanIN-1B (papillary hyperplasia), PanIN-2 (atypical hyperplasia) or PanIN-3 (carcinoma in situ); and tested the PanIN lesions for expression of MUC1 (pan-epithelial membrane-associated mucin) and MUC5AC (gastric secretory mucin) which were both previously detected in PDACs. RESULTS: In normal PanIN-1A, PanIN-1B and PanIN-2 specimens, MUC1 was expressed in 2.8, 10.5 and 9.1%, respectively, compared to 19.1, 27.6 and 13.0% in PDAC PanIN-1A, PanIN-1B and PanIN-2 specimens, respectively. MUC5AC was expressed in 41.0, 65.7 and 36.4% of normal PanIN-1A, PanIN-1B and PanIN-2 specimens, respectively, and in 80.9, 75.8 and 78.3% of PDAC PanIN-1A, PanIN-1B and PanIN-2 specimens, respectively. Differences in the frequency of MUC1 expression were significant between normal and PDAC PanIN-1A (p < 0.0001) and PanIN-1B (p < 0.05); and differences in the frequency of MUC5AC expression were significant between normal and PDAC PanIN-1A (p < 0.0001) and PanIN-2 (p < 0.05). CONCLUSIONS: Normal PanIN and PDAC PanIN lesions differed in the rates of MUC1 and MUC5AC expression.

Findings of multidetector row computed tomography of HCCs treated by HIFU ablation.

PURPOSE: We evaluated the efficacy of high-intensity focused ultrasound (HIFU) ablation for hepatocellular carcinoma (HCC), and a long-term study by follow-up multidetector-row computed tomography (CT) was conducted to evaluate the changes occurring in the treatment area following the HIFU ablation. MATERIALS AND METHODS: HIFU ablation was carried out in 14 patients with small HCCs (≤3 lesions, ≤3cm in diameter). The HIFU system (Chongqing Haifu Tech) was used under ultrasound guidance. The evaluations were performed by follow-up CT at 1 week, 1, 3, 6 and 12 months after the HIFU ablation. RESULTS: HIFU ablation was carried out successfully in 11 of the 14 patients. At 1 week after the HIFU, a peripheral rim enhancement was found in all cases (100%). This finding was persistent in 6 of the 11 cases (54.5%) at 1 month, and in 1 of the 11 (9%) cases at 3 months after HIFU ablation. In all cases, the rim enhancement disappeared by 6 or 12 months after the HIFU ablation. At the 12 months follow-up, a decrease in the diameter of the ablated lesions was found. The enhancement around the treated area was found to be persistent at the 12 months follow-up in the one case of recurrence of the treated site in which the safety margin was not sufficiently wide. During the follow-up period, there were 2 cases with residual of HCC tumors. We performed radiofrequency ablation (RFA) for these residual tumors after the HIFU ablation. CONCLUSION: To ascertain the cause of the peripheral enhancement on follow-up CT images after the HIFU ablation, in particular, to determine whether it might be caused by residual tumor or recurrence at the treated site, careful follow-up is important, especially in cases where the safety margin of the ablated area was not sufficiently wide.

Hyperecho in ultrasound images during high-intensity focused ultrasound ablation for hepatocellular carcinomas.

High-intensity focused ultrasound (HIFU) is a noninvasive method that can cause complete coagulation necrosis without requiring the insertion of any instruments. The hyperechoic grayscale change (hyperechoic region) is used as a sign that the treated lesion has been completely coagulated. The purpose of this study was to evaluate the first hyperechoic region during treatment using HIFU ablation according to various conditions, such as the sonication power, the depth of the tumor from the surface of the skin, and the shield rate. HIFU treatment was performed in 20 patients. The HIFU system (Chongqing Haifu Tech, Chongqing, China) was used under ultrasound guidance. Complete coagulation was achieved in 17 cases. Hyperechoic region were detected after HIFU ablation in 17 patients. The size of the hyperechoic region at a depth of >50 mm was significantly smaller than that at a depth of ≤50 mm. The number and power of the sonications for areas at a depth of >50 mm were significantly larger than those for areas at a depth of ≤50 mm. The number and power in cases with a shield rate of 31-60% were significantly larger than those in cases with a shield rate of 0-30%. When the shield rate was 0%, a hyperechoic region occurred, even when a maximum sonication power was not used. In all three cases with tumors located at a depth of greater than 70 mm and a shield rate of larger than 60%, a hyperechoic region was not seen. In conclusion, hyperechoic regions are easy to visualize in cases with tumors located at a depth of ≤50 mm or shield rates of 0-30%.

Treatment of small hepatocellular carcinomas with US-guided high-intensity focused ultrasound.

High-intensity focused ultrasound (HIFU) is a noninvasive method that can cause complete coagulation necrosis without requiring the insertion of any instruments. The purpose of this study was to evaluate the safety and efficacy of HIFU treatment for small liver cancers without performing transcatheter arterial chemoembolization (TACE) or rib resection. HIFU ablation was performed without rib resection or the aid of TACE or percutaneous ethanol injection (PEI) in 12 patients with hepatocelullar carcinoma. The HIFU system (Chongqing Haifu Tech, Chongqing, China) was used under ultrasound guidance. All 12 patients completed the treatment without experiencing any adverse events. Complete coagulation was achieved by applying the sonications from the intercostal space when the tumor was located in the right lobe. After treatment, serum alanine aminotransferase (ALT) and serum aspartate aminotransferase (AST) levels were significantly higher than the baseline values; these levels recovered within 1 week. C-reactive protein (CRP) levels increased 1 week after treatment but decreased within 1 month. An epidural anesthetic provided sufficient pain suppression during the procedure. Edema of the subcutaneous tissue was detected in five cases, but the edema disappeared within 1 month. None of the patients developed acute hepatic failure, liver abscess or renal dysfunction. In conclusion, HIFU is effective for the treatment of patients with small liver cancer.

Usefulness of US-CT 3D dual imaging for the planning and monitoring of hepatocellular carcinoma treatment using HIFU.

PURPOSE: We evaluated the safety and usefulness of high-intensity focused ultrasound (HIFU) assisted by ultrasound-computed tomography three-dimensional (US-CT 3D) dual imaging for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: HIFU ablation was performed in 13 patients with small HCC (≤3 lesions, ≤3 cm in diameter). The HIFU system (Chongqing Haifu Tech) was used under ultrasound guidance. By transferring the sagittal or axial plane of the 3D US and the CT volume data into the ZioM900, multiplanar reconstruction images were displayed in a manner resembling conventional monitor US to assist the HIFU treatment. RESULTS: Overall, 69% (9/13) of the patients in whom good visualization using B-mode sonography could not be obtained because of the influence of multi-reflections, rib shadows, and unclear tumor margins were successfully treated under the guidance of US-CT 3D dual imaging. In 5 of the 13 patients, multi-reflections were responsible for the poor visualization. In 2 cases, the tumor was poorly visualized because of a rib shadow. In one case, the margin of the tumor was too unclear to be detected using ultrasography. The 3D US images obtained as part of the US-CT 3D dual imaging had a high resolution and were useful for examining the area of HCC invasion and for determining the extent of the ablation area. The CT images, which are not influenced by bone shadows or multi-reflections, were useful for detecting the tumors and for visualizing the presence of the intestines in the sonication zone. HIFU treatments were successfully performed in all the patients with the assistance of US-CT 3D dual imaging. CONCLUSION: US-CT 3D dual imaging is useful for HIFU treatment for HCC, compensating for the occasionally poor visualization provided by US monitor.

Contrast-enhanced 3D ultrasonography in minute hepatocellular carcinoma.

PURPOSE: The study aimed to clarify whether contrast-enhanced (CE) three-dimensional (3D) ultrasonography (US) can depict characteristic hyperstain and washout patterns in minute nodules ≤10 mm of hepatocellular carcinoma (minute HCC), and whether it serves as a potent diagnostic modality. METHODS: CE 3D US was carried out to depict hyperstain and washout of a solitary nodule ≤10 mm in patients with liver cirrhosis. When both patterns were depicted with success, CE computed tomography (CT) and CE magnetic resonance imaging (MRI) were also carried out as part of a comparative study, and then a histological specimen was obtained by needle biopsy. The final diagnosis was based on the histopathological findings and a follow-up on the growth of nodules. RESULTS: All 12 minute nodules exhibiting hyperstain and washout showed evidence of HCC when examined by CE 3D US. The CE CT and CE MRI examinations could depict both of these patterns, characteristic of HCC, in most of the nodules but rather less successfully than CE 3D US. CONCLUSION: CE 3D US can depict hyperstain and washout patterns in minute HCC and serves as a potent modality for diagnosis.

Pancreatic intraepithelial neoplasms in the normal appearing pancreas: on their precise relationship with age.

BACKGROUND/AIMS: Pancreatic intraepithelial neoplasms (PanINs) have been considered as age-related lesions as well as precancerous lesions. However, we do not know their true relationship with age because the former studies did not deal with all age groups. Moreover, the numbers of the patients in each age group were not the same. This study was done to examine the "true relationship" between PanINs and age. METHODOLOGY: Ninety autopsied normal appearing pancreases from all age groups (from under 10s to 80s) were examined. Each group had 10 patients. The relationship between PanINs and age was studied. The sexual difference was also studied. RESULTS: Both the incidence of PanIN positive patients and the number of PanINs increased with age from under 10s to 40s, but they did not correlate with patient age after 40s. The number of PanIN positive patients in the under 10s, 40s and 80s were 2, 10 and 9, respectively. The number of PanINs in the under 10s, 40s and 80s were 11, 127 and 130, respectively. A sexual difference was not seen. CONCLUSIONS: The relationship between PanINs and age showed a biphasic correlation pattern before and after 40s. The presence of PanIN positive patients in their first year of age was also a new finding.