Conditional deletion of IκBζ in hematopoietic cells promotes functional recovery after spinal cord injury in mice.

BACKGROUND: Transcription factor protein IκBζ (encoded by the Nfkbiz gene) regulates nuclear factor-κB (NF-κB) and is involved in the pathophysiology of various inflammatory diseases. However, the role of IκBζ in secondary damage following spinal cord injury (SCI) remains to be determined. Here, we investigated the effect of IκBζ expressed in hematopoietic cells on the progression of secondary damage and functional recovery after SCI. METHODS: We used conditional IκBζ-knockout mice (Mx1-Cre;Nfkbizfl/f) to examine the role of IκBζ in hematopoietic cells after SCI. Contusion SCI was induced using a force of 60 kdyn. The recovery of locomotor performance was evaluated using the nine-point Basso Mouse Scale (BMS) until 42 days post-injury. Expression patterns of inflammatory cytokines and chemokines were examined by quantitative real-time PCR or proteome array analysis. Bone marrow transplantation (BMT) was performed to eliminate the effect of IκBζ deletion in non-hematopoietic cells. RESULTS: Mx1-Cre;Nfkbizfl/fl mice had significantly improved locomotor function compared with wild-type (WT) mice. The mRNA expression of Nfkbiz in WT mice peaked at 12 h after SCI and then decreased slowly in both the spinal cord and white blood cells. In situ hybridization showed that Nfkbiz mRNA was localized in cell nuclei, including macrophage-like cells, in the injured spinal cord of WT mice at 1 day after SCI. Compared with WT mice, Mx1-Cre;Nfkbizfl/fl mice had significantly increased mRNA expressions of interleukin (Il)-4 and Il-10 in the injured spinal cord. In addition, Mx1-Cre;Nfkbizfl/fl mice had significantly higher protein levels of granulocyte-macrophage colony-stimulating factor and C-C motif chemokine 11 compared with WT mice. BMT from Mx1-Cre;Nfkbizfl/fl mice into WT mice improved functional recovery after SCI compared with control mice (WT cells into WT mice). CONCLUSIONS: IκBζ deletion in hematopoietic cells improved functional recovery after SCI, possibly by shifting the inflammatory balance towards anti-inflammatory and pro-regenerative directions.

Biomechanical Comparison of Short-, Mid-, and Long-Length Proximal Femoral Nails for Femoral Intertrochanteric Fracture (AO/OTA 31A3.3) Fixation.

Introduction: In surgeries for unstable AO/OTA 31A3.3 fractures, surgeons use various lengths of intramedullary nails (IMNs). However, there is insufficient evidence regarding the appropriate nail length for these fractures. This study compared the biomechanical properties of IMNs of different lengths for AO/OTA 31A3.3 fractures. Methods: 30 synthetic femora of AO/OTA 31A3.3 fracture model were randomly assigned to the following three groups: short- (170 mm), mid- (235 mm), and long-length (300 mm) nail groups, and were performed fixation surgery. The translation patterns of the constructs were examined by cyclic testing and compared among three groups. Additionally, changes in the neck-shaft and shaft-nail angles after cyclic testing were evaluated using radiological images. Results: The translation patterns during cyclic loading did not differ among the groups. Conversely, one-way analysis of variance (ANOVA) revealed a significant difference in the neck-shaft angle change (5.8° ± 1.8°, 2.8° ± 1.3°, and 1.9° ± .9° in the short-, mid-, and long-length groups, respectively; P < .001), and post-hoc analysis revealed that the change was greater in the short-length group than in the mid- and long-length groups (P < .001 and P < .001, respectively). Furthermore, one-way ANOVA revealed a significant difference in the shaft-nail angle change (3.1° ± 2.1°, 1.4° ± 1.4°, and .1° ± .6° in the short-, mid-, and long-length groups, respectively; P < .001), and post-hoc analysis revealed that the change was greater in the short-length group than in the mid- and long-length groups (P = .044 and P < .001, respectively). Conclusions: Short-length nails were associated with relevant changes in the neck-shaft and shaft-nail angles in our AO/OTA 31A3.3 fracture model. Thus, the selection of mid- or long-length nails instead of short-length nails might be better in IMN surgery for these fractures to prevent postoperative varus deformity.

Flexion contracture can cause component mismatch in the Prophecy® preoperative patient-specific instrumentation for Evolution® medial-pivot knee system.

INTRODUCTION: Patient-specific instrumentation (PSI) systems are used to conduct total knee arthroplasty. PSI reduces operative time, is less invasive and easier to use, and minimizes the risk of errors by providing precise measurements and reducing operating room turnover time. However, a study on the accuracy of Prophecy Evolution PSI (Microport Inc., Arlington, TN, USA) reported that 94% were below the error margin of 1.5 mm and 90% had error margins of 1 mm. This study aimed to evaluate the accuracy of the Prophecy Evolution PSI system in terms of the thickness of "total" bony resection required to achieve adequate extension/flexion gaps and the component match ratio between preoperative planning and actual component size inserted. METHODS: Comparisons were made between the sizes of femoral and tibial components planned with PSI and those inserted. The primary outcome was the average preoperative range of motion with and without matched femoral/tibial components. The study further analyzed the proportions of cases in which both the femoral and tibial components matched, neither matched, and only one of the femoral or tibial components matched. RESULTS: The ratio of the same sizes between the PSI planning and those inserted was 50.8% (33 patients) for both the femoral and tibial components. For the femoral component alone, the ratio was 84.6% (55 patients), and for the tibial component, it was 58.4% (38 patients). A receiver-operating characteristic curve analysis indicated that flexion contracture greater than 20° was a significant prognostic factor for the PSI component match group versus the mismatch group. DISCUSSION: Flexion contracture may cause PSI mismatch. Notably, flexion contracture greater than 20° was a significant risk factor for the PSI component match group versus the mismatch group. During preoperative planning for a patient with flexion contracture, surgeons should prepare for the possibility of inserting an undersized tibial component.

Comparison of postoperative clinical outcome in medial-pivotal and gradually reducing radius design cruciate-retaining total knee arthroplasty-A multicenter analysis of propensity-matched cohorts.

Purpose: To clarify differences in surgery duration, postoperative knee range of motion (ROM), anterior and posterior (AP) laxity, and Forgotten Joint Score (FJS) in patients undergoing medial-pivot (MP) and GRADIUS cruciate-retaining (CR) total knee arthroplasty (TKA) surgeries. Methods: We examined patients who underwent either MP or CR TKA at six different Japanese centres. Patients were propensity score matched for age, sex, and preoperative hip-knee angle (HKA). We compared the groups' average surgery duration, postoperative knee ROM, AP laxity, and FJS 1 year after surgery. Results: There were 86 study patients: 43 MP and 43 CR TKA matched for age, sex, and preoperative HKA. The MP group enjoyed a significantly shorter surgery duration (89.1 ± 10.9 mins vs. 95.7 ± 12.0 mins, p = 0.0091) and significantly better postoperative knee flexion than the CR group (123.7 ± 9.1° vs. 115.3 ± 12.4°, p < 0.001). The MP had significantly smaller postoperative AP laxity with 30° of knee flexion than the CR group (3.4 ± 1.3 vs. 5.6 ± 2.2 mm, p < 0.001). Conversely, postoperative AP laxity with 90° of knee flexion was significantly larger for the MP group (3.6 ± 1.3 vs. 2.7 ± 1.9 mm, p = 0.0098). There were no between-group differences in postoperative FJS. Conclusions: The MP group showed better postoperative knee flexion, midrange AP knee stability, and shorter surgery duration. Level of Evidence: Level III, retrospective comparative study.

The onset of intermetatarsal bursitis in patient with rheumatoid arthritis - Case report of surgical treatment.

INTRODUCTION: Mono-arthritis and intermetatarsal bursitis according to rheumatoid arthritis aren't aware among general orthopedic surgeon. This report describes a case of surgical treatment of intermetatarsal bursitis. PRESENTATION OF CASE: A 50-year-old female presented with three years of metatarsophalangeal joint pain and deformity. MRI showed bursitis and synovial proliferation around the joint. Synovectomy reduced pain and foot deformity. After surgery, the patient was administered methotrexate. DISCUSSION: There were previous studies reporting intermetatarsal bursitis associated with rheumatoid arthritis, few case reports were found in which surgery and pathological examination were performed. CONCLUSION: Intermetatarsal bursitis is common for patients with rheumatoid arthritis. Early diagnosis and early appropriate treatment is necessary.

Relationship Between Intraoperative Macroscopic Anterior Cruciate Ligament Findings, Perioperative Surgical Findings, and Postoperative Clinical Outcome After Cruciate-Retaining Total Knee Arthroplasty.

PURPOSE: To assess how intraoperative macroscopical anterior cruciate ligament (ACL) findings affect perioperative procedures, biomarkers, and postoperative anterior-posterior (AP) laxity and range of motion (ROM) after cruciate-retaining (CR) total knee arthroplasty (TKA) and to determine how chronic ACL deficiency may affect postoperative inflammatory biomarker, AP laxity, and ROM. METHODS: A total of 121 patients with varus knee osteoarthritis without a history of ACL injury who underwent ATTUNE® (DePuy Synthes, Warsaw, IN) CR TKA were analyzed. Intraoperative ACL findings were stratified into intact, damaged, and diminished, according to the tension by probing, synovial coverage, and vascularity. C-reactive protein (CRP) levels were examined at one, seven, and 14 days after surgery. Knee AP laxity measurements using Kneelax 3 (Monitored Rehab Systems, Haarlem, The Netherlands) and postoperative knee ROM were also compared. RESULTS: One-way ANOVA showed significant differences in CRP levels examined one day after surgery observed between the three groups (8.4 (3.8), 9.8 (4.3), and 13.2 (7.7) mg/dL, respectively; P = 0.018), with post hoc analysis showing that CRP levels one day after surgery were significantly greater in the diminished group than in the intact and damaged groups (P = 0.012 and 0.023, respectively). AP laxity in 30° of knee flexion was observed between the three groups (5.4 (2.3), 5.8 (2.5), and 7.1 (2.8) mm, respectively; P = 0.039), with post hoc analysis showing that AP laxity in 30° of knee flexion was significantly greater in the diminished group than in the intact group (P = 0.038). Knee ROM showed no significant differences. CONCLUSION: Intraoperative ACL diminishment was associated with higher CRP one day after surgery and midrange AP laxity one year after surgery.

Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs.

BACKGROUND: Instrumentation failure (IF) is a major complication associated with growth-sparing surgery for pediatric spinal deformities; however, studies focusing on IF following each surgical procedure are lacking. We aimed to evaluate the incidence, timing, and rates of unplanned return to the operating room (UPROR) associated with IF following each surgical procedure in growth-sparing surgeries using traditional growing rods (TGRs) and vertical expandable prosthetic titanium ribs (VEPTRs). METHODS: We reviewed 1,139 surgical procedures documented in a Japanese multicenter database from 2015 to 2017. Of these, 544 TGR and 455 VEPTR procedures were included for evaluation on a per-surgery basis. IF was defined as the occurrence of an implant-related complication requiring revision surgery. RESULTS: The surgery-based incidences of IF requiring revision surgery in the TGR and VEPTR groups were 4.3% and 4.0%, respectively, with no significant intergroup difference. Remarkably, there was a negative correlation between IF incidence per surgical procedure and the number of lengthening surgeries in both groups. In addition, rod breakage in the TGR group and anchor-related complications in the VEPTR group tended to occur relatively early in the treatment course. The surgery-based rates of UPROR due to IF in the TGR and VEPTR groups were 2.0% and 1.5%, respectively, showing no statistically significant difference. CONCLUSIONS: We found that IF, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. This finding may help in patient counseling and highlights the importance of close postoperative follow-up to detect IF and improve outcomes.

Effectiveness of a two-stage posterior-anterior-posterior surgery using subcutaneously preserved autologous bone grafts for adult spinal deformity: a retrospective observational study.

BACKGROUND: To achieve optimal correction of rigid kyphoscoliosis, we developed a novel two-stage posterior-anterior-posterior (PAP) surgery using subcutaneously preserved autologous bone grafts. This study aimed to investigate the effectiveness of two-stage PAP surgery versus single-stage anterior-posterior (AP) surgery. METHODS: This was a retrospective analysis of patients undergoing combined anterior-posterior long-level fusion for adult spinal deformity (ASD) with a minimum 2-year follow-up. The indications for two-stage PAP surgery were rigid thoracolumbar deformity associated with hypertrophic facet arthritis and/or a large pelvic incidence-lumbar lordosis mismatch of > 25°. In the first stage of PAP surgery, pedicle screw insertion and multilevel Ponte osteotomies were performed. The resected local bone was embedded under sutured fascia. One week later, the embedded bone was retrieved in the right lateral position and used as an autograft for lateral lumbar interbody fusion. Final deformity correction was performed in the prone position. RESULTS: From January 2018 to April 2021, 12 and 16 patients with ASD underwent two-stage PAP surgery (PAP group) and single-stage AP surgery (AP group), respectively. Although PAP surgery was associated with a significantly longer operation time, the total blood loss volume was significantly less in the PAP group than the AP group. Compared with the AP group, the PAP group showed significantly larger postoperative changes in radiological parameters in the sagittal and coronal planes. The overall complication rate did not differ significantly between the two groups. CONCLUSION: Two-stage PAP surgery provided effective correction of rigid kyphoscoliosis without increasing blood loss and postoperative complication rates.

Coexisting Lower Back Pain in Patients With Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of the present study is to investigate the coexisting lower back pain (LBP) in patients with cervical myelopathy and to evaluate changes in LBP after cervical spine surgery. SUMMARY OF BACKGROUND DATA: Only a few studies with a small number of participants have evaluated the association between cervical myelopathy surgery and postoperative improvement in LBP. METHODS: Patients who underwent primary cervical decompression surgery with or without fusion for myelopathy and completed preoperative and 1-year postoperative questionnaires were reviewed using a prospectively collected database involving 9 tertiary referral hospitals. The questionnaires included the patient-reported Japanese Orthopaedic Association (PRO-JOA) score and Numerical Rating Scales (NRS). The minimum clinically important difference (MCID) for NRS-LBP was defined as >30% improvement from baseline. Patient demographics, characteristics, and PRO-JOA score were compared between patients with and without concurrent LBP, and the contributor to achieving the MCID for LBP was analyzed using logistic regression analysis. RESULTS: A total of 786 consecutive patients with cervical myelopathy were included, of which 525 (67%) presented with concurrent LBP. LBP was associated with a higher body mass index (P<0.001) and worse preoperative PRO-JOA score (P<0.001). Among the 525 patients with concurrent LBP, the mean postoperative NRS-LBP significantly improved from 4.5±2.4 to 3.4±2.7 (P<0.01) postoperatively, with 248 (47%) patients reaching the MCID cutoff. Patients with a PRO-JOA recovery rate >50% were more likely to achieve MCID compared with those with a recovery rate <0% (adjusted odd ratio 4.02, P<0.001). CONCLUSIONS: More than 50% of patients with myelopathy reported improvement in LBP after cervical spine surgery, and 47% achieved the MCID for LBP, which was positively correlated with a better PRO-JOA recovery rate. Treating cervical myelopathy in patients with concomitant LBP may be sufficient to mitigate concomitant LBP. LEVEL OF EVIDENCE: Level Ⅲ.

Evaluation of skeletal muscle elasticity using color Doppler shear wave imaging.

PURPOSE: This study aimed to (1) assess the precision and reproducibility of color Doppler shear wave imaging (CD SWI) by comparing it with shear wave elastography (SWE) via elasticity phantom measurements, and (2) investigate the potential clinical applications of CD SWI in the upper limb muscles by assessing the reproducibility of skeletal muscle elasticity evaluations. METHODS: Four elastography phantoms of different stiffness (6.0-7.5 wt%) were used to assess the precision and reproducibility of CD SWI (compared with SWE) at depths. Typical upper limb muscles of 24 men were also assessed for this comparison. RESULTS: At superficial depths (0-2 cm), the phantom measurements obtained using CD SWI and SWE were similar at all levels of stiffness. Furthermore, both methods were highly reliable, with almost perfect intra- and inter-operator reliabilities. At greater depths (2-4 cm), measurements obtained using both methods were similar at all stiffness levels. Although standard deviations (SDs) of the phantom measurements obtained using both methods at lower stiffness were similar, those at higher stiffness were different. The SD of the CD SWI measurements was < 50% of that of the SWE measurements. However, both methods were highly reliable in the phantom test, with almost perfect intra- and inter-operator reliabilities. The intra- and inter-operator reliabilities of the shear wave velocity measurements for typical muscles of the upper limbs were also substantial in clinical settings. CONCLUSION: CD SWI is a valid method for measuring elasticity, with precision and reliability as high as those of SWE.

Plate Hooking Transtibial Medial Meniscus Posterior Root Pull-Out Repair with Medial Open-Wedge High Tibial Osteotomy for Knee Osteoarthritis with Medial Meniscus Posterior Root Tear.

Medial meniscus posterior root tears (MMPRT) are a risk factor for knee osteoarthritis (KOA) because it involves disruption of the hoop structure of the meniscus. In recent years, MMPRT pullout repair has been performed to restore the native anatomy of the meniscus attachment. In addition, medial open-wedge high tibial osteotomy (MOWHTO) has been performed with MMPRT pullout repair to reduce the pressure on the medial compartment. However, it has been noted that when MMPRT pullout repair and HTO are performed simultaneously in a patient, the locking screws of the plate interfere with the tibial bone tunnel, which damages the suture. In this technical note, we developed a method to reduce the probability of interference by placing the plate further anteroinferior when digging the bone tunnel from the PM position. This technical note aimed to provide a comprehensive description of the safety of transtibial MMPRT repair with MOWHTO for medial KOA with MMPRT.

Relationship Between Achilles Tendon Stiffness Using Myoton PRO and Translation Using a Tensile Testing Machine: A Biomechanical Study of a Porcine Model.

Background Achilles tendinopathy is a common ankle disorder in both the general population and athletes. This condition can alter the mechanical characteristics of the Achilles tendon (AT) by decreasing tendon stiffness. Achilles tendinopathy is primarily treated conservatively; however, few monitoring tools exist for evaluating the condition of the AT. The Myoton PRO (Myoton AS, Tallinn, Estonia) device is a handheld tool used to evaluate tissue stiffness. However, no basic studies have examined the validity of Myoton PRO for assessing the AT. This study aimed to assess the validity of Myoton PRO using animal ATs and to examine its clinical applicability. Methods We used 28 fresh porcine ankles and evaluated AT stiffness at the calcaneus insertion site (AT0) and 2.0 cm above the calcaneus (AT2) using Myoton PRO. We also measured changes in the AT length using a tensile testing machine during the cyclic loading test. We investigated the correlation between dynamic stiffness and length change. Furthermore, we assessed the difference in stiffness between AT0 and AT2. Results The dynamic stiffness was 717.6 ± 183.1 N/m at AT0 and 467.4 ± 152.3 N/m at AT2. The change in length during the cyclic loading test was 1.8 ± 0.7 mm. The correlation between dynamic stiffness and length change was as follows: AT0, r=-0.61; AT2, r=-0.64 (P<0.001). The dynamic stiffness at AT0 was significantly greater than that at AT2 (P<0.001). Conclusions AT assessment using Myoton PRO has potential clinical utility as an indicator of tissue stiffness.

Use of a preoperative 3D templating and proximal lateral tibial fitting patient-specific instrumentation in fixed valgus complex primary total knee arthroplasty for a patient with retaining hardware for internal fixation to treat Schatzker type V tibial plateau fracture: A case report.

A 72-year-old female patient with a fixed valgus knee deformity due to a Schatzker type V tibial plateau fracture treated with bilateral locking plates 8 years ago was admitted to our clinic with complaints of chronic pain and knee instability when walking. Radiographs revealed Kellgren-Lawrence Classification grade 4 knee osteoarthritis and 20.5° of valgus knee deformity. She was treated with three-dimensional templating and proximal lateral tibial fitting patient-specific instrumentation-assisted mechanically aligned posterior sacrificing total knee arthroplasty with minimal removal of the retained hardware for the internal fixation of the tibial plateau fracture via a lateral approach, resulting in a favorable clinical outcome. The use of proximal lateral tibial fitting patient-specific instrumentation in fixed valgus complex primary total knee arthroplasty for patients with retaining hardware for internal fixation to treat tibial plateau fractures is considered a treatment option to decrease surgical invasion.

Comparison of Electrothermal Ablation and Electrolyte Plasmalization Devices Based on the Mechanical Properties of Anterior Cruciate Ligament Femoral Attachment Following Partial Debridement: A Biomechanical Study Using a Porcine Model.

Purpose This study aimed to clarify whether differences in ablation devices used in the knee joint during partial debridement of the proximal end of the femoral attachment of the anterior cruciate ligament (ACL) affect the mechanical properties of the femur-ACL-tibia complex. Methods Electrothermal ablation was generated from Vulcan for the left knees, and radiofrequency ablation was generated from Werewolf Flow 50 Wand for the right knees. The probes were set to the default setting of 120 W and 150 W for Vulcan and Werewolf Flow 50 Wand, respectively. To mimic partial debridement in remnant tissue-preserving (RTP) ACL reconstruction, the bipolar ablation mode and serpentine movements were employed while in contact with the femoral fan-like extension fibers of the ACL. To simulate the arthroscopic environment, the model was immersed in a saline solution. The probes were applied for 60 s, and their biomechanical properties were evaluated. Results A significant difference was observed in the upper yield load between the two groups (Vulcan group, 107.1 ± 93.4 N; Werewolf group, 177.9 ± 108.8 N; P = 0.045). However, no significant differences were noted in linear stiffness (Vulcan group, 47.6 ± 30.9 N/mm; Werewolf group, 50.1 ± 30.5 N/mm; P = 0.85), maximum load (Vulcan group, 276.2 ± 171.8 N; Werewolf group, 397.7 ± 150.8 N; P = 0.26), or elongation at failure (Vulcan group, 6.1 ± 0.9 mm; Werewolf group, 11.6 ± 10.4 mm; P = 0.20) between the two groups. Conclusion The mechanical properties of the ACL after partial ACL femoral attachment debridement for RTP-ACL reconstruction were better when an electrolyte plasmalization device was used. When performing RTP-ACL reconstruction, surgeons must consider that the device used for partial femoral ACL stump debridement may affect the mechanical properties of the ACL remnant tissue. Clinical relevance When performing RTP-ACL reconstruction, surgeons must consider that the device used for partial femoral ACL stump debridement may affect the mechanical properties of the ACL remnant tissue.

Morphological and histological evaluation of the tendon-bone junction in porcine shoulders to create a rotator cuff tear and repair model.

BACKGROUND: This study aimed to morphologically and histologically examine whether pig is useful as models for rotator cuff tear (RCT). METHODS: The morphology of the scapula and humerus bones was evaluated by taking X-ray and three-dimensional computed tomography (3D CT) scans of the right shoulders of five female pigs (age: 4 months). The rotator cuff (RC) footprint at the humeral insertion of these was observed and its shape was measured. Next, they underwent general anesthesia and an acute rotator cuff tear/rotator cuff repair (RCT/RCR) model was created using a deltoid split approach. Four weeks after surgery, the animals were euthanized, the shoulder joints were harvested, and the repaired RC was evaluated by hematoxylin and eosin staining and toluidine blue staining. RESULTS: The scapula of the pig had a vestigial acromion, in contrast to that in humans. The supraspinatus and infraspinatus tendons were connected so as to overlap each other and attached to the postero-superior part of the greater tuberosity. These tendons were located extra-articularly, separate from the joint capsule. The average antero-posterior length of the foot print was 17.4 ± 0.7 mm on the medial margin and 19.1 ± 2.2 mm on the lateral margin. The maximum medial-to-lateral width of it was 5.1 ± 0.5 mm. In all RCT/RCR models at 4 weeks after surgery, the repaired RC compound tendon was visually confirmed to be continuous with the footprint. Histologically, it was confirmed that regeneration of the four-layer structure of the bone-tendon junction had occurred. CONCLUSION: Porcine supraspinatus and infraspinatus attachment to the greater tuberosity have a structure similar to that of sheep and dogs, which is advantageous for creating the RCT/RCR model. It might be used for future in vivo studies of shoulder joint diseases. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Pigs could potentially serve as a viable model for rotator cuff tears.

Clinical outcomes and cost-effectiveness of manipulation under brachial plexus block versus physiotherapy for refractory frozen shoulder: a prospective observational study.

Background: Frozen shoulder (FS) is a pathological condition that involves a painful and stiff shoulder joint, most commonly in people aged 40-60 years. Most literature supports treatment with physical therapy (PT), although some studies have demonstrated years of continuing pain and functional deficits. Manipulation under anesthesia is effective at eliminating the contracture of intra-articular lesions for refractory FS. This study aimed to compare whether manipulation under anesthesia or PT is a more effective treatment in refractory FS. Methods: This study was a prospective observational study. A total of 102 patients with refractory FS were enrolled in this study in the medical records, all of whom had severe and multidirectional loss of motion and thickening of the joint capsule and coracohumeral ligament on magnetic resonance imaging. Fifty-one patients were in the manipulation under brachial plexus block (MUB) group (34 females, median age: 57 years), and 51 patients were in the PT group (34 females, median age: 59 years). The MUB procedure consisted of the conventional method with additional adduction manipulation, in which one examiner initially abducted the shoulder joint as much as possible. We recorded the visual analog scale, shoulder range of motion, and American Shoulder and Elbow Surgeons and Constant Scores at the initial baseline visit and at the 1-, 3-, 6-, and 12-month follow-ups. The total cost was calculated from the medical records, and cost-effectiveness was evaluated using quality-adjusted life year and incremental cost-effectiveness ratio. Results: Visual analog scale (P < .001), range of motion (P < .001), and American Shoulder and Elbow Surgeons and Constant Scores (P < .001) in the MUB group were significantly superior to those in the PT group at 1, 3, 6, and 12 months after treatment. The median cost and total quality-adjusted life year in the MUB and PT groups were $1375 versus $2751 and 2.95 versus 2.68, respectively, and the cost-effectiveness ratio between the MUB and PT groups was calculated as -$560. Conclusions: The new MUB procedure provides a shorter treatment period, better clinical outcomes, and higher cost-effectiveness in patients with refractory FS compared to PT.

Association between intraoperative findings and postoperative knee range motion after cruciate-retaining total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) alleviates pain and improves daily living activities in individuals with end-stage osteoarthritis of the knee. However, up to 20% of patients have sub-optimal outcomes after TKA. OBJECTIVE: No studies have clarified the intraoperative factors that affect postoperative range of motion (ROM) after cruciate-retaining (CR) TKA. Thus, this study aims to clarify these factors. METHODS: Patients with knee osteoarthritis with varus knee deformity who underwent CR-TKA between May 2019 and December 2020 were included in this study. One year after surgery, patients were stratified into two groups based on knee flexion: Group F (over 120∘) and Group NF (below 120∘). Patient backgrounds including age, body mass index, hip knee angle, preoperative range of motion for both extension and flexion, intraoperative center joint-gap measurements of 0∘, 30∘, 45∘, 60∘, 90∘, and 120∘ of knee flexion using a tensor, intraoperative anterior-posterior (AP) laxity measurements of 30∘ and 90∘ of knee flexion using an instrumental laximeter were compared between the groups. Univariate analyses between the groups were used to construct the initial model. The receiver operating characteristic curve was also analyzed. The predictive variables included in the final model were selected by stepwise backward elimination. RESULTS: Intraoperative AP laxity with 30∘ of knee flexion smaller than 10.8 mm was a significant positive prognostic factor (OR: 1.39, 95% CI: 1.08-1.79, P= 0.011) of postoperative ROM over 120∘ of knee flexion one year after surgery. The sensitivity, specificity, PPV, and NPV were 70.9%, 82.4%, 92.9%, and 46.7%, respectively. CONCLUSION: Intraoperative AP laxity smaller than 10.8 mm was a significant positive predictive factor for obtaining knee flexion greater than 120∘ one year after surgery when using CR-TKA and its PPV was high up to 92.9%.

Risk of peri­implant femoral fracture after cephalomedullary nailing in older patients with trochanteric fractures.

INTRODUCTION: Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri­implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients. METHODS: A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors. RESULTS: Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors. CONCLUSIONS: Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures.

Epidemiology of fragility fracture of the pelvic ring: a regional population-based study in Northern Japan.

Using a regional population-based dataset in Japan, we identified the epidemiological characteristics of patients with fragility fractures of the pelvic ring. The incidence rate was 35.5-121.2 per 100,000 population/year. Age-specific incidence increased after 75 years. This fracture is associated with worse prognosis in terms of walking function and life expectancy. PURPOSE: Fragility fracture of the pelvic ring (FFP) is common among older patients; however, little information is available on the epidemiology of FFP worldwide. We aimed to identify the epidemiological characteristics of patients with FFP using a regional population-based dataset in Japan. METHODS: This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with FFP from January 1, 2011 through December 31, 2020 at a regional dominant hospital in Japan. We calculated the crude and age-adjusted annual incidences and the age-specific incidence and described epidemiological date, injury characteristics, walking ability before and after FFP, and mortality. Additionally, we investigated factors associated with walking ability. RESULTS: We identified 66 FFP patients, of whom 55 (83.3%) were female, with a mean age of 82.2 years. The crude annual incidence of FFP ranged from 35.5-121.2 per 100,000 population/year during the study period. The age-specific incidence of FFP increased after 75 and 80 years in females and males, respectively. In total, 44.4% of patients had declines in walking ability 1 year after their FFP injuries. Patients with declining walking ability were significantly older (p < 0.01), and age ≥ 80 years was significantly associated with the decline in walking ability (p < 0.01). The 1- and 5-year mortality rates were 15.4% and 39.9%, respectively. CONCLUSION: The incidence rate of FFP was 35.5-121.2 per 100,000 population/year. Age-specific incidence of FFP increased after 75 years. Our results indicate that FFP is associated with worse prognosis of walking function and life expectancy.