Retro-tubercular Biplanar Medial Opening-Wedge High Tibial Osteotomy Results in Superior Patellofemoral Alignment Versus Supra-tubercular Osteotomy.

PURPOSE: To compare the changes in patellofemoral (PF) joint alignment, focusing on multiple planes, between two different types of biplanar medial opening-wedge high tibial osteotomy (OWHTO). METHODS: Patients who underwent biplanar OWHTO between July 2017 and May 2021 were retrospectively evaluated. They were allocated to either the supra-tubercular (ST)- or retro-tubercular (RT)-OWHTO group. The following radiologic parameters were compared between the two groups: 1) weight-bearing line ratio (WBLR), 2) patellar height, 3) posterior tibial slope (PTS), 4) tibial tubercle-trochlear groove (TT-TG) distance, 5) TT-TG angle, and 6) femoral shaft-patellar tendon (FS-PT) angle. Clinical outcomes and the minimal clinically important difference (MCID) were also evaluated. RESULTS: In total, 104 knees that underwent ST-OWHTO and 105 knees that underwent RT-OWHTO were evaluated. The patellar height significantly decreased only after ST-OWHTO (P < .001). The TT-TG distance and FS-PT angle significantly increased, more after ST-OWHTO than RT-OWHTO (mean change value: 5.72 mm vs 1.91 mm; P < .001 for TT-TG distance; and 4.72° vs 1.80°; P < .001 for FS-PT angle). The TT-TG angle increased significantly after ST-OWHTO (mean change value: 7.62°; P < .001) but decreased after RT-OWHTO mean change value: -4.30°; P < .001). The PTS more increased after RT-OWHTO than after ST-OWHTO (mean change value: 0.91° vs 1.69°; P = .003). Clinical outcomes in both groups improved postoperatively, and no significant differences were observed between the groups. CONCLUSIONS: RT-OWHTO resulted in lesser changes in multiplane PF joint alignment than ST-OWHTO. However, no difference was observed in clinical outcomes between both groups, and PTS increased after RT-OWHTO. Therefore, these aspects of RT-OWHTO should also be considered. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Arthroscopic Meniscal Repair and Meniscectomy for Adult Discoid Lateral Meniscus Results in Progression to Valgus Alignment and Lateral Compartment Degeneration Compared With Nonoperative Treatment and Nondiscoid Lateral Meniscus.

PURPOSE: To analyze the effect of the arthroscopic meniscal procedure in adult discoid lateral meniscus (DLM) according to the age and meniscal-preserving by making comparisons with the nondiscoid lateral meniscus (N-DLM). METHODS: From March 2014 to October 2020, a comparative analysis was performed in adults with DLM who underwent arthroscopic meniscal procedures (operative DLM: 134 knees), nonoperative treatment (nonoperative DLM: 56 knees), and adult N-DLM who underwent arthroscopic meniscal procedures (operative N-DLM: 64 knees). These patients were between 20 and 65 years old and completed a minimum follow-up of 2 years. Patients with DLM who underwent arthroscopic procedure were divided into subgroups according to age and extent of the meniscal-preserving. The following parameters were assessed and compared between the groups: (1) coronal limb alignment, (2) osteoarthritis grade, and (3) clinical outcomes and the minimal clinically important difference. RESULTS: The coronal limb alignment was significantly changed to valgus in the order of operative DLM, N-DLM, and nonoperative DLM (Δ mechanical hip-knee-ankle angle: 3.23 ± 1.85 vs 1.35 ± 1.03° vs -0.57 ± 1.88°; P < .05). Operative DLM showed most prominent osteoarthritic change in the lateral compartment, followed by the N-DLM and nonoperative DLM groups (40.3% vs 17.2% vs 5.3%; P < .05). These changes in operative DLM were more prominent in older adults who underwent meniscal-sacrificing procedures and resulted in less-satisfactory clinical outcomes (all P < .05). CONCLUSIONS: Arthroscopic surgery for adult DLM resulted in progression to valgus alignment and lateral compartment degeneration compared with nonoperative treatment and arthroscopic surgery of the adult N-DLM. Old ager and having a meniscal-sacrificing procedure showed more rapid radiographic changes and lower clinical outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparison study.

Age and medial compartmental OA were important predictors of the lateral compartmental OA in the discoid lateral meniscus: Analysis using machine learning approach.

PURPOSE: The objective of this study was to develop a machine learning model that would predict lateral compartment osteoarthritis (OA) in the discoid lateral meniscus (DLM), from which to then identify factors contributing to lateral compartment OA, with a key focus on the patient's age. METHODS: Data were collected from 611 patients with symptomatic DLM diagnosed using magnetic resonance imaging between April 2003 and May 2022. Twenty features, including demographic, clinical and radiological data and six algorithms were used to develop the predictive machine learning models. Shapley additive explanation (SHAP) analysis was performed on the best model, in addition to subgroup analyses according to age. RESULTS: Extreme gradient boosting classifier was identified as the best prediction model, with an area under the receiver operating characteristic curve (AUROC) of 0.968, the highest among all the models, regardless of age (AUROC of 0.977 in young age and AUROC of 0.937 in old age). In the SHAP analysis, the most predictive feature was age, followed by the presence of medial compartment OA. In the subgroup analysis, the most predictive feature was age in young age, whereas the most predictive feature was the presence of medial compartment OA in old age. CONCLUSION: The machine learning model developed in this study showed a high predictive performance with regard to predicting lateral compartment OA of the DLM. Age was identified as the most important factor, followed by medial compartment OA. In subgroup analysis, medial compartmental OA was found to be the most important factor in the older age group, whereas age remained the most important factor in the younger age group. These findings provide insights that may prove useful for the establishment of strategies for the treatment of patients with symptomatic DLM. LEVEL OF EVIDENCE: Level III.

Constitutional and postoperative joint line obliquity can predict serial alignment change after opening-wedge high tibial osteotomy: analysis using coronal plane alignment of the knee classification.

PURPOSE: The purposes of this study were (1) to clarify the distribution of the Coronal Plane Alignment of the Knee (CPAK) phenotype in patients who underwent medial opening-wedge high tibial osteotomy (OWHTO) and (2) to identify the predictive factors for postoperative serial alignment changes after OWHTO by analyzing constitutional phenotypes. METHODS: Patients who underwent OWHTO between March 2014 and December 2019 were retrospectively evaluated. Those who completed a minimum follow-up of 3 years were divided into three groups based on the direction of alignment changes from postoperative 3 months to the final follow-up: Group 1 (varus direction) when the weight-bearing line ratio (WBLR) change was less than - 4%, Group 2 (maintained) when the WBLR change was between - 4% and 4%, and Group 3 (valgus direction) when the WBLR change was greater than 4%. The following parameters were assessed serially and compared between the groups: (1) radiologic parameters of coronal limb alignment such as joint line obliquity (JLO), (2) CPAK phenotypes, and (3) clinical outcomes. RESULTS: In total, 163 knees were included, and the average duration of follow-up was 4.8 ± 1.6 years. More apex distal JLO was observed in the order of Group 1, 2, and 3 at all times (all p < 0.05). The most common CPAK type was type (I + II) (constitutional: apex distal JLO) + type (V + VI) (postoperative 3 months: neutral JLO) in Group 1 (29.4%; p = 0.000); otherwise, the most common CPAK type was type (IV + V) (constitutional: neutral JLO) + type (VIII + IX) (postoperative 3 months: apex proximal JLO) in Group 3 (11.7%; p = 0.000). Clinical outcomes did not differ between the groups. CONCLUSION: Constitutional and postoperative JLO were predictive factors of postoperative alignment changes after OWHTO. Constitutional apex distal and postoperative neutral JLO had a tendency for varus alignment progression, whereas constitutional neutral and postoperative apex proximal JLO had a tendency for valgus alignment progression. LEVEL OF EVIDENCE: Retrospective cohort study; Level III.

Constitutional alignment predicts medial ligament balancing in mechanically aligned total knee arthroplasty for varus knees.

PURPOSE: The aim of this study was to identify if constitutional alignment and preoperative radiologic parameters determined whether medial gap balancing was required in mechanically aligned total knee arthroplasty (TKA). METHODS: Two hundred and sixty three patients with 394 consecutive knees who underwent primary TKAs were retrospectively analysed in this study. Selective sequential multiple needle puncturing (MNP) was performed for medial ligament balancing when required. Constitutional alignment, which was determined using the Coronal Plane Alignment of the Knee (CPAK) classification, as well as preoperative and postoperative radiologic parameters was evaluated to identify factors which predicted the need for MNP. RESULTS: One hundred and fifty eight (40.1%) knees required medial ligament balancing with MNP. Patients who required MNP during surgery had significantly more constitutional varus, more varus preoperative mechanical Hip-Knee-Ankle angle (mHKA), smaller preoperative medial proximal tibial angle (MPTA) and a larger change in mHKA and MPTA after surgery than those who did not. Patients with constitutional varus also had a higher incidence of having had MNP to both anterior and posterior superficial medial collateral ligament (sMCL) fibres. There was no significant difference in preoperative lateral distal femoral angle (LDFA), posterior tibial slope (PTS) and varus-valgus difference (VVD) between groups. CONCLUSION: Ligament balancing using MNP was determined by constitutional alignment rather than medial soft tissue contracture. Patients with constitutional varus who had a larger medio-lateral gap difference in extension also had a higher incidence of having had MNP to both anterior and posterior sMCL fibres. LEVEL OF EVIDENCE: Retrospective comparative study, level IV.

Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging-based study in outside-in anterior cruciate ligament reconstruction.

PURPOSE: In this study, the relationship between patient-specific geometric factors and tunnel placement in graft impingement was identified by using magnetic resonance imaging (MRI) signal intensity of anterior cruciate ligament (ACL) grafts. METHODS: Ninety-two patients, who were treated between 2014 and 2020, were included retrospectively. These patients underwent primary remnant-preserving outside-in ACL reconstruction (ACLR) and were followed up with postoperative MRI at least one year after surgery. Plain radiographs and computed tomography (CT) were used to analyze tibial and femoral tunnel positions. Postoperative MRI was performed, at 32.8 ± 17.5 months after surgery, to evaluate the graft signal intensity, the ACL/posterior cruciate ligament (PCL) ratio (APR), ACL/muscle ratio (AMR), tunnel positions, and graft impingement. Clinical and stability outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective and objective scores, Lysholm scores, and side-to-side differences (SS-D). RESULTS: The mean APR and AMR of the proximal third of the grafts were significantly lower than those of the middle third of the grafts (p = 0.017 and p = 0.045, respectively). Multivariate regression analysis showed that there was a negative association between the mean APR and AMR of entire intra-articular ACL graft and the distance from the anterior end of the intercondylar roof to the center of the tibial tunnel in the sagittal plane (p < 0.001 and p < 0.001, respectively) and the notch width index (p < 0.001 and p = 0.002, respectively). No significant correlations were found between tunneling and geometric factors, and clinical scores or SS-D. CONCLUSIONS: Graft impingement on the anterior tibial tunnel relative to the end of the intercondylar roof and narrow notch was a more significant contributing factor on increased signal intensities of the ACL graft, compared with the acute femoral bending angle in remnant-preserving outside-in ACLR. Therefore, surgeons should focus on intercondylar notch anatomy during tibial tunnel placement to avoid roof impingement. LEVEL OF EVIDENCE: Level III.

POSTTREATMENT POLYP REGRESSION AND RISK OF MASSIVE SUBMACULAR HEMORRHAGE IN EYES WITH POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: To study the association between the risk of massive submacular hemorrhage (SMH) and polyp regression after initial treatment of polypoidal choroidal vasculopathy using long-term follow-up data. METHODS: Retrospective study of 223 patients who were diagnosed with polypoidal choroidal vasculopathy and were followed up for up to 11 years. Subjects were categorized into "regression" and "no regression" groups, according to their polyp status after the initial treatment. Kaplan-Meier survival analyses were performed on development of massive SMH. The association between treatment methods and the occurrence of massive SMH was also analyzed. RESULTS: The incidence rates of massive SMH at 3, 6, and 9 years in the "no regression" group were 6.50, 22.59, and 38.03%, respectively, and in the "regression" group were 1.14, 6.47, and 10.92%, respectively (P = 0.005, log-rank test). The hazard ratio of massive SMH was 3.677 for cluster-type polyps and 0.271 for polyp regression after initial treatment. A higher rate of polyp regression was associated with photodynamic therapy (PDT) than anti-VEGF monotherapy (64.4 vs. 33.3%, P < 0.001). Additional anti-VEGF treatments after initial PDT showed lower risk of massive SMH than PDT only. (9.5 vs 38.5%, P = 0.005). CONCLUSION: The long-term risk of massive SMH after initial treatment on polypoidal choroidal vasculopathy is significantly higher in eyes with persistent polyps than those with regressed polyps. Ophthalmologists should pay attention to the risk of massive SMH and the polyp status when treating polypoidal choroidal vasculopathy.

Foveal microvasculature features of surgically closed macular hole using optical coherence tomography angiography.

BACKGROUND: To describe the features of foveal microvasculature using optical coherence tomography angiography (OCTA) and to determine the related clinical factors in eyes with surgically closed macular hole (MH). METHODS: A retrospective case series of 18 patients with unilateral MH was reviewed. The patients maintained complete hole closure after vitrectomy with inner limiting membrane (ILM) peeling for at least 12 months. The healthy fellow eyes were studied as controls. The foveal microvasculature of both eyes was examined by OCTA. The area of the foveal avascular zone (FAZ) and the vascular density (VD) ratio in the superficial and deep capillary plexuses (SCP and DCP) were determined after surgery. Several clinical factors including age, stage and dimensions of MH, papillofoveal distance, the extent of nasal displacement of the fovea after surgery, postoperative central foveal thickness, and outer-retina integrity were evaluated to determine any relationships with the OCTA parameters. RESULTS: The mean FAZ area in both the SCP and DCP (0.29 ± 0.11 mm2 and 0.39 ± 0.14 mm2) was significantly smaller than those of the controls (0.45 ± 0.14 mm2 and 0.62 ± 0.22 mm2) (p = 0.001 and <0.001, respectively). The mean VD ratio in the SCP (0.270 ± 0.349) was similar to that of the controls (0.321 ± 0.189) (p = 0.231); however, that in the DCP (0.321 ± 0.189) was significantly lower than that of the controls (0.331 ± 0.119) (p = 0.025). Only the extent of nasal displacement of the fovea was correlated with the DCP FAZ-area difference values between the study group and the controls (correlation coefficient = 0.577; p = 0.012). CONCLUSIONS: After successful MH surgery, the FAZ area in both the SCP and DCP was smaller and the VD ratio of the DCP was lower, suggesting a possible DCP vulnerability to tractional stress. As the FAZ area of the DCP in closed-MH eyes became smaller than that in the controls, the fovea was less displaced toward the optic disc, possibly reflecting a lack of retinal redundancy caused by horizontal stretching accompanied by foveal displacement.

Development of a machine learning model for identifying the optimal situation favoring double-level osteotomy over single-level high tibial osteotomy.

BACKGROUND: This study aimed to develop a machine learning (ML) model to identify the optimal situation wherein double-level osteotomy (DLO) is favored for severe varus knees by analyzing unfavorable outcomes. This study hypothesized that there are the most favorable algorithms and contributing factors for identifying the optimal situation favoring DLO over opening-wedge high tibial osteotomy (OWHTO). METHODS: Data were retrospectively collected from patients who underwent OWHTO (505 knees). Unfavorable outcome parameters were defined as follows: (1) medial proximal tibial angle (MPTA) > 95°, (2) joint line convergence angle (JLCA) > 4° (insufficient medial release), (3) JLCA < 0° (medial instability), (4) recurrence of varus deformity, and (5) lateral hinge fracture. The input data for the ML model included demographic data and preoperative radiological and intra-operative factors. The ML model was used to evaluate overall and to evaluate each unfavorable outcome. Interpretation by the model was performed by SHapley Additive exPlanations. RESULTS: The unfavorable group had a larger JLCA and MPTA preoperatively than the favorable group in the conventional comparison. The light gradient boosting machine (LGBM) demonstrated the highest AUC of 0.66 and F-1 score of 0.72 among the ML algorithms. In the overall assessment, the preoperative weight-bearing line ratio (WBLR) was the factor that contributed the most, followed by the preoperative JLCA and the ΔWBLR. ΔWBLR and the preoperative JLCA were the contributing factors for each outcome. CONCLUSIONS: The LGBM model was superior in predicting the optimal situations favoring DLO over OWHTO. Preoperative WBLR, preoperative JLCA, and ΔWBLR significantly contributed to the unfavorable outcomes overall and for each outcome in the ML model.

Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty.

Iron supplementation provides iron storage and facilitates effective production of hemoglobin. The purpose of this study was to investigate the effect of early postoperative intravenous (IV) iron supplementation in different types of total knee arthroplasty (TKA) surgery. We retrospectively analyzed 863 patients who underwent TKA between September 2017 and September 2021. The IV iron (I) and non-IV iron (NI) groups were compared. Hemoglobin responders, defined as patients who showed a change in hemoglobin level of ≥2 g/dL at 6 weeks of surgery compared to the baseline immediate postoperative hemoglobin level, were identified and they were compared with the nonresponders. After logistic regression analysis, the patients were classified according to the type of surgery (unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA). A subgroup analysis was performed according to the comorbidity as Charlson Comorbidity Index (CCI). The type of surgery and the rate of hemoglobin responders differed between the I and NI groups. The surgery type and iron supplementation significantly affected the hemoglobin responder in the logistic regression model. In each surgery type, hemoglobin drop in the I group was generally lower in the second and sixth weeks than that in the NI group. It was also effective in reducing hemoglobin drop on the first day of the second surgery in staged bilateral TKA. In addition, the number of hospital days was lower in the IV iron supplementation group who underwent a staged bilateral TKA. CCI did not affect hemoglobin responder, hemoglobin drop, and transfusion rate in both the I and NI groups. Postoperative IV iron supplementation affected the outcome of hemoglobin responders. In addition, it reduced early postoperative hemoglobin drop. However, iron supplementation did not affect the transfusion rate, complications, and clinical outcome, regardless of the type of surgery. LEVEL OF EVIDENCE: Level III, case-control study.

Does referencing system affect the selection of implant size, position and gap balance in total knee arthroplasty?

BACKGROUND: (1) To evaluate if referencing system affects selection of implant size, position, and gap balance in total knee arthroplasty (TKA) with the use of contemporary implant designs and (2) to describe the authors' intraoperative sizing strategy using anterior referencing (AR) and posterior referencing (PR) systems. METHODS: This was a retrospective review of 270 consecutive patients (397 knees) who underwent primary TKA with an AR or PR system. Selection of implant size, mediolateral and anteroposterior alignment of the femoral component, as well as gaps were compared between groups. RESULTS: In the AR group, more patients had femoral components which were upsized or downsized compared to those in the PR group (29.5% vs 12.0% respectively) and in patients who underwent bilateral TKA, 49.4% of those in the AR group had femur component size asymmetry. The AR group had better medio-lateral (ML) fit over the distal cutting surface area, smaller change in anterior offset but higher incidence of anterior notching when compared to the PR group. Posterior condylar offset (PCO) was restored in both groups and gap differences in flexion-extension and ML were comparable. There was also no difference in clinical scores and ROM between groups at 2-years follow-up. CONCLUSION: In this study, conventional implications related to referencing system were not observed. In practice, AR systems can restore PCO while PR systems do not result in increased anterior notching or anterior overstuffing. Differences observed in this study are most likely related to implant design specifics and surgical technique.

The use of an anatomic tibial baseplate in total knee arthroplasty optimizes coverage without compromising rotation: A propensity-matched evaluation.

BACKGROUND: The aims of this study were (1) to compare in vivo coverage and rotational alignment of 2 tibial component designs: anatomic and symmetrical; and (2) to determine if coronal deformity and tibial torsion were related to rotation and coverage. METHODS: Postoperative CT scans of 200 propensity score-matched patients who underwent TKA with either an anatomic (ATC) or symmetrical tibia component (STC) were analyzed. Rotation was measured using four axes: surgical transepicondylar axis (sTEA), Berger's protocol, medio-lateral (ML) axis and posterior borders of the tibial plateau, while coverage was assessed by measuring fit and surface area. The relationship between coronal deformity, tibial torsion, rotation, and coverage was investigated. RESULTS: Overall, STCs had more internal rotation when measured using the sTEA (-0.6° ± 3.5 vs 0.5° ± 3.6, p = 0.03), Berger's protocol (-21.6° ± 7.1 vs -17.9° ± 6.2, p = 0.000) and ML axes (2.9° ± 3.9 vs 8.1° ± 5.1, p = 0.000) compared to ATCs. STCs also had more posteromedial underhang (-3.3 mm ± 2.4 mm vs -1.7 mm ± 2.5 mm, p = 0.000) but smaller change in tibial torsion postoperatively (-18.4° ± 9.9° vs -13.1° ± 9.4°, p = 0.000). Tibial torsion was more pronounced in valgus than varus knees both preoperative (-25.4° ± 6.5° vs -20.2° ± 9.3°, p = 0.02) and postoperatively (-19.7° ± 7.2° vs -14.7° ± 10.3°, p = 0.04), but there was no difference in postoperative tibial torsion between ATCs and STCs in this subgroup. CONCLUSION: The use of an anatomic tibial baseplate optimizes coverage by reducing posterolateral overhang and posteromedial underhang. It also achieved better rotational profiles compared to STCs. However, it resulted in a larger change in tibial torsion after TKA.

The development of machine learning algorithms that can predict patients satisfaction using baseline characteristics, and preoperative and operative factors of total knee arthroplasty.

BACKGROUND: Patient satisfaction following primary total knee arthroplasty (TKA) is a crucial part to evaluate the success of the procedure. The purpose of this study was to develop to predict patient satisfaction following TKA. METHODS: Satisfaction outcome data after 435 consecutive conventional TKAs performed between August 2020 and December 2021 were retrospectively collected. The total 26 input data were collected. The most favorable algorithm was first found using logistic regression (LR) and machine learning (ML) algorithms. To evaluate the predictive performance of the models, both area under curve (AUC) and F1-score were used as the primary metrics. The shapley additive explanations (SHAP) feature explanation in XGBoost and LR analysis were performed to interpret the model. RESULTS: The performance of extreme gradient boosting classifier (XGBoost) was only higher than that of conventional LR in AUC (0.782 vs. 0.689). Comparing the F-1 score, only XGBoost showed better performance than LR (0.857 vs. 0.800). The most predictive feature in XGBoost was Short Form-36 physical and mental component summary scores (SF-36 MCS), followed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, Bone mineral density (BMD). In the LR analysis, lumbar spine disease, WOMAC pain, and BMD were statistically significant. CONCLUSION: XGboost showed the best performance and was superior to conventional LR in the prediction of patient satisfaction after TKA. The SF-36 MCS was the most important feature in the ML model. WOMAC pain and BMD were meaningful variables and demonstrated a linear relationship with satisfaction in both the LR and ML models. LEVEL OF EVIDENCE: Retrospective cohort study; Level of evidence 3.

Key-Point Detection Algorithm of Deep Learning Can Predict Lower Limb Alignment with Simple Knee Radiographs.

(1) Background: There have been many attempts to predict the weight-bearing line (WBL) ratio using simple knee radiographs. Using a convolutional neural network (CNN), we focused on predicting the WBL ratio quantitatively. (2) Methods: From March 2003 to December 2021, 2410 patients with 4790 knee AP radiographs were randomly selected using stratified random sampling. Our dataset was cropped by four points annotated by a specialist with a 10-pixel margin. The model predicted our interest points, which were both plateau points, i.e., starting WBL point and exit WBL point. The resulting value of the model was analyzed in two ways: pixel units and WBL error values. (3) Results: The mean accuracy (MA) was increased from around 0.5 using a 2-pixel unit to around 0.8 using 6 pixels in both the validation and the test sets. When the tibial plateau length was taken as 100%, the MA was increased from approximately 0.1, using 1%, to approximately 0.5, using 5% in both the validation and the test sets. (4) Conclusions: The DL-based key-point detection algorithm for predicting lower limb alignment through labeling using simple knee AP radiographs demonstrated comparable accuracy to that of the direct measurement using whole leg radiographs. Using this algorithm, the WBL ratio prediction with simple knee AP radiographs could be useful to diagnose lower limb alignment in osteoarthritis patients in primary care.

Increased risk of cancer in patients with retinal vein occlusion: a 12-year nationwide cohort study.

AIMS: To investigate the association between incident retinal vein occlusion (RVO) and the subsequent development of cancer. METHODS: In this nationwide population-based retrospective study using 2002-2013 National Health Insurance Service database which covers the entire South Korean population, 186 701 incident RVO patients and their 1:1 propensity-score matched controls were included. We defined the fixed cohort from January 1st, 2004 to December 31st, 2013; the cohort included patients who suffered incident RVO after entering the cohort and their matched controls, and excluded patients having any cancer history before entering the cohort. The association of RVO and cancer was assessed by time-varying covariate Cox regression models; Model 1 included RVO as a time-varying covariate, Model 2 included Model 1 plus demographic information and Model 3 included Model 2 and comorbidities. RESULTS: RVO was associated with an increased risk of subsequent cancer (HR=1.29; 95% CI, 1.26-1.31 in Model 1), which was consistent in Models 2 and 3. The incidence rate of overall cancer during the study period was 25.55 (95% CI, 25.19-25.91) per 1000 person-years in the RVO group and 18.62 (95% CI, 18.46-18.79) per 1000 person-years in the control group. In the subgroup analysis, haematological malignancies showed the highest association with RVO (HR=1.65; 95% CI, 1.49-1.83). CONCLUSION: Patients with RVO have an increased risk of subsequent cancer development even after adjusting for demographic factors and comorbidities. Further study is warranted to elucidate these associations to provide proper recommendations for RVO patients regarding the cancer screening.

Short-term Efficacy and Safety of Ranibizumab for Neovascular Age-related Macular Degeneration in the Real World: A Post-marketing Surveillance Study.

PURPOSE: To investigate the short-term efficacy and safety of ranibizumab in the routine clinical setting in patients with neovascular age-related macular degeneration and to analyze the associated factors for visual outcome. METHODS: This was a post-hoc analysis of a ranibizumab regulatory post-marketing surveillance study in which 4,136 patients were enrolled and followed for 12 weeks. Change in best-corrected visual acuity (BCVA), size of choroidal neovascularization, and the presence of hemorrhage and exudate were analyzed and the association between BCVA change and baseline characteristics were investigated. Data on ocular and systemic adverse events were collected. RESULTS: Mean BCVA improved significantly and mean BCVA change was the logarithm of the minimal angle of resolution 0.13 ± 0.01 (p < 0.001). A lower baseline BCVA and younger age were significant predictive factors for visual improvement or maintenance (≥0 lines). For greater visual acuity gain (≥3 lines), no treatment history, lower baseline BCVA, younger age, and classic-type choroidal neovascularization were significant predictive factors. No new safety signals were found. CONCLUSIONS: In this study, conducted in real-world clinical practice with a large number of neovascular age-related macular degeneration patients, visual and anatomical outcomes improved significantly after three monthly ranibizumab treatments. Treatment-naive patients had a higher chance of greater visual gain (≥3 lines) than non-naive patients.

Optical Quality Assessment in Patients with Macular Diseases Using Optical Quality Analysis System.

Macular diseases cause vision loss, as the macula is the functional center for vision. In this study we assessed optical quality in eyes with macular diseases and evaluated the effectiveness of the Optical Quality Analysis System (OQAS) to detect macular diseases. We analyzed 88 eyes of 88 patients with macular diseases (51 men and 37 women; mean age: 65.24 ± 12.96 years) and 43 eyes of 43 control subjects (11 men and 32 women; mean age: 54.70 ± 15.03 years). The macular diseases included age-related macular disease (n = 62), diabetic macular edema (n = 19), and retinal vein occlusion (n = 7). We measured the objective scattering index (OSI), modulation transfer function (MTF), Strehl ratio, and predicted visual acuities (PVAs) at 100, 20, and 10% contrast levels in both groups using OQAS. We measured the retinal thickness in the macular disease group on optical coherence tomography. The macular disease and control groups significantly differed in OSI, MTF, Strehl ratio, and PVAs at 20 and 10% contrast levels (p < 0.05). In the macular disease group, retinal thickness correlated with OSI (r = 0.370, p < 0.001) and MTF (r = -0.264, p = 0.014). In conclusion, optical quality was worse in the patients with macular diseases compared to the control subjects, and retinal thickness affected optical quality. Therefore, the distortion of macular shape may contribute to vision disturbance in patients with macular diseases.

Intraoperative Graft Isometry in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction.

PURPOSE: Little is known about the isometry of anatomic single-bundle anterior cruciate ligament (ACL) tunnel positions in vivo although it is closely related to graft tension throughout the range of motion. The purpose of this study was to evaluate intraoperative graft isometry in anatomic single-bundle ACL reconstruction in vivo. MATERIALS AND METHODS: Graft length changes were assessed before bio-screw fixation in the tibial tunnel by pulling the graft with tensions of 20 lbs and 30 lbs in full extension at flexion angles of 30°, 60°, 90°, and 120°. RESULTS: At the flexion angle of 30°, 20 lbs and 30 lbs of tension showed -0.4 mm and -0.6 mm length changes, respectively. The greater the flexion angle of the knee, the shorter the graft length in the joint. At the flexion angles of 90° and 120°, there was significant difference in the graft length change between 20 lbs and 30 lbs of tension. CONCLUSIONS: Anatomic single-bundle ACL reconstruction was non-isometric. The graft length was the longest in full extension. The tension of graft became loose in flexion. At the flexion angles of 90° and 120°, there was significant difference in the graft length change between 20 lbs and 30 lbs of tension.

Risk factors for retinal microvascular impairment in type 2 diabetic patients without diabetic retinopathy.

OBJECTIVES: To determine the risk factors for retinal microvascular impairment on optical coherence tomography angiography (OCT-A) in type 2 diabetic patients without clinical diabetic retinopathy (DR). METHODS: This retrospective and cross-sectional study enrolled 74 diabetic patients without clinically evident DR for the study group and 34 healthy subjects for the control group. OCT-A parameters were measured to determine vascular density (VD) and the foveal avascular zone (FAZ) size in the superficial and deep capillary plexuses (SCP/DCP) of the retina. Clinical data were collected on sex, age, diabetes duration, hemoglobin A1c (HbA1c), hypertension, dyslipidemia, low-density lipoprotein cholesterol (LDL-C), estimated glomerular filtration rate (eGFR) and smoking status. Multiple linear regression analyses were performed to represent the associated clinical variables with OCT-A parameters in diabetic patients. RESULTS: In comparison between the study and control groups, the VD in the SCP and DCP were significantly lower in diabetic patients compared to the controls (P = 0.022 and 0.003, respectively). The FAZ size in the SCP and DCP were significantly greater in diabetic patients compared to the controls (P = 0.035 and <0.001, respectively). In age- and sex-adjusted multiple regression analyses for the diabetic patients, dyslipidemia and hypertension were negatively associated with SCP-VD (ß = -0.357, P = 0.002; ß = -0.239, P = 0.039, respectively). Current smoking was correlated with lower DCP-VD (ß = -0.255, P = 0.043). Greater SCP-FAZ size was associated with dyslipidemia and greater LDL-C (ß = 0.254, P = 0.013; ß = 0.232, P = 0.029, respectively), and greater DCP-FAZ size, with lower eGFR and greater LDL-C (ß = -0.355, P = 0.004; ß = 0.235, P = 0.037, respectively). CONCLUSIONS: Diabetic patients without clinical DR showed lower VD and greater FAZ size in the SCP and DCP compared to healthy controls. In diabetic patients without clinical DR, dyslipidemia and/or high LDL-C were important risk factors for retinal microvascular impairment. Hypertension, current smoking and lower eGFR also contributed to microvascular impairment.