Using a Markerless Motion Capture System to Identify Preinjury Differences in Functional Assessments.

Functional assessments identify biomechanical issues which may indicate risk for injury and can be used to monitor functional recovery after an injury or surgery. Although the gold standard to assess functional movements is marker-based motion capture systems, these are cost prohibitive and have high participant burden. As such, this study was conducted to determine if a markerless motion capture system could detect preinjury differences in functional movements between those who did and did not experience a noncontact lower extremity injury (NCLEI). A three-dimensional markerless motion capture system comprised an area of 3 m × 5 m × 2.75 m was used. Participants were Division I collegiate athletes wearing plain black long-sleeve shirts, pants, and running shoes of their choice. Functional assessments were the bilateral squat, right and left squat, double leg drop vertical jump, static vertical jump, right and left vertical jump, and right and left 5 hop. Measures were recorded once and the first NCLEI was recorded during the first year after measurement. Two-factor analysis of variance models were used for each measure with factors sex and injury status. Preinjury functional measures averaged 8.4 ± 3.4 minutes capture time. Out of the 333 participants recruited, 209 were male and 124 were female. Of those, 127 males (61%) and 92 females (74%) experienced later NCLEI. The most common initial NCLEI was nonanterior cruciate ligament knee injury in 38 females (41.3%) and 80 males (62.0%). Females had decreased flexion and lower valgus/varus displacement during the bilateral squat (p < 0.006). In addition, knee loading flexion for those who were not injured were more than that seen in the injured group, and was more pronounced for injured females (p < 0.03). The markerless motion capture system can efficiently provide data that can identify preinjury functional differences for lower extremity noncontact injuries. This method holds promise for effectively screening patients or other populations at risk of injury, as well as for monitoring pre-/postsurgery function, without the large costs or participant burden.

Minimally Invasive Knee Lateral Collateral Ligament Reconstruction Using Partial Biceps Femoris Tendon Autograft.

Lateral collateral ligament (LCL) is known as an important ligament to restrain varus force of the knee, especially in 30° knee flexion. From the anatomical study, the insertion of LCL at proximal fibula is intimately close to the insertion of biceps femoris (BF) tendon. Since LCL is infrequently injured in isolation, and with limitation in availability of autograft and allograft, this study proposes the partial anterior BF tendon as an alternative autograft source to reconstruct the LCL. This could be performed either by minimally invasive procedure or standard open technique. The core concept is to preserve the posterior part of the BF tendon to protect the peroneal nerve, by which exploration of this nerve and the proximal fibula prior to LCL reconstruction could be exempted. Minimally invasive LCL reconstruction using this autograft would essentially reduce soft tissue injury, shorten the operative time, and enhance recovery of the reconstructed knee.

Hybrid Inside-Out-Outside-In Meniscal Repair Through a Small Skin Incision.

Although the updated generation of all-inside devices for meniscal repair is more convenient to deploy and can provide comparable clinical outcomes with those of the inside-out procedure, the latter is still a very useful technique, giving many advantages over the former. The critical drawback of the conventional inside-out technique is the need for preparation of the accessory incision to prevent the risk of soft-tissue entrapment and neurovascular injury while retrieving the exiting meniscal needles, especially at the posterior corner of the knee. To minimize the space volume of the incision, a small, bluntly dissected track guided by the first exiting meniscal needle is sufficient in our hybrid inside-out-outside-in technique. The guiding cannula for the first meniscal needle passage is a commercial inside-out device, whereas the guiding cannula for retrieval in the subsequent meniscal needle passages is a spinal needle applied in an outside-in manner via the small track. Subsequent meniscal needles can be inserted in an inside-out or outside-in manner according to the design of the suture construct.

A comparative study comparing area of extension of posterior knee capsule via posteromedial injection: a cadaveric study.

BACKGROUND: Periarticular multimodal drug injection (PMDI) has gained popularity as common postoperative pain protocols in knee arthroplasty. PMDI sites can vary, but posterior capsule (PC) is a common injection site because of its abundance of pain nociceptors. PURPOSE: To prove the hypothesis whether posteromedial drug injection alone is sufficient to provide enough effect covering the PC in order to reduce risks of neurovascular injury. Secondary outcomes are to find proper volume of injection and safe zone for PMDI injection. METHODS: Ten fresh cadaveric knees were allocated into two equal groups, which differed in volume of dye injection: 25 ml and 50 ml. Dyes were injected into posteromedial capsule compartment, and the limbs were stored in a freezer for 2 weeks. Then the posterior compartment was carefully dissected to examine spreading of the dye solution. RESULTS: No dye staining was seen superficially beneath subcutaneous tissue of the knees. In deeper layer, the dye mostly occupied medially along the fascia covering semimembranosus muscles. However, dispersion was limited distally by intermuscular septa and popliteal vessels. The 50-ml injection group provided wider extension in the superficial layer, but not in the deep layer. CONCLUSION: The intermuscular septa and the fascia of popliteal vessels were shown to be the boundary between posteromedial and posterolateral compartments of the knee. Separate PMDI for both compartments is necessary to occupy the entire PC. We suggest that 1.5 cm lateral to lateral border of PCL insertion, just above popliteus tendon, is the safe zone for injecting PMDI into the posterolateral capsule.

Prognostic and risk factors in patients with metastatic bone disease of an upper extremity.

BACKGROUND: The aim of this study was to evaluate survival of metastatic bone disease of an upper extremity, and to identify the prognostic factors that influence survival. METHODS: Patients with metastatic bone disease of an upper extremity between 2008 and 2015 were reviewed from the database of a tertiary university hospital. RESULTS: Of 102 patients, 48 males and 54 females with a median age of 61 (range, 28-82 years), the humerus (64.7%), clavicle (13.7%), and scapula (12.7%) were the common sites for bone metastasis of an upper extremity. Fifty-nine (57.8%) presented with pathologic fracture. No history of cancer was found in 76.5% of patients. The mean onset of metastatic bone disease after the first diagnosis of primary cancer was 4.74 ± 14.07 months (range, 0-84 months). Lung (31.4%) was the most common primary cancer followed by liver (14.7%), breast (12.7%), thyroid (7.8%), and renal (3.9%). Eighty-two cases (80.39%) died from the disease such that the median survival was 4.08 months (95% CI 2.57-6.17). The significant risk factors were the type of primary tumor (P < 0.001, HR = 4.44; 95% CI, 1.99-9.90) and ECOG performance status (P = 0.021, HR = 2.11, 95% CI 1.12-3.99). CONCLUSIONS: Patients with metastatic bone disease of an upper extremity have a limited life expectancy. The type of primary tumor and ECOG performance status were the important prognostic factors that influenced overall survival. Our data help in the management of patients, families, and doctors, so as to avoid over- or under-treatment.

Direct Visualization of Suspensory Fixation Deployment in Knee Ligament Reconstructions Without Fluoroscopic Imaging.

The authors describe a technique for visualizing the deployment of femoral suspensory fixation during ligament reconstructions that avoids the need for intraoperative fluoroscopic radiographs. Many surgeons currently use intraoperative fluoroscopic radiographs to confirm satisfactory deployment of the suspensory button on the femur; however, this technique involves prolonged surgical time, additional costs, and radiation exposure to the surgical team and patient. The authors' technique uses novel leg and camera positioning to allow for direct visualization of the button deployment. This technique can greatly improve operating room efficiency, save money, and decrease radiation exposure during surgery. [Orthopedics. 2018; 41(4):e587-e590.].

Cholangiocarcinoma with spinal metastasis: Single center survival analysis.

The aim of this study was to perform a survival analysis of Cholangiocarcinoma (CCA) with spinal metastases. 55 cases of CCA with spinal metastases were retrospectively reviewed. We recorded age, sex, Kanofsky performance score, Frankel scale, number and region of affected vertebrae, presence of appendicular bone metastases, treatment received, and survival time; then performed a survival analysis. Overall median survival was 4months (95%CI, 2.89-5.11). Frankel A had the poorest survival (2months-95%CI, 1.15-2.85) compared to Frankel C and D (P=0.004 and <0.001, respectively). One-level spinal metastasis had the longest survival (8months-95%CI, 5.98-10.02) compared to two-level and more than two-level involvement (P=0.036 and 0.001, respectively). The higher Kanofsky score had the longer survival (11months-95%CI, 9.61-12.39) compared with the low and moderate score groups (P<0.001 and 0.012, respectively). Radiation therapy had a survival of 6months (95%CI, 3.41-8.59), significantly longer than the 3months for palliative spine surgery and 2months for palliative treatment alone. CCA resection and palliative spine surgery-when performed together and/or combined with other adjuvant treatment(s)-had a survival time of longer than 9months. In conclusion, CCA with spinal metastases had a poor median survival. A single level of affected spine, a Frankel scale of C or better, a moderate to high Kanofsky score, and radiation therapy were associated with significantly longer median survival. CCA resection and spinal surgery may play an important role in prolonging survival when used in conjunction with other adjuvant treatment modalities.

The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ): A validation of the reliability of the Thai version.

BACKGROUND: The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was developed by the Japanese Orthopedic Association (JOA) for assessment of lower back pain and lumbar spinal disease. We aimed to translate the JOABPEQ into Thai and test its reliability and validity in the Thai context. METHODS: The original JOABPEQ was translated into Thai in accordance with international recommendations. Then 180 lumbar spinal disease patients (mean age 58.58 ± 11.97, 68.3% female) were asked to complete the Thai version of the JOABPEQ twice at 2-week intervals. Test-retest reliability was analyzed using the intra-class correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was compared with the Thai version of the modified SF-36, and tested using the Spearman's rank correlation coefficient. RESULTS: The Thai JOABPEQ showed satisfactory test-retest reliability in all parameters (Intra-class Correlation Coefficient 0.761-0.862). The variables low back pain, walking ability, social life function, and mental health had satisfactory internal consistency (the respective Cronbach's α was 0.798, 0.721, 0.707, and 0.795). Only the lumbar function parameter showed moderate reliability (Cronbach's α = 0.654). All of the variables in the Thai JOABPEQ had a statistically positive correlation with the correspondent Thai SF-36 subscales (Spearman's rank correlation p value < 0.05). CONCLUSION: The Thai version of JOABPEQ had satisfactory internal consistency, test-retest reliability, and construct validity; it can be used as a reliable tool for assessing quality of life for lumbar spinal disease patients in Thailand.

The Sliding, Interlocking "8-2-Alpha Knot" for Arthroscopic Surgery.

We describe a sliding knot that is ideally lockable by transforming the original simple figure-of-8 configuration into a true interlocking, low-profile knot with an α-α configuration that creates strong primary knot security when tying is finished. Reversed half-hitches on alternating posts for secondary knot security can be added, but to save surgical time, these are not obligatory. Three simple knot-tying methods are presented; the choice of which to use is based on the surgeon's preference. Pulling the loop limb simultaneously on both sides of the knot could trigger premature knot flipping. Therefore, the loop limb should not be over-tensioned while sliding down the knot; the knot should always be "pulled" down, rather than "pushed" down, onto the target tissues. Because all loops would be disassembled after the post limb is removed from the knot, a salvage procedure is proposed to save the suture from unintentional premature locking.

Cross-cultural adaptation and validation of the reliability of the Thai version of the Hip disability and Osteoarthritis Outcome Score (HOOS).

HOOS was developed as an extension of the Western Ontario and McMaster Universities' Osteoarthritis Index questionnaire for measuring symptoms and functional limitations related to the hip(s) of patients with osteoarthritis. To determine the validity and reliability of the Thai version of the Hip disability and Osteoarthritis Outcome Score (HOOS) vis-à-vis hip osteoarthritis, the original HOOS was translated into a Thai version of HOOS, according to international recommendations. Patients with hip osteoarthritis (n = 57; 25 males) were asked to complete the Thai version of HOOS twice: once then again after a 3-week interval. The test-retest reliability was analyzed using the intraclass correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was tested by comparing the Thai HOOS with the Thai modified SF-36 and calculating the Spearman's rank correlation coefficients. The Thai HOOS produced good reliability (i.e., the ICC was greater than 0.9 in all five subscales). All of the Cronbach's alpha showed that the Thai HOOS had high internal consistency (Cronbach's alpha greater than 0.8), especially for the pain and ADL subscales (0.89 and 0.90, respectively). The Spearman's rank correlation for all five subscales of the Thai HOOS had moderate correlation with the Bodily Pain subscale of the Thai SF-36. The pain subscale of the Thai HOOS had a high correlation with the Vitality and Social Function subscales of the Thai SF-36 (r = 0.55 and 0.54)-with which the symptom subscale had a moderate correlation. The Thai version of HOOS had excellent internal consistency, excellent test-retest reliability, and good construct validity. It can be used as a reliable tool for assessing quality of life for patients with hip osteoarthritis in Thailand.

Validation of the reliability of the Thai version of the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ).

BACKGROUND: The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) was developed to resolve problems associated with the original evaluation of cervical myelopathic patients. The aim of this study was to translate the JOACMEQ into Thai as per international recommendations, and to test its reliability and validity in the Thai context METHODS: The JOACMEQ was translated into Thai, using international guidelines. Cervical myelopathy patients (n = 70; 31 males) were asked to complete the Thai version JOACMEQ twice (4 weeks apart). Test-retest reliability was analyzed using the intra-class correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was compared with the Thai version modified SF-36; using the Spearman's rank correlation coefficient. RESULTS: The Thai JOACMEQ produced good reliability (i.e., the ICC was >0.9 in 2 parameters and >0.8 in one). Overall the Cronbach's α for the 24 questions showed very high internal consistency (Cronbach's α > 0.8) and almost all Cronbach's α showed satisfactory internal consistency except for bladder function. The Spearman's rank correlation for all the JOACMEQ parameters had a positive correlation with all Thai SF 36 subscales, especially the quality of life parameter, which showed a strong correlation with all SF-36 subscales. CONCLUSION: The Thai version of the JOACMEQ had satisfactory internal consistency and test-retest reliability: it also had good construct validity. It can therefore be used as a reliable tool for assessing quality of life for cervical myelopathy patients in Thailand.

Fatal peripheral T-cell lymphoma following intramuscular tuberculosis of the forearm.

Intramuscular tuberculosis (TB) is a rare disease, and lymphoma may occur following a bout of TB. We report on an unusual presentation of peripheral T-cell lymphoma that occurred after an infiltrative lesion of intramuscular TB of the forearm in an immunocompetent host. To our knowledge, this is the first case where TB of a muscle presenting as an infiltrative lesion instead of an abscess developed into peripheral T-cell lymphoma.

Meta-analysis comparing bioabsorbable versus metal interference screw for adverse and clinical outcomes in anterior cruciate ligament reconstruction.

PURPOSE: To compare bioabsorbable screw (BS) against metal screw (MS) primarily on adverse effects and secondarily on clinical outcomes after single-bundle primary anterior cruciate ligament reconstruction. METHODS: Electronic searches were performed using search strategies meeting the mentioned purposes. Retrieved articles were selected for randomised controlled trials (RCTs) reporting at least 1-year follow-up. Potential studies were selected under inclusion and exclusion criteria. Risk of biases and data extraction was completed by two review authors. Discrepancies were resolved through discussion. Mean difference and risk ratio with 95 % confidence interval (CI) were used for continuous and binary outcomes, respectively. Heterogeneity was assessed using I (2). Pooled treatment effects with 95 % CI were estimated using the fixed- or random-effect model where appropriate. RESULTS: Eleven RCTs with 878 randomly allocated patients were included, and 711 patients (81 %) with eligible follow-up time up to 8 years were analysed. Comparing with the MS group, BS group using medial hamstring graft showed evidence of larger tunnel widening on the femoral side measured from radiographs or magnetic resonance imaging, though data could not be pooled because diverse measurement methods had been used. Significantly higher rates of effusion and screw breakage, and fewer cases of complete tunnel healing were reported in the BS group. Nevertheless, functional and clinical results were not deteriorated by the presence of these adverse effects for both short- and longer-term follow-ups. CONCLUSION: This is the first systematic review focusing on adverse effects of the BS, such as larger tunnel widening and higher rates of other complications. With these effects, routine use of the BS should be balanced with the advantages claimed. Cost-effectiveness is another issue, and well-designed RCTs are needed to better validate the implication.

Tibial inlay technique using hamstring graft for posterior cruciate ligament reconstruction and remnant revision.

The posterior tibial inlay technique is currently accepted as a standard operation for the posterior cruciate ligament-deficient knee. The classical technique requires a graft construct consisting of a bony part to be fitted into the posterior tibial socket. When an autogenous source is chosen, morbidity at the donor site generated by obtaining the graft with a bony part (e.g., bone-patellar tendon-bone or quadriceps tendon-bone) can be more serious than when obtaining the soft-tissue graft (e.g., hamstring). This study describes an alternative use of soft-tissue graft anchored in a bone socket at the posterior tibial margin by a transfixing cancellous screw. The graft is secured on top by a "bone washer" harvested from this bone socket to provide biological bone-tendon-bone healing. The posterior cruciate ligament remnant with integral fibers at the femur can have its tibial part revised, tensioned, and reattached concomitantly. This additional procedure is deemed to enhance joint stability and promote graft healing.