Alignment changes after open-wedge high tibial osteotomy result in offloading in the patellofemoral joint: a SPECT/CT analysis.

PURPOSE: The patellofemoral (PF) joint may be adversely affected by medial open-wedge high tibial osteotomy (OWHTO). This study aimed to evaluate the PF compartmental changes using combined single-photon emission computed tomography (SPECT) and conventional computed tomography (CT) after OWHTO to provide clinical guidance regarding the PF joint pressure and force. METHODS: Patients with medial osteoarthritis and varus malalignment > 5° were treated using OWHTO. Patients with a minimum 2-year follow-up were included in the study. The patellar positions were evaluated based on the radiographic parameters. The changes in chondral lesions during second-look arthroscopic examination were evaluated, and the PF joint arthritis grade was recorded on patellar Merchant radiographs using Kellgren-Lawrence classification. The PF compartmental changes according to SPECT/CT analysis after OWHTO were evaluated in all patients. The scintigraphic uptake was graded on four scales. Patients were divided into improved and unimproved groups according to the PF compartmental grade using the SPECT/CT uptake grading system. RESULTS: At a mean follow-up period of 47.0 months (range 25-74 months), the mean mechanical femorotibial angle changed significantly from varus 6.3° (range 5-12°) to valgus 2.6° (range 0-8°); p < 0.001) postoperatively. The radiological parameters presenting patellar positions, including the tibial slope, patellar convergence angle, and lateral tilt angle, did not change significantly between the preoperative values and the 2-year follow-up values. The mean patellar height significantly decreased (0.07 ± 0.14, p = 0.001 according to the Blackburn-Peel index and 0.32 ± 0.23, p < 0.001 using the modified Insall-Salvati ratio). The average tibial tubercle to trochlear groove (TT-TG) distance significantly decreased from 14.1 to 12.2 mm (p < 0.001). The Q angle also significantly decreased from 9.8o to 7.7o (p = 0.008). Chondral lesions of the patella and trochlear groove revealed significant deterioration; at 2 years after OWHTO, the arthritic grades of the PF joints worsened significantly, as determined by radiography (p = 0.007). Scintigraphic uptake in the PF joint was significantly lower (from 2 to 1) at 2 years postoperatively compared to that immediately after the index operation (p < 0.001). Only 4 of 56 (7.1%) patients showed increased uptake. Comparison between the improved and unimproved groups according to scintigraphic uptake changes revealed that the changes in the cartilage status on the patellar undersurface and TT-TG distance were the most significant predictive factors of increased scintigraphic uptake in the PF joint after OWHTO. CONCLUSION: Alignment correction by OWHTO result in PF compartment offloading and should be considered when identifying the surgical indications for OWHTO. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Clinical efficacy of adductor canal block in medial open wedge high tibial osteotomy.

BACKGROUND: To evaluate the effect of adductor canal block (ACB) on short-term postoperative outcomes in patients who underwent medial open-wedge high tibial osteotomy (MOWHTO) compared to that of a placebo. METHODS: 35 patients who underwent unilateral MOWHTO between 2017 and 2019 were prospectively reviewed and randomly divided into two groups: 19 patients who received a single-shot ACB and 16 patients who received a saline injection (a placebo group). Primary outcomes were (1) pain measured using the visual analog scale and range of motion, (2) patient satisfaction, (3) postoperative need for additional opioids, (3) quadriceps strength (the time to straight leg raising [SLR]), (4) clinical outcomes, and (5) complications. RESULTS: The pain score was lower in the ACB group than in the placebo group in the first 12 h (p = 0.04). ACB did not exhibit significantly less quadriceps strength weakness postoperatively. There was no statistical difference in the time to SLR (23.5 ± 17.7 h in ACB vs. 27.6 ± 11.4 in placebo, p = 0.520). The opioid consumption rate within postoperative 12 h was significantly decreased after ACB (16.7% in ACB, 70% in placebo, p = 0.017). The proportion of patients with more than 5 opioid injections within 72 h postoperatively was lower in the ACB group (8.3% in ACB, 50% in placebo, p = 0.043). Both groups did not show any localized and systemic complications. CONCLUSION: ACB following MOWHTO exhibited better outcomes than a placebo with respect to opioid consumption with no changes in the quadriceps strength and complications. LEVEL OF EVIDENCE: II, Prospectively comparative study.

Change of joint-line convergence angle should be considered for accurate alignment correction in high tibial osteotomy.

BACKGROUND: The alignment correction after high tibial osteotomy (HTO) is made both by bony correction and soft-tissue correction around the knee. Change of the joint-line convergence angle (JLCA) represents the soft-tissue correction after HTO, which is the angle made by a tangential line between the femoral condyles and the tibial plateau. We described the patterns of JLCA change and related factors after HTO and investigated the appropriate preoperative planning method. METHODS: Eighty patients who underwent HTO between 2013 and 2016 were included for this retrospective study. Standing, whole-limb radiograph, supine knee anteroposterior (AP) and lateral were measured on the preoperative and postoperative radiographs. The patterns of JLCA changes and related factors were analyzed. RESULTS: JLCA decreased by a mean of 0.9° ± 1.2° (P < 0.001) after HTO. Sixteen patients (20%, group II) showed a greater JLCA decrease ≥ 2°, while 64 (80%, group I) patients remained in a narrow range of JLCA change < 2°. Group II showed more varus deformity (varus 8.1° vs. varus 4.7° in the mechanical femorotibial angle, P < 0.001), greater JLCA on standing (4.9° vs. 2.1°, P < 0.001), and the difference of JLCA in the standing and supine positions (2.8° vs. 0.7°, P < 0.001) preoperatively compared to group I. The risk of a greater JLCA decrease ≥ 2° was associated with greater preoperative JLCA in the standing position and the difference between the JLCA in the standing and supine positions. Postoperative JLCA correlated better with preoperative JLCA in the supine position than those in the standing position. A preoperative JLCA ≥ 4° or the difference of preoperative JLCA in the standing and supine positions ≥ 1.7° was the cut-off value to predict a large JLCA decrease ≥ 2° after HTO in the receiver operating characteristic (ROC) curve analysis. CONCLUSIONS: Surgeons should consider the effect of the JLCA change during the preoperative planning and intraoperative procedure to avoid unintended overcorrection.

Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cell Implantation Versus Microfracture for Large, Full-Thickness Cartilage Defects in Older Patients: A Multicenter Randomized Clinical Trial and Extended 5-Year Clinical Follow-up.

BACKGROUND: There is currently no optimal method for cartilage restoration in large, full-thickness cartilage defects in older patients. PURPOSE: To determine whether implantation of a composite of allogeneic umbilical cord blood-derived mesenchymal stem cells and 4% hyaluronate (UCB-MSC-HA) will result in reliable cartilage restoration in patients with large, full-thickness cartilage defects and whether any clinical improvements can be maintained up to 5 years postoperatively. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A randomized controlled phase 3 clinical trial was conducted for 48 weeks, and the participants then underwent extended 5-year observational follow-up. Enrolled were patients with large, full-thickness cartilage defects (International Cartilage Repair Society [ICRS] grade 4) in a single compartment of the knee joint, as confirmed by arthroscopy. The defect was treated either with UCB-MSC-HA implantation through mini-arthrotomy or with microfracture. The primary outcome was proportion of participants who improved by ≥1 grade on the ICRS Macroscopic Cartilage Repair Assessment (blinded evaluation) at 48-week arthroscopy. Secondary outcomes included histologic assessment; changes in pain visual analog scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and International Knee Documentation Committee (IKDC) score from baseline; and adverse events. RESULTS: Among 114 randomized participants (mean age, 55.9 years; 67% female; body mass index, 26.2 kg/m2), 89 completed the phase 3 clinical trial and 73 were enrolled in the 5-year follow-up study. The mean defect size was 4.9 cm2 in the UCB-MSC-HA group and 4.0 cm2 in the microfracture group (P = .051). At 48 weeks, improvement by ≥1 ICRS grade was seen in 97.7% of the UCB-MSC-HA group versus 71.7% of the microfracture group (P = .001); the overall histologic assessment score was also superior in the UCB-MSC-HA group (P = .036). Improvement in VAS pain, WOMAC, and IKDC scores were not significantly different between the groups at 48 weeks, however the clinical results were significantly better in the UCB-MSC-HA group at 3- to 5-year follow-up (P < .05). There were no differences between the groups in adverse events. CONCLUSION: In older patients with symptomatic, large, full-thickness cartilage defects with or without osteoarthritis, UCB-MSC-HA implantation resulted in improved cartilage grade at second-look arthroscopy and provided more improvement in pain and function up to 5 years compared with microfracture. REGISTRATION: NCT01041001, NCT01626677 (ClinicalTrials.gov identifier).

The effect of interleukin-8 in the early stage after anterior cruciate ligament reconstruction with remnant preservation.

PURPOSE: We studied the effect of interleukin-8 (IL-8) as the factor for angiogenesis in the joint fluid of remnant-preserved anterior cruciate ligament reconstruction (RP-ACLR). MATERIALS AND METHODS: We measured 12 cytokines in joint fluid by multiplex assay and assessed the relationship between IL-8 and vascular endothelial growth factor (VEGF) concentrations. The signal intensity and mean sagittal diameter via postoperative magnetic resonance imaging (MRI) scans were evaluated and the stress X-ray image was analyzed at 3, 6, and 12 months after operation. RESULTS: The IL-8 concentration was highest 3 months postoperatively in those patients who underwent RP-ACLR. Clinical data also showed that the signal intensity and stress radiography of the knee graft were significantly better at the early postoperative stage. DISCUSSION: Our results show that IL-8 plays an important role in angiogenesis within 3 months after RP-ACLR. This effect yields better recovery after operation. RP-ACLR patients with high knee stability in clinical data were identical to those with high expression of IL-8 in experimental data. Therefore, IL-8 has been shown to help revascularization and ligamentization of the grafted tendon. These results indicate that IL-8 in RP-ACLR is an important factor for angiogenesis after operation. Unfortunately, the relationship of IL-8 and VEGF in vivo has not been studied. CONCLUSION: Our results showed that the IL-8 concentration was very high within 3 months after RP-ACLR operation. The increase in concentration of IL-8 over time was consistent with the increase in VEGF concentration. In the IL-8 clinical setting, MRI analysis showed that ACL synovialization and tension were better in patients who underwent the remnant preservation method. In addition, it was shown that RP-ACLR may be advantageous for early anterior stability within 1 year post operation and beneficial for tendon graft in the early stage post operation. Taken together, our findings suggest that IL-8 may contribute to angiogenesis which is helpful for revascularization and ligamentization of the graft tendon in the early stages of RP-ACLR.

Analysis of Mechanical Loading after Anatomic Anterior Cruciate Ligament Reconstruction Using Combined Single-Photon Emission Computerized Tomography and Conventional Computerized Tomography.

PURPOSE: This study was to evaluate changes of the mechanical loading pattern after anatomic anterior cruciate ligament (ACL) reconstruction by analyzing uptake patterns using combined single-photon emission computerized tomography and conventional computerized tomography (SPECT/CT). MATERIALS AND METHODS: On SPECT/CT, high signal intensity of the articular surface which shows biological activity and mean increase of mechanical loading was compared with that of the tibiofemoral shaft as a comparative signal. The proportion of positive signals was evaluated in all compartments of the operated knee. Analysis was performed according to combined injury. RESULTS: A relatively high proportion of positive signals was detected in the posterior zone of the lateral tibial plateau (23.5%) and trochlear groove (23.5%) although increased signal intensity was detected in all compartments. There was no statistical difference depending on the presence of combined injury and between single-bundle and double-bundle ACL reconstruction. CONCLUSIONS: Following anatomic ACL reconstruction, higher signal intensity was detected, particularly in the posterior part of the lateral tibial plateau and trochlear groove. Close observation for further signal changes or osteoarthritic changes would be required even if there was no combined injury and anatomic reconstruction was performed.

The mechanism and cause of anterior cruciate ligament tear in the Korean military environment.

PURPOSE: Anterior cruciate ligament (ACL) injury is very common but few studies have analyzed the injury mechanism and cause of ACL tear in a specific environment such as a military institution. The purpose of this study was to analyze the injury mechanism and cause of ACL injury in the military environment. Additionally, this study could provide outcomes that may aid future studies on prevention of ACL injury in military personnel. MATERIALS AND METHODS: This study retrospectively analyzed 168 patients who sustained ACL tear while in military service and underwent ACL reconstruction surgery in a military hospital. Analysis of the injury mechanism and the cause was evaluated by analyzing the medical records. Knee magnetic resonance imaging analysis was also conducted for further evaluation of associated injury. RESULTS: The majority of ACL injuries in the military environment occurred through non-contact injury. Changing direction (46.4%) was the most common lower-leg position, followed by landing with the knee in a valgus position (26.8%). The activity undertaken at the time of injury was exercise in 76.2% of cases and military training/daily activities in 23.8% of cases. The incidence of ACL injury was higher in the soldier compared to the officer group during exercise (P = 0.017). Soccer was the most common activity at the time of injury (54.1%), followed by military training/daily activities, futsal, and basketball. The most common injury time was between 30 and 60 min after the start of exercise. Commonly associated injury sites were the medial meniscus and the medial collateral ligament. CONCLUSIONS: The main mechanism of ACL injury occurring in the military environment was non-contact injury, especially on changing the direction of the lower leg. Soccer was the most frequent activity at the time of the injury. These findings suggested that preventive strategies against ACL injury in the military environment could effectively reduce the incidence of ACL injury.

Can osteoarthritic patients with mild varus deformity be indicated for high tibial osteotomy?

BACKGROUND: Whether osteoarthritic patients with mild varus deformity can be indicated for high tibial osteotomy (HTO) is not established. We examined the preoperative characteristics and postoperative outcomes of HTO in patients with mild genu varum compared to patients with greater varus deformity. METHODS: Seventy-one patients who underwent HTO were included in this retrospective study. Patients were divided into either mild varus (MV, mechanical femorotibial angle (mFTA) ≤4°, n = 31 (44%)) and greater varus (GV, mFTA >4°, n = 40 (56%)) groups. Preoperative characteristics on single photon emission computed tomography-computed tomography (SPECT-CT), magnetic resonance image and radiograph were evaluated. Alignment parameters and functional outcomes were compared pre- and postoperatively between the groups. RESULTS: Preoperative characteristics were similar between the two groups, except the severity of arthritis and coronal alignment. There was no difference in the proportion of hot uptake in the medial compartment; medial meniscus posterior horn root tear, complex or radial tear; bone marrow edema. Full-thickness cartilage defect of medial compartment was more frequent and arthritis grade was also more severe in GV group. Coronal alignment of the MV group was corrected into more valgus than the GV group (4.5° vs. 2.8° in mFTA, P = 0.012). Pre- and postoperative Knee Society knee and function scores were also comparable in the two groups. CONCLUSIONS: Mild varus patients are similar to greater varus patients regarding preoperative features and achieve the comparable functional outcome. A selected subset of osteoarthritic patients with mild varus deformity might be indicated for HTO. LEVEL OF EVIDENCE: III (Retrospective comparative study).

Clinical and radiologic evaluation of medial epicondylar osteotomy for varus total knee arthroplasty.

BACKGROUND: In varus total knee arthroplasty (TKA), a pathologic contracture of the medial soft tissue should be released for ligament balancing. A medial epicondylar osteotomy has been performed as an alternative method for this. The purpose of this study was to demonstrate the clinical and radiologic results of medial epicondylar osteotomy for varus TKA, focusing on the union type of osteotomy site. METHODS: The study retrospectively evaluated 61 cases with a mean femorotibial angle of 10.4° varus and a mean flexion contracture angle of 8.5±9.8°. Intraoperative medial and lateral gap difference in extension and 90° flexion was accepted at <2mm. Clinical outcomes (Knee Society Scores, range of motion) and radiologic outcomes (coronal alignment and valgus stability) were compared between the two groups divided by the union type of osteotomy site (bony union or fibrous union). RESULTS: The clinical and radiologic outcomes were significantly improved at the latest follow-up. Bony union was achieved in 39 (63.9%) patients, whereas 22 patients showed fibrous union. There was no difference in the varus-valgus angle on the stress radiographs between the bony union and fibrous union group (1.6±1.2° vs. 1.6±0.8°, P<0.916). The Knee Society Scores (knee, function), range of motion and radiographic alignment did not differ between the two groups. CONCLUSION: Medial epicondylar osteotomy was a good option for gap balancing during TKA, as it provided satisfactory clinical and radiological results, regardless of union type of the osteotomy site.

A Randomized, Multicenter, Phase III Trial to Evaluate the Efficacy and Safety of Polmacoxib Compared with Celecoxib and Placebo for Patients with Osteoarthritis.

BACKGROUND: The aim of this study was to evaluate the safety and analgesic efficacy of polmacoxib 2 mg versus placebo in a superiority comparison or versus celecoxib 200 mg in a noninferiority comparison in patients with osteoarthritis (OA). METHODS: This study was a 6-week, phase III, randomized, double-blind, and parallel-group trial followed by an 18-week, single arm, open-label extension. Of the 441 patients with knee or hip OA screened, 362 were randomized; 324 completed 6 weeks of treatment and 220 completed the extension. Patients were randomized to receive oral polmacoxib 2 mg (n = 146), celecoxib 200 mg (n = 145), or placebo (n = 71) once daily for 6 weeks. During the extension, all participants received open-label polmacoxib 2 mg. The primary endpoint was the change in Western Ontario and McMaster Universities (WOMAC)-pain subscale score from baseline to week 6. Secondary endpoints included WOMAC-OA Index, OA subscales (pain, stiffness, and physical function) and Physician's and Subject's Global Assessments at weeks 3 and 6. Other outcome measures included adverse events (AEs), laboratory tests, vital signs, electrocardiograms, and physical examinations. RESULTS: After 6 weeks, the polmacoxib-placebo treatment difference was -2.5 (95% confidence interval [CI], -4.4 to -0.6; p = 0.011) and the polmacoxib-celecoxib treatment difference was 0.6 (CI, -0.9 to 2.2; p = 0.425). According to Physician's Global Assessments, more subjects were "much improved" at week 3 with polmacoxib than with celecoxib or placebo. Gastrointestinal and general disorder AEs occurred with a greater frequency with polmacoxib or celecoxib than with placebo. CONCLUSIONS: Polmacoxib 2 mg was relatively well tolerated and demonstrated efficacy superior to placebo and noninferior to celecoxib after 6 weeks of treatment in patients with OA. The results obtained during the 18-week trial extension with polmacoxib 2 mg were consistent with those observed during the 6-week treatment period, indicating that polmacoxib can be considered safe for long-term use based on this relatively small scale of study in a Korean population. More importantly, the results of this study showed that polmacoxib has the potential to be used as a pain relief drug with reduced gastrointestinal side effects compared to traditional nonsteroidal anti-inflammatory drugs for OA.

The SPECT/CT Evaluation of Compartmental Changes after Open Wedge High Tibial Osteotomy.

PURPOSE: The purpose of this study was to evaluate compartmental changes using combined single-photon emission computerized tomography and conventional computerized tomography (SPECT/CT) after open wedge high tibial osteotomy (OWHTO) for providing clinical guidance for proper correction. MATERIALS AND METHODS: Analysis was performed using SPECT/CT from around 1 year after surgery on 22 patients who underwent OWHTO. Postoperative mechanical axis was measured and classified into 3 groups: group I (varus), group II (0°-3° valgus), and group III (>3° valgus). Patella location was evaluated using Blackburne-Peel (BP) ratio. On SPECT/CT, the knee joint was divided into medial, lateral, and patellofemoral compartments and the brighter signal was marked as a positive signal. RESULTS: Increased signal activity in the medial compartment was observed in 12 cases. No correlation was observed between postoperative mechanical axis and medial signal increase. Lateral increased signal activity was observed in 3 cases, and as valgus degree increased, lateral compartment's signal activity increased. Increased signal activity of the patellofemoral joint was observed in 7 cases, and significant correlation was observed between changes in BP ratio and increased signal activity. CONCLUSIONS: For the treatment of medial osteoarthritis, OWHTO requires overcorrection that does not exceed 3 valgus. In addition, the possibility of a patellofemoral joint problem after OWHTO should be kept in mind.

Effects of health literacy on treatment outcome and satisfaction in patients with mallet finger injury.

STUDY DESIGN: Prospective cohort. INTRODUCTION: Patient comprehension of their injury, its treatment, and health care provider's instructions plays an important role in health management and recovery from trauma. PURPOSE OF THE STUDY: This study investigates the effects of health literacy (the ability to obtain, process, and understand health information needed to make appropriate health decisions) on treatment outcomes and satisfaction in patients with mallet finger injuries. METHODS: A total of 72 patients who had been treated with an orthosis for an acute mallet finger injury were enrolled in this prospective study. Health literacy was measured according to the newest vital sign during the initial visit, and adherence according to the treatment protocol was rated at week 7 when orthotic intervention was ceased. At 6 months, a follow-up visit was conducted to assess the extensor lag, treatment satisfaction, and disability (through the Quick Disabilities of the Arm, Shoulder, and Hand score). Bivariate and multivariable analyses were performed to determine whether patient demographics, injury characteristics, and health literacy factors accounted for following outcomes: extensor lag, satisfaction, and disability. RESULTS: The newest vital sign scores were moderately correlated with patient adherence and age. Extensor lag was associated with an increase in age, poor adherence, and low health literacy, and these 3 factors accounted for 28% of the variation in the extensor lag. A greater disability was associated with poor adherence, which accounted for 12% of the variance in disability. Lower treatment satisfaction was associated with low health literacy and poor adherence, and these 2 factors accounted for 21% of the variation in treatment satisfaction. DISCUSSION AND CONCLUSIONS: Limited health literacy was associated with poor adherence in orthosis care for mallet finger injuries and led to poorer treatment outcomes in terms of extensor lag and treatment satisfaction. LEVEL OF EVIDENCE: 2B.

Effect of Metabolic Syndrome on the Outcome of Corticosteroid Injection for Trigger Finger: Matched Case-Control Study.

PURPOSE: To compare the efficacy of corticosteroid injections in treating trigger finger in patients with and without metabolic syndrome (MS). METHODS: Fifty-one patients with trigger finger and MS were matched for age and sex with 52 control patients without MS. All patients were treated with a single corticosteroid injection. The response to treatment, including objective triggering, tenderness at the A1 pulley, and Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH) were assessed at 6, 12, and 24 weeks' follow-up. Before the 24-week evaluation, 7 in the MS group and 10 in the control group were lost to follow-up. RESULTS: Prior to treatment, patients with MS had Quinnell grades and initial mean QuickDASH scores similar to those in the control group. The proportion of treatment failure for the MS group (49%) was significantly higher than that of control group (19%) after 6 months' follow-up. Unresolved triggering was more prevalent in patients in the MS group at the 12- and 24-week follow-ups. Local tenderness was more persistent in the MS group than in the control group throughout the 24 weeks of follow-up. After 24 weeks of follow-up, 14 patients (27%) in the MS group and 6 (12%) in the control group underwent surgical release. QuickDASH scores of the MS group were worse than those of the control group at the 12- and 24-week follow-ups. CONCLUSIONS: Trigger finger patients with MS are at risk of poorer functional outcomes and treatment failure after a single corticosteroid injection than age- and sex-matched controls. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Posterior Shift of Contact Point between Femoral Component and Polyethylene in the LCS Rotating Platform Implant under Weight Bearing Condition.

PURPOSE: To analyze the contact mechanics of the femoral component and polyethylene of the Low Contact Stress rotating platform (LCS-RP) in nonweight bearing and weight bearing conditions using full flexion lateral radiographs. MATERIALS AND METHODS: From May 2009 to December 2013, 58 knees in 41 patients diagnosed with osteoarthritis and treated with total knee arthroplasty (TKA) were included in this study. TKA was performed using an LCS-RP knee prosthesis. Full flexion lateral radiographs in both weight bearing and nonweight bearing condition were taken at least one month postoperatively (average, 28.8 months). Translation of femoral component was determined by the contact point between the femoral component and polyethylene. Maximum flexion was measured as the angle between the lines drawn at the midpoint of the femur and tibia. RESULTS: Posterior shift of the contact point in LCS-RP TKA was observed under weight bearing condition, which resulted in deeper flexion compared to LCS-RP TKA under nonweight bearing condition. CONCLUSIONS: In the LCS-RP TKA, the contact point between the femoral component and polyethylene moved posteriorly under weight bearing condition, and the joint was more congruent and maximum flexion increased with weight bearing.

Correlation of Uptake Patterns on Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) and Treatment Response in Patients with Knee Pain.

PURPOSE: To determine whether treatment response in patients with knee pain could be predicted using uptake patterns on single-photon emission computed tomography/computed tomography (SPECT/CT) images. METHODS: Ninety-five patients with knee pain who had undergone SPECT/CT were included in this retrospective study. Subjects were divided into three groups: increased focal uptake (FTU), increased irregular tracer uptake (ITU), and no tracer uptake (NTU). A numeric rating scale (NRS-11) assessed pain intensity. We analyzed the association between uptake patterns and treatment response using Pearson's chi-square test and Fisher's exact test. Uptake was quantified from SPECT/CT with region of interest (ROI) counting, and an intraclass correlation coefficient (ICC) calculated agreement. We used Student's t-test to calculate statistically significant differences of counts between groups and the Pearson correlation to measure the relationship between counts and initial NRS-1k1. Multivariate logistic regression analysis determined which variables were significantly associated with uptake. RESULTS: The FTU group included 32 patients; ITU, 39; and NTU, 24. With conservative management, 64 % of patients with increased tracer uptake (TU, both focal and irregular) and 36 % with NTU showed positive response. Conservative treatment response of FTU was better than NTU, but did not differ from that of ITU. Conservative treatment response of TU was significantly different from that of NTU (OR 3.1; p = 0.036). Moderate positive correlation was observed between ITU and initial NRS-11. Age and initial NRS-11 significantly predicted uptake. CONCLUSIONS: Patients with uptake in their knee(s) on SPECT/CT showed positive treatment response under conservative treatment.

Concomitant posterior cruciate ligament injuries with direct injury-related patellar fractures.

INTRODUCTION: Posterior cruciate ligament (PCL) injuries and direct injury-related patellar fractures have similar causative factors. However, the mechanisms underlying these injuries differ. We aimed to evaluate the incidence and relationship between PCL injuries and direct injury-related patellar fractures. MATERIALS AND METHODS: Of the 195 patients diagnosed with a patellar fracture at our clinic during 2007-2011, 104 required surgical treatment and underwent the posterior drawer test under general anesthesia and magnetic resonance imaging. We assessed whether the causes of trauma, fracture classification, compression of the fracture fragment, and fracture displacement were related to the incidence of PCL injuries. RESULTS: Of the 104 patients, 26 had concomitant PCL injuries with direct injury-related patellar fractures. Most of the PCL injuries were grades 1 and 2, observed in 14 and 9 patients, respectively. Among three patients with grade 3 PCL injury, only two required PCL reconstruction. No significant relationship was observed between the causes of trauma and the incidence of PCL injury. According to the fracture classification, lower pole and comminuted fractures were associated with higher incidence rates of PCL injury than transverse and vertical fractures. Compressed and displaced patellar fractures were also associated with higher incidence rates of PCL injury. CONCLUSION: Although a PCL injury requiring surgical intervention was extremely rare, 25 % patients who required surgery for patellar fractures presented with a PCL injury. The incidence of a PCL injury was higher in the lower pole, comminuted, displaced, and compressed patellar fractures.

Analysis of the Causes of Elevated C-Reactive Protein Level in the Early Postoperative Period After Primary Total Knee Arthroplasty.

BACKGROUND: Measurement of C-reactive protein (CRP) levels as a screening test for acute periprosthetic joint infection has high sensitivity and low specificity. We performed the present study to analyze the causes of elevated CRP levels in the early postoperative period after primary total knee arthroplasty (TKA). This study is intended to help the postoperative care of patients through understanding the factors associated with postoperative elevation of CRP. METHODS: The records for 627 patients who underwent primary TKA between January 2005 and May 2013 were examined. We excluded 50 patients for whom TKA with inflammatory arthritis or revision TKA was performed. We measured serial CRP levels during the 4-week early postoperative period in all included cases to find the cases that showed a CRP pattern of elevation-depression-elevation (a bimodal pattern). We analyzed the causes of re-elevated CRP levels in patients with a bimodal pattern of CRP change. RESULTS: Of the 577 included patients, 76 showed bimodal CRP elevation patterns. Eighteen elevations were caused by postoperative infections (periprosthetic infection), 10 by cardiovascular problems, 11 by gastrointestinal problems, 12 by urologic problems, 10 by respiratory problems, and 15 had unknown origins. CONCLUSION: Our study shows that elevated CRP levels after TKA can have various causes. Although there may be other causes for an elevated CRP, it is essential to perform a work-up for prosthetic joint infections. In addition, there seems to be a need to evaluate noninfectious causes and infection of other sites, in addition to periprosthetic infection.

Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy.

PURPOSE: The objectives of this study were (1) to evaluate the clinical and radiologic outcomes of open-wedge high tibial osteotomy focusing on patellofemoral alignment and (2) to search for correlation between variables and patellofemoral malalignment. METHODS: A total of 46 knees (46 patients) from 32 females and 14 males who underwent open-wedge high tibial osteotomy were included in this retrospective case series. Outcomes were evaluated using clinical scales and radiologic parameters at the last follow-up. Pre-operative and final follow-up values were compared for the outcome analysis. For the focused analysis of the patellofemoral joint, correlation analyses between patellofemoral variables and pre- and post-operative weight-bearing line (WBL), clinical score, posterior slope, Blackburn Peel ratio, lateral patellar tilt, lateral patellar shift, and congruence angle were performed. RESULTS: The minimum follow-up period was 2 years and median follow-up period was 44 months (range 24-88 months). The percentage of weight-bearing line was shifted from 17.2 ± 11.1 to 56.7 ± 12.7%, and it was statistically significant (p < 0.01). Regarding the clinical results, statistical significance was observed using all scores (p < 0.01). In the radiologic evaluation, patellar descent was observed with statistical significance (p < 0.01). Last follow-up lateral patellar tilt was decreased with statistical significance (p < 0.01). In correlation analysis between variables of patellofemoral malalignment, the pre-operative weight-bearing line showed an association with the change in lateral patellar tilt and lateral patellar shift (correlation coefficient: 0.3). CONCLUSION: After open-wedge high tibial osteotomy, clinical results showed improvement, compared to pre-operative values. The patellar tilt and lateral patellar shift were not changed; however, descent of the patella was observed. Therefore, mild patellofemoral problems should not be a contraindication of the open-wedge high tibial osteotomy. LEVEL OF EVIDENCE: Case series, Level IV.

Effects of Metabolic Syndrome on the Outcome of Carpal Tunnel Release: A Matched Case-Control Study.

PURPOSE: To compare outcomes of carpal tunnel release in patients with or without metabolic syndrome. METHODS: In a prospective consecutive series, 35 patients with metabolic syndrome and surgically treated carpal tunnel syndrome (CTS) were age- and sex- matched with 37 control patients without metabolic syndrome. Grip, pinch strength, perception of touch with Semmes-Weinstein monofilament, and Boston Carpal Tunnel Questionnaires (BCTQ) were assessed preoperatively and at 3, 6, and 12 months postoperatively. RESULTS: Patients with metabolic syndrome had more severe electrophysiologic grade of CTS than those without metabolic syndrome, but the 2 groups had similar preoperative grip/pinch strength and BCTQ scores. The BCTQ symptom score for the metabolic syndrome group was significantly greater than that of the control group at 3 months, and the BCTQ function score of the metabolic syndrome group was significantly greater than that of the control group at 3 and 6 months' follow-up. However, there was no significant difference in BCTQ symptom or functional scores between groups at 12 months' follow-up. There was no significant difference in grip strength between groups through 12 months' follow-up whereas the pinch strength of the control group was significantly greater than that of the metabolic syndrome group at 12 months' follow-up. Semmes-Weinstein monofilament test results were significantly greater in the control group than in the metabolic syndrome group at 3 and 6 months' follow-up but were similar at 12 months. CONCLUSIONS: Patients with CTS and metabolic syndrome have delayed functional recovery after carpal tunnel release, but noteworthy improvements in symptom severity and hand function are similar to those in patients without metabolic syndrome 1 year after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using an Outside-in Technique: Two- to Six-Year Clinical and Radiological Follow-up.

PURPOSE: We evaluated the clinical and radiological outcomes of double-bundle anterior cruciate ligament (ACL) reconstruction using an outside-in technique with a follow-up of two- to six-years, especially in terms of the sports activity level and radiological degeneration. MATERIALS AND METHODS: Sixty-seven patients who were available for a minimum two-year follow-up after double-bundle ACL reconstruction using an outside-in technique were retrospectively evaluated. The mean follow-up period was 43.7 months. The knee function and stability were evaluated before the operation, one year after the operation (short-term follow-up), and more than two years after the operation (last follow-up). RESULTS: Regarding the knee function, the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, and hop test showed significant improvement. Regarding the stability, the Lachman test, pivot shift test, KT-2000 arthrometer data, and anterior drawer radiographs using Telos showed significant improvement. Regarding the sports activity level, the patients who returned to pre-injury level activity was 68.7% according to the Tegner activity score and 76.1% according to the Cincinnati sports activity scale score. The incidence of aggravated degeneration or development of greater than IKDC grade A degeneration after surgery was 10.4%. CONCLUSIONS: Double-bundle ACL reconstruction using an outside-in technique showed favorable clinical and radiological outcomes with respect to the knee function and stability, joint degeneraion, and, especially, return to pre-injury sports activity.