Association of general and central obesity, and their changes with risk of knee osteoarthritis: a nationwide population-based cohort study.

In this study, we aimed to evaluate the association between general and central obesity, and their changes with risk of knee osteoarthritis (OA) using retrospective cohort data collected from the Korean National Health Insurance Service. We studied 1,139,463 people aged 50 and over who received a health examination in 2009. To evaluate the association between general and/or central obesity and knee OA risk, a Cox proportional hazard models were used. Additionally, we investigate knee OA risk according to the change in obesity status over 2 years for subjects who had undergone health examinations for 2 consecutive years. General obesity without central obesity (HR 1.281, 95% CI 1.270-1.292) and central obesity without general obesity (HR 1.167, 95% CI 1.150-1.184) were associated with increased knee OA risk than the comparison group. Individuals with both general with central obesity had the highest risk (HR 1.418, 95% CI 1.406-1.429). This association was more pronounced in women and younger age group. Remarkably, the remission of general or central obesity over two years was associated with decreased knee OA risk (HR 0.884; 95% CI 0.867-0.902; HR 0.900; 95% CI 0.884-0.916, respectively). The present study found that both general and central obesity were associated with increased risk of knee OA and the risk was highest when the two types of obesity were accompanied. Changes in obesity status have been confirmed to alter the risk of knee OA.

Bone Marrow Aspirate Concentrate versus Human Umbilical Cord Blood-Derived Mesenchymal Stem Cells for Combined Cartilage Regeneration Procedure in Patients Undergoing High Tibial Osteotomy: A Systematic Review and Meta-Analysis.

Background and objectives: Cartilage regeneration using mesenchymal stem cells (MSCs) has been attempted to improve articular cartilage regeneration in varus knee osteoarthritis (OA) patients undergoing high tibial osteotomy (HTO). Bone marrow aspirate concentrate (BMAC) and human umbilical cord blood-derived MSCs (hUCB-MSCs) have been reported to be effective. However, whether BMAC is superior to hUCB-MSCs remains unclear. This systematic review and meta-analysis aimed to determine the clinical efficacy of cartilage repair procedures with BMAC or hUCB-MSCs in patients undergoing HTO. Materials and Methods: A systematic search was conducted using three global databases, PubMed, EMBASE, and the Cochrane Library, for studies in which the clinical outcomes after BMAC or hUCB-MSCs were used in patients undergoing HTO for varus knee OA. Data extraction, quality control, and meta-analysis were performed. To compare the clinical efficacy of BMAC and hUCB-MSCs, reported clinical outcome assessments and second-look arthroscopic findings were analyzed using standardized mean differences (SMDs) with 95% confidence intervals (CIs). Results: The present review included seven studies of 499 patients who received either BMAC (BMAC group, n = 169) or hUCB-MSCs (hUCB-MSC group, n = 330). Improved clinical outcomes were found in both BMAC and hUCB-MSC groups; however, a significant difference was not observed between procedures (International Knee Documentation Committee score; p = 0.91, Western Ontario and McMaster Universities OA Index; p = 0.05, Knee Society Score (KSS) Pain; p = 0.85, KSS Function; p = 0.37). On second-look arthroscopy, the hUCB-MSC group showed better International Cartilage Repair Society Cartilage Repair Assessment grade compared with the BMAC group (p < 0.001). Conclusions: Both BMAC and hUCB-MSCs with HTO improved clinical outcomes in varus knee OA patients, and there was no difference in clinical outcomes between them. However, hUCB-MSCs were more effective in articular cartilage regeneration than BMAC augmentation.

Association between knee osteoarthritis and the risk of cardiovascular disease and the synergistic adverse effects of lack of exercise.

We aimed to determine whether knee OA is associated with CVD risk and all-cause death and to evaluate whether the association differs by exercise behavior. We used Korea National Health Insurance Service (KNHIS) database and included 201,466 participants (7572 subjects diagnosed with knee OA) who underwent health screening between 2009 and 2015. Those who had been diagnosed with knee OA or CVD before the index year were excluded. Cox proportional hazard models were used after adjusting for sociodemographic and CVD risk factors to evaluate the association between knee OA and CVD risk and all-cause death. Stratification analysis was further performed to determine the effect of exercise behavior on this relationship. During a median follow-up of 7.06 ± 2.24 years, 8743 CVD (2510 MI and 6553 stroke) cases developed. Individuals with knee OA had increased risks of CVD [hazard ratio (HR) 1.26, 95% confidence interval (CI) 1.15-1.38], myocardial infarction (MI) (HR 1.20, 95% CI 1.00-1.44), and stroke (HR 1.29, 95% CI 1.16-1.43) compared with those without knee OA. Those with knee OA who did not exercise had an increased risk of CVD (HR 1.25, 95% CI 1.11-1.40), whereas no significant increased CVD risk was observed in those with knee OA who exercised at least once a week (HR 1.11, 95% CI 0.96-1.28). There was no association between knee osteoarthritis and all-cause death. Knee OA was independently associated with an increased risk of CVD. Lack of exercise might have a synergistic adverse effect on the association between knee OA and CVD.

A novel technique of tibial tuberosity fracture fixation with two knotless suture anchors in an adult: A case report and literature review.

Tibial tuberosity fractures are uncommon in adults. Surgery for these types of fractures is performed similarly to that of tibial tuberosity avulsion fractures in adolescents. The most commonly introduced method is to fix the displaced bone fragments using screws or wires and, if necessary, use tension band wiring for augmentation. However, if the bone fragments are too small or severely comminuted, it may be challenging to fix them using the conventional method. In this study, we introduced a fixation method using two knotless suture anchors that could be attempted in such cases. Since this surgical method fixes the bone fragments without direct damage to the bone fragments, it can be used even when the fragments are small or comminuted. This technique achieved a nearly full active range of knee motion without an extension lag at four weeks postoperatively. In addition, there were no complications related to surgery, and a complete bone union was achieved without additional dislocation. Therefore, this surgical method may be a good alternative if a fixation of the fracture is considered problematic by the conventional method.

High prevalence of sarcopenia in Asian female patients awaiting primary total knee arthroplasty: Application of updated diagnostic tools from the Asian working group for sarcopenia.

INTRODUCTION: Sarcopenia, a loss of muscle mass and strength with aging, is associated with various TKA-related complications. In 2020, the AWGS published an undated guideline (AWGS 2019) based on studies from East and Southeast Asia. The purpose of this study was to determine the prevalence of sarcopenia in Asian female patients awaiting primary total knee arthroplasty due to advanced knee osteoarthritis using the updated AWGS criteria. MATERIALS AND METHODS: The present study included 138 female patients who scheduled for primary TKA with severe osteoarthritis. The included patients were assessed with use of an AWGS 2019 diagnostic criteria based on muscle strength, physical performance, and appendicular skeletal muscle mass. Clinical parameters related to sarcopenia were collected and knee status assessed using the Knee Society scoring system. To better define the association with age, patients were stratified into following four groups: <60, 60-69, 70-79, ≥80. The prevalence of sarcopenia was identified, and the association between sarcopenia and clinical variables was analyzed. RESULTS: The prevalence of sarcopenia and severe sarcopenia in this cohort according to the updated AWGS criteria was 35.5% and 21.7%. Prevalence of sarcopenia and severe sarcopenia significantly increased with advancing age (p = .003, p = .040, respectively). Although not statistically significant, the proportion of severe sarcopenia among sarcopenia also increased with age. Multivariate logistic regression analysis revealed that lower BMI and lower 25-OH-vitamin D3 level were independent risk factors associated with sarcopenia in women awaiting TKA. CONCLUSIONS: In conclusion, our study confirmed that sarcopenia is more prominent amongst female patients awaiting primary TKA than the general population. Therefore, orthopedic surgeons should consider sarcopenia prevention and intervention in this group. Further studies are needed to investigate the effect of TKA on sarcopenia, and the difference of TKA outcomes between groups with or without underlying sarcopenia.

Association Between Pain Catastrophizing and Central Sensitization Among Patients With Severe Knee Osteoarthritis Awaiting Primary Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is among the most successful types of surgery for the treatment of knee osteoarthritis (OA). However, nearly 20% of patients report unexpected pain after surgery. Recently, some studies have proposed that pain after TKA is related to pain catastrophizing (PC) and central sensitization (CS). However, there is no study comparing PC and CS for the same patient with knee OA requiring TKA. Thus, the goal of this study was to confirm the association between PC and CS among patients with knee OA awaiting primary TKA. This study was conducted with the clinical data of 153 patients collected between July 2019 and February 2021. Both PC and CS were evaluated with the Pain Catastrophizing Scale (PCS) and the Central Sensitizing Inventory (CSI). Patients with PCS scores higher than 30 were classified as high-level catastrophizing. Patients with CSI scores higher than 40 were classified as central sensitized. The distribution of PC and CS levels was confirmed, and the correlation between PC and CS was analyzed. A significant correlation was found between PCS and CSI scores, with Pearson's correlation coefficient of 0.606. Participants with high-level catastrophizing were 2.07 times more likely to belong to the central sensitized group compared with those who did not show high-level catastrophizing. Participants in the central sensitized group were 3.02 times more likely to belong to the high-level catastrophizing group than those who were not central sensitized. In conclusion, many patients with knee OA awaiting primary TKA had high-level catastrophizing, and a significant association was found between PC and CS. [Orthopedics. 2022;45(4):197-202.].

Interrupted Incision Fasciotomy for Acute Compartment Syndrome After Extracorporeal Membrane Oxygenation: Surgical Technique with a Report of Two Cases.

BACKGROUND: After extracorporeal membrane oxygenation (ECMO), acute compartment syndrome (ACS) can develop because of limb ischemia or reperfusion. The standard treatment for ACS is emergency fasciotomy. We introduced an interrupted incision technique instead of a long double-incision to reduce blood loss and subsequent hypovolemia in ECMO patients. CASE PRESENTATION: Two patients were treated venoarterial ECMO with heparinization by inserting cannulas into their right femoral vessels: Case #1 after emergency pulmonary thrombectomy for massive pulmonary thrombi and Case #2 after percutaneous coronary intervention for ST-elevation myocardial infarction with ventricular fibrillation. Some of the '5 P' signs of ACS were detected on their right legs. We treated them with the interrupted incision fasciotomy: four or five skin incisions of 2-3 cm each on lateral side; one 6-7 cm proximal skin incision with one or two separate short distal skin incisions of 1-1.5 cm each on the posteromedial side. The subcutaneous layer was also incised through these interrupted incisions; interrupted multiple "soft tissue tunnels" can be formed above muscle layer between the incisions. Once the fascia was exposed, the connected fasciotomy was performed with the knife blade facing subcutaneous layer, rather than muscle. The two patients' foot pulse, skin color, and muscle tone were immediately restored, and delayed primary wound closures were possible. Both patients were satisfied with their limb salvage and could walk with a little help using an orthosis or a cane. CONCLUSIONS: We recommend the interrupted incision fasciotomy as an attractive and effective technique for ACS, particularly after ECMO.

Transtibial Amputation with Removal of the Tibial Intramedullary Nail: Hardware Removal in a Retrograde Manner.

Transtibial amputation is the preferred strategy for treating a diabetic foot with an infection and necrosis. However, if a tibial intramedullary nail was previously inserted into the ipsilateral lower extremity, the nail must be removed to perform the transtibial amputation. In this special situation, the removal of the tibial intramedullary nail can cause various complications after transtibial amputation. We present a case and surgical technique report of a 46-year-old male with an uncontrolled diabetic foot with tibial intramedullary nail insertion. With the nail and ankle fixed by distal interlocking screws, a below-knee amputation was performed by removing the nail and the amputated limb together. This surgical method is expected to reduce postoperative complications such as infections and patella instability after the amputation of a diabetic foot.

3-h drain clamping is not effective to reduce total blood loss after primary total knowledge.

PURPOSE: Total knee arthroplasty (TKA) is a clinically efficacious surgical option for end-stage knee osteoarthritis. However, TKA increases the risk of serious bleeding and blood transfusion. The objective of this study was to evaluate the difference in postoperative blood loss in groups subjected to 3 h of clamping and non-clamping and determine the variations in rate and amount of transfusion after TKA between the two groups. MATERIALS AND METHODS: Propensity score matching of the group subjected to 3-h drain clamping (43 patients; September 2015 to April 2016) and the control group (43 patients; before initiating the clamping method) was performed in patients undergoing unilateral primary posterior stabilized TKA. The two groups were compared. We measured the total drained blood volume until the drain was removed 48 h after surgery, and we compared the preoperative levels of hemoglobin and hematocrit with levels observed on days 1 and 2 after surgery. We also determined the blood transfusion rate and volume as well as the occurrence of clamping-associated complications. RESULTS: In the group subjected to 3-h drain clamping, the mean volume of total drained blood was significantly lower than in the control group (333.8 ± 190.2 mL vs. 839.9 ± 339.8 mL, P <0.001). There was no significant difference in total blood loss between the two groups (1226.9 ± 488.1 mL vs. 1127.1 ± 424.5 mL, P = 0.315), but the hidden blood loss was significantly higher in the 3-h drain clamping group than in the control group (893.1 ± 487.7 mL vs. 294.7 ± 531.8 mL, P <0.001). Both the transfusion rate and amount in the 3-h drain clamped group were higher than in the control group but were not statistically significant (30.2% vs. 37.2%, P = 0.494 and 269.8 ± 483.8 mL vs. 316.3 ± 158.2 mL, P = 0.648, respectively). No significant differences in complications, including deep vein thrombosis, pulmonary thromboembolism, and oozing, were noted between the two groups (all, P = 1.000). CONCLUSIONS: The 3-h drain clamping method after primary TKA using posterior stabilized implant reduced the loss of postoperative drained blood. However, hidden blood loss was significantly higher in the 3-h drain clamping group; as a result, there were no differences in total blood loss and transfusion rate. The clamping method did not significantly alter the complication rate.

What should we be careful of ankle arthroscopy?

PURPOSE: Ankle arthroscopy has been used as a standard tool by foot and ankle surgeons. To overcome the narrowness of ankle joint, a noninvasive distraction technique is used for the successful visualization in ankle arthroscopy. The aim of this study was to investigate the incidence and type of complications associated with ankle arthroscopy using a noninvasive distraction technique and to report a troublesome complication. METHODS: We reviewed 514 patients' charts from 2003 to 2011. The same noninvasive distraction technique was used. Patients' demography, duration of follow-up, diagnoses, procedures, and complications related to ankle arthroscopy were analyzed. RESULTS: There were 388 male and 126 female; mean age was 37.2 years; mean follow-up duration was 33 months. The diagnoses were osteochondral lesion of talus, chronic ankle instability, anterolateral soft tissue impingement syndrome, and anterior bony impingement. We performed arthroscopic synovectomy, osteochondral procedure, bony spur excision, and loose body removal. The mean time of arthroscopic procedure was 47 min. There were neurologic complications (eight cases), skin necrosis of posterior thigh (three cases), instrument breakage (two cases), and superficial wound infection (one case). All complications were well resolved. The total duration of distraction plus tourniquet inflation exceeded 120 min in the three cases of skin necrosis. Skin necrosis was deemed to be resulted from the long tourniquet time. CONCLUSION: The noninvasive distraction technique is safe and effective for ankle arthroscopy. However, the distraction plus tourniquet requires attention because it can cause high pressure on posterior thigh resulting in soft tissue injury.

Feasibility of sentinel lymph node dissection using Tc-99m phytate in papillary thyroid carcinoma.

PURPOSE: Various methods of sentinel lymph node (SLN) biopsy in thyroid cancer have been introduced. Tc-99m phytate as a radiotracer has been successfully utilized for SLN biopsy in breast, cervix, and endometrial cancer. We assessed the feasibility of SLN dissection using Tc-99m phytate in papillary thyroid carcinoma (PTC). METHODS: Seventeen patients with PTC were prospectively enrolled. Ultrasound-guided peritumoral injection of 55.5 MBq Tc-99m phytate in 0.25-mL normal saline was performed. Preoperative single-photon emission-computed tomography (SPECT) and intraoperative gamma-probe were used for SLN detection during operation. RESULTS: Identification rate of SLNs was 70.6% (12 of 17) with SPECT, and 88.2% (15 of 17) with gamma-probe. Combined SPECT and gamma-probe had identification rates of 88.2% (15 of 17). Identification rates of SLNs in central LN compartments were 82.4% (14 of 17) and 41.2% (7 of 17) in lateral LN compartments. Overall sensitivity, specificity, positive predictive value, and negative predictive value of the results of SLN biopsy were 91.6%, 100%, 88.4%, and 100%, respectively. Eight patients (47.1%) had metastasis in SLNs; all patients had SLN metastasis in the central compartment and 2 patients had SLN metastasis in both the central and lateral compartments. CONCLUSION: Combined SPECT and gamma-probe could detect SLNs with an 88.2% identification rate in PTC. SLN biopsy using Tc-99m phytate is technically feasible. Further investigation is warranted for clinical application of Tc-99m phytate in PTC.

Diabetes mellitus and risk of thyroid cancer: a meta-analysis.

INTRODUCTION: Diabetes mellitus (DM) is an important risk factor for endocrine cancers; however, the association with thyroid cancer is not clear. We performed a systematic review and meta-analysis to clarify the association between thyroid cancer and DM. METHODS: We searched MEDLINE, PUBMED and EMBASE databases through July 2012, using search terms related to diabetes mellitus, cancer, and thyroid cancer. We conducted a meta-analysis of the risk of incidence of thyroid cancer from pre-existing diabetes. Of 2,123 titles initially identified, sixteen articles met our inclusion criteria. An additional article was identified from a bibliography. Totally, 14 cohort and 3 case-control studies were selected for the meta-analysis. The risks were estimated using random-effects model and sensitivity test for the studies which reported risk estimates and used different definition of DM. RESULTS: Compared with individuals without DM, the patients with DM were at 1.34-fold higher risk for thyroid cancer (95% CI 1.11-1.63). However, there was heterogeneity in the results (p<0.0001). Sensitivity tests and studies judged to be high quality did not show heterogeneity and DM was associated with higher risk for thyroid cancer in these sub-analyses (both of RRs = 1.18, 95% CIs 1.08-1.28). DM was associated with a 1.38-fold increased risk of thyroid cancer in women (95% CI 1.13-1.67) after sensitivity test. Risk of thyroid cancer in men did not remain significant (RR 1.11, 95% CI 0.80-1.53). CONCLUSIONS: Compared with their non-diabetic counterparts, women with pre-existing DM have an increased risk of thyroid cancer.

Metastatic follicular struma ovarii complicating pregnancy: a case report and review of the literature.

A 35-year-old woman was determined to have an ovarian cyst and underwent a right ovarian cystectomy at 10 weeks of gestation. A histopathological examination revealed follicular carcinoma arising in a teratoma. No evidence of metastasis was found after delivery. She underwent a total thyroidectomy, followed by radioactive iodine (RAI) therapy. However, her serum thyroglobulin level increased to 1,437 ng/ml (normal range: 0-52 ng/ml) after 10 months. Radioiodine scintigraphy and abdominal computed tomography revealed liver metastasis and peritoneal seeding. She underwent debulking surgery of the liver, right salpinx, and peritoneal seeding nodules. A pathological examination showed metastatic follicular carcinoma with focal poorly differentiated features. Adjuvant RAI therapy was restarted, and her serum thyroglobulin levels returned to normal. In conclusion, metastatic lesions were successfully treated with a combination of debulking surgery and RAI therapy. Close medical follow-up monitoring serum thyroglobulin levels is mandatory in such patients.