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Abstract Pure-tone audiometry (PTA) is the gold standard for assessing hearing loss. However, traditional PTA tests require specialized equipment, trained personnel, and a soundproof environment. Recently, smartphone-based PTA tests have been developed as an alternative method for hearing assessment. The aim of this study was to validate the accuracy and reliability of a smartphone application-based audiometry test. This study was conducted to assess the performance of application-based audiometry from November 2021 to January 2022. Pure-tone thresholds were measured using a smartphone application-based PTA test and compared with results obtained using a traditional audiometer in a sound-treated booth. The smartphone application used in this study was the "Care4Ear (Care4ear, version 1.0.6, MIJ Co., Ltd.)". Hearing thresholds less than 35 dB HL were classified as group A, 35-64 dB HL as group B, and 65 dB HL or greater as group C for the classification of hearing levels. We evaluated the accuracy of smartphone audiometry for each group and compared the results of frequency-specific hearing tests. Additionally, we examined the results of smartphone audiometry in individuals (n = 27) with asymmetric hearing loss. Seventy subjects completed both conventional audiometry and smartphone application-based hearing tests. Among the ears assessed, 55.7% were classified as group A, while 25.7% and 18.6% were classified as group B and group C, respectively. The average hearing threshold obtained from conventional pure-tone audiometry was 37.7 ± 25.2 dB HL, whereas the application-based hearing test yielded thresholds of 21.0 ± 23.0 dB HL. A significant correlation (r = 0.69, p

Background One-stage reconstruction with “thin perforator flaps” has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities.

Background: Patients with lower extremity burn injuries have decreased gait function. Gait dysfunctions are compensated by activation of executive areas such as the prefrontal cortex (PFC). Although robot-assisted gait training (RAGT) can improve gait function, the training mechanisms of RAGT are unknown. We aimed to determine the clinical effects of RAGT in patients with burns and investigate their underlying mechanisms. Methods: This single-blind, randomized controlled trial involved 54 patients with lower extremity burns. The RAGT group underwent RAGT using SUBAR® and conventional training. The control (CON) group underwent only conventional training. The primary outcome was cortical activity measured using a functional near-infrared spectroscopy device before and after 8 weeks of training to confirm the compensatory effect of gait dysfunction. The secondary outcomes were the functional ambulation category (FAC) to evaluate gait performance, 6-min walking test (6 MWT) distance to measure gait speed, isometric force and range of motion (ROM) of lower extremities to evaluate physical function, and the visual analog scale (VAS) score to evaluate subjective pain during gait. Results: PFC activation during the gait phase in the RAGT group decreased significantly compared with that of the CON. The VAS score decreased and FAC score improved after 8 weeks of training in both groups. The 6 MWT scores, isometric strengths (the left knee flexor and bilateral ankle plantar flexors), and the ROMs (the extensions of bilateral hip and bilateral knee) of the RAGT group were significantly improved compared with those of the CON. RAGT improved gait speed, lower extremity ROMs, and lower extremity muscles strengths in patients with burns. Conclusions: The improvement in gait speed and cerebral blood flow evaluation results suggests that the automatization of gait is related to the treatment mechanism during RAGT.

Objective To determine correlations of alternation motor rate (AMR), sequential motor rate (SMR), and maximum phonation time (MPT) with the severity of dysphagia in subacute stroke patients. Methods This was a retrospective chart review study. Data of 171 subacute stroke patients were analyzed. Patient’s AMR, SMR, and MPT data were collected from their language evaluations. Video fluoroscopic swallowing study (VFSS) was done. Data of dysphagia scales including penetration-aspiration scale (PAS), American Speech-Language-Hearing Association National Outcomes Measurement System (ASHA-NOMS) scale, clinical dysphagia scale (CDS), and videofluoroscopic dysphagia scale (VDS) were obtained. AMR, SMR, and MPT were compared between a non-aspirator group and an aspirator group. Correlations of AMR, SMR, and MPT with dysphagia scales were analyzed. Results AMR ("ka"), SMR, and modified Rankin Scale were significant associated factors between non-aspirator group and aspirator group, while AMR ("pa"), AMR ("ta"), and MPT were not. AMR, SMR, and MPT showed significant correlations with PAS score, ASHA-NOMS scale, CDS, VDS oral, and VDS pharyngeal scores. The cut-off value for distinguishing non-aspirator group and aspiration group was 18.5 for AMR ("ka") (sensitivity of 74.4%, specificity of 70.8%) and 7.5 for SMR (sensitivity of 89.9%, specificity of 61.0%). AMR and SMR were significantly lower in before-swallow aspiration group. Conclusion Articulatory diadochokinetic tasks that can be easily performed at the bedside would be particularly helpful in determining the oral feeding possibility of subacute stroke patients who cannot undergo VFSS, which is the gold standard for dysphagia assessment.

Abstract Background Femoral torsion is primarily measured by computed tomography (CT), which has cost and radiation exposure concerns. Recently, femoral anteversion measurement by a simple radiograph-based mobile application was developed for patients with cerebral palsy. This study aimed to validate the use of a mobile application that can reconstruct a three-dimensional model of the femur from conventional radiographs for adults. Methods Medical records of 76 patients undergoing conventional femur anteroposterior/lateral radiography and femur CT were reviewed. To measure femoral anteversion on the reconstructed 3-dimensional images from both the mobile application and CT, we drew a line which connects the posterior margins of each femoral condyle and another line which passes through the center of the femoral head and the midpoint of the femoral neck. After the reliability test, a single examiner measured femoral anteversion on the mobile application and CT. Pearson’s correlation analysis was used to assess the correlation between anteversion on the mobile application and CT. Results Femoral anteversion measured on both CT and the mobile application showed excellent reliability (intraclass correlation coefficients: 0.808–0.910). The correlation coefficient between femoral anteversion measured using CT and the mobile application was 0.933 (p

Objective To investigate the relationship between Trunk Impairment Scale (TIS) and lumbar spine bone mineral density (BMD) in subacute stroke patients. Methods Twenty-three subacute male stroke patients under the age of 65 were prospectively enrolled to exclude both postmenopausal and senile effects on BMD. The TIS, Berg Balance Scale, the Korean version of the Modified Barthel Index, and manual muscle test were measured at admission and 3 months after stroke onset. BMD of the bilateral lower extremities and lumbar vertebrae was measured by dual-energy X-ray absorptiometry 3 months after stroke onset. Results TIS at baseline (TIS_B) and TIS at 3 months after stroke (TIS_3m) showed significant correlations with lumbar BMD (TIS_B, r=0.522; TIS_3m, r=0.517). Through multiple regression analysis, the TIS_B was associated with lumbar BMD (adjusted R2=0.474). However, BMD of the bilateral lower extremities was not correlated with any clinical measurements except body mass index. Conclusion We found a relationship between TIS_B and lumbar BMD in subacute young male stroke patients. Stroke patients with poor trunk control in the early subacute stage would have low BMD of vertebral bones at 3 months. The TIS can be useful for estimating bone fragility in the lumbar vertebrae of subacute stroke patients.

In this study, we introduce a novel approach for synthesizing lignin-incorporated castor-oil-based cationic waterborne polyurethane (CWPU-LX), diverging significantly from conventional waterborne polyurethane dispersion synthesis methods. Our innovative method efficiently reduces the required solvent quantity for CWPU-LX synthesis to approximately 50% of that employed in traditional WBPU experimental procedures. By incorporating lignin into the polyurethane matrix using this efficient and reduced-solvent method, CWPU-LX demonstrates enhanced properties, rendering it a promising material for diverse applications. Dynamic interactions between lignin and polyurethane molecules contribute to improved mechanical properties, enhanced thermal stability, and increased solvent resistance. Dynamic interactions between lignin and polyurethane molecules contribute to improved tensile strength, up to 250% compared to CWPU samples. Furthermore, the inclusion of lignin enhanced thermal stability, showcasing a 4.6% increase in thermal decomposition temperature compared to conventional samples and increased solvent resistance to ethanol. Moreover, CWPU-LX exhibits desirable characteristics such as protection against ultraviolet light and antibacterial properties. These unique properties can be attributed to the presence of the polyphenolic group and the three-dimensional structure of lignin, further highlighting the versatility and potential of this material in various application domains. The integration of lignin, a renewable and abundant resource, into CWPU-LX exemplifies the commitment to environmentally conscious practices and underscores the significance of greener materials in achieving a more sustainable future.

Abstract Background Organogenesis from tonsil-derived mesenchymal cells (TMSCs) has been reported, wherein tenogenic markers are expressed depending on the chemical stimulation during tenogenesis. However, there are insufficient studies on the mechanical strain stimulation for tenogenic cell differentiation of TMSCs, although these cells possess advantages as a cell source for generating tendinous tissue. The purpose of this study was to investigate the effects of mechanical strain and transforming growth factor-beta 3 (TGF-β3) on the tenogenic differentiation of TMSCs and evaluate the expression of tendon-related genes and extracellular matrix (ECM) components, such as collagen. Results mRNA expression of tenogenic genes was significantly higher when the mechanical strain was applied than under static conditions. Moreover, mRNA expression of tenogenic genes was significantly higher with TGF-β3 treatment than without. mRNA expression of osteogenic and chondrogenic genes was not significantly different among different mechanical strain intensities. In cells without TGF-β3 treatment, double-stranded DNA concentration decreased, while the amount of normalized collagen increased as the intensity of mechanical strain increased. Conclusions Mechanical strain and TGF-β3 have significant effects on TMSC differentiation into tenocytes. Mechanical strain stimulates the differentiation of TMSCs, particularly into tenocytes, and cell differentiation, rather than proliferation. However, a combination of these two did not have a synergistic effect on differentiation. In other words, mechanical loading did not stimulate the differentiation of TMSCs with TGF-β3 supplementation. The effect of mechanical loading with TGF-β3 treatment on TMSC differentiation can be manipulated according to the differentiation stage of TMSCs. Moreover, TMSCs have the potential to be used for cell banking, and compared to other mesenchymal stem cells, they can be procured from patients via less invasive procedures.

Abstract Background Stationary cycling is commonly used for postoperative rehabilitation of physical disabilities; however, few studies have focused on the three-dimensional (3D) kinematics of rehabilitation. This study aimed to elucidate the three-dimensional lower limb kinematics of people with healthy musculoskeletal function and the effect of sex and age on kinematics using a controlled bicycle configuration. Methods Thirty-one healthy adults participated in the study. The position of the stationary cycle was standardized using the LeMond method by setting the saddle height to 85.5% of the participant’s inseam. The participants maintained a pedaling rate of 10–12 km/h, and the average value of three successive cycles of the right leg was used for analysis. The pelvis, hip, knee, and ankle joint motions during cycling were evaluated in the sagittal, coronal, and transverse planes. Kinematic data were normalized to 0–100% of the cycling cycle. The Kolmogorov-Smirnov test, Mann-Whitney U test, Kruskal-Wallis test, and k-fold cross-validation were used to analyze the data. Results In the sagittal plane, the cycling ranges of motion (ROMs) were 1.6° (pelvis), 43.9° (hip), 75.2° (knee), and 26.9° (ankle). The coronal plane movement was observed in all joints, and the specific ROMs were 6.6° (knee) and 5.8° (ankle). There was significant internal and external rotation of the hip (ROM: 11.6°), knee (ROM: 6.6°), and ankle (ROM: 10.3°) during cycling. There was no difference in kinematic data of the pelvis, hip, knee, and ankle between the sexes (p = 0.12 to 0.95) and between different age groups (p = 0.11 to 0.96) in all anatomical planes. Conclusions The kinematic results support the view that cycling is highly beneficial for comprehensive musculoskeletal rehabilitation. These results might help clinicians set a target of recovery ROM based on healthy and non-elite individuals and issue suitable guidelines to patients.

Objective The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries. Methods Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method. Results A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost. Conclusion This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Epidermal keratinocytes are highly activated, hyper-proliferated, and abnormally differentiated in the post-burn hypertrophic scar (HTS); however, the effects of scar fibroblasts (SFs) on keratinocytes through cell–cell interaction in HTS remain unknown. Here, we investigated the effects of HTSF-derived exosomes on the proliferation and differentiation of normal human keratinocytes (NHKs) compared with normal fibroblasts (NFs) and their possible mechanism to provide a reference for clinical intervention of HTS. Fibroblasts were isolated and cultured from HTS and normal skin. Both HTSF-exosomes and NF-exosomes were extracted via a column-based method from the cell culture supernatant. NHKs were treated for 24 or 48 h with 100 μg/mL of cell-derived exosomes. The expression of proliferation markers (Ki-67 and keratin 14), activation markers (keratins 6, 16, and 17), differentiation markers (keratins 1 and 10), apoptosis factors (Bax, Bcl2, caspase 14, and ASK1), proliferation/differentiation regulators (p21 and p27), and epithelial–mesenchymal transition (EMT) markers (E-cadherin, N-cadherin, and vimentin) was investigated. Compared with NF-exosomes, HTSF-exosomes altered the molecular pattern of proliferation, activation, differentiation, and apoptosis, proliferation/differentiation regulators of NHKs, and EMT markers differently. In conclusion, our findings indicate that HTSF-derived exosomes may play a role in the epidermal pathological development of HTS.

Objective To determine the most optimal needle insertion point of extensor indicis (EI) using ultrasound. Methods A total 80 forearms of 40 healthy volunteers were recruited. We identified midpoint (MP) of EI using ultrasound and set MP as optimal needle insertion point. The location of MP was suggested using distances from landmarks. Distance from MP to medial border of ulna (MP-X) and to lower margin of ulnar head (MP-Y) were measured. Ratios of MP-X to Forearm circumference (X ratio) and MP-Y to forearm length (Y ratio) were calculated. In cross-sectional view, depth of MP (Dmp), defined as middle value of superficial depth (Ds) and deep depth (Dd) was measured and suggested as proper depth of needle insertion. Results Mean MP-X was 1.37±0.14 cm and mean MP-Y was 5.50±0.46 cm. Mean X ratio was 8.10±0.53 and mean Y ratio was 22.15±0.47. Mean Dmp was 7.63±0.96 mm. Conclusion We suggested that novel optimal needle insertion point of the EI. It is about 7.6 mm in depth at about 22% of the forearm length proximal from the lower margin of the ulnar head and about 8.1% of the forearm circumference radial from medial border of ulna.

Abstract Background In order to optimize the tenogenic differentiation of mesenchymal stem cells (MSCs), researchers should consider various factors. However, this requires testing numerous experimental settings, which is costly and time-consuming. We aimed to assess the differential effects of transforming growth factor beta-3 (TGF-β3) on the tenogenesis of tonsil-derived MSCs (T-MSCs) and bone marrow-derived MSCs (BM-MSCs) using response surface methodology (RSM). Methods Bone marrow and tonsillar tissue were collected from four patients; mononuclear cells were separated and treated with 5 or 10 ng/mL of TGF-β3. A full factorial experimental design with a categorical factor of 0 was employed to study the effect of tension based on T-MSCs. Eighty-four trials were fitted with RSM and then used to obtain mathematical prediction models. Results Exposure of T-MSCs and BM-MSCs to TGF-β3 increased the expression of scleraxis (SCX), tenomodulin (TNMD), decorin, collagen I, and tenascin C. Expression of most of these factors reached a maximum after 2–3 days of treatment. The model predicted that the values of the tenocyte lineage-related factors assessed would be significantly increased at 2.5 days of culture with 2.7 ng/mL of TGF-β3 for T-MSCs and at 2.3 days of culture regardless of TGF-β3 concentration for BM-MSCs. Conclusions This study demonstrated that the RSM prediction of the culture time necessary for the tenogenic differentiation of T-MSCs and BM-MSCs under TGF-β3 stimulation was similar to the experimentally determined time of peak expression of tenocyte-related mRNAs, suggesting the potential of using the RSM approach for optimization of the culture protocol for tenogenesis of MSCs.

Compression therapy for burn scars can accelerate scar maturation and improve clinical symptoms (pruritus and pain). This study objectively verified the effect of pressure garment therapy in maintaining a therapeutic pressure range for hypertrophic scars. Sixty-five participants (aged 20~70 years) with partial- or full-thickness burns, Vancouver scar scale score of ≥4, and a hypertrophic scar of ≥4 cm × 4 cm were enrolled. Compression pressure was measured weekly using a portable pressure-monitoring device to regulate this pressure at 15~25 mmHg for 2 months. In the control group, the compression garment use duration and all other burn rehabilitation measures were identical except for compression monitoring. No significant difference was noted in the initial evaluations between the two groups (p > 0.05). The improvements in the amount of change in scar thickness (p = 0.03), erythema (p = 0.03), and sebum (p = 0.02) were significantly more in the pressure monitoring group than in the control group. No significant differences were noted in melanin levels, trans-epidermal water loss, or changes measured using the Cutometer® between the two groups. The efficacy of compression garment therapy for burn-related hypertrophic scars can be improved using a pressure-monitoring device to maintain the therapeutic range.

Chronic pain is common after burn injuries, and post-burn neuropathic pain is the most important complication that is difficult to treat. Scrambler therapy (ST) is a non-invasive modality that uses patient-specific electrocutaneous nerve stimulation and is an effective treatment for many chronic pain disorders. This study used magnetic resonance imaging (MRI) to evaluate the pain network-related mechanisms that underlie the clinical effect of ST in patients with chronic burn-related pain. This prospective, double-blinded, randomized controlled trial (ClinicalTrials.gov: NCT03865693) enrolled 43 patients who were experiencing chronic neuropathic pain after unilateral burn injuries. The patients had moderate or greater chronic pain (a visual analogue scale (VAS) score of ≥5), despite treatment using gabapentin and other physical modalities, and were randomized 1:1 to receive real or sham ST sessions. The ST was performed using the MC5-A Calmare device for ten 45 min sessions (Monday to Friday for 2 weeks). Baseline and post-treatment parameters were evaluated subjectively using the VAS score for pain and the Hamilton Depression Rating Scale; MRI was performed to identify objective central nervous system changes by measuring the cerebral blood volume (CBV). After 10 ST sessions (two weeks), the treatment group exhibited a significant reduction in pain relative to the sham group. Furthermore, relative to the pre-ST findings, the post-ST MRI evaluations revealed significantly decreased CBV in the orbito-frontal gyrus, middle frontal gyrus, superior frontal gyrus, and gyrus rectus. In addition, the CBV was increased in the precentral gyrus and postcentral gyrus of the hemisphere associated with the burned limb in the ST group, as compared with the CBV of the sham group. Thus, a clinical effect from ST on burn pain was observed after 2 weeks, and a potential mechanism for the treatment effect was identified. These findings suggest that ST may be an alternative strategy for managing chronic pain in burn patients.

Burn injuries and their treatment are extremely painful. This study aimed to determine whether virtual reality (VR) could reduce pain during robot-assisted gait training (RAGT) in burn patients by analyzing the cerebral blood flow (CBF) in the prefrontal cortex over time using functional near-infrared spectroscopy (fNIRS). The patients included in this study complained of a pain score ≥5 on a visual analog scale (VAS) during RAGT, which was performed 10 times for 2 weeks. Each session consisted of 15 min of VR application, with a 2-min break, and 15 min without VR. The average values of oxyhemoglobin and deoxyhemoglobin concentrations in the prefrontal cortex on fNIRS were calculated at four stages: temporal delay time with only RAGT, RAGT without VR, temporal delay time with RAGT and VR, and RAGT with VR. The pain scores and CBF were evaluated in sessions 1, 5, and 10 of the RAGT. The mean VAS pain scores were significantly lower (p < 0.05) in the experimental condition than in the control condition. Oxyhemoglobin in the prefrontal lobe significantly increased when RAGT was performed with VR. In conclusion, VR may be a strong nonpharmacological pain reduction technique for burn patients during physical therapy.

Objective To compare the effects of neuromuscular electrical stimulation (NMES) to abdominal muscles and back muscles on postural balance in post-stroke hemiplegic patients. Methods Thirty post-stroke hemiplegic patients were prospectively enrolled and randomly assigned to one of the three groups: core muscle-strengthening exercise (CME) with NMES to abdominal muscles (group A), CME with NMES to back muscles (group B), and CME alone (group C). All subjects underwent their targeted interventions for 30 minutes each day, 5 days per week for 3 weeks under a conventional stroke rehabilitation program. Subjects were evaluated using Korean version of Berg Balance Scale (K-BBS), Trunk Impairment Scale (TIS), Korean version of Modified Barthel Index (K-MBI), Weight Distribution Index (WDI), and Stability Index (SI) just before and 3 weeks after intervention. Results Changes in K-BBS (p

Cochlear synaptopathy refers to a subclinical hearing pathology which could potentially explain hearing difficulties within the normal hearing threshold; it is also called “hidden hearing loss”. We hypothesized that a temporary threshold shift in sudden sensorineural hearing loss (ISSNHL) also affects the function in the synapse. The aim of the study was to evaluate the presence of cochlear synaptopathy in patients who had completely recovered from unilateral SSNHL Nineteen patients who had completely recovered from ISSNHL from January 2018 to June 2021 were assessed. Complete recovery was established by pure tone audiometry (PTA) 3 months after treatment, according to the American Academy of Otolaryngology–Head and Neck Surgery criteria. Subjects completed the pure tone audiometry, speech audiometry and auditory brain stem response (ABR) test, and completed a questionnaire regarding hearing loss after hearing recovery. The ABR amplitudes of wave I and wave V, and the ratio of wave I/V of both ears (recovered side and healthy side) were assessed. A visual analog scale (VAS) and a hidden hearing loss questionnaire were used to evaluate subjective hearing difficulty. The ABR waves I of the recovered ears had a significantly lower amplitude (p = 0.002) than those of the healthy side, whereas there was no difference in wave V (p = 0.985) or in the ratio of wave I/V (p = 0.107). Some patients still felt mild hearing difficulty although their PTA results were normal, but there was no clear relationship between the VAS score, wave I amplitude and speech recognition scores. The present findings point to the possible existence of cochlear synaptopathy in ears that have completely recovered from unilateral sudden sensorineural hearing loss. We suggest that the causes of cochlear synaptopathy and of idiopathic sudden hearing loss may have something in common.

Summary:. The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient’s foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.

Assessment of functional independence and residual disability is very important for measuring treatment outcome after stroke. The modified Rankin Scale (mRS) and the modified Barthel Index (MBI) are commonly used scales to measure disability or dependence in activities of daily living (ADL) of stroke survivors. Lack of consensus regarding MBI score categories has caused confusion in interpreting stroke outcomes. The purpose of this study was to identify the optimal corresponding MBI and modified Rankin scale (mRS) grades for categorization of MBI. The Korean versions of the MBI (K-MBI) and mRS were collected from 5,759 stroke patients at 3 months after onset of stroke. The sensitivity and specificity were calculated at K-MBI score cutoffs for each mRS grade to obtain optimally corresponding K-MBI scores and mRS grades. We also plotted receiver operating characteristic (ROC) curves of sensitivity and specificity and determined the area under the curve (AUC). The K-MBI cutoff points with the highest sum of sensitivity and specificity were 100 (sensitivity 0.940; specificity 0.612), 98 (sensitivity 0.904; specificity 0.838), 94 (sensitivity 0.885; specificity 0.937), 78 (sensitivity 0.946; specificity, 0.973), and 55 (sensitivity 937; specificity 0.986) for mRS grades 0, 1, 2, 3, and 4, respectively. From this result, the K-MBI cutoff score range for each mRS grade can be obtained. For mRS grade 0, the K-MBI cutoff score is 100, indicating no associated score range. For mRS grades 1, 2, 3, 4, and 5, the K-MBI score ranges is from 99 to 98, 97 to 94, 93 to 78, 77 to 55, and under 54, respectively.The AUC for the ROC curve was 0.791 for mRS grade 0, 0.919 for mRS grade 1, 0.970 for mRS grade 2, 0.0 for mRS grade 3, and 0.991 for mRS grade 4. The K-MBI cutoff score ranges for representing mRS grades were variable; mRS grades 0, 1, and 2 had narrow K-MBI score ranges, while mRS grades 3, 4, and 5 exhibited broad K-MBI score ranges. mRS grade seemed to sensitively differentiate mild residual disability of stroke survivors, whereas K-MBI provided more specific information of the functional status of stroke survivors with moderate to severe residual impairment.

Category: Ankle, Hindfoot Introduction/Purpose: Varus limb malalignment results in an imbalance of force transmission to the knee joint, resulting in a concentrated load in the medial compartment. A varus knee correction may affect the ankle and subtalar joint, because the weight-bearing load on the lower extremity extends from the hip to the foot. A previous study suggested that the true mechanical axis of the lower limb should be calculated with a line from the center of the femoral head to the lowest point of the calcaneus, not to the center of the tibial plafond. Therefore, we performed this study to evaluate changes in the mechanical axis and weight- bearing line of the ankle after varus knee correction. Methods: Patients with a varus knee who were followed-up after they had undergone high tibial osteotomy (HTO) or total knee replacement arthroplasty (TKA) at an age of >20 years, and who had undergone preoperative and postoperative scanogram were included in this study. The hip-knee-ankle (HKA) angle, mechanical axis, and weight-bearing line (line from the center of the femoral head to the lowest point of the calcaneus) were measured on the radiographs. The point at which the mechanical axis and weight-bearing line passed through the tibial plafond was the ankle joint axis point. The postoperative change in the ankle joint axis point on the mechanical axis and weight-bearing line according to the HKA angle correction was adjusted by multiple factors using a linear mixed model. Results: A total of 257 limbs from 198 patients were included in this study. The preoperative HKA was 7.3 ± 4.7° and corrected to 0.4 ± 3.8°. Although the ankle axis points on both axes moved laterally after HTO and TKA, the ankle joint axis of the weight- bearing line showed a significant larger lateral movement (22.5±35.7%) (Fig.) than that of the mechanical axis (15.7±16.0%) in terms of rate of change (p = 0.006). The ankle joint axis point on the weight-bearing line moved laterally by 0.9% per degree of postoperative HKA angle decrease (p < 0.001). The change in the ankle joint axis point on the mechanical axis was not statistically significant after HTO and TKA (p = 0.223). Conclusion: The mechanical axis and weight-bearing line of the ankle moved laterally after the varus knee correction. The ankle joint axis on the weight-bearing line moved laterally as the HKA angle decreased after the surgery, whereas the varus knee correction did not significantly affect the ankle joint axis on the mechanical axis. The varus knee correction might affect the subtalar joint as well as the ankle joint. Therefore, we believe that our findings warrant consideration in pre- and postoperative evaluations using the weight-bearing line of patients undergoing varus knee correction.

Abstract Background Concurrent prophylactic femoral varization osteotomy (FVO) for stable hips has been performed in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for the contralateral displaced hip. However, there is currently a lack of studies investigating the outcome after the prophylactic FVO in stable hip. This study investigated the outcomes after FVO in stable hips with CP and influencing factors. In addition, this study compared the outcomes with those after hip reconstructive surgery in the contralateral displaced hip. Methods This study included 119 CP patients with 224 hips (80 stable, 144 displaced) undergoing hip reconstructive surgery including FVO. Migration percentage (MP), neck-shaft angle (NSA), and head-shaft angle (HSA) were measured through preoperative and follow-up hip radiographs. All hips were divided into the stable (MP ≤ 33%) and displaced hip groups (MP > 33%) according to the preoperative radiographs, and the annual changes in the radiographic indices after FVO were analyzed. Results In stable hip group, MP did not significantly increase over time (p = 0.057) after prophylactic FVO. In displaced hip group, MP significantly increased over time (1.6%/year, p

Abstract Background Simultaneous motion of the knee and ankle joints is required for many activities including gait. We aimed to evaluate the influence of surgery involving tendons around the knee on ankle motion during gait in the sagittal plane in cerebral palsy patients. Methods We included data from 55 limbs in 34 patients with spastic cerebral palsy. Patients were followed up after undergoing only distal hamstring lengthening with or without additional rectus femoris transfer. The patients’ mean age at the time of knee surgery was 11.2 ± 4.7 years, and the mean follow-up duration was 2.2 ± 1.5 years (range, 0.9–6.0 years). Pre- and postoperative kinematic variables that were extracted from three-dimensional gait analyses were then compared to assess changes in ankle motion after knee surgery. Outcome measures included ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, peak ankle dorsiflexion during swing, and dynamic range of motion of the ankle. Various sagittal plane knee kinematics were also measured and used to predict ankle kinematics. A linear mixed model was constructed to estimate changes in ankle motion after adjusting for multiple factors. Results Improvement in total range of motion of the knee resulted in improved motion of the ankle joint. We estimated that after knee surgery, ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, peak ankle dorsiflexion during swing, and dynamic range of motion of the ankle decreased, respectively, by 0.4° (p = 0.016), 0.6° (p

ObjectiveTo investigate the immediate therapeutic effects of mental singing while walking intervention on gait disturbances in hemiplegic stroke patients.MethodsEligible, post-stroke, hemiplegic patients were prospectively enrolled in this study. The inclusion criteria were a diagnosis of hemiplegia due to stroke, and ability to walk more than 10 m with or without gait aids. Each patient underwent structured music therapy sessions comprising 7 consecutive tasks, and were trained to sing in their mind (mental singing) while walking. Before, and after training sessions, gait ability was assessed using the 10-Meter Walk Test (10MWT), the Timed Up and Go test (TUG), gait velocity, cadence and stride length.ResultsTwenty patients were enrolled in the interventions. Following the mental singing while walking intervention, significant improvement was observed in the 10MWT (13.16±7.61 to 12.27±7.58; p=0.002) and the TUG test (19.36±15.37 to 18.42±16.43; p=0.006). Significant improvement was also seen in gait cadence (90.36±29.11 to 95.36±30.2; p

Abstract Background We performed this study to investigate the influence of recombinant human growth hormone (rhGH) therapy on radiographic indices of the spine using propensity-matched analysis. Methods Patients with idiopathic short stature who had undergone both growth hormone therapy and whole-spine radiographs more than twice prior to 15 years of age were included in the patient group. Other patients who had undergone whole-spine radiographs more than twice prior to the same age during regular checkups for idiopathic scoliosis formed the control group. Propensity-matched analysis was performed to reduce the selection bias. The scoliosis Cobb angle, coronal balance, apical vertebral translation, apical rotation, and pelvic obliquity were measured from the radiographs taken at the periodic follow-ups. The rate of progression of the measurements was adjusted by multiple factors using a linear mixed model with sex as the fixed effect and age and each subject as the random effects. Results Using a propensity-matched analysis, 48 patients were finally included in both groups. The scoliosis Cobb angle increased by 1.0° (p

This study investigated the effects of robot-assisted gait training (RAGT) on gait function in burn patients. Briefly, 40 burn patients were randomly divided into an RAGT group or a conventional training (CON) group. SUBAR® (Cretem, Korea) is a wearable robot with a footplate that simulates normal gait cycles. The RAGT group underwent 30 min of robot-assisted training using SUBAR® with 30 min of conventional physiotherapy once a day, 5 days a week for 12 weeks. Patients in the CON group received 30 min of overground gait training and range-of-motion (ROM) exercises twice a day for 5 days a week for 12 weeks. The RAGT group and the CON group underwent 60 min of training per day. The intervention frequency and duration did not differ between the RAGT group and the CON group. The main outcomes were functional ambulatory category (FAC); 6-min walking test (6MWT); visual analogue scale (VAS) during gait movement; ROM; and isometric forces of bilateral hip, knee, and ankle muscles before and after 12 weeks of training. The results of the VAS, FAC, and 6MWT (8.06 ± 0.66, 1.76 ± 0.56, and 204.41 ± 85.60) before training in the RAGT group improved significantly (4.41 ± 1.18, 4.18 ± 0.39, and 298.53 ± 47.75) after training (p < 0.001, p < 0.001, and p < 0.001). The results of the VAS, FAC, and 6MWT (8.00 ± 1.21, 1.75 ± 0.58, and 220.94 ± 116.88) before training in the CON group improved significantly (5.00 ± 1.03, 3.81 ± 1.05, and 272.19 ± 110.14) after training (p < 0.001, p < 0.001, and p = 0.05). There were differences in the improvement of results of the VAS, FAC, and 6MWT between groups after training, but they were not statistically significant (p = 0.23, p = 0.14, and p = 0.05). The isometric strengths of the right hip extensor (p = 0.02), bilateral knee flexor (p = 0.04 in the right, and p = 0.001 in the left), bilateral knee extensor (p = 0.003 in the right, and p = 0.002 in the left), bilateral ankle dorsiflexor (p = 0.04 in the right, and p = 0.02 in the left), and bilateral ankle plantarflexor (p = 0.001 in the right, and p = 0.008 in the left) after training were significantly improved compared with those before training in the RAGT group. The ROMs of the right knee extension (p = 0.03) and bilateral ankle plantarflexion (p = 0.008 in the right, and p = 0.03 in the left) were significantly improved compared with measurements before training in the RAGT. There were no significant differences of the isometric strengths and ROMs of the bilateral hip, knee, and ankle muscles after training in the CON group. There were significant improvements in the isometric strengths of the left knee flexor (p = 0.01), left ankle dorsiflexor (p = 0.01), and left ankle plantarflexor (p = 0.003) between the two groups. The results suggested that RAGT is effective to facilitate early recovery of muscles strength after a burn injury. This is the first study to evaluate the effectiveness of RAGT in patients with burns compared with those receiving conventional training. The absence of complications in burn patients provides an opportunity to enlarge the application area of RAGT.

Postburn hypertrophic scarring is a common complication in burn injuries to the hands, often associated with impaired hand function. We evaluated the effects of extracorporeal shock wave therapy (ESWT), compared to a sham stimulation therapy, on hypertrophic scars of the hand caused by burn injury and investigated its effects on hand function. This was a double-blinded, randomized, controlled trial of 48 patients with a burn to their dominant right hand. The parameters of ESWT were as follows: energy flux density, 0.05–0.30 mJ/mm2; frequency, 4 Hz; 1000 to 2000 impulses per treatment; four treatments, once a week for four weeks. The outcomes measured were as follows: a 10-point visual analogue scale pain score; Vancouver scar scale for scar vascularity, height, pliability and pigmentation; ultrasound measurement of scar thickness; Jebsen−Taylor hand function test; grip strength; Perdue pegboard test; and the Michigan hand outcomes questionnaire. The change in the score from baseline to post-treatment was compared between the two groups. ESWT improved the pain score (p = 0.001), scar thickness (p = 0.018), scar vascularity (p = 0.0015), and improved hand function (simulated card-turning, p = 0.02; picking up small objects, p = 0.004). The other measured outcomes were not different between the two groups. ESWT is effective in decreasing pain, suppressing hypertrophic scarring, and improving hand function.

Hands are the most frequent burn injury sites. Appropriate rehabilitation is essential to ensure good functional recovery. Virtual reality (VR)-based rehabilitation has proven to be beneficial for the functional recovery of the upper extremities. We investigated and compared VR-based rehabilitation with conventional rehabilitation (CON) in patients with burned hands. Fifty-seven patients were randomized into a VR or CON group. Each intervention was applied to the affected hand for four weeks, and clinical and functional variables were evaluated. Hand function was evaluated before intervention and four weeks after intervention using the Jebsen-Taylor hand function test (JTT), Grasp and Pinch Power Test, Purdue Pegboard test (PPT), and Michigan Hand Outcomes Questionnaire (MHQ). The JTT scores for picking up small objects and the MHQ scores for hand function, functional ADL, work, pain, aesthetics, and patient satisfaction were significantly higher in the VR group than in the CON group (p < 0.05). The results suggested that VR-based rehabilitation is likely to be as effective as conventional rehabilitation for recovering function in a burned hand. VR-based rehabilitation may be considered as a treatment option for patients with burned hands.

Category: Basic Sciences/Biologics Introduction/Purpose: Tendon repair has been a challenging issue for surgeons in treating. Although tissue engineering with mesenchymal stem cells (MSC) have been used for tendon repair in both in vivo and in vitro, the stem cells are obtained through invasive procedures, and there is usually a lack of adequate numbers for clinical use. The purpose of this study was to compare the potential of tri-lineage differentiation and to investigate the potential of tenogenic differentiation of human tonsil derived MSCs (T-MSCs), bone marrow derived MSCs (BM-MSCs), and adipose tissue derived MSCs (AD-MSCs). Methods: Each tissue was obtained from 8 patients. After isolation of MSCs, flow cytometry analysis was used to characterize the phenotypes of the MSCs. Differentiation capacity to adipo-, osteo-, and chondrocytes were induced by culturing each MSCs for 3 weeks in commercially available media. Each MSCs was treated with 5ng/ml and 10ng/ml of TGF-ß3 with vehicle control. Results: Immunophenotypic surface marker analysis of BM-MSC, AD-MSC, and TMSCs revealed that these MSCs expressed a typical MSCs. mRNA expression levels of the markers for tri-lineage differentiation were significantly lower in TMSC than other MSCs. The tenogenic transcription factor, scleraxis, showed a statistically significant increase in all MSCs differentiation groups except for the 7th day TMSC differentiation group (Figure). Gene expression of tenascin-C, an ECM glycoprotein, was specifically expressed in the T-MSC differentiation group at 14 days (Figure). Comparing the ratio of collagen 1 to collagen 3 genes, the BM-MSC showed a decrease in the ratio on days 3 and 7 unlike AD-MSCs and TMSCs. Only TMSC showed a significant increase in the ratio compared with other MSCs on the 14th day. Conclusion: The tonsil-MSC has low fat, bone and cartilage differentiation potential and has excellent tendon-specific differentiation potential, thus being highly useful as a tendon-tailored cell therapy agent.

Category: Basic Sciences/Biologics Introduction/Purpose: Researchers should consider various potential factors that affect tenogenic differentiation of MSCs. Numerous experimental settings are associated with high cost and time. Response surface methodology (RSM), a component in the design of experiments (DOE), is gaining recognition as a powerful tool in optimizing conditions for the production of industrially important products such as chemicals and enzymes. The purpose of this study was to access the differential effects of transforming growth factor beta 3 (TGF-β3) on the tenogenesis of tonsil-derived mesenchymal stem cells (T-MSCs) and bone marrow-derived mesenchymal stem cells (BM-MSCs) using RSM. Methods: Bone marrow was collected from four patients (mean age: 79.0±2.2) and mononuclear cells were separated. The tonsillar tissues were collected from four patients (mean age: 7.6±0.6). After isolation of MSCs, they were treated with 5ng/ml and 10ng/ml of TGF-β3 with vehicle control. The full-factorial experimental design was employed to study the effect of tension based on T-MSCs. The design was composed of three levels being coded as -1, 0 and +1 and a total of 18 runs were carried out in duplicates to optimize the level of chosen variables, such as days and amount. A total of 84 trials were utilized and fitted with RSM; they were then used to obtain mathematical prediction models. Results: Exposure of TGF-β3 to T-MSCs and BM-MSCs resulted in an increase in the expression of SCX, TNMD, decorin, collagen I, and tenacin C. Most tenocyte lineage-related factors from T-MSCs and BM-MSCs presented a maximum increase in 2- 3 day treatment. Considering all of tenocyte lineage-related factors that we assessed, the predicted value of the factors was significantly induced at 2.7 ng/mL of TGF-β3 (p < 0.001) on 2.5-day culture (p = 0.001). (Fig A) Considering all of tenocyte lineage-related factors that we assessed, the predicted value of the factors was significantly induced on 2.3-day culture (p = 0.004) regardless of the concentration of TGF-β3. (Fig B) Conclusion: We demonstrated that tenocyte-like cells can be successfully differentiated from T-MSCs and BM-MSCs under TGF- β3 stimulation. This study demonstrated that T-MSCs and BM-MSCs in tenogenic stimulation with TGF-β3 have a similar tenogenic differentiation potential using RSM.

Category: Bunion Introduction/Purpose: There is a lack of quantitative studies on the progression of juvenile hallux valgus deformity. Therefore, we performed this study to estimate an annual change of radiographic indices for juvenile hallux valgus. Methods: We reviewed medical records of consecutive patients under the age of 15 with juvenile hallux valgus who underwent weight-bearing foot radiographs more than twice, and were followed over a period of one year or more. A total of 133 feet from 69 patients were included. Hallux valgus angle, hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-1st metatarsal angle, anteroposterior talo-2nd metatarsal angle, and lateral talo-1st metatarsal angle were measured and were used as a study criteria. The progression rate of hallux valgus angle was adjusted by multiple factors including the use of a linear mixed model with gender and radiographic measurements as the fixed effects and laterality and each subject as the random effect. Results: Our results demonstrate that the value of hallux valgus angle on the radiographs progressed as the patients grew older. The hallux valgus angle increased by 0.8° per year (p

Category: Hindfoot Introduction/Purpose: Posterior tibial tendon’s condition has traditionally been evaluated using ultrasonography or magnetic resonance imaging, but recent advancements in radiography have increased the resolution of radiographic soft tissue images. We performed this study to examined whether the posterior tibial tendon could be screened using anteroposterior foot radiographs, based on interobserver agreement and accuracy. Methods: We retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on a suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by two orthopaedic surgeons (8 years and 3 years of experience) using foot radiographs, and scored as having normal or abnormal tendon integrity (Fig). We evaluated interobserver agreement between the two surgeons, and the ultrasonography and radiography findings were compared to evaluate diagnostic accuracy. Results: We included 21 patients with a mean age of 51.5 ± 15.7 years (5 men and 16 women). Ultrasonography revealed 4 patients with normal tendon integrity, 6 patients with tenosynovitis and no tendinopathy, 8 patients with tendinopathy and tendon continuity, and 3 patients with loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of the patients (17/21; kappa = 0.576, p = 0.007). Based on the ultrasonographic findings, the surgeons provided accuracies of 76.2% (16/21) and 61.9% (13/21). Conclusion: The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow physicians to predict the prognosis of patients with PTTD, to determine the extent of surgical treatment, and to evaluate the postoperative tendon integrity.

Category: Ankle, Trauma Introduction/Purpose: Several methods like cortical screw, Kirschner (K) wire have been used for stabilizing the Lisfranc joint. We performed this study to assess whether single dorsal plating can be used as an alternative treatment method for a Lisfranc injury. Methods: Patients were followed up for more than 1 year after the initial surgery.Following open reduction of the joint with a bone reduction clamp, a single dorsal plate was used to perform Lisfranc joint fixation. The plate was fixed with 2.7-mm locking screws on the first metatarsal, second metatarsal, medial cuneiform, and intermediate cuneiform. Three weeks postoperatively, the cast was removed, and patients progressively advanced to full weight bearing while wearing a postoperative shoe. The plate was removed 3 months postoperatively. One year postoperatively, weight-bearing foot radiographs and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score were obtained. Results: Eighteen patients with a Lisfranc injury who were treated with open reduction and internal fixation using a single dorsal plate were included. The average AOFAS midfoot score for pain was 35, and the total score was 80.8 (range, 67–95). Six patients (33.3%) had an excellent outcome (score =90); eight (44.4%) had a good outcome (90 > score = 75); and four (22.2%) had a fair outcome (75 > score = 50). Radiographs during the follow-up period showed no loss of reduction or arthritic change. Screw breakage occurred in 3 cases. But the injury ultimately healed anatomically. Conclusion: Single dorsal plating can be an alternative treatment method for a Lisfranc injury, as it provides a good short-term outcome without causing further joint injury.

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: There is a lack of quantitative studies on the progression of juvenile hallux valgus deformity. Therefore, we performed this study to estimate an annual change of radiographic indices for juvenile hallux valgus. Methods: We reviewed medical records of consecutive patients under the age of 15 with juvenile hallux valgus who underwent weight-bearing foot radiographs more than twice, and were followed over a period of one year or more. A total of 133 feet from 69 patients were included. Hallux valgus angle, hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-1st metatarsal angle, anteroposterior talo-2nd metatarsal angle, and lateral talo-1st metatarsal angle were measured and were used as a study criteria. The progression rate of hallux valgus angle was adjusted by multiple factors including the use of a linear mixed model with gender and radiographic measurements as the fixed effects and laterality and each subject as the random effect. Results: Our results demonstrate that the value of hallux valgus angle on the radiographs progressed as the patients grew older. The hallux valgus angle increased by 0.8° per year (p

Category: Ankle, Sports Introduction/Purpose: We hypothesized that the bony configuration of the ankle could also be associated with ankle stress radiographs, in addition to ligament injury of the ankle. Therefore, this study aimed to investigate the relationship between bone morphology and injured ligament on imaging studies and laxity on ankle stress radiographs in patients with lateral ankle instability. Methods: In total, 115 patients who had undergone ankle MRI, ankle radiography, and stress radiography were included. Distal tibial articular surface angle, bimalleolar tilt, medial and lateral malleolar relative length, medial malleolar slip angle, anterior inclination of the tibia, and fibular position were measured on ankle radiographs. Tibiotalar tilt angle and anterior translation of the talus were measured on ankle stress radiographs. Degree of ligament injury was evaluated on ankle MRIs. Multiple regression analysis was performed using the following independent variables: age, sex, and factors significantly associated with ankle stress view on univariate linear regression analysis. Results: Age (p = 0.041), sex (p = 0.014), degree of anterior talofibular ligament injury (p < 0.001), and bimalleolar tilt (p = 0.016) were correlated with tibiotalar tilt angle (Table). Younger patients demonstrated a larger tibiotalar tilt angle than older patients, and the angle decreased by 0.07° per year of age. Tibiotalar tilt angle in female patients was 2.2° larger than that in male patients. Fibular position and degree of posterior talofibular ligament injury were factors significantly related to anterior translation of the talus. Conclusion: Differences in patient characteristics might predispose ankle stress radiograph results. Comparison of both ankles on stress radiographs is superior to applying fixed numerical values to the injured side, in order to reduce the influence of patient factors.

Category: Bunion Introduction/Purpose: There have been few longitudinal studies regarding hallux valgus deformity. This retrospective study aimed to investigate the radiographic measurements associated with the progression of hallux valgus deformity during at least two years of follow-up. Methods: Seventy adult patients (mean age, 58.0 years; standard deviation [SD], 12.3 years; 13 males and 57 females) with hallux valgus who were followed-up for at least two years and underwent weight-bearing foot radiography were included. Radiographic measurements included the hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle (IMA), metatarsus adductus angle, distal metatarsal articular angle (DMAA), tibial sesamoid position, anteroposterior (AP) talo-first metatarsal angle, and lateral talo-first metatarsal angle. Progression of hallux valgus deformity was defined as an increase of 5 degrees or more in the HVA during follow-up. Patients were divided into progressive and non-progressive groups. Binary logistic regression analysis was performed to identify factors that significantly affect the progression of hallux valgus deformity. The correlation between change in HVA and changes in other radiographic indices during follow-up was analyzed. Results: Eighteen out of 70 patients showed progression of 5 degrees or more in the HVA during the mean follow-up of 47.0 months (SD, 19.8 months). The DMAA (p=0.027) and AP talo-first metatarsal angle (p=0.034) at initial presentation were found to be significant factors affecting the progression of hallux valgus deformity. Change in the HVA during follow-up was significantly correlated with changes in the IMA (r=0.423; p=0.001) and DMAA (r=0.541; p

Category: Basic Sciences/Biologics Introduction/Purpose: Human palatine tonsil-derived mesenchymal stem cells (T-MSCs) are known to be a new source of progenitor cells. Using waste tissue after tonsillectomy as a cell provider can be the biggest benefit of T-MSCs, compared with other stem cells. The purpose of this study was to investigate tenogenic differentiation of T-MSCs and to access the differential effects of TGF-ß3 on the tenogenesis of T-MSCs. Methods: Human tonsil was obtained after tonsillectomy.Using a cytometric analysis, we were able to find that the T-MSCs had typical mesenchymal stem cell markers: positive for CD73, CD90 and CD105, and negative for CD14, CD34 and CD45. Using a Transforming growth factor beta 3 (TGF-ß3), the expressions of tenocyte-specific genes and proteins, such as Collagen type I (COL1), Tenomodulin (TNMD), and Scleraxis (SCX), were measured by a quantitative polymerase chain reaction (PCR) assay, immunofluorescence staining, immunohistochemistry and Western blot analysis. Results: Quantitative PCR assay showed that TGF-ß3 significantly increased the expressions of tenocyte lineage marker genes, including Collagen type I (COL1), Tenomodulin (TNMD), and Scleraxis (SCX), at a 3-day treatment, compared with control. However, these increases were not found at long-term exposures (7 or 10 days), except that TNMD expression was maintained at 50 ng/ml at 7-day exposure to TGF-ß3 (Fig). Like genes, the protein expression levels of COL1, TNMD, and SCX were also induced in TGF-ß3-treated T-MSCsin 3-day treatments. Moreover, the protein levels were maintained for 10 days, as evidenced by immunofluorescence staining, immunohistochemistry and Western blot analyses. Conclusion: This study demonstrated that T-MSCs in tenogenic stimulation with TGF-ß3 have high tenogenic differentiation potential.

Category: Basic Sciences/Biologics Introduction/Purpose: Although pedobarographic measurement is increasingly used for clinical and research purposes, relatively few published studies have investigated normative data. This study examined pedobarographic findings in young healthy adults with regard to sex-related differences and correlations among measurement indices. Methods: Twenty young healthy adults (mean age 22.4 years, SD 1.2 years; 10 males and 10 females) were included. Weightbearing anteroposterior and lateral foot radiographs were taken, and dynamic pedobarographic data during treadmill walking and maximum ankle dorsiflexion were obtained. AP talo-first metatarsal angle, naviculocuboid overlap, lateral talo-first metatarsal angle, and plantar soft tissue thickness were measured on foot radiographs. Pedobarographic data including peak pressure and pressure-time integral were measured on five plantar segments: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot (MMF), lateral midfoot (LMF), and heel. Results: Male and female subjects significantly differed in BMI (p

Category: Ankle Introduction/Purpose: The gastrocnemius, a biarticular muscle that crosses the knee and ankle, acts as a knee flexor as well as an ankle plantar flexor. Although simultaneous motion of the knee and ankle joints is required for many activities including standing, running, swimming, and cycling, the change in ankle motion during gait has not been described in patients with cerebral palsy who underwent distal hamstring lengthening or distal hamstring lengthening with rectus femoris transfer. Therefore, we aimed to evaluate the influence of surgery involving tendons around the knee on ankle motion during gait in cerebral palsy patients. Methods: The analysis included data regarding 55 limbs from 34 patients with spastic cerebral palsy, who were followed-up after they had undergone distal hamstring lengthening with or without additional rectus femoris transfer. Mean age of the patients at time of the knee surgery was 11.2 ± 4.7 years. Preoperative and postoperative kinematic variables that were extracted from three-dimensional gait analyses were compared to assess the change in ankle motion after surgery involving tendons around the knee. The postoperative 3D gait analysis was performed at a mean of 0.9 ± 1.3 years after the surgery. The outcome measures were relevant kinematics parameters including peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle. A linear mixed model was constructed to estimate the changes in ankle motion after adjusting for multiple factors. Results: We estimated that peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle decreased, respectively, by 0.4º (p=0.016), 0.6º (p

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: This meta-analysis was performed to determine whether the arthroscopically assisted open reduction and internal fixation (ORIF) for ankle fractures is more beneficial than the conventional ORIF. Methods: Articles in electronic medial databases were searched between March 1983 and August 2016, including Pubmed and SCOPUS. We included the studies with comparative design comparing the surgical outcomes between the arthroscopically assisted ORIF for ankle fractures and the conventional ORIF. Finally, two RCTs and two retrospective comparative studies were included for analysis. Mean and standard deviation (SD) of postoperative functional scores, number of subjects, and P-values were extracted from the studies. In addition, postoperative follow-up period, fracture type, and study quality were collected. Results: The pooled effect size of the four studies 0.535 (95% CI, 0.247 to 0.823) in Hedges’s g, which favored the arthroscopically assisted ORIF over conventional ORIF. There was no evidence of publication bias in funnel plot and in Egger’s test (p=0.534). Conclusion: The arthroscopically assisted ORIF for ankle fractures were more beneficial than the conventional ORIF in the current evidences. However, since it needs more medical cost and longer operation time, possible additional complications and cost effectiveness are to be validated in future studies.

Category: Ankle Introduction/Purpose: Although comparison to radiographic standards for ankle joint is critical for evaluation of syndemosis injuries, such standards are not well defined for children and adolescents. The purpose of this study was to determine the reliability of numerous radiographic measurements of the skeletally immature ankle joint, timing of ossification of medial malleolus and appearance of tibial incisura and differences in the values of radiographic measurements based on age and sex. Methods: This study included 590 subjects (0 to 15 years), who underwent ankle AP, lateral and mortise radiographs. Presence of the medial malleolus and incisura fibularis were recorded (Fig 1). Tibiofibular overlap, tibiofibular clear space, medial clear space, talar tilt, talocrural angle, relative fibular width and fibular position were measured (Fig 2). A inter- and intrareliability test was conducted before the main measurements using intraclass correlation coefficients (ICC). To determine the timing of the ossification center of medial malleolus and appearance of tibial incisura, multinomial logistic regression was used. The generalized linear model was used to estimate the radiographic measurements by age and sex. The 100-quantiles were calculated to determine the normal value of the tibiofibular clear space, tibiofibular overlap and medial clear space. Results: All radiographic measurements showed good to excellent intraobserver(ICC, 0.603–0.934) and interobserver reliability(ICC, 0.704–0.972). The timing of ossification of medial malleolus and appearance of tibial incisura between boys and girls were not different. Tibiofibular clear space on mortise view, and medial clear space on AP and mortise view significantly decreased by age. Tibiofibular overlap on AP and mortise views, relative fibular width on AP view significantly increased by age. Talocrural angle, tibiofibular overlap on AP view, tibiofibular clear space on AP and mortise views, medial clear space on AP and mortise views and fibular position were significantly larger in boys than in girls. The difference in tibiofibular overlap, tibiofibular clear space and medial clear space on mortise view of both sides was < 50% in 98.1%, 99.3%, and 100% of patients, respectively. Conclusion: Tibiofibular clear space, tibiofibular overlap and medial clear space can be parameter to assess distal tibiofibular syndesmosis or deltoid ligament injury in skeletally immature patients. For these patients, the criteria of absolute radiographic values used in adults cannot be applied, but comparison of both sides could help physicians to predict the need for additional evaluations.

Category: Ankle Introduction/Purpose: Although previous studies have demonstrated the potential of conventional computed tomography (CT) as a screening tool for osteoporosis, the assessment correlation of BMD in those studies was limited to the spine. This study aimed to evaluate the reliability and validity of CT as a screening tool for osteoporosis and to estimate the correlation between central BMD and peripheral bone attenuation using lower extremity CT. Methods: In total, 292 patients who underwent a lower extremity, lumbar spine, or abdomen and pelvic CT scan within a 3- month interval of a dual-energy X-ray absorptiometry (DEXA) examination were included (Fig 1). Following reliability testing, bone attenuation of the L1, L2, L3, L4, femoral head, femoral neck, greater trochanter, distal femur, proximal tibia, distal tibia, and talus was measured by placing a circular region of interest on the central part of each bony region on a coronal CT image (Fig 2 and 3). Partial correlation was used to assess the correlation between CT and DEXA, after adjusting for age and body mass index. Results: In terms of reliability, all bone attenuation measurements, except the femoral neck, showed good to excellent interobserver reliability (intraclass correlation coefficients, 0.691–0.941). In terms of validity, bone attenuation of the L1 to L4, femoral neck, and greater trochanter on CT showed significant correlations with BMD of each area on DEXA (correlation coefficients, 0.399–0.613). Bone attenuation of the distal tibia and talus on CT showed significant correlations with BMD of all parts on DEXA (correlation coefficients, 0.493–0.581 for distal tibia, 0.396–0.579 for talus). Conclusion: Lower extremity CT is a useful screening tool for osteoporosis, and peripheral bone attenuation on lower extremity CT adequately reflects central BMD on DEXA.

The purpose of this study is to assess health-related quality of life in polio survivors (PS) compared with that in the general population in Korea. Polio survivors (n = 120) from outpatient clinics at two hospitals, healthy controls (HC, n = 121) and members of the general population with activity limitations (AL, n = 121) recruited through a proportional-allocation, systematic sampling strategy from the Fourth Korean National Health and Nutrition Examination Survey were surveyed with self-rated health-related quality of life (Euro QoL five-dimensions). The proportion of participants who reported problems in mobility, usual activity, and symptoms of anxiety/depression were higher in the PS group compared with the HC and AL groups. There was no significant difference in the self-care dimension across the groups. Polio-specific questionnaire, pain, depression, fatigue, Modified Barthel Index (K-MBI) and Short Physical Performance Battery (SPPB) were assessed in the PS group. Those with post-poliomyelitis syndrome had greater problems in mobility, usual activity, and depression/anxiety. Polio survivors, especially those with more pain and fatigue symptoms, and those who did not have access to medical services had poorer health-related quality of life. These findings afford useful information for potential intervention improving quality of life in polio survivors.