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We aimed to compare clinical and radiologic outcomes in patients with cam-type femoroacetabular impingement (FAI), with and without a partial ligamentum teres (LT) tear, who underwent hip arthroscopy (HA) with ≥10 years of follow-up. Among the patients who underwent HA for a cam-type FAI diagnosis with a labral tear, 28 patients (28 hips) with a partial LT tear and 87 patients (99 hips) with an intact LT were assigned to Groups A and B, respectively. All patients underwent partial labral debridement and femoroplasty. Debridement and thermal shrinkage were performed for LT tears. The grade of chondral damage was measured intraoperatively. Clinical items were assessed preoperatively and at the last follow-up. Patients’ satisfaction with the surgery and changes in postoperative sports ability in those who had previously been active in sports were assessed at the last follow-up. The Tönnis grade was assessed preoperatively and at the last follow-up for radiologic evaluation. Chondral damage to the acetabular and femoral head detected intraoperatively was significantly different between the groups (P = 0.005 and P

Backgrounds/Aims Intrahepatic recurrence is frequent result after hepatectomy for hepatocellular carcinoma (HCC). We analyzed the clinical results of patients who had the intrahepatic recurrences of HCC after curative surgical resections. Methods From January 2009 to December 2016, 320 patients underwent curative surgical resection for HCC in department of Surgery, Korea Cancer Center Hospital. After surgical resection, 155 patients had suffered HCC recurrence during follow-up period. Among them, 122 patients had only intrahepatic recurrence initially, who were included in this retrospective study. We analyzed about the period of the recurrence after surgery, treatment methods for the recurred tumors, and poor prognostic factors for survival after intrahepatic recurrences. Results Among the 122 patients, 83 patients had recurrence within 24 months after surgery. Thirty-eight patients underwent curative treatment for the recurred tumors (re-resection in 18, radiofrequency ablation in 20 patients). Non-curative treatments were performed in 77 patients (TACE in 68 patients, radiotherapy in 9 patients) and conservative management in 7 patients. Five-year survival rate of patients who underwent curative treatment is 86.4% (p≤0.001). Five-year survival rate of non-curative treatment is 55.7% (p≤0.001), conservative management is 0% (p=0.021). Among the clinical factors, non-curative treatment for recurred tumor, AFP level at the time of recurrence, size of recurred tumor were independent poor prognostic factors for survival after intrahepatic recurrences (p

Background Extrahepatic metastasis (EHM) from hepatocellular carcinoma (HCC) occurs in 10%-15% of cases following initial treatment. The most frequent sites of EHM are the lung, lymph nodes, and bone. Gastrointestinal or brain metastasis from HCC is rarely reported. Here, we report a rare case of concurrent HCC metastases to the stomach, colon, and brain. Case summary A 72-year-old male with a history of alcohol induced HCC presented with multiple intrahepatic recurrences and tumorous lesions in the stomach and ascending colon. Three years earlier, he underwent right hemihepatectomy, and 1 year ago, he had a video-assisted thoracoscopic wedge resection for pulmonary metastasis of HCC. We decided on surgical resection of the new metastases because of massive gastric bleeding and concern for possible colonic obstruction. The patient underwent gastric wedge resection and right hemicolectomy. Two weeks later, the patient developed dysarthria and mild cognitive disorder. Magnetic resonance imaging of the brain revealed a left frontal lobe lesion, and he underwent resection of a metastatic brain tumor. Unfortunately, he died 6 weeks after the last surgery due to hepatorenal syndrome. Conclusion Decision of surgery was carefully recommended in this case and may extend survival in other metastatic HCC patients with well-preserved hepatic function.

BACKGROUND Although several prospective studies have reported the efficacy of stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC), treatment-related toxicity varies and has not been determined. Therefore, the authors evaluated the safety and efficacy of SBRT for patients with HCC in a hepatitis B virus-endemic area. METHODS This multicenter phase 2 trial enrolled patients with unresectable HCC. Patients received SBRT with 45 to 60 Gy in 3 fractions. To evaluate gastroduodenal toxicity, esophagogastroduodenoscopy (EGD) was performed before and 2 months after SBRT. The primary endpoint was treatment-related severe toxicity at 1 year after SBRT. The secondary endpoints were the 2-year local control, progression-free survival, and overall survival rates. RESULTS In total, 74 patients were enrolled between January 2012 and April 2015, and 65 eligible patients were analyzed. One patient experienced radiation-induced liver disease with acute grade ≥3 toxicity 1 month after SBRT. In addition, 1 patient had a grade 3 esophageal ulcer with stenosis 5 months after SBRT. The actuarial rate of treatment-related severe toxicity at 1 year was 3%. The pre-SBRT and post-SBRT EGD findings were not significantly different among the 57 evaluable patients who underwent EGD. The 2-year and 3-year local control rates were 97% and 95%, respectively. The progression-free and overall survival rates were 48% and 84% at 2 years, respectively, and 36% and 76% at 3 years, respectively. CONCLUSIONS With a median follow-up of 41 months, this prospective multicenter study demonstrated that SBRT for patients with HCC is well tolerated and is an effective treatment modality.

Oblique lumbar interbody fusion (OLIF) improves the spinal canal, with favorable clinical outcomes. However, it may not be useful for treating concurrent, severe central canal stenosis (SCCS). Therefore, we added biportal endoscopic spinal surgery (BESS) after OLIF, evaluated the combined procedure for one-segment fusion with clinical outcomes, and compared it to open conventional TLIF. Patients were divided into two groups: Group A underwent BESS with OLIF, and Group B were treated via TLIF. The length of hospital stay (LOS), follow-up period, operative time, estimated blood loss (EBL), fusion segment, complications, and clinical outcomes were evaluated. Clinical outcomes were measured using Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified Macnab criteria. All the clinical parameters improved significantly after the operation in Group A. The only significant between-group difference was that the EBL was significantly lower in Group A. At the final follow-up, no clinical parameter differed significantly between the groups. No complications developed in either group. We suggest that our combination technique is a useful, alternative, minimally invasive procedure for the treatment of one-segment lumbar SCCS associated with foraminal stenosis or segmental instability.

Colorectal cancer (CRC) is one of the leading causes of world cancer deaths. To improve the survival rate of CRC, diagnosis and post-operative monitoring is necessary. Currently, biomarkers are used for CRC diagnosis and prognosis. However, these biomarkers have limitations of specificity and sensitivity. Levels of plasma lysyl-tRNA synthetase (KARS1), which was reported to be secreted from colon cancer cells by stimuli, along with other secreted aminoacyl-tRNA synthetases (ARSs), were analyzed in CRC and compared with the currently used biomarkers. The KARS1 levels of CRC patients (n = 164) plasma were shown to be higher than those of healthy volunteers (n = 32). The diagnostic values of plasma KARS1 were also evaluated by receiving operating characteristic (ROC) curve. Compared with other biomarkers and ARSs, KARS1 showed the best diagnostic value for CRC. The cancer specificity and burden correlation of plasma KARS1 level were validated using azoxymethane (AOM)/dextran sodium sulfate (DSS) model, and paired pre- and post-surgery CRC patient plasma. In the AOM/DSS model, the plasma level of KARS1 showed high correlation with number of polyps, but not for inflammation. Using paired pre- and post-surgery CRC plasma samples (n = 60), the plasma level of KARS1 was significantly decreased in post-surgery samples. Based on these evidence, KARS1, a surrogate biomarker reflecting CRC burden, can be used as a novel diagnostic and post-operative monitoring biomarker for CRC.

Background We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle. Methods Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound-guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25mg) was applied in group A (30 patients). Diluted anesthetic (0.2% ropivacaine, 30ml) was injected into the sciatic nerve once, about 12h after the preoperative nerve block, in group B (27 patients). Periodic intramuscular injection of an analgesic (ketorolac [Tarasyn], 30mg) was performed in group C (27 patients). The visual analogue scale (VAS) pain scores at 6, 12, 18, 24, and 48h after surgery were checked, and the complications of all methods were monitored. Results The mean VAS pain score was lower in group B, with a statistically significant difference ( P .05) between groups A, B, and C at 12 and 18h after surgery. Four patients in group A experienced nausea and vomiting; however, no other patients complained of any complications or adverse effects. Conclusion The ultrasound-guided injection of a diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase after bone surgery in the foot and ankle. The injection of the diluted anesthetic once on the evening of the day of surgery resulted in less postoperative pain in the patients. Level of evidence II.

Purpose The purpose was to evaluate and compare the revision rate due to aseptic loosening between a high-flex prosthesis and a conventional prosthesis. Materials and methods Two thousand seventy-eight knees (1,377 patients) with at least 2 years of follow-up after total knee arthroplasty were reviewed. Two types of implants were selected (LPS-Flex and LPS, Zimmer) to compare revision and survival rates and sites of loosened prosthesis component. Results The revision rate of the LPS-Flex (4.9%) was significantly higher than that of the conventional prosthesis (0.6%) (p＜0.001). The 5-, 10-, and 15-year survival rates were 98.9%, 96.2% and 92.0%, respectively, for the LPS-Flex and 99.8%, 98.5% and 93.5%, respectively, for the LPS. The survival rate of the high-flex prosthesis was significantly lower than that of the conventional prosthesis, especially in the mid-term period (range, 5 to 10 years; p=0.002). The loosening rate of the femoral component was significantly higher in the LPS-Flex prosthesis (p=0.001). Conclusions The LPS-Flex had a higher revision rate due to aseptic loosening than the LPS prosthesis in the large population series with a long follow-up. The LPS-Flex should be used carefully considering the risk of femoral component aseptic loosening in the mid-term (range, 5 to 10 years) follow-up period after initial operation.

Study design Prospective clinical pilot study. Objective To confirm the accuracy of thoracic pedicle screw placement by using the unilateral spinous noncovering hook type patient-specific drill template (PSDT) made through rapid prototyping (RP) and to analyze previously reported PSDT designs and their characteristics. Summary of background data Pedicle screw fixation is the most common form of the posterior instrumentation of the thoracic and lumbar spine. Various techniques have been introduced to improve pedicle screw placement. Among them PSDT with a preplanned trajectory has been considered a promising solution; however, we don't have consensus on proper character of the template. Methods Preoperative spiral three-dimensional (3D) computed tomography (CT) was performed on the thoracic spine. The images were stored in DICOM format and transferred to a workstation running MIMICS 17.0 software to generate a 3D reconstruction template for the desired thoracic vertebra. The accurate trajectory and screw diameter and length were calculated with UG Imageware 12.1. The guide template was sterilized and used intraoperatively to assist with the placement of thoracic pedicle screws. After all pedicle trajectory screws had been inserted. We reviewed 12 previous reports and classified them according to the shape and system of PSDT that met the inclusion criteria of the review. Results Ten screws were placed by using the PSDT without violating the single laminar cortex. There was no violation of the spinal canal or the cortex of pedicle on postoperative CT scans. The results of 13 PSDT types included in the current study suggested that there is no significant difference in accuracy between the PSDTs. Conclusion The unilateral spinous process noncovering hook type PSDT made through RP provided an accurate trajectory for the thoracic vertebra, and the classification of PSDT in this study could be helpful for further studies. Level of evidence 5.

Background The purpose of this prospective, open-label, observational study was to assess the fracture preventing effect of Maxmarvil® tablets (alendronate 5 mg + calcitriol 0.5 µg) in patients with osteoporosis and to evaluate the change in bone mineral density (BMD) at the minimum 1-year follow-up. Methods In this multicenter observational study, 691 patients with osteoporosis (aged 50 years or older) were treated with alendronate 5 mg + calcitriol 0.5 µg/day during their normal course of care. Patients were assessed at baseline and at 6 and 12 months. Baseline characteristics (including age, gender, concomitant disease, and baseline fractures) were evaluated. Results From among the 848 participants, 149 individuals were lost to follow-up at the time of the study and 8 people had died. The 691 participants (54 men and 637 women) finished the follow-up study and completed the questionnaire. The mean age of the participants was 71.5 years (range, 50-92 years; mean age, 72.3 years for men and 71.4 years for women). Osteoporotic fracture occurred in 19 patients (2.7%). BMD of the lumbar spine and hip was improved by 5% and 1.5% at the latest follow-up. At the latest follow-up, 24 patients (3.5%) complained of drug-related complications such as dyspepsia, constipation, and nausea. Conclusions This prospective observational study demonstrated that alendronate 5 mg + calcitriol 0.5 µg/day had a preventive effect on osteoporotic fracture and it increased the BMD of the lumbar spine by 5% at the latest follow-up.

Background: This study aimed to identify the factors associated with patient satisfaction with the outcome of meniscal allograft transplantation (MAT). Materials and Methods: Patients treated with MAT from March 2006 to May 2009 were asked to complete a five-point Likert scale regarding satisfaction with the outcome of MAT, in addition to the following subjective outcome evaluation forms: the International Knee Documentation Committee (IKDC) subjective forms, Knee Society Score knee and function forms, and Lysholm Knee Scoring Scale. We collected radiologic data using X-ray and magnetic resonance imaging and assessed isokinetic muscle strength test using the Biodex System 3. We investigated whether these parameters were significantly associated with patient satisfaction. Statistical analysis was computed using univariate and multivariable logistic regression. Results: Among the 130 patients who underwent MAT, 49 participated in the interview and were included in this study. The mean followup period was 50.4 months. Mean patient age was 40 (±9) years; 33 were male and 16 were female (33%). The lateral meniscus was transplanted in 13 (27%) patients, while the medial meniscus was involved in 36 (73%) patients. On univariate analysis, sex and isokinetic extension strength deficit at 60° and 180° as well as the IKDC, Knee Society, and Lysholm scores showed significant association with patient satisfaction regarding the outcome. On multivariable logistic regression, only the IKDC score showed a significant association, with P = 0.04. Conclusions: The study results support the importance of patient-reported subjective outcomes in terms of patient satisfaction following a surgical procedure. Regarding MAT, the IKDC outcome score reflects patient satisfaction. Level of evidence: Level III.

Backgrounds/aims Hilar cholangiocarcinomas (HLC) are known to have worse prognoses than mid-to-distal cholangiocarcinomas (CBDC). We analyzed the clinical results of surgical resections for extrahepatic cholangiocarcinomas to validate the differences in the prognoses of HLC and CBDC. Methods Two hundred and eighty-one patients underwent curative surgical resections for extrahepatic cholangiocarcinomas at the Department of Surgery in the Korea Cancer Center Hospital. Among them, we analyzed the T2 and T3 patients and compared the clinical results between those with HLC (n=74) and those with CBDC (n=65). Results The rate of R1 resections was significantly higher in the HLC patients compared to the CBDC patients (31.1% vs 12.3%, p=0.006). The overall survival rate of the T2/T3 patients was lower in the HLC group than in the CBDC group (24.5% vs 51.7, p=0.039). The recurrence-free survival rate was 23.3% in the HCL patients and 50.9% in the CBDC patients (p=0.06). In the subgroup analysis, the survival rates were not different in patients who had lymph node metastases or in patients who underwent R1 resections between the HLC and CBDC patients. Poor independent prognostic factors for the overall and recurrence-free survival rates in the T2/T3 extrahepatic cholangiocarcinoma patients were the presence of lymph node metastases and the hilar locations of tumor. Conclusions HLC patients had poorer prognoses than CBDC patients. However, in patients with lymph node metastases, the prognosis was poor and was not different between the HLC and CBDC patients. Other adjuvant treatment methods are needed for extrahepatic cholangiocarcinoma patients with lymph node metastases to improve their prognoses.

The treatment of a large segmental defect of over 6 cm in a long bone is a challenging procedure. Treatment options include cancellous bone graft (e.g., the Masquelet technique), vascularized fibular graft (VFG), and internal bone transport (IBT) with an external fixator. These methods may be performed with intramedullary (IM) nailing or plate fixation to enhance stability or to lessen the time of external fixation. Each method has its own advantages and limitations. This study aimed to describe the advantages of additional plate augmentation and autologous bone grafting after IM nail implantation. Three patients with large segmental femoral bone defects were treated with IM nail implantation; then, one- or two-stage autologous iliac bone grafting with additional plate augmentation was performed. All patients achieved bony union without metal failure. We describe a technique involving additional plate augmentation and autologous iliac bone grafting for treating large femoral defects after restoring the length of the femur using an IM nail implantation and an external fixator.

Background: As intramedullary (IM) fixation is one of the fixation methods used in neck fractures of the fifth metacarpal, an early motion of injured finger can be allowed. The purpose of this study is to evaluate whether immediate active motion affects the stability of antegrade IM fixation in surgical treatment of neck fractures of the fifth metacarpal bone and to assess related factors. Methods: Thirty one patients treated by closed reduction and antegrade IM fixation were consecutively enrolled. All patients started active motion of the little finger since 7 postoperative days and only daily activities including writing, typing or washing were allowed until the union of fracture. All fractures were healed within four to eight weeks. The changes of angulation, fifth metacarpal length and tip to head distance of K-wire were compared between immediate postoperative radiographs and radiographs at eight weeks. In addition, the effects by age, gender, initial angulation and comminution of the metacarpal neck were assessed. Results: The average change of angulation was 0.12°, 5th metacarpal length was 1.49mm and tip to head distance of K-wire was 1.31mm. There was no significant difference in the change of angulation (p = 0.137). But, there were significant differences in the change of 5th metacarpal length and tip to head distance of K-wire ([Formula: see text]). The change of angulation was related to a comminution of the metacarpal neck and that of 5th metacarpal length was related to age and sex. Conclusions: The change of 5th metacarpal length and tip to head distance of K-wire can occur by an early mobilization in the antegrade IM fixation for neck fractures of the fifth metacarpal. However, we thought that an early active motion after surgery is important to increase the patients' satisfaction, even though careful selection of candidates is necessary.

Background Plate fixation is the most commonly used technique for the treatment of shaft fractures of both forearm bones (SFBFBs). However, all fractures are difficult to treat with plate fixation because of soft tissue injuries, fracture patterns, or the patient's condition. The purpose of this study is to compare the functional results of plate fixation only and combined plate and intramedullary (IM) nail fixation in SFBFBs. Methods Fifty-nine cases of SFBFBs that were surgically treated from June 2007 to July 2012 were retrospectively reviewed. In this study, 47 cases that were followed up for more than 12 months were included. All SFBFBs were divided into two groups according to the methods used for internal fixation: plate fixation only (group A) and combined plate and IM nail fixation (group B). The fixation methods were determined intraoperatively. Plate fixation was considered as the first option in all cases, but combined plate and IM nail fixation was selected as the second option if it was difficult to be fixed with plate only. Groups A and B comprised of 31 and 16 cases, respectively. The functional results were evaluated by the Grace and Eversmann rating system and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results In groups A and B, a radiologic union was achieved in 30/31 and 14/16 cases and average union time was 11.1 and 17.8 weeks, respectively. According to the Grace and Eversmann rating system, group A had excellent results in 15 cases, good in 14, acceptable in one, and unacceptable in one. Group B had excellent results in three cases, good in nine, acceptable in two, and unacceptable in two. The average DASH score was 7.1 points (range, 0 to 19.2 points) in group A and 15.1 points (range, 0 to 29.6 points) in group B. Three cases of nonunion with unacceptable results achieved a bony union by additional procedures and the functional results of these cases improved to good or excellent. Conclusions The functional results and the average union time were superior in group A than in group B. However, we think that combined fixation is a useful method for SFBFBs that cannot be treated with plate fixation only.

Purpose: Combined hepatocellular cholangiocarcinoma (ChC) is a rare type of primary liver cancer, which is thought to have a poorer prognosis than hepatocellular carcinoma (HCC). Cancer stem cells are associated with tumorigenesis, tumor progression, recurrence, metastasis, and poor prognosis in several malignancies including HCC. The aim of this study was to investigate the expression pattern of cancer stem cell markers in ChC and HCC, and to evaluate whether this pattern correlated to patient prognosis. Methods: Thirteen patients who underwent curative hepatic resection for ChC and 13 patients who underwent curative hepatic resection for HCC (matched control cases) were included. Immunohistochemical staining for cancer stem cell markers (cytokeratin [CK]7, CK19, C-kit, cluster of differentiation [CD] 44, CD133, and epithelial cell adhesion molecule) was performed and clinical outcomes were analyzed retrospectively. Results: There was no significant difference in cancer stem cell marker expression between ChC and HCC. In ChC, the group that expressed CD44 showed earlier recurrence than the group that did not express CD44 (P = 0.040). Conclusion: The expression of cancer stem cell markers in ChC did not show a different pattern compared to that found in HCC. The expression of cancer stem cell marker CD44 was associated with poor prognosis in patients with ChC.

During varus deformity correction in a patient undergoing total knee arthroplasty (TKA), the medial collateral ligament (MCL) could get completely detached from its distal insertion site. Our aim was to evaluate the (1) mid-term clinical outcome and implant survival after conservative treatment in patients with intraoperatively over-released MCL and (2) preoperative risk factors for MCL over-release. A retrospective study was conducted on patients who had undergone a primary TKA between 2001 and 2006. The number of knees with intraoperative MCL over-release (over-released group) was 47 (40 patients); we compared these with the knees that had intact MCL (intact group, 502 knees). Simple anchoring of MCL was performed with no additional protection. The postoperative clinical outcome and implant survival were compared. Risk factors for MCL over-release were identified using multivariate analysis. The average follow-up period was 7.5 years. The mean Knee Society score of the over-released group improved from 23.3 to 92.7 and it was not significantly different from the intact group. Three cases of aseptic loosening occurred in the over-released group and 19 in the intact group (p = 0.423). The survival rates of the implant were 94.4% and 96.1%, respectively, at 13 years postoperatively. Multivariate analysis showed preoperative femoral–tibial angle as the only risk factor for over-release. This study showed that even MCL was over-released inadvertently, but it did not affect the clinical outcome. Preoperative femoral–tibial angle was the only predictable risk factor for MCL over-release.

Although ACL reconstruction is prevalent, the most effective method for ACL reconstruction still remains controversial. The purpose of this study was to evaluate the effect of the preserved remnant in ACL reconstruction on graft morphology at second-look arthroscopy and clinical outcomes.66 consecutive patients who underwent a second-look arthroscopy after a remnant-preserving ACL reconstruction were enrolled. The patients were divided into two groups according to whether the remnant ACL fibers could be preserved by over 50% (Group I) or not (Group II). The Lysholm score, IKDC subjective score, Tegner activity score, pivot-shift test, and KT-2000 arthrometric findings were evaluated preoperatively and just prior to the second-look arthroscopy to assess clinical outcomes. At second-look arthroscopy, graft morphology was evaluated using hypertrophy rate and synovialization.At second-look arthroscopy, the hypertrophy rate of Group I (42.1%) was higher than Group II (25.1%), which was statistically significant (p=0.002). In graft synovialization, there was a statistically significant difference between the two groups (p0.001). The IKDC subjective score improved from 42.9, 43.1 to 77.8, 75.0 for Group I and Group II, respectively (p=0.025). For the Lysholm score, Group I and Group II improved from 55.4 and 55.7 to 87.8 and 84.9 (p=0.031). There was also a significant difference between the pivot shift tests between the groups (p=0.039). Other clinical tests showed no statistically significant differences.Preserving the remnant ACL tissue during ACL reconstruction could have a positive effect on graft hypertrophy, synovialization and clinical outcomes.III, retrospective comparative study.

The purpose of this study was to verify a recently developed picture-archiving and communications system-photoshop method by comparing reliabilities between real-size paper template and the PACS-photoshop methods in preoperative planning of open-wedge high tibial osteotomy. A prospective case series was conducted, including patients with medial osteoarthritis undergoing open-wedge high tibial osteotomy. In the preoperative planning, the picture-archiving and communications system-photoshop method and real-size paper template method were used simultaneously in all patients. Preoperative hip–knee–ankle angle, height, and angle of the osteotomy were evaluated. The reliability of this newly devised method was evaluated, and the consistency between the two methods was also evaluated using intra-class correlation coefficient. Using the picture-archiving and communications system-photoshop method, the mean correction angle and height of osteotomy gap of rater-1 were 11.7° ± 3.6° and 10.7 ± 3.6 mm, respectively. The mean correction angle and height of osteotomy gap of rater-2 were 12.0 ± 2.6 and 10.8 ± 3.6, respectively. The inter- and intra-rater reliabilities of the correction angle were 0.956 ~ 0.979 and 0.980 ~ 0.992, respectively. The inter- and intra-rater reliabilities of the height of the osteotomy gap were 0.968 ~ 0.985 and 0.971 ~ 0.994, respectively (p

The purpose of this study is to identify the predictors for severe intestinal toxicity (IT) in patients with abdominopelvic malignancies treated with three fractions of stereotactic ablative radiotherapy (SABR). From 2001 to 2011, 202 patients with abdominopelvic malignancies were treated with curative-intent SABR. Among these, we retrospectively reviewed the clinical records of 55 patients with the presence of the intestine that received a dose ≥20 % of the prescribed dose. The total dose ranged from 33 to 60 Gy in three fractionations (median dose, 45 Gy). We analyzed the clinical and dosimetric parameters for severe IT ≥ grade 3 according to the National Cancer Institute Common Toxicity Criteria v4.0: V 20–35 (volume of the intestine that received xGy) and D max (maximum point dose). Severe IT was found in six patients (the median time, 3 months). V 25 was the best dosimetric predictor for severe IT (P = 0.004). With V 25 ≤ 20 ml, severe IT decreased from 50 to 4 %. SABR duration was the best clinical predictor. Severe IT decreased in patients who received SABR at 4–8 days than on three consecutive days (0 vs. 18 %, P = 0.037). Following three fractions of SABR, V 25 is a valuable predictor of severe IT. And SABR would be conducted with a treatment interval of at least 48 h if possible.

To investigate the effect of synovialization of graft following anterior cruciate ligament reconstruction (ACLR) on functional performance test (FPT) and clinical outcomes. Eighty-four male patients who underwent second-look arthroscopy at 2-year follow-up after unilateral ACLR using hamstring autograft were analyzed retrospectively. Patients were categorized by synovial coverage into A group (42 subjects, poor synovial coverage) and B group (42 subjects, good synovial coverage). FPT results, including those of single leg hop test (cm) of the involved limb, co-contraction test (s), shuttle run test (s), and carioca test (s), were compared between groups. Clinical scores, including Lysholm score, International Knee Documentation Committee (IKDC) subjective score, and Tegner activity score; stability assessments including Lachman test, Pivot-shift test, and side-to-side differences (cm) measured using a KT-2000 arthrometer were also compared between groups. Based on FPT results, no difference was evident between groups. Single leg hop test results were 144.3 ± 25.5 in A group and 145.4 ± 24.7 in B group (P = 0.849). Co-contraction test results were 17.1 ± 2.9 in A group and 16.9 ± 3.6 in B group (P = 0.827). Shuttle run test results were 9.3 ± 1.9 in A group and 9.3 ± 1.9 in B group (P = 0.935). Carioca test results were 11.4 ± 2.9 in A group and 10.5 ± 2.5 in B group (P = 0.149). Clinical scores and stability assessments did not differ between groups (P > 0.05). Based on functional performance results, well-synovialized grafts did not yield better functional performance outcomes following ACLR compared to poorly synovialized grafts at 2-year follow-up. The same was true of clinical outcomes. Thus, the success of synovialization does not improve functional performance and clinical outcomes following ACL reconstruction in an all-male population.

Study design Cadaveric. Objective Determine optimal fluoroscopic views for detecting cervical lateral mass screw (LMS) violations. Summary of background data Single plane intraoperative x-rays are commonly used but frequently inadequate due to its complex trajectory. Fluoroscopy can be taken in multiple planes, but the ideal fluoroscopic view to assess malposition is not known: depending on the view, any given screw may look "in" or "out." Methods C3-6 LMS were inserted in three cadavers. To evaluate neuroforaminal violation, LMS were inserted into the foramen with the tip penetrating the anterior cortex by 0, 2, and 4 mm. To assess facet joint violation, LMS were inserted toward the subjacent facet joint with the tip penetrating the anterior cortex by 0 and 2 mm. Fluoroscopic views were taken 0°, 10°, 20°, 30°, and 40° to the lateral plane. Views were independently evaluated by three blinded spine surgeons. Results Twenty-degree oblique view correctly identified a 2 mm penetration into the neuroforamen in 79%, and a 4 mm penetration in 86%, for a sensitivity of 83% and specificity of 90%. Thirty-degree view had lower sensitivity (76%) but slightly higher specificity (93%). Twenty-degree and 30° views were significantly more sensitive than the other views. Zero-degree view correctly identified a 2 mm penetration into the facet joint in 93%, for a sensitivity of 93% and specificity of 92%. Ten-degree view had lower sensitivity (72%) but higher specificity (100%). The 0° view was significantly more sensitive than the other views. Conclusion Twenty-degree and 30° oblique views significantly provided the most sensitive assessment of LMS potentially violating the neuroforamen, whereas the 0° neutral lateral view significantly provided the most sensitive assessment of facet violations. The specificities were also high (in the 90% range) for these views. We recommend the use of these views intraoperatively when assessing proper placement of LMS fluoroscopically. Level of evidence N/A.

The present randomized controlled trial evaluated the usefulness of ultrasound (US)-guided nerve block (NB) for emergency external fixation of lower leg fractures, by investigating the time required before surgery and the clinical results stratified by the anesthesia method (US-guided NB or general anesthesia [GA]). From June 2014 to April 2016, 40 patients who had undergone emergency surgery for external fixator application were enrolled in the present study. We measured the lead time before the start of surgery after the decision to perform emergency surgery in both groups. The US-guided NB group included 17 males (85%) and 3 females (15%), with a mean age of 55.6 (range 33 to 77) years. Of these 20 patients, 12 (60%) had comorbidities such as diabetes mellitus, hypertension, and kidney-related disease. Fracture type 42, 43, and 44 in the AO classification were observed in 3 (15%), 12 (60%), and 5 (25%) cases, respectively. The mean interval before emergency surgery was 4.3 (range 2 to 6.25) hours in the US-guided NB group. In the GA group (n = 20 patients), the mean interval before emergency surgery was 9.4 (range 3 to 14) hours, and this difference was statistically significant (p .001). In the US-guided NB group, no cases of anesthesia failure or unstable vital signs occurred during surgery. Also, no postoperative complications related to the anesthesia method, such as aggravation of the general condition, developed. In contrast, 1 case of postoperative atelectasis occurred in the GA group. Emergency external fixation with US-guided NB in patients with lower extremity trauma can be implemented in less time, regardless of the preoperative preparation, which is a requirement for GA.

Background This study aimed to evaluate the effect of stereotactic ablative radiotherapy (SABR) after incomplete transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) patients. Methods The study enrolled 178 HCC patients initially treated with TACE between 2006 and 2011. Patients were included if they had Barcelona Clinic Liver Cancer stage 0 or A, ≤3 nodules with a total sum of longest diameter ≤10 cm, Child-Turcotte-Pugh score of ≤7, no major vessel invasion, and no extra-hepatic metastases. Results Twenty-four patients achieved a complete response to TACE (group 1). Among those with incomplete response, 47 patients received other curative treatments (group 2), 37 received SABR (group 3), and 70 received non-curative treatments (group 4). The 2–year overall survival (OS) rates for groups 1, 2, 3, and 4 were 88 %, 81 %, 73 %, and 54 %, respectively. The corresponding 5-year OS rates were 50 %, 58 %, 53 %, and 28 %, respectively. Conclusions Patients treated with SABR after incomplete TACE had similar survival outcomes to those achieving complete response to TACE or receiving curative treatments. However, patients receiving non-curative treatments had significantly lower survival rates than the other groups. Therefore, if SABR was indicated at the initial diagnosis, it might be recommended after TACE failure.

Granular cell tumor (GCT) is a benign neoplasm showing neuroectodermal differentiation and is most commonly found in the head and neck region, including the tongue [1]. This tumor is now believed to occur in virtually any site of the body, including skin, breast, and gastrointestinal tract, with less than 1% developing in the biliary tract [2]. To our knowledge, only one case of GCT of the biliary tract has been reported in Korea, which occurred in the gallbladder [3]. Herein, we present another case of GCT of the biliary tract.

Curative resection, including gastrectomy, extensive lymph node dissection, and combined resection of invaded organs, is the mainstay of treatment for T4b gastric cancers. We sought to investigate the clinicopathologic features, surgical outcomes, and prognostic factors of curatively resected pathologic T4b gastric cancer with a focus on organs invaded.Data of 243 pT4b gastric cancer patients who underwent curative resection at Korea Cancer Center Hospital from 1991 to 2005 were retrospectively subjected to univariate and multivariate analyses.Overall 5-year survival rate and median survival time were 36.8% and 26 months, respectively. Five-year survival rates were 23.3% in the pancreatic invasion group (n = 67) and 42.1% in the nonpancreatic invasion group (n = 176) (P = 0.002). Regarding operative methods used for pancreatectomy in pancreatic invasion group, 5-year survival rates were 0% in the pancreaticoduodenectomy group (n = 9) and 27.4% in the other pancreatectomies group (n = 58) (P = 0.013). Multivariate analysis revealed that advanced lymph node stages (hazard ratio [HR] 1.637 for N0 vs. N1, HR 2.177 for N0 vs. N2, HR 3.241 for N0 vs. N3a, and HR 4.000 for N0 vs. N3b), encircling type of tumor (HR 1.804), and pancreatic invasion (HR 1.463) were independently unfavorable prognostic factors.In pT4b gastric cancer, pancreatic invasion was found to portend the least favorable prognosis, especially in cases requiring pancreaticoduodenectomy. However, prognoses were more favorable after curative resection in patients without advanced lymph node stages (N2, N3a, and N3b), an encircling type of gastric tumor, or pancreatic invasion. We propose a novel therapeutic strategy for patients with T4b gastric cancer.

We report here on a new technique using polymethylmethacrylate to manage vertebral osteoporotic compression fractures in three patients. These patients presented with acute back pain that manifested itself after minor trauma. Osteoporotic compression fractures were diagnosed via plain X-ray and magnetic resonance imaging studies. The patients were treated with absolute bed rest and non-steroidal anti-inflammatory drugs. Despite of the conservative treatment, the patients experienced severe, recalcitrant and progressive pain. The vertebrae were collapsed over 50% or kyphotic deformity was seen on the radiologic materials. We performed a new technique called lordoplasty, which is derived from percutaneous vertebroplasty. The patients experienced a reduction in pain after the procedure. The wedge and kyphotic angles of the fractured vertebrae were significantly restored.

The tissue environment in the region of hepatocellular carcinoma (HCC) influences both vascular invasion and recurrence. Thus, HCC patient prognosis depends on the characteristics not only of the tumor but also those of adjacent surrounding liver tissue. Expression profiles of both tumor and adjacent liver tissue following curative resection were measured to discriminate 56 hepatitis B virus-positive HCC patients into subgroups based on survival risk. This approach was further tested in 40 patients. Expression profiles of both tumor and adjacent liver tissue successfully discriminated 56 training samples into 2 subgroups, those at low- or high-risk for survival and recurrence. However, the prognostic gene set selected for tumor tissue was quite different from that for adjacent tissues. This variation in prognostic genes resulted in a change in allocation of patients within each low- or high-risk group. Combination of survival subgroups from tumor and adjacent liver tissue significantly improved the prediction of prognostic outcome. This integrative approach was confirmed to be effective in a further 40 test patients. A clinicopathological study showed that survival subgroups divided by tumor and adjacent liver tissue gene expression were also statistically associated with UICC stage and extent of cell differentiation, respectively. Variation in gene expression during the nontumor stage as well as the tumor stage may affect the prognosis of HCC patients, and integration of the gene expression profiles of HCC and adjacent liver tissue increases discriminatory effectiveness between patient groups, predicting clinical outcomes with enhanced statistical reliability.

Background/Aims: Brachial-ankle pulse wave velocity (baPWV) is a marker of vascular stiffness and is reported to be associated with diabetic neuropathy; however, the relationship between baPWV and nerve conduction study (NCS) has yet to be examined. Methods: Between January 2006 and December 2008, we investigated this relationship in diabetic patients. To this end, we reviewed the medical records of 100 diabetic patients for whom both baPWV and NCS had been examined. Results: The mean age of patients was 55.4 ± 10.6 years, and the mean duration of diabetes mellitus was 6.3 ± 7.3 years. A statistically significant inverse correlation between baPWV and NCS was observed, especially in the lower extremity sensory NCS [superficial peroneal sensory nerve action potential (SNAP), r = –0.466, p Conclusion: These results indicate that the degree of systemic arterial stiffness is associated with peripheral nerve status in diabetic patients, but it is unclear what this signifies and further study is needed.

Background: To assess the radiographic results in patients who underwent transforaminal lumbar interbody fusion (TLIF), particularly the changes in segmental lordosis in the fusion segment, whole lumbar lordosis and disc height. Methods: Twenty six cases of single-level TLIF in degenerative lumbar diseases were analyzed. The changes in segmental lordosis, whole lumbar lordosis, and disc height were evaluated before surgery, after surgery and at the fi nal follow-up. Results: The segmental lordosis increased significantly after surgery but decreased at the final follow-up. Compared to the preoperative values, the segmental lordosis did not change signifi cantly at the fi nal follow-up. Whole lumbar lordosis at the fi nal follow-up was significantly higher than the preoperative values. The disc height was significantly higher in after surgery than before surgery (p = 0.000) and the disc height alter surgery and at the fi nal follow-up was similar. Conclusions: When performing TLIF, careful surgical techniques and attention are needed to restore and maintain the segmental lordosis at the fusion level.

The authors report a case of bladder fistula associated with a medial thigh cutaneous fistula and chronic osteomyelitis of the pubic bone 11 years after surgery for a pelvic bone fracture and bladder rupture. In the presenting case, despite the clinical suspicion, none of the diagnostic tools demonstrated the bladder fistula preoperatively. This case suggests that bladder repair should be prepared, even if the bladder fistula cannot be confirmed by imaging studies because the amount of urine leakage can be minimal or the fistula can close spontaneously.

The purpose of this study was to investigate muscle activity and gait pattern in lower limb depending on the outsole of heel rockers. Fifteen healthy men volunteered for this experiment. Each subject performed totally three trails with two pairs of different heel rocker shoes and a pair of normal running shoes at speed of 1.33m/s for 1 minute during walking on a treadmill. Kinematic data gathered in 100Hz was recorded and analyzed by using the 3D motion capture system to measure the trunk tilt and joint angle of the right lower limb. And the lower extremity muscle activities were simultaneously recorded in 1000Hz and assessed by using EMG. The statistical analysis was the one-way ANOVA with the repeated measures to compare among the three kinds of shoes. The level of statistical significance for all tests was 0.05. Joint angle of lower limb was showed statistically significant different in MST(hip joint), LHS(ankle joint), and RTO(knee and ankle joint). Muscle activity of rectus femoris and biceps femoris was statistically increased in both heel rocker shoes during gait cycle on treadmill. The maximum peak time of tibialis anterior in the negative heel rocker showed the delay of approximately 23.8%time than normal shoes. Gait pattern variability of the negative heel rocker was increased in the first half of the stance phase and the variability of the positive heel rocker was increased in the terminal stance phase. In Conclusion, stability was decreased in between joints of lower limb on positive heel rocker than negative heel rocker. This study found that there were different joint angle, muscle activity, gait pattern and coordinate system of the lower limb in each kind of shoes. These unstability affected the lower extremity and the whole body. A further study has to be continued with study of rehabilitation and exercise for a long-term.

Background Despite the recent identification of several prognostic gene signatures, the lack of common genes among experimental cohorts has posed a considerable challenge in uncovering the molecular basis underlying hepatocellular carcinoma (HCC) recurrence for application in clinical purposes. To overcome the limitations of individual gene-based analysis, we applied a pathway-based approach for analysis of HCC recurrence. Results By implementing a permutation-based semi-supervised principal component analysis algorithm using the optimal principal component, we selected sixty-four pathways associated with hepatitis B virus (HBV)-positive HCC recurrence (p

The aims of study were to compare the rates of ipsilateral breast tumor recurrence (IBTR), for patients treated with either quadrantectomy or lumpectomy at a single institution, and to identify predictors of IBTR after breast-conserving therapy (BCT). The database and medical records of 807 patients who underwent BCT for breast cancer between 1987 and 2002 were reviewed. The age of the patient, tumor size, lymph node status, extensive intraductal component (EIC), re-excision, final margin status, and the extent of surgery were examined in reference to IBTR rates. Of the total 807 patients, 456 (56.5%) had undergone quadrantectomy and 351 patients (43.5%) had lumpectomy. Apart from the higher re-excision rate in the lumpectomy group (p < 0.001), there were no significant differences in clinical and pathologic characteristics between the patients in the two groups. At the median follow-up time of 72 months, 28 cases of IBTR (3.4%) and 56 cases of systemic recurrence (6.9%) had developed in 72 patients (8.9%). On multivariate analysis, young age (≤ 35) (p = 0.041), positive lymph node (p

Purpose: This paper analyzes the results of arthroscopic bankart repair for anterior recurrent dislocation following a trauma on shoulder. Material and Methods: The subjects were twenty-three (23) cases that were available to follow up for more than eighteen months during the period from November 2001 to June 2003 and were chosen from patients to whom arthroscopic bankart repair was applied using a knotless suture anchor for their traumatic anterior recurrent dislocation on the shoulder. Their average age was 28 (ranging from 15 to 60) with 20 males and 3 females. The injury from sports activities accounted for the most cases with 14 subjects. The average follow-up period was 27 months (ranging from 18 months to 35 months). There were 19 cases of bankart lesions, 4 cases of ALPSA lesions and associated with 5 cases of partial tear in the rotator cuff. The anchors employed were knotless anchor (Mitek) for all the cases. Rowe scoring scale was adopted to judge the results after operations. Patients` subjective satisfaction and range of motion of external rotation were addressed together. Results: Rowe scores showed that 20 cases (87%) reaches the level of `good` and hinger. The average patients` satisfaction accounted for 90 points out of 100. It was also found that external rotations averagely decreased by 6.5 degree when the range of motion was in at the side. Conclusion: There were satisfactory results of arthroscopic bankart repair using knotless suture anchors as an operative treatment for traumatic anterior recurrent dislocation on shoulder.

Superficial lipoma was easy to diagnose, but deep lipoma, especially intraosseus lipoma, was difficult to detect pre-operatively. Intraosseous lipoma is very rare and had been difficult to differentiate from other tumors before image diagnosis was developed. Recently, the detecting ratio has increased due to advanced diagnostic tools. Preoperative diagnosis is crucial for the treatment plan and influences the approach method for excision. We experienced one case of misdiagnosis which was diagnosed as intraosseous lipoma according to the preoperative MRI but turned out to be a parosteal lipoma after the surgery.

Background The sagittal alignment of the spine and pelvis is not only closely related to the overall posture of the body but also to the evaluation and treatment of spine disease. In the last few years, the EOS imaging system, a new low-dose radiation X-ray device, became available for sagittal alignment assessment. However, there has been little research on the reliability of EOS. The purpose of this study was to evaluate the intrarater and interrater reliability of EOS for the sagittal alignment assessment of the spine and pelvis. Methods Records of 46 patients were selected from the EOS recording system between November 2016 and April 2017. The exclusion criteria were congenital spinal anomaly and deformity, and previous history of spine and pelvis operation. Sagittal parameters of the spine and pelvis were measured by three examiners three times each using both manual and EOS methods. Means comparison t-test, Pearson bivariate correlation analysis, and reliability analysis by intraclass correlation coefficients (ICCs) for intrarater and interrater reliability were performed using R package "irr." Results We found excellent intrarater and interrater reliability of EOS measurements. For intrarater reliability, the ICC ranged from 0.898 to 0.982. For interrater reliability, the ICC ranged from 0.794 to 0.837. We used a paired t-test to compare the values measured by manual and EOS methods: there was no statistically significant difference between the two methods. Correlation analysis also showed a statistically significant positive correlation. Conclusions EOS showed excellent reliability for assessment of the sagittal alignment of the spine and pelvis.

MicroRNAs (miRNAs), endogenous non-coding small RNAs, are sensitive to environmental changes, and their differential expression is important for adaptation to the environment. However, application of miRNAs as a clinical prognostic or diagnostic tool remains unproven. In this study we demonstrate a chronic/persistent change of miRNAs from the plasma of a colorectal cancer susceptible mouse model (CPC;Apc) about 250 days after exposure to a simulated solar particle event (SPE). Differentially expressed miRNAs were identified compared to unirradiated control mice, including miR-31-5p, which we investigated further. To address the cellular function of miR-31-5p, we transfected a miR-31-5p mimic (sense) or inhibitor (antisense) into immortalized human colonic epithelial cells followed by gamma-irradiation. A miR-31-5p mimic sensitized but a miR-31-5p inhibitor protected colonic epithelial cells against radiation induced killing. We found that the miR-31-5p mimic inhibited the induction of hMLH1 expression after irradiation, whereas the miR-31-5p inhibitor increased the basal level of hMLH1 expression. The miR-31-5p inhibitor failed to modulate radiosensitivity in an hMLH1-deficient HCT116 colon cancer cell line but protected HCT116 3-6 and DLD-1 (both hMLH1-positive) colon cancer cell lines. Our findings demonstrate that miR-31-5p has an important role in radiation responses through regulation of hMLH1 expression. Targeting this pathway could be a promising therapeutic strategy for future personalized anti-cancer radiotherapy.

Aberrant Hedgehog (HH) signaling activation is important in cancer growth and mediates the interaction between cancer cells and the surrounding stromal cells. This study investigated the role of HH signaling on the growth of cholangiocarcinoma (CC), focusing on the interaction of CC cells with stromal cells. To evaluate the interaction between human CC cells (SNU-1196, SNU-246, SNU-308, SNU-1079, and HuCCT-1) and stromal cells (hepatic stellate cell line, Lx-2), co-culture proliferation, migration, and invasion assays were performed. In vivo nude mice experiments were conducted using two groups—HuCCT-1 single implant xenograft (SX) and co-implant xenograft (CX) with HuCCT-1 and Lx-2. When HuCCT-1 cells were co-cultured with Lx-2 cells, the expression of HH signaling-related proteins increased in both HuCCT-1 and Lx-2 cells. Co-culture with Lx-2 cells stimulated the proliferation, migration, and invasion of CC cells, and these effects were mediated by HH signaling. Co-culture of HuCCT-1 and Lx-2 cells increased the secretion of several cytokines. In an ectopic xenograft model, Lx-2 co-implantation increased CC tumor growth and stimulated angiogenesis. Cyclopamine attenuated tumor growth in the CX group, but not in the HuCCT-1 mono-implant (SX) group. Cyclopamine treatment decreased CC cell proliferation, suppressed microvessel density, and increased tumor necrosis in the CX group, but not in the SX group. Hepatic stellate cells stimulate the proliferation, migration, and invasion of CC cells, promote angiogenesis through HH signaling activation, and render CC more susceptible to necrosis by HH inhibitor.