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STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze the risk factors for bony proximal junctional failure (B-PJF) and ligamentous PJF (L-PJF) separately after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Despite numerous studies about the risk factors of PJF, it remains unclear whether same risk factors can be applied to both B-PJF and L-PJF. METHODS: Patients who underwent corrective surgery from low thoracic level (T9-T12) to pelvis with minimum follow-up duration of two years were included in this study. Patients with PJF were divided into two groups according to the involvement of bony structure: B-PJF and L-PJF. The control group was created using patients who did not develop PJF for ≥2 years postoperatively (no-PJF group). Risk factors were analyzed by comparing various clinical and radiographic parameters between no PJF versus B-PJF group and between no PJF versus L-PJF groups. RESULTS: The final study cohort comprised 240 patients. The mean age was 68.7 years, and there were 205 women (85.4%). On average, 8.1 levels were fused. PJF developed in 103 patients, with 70 (68.0%) in the B-PJF group and 33 (32.0%) in the L-PJF group. Stepwise logistic regression analyses revealed that older age (odds ratio [OR]=1.088), higher body mass index (BMI) (OR=1.161), osteoporosis (OR=3.293), greater postoperative lumbar distribution index (OR=1.032), and overcorrection relative to the age-adjusted pelvic incidence - lumbar lordosis (OR=3.964) were significant risk factors for B-PJF. Meanwhile, no use of transverse process (TP) hook was the single risk factor for L-PJF (OR=4.724). CONCLUSIONS: Understanding the difference in risk factors between B-PJF and L-PJF will facilitate the optimization of surgical outcome for patients with ASD. Appropriate correction of sagittal malalignment along with use of TP hook is advisable to mitigate both B-PJF and L-PJF development.

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STUDY DESIGN: Retrospective study. OBJECTIVES: To validate the sagittal age-adjusted score (SAAS) in predicting proximal junctional kyphosis/failure (PJK/F) and good clinical outcomes following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: SAAS is a relatively new assessment system that incorporates age-adjusted sagittal parameters of pelvic incidence (PI) - lumbar lordosis (LL), pelvic tilt (PT), and T1 pelvic angle (TPA) to predict the PJK/F. External validation is required to verify its clinical usefulness. METHODS: We included patients with ASD undergoing ≥5-level fusion including the sacrum or pelvis. SAAS was calculated based on the scores of the three components: PI-LL, PT, and TPA. PJK/F rates and clinical outcomes were compared among the correction categories (undercorrection, matched correction, and overcorrection) for the SAAS as well as for each of the three components. PJK/F rates were compared according to the correction groups of the sagittal components and total SAAS using the chi-square test. Receiver operating characteristic (ROC) analysis was performed to evaluate the predictive ability of overcorrection to develop PJK/F for the three sagittal parameters and SAAS. PROMs at final follow-up were compared among correction groups using ANOVA with Bonferroni post-hoc corrections. RESULTS: A total 411 patients were included in the study (mean age: 69.3 y, mean body mass index: 25.9 kg/m2, total levels fused: 7.7 levels, and follow-up duration: 43.3 mo). Postoperative SAAS categories were as follow: undercorrection (13.4%), matched correction (30.2%), and overcorrection (56.4%). The PJK/F rates were significantly higher in the overcorrection group relative to PI-LL component (P=0.001) as well as SAAS (P=0.038) compared to undercorrection or matched correction groups. The clinical outcomes were best in patients who achieved matched correction relative to PI-LL component as well as SAAS compared to the other correction groups. However, the differentiating power of clinical outcomes across the correction categories was greater in the PI-LL component than in the SAAS. CONCLUSION: This study validated the efficacy of SAAS system to differentiate PJK/F development and good clinical outcomes. However, its differentiating power seems to be largely attributable to the function of the PI-LL component, as the PI-LL correction status better predicted PJK/F risk and clinical outcomes than SAAS.

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BACKGROUND CONTEXT: While numerous studies have been conducted on proximal junctional failure (PJF), the clinical significance of acute and delayed PJF remains poorly understood. PURPOSE: The primary object of this study is to investigate the risk factors separately for acute and delayed PJF. Secondly, we aim to assess the incidence of each failure mode and their clinical consequences in relation to acute and delayed PJF. STUDY DESIGN/SETTING: Retrospective comparative study. PATIENT SAMPLE: Patients aged ≥60 years who underwent deformity correction with ≥5-level fusion to sacrum. OUTCOME MEASURES: Risk factor, failure modes, and patient-reported outcome measure (PROM). METHODS: Acute PJF is defined as PJF occurring within 6 months, while delayed PJF occurring after 6 months. Risk factors were analyzed by comparing various clinical and radiographic parameters among 3 groups: no, acute, and delayed PJF groups. The failure modes, including soft tissue failure, vertebral fracture, fixation failure, and myelopathy, were compared among these groups. The clinical subsequences after PJF development were evaluated by assessing the change in proximal junctional angle (PJA), revision rate, and patient-reported outcome measure (PROM). RESULTS: A study cohort of 363 patients was included in the analysis. Among them, 156 patients experienced PJF, with 87 patients (55.8%) in the acute PJF group and 69 patients (44.2%) in the delayed PJF group. Multivariate analyses showed that older age (Odds ratio [OR] = 1.057, 95% confidence interval [CI] = 1.002-1.118), osteoporosis (OR=2.149, 95% CI = 1.074-4.300), high American Society of Anesthesiology ASA score (OR=2.150, 95% CI = 1.089-4.245), and overcorrection relative to the age-adjusted pelvic incidence - lumbar lordosis target (OR=4.031, 95% CI = 1.962-8.280) were identified as risk factors for the development of acute PJF. On the other hand, a high body mass index (OR=1.150, 95% CI = 1.049-1.251) and an uppermost instrumented vertebra located at ≤T10 (OR=2.267, 95% CI = 1.205-4.268) were found to be associated with delayed occurrence of PJF. No radiographic parameters were found to be related to the development of delayed PJF. In terms of failure modes, vertebral fracture and fixation failure were more commonly observed in acute PJF, while soft tissue failure and myelopathy were more predominant in delayed PJF. The clinical course was more aggressive in the acute PJF group compared to the delayed PJF group, as evidenced by a greater increase in PJA, a higher revision rate, and worse PROM. CONCLUSIONS: This study demonstrated different risk factors between the acute and delayed PJF. It was found that overcorrection relative to the age-adjusted PI-LL target increased the risk of acute PJF, but had no impact on the development of delayed PJF. Therefore, a different surgical strategy needs to be established to mitigate both acute and delayed PJF.

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STUDY DESIGN: Retrospective study. OBJECTIVES: To investigate the incidence and risk factors of mechanical failure (MF) following anterior column realignment (ACR) in patients with severe degenerative sagittal imbalance (DSI). SUMMARY OF BACKGROUND DATA: Considering the biomechanical properties of the procedure, ACR may increase the risk of MF, including proximal junctional kyphosis (PJK) and rod fracture (RF). However, this issue has been poorly documented in the literature. METHODS: We included patients aged ≥60 years with severe DSI radiographically defined by pelvic incidence (PI) - lumbar lordosis (LL) ≥20° undergoing ≥5-level fusion, including the sacrum. PJK was defined radiographically as a proximal junctional angle (PJA)>28° plus Δ PJA of>22°. RF was evaluated at ACR levels performed. Clinical and radiographic variables were compared to identify the risk factors for PJK and RF, then multivariate analysis was performed by combining PJK and RF into a single composite outcome of MF. RESULTS: We included a total of 147 patients in the final study cohort. The mean age was 70.3 years, and there were 126 women (90.6%). The median fusion length was 8 levels. After surgery, PI-LL was corrected from 48.1° to 4.3°. MF developed in 49 patients (33.3%); PJK in 41 (27.9%), RF in 11 (7.5%), and both PJK and RF in 3 (2.0%) patients. Multivariate analyses revealed that osteoporosis (odds ratio [OR]=2.361, 95% confidence interval [CI]=1.270 - 5.590, P=0.048) and an increased number of ACR levels (OR=1.762, 95% CI=1.039 - 3.587, P=0.036) were significant risk factors for MF. CONCLUSION: A considerable number of patients (33.3%) developed MF after deformity correction using ACR procedures. Therefore, appropriate surgical strategies are necessary to prevent MF in patients undergoing deformity correction using ACR, with special attention to the risk factors we identified here.

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Background: Lospa posterior-stabilized (PS) Plus type is a modified version of Lospa PS, in which the polyethylene insert shape is modified to reinforce stability and prevent patella-post impingement compared to Lospa PS. However, studies comparing the clinical and radiographic results of the two designs have not been reported yet. This study aimed to compare the clinical results of total knee arthroplasty (TKA) using the existing PS type and the modified Lospa PS Plus type. Methods: A retrospective study was performed on 558 knees of 342 patients who underwent TKA using the Lospa PS or PS Plus types and were followed up for at least 2 years. Cases were divided into two groups according to the implant used: 212 cases in the PS group and 346 cases in the PS Plus group. For clinical outcome assessment, knee range of motion (ROM), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Knee Society Score (KSS) were recorded before surgery and at the 2-year follow-up. Radiographic outcomes were evaluated according to the American Knee Society method. The incidence of postoperative complications and survival rates were compared between the two groups. Results: Both groups showed significant clinical improvement after surgery. The average KSS significantly improved from 53.4 points in the PS group and 52.3 points in the PS Plus group preoperatively to 91.3 points and 93.2 points after surgery, respectively (p < 0.001). The average WOMAC score improved from 50.4 points in the PS group and 52.3 points in the PS Plus group before surgery to 15.6 points and 14.8 points after surgery, respectively (p < 0.001). There was no significant difference between the two groups in ROM, the alignment of the lower limbs, and the implant position after surgery. The complication rates were also similar between the groups (p = 0.167). Conclusions: The Lospa PS Plus model is a modified design that improves the post structure from the previous PS type. Compared to the PS type, the PS Plus type showed similar statistical results at 2-year follow-up and good clinical results. The short-term average survival rate was over 98%, showing promising results.

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BACKGROUND: Although the Nirschl technique was introduced approximately 40 years ago, only limited information is available about the long-term results, especially concerning extensor power changes after surgery. The purpose of this study was to investigate long-term clinical results of surgical treatment of lateral epicondylitis using the modified Nirschl technique. The main outcome variable was muscle strength for wrist extension because the extensor origin was not reattached after removal of the degenerative extensor tendon. METHODS: Data from 99 patients who underwent surgical lateral epicondylitis treatment between 2007 to 2012 were included in the study. The mean follow-up period was 8.5 years (5 to 10, ± 1.1 years) and the mean age at surgery was 44.8 years (32 to 70, ± 9.8 years). The surgeries were performed using the modified Nirschl method and did not include extensor origin reattachment. Outcome measurements included the Visual Analogue Scale (VAS) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, the MAYO elbow performance score, and Nirschl and Pettrone's grades. Wrist extension and grip strength were analyzed using a digital handgrip dynamometer (microFET2TM system) and JAMA hand dynamometer. RESULTS: Mean time required to return to work was 2.4 months after surgery. At the last follow-up after surgery, the mean VAS score had significantly improved, from 4.9 to 1.1. Mean MAYO elbow performance scores significantly improved, from 64 to 90, and mean DASH scores improved from 50 to 13. The Nirschl and Pettrone's grades were 80% rated as 'excellent' and 16% rated as 'good'. After adjusting for power differences between the dominant and non-dominant arms, the difference between wrist extensor power of the operated elbow and the non-operated opposite elbow at the final follow-up was not statistically significant. No patients complained about wrist extension weakness. CONCLUSION: Although reattachment of the extensor origin was not performed during the modified Nirschl surgical technique, there was no significant weakness in wrist extension power and the long-term follow-up revealed favorable clinical results. LEVEL OF EVIDENCE: Level IV (case series). Retrospective study.

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BACKGROUND: Multiple Symmetric Lipomatosis (MSL) is a rare disorder related to fat metabolism and lipid storage. The condition results in characteristic depositions of fat, especially around the cephalic, cervical, and upper thoracic subcutaneous. It is much more common in adult males who live in the Mediterranean region and has only rarely been reported in Asian females. In this report, we present a case of an Asian female with MSL and also review the clinical features of the condition, including radiological and histological findings required for proper diagnosis and management. CASE PRESENTATION: A 59-year-old Korean female came in with a chief complaint of palpable mass present in shoulder and upper back regions. Images showed diffuse non-encapsulated adipose tissue in the subcutaneous layer of the suboccipital, posterior neck area. The patient wanted to remove the mass for cosmetic reasons and discomfort. Excisional biopsy was planned. Preoperative blood analyses showed deteriorated liver function, and the computed tomography findings were consistent with liver cirrhosis. Detailed history taking revealed that she consumed highly levels of alcohol. Lipectomy was performed and the histological findings demonstrated large dystrophic adipocyte morphology. The patient was recovered uneventfully. CONCLUSION: When patients have multiple symmetric lipomatous lesions, clinicians should suspect MSL and survey possible associated conditions, such as alcoholism, liver cirrhosis, dyspnea, and neuropathy in detail.

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INTRODUCTION: Although the major cause of carpal tunnel syndrome (CTS) remains idiopathic, many male CTS patients are clinically different from female patients and often have specific risk factors associated with their conditions. An accurate analysis of such propensity has yet to be established. The purpose of this study is to compare male and female patients by analyzing the risk factors associated with CTS patients who underwent surgical treatment, with focus on their occupation. PATIENTS/MATERIAL AND METHODS: retrospective chart review of 818 patients with CTS was performed to identify the associated risk factors. Patients were stratified by gender: female (n = 707, 86.4 %) and male (n = 111, 13.6 %). The mean patient age was 54.5 (range: 16-85 yr.) for all groups. The medical history and risk factors of each patient was thoroughly reviewed by medical charts and telephone survey. We categorized the risk factors of CTS into 7 categories: anatomic, neuropathic, inflammatory, alteration of fluid balance, distal radius fracture associated, occupational risk factor related, and idiopathic. Occupations of CTS patients were divided into high risk occupations (vibratory tools, assembly jobs, and food processing and packaging jobs, and other occupations of repetitive wrist motion and forceful gripping) and nonrisk occupations. All variables were analyzed with chi-square or Fisher's exact test for differences between men and women. RESULTS: The number of individuals with known risk factors of CTS was greater in male, compared to that of female patients; 97 (87.4 %) male patients had the risk factors of CTS, while 361 (51.1 %) female patients (p < 0.001) did. In subgroup analysis of risk factors, male patients had frequent risk factors in neuropathic, inflammatory, and alteration of fluid balance (p < 0.001). Occupational risk was strongly associated with male gender (p < 0.001). CONCLUSION: Male CTS patients who underwent surgery are more likely to have a reason and have many occupational risk factors than women.

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Osgood-Schlatter disease (OSD) is known as a self-limiting condition but surgical excision of the ossicles may be required in adults resistant to conservative treatments. The ossicle associated to OSD is generally small and located outside the joint near the tibial tubercle; however, large or intra-articular ossicle has been reported rarely. Here, we report an unusual case of OSD with a separated, large-sized ossicle that protruded into the knee joint and treated by arthroscopy-assisted excision of the ossicle.

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BACKGROUND: Graft shrinkage or radial extrusion is a reported complication after meniscus allograft transplantation (MAT). Whether shrinkage or extrusion progress after surgery and whether they are associated with the clinical outcome of MAT remain debatable. In this study, graft shrinkage and extrusion were measured in the coronal and sagittal planes using serial postoperative magnetic resonance imaging (MRI). The purpose of this study was to evaluate if graft shrinkage or extrusion is correlated to the clinical outcome of MAT. METHODS: MRIs acquired at 3 and 12 months postoperatively in 30 patients (21 men and 9 women) who underwent MAT (6 medial and 24 lateral menisci) from 2010 to 2016 were analyzed. Two orthopedic surgeons and two musculoskeletal specialized radiologists each performed the MRI measurements. Allograft shrinkage was measured by the width and thickness of the graft at the coronal and sagittal planes. To determine the graft extrusion, distances between the proximal tibia cartilage margin and the extruded graft margin were measured in both coronal (either lateral or medial) and sagittal (both anterior and posterior) plane and relative percentage of extrusion (RPE) were calculated. Subjective International Knee Documentation Committee (IKDC) scores at 12 months were evaluated as a clinical outcome measurement, and correlations between shrinkage or extrusion of allograft and IKDC score were analyzed. RESULTS: In the coronal plane, radial RPE averaged 43.6% at postoperative 3 months, but there was no significant progression of extrusion at 12 months (average 42.0%) (P = 0.728). In the sagittal plane, there were no significant progressions of anterior and posterior RPE (P = 0.487 and 0.166, respectively) between postoperative 3 and 12 months. Shrinkage was calculated by multiplying the width and height of the three sections and summing these values. There was no significant progression of shrinkage between postoperative 3 and 12 months (P = 0.150). RPE in the radial (R = 0.147, P = 0.525), anterior (R = 0.249, P = 0.264), and posterior (R = 0.230, P = 0.315) directions and shrinkage (R = 0.176, P = 0.435) were not correlated to IKDC score at postoperative 12 months. CONCLUSIONS: In the coronal and sagittal planes, extrusion and shrinkage did not progress from 3 months to 1 year. Extrusion and shrinkage had no correlation with early clinical outcomes. This finding suggests that graft extrusion or shrinkage may be not a great concern especially in early postoperative period of MAT, and multiple, serial MRI may be not necessary.

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BACKGROUND: Authors assessed lean body mass (fat free tissue), upper and lower, and bone mineral density (BMD) in patients of osteoporotic bone distal radius fracture (DRF) and degenerative rotator cuff tear (RCT) patients of shoulder. We predict inferior muscle mass and osteoporosis are more frequent in DRF group than RCT group. METHODS: Between January 2016 and June 2017, overall 38 of DRF and 30 of RCT were eligible for this retrospective comparison study after excluding of patients with compounding factors. BMD and other body composition, fat and lean body mass, were assessed with a single dual energy X-ray absorptiometry in one hospital. RESULTS: T-score of spine were -2.2 and -1.6 in DRF and RCT patients with significant difference (P=0.040). Final BMD score, lower score of patient between spine and femoral score, of both group also presented difference with significance, -2.4 of DRF and -1.9 of RCT patients (P=0.047). Diagnosis of osteoporosis was confirmed in 19 patients (50%) from DRF compared with 9 patients (30%) from RCT. The mean lean soft tissue mass of the arm was 3.7 kg and 3.8 kg in the DRF and RCT, respectively, without significant difference (P=0.882). The mean lean body mass of the leg was 11.0 kg and 10.5 kg in the DRF and RCT, respectively, without significant difference (P=0.189). The relative overall appendicular lean mass was not significantly different between groups. CONCLUSIONS: Even though BMD difference, we did not find muscle mass difference between DRF and RCT patients.

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Super- and sub-critical water treatments have been of interest as novel methods for protein hydrolysis. In the present study, we studied the effect of sub-critical water (Sub-H2O, 300℃, 80 bar) treatment as well as super-critical water (Super-H2O, 400℃, 280 bar) treatment on the physicochemical properties of porcine skin (PS), which has abundant collagen. Porcine skin was subjected to pre-thermal treatment by immersion in water at 70℃, and then treated with sub- or super-critical water. Physicochemical properties of the hydrolysates, such as molecular weight distribution, free amino acid content, amino acid profile, pH, color, and water content were determined. For the molecular weight distribution analysis, 1 kDa hydrolyzed porcine skin (H-PS) was produced by Super-H2O or Sub-H2O treatment. The free amino acid content was 57.18 mM and 30.13 mM after Sub-H2O and Super-H2O treatment, respectively. Determination of amino acid profile revealed that the content of Glu (22.5%) and Pro (30%) was higher after Super-H2O treatment than after Sub-H2O treatment, whereas the content of Gly (28%) and Ala (13.1%) was higher after Sub-H2O treatment. Super-H2O or Sub-H2O treatment affected the pH of PS, which changed from 7.29 (Raw) to 9.22 (after Sub-H2O treatment) and 9.49 (after Super-H2O treatment). Taken together, these results showed that Sub-H2O treatment was slightly more effective for hydrolysis than Super-H2O was. However, both Sub-H2O and Super-H2O treatments were effective processing methods for hydrolysis of PS collagen in a short time and can be regarded as a green chemistry technology.

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In the flanker paradigm, participants identify a target letter while attempting to ignore an irrelevant flanker. When the identity of this flanker mismatches the target, target identification is slowed (called the flanker compatibility effect). Interestingly, reducing the array set size greatly increases flanker compatibility effects. This finding inspired 2 prominent explanations: perceptual load (mandatory capacity spillover) and dilution (visual interference). However, an alternative explanation, based on early selection theory and attention capture research, can also explain the data pattern. According to this "slippage" account, observers sometimes accidentally allocate spatial attention to the flanker (see Lachter, Forster, & Ruthruff, 2004), especially when the flanker has the property used to find the target (cf. contingent capture). In Experiments 1 through 4, deterring slippage to the flanker nearly eliminated flanker compatibility effects, even at the low set size. In Experiment 5, promoting slippage to the flanker dramatically enhanced compatibility effects, even at the high set size. Thus, slippage strongly modulates flanker effects and can, by itself, readily explain the impact of set size. The perceptual load and dilution accounts are, at best, incomplete, and, at worst, not needed.

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This study investigated the effects of three proteases (trypsin, pepsin and chymotrypsin) on the hydrolysis efficiency of porcine placenta and the molecular weight (Mw) distributions of the placental hydrolysates. Because placenta was made up of insoluble collagen, the placenta was gelatinized by applying thermal treatment at 90 ℃ for 1 h and used as the sample. The placental hydrolyzing activities of the enzymes at varying concentrations and incubation times were determined by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and gel permeation chromatography (GPC). Based on the SDS-PAGE, the best placental hydrolysis efficiency was observed in trypsin treatments where all peptide bands disappeared after 1 h of incubation as compared to 6 h of chymotrypsin. Pepsin hardly hydrolyzed the placenta as compared to the other two enzymes. The Mw distribution revealed that the trypsin produced placental peptides with Mw of 106 and 500 Da. Peptides produced by chymotrypsin exhibited broad ranges of Mw distribution (1-20 kDa), while the pepsin treatment showed Mw greater than 7 kDa. For comparisons of pre-treatments, the subcritical water processing (37.5 MPa and 200 ℃ of raw placenta improved the efficiency of tryptic digestions to a greater level than that of a preheating treatment (90 ℃ for 1 h). Consequently, subcritical water processing followed by enzymatic digestions has the potential of an advanced collagen hydrolysis technique.

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Much research has suggested that facial identification has some characteristics of automaticity, in that it is rapid, nonconscious, and mandatory. However, little research has tested whether it can occur even if attention is already devoted to the demanding central processes of another task. In the present study, we addressed this type of automaticity using the psychological refractory period paradigm. In Experiments 1 and 2, participants successfully identified familiar faces, even while they were engaged with another task, indicating the automaticity of familiar-face identification. In Experiments 3 and 4, however, participants could not identify unfamiliar faces as automatically as they could identify the familiar faces. We concluded that automatic face identification is possible, but dependent on prior familiarity.

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Theeuwes (Psychonomic Bulletin & Review 11:65-70, 2004) proposed that stimulus-driven capture occurs primarily for salient stimuli that fall within the observer's attentional window, such as when performing a parallel search. This proposal, which is supported by some studies, can explain many seemingly discrepant results in the literature. The present study tested this proposal using a modified precuing paradigm. Search mode was manipulated via target-distractor similarity in color space. In the parallel search condition, the orange target "popped out" from a set of distantly colored distractors (blue and green). In the serial search condition, the orange target was more difficult to find amongst a set of similarly colored distractors (yellow and red). In Experiments 1 and 2, cue validity effects for irrelevant-color singleton cues were greater under parallel than under serial search, at least partially replicating previous studies favoring the attentional-window account (e.g., Belopolsky, Zwaan, Theeuwes, & Kramer, Psychonomic Bulletin & Review 14:934-938, 2007). We found the opposite pattern, however, for capture by abrupt onsets (Experiments 3 and 4), in which case capture effects were actually greater under serial search. In sum, parallel search appears to facilitate capture by color singletons, yet to inhibit capture by abrupt onsets.

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