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Masaki Nakano,1,* Haruka Yui,1,* Shingo Kikugawa,2 Ryosuke Tokida,3 Noriko Sakai,4 Naoki Kondo,5 Naoto Endo,5 Hirotaka Haro,6 Hiroki Shimodaira,1 Takako Suzuki,1,7 Hiroyuki Kato,1 Jun Takahashi,1 Yukio Nakamura1 1Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, 390-8621, Japan; 2DNA Chip Research Inc., Minato-ku, Tokyo, 105-0022, Japan; 3Rehabilitation Center, Shinshu University Hospital, Matsumoto, Nagano, 390-8621, Japan; 4Department of Orthopaedic Surgery, New Life Hospital, Obuse, Nagano, 381-0295, Japan; 5Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, 951-8510, Japan; 6Department of Orthopaedic Surgery, University of Yamanashi Graduate School of Medicine, Chuo, Yamanashi, 409-3898, Japan; 7Department of Human Nutrition, Faculty of Human Nutrition, Tokyo Kasei Gakuin University, Chiyoda-ku, Tokyo, 102-8341, Japan*These authors contributed equally to this workCorrespondence: Yukio NakamuraDepartment of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, JapanTel +81-263-37-2659Fax +81-263-35-8844Email yxn14@aol.jpObjective: Osteoarthritis (OA) is a common and degenerative joint disorder in the elderly. A greater importance of understanding the relationship between genetic factors and OA prevalence has emerged with population aging. We therefore investigated the associations of several bone disease-related genetic variants with the prevalence of OA and osteoporosis in Japanese elderly women from the Obuse study cohort, which was randomly sampled from a basic town resident registry.Methods and Results: In total, 206 female participants (mean ± standard deviation age: 69.7 ± 11.0 years) who completed OA, bone mineral density, and genotype assessments were included. The number of patients diagnosed as having knee/hip OA and osteoporosis was 59 (28.6%) and 30 (14.6%), respectively. Fisher’s exact testing revealed significant relationships between the minor T allele of LDL receptor related protein 5 (LRP5) rs3736228 and the prevalence of knee/hip OA and osteoporosis. The respective odds ratios (ORs) of the TT genotype for knee/hip OA and osteoporosis were 7.28 (95% confidence interval [CI] 2.22– 28.08) and 5.24 (95% CI 0.95– 26.98). An additional subgroup analysis for knee OA revealed that the frequency of the common C allele of methylenetetrahydrofolate reductase (MTHFR) rs1801133 had a statistically significant protective association with the prevalence of knee OA (OR 0.58, 95% CI 0.35– 0.97).Conclusion: In sum, the present study demonstrated significant associations of LRP5 rs3736228 and MTHFR rs1801133 with knee/hip OA and osteoporosis prevalences and knee OA prevalence, respectively, in Japanese elderly women. These results will help further the understanding of OA pathogenesis and related genetic risk factors.Keywords: genetic variant, LRP5, MTHFR, osteoarthritis, osteoporosis

Purpose The aim of this study was to verify the effects of a new remnant augmentation technique with anatomical double-bundle anterior cruciate ligament (ACL) reconstruction for postoperative clinical scores, anterior stability and frequency of complications compared to remnant removal and cases with remnant defects. Methods The 105 patients who underwent anatomical double-bundle ACL reconstruction were divided into three groups. If the remnant was a Crain I-III type, remnant-preserving bone tunnel creation was attempted. After the creation of the bone tunnel, good continuity was maintained in 34 patients (preserved group). Due to lost continuity, the remnant was resected in 26 patients (resected group). No identifiable remnant continuity remained (Crain IV) in 45 patients (absent group). The Lysholm knee score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective score, anterior stability measured using the KT-1000 arthrometer at 2 years postoperatively, and frequency of complications were compared among the three groups. Univariate and multiple linear regression analysis were performed to clarify the factors affecting postoperative anterior stability. Results The Lysholm knee score, Tegner activity scale, IKDC subjective score, and frequency of complications were not significantly different among the groups. The mean side-to-side difference of anterior stability was significantly better in the preserved group (0.3 ± 1.6 mm) compared to the resected group (1.6 ± 2.3 mm, p = 0.003) and absent group (1.6 mm ± 1.7, p = 0.009). The multiple linear regression analysis showed remnant preservation significantly related to postoperative anterior stability. Conclusion Although there were no differences in clinical scores, the ACL reconstruction with new preservation technique showed good anterior stability and no difference in the frequency of complications.

Recent studies on the detailed anatomy of the medial patellar stabilizer have revealed that the medial patellofemoral ligament (MPFL) not only attaches to the patella but also has fibers that attach to the quadriceps muscle, known as the medial quadriceps tendon femoral ligament (MQTFL). Reconstruction of the medial stabilizer for patellar dislocation that includes both the MPFL and MQTFL may achieve better anatomical and physiological correction. In this Technical Note, we will describe a simultaneous reconstruction technique of the MPFL and MQTFL for patellar dislocation using an artificial ligament.

Femoroacetabular impingement syndrome (FAIS) has been associated with osteitis pubis; however, it is still unclear whether hip dysplasia is associated with osteitis pubis. This study aimed to investigate (i) the incidence of pubic bone marrow edema (BME) on magnetic resonance imaging in symptomatic patients with FAIS, borderline developmental dysplasia of the hip (BDDH) and developmental dysplasia of the hip (DDH) undergoing hip arthroscopic surgery with labral preservation and (ii) the demographic and radiographic factors associated with pubic BME. A total of 259 symptomatic patients undergoing hip arthroscopic surgery between July 2016 and April 2019 were retrospectively reviewed and divided into three groups: FAIS (180 patients), BDDH (29 patients) and DDH (50 patients). Diffuse changes in the pubic bone adjacent to the pubic symphysis were labeled pubic BME, and the prevalence of their occurrence was examined. Multivariate logistic regression analysis was performed to identify factors involved in pubic BME, and odds ratios (ORs) for relevant factors were calculated. There was no significant difference in the prevalence of pubic BME among the three groups (20 [11.1%] of 180 FAIS patients, 6 [20.6%] of 29 BDDH patients and 7 [14%] of 50 DDH patients, P = 0.325). Multivariate logistic regression analysis showed that acetabular coverage was not associated with pubic BME, whereas younger age and greater alpha angle were still independent associated factors [age ≤26 years (OR, 65.7) and alpha angle ≥73.5° (OR, 4.79)]. Determining the possible association of osteitis pubis with cam impingement in dysplastic hips may provide insights toward a more accurate understanding of its pathophysiology.

Case. We report a rare case of prefemoral fat pad impingement syndrome that was caused by a hyperplasia of the normal suprapatellar fat pad. Pain and catching were observed in the proximal-lateral patellofemoral joint, and MRI imaging confirmed a hyperplasic mass in the same area. Although conservative treatment showed no signs of improvement, symptoms improved after an arthroscopic excision of the mass. Conclusion. Prefemoral fat pad impingement syndrome is related to patellar motion and should be considered as one of the underlying causes of anterior knee pain (AKP). Surgeons should recognize that a small hyperplasia composed of normal adipose tissue can cause AKP.

Osteoarthritis (OA) is a common and degenerative joint disorder in the elderly. A greater importance of understanding the relationship between genetic factors and OA prevalence has emerged with population aging. We therefore investigated the associations of several bone disease-related genetic variants with the prevalence of OA and osteoporosis in Japanese elderly women from the Obuse study cohort, which was randomly sampled from a basic town resident registry. In total, 206 female participants (mean ± standard deviation age: 69.7 ± 11.0 years) who completed OA, bone mineral density, and genotype assessments were included. The number of patients diagnosed as having knee/hip OA and osteoporosis was 59 (28.6%) and 30 (14.6%), respectively. Fisher's exact testing revealed significant relationships between the minor T allele of LDL receptor related protein 5 (LRP5) rs3736228 and the prevalences of knee/hip OA and osteoporosis. The respective odds ratios (ORs) of the TT genotype for knee/hip OA and osteoporosis were 7.28 (95% confidence interval [CI] 2.22–28.08) and 5.24 (95% CI 0.95–26.98). An additional subgroup analysis for knee OA revealed that the frequency of the common C allele of methylenetetrahydrofolate reductase (MTHFR) rs1801133 had a statistically significant protective association with the prevalence of knee OA (OR 0.58, 95% CI 0.35–0.97). In sum, the present study demonstrated significant associations of LRP5 rs3736228 and MTHFR rs1801133 with knee/hip OA and osteoporosis prevalences and knee OA prevalence, respectively, in Japanese elderly women. These results will help further the understanding of OA pathogenesis and related genetic risk factors.

A 16-year-old female with a history of left recurrent patellar dislocation underwent medial patellofemoral ligament (MPFL) reconstruction surgery. Two months postoperatively, the patient presented with medial patellar pain. Left medial plica syndrome was suspected, and we performed a partial arthroscopic resection of the medial synovial plica. The symptom gradually improved after surgery. To the best of our knowledge, there are no reports that discuss the relationship between postoperative pain of MPFL reconstruction and synovial plica as found in this case report. Surgeons should be aware of the possibility that asymptomatic synovial plica could become symptomatic.

Because various biomechanical studies and clinical results have shown the effectiveness of an anatomical approach for anterior cruciate ligament (ACL) reconstruction, this approach has become gradually commonplace to improve postoperative performance. Standard tunnel positioning methods with accuracy, reproducibility, and adaptability to varied concepts are essential for the success of anatomical ACL reconstruction. However, there were no standard tibial tunnel positioning methods to satisfy these conditions. This technical note reports our tibial tunnel positioning technique using bony and/or anatomical landmarks for anatomical ACL reconstruction.

Purpose To assess (1) if 6 anatomic landmarks (ALs) could be arthroscopically confirmed with remnant preservation and (2) if creating tibial tunnels using these landmarks reduces individual variation and improves reproducibility in double-bundle anterior cruciate ligament (ACL) reconstruction. Methods We retrospectively reviewed data of patients who chronologically underwent double-bundle ACL reconstruction by either referencing the footprint after remnant dissection (non-AL group) or subsequently with the ALs (AL group). Using operative videos, 3 independent observers judged whether they could confirm 6 ALs (medial intercondylar ridge, medial and lateral intercondylar tubercles, anterior horn of lateral meniscus, Parsons' knob, and L-shaped ridge) in 20 patients randomly selected from the AL group. We then compared tunnel positions between the 2 groups, measured from the anterior and medial borders of the proximal tibia and expressed as percentage of the total depth and width of the proximal tibia using 3-dimensional computed tomography. Results One hundred four patients (non-AL group, n = 54; AL group, n = 50) were included. All 6 ALs were arthroscopically confirmed in most cases (89.7% to 100%). The mean percentages of the anteroposterior (AP) depth for anteromedial (AM) tunnel, mediolateral (ML) width for AM tunnel, AP depth for posterolateral (PL) tunnel, and ML width for PL tunnel, respectively, were 27.8% ± 6.6%, 46.7% ± 2.8%, 41.4% ± 7.3%, and 46.1% ± 2.6% for the non-AL group and 30.7% ± 4.5%, 45.7% ± 2.2%, 45.2% ± 4.5%, and 46.9% ± 2.1% for the AL group, revealing significantly less variation in the AL group compared with the non-AL group, excluding the ML width of the PL tunnel ( P = .007, .046, .002, .209, respectively). Conclusions Six landmarks could be reliably confirmed in cases with remnant preservation, and creating tibial tunnels using these landmarks were reproducible and resulted in less individual variation. Level of Evidence Level III, retrospective comparative study.

In anatomical anterior cruciate ligament reconstruction surgery using the outside-in technique, the aperture of the femoral lateral cortex may become elliptical. Retrospective cross-sectional study To evaluate the extent of elliptical eccentricity in lateral apertures relative to aperture positioning and clinical failure rate in anatomical anterior cruciate ligament double-bundle reconstruction using outside-in technique. In 75 patients, the aperture elongation factor was defined as the ratio of the major axis of the elliptical aperture to the drill size. Using the lateral epicondyle as a reference point, the lateral femur was divided into sections by distance and angle, and the minimum area was evaluated to assess the relationship between the elongation factor and aperture position of the lateral cortex for each bundle. The incidence and associated clinical performance regarding cortical button migration were also investigated. Aperture elongation factors were 120.2 ± 13.3% and 120.0 ± 16.3% on the anteromedial (AM) and posterolateral (PL) sides, respectively. Femoral tunnel elongation was smallest when the entry point axis were both between 30 to 60° and distance was between 10 to 20 mm and 0 to 10 mm on the AM and PL sides, respectively. During the postoperative follow-up period, intra-tunnel migration was confirmed in 4 of 75 cases (5.3%). Fixation failure neither affected clinical scores nor knee laxity. Areas of minimum elongation for each bundle on both AM and PL sides were found anteroproximally to the lateral epicondyle and positioned near each other. Elongation did not directly affect the clinical outcome. Level of evidence grade: prognostic level III

Background: The tibial tuberosity-trochlear groove distance is used as an indicator for medial tibial tubercle transfer; however, to our knowledge, no studies have verified whether this distance is strongly affected by tubercle lateralization at the proximal part of the tibia. We hypothesized that the tibial tuberosity-trochlear groove distance is mainly affected by tibial tubercle lateralization at the proximal part of the tibia. Methods: Forty-four patients with a history of patellar dislocation and forty-four age and sex-matched controls were analyzed with use of computed tomography. The tibial tuberosity-trochlear groove distance, tibial tubercle lateralization, trochlear groove medialization, and knee rotation were measured and were compared between the patellar dislocation group and the control group. The association between the tibial tuberosity-trochlear groove distance and three other parameters was calculated with use of the Pearson correlation coefficient and partial correlation analysis. Results: There were significant differences in the tibial tuberosity-trochlear groove distance (p < 0.001) and knee rotation (p < 0.001), but there was no difference in the tibial tubercle lateralization (p = 0.13) and trochlear groove medialization (p = 0.08) between the patellar dislocation group and the control group. The tibial tuberosity-trochlear groove distance had no linear correlation with tubercle lateralization (r = 0.21) or groove medialization (r = −0.15); however, knee rotation had a good positive correlation in the patellar dislocation group (r = 0.62). After adjusting for the remaining parameters, knee rotation strongly correlated with the tibial tuberosity-trochlear groove distance (r = 0.69, p < 0.001), whereas tubercle lateralization showed moderate significant correlations in the patellar dislocation group (r = 0.42; p = 0.005). Conclusions: Because the tibial tuberosity-trochlear groove distance is affected more by knee rotation than by tubercle malposition, its use as an indicator for tibial tubercle transfer may not be appropriate. Clinical Relevance: Surgical decisions of tibial tubercle transfer should be made after the careful analysis of several underlying factors of patellar dislocation.