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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.

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.

Background: Ankle sprains are one of the most common musculoskeletal injuries. However, they may be more serious than commonly believed since many patients reportedly experience chronic problems afterwards. It is necessary to improve the treatment, such as the method and duration of fixation, of sprained ankles.Methods: Magnetic resonance imaging of 70 patients with acute moderate or advanced ankle sprains presenting consecutively between November 2014 and December 2019 were reviewed for analysis of bone bruising associated with ankle sprains. The patients were treated conservatively with a solid splint or cast until walking pain could be resolved without external fixation. In cases with pain at the time of weight bearing after solid fixation, crutches were prescribed for pain relief. The fixation period ranged from 8 days to 72 days (mean: 29.5 days). Afterwards, 54.0% of patients had walking pain and required the use of crutches. The ankle joint pain disappeared after conservative treatment in all patients.Results: The incidence of bone bruises detected by magnetic resonance imaging in the ankle and midfoot associated with ankle sprain was 81.4%. Bone bruises of the midfoot, including the tarsal bone and Chopart joint, were found in 34.3% of ankle sprains. Bone bruises of the talus were the most common, being present in 60% of ankle sprains. Bone bruises were also evident in the tibia (44.3%), the calcaneus (21.4%), and the tarsal bone (25.7%). There was a significant association between bone bruises of the talocrural joint surface and use of the crutches after fixation (P=0.041). Multiple regression analysis adjusted for age and gender revealed that bone bruises of the talocrural joint surface of the talus was a significant independent predictor of crutch use (P=0.045), with an odds ratio (95% confidence interval) of 3.03 (1.03-8.94).Conclusion: Bone bruises of the ankle and midfoot are often present in ankle sprains. In moderate or advanced cases of ankle sprain, external solid fixation of both the ankle and midfoot should be performed. In cases with pain at weight bearing following solid fixation, crutches are advised for pain relief and proper ligament and bone healing.

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.

Purpose To evaluate the postoperative change in patellar position after medial closed distal femoral osteotomy (DFO) performed for valgus osteoarthritic knees. Methods The study included 21 consecutive knees in 20 patients undergoing DFO. A minimum of 2-year follow-up data was obtained for all subjects with a mean follow-up period of 42 months (range 31–59 months). The patellar position was evaluated on plain radiographs preoperatively, 1-year postoperatively, and 2-year postoperatively. For patellar height, the modified Insall–Salvati Index (mISI), modified Caton–Deschamps Index (mCDI) and modified Blackburne–Peel Index (mBPI) were measured on the standing lateral radiographs. Patellofemoral alignment on the axial plane was assessed on skyline views with 30° flexion based on the measurements for lateral patellar tilt (LPT) and lateral patellar shift (LPS). Measured values at pre- and postoperative phases were statistically compared using a two-way analysis of variance. Results All indices including mISI, mCDI, mBPI, LPT and LPS showed no statistically significant postoperative changes. Conclusion Medial closed-wedge DFO performed for valgus osteoarthritic knees did not significantly influence patellofemoral alignment either on the sagittal or axial plane. Therefore, to highlight the clinical relevance of our findings, medial closed-wedge DFO for the valgus knee does not adversely affect the patellofemoral joint. Level of evidence Level IV, case series.

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

[Purpose] The aim of this study was to investigate the feasibility of using the current perception threshold (CPT), in a comparison with the visual analog scale (VAS), to assess its selectivity in assessing the excitability of Aβ, Aδ and C fibers in subjects with sub-acute post-operative pain who were being treated with conventional transcutaneous electrical nerve stimulation (TENS). [Subjects and Methods] A total of 17 subjects (mean age of 29.2 ±10.8 years) participated in this study. For all subjects, the study commenced on the fifth post-operative day and continued for the next five consecutive days following a descriptive time-series design. Both CPT and VAS were measured for all subjects on all five days following 15 minutes rest with the TENS output intensity set at zero on the baseline days (Days 1, 3, 5), and after 15 minutes TENS stimulation on the intervention days (Days 2 and 4). [Results] The results demonstrate that CPT was able to selectively assess the excitability of the Aβ and Aδ fibers. However, the selectivity of CPT in assessing the C fibers could not be verified in this study. [Conclusion] The various limitations of the time series design used in this study suggest the need to verify some of these results in a different experimental design in future studies.

The proliferation of human bone marrow mesenchymal stem cells (MSCs) employing xeno-free materials not containing fetal calf serum (FCS) and porcine trypsin was investigated for the regenerative medicine of cartilage using MSCs. Four sequential subcultivations of MSCs using a medium containing 10% FCS and recombinant trypsin (TrypLESelect™) resulted in cell growth comparable to that with porcine trypsin. There was no apparent difference in the cell growth and morphology between two kinds of MSC stored in liquid nitrogen using 10% FCS plus DMSO or serum-free TC protector™. MSCs were isolated from human bone marrow cells, stored in liquid nitrogen, and sequentially subcultivated four times employing conventional materials that included FCS, porcine trypsin, and DMSO, or xeno-free materials that included serum-free medium (MesenCult-XF™), TC protector™ and TrypLESelect™. Cells in the culture using the xeno-free materials maintained typical fibroblast-like morphology and grew more rapidly than the cells in the culture using the conventional materials, while the cell surface markers of MSCs (CD90 and CD166) were well maintained in both cultures. Chondrogenic pellet cultures were carried out using these subcultivated cells and a medium containing TGFβ3 and IGF1. The pellet culture using cells grown with the xeno-free materials showed an apparently higher gene expression of aggrecan, a chondrocyte marker, than the pellet culture using cells grown with the conventional materials. Consequently, MSCs that are isolated, stored, and grown using the xeno-free materials including the serum-free medium (MesenCult-XF™), TC protector™, and recombinant trypsin (TrypLESelect™) might be applicable for regenerative medicine of cartilage.

Accurate placement of separate anteromedial and posterolateral bundle bone tunnels is crucial for anatomic, double-bundle anterior cruciate ligament (ACL) reconstruction. However, identifying the anatomic footprint at which to make the tibial and femoral bone tunnels is not a straightforward procedure. To overcome this problem, we used a CT-based navigation technique with a registration procedure based on fiducial markers (FMs). Preoperatively, 10 FM points were placed on skin around knee joint and scanned with CT. Imaging data of the knee were recorded on the computer system for preoperative registration and surgical planning. Intraoperatively, with a reference frame fixed to the distal medial aspect of femur and tibia, paired-point matching registration was performed with the use of points marked on skin through FM center holes. During tibial tunnel guide wire placement, tibial aiming guide with tracking device fed back the position of tip and direction of the guide wire on the three-dimensional (3D) tibia bone surface image and multiple image planes in real time. For the femoral side, the navigation pointer was placed at the footprint center with visual guidance of 3D image of lateral wall sagittal view on navigation monitor and marked with navigation awl. The average registration accuracy of 22 consecutive patients was 0.7 +/- A 0.2 mm and 0.6 +/- A 0.2 mm for femoral and tibial bone, respectively. Most of the bone tunnel positions evaluated with 3D-CT image were confirmed to be accurately placed in reference to the preoperative plan. There was no damage to femoral condyle cartilage and no other complication. This new CT-based computer navigation system opens the possibility for surgeons to plan bone tunnel positioning preoperatively and control it during technically demanding anatomic double-bundle ACL reconstruction., Article, KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY. 19(3):378-383 (2011)

Background and purpose Osteochondral defects have a limited capacity for repair. We therefore investigated the effects of tumor necrosis factor (TNF) signal blockade by etanercept (human recombinant soluble TNF receptor) on the repair of osteochondral defects in rabbit knees. Material and methods Osteochondral defects (5 mm in diameter) were created in the femoral patellar groove in rabbits. Soon after the procedure, a first subcutaneous injection of etanercept was performed. This single injection or, alternatively, 4 injections in total (twice a week for 2 weeks) were given. Each of these 2 groups was divided further into 3 subgroups: a low-dose group (0.05 μg/kg), an intermediate-dose group (0.4 μ g/kg), and a high-dose group (1.6 μ g /kg) with 19 rabbits in each. As a control, 19 rabbits were injected with water alone. The rabbits in each subgroup were killed 4 weeks (6 rabbits), 8 weeks (6 rabbits), or 24 weeks (7 rabbits) after surgery and repair was assessed histologically. Results Histological examination revealed that the natural process of repair of the osteochondral defects was promoted by 4 subcutaneous injections of intermediate-dose etanercept and by 1 or 4 injections of high-dose etanercept at the various time points examined postoperatively (4, 8, and 24 weeks). Western blot showed that rabbit TNFα had a high affinity for etanercept. Interpretation Blocking of TNF by etanercept enabled repair of osteochondral defects in rabbit knee. Anti-TNF therapy could be a strategy for the use of tissue engineering for bone and cartilage repair.

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.

Objective To evaluate whether microbubble-enhanced ultrasound (US) treatment promotes the delivery of methotrexate (MTX) into synovial cells and the enhanced antiinflammatory effects of intraarticular MTX therapy in a rabbit arthritis model. Methods Arthritis was induced in both knees of 53 rabbits by immunization with ovalbumin. MTX including a microbubble agent was then injected into the left and right knee joints, and the right knees were exposed to US (MTX+/US+ group), while the left knees were not (MTX+/US− group). The knee joints were evaluated histologically in 7 rabbits at 5 time points up to day 56. Quantitative gene expression of interleukin-1β (IL-1β) in synovial tissue was measured on days 7 and 28. Eight rabbits were used for the measurement of MTX concentration in synovial tissue 12 hours after treatment. To evaluate the effect of microbubble-enhanced US treatment in the absence of MTX, only the microbubble agent was injected into the left and right knee joints of 10 rabbits with or without US exposure, and these animals were evaluated histologically on days 7 and 28. Results The MTX concentration in synovial tissue was significantly higher in the MTX+/US+ group than in the MTX+/US− group. Synovial inflammation was less prominent in the MTX+/US+ group compared with the MTX+/US− group, judging from the results of the histologic evaluation and the gene expression levels of IL-1β in synovial tissue. It also appeared that microbubble-enhanced US exposure itself did not affect inflammation. Conclusion Microbubble-enhanced US exposure promoted the uptake of MTX into synovial cells, which resulted in enhancement of the antiinflammatory effects of the intraarticular MTX injection. These results suggest that application of this technique may have clinical benefit.

Aiming to construct an osteochondral-like structure, the combination of a β-tricalcium phosphate (βTCP) block with a scaffold-free sheet formed using mesenchymal stem cells (MSCs) was investigated.Human bone marrow MSCs in a cell culture insert that was set in a 24-well plate were cultivated using a chondrogenic medium containing dexamethasone, IGF-1, and TGFβ3 for 3 weeks during which a cylindrical βTCP block was put on the sheet at day 1, and the cell sheet construct was harvested. In other experiments, at day 14, the construct was put on a cell sheet that was prepared the day before and cultivated for 3 weeks.The addition of a βTCP block resulted in a combined osteochondral-like construct and comparable staining intensity by Alcian blue, while the expression levels of the aggrecan and type II collagen genes decreased a little. During the culture with the βTCP block, the expression levels of the aggrecan gene increased monotonically. The increase in the inoculum cell number from 1.86 to 3.72 × 10(6) cells resulted in marked increases in the thickness of cell sheet parts in the βTCP block and expression levels of the aggrecan and type II collagen genes, while the thickness of cell sheet parts on the βTCP block scarcely changed. On the other hand, the addition of a cell sheet that was prepared a day before to the construct at day 14 resulted in the marked increase in thickness of the cell sheet part on the βTCP block, while the thickness of that in the βTCP block did not increase.A combined osteochondral-like structure was produced by putting a βTCP block on the sheet of MSC. The thickness of the cell sheet parts in and on the βTCP block could be increased by the increase in inoculum cell number and by providing an additional cell sheet, respectively.

Background Broad dissection with a long skin incision and detachment of the gluteus medius muscle performed for rotational acetabular osteotomy (RAO) can result in weakness in abduction strength of the hip. We use a surgical procedure for RAO that minimizes operative invasion of soft tissue and reduces incision length compared with conventional procedures. Questions/Purposes We evaluated the clinical results of this less-invasive RAO comparing it with the more-invasive prior procedure with respect to improvement in clinical hip scores and radiographic coverage and overall hip survival after the procedure. Methods In this less-invasive exposure, the medial gluteus muscle is retracted to expose the ilium without detachment from the iliac crest. Similarly, the rectus femoris muscle tendon is retracted, not excised. The lateral part of the osteotomized ilium is cut to form the bone graft instead of harvesting it from the outer cortical bone of the ilium. Between 2000 and 2009, 62 patients (71 hips) underwent this procedure. Twenty-eight hips had early-stage osteoarthritis and 43 had advanced-stage osteoarthritis. Mean patient age was 40 years at the time of surgery. We evaluated improvement in hip scores (Merle d’Aubigné-Postel, Japanese Orthopaedic Association) and radiographic appearance (lateral center-edge angle, Sharp’s angle, acetabular head index [AHI]). Kaplan-Meier survivorship analysis was performed. Mean followup was 5 years (range, 2.0–10.4 years). Results Clinical hip scores improved postoperatively. On average, lateral center-edge angle, Sharp’s angle, and AHI improved by 38°, 11°, and 42%, respectively. Predicted 10-year survival rates were 100% and 72% for hips with early- and advanced-stage osteoarthritis, respectively. Conclusions In hips with early-stage osteoarthritis treated by this less-invasive approach, no progression of osteoarthritis was documented and Trendelenburg gait was avoided. However, further investigation is necessary for hips with advanced-stage osteoarthritis. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The online version of the original article can be found under doi:10.1007/s11999-012-2599-6.