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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. [ABSTRACT FROM AUTHOR]

Background: 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. Methods: 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. Results: 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 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. Conclusion: 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Acetabular bone deficiency, especially proximal and lateral deficiency, is a difficult technical problem during primary total hip arthroplasty (THA) in developmental dysplasia of the hip (DDH). We report a new reconstruction method using a medial-reduced cemented socket and additional bulk bone in conjunction with impaction morselized bone grafting (additional bulk bone grafting method).Questions/purposes: In a population of patients with acetabular dysplasia undergoing THA using a medial-reduced cemented socket and additional bulk bone with impacted morselized bone grafting, we evaluated (1) the radiographic appearance of bone graft; (2) the proportion of cups that developed loosening and subsequent revision; and (3) clinical results (outcome scores and complications).Methods: Forty percent of 330 THAs for DDH performed at one center between 1999 and 2009 were defined as shallow dysplastic hips. The additional bulk bone grafting method was performed on 102 THAs with shallow acetabulum (31% for DDH) at one center between 1999 and 2009. We used this approach and technique for shallow acetabuli when a cup protruded from the lateral acetabular edge in preoperative templating. The other 132 dysplastic hips without bone grafting had THA performed at the same periods and served as a control. Acetabuli were defined as shallow when the depth was less than or equal to one-fifth of the pelvic height (cranial-caudal length on radiograph). The additional bulk bone grafting technique was as follows: the resected femoral head was sectioned at 1 to 2 cm thickness, and a suitable size of the bulk bone graft was placed on the lateral iliac cortex and fixed by poly-L-lactate absorbable screws. Autologous impaction morselized bone grafting, with or without hydroxyapatite granules, was performed along with the implantation of a medial-reduced cemented socket. We defined an "incorporated" graft as remodeling and trabeculation including rounding off of the protruding edge of a graft beyond the socket. Radiographic criteria used for determining loosening were migration or a continuous radiolucent zone between the prosthesis/bone cement and host bone. Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) and the Merle d'Aubigne and Postel score; complications were tallied from chart review. The followup was 10 ± 3 years (range, 6-15 years).Results: One acetabular component (1%) with severe shallow and steep acetabuli showed definite radiographic evidence of loosening and was revised. Clinically, the mean JOA score for the hips treated with additional bulk bone grafting THA in this study improved from 39 ± 10 points preoperatively to 95 ± 5 points postoperatively (p < 0.05, paired t-test). The mean Merle d'Aubigne and Postel score for the hips improved from 7 ± 2 points to 17 ± 1 points (p < 0.05, paired t-test). Complications included a Trendelenburg sign in one hip, dislocation in one, and transient partial sciatic nerve palsy in one. Within 3 years 6 months postoperatively, 101 of 102 additional bulk bone grafting cases showed successful bone remodeling and bone graft reorientation without collapse on radiographs. Partial resorption of the additional bone graft on the lateral side was observed in two hips (2%) with socket abduction angles of < 35°.Conclusions: Achieving stable acetabular fixation is often challenging in the dysplastic hip, especially shallow acetabulum, and a variety of techniques have been described. Early results of combining bulk graft with impaction of morselized graft are promising. Although each surgical technique was well established, further investigation for clinical results of a combination of these techniques might be necessary to confirm longer term outcomes.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

A correction to the article "Less Invasive Rotational Acetabular Osteotomy for Hip Dysplasia," that was published in a previous issue is presented.

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. [ABSTRACT FROM AUTHOR]