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Objective To investigate variables for assessment of stroke-related sarcopenia that are alternative options to the current assessment for sarcopenia, which focuses on age-related sarcopenia and also has limitations in addressing sarcopenia due to weakness resulting from stroke.Methods Forty patients (17 men, 23 women; mean age, 66.9±15.4 years) with first-ever stroke who can walk independently were included. Muscle mass was determined by measuring ultrasonographic muscle thickness of vastus intermedius, rectus femoris, tibialis anterior, medial gastrocnemius, and biceps brachii muscles in addition to using the skeletal muscle index (SMI) with bioelectrical impedance analysis. Muscle strength was assessed with the Medical Research Council (MRC) sum score as well as handgrip (HG) strength. Physical performance was measured by the Berg Balance Scale (BBS) along with 4-meter gait speed (4MGS). Correlations between each assessment in the three categories were analyzed and adjusted by stroke severity, comorbidity, and nutritional status.Results For muscle mass, SMI showed the highest correlation with the tibialis anterior muscle (r=0.783, p

BACKGROUND Post-stroke sitting balance is a known predictor of independence of gait after stroke. However, previous studies used only qualitative scales or measured static or dynamic sitting balance alone. OBJECTIVES To investigate whether quantitative parameters of sitting posturography at post-stroke 1 month can predict independent gait. METHODS In this prospective cohort study, we enrolled patients with first-ever stroke who could hold a sitting posture at post-stroke 1 month. Sitting balance was assessed using posturography at post-stroke 1 month. Independence of gait was assessed using functional ambulation categories at post-stroke 2 months. We predicted mobility independence at post-stroke 2 months according to sitting balance at post-stroke 1 month. We also assessed the correlation between sitting posturography parameters and clinical scales. RESULTS We enrolled 27 patients. The limit of stability deviation predicted independent gait at post stroke 2 months (cutoff, 78.4%). Further, there was a high degree of correlation between sitting posturography parameters (weight-bearing distribution deviation and limit of stability deviation) and Berg Balance Scale (ρ = 0.763, ρ = 0.777; p

Objectives To investigate the effects of Computerized Neuropsychologic Test (CNT) on cognitive function and daily life performance in subacute post-stroke patients with cognitive impairment. Methods Korean Mini-Mentals State Examination (K-MMSE), Korean version of Modified Barthel Index (K-MBI) were investigated in 125 subacute post-stroke patients with cognitive impairment. We analyzed K-MMSE and K-MBI which were conducted 63 patients who had received CNT and 62 patient who had not received CNT from baseline to 8 weeks follow-up. In the experimental group, initial K-MMSE and K-MBI were conducted 13.3 ± 6.8 weeks after the onset of stroke and their age was 63.4 ± 13.3. In the control group, initial K-MMSE and K-MBI were conducted 13.2 ± 7.7 weeks after the onset of stroke and their age was 65.1 ± 11.6. Results The 8 weeks follow-up total K-MMSE score and total K-MBI score of experimental group were significantly higher than control group ( P < 0.05). In K-MMSE subsection, orientation, judgement, recall, language & visual reconstruction were significantly higher in experimental group than control group ( P < 0.05). In K-MBI subsection, personal hygiene, bathing self, toilet, dressing, ambulation, chair/bed transfer were significantly higher in experimental group than control group ( P < 0.05). The change of total K-MMSE score of experimental group was significantly correlated with change of total K-MBI score ( P < 0.05), but control group was not ( P > 0.05). In K-MMSE subsection, change of orientation, registration, language and visual reconstruction were correlated with total K-MBI s core after CNT. Especially, the experimental group, total K-MBI score of the left hemisphere damage group was significantly higher than the right hemisphere damage group ( P < 0.05). Conclusions This study shows that CNT is effective on subacute post-stroke patients with cognitive impairment. Improvement of cognitive function can expect a positive outcome on daily life performance, in particular, it can be expected to improve the prognosis of patients with stroke, the left hemisphere lesions.

Sleep is an essential physiological process, especially for proper brain function through the formation of new pathways and processing information and cognition. Therefore, when sleep is insufficient, this can result in pathophysiologic conditions. Sleep deficiency is a risk factor for various conditions, including dementia, diabetes, and obesity. Recent studies have shown that there are differences in the prevalence of sleep disorders between genders. Insomnia, the most common type of sleep disorder, has been reported to have a higher incidence in females than in males. However, sex/gender differences in other sleep disorder subtypes are not thoroughly understood. Currently, increasing evidence suggests that gender issues should be considered important when prescribing medicine. Therefore, an investigation of the gender-dependent differences in sleep disorders is required. In this review, we first describe sex/gender differences not only in the prevalence of sleep disorders by category but in the efficacy of sleep medications. In addition, we summarize sex/gender differences in the impact of sleep disorders on incident dementia. This may help understand gender-dependent pathogenesis of sleep disorders and develop therapeutic strategies in men and women.

The aim of the study was to identify the risk factors for mobility decline among hospitalized older patients early.This is a prospective cohort study. A total of 875 older patients were divided into two groups: older patients with and without mobility decline. The mobility level was measured using the item of functional mobility in the Geriatric Screening for Care 10. The change in mobility between admission and discharge was determined as the dependent variable. There were a total of 18 independent variables, which consisted of three demographic variables, 10 most problematic domains of geriatric care, and five other health-related variables. A multivariable logistic regression analysis was conducted to identify the risk factors for mobility decline during hospitalization.Of the 875 older patients, 135 (15.4%) experienced mobility decline during hospitalization. The multivariable logistic regression analysis revealed female sex, cognitive impairment, and underweight as the risk factors for mobility decline during hospitalization.The identified risk factors should be considered to identify patients at a risk of mobility decline early and to provide targeted interventions, which can prevent mobility decline.

We present the surgical technique for arthroscopic revision posterior cruciate ligament (PCL) reconstruction with use of the modified tibial-inlay double-bundle method without a change of the patient's position from supine to prone.Create the Achilles tendon allograft as a tibial bone block with two femoral bundles.With the patient in the supine position, flexion, abduction, and external rotation of the hip and flexion of the knee 60° to 90° can provide easier access to the popliteal area.Make the tibial tunnel with the patient supine with the hip flexed, abducted, and externally rotated and the knee flexed 60° to 90° to provide easier access to the popliteal area.Using a wire loop, pass the graft through the knee joint posterior to the intercondylar notch into the femoral tunnel.Use a cannulated screw with a spiked washer to secure fixation of the bone block to the tibia.Rehabilitation after a PCL repair is generally more conservative than the accelerated rehabilitation used after an ACL repair.In our study, twenty-two patients (twenty men and two women; mean age, 37.4 years) were treated with revision PCL reconstruction performed with the described technique and followed for a mean of 39.6 months (range, twenty-four to seventy-two months)

The purpose of this study was to evaluate the influence of intra-operative soft tissue balancing and distal femoral cutting on flexion contracture in navigated TKA. This was a prospective cohort study. Fifty-nine patients of primary navigation-assisted TKA were included with over 15° of flexion contracture and excluded valgus knees. Among the cases, 43 cases were performed with soft tissue balancing procedures only, and 16 cases were performed with soft tissue balancing and additional distal femoral bone cutting. The mean preoperative flexion contracture was 17.5° ± 2.7°. The angles of flexion contracture were recorded at each surgical step with navigation. The mean difference in flexion contracture angle between initial angle and angle after medial release was 5.2° ± 2.8°. The mean difference in flexion contracture angle between medial release step and after posterior cruciate ligament (PCL) release was 2.5° ± 2.2°. The mean difference in flexion contracture angle between PCL release step and after routine bone cutting was 3.1° ± 3.2°. The mean difference in flexion contracture angle between after trial insertion and after posterior clearing procedure was 2.7° ± 1.9°. Among the cases, TKA with 2 mm additional bone cutting were performed in 16 cases. The mean difference in flexion contracture angle after additional femoral bone cutting was 4.8° ± 2.1°. The medial release and 2 mm additional bone cutting could correct flexion contracture by 5°. The appropriate soft tissue balancing and bone cutting could correct flexion contracture intra-operatively up to 5° in each step. II.

Purpose We hypothesized that the low contact stress (LCS) posterior stabilization system in knees with ≤3° deviation of coronal alignment would provide more favorable clinical outcomes and survival rate over the course of time. Materials and Methods A retrospective study was performed on 253 consecutive cases of primary total knee arthroplasty (TKA). Patients were classified according to the degree of deviation of coronal alignment on the initial postoperative radiograph as Group 1 (≤3° deviation) and Group 2 (>3° deviation). The clinical assessments were performed using the Knee Society score and Hospital for Special Surgery systems and Western Ontario and McMaster Universities index. Results The survival rate was 97.4% in Group 1 and 96.8% in Group 2. No statistically significant intergroup difference was observed in the clinical scores before surgery and since 1 year after surgery (p>0.05). However, a significant intergroup difference was noted between 6 months to 1 year after surgery (p

To evaluate cartilage healing using second-look arthroscopic examination in tibia plateau fracture patients who have undergone open reduction and internal fixation with a submeniscal approach technique.Between January 2007 and January 2010, we used second-look arthroscopy during 18-24-month follow-up of 20 patients with Schatzkar type II tibial plateau fractures who had undergone open reduction and internal fixation with a submeniscal approach technique. We classified patients according to step-off, knee range of motion, and Knee Society Score, and compared the results with those obtained by arthroscopy.Radiologically, 16 cases (80 %) were reduced within 2 mm of step-off. In 11 of these cases, according to the Outerbridge classification, we checked for chondromalacia from grade II to III. We observed 2 mm of step-off in four cases, and each had chondromalacia of at least grade III. The Knee Society Score was associated with chondromalacia grade (p0.05).Even in patients with normal joint range of motion and good clinical and radiological results, the actual condition of the articular cartilage varied significantly. Therefore, more long-term and regular follow-up is needed for proximal plateau fractures.

The bone healing process of fractured tibias applied with various composite IM rods, respectively, was analyzed using finite element analysis. Based on a mechano-regulation theory with a deviatoric strain as a mechanical stimulation the process of tissue differentiation was simulated by a user’s subroutine programmed by a Python code for an iterative calculation. Several representative composite IM rods (fabric composites made of a carbon/epoxy and a glass/polypropylene) were investigated to find the rod modulus appropriate for healing bone fractures. It was found that the initial loading condition was the most sensitive factor of healing performance and that the flexible composite IM rod (WSN3k [±45]nT) was able to accelerate tissue differentiation under a reasonable initial loading condition (3 point gait after surgery), resulting in early bone union.

The current case report describes an adult male with an intracortical lipoma accompanied by cystic changes in the tibial diaphysis. To the best of our knowledge, intracortical lipoma in an adult tibia has not been previously described. An anteroposterior radiograph of the tibia revealed an osteolytic lesion on the diaphysis. Magnetic resonance imaging and computed tomography revealed that the lesion was located in the cortex and consisted of fat and cyst tissue. Surgical excision of the lesion confirmed diagnosis of an intracortical lipoma.

The purpose of this study was to evaluate the stability and functional outcomes of anterior cruciate ligament (ACL) reconstruction by tensioning of the ACL remnant using pull-out sutures compared with ACL double-bundle reconstruction. Forty-four patients were included in single-bundle reconstruction with remnant tensioning group (Group 1), and 56 patients were included in the double-bundle reconstruction group (Group 2). The remnant tissue was tensioned to the direction of posterolateral bundle, which unrelated to the type of remnant bundle. Objective knee stability was evaluated by anterior stress radiography, KT-1000 and lateral pivot shift tests. The Tegner activity scale, International Knee Documentation Committee and OrthopadischeArbeitsgruppeKnie scoring systems were used for clinical evaluation. No statistically significant intergroup differences were observed in mechanical stability and clinical results (n.s). However, surgical time of remnant tensioning group is shorter than double-bundle reconstruction group (P = 0.005). Remnant tensioning suture with single-bundle reconstruction could be used with positive results as good as double-bundle technique if a good ACL remnant was found bridging the femur and tibia, rather than debride or damage to the remnant tissue during operation. Retrospective, comparative cohort study, Level IV.

Despite the suitable characteristics of ropivacaine as an epidural analgesic agent, such as better preservation of motor function and less neurotoxicity, we are aware of no data on its clinical application in pain management following lumbar spine surgery. The purpose of the present study was to evaluate the preemptive analgesic effects and safety of a single epidural injection of ropivacaine during lumbar arthrodesis.We performed a randomized, double-blinded, intention-to-treat study. Patients with planned one-level posterior lumbar interbody arthrodesis were randomly assigned to either the injection group (n = 32) or the control group (n = 34). The injection group received a 10-mL epidural injection of 0.1% ropivacaine twenty minutes before the skin incision at the planned vertebral level, and the control group received an epidural injection of 10 mL of 0.9% saline solution. A numeric rating scale (from 0 to 10) was measured at seven time points after surgery (at two, four, eight, twelve, twenty-four, and forty-eight hours and at the time of discharge), and the frequency of pushed-button patient-controlled analgesia and total fentanyl consumption were assessed at similar time points (up to two, up to four, up to eight, up to twelve, up to twenty-four, and up to forty-eight hours after surgery). Postoperative nausea and vomiting, the duration of the hospital stay, and the Likert satisfaction score at the time of discharge were evaluated.There were no significant differences between the two groups preoperatively. The numeric rating scale score was higher until twelve hours (p0.05) and the frequency of button pushes was higher at every time point except eight to twelve hours (p0.05) in the control group as compared with the injection group. Fentanyl consumption until eight to twelve hours (p0.05) and total consumption (p0.001) at discharge were higher in the control group. There were no differences between the two groups in terms of postoperative nausea and vomiting, the duration of hospital stay, or the mean satisfaction score, and no transient motor weakness was seen in relation to epidural injection of ropivacaine.A single-dose epidural injection of 0.1% ropivacaine before lumbar spine surgery is effective for reducing early postoperative pain without related complications such as transient motor weakness.

A comparison has been made between navigation-assisted and conventional measured resection total knee arthroplasty (TKA), under the hypothesis that navigation assistance would improve the precision and consistency of component alignment and femoral component rotation.The following radiographic parameters were measured: mechanical femorotibial angle, coronal and sagittal component angle, and femoral component rotation. Femoral condylar lift-off was checked by axial radiographs, and thresholds for outliers were set at 1.0 mm.Clinical results obtained using Knee Society and Hospital for Special Surgery systems were not statistically different. The mean mechanical femorotibial angle was 2.2° (SD: 0.9) in the conventional group and 1.7° (SD: 0.7) in navigation group (p = 0.001). The mean coronal femoral component angle was 89.2° (SD: 2.2) in conventional group and 90.4° (SD: 1.8) in navigation group (p = 0.006). The mean transepicondylar-posterior condylar axis angle was 1.7° (SD: 0.9) in conventional group and 1.2° (SD: 0.5) in navigation group (p = 0.008). Femoral condylar lift-off greater than 1 mm occurred more frequently (p = 0.000) in conventional group.Coronal plane stability and precision of femoral component rotation were impacted by navigation system. The use of a navigation system with measured resection TKA can help optimize coronal stability and parallel component position.Retrospective case control study, Level IV.

The endochondral ossification process of fractured long bones was simulated using a three-dimensional finite element model when various composite bone plates were applied to the fracture site. To simulate time-varying cell phenotypes and the corresponding deviatoric strains in the calluses, a user’s subroutine was programmed for iterative calculations. Three representative initial loading conditions were investigated to find a relationship between the initial loading condition and tissue differentiation. Through finite element analysis, the trends in tissue differentiation and healing efficiency in the calluses were evaluated according to the plate modulus and loading conditions; further, the most appropriate plate modulus under each initial loading condition was suggested.

This study aimed to compare the clinical and radiological results of navigation-assisted TKAs performed using the measured gap resection or the gap balancing technique in thirty patients who underwent bilateral primary TKAs.Sixty cases of navigation-assisted TKAs [30 TKAs performed using the measured gap resection technique (Group A) and 30 TKAs performed using the gap balancing technique (Group B)] were analyzed prospectively with minimum follow-up of 2 years. The joint line positions were measured using preoperative and postoperative weight-bearing anteroposterior and lateral radiographs. Clinical results were evaluated using knee scores and functional scores.No significant differences in knee scores or functional scores were observed. Polyethylene thickness and flexion/extension gaps were significantly larger in Group B (P0.05). The meaningful proximal shift of the joint line was shown in Group B (P0.05).The navigation-assisted TKA with measured gap resection technique could be a useful technique with regard to restoration of the joint line.

The purpose of this study was to evaluate the clinical and radiographic results of open wedge HTO below the tubercle for genu varum in relatively young patients. Thirty-seven knees in 19 patients with genu varum treated by open wedge HTO below the tubercle between 2001 and 2008 were retrospectively studied. Median follow-up was 36 months (12–108), and median patient age at the time of surgery was 26 years (16–45). Clinical results were evaluated using Lysholm knee scores and Hospital for Special Surgery knee scores. Satisfaction with the results of surgery (0–10 points) was subjectively evaluated using operative scar (1–5 points) and leg shape (1–5 points) results at follow-up. Radiographic evaluations were made using: (1) tibiofemoral angles, (2) mechanical axis deviations, (3) varus-valgus inclinations of the tibial plateau, (4) tibial slopes, and (5) Insall-Savati and (6) Blackburne-Peel ratios. All but one patient achieved radiographic healing and union at the osteotomy site at an average of 3 months postoperatively. Average Lysholm knee score improved from 89.4 ± 8.7 preoperatively to 98.6 ± 2.5 at final follow-up (P = 0.0001), and mean HSS score improved from 91.1 ± 5.6 preoperatively to 98.5 ± 2.0 at final follow-up (P = 0.0001). Mean patient satisfaction score at final follow-up was 8.6 ± 1.0, and mean tibiofemoral angle increased from −1.6° preoperatively to 7.7° at final follow-up (P

The purpose of this study was to investigate the relationship between the proximity of neural structures to standard posterior portals in different knee positions. Ten fresh cadaveric knees were used to establish the standard posteromedial and posterolateral portals using an outside-in technique with arthroscopic transillumination. The distance from each portal site to the adjacent neurovascular structures (infrapatellar branches of the saphenous nerve) and the sartorial branch of saphenous nerve from the posteromedial portal, and the common peroneal nerve from posterolateral portal was measured using a precision caliper. Distances were recorded with the knees in extension, 45° of flexion and 90° of flexion in order to examine the effect of dynamic knee motion on nerve position. The mean distance between the posteromedial portal and the superior and inferior branches of infrapatellar branches of the saphenous nerve at full extension was significantly greater than at 90° of flexion. However, there was no difference observed between at 45° and at 90° of flexion. The mean distance from the posteromedial portal to the sartorial branch of saphenous nerve at 90° of flexion was significantly greater (26.1 mm, SD: 4.7) than that at 45° of flexion (18.4 mm, SD: 4.6), and at full extension (14 mm, SD: 4.3) (P

This paper addresses the use of composite bone plates in healing long-bone fractures such as transverse fractures of the tibia using finite element analysis, that takes into consideration contact conditions and material property variations of calluses in relation to the healing period. For the time-varying properties of calluses in relation to the healing period, stepwise material properties were imposed on the callus part based on the time elapsed, and the loading conditions were coupled with the callus properties based on the length of the healing period. The strain distributions at the fracture site were calculated according to the stacking sequence of the bone plate and healing time. The analysis results showed that composite bone plates with stacking sequences of [0] 12T for the Kevlar/BCP composites generated the most appropriate strain distributions at the fracture site during the early healing process.

Purpose The purpose of this study was to compare the clinical results of arthroscopic single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction. Methods We designed a prospective study that included patients with an isolated ACL injury. From April 2004 to February 2007, of 147 patients who underwent ACL reconstruction, 113 were included in this study. We serially obtained clinical and radiologic data preoperatively and postoperatively. We compared preoperative data and data at 2 years postoperatively in patients who had undergone single-bundle ACL reconstruction versus patients who had undergone double-bundle ACL reconstruction. There were 50 single-bundle reconstructions and 63 double-bundle reconstructions. Anteroposterior stability was assessed objectively by anterior stress radiographs with the telos device (telos, Marburg, Germany) and the maximal manual test with the KT-2000 arthrometer (MEDmetric, San Diego, CA). Rotational stability was determined by lateral pivot-shift test. The clinical results were assessed by International Knee Documentation Committee and Orthopadische Arbeitsgruppe Knie scores and Tegner activity scale. In addition, we evaluated postoperative thigh circumference and range of motion. Results Residual anteroposterior laxity determined at 2 years postoperatively by telos and KT-2000 was 1.74mm ± 1.67mm and 1.79mm ± 1.56mm, respectively, in the single-bundle reconstruction group and 1.63mm ± 1.50mm and 1.61mm ± 1.22mm, respectively, in the double-bundle reconstruction group. There were no statistically significant differences. For the lateral pivot-shift test done at 2 years postoperatively, there was no statistically significant difference. In addition, clinical results such as International Knee Documentation Committee score, Orthopadische Arbeitsgruppe Knie score, Tegner activity scale, thigh circumference, and range of motion showed no significant differences between the 2 groups. Conclusions Double-bundle reconstruction of the ACL by a method using 2 femoral tunnel and 2 tibial tunnels showed no differences in stability results or any other clinical aspects or in terms of patient satisfaction. Level of Evidence Level II, prospective comparative study.

Use of novel tissue engineering approaches to heal an injured anterior cruciate ligament (ACL) requires suture repair and/or augmentation to provide joint stability. We evaluated the effects of the location of suture augmentation at the femur and tibia in terms of joint stability using a goat model. Eight goat stifle joints were tested with augmentation sutures placed in two femoral tunnel locations: (1) anterior to, or (2) through the ACL footprint, and two tibial tunnel locations: (1) medial to, or (2) medial and lateral to the footprint. Using a robotic/universal force-moment sensor testing system, the anterior tibial translation (ATT) and the corresponding in situ force carried by the sutures were obtained at 30°, 60°, and 90° of flexion in response to external loads. No significant differences were found between augmentation groups due to tunnel location in terms of ATT or the in situ forces carried by the sutures at all flexion angles tested. Similar results were found under 5 N m of varus–valgus torque. Under a 67 N anterior tibial load, the ATT was restored to within 3 mm of the intact joint following suture augmentation (p > 0.05). Suture augmentation, when placed close to the ACL insertion, could be helpful in providing initial joint stability to aid ACL healing in the goat model. Published by Wiley Periodicals, Inc. J Orthop Res 28:1373–1379, 2010

This study examined the effect of the anteroposterior (AP) direction force on the tibial external rotation of a posterior cruciate ligament (PCL)/posterolateral corner (PLC)-deficient knee in a clinical setting.Between December 2006 and December 2007, 21 patients with a PCL-PLC injury were assessed using a dial test. The thigh-foot angle (TFA) and patella-tubercle angle (PTA) were measured with an external rotation stress applied to the tibia at both 30 degrees and 90 degrees of knee flexion in 2 different positions (reduced and posterior subluxed). The test was performed with the patient in the supine position and with an AP force applied to the tibia by an assistant. To reduce intra- and interobserver bias, the measurements were taken twice by 2 orthopaedic surgeons for all patients.In the subluxed position, the mean side-to-side differences in the TFA at 30 degrees and 90 degrees knee flexion were 12.6 degrees +/- 2.0 degrees and 12.3 degrees +/- 1.4 degrees , respectively. In the reduced position, the mean side-to-side differences in the TFA at 30 degrees and 90 degrees knee flexion were 18.4 degrees +/- 1.4 degrees and 18.5 degrees +/- 1.5 degrees , respectively. In the subluxed position, the mean side-to-side differences in the PTA at 30 degrees and 90 degrees knee flexion were 9.1 degrees +/- 0.8 degrees and 9.0 degrees +/- 0.7 degrees , respectively. In the reduced position, the mean side-to-side differences in the PTA at 30 degrees and 90 degrees knee flexion were 13.3 degrees +/- 0.6 degrees and 13.2 degrees +/- 0.6 degrees , respectively.The reduction of a posteriorly subluxed knee increased the tibial external rotation (TFA and PTA) during the dial test of combined PCL-PLC injuries in a clinical setting. The accuracy of the dial test may help present surgeons from missing a combined PLC injury that should be corrected in a PCL deficient knee.Level I, testing of previously developed diagnostic criteria in series of consecutive patients.

STUDY DESIGN Retrospective study. OBJECTIVE To determine whether magnetic resonance myelography (MRM) improves the evaluation of the severity of stenosis in patients with multilevel lumbar stenosis. SUMMARY OF BACKGROUND DATA MRM shows a similar image as myelography in a noninvasive manner. METHODS One hundred patients over 50 years of age with multiple lumbar stenosis who were prospectively referred for MR imaging (MRI) with MRM were enrolled in the study. The most severe stenotic segment and the degree of stenosis of that segment, as assessed by the extent of remaining subarachnoidal space (1: normal to 50%; 2: over 50% but not a total blockage; 3: total blockage) were evaluated in a blinded manner by 2 observers. Conventional MRI (class A), MRM (class B), and MRI combined with MRM (class C) were evaluated independently and interobserver and intraobserver reliability were assessed. RESULTS In the selection of the most severe segment and degree of stenosis, for both observers, the consensus between class (B) and class (C), was higher than that of class (A) and class (C). The average kappa values for interobserver agreement in the selection of the most severe segment/assessing the degree of stenosis for classes (A), (B), and (C) were 0.649/0.727, 0.782/0.771, and 0.832/0.784, respectively. Intraobserver kappa values were also highest for class (B), followed by class (C), and then class (A). Observations were within the range of "almost perfect" (0.81< or =kappa< or =1), with the exception of the selection of the most severe segment in class (A) by one of the observers. CONCLUSIONS When employed in routine practice, MRM could be of value for improving observer reliability in the assessment of severity of stenosis in multiple lumbar stenosis.

Purpose To explore the healing process of the injured posterior cruciate ligament (PCL) by evaluating instability measurements and magnetic resonance imaging (MRI) findings. Materials and Methods A retrospective cross-sectional study of 46 cases of complete PCL tear who obtained MRI more than two months after injury. Results A total of 13 cases (28%) showed nearly normal PCL contour, 20 cases (44%) showed continuity but deformed PCL contour, and 13 cases (28%) showed discontinuity. The duration from injury to MRI was not directly correlated with continuity. However, the group that obtained MRI more than six months after injury showed more continuity than the group that obtained MRI within six months of the injury (P < 0.01). The group with nearly normal continuity showed better stability results in the KT-1000 arthrometer and stress radiographs than the group with discontinuity (P < 0.05). The presence of other combined ligament injuries had a negative effect on regaining PCL continuity (P

The objective of our study was to investigate the outcome of an active non-operative treatment of the acute isolated posterior cruciate ligament (PCL) injury using cylinder cast immobilization and brace with tibial supporter. This study included 17 acute and isolated PCL injuries with two years or more of follow-up for each patient. We applied a cylinder cast immobilization with tibial supporter with full extension of the knee for 6 weeks, and then another 6 weeks of PCL brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. There was improved anteroposterior stability with some residual laxity and improved clinical results at the last follow-up. The conservative treatment utilizing cylinder cast immobilization and brace may be one of the recommendable treatment methods in an isolated and acute PCL injury.

The aim of this study was to compare the results of two different methods of posterolateral corner reconstruction (fibular head tunnel versus tibial tunnel), performed at the same time as a posterior cruciate ligament reconstruction. Between January 1999 and October 2003, 47 patients underwent tensioning of a remnant posterior cruciate ligament and anterolateral bundle reconstruction along with a posterolateral corner reconstruction using a fibular head bone or tibial bone tunnel. Thirty-nine patients determined to be eligible were enrolled in this retrospective study after a minimum follow-up duration of 2 years. The average duration of follow-up was 35.3 months (range 24-70 months). Satisfactory results were achieved in 32 patients (82%) according to the International Knee Documentation Committee(IKDC) scores, and 29 patients (74%) had restored external rotational stability. The fibular head tunnel was superior to the tibial tunnel method in terms of operation time (43.0 +/- 15.7 vs. 66.6 +/- 9.4 min, respectively, P0.001) and improved rotational stability (85 vs. 65%, respectively, P = 0.007). However, there were no significant differences seen in anteroposterior stability and clinical assessments [Orthopädische Arbeitsgruppe Knie (OAK) P = 0.277 and IKDC scores P = 0.564]. In grade 2 chronic posterolateral rotatory instability with little or no varus instability associated with injury to the posterior cruciate ligament, a posterolateral reconstructive procedure with a single sling through the fibular tunnel offers advantages of less surgical morbidity and operation time, as well as better rotational stability, over reconstruction through the tibial tunnel.

The purpose of this study was to introduce transradioulnar single Kirschner-wire (K-wire) fixation technique for unstable fractures of both of the distal forearm bones in children and to evaluate the differences in clinical and radiographic results of osteosynthesis between this method and conventional K-wire fixation. Forty-one patients (20 conventional K-wire fixation, 21 transradioulnar single K-wire fixation) were reviewed who underwent a closed or mini-open reduction with K-wire fixation for fractures of both of the distal forearm bones. Their mean age at operation was 10.7 years (range, 8-16 years). Surgical intervention was indicated (1) when in addition to a complete ulnar fracture, the radius showed a 50% of displacement or greater, or 20-degree angulation or greater, (2) when in addition to an incomplete ulnar fracture, the radius was completely displaced, and (3) when reangulation was 15 degrees or greater in any direction at follow-up. The minimum follow-up period was 2 years. Bony union was achieved in both groups at approximately 7 weeks after surgery, and there were no significant differences in the operative time, duration of hospitalization, and duration of external support between the 2 groups. There were no major complications such as nonunion, radioulnar synostosis, premature physeal closure, or redisplacement or reangulation. Transradioulnar single K-wire fixation technique was a relatively simple procedure with comparable outcomes compared with conventional K-wire fixation technique. In addition, physeal injuries could be avoided, and there was no need for passing across the fracture line. Thus, it is suggested that transradioulnar single K-wire fixation technique can be a good alternative method for high-risk fractures of both of the distal forearm bones in children.

The intramedullary insertion of antibiotic-impregnated cement beads is used widely for the treatment of intramedullary infection. This report describes an improved technique for removing chains of antibiotic beads inserted into the intramedullary cavity.We examined four cases in three patients of the intramedullary insertion of chains of antibiotic-impregnated cement beads for the treatment of osteomyelitis of the diaphysis of the tibia after the fixation of fractures with interlocking nails. During bead removal, the tip of an intramedullary guidewire was bent into a hook shape and was then engaged with the chain of impacted beads. The guidewire was removed from the intramedullary cavity, permitting the extraction of any beads adhering to the wire.As beads came into contact with the tip of the intramedullary guidewire, they could be extracted easily. No additional incision or bone fenestration was required.The use of a hook-shaped intramedullary guidewire simplifies the removal of chains of antibiotic-impregnated cement beads without the need for an invasive procedure. This technique makes the use of chains of cement beads a favorable choice for treating intramedullary infection.

Early proper diagnosis of non-Hodgkin's lymphoma is critical. However, without a high index of suspicion, the diagnosis can often be missed because of the nonspecific symptoms and normal plain radiographs. Further, non-Hodgkin's lymphoma can be misdiagnosed as an infectious condition - such as osteomyelitis or septic arthritis - or as an inflammatory disease. The authors report a case of mature B-cell lymphoma of the small intestine or colorectal primary malignancy with peritoneal seeding and multiple bone metastases in an 8-year-old boy. This case report emphasizes the importance of a comprehensive approach with patients, including children with nonspecific symptoms, to orthopedic surgeons.

[Introduction][1] We present the surgical technique for arthroscopic revision posterior cruciate ligament (PCL) reconstruction with use of the modified tibial-inlay double-bundle method without a change of the patient’s position from supine to prone. [Step 1: Graft Preparation][2] Create the Achilles tendon allograft as a tibial bone block with two femoral bundles. ![Figure][3] [Step 2: Patient Position][4] With the patient in the supine position, flexion, abduction, and external rotation of the hip and flexion of the knee 60° to 90° can provide easier access to the popliteal area. [Step 3: Femoral Tunnel Preparation][5] Make anterolateral and posteromedial femoral tunnels in a shallow-shallow position using an outside-in technique for the anterolateral bundle and the inside-out technique for the posteromedial bundle . ![Figure][3] [Step 4: Tibial Tunnel Preparation][6] Make the tibial tunnel with the patient supine with the hip flexed, abducted, and externally rotated and the knee flexed 60° to 90° to provide easier access to the popliteal area. ![Figure][3] ![Figure][3] ![Figure][3] [Step 5: Graft Passage][7] Using a wire loop, pass the graft through the knee joint posterior to the intercondylar notch into the femoral tunnel. [Step 6: Graft Fixation][8] Use a cannulated screw with a spiked washer to secure fixation of the bone block to the tibia. ![Figure][3] [Step 7: Postoperative Rehabilitation][9] Rehabilitation after a PCL repair is generally more conservative than the accelerated rehabilitation used after an ACL repair. [Results][10] In our study, twenty-two patients (twenty men and two women; mean age, 37.4 years) were treated with revision PCL reconstruction performed with the described technique and followed for a mean of 39.6 months (range, twenty-four to seventy-two months)[14][11]. [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [Introduction][1] We present the surgical technique for arthroscopic revision posterior cruciate ligament (PCL) reconstruction with use of the modified tibial-inlay double-bundle method without a change of the patient’s position from supine to prone. [Step 1: Graft Preparation][2] Create the Achilles tendon allograft as a tibial bone block with two femoral bundles. ![Figure][3] [Step 2: Patient Position][4] With the patient in the supine position, flexion, abduction, and external rotation of the hip and flexion of the knee 60° to 90° can provide easier access to the popliteal area. [Step 3: Femoral Tunnel Preparation][5] Make anterolateral and posteromedial femoral tunnels in a shallow-shallow position using an outside-in technique for the anterolateral bundle and the inside-out technique for the posteromedial bundle . ![Figure][3] [Step 4: Tibial Tunnel Preparation][6] Make the tibial tunnel with the patient supine with the hip flexed, abducted, and externally rotated and the knee flexed 60° to 90° to provide easier access to the popliteal area. ![Figure][3] ![Figure][3] ![Figure][3] [Step 5: Graft Passage][7] Using a wire loop, pass the graft through the knee joint posterior to the intercondylar notch into the femoral tunnel. [Step 6: Graft Fixation][8] Use a cannulated screw with a spiked washer to secure fixation of the bone block to the tibia. ![Figure][3] [Step 7: Postoperative Rehabilitation][9] Rehabilitation after a PCL repair is generally more conservative than the accelerated rehabilitation used after an ACL repair. [Results][10] In our study, twenty-two patients (twenty men and two women; mean age, 37.4 years) were treated with revision PCL reconstruction performed with the described technique and followed for a mean of 39.6 months (range, twenty-four to seventy-two months)[14][11]. [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [1]: #sec-10 [2]: #sec-11 [3]: pending:yes [4]: #sec-12 [5]: #sec-13 [6]: #sec-14 [7]: #sec-15 [8]: #sec-16 [9]: #sec-17 [10]: #sec-18 [11]: #ref-14 [12]: #sec-20 [13]: #sec-21 [14]: #sec-22

It is reported that the length of the posterior cruciate ligament (PCL) fibres increases as the knee flexes, and the magnitude of the length change reaches up to 9.8 mm throughout the range of motion, which exceeds the range of failure strain. Therefore, we postulated that a compensatory mechanism must be recruited to overcome this large strain in order to maintain physiologic function as a key component of joint kinematics. Our main objective was to compare the length change pattern for the linear distance between the femoral and tibial tunnels with the length change patterns derived from a real isometer test of different curvatures.We utilized ten intact cadaveric knees and created a vertical femoral tunnel (5 mm medial to the roof of the intercondylar notch and 5 mm proximal from the articular margin) and lateral tibial tunnels (5 mm proximal to the posterior bony ridge on the lateral side of the PCL fibre) and performed a 3D-CT scan at 0º, 30º, 60º, 90º, and 120º. The distances between the femoral and tibial tunnels were calculated from the 3D coordinates. Real isometry was checked both (1) over the PCL and (2) under the PCL using an isometer with an accuracy of 0.1 mm.The path over the PCL had the longest intra-articular length, followed by the path under the PCL, and the lengths measured by CT, respectively. The path over the PCL had a more curved path compared with the path under the PCL and the lengths measured by CT. The lengths measured by CT showed significantly larger excursion than the real isometer test. The path over the PCL showed the least excursion through the range of motion, followed by the path under the PCL, and the lengths measured by CT, respectively.Our findings suggested that a more curved PCL path has better isometry because the curvature of the PCL compensates for the length change between 0º and 60º flexion. In remnant preservation PCL reconstruction, the passage of graft over the PCL would have increased intra-articular length and better isometry compared with straight under the PCL path.Basic science study.

We analyzed the outcomes of our conservative treatment for pediatric trigger thumb. Since March 2004, we have used conservative treatment for all patients with pediatric trigger thumb. We prospectively analyzed 30 patients in whom 35 thumbs were affected (10 right, 15 left, 5 bilateral). The mean age at diagnosis was 28 (11–50) months. The treatment consisted of passive exercises performed by the children’s mothers, 10–20 times daily. How reliably this was performed is unproven. Trigger thumb severity was graded as 0A (extension beyond 0°), 0B (extension to 0°), 1 (active extension with triggering), 2 (passive extension with triggering), and 3 (cannot extend either actively or passively i.e. locked). At diagnosis, six of the 35 thumbs (17%) were grade 1, 25 (71%) were grade 2, and four (11%) were grade 3. After a mean follow-up period of 63 (range, 49–73) months, 28 thumbs (80%) were grade 0A or 0B, 5 (14%) were grade 1 and 2 (6%) were grade 2. The bilateral cases and the patients who initially had grade 3 severity had significantly more unfavorable results than the other patients. This study suggests that conservative treatment for pediatric trigger thumb is a successful method, although cases that present with bilateral involvement or locking (grade 3) should be considered for early surgical release.

In this chapter, the use of a robotic/universal force-moment sensor (UFS) testing system to gain quantitative data on multiple degree of freedom kinematics of the knee simultaneously with the in situ forces in normal and repaired soft tissues, is discussed. In particular, the complex interactions of the anteromedial and posterolateral bundles of the anterior cruciate ligament (ACL), as well as several key biomechanical variables in ACL reconstruction, such as femoral tunnel placement and graft fixation, were investigated. This is followed by a brief review of clinical outcome studies following ACL reconstruction along with a word of caution regarding the interpretation of these data. Finally, a novel methodology is proposed to move from in vitro to in vivo studies to gain further insight into the function of the ACL and ACL replacement grafts. All of these studies will help us to better understand the function of the ACL as well as to design scientifically based surgical procedures and postoperative rehabilitation protocols to improve patient outcome.

A torn anterior cruciate ligament (ACL) of the knee has poor healing potential, and thus, surgical reconstruction using soft tissue autografts is needed to restore knee stability. Unfortunately, these procedures have a high incidence of donor site morbidity and the progression to osteoarthritis in the long-term 1. In recent years, biological stimulation by means of growth factors and bioscaffolds has demonstrated successful early clinical results 2. Our research center has used extracellular matrix (ECM) bioscaffolds as a biological agent to improve ACL healing in a goat model 7, 8. Indeed, there was sufficient formation of neo-ACL tissue that led to up to a 30% reduction in the instability of the stifle joint by 12 weeks. Its biomechanical properties also increased by two-fold in comparison to those with suture repair alone 7, 8.

Functional tissue engineering (FTE) approaches have shown promise in healing an injured anterior cruciate ligament (ACL) of the knee. Nevertheless, additional mechanical augmentation is needed to maintain joint stability and appropriate loading of the joint while the ACL heals. The objective of this study was to quantitatively evaluate how mechanical augmentation using sutures restores the joint kinematics as well as the distribution of loading among the ACL, medial collateral ligament, and medial meniscus (MM) in response to externally applied loads. Eight goat stifle joints were tested on a robotic/universal force-moment sensor testing system under two loading conditions: (1) a 67N anterior tibial load (ATL) and (2) a 67N ATL with 100N axial compression. For each joint, four experimental conditions were tested at 30°, 60°, and 90° of flexion: the (1) intact and (2) ACL-deficient joint, as well as following (3) suture repair of the transected ACL, and (4) augmentation using sutures passed from the femur to the tibia. Under the 67N ATL, suture augmentation could restore the anterior tibial translation (ATT) to within 3mm of the intact joint (p>0.05), representing a 54-76% improvement over suture repair (p

Purpose To evaluate the stability and functional outcomes of anterior cruciate ligament (ACL) reconstruction by tensioning of the ACL remnant using pullout sutures compared with a remnant preservation technique only. Methods The data of 33 patients who underwent ACL reconstruction by a remnant tensioning technique (tensioning group) were reviewed retrospectively and compared with the data of 43 patients who underwent ACL reconstruction with remnant preservation without tensioning (preservation-only group) from September 2004 to April 2008 with a minimum follow-up of 2 years. The stability and function were assessed from the side-to-side difference with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and Telos device (Austin & Associates, Fallston, MD), as well as International Knee Documentation Committee and Orthopadische Arbeitsgruppe Knie scores. Results There were no significant differences between the groups with respect to the subjective and objective International Knee Documentation Committee scores ( P = .808 and P = .152, respectively) and Orthopadische Arbeitsgruppe Knie score ( P = .702) at the last follow-up. No significant differences in mechanical stability were observed with the KT-1000 arthrometer and stress radiographs between the groups ( P = .650 and P = .791, respectively). The remnant tensioning group took a longer surgical time than the preservation-only group (156.4 minutes v 134.5 minutes, P = .117). Conclusions The ACL remnant tensioning procedure did not improve the final results of an ACL reconstruction in terms of the clinical function and stability compared with an ACL reconstruction using the preservation-only technique. Level of Evidence Level III, retrospective comparative study.

Due to the poor healing potential of the anterior cruciate ligament (ACL) of the knee, surgical reconstruction using soft tissue replacement grafts is performed to restore knee stability and function. However, the surgery has serious complications including a high incidence of donor site morbidity and the development of osteoarthritis in the long-term. Recently, functional tissue engineering approaches to heal an injured ACL using biological stimulation via growth factors and bioscaffolds have yielded some positive clinical and laboratory results. As the healing process for the ACL is slow, additional suture repair of the ACL has been needed to provide initial joint stability and to reduce the risk of injury to neighboring tissues.Copyright © 2010 by ASME

To evaluate functional results and knee stability after tensioning of remnant posterior cruciate ligament (PCL) with anterolateral (AL) bundle reconstruction and posterolateral corner (PLC) reconstruction in chronic PCL and PLC injuries.Between March 2001 and March 2007, 95 patients with chronic PCL injuries combined with PLC injuries underwent tensioning of the remnant PCL with AL bundle reconstruction and PLC reconstruction. Among these 95 patients, 70 who were satisfied with our inclusion were reviewed. The mean follow-up period was 40.1 months (range, 24 to 96 months). Tensioning of remnant PCL fibers was performed by distal transfer of the posterior tibial attachment. The AL bundle of the PCL was reconstructed by use of the modified inlay technique. The PLC reconstructive procedure was performed with a single sling through fibular tunnel. Stability was measured on posterior stress radiographs and by use of a maximal manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee and Orthopädishe Arbeitsgruppe Knie scoring systems were used for clinical evaluation.Stress radiographs showed that the mean side-to-side difference (posterior tibial translation compared with that of the contralateral knee) was reduced from 10.3 ± 2.4 mm preoperatively to 2.2 ± 1.5 mm at the last follow-up (P.001), whereas the KT-1000 tests showed that this difference was reduced from 8.4 ± 2.2 mm preoperatively to 2.0 ± 1.4 mm (P.001). The final International Knee Documentation Committee objective score was A in 30 patients (42.8%), B in 34 (48.6%), and C in 6 (8.6%). The mean Orthopädishe Arbeitsgruppe Knie score improved from 63.5 ± 10.4 to 88.9 ± 7.6 (P.001).Excellent posterior stability and relatively good clinical results were achieved with tensioning of the remnant PCL and AL bundle and PLC reconstruction by use of fibular tunnel for patients with chronic combined PCL-PLC injuries.Level IV, case series.

If posterolateral rotatory instability (PLRI) injury in patients with a torn anterior cruciate ligament (ACL) is not diagnosed and treated, ACL reconstruction can fail. We retrospectively evaluated the clinical outcome after reconstructions between 2002 and 2007 of both the ACL and the posterolateral corner (PLC) in 44 knees with combined ACL and PLC injuries. The median follow-up duration was 49 months (range, 24-68 months). ACL reconstruction employed autogenous hamstring grafts from the ipsilateral knee. For grade II PLRI, a posterolateral corner sling through the fibular head was placed obliquely from the anteroinferior aspect to the posterosuperior aspect using autogenous hamstring grafts of the contralateral knee. Clinical outcomes were evaluated using the OAK (Orthopadishe Arbeitsgruppe Knie) and IKDC (International Knee Documentation Committee) knee scoring systems. Anterior stability was measured on pull stress radiographs using a Telos stress device and the manual maximum displacement test using a KT-1000 arthrometer with the knee flexed 30 degrees. PLRI was classified according to varus and rotational instability preoperatively and at final follow-up. Median OAK scores improved from 71 points (range, 48-86) to 93 points (range, 75-100). Satisfactory IKDC results were achieved in 39 knees (89%). As for anterior stability, as measured by anterior stress radiography, mean side-to-side displacement difference dropped significantly from 6.9 +/- 1.9 preoperatively to 1.4 +/- 1.1 mm at final follow-up. Forty patients (91%) had the same or better rotational stability compared to the normal side. Varus stress radiographs showed mean side-to-side displacement differences dropped from 1.8 +/- 1.7 preoperatively to 0.4 +/- 0.8 mm at final follow-up. Thus, chronic ACL deficiency is often accompanied by grade II PLRI and can be treated successfully by arthroscopic ACL reconstruction paired with posterolateral reconstruction employing a single sling through the fibular tunnel and a hamstring tendon autograft.

The anterior cruciate ligament (ACL) of the knee is frequently injured, but it has limited healing potential. Surgical reconstruction using soft tissue autografts is often required for active patients. However, about 20–25% of patients have less than satisfactory results and some even developed of osteoarthritis in the long-term. Thus, there is a need for alternative approaches. With advances in functional tissue engineering, healing of the ACL using growth factors and/or bioscaffolds has generated new clinical interests [1].Copyright © 2009 by ASME

Background The hemiepiphyseal stapling has both positive and negative effects on effective leg length. The purpose of this study was to analyze change in effective leg length after angular correction by hemiepiphyseal stapling, and to validate in clinical cases. Methods Mathematical analysis of a hemiepiphyseal stapling model was conducted. The induced formula was validated in 6 cases fulfilling the assumptions of the model. Anatomical parameters involved in this formula were measured in additional 21 cases undergoing hemiepiphyseal stapling or hemiepiphysiodesis. Results Effective leg length increased or decreased according to three parameters in this model: 1) limb length distal to the operated physis (L), 2) width of the operated physis (d), and 3) the amount of angular deformity to be corrected (θ). Actual change in effective leg length of 6 cases similar to this model coincided with the predicted change at least in its direction. L/d ratio was 4.82 ± 0.51. Conclusions Considering the narrow range of the L/d ratio, hemiepiphyseal stapling is likely to decrease effective leg length if the amount of angular correction is less than 10°, whereas to increase it if the amount of angular correction is larger than 16°. This should be taken into consideration when selecting the surgical method for angular deformity correction in skeletally immature patients.

Purpose To evaluate the results of a remnant posterior cruciate ligament (PCL)–augmenting stent procedure for acute- or subacute-stage PCL injuries in terms of stability and clinical results. Methods Between September 2003 and March 2006, 32 patients with a PCL tear underwent a reconstructive stent procedure with an autogenous hamstring tendon graft to augment the remains of the injured PCL. Of these patients, 20 who satisfied our inclusion criteria and could be followed up for a minimum duration of 24 months were enrolled in our study. The remnant PCL and synovium were preserved, and augmentation was performed by use of the transtibial technique. A femoral tunnel was created near the footprint of the anterolateral bundle. Stability was measured on posterior stress radiographs and by use of a maximum manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee (IKDC) and Orthopadische Arbeitsgruppe Knie scoring systems were used for clinical evaluation. Results Stress radiographs showed that the mean side-to-side differences in displacement were reduced from 9.9 ± 4.0 mm preoperatively to 3.0 ± 2.6 mm at the last follow-up, whereas KT-1000 tests showed that these differences were reduced from 6.9 ± 2.1 mm preoperatively to 2.7 ± 1.5 mm. The final IKDC score was A in 7 patients (35%), B in 10 (50%), C in 2 (10%), and D in 1 (5%). The mean Orthopadische Arbeitsgruppe Knie score improved from 61.6 ± 13.1 to 88.2 ± 9.5. Conclusions Of the patients, 90% showed satisfactory posterior stability and 85% had a normal or nearly normal rating based on the IKDC score at a mean of 3 years after the remnant PCL–augmenting stent procedure in the acute or subacute stage of PCL injuries. Level of Evidence Level IV, therapeutic case series.

Most pseudoaneurysms forming after arthroscopic surgery have involved the popliteal vessels after knee arthroscopy1,2. However, the cases of five patients who had a pseudoaneurysm of the anterior tibial artery after ankle arthroscopy have been reported in the English-language literature and were found after a search of the PubMed database with use of three keywords: pseudoaneurysm, ankle, and arthroscopy1,3-6. Although the cases of two patients involved anticoagulation therapy5 and hemophilia3, which increase the risk of arterial injury, iatrogenic trauma may have occurred during portal placement or operative procedures, such as synovectomy and osteophyte resection. All five patients described in the literature were treated by different surgical techniques. We present the case of a patient who had delayed detection of an anterior tibial artery pseudoaneurysm with osseous erosion after ankle arthroscopy. The condition was treated effectively with ultrasound-guided compression therapy. The patient was informed that data concerning the case would be submitted for publication, and he consented. A twenty-five-year-old man, in good general health, presented with a four-year history of pain and swelling in the anterolateral aspect of the right ankle. In addition, the ankle had sustained recurrent plantar flexion and inversion sprains that had been treated conservatively with rest, compression, and intermittent splinting. Physical examination revealed tenderness and moderate swelling of the anterolateral aspect of the right ankle with a positive anteromedial rotatory drawer maneuver7. Stress radiographs demonstrated a positive anterior drawer sign, and magnetic resonance imaging showed increased signal intensity in the anterior talofibular ligament and anterolateral synovitis of the right ankle. The patient underwent ankle arthroscopy with a 4.0-mm, 30° arthroscope with use of standard anteromedial and anterolateral portals under tourniquet control and noninvasive distraction of up to 20 lb (9 kg) with an …