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Several studies reported that excessive correction of severe genu varum deformity with total knee arthroplasty or high tibial osteotomy (HTO) could result in ankle joint pain and osteoarthritis progression. However, few studies have evaluated the change in the weight-bearing-line (WBL) ratio of the ankle joint after knee arthroplasty or HTO in patients with genu varum deformities. This study aimed to investigate the change in the WBL ratio of the ankle joint and ankle joint line orientation after knee arthroplasty or HTO in patients with genu varum deformities. We retrospectively evaluated 40 patients (mean age, 69.9 ± 8.0 years) with genu varum deformities of > 5° and underwent knee arthroplasty or HTO. Three radiologic parameters, including (1) the hip-knee-ankle (HKA) angle, (2) WBL ratio of the ankle joint, and (3) ankle joint line orientation relative to the ground (AJLO-G), were assessed using pre-operative and post-operative orthoradiographs. A paired t test was used to evaluate post-operative changes in the three parameters. Correlations between the change in HKA angle and that in the WBL ratio of the ankle joint and AJLO-G were analyzed. The mean HKA angle significantly decreased post-operatively (10.6° ± 5.3° to 1.1° ± 3.4°; P

To (1) compare the weight-bearing line (WBL) ratios of the knee joints measured using the conventional (hip-to-talus radiographs, HTRs) and novel (hip-to-calcaneus radiographs, HCRs) orthoradiograms, (2) compare the hip-knee-ankle (HKA) angle between cases with 5% and 5% differences in WBL ratios between two orthoradiograms, and (3) investigate the optimal cutoff value (COV) of the HKA angle causing inconsistency in the orthoradiograms.Sixty limbs of 31 patients with HTR and HCR records were retrospectively reviewed. After drawing the mechanical axis on each radiograph, the WBL ratios of the knees were calculated and compared between the conventional and novel orthoradiograms. In subgroup analysis, cases with 5% and 5% differences in WBL ratios between two orthoradiograms were classified as consistent and inconsistent groups, respectively. Receiver operating characteristic curve based on the HKA angles of the lower limbs was used to identify the COV causing the inconsistency between the orthoradiograms.Inter- and intra-rater reliabilities of all radiologic measurements were 0.75. The WBL ratios showed no significant difference between the two orthoradiograms. However, the HKA angle was significantly larger in the inconsistent group than in the consistent group (7.0° ± 1.8° vs. 4.4° ± 2.5°; P 0.001). The COV of the HKA angle that caused inconsistency in the two orthoradiograms was 4.0° (area under the curve, 0.774).The hip-to-calcaneus alignment differed significantly from the hip-to-talus alignment in patients with genu varum deformity. HCR measurement can be a complementary method for planning corrective osteotomy for patients with genu varum deformity.IV.

Inflammatory environments provide vital biochemical stimuli (i.e., oxidative stress, pH, and enzymes) for triggered drug delivery in a controlled manner. Inflammation alters the local pH within the affected tissues. As a result, pH-sensitive nanomaterials can be used to effectively target drugs to the site of inflammation. Herein, we designed pH-sensitive nanoparticles in which resveratrol (an anti-inflammatory and antioxidant compound (RES)) and urocanic acid (UA) were complexed with a pH-sensitive moiety using an emulsion method. These RES-UA NPs were characterized by transmission electron microscopy, dynamic light scattering, zeta potential, and FT-IR spectroscopy. The anti-inflammatory and antioxidant activities of the RES-UA NPs were assessed in RAW 264.7 macrophages. The NPs were circular in shape and ranged in size from 106 to 180 nm. The RES-UA NPs suppressed the mRNA expression of the pro-inflammatory molecules inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α) in lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophages in a concentration-dependent manner. Incubation of LPS-stimulated macrophages with RES-UA NPs reduced the generation of reactive oxygen species (ROS) in a concentration-dependent manner. These results suggest that pH-responsive RES-UA NPs can be used to decrease ROS generation and inflammation.

Background This study investigated the epidemiology and causes of bearing dislocations following mobile-bearing unicompartmental knee arthroplasty (MUKA) and determined whether the incidence of primary bearing dislocations decreases as surgeon experience increases. Methods We retrospectively reviewed the bearing dislocations following MUKAs performed by 14 surgeons with variable experience levels. Causes of bearing dislocations were determined based on the surgical records, radiographs, and operator’s suggestion. Using a chi-squared test, the incidence of bearing dislocation was compared between the first 50, the second 50, and the next 100 unicompartmental knee arthroplasties (UKAs) of each surgeon's cohort. Results There were 67 (3.6%) bearing dislocations from 1853 MUKAs. The mean time to bearing dislocations after index MUKAs was 33 months (range, 1-144 months); 55% of the bearing dislocations occurred within 2 years after the index MUKAs. Primary bearing dislocations (n = 58) were the most common, followed by secondary (n = 6) and traumatic dislocations (n = 3). There was no significant difference in the incidence of bearing dislocation between the first 50 and second 50 UKAs for each surgeon. Two surgeons showed a significant decrease in bearing dislocations in their second 100 UKAs, while the other surgeons did not show a difference between their first 100 and second 100 UKAs. Conclusion Most bearing dislocations after MUKAs were related to technical errors such as component malposition or gap imbalance. This study did not confirm that the incidence of bearing dislocations decreases as the number of cases increases. Level of Evidence IV, Case series.

Poly(ethylene terephthalate) (PET), composed of terephthalic acid (TPA) and ethylene glycol (EG), is the most commonly produced polyester. Unrecycled PET waste causes serious environmental problems...

BACKGROUND: Most tendon injuries are occurring from a gradual wearing and tearing of the tendon tissues from overuse. Such injuries are usually seen in sports, exercising, or daily activities that involve a high mechanical load and weight bearing. However, owing to the lack of both cellularity and blood vessels in tendons, the process of tendon repair is slow and inefficient. Although various conservative (non-surgical) and surgical management options are conducted by the clinicians, a gold standard of these approaches does not exist. In this regard, the treatment of tendon injuries is challenging. METHOD: Here, we describe the recent advances of biomaterial-based approaches for the treatment of injured tendons. RESULTS: Regenerative medicine is an emerging multidisciplinary research that specializes in the repair of damaged tendon tissues through the delivery of regenerative factors by biomaterials. CONCLUSION: Although current biomaterial-based treatment strategies have shown their potential for tendon healing, future research and clinical applications should focused on finding the optimum combinations of regenerative factors with ideal biomaterials for the repair of tendons.

Purpose: To compare the clinical outcomes of the arthroscopic treatments for popliteal cysts with and without cystectomy. Methods: PubMed/MEDLINE, EMBASE, KoreaMed, and Cochrane Library were searched from the earliest available date of indexing through August 2016. The methodological quality of all articles was assessed according to the Coleman methodology score (CMS). Studies were grouped according to the surgical method, and a meta-analysis was conducted to identify the unsuccessful clinical outcome and complication rates. Results: Nine studies were included; the mean CMS was 67.33 (standard deviation, 8.75 points). Cystectomy was reported in five studies; cystectomy was not performed in four studies. The odds ratio of unsuccessful clinical outcomes evaluated by Rauschning and Lindgren score was 122.05 (p

We fabricated diclofenac-immobilized polycaprolactone (DFN/PCL) fibrous sheets to improve tendon healing of rabbits with collagenase-induced Achilles tendinitis. DFN/PCL have anti-inflammatory effects related to suppression of mRNA levels of pro-inflammatory factors including COX-2, IL-6, TNF-α, and MMP-3 in inflamed tenocytes and tendon tissues of rabbits with Achilles tendinitis as well as those of anti-inflammatory cytokines including IL-4, IL-10, and IL-13. In vivo studies, wrapping of tendon tissues with DFN/PCL fibrous sheets may afford superior tendon healing, with decreased inflammatory cells, increased collagen content, restored collagen fiber organization, and improved mechanical strength. This approach will be a promising treatment from Achilles tendinitis.

The purposes were to analyze correlations between the frequency of beverage drinking (coffee, green tea, milk, and soft drinks) and the presence of radiographic knee osteoarthritis (OA) in relation to sex. We performed this study using the Korea National Health and Nutrition Examination Survey (KHANES V-1, 2). We examined data from 5503 subjects after exclusion. We utilized the food frequency questionnaires from KHANES, and reorganized them into 2 or 3 groups according to the frequency of beverage consumption. We analyzed the relationship between radiographic knee OA and beverage consumption statistically after adjusting confounding factors with multivariable logistic regression analysis. Knee OA was inversely associated with coffee consumption only in women (P.05). The odds ratio of knee OA was lower in those who drank at least a cup of coffee than in those who did not drink coffee in women (P for trend.05). However, there was no significant linear trend of the odds ratio of each group in both sexes for drinking other beverages. As the coffee consumption increased, the radiographic knee OA group showed decreasing linear trend only in women. However, other beverages did not show a significant relation to the radiographic knee OA in both sexes.

PURPOSE: This study aimed to compare the clinical outcomes between accelerated rehabilitation (AR) and non-accelerated rehabilitation (NR) after anterior cruciate ligament reconstruction (ACLR) using hamstring autografts through a systematic review and meta-analysis. METHODS: To compare the outcomes between AR and NR, we searched Medline, Embase, and the Cochrane Library. Studies comparing their clinical outcomes after ACLR using hamstring autografts were included. AR was characterized by the starting range of motion and weight-bearing within 3 days and return to sports within 6–9 months. A meta-analysis of clinical outcome parameters used in ≥ 3 studies was conducted. RESULTS: Seven studies were included. The International Knee Documentation Committee subjective score was significantly higher in AR than in NR at the 3- (mean difference [MD], 7.30; 95% confidence interval [CI] 1.55–13.05; P = 0.013) and 6-month follow-ups (MD, 5.64; 95% CI 0.11–11.17; P = 0.046). The side-to-side difference in anterior tibial translation at the final follow-up assessed in four studies was significantly lower in NR than in AR (MD, 0.59; 95% CI 0.12–1.07; P = 0.015). Overall Tunnel widening at the final follow-up assessed in four studies was also smaller in NR than in AR (MD, 0.48; 95% CI 0.00–0.96; P = 0.0479). However, the mean side-to-side difference and overall tunnel widening between them was

Background The lignocellulosic biomass feedstocks such as empty fruit bunches (EFBs) prove to be potential renewable resources owing to their abundance, low prices, and high carbohydrate contents. Generally, the conversion of lignocellulosic biomass into chemicals, fuels, and materials mainly includes pretreatment, enzymatic hydrolysis, fermentation, and recovery of final products. To increase the economic viability of such processes, the cost of cellulase production and enzymatic hydrolysis should be reduced. For this, recycling cellulase can be considered for reducing the saccharification cost of lignocellulose. In this study, cellulase recycling for high-solids enzymatic hydrolysis (i.e., 20%) was evaluated in saccharification of hydrothermally-pretreated EFBs. Results High-solids (20%) enzymatic hydrolysis of hydrothermally-pretreated empty fruit bunches with 40 FPU of Cellic CTec3/g glucan was carried out for cellulase recycling. In the second round of hydrolysis using a recycled enzyme, only 19.3% of glucose yield was obtained. The most important limiting factors for cellulase recycling of this study were identified as the enzyme inhibition by glucose, the loss of enzyme activities, and the non-productive binding of enzymes to insoluble biomass solids. To overcome these limitations, PEG was added prior to the first-round hydrolysis to reduce non-productive enzyme binding, glucose was removed from the enzyme fraction to be reused in the second-round hydrolysis, and EFB solids from the first-round hydrolysis were used in the second-round hydrolysis. These three additional measures with cellulase recycling resulted in a 3.5 times higher glucose yield (i.e., 68.0%) at the second round than that of the control, the second-round hydrolysis with cellulase recycling but without these measures. Conclusions Because of the high obstacles found in this study in achieving high saccharification yields in the high-solids saccharification of high-lignin lignocellulose with cellulase recycling, effective measures for improving enzymatic saccharification yields need to be accompanied with cellulase recycling.

The purpose of our study was to analyze the graft contact stress at the tunnel after transtibial single-bundle (SB) and transportal double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. After transtibial SB (20 cases) and transportal DB (29 cases) ACL reconstruction, the three-dimensional image of each patient made by postoperative computed tomography was adjusted to the validation model of a normal knee and simulated SB and DB ACL reconstructions were created based on the average tunnel position and direction of each group. We also measured graft and contact stresses at the tunnel after a 134 N anterior load from 0° to 90° flexion. The graft and contact stresses became the greatest at 30° and 0° flexion, respectively. The total graft and contact stresses after DB ACL reconstruction were greater than those after SB ACL reconstruction from 0° to 30° and 0° to 90° knee flexion, respectively. However, the graft and contact stresses of each graft after DB ACL reconstruction were less than those after SB ACL reconstruction. In conclusion, the total graft and total contact stresses after DB ACL reconstruction are higher than those after SB ACL reconstruction from 0° to 30° and 0° to 90° knee flexion, respectively. However, the stresses of each graft after DB ACL reconstruction are about half of those after SB ACL reconstruction.

There is a greater incidence of discoid meniscus in Asian countries than in Western countries, and bilateral discoid menisci are also common. The discoid meniscus may be a congenital anomaly, and genetics or family history may play a role in the development of discoid menisci. Because the histology of discoid meniscus is different from that of normal meniscus, it is prone to tearing. Individuals with a discoid meniscus can be asymptomatic or symptomatic. Asymptomatic discoid menisci do not require treatment. However, operative treatment is necessary if there are symptoms. Total meniscectomy leads to an increased risk of osteoarthritis. Therefore, total meniscectomy is generally reserved for rare unsalvageable cases. Partial meniscectomy (saucerization) with preservation of a stable peripheral rim combined with or without peripheral repair is effective, and good short-, mid-, and long-term clinical results have been reported.

Unlike postoperative changes in posterior tibial slope after medial open-wedge high tibial osteotomy, sagittal osteotomy inclination has not been examined. It has been recommended that the osteotomy line in the sagittal plane be parallel to the medial posterior tibial slope. The purpose of this study was to determine the frequency of parallel osteotomy in medial open-wedge high tibial osteotomy. To determine the sagittal osteotomy inclination, the angle between the medial joint line and the osteotomy line was measured in the lateral radiograph. A positive angle value indicates that the osteotomy is anteriorly inclined relative to the medial posterior tibial slope. Correlation between the sagittal osteotomy inclination and posterior tibial slope was also evaluated. The mean sagittal osteotomy inclination was 15.1 ± 7.5°. The majority 87.1 % of knees showed an anterior-inclined osteotomy. There was a significantly positive correlation between the postoperative posterior tibial slope and the sagittal osteotomy inclination (r, 0.33; 95 % confidence interval (CI) 0.19–0.46; P

Gradual wear and tear can cause a local inflammatory response in tendons. The trauma and inflammatory reaction eventually impair the biomechanical properties of the tendon. In this study, we prepared lactoferrin-immobilized, heparin-anchored, poly(lactic-co-glycolic acid) nanoparticles (LF/Hep-PLGA NPs) and evaluated their in vitro anti-inflammatory effects on interleukin-1β (IL-1β)-treated tenocytes and in vivo tendon healing effects in a rat model of Achilles tendinitis. Long-term LF-deliverable NPs (LF/Hep-PLGA NPs) remarkably decreased mRNA levels of pro-inflammatory factors [cyclooxygenase-2 (COX-2), IL-1β, matrix metalloproteinase-3 (MMP-3), MMP-13, IL-6, and tumor necrosis factor-α (TNF-α)] and increased mRNA levels of anti-inflammatory cytokines (IL-4 and IL-10) in both IL-1β-treated tenocytes and the Achilles tendons of a collagenase-induced Achilles tendinitis rat model. Interestingly, anti-inflammatory LF/Hep-PLGA NPs greatly enhanced collagen content, mRNA levels of tenogenic markers [collagen type I (COL1A1), decorin (DCN), tenascin-C (TNC)], and biomechanical properties such as tendon stiffness and tensile strength. These results suggest that anti-inflammatory LF/Hep-PLGA NPs are effective at restoring tendons in Achilles tendinitis.

Lateral hinge fracture (LHF) is a common complication after opening wedge high tibial osteotomy. Such a fracture can be caused by many factors such as osteotomy level, amount of opening, hinge position, and kind of plate. In particular, long locking plates have superior biomechanical stability in cases of LHF compared with short plates. Therefore, these long locking plates should be used in cases of LHF after opening wedge high tibial osteotomy.

The aim of this study was to evaluate which lower extremity alignment (knee and ankle joint) parameters affect knee joint line obliquity (KJLO) in the coronal plane after open wedge high tibial osteotomy (OWHTO). Overall, 69 knees of patients that underwent OWHTO were evaluated using radiographs obtained preoperatively and from 6 weeks to 3 months postoperatively. We measured multiple parameters of knee and ankle joint alignment (hip-knee-ankle angle [HKA], joint line height [JLH], posterior tibial slope [PS], femoral condyle-tibial plateau angle [FCTP], medial proximal tibial angle [MPTA], mechanical lateral distal femoral angle [mLDFA], KJLO, talar tilt angle [TTA], ankle joint obliquity [AJO], and the lateral distal tibial ground surface angle [LDTGA]; preoperative [-pre], postoperative [-post], and the difference between -pre and -post values [-Δ]). We categorized patients into two groups according to the KJLO-post value (the normal group [within ± 4 degrees, 56 knees] and the abnormal group [greater than ± 4 degrees, 13 knees]), and compared their -pre parameters. Multiple logistic regression analysis was used to examine the contribution of the -pre parameters to abnormal KJLO-post. The mean HKA-Δ (-9.4 ± 4.7 degrees) was larger than the mean KJLO-Δ (-2.1 ± 3.2 degrees). The knee joint alignment parameters (the HKA-pre, FCTP-pre) differed significantly between the two groups (p

Background: We described a surgical method for osteosynthesis and reported the resultant strength after application of a PHILOS plate through the anterolateral approach for the treatment of fractures of the distal humerus. Methods: Between February 2010 and March 2012, open reduction and internal fixation operations with the PHILOS plate for treatment of fracture of the distal humerus were performed on a total of nine patients (five men, four women). The mean age was 40.8 years (range, 24?50 years), and the average follow-up period was 9.1 months (range, 6?15 months). Clinical evaluations were performed 6 months after the operation. Clinical assessment included determination of the range of motion of the elbow, the Mayo and Oxford elbow scores, and any postoperative complications. Results: Fracture union was noted in all patients, with an average period of 12.4 weeks. The average Mayo elbow and Oxford elbow scores were 87.2 (of a total of 100) and 43.3 (of a total of 48), respectively. For the postoperative range of motion of the elbow, all patients showed complete recovery to the preoperative range of motion. No other conditions, such as neurolepsis, plate breakage, or rotational deformity, were observed. Conclusions: Open reduction and internal fixation of distal humerus fractures with a PHILOS plating system via anterolateral approach can be effective. A high rate of union with good outcomes can be assumed.

Background: Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques. Purpose: To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups. Results: No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05). Conclusion: With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.

Case: We present two cases of anterior cruciate ligament reconstruction with use of the flexible reamer system. In both patients, the starting reamers were broken during femoral reaming. The location of the breaks was approximately 60 mm from the tip of the reamer, which is the transitional zone between the proximal and distal portions of the reamer. Conclusion: We believe that several conditions could have resulted in abnormal stress concentration on the flexible reamers, including engagement of the flexible reamer with a physeal scar or the posterior cortex, an inappropriate flexion angle of the knee, and acute bending of the flexible pin.

To evaluate the clinical and radiological results of no bone graft (NBG) after opening wedge high tibial osteotomy (OWHTO) with a locking plate and to compare the bone union rate between the synthetic bone graft (SBG) group and the NBG group after OWHTO using serial radiographs.From 2012 to 2015, OWHTOs were performed with SBG or without bone graft using long locking plates. Inclusion criteria were: (1) OWHTO for disease of the medial compartment with varus deformity, and (2) minimum 2-year follow-up and radiographs taken serially to 2 years. Exclusion criteria were: (1) follow-up period2 years (n = 8) or (2) absence of at least 1 radiograph taken at each follow-up point (n = 14). We retrospectively reviewed radiographs taken preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Groups comprised those filled with a synthetic bone [hydroxyapatite (HA) and β-tricalciumphosphate (TCP), n=33, SBG group] or without a bone graft (n = 38, NBG group). We compared bone union rate between the 2 groups by measuring the union zone from zone 1 to zone 5 in serial radiographs using Fisher's exact test.OWHTO was performed in a total of 93 knees and 71 knees were included in this study. Both groups showed good clinical and radiological results without correction loss at 2 years. The entire NBG group and 93.9% of the SBG group showed union over zone 3 at 2 years. However, the NBG group showed significantly more incorporation than the SBG group at 6 months (P = .006), 1 year (P = .0003), and 2 years (P = .0003).Union without correction loss was obtained after OWHTO without bone graft. The NBG group showed significantly more incorporation than the SBG group (HA and β-TCP) within 2 years.Level IV, case series.

Using second-look arthroscopy, graft maturation was investigated and compared between hamstring (HA) autografts and tibialis anterior (TA) allografts after anatomic single-bundle anterior cruciate ligament reconstruction (ACLR). Fifty-six patients who underwent second-look arthroscopy after anatomic single-bundle ACLR with either HA autografts (26, HA group) or TA allografts (30, TA group) from 2007 to 2016 were retrospectively reviewed. Graft maturation on second-look arthroscopy was evaluated in terms of four parameters: graft integrity (tear), synovial coverage, graft tension, and graft vascularization. Each parameter received a maximum of two points, depending on the status of the reconstructed graft. The total graft maturation score was calculated as the sum of the parameter scores. The total graft maturation and individual parameter scores were compared between the two groups. The mean time from ACLR to second-look arthroscopy was 22.5 ± 7.8 months. The maturation scores in the HA group were significantly better in terms of graft integrity (p = 0.041), graft tension (p = 0.010), and graft vascularization (p = 0.024), whereas the graft synovial coverage score was not significantly different. The total graft maturation score of the HA group was significantly higher than that of the TA group (6.3 ± 0.4 vs. 4.9 ± 0.3, p = 0.013). This study shows the superior graft maturation of HA autografts compared with that of TA allografts at a mean follow-up of 22.5 ± 7.8 months after anatomic single-bundle ACLR. When anatomic ACLR using soft tissue graft is planned, HA autograft is recommended rather than soft tissue allograft, especially in young and active patients. Retrospective cohort review, Level III.

Background The diagnosis of periprosthetic joint infection (PJI) remains difficult, particularly in acute postoperative stage. The purpose of this study was to investigate the optimal cutoff value of synovial white blood cell (WBC) count, percentage of polymorphonuclear cells, erythrocyte sedimentation rate, and C-reactive protein (CRP) for diagnosing early postoperative infection after knee joint arthroplasty. Methods We retrospectively reviewed primary total knee arthroplasties and unicompartmental knee arthroplasties, with a knee aspiration within 3 weeks of surgery, from January 2006 to November 2016. Twelve infected cases and 185 uninfected cases met the inclusion criteria of our study. We compared the laboratory parameters (synovial WBC count, percentage of polymorphonuclear cells, erythrocyte sedimentation rate, and CRP levels) between the 2 groups. Receiver operating characteristic curves were constructed to determine the optimal cutoff values for each parameter. Each parameter was studied to determine its sensitivity, specificity, and positive and negative predictive values (PPV and NPV) in diagnosing acute PJI. Results There were 2 optimal cutoff values for synovial WBC count and CRP levels. With the cutoff value of synovial WBC set at 11,200 cells/μL, acute PJI could be diagnosed with the highest sensitivity (100%) and specificity (98.9%); with the cutoff value set at 16,000 cells/μL, the best PPV and NPV were found (100% and 99.5%, respectively). Similarly, the CRP level >34.9 mg/L had the best sensitivity (100%) and specificity (90.3%), whereas the CRP level >74.5 mg/L had the best PPV (100%) and NPV (99.2%). Conclusion Synovial WBC count and CRP levels are useful in diagnosing acute PJI between 1 and 3 weeks after primary knee arthroplasty.

The aim of this study was to evaluate the risk factors for dislocation of the bearing after a mobile-bearing Oxford medial unicompartmental knee replacement (UKR) and to test the hypothesis that surgical factors, as measured from post-operative radiographs, are associated with its dislocation From a total of 480 UKRs performed between 2001 and 2012, in 391 patients with a mean age of 66.5 years (45 to 82) (316 female, 75 male), we identified 17 UKRs where bearing dislocation occurred. The post-operative radiological measurements of the 17 UKRs and 51 matched controls were analysed using conditional logistic regression analysis. The post-operative radiological measurements included post-operative change in limb alignment, the position of the femoral and tibial components, the resection depth of the proximal tibia, and the femoral component-posterior condyle classification. We concluded that a post-operative decrease in the posterior tibial slope relative to the pre-operative value was the only significant determinant of dislocation of the bearing after medial Oxford UKR (odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative posterior tibial slope < 8.45° and a difference between the pre-operative and post-operative posterior tibial slope of > 2.19° may increase the risk of dislocation. Cite this article: Bone Joint J 2014; 96-B:914–22.

The desire to perform independent femoral drilling in anterior cruciate ligament (ACL) reconstruction has prompted interest in both the transportal (TP) and outside-in (OI) techniques. However, there have been no in vivo studies on the differences in femoral aperture shape between the 2 techniques.To evaluate the femoral tunnel aperture shape and femoral tunnel position between ACL reconstruction using the TP and OI techniques.Randomized controlled trial; Level of evidence, 1.A total of 80 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n = 40) or OI (n = 40) technique. The femoral tunnel aperture shape (height/width ratio), aperture axis angle (angle between the aperture axis and femoral shaft axis), and femoral tunnel position were assessed by computed tomography.The mean height/width ratio of the anteromedial (AM) femoral tunnels in the TP group (1.35 ± 0.16) was significantly more ellipsoidal than that in the OI group (1.22 ± 0.16) (P = .008). There was no difference between the 2 groups in the posterolateral (PL) tunnels (TP, 1.32 ± 0.23; OI, 1.35 ± 0.29; P = .99). The mean aperture axis angle of the PL femoral tunnels in the OI group was significantly more perpendicular to the femoral shaft axis and had a more variable range than that in the TP group (P = .007). The mean PL femoral tunnel position in the OI group was significantly shallower and a little higher than that in the TP group (P = .006).The TP technique revealed a more ellipsoidal AM femoral tunnel aperture than the OI technique. The mean PL femoral tunnel position in the OI group was significantly shallower than that in the TP group, with a more variable and more perpendicular aperture axis angle to the femoral shaft axis.The TP technique might be more advantageous than the OI technique in terms of graft coverage, with a more ellipsoidal AM femoral tunnel and more horizontal and consistent PL aperture axis angle. In addition, it may be useful to consider the shallower PL femoral tunnel positions created with the OI technique.

The purpose of this study is to present and evaluate a new arthroscopic technique using three-point suture fixation for anterior cruciate ligament (ACL) tibial avulsion fracture with accompanying detachment of the anterior horn of the lateral meniscus.Eleven patients with a diagnosis of ACL tibial avulsion fracture underwent arthroscopic suture fixation from January 2007 to December 2009. Out of the 11 patients, six had cases of ACL tibial avulsion fractures (four were type III and two were type IV) with accompanying detachment of the anterior horn of the lateral meniscus and were treated using three-point suture fixation. The patients were followed up and evaluated according to Lysholm scores, International Knee Documentation Committee (IKDC) subjective scores, Tegner activity level scales, anterior drawer testing and KT-2000 arthrometer testing.All patients were followed up for more than 2 years (range 25-40 months). The fracture fragments were united at a mean of 10.3 weeks (range 8-13). All patients were negative for the Lachman test and the anterior drawer test and had3 mm side-to-side difference with the KT-2000 arthrometer. The postoperative mean Lysholm score improved to 98 (range 96-100, P0.05). The postoperative mean IKDC subjective score was 93.3 (range 91-98, P0.05). The median Tegner score improved from 2.5 (range 2-3) to 8.5 (range 8-9) postoperatively (P0.05). The type of avulsion fracture (III or IV) did not significantly impact clinical results (Lysholm score, IKDC score, Tegner activity level, P0.05).ACL avulsion fractures with accompanying detachment of the anterior horn of the lateral meniscus should be treated as another type of ACL avulsion fracture. Arthroscopic treatment using the three-point suture fixation technique is effective for this type of ACL avulsion fracture and can restore the function and stability of the knee joint.

Background: It has been reported previously that single-bundle anterior cruciate ligament (ACL) reconstruction with more accurate restoration of the footprint of the native ACL fails to restore the graft obliquity of the native ACL in the coronal plane. Whether double-bundle ACL reconstruction restores the graft obliquity of each bundle of the native ACL has not yet been determined. Hypothesis: Anatomic double-bundle ACL reconstruction using transportal (TP) and outside-in (OI) techniques can restore the graft obliquities of both anteromedial (AM) and posterolateral (PL) bundles in the native ACL in both sagittal and coronal planes. Study Design: Cohort study; Level of evidence, 2. Methods: Seventy-six patients underwent anatomic double-bundle ACL reconstruction. Patients were randomized to 2 groups to undergo either TP or OI tibial tunnel–independent anatomic ACL reconstruction. All participants underwent postoperative magnetic resonance imaging of both knees, and the native ACL obliquity was determined using the participant’s contralateral knee. Graft obliquities were determined by measuring the angles between the center line of the graft and the surface line of the tibial plateau, and the obliquities of paired knees were compared. Graft obliquities were analyzed in each group. Results: In the sagittal plane, the mean AM graft obliquity was 54.2° on the operated side and 54.6° on the nonoperated side, and the difference between sides was not statistically significant ( P = .352). The mean PL graft obliquity in the sagittal plane was 54.1° on the operated side and 53.0° on the nonoperated side, and the difference between sides was also not statistically significant ( P = .228). In the coronal plane, the mean AM graft obliquity was 73.8° on the operated side and 73.4° on the nonoperated side, and the mean PL graft obliquity was 65.5° on the operated side and 66.4° on the nonoperated side. There were no statistically significant differences between sides ( P = .418 for AM graft; P = .328 for PL graft). Differences in the paired graft obliquities in each group were also statistically insignificant between the TP and OI groups. Conclusion: Both TP and OI anatomic double-bundle reconstruction techniques can result in graft obliquities in both bundles that resemble the native ACL in both sagittal and coronal planes. Clinical Relevance: Double-bundle ACL reconstruction techniques might more closely restore the normal kinematics of the native ACL by restoring the normal obliquity of both ACL bundles.

To compare femoral graft bending angles and femoral tunnel geometries between the transportal (TP) and outside-in (OI) techniques after anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction.Thirty-nine patients underwent DB ACL reconstruction with the TP and OI techniques. They were randomized on the day of surgery to either the TP group (group I, 21 cases) or the OI group (group II, 18 cases). Femoral graft bending angle, femoral tunnel geometry, posterior wall breakage, and tunnel communication were assessed by computed tomography imaging with OsiriX imaging software (Pixmeo, Geneva, Switzerland).The mean anteromedial (AM) and posterolateral (PL) femoral graft bending angles of group II (97.3° ± 8.3° and 97.4° ± 8.6°, respectively) were significantly more acute than those of group I (108.2° ± 8.4° and 109.9° ± 8.8°, respectively) (P.001). The mean AM femoral tunnel length of group II (34.3 ± 3.9 mm) was significantly longer than that of group I (31.9 ± 2.7 mm) (P = .02). However, the mean PL femoral tunnel lengths did not differ between groups. In 7 cases-4 cases (19.0%) in group I and 3 cases (16.6%) in group II-the femoral tunnel communication was found around the intra-articular aperture. Posterior wall breakage was observed in 5 cases (23.8%), which were all in AM femoral tunnels of group I.The OI technique resulted in more acute femoral graft bending angles (difference of 10.9° and 12.5° for AM and PL, respectively) and longer mean AM femoral tunnel lengths (difference of 2.4 mm) than the TP technique after anatomic DB ACL reconstruction, even though these small differences might be unlikely to be of clinical significance. Femoral tunnel communication was found in both groups, and posterior wall breakage was observed in AM femoral tunnels with the TP technique.Level I, prospective randomized trial.

Purpose To analyze femoral tunnel geometry using computed tomography (CT) imaging and evaluate the anatomic factors affecting femoral tunnel length after anterior cruciate ligament (ACL) reconstruction by the transportal technique. Methods Twenty-nine patients underwent an anatomic double-bundle ACL reconstruction with a femoral tunnel drill by the transportal technique. CT imaging with OsiriX software (version 3.8; Pixmeo, Geneva, Switzerland) was used to measure femoral tunnel length (anteromedial [AM], posterolateral [PL], and central), femoral tunnel divergent angle, and femoral condyle size and intercondylar notch size parameters. Correlations between femoral tunnel length and femoral condyle size and intercondylar notch size parameters were analyzed. Results The mean AM, PL, and central femoral tunnel lengths were 33.3 ± 3.9 mm, 33.6 ± 3.6 mm, and 34.3 ± 3.2 mm, respectively. A femoral tunnel length of less than 30 mm developed in 7 cases (24.1%) in the AM aspect and 4 cases (13.8%) in the PL aspect. The mean femoral tunnel divergent angle was 14.4° ± 4.1°. A positive correlation was found between AM, not PL or central, femoral tunnel length and medial femoral condyle anteroposterior (AP) distance ( P = .01, r = 0.46), lateral femoral condyle AP distance ( P = .01, r = 0.43), medial-to-lateral epicondylar distance ( P = .03, r = 0.39), middle notch width ( P = .009, r = 0.47), notch height ( P = .001, r = 0.57), and notch area ( P r = 0.58). Conclusions After double-bundle ACL reconstruction with the transportal technique through the accessory anteromedial portal, the AM and PL femoral tunnels showed mean tunnel length greater than 30 mm and a divergent angle. However, a femoral tunnel length of less than 30 mm developed in some cases. AM femoral tunnel length was correlated with femoral condyle size (medial femoral condyle AP distance, lateral femoral condyle AP distance, and medial-to-lateral epicondylar distance) and intercondylar notch size (notch width, notch height, and notch area). Level of Evidence Level IV, therapeutic case series.

To evaluate the accuracy of intraoperative femoral tunnel length measurement and to compare this between the transportal (TP) and outside-in (OI) techniques for double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. Eighty patients underwent a DB ACL reconstruction using either the TP or the OI technique. The participants were randomized to either a TP group (I, 40 cases) or a OI group (II, 40 cases). The intraoperatively measured femoral tunnel length was recorded, and the postoperative femoral tunnel length was measured using computed tomography with OsiriX® imaging software. The mean femoral tunnel lengths measured intraoperatively in Group II (38.9 ± 3.0 mm for anteromedial [AM], 39.3 ± 3.4 mm for posterolateral [PL]) were significantly longer than those of Group I (34.8 ± 2.7 mm for AM, 36.0 ± 3.2 mm for PL) (P

A functional total knee replacement has to be well aligned, which implies that it should lie along the mechanical axis and in the correct axial and rotational planes. Incorrect alignment will lead to abnormal wear, early mechanical loosening, and patellofemoral problems. There has been increased interest of late in total knee arthroplasty with robotic assistance. This study was conducted to determine whether robot-assisted total knee arthroplasty is superior to the conventional surgical method with regard to the precision of implant positioning.Twenty knee replacements, comprising ten robot-assisted procedures and ten conventional operations, were performed on ten cadavers. Two experienced surgeons performed the surgeries. Both procedures on each cadaver were performed by the same surgeon. The choice of which procedure was to be performed first was randomized. Following implantation of the prosthesis, the mechanical axis deviation, femoral coronal angle, tibial coronal angle, femoral sagittal angle, tibial sagittal angle, and femoral rotational alignment were measured via 3D CT scanning. These variables were then compared with the preoperatively planned values.In the knees that underwent robot-assisted surgery, the mechanical axis deviation ranged from -1.94° to 2.13° (mean: -0.21°), the femoral coronal angle from 88.08° to 90.99° (mean: 89.81°), the tibial coronal angle from 89.01° to 92.36° (mean: 90.42°), the tibial sagittal angle from 81.72° to 86.24° (mean: 83.20°), and the femoral rotational alignment from 0.02° to 1.15° (mean: 0.52°) in relation to the transepicondylar axis. In the knees that underwent conventional surgery, the mechanical axis deviation ranged from -3.19° to 3.84° (mean: -0.48°), the femoral coronal angle from 88.36° to 92.29° (mean: 90.50°), the tibial coronal angle from 88.15° to 91.51° (mean: 89.83°), the tibial sagittal angle from 80.06° to 87.34° (mean: 84.50°), and the femoral rotational alignment from 0.32° to 4.13° (mean: 2.76°) in relation to the transepicondylar axis. In the conventional knee replacement group, there were two instances of outliers outside the range of 3° varus/valgus for the mechanical axis deviation. The robot-assisted knee replacements showed significantly superior femoral rotational alignment results compared with conventional surgery (p = 0.006). There was no statistically significant difference between robot-assisted and conventional total knee arthroplasty with regard to the other variables. All the measurements showed high intra-observer and inter-observer reliability.Robot-assisted total knee arthroplasty showed excellent precision in the sagittal and coronal planes of the 3D CT scan. In particular, the robot-assisted technique showed better accuracy in femoral rotational alignment compared to the conventional surgery, despite the fact that the surgeons who performed the operations were more experienced and familiar with the conventional method than with robot-assisted surgery. It can thus be concluded that robot-assisted total knee arthroplasty is superior to conventional total knee arthroplasty.

Purpose The purpose of this study was to investigate the clinical and magnetic resonance imaging (MRI) results of anterior cruciate ligament (ACL) reconstruction with autogenous hamstring tendon by use of remnant preservation and a femoral tensioning technique. Methods A total of 53 patients who had ACL reconstruction by use of remnant ACL stump preservation and a femoral tensioning technique were evaluated. Clinical evaluation at a minimum of 2 years after surgery included range of motion, Lachman test, pivot-shift test, KT-2000 arthrometer testing (MEDmetric, San Diego, CA), and clinical scores. Plain radiographs were evaluated for tunnel enlargement. MRI was obtained for evaluation of graft continuity, cyclops-like mass lesion, and positioning of the tibial tunnel. Second-look arthroscopy was performed in 33 patients. Results The clinical scores improved postoperatively. There were statistically significant differences between preoperative and postoperative Lachman tests, pivot-shift tests, and KT-2000 arthrometer measurements. Postoperative MRI was available in 48 patients, and it showed intact graft in 45 patients, 2 partial tears, and 1 complete loss of graft. There were cyclops-like mass lesions in 12 patients, but none showed an extension limitation or pain at extension. The position of the tibial tunnel on the sagittal and coronal view was similar to the position of the normal ACL tibial insertion. The measured tibial tunnel widening on the radiographs at final follow-up was 2.2 ± 1.5 mm. Conclusions Reconstruction of the ACL by use of preservation and femoral tensioning of the remnant tissue showed good clinical results without increased concerns regarding incorrect tunnel formation. Postoperative MRI showed an increased incidence of cyclops-like mass lesions, but no clinical significance was observed. Level of Evidence Level IV, case series.

Introduction Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the two techniques. We aimed to compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. Methods From November 2010 to March 2013, 128 cases were enrolled in this study and were randomly assigned to either the TP group (64 cases) or the OI group (64 cases), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7 %) were evaluated with multiple clinical scores and stability tests. Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by using second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). Results There were no significant differences between the two groups in terms of clinical evaluation, with the exception of postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the functional test of the objective IKDC score was significantly larger for the OI group than the TP group (P = 0.005). The second-look arthroscopic findings were not significantly different between the two groups in either bundle (P > 0.05). In addition, MRI findings did not differ significantly between the two groups (P > 0.05). Conclusion With the exception of the functional test of IKDC objective score, clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction.

The goal of this study was to compare treatment outcomes of screw proximal femoral nails and helical proximal femoral nails and to investigate the effectiveness of helical proximal femoral nails for the treatment of intertrochanteric fractures. Forty patients with intertrochanteric fractures were treated at our institution between January 2005 and January 2007, with a minimum follow-up of 1.5 years. Seventeen patients were treated with screw proximal femoral nails (mean patient age, 67 years; age range, 45–89 years; men:women ratio, 3:14), and 23 were treated with helical proximal femoral nails (mean patient age, 74 years; age range, 64–91 years; men:women ratio, 6:17). We evaluated mean operation time, amount of bleeding, time to ambulation, average union period, changes in neck shaft angle, and complications, and performed radiographic reviews, telephone interviews, and direct contact interviews at an outpatient clinic. We evaluated postoperative function and mobility using social function scores and mobility scores. Helical proximal femoral nails produced better results in terms of social function scores, mobility scores, and complication rates with statistical significance. No significant differences were found between the 2 nails in terms of mean operation time, amount of bleeding, average union period, time to ambulation, or neck shaft angle changes. Screw proximal femoral nails and helical proximal femoral nails are suitable implants for intertrochanteric fractures, but helical proximal femoral nails are better in terms of functional aspects and complication rates.

Irreducible knee dislocation due to incarcerated soft tissue structures in associated fractures is extremely uncommon. We report a case of irreducible, closed dislocation of the knee secondary to incarcerated patellar tendon in a Hoffa fracture (unicondylar fracture of femur in the coronal plane) with associated communited fracture of patella and disruption of both cruciates. We treated this case initially with open reduction and internal fixation of fracture and repair of the patellar tendon. During the total followup period of eighteen months, the patient had restricted joint range of motion with no joint instability despite aggressive physiotherapy and further surgical intervention. The prognosis of such complex knee injuries with combination of ligamentous injuries and associated fractures is much worse when compared to either injuries alone.

Synovial cysts are well-defined fluid filled cysts that can extend for a variable distance outside the joint space. These cysts can sometimes grow to a large size making its treatment challenging especially when associated with intra-articular pathologies. We describe a case of giant synovial cyst arising from the left knee and extending to the medial proximal calf in a 77-year old female who presented with knee joint pain, episodes of locking and calf mass occurring within 2 months of onset. Imaging studies also showed associated medial and lateral meniscal tears with medial compartment and patellofemoral osteoarthritis. The cyst was treated by disrupting the valvular mechanism using a standard posteromedial portal and complete excision of the cyst wall via a posteromedial cystic portal. The meniscal lesions were dealt with through the standard anterior portals. At 25-month follow up there were no signs of recurrence of the cyst clinically or with MRI. The cystic portal technique is effective in treating a giant synovial cyst of the knee even in the presence of meniscal tears and high grade chondral lesions.

Purpose: To evaluate the relationship between the clinical outcome and the cuff integrity following open repair in large and massive rotator cuff tears using ultrasonography as an imaging modality. Material and Methods: From November 2001 to April 2005, 17 cases(16 patients) who had open repair of tear measuring more than 3cm were assessed with minimal follow-up of 12 months in this study. 6 cases had a large tear and 11 cases a massive tear. There were 6 men and 11 women with a mean age of 52 years at surgery (range, 33 to 72 years). The evaluation consisted of the preoperative and postoperative shoulder scores according to UCLA shoulder scoring system and Visual analogue scale (VAS). Ultrasonography was performed by a experienced musculoskeletal physician at a minimum of 12 months postoperatively to evaluate the postoperative cuff integrity. Results: Retear were detected in four of seventeen cases. Regardless of the presence of recurrent tear, 14 cases had UCLA score of more than 29 points (good grade). All 17 had an improvement in the functional score, which increased from an average of 15.1 to 31.2 points. All cases showed pain relief and five cases had no pain. Sixteen cases except one had the range of motion of forward elevation above . Conclusion: Open rotator cuff repair in large and massive tears showed low retear rate. At a minimum of twelve months follow-up, all cases had improvement on UCLA score, pain relief, increased range of motion of the shoulder regardless of retear. And the correlation between recurrent tear and function score was not statistically significant.

Purpose The purpose of this study was to evaluate the demographics, clinical features, and outcomes of arthroscopic partial meniscectomy (APM) for isolated medial meniscus horizontal cleavage tears (MMHCTs) in patients under 45 years of age. Materials and methods We retrospectively reviewed 98 patients (100 knees) under 45 years who underwent APM for MMHCTs. Clinical outcomes were assessed using International Knee Document Committee (IKDC) subjective core, Tegner activity scale, visual analog scale (VAS) pain score, and a question on the symptom relief. Results 79% were male and 70% had no trauma. The mean symptom duration was 10 months. At arthroscopy, a flap tear was identified in 75%. At a mean of 19-month follow-up, the IKDC subjective score, Tegner activity scale, and VAS pain score were significantly improved compared to the preoperative values (p=0.025, p=0.043, and p=0.032, respectively). While 85% were free of symptoms, 15% had persistent pain. No significant differences in outcomes were observed based on the tear type and the presence of flap tears. No progression or development of radiographic degenerative changes was observed in all knees. Conclusions Demographics of MMHCTs under age 45 showed a male dominance and higher frequency of non-traumatic tears. APM was beneficial to symptomatic HCTs in this cohort during the short-term follow-up. Type of HCTs and combined flap tears did not affect clinical outcomes.

To evaluate the effect of high axial loading (AL) on anterior tibial translation (ATT) according to the increase in knee flexion and the effect of valgus stress (VS) and internal rotation (IR) combined with high AL in intact and anterior cruciate ligament (ACL)-deficient knees according to the increase in knee flexion.We used 10 fresh-frozen, human cadaveric knees. Different loading conditions (134-N anterior drawer, 1,000-N AL, 10-Nm VS, and 5-Nm IR) were sequentially combined, and ATT was measured at 0°, 15°, 30°, 45°, and 60° of flexion in the intact and ACL-deficient knees.ATT increased significantly by adding high AL in intact knees (P = .001) and ACL-deficient knees (P .0001) according to the change in flexion angle (P.0001). Under high AL, ATT in the ACL-deficient knees was significantly larger than that in the intact knees for all loading conditions, and it also increased gradually according to the increase in knee flexion (P = .0001). ATT increased significantly after adding IR or VS with high AL in intact knees (VS, P = .002; VS/IR, P = .03) and ACL-deficient knees (VS, P = .0004) at some of the flexion angles.The added high AL increased ATT in intact and ACL-deficient knees from 0° to 60° of flexion. The effect of high AL on ATT became greater in ACL-deficient knees than in intact knees, and ATT also gradually increased according to the increase in knee flexion from 0° to 60°. In both the intact and ACL-deficient knees, ATT increased significantly after valgus stress or IR from 0° to 60°.ATT during weight bearing increases stress to the ACL, which worsens with valgus stress and/or IR forces. This finding should be considered when one is studying ACL injury mechanisms, as well as prescribing rehabilitation after ACL surgery.

The aim of this study was to compare femoral tunnel length, femoral graft-bending angle, posterior wall breakage, and femoral aperture morphologic characteristics between rigid and flexible systems after double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using the transportal (TP) technique.We evaluated 3-dimensional computed tomography (3D-CT) results for 54 patients who underwent DB ACL reconstruction using the TP technique with either a flexible system (n = 27) or a rigid system (n = 27). The femoral tunnel length, femoral graft-bending angle, posterior wall breakage, femoral tunnel aperture height to width (H:W) ratio, aperture axis angle, and femoral tunnel position were assessed using OsiriX Imaging Software and Geomagic Qualify 2012 (Geomagic, Cary, NC).The mean anteromedial (AM) femoral tunnel length of the flexible group was significantly longer than that of the rigid group (P = .009). The mean femoral graft-bending angles in the flexible group were significantly less acute than those in the rigid group (AM, P.001; posterolateral [PL], P = .003]. Posterior wall breakage was observed in both groups (P = 1.00). The mean H:W ratios in the rigid group were significantly larger (more elliptical) than those of the flexible group (AM, P.001; PL, P = .006). The mean aperture axis angle of the PL femoral tunnel in the rigid group was more parallel to the femoral shaft axis than that in the flexible group (P.001). There were no significant differences in femoral tunnel position between the 2 groups.The AM femoral tunnel length and the AM/PL femoral graft-bending angle of the flexible system were significantly longer and less acute than those of the rigid system. However, the aperture morphologic characteristics of the AM/PL femoral tunnel and the aperture axis angle of the PL femoral tunnel in the rigid system were significantly more elliptical and closer to parallel to the femoral shaft axis than those of the flexible system.Level III, retrospective comparative study.

Background The aims of our study were to evaluate the success rate of irrigation and debridement with component retention (IDCR) for acutely infected total knee arthroplasty (TKA) (< 4 weeks of symptom duration) and to analyze the factors affecting prognosis of IDCR. Methods We retrospectively reviewed 28 knees treated by IDCR for acutely infected TKA from 2003 to 2012. We evaluated the success rate of IDCR. All variables were compared between the success and failure groups. Multivariable logistic regression analysis was also used to examine the relative contribution of these parameters to the success of IDCR. Results Seventeen knees (60.7%) were successfully treated. Between the success and failure groups, there were significant differences in the time from primary TKA to IDCR (p = 0.021), the preoperative erythrocyte sedimentation rate (ESR; p = 0.021), microorganism (p = 0.006), and polyethylene liner exchange (p = 0.017). Multivariable logistic regression analysis of parameters affecting the success of IDCR demonstrated that preoperative ESR (odds ratio [OR], 1.02; p = 0.041), microorganism (OR, 12.4; p = 0.006), and polyethylene liner exchange (OR, 0.07; p = 0.021) were significant parameters. Conclusions The results show that 60.7% of the cases were successfully treated by IDCR for acutely infected TKA. The preoperative ESR, microorganism, and polyethylene liner exchange were factors that affected the success of IDCR in acutely infected TKA.

The aim of this study was to analyze clinical and radiologic results of an arthroscopic medial plication with the pullout technique and to define indications and limitations of this procedure for patellar instability. Records of 45 patients treated for patellar instability with arthroscopic medial plication with the pullout technique were reviewed. The mean patient age was 22.8±8.3 years. The tibial tuberosity-trochlear groove distance, trochlear depth (TD), and Insall-Salvati ratio were measured using magnetic resonance imaging taken preoperatively. Patients were evaluated clinically by the Insall and Kujala score and radiographically by measuring the congruence angle, lateral patellofemoral angle, and lateral patellar translation pre- and postoperatively. Patients were classified into 2 groups: group 1 comprised 23 patients with TD greater than or equal to 3.0 mm and group 2 comprised 22 patients with TD less than 3.0 mm. A significant improvement ( P =.007) in postoperative clinical scores compared with preoperative values was observed. The congruence angle improved to 11.0°±20.6° ( P =.006), the lateral patellofemoral angle improved to −1.6°±7.7° ( P ⩽.0001), and the lateral patellar translation improved to 8.7±5.3 mm ( P ⩽.0001) postoperatively. There were 5 (11%) failure cases. No significant difference existed in the number of failure cases and clinical scores between the 2 groups. This arthroscopic medial soft tissue pullout technique showed good clinical and radiologic results for patellar instability even in the presence of mild to moderate trochlear dysplasia. However, the technique showed limited success in severe trochlear dysplasia cases.

The purpose of this study was to determine the effect of physiological axial loading during knee flexion on changes in anterior cruciate ligament (ACL) end-to-end distance for normal and ACL-deficient knees. Biomechanical tests were conducted on ten cadaveric knees using an Instron machine. We gathered positional data of the tibia and femur at low to middle flexion angles (0°, 15°, 30°, 45° and 60°) with/without axial loading. First, no external load was applied to the specimens at each angle, and then, a 1000-N axial load was applied to the knees. The same test protocols were repeated after transection of the ACL. Using computer software (Geomagic Studio 10), we regenerated positional data and calculated the end-to-end distances of the anteromedial, posterolateral and the entire ACL bundle at each angle. Compared with ACL-intact knees without axial loading, knees under axial loading did not show significant increases in end-to-end distance. Under axial loading, we found no significant differences in end-to-end distances between bundles in ACL-intact knees according to the increase in knee flexion angle. After ACL transection, axial loading significantly increased end-to-end distances of all three bundles (P

Unpredicted overcorrection of the mechanical axis can occur during navigation-assisted high tibial osteotomy (HTO). It is not clear whether the erroneous overcorrection stems from the navigation system itself or from other causes.To evaluate the accuracy of the navigation system in HTO by comparing the change in the femorotibial angle provided by the navigation system with the bony correction angle of the proximal tibia on 3-dimensional computed tomography (3D CT) and with the change in mechanical femorotibial alignment on standing whole-leg radiographs.Cohort study (diagnosis); Level of evidence, 2.A total of 16 knees underwent navigation-assisted HTO, and their alignment data were obtained before and after correction. For comparison, preoperative and follow-up standing whole-leg anteroposterior radiographs, lateral knee radiographs, and preoperative and postoperative 3D CT scans were taken. The medial proximal tibial angle (MPTA), posterior tibial slope, and mechanical femorotibial angle (mFTA) were measured in these images, and the 3 coronal and 3 sagittal correction angles were compared with each other.In the coronal plane, the mean correction angle of the navigation system was 9.3° ± 2.0° valgus (range, 6°-13°), and the mean MPTA on 3D CT increased 9.7° ± 2.0° (range, 6.7°-13.8°) after correction. The mean correction angle of the mFTA on standing radiographs was 11.9° ± 3.2° valgus (range, 6.9°-16.5°). There was no statistical significance between the navigation system and 3D CT (P = .187), but there was a statistically significant difference between the navigation system and standing radiographs (P = .001). The results of the correction angle in the sagittal plane were similar to those in the coronal plane.The correction of the femorotibial angle by the navigation system was not different from the bony correction angle on 3D CT. There was a discrepancy between the correction angle of the navigation system and that of the standing radiograph.Surgeons must be cautious about the tension of soft tissue, even when using the navigation system during HTO.