Evaluation of the morphological variations of the meniscus: a cadaver study.

PURPOSE: The purpose of this study was to reveal the prevalence of the subtypes of the meniscus using human cadaver knees. METHODS: Four hundred and thirty-seven cadaveric knees in 219 subjects (formalin fixed, Japanese population) with a median age of 83 years (54-97) were included in this study. All soft tissues surrounding the knee, excluding the meniscus, were resected, and macroscopic assessment of the meniscus was performed. Meniscus subtypes were classified as: (1) normal meniscus, (2) complete discoid, (3) incomplete discoid, (4) ring-shaped, and (5) double-layered. RESULTS: All subtypes of the meniscus were observed in the lateral meniscus. Complete discoid lateral meniscus was observed in 27 knees (6.2%), incomplete discoid lateral meniscus was observed in 139 knees (31.8%), ring-shaped lateral meniscus was observed in 4 knees (0.9%), and double-layered meniscus was observed in 2 knees (0.5%). CONCLUSION: This study reports the accurate prevalence of ring-shaped and double-layered meniscus. None of the subtypes were detected in the medial meniscus in this study. For clinical relevance, the results of this study can be useful in assisting the diagnosis of meniscus tear in clinical situations.

[Present and future for LLLT in the area of orthopedics].

The biological tissue is irradiated with laser light, and carbonization, incineration, evaporation, blood coagulation, protein denaturation, and photoactivation will arise in order of the strength of the reaction. LLLT is the application of those photoactivated biological effects. In this paper, effective pain relief, photoactivation effect on chondrocytes, and, PDT (photodynamic therapy) using photosensitizer are introduced.

Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes.

BACKGROUND: Intercondylar notch narrowing is a risk factor for anterior cruciate ligament (ACL) injuries, but it is unclear whether a narrow intercondylar notch correlates with bilateral ACL injuries. PURPOSE: To determine whether a narrow intercondylar notch is associated with bilateral ACL knee injuries in athletes, using magnetic resonance imaging (MRI) and radiography to investigate the notch size. STUDY DESIGN: A retrospective case-control study. METHODS: This was a comparative cohort study on 50 subjects of which 25 patients with sport trauma-associated bilateral ACL injuries, 30 with unilateral ACL injuries, and 20 healthy subjects. The notch width index (NWI) was measured as the ratio of the width of the intercondylar notch to the femoral condylar width on radiography and the MRI slice containing the region near the ACL attachment site on the femoral side (NWI-A) and on the following posterior slice (NWI-P). RESULTS: The mean NWI values on radiography were 0.257 (SD 0.040), 0.332 (SD 0.036), and 0.341 (SD 0.027) in the bilateral, unilateral, and control groups, respectively, with significant differences between the bilateral and unilateral groups and the bilateral and healthy groups. On MRI, the mean NWI-A values were 0.236 (SD 0.025), 0.243 (SD 0.048), and 0.266 (SD 0.030), respectively, with a significant difference between the bilateral and healthy groups. The mean NWI-P values were 0.239 (SD 0.021), 0.258 (SD 0.038), and 0.273 (SD 0.033), respectively, with significant differences between the bilateral and unilateral groups and the unilateral and healthy groups. A cutoff value of 0.25 for NWI-P gave an odds ratio of 22.667 for the risk of developing bilateral ACL knee injuries. CONCLUSIONS: The intercondylar notch was significantly narrower in subjects with bilateral ACL injuries than in healthy subjects. NWI measurement using coronal MRI is useful for judging intercondylar notch narrowing. The risk for ACL injuries is very high when NWI is ≤0.25. Preventive measures for the unaffected knee are required for patients with a narrow intercondylar notch.

Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model.

Attention has been focused on the importance of anatomical tunnel placement in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the effect of different tunnel positions for single-bundle (SB) ACL reconstruction on knee kinematics. Ten porcine knees were used for the following reconstruction techniques: three different anatomic SB [AM-AM (antero-medial), PL-PL (postero-lateral), and MID-MID] (n = 5 for each group), conventional SB (PL-high AM) (n = 5), and anatomic double-bundle (DB) (n = 5). Using a robotic/universal force-moment sensor testing system, an 89 N anterior load (simulated KT1000 test) at 30, 60, and 90 degrees of knee flexion and a combined internal rotation (4 N m) and valgus (7 N m) moment (simulated pivot-shift test) at 30 and 60 degrees were applied. Anterior tibial translation (ATT) (mm) and in situ forces (N) of reconstructed grafts were calculated. During simulated KT1000 test at 60 degrees of knee flexion, the PL-PL had significantly lower in situ force than the intact ACL (P < 0.01). In situ force of the MID-MID was higher than other SB reconstructions (at 30 degrees : 94.8 +/- 2.5 N; at 60 degrees : 85.2 +/- 5.3 N; and 90 degrees: 66.0 +/- 8.7 N). At 30 degrees of knee flexion, the PL-high AM had the lowest in situ values (67.1 +/- 19.3 N). At 60 and 90 degrees of knee flexion the PL-PL had the lowest in situ values (at 60 degrees : 60.8 +/- 19.9 N; 90 degrees : 38.4 +/- 19.2 N). The MID-MID and DB had no significant in situ force differences at 30 and 60 degrees of knee flexion. During simulated pivot-shift test at 60 degrees of knee flexion, the PL-PL and PL-high AM reconstructions had a significant lower in situ force than the intact ACL (P < 0.01). During simulated KT1000 test at 30, 60, and 90 degrees of knee flexion, the PL-PL and PL-high AM had significantly lower ATT than the intact ACL (P < 0.01). During simulated KT1000 test at 60 and 90 degrees, the MID-MID, AM-AM, and DB had significantly lower ATT than the ACL deficient knee (P < 0.01). During simulated KT1000 test at 90 degrees, every reconstructed knee had significantly higher ATT than the intact knee (P < 0.01). In conclusion, the MID-MID position provided the best stability among all anatomic SB reconstructions and more closely restored normal knee kinematics.

Evaluation of the tunnel placement in the anatomical double-bundle ACL reconstruction: a cadaver study.

The objective of this study was to investigate the accurate AM and PL tunnel positions in an anatomical double-bundle ACL reconstruction using human cadaver knees with an intact ACL. Fifteen fresh-frozen non-paired adult human knees with a median age of 60 were used. AM and PL bundles were identified by the difference in tension patterns. First, the center of femoral PL and AM bundles were marked with a K-wire and cut from the femoral insertion site. Next, each bundle was divided at the tibial side, and the center of each AM and PL tibial insertion was again marked with a K-wire. Tunnel placement was evaluated using a C-arm radiographic device. For the femoral side assessment, Bernard and Hertel's technique was used. For the tibial side assessment, Staubli's technique was used. After radiographic evaluations, all tibias' soft tissues were removed with a 10% NaOH solution, and tunnel placements were evaluated. In the radiographic evaluation, the center of the femoral AM tunnel was placed at 15% in a shallow-deep direction and at 26% in a high-low direction. The center of the PL bundle was found at 32% in a shallow-deep direction and 52% in a high-low direction. On the tibial side, the center of the AM tunnel was placed at 31% from the anterior edge of the tibia, and the PL tunnel at 50%. The ACL tibial footprint was placed close to the center of the tibia and was oriented sagittally. AM and PL tunnels can be placed in the ACL insertions without any coalition. The native ACL insertion site has morphological variety in both the femoral and tibial sides. This study showed, anatomically and radiologically, the AM and PL tunnel positions in an anatomical ACL reconstruction. We believe that this study will contribute to an accurate tunnel placement during ACL reconstruction surgery and provide reference data for postoperative radiographic evaluation.

Intensity of physiotherapy after anterior cruciate ligament reconstruction: a comparison of two rehabilitation regimen.

BACKGROUND: Rehabilitation is one of the most critical points after anterior cruciate ligament (ACL) reconstruction. However, the recent trend of low-cost, short-term hospitalization makes sufficient rehabilitation after ACL reconstruction difficult. LEVEL OF EVIDENCE III: 34 patients who underwent non-anatomical single bundle ACL reconstruction using a hamstring auto graft were evaluated. Twenty patients (12 males and 8 females) were transferred to a special rehabilitation hospital (RH hospital group) after operation and concentrated rehabilitation was performed up to 4 h per day. Fourteen (9 males and 5 females) patients performed clinic-based rehabilitation at a university hospital three times per week (clinic group). Strength of quadriceps and knee flexion muscles was assessed at 60 degrees /s using a Cybex II dynamometer (Lumex, Ronkonkoma, NY, USA) at 3, 6 and 9 months after ACL reconstruction. Anterior tibial translation (ATT) and pivot shift test were also evaluated. RESULTS: No significant difference in muscle recovery in the lower extremity was observed at any time point after ACL reconstruction between the clinic group and the RH hospital group. However, 3 months after operation, the average muscle strength of the RH hospital group tended to be higher than that of the clinic group. There was no significant difference in ATT or pivot shift (each group included 4 positive pivot shift subjects) in the patients who were tested between the clinic group and the RH hospital group. CONCLUSION: Concentrated rehabilitation at a rehabilitation hospital after ACL reconstruction has the potential to improve muscle strength in the lower extremities more dramatically in the early stages of post operation. However, the initial benefits of intensive physiotherapy disappear after 6 months.

Intercondylar roof impingement pressure after anterior cruciate ligament reconstruction in a porcine model.

Anterior cruciate ligament (ACL) graft impingement against the intercondylar roof has been postulated, but not thoroughly investigated. The roof impingement pressure changes with different tibial and femoral tunnel positions in ACL reconstruction. Anterior tibial translation is also affected by the tunnel positions of ACL reconstruction. The study design included a controlled laboratory study. In 15 pig knees, the impingement pressure between ACL and intercondylar roof was measured using pressure sensitive film before and after ACL single bundle reconstruction. ACL reconstructions were performed in each knee with two different tibial and femoral tunnel position combinations: (1) tibial antero-medial (AM) tunnel to femoral AM tunnel (AM to AM) and (2) tibial postero-lateral (PL) tunnel to femoral High-AM tunnel (PL to High-AM). Anterior tibial translation (ATT) was evaluated after each ACL reconstruction using robotic/universal force-moment sensor testing system. Neither the AM to AM nor the PL to High-AM ACL reconstruction groups showed significant difference when compared with intact ACL in roof impingement pressure. The AM to AM group had a significantly higher failure load than PL to High-AM group. This study showed how different tunnel placements affect the ACL-roof impingement pressure and anterior-posterior laxity in ACL reconstruction. Anatomical ACL reconstruction does not cause roof impingement and it has a biomechanical advantage in ATT when compared with non-anatomical ACL reconstructions in the pig knee. There is no intercondylar roof impingement after anatomical single bundle ACL reconstruction.

The minimum influences for murine normal joint tissue by novel bactericidal treatment and photodynamic therapy using na-pheophorbide a for septic arthritis.

OBJECTIVE: In this study, we examined the effect of photodynamic therapy (PDT) using Na-pheophorbide a (Na-Phde a) on normal joint tissue. BACKGROUND DATA: The treatment of methicillin-resistant Staphylococcus aureus (MRSA) infection is a serious issue. Recently, an experimental in vivo and in vitro model for the inactivation of MRSA by PDT using a photosensitizer, Na-Phde a, has been developed. MATERIALS AND METHODS: The knee joints of mice were injected with 560 or 280 micromol/L of Na-Phde a. Thirty minutes after injection, percutaneous laser irradiation was applied for 5 min using a semiconductor laser (power: 125 mW; wavelength: 664 nm; total energy: 12 J/cm2). The joint perimeter and body weight of the treated mice were monitored, and histological evaluation was also done. RESULTS: Joint swelling was observed up to 3 wk after PDT (p < 0.05). On histology 1 wk post-PDT, the treated knees were found to have inflammatory changes, primarily in synovial tissue. Eight weeks after PDT, the synovitis was no longer present. No significant effects were observed on cartilage, bone marrow, or menisci. CONCLUSIONS: The results of this experiment showed that PDT with Na-Phde a induced arthritis for a short time after treatment. However, this arthritis was reversible, and the PDT did not appear to induce osteoarthritic changes in normal joint tissue. These findings indicate that PDT using Na-Phde a caused minimal but reversible changes in joint tissue, suggesting that it would be a safe and useful treatment for bacterial septic arthritis.

New meniscus repair by an all-inside knot suture technique.

The indications for the all-inside knot suture technique include tears in the red-red zone or red-white zone in the meniscus, and a horizontal tear, a vertical tear, and a peripheral tear. First, find an appropriate place for a suture insertion site with a Kateran needle or a spinal needle. Make sure it exits beyond the tear in the meniscus. Once the insertion site is chosen, a suture is passed into and through the joint. The suture is slowly pulled back. You should be able to feel the tip of the suture come out of the joint capsule. If you want to make a vertical suture to suture the tear, move the suture vertically apex. Then insert the suture back into the joint through the capsule. Make sure the suture stays inside the joint. Find and grab the suture with a punch inserted from the clear cannula. Pull the suture out of the joint through the clear cannula with the punch. Tighten the knot with a knot pusher. Then confirm the stability of the sutured site with the probe. Our all-inside knot suture technique can be performed arthroscopically, allowing reliable repair of the torn meniscus.

Patellar dislocation: arthroscopic patellar stabilization with anchor sutures.

There are many procedures to treat recurrent patellar subluxations and dislocations. Most of these procedures are open repairs for acute conditions or open reconstructions for chronic conditions, and both surgeries need large skin incisions. Although there are many arthroscopic procedures for meniscal and ligament injuries, there are very few arthroscopic procedures described for patellofemoral instability. In this report, we describe a new arthroscopic method to stabilize the patella for acute dislocation. Our technique includes an arthroscopic lateral release and a medial structure repair. We suggest that this procedure is minimally invasive and easier than traditional open procedures. Moreover, this may prevent patients from developing chronic instability of the patellofemoral joint.

Phototoxic effect of na-pheophorbide a toward osteosarcoma cells in vitro using a laser diode.

OBJECTIVE: The purpose of this study was to investigate the effectiveness of photodynamic therapy (PDT) with Na-pheophorbide A in anticancer treatment, using osteosarcoma cells in vitro. BACKGROUND DATA: It has been reported that PDT with chlorophyll derivatives inhibits the proliferation of various cancer cells. However, there have been no reports that have evaluated the effectiveness of PDT in suppressing osteosarcoma cells. MATERIALS AND METHODS: Uptake of Na-pheophorbide A into Hu09 cells (osteosarcoma cells) was assayed using fluorescence microscopy following incubation of the cells with 28 µmol/L of Na-pheophorbide A. The viability of Hu09 cells after PDT treatment was assessed using trypan blue dye staining and MTS assays. PDT-induced apoptosis was determined by evaluation of the activity of selected members of the caspase family and by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining of cells. RESULTS: Na-pheophorbide A uptake by cells was rapid, being observed after 60 min of treatment, and Na-pheophorbide A persisted in cells for >24 h. PDT treatment decreased cell viability compared with the control group, indicating high cytocidal activity of PDT. This cytocidal effect was dependent upon drug concentration, light dose, and the number of irradiation times. An increase in the number of cells positive for TUNEL staining and increases in the activity of caspases-3, -8 and -9 were observed in the first 2 h after PDT treatment. CONCLUSIONS: A cytotoxic effect of PDT with Na-pheophorbide A on an osteosarcoma cell line in vitro was shown. Caspase activity assays suggested that PDT with Na-pheophorbide A induced an apoptotic change in HuO9 cells, mainly via activation of mitochondrial caspase -9 and -3 pathways.

Low level laser therapy for sports injuries.

BACKGROUND AND AIMS: Our hospital has used LLLT in the treatment of athletes since 1990. We had a good result about LLLT for sports injuries. However, few articles have attempted to evaluate the efficacy of LLLT for sports injuries. The aims of this study was to evaluate the efficacy of LLLT for sports injuries. Materials (Subjects) and Methods: Forty one patients underwent LLLT in our hospital. These patients included 22 men and 19 women with an average age of 38.9 years old. Patients were irradiated by diode laser at points of pain and/or acupuncture points. Patients underwent LLLT a maximum treatment of 10 times (mean 4.1 times). We evaluated the efficacy of LLLT using a Pain relief score (PRS). A score of 2 to 5 after treatment was regarded as very good, 6 to 8 as good, and 9 to 10 as poor. A PRS score of less than 5 was regarded as effective. RESULTS: The rate of effectiveness (PRS of 5 or less) after LLLT was 65.9% (27/41 patients). DISCUSSION: In this study, the resulting rate of effectiveness was 65.9% for all sports injuries. However, we have a high rate of effectiveness for Jumper's knee, tennis elbow and Achilles tendinitis and cases that were irradiated laser by a physician. CONCLUSIONS: LLLT is an effective treatment for sports injuries, particularly jumper's knee, tennis elbow and Achilles tendinitis.

Therapeutic effect of photodynamic therapy using Na-pheophorbide a on osteomyelitis models in rats.

OBJECTIVE: In this study, we examined the therapeutic effect of photodynamic therapy (PDT) using the photosensitizer Na-Pheophorbide a (Na-Phde a) on osteomyelitis models in rats. BACKGROUND: Osteomyelitis is one of the most serious infectious problems in the orthopedic field. Recently, as a new clinical approach against septic arthritis, an experimental in vivo and in vitro model for the inactivation of methicillin-resistant-Staphylococcus aureus by PDT using Na-Phde a has been developed. METHODS: Methicillin-sensitive Staphylococcus aureus (MSSA) was injected into the tibia of the rats to create osteomyelitis models (n = 10, 10 legs). A total of 560 µmol/l of Na-Phde a solution was injected into five of these tibial osteomyelitis models (five legs) 48 h after the initial MSSA infection. Sixty minutes after the Na-Phde a injection, a semiconductor laser (125 mW, 670 nm) was used to irradiate the models for 10 min with a total energy of 93.8 J/mm(2). As a control group, five rats (five legs) were treated with a phosphate buffered saline injection at 48 h after MSSA infection. Weight and leg perimeter changes were plotted. Bacterial growth, histological examination and radiological examination were evaluated at 14 days after initial treatment. RESULTS: PDT with Na-Phde a significantly prevented leg swelling. In the PDT group, bone destruction owing to osteomyelitis was inhibited not only histologically but also radiographically. CONCLUSIONS: The results in these experiments show that PDT using Na-Phde a improved osteomyelitis in rats. This suggests that PDT using Na- Phde a can be a useful treatment for osteomyelitis.

In vivo transdermal delivery of diclofenac by ion-exchange iontophoresis with geraniol.

A novel iontophoretic system utilizing ion-exchange membranes is effective for selective transdermal delivery of ionized drugs. In the present study, we examined in vivo availability and safety of ion-exchange iontophoresis in the transdermal delivery of anionic diclofenac, a well known anti-inflammatory medication, to rat dorsal skin. While iontophoresis increased the plasma concentration of diclofenac sodium and skin injury was not observed, no anti-inflammatory effect was exerted. To enhance the efficiency of transdermal delivery of diclofenac sodium, iontophoresis was combined with topical application of one of three terpenes (menthol, nerolidol or geraniol) as chemical enhancers. By combining iontophoresis with geraniol, the plasma concentration of diclofenac sodium increased over 20-fold, and suppression of inflammation was achieved. Skin irritation was not seen even after 1.5 h iontophoresis. The enhancing effect of geraniol is attributed to increased penetration of the drug into the stratum corneum as well as enhanced transport across the anion-exchange membrane. Ion-exchange iontophoresis combined with geraniol is a highly effective transdermal delivery system.

Bactericidal effect of photodynamic therapy using Na-pheophorbide a: evaluation of adequate light source.

OBJECTIVE: To evaluate the efficacy of photodynamic therapy (PDT) against methicillin resistant-Staphylococcus aureus (MRSA) by selecting different light sources for irradiation and combining them with the photosensitizer Na-Pheophorbide a (Na-Phde a). BACKGROUND: The treatment of drug-resistant bacterial infection is a serious issue. Recently, as a new clinical approach against septic arthritis, an experimental in vivo and in vitro model for the inactivation of MRSA by PDT using the photosensitizer Na-Phde a has been developed. MATERIALS AND METHODS: Na-Phde a solution (280 micromol/L) was mixed with MRSA strain bacterial inoculum. After 60 minutes, light was irradiated for 30 minutes using the following light sources: GaA1p semiconductor laser (300 mW, 670 nm), halogen lamp (75 W), xenon lamp (300 W) and fluorescent lamp (27 W). Bacterial growth was evaluated after 24 hours incubation in a blood agar culture. RESULTS: The semiconductor laser and halogen lamp groups showed perfect bactericidal effects after PDT. The xenon lamp and fluorescent lamp groups showed partial bactericidal effects. CONCLUSIONS: The results of this experiment showed that PDT using the combination of Na-Phde a with a semiconductor laser or halogen lamp showed a better bactericidal performance than with xenon or fluorescent lamps. These findings indicated that PDT using Na-Phde a could be a useful treatment for septic arthritis and soft tissue infection.

Discoid lateral menisci in Japanese cadaver knees.

We undertook a descriptive, observational study to determine the prevalence of the discoid lateral menisci. The relation between the lateral meniscal shapes and the incidence of meniscal tears were studied, and the gender differences in discoid lateral menisci and the similarities of the lateral meniscal shapes in bilateral knees were examined. A total of 602 knees from 306 cadavers were macroscopically analyzed. Altogether, 577 lateral menisci were classified into the following three types: normal type (NM); incomplete discoid type (ICDM); and complete discoid type (CDM). Each lateral meniscus was examined for meniscal tears. The prevalence of a discoid lateral meniscus and gender differences in its prevalence were examined, as were the presence of a meniscal tear for the three types of lateral meniscus. In all, there were 21 (3. 6%) CDM cases and 171 ICDM cases (29.6%). The prevalence of discoid lateral meniscus, including ICDM and CDM, in the female cadavers was significantly higher than that in the male cadavers, but there was no significant gender difference in the prevalence of CDM. It was found that the shape of the lateral meniscus was similar bilaterally. The incidence of meniscal tears for ICDM was significantly higher than that for NM.