Cartilage degeneration of patellofemoral joint occurs in open wedge high tibial osteotomy, rather than in hybrid closed wedge high tibial osteotomy, during the early postoperative period: A qualitative analysis using MRI T2 mapping.

PURPOSE: After high tibial osteotomy, the patella may change position and osteoarthritis of the patellofemoral joint (PFJ) may occur. It was hypothesized that the course of PFJ degeneration would differ between open wedge high tibial osteotomy (OWHTO) and hybrid closed wedge high tibial osteotomy (hybrid HTO). Accordingly, this study aimed to evaluate the qualitative changes in PFJ articular cartilage, during the early postoperative period after OWHTO and hybrid HTO. METHODS: This was a retrospective observational study of 75 knees that underwent OWHTO (N = 37) or hybrid HTO (N = 38) for medial knee osteoarthritis. OWHTO and hybrid HTO were indicated for corrections of less than 10° and more than 10°, respectively. MRI of all knees was performed before and 6 months after surgery to evaluate patellar cartilage in sagittal images for T2 mapping. Three regions of interest (medial, middle, and lateral facets) were defined in the articular cartilage, and T2 values were measured. Patellar tilting angle, lateral shift ratio, and patellar height were compared before and after surgery. RESULTS: There was no significant change in arthroscopic findings of PFJ articular cartilage between the OWHTO and hybrid HTO groups. In the OWHTO group, the mean T2 value of medial and middle facets increased significantly (lateral, 43.0 ± 3.9 to 43.7 ± 3.5; middle, 44.2 ± 3.9 to 46.2 ± 3.8; medial 41.0 ± 4.3 to 42.4 ± 4.0). Conversely, no significant change was observed in the hybrid HTO group (lateral, 41.1 ± 4.0 to 42.3 ± 4.0; middle, 43.6 ± 4.2 to 44.5 ± 4.3; medial, 40.7 ± 4.1 to 41.5 ± 4.5). Patellar height decreased and increased in the OWHTO and hybrid HTO groups, respectively, and patellar tilt decreased in the OWHTO group. Lateral shift ratio decreased significantly in both groups. CONCLUSIONS: OWHTO with a small correction angle may result in qualitative changes in PFJ articular cartilage from an early stage, while hybrid HTO with a relatively large correction angle is unlikely to affect PFJ articular cartilage.

Revision Anterior Cruciate Ligament Reconstruction Using Semitendinosus Tendon With Bone Fragment.

After anterior cruciate ligament (ACL) reconstruction, the tibial tunnel becomes widened over time. A revision surgery of the ACL reconstruction is required to fill the widened tunnels. Bone-patellar tendon-bone grafts often are used to fill enlarged bone tunnels. However, due to the variation in tendon length, it is often difficult to adjust the position of the bone fragment to the enlarged part of the bone tunnel. This study describes an arthroscopic ACL reconstruction technique using the semitendinosus tendon as well as a bone fragment which is placed in the enlarged tibial tunnel. The tendon and cortical bone were collected together at the tendon attachment using a flat chisel. The bone fragment was inserted through the tendon in a controlled manner and ultimately placed at the posterior wall of the tibial foramen. This technique was determined to be less invasive than using bone-patellar tendon-bone in a 2-stage revision ACL reconstruction. In addition, this technique can be easily performed by any surgeon who is accustomed to conventional ACL reconstruction using the semitendinosus tendon and does not require any special equipment. Our findings suggest that this technique may be useful for revision ACL reconstruction.

Clinical outcomes after medial patellofemoral ligament reconstruction: an analysis of changes in the patellofemoral joint alignment.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction using the hamstring tendon is widely performed to treat recurrent patellar dislocation. MPFL reconstruction includes a post-operative process of necrosis and reperfusion of the hamstring tendon graft. We hypothesise that the patella gradually shifts laterally because of this process, ultimately affecting the patellofemoral joint alignment. This study aimed to analyse the chronological changes in the patellofemoral joint alignment and the outcomes of MPFL reconstruction. METHODS: In this retrospective case-series study, the Knee Society, Lysholm, and Kujala scores were evaluated in 24 consecutive patients (27 knees). To evaluate patellar tracking defects, radiographic indices including the tilting angle, the lateral shift ratio, and the congruence angle were measured before, immediately after, and three, 12, and 36 months after MPFL reconstruction. RESULTS: Post-operative Kujala, Knee Society, and Lysholm scores for the study population significantly improved relative to the pre-operative scores. The tilting and congruence angles at three months after the operation significantly increased relative to those recorded immediately after the operation. The tilting and congruence angles were not significantly different at three, 12, and 36 months after the operation. CONCLUSIONS: The post-operative outcomes of MPFL reconstruction for recurrent patellar dislocation were favourable. Insufficient union between the bone tunnel and tendon graft, along with an elongation of the necrotic tendon graft, may change the alignment of the patellofemoral joint within three months after the operation. Therefore, we believe it is necessary to refrain from knee rotation that places lateral stress on the patella until three months after the operation.

Arthroscopic Fixation Technique for Avulsion Fracture of the Posterior Cruciate Ligament From the Tibia.

This study describes an arthroscopic pullout fixation technique for small and comminuted avulsion fractures of the posterior cruciate ligament from the tibia. Intra-articular surgery required 3 arthroscopic portals, the anterolateral, anteromedial, and posteromedial portals. To simplify surgery, the posterolateral portal was omitted. A 2.4-mm K-wire was inserted through the anterior incision to the center of the bone fragment. This central guidewire was subsequently overdrilled with a 4.0-mm cannulated drill. The fixation material consisted of Pass Telos artificial ligaments inserted through the fiber loop of a fixed suspensory device such as RIGIDLOOP. The leading end of the thread of the RIGIDLOOP was pulled out through the anteromedial portal. The button of RIGIDLOOP was gradually advanced through the bone tunnel. The button was pulled out and flipped over the bony fragment. The artificial ligament was pulled distally to reduce the bony fragment, and fixed onto the tibia using a ligament button while applying anterior drawer force to the proximal tibia with the knee flexed at 90°. This minimally invasive procedure was successful in treating small and comminuted avulsion fracture of the tibial attachment of the posterior cruciate ligament.

Extensor hallucis longus tendon is a new distal landmark for coronal tibial component alignment in total knee arthroplasty: A study of magnetic resonance imaging.

PURPOSE: In total knee arthroplasty (TKA), various landmarks are generally used to ensure correct osteotomy. In this study, we examined whether the tibialis anterior tendon (TAT) or the extensor hallucis longus tendon (EHLT) could be used as a landmark of the center of the ankle joint in patients with knee osteoarthrosis (OA), using magnetic resonance imaging (MRI). METHODS: The subjects were 61 patients with OA in 79 knees (males: 8 with 9 knees and females: 53 with 70 knees). With the ankle joint secured in the intermediate position, MRI from the knee joint to the ankle joint was performed in the same foot position. We prepared individual lines connecting the center of the ankle joint with the TAT or EHLT to measure the angle difference (ΔA) from Akagi's line in the knee joint. We analyzed whether the ΔA might be affected by deformity of the knee joint or foot region, and tibial torsion. RESULTS: At the ankle joint level, the ΔA of EHLT was the smallest, with an average of 1.6 ± 3.4°. The ΔA for the femorotibial angle, hallux valgus angle, and varus-valgus angle showed no correlations with deformity of the knee joint and foot region, or tibial torsion. CONCLUSIONS: MRI findings showed that EHLT would be useful as a landmark of the ankle joint center in extramedullary tibial osteotomy in TKA for medial knee OA. It was also clarified that the landmark would not be affected by severe deformity of the knee joint, deformity of the foot region, or external torsion of the tibia.

Large deformity correction in medial open-wedge high tibial osteotomy may cause degeneration of patellofemoral cartilage: A retrospective study.

To evaluate retrospectively any association between the degree of deformity correction by medial open-wedge high tibial osteotomy (HTO) and patellofemoral joint degeneration. We hypothesized that development of patellofemoral joint degeneration depended on the degree of intraoperative deformity correction.Fifty-seven patients who underwent medial open-wedge HTO for treatment of osteoarthritis in one knee were included in this study. Knees were classified into degeneration (D) and non-degeneration (ND) groups according to worsening of the patellar and/or femoral trochlear cartilage at the time of hardware removal (D group, 27 knees) and no degeneration or improvement (ND group, 30 knees). We compared pre- to post-surgery change in hip-knee-ankle angle (HKA) and medial-proximal-tibial angle (MPTA), open-wedge HTO correction angle, and arthroscopic findings between groups.Mean age, height, weight, and body mass index were 54.1 ±â€Š9.9 years, 160.4 ±â€Š8.7 cm, 66.4 ±â€Š12.1 kg, and 25.7 ±â€Š3.3 kg/m, respectively. Change in both HKA and MPTA differed significantly between groups. The MPTA cut-off values to predict patellofemoral degeneration were determined to be 10°, associated with an AUC of 0.75 (95% confidence interval [CI] 0.62-0.87).This study evaluated retrospectively the effect of the correction angle during medial open-wedge HTO on patellofemoral joint degeneration. If deformity correction exceeds an MPTA of 10° during open-wedge HTO, degeneration of patellofemoral joint needs to be considered.Level of evidence: Level IV.

All-Inside Meniscus Repair Method for Injury of the Margin of the Anterior Segment of the Meniscus.

Although the outside-in method has been used to treat injuries to the anterior segment of the meniscus, this method has drawbacks including the need to make a skin incision and portals for arthroscopy, pain caused by strangulation of the subcutaneous tissue and joint capsule, and protrusion of the knots. To resolve these problems, we present an all-inside method that enables simple suture of injuries to the anterior segment of the meniscus through arthroscopic portals placed only on the anteromedial and lateral sides without using a specific instrument. This simple, low-cost, low-invasive technique may be useful for suturing marginal injuries to the anterior segment of the meniscus.

Outcome of Low-Invasive Local Split-Thickness Lengthening for Iliotibial Band Friction Syndrome.

Conventional surgical methods for iliotibial band friction syndrome (ITBFS) may affect the iliotibial band (ITB), delaying return to sports activities or impeding performance. We have developed a minimally invasive method. This study retrospectively analyzed the outcomes of this procedure in individuals with ITBFS. This study included 34 knees of 31 individuals. Surgery involved lengthening the central part of the ITB by splitting it into a superficial and a deep layer, maintaining the anterior and posterior fibers immediately above the lateral epicondyle. Outcomes included time to resume sports activity, personal best times to run a 5000-m race before and after surgery, and 2-month post-surgery muscle strengths. The mean postoperative time to return to competition was 5.8 weeks. Personal best times of 5000-m race improved in 13 of 17 runners. Two months post-surgery, the mean extensor muscle strengths on the healthy and affected sides did not significantly differ nor did the flexor muscle strengths. In ITBFS, the ITB itself is normal. Lengthening the limited region of the ITB immediately above the lateral femoral epicondyle removes the cause of ITBFS, with a reduction in inflammation. This technique resulted in early return to competition without degrading performance.

Fixed-flexion view X-ray of the knee superior in detection and follow-up of knee osteoarthritis.

A fixed flexion view (FFV) is useful for evaluating joint space when assessing the severity of osteoarthritis (OA) of the knee. We analyzed changes in joint space revealed by standing extended view (SEV) and FFV over a mean 4 years, to compare both views on their capacity to measure joint space width accurately at particular time points during follow-up.SEV and FFV images were acquired in patients with knee OA. The 81 patients (157 knees) followed up for ≥24 months were selected as study subjects. Medial joint space widths (MJSW), Kellgren-Lawrence (KL) grades, and reductions in MJSW on SEV (ΔSEV) and FFV (ΔFFV) were compared in knees evaluated by SEV and FFV.At both time-points, mean MJSW was significantly lower by FFV than by SEV. Mean MJSW was significantly lower at follow-up than at first examination by both SEV and FFV. At both time-points, the KL grade was higher by FFV than by SEV group. The ΔFFV was significantly greater than the ΔSEV. ΔSEV did not differ significantly among KL grades, but ΔFFV was significantly greater in patients with KL grade II than in patients with other KL grades.FFV is not only useful for evaluating joint space in knees with OA, but also for accurately evaluating the progression of OA. The risk of rapid progression of knee OA may be higher in patients with KL grade II, as determined by FFV. FFV may be superior to SEV in determining appropriate treatment strategies for knee OA.

Radiographic Measurement of Joint Space Width Using the Fixed Flexion View in 1,102 Knees of Japanese Patients with Osteoarthritis in Comparison with the Standing Extended View.

PURPOSE: The fixed flexion view (FFV) of the knee is considered useful for evaluating the joint space when assessing the severity of osteoarthritis (OA) of the knee. To clarify the usefulness of FFV for evaluation of the joint space and severity of knee OA, this study evaluated changes in the joint space on the FFV and standing extended view (SEV) in patients with knee OA. MATERIALS AND METHODS: The SEV and FFV images were acquired in 567 patients (1,102 knees) who visited the hospital with a chief complaint of knee joint pain. Medial joint space width (MJSW) and Kellgren-Lawrence (K-L) classification assessed using the SEV and FFV images were compared. RESULTS: Mean MJSW was significantly smaller when assessed on the FFV than on the SEV (3.02±1.55 mm vs. 4.31±1.30 mm; p<0.001). The K-L grade was the same or higher on the FFV than on the SEV. CONCLUSIONS: The FFV is more useful than the SEV for evaluating the joint space in OA knees. Treatment strategies in patients with knee OA should be determined based on routinely acquired FFV images.

Medial and Lateral Discoid Menisci of Both Knees.

Discoid menisci on both the medial and lateral sides are rare, and there are very few reports on cases involving both sides. We report a case of a 52-year-old female with medial and lateral discoid menisci in both knees. Arthroscopy revealed the lateral menisci of both knees were complete discoid menisci, and partial meniscectomy was performed. The medial menisci were incomplete discoid menisci, but there were no findings of abnormal mobility or injury; therefore, the medial menisci were observed without treatment. At six months postoperatively, her pain and range of motion restrictions disappeared.

Comparative Effects of Periarticular Multimodal Drug Injection and Single-Shot Femoral Nerve Block on Pain Following Total Knee Arthroplasty and Factors Influencing Their Effectiveness.

PURPOSE: This study compared the analgesic effects of local infiltration analgesia (LIA) and femoral nerve block (FNB) after total knee arthroplasty (TKA) and assessed factors associated with analgesia obtained by these two methods. MATERIALS AND METHODS: Study subjects included 66 patients (72 knees) who underwent TKA for osteoarthritis of the knee. Pain visual analogue scale (VAS), the amount of analgesics used, number of days to achieve 90° of flexion of the knee joint, date of initiating parallel-bar walking, range of motion of the knee joint at discharge, and adverse events were investigated. RESULTS: The VAS scores did not differ significantly between two groups, whereas the amount of analgesics used was significantly lower in the LIA group. Preoperative flexion contracture was significantly more severe in the LIA group with high VAS compared with low VAS. No serious adverse event occurred in the LIA or FNB group. CONCLUSIONS: The lower analgesic usage in the LIA group than the FNB group indicates that the analgesic effect of LIA was greater than that of singleshot FNB after TKA. There were no serious complications in either group. The postoperative analgesic effect of LIA was smaller in patients with severe than less severe preoperative flexion contracture.

Arthroscopic Microfracture Technique for Cartilage Damage to the Lateral Condyle of the Tibia.

This report describes the use of arthroscopic microfracture to treat a 10-year-old female patient with extensive damage to the cartilage of the lateral condyle of the tibia before epiphyseal closure, resulting in good cartilage recovery. Magnetic resonance imaging showed a defect in part of the load-bearing surface of the articular cartilage of the condyle articular of the tibia. The patient was diagnosed with damage to the lateral condyle cartilage of the tibia following meniscectomy, and arthroscopic surgery was performed. The cartilage defect measured approximately 20 × 20 mm, and microfracture was performed. Arthroscopy performed four months postoperatively showed that the cartilage defect was completely covered with fibrous cartilage, and the patient was allowed to resume sports activities. Four years postoperatively, she has had no recurrence of pain or hydrarthrosis.

Early postoperative cartilage evaluation by magnetic resonance imaging using T2 mapping after arthroscopic partial medial meniscectomy.

PURPOSE: This study was performed to quantitatively evaluate postoperative changes in cartilage by T2 mapping after arthroscopic partial medial meniscectomy. MATERIAL AND METHODS: The study enrolled 17 patients with 20 knees that underwent arthroscopic partial medial meniscectomy. MRI was performed preoperatively and at six months postoperatively, with subjects evaluated by T2 mapping of the central part of the medial condyle of the femur in the sagittal plane. Regions of interest (ROIs) were set at 10 points between the point of intersection of the anatomical axis of the femur and the articular surface of the medial condyle and posterior area approximately 90 degrees to the anatomical axis. Pre- and postoperative T2 values at each ROI were evaluated. RESULTS: Postoperative T2 values were significantly longer than preoperative values at approximately 20, 30, 40, and 50 degrees to the anatomical axis of the femur. The maximum change between pre- and postoperative T2 values was +6.65% at 30 degrees to the anatomical axis. CONCLUSIONS: Mechanical stress at positions approximately 20, 30, 40, and 50 degrees relative to the anatomical axis of the femur increased soon after arthroscopic medial meniscectomy. These findings indicate the start of degeneration, via disorganization of collagen arrays, of the articular cartilage and increased water content.

Characteristics of medial plica syndrome complicated with cartilage damage.

PURPOSE: This study was designed to evaluate the characteristics of patients with medial plica syndrome and associated cartilage damage. METHODS: The study subjects included 44 patients with 57 knees arthroscopically diagnosed with medial plica syndrome. Subjects were divided into those with severe cartilage damage, defined as International Cartilage Research Society (ICRS) stage 2 or higher, and those with mild cartilage damage, defined as ICRS stage 1 or lower. Local findings, period from onset to surgery, arthroscopic findings, and postoperative results were compared in the two groups. RESULTS: The shapes of the medial synovial plica were types C and D of the Sakakibara classification in the severe group, and types A, B, and C in the mild group. Patellar ballottement tended to be more common in the severe than in the mild group (P = 0.059). The duration from onset to surgery was significantly longer in the severe than in the mild group (29.0 vs. 11.6 months, P = 0.043). Postoperative results were significantly better in the mild than in the severe group (P = 0.0017). CONCLUSIONS: The shape of the medial synovial plica and the duration between symptom onset and surgery were associated with cartilage damage. Surgical treatment should be considered when the medial synovial plica covers part of the anterior aspect of the medial femoral condyle or ruptures, or when pain persists over a long period, thus reducing the potential for cartilage damage. LEVEL OF EVIDENCE: Level IV.

Medial patellofemoral ligament reconstruction procedure using a suspensory femoral fixation system.

Recurrent patellar dislocation has recently been treated with anatomic medial patellofemoral ligament (MPFL) reconstruction using a semitendinosus muscle tendon. Although it is necessary to add tension to fix the tendon graft without loading excess stress on the patellofemoral joint, adjustment of the tension can be difficult. To resolve this problem, we developed an MPFL reconstruction procedure using the ToggleLoc Fixation Device (Biomet, Warsaw, IN), in which the semitendinosus muscle tendon is folded and used as a double-bundle tendon graft and 2 bone tunnels and 1 bone tunnel are made on the patellar and femoral sides, respectively. The patellar side of the tendon graft is fixed with an EndoButton (Smith & Nephew, London, England), and the femoral side is fixed with the ToggleLoc. Stepless adjustment of tension of the tendon graft is possible by reducing the size of the loop of the ToggleLoc hung onto the tendon graft. It may be useful to position the patella in the center of the femoral sulcus by confirming the patellofemoral joint fitting. Stability can be confirmed by loading lateral stress on the patella in the extended knee joint. This procedure is less invasive because opening of the lateral side of the femur is not necessary, and it may be useful for MPFL reconstruction.

Biological activity of 3-formylchromones and related compounds.

Several 3-formylchromone derivatives were examined for their tumor cell-cytotoxic, anti-Helicobacter pylori, urease inhibitory and anti-HIV activity. Comparing their relative cytotoxicity against four human tumor cell lines and three normal human cells, tumor cell-specific cytotoxicity was detected in some 3-formylchromone derivatives. There was no clear-cut relationship between the cytotoxicity and the chemical structures of the compounds. 6,8-Dichloro-3-formylchromone (FC10) showed comparable anti-H. pylori activity with metronidazole and potent urease inhibition against jack bean urease. On the other hand, 6,8-dibromo-3-formylchromone (FC11) exhibited potent inhibitory activity against the urease, but had no anti-H. pylori activity. No chromones (FC1-16) exhibited anti-HIV activity.