Follistatin Mitigates Myofibroblast Differentiation and Collagen Synthesis of Fibroblasts from Scar Tissue around Injured Flexor Tendons.

PURPOSE: The aim of this study was to investigate the effect of FST gene on the inhibition of fibrosis in fibroblastic cells from scar tissue around repaired zone II flexor tendons. MATERIALS AND METHODS: Immunohistochemistry was conducted on fibroblast cells transfected with adenovirus-LacZ (Ad-LacZ) as a marker gene (control), or with adenovirus-FST (Ad-FST) as a therapeutic gene. Fibroblast cultures without adenoviral exposure served as controls. RESULTS: Fibroblastic cells transfected with Ad-FST demonstrated significant decrease in collagen type I, MMP-1, MMP2, and α-SMA mRNA expressions compared to those transfected with Ad-LacZ. In addition, fibroblastic cells transfected with Ad-FST exhibited significant decrease in MMP-1, TIMP-1, fibronectin, PAI-1, TRPV4, α-SMA, desmin, and PAX7 protein expressions. CONCLUSION: Based on these findings, we conclude that FST may be a novel therapeutic strategy for preventing scar adhesions around repaired tendons by inhibiting fibroblasts from differentiating into myofibroblasts, in addition to producing type I collagen and regulating extracellular matrix turnover via the downregulation of MMP-1 and TIMP-1. FST may also decrease contracture of the scar by inhibiting Ca2+-dependent cell contraction.

Ring-shaped lateral meniscus combined with an accessory meniscus: A rare anatomical variant.

A ring-shaped meniscus is a very rare anatomical variant among all meniscal abnormalities. Additionally, an accessory meniscus is extremely rare, and only a few cases have been reported. We herein report a case involving the combination of these two features in a single lateral meniscus. These abnormalities were found during arthroscopic surgery for removal of an osteochondral fragment that had detached from the patellar bone and plication of the medial patellofemoral ligament in a patient with acute patellar dislocation. To our knowledge, each variant is extremely rare and the combination of the two variants has not been reported.

Clinical and Radiological Changes after Microfracture of Knee Chondral Lesions in Middle-Aged Asian Patients.

BACKGROUND: Although microfracture is widely accepted as an effective treatment option for knee chondral lesions, little is known about the deterioration of clinical outcomes and radiological progression in middle-aged patients. Therefore, this study was conducted to evaluate the clinical and radiological changes after microfracture of knee chondral lesions in middle-aged Asian patients. METHODS: A total of 71 patients were included in the study. They were between the ages of 40 and 60 years and underwent arthroscopic microfracture for localized full-thickness cartilage defects of the knee from January 2000 to September 2015. The recovery status of chondral lesions was assessed by using the magnetic resonance observation of cartilage repair tissue (MOCART) score in postoperative magnetic resonance imaging (MRI). Clinical and radiological results were reviewed, and survival rate with conversion to arthroplasty or osteotomy as an end point was evaluated. RESULTS: The mean age of the patients at surgery was 51.3 ± 4.7 years (range, 40 to 60 years), and the mean follow-up period was 7.2 ± 2.6 years (range, 1.0 to 17.4 years). The MOCART scores of 32 patients at mean postoperative 2.1 years showed three cases (9%) of full recovery, two cases (7%) of hyperplastic recovery, 23 cases (70%) with more than 50% filling, and four cases (14%) with less than 50% filling. Clinical scores improved significantly at 1 year after surgery (p < 0.05); however, the scores deteriorated over time after postoperative 1 year, and the mean values reached preoperative levels at postoperative 10 years. Significant radiological progression of arthritis (Kellgren-Lawrence grade) was observed at 5 years after surgery. Four patients underwent total knee arthroplasty during follow-up. CONCLUSIONS: Most patients showed more than 50% of defect filling at 2 years after surgery on MRI. Clinical results of microfracture of knee chondral lesion showed the best improvement at postoperative 1 year but gradually worsened thereafter until postoperative 10 years. Radiological progression of arthritis was observed from 5 years after surgery.

Posterior Horn Repair Augmented With the Central Portion of Thickened Meniscus for Large Posterolateral Corner Loss Type of Discoid Lateral Meniscus.

Large posterolateral corner loss type of discoid lateral meniscus tear is unsalvageable. Therefore, subtotal meniscectomy has been the only treatment option in this case. However, long-term results of subtotal or total meniscectomy have shown a high prevalence of early degenerative changes. Persistent symptoms, such as increased pain, snapping, giving way, locking, and limited extension, can be attributed to progressive loss of posterior tibial meniscal attachment and meniscal degeneration, especially in the posterior horn. The purpose of this technique-based article is to describe a partial repair, posterior horn repair augmented with the central portion of the discoid lateral meniscus that would have been removed if a subtotal meniscectomy were performed and bone marrow stimulation in the intercondylar notch to improve meniscal healing.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft with Remnant Preservation: Comparison of Outcomes According to the Amount of Remnant Tissue.

There has been controversy about whether remnant tissue of anterior cruciate ligament (ACL) has to be preserved in ACL reconstruction. The purpose of the study was to compare clinical outcomes between groups of patients who underwent ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft divided according to amount of ACL remnant and investigate effect of remnant preservation on outcomes of ACL reconstruction. A total of 185 patients who underwent ACL reconstruction with BPTB autograft were retrospectively reviewed. Patients were divided into four groups according to proportion of length of remnant tissue of injured ACL covering part of reconstructed ACL to total length of reconstructed ACL: group A included 83 patients with no remnant, group B consisted of 38 patients with remnant of < 1/3, group C consisted of 35 patients with remnant of 1/3 to2/3, and group D consisted of 29 patients with remnant of > 2/3. Primary outcome was International Knee Documentation Committee (IKDC) subjective score. Secondary outcomes were stability, range of motion, patient-reported outcomes determined by Lysholm knee scoring scale and Tegner activity scale, IKDC objective grade, and single hop for distance. Return to activity and near-return to activity were investigated. A minimum follow-up duration was 24 months. There was no statistically significant difference between four groups regarding postoperative anterior translation (p = 0.731), Lysholm knee score (p = 0.599), IKDC objective grade (p > 0.999), hop test (p = 0.878), and near-return to activity (p = 0.193). However, patients of group D had significantly better outcomes in IKDC subjective score (group A = 85.0 ± 5.9, group B = 84.9 ± 8.1, group C = 87.4 ± 6.4, group D = 89.2 ± 8.1, p = 0.017), Tegner activity scale (group A = 5.0 ± 1.1, group B = 5.2 ± 1.0, group C = 5.7 ± 1.3, group D = 5.9 ± 1.0, p = 0.001), and return to activity (group A = 25.3%, group B = 31.6%, group C = 45.7%, group D = 55.2%, p = 0.014). ACL reconstruction using BPTB autograft with remnant preservation did not provide better anterior stability compared with conventional ACL reconstruction. However, preservation of remnant of > 2/3 led to more improved activity-related clinical outcomes than no remnant preservation. In cases with substantial remnant tissue of injured ACL remaining, reconstruction of ACL while preserving as much remnant tissue as possible is recommended. This is a Level III, retrospective comparative therapeutic study.

Medial Meniscal Root Repair Using Curved Guide and Soft Suture Anchor.

Medial meniscal root tears have been repaired using various methods. Arthroscopic all-inside repair using a suture anchor is one of the popular methods. However, insertion of the suture anchor into the proper position at the posterior root of the medial meniscus is technically difficult. Some methods have been reported to facilitate suture anchor insertion through a high posteromedial portal, a posterior trans-septal portal, or a medial quadriceptal portal. Nevertheless, many surgeons still have difficulty during anchor insertion. We introduce a technical tip for easy suture anchor insertion using a 25° curved guide and a soft suture anchor through a routine posteromedial portal.

Bone-patellar tendon-bone autograft could be recommended as a superior graft to hamstring autograft for ACL reconstruction in patients with generalized joint laxity: 2- and 5-year follow-up study.

PURPOSE: The present study aimed to compare 2- and 5-year outcomes of ACL reconstruction between patients with and without generalized joint laxity and to perform comparative evaluation between two types of grafts used for ACL reconstruction in patients with generalized joint laxity. METHODS: Two hundred and thirty-seven patients who underwent ACL reconstruction from 2001 to 2008 were included. Patients were classified into two groups according to the presence or the absence of generalized joint laxity, and further subdivided into two subgroups based on the type of graft used: bone-patellar tendon-bone (BPTB) or hamstring. Generalized joint laxity was assessed with the Beighton and Horan criteria using a point scoring system. Stability reflected by the Lachman test, pivot-shift test, and anterior translation measured with KT-2000, and functional outcomes reflected by Lysholm knee score, and International Knee Documentation Committee (IKDC) subjective score were investigated. IKDC objective grade and radiographic grade were also assessed. Clinical assessments were conducted preoperatively and at 2 and 5 years after operation. RESULTS: Two-year follow-up results showed that patients with generalized joint laxity receiving hamstring grafts had poorer outcomes than those without generalized joint laxity. Five-year follow-up results showed that patients with generalized joint laxity experienced poorer outcomes than patients without generalized joint laxity, irrespective of the type of graft. Comparison of grafts used showed that, in patients with generalized joint laxity, BPTB graft provided significantly better stability and functional outcomes than hamstring graft at both 2- and 5-year follow-ups. Comparisons between serial outcomes measured at 2 and 5 years demonstrated that stability and functional outcomes deteriorated over time in patients with generalized joint laxity. CONCLUSIONS: Less satisfactory stability and functional outcomes were noted in patients with generalized joint laxity, compared to patients without generalized joint laxity. Comparisons of stability and functional outcomes after ACL reconstruction in patients with generalized joint laxity between two different grafts demonstrated that BPTB graft achieves better results than hamstring graft. LEVEL OF EVIDENCE: III, a retrospective cohort study.

Minimum Two-Year Follow-up of Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity.

BACKGROUND: The purposes of this investigation were to compare outcomes of anterior cruciate ligament (ACL) reconstruction between patients with generalized joint laxity and those without it and to investigate the effect of generalized joint laxity on outcomes of ACL reconstruction from 2 to 8 years postoperatively. METHODS: We retrospectively reviewed 163 patients who had undergone unilateral ACL reconstruction from January 2001 to December 2008. Patients were divided into 2 groups according to presence or absence of generalized joint laxity. The proportions of patients with meniscectomy, graft rupture, and contralateral ACL rupture were compared. Rupture rates were compared with Kaplan-Meier analysis. The Lachman test, pivot-shift test, and anterior translation measured with the KT-2000 arthrometer were evaluated. The Lysholm knee score and International Knee Documentation Committee (IKDC) subjective score were compared. The IKDC objective grade and radiographic grade were also evaluated. Follow-up assessments were performed at 2, 5, and 8 years postoperatively. RESULTS: The proportions of meniscectomy, graft rupture, and contralateral ACL rupture in patients with generalized joint laxity were higher than in patients without generalized joint laxity during the whole evaluation period. However, differences in proportions and cumulative rupture rates did not reach significance (p > 0.05). Patients with generalized joint laxity had less stability and poorer functional outcomes at the 8-year follow-up compared with patients without generalized joint laxity. With regard to the Lachman test and anterior translation, poorer results were shown in patients with generalized joint laxity than in patients without generalized joint laxity during the whole evaluation period. The results of pivot-shift testing differed significantly at 5 years (p = 0.002) and 8 years (p = 0.007). Patients with generalized joint laxity also had worse Lysholm knee scores and IKDC subjective scores during the whole evaluation period; these differences may not be clinically important. Comparisons between serial outcomes measured at 2, 5, and 8-year follow-ups within each patient group showed that anterior translation (p = 0.002), Lysholm knee score (p = 0.014), and IKDC subjective score (p = 0.002) deteriorated over time, although the values at 8 years were similar to those at 5 years, in patients with generalized joint laxity. CONCLUSIONS: Generalized joint laxity as an inherent physiologic characteristic of patients was related to a significant adverse effect on stability and functional outcomes of ACL reconstruction for patients followed for 2 to 8 years. Generalized joint laxity should be considered a risk factor for poor outcomes after ACL reconstruction. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The percutaneous pie-crusting medial release during arthroscopic procedures of the medial meniscus does neither affect valgus laxity nor clinical outcome.

PURPOSE: To analyze the effect of percutaneous pie-crusting medial release on valgus laxity before and after surgery and on clinical outcomes. METHODS: Eight-hundred fourteen consecutive patients who underwent an arthroscopic procedure for the medial compartment of the knee were evaluated retrospectively. Sex, age, type of operation (meniscectomy, meniscal repair, and posterior root repair), type of accompanying surgery (none, cartilage procedure, ligament procedure and osteotomy) were documented. Sixty-four patients who underwent percutaneous pie-crusting medial release (release group) and 64 who did not undergo medial release (non-release group) were matched using the propensity score method. Each patient was evaluated for the following variables: degree of valgus laxity on stress radiographs, Lysholm knee score, visual analog scale score, and International Knee Documentation Committee knee score and grade. RESULTS: At the 24-month follow-up, no significant increase in side-to-side differences in the valgus gap was observed in comparison to the preoperative value in the release group [preoperative, - 0.1 ± 1.3 mm; follow-up, - 0.1 ± 1.4 mm; (n.s.)]. The follow-up Lysholm score, visual analog scale score and International Knee Documentation Committee knee score and grade were similar between the two groups. CONCLUSIONS: Percutaneous pie-crusting medial release is an additional procedure that can be performed during arthroscopic surgery for patients with a narrow medial joint space of the knee. Percutaneous pie-crusting medial release reduces iatrogenic injury to the cartilage and does not produce any residual valgus laxity of the knee. LEVEL OF EVIDENCE: IV.

Influence of knee flexion angle and transverse drill angle on creation of femoral tunnels in double-bundle anterior cruciate ligament reconstruction using the transportal technique: Three-dimensional computed tomography simulation analysis.

BACKGROUND: The purpose of this study was to find appropriate flexion angle and transverse drill angle for optimal femoral tunnels of anteromedial (AM) bundle and posterolateral (PL) bundle in double-bundle ACL reconstruction using transportal technique. METHODS: Thirty three-dimensional knee models were reconstructed. Knee flexion angles were altered from 100° to 130° at intervals of 10°. Maximum transverse drill angle (MTA), MTA minus 10° and 20° were set up. Twelve different tunnels were determined by four flexion angles and three transverse drill angles for each bundle. Tunnel length, wall breakage, inter-tunnel communication and graft-bending angle were assessed. RESULTS: Mean tunnel length of AM bundle was >30mm at 120° and 130° of flexion in all transverse drill angles. Mean tunnel length of PL bundle was >30mm during every condition. There were ≥1 cases of wall breakage except at 120° and 130° of flexion with MTA for AM bundle. There was no case of wall breakage for PL bundle. Considering inter-tunnel gap of >2mm without communication and obtuse graft-bending angle, 120° of flexion and MTA could be recommended as optimal condition for femoral tunnels of AM and PL bundles. CONCLUSION: Flexion angle and transverse drill angle had combined effect on femoral tunnel in double-bundle ACL reconstruction using transportal technique. Achieving flexion angle of 120° and transverse drill angle close to the medial femoral condyle could be recommended as optimal condition for femoral tunnels of AM and PL bundles to avoid insufficient tunnel length, wall breakage, inter-tunnel communication and acute graft-bending angle.

Relationship Between Preoperative Extrusion of the Medial Meniscus and Surgical Outcomes After Partial Meniscectomy.

BACKGROUND: No previous study has examined arthritic change after meniscectomy with regard to extrusion of the medial meniscus. PURPOSE: (1) To determine the factors related to preoperative meniscal extrusion; (2) to investigate the relationship between medial meniscal extrusion and postoperative outcomes of partial meniscectomy, and to identify a cutoff point of meniscal extrusion that contributes to arthritic change after partial meniscectomy in nonosteoarthritic knees. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 208 patients who underwent partial meniscectomy of the medial meniscus between January 2000 and September 2006 were retrospectively reviewed. The extent of extrusion and severity of degeneration of the medial meniscus as shown on preoperative MRI were evaluated. The minimum follow-up duration was 7 years. Clinical function was assessed with the Lysholm knee scoring scale, the International Knee Documentation Committee (IKDC) subjective knee evaluation form, and the Tapper and Hoover grading system. Radiological evaluation was conducted by use of the IKDC radiographic assessment scale. Regression analysis was performed to identify factors affecting preoperative extrusion of the medial meniscus and factors influencing follow-up results after partial meniscectomy. Receiver operating characteristic curve was used to identify a cutoff point for the extent of meniscal extrusion that was associated with arthritic change. RESULTS: The mean ± SD preoperative Lysholm knee score was 65.0 ± 6.3 and the mean IKDC subjective score was 60.1 ± 7.5. The mean follow-up functional scores were 93.2 ± 5.1 ( P < .001) for the Lysholm knee score and 89.0 ± 6.2 for the IKDC subjective score ( P < .001). Preoperative extent of meniscal degeneration ( P < .001) and preoperative pattern of meniscal tear ( P < .001) were related to preoperative meniscal extrusion. Preoperative extrusion of the meniscus showed a tendency to increase as the extent of intrameniscal degeneration increased, and the medial meniscus was extruded more in patients with horizontal, horizontal flap, and complex tears. The preoperative extent of meniscal extrusion had a statistically significant correlation with follow-up Lysholm knee score (coefficient = -0.10, P = .002), IKDC subjective score (coefficient = -0.09, P = .007), Tapper and Hoover grade (odds ratio = 1.05, P < .001), and IKDC radiographic grade (odds ratio = 1.13, P < .001) at the mean follow-up period of 88.6 months. The cutoff point for the relative value of preoperative meniscal extrusion associated with arthritic change was 34.6% (sensitivity = 69.3%; specificity = 82.7%; accuracy = 77.9%). CONCLUSION: The preoperative extent of intrameniscal degeneration and the preoperative patterns of meniscal tear including horizontal, horizontal flap, and complex tears were associated with preoperative extrusion of the medial meniscus. The preoperative extrusion of the medial meniscus was negatively correlated with outcomes of partial meniscectomy. The preoperative extent of meniscal extrusion can be used as a predictive factor for osteoarthritis in partial meniscectomy.

The Results of Proximal Femoral Nail for Intertrochanteric Fracture in Hemodialysis Patient.

PURPOSE: Hip fractures in hemodialysis patients are accompanied by high rates of complications and morbidities. Previous studies have mainly reported on nonunion and avascular necrosis of femoral neck fractures in this patient group. In this study the complication and clinical results of hemodialysis patients with intertrochanteric fractures treated with proximal femoral intramedullary nailing have been investigated through comparison with patients with normal kidney function. MATERIALS AND METHODS: Forty-seven patients were included; the hemodialysis group (n=17) and the control group with normal kidney function (n=30). The medical history and clinical findings including preoperative and postoperative blood examinations, radiological examinations and ambulatory status (measured using the Koval score). The rate of complications and morbidities were also investigated and compared. RESULTS: Preoperative hemoglobin/hematocrit was lower but a significant increase in partial thromboplastin time was observed in the hemodialysis group. The amount of bleeding/transfusions were higher and operative time was longer in the hemodialysis group. Upon radiologic examination, there was no significant difference in rate of unstable fracture and nonunion between the two groups. However the postoperative Koval score was significantly worse and the odds ratio of inability to walk after surgery was 13.5 times higher in the hemodialysis group. CONCLUSION: There was no significant difference in radiological results, but the risk of inability to walk after surgery was 13.5 times higher in the hemodialysis group. Hemodialysis patients have more morbidities and are hemodynamically unstable therefore require special attention. Accurate reduction and firm fixation is required and attentive postoperative rehabilitation is needed.

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning.

BACKGROUND: To evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position. METHODS: Sixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5° (± 14.9°), average intraoperative lordosis was 48.8° (± 13.2°), average postoperative lordosis was 46.5° (± 16.1°) and the average change on the frame was 5.3° (± 10.6°). RESULTS: Among all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033). CONCLUSIONS: Intraoperative lumbar lordosis on the OSI frame with a prone position was larger in the SS patients than the spondylolisthesis patients, which also produced a larger postoperative lordosis angle after posterior spinal fusion surgery. An increase in lumbar lordosis on the OSI frame should be considered during posterior spinal fusion surgery, especially in spondylolisthesis patients.

The Use of T1 Sagittal Angle in Predicting Cervical Disc Degeneration.

STUDY DESIGN: Retrospective evaluation. PURPOSE: To analyze the effect of T1 slope on degree of degeneration in patients with cervical disc degeneration. OVERVIEW OF LITERATURE: The T1 slope is well known parameter that may be very useful in evaluating sagittal balance. There are no reports on the analysis of the relationship between T1 slope and cervical disc degeneration. We hypothesized that T1 slope has an effect on the degree of cervical degeneration. METHODS: Sixty patients who had cervical spine magnetic resonance imaging (MRI) in our orthopedic clinic were enrolled. Patients were divided into two groups according to T1 slope. Radiologic parameters obtained from radiography and cervical spine MRI were compared between low T1 slope group (≤25) and high T1 slope group (>25). RESULTS: Among low T1 slope group, average degeneration grade of each cervical segment was 2.65 in C2-3, 2.50 in C3-4, 2.62 in C4-5, 3.23 in C5-6, and 2.81 in C6-7. And that of high T1 group was 2.35 in C2-3, 2.32 in C3-4, 2.59 in C4-5, 2.79 in C5-6, and 2.32 in C6-7. Grade of degeneration of low T1 group was significantly higher, as compared with high T1 group in C5-6 (p=0.028) and C6-7 (p=0.009). Percentage of high grade degeneration of more than grand III was 65.4% in low T1 group and 32.4% in high T1 group (p=0.018). Risk of high grade degeneration of C6-7 was significantly higher in low T1 group (odds ratio, 5.63; 95% confidence interval, 1.665-19.057; p=0.005). CONCLUSIONS: Patients with low T1 slope had higher grade of degeneration regardless of age and gender. Low T1 slope is a potential risk factor of cervical spondylosis especially in the C6-7 cervical segment.

Does decreased meniscal thickness affect surgical outcomes after medial meniscectomy?

BACKGROUND: There have been no clinical studies regarding the effect of decreased meniscal thickness on outcomes after meniscectomy. PURPOSE: To examine the postoperative outcomes of partial meniscectomy with or without horizontal resection compared with the outcomes of subtotal meniscectomy and to evaluate the influence of decreased thickness of the medial meniscus on outcomes after partial meniscectomy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 312 patients who underwent medial meniscectomy were retrospectively reviewed. Patients were divided into 3 groups: group A (n = 84) included patients with partial meniscectomy with vertical resection, group B (n = 140) consisted of those with partial meniscectomy with horizontal resection, and group C (n = 88) included those with subtotal meniscectomy. Clinical function was evaluated by use of the Lysholm knee scoring scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, and Tapper and Hoover grading system. Radiologic evaluation was performed with the IKDC radiographic assessment scale as well as with measurements of the medial compartment height at the tibiofemoral joint. Preoperative values and postoperative values measured 5 years after operation were assessed. RESULTS: Functional outcomes in group C were inferior to those in groups A and B according to the Lysholm knee score (mean ± SD for group A = 96.1 ± 4.7, group B = 94.9 ± 5.2, group C = 84.8 ± 11.4; P < .001), IKDC subjective score (group A = 92.1 ± 6.5, group B = 91.3 ± 8.8, group C = 81 ± 11.4; P < .001), and Tapper and Hoover grading system (P = .003). There was no significant difference in scores between groups A and B. With regard to radiologic evaluation, the IKDC radiographic grade for group C was worse than the grades for groups A and B (P < .001); there was no significant difference between groups A and B. However, the postoperative joint space on the affected side was higher for group A (4.7 ± 0.6 mm) than for groups B (4.3 ± 0.5 mm; P < .001) and C (3.7 ± 0.8 mm; P < .001). The joint space was higher in group B than in group C (P < .001). CONCLUSION: Despite joint space narrowing, decreases in meniscal thickness after partial meniscectomy for horizontal tear had no additional adverse effect on 5-year functional and radiographic outcomes compared with conventional partial meniscectomy preserving whole meniscal thickness. In treating horizontal tears of the meniscus, partial meniscectomy with complete resection of the unstable leaf was an effective method in a 5-year follow-up study.

Effect of Cigarette Smoking on the Clinical Outcomes of ACL Reconstruction.

BACKGROUND: We compared the clinical outcomes of nonsmokers, current smokers, and former smokers following reconstruction of the anterior cruciate ligament (ACL) and investigated the association between the amount of smoking and outcomes following ACL reconstruction. METHODS: We retrospectively reviewed the records of 251 patients who underwent unilateral ACL reconstruction with use of bone-patellar tendon-bone autograft between January 2002 and August 2009. Patients were divided into three groups according to smoking history: Group 1, nonsmokers; Group 2, current smokers; and Group 3, former smokers. Preoperative values and twenty-four-month postoperative findings were compared among the groups. The stability of the ACL was evaluated with use of the Lachman test and the pivot-shift test, and anterior translation was tested with a KT2000 arthrometer. Functional outcomes were assessed on the basis of the Lysholm score and the International Knee Documentation Committee (IKDC) subjective score and objective grade. RESULTS: The three groups differed significantly in terms of postoperative knee translation, Lysholm score, and IKDC subjective score. The mean side-to-side difference in anterior translation (and standard deviation) was 2.08 ± 1.08 mm in Group 1 (nonsmokers), 2.65 ± 1.31 mm in Group 2 (smokers), and 2.15 ± 1.05 mm in Group 3 (former smokers) (p = 0.003). The mean Lysholm score was 90.5 ± 6.5 in Group 1, 86.0 ± 7.1 in Group 2, and 89.8 ± 6.3 in Group 3 (p < 0.001). The mean IKDC subjective score was 89.3 ± 5.1 in Group 1, 84.9 ± 7.5 in Group 2, and 88.5 ± 4.2 in Group 3 (p < 0.001). However, the difference in the IKDC subjective score among the three groups did not demonstrate a minimal clinically important difference. A dose-dependent association was noted between pack-years of exposure and postoperative anterior translation (estimate, 0.039; p = 0.015) and IKDC objective grade (odds ratio, 1.083; p = 0.002). A comparison of the three subgroups of smokers showed a significant difference in anterior translation (a mean side-to-side difference in anterior translation of 2.31 ± 1.17 mm for the light smokers, 2.60 ± 1.14 mm for the moderate smokers, and 3.29 ± 1.55 mm for the heavy smokers; p = 0.038). The three subgroups also differed significantly in terms of the proportion of cases by IKDC objective grade; among the light smokers, thirteen (42%) were grade A, fifteen (48%) were grade B, two (7%) were grade C, and one (3%) was grade D; among the moderate smokers, seven (35%) were grade A, eight (40%) were grade B, four (20%) were grade C, and one (5%) was grade D; and among the heavy smokers, one (6%) was grade A, eight (44%) were grade B, eight (44%) were grade C, and one (6%) was grade D (p = 0.013). CONCLUSIONS: Cigarette smoking appeared to have a negative effect on subjective and objective outcomes of ACL reconstruction, and heavy smokers showed greater knee instability. Patients who had stopped smoking at least one month prior to ACL reconstruction had no significant difference in outcomes compared with patients who had never smoked. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does anterior laxity of the uninjured knee influence clinical outcomes of ACL reconstruction?

BACKGROUND: The purpose of this study was to evaluate the association between the postoperative outcomes of anterior cruciate ligament (ACL) reconstruction and the anterior laxity of the uninjured knee. METHODS: We retrospectively reviewed 163 patients who had undergone unilateral ACL reconstruction from January 2002 to August 2009. Patients were divided into three groups according to the anterior laxity of the contralateral, normal knee in 30° of knee flexion as measured with a KT2000 arthrometer exerting a force of 134 N: <5 mm for Group 1, 5 to 7.5 mm for Group 2, and >7.5 mm for Group 3. Anterior laxity of the uninjured knee was assessed preoperatively, and anterior laxity of the reconstructed knee was assessed at twenty-four months postoperatively. Anterior stability of the knee was also assessed with use of the Lachman and pivot-shift tests. Functional outcomes were assessed with the Lysholm score and the International Knee Documentation Committee (IKDC) score. RESULTS: The three groups differed significantly with respect to the postoperative side-to-side difference in anterior laxity (p = 0.015), Lysholm score (p < 0.001), and IKDC subjective score (p < 0.001). The mean side-to-side difference in anterior laxity of the reconstructed knee was 2.1 ± 1.3 mm in Group 1, 2.2 ± 1.3 mm in Group 2, and 2.9 ± 1.4 mm in Group 3. The postoperative Lysholm score was 91.8 ± 4.5 in Group 1, 90.3 ± 5.5 in Group 2, and 85.4 ± 6.6 in Group 3. The postoperative IKDC subjective score was 89.3 ± 6.4 in Group 1, 87.9 ± 6.0 in Group 2, and 82.6 ± 8.2 in Group 3. Post hoc testing showed that Group 3 had significantly greater anterior laxity (p ≤ 0.039) and lower functional scores (p ≤ 0.001) compared with Groups 1 and 2. CONCLUSIONS: Greater anterior laxity of the uninjured knee was associated with poorer stability and functional outcomes after ACL reconstruction. Excessive anterior laxity of the uninjured knee thus appears to represent a risk factor for inferior outcomes.

Graft selection in anterior cruciate ligament reconstruction for smoking patients.

BACKGROUND: There has been no previous study regarding graft selection in anterior cruciate ligament (ACL) reconstruction for smoking patients. PURPOSE: To compare the clinical outcomes of ACL reconstruction between smokers and nonsmokers and to find an optimal graft in ACL reconstruction with regard to clinical outcomes for smoking patients. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 487 patients who underwent unilateral ACL reconstruction were retrospectively reviewed. Included patients were divided into 2 groups according to their history of smoking. Group 1 was composed of patients who had never smoked (n = 322), and group 2 consisted of patients who had reported smoking before ACL reconstruction and during rehabilitation (n = 165). Additionally, each group was divided into 4 subgroups according to the selected graft type (bone-patellar tendon-bone autograft, hamstring [semitendinosus-gracilis] tendon autograft, quadriceps tendon-bone autograft, or Achilles tendon-bone allograft). Patients were assessed for knee instability with the Lachman and pivot-shift tests as well as anterior translation measured by the KT-2000 arthrometer. Functional outcomes were evaluated with the Lysholm knee score, International Knee Documentation Committee (IKDC) subjective score, and IKDC objective grade. RESULTS: The minimum follow-up period was 24 months. At the final follow-up evaluation, there were significant mean between-group differences regarding the side-to-side difference in anterior translation (group 1, 2.15 ± 1.11 mm; group 2, 2.88 ± 1.38 mm; P < .001), Lysholm knee score (group 1, 90.25 ± 6.18; group 2, 84.79 ± 6.67; P < .001), IKDC subjective score (group 1, 89.16 ± 5.01; group 2, 83.60 ± 7.48; P < .001), and IKDC objective grade (group 1, grade A = 151, B = 130, C = 36, D = 5 patients; group 2, grade A = 48, B = 71, C = 37, D = 9 patients; P < .001). With regard to differences in outcomes between the selected grafts within each group, the Achilles tendon-bone allograft showed the worst outcomes, with statistically significant mean differences for smoking patients in the side-to-side difference in anterior translation (3.59 ± 1.26 mm), Lysholm knee score (81.05 ± 2.82), and IKDC subjective score (79.73 ± 4.29). CONCLUSION: Unsatisfactory outcomes with regard to stability and functional scores were shown in the smoking group compared with the nonsmoking group. In smokers, the patients receiving an Achilles tendon-bone allograft had poorer outcomes than those with autografts. The bone-patellar tendon-bone autograft is recommendable for ACL reconstruction in a smoking patient.

Quality of Life Comparison between Vertebroplasty and Kyphoplasty in Patients with Osteoporotic Vertebral Fractures.

STUDY DESIGN: Retrospective evaluation. PURPOSE: To compare quality of life in postmenopausal women with osteoporotic vertebral fractures (OVFs) who underwent vertebroplasty (VP) or kyphoplasty (KP). OVERVIEW OF LITERATURE: Patient with OVFs who do not respond to conservative treatment can be treated with VP or ballon KP for faster pain relief. There are controversies on which procedure is more effective. METHODS: Five hundred twenty-eight postmenopausal women in nationwide hospitals with age of 50 years or older who underwent VP of KP for OVFs were enrolled in this study. Health related quality of life was measured using the European Quality of Life 5 Domains (EQ-5D) and visual analogue scale (VAS). RESULTS: In the VP group, average EQ-5D dimension was 1.95 in mobility, 1.86 in self care, 2.02 in usual activity, 2.19 in pain, 1.69 in anxiety or depression. In the KP group, average EQ-5D dimension was 1.83 in mobility, 1.78 in self care, 1.98 in usual activity, 2.03 in pain, 1.55 in anxiety or depression. Quality of life of KP group was significantly better than that of the VP group in mobility (p=0.016), pain (p=0.001), and anxiety or depression (p=0.008). Average EQ-5D index of the VP and the KP group was 0.353 (±0.472) and 0.485 (±0.357), respectively. The EQ-5D index of the KP group was significantly (p<0.001) higher than that of the KP group. The difference of VAS between VP and KP group was not statistically significant (p=0.580). CONCLUSIONS: Quality of life in patient with OVFs who underwent KP was significantly better than that of patients who underwent VP.

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity.

BACKGROUND: Few studies of large-to-massive contracted rotator cuff tears have examined the arthroscopic complete repair obtained by a posterior interval slide and whether the clinical outcomes or structural integrity achieved are better than those after partial repair without the posterior interval slide. METHOD: The study included forty-one patients with large-to-massive contracted rotator cuff tears, not amenable to complete repair with margin convergence alone. The patients underwent either arthroscopic complete repair with a posterior interval slide and side-to-side repair of the interval slide edge (twenty-two patients; Group P) or partial repair with margin convergence (nineteen patients; Group M). The patient assignment was not randomized. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and range of motion were used to compare the functional outcomes. Preoperative and six-month postoperative magnetic resonance arthrography (MRA) images were compared within or between groups. RESULTS: At the two-year follow-up evaluation, the SST, ASES score, UCLA score, and range of motion had significantly improved (p < 0.001 for all) in both groups. However, no significant differences were detected between groups. Even though the difference in preoperative tear size on MRA images was not significant, follow-up MRA images identified a retear in twenty patients (91%) in Group P and a significant difference in tear size between groups (p = 0.007). CONCLUSIONS: The complete repair group with an aggressive release had no better clinical or structural outcomes compared with the partial repair group with margin convergence alone for large-to-massive contracted rotator cuff tears. In addition, the complete repair group had a 91% retear rate and a greater defect on follow-up MRA images. Even though this study had a relatively short-term follow-up, a complete repair of large-to-massive contracted rotator cuff tears, with an aggressive release such as posterior interval slide, may not have an increased benefit compared with partial repair without posterior interval slide.