Material Properties of Suture Augmentation of Knee Medial Collateral Ligament Repair Did Not Influence Length Changes or Failure Loads in a Caged Porcine Model.

Purpose: To investigate whether the biomechanical properties of the healed superficial medial collateral ligament (sMCL) repaired by augmentation vary depending on the material properties of the suture augmentation. Methods: In 8 of 10 porcines (16 hindlimbs), the sMCL was detached from the femoral attachment using a scalpel under intubated general anesthesia. sMCL repair was performed using an ultra-high-molecular-weight polyethylene (UHMWPE) tape for the right hindlimbs and polyester tape (PE) for the left hindlimbs. They were sacrificed at 4 weeks postoperatively. The remaining 2 animals were assigned to the native control group (left and right hindlimb; n = 4). All connective tissues and suture augmentation, except for the repaired sMCL, were removed, and their biomechanical properties were evaluated. Results: No significant differences were observed in the upper yield load (PE group, 247.4 ± 116.0 N; UHMWPE group, 279.9 ± 95.7 N; and sham group, 231.6 ± 50.6 N; P = .70), maximum yield load (PE group, 310.1 ± 166.1 N; UHMWPE group, 334.6 ± 95.2 N; and sham group, 290.9 ± 42.3 N; P = .84), linear stiffness (PE group, 43.3 ± 16.5 N/mm; UHMWPE group, 52.0 ± 28.2 N/mm; and sham group, 44.7 ± 7.2 N/mm; P = .66), and elongation at failure (PE group, 9.4 ± 4.3 mm; UHMWPE group, 9.1 ± 2.7 mm; and sham group, 10.1 ± 2.1 mm; P = .89). Statistical analysis of failure modes showed no significant difference between the groups (P = .21). Conclusions: The material properties of suture augmentation used for sMCL repair did not significantly influence length changes during cyclic loading, postoperative structural properties, or failure modes. Clinical Relevance: The results of this study provide valuable information regarding the efficacy of suture augmentation repair regardless of the materials used.

Development of the Protocol to Deliver Graded Stimulation Intensity on Lower Limbs Using Belt-shaped Electrode Skeletal Muscle Stimulation.

OBJECTIVES: Current advancements in neuromuscular electrical stimulation (NMES) include belt-shaped electrode skeletal muscle electrical stimulation (B-SES), which was developed to induce whole leg muscle contraction in a single session. Delivering the optimal amount of stimulation is critical in NMES; therefore, we set out to establish a method to determine the B-SES stimulation intensity needed to induce muscle contraction sufficient for clinical purposes. METHODS: We used the Auto Tens Pro system (Homer Ion Laboratory), which is a B-SES device. Stimulation at 20 Hz was delivered for 5 s, followed by 2 s rest. Twenty-four patients who were hospitalized for musculoskeletal diseases were enrolled at two hospitals. Patients were randomly assigned to one of three groups of subjectively graded stimulation intensities: moderate, strong, or very strong. To achieve each target intensity, we developed a structured verbal instruction protocol that aimed to help therapists deliver the target level of stimulation. As a physiological assessment of muscle contraction, serum lactate levels were measured before and after a single 20-min B-SES session. RESULTS: The electric current intensity required to achieve a target subjective muscle contraction gradually increase according to the subjective contraction level. The increase in serum lactate level was significantly larger in the very strong group than in the moderate group. CONCLUSIONS: B-SES stimulators have the potential to induce efficient muscle strengthening in patients with musculoskeletal diseases. The structured verbal protocol developed here could help therapists achieve the appropriate stimulation intensity for each patient.

New method for acquiring the expected extension gap in total knee arthroplasty.

PURPOSE: Adjusting the soft-tissue balance during surgery is crucial in total knee arthroplasty (TKA). However, even using the gap technique, the expected tibial gap is sometimes not achievable. We developed a new method of proximal tibial cutting to acquire the expected tibial gap and insert a tibial liner of appropriate thickness. METHODS: This study included 128 patients who underwent medial pivot-type TKA for varus knee osteoarthrosis. After completion of the femoral cut using and removal of the bony spur at the medial tibia according to the preoperative plan, we inserted a trial femoral component to the distal femur. Applying valgus manual stress on the knee in extension, we measured the medial gap between the femoral trial and tibial plateau using calipers, defining this medial gap as "pre-gap". A proximal tibial cut was made referring to the pre-gap in the pre-gap group (n = 64). We defined Δgap as the difference between the expected tibial liner thickness and the final tibial liner thickness during surgery. We compared Δgap between the pre-gap group and a control group with conventional tibial cutting without pre-gap measurement (n = 64). RESULTS: The frequency of an ideal tibial cut (Δgap = 0) was 82% in the pre-gap group and 61% in the control group. The frequency of outliers (Δgap ≥ 2 mm) was 4% and 18%, respectively. The expected tibial liner was selected more frequently in the pre-gap group than in the control group. CONCLUSIONS: Our method was beneficial for acquiring the expected gap in extension to avoid an inadequate gap. LEVEL OF EVIDENCE III: Case-control study.

Recurrent Intrathoracic Locking of the Scapula after Lung Cancer Resection and Combined Rib Resection.

We report a case of recurrent locking of the scapula in the thorax after combined lobectomy and thoracic wall resection for advanced lung cancer. The patient was a 52-year-old man with advanced spindle cell carcinoma in his right lung. He had undergone right lung lobectomy and thoracic wall excision (Th1-5). Intrathoracic repair had not been performed to address the defect in the thoracic wall. Two months after the operation he experienced sudden acute pain in the right shoulder. Three-dimensional computed tomography revealed locking of the scapula intrathoracically. The diagnosis was recurrent locking of the scapula in the thorax. He underwent conservative treatment. Because his symptoms were not alleviated and he continued to experience recurrent locking, we performed partial resection of the inferior part of the scapula. Although scapular locking diminished after this procedure, there were still some pain and "catching" between the scapula and the thoracic wall (T6) when he undertook certain movements. No further surgery could be performed, however, because the cancer from the primary lesion had recurred near the previously operated thoracic wall. A procedure for recurrent intrathoracic locking of the scapula was not successful in this case.

Painful Knee is not Uncommon after total Knee Arthroplasty and can be Treated by Arthroscopic Debridement.

BACKGROUND: After total knee arthroplasty (TKA), most patients have an improvement; however, a few continue to have residual pain. We reported a case series of painful knee after TKA with unreported reason. MATERIAL AND METHODS: Forty-six arthroscopic surgeries were performed for painful knee after TKA. Of these, 16 were excluded due to infection, patellar clunk syndrome, patellofemoral synovial hyperplasia, aseptic loosening, or short follow up less than 6 months. Remaining 30 cases had marked tenderness at the medial and/or lateral tibiofemoral joint space, and they had pain during walking with pain or without pain at rest. The mean period from initial TKA to arthroscopy was 29 months, and the mean follow-up after arthroscopy was 36 months. All arthroscopic debridement was performed through 3 portals. Scar tissue impingements graded moderate or severe were found only in 30% of the cases in both the medial and lateral tibiofemoral joint spaces. The infrapatellar fat pad was covered with whitish scar tissue in all cases, and the tissue was connected with the scar tissue at the medial or lateral tibiofemoral joint spaces. All scar tissue was removed with a motorized shaver or punches. RESULTS: At the final follow-up, 63% were pain free, 3% had marked improvement, 20% had half improvement, 3% had slight improvement, and 11% had no change. We hypothesized that the lesser mobility of the scar tissue due to the continuity of the tissue between the infrapatellar fat pad and the tibiofemoral joint space could cause easy impingement at the tibiofemoral joint, even with the small volume of scar tissue. CONCLUSION: If infection and aseptic loosening could be ruled out in a painful knee after TKA, arthroscopic debridement appeared to be a good option to resolve the pain.

Arthroscopic fixation with EndoButton for tibial eminence fractures visualised through a proximal superomedial portal: a surgical technique.

Most tibial eminence fractures are avulsion fractures of the anterior cruciate ligament (ACL) from its tibial insertion. This study describes a new arthroscopic technique using an additional proximal superomedial portal to visualise the tibial eminence fracture and to fix the fracture with the EndoButton to avoid the risk of fragment breakage. The proximal superomedial portal enables fracture reduction without damage to the intermeniscal ligament. Fixation with the EndoButton is strong enough to allow early rehabilitation with vigorous exercise. All 5 patients achieved bone union; no young patient had growth disturbance of the tibia; all knees were stable with excellent range of motion and negative Lachman and pivot shift tests and no flexion contracture. Arthroscopic fixation with the EndoButton visualised through the proximal superomedial portal is a safe, simple, and secure method for treating tibial eminence fractures, particularly in children with small fragments.

Accuracy of a proximal tibial cutting method using the anterior tibial border in TKA.

PURPOSE: In conventional total knee arthroplasty (TKA) using extramedullary alignment guides, it is not always easy to cut the proximal tibia precisely perpendicular to the tibial axis. The purpose of this study was to compare the radiographic accuracy of cutting the proximal tibia between the use of the bony landmarks of the anterior tibial border and the use of the conventional technique. METHODS: A total of 173 patients underwent primary TKA. In 76 TKAs, we used the bony landmark method, and in 97 TKAs, we used the conventional method. In the bony landmark method, we set the coronal alignment in reference to the line connecting the proximal and distal one-third of the anterior tibial border, and we determined the 5° posterior slope in reference to this line. Six months postoperatively, radiological evaluations were performed using full-length standing anteroposterior and lateral radiographs of the knee. RESULTS: No significant differences in the coronal tibial component angle were found between the groups. The posterior tilt of the tibial component was significantly smaller in the bony landmark method than in the conventional method (5.1° ± 2.9° vs. 6.4° ± 3.2°, respectively; p = 0.007). The percentage of patients whose posterior tilt of the tibial component was within ±3° of 5° was significantly larger in the bony landmark method than in the conventional method (70 vs. 62%, respectively; p = 0.04). CONCLUSIONS: The bony landmark method provided a more accurate posterior tibial slope than the conventional method. However, there was no difference in coronal alignment compared with the conventional method.

Changes in blood coagulation-fibrinolysis markers by pneumatic tourniquet during total knee joint arthroplasty with venous thromboembolism.

This study investigated changes in blood coagulation-fibrinolysis markers during total knee arthroplasty (TKA). Preoperative 16-row multidetector row computed tomography (MDCT) revealed no asymptomatic venous thromboembolism (VTE) in the 42 patients recruited. Using MDCT postoperatively, patients were divided into thrombus (asymptomatic VTE, 19 patients) and no-thrombus (23 patients) groups. Blood taken at intervals before and after pneumatic tourniquet release revealed increased plasminogen activator inhibitor type-1 (PAI-1) at 30s for both groups and at 90s (both P=0.01) in the thrombus group. D-dimer levels were highest at 30 and 90s for both groups (P = 0.01). PAI-1 and D-dimer levels were strongly correlated at both time points in the thrombus group. Inactivating fibrinolysis due to PAI-1 may lead to asymptomatic VTE after TKA.

Lateral approach is advantageous in total knee arthroplasty for valgus deformed knee.

INTRODUCTION: For the total knee arthroplasty in valgus deformed knee, superiority of the medial or lateral approach is still controversial. We compared the short-term result of two approach groups. MATERIALS AND METHODS: Forty-seven knees in rheumatoid arthritis with valgus deformity from 6° to 24° were randomly divided into two group; medial approach (24 knees) and lateral approach (24 knees). We used Scorpio NRG PS for all knees. Median postoperative periods were 43 months in both groups. We compared the surgical time, and alignment on standing radiograph, range of motion (ROM) pre/postoperatively, and degrees of soft-tissue release procedure, and lateral laxity measured by stress radiograph immediately after operation and at final follow-up. RESULT: Pre/postoperative alignment, surgical time, lateral laxity, and preoperative ROM had no significant in two groups; however, postoperative flexion was superior in lateral approach group 123.8°, 109° in medial approach group. All cases required iliotibial band (ITB) release at Gerdy's tubercle, 83 % ITB at joint level, 21 % lateral collateral ligament (LCL), 17 % popliteus tendon (PT) in medial approach group, and 88 % ITB at Gerdy's tubercle, 46 % ITB at joint level, 13 % LCL, 4 % PT in lateral approach group. DISCUSSION: In the valgus knee, lateral structures are tight. Lateral approach can directly adjust the tight structure, and also less vascular compromise to the patella than medial approach with lateral patellar release. Less invasiveness to the quadriceps muscle in lateral approach could result into better range of motion after the surgery.

Sustained elevation of interleukin-33 in sera and synovial fluids from patients with rheumatoid arthritis non-responsive to anti-tumor necrosis factor: possible association with persistent IL-1ß signaling and a poor clinical response.

Although TNF inhibitors have dramatically improved the outcome of patients with rheumatoid arthritis, 30-40% of patients do not respond well to them and treatment needs to be changed. In an effort to discriminate good and poor responders, we focused on the change in serum and synovial fluid levels of interleukin (IL-) 33 before and after treatment with TNF inhibitors. They were also measured in synovial fluids from 17 TNF inhibitor-naïve patients, and fibroblast-like synoviocytes (FLS) in-culture from 6 patients and correlated with various pro-inflammatory cytokines. Serum levels of IL-33 at 6 months after treatment decreased significantly in responders, while they did not change in non-responders. Synovial fluid levels of IL-33 in 6 patients under treatment with TNF inhibitors stayed high in 3 who were refractory and slightly elevated in 2 moderate responders, while they were undetectable in one patient under remission. Among inflammatory cytokines measured in 17 synovial fluids from TNF inhibitor-naïve patients, levels of IL-33 showed a significant positive correlation only to those of IL-1ß. IL-1ß increased IL-33 expression markedly in FLS in vitro, compared to TNF-α. IL-1ß might be inducing RA inflammation through producing pro-inflammatory IL-33 in TNF inhibitor-hypo-responders. Sustained elevation of serum and/or synovial levels of IL-33 may account for a poor response to TNF inhibitors, although how TNF inhibitors affect the level of IL-33 remains to be elucidated.

Predictive blood coagulation markers for early diagnosis of venous thromboembolism after total knee joint replacement.

Pulmonary embolism development may be prevented if asymptomatic venous thromboembolism (VTE) can be predicted and treated preoperatively or soon after total knee arthroplasty (TKA). The purpose of this study was to evaluate whether asymptomatic VTE can be predicted by blood coagulation markers preoperatively or early after TKA. This prospective single-centre study enrolled 68 patients (6 men, 62 women; mean age: 71 years) who underwent TKA between September 2004 and August 2009. Sixteen-row multidetector computed tomography was performed 4 days before and after surgery for diagnosis of asymptomatic VTE. Blood samples were taken to measure the plasma levels of soluble fibrin monomer complex (SFMC), D-dimer and cross-linked fibrin degradation products by leukocyte elastase (e-XDP) at 4 days preoperatively, and at 1 hour, 1 day and 4 days postoperatively. The preoperative SFMC, D-dimer and e-XDP levels did not differ significantly between the thrombus (n=36) and no-thrombus (n=32) groups. D-dimer and e-XDP levels showed the most significant increases at days 4 and 1, respectively, after surgery in the thrombus group. With cut-off points of 7.5 µg/ml for D-dimer and 8.2 U/ml for e-XDP, the sensitivities were 75% and 75%, and the specificities were 63% and 59%, respectively. By multiple logistic regression analysis, D-dimer at day 4 and e-XDP at day 1 postoperatively were independent markers for early diagnosis of VTE (odds ratio=1.61 and 1.19, P=0.01 and 0.04, respectively). The postoperative occurrence of new asymptomatic VTE may be predicted by D-dimer at day 4 and e-XDP at day 1 after TKA.

Arthroscopic tibiotalocalcaneal arthrodesis with intramedullary nail with fins: a case series.

Arthroscopic arthrodesis of the ankle has several advantages compared with open arthrodesis, including a smaller skin incision, less damage to the soft tissue around the joint, a lower risk of skin necrosis and infection, a lower incidence of postoperative infection and swelling, and better preservation of the contour of the surface of the joint, which maintains a larger contact area between the talus and tibia. We successfully performed arthroscopic arthrodesis of the tibiotalocalcaneal joints with intramedullary nails with fins in 9 ankles of 8 patients. Solid fusion was attained in all cases, except for 1 case of nonunion at the subtalar joint. We also corrected the alignment in 1 patient with a varus deformity. The fixation was strong, even in the case of poor bone quality, such as occurs in rheumatoid arthritis. The intramedullary nails with fins allowed for appropriate compression for bone consolidation without loss of rotational stability. Arthroscopic tibiotalocalcaneal arthrodesis, a less-invasive technique than conventional open surgery, is effective treatment, especially in patients with poor skin conditions secondary to diseases such as rheumatoid arthritis and diabetes mellitus.

The incidence of venous thromboembolism before and after total knee arthroplasty using 16-row multidetector computed tomography.

We performed a prospective study to determine the incidence of venous thromboembolism (VTE) using 16-row multidetector computed tomography (MDCT). The study included 71 patients who underwent total knee arthroplasty between September 2004 and March 2009. Multidetector computed tomography was performed 4 days before and after surgery. No patient had any presurgical symptoms of VTE. Presurgical and postsurgical incidences of pulmonary thromboembolism plus deep vein thrombosis were 0% and 13%, respectively; pulmonary thromboembolism alone, 1% and 3%, respectively; and deep vein thrombosis alone, 8% and 34%, respectively. Because asymptomatic VTE was noted in 9% of patients before surgery and 51% after surgery, we conclude that performing MDCT before and after total knee arthroplasty may be useful to clarify the incidence of VTE and to develop appropriate strategies for treatment and prevention.

Efficient strategy for controlling postoperative hemorrhage in total knee arthroplasty.

PURPOSE: The objective of the present study was to compare the intraoperative use of tranexamic acid (TNA) plus intra-articular diluted-epinephrine (DEP) with preoperative autologous blood donations and transfusions in reducing an allogeneic blood transfusion (ABT) in primary unilateral total knee arthroplasty (TKA). METHODS: Patients (n=133) treated with unilateral primary TKA were divided into three groups retrospectively: patients administered autologous blood transfusions were assigned to group A (n=51); patients administered preoperative injections of TNA and postoperative intra-articular injections of DEP were assigned to group B (n=42); and patients treated with the drain-clamp method in addition to injections of TNA and DEP were assigned to group C (n=40). The rate of avoidance of ABTs, postoperative blood loss, and complications (DVT/PE, skin problems) were examined. RESULTS: The differences among the three groups were not significant in terms of the proportion of patients requiring no ABTs (94% in group A, 93% in group B and 95% in group C, n.s.). The total blood loss calculated was 1,140±451 ml, 852±343 ml, and 850±296 ml, respectively (group B>A, group C>A, P=0.0009). The significant complications were not observed in three groups. CONCLUSION: The results of the study showed that the TNA plus DEP combination exerted a comparable effect with preoperative autologous blood transfusion in avoiding ABTs in unilateral primary TKA. Considering several problems of preoperative autologous blood donation, the use of TNA plus DEP is recommended. In addition, it is highly possible that allogeneic blood transfusions can be avoided for patients with preoperative Hb values≥10.5 using the method described in this study, and the need for preoperative autologous blood donations can be decreased.

Evaluation of soft-tissue balance during total knee arthroplasty.

PURPOSE: To evaluate soft-tissue balance during versus after total knee arthroplasty (TKA). METHODS: 18 men and 75 women aged 52 to 85 (mean, 68) years who had moderate-to-severe varus deformity underwent TKAs using the Scorpio non-restrictive geometry posterior-stabilised system (Stryker Howmedica Osteonics; Allendale, [NJ], USA). All surgeries were performed by a single surgeon using the medial parapatellar approach. After the bony and soft-tissue procedures, soft-tissue balance was measured intra-operatively using a tensor/balancer device. The coronal laxity--angles between the cut surfaces of the femur and tibia--were measured at 0 degree (in extension) and 90 degrees (in flexion). The central gap was also measured. Immediate postoperative soft-tissue balance was measured using an arthrometer, while anteroposterior stress radiographs were being taken. A valgus or varus force was applied just above the knee on the lateral or medial side, with the knee counter-supported and at 15 degrees flexion. RESULTS: Intra-operatively, the mean coronal laxity at 0 degree (in extension) and 90 degrees (in flexion) was 2.1 degrees and -1.6 degrees, and the mean central gaps were 21.2 and 23.5 mm, respectively. Immediate postoperative mean coronal laxity was 2.9 degrees, indicating that lateral laxity was greater than medial laxity. The postoperative coronal laxity was positively corrected to the intra-operative coronal laxity at 0 degree (r=0.304, p=0.003), but not to the intra-operative coronal laxity at 90 degrees (r= -0.07, p=0.47). CONCLUSION: Slightly greater lateral laxity was observed after TKA, although equal medial-lateral balance was achieved intra-operatively.

Postoperative lateral ligamentous laxity diminishes with time after TKA in the varus knee.

For successful TKA, good soft tissue balance is one of the most important factors; however, it is unknown whether the coronal balance immediately after surgery is maintained with time. We hypothesized, if neutral mechanical alignment was achieved at the time of TKA, some degree of lateral ligamentous laxity could be accepted and the laxity would diminish with time. To confirm this hypothesis, we posed two scientific questions: (1) Does the coronal ligament balance measured immediately after TKA change with time? (2) Does the degree of preoperative varus alignment correlate with the lateral or medial ligamentous laxity observed after TKA? We measured coronal lateral or medial ligamentous laxity in 71 knees with varus deformities immediately after surgery and at 3, 6, and 12 months thereafter. The mean mechanical axis was 15.9 degrees varus preoperatively and 0.4 degrees varus postoperatively. The mean medial ligamentous laxity was relatively constant postoperatively from immediately after surgery to 12 months. However, the mean lateral ligamentous laxity was as much as 8.6 degrees immediately after surgery and decreased to 5.1 degrees at 3 months. The lateral ligamentous laxity immediately after surgery correlated with the preoperative varus mechanical axis. Our data show residual lateral ligamentous laxity observed in preoperative varus deformity may be corrected spontaneously after TKA.

Arthroscopic-assisted tibiotalocalcaneal arthrodesis using an intramedullary nail with fins: a case report.

Arthroscopic arthrodesis of the ankle has become popular because of the reduced invasiveness of the procedure and good bony consolidation compared with conventional open techniques. However, arthroscopic arthrodesis of the subtalar joint has not been as universally accepted. Rheumatoid arthritis frequently involves the talocalcaneal joint in addition to the tibiotalar joint. In such cases, simultaneous fixation of both tibiotalar and talocalcaneal joints is desirable. We undertook arthroscopic-assisted arthrodesis of the tibiotalocalcaneal joint using intramedullary nails with fins for a 76-year-old man with rheumatoid arthritis. Although the patient presented with poor skin condition and osteoporotic bone due to long-term use of systemic corticosteroids, weight bearing was allowed 2 weeks after the surgery. Solid fusion of the tibiotalocalcaneal joint occurred without any complications. Given the twin benefits of reduced invasiveness and secure fixation, this method should be considered for patients requiring both tibiotalar and talocalcaneal joint fusion, when a more extensive surgical exposure would be more risky.