Patch augmentation does not provide better clinical outcomes than arthroscopic rotator cuff repair for large to massive rotator cuff tears.

PURPOSE: Patch augmentation for large and massive rotator cuff tears (LMRCTs) has been suggested as a repair strategy that can mechanically reinforce tendons and biologically enhance healing potential. The purpose of this study was to determine whether patients who underwent patch augmentation would have lower rates of retears and superior functional outcomes. METHODS: Patients who underwent arthroscopic rotator cuff repair (ARCR) with patch augmentation (group A) were matched by age, sex, degree of retraction, and supraspinatus muscle occupation ratio to those treated with ARCR without using a patch (group B) with a minimum follow-up of 24 months. The retear (Sugaya IV or V) rates were evaluated by magnetic resonance imaging at 3 and 12 months post-surgery. The Constant- Murley Score (CMS), Korean Shoulder Score (KSS), and University of California-Los Angeles Shoulder Rating Scale (UCLA) score were retrospectively analyzed. RESULTS: This study included 34 patients (group A, n = 17; group B, n = 17). The mean follow-up period was 46.5 ± 17.4 months. At postoperative 1-year follow-up, group B (6 patients, 35.3%) showed higher rates of retears than group A (1 patient, 5.9%), which was statistically significant (P = 0.034). However, the postoperative CMS, KSS, and UCLA scores did not differ between the two groups at 3 months, 12 months, and the final follow-up. Additionally, the clinical outcomes of patients with retear were not significantly different from those of the healed patients in both groups. CONCLUSION: The use of an allodermal patch for LMRCT is effective in preventing retears without complications. However, the clinical outcomes of ARCR using allodermal patch augmentation were not superior to those of only ARCR. LEVEL OF EVIDENCE: III.

Low serum vitamin B12 levels are associated with degenerative rotator cuff tear.

BACKGROUND: Vitamin B12 (Vit B12) deficiency results in elevated homocysteine levels and interference with collagen cross-linking, which may affect tendon integrity. The purpose of this study was to investigate whether serum Vit B12 levels were correlated with degenerative rotator cuff (RC) tear. METHODS: Eighty-seven consecutive patients with or without degenerative RC tear were enrolled as study participants. Possible risk factors (age, sex, medical history, bone mineral density, and serum chemistries including glucose, magnesium, calcium, phosphorus, zinc, homocysteine, Vitamin D, Vit B12, homocysteine, and folate) were assessed. Significant variables were selected based on the results of univariate analyses, and a logistic regression model (backward elimination) was constructed to predict the presence of degenerative RC tear. RESULTS: In the univariate analysis, the group of patients with degenerative RC tear had a mean concentration of 528.4 pg/mL Vit B12, which was significantly lower than the healthy control group (627.1 pg/mL). Logistic regression analysis using Vit B12 as an independent variable revealed that Vit B12 concentrations were significantly correlated with degenerative RC tear (p = 0.044). However, Vit B12 levels were not associated with tear size. CONCLUSION: Low serum levels of Vit B12 were independently related to degenerative RC tear. Further investigations are warranted to determine if Vit B12 supplementation can decrease the risk of this condition.

Factors related to the early outcome of medial open wedge high tibial osteotomy: coronal limb alignment affects more than cartilage degeneration state.

INTRODUCTION: This study aimed to identify possible factors influencing the early outcome after medial open wedge high tibial osteotomy (MOWHTO). MATERIALS AND METHODS: A total of 87 MOWHTO cases with a minimum of 2-year follow-up and second-look arthroscopic results available were enrolled. The cartilage degeneration state was evaluated by the International Cartilage Repair Society (ICRS) grading. Radiographic parameters including the hip-knee-ankle axis (HKA), medial proximal tibia angle (MPTA), posterior tibial slope, patellar height, mechanical lateral distal femoral angle (LDFA), joint line convergence angle (JLCA), joint line obliquity (JLO), and weight-bearing line ratio (WBLR) were measured. The pre-operative arthritic change was evaluated by Kellgren-Lawrence (KL) classification. According to the post-operative HKA, knees were divided into three (Under/Optimal/Over-correction) subgroups. Subjective International Knee Documentation Committee (IKDC) scores were evaluated and factors related to post-operative IKDC scores were analyzed. RESULTS: The pre-operative HKA (P = 0.002), post-operative HKA (P = 0.007), pre-operative MPTA (P = 0.011), and pre-operative WBLR (P = 0.031) were significantly related to the post-operative IKDC score. Cartilage degeneration states evaluated from first and second-look arthroscopy were not associated with post-operative IKDC score. Subgroup analysis revealed that the Under-correction group had significantly lower post-operative IKDC scores compared to the Optimal and Over-correction group (P = 0.012 and P = 0.030, respectively). CONCLUSION: Our result suggests that a sub-optimal correction of coronal limb alignment negatively affects the early outcome of MOWHTO. On the other hand, the effect of the degree of cartilage degeneration was not significant.

Effect of preoperative vitamin D deficiency on functional outcomes after high tibial osteotomy: a retrospective case control study.

BACKGROUND: This study aimed to evaluate the effects of vitamin D deficiency on the functional outcomes following a high tibial osteotomy (HTO). METHODS: Clinical data of 209 patients (327 knees) who underwent HTO done by a single surgeon were retrospectively registered for the study. Ninety-four patients (94 knees) who underwent HTO were analyzed. Patients were assigned into two groups according to their preoperative serum vitamin D levels (D- Deficiency and S- Sufficient); < 20 ng/ml (group D, N = 48) and ≥ 20 ng/ml (group S, N = 46) respectively. A subjective form of International Knee Documentation Committee (IKDC) score, mechanical alignment, and cartilage status before and 1 year following HTO were studied between groups. RESULTS: The mean postoperative IKDC score was significantly higher in group S (p = 0.012). Moreover, the difference of IKDC score between pre- and post- HTO was also significantly higher in group S (p = 0.006). Preoperative vitamin D level and IKDC score did not show a significant correlation. Serum vitamin D level was found to be moderately correlated to postoperative IKDC score (r = 0.342 and, p = 0.001). A moderately positive correlation between serum vitamin D level and improvement of IKDC score following osteotomy was appreciated (r = 0.381 and, p < 0.001). CONCLUSION: Patients with vitamin D deficiency had less satisfactory functional outcomes within 1 year from HTO surgery. Our results suggest that preoperative serum vitamin D level is one of the factors affecting the outcome after HTO. We recommended analyzing serum vitamin D levels as part of the routine workup in patients undergoing HTO.

Fixator-assisted Technique Enables Less Invasive Plate Osteosynthesis in Medial Opening-wedge High Tibial Osteotomy: A Novel Technique.

BACKGROUND: Opening-wedge high tibial osteotomy is a well-established procedure in the management of medial osteoarthritis of the knee and correction of proximal tibia vara. Recently, surgical approaches using less invasive plate osteosynthesis have been used with the goal of minimizing complications from more extensive soft tissue exposures. However, to our knowledge, less invasive fixator-assisted plate osteosynthesis has not been tested in the setting of opening-wedge high tibial osteotomy. QUESTIONS/PURPOSES: The purposes of this study were (1) to assess the complications associated with use of a fixator-assisted less invasive plate osteosynthesis technique to stabilize an opening-wedge high tibial osteotomy in the treatment of proximal tibial vara; and (2) to evaluate the ability of this technique to achieve correction of the proximal tibial deformity and achieve osseous union. METHODS: From June 2011 to June 2013, a total of 157 limbs in 83 patients who underwent fixator-assisted high tibial osteotomy for (1) idiopathic genu vara; or (2) osteoarthritis of the knee with proximal tibia vara were initially enrolled. Of these, eight limbs (5%) were excluded on the way; thus, 149 limbs in 77 patients were evaluated. During the period in question, no other techniques were used for proximal tibial osteotomy. The surgical procedures included less preparation of soft tissue, proximal tibial osteotomy, application of a temporary external fixator, correction of alignment, and final fixation with the help of an external fixator. Complications were assessed by chart review and the alignment in both coronal and sagittal planes was compared pre- and postoperatively. Radiographic review to confirm osseous union and alignment was performed by two of the authors not involved in clinical care of the patient. Delayed union was described as union occurring later than 4 months. RESULTS: Thirty limbs out of 149 tibiae (20%) showed complications, all of which were resolved without leaving any sequela. Twenty-seven limbs out of 149 limbs (18%) showed lateral cortical hinge fracture and three limbs out of 149 limbs (2%) showed soft tissue complications (two superficial infections, one wound hematoma). The overall completeness of reaching the target correction was excellent. In the coronal plane, the difference between the amount of real correction and the amount of target correction was 0.3° ± 0.7° (p < 0.001). In the sagittal plane, the difference between pre- and postoperative posterior proximal tibial angle was -0.1° ± 0.2° (p < 0.001). All osteotomies healed before 4 months. CONCLUSIONS: Fixator-assisted high tibial osteotomy is a valid option for medial opening-wedge high tibial osteotomy, which enables less invasive surgery with excellent coronal/sagittal/rotational alignment control. However, future studies should compare this approach with other approaches for proximal tibial osteotomy to ascertain whether indeed this procedure is less invasive or more reliable. LEVEL OF EVIDENCE: Level IV, therapeutic study.

An analysis of normative data on the knee rotatory profile and the usefulness of the Rotatometer, a new instrument for measuring tibiofemoral rotation: the reliability of the knee Rotatometer.

PURPOSE: This study proposes a simple and noninvasive instrument called the "Rotatometer" to measure tibiofemoral rotation and investigates its clinical applicability to the assessment of static rotational knee laxity. METHODS: The degree of tibiofemoral rotation was measured for a sample of 94 healthy volunteers with 188 knees by using the Rotatometer. The measurement was made by two independent and blinded examiners in three sessions at one-month intervals. The normative rotational profile and its relationship with gender and age were evaluated, and inter-observer reliability and intra-observer reliability were calculated. RESULTS: Males showed 62° ± 5° of external rotation, whereas females, 64° ± 5°. Males showed 44° ± 5° of internal rotation, whereas females, 49° ± 4°. Females showed significantly higher degrees of rotation than males. Tibiofemoral rotation was not correlated with age, and external rotation and internal rotation had a moderate positive relationship. Inter-observer reliability ranged from 0.84 to 0.91 for external rotation and 0.90 to 0.95 for internal rotation, and intra-observer reliability ranged from 0.69 to 0.89 for external rotation and 0.87 to 0.95 for internal rotation. CONCLUSIONS: The results suggest the Rotatometer to be a simple and noninvasive device with high inter- and intra-observer reliability. The device can provide a normative rotational profile for reference purposes and thus can be used to determine the preoperative and postoperative rotational status of knees with anterior cruciate ligament injuries and compare results from different reconstruction techniques.

The association between meniscal subluxation and cartilage degeneration.

PURPOSE: The menisci play a critical protective role for the knee joint through shock absorption and load distribution. We hypothesized that cartilage degeneration will be abruptly progressed if meniscal subluxation exceeds a critical point. METHODS: Of 56 cases that showed medial meniscal subluxation without cartilage degeneration of ipsilateral medial femoral condyle (MFC) on initial MRI, from January 2005 to June 2007, meniscal subluxation index (MSI), the ratio of meniscal overhang to meniscal width in mid-coronal image of initial MRI, was measured. After 2 years, 40 cases were evaluated for cartilage degeneration of ipsilateral MFC on follow-up MRI. The relationship between medial MSI on initial MRI and cartilage degeneration of MFC on follow-up MRI was analyzed. Logistic regression analysis was conducted to find a critical point of meniscal subluxation related to cartilage degeneration. RESULTS: Abrupt progression of cartilage degeneration was observed from which MSI was 0.38. Logistic regression showed that if MSI was at the critical point, which was 0.38 in our study, then the probability of cartilage degeneration to grade 3 or 4 after 2 years was 44 %. If MSI was 0.4, then the probability was 50 %. If MSI was 0.6, then the probability was 99 %. CONCLUSIONS: The results suggest the existence of critical point from which the protective function of the meniscus appears to be significantly altered, and the degree of cartilage degeneration of ipsilateral femoral condyle corresponding to the amount of medial meniscal subluxation may be predictable.

Clinical and radiological results of high tibial of osteotomy over the age of 65 are comparable to that of under 55 at minimum 2-year follow-up: a propensity score matched analysis.

PURPOSE: The results of medial open-wedge high tibial osteotomy (MOWHTO) according to age is inconclusive. This study aimed to compare the clinical outcomes and failure of MOWHTO in patients < 55 years and > 65 years. METHODS: Consecutive patients who underwent MOWHTO from July 2009 to August 2020 were retrospectively analyzed. 205 patients were considered for analysis. A 1-to-1 propensity score matched analysis to assess clinical outcomes scores including International Knee Documentation Committee (IKDC) subjective score and Lysholm score, radiologic outcomes, complication, and Total Knee Arthroplasty (TKA) conversion between patients > 65 years and patients < 55 years was performed. Radiologic outcomes included Hip-Knee-Ankle (HKA) angle, Weight Bearing Line ratio (WBLR), posterior tibial slope (PTS), and Insall-Salvati (IS) ratio before and after surgery. RESULTS: The follow-up period was 50.4 months in patients > 65 years and 55.3 months in patients < 55 years. There was no significant difference in the preoperative and postoperative HKA angle, WBLR, PTS, IS ratio, IKDC score and Lysholm score between the two groups. The arthroscopic evaluation of cartilage did not show any statistically significant differences between the two groups. Regarding Minimal clinically important differences (MCID), in the 26% of the older group exceeded MCID of IKDC score; 45% of the older group exceeded MCID of Lysholm score. In the younger group, 24% exceeded MCID of IKDC score and 35% exceeded MCID of Lysholm score. In older group, there were 7 (11.3%) cases of TKA conversion while no TKA conversion was recorded in the younger group. (P = 0.007) The average time to TKA conversion was 67 months. (42 months to 90 months) Kaplan-Meier analysis revealed that the survival rate was 95.2% at 4 years in the older group. CONCLUSION: Similar clinical results were obtained in patients over 65 years of age that were eligible for MOWHTO at minimum 2-year follow-up as in patients under 55 years of age. MOWHTO may be a viable option in older patients if proper indications are met. However, the risk of TKA conversion must be considered preoperatively and discussed with patients. STUDY DESIGN: Cohort study; Level of evidence, 3.

Traumatic and non-traumatic isolated horizontal meniscal tears of the knee in patients less than 40 years of age.

PURPOSE: The aim of this study is to analyze the characteristics of isolated horizontal meniscal tears in young patients and compared traumatic and non-traumatic isolated horizontal meniscal tear without other type of meniscal tear. METHODS: Forty patients who underwent partial meniscectomy with isolated horizontal meniscal tears and followed up for more than 2 years were divided into two groups according to the presence of distinct previous traumatic events (defined as contusion or sprain) to the knees. Analyzed variables included in this descriptive statistics were involved side of knee and location of meniscus, physical examinations (joint line tenderness and McMurray's testing), subjective International Knee Documentation Committee (IKDC) criteria, and Lysholm functional questionnaires. RESULTS: Twenty-two of the forty patients (55 %) had distinct previous traumatic events. Fourteen cases (63.6 %) in traumatic group and 14 cases (77.8 %) in non-traumatic group are involved non-dominant knees during locomotion or playing sports. Twenty patients (90.9 %) in traumatic group and eight patients (44.4 %) in non-traumatic group presented with tear in the midportion of the medial meniscus on arthroscopic findings (p < 0.01). Six patients (60.0 %) in traumatic group and twelve patients (85.7 %) in non-traumatic group had meniscal cysts on arthroscopic findings at the time of surgery (p < 0.01). There was no statistic difference between the two groups with respect to physical examinations, subjective IKDC scores, and Lysholm functional scores. CONCLUSIONS: Isolated horizontal meniscal tears in young patients predominantly involved non-dominant knees and medial meniscus. Anterior aspect of medial meniscus was more frequently involved in traumatic group. Meniscal cysts were more frequently showed in non-traumatic group.

Combined medial open-wedge high tibial osteotomy and modified Maquet procedure for medial compartmental osteoarthritis and patellofemoral arthritis of the knee.

PURPOSE: Patellofemoral arthritis comes frequently with medial compartmental osteoarthritis. The combination of closed wedge high tibial osteotomy with tibial tuberosity anteriorization osteotomy has been introduced in several reports, but this technique is a technically demanding procedure and the outcomes of this technique show variable results. This article describes a novel osteotomy technique that combines medial open-wedge high tibial osteotomy (HTO) and tibial tuberosity anteriorization osteotomy (TTAO) for medial compartmental osteoarthritis and patellofemoral arthritis of the knee. METHODS: Twelve knees in 10 patients who were diagnosed with combined medial compartmental osteoarthritis with patellofemoral compartmental arthritis were treated with the combination of medial open-wedge HTO and TTAO and were followed up for more than 1 year. We evaluated the patients with the Lysholm functional questionnaires, the hospital for special surgery score (HSS), and the international knee documentation committee (IKDC) criteria (mean follow-up, 14.8 months). RESULTS: Union was achieved in all cases within 12 weeks. The mean Lysholm score increased from 42 preoperatively to 82.5 postoperatively (p < 0.001), the HSS increased from 57.5 preoperatively to 83 postoperatively (p < 0.001), and the IKDC score increased from 51 preoperatively to 82 postoperatively (p < 0.001). There were no other complications, such as iatrogenic fractures, nonunion, wound problem, collapse or loss of correction, and so on. CONCLUSIONS: The combination of medial open-wedge HTO and modified Maquet procedure (TTAO) is considered to be an effective treatment modality for medial and patellofemoral compartmental osteoarthritis. This technique could, therefore, constantly provide a minimally invasive, precise correction of the deformity and a firm fixation that is enough to allow early rehabilitation.

Can a high acromion index predict rotator cuff tears?

PURPOSE: The purpose of this study was to identify the relationship between an acromion index (AI) and the size of a rotator cuff tear. The hypothesis of our study was that an AI will be higher in patients with a full-thickness tear than in patients with a partial-thickness articular-side tear, and that it can be used as a predictor for the size of a rotator cuff tear. METHODS: We included 284 patients who had been diagnosed with rotator cuff tears and had undergone arthroscopic rotator cuff repair at our institute. All patients were divided into five distinct groups (partial-thickness articular side tear, and four subgroups of full-thickness tears) depending on the size of the rotator cuff tear on arthroscopy. In each patient, an AI was measured on the pre-operative oblique coronal MR images and then analysed to determine the difference between groups. RESULTS: There were statistically significant differences between the partial-thickness articular side rotator cuff tear and large-to-massive rotator cuff tear groups (p < 0.01), and the mean value of an AI was highest in the large-sized full-thickness tear group. The AI of the partial-thickness articular-side rotator cuff tear group was statistically different from the large-to-massive rotator cuff tear groups. CONCLUSIONS: The AI can be a predictor which can differentiate a partial-thickness articular-side tear and a large-to-massive rotator cuff tear pre-operatively. However the AI could not provide useful guidance on predicting the differences in tear size in full-thickness tear patients. We suggest that a high AI can be one of the associated factors for progression to large-to-massive rotator cuff tears in a rotator cuff disease.

Prognostic Factors Leading to Good or Poor Outcomes Based on Functional and Radiological Findings After a Rotator Cuff Retear.

BACKGROUND: A retear after rotator cuff repair is a common problem; however, there is little information related to the prognosis after a retear. In addition, some patients with retears have satisfactory outcomes, which raises the question of whether a retear leads to a poor prognosis. PURPOSE: To identify radiological factors that influence the prognosis after a retear. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 51 patients with retears confirmed by magnetic resonance imaging at 1 year after arthroscopic rotator cuff repair with a minimum follow-up of 24 months were enrolled in this study. Patients were divided into 2 groups according to whether they achieved the minimal clinically important difference for clinical outcome measures. Range of motion and radiological variables, including preoperative and postoperative anteroposterior (AP) and mediolateral (ML) tear sizes, sagittal extent of the retear, acromiohumeral distance (AHD), and degree of fatty degeneration, were analyzed using magnetic resonance imaging. RESULTS: Overall, 36 patients were allocated to the good prognosis (GP) group and 15 to the poor prognosis (PP) group. The 2 groups had no significant differences in baseline demographics and preoperative radiological parameters. Postoperative range of motion was decreased in the PP group at the last follow-up. The AP and ML retear sizes decreased in both groups after arthroscopic rotator cuff repair, but the retear size was significantly larger in the PP group (both P < .05). The AHD increased in the GP group (P < .001) but decreased in the PP group (P = .230) postoperatively. Logistic regression analysis revealed that postoperative AHD (P = .003), fatty degeneration of the infraspinatus tendon (P = .001), posterior (P = .007) and anterior (P = .025) sagittal extent of the retear, and change in the AP tear size (P = .017) were related to poor outcomes after a retear. However, change in the ML tear size (P = .105) and middle sagittal extent of the retear (P = .878) were not related to a poor prognosis. Also, further analysis showed that posterior (P = .006) and anterior (P = .003) sagittal extent of the retear were related to rotator cable involvement. CONCLUSION: An increased AP retear size and decreased AHD were radiological parameters that were associated with poor clinical outcomes after a retear. In particular, patients who had posterior and anterior sagittal extent of the retear, possibly with rotator cable involvement and more severe fatty degeneration of the infraspinatus tendon, showed worse outcomes.

Genome-Wide Association Study Identifies Genetic Variants Associated with Rotator Cuff Tear-A Pilot Study.

A rotator cuff is a muscle and tendon surrounding the shoulder joint, and a rotator cuff tear can be caused by overuse or injury, which leads to great pain in affected individuals. However, rotator cuff tear is a multifactorial process whose underlying mechanism is still unclear. Many previous studies have suggested an important role of genetic predisposition, such as single-nucleotide polymorphisms (SNPs), in explaining the genesis of tendinopathy. This study aimed to identify specific genes or genetic variants associated with rotator cuff tears by performing a genome-wide association study (GWAS) using an independent case of rotator cuff tears. GWAS was performed using data from CHA Bundang Medical Center with 20 cases of rotator cuff tears, and 20 cases of healthy controls genotyped on the Illumina HiSeq 2500. Tests of association were performed using the Burrows−Wheeler Aligner (BWA) software at 284,246 SNPs. Data were filtered based on sequence ontology, minor allele frequency, and Hardy−Weinberg equilibrium values, and SNPs were considered significant if the p-value was <0.05. The tests of association revealed more than 20 significantly associated SNPs. SNPs showing the highest significance occurred in candidate genes, including LAIR2 (rs2287828, OR 9.116, p-value 5.49 × 10−4) on chromosome 19 and CRIPAK (rs9328733, OR 6, p-value 1.11 × 10−3) and REST (rs2228991, OR 8.222, p-value 1.20 × 10−3) on chromosome 4. This study attempted to identify genetic variants influencing rotator cuff tears through a genome-wide association study using a dense set of SNPs. More than 20 SNPs were significantly associated with rotator cuff tears. The major limitation of this study is that it was conducted on a small study group and requires further validation. Nevertheless, the identification of potential genetic variants related to rotator cuff injury would aid in the early detection of individuals at risk for the development of tendinopathy and will provide insight into future gene therapies.

Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: a prospective comparison study.

PURPOSE: To evaluate functional and radiographic results of arthroscopic suture anchor repair for posterior root tear of the medial meniscus (PRTMM) and compare with pullout suture repair. METHODS: From December 2006 to August 2008, 51 consecutive patients underwent arthroscopic repair of PRTMM at our hospital. The repair technique was switched over time from pullout suture repair (group 1) to suture anchor repair (group 2). Of the patients, 6 were lost to follow-up, leaving a study population of 45 patients, with 22 menisci (48.9%) in group 1 and 23 (51.1%) menisci in group 2. The mean follow-up duration was 25.9 months (range, 24 to 27 months) in group 1 and 26.8 months (range, 24 to 28 months) in group 2. Compared variables included International Knee Documentation Committee criteria, Kellgren-Lawrence grade, gap distance at PRTMM, structural healing, meniscal extrusion, and cartilage degeneration of the medial femoral condyle. RESULTS: At 2 years postoperatively, both groups showed significant improvements in function (P < .05) and did not show significant differences in Kellgren-Lawrence grade (P > .05) compared with preoperatively. On magnetic resonance imaging, the gap distance at PRTMM was 3.2 ± 1.1 mm in group 1 and 2.9 ± 0.9 mm in group 2 preoperatively (P > .05). Complete structural healing was seen in 11 cases in group 1 and 12 cases in group 2 (P > .05). Mean meniscal extrusion of 4.3 ± 0.9 mm (group 1) and 4.1 ± 1.0 mm (group 2) preoperatively was significantly decreased to 2.1 ± 1.0 mm (group 1) and 2.2 ± 0.8 mm (group 2) postoperatively (P < .05). Regardless of repair technique, incompletely healed cases showed progression of cartilage degeneration (4 cases in group 1 and 2 cases in group 2). CONCLUSIONS: For PRTMM, our results show significant functional improvement in both the suture anchor repair and pullout suture repair groups. Reduction of meniscal extrusion seems to be appropriate to preserve its protective role against progression of cartilage degeneration after complete healing at PRTMM. LEVEL OF EVIDENCE: Level III, prospective therapeutic comparative study.

Incidence and Factors Affecting the Occurrence of Lateral Hinge Fracture After Medial Opening-Wedge High Tibial Osteotomy.

BACKGROUND: Few clinical studies have reported the predictors of lateral hinge fracture (LHF) after medial opening-wedge high tibial osteotomy (MOWHTO). PURPOSE/HYPOTHESIS: The purpose was to compare the incidence of LHF on plain radiographs versus computed tomography (CT) scans and to investigate the factors related to the development of LHF after MOWHTO. We hypothesized that (1) a higher LHF detection rate would be seen on CT scans versus plain radiographs and (2) LHF incidence would be related to opening gap width and hinge position. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 97 MOWHTO cases were included. The presence and types of LHF were determined from plain radiographs and CT scans. Radiographic parameters were measured on plain radiographs taken 6 weeks postoperatively. Anterior and posterior opening gap widths, coronal and sagittal osteotomy slopes, and fibular height were calculated from CT scans. The wedge-hinge relationship and the zone of hinge position were assessed, and the patient and radiographic factors related to LHF occurrence were evaluated. RESULTS: Seventeen LHF cases (20.5%) were detected on plain radiographs, while significantly more (37 cases; 44.6%) were found on CT scans (P = .001). Based on Takeuchi classification, 28 LHF cases were considered type 1, 7 were type 2, and 2 were type 3. Logistic regression analysis revealed that opening gap width (odds ratio, 1.615; 95% confidence interval, 1.232-2.118; P = .001) and posterior opening gap width (odds ratio, 3.731; 95% confidence interval, 1.642-4.351; P = .008,) differed significantly between patients with versus without LHF. Other patient and radiographic factors were not significantly related to LHF occurrence. Receiver operating characteristic curve analysis identified the opening gap width cutoff values for LHF as 11.0 mm (area under the curve, 0.81; sensitivity, 78.4%; specificity, 73.9%). CONCLUSION: The incidence of LHF after MOWHTO can be underestimated on plain radiographs compared with CT scans. Only large opening gap width, especially posterior gap width, was found to have a statistically significant relationship with occurrence of LHF. Therefore, special caution for possible LHF may be needed if a large correction is planned.

An osteoconductive PLGA scaffold with bioactive ß-TCP and anti-inflammatory Mg(OH)2 to improve in vivo bone regeneration.

Poly(lactic-co-glycolic acid) (PLGA) has been widely used as a biomaterial for pharmaceutical and medical applications. However, the decomposition products of PLGA are known to acidify the surrounding tissue of the implanted site, causing an inflammatory response. Previously, we developed PLGA/inorganic nanocomposites and optimized the amounts of inorganic compounds, ß-tricalcium phosphate (ß-TCP) and magnesium hydroxide [Mg(OH)2], in terms of osteogenesis of normal human osteoblasts and anti-inflammatory responses of preosteoclastic cells in vitro. In this study, the potential of the optimized PLGA/ß-TCP/Mg(OH)2 nanocomposite (TCP/MH) to promote bone repair through osteoinductive, osteoconductive, and anti-inflammatory abilities was assessed using a bone defect in a rat humeral defect model. PLGA nanocomposites with or without inorganic compounds, PLGA, ß-TCP, MH, and TCP/MH were prepared through one-step bulk modification using a twin-screw extruder. The resulting TCP/MH nanocomposite successfully enhanced the bone regeneration rate for allowing complete bone defect healing with significantly suppressed inflammatory responses. Taken together, the organic and inorganic bioactive nanocomposite developed in this study, TCP/MH, is a promising material in orthopedic implantation.

A proinflammatory cytokine interleukin-32beta promotes the production of an anti-inflammatory cytokine interleukin-10.

A new proinflammatory cytokine interleukin-32 (IL-32) has six isoforms. Although IL-32 can be detected in sera from patients suffering from Crohn's disease and rheumatoid arthritis, it is unclear which isoforms are involved. To this end, we investigated the functions of the most abundant IL-32beta by generating K562-IL-32beta stable cell lines. This report confirms, using IL-32 small interfering RNA, that IL-32beta induces an anti-inflammatory cytokine IL-10 in K562-IL-32beta cells and U937 promonocytic cells, which express endogenous IL-32beta upon phorbol 12-myristate 13-acetate (PMA) treatment, and monocyte-derived dendritic cells (DC) upon lipopolysaccharide (LPS) treatment. Interleukin-32beta was induced in monocyte-derived macrophages by LPS and in monocyte-derived DC by LPS, poly(I:C), or anti-CD40 antibody, but was not induced by PMA. We showed that IL-32beta expression was increased in a time-dependent manner in monocyte-derived DC upon LPS treatment and peaked at 24 hr. Production of IL-10 was exactly coincident with IL-32beta expression, but IL-1beta and tumour necrosis factor-alpha production peaked at 6 hr after LPS treatment, then steeply declined. Interleukin-12 p40 was induced at 9 hr and gradually increased until 48 hr, at which time IL-32beta and IL-10 were no longer increased. Knock-down of IL-32beta by IL-32 small interfering RNA led to the decrease of IL-10, but the increase of IL-12 in monocyte-derived DC, which means that IL-32beta promotes IL-10 production, but limits IL-12 production. We also showed that IL-10 neutralization increases IL-12, IL-1beta and tumour necrosis factor-alpha production, which implies that IL-10 suppresses such proinflammatory cytokines. Taken together, our results suggest that IL-32beta upregulates the production of an anti-inflammatory cytokine IL-10, and then IL-10 suppresses proinflammatory cytokines.

Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: technical note.

A root attachment injury (root tear) of the meniscus can abolish the ability of the meniscus to bear hoop stress and predispose to increase articular contact stress which contribute to femorotibial degenerative changes. A pull out suture technique to repair the root tear has been described, but the procedure making the tibial tunnel may be difficult and troublesome. This article describes a repair technique using a suture anchor and posterior trans-septal portal.

The effects of graft shrinkage and extrusion on early clinical outcomes after meniscal allograft transplantation.

BACKGROUND: Graft shrinkage or radial extrusion is a reported complication after meniscus allograft transplantation (MAT). Whether shrinkage or extrusion progress after surgery and whether they are associated with the clinical outcome of MAT remain debatable. In this study, graft shrinkage and extrusion were measured in the coronal and sagittal planes using serial postoperative magnetic resonance imaging (MRI). The purpose of this study was to evaluate if graft shrinkage or extrusion is correlated to the clinical outcome of MAT. METHODS: MRIs acquired at 3 and 12 months postoperatively in 30 patients (21 men and 9 women) who underwent MAT (6 medial and 24 lateral menisci) from 2010 to 2016 were analyzed. Two orthopedic surgeons and two musculoskeletal specialized radiologists each performed the MRI measurements. Allograft shrinkage was measured by the width and thickness of the graft at the coronal and sagittal planes. To determine the graft extrusion, distances between the proximal tibia cartilage margin and the extruded graft margin were measured in both coronal (either lateral or medial) and sagittal (both anterior and posterior) plane and relative percentage of extrusion (RPE) were calculated. Subjective International Knee Documentation Committee (IKDC) scores at 12 months were evaluated as a clinical outcome measurement, and correlations between shrinkage or extrusion of allograft and IKDC score were analyzed. RESULTS: In the coronal plane, radial RPE averaged 43.6% at postoperative 3 months, but there was no significant progression of extrusion at 12 months (average 42.0%) (P = 0.728). In the sagittal plane, there were no significant progressions of anterior and posterior RPE (P = 0.487 and 0.166, respectively) between postoperative 3 and 12 months. Shrinkage was calculated by multiplying the width and height of the three sections and summing these values. There was no significant progression of shrinkage between postoperative 3 and 12 months (P = 0.150). RPE in the radial (R = 0.147, P = 0.525), anterior (R = 0.249, P = 0.264), and posterior (R = 0.230, P = 0.315) directions and shrinkage (R = 0.176, P = 0.435) were not correlated to IKDC score at postoperative 12 months. CONCLUSIONS: In the coronal and sagittal planes, extrusion and shrinkage did not progress from 3 months to 1 year. Extrusion and shrinkage had no correlation with early clinical outcomes. This finding suggests that graft extrusion or shrinkage may be not a great concern especially in early postoperative period of MAT, and multiple, serial MRI may be not necessary.