Gerdy's tubercle as a novel anatomical landmark for the proximal tibial cut in total knee arthroplasty.

OBJECTIVES: This study aimed to explore the use of Gerdy's tubercle (GT) as an innovative and dependable anatomical landmark for the proximal tibial cut in total knee arthroplasty (TKA) in cases with extensive knee degeneration. MATERIALS AND METHODS: One hundred dry tibia bones and 10 formalin-fixed cadaveric knee specimens of both sexes were examined. A Zimmer NexGen tibial cutting guide and a Mitutoyo digital caliper were utilized to align the guide with the tibia's mechanical axis. The procedure was replicated on cadaver knees using a standardized medial parapatellar arthrotomy approach. Measurements included the distance from GT superior border to the resection line and the length of the tibia. A radiological study involving magnetic resonance imaging examinations of 48 patients, which were evaluated focusing on the upper border of GT and the least degenerated segment of the posterolateral part of the lateral tibial condyle, was conducted. RESULTS: Anatomical measurements of GT and proximal tibial areas in 110 specimens showed slight but consistent variations with cadaver measurements. Magnetic resonance imaging analysis of 48 patients revealed notable sex differences in the distance between the superior border of GT and the tibia's posterolateral surface. There was also a significant negative correlation between the distance from GT to the posterolateral corner and cartilage thickness. CONCLUSION: Proper alignment in TKA is crucial for success, but identifying an extra-articular landmark for horizontal tibial resection remains challenging, particularly in severely arthritic knees. This study introduces GT as a novel anatomical landmark for TKA, offering a more reliable reference for achieving desired joint levels in knees with significant degenerative changes.

Impact of postoperative femorotibial axis on functional outcomes in unicompartmental knee arthroplasty.

OBJECTIVES: This study aimed to compare the functional outcomes of patients undergoing fixed-bearing medial unicompartmental knee arthroplasty (UKA) classified as either varus or neutral based on their postoperative femorotibial angle (FTA), with the goal of evaluating the impact of FTA on functional results. PATIENTS AND METHODS: A total of 38 knees of 35 patients (27 females, 8 males; mean age: 63.6±7.1 years; range, 52 to 75 years) were included in this retrospective study. The data was collected between December 15, 2020, and January 15, 2021. Patients were categorized into two groups based on their postoperative FTA. The neutral group consisted of patients with an FTA range of 5.1° to 7.4°, while the varus group included patients with an FTA range of 0.1° to 4.8°. Knee Outcome Osteoarthritis Score (KOOS), Visual Analog Scale (VAS) scores, sit to stand test results, and six minute walk test data were analyzed. RESULTS: The mean follow-up was 42.0±19.3 months. The postoperative VAS score for the varus group was 0.95±0.99, whereas the neutral group had a VAS score of 2.19±1.83 (p=0.021). The mean KOOS for the varus group was 88.01±7.88, whereas the neutral group had a mean KOOS score of 78.46±13.69 (p=0.006). CONCLUSION: In patients undergoing UKA, mild varus alignment could yield superior early and midterm functional outcomes compared to a neutral femorotibial angle.

Does medullary diameter to stem width ratio and stem length affect outcomes of revision total knee arthroplasties? A case series.

OBJECTIVES: This study aimed to investigate the relationship between the ratio of stem size to intramedullary canal diameter, stem length, and functional outcome in revision total knee arthroplasty (RTKA) procedures, which remains largely unexplored in the current literature. PATIENTS AND METHODS: A single surgeon series of RTKA procedures performed between October 2014 and November 2022 were included in this case series, and data were analyzed retrospectively. A total of 32 patients (27 females, 5 males; mean age: 73.2±8.1 years; range, 52 to 88 years) were identified, with a minimum follow-up period of five months and a maximum of eight years. Filtering the patients based on >24 month follow-up, we were left with 13 patients aged between 65 and 88 (mean 74.9±6.9) years. The latest X-rays of patients were analyzed, and the ratio of intramedullary canal diameter to stem width was calculated for both femur and tibia in both anteroposterior and lateral planes. Household income, preoperative C-reactive protein, erythrocyte sedimentation rate, comorbidities, body mass index, and implant dimensions were also recorded. Postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12 (SF-12) scores, and range of motion (ROM) measurements were used to evaluate functional outcome. RESULTS: A moderate negative relationship between the tibial canal fill ratio (CFR) in anteroposterior views and ROM of the patients was noted. Additionally, a significant positive correlation was found between SF-12 physical score and CFR in lateral view. A moderate level of correlation between femoral CFR in anteroposterior views was also established. Due to insufficient data, joint ROM data did not show normal distribution. Therefore, a cutoff value indicating the relationship between the stem size and knee ROM could not be calculated using receiver operating characteristic analysis. Multiple regression analysis did not yield significant results, suggesting that hypothesized predictor variables were not sufficient to predict the variation in functional scores. Otherwise, no clear statistical importance or correlation between functional scores, such as WOMAC or SF-12, and CFR was found. CONCLUSION: In conclusion, the findings suggest that other factors, such as other patient characteristics, surgical techniques, or implant designs, may have a more substantial impact on the functional outcomes in RTKA patients.

Radiographic assessment of bone tunnels after anterior cruciate ligament reconstruction: A comparison of hamstring tendon and bone-patellar tendon-bone autografting technique.

OBJECTIVES: This study aims to compare the postoperative change of femoral and tibial tunnel widths after hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografting in primary anterior cruciate ligament (ACL) reconstruction surgery with the anteromedial portal technique. PATIENTS AND METHODS: This case-control and retrospective study included 39 patients (36 males, 3 females; mean age 30.1±7.9; range, 17 to 44 years) who underwent primary ACL reconstruction surgery with either BPTB autografting method (BPTB group, n=18) or HT autografting method (HT group, n=21) between March 2014 and December 2016. Femoral fixation was achieved with bioabsorbable screw in BPTB group and endobutton in HT group. Tibial fixation was achieved with bioabsorbable interference screw in both groups. Femoral and tibial tunnel widths of groups were compared on digital radiographs. RESULTS: When we compared the baseline values with the second-year results, the mean of femoral tunnel widths were significantly lower on radiographs at the second-year evaluation in both groups (p<0.001 for all). However, the means of tibial tunnel widths were significantly lower only in the BPTB group (p<0.001 for BPTB group and p=0.616 for HT group). Change levels of anteroposterior and lateral widths were more prominent in BPTB group than HT group (p<0.001 for all). CONCLUSION: Changes in tunnel widths show us superior ossification in BPTB grafting. This can be explained by superior bone-to-bone healing. As a result of radiological evaluation, we think that BPTB grafting can be more strong and durable.

Correction to: Patella-patellar tendon angle and lateral patella-tilt angle decrease patients with chondromalacia patella.

The original article can be found online.

Is iliac autogenous graft augmentation in medial open wedge high tibial osteotomies superior to no augmentation in terms of bone healing?

OBJECTIVES: This study aims to investigate if iliac autogenous graft augmentation in medial open wedge high tibial osteotomies (OWHTOs) is superior to no augmentation in terms of bone healing. PATIENTS AND METHODS: Twenty-five patients (14 males, 11 females; mean age 40.9±4.0 years; range, 33 to 48 years) with medial compartmental osteoarthritis of knee joint who underwent high tibial osteotomy with medial open wedge between January 2016 and December 2018 were included in this retrospective study. Twelve of the operated knees were the right knee. Graft was used in 13 patients (52%). Data including age, gender, body mass index (BMI), direction, follow-up period, union, Lysholm and International Knee Documentation Committee (IKDC) scores, pre- and postoperative femoral tibial angles (FTAs) and posterior tibial slopes were evaluated. RESULTS: The mean BMI was 26.4±1.9 (range, 22.0 to 30.0). Only 48% of the patients were smoking. The mean follow-up period was 28.6±5.3 months (range, 24 to 38 months). No statistically significant difference was found between the grafted and non-grafted groups in terms of age, BMI, follow-up time, gender, side and smoking status (p>0.05) There was no statistically significant difference between two groups in terms of pre- and postoperative Lysholm scores, pre- and postoperative IKDC scores, or pre- and postoperative FTA values (p>0.050). CONCLUSION: Iliac autogenous graft augmentation in medial OWHTO has no effect on union but shortens the union time. Preoperative high varus degree adversely affects union. Therefore, routine use of iliac crest autograft is not recommended.

Patella-patellar tendon angle and lateral patella-tilt angle decrease patients with chondromalacia patella.

PURPOSE: The aim of the present study was to evaluate the effect of patellofemoral joint morphology and patellar alignment (lateral patellar tilt and sagittal patellar tilt) on the presence and stage of CP, and identify the differences between sexes. METHODS: MRI of 243 patients [146 men (60.1%)] were evaluated retrospectively. Patients were grouped as normal group without chondromalacia, group with mild chondromalacia (grades 1-2) and group with severe chondromalacia (grades 3-4). Sagittal patellofemoral alignment was assessed by the angle between the patella and patellar tendon (P-PTA), and the angle between the quadriceps tendon and patella (Q-PA). Patellar tilt was assessed by lateral patellar tilt angle (LPTA). In addition, patellofemoral joint morphology was evaluated by measuring trochlear depth (TD), trochlear sulcus angle (TSA) and patella angle (PA). RESULTS: P-PTA, Q-PA, LPTA and TD values were significantly lower in patients with severe chondromalacia than in patients with both normal and mild chondromalacia (P < 0.001). TSA values were significantly higher in patients with severe chondromalacia than those with both normal and mild chondromalacia (P < 0.001). TSA was higher and TD was lower in women compared to men (P < 0.001). LPTA and P-PTA were lower in women compared to men, and the difference was significant. There was no difference in PA between the two sexes. CONCLUSIONS: Patellar cartilage degeneration increases with trochlear dysplasia. There is a strong correlation between patellar malalignment (lateral patellar tilt and sagittal patellar tilt) and chondromalacia patella. Women are more prone to developing CP than men.

The Relationship Between Nasal Septal Deviation and Paranasal Pneumatization.

OBJECTIVE: To investigate the impact of the presence and the severity of the nasal septal deviation (NSD) on the paranasal pneumatization. METHODS: Initially, the deviated and contralateral sides was compared to evaluate the impact of the presence of NSD on pneumatization. Then, NSD classification groups were categorized according to the severity of deviation degree; 1: mild (<9°), 2: moderate (9°-15°), and 3: severe (>15°). Pneumatization of all paranasal sinuses, osteomeatal complex (OMC), frontoethmoid recess (FER) and variant structures were compared according to the NSD classification groups separately both for the deviated and the contralateral sides. RESULTS: Although there was no statistically significant difference in pneumatization of the paranasal sinuses between the deviated and contralateral sides, a significant difference was observed in OMC and FER diameters. In the deviated side, there was statistically significant difference in ethmoid sinus volume, in FER and OMC diameters between NSD classification groups. In the contralateral side, FER and OMC diameters were found to be significantly different between group 1 and group 2 and between group 1 and group 3, respectively (P = 0.04 and 0.06, respectively). Both the presence and severity of the NSD did not statistically significant influence the pneumatization of variant structures, air cells and vital structures. CONCLUSION: The severity of NSD effects the ethmoid sinus volume. The relationship of FER and OMC with NSD is evident, however this may not always be in a proportional pattern. The paranasal pneumatization did not affect Keros type, bone integrity of carotid canal and optic canal.

Higher Body Mass Index Adversely Affects Knee Function After Anterior Cruciate Ligament Reconstruction in Individuals Who Are Recreationally Active.

OBJECTIVE: Our aim was to investigate the effect of body mass index (BMI) levels on quadriceps and hamstring strength and functional outcomes up to 6 months after anterior cruciate ligament reconstruction (ACLR) with hamstring tendon autograft (HTG). DESIGN: Prospective, controlled study. SETTING: University clinical laboratory. PATIENTS: Ninety-one participants who had undergone unilateral ACLR with HTG were divided into 2 groups according to their BMI. The participants whose BMI were between 18.5 and 24.9 kg/m were included in group 1 (n = 50, age: 27.2 ± 6.7 years, BMI: 22.3 ± 1.6 kg/m) and those whose BMI > 24.9 kg/m were included in group 2 (n = 41, age: 30.2 ± 6.9 years, BMI: 28.0 ± 2.4 kg/m). INTERVENTIONS: Quadriceps and hamstring strength, functional performance including hop, jump, and balance performance, and IKDC score. MAIN OUTCOME MEASURES: Maximum voluntary isometric contraction of the quadriceps and hamstring muscles and the body mass were measured at 1, 3, and 6 months after surgery. Absolute peak torques and normalized peak torques to body weight for both limbs were recorded. Functional outcomes were evaluated at 6 months after surgery. RESULTS: Normalized quadriceps strength improvement was lower in group 2 when compared with group 1 (F(2,178) = 6.23, P = 0.003). Group 2 also demonstrated lower scores in functional performance (P < 0.05). Normalized hamstring and absolute quadriceps and hamstring strength improvement was not affected by higher BMI level (P > 0.05). CONCLUSIONS: Higher BMI levels adversely affect quadriceps strength capacity and performance in patients who have undergone ACLR with HTG. Clinicians should consider BMI levels of patients when assessing and targeting muscle recovery because it could negatively affect the success of the ACLR rehabilitation.

A comprehensive ultrasonographic investigation of the common flexor tendon and medial epicondyle in asymptomatic individuals.

AIM: To investigate the common flexor tendon (CFT) thickness and the frequency of ultrasound (US) pathological alterations in its structure in a healthy population and to evaluate if these findings can be correlated with dominant hand, age, gender, body mass index, workload, menopause status. MATERIAL AND METHODS: The study population consisted of 111 healthy volunteers. Bilateral CFT thicknesses were measured at 5 mm, 10 mm and 15 mm distance to medial epicondyle. Tendon echotexture, tears, calcification, enthesophyte, and neovascularization were also evaluated. RESULTS: The CFT was thicker on the dominant side at all three locations (2.1 versus 1.9 mm proximal, 4.0 versus 3.7 mm in the middle and 7.0 versus 6.6 mm distal, all p<0.05). Thickness correlated negatively with postmenopausal duration in all landmarks, except for the nondominant side distal part and positive with body mass index, significantly on the dominant side proximal and middle parts. A statistically significant correlation was found between heavy workers group and tendon thicknesses on the proximal and middle parts of the dominant side and the distal part of the non-dominant sides. US tendinosis was detected in 24/222 tendons, calcification in 11/222 tendons and enthesophyte in 33/222 tendons. The threshold age was 46.5 years for enthesophytes and 51.5 years for calcifications. The prevalence of calcification and enthesophyte tended to be higher in blue-collar workers and on the dominant side. CONCLUSIONS: The CFT thickness varies depending on measurement locations, handedness, body mass index, postmenopausal duration and workload. The US signs of tendinosis may be encountered in a symptom-free population. Calcification and enthesophyte tended to be more frequent in blue-collar workers.

Short-Term Results of Flexor Hallucis Longus Transfer in Delayed and Neglected Achilles Tendon Repair.

Flexor hallucis longus (FHL) tendon transfer to the calcaneus in the repair of delayed or neglected Achilles tendon (AT) injuries is a viable and dynamic option. Nineteen patients (18 males, 1 female; mean age 47.4 ± 12.4, range 24 to 74, years; body mass index 27.5 ± 4.5, range 23.2 to 38.9, kg/m2; interval from injury to surgery 40.8 ± 11.6, range 28 to 60, days) with delayed or neglected repair of AT rupture were included in the present study. FHL transfer to the calcaneus through a single incision and repair of the defect with native tendon lengthening or a tendinous turndown flap was performed. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot and hallux scale scores, balance and jump performance, ankle dorsiflexion range of motion, and lower extremity concentric and eccentric strength were evaluated 6 months postoperatively. Student's t test was used to compare the outcomes between the operated and nonoperated sides. AOFAS hindfoot and hallux scale scores were 93.83 and 86.9, respectively. No significant difference was found in vertical jump (p = .60), forward jump (p = .68), or balance performance (p > .05). However, less ankle dorsiflexion on the operated side was recorded compared with the nonoperated side (p = .008). Concentric/eccentric muscle strength between the operated and nonoperated side was similar (p > .05). The concentric strength of the operated side reached 92% and eccentric strength reached 101.7% of the nonoperated side's strength. All the patients were satisfied with their results and return to preinjury daily activities. AT repair of a delayed and neglected injury using FHL transfer to the calcaneus in a dynamic fashion provided excellent outcomes.

Do peak torque angles of muscles change following anterior cruciate ligament reconstruction using hamstring or patellar tendon graft?

OBJECTIVES: This study aims to compare the effects of anterior cruciate ligament (ACL) reconstruction using autogenous hamstring or patellar tendon graft on the peak torque angle. PATIENTS AND METHODS: The study included 132 patients (103 males, 29 females; mean age 29±9 year) who were performed ACL reconstruction with autogenous hamstring or patellar tendon graft. The peak torque angles in the quadriceps and hamstring muscles were recorded using an isokinetic dynamometer. RESULTS: Angle of peak knee flexion torque occurred significantly earlier within the range of motion on the operated side than nonoperated side at 180°/second in the hamstring tendon group. Angle of peak knee extension torque occurred significantly earlier within the range of motion on the operated side than nonoperated side at 180°/second in the patellar tendon group. There were no statistically significant differences in the flexion and extension peak torque angles between the operated and nonoperated knees at 60°/second in both groups. CONCLUSION: The angle of peak torque at relatively high angular velocities is affected after ACL reconstruction in patients with hamstring or patellar tendon grafts. The graft donor site directly influences this parameter. This finding may be important for clinicians in terms of preventing re-injury.

Total patellectomy for patellar aneurysmal bone cyst.

Herein we report a case of patellar aneurysmal bone cyst of a 32-year-old female patient who was admitted to our outpatient clinic due to the swelling on her left knee. She was describing no trauma history but increasing pain and that the mass was expanding gradually by the time. Although it occurs rarely in patella, evaluation by radiographic and magnetic resonance images revealed that the mass was due to the patellar aneurysmal bone cyst, which also destructed the surface of the joint. Although there was no impairment in the range of motion of the patient's left knee in the preoperative evaluation, because of the destruction, we performed total patellectomy and extensor mechanism reconstruction by Zaricznyj technique instead of curettage and grafting. The patient was satisfied with the procedure performed after the surgery and there was no complication in the follow-up.

Achilles Tendon Open Repair Augmented With Distal Turndown Tendon Flap and Posterior Crural Fasciotomy.

The aim of the present study was to investigate the outcomes after open repair of Achilles tendon rupture augmented with a distal turndown gastrocnemius flap and deep posterior crural fasciotomy based on the modified Lindholm technique. Twenty-three patients with acute Achilles tendon injury underwent open end-to-end tendon repair augmented with a distal turndown gastrocnemius flap and deep posterior compartment fasciotomy. The concentric and eccentric muscle strength was measured using a functional squat system, and dynamic balance was assessed using the Y-balance test with anterior, posteromedial, and posterolateral reach distances. Jump performance was assessed using the vertical jump and 1-leg hop tests. All patients returned to their preinjury activity level, and their mean American Orthopaedic Foot and Ankle Society hindfoot scale score was 98.2 ± 2.3 after surgery. No significant difference was found between the involved and uninvolved extremities in terms of concentric and eccentric muscle strength (p = .82 and p = .53, respectively). In addition, no significant differences were seen between legs in the vertical jump (p = .16), one-leg hop (p = .15), and balance (p > .05) tests. Open end-to-end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complications. Functional performance of the involved leg after recovery was similar to that of the uninvolved leg. The modified Lindholm surgical technique described in our report appears to be a useful intervention for acute Achilles tendon rupture.

Quadriceps and Hamstring Strength Recovery During Early Neuromuscular Rehabilitation After ACL Hamstring-Tendon Autograft Reconstruction.

CONTEXT: There is lack of information related to quadriceps and hamstring strength recovery during the early period of rehabilitation after anterior cruciate ligament reconstruction (ACLR) using hamstring-tendon graft (HTG). OBJECTIVE: To investigate quadriceps and hamstring isometric strength at 4-, 8-, and 12-wk time points after ACLR and to document the strength changes of these muscles over time. DESIGN: Longitudinal study. PARTICIPANTS: 24 patients (age 28.1 ± 8.1 y) who underwent unilateral single-bundle anatomic ACLR with 4-strand semitendinosus and gracilis tendon graft. MAIN OUTCOME MEASURES: The isometric strength of quadriceps and hamstring muscles was measured on an isokinetic dynamometer at a 60° knee-flexion angle 4, 8, and 12 wk after surgery. RESULTS: Quadriceps and hamstring strength significantly increased over time for both the involved limb (quadriceps F2,46 = 58.3, P < .001; hamstring F2,46 = 35.7, P < .001) and uninvolved limb (quadriceps F2,46 = 17.9, P < .001; hamstring F2,46 =56.9, P = .001). Quadriceps and hamstring indexes significantly changed from 4 wk (QI 57.9, HI 54.4) to 8 wk (QI 78.8, HI 69.9) and from 8 wk to 12 wk (QI 82, HI 75.7) (P < .001); however, there was no difference between indexes at the 12-wk time point (P = .17). CONCLUSIONS: The results of this study serve as a reference for clinicians while directing a rehabilitation protocol for HTG ACLR patients to better appreciate expected strength changes of the muscles in the early phase of recovery.

Comparison between Nintendo Wii Fit and conventional rehabilitation on functional performance outcomes after hamstring anterior cruciate ligament reconstruction: prospective, randomized, controlled, double-blind clinical trial.

PURPOSE: The aim of this prospective, randomized, controlled, double-blind clinical trial was to compare the outcomes, including knee strength, balance, coordination, proprioception and response time, of Nintendo Wii Fit with those of conventional rehabilitation on the subjects with anterior cruciate ligament reconstruction. METHODS: Thirty volunteer subjects were enrolled in either Wii Fit (n = 15; mean age, 29 ± 7 years) or conventional rehabilitation (n = 15; mean age, 29 ± 6 years) programmes from the first week up to 12th weeks of the operation. Endoscopic reconstruction of a completely ruptured ACL was performed by using graft harvested from hamstrings. Each subject underwent an individual therapeutic programme. Functional examinations included the measurements of the balance using modified star excursion balance test, coordination, proprioception and response time using functional squat system and strength of flexor and extensor muscles of the involved and uninvolved leg using an isokinetic machine. RESULTS: There was no significant difference between Wii Fit and conventional group in terms of isokinetic knee strength at 12th week, and dynamic balance, and functional squat tests including coordination, proprioception and response time at first, 8th and 12th weeks of the rehabilitation. CONCLUSION: Two different 12-week-physiotherapy programmes following ACL reconstruction have the same affect on muscle strength, dynamic balance and functional performance values in both groups. We considered that the practice of Wii Fit activities like conventional rehabilitation could also address physical therapy goals, which included improving visual-perceptual processing, coordination, proprioception and functional mobility.

Long-term functional and sonographic outcomes in Osgood-Schlatter disease.

PURPOSE: To evaluate the sonographic characteristics, functional aspects and life quality of a group of adolescent patients 2 years after having been diagnosed with Osgood-Schlatter disease and compare them with an age-matched healthy control group. METHODS: The study was conducted on eighteen Osgood-Schlatter patients with unilateral involvement and 14 age-matched healthy controls. The Flaviis classification and patellar tendon characteristics were observed using a GE Logiq 9 scanner. Broad and vertical jump tests were used for jumping performance. The coordination, proprioception, strength and endurance functions were assessed with the Functional Squat System. For the quality of life, the SF-36 questionnaire was used. The Wilcoxon test for the patients' initial and second-year assessment and Mann-Whitney U test for the comparison between the patient and control groups were used. RESULTS: By the end of second year, 38.9% of the patients had totally recovered. The patellar tendon lengthened, distal diameter and distal area of the tendon had lessened, and no significant difference was observed between patient and control groups (n.s). Improvements were detected for the bilateral broad jump test scores, the quality of life and coordination of the patients after 2 years (p < 0.05). The average power of endurance and the total work of strength were significantly higher in control group (p < 0.05). CONCLUSIONS: According to the sonography results 2 years after diagnosis, nearly half of the patients had totally recovered. Coordination was the only parameter that improved over the 2-year period. The patient group strength and endurance function remained lower than the control group. LEVEL OF EVIDENCE: III.