Arthroscopic Posterior Cruciate Ligament Reconstruction: The Achilles Tendon Allograft versus the Quadriceps Tendon Allograft.

We aimed to compare and analyze the outcomes of arthroscopic posterior cruciate ligament (PCL) reconstruction with the Achilles tendon allograft and the quadriceps tendon allograft. Twenty-nine patients who received the same procedure of arthroscopic PCL reconstruction within our inclusion criteria were reviewed retrospectively. There were 13 patients in the Achilles tendon allograft group and 16 patients in the quadriceps tendon allograft group. At least in 2 years of follow-up period, we evaluated the patients using the posterior drawer test, KT 2000 test, Lysholm knee scoring scale, Tegner activity scale score, International Knee Documentation Committee (IKDC) subjective knee form score, and Telos stress radiography. Between the two groups, no differences were found in preoperative patient demographic factors (age, gender, mean time of surgery, average follow-up period, cause of injury, and combined injury) (p > 0.05). Results of the posterior drawer test, KT 2000 test, Telos stress radiography, Lysholm score, Tegner activity score, and IKDC subjective score were not significantly different between the two groups at preoperative evaluation and after surgery (p > 0.05). On comparing preoperative evaluation and follow-up after surgery, the Achilles tendon allograft group showed significant improvement in the results of the KT 2000 test, Telos stress radiology, and Lysholm score, whereas the quadriceps tendon allograft group showed significant improvement in the results of the KT 2000 test, Telos stress radiology, Lysholm score, Tegner activity score, and IKDC subjective score (p < 0.05). The quadriceps tendon for arthroscopic PCL reconstruction is good alternative allograft for the Achilles tendon for arthroscopic PCL reconstruction. This is a retrospective comparative study.

Risk Factors That Influence Subsequent Recurrent Instability in Terrible Triad Injury of the Elbow.

OBJECTIVE: To identify risk factors associated with subsequent recurrent instability and to identify predictors of poor outcomes in terrible triad injury of the elbow. DESIGN: Retrospective cohort study. SETTING: University trauma center. PATIENTS/PARTICIPANTS: Seventy-six patients who were surgically treated for terrible triad injury of the elbow. INTERVENTION: Review of charts and standardized x-ray images before surgery and 2 years after surgery. Patients were categorized into 2 groups: recurrent instability (group A) or concentric stability (group B). MAIN OUTCOME MEASUREMENT: Primary outcome measures were injury mechanism, time between injury and operation, fracture type, ligament injury, radial head fixation, coronoid fixation, ligament repair, period of postoperative immobilization, joint space restoration, healing progress, secondary operation, functional outcomes, and complications. Secondary outcome measures were age, sex, height, body mass index, bone mineral density, and comorbidities (hypertension and diabetes). Outcomes were measured before surgery and 2 years after surgery and were compared between groups. RESULTS: Recurrent instability occurred in 19.7% of cases; revision surgeries were performed in 12 cases (80%). High-energy trauma (P = 0.012), time between injury and operation (P = 0.001), radial head comminution (P = 0.001), medial collateral injury (P = 0.041), and coronoid nonrepair (P = 0.030) were associated with recurrent instability. Posttraumatic arthritis developed more often in group A (P = 0.001). CONCLUSIONS: Recurrent instability was associated with high-energy trauma, time between injury and operation, Mason type III radial head fracture, medial collateral injury, and coronoid nonrepair. Patients with recurrent instability were more likely to require secondary surgery and develop posttraumatic arthritis than those with concentric stability. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up.

BACKGROUND: Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques. PURPOSE: To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups. RESULTS: No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05). CONCLUSION: With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.

The clinical and radiological results of individualized surgical treatment depending on pathologic abnormalities in recurrent patellar dislocation: low recurrence rate, but unintended patella baja.

PURPOSE: To evaluate the clinical and radiological outcomes and chondral lesion change using individualized surgery for recurrent patellar dislocation. METHODS: A total of 31 knees with recurrent patellar dislocation underwent surgery depending on individual pathologic abnormalities. Pathologic abnormalities including medial laxity, lateral tightness, increased tibial tuberosity (TT)-to-trochlear groove distance (>20 mm), and patella alta (Caton-Deschamps ratio >1.2) were evaluated in each patient. The abnormalities were corrected through medial patellofemoral ligament reconstruction, TT distalization, TT anteromedialization, and lateral retinacula release. The mean follow-up period was 33 months. RESULTS: There was one recurrent case (3.2%), requiring additional surgery. The mean Kujala scores were significantly (P = 0.002) improved from 75.8 (SD 12.4) to 84.6 (SD 13.1). Tegner scores were significantly improved from 3.7 (range 1-9) to 5.4 (range 2-9) (P < 0.001), as were and visual analogue scale pain scores from 4.7 (SD 2.5) to 2.6 (SD 2.2) (P = 0.001). Caton-Deschamps ratio was significantly decreased from 1.1 (SD 0.2) to 0.9 (SD 0.1) (P < 0.001), regardless of TT distalization. Chondral lesions of the patella and trochlear groove were improved or maintained in 57.1 and 71.4% of patients, respectively. CONCLUSION: Individualized surgery in recurrent patellar dislocation was effective and safe with a low recurrence rate. However, the possibility of unintended patella baja, which might be related to post-operative anterior knee pain, should be considered. LEVEL OF EVIDENCE: IV.

Monoclonal antibodies against autocrine motility factor suppress gastric cancer.

Autocrine motility factor (AMF), which is a secreted form of phosphoglucose isomerase, is mainly secreted by various tumors and has cytokine-like activity. AMF is known to stimulate proliferation, survival and metastasis of cancer cells, and angiogenesis within a tumor. The present study investigated whether inhibition of AMF using targeted-antibodies was able to suppress the growth of cancer. A migration assay using a Boyden chamber was utilized to measure the activity of AMF on the motility of cancer cells. A recombinant human AMF (rhAMF) prepared from E. coli transformed with the pET22b-AMF vector increased the motility of MDA-MB-231 and A549 cells, but it did not affect that of NCI-N87 or HepG2 cells, which exhibited the ability to secrete high amounts of their own endogenous AMF into the culture medium. The extent to which the AMF receptor was expressed on cancer cells did not correlate clearly with the cell motility stimulated by rhAMF. In A549-xenografted nude mice treated with sunitinib or cetuximab, a decrease in the plasma AMF concentration was accompanied by a reduction in tumor weight, suggesting an association between the plasma AMF concentration and anticancer activity. A monoclonal antibody (9A-4H), which revealed a high binding affinity for E. coli-derived rhAMF, significantly suppressed the growth of tumors in Balb/c nude mice transplanted with the human gastric cancer cell line NCI-N87, to the similar extent as trastuzumab, an anticancer antibody. The present study suggests, for the first time, that an antibody specific to AMF may be a therapeutic agent for gastric cancer.

Vertical Lifting: A New Optimal Thread Lifting Technique for Asians.

BACKGROUND: With the evolution of facial rejuvenation methods, thread lifts have gained popularity among patients who seek cosmetic improvement. Absorbable wedge-shaped polydioxanone (PDO) sutures are currently available, and they are extremely popular in the aesthetic clinics in Korea. In case of midface and mandibular jowl lift, threads are most often inserted in an oblique manner with vectors of rejuvenation directed toward the temple. However, specific characteristics of skeletal anatomy should be considered when deciding which technique to use in Asians. Herein, the authors introduce a vertical lifting technique most suitable for Asians, in which short (6 cm in length), wedge-shaped PDO sutures are inserted vertically downward in the anterior malar and submalar areas. OBJECTIVE: To describe a novel technique adopted to counteract the descent and laxity of the Asian face. The authors also aimed to assess the overall safety and efficacy of wedge-shaped PDO thread lift in facial rejuvenation. METHODS: A retrospective chart review was performed on cases of facial laxity treated with vertical thread lifting. A total of 39 Korean patients were included. All participants underwent a single treatment session. The results were assessed objectively using serial photography and subjectively based on the patients' satisfaction scores. Complications were also recorded. RESULTS: Most patients (89.7%) considered the results satisfactory. Consensus ratings by 2 independent dermatologists showed that the objective outcomes at the 6-month follow-up were largely categorized as very much improved (10.3%), much improved (43.6%), and improved (33.3%). The incidence of complications was low, and the complications were minor. CONCLUSION: Thread lifting with short, wedge-shaped PDO sutures is safe and effective for facial rejuvenation. The authors' vertical lifting technique has several advantages over the current approaches. First, the vectors directly oppose the vertical sagging of the face, which makes the technique highly efficient. The technique also carries a lower risk of accentuating the cheekbones, a feature which most Asians do not prefer.

Arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears.

PURPOSE: While a conventional single- or double-row repair technique could be applied for repair of C-shaped tears, a different surgical strategy should be considered for repair of U- or L-shaped tears because they typically have complex patterns with anterior, posterior, or both mobile leaves. This study was performed to examine the outcomes of the modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears. METHODS: Thirty-two patients who underwent an arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears between January 2012 and December 2013 were included in this study. Margin convergence was first performed to reduce the tear gap and tension, and then, an arthroscopic Mason-Allen technique was performed to restore the rotator cuff footprint in a side-to-end repair fashion. All patients were evaluated preoperatively and for a minimum of 2 years of follow-up with a visual analog scale (VAS) for pain, Constant score, and ultrasonography. RESULTS: There was significant improvement in all VAS and Constant scores compared with the preoperative values (P < 0.001). Functional results by Constant scores included 9 cases that were classified as excellent, 11 cases as good, 8 cases as fair, and 2 cases as poor. Binary logistic regression analysis revealed that heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes. Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair/poor clinical outcomes. Complications occurred in 5 of the 32 patients (15.6 %), and the reoperation rate due to complications was 6.3 % (2 of 32 patients). CONCLUSIONS: An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears. LEVEL OF EVIDENCE: Case Series, Therapeutic Level IV.

Discrepancy of alignment in different weight bearing conditions before and after high tibial osteotomy.

PURPOSE: To evaluate the differences in the amount of varus malalignment and valgus (over) correction in relation to three different weight bearing conditions from whole leg AP radiographs (single-limb (SL) stance, double-limb (DL) stance, supine position (S)) before and after high tibial osteotomy (HTO), and to evaluate which alignment parameters affect the changes for patients in three different weight bearing conditions. METHODS: A total of 40 consecutive patients (43 knees) with varus osteoarthritis underwent navigation assisted open wedge HTO. Mechanical axis angle (MA) was measured before and after surgery from hip-to-ankle radiographs taken with patients in three different weight bearing conditions. To find significant factors that affect the alignment differences, several variables including patient demographics, soft tissue laxity, pelvic obliquity, and ground mechanical axis deviation of tibia (calculated by the angle between two lines, tibial anatomical axis and weight-bearing line) were evaluated. RESULTS: Pre-operatively, mean MA measured on SL stance radiographs was significantly more varus than on DL stance (10.1° ± 2.4° and 8.0° ± 2.6°, respectively, p < 0.001), which was significantly more varus than on supine position (6.6° ± 2.6°, p < 0.001). Meanwhile, in patients with post-operatively valgus corrected knee, MA did not show the same pattern of change as with pre-operative varus knee. Mean MA measured on DL stance radiographs was more valgus than in supine position (-3.0o ± 2.4o and -2.6o ± 3.1o, p = 0.455), while mean MA on SL stance radiographs (-2.0o ± 2.1o) was significantly less valgus than on DL stance (p = 0.002). The ground mechanical axis deviation of tibia showed a significant correlation with MA difference between SL and DL stance radiographs before (ß = -0.341, p = 0.045) and after surgery (ß = -0.536, p = 0.001). CONCLUSION: In pre-operative varus knee, the mean MA on SL stance was changed to more varus than on DL stance, which changed to less valgus in post-operative valgus knee. The understanding in discrepancy of alignment in different weight bearing conditions before and after HTO should be considered for the appropriate realignment of the limb. STUDY DESIGN: Level II Prospective comparative study.

Atypical Complete Femoral Fractures Associated with Bisphosphonate Use or Not Associated with Bisphosphonate Use: Is There a Difference?

The purpose of this study is to compare clinical characteristics and surgical outcome of atypical complete femoral fractures associated with bisphosphonates (BPs) use and those of fractures not associated with BPs use. Seventy-six consecutive patients (81 fractures) who had been operatively treated for a complete atypical femoral fracture were recruited. Of the 81 fractures, 73 occurred after BPs medication of at least 3 years (BP group) while 8 occurred without a history of BP medication (non-BP group). There were no differences in demographic data and fracture- and surgery-associated factors between the two groups. Of 76 patients (81 fractures), 54 (66.7%) fractures showed bony union within 6 months after the index surgery and 23 (28.4%) showed delayed union at a mean of 11.2 months (range, 8-18 months). The remaining 4 fractures were not healed, even 18 months after the index surgery. There was no difference in healing rate between the BP group and the non-BP group. There were strong correlations between the fracture height and the degree of bowing regardless of BPs medication. All fractures except 1 occurred at the diaphyseal region of the femur when not associated with BP medication.

Triangular Fixation Technique for Bicolumn Restoration in Treatment of Distal Humerus Intercondylar Fracture.

BACKGROUND: Distal humerus intercondylar fractures are intra-articular and comminuted fractures involving soft tissue injury. As distal humerus is triangle-shaped, parallel plating coupled with articular fixation would be suitable for bicolumn restoration in treatment of distal humerus intercondylar fracture. METHODS: This study included 38 patients (15 males and 23 females) who underwent olecranon osteotomy, open reduction and internal fixation with the triangle-shaped cannulated screw and parallel locking plates (triangular fixation technique). Functional results were assessed with the visual analog scale (VAS) scores, Mayo elbow performance (MEP) scores and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. Anteroposterior and lateral elbow radiographs were assessed for reduction, alignment, fracture union, posttraumatic arthrosis, and heterotopic ossification, and computed tomography (CT) scans were used to obtain more accurate measurements of articular discrepancy. RESULTS: All fractures healed primarily with no loss of reduction. The mean VAS, MEP, and DASH scores of the affected elbow were not significantly different from those of the unaffected elbow (p = 0.140, p = 0.090, and p = 0.262, respectively). The mean degree of flexion was significantly lower in the affected elbow than in the unaffected elbow, but was still considered as functional (p = 0.001, > 100° in 33 of 38 patients). Two cases of articular step-offs (> 2 mm) were seen on follow-up CT scans, but not significantly higher in the affected elbow than in the unaffected elbow (p = 0.657). Binary logistic regression analysis revealed that only Association for Osteosynthesis (AO) type C3 fractures correlated with good/excellent functional outcome (p = 0.012). Complications occurred in 12 of the 38 patients, and the overall reoperation rate for complications was 10.5% (4 of 38 patients). CONCLUSIONS: Triangular fixation technique for bicolumn restoration was an effective and reliable method in treatment of distal humerus intercondylar fracture. This technique maintained articular congruency and restored both medial and lateral columns, resulting in good elbow function.

Standard versus over-tensioning in the transfer of extensor indicis proprius to extensor pollicis longus for chronic rupture of the thumb extensor.

PURPOSE: The purpose of this study was to evaluate the functional outcomes of the over-tensioning technique compared with those of the standard tensioning technique in the transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) for the chronic rupture of the thumb extensor. METHODS: Data were collected from patients who underwent tendon transfer using EIP between March 2003 and August 2011. 23 were treated with the standard tensioning technique and 25 patients (Group B) with the over-tensioning technique. While standard tension was maintained with the thumb in full extension and the wrist in 30° of flexion, over-tension was maintained with the thumb in full extension and the wrist in the neutral position. All patients were assessed for total range of motion, elevation and flexion deficit, the thumb grip and pinch strength, and the thumb and the index extension strength compared to the unaffected side, EIP-EPL evaluation as suggested by Lemmen et al. and Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). RESULTS: Group A: total range of motion 115°, elevation deficit 2.0 cm, combined flexion deficit 1.0 cm, thumb extension strength 75%, thumb grip strength 91%, and pinch strength 87%. Functional outcomes were 13 excellent, 6 good, 3 fair, and 1 poor. Median DASH score was 21.3 points. Group B: total range of motion 125°, elevation deficit 1.0 cm, combined flexion deficit 1.5 cm, thumb extension strength 85%, thumb grip strength 88%, and pinch strength 83%. Functional outcomes were 16 excellent, 7 good, 2 fair, and 0 poor. Median DASH score was 19.8 points. There are significant differences in the range of motion, elevation deficit, and extension strength of thumb between the two groups (p=.001, p=.001, and p=.028, respectively). CONCLUSION: While the functional outcomes of both groups were favorably acceptable in a majority of the patients, there were significant differences in aspects of range of motion, elevation deficit, and strength of the thumb between both groups. LEVEL OF EVIDENCE: Case-control study, Level III.