Bone mineral density around the knee after open wedge high tibial osteotomy measured up to 24 months in 51 patients.

PURPOSE: To evaluate bone mineral density (BMD) and radiographic and clinical outcomes of patients with varus knee osteoarthritis treated with open wedge high tibial osteotomy (OWHTO). We hypothesised that medial condyle BMD would decrease and lateral condyle BMD would increase after OWHTO. METHODS: Overall, 51 patients (mean age: 65.3 years; female: 40, male: 11) treated with OWHTO were prospectively enrolled. Several angles using whole single-leg radiographs were measured preoperatively and up to 24 months postoperatively. Five square tibial regions of interest (ROI) located below the proximal tibia as T1-T5 from medial to lateral regions and two square femoral ROI as F1 and F2 from medial and lateral regions, respectively, were defined. M/L BMD ratio was used to define the medial-to-lateral condyle BMD ratio. Femoral condyle BMD (F1 and F2) around the knee, as well as lumbar spine, and ipsilateral and contralateral femoral neck BMD, were measured before OWHTO and 3, 6, 12 and 24 months after OWHTO using dual-energy X-ray absorptiometry. Furthermore, tibial condyle BMD (T1-T5) around the knee was measured before and 24 months after OWHTO. Clinical outcomes were evaluated using the Knee Society knee and function scores, the Knee Injury and Osteoarthritis Outcome Score, and the Lysholm score preoperatively and 24 months postoperatively. A power analysis was performed. RESULTS: F1 BMD decreased by 19.2% from before to 3 months postoperatively. F2 BMD did not change up to 24 months after OWHTO. Femoral M/L BMD ratio decreased by 22.2% 3 months after OWHTO. T1 BMD and tibial M/L BMD ratio decreased, whilst T3, T4 and T5 BMD increased 24 months after OWHTO. Mean hip-knee-ankle angle (HKA) and weight-bearing line ratio were corrected from - 6.8° to 4.5° and 14.7 to 60.7%, respectively, postoperatively. Lumbar spine BMD did not change up to 12 months postoperatively. Ipsilateral femoral neck BMD decreased up to 6 months after OWHTO. CONCLUSION: Medial femoral condyle BMD decreased rapidly within 3 months and continued to decrease up to 12 months, but lateral femoral condyle BMD did not change after OWHTO. BMD measurements around the knee condyle enabled the evaluation of the changes in stress distribution before and after OWHTO with accelerated rehabilitation. LEVEL OF EVIDENCE: II.

Can double-level osteotomy prevent patellofemoral osteoarthritis progression compared with open wedge high tibial osteotomy?

PURPOSE: To compare radiographic, clinical, and arthroscopic findings in patellofemoral (PF) osteoarthritis (OA) between open wedge high tibial osteotomy (OWHTO) and double-level osteotomy (DLO) with the same operative indication. METHODS: After adjustment for patient age, and coronal alignment, 36 knees with OWHTO alone and 36 knees with DLO were compared. Radiographic, clinical, and arthroscopic findings were documented before osteotomy. Arthroscopic findings were observed 1 year after osteotomy, and clinical and radiographic findings were observed 2 years after osteotomy. Patellar height was evaluated using the Insall-Salvati (IS) ratio, Carton-Deschamps (CD) index, and Blackburne-Peel (BP) index. Lateral patellar tilt and patellar shift were measured. A power analysis was performed. RESULTS: The postoperative CD and BP indices in the OWHTO group were lower than those in the DLO group (p < 0.001 and p = 0.001, respectively). The CD and BP indices in both groups significantly decreased postoperatively (all p < 0.001). Tilting angles in the OWHTO and DLO groups significantly decreased postoperatively (p < 0.001 and p = 0.002, respectively). There were no significant differences in American Knee Society scores, Kujala score, and the Knee Injury and Osteoarthritis Outcome Scores between both groups. The PF OA progression of the trochlear in the OWHTO group was higher than that in the DLO group (p = 0.002), and the PF OA progression of the patellar facet in the DLO group and anterior femoral condyle in both groups on the lateral side were higher than those on the medial side (p = 0.006, 0.032, and 0.041, respectively). CONCLUSIONS: DLO decreased the rate of low patellar height compared with OWHTO. DLO decreased the rate of PF OA progression in the trochlea compared with OWHTO. There were no significant differences in clinical outcomes in both groups. LEVEL OF EVIDENCE: Level III, case-control study.

Surgical treatment for a combined anterior cruciate ligament and posterior cruciate ligament avulsion fracture: A case report.

BACKGROUND: Independent avulsion fractures with anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) attachment are relatively common among tibial intercondylar eminence fractures, and their postoperative outcomes are generally favorable. Conversely, huge avulsion fractures of the intercondylar eminence containing the attachment site of both the ACL and the PCL are extremely rare, and the reported clinical outcomes are poor. CASE SUMMARY: We describe a 30-year-old Japanese male's huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and PCL, together with a complete tear of the medial collateral ligament and a partial tear of both the medial and lateral menisci caused by a fall from a high place. All of these injuries were treated surgically, with anatomical reduction and stable fixation. The limb function at 1 year post-surgery was excellent (Lysholm score: 100 points). CONCLUSION: Although this patient's complete surgical repair was complex, it should be performed in similar cases for an excellent final clinical outcome.

Acetabular cartilage abnormalities in elderly patients with femoral neck fractures.

INTRODUCTION: Both hemiarthroplasty (HA) and total hip arthroplasty (THA) are widely accepted surgical procedures for hip replacement following displaced femoral neck fractures. However, in cases involving an intact joint line before surgery, the choice between HA and THA remains debatable. This study investigated the prevalence of acetabular cartilage and labral abnormalities in elderly patients with femoral neck fractures. METHODS: Thirty-seven patients underwent hip arthroplasty for femoral neck fractures between April 2020 and February 2021. After excluding 4 patients, 33 patients (6 men and 27 women; mean age = 82.2 [range = 67-98] years) with fractures in 12 left and 21 right hips were included. After femoral head removal during arthroplasty, the acetabulum was macroscopically examined for the presence of cartilage and labral lesions. Acetabular cartilage abnormalities were classified as either overall degeneration or partial damage according to the cartilage damage classification system. RESULTS: Acetabular cartilage abnormalities, including overall degeneration or partial damage, were found in all hips (100%). Out of the 33 hips, overall degeneration, partial damage, and labral abnormalities were detected in 32 (96.9%), 16 (48.4%), and 9 (27.2%) hips, respectively. DISCUSSION: In this study, most elderly patients with femoral neck fractures exhibited acetabular cartilage and labral abnormalities, which were already present at the time of surgery. Therefore, surgeons should carefully examine these abnormalities as they may impact postoperative outcomes such as pain and function.

Joint line obliquity was maintained after double-level osteotomy, but was increased after open-wedge high tibial osteotomy.

PURPOSE: To compare the radiographic, clinical, and arthroscopic outcomes of varus osteoarthritic knees treated with an open-wedge high tibial osteotomy (OWHTO) alone or with a double-level osteotomy (DLO). It was hypothesized that treatment with DLO would maintain the joint line obliquity (JLO) and acquire better arthroscopic and clinical outcomes after surgery than OWHTO alone. METHODS: Knees with predicted medial proximal tibial angle (MPTA) > 95° were treated with OWHTO alone or with DLO. Preoperatively, age, body mass index, and hip-knee-ankle angle (HKA) differed between the two groups. Therefore, after adjustment for those factors, 34 knees with OWHTO alone and 34 knees with DLO were compared. On whole-leg radiographs for a single leg, HKA, weightbearing line (WBL) ratio, lateral distal femoral angle (LDFA), MPTA, and JLO were measured before and 2 years after surgery. Clinical outcomes were evaluated by the Knee Society Score (KSS) knee, KSS function, Lysholm, and Knee injury and Osteoarthritis Outcome Score (KOOS) scores before and 2 years after surgery. Arthroscopic findings were obtained before and 1 year after surgery. Various factors were compared between the two groups. RESULTS: JLO increased significantly from 1.4° to 6.3° in the OWHTO group (p < 0.001) and changed from 1.0° to 1.3° in the DLO group (n.s.). Postoperative MPTA and JLO in the OWHTO group were significantly higher than those in the DLO group (both p < 0.001). There were no significant differences in the KSS knee, KSS function, and KOOS scores between the two groups. Postoperative Lysholm score in the DLO group was higher than that in the OWHTO group (p < 0.025). Femoral and tibial cartilage regeneration in the medial condyles and deterioration in the lateral condyles did not differ between the two groups on second-look arthroscopy. CONCLUSIONS: JLO was not significantly changed after surgery in the DLO group. DLO enabled the acquisition of physiological JLO compared with OWHTO alone. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Open-wedge high tibial osteotomy using intraoperative control of joint line convergence angle with reference to preoperative supine radiograph.

INTRODUCTION: Preoperative supine joint line convergence angle (JLCA) correlates with postoperative standing JLCA. Here, we compared the radiographic and clinical outcomes of knees with preoperative JLCAs of ≥ 4° and < 4° in open-wedge high tibial osteotomy (OWHTO). We hypothesized that the postoperative coronal alignment in both groups would not be affected by a change in JLCA if this change could predict before surgery. MATERIALS AND METHODS: Eighty-four patients with medial knee osteoarthritis who underwent OWHTO were enrolled retrospectively. A weight-bearing line (WBL) ratio of 62% and a JCLA equivalent to the preoperative supine JLCA were anticipated in preoperative planning. These were intraoperatively set using an alignment rod and a radiolucent protractor under fluoroscopy. Soft tissue correction was defined as correction angle minus bone correction. The participants with preoperative JLCAs of < 4° (low-JLCA group) and ≥ 4° (high-JLCA group) were compared. RESULTS: No significant difference in the coronal alignment was found between the groups after OWHTO. No significant differences in correction angle or bone correction were found between the groups, but the soft tissue correction in the high-JLCA group was higher than that in the low-JLCA group after OWHTO (p = 0.013). CONCLUSIONS: When we controlled intraoperative JLCA, the postoperative coronal alignment was not affected by the change in JLCA and the differences in soft tissue correction between the low-JLCA and high-JLCA groups. However, overcorrection compared with the target coronal alignment remained in both groups. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Varus inclination of the tibia is related to patellofemoral osteoarthritis in Japanese female patients with moderate knee osteoarthritis.

PURPOSE: The aim of this study was to investigate whether the tibial tuberosity-trochlear groove (TT-TG) distance and lateral patellar tilt, which induce patellofemoral osteoarthritis (OA), are related to the coronal deformity of the lower limb in varus knee OA. It was hypothesized that varus inclination of the tibia was negatively correlated with the TT-TG distance and lateral patellar tilt in Japanese female patients with moderate knee OA. METHODS: A total of 104 female patients (139 knees) scheduled to undergo knee osteotomy for varus knee OA were enrolled. The coronal lower limb alignment was measured on anteroposterior whole-leg radiographs. The TT-TG distance, patellar tilt angle, and the patellofemoral joint space were measured both medially and laterally on computed tomography images. The correlations between coronal lower limb alignment and the TT-TG distance or patellar tilt angle, and the correlations between the TT-TG distance or patellar tilt angle and patellofemoral joint space were evaluated. RESULTS: The medial proximal tibial angle was negatively correlated with the TT-TG distance (r = - 0.383, P < 0.01) and patellar tilt angle (r = - 0.34, P < 0.01). Lateral patellofemoral joint space was negatively correlated with the TT-TG distance (r = - 0.256, P = 0.002) and patellar tilt angle (r = - 0.205, P = 0.016). CONCLUSIONS: Varus inclination of the proximal tibia may induce lateralization of the tibial tuberosity and lateral patellar tilt. The tibial tuberosity lateralization and lateral patellar tilt may induce lateral patellofemoral OA in patients with varus knee OA. LEVEL OF EVIDENCE: III.

Coronal shaft bowing of the femur affects varus inclination of the surgical transepicondylar axis in varus knee osteoarthritis.

PURPOSE: This study investigated the relationship between femoral shaft bowing and the orientation of the surgical transepicondylar axis (TEA) in the coronal plane in varus knee osteoarthritis (OA). METHODS: A total of 82 knees scheduled to undergo total knee arthroplasty (TKA) for the treatment of varus knee OA were enrolled. The hip-knee-ankle angle (HKA) was measured preoperatively on anteroposterior whole-leg standing radiographs. The lateral angle between the TEA and the mechanical axis of the femur (MA-TEA) was measured in the coronal plane from preoperative computed tomography (CT) images. Femoral shaft bowing was measured on CT images. Pearson's correlation coefficient was used to examine the correlation of the MA-TEA with the HKA and femoral shaft bowing. RESULTS: The MA-TEA correlated negatively with the HKA (r = - 0.321, P < 0.01) and positively with femoral shaft bowing (r = 0.415, P < 0.01). CONCLUSIONS: The TEA changed to varus as femoral shaft bowing increased in patients with varus knee OA. This suggests that the TEA is not always the centre of the rotational axis of the femur after TKA. In addition, the TEA may not be useful as a consistent parameter in the coronal plane in patients with increasing femoral shaft bowing. LEVEL OF EVIDENCE: III.

Correction to: Pre-operative templating in THA. Part II: a CT-based strategy to correct architectural hip deformities.

The original version of this article unfortunately contained a mistake. The spelling of the Geert Pagenstert name was incorrect.

Nasal absorption enhancement of protein drugs independent to their chemical properties in the presence of hyaluronic acid modified with tetraglycine-L-octaarginine.

Our previous mouse studies demonstrated that mean bioavailability of exendin-4, which is an injectable glucagon-like peptide-1 (GLP-1) analogue whose molecular weight (Mw) and isoelectric point (pI) are ca. 4.2 kDa and 4.5, respectively, administered nasally with poly(N-vinylacetamide-co-acrylic acid) (PNVA-co-AA) bearing D-octaarginine, which is a typical cell-penetrating peptide, was 20% relative to subcutaneous administration even though it was less than 1% when exendin-4 alone was given nasally. The studies also revealed that the absorption-enhancing ability of D-octaarginine-linked PNVA-co-AA for exendin-4 was statistically equivalent to that of sodium salcaprozate (SNAC), which is an absorption enhancer formulated in tablets of semaglutide approved recently as an orally available GLP-1 analogue. From a perspective of clinical application of our technology, we have separately developed hyaluronic acid modified with L-octaarginine via a tetraglycine spacer which would be degraded in biological conditions. The present study revealed that tetraglycine-L-octaarginine-linked hyaluronic acid enhanced nasal absorption of exendin-4 in mice, as did D-octaarginine-linked PNVA-co-AA. There was no significant difference in absorption-enhancing abilities between the hyaluronic acid derivative and SNAC when octreotide (Mw: ca. 1.0 kDa, pI: 8.3) and lixisenatide (Mw: ca. 4.9 kDa, pI: 9.5) were used as a model protein drug. On the other hand, SNAC did not significantly enhance nasal absorption of somatropin (Mw: ca. 22.1 kDa, pI: 5.3) when compared with absorption enhancer-free conditions. Substitution of SNAC with tetraglycine-L-octaarginine-linked hyaluronic acid resulted in a 5-fold increase in absolute bioavailability of somatropin with statistical significance. It appeared that pI hardly ever influenced absorption-enhancing abilities of both enhancers. Results indicated that our polysaccharide derivative would be a promising absorption enhancer which delivers biologics applied on the nasal mucosa into systemic circulation and was of greater advantage than SNAC for enhancing nasal absorption of protein drugs with a larger Mw.

Use of traction table did not increase complications in total hip arthroplasty through direct anterior approach performed by novice surgeon.

PURPOSE: The purpose of this study was to investigate the surgical outcomes of total hip arthroplasty (THA) through direct anterior approach (DAA) performed by beginners by comparing the outcomes after the introduction of DAA-THA between using a normal operating table and a traction table. METHODS: The total subjects were 200 patients, there were 120 cases from the introduction of three surgeons using a normal table and 80 cases from two surgeons using a traction table. The surgical procedure was standardized, and a surgeon skilled in DAA entered the operating room and instructed the novice surgeons of DAA in all cases. RESULTS: The mean operative time was no significant difference between the two groups (p = 0.093). The difference in slope of the operative time was no significant difference between the two groups (p value = 0.089). The mean fluoroscopy time and the mean blood loss were significant difference between the two groups (p < 0.05). The difference in slope of the fluoroscopy time and blood loss were significant difference between the two groups (p < 0.05). There were no intraoperative complications and no reoperations for any reason. CONCLUSIONS: At the facility with a surgeon skilled in DAA, the use of a traction table in DAA did not increase the complication rate compared with the use of a normal operating table when the exclusion criteria for DAA were set and surgery was performed using intraoperative fluoroscopy under supervision by a skilled surgeon.

Pre-operative planning in THA. Part III: do implant size prediction and offset restoration influence functional outcomes after THA?

INTRODUCTION: Few studies evaluated clinical benefits of pre-operative templating in total hip arthroplasty (THA). We investigated whether mismatch between planned and real implant sizes and medio-lateral offsets compromises THA outcomes. MATERIALS AND METHODS: We reviewed records of 184 primary THAs with pre-operative CT scans used for templating. Acetabular offset (AO), femoral offset (FO) and global offset (GO) were measured on pre-operative CT scans, during acetate templating, and post-operative antero-posterior radiographs. Multivariable analyses were performed to determine if Forgotten Joint Score (FJS) and Oxford Hip Score (OHS) at > 2 years were associated with differences between post-operative and planned parameters. RESULTS: The FJS and OHS were not influenced by mismatch of component sizes nor of FO and GO. The FJS was better when the post-operative AO was greater than planned (p = 0.050). The FJS differed among arthritic types (p = 0.015). Multivariable analyses confirmed that older patients had better OHS (beta - 0.16; p = 0.033) and FJS (beta 0.74; p = 0.002), medialized hips had worse FJS (beta - 20.1; p = 0.041) and hips with greater AO than planned had better FJS (beta 1.71; p = 0.024) CONCLUSIONS: Implanting a component of different size than planned did not compromise THA outcomes, but medialized hips had worse scores, and conservative acetabular reaming improved scores.

Pre-operative templating in THA. Part II: a CT-based strategy to correct architectural hip deformities.

INTRODUCTION: Pre-operative templating for total hip arthroplasty (THA) remains inaccurate due to improper magnification and alignment. We aimed to describe an improved templating strategy using computed tomography (CT) to predict component sizes and offsets with greater accuracy. MATERIALS AND METHODS: We analysed 184 CT images acquired for pre-operative templating of primary THA. We aimed to restore native (pre-arthritic) femoral offset and limb length, by raising the head center to the level of the templated cup center cranio-caudally, but maintaining the pathologic (pre-operative) head center medio-laterally (except in medialized hips). Acetabular offset (AO) and femoral offset (FO) were measured on pre-operative CT scans, during acetate templating, and on post-operative true antero-posterior radiographs. RESULTS: The post-operative offsets were within ± 5 mm from templated estimates in 174 hips (91%) for AO, in 116 hips (61%) for FO, in 111 hips (58%) for GO, and in 134 hips (70%) for neck cut level. The post-operative hip architecture reproduced the templated hip architecture within ±5 mm in 77 hips (40%). The agreement between planned and post-operative parameters was moderate for stem size (0.57), cup size (0.62), AO (0.50), but fair for FO (0.45). The AO decreased in most arthritic types, notably in lateralized hips (6.6 mm), but remained unchanged in medialized hips. The FO increased in most arthritic types (1.8-3.1 mm) but remained unchanged in medialized and lateralized hips. CONCLUSIONS: We described a strategy for pre-operative templating in THA. Despite the accuracy of CT, the authors found significant variations between planned and post-operative reconstructions, which suggest that pre-operative templating should only be used as an approximate guide.

Joint line convergence angle predicts outliers of coronal alignment in navigated open-wedge high tibial osteotomy.

INTRODUCTION: Using a navigation system in open-wedge high tibial osteotomy (OWHTO) has higher accuracy than using the conventional method. However, unintentional over- and under-correction still exist. This study aimed to compare various factors related to over- and under-correction and to assess their predictive factors in the preoperative radiographs. MATERIALS AND METHODS: This study involved 96 knees. The difference in the hip-knee-ankle angle (HKA) between the intraoperative navigation system and postoperative radiograph was termed navigation correction loss (NCL). Knees with absolute values of NCL (|NCL|) ≦ 1.5° and |NCL| > 1.5° were categorised into acceptable (n = 46) and outlier (n = 50) groups, respectively. The differences in joint line convergence angle (JLCA) between varus and valgus radiographs, varus JLCA, valgus JLCA, standing JLCA and standing HKA were compared between the two groups. Clinical results were evaluated using the American Knee Society (AKS) scores. RESULTS: The mean intraoperative HKA in the navigation system was - 3.8 ± 1.8°, and that in the postoperative standing radiograph was - 4.2 ± 2.5° (p = 0.033). Preoperative varus, valgus and standing JLCA were higher in the outlier group (p = 0.018, p = 0.020 and p = 0.001, respectively). Logistic regression analyses for preoperative factors of |NCL| ≦ 1.5° showed that standing JLCA was a determining factor, with an odds ratio of 1.334 (confidence interval was 1.087-1.637, p = 0.006). AKS score was higher in the acceptable group (p = 0.040) postoperatively. CONCLUSIONS: Higher preoperative standing JLCA was the predictive factor of |NCL| > 1.5°. This factor reduced the rates of under- and over-correction and resulted in better AKS score in OWHTO.

Effect of Increased Coronal Inclination of the Tibial Plateau After Opening-Wedge High Tibial Osteotomy.

PURPOSE: To assess whether the increased inclination of the tibial plateau on the coronal view after opening-wedge high tibial osteotomy affects radiographic coronal alignment, clinical outcomes, and cartilage findings. METHODS: After adjustment for the preoperative medial proximal tibial angle (MPTA), patients who underwent opening-wedge high tibial osteotomy were retrospectively divided into those with postoperative MPTA values of 95° or less (normal group) and greater than 95° (increased group), with each group containing 43 knees. The 2 groups were compared regarding their arthroscopic cartilage findings at 1 year postoperatively and radiographic coronal alignment and clinical outcomes at 2 years postoperatively. Cartilage regeneration in the medial condyles and cartilage deterioration in the lateral condyles were evaluated at the time of second-look arthroscopy. Clinical outcomes were evaluated by the American Knee Society knee and function scores, Lysholm knee scoring scale, and Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: The postoperative anatomic femorotibial angle in the increased group was lower than that in the normal group (P < .001), and the amount of overcorrection in the increased group was higher than that in the normal group (P < .001). The postoperative joint line obliquity in the increased group was higher than that in the normal group (P < .001). Cartilage regeneration in the medial condyles and deterioration in the lateral condyles did not differ significantly on the femoral and tibial sides between the groups. The postoperative American Knee Society knee score and KOOS sports and recreational function subscale score in the normal group were higher than those in the increased group (both P < .001). CONCLUSIONS: There were no significant differences in the changes in the appearance of the articular surfaces between the 2 groups at 1 year postoperatively. Patients with a postoperative MPTA greater than 95° had more valgus alignment and higher joint line obliquity and had a lower KOOS sports and recreational function subscale score than patients with a postoperative MPTA of 95° or less at 2 years postoperatively. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Midterm Clinical Results in Rugby Players Treated With the Bristow Procedure.

BACKGROUND: Although surgical shoulder stabilization by coracoid transfer is effective for collision athletes and has a low reinjury rate, no reports have described the midterm results of this procedure in specific patient cohorts of sufficient number or provided subjective assessments of these patients. PURPOSE: To evaluate midterm results after treatment of shoulder instability with the Bristow procedure in a large cohort of rugby players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 176 shoulders of 152 competitive rugby players who underwent shoulder stabilization surgery (Bristow procedure with Bankart repair) with a mean follow-up of 4 years (minimum of 2 years) in our institute. The primary outcome measure was the difference in the presurgical and postsurgical functional Rowe score and Western Ontario Shoulder Instability index (WOSI) score and factors affecting these scores. Complication rates and associated factors were also investigated. RESULTS: In total, 176 shoulders of 152 patients underwent the Bristow procedure with Bankart repair, and 93.2% of the players returned to their preinjury competition level at a mean of 6.3 months postoperatively. All Rowe and WOSI scores were significantly improved after surgery. The numbers of shoulders with functional failure as indicated by the Rowe score, WOSI score, and inability to return to the previous level of play were 28 (15.9%), 54 (30.7%), and 12 (6.8%), respectively. Multiple logistic regression analyses demonstrated that reinjury after surgery (odds ratio [OR] = 35.1) and the number of shoulder dislocations (OR = 11.2-11.4) negatively affected the competition level after return to play, while reinjury (OR = 11.1-17.8), the number of shoulder subluxations (OR = 1.1-2.9), injury in the dominant shoulder (OR = 1.2-2.2), and large bone defects (OR = 1.1-11.5) negatively affected functional scores. Reinjury after shoulder stabilization occurred in 6 of 176 shoulders (3.4%). Multiple logistic regression analysis demonstrated that reinjury after surgery occurred more frequently in players at lower versus higher grade levels of competition (OR = 21.0). Although differences were not significant, a trend was noted toward higher postoperative reinjury rates in forward players, those in the upper categories (professional and college), and those with injury in the nondominant shoulder. CONCLUSION: The Bristow procedure provides good midterm outcomes for competitive collision athletes, while postsurgical reinjury, the number of preoperative dislocations and subluxations, and large bone defects negatively affect postsurgical shoulder function. This information may be useful for treatment of shoulder dislocations in collision athletes.

Mosaic Osteochondral Autograft Transplantation Versus Bone Marrow Stimulation Technique as a Concomitant Procedure With Opening-Wedge High Tibial Osteotomy for Spontaneous Osteonecrosis of the Medial Femoral Condyle.

PURPOSE: To evaluate the effects of osteochondral autograft transplantation (OAT) mosaicplasty as a concomitant procedure with opening-wedge valgus high tibial osteotomy (HTO) for spontaneous osteonecrosis of the medial femoral condyle (MFC) on clinical outcomes and cartilage status in comparison with bone marrow stimulation (BMS) by drilling, and to assess the relation between lesion size and postoperative cartilage status. METHODS: Fifty-eight patients with spontaneous osteonecrosis of the MFC were treated with opening-wedge HTO and a concomitant procedure of BMS (28 patients) or OAT (30 patients). Clinical evaluation was carried out using the Knee Society Score at postoperative 2 years. Postoperative status of articular cartilage was assessed by arthroscopy according to the International Cartilage Repair Society (ICRS) grade at the time of plate removal. RESULTS: The Knee Society Score objective score and function score were improved at postoperative 2 years compared with preoperative value in both groups, but no significant difference was found between the 2 groups. According to the ICRS overall repair grade, cartilage status was rated as normal or nearly normal (ICRS overall score ≥8) in 41% of the BMS group and 90% of the OAT group. The results suggested that cartilage repair in OAT was significantly better than that in BMS (P = .0015). Furthermore, the BMS group revealed that repair with normal or nearly normal was observed in all less than 4 cm2 of lesion size, whereas the OAT group exhibited that repair with normal or nearly normal was independent of lesion size. CONCLUSIONS: This study suggested that OAT is superior to BMS as a concomitant procedure with opening-wedge valgus HTO for spontaneous osteonecrosis of the MFC in the success of cartilage repair. However, clinical outcomes were not significantly different between these 2 procedures. When treating the lesion larger than 4 cm2 by joint-preserving surgery, OAT mosaicplasty is recommended as a concomitant procedure with HTO. LEVEL OF EVIDENCE: Level III, therapeutic case-control study.

Combined CT-based and image-free navigation systems in TKA reduces postoperative outliers of rotational alignment of the tibial component.

INTRODUCTION: Rotational malpositioning of the tibial component can lead to poor functional outcome in TKA. Although various surgical techniques have been proposed, precise rotational placement of the tibial component was difficult to accomplish even with the use of a navigation system. The purpose of this study is to assess whether combined CT-based and image-free navigation systems replicate accurately the rotational alignment of tibial component that was preoperatively planned on CT, compared with the conventional method. MATERIALS AND METHODS: We compared the number of outliers for rotational alignment of the tibial component using combined CT-based and image-free navigation systems (navigated group) with those of conventional method (conventional group). Seventy-two TKAs were performed between May 2012 and December 2014. In the navigated group, the anteroposterior axis was prepared using CT-based navigation system and the tibial component was positioned under control of the navigation. In the conventional group, the tibial component was placed with reference to the Akagi line that was determined visually. Fisher's exact probability test was performed to evaluate the results. RESULTS: There was a significant difference between the two groups with regard to the number of outliers: 3 outliers in the navigated group compared with 12 outliers in the conventional group (P < 0.01). CONCLUSIONS: We concluded that combined CT-based and image-free navigation systems decreased the number of rotational outliers of tibial component, and was helpful for the replication of the accurate rotational alignment of the tibial component that was preoperatively planned.

Total hip arthroplasty via the direct anterior approach with a dual mobility cup for displaced femoral neck fracture in patients with a high risk of dislocation.

INTRODUCTION: Although total hip arthroplasty (THA) is superior to bipolar hemiarthroplasty (BHA) for displaced femoral neck fracture in terms of hip pain, function and reoperation rate, THA has a higher rate of dislocation. The direct anterior approach (DAA) and a dual mobility cup (DMC) are associated with lower rates of dislocation. The aim of this study was to investigate the outcomes of THA compared with BHA, and in those patients who had a THA we investigated those with a DMC (DMC-THA) and compared them with those had a single conventional cup (Single cup-THA). MATERIALS: A total of 89 patients living independently were included between 2009 and 2015. We assessed patient characteristics, peri- and post-operative outcomes, walking ability and one-year mortality. Adjusted odds ratios (Adjusted ORs) were estimated for decrease of walking ability and one-year mortality using a logistic regression model with adjustment for potential confounders such as age, neuromuscular diseases with weakness, duration of surgery, perioperative blood loss and preoperative walking ability. RESULTS: BHA (20 patients) versus THA (69 patients): There was no significant difference in the walking ability in either group. Multivariable logistic regression analysis demonstrated a significant association with one-year mortality in both groups [THA Adjusted ORs 0.088 (95% CI 0.0007-0.69); p = 0.020]. Single cup-THA (36 patients) versus DMC-THA (33 patients): The DMC-THA group had significantly greater age and more patients with neuromuscular diseases with weakness compared with the Single cup-THA group. Multivariable logistic regression analysis demonstrated no significant difference in the decrease of walking ability and in the one-year mortality between the groups. There were no post operative dislocations in any group. DISCUSSION: THA via the DAA is one of the best treatments for displaced femoral neck fracture with a low risk of dislocation. THA via the DAA with a DMC is a safe and effective treatment for the patients with a high risk of dislocation.

Prolonged infection at the tibial bone tunnel after anterior cruciate ligament reconstruction.

A 24-year-old man with severe atopic dermatitis underwent anterior cruciate ligament (ACL) reconstruction of the right knee seven years earlier but developed a surgical site infection. The infection did not heal after removal of the metal implants, and a fistula eventually developed. This condition was left untreated for six years before he was referred to our hospital. Magnetic resonance imaging showed fluid in the tibial bone tunnel and extensive bone marrow edema surrounding the bone tunnel. Based on these findings, abscess formation within the tibial bone tunnel and osteomyelitis spreading to the proximal tibia were suspected. During the surgery, a portion of artificial ligament and non-absorbable suture were observed in the bone tunnel, and the infection healed immediately after removal of this complex. When surgical site infection occurs after ACL reconstruction, it is important to completely remove all artificial materials as early as possible.