Transvaginal approach combined intracavitary and interstitial brachytherapy assisted by transrectal ultrasound: results from 30 patients with locally advanced cervical cancer.

PURPOSE: This study evaluated the efficacy and safety of transvaginal approach combined intracavitary and interstitial brachytherapy (IC/IS BT) assisted by transrectal ultrasound (TRUS) for treatment of locally advanced cervical cancer (LACC). MATERIALS AND METHODS: A total of 30 patients of LACC treated with external beam radiotherapy and IC/IS BT via transvaginal approach assisted by transrectal ultrasound were observed retrospectively. The 2-year local control (LC), progression-free survival (PFS), and overall survival (OS) were analyzed using the Kaplan-Meier method. Late adverse events were also evaluated to assess the safety of IC/IS BT. RESULTS: The median follow-up period was 22 months. The 2-year LC, PFS, and OS were 90%, 61%, and 82%, respectively. We observed no critical complications related to the IC/IS BT technique. Late adverse events of grade 3 or more included one case of grade 4 colon perforation. CONCLUSION: Our patient series demonstrated that radiotherapy combined with transvaginal approach, TRUS-assisted IC/IS BT achieves favorable local control and safety for LACC.

Ultrasonographic diagnosis of medial meniscus posterior root tear in early knee osteoarthritis: a comparative study.

INTRODUCTION: This study aimed to detect medial meniscal posterior root tear (MMPRT) diagnostic methods with high sensitivity and specificity using dynamic ultrasonographic evaluation in patients with early knee osteoarthritis (OA) and demonstrate the usefulness of dynamic ultrasonographic medial meniscal extrusion (MME) evaluation in MMPRT diagnosis using a cutoff value. MATERIALS AND METHODS: Between 2018 and 2020, a total of 120 patients were diagnosed with early knee OA using clinical and radiographic findings. Dynamic ultrasonographic evaluations and magnetic resonance imaging were performed in all patients, and 47 patients who had and 73 patients who did not have MMPRT were classified into the MMPRT and non-MMPRT groups, respectively. Age, sex, femorotibial angle, MME of knee extension and flexion, and MME at weight-bearing were compared between the two groups. Additionally, the sensitivity and specificity of significant ultrasonographic findings were calculated using a receiver operating characteristic (ROC) curve. RESULTS: The MMEs under knee extension-flexion and weight-loading in the MMPRT group were significantly larger than those in the non-MMPRT group. ROC curve analysis for each ultrasonographic evaluation condition to diagnose MMPRT indicated that the sensitivity was 72-88% and the specificity was 66-85% when the cutoff values of MME under knee flexion at 0°, 90°, and weight-loading were set at 2.55 mm, 2.00 mm, and 3.55 mm, respectively. The highest sensitivity (88%) and specificity (85%) were exhibited upon > 2 mm MME at a knee flexion of 90° and were the most useful indicators for MME diagnosis. CONCLUSIONS: Ultrasonographic MME evaluations for MMPRT diagnosis showed relatively high sensitivity and specificity in patients with early knee OA. Dynamic ultrasonographic MME evaluation may lead to appropriate additional examinations, early diagnosis, and intervention for MMPRT in patients with early knee OA.

Usefulness of Intraoperative Narrow-Band Imaging in the Site Diagnosis of Respiratory Papillomatosis.

OBJECTIVE: Narrow-band imaging (NBI) is considered useful for detecting respiratory papillomatosis. However, the choice between preoperative and intraoperative NBI depends on the facility. We investigated the usefulness of NBI and determined whether preoperative NBI can replace intraoperative NBI with a comparable detection rate. METHODS: In this retrospective cohort study conducted at single a tertiary care center, patients with respiratory papillomatosis treated between 2017 and 2022 were enrolled. We systematically compared preoperative white light imaging (WLI) with preoperative and intraoperative NBI. The primary endpoints were the papilloma detection rate and lesion site assessed by the Derkay scoring system. The secondary endpoints were the risk factors for increased Derkay scores. RESULTS: The study included 127 patients with papilloma. Intraoperative NBI yielded significantly higher Derkay scores than preoperative WLI (p < 0.001) and preoperative NBI (p = 0.004). The papilloma detection rates of preoperative WLI and preoperative NBI were not significantly different. Intraoperative NBI detected more lesions than preoperative NBI in 37 of 127 (29%) patients; the overall number of additional lesions was 47 of 279 (17%). Compared with preoperative NBI, intraoperative NBI yielded significantly higher scores for the vocal cords (p = 0.005), false vocal cords (p = 0.010), and ventricle of the larynx (p < 0.001). Elevated Derkay scores were significantly associated with male sex (p = 0.012) and alcohol consumption (p = 0.007). CONCLUSION: Intraoperative NBI is more accurate in detecting papillomatous lesions, and preoperative NBI cannot replace intraoperative NBI. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1820-1824, 2024.

Tracheostoma Closure Technique Using Three Local Flaps.

When a tracheostoma is no longer needed, the opening normally closes spontaneously after cannula removal, but some cases require tracheostoma closure. This procedure has been well described, but must be performed in such a way as to minimize its invasiveness and complications while securing a high closure rate. Our procedure for conducting tracheostoma closure technique involves the creation of two hinge flaps and one cover flap to close the tracheostomy opening. We reviewed the medical records of 23 patients (12 men, 11 women; mean age 60.0 SD19.7 years) who underwent tracheostoma closure technique between 2001 and 2019. Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2 months following cannula removal. The surgical procedure began by raising two hinge flaps on either side of the tracheostomy opening, turning the skin surface to the luminal side to form the anterior tracheal wall. Rather than a single layer of skin, multiple skin layers were sutured together to prevent air leakage from between hinge flaps. A further cover flap was produced to cover the anterior tracheal wall, closing the tracheostomy opening. Postoperatively, the tracheal lumen was observed via fiberscopy. No stenosis of the tracheal lumen occurred in any patients, and the tracheocutaneous fistula was successfully closed in all cases. Tracheostoma closure technique using hinge flaps to reconstruct the anterior tracheal wall and a cover flap as a skin flap to cover the skin defect appears useful for patients with failure of spontaneous tracheocutaneous fistula closure.

Repeated Surgery in a Case of Epithelial-Myoepithelial Carcinoma of the Parotid Gland that was Difficult to Distinguish from Pleomorphic Adenoma.

Epithelial-myoepithelial carcinoma (EMC) of the parotid gland is a comparatively rare tumor that accounts for less than 1% of all salivary gland tumors. A patient with EMC of the parotid gland that was initially diagnosed as pleomorphic adenoma and that recurred locally during the watchful waiting period but was controlled by surgery under local anesthesia is reported. An 80-year-old man had noticed a swelling in the left infra aural region. A left parotid gland tumor was suspected, and he was referred to our department. Magnetic resonance imaging (MRI) and fine-needle aspiration cytology findings were suggestive of pleomorphic adenoma of the superficial lobe of the parotid gland, and this was therefore resected under general anesthesia. Postoperative histopathological examination, immunostaining, and genetic tests resulted in a diagnosis of EMC. Postoperative pathological review showed that part of the resection margin was positive. The possibility of recurrence was explained to the patient, and additional treatment was recommended, but since the patient did not desire this, a policy of watchful waiting was adopted. Signs of cutaneous metastasis in the left infra aural region were detected at 13 months postoperatively, and this metastasis was excised under local anesthesia. The resection margin was negative, and the patient's course remains uneventful. EMC is classified as a low-grade malignant tumor, but it requires stringent monitoring because of its frequent local recurrence. Since local control can usually be achieved by surgical treatment alone, and postoperative adjuvant therapy may not necessarily warranted.

Ultrasound-guided adductor canal block is superior to femoral nerve block for early postoperative pain relief after single-bundle anterior cruciate ligament reconstruction with hamstring autograft.

PURPOSE: This study aimed to compare the combination of a lateral femoral cutaneous nerve (LFCN) block with a femoral nerve block (FNB) and an adductor canal block (ACB) for postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring autograft. METHODS: A non-randomized, prospective, controlled clinical trial was conducted. The FNB and ACB groups consisted of 41 and 40 patients, respectively. Thirty minutes prior to surgery, the patients received an ultrasound-guided LFCN block either with FNB or ACB. The following values were recorded and compared between the two groups: duration of surgery, pain management during surgery (including total amount of fentanyl administered), and numerical rating scale (NRS) scores at 30 min and 4, 8, 12, 24, 48, and 72 h after surgery. Factors affecting pain relief (NRS < 2) were evaluated, including block type, total amount of fentanyl administered, duration of surgery, age, sex, body mass index, and postoperative suppository use. Significant factors predicting pain relief were determined using the Cox proportional hazard regression model. RESULTS: There were no significant differences in pain management during the surgery. Pain scores were significantly lower in the ACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The Cox proportional hazard regression model identified ACB as a significant factor for pain relief (hazard ratio: 1.88; 95% confidence interval: 1.12-3.13; p = 0.018). CONCLUSION: The combination of ACB with LFCN block during ACL reconstruction significantly reduced pain in the early postoperative period compared to FNB with LFCN block.

Inferior Surface Leukoplakia of Vocal Folds: Risk of Recurrence: A Preliminary Study.

OBJECTIVES: This study aimed to identify vocal fold leukoplakia (VFL) lesions on the inferior surface as a risk factor for recurrence. METHODS: This was a retrospective study with data collected from 2001 to 2018. The study comprised 37 patients with VFL, divided into the nonrecurrent and recurrent groups. We examined the clinicopathological characteristics and the surgical procedures performed in each patient. RESULTS: Among the 37 patients, 15 (40.5%) had residual (3) or recurrent (12) VFL. Of those patients with and without recurrence, 8 of 12 (66.7%) and 6 of 22 (27.3%), respectively, had inferior surface lesions of the vocal fold at the initial operation (P = .036). Recurrences were significantly higher in patients with inferior surface lesions. Other evaluated factors did not show significance for recurrence. CONCLUSION: The presence of VFL lesions on the inferior surface is a significant risk factor for recurrence.

Posterior Cervical Intramuscular Schwannoma Within the Trapezius Muscle: A Case Report.

Schwannomas are benign soft tissue tumors derived from the Schwann cells of the peripheral nerves. An intramuscular schwannoma arising within the trapezius muscle in the posterior neck is rare. We report a case of a 31-year-old woman with an intramuscular schwannoma in the trapezius muscle. A painless and smooth-surfaced mass from 10 years ago was evident on palpation in the right posterior neck. Ultrasonography revealed an oval mass with clear borders and slight internal blood flow. No continuous hypoechoic lesions were noted at the tip of the mass. Magnetic resonance imaging of the neck revealed a mass in the right posterior cervical trapezius muscle with isointensity on T1-weighted imaging and heterointensity on T2-weighted imaging. Based on these findings, a schwannoma was suspected. Ultrasonography guided fine needle aspiration cytology revealed no significant findings. During surgery, a white-colored, encapsulated-tumor mass was found in the trapezius muscle. Histopathologically, hypocellular and hypercellular areas of fusiform cells were conspicuous, and nuclear palisading was observed in a part of the hypercellular region, confirming the diagnosis of schwannoma. To our knowledge, this is an extremely rare report of an intramuscular schwannoma within the trapezius muscle; herein, we report its clinical, radiological, and pathological features.

Human Papillomavirus Vaccination as an Adjuvant Therapy for Recurrent Respiratory Papillomatosis: Additional Case Series.

Prevention of the recurrence of recurrent respiratory papillomatosis (RRP), a neoplasm of the respiratory tract, is a challenge. Human papillomavirus (HPV) vaccine has been expected to suppress the aggressiveness of RRP. However, there has been insufficient data to verify whether HPV vaccination can serve as an adjuvant therapy option for RRP. The aim of this study was to add our data on the efficacy of HPV vaccination for RRP to the academic discipline. Twenty-four RRP patients were treated with a combination therapy of surgery and three sessions of quadrivalent HPV vaccine. The patients' clinical courses, which were HPV infection status changes, intersurgical interval, and disease severity score (Derkay's site score), were statistically analyzed before and after combination therapy. Twelve of the 24 (52.5%) RRP patients who were HPV-DNA positive turned negative after the combination therapy. The mean of intersurgical interval was significantly extended from 6.85 ± 4.49 months to 30.5 ± 27.6 months after the therapy (P <0.01). The median of Derkay's score of the participants also significantly decreased from 7.5 (interquartile range, 5-12) to 1 (interquartile range, 0-4.25) after the therapy (P <0.01). Thus, combination therapy comprising of surgery and HPV vaccination can postpone the recurrence and lessen the severity of RRP.

Thyroid hyalinizing trabecular adenoma with a high thyroglobulin level: a case report.

Thyroid hyalinizing trabecular adenoma (HTA) is a rare and borderline tumor of follicular origin. It is characterized by a trabecular growth pattern and marked intratrabecular hyalinization. Excessively elevated thyroglobulin levels have not been reported previously in cases without bilateral lung metastases. Here, we present a case of a 54-year-old woman with chronic thyroiditis with a 50-mm tumor in the left lobe of the thyroid gland, which was observed on ultrasonography. Her thyroglobulin level was found to be elevated at 684 ng/ml. Since fine needle aspiration cytology could not exclude possible malignancy, she underwent thyroid lobectomy; the final diagnosis was thyroid HTA. Two weeks after resection, her thyroglobulin level showed negative conversion. To our knowledge, this is the first report of a patient with a thyroid HTA exhibiting a thyroglobulin level as high as that for a patient with hyalinizing trabecular carcinoma.

Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.

OBJECTIVE: The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. METHODS: A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N. RESULTS: Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032). CONCLUSION: In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics. LEVEL OF EVIDENCE: The level-of-evidence statement does not apply for this laboratory experiments study.

Tegner level is predictive for successful return to sport 2 years after anterior cruciate ligament reconstruction.

PURPOSE: For a successful return to sport (RTS) after an anterior cruciate ligament reconstruction (ACLR), patients are recommended to attend a comprehensive rehabilitation program, followed by an RTS assessment, that is a combination of tests. The purpose of this study was to predict a successful return to sport using the results of the RTS assessment and self-reported questionnaires at minimum 2 years after ACLR. METHODS: A total of 123 consecutive ACLR patients undertook an intensive rehabilitation program followed by a comprehensive RTS assessment that included an established combination of balance and strength tests, the ACL-return to sport after Injury scale (ACL-RSI) questionnaire and a KT1000 laximetry test. Preinjury and expected Tegner and Lysholm were collected at baseline, at RTS and prospectively collected at minimum 2-year follow-up. The patients were asked if they returned to their previous sport and at which level. All variables were included in a regression analysis predicting a successful return to previous sport, return to the same level of sport as well as the Tegner level at 2 years. RESULTS: Sixty-two patients (50%) returned to their previous sport by the 2-year follow-up, without a difference in preinjury Tegner between these two groups (n.s.). Expected preoperative Tegner was the only significant predictor of a successful return to previous sport (p = 0.042; OR 1.300, 95% CI 1.010-1.672). Out of the 62 patients returning to their previous sport, 38 (61%) reported to be on the same or higher level. The only predictive variable for returning to the same level was the higher preinjury Tegner level (p = 0.048; OR 1.522). Multivariate regression analysis of Tegner level at 2 years found younger age to be the only predictive value. From the RTS assessment tests, the ACL-RSI questionnaire and the posterolateral balance test were predictive variables for Tegner at 2-year follow-up, albeit in the univariate regression analysis. CONCLUSIONS: Preoperative Tegner and expected Tegner level collected prior to an ACL reconstruction can aid in the objective prediction of patients' return to sport after 2 years. High-level athletes are more likely to return to their previous sport and to the previous level. Younger patients achieve a higher Tegner level at 2 years. LEVEL OF EVIDENCE: Level III study.

Adjustable suspension versus hybrid fixation in hamstring autograft anterior cruciate ligament reconstruction.

BACKGROUND: There has been increased use of adjustable suspensory fixation (ASF) for anterior cruciate ligament reconstruction (ACLR). Potential benefits are the ability to use a shorter graft and to prevent graft displacement and damage. The purpose of this study was to establish the efficacy of this fixation method and assess whether it leads to less tunnel widening, and avoids known complications of screw fixation. METHODS: Thirty-eight patients who underwent ACLR with ASF on both the femoral and tibial sides met the inclusion criteria and were propensity matched demographically with 38 patients who underwent hybrid fixation with femoral suspensory and tibial screw and sheath. At one-year, KT-1000 knee laxity measurements were recorded and detailed MRI analysis looking at tunnel aperture widening, tunnel appearance, graft integration within the tunnels, and graft healing. RESULTS: MRI comparison between ASF and hybrid cohorts revealed no significant differences in graft signal or integration, and clinically there were no differences in knee laxity between cohorts (mean 1.5 mm ± 2.0 and 1.5 mm ± 2.3 (n.s.) in the ASF and hybrid fixation respectively). Significantly less aperture tibial tunnel widening (2.2 mm versus 4.4 mm, p < 0.0001) and tibial cysts (2 versus 9, p = 0.047) were observed in the ASF cohort, whilst mean femoral tunnel widening was comparable between both cohorts (ASF 2.8 mm, hybrid 3.2 mm; n.s.). CONCLUSIONS: Hamstring autografts for ACLR fixed using either ASF or a hybrid fixation technique provided comparable knee stability and MRI graft signal intensity. Tibial ASF demonstrated significantly less tibial aperture widening and tunnel cyst formation when compared to screw and sheath fixation.

Functional recurrent laryngeal nerve regeneration using a silicon tube containing a collagen gel in a rat model.

In this study, we examined the effect of differing gap lengths on regeneration of transected recurrent laryngeal nerves using silicon tubes containing type I collagen gel and the ability of this regeneration to result in restoration of vocal fold movements in rats. We simulated nerve gaps in Sprague-Dawley rats by transecting the left recurrent laryngeal nerves and bridged the nerve stumps using silicon tubes containing type 1 collagen gel. Three experimental groups, in which the gap lengths between the stumps were 1, 3, or 5 mm, were compared with a control group in which the nerve was transected but was not bridged. After surgery, we observed vocal fold movements over time with a laryngoscope. At week 15, we assessed the extent of nerve regeneration in the tube, histologically and electrophysiologically. We also assessed the degree of atrophy of the thyroarytenoid muscle (T/U ratio). Restoration of vocal fold movements was observed in 9 rats in the 1-mm group, in 6 rats in the 3-mm group, and in 3 rats in the 5-mm group. However, in most rats, restoration was temporary, with only one rat demonstrating continued vocal fold movements at week 15. In electromyograph, evoked potentials were observed in rats in the 1-mm and 3-mm groups. Regenerated tissue in the tube was thickest in the 1-mm group, followed by the 3-mm and 5-mm groups. The regenerated tissue showed the presence of myelinated and unmyelinated nerve fibers. In assessment of thyroarytenoid muscle atrophy, the T/U ratio was highest in the 1-mm group, followed by the 3-mm and 5-mm groups. We successfully regenerated the nerves and produced a rat model of recurrent laryngeal nerve regeneration that demonstrated temporary recovery of vocal fold movements. This rat model could be useful for assessing novel treatments developing in the future.

The successful management for long-term intractable enteroatmospheric fistula: A case report.

INTRODUCTION: Efficacy of open abdomen management with negative pressure wound therapy for enteroatmospheric fistula has been performed. But, few reports have shown its utility for enteroatmospheric fistula several years after onset. PRESENTATION OF CASE: A 46 year-old woman underwent total colectomy due to total ulcerative colitis in her twenties. Three years before the onset of enteroatmospheric fistula, she underwent simple total hysterectomy for uterine smooth muscle tumor. Small bowel obstruction occurred early and a small bowel bypass was performed. However, she had sudden abdominal pain and was diagnosed with anastomotic leakage of small bowel bypass. Although antibiotic treatment was initiated, infection was difficult to control, and a midline abdominal incision was performed, followed by the formation of enteroatmospheric fistula. She declined early surgical intervention and started receiving home parenteral nutrition with antibiotic treatment. Although central vein management was continued, catheter infection became frequent. Hence, surgical intervention was planned 30 months after the formation of enteroatmospheric fistula. Two-stage abdominal wall reconstruction using open abdomen management with negative pressure wound therapy was planned. The definitive abdominal wall reconstruction was performed 14 days after the initial operation. Finally, she was discharged without reoperation. DISCUSSION: Enteroatmospheric fistula has no overlying soft tissue and no real fistula tract. Besides these complications, there were complications of the scarred abdominal wall from intestinal fluid exposure for 30 months. CONCLUSION: The strategy using open abdomen management with negative pressure wound therapy for long-term enteroatmospheric fistula will have a good postoperative outcome with the same as early intervention.

Partial resection of the infrapatellar fat pad during anterior cruciate ligament reconstruction has no effect on clinical outcomes including anterior knee pain.

BACKGROUND: Anterior knee pain (AKP) is a major complication that occurs after anterior cruciate ligament reconstruction (ACLR), even when hamstring tendon (HT) grafts are used. Damage to the infrapatellar fat pad (IPFP) during arthroscopy can cause AKP. The purpose of this study was to evaluate the influence of IPFP preservation on clinical outcomes, including AKP, in patients who underwent ACLR with HT autografts using the inside-out technique. METHODS: Forty-two patients who underwent primary ACLR with HT autografts were prospectively assessed for 2 years after surgery. They were randomly selected to undergo treatment with as much intercondylar IPFP preservation as possible or with intercondylar IPFP resection to confirm the ACL origin on the femoral and tibial sides, especially the femoral footprint in deep flexion of the knee joint. The total IPFP volume was calculated using sagittal MR images before and 6 months after surgery. The patients completed a subjective knee score questionnaire and were assessed for patellar tendon tenderness and pain with the half-squat test or single-leg hop test at 6 months and 2 years postoperatively. RESULTS: There were no differences in the patient characteristics, including age, sex, BMI, time from injury to surgery, and meniscus tear. The difference in the total size of the IPFP preserved was significant (P = 0.004). However, there were no significant differences in the subjective knee scores. Moreover, there were no differences in the clinical assessment parameters between the IPFP preservation and resection groups. CONCLUSIONS: The size of the IPFP decreased more in the resection group than in the preservation group at 6 months after surgery. However, partial IPFP resection, which was used to better visualize the origin of the ACL, had no effect on the clinical outcomes, including AKP. LEVEL OF EVIDENCE: Level II.

Anterior knee translation measurements after ACL reconstruction are influenced by the type of laximeter used.

PURPOSE: Laximeters were designed to diagnose an anterior cruciate ligament (ACL) deficient knee, but their use has now focused on providing an objective assessment of the anterior translation (AT) of an intact and ACL-reconstructed knee. In this study we report the introduction and direct comparison of an automated and computerized AT measurement device, GNRB, with the device previously established by the institute and as the current literature standard, the KT1000. METHODS: A prospective data collection was commenced upon introduction of the GNRB. The measurements of AT in each patient were performed by the same investigator with each device using 134 N applied to both knees, giving a side-to-side difference. The investigators were a sport scientist, a biomechanical engineer and a physiotherapist. Increased AT was defined as a difference > 3 mm. RESULTS: Three investigators performed the measurements in 122 patients, 9.8 (± 1.8) months after ACL reconstruction. Mean AT of the healthy knee was 5.7 mm with KT1000 and 4.4 mm with GNRB (p = 0.002). Mean AT of the ACL reconstructed knee was 7.0 mm with the KT1000 and 5.3 mm with the GNRB (p = 0.037). The KT1000 had a higher variance of results than the GNRB (p < 0.001). There were 25 patients with increased AT measured by KT1000 compared with 12 patients using the GNRB (p < 0.016), with only 5 on both devices. CONCLUSIONS: GNRB has better consistency of results when compared to the KT1000. Both devices lack comparability for detecting increased AT, with the KT1000 recording a side-to-side difference of more than 3 mm in twice as many patients as the GNRB. LEVEL OF EVIDENCE: II.

The space available for the anterior cruciate ligament in the intercondylar notch is less in patients with ACL injury.

PURPOSE: The aim of this study was to determine if a difference exists in the relationship between the femoral intercondylar notch volume, and the volumes of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) in ACL injured patients and healthy subjects. METHODS: Intact knees of 19 healthy subjects and bilateral knees of 18 ipsilateral ACL reconstructed patients were scanned using 3-tesla high-resolution magnetic resonance imaging. The intercondylar notch, ACL, PCL and hamstring graft were segmented using three-dimensional (3D) processing software. The native intercondylar notch, ACL, and PCL volumes were compared between both groups. The volumes of native ACL and graft were compared in ACL injured patients. RESULTS: The following volumes showed no significant differences between the ACL injured group and control group; intercondylar notch (9.9 ± 2.3 vs 9.6 ± 1.7 cm3), ACL (2.4 ± 0.7 vs 2.4 ± 0.6 cm3) and PCL (3.9 ± 1.0 vs 3.4 ± 0.8 cm3), and the ratio of the ACL to the intercondylar notch (24.6 ± 5.0 vs 25.4 ± 2.9%). There was a significant difference in the ratio of PCL to the intercondylar notch (39.1 ± 4.3 vs 35.9 ± 4.9%, p = 0.023). The graft was significantly larger than native ACL volume (3.0 ± 0.7 vs 2.4 ± 0.7 cm3, p = 0.012). CONCLUSIONS: The ratio of the PCL volume in the femoral intercondylar notch was higher in the ACL injured group compared to the healthy control group, despite the ratio of ACL volume in the femoral intercondylar notch being similar in both groups. A greater awareness of the potentially limited space for the graft alongside the PCL within the femoral intercondylar notch may allow surgeons a more informed choice of graft type and size. LEVEL OF EVIDENCE: IV.

Large osteophyte removal from the posterior femoral condyle significantly improves extension at the time of surgery in a total knee arthroplasty.

Removing osteophytes from the posterior compartment of the femur eliminates the tenting effects on the joint capsule and consequently increases the extension gap in total knee arthroplasty. However, there is no clear association with the size of osteophytes removed and the potential degree of additional extension achieved at time of surgery. AIMS: Correlate the size of posterior osteophytes removed with the degree of extension gained intraoperatively in total knee arthroplasty and develop a radiological classification system to grade these osteophytes. METHODS: Patients who underwent a TKA had pre and post operative sagittal radiographs assessed and classified according to 4 different categories of a proposed classification system. Knee extension was then assessed by a computer navigated system before incision and after implant insertion. Confounding factors were controlled and considered on the analysis. The study was done retrospectively. RESULTS: 147 patients were included in the study. Ninety-three (63.2%) patients had osteophytes on the posterior aspect of the femur completely removed and fifty-four patients (36.8%) did not have radiological evidence of osteophytes on the posterior aspect of the femur. There was a positive and linear correlation (Pearson correlation 0.327, p .005) between osteophyte size and degree of extension corrected at time of surgery. On Multivariate Logistic Regression Analysis, we found that small osteophytes (Grade 1) did not seem to affect the extension, while removing Grade 2 or Grade 3 osteophytes lead to a gain in extension of 2.7 and 4.5° respectively. CONCLUSION: Removing large osteophytes (Grade 2 and Grade 3) from the posterior femoral compartment can be used as an adjuvant strategy to ensure that intraoperative extension is optimal. However removing small osteophytes (Grade 1) should not be expected to affect extension at the time of surgery in TKA and could increase intra-operative time and morbidity.

Partial lateral meniscus anterior root injuries during anatomical single-bundle anterior cruciate ligament reconstruction are likely to occur in women with small skeletons.

PURPOSE: This study aimed to investigate the occurrence and characteristics of lateral meniscus anterior root injuries during anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: Between 2011 and 2018, 70 women who had ACL injuries without lateral meniscal tears underwent anatomical single-bundle ACL reconstruction. Using computed tomography, the anatomical relationship between the predicted lateral meniscus anterior root insertion and the tibial tunnel was retrospectively assessed, and the patients were divided into partial lateral meniscus anterior root injury and intact groups. The demographic characteristics, the distances between bony landmarks, the tibial tunnel sizes, and lateral meniscal extrusion assessed by magnetic resonance imaging were compared between the two groups. RESULTS: Thirteen of the 70 patients had suspected partial lateral meniscus anterior root injuries. Patient height was significantly shorter in the injury group than in the intact group (157.7 ± 6.4 vs. 161.4 ± 5.4 cm: p = 0.03); the distance from the apex to the bottom of the slope of the medial intercondylar ridge was significantly shorter in the injury group than in the intact group (15.1 ± 1.9 vs. 16.7 ± 1.4 mm: p = 0.001). CONCLUSIONS: Partial lateral meniscus anterior root injury during anatomical single-bundle ACL reconstruction was suspected in 18% of cases. Patient height and the distance between bony landmarks were significantly shorter in the injury group than in the intact group. Surgeons should understand that even a slight deviation of the tibial tunnel position can lead to partial lateral meniscus anterior root injury in patients with small skeletons. LEVEL OF EVIDENCE: IV.