Influence of soft tissue balancing and distal femoral resection on flexion contracture in navigated total knee arthroplasty.

PURPOSE: The purpose of this study was to evaluate the influence of intra-operative soft tissue balancing and distal femoral cutting on flexion contracture in navigated TKA. METHODS: This was a prospective cohort study. Fifty-nine patients of primary navigation-assisted TKA were included with over 15° of flexion contracture and excluded valgus knees. Among the cases, 43 cases were performed with soft tissue balancing procedures only, and 16 cases were performed with soft tissue balancing and additional distal femoral bone cutting. The mean preoperative flexion contracture was 17.5° ± 2.7°. The angles of flexion contracture were recorded at each surgical step with navigation. RESULTS: The mean difference in flexion contracture angle between initial angle and angle after medial release was 5.2° ± 2.8°. The mean difference in flexion contracture angle between medial release step and after posterior cruciate ligament (PCL) release was 2.5° ± 2.2°. The mean difference in flexion contracture angle between PCL release step and after routine bone cutting was 3.1° ± 3.2°. The mean difference in flexion contracture angle between after trial insertion and after posterior clearing procedure was 2.7° ± 1.9°. Among the cases, TKA with 2 mm additional bone cutting were performed in 16 cases. The mean difference in flexion contracture angle after additional femoral bone cutting was 4.8° ± 2.1°. CONCLUSION: The medial release and 2 mm additional bone cutting could correct flexion contracture by 5°. The appropriate soft tissue balancing and bone cutting could correct flexion contracture intra-operatively up to 5° in each step. LEVEL OF EVIDENCE: II.

Comparison of double-bundle anterior cruciate ligament (ACL) reconstruction and single-bundle reconstruction with remnant pull-out suture.

PURPOSE: The purpose of this study was to evaluate the stability and functional outcomes of anterior cruciate ligament (ACL) reconstruction by tensioning of the ACL remnant using pull-out sutures compared with ACL double-bundle reconstruction. METHODS: Forty-four patients were included in single-bundle reconstruction with remnant tensioning group (Group 1), and 56 patients were included in the double-bundle reconstruction group (Group 2). The remnant tissue was tensioned to the direction of posterolateral bundle, which unrelated to the type of remnant bundle. Objective knee stability was evaluated by anterior stress radiography, KT-1000 and lateral pivot shift tests. The Tegner activity scale, International Knee Documentation Committee and OrthopädischeArbeitsgruppeKnie scoring systems were used for clinical evaluation. RESULTS: No statistically significant intergroup differences were observed in mechanical stability and clinical results (n.s). However, surgical time of remnant tensioning group is shorter than double-bundle reconstruction group (P = 0.005). CONCLUSION: Remnant tensioning suture with single-bundle reconstruction could be used with positive results as good as double-bundle technique if a good ACL remnant was found bridging the femur and tibia, rather than debride or damage to the remnant tissue during operation. LEVEL OF EVIDENCE: Retrospective, comparative cohort study, Level IV.

Second-look arthroscopy after surgical treatment of Schatzker type II plateau fractures through the lateral submeniscal approach.

MAIN PROBLEM: To evaluate cartilage healing using second-look arthroscopic examination in tibia plateau fracture patients who have undergone open reduction and internal fixation with a submeniscal approach technique. METHODS: Between January 2007 and January 2010, we used second-look arthroscopy during 18-24-month follow-up of 20 patients with Schatzkar type II tibial plateau fractures who had undergone open reduction and internal fixation with a submeniscal approach technique. We classified patients according to step-off, knee range of motion, and Knee Society Score, and compared the results with those obtained by arthroscopy. RESULTS: Radiologically, 16 cases (80 %) were reduced within 2 mm of step-off. In 11 of these cases, according to the Outerbridge classification, we checked for chondromalacia from grade II to III. We observed 2 mm of step-off in four cases, and each had chondromalacia of at least grade III. The Knee Society Score was associated with chondromalacia grade (p < 0.05). CONCLUSION: Even in patients with normal joint range of motion and good clinical and radiological results, the actual condition of the articular cartilage varied significantly. Therefore, more long-term and regular follow-up is needed for proximal plateau fractures.

High tibial open wedge osteotomy below the tibial tubercle: clinical and radiographic results.

PURPOSE: The purpose of this study was to evaluate the clinical and radiographic results of open wedge HTO below the tubercle for genu varum in relatively young patients. METHODS: Thirty-seven knees in 19 patients with genu varum treated by open wedge HTO below the tubercle between 2001 and 2008 were retrospectively studied. Median follow-up was 36 months (12-108), and median patient age at the time of surgery was 26 years (16-45). Clinical results were evaluated using Lysholm knee scores and Hospital for Special Surgery knee scores. Satisfaction with the results of surgery (0-10 points) was subjectively evaluated using operative scar (1-5 points) and leg shape (1-5 points) results at follow-up. Radiographic evaluations were made using: (1) tibiofemoral angles, (2) mechanical axis deviations, (3) varus-valgus inclinations of the tibial plateau, (4) tibial slopes, and (5) Insall-Savati and (6) Blackburne-Peel ratios. RESULTS: All but one patient achieved radiographic healing and union at the osteotomy site at an average of 3 months postoperatively. Average Lysholm knee score improved from 89.4 ± 8.7 preoperatively to 98.6 ± 2.5 at final follow-up (P = 0.0001), and mean HSS score improved from 91.1 ± 5.6 preoperatively to 98.5 ± 2.0 at final follow-up (P = 0.0001). Mean patient satisfaction score at final follow-up was 8.6 ± 1.0, and mean tibiofemoral angle increased from -1.6° preoperatively to 7.7° at final follow-up (P < 0.0001). The point where the mechanical axis crosses the tibial plateau also shifted significantly from 15.0% preoperatively to 50.6% at final follow-up (P = 0.0002). However, mean posterior tibial slope did not change significantly (9.7° preoperatively and 8.7° at final follow-up; P = NS), and neither did patella heights as measured by Insall-Savati and Blackburne-Peel ratios. CONCLUSION: Both functional assessment and radiographic measures indicated that HTO below the tibial tubercle leads to significant improvements in radiographic parameters and knee function without changes in patellar height or posterior tibial slope. The results obtained support the hypotheses that opening wedge HTO below the tibial tubercle should be recommended in relatively young patients with genu varum. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Less femoral lift-off and better femoral alignment in TKA using computer-assisted surgery.

PURPOSE: A comparison has been made between navigation-assisted and conventional measured resection total knee arthroplasty (TKA), under the hypothesis that navigation assistance would improve the precision and consistency of component alignment and femoral component rotation. METHODS: The following radiographic parameters were measured: mechanical femorotibial angle, coronal and sagittal component angle, and femoral component rotation. Femoral condylar lift-off was checked by axial radiographs, and thresholds for outliers were set at 1.0 mm. RESULTS: Clinical results obtained using Knee Society and Hospital for Special Surgery systems were not statistically different. The mean mechanical femorotibial angle was 2.2° (SD: 0.9) in the conventional group and 1.7° (SD: 0.7) in navigation group (p = 0.001). The mean coronal femoral component angle was 89.2° (SD: 2.2) in conventional group and 90.4° (SD: 1.8) in navigation group (p = 0.006). The mean transepicondylar-posterior condylar axis angle was 1.7° (SD: 0.9) in conventional group and 1.2° (SD: 0.5) in navigation group (p = 0.008). Femoral condylar lift-off greater than 1 mm occurred more frequently (p = 0.000) in conventional group. CONCLUSION: Coronal plane stability and precision of femoral component rotation were impacted by navigation system. The use of a navigation system with measured resection TKA can help optimize coronal stability and parallel component position. LEVEL OF EVIDENCE: Retrospective case control study, Level IV.

The isometry of two different paths for remnant-preserving posterior cruciate ligament reconstruction.

PURPOSE: It is reported that the length of the posterior cruciate ligament (PCL) fibres increases as the knee flexes, and the magnitude of the length change reaches up to 9.8 mm throughout the range of motion, which exceeds the range of failure strain. Therefore, we postulated that a compensatory mechanism must be recruited to overcome this large strain in order to maintain physiologic function as a key component of joint kinematics. Our main objective was to compare the length change pattern for the linear distance between the femoral and tibial tunnels with the length change patterns derived from a real isometer test of different curvatures. METHODS: We utilized ten intact cadaveric knees and created a vertical femoral tunnel (5 mm medial to the roof of the intercondylar notch and 5 mm proximal from the articular margin) and lateral tibial tunnels (5 mm proximal to the posterior bony ridge on the lateral side of the PCL fibre) and performed a 3D-CT scan at 0º, 30º, 60º, 90º, and 120º. The distances between the femoral and tibial tunnels were calculated from the 3D coordinates. Real isometry was checked both (1) over the PCL and (2) under the PCL using an isometer with an accuracy of 0.1 mm. RESULTS: The path over the PCL had the longest intra-articular length, followed by the path under the PCL, and the lengths measured by CT, respectively. The path over the PCL had a more curved path compared with the path under the PCL and the lengths measured by CT. The lengths measured by CT showed significantly larger excursion than the real isometer test. The path over the PCL showed the least excursion through the range of motion, followed by the path under the PCL, and the lengths measured by CT, respectively. CONCLUSION: Our findings suggested that a more curved PCL path has better isometry because the curvature of the PCL compensates for the length change between 0º and 60º flexion. In remnant preservation PCL reconstruction, the passage of graft over the PCL would have increased intra-articular length and better isometry compared with straight under the PCL path. LEVEL OF EVIDENCE: Basic science study.

Evaluation of tunnel position of posterolateral corner reconstruction using 3-dimensional computed tomogram.

PURPOSE: To evaluate the isometry of different tunnel positions in posterolateral corner (PLC) reconstruction using 3-dimensional computed tomography. METHODS: In 10 fresh-frozen cadaveric knees, fibular tunnels were made from the anterodistal surface of the fibular neck to the posteroproximal fibular tip. Tibial tunnels were made from just medial to the Gerdy tubercle to a point 1 to 1.5 cm medial to the proximal tibiofibular joint. Femoral condyles were marked at 3 different locations: (1) epicondyle, (2) 5 mm distal-anterior to the epicondyle, and (3) 18 mm distal-anterior to the epicondyle. All specimens were scanned by computed tomography at different ranges of motion. Relative length changes between the tunnels were calculated by use of medical imaging software, and the center of rotation (COR) of each distal tunnel was obtained by use of a least-squares circle-fitting algorithm. RESULTS: The anterior fibular tunnel to lateral epicondyle and the posterior fibular or posterior tibial tunnel to 5 mm distal-anterior to the lateral epicondyle showed the best results in terms of isometry. The COR of the posterior fibular tunnel is distal and anterior to the epicondyle, whereas the COR of the posterior tibial tunnel is distal and slightly posterior to the epicondyle (8.4 mm away from the epicondyle, with a -8.4° angle along the longitudinal axis of the femur). The COR of the anterior fibular tunnel is located posterior and distal to the epicondyle. CONCLUSIONS: Contrary to our hypothesis, the distal tunnels for PLC reconstruction each have different isometric points. The isometric point of the posterior fibular tunnel is distal and anterior to the epicondyle, whereas the isometric points of the posterior tibial and anterior fibular tunnels are distal and posterior to the epicondyle. CLINICAL RELEVANCE: The isometric pattern of each tunnel combination should be considered in PLC reconstruction; currently, popliteus tendon reconstruction is non-isometric.

How isometric are the anatomic femoral tunnel and the anterior tibial tunnel for anterior cruciate ligament reconstruction?

PURPOSE: The purpose of this study was to evaluate the isometry of an anatomic femoral tunnel and anterior tibial tunnel positions. METHODS: Tibial tunnels were made at 2 different locations in 10 cadaveric knees: the conventional tunnel and a more anterior position. Three-dimensional computed tomography (CT) scanning was then performed at 0°, 30°, 60°, 90°, and 120°. After removal of the anterior cruciate ligament from its femoral attachment, the 2 different femoral tunnels were marked at (1) the vertical femoral tunnel point and (2) the anatomic femoral tunnel point. After scans were repeated for coordinate transformation, the change in length between the tunnels was calculated with imaging software (OsiriX, version 3.2; Apple, Cupertino, CA) and the center of rotation for the femoral tunnels was calculated with a least squares fitting algorithm. RESULTS: The conventional tibial tunnel-vertical femoral tunnel combination showed the least excursion as knee flexion angle changed. The vertical femoral tunnel combination groups showed a trend toward increasing length as the knee flexion angle increased. In contrast, the anatomic femoral tunnel combination groups displayed a trend toward decreased length with increasing knee flexion. At less than 30° of flexion, the tibial anterior-anatomic femoral tunnel showed the least excursion. CONCLUSIONS: The anatomic femoral tunnel was nonisometric, and the differences in isometry for each tunnel type were explained primarily by differences in relations between the centers of rotation of tunnels and tunnel position. When a femoral anatomic tunnel is chosen for anterior cruciate ligament reconstruction, the anterior tibial tunnel offers greater isometric benefits than the conventional tibial tunnel, especially in near full extension. CLINICAL RELEVANCE: The distance between anatomic femoral and tibial tunnels is greatest in full extension and decreases with flexion. This would result in graft laxity. The surgeon should give consideration to a more anterior tibial tunnel position, which shows less excursion in early flexion.

Potential of healing a transected anterior cruciate ligament with genetically modified extracellular matrix bioscaffolds in a goat model.

PURPOSE: Biological augmentation to heal a torn anterior cruciate ligament (ACL) has gained significant interest. This study examined the potential advantages of using extracellular matrix (ECM) bioscaffolds from galactosyl-α(1,3)galactose deficient pigs to heal the transected ACL. METHODS: In 16 skeletally mature goats, the ACL in the right hindlimb was transected and repaired. In 9 of these animals, an ECM sheet was wrapped around the injury site and with an ECM hydrogel injected into the transected site. The remaining 7 animals were treated with suture repair only. The left hindlimb served as a sham-operated control. RESULTS: After 12 weeks, the healing ACL in the ECM-treated group showed an abundance of continuous neo-tissue formation, while only limited tissue growth was found after suture repair only. The cross-sectional area of the ACL from the ECM-treated group was similar to sham-operated controls (n.s.) and was 4.5 times those of the suture repair group (P < 0.05). The stiffness of the femur-ACL-tibia complexes from the ECM-treated group was 2.4 times those of the suture repair group (P < 0.05). Furthermore, these values reached 48% of the sham-operated controls (53 ± 19 N/mm and 112 ± 21 N/mm, respectively, P < 0.05). CONCLUSIONS: The application of an ECM bioscaffold and hydrogel was found to accelerate the healing of a transected ACL following suture repair in the goat model with limited tissue hypertrophy and improvement in some of its biomechanical properties. Although more work is necessary to fully restore the function of the normal ACL, these early results offer a potential new approach to aid ACL healing.

Accuracy and reliability of length measurements on three-dimensional computed tomography using open-source OsiriX software.

There is a growing interest in three-dimensional computed tomography (3D-CT) as a research tool for the study of bone, joint anatomy, and kinematics. However, when CT data are processed and handled manually using image processing programs to yield 3D image and coordinate value, systematic and random errors should be validated. We evaluated the accuracy and reliability of length measurement on CT with OsiriX software. 3D-CT scans were made of 14 frozen pig knees with five transosseous holes in the metaphyseal portion of femur. The lengths between tunnel orifices were measured using Mitutoyo Digimatic digital calipers to establish the gold standard, and with the OsiriX program in 3D multi-planar reformatting mode for comparison. All measurements were recorded by a principal (replicate 1, trial 1) and a secondary observer (replicate 2, trial 1) and were repeated once by each observer (trial 2). The mean differences between OsiriX and real measurements were less than 0.1 mm in both replicates, and maximum differences were less than 0.3 mm. There were no significant differences between the replicates and real measurements (p=0.544 and 0.622 for replicates 1 and 2, respectively). The intraclass correlation coefficients (ICC) were very high between trials and between replicates (ICC=0.998 and 0.999, respectively). For kinematic analysis of the knees, length measurements on 3D-CT using OsiriX program can be used as alternatives to real measurements with less than 0.3-mm accuracy and very high reliability.

Comparison of anterior cruciate ligament reconstruction with preservation only versus remnant tensioning technique.

PURPOSE: To evaluate the stability and functional outcomes of anterior cruciate ligament (ACL) reconstruction by tensioning of the ACL remnant using pullout sutures compared with a remnant preservation technique only. METHODS: The data of 33 patients who underwent ACL reconstruction by a remnant tensioning technique (tensioning group) were reviewed retrospectively and compared with the data of 43 patients who underwent ACL reconstruction with remnant preservation without tensioning (preservation-only group) from September 2004 to April 2008 with a minimum follow-up of 2 years. The stability and function were assessed from the side-to-side difference with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and Telos device (Austin & Associates, Fallston, MD), as well as International Knee Documentation Committee and Orthopadische Arbeitsgruppe Knie scores. RESULTS: There were no significant differences between the groups with respect to the subjective and objective International Knee Documentation Committee scores (P = .808 and P = .152, respectively) and Orthopadische Arbeitsgruppe Knie score (P = .702) at the last follow-up. No significant differences in mechanical stability were observed with the KT-1000 arthrometer and stress radiographs between the groups (P = .650 and P = .791, respectively). The remnant tensioning group took a longer surgical time than the preservation-only group (156.4 minutes v 134.5 minutes, P = .117). CONCLUSIONS: The ACL remnant tensioning procedure did not improve the final results of an ACL reconstruction in terms of the clinical function and stability compared with an ACL reconstruction using the preservation-only technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Combined posterolateral corner reconstruction with remnant tensioning and augmentation in chronic posterior cruciate ligament injuries: minimum 2-year follow-up.

PURPOSE: To evaluate functional results and knee stability after tensioning of remnant posterior cruciate ligament (PCL) with anterolateral (AL) bundle reconstruction and posterolateral corner (PLC) reconstruction in chronic PCL and PLC injuries. METHODS: Between March 2001 and March 2007, 95 patients with chronic PCL injuries combined with PLC injuries underwent tensioning of the remnant PCL with AL bundle reconstruction and PLC reconstruction. Among these 95 patients, 70 who were satisfied with our inclusion were reviewed. The mean follow-up period was 40.1 months (range, 24 to 96 months). Tensioning of remnant PCL fibers was performed by distal transfer of the posterior tibial attachment. The AL bundle of the PCL was reconstructed by use of the modified inlay technique. The PLC reconstructive procedure was performed with a single sling through fibular tunnel. Stability was measured on posterior stress radiographs and by use of a maximal manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee and Orthopädishe Arbeitsgruppe Knie scoring systems were used for clinical evaluation. RESULTS: Stress radiographs showed that the mean side-to-side difference (posterior tibial translation compared with that of the contralateral knee) was reduced from 10.3 ± 2.4 mm preoperatively to 2.2 ± 1.5 mm at the last follow-up (P < .001), whereas the KT-1000 tests showed that this difference was reduced from 8.4 ± 2.2 mm preoperatively to 2.0 ± 1.4 mm (P < .001). The final International Knee Documentation Committee objective score was A in 30 patients (42.8%), B in 34 (48.6%), and C in 6 (8.6%). The mean Orthopädishe Arbeitsgruppe Knie score improved from 63.5 ± 10.4 to 88.9 ± 7.6 (P < .001). CONCLUSIONS: Excellent posterior stability and relatively good clinical results were achieved with tensioning of the remnant PCL and AL bundle and PLC reconstruction by use of fibular tunnel for patients with chronic combined PCL-PLC injuries. LEVEL OF EVIDENCE: Level IV, case series.

The relationship of neural structures to arthroscopic posterior portals according to knee positioning.

PURPOSE: The purpose of this study was to investigate the relationship between the proximity of neural structures to standard posterior portals in different knee positions. METHODS: Ten fresh cadaveric knees were used to establish the standard posteromedial and posterolateral portals using an outside-in technique with arthroscopic transillumination. The distance from each portal site to the adjacent neurovascular structures (infrapatellar branches of the saphenous nerve) and the sartorial branch of saphenous nerve from the posteromedial portal, and the common peroneal nerve from posterolateral portal was measured using a precision caliper. Distances were recorded with the knees in extension, 45° of flexion and 90° of flexion in order to examine the effect of dynamic knee motion on nerve position. RESULTS: The mean distance between the posteromedial portal and the superior and inferior branches of infrapatellar branches of the saphenous nerve at full extension was significantly greater than at 90° of flexion. However, there was no difference observed between at 45° and at 90° of flexion. The mean distance from the posteromedial portal to the sartorial branch of saphenous nerve at 90° of flexion was significantly greater (26.1 mm, SD: 4.7) than that at 45° of flexion (18.4 mm, SD: 4.6), and at full extension (14 mm, SD: 4.3) (P < 0.0001). The mean distance between the posterolateral portal to the common peroneal nerve at 90° of flexion was also significantly greater (25.4 mm, SD: 9.2) than that at 45° of flexion (22.5 mm, SD: 8.1), and at full extension (20.1 mm, SD: 9.1) (P < 0.0001). CONCLUSION: In this cadaveric study, it shows that position of 90° knee flexion is reasonably safe, in order to establish a posterior portal in knee arthroscopy using the technique described in the current study, especially to avoid the sartorial branch of saphenous nerve and the common peroneal nerve injuries. Results of this study suggest the establishment of posterior portals, while the knee is flexed at an angle of 90° is recommended to ensure the safety of these structures.

Comparison of joint line position changes after primary bilateral total knee arthroplasty performed using the navigation-assisted measured gap resection or gap balancing techniques.

PURPOSE: This study aimed to compare the clinical and radiological results of navigation-assisted TKAs performed using the measured gap resection or the gap balancing technique in thirty patients who underwent bilateral primary TKAs. METHODS: Sixty cases of navigation-assisted TKAs [30 TKAs performed using the measured gap resection technique (Group A) and 30 TKAs performed using the gap balancing technique (Group B)] were analyzed prospectively with minimum follow-up of 2 years. The joint line positions were measured using preoperative and postoperative weight-bearing anteroposterior and lateral radiographs. Clinical results were evaluated using knee scores and functional scores. RESULTS: No significant differences in knee scores or functional scores were observed. Polyethylene thickness and flexion/extension gaps were significantly larger in Group B (P < 0.05). The meaningful proximal shift of the joint line was shown in Group B (P < 0.05). CONCLUSION: The navigation-assisted TKA with measured gap resection technique could be a useful technique with regard to restoration of the joint line.

Predicting independence of gait by assessing sitting balance through sitting posturography in patients with subacute hemiplegic stroke.

BACKGROUND: Post-stroke sitting balance is a known predictor of independence of gait after stroke. However, previous studies used only qualitative scales or measured static or dynamic sitting balance alone. OBJECTIVES: To investigate whether quantitative parameters of sitting posturography at post-stroke 1 month can predict independent gait. METHODS: In this prospective cohort study, we enrolled patients with first-ever stroke who could hold a sitting posture at post-stroke 1 month. Sitting balance was assessed using posturography at post-stroke 1 month. Independence of gait was assessed using functional ambulation categories at post-stroke 2 months. We predicted mobility independence at post-stroke 2 months according to sitting balance at post-stroke 1 month. We also assessed the correlation between sitting posturography parameters and clinical scales. RESULTS: We enrolled 27 patients. The limit of stability deviation predicted independent gait at post stroke 2 months (cutoff, 78.4%). Further, there was a high degree of correlation between sitting posturography parameters (weight-bearing distribution deviation and limit of stability deviation) and Berg Balance Scale (ρ = 0.763, ρ = 0.777; p < .001, respectively), Scale for Assessment and Rating of Ataxia (ρ = -0.853, ρ = -0.929; p < .001, respectively), and Fugl-Meyer Assessment scale (upper extremities: ρ = 0.520, ρ = 0.480 [p = .005, p = .011, respectively]; lower extremities: ρ = 0.744, ρ = 0.564 [p < .001, p = .002, respectively]) scores. CONCLUSIONS: Sitting posturography parameters is clinically useful because they can quantitatively assess post-stroke balance and neurological impairment and predict post-stroke independence of gait even when patients cannot reach their arms forward or stand upright.

Remnant posterior cruciate ligament-augmenting stent procedure for injuries in the acute or subacute stage.

PURPOSE: To evaluate the results of a remnant posterior cruciate ligament (PCL)-augmenting stent procedure for acute- or subacute-stage PCL injuries in terms of stability and clinical results. METHODS: Between September 2003 and March 2006, 32 patients with a PCL tear underwent a reconstructive stent procedure with an autogenous hamstring tendon graft to augment the remains of the injured PCL. Of these patients, 20 who satisfied our inclusion criteria and could be followed up for a minimum duration of 24 months were enrolled in our study. The remnant PCL and synovium were preserved, and augmentation was performed by use of the transtibial technique. A femoral tunnel was created near the footprint of the anterolateral bundle. Stability was measured on posterior stress radiographs and by use of a maximum manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee (IKDC) and Orthopädische Arbeitsgruppe Knie scoring systems were used for clinical evaluation. RESULTS: Stress radiographs showed that the mean side-to-side differences in displacement were reduced from 9.9 +/- 4.0 mm preoperatively to 3.0 +/- 2.6 mm at the last follow-up, whereas KT-1000 tests showed that these differences were reduced from 6.9 +/- 2.1 mm preoperatively to 2.7 +/- 1.5 mm. The final IKDC score was A in 7 patients (35%), B in 10 (50%), C in 2 (10%), and D in 1 (5%). The mean Orthopädische Arbeitsgruppe Knie score improved from 61.6 +/- 13.1 to 88.2 +/- 9.5. CONCLUSIONS: Of the patients, 90% showed satisfactory posterior stability and 85% had a normal or nearly normal rating based on the IKDC score at a mean of 3 years after the remnant PCL-augmenting stent procedure in the acute or subacute stage of PCL injuries.

Outcome of arthroscopic single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a preliminary 2-year prospective study.

PURPOSE: The purpose of this study was to compare the clinical results of arthroscopic single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: We designed a prospective study that included patients with an isolated ACL injury. From April 2004 to February 2007, of 147 patients who underwent ACL reconstruction, 113 were included in this study. We serially obtained clinical and radiologic data preoperatively and postoperatively. We compared preoperative data and data at 2 years postoperatively in patients who had undergone single-bundle ACL reconstruction versus patients who had undergone double-bundle ACL reconstruction. There were 50 single-bundle reconstructions and 63 double-bundle reconstructions. Anteroposterior stability was assessed objectively by anterior stress radiographs with the telos device (telos, Marburg, Germany) and the maximal manual test with the KT-2000 arthrometer (MEDmetric, San Diego, CA). Rotational stability was determined by lateral pivot-shift test. The clinical results were assessed by International Knee Documentation Committee and Orthopadische Arbeitsgruppe Knie scores and Tegner activity scale. In addition, we evaluated postoperative thigh circumference and range of motion. RESULTS: Residual anteroposterior laxity determined at 2 years postoperatively by telos and KT-2000 was 1.74mm +/- 1.67mm and 1.79mm +/- 1.56mm, respectively, in the single-bundle reconstruction group and 1.63mm +/- 1.50mm and 1.61mm +/- 1.22mm, respectively, in the double-bundle reconstruction group. There were no statistically significant differences. For the lateral pivot-shift test done at 2 years postoperatively, there was no statistically significant difference. In addition, clinical results such as International Knee Documentation Committee score, Orthopadische Arbeitsgruppe Knie score, Tegner activity scale, thigh circumference, and range of motion showed no significant differences between the 2 groups. CONCLUSIONS: Double-bundle reconstruction of the ACL by a method using 2 femoral tunnel and 2 tibial tunnels showed no differences in stability results or any other clinical aspects or in terms of patient satisfaction. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Long-term results of primary total knee arthroplasty with and without patellar resurfacing.

Among patients that underwent total knee arthroplasty from June, 1990 to January, 1999, 61 cases (44 patients) that could be followed for more than 10 years were included in this study. The patients were divided into a patellar retention group and a patellar resurfacing group, and were compared with regard to their clinical and radiological outcomes. In patients undergoing primary TKA, a selective patellar resurfacing protocol was used. The indications for patellar retention were a small patella, nearly normal articular cartilage, minimal preoperative patellofemoral pain, poor patellar bone quality, and young patient age. When patellar retention was performed, osteophytes of the patella were removed and marginal electrocauterization was carried out. There were 25 cases (20 patients) in the patellar retention group and 36 cases (29 patients) in the patellar resurfacing group. The mean follow-up period was 140.7 months in the patellar retention group and 149.0 months in the patellar resurfacing group. The selective patellar resurfacing with total knee arthroplasty had a favorable outcome;there were a significant difference noted between the 2 groups in the functional scores, which showed better outcomes in the patellar resurfacing group than in the patellar retention group.

Combined reconstruction for posterolateral rotatory instability with anterior cruciate ligament injuries of the knee.

If posterolateral rotatory instability (PLRI) injury in patients with a torn anterior cruciate ligament (ACL) is not diagnosed and treated, ACL reconstruction can fail. We retrospectively evaluated the clinical outcome after reconstructions between 2002 and 2007 of both the ACL and the posterolateral corner (PLC) in 44 knees with combined ACL and PLC injuries. The median follow-up duration was 49 months (range, 24-68 months). ACL reconstruction employed autogenous hamstring grafts from the ipsilateral knee. For grade II PLRI, a posterolateral corner sling through the fibular head was placed obliquely from the anteroinferior aspect to the posterosuperior aspect using autogenous hamstring grafts of the contralateral knee. Clinical outcomes were evaluated using the OAK (Orthopadishe Arbeitsgruppe Knie) and IKDC (International Knee Documentation Committee) knee scoring systems. Anterior stability was measured on pull stress radiographs using a Telos stress device and the manual maximum displacement test using a KT-1000 arthrometer with the knee flexed 30 degrees. PLRI was classified according to varus and rotational instability preoperatively and at final follow-up. Median OAK scores improved from 71 points (range, 48-86) to 93 points (range, 75-100). Satisfactory IKDC results were achieved in 39 knees (89%). As for anterior stability, as measured by anterior stress radiography, mean side-to-side displacement difference dropped significantly from 6.9 +/- 1.9 preoperatively to 1.4 +/- 1.1 mm at final follow-up. Forty patients (91%) had the same or better rotational stability compared to the normal side. Varus stress radiographs showed mean side-to-side displacement differences dropped from 1.8 +/- 1.7 preoperatively to 0.4 +/- 0.8 mm at final follow-up. Thus, chronic ACL deficiency is often accompanied by grade II PLRI and can be treated successfully by arthroscopic ACL reconstruction paired with posterolateral reconstruction employing a single sling through the fibular tunnel and a hamstring tendon autograft.

Suggested Assessments for Sarcopenia in Patients With Stroke Who Can Walk Independently.

OBJECTIVE: To investigate variables for assessment of stroke-related sarcopenia that are alternative options to the current assessment for sarcopenia, which focuses on age-related sarcopenia and also has limitations in addressing sarcopenia due to weakness resulting from stroke. METHODS: Forty patients (17 men, 23 women; mean age, 66.9±15.4 years) with first-ever stroke who can walk independently were included. Muscle mass was determined by measuring ultrasonographic muscle thickness of vastus intermedius, rectus femoris, tibialis anterior, medial gastrocnemius, and biceps brachii muscles in addition to using the skeletal muscle index (SMI) with bioelectrical impedance analysis. Muscle strength was assessed with the Medical Research Council (MRC) sum score as well as handgrip (HG) strength. Physical performance was measured by the Berg Balance Scale (BBS) along with 4-meter gait speed (4MGS). Correlations between each assessment in the three categories were analyzed and adjusted by stroke severity, comorbidity, and nutritional status. RESULTS: For muscle mass, SMI showed the highest correlation with the tibialis anterior muscle (r=0.783, p<0.001) among the other muscles. Regarding muscle strength, the MRC sum score correlated with the HG (r=0.660, p<0.001). For physical performance, the BBS correlated with the 4MGS (r=0.834, p<0.001). The same result was obtained after adjusting for factors of stroke severity, comorbidity, and nutritional status. CONCLUSION: These results suggest that ultrasonographic muscle thickness of the tibialis anterior, the MRC sum score, and BBS might be alternatives to SMI, HG, and usual gait speed for sarcopenia in stroke patients.