Evaluation of the Anterior Cruciate Ligament Injury Risk During a Jump-Landing Task Using 3-Dimensional Kinematic Analysis Versus the Landing Error Scoring System.

Background: The Landing Error Scoring System (LESS) has been utilized on the field or in the clinic to identify patients with an increased risk for anterior cruciate ligament (ACL) injuries; however, its validity and efficacy have not been fully confirmed. Purpose: To assess the efficacy of the LESS in identifying the ACL injury risk by examining the correlation between the LESS score and motion patterns on 3-dimensional kinematic analysis. Study Design: Controlled laboratory study. Methods: The jump-landing motion was analyzed for 16 female basketball or badminton players who volunteered to participate in the study. All study participants were aged 19 or 20 years. The sequence of motion was evaluated with the LESS, while kinematic data were simultaneously acquired with a 3-dimensional motion analysis system utilizing the point cluster method. The correlation between the LESS score and knee kinematics was statistically analyzed. Results: When a LESS score ≥6 was defined to be a risk factor for ACL injuries, 7 of the 16 participants (43.8%) were found to exhibit risky motion patterns. Significant correlations were noted between the LESS score and knee valgus (r = 0.87; P < .0001) and internal tibial rotation (r = 0.57; P = .02) at landing. By contrast, a substantial variability was present in knee flexion, showing no correlation with the LESS score. Conclusion: Significant correlations were found between the LESS score and knee valgus and internal tibial rotation during a jump-landing task. Clinical Relevance: The LESS can be regarded as an effective measure to identify risky motion patterns that may increase the likelihood of ACL injuries.

Osteochondral autologous transplantation for large steroid-induced osteonecrosis lesion of the knee in a young patient yielding satisfactory results despite only partial coverage: a case report.

Osteochondral autologous transplantation (OAT) is one of the most common surgical options for osteochondral disorders of the knee. In cases where OAT is performed for steroid-induced osteonecrosis, there are several problems potentially affecting the surgical outcomes such as large chondral damage area and compromised host bone. In addition, steroid administration for a long period of time may lead to extensive lesion, which poses difficulty in obtaining sufficient donor tissue. Those factors affect the prognosis of steroid-induced osteonecrosis resulting in inferior treatment outcomes. We present a young female with a large steroid-induced osteonecrosis lesion repaired only with two osteochondral plugs harvested from the healthy area. The reported case indicates that only partial osteochondral grafting limiting to the weight-bearing area may yield satisfactory outcome when OAT is performed for large steroid-induced osteonecrosis of the knee.

High prevalence of associated intra-articular injuries with increasing time period from anterior cruciate ligament injury to reconstruction, even in apparent copers.

BACKGROUND: It still unclear whether copers may bear the same time-sensitive risk of intra-articular injury as non-copers. The objectives were to investigate the clinical characteristics of copers and non-copers that have sustained an anterior cruciate ligament (ACL) injury, and to examine and compare the intra-articular pathologies in delayed ACL reconstruction (ACLR) in copers and noncopers. METHODS: Patients who sustained ACL injury while participating in high-performance sports and opted for non-operative treatment were enrolled in this study. Depending on the occurrence of the knee giving way, patients were classified into copers and noncopers. Clinical characteristics were compared between the two groups. Additionally, intra-articular injuries were evaluated for those who eventually underwent delayed ACLR. RESULTS: 11 of the 75 patients (14.7%) were classified as copers. No major differences were found in the clinical characteristics between groups. Following the initial non-operative treatment, 67 patients underwent delayed ACLR. When examining intra-articular abrasions at the time of surgery, non-copers who continued sports activities for 3 to 12 months exhibited a significantly higher rate of injury as opposed to their coper counterparts. However, the difference in the prevalence of intra-articular lesions between the two groups in patients who continued to play sports for at least 12 months before surgery was nominal. CONCLUSION: The rate of copers was relatively low in patients who resumed playing high-level sports after ACL injury. Additionally, even in copers, those who continued sports activities for more than 12 months had comparably high prevalence of intra-articular injuries with noncopers. STUDY DESIGN: Retrospective case-control study; Level of evidence, 3.

Optimal additional support screw position for prevention of hinge fracture in biplanar closed wedge distal femoral osteotomy.

Background: The purpose of this study was to examine the biomechanical significance of supplemental fixation using a positional screw in prevention of the hinge fracture in lateral closed-wedge distal femoral osteotomy (LCW-DFO) by means of a three-dimensional finite element analysis. Methods: The three-dimensional numerical knee models with LCW-DFO were developed. To assess the mechanical efficacy of the positional screw and determine its optimal position and orientation, in total, 13 screwing methods were analyzed. In the first four methods, the screw was supported by the cortical bone only on the medial surface (mono-cortical). In the other 9 models, the screw was supported by both medial and lateral cortical bones (bi-cortical). Under 1000 N of vertical force and 5 Nm of rotational torques, the highest shear stress value around the medial hinge area was adopted as an analytical parameter. Results: In mono-cortical methods, with the cancellous bone support, all methods were able to reduce the highest stress value compared to the value without the screw, while the efficacy was rather inferior when the screw was in horizontal direction. Without the cancellous bone support, however, all methods were not able to reduce the stress value. In bi-cortical methods, with the cancellous bone support, almost all screw augmentation methods were able to reduce the stress value. When screwing from the medial to the lateral, it only gets worse when going extremely posterior. Without the cancellous bone support, all methods were able to reduce the stress value. Conclusion: The mechanical efficacy of the bi-cortical method was proven regardless of the quality of the local cancellous bone.

Persistent Hemarthrosis of the Knee after Arthroscopic Meniscal Repair.

Introduction: In this case report, we report a patient with complicated with persistent hemarthrosis following arthroscopic meniscal repair. Case Presentation. A 41-year-old male patient presented with persistent swelling of the knee 6 months after arthroscopic meniscal repair and partial meniscectomy performed for lateral discoid meniscal tear. The initial surgery was performed at another hospital. Four months after the surgery, swelling of the knee was noted when he resumed running. At his initial visit to our hospital, intra-articular blood accumulation was revealed via joint aspiration. A second arthroscopic examination performed 7 months after the initial procedure showed healing of the meniscal repair site and synovial proliferation. The suture materials identified during the arthroscopy were removed. Histological examination of the resected synovial tissue showed inflammatory cell infiltration and neovascularization. In addition, a multinucleated giant cell was identified in the superficial layer. After the second arthroscopic surgery, the hemarthrosis did not recur, and the patient was able to resume running without symptom one and a half years post-surgery. Conclusion: Bleeding from the proliferated synovia at or near the periphery of the lateral meniscus was thought to be the cause of the hemarthrosis as a rare complication following arthroscopic meniscal repair.

Postoperative Tunnel Widening, Elliptical Aperture Shape, and No Preservation of the Remnant Are Related to the Tendon Graft-Bone Tunnel Gap Formation at the Intra-Articular Aperture After Double-Bundle Anterior Cruciate Ligament Reconstruction.

Purpose: To examine the bone-tendon healing at the posterolateral (PL) femoral tunnel aperture by second-look arthroscopy after double-bundle anterior cruciate ligament reconstruction (ACLR), and assess the risk factors for impaired healing at the tendon-bone interface. Methods: A consecutive series of knees undergoing primary double-bundle ACLR using hamstring tendon autografts were enrolled in the study. The exclusion criteria were as follows: previous knee surgeries, concomitant ligamentous and osseous procedures, and a lack of second-look arthroscopy or postoperative computed tomography data for the analysis. Cases in which a gap was identified between the graft and tunnel aperture during the second-look arthroscopic examination were classified as the gap formation (GF) group. A multivariate logistic regression analysis was performed to assess the relationship between the GF and variables that may determine prognosis. Results: A total of 54 knees that met the inclusion/exclusion criteria were included in the study. Second-look arthroscopy revealed the GF at the PL aperture in 22 of the 54 knees (40%). The time period from surgery to arthroscopy averaged 16 months. In the multivariate logistic regression analysis, the percentage tunnel widening at 1 year on computed tomography (odds ratio, 10.4; 95% confidence interval [CI] 1.56-69.2), ellipticity of the tunnel aperture (odds ratio, 3.57; 95% CI, 0.79-16.11), and no ACL remnant preservation (odds ratio, 5.99; 95% CI, 1.23-29.06) were identified as prognostic factors significantly related to graft-bone tunnel GF. Conclusions: Second-look arthroscopy revealed GF at the PL graft-bone tunnel interface in 40% of the knees after double-bundle ACLR. Incomplete healing of the interface, as evidenced by a graft-bone gap at the tunnel aperture, was associated with tunnel widening 1-year postsurgery, an elliptical aperture shape, and no preservation of the ACL remnant. Level of Evidence: Ⅲ, retrospective case-control study.

Efficacy of intravenous tranexamic acid administration in medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO) for varus knee osteoarthritis: a randomized control trial.

BACKGROUND: This randomized controlled study was undertaken to investigate the efficacy of intravenous tranexamic acid (TXA) administration in reducing perioperative blood loss in patients undergoing medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO). It was hypothesized that TXA would reduce perioperative blood loss in MOWDTO. METHODS: A total of 61 knees in 59 patients who underwent MOWDTO during the study period were randomly assigned to either of the groups with intravenous TXA administration (TXA group) or without TXA administration (control group). In the TXA group, patients received 1000 mg of TXA intravenously before skin incision and 6 h after the first dose. The primary outcomes was the volume of perioperative total blood loss which calculated using the blood volume and hemoglobin (Hb) drop. The Hb drop was calculated as the difference between preoperative Hb and postoperative Hb at days 1, 3, and 7. RESULTS: The perioperative total blood loss was significantly lower in the TXA group (543 ± 219 ml vs. 880 ± 268 ml, P < 0.001). The Hb drop was significantly lower at postoperative days 1, 3 and 7 in the TXA group than in the control group (day 1: 1.28 ± 0.68 g/dl vs. 1.91 ± 0.69 g/dl, P = 0.001; day 3: 1.54 ± 0.66 g/dl vs. 2.69 ± 1.00 g/dl, P < 0.001; day 7: 1.74 ± 0.66 g/dl vs. 2.83 ± 0.91 g/dl, P < 0.001). CONCLUSION: Intravenous TXA administration in MOWDTO could reduce the perioperative blood loss. Trial registration The study was approved by the institutional review board. (Registered on 26/02/2019 Registration Number 3136). Level of Evidence Level I, randomized controlled trial.

Editorial Commentary: Radiographic Quantification of Patellar Alta May Reference Patellar Position Relative to the Tibia or to the Femur.

Assessment of etiologic factors for the knee with patellar instability is important to construct an effective treatment strategy for each patient. Among the multiple risk factors for patellar instability, patella alta has been regarded as one of the principal morphologic abnormalities affecting bony constraint on excessive patellar motion. Although a number of radiographic measurement methods for patellar height have been proposed and tested for the reliability and diagnostic accuracy in the literature, consensus has not been reached on the optimal method of image assessment. The patella-posterior turning point of the distal femur (P-PTP) distance is an innovative indicator for quantifying patella alta. Conventional methods for quantifying patella alta measure the distance between the patella and the tibia. In contrast, P-PTP references the patellar height measurement to the femur. A challenge is that P-PTP requires imaging a supine patient in full knee extension.

Effect of Cross-sectional Area of the Hamstring Tendon Autograft on Failure Rate or Clinical Outcomes After Double-Bundle ACL Reconstruction: Tendon Autograft.

Background: In previous studies examining the relationship between graft size and failure rate after anterior cruciate ligament reconstruction (ACLR), graft size was determined as diameter of the bone tunnel, and graft failure was defined as revision surgery. Consequently, the correlation between graft size and postoperative recurrent instability could not be assessed. Purpose: (1) To intraoperatively measure the cross-sectional area (CSA) of the hamstring tendon (HT) autograft and compare the CSA of the autograft with the bone tunnel and (2) to assess the effect of the graft CSA on postoperative graft failure among patients who underwent double-bundle ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: The study included 129 patients who underwent double-bundle ACLR using an HT autograft (mean ± SD age, 16.7 ± 1.7 years; all with a Tegner activity level ≥6). All patients had a minimum follow-up of 2 years. During surgery, the graft CSA was measured using an area micrometer, combining the anteromedial (AM) and posterolateral (PL) grafts. The total area of the bone tunnel was defined as the combined CSAs of the AM and PL tunnels as calculated by the diameter of the drill. The relationship between the CSAs of the combined HT graft and the bone tunnel was statistically compared, as was the relationship between graft CSAs and graft failure, defined as reinjury, recurrent instability manifested as quantitative laxity measurement, or revision ACLR. Results: The CSAs of the midsubstance of the combined AM and PL graft significantly correlated with those of the bone tunnels (femoral side, R 2 = 0.334, P < .0001; tibial side, R 2 = 0.421, P < .0001). As for the relationship between the graft CSA and ACLR failure, there was no significant difference in the graft CSAs between the groups with and without graft failure in any of the failure criteria (P = .188). Conclusion: The graft CSA was not a predictor of early failure after double-bundle ACLR using an HT autograft in this patient population.

Preoperative Ahlbäck radiographic classification grade significantly influences clinical outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity.

PURPOSE: The purpose of this study was to examine the relationship between preoperative Ahlbäck radiographic classification grade and the clinical outcomes of double level osteotomy (DLO) performed for osteoarthritic knees with severe varus deformity. METHODS: The study population comprised a consecutive series of 99 knees (68 patients) for which DLO was performed and follow-up results for a minimum of two years were available. The Ahlbäck radiographic classification system was used to determine the osteoarthritic grade. The following radiological parameters for alignment and bone geometry were measured: mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), joint-line convergence angle (JLCA), and mechanical tibiofemoral angle (mTFA). Clinical results were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) subjective score preoperatively and at 2 years after surgery. Difference between preoperative and postoperative measurements as well as relationship between Ahlbäck grade and radiological/clinical results were statistically assessed. RESULTS: The average age of the study participants was 60.9 ± 6.2 years and the mean follow-up period was 45.4 ± 15.2 months. Each of the radiological parameters exhibited preoperative abnormal values. Knees with Ahlbäck grade 3 and 4 osteoarthritis exhibited significantly greater JLCA and mTFA than grade 1 knees. Two years post-surgery, all radiological parameter values measured within a normal range. Clinical evaluation showed significant improvement in KOOS after surgery. Analysis of the relationship between Ahlbäck grade and clinical score showed that the 2-year postoperative KOOS scores in grade 3 and 4 osteoarthritic knees were significantly lower than grade 1 knees (with the mean 2-year KOOS scores of 350.0 ± 79.9, 317.9 ± 78.3, and 420.2 ± 42.9, respectively). CONCLUSIONS: While DLO may produce significant radiological and clinical improvement in knees with joint space obliteration, Ahlbäck grade 3 and 4 osteoarthritic knees associated with larger JLCA and mTFA showed less satisfactory clinical results compared to grade 1 knees. LEVEL OF EVIDENCE: IV case series.

Increased posterior slope and coronal inclination of the tibial joint line after opening wedge high tibial osteotomy may induce mucoid degeneration of the anterior cruciate ligament: A case report.

A mucoid degeneration of the anterior cruciate ligament (ACL) is regarded as a degenerative change in the ligament, which is clinically presented with pain on full extension or flexion. Regarding morphological factors, it has been reported that an increased posterior tibial slope can be a cause of ACL degeneration secondary to the repetitive overload. The increase in the tibial slope is among the potential problems after medial opening wedge high tibial osteotomy (OWHTO). Especially, a large wedge opening in the correction of severe varus deformity may lead to non-physiologic bony geometry including an increased posterior tibial slope and medial tibial coronal inclination. We present a 69-year-old man had undergone OWHTO with a wedge correction angle of 12.4° for Kellegren-Lawrence grade 2, medial uni-compartmental osteoarthritis of the left knee. Evaluations of the postoperative radiographs revealed postoperative changes in radiological parameters with mechanical medial proximal tibial axis (mMPTA) from 81.3° to 94.3°, and posterior tibial slope (PTS) from 12.2° to 15.8°. Physical examination at 3 years after surgery revealed a knee extension of 0° and a limitation to knee flexion with maximum flexion of 110° and, and severe knee pain was elicited when the knee approached deep flexion. MRI revealed an increased signal intensity along the substance of the ACL and multiple cystic lesions indicative of a ganglion formation around the proximal ACL attachment site extending into the adjacent lateral femoral condyle. Microscopic examination of the resected tissues showed mucoid degeneration and mucous cysts indicative of ganglions formation within the ligament substance and the bone at the attachment site. The reported case illustrates the importance of being aware of this potential complication following OWHTO.

Tibial Condylar Valgus Osteotomy Combined With Medial Open-Wedge Distal Tuberosity Tibial Osteotomy.

Severe varus deformity in osteoarthritic knees is attributed not only to bony deformity but also to intra-articular deformity as a result of medial joint space narrowing with lateral joint space widening (increased joint line convergence angle). In such knees, correction of bony deformity by high tibial osteotomy (HTO) alone may not be capable of restoring physiological joint geometry and biomechanics. Tibial condylar valgus osteotomy (TCVO), an L-shaped osteotomy in the medial tibial condyle, has been proposed to improve articular stability and congruity by elevating the medial tibial joint line and addressing the articular component of the deformity; however, its surgical efficacy for correction of the valgus deformity is limited. Therefore a procedure combining HTO and TCVO can be a reasonable option to achieve restoration of the knee joint physiology in such situations. In our current practice, medial open-wedge distal tuberosity tibial osteotomy (MOW-DTO) has been the procedure of primary option among the HTO procedures to avoid patellofemoral overload which could be an inherent problem in medial open-wedge HTO. In this article, the surgical rationale and the combined procedure of TCVO and MOW-DTO are described.

The Effectiveness of Intramedullary Screw Fixation Using the Herbert Screw for Fifth Metatarsal Stress Fractures in High-Level Athletes.

BACKGROUND: Intramedullary screw fixation is the most common operative procedure used for treatment of fifth metatarsal stress fractures in athletes. However, the optimal implant in intramedullary screw fixation is still being investigated. PURPOSE: To review experiences with intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures in high-level athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors retrospectively analyzed 37 high-level athletes (Tegner activity score ≥7) who underwent intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures between August 2005 and August 2017. The minimum follow-up period of the patients was 2 years. In assessing the surgical results, time to obtain bone union, time to return to original level of sport participation, and treatment failures/complications were reviewed. Additionally, the effect of intraoperative plantar gap widening caused by the screw insertion was analyzed. The surgical results of the 2 groups, the no-gap group (intraoperative plantar gap widening, <1 mm) and the gap group (intraoperative plantar gap widening, ≥1 mm), were compared, while correlations between intraoperative plantar gap widening and the surgical results were statistically analyzed. RESULTS: Bone union and return to the original sport were attained in all patients without treatment failures/complications such as delayed union, nonunion, or refracture. The mean time to obtain bone union was 10.1 weeks, and the mean time to return to sport was 10.9 weeks. In comparing the no-gap group (n = 16) and the gap group (n = 21), no significant differences in the time to obtain bone union (P = .392) or to return to sport (P = .399) were noted. Additionally, there was no correlation between intraoperative plantar gap widening and the time to obtain bone union (r = 0.131; P = .428) or to return to sport (r = 0.160; P = .331). CONCLUSION: The use of the Herbert screw for intramedullary screw fixation to treat fifth metatarsal stress fractures in high-level athletes provided satisfactory results enabling all the athletes to return to the original sport without treatment failures/complications. Additionally, intraoperative plantar gap widening does not affect the surgical results using this technique.

Total Hip Arthroplasty Concomitant with Patellofemoral Arthroplasty and Medial Patellofemoral Ligament Reconstruction for a Patient with Patellar Dislocation Combined with Hip Dysplasia: A Case Report of a Successful Outcome at 5-Year Follow-Up.

BACKGROUND: Posttraumatic patellar dislocation is rare, and consistent surgical strategy therefore has not been defined due to multifactorial factor. In this case study, we treated a case of a patellar dislocation with hip osteoarthritis and increased femoral anteversion by performing a two-staged surgery. In the first stage, total hip arthroplasty was performed, and in the second stage, simultaneous patellofemoral arthroplasty and medial patellofemoral ligament reconstruction using semitendinosus tendon autograft were performed. Case Report. A 56-year-old female patient who previously had right hip osteoarthritis complained of right knee pain after a fall. Radiographic examination showed lateral dislocation of the patella with osteoarthritic (OA) change in the patellofemoral joint and an excessive femoral anteversion with OA change on the right hip joint. Total hip arthroplasty was performed firstly to decrease femoral anteversion. Then, simultaneous patellofemoral arthroplasty and medial patellofemoral ligament reconstruction was performed for residual patellar dislocation and patellofemoral OA without tibiofemoral joint OA. At the time of the 5-year follow-up after surgery, the patient was able to walk with a wheelbarrow without any complications. CONCLUSION: To the best of our knowledge, this is the first case of a patellar dislocation with an increased femoral anteversion and patellofemoral OA treated by a combination of total hip arthroplasty, patellofemoral arthroplasty, and medial patellofemoral ligament reconstruction. The clinical outcome improved at 5 years after these surgeries. Therefore, these surgical options can be considered to be useful.

Characteristic Poses in Ballet in the Case of a Retired Classical Ballerina after Bilateral THA: A Case Report and Review of Literature.

BACKGROUND: Ballet dance involves extreme range of motion (ROM) in the hip joint. This ROM can cause injuries including labral strain, tears, and subluxation episodes. Case Presentation. A 69-year-old female classical ballet dance instructor presented bilateral hip pain. The plain radiograph showed end-stage osteoarthritic change in the bilateral hip. She could neither dance nor perform daily activities. Bilateral hybrid total hip arthroplasty (THA) was performed. After surgery, she was able to demonstrate the split position on the floor as an active classical ballerina. The plain radiograph was taken in the split position, and the radiograph did not show any characteristics of impingement or subluxation of the femoral head. CONCLUSION: She was able to continue working as a classical ballet instructor after bilateral THA. Additionally, any characteristics of impingement or subluxation of the femoral head were not revealed in the postoperative radiograph in the split position.

Three dimensional CT analysis of the change in rotational alignment in double level osteotomy after double level osteotomy performed for varus osteoarthritic knees.

PURPOSE: To analyze the change in rotational alignment caused by double level osteotomy (DLO) based on comparative three-dimensional image analysis of pre- and postoperative CT images. METHODS: Pre- and postoperative CT examination of the lower extremities were performed with informed consent for 39 consecutive knees undergoing DLO for varus knee deformity. The DLO procedure consisted of closed wedge distal femoral osteotomy (CWDFO) and open wedge high tibial osteotomy (OWHTO). Among those cases, 20 knees complicated with hinge fracture at the osteotomy site were excluded from the analysis to eliminate a confounding factor affecting the results. Consequently, data obtained from 19 knees were subjected to the study analysis while osteotomies with hinge fractures complications were excluded from the study. In the three-dimensional CT image analysis of axial plane images, femoral torsion (the angle between midline along the femoral neck axis and the tangent of the posterior edges of the medial/lateral femoral condyles) and tibial torsion (the angle between the tangent of the posterior edges of the medial/lateral tibial condyles and the transmalleolar axis) were measured. The torsion angle was measured in each of the femurs and the tibias on both pre- and postoperative CT axial images, and the change induced by the osteotomy was calculated and statistically(using Wilcoxon signed-rank test) compared. RESULTS: The mean pre- and postoperative femoral torsion (anteversion) angles were 29.3° and 31.4° with a significant postoperative increase in internal rotation of the bony segment distal to the osteotomy(P = 0.002). On the tibial side, the mean pre- and postoperative torsion angles were 26.5° and 25.7°, indicating no significant postoperative change(P = 0.199)（NS）. CONCLUSIONS: This study showed that the DLO procedure (combining CWDFO and OWHTO) increased torsion (anteversion) of the femur by 2.1° on average while inducing no significant rotational change on the tibial side.

Double-level osteotomy for severe varus osteoarthritic knees can prevent change in leg length and restore physiological joint geometry.

BACKGROUND: It is unclear whether double-level osteotomy (DLO) combining closed-wedge osteotomy in the distal femur and open-wedge osteotomy in the proximal tibia deformity can prevent change in leg length and excessive coronal inclination of the tibial articular surface in surgical correction of the severe varus knee. The purpose of this study was to examine the postoperative change in leg length as well as radiological and clinical outcomes following DLO compared with the results obtained from knees undergoing isolated open-wedge high tibial osteotomy (OW-HTO). METHODS: In cases of severe varus knee deformity (hip-knee-ankle angle (HKA) > 10°) 29 patients undergoing DLO and 35 patients undergoing OW-HTO were included. If the predicted mechanical medial proximal tibial angle (mMPTA) was 95° or greater or the wedge size was 15 mm or greater in the surgical simulation, then DLO was considered as the surgical of option. In cases where these criteria were not met, OW-HTO was selected. All patients were followed up for a minimum of 2 years. RESULTS: The changes in the length of the whole leg in the DLO and OW-HTO groups averaged 2.3 ±â€¯4.8 mm and 9.3 ±â€¯7.2 mm, respectively (P < 0.001). mMPTA of more than 95° was found in no knee in the DLO group. CONCLUSIONS: This study showed that DLO could avoid leg length change and non-physiologic joint lines when performed in patients with varus HKA > 10°, and the predicted mMPTA was 95° or greater or the wedge size was 15 mm or greater in the surgical simulation.

Mucoid degeneration of the posterior cruciate ligament in a college soccer player: a case report.

BACKGROUND: To the best of our knowledge, arthroscopic treatment for symptomatic mucoid degeneration of the posterior cruciate ligament in young athletes has not been reported before. CASE PRESENTATION: An 18-year-old Asian male college soccer player presented with a 3-month history of right knee pain without episodes of trauma. Despite conservative treatment over the preceding 3 months, his symptoms persisted. Physical examination of the right knee revealed full range of motion, though posterior knee pain was induced when the knee approached full flexion. On ligament examination, posterior sagging and Lachman test were negative, and no clinical finding indicative of ligament insufficiency was noted. Magnetic resonance imaging showed a diffusely thickened posterior cruciate ligament with increased signal intensity on the T2-weighted sequence. A few intact fibers were observed with continuous margin from origin to insertion. Based on the patient's history and the magnetic resonance imaging findings, we suspected mucoid degeneration of the posterior cruciate ligament as the cause of the patient's symptoms. Since conservative treatment had failed to relieve the symptoms, arthroscopic treatment was indicated. Arthroscopic examination revealed yellowish crumbly tissues along the thickened posterior cruciate ligament. Tension and bulk of the posterior cruciate ligament were well preserved. Curettage of degenerative tissue and decompression of the posterior cruciate ligament resulted in symptom relief without instability of the knee joint. The patient returned to play at 3 months. At 12 months, postoperative magnetic resonance imaging showed no evidence of recurrence and indicated that the remaining posterior cruciate ligament was thicker than before the surgery. At 2 years follow-up, the patient remained asymptomatic and could play soccer at the same level as before the onset of pain. CONCLUSIONS: Arthroscopic decompression of the posterior cruciate ligament may relieve knee pain and facilitate early return to play with good functional results.

Percutaneous periarticular analgesic injection at one day after simultaneous bilateral total knee arthroplasty: an open-label randomized control trial.

BACKGROUND: The postoperative pain after total knee arthroplasty (TKA) remains a critical issue. The aim of this study was to assess the clinical effectiveness of percutaneous periarticular injection at 1 day following simultaneous bilateral TKA. METHODS: A total of 88 knees in 44 patients who underwent simultaneous bilateral TKA were randomly assigned to receive a percutaneous periarticular injection at 1 day following surgery (n = 22 patients) or no injection (n = 22 patients). In the additional injection group, we injected a solution including methylprednisolone, ropivacaine, and epinephrine into the muscle belly of the vastus medialis at 1 day after surgery. In both groups, patients received an intraoperative periarticular multi-drug injection and postoperative intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome measure was the postoperative pain at rest using a visual analog scale (VAS) and analyzed with Student's t test. RESULTS: Compared to the no additional injection group, the additional periarticular injection group had significantly lower VAS score at 8:00 PM postoperative day 1, 6:00 AM postoperative day 2, 12:00 PM postoperative day 2, 6:00 AM postoperative day 5, 12:00 PM postoperative day 5, and 8:00 PM postoperative day 5 (p < 0.05). The rate of complication did not differ between groups (p > 0.05). CONCLUSION: Additional percutaneous periarticular injection at 1 day following TKA adding to intraoperative periarticular injection provided better postoperative pain relief. TRIAL REGISTRATION: Registered at the University Hospital Medical Information Network (registration number: UMIN000029759 ).

Cartilage repair examined by second-look arthroscopy following double-level osteotomy performed for osteoarthritic knees with severe varus deformity.

BACKGROUND: The purpose of this study was to examine the status of cartilage repair by second-look arthroscopy following double-level osteotomy (DLO) performed for osteoarthritic knees with severe varus deformity. METHODS: Forty-seven consecutive knees in 33 patients who underwent DLO were included in the study. The surgical technique used was a minimally invasive DLO procedure combining lateral closed-wedge distal femoral and medial open-wedge high tibial osteotomies. In the second-look arthroscopic evaluation, the following grading system proposed by Koshino was adopted: Stage A, no repair; stage B, pink fibrous tissue with or without partial coverage with white fibrocartilage; and stage C, total coverage with cartilage. The findings corresponding to stage B or C were considered as repaired. Arthroscopic assessment was performed for each compartment. Clinical outcomes were evaluated using the validated outcome measures. RESULTS: The mean age at surgery was 62.8 ± 6.2 years (range: 45-75 years), and the mean time period from DLO to second-look arthroscopy was 17.1 ± 5.0 months (range: 12-33 months). Cartilage repair to some extent was identified in over 90% of the medial femoral and tibial condyles, and 12.8% of the patellar facet. As for clinical scores, both Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form (IKDC) subjective scores significantly improved after surgery (P < 0.01). CONCLUSIONS: Evaluation of the present study subjects showed that DLO could induce cartilage repair in the majority of the affected femoral and tibial articular surfaces with significant clinical improvement. In the patellar facet, however, cartilage repair could be identified in only 12.8% of cases.