New bone formation after arthroscopic Bankart repair for unstable shoulders with an erosion-type glenoid defect.

BACKGROUND: The purpose of the present study was to retrospectively evaluate new bone formation after arthroscopic Bankart repair (ABR) and the influence of new bone formation on recurrence in shoulders with an erosion-type glenoid defect. METHODS: We analyzed data on shoulders with an erosion-type glenoid defect. Participants were patients who underwent computed tomography to evaluate new bone formation after ABR performed from 2004 to 2021 and were followed for a minimum of 2 years. We investigated the factors influencing new bone formation, in particular the presence of an intraoperative bone fragment, and the influence of new bone formation and its size on postoperative recurrence. RESULTS: A total of 100 shoulders were included. The mean glenoid defect size was 10.1% ± 6.3% (range, 1.2%-31.5%). New bone formed postoperatively in 15 shoulders (15.0%) and was seen in significantly more shoulders with an intraoperative bone fragment (11 of 18, 61.1%) than in those without a fragment (4 of 82, 4.9%; P < .001). Recurrence occurred in 22 shoulders (22.0%), and the rate of recurrence was not different between shoulders with new bone formation (3 of 15, 20.0%) and without new bone formation (19 of 85, 22.4%; P = .999). Among the 15 shoulders with new bone formation, the size of the new bone fragments relative to glenoid width was <5% in 2 shoulders, 5%-<7.5% in 8 shoulders, 7.5%-<10% in 3 shoulders, and ≥10% in 2 shoulders; in all 3 shoulders with postoperative recurrence, the relative size was <7.5%. CONCLUSIONS: Even in shoulders with an erosion-type glenoid defect, new bone may form after ABR, especially in shoulders with an intraoperative bone fragment. However, new bone formation does not decrease the rate of postoperative recurrence.

Rectangular bone-patellar tendon bone grafts reduce early graft failure in chronic ACL-Deficient knees.

BACKGROUND: The aim of this study was to assess early graft failure after anterior cruciate ligament (ACL) reconstruction according to chronicity of ACL deficiency (ACLD) and clarify predisposing factors. METHODS: A total of 731 patients who underwent anatomic ACL reconstruction were divided into 3 groups based on chronicity of ACLD: <6 months (Group 1), 6 months to 2 years (Group 2), and >2 years (Group 3). Types of ACL grafts used included single-bundle hamstring tendon (HT), multiple-bundle HT, and rectangular bone-patellar tendon-bone (BTB) grafts. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken to examine anterior tibial subluxation (ATS). All ACL grafts were evaluated by MRI at 6 months to identify graft failure. The group with the highest failure rate was further examined to compare possible risk factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors. RESULTS: Early graft failure on MRI without any episode of postoperative trauma was observed in 7 (1.4%), 2 (1.8%), and 11 (9.2%) patients in Groups 1, 2, and 3, respectively, with a significantly higher rate in Group 3 (P < 0.001). Of the 119 patients in Group 3, significant differences were observed between intact and failure subgroups with regard to surgical procedure (P = 0.03), chondral lesions (P < 0.01), and preoperative ATS (P < 0.01). Multivariate logistic regression analysis revealed that surgical procedures (odds ratio, 3.8; 95%CI, 1.16-12.59) and preoperative ATS (odd ratio, 2.4; 95%CI, 1.26-4.38) were predisposing factors of early graft failure. CONCLUSION: Patients with ACLD for >2 years experienced early graft failure with an incidence rate of 9.2%. Predisposing factors of early graft failure in these patients included the use of single-bundle HT grafts and preoperative ATS. The use of rectangular BTB grafts resulted in a lower graft failure rate. STUDY DESIGN: Case Series.

A Glenoid Defect of 13.5% or Larger Is Not Always Critical in Male Competitive Rugby and American Football Players Undergoing Arthroscopic Bony Bankart Repair: Contribution of Resultant Large Bone Fragment.

PURPOSE: To investigate bone union and postoperative recurrence after arthroscopic bony Bankart repair (ABBR) in male competitive rugby and American football players with a subcritical glenoid defect of ≥13.5% and to compare findings with those in players with a glenoid defect of <13.5%. METHODS: Participants were male competitive rugby or American football players with a glenoid defect and bone fragment who underwent ABBR from July 2011 to December 2018 and were followed for a minimum of 2 years. We investigated the influence of glenoid defect and bone fragment size on bone union and postoperative recurrence after ABBR. RESULTS: We included 45 rugby players and 35 American football players. A total of 38 shoulders were assigned to the small defect group (<13.5%) and 42 to the large defect group (≥13.5%). The complete bone union rate was 47.4% in the small defect group and 71.4% in the large defect group (P = .040), and postoperative recurrence was seen in 13 (34.2%) and 5 shoulders (11.9%), respectively (P = .030). In the small defect group, the bone fragment size was <7.5% in 30 shoulders and ≥7.5% in 8 shoulders; in comparison, the respective numbers were 12 and 30 shoulders in the large defect group, and large fragments (>7.5%) were significantly more common in this group (P < .001). The complete union rate was significantly higher in shoulders with a large fragment (≥7.5%) than in those with a small fragment (<7.5%; 78.9% versus 42.9%, respectively; P = .001). The recurrence rate was 33.3% in shoulders with a small fragment (<7.5%) and 10.5% in shoulders with a large fragment (≥7.5%; P = .017) and was significantly lower in shoulders with a complete union than in those without a complete union (6.3% versus 46.9%, respectively; P < .001). CONCLUSION: The postoperative recurrence rate after ABBR was lower in male competitive rugby and American football players with a large glenoid defect (≥13.5%) than in those with a small glenoid defect (<13.5%) and might be associated with a higher rate of complete bone union of the resultant large bone fragment (≥7.5%). LEVEL OF EVIDENCE: III, case-control study.

On-the-Edge Anchor Placement May Be Protective Against Glenoid Rim Erosion After Arthroscopic Bankart Repair Compared to On-the-Face Anchor Placement.

PURPOSE: This retrospective study aimed to compare the effects of 2 different anchoring placements on glenoid rim erosion after arthroscopic Bankart repair (ABR). METHODS: Shoulders that underwent ABR from January 2013 to July 2020 were divided into 2 groups according to anchor placement (on-the-face, group F; on-the-edge, group E). We retrospectively calculated the percent change of glenoid width (Δ) on the first postoperative computed tomography scan (CT; performed within 6 months) and second postoperative CT (performed at 6 to 12 months) relative to the width on the preoperative CT and compared percent changes between the 2 groups. Also, we investigated the influence of preoperative glenoid structures (normal, erosion, bony Bankart) and the postoperative recurrence rate. RESULTS: We examined 225 shoulders in 214 patients (group F, n = 151; group E, n = 74). At first CT, anchoring placement was significantly associated with postoperative decrease of glenoid width (group F, -7.6% ± 7.9%; group E, -0.1% ± 9.7%; P < .0001). The difference between groups F and E was significant in shoulders with a preoperative glenoid defect (bony Bankart, -6.6% ± 8.8% vs 2.5% ± 11.2%, respectively; P < .0001; erosion, -6.6% ± 6.2% vs -2.6% ± 5.3%, respectively; P = .03). In 112 shoulders, CT was performed twice; Δ was -6.9% ± 7.3% in group F (n = 64) and -1.7% ± 10.1% in group E (n = 48; P = .005) at the first CT and -3.2% ± 10.0% and 1.0% ± 10.6% (P = .10), respectively, at the second CT, indicating recovery of glenoid width in both groups. The postoperative recurrence rate in patients with at least 2 years' follow-up was 14.7% in group F and 14.6% in group E. CONCLUSIONS: In the early stage after ABR, on-the-edge glenoid anchor placement was associated with less glenoid rim erosion than on-the-face anchor placement. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Anatomical rectangular tunnel anterior cruciate ligament reconstruction provides excellent clinical outcomes.

PURPOSE: The purpose of this study was to prospectively evaluate the clinical outcomes following anatomical rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone (BTB) graft using an adjustable-length femoral cortical fixation device with enough patients and a high follow-up rate. METHODS: This study included 125 patients who underwent anatomical rectangular tunnel ACL reconstruction with a BTB graft. A BTB TightRope® was used for femoral graft fixation. Clinical evaluations were performed more than 2 years after surgery using the International Knee Documentation Committee (IKDC) Form. Patients interviewed by telephone were only subjectively evaluated. The side-to-side difference in anterior laxity at a manual maximum force was measured using the KT-2000 Arthrometer®. RESULTS: Among the 125 patients, 99 were ultimately included and 26 were lost to follow-up (follow-up rate: 79%). Eight patients had re-tear (re-tear rate: 8%) and six patients had ACL injuries to the contralateral knee. Three patients did not follow our rehabilitation programme. One patient suffered septic arthritis. These 18 patients were considered ineligible for clinical evaluations. Therefore, clinical evaluations were performed in 81 of the 99 patients (64 were available for direct follow-up and 17 were available for a telephone interview). The follow-up period was 30 ± 10 months (range 24-68 months). According to the IKDC subjective assessment, 48 (59%) and 33 (41%) knees were graded as normal and nearly normal, respectively. A loss of extension (3°-5°) was observed in five patients (8%), whereas one patient (2%) exhibited a loss of flexion (3°-5°). The Lachman test was negative in 63 patients (98%). The pivot shift test was negative in 59 patients (92%). The side-to-side difference in KT value was 0.4 ± 0.7 mm (range - 1-4 mm). CONCLUSION: Anatomical rectangular tunnel ACL reconstruction with a BTB graft using an adjustable-length femoral cortical fixation device provided excellent clinical outcomes both subjectively and objectively more than 2 years after surgery, whereas 8 of the 99 patients had re-tear of the graft. The adjustable-length femoral cortical fixation device could be safely used in anatomical rectangular tunnel ACL reconstruction with a BTB graft. LEVEL OF EVIDENCE: III.

Unrecognized glenoid fracture in opposite shoulders with symptomatic anterior instability.

BACKGROUND: The purpose of the present study was to investigate the characteristics of unrecognized glenoid fracture in opposite shoulders with symptomatic anterior instability. METHODS: Participants were 38 patients, who had complaints of instability on only one side (symptomatic shoulder) and had no complaints despite of a glenoid fracture on the other shoulder (asymptomatic shoulder) from 2011 to 2020. Factors that could influence the onset of symptoms including glenoid rim morphology were retrospectively investigated. RESULTS: Among the asymptomatic shoulders, 16 had a single traumatic event and 22 had no history of trauma. The glenoid morphology was normal in 6, erosion in 12 and bony Bankart in 20 on the symptomatic side, whereas the respective shoulders were 0, 16 and 22 on the asymptomatic side. Bone union of bony Bankart was complete in 9, partial in 3 and non-union in 8 on the symptomatic side, whereas the respective shoulders were 18, 3 and 1 on the asymptomatic side. The mean glenoid defect size was 10.4% and 7.8%, and the mean bone fragment size was 5.0% and 4.5%, respectively. The mean medial displacement of bone fragments was 2.6 mm and 1.0 mm, respectively (p < 0.001). A larger glenoid defect (≥10%) was recognized in 19 symptomatic shoulders and 10 asymptomatic shoulders. Among them, erosion was solely recognized in 5 symptomatic shoulders. In shoulders with bony Bankart, all 10 asymptomatic shoulders had a completely or partially united fragment with less than 2 mm displacement. On the other hand, among 14 symptomatic shoulders, united fragment was solely recognized in 8 shoulders, in which medial displacement was less than 2 mm in 3 shoulders. CONCLUSIONS: Even if a glenoid fracture occurred, symptom such as instability or pain was not always recognized by all patients. Regardless of glenoid defect size, shoulders with a completely or partially united bone fragment and with less than 2 mm displacement were found to be asymptomatic.

The process of bone union after arthroscopic bony Bankart repair in younger athletes with a subcritical glenoid defect: An advantage of remained large bone fragment.

BACKGROUND: The purpose of the present study was to investigate the bone union process after arthroscopic bony Bankart repair (ABBR) in shoulders with a subcritical glenoid defect of 13.5% or larger. METHODS: Bone union process after ABBR performed from 2011 to 2018 were retrospectively investigated in 47 athletes younger than 30 years with a subcritical glenoid defect, who underwent CT at least twice postoperatively. The change of bone union between first CT within 6 months and final CT later than 6 months was investigated, especially noticing bone fragment size (≥7.5% versus <7.5%). RESULTS: The mean period at first CT and at final CT was 4.1 ± 0.6 months (3-6 months) and 16.8 ± 11.6 months (7-71 months), respectively. From the first to final CT, among 15 shoulders with a small bone fragment (<7.5%), complete union increased from 4 shoulders (26.7%) to 8 shoulders (53.3%), while among 32 shoulders with a large bone fragment (≥7.5%), complete union increased from 15 shoulders (46.9%) to 25 shoulders (78.1%). On the other hand, while non-union or disappeared bone fragment was recognized in 8 shoulders (53.3%) with a small fragment and in 2 shoulders (6.3%) with a large fragment at first CT, it was solely recognized in 4 shoulders (26.7%) with a small fragment and in no shoulders with a large fragment at final CT. While postoperative glenoid fracture at the site of bone union was recognized in 7 shoulders, complete union was finally obtained after conservative treatment in 5 shoulders. So, final complete union was obtained in 9 (60%) of 15 shoulders with a small fragment and in 29 (90.6%) of 32 shoulders with a large fragment (p = 0.021). CONCLUSIONS: In shoulders with a subcritical glenoid defect, when a large bone fragment (≥7.5%) was repaired, complete union rate was higher and complete union could be obtained earlier.

Knot location in arthroscopic inside-out meniscal repair: Cadaveric evaluation.

BACKGROUND: The inside-out repair technique is the gold standard for treatment of meniscal tears, while some soft tissues can be hung as the sutures are tied outside the capsule. The purpose was to clarify the association between the suture site and knot location in the arthroscopic inside-out technique. METHODS: Inside-out meniscal suture was arthroscopically performed on medial and lateral menisci in twenty-three cadaveric knees, on the assumption that longitudinal tear existed. A retractor was inserted above the semi-membranous tendon and anterior to the gastrocnemius for the medial side, while the retractor was placed in the anterior space of the gastrocnemius for the lateral side. After identifying three segments (anterior, middle and posterior segments), eight sutures were inserted into the following eight areas in each knee: anterior (M1, L1) and posterior (M2, L2) areas of the middle segment, and anterior (M3, L3) and posterior (M4, L4) areas of the posterior segment. Twelve knees underwent meniscal repair on femoral side and eleven passed sutures on the tibial side, while knots were tied outside of the joint. Attentive dissection was performed to assess the relation between knot locations and the principal structures around the knee joint. RESULTS: In medial meniscal suture, most sutures for the middle portion (M1, 2) bound medial collateral ligament (MCL), while a few cases included the semi-membranous tendon for the M4 area. In lateral meniscal suture, sutures for the L1 area tied some fibers of lateral collateral ligament (LCL) in high frequency, while popliteal muscles/tendons were tied over at the L3 area. CONCLUSIONS: Most suture knots were located on MCL or capsule in medial meniscus suture, while more than half sutures passed through LCL or popliteal tendon/muscle in lateral meniscus suture. An assistant should retract LCL under direct observation and the surgeon must confirm the direction of needle for lateral meniscal repair.

The lateral meniscal extrusion after repair with concomitant anterior cruciate ligament reconstruction at a mean follow-up of 3.5 years.

BACKGROUND: A meniscal repair is often performed on radial/flap or longitudinal tears of the lateral meniscus (LM) combined with anterior cruciate ligament reconstruction (ACLR). However, it is unknown if meniscal extrusion changes over time after repair. This study evaluated whether meniscal extrusion of the LM is maintained after repair or progresses with time using magnetic resonance imaging (MRI). METHODS: Among 574 patients who underwent primary anatomic ACLR, 123 patients followed up for more than 2 years were retrospectively analyzed. Forty patients with concomitant radial/flap tears of the LM (group R), 43 with longitudinal LM tears (group L), and 40 with intact LM (group C, matched-control group) were included. Clinical findings (pain, range of motion, swelling, and anterior laxity), lateral joint space on radiograph, and meniscal extrusion on MRI were assessed. Lateral/posterior meniscal extrusions were examined preoperatively, within 3 weeks after surgery, and at the final follow-up, and the absolute values and relative values (the preoperative values as baseline) were assessed respectively. RESULTS: There were no significant differences in the clinical and roentgenographic findings among the groups. No difference was observed in the relative values within 3 weeks after surgery among three groups, although the absolute values were larger in the repaired groups than in group C. At the final follow-up, however, the lateral extrusion in group L had progressed significantly, compared with that in group C (P = 0.033), while no significant difference was detected in the lateral extrusion between groups R and C (P = 0.177). The posterior extrusion in groups R and L had progressed significantly compared with that in group C (P < 0.001). CONCLUSIONS: LM extrusion could not be improved even immediately after meniscal repair, and it progressed laterally and posteriorly for more than 2 years after surgery.

Anatomical Triple Bundle Anterior Cruciate Ligament Reconstructions With Hamstring Tendon Autografts: Tunnel Locations and 2-Year Clinical Outcomes.

PURPOSE: To anatomically clarify the location of the tunnel apertures created using the bony landmark strategy and to elucidate clinical outcomes after anatomic triple-bundle (ATB) anterior cruciate ligament (ACL) reconstruction. METHODS: Thirty-two patients with unilateral ACL injury who had consented to undergo computed tomography (CT) at 3 weeks, as well as 2-year follow-up evaluation, were enrolled. At the time of surgery, remnant tissues were thoroughly cleared to create 2 femoral and 3 tibial tunnels inside the ACL attachment areas bordered by the bony landmarks. Two double-looped semitendinosus tendon autografts were prepared and fixed on the femur with two EndoButton-CLs and secured to the tibia with pullout sutures and plates with 10-20N of tension. The location of the tunnel aperture areas was assessed using 3-dimensional CT images, and 2-year postoperative clinical outcomes were evaluated. RESULTS: The CT evaluation showed 100% of the femoral tunnel aperture area and at least 79% of the tibial tunnel aperture area were located inside the anatomic attachment areas. Thirty patients were available for clinical evaluation. The International Knee Documentation Committee subjective assessment showed all of the patients were classified as "normal" or "nearly normal." Lachman and pivot-shift tests were negative in 100% and 93%, respectively. The mean side-to-side difference of anterior laxity at the maximum manual force with a KT-1000 Knee Arthrometer was 0.7 ± 0.7 mm, ranging from 0 to 2 mm. CONCLUSION: In ATB ACL reconstructions with hamstring tendon grafts, the tunnels can be created in proper locations using the arthroscopically-identifiable bony landmarks. Moreover, ATB ACL reconstruction with hamstring tendon grafts via the proper tunnels result in consistently satisfactory clinical outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Significant anterior enlargement of femoral tunnel aperture after hamstring ACL reconstruction, compared to bone-patellar tendon-bone graft.

PURPOSE: This study aimed to retrospectively compare the enlargement and migration of the femoral tunnel aperture after anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patella tendon-bone (BTB) or hamstring tendon (HT) graft using three-dimensional (3-D) computer models. METHODS: Thirty-two patients who underwent ACL reconstruction and postoperative computed tomography (CT) at 3 weeks and 6 months were included in this study. Of these, 20 patients underwent ACL reconstruction with a BTB graft (BTBR group), and the remaining 12 with an HT graft (HTR group). The area of the femoral tunnel aperture was extracted and measured using a 3-D computer model generated from CT images. Changes in the area and migration direction of the femoral tunnel aperture during this period were compared between the two groups. RESULTS: In the HTR group, the area of the femoral tunnel aperture was significantly increased at 6 months compared to 3 weeks postoperatively (P < 0.05). The average area of the femoral tunnel aperture at 6 months postoperatively was larger by 16.0 ± 12.4% in the BTBR group and 41.9 ± 22.2% in the HTR group, relative to that measured at 3 weeks postoperatively (P < 0.05). The femoral tunnel aperture migrated in the anteroinferior direction in the HTR group, and only in the inferior direction in the BTBR group. CONCLUSIONS: The femoral tunnel aperture in the HTR group was significantly more enlarged and more anteriorly located at 6 months after ACL reconstruction, compared to the BTBR group. LEVEL OF EVIDENCE: IV.

Relationship between bone plug position and morphological changes of tunnel aperture in anatomic rectangular tunnel ACL reconstruction.

PURPOSE: In animal studies after ACL reconstruction (ACL-R) using the bone-patellar tendon-bone (BTB), the graft-healing pattern was found to depend on the relationship between bone plug and the tunnel wall. This difference of graft-healing pattern could influence the postoperative morphological changes of the tunnel. However, no study has assessed the relationship between bone plug position and the change of tunnel morphology. Therefore, the main purpose of this study was to investigate the relationship between the bone plug position within femoral or tibial tunnel and morphological changes of each tunnel aperture in ACL-R using computed tomography. METHODS: Subjects were 30 consecutive patients (six females and 24 males; mean age, 20.4 ± 5.4 years) who underwent primary ACL-R using BTB. The distance from the tunnel aperture to the tendon-bone junction (TBJ) at 2 weeks postoperatively, and tunnel aperture enlargement and tunnel wall migration from 2 weeks to 6 months postoperatively, were evaluated. RESULTS: The distance from the femoral tunnel aperture to the TBJ in most cases was less than 2 mm, whereas the TBJ was located within the tibial tunnel. Femoral tunnel aperture was significantly enlarged (17.0 ± 11.7%) distally, and the tibial tunnel aperture was significantly enlarged (19.6 ± 12.5%) posterolaterally. Only the position at distal portion of femoral bone plug was correlated with femoral tunnel aperture enlargement (r = 0.454, p = 0.0015). CONCLUSION: Both femoral and tibial tunnel aperture were significantly enlarged distally and posterolaterally 6 months postoperatively. Only correlation between the position at distal portion of femoral bone plug and femoral tunnel enlargement were found, suggesting the deep plug position in the tunnel is a risk factor for femoral tunnel enlargement, highlighting the importance of accurately locating the TBJ just at the femoral tunnel aperture. Another option is to deviate the harvest site in the patellar tendon to match the shape of the TBJ and the tunnel aperture. LEVEL OF EVIDENCE: 4 (case series).

Loop Length Change of an Adjustable-Length Femoral Cortical Suspension Device in Anatomic Rectangular Tunnel Anterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Graft and Associated Clinical Outcomes.

PURPOSE: To evaluate loop length changes of an adjustable femoral cortical suspensory fixation device and assess the clinical results after anatomic rectangular tunnel anterior cruciate ligament (ART-ACL) reconstruction with a bone-tendon-bone (BTB) graft. METHODS: The study included 50 patients who underwent ART-ACL reconstruction with a BTB graft fixed using the adjustable-length device BTB TightRope for femoral fixation between July 2013 and December 2014. Computed tomography examinations were performed at 1 and 12 weeks after the surgery. Loop length was measured in the reconstructed plane just parallel to the femoral tunnel, including the bone plug and the button. Measurement was performed thrice, and the mean value was used. Loop length change was defined as the difference in loop length between 1 and 12 weeks after the surgery. A paired t test was conducted with the effect size for statistical analysis. At 2 years postoperatively, clinical evaluations, including subjective and objective assessments, were performed. RESULTS: The mean loop lengths at 1 and 12 weeks were 25.77 ± 3.88 mm and 25.81 ± 3.89 mm, respectively, with a significant difference (P = .01). However, the effect size was 0.01, suggesting that the difference was not meaningful. The mean individual loop length change was 0.04 ± 0.13 mm. All individual loop length changes were within the measurement error range. At 2 years postoperatively, 49 patients (98%) were graded as normal or nearly normal according to the International Knee Documentation Committee form. The mean side-to-side difference in anterior laxity at manual maximum force was 0.2 ± 0.5 mm. CONCLUSIONS: The loop length change of an adjustable-length femoral cortical suspension device was negligible after ART-ACL reconstruction with a BTB graft. This ART-ACL reconstruction with a BTB graft using an adjustable-length device could safely provide sufficient stability to the operated knee. LEVEL OF EVIDENCE: Level Ⅳ, therapeutic case series.

Second look arthroscopic evaluation of repaired radial/oblique tears of the midbody of the lateral meniscus in stable knees.

BACKGROUND: Radial/oblique tears of the midbody of the lateral meniscus significantly impair the ability of the meniscus to withstand the tibiofemoral load, requiring meniscal repair. However, healing status after meniscal repair has not been fully elucidated. This study aimed to evaluate arthroscopic findings after inside-out suture repair for isolated radial/oblique tears of the midbody of the lateral meniscus. METHODS: From 2011 to 2015, 18 consecutive patients with isolated radial/oblique tears of the midbody of the lateral meniscus underwent arthroscopic inside-out repair with the tie-grip suture technique. All knees were stable with no previous surgery. All patients were evaluated by second-look arthroscopy at six months postoperatively. Activities including jogging were not allowed until meniscal status was evaluated arthroscopically. To analyze factors associated with healing rates, age, time from injury to initial surgery, and tear zone were compared. RESULTS: Second-look arthroscopy revealed complete healing in four (22%) patients, partial healing in seven (39%), and failure to heal in seven (39%). Significant differences were observed for tear zone (p < 0.0001), but not for age and timing of repair. CONCLUSIONS: Arthroscopic evaluation revealed that inside-out repair with the tie-grip suture technique for isolated radial/oblique tears of the midbody of the lateral meniscus achieved complete or partial healing only in 61% of patients. Satisfactory results were observed particularly in patients with tears extending to the vascular zone, whereas those with tears in the avascular zone failed to achieve healing. Therefore, the operative indication of inside-out repair for radial/oblique tears of the midbody of the lateral meniscus might be limited to tears extending into the vascular zone. Given that 39% of cases were arthroscopically considered a failure even if patients complained of no symptoms in daily life, decisions should be made carefully to allow patients to return to sports activities.

Biomechanical characteristics of the anatomic rectangular tunnel anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft.

PURPOSE: To clarify 1) the force sharing between two portions of BTB graft in anatomic rectangular tunnel (ART) reconstruction and 2) the knee stability in ART technique under anterior tibial load. METHODS: Eleven fresh cadaveric knees were used. First, anterior-posterior (A-P) laxity was measured with Knee Laxity Tester® in response to 134 N of A-P tibial load at 20° on the normal knees. Then ART ACL reconstruction was performed with a BTB graft. For graft, the patellar bone plug and tendon portion was longitudinally cut into half as AM and PL portions. After the tibial bone plug was fixed at femoral aperture, AM/PL portions were connected to the tension-adjustable force gauges at tibial tubercle, and were fixed with 10 N to each portion at 20°. Then the tension was measured 1) under anterior tibial load of 134 N at 0, 30, 60, and 90°, and 2) during passive knee extension from 120 to 0°. Next the graft tension was set at 0, 10, 20, 30, or 40 N at 20°, and the A-P laxity was measured by applying A-P load of 134 N. By comparing the laxity for the normal knee, the tension to restore the normal A-P laxity (LMP) was estimated. RESULTS: The AM force was significantly smaller at 0° and larger at 90° than the PL force under anterior load, while the force sharing showed a reciprocal pattern. During knee extension motion, the tension of both portions gradually increased from around 5 N to 20-30 N with knee extended. And the LMP was 1.6 ± 1.0 N with a range from 0.3 to 3.5 N. CONCLUSION: The pattern of force sharing was similar to that in the normal ACL in response to anterior tibial load and during passive knee extension motion. LMP in this procedure was close to the tension in the normal ACL. LEVEL OF EVIDENCE: Level IV, a controlled-laboratory study.

Outcome of anatomical double-bundle ACL reconstruction using hamstring tendons via an outside-in approach.

PURPOSE: To evaluate the clinical outcome of anatomical double-bundle anterior cruciate ligament (ACL) reconstruction using multistranded hamstring tendons via an outside-in approach. METHODS: One hundred and twenty-one patients (mean age 28 ± 10 years) who underwent ACL reconstruction were examined. Using an outside-in femoral drill guide, an upper femoral tunnel for the anteromedial (AM) graft was created just below the superior articular cartilage margin of the medial wall of the lateral condyle through a small incision. A lower femoral tunnel for the posterolateral (PL) graft was drilled in the centre of the inferior-posterior half of the attachment area behind the resident's ridge in the same manner. Two tibial tunnels were created at the centre of the AM and PL bundle footprints of a normal ACL. Patients were evaluated at 24 months postoperatively. RESULTS: According to the IKDC form, 52 knees (43 %) were graded as normal, 64 (53 %) as nearly normal, 1 (1 %) as abnormal and 4 (3 %) as graft rupture due to re-injury. Loss of knee extension of <5° was observed in one patient (1 %). Among 111 patients who were directly evaluated, none showed loss of flexion of <5°. Lachman sign was negative in 103 patients (93 %), while the pivot shift test result was negative or equivalent to that of the contralateral healthy knee in 103 patients (93 %). The mean side-to-side difference in anterior laxity at manual maximum force with the KT-2000 arthrometer(®) was 0.9 ± 1.1 mm, and 94 % of patients showed a range between -1 and +2 mm. CONCLUSION: The anatomical double-bundle outside-in ACL reconstruction provided a satisfactory short-term outcome. LEVEL OF EVIDENCE: Case series, Level IV.

The effect of cortical button location on its post-operative migration in anatomical double-bundle anterior cruciate ligament reconstruction.

PURPOSE: To investigate the effect of EndoButton (Smith & Nephew Endoscopy, Andover, MA, USA) location on post-operative migration in anterior cruciate ligament (ACL) reconstruction. METHODS: Seventy-seven patients underwent anatomical double-bundle ACL reconstruction using EndoButtons. Comparing patient radiographs immediately post-operatively with those at 1 year, migration was defined when EndoButtons moved more than 1 mm or rotated over 5°. Initial location of EndoButtons was evaluated on radiographs immediately post-operatively. We measured distances from the EndoButton to the posterior and distal edge of the femur (D1, D2) on lateral radiographs and distances from the EndoButton to the lateral and distal edge of the femur (D3, D4) on anteroposterior radiographs. The relationship between supracondylar line and the ratio of migration was also investigated. RESULTS: D1 in the migrated group were significantly lower than those in the non-migrated group (11.8 ± 12.7 vs. 16.0 ± 10.2 mm). D2, D3 and D4 were not of significant difference in the two groups. The ratio of migration in the area posterior to the supracondylar line was significantly higher than that in the anterior area (54.3 vs. 15.1%). CONCLUSION: EndoButtons, which was located distally and posteriorly, especially in the area posterior to the lateral supracondylar line, migrated more frequently, although migration of the button had no effect on the clinical parameters evaluated in this study. CLINICAL RELEVANCE: It is preferable to settle EndoButton anteriorly to the lateral supracondylar line in order to avoid its migration for the graft tension due to our findings about the relationship between initial location of EndoButton and the rate of migration. LEVEL OF EVIDENCE: Prognostic case series, Level IV.

Repair of Achilles tendon rupture using autologous semitendinosus graft in a kidney transplant recipient.

Insertional Achilles tendon injuries can be difficult to treat when minimal tendon tissue remains for anastomosis. Moreover, in the chronic case with tendon shortening, operative repair can be more difficult than acute rupture. It is particularly desirable to reinforce the tendons, in addition to performing primary repair, in patients with renal or systemic diseases because of the accelerated collagen degeneration. Many techniques have been described for the surgical management of Achilles tendon rupture; however, none has shown clear superiority. We report the case of a 50-year-old renal transplant patient with a spontaneous distal Achilles tendon injury that we repaired using the pull-out technique reinforced with an autologous semitendinosus graft. At 2 years postoperatively, the ankle-hindfoot scale score was 92 points, and the postoperative course was without complication. We believe that the free hamstring tendon autograft is advantageous for this repair, because it is easy to handle, has limited donor site morbidity, and preserves the structures around the ankle.

All-inside suture meniscal repair using suture passer.

In recent years, to save the meniscus and prevent the progression of knee osteoarthritis, the indications for meniscus repair have been expanding instead of partial menisectomy. Accordingly, various repair techniques for meniscus tears have been developed. The conventional inside-out and outside-in meniscus repair techniques and all-inside repair technique with an implant/anchor can be classified as trans-capsular (TC) repair from the perspective of suture with penetrating capsule. Recently, new suture passers for all-inside meniscus repair have been developed. To distinguish from conventional all-inside repair with implant/anchors, all-inside repair with only suture using these suture passers was described as all-inside suture (AIS) repair. This AIS repair could achieve meniscus-to-meniscus suture across the tear without interposition of soft tissues including the capsule between suture and meniscus, leading direct gap closing of torn edges. In this respect, AIS repair is considered to be "anatomical meniscus repair". Actually, some reports showed biomechanical and clinical advantages of AIS repair. However, there is still limited evidence in clinical practice. Moreover, there are some disadvantages for AIS repair. Not only further studies but also development of new devices and surgical techniques for AIS should be required. This review describes the current status of AIS repair for each type of tear.

Significantly smaller lateral extrusion was observed within 24 weeks after all-inside suture repairs of radial tear in the middle segment of lateral meniscus compared to inside-out repairs.

Purpose: To evaluate the postoperative meniscal extrusion between all-inside suture (AIS) and trans-capsular suture (TCS) repair techniques. Methods: Thirteen patients (mean age, 19.4 years) underwent AIS repairs using only sutures (AIS group) for radial tears in the middle segment of the lateral meniscus (RTMLM), and seven patients (mean age, 20.3 years) underwent inside-out repairs among TCS (TCS group). For all cases, lateral (LE), anterior (AE) and posterior (PE) meniscal extrusions of the lateral meniscus were measured during preoperative and 3-, 12- and 24-week postoperative MRIs. Then, the change of each extrusion from preoperative to each postoperative period was calculated as ∆LE, ∆AE and ∆PE. Results: There was no significant difference between the AIS and TCS groups in the preoperative extrusions. As for postoperative extrusions, only ∆LEs in the AIS group was significantly smaller than those in the TCS group at all postoperative periods (-1.5 ± 1.7 vs. 0.9 ± 0.7 mm at 3-week, -0.9 ± 0.9 vs. 0.4 ± 0.9 mm at 12-week and -0.3 ± 1.0 vs. 0.6 ± 1.1 mm at 24-week postoperation). In ∆AEs and ∆PEs, at all three postoperative periods, there were no significant differences. Conclusion: Postoperative LE, AE and PE on MRIs after AIS and TCS repairs for RTMLM were investigated. Significantly smaller lateral extrusion was observed within 24 weeks after AIS repairs of RTMLM compared to TCS repairs, which could lead to stabilization of the repair site and prevent degenerative changes. Level of Evidence: Case-control study, retrospective comparative study, Level Ⅲ.