Huge intrameniscal cyst successfully treated by open debridement and combined arthroscopic and open repair: a case report.

BACKGROUND: Meniscal cysts are not uncommon in clinical practice, with reported incidence rates varying from 1 to 22%. Most meniscal cysts are parameniscal cysts, which are created by extravasation of synovial fluid through the meniscal tear into the adjacent soft tissue. In contrast, intrameniscal cysts in which the fluid collects in the meniscus are very rare. We encountered a teenager with a huge intrameniscal cyst accompanied by a small vertical meniscal tear in the red-white zone of the upper surface of the medial meniscus. A literature search revealed no information regarding the appropriate treatment methods and results for this type of lesion. CASE PRESENTATION: A 14-year-old boy presented to our outpatient clinic because of right knee pain that had been present for the previous 2 months. The patient participated in Hapkido, but had no specific trauma history. Magnetic resonance imaging revealed a huge intrameniscal cyst located in the central parenchyma of the posteromedial corner of the medial meniscus. In addition, one sagittal slice on MRI revealed a vertical tear in the red-white zone of the upper surface of the medial meniscus. The presence of such a tear accompanied by a huge intrameniscal cyst is very unusual. The patient was treated via arthroscopic inside-out meniscal suture repair and open cystic debridement with additional meniscocapsular suturing. During 4 years of magnetic resonance imaging follow-up, the lesion has completely disappeared and the meniscus has successfully recovered its normal form. CONCLUSIONS: Our treatment method may be considered as the first choice for young patients who require surgical treatment for large intrameniscal cysts with accompanying small vertical meniscal tears.

Risk factors for failure of eradicating infection in a single arthroscopic surgical procedure for septic arthritis of the adult native shoulder with a focus on the volume of irrigation.

BACKGROUND: Septic arthritis of a native joint is relatively rare but is still a challenging and important orthopedic emergency. Most previous reports have focused on the clinical outcomes rather than the risk factors for failure in arthroscopic surgery. METHODS: We retrospectively reviewed the records of patients with septic monoarthritis of the shoulder who underwent arthroscopic irrigation and débridement between January 2007 and January 2019. All patients were divided into 2 groups according to recurrence after a single arthroscopic surgical procedure: eradicated group or recurred group. To identify risk factors affecting the recurrence of septic arthritis of the shoulder after arthroscopic surgery, the following parameters were considered: age; sex; involved side; presentation of rotator cuff tear; volume of irrigation; bacterial organism involved; preoperative erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count in blood and joint fluid; diabetes mellitus; and hypertension. We compared the eradicated and recurred groups regarding the presence of potential risk factors. RESULTS: The study included 97 patients with a mean age of 61 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgical procedure in 85 patients. However, a second arthroscopic surgical procedure was necessary in 12 patients (12.4%) because of infection recurrence. No significant differences were found between groups except in the volume of irrigation (P < .001). CONCLUSIONS: Most patients with septic arthritis (87.6%) of native shoulders were effectively treated with a single arthroscopic irrigation and débridement. The amount of irrigation may be the most important factor for preventing the need for additional surgical management.

Anteromedial Meniscofemoral Ligament of the Anterior Horn of the Medial Meniscus: Clinical, Magnetic Resonance Imaging, and Arthroscopic Features.

PURPOSE: To describe the clinical, arthroscopic, and magnetic resonance imaging (MRI) findings of knees with anomalous insertion of the anterior horn of the medial meniscus (AHMM) into the intercondylar notch via an anteromedial meniscofemoral ligament (AMMFL). METHODS: A total of 2,503 arthroscopic knee surgeries performed from July 2003 to October 2016 were reviewed retrospectively to identify knees with an AMMFL. Medical records, arthroscopic photographs, and MRI of identified cases were analyzed. Meniscus width and extrusion were measured on MRI. Fifty patients with a normal meniscus were selected as a control group. RESULTS: A total of 13 (0.52%) patients had an AMMFL with insertion at the intercondylar notch. All cases were diagnosed incidentally during arthroscopy. The characteristics of knee pain were related to surgical pathology. Arthroscopic examination revealed the AMMFL as a band-like structure covering the anterior cruciate ligament. In all cases, the AHMM had no bony attachment to the tibia, and increased mobility was observed on probing of the AHMM. The medial meniscus (MM) was significantly larger than the general size in 8 cases (61.5%). Twelve knees (92.3%) had meniscus tears. On MRI, the AMMFL appeared as a low-signal linear structure arising at the AHMM and coursing superiorly along the anterior cruciate ligament. The mean MM width was greater than that in the control group at the mid-body (P = .030), anterior horn (P = .002), and posterior horn (P = .001). CONCLUSIONS: All cases of AMMFL were found incidentally during arthroscopic surgery, and the AMMFL was a silent lesion. There was no significant meniscal extrusion, although the AHMM had no bony attachment. This is because the AMMFL may act as an anchor for the AHMM. Therefore, the AMMFL should not always be removed. The MM with an AMMFL tended to be larger than the typical MM and may be related to some degree of hypermobility, which raises the risk of meniscal tears. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Can ultrasound-guided nerve block be a useful method of anesthesia for arthroscopic knee surgery?

PURPOSE: This study was performed to compare general anesthesia, spinal anesthesia, and ultrasound (US)-guided nerve block for knee arthroscopic surgery. Also, whether US-guided nerve block is a useful method of anesthesia for arthroscopic knee surgery was investigated. METHODS: In this prospective, randomized study, 400 patients who underwent knee arthroscopy surgery between February 2011 and September 2012 were allocated to one of three groups: spinal anesthesia (n = 100), general anesthesia (n = 100), or US-guided nerve block (n = 200). All patients completed a questionnaire with three questions 6 months after surgery. For the nerve block group, the procedure duration, interval between the procedure and onset of the anesthetic effect, the point of loss of the anesthetic effect, intraoperative, postoperative visual analog scale (VAS) pain score, and discomfort during surgery were assessed. RESULTS: There was no patient in which the anesthetic was changed to another method during the operation. VAS pain score of postoperative 1 h was significantly different between the nerve block (1.4 ± 1.7), spinal anesthesia (1.5 ± 1.1), and general anesthesia groups (6.2 ± 5.1) (P < 0.05). In addition, VAS pain scores at postoperative 6 and 12 h were significantly different among the regional nerve block group (2.2 ± 1.5 and 3.0 ± 1.8, respectively), spinal anesthesia group (5.2 ± 3.2 and 5.1 ± 4.0, respectively), and general anesthesia group (5.2 ± 3.9 and 5.4 ± 4.5, respectively). One hundred and ninety regional nerve block (95 %), 68 spinal anesthesia (68 %), and 75 general anesthesia patients (75 %) reported that they would prefer the same type of anesthesia if they were to undergo knee surgery again; these differences were significant (P < 0.05). There were no long-term complications, such as neurological deficits or infection, after the procedure in all patients. CONCLUSION: Arthroscopic knee surgery, such as meniscal repair or meniscectomy, synovectomy, debridement, and other procedures, was performed safely and effectively under US-guided nerve block. These results indicated that US-guided nerve block for arthroscopic knee surgery is a highly satisfactory and safe procedure without complications and is available for use by any orthopedist. LEVEL OF EVIDENCE: Prospective case series, Level IV.

Pullout failure strength of the posterior horn of the medial meniscus with root ligament tear.

PURPOSE: To evaluate the reparability of the posterior horn of the medial meniscus with root ligament tear by measuring the actual pullout failure strength of a simple vertical suture of an arthroscopic subtotal meniscectomized posterior horn of the medial meniscus. METHODS: From November 2009 to May 2010, nine posterior horns of the medial meniscus specimens were collected from arthroscopic subtotal meniscectomy performed as a treatment for root ligament rupture of the posterior horn of the medial meniscus. Simple vertical sutures were performed on the specimens, and pullout failure load was tested with a biaxial servohydraulic testing machine (Model 8874; Instron Corp., Norwood, MA, USA). The degree of degeneration, extrusion, and medial displacement of the medial meniscus were evaluated with magnetic resonance imaging (MRI). The Kellgren-Lawrence classification was used in standing plain radiography, and mechanical alignment was measured using orthoroentgenography. Tear morphology was classified into ligament proper type or meniscoligamentous junctional type according to the site of the torn root ligament of the posterior horn of the medial meniscus during arthroscopy. RESULTS: The mean pullout failure strength of the posterior horn of the medial meniscus was 71.6 ± 23.2 N (range, 41.4-107.7 N). The degree of degeneration of the posterior horn of the medial meniscus on MRI showed statistically significant correlation with pullout failure strength and Kellgren-Lawrence classification. Pullout failure strength showed correlation with mechanical alignment and Kellgren-Lawrence classification (P < 0.05). CONCLUSIONS: The measurement of pullout failure strength of the posterior horn of the medial meniscus with root ligament tear showed a degree of repairability. The degree of degeneration of the posterior horn of the medial meniscus on MRI showed a significant correlation with the pullout failure strength. The pullout failure strength was also not only correlated with the degree of degeneration of the posterior horn of the medial meniscus, but also with mechanical alignment and Kellgren-Lawrence classification, which represent bony degenerative change.

Role of the mechanical axis of lower limb and body weight in the horizontal tear and root ligament tear of the posterior horn of the medial meniscus.

PURPOSE: To compare and analyse the relationship between horizontal tear and root ligament tear of the posterior horn of the medial meniscus (PHMM) and the degree of varus in the axis of lower limb and body weight. METHODS: One hundred and nineteen patients underwent surgical treatment as they were diagnosed with medial meniscus tear in our hospital from May 2006 to December 2009. Of these, 19 cases (group 1), underwent partial meniscectomy as they were confirmed to solely have horizontal tear of the PHMM on arthroscopic examination and 27 cases (group 2), underwent subtotal meniscectomy as they were confirmed to solely have root ligament tear of the PHMM on arthroscopic examination, were chosen for retrospective study. Standing radiographs were taken of every case prior to arthroscopic surgery to measure varus angle. Also, we checked body mass index (BMI) of two groups. The difference of varus angle and BMI between two groups were statistically verified using the Levene's test, paired t-test. RESULTS: Group 1 showed mean value of varus angle of 2.30 ± 0.54, and BMI of 25.32 ± 3.23. Group 2 showed mean value of varus angle of 5.64 ± 0.54, and BMI of 25.67 ± 3.12. The degree of varus of group 2 was statistically significantly higher than group 1 (p = 0.002). Comparison between the BMI of two groups showed no statistical significance (p = 0.053). CONCLUSION: Through a comparative study of sole horizontal tear and root ligament tear of the PHMM, the authors have found that sole root ligament tear of the PHMM is more relative to the genu varum than sole horizontal tear of the PHMM. However, body weight was statistically irrelevant to the incidence of the two lesions.

Iatrogenic Vertebral Fracture During Intramedullary Nailing for Femoral Fracture: A Case Report.

CASE: A 73-year-old woman with advanced ankylosing spondylitis (AS) underwent closed reduction and internal fixation using antegrade intramedullary nailing because of midshaft fracture of her right femur. After the surgery had been performed, a fracture and dislocation at T12-L1 was detected. Therefore, emergency spinal decompression and posterior instrumentation placement from T11 to L5 were then performed. CONCLUSION: Patients with advanced AS have a high risk of vertebral fracture, so special care must be taken not to transmit excessive stress on the spine for surgical reduction and manipulation of the lower extremity.

p16INK4a-siRNA nanoparticles attenuate cartilage degeneration in osteoarthritis by inhibiting inflammation in fibroblast-like synoviocytes.

In osteoarthritis (OA), chondrocytes in cartilage undergo phenotypic changes and senescence, restricting cartilage regeneration and favoring disease progression. Although senescence biomarker p16INK4a expression is known to induce aging by halting the cell cycle, therapeutic applications for p16INK4a targeting are limited. Here, we aimed to reduce cartilage damage and alleviate pain using p16INK4a nanoparticles in OA. The p16INK4a expression of human OA chondrocytes and synoviocytes from patients with knee OA was measured and the levels of p16INK4a, tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-6, and matrix metalloproteinase (MMP) 13 were examined. p16INK4a siRNA was encapsulated into poly (lactic-co-glycolic acid) (PLGA) nanoparticles and characterized. The partial medial meniscectomy (pMMx) model was performed for the OA model which was investigated by molecular analysis and behavioral tests. The expression of p16INK4a was increased in the synovium and articular cartilage from OA patients. p16INK4a siRNA-loaded PLGA nanoparticles (p16 si_NP) reduced the levels of TNF-α, IL-1ß, and IL-6 especially in fibroblast-like synoviocytes (FLSs), and MMP13 in chondrocytes. Rhodamine-tagged NPs injected into the mouse knee joints were found mainly in the synovium. p16 si_NP injection in the pMMx model alleviated pain-associated behavior, and reduced cartilage damage and p16INK4a in the synovium, and MMP13, collagen X, and NITEGE in cartilage. The preferential reduction of p16INK4a in FLSs by the application of RNAi nanomedicine could contribute to the recovery of osteoarthritic cartilage and relieve pain, suggesting that p16INK4a may be a viable future therapeutic candidate.

Application of Three-Dimensional Computed Tomography Improved the Interrater Reliability of the AO/OTA Classification Decision in a Patellar Fracture.

We investigated whether interrater reliabilities of the AO/OTA classification of patellar fracture change with the imaging modalities applied, including plain radiography and two- and three-dimensional (2-D and 3-D) computed tomography (CT). Seven orthopedic specialists and four orthopedic residents completed a survey of 50 patellar fractures to classify the fractures according to the AO/OTA classification for patellar fractures. Initially, the survey was conducted using plain radiography only, then with 2-D CT introduced three weeks later and 3-D CT introduced six weeks later. Fleiss' Kappa coefficients were calculated to determine interrater reliability. The overall interrater reliability of the AO/OTA classifications was 0.40 (95% CI, 0.38-0.42) with plain radiography only and 0.43 (95% CI, 0.41-0.45) with the addition of 2-D CT. With the addition of 3-D CT, the reliability was significantly improved to 0.54 (95% CI, 0.52-0.56). In specialists, interrater reliability of the classifications was moderate with all three imaging modalities. With the use of 3-D CT, interrater reliability of the classification was 0.53 (95% CI, 0.50-0.56), which was significantly higher than that with the use of 2-D CT (κ = 0.45; 95% CI, 0.42-0.48). In residents, interrater reliability of the classification was 0.30 (95% CI, 0.24-0.36) with plain radiography. The reliability improved to 0.49 (95% CI, 0.43-0.56) with the addition of 2-D CT, which was significantly higher than that with plain radiography only. The use of 3-D CT imaging improved interrater reliability of the classification. Therefore, surgeons, especially residents, may benefit from using 3-D CT imaging for classifying and planning the treatment of patellar fractures.

Does Demineralized Bone Matrix Enhance Tendon-to-Bone Healing after Rotator Cuff Repair in a Rabbit Model?

BACKGROUD: The purpose of this study was to compare the histologic outcomes of rotator cuff (RC) repair with demineralized bone matrix (DBM) augmentation and those without DBM augmentation and to evaluate the role of DBM for tendon-to-bone (TB) healing in a rabbit model. METHODS: Twenty-six adult male New Zealand white rabbits were randomly allocated to the control group (n = 13) or the DBM group (n = 13). Repair was performed 8 weeks after complete transection of the right supraspinatus tendon of all rabbits. In the control group, RC repair was achieved by a standard transosseous technique. In the DBM group, RC repair was achieved using the same technique, and DBM was interposed between the cuff and bone. After 8 weeks, the RC tendon entheses from all rabbits were processed for gross and histologic examination. RESULTS: On gross TB healing, 2 of 11 specimens in the control group were unhealed and no specimen was grossly unhealed in the DBM group (p = 0.421). In the control group, the tendon midsubstance was disorganized with randomly and loosely arranged collagen fibers and rounded fibroblastic nuclei. The TB interface was predominantly fibrous with small regions of fibrocartilage, especially mineralized fibrocartilage. In the DBM group, the tendon midsubstance appeared normal and comprised densely arranged collagen fibers, with orientated crimped collagen fibers running in the longitudinal direction of the tendon. These fibers were interspersed with elongated fibroblast nuclei. The TB interface consisted of organized collagen fibers with large quantities of fibrocartilage and mineralized fibrocartilage. CONCLUSIONS: The use of DBM for TB interface healing in rabbit experiments showed good results in gross and histologic analysis. However, it is difficult to draw a solid conclusion because the sample size is small. Further evaluation in the in vivo setting is necessary to determine clinical recommendations.

TAP2, a peptide antagonist of Toll-like receptor 4, attenuates pain and cartilage degradation in a monoiodoacetate-induced arthritis rat model.

Because inflammation in osteoarthritis (OA) is related to the Toll-like receptor 4 (TLR4) signaling cascades, TLR4 is a reasonable target for developing therapeutics for OA. Thus, we investigated whether TAP2, a peptide antagonist of TLR4, reduces the monoiodoacetate (MIA)-induced arthritic pain and cartilage degradation in rats. TLR4 expression of human OA chondrocytes and synoviocytes and the knee joint tissue of MIA-induced arthritis were evaluated. MIA-induced arthritic model using Sprague-Dawley rats (6 week-old-male) were treated with TAP2, a TLR4 antagonist, and evaluated with behavioral test, immunohistochemistry, and quantitative PCR. TLR4 was highly expressed in the knee joints of patients with OA and the MIA-induced rat model. Further, a single intraarticular injection of TAP2 (25 nmol/rat) molecules targeting TLR4 on day 7 after MIA injection dramatically attenuated pain behavior for about 3 weeks and reduced cartilage loss in the knee joints and microglial activation in the spinal dorsal horns. Likewise, the mRNA levels of TNFα and IL-1ß, reactive oxygen species, and the expression of MMP13 in the knee joints of TAP2-treated rats was significantly decreased by TAP2 treatment compared with the control. Moreover, interestingly, the duration of OA pain relief by TAP2 was much longer than that of chemical TLR4 antagonists, such as C34 and M62812. In conclusion, TAP2 could effectively attenuate MIA-induced arthritis in rats by blocking TLR4 and its successive inflammatory cytokines and MMP13. Therefore, TAP2 could be a prospective therapeutic to treat patients with OA.

p66shc siRNA Nanoparticles Ameliorate Chondrocytic Mitochondrial Dysfunction in Osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is the most common type of joint disease associated with cartilage breakdown. However, the role played by mitochondrial dysfunction in OA remains inadequately understood. Therefore, we investigated the role played by p66shc during oxidative damage and mitochondrial dysfunction in OA and the effects of p66shc downregulation on OA progression. METHODS: Monosodium iodoacetate (MIA), which is commonly used to generate OA animal models, inhibits glycolysis and biosynthetic processes in chondrocytes, eventually causing cell death. To observe the effects of MIA and poly(lactic-co-glycolic acid) (PLGA)-based nanoparticles, histological analysis, immunohistochemistry, micro-CT, mechanical paw withdrawal thresholds, quantitative PCR, and measurement of oxygen consumption rate and extracellular acidification rate were conducted. RESULTS: p-p66shc was highly expressed in cartilage from OA patients and rats with MIA-induced OA. MIA caused mitochondrial dysfunction and reactive oxygen species (ROS) production, and the inhibition of p66shc phosphorylation attenuated MIA-induced ROS production in human chondrocytes. Inhibition of p66shc by PLGA-based nanoparticles-delivered siRNA ameliorated pain behavior, cartilage damage, and inflammatory cytokine production in the knee joints of MIA-induced OA rats. CONCLUSION: p66shc is involved in cartilage degeneration in OA. By delivering p66shc-siRNA-loaded nanoparticles into the knee joints with OA, mitochondrial dysfunction-induced cartilage damage can be significantly decreased. Thus, p66shc siRNA PLGA nanoparticles may be a promising option for the treatment of OA.

p47phox siRNA-Loaded PLGA Nanoparticles Suppress ROS/Oxidative Stress-Induced Chondrocyte Damage in Osteoarthritis.

Osteoarthritis (OA) is the most common joint disorder that has had an increasing prevalence due to the aging of the population. Recent studies have concluded that OA progression is related to oxidative stress and reactive oxygen species (ROS). ROS are produced at low levels in articular chondrocytes, mainly by the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, and ROS production and oxidative stress have been found to be elevated in patients with OA. The cartilage of OA-affected rat exhibits a significant induction of p47phox, a cytosolic subunit of the NADPH oxidase, similarly to human osteoarthritis cartilage. Therefore, this study tested whether siRNA p47phox that is introduced with poly (D,L-lactic-co-glycolic acid) (PLGA) nanoparticles (p47phox si_NPs) can alleviate chondrocyte cell death by reducing ROS production. Here, we confirm that p47phox si_NPs significantly attenuated oxidative stress and decreased cartilage damage in mono-iodoacetate (MIA)-induced OA. In conclusion, these data suggest that p47phox si_NPs may be of therapeutic value in the treatment of osteoarthritis.

Arthroscopic Treatment of Infrapatellar Fat Pad Impingement between the Patella and Femoral Trochlea: Comparison of the Clinical Outcomes of Partial and Subtotal Resection.

PURPOSE: To compare the clinical outcomes of arthroscopic partial and subtotal resection of the impinged infrapatellar fat pad (IFP). MATERIALS AND METHODS: This study enrolled 55 patients with IFP impingement who underwent partial resection (n=29, P group) or subtotal resection (n=26, S group). Clinical outcomes at least 2 years postoperatively were evaluated using a visual analog scale (VAS) for pain, the International Knee Documentation Committee (IKDC) 2000 subjective knee score, and the Lysholm score. RESULTS: In the P group, the preoperative mean VAS, IKDC 2000, and Lysholm scores were 5.6±0.61, 47.5±7.41, and 42.5±7.17, respectively, which improved significantly to 1.4±0.63, 70.9±6.15, and 82.2±7.61, respectively (all, p≤0.001). In the S group, the preoperative mean VAS, IKDC 2000, and Lysholm scores were 5.7±0.43, 47.7±9.09, and 45.2±4.18, respectively, which improved significantly to 1.8±0.77, 71.9±9.33, and 82.3±6.01, respectively (all, p≤0.001). There were no significant differences in any outcome measure between the groups at the final follow-up. CONCLUSIONS: Arthroscopic resection of the impinged IFP between the patella and femoral trochlea resulted in favorable clinical outcomes regardless of whether the resection was partial or subtotal. Thus, partial resection can be an appropriate treatment option, considering partial resection was as effective as subtotal resection and retained more of the IFP.

The role of platelet hyperreactivity in venous thromboembolism after total knee arthroplasty in elderly population without pharmacologic prophylaxis: A single-center study.

INTRODUCTION: While it is suggested that platelet hyperreactivity plays a role in the arterial thrombi, its link with venous thromboembolism (VTE) is not well defined. Aggregometry using low concentrations of agonists is proposed as a reliable method to detect hyperreactivity. The aim of this study was to examine whether platelet hyperreactivity affects the development of VTE after total knee arthroplasty (TKA). METHODS: Total 150 elderly patients without VTE history were enrolled. Mechanical prophylaxis was used for VTE after TKA. We performed platelet aggregation using Chrono-log (Chrono-log Corporation, USA) in the presence of low concentrations of ADP (1.0 µmol/L) and epinephrine (0.4, 1.0 µmol/L), and measured maximal aggregation (%). RESULTS: At 0.4 µmol/L epinephrine, 69.3%, 15.3%, and 15.3% displayed low (<40%), moderate (40-60%), and high (>60%) levels of aggregation, respectively. The proportion of high level of aggregation was 36.7%, 30.7% at 1.0 µmol/L of epinephrine and ADP, respectively. The incidence of VTE was higher in the moderate/high aggregation group (10/46, 21.7%) than in the low aggregation group (1/104, 1.0%) at 0.4 µmol/L epinephrine (P < 0.0001). In predicting postoperative VTE, sensitivity and specificity of ≥40% aggregation at 0.4 µmol/L epinephrine were 90.9% and 74.1%. Higher mean platelet volume and lower volume of blood loss were seen in the high aggregation group than in the low aggregation group. CONCLUSION: Aggregation response to 0.4 µmol/L epinephrine is an optimal assay to classify platelet activity. Platelet hyperreactivity may increase the risk of postoperative VTE in an elderly population, and can be an indication of pharmacologic prophylaxis.

The role of ultrasound-guided single-shot femoral and sciatic nerve blocks on pain management after total knee arthroplasty.

BACKGROUND: Peripheral nerve blocks reduce postoperative pain and opioid consumption after total knee arthroplasty (TKA). The aim of this study was to evaluate the effects of single-shot femoral nerve and sciatic nerve blocks on postoperative pain management and opioid consumption after TKA. METHODS: This study included 100 patients who underwent TKA between July 2015 and September 2017. Fifty patients received pre-operative, single-injection, ultrasound-guided femoral and sciatic nerve blocks (Group 1) and 50 did not (Group 2). Multimodal analgesia was otherwise identical, and oxycodone was administered either intravenously or orally if the patients complained of postoperative pain ≥6 on the visual analog scale (VAS). Postoperative VAS scores, opioid consumption, and the fear of future TKA were compared between the groups. RESULTS: The mean VAS in the first 18 postoperative hours was significantly lower in Group 1 (P ≤ 0.002). The mean amount of oxycodone taken in the first three postoperative days was significantly lower in Group 1 (P = 0.001). Patient fear of future TKA at 14 days postoperatively was significantly lower in Group 1 (P = 0.027). CONCLUSIONS: Pre-operative ultrasound-guided, single-shot femoral and sciatic nerve blocks afforded effective pain control in the first 18 h after TKA, and significantly reduced oxycodone consumption in the first three postoperative days.

Repair integrity and functional outcomes of arthroscopic repair for intratendinous partial-thickness rotator cuff tears.

PURPOSE: We evaluated the clinical and radiological outcomes of arthroscopic repair of intratendinous partial-thickness rotator cuff tears. METHODS: We retrospectively reviewed 30 patients who underwent arthroscopic repair of intratendinous partial-thickness rotator cuff tears from January 2010 to January 2015 in a single institute. Five outcome measures were used: a visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons score, the shoulder rating scale of the University of California at Los Angeles, the Constant-Murley score, and range of motion (ROM). Pain was recorded using the VAS. Active ROM was measured goniometrically. Rotator cuff repair integrity was determined via magnetic resonance imaging or ultrasonography at least 6 months after arthroscopic repair. RESULTS: Of the 30 patients, 29 (96.6%) returned for functional follow-up evaluation no earlier than 2 years after the operation. All functional scores exhibited significant improvements (all p = 0.000). The VAS improved from a mean of 5.8 ± 1.6 to 2.5 ± 2.6 ( p = 0.000). The mean active ROM of forward flexion changed from 149.8 ± 33.8° preoperatively to 172.4 ± 9.1° ( p = 0.001) at the last follow-up; abduction changed from 115.6 ± 50.3° to 171.3 ± 15.9° ( p = 0.000). Postoperative radiological evaluation revealed retearing in three patients (3/28, 10.7%), including two with articular-side partial-thickness retears and one with a bursal-side partial-thickness retear. CONCLUSION: Arthroscopic repair of intratendinous partial-thickness rotator cuff tears was associated with a retearing rate of 10.7% on radiological follow-up and afforded significant clinical and functional improvements.

Femoral Footprint for Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study.

PURPOSE: To identify the femoral footprint of the anterior cruciate ligament (ACL) in Koreans. MATERIALS AND METHODS: Eighteen embalmed cadaveric knees (mean age, 70 years) were examined. First, the shape of the ACL was determined macroscopically. After the ACL femoral footprint was defined, the ACL was cut from the femur and a Kirschner wire was inserted into the center of the ACL, and the position was verified with a C-arm. The position was quantified on the C-arm field using the quadrant method. The length and width of the ACL were measured. RESULTS: Macroscopically, the ACL is a flat single bundle with an average length of 34 mm and an average width of 9 mm. On average, the center of the ACL insertion site measured with the quadrant method was positioned at 29.5%±2.8% in an anterior direction (from posterior), and at 38.5%±3.2% in a distal direction (from Blumensaat's line). The anterior and posterior margins of the ACL femoral footprint were the resident's ridge and the cartilage margin of the lateral femoral condyle, respectively. CONCLUSIONS: The center of the ACL femoral footprint is positioned more anteriorly and distally than the positions identified in previous studies.

The Optimal Suture Site for the Repair of Posterior Horn Root Tears: Biomechanical Evaluation of Pullout Strength in Porcine Menisci.

PURPOSE: There are few studies on biomechanical evaluation of suture points in repair of root tears. The purpose of this study was to determine the point of greatest pullout strength for root tear repair. MATERIALS AND METHODS: A total of 120 fresh porcine medial menisci were obtained. The red-red and red-white zones of the meniscus were divided by two lines designated as lines A and B (groups A and B). Groups A and B were further divided into three groups each by dividing lines A and B into three points: 3, 5, and 7 mm from the meniscal ligament root insertion. Vertical meniscal repair was performed on each point. The pullout failure strength was tested using a biaxial servohydraulic testing machine. RESULTS: The average maximal load at failure was significantly greater in group A than group B (87.65 vs. 62.93; p<0.001) The average length at maximal load failure was greater in group A than group B (4.35 vs. 3.2; p<0.001). Among the subgroups of 3, 5, and 7 mm in both groups A and B, 7 mm showed the greatest maximal load (p<0.001). CONCLUSIONS: The pullout strength was statistically significantly greater in group A than group B and in the 7 mm subgroup than the 3 and 5 mm subgroups. Thus, the 7 mm subgroup in group A showed the greatest pullout strength.