Morphological Risk Factors for Posterior Cruciate Ligament Tear and Tibial Avulsion Injuries of the Tibial Plateau and Femoral Condyle.

BACKGROUND: Identification of morphological risk factors associated with the knee that threaten ligaments is important for understanding injury mechanisms and prevention. However, the morphological risk factors for posterior cruciate ligament (PCL) lesions are not clearly understood. PURPOSE: To investigate whether the medial tibial depth (MTD), medial and lateral posterior tibial slope, asymmetry of the medial and lateral slopes, radius of the sagittal plane medial femoral condyle, coronal tibial slope, and notch width index (NWI) were risk factors for PCL intrasubstance tearing (PCLIT) and tibial avulsion fractures (PCLAF). STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Between January 2015 and March 2022, 82 patients with isolated PCLIT, 68 patients with isolated PCLAF, and 82 controls without any ligamentous or meniscal pathologic findings as determined via physical examination and magnetic resonance imaging were included. Values were compared among the 3 groups. Logistic regression analysis was performed to confirm the risk factors. Receiver operating characteristic curves were defined for the morphological indicators and combination of risk factors. RESULTS: Logistic regression analysis revealed (1) MTD, lateral minus medial posterior tibial slope, radius of the posterior circle of the medial femoral condyle, and NWI as significant independent predictors for PCLIT and (2) MTD and NWI for PCLAF. The areas under the curve combining the 4 indicators for PCLIT and noncontact PCLIT were 0.79 (95% CI, 0.72-0.86) and 0.90 (95% CI, 0.85-0.96), respectively. The area under the curve for the combination of MTD and NWI for PCLAF was 0.78 (95% CI, 0.70-0.86). CONCLUSION: Decreased MTD and NWI were associated with an increased incidence of PCLIT and PCLAF. Increased asymmetry of the medial and lateral slopes and the radius of the posterior circle of the medial femoral condyle were associated with the presence of PCLIT. In addition, the model of a combination of risk factors showed good predictive ability for noncontact PCLIT. These findings may aid clinicians in identifying patients at risk for PCL lesions. Further studies are warranted for identifying the effect of these factors on biomechanical mechanisms.

Intercondylar notch volume in patients with posterior cruciate ligament tears and tibial avulsion injuries: a study applying computed tomography.

BACKGROUND: Two relatively common forms of injury exist in the posterior cruciate ligament (PCL) after the onset of trauma: PCL tear and tibial avulsion fracture. The mechanism for the occurrence of these different forms of injury is not known. Herein, we aimed to investigate this mechanism by comparing the intercondylar notch parameters between patients with PCL tears and those with PCL avulsion fractures of the tibial insertion. METHODS: Fifty-three patients with PCL tears (37 male, 16 female: median age of 37 years: range 18-54 years) and 46 patients with avulsion fractures of tibial insertion (33 male, 13 female: median age of 33 years: range 18-55 years) were included in this study. Three-dimensional computed tomography (CT) was applied to measure the intercondylar notch width index and intercondylar notch volume. The intercondylar notch volume was simulated as the truncated-pyramid shape. Measurements of the top and bottom areas of this model were conducted on the slice containing the most proximal (S1) and most distal (S2) levels of Blumensaat's line. Femoral condyle height (h) was defined as the vertical distance between two parallel planes, and the volume was calculated as h(S1 + S2 + √(S1S2))/3. The values of S1, S2, h, notch volume, the body mass index (BMI), intercondylar notch width (NW), femoral condylar width (FW) and notch width index (NWI) were compared among the PCL tear and avulsion-fracture groups. RESULTS: The results show a significant difference in the S2 and normalized intercondylar notch volumes among patients with PCL tears and tibial avulsion injuries. Patients with PCL tears have smaller S2 and intercondylar notch volumes than those with tibial avulsion. There were no significant differences between the two groups in S1 or the 2D notch measurement parameters, such as the NW, FW and NWI. In addition, logistic regression analysis revealed notch volume and body mass index (BMI) as two significant independent predictors for PCL tears. CONCLUSION: Decreased intercondylar notch volume and increased BMI are associated with an increased incidence of PCL tears. The occurrence of PCL tears and tibial avulsion injuries is influenced by the femoral intercondylar notch volume, and the measurement of the notch volume could be useful for identifying patients at risk for PCL tears.

A Sagittal Patellar Angle Linear Equation Reflecting Patellofemoral Kinematics: Evaluation of Patellar Height at any Degree of Knee Flexion Angle.

OBJECTIVE: To confirm whether a novel sagittal patellar angle linear equation used for evaluating patellar height by calculating expected sagittal patellar angle (SPA) at any degree of knee flexion angle is suitable for patients older than 17 years and its reliability compared with other commonly used methods. METHODS: From September 2016 to September 2019, a total number of 202 consecutive outpatients' knee lateral X-ray radiographs were retrospectively measured and evaluated using a recently proposed linear equation Y = 1.94 + 0.74 × knee flexion(KF) angle. Patients were divided by ages into ayounger group, whose ages were between 17-49 years, and an older group, whose ages were older than 49 years, which has not been validated in the original study. Parameters such as KF, SPA, patella and patella tendon length and so on were measured on computer with picture archiving and communication system by two independent observers at an interval of 1 month. Insall-Salvati (IS) index, Caton-Deschamps (CD) index and Y value, correlation coefficients were calculated and compared using SPSS 22.0 software. RESULTS: In the younger group, 143 patients (165 knees) were included, ages were 17-49 (31.62 ± 11.38) years, males/females were 70 (48.95%)/73 (51.05%), left knees/right knees were 83 (50.30%)/82 (49.70%), mean value of Y was 31.50° ± 10.07°, and SPA was 34.38° ± 12.38°, mean value of IS was 1.06 ± 0.17, mean value of CD was 1.04 ± 0.18. While in older group, 59 patients (78 knees) were included, ages were 50-60 (mean 54.61 ± 2.99) years, there were 32 males (54.24%) and 27 females (45.76%), 42 knees were left (53.85%) and 36 knees were right (46.15%), mean values of Y and SPA were 25.90° ± 11.55° and 29.36° ± 14.22°, mean IS index in older group was 1.06 ± 0.18, mean CD index was 1.00 ± 0.16. Intra- and inter-observer reliabilities of Y in younger and older groups were 0.999, 0.999, 1.000 and 0.999, meaning high reliability and reproducibility, but low Pearson's correlation coefficients with IS and CD index were showed as -0.213 and - 0.216 in younger group and - 0.113 and - 0.316 in older group. CONCLUSIONS: In patients older than 17 years, the linear equation Y = 1.94 + 0.74 × KF is a reliable and practical method to evaluate SPA regardless of age and knee flexion angle, but has weak correlation coefficients with the IS and CD index.

A Retrospective Study of the Risk Factors for Postoperative Foot or Ankle Pain in 90 Patients with Varus Osteoarthritis of the Knee who Underwent Total Knee Arthroplasty.

BACKGROUND The reasons for foot and ankle pain following total knee arthroplasty (TKA) for knee varus osteoarthritis are unknown. This retrospective study aimed to investigate the risk factors for postoperative foot and ankle pain in patients with varus osteoarthritis of the knee who underwent TKA. MATERIAL AND METHODS We enrolled 90 patients who underwent TKA for varus knee osteoarthritis. The visual analog scale (VAS) was used to evaluate patients' foot or ankle pain before and after surgery. The correlation between independent variables (eg, age, sex, body mass index [BMI], ankle osteoarthritis, and varus angle) and foot and ankle pain in patients with osteoarthritis of the knee was measured. Moreover, radiological changes were compared between the groups with and without worsened pain. RESULTS No significant difference in VAS was found between patients <60 and ≥60 years of age (P>0.05). Male sex and BMI <30 kg/m² were weakly correlated with preoperative foot or ankle pain. However, patients with varus of ≥6° and preexisting ankle osteoarthritis had a higher incidence of foot or ankle pain before surgery. Moreover, no significant differences in radiological changes were found between the groups with and without worsened foot or ankle pain after surgery (P>0.05). CONCLUSIONS In male patients with osteoarthritis of the knee, a BMI <30 kg/m², varus of <6°, and no preexisting ankle osteoarthritis were protective factors for foot and ankle pain. TKA corrected knee and ankle malalignment. Therefore, postoperative foot and ankle pain was not associated only with TKA surgery.

Hamstring Autograft Versus Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

BACKGROUND: Hamstring tendon autografts are commonly used for primary anterior cruciate ligament (ACL) reconstruction. Some patients have small hamstring tendons however, which may compromise the clinical outcome of the autograft. To solve this problem, many surgeons use hybrid grafting that involves augmentation of small hamstring autografts with allograft tissue. PURPOSE/HYPOTHESIS: The purpose was to compare the clinical outcomes between primary ACL reconstructions performed with hamstring autografts and those performed with hybrid grafts in terms of patient-reported evaluation, failure rate, and knee stability. The hypothesis was that primary ACL reconstruction performed with hamstring autograft alone will not differ significantly from that performed with a hybrid graft in terms of patient-reported evaluation, failure rate, or knee stability. STUDY DESIGN: Systematic review. METHODS: A systematic review was performed to identify prospective and retrospective comparative studies and cohort studies (evidence levels 1-3) comparing outcomes of primary ACL reconstructions performed with hamstring autografting alone and hybrid grafting. Outcomes included patient-reported evaluation, failure rate, and knee stability. RESULTS: Ten studies were included: 1 of level 2 and 9 of level 3. Collectively, they included 398 autografts and 341 hybrid grafts. Mean respective follow-up durations ranged from 24.0 to 69.6 months and from 24.0 to 70.8 months. Patient-reported evaluations, including Lysholm, Tegner, and subjective International Knee Documentation Committee scores, were reported in 8 of 10 studies. Failure rates were reported in all 10 studies. Results of knee stability examinations-including KT-1000 arthrometer measurements, the pivot-shift test, Lachman test, and overall International Knee Documentation Committee results-were reported in 4 of 10 studies. In this review, there were no statistically significant differences between autografts and hybrid grafts in terms of patient-reported evaluations, failure rates, or KT-1000 measurements. CONCLUSION: In this systematic review, there was no significant difference in patient-reported evaluation or failure rate between primary ACL reconstructions performed with autografts alone and those performed with hybrid grafts. Whether there is a substantial difference in knee stability examination results between autografts and hybrid grafts remains unknown, given a relative lack of reports on knee stability.

Remnant preservation technique versus standard technique for anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials.

BACKGROUND: This meta-analysis was performed to compare the clinical outcomes of primary anterior cruciate ligament (ACL) reconstruction using the ACL remnant preservation technique versus the standard technique. METHODS: PubMed, Embase, and the Cochrane Library were searched through December 24, 2017, to identify randomized controlled studies that compared the use of the ACL remnant preservation technique versus the standard technique for primary ACL reconstruction. Statistical heterogeneity among the trials was evaluated with chi-square and I-square tests. A sensitivity analysis was conducted to explore sources of heterogeneity. Subgroup analysis was performed to identify potential differences according to type of ACL remnant tissue (remnant bundle or remnant fibers). RESULTS: Seven studies with a combined 412 patients (208 in the remnant preservation technique group and 204 in the standard technique group) were included in the meta-analysis. There was a significant difference between the groups in Lysholm score (mean difference (MD), 2.20; 95% confidence interval (CI), 0.95-3.45; P = 0.0006) and side-to-side difference (MD, - 0.71; 95% CI, - 0.87 to - 0.55; P < 0.01). There was no significant difference between the groups in subjective International Knee Documentation Committee (IKDC) score, complications, pivot shift test, Lachman test, or overall IKDC score. Subgroup analysis demonstrated that for primary ACL reconstruction with preservation of remnant fibers, the remnant preservation technique was superior to the standard technique based on Lysholm scores (P < 0.01) and side-to-side difference (P < 0.01). CONCLUSIONS: Based on the current literature, using the remnant preservation technique showed a better clinical outcome than using the standard technique for patients undergoing primary ACL reconstruction with respect to Lysholm score and side-to-side difference. However, it remains unclear that there is a definite advantage to use the remnant preservation technique compared with the standard technique.

Rational modification of tricarboxylic acid cycle for improving L-lysine production in Corynebacterium glutamicum.

BACKGROUND: Oxaloacetate (OAA) and L-glutamate are essential precursors for the biosynthesis of L-lysine. Reasonable control of all potentially rate-limiting steps, including the precursors supply rate, is of vital importance to maximize the efficiency of L-lysine fermentation process. RESULTS: In this paper, we have rationally engineered the tricarboxylic acid (TCA) cycle that increased the carbon yield (from 36.18 to 59.65%), final titer (from 14.47 ± 0.41 to 23.86 ± 2.16 g L-1) and productivity (from 0.30 to 0.50 g L-1 h-1) of L-lysine by Corynebacterium glutamicum in shake-flask fermentation because of improving the OAA and L-glutamate availability. To do this, the phosphoenolpyruvate-pyruvate-oxaloacetate (PEP-pyruvate-OAA) node's genes ppc and pyc were inserted in the genes pck and odx loci, the P1 promoter of the TCA cycle's gene gltA was deleted, and the nature promoter of glutamate dehydrogenase-coding gene gdh was replaced by Ptac-M promoter that resulted in the final engineered strain C. glutamicum JL-69Ptac-M gdh. Furthermore, the suitable addition of biotin accelerates the L-lysine production in strain JL-69Ptac-M gdh because it elastically adjusts the carbon flux for cell growth and precursor supply. The final strain JL-69Ptac-M gdh could produce 181.5 ± 11.74 g L-1 of L-lysine with a productivity of 3.78 g L-1 h-1 and maximal specific production rate (qLys, max.) of 0.73 ± 0.16 g g-1 h-1 in fed-batch culture during adding 2.4 mg L-1 biotin with four times. CONCLUSIONS: Our results reveal that sufficient biomass, OAA and L-glutamate are equally important in the development of L-lysine high-yielding strain, and it is the first time to verify that fed-batch biotin plays a positive role in improving L-lysine production.

Comparison of Clinical Outcomes After Anterior Cruciate Ligament Reconstruction Using a Hybrid Graft Versus a Hamstring Autograft.

PURPOSE: This study aimed to compare the clinical outcomes of patients who underwent anterior cruciate ligament (ACL) reconstruction with a hybrid graft versus an autograft after 3 years of follow-up. METHODS: Among 57 patients with an ACL injury who underwent ACL reconstruction, 28 patients received a hybrid graft (gracilis and semitendinosus tendon autograft plus a soft tissue allograft) and 29 patients received an autograft (gracilis and semitendinosus tendon autograft). The 2 groups were compared after a minimum 3-year follow-up regarding International Knee Documentation Committee (IKDC) assessment of knee function and stability, pivot-shift test, Lachman test, and KT-1000 side-to-side differences. The patient-reported Tegner activity score, Lysholm score, and subjective IKDC score were also compared. Graft failures were identified by patient-reported outcomes, physical examinations, or magnetic resonance imaging, and were confirmed on second-look arthroscopy; failure rate was compared between groups. RESULTS: At final follow-up, the 2 groups significantly differed in pivot-shift test result (P = .013) and Lachman test result (P = .027). The failure rate tended to be greater in the hybrid graft group (14.3%) than in the autograft group (3.4%) (P = .148). All 5 patients with failed graft reconstruction were revised after second-look arthroscopy. The KT-1000 side-to-side differences at final follow-up were significantly inferior in the hybrid graft group (3.5 ± 2.0) compared with the autograft group (2.5 ± 1.0, P = .024). The hybrid graft group also had a lower mean Lysholm score (P = .000) and subjective IKDC score (P = .006) than the autograft group. The mean Tegner activity score was 6.8 ± 0.8 in the hybrid graft group and 6.9 ± 0.6 in the autograft group (P = .436). CONCLUSIONS: The knee stability and patient-reported scores in the autograft-irradiated allograft hybrid graft ACL reconstruction group were significantly inferior compared with those in the autograft ACL reconstruction group. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Bilateral discoid medial meniscus associated with meniscal tears and hypoplasia of the medial femoral condyle: A case report.

RATIONALE: Bilateral discoid medial menisci is an extremely rare abnormality of the knee joint. The presence of a discoid medial meniscus has been associated with magnetic resonance imaging (MRI) and radiographic changes in the tibial region, such as cupping of the medial tibial plateau and tibial physis collapse. While discoid medial meniscal tears with hypoplasia of the femoral medial condyles have not been previously reported. Herein, we report a case of bilateral discoid medial menisci associated with meniscal tears and femoral bone changes. PATIENT CONCERNS: A 28-year-old man presented with left knee pain and restricted range of motion; the right knee was asymptomatic. DIAGNOSES: Based on radiographic and MRI findings, he was diagnosed with bilateral discoid medial meniscal tears. INTERVENTIONS: Partial meniscectomy and reshaping were performed for the torn discoid medial meniscus of the left knee only. OUTCOMES: MRI revealed short, flattened femoral medial condyles in the coronal and sagittal planes, and hypoplasia of the femoral medial condyles in the axial plane; these findings were confirmed arthroscopically in the left knee. The patient had a satisfactory results at the 12-month follow-up. LESSONS: This case indicates a potential link between discoid medial menisci and hypoplasia of the femoral medial condyle. We recommend preservation of the discoid medial meniscus in asymptomatic patients, while arthroscopic partial meniscectomy and reshaping is recommended in symptomatic patients.

Improved arthroscopic one-piece excision technique for the treatment of symptomatic discoid medial meniscus.

BACKGROUND: Discoid medial meniscus is an extremely rare abnormality of the knee. During arthroscopic meniscectomy for symptomatic discoid medial meniscus, it is difficult to remove the posterior portion of the meniscus because of the confined working space within the compartment and the obstruction caused by the anterior cruciate ligament and the tibial intercondylar eminence. To overcome these problems, we describe an improved arthroscopic technique for one-piece excision of symptomatic discoid medial meniscus through three unique portals. METHODS: Three improved portals were made in the injured knee: a standard anteromedial portal, a central transpatellar tendon portal, and a high anterolateral portal. The anterior side of the discoid medial meniscus was cut 7 mm from the periphery of the meniscus. Next, the anterior portion of the free discoid meniscus fragment was pulled in the anterolateral direction with tension. A curve-shaped cut was made along the longitudinal tear to the posterior horn using basket forceps through the standard anteromedial portal. Then, the anterior portion of the free discoid meniscus was pulled in the anteromedial direction. Pulling the fragment under tension made it easier to cut the posterior side of the discoid meniscus. The posterior side of the discoid meniscus was cut 7 mm from the periphery of the meniscus with straight scissors or basket forceps through the central transpatellar tendon portal. RESULTS: This technique resulted in satisfactory results. Excellent visualization of the posterior part of the discoid medial meniscus was gained during the procedure, and it was easy to cut the posterior part of the discoid medial meniscus. No recurrent symptoms were found. CONCLUSIONS: This improved arthroscopic one-piece excision technique for the treatment of symptomatic discoid medial meniscus enables the posterior part of the meniscus to be cut satisfactorily. Moreover, compared with previous techniques, this novel technique causes less formation of foreign bodies and less damage to the anterior cruciate ligament, medial collateral ligament, and cartilage and requires a shorter procedural time.

Surgical Technique of Total Knee Arthroplasty without Soft Tissue Balance.

Total knee arthroplasty (TKA) without soft tissue balance can create a balanced knee to a mechanical axis of near neutral with bone cuts, and remove osteophytes thoroughly. In this study, the authors present detailed steps for performing TKA. The attached video demonstrates the TKA procedure. The patient is a 77-year-old man who had suffered from knee pain for 12 years. Physical examination showed the Apley test to be positive and that the range of motion (ROM) decreased. An X-ray filmed at the positive lateral of the knee joint and the double lower extremity revealed a progression of degenerative osteoarthritis with genu varum. The key point of no soft tissue release is to make a rectangular extensional space by osteotomy. In addition, the osteophytes, especially syndesmophytes, should be removed thoroughly. As a result, the ligaments can achieve ideal length and the flexion contracture can also be remedied. Moreover, in surgeries without soft tissue release, bone mass and normal tissue are retained. Patients are satisfied to the surgery not only with less blood loss, anterior knee pain and DVT, but also faster rehabilitation. In summary, TKA without soft tissue balance is an efficient procedure for patients with knee osteoarthritis which can result in good prognosis.

Medial patellofemoral ligament reconstruction using a bone groove and a suture anchor at patellar: a safe and firm fixation technique and 3-year follow-up study.

BACKGROUND: Graft fixation is critical to the restoration of the medial patella of femoral ligament function and long-term success. Numerous fixations at the patella have been described, while the complications including patellar fractures, violation of the posterior patella and delay of tendon-to-bone healing remain significant challenges. Here, we describe a safe and firm fixation at the patellar for medial patellofemoral ligament (MPFL) reconstruction and explore the safety angle of drilling the suture anchor at different morphology of the patellar. Moreover, we evaluate the results at a 3-year follow-up. METHODS: Combined bone groove and suture anchor fixation at the patella was performed on 26 patients (16 females, 10 males; mean age 26.3 ± 4.7 years) diagnosed with recurrent patellar dislocation. The drilling direction of the suture anchor referred to the safety angle according to the Wiberg type classification. The safety angle was defined as the angle between the drill tunnel and a line that connected the medial and lateral margins of the patella and was established following computed tomography assessment of 117 patients who were diagnosed with patellar dislocation in our hospital according to the Wiberg type classification (I:29, II:65, III:23). X-ray, Lysholm, Kujala and Tegner scores were obtained preoperatively and at the time of final follow-up. RESULTS: There were no patellar complications, including fracture and redislocation. Average congruence, patella tilt angles and lateral patella angle were significantly changed (P < 0.01). The Lysholm, Kujala and Tegner scores were significantly increased (P < 0.01). The safe angles of male and female patients according to the patellar Wiberg type classification were less than 45.32 ± 1.76 and 41.20 ± 1.33, 69.74 ± 1.38 and 63.66 ± 1.45 and 84.11 ± 1.67 and 80.26 ± 1.73, respectively. CONCLUSIONS: We achieved encouraging results with this fixation at the patellar. When drilling from Wiberg type I to type III patellar, the suture anchor should be more vertical. When fixing the patellar of female patients, the drilling suture anchor should be more sloping.

Thymosin ß4 impeded murine stem cell proliferation with an intact cardiovascular differentiation.

Thymosin ß4 (Tß4) is a key factor in cardiac development, growth, disease, epicardial integrity, blood vessel formation and has cardio-protective properties. However, its role in murine embryonic stem cells (mESCs) proliferation and cardiovascular differentiation remains unclear. Thus we aimed to elucidate the influence of Tß4 on mESCs. Target genes during mESCs proliferation and differentiation were detected by real-time PCR or Western blotting, and patch clamp was applied to characterize the mESCs-derived cardiomyocytes. It was found that Tß4 decreased mESCs proliferation in a partial dose-dependent manner and the expression of cell cycle regulatory genes c-myc, c-fos and c-jun. However, mESCs self-renewal markers Oct4 and Nanog were elevated, indicating the maintenance of self-renewal ability in these mESCs. Phosphorylation of STAT3 and Akt was inhibited by Tß4 while the expression of RAS and phosphorylation of ERK were enhanced. No significant difference was found in BMP2/BMP4 or their downstream protein smad. Wnt3 and Wnt11 were remarkably decreased by Tß4 with upregulation of Tcf3 and constant ß-catenin. Under mESCs differentiation, Tß4 treatment did not change the expression of cardiovascular cell markers α-MHC, PECAM, and α-SMA. Neither the electrophysiological properties of mESCs-derived cardiomyocytes nor the hormonal regulation by Iso/Cch was affected by Tß4. In conclusion, Tß4 suppressed mESCs proliferation by affecting the activity of STAT3, Akt, ERK and Wnt pathways. However, Tß4 did not influence the in vitro cardiovascular differentiation.

Medial Compartment Decompression by Fibular Osteotomy to Treat Medial Compartment Knee Osteoarthritis: A Pilot Study.

Compared with high tibial osteotomy and total knee arthroplasty, the authors found a simpler surgical procedure, partial fibular osteotomy, could effectively relieve knee pain and also correct the varus deformity for patients with medial compartment knee osteoarthritis (OA). From January 1996 to April 2012, a total of 156 patients with medial compartment OA were treated by proximal fibular osteotomy in the authors' hospital. A 2-cm-long section of fibula was resected 6 to 10 cm below the fibular head. A total of 110 patients with follow-up of more than 2 years were included in the study, including 34 males and 76 females with an average age of 59.2 years. Anteroposterior and lateral weight-bearing radiographs, the femorotibial angle (FTA) and lateral joint space, and the American Knee Society Score (KSS) and the visual analog scale (VAS) score of the knee joint were evaluated preoperatively and at final follow-up, respectively. At final follow-up, mean FTA and lateral joint space were 179.4°±1.8° and 6.9±0.7 mm, respectively, which were significantly smaller than those measured preoperatively (182.7°±2.0° and 12.2±1.1 mm, respectively; both P<.001). Mean KSS at final follow-up was 92.3±31.7, significantly higher than the mean preoperative score of 45.0±21.3 (P<.001). Mean VAS score and interquartile range were 2.0 and 2.0, significantly lower than the preoperative data (7 and 1.0, respectively; P<.001). The authors found that proximal fibular osteotomy can significantly improve both the radiographic appearance and function of the affected knee joint and also achieve long-term pain relief. This procedure may be an alternative treatment option for medial compartment OA.

Surgical Treatment of Acute Grade III Medial Collateral Ligament Injury Combined With Anterior Cruciate Ligament Injury: Anatomic Ligament Repair Versus Triangular Ligament Reconstruction.

PURPOSE: The purpose of this study was to evaluate the clinical results of medial collateral ligament (MCL) anatomic ligament repair (ALR) and triangular ligament reconstruction (TLR) in treating acute grade III MCL injury with respect to imaging and functional results. METHODS: Between January 2009 and October 2011, a total of 69 patients with an acute grade III MCL tear combined with an anterior cruciate ligament tear were divided into 2 groups: those who underwent ALR and those who underwent TLR. Single-bundle anterior cruciate ligament reconstruction was also performed in all patients. A radiographic stress-position imaging test was performed to evaluate excessive medial opening of the knee. In addition, the Slocum test was carried out to assess anteromedial rotatory instability before surgery and at follow-up. The subjective symptoms and functional outcomes were evaluated preoperatively and postoperatively with International Knee Documentation Committee (IKDC) assessment. RESULTS: Sixty-four patients with a mean follow-up period of 34 months were included in the final analysis. The measurement results for medial opening at the last follow-up appointment decreased significantly from the pretreatment measurements and fell within the normal range, without a statistically significant difference between the 2 groups (P > .05). The overall incidence of anteromedial rotatory instability was reduced to 21.9% compared with 62.5% preoperatively. However, the incidence of anteromedial rotatory instability in the TLR group (9.4%) decreased significantly compared with that in the ALR group (34.4%) (P < .05). All patients' IKDC subjective scores significantly improved after surgery. No statistically significant difference was found between the 2 groups at the last follow-up (P > .05). The comparison of IKDC extension and flexion deficit scores between the 2 groups showed no significant differences. Eleven patients in the ALR group and 4 in the TLR group complained of medial knee pain. The comparison between the 2 groups showed no significant difference (P > .05). CONCLUSIONS: The clinical outcomes of this study showed that no major difference existed in the ALR and TLR groups based on IKDC scores and medial opening evaluations in the short-term. However, TLR offered better rotatory stability than ALR at final follow-up. LEVEL OF EVIDENCE: Level II, lesser-quality randomized controlled trial.

Incidence of deep venous thrombosis in Chinese patients undergoing arthroscopic knee surgery for cruciate ligament reconstruction.

PURPOSE: This study investigated the incidence of deep venous thrombosis (DVT) in patients undergoing arthroscopic cruciate ligament surgery. METHODS: A total of 282 patients were examined by color Doppler ultrasound preoperatively and 3 and 7 days postoperatively. RESULTS: DVT was present in 34 of 282 patients (12.1 %); of these, 11 (32.6 %) underwent reconstruction of the anterior cruciate ligament (ACL), alone or in conjunction with the medial or lateral collateral ligament (MCL or LCL, respectively; 17.6 %); eight (23.5 %) of the posterior cruciate ligament (PCL); four (11.8 %) of the PCL-MCL/LCL; and five (14.7 %) of the ACL-MCL. In patients with tourniquets applied for <90, 90-120, and >120 min, the incidence of DVT was 5.6, 12.8, and 17.4 %, respectively. CONCLUSION: The incidence of DVT in normal patients undergoing ACL surgery was 12.1 %. A higher incidence was observed among cases of multiligament reconstruction, especially those involving the PCL, as well as in patients with tourniquets applied for more than 2 h. Based on these findings, prophylactic measures for DVT may be considered after arthroscopic knee surgery in order to decrease the incidence of DVT if specific risk factors are present. LEVELS OF EVIDENCE: IV.

[Experimental research on repairing full-thickness articular cartilage defects by transplantation of autologous uncultured bone-marrow-derived mononuclear cells in combination with micro-fracture].

OBJECTIVE: To examine the feasibility of autologous uncultured bone-marrow-derived mononuclear cells (BM-MNCs) in combination with microfracture in a full-thickness articular cartilage defect model so as to provide experimental rationales for clinical applications. METHODS: A total of 40 rabbits were divided randomly into groups A, B, C and D (n = 10 each). In groups A and C, 5 ml marrow samples were harvested from left femur and then autologous BM-MNCs isolated. The full-thickness articular cartilage defects were made on femoral intercondylar fossa in right knees of rabbits. Group A: micro-fracture was made on cartilage defect and then autologous uncultured BM-MNCs-autologous fibrin gel complex implanted; Group B:the same micro-fracture was made on cartilage defect and autologous fibrin gel implanted; Group C:the cartilage defect was implanted with autologous uncultured BM-MNCs-autologous fibrin gel complex; Group D:the cartilage defect was implanted with autologous fibrin gel. Five rabbits were sacrificed at Weeks 8 and 12 post-transplantation in each group. And the reparative tissue samples evaluated grossly, histologically and immunohistochemically were graded according to the gross and histological scales. RESULTS: The statistical analyses of histological gradings at Weeks 8 and 12 showed that group A was significantly better than groups B, C and D (P < 0.05), groups B and C were better than group D (P < 0.05) and each group at Week 12 was better than itself at Week 6 (P < 0.05). CONCLUSION: Both of micro-fracture and transplantation of uncultured autologous BM-MNCs plus autologous fiber gel can promote the repair of cartilage defects. The combined use of micro-fracture and autologous uncultured BM-MNCs promotes the regeneration of articular cartilage so that it may provide theoretical rationales for clinical applications.

[Comparison of efficacies for two surgical methods in the treatment of medial tibial-femoral osteoarthritis].

OBJECTIVE: To compare the clinical efficacies of two surgical methods in the treatment of medial tibial-femoral osteoarthritis. METHODS: Between October 2007 and June 2010, a total of 22 cases (25 knees) with severe osteoarthritis in medial tibial-femoral compartment underwent minimally invasive unicompartmental knee arthroplasty (UKA) with Sled prosthesis after arthroscopic procedure. And its clinical efficacy was compared with that of 22 cases (25 knees) undergoing total knee arthroplasty (TKA) with Gemini MKII prosthesis almost simultaneously. RESULTS: There were no significant difference in general data between 2 groups (P > 0.05). Compared with the TKA group, the UKA group had a smaller blood loss ((148 ± 26) vs (278 ± 36) ml), a shorter operative duration ((68 ± 12) vs (86 ± 12) min), a faster progress of resuming 90° flexion ((3.18 ± 1.8) vs (9.1 ± 2.2) d) and an earlier off-bed time (P < 0.05). All patients were followed up for 6 - 34 months. There was no significant difference in KSS (Knee Society Score), function score or WOMAC (Western Ontario and McMaster Universities) score between 2 groups at the last follow-up (P > 0.05). CONCLUSION: The treatment of medial tibial-femoral osteoarthritis with minimally invasive UKA is superior to that with TKA in that it is less invasive, there is a faster recovery of joint functions and no significant difference exists in the mid-term clinical efficacies between them.

[A cadaveric study of relationships among rotational alignment reference axes of distal femur and tibial mechanical axis].

OBJECTIVES: To investigate the relationships among rotational alignment reference axes of distal femur and tibial mechanical axis, and determine the safest rotational alignment reference axis. METHODS: Digital photos were taken of 30 cadaveric lower extremities with knee in extension and flexion at 90 degrees , angles were measured among tibial mechanical axis and a line perpendicular to clinical epicondylar axis, a line perpendicular to surgical epicondylar axis, Whiteside's line and femoral mechanical axis. Statistical analysis of relationships among those axes were performed. RESULTS: The angles among the tibial mechanical axis and a line perpendicular to the clinical epicondylar axis, a line perpendicular to the surgical epicondylar axis, Whiteside's line and femoral mechanical axis were 0.6 degrees varus, 3.9 degrees varus, 0.2 degrees valgus and 3.0 degrees varus respectively. The angle between the femoral mechanical axis and the tibial mechanical axis was significantly larger than the angles among the tibial mechanical axis and a line perpendicular to the clinical epicondylar axis, the Whiteside's line (P < 0.05). There was no significant difference compared with the angle between a line perpendicular to the surgical epicondylar axis and the tibial mechanical axis. Angles of the clinical epicondylar axis, the surgical epicondylar axis and the Whiteside's line between knee extension and flexion were 2.3 degrees valgus, 0.9 degrees varus and 3.1 degrees valgus respectively. CONCLUSION: The surgical epicondylar axis rather than the clinical epicondylar axis or the Whiteside's line is the safest femoral rotational alignment reference axis intraoperatively.

[Arthroscopic simultaneous reconstruction of posterior cruciate ligament using double femoral tunnel technique and anterior cruciate ligament with achilles allograft].

OBJECTIVES: To introduce the technique of arthroscopic simultaneous reconstruction of posterior cruciate ligament (PCL) using double femoral tunnel, single-bundle transtibial tunnel PCL technique and anterior cruciate ligament (ACL) with achilles allograft, and to evaluate the clinical outcome. METHODS: Fourteen patients with PCL and ACL injuries after a minimum follow-up 18 months were received. Arthroscopically assisted simultaneous ACL/PCL reconstruction with achilles allograft were performed using the single-incision endoscopic ACL technique and the double femoral tunnel, single-bundle transtibial tunnel PCL technique. The Lysholm and Tegner knee score scale were used for functional evaluation. All patients were evaluated with physical examination and KT-1000 arthrometer testing. The mean knee flexion was (123.6 +/- 2.5) degrees preoperatively. The Lysholm score was 52.8 +/- 2.2. The Tegner score was 5.9 +/- 0.5 before injury, 1.2 +/- 0.9 preoperatively. RESULTS: The mean time from injury to the reconstructive procedure was 19.5 d. The mean knee flexion was (117.9 +/- 2.8) degrees postoperatively( t = 1.54, P = 0.14). As to the Lachman test for 14 patients, the results of 13 patients (92.9%) was negative. As to posterior drawer test, the results of 12 patients (85.7%) was negative. The Lysholm score was 92.9 +/- 3.3 at final evaluation (t = 17.009, P < 0.001). KT-1000 arthrometer testing at 25 degrees knee flexion showed that the side-to-side difference was below 2 mm in 9 cases, 3-5 mm in 4 cases, 6 mm in 1 case. At 75 degrees knee flexion the difference was below 2 mm in 10 cases, 3-5 mm in 3 cases, 6 mm in 1 case. The Tegner score was 5.4 +/- 0.8 at final evaluation. The difference between the preoperative score and the postoperative was statistically significant (F = 4.2, P < 0.01). CONCLUSIONS: Combined ACL and PCL injuries can be successfully treated with arthroscopic simultaneous reconstruction of PCL using double femoral tunnel technique and ACL with achilles allograft. The double femoral tunnel technique more closely approximates the anatomic insertion the native PCL. Most patients recover a functionally stable knee.