Evaluation of the Angle Between the Long Axis of the Femoral Anterior Cruciate Ligament Footprint and Bony Morphology of the Knee: A Cadaveric Descriptive Study.

Purpose: There have been numerous studies of the anterior cruciate ligament (ACL) anatomy, but few have focused on the long axis angle of the femoral ACL footprint. This study investigated the angle between the long axis of the femoral ACL footprint and the bony morphology of the knee. Methods: This study is a cadaveric descriptive study. Thirty non-paired formalin-fixed knees of Japanese cadavers were used. Anteromedial (AM) and posterolateral (PL) bundles were identified according to the tension pattern differences during the complete range of motion of the knee. In the ACL femoral footprint, there is a fold between the mid-substance insertion site and fan-like extension fibers. After identifying AM and PL bundles of mid-substance fibers, the mid-substance and fan-like extension fibers were divided into those bundles and stained. We defined the line passing through the center of the AM and PL bundles as the long axis of the ACL. The center points of each of the four areas and the angle between the long axis of the ACL and the bony morphology of the knee were calculated using Image J software. Results: The mean angle between the axis of the femoral shaft and the long axis of the ACL mid-substance insertion was 28.8 ± 12.2 degrees. The mean angle between the Blumensaat line and the long axis of the mid-substance was 54.2 ± 13.5 degrees. Conclusion: The mean angle between the axis of the femoral shaft and the long axis of the femoral ACL footprint was approximately 29 degrees. There is a wide variation in the long axis of the femoral ACL footprint. To achieve better clinical results through a more anatomically accurate reconstruction, it can be beneficial to replicate the ACL femoral footprint along its native long axis.

Size Comparison of the Cadaveric Anterior Cruciate Ligament Midsubstance Cross-Sectional Area and the Cross-Sectional Area of Semitendinosus Double-Bundle Anterior Cruciate Ligament Reconstruction Autografts in Surgery.

The purpose of this study was to compare the cadaveric midsubstance cross-sectional anterior cruciate ligament (ACL) area and the cross-sectional semitendinosus (ST) double-bundle ACL autograft area in surgery. Thirty-nine nonpaired formalin-fixed cadaveric knees and 39 subjects undergoing ST double-bundle ACL reconstruction were included in this study. After soft tissue resection, cadaveric knees were flexed at 90 degrees, and the tangential line of the femoral posterior condyles was marked and sliced on the ACL midsubstance. The cross-sectional ACL area was measured using Image J software. In the patients undergoing ACL surgery, the harvested ST was cut and divided into anteromedial (AM) bundle and posterolateral (PL) bundle. Each graft edge diameter was measured by a sizing tube, and the cross-sectional graft area was calculated: (AM diameter/2)2 × 3.14 + (PL diameter/2)2 × 3.14. Statistical analysis was performed for the comparison of the cross-sectional area between the cadaveric ACL midsubstance and the ST double-bundle ACL autografts. The cadaveric midsubstance cross-sectional ACL area was 49.0 ± 16.3 mm2. The cross-sectional ST double-bundle autografts area was 52.8 ± 7.6 mm2. The ST double-bundle autograft area showed no significant difference when compared with the midsubstance cross-sectional ACL area. ST double-bundle autografts were shown to be capable of reproducing the midsubstance cross-sectional ACL area.

Correlation between the mid-substance cross-sectional anterior cruciate ligament size and the knee osseous morphology.

INTRODUCTION: One of the final goals of anatomical anterior cruciate ligament (ACL) reconstruction is the restoration of native anatomy. It is essential to obtain more accurate predictors of mid-substance ACL size before surgery. However, to the best of our knowledge, no study has reported correlation between the mid-substance cross-sectional ACL size and the knee osseous morphology. The purpose of this study was to reveal correlation between the mid-substance cross-sectional ACL size and the knee osseous morphology. MATERIALS AND METHODS: We used 39 non-paired formalin fixed Japanese cadaveric knees. All surrounding muscles, ligaments and soft tissues in the knee were resected. After soft tissue resection, the knee was flexed at 90°, and a tangential plane of the femoral posterior condyles was marked and cut the ACL. Femoral ACL footprint size, Blumensaat's line length, lateral wall of the femoral intercondylar notch size, lateral wall of the femoral intercondylar notch height, tibial ACL footprint size, tibia plateau size, the whole anterior-posterior (AP) length, the medial and the lateral AP length of the tibia plateau, and the medial-lateral (ML) length of the tibia plateau were measured. The Pearson's product movement correlation was calculated to reveal correlation between the mid-substance cross-sectional ACL size and the measured parameters of the knee osseous morphology. RESULTS: The measured mid-substance cross-sectional ACL size was 49.9 ± 16.3 mm2. The tibial ACL footprint size, the tibia plateau size, the whole AP length of the tibia plateau, the lateral AP length of the tibia plateau and the ML length of the tibia plateau were significantly correlated with the mid-substance cross-sectional ACL size. CONCLUSIONS: For clinical relevance, some tibial sides of the knee osseous morphology were significantly correlated with the mid-substance cross-sectional ACL size. It might be possible to predict the mid-substance ACL size measuring these parameters.

Verification of phycological factors related to health-related quality of life in elderly knee osteoarthritis: A prospective cohort study.

BACKGROUND: In recent years, locomotive syndrome, which is a condition requiring nursing care due to musculoskeletal disease, has been reported, and interest in knee osteoarthritis has been increasing. Several studies have reported the physical factors influencing the relationship between knee osteoarthritis and health-related quality of life (HRQOL), but there have been no reports verifying the changes over time in the relationship between psychosocial factors and HRQOL. This study aimed to investigate the influence of psychosocial factors on HRQOL in elderly patients with knee osteoarthritis. METHODS: Evaluations were conducted at four time points: before exercise therapy intervention, 1 month into intervention, 3 months into intervention, and 1 month after completion of intervention. The items investigated were (1) Japanese Orthopedic Association (JOA) score, (2) Kellgren-Lawrence (K-L) grading system, (3) Fall Efficacy Scale (FES), (4) Frenchay Activities Index (FAI), (5) Geriatric Depression Scale (GDS), and (6) Short Form-8 (SF-8). RESULTS: No significant differences were seen between each time point of exercise therapy intervention in depression and HRQOL scale but a significant improvement was seen in instrumental ADL and fear of falling at 3 months into intervention. On multiple regression analysis with SF-8 subscales, fear of falling and degree of depression were determined as significant factors affecting physical and mental summary scores. CONCLUSION: Elderly patients with knee osteoarthritis require not only intervention for knee function, but also psychological intervention to address decreased activity and depression to improve their HRQOL.

Measurement of the Whole and Midsubstance Femoral Insertion of the Anterior Cruciate Ligament: The Comparison with the Elliptically Calculated Femoral Anterior Cruciate Ligament Footprint Area.

PURPOSE: The purpose of this study was to measure the detailed morphology of the femoral anterior cruciate ligament (ACL) footprint. The correlation and the comparison between the measured area and the area which mathematically calculated as elliptical were also evaluated. MATERIALS AND METHODS: Thirty nine nonpaired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on both the whole footprint and the midsubstance insertion. Lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area, length, and width of the femoral ACL footprint were measured with Image J software (National Institution of Health). Using the length and width of the femoral ACL footprint, the elliptical area was calculated as 0.25 π (length × width). Statistical analysis was performed to reveal the correlation and the comparison of the measured and elliptically calculated area. RESULTS: The sizes of the whole and midsubstance femoral ACL footprints were 127.6 ± 41.7 mm2 and 61 ± 20.2 mm2, respectively. The sizes of the elliptically calculated whole and midsubstance femoral ACL footprints were 113.9 ± 4.5 mm2 and 58.4 ± 3 mm2, respectively. Significant difference was observed between the measured and the elliptically calculated area. In the midsubstance insertion, significant correlation was observed between the measured and the elliptically calculated area (Pearson's correlation coefficient = 0.603, P = 0.001). However, no correlation was observed in the whole ACL insertion area. CONCLUSION: The morphology of the femoral ACL insertion resembles an elliptical shape. However, due to the wide variation in morphology, the femoral ACL insertion cannot be considered mathematically elliptical.

The correlation between the femoral anterior cruciate ligament footprint area and the morphology of the distal femur: three-dimensional CT evaluation in cadaveric knees.

BACKGROUNDS: "Anatomical" anterior cruciate ligament (ACL) reconstruction is defined as the functional restoration of the ACL to its native dimensions. It is essential to obtain more accurate predictors of ACL size before surgery. The purpose of this study was to investigate the correlation between the native femoral ACL footprint size and the morphology of the distal femur using three-dimensional CT (3D-CT). METHODS: Thirty non-paired Japanese human cadaver knees were used. All soft tissues around the knee were resected except the ACL. For the evaluation of femoral condyle morphology, trans-epicondylar length (TEL), notch outlet length, axial notch area, and notch width index were measured using 3D-CT. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the boundaries of the ACL insertion site were outlined on the femoral side. An accurate lateral view of the femoral condyle was photographed with a digital camera. The size of the femoral ACL footprint, length of Blumensaat's line, and the height and area of the lateral wall of the femoral intercondylar notch were measured with ImageJ software. RESULTS: Notch height, lateral notch area, and TEL were significantly correlated with the femoral ACL footprint area. Both axial notch area and notch outlet length were significantly correlated with the femoral mid-substance insertion area. CONCLUSION: Morphological evaluation using 3D-CT preoperatively may be useful in predicting the femoral ACL footprint size.

The importance of Blumensaat's line morphology for accurate femoral ACL footprint evaluation using the quadrant method.

PURPOSE: The purpose of this study was to evaluate the difference in the center position of the ACL footprint based on grid placement using the quadrant method according to the morphological variations of the Blumensaat's line. METHODS: Fifty-nine non-paired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch, and the digital images were evaluated using Image J software. The femoral ACL footprint was periphery outlined and the center position was automatically measured. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight, small hill, and large hill types. From the images, grid quadrants were placed as: Grid (1) without consideration of hill existence and not including the chondral lesion. Grid (2) without consideration of hill existence and including the chondral lesion. Grid (3) with consideration of hill existence and not including the chondral lesion. Grid (4) with consideration of hill existence and including the chondral lesion. RESULTS: The straight type consisted of 19 knees, the small hill type 13 knees, and the large hill type 27 knees. Depending on the quadrant grid placement, significant center position difference was observed both in the shallow-deep, and high-low direction. When hill existence was considered, the center position of the ACL was significantly changed to a high position. CONCLUSION: The center position of the ACL footprint exhibited significant differences according to Blumensaat's line morphology. For clinical relevance, when ACL surgery is performed in knees with small or large hill type variations, surgeons should pay close attention to femoral tunnel evaluation and placement, especially when using the quadrant method.

Morphological size evaluation of the mid-substance insertion areas and the fan-like extension fibers in the femoral ACL footprint.

PURPOSE: The purpose of this study was to evaluate the detailed anatomy of the femoral anterior cruciate ligament (ACL) insertion site, with special attention given to the morphology of the mid-substance insertion areas and the fan-like extension fibers. METHODS: Twenty-three non-paired human cadaver knees were used (7 Males, 16 Females, median age 83, range 69-96). All soft tissues around the knee were resected except the ligaments. The ACL was divided into antero-medial (AM) and postero-lateral (PL) bundles according to the difference in macroscopic tension patterns. The ACL was carefully dissected and two outlines were made of the periphery of each bundle insertion site: those which included and those which excluded the fan-like extension fibers. An accurate lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area of each bundle, including and excluding the fan-like extension fibers, was measured with Image J software (National Institution of Health). The width and length of the mid-substance insertion sites were also evaluated using same image. RESULTS: The femoral ACL footprint was divided into four regions (mid-substance insertion sites of the AM and PL bundles, and fan-like extensions of the AM and PL bundles). The measured areas of the mid-substance insertion sites of the AM and PL bundles were 35.5 ± 12.5, and 32.4 ± 13.8 mm2, respectively. Whole width and length of the mid-substance insertion sites were 5.3 ± 1.4, and 15.5 ± 2.9 mm, respectively. The measured areas of the fan-like extensions of the AM and PL bundles were 27 ± 11.5, and 29.5 ± 12.4 mm2, respectively. CONCLUSION: The femoral ACL footprint was divided into quarters of approximately equal size (mid-substance insertion sites of the AM and PL bundles, and fan-like extensions of the AM and PL bundles). For clinical relevance, to perform highly reproducible anatomical ACL reconstruction, the presence of the fan-like extension fibers should be taken into consideration.

[Present and future for LLLT in the area of orthopedics].

The biological tissue is irradiated with laser light, and carbonization, incineration, evaporation, blood coagulation, protein denaturation, and photoactivation will arise in order of the strength of the reaction. LLLT is the application of those photoactivated biological effects. In this paper, effective pain relief, photoactivation effect on chondrocytes, and, PDT (photodynamic therapy) using photosensitizer are introduced.

Rollback of the femoral condyle in anatomical double-bundle anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to evaluate rollback of the femoral condyle in anatomical double-bundle anterior cruciate ligament reconstruction (ACL). METHODS: Twenty-two subjects who underwent anatomical double-bundle ACL reconstruction were included in this study. More than 6 months after surgery, lateral radiographic imaging of the knee was performed with active full knee flexion. The most posterior tibiofemoral contact point was measured for evaluation of femoral rollback (rollback ratio). Flexion angle was also measured using the same radiograph, and the correlation between rollback and flexion angle was analyzed. As a control, radiographs of the healthy contralateral knees were evaluated. For clinical evaluation, side-to-side difference in anterior tibial translation (ATT) and pivot shift test were analyzed approximately 1 year after surgery. RESULTS: The rollback ratios of the operated knees and the healthy contralateral knees were 28.7 ± 6.6 and 29.7 ± 6.7%, respectively, from the posterior edge of the tibia. No significant difference in rollback was observed. The flexion angles of the operated knees and the healthy contralateral knees were 136 ± 11° and 140 ± 9°, respectively. No significant difference in knee flexion angle was observed. Significant correlation between femoral rollback and knee flexion angle was observed. The side-to-side difference in ATT was 0.7 mm, and no cases of positive pivot shift were observed. CONCLUSION: Anatomical double-bundle ACL reconstruction can restore normal femoral rollback in active full knee flexion. For clinical relevance, knees with anatomical double-bundle ACL reconstruction can flex with normal kinematics at the end of knee flexion angle. LEVEL OF EVIDENCE: III.

Age as a predictor of residual muscle weakness after anterior cruciate ligament reconstruction.

PURPOSE: The objective of this study was to reveal the predicting factors for muscle recovery in the lower extremity after anterior cruciate ligament (ACL) reconstruction. METHODS: One hundred and thirty-five (135) patients who underwent ACL reconstruction using hamstring autograft were evaluated. Exclusion criteria were bilateral ACL injury, chondral treatment and multiple ligament injury. Nonanatomical single-bundle reconstruction (SB) was performed in 79 patients, and anatomical double-bundle reconstruction (DB) was performed in 56 patients. Strength of quadriceps and knee flexion muscles were assessed at 60°/s using a Cybex II dynamometer (Lumex, Ronkonkoma, NY) at 3, 6 and 9 months after ACL reconstruction. Anterior tibial translation and pivot shift test were also evaluated. The medical records were reviewed to extract the following information: age, gender, the amount of pre and postoperative KT 1000, technique of reconstruction (SB or DB) and postoperative knee rotation. RESULTS: No significant difference of muscle recovery in the lower extremity was observed at any time point after ACL reconstruction between the SB and DB groups. The DB group showed significantly better postoperative antero-posterior and rotational knee laxity than the SB group. Logistic regression analysis showed significant correlation with only age and muscle recovery. CONCLUSION: For clinical relevance, there is a risk of muscle recovery delay when ACL reconstruction is performed in elderly patients. Anatomical DB reconstruction resulted in significantly better knee stability, but had no positive effect on muscle recovery. LEVEL OF EVIDENCE: Retrospective study, Level II.

In vitro and in vivo AM and PL tunnel positioning in anatomical double bundle anterior cruciate ligament reconstruction.

BACKGROUND: There have been few studies investigating the correct anatomical femoral and tibial tunnel placement in double bundle anterior cruciate ligament (ACL) reconstruction. OBJECTIVE: To compare anteromedial (AM) and posterolateral (PL) tunnel positions in anatomical double bundle ACL reconstruction in human cadaver and patient knees. MATERIALS AND METHODS: Fifteen fresh-frozen non-paired adult human knees and 27 patients (27 knees) were evaluated. In the cadaver knees, AM and PL bundles were identified by their difference in tension patterns. Their femoral centers were marked with a K-wire, and cut from the femoral insertion site. After this, each bundle was divided at the tibial side. The center of each bundle insertion was again marked with a K-wire, and 5-7-mm tunnels were drilled with transportal or outside-in technique. In patient knees, each tunnel was made according to the native ACL foot print and bony landmarks using transtibial technique (n = 5) and transportal technique (n = 22). Tunnel placement was evaluated using a C-arm X-ray device and 3D CT. For the femoral side assessment, Bernard and Hertel's technique was used. For the tibial side assessment, Amis and Jakob's technique was used. RESULTS: The femoral AM tunnel in the cadaver knees was placed in a significantly deeper position when compared to patient knees. There was no significant difference in the AM vertical placement or in the PL tunnel placement in the femur. No significant differences were observed in the tibial tunnel placements between cadaver and patient knees. CONCLUSION: In vivo positioning of the femoral AM bundle differed significantly from the in vitro positioning.

Full knee extension magnetic resonance imaging for the evaluation of intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to reveal the relationship between anatomically placed anterior cruciate ligament (ACL) graft and the intercondylar roof using magnetic resonance imaging (MRI). METHODS: Twenty patients undergoing anatomical double-bundle ACL reconstruction were included in this study. Anatomical double-bundle ACL reconstruction was performed with two femoral tunnels (antero-medial; AM and postero-lateral; PL) and two tibial tunnels. Hamstring autograft was used in all cases. More than 6 months after operation, MRI was performed with full knee extension. The relationship between the graft and the intercondylar roof was evaluated using an axial view of the T2 image at the most distal slice of the intercondylar roof. Qualitative evaluation of the ACL graft was performed with a sagittal view of the T2 image. Tunnel placement was evaluated with three-dimensional computed tomography (3D-CT) and radiographs. The extension angle of the knee was also evaluated with 3D-CT. RESULTS: In 12 subjects, the ACL graft touched the roof (Touch group) but no graft deformation was observed. In 8 subjects, no roof-graft contact was observed (Non-touch group). In 1 case, the ACL graft was bowed posteriorly. Signal intensity alteration of the graft was observed in 3 cases. No significant difference in femoral and tibial tunnel placement was observed between the Touch and Non-touch groups. All subjects attained full knee extension. CONCLUSION: Although graft-roof impingement after anatomical double-bundle ACL reconstruction was suspected in some cases after the MRI evaluation, no extension loss in the knee was observed. In these suspected cases of impingement, long-term follow-up will be needed to determine the connection between any potential pathological effects. For the clinical relevance, MRI is an effective tool to determine the status of roof impingement in anatomical double-bundle ACL reconstruction.

Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes.

BACKGROUND: Intercondylar notch narrowing is a risk factor for anterior cruciate ligament (ACL) injuries, but it is unclear whether a narrow intercondylar notch correlates with bilateral ACL injuries. PURPOSE: To determine whether a narrow intercondylar notch is associated with bilateral ACL knee injuries in athletes, using magnetic resonance imaging (MRI) and radiography to investigate the notch size. STUDY DESIGN: A retrospective case-control study. METHODS: This was a comparative cohort study on 50 subjects of which 25 patients with sport trauma-associated bilateral ACL injuries, 30 with unilateral ACL injuries, and 20 healthy subjects. The notch width index (NWI) was measured as the ratio of the width of the intercondylar notch to the femoral condylar width on radiography and the MRI slice containing the region near the ACL attachment site on the femoral side (NWI-A) and on the following posterior slice (NWI-P). RESULTS: The mean NWI values on radiography were 0.257 (SD 0.040), 0.332 (SD 0.036), and 0.341 (SD 0.027) in the bilateral, unilateral, and control groups, respectively, with significant differences between the bilateral and unilateral groups and the bilateral and healthy groups. On MRI, the mean NWI-A values were 0.236 (SD 0.025), 0.243 (SD 0.048), and 0.266 (SD 0.030), respectively, with a significant difference between the bilateral and healthy groups. The mean NWI-P values were 0.239 (SD 0.021), 0.258 (SD 0.038), and 0.273 (SD 0.033), respectively, with significant differences between the bilateral and unilateral groups and the unilateral and healthy groups. A cutoff value of 0.25 for NWI-P gave an odds ratio of 22.667 for the risk of developing bilateral ACL knee injuries. CONCLUSIONS: The intercondylar notch was significantly narrower in subjects with bilateral ACL injuries than in healthy subjects. NWI measurement using coronal MRI is useful for judging intercondylar notch narrowing. The risk for ACL injuries is very high when NWI is ≤0.25. Preventive measures for the unaffected knee are required for patients with a narrow intercondylar notch.

Therapeutic effect of photodynamic therapy using Na-pheophorbide a on osteomyelitis models in rats.

OBJECTIVE: In this study, we examined the therapeutic effect of photodynamic therapy (PDT) using the photosensitizer Na-Pheophorbide a (Na-Phde a) on osteomyelitis models in rats. BACKGROUND: Osteomyelitis is one of the most serious infectious problems in the orthopedic field. Recently, as a new clinical approach against septic arthritis, an experimental in vivo and in vitro model for the inactivation of methicillin-resistant-Staphylococcus aureus by PDT using Na-Phde a has been developed. METHODS: Methicillin-sensitive Staphylococcus aureus (MSSA) was injected into the tibia of the rats to create osteomyelitis models (n = 10, 10 legs). A total of 560 µmol/l of Na-Phde a solution was injected into five of these tibial osteomyelitis models (five legs) 48 h after the initial MSSA infection. Sixty minutes after the Na-Phde a injection, a semiconductor laser (125 mW, 670 nm) was used to irradiate the models for 10 min with a total energy of 93.8 J/mm(2). As a control group, five rats (five legs) were treated with a phosphate buffered saline injection at 48 h after MSSA infection. Weight and leg perimeter changes were plotted. Bacterial growth, histological examination and radiological examination were evaluated at 14 days after initial treatment. RESULTS: PDT with Na-Phde a significantly prevented leg swelling. In the PDT group, bone destruction owing to osteomyelitis was inhibited not only histologically but also radiographically. CONCLUSIONS: The results in these experiments show that PDT using Na-Phde a improved osteomyelitis in rats. This suggests that PDT using Na- Phde a can be a useful treatment for osteomyelitis.

Evaluation of the intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction using 3D-CT.

PURPOSE: To reveal the relationship between anatomically placed anterior cruciate ligament (ACL) graft and the intercondylar roof using three-dimensional computed tomography (3D-CT). METHODS: Twenty-four patients undergoing anatomical double-bundle ACL reconstruction were included in this study. Anatomical double-bundle ACL reconstruction was performed with two femoral tunnels (antero-medial; AM and postero-lateral; PL) and two tibial tunnels. Hamstring autograft was used in all cases. Six to eight weeks after operation and when the subjects had obtained full extension of the knee, 3D-CT was performed with full knee extension. In the 3D-CT, the ACL graft was also reconstructed and visualized three dimensionally. Tunnel placement was evaluated with 3D-CT and intra-operative radiographs. The extension angle of the knee was also evaluated with 3D-CT. RESULTS: No intercondylar roof impingement was observed. In 12 subjects, the ACL graft touched the roof (Touch group) but no graft deformation was observed. In 12 subjects, no roof-graft contact was observed (Non-touch group). No significant difference in femoral and tibial tunnel placement was observed between the Touch and Non-touch groups. All subjects attained full knee extension. CONCLUSION: We believe that 3D-CT is an effective means of evaluating impingement after ACL reconstruction. For the clinical relevance, when the grafts are positioned in an anatomical fashion, there is no risk of impingement, and surgeons can perform anatomical double-bundle ACL as an impingement-free reconstruction. LEVEL OF EVIDENCE: III (Case control study).

Intensity of physiotherapy after anterior cruciate ligament reconstruction: a comparison of two rehabilitation regimen.

BACKGROUND: Rehabilitation is one of the most critical points after anterior cruciate ligament (ACL) reconstruction. However, the recent trend of low-cost, short-term hospitalization makes sufficient rehabilitation after ACL reconstruction difficult. LEVEL OF EVIDENCE III: 34 patients who underwent non-anatomical single bundle ACL reconstruction using a hamstring auto graft were evaluated. Twenty patients (12 males and 8 females) were transferred to a special rehabilitation hospital (RH hospital group) after operation and concentrated rehabilitation was performed up to 4 h per day. Fourteen (9 males and 5 females) patients performed clinic-based rehabilitation at a university hospital three times per week (clinic group). Strength of quadriceps and knee flexion muscles was assessed at 60 degrees /s using a Cybex II dynamometer (Lumex, Ronkonkoma, NY, USA) at 3, 6 and 9 months after ACL reconstruction. Anterior tibial translation (ATT) and pivot shift test were also evaluated. RESULTS: No significant difference in muscle recovery in the lower extremity was observed at any time point after ACL reconstruction between the clinic group and the RH hospital group. However, 3 months after operation, the average muscle strength of the RH hospital group tended to be higher than that of the clinic group. There was no significant difference in ATT or pivot shift (each group included 4 positive pivot shift subjects) in the patients who were tested between the clinic group and the RH hospital group. CONCLUSION: Concentrated rehabilitation at a rehabilitation hospital after ACL reconstruction has the potential to improve muscle strength in the lower extremities more dramatically in the early stages of post operation. However, the initial benefits of intensive physiotherapy disappear after 6 months.

Evaluation of the tunnel placement in the anatomical double-bundle ACL reconstruction: a cadaver study.

The objective of this study was to investigate the accurate AM and PL tunnel positions in an anatomical double-bundle ACL reconstruction using human cadaver knees with an intact ACL. Fifteen fresh-frozen non-paired adult human knees with a median age of 60 were used. AM and PL bundles were identified by the difference in tension patterns. First, the center of femoral PL and AM bundles were marked with a K-wire and cut from the femoral insertion site. Next, each bundle was divided at the tibial side, and the center of each AM and PL tibial insertion was again marked with a K-wire. Tunnel placement was evaluated using a C-arm radiographic device. For the femoral side assessment, Bernard and Hertel's technique was used. For the tibial side assessment, Staubli's technique was used. After radiographic evaluations, all tibias' soft tissues were removed with a 10% NaOH solution, and tunnel placements were evaluated. In the radiographic evaluation, the center of the femoral AM tunnel was placed at 15% in a shallow-deep direction and at 26% in a high-low direction. The center of the PL bundle was found at 32% in a shallow-deep direction and 52% in a high-low direction. On the tibial side, the center of the AM tunnel was placed at 31% from the anterior edge of the tibia, and the PL tunnel at 50%. The ACL tibial footprint was placed close to the center of the tibia and was oriented sagittally. AM and PL tunnels can be placed in the ACL insertions without any coalition. The native ACL insertion site has morphological variety in both the femoral and tibial sides. This study showed, anatomically and radiologically, the AM and PL tunnel positions in an anatomical ACL reconstruction. We believe that this study will contribute to an accurate tunnel placement during ACL reconstruction surgery and provide reference data for postoperative radiographic evaluation.

Biomechanics of the porcine triple bundle anterior cruciate ligament.

Several species of animals are used as a model to study human anterior cruciate ligament (ACL) reconstruction. In many animals, three bundles were clearly discernible during dissection in the ACL. However, there are few reports about the biomechanical role of each bundle in the porcine knee. The purpose of this study is to investigate the role of each of the three bundles in the porcine knee, especially the intermediate bundle. Ten porcine knees were tested using a robotic/universal forcemoment sensor system. This system applied anterior loading of 89 N at 30 degrees, 60 degrees and 90 degrees of flexion, and a combined 7 Nm valgus and 4 Nm internal tibial torque at 30 degrees and 60 degrees of flexion before and after each bundle was selectively cut. The in situ force (N) for each bundle of the ACL was measured. Both intermediate (IM) bundle and postero-lateral (PL) bundle had significantly lower in situ force than the antero-medial (AM) bundle in anterior loading. The IM and PL bundles carried a larger proportion of the force under the torsional loads than the anterior loads. But IM bundle had a significant lower in situ force during the combined torque at 60 degrees of knee flexion, when compared intact ACL. In summary, IM bundle has a subordinate role to the AM and PL bundles. AM bundle is more dominant than IM and PL bundles. The porcine knee is a suitable model for ACL studies, especially for AP stability.

Bactericidal effect of photodynamic therapy using Na-pheophorbide a: evaluation of adequate light source.

OBJECTIVE: To evaluate the efficacy of photodynamic therapy (PDT) against methicillin resistant-Staphylococcus aureus (MRSA) by selecting different light sources for irradiation and combining them with the photosensitizer Na-Pheophorbide a (Na-Phde a). BACKGROUND: The treatment of drug-resistant bacterial infection is a serious issue. Recently, as a new clinical approach against septic arthritis, an experimental in vivo and in vitro model for the inactivation of MRSA by PDT using the photosensitizer Na-Phde a has been developed. MATERIALS AND METHODS: Na-Phde a solution (280 micromol/L) was mixed with MRSA strain bacterial inoculum. After 60 minutes, light was irradiated for 30 minutes using the following light sources: GaA1p semiconductor laser (300 mW, 670 nm), halogen lamp (75 W), xenon lamp (300 W) and fluorescent lamp (27 W). Bacterial growth was evaluated after 24 hours incubation in a blood agar culture. RESULTS: The semiconductor laser and halogen lamp groups showed perfect bactericidal effects after PDT. The xenon lamp and fluorescent lamp groups showed partial bactericidal effects. CONCLUSIONS: The results of this experiment showed that PDT using the combination of Na-Phde a with a semiconductor laser or halogen lamp showed a better bactericidal performance than with xenon or fluorescent lamps. These findings indicated that PDT using Na-Phde a could be a useful treatment for septic arthritis and soft tissue infection.