Comparison of complete distal release of the medial collateral ligament and medial epicondylar osteotomy during ligament balancing in varus knee total knee arthroplasty.

BACKGROUND: During ligament balancing for severe medial contracture in varus knee total knee arthroplasty (TKA), complete distal release of the medial collateral ligament (MCL) or a medial epicondylar osteotomy can be necessary if a large amount of correction is needed. METHODS: This study retrospectively reviewed 9 cases of complete distal release of the MCL and 11 cases of medial epicondylar osteotomy which were used to correct severe medial contracture. The mean follow-up periods were 46.5 months (range, 36 to 78 months) and 39.8 months (range, 32 to 65 months), respectively. RESULTS: There were no significant differences in the clinical results between the two groups. However, the valgus stress radiograph revealed significant differences in medial instability. In complete distal release of the MCL, some stability was obtained by repair and bracing but the medial instability could not be removed completely. CONCLUSIONS: Medial epicondylar osteotomy for a varus deformity in TKA could provide constant medial stability and be a useful ligament balancing technique.

Specific compartmental analysis of cartilage status in double-bundle ACL reconstruction patients: a comparative study using pre- and postoperative MR images.

PURPOSE: The purpose of this study was to evaluate the changes in the site-specific cartilage status after a double-bundle ACL reconstruction using preoperative and follow-up MR images. METHODS: Thirty-six knees that underwent a double-bundle ACL reconstruction from 2001 to 2009 with the available preoperative and follow-up magnetic resonance imaging were included. Patients with a meniscal injury were compared with those without a meniscal injury. The cartilage morphology was classified using a 6-grade scale [from 0 = normal thickness and signal, to 6 = diffuse full-thickness loss (>75 % of the region)]. The changes in cartilage status were evaluated at 14 sites. RESULTS: Cartilage changes were observed in all sites and were classified according to the site and degree of change. The majority of changes were grade 0 and 1, which accounted for 68 and 16.8 % of changes, respectively. The patella medial facet and anterolateral and centromedial femoral regions showed significantly more cartilage loss than the posteromedial, centrolateral, anterolateral, and anteromedial tibial regions. No significance was observed between the knees with or without combined injuries (n.s.). On the other hand, knees with or without combined injuries showed a different pattern of cartilage change, as demonstrated by different levels of grade change at sites. CONCLUSIONS: The change in cartilage status was minimal after a double-bundle ACL reconstruction. The patella medial facet, lateral femur anterior region, and medial femur central region showed significantly more cartilage loss than the medial tibia posterior, lateral tibia central, lateral tibia anterior, and medial tibia anterior regions. The presence of a combined injury did not affect the cartilage status changes, even though it was underpowered and too short term to assess the influence of the meniscal injury. LEVEL OF EVIDENCE: Case series, Level IV.

Foot drop secondary to peroneal intraneural cyst arising from tibiofibular joint.

UNLABELLED: An 11-year-old boy presented to our outpatient clinic with a three-month history of pain over the fibular head area and gait difficulty. Surgical exploration revealed a mass arising from the superior tibiofibular joint invading the peroneal nerve along the articular branch of the common peroneal nerve. The pathogenesis of the intraneural ganglion of the peroneal nerve may be an articular origin and superior tibiofibular joint is the central point. LEVEL OF EVIDENCE: V.

Relationship between Tibial Bone Defect and Extent of Medial Release in Total Knee Arthroplasty.

PURPOSE: To understand the relationship between tibial bone defect and extent of medial release in total knee arthroplasty. MATERIALS AND METHODS: We evaluated 32 knees in 22 patients with variable degrees of tibial bone defect on medial plateau has undergone total knee arthroplasty. In this study, 31 cases had been diagnosed as degenerative osteoarthritis and 1 case was osteonecrosis. We excluded cases with infection, traumatic arthritis, or neuropathic joints. With regard to gender, 29 cases were female and 3 cases were male. The following relationships were analyzed: preoperative degrees of tibial bone defect and varus deformity; the femorotibial angle of both weight-bearing whole extremity radiogram, distractive stress radiogram, and the extent of medial release. RESULTS: Average tibial bone defect was 9.8±4.1 mm. Average femorotibial angle on weight-bearing whole extremity radiograph was varus 10.0°±6.2°. Average femorotibial angle on distractive stress radiograph was varus 0.7°±4.6°. Statistically the extent of medial release showed no significant relationship with the degree of tibial bone defect and femoro-tibial angle of whole extremity radiogram. However, it revealed a statistically significant relationship with the femorotibial angle on distractive radiogram (r=0.465, p=0.007). CONCLUSIONS: Preoperative distractive stress radiograph might be a useful method to predict the extent of intraoperative medial release during total knee arthroplasty.

Comparative analysis of femoral tunnels between outside-in and transtibial double-bundle anterior cruciate ligament reconstruction: a 3-dimensional computed tomography study.

PURPOSE: The objectives of this study were (1) to compare locations of the femoral tunnels created by outside-in and transtibial techniques and the reference data and (2) to compare the diameter of the tunnel entrance based on the real reaming size. METHODS: A comparative study was performed with 20 outside-in and 22 transtibial double-bundle anterior cruciate ligament reconstruction patients. Computed tomography scans of the operated knees of the outside-in and transtibial groups were performed at 1.25 days (range, 1 to 3 days) and 2.7 weeks (range, 3 days to 4 weeks), respectively. Three-dimensional surface models were then produced. For all 3 plane data sets, the positions of the femoral tunnels were measured by an anatomic coordinate axis method. For comparison of the tunnel diameter at the entrance of tunnel, the difference between the real reaming and measured diameter was determined first on computed tomography images. Subsequently, the differences in the outside-in and transtibial techniques were compared. RESULTS: In the comparison between outside-in and reference data, the posterior-anterior direction of the posterolateral (PL) tunnel showed an anterior position compared with reference data, even though it was positioned more posteriorly compared with that of the transtibial technique (P = .003). In the comparison between transtibial and reference data, the posterior-anterior direction of the anteromedial (AM) and PL tunnels showed an anterior position compared with reference data (P = .019 and P = .005, respectively). The transtibial technique showed significantly larger diameters in both AM and PL tunnels (P < .001 and P < .001, respectively). CONCLUSIONS: The outside-in technique showed more accurate replication of the femoral tunnels than the transtibial technique, particularly the AM tunnel of the femur. The transtibial technique showed an ellipsoidal tunnel configuration at the entrance of the tunnel, which suggests that eccentric reaming is unavoidable because the reaming angle is determined by the tibial tunnel. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A Comparison of the Clinical and Radiographic Results of Press Fit Condylar Rotating-Platform High-Flexion and Low Contact Stress Mobile Bearing Prosthesis in Total Knee Arthroplasty: Short term Results.

PURPOSE: This study compared the results of rotating-platform high-flexion (RP-F) total knee arthroplasty with low contact stress (LCS) for clinical and radiographical assessment after a short-term period. MATERIALS AND METHODS: 68 total knee arthroplasties using a RP-F and LCS system were analyzed retrospectively. Thirty-five of the 68 were osteoarthritic knees and were followed-up for more than 2 years. The clinical evaluation included range of motion (ROM), Knee Society Knee Score and Function Score (KSKS and KSFS), tailor position and kneeling. The radiographic evaluation included femorotibial angle, position of implants, radiolucent line and position of patella. RESULTS: The postoperative ROM, KSKS, and KSFS improved statistically in both implants. Comparing RP-F with LCS there were statistically no differences in ROM (p=0.863), KSKS (p=0.835), KSFS (p=0.535) and tailor position (p=0.489). There were no significant radiographic differences. CONCLUSIONS: Total knee arthroplasty with RP-F and LCS showed similar clinical and radiographic results; it also showed excellent and predictable results at the short-term follow up. However, in RP-F there was 1 case of early osteolysis, 1 case of patella clunk syndrome and 1 case of painful patella crepitus; therefore, further case studies and follow-up are needed.

Analysis of tunnel widening after double-bundle ACL reconstruction.

PURPOSE: The purpose of this study was to evaluate the tunnel widening using a multi-planar reformation of MRI (Magnetic Resonance Imaging) in the orientation of the tunnel. The hypotheses of this study were as follows: (1) tunnel widening would be reduced with the above-mentioned technique, (2) the degree of tunnel widening would be different at the site of the tunnels, and (3) the time interval from surgery to MRI acquisition would affect the magnitude of tunnel widening. METHODS: Forty double-bundle ACL reconstructed patients who underwent postoperative MRI were enrolled in this study. The postoperative MRI was performed at 26.7 ± 7.4 months in terms of time. The tunnel widening was examined using a multi-planar reformation of MRI in the orientation of the tunnel. Site-specific analysis was performed according to the depth (the entrance, mid, and exit portion) and wall (anterior, posterior, medial, and lateral walls). The correlation between MRI and widening was also evaluated. RESULTS: The mean tunnel widening of the femoral AM (Anteromedial), femoral PL (Posterolateral), tibial AM, and tibial PL in terms of the most widened diameter was 1.9 (25.4), 2.1 (30.8), 2.5 (32.8), and 3.2 mm (44.5%), respectively. The tibial PL tunnel showed significant widening than the other tunnels. At the entrance, tunnel widening occurred mostly, followed by the order of the mid and exit portion. Correlation analysis of the time interval of MRI acquisition and tunnel widening showed little association. CONCLUSIONS: Tunnel widening after a double-bundle ACL reconstruction using an outside-in technique with press-fitting of the graft was acceptable compared to previously published studies. The tibial PL tunnel showed the most widening among the 4 tunnels examined with the tunnel entrance being most widened area. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Surgical treatment of habitual patella dislocation with genu valgum.

Habitual dislocation of patella is a rare disorder. Sometimes it is associated with angular deformity such as genu valgum. We experienced habitual patella dislocation associated with genu valgum that was treated with corrective osteotomy of distal femur and soft tissue realignment procedure including lateral release and medial reefing.

Delayed knee locking after complicated anterior cruciate ligament reconstruction despite good stability using a bio-transfix.

We describe a case of delayed cyst formation that presented as intermittent knee locking after complicated anterior cruciate ligament (ACL) reconstruction using a Bio-TransFix implant in a 21-year-old male patient. During femoral fixation, we could not pull out the guide wire that was temporarily used for the femoral fixation. However, stability was good, and the guide wire was not removed. This was shown to be a wrong type of fixation in a later study. During follow-up, the patient was satisfied and stability was relatively good until 18 months post-operatively. From the 2nd post-operative year, he experienced intermittent knee swelling and locking and pain around the lateral femoral condyle. Follow-up magnetic resonance imaging showed a large cyst around the broken wire tip, but the reconstructed ACL was fine.

Vitamin C deficiency increases the binucleation of hepatocytes in SMP30 knock-out mice.

BACKGROUND AND AIMS: The binucleation of hepatocytes, which was known as an important feature of liver growth and physiology, has been reported to be increased during the chronic oxidative injury stage and has been regarded as an age-related change of hepatic structures. Therefore, we investigated the binuclearity pattern in the livers of senescence marker proteins-30 (SMP30) knock-out (KO) mice compared with wild-type (WT) mice and vitamin C-treated KO (KO + VC) mice. METHODS: The WT, KO and KO + VC mice were fed a vitamin C free diet and VC(+) group mice were given vitamin C water containing 1.5 g/L of vitamin C, whereas VC(-) group was given normal drinking water without vitamin C, for 16 weeks. RESULTS: In microscopic examination, the livers of KO mice showed a significantly increased number of binuclear hepatocytes compared with that of WT mice and KO + VC mice. KO mice also showed the most increased expression level of CYP2E1 and PCNA determined by immunohistochemistry and immunoblot analysis. Moreover, KO mice indicated the highest level of serum alanine aminotransferase and aspartate aminotransferase level in serum biochemical analysis. Accordingly, significantly decreased levels of reactive oxygen species, MDA (malondialdehyde) and HAE (4-hydroxyalkenals) were detected in KO + VC mice compared with KO mice. CONCLUSION: Therefore, it is concluded that vitamin C deficiency induces an increase of CYP2E1 expression and elevated ROS production, which causes oxidative liver injury and the elevation of hepatocyte binucleation in SMP30 KO mice.

Effect of weight-bearing on the alignment after open wedge high tibial osteotomy.

This study examined the changes in knee alignment after an open wedge high tibial osteotomy before and after weight-bearing. From 2004 to 2006, 36 high tibial osteotomies were performed to treat unicompartmental arthritis with a varus deformity. Thirteen patients without instability and with an accurate radiographic evaluation were included. The changes in the deviation of the mechanical axis and femorotibial angle were evaluated retrospectively using whole extremity radiographs immediately after surgery (supine position) and 4 months after surgery (weight-bearing position). In the nonweight-bearing radiograph obtained immediately after surgery, the mean deviation of the mechanical axis was 22% laterally and the mean femorotibial angle was valgus 8.9 degrees . The weight-bearing radiograph at 4 months after surgery showed that the former shifted laterally 34% and the latter shifted valgus 10.6 degrees . The changes in the mechanical axis and femorotibial angle were significant (P < 0.001). During open wedge high tibial osteotomy, the surgeon should consider the increase in deviation of the mechanical axis and femorotibial angle after weight-bearing.

The use of medulloscopy for localized intramedullary lesions: review of 5 cases.

We report 5 cases of a localized lesion (4 with osteomyelitis and 1 with an intraosseous ganglion cyst) that were treated successfully by medulloscopy. Medulloscopy is a standard arthroscopic technique for visualizing the intramedullary canal of the tibia. Two portals were created to allow easy access and triangulation to the lesion, one for the 5-mm arthroscope and the other for the instrument. Debridement, irrigation, and resection of the sequestrum were performed for the cases with osteomyelitis, and the intraosseous ganglion cyst was treated with biopsy, debridement, and autogenous bone grafting. All cases were treated successfully with medulloscopy and did not show recurrence at the last follow-up. In addition, there were no complications related to the procedure.

Utility of preoperative distractive stress radiograph for beginners to extent of medial release in total knee arthroplasty.

BACKGROUND: This study evaluated the preoperative distractive stress radiographs in order to quantify and predict the extent of medial release according to the degree of varus deformity in primary total knee arthroplasty. METHODS: We evaluated 120 varus, osteoarthritic knee joints (75 patients). The association of the angle on the distractive stress radiograph with extent of medial release was analyzed. The extent of medial release was classified into the following 4 groups according to the stage: release of the deep medial collateral ligament (group 1), release of the posterior oblique ligament and/or semimembranous tendon (group 2), release of the posterior capsule (group 3) and release of the superficial medial collateral ligament (group 4). RESULTS: The mean femorotibial angle on the preoperative distractive stress radiograph was valgus 2.4 degrees (group 1), valgus 0.8 degrees (group 2), varus 2.1 degrees (group 3) and varus 2.7 degrees (group 4). The extent of medial release increased with increasing degree of varus deformity seen on the preoperative distractive stress radiograph. CONCLUSIONS: The preoperative distractive stress radiograph was useful for predicting the extent of medial release when performing primary total knee arthroplasty.

Comparative biomechanical study of the Ligament Plate and other fixation devices in ACL reconstruction.

The objective of this study was to evaluate and compare the biomechanical properties of the Ligament Plate with other femoral fixation devices. The Ligament Plate and three different femoral fixation devices were used in fixation of 60 porcine femora and harvested porcine tendons. For each fixation device, a porcine graft-tendon complex was used for the simple load-to-failure test and the load-to-failure test after a cyclic loading test, and the maximal failure load was measured. The amount of graft elongation and failure pattern after the cyclic loading test and load-to-failure test were evaluated. In the BioScrew group, the mean maximal failure load in the load-to-failure test and load-to-failure test after a cyclic loading test was significantly lower and significant graft elongation was noted. There were no significant differences between the other groups. The Ligament Plate provided adequate initial fixation power suitable for early rehabilitation.

Knee arthrodesis in failed total knee arthroplasty with severe osteolysis and ipsilateral long-stem total hip arthroplasty.

We report a case of knee fusion after a failed total knee arthroplasty (TKA) with severe osteolysis including the epicondyle and ipsilateral total hip arthroplasty (THA) with long Wagner revision stem (Sulzer Orthopedics, Baar, Switzerland). The conventional devices for arthrodesis were unavailable in this case because of the long Wagner revision stem and poor bone stock. A connector was made between the long Wagner revision stem and an intramedullary nail (IM nail; Solco, Seoul, Korea). The custom-made connector was coupled with a femoral stem by cylindrical taper fit with additional cement augmentation and an intramedullary nail by screws. Osseous fusion was achieved without pain or instability.

Delayed intra-articular inflammatory reaction due to poly-L-lactide bioabsorbable interference screw used in anterior cruciate ligament reconstruction.

Bioabsorbable interference screws have replaced metal interference screws in anterior cruciate ligament reconstruction surgery because they have several advantages. Poly-L-lactide (PLLA) is one of the commonly used materials for bioabsorbable interference screws. PLLA produces a lower inflammatory reaction than polyglycolide as a result of its slower degradation rate and better biocompatibility. We describe a case of a delayed intra-articular inflammatory reaction caused by a PLLA bioabsorbable interference screw used in anterior cruciate ligament reconstruction.

New posteromedial portal for ankle arthroscopy.

We describe a new posteromedial portal through the bed of the posterior tibial tendon. It can be made easily with a 0.5-inch posteromedial skin incision along the course of the posterior tibial tendon just behind the posterior colliculus of the medial malleolus. After the flexor retinaculum is incised and the posterior tibial tendon is retracted anteriorly, a small bulging area of capsule can be seen as a result of saline inflation. The new posteromedial portal can then be made easily through this inflated capsule. This portal allows good access to the posterior joint surface and has a minimal risk of injury to the medial neurovascular bundle.