A modified anatomical posterior cruciate ligament reconstruction technique using the posterior septum and posterior capsule as landmarks to position the low tibial tunnel.

BACKGROUND: Lowering the exit position of the tibial tunnel can improve the clinical efficacy of posterior cruciate ligament (PCL) reconstruction, however, there is no unified positioning standard. This study aimed to use novel soft tissue landmarks to create a low tunnel. METHODS: A total of 14 human cadaveric knees and 12 patients with PCL injury were included in this study. Firstly, we observed the anatomical position between the PCL, posterior septum, and other tissue, and evaluated the relationship between the center of the low tibial tunnel (SP tunnel) and posterior septum and distal reflection of posterior capsule, and using computed tomography (CT) to evaluate distance between the center of the SP tunnel with bony landmarks. Then, evaluated the blood vessels content in the posterior septum with HE staining. Finally, observed the posterior septum and distal reflection of the posterior capsule under arthroscopy to explore the clinical feasibility of creating a low tibial tunnel, and assessed the risk of surgery by using ultrasound to detect the distance between the popliteal artery and the posterior edge of tibial plateau bone cortex. RESULTS: In all 14 cadaveric specimens, the PCL tibial insertions were located completely within the posterior medial compartment of the knee. The distance between the center of the SP tunnel and the the articular surface of tibial plateau was 9.4 ± 0.4 mm. All SP tunnels retained an intact posterior wall, which was 1.6 ± 0.3 mm from the distal reflection of the posterior capsule. The distances between the center of the SP tunnel and the the articular surface of tibial plateau, the champagne glass drop-off were 9.2 ± 0.4 mm (ICC: 0.932, 95%CI 0.806-0.978) and 1.5 ± 0.2 mm (ICC:0.925, 95%CI 0.788-0.975) in CT image. Compared with the posterior capsule, the posterior septum contained more vascular structures. Last, all 12 patients successfully established low tibial tunnels under arthroscopy, and the distance between the posterior edge of tibial plateau bone cortex and the popliteal artery was 7.8 ± 0.3, 9.4 ± 0.4 and 7.4 ± 0.3 mm at 30°, 60° and 90° flexion angels after filling with water and supporting with shaver in posterior-medial compartment of knee joint. CONCLUSIONS: A modified low tibial tunnel could be established in the PCL anatomical footprint by using the posterior septum and posterior capsule as landmarks.

Intra-articular Injection of Mesenchymal Stem Cells After High Tibial Osteotomy: A Systematic Review and Meta-analysis.

Background: Multiple studies have investigated the use of mesenchymal stem cells (MSCs) for patients undergoing high tibial osteotomy (HTO), and the effectiveness thereof remains controversial. Purpose: To analyze the effectiveness of intra-articular MSC injection in patients who underwent HTO in terms of clinical outcomes, radiological outcomes, and cartilage repair by a meta-analysis of the available literature. Study Design: Systematic review; Level of evidence, 3. Methods: The electronic databases of PubMed, Embase, Web of Science, and the Cochrane Library were searched from their inception to October 30, 2021, for comparative studies between patients who underwent HTO with and without intra-articular injection of MSCs, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study quality was assessed by the Coleman Methodology Score (CMS). Data with comparable results were pooled for meta-analysis. The primary outcomes of interest were the Hospital for Special Surgery (HSS), International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores, as well as the International Cartilage Regeneration & Joint Preservation Society (ICRS) grade of cartilage repair. Radiological outcomes including femorotibial angle, posterior tibial slope, and hip-knee-ankle (HKA) angle were included as secondary outcomes. A fixed-model effect was used for meta-analyses with low heterogeneity between studies (I 2 < 25%), while the random-model effect was used for medium- to high-heterogeneity analyses (I 2 ≥ 25%). Results: A total of 843 studies were screened, of which 6 studies with 452 patients met the inclusion criteria and were included. The mean CMS was 81.17. Patients with MSC injection had significantly higher Lysholm scores (P = .007) and HSS scores (P = .01) and higher proportions of ICRS grade 1 (P = .03) and grade 2 (P = .02) cartilage repair in the medial femoral condyle and grade 2 cartilage repair in the tibial plateau (P = .04). There were no significant differences between groups in the IKDC score, KOOS Pain and Symptoms subscales, femorotibial angle, posterior tibial slope, or HKA angle. Conclusion: Intra-articular MSC injection may enhance the cartilage repair for patients who undergo HTO. However, evidence of improvement in knee functions remains limited. Registration: CRD42021291345 (PROSPERO).

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.

[Nocturnal heart rhythm disorder in patients with obstructive sleep apnea syndrome].

OBJECTIVE: To explore the clinical characteristics of patients with obstructive sleep apnea syndrome (OSAS) and nocturnal arrhythmia. METHODS: During September 2010 to August 2011, a total of 446 subjects were recruited from Department of Sleep Breathing Disorder, Third Hospital, Hebei Medical University to receive polysomnography examination and electrocardiogram monitoring. According to the results, they were classified as mild (5 ≤ AHI < 15/h) or moderate (15 ≤ AHI < 40/h) or severe (AHI ≥ 40/h) OSAS. Then the incidence of different types of arrhythmias, risk factors and the relationship with OSAS severity were examined. RESULTS: Among 446 patients, the incidence of arrhythmia was 24.4% (109/446). The severity of OSAS (r = 1.857, P = 0.043) and age (r = 1.030, P = 0.003) had a positive relationship with the incidence of arrhythmias.Sinus bradycardia (79.8%, 87/109) and accidental ventricular premature beat (54.1%, 59/109) were most likely to occur than other types of arrhythmias (P < 0.01).In moderate and severity OSAS patients, the incidence of sinus bradycardia, frequent atrial premature beat, combined over two kinds of arrhythmias, atrial fibrillation and atrioventricular block were 50.0%, 0, 42.9%, 7.1%,0 and 90.9%, 14.8%, 57.9%, 4.5%, 5.7% respectively. And they were significantly higher than those of mild patients (all = 0) (all P < 0.05). CONCLUSIONS: Age and severity of OSAS have a positive relationship with the incidence of nocturnal arrhythmias.Sinus bradycardia and ventricular premature beat are the most likely to occur in OSAS patients.In moderate and severe group, sinus bradycardia, frequent atrial premature beat, combined over two kinds of arrhythmias, atrial fibrillation and atrioventricular block are more commonly encountered.