Open wedge high tibial osteotomy does not decrease patellar height relative to femur: A three-dimensional computer model analysis.

BACKGROUND: Patellar height, which decreases after open wedge high tibial osteotomy (OWHTO), has conventionally been assessed by tibial references using lateral radiographs of the knee; however, changes in the proximal tibia shape after OWHTO may affect this method. We aimed to evaluate the changes in patellar height position relative to the transepicondylar axis of the femur after OWHTO using in vivo three-dimensional (3D) computer models. METHODS: Fourteen patients who underwent 3D magnetic resonance imaging (MRI) at 30° and 50° knee flexion before OWHTO and after hardware removal were included. 3D computer models of the knee were created from the MRI scans and superimposed over the images taken in each position using voxel-based registration. For patellar height evaluation, a patellar reference point was established at each flexion angle and the femoral condylar planes (FCP) were set, including the transepicondylar axis. The patellar center angle was defined as the angle between an FCP that included the top of the intercondylar notch and an FCP that included the patellar reference point. The patellar center angle was evaluated at 30° and 50° knee flexion before and after OWHTO. RESULTS: The patellar center angle at 30° and 50° knee flexion did not significantly decrease after OWHTO, whereas the Caton-Deschamps index and Blackburne-Peel index based on tibia-referenced measurements significantly decreased postoperatively. CONCLUSION: Patellar height position relative to the femur in the 3D computer model did not decrease after OWHTO, whereas tibia-referenced conventional radiographic measurements significantly decreased. When evaluating patellar height, characteristics of each parameter should be considered.

[Surgical Explantation of a Bioprosthesis Nine Months After Transcatheter Aortic Valve Implantation].

CASE: 82-year-old female. In October 2020, the patient underwent transcatheter aortic valve implantation( TAVI)[Evolut PRO R 23 mm] via left subclavian artery approach for severe aortic valve stenosis. The patient was discharged home without any issues. However, nine months after surgery, the patient was hospitalized at another hospital for a right upper arm fracture and developed a fever. The patient was transferred to our hospital and was diagnosed with Enterococcal bacteremia while receiving antibiotic treatment. Echocardiography revealed leaflet thickening and cord-like structure on the artificial valve, and a diagnosis of prosthetic valve endocarditis (PVE) was made. The patient then underwent surgical removal of the valve. The patient had a good postoperative course and completed 4 weeks of antibiotic treatment before being transferred back to the referring hospital 31 days after surgery. TAVI made unprecendented revolution in the treatment of aortic valve stenosis. TAVI is often used for elderly patients with comorbidities because of high perioperative risk is for surgical aortic valve replacement. Although TAVI is widely promoted for its benefits, it is not without limitations. In cases with more than one year of follow-up, there are many complications and the risk of surgery is high. There have been few reports of cases from Japan requiring surgical removal of TAVI valve. In this case, PVE was diagnosed nine months after TAVI and the patient had a good outcome.

Posterior Ankle Impingement Caused by Hyaline-Like Cartilage Generation in Ballet Dancers-A Report of 2 Cases.

Posterior ankle impingement syndrome is mainly seen in ballet dancers and frequently associated with specific movements in ballet such as pointe and demi pointe in which the whole-body weight is applied to the maximally plantar flexed ankle. We performed arthroscopic debridement for 2 dedicated ballet dancers on the intervening soft tissue causing posterior ankle impingement syndrome (PAIS). In both cases, T2-weighted magnetic resonance imaging (MRI) revealed low-signal intensity of meniscus-like soft tissue without abnormal osseous findings, connecting from the posterior side of the talus to Kager's fat pad. To examine the intervening soft tissue in detail, we performed histological evaluation by hematoxylin and eosin staining, Safranin O fast green staining, and immunohistochemistry for type I collagen and type II collagen. Hematoxylin and eosin staining showed that there was cartilage-like tissue including chondrocyte-like cells in contact with fibrous tissue. The extracellular matrix in the cartilage zone was consistently stained by Safranin O staining and type II collagen without any staining with type I collagen. These findings suggested that the meniscus-like soft tissue appearing as low-signal intensity on MRI at the posterior side of talus included hyaline-like cartilage. To the extent of our knowledge, these were rare cases of hyaline-like cartilage generation causing PAIS in ballet dancers, which might be associated with ballet specific movements resulting in chondrogenesis.

Second-look arthroscopy after anatomic anterior cruciate ligament reconstruction: Bone-patellar tendon-bone versus hamstring tendon graft.

PURPOSE: The purpose of this study was to compare the morphological and clinical outcomes between anatomic rectangular tunnel (ART) ACL reconstruction with a BTB graft and anatomic triple-bundle (ATB) ACL reconstruction with hamstring tendon (HST) grafts. METHODS: The anatomic ACL reconstructions were performed on 467 patients; 233 patients with ART technique and 234 with ATB procedure. ART procedure was predominantly indicated for athletes with higher motivation to return to sports and aggressiveness for muscle training. A total of 113 patients, with a mean age of 20.7 years, had consented to undergo second-look arthroscopy. The average time from ACL reconstruction to the second-look was 10.0 months. This study included 56 ART techniques and 57 ATB procedures. The grafts underwent meticulous probing, and were evaluated based on tension, graft damage, and synovial coverage. Moreover, the femoral tunnel aperture was also observed in detail to assess the space between the femoral tunnel and the graft. As clinical evaluation, knee effusion, range of motion, Lachman test, pivot shift test, KT side-to-side difference, and Lysholm score were assessed. RESULTS: There was no significant difference in graft tension between two procedures, while HST graft in ATB procedure had more cases with graft damage (p = 0.05). Good synovial coverage was found in 98% in ART procedure and 70% in ATB procedure, showing a significant difference (P < 0.001). At femoral tunnel aperture, there were no cases with the space around BTB graft, while 33% showed the space around HST graft, again showing a significant difference (P < 0.001). There were no significant differences in clinical outcomes. CONCLUSION: BTB graft with the ART procedure was superior to HST graft with the ATB procedure in morphology at second-look arthroscopy, while there was no significant difference in clinical outcomes between two procedures.

Anterior laxity of the knee assessed with gravity stress radiograph.

OBJECTIVE: To clarify the advantage of prone position over supine position in radiographically-demonstrating anterior knee laxity measurement for anterior cruciate ligament (ACL) injury, and to optimize the radiographic technique for the ACL-deficient knees in a clinical setting. MATERIALS AND METHODS: Thirty-nine patients with unilateral ACL injury had consented to participate in this study. They were divided into two groups and subjected to the different radiographic evaluations: study 1 (20 patients); supine versus prone position with knee full-extended, and study 2 (19 patients); comparison of (1) prone position with knee full-extended (FPV), (2) prone position with knee flexed at 15° (AGV), and (3) supine position with calf put on a board at 15° of knee flexion (SGV). Lateral radiographs for both knees were taken and were measured the side-to-side difference of tibial position related to femur. RESULTS: In study 1, the side-to-side difference was 2.8 ± 1.0 mm in supine position and 4.3 ± 2.1 mm in prone position, showing a statistically significant difference. In study 2, the side-to-side difference was 3.7 ± 2.4 mm in FPV, 4.6 ± 2.0 mm in AGV, and 4.2 ± 2.8 mm in SGV, while the difference in the latter two positions was larger than that in FPV. CONCLUSIONS: The anterior laxity in prone position is larger than that in supine position for ACL injury. Moreover, the gravity-assisted lateral radiograph in prone position with knee flexed at 15° could be one of the preferable radiographic techniques and could provide more information than the simple radiograph.

Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques.

PURPOSE: The purpose of this study was to compare the femoral tunnel length, the femoral graft bending angle at the femoral tunnel aperture, and the contact area between the femoral tunnel wall and an interference screw used for fixation in anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction (ART ACLR). METHODS: The study included 149 patients with primary ACL injury who underwent ART ACLR. Preoperatively, flexion angle of the index knee was checked under general anaesthesia. Those of less than 130° of passive flexion were assigned to the outside-in (OI) technique (78 patients), while the others to the trans-portal inside-out (TP) technique (71 patients). The patients underwent computed tomography with multiplanar reconstruction at 3-5 weeks post-operatively. Femoral tunnel length, graft bending angle, and contact ratio between the IFS and femoral tunnel were assessed. P < 0.05 was considered statistically significant. RESULTS: The femoral tunnel length in the OI technique was significantly longer than that in the TP technique (P < 0.001). The femoral graft bending angle in the OI technique was significantly more acute than that in the TP technique (P < 0.001). The contact ratio in the OI technique was significantly larger than that in the TP technique at every point in the femoral tunnel (P < 0.001). CONCLUSIONS: The OI technique resulted in a more acute femoral graft bending angle, longer mean femoral tunnel length, and larger contact ratio than the TP technique after ART ACLR. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear: a report of two cases and a review of the literature.

Drop foot is typically caused by neurologic disease such as lumbar disc herniation, but we report two rare cases of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tears. Both patients developed mild pain in the lower legs while playing sport, and were aware of drop foot. As compartment pressures were elevated, fasciotomy was performed immediately, and the tendon of the peroneus longus was completely detached from its proximal origin. The patients were able to return their original sports after 3 months, and clinical examination revealed no hypesthesia or muscle weakness in the deep peroneal nerve area at the time of last follow-up. The common peroneal nerve pierced the deep fascia and lay over the fibular neck, which formed the floor of a short tunnel (the so-called fibular tunnel), then passed the lateral compartment just behind the peroneus longus. The characteristic anatomical situation between the fibular tunnel and peroneus longus might have caused deep peroneal nerve palsy in these two cases after hematoma adjacent to the fibular tunnel increased lateral compartment pressure.

SIK3 is essential for chondrocyte hypertrophy during skeletal development in mice.

Chondrocyte hypertrophy is crucial for endochondral ossification, but the mechanism underlying this process is not fully understood. We report that salt-inducible kinase 3 (SIK3) deficiency causes severe inhibition of chondrocyte hypertrophy in mice. SIK3-deficient mice showed dwarfism as they aged, whereas body size was unaffected during embryogenesis. Anatomical and histological analyses revealed marked expansion of the growth plate and articular cartilage regions in the limbs, accumulation of chondrocytes in the sternum, ribs and spine, and impaired skull bone formation in SIK3-deficient mice. The primary phenotype in the skeletal tissue of SIK3-deficient mice was in the humerus at E14.5, where chondrocyte hypertrophy was markedly delayed. Chondrocyte hypertrophy was severely blocked until E18.5, and the proliferative chondrocytes occupied the inside of the humerus. Consistent with impaired chondrocyte hypertrophy in SIK3-deficient mice, native SIK3 expression was detected in the cytoplasm of prehypertrophic and hypertrophic chondrocytes in developing bones in embryos and in the growth plates in postnatal mice. HDAC4, a crucial repressor of chondrocyte hypertrophy, remained in the nuclei in SIK3-deficient chondrocytes, but was localized in the cytoplasm in wild-type hypertrophic chondrocytes. Molecular and cellular analyses demonstrated that SIK3 was required for anchoring HDAC4 in the cytoplasm, thereby releasing MEF2C, a crucial facilitator of chondrocyte hypertrophy, from suppression by HDAC4 in nuclei. Chondrocyte-specific overexpression of SIK3 induced closure of growth plates in adulthood, and the SIK3-deficient cartilage phenotype was rescued by transgenic SIK3 expression in the humerus. These results demonstrate an essential role for SIK3 in facilitating chondrocyte hypertrophy during skeletogenesis and growth plate maintenance.

Association of Stability and Size of Unhealed Area With Failure After Internal Fixation for Osteochondritis Dissecans Lesions of the Knee: Radiological Evaluation Using Computed Tomography.

BACKGROUND: Open reduction and internal fixation (ORIF) has been widely performed because the osteochondral component of the osteochondritis dissecans (OCD) lesion is the most suitable for reconstructing the joint structure. PURPOSE: To evaluate radiological healing in terms of reconstructed bony structure after ORIF with bone graft by computed tomography (CT), to identify preoperative prognostic factors for failure, and to determine the cutoff value of radiological healing for risk of failure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective cohort study of 42 patients (44 knees) who underwent internal fixation with bone graft for OCD lesions of the knee from 2004 to 2018 was conducted. All patients were evaluated 6 months postoperatively, and if not healed 6 months after surgery, they were evaluated by CT periodically thereafter. Radiological healing was judged according to the following 3 criteria: (1) reossification of the OCD lesion, (2) bony continuity between the OCD lesion and basal floor, and (3) reconstructed bony surface of the femoral condyle reconstructed to match the normal joint. Then, the percentage of the radiological healing area was calculated as the ratio of the healing length to the total lesion length. The nonhealing area was calculated by multiplying the sum of the total nonhealing length. Clinical failure was defined as any definitive reoperation for the same OCD lesion, such as fragment excision, or a cartilage restoration procedure. After 6 months, all eligible patients underwent arthroscopy to check for protrusion of the absorbable pin into the joint; the removal of an absorbable pin protruding into the joint was not considered a failure. RESULTS: Clinical failure was recorded for 4 cases (9.1%). The mean overall percentage of the radiological healing area of OCD 6 months after ORIF with bone graft was 79.5% ± 24.4%, and the mean overall nonhealing area at 6 months was 87.8 ± 107.9 mm2. The percentages of radiological healing area of stable (International Cartilage Regeneration & Joint Preservation Society OCD II) lesions and femoral condylar (lateral femoral condyle + medial femoral condyle) lesions were significantly lower than unstable lesions and femoral groove lesions, respectively (P = .01 and P = .03, respectively). On receiver operating characteristic curve analysis, the cutoff points for predicting a significantly increased risk of failure were 33.9% (sensitivity, 100%; specificity, 100%; area under the curve, 1) for the percentage of radiological healing area and 222.9 mm2 (sensitivity, 95%; specificity, 100%; area under the curve, 0.956) for the nonhealing area 6 months postoperatively. CONCLUSION: A stable lesion and a femoral condylar lesion were the predictors of poor radiological healing on CT images 6 months after ORIF with bone graft. The risk of failure was increased significantly in cases with only approximately one-third of the lesion healed or in cases with large nonhealing areas at 6 months postoperatively.

Single-Leg Loading Test to Predict Time to Jog and Return to Sports after Acute Lateral Ankle Sprain in Competitive Athletes.

In a previous study, the utility of a single-leg loading (SLL) test after acute lateral ankle sprain (LAS) was reported. However, whether the severity level assessed by the SLL test is associated with the time to jog and return to sports (RTS) remains unclear. Therefore, this study aimed to examine whether the time to jog and RTS differ depending on the severity level. A total of 240 athletes after sustaining acute LAS were included in this study. The SLL test was performed at the first visit, and the patients were classified into four levels (Levels 1-4). The Steel-Dwass multiple comparison method and multiple regression analysis was performed to verify whether the SLL test can predict the time to jog and RTS. On examining the relationship between the severity levels assessed by the SLL test and time to jog and RTS, significant differences were found among almost all the severity levels. Moreover, the multiple regression analysis revealed that only the SLL test showed a significant correlation with both the time to jog and RTS. This study suggested that the time to jog and RTS can be predicted by conducting the SLL test for acute LAS and dividing the severity into four levels.

Glenoid rim morphology in young athletes with unstable painful shoulders: primarily painful vs. frankly unstable.

Background: To investigate the characteristics of glenoid rim morphology in young athletes (<40 yr) with unstable painful shoulder. Methods: This was a retrospective case series. The inclusion criteria were as follows: (1) shoulder pain during sports activity, (2) traumatic onset, (3) no complaint of shoulder instability, and (4) soft tissue or bony lesions confirmed on imaging examinations (computed tomography and magnetic resonance imaging). The above-mentioned painful cohort was then compared (in a 2:1 ratio) to a match-paired control group of patients with similar demographics but with frank anterior glenohumeral instability as defined by imaging and physical findings. The pain (not apprehension) was reproduced during the anterior apprehension test in supine position and relieved by relocation test in all patients. Glenoid rim morphology, bone union in shoulders with a fragment-type glenoid, glenoid defect size, bone fragment size, medial displacement of bone fragments (MDBF), and medial distance of erosion (MDE) were compared between painful shoulders and unstable shoulders. Results: There were 79 painful shoulders and 165 unstable shoulders. The glenoid rim morphology was normal in 33 shoulders, erosion-type in 15 shoulders, and fragment-type in 31 shoulders among painful shoulders, whereas the respective shoulders were 19, 33, and 113 among unstable shoulders (P < .001). Bone union was complete in 15 shoulders, partial in 14 shoulders, and nonunion in 2 shoulders among painful shoulders, whereas the respective shoulders were 43, 31, and 39 among unstable shoulders (P = .001). The mean glenoid defect size was 6.0 ± 7.2% and 12.7 ± 7.4%, respectively (P < .001), and the mean bone fragment size was 5.8 ± 6.4% and 5.4 ± 4.6%, respectively, (P = .591). The mean MDBF was 1.4 ± 1.5 mm and 3.0 ± 2.2 mm, respectively (P < .001), and the mean MDE was 2.3 ± 1.2 mm and 5.2 ± 2.4 mm, respectively (P < .001). In shoulders with a smaller glenoid defect (<13.5%), the prevalence of shoulders with MDBF (<2 mm) and shoulders with MDE (<2 mm) was more frequent in painful shoulders. On the other hand, in shoulders with a larger glenoid defect (≥13.5%), erosion-type glenoid, nonunion in fragment-type glenoid and bone fragment smaller than 7.5% was not recognized in painful shoulders. Shoulders with MDBF (<2 mm) were significantly more frequent in painful shoulders (P = .009). Conclusions: In painful shoulders normal or erosion-type glenoid was predominant, and glenoid defect size was significantly smaller than unstable shoulders. On the other hand, a large bone fragment (≥7.5%) remained and united completely or partially in all shoulders with a larger glenoid defect (≥13.5%). Bone union was obtained within 2 mm from the articular surface in most of them.

Factors Associated with Postoperative Knee Joint Line Obliquity After Medial Open Wedge High Tibial Osteotomy.

BACKGROUND: There are still few reports on factors associated with postoperative knee joint line obliquity (KJLO). PURPOSE: The purpose was to determine preoperative radiographic factors that are associated with KJLO postoperatively after open wedge high tibial osteotomy (OWHTO) using multivariable linear regression analysis and multivariable logistic regression analysis. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 60 patients with 65 varus knees who underwent OWHTO between December 2012 and June 2018 at a single institution were retrospectively enrolled in this study. The authors evaluated radiologic parameters including the weightbearing line ratio, femorotibial angle, medial proximal tibial angle, mechanical lateral distal femoral angle (LDFA), lateral distal tibial angle, joint line convergence angle (JLCA), KJLO, and ankle joint obliquity. They also categorized these radiographic parameters as preoperative and postoperative and calculated the difference (Δ) between preoperative and postoperative values. To determine which of the radiographic parameters were most associated with postoperative KJLO, multivariable linear regression analysis was performed using the stepwise method. Multivariable logistic regression analysis was used to examine the relative contribution of the preoperative radiographic parameters to an abnormal postoperative KJLO (>4°). RESULTS: In the multivariable linear regression analysis, the preoperative LDFA and JLCA showed a statistically significant correlation. Multivariable logistic regression analysis revealed that the mean preoperative LDFA was significantly larger in the group with abnormal KJLO than in the group with the control group (odds ratio, 1.84; 95% CI, 1.12-3.02; P = .02), while preoperative JLCA tended to be larger in the abnormal KJLO group than the control group but not statistically significantly different. CONCLUSION: KJLO after OWHTO was associated with preoperative LDFA and JLCA in multivariable linear regression analysis, and preoperative LDFA was the most important factor associated with abnormal KJLO after OWHTO in multivariable logistic regression analysis.

Induction of chondrogenic cells from dermal fibroblast culture by defined factors does not involve a pluripotent state.

There is a significant need for cell sources for cartilage regenerative medicine. It has been reported that the combined transduction of two reprogramming factors (c-Myc and Klf4) and one chondrogenic factor (SOX9) directly induces chondrogenic cells from mouse dermal fibroblast (MDF) culture. To gain insights into the process by which cellular characteristics are altered by transduction of c-Myc, Klf4 and SOX9, we examined marker gene expression in the MDF culture at various time points after transduction. The expression of fibroblast-markers was reduced first, followed by an increase in the expression of a chondrocyte-marker. We detected no expression of pluripotent markers at any time point examined. To determine whether or not induced chondrogenic cells go through a pluripotent state after transduction, we analyzed MDFs prepared from Nanog-GFP transgenic mice by monitoring expression of the GFP-labeled pluripotent marker Nanog-GFP in the MDF culture, using time-lapse microscopic observation. Whole-well time-lapse observation revealed that none of the induced chondrogenic cells displayed GFP fluorescence during induction. These results indicate that cells do not undergo a pluripotent state during direct induction of chondrogenic cells from fibroblast culture by transduction of c-Myc, Klf4 and SOX9.

Expression of dominant negative TGF-ß receptors inhibits cartilage formation in conditional transgenic mice.

Although transforming growth factor-ß (TGF-ß) signaling has been implicated in cartilage formation in various studies, the exact role played by TGF-ß in this process remains controversial. TGF-ß signals are transduced through TGF-ß type II receptor (TGF-ßRΙΙ) and type I receptor (ALK5). Col2a1-Cre-mediated deletion of Tgfbr2 did not cause obvious defects in long bone formation, suggesting that TGF-ß signals are dispensable for normal cartilage formation in the stage of condensing mesenchymal cells and chondrocytes or that related molecules can compensate for the lack of TGF-ßRΙΙ. In the present study, we established a conditional transgenic mouse in which a dominant negative form of TGF-ßRII (dnTGF-ßRII) is expressed in condensing mesenchymal cells and chondrocytes in limbs using the Cre/loxP system. Recombination at loxP sites and expression of dnTgfbr2 were monitored by the disappearance of LacZ expression. The conditional transgenic mice expressing dnTgfbr2 developed hypoplastic cartilage. The phenotype was much more severe than that of Col2a1-Cre-mediated Tgfbr2 conditional knockout mice, although the pattern of dnTgfbr2 expression appears similar to the pattern of Tgfbr2 deletion. These phenotypic differences suggest that the signaling through TGF-ß receptors is complex in cartilage.

Abrasion arthroplasty promotes improvement of degenerated femoral trochlear cartilage after medial open wedge high tibial osteotomy.

OBJECTIVES: Several studies have reported negative effects of open wedge high tibial osteotomy (OWHTO) on patellofemoral joints with cartilage degeneration and recommended performing other procedures. However, if chondral resurfacing surgery could promote improvement of cartilage degeneration in the patellofemoral joint, OWHTO would be an acceptable option. The purposes of this study were to arthroscopically evaluate the femoral trochlear articular cartilage after abrasion arthroplasty combined with OWHTO and to investigate the factors promoting improvement of that cartilage. METHODS: The present study cohort comprised 18 knees of 18 patients with varus osteoarthritis of the knee who had (1) International Cartilage Repair Society (ICRS) grade 4 femoral trochlear chondral lesions at the time of OWHTO; (2) undergone abrasion arthroplasty of the femoral trochlear cartilage in combination with OWHTO; (3) undergone second-look arthroscopy; and (4) been followed up for more than 2 years. Cartilage status was arthroscopically graded at the time of OWHTO and second-look arthroscopy. Patients were allocated to two groups according to the status of the femoral trochlear cartilage at the time of second-look arthroscopy: the improved group comprised patients with an ICRS grade of less than 3, and the not improved group comprised those with an ICRS grade of 4. Clinical outcomes, expressed as Knee Injury and Osteoarthritis Outcome Score (symptoms, pain, activities of daily living, function in sports/recreation and quality of life) and selected radiographic variables were compared between the two groups. RESULTS: There were 11 (61%) knees in the improved group and 7 (39%) in the not improved group. A comparison of radiographic variables between the two groups revealed that neither limb alignment nor patellar height affected cartilage changes. The two groups had similar results on the symptoms, pain, sports/recreation and activities of daily living subscales of the Knee Injury and Osteoarthritis Outcome Score. However, the quality of life subscale significantly differed between the two groups (p=0.025). CONCLUSION: Degenerated femoral trochlear cartilage can improve after combined abrasion arthroplasty and OWHTO. A comparison of clinical outcomes between the improved and not improved groups revealed that neither radiographic variables nor clinical symptoms, including pain, affected cartilage changes at short-term follow-up. LEVEL OF EVIDENCE: Case series, level V.

Quick and simple test to evaluate severity of acute lateral ankle sprain.

BACKGROUND/OBJECTIVE: For early return to sports after a lateral ankle sprain (LAS) and recurrence prevention, effective rehabilitation and gradual return to sports should be initiated while predicting the return time based on the appropriate severity evaluation immediately after injury. However, since severity evaluations performed in previous studies required large space and stairs and involved high-revel activity, their use as a test and index to evaluate severity after LAS was not appropriate considering convenience and risk of re-injury. Therefore, a quick and simple test was developed to evaluate the severity of acute LAS. This study aimed to verify the association between ankle function for severity evaluation and anterior talofibular ligament (ATFL) injury type by ultrasonography and to clarify the usefulness for acute LAS severity evaluation of the single-leg loading (SLL) test. METHODS: In total, 50 patients (34 men, 16 women) out of 58 patients who visited our sports clinic within 3 days after acute LAS and who conformed to the study criteria were included in this study. During the first visit, SLL test and objective/subjective ankle joint evaluation were performed. The SLL test consists of single-leg standing, single-leg heel raising and single-leg hopping, and patients were classified into four levels from 1 to 4 according to results. In addition, ultrasonographic evaluation was performed within 1 week after the first visit to evaluate the type of ATFL injury. Type I was defined as intact ATFL, Type II as swollen ATFL with an almost intact fibrillar pattern and Type III as ATFL appearing swollen with a disrupted fibrillar pattern. The relationship between the SLL test and each evaluation item was investigated using Spearman's correlation coefficient. RESULTS: As a result of the SLL test, 15 patients had Level 1 (30%), 19 Level 2 (38%), 5 Level 3 (10%) and 11 Level 4 (22%). With regard to correlation coefficients of the SLL test, Japanese Society for Surgery of the Foot ankle/hindfoot scale and sports activity were rs = 0.71 (p < 0.001) and rs = 0.66 (p < 0.001), respectively, showing a significant positive correlation. SLL test and the type of ATFL injury also showed a significant negative correlation (rs = -0.58, p < 0.001). CONCLUSIONS: The SLL test was a simple and useful test that can be used as an index to evaluate the severity of acute LAS.

Anterior tibial loading on the calf enhances anterior tibial translation in the anterior cruciate ligament deficient knee in the anterior gravity radiographic view.

BACKGROUND: Lateral radiograph in the prone position with the knee flexed at 15° (anterior gravity view (AGV)) is useful as a screening for anterior cruciate ligament (ACL) injuries, while it is sometimes difficult to find the side-to-side difference (SSD) in anterior tibial translation. Thus, we applied a weight (three kilograms) around the lower leg to increase anterior tibial translation. We aimed to determine whether weight load confers an advantage in visualizing anterior knee laxity in ACL injuries. METHODS: Fifty-eight patients with confirmed unilateral ACL tears from February 2012 to April 2014 had consented to participate in this study. Lateral radiographs for both knees were taken in AGV and in AGV with a three-kilogram weight load applied to the proximal lower leg. Then, the SSD of tibial position related to the femur was measured in these radiographs. RESULTS: The SSD with the weight was significantly greater than that without the weight (5.9 ± 2.1 and 3.5 ± 1.6 mm, respectively, p < 0.01). The ratio of patients with SSD of three millimeters or more in AGV with the weight was also significantly larger than that without the weight (p < 0.01). CONCLUSIONS: The anterior laxity in AGV with the three-kilogram weight is larger than that without the weight. Thus, the AGV with the weight could be one of the helpful radiographic technique for auxiliary diagnosis of ACL injury. Level of evidence Cohort study, Level IV.

Ultrasonographic Evaluation of the Early Healing Process After Achilles Tendon Repair.

BACKGROUND: Little is known about early healing of repaired Achilles tendons on imaging, particularly up to 6 months postoperatively, when patients generally return to participation in sports. PURPOSE: To examine changes in repaired Achilles tendon healing with ultrasonography for up to 12 months after surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Ultrasonographic images of 26 ruptured Achilles tendons were analyzed at 1, 2, 3, 4, 6, and 12 months after primary repair. The cross-sectional areas (CSAs) and intratendinous morphology of the repaired tendons were evaluated using the authors' own grading system (tendon repair scores), which assessed the anechoic tendon defect area, intratendinous hyperechoic area, continuity of intratendinous fibrillar appearance, and paratendinous edema. RESULTS: The mean ratios (%) of the CSA for the affected versus unaffected side of repaired Achilles tendons gradually increased postoperatively, reached a maximum (632%) at 6 months, and then decreased at 12 months. The mean tendon repair scores increased over time and reached a plateau at 6 months. CONCLUSION: Ultrasonography is useful to observe the intratendinous morphology of repaired Achilles tendons and to provide useful information for patients who wish to return to sports. Clinical parameters such as strength, functional performance, and quality of healed repaired tendons should also be assessed before allowing patients to return to sports.

Effects of suture site or penetration depth on anchor location in all-inside meniscal repair.

BACKGROUND: To evaluate the effects of suture site or penetration depth on anchor location in all-inside meniscal repair. METHODS: Eight fresh-frozen cadaveric knees were evaluated after meniscal repair using eight FasT-Fix360 (FF360) devices (Smith & Nephew Endoscopy, Andover, MA) (16 anchors) for each knee. The penetration depth was 14mm, the distance same from the periphery to insertion point, in four knees (Group A) and that in the remaining four knees (Group B) was 18mm. The anchor location in two groups was evaluated after attentive dissection. RESULTS: Of 32 anchors for the medial meniscus, 94% were on the capsule, including the superficial medial collateral ligament (sMCL) in both groups. For the lateral meniscus, 47% anchors in Group A and 44% anchors in Group B were on the capsule. Total three anchors were over the lateral collateral ligament (LCL), whereas 15 anchors were behind the popliteus tendon (POP). Although all three anchors settled in the subcutaneous fat were in Group B, no significant difference was observed in anchor location between two groups. CONCLUSIONS: Secure fixation to thin membranous tissue can be achieved for the medial meniscal repair using FF360, while some were located in/on bunchy LCL or POP in lateral meniscal repair. Only anchors with additional four-millimeter penetration depth were in the subcutaneous fat, although there was no effect of the penetration depth to anchor location. Clinically, for lateral meniscal repair, penetrating toward POP/LCL should be avoided and four-millimeter deeper penetration depth might be a risk for the subcutaneous irritation.