Hiroshi Takuwa

A comparison of patient-reported outcomes and arthroscopic findings between drilling and autologous osteochondral grafting for the treatment of articular cartilage defects combined with anterior cruciate ligament injury.

BACKGROUND To compare the patient-reported outcomes and arthroscopic findings between drilling and autologous osteochondral grafting (AOG) for the treatment of articular cartilage defects combined with anterior cruciate ligament (ACL) injuries. METHODS The subjects were 40 patients who had articular cartilage defects in the weight-bearing part of the medial and lateral femur condyle combined with ACL injuries that were treated by drilling (20 patients) or AOG (20 patients) at the same time as ACL reconstruction was performed. In the drilling group patients, lesions were penetrated with multiple 1.2-mm Kirschner wires, and in the AOG group patients, grafts were made to cartilage defects from one to three osteochondral pegs harvested from the less-weight-bearing periphery of the articular surface of the femoral condyle. The patient-reported outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective knee examination score. Second-look arthroscopy was performed to evaluate the repaired cartilage macroscopically. RESULTS The median follow-up duration was 25 (range, 12-42) months. The IKDC scores were significantly improved from 64.4 to 95.4 points in the drilling group and from 52.3 to 94.3 points in the AOG group, with no difference between the two groups, although there was a difference in the repaired cartilage findings of arthroscopy. CONCLUSION In this study, no differences in IKDC scores were found in patients with a concomitant ACL rupture and an osteochondral lesion treated by drilling or AOG at a minimum follow-up of 1year, regardless of the differences at arthroscopic grading of the ICRS classification. LEVEL OF EVIDENCE Case-control study (LEVEL III).

Longitudinal Change of Medial and Lateral Patellar Stiffness After Reconstruction of the Medial Patellofemoral Ligament for Patients with Recurrent Patellar Dislocation.

BACKGROUND Longitudinal changes in patellar stiffness following reconstruction of the medial patellofemoral ligament for recurrent patellar dislocation at full extension are unknown. METHODS Fifteen consecutive patients (three men and twelve women, with a mean age of twenty-two years) with seventeen knees were matched by sex and age to thirty-two reference subjects in this prospective study. The follow-up period was a minimum of twenty-four months. The medial patellofemoral ligament reconstruction used an autograft semitendinosus tendon and an interference screw system with or without lateral release under 10 N of laterally directed force. The medial patellar stiffness and lateral patellar stiffness were measured in 0° of knee extension using the Patella Stability Tester preoperatively; postoperatively at three, six, twelve, and eighteen months; and at the time of the latest follow-up. Before and after the surgical procedure, patients were evaluated for apprehension and Kujala and Lysholm scores; radiographic examinations were performed to evaluate changes, including osteoarthritic changes. RESULTS The medial stiffness of the affected side before the surgical procedure was significantly lower than the lateral stiffness (p = 0.004) and the stiffness for healthy reference knees (p = 0.004). Medial stiffness three months after the surgical procedure was significantly elevated compared with lateral values (p = 0.027), preoperative values (p < 0.001), and reference group values (p = 0.002); reached the reference level by six months; and was maintained for up to two years. Furthermore, medial stiffness and lateral stiffness were well balanced after six months and this balance was sustained for up to two years postoperatively. No recurrent dislocation occurred during the follow-up period; one patient experienced apprehension. Postoperative radiographic findings and clinical scores were significantly improved at the time of the latest follow-up (p < 0.05). One knee progressed to patellofemoral osteoarthritis. CONCLUSIONS The value for medial stiffness was significantly improved three months after medial patellofemoral ligament reconstruction compared with the preoperative and lateral values and returned to the reference level by six months. Medial stiffness and lateral stiffness of the patella were well balanced by six months and retained that balance for up to two years, with good clinical results. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fixation of osteochondral fractures of the patella using autologous bone screws when reconstructing the medial patellofemoral ligament after recurrent patellar dislocation: report of two cases

Osteochondral fractures of the patella are commonly seen after its acute or recurrent dislocation. Without fixation of the osteochondral fragment, osteoarthritis can occur [1, 2]. Conventional methods for fixation of osteochondral fractures of the patella include metal screws [3, 4], bioabsorbable pins and screws [5], and bone pegs [6–8]. Bone screws for some clinical applications have been reported for osteosynthesis after mandibular correction osteotomy [9]. Mori et al. developed bone screws made of cortical bone for osteochondral fragment fixation which have osteointegrative properties and high mechanical strength comparable with that of conventional screws [10]; they ensure successful fixation because of precise and stable repair and biological healing [10, 11]. Kono et al. [12] reported better tissue repair of cartilage defects on fragments at the entrance to screw holes when osteochondral fractures were treated with bone screws rather than poly-Llactic acid (PLLA) screws. There have been no reports of precise clinical observations after use of bone screws to treat osteochondral fractures of the patella. The purpose of this study was to evaluate the use of this bone-screw technique to repair osteochondral fractures after recurrent patellar dislocation. Two cases of fixation of osteochondral fractures of the patella using autologous bone screws with medial patellofemoral ligament (MPFL) reconstruction are reported. Report of two cases

Atraumatic Spontaneous Achilles Tendon Rupture in Patients Receiving Oral Corticosteroids Treated With the Modified Side-Locking Loop Suture Technique

Atraumatic spontaneous Achilles tendon ruptures sometimes occur in patients receiving oral corticosteroids. In general, these cases are treated surgically; however, delayed postoperative management can lead to impaired activities of daily living. The modified side-locking loop suture (SLLS) technique is a useful suture method for safe and early active mobilization. Three cases of spontaneous Achilles tendon ruptures were treated with the modified SLLS technique with good clinical results. The modified SLLS technique is a useful method with a short rehabilitation period for treating atraumatic spontaneous Achilles tendon rupture in patients undergoing corticosteroid therapy.

Ultrasonographic evaluation of early knee osteoarthritis

Ultrasonography (US) is non-invasive, fast, easy-to-use and safe. The quality and resolution of US has been improved in recent years. Recently, in orthopaedics, US measurements have been used for the diagnosis of osteoarthritis (OA), which can provide the basis for proper early treatment. In this chapter, we review the published articles about US evaluation of knee OA, especially focused on cartilage, including probe selection, probe direction, evaluation site, knee position, measurement of thickness, echogenesis and superficial sharpness of cartilage with histological findings and accuracy to detect early OA changes.

Genome-wide association study of knee osteoarthritis: present and future

Knee osteoarthritis (KOA) is a complex disease. Although the genome-wide association study (GWAS) has elucidated many KOA susceptibility genes, they explain only a small part of heritability of KOA and their replicability is low. The sample size and phenotype definition are important factors to improve statistical power of the GWAS. The low replicability of the KOA GWASs would be mainly caused by their small sample size and the indistinct definition of KOA. We seek to establish the more distinct KOA definition to improve OA GWAS. We reveal the effectiveness of the ultrasonography (US) to evaluate the early change of OA cartilage and conduct the epidemiological study of KOA defined by US in a cohort (Shimane COHRE study). Now we are performing the GWAS for early KOA based on the cohort study.

Symptoms and physical findings of early knee osteoarthritis

Background: There is an increasing need on identifying symptoms and physical findings of the early knee osteoarthritis (KOA). The purpose of this study was to clarify clinical manifestation of early KOA detected by ultrasonography (US) and standard radiographs, and to characterize them for early detection of KOA. Methods: A total of 1,090 participants (2,180 knees) recruited at residential health examinations were evaluated by visual analogue scale of pain, the Japanese Knee Osteoarthritis Measure (JKOM) score as a health-related score, knee extension muscle strength, and images (US and radiographs). Among them, 663 knees with Kellgren-Lawrence Grade (KLG) 0 and 1 were divided into four groups; Group A (with no pain and echo-negative OA findings, n=192), Group B (with no pain and echo-positive OA findings, n=284), Group C (with pain and echo-negative OA findings, n=84), and Group D (with pain and echo-positive OA findings, n=103). Results: Group C and D indicated a significant higher JKOM score than Group A and B, especially in terms of disturbance of activities of daily living (ADLs) such as ascending upstairs or descending downstairs, standing up, and squatting. Group B showed significant higher subscales in disturbance of these ADLs than Group A, although Group B has no pain. Maximum knee extension muscle strength in Group C and D were weaker than Group A and B. Group D indicated the weakest knee extension muscle strength among the groups. In women, weak knee extension muscle strength was significantly correlated with pain and echo-positive OA findings. The risk factors of early KOA were woman, high BMI, and weak extension muscle strength. Conclusions: This study showed that symptoms of early KOA might be not only pain but also the disturbance of ADLs such as ascending upstairs or descending downstairs, standing up, and squatting with weak knee extension muscle strength. Pain-free knees with positive US findings, when disturbing these ADLs, might be the pre-stage of early KOA, namely super-early KOA. For not only treatment of the established KOA, but also prevention of proceeding to early KOA, strengthening of the knee extension muscle to maintain these ADLs might be recommended.

Fibromas arising from the posterior cruciate ligament tendon sheath in the bilateral knee joints: Case report

Fibroma of tendon sheath in the intra-knee joint is a very rare and benign soft-tissue tumour which has been reported unilaterally in the various aged people. To help distinguish it from other similar kinds of lesions and symptoms including osteoarthritis, we report the oldest case of fibromas arising from the posterior cruciate ligament tendon sheath in the bilateral knee joints within one year of each other confirmed with magnetic resonance imaging (MRI) features, operative findings and histological examination.

Simultaneous anterior cruciate ligament reconstruction and dome-shaped high tibial osteotomy for severe medial compartment osteoarthritis of the knee

Background The optimal surgical procedure to address both anterior cruciate ligament (ACL) deficiency and medial compartment osteoarthritis (OA) has been controversial. Case report A 49-year-old woman with a 30-year history of chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis, and varus deformity presented with medial knee pain and apprehension with walking and playing soccer. Her preoperative range of motion was from 0° of extension to 135° of flexion. The anterior drawer sign (1+), Lachman test (1+), and pivot shift test (glide) were positive before surgery, as measured by the International Knee Documentation Committee knee examination form. The patient underwent simultaneous arthroscopic ACL single-socket and single-bundle reconstruction using hamstring tendons, dome-shaped high tibial osteotomy using the TomoFix fixation device, and mosaicplasty to the medial condyle. The standing femorotibial angle changed from 185° preoperatively to 172° postoperatively. Range of motion exercises were started 1 week after surgery, and partial weight bearing was allowed 2 weeks after surgery. The patient returned to her baseline physical level 2 years after the operation. Range of motion was –10° of extension and 130° of flexion, and the anterior drawer sign, Lachman test, and pivot shift test were all negative at the final 3-year follow-up. Conclusion An ACL reconstruction combined with a dome-shaped high tibial osteotomy using a locking plate is one option for treating an aged athlete with ACL deficiency and severe medial compartment osteoarthritis, and can allow the athlete to return to sports activity.