Hitoaki Numata

Ultrasonography imaging of the anterolateral ligament using real-time virtual sonography.

BACKGROUND The anterolateral ligament (ALL) functions as a stabilizer in the internal rotation of the knee. Previous studies have reported the ALL can be identified using magnetic resonance imaging (MRI); however, there are no reports on using ultrasonography (US) for this purpose. Real-time virtual sonography (RVS) uses magnetic navigation and computer software for the synchronized display of real-time US and multiplanar reconstruction MRI images. This study investigated the ability of using US with RVS to evaluate the ALL. METHODS Nine healthy subjects were enrolled. The Digital Imaging Communications in Medicine MRI dataset was loaded into the Hitachi Aloka Preirus, and US images were displayed on the same monitor. When the ALL was identified using MRI, the monitor was frozen to evaluate the ALL. The ALL was divided into the femoral, meniscal, and tibial portions. The portions and thickness of the ALLs and the lateral inferior genicular artery (LIGA), a landmark for the ALL, were evaluated. RESULTS All portions of the ALL could be identified using MRI. Using US, the tibial portion of the ALL was detected in all subjects and the femoral portion was detected in seven subjects; however, the meniscal portions could not be identified. The average ALL thickness as measured by US was 1.3±0.1 mm and the LIGA was identified in all cases. CONCLUSIONS Most portions of the ALL can be identified using US. As most ALL injuries occur at the femoral or tibial portion, US may be useful as a diagnostic tool for ALL injury. LEVEL OF EVIDENCE 4.

Repair and augmentation of a spontaneous patellar tendon rupture in a patient with Ehlers–Danlos syndrome: a case report

AbstractIntroduction Disruption of the knee extensor mechanism is a serious disorder that requires prompt treatment. It often occurs in the form of a patellar tendon rupture. It may occur in association with systemic disease or after administration of corticosteroids or fluoroquinolones. These conditions can cause tendon weakness, and consequent ruptures usually require both repair and augmentation. This paper reports on repair and augmentation for treating patellar tendon rupture in patients with Ehlers–Danlos syndrome (EDS).Case reportWe report a patellar tendon rupture in a 27-year-old man with EDS, which occurred in the midsubstance of the patella. As the patient has tendon weakness, extensive repair will increase the risk of patella baja, and the use of end-to-end suturing technique alone will not be enough to prevent a rupture recurring; however, augmentation could be used to address the tendon weakness. Repair of the rupture and augmentation with hamstring tendon was performed. One year after the surgery, the patient was able to move his knee joint without pain and had an active range of motion of 0° (passive 20°)–145°. He was able to perform a straight leg raise without an extension lag.ConclusionsRepair and augmentation with hamstring tendon was an effective treatment option for patellar tendon rupture in a patient with EDS.

Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator

BACKGROUND This study aimed to present a new technique for anatomical single bundle anterior cruciate ligament (ACL) reconstruction. We developed an original rounded rectangular dilator set to create rounded rectangular femoral tunnels. This technique can increase the femoral tunnel size without roof impingement, and has the potential to reduce the graft failure rate. We investigated the tunnel position and the incidence of intraoperative complications. METHOD The presented technique is anatomical single bundle ACL reconstruction using a semitendinosus graft (with or without the gracilis tendon). The tunnel was drilled via an additional medial portal. Rounded rectangular tunnels were created using a special dilator. Tibial tunnels were created using conventional rounded tunnels. Fixation was achieved using a suspensory device on the femoral side and a plate and screw on the tibial side. PATIENTS Fifty patients underwent this surgery, and intraoperative complications were investigated. The femoral tunnel positions were documented postoperatively from computed tomography scans using the quadrant method. The tibial tunnel positions (anterior-to-posterior, medial-to-lateral) were documented using intraoperative X-ray scans. RESULTS Only one patient had a partial posterior tunnel wall blowout. The femoral tunnel length varied between 30 and 40mm (mean, 34.9±3.3mm). All femoral and tibial tunnels were located within the area of the anatomical ACL insertions. CONCLUSION We did not experience any serious intraoperative complications during anatomical single bundle ACL reconstruction using a rounded rectangle dilator, and the resulting locations of the femoral and tibial tunnels were within the anatomical ACL footprint. LEVEL OF EVIDENCE Level IV.

Common Peroneal Nerve Palsy with Multiple-Ligament Knee Injury and Distal Avulsion of the Biceps Femoris Tendon

A multiple-ligament knee injury that includes posterolateral corner (PLC) disruption often causes palsy of the common peroneal nerve (CPN), which occurs in 44% of cases with PLC injury and biceps femoris tendon rupture or avulsion of the fibular head. Approximately half of these cases do not show functional recovery. This case report aims to present a criteria-based approach to the operation and postoperative management of CPN palsy that resulted from a multiple-ligament knee injury in a 22-year-old man that occurred during judo. We performed a two-staged surgery. The first stage was to repair the injuries to the PLC and biceps femoris. The second stage involved anterior cruciate ligament reconstruction. The outcomes were excellent, with a stable knee, excellent range of motion, and improvement in the palsy. The patient was able to return to judo competition 27 weeks after the injury. To the best of our knowledge, this is the first case report describing a return to sports following CPN palsy with multiple-ligament knee injury.

Psychological traits regarding competitiveness are related to the incidence of anterior cruciate ligament injury in high school female athletes

BACKGROUND The purpose of this study was to investigate the relationship between psychological competitive ability and the incidence of noncontact ACL injuries among high school female athletes. METHODS A three-year prospective cohort study was conducted using 300 15-year-old high school female athletes with no previous injuries or symptoms in their lower limbs (106 handball players and 194 basketball players). At baseline, their psychological competitive abilities were assessed using a self-administered questionnaire-the Diagnostic Inventory of Psychological Competitive Ability (DIPCA.3). After the baseline examination was performed at high school entry, all players were prospectively followed for 36months to document any subsequent incidence of ACL injury, according to their coaches. An unpaired t-test with Welchs correction was performed to compare the differences in the psychological competitive abilities between the injured and uninjured players. RESULTS Of the 300 players, 25 (8.3%) experienced a noncontact ACL injury during the three-year observation period. The injured players had significantly higher total DIPCA.3 scores for psychological competitive ability than the uninjured players (169.9±18.8 vs. 159.2±21.6, P=.036). Additionally, the injured players had significantly higher scores than the uninjured players in the following categories: aggressiveness, volition for self-realization, volition for winning, judgment, and cooperation. However, no significant differences were observed in patience, self-control, ability to relax, concentration, confidence, decision, and predictive ability. CONCLUSIONS High psychological competitive ability was associated with the incidence of noncontact ACL injuries in high school female athletes. LEVEL OF EVIDENCE Level II (prospective cohort study).

Changes in muscle activity after performing the FIFA 11+ programme part 2 for 4 weeks.

ABSTRACT Changes in muscle activity were evaluated by positron emission tomography–computed tomography (PET–CT) after performing part 2 of the Fédération Internationale de Football Association’s 11+ programme (11+) for 4 weeks. Eleven males performed part 2 of the 11+ for 20 min before and after 37 MBq of 18F-fluorodeoxyglucose (FDG) was injected intravenously. PET–CT images were obtained 50 min after FDG injection. The participants were then instructed to perform part 2 of the 11+ 3 times per week for 4 consecutive weeks, after which another set of PET–CT images was obtained following the same procedure. Regions of interest were defined within 30 muscles. The standardised uptake value (SUV) of FDG by muscle tissue per unit volume was calculated, and FDG accumulation was compared between pre- and post-training PET–CT results. Performing part 2 of the 11+ for 4 weeks increased mean SUV in the sartorius, semimembranosus, biceps femoris, abductor hallucis, and flexor hallucis brevis muscles (P < 0.05). In conclusion, routinely performing part 2 of the 11+ for 4 weeks increased glucose uptake related to muscle activity in the hamstrings and hallux muscles. We speculate that there is some possibility of this change of muscle activity contributing to a decrease in sports-related injuries.

Conscious performance and arthroscopic findings in athletes with anterior cruciate ligament injuries treated via conservative therapy during the competitive season

Purpose: Athletes often receive conservative treatment for injured anterior cruciate ligaments (ACLs) so that they can continue to play to the end of their season. The purpose of this study was to examine the conscious performance and arthroscopic findings of athletes who received conservative therapy for ACL injuries. Methods: Forty-two patients with ACL injuries underwent conservative treatment. After the season ended, ACL reconstruction was performed. We examined the following parameters: (1) time required for return to competition after injury, (2) conscious performance after return to competition, (3) whether the injured knee gave way during conservative therapy or after return to competition, and (4) cause of performance deterioration if applicable. To determine conscious performance, patients were asked to rate their performance after therapy relative to their performance before injury. Results: Thirty-eight of the 42 patients (90.5%) returned to competition after conservative treatment. The mean time to return was 13.8 ± 7.6 weeks, and the mean conscious performance score was 58.4 ± 16.5%. Thirty-eight patients (90.5%) experienced their knee giving way, of whom 36 (94.9%) stated that fear of their knee giving way hampered their performance. At the time of ACL reconstruction, 9 patients had chondral injuries and 22 patients had meniscus injuries. Conclusion: Most athletes with damaged ACLs returned to the field within the same season after conservative treatment. However, conscious performance was only about 60%. It is possible that knees giving way caused secondary meniscus and joint cartilage damage. Therefore, conservative treatment of individuals with ACL injuries should be considered carefully.

RISK FACTORS FOR NON-CONTACT ANTERIOR CRUCIATE LIGAMENT INJURY IN JAPANESE FEMALE HIGH SCHOOL BASKETBALL AND HANDBALL PLAYERS. A PROSPECTIVE THREE-YEAR COHORT STUDY

Background Many studies have explored the risk factors for noncontact anterior cruciate ligament (ACL) injuries. Objective To prospectively evaluate risk factors for noncontact ACL injury in Japanese female high school basketball and handball players. We hypothesized those female high-school athletes suffering non-contact ACL injuries would demonstrate weaker hip abductor and knee flexor muscle strength, when compared to those without injury. Design Prospective cohort study. Setting & Participants A 3-year prospective cohort study was conducted using 317, 15-year-old high school female athletes between 2009 and 2014. At baseline, they underwent detailed examinations for various parameters that were documented at their first-year of high school. Assessment of Risk Factors The parameters assessed were height, weight, body mass index, general joint laxity, navicular drop measurement, anterior laxity of the knee, and angle of femoral anteversion, and strength assessment included knee extensor/flexor muscle strength and hip abductor strength. All ACL injuries that occurred during these 3 years were recorded. The parameters were compared using the Student t-test. Parameters with P values<0.2 were considered independent variables by logistic regression analysis (simultaneous). The level of significance for all statistical analyses was set at α=0.05. Results Of the 317 players, 27 were excluded because they either had a history of ACL injury or could not complete the study. A total of 30 ACL tears occurred. Three of the ACL injuries were contact injuries, whereas the remaining 27 were noncontact ACL injuries. Muscle strength of hip abduction (P=0.001, 95% CI, 1.793–67.534) and femoral anteversion (P=0.037, 95% CI, 0.759–0.991) were found to be independent risk factors in logistic regression analysis. Conclusions We found that increased hip abductor muscle strength and decreased femoral anteversion were risk factors for noncontact ACL injury. However, there was only a little difference.

A Novel Injective Approach For Osgood-schlatter Disease: A Prospective Randomized Double-blind Study

Objectives: Despite first being reported more than 100 years ago, Osgood-Schlatter disease(OSD) currently has no effective treatment. The recent use of ultrasonography in the orthopedic surgery and sports medicine fields revealed that patellar tendinopathy and deep infrapatellar bursitis contributes to the pain experienced by patients with OSD. Considering the reported effectiveness and safety of hyperosmolar dextrose injection for patellar tendinopathy, here we investigated the efficacy and safety of hyperosmolar dextrose injection as a novel treatment for OSD. Our hypothesis was that hyperosmolar dextrose injection would be safe and well tolerated by patients with OSD. Methods: We performed this prospective randomized double-blind clinical trial between April 2012 and June 2015. A total of 44 knees in 36 boys (average age, 12.3 ± 1.1 years) for whom conventional conservative therapy for >1 month was ineffective were randomly assigned to the double-blind injection of 1% lidocaine (1 mL) with saline (1 mL) (Saline group) or 1% lidocaine (1 mL) with 20% dextrose (1 mL) (Dextrose group). Half of the solution was injected into the distal attachment of the patellar tendon, while the remaining half was injected into the deep infrapatellar bursa or infrapatellar fat pad under ultrasound guidance. Injections were administered monthly for 3 months by a single investigator. The Victorian Institute of Sport Assessment (VISA) score was used to evaluate pain. Results: A total of 40 knees in 33 boys were included in this clinical trial. The mean pre-injection VISA scores of the Dextrose and Saline groups were 59.6 ± 19.1 and 62.5 ± 16.6, while those at the final follow-up were 83.6 ± 19.3 and 84.1 ± 19.1, respectively. There were no significant differences in the two group pre-injection versus at the final follow-up (P = 0.61 and 0.93, respectively). In contrast, the mean VISA score significantly increased in both group between pre-injection and final follow-up (P < 0.01). There were no adverse effects of the injection. Conclusion: We were not able to prove the efficacy of the Dextrose injection compared with control; however, our results suggest superior symptom reduction efficacy of injection therapy for both treatments compared to usual care in the treatment of OSD. Thus, injection over the distal attachment of the patella tendon and into the deep infrapatellar bursa or infrapatellar fat pad under ultrasound guidance may become a new treatment method for OSD.

A Novel Technique for Calcaneal Avulsion Fracture: A Case Report

Avulsion fractures of the calcaneal tuberosity constitute only a small percentage of calcaneal fractures. Avulsion fractures often occur in elderly women with osteoporosis. Various surgical methods are used in the treatment of this type of fracture. These include tension band wiring, suture anchor fixation, lag screw fixation, and TightRope® technique. In order to manage these fractures effectively, it is important to avoid skin necrosis and to ensure strong fixation that can resist the pull of triceps surae. We performed a novel technique using Achilles SpeedBridge™ and a cannulated lag screw. This technique allows for strong and easy fixation. A 57-year-old man presented to our department with a left ankle injury caused by slipping on a rocky area next to the sea. We diagnosed a type I calcaneal avulsion fracture, and planned surgical fixation. Surgery was performed 3 days after the injury. Postoperatively, the patient used a brace to maintain the ankle in the natural position for three weeks. Full weight bearing was started with Achilles boots after the brace was removed. His ankle range of motion was 30° plantar flexion and 60° dorsiflexion. He could perform all movements without any issues and without requiring support. His preoperative American Orhopaedic Foot and Ankle Society score was 52/100, and after 3 months this had increased to 100/100. We believe that this technique is highly effective for the treatment of type I calcaneal avulsion fractures.