Jae Ang Sim

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.

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.

Autogenous graft repair using semitendinous tendon for a chronic multifocal rupture of the extensor hallucis longus tendon: A case report

Chronic multifocal closed rupture of the extensor hallucis longus tendon is an extremely rare injury. Previously, chronic multifocal partial rupture of the extensor hallucis longus tendon had not been reported. This case study reports one case of autogenous graft repair of a chronic multifocal rupture of the extensor hallucis longus tendon using a semitendinous tendon autograft.

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.

Comparison of anatomic ACL reconstruction between selective bundle reconstruction and double-bundle reconstruction

AbstractPurpose The objective of this study was to compare the clinical and radiologic results of preserved ligament remnants in the selective bundle anterior cruciate ligament (ACL) reconstruction and totally sacrificed ligament remnant in the double-bundle ACL reconstruction in order to confirm the evidence of selective bundle reconstruction.MethodsThis retrospective comparative study was conducted for comparison between preserved ligament remnants in the selective bundle ACL reconstruction and totally sacrificed ligament remnant in the double-bundle ACL reconstruction. From 2008 to 2010, 16 patients (group I) underwent selective bundle ACL reconstruction and 30 patients (group II) underwent double-bundle ACL reconstruction. Clinical, stability and radiologic results (tunnel locations of femoral tunnels using 3-D computed tomography and graft signal intensity using magnetic resonance imaging) were compared.ResultsIn comparison with functional results, no statistical differences in the Lysholm, Tegner and International Knee Documentation Committee scores were observed between the two groups (n.s.). In comparison with stability results between the two groups, no statistical differences were observed in the Lachman, pivot shift and anterior drawer stress tests using a Telos® device at 30° and 90° flexed positions (n.s.). In evaluation of the femoral tunnel location, no statistical significant differences in the tunnel position were observed between the groups (n.s.). No statistically significant differences in signal intensity were observed between the two groups (n.s.).ConclusionsCompared to the double-bundle ACL reconstruction, selective bundle ACL reconstruction produced comparable clinical and radiologic results. Selective bundle ACL reconstruction could be performed instead of double-bundle ACL reconstruction if some intact bundle exists.Level of evidenceComparative study, Level III.

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.

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.RésuméL’objectif de cette étude est d’évaluer et de comparer les propriétés biomécaniques du ligament plaque® avec d’autres systèmes de fixation fémorale. Matériel et méthode: le ligament plaque et différents matériels de fixation fémorale ont été utilisés dans le traitement des fractures fémorales chez le porc. Pour chaque matériel de fixation la greffe tendineuse de porc a été testée en charge jusqu’à la rupture avec élongation de la greffe et test cyclique de rupture en charge. Résultats: Dans le groupe Bioscrew les tests en charge sont moins bons, néanmoins, il n’y a pas de différence significative dans les deux groupes. En conclusion: le ligament Plaque permet d’avoir une bonne fixation initale et permet une réhabilitation précoce.

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° (group 1), valgus 0.8° (group 2), varus 2.1° (group 3) and varus 2.7° (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 arthroplaty.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using an Outside-in Technique: Two- to Six-Year Clinical and Radiological Follow-up

Purpose We evaluated the clinical and radiological outcomes of double-bundle anterior cruciate ligament (ACL) reconstruction using an outside-in technique with a follow-up of two- to six-years, especially in terms of the sports activity level and radiological degeneration. Materials and Methods Sixty-seven patients who were available for a minimum two-year follow-up after double-bundle ACL reconstruction using an outside-in technique were retrospectively evaluated. The mean follow-up period was 43.7 months. The knee function and stability were evaluated before the operation, one year after the operation (short-term follow-up), and more than two years after the operation (last follow-up). Results Regarding the knee function, the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, and hop test showed significant improvement. Regarding the stability, the Lachman test, pivot shift test, KT-2000 arthrometer data, and anterior drawer radiographs using Telos showed significant improvement. Regarding the sports activity level, the patients who returned to pre-injury level activity was 68.7% according to the Tegner activity score and 76.1% according to the Cincinnati sports activity scale score. The incidence of aggravated degeneration or development of greater than IKDC grade A degeneration after surgery was 10.4%. Conclusions Double-bundle ACL reconstruction using an outside-in technique showed favorable clinical and radiological outcomes with respect to the knee function and stability, joint degeneraion, and, especially, return to pre-injury sports activity.

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.