Jinzhong Zhao

Prediction of the Graft Size of 4-Stranded Semitendinosus Tendon and 4-Stranded Gracilis Tendon for Anterior Cruciate Ligament Reconstruction: A Chinese Han Patient Study

Background: Little information is available regarding parameters that would enable a surgeon to predict the size and length of 4-stranded semitendinosus (ST) and 4-stranded gracilis tendon (GT) grafts. Purpose: To evaluate whether certain preoperative anthropometric data enable prediction of the size of 4-stranded ST and GT autograft for anterior cruciate ligament (ACL) reconstruction. Study Design: Cohort study (prevalence); Level of evidence, 2. Methods: This study involved 235 Chinese Han patients who underwent double-bundle ACL reconstruction with 4-stranded autogenous ST and GT grafts. Preoperatively, the authors recorded height, weight, body mass index (BMI), gender, age, and sports activity. During surgery, the usable length of the ST and GT and the diameter of the 4-stranded grafts made of ST and GT were measured. Multiple regression analysis was used to determine relationships between anthropometric measurements and the length and diameter of intraoperatively measured ST and GT grafts. Results: Strongest correlations for ST and GT length and GT graft diameter were height and weight. The strongest correlations for ST graft diameter were gender and weight. Body mass index had only moderate correlations with ST and GT graft size. Self-reported activity level was not correlated. Women had significantly smaller GT and ST graft diameters and shorter tendon lengths than did men. Semitendinosus graft size was significantly larger and longer than was the GT graft (7.4 ± 0.7 mm vs 5.9 ± 0.6 mm and 279.9 ± 20.8 mm vs 251.5 ± 20.8 mm, respectively). Simple regression analysis demonstrated that height, weight, and BMI can be used to predict ST and GT autograft length and diameter. Conclusion: Several preoperative anthropometric measurements showed correlation with the length of the ST and GT and diameter of 4-stranded ST and GT grafts. The current data may provide surgeons with important preoperative information about size of ST and GT grafts and would be useful for patient counseling and alternative graft source planning.

The Role of Medial Retinaculum Plication Versus Medial Patellofemoral Ligament Reconstruction in Combined Procedures for Recurrent Patellar Instability in Adults

Background: The comparative clinical outcome of medial retinaculum plication (MRP) versus medial patellofemoral ligament reconstruction (MPFLR) for recurrent patellar instability in adults is unknown. Hypothesis: Arthroscopic MRP can yield similar results to MPFLR for recurrent patellar instability in adults. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: One hundred patients with recurrent patellar instability were randomly divided into 2 groups receiving either arthroscopic MRP or MPFLR. Lateral release and anteromedial or distal tibial tubercle transfers were also performed as indicated. Follow-ups were performed at 12, 24, and 60 months postoperatively, and computed tomography (CT) was performed immediately after the operation and at follow-up. The passive patella glide test was performed before surgery and at each follow-up point. The degree of knee function was evaluated preoperatively and at 2 and 5 years postoperatively using the International Knee Documentation Committee (IKDC), Lysholm, and Kujala rating scales. Survival analysis was performed, and redislocation or multiple episodes of patellar instability were considered as indicating failure. Results: Forty-three patients in the MRP group and 45 patients in the MPFLR group were followed for 5 years and received complete evaluations. The correction of the static patellar position deteriorated over time in both groups, but significantly better results were observed for the MPFLR group. The results of the passive patella glide test indicated more stable patellae in the MPFLR group at each follow-up point. Functional evaluations at 2 and 5 years (final Lysholm score, 69.3 ± 6.9 vs 86.9 ± 6.1; Kujala score, 73.8 ± 5.5 vs 87.4 ± 5.7) revealed statistically significant superior results in the MPFLR group. Finally, 4 patients (9.3%) in the MRP group and 1 (2.2%) in the MPFLR group experienced episodes of redislocation, and 7 patients (16.3%) in the MRP group and 3 (6.7%) in the MPFLR group experienced multiple episodes of patellar instability (P = .037). Kaplan-Meier survival analysis and a log-rank test indicated better results and a significantly higher survival rate (P = .006) in the MPFLR group. Conclusion: MPFLR results in better static patellar position and functional outcome than MRP in the treatment of recurrent patellar dislocation in adults.

Sandwich-Style Posterior Cruciate Ligament Reconstruction

PURPOSE The purpose of this study was to evaluate the results of a sandwich-style posterior cruciate ligament (PCL) reconstruction, namely double-bundle PCL reconstruction with 8 strands of hamstring tendons and remnant preservation. METHODS Eighteen cases of isolated chronic PCL rupture were reconstructed arthroscopically with 8 strands of autogenous hamstring tendons by way of 2-bundle and 4-tunnel reconstruction, as well as preservation of the remnant between the 2 reconstructed bundles. Quadruple-stranded semitendinosus tendon was used to reconstruct the anterolateral bundle, and quadruple-stranded gracilis tendon was used to reconstruct the posteromedial bundle. The grafts were fixed with a suspension technique by mini-plates and mini-buttons. The patients were followed up for a minimum of 2 years and evaluated according to the International Knee Documentation Committee (IKDC), Lysholm, and Tegner rating scales. RESULTS At a minimum of 2 years after surgery, 17 patients (94.4%) had a negative posterior drawer test and 1 had a 1+ posterior drawer test. The mean KT-1000 examination results (MEDmetric, San Diego, CA) changed from 9.3 +/- 1.4 mm preoperatively to 0.7 +/- 0.9 mm postoperatively (P < .001). According to the IKDC knee examination form, the results were graded as normal in 16 patients (88.9%) and nearly normal in 2 (11.1%). The IKDC subjective results increased from 64.1 +/- 3.3 to 95.6 +/- 3.1 (P < .001), and the Lysholm score increased from 58.6 +/- 4.4 to 94.9 +/- 3.6 (P < .001). The mean Tegner score was 7.1 before injury, 5.6 before surgery, and 6.9 at the last follow-up. CONCLUSIONS Arthroscopic sandwich-style PCL reconstruction can yield normal results in 88.9% of patients and nearly normal results in 11.1% at a minimum of 2 years.

A new treatment strategy for severe arthrofibrosis of the knee. A review of twenty-two cases.

BACKGROUND To reduce the morbidity of traditional quadricepsplasty for the treatment of severe arthrofibrosis of the knee, we instituted a treatment regimen consisting of an initial extra-articular mini-invasive quadricepsplasty and subsequent intra-articular arthroscopic lysis of adhesions during the same anesthesia session. The purpose of the present study was to determine the results of this technique. METHODS From 1998 to 2001, twenty-two patients with severely arthrofibrotic knees were managed with this operative technique. The mean age of the patients at the time of the operation was thirty-seven years. After a mean duration of follow-up of forty-four months (minimum, twenty-four months), all patients were evaluated according to the criteria of Judet and The Hospital for Special Surgery knee-rating system. RESULTS The average maximum degree of flexion increased from 27 degrees preoperatively to 115 degrees at the time of the most recent follow-up (p < 0.001). According to the criteria of Judet, the result was excellent for sixteen knees, good for five, and fair for one. The average Hospital for Special Surgery knee score improved from 74 points preoperatively to 94 points at the time of the most recent follow-up (p < 0.001). A superficial wound infection occurred in one patient. Only one patient had a persistent 15 degrees extension lag. CONCLUSIONS This mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome.

Effect of the Interposition of Calcium Phosphate Materials on Tendon-Bone Healing During Repair of Chronic Rotator Cuff Tear

Background: The current nature of tendon-bone healing after rotator cuff (RC) repair is still the formation of granulation tissue at the tendon-bone interface rather than the formation of fibrocartilage, which is the crucial structure in native tendon insertion and can be observed after knee ligament reconstruction. The interposition of calcium phosphate materials has been found to be able to enhance tendon-bone healing in knee ligament reconstruction. However, whether the interposition of these kinds of materials can enhance tendon-bone healing or even change the current nature of tendon-bone healing after RC repair still needs to be explored. Hypothesis: The interposition of calcium phosphate materials during RC repair would enhance tendon-bone healing or change its current nature of granulation tissue formation into a more favorable process. Study Design: Controlled laboratory study. Methods: A total of 144 male Sprague-Dawley rats underwent unilateral detachment of the supraspinatus tendon, followed by delayed repair after 3 weeks. The animals were allocated into 1 of 3 groups: (1) repair alone, (2) repair with Ca5(PO4)2SiO4 (CPS) bioceramic interposition, or (3) repair with hydroxyapatite (HA) bioceramic interposition at the tendon-bone interface. Animals were sacrificed at 2, 4, or 8 weeks postoperatively, and microcomputed tomography (micro-CT) was used to quantify the new bone formation at the repair site. New fibrocartilage formation and collagen organization at the tendon-bone interface was evaluated by histomorphometric analysis. Biomechanical testing of the supraspinatus tendon-bone complex was performed. Statistical analysis was performed using 1-way analysis of variance. Significance was set at P < .05. Results: The micro-CT analysis demonstrated remarkable osteogenic activity and osteoconductivity to promote new bone formation and ingrowth of CPS and HA bioceramic, with CPS bioceramic showing better results than HA. Histological observations indicated that CPS bioceramic had excellent biocompatibility and biodegradability. At early time points after the RC repair, CPS bioceramic significantly increased the area of fibrocartilage at the tendon-bone interface compared with the control and HA groups. Moreover, CPS and HA bioceramics had significantly improved collagen organization. Biomechanical tests indicated that the CPS and HA groups have greater ultimate load to failure and stiffness than the control group at 4 and 8 weeks, and the CPS specimens exhibited the maximum ultimate load to failure, stiffness, and stress of the healing enthesis. Conclusion: Both CPS and HA bioceramics aid in cell attachment and proliferation and accelerate new bone formation, and CPS bioceramic has a more prominent effect on tendon-to-bone healing. Clinical Relevance: Local application of CPS and HA bioceramic at the tendon-bone interface shows promise in improving healing after rotator cuff tear repair.

The effect of platelet-rich plasma on patterns of gene expression in a dog model of anterior cruciate ligament reconstruction

BACKGROUND Autologous platelet-rich plasma (PRP) has been investigated as a potential promoter of tendon healing and has an enhancing effect on the anterior cruciate ligament (ACL) graft maturation process. However, the influence of PRP on the synthesis and degradation of the extracellular matrix during the ACL graft remodeling process has never been investigated. MATERIALS AND METHODS Healthy and mature beagle dogs were randomly assigned to one of four groups: in group I (PRP group), ACL grafts were treated with PRP; in group II (control group), ACL grafts were treated with saline; in group III (sham group), only the knee joints were exposed; in group IV (normal control group), no surgery was performed to the knees. Ligament tissue was dissected at 2, 6, and 12 wk after surgery, and real-time PCR was performed using primers for growth factor-β1 (TGF-β1), collagen type1A1 (COL1Al), collagen type3A1 (COL3A1), decorin, biglycan, matrix metalloproteinase-1 (MMP-1), matrix metalloproteinase-13 (MMP-13), and tissue inhibitor of metalloproteinase-1 (TIMP-1). RESULT In group I, the messenger RNA (mRNA) levels of collagen type 1A1, biglycan, and MMP-1 all increased 2, 6, and 12 wk after surgery, compared with group II (P < 0.05). At 2 and 6 wk after surgery, increased levels of COL3A1, MMP-1, and MMP-13 mRNA were also detected in group I (P < 0.05). Increased levels of TGF-β1 mRNA was observed at 6 and 12 wk in group I after surgery (P < 0.05). CONCLUSIONS During the graft remodeling process, we observed a time-dependent change of gene expression following ACL reconstruction surgery. Furthermore, our results demonstrate that PRP alters the expression of some target genes at certain time points, especially during the early stages of graft remodeling, which might explain the enhancing effect of PRP on the ACL graft maturation process.

A new treatment strategy for severe arthrofibrosis of the knee. Surgical technique.

BACKGROUND To reduce the morbidity of traditional quadricepsplasty for the treatment of severe arthrofibrosis of the knee, we instituted a treatment regimen consisting of an initial extra-articular mini-invasive quadricepsplasty and subsequent intra-articular arthroscopic lysis of adhesions during the same anesthesia session. The purpose of the present study was to determine the results of this technique. METHODS From 1998 to 2001, twenty-two patients with severely arthrofibrotic knees were managed with this operative technique. The mean age of the patients at the time of the operation was thirty-seven years. After a mean duration of follow-up of forty-four months (minimum, twenty-four months), all patients were evaluated according to the criteria of Judet and The Hospital for Special Surgery knee-rating system. RESULTS The average maximum degree of flexion increased from 27 degrees preoperatively to 115 degrees at the time of the most recent follow-up (p < 0.001). According to the criteria of Judet, the result was excellent for sixteen knees, good for five, and fair for one. The average Hospital for Special Surgery knee score improved from 74 points preoperatively to 94 points at the time of the most recent follow-up (p < 0.001). A superficial wound infection occurred in one patient. Only one patient had a persistent 15 degrees extension lag. CONCLUSIONS This mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome.

Platelet-rich plasma enhances autograft revascularization and reinnervation in a dog model of anterior cruciate ligament reconstruction

BACKGROUND Autologous platelet-rich plasma (PRP) has been investigated as a potential promoter of tendon healing that affects the anterior cruciate ligament (ACL) graft maturation process. However, the influence of PRP on revascularization and reinnervation during the ACL graft remodeling has never been investigated. MATERIALS AND METHODS We randomly assigned healthy and mature beagles to one of four groups. In group 1 (PRP group), we treated the ACL grafts with PRP. In group 2 (control group), we treated the ACL grafts with saline. In group 3 (sham group), we exposed only the knee joints. In group 4 (normal control group), no surgery was performed on the knees. We dissected the ligament tissue at 2, 6, and 12 wk after surgery and performed real-time polymerase chain reaction using primers for cluster of differentiation molecule 31, vascular endothelial growth factor, thrombospondin-1 (TSP-1), neurotrophin-3, growth-associated protein-43 (GAP-43), and nerve growth factor. RESULTS We observed the increased expression of vascular endothelial growth factor, TSP-1, neurotrophin-3, GAP-43, and nerve growth factor mRNA in group 1 at 2, 6, and 12 wk after surgery, compared with that in group 2 (P < 0.05). We also detected increased levels of cluster of differentiation molecule 31 expression in group 1 (P < 0.05) at 2 and 6 wk after surgery. The levels of TSP-1 and GAP-43 mRNA were significantly increased in group 3 compared with those in group 4 at 2 wk after surgery (P < 0.05). CONCLUSIONS During graft remodeling, we observed a time-dependent change in gene expression after ACL reconstruction surgery. In addition, these results demonstrate that PRP alters the expression of some target genes at certain times, particularly during the early stages of graft remodeling. Platelet-rich plasma could promote revascularization and reinnervation, which might explain the enhancing effect of PRP on ACL graft maturation.

Arthroscopic Glenoid Bone Grafting With Nonrigid Fixation for Anterior Shoulder Instability 52 Patients With 2- to 5-Year Follow-up

Background: The healing rate and clinical outcomes of glenoid bone grafting with nonrigid fixation for patients with recurrent anterior shoulder instability are unknown. Hypothesis: Glenoid bone grafting with nonrigid fixation can yield satisfactory results for patients with recurrent anterior shoulder instability with regard to graft healing and the restoration of shoulder stability. Study Design: Case series; Level of evidence, 4. Methods: A total of 52 patients with recurrent anterior shoulder instability underwent Bankart or bony Bankart repair as well as arthroscopic glenoid bone grafting. Allogenic bicortical iliac grafts were used. Instead of firm fixation, the grafts were tethered to the glenoid by sutures from anchors placed in the glenoid surface. Follow-up occurred at 3, 6, 12, and 24 months. Computed tomography and magnetic resonance imaging examinations were performed immediately after surgery and at each follow-up visit to evaluate the healing of the graft and the changes in the repaired capsule-labrum structure. Functional evaluations were taken at 24 months with the Oxford Shoulder Instability Score and the Rowe Score for Shoulder Instability. For the patients who underwent surgery 2.5 years earlier, an additional review was conducted to evaluate the latest stability status of the shoulder. Failure was defined as recurrence of dislocation or instability. Results: The mean follow-up time was 39 months (range, 24-64 months). In all cases, the grafts healed to the glenoid at 3 or 6 months, and glenoid remodeling was complete within 12 months; in most cases, a robust bone-capsule structure formed on the anterior side of the glenoid. The glenoid defect area changed from 32.7% ± 8.7% (range, 10.7% to 53.9%) to −16.3% ± 3.3% (range, −26.7% to 5.9%), and the glenoid defect width changed from 28.3% ± 8.7% (range, 10.4% to 54.5%) to −16.9% ± 7.3% (range, −33.4% to 2.8%). Compared with the presumed normal glenoid, the final glenoid surface area increased in 94.2% of patients and final glenoid width increased in 96.2% of patients. One patient experienced redislocation and 2 experienced a sense of instability without dislocation, which resulted in a failure rate of 5.8%. Six patients exhibited slight pain. The Oxford score improved from 29.7 ± 5.6 preoperatively to 42.4 ± 3.3 at 2 years postoperatively, and the Rowe score improved from 34.7 ± 6.1 preoperatively to 91.8 ± 2.8 at 2 years postoperatively. Conclusion: In this study, arthroscopic glenoid bone grafting with nonrigid fixation in combination with Bankart repair resulted in 100% graft healing and the satisfactory restoration of shoulder stability.

Simultaneous Double-Bundle Anterior Cruciate Ligament and Posterior Cruciate Ligament Reconstruction With Autogenous Hamstring Tendons

PURPOSE The purpose of this study was to evaluate the clinical results of simultaneous double-bundle anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction. METHODS We performed arthroscopic reconstruction in 21 cases of combined ACL/PCL rupture, 14 chronic and 7 acute, with autogenous hamstring tendons in 1 stage, both in a double-bundle and 4-tunnel manner. The semitendinosus tendon and gracilis tendon from the uninjured leg were used to make two 4-stranded grafts to reconstruct the PCL, and those from the injured leg were used to make two 4-stranded grafts to reconstruct the ACL. The grafts were suspended with a mini-plate and buttons. The patients were followed up for a minimum of 2 years and evaluated according to the International Knee Documentation Committee (IKDC) and Lysholm rating scale. The anterior-posterior knee laxity was assessed by KT-1000 examination (MEDmetric, San Diego, CA). RESULTS At the last follow-up, all patients showed normal knee extension. One patient had a 10 degrees flexion limitation, and four had a 5 degrees flexion limitation. KT-1000 examination showed that the side-to-side difference in overall anterior-posterior laxity at 70 degrees flexion was 0 to 2 mm in 16 patients, 3 to 5 mm in 4 patients, and 6 to 10 mm in 1 patient; the side-to-side difference in overall anterior-posterior laxity at 25 degrees flexion was 0 to 2 mm in 14 patients, 3 to 5 mm in 6 patients, and 6 to 10 mm in 1 patient. The IKDC subjective, Lysholm, and Tegner scores were 85.5 +/- 5.8, 91.9 +/- 4.2, and 5.0 +/- 1.9, respectively. According to the last IKDC evaluation, the results were graded as normal in 13 patients (61.9%), nearly normal in 7 patients (33.3%), and abnormal in 1 patient (4.8%). CONCLUSIONS Simultaneous double-bundle ACL and PCL reconstruction with autogenous hamstring tendons can yield normal results in 61.9% of patients and nearly normal results in 33.3% at a minimum of 2 years. LEVEL OF EVIDENCE Level IV, therapeutic case series.