Joon Ho Wang

A pull out suture for transection of the posterior horn of the medial meniscus: using a posterior trans-septal portal.

A transection (root tear or complete radial tear) injury of the medial meniscus posterior horn is not rare in the oriental area and needs to be repaired to restore the hoop tension and to reduce the extruded meniscus, which leads to osteoarthritis of the knee. In cases with transection of the medial meniscus posterior horn, the meniscus can be repaired by a pull out suture technique. However, it is difficult to manipulate a suture hook and drill a tibial tunnel in the narrow medial joint space using the traditional anterior arthroscopic technique. This article describes a new pull out suture technique for transection of the medial meniscus posterior horn using a posterior trans-septal portal that provides a safe and wide field of vision. The handling of the suture hook and a guide may reduce the possibility of a chondral or meniscal injury.

Evaluation of the Reliability of the Dial Test for Posterolateral Rotatory Instability: A Cadaveric Study Using an Isotonic Rotation Machine

PURPOSE The purpose of our study was to evaluate the reliability of the dial test by assessing the correlation between the severity of posterolateral corner injuries and the amount of external rotation of the tibia. METHODS Fourteen paired cadaveric legs were fixed into a custom-made isotonic rotation machine with the knee flexed at 30 degrees . For group I (7 right knees), the lateral collateral ligament, popliteofibular ligament, popliteus tendon, and posterior cruciate ligament (PCL) were cut serially. For group II (7 left knees), the PCL, lateral collateral ligament, popliteofibular ligament, and popliteus tendon were cut. The external rotation angles were measured with a 6-Nm rotational torque. RESULTS For group I, the mean increase in the external rotation angle after cutting of the 3 posterolateral ligament structures was 17.9 degrees +/- 6.4 degrees. The additional increase in mean external rotation after cutting of the PCL was 4.7 degrees +/- 2.1 degrees. For group II, the mean increase in the external rotation angle after cutting of the PCL was 8 degrees +/- 4 degrees. Cutting the 3 posterolateral ligament structures increased the external rotation by 10.7 degrees +/- 5.3 degrees. The increase in external rotation was significant in group I after cutting of the 3 posterolateral structures and in group II after cutting of the PCL and 2 posterolateral structures (P = .05, Duncan test). CONCLUSIONS The dial test may be a valuable diagnostic method in cases of injury to 3 posterolateral structures or combined injuries to the PCL and 2 posterolateral structures. However, posterolateral instability with injuries to only 1 or 2 posterolateral structures may not be clinically detected by the dial test. CLINICAL RELEVANCE In the case of posterolateral instability with only 1 or 2 structure injuries, comprehensive diagnostic methods including the patients history, other physical examinations, radiographs, and magnetic resonance imaging should be used to diagnose posterolateral rotatory instability.

Medial open wedge high tibial osteotomy: the effect of the cortical hinge on posterior tibial slope.

Background High tibial osteotomy can affect the posterior tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia. However, the effect of the location of cortical hinge on posterior tibial slope has not been previously described. Hypothesis Posterolateral location of the cortical hinge will increase posterior tibial slope after medial open wedge osteotomy, and lateral location of the cortical hinge will not affect the change of the posterior tibial slope. Study Design Controlled laboratory study. Methods We performed incomplete valgus open wedge osteotomy on 12 paired knees of 6 fresh-frozen human cadavers (age, 63.4 ± 7.5 years) using an OrthoPilot navigation system. The left and right legs of each specimen were randomly assigned to a posterolateral (group A) or a lateral (group B) cortical hinge group. Changes in mean medial proximal tibial angle, posterior tibial slope, and opening wedge angle were measured and compared after surgery. Results In group A, mean medial proximal tibial angle changed from 84.37° ± 2.8° to 93.48° ± 3.06° (P = .028); mean posterior tibial slope increased significantly from 8.71° ± 0.81° to 12.16° ± 0.84° (P = .031); and mean wedge angle was 1.92° ± 0.46°. In group B, mean medial proximal tibial angle changed from 82.98° ± 2.53° to 90.89° ± 3.25° (P = .027); mean posterior tibial slope changed from 9.19° ± 1.11° to 9.78° ± 1.27° (P = .029); and mean wedge angle was 7.25° ± 0.72°. Conclusion The location of the intact cortical hinge affects the posterior tibia slope. During medial open wedge osteotomy, the change of posterior tibial slope was larger in the posterolateral than in the lateral cortical hinge group. Clinical Relevance To prevent the unintentional increase of the posterior tibial slope, special attention should be paid to locate the intact cortical hinge on the lateral, not the posterolateral, side of the tibia.

Increasing the Distance Between the Posterior Cruciate Ligament and the Popliteal Neurovascular Bundle by a Limited Posterior Capsular Release During Arthroscopic Transtibial Posterior Cruciate Ligament Reconstruction: A Cadaveric Angiographic Study

Background During arthroscopic transtibial posterior cruciate ligament reconstruction, popliteal vessel injury is the most serious complication, and it rarely occurs. Purpose To evaluate the distance change between the posterior cruciate ligament and the neurovascular bundle by limited release of the posterior capsule during arthroscopic posterior cruciate ligament reconstruction. Study Design Controlled laboratory study. Methods The authors performed an arthroscopic posterior cruciate ligament reconstruction procedure on 10 fresh-frozen cadaveric knees. The experimental procedure included 4 steps. Before the procedure and just after each step, angiographic lateral radiographs were checked to find the relationship and the distances between the popliteal artery and the posterior cruciate ligament. Changes in the distances at each step were compared and analyzed by ANOVA with Bonferroni correction. Results The mean distance between the popliteal artery and the tibial insertion of the posterior cruciate ligament increased significantly (from 4.4 ± 3.2 mm to 14.7 ± 4.1 mm) after limited posterior capsular release (P < .01). The distance from the popliteal artery to the midsubstance of the posterior cruciate ligament at the level of the posterior trans-septal portal significantly increased (from 11.3 ± 3.9 mm to 17.6 ± 4.0 mm) just after distension of the knee joint with a pump (P < .01). Conclusion This study showed a significant increase in the distance from the popliteal artery to the posterior cruciate ligament through arthroscopic limited posterior capsular release during arthroscopic transtibial posterior cruciate ligament reconstruction. Clinical Relevance The results of this study support the claim that risk of iatrogenic popliteal vessel injury could be reduced by limited posterior capsular release during arthroscopic transtibial posterior cruciate ligament reconstruction.

Double transosseous pull out suture technique for transection of posterior horn of medial meniscus

Transection injury (complete radial tear, root tear) in the posterior horn of medial meniscus will lead to loss of hoop strain, extrusion of the meniscus and early degenerative changes. The posterior horn of medial meniscus is amenable to repair due to its good blood supply and repair is the procedure of choice for these injuries. In cases of transection of the medial meniscus posterior horn, the meniscus can be repaired by a pull out suture technique using trans-septal portal. The single transosseous pull out suturing technique is a point fixation technique with limited contact area having low and inhomogeneous contact pressure. This article describes a double transosseous pull out suture technique using trans-septal portal for the repair of transection of posterior horn of medial meniscus. Use of double transosseous technique provides more secure fixation, more homogeneous and wider contact pressure area between meniscus and the bone, improving the healing potential of the repair.

Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: a cadaveric study.

The modified Brostrom procedure is commonly recommended for reconstruction of the anterior talofibular ligament (ATF) and calcaneofibular ligament (CF) with an advancement of the inferior retinaculum. However, some surgeons perform the modified Bostrom procedure with an semi-single ATF ligament reconstruction and advancement of the inferior retinaculum for simplicity. This study evaluated the initial stability of the modified Brostrom procedure and compared a two ligaments (ATF + CF) reconstruction group with a semi-single ligament (ATF) reconstruction group. Sixteen paired fresh frozen cadaveric ankle joints were used in this study. The ankle joint laxity was measured on the plane radiographs with 150 N anterior drawer force and 150 N varus stress force. The anterior displacement distances and varus tilt angles were measured before and after cutting the ATF and CF ligaments. A two ligaments (ATF + CF) reconstruction with an advancement of the inferior retinaculum was performed on eight left cadaveric ankles, and an semi-single ligament (ATF) reconstruction with an advancement of the inferior retinaculum was performed on eight right cadaveric ankles. The ankle instability was rechecked after surgery. The decreases in instability of the ankle after surgery were measured and the difference in the decrease was compared using a Mann–Whitney U test. The mean decreases in anterior displacement were 3.4 and 4.0 mm in the two ligaments reconstruction and semi-single ligament reconstruction groups, respectively. There was no significant difference between the two groups (P = 0.489). The mean decreases in the varus tilt angle in the two ligaments reconstruction and semi-single ligament reconstruction groups were 12.6° and 12.2°, respectively. There was no significant difference between the two groups (P = 0.399). In this cadaveric study, a substantial level of initial stability can be obtained using an anatomical reconstruction of the anterior talofibular ligament only and reinforcement with the inferior retinaculum. The modified Brostrom procedure with a semi-single ligament (Anterior talofibular ligament) reconstruction with an advancement of the inferior retinaculum can provide as much initial stability as the two ligaments (Anterior talofibular ligament and calcaneofibular ligament) reconstruction procedure.

Transtibial double bundle posterior cruciate ligament reconstruction using TransFix tibial fixation

Previous transtibial double bundle posterior cruciate ligament (PCL) reconstruction methods have several problems in graft length and tibial fixation. We introduce new surgical method that is less restrictive by graft length and is more stable with single tibial fixation. After diagnostic arthroscopy, we prepare the graft, ream the tibial tunnel, and perform the procedure for TransFix tibial fixation. Femoral 2 tunnel is made and graft is passed via anteromedial (AM) portal. Tibial fixation is done and femoral 2 graft is fixed sequentially at each knee position. TransFix tibial single fixation method in double bundle PCL reconstruction provides more stable fixation, more free graft selection, and prevents graft damage by passing the graft via AM portal.

A Comparative Study of Screw and Helical Proximal Femoral Nails for the Treatment of Intertrochanteric Fractures

The goal of this study was to compare treatment outcomes of screw proximal femoral nails and helical proximal femoral nails and to investigate the effectiveness of helical proximal femoral nails for the treatment of intertrochanteric fractures. Forty patients with intertrochanteric fractures were treated at our institution between January 2005 and January 2007, with a minimum follow-up of 1.5 years. Seventeen patients were treated with screw proximal femoral nails (mean patient age, 67 years; age range, 45-89 years; men:women ratio, 3:14), and 23 were treated with helical proximal femoral nails (mean patient age, 74 years; age range, 64-91 years; men:women ratio, 6:17). We evaluated mean operation time, amount of bleeding, time to ambulation, average union period, changes in neck shaft angle, and complications, and performed radiographic reviews, telephone interviews, and direct contact interviews at an outpatient clinic. We evaluated postoperative function and mobility using social function scores and mobility scores.Helical proximal femoral nails produced better results in terms of social function scores, mobility scores, and complication rates with statistical significance. No significant differences were found between the 2 nails in terms of mean operation time, amount of bleeding, average union period, time to ambulation, or neck shaft angle changes. Screw proximal femoral nails and helical proximal femoral nails are suitable implants for intertrochanteric fractures, but helical proximal femoral nails are better in terms of functional aspects and complication rates.

Biomechanical Evaluation of Cross-Pin Versus Interference Screw Tibial Fixation Using a Soft-Tissue Graft During Transtibial Posterior Cruciate Ligament Reconstruction

PURPOSE This article reports the biomechanical demonstration of a technique for transtibial posterior cruciate ligament (PCL) reconstruction using a soft-tissue graft with cross-pin fixation in the tibia and compares this with the biomechanical properties achieved with other methods. METHODS We used 5 paired cadaveric knees and another 10 tibias. Soft-tissue grafts were randomized. The femoral side of the anterior cruciate ligament was fixed with a Bio-TransFix device (Arthrex, Naples, FL) (group I), and the tibial side of the PCL was fixed with a Bio-TransFix device (group II). In another 10 tibias, tibial fixations were performed by use of a bio-interference screw (group III). Biomechanical testing was carried out on a testing machine, and maximal failure load, stiffness, and displacement were analyzed. The lengths of the slots of the TransFix device (Arthrex) from the near cortex were measured to compare the proper length of the device. RESULTS Maximal mean failure loads in groups I, II, and III were 549.3 +/- 55.4 N, 570.8 +/- 96.9 N, and 371.3 +/- 106.2 N, respectively, showing a significant difference (P = .0003). Stiffnesses were 47.52 +/- 16.84 N/mm, 59.14 +/- 17.09 N/mm, and 27.60 +/- 16.73 N/mm, respectively, showing a significant difference (P = .01). Mean displacements were 19.99 +/- 5.79 mm, 19.09 +/- 8.51 mm, and 17.58 +/- 7.10 mm, respectively, showing no significant difference (P = .7535). The mean lengths of the slots of the TransFix device of the femurs and tibias were similar at 20.3 +/- 1.25 mm and 20.2 +/- 1.32 mm, respectively, showing no significant difference (P = .8637). CONCLUSIONS The transtibial technique by use of cross-pin tibial fixation with a Bio-TransFix device in PCL reconstruction provides stable fixation that is comparable to that achieved by use of conventional bio-interference screw fixation and femoral fixation in an anterior cruciate ligament reconstruction, an already well-established technique. CLINICAL RELEVANCE Biomechanically, tibial cross-pin fixation compares favorably with interference screw fixation and is useful when a graft is short. However, safety issues have not yet been resolved.

Double-bundle anterior cruciate ligament reconstruction using two different suspensory femoral fixation: a technical note

We describe a novel double-bundle reconstruction method for ACL deficient knee. Grafts are tibialis allograft for AMB (anteromedial bundle) and semitendinosus autograft for PLB (posterolateral bundle). Femoral fixations are done by Bio-TransFix for AMB and EndoButton for PLB. Tibial fixations are done by Bio-interference screw for AMB at 60–70° knee flexion and secure the PLB and remnant AMB graft simultaneously onto anteromedial aspect of tibia at 10–20° knee flexion with spiked washer and screw. With our technique, graft lengths are not restricted and we provide strong femoral and tibial fixation if it is compared with previous techniques.