Kazutaka Kinugasa

Influence of Glenoid Defect Size and Bone Fragment Size on the Clinical Outcome After Arthroscopic Bankart Repair in Male Collision/Contact Athletes

Background: The usefulness of arthroscopic Bankart repair for collision/contact athletes has varied in previous reports. Purpose: To investigate the influence of glenoid rim morphologic characteristics on the clinical outcome after arthroscopic Bankart repair without additional reinforcement procedures in male collision/contact athletes, including athletes with a large glenoid defect. Study Design: Case-control study; Level of evidence, 3. Methods: Eighty-six athletes (93 shoulders) followed for a minimum of 2 years were retrospectively investigated. The sports were rugby (36 shoulders), American football (29 shoulders), and other collision/contact sports (28 shoulders). Preoperative glenoid defect size, bone fragment size, and bone union after bony Bankart repair were investigated regarding factors influencing postoperative recurrence. Postoperative changes in glenoid defect size and bone fragment size were investigated as well as their influence on the clinical outcome. Results: Postoperative recurrence of instability was noted in 22 shoulders (23.7%). The recurrence rate was 33.3% in rugby, 17.2% in American football, and 17.9% in other collision/contact sports. The recurrence rate was only 7.1% in 28 shoulders without a preoperative glenoid defect, but it increased to 43.8% in 16 shoulders that did not have a bone fragment even though there was a preoperative glenoid defect. Additionally, the recurrence rate was 7.7% in 26 shoulders with bone union after arthroscopic bony Bankart repair but rose to 45% in 20 shoulders without bone union. In the shoulders with bone union, the mean bone fragment size increased from 8.2% preoperatively to 15.2% postoperatively, while the mean glenoid defect size decreased from 18.0% to 2.8%, respectively. The recurrence rate was 8.3% in shoulders with a final glenoid defect 5% or less versus 38.1% in shoulders with a defect greater than 5%. While the recurrence rate was low among athletes other than rugby players with a final defect of 10% or less, it was low in only the rugby players with a defect of 0%. Conclusion: In male collision/contact athletes, while the overall clinical outcome was unsatisfactory, a favorable outcome was achieved in athletes without a preoperative glenoid defect and athletes with bone union. The glenoid defect decreased in size postoperatively due to remodeling of the united bone fragment, and the recurrence rate was low when the final glenoid defect size was 5% or less.

In Vivo Graft Tension in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction During Active Leg-Raising Motion With the Knee Splinted

PURPOSE The purpose of this study was to measure the in vivo graft tension in anatomic 2-bundle anterior cruciate ligament (ACL) reconstruction during active leg-raising exercise with the knee immobilized. METHODS Anatomic double-bundle ACL reconstruction was performed with autogenous semitendinosus tendons in 7 patients while under general anesthesia. Two grafts were fixed with 2 EndoButton-CL devices (Smith & Nephew Endoscopy, Andover, MA) on the femur and were temporarily fixed to 2 tension-adjustable force gauges on the anterior tibial cortex. Then, a knee brace in semi-flexion was put around the knee, and 10 N of initial tension was applied to each graft at 20° of flexion. The tension on the anteromedial (AM) and posterolateral (PL) grafts was continuously measured during active leg-raising motion with the knee immobilized after patients had awoken from anesthesia. Then, the tension measurement was repeated during active leg-raising motion with the knee immobilized while a 2-kg weight was fitted around the ankle. RESULTS In situ graft tension during active leg-raising motion with a knee brace was 10.9 ± 4.0 N for the AM graft and 8.6 ± 5.1 N for the PL graft, whereas the tension with a 2-kg weight around the ankle was 10.9 ± 3.4 N for the AM graft and 9.9 ± 3.6 N for the PL graft. There was no significant difference between each graft in the 2 motions with a paired t test. CONCLUSIONS Graft tension with the knee immobilized with a semi-flexed knee brace during active leg-raising motion was 19.5 N with no weight and 20.8 N with additional weight, both of which were almost equal to the initial graft tension at the time of fixation at 20°. Thus the leg-raising exercise can be recommended as safe when a semi-flexed knee brace is worn after ACL reconstruction. CLINICAL RELEVANCE These findings will help to plan postoperative rehabilitation programs with security.

Effects of suture site or penetration depth on anchor location in all-inside meniscal repair.

BACKGROUND To evaluate the effects of suture site or penetration depth on anchor location in all-inside meniscal repair. METHODS Eight fresh-frozen cadaveric knees were evaluated after meniscal repair using eight FasT-Fix360 (FF360) devices (Smith & Nephew Endoscopy, Andover, MA) (16 anchors) for each knee. The penetration depth was 14mm, the distance same from the periphery to insertion point, in four knees (Group A) and that in the remaining four knees (Group B) was 18mm. The anchor location in two groups was evaluated after attentive dissection. RESULTS Of 32 anchors for the medial meniscus, 94% were on the capsule, including the superficial medial collateral ligament (sMCL) in both groups. For the lateral meniscus, 47% anchors in Group A and 44% anchors in Group B were on the capsule. Total three anchors were over the lateral collateral ligament (LCL), whereas 15 anchors were behind the popliteus tendon (POP). Although all three anchors settled in the subcutaneous fat were in Group B, no significant difference was observed in anchor location between two groups. CONCLUSIONS Secure fixation to thin membranous tissue can be achieved for the medial meniscal repair using FF360, while some were located in/on bunchy LCL or POP in lateral meniscal repair. Only anchors with additional four-millimeter penetration depth were in the subcutaneous fat, although there was no effect of the penetration depth to anchor location. Clinically, for lateral meniscal repair, penetrating toward POP/LCL should be avoided and four-millimeter deeper penetration depth might be a risk for the subcutaneous irritation.

Chronicity of Anterior Cruciate Ligament Deficiency, Part 1: Effects on the Tibiofemoral Relationship Before and Immediately After Anatomic ACL Reconstruction With Autologous Hamstring Grafts:

Background: It remains unclear whether the tibiofemoral relationship in the sagittal plane is restored after anatomic anterior cruciate ligament (ACL) reconstruction, particularly in cases of chronic ACL deficiency (ACLD). Hypothesis: Patients with long-term ACLD will exhibit an anteriorly subluxed tibia both preoperatively and immediately postoperatively, even after anatomic reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: In total, 358 patients who had undergone anatomic ACL reconstruction with autologous semitendinosus grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, all patients underwent lateral radiography in extension to evaluate the tibiofemoral relationship, specifically with regard to anterior tibial subluxation (ATS), space for the ACL (sACL), and extension angle. Demographic and radiographic factors were compared among the 5 groups. Results: Preoperative ATS values in groups 4 (mean ± SD, 2.9 ± 2.1 mm) and 5 (2.6 ± 1.9 mm) were significantly greater than in group 1 (1.6 ± 1.9 mm). Postoperatively, the tibia was posteriorly overconstrained in all groups, and there was no difference in immediately postoperative ATS among the 5 groups. Further evaluation of the tibiofemoral relationship in the sagittal plane revealed that the mean preoperative side-to-side difference in sACL (sACL-SSD) was greater in groups 4 (2.5 ± 1.6 mm) and 5 (2.2 ± 1.7 mm) than in group 1 (1.2 ± 1.5 mm). Immediately after ACL reconstruction, however, there were no group-dependent differences in sACL-SSD. No significant group-dependent differences were found for extension deficit. Conclusion: Chronicity of ACLD had an effect on the preoperative tibiofemoral relationship in the sagittal plane, including ATS and sACL-SSD, especially in patients with ACLD longer than 2 years. However, preoperative extension deficit was not influenced by chronicity. Immediately postoperatively, chronicity did not affect the ability of anatomic ACL reconstruction to reduce subluxation.

Chronicity of Anterior Cruciate Ligament Deficiency, Part 2: Radiographic Predictors of Early Graft Failure

Background: Accumulating evidence suggests that long-term anterior cruciate ligament (ACL) deficiency can give rise to an abnormal tibiofemoral relationship and subsequent intra-articular lesions. However, the effects of chronic ACL deficiency (ACLD) on early graft failure after anatomic reconstruction remain unclear. Hypothesis: We hypothesized that patients with long-term ACLD lasting more than 5 years would have a greater rate of early graft failure due to insufficient intraoperative reduction of the tibia and that the preoperative and immediately postoperative abnormal tibiofemoral relationship in the sagittal plane, such as anterior tibial subluxation (ATS), would correlate with the graft status on postoperative magnetic resonance imaging (MRI). Study Design: Cohort study; Level of evidence, 3. Methods: A total of 358 patients who had undergone anatomic ACL reconstruction with hamstring grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken in all patients to evaluate the tibiofemoral relationship, specifically with regard to ATS, space for the ACL (sACL), and extension angle. All patients underwent MRI at 6 months to reveal graft status. Groups with a high rate of graft failure were further analyzed to compare demographic and radiographic factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors. Results: Graft failure without trauma was observed in 4 (1.8%), 0 (0%), 1 (3.7%), 3 (9.7%), and 8 patients (17.7%) in groups 1, 2, 3, 4, and 5, respectively. Of the 76 patients in groups 4 and 5, significant differences were noted between the failure and intact subgroups in preoperative ATS (4.9 vs 2.4 mm, respectively; P < .01), side-to-side differences in sACL (sACL-SSD) (4.7 vs 1.9 mm, respectively; P < .01), extension deficit (4.4° vs 1.3°, respectively; P < .01), and chondral lesions (P = .02), while postoperative ATS and sACL-SSD showed no differences. Multivariate logistic regression analysis revealed that of these factors, preoperative sACL-SSD could be a risk factor for early graft failure (odds ratio, 3.2; 95% CI, 1.37-7.46). Conclusion Early graft failure at 6 months increased in patients with ACLD longer than 2 years. In this population, preoperative sACL-SSD was the most significant risk factor for early graft failure on MRI. However, immediately postoperative radiographic measurements had no effect on graft failure rates.

Posttraumatic calcaneocuboid impingement syndrome: A case report

Lateral ankleefoot sprain is one of the most common sportsrelated injuries in the younger generation. Following this type of sprain, patients often sustain lateral collateral ligament injury in the ankle joint; however, they occasionally complain of lateral midhind foot pain [1,2]. In cases of fracture and/or dislocation of the associated bones, the diagnosis would be easy due to the presence of strong localized symptoms and valuable findings in radiographs or computed tomography (CT) images. In contrast, if the pain is caused by some soft-tissue injury at the lateral mid-hind foot, the disorder may be overlooked because of its poor physical findings and the lack of remarkable bony lesions in imaging studies. Therefore, this may lead to prolonged lateral mid-hind foot pain after trauma. Some soft-tissue injuries causing persistent lateral mid-hind foot pain have been reported. Cuboid syndrome is calcaneocuboid joint incongruity derived from chronic deficiency of the bifurcated and/or the dorsal calcaneocuboid ligament [1e8]. Peroneal tendon disorders include tendon tear, tendinopathy, tenosynovitis, painful os peroneum syndrome, and distal tendon dislocation (superior subluxation of the peroneus longus due to inferior peroneal retinaculum tear) [9e14]. However, there is no report of residual lateral mid-hind foot pain caused by hypertrophic scar tissue impingement in the calcaneocuboid joint after ankleefoot sprain found in