Kyle S. Jansson

Altered Tibiofemoral Contact Mechanics Due to Lateral Meniscus Posterior Horn Root Avulsions and Radial Tears Can Be Restored with in Situ Pull-Out Suture Repairs

BACKGROUND An avulsion of the posterior root attachment of the lateral meniscus or a radial tear close to the root attachment can lead to degenerative knee arthritis. Although the biomechanical effects of comparable injuries involving the medial meniscus have been studied, we are aware of no such study involving the lateral meniscus. We hypothesized that in situ pull-out suture repair of lateral meniscus root avulsions and of complete radial tears 3 and 6 mm from the root attachment would increase the contact area and decrease mean and peak tibiofemoral contact pressures, at all knee flexion angles, relative to the corresponding avulsion or tear condition. METHODS Eight human cadaveric knees underwent biomechanical testing. Eight lateral meniscus conditions (intact, footprint tear, root avulsion, root avulsion repair, radial tears at 3 and 6 mm from the posterior root, and repairs of the 3 and 6-mm tears) were tested at five different flexion angles (0°, 30°, 45°, 60°, and 90°) under a compressive 1000-N load. RESULTS Avulsion of the posterior root of the lateral meniscus or an adjacent radial tear resulted in significantly decreased contact area and increased mean and peak contact pressures in the lateral compartment, relative to the intact condition, in all cases except the root avulsion condition at 0° of flexion. In situ pull-out suture repair of the root avulsion or radial tear significantly reduced mean contact pressures, relative to the corresponding avulsion or tear condition, when the results for each condition were pooled across all flexion angles. CONCLUSIONS Posterior horn root avulsions and radial tears adjacent to the root attachment of the lateral meniscus significantly increased contact pressures in the lateral compartment. In situ pull-out suture repairs of these tears significantly improved lateral compartment joint contact pressures. CLINICAL RELEVANCE In situ repair may be an effective treatment to improve tibiofemoral contact profiles after an avulsion of the posterior root of the lateral meniscus or a complete radial tear adjacent to the root. In situ repairs should be further investigated clinically as an alternative to partial lateral meniscectomy.

Tekscan pressure sensor output changes in the presence of liquid exposure

The purpose of the study was to evaluate the load output of a pressure sensor in the presence of liquid saturation in a controlled environment. We hypothesized that a calibrated pressure sensor would provide diminishing load outputs over time in controlled environments of both humidified air and while submerged in saline and the sensors would reach a steady state output once saturated. A consistent compressive load was repeatedly applied to pressure sensors over time (Model 4000, Tekscan, Inc., South Boston, MA) with a tensile testing machine (Instron ElectroPuls E10000, Norwood, MA). All sensors were initially calibrated in a dry environment and were tested in three groups: humid air, submerged in 0.9% saline solution, and dry. Linear regression of load output over time for the pressure sensors exposed to humidity and submerged showed a 4.6% and 4.7% decline in load output each hour for the initial 6h, respectively (β=-0.046, 95% CI: [-0.053 to -0.039]; p<0.001) (β=-0.047, 95% CI: [-0.053 to -0.042; p<0.001). Tests after 72 h of exposure had linear regression decline in load output over time of 0.40% and 0.47% per hour for humidified and submerged sensors, respectively (β=-0.004, 95% CI: [-0.006 to -0.003]; p<0.001) (β=-0.047, 95% CI: [-0.053 to -0.042]; p<0.001). Because outcomes in biomedical research can affect clinical practices and treatments, the diminishing load output of the sensor in the presence of liquids should be accounted for. We recommend soaking sensors for more than 48 h prior to testing in a moist environment.

Characterization of robotic system passive path repeatability during specimen removal and reinstallation for in vitro knee joint testing

Robotic testing systems are commonly utilized for the study of orthopaedic biomechanics. Quantification of system error is essential for reliable use of robotic systems. Therefore, the purpose of this study was to quantify a 6-DOF robotic systems repeatability during knee biomechanical testing and characterize the error induced in passive path repeatability by removing and reinstalling the knee. We hypothesized removing and reinstalling the knee would substantially alter passive path repeatability. Testing was performed on four fresh-frozen cadaver knees. To determine repeatability and reproducibility, the passive path was collected three times per knee following the initial setup (intra-setup), and a single time following two subsequent re-setups (inter-setup). Repeatability was calculated as root mean square error. The intra-setup passive path had a position repeatability of 0.23 mm. In contrast, inter-setup passive paths had a position repeatability of 0.89 mm. When a previously collected passive path was replayed following re-setup of the knee, resultant total force repeatability across the passive path increased to 28.2N (6.4N medial-lateral, 25.4N proximal-distal, and 10.5 N anterior-posterior). This study demonstrated that removal and re-setup of a knee can have substantial, clinically significant changes on our systems repeatability and ultimately, accuracy of the reported results.

Fracture mechanics of the femoral neck in a composite bone model: effects of platen geometry.

Load applicator (platen) geometry used for axial load to failure testing of the femoral neck varies between studies and the biomechanical consequences are unknown. The purpose of this study was to determine if load application with a flat versus a conical platen results in differing fracture mechanics. Femurs were aligned in 25° of adduction and an axial compressive force was applied to the femoral heads at a rate of 6 mm/min until failure. Load application with the conical platen resulted in an average ultimate failure load, stiffness, and energy to failure of 9067 N, 4033 N/mm, and 12.12 J, respectively. Load application with the flat platen resulted in a significant (p<0.05) reduction in ultimate failure load (7620 N) and stiffness (2924 N/mm). Energy to failure (12.30 J) was not significantly different (p=0.893). Different fracture patterns were observed for the two platens and the conical platen produced fractures more similar to clinical observations. Use of a flat platen underestimates the strength and stiffness of the femoral neck and inaccurately predicts the associated fracture pattern. These findings must be considered when interpreting the results of prior biomechanical studies on femoral neck fracture and for the development of future femoral neck fracture models.

Biomechanical Consequences of a Complete Radial Tear Adjacent to the Medial Meniscus Posterior Root Attachment Site

Objectives: Complete radial tears near the medial meniscus posterior root attachment site disrupt the circumferential integrity of the meniscus (similar to a posterior root avulsion). These tears can compromise the circumferential integrity and have been reported in biomechanical studies to simulate the meniscectomized state. The purpose of the study was to quantify the tibiofemoral contact load and contact area changes that occur in cadaveric knees from complete posterior horn radial tears and subsequent repairs of the medial meniscus adjacent to the posterior root attachment site. Methods: Six non-paired fresh-frozen human cadaveric knees each underwent 45 different testing conditions: 9 medial meniscus conditions (intact, root avulsion, root repair, serial radial tear and in-situ repair at 3, 6, and 9 mm from the root attachment site) at 5 flexion angles (0°, 30°, 45°, 60° and 90°); under a 1000-N axial load. Tekscan sensors were used to measure contact area and pressure in the medial and lateral compartments. Results: The medial meniscus root avulsion and all radial tear conditions resulted in significantly decreased contact area and increased mean contact pressure compared with the intact state for knee flexion angles beyond 0° (P < .05). Medial Compartment Contact Area Individual comparisons of meniscus conditions for results at 30°, 45°, 60° and 90° of flexion demonstrated the following. At each angle, the root avulsion and 3, 6 and 9 mm radial tears resulted in a significant reduction (range 33%-45% decrease) in medial compartment contact area. Medial Compartment Contact PressureIndividual comparisons of meniscus conditions were performed at 30°, 45°, 60° and 90° of flexion. At each angle, the root avulsion and all radial tears resulted in a significant increase in average contact pressure (range 46%-110%) when compared to the intact meniscus. Root Repair and In-situ Repairs The root repair and in-situ repairs restored contact area and pressure to levels statistically indistinguishable from the intact meniscus, and increased contact area and decreased contact pressure when compared to the corresponding tear conditions (Figure). Conclusion: Posterior horn radial tears adjacent to the medial meniscus root that extend to the meniscocapsular junction can lead to derangement of the loading profiles of the medial compartment that are similar to a root avulsion. Repair of these radial tears with an in-situ pullout technique restored joint mechanics to the intact state. Clinical Relevance Complete radial tears of the posterior horn of the medial meniscus, are biomechanically equivalent to root avulsions and could potentially lead to medial compartment arthrosis. An in-situ repair offers an alternative treatment to meniscectomy and can reestablish the posterior anchor point, thus improving load distribution in the medial compartment.

Comparison of Lateralizing Calcaneal Osteotomies for Varus Hindfoot Correction

Background: There is limited consensus on the optimal operative technique for correcting heel varus in patients with Charcot-Marie-Tooth (CMT) disease. This comparative study evaluated the ability of 4 lateralizing calcaneal osteotomies, with and without Dwyer wedge resection and coronal rotation of the posterior tuberosity, to correct severe heel varus. Methods: The computed tomography (CT) scan of a teenage CMT patient with severe hindfoot varus was used to create 3-dimensional (3D)–printed models of the talus, calcaneus, and cuboid. A custom jig facilitated precise replication of the osteotomy cuts. Four different configurations were created: oblique osteotomy with lateralization, oblique osteotomy with lateralization and internal rotation of the posterior tuberosity, Dwyer wedge resection with lateralization, and Dwyer wedge resection with lateralization and internal rotation. CT scans were performed on each model before and after osteotomy. Statistical analysis was used to evaluate differences in several predefined radiographic parameters. Results: The sequential transformations generated increasing lateral translation of the weight-bearing calcaneus. Dwyer wedge osteotomy significantly improved lateralization (effect = 8.0 mm), valgus hindfoot angle (effect = 6.1 degrees), and coronal calcaneal tilt (effect = −17.6 degrees) compared with the oblique osteotomy. Internal rotation of the posterior tuberosity further improved lateralization (effect = 3.3 mm), valgus hindfoot angle (effect = 2.5 degrees), and coronal calcaneal tilt (effect = −11.7 degrees). Dwyer osteotomy models had on average 5-mm shorter posterior tuberosity lengths than the oblique osteotomies. The addition of rotation did not significantly affect length. Conclusions: Significant lateralization of the posterior tuberosity was achieved in all transformations. The Dwyer wedge osteotomy improved hindfoot valgus angle, coronal calcaneal tilt, and lateralization of the weight-bearing surface compared with oblique osteotomy. Posterior tuberosity internal rotation further lateralized the plantar surface and normalized weight bearing. Lateralization, combined with Dwyer osteotomy and coronal plane internal rotation, achieved the greatest correction of varus heel. Clinical Relevance: This study compares multiple lateralizing calcaneal osteotomies and proposes a combined technique of lateralization, Dwyer wedge resection, and coronal plane rotation to address advanced cavovarus hindfoot deformities.

The ability of massive osteochondral allografts from the medial tibial plateau to reproduce normal joint contact pressures after glenoid resurfacing: the effect of computed tomography matching

BACKGROUND Current techniques for resurfacing of the glenoid in the treatment of arthritis are unpredictable. Computed tomography (CT) studies have demonstrated that the medial tibial plateau has close similarity to the glenoid. The purpose of this study was to assess contact pressures of transplanted massive tibial osteochondral allografts to resurface the glenoid without and with CT matching. METHODS Ten unmatched cadaveric tibiae were used to resurface 10 cadaveric glenoids with osteochondral allografts. Five cadaveric tibiae and glenoids were CT matched and studied. An internal control group of 4 matched pairs of glenoids, with the contralateral glenoid transplanted to the opposite glenoid, was also included as a best-case scenario to measure the effects of the surgical technique. All glenoids were tested before and after grafting at different abduction and rotation angles, with recording of peak contact pressures. RESULTS Peak contact pressures were not different from the intact state in the autografted group but were increased in both allografted groups. CT-matched tibial grafts had lower peak pressures than unmatched grafts. Peak pressures were on average 24.8% (range [18.3%, 29.6%]) greater than in the native glenoids for unmatched allografts, 21.8% ([17.0%, 25.5%]) greater for the matched allografts, and 4.9% ([3.8%, 5.5%]) greater for matched autografts. CONCLUSION Osteochondral grafting from the medial tibial plateau to the glenoid is feasible but results in increased peak contact pressures. The technique is reproducible as defined by the autografted group. Contact pressures between native and allografted glenoids were significantly different. The clinical significance remains unknown. Peak pressures experienced by the glenoid seem highly sensitive to deviations from the native glenoid shape.