Michiya Hara

Evaluation of patellar retinacular tension during total knee arthroplasty: Special emphasis on lateral retinacular release

Tension of a suture placed to the patella to close the medial capsule during 35 primary total knee arthroplasties was measured. The increase in tension with flexion after arthrotomy was significantly smaller in 10 knees with a subvastus incision (subvastus group) than in 25 knees with a standard medial parapatellar incision (standard group). With the prosthesis in place, the patella showed maltracking with the no-thumb technique in 1 knee (10%) of the subvastus group and in 9 knees (36%) of the standard group. A lateral retinacular release was performed in 5 of these 10 knees but not in the remaining 5 knees because the increase in tension was a minimum. There was no case of patellar maltracking at an average follow-up period of 2.1 years after surgery, suggesting that a lateral release is not always needed if retinacular tension shows no significant increase, even cases where the patella dislocates with the no-thumb technique.

the relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty

Neglect-like symptoms have been defined as a loss of perception of a limb, with pain and excessive effort necessary to move the limb. This phenomenon has been studied in patients with complex regional pain syndrome, but has not been assessed in patients who have undergone orthopedic procedures such as total knee arthroplasty. The authors of this study assessed neglect-like symptoms in a group of 90 patients three and six weeks after total knee arthroplasty.

The effect of surgical dissections on blood flow to the tibial tubercle

Tibial tubercle transfer is often used for the treatment of patella maltracking. Because the periosteum of both sides of the tibia is stripped off along the tibial tubercle and then the bilateral cortices are transferred, this procedure may disturb the blood supply to the tibial tubercle. However, the blood supply to the tibial tubercle has not yet been clearly elucidated. The purpose of this study is to investigate the effect of surgical dissection on blood flow to the tibial tubercle in an animal model using a hydrogen washout technique. Eleven knees of nine mongrel dogs weighing from 7.0 to 19.1 kg were utilized. The blood flow was measured using a hydrogen washout technique. Before performing the surgical procedures, the control blood flow rate of the tibial tubercle averaged 19.6 ml/min per 100 g of tissue. The blood flow rate did not significantly decrease after transecting the periosteum on the lateral side of the tibia alone (P > 0.05). After completing the tibial tubercle osteotomy, the blood flow rate averaged 11.5 ml/min per 100 g of tissue, which is a 25.3% decrease as compared with the value after transecting the periosteum on the lateral side of the tibia alone (P < 0.05). The blood flow rate significantly decreased to 3.4 ml/min per 100 g of tissue after the distal periosteal transection and osteotomy of the distal cortex of the tibial tubercle (P < 0.05). The addition of a medial periosteal transection caused a complete arrest of the blood flow in 10 out of 11 knees, or a 91.2% decrease as compared with the value after a distal periosteal transection and osteotomy of the distal cortex of the tibial tubercle (P < 0.05).

Analysis of the significance of the measurement of acceleration with respect to lateral laxity of the anterior cruciate ligament insufficient knee

Abstract The purpose of this study was to assess dynamically the lateral thrust of anterior cruciate ligament (ACL) insufficient knees, and from the findings determine any relationship between ACL insufficiency and the later development of osteoarthritis (OA). We investigated 80 knees in 40 patients awaiting ACL reconstruction and 25 knees of 25 patients, which had undergone ACL reconstruction. An acceleration sensor was fixed to the anterior tibial tubercle and this ’acted’ in two directions – medial lateral and perpendicular. The peak value of the lateral acceleration immediately after heel strike was significantly greater in the ACL insufficient knees when compared to their opposite normal knees. When the periods from injury were compared, the lateral thrust of the injured side after 3 years or more was significantly greater than in the first 3 years. There was no significant difference between the normal knees and the ACL reconstructed knees. The results indicated that the lateral acceleration peak value was significantly greater in the ACL insufficient knees than in their opposite normal knees.Résumé  A partir d’une évaluation dynamique de l’instabilité de genoux atteints d’insuffisance du ligament croisé antérieur (LCA), nous avons tenté de déterminer la relation entre l’apparition de l’arthrose du genou et l’insuffisance du LCA. Notre étude a porté sur 40 patients (80 genoux) devant subir une opération de reconstruction du LCA et 25 patients (25 genoux) après l’opération de reconstruction du LCA. Des détecteurs d’accélération ont été placé sur la tubérosité tibiale antérieure. Les pics d’accélération latérale suivant immédiatement le contact au sol du talon étaient significativement plus élevés chez les patients avec un genou atteint d’insuffisance du LCA que chez les patients normaux. Il est également apparu que les pics d’accélération latérale étaient significativement plus élevés dans les cas ou le délai après l’altération du LCA étaient de 3 ans ou plus que dans les cas ou cette période était inférieure à 3 ans. L’opération de reconstruction a permis une diminution significative des pics d’accélération au point que ceux-ci ne présentaient aucune différence significative avec ceux enregistrés avec les genoux normaux.

The effect of wedged insoles on the lateral thrust of anterior cruciate ligament-insufficient knees

Background Patients with untreated anterior cruciate ligament insufficiency often develop osteoarthritis. In Japan, laterally or medially elevated insoles have been widely used for the relief of symptoms associated with unicompartmental osteoarthritis of the knee. Hypothesis The use of a valgus wedge in the shoe of a patient with anterior cruciate ligament insufficiency will decrease lateral thrust. Study Design Controlled laboratory study. Methods An accelerometer was used to measure thrust force in 60 control knees and 35 knees with anterior cruciate ligament insufficiency. The sensor was attached to the affected and the control anterior tibial tubercles to record motion in the medial-lateral and perpendicular directions. The lateral thrust immediately after heel strike was measured continuously by a telemeter under stabilized walking conditions. Measurements were made both with and without wedged insoles. Results When compared with the control knee, the peak value of lateral acceleration immediately after heel strike was significantly greater in the anterior cruciate ligament-insufficient knees. However, lateral thrust decreased significantly in the anterior cruciate ligament-insufficient knees when a wedged insole was used. Conclusions Use of an insole resulted in a significant decrease in lateral thrust, even in anterior cruciate ligament-insufficient knees. Clinical Relevance Use of an insole is one possible prophylaxis for osteoarthritis for an anterior cruciate ligament-insufficient knee.

Magnetic resonance evaluation of remodeling process in patellar tendon graft.

Several studies have shown the accuracy of magnetic resonance imaging in evaluating the reconstructed anterior cruciate ligament. The purpose of the current study was to clarify the clinical usefulness of magnetic resonance imaging for evaluating the reconstructed anterior cruciate ligament in comparison with using arthroscopy. Sixty-nine patients who had an anterior cruciate ligament reconstruction using a bone-tendon-bone autograft were examined by magnetic resonance imaging and arthroscopy an average of 12 months after surgery. There were 41 males and 28 females with an average age of 25.9 years (range, 15–66 years). The interval from surgery to the magnetic resonance imaging or arthroscopic evaluation was a mean of 12 months (range, 4–32 months). The magnetic resonance imaging findings of the reconstructed anterior cruciate ligament were classified as either high, intermediate, or low intensity. The arthroscopic findings also were classified as either graft impingement at the intercondylar notch or no impingement. In the 47 anterior cruciate ligament grafts that were not impinged, the signal intensity remained low and did not increase during second-look arthroscopy. In contrast, 22 anterior cruciate ligament grafts that were impinged showed an increased signal intensity in the distal area of the graft at the time of the second-look arthroscopy. Furthermore, no significant correlation was observed between the presence of a high signal intensity and postoperative instability. The high signal intensity of the anterior cruciate ligament graft on magnetic resonance imaging was found to be caused by graft impingement. These findings therefore show a clear association between graft impingement and the subsequent appearance of the graft on magnetic resonance imaging.

Adductor insertion avulsion syndrome mimicking neoplastic processes in a 14-year-old long-distance runner.

Adductor insertion avulsion syndrome, also known as thigh splints, is an uncommon condition that can mimic primary bone tumors or osteomyelitis. This article describes the clinical and imaging findings of adductor insertion avulsion syndrome in a 14-year-old male long-distance runner. The patient presented with a 1-month history of progressively worsening pain in the medial aspect of the left thigh. No significant findings were noted on physical examination except slight tenderness to palpation. Radiographs revealed an intracortical radiolucent lesion with a solid periosteal reaction in the medial aspect of the femoral diaphysis. Bone scintigraphy showed an increased uptake corresponding with the lesion of the left medial femoral diaphysis. Computed tomography confirmed the presence of periosteal reaction and intracortical linear hypoattenuation and showed no fracture line. Magnetic resonance imaging revealed periosteal, cortical, and intramedullary signal intensity abnormalities. These clinical and radiologic features suggested adductor insertion avulsion syndrome. The patient was treated with initial avoidance of weight bearing using 2 crutches for ambulation, followed by progressive weight bearing over a period of 2 weeks. The symptom resolved completely 7 weeks after initial evaluation, and the patient had normal gait without pain. Knowledge of this condition is important for the appropriate interpretation of imaging findings and the avoidance of unnecessary biopsy with potentially misleading results. Moreover, this case provides a time line as a reference for the rehabilitation of patients in similar cases.

Immediate effects of leg-press exercises with tibial internal rotation on individuals with medial knee osteoarthritis

OBJECTIVE Although patients with knee osteoarthritis (OA) demonstrate abnormal kinematics involving greater tibial external rotation during squatting, there have not been any previous studies investigating an exercise focused on correcting knee rotational kinematics. This study aimed to determine the immediate effects of exercise with tibial internal rotation (IR) on symptoms and functions in patients with knee osteoarthritis (KOA). METHODS This study provides Level II evidence using a small randomized controlled trial. Sixty patients were allocated to either the tibial IR or neutral rotation (NR) group in this randomized controlled trial. The IR group performed a leg press activity with the tibia in maximal IR, whereas the NR group performed leg press activity with the tibia in NR. Outcome measures were (a) 10-m walk test; (b) Timed Up and Go test, (c) knee flexion angle while squatting, (d) knee pain during walking and squatting, and (e) difficulty during walking and squatting. RESULTS Significant interaction was observed in all outcomes. The IR group exhibited significant improvement on all outcome measures, whereas the NR group exhibited significant improvements only in the 10-m walk. CONCLUSION The IR group exhibited greater improvements than the NR group on all outcome measures. After a single session, leg press activity with the tibia in maximal IR improved the symptoms and functions measured in this study more effectively than leg press activity with the tibia in a neutral position. This suggests that correcting rotational malalignment is more important than strengthening the quadriceps for maintaining or even improving function of OA knees. (Clinical trials registration number: UMIN000021751).