Shugo Maeda

Intraoperative Navigation Evaluation of Tibial Translation After Resection of Anterior Cruciate Ligament Remnants

PURPOSE This study aimed to assess knee laxity before and after resection of the anterior cruciate ligament (ACL) remnants, using a computer navigation system. METHODS This prospective study included 83 knees undergoing primary navigated ACL reconstruction. ACL remnants were classified into 4 morphologic types based on the arthroscopic findings: type 1, bridging between the posterior cruciate ligament and tibia; type 2, bridging between the roof of the intercondylar notch and tibia; type 3, bridging between the lateral wall of the intercondylar notch and tibia; and type 4, no substantial ACL remnants. Anterior tibial translation (ATT) and range of internal-external rotation of tibia (total rotation) at 15°, 30°, 45°, 60°, 75°, and 90° of knee flexion were measured before and after resection of the ACL remnants by use of the additional functions of the navigation system. RESULTS The different morphologic types of the ACL remnants were as follows: type 1, 12 knees; type 2, 16 knees; type 3, 51 knees; and type 4, 4 knees. There were no significant differences in the mean ATT before and after resection at any knee flexion angle in type 1, 2, or 4 knees. In type 3 knees the mean ATT at 15° of knee flexion before resection significantly increased after resection. There were no significant differences in the mean total rotation before and after resection at any knee flexion angle for each type. After resection of the ACL remnants, 12 knees (14.5%) in the type 3 showed an increased ATT by 3 mm or more. CONCLUSIONS This study suggests that the ACL remnant does not play a major role in stabilization of the knee. Although type 3 ACL remnants significantly decreased anterior knee laxity in the knee extension position, the knee stability provided by the ACL remnants was not adequate. LEVEL OF EVIDENCE Level II, prognostic study.

Comparison between clinical grading and navigation data of knee laxity in ACL-deficient knees

BackgroundThe latest version of the navigation system for anterior cruciate ligament (ACL) reconstruction has the supplementary ability to assess knee stability before and after ACL reconstruction. In this study, we compared navigation data between clinical grades in ACL-deficient knees and also analyzed correlation between clinical grading and navigation data.Methods150 ACL deficient knees that received primary ACL reconstruction using an image-free navigation system were included. For clinical evaluation, the Lachman, anterior drawer, and pivot shift tests were performed under general anesthesia and were graded by an examiner. For the assessment of knee stability using the navigation system, manual tests were performed again before ACL reconstruction. Navigation data were recorded as anteroposterior (AP) displacement of the tibia for the Lachman and anterior drawer tests, and both AP displacement and tibial rotation for the pivot shift test.ResultsNavigation data of each clinical grade were as follows; Lachman test grade 1+: 10.0 mm, grade 2+: 13.2 ± 3.1 mm, grade 3+: 14.5 ± 3.3 mm, anterior drawer test grade 1+: 6.8 ± 1.4 mm, grade 2+: 7.4 ± 1.8 mm, grade 3+: 9.1 ± 2.3 mm, pivot shift test grade 1+: 3.9 ± 1.8 mm/21.5° ± 7.8°, grade 2+: 4.8 ± 2.1 mm/21.8° ± 7.1°, and grade 3+: 6.0 ± 3.2 mm/21.1° ± 7.1°. There were positive correlations between clinical grading and AP displacement in the Lachman, and anterior drawer tests. Although positive correlations between clinical grading and AP displacement in pivot shift test were found, there were no correlations between clinical grading and tibial rotation in pivot shift test.ConclusionsIn response to AP force, the navigation system can provide the surgeon with correct objective data for knee laxity in ACL deficient knees. During the pivot shift test, physicians may grade according to the displacement of the tibia, rather than rotation.

Nocturnal Knee Pain Increases With the Severity of Knee Osteoarthritis, Disturbing Patient Sleep Quality

Sleep disturbances frequently accompany chronic pain from osteoarthritis (OA). Effective management of sleep disturbances may require successful treatment of chronic pain, a key factor in the clinical evaluation of knee OA. However, the relationship between the severity of knee OA and sleep quality is unclear. Our purpose was to correlate the prevalence of nocturnal knee pain with different OA severity levels and to determine its influence on sleep quality.

Prospective Randomized Study of Objective and Subjective Clinical Results Between Double-Bundle and Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: There is controversy as to whether double-bundle anterior cruciate ligament (ACL) reconstruction with hamstring tendon graft (DB-HT) or single-bundle ACL reconstruction with patellar tendon graft (SB-PT) obtains the best clinical outcomes. Purpose: To compare the short-term clinical outcomes of DB-HT with those of rectangular-tunnel SB-PT (RTSB-PT) at 2-year follow-up and to identify the factors that affect subjective knee functional score. Study Design: Randomized controlled trial. Level of evidence, 1. Methods: Sixty-three male patients (mean age, 26.1 years) and 87 female patients (mean age, 25.8 years) were included in this study and were randomly distributed to either the DB-HT (n = 76) or RTSB-PT (n = 74) group. Clinical outcomes (knee flexion range of motion [ROM], heel-height difference, side-to-side difference in anterior laxity, rotational laxity, and Tegner activity score) were compared between the DB-HT and RTSB-PT groups, and examination of factors affecting subjective outcomes (Knee Injury and Osteoarthritis and Outcome Score [KOOS] results) was performed by multiple linear regression analysis. Results: Fourteen patients (9 DB-HT, 5 RTSB-PT) had secondary ACL injury within 2 years after primary ACL reconstruction and were excluded from analysis. In the examination of 136 patients at the 24-month follow-up, there was no significant difference between the 2 groups in clinical or subjective outcomes. The normalized knee extensor strength of the RTSB-PT group showed negative surgical technique effect in the early postoperative phase (P = .005), but there was no significant difference between the 2 groups at the 24-month follow-up (P = .114). There was no significant difference in change of normalized knee flexor strength between the 2 groups (P = .493). Age, sex, body mass index (BMI), and presence of meniscus injury were the factors that affected KOOS subscale scores. Conclusion: In this prospective randomized controlled study, there was no significant difference in the incidence of secondary ACL injury and no difference in objective or subjective outcomes between the DB-HT and RTSB-PT reconstruction at 24-month follow-up. Age, sex, presence of meniscus injury, and BMI affected subjective KOOS subscale scores, while surgical technique did not.

Osteochondral Autograft Transplantation for Advanced Stage Freiberg Disease in Adolescent Athletes: A Report of 3 Cases and Surgical Procedures

Osteochondral infraction of the lesser metatarsal head was initially presented with 6 clinical cases by Freiberg in 1914, and has been called Freiberg disease after his description. Freiberg disease is clinically characterized by higher incidence in the second and third metatarsal head of female teenagers. Although a general consensus of the pathomechanism has not been established, metatarsophalangeal (MTP) joint impingement by singular or repetitive trauma, epiphysial ischemia caused by arterial spasm, and a combination of multiple factors have been advocated as the potential causes. For the early stage of Freiberg disease, as in stage I and II of Smillie’s classification, nonoperative therapy should be applied as the first choice of treatment. Surgical intervention is usually required for stages III and IV of advanced Freiberg disease to relieve symptoms and prevent development of osteoarthritis. Dorsiflexion closingwedge osteotomy of the metatarsal head, which was presented by Gauthier and Elbaz in 1979, has been widely used in the original or with some modifications and satisfactory outcomes have been reported. Although adolescence is the typical age for the onset of symptoms in Freiberg disease, little concern with postoperative return to sports activities has been shown in the literature. Osteochondral autograft transplantation is one of the well-accepted surgical options to treat osteochondral lesions of the knee, ankle, and elbow joints. Recently, Hayashi et al presented a case report of osteochondral autograft transplantation for advanced stage Freiberg disease. In this report of 3 cases, we show the detailed surgical procedures of osteochondral plug transplantation into the metatarsal head in Freiberg disease, and the shortterm results with a concern for return to sports.

The Knee injury and Osteoarthritis Outcome Score reflects the severity of knee osteoarthritis better than the revised Knee Society Score in a general Japanese population

PURPOSE The purposes of this study were to examine population-based reference data for sex- and age-related differences between the 2011 revised Knee Society Score (KSS2011) and the Knee injury and Osteoarthritis Outcome Score (KOOS), to assess the correlation between those scores and radiographic knee osteoarthritis (OA), and to validate the use of the scores in a general Japanese population. METHODS This cross-sectional study included 963 volunteers (368 males, 595 females; mean age: 54.7years). Participants were classified into five subgroups by age: under 40, 40s, 50s, 60s, and over 70years old. The KSS2011 and KOOS were determined using self-administered questionnaires. Weight-bearing radiographs of the bilateral knee were taken and graded according to the Kellgren-Lawrence (KL) scale. The mean KSS2011 and KOOS were compared among age groups. Correlations between the severity of knee OA and each score were assessed using multiple regression analysis. RESULTS The overall KSS2011 tended to gradually decrease with age. Most subscales of the KSS2011 did not show sex-related differences. Similarly, the overall KOOS and all its subscales steadily decreased by approximately 20 points per decade with age. Most subscales of the KOOS were significantly decreased in females over 50. The KL grade was significantly related to both the overall KOOS (β=-0.42, p<0.001) and KSS2011 (β=-0.13, p=0.001), though the correlation to the KOOS was stronger. CONCLUSION The overall KSS2011 and KOOS appear to decrease with age. In this population, the KOOS reflects the severity of knee OA better than the KSS2011.

Hyaluronic acid induces the release of growth factors from platelet-rich plasma

Background/Objective Platelet-rich plasma (PRP) and hyaluronic acid (HA) injection are both therapeutic options for osteoarthritis and chronic tendinopathy. Although several comparative studies on the two have been published, the effects of mixing PRP and HA are not fully understood. The purpose of this study is to investigate the influence of HA on platelets in PRP by measuring releasing growth factors. Methods PRP was produced from nine healthy adult volunteers (mean age, 32.8 ± 2.9 years; range, 29–37) with a commercial separation system. HA of weight-average molecular weight of 50–120 kDa was used. PRP group (PRP 1 mL + phosphate buffered saline 0.2 mL) and PRP + HA group (PRP 1 mL + HA 0.2 mL) were incubated at 37°C for 2 hours. The amounts of transforming growth factor β1 (TGF-β1) and platelet-derived growth factor (PDGF-AA) released from the PRP and PRP + HA samples were measured on Day 0, Day 3, and Day 5. In addition, the same growth factors on Day 5 were measured for PRP + high HA group (PRP 1 mL + HA 0.6 mL) with five donors. After collecting all of the samples on Day 5, the remaining gels were observed with Giemsa stain. Statistical analyses were performed using paired t tests to compare the PRP and HA groups at each time point, and a one-way analysis of variance (one-way ANOVA) with Tukey post hoc tests was used to compare the PRP, PRP + HA, and PRP + high HA groups. Results The TGF-β1 concentrations in the PRP and PRP + HA were 24.3 ± 7.2 μg/mL and 22.4 ± 1.8 μg/mL (p = 0.689) on Day 0, 17.2 ± 13.9 μg/mL and 25.4 ± 7.1 μg/mL (p = 0.331) on Day 3, and 12.7 ± 10.5 μg/mL and 33.7 ± 8.3 μg/mL (p = 0.034) on Day 5. The TGF-β1 concentrations on Day 5 were 24.1 ± 5.2 μg/mL (PRP group), 28.3 ± 2.4 μg/mL (PRP + HA), and 31.9 ± 4.8 μg/mL (PRP + high HA; one-way ANOVA: p = 0.003; post hoc PRP vs. PRP + HA: p = 0.016). The PDGF-AA concentrations in the PRP and PRP + HA groups were 2.30 ± 1.21 μg/mL and 2.32 ± 0.79 μg/mL (p = 0.931) on Day 0, 2.03 ± 0.53 μg/mL and 2.13 ± 0.73 μg/mL (p = 0.500) on Day 3, and 1.51 ± 0.40 μg/mL and 2.00 ± 0.52 μg/mL (p = 0.003) on Day 5. The PDGF-AA concentrations were 1.48 ± 0.46 μg/mL (PRP group), 1.94 ± 0.57 μg/mL (PRP + HA), and 2.69 ± 0.70 μg/mL (PRP + high HA; one-way ANOVA: p = 0.0002; PRP vs. PRP + high HA: p = 0.002; PRP + HA vs. PRP + high HA: p = 0.011) on Day 5. The PRP showed larger coagulated masses than the PRP + HA. The high concentration HA group had the smallest coagulated mass of all of the group. Conclusion The levels of growth factors released by PRP on Day 5 were increased by the addition of HA. A mixture of PRP and HA may be a more effective therapy than PRP or HA alone for osteoarthritis and tendinopathy.

TRUNK MOTION AND MUSCULAR STRENGTH AFFECT KNEE VALGUS MOMENT DURING SINGLE-LEG LANDING AFTER OVERHEAD STROKE IN BADMINTON

Background Anterior cruciate ligament (ACL) injury in knees opposite to the racket-hand side frequent occurs during single-leg landing after overhead stroke in badminton. Although large lateral inclination of trunk during single-leg landing seems to generate knee valgus moment which causes ACL injury, it has not been examined. Objective To evaluate if there was a correlation between trunk kinematics and knee valgus moment during single-leg landing after overhead stroke, in addition, to evaluate an association with muscular strength of trunk. Design Controlled laboratory study. Setting Female college badminton players with no history of knee injury. Participants 8 right-handed players. Risk factor assessment Subjects performed single-left-legged landing after an overhead stroke following back-stepping. The kinematic and kinetic data of the trunk and left lower extremity during landing were measured using 3-dimensional motion analysis system. Isometric trunk flexion and extension strength was measured using a dynamometer. Main outcome measurement Change in lateral trunk bending angle and maximum knee valgus moment during landing were measured. The correlation between these and trunk strength were analyzed. Results The average of maximum knee valgus moment was 0.34±0.24 Nm/kg/m, and the change in lateral trunk bending angle was 22.9±13.3 degrees, respectively. The mean trunk flexion strength was 2.2±0.9 Nm/kg. The knee valgus moment was significantly correlated with the change in lateral trunk bending angle (r=0.87, P<.05) and the trunk flexion strength (r=−0.94, P<.01). The change in lateral trunk bending angle was also significantly correlated with the trunk flexion strength (r=−0.94, P<.01). Conclusions Larger lateral trunk bending associated with weak flexion strength increased knee valgus moment during single-leg landing. The core muscle training focused on trunk flexion strength may improve neuromuscular control of trunk and avoid excessive knee valgus moment in playing badminton, and this may play an important role of ACL injury prevention.

Characteristics of elongated and ruptured anterior cruciate ligament grafts: An analysis of 21 consecutive revision cases

Background/objective Anterior cruciate ligament (ACL) reconstructions often fail without graft rupture. The purpose of this study was to compare the characteristics of patients with elongated and ruptured bone-patellar tendon-bone (BTB) grafts that required revision surgery. Methods Twenty one patients who required revisions of a BTB-reconstructed ACL between 2010 and 2015 were enrolled in this study. All patients were evaluated for bone tunnel position using computed tomography. Tunnel angle was calculated with radiographs. Stability under anaesthesia, and meniscus and cartilage condition were evaluated during the revision surgery. Age at primary surgery, time between primary and revision surgery, activity level, original tunnel position of the graft, and meniscus and cartilage condition were compared between elongated and ruptured grafts. Results Age at primary surgery was not significantly different between the two groups (p = 0.528). Time between primary and revision surgery as well as activity level were also not significantly different between the two groups (p = 0.010 and p = 0.307, respectively). Femoral bone tunnel position was more proximal (p = 0.003), and radiographic tunnel angle was not significantly different between the two groups (p = 0.029). The rupture group was significantly more unstable on the pivot shift (p < 0.003). Meniscus degeneration, meniscus tear, and cartilage damage were not significantly different between the two groups (p = 0.030, p = 0.311, and p = 0.505, respectively). Conclusion The location of the original femoral tunnel was more proximal in patients with elongated grafts than in those with ruptured grafts. Different bone tunnel position from native ACL might lead to graft elongation.

Severe valgus knee deformity caused by chondronecrosis after using a radiofrequency device

Currently, radiofrequency (RF) devices are widely used because of their speed and convenience during arthroscopic surgery, including meniscectomy. Discoid meniscus is a common cause of knee pain, giving way, snapping, clunking and locking in children, and arthroscopic meniscectomy is often performed to relieve these symptoms. Although complications related to RF devices have been reported [1, 2], these are few in number. Generally, the RF device is considered safe if used correctly. However, we experienced a case of chondronecrosis of the knee after lateral discoid meniscectomy from using an RF device. The patient and her parents gave informed consent for submission of data for publication.