Yukiyoshi Toritsuka

Autologous bone marrow stromal cell transplantation for repair of full-thickness articular cartilage defects in human patellae : two case reports

This study assessed the effectiveness of autologous bone marrow stromal cell transplantation for the repair of full-thickness articular cartilage defects in the patellae of a 26-year-old female and a 44-year-old male. These two patients presented in our clinic because their knee pain prevented them from walking normally. After thorough examination, we concluded that the knee pain was due to the injured articular cartilage and decided to repair the defect with bone marrow stromal cell transplantation. Three weeks before transplantation, bone marrow was aspirated from the iliac crest of each patient. After erythrocytes had been removed by use of dextran, the remaining nucleated cells were placed in culture. When the attached cells reached subconfluence, they were passaged to expand in culture. Adherent cells were subsequently collected, embedded in a collagen gel, transplanted into the articular cartilage defect in the patellae, and covered with autologous periosteum. Six months after transplantation, clinical symptoms (pain and walking ability) had improved significantly and the improvement has remained in effect (5 years and 9 months posttransplantation in one case, and 4 years in the other), and both patients have been satisfied with the outcome. As early as 2 months after transplantation, the defects were covered with tissue that showed slight metachromatic staining. Two years after the first and 1 year after the second transplantation, arthroscopy was performed and the defects were repaired with fibrocartilage. Results indicate autologous bone marrow stromal cell transplantation is an effective approach in promoting the repair of articular cartilage defects.

Rectangular Tunnel Double-Bundle Anterior Cruciate Ligament Reconstruction with Bone-Patellar Tendon-Bone Graft to Mimic Natural Fiber Arrangement

We describe our current technique of anatomic, double-bundle (DB), rectangular tunnel anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) graft. This technique mimics the natural, or anatomic, arrangement of the native ACL fibers. This technique has the following advantages: (1) creation of a DB ACL reconstruction with a single BPTB graft; (2) maximization of graft-tunnel contact area; (3) containment of the tunnel apertures within the anatomic ACL attachment footprint; (4) rotational control of the graft within the tunnels during and after fixation; and (5) preservation of notch anatomy.

Allograft Anterior Cruciate Ligament Reconstruction

Tendon allograft is one of the useful ways to reconstruct the anterior cruciate ligament (ACL) without sacrificing normal tissues. Because it has advantages and disadvantages/concerns, this article makes suggestions regarding graft collection/selection, indication for the procedure, graft preparation, the currently performed technique to mimic the anatomic two bundles of ACL, and postoperative rehabilitation.

Acute Grade III Medial Collateral Ligament Injury of the Knee Associated with Anterior Cruciate Ligament Tear The Usefulness of Magnetic Resonance Imaging in Determining a Treatment Regimen

Background: The appropriate management of acute grade III medial collateral ligament injury when it is combined with a torn anterior cruciate ligament has not been determined. Hypothesis: Magnetic resonance imaging grading of grade III medial collateral ligament injury in patients who also have anterior cruciate ligament injury correlates with the outcome of their nonoperative treatment. Study Design: Prospective cohort study. Methods: Seventeen patients were first treated nonoperatively with bracing. Eleven patients with restored valgus stability received anterior cruciate ligament reconstruction only, and six with residual valgus laxity also received medial collateral ligament surgery. Results: Magnetic resonance imaging depicted complete disruption of the superficial layer of the medial collateral ligament in all 17 patients and disruption of the deep layer in 14. Restoration of valgus stability was significantly correlated with the location of superficial fiber damage. Damage was evident over the whole length of the superficial layer in five patients, and all five patients had residual valgus laxity despite bracing. Both groups had good-to-excellent results 5 years later. Conclusions: Location of injury in the superficial layer may be useful in predicting the outcome of nonoperative treatment for acute grade III medial collateral ligament lesions combined with anterior cruciate ligament injury.

Arthroscopic Anterior Cruciate Ligament Reconstruction Using Fresh-Frozen Bone Plug-Free Allogeneic Tendons : 10-Year Follow-up

PURPOSEnTo evaluate the long-term outcomes following arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction using fresh-frozen allogeneic tendon.nnnMETHODSnSixty-one athletically active patients (mean age at surgery, 20.9 years) who had arthroscopic-assisted ACL reconstruction using fresh-frozen free tendon allograft underwent physical examination, instrumented laxity measurement, radiographs, and thigh muscle strength at 10 to 14 years (mean, 11.5) postoperatively, and these data were compared with results of similar measurements obtained at 2 years postoperatively.nnnRESULTSnLachman test and pivot shift test were maintained as negative in 53 (87%) and 52 (85%) patients at follow-up, respectively. Quantitative measurements using the KT-2000 knee arthrometer showed 1.6 +/- 1.3 (mean +/- SD) mm in the side-to-side difference, and no more than 3 mm in 56 patients (92%) at final follow-up. All but one was assessed as normal or nearly normal by International Knee Documentation Committee score. Patient activity level was decreased at the long-term follow-up, but this change was mainly associated with changes in social context (e.g., graduation from school) rather than with knee limitations. None of the patients experienced deep infection or graft rejection. Degenerative joint disease on radiographs was seen in 13 out of 15 patients (87%) whose menisci had been excised, whereas it was observed in 12 out of 46 (26%) whose menisci had been preserved.nnnCONCLUSIONSnA series of 61 patients with fresh-frozen bone plug-free tendon allografts using a 2-incision technique for arthroscopic ACL reconstruction results in long-term knee stabilization and functioning among young active individuals while simultaneously avoiding graft harvest site morbidity.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Optimization of Graft Fixation at the Time of Anterior Cruciate Ligament Reconstruction: Part II: Effect of Knee Flexion Angle

Background There is no consensus about flexion angle of the knee at the time of graft fixation in anterior cruciate ligament reconstruction. Purpose To evaluate the effect of flexion angle at the final graft fixation on the positional relationship as well as the load between femur and tibia. Study Design Controlled laboratory study. Methods Six intact cadaveric knees were passively flexed and extended under 6 degrees of freedom with the robotic system developed in our laboratory, while their 3-dimensional paths were recorded. Anterior cruciate ligament reconstruction was performed with a single-socket technique using autogenous quadrupled hamstring tendons, while the graft was fixed at 0° (group A) 20° (group B) or 90° (group C) with a constant initial tension of 44 N. The knees then repeated the same movement as before while the relative position between femur and tibia was recorded. The load in the femorotibial joint was also calculated based on the principle of superposition. Results Posterior displacement of the tibia compared with the normal knee was the smallest in group B at all flexion angles, while the load between tibia and femur in group B was also the smallest and the closest to the normal knee. Conclusion As the positional relationship as well as the load between femur and tibia in group B was the closest to that in the normal knee, 20° of flexion is the most desirable of the positions tested for graft tensioning and fixation at the time of anterior cruciate ligament reconstruction. Clinical Relevance The tibia-femur position is well retained when the graft was fixed at 20° of flexion in anterior cruciate ligament reconstruction.

Dual tunnel medial patellofemoral ligament reconstruction for patients with patellar dislocation using a semitendinosus tendon autograft.

The purpose of this study was to describe a safer and more anatomical technique of MPFL reconstruction and to report the short-term results. The subjects included 20 patients with patellar dislocation with a mean age of 23. The operation was performed using a double-looped autogenous semitendinosus tendon graft. Two small bone tunnels were made at the medial edge of the patella, mimicking the wide patellar insertion of the MPFL and a bone tunnel was made at the femoral insertion site. The free ends of the graft attached to the patella and the loop end was fixed to the femoral side. Five patients were available for follow-up interviews by telephone and the remaining 15 were directly examined by physical examination and radiographic evaluation at 2 years or longer postoperatively. The average follow-up period was 30 months. Re-dislocation or patellar fracture was not seen in any patients. The average Kujalas score was 96 with a range from 84 to 100. Six patients were classified as excellent and 14 as good, according to the Crosby and Insall grading system. Radiographically, narrowing of the patellofemoral joint space was observed in 2 cases with previous osteochondral fracture out of those who were directly examined. The dual tunnel MPFL reconstruction produces favorable results in subjective and functional assessment of outcome without complications.

Optimization of Graft Fixation at the Time of Anterior Cruciate Ligament Reconstruction Part I: Effect of Initial Tension

Background Although anterior cruciate ligament (ACL) reconstructions are frequently performed, little is known about the effect of initial tension on an ACL graft at the time of its fixation. Purpose The objective of this study was to evaluate the effects of initial tension on the relative position and the load between femur and tibia during passive motion. Study Design Controlled laboratory study. Methods Seven cadaveric knees underwent a passive flexion-extension movement from 0° to 90° with a robotic system developed in the authors’ laboratory under 6 degrees of freedom, while their 3-dimensional paths were recorded. A single-socket ACL reconstruction was performed with an autogenous quadrupled hamstring tendon graft, while the knees underwent the same movement as before with the initial graft tension of 22 N (group A), 44 N (group B), or 88 N (group C) at 20°. The relative position between the femur and the tibia was recorded, and the load in the femorotibial joint was calculated using the principle of superposition. Results The tibia in group C was most posteriorly positioned among the 3 groups (an average posterior translation of 0.6, 1.3, and 2.6 mm in groups A, B, and C, respectively). The tibia also moved proximally and laterally with external and valgus rotation with an increase in initial tension, and consequently the load in the femorotibial joint increased at ail flexion angles. Conclusion With an increase in initial tension, the tibia moved posterolaterally with external and valgus rotation, and consequently the contact force in the femorotibial joint increased. Clinical Relevance Excessive initial tension at the time of ACL reconstruction may potentially bring deleterious effects to the articular surface, leading to cartilage degeneration.

Arthroscopic posterior cruciate ligament reconstruction using hamstring tendons: One-incision technique with Endobutton

The one-incision surgical technique using autogenous hamstring tendons with Endobutton (Acufex Microsurgical Inc. Mansfield, MA) femoral end fixation for posterior cruciate ligament reconstruction is described. This technique avoids a second incision on the femoral side, and is adaptable to various graft materials (autogenous or allogeneic bone-patellar tendon-bone, hamstring, or Achilles tendon.

Chondral Injury Associated With Acute Isolated Posterior Cruciate Ligament Injury

SUMMARYnTo evaluate associated cartilaginous damage with acute isolated posterior cruciate ligament (PCL) injury without other concomitant ligamentous injury, arthroscopic evaluations were performed on 61 consecutive patients. Meniscal tear was found in 17 cases (28%). Of these, 3 had medial meniscal tear, 11 had lateral meniscal tear, and 3 had both medial and lateral meniscal tears. Longitudinal tears of anterior segment in lateral menisci were the most common (10 cases). Thirty-two patients (52%) had articular cartilage injury. Of these, 7 had damage greater than one half of the thickness of the articular cartilage, and 3 had erosion that extended to the subchondral bone. The most frequently injured location was the medial femoral condyle (19 cases, 31%). Significant cartilaginous injury could be combined in acute isolated PCL injury. Therefore, it is unreasonable to manage every acute isolated PCL-injured knee using a single treatment modality. Concomitant meniscal and articular cartilaginous lesions should be evaluated when treatment for acute PCL injury is planned.