Management of Neglected Multiple Ligament Rupture of the Knee: A Case Report

@#Delayed or neglected multiple ligament injury of the knee is challenging or doctors and physiotherapists. We report on a 36-year-old army man who presented to the outpatient orthopaedic department with complaints of pain and deformity of his right knee and an inability to weight-bear on the right leg. The examination of the right knee revealed an unreduced posterior dislocation of the knee with instability in all planes and a limited range of motion (ROM) from 10° to 100°. Quadriceps wasting was noted. Roentgenograms revealed a posterior dislocation of the knee. Magnetic resonance imaging (MRI) showed complete rupture of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and the patellar tendon. A two-stage surgery was planned, involving soft tissue distraction with external fixation to restore the knee joint, followed by multiple ligament reconstruction. Three months after surgery, the patient could walk normally with ROM between 0° to 120°.

Factors Affecting Postoperative Sagittal Alignment after Lateral Lumbar Interbody Fusion in Adult Spinal Deformity: Posterior Osteotomy, Anterior Longitudinal Ligament Rupture, and Endplate Injury

STUDY DESIGN: Prospective cohort study. PURPOSE: To identify factors that affect sagittal alignment correction in lateral lumbar interbody fusion (LIF) surgery for adult spinal deformity (ASD) and to investigate the degree of correction in each condition. OVERVIEW OF LITERATURE: LIF is a useful procedure for ASD, but the degree of correction can be affected by posterior osteotomy, intraoperative endplate injury, or anterior longitudinal ligament (ALL) rupture. METHODS: Radiographical data for 30 patients who underwent LIF for ASD were examined prospectively. All underwent two-stage surgery (LIF followed by posterior fixation). Radiographical parameters were measured preoperatively, after LIF, and after posterior fixation; these included the segmental lordotic angle, lumbar lordosis (LL), and other sagittal alignment factors. RESULTS: LL was corrected from 16.5°±16.7° preoperatively to 33.4°±13.8° after LIF (p<0.001) and then to 52.1°±7.9° following posterior fixation (p<0.001). At levels where Schwab grade 2 osteotomy was performed, the acquired segmental lordotic angles from the preoperative value to after posterior fixation and from after LIF to after posterior fixation were 19.5°±9.2° and 9.9°±3.9°, respectively. On average, 12.4° more was added than in cases without osteotomy. Endplate injury was identified at 21 levels (19.4%) after LIF, with a mean loss of 3.4° in the acquired segmental lordotic angle (5.3°±8.4° and 1.9°±5.9° without and with endplate injury, respectively). ALL rupture was identified at seven levels (6.5%), and on average 19.3° more was added in these cases between the preoperative and postoperative values than in cases without ALL rupture. CONCLUSIONS: LIF provides adequate sagittal alignment restoration for ASD, but the degree of correction is affected by grade 2 osteotomy, intraoperative endplate injury, and ALL rupture.

Técnica de TightRope modificada no tratamento da doença do ligamento cruzado cranial em cães: resultados a longo prazo / Modified TightRope technique for treatment of the cranial cruciate ligament disease in dogs: long term outcomes

O objetivo deste estudo foi descrever os resultados a longo prazo do uso da técnica extracapsular TightRope (TR) modificada no tratamento da doença do ligamento cruzado cranial (LCCr) em oito cães (10 articulações) com peso corporal variando entre 4kg e 28kg. Todos os animais selecionados foram submetidos aos exames ortopédicos específicos, sendo diagnosticada ruptura completa do LCCr pelos testes de gaveta e de compressão tibial. Realizaram-se exames radiográficos convencionais e em posição de estresse das articulações. A técnica TR foi modificada utilizando-se o fio de náilon substituindo o fio de fibra empregado na técnica original, facilitando a disponibilidade de obtenção do material. Houve também modificação na origem da perfuração do túnel tibial, sendo realizada imediatamente cranial ao sulco do tendão extensor digital longo. Todos os cães foram submetidos ao exame radiográfico tanto no pós-operatório imediato como no tardio. Aos 30 dias após a intervenção cirúrgica, os pacientes apresentavam claudicação nos membros pélvicos operados de grau discreto a moderado. Foi observado discreto movimento de gaveta cranial em 60% das articulações acometidas. Aos três meses após o procedimento cirúrgico, os animais apresentaram ausência de dor e discreta redução na amplitude dos movimentos articulares. Em duas articulações (20%) observou-se discreto deslocamento cranial da tíbia no teste de gaveta. Nesta fase, 80% dos membros avaliados apresentavam apoio normal. Um ano após a intervenção cirúrgica, observou-se ao exame radiográfico discreta progressão da doença articular degenerativa em 50% das articulações operadas. Das oito articulações avaliadas a longo prazo, em apenas um membro operado observou-se discreta claudicação com reduzida transferência de peso para o membro contralateral. Os demais membros pélvicos avaliados (87,5%) demonstraram ausência de claudicação e adequada recuperação da função articular. Concluiu-se que a técnica cirúrgica extracapsular TR modificada mostrou-se efetiva como opção de tratamento para doença do LCCr em cães de porte pequeno e médio, não apresentando complicações. As modificações do fio cirúrgico e da perfuração da tíbia na técnica TR parecem ter efeitos positivos na estabilização da articulação do joelho.(AU)

The aim of the study was to describe the long term outcomes of the modified extracapsular TightRope (TR) technique in the treatment of the cranial cruciate ligament (CCL) disease in eight dogs (10 joints) with a body weight ranging from 4kg to 28kg. The animals were submitted to specific orthopedic examinations and were diagnosed with total CCL rupture by drawer and tibial compression tests. Conventional and stress positional radiographic examinations of the affected joints were performed. The TR technique was modified using the nylon suture thread replacing the fiber suture used in the original technique, which facilitated the availability of obtaining the material. There was also modification in the origin of the tibial tunnel perforation that was performed immediately cranial to the groove of the long digital extensor tendon. The dogs underwent radiographic examination in the immediate postoperative and in later periods. At one month after surgical procedure, the animals showed mild or moderate lameness in the affected pelvic limbs. Mild cranial tibial drawer was observed in 60% of the operated joints. At three months after the procedure, the animals have mild decrease in the range of joint motion, but without signs of pain. Two stifle joints (20%) showed a slight cranial displacement of the tibia in the drawer test. In this period, 80% of the affected joints showed normal limb support. At one year after the procedure, radiographic examination showed a discrete progression of the degenerative joint disease in 50% of the operated joints. The long term outcomes were obtained from eight joints and in only one pelvic limb was observed mild lameness with slight weight transfer to the normal contralateral limb. All other evaluated pelvic limbs (87.5%) showed no lameness and proper recovery of joint function. In conclusion, the modified TR extracapsular surgical technique proved to be effective as a treatment option for CCL disease in small and medium dogs, with no complications. Modifications of the surgical suture thread and the tibial site perforation of the TR technique seem to have positive effects on stabilization of the stifle joint.(AU)

Stener-Like Lesions in the Metacarpophalangeal Joint of the Fingers / 대한정형외과학회잡지

Three Stener-like lesions of the metacarpophalangeal joint of the fingers and a rupture of the first dorsal interosseous muscle mimicking the lesion in the index finger were observed. Two cases in the little fingers had a true Stener's lesion. In one case in the index finger, the ruptured ligament was retracted and located under the intact sagittal band, which was also observed by preoperative magnetic resonance imaging (MRI). Rupture of the first dorsal interosseous muscle was misdiagnosed preoperatively as a Stener's lesion in the index finger by ultrasonography. MRI should be an essential differential diagnostic exam for collateral ligament ruptures of the metacarpophalangeal joint of the fingers.

Evaluation of four physical examinations in diagnosis of complete rupture of anterior cruciate ligament / 上海交通大学学报（医学版）

Objective· To estimate the value of four physical examination methods in the diagnosis of anterior cruciate ligament complete rupture. Methods · A retrospective study was conducted on 100 patients who underwent surgical treatment for knee joint injury from July 11, 2016 to June 10, 2017. They received four physical examinations including Lachman test, anterior drawer test, lever sign test and pivot shift test. The results of the arthroscopy inspections were used as gold standard. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, accuracy and other parameter of four physical examinations were comprehensively discussed. Results · Arthroscopic examination confirmed that 81 patients had complete rupture of anterior cruciate ligament. The sensitivities of anterior drawer test, lever test, pivot shift test and Lachman test were 87.7%, 100.0%, 97.5% and 96.3%, and the specificities were 84.2%, 78.9%, 73.7% and 63.2%, respectively. The positive predictive values were 95.9%, 95.3%, 94.0% and 91.8%, while the negative predictive values were 61.5%, 100.0%, 87.5% and 80.0%, respectively. The accuracies were 87%, 96%, 93% and 90%, respectively. The positive likelihood ratios were 5.6, 4.7, 3.7 and 2.6, while the negative ones were 0.1, 0, 0 and 0.1, respectively. Conclusion · Anterior drawer test is the most effective in diagnosing the complete rupture of the anterior cruciate ligament, while lever sign test is the most effective in excluding one. Lever sign test is the most sensitive and easy to operate, especially for fresh bruise, acute injury, limb swelling and obesity, with high diagnostic value.

Observation of artificial lens implantation suture fixation into capsular bag when cataract suspensory ligament rupture without capsular tension ring / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To explore the cataract suspensory ligament rupture and artificial lens implantation suture fixation into capsular bag without capsular tension ring(CTR).METHODS:We reviewed 20 cases of 20 cataract suspensory ligament rupture without CTR intraocular lens (IOL) implantation fixation in our department from Jan.2012 to Dec.2016.The needle crossed into ocular ciliary sulcus, in the equator of the eye ball which suspensory ligament rupture from, then the needle crossed out 1.5mm away from the angle of sclera.Sutures fixed on the IOL, then the artificial lens implantation in the pouch, carried out in accordance with the Z type suture, or to the beforehand prepared triangle scleral flap.The visual acuity, intraocular pressure, the anterior chamber and the IOL position were measured after operations.RESULTS:All of the postoperative visual acuity improved different level.The postoperative best corrected visual acuity(BCVA) was ≥0.8 in 4 eyes(20%), 0.5-0.6 in 7 eyes(35%), 0.3-0.4 in 8 eyes(40%), 0.1 in 1 eye(5%) because of the glaucoma optic atrophy.There were 12 cases with mild corneal endothelium edema, 4 cases exudation membrane in the pupil area, 2 cases hyphema, all of which recovered after treatment.There were 2 eyes with vitreous prolapse in the pupil, 1 case appeared mild IOL center deviation and no special treatment for the vision did not be involved.Followed up for 6mo, displaced stitches or artificial lens shift did not occur.CONCLUSION:Without CTR, the IOL implantation and suture fixation in capsular bag during cataract surgery is a surgical method for basic-level hospitals.

Comportamento biomecânico de diferentes placas de avanço da tuberosidade da tíbia em cães: estudo comparativo ex vivo / Biomechanical behavior of two different tibial tuberosity advancement plates in dogs: comparative ex vivo biomechanical study

Este é o primeiro estudo que compara o comportamento biomecânico de duas diferentes placas de avanço da tuberosidade tibial (ATT). Com o objetivo de minimizar a incidência de falhas de implante, foram realizados ensaios biomecânicos em 10 pares de membros pélvicos de cadáveres de cães. No membro pélvico direito, foi colocada placa de ATT fixa por garfo, e no membro pélvico esquerdo placa fixa por parafusos. Os ensaios foram realizados utilizando-se máquina universal de ensaios mecânicos Kratos(r), modelo KE3000, dotada de célula de carga de 3000N, com velocidade de ensaio de 20mm/min. O parâmetro força e os gráficos gerados foram gravados por meio de sistema de aquisição analógica TRACOMP-W95 (TRCV61285). A média da carga máxima até a falha foi de 128,70kg/F (mínimo 104,55kg/F e máximo 151,80kg/F) e de 141,99kg/F (mínimo 111,60kg/F e máximo 169,65kg/F) no grupo utilizando garfo e parafusos, respectivamente. O desvio-padrão dos grupos garfo e parafuso foi baixo, 12,99 e 17,21, respectivamente. Foi encontrada diferença significativa (P=0,03) entre as médias dos grupos. Com base nos resultados obtidos, conclui-se que existe diferença estatística significativa na resistência promovida entre as placas testadas, quando se observou que a placa fixa por parafusos promove maior resistência.(AU)

This is the first study to compare the biomechanical strength between the two different TTA plates. With the purpose of minimizing the incidence of implant failure, biomechanical tests were performed on 10 pairs of cadaveric hind limbs from dogs. The right hind limb of each dog was used as a model for the TTA plate fixed by fork, and the left pelvic limb was used as a model for the TTA plate fixed by screws. Tests were performed using a universal mechanical testing Kratos (r) machine, model KE 3000, equipped with a load cell of 3000N with a test speed of 20mm/min. The strength parameter and graphs generated were recorded via analog acquisition system TRACOMP-W95 (TRCV61285). The mean load to failure was 128.70kg/F (minimum 104.55kg and maximum 151.80kg/F) and 141.99kg/F (minimum 111.60kg/F and maximum 169.65kg/F) in the fork and screws groups respectively. The standard deviation of the fork and screws groups was low: 12.99 and 17.21 respectively. Significant difference (P= 0.03) between means of the groups was observed. From the results obtained it was concluded that there is a statistically significant difference in the resistance between plates and the plate fixed by screws promotes increased strength.(AU)

Spontaneous Rupture of the Extensor Carpi Radialis Brevis and Radial Collateral Ligament of the Elbow in a Recreational Golfer: Surgical Experience of Repair of a Chronic Retracted Tendon and Ligament

Lateral epicondylitis with rupture of the radial collateral ligament of the elbow has not been reported in the literature. We report on a case of a recreational golfer who had not received steroid injection and had no trauma history. The patient was treated with open surgical repair. At 2 years follow-up, satisfactory clinical and radiological outcomes were observed with return to pre-injury level. The authors report this case and review the literature.

Spontaneous Rupture of the Extensor Carpi Radialis Brevis and Radial Collateral Ligament of the Elbow in a Recreational Golfer: Surgical Experience of Repair of a Chronic Retracted Tendon and Ligament

Lateral epicondylitis with rupture of the radial collateral ligament of the elbow has not been reported in the literature. We report on a case of a recreational golfer who had not received steroid injection and had no trauma history. The patient was treated with open surgical repair. At 2 years follow-up, satisfactory clinical and radiological outcomes were observed with return to pre-injury level. The authors report this case and review the literature.

Rupture of the cranial cruciate ligament in dogs / Ruptura del ligamento cruzado craneal en perros / Ruptura do ligamento cruzado cranial em cães

Rupture of the cranial cruciate ligament (LCCr) is one of the most common causes of lameness in dogs. It generates joint instability, leading to a degeneration of the affected knee. It is thought that most LCCr rupture cases are due to progressive degeneration along with mild traumas. The diagnosis is primarily based on orthopedic examination and X-rays of the knee; a positive drawer test is important to detect total rupture of LCCr. On the other hand, partial LCCr injuries are difficult to diagnose, so arthroscopy and magnetic resonance imaging have been increasingly used as diagnostic methods in recent years. Many surgical procedures have been described to stabilize the affected knee in the last decades. Such treatments can be divided into intra-articular procedures, extra-articular methods and proximal tibial osteotomies. Despite important scientific developments in recent years regarding this disease there is no treatment to prevent secondary diseases following LCCr rupture, such as osteo-arthrosis and meniscus injuries. The aim of this paper is to provide a brief review of the current literature related to the rupture of the cranial cruciate ligament in dogs.

La ruptura del ligamento cruzado craneal (LCCr) es una de las causas más comunes de claudicación en perros, produciendo inestabilidad articular lo que conlleva en consecuencia a una degeneración de la rodilla afectada. En la actualidad se piensa que en la mayoría de los pacientes afectados se produce una degeneración del LCCr progresiva, que con el tiempo y traumas leves continuados pueden llegar a una ruptura total del ligamento. El diagnóstico se basa principalmente en el examen ortopédico y la toma de radiografías de la rodilla, siendo la prueba de cajón positiva importante para detectar la ruptura total del LCCr, por otro lado, las lesiones parciales del LCCr son de difícil diagnóstico, por lo que en los últimos años se ha ido incrementado el uso de la artroscopía y la resonancia magnética como métodos diagnósticos en medicina veterinaria. En las últimas décadas se han descrito un gran número de tratamientos quirúrgicos con el fin de estabilizar nuevamente la rodilla afectada. Dichos tratamientos pueden dividirse en métodos intraarticulares, métodos extraarticulares y osteotomías de la tibia proximal. A pesar del gran desarrollo científico realizado en los últimos años respecto a dicha patología, no existe un tratamiento que evite el desarrollo de patologías secundarias a la ruptura del LCCr, como artrosis articular y frecuentemente lesiones en los meniscos. El objetivo del presente artículo, es proveer una breve revisión actual de la literatura relacionada a la ruptura del ligamento cruzado craneal en perros.

A ruptura do ligamento cruzado cranial (LCCr) é uma das causas mais comuns de claudicação nos cães, produzindo uma instabilidade articular que leva em consequência a uma degeneração do joelho afetado. Na atualidade se acha que nos pacientes afetados se produz uma degeneração do LCCr progressiva, que com o tempo e traumas leves continuados pode se chegar a desenvolver em uma ruptura total do ligamento. O diagnóstico baseia-se principalmente no exame ortopédico e a toma de radiografias do joelho, sendo os testes mais importantes para detectar a ruptura total do LCCr, de outro lado, as lesões parciais do LCCr são de difícil diagnóstico, pelo que nos últimos anos tem se incrementado o uso da artroscopia e a ressonância magnética como métodos diagnósticos na medicina veterinária. Nas ultimas décadas tem se descrevido um grande numero de tratamentos cirúrgicos com o fim de estabilizar novamente o joelho afetado. Esses tratamentos podem se-dividir em métodos intra-articulares, métodos extra-articulares e osteotomias da tíbia proximal. Ainda que houvesse um grande desenvolvimento cientifico realizado nos últimos anos com respeito a essa patologia, não existe um tratamento que evite o desenvolvimento de patologias secundarias a ruptura do LCCr, como artrose articular e frequentemente lesões nos meniscos. O objetivo do presente artigo é ministrar uma curta revisão atualizada da literatura relacionada à ruptura do ligamento cruzado cranial em cães.

Feasibility of utilizing the patellar ligament angle for assessing cranial cruciate ligament rupture in dogs

The patellar ligament angle (PLA) was assessed in 105 normal stifle joints of 79 dogs and 33 stifle joints of 26 dogs with a ruptured cranial cruciate ligament (CrCL). The PLA of stifles with complete CrCL rupture was significantly lower than that of normal stifles, particularly at a flexion angle of 60~80degrees in both plain and stress views. If the PLA was <90.55degrees on the stress view with a 60~80degrees flexion angle, the dog was diagnosed with a complete rupture of the CrCL with a sensitivity of 83.9% and specificity of 100%. In conclusion, measuring the PLA is a quantitative method for diagnosing complete CrCL rupture in canines.

Ruptura de menisco associada à ruptura de ligamento cruzado cranial em cães / Association of meniscal lesion and cranial cruciate ligament insufficiency in dogs

O trabalho descreve as lesões de menisco associadas com ruptura do ligamento cruzado cranial em 82 pacientes de diferentes raças, idades e pesos, com o objetivo de avaliar o tipo de ruptura de menisco associada a lesões do ligamento cruzado cranial. No período pré-operatório, os animais foram submetidos à avaliação clínica e radiológica. Todos os animais apresentaram ruptura total ou parcial do ligamento cruzado cranial; 21 (24,14%) animais não apresentaram nenhuma lesão de menisco, os restantes (75,86%) apresentaram apenas lesão no menisco medial. As lesões encontradas no menisco medial foram as seguintes: 33 joelhos (37,93%) apresentaram eversão do corno caudal (Tipo 1); 15 (17,24%) apresentaram lesão em alça de balde (Tipo 6); 3 (3,45%) lesão de fibrilação (Tipo 4); 3 (3,45%) ruptura longitudinal múltipla (Tipo 3); 3 (3,45%) lesão longitudinal (Tipo 2); 1 (1,15%) lesão tipo 7; e 10 (11,49) apresentaram lesões múltiplas. A meniscectomia parcial do menisco medial foi realizada em 63 (72,41%) joelhos e a meniscectomia total em 3 (13,04%). O procedimento cirúrgico para a resolução da ruptura do ligamento cruzado cranial incluiu: avanço da tuberosidade tibial (TTA) (49 joelhos), osteotomia niveladora do platô tibial (TPLO) (15 joelhos), osteotomia em cunha da tíbia (CWO) (14 joelhos), extracapsular (quatro joelhos) e meniscectomia (cinco joelhos). Todos os casos evoluíram com o retorno à função habitual do membro pélvico acometido na primeira semana do período pós-operatório, e com a ausência de complicações. A alta porcentagem (75,86%) de ruptura do menisco medial encontrada no presente trabalho demonstra a importância da avaliação prévia dos meniscos antes da realização da técnica de estabilização da articulação femorotibiopatelar.

The following study describes meniscus ruptures associated to cranial cruciate ruptures, in 34 dogs of different breeds, ages and weights. Before surgery the animals underwent clinical and radiographic examinations. All animals presented either total or partial cranial cruciate ruptures: 21 (24.14%) of the animals didn’t present any meniscus lesions, and the rest (75.86%) presented only a medial meniscus lesion. The lesions found in the medial meniscus were the following: 33 stifles (37.93%) presented with eversion of the caudal pole (Type 1), 15 (17.24%) showed a bucked handle lesion (Type 6), 3 (3.45%) presented with fibrillation lesion (Type 4), 3 (3.45%) multiple fibrillation lesion (Type 3), 3 (3.45%) longitudinal lesion (Type 2), 1 (1.15%) lesion type 7 and 10 (11.49%) presented multiple lesion. Surgical procedure for cranial cruciate rupture included: tibial tuberosity advancement (TTA) (49 stifle), tibial plateau leveling osteotomies (TPLO) (15 stifle), closing wedge osteotomy (CWO) (14 stifle), extracapsular (4 stifle) and meniscectomy alone (5 stifle), and all these techniques guaranteed weight baring and return to function in the first week after surgery, with no complications. Through this study we could demonstrate that meniscus tear is highly associated to cranial cruciate rupture and that the most common is type 1 (eversion of the caudal pole) and that cronicity of the lesion increases the probability of meniscus tear.

Effect of anterior cruciate ligament rupture on the strain of medial collateral ligament / 中南大学学报(医学版)

Objective To explore the effect of anterior cruciate ligament (ACL) rupture on the biomechanics of medial collateral ligament (MCL). Methods Six fresh human knee joints were fixed on the self-made fixture and flexed 90°. ACL was divided into a normal group, an anteromedi-al bundle(AMB) break group, and an ACL complete break group. 800N burden was loaded, and the MCL strain data were compared among the 3 groups. Results The MCL strain was significantly increased in the AMB break group and the ACL complete break group than that in the normal group (P<0.05). There was no significant difference in the MCL strain between the AMB break group and the ACL complete break group (P>0.05). Conclusion ACL rupture may cause significant changes in the MCL biomechanics, but the effect of AMB break and ACL complete break on MCL has no significant difference.

Estabilização extra-articular do joelho com fáscia lata autógena em cães de raças de grande porte / Autogen fascia lata on extra-articular stifle stabilization in large breed dogs joint

Avaliou-se a sutura fabelar lateral (SFL) com fáscia lata autógena para estabilização dos joelhos de cães de raças de grande porte, acometidos por ruptura do ligamento cruzado cranial (RLCCr). Os animais foram submetidos à avaliação clínica e radiográfica no pré-operatório e aos 60, 180 e, em alguns casos, 360 dias de pós-operatório. A partir do 60º dia, os cães apresentavam-se apoiando o membro normalmente ou com claudicação com apoio contínuo do membro. No 360º dia, quatro joelhos apresentavam-se estáveis, e o restante demonstrava instabilidade leve. No 360º dia, dos seis membros avaliados, três não haviam recuperado a medida da coxa aferida no pré-operatório. Os escores de doença articular degenerativa (DAD) para os períodos de 180 e 360 dias foram significativamente maiores que os atribuídos no pré-operatório. A SFL com fáscia lata foi adequada para o tratamento de RLCCr em cães de raças de grande porte, quando consideradas a estabilidade do joelho e a deambulação, e não impediu ou retardou a evolução da DAD.

The lateral fabellar suture (LFS) performed with autogenous fascia lata to stabilize the stifles of large breed dogs with cranial cruciate ligament rupture (CrCLR) was evaluated. The dogs were submitted to clinic and radiographic evaluation in the preoperative period and on the 60th, 180th and in some cases 360th day of the postoperative period. After the 60th day, almost every dog presented normal gait or lameness with continuous gait. On the 360th day, four stifles presented themselves as stable and the remainder presented mild instability. On the 360th day, three out of six limbs evaluated did not recover the thigh perimeter of the preoperative period. Stifle degenerative joint disease (DJD) scores on the 180th and 360th day of the postoperative period were significantly higher than those in the preoperative period. LFS is suitable to treat CrCLR on large breed dogs if consider stifle stability and gait, and that did not prevent or delay progression of DJD.

Evaluation of Posterior Cruciate Ligament Reconstruction Using the Femoral Double Tunnel and Tibial Inlay Techniques / 대한정형외과학회잡지

PURPOSE: This study was performed to evaluate the clinical usefulness of femoral double tunnel PCL reconstruction using the tibial inlay technique. MATERIALS AND METHODS: From January 2001 to August 2002, 21 patients underwent femoral double tunnel PCL reconstruction using the tibial inlay technique and were followed for more than 21 months. The mean age was 37 years old (range 16 to 60 years old). The clinical results were evaluated with the Lysholm score and the Tegner activity score. Radiologic analysis was performed using the posterior stress and Telos stress views. RESULTS: The average preoperative Lysholm and Tegner activity scores were 46.0 and 2.3, respectively, and improved to 94.5 and 5.3, respectively, at the final follow-up. The average preoperative scores of the combined posterolateral ligament injury group was 40.6 and 1.5, which improved to 77.1 and 3.5 at the final follow-up. Preoperatively, two cases were grade II, 13 cases were grade III, 6 cases were grade IV, and posterior translation was an average of 14.6 mm. Postoperatively, 18 cases were grade I, 3 cases were grade II, and posterior translation was an average 2.9 mm. In a push view using the Telos device (15 kg) at 30o and 90o of knee flexion, there were no differences in posterior translation. Complications were limitation of flexion (3 cases), limitation of extension (1 case) and quadriceps atrophy (mean, 2.6 cm). CONCLUSION: It is suggested that femoral double tunnel PCL reconstruction with the tibial inlay technique using anterolateral and posteromedial bundles is an effective technique for the restoration of knee function, stability, and activity. However long-term evaluation of patients and comparisons with femoral single tunnel reconstruction are required to confirm the effectiveness of this procedure.

The Effect of the Photo-immobilized Epidermal Growth Factor on the Proliferation of the Anterior Cruciate Ligament Cell of the Knee / 대한정형외과연구학회지

PURPOSE: The purpose of this study is to find out the possibilities of the early treatment via artificial juxtacrine stimulation by photo-immobilization of growth factor in the anterior cruciate ligament (ACL) injury. MATERIALS AND METHODS: Photo-reactive Epidermal Growth Factor (EGF-Az) was synthesized by conjugating EGF with N-(4-azidobenzoyloxy)succinimide and was immobilized onto the polystyrene culture plates by UV irradiation. Human ACL cells (1 x 10 5 cells/ml , 100 m l /well) were cultured with serum free media in each group (group 1 : no EGF, group 2 : native EGF 2 m g /ml , group 3 : 50 m l EGF-Az immobilization, group 4 : 100 m l EGF-Az immobilization). We observed the changes of cells with long-term culture and compared the difference of cellular response of EGF-treated and non-treated groups. To examine the cellular migration, in vitro wound closure assay was performed. RESULTS: Cells were proliferated for 3 days. It was not changed significantly after that time. Cellular growth was more remarkable in the photo-immobilized EGF group. In cell migration test, the defect site in the photo-immobilized group was indistinguishable from the non-scratched area after culture for 72 hours, while cellfree area was still clearly visible in the no EGF group. CONCLUSION: Photo-immobilized EGF induce rapid proliferation of fibroblasts via artificial juxtacrine stimulation. If EGF is immobilized onto bioabsorbable materials such as polyglycolic acid or polylactic acid for clinical application, it will contribute to the treatment of ACL.

Conservative Treatment of Anterior Cruciate Ligament Rupture / 대한정형외과학회잡지

Between August 1994 and June 1995, seventeen patients diagnosed as having partial or complete ruptures of the anterior cruciate ligament on MRI were managed by non-operative methods. Among them four patients were excluded due to operation during follow-up and the results were evaluated at a one year follow-up. We selected the patients prospectively for non-operative care using the selection criteria of age, degree of instability, activity level and patient compliance. The average age of them was 37.7 years. Initially knee stress test and MRI were checked, and Cybex study and Lysholm knee scoring were done at post-trauma one year follow-up. They were managed conservatively by ROM and muscle strengthening exercises and a brace fitting schedule for three months. Among them, six cases had partial tears and seven had a complete tear initially. At the one year follow-up, five of six cases who had shown partial ruptures, and two of seven cases with complete tears, recovered continuity of the ruptured ACL on MRI. Their Lysholm knee score was 84.4, and the Cybex test showed no difference in muscle power between the injured and uninjuried side. Those patients who had loss of continuity on follow-up MRI showed Lysholm score of 57.4 and decreased muscle power on Cybex study. Although there are still controversies about the adequate management of ACL injuries, our study suggests that conservative management is a viable alternative to surgery as long as the patients are selected prudently. For more concrete results, however, careful analysis based on a longer follow up period is necessary.

Morphologic change of PCL of MRI in the tear of ACL / 대한정형외과학회잡지

MRI has proved to be very reliable in evaluating the menisci and cruciate ligaments. On MRI, several diagnostic criteria of ruptured ACL were reported. Boeree and Ackyroyd reported that when the ACL is ruptured the PCL may appear to be curled up or sigmoid. But these morphologic changes may be shown in the normal ACL, so the quantitative analysis of these morphologic changes in considered as a way to increase the diagnostic sensitivity. We have used 1.0 tesla MRI scanner(SIMENS W. Germany) with a surface coil. We compared two groups of patients; a ruptured ACL group(16 patients) in which had indicated and arthroscopy confirmed rupture of the ACL and control group(46 patients), in which had shown the ACL to be entirely normal. At first, we made a line(basal line) between the femoral attachment and tibial attachment of the PCL and decided the point(apex) which was located far distant from the line. And we made a line(A line) between the femoral attachment and apex of the PCL, another line(B line) between the tibial attachment and apex of the PCL. We divided the basal line into the four areas. We measured the each angle between basal line and A line(angle a), between basal line and B line(angle b). And we measured the entire length of basal line, each height of the PCL previously divided point of the basal line(H1, H2, H3) and the apex of the PCL on the basal line. We compared the control group and ruptured ACL group by t-test from the measured factors angle a, angle b, H1, H2, H3, H4, and length of basal line. We studied factors which were able to decide whether the ACL was ruptured or not in MRI finding by logistic regression. 1. H1, the distance from the basal line to the PCL at 1/4 point on the basal line, were 5.7±1.6 mm in ruptured ACL group, 4.7±1.3 mm in control group, so there was statistically significant increase in ruptured ACL group. 2. The angle a were 56.0±14.4° in ruptured ACL group, 39.7±10.1° in control group, so there was statistically significant increase in ruptured ACL group. 3. From the measured factors angle a was able to decide whether the ACL was ruptured or not in MRI and the slope of angle a in logistic regression was 0.1. In conclusion, when the apex of the PCL is located at proximal 1/4 of the PCL and PCL and greater curve, above signs will be considered to be a sign of ruptured ACL in MRI.

MRI Findings of Bone Bruises Associated with Acute Anterior Cruciate Ligament Ruptures / 中国运动医学杂志

Objective To study the magnetic resonance imaging (MRI) characteristic of bone bruises associated with acute anterior cruciate ligament (ACL) ruptures and to investigate the correlation between bone bruises and cartilage lesions. Methods The MRI findings of 37 cases of acute ACL ruptures associated with bone bruises were studied retrospestively. The classification and distribution of bone bruises were analyzed and the cartilage lesions were also observed under arthroscopy. Results A total of 57 independent bone bruises(type Ⅰ:14, type Ⅱ:32, type Ⅲ:3, type Ⅳ:6 and type Ⅴ:2) were documented by MRI in the 37 patients. 54 (94.7%) bone bruises located in lateral joint compartment with involvement of lateral femoral condyle in 31 and lateral tibial plateau in 23. Nine cases (15.8%) of articular cartilage lesions were found under arthroscopy in the area overlying bone bruises. Conclusion Bone bruises associated with acute ACL ruptures mainly located in the lateral compartment of knee, especially in anterior portion of lateral femoral condyle and posterior portion of lateral tibial plateau. Arthroscopic cartilage lesions were not corresponding to bone bruises.