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).

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

BACKGROUND: Persistent postoperative pain has a significant relationship with patient health and satisfaction. OBJECTIVES: To investigate the prevalence and association of neglect-like symptoms (NLS) and other psychological factors on postoperative pain in patients following total knee arthroplasty (TKA). NLS are defined as the loss of perception of the limb with pain and excessive effort required to move the limb. The authors hypothesized that NLS were an important contributor to postoperative pain. METHODS: The factors influencing pain were investigated using a longitudinal study with assessments at three and six weeks postsurgery. The relationships among demographic factors (age, body weight, body mass index), psychological factors (State-Trait Anxiety Inventory and Pain Catastrophizing Scale [PCS]) and NLS with postoperative pain were investigated in 90 patients after TKA. The associations among motor functions (muscle strength of knee extension, range of motion), sensory functions (joint position sense and two-point discrimination in the thigh) and NLS were also investigated. RESULTS: At three and six weeks after surgery, 36% and 19% of patients, respectively, experienced NLS. In hierarchical multiple regression analysis, NLS and PCS scores were significantly associated with postoperative pain, while joint position sense and range of motion were significantly associated with NLS. CONCLUSIONS: These results suggest that facilitation of sensory integration is important in rehabilitation after TKA because NLS appears to result from impaired sensory integration. The association of PCS scores with postoperative pain and NLS suggests the need to provide appropriate postoperative education to reduce persistent negative thoughts regarding future pain.

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.

Tibial tubercle transfer on a medial periosteal pedicle--a report of a new technique.

Tibial tubercle transfer is still probably the most widely used procedure of the numerous operative procedures described to realign the patella and extensor mechanism and to prevent a recurrent dislocation. Although this procedure most likely disturbs the blood supply to the tibial tubercle and thus may lead to a delayed union. Tibial tubercle transfer is also considered to play a role in the incidence of a tibial tubercle delayed union. Furthermore, a fracture of the tibial metaphysis has been reported to occur in some cases. We therefore devised a new procedure in which the periosteum of the medial side of the proximal portion of the tibia was left intact when tibial tubercle transfer is performed. The current paper describes the results of new technique in 25 knees with patellar maltracking. Eighty-four percent of the patients had good or excellent results at a mean follow-up time of 49 months. All of the patients achieved complete healing radiographically within 2 months after the operation. Serious complications such as compartment syndrome, infection and skin slough were also completely avoided in all cases. This new procedure that the use of a protective maneuver for the periosteum of the medial side of the tibia may thus reduce the incidence of a delayed union and thereby promote early postoperative rehabilitation after tibial tubercle transfer.

Bilateral meniscal cysts of medial menisci occurring in a career soldier.

A young male career soldier presented with bilateral meniscal cysts of the medial menisci combined with a meniscal tear. This was confirmed by magnetic resonance imaging and was treated by arthroscopic procedures. An arthroscopic examination showed mucous fluid to be leaking from a torn portion of his left knee; however, no similar leaking was observed in his right knee. These arthroscopic results thus will support an etiology in which meniscal cysts occur as a result of an extrusion of synovial fluid through meniscal tears.

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.

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.

The influences of biomechanical factors on cartilage regeneration after high tibial osteotomy for knees with medial compartment osteoarthritis: clinical and arthroscopic observations.

PURPOSE: A high tibial osteotomy (HTO) is often performed on knees with medial compartment osteoarthritis. However, in varus knees with medial compartment osteoarthritis, degeneration of the articular cartilage tends to progress due to medial deviation of the mechanical axis. This can result in eburnated bone. A widening of the medial joint space has been observed after HTO with a proper correction as a result of decreased stress on the load-bearing cartilage in the medial compartment. Researchers have reported obtaining a repair of the articular cartilage with both eburnation and clinical improvement using HTO in patients showing a medial deviation of the mechanical axis. However, which factors influence cartilage regeneration remain unclear. The purpose of this study was to quantitatively evaluate the influence of cartilage regeneration after a high tibial osteotomy for knees with medial compartment osteoarthritis. TYPE OF STUDY: Observational cohort study. METHODS: The study involved 58 knees in 47 patients. A modified Noyes classification was used for arthroscopic grading. The patients underwent a second look arthroscopic evaluation of the articular cartilage 18 months after surgery. The articular cartilage was classified as no regenerative change (grade 1), white scattering with fibrocartilage (grade 2), partial coverage with fibrocartilage (grade 3), and even coverage with fibrocartilage (grade 4). The functional results were evaluated according to the Japanese Orthopedic Association score for osteoarthritic knees (JOA score), femorotibial angle (FTA), percentage of mechanical axis, and body mass index (BMI). RESULTS: Partial or even coverage with fibrocartilage (grade 3 and 4) was achieved on 55% of the femorotibial joint surfaces. A repair with white scattering with fibrocartilage (grade 2) was achieved in 34%, and 3 knees showed no regenerative change (grade 1). At follow up, significant differences were seen between grade 4 and grade 1 in JOA score and percentage of mechanical axis. CONCLUSIONS: This study demonstrates the correlation between the visible improvement of the articular surface, the functional score, and the degree of correction obtained with a lateral closing wedge HTO.

Magnetic resonance imaging evaluation after re-notchplasty at second-look arthroscopy.

PURPOSE: To clarify the effects of re-notchplasty on magnetic resonance imaging (MRI) for evaluating the reconstructed anterior cruciate ligament (ACL). TYPE OF STUDY: Observational cohort study. METHODS: Twenty-one patients who underwent re-notchplasty at second-look arthroscopy were examined. The MRI findings of the reconstructed ACL were classified as having either high, intermediate, or low intensity based on the clarity of appearance. RESULTS: The impinged group at second-look arthroscopy underwent re-notchplasty. Twelve patients continued to show a high signal intensity that did not decrease after re-notchplasty at the second-look operation. In contrast, 9 impinged ACL grafts showed a decreased signal intensity of the graft after re-notchplasty. CONCLUSIONS: In this study, 9 cases showed a decreased intensity and were considered to have an impingement at the notch, which thus influenced the maturity process by decreasing the compression on the reconstructed ACL.