Risk factors for anteroposterior laxity increase over time in double-bundle anterior cruciate ligament reconstruction using hamstring autografts.

PURPOSE: An anteroposterior (AP) laxity can increase over time after anterior cruciate ligament reconstruction (ACLR) using hamstring tendons; however, the associated risk factors remain unclear. This study aimed to investigate the risk factors of this phenomenon. METHODS: Overall, 151 patients who underwent ACLR using hamstring autografts were recruited. AP laxity was evaluated using Knee Lax 3 arthrometer at 5 months, 1 and 2 years postsurgery. Patients were categorised into groups I (>1 mm increase) and C (<1 mm increase) based on whether they experienced an irreversible increase in AP laxity after 1 or 2 years compared with 5 months. Patient demographics and Knee injury and Osteoarthritis Outcome Score (KOOS) at 2 years postsurgery were compared between groups. RESULTS: Group I (n = 33, 21%) showed a side-to-side difference of 4.6 (3.0-7.2) mm in AP laxity preoperatively and 0.3 (-0.7 to 1.3), 1.1 (0.2-1.9) and 2.4 (1.7-3.2) mm at 5 months, 1 and 2 years postoperatively, while group C (n = 119, 79%) showed 4.3 (2.8-5.7) mm preoperatively and 1.3 (0-1.9), 0.9 (0.1-1.8) and 0.6 (-0.3 to 1.5) mm, respectively. No significant differences were observed in the overall KOOS at 2 years (n.s.). However, group I was older (36 [22-46] vs. 28 [19-39] years; p = 0.044), had longer surgical waiting periods (122 [69-341] vs. 81 [52-136] days; p = 0.041) and lower preoperative Tegner activity scale scores (6 [5-7] vs. 7 [6,7]; p = 0.002). CONCLUSION: While 33 patients (21%) experienced AP laxity increase over time, they had comparable clinical outcomes with group C. LEVEL OF EVIDENCE: Level III.

Fibular morphology is not associated with incidence of peroneal tendon dislocation.

PURPOSE: The association of peroneal tendon dislocation with peroneal bone morphology and postoperative redislocation rates remains unknown. This study compared the fibula morphology in patients with peroneal tendon dislocation with that in a control population. METHODS: The study enrolled 48 patients who underwent surgery for peroneal tendon dislocation at our institution during between 2018 and 2023. Thirty-five patients with preoperative magnetic resonance imaging of the ankle were defined as Group D and 35 with magnetic resonance imaging of the ankle for other reasons and with similar background data were selected as the control group (Group C). The posterior tilting angle of the fibula, posterolateral angle and posterolateral edge angle were evaluated at the plafond level. The posterior tilting angle, posterolateral angle and retromalleolar bone shape according to the Rosenberg classification (flat, convex, concave) were evaluated at the midpoint between the plafond and the tip. RESULTS: At the plafond level, the posterior tilting, posterolateral and posterolateral edge angles were 57.7 ± 11.1°, 123.8 ± 12.3° and 90.8 ± 13.7°, respectively, in Group D and 64.1 ± 15.4°, 121.1 ± 12.3° and 88.7 ± 12.2°, respectively, in Group C, with no significant differences. No significant between-group differences existed in the posterior tilting and posterolateral angles at the midpoint level. Moreover, no significant differences existed in distribution of the bone geometry according to the Rosenberg classification. CONCLUSION: There were no differences in morphology between patients with peroneal tendon dislocation and controls. This study provides useful information on the indications for primary surgery and whether bony approach is useful for peroneal tendon dislocation. LEVEL OF EVIDENCE: Level IV.

Quadriceps strength is an early indicator of return to competitive sports 1 year after anterior cruciate ligament reconstruction in adult amateur athletes.

BACKGROUND: Return to sports is one of the important reasons why athletes with an anterior cruciate ligament (ACL) injury undergo surgery. There are few reports on return to sports among adult amateur athletes (individuals older than the college age who participate in competitive sports). This study aimed to investigate the return of adult amateur athletes to competitive sports 1 year after ACL reconstruction and to identify the indicators for return to competitive sports. METHODS: Between January 2015 and December 2017, adult amateur athletes who underwent primary ACL reconstruction were retrospectively investigated. The rate of return to competitive sports 1 year after surgery was evaluated. The patients were categorized into two groups: return to sports group (R group) and non-return to sports group (N group). Pre- and postoperative range of motion, pivot-shift test, anteroposterior laxity, quadriceps strength, Lysholm score, and the International Knee Documentation Committee score were compared between the groups. RESULTS: This study included 78 patients (48 men, 30 women; age range, 22-53 years). Five months after ACL reconstruction, quadriceps strength was significantly lower in the N group than in the R group, denoting muscle weakness in the N group at that time. No significant differences were found in the other items between the groups preoperatively and 1 year after surgery. CONCLUSION: In this study, the rate of return to competitive sports of adult amateur athletes 1 year after ACL reconstruction was 76.9%. Quadriceps strength may be an early indicator of return to competitive sports 1 year after reconstruction.

Predictive factors for the bone union disorder of intramedullary screw fixation in proximal fifth metatarsal bone fractures.

INTRODUCTION: Although intramedullary screw fixation likely leads to successful union of Jones fractures compared to that of nonoperative treatments, bony union disorder after surgical treatment remains to be elucidated. METHODS: Intramedullary screw fixation was performed for the surgical treatment of proximal fifth metatarsal stress fractures in this series. Between January 2008 and December 2019, the feet of 222 patients were investigated regarding the effective factors for postoperative bony union between the normal union group and the bony union disorder group according to the patients' physical status, radiological assessment, and screw size. The mean postoperative follow-up period was 11.1 months. Bone union disorder was defined as delayed union, nonunion, or a re-fracture recognized through a radiographic image. RESULTS: The prevalence rate of union disorders occurred in 14% (31/222) of the patients. The risk of bone union disorder significantly increased when using a small-diameter screw (odds ratio 4.81, 95% confidence interval [CI] 1.62-14.2, p = 0.004) and non-bone graft procedures (odds ratio 3.13, 95% CI 1.22-8.02, p = 0.02). Screw length, preoperative Torg's classification, or patients' physical status did not affect postoperative bony union. CONCLUSIONS: Approximately 14.0% of the patients in our study had postoperative bone union disorder. Small-diameter screws and non-bone graft procedures increased the risk of bone union disorder in the intramedullary screw fixation technique of fifth metatarsal bone stress fractures. LEVEL OF EVIDENCE: Level 4, case series.

A Modified Anatomic Transtibial Double-Bundle Anterior Cruciate Ligament Reconstruction Provides Reliable Bone Tunnel Positioning.

Purpose: To evaluate the femoral and tibial tunnel positions via a modified anatomic transtibial double-bundle anterior cruciate ligament (ACL) reconstruction. Methods: Patients who underwent double-bundle ACL reconstruction using the transtibial tunnel creation technique were identified. Double-bundle ACL reconstruction was performed for 94 knees using the transtibial tunnel creation technique. Tunnel aperture configurations and center positions of the anteromedial (AM) and posterolateral (PL) tunnels via postoperative 3-dimensional computed tomography were evaluated. Results: There were 94 knees included. Regarding the intra-articular tunnel aperture configurations, the AM and PL tunnels overlapped at the femoral and tibial aperture in 66.0% and 94.7% cases, respectively. The mean femoral bone tunnel center was located at 23.0 ± 3.9% in the posterior-to-anterior ratio and 28.7 ± 6.0% in the proximal-to-distal ratio for the AM tunnels and at 32.8 ± 4.7% and 51.2 ± 5.2% for the PL tunnels, respectively. In the tibial tunnels, the mean AM tunnel center was located at 31.4 ± 3.6% in the anterior-to-posterior ratio and 44.3 ± 1.8% in the medial-to-lateral ratio and at 47.5 ± 3.8% and 44.3 ± 1.9% in the PL tunnel center, respectively. The femoral tunnels of outliers, both those created in nonanatomic positions as well as the posterior wall blowouts, were revealed in 7.4% cases. The nonanatomical bone tunnel group had significant heavier weight patients, lower tibial posterior slope, and were anterior in the AM and PL tunnel position. Posterior wall blowouts were related to posterior and proximal PL bone tunnel positions. Conclusions: Modified transtibial double-bundle ACL reconstruction is a reliable tunnel creation technique with anatomic placement in 92.6% of the cases. The modification required that partially superimposing configuration of the 2 tibial tunnel apertures. The nonanatomic tunnels were related to patients of heavier weight and lower tibial posterior sloped knees, whereas the posterior wall blowouts were related to the posterior and proximal PL bone tunnel positions. Level of Evidence: Level IV, therapeutic case series.

Less Invasive Surgery With Autologous Bone Grafting for Proximal Fifth Metatarsal Diaphyseal Stress Fractures.

Surgery with autologous bone grafting for proximal fifth metatarsal diaphyseal stress fracture has a potential to decrease nonunion, but it is not performed widely as the primary surgery because of donor-site morbidity. We have devised and performed a less invasive surgical procedure with autologous bone grafting and aimed to investigate the clinical and radiologic outcomes of this procedure. The data for 73 patients who underwent primary intramedullary screw fixation with autologous bone grafting from the fifth metatarsal base for proximal fifth metatarsal diaphyseal stress fractures were investigated retrospectively. The clinical and radiologic outcomes were evaluated. The mean time to bone union, starting running, and return to play was 11.8, 6.3, and 13.4 weeks, respectively. Bone union was achieved in 76 of the 78 cases. Intramedullary screw fixation with autologous bone grafting from the fifth metatarsal base showed good outcomes. It may be a useful surgical option for patients with proximal fifth metatarsal diaphyseal stress fractures.

Comparison Study of Mini-Incision Versus Original Open Technique of the Half-Mini-Bunnell Achilles Tendon Repair.

Mini-incision surgical procedures in our institution have been developed by decreasing the total skin incision length from the original mini half-Bunnell tendon repair technique. We hypothesized that the mini-incision, or minimum invasive Achilles tendon repair technique, would promote the tendon healing process leading to better outcomes and a reduced complication rate compared to the conventional open repair. The study sought to determine the more optimal method by comparing 44 mini-incision sutures to the 99 sutures in the original open Achilles tendon repairs. The mean skin incision length of the mini-incision surgery was 2.9 (range 2.5-3.0) cm and the original repair was 4.2 (range 3.5-7.0) cm. The mean surgery time was 60.0 minutes in the mini-incision repair and 68.1 minutes in the original one (p = .0003). The mean achievement time of bilateral heel-rise, starting jogging, single-legged heel-rise movement and the time to return-to-play was not significantly different between the 2 groups. Achilles Tendon Rupture Score was not significantly different from 3 to 9 months after surgery. Re-injury rate was 1/44 (2.3%) in mini-incision and 4/99 (4.0%) in conventional open repair (p = .36). No patients in either group developed any postoperative infections nor deep vein thrombosis complications. Although the mini-incision half-mini-Bunnell suture was showed equivalent clinical results to the original open repair, the technique is recommended in terms of curtailment of the surgery time without increase of complication ratio.

Can low-intensity pulsed ultrasound (LIPUS) accelerate bone healing after intramedullary screw fixation for proximal fifth metatarsal stress fractures? A retrospective study.

BACKGROUND: Intramedullary screw fixation is considered the standard treatment for proximal fifth metatarsal stress fractures. Low-intensity pulsed ultrasound (LIPUS) is a well-known bone-healing enhancement device. However, to the best of our knowledge, no clinical study has focused on the effect of LIPUS for postoperative bone union in proximal fifth metatarsal stress fractures. This study aimed to investigate the effect of LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures. METHODS: Between January 2015 and March 2020, patients who underwent intramedullary screw fixation for proximal fifth metatarsal stress fractures were investigated retrospectively. All patients underwent intramedullary screw fixation using a headless compression screw with autologous bone grafts from the base of the fifth metatarsal. The time to restart running and return to sports, as well as that for radiographic bone union, were compared between groups with or without LIPUS treatment. LIPUS treatment was initiated within 3 weeks of surgery in all cases. RESULTS: Of the 101 ft analyzed, 57 ft were assigned to the LIPUS treatment group, and 44 ft were assigned to the non-LIPUS treatment group. The mean time to restart running and return to sports was 6.8 and 13.7 weeks in the LIPUS treatment group and was 6.2 and 13.2 weeks in the non-LIPUS treatment group, respectively. There were no significant differences in these parameters between groups. In addition, the mean time to radiographic bone union was not significantly different between the LIPUS treatment group (11.9 weeks) and the non-LIPUS treatment group (12.0 weeks). The rate of postoperative nonunion in the LIPUS treatment group was 0% (0/57), while that in the non-LIPUS treatment group was 4.5% (2/44). However, this difference was not statistically significant. CONCLUSIONS: There were no statistically significant differences regarding the time to start running, return to sports, and radiographic bone union in patients with or without LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures. Therefore, we cannot recommend the routine use of LIPUS to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures.

All-Inside Repair for Radial Tear at the Posterior Horn of the Lateral Meniscus: A Figure-8 Suture Technique.

Arthroscopic suture repair for a radial tear at the posterior horn of the lateral meniscus poses a technical procedure for surgeons. We describe an all-inside repair technique using all-inside meniscal repair devices without adding any accessory portals. This simple technique provides precise reduction and stabilization of the meniscus by pinching 2 all-inside vertical sutures consecutively across the tear site.

Morphology of Acute Achilles Tendon Rupture by Intraoperative Evaluation.

The purpose of this study was to clarify the morphology of acute Achilles tendon rupture (ATR) according to intraoperative evaluation. The morphology of 220 cases was evaluated retrospectively from intraoperative findings from June 2014 to December 2015. We noted 3 characteristics of rupture. First, we divided the ruptures into complete or partial type. Second, according to the level of rupture, we classified them into muscle-tendon junctional type, mid-substantial type, or calcaneal insertional avulsion type. Lastly, on the basis of the pattern of rupture, we divided them into transverse pattern, double-layer pattern, or Z-shaped pattern. All ruptured tendons were repaired with surgical procedures on the basis of the classification of rupture type or pattern. Of the total of 220 cases, 217 were complete ruptures (98.7%) and 3 partial ruptures (1.3%). Regarding the level of rupture, 5 cases were of the muscle-tendon junctional type (2.3%), 209 cases of the mid-substantial type (95%), and 6 cases of the calcaneal insertional avulsion type (2.7%). In terms of the pattern of rupture, there were 198 cases of the transverse pattern (90%), 10 cases of the double-layer pattern (4.5%), and 12 cases of the Z-shaped pattern (5.5%). There was significant gender difference only in the mid-substantial type. Although the morphology of a typical acute ATR was complete, of mid-substance type, and with transverse pattern, other types of ATR were recognized from the intraoperative investigation.

Anatomic Anterior Cruciate Ligament Reconstruction Using Rectangular Bone-Tendon- Bone Autograft Versus Double-Bundle Hamstring Tendon Autograft in Young Female Athletes.

PURPOSE: To assess the clinical outcomes comparing rectangular bone-tendon-bone (BTB) grafts and double-bundle hamstring tendon (HM) grafts used for anatomic anterior cruciate ligament (ACL) reconstruction in young female athletes. METHODS: From January 2014 to November 2017, young female athletes 20 years or younger who underwent primary ACL reconstructions by a single surgeon were identified. Patients with concomitant injuries, not being a regular sports participant, the existence of contralateral ACL reconstruction, and who did not have a minimum of 1-year follow-up were excluded. We searched the rate and time for return-to-play, clinical outcomes including chronological instrumental side-to-side tibial translation difference, and muscle strength. Second ACL injury rates between the 2 groups during follow-up period were evaluated. RESULTS: Twenty-seven BTB ACL reconstructions and 29 HM ACL reconstructions were performed. The mean follow-up periods were 35.2 months in the BTB group and 33.8 months in the HM group. The BTB group showed better knee stability in mean side-to-side translational difference via arthrometric testing of 0.6 mm in the BTB versus 1.7 mm in the HM group at 5 months (P = .01) and 1.1 mm and 2.0 mm at 12 months, respectively (P = .02). There was no significant side-by-side difference in quadriceps muscle strength ratio, but the hamstring muscle strength was significantly better in the BTB group. The graft reinjury rate in the BTB group and the HM group was 0% (0/27) and 10.3% (3/29) (P = .09), respectively. In contrast, contralateral ACL injuries occurred in 17.3% (4/27) of the BTB group and 3.5% (1/29) of the HM group (P = .12). CONCLUSIONS: For young female athletes aged 20 years or younger, the BTB group had better knee instrumental stability than the HM group without range of motion loss or knee extensor muscle strength deficit. Although there was no statistical significance in terms of second ACL injury, we observed fewer graft rerupture and an increasing rate of contralateral ACL injuries in the BTB group. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Single-Stage Arthroscopic Anterior and Posterior Cruciate Ligament Repairs and Open Medial Collateral Ligament Repair for Acute Knee Dislocation.

Till date, there are no clear guidelines regarding the treatment of multiple ligament knee injuries. Ligament repair is advantageous as it preserves proprioception and does not involve grafting. Many studies have reported the use of open repair and reconstruction for multiple ligament knee injuries; however, reports on arthroscopic-combined single-stage anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) repairs are scarce. In this report, we describe a case of type III knee dislocation (ACL, PCL, and medial collateral ligament (MCL) injuries) in a 43-year-old man, caused by contact while playing futsal. On the sixth day after injury, arthroscopic ACL and PCL repairs were performed with open MCL repair. The proximal lesions in the three ligaments that were injured were sutured using no. 2 strong surgical sutures. The ACL was pulled out to the lateral condyle of the femur and fixed using a suspensory fixation device. The PCL was pulled out to the medial condyle of the femur, and the MCL was pulled towards the proximal end of the femur; both were fixed using suture anchors. Early mobilization was performed, and both, clinical and imaging outcomes, were good two years after surgery.

Patients aged in their 70s do not have a high risk of progressive osteoarthritis following arthroscopic femoroacetabular impingement correction and labral preservation surgery.

PURPOSE: The purposes of this study were to (1) evaluate the effect of age on clinical outcomes of arthroscopic femoroacetabular impingement (FAI) with labral preservation surgery and (2) identify predictors of poor postoperative clinical outcomes. METHODS: Eighty-four patients who underwent hip arthroscopic treatment for FAI between 2009 and 2013 were retrospectively reviewed. Patients were divided into three groups based on age. The Advanced age group consisted of patients over 70 years old, the Middle age group consisted of patients in their 50s and 60s, and the Younger age group consisted of patients less than 50 years of age. Total hip arthroplasty (THA) conversion, radiographic progression of osteoarthritis and patient-reported outcomes including modified Harris Hip Score (MHHS) and Non-arthritic Hip Score (NAHS) were investigated. RESULTS: The mean follow-up period was 32.2 (range 24-60) months. THA was required in 3 patients in their 50s and 60s, which was a significantly higher rate compared to that in patients Younger than 50 years old (17% vs 0%, p = 0.036). Progression to osteoarthritis was also significantly more frequent in patients in their 50s and 60s than in patients in their 70s (50s and 60s: 33%; 70s: 0%, p = 0.030). In all age groups, the preoperative MHHS and NAHS improved at last follow-up (p < 0.001). The 50s and 60s age group [hazard ratio (HR) 6.62], preoperative mild osteoarthritic change (Tönnis grade 1, HR: 3.29) and severe cartilage damage on the acetabulum (HR: 2.63) were risk factors for progressive osteoarthritis and THA conversion. CONCLUSIONS: Arthroscopic FAI correction and labral preservation surgery provide favourable clinical outcomes for patients over 70 years old in the absence of significant osteoarthritis and severe acetabular chondral damage. Patients in their 50s and 60s have a higher risk of both THA conversion and progressive osteoarthritis, while patients aged over 70 years show no evidence of progressive osteoarthritis. Chronologic age in isolation is not an absolute contra-indication to hip arthroscopy. LEVEL OF EVIDENCE: III.

An Anatomical Study of the Anterosuperior Capsular Attachment Site on the Acetabulum.

BACKGROUND: Despite the fact that many surgeons perform partial capsular detachment from the anterosuperior aspect of the acetabulum to correct acetabular deformities during hip arthroscopy, few studies have focused on whether these detachments influence hip joint stability. The aim of this study was to investigate the capsular attachment on the anterosuperior aspect of the acetabulum. We hypothesized that the attachment on the inferior aspect of the anterior inferior iliac spine (AIIS) is wide and fibrocartilaginous and might have a substantial role in hip joint stability. METHODS: Fifteen hips from 9 cadavers of Japanese donors were analyzed. Eleven hips were analyzed macroscopically, and the other 4 were analyzed histologically. In all specimens, the 3-dimensional morphology of the acetabulum and AIIS was examined using micro-computed tomography (micro-CT). RESULTS: Macroscopic analysis showed that the widths of the capsular attachments varied according to the location, and the attachment width on the inferior edge of the AIIS was significantly larger than that on the anterosuperior aspect of the acetabulum. Moreover, the capsular attachment on the inferior edge of the AIIS corresponded with the impression, which was identified by micro-CT. Histological analysis revealed that the hip joint capsule on the inferior edge of the AIIS attached to the acetabulum adjacent to the proximal margin of the labrum. In addition, the hip joint capsule attached to the inferior edge of the AIIS via the fibrocartilage. CONCLUSIONS: The capsular attachment on the inferior edge of the AIIS was characterized by an osseous impression, large attachment width, and distributed fibrocartilage. CLINICAL RELEVANCE: It appeared that the capsular attachment on the inferior edge of the AIIS was highly adaptive to mechanical stress, on the basis of its osseous impression, attachment width, and histological features. Anatomical knowledge of the capsular attachment on the inferior edge of the AIIS provides a better understanding of the pathological condition of hip joint instability.

Arthroscopic Treatment of a Displaced Nonunion of the Anterior Inferior Iliac Spine Causing Extra-articular Impingement.

This report describes a case of nonunion of an anterior inferior iliac spine (AIIS) apophyseal avulsion fracture with resultant subspine impingement combined with symptomatic femoroacetabular impingement (FAI). A 16-year-old male soccer player presented with a 6-month history of right groin pain exacerbated by kicking and running. The patient was diagnosed with a displaced nonunion of the AIIS apophysis avulsion fracture causing secondary extra-articular impingement beyond cam-type FAI by physical examination and radiological findings. The authors performed arthroscopic AIIS decompression, with concurrent FAI correction and labral repair and capsular closure. At 4 months after surgery, a radiograph and a computed tomography scan showed complete bony union of the AIIS apophyseal nonunion. Modified Harris Hip Sore and Nonarthritic Hip Score improved from 74.8 and 61, respectively, to 100 for both at final follow-up. The effectiveness of arthroscopic decompression of the AIIS as part of a comprehensive minimally invasive surgery including FAI correction and labral repair resulted in complete union of the AIIS and pain-free return to sport and bony union. [Orthopedics. 2017; 40(4):e725-e728.].

Arthroscopic osteochondral autologous transplantation for the treatment of osteochondritis dissecans of the femoral head.

Osteochondritis dissecans (OCD) of the femoral head is an unusual cause of hip pain. It can be associated with other intra-articular pathologies including: acetabular labral tears or bone deformities such as Legg-Calve-Perthes Disease (LCPD). In this article, we propose a modern surgical technique using an arthroscopic antegrade and retrograde osteochondral autologous transplantation (OAT) procedure for assessing and treating OCD lesions of the femoral head.