All-inside suture meniscal repair using suture passer.

In recent years, to save the meniscus and prevent the progression of knee osteoarthritis, the indications for meniscus repair have been expanding instead of partial menisectomy. Accordingly, various repair techniques for meniscus tears have been developed. The conventional inside-out and outside-in meniscus repair techniques and all-inside repair technique with an implant/anchor can be classified as trans-capsular (TC) repair from the perspective of suture with penetrating capsule. Recently, new suture passers for all-inside meniscus repair have been developed. To distinguish from conventional all-inside repair with implant/anchors, all-inside repair with only suture using these suture passers was described as all-inside suture (AIS) repair. This AIS repair could achieve meniscus-to-meniscus suture across the tear without interposition of soft tissues including the capsule between suture and meniscus, leading direct gap closing of torn edges. In this respect, AIS repair is considered to be "anatomical meniscus repair". Actually, some reports showed biomechanical and clinical advantages of AIS repair. However, there is still limited evidence in clinical practice. Moreover, there are some disadvantages for AIS repair. Not only further studies but also development of new devices and surgical techniques for AIS should be required. This review describes the current status of AIS repair for each type of tear.

Mechanical Evaluation of Bone-Patellar Tendon-Bone Graft Fixation to the Tibia in ACL Reconstruction: Bone Plug Tensioning and Fixation System versus Interference Screw.

This study aimed to evaluate the mechanical properties of bone plug fixation to the tibia with a novel device, the Bone plug Tensioning and Fixation (BTF) system.Forty bone-tendon-bone grafts consisting of the whole patella-patellar tendon-tibial bone plug of 10-mm width and tibiae from the porcine were prepared. After creating a 10-mm tibial tunnel, the tibial bone plug was fixed to the tibia with the BTF system or the interference screw (IFS) to prepare a test specimen of the patella-patellar tendon-tibial bone plug fixed to the tibia. For the graft tension controllability study, a predetermined initial tension of 9.8 or 19.6 N was applied and maintained for 5 minutes. Then the bone plug was fixed to the tibia with the BTF system or IFS in 10 specimens, monitoring the residual tension for an additional 5 minutes. Then, a cyclic loading test and a tension-to-failure test were performed.The mean difference between the residual tension and the predetermined tension was significantly smaller in BTF fixation (9.8 N → 10.6 ± 2.2 N; 19.6 N → 18.9 ± 2.1 N) than in IFS fixation (9.8 N → 23.4 ± 7.4 N; 19.6 N → 28.9 ± 11.5 N). The mean displacement of the bone plug after cyclic loading was significantly less in the BTF group (1.2 ± 0.6 mm) than in the IFS group (2.2 ± 1.0 mm; p < 0.01). Stiffness was significantly greater in the BTF group (504.6 ± 148.8 N/mm) than in the IFS group (294.7 ± 96.7 N/mm; p < 0.01), whereas the maximum failure loads in the two groups did not differ significantly (724.2 ± 180.3 N in the BTF and 634.8 ± 159.4 N in the IFS groups).BTF system better performed in graft tension controllability than IFS did. BTF fixation was superior to IFS fixation in the displacement of the bone plug during the cyclic loading test and in stiffness in the tension-to-failure test.

Leaf spring exercise: A safe quadriceps strengthening exercise after anterior cruciate ligament reconstruction.

BACKGROUND: Leg extensions should be avoided in the early stages after anterior cruciate ligament reconstruction because the force exerted by the quadriceps muscle leads to anterior tibial displacement. To allow for safe quadriceps training in the knee extension range during this period, we devised the leaf spring exercise, which involves placing subjects in the prone position with their knee slightly flexed and instructing them to perform maximum isometric quadriceps contractions while supporting the proximal region of the lower leg's anterior surface and immobilizing the femur's posterior surface to prevent lifting. The current study aimed to examine the safety of Leaf spring exercise by determining the femur-tibia relationship using ultrasound imaging. METHODS: This controlled laboratory study included patients with unilateral anterior cruciate ligament-deficient knees (8 men and 8 women; age, 24.2 ± 8.3 years) who were instructed to perform Leaf spring exercise of both lower limbs. We measured the femur-tibia-step-off, which indicates the distance between the last point of the medial and lateral condyles of the femur and posterior margin of the tibial plateau, as a parameter to evaluate anterior tibial displacement via ultrasound diagnostic device. Further, peak torque of the quadriceps muscle was calculated using force measurement device. FINDINGS: No difference in anterior tibial displacement and peak torque was observed between the uninjured and injured sides during Leaf spring exercise. INTERPRETATION: Leaf spring exercise may add some strain on the reconstructed anterior cruciate ligament; hence, it can be considered a safe quadriceps exercise in the knee extension range.

Clinical outcomes after repair of an isolated radial tear in the middle segment of the lateral meniscus - All-inside suture repair vs trans-capsular suture repair.

Background/objective: For radial tears, all-inside suture (AIS) repair was clearly biomechanically superior, compared to conventional trans-capsular suture (TCS) repairs. However, clinical comparative studies of these two repairs techniques have not to be performed. Therefore, the aim of this study was to compare the clinical outcomes after AIS repair and TCS repairs for isolated radial tear at middle segment of lateral meniscus (RTMLM) in stable knees of young athletes. Methods: Twenty-six athletes (mean age, 19.1 years) underwent AIS repair with the double horizontal suture technique, using SutureLasso™ (Arthrex, Naples, FL) for isolated RTMLM (AIS group), and 20 athletes (mean age, 19.0 years) underwent inside-out repair, one of TCS repairs, with tie-grip suture technique (TCS group). All athletes were assessed for preoperative and two-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS). At six-month after repair, the lateral meniscal extrusion on mid-coronal plane on MRI and healing status on second-look arthroscopy were also evaluated in all patients. Results: In both groups, KOOS improved to either good or excellent postoperatively, while complete healing was found in only 23 and 25% at second-look arthroscopy. We identified no group-dependent differences in KOOS or healing status on arthroscopy. However, a close examination of failure rates revealed significant lower rates in AIS group relative to that of TCS group (p = 0.048). Moreover, the change from preoperative to postoperative lateral meniscal extrusion in AIS group was significantly smaller than that in TCS group (p = 0.038). Conclusions: AIS and TCS repairs for RTMLM were comparable in providing satisfactory clinical results with low rates of complete healing on arthroscopy. However, AIS repair could have lower failure rate of healing on arthroscopy and minimize postoperative lateral meniscal extrusion more effectively than TCS repair on MRI.

A Biomechanical Comparison of 2 Over-the-Top Anterior Cruciate Ligament Reconstruction Techniques: A Cadaveric Study Using a Robotic Simulator.

Background: For skeletally immature patients, over-the-top (OTT) anterior cruciate ligament (ACL) reconstruction (ACLR) is preferred. However, increased anterior laxity at deep knee flexion angles remains concerning. We modified the procedure to proximally shift the graft fixation site on the femur to prevent graft loosening at higher knee flexion angles and named it the supra-OTT procedure. Purpose: To compare anterior laxity and in situ forces of the ACL graft between conventional OTT and supra-OTT ACLR in a cadaveric model. Study Design: Controlled laboratory study. Methods: A total of 11 fresh-frozen cadaveric knee specimens underwent 4 robotic testing conditions: ACL intact, ACL resected, conventional OTT, and supra-OTT. For each condition, a 100-N load was applied at 0°, 15°, 30°, 60°, and 90° of knee flexion to simulate the Lachman test or anterior drawer test. In addition, a combined load of 5-N·m internal tibial torque and 10-N·m valgus torque was applied at 15° and 30° of knee flexion as a simulated pivot-shift test. Anterior tibial translation and in situ graft forces were recorded. The only difference between conventional OTT and supra-OTT ACLR was the graft fixation site on the femur. For conventional OTT ACLR, graft fixation was performed just on the proximal and lateral ends of the posterior condyle. For supra-OTT ACLR, the fixation point was around the proximal insertion of the lateral head of the gastrocnemius and the lateral edge of the posterior cortex, approximately 2 cm proximal to the conventional OTT position. Results: On the simulated anterior drawer test at 60° and 90° of knee flexion, anterior tibial translation after supra-OTT ACLR was significantly smaller than after conventional OTT ACLR (P < .01). However, no significant differences were noted at other flexion angles or on the simulated pivot-shift test between the conventional OTT and supra-OTT procedures. Some overconstraint and higher graft forces were noted with both techniques, but the supra-OTT technique caused even more overconstraint at higher flexion angles. Conclusion: Supra-OTT ACLR showed better biomechanical performance to control anterior laxity than conventional OTT ACLR at higher knee flexion angles. Clinical Relevance: The supra-OTT procedure may improve anterior stability at deep knee flexion angles.

Comparison of anterior knee laxity immediately after anatomic double-bundle anterior cruciate ligament reconstruction: Manual tensioning vs tensioning boot techniques.

Purpose: Tensioning technique at graft fixation is one of key factors for successful outcomes in ACL reconstruction. The tensioning boot, which had two tensioners and was fixed to the tibia with a bandage, was developed for precise graft tensioning. The purpose was to compare the anterior knee laxity between the manual tensioning and the tensioning boot techniques immediately after ACL reconstruction under anesthesia in order to elucidate the effectiveness of using the tensioning boot. Methods: 33 patients had anatomic double-bundle ACL reconstruction with semitendinosus tendon graft. After grafts were fixed with EndoButton-CL on lateral femoral cortex, grafts were tied to Double Spike Plate (DSP). Each graft was pre-tensioning with 20 N (totally 40 N) at 20 degree of flexion for 3 minutes using manually-held tensioner in 11 patients and using tensioner installed to tensioning boot in the remaining 22 patients before graft fixation, and were then fixed in the same manner. Tibial displacement under 67 and 89 N of tibial anterior load was measured by KT-2000 Knee Arthrometer under anesthesia before and immediately after operation. Results: The anterior knee laxity in the operated knee was 4.5 ± 1.0 mm in the manual tensioning group and 2.9 ± 0.9 mm in the tensioning boot group at 89 N of anterior load, showing a significant difference. (P < .0001) The side-to-side difference in the manual tensioning group was significantly less than that in the tensioning boot group. (P = .002). Conclusions: Anterior laxity of the operated knees as well as KT side-to-side difference immediately after ACL reconstruction was larger in the tensioning boot technique than the manual tensioning technique, when the graft was fixed in the same manner. Thus, the initial tension at graft fixation with the tensioning boot can be smaller than 40 N.

Posterior Ankle Impingement Caused by Hyaline-Like Cartilage Generation in Ballet Dancers-A Report of 2 Cases.

Posterior ankle impingement syndrome is mainly seen in ballet dancers and frequently associated with specific movements in ballet such as pointe and demi pointe in which the whole-body weight is applied to the maximally plantar flexed ankle. We performed arthroscopic debridement for 2 dedicated ballet dancers on the intervening soft tissue causing posterior ankle impingement syndrome (PAIS). In both cases, T2-weighted magnetic resonance imaging (MRI) revealed low-signal intensity of meniscus-like soft tissue without abnormal osseous findings, connecting from the posterior side of the talus to Kager's fat pad. To examine the intervening soft tissue in detail, we performed histological evaluation by hematoxylin and eosin staining, Safranin O fast green staining, and immunohistochemistry for type I collagen and type II collagen. Hematoxylin and eosin staining showed that there was cartilage-like tissue including chondrocyte-like cells in contact with fibrous tissue. The extracellular matrix in the cartilage zone was consistently stained by Safranin O staining and type II collagen without any staining with type I collagen. These findings suggested that the meniscus-like soft tissue appearing as low-signal intensity on MRI at the posterior side of talus included hyaline-like cartilage. To the extent of our knowledge, these were rare cases of hyaline-like cartilage generation causing PAIS in ballet dancers, which might be associated with ballet specific movements resulting in chondrogenesis.

Tibiofemoral Relationship 3 Weeks After Anatomic Triple-Bundle Anterior Cruciate Ligament Reconstruction With 10 N of Initial Tension Is Closer to Normal Knee Versus That With 20 N of Initial Tension.

PURPOSE: This study aimed to clarify the effect of initial graft tension on the ensuing tibiofemoral relationship and on 2-year clinical outcomes after anatomic triple-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 31 patients with primary unilateral ACL rupture (mean age, 25.1 years) were enrolled. Anatomic triple-bundle ACL reconstruction was performed using semitendinosus tendon autografts, and patients were grouped according to the total initial tension at graft fixation: 20 N for 16 patients between January 2012 and December 2012 and 10 N for 15 patients between January 2013 and December 2013. Three-dimensional computed tomography scans were performed preoperatively and at 3 weeks and 6 months postoperatively. The side-to-side difference of the 3-dimensional tibial position relative to the femur was compared at each time point. The side-to-side difference in anterior laxity was sequentially compared preoperatively, immediately after surgery, and at 6 months and 2 years postoperatively. Clinical outcomes at 2 years were likewise compared. RESULTS: One patient in each group was excluded because of secondary ACL injury. At 3 weeks postoperatively, 2.5 ± 1.3 and 1.0 ± 1.3 mm of posterior tibial displacement and 3.8° ± 2.4° and 2.0° ± 1.7° of external rotation were observed in the 20- and 10-N initial tension groups, respectively, with significant differences (P = .006 and .033). At 6 months postoperatively, anterior displacement was 0.1/0.1 mm and external rotation was 0.8°/0.4° in both groups, without any significant differences. The 2-year clinical outcomes were satisfactory, including mean side-to-side difference in anterior knee laxity of 0.5 mm in both groups. CONCLUSION: The tibiofemoral relationship 3 weeks after anatomic triple-bundle ACL reconstruction with 10 N of initial tension is less constrained than that with 20 N. Six-month tibiofemoral relationship and 2-year clinical outcomes are satisfactory in both groups. LEVEL OF EVIDENCE: III, retrospective comparative trial.

Anatomical Triple Bundle Anterior Cruciate Ligament Reconstructions With Hamstring Tendon Autografts: Tunnel Locations and 2-Year Clinical Outcomes.

PURPOSE: To anatomically clarify the location of the tunnel apertures created using the bony landmark strategy and to elucidate clinical outcomes after anatomic triple-bundle (ATB) anterior cruciate ligament (ACL) reconstruction. METHODS: Thirty-two patients with unilateral ACL injury who had consented to undergo computed tomography (CT) at 3 weeks, as well as 2-year follow-up evaluation, were enrolled. At the time of surgery, remnant tissues were thoroughly cleared to create 2 femoral and 3 tibial tunnels inside the ACL attachment areas bordered by the bony landmarks. Two double-looped semitendinosus tendon autografts were prepared and fixed on the femur with two EndoButton-CLs and secured to the tibia with pullout sutures and plates with 10-20N of tension. The location of the tunnel aperture areas was assessed using 3-dimensional CT images, and 2-year postoperative clinical outcomes were evaluated. RESULTS: The CT evaluation showed 100% of the femoral tunnel aperture area and at least 79% of the tibial tunnel aperture area were located inside the anatomic attachment areas. Thirty patients were available for clinical evaluation. The International Knee Documentation Committee subjective assessment showed all of the patients were classified as "normal" or "nearly normal." Lachman and pivot-shift tests were negative in 100% and 93%, respectively. The mean side-to-side difference of anterior laxity at the maximum manual force with a KT-1000 Knee Arthrometer was 0.7 ± 0.7 mm, ranging from 0 to 2 mm. CONCLUSION: In ATB ACL reconstructions with hamstring tendon grafts, the tunnels can be created in proper locations using the arthroscopically-identifiable bony landmarks. Moreover, ATB ACL reconstruction with hamstring tendon grafts via the proper tunnels result in consistently satisfactory clinical outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Chronological changes in cross-sectional area of the bone-patellar tendon-bone autograft after anatomic rectangular tunnel ACL reconstruction.

PURPOSE: The purpose of this study was to evaluate the change in cross-sectional area (CSA) of bone-patellar tendon-bone (BTB) autografts up to 5 years after the anatomic rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR). The changing pattern in CSA might be a potential indicator of the graft remodeling process. METHODS: Ninety-six (62 males, 34 females, mean age 27.0 years) patients were enrolled in this study with a total of 220 MRI scans after ART BTB ACLR to evaluate the CSA of the ACL autografts. The patients with first time unilateral ACLR that consented to undergo MRI evaluations at postoperative periods were included in this study. Intraoperatively, the CSA of the graft was measured directly using a custom-made area micrometer at the midpoint of the graft. Postoperatively, using an oblique axial slice MRI that was perpendicular to the long axis of the graft, the CSA of the graft was measured with digital radiology viewing program "SYNAPSE" at the midpoint of the graft. The postoperative MRI scans were classified into seven groups according to the period from ACLR to MRI evaluation: Group 0-2 months (m.), Group 3-6 m., Group 7-12 m., Group 1-2 years (y.), Group 2-3 y., Group 3-4 y., and Group 4 y.-. The percent increase of the CSA was calculated by dividing the postoperative CSA by the intraoperative CSA. RESULTS: The postoperative CSA was significantly larger than the intraoperative CSA in each group, with the exception of Group 0-2 m. The mean percent increase of the CSA in Group 0-2 m., 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., 4 y.- was 101.8 ± 18.2, 188.9 ± 27.4, 190.9 ± 43.7, 183.3 ± 28.9, 175.2 ± 27.9, 163.9 ± 19.8, 164.5 ± 25.4% respectively. The percent increase in Group 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., and 4 y.- was significantly greater than that in Group 0-2 m. CONCLUSIONS: The CSA of the BTB autografts after the ART BTB ACLR increases rapidly by 3-6 months after ACLR, reached a maximum value of 190% at around 1 year, decreases gradually after that, and reaches a plateau at around 3 years. The current study might help clinicians to estimate an individual BTB autograft's remodeling stages when considering returning patients to sports. LEVEL OF EVIDENCE: IV.

Different effects of the lateral meniscus complete radial tear on the load distribution and transmission functions depending on the tear site.

PURPOSE: To compare the effect of the lateral meniscus (LM) complete radial tear at different tear sites on the load distribution and transmission functions. METHODS: A compressive load of 300 N was applied to the intact porcine knees (n = 30) at 15°, 30°, 60°, 90°, and 120° of flexion. The LM complete radial tears were created at the middle portion (group M), the posterior portion (group P), or the posterior root (group R) (n = 10, each group), and the same loading procedure was followed. Finally, the recorded three-dimensional paths were reproduced on the LM-removed knees. The peak contact pressure (contact area) in the lateral compartment and the calculated in situ force of the LM under the principle of superposition were compared among the four groups (intact, group M, group P, and group R). RESULTS: At all the flexion angles, the peak contact pressure (contact area) was significantly higher (lower) after creating the LM complete radial tear as compared to that in the intact state (p < 0.01). At 120° of flexion, group R represented the highest peak contact pressure (lowest contact area), followed by group P and group M (p < 0.05). The results of the in situ force carried by the LM were similar to those of the tibiofemoral contact mechanics. CONCLUSION: The detrimental effect of the LM complete radial tear on the load distribution and transmission functions was greatest in the posterior root tear, followed by the posterior portion tear and the middle portion tear in the deep-flexed position. Complete radial tars of the meniscus, especially at the posterior root, should be repaired to restore the biomechanical function.

Anterior tibial loading on the calf enhances anterior tibial translation in the anterior cruciate ligament deficient knee in the anterior gravity radiographic view.

BACKGROUND: Lateral radiograph in the prone position with the knee flexed at 15° (anterior gravity view (AGV)) is useful as a screening for anterior cruciate ligament (ACL) injuries, while it is sometimes difficult to find the side-to-side difference (SSD) in anterior tibial translation. Thus, we applied a weight (three kilograms) around the lower leg to increase anterior tibial translation. We aimed to determine whether weight load confers an advantage in visualizing anterior knee laxity in ACL injuries. METHODS: Fifty-eight patients with confirmed unilateral ACL tears from February 2012 to April 2014 had consented to participate in this study. Lateral radiographs for both knees were taken in AGV and in AGV with a three-kilogram weight load applied to the proximal lower leg. Then, the SSD of tibial position related to the femur was measured in these radiographs. RESULTS: The SSD with the weight was significantly greater than that without the weight (5.9 ± 2.1 and 3.5 ± 1.6 mm, respectively, p < 0.01). The ratio of patients with SSD of three millimeters or more in AGV with the weight was also significantly larger than that without the weight (p < 0.01). CONCLUSIONS: The anterior laxity in AGV with the three-kilogram weight is larger than that without the weight. Thus, the AGV with the weight could be one of the helpful radiographic technique for auxiliary diagnosis of ACL injury. Level of evidence Cohort study, Level IV.

Quantitative Evaluation of Functional Instability Due to Anterior Cruciate Ligament Deficiency.

BACKGROUND: A safe and simple procedure to evaluate functional instability due to anterior cruciate ligament (ACL) deficiency (ACLD) has not been established. The angle of trunk backward tilting, which is known as a posture at risk for ACL injuries, could be used as a parameter to evaluate functional instability due to ACLD. PURPOSE: To measure the backward tilt angle of the trunk with participants standing upright on 1 leg and to investigate its usefulness to quantitatively evaluate functional instability due to ACLD. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Our cohort included 50 participants with unilateral ACLD and 40 participants with bilateral healthy knees. The trunk backward tilt (TBT) test was conducted as follows: the participant was asked to maximally tilt the trunk backward in a single-leg standing position, while forward tilt of the index leg was blocked with a custom-made device. The TBT angle was measured using a side-view photograph. Subjective knee instability during the test was recorded using a visual analog scale (VAS). The relative and absolute reliability of the TBT test were verified in a sample of healthy participants and those with ACLD, and comparisons between indicators were performed. Multiple regression analysis was performed with the injured/uninjured side ratio (I/U ratio) of the TBT angle as the dependent variable and the following independent variables: (1) I/U ratio of knee extension muscle strength, (2) I/U ratio of knee flexion muscle strength, (3) side-to-side difference (SSD) of the KT-1000 arthrometer measurement, (4) sex, and (5) SSD of the VAS score. RESULTS: The TBT test had high reliability among healthy participants and those with ACLD. The TBT angle was significantly smaller and the VAS score was significantly higher on the injured side compared with the uninjured side and with healthy knees (P < .001 for all). Among the independent variables, the SSD of the VAS score had a negative influence on the I/U ratio of the TBT angle (R 2 = 0.59; P < .001). CONCLUSION: The TBT test is a simple, safe, and reliable method for quantitatively evaluating functional instability due to ACLD under weightbearing conditions that reflect subjective knee instability. The test will provide an index of treatment outcomes and return to sports through additional objective measurements before and after ACL reconstruction.

Residual graft tension after graft fixation in anterior cruciate ligament reconstruction: Manual vs tensioning boot techniques.

BACKGROUND: Graft fixation at quantitative tension using a manual tensioner was advocated in ACL reconstruction, while the measured tension that is based on the surgeon's hand with the tensioner decreases after graft fixation. Therefore, our purpose is to elucidate how effectively the pre-determined graft tension maintained after final fixation of the graft to the tibia using a tensioning boot system fixed to the calf with a bandage, while monitoring the graft tension based on tibia. METHODS: Eight cadaveric legs (mean age: 83; 3 males and 5 females) underwent an anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with hamstring tendon grafts. Two tension-adjustable force gauges were installed on the lateral femoral cortex beside the femoral tunnel. Then #5 strong suture wires through the loop end of grafts were tied to the force gauges using Endo-Buttons. After manual maximum load was repeatedly applied to each graft for 3 min, the grafts were fixed to the tibia with 10 N or 20 N at 20 degree of flexion with the following tensioning techniques using double spike plate system: (1) Manually tensioning technique (MT); (2) Tensioning boot technique with flexion-extension motion (TB-FE); and (3) Tensioning boot technique with repetitive pull (TB-RP). The residual tension at 20 was measured 3 min after grafts fixation, and also after 10 and 50 times of repeated flexion-extension motion. One-way repeated measures ANOVA was used for statistical analysis among the three techniques. RESULTS: There were significant differences among three techniques fixing grafts with 10/20 N of initial tension in the residual tension 3 min after graft fixation and after 10 and 50 times of repeated flexion-extension motion. Among them, the residual tension in TB-RP was the greatest in most conditions. CONCLUSION: TB-RP is the most secure procedure to maintain the graft tension closer to the intended initial tension in ACL reconstruction.

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft. Part 2: Factors related to the tibial tunnel enlargement.

BACKGROUND: Factors related to tunnel enlargement after anterior cruciate ligament (ACL) reconstruction should be evaluated by multivariate analysis, because the phenomenon has multifactorial characteristics. The purpose of this study was to elucidate the factors related to the tibial tunnel enlargement rate after anatomic ACL reconstruction with a bone-patellar tendon-bone (BTB) graft using multivariate analysis. METHODS: Eighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture. The CSA was measured at 3 weeks and 1 year after surgery, and the tunnel enlargement rate at the aperture was calculated. Multiple linear regression analysis was performed to detect the significantly related factors to the tibial tunnel enlargement rate at the aperture among potential factors consisting of preoperative demographic factors and predisposing factors with the tibial tunnel. RESULTS: The tibial tunnel enlargement rate at the aperture was 21.9 ± 14.1% (mean ± standard deviation). Multiple linear regression analysis detected the tendon length inside the tunnel as a significantly independent factor related to the tibial tunnel enlargement rate at the aperture (standardized ß = 0.726, P = 0.008). There was no significant relationship between the tibial tunnel enlargement rate at the aperture and postoperative side-to-side difference (SSD) of the anterior knee laxity or Tegner activity level scale under single linear regression analysis. CONCLUSION: The greater tendon length inside the tunnel was independently related to the higher tibial tunnel enlargement rate at the aperture 1-year after anatomic ACL reconstruction with a BTB graft under multiple linear regression analysis.

Minimal tibial tunnel enlargement after anatomic rectangular tunnel anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.

BACKGROUND: The purpose of this study was to evaluate the tibial tunnel enlargement after the anatomical rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone (BTB) graft and to elucidate the correlation between the enlargement and length of the tendinous portion inside the tibial tunnel. In addition, we aimed to analyze the correlation between patient characteristics and tibial tunnel enlargement. METHODS: This study included 50 patients who underwent ART ACLR. Lateral radiographs at the time of surgery and at 2 years were compared to evaluate the tibial tunnel enlargement. Subsequently, correlations between the tunnel enlargement and (1) length of tendinous portion inside the tibial tunnel or (2) characteristics of the patients, including anterior knee laxity measured by KT-1000 arthrometer, age, sex, height, body weight, and Tegner activity level scale, were analyzed. RESULTS: The tibial tunnel was enlarged by 2.6 ± 4.2% 2 years postoperatively. The length of the tendinous portion inside the tibial tunnel was 7.8 ± 4.9 mm. There was no significant correlation between tunnel enlargement and length of tendinous portion inside the tunnel. None of the patient characteristics were detected as a risk factor for tibial tunnel enlargement. CONCLUSIONS: (1) The postoperative tibial tunnel enlargement was minimum after ART ACLR with a BTB graft. (2) There was no correlation between tibial tunnel enlargement and length of tendinous portion of BTB graft inside the tunnel. (3) None of the patient characteristics were detected as a risk factor of the tibial tunnel enlargement.

Functional Adaptation of the Fibrocartilage and Bony Trabeculae at the Attachment Sites of the Anterior Cruciate Ligament.

The direct insertion of an enthesis is composed of uncalcified fibrocartilage (FC) and calcified FC, believed to function as buffers for multidirectional forces applied to the ligament. This study was performed to investigate the relationship between the FC thickness and bony trabecular orientation of the anterior cruciate ligament (ACL) on both the femoral and tibial sides. Six cadavers were examined (age at death: 73-92 years). Both femoral and tibial insertions of the ACL were harvested and used to make 0.5 mm interval semi-serial sections. Microdigital images were taken and used to measure the maximum thickness of both the uncalcified FC and Calcified FC. Two-dimensional discrete Fourier analysis was also performed to determine the orientation angle and orientation intensity of bony trabeculae directly under the FC. The mean thicknesses of the uncalcified FC at the femoral and tibial insertions were 0.98 mm and 0.49 mm, respectively. The mean thicknesses of the calcified FC were 0.47 mm and 0.38 mm, respectively. There was a significant difference in the uncalcified FC thickness, but not in the calcified FC thickness. The bony trabeculae showed a prominent orientation parallel to the ACL fiber on both sides, but it was more intense on the tibial side than on the femoral side. The trabecular orientation was prominent in the proximal-posterior part of the femoral side and in the anteromedial part of the tibial side, suggesting that mechanical stress is greater in these parts. The dominant bony trabecular angle was 69.0° on the femoral side and 59.8° on the tibial side when the tidemark was set at 0°. These findings suggest that the femoral side receives multidirectional stresses, while relatively unidirectional stress is loaded on the tibial side. Furthermore, stress is considered to be greater in the proximal-posterior part of the femoral insertion and in the anteromedial part of the tibial insertion. At the time of ACL reconstruction, attention should be paid to assign a robust portion of the graft to the posterior part of the femoral insertion and anteromedial part of the tibial insertion. Clin. Anat., 33:988-996, 2020. © 2019 Wiley Periodicals, Inc.

A longitudinal tear in the medial meniscal body decreased the in situ meniscus force under an axial load.

PURPOSE: To clarify the effect of longitudinal tears of the medial meniscus on the in situ meniscus force and the tibiofemoral relationship under axial load. METHODS: Twenty-one intact porcine knees were mounted on a 6-degrees of freedom robotic system, and the force and three-dimensional path of the knee joints were recorded during three cycles under a 250-N axial load at 30°, 60°, 90° and 120° of knee flexion. They were divided into three groups of seven knees with longitudinal tears in the middle to the posterior segment of the medial meniscus based on the tear site: rim, outer one-third and inner one-third of the meniscal body. After creating tears, the same tests were performed. Finally, all paths were reproduced after total medial meniscectomy, and the in situ force of the medial meniscus was calculated based on the principle of superposition. RESULTS: With a longitudinal tear, the in situ force of the medial meniscus was significantly decreased at 60°, 90° and 120° of knee flexion, regardless of the tear site. The decrement was greater with a tear in the meniscal body than a tear in the rim. A longitudinal tear in the meniscal body caused a significantly greater tibial varus rotation than a tear in the rim at all flexion angles. CONCLUSION: Longitudinal tears significantly decreased the in situ force of the medial meniscus. Tears in the meniscal body caused a larger decrease of the in situ meniscus force and greater varus tibial rotation than tears in the rim.

Sequential analysis of three-dimensional tibiofemoral relationship through anatomic anterior cruciate ligament reconstruction with gravity-assisted radiographic technique in prone position.

BACKGROUND/OBJECTIVES: It is important to restore the tibiofemoral relationship as well as the anterior knee laxity for more successful anterior cruciate ligament (ACL) reconstruction, since a residual abnormality in the tibiofemoral relationship would lead an abnormal stress on the articular cartilages/menisci and consequently increase the risk of osteoarthritis in the future. This study aimed to sequentially clarify the three-dimensional tibiofemoral relationship before and after anatomic anterior cruciate ligament (ACL) reconstruction under an anterior tibial load with a gravity-assisted radiographic technique in the prone position. METHODS: Fifteen patients with unilateral ACL injury participated in the study. Anatomic triple-bundle ACL reconstruction was performed using semitendinosus tendon autografts. During the computed tomography scans that were performed preoperatively, and those performed at 3 weeks and at 6 months postoperatively, the patients lay in the prone position with the knee flexed at 15°, wherein the calf weight could exert an anterior drawer force on the tibia due to gravity. Three-dimensional the tibial position relative to the femur were evaluated for each time point, followed by calculation of side-to-side differences in the parameters between the ACL-deficient/ACL-reconstructed knees and the contralateral intact knees. Seven healthy volunteers were enrolled in the control group and the side-to-side differences (right minus left) in these parameters were calculated. RESULTS: The tibia in the ACL-deficient knee was located anteriorly by 3.5 ±â€¯1.1 mm and rotated internally by 2.4° ± 2.3°; these values were significantly larger than the corresponding values of -0.2 ±â€¯1.5 mm and 0.1° ± 2.2° in the control group. However, at 3 weeks postoperatively, the tibia in the ACL-reconstructed knee was over-constrained as compared to that in the control group; it was located posteriorly by 2.5 ±â€¯1.4 mm and rotated externally by 3.4° ± 3.4°. At 6 months postoperatively, no significant difference was observed in the tibial displacements/rotations between the patient and control groups. The side-to-side difference in the anterior knee laxity at the manual maximum anterior load was 0.1 ±â€¯1.2 mm at 6 months postoperatively, with a significant improvement over the preoperative value of 7.4 ±â€¯2.5 mm. CONCLUSIONS: Anatomic ACL reconstruction could restore not only the normal anterior knee laxity, but also the normal tibiofemoral relationship even under an anterior tibial load.