[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: In the anatomic double-bundle ACL reconstruction, 2 femoral tunnel positions are particularly critical to obtain better clinical results. Recently, a few studies have reported quantitative identification methods for posterolateral (PL) bundle reconstruction. Concerning anteromedial (AM) bundle reconstruction, however, no quantitative clinically available methods to insert a guide wire at the center of the direct attachment of the AM mid-substance fibers have been reported to date. METHODS: First, we determined the center of the femoral attachment of the AM mid-substance fibers using 38 fresh frozen cadaveric knees. Based on this anatomical sub-study, we developed a quantitative clinical technique to insert a guide wire at the averaged center for anatomic double-bundle ACL reconstruction. In the second clinical sub-study with 63 patients who underwent anatomic ACL reconstruction with this quantitative technique, we determined the center of an actually created AM tunnel. Then, we compared the results of the second sub-study with those of the first sub-study to validate the accuracy of the quantitative technique. In both the sub-studies, we determined the center of the anatomical attachment and the tunnel outlet using the "3-dimensional clock" system. The tunnel outlet was evaluated using the "transparent" 3-dimensional computed tomography RESULTS: The averaged center of the direct attachment of the AM bundle midsubstance fibers was located on the cylindrical surface of the femoral intercondylar notch at "10:37" (or "1:23") o'clock orientation in the distal view and at 5.0-mm from the proximal outlet of the intercondylar notch (POIN) in the lateral view. The AM tunnel actually created in ACL reconstruction was located at "10:41" (or "1:19") o'clock orientation in the average and at 5.0-mm from the POIN. There was no significant difference between the 2 center locations. CONCLUSIONS: The quantitative technique enabled us to easily create the femoral AM tunnel at the averaged center of the direct attachment of the AM bundle midsubstance fibers with high accuracy. This study reported information on the geometric location of the femoral attachment of the AM bundle and a clinically useful technique for its anatomical reconstruction.
[Show abstract][Hide abstract] ABSTRACT: Authors have hypothesized that the incidence and the degree of femoral tunnel enlargement after the hamstring ACL reconstruction may be significantly less in the anatomic double-bundle procedure than in single-bundle procedure. The purpose of this study is to test this hypothesis.
Seventy-two patients who underwent single-bundle reconstruction (Group S) and 97 patients who underwent anatomic double-bundle reconstruction (Group D) were followed up for 2 years after surgery. The hamstring tendon grafts were used in each procedure. All of the 169 patients were examined with computed radiography, and the standard clinical evaluation methods.
In Group S, the incidence of femoral tunnel enlargement was 48.6 and 54.2% in the anteroposterior and lateral views. In Group D, the incidence of femoral anteromedial and posterolateral tunnel enlargement was 36.1 and 23.7%, respectively, in the anteroposterior view, and that of femoral anteromedial and posterolateral tunnel enlargement was 33.0 and 21.6%, respectively, in the lateral view. The incidence of femoral tunnel enlargement was significantly less in Group D than in Group S (P < 0.0133). Concerning the degree of the tunnel enlargement, a similar tendency with statistical significance was observed (P < 0.0001). In each group, there were no significant relationships between the degree of tunnel enlargement and each clinical measure.
Both the incidence and the degree of femoral tunnel enlargement after anatomic double-bundle reconstruction with the hamstring tendon grafts are significantly less than those after single-bundle reconstruction with the same graft.
Prospective comparative cohort study, Level II.
[Show abstract][Hide abstract] ABSTRACT: It is difficult to precisely identify the locations of tunnels after double-bundle anterior cruciate ligament (ACL) reconstruction postoperatively. Using our novel transparent 3-dimensional computed tomography (T-3DCT), we evaluated intra-articular outlet locations and the angles of the anteromedial (AM) and posterolateral (PL) tunnels after anatomic double-bundle ACL reconstruction using the trans-tibial technique. A prospective study was performed with 123 consecutive patients. Tunnel outlet locations were identified on T-3DCT images showing the true lateral view of the femur and indicated by our originally defined X, Y coordinates. We also determined the angles between the tunnel axis and a joint surface line in the coronal plane, the long axis of the femur in the sagittal plane, and the posterior condyle line in the axial plane of both the femur and the tibia. The mean X, Y coordinates of the AM and PL tunnel outlets were 21, 43% and 0, 33%, respectively. In the coronal, sagittal, and axial planes, the mean AM femoral tunnel angles were 63 degrees, 48 degrees, and 55 degrees, respectively; the mean AM tibial tunnel angles in the tibia were 63 degrees, 49 degrees, and 71 degrees, respectively; the mean PL femoral tunnel angles were 38 degrees, 58 degrees, and 43 degrees, respectively; and the mean PL tibial tunnel angles were 46 degrees, 53 degrees, and 45 degrees, respectively. The AM and PL tunnel outlets and angles could be detailed precisely in three dimensions by using T-3DCT. This imaging technique may be useful to confirm surgical techniques and to improve clinical outcomes.
[Show abstract][Hide abstract] ABSTRACT: This is the first report of an anatomic double-bundle ACL and PCL reconstruction procedure with the autogenous hamstring tendons. We prepare two pairs of the doubled tendon grafts, to which a polyester tape and an Endobutton-CL are attached using our original technique at the tibial and femoral ends, respectively. Under arthroscopic and fluoroscopic observations, two tibial tunnels for PCL reconstruction are created so that they pass through the posteromedial and anterolateral bundle attachments, respectively. Then, we create two tibial tunnels for anatomic double-bundle ACL reconstruction so that each tunnel axis is aimed at a targeted point on the femoral condyle. Using the outside-in technique, two femoral tunnels for PCL reconstruction are created so that the tunnel outlets are located at the center of the anterolateral and posteromedial bundle attachments. Then, two femoral tunnels for anatomic double-bundle ACL reconstruction are created with the trans-tibial tunnel technique. After the two grafts have been placed for PCL reconstruction, the two grafts are placed for ACL reconstruction. After all the femoral graft ends are fixed, the knee joint is reduced to the full extension position, and then, the four tibial tape portions are simultaneously fixed with the turn-buckle stapling technique.
[Show abstract][Hide abstract] ABSTRACT: The purposes of this study were to determine the relation between the graft tension and the knee flexion angle in the anteromedial (AM) and posterolateral (PL) bundles of a clinically simulated anatomic double-bundle anterior cruciate ligament (ACL) reconstruction procedure and to clarify the effect of initial tension on the tension-versus-flexion curve of each graft, as well as the effect of internal rotation of the tibia on the tension of the 2 grafts.
During ACL reconstruction in 30 patients, 2 suture anchors with a No. 1 polyester suture were firmly screwed into the center of the anatomic attachment of the AM and PL bundles on the femur, respectively, and each graft tension was measured with a strain gauge-type tensiometer attached at the end of the suture under 2 conditions of initial tension.
The averaged tension-versus-flexion curves were significantly different between the AM and PL grafts under each initial tension condition (P < .0001). The initial tension applied at 30 degrees of knee flexion significantly affected the absolute values of each graft tension at each knee flexion angle (P < .0001) but did not significantly affect the tension-versus-flexion curve pattern of each graft. The maximal internal rotation of the tibia significantly increased the tension on both the AM and PL grafts at knee flexion angles of less than 60 degrees under each initial tension condition (P < .0001).
The tension-versus-flexion curves of the 2 sutures, which mimicked the AM and PL grafts reconstructed clinically with the anatomic double-bundle ACL reconstruction procedure, were significantly different in the tension values. Differences in initial tension applied to the 2 grafts significantly affected the absolute values of each graft tension at each knee flexion angle but did not significantly affect the tension-versus-flexion curve pattern. The maximal internal rotation of the tibia significantly increased the tension on both the AM and PL suture grafts at knee flexion angles of less than 60 degrees . Level of Evidence: Level I, testing of previously developed diagnostic criteria in series of consecutive patients with universally applied gold standard.
Arthroscopy The Journal of Arthroscopic and Related Surgery 03/2008; 24(3):276-84. · 3.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this retrospective study is to evaluate the middle-term results of the alumina ceramic posterior cruciate ligament-retaining total knee prosthesis. The femoral component was made of highly pure alumina ceramics. The shape of the condylar portion was designed to be as similar as that of the normal femoral condyles so that it allowed for retaining the posterior cruciate ligament. The tibial component consisted of a polyethylene insert and a titanium tibial tray with a square-shaped stem. One hundred five knees in 81 patients were clinically and radiographically evaluated in the present study (examination rate, 92.2%). Of the 105 patients, 16 patients (17 knees) were men, and 65 patients (88 knees) were women. The diseases were osteoarthritis (OA) in 49 knees (40 patients) and rheumatoid arthritis (RA) in 56 knees (14 patients). The patients were followed for a mean of 8.1 years (range, 4-13 years). Of 105 knees, 2 knees had undergone revision surgery before this survey because of breakage of a medial part of the titanium tibial tray and delayed infection. The mean postoperative knee score (full mark, 100 points) was 79.9 points in the OA patients, and 87.3 points in the RA patients. The postoperative range of flexion averaged 114.6 degrees in the OA knees and 108.7 degrees in the RA knees. The postoperative femorotibial angle averaged 175.3 degrees in the OA knees and 173.3 degrees in the RA knees. No loosening or osteolysis was found in the 103 knees that had not undergone revision surgery. A focal radiolucent line less than 1 mm in width was found beneath the anterior fringe of the femoral component in 2%, and beneath the tibial tray in 4%. Any radiolucent lines more than 1 mm in width or obvious wear of polyethylene insert were not found. The PCL-retaining total knee prosthesis (LFA-I) knee are comparable to those of the cobalt-chrome alloy knees. Thus, we could not find any disadvantages in the total knee arthroplasty with the alumina ceramic LFA-I knee compared with the cobalt-chrome alloy knees. These radiological results encourage us to conduct a long-term follow-up study of the alumina ceramic LFA-I knee, specifically concerning the ratio of revision and osteolysis.
[Show abstract][Hide abstract] ABSTRACT: In the posterior cruciate ligament avulsion fracture, posterior instability cannot be completely restored by the anatomical reduction and fixation of an avulsed fragment.
The occult midsubstance injury inside the posterior cruciate ligament may affect the residual posterior instability after anatomical reduction and internal fixation of the avulsed fragment.
Prospective comparative clinical study.
Thirty-one patients were followed for a period of 2 to 8 years. Based on magnetic resonance images taken immediately after the injury, these patients were divided into 2 groups, the occult injury group (group O, 15 knees) and the uninjured group (group N, 16 knees).
The side-to-side difference of the posterior knee instability was 3.2 mm in group O and 3.0 mm in group N. Approximately 60% of the knees examined showed mild posterior instability in both groups. There were no significant differences found between the 2 groups.
The occult posterior cruciate ligament midsubstance injury does not significantly affect postoperative posterior instability of the knee. This fact did not support the hypothesis that has been commonly considered thus far.
It is not necessary for orthopaedic surgeons to be overly apprehensive about occult midsubstance injury in the treatment of posterior cruciate ligament avulsion fracture.
The American Journal of Sports Medicine 01/2004; 32(5):1230-7. · 4.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Melorheostosis is an unusual sclerotic dysplasia of bone. The case of a 51-year-old female patient with melorheostosis and occlusion of the dorsalis pedis artery is described. Although numerous vascular anomalies have been noted in patients with melorheostosis, occlusion of the dorsalis pedis artery has not been reported previously.
Archives of Orthopaedic and Trauma Surgery 03/2002; 122(1):56-7. · 1.31 Impact Factor