Objective To compare the effectiveness between lower tibial tunnel placement combined with internal tension relieving suture and simple lower tibial tunnel placement for posterior cruciate ligament (PCL) reconstruction. MethodsThe clinical data of 83 patients with simple PCL injury who met the selection criteria between January 2014 and February 2022 were retrospectively analyzed. Among them, 44 patients underwent PCL reconstruction through lower tibial tunnel placement combined with internal tension relieving suture (tension relieving suture group), and 39 patients underwent PCL reconstruction through simple lower tibial tunnel placement (control group). Baseline characteristics, including gender, age, body mass index, side of injury, cause of injury, preoperative side-to-side difference (SSD) in posterior tibial translation, visual analogue scale (VAS) score, knee range of motion (ROM), Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) scores (including symptom, daily activities, and knee function scores) were compared between the two groups, showing no significant difference (P>0.05). The operation time and intraoperative blood loss were recorded and compared between the two groups. The effectiveness was evaluated by Lysholm score, IKDC scores, Tegner score, VAS score, knee ROM, SSD in posterior tibial translation before operation and at last follow-up, the patient satisfaction at last follow-up, and the postoperative graft recovery was evaluated by MRI. ResultsThere was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05). All patients were followed up 12-60 months, and there was no significant difference between the two groups (P>0.05). Postoperative MRI showed that the graft was in good condition, and the reconstructed PCL graft had good signal, continuity, and tension. During the follow-up, there was no complication such as re-rupture or donor site discomfort in both groups. At last follow-up, the Lysholm score, IKDC scores, Tegner score, VAS score, knee ROM, and SSD in posterior tibial translation significantly improved in both groups when compared with those before operation (P<0.05). The changes of Lysholm score, Tegner score, IKDC knee symptom score, and SSD in posterior tibial translation between pre- and post-operation were significantly superior in the tension relieving suture group compared to the control group (P<0.05). However, no significant difference was found between the two groups in the changes of VAS score, knee ROM, IKDC daily activities score or knee function score between pre- and post-operation, and the satisfaction score (P>0.05). ConclusionLower tibial tunnel placement combined with internal tension relieving suture PCL reconstruction represents a more effective surgical approach for improving postoperative laxity of PCL and knee function recovery comparing to simple lower tibial tunnel placement PCL reconstruction.
ObjectiveTo compare the strength difference between the interfacial screw and the interfacial screw combined with bone tunnel crossing technology to fix the tibial end of ligament during anterior cruciate ligament (ACL) reconstruction through the biomechanical test.MethodsTwenty fresh frozen pig tibia were randomly divided into two groups (n=10) to prepare ACL reconstruction models. The graft tendons in the experimental group were fixed with interfacial screw combined with bone tunnel crossing technology, and the graft tendons in the control group were fixed with interfacial screw. The two groups of specimens were fixed in the high-frequency dynamic mechanics test system M-3000, and the length change (displacement), ultimate load, and stiffness of graft tendons were measured through the reciprocating test and load-failure test.ResultsThe results of reciprocating test showed that the displacement of the experimental group was (3.06±0.58) mm, and that of the control group was (2.82±0.46) mm, and there was no significant difference between the two groups (t=0.641, P=0.529). The load-failure test results showed that the stiffness of the experimental group and the control group were (95.39±13.63) and (91.38±14.28) N/mm, respectively, with no significant difference (t=1.021, P=0.321). The ultimate load of the experimental group was (743.15±173.96) N, which was significantly higher than that of the control group (574.70±74.43) N (t=2.648, P=0.016).ConclusionIn ACL reconstruction, the fixation strength of tibial end with interface screw combined with bone tunnel crossing technology is obviously better than that of interface screw alone.
Objective To investigate the effectiveness of modified single patellar tunnel medial patella femoral ligament (MPFL) reconstruction in the treatment of recurrent patellar dislocation. MethodsBetween January 2023 and June 2023, a total of 61 patients with recurrent patellar dislocation who underwent MPFL reconstruction with autologous semitendinosus were enrolled and divided into 2 groups using random number table method. In the patellar anchor group, 31 patients were treated with MPFL reconstruction with double medial patellar anchors, and 30 patients in the patellar tunnel group were treated with MPFL reconstruction with single patellar tunnel. The femoral ends of both groups were fixed with absorbable compression screws. There was no significant difference in baseline data such as gender, age, side, tibial tubercle-trochlear groove (TT-TG), Q angle, Caton-Deschamps index, number of dislocation, and preoperative Kujala score, preoperative patellar inclination angle (P>0.05). Patellar tunnel, patellar anchor position, patellar reduction, and the patellar inclination angle were measured by CT scan after operation. Kujala score was used to evaluate the function of knee joint before operation, at 2 weeks and 1, 3, 6, 12 months after operation. Incision aesthetic satisfaction score was performed at 3 months after operation. The signal-to-noise quotient (SNQ) of the transplanted tendon was measured by knee MRI at 12 months after operation to compare the maturity of the graft between the two groups. Results There was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05). Knee CT reexamination showed that the patellar tunnel and the patellar anchor position were consistent with the intraoperative fluoroscopy. There was no significant difference in the difference of the patellar inclination angle between the two groups before and after operation (P>0.05). All patients were followed up 12-14 months (mean, 12.8 months). There was 1 case of patellar anchor suture rejection in patellar anchor group, and the wound healed after debridement and dressing change. During the follow-up, there was no complication such as recurrence of patellar dislocation, infection and postoperative stiffness. The Kujala scores of the two groups significantly improved at each time point after 1 month of operation when compared with those before operation (P<0.05), and the Kujala scores of the two groups returned to normal levels at 3 months after operation. The Kujala score in the patellar tunnel group was significantly higher than that in the patellar anchor group in the very early stage (2 weeks) (P<0.05), and there was no significant difference between the two groups at other time points (P>0.05). Patients in the patellar tunnel group were significantly better than those in the patellar anchor group in the score of incision aesthetic satisfaction at 3 months after operation and the SNQ at 12 months after operation (P<0.05). Conclusion Modified single patellar tunnel MPFL reconstruction was used to treat patients with recurrent patellar dislocation without pathological TT-TG. The slide-fixation structure formed by single patellar tunnel positioning provides a variable degree of freedom for the reconstructed MPFL, which shows good effectiveness in the very early stage of the rehabilitation process.
ObjectiveTo investigate the effects of different concentrations of osteoprotegerin (OPG) combined with deproteinized bone (DPB) on the bone tunnel after the anterior cruciate ligament (ACL) reconstruction. MethodsThe femoral epiphyseal side was harvested from newborn calf, and allogenic DPB were prepared by hydrogen peroxide-chloroform/methanol method. Then, DPB were immersed in 3 concentrations levels of OPG (30, 60, 100 μg/mL) and 3 concentration ratios (30%, 60%, 100%) of the gel complex were prepared. Sixty healthy New Zealand white rabbits, male or female, weighing (2.7±0.4) kg, were divided randomly into 4 groups (n=15):control group (group A), 30% (group B), 60% (group C), and 100% (group D) OPG/DPB gel complex. The ACL reconstruction models were established by autologous Achilles tendon. Different ratios of OPG/DPB gel complex were implanted in the femoral and tibial bone tunnel of groups B, C, and D, but group A was not treated. The pathology observation (including the percentage of the femoral bone tunnel enlargement) and histological observation were performed and the biomechanical properties were measured at 4, 8, and 12 weeks after operation. ResultsOne rabbit died of infection in groups A and D, 2 rabbits in groups B and C respectively, and were added. General pathology observation showed that the internal orifices of the femoral and tibia tunnels were covered by a little of scar tissue at 4 weeks in all groups. At 8 weeks, white chondroid tissues were observed around the internal orifices of the femoral and tibia tunnels, especially in groups C and D. At 12 weeks, the internal orifices of the femoral and tibia tunnels enlarged in groups A, B, and C, but it was completely closed in group D. At each time point, the rates of the femoral bone tunnel enlargement in groups B, C, and D were significantly lower than that in group A, and group D was significantly lower than groups B and C (P<0.05); group C was significantly lower than group B at 8 weeks, but no significant difference was found at 4 and 12 weeks (P<0.05). Hisological observation showed that fresh fibrous connective tissue was observed in 4 groups at 4 weeks; there was various arrangements of Sharpey fiber in all groups at 8 weeks and the atypical 4-layer structure of bone was seen in group D; at 12 weeks, Sharpey fiber arranged regularly in all groups, with typical 4-layer structure of bone in groups B, C, and D, and an irregular "tidal line" formed, especially in group D. Biomechanics measurement showed that the maximum tensile load in group D was significantly higher than that in groups A and B at 4 weeks (P<0.05), but no significant difference was shown among groups A, B, and C, and between groups C and D (P>0.05); at 8 weeks, it was significantly higher in groups C and group D than group A, and in group D than group B (P<0.05), but there was no significant difference between groups A, C and group B (P>0.05); at 12 weeks, it was significantly higher in groups C and D than groups A and B, and in group D than group C (P<0.05), but difference was not significant between groups A and B (P>0.05). ConclusionDifferent concentrations ratios of OPG/DPB gel complexes have different effects on the bone tunnel after ACL reconstruction. 100% OPG/DPB gel complex has significant effects to prevent the enlargement of bone tunnel and to enhance tendon bone healing.
Objective To investigate the short-term effectiveness of transtibial pull-out technique combined with side-to-side suture technique in treatment of complete radial tear of lateral meniscus body. Methods Between May 2020 and August 2023, 15 patients with complete radial tear of lateral meniscus body were repaired by arthroscopic transtibial pull-out technique combined with side-to-side suture technique. There were 11 males and 4 females, with an average age of 25.2 years (range, 15-43 years). Twelve cases were acute injuries and 3 were chronic injuries. All patients had tenderness in the lateral compartment of the knee. No abnormal alignment was observed on the X-ray films of the knee. MRI showed the complete radial tear of lateral meniscus body without associated injuries such as anterior cruciate ligament or cartilage. Preoperative Lysholm score was 44.5±6.4, International Knee Documentation Committee (IKDC) subjective score was 40.2±8.4, Tegner score was 1.3±1.1, and visual analogue scale (VAS) score for pain was 5.1±1.1. The operation time, incision healing, and complications such as vascular/nerve injury were recorded. During follow-up, the range of motion of the knee and tenderness in the lateral compartment of the knee were observed. The knee function and pain were evaluated using Lysholm score, Tegner score, IKDC subjective score, and VAS score. X-ray films and MRI of the knee were reexamined to assess knee degeneration. Results The operation time was 60-145 minutes (mean, 89.6 minutes). All incisions healed by first intention, and no complication such as vascular/nerve injury occurred. All patients were followed up 17-56 months (mean, 38.4 months). All patients had no knee extension limitation and 3 cases had tenderness in the lateral compartment of the knee. At last follow-up, the Lysholm score, IKDC subjective score, Tegner score, and VAS score for pain were 85.3±7.8, 82.1±15.7, 4.7±1.2, and 1.5±1.0, respectively, which were superior to those before operation (P<0.05). Imaging reexamination showed that the meniscus was reset at 1 day after operation, and there was no sign of knee degeneration at last follow-up. Conclusion Transtibial pull-out technique combined with side-to-side suture technique can effectively treat the complete radial tear of lateral meniscus body and obtain good short-term effectiveness.
To observe the histology change of the insertion using different diamertrical bone tunnel in anterior cruciate l igament (ACL) reconstruction. Methods Ninety Japanese rabbits were selected, wihout female and male l imit, weighing 2.5-3.0 kg, and were randomly divided into 3 groups, 30 in each group. The ratio of transplantation l igament diameter and bone tunnel diameter was 1/1 (group A), the ratio was 1/1.5 (group B), and the ratio was 1/2 (group C). Bone tunnel observation and histology observation were carried out in the 4th, 8th and 16th weeks postoperat ively. Results Wound healed well in 3 groups. The mean time of walking functional recovery was 1.5, 2.0 and 3.5 days in groups A, B and C respectively. After 4 weeks of operation, more soft tissues at tunnel entry were observed in group A and group B than in group C; after 8 weeks of operation, there was no crevice at bone-tunnel entry of the groups A and B, there was no improvement in group C; after 16 weeks of operation, groups A and B showed the normal insertion, group C had no normal insertion. Histology observation: in groups A, B and C, bone-tunnel was filled with loose connective tissue after 4 weeks of operation; group A and group B emerged the discontinuation ACL insertion tidal l ine after 8 weeks of operation, group C had no insertion; groups A and B emerged the similarity normal ACL insertion tidal l ine structure after 16 weeks of operation, but group C had no this structure. The results of ultimate tensile strength in groups A, B and C were (75.44 ± 7.06), (91.37 ± 6.14) and (126.91 ± 4.61) N respectively at 4 weeks; the results were (74.31 ± 4.81), (88.30 ± 7.46) and (124.34±8.44) N respectively at 8 weeks; and the results were (62.20 ± 5.32), (71.53 ± 5.99) and (83.62 ± 5.69) N respectively at 16 weeks. There was no significant difference between group A and group B (P gt; 0.05), and there were significant differences between groups A, B and group C (P lt; 0.05). Conclusion In the ACL reconstruction, the ratioof transplantation l igament diameter and bone tunnel diameter being 1/1.5 will not affect the insertion outcome, but if theratio less than the l imit it will affect the insertion outcome.
Objective To investigate whether the outlet of the femoral tunnel will cause iatrogenic injury to the medial collateral ligament (MCL) during posterior cruciate ligament reconstruction (PCLR) and estimate the safe angle of femoral tunnel placement. MethodsThirteen formaldehyde-soaked human knee joint specimens were used, 8 from men and 5 from women; the donors’ age ranged from 49 to 71 years, with an average of 61 years. First, the medial part of the femur was carefully dissected to clearly expose the region of the MCL course and attachment on the femoral medial aspect and to outline the anterior margin of the region with a marked line. The marked line divided the medial femoral condyle into an area with an MCL course and a bare bone area which is regarded relatively safe for no MCL course. Then, the posterior cruciate ligament (PCL) was cut to identify the femoral attachment of the PCL. After the knee joint was fixed at a 120° flexion angle, the process of femoral tunnel preparation for the PCL single-bundle reconstruction was simulated. The inside-out technique was used to drill the femoral tunnel from the PCL femoral footprint inside the knee joint with an orientation to exit the medial condyle of the femur, and the combination angle of the two planes, the axial plane and the coronal plane, was adapted to the process of drilling femoral tunnels at different orientations. The following 15 angle combinations were used in the study: 0°/30°, 0°/45°, 0°/60°, 15°/30°, 15°/45°, 15°/60°, 30°/30°, 30°/45°, 30°/60°, 45°/30°, 45°/45°, 45°/60°, 60°/30°, 60°/45°, 60°/60° (axial/coronal). The positional relationship between the femoral tunnel outlet on the femoral medial condyle and the marked line was used to verify whether the tunnel drilling angle was a risk factor for MCL injury or not, and whether the shortest distance between the femoral exit center and the marked line was affected by the various angle combinations. Furthermore, the safe orientation of the femoral tunnel placement would estimated. ResultsWhen creating the femoral tunnel for PCLR, there was a risk of damage to the MCL caused by the tunnel outlet, and the incidence was from 0 to 100%; when the drilling angle of the axial plane was 0° and 15°, the incidence of MCL damage was from 69.23% to 100%. There was a significant difference in the incidence of MCL damage among femoral tunnels of 15 angle combinations (χ2=148.195, P<0.001). By comparison between groups, it was found that when drilling femoral tunnels at 5 combinations of 45°/45°, 45°/60°, 60°/30°, 60°/45°, and 60°/60° (axial/coronal), the shortest distances between the tunnel exit and the marked line were significantly different than 0°/45°, 0°/60°, 15°/45°, 15°/60°, and 30°/30° (axial/coronal) (P<0.05). Additionally, after comparing the median of the shortest distance with other groups, the outlets generated by these 5 angles were farther from the marked line and the posterior MCL. ConclusionThe creation of the femoral tunnel in PCLR can cause iatrogenic MCL injury, and the risk is affected by the tunnel angle. To reduce the risk of iatrogenic injury, angle combinations of 45°/45°, 45°/60°, 60°/30°, 60°/45°, and 60°/60° (axial/coronal) are recommended for preparing the femoral tunnel in PCLR.
Objective To review the research progress of Schöttle’s method in medial patellofemoral ligament reconstruction (MPFLR), and provide the latest knowledge and suggestions for surgical treatment. Methods The studies on Schöttle’s method at home and abroad in recent years were extensively collected, then summarized the problems affecting the accuracy of Schöttle’s method and the new ideas to improve the accuracy of localization. Results It’s vital to accurately locate the femoral tunnel during MPFLR. Malposition of the femoral tunnel is the main cause of postoperative complications and surgical failure. Schöttle’s method is the most well studied and most reproducible method for femoral tunnel localization, which is widely used as the “gold standard”. However, there are still problems that affect the accuracy of Schöttle’s method, including the impact of the internal/external rotation and varus/valgus of the knee on localization accuracy, unclear requirements for X-ray imaging and anatomical landmark reference line drawing standards, no suitable for patients with anatomical variations, and lack of further research on pediatric patients. In recent years, some new ideas are proposed to improve the Schöttle’s method to improve the localization accuracy. ConclusionFuture research should combine new technologies such as three-dimensional (3D) printing and intraoperative navigation to develop personalized and intelligent Schöttle’s method, further improving their localization accuracy.
ObjectiveTo compare the incidence of chondral injury using Rigidfix femoral fixation device via the anteromedial approach and the tibial tunnel approach during anterior cruciate ligament (ACL) reconstruction. MethodsEighteen adult cadaver knees were divided randomly into 2 groups, 9 knees in each group. Femoral tunnel drilling and cross-pin guide insertions were performed using the Rigidfix femoral fixation device through the anteromedial approach (group A) and the tibial tunnel approach (group B). ACL reconstruction simulation was performed at 0, 10, 20, 30, 45, 60, 70, 80, and 90°in the horizontal position. The correlation between incidence of chondral injury and slope angles was analyzed, and then the incidence was compared between the 2 groups. ResultsThe correlation analysis indicated that the chondral injury incidence increased with the increasing of the slope angle (r=0.611, P=0.000; r=0.852, P=0.000). The incidence of chondral injury was 69.1% (56/81) and 48.1% (39/81) in groups A and B respectively, showing significant difference (χ2=7.356, P=0.007). The sublevel analysis showed that the chondral injury incidence of group A (36.1%, 13/36) was significantly higher than that of group B (0) at 0-30°(χ2=15.864, P=0.000), but no significant difference was found between group A (95.6%, 43/45) and group B (86.7%, 39/45) at 45-90°(P=0.267). ConclusionIt has more risk of chondral injury to use Rigidfix femoral fixation device via the anteromedial approach than the tibial tunnel approach to reconstruct ACL.