Tibial Site Research Articles

Guidelines for the assessment of bone density and microarchitecture in vivo using high-resolution peripheral quantitative computed tomography.

The application of high-resolution peripheral quantitative computed tomography (HR-pQCT) to assess bone microarchitecture has grown rapidly since its introduction in 2005. As the use of HR-pQCT for clinical research continues to grow, there is an urgent need to form a consensus on imaging and analysis methodologies so that studies can be appropriately compared. In addition, with the recent introduction of the second-generation HrpQCT, which differs from the first-generation HR-pQCT in scan region, resolution, and morphological measurement techniques, there is a need for guidelines on appropriate reporting of results and considerations as the field adopts newer systems. A joint working group between the International Osteoporosis Foundation, American Society of Bone and Mineral Research, and European Calcified Tissue Society convened in person and by teleconference over several years to produce the guidelines and recommendations presented in this document. An overview and discussion is provided for (1) standardized protocol for imaging distal radius and tibia sites using HR-pQCT, with the importance of quality control and operator training discussed; (2) standardized terminology and recommendations on reporting results; (3) factors influencing accuracy and precision error, with considerations for longitudinal and multi-center study designs; and finally (4) comparison between scanner generations and other high-resolution CT systems. This article addresses the need for standardization of HR-pQCT imaging techniques and terminology, provides guidance on interpretation and reporting of results, and discusses unresolved issues in the field.

Interscholastic Athletics and Bone Strength: The Iowa Bone Development Study.

Pashkova, A, Hartman, JM, Letuchy, EM, and Janz, KF. Interscholastic athletics and bone strength: the Iowa bone development study. J Strength Cond Res 36(5): 1271-1276, 2022-The objective of this study was to determine the relationship between adolescents' participation in various interscholastic sports and differences in bone strength outcomes. Subjects (N = 380) were recruited from the Iowa Bone Development Study and categorized based on sport participation into 3 power groups: no-power, low-power, and high-power. Sports such as basketball, cheerleading/poms, gymnastics, volleyball, track, football, tennis, and soccer were considered high-power. Peripheral quantitative computed tomography (pQCT) was used to determine bone measures of polar stress-strain index (measure of torsion strength), cortical content (measure of cortical bone size and area at the 66% tibia site), and bone strength index (measure of compression strength based on total bone density and area at the 4% tibia site). Adjusted pairwise comparison for group least squares means high-power sport participation compared with no-power sport participation showed significant differences in all bone strength outcomes for both men and women (p value < 0.01). There was a significant difference in all bone strength measures between low-power and no-power groups for men (p value < 0.05), but not women. Because of decreasing levels of physical activity in late adolescence, the promotion of high-power sports may be particularly important for optimal bone development in the final years before peak bone mass.

Providing Graft Tension in ACL Reconstruction with Preservation of the Hamstring Tibial Attachment Site: A Report on the Technique and Clinical Results

Providing Graft Tension in ACL Reconstruction with Preservation of the Hamstring Tibial Attachment Site: A Report on the Technique and Clinical Results

A comparative study of a new “off-centre:off-centre” technique of transtibial ACL reconstruction with “centre:centre” transportal ACL reconstruction

Background & introductionA Single Bundle ACL Reconstruction aims at placing Tibial and Femoral attachment sites of graft from Centre of Native Tibial Foot-print to Centre of Native Femoral Footprint. In tibial tunnel independent Transportal Reconstruction, where the two points are chosen separately, the objective is easily achievable. In Tibial tunnel dependent Transtibial ACL reconstruction, Capture of Centre of femoral tunnel is dictated by Trajectory of Tibial Tunnel. Heming et al. remarked that a TT technique could produce tunnel centred in the both the tibial and femoral footprint but only if a starting point “prohibitively close” to the joint line with a correspondingly short tibial tunnel were used. A new technique wherein authors aim to place the mouths of Tibial & Femoral tunnel at off-centre location, taking care to contain these tunnels still within native footprints to achieve a tunnel which is of adequate length and does not come too close to the joint and saves MCL from violation. ObjectiveTo study the clinic-radiological outcome of a new “Off-centre to Off-centre” method of Transtibial Reconstruction and compare the results with “centre to centre” method of Transportal reconstruction. MethodsA prospective randomised comparative study of consecutive 75 clinico-radiological cases of ACL tear with definitive clinical symptoms of knee instability who underwent arthroscopic ACL reconstruction by Same Arthroscopy Surgeon was conducted between 2016 and 2018. A modification, as described herein below, was used in Transtibial technique with placement of centre of mouth of internal opening of tibial tunnel “off-centre” that allowed a predictable capture of Femoral Footprint in “off-centre” location without tunnel being too close to joint line. Only those cases were included in which the mouths of tunnel were completely contained within footprints. Capture of footprints was verified during arthroscopy. 11 cases were excluded because either the native footprint was not clearly delineated, or surgeon failed to completely contain the mouth of tunnel/socket within the delineated footprint of tibia or femur. Hence 64 patients, 32 each in Transtibial & Transportal group were enrolled into the study. The results were analysed with the objective to arrive at recommendations for improving capture of anatomical footprints at both ends by Transtibial technique. ResultsThere were no statistically significant differences in Clinical outcome scores. However there were statistically significant differences in length of Femoral Tunnel, Obliquity of Femoral tunnel as well as Femoral Tunnel Placements. Likewise, Tibial Tunnel Angle in AP & Lateral View as well as Tibial tunnel placement were also significantly different. ConclusionIt is concluded that tunnels follow much different trajectories in the bones in two techniques and trying to apply “Centre of Tibial footprint to Centre of Femoral footprint” philosophy of Transportal technique may be imprudent for Transtibial Technique. An “Off-centre to Off-centre but contained within Footprints” may afford a more predictable and reliable capture of anatomical foot prints without any adverse effect on outcomes.

Complications of Bioabsorbable Tibial Interference Screws After Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Athletes.

Background:Interference screw fixation using bioabsorbable implants has become the most common form of tibial-sided graft fixation in anterior cruciate ligament reconstruction (ACLR). Complications related to implant use in the pediatric and adolescent population have not been well studied.Purpose/Hypothesis:The purpose of this study was to retrospectively analyze the complications associated with tibial bioabsorbable interference screw use in adolescents after ACLR. We hypothesized that complication rates would be low (<5%) and that different screw types would have similar complication rates and clinical outcomes.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were patients aged ≤18 years who underwent ACLR with a bioabsorbable tibial interference screw between 2000 and 2011 at a single institution. The subpopulation with screw-related symptoms or complications were identified through chart review. The following 2 outcomes were considered: screw-related symptoms and secondary surgery related to the screw. Multivariable logistic regression was used for adjusted analysis of any screw-related problem.Results:There were 925 ACLR procedures in 858 patients (mean age, 15.7 years; range, 10-18 years) who met inclusion criteria. The median follow-up period was 32.0 months. Of the 925 knees, 89 (9.6%) developed a screw-related problem. In 44 (4.8%) cases, no surgery was required; in 45 (4.9%) cases, surgery for a screw-related problem occurred at a median of 24 months postoperatively. The most common surgical indication was pain at the tibial screw site (42/45, 93%), followed by intra-articular screw issues (3/45, 7%). In adjusted analysis, ACLR procedure performed by a “low-volume” ACL surgeon was the only significant predictor identified. After screw removal surgery, 25 of 27 (93%) patients with at least 12 months of follow-up had complete resolution of screw site symptoms, 18 of 23 (78%) evaluable patients returned to sports, while 8 of 27 (30%) patients underwent additional surgeries, 7 of which were unrelated to the screw procedure.Conclusion:The rate of clinical sequelae from bioabsorbable tibial interference screws was surprisingly high, with symptoms arising after approximately 1 of 10 ACLRs in adolescents. Reoperation for these symptoms was performed in approximately 5% of the knees in the study, at a median 2 years postoperatively. Most patients were able to return to sports after screw removal surgery.

In Vivo Assessment of a Hydroxyapatite/κ-Carrageenan-Maleic Anhydride-Casein/Doxorubicin Composite-Coated Titanium Bone Implant.

Here, we focus on the fabrications of an osteosarcoma implant for bone repair via the development of a hydroxyapatite/κ-carrageenan-maleic anhydride/casein with doxorubicin (HAP/κ-CA-MA-CAS/DOX) composite-deposited titanium (Ti) plate. The HAP/κ-CA-MA-CAS/DOX material was coated on the Ti plate through the EPD method (electrophoretic deposition), applying direct current (DC) signals to deposit the composite on the surface of the Ti plate. The physicochemical and morphological possessions and biocompatibility in vitro of the prepared nanocomposite were examined to assess its prospective effectiveness for purposes of bone regeneration. Excellent biocompatibility and elevated osteoconductivity were confirmed using MG63 osteoblast-like cells. In vivo studies were performed at tibia sites in Wistar rats, and rapid bone regeneration was detected at four weeks in defective bone. Overall, the studies demonstrate that the HAP/κ-CA-MA-CAS/DOX composite enhances the biocompatible and cell-stimulating biointerface of Ti metallic implants. As such, HAP/κ-CA-MA-CAS/DOX implants are viable prospects for osteosarcoma-affected bone regeneration.

Analysis of donor site complications at the anterior iliac crest harvest site for treatment of tibial plateau fractures

Introduction: In tibial plateau fractures with intraarticular depression and metaphyseal comminution, bone grafting or the use of a bone substitute may be required. Harvesting autologous iliac crest bone graft for other orthopedic procedures has complications. The aim of this study was to evaluate the complication rate after harvesting bone graft as used for the treatment of tibial plateau fractures. Patients and methods: Patients treated in a tertiary care hospital with operative intervention for tibial plateau fractures with iliac crest bone graft between January 2015 and December 2018 were included in this retrospective study. Patients’ records were evaluated and clinical evaluation was performed at follow-up. Results: 46 patients (20 females, 26 males, mean age 55.2±14.9 years) were included in this study. Follow-up was mean 4.3±1.2 years. Only minor complications such as hematoma could be identified; in one patient, repeat surgery for bleeding was performed. No nerve injuries, long-term pain, fractures, infections or wound healing disturbances could be seen. The use of a drain, the type of wound closure or amount of harvested bone did not influence complication rate. Conclusion: This study shows that harvesting of iliac crest bone graft for the treatment of tibial plateau fractures is a safe procedure with a very low complication rate. Keywords: Tibial plateau fractures Iliac crest bone graft Donor site complications

Tibial Fixation Techniques for Soft-Tissue Grafts in Anterior Cruciate Ligament Reconstruction.

» The method of graft fixation in anterior cruciate ligament (ACL) reconstruction is important for initial stability. The tibial fixation site is reported to be the weakest point in ACL reconstructions.» Tibial fixation techniques include aperture fixation (intra-tunnel), suspensory fixation (extra-tunnel), and hybrid tibial fixation.» Although biomechanical data have demonstrated superior pull-out strength and resistance to cyclic loading with certain tibial fixation devices, the available clinical data have overall demonstrated no significant differences in patient outcomes and failure rates among methods.» Further work is necessary to determine which technique optimizes biologic maturation and incorporation of the graft within the tibial tunnel.

Mini-Invasive Extraarticular Stabilization of the Cranial Cruciate Deficient Stifle in Dogs

The purpose of this work was to describe three mini-invasive techniques for extraarticular stabilization of the deficient stifle based of bone anchores inserted in quasi-isometric sites.Suture stabilization of the stifle consisted of placing a monofilament nylon leader line or polyethylene suture between femoral site adjacent to the distal poles of the fabella, and tibial site immediately cranial to the long digital extensor tendon, using two anchor types. Each stifle was tested (cranial drawer test and tibial compression test) before and after arthroscopic transection of the cranial cruciate ligament and after performing the assigned procedure. Surgical approach, order of procedural steps, drill hole entrance and exit points, and techniques for anchors placement, tensioning, and securing were described.The results of the cranial drawer test and tibial compression test do not show statistically significant differences between the three applied techniques. All three techniques provide passive stability to the deficient stifle.

Peripheral quantitative computed tomography (pQCT)-based finite element analysis provides enhanced diagnostic performance in identifying non-vertebral fracture patients compared with dual-energy X-ray absorptiometry.

Dual-energy X-ray absorptiometry (DXA), the predominant clinical method for diagnosing osteoporosis, has limitations in identifying individuals with increased fracture risk. Peripheral quantitative computed tomography (pQCT) provides additional information and can be used to generate finite element (FE) models from which bone strength properties can be estimated. We investigated the ability of pQCT-FE properties to distinguish peripheral low-trauma fracture patients from healthy controls, by comparison with DXA and standard pQCT. One hundred and eight fracture patients (77 females aged 67.7 ± 7.9 years, 31 males aged 69.7 ± 8.9 years) were recruited from a hospital fracture liaison service. One hundred and twenty healthy community controls (85 females aged 69.8 ± 8.5 years, 35 males aged 68.9 ± 7.2 years) were recruited. Significant differences between groups were observed in pQCT-FE properties, especially at the 4% tibia site. Fracture odds increased most per standard deviation decrease in pQCT-FE at this location [shear stiffness estimate, kshear, in females, OR = 10.34, 95% CI (1.91, 43.98); bending stiffness estimate, kbend, in males, OR = 8.32, 95% CI (4.15, 33.84)]. Area under the receiver operating characteristics curve (AUROC) was observed to be highest with pQCT-FE properties at 4% the tibia site. In females, this was 0.83 for the pQCT-FE variable kshear, compared with 0.72 for DXA total hip bone density (TH aBMD) and 0.76 for pQCT tibia trabecular density (Trb vBMD); in males, this was 0.81 for the pQCT-FE variable kbend at the 4% tibia site, compared with 0.62 for TH aBMD and 0.71 for Trb vBMD. There were significant differences in AUROC between DXA and pQCT-FE variables in both females (p = 0.02) and males (p = 0.03), while no difference was observed in AUROC between primary pQCT and pQCT-FE variables. pQCT-FE modeling can provide enhanced diagnostic performance compared with DXA and, given its moderate cost, may be useful in clinical settings.

Bone geometry and lower extremity bone stress injuries in male runners

Bone stress injuries (BSI) are common among distance runners and research investigations examining risk factors for BSI among men are limited. Therefore, investigations are needed to determine if men with a history of BSI have skeletal properties that may heighten BSI incidence. ObjectivesTo analyze differences in bone density, bone geometry, and estimates of bone strength in male runners with and without a BSI history. DesignCross-sectional. MethodsWe recruited 36 male distance runners ages 18–41 for this study. We used peripheral quantitative computed tomography (pQCT) to assess volumetric bone mineral density (vBMD, mg/mm3), bone geometry (total and cortical bone area, mm2), tibia robustness (total area/tibia length, mm) and estimates of bone strength (section modulus and polar strength-strain index, mm3) at 5 tibial sites. ResultsAfter adjusting for age, the BSI group had more slender tibias (9%), lower stress strain indices (−16%), lower section moduli (−17%) and smaller total cross-sectional (−11%) and cortical areas (−12%) at the 66% site of the tibia compared with controls (P < 0.05 for all). Similar differences were found at all other measurement sites. After adjusting for body size, differences in bone outcomes remained significant at the 66% site. ConclusionsThese results indicate that men with a history of BSI have lower estimated bending strength compared to controls because of narrower tibias. However, differences are largely attenuated in the distal ½ of the tibia after adjusting for body size. Thus, smaller tibia size, particularly at the mid-diaphysis, may be an important indicator for BSI incidence.

Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL’s native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established. Purpose: To use 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Forty patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel. Results: The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm (P < .001) medial and 5.11 ± 3.57 mm (P < .001) posterior to the native ACL footprint. The mean distance between the center of the native and reconstructed ACL at the tibial attachment site was 6.24 mm. Of the 40 patients, 18 patients had a tibial tunnel that overlapped more than 50% of the native footprint, and 10 patients had maximal (100%) overlap. Further, 22 of the 40 patients had less than 50% overlap with the native footprint, and in 12 patients the footprint was missing completely. Conclusion: Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.

Congenital pseudarthrosis of the tibia: the outcome of a pathology-oriented classification system and treatment protocol.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

Promoted Osteoconduction of Polyurethane-Urea Based 3D Nanohybrid Scaffold through Nanohydroxyapatite Adorned Hierarchical Titanium Phosphate.

The lack of optimal physiological properties, bacterial colonization, and auto-osteoinduction, are the foremost issues of orthopedic implantations. In terms of bone healing, many researchers have reported the release of additional growth factors of the implanted biomaterials to accelerate the bone regeneration process. However, the additional growth factor may cause side effects such as contagion, nerve pain, and the formation of ectopic bone. Thus, the design of an osteoconductive scaffold having excellent biocompatibility, appropriate physicomechanical properties, and promoted auto osteoinductivity with antibacterial activity is greatly desired. In this study, 2D rodlike nanohydroxyapatite (nHA) adorned titanium phosphate (TP) with a flowerlike morphology was synthesized by a hydrothermal precipitation reaction. The nanohybrid material (nHA-TP) was incorporated into the synthesized polycaprolactone diol and spermine based thermoplastic polyurethane-urea (PUU) via in situ technique followed by salt leaching to fabricate the macroporous 3D polymer nanohybrid scaffold (PUU/nHA-TP). Structure explication of PUU was performed by NMR spectroscopy. The synthesized nanohybrid scaffold with 1% nHA-TP showed 67% increase of tensile strength and 18% improved modulus compared to the pristine PUU via formation of H-bonding or dative bonds between the metal and the amide linkage of the polyurethane or polyurea. In vitro study showing improved cell viability and proliferation of the seeded cell revealed the superior osteoconductivity of the nanohybrid scaffold. Most importantly, the in vivo experiments revealed a significant amount of bone regeneration in the nanohybrid scaffold implanted tibial site compared to the pristine scaffold without any toxic effect. Introduction of the minute amount of titanium phosphate within the adorned nHA promotes the osteoconductivity significantly by the capability of forming coordinate bonds of the titanium ion. Depending on the mechanical, physicochemical, in vitro characteristics, and in vivo osteoconductivity, the PUU/nHA-TP nanohybrid scaffold has great potential as an alternative biomaterial in bone tissue regeneration application.

PQCT bone geometry and strength: population epidemiology and concordance in Australian children aged 11-12 years and their parents.

ObjectivesTo describe the epidemiology and concordance of bone health in a population-based sample of Australian parent-child dyads at child age 11–12 years.DesignPopulation-based cross-sectional study (the Child Health CheckPoint) nested between waves 6 and 7 of the Longitudinal Study of Australian Children (LSAC).SettingAssessment centres in seven cities around Australia, February 2015–March 2016.Participants: of all participating CheckPoint families (n=1874), bone data were available for 1222 dyads (1271 children, 50% girls; 1250 parents, 86% mothers).Outcome measuresPeripheral quantitative CT (pQCT) of the non-dominant leg scanned at the 4% (distal) and 66% (mid-calf) tibial sites. Stratec XCT 2000 software generated estimates of bone density, geometry and polar stress-strain index.Parent-child concordance were assessed using Pearson’s correlation coefficients and multivariable linear regression models. Percentiles were determined using survey weights. Survey weights and methods accounted for LSAC’s complex sampling, stratification and clustering within postcodes.ResultsConcordances were greater for the geometric pQCT parameters (periosteal circumference 0.38, 95% CI 0.33 to 0.43; endosteal circumference 0.42, 95% CI 0.37 to 0.47; total cross-sectional area 0.37, 95% CI 0.32 to 0.42) than density (cortical density 0.25, 95% CI 0.19 to 0.30). Mother-child and father-child values were similar. Relationships attenuated only slightly on adjustment for age, sex and body mass index. Percentiles and concordance are presented for the whole sample and by sex.ConclusionsThere is strong parent-child concordance in bone geometry and, to a lesser extent, density even before the period of peak adolescent bone deposition. This geometrical concordance suggests that future intergenerational bone studies could consider using pQCT rather than the more commonly used dual X-ray absorptiometry (DXA).

The Association between Quantified Training Load and Bone Adaptation

PURPOSE: Habitual mechanical loading during pubertal stages has consistently been associated with current and future anabolic effects on bone characteristics. However, the specific aspects of mechanical loading that bring about anabolic effects are yet to be established. The present study investigated the relationship between soccer specific loading patterns and subsequent bone adaptation in youth soccer players. METHODS: 17 elite adolescent soccer players (mean ± SD =age: 16.3±0.5 years; height: 1.79±0.07m; body mass:74.9±6.7 kg) gave informed consent to take part in a study approved by the National Research Ethics Service. Peripheral quantitative computed tomography scans of the tibia of the dominant leg were taken at the beginning of pre-season training and 12-weeks later. Tibial mass (g), trabecular area (mm2), cortical area (mm2) and density (mg·cm2), periosteal circumference (mm) and strength strain index (SSI) (mm3) at the 4, 14, 38 and 66% sites were measured. During the 12 week training period, workload was quantified using a global positioning system (GPS). The following metrics were analysed: session duration (min), total distance covered (m), and high-speed running distance (17.0 km.h-1). Changes in bone characteristics were assessed using paired sample t-tests, and associations between GPS metrics and bone adaptation were assessed using Person’s correlation coefficient. RESULTS: Tibial mass increased by 2.9, 1.2 and 0.7% at the 4, 14 and 38% tibial sites (P < .05). SSI (38%; 2337.1±340.9 compared to 2383.1±317.3, P = .05) and cortical area (38%; 380.9±23.2 mm2 compared to 383.1±30.8 mm2, P = .02) increased following 12-weeks of soccer specific training. Average session duration was positively correlated with increased trabecular area (4%; P=.02, r=0.61) and periosteal circumference (38%; P=.03, r=0.55). Average high-speed running was positively correlated with changes in SSI (14%; P=.05, r=0.51) and cortical density (38%; P=.05, r=0.52). CONCLUSIONS: Soccer specific training increases tibial bone characteristics at the 4, 14 and 38% sites. Moreover, session duration and high-speed running were associated with increased tibial strength, size and density following 12-weeks of soccer specific training. These factors should be considered when recommending exercise for bone health.

Functional Anatomy of the Craniomedial and Caudolateral Bundles of the Cranial Cruciate Ligament in Beagle Dogs

The aim of this study was to investigate detailed functional anatomy of the craniomedial bundle (CrMB) and caudolateral bundle (CdLB) of cranial cruciate ligament (CrCL) for application of intra-articular anatomical reconstruction in dogs. Twelve stifle joint of 12 Beagle cadavers were used. Anatomical characteristics of femoral attachment regions of the CrCL were determined. Then, the location and area of the footprints of the CrMB and CdLB were objectively measured. Each bundle was equally divided into four fibre bundles, and changes in the fibre arrangement were recorded during stifle range of motion. Additionally, the tension of each fibre bundle at various stifle joint angles was objectively measured. The attachment region of the CrCL clearly differed from that reported in humans. The centre of the CdLB attachment site was located craniodistal to that of the CrMB on the femur and slightly caudal to that of the CrMB on the tibia. The area of the CrMB on the femoral and tibial attachment sites was larger than that of the CdLB. During stifle range of motion, each divided fibre bundle in the CrMB and CdLB was twisted intricately. The tension of the CrMB was higher than that of CdLB. The central part of the CrMB was always tense during stifle range of motion. These results may contribute to the application of anatomical reconstruction surgery for CrCL deficient stifle in dogs.

The Presence of the Arthroscopic “Floating Meniscus” Sign as an Indicator for Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury

To compare the outcomes of patients with an arthroscopic floating meniscus sign at 24-month follow-up when treated with and without medial compartment reconstruction surgery. Another aim of the present study was to compare magnetic resonance imaging and arthroscopic findings directly related to the characterization and localization medial collateral ligament (MCL) injuries. A total of 112 patients diagnosed with combined anterior cruciate ligament (ACL)-MCL grade II injuries to be treated with ACL reconstruction surgery were included in the study. During arthroscopy, patients diagnosed with the "floating meniscus" sign were divided into 2 groups: group 1 (n= 58) was treated with ACL and medial compartment reconstruction surgery and group 2 (n= 54) was treated with ACL reconstruction and nonsurgical medial compartment treatment. Return to competitive sports (Tegner score), Lysholm scores, ACL reconstruction failure, and residual MCL laxity were evaluated 6, 12, and 24months after surgery. After 24months, patients from group 1 (n= 58) had an average Tegner score of 8.98 and Lysholm score of 89.67; 2 patients presented with ACL reconstruction failure and none presented with residual MCL laxity. Patients from group 2 (n= 54) had an average Tegner score of 6.7 and Lysholm score of 78.12; 16 patients presented with ACL reconstruction failure and 13 presented with residual MCL laxity. In the presence of a floating meniscus arthroscopic sign, patients with combined ACL and grade II MCL injuries treated with ACL and MCL reconstruction surgery had significantly lower frequency of ACL reconstruction failure, residual MCL laxity, and better Tegner and Lysholm scores at 24months' follow-up (P < .05). Additionally, magnetic resonance imaging and arthroscopy differed significantly (P < .05) in their ability to identify mid-substance and tibial site MCL injuries. Level I, randomized clinical trial.

Effects of Povidone-Iodine or Ethanol Exposure on Bone Formation at the Osteotomy Site of the Proximal Tibia in Rats

Background: Povidone-iodine (PVI) irrigation is currently used to decrease the frequency of postoperative surgical site infections. Ethanol (EtOH) is sometimes applied to prevent local recurrence after curettage of benign bone tumors. However, the effects of PVI and EtOH on surrounding soft tissue and on bone union are unclear. The purpose of this study was to determine whether PVI or EtOH adversely affects the cancellous bone healing of the osteotomy site at the proximal tibia in rats. Methods: A cancellous bone osteotomy was performed at the right proximal tibia in 4-month-old, female, Sprague Dawley rats. Vehicle, 10% PVI, or 95% EtOH-soaked gauze was inserted into the osteotomy site and maintained for 6 minutes. The rats were euthanized 2 or 4 weeks after the osteotomy. Results: Two weeks after treatment, the bone union rate was significantly higher in the vehicle group than in the PVI group and the EtOH group (p < 0.001). However, the bone union rate was not significantly different between the PVI and EtOH groups. There was no significant difference among the three groups in the bone union rate 4 weeks after treatment. Conclusion: PVI or EtOH delayed bone union of the cancellous bone osteotomy site of the proximal tibia in the early phase (2 weeks), but not at 4 weeks, in rats.

Technical considerations in lateral extra-articular reconstruction coupled with anterior cruciate ligament reconstruction: A simulation study evaluating the influence of surgical parameters on control of knee stability

BackgroundSurgical parameters such as the selection of tibial and femoral attachment site, graft tension, and knee flexion angle at the time of fixation may influence the control of knee stability after lateral extra-articular reconstruction. This study aimed to determine how sensitive is the control of knee rotation and translation, during simulated pivot-shift scenarios, to these four surgery settings. MethodsA computer model was used to simulate 625 lateral extra-articular reconstructions based upon five different variations of each of the following parameters: femoral and tibial attachment sites, knee flexion angle and graft tension at the time of fixation. For each simulated surgery, the lateral extra-articular reconstruction external rotation moment at the knee joint center was computed during simulated pivot-shift scenarios. The sensitivity of the control of knee rotation and translation to a given surgery setting was assessed by calculating the coefficient of variation of the lateral extra-articular reconstruction external rotation moment. FindingsGraft tension had minimal influence on the control of knee rotation and translation with less than 2.4% of variation across the scenarios tested. Control of knee rotation and translation was the least affected by the femoral attachment site if the knee was close to full extension at the time of graft fixation. The choice of the tibial attachment site was crucial when the femoral fixation was proximal and posterior to the femoral epicondyle since 15 to 67% of variation was observed in the control of knee rotation and translation. InterpretationFemoral and tibial attachment sites as well as knee flexion angle at the time of fixation should be considered by surgeons when performing lateral extra-articular reconstruction. Variation in graft tension between the ranges 20–40 N has minimal influence on the control of knee rotation and translation.