Tibial Tubercle Research Articles

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft

The lateral stability of the knee, A review of the clinical Anatomy of the Popliteal hiatus and its clinical pathologies

As a modified hinge joint, the knee joint facilitates the erect posture and greater mobilization of the human body. Varusvalgus angulation, external-internal rotation, and anteriorposterior stability are primarily maintained by the tibial bony eminences, menisci, and the congruencies of the femoral and tibial articular surfaces. The primary restrainer for the valgus angulation is the medial collateral ligament (MCL). The primary restrainer for varus angulation is the lateral collateral ligament (LCL). Even though the LCL is the principal lateral stabilizer for the knee, it is supported by the surrounding ligaments, muscles, and tendons. Non -uniformity in the nomenclature of these structures and complexity in the anatomical arrangements lead to complexity of understanding and clinical interpretation. The popliteus is a very small muscle but a unique muscle to the knee with specialized functions. It is highly vulnerable to injuries during trauma with posterior lateral corner injuries of the knee. Proper history of the injury and clinical assessment will help in a proper diagnosis. However acute pain in the knee may interfere with a proper clinical diagnosis. During total knee arthroplasty, special care should be taken to minimize the iatrogenic popliteal ligament injuries during bone cuts and lateral release in soft tissue gap balancing.

Does Tibial Tuberosity Osteotomy Improve Outcomes When Combined With Medial Patellofemoral Ligament Reconstruction in the Presence of Increased Tibial Tuberosity-Trochlear Groove Distance? A Systematic Review and Meta-analysis.

There has been recent debate regarding the optimal surgical management strategy for recurrent patellofemoral instability in the presence of an increased tibial tuberosity-trochlear groove (TT-TG) distance. In particular, performing a combined tibial tuberosity osteotomy (TTO) and medial patellofemoral ligament reconstruction (MPFLR) for patients with a TT-TG >20 mm has been questioned, with the hypothesis that an isolated MPFLR (iMPFLR) would be just as effective. To pool and compare outcomes after MPFLR+TTO versus iMPFLR in patients with a TT-TG >20 mm. Systematic review; Level of evidence, 4. PubMed-MEDLINE, Embase, Web of Science, and Cochrane Central were searched, and a systematic review was performed. Included were studies that reported postoperative redislocation rates and/or functional outcome scores for patients with recurrent patellar instability and a TT-TG >20 mm who underwent either MPFLR+TTO or iMPFLR and had minimum 2-year follow-up data. Methodologic quality was assessed using the modified Coleman Methodology Score (mCMS). A proportional meta-analysis comparing redislocation, subjective instability, and total complication rates was performed, and mean postoperative functional outcome scores were pooled using a random-effects model with a restricted maximum likelihood estimator. In total, 1548 studies were screened, from which 13 were included for analysis. Of the 386 included patients (406 knees), 276 underwent MPFLR+TTO and 110 underwent iMPFLR. The mean mCMS was 61.3 ± 10.5 (range, 48-77). The pooled postoperative redislocation rate was 1.22% (95% CI, 0.22%-7%), with no significant difference between the study groups (P = .9995). The pooled complication rate was 10.17% (95% CI, 6.2%-16.3%) with no difference between groups (P = .9275), although the MPFLR+TTO group had higher heterogeneity in complication rates (I2 = 79.4%) compared with iMPFLR (I2 = 0%). There was no group difference in the pooled postoperative Lysholm scores (P = .5177), but patients who underwent iMPFLR had significantly higher postoperative Kujala scores compared with those who underwent MPFLR+TTO (P = .0283). Even in the presence of previously indicative anatomic factors (TT-TG >20 mm), TTO combined with MPFLR does not seem to confer additional benefit compared with iMPFLR. This finding could be advantageous in minimizing the burden of additional surgery with its associated risks. The study findings should, however, be interpreted with caution given the heterogeneity of the studies.

A modified Delphi consensus statement on patellar instability: part II.

The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

Correlation of tibial tuberosity–trochlear groove distance, anterolateral ligament injury, and the type of trochlear dysplasia with the grade of anterior cruciate ligaments tear

BackgroundThe anterior cruciate ligament (ACL) is the most frequently injured ligament. The grade of ACL tear on magnetic resonance imaging (MRI) can help determine the ACL injury treatment. Lateralization of the tibial tubercle is indicated by an increase in the distance of the tibial tuberosity–trochlear groove (TT-TG). Anterolateral ligament (ALL) injury affects a high degree of pivot shift in the knee joint with ACL deficiency. Trochlear dysplasia (TD) is a congenital morphological deformity of the femoral trochlea. An increase in the TT-TG distance, as well as the presence of ALL injuries and TD, can elevate the likelihood of experiencing ACL injuries. This study aims to analyze the correlation of TT-TG distance, ALL injury, and type of TD with the grade of ACL tear through MRI.MethodsThis analytical cross-sectional study was conducted from November 2021 to June 2022 at RSUP Dr. Kariadi Hospital, Semarang. The ACL tear was divided into three degrees. The Schoettle or the Nizić method was used to measure the TT-TG distance. ALL injuries were evaluated by looking at the integrity of the ligament. TD assessment was according to the Dejour classification.ResultsA total of 50 subjects participated in the study. The TT-TG distance for grade I ACL tears was 5.90–14.6 mm (22%), 1.69–18.30 mm (44%) for grade II, and 1.01–14.10 mm (34%) for grade III. The ANOVA test showed no significant relationship between the TT-TG distance and the degree of ACL tear (p = 0.146). ALL injuries were found in six study subjects: One subject (16.7%) had grade I ACL tear, three subjects (50%) had grade II, and two subjects (33.3%) had grade III. The Chi-square test showed no significant correlation between ALL injuries and the degree of ACL tear (p = 0.930). Most subjects did not experience TD (78%), while 20% experienced TD type A and 2% experienced TD type B. In type A TD, 50% of ACL tears were grade I, 30% grade II, and 20% grade III. Among all subjects with TD type B, only one was found to have a grade III ACL tear. Based on the Chi-square test, there was no significant correlation between TD type and the degree of ACL tear (p = 0.110).ConclusionsThere is no significant correlation between the tibial tuberosity–trochlear groove distance, ALL injury, and type of trochlear dysplasia with the grade of ACL tear.

Patellar Base Support Technique During Manipulation Under Anesthesia for Knee Arthrofibrosis Limits the Risk of Iatrogenic Complications

Knee extension contracture is a common postinjury and postsurgical complication, which decreases knee joint flexion. Many techniques have been described in the literature to restore knee flexion, with the most common one being an arthroscopic lysis of adhesions. However, in severe cases, additional intra- and extra-articular procedures are needed to restore full knee flexion. Manipulation under anesthesia (MUA) is one of them. Unfortunately, it may lead to devastating complications, such as iatrogenic rupture of the patellar tendon or fractures of the patella or tibial tuberosity. Therefore, the purpose of this report is to present a safer modification of MUA for knee extension contracture in cases in which excessive force is demanded to achieve flexion. The key aim of the “patellar base support” technique (PBS technique) is to stretch the contracted quadriceps muscle with controlled and decreased tension on the patella, patellar tendon, and tibial tuberosity.

Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis.

The purposes of this study are to, firstly, develop techniques to accurately identify extensor mechanism malalignment by measuring the alignment of the quadriceps tendon (QTA) with computerized tomography (CT) scans. Secondly, to investigate correlations between QTA and lower limb bony anatomical variations within a representative normal population. Lastly, to evaluate the clinical significance of QTA by establishing its potential connection with lateral facet patellofemoral joint osteoarthritis (LFPFJOA). CT scans were orientated to a mechanical axis reference frame and three techniques developed to measure the alignment of the quadriceps tendon. Multiple measurement of bony alignment from the hip to the ankle were performed on each scan. A series of 110 cadaveric CT scans were measured to determine normal values, reproducibility, and correlations with bony anatomy. Secondly, a comparison between 2 groups of 25 patients, 1 group with LFPFJOA and 1 group with isolated medial OA and no LFPFJOA. From the cadaveric study, it was determined that the alignment of the quadriceps tendon is on average 4.3° (SD 3.9) varus and the apex of the tendon is 9.1mm (SD 7.7mm) lateral to the trochlear groove and externally rotated 1.9° (SD 12.4°) from the centre of the femoral shaft. There was no association between the quadriceps tendon alignment and any other bony measurements including tibial tubercle trochlear groove distance (TTTG), coronal alignment, trochlear groove alignment and femoral neck anteversion. A lateralized QTA was significantly associated with LFPFJOA. QTA in the LFPFJOA group was 9.6° varus (SD 2.8°), 21.3mm (SD 6.6) lateralised and 17.3° ER (SD 11°) compared to 5.5° (SD 2.3°), 10.7mm (SD 4.9) and 3.3° (SD 7.2°), respectively, in the control group (p < 0.001). A significant association with LFPFJOA was also found for TTTG (17.2mm (SD 5.7) vs 12.1mm (SD 4.3), p < 0.01). Logistic regression analysis confirmed the QTA as having the stronger association with LFPFJOA than TTTG (AUC 0.87 to 0.92 for QTA vs 0.79 for TTTG). These studies have confirmed the ability to accurately determine QTA on CT scans. The normal values indicate that the QTA is highly variable and unrelated to bony anatomy. The comparative study has determined that QTA is clinically relevant and a lateralised QTA is the dominant predictor of severe LFPFJOA. This deformity should be considered when assessing patella maltracking associated with patella osteoarthritis, patella instability and arthroplasty. III (retrospective cohort study).

Objective and owner-reported outcomes after modified cranial closing wedge ostectomy: a case series

Immediate and longer-term outcomes of a cranial closing wedge ostectomy variant for management of canine cranial cruciate ligament disease were assessed in this single-center retrospective consecutive study. Records and radiographs were retrieved and assessed by three independent observers to evaluate tibial plateau angle, anatomical-mechanical axis angle, tibial tuberosity distalization, and mechanical axis length before and after surgery. Kinetic gait analysis and owner questionnaires were used to assess clinical outcomes. Seventeen stifles from fifteen dogs were evaluated radiographically. Mean error from target tibial plateau angle was 0.4 degrees. Anatomical-mechanical axis angles reduced from mean 2.9 degrees preoperatively to mean − 0.9 degrees postoperatively. Tibial tuberosity distalization was mean 5.0% of mechanical axis length, and mean reduction in mechanical axis length was 0.1%. Increased tibial plateau angles were noted in 8/17 stifles, with a mean of 9.6 degrees at short-term follow-up. Major complications were observed in 9/17 stifles. Long term follow-up (mean 832 days) was obtained with gait analysis in 8/15 dogs and with questionnaire in 11/15. Most dogs (9/11) were weakly to moderately affected by osteoarthritis symptoms. All values for peak vertical force and vertical impulse normalized to body weight exceeded local lower reference limits for normal dogs, indicating acceptable limb use. Satisfactory immediate and long-term clinical outcomes appear to be possible with this technique, but the high incidence of shorter-term complications may caution against the technique or the fixation and management described here.

Ambulatory surgical management of most displaced tibial tubercle fractures in children is safe and efficient.

The purpose of this study is to compare the outcome of patients with displaced tibial tubercle fractures treated surgically who spent one or more nights in the hospital after surgery with that of patients treated in an ambulatory setting with no perioperative hospitalization. We hypothesized that tibial tubercle fractures have a low rate of complications and that most patients do well without an overnight hospital stay for observation. We retrospectively reviewed all pediatric tibial tubercle fractures treated operatively by a single surgeon over a 13.5-year period. Fractures treated in an inpatient setting, defined as at least one night of overnight hospitalization postoperatively, were compared with fractures treated in an ambulatory setting with no perioperative hospitalization. Seventy-one fractures in 70 patients were analyzed. All fractures were treated with open reduction and internal fixation with unicortical screws. Thirty-five fractures (49.3%) were fixed in an ambulatory setting, while 36 (50.7%) were inpatient. There were no significant differences between inpatient demographics (age, gender, body mass index, fracture type). Average operative time was significantly longer in the inpatient group compared with the ambulatory group (97.8 min versus 58.8 min, p < 0.001). There was no significant difference in the incidence of complications between inpatient and ambulatory groups (25.0% versus 11.4%, p = 0.22). No cases of compartment syndrome were noted. Ambulatory surgical treatment of select tibial tubercle fractures with same-day discharge is safe and efficient. Not all patients with surgically treated tibial tubercle fractures need to stay overnight in the hospital.

Length Changes of the Medial Patellofemoral Ligament During In Vivo Knee Motion: An Evaluation Using Dynamic Computed Tomography

Background: Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve clinical outcomes, it is crucial to gain a better understanding of MPFL elongation patterns. Purpose: To assess MPFL length changes in healthy knees from 0° to 90° of dynamic flexion and their relationship with anatomic parameters of the patellofemoral joint. Study Design: Descriptive laboratory study. Methods: Dynamic computed tomography scans of an active flexion-extension-flexion movement in 115 knees from 63 healthy participants were evaluated to construct knee joint models. Using these models, the MPFL length was measured as the shortest wrapping path from the Schöttle point on the femur to 3 insertion points on the superomedial border of the patella (proximal, central, and distal). MPFL length changes (%) relative to the length in full extension were calculated, and their correlations with the tibial tuberosity–trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination were analyzed. Results: The proximal fiber was the longest in full extension and progressively decreased to a median length of −6.0% at 90° of flexion. The central fiber exhibited the most isometric pattern during knee flexion, showing a median maximal decrease of 2.8% relative to the full extension length and no evident elongation. The distal fiber first slightly decreased in length but increased at deeper flexion angles. The median overall length changes were 4.6, 4.7, and 5.7 mm for the proximal, central, and distal patellar insertion, respectively. These values were either not or very weakly correlated with the tibial tuberosity–trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination when the anatomic parameters were within the healthy range. Conclusion: The median MPFL length changed by approximately 5 mm between 0° and 90° of flexion. Proximally, the length continuously decreased, indicating slackening behavior. Distally, the length increased at deeper flexion angles, indicating tightening behavior. Clinical Relevance: In MPFL reconstruction techniques utilizing the Schöttle point to establish the femoral insertion, one should avoid distal patellar insertion, as it causes elongation of the ligament, which may increase the risk for complications due to overloading.

Comparison and interobserver reliability of three different methods for measuring the amount of the tibial tuberosity advancement in the preoperative planning of TTAT.

The goal of preoperative planning techniques for advancement of the tibial tuberosity is to determine the amount of advancement required to achieve a postoperative patellar tendon angle of 90° and to select the optimal wedge size to achieve this target. Three radiographic methods for determining the advancement distance for the tibial tuberosity were evaluated for comparability and interobserver reliability. Among the methods developed, we decided to include the common tangent method, the tibial anatomy-based method, and the Bielecki method. For all techniques, radiographs were taken in mediolateral projection with the knee joint flexed at 135°. Three observers with different levels of experience independently evaluated and scored the degree of osteoarthritis for each stifle, as previously described, and performed measurements of the amount of advancement of the tibial tuberosity on 33 stifles using common tangent method, tibial anatomy-based method, and Bielecki method. According to the results, the overall score for osteoarthritis in the mediolateral view was influenced by the experience of the observers, which contradicts the results from a previous study. Regarding the measurement methods used to assess advancement, poor interobserver reliability was found for common tangent method and Bielecki method, while only a slightly moderate interobserver agreement was found for tibial anatomy-based method. These results are inconsistent with data collected by Bielecki and colleagues. Moreover, measurements from common tangent method and tibial anatomy-based method were overlapping, as confirmed previously. Conversely, Bielecki method showed no agreement with the other methods included in the present study, with a significantly higher mean rank, probably due to its correction formula. Based on the results of the present study, tibial anatomy-based method has better interobserver reliability and is easier to perform according to the observers.

Anteromedial Tibial Tubercle Osteotomy for Recurrent Patella Subluxation

Background: Patellofemoral pathology resulting from improper biomechanics is difficult to treat, and lateral patellar instability requires individualized treatment, which may include tibial tubercle osteotomy (TTO) with anteromedial repositioning. Indications: Symptomatic patellofemoral instability with maltracking, particularly in cases with a tibial tuberosity-trochlear groove distance &gt;16 mm. Technique Description: We describe an oblique osteotomy from medial to lateral. A careful completion of the osteotomy is made with an osteotome, and the resulting fragment is mobilized to achieve anteromedial repositioning—as well as distalization in cases of patella alta. Two bicortical screws with a washer are used for fixation of the tibial tubercle following anteromedialization. Results: Systematic reviews demonstrated that the treatment of the lateral patellar instability requires an individual treatment and the anteromedial TTO is a very important procedure alone or in association with medial patellofemoral ligament. Discussion/Conclusion: Recurrent lateral patellar instability is a challenging condition with complex causes and various treatment options, but anteromedial TTO provides an effective way to improve clinical outcomes and correct patellar maltracking, with relatively low complication rates. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Dome trochleoplasty for correction of patella alta and patella luxation in dogs > 20 kg.

To describe the dome trochleoplasty procedure and report the short-term outcomes and complications associated with a novel technique to correct patellar luxation and patella alta. 13 dogs (16 stifle joints) diagnosed with medial patellar luxation with concurrent patella alta in dogs > 20 kg. Medical records of dogs weighing > 20 kg that underwent a dome trochleoplasty for correction of a medial luxating patella were prospectively evaluated. The procedure described involves an osteotomy of the femoral trochlea, which is then translated and/or rotated to correct patellar luxation. Clinical results were assessed using subjective lameness scoring, radiographic evaluation, and the Canine Brief Pain Inventory (CBPI) tool. 16 stifle joints were included in this study. The overall complication rate was 50%. Major complications occurred in 43.8% of stifle joints due to pin migration and recurrent luxation of the patella. One dog experienced a catastrophic complication 4 months postoperatively. Uncomplicated osteotomy healing was present in 94% of dogs. The median initial lameness score was 2 (mean, 1.81; range, 0 to 4) and at the final recheck was 0 (mean, 0.31; range, 0 to 2). The CBPI scores were available for 50% of stifle joints. The median initial CBPI score was 45.5 (mean, 48.8; range, 32 to 74) and at the final recheck was 17.5 (mean, 20.5; range, 0 to 43). The dome trochleoplasty procedure offers an alternative technique for surgical correction of patellar luxation secondary to patella alta in large-breed dogs, but due to its higher complication and reluxation rates, it should be used cautiously and probably in combination with other corrective procedures, such as tibial tuberosity transposition, soft tissue imbrication, and/or soft tissue release rather than as a stand-alone procedure.

Arthroscopic-assisted Treatment of a Posterolateral Tibial Plateau Fracture with an Accompanying Tibial Eminence Fracture. Case Report

Posterolateral tibial plateau fractures pose a challenge even to the most experienced orthopedic trauma specialists. Arthroscopic fracture management techniques have been emerging as an increasingly popular alternative in the treatment of selected tibial plateau fractures. This technique enables precise visualization of the articular surface of the tibia and its anatomical reduction with lateral meniscus repair, which further enables the restoration of biomechanical function of the meniscus and prevents early degeneration. In addition, this method minimizes soft tissue injury, shortens the duration of hospital stay and postoperative care, and enables treatment of accompanying intra-articular injuries. In our article, we present a case of posterolateral tibial plateau fracture with articular displacement and depression, and loss of support for the posterior margin of the lateral meniscus with an accompanying tibial eminence fracture. The fracture was treated with arthroscopic assistance. Anatomical reduction of the tibial eminence and the fragment of the posterolateral tibial plateau, as well as lateral meniscus repair was achieved intraoperatively. Postoperative radiographic assessment showed anatomical restoration of the articular surface. A full range of motion and pain-free knee stability were achieved following rehabilitation.

Prospective measurement of outcomes and complications of tibial tuberosity advancement using novel mini plates in small breed dogs.

Cranial cruciate ligament (CrCL) disease is a common orthopedic disease in canine patients. Tibial osteotomy procedures for the treatment of cranial cruciate ligament disease in small breed dogs (<15 kg) have previously been limited. A total of 22 client-owned dogs, 26 stifles, with cranial cruciate ligament disease were treated with novel mini-tibial tuberosity advancement plates. The most common intraoperative complications included the need for plate-cage overlap in 7 stifles (26.92%) and screw head fracture in 1 (3.85%). Post-operative complications included tibial tuberosity fracture (3.85%), post-operative medial patella luxation (7.69%), and persistent lameness (7.69%). Of the 26 stifles evaluated in the medium term (>6-12 months) post-operatively, 92.3% had no lameness, with the remaining 7.7% having Grade 1 lameness. A good to excellent clinical outcome was noted in all 26 stifles that underwent TTA with novel mini plates.

Enhanced Pain Relief and Function Improvement in Children with Osgood-Schlatter Disease: Leukocyte-Rich Platelet-Rich Plasma (LR-PRP) as a Complementary Treatment to Standard Conservative Therapy.

BACKGROUND Osgood-Schlatter disease (OSD) causes pain and loss of function of the knee in growing children. This study aimed to evaluate pain and function of the knee joint in 152 growing children with chronic OSD before and after treatment with LR-PRP when used with standard conservative treatment. MATERIAL AND METHODS Treatment efficacy was evaluated using the VAS, Tegner, Lyshom, and KOOS scales. Patient satisfaction, post-surgery athletic performance, and X-ray assessment were also used to determine the success of the procedure. RESULTS We found that 75% of the subjects were satisfied with the results of the treatment, and 72% of the subjects returned to full physical activity. The analysis showed a significant decrease in the median VAS score after treatment compared to the pre-treatment score (P<0.05), and an increase in the median scores of the Tegner, Lysholm, and KOOS scales compared to the pre-treatment score (P<0.05; P<0.05; P<0.05, respectively). The results showed that the shorter the duration of the disease, the better the treatment results were received. Return to activity and patient satisfaction were highest in the study group previously rehabilitated. CONCLUSIONS LR-PRP injection of the tibial tuberosity in patients with chronic OSD with open growth cartilage is an effective and uncomplicated method. We did not observe any adverse effects, which suggests the relatively high safety of the procedure. The use of PRP in the earlier phase of the disease and additional rehabilitation before treatment significantly increases the effectiveness of treatment.

Improving alignment in total knee arthroplasty: a cadaveric assessment of a surgical navigation tool with computed tomography imaging

Purpose To investigate the accuracy of an imageless, optical surgical navigation tool to assist with femoral and tibial bone cuts performed during TKA. Patients and methods Six board-certified orthopedic surgeons participated in a laboratory cadaver investigation, performing femoral and tibial bone cuts with the assistance of a computer navigation tool. Femoral and tibial varus/valgus, tibial slope, femoral flexion, and both femoral and tibial rotation measurements from the device were compared with angular measurements calculated from computed tomography (CT) images of the knees. Results Measurements with the navigation tool were highly correlated with those obtained from CT scans in all three axes. For the distal femoral cut, the absolute mean difference in varus/valgus was 0.83° (SD 0.46°, r = 0.76), femoral flexion was 1.91° (SD 1.16°, r = 0.85), and femoral rotation was 1.29° (SD 1.01°, r = 0.88) relative to Whiteside’s line and 0.97° (SD 0.56°, r = 0.81) relative to the posterior condylar axis. For the tibia, the absolute mean difference in varus/valgus was 1.08° (SD 0.64°, r = 0.85), posterior slope was 2.78° (SD 1.40°, r = 0.60), and rotation relative to the anteroposterior axis (posterior cruciate ligament to the medial third of the tibial tuberosity) was 2.98° (SD 2.54°, r = 0.79). Conclusion Utilization of an imageless navigation tool may aid surgeons in accurately performing and monitoring femoral and tibial bone cuts, and implant rotation in TKA and thus, more accurately align TKA components.

A modified triple tibial osteotomy for management of canine cranial cruciate ligament disease: retrospective assessment of 309 procedures (2017–2020)

ABSTRACTCase historyMedical records from a single referral hospital (Animal Referral Hospital, Sinnamon Park, Australia) of dogs treated with modified triple tibial osteotomy (TTO) for management of cranial cruciate ligament (CrCL) disease from June 2017 to June 2020 were reviewed. Modifications to the originally described TTO procedure included a modified wedge angle calculation and performing the tibial osteotomies without the use of pre-drilled guide holes.Clinical findingsA total of 253 dogs met the inclusion criteria. Two dogs were excluded, leaving 251 dogs that had undergone 309 procedures for assessment, and data from these, including complications, were reviewed. Complete, partial competent, and partial incompetent rupture of the cranial cruciate ligament was identified in 202/309 (65.4%), 79/309 (25.6%), and 28/309 (9.1%) stifles, respectively. Medial meniscal injury was identified in 207/309 (67.0%) stifles at the time of initial surgery.Treatment and outcomeFifty-eight dogs had bilateral procedures, including both single-session and staged surgeries, and 48 of these were available for analyses. The modifications to the TTO procedure described herein resulted in a median wedge angle of 21° and a median post-operative tibial plateau angle of 5.8°. Tibial compression testing following surgery indicated elimination of cranial tibial thrust in all stifles in this series. The most common intra-operative complication was tibial tuberosity fracture (15/309; 4.9%). Minor post-operative complications occurred in 37/309 (12.0%) procedures, with infection being the most common (27/309; 8.7%). Major post-operative complications occurred in 9/309 (2.9%) procedures. The intra- and post-operative complication rates for dogs undergoing bilateral single-session TTO were both 8.3% (2/24). The intra- and post-operative complication rates for dogs undergoing bilateral staged TTO were both 4.2% (1/24). The low number of complications for both the bilateral single-session and bilateral staged TTO groups precluded statistical analysis. All complications resolved uneventfully as determined by the attending surgeon.Clinical relevanceThe modified TTO technique described here was safe and effective for the management of canine CrCL disease in the dogs included in the case series. Findings of this study suggest that, with careful case selection, the modified TTO may be performed as a bilateral single-session procedure in dogs with concurrent bilateral cranial cruciate ligament disease. Future studies analysing the effects of these modifications on stifle biomechanics would be beneficial.AbbreviationsCrCL: Cranial cruciate ligament; SSI: Surgical site infection; TPA: Tibial plateau angle; TPLO: Tibial plateau levelling osteotomy; TTA: Tibial tuberosity advancement; TTO: Triple tibial osteotomy

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

IntroductionMiserable malalignment syndrome is a complex torsional lower limb deformity with limited consensus on surgical treatment. We present the outcome of de-rotation of the tibia alone using an external fixator.MethodsFifteen patients (22 segments) were operated on between 2012 and 2020; 13 presented with anterior knee pain, and two presented with out-toeing. Gait analysis was done in nine patients, and CT scan rotational profile, including tibial tubercle–trochlear groove distance, femoral version, and tibial torsion, were calculated. Kujala knee pain score and visual analogue pain score (VAS) were recorded. All underwent infra-tubercular osteotomy of the tibia and midshaft osteotmy of the fibula and application of a hexapod circular frame to gradually internally rotate the tibia until the foot aligned with the patella.ResultsThere was no preoperative clinical or radiographic evidence for patellar instability, femoral anteversion 30° (21°–54°), and external tibial torsion 50° (37–70). The mean age at surgery was 21 years (12–37) with a mean follow-up of 20 months (9–83). All osteotomies healed, and the frames were removed at a mean of 111 days (80–168). The mean VAS score improved from 8(5–9) to 1(0–4) postoperatively (P < 0.001). The mean Kujala knee pain score increased from 53 (30–75) to 92 (54–100) postoperatively (P < 0.001). The mean preoperative foot progression angle (FPA) was 37° (20°–50°), with 13 postoperatively walking with neutral FPA. One patient walked with symmetrical + 10° and the other with − 5° FPA. All patients reported relief of knee pain and were satisfied with the alignment.ConclusionGradual correction of severe external tibia torsion with a hexapod external fixator and an infra-tubercle tibial osteotomy could provide an optimum method to eliminate knee pain and improve limb alignment in miserable malalignment syndrome.

ENPP1 downregulation and FGF23 upregulation in growth-related calcification of the tibial tuberosity in rats.

During tibial tuberosity growth, superficial and deep portions can be observed; however, the deep portion is not observed after the growth period, as it develops into bone tissues. Calcification in vivo is known to be constitutively suppressed by ectonucleotide pyrophosphatase/phosphodiesterase-1 (ENPP1) but promoted by tissue-nonspecific alkaline phosphatase (TNAP). FGF23 promotes calcification of enthesis. Gene expression of FGF23 increased rapidly at 13W in this study. Therefore, the tibial tuberosity is speculated to develop via Enpp1 downregulation and Tnap upregulation; however, the understanding of these processes remains unclear. Hence, in the present study, we aimed to explore the age-related structural changes and underlying gene expression changes in the tibial tuberosity of rats. Male Wistar rats were divided into three groups (3-, 7-, and 13-week-old; eight each). The tibial tuberosity superficial and deep portions were clearly observed in 3- and 7-week-old rats, but the presence of the deep portion was not confirmed in 13-week-old rats. The extracellular matrix of hypertrophic chondrocytes was calcified. Furthermore, the Enpp1 expression was the highest in 3-week-old rats and decreased with growth. The TNAP expression did not differ significantly among the groups. The deep portion area was significantly lower in 3-week-old rats than in 7-week-old rats. Generally, the extracellular matrix of the immature chondrocytes is not calcified. Therefore, we speculated that the cartilaginous tibial tuberosity calcifies and ossifies with growth. The Enpp1 expression decreased with growth, whereas the Tnap expression remained unchanged. Thus, we surmise that the tibial tuberosity calcifies with growth and that this process involves Enpp1 downregulation and FGF23 upregulation. As Osgood-Schlatter disease is closely related to the calcification of the tibial tuberosity, these findings may help clarify the pathogenesis of this disease.