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Boksh K, E T Shepherd D, M Espino D, Ghosh A, Aujla R, Boutefnouchet T. Centralization reduces meniscal extrusion, improves joint mechanics and functional outcomes in patients undergoing meniscus surgery: A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39118448 DOI: 10.1002/ksa.12410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE To perform a systematic review and meta-analysis of the existing literature on meniscal centralisation procedures, analysing its impact on meniscal extrusion, joint biomechanics and clinical and radiological outcome measures. METHODS The Cochrane Controlled Register of Trials, PubMed (MEDLINE) and Embase were used to perform a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Biomechanical studies on healthy animal or human cadaveric knee joints that assessed meniscal extrusion or tibiofemoral contact mechanics (contact area and pressure) following centralization for meniscal pathologies were included. For clinical studies, those that prospectively or retrospectively assessed patient-reported outcome measures (PROMs), postoperative knee motion, complications and radiological extrusion following centralization for meniscal pathologies were included. RESULTS Fifteen studies were included in the analysis, comprising eight biomechanical, six clinical and one both. There were 92 knee specimens for biomechanical testing, of which 40 were human cadaveric and 52 porcine models. Biomechanical data revealed centralization to be commonly performed for posterior meniscal root tears and significantly reduced extrusion and contact pressure whilst improving contact area following a tear (p < 0.00001). Centralization restored extrusion to that of the native knee at all flexion angles described (0-90°, p = 0.25) and, compared to the torn state, brought tibiofemoral contact mechanics 3.2-5.0 times closer to the native state. Clinical data showed that 158 patients underwent centralization for extrusion. It improved postoperative Knee Injury and Osteoarthritis Outcome score (KOOS) (p = 0.006) and Lysholm scores (p < 0.00001) at 25.0 months, maintained extrusion reduction at 17.1 months (p < 0.00001) and preserved knee motion. CONCLUSION Centralisation for various meniscal injuries associated with extrusion can reduce meniscal extrusion and improve joint biomechanics, along with clinical and radiological outcomes. Existing evidence is still scarce and exhibits a notable amount of methodological heterogeneity. LEVEL OF EVIDENCE Systematic review of Level IV evidence.
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Affiliation(s)
- Khalis Boksh
- Department of Biomedical Engineering, University of Birmingham, Birmingham, UK
- Leicester Academic Knee Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Duncan E T Shepherd
- Department of Biomedical Engineering, University of Birmingham, Birmingham, UK
| | - Daniel M Espino
- Department of Biomedical Engineering, University of Birmingham, Birmingham, UK
| | - Arijit Ghosh
- Leicester Academic Knee Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Randeep Aujla
- Leicester Academic Knee Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tarek Boutefnouchet
- Department of Biomedical Engineering, University of Birmingham, Birmingham, UK
- Department of Trauma & Orthopaedics, University Hospitals of Birmingham NHS Trust, Birmingham, UK
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Nakamura T, Koga H. Review of the Development of Meniscus Centralization. Curr Rev Musculoskelet Med 2024; 17:303-312. [PMID: 38760631 PMCID: PMC11219636 DOI: 10.1007/s12178-024-09905-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE OF REVIEW With an aging population, extending healthy life expectancy is a global challenge. Maintaining healthy knee joint function is one of the essential factors to preserve the ability to walk and extend healthy life expectancy. Meniscus centralization was introduced in 2012 as a procedure for meniscus extrusion, one of the causes of knee osteoarthritis (OA). Initially, it was performed only for lateral meniscus (LM) extrusion, and favorable 2-year results were reported in 2016. Gradually, basic studies supporting the effectiveness of meniscus centralization have been reported, and it has also been performed for medial meniscus (MM) extrusion, with some positive results reported. Although the surgical procedures vary among the institutions, the basic concept is to reattach the loosened meniscotibial ligament to the edge of the tibial plateau to re-tension it. This review will discuss the history of development and the current status of meniscus centralization. RECENT FINDINGS Current research shows that meniscus centralization is not performed in isolation but is often used as an augmentation along with the conventional repair of meniscus injuries, particularly posterior root tears. Biomechanical studies demonstrated that MM centralization with a posteromedial anchor can better restore meniscus function. CONCLUSION Despite its relatively short publication history of just over ten years, meniscus centralization has shown potential as a treatment to curb the progression of knee OA and extend a healthy life. While more evidence is needed, this conclusion underscores the promising role for meniscus centralization, making it a topic of significant interest for knee surgeons and researchers.
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Affiliation(s)
- Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
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Tachibana T, Katagiri H, Matsuda J, Ozeki N, Watanabe T, Sekiya I, Jinno T. Biomechanical analysis of load distribution in porcine hip joints at different acetabular coverages. BMC Musculoskelet Disord 2024; 25:576. [PMID: 39049016 PMCID: PMC11267855 DOI: 10.1186/s12891-024-07701-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Developmental dysplasia of the hip causes secondary osteoarthritis. Finite element analysis suggests high hip joint contact pressure in patients with hip dysplasia and a reduction in contact pressure after periacetabular osteotomy. However, few biomechanical studies have examined the load distribution in the hip joint. This study aimed to investigate the biomechanical properties of load distribution in porcine hip joints at different acetabular coverages. METHODS Six porcine hip joints were analyzed using three models: 1) neutral coverage, 2) 15° under-coverage (defined as dysplasia model), and 3) 15° over-coverage created by varying the acetabular coverage. The load distribution was assessed using a pressure-mapping sensor system after applying a loading force of 100 N to the hip joint. RESULTS In the dysplasia model, the load was concentrated at the acetabular rim; in the neutral and over-coverage models, it was dispersed. The average contact pressure was significantly higher in the dysplasia model than in the neutral coverage model ([0.42 vs. 0.3 MPa]; p = 0.004). The contact area was significantly smaller in the dysplasia model than in the neutral coverage model ([250.7 vs. 345.0 mm2]; p = 0.004). No significant differences were observed in contact pressure or area between the neutral and over-coverage models. CONCLUSIONS Insufficient acetabular coverage in the dysplasia model demonstrated higher contact pressure and smaller contact area than the neutral model. Conversely, the contact pressure and area in the over-coverage model did not differ significantly from those in the normal model. Therefore, surgeons should note that acetabular coverage overcorrection has limited effect; normalization is crucial during periacetabular osteotomy.
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Affiliation(s)
- Tetsuya Tachibana
- Department of Orthopedic Surgery, Dokkyo Medical University, Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hiroki Katagiri
- Department of Orthopedic Surgery, Dokkyo Medical University, Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan.
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
| | - Junpei Matsuda
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutake Ozeki
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Watanabe
- Department of Orthopedic Surgery, Dokkyo Medical University, Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Jinno
- Department of Orthopedic Surgery, Dokkyo Medical University, Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan
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Ozeki N, Koga H, Nakamura T, Katagiri H, Nakagawa Y, Hoshino T, Katakura M, Amemiya M, Yoshihara A, Katano H, Mizuno M, Endo K, Masumoto J, Sekiya I. The association of the medial meniscus covering ratio with knee cartilage thickness at 15 medial compartment subregions as found by three-dimensional analysis using MRI. J Exp Orthop 2024; 11:e70005. [PMID: 39193488 PMCID: PMC11347932 DOI: 10.1002/jeo2.70005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/15/2024] [Accepted: 06/21/2024] [Indexed: 08/29/2024] Open
Abstract
Purpose The correlation of cartilage thickness measured by three-dimensional (3D) magnetic resonance imaging (MRI) and the medial meniscal coverage ratio (MMCR), which presented pathology of the medial meniscus extrusion (MME) in 3D MRI, has not yet been elucidated. The study's purpose was to retrospectively verify whether the average cartilage thickness calculated by the automatic MRI 3D analysis system for each subregion was correlated with MMCR. Methods A total of 60 patients underwent medial meniscus repair or high tibial osteotomy to treat their medial knee osteoarthritis. Cartilage thickness and MMCR were automatically calculated using 3D MRI software. The MMCR was defined as the ratio of the area covered by the meniscus within the medial tibial cartilage area to the total medial tibial cartilage area. The association between MMCR and the average cartilage thickness at 15 subregions in the medial femoral condyle (MFC) and medial tibial plateau (MTP) was evaluated using Spearman's rank correlation coefficient. Results Kellgren-Lawrence grade exhibited a negative correlation with MMCR and a positive correlation with MME width. Cartilage thickness in the MTP had a moderately positive correlation with MMCR at four subregions and a weakly positive correlation at another subregion. Cartilage thickness in the MFC showed a moderately positive correlation with MMCR at five subregions and a weakly positive correlation at one subregion. Conclusions Cartilage thickness calculated by automatic MRI 3D analysis system had a positive correlation with MMCR for all subregions of the anterior and middle subregions in the MFC and for five regions of nine subregions of the anterior and middle subregions in the MTP. Level of evidence Level II, cross-sectional study (diagnosis).
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Affiliation(s)
- Nobutake Ozeki
- Center for Stem Cell and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Yusuke Nakagawa
- Department of Cartilage RegenerationTokyo Medical and Dental UniversityTokyoJapan
| | - Takashi Hoshino
- Clinical Center for Sports MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Mai Katakura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Masaki Amemiya
- Clinical Center for Sports MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Aritoshi Yoshihara
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Hisako Katano
- Center for Stem Cell and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Mitsuru Mizuno
- Center for Stem Cell and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Kentaro Endo
- Center for Stem Cell and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | | | - Ichiro Sekiya
- Center for Stem Cell and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
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Aizawa J, Hirohata K, Ohji S, Mitomo S, Ohmi T, Koga H, Yagishita K. Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) subcategories are affected by subjective running ability and medial single-leg hop distance in postreconstruction patients at 6 months. J Exp Orthop 2024; 11:e12004. [PMID: 38455451 PMCID: PMC10903433 DOI: 10.1002/jeo2.12004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose This study aimed to investigate the intricate relationship between physical function factors and each subcategory score of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale among patients following ACL reconstruction. Methods Participants comprised 59 patients who had undergone primary ACL reconstruction using hamstring tendon. The ACL-RSI was completed 6 months after reconstruction and five physical functions were measured in patients on the same day. Simple linear regression was performed multiple times to investigate the relationship between ACL-RSI subcategory scores as a dependent variable and each independent variable (knee strength, leg anterior reach distance, single-leg hop [SLH] distances, side bridge endurance, and subjective running ability). Multiple regression analysis was performed using a stepwise method, with factors showing a risk rate <0.05 in simple linear regression analyses as independent variables and the ACL-RSI in each subcategory score as the dependent variable. Results Multiple regression analysis showed that subjective running ability affected all subcategories (p ≤ 0.001), and that the limb symmetry index of medial SLH distance affected both the Emotions (p = 0.047) and Confidence (p = 0.009) subcategories. Higher subjective running ability and greater limb symmetry in the medial SLH were thus positively associated with each dimension of psychological readiness. Conclusions This study highlights the differential impact of physical function factors on specific subcategories of the ACL-RSI scale, providing clinicians with insights for designing targeted rehabilitation strategies. This original paper suggests the importance of analysing factors related to subcategory scores in addition to total ACL-RSI score, and could contribute to the understanding of determinants for a successful return to sport following ACL reconstruction. Level of Evidence Level IV.
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Affiliation(s)
- Jun‐ya Aizawa
- Department of Physical TherapyJuntendo UniversityTokyoJapan
- Department of Rehabilitation Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Kenji Hirohata
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
| | - Shunsuke Ohji
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
| | - Sho Mitomo
- Department of Rehabilitation Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
- Japan Sports AgencyTokyoJapan
| | - Takehiro Ohmi
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Kazuyoshi Yagishita
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
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王 俊, 赵 智, 姜 程, 聂 闯, 时 全, 刘 猛, 顾 建. [Design and validation of a novel knee biomechanical test method]. SHENG WU YI XUE GONG CHENG XUE ZA ZHI = JOURNAL OF BIOMEDICAL ENGINEERING = SHENGWU YIXUE GONGCHENGXUE ZAZHI 2023; 40:1185-1191. [PMID: 38151942 PMCID: PMC10753301 DOI: 10.7507/1001-5515.202304042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/30/2023] [Indexed: 12/29/2023]
Abstract
A novel structural dynamics test method and device were designed to test the biomechanical effects of dynamic axial loading on knee cartilage and meniscus. Firstly, the maximum acceleration signal-to-noise ratio of the experimental device was calculated by applying axial dynamic load to the experimental device under unloaded condition with different force hammers. Then the experimental samples were divided into non-specimen group (no specimen loaded), sham specimen group (loaded with polypropylene samples) and bovine knee joint specimen group (loaded with bovine knee joint samples) for testing. The test results show that the experimental device and method can provide stable axial dynamic load, and the experimental results have good repeatability. The final results confirm that the dynamic characteristics of experimental samples can be distinguished effectively by this device. The experimental method proposed in this study provides a new way to further study the biomechanical mechanism of knee joint structural response under axial dynamic load.
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Affiliation(s)
- 俊瑞 王
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
- 成都市第二人民医院 骨外科(成都 610000)Department of Orthopaedics, Chengdu Second People’s Hospital, Chengdu 610000, P. R. China
| | - 智平 赵
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
- 成都市第二人民医院 骨外科(成都 610000)Department of Orthopaedics, Chengdu Second People’s Hospital, Chengdu 610000, P. R. China
| | - 程腾 姜
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
| | - 闯 聂
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
| | - 全星 时
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
| | - 猛 刘
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
| | - 建文 顾
- 中国科学院大学 存济医学院(北京 100000)Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100000, P. R. China
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Amano Y, Ozeki N, Matsuda J, Nakamura T, Nakagawa Y, Sekiya I, Koga H. Augmentation of a Nonanatomical Repair of a Medial Meniscus Posterior Root Tear With Centralization Using Three Knotless Anchors May Be Associated With Less Meniscal Extrusion and Better Compressive Load Distribution in Mid-Flexion Compared With Non-Anatomical Root Repair Alone in a Porcine Knee Model. Arthroscopy 2023; 39:2487-2498.e4. [PMID: 37142135 DOI: 10.1016/j.arthro.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/08/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE To investigate the biomechanics of the centralization augmentation using knotless soft anchors to a nonanatomical transtibial pull-out root repair in a porcine medial meniscus posterior root tear (MMPRT) model. METHODS Porcine knee joints (N = 10) were used to perform one of the following procedures: (1) intact; (2) MMPRT; (3) nonanatomical root repair; (4) nonanatomical root repair with centralization using 2 anchors: anchors were inserted at the posterior medial collateral ligament (MCL) border and 10 mm anterior to the posterior MCL border; and (5) nonanatomical root repair with centralization using 3 anchors: another anchor was placed 10 mm posterior to the posterior MCL border. Contact area on the medial meniscus (MM), contact pressure in the MM and tibial cartilage, and MM extrusion were evaluated at 30°, 45°, 60°, and 90° knee flexions under 200 N compressive force. RESULTS MM extrusion at the posterior MCL border was significantly reduced after root repair with centralization using 3 anchors than after root repair alone at 30° (-0.063 mm vs 1.5 mm, P = .017), 45° (0.21 mm vs 1.7 mm, P = .018), and 60° (0.78 mm vs 2.3 mm, P = .019). There were no significant differences in MM extrusion between the root repair alone and root repair with centralization using 2 anchors at all flexion angles. The contact area in the middle and posterior MM was significantly greater after centralization with 3 anchors than after root repair alone at all flexion angles (except the posterior MM at 90°). The mean contact pressure in the tibial cartilage was significantly lower after centralization with 3 anchors than after root repair at all angles. CONCLUSIONS Augmentation of a nonanatomical repair of a medial meniscus posterior root tear with centralization using three knotless anchors may be associated with less meniscal extrusion and better compressive load distribution between 30° and 60° flexion compared with nonanatomical root repair alone in a porcine model. CLINICAL RELEVANCE This biomechanical study at time zero suggests that the addition of centralization using 3 knotless anchors may reduce MM extrusion and restore the load-distributing function of the MM.
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Affiliation(s)
- Yusuke Amano
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutake Ozeki
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junpei Matsuda
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.
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Morales-Avalos R, Diabb-Zavala JM, Mohamed-Noriega N, Vilchez-Cavazos F, Perelli S, Padilla-Medina JR, Torres-Gaytán AG, Huesca-Pérez HA, Erosa-Villarreal RA, Monllau JC. Effect of Injury to the Lateral Meniscotibial Ligament and Meniscofibular Ligament on Meniscal Extrusion: Biomechanical Evaluation of the Capsulodesis and Centralization Techniques in a Porcine Knee Model. Orthop J Sports Med 2023; 11:23259671231212856. [PMID: 38021298 PMCID: PMC10668570 DOI: 10.1177/23259671231212856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background Previous biomechanical studies of the meniscotibial ligament have determined that it contributes to meniscal stability. An injury to it can cause the meniscus to extrude, and reconstruction of that ligament significantly reduces extrusion. Purpose To assess the biomechanical effects of sectioning the lateral meniscotibial ligament (LMTL) and the meniscofibular ligament (MFL) with respect to the radial mobility of the lateral meniscus and to evaluate the biomechanical effects of the capsulodesis and centralization techniques. Study Design Controlled laboratory study. Methods The lateral meniscus of 22 porcine knees was evaluated. They were mounted on a testing apparatus to apply muscle and ground-reaction forces. The meniscus was evaluated at 30° and 60° of knee flexion using 2 markers placed on the posterior cruciate ligament and the lateral meniscus after applying an axial compression of 200 N to the knee joint. Measurements were recorded under 5 conditions: intact lateral meniscus, injury of the LMTL, subsequent injury of the MFL, the use of the open capsulodesis technique, and the reconstruction of the LMTL and the MFL with the centralization technique. Results The distance between the 2 markers was significantly greater in the extrusion group (combined lesion of the LMTL and MFL) than in the intact or reconstruction groups (capsulodesis and centralization techniques; P < .001 in all cases). In the cases of load application, no significant differences were observed between the control group (intact meniscus) and the groups on which the reconstruction techniques were performed. There were also no differences when comparing the results obtained between both reconstruction techniques. In all settings, the distance between the 2 markers increased with the increase in the knee flexion angle. Conclusion In a porcine model, the LMTL and the MFL participated as restrictors of the radial mobility of the lateral meniscus during loading. Their injury caused a significant increase in lateral meniscal extrusion, and the centralization and the capsulodesis procedures were able to reduce extrusion. Clinical Relevance This study demonstrates the capacity of the LMTL and the MFL to restrict the radial mobility of the lateral meniscus during loading and how it is affected when they are injured.
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Affiliation(s)
- Rodolfo Morales-Avalos
- Laboratory of Biomechanics, Articular Physiology and Experimental Orthopedic Surgery; Department of Physiology, Faculty of Medicine, Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo Leon, Mexico
- Departamento de Cirugia, Facultad de Medicina, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - José Manuel Diabb-Zavala
- Facultad de Ingeniería Mecánica y Eléctrica (FIME), Universidad Autónoma de Nuevo León (UANL), San Nicolás de los Garza, Nuevo León, Mexico
| | - Nasser Mohamed-Noriega
- Facultad de Ingeniería Mecánica y Eléctrica (FIME), Universidad Autónoma de Nuevo León (UANL), San Nicolás de los Garza, Nuevo León, Mexico
| | - Félix Vilchez-Cavazos
- Department of Orthopedic Surgery and Traumatology, University Hospital “Dr. José Eleuterio González,” Universidad Autonoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Simone Perelli
- ICATKnee (ICATME), Hospital Universitari Dexeus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - José Ramón Padilla-Medina
- Department of Orthopedic Surgery and Traumatology, University Hospital “Dr. José Eleuterio González,” Universidad Autonoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Adrián Gerardo Torres-Gaytán
- Department of Orthopedic Surgery and Traumatology, University Hospital “Dr. José Eleuterio González,” Universidad Autonoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Héctor Adán Huesca-Pérez
- Department of Orthopedic Surgery and Traumatology, University Hospital “Dr. José Eleuterio González,” Universidad Autonoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Roger Armando Erosa-Villarreal
- Department of Orthopedic Surgery and Traumatology, University Hospital “Dr. José Eleuterio González,” Universidad Autonoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Joan Carles Monllau
- Departamento de Cirugia, Facultad de Medicina, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
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Yoshihara A, Siboni R, Nakagawa Y, Mouton C, Jacquet C, Nakamura T, Sekiya I, Seil R, Koga H. Lateral-medial asymmetry of posterior tibial slope and small lateral tibial plateau articular surface depth are morphological factors of lateral meniscus posterior root tears in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 2023; 31:3594-3603. [PMID: 36656347 DOI: 10.1007/s00167-023-07317-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE To investigate whether knee morphological features, patient characteristics, and intraoperative findings are associated with a lateral meniscus (LM) posterior root tear (LMPRT) in anterior cruciate ligament (ACL) injuries with the integrated data from two academic centres. METHODS This retrospective study used registry data acquired prospectively at two academic centres. Patients with ACL reconstruction (ACLR) with LMPRT and no other LM injury were selected (LMPRT group) from each database. The control group included patients who underwent ACLR without LM tears. Patients were matched to the LMPRT group according to age and gender (1:1). Morphological factors evaluated on preoperative magnetic resonance image scans included lateral femoral condyle (LFC) anterior-posterior diameter, height, and depth; lateral tibial plateau (LTP) articular surface (AS) depth and sagittal plane depth; and lateral and medial posterior tibial slopes (PTSs). LFC height and depth ratios, LTP AS depth and sagittal plane depth ratios, and lateral-to-medial slope asymmetry were computed from previous measurements. Patient characteristics and intraoperative findings were extracted and compared between both groups. RESULTS The study included 252 patients (126 in each group). The lateral-medial asymmetry of PTS was greater in the LMPRT group (1.2° vs 0.3°, p < 0.05), and the LTP AS depth was smaller in the LMPRT group (31.4 mm vs 33.2 mm, p < 0.01). There were no differences in LFC morphology between the control and LMPRT groups. Pivot shift grade (p < 0.05), percentage of complete ACL tears (p < 0.05), and medial meniscus ramp lesions (p < 0.05) were significantly higher in the LMPRT group. CONCLUSION LMPRT was associated with significantly increased lateral-medial asymmetry of PTS and significantly smaller LTP AS depth. LMPRT was also associated with an increase in the preoperative pivot shift grade and the presence of a medial meniscus ramp lesion. These morphological characteristics are rather simple to measure and would serve as helpful indicators to preoperatively detect LMPRT, which is frequently challenging to diagnose preoperatively. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Aritoshi Yoshihara
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Renaud Siboni
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Department of Orthopedics Surgery, Reims Teaching Hospital, Reims, France
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Caroline Mouton
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg
| | - Christophe Jacquet
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Department of Orthopaedic Surgery and Traumatology, Institute for Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg
- Orthopaedics, Sports Medicine and Digital Methods, Human Motion, Luxembourg, Luxembourg
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
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Sundararajan SR, Ramakanth R, D’Souza T, Rajasekaran S. Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique). JBJS Essent Surg Tech 2023; 13:e22.00008. [PMID: 38282727 PMCID: PMC10810590 DOI: 10.2106/jbjs.st.22.00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Background Meniscal extrusion is a phenomenon in which a degenerative posterior horn tear, radial tear, or root tear results in displacement of the body of the meniscus medial to the tibial rim. The paramount function of the meniscus is to provide load distribution across the knee joint. Meniscal extrusion will prevent the meniscus from properly fulfilling this function and eventually leads to progression of osteoarthritis1. Thus, root repair accompanied by arthroscopic meniscal extrusion repair (by a centralization technique) has been suggested for restoration of meniscal function2-5. There are various techniques to correct meniscal extrusion, including a dual-tunnel suture pull-out technique2 (to address extrusion and root tear2), a knotless suture anchor4,6 technique, and an all-inside suture anchor repair7. The indications for extrusion repair are not consistently reported in the literature, and the procedure is not always easy to perform. Currently, there is no consensus regarding the ideal technique. In the present article, we describe the steps for successful combined medial meniscal root repair with extrusion repair and centralization. Description Place the patient in the supine position with the knee supported in 90° of flexion and the feet at the edge of the operating table with foot-positioner support. First, meniscal root repair is performed with use of the suture pull-out technique, utilizing a cinch suture configuration to hold the root in place, and the suture tapes are fixed over the anterior cortex of the tibia with a suture button. Next, the meniscal body is arthroscopically assessed for residual extrusion from the medial tibial rim. Extrusion repair is indicated in cases with >3 mm of extrusion7-9, as measured on magnetic resonance imaging. In our technique, any extrusion beyond the medial tibial rim is reduced and secured with use of a double-loaded 2.3-mm all-suture type of anchor. Alternatives Alternatives include surgical procedures in which the root repair is performed with use of suture-anchor fixation10,11 and the extrusion repair is performed with use of the transtibial suture pull-out method. Rationale Root repair performed with the most common fixation techniques does not always reduce meniscal extrusion or restore meniscal function12,13. Consequently, several augmentation techniques have been reported to address meniscal extrusion3,14, including those that use arthroscopy to centralize the midbody of the meniscus over the rim of the tibial plateau. The rationale for this combined procedure is to restore the hoop-stress distribution and maintain meniscal function by repairing the extrusion of the meniscus. Addressing all intra-articular pathologies in a single stage is a challenging situation, and the sequence of the repair is important to achieve optimal postoperative results. Expected Outcomes Several surgical techniques have been described for the operative treatment of extrusion repair with use of centralization sutures2,3,5,6, and each has its own distinctive pearls and pitfalls for each. To combine root repair and extrusion repair presents a challenge for surgeons. From our clinical experience, a methodical approach to understanding the pathoanatomy and sequential execution of repair techniques would yield desired results. Extrusion correction through the use of a peripheral suture anchor over the medial rim of the tibia and knot tying are relatively easier to perform than some other published extrusion-repair techniques. Although no consensus has been achieved yet regarding the best technique, recent literature has suggested that the use of centralization sutures is effective to restore the native biomechanical properties of the medial meniscus5.Mochizuki et al. assessed the clinical and radiological outcomes of combined medial meniscal root repair and centralization in 26 patients with a minimum follow-up of 2 years. Both Lysholm scores and Knee injury and Osteoarthritis Outcome Scores improved significantly after surgery, with a significant reduction in extrusion distance from preoperatively to 2 years postoperatively20. Koga et al21 assessed the 2-year outcomes of lateral arthroscopic meniscal centralization, finding significantly reduced meniscal extrusion at both 3 months and 1 year postoperatively. Biomechanical studies have demonstrated that centralization can improve meniscal mechanics and potentially reduce the risk of osteoarthritis. The centralization suture technique for extrusion repair has the theoretical advantage of restoring meniscal function following meniscal root repair; however, there are also concerns regarding over-constraint of the meniscus. We believe that the medial meniscus, being less mobile than the lateral meniscus, can withstand the constraint created by the use of centralization. Meniscal centralization is a technically demanding surgical procedure, but with a systematic approach and meticulous technique, we have observed good short-term outcome in our patients. Important Tips A tight medial compartment is one of the most common problems encountered during a medial meniscal root repair. "Pie-crusting" of the superficial medial collateral ligament at the tibial insertion aids in improving the space, thereby reducing chondral damage during the root repair.It is challenging to achieve the correct inclination of insertion when inserting the suture anchor through a mid-medial portal. This limitation can be mitigated by utilizing a 16G or 18G needle before making the portal, as the needle direction, trajectory, and extent of accessibility within the joint will aid in proper portal placement and anchor insertion.Suture management is another technical challenge. Suture tape is first cinched to the root of the meniscus and then shuttled into the transtibial tunnel in order to discern the reducibility of the meniscus and the extent of possible extrusion correction. Then, extrusion repair is performed. This sequence allows the surgeon to avoid mixing of root-repair sutures and extrusion-repair sutures. Following insertion of the all-suture anchor, each suture limb is brought out through the anteromedial portal, passed through the nitinol loop from the lasso, and shuttled back through the mid-medial portal. Knot tying is performed through the mid-medial portal. Acronyms and Abbreviations ACL = anterior cruciate ligamentPCL = posterior cruciate ligamentICRS grading = International Cartilage Research Society system for classification of cartilage lesionsKL grade = Kellgren-Lawrence system for classification of osteoarthritisMRI = magnetic resonance imagingMC = medial femoral condyleMPTA = medial proximal tibial angleLC = lateral femoral condyleHTO = high tibial osteotomyMCL = medial collateral ligamentAM = anteromedialKOOS = Knee injury and Osteoarthritis Outcome ScoreMME = medial meniscus extrusion.
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Affiliation(s)
| | | | - Terence D’Souza
- Ganga Medical Centre & Hospitals, Coimbatore, Tamil Nadu, India
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Ueki H, Kanto R, DiNenna M, Linde MA, Fu FH, Smolinski P. Arthroscopic centralization reduces extrusion of the medial meniscus with posterior root defect in the ACL reconstructed knee. Knee Surg Sports Traumatol Arthrosc 2023; 31:543-550. [PMID: 36114341 DOI: 10.1007/s00167-022-07160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/06/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the effects of arthroscopic meniscal centralization reinforcement for a medial meniscus (MM) posterior root defect on knee kinematics and meniscal extrusion in the anterior cruciate ligament reconstructed (ACLR) knee. The hypothesis was that the medial meniscus centralization would reduce extrusion and anterior laxity in ACLR knee with a medical meniscal defect. METHODS Fourteen fresh-frozen human cadaveric knees were tested using a six-degrees-of-freedom robotic system under the following loading conditions: (a) an 89.0 N anterior tibial load, (b) 5.0 Nm internal and external rotational torques, (c) a 10.0 Nm valgus and varus loadings, and (d) a combined 7.0 Nm valgus moment and then a 5.0 Nm internal rotation torque as a static simulated pivot shift. The tested knee states included: (1) anatomic single-bundle cruciate ligament reconstruction with intact medial meniscus (MM Intact), (2) anatomic single-bundle cruciate ligament reconstruction with medial meniscus posterior root defect (MM Defect), (3) Anatomic single-bundle cruciate ligament reconstruction with medial meniscus arthroscopic centralization (MM Centralization). Medial meniscus arthroscopic centralization was performed using 1.4 mm anchors with #2 suture. The MM extrusion (MME) was measured using ultrasound under unloaded and varus loading conditions at 0° and 30° of flexion. RESULTS Anterior tibial translation (ATT) increased significantly with MM posterior root defect compared to MM intact at all flexion angles. With MM centralization, ATT was not significantly different from the intact meniscus at 15° and 30° of flexion. Meniscus extrusion increased significantly with the root defect compared to intact meniscus and decreased significantly with meniscal centralization compared to the root defect at both flexion angles. CONCLUSIONS In ACL reconstruction, cases involving irreparable medial meniscal posterior root tears, applying arthroscopic centralization for avoiding the meniscal extrusion should be considered. Clinically, in ACL reconstruction cases with irreparable medial meniscal posterior root tears, applying arthroscopic meniscal centralization for avoiding the meniscal extrusion should be considered. Meniscal centralization decreases the extrusion of the MM and offers improvements in knee laxity.
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Affiliation(s)
- Hiroko Ueki
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryo Kanto
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael DiNenna
- Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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12
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Association Between Knee Extension Strength at 3 and 6 Months After Anterior Cruciate Ligament Reconstruction. J Sport Rehabil 2023; 32:76-84. [PMID: 35926847 DOI: 10.1123/jsr.2021-0336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 01/03/2023]
Abstract
CONTEXT Deficits in knee extension strength after anterior cruciate ligament reconstruction have been a major problem. The inadequate recovery of the knee extension strength of surgical limb reportedly delays return to sports and increases reinjury risk. Accordingly, the early detection of knee extension strength deficits after reconstruction may help plan early interventions to manage impairment. This study aimed to clarify the association between knee extension strength at 3 and 6 months after anterior cruciate ligament reconstruction. DESIGN Retrospective study. METHODS Fifty patients who underwent primary anterior cruciate ligament reconstruction using hamstring grafts were included. At 3 months postoperatively, the limb symmetry index (LSI) of isokinetic knee extension strength (IKE) at 60°/s, degree of swelling, passive range of motion of knee flexion and extension, and anterior leg reach distance were measured. At 6 months postoperatively, the LSI of IKE was measured at 60°/s, which was used as the main outcome. A correlation analysis was performed with the LSI of IKE at 6 months postoperatively as the dependent variable and the LSI of IKE at 3 months postoperatively as the independent variable. Subsequently, a multiple regression analysis was performed, with LSI of IKE at 6 months postoperatively as the dependent variable; LSI of IKE at 3 months postoperatively as the independent variable; and other variables, demographic information, and surgical data as covariates. RESULTS The correlation analysis revealed that the LSIs of IKE at 3 and 6 months postoperatively were correlated (r = .535, P < .001). In the multiple regression analysis, the LSI of IKE at 3 months postoperatively was significantly associated with that at 6 months postoperatively, even when other variables were included as covariates (R2 = .349, P = .004). CONCLUSION Asymmetry of knee extension strength at 3 months postoperatively could be more useful than other variables related to knee strength in predicting the asymmetry of knee extension strength at 6 months postoperatively.
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13
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Aizawa J, Hirohata K, Ohji S, Ohmi T, Mitomo S, Koga H, Yagishita K. Cross-sectional study on relationships between physical function and psychological readiness to return to sport after anterior cruciate ligament reconstruction. BMC Sports Sci Med Rehabil 2022; 14:97. [PMID: 35650622 PMCID: PMC9161472 DOI: 10.1186/s13102-022-00491-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/23/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Information about specific factors of physical function that contribute to psychological readiness is needed to plan rehabilitation for a return to sports. The purpose of this study was to identify specific physical functions related to the psychological readiness of patients aiming to return to sports 6 months after reconstruction. We hypothesized that the knee strength is a factor related to the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) cutoff score for a return to sports. METHODS This was a cross-sectional study. Fifty-four patients who had undergone primary reconstruction using hamstring tendon participated in this study. Psychological readiness was measured using the ACL-RSI in patients at 6 months after reconstruction. To identify specific physical functions related to the ACL-RSI score, participants were divided into groups with ACL-RSI scores of ≥ 60 or < 60. Non-paired t-tests or the Mann-Whitney test were performed to analyze group differences in objective variables in physical function: (1) knee strength in both legs; (2) leg anterior reach distance on both sides; and (3) single-leg hop (SLH) distances in three directions for both legs. RESULTS Significant differences between groups were identified in knee flexion strength (60°/s) for the uninvolved limb, hamstring-to-quadriceps ratio (60°/s) for the uninvolved limb, knee flexion strength (180°/s) for the involved limb, limb symmetry index (LSI) of leg anterior reach distance, the ratio of the distance to the height of the patient and LSI of SLH distances in lateral and medial directions. CONCLUSION This study revealed that at 6 months after reconstruction, increased knee flexion strength (ratio of peak torque measured to body mass of the patient), hamstring-to-quadriceps ratio, leg anterior reach distance LSI, and lateral and medial SLH appear important to exceed the ACL-RSI cutoff for a return to sports. The present results may be useful for planning post-operative rehabilitation for long-term return to sports after reconstruction.
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Affiliation(s)
- Junya Aizawa
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, 3-2-12 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Rehabilitation Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kenji Hirohata
- Clinical Center for Sports Medicine and Sports Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shunsuke Ohji
- Clinical Center for Sports Medicine and Sports Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takehiro Ohmi
- Clinical Center for Sports Medicine and Sports Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sho Mitomo
- Clinical Center for Sports Medicine and Sports Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuyoshi Yagishita
- Clinical Center for Sports Medicine and Sports Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
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Hirose T, Mae T, Ogasawara I, Yamakawa S, Nakata K, Ohori T, Tsujii A, Okada S. Meniscal Displacement and Loss of Load-Transmission Function After Radial Tear of the Lateral Meniscus in a Porcine Model: New Insights Into the Functional Dynamics of the Injured Meniscus. Am J Sports Med 2022; 50:1850-1857. [PMID: 35416074 DOI: 10.1177/03635465221090543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal extrusion/translation has been used as an index for meniscal treatment. However, the relationship between meniscal displacement and the degree of meniscal tear or load-transmission function of the lateral meniscus (LM) remains unclear. PURPOSE To clarify the relationship between the width of the radial tear of the LM and (1) meniscal displacement or (2) resultant force through the meniscus under axial compressive load in the porcine model. STUDY DESIGN Controlled laboratory study. METHODS Eight intact porcine knees with or without a partial radial tear at the midbody of the LM (involving 30%, 60%, or 90% of its width) were investigated. Reflective markers were attached to the outer wall of the anterior, anteromiddle, posteromiddle, and posterior segments of the LM. A 300-N axial load was applied at 2 flexion angles (30° and 60°), and the 3-dimensional forces and trajectories of the knees were recorded. Marker movements were simultaneously tracked using a motion capture camera system. After total meniscectomy of the LM, the recorded knee trajectories were reproduced, and the resultant force through the LM was calculated (a force carried only by the meniscus in response to a load applied to the whole knee joint). RESULTS At both flexion angles, the change in distance (mean ± SD) between the anterior and posterior markers under load increased significantly more in the anteroposterior direction in LMs with a 90% tear than in intact LMs (30°, 0.4 ± 0.3 vs 1.4 ± 0.8 mm, P = .004; 60°, 0.1 ± 0.7 vs 1.4 ± 1.0 mm, P < .001 [intact vs 90% tear]). The change in distance between the anteromiddle and posteromiddle markers at 30° also significantly increased in LMs with a 90% tear (0.2 ± 0.2 vs 1.3 ± 1.2 mm, P = .02 [intact vs 90% tear]). The resultant force was significantly lower in LMs with a 90% tear than in intact LMs (30°, 125 ± 47 vs 48 ± 20 N, P < .001; 60°, 93 ± 46 vs 43 ± 11 N, P = .002 [intact vs 90% tear]). We found no significant differences in either meniscal displacements or resultant forces between intact LMs and those with 30% or 60% tears. CONCLUSION LMs with a 90%-width midbody radial tear lost load-transmission function with their displacement relative to the tibia primarily in the anteroposterior direction in the porcine model. CLINICAL RELEVANCE Even 1 mm of displacement after meniscal injury is evidence that the load-transmission function of the meniscus is greatly impaired. When a displaced torn LM is diagnosed in preoperative imaging, meniscal repair surgery should be considered.
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Affiliation(s)
- Takehito Hirose
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Issei Ogasawara
- Department of Health and Sports Sciences, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Satoshi Yamakawa
- Department of Sports Medical Biomechanics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Ken Nakata
- Department of Health and Sports Sciences, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tomoki Ohori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Akira Tsujii
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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Kohno Y, Koga H, Ozeki N, Matsuda J, Mizuno M, Katano H, Sekiya I. Biomechanical analysis of a centralization procedure for extruded lateral meniscus after meniscectomy in porcine knee joints. J Orthop Res 2022; 40:1097-1103. [PMID: 34314533 PMCID: PMC9292650 DOI: 10.1002/jor.25146] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 06/02/2021] [Accepted: 07/13/2021] [Indexed: 02/04/2023]
Abstract
The recently developed arthroscopic centralization for lateral meniscal extrusion has obtained satisfactory short-term clinical and radiological results and improves the meniscus biomechanical properties. However, the effectiveness of treatment for meniscus extrusion after partial meniscectomy still requires elucidation. This study investigated the effect of centralization with modifications from a mechanical viewpoint. Porcine knee joints (N = 6) were set in a universal tester under the following conditions: (1) Intact; (2) Meniscectomy: Inner half of the posterior half meniscus was removed; (3) Extrusion: Posterior meniscus was dislocated laterally by transecting the posterior root and the meniscotibial ligament; (4) Centralization-1: Centralization procedure using one anchor; (5) Centralization-2: Centralization procedure using two anchors; and (6) Centralization-ad: Centralization with capsular advancement using two anchors. Load distributions and contact pressure in the meniscus and tibial cartilage were evaluated with an axial compressive force of 200 N. After meniscectomy, the tibial cartilage load increased and that of the medial margin of the posterior part of the meniscus decreased. When the meniscus was extruded, the load was concentrated only on the tibial cartilage. Centralization-1 increased the load on the meniscus, while Centralization-2 further increased the meniscus load but decreased the tibial cartilage load. Centralization-ad further decreased the load on the tibial plateau. The average contact pressure of the tibial cartilage was significantly higher in the Extrusion group than in the Intact group or the Centralization-ad group. From a biomechanical viewpoint, centralization with capsular advancement was the most effective of the tested procedures for treatment for an extruded meniscus after partial meniscectomy.
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Affiliation(s)
- Yuji Kohno
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Nobutake Ozeki
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Junpei Matsuda
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Mitsuru Mizuno
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Hisako Katano
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Ichiro Sekiya
- Center for Stem Cells and Regenerative MedicineTokyo Medical and Dental UniversityTokyoJapan
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Ozeki N, Koga H, Sekiya I. Degenerative Meniscus in Knee Osteoarthritis: From Pathology to Treatment. Life (Basel) 2022; 12:603. [PMID: 35455094 PMCID: PMC9032096 DOI: 10.3390/life12040603] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/31/2022] [Accepted: 04/14/2022] [Indexed: 12/16/2022] Open
Abstract
Knee osteoarthritis is a common degenerative joint disease characterized by chronic knee pain and disability in daily living. The lesion can involve the cartilage as well as the synovium, bone, ligaments, and meniscus, indicating a complicated pathology for knee osteoarthritis. The association with the meniscus has recently attracted much attention. Meniscal tears can initiate and progress knee osteoarthritis, with deleterious effects on the important roles of the meniscus in load distribution, shock absorption, and stability of the knee joint. Degenerative meniscus lesions are commonly observed in elderly people, but they have less impact on the prognosis of osteoarthritis. However, they are often accompanied by meniscal extrusion, which substantially decreases the hoop function of the meniscus and increases the risk of knee osteoarthritis. When surgical treatment is necessary, meniscal tears should be repaired to the greatest extent possible to preserve meniscus function. Long-term studies show better clinical outcomes and less degenerative osteoarthritis changes following meniscal repair than following partial meniscectomy. For meniscal extrusion repair, centralization techniques have been proposed that involve suturing the meniscus-capsule complex to the edge of the tibial plateau. Advancements in orthobiologics, such as platelet-rich plasma or stem cell therapy, have the potential to prevent the initiation or progression of osteoarthritis.
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Affiliation(s)
- Nobutake Ozeki
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan;
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan;
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan;
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Nakagawa Y, Ozeki N, Koga H. A narrative review of lateral meniscus root tears and extrusion: techniques and outcomes. ANNALS OF JOINT 2022; 7:15. [PMID: 38529138 PMCID: PMC10929309 DOI: 10.21037/aoj-20-112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 04/23/2021] [Indexed: 03/27/2024]
Abstract
Objective In this review, we performed a literature search and described the surgical procedure for a lateral meniscus posterior root tears (LMPRT) repair using a pull-out technique and an arthroscopic centralization for lateral meniscus (LM) extrusion. Background The menisci play a pivotal role in the shock-absorbing and load-dispersing functions of the knee joint. They also contribute to its stability. Meniscal root tears substantially affect meniscal hoop function and accelerate cartilage degeneration. Additionally, LMPRT have been shown to affect anterolateral knee laxity and tibiofemoral contact pressure in knees with anterior cruciate ligament (ACL) injury. Therefore, appropriate management of LMPRT is essential for restoring knee function. Meniscus extrusion has attracted attention due to its association with early osteoarthritis (OA). Recently, an arthroscopic centralization technique has been proposed to reduce meniscal extrusion. During this procedure the capsule attached to the meniscus is sutured to the edge of the tibial plateau using suture anchors. Methods A narrative review of LMPRT repair and arthroscopic centralization of lateral meniscal extrusion was performed through a PubMed search. Conclusions Specific magnetic resonance imaging (MRI) signs were useful for the diagnosis of LMPRT. Pull-out techniques can restore knee stability and load distribution function and result in favorable clinical outcomes. Arthroscopic centralization of the extruded LM caused by meniscectomy and lateral discoid meniscus achieved satisfactory clinical outcomes at the 2-year follow-up. Biomechanical studies demonstrated that this procedure reduced meniscus extrusion and had beneficial effects on load distribution and joint stability. In summary, to restore knee function, LMPRT should be repaired as much as possible. The centralization technique is a promising surgical treatment for extruded lateral menisci due to meniscectomy and discoid meniscus. However, due to the lack of high-level evidence studies such as randomized control trials (RCTs) in this field, it remains necessary to accumulate evidence to confirm the efficacy of LMPRT repair and the centralization technique.
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Affiliation(s)
- Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Nobutake Ozeki
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
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Di Paolo S, Grassi A, Lucidi GA, Macchiarola L, Dal Fabbro G, Zaffagnini S. Biomechanics of the lateral meniscus: evidences from narrative review. ANNALS OF JOINT 2022; 7:19. [PMID: 38529143 PMCID: PMC10929336 DOI: 10.21037/aoj-20-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/18/2021] [Indexed: 03/27/2024]
Abstract
Lateral meniscus plays a crucial role in the knee stability and function. Although complex settings are required for lateral meniscus biomechanical assessment, such characteristics have been investigated over time to optimize the daily clinical practice surgical procedure. The aim of the present study was to provide an overview of literature knowledge regarding the biomechanics of lateral meniscus and give further insights about novel experimental analyses. Studies regarding lateral meniscus mobility, effect on knee laxity, and contact mechanics were included in the review. The effect of meniscal lesion, meniscal repair, partial meniscectomy, and meniscus allograft transplantation were retrieved for either in vivo, cadaveric, or in-silico computational settings. Knee laxity was evaluated both in presence of isolated meniscal tears and in anterior cruciate ligament (ACL) deficient knees. Surgical navigation systems and robots were mainly used for the investigations in vivo and in cadaveric studies, while accelerometers emerged as an alternative for ambulatory assessments. Contact mechanics was only assessed in cadaveric and computational studies. Great effort has been put into exploring lateral meniscus biomechanics from multiple perspectives. Strong evidence emerged regarding the importance of lateral meniscus repair: increased knee stability at high degrees of knee flexion and reduction of peak contact pressures on tibial cartilage were the most reported benefits. The meniscus allograft transplantation also emerged as a concrete solution for irreparable tears and further studies are needed to investigate its long-term influence on knee stability.
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Affiliation(s)
- Stefano Di Paolo
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Alberto Grassi
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gian Andrea Lucidi
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Macchiarola
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giacomo Dal Fabbro
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Park DY, Yin XY, Chung JY, Jin YJ, Kwon HJ, Lee GB, Park JH, Min BH. Circumferential Rim Augmentation Suture Around the Perimeniscal Capsule Decreases Meniscal Extrusion and Progression of Osteoarthritis in Rabbit Meniscus Root Tear Model. Am J Sports Med 2022; 50:689-698. [PMID: 35289232 DOI: 10.1177/03635465211064297] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We recently analyzed the joint capsule adjacent to the medial meniscus and found that the perimeniscal joint capsule has collagen fiber orientation similar to that of circumferential meniscal fibers, potentially playing a role in preventing extrusion. PURPOSE To analyze the meniscal extrusion prevention potential of the circumferential rim augmentation suture around the perimeniscal capsule in a rabbit root tear model and analyze the biomechanical function in a porcine cadaveric knee. STUDY DESIGN Controlled laboratory study. METHODS Rabbit medial meniscus root tear models were divided into 3 experimental groups: root tear, root tear and suture repair, and root tear and circumferential rim augmentation suture. As for the circumferential rim augmentation suture procedure, a suture was placed to circumscribe the outer rim of the medial meniscus and passed through bone tunnels located at the tibial insertion of each root. After 4 and 8 weeks, meniscal extrusion was analyzed by micro-computed tomography, gross morphology, and histologic analysis of the medial femoral cartilage. For biomechanical analysis, porcine knees were divided into groups similar to rabbit experiments. Tibiofemoral contact parameters were assessed using a pressure mapping sensor system after applying a load of 200 N on the knee joint. RESULTS The root tear and circumferential rim augmentation suture group showed less meniscal extrusion, less gap within the tear site, and less cartilage degeneration compared with other groups after 4 and 8 weeks of surgery in the rabbit root tear model. Biomechanical analysis showed the root tear and circumferential rim augmentation suture group had larger contact area and lower peak contact pressure compared with root tear and root tear and suture repair groups. CONCLUSION The circumferential rim augmentation suture reduced the degree of meniscal extrusion while restoring meniscal function, potentially preventing progression of arthritis in a rabbit root tear model and porcine knee biomechanical analysis. CLINICAL RELEVANCE The circumferential rim augmentation suture may be a novel augmentation option during root tear treatment.
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Affiliation(s)
- Do Young Park
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea.,Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea
| | - Xiang Yun Yin
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea.,Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea
| | - Jun Young Chung
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Yong Jun Jin
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea.,Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea
| | - Hyeon Jae Kwon
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
| | - Ga Bin Lee
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
| | - Jin Ho Park
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
| | - Byoung-Hyun Min
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea.,Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
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Correlations between isokinetic knee torques and single-leg hop distances in three directions in patients after ACL reconstruction. BMC Sports Sci Med Rehabil 2021; 13:38. [PMID: 33836820 PMCID: PMC8033656 DOI: 10.1186/s13102-021-00265-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/16/2021] [Indexed: 11/25/2022]
Abstract
Background When planning rehabilitation and conditioning for performance enhancement and a return to sports after anterior cruciate ligament reconstruction, identifying the elements of physical function associated with single-leg hop is important. The purpose of this study was to clarify the relationship between single-leg hop distances in three directions and knee extensor and flexor strengths at 6 months after reconstruction. Methods Participants were 47 patients taking part in training sessions for sports involving cutting, pivoting, and jump-landing 6 months after reconstruction using a hamstring tendon. Single-leg hop distances in 3 directions (anterior, lateral, and medial) and isokinetic concentric strengths of knee extension and flexion were assessed at an angular velocity of 60°/s and 180°/s. Simple regression analyses using Spearman’s rank correlation coefficient were performed to assess relationships between single-leg hop distances and knee strengths. Results In the involved limb, correlations between single-leg hop distances in 3 directions and knee strengths were significant (P < 0.01) and correlation coefficients ranged from 0.48 to 0.65. Correlation coefficients between all single-leg hop parameters and knee extension/flexion strengths at an angular velocity of 180°/s were greater than those of 60°/s. Conclusions In this cross-sectional study of patients who participated in sports training sessions that required jump-landings and cutting approximately 6 months after reconstruction using hamstring grafts, isokinetic knee flexor, and extensor torques were moderately to strongly associated with single-leg hop distances in lateral, medial, and anterior directions. Given these relationships, assessments and exercises for knee strength and single-leg hop distances should be planned.
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Arthroscopic Centralization Using Knotless Anchors for Extruded Medial Meniscus. Arthrosc Tech 2021; 10:e639-e645. [PMID: 33738196 PMCID: PMC7953036 DOI: 10.1016/j.eats.2020.10.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/22/2020] [Indexed: 02/03/2023] Open
Abstract
The load-distributing function is most critical in meniscal function, and meniscal extrusion suggests failure of this function, leading to the progression of osteoarthritis. The arthroscopic centralization technique has been developed to reduce meniscal extrusion; however, existing arthroscopic techniques sometimes fail to reduce the most extruded region, especially in cases with a medial meniscus (MM) posterior root tear, in which the most extruded region is on the posterior border of the medial collateral ligament, which is very difficult to approach. This Technical Note describes an arthroscopic technique for extrusion of the MM in which a centralization technique using knotless anchors efficiently reduces the MM extrusion at the posteromedial part and consequently restores the MM function. This technique efficiently reduces MM extrusion and restores its function, thus preventing the progression of osteoarthritis.
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