Surgical Epicondylar Axis of the Knee and Its Relationship to the Axial Tibia Alignment in Knee Osteoarthritis: The Concept of Proximal Twist Tibia

The proximal tibia and distal femur are intimately linked with the biomechanics of the knee and they are to be considered in total knee arthroplasty (TKA). The aim of the present study was to evaluate the proximal tibial torsion (PTT) in relation to surgical epicondylar axis (SEA) in a healthy cohort and a pathological cohort affected by knee osteoarthritis (OA). We retrospectively analyzed computed tomography of OA knee of 59 patients before they underwent TKA and nonarthritic knee of 39 patients as control. Posterior condylar angle (PCAn), femoral tibial torsion (SEA-proximal tibial condyle [PTC] and SEA-PTT), PTT (PTC-PTT and posterior condylar axes [PCAx]-PTC), and distance between tibial tuberosity and the trochlear groove (TT-TG) were measured. No differences were found for gender, age, TT-TG, and PCAn angles. Statistically significant differences were found for all the other angles considered. Significant correlation was found between tibial torsion and SEA-PTT angles, between PCAx-PTC and SEA-PTC, between SEA-PTT and SEA-PTC, and between PCAx-PTC and SEA-PTT. All measures, except TT-TG and PCAn angles, showed high validity (area under the curve [AUC] > 75%) in associating with OA, with SEA-PTT displaying the highest validity with an AUC of 94.38%. This is the first study to find significant differences in terms of proximal tibia geometry and anatomy between nonarthritic and OA knees. From our results, we reported that OA group was characterized by a greater internal rotation of tibia with respect to SEAs compared with control group. Since the design of the study cannot evaluate a cause–effect relationship, further studies need to be performed to assess the potential implications of these anatomic differences for knee OA and arthroplasty surgeries.

Tibial Condyle Valgus Osteotomy for Ipsilateral Knee Osteoarthritis after Hip Arthrodesis

We report a case of tibial condylar valgus osteotomy (TCVO) for ipsilateral knee osteoarthritis (OA) after hip arthrodesis. A 58-year-old woman developed right purulent hip arthritis at one month of age and underwent right hip fusion at 16 years old. She visited our department at the age of 57 because her right knee joint pain worsened. The range of motion for her right knee was 80° and -5° of flexion and extension, respectively, and she experienced medial weight-bearing pain. A plain X-ray image showed that the right knee joint had end-stage knee OA with a bone defect inside the tibia, and the tibial plateau shape was the pagoda type. There was a marked instability in her right knee with a valgus of 9° and varus of 7° on stress photography. She underwent TCVO on her right knee and was allowed full load four weeks after surgery. Computed tomography imaging showed bone union nine months after surgery. Two years after the operation, there was no correction loss, and she could walk independently without pain. In general, total knee arthroplasty (TKA) is indicated for end-stage knee OA; however, there are problems, such as early loosening due to the increased mechanical load on the knee after hip OA. In this case, since a good course was obtained, TCVO is considered a treatment option for terminal knee OA after hip arthrodesis.

REHABILITATION OF A 60-YEAR-OLD WOMAN’S TIBIAL PLATEAU FRACTURE

Tibial plateau fracture is one of the commonest fractures which leads to the break in the continuity of the upper part of the tibia (shinbone) that involves the knee joint. It involves either lateral tibial condyle or medial tibial condyle or both. This fracture interferes with the normal functioning of the body in day-to-day life. Therefore, physiotherapy rehabilitation after surgery is essential to get back to normal functioning. A 60-year-old female who slipped from a two-wheeler started experiencing severe pain & swelling around the knee joint. Her relatives brought her to Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi, Wardha, Maharashtra. X-ray was done and she was diagnosed with lateral tibial condyle fracture (tibial plateau fracture) and then underwent open reduction internal fixation with plate osteosynthesis. Later, she was referred for physiotherapy rehabilitation, which aimed to restore mobility, regain full range of motion, develop muscle strength and build up to weight-bearing. The tibial plateau fracture is a form of fracture with a low occurrence and is a complicated fracture to treat.The above case study concludes that a traditional surgical procedure combined with timely planned physiotherapy rehabilitation contributed to progressive improvement in functional goals, which is an important factor in achieving a good recovery in such post-operative cases.

First Experimental Study of the Influence of Extracellular Vesicles Derived from Multipotent Stromal Cells on Osseointegration of Dental Implants

Herein, the aim was to study the state of the bone tissue adjacent to dental implants after the use of extracellular vesicles derived from multipotent stromal cells (MSC EVs) of bone marrow origin in the experiment. In compliance with the rules of asepsis and antiseptics under general intravenous anesthesia with propofol, the screw dental implants were installed in the proximal condyles of the tibia of outbred rabbits without and with preliminary introduction of 19.2 μg MSC EVs into each bone tissue defect. In 3, 7, and 10 days after the operation, the density of bone tissue adjacent to different parts of the implant using an X-ray unit with densitometer was measured. In addition, the histological examinations of the bone site with the hole from the removed device and the soft tissues from the surface of the proximal tibial condyle in the area of intra-bone implants were made. It was found out that 3 days after implantation with the use of MSC EVs, the bone density was statistically significantly higher by 47.2% than after the same implantation, but without the injection of MSC EVs. It is possible that as a result of the immunomodulatory action of MSC EVs, the activity of inflammation decreases, and, respectively, the degree of vasodilation in bones and leukocyte infiltration of the soft tissues are lower, in comparison with the surgery performed in the control group. The bone fragments formed during implantation are mainly consolidated with each other and with the regenerating bone. Day 10 demonstrated that all animals with the use of MSC EVs had almost complete fusion of the screw device with the bone tissue, whereas after the operation without the application of MSC EVs, the heterogeneous histologic pattern was observed: From almost complete osseointegration of the implant to the absolute absence of contact between the foreign body and the new formed bone. Therefore, the use of MSC EVs during the introduction of dental implants into the proximal condyle of the tibia of rabbits contributes to an increase of the bone tissue density near the device after 3 days and to the achievement of consistently successful osseointegration of implants 10 days after the surgery.

Association of Jump-Landing Biomechanics With Tibiofemoral Articular Cartilage Composition 12 Months After ACL Reconstruction

Background: Excessively high joint loading during dynamic movements may negatively influence articular cartilage health and contribute to the development of posttraumatic osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Little is known regarding the link between aberrant jump-landing biomechanics and articular cartilage health after ACLR. Purpose/Hypothesis: The purpose of this study was to determine the associations between jump-landing biomechanics and tibiofemoral articular cartilage composition measured using T1ρ magnetic resonance imaging (MRI) relaxation times 12 months postoperatively. We hypothesized that individuals who demonstrate alterations in jump-landing biomechanics, commonly observed after ACLR, would have longer T1ρ MRI relaxation times (longer T1ρ relaxation times associated with less proteoglycan density). Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 27 individuals with unilateral ACLR participated in this cross-sectional study. Jump-landing biomechanics (peak vertical ground-reaction force [vGRF], peak internal knee extension moment [KEM], peak internal knee adduction moment [KAM]) and T1ρ MRI were collected 12 months postoperatively. Mean T1ρ relaxation times for the entire weightbearing medial femoral condyle, lateral femoral condyle (global LFC), medial tibial condyle, and lateral tibial condyle (global LTC) were calculated bilaterally. Global regions of interest were further subsectioned into posterior, central, and anterior regions of interest. All T1ρ relaxation times in the ACLR limb were normalized to the uninjured contralateral limb. Linear regressions were used to determine associations between T1ρ relaxation times and biomechanics after accounting for meniscal/chondral injury. Results: Lower ACLR limb KEM was associated with longer T1ρ relaxation times for the global LTC (Δ R 2 = 0.24; P = .02), posterior LTC (Δ R 2 = 0.21; P = .03), and anterior LTC (Δ R 2 = 0.18; P = .04). Greater ACLR limb peak vGRF was associated with longer T1ρ relaxation times for the global LFC (Δ R 2 = 0.20; P = .02) and central LFC (Δ R 2 = 0.15; P = .05). Peak KAM was not associated with T1ρ outcomes. Conclusion: At 12 months postoperatively, lower peak KEM and greater peak vGRF during jump landing were related to longer T1ρ relaxation times, suggesting worse articular cartilage composition.

Rotationplasty for Severe Congenital Femoral Deficiency

Rotationplasty is a reconstructive option for severe congenital femoral deficiency (CFD). The senior author (D.P.) developed five new rotationplasty techniques for use in CFD based on the Paley classification, including the Paley–Brown (fusion femur to pelvis), Paley (fusion femur to femoral head), Paley–Winkelman (insertion tibial condyle to acetabulum), PaleySUPERhip–Van Nes (hip osteotomy with knee fusion) and PaleySling–Van Nes (hip reconstruction with knee fusion revision) rotationplasty techniques. The purpose of this study is to retrospectively evaluate the complications, radiographic outcomes and need for secondary surgery in 19 rotationplasty cases performed by the senior author (D.P.) for severe CFD from 2009 to 2019. Rotationplasty comprised only 2% of the authors treated CFD cases during this period. Average age at surgery was 8.6 years old. Average follow-up was 3.3 years. Sixteen concomitant procedures were performed including temporary arthrodesis, tibial osteotomy and SUPERhip procedure. The most common complication was wound necrosis/dehiscence, which occurred in 52% of the cases related to the circumferential incision and required a total of 31 additional debridements. Additional complications were successfully treated and included sciatic nerve palsy decompressed by abducting the femur, a tibial delayed union that underwent bone grafting, two distal femur failed epiphysiodesis treated by revision with one osteotomy and a thigh compartment syndrome requiring debridement. Indication specific rotationplasty successfully addresses the severe degree of femoral deficiency, deformity, and discrepancy in patients with CFD, despite high rates of wound complications.

A TRIATHLETE WITH MEDIAL MENISCUS TEAR AND SUBCHONDRAL INSUFFICIENCY FRACTURE

Subchondral insufficiency fracture of the knee (SIFK) is an important differential diagnosis for knee pain. If diagnosed early, SIFK can be treated conservatively with non-weight bearing ambulation. If left untreated, this disease may lead to catastrophic complications such as subchondral fragment detachment and fragmentation or subchondral collapse which will warrant the need for surgical intervention. The author reports a 44-year-old triathlete that presented with complaint of a trivial left anteromedial knee pain for one-year duration. This disease presented at an unusual site of the medial tibial condyle. Moreover, the patient is a healthy triathlete that does not have any predisposing factors for SIFK. Magnetic resonance imaging showed subchondral insufficiency fracture of the medial tibial condyle with a complex multi-directional medial meniscus tear in the same knee. Could the undiagnosed medial meniscus injury be the causation leading to the development of SIFK? Here, the author will summarize the literature on various clinical features, work-up and management of SIFK.

Comparison of Three Imaging Methods for the Evaluation of Osteoarthritis Induced by Cranial Cruciate Ligament Transection in Rabbits

Background:Osteoarthritis is a degenerative joint disease that affects specially cartilage, meniscus, and tendons. Ligaments, muscles, subchondral bone and synovium. This pathology is a common condition limiting the quality of life of patients. Imaging modalities have also been used for evaluation the progression of the osteoarthritis, or degenerative processes induced by acute injury. In order to use more accessible imaging modalities for experimentation, this study aimed to compare radiographic, computed tomography, and ultrasound findings in the evaluation of osteoarthritis induced by the cranial cruciate ligament transection model in rabbits.Materials, Methods & Results:Twenty-four male Norfolk rabbits aged approximately 5 months old were used. All rabbits were submitted to cranial cruciate ligament transection of the left stifle and evaluated 45 days after the surgery. The radiographic findings were subchondral bone sclerosis (33.33%); joint space narrowing (66%); presence of osteophytes at medial femoral condyle (4.16%), lateral femoral condyle (4.16%), medial fabela (20.83%), lateral fabela (8.33%) and sesamoid of the popliteal muscle (4.16%). No osteophytes were seen at medial and lateral tibial condyles. The tomographic computed findings were joint space narrowing (62.5%); presence of osteophytes at medial femoral condyle (75%), lateral femoral condyle (54.16%), medial fabela (66.66%), lateral fabela (37.5%), medial tibial condyle (75%), lateral tibial condyle (20.83%) and sesamoid of the popliteal muscle (37.5%). The ultrasound findings were synovial hypertrophy (95.83%); effusion in the suprapatellar recess (75%), distal tibial recess (16.66%) and cranial joint space (75%); changes (hyperechogenic foci and heterogeneity) of the lateral meniscus (50%) and medial meniscus (25%); increased thickness of the medial condyle (54.16%) and lateral condyle (45.83%); irregularity of the medial condyle (66.66%) and lateral condyle (58.33%); alterations of the patellar tendon (12.5%) and extensor ligament (effusion and increased echogenicity) (20.83%).Discussion: Osteoarthritis is a degenerative joint disease and is common condition which limiting the quality of life of patients. Many studies performed in rabbits have evaluated the development of osteoarthritis through post-mortem macroscopic or microscopic assessments. Imaging modalities have also been used for evaluation the progression of the osteoarthritis, or degenerative processes induced by acute injury. High quality radiographs are accurate in identifying structural changes resulted from osteoarthritis, but computed tomography allows earlier identification in relation to conventional radiography. The three imaging modalities were helpful to identify the osteoarthritis, but the findings were different and compatible with each analysis method. The computed tomographic detected a higher number of osteophytes than plain radiographs. Also, osteophytes did not visualized by radiographic examination, such as medial tibial condyle and lateral tibial condyle, were identified by computed tomography. In turn, the ultrasound examination enabled identification of lesions did not seen on radiographic and computed tomography examinations. Synovial hypertrophy and joint effusion had the highest percentage. In human patients, ultrasound examination has been used to assess hypertrophy and inflammation of the synovium due to osteoarthritis. In conclusion, computerized tomography images provided more information than plain X-ray images and can be complemented by ultrasound examination to identify osteoarthritis induced by cranial cruciate ligament transection in rabbits.Comparison of Three Imaging Methods for the Evaluation of Osteoarthritis Induced by Cranial Cruciate Ligament Transection in Rabbits

Macroscopic and microscopic analysis of the structures inserted in the posterior segment of the medial meniscus. How is the semimembranosus tendon involved in ramp lesions?

Objectives: The anatomical description of the posterior segment of the medial meniscus is debatable. The aim of this study was to describe by macroscopic and microscopic analysis the histological nature of the posterior segment of the medial meniscus and the inserted structures (semimembranosus tendon and menisco-tibial ligament) Methods: Fourteen fresh knees were dissected. For each specimen, a stable anatomical piece was taken en bloc, including the medial femoral condyle, the medial tibial condyle, the entire medial meniscus, the cruciate ligaments and the joint capsule, and the distal insertion of the semimembranosus tendon was preserved in its entirety. At this stage, a macroscopic analysis was performed. The blocks were cut along the sagittal plane in order to isolate the distal insertion of the semimembranosus tendon on the posterior joint capsule and the posterior segment of the medial meniscus in the same section. Histological slides were produced from these samples and were microscopically analyzed. Results: In all patients, the macroscopic analysis showed direct semimembranosus tendon expansion and tendinous capsular expansion ending behind the posterior segment of the medial meniscus. It projected onto the joint capsule, on the meniscotibial ligament at the bottom and the meniscocapsular ligament at the top, but never ended directly in the meniscal tissue. On average, the tendon directly inserted 11 ± 2.8 mm below the articular surface of the tibial plateau. The length of the capsular expansion was 14.3 ± 4.4 mm. The meniscotibial ligament was inserted in the posterior-inferior edge of the posterior segment of the medial meniscus and the meniscocapsular ligament in the posterior-superior edge. There was a particularly vascularized adipocyte space delimited by the posterior segment of the medial meniscus, the meniscotibial ligament, the meniscocapsular ligament and the capsular expansion of the semimembranosus tendon. Conclusion: We repeatedly noted capsular expansion of the semimembranosus tendon that inserted behind the medial meniscus. There is an interposing zone between the tendon insertion and the body of the meniscus which creates a fragile zone. The capsular tendon expansion also inserts in the meniscotibial ligaments at the bottom and meniscocapsular ligaments at the top.