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Purpose This study aimed to compare the difference in posterior tibial slope (PTS) measurements based on the full-length and half-length tibial anatomic axes of the same group of patients. It was hypothesized that the obtained PTS values would be affected by the length of tibia chosen during the measurements. Methods Full-length true lateral tibia radiographs were obtained for each patient who underwent anterior cruciate ligament reconstruction (ACLR) in our department. PTS measurements were obtained by measuring the angle between the full-length or half-length tibial anatomic axis and an average of the lateral and medial tibial plateau. The anatomic axis was defined as the center of the tibial diaphysis. The PTS measurements from the full-length and half-length true lateral tibia radiographs were obtained and compared. Additionally, the absolute difference and the relationship between the two PTS measurements were calculated and analyzed. Results A total of 200 ACL-injured patients were included in this study. The average PTS values using the anatomic axis were 15.9 ± 3.7° and 14.1 ± 3.7° on full-length and half-length true lateral tibial radiographs. There was a significant difference between the measurements with the full-length and half-length tibial radiographs ( P  < 0.01). Additionally, 49.5% ( n  = 99) of patients had ≥ 2.0° differences between the full-length and half-length anatomic axis PTS measurement techniques; meanwhile, a strong and significant linear relationship ( r  = 0.95; P  < 0.001) was identified between the two PTS measurements. Conclusion There were significant differences and linear relationships between PTS measurements that measured the anatomic axis from full-length and half-length true lateral tibia radiographs. Therefore, the obtained PTS values were strongly associated with the length of tibia chosen during the measurements. Surgeons should pay more attention to the measurement techniques and the tibial length when considering the role of PTS in ACL injury and ACLR failure. Knowledge of the association is very important for calculating potential closing wedge proximal tibial osteotomies to correct excessive PTS in the setting of ACLR failures. Level of evidence IV.

Purpose The aim of the present study was to examine changes in radiological variables in a prospective randomized study comparing opening wedge (OW) and closing wedge (CW) techniques of high tibial osteotomy (HTO). Our hypothesis was that there would be no differences in joint line angles or correction accuracy between the two groups, that patellar height would increase after CW HTO and decrease after OW HTO, and that leg length and posterior tibial slope would decrease after CW HTO and increase after OW HTO. Methods Radiological data were collected from 70 patients participating in an ongoing prospective randomized clinical trial comparing OW and CW HTOs. Digital standing hip–knee–ankle (HKA) radiographs as well as lateral radiographs in 30° of flexion were obtained preoperatively and at 6 months for each patient. Joint line angles, HKA angle, leg length, Insall–Salvati index, Miura–Kawamura index and posterior tibial slope were measured using medical planning software. The complete preoperative radiological examinations of the first 50 patients were used in a study of intra- and inter-rater reliability of the measurements. Results The mean posterior slope was reduced by 2.5° in CW HTO, whereas it remained unchanged in OW HTO ( p  < 0.001). Mean leg length decreased 5.7 mm in CW HTO and increased 3.1 mm in OW HTO ( p  < 0.001). Changes in joint line angles, patellar height indexes and the correction accuracy showed no significant differences comparing the two techniques. Frontal plane reliability measurement intra- and inter-rater intraclass correlation coefficient (ICC) varied from 0.81 to 0.99. Sagittal plane intra- and inter-rater ICC varied from 0.60 to 0.87. Posterior tibial slope intra- and inter-rater ICC showed the lowest values (0.70 and 0.60, respectively) corresponding to a smallest real difference of 4.5° and 5.5°, respectively. Conclusions Posterior tibial slope and leg length changes were significantly different in CW compared to OW HTOs. We recommend that possible alterations in tibial slope and leg length are considered when the technique of HTO is to be chosen. Landmark-based medical planning software shows good reliability and can be used in preoperative planning and postoperative evaluations of HTOs. Level of evidence I.

Purpose The purpose of the study was to evaluate the frontal gait patterns in patients with chronic patellofemoral instability compared to healthy controls. The hypothesis was that internal-rotation–adduction moment of the knee as altered dynamic Q-angle is evident in patients and correlates positively with increased femoral torsion. Methods Thirty-five patients with symptomatic recurrent patellofemoral instability requiring surgical treatment were matched for average age, sex, and body mass index with 15 healthy controls (30 knees). Several clinical and radiographic measurements were taken from each participant: internal and external rotation (hipIR, hipER), Q-angle, tubercle sulcus angle (TS-angle), femoral antetorsion (femAT), tibial tubercle–trochlear groove (TT-TG) distance, and frontal leg axis. Additionally, three frontal gait patterns were defined and recorded: (1) internal-rotation–adduction moment of the knee during normal walking, (2) dynamic valgus of the knee, and (3) Trendelenburg’s sign in a single-leg squat. Randomized videography was evaluated by three independent blinded observers. Statistical analysis was performed using regression models and comparisons of gait patterns and clinical and radiological measurements. Furthermore, observer reliability was correlated to gradings of radiological parameters. Results Patients showed altered dynamic Q-angle gait pattern during normal walking ( p  < 0.001) compared to healthy controls (interrater kappa = 0.61), whereas highest observer agreement was reported if femAT was greater than 20° (kappa = 0.85). Logistic regression model revealed higher femAT (18.2° ± 12.5 versus 11.9° ± 7.0 ( p  = 0.004) as a significant variable, as well as lower TT–TG distance (23.6 mm ± 2.8 vs. 16.6 mm ± 4.9, p  = 0.004) on evident dynamic Q-angle gait pattern. Dynamic valgus in a single-leg squat was observed significantly more often in patients ( p  < 0.001) compared to controls (interrater kappa = 0.7). However, besides the static measured Q-angle as the only significant variable on evident dynamic valgus pattern (13.6° ± 4.6 vs. 10.3° ± 5.2, p  = 0.003), no radiological parameter was detected to correlate significantly with dynamic valgus and Trendelenburg's sign (n.s.). Conclusions Clinical detection of pathologic torsion and bony alignment may be difficult in patients with patellofemoral instability. The present study demonstrated that dynamic Q-angle gait pattern is significantly altered in patients with chronic patellofemoral instability compared to healthy controls. Moreover, dynamic Q-angle correlates positively with higher femoral torsion and negatively with higher TT–TG distance. Therefore, clinical and radiological assessment of maltorsion should be added to the standard diagnostic workup in cases of patellofemoral instability. Level of evidence Level II.

Purpose It was our hypothesis that patient-specific instrumentation (PSI) can improve the accuracy of the rotational alignment in TKA based on the concept of the system and on the potential to clearly identify pre-operatively during planning the classical anatomical landmarks that serve as references to set-up the rotation both for the femur and tibia. Materials and methods In this prospective comparative randomized study, 40 patients (20 in each group) operated in our institution between September 2012 and January 2013 by the 2 senior authors were included. Randomization of patients into one of the two groups was done by the Hospital Informatics Department with the use of a systematic sampling method. All patients received the same cemented high-flex mobile bearing TKA. In the PSI group, implant position was compared to the planed position using previously validated dedicated software. The position of the implants (frontal and sagittal) was compared in the 2 groups on standard X-rays, and the rotational position was analysed on post-operative CT-scan. Results 90 % of the patients add <2° or mm of difference between the planned position of the implants and the obtained position, except for the tibial rotation where the variations were much higher. Mean HKA was 179° (171–185) in the PSI group with 4 outliers (2 varus: 171° and 172°:184° and 185°) and 178.3° with 2 outliers (171° and 176°) in the control group. No difference was observed between the two groups concerning the frontal and sagittal position of the implants on the ML and AP X-rays. No significant difference of femoral rotation was observed between the two groups with a mean of 0.4° in the PSI group and 0.2° in the control group ( p : n.s). Mean tibial rotation was 8° of internal rotation in the PSI group and 15° of internal rotation in the standard group ( p : n.s). Conclusion Based on our results, we were unable to confirm our hypothesis as PSI cannot improve rotation in TKA. More work needs to be done to more clearly define the place of PSI in TKA, to keep on improving the accuracy of the system and to better define the individual targets in TKA in terms of frontal, sagittal and rotational positioning of the implant for each patient. Level of evidence Prospective comparative randomized study, Level II.

Background During lower limb lengthening, poor bone regeneration is a devastating complication. Several local or systemic applications have been used to promote osteogenesis, and biologic stimulations are gaining attention, but their utility has not been proven in this setting. Questions/purposes In patients undergoing bilateral tibial lengthening, we compared those receiving an osteotomy site injection of autologous bone marrow aspirate concentrate (BMAC) plus platelet-rich plasma (PRP) with those not receiving such an injection in terms of external fixator index (time in external fixation divided by amount of lengthening), full weightbearing index (time until a patient was permitted to do full weightbearing divided by amount of lengthening), four cortical healing indexes (time until each cortical union divided by amount of lengthening), and callus shape and type. Methods Twenty-two patients (44 tibias) undergoing bilateral tibial lengthening enrolled in this randomized trial. Two patients were excluded, one due to insufficient radiographic evaluation and one who was lost to followup, leaving 20 patients (40 segments) for inclusion. Ten patients (20 segments) received BMAC combined with PRP injection (treatment group) and 10 patients (20 segments) received no injection (control group). All patients underwent stature lengthening for familial short stature with the lengthening over nail technique. Autologous BMAC combined with PRP was injected at the tibial osteotomy site at the end of the index surgery. Mean distraction rates were similar between groups (0.75 mm/day in the treatment group versus 0.72 mm/day in the control group; p = 0.24). Full weightbearing was permitted when we observed radiographic evidence of healing at two cortices; this assessment was made by the surgeon who was blinded to the treatment each patient received. Minimum followup was 24 months (mean, 28 months; range, 24–34 months). Results There was no difference in mean external fixator index between groups. However, mean cortical healing indexes (anterior/posterior/medial/lateral) were 1.14/0.81/0.96/0.88 months/cm in the treatment group and 1.47/1.26/1.42/1.22 months/cm in the control group (all p < 0.001), showing faster healing in the treatment group at each cortex. Full weightbearing was permitted earlier in the treatment group than in the control group (index: 0.99 months/cm and 1.38 months/cm, respectively, p < 0.001). Callus shape and type were not different between groups. Conclusions Autologous BMAC combined with PRP injection at the osteotomy site helped improve bone healing in distraction osteogenesis of the tibia, although the effect size was small. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Purpose Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. Methods Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the “Graft” was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The “Tibial Tunnel” was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0–10. Tunnel and graft positioning were evaluated. Results At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months ( p  = 0.008) and 18-months ( p  = 0.028), the tunnel was significantly smaller ( p  < 0.05) and less enlarged at both follow-ups ( p  < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months ( p  < 0.05). The total score of the non-detached group saw a significant improvement at 4-months ( p  = 0.006) that remained stable at 18-months (n.s.). Conclusions Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. Level of evidence IV.

Purpose This study aimed to compare the clinical and radiographic outcomes and arthroscopic findings after high tibial osteotomy (HTO) between neutral and classic targeted coronal alignments in patients with medial meniscus posterior root tears (MMPRTs). Methods Ninety-eight patients with MMPRT were prospectively enrolled in the final cohort and randomized into two groups. Fifty-two patients with the targeted alignment through the Fujisawa point (60–62.5% of the entire tibial plateau width measured from the medial side) during HTO were included in group A, whereas 46 patients with the targeted alignment through the point at 50–55% of the tibial plateau width were included in group B. The clinical and radiographic outcomes and second-look arthroscopic findings were statistically compared for comprehensive assessments. Results After a mean follow-up of 37.1 months, we found no significant differences between the two groups regarding the final Lysholm ( p  = 0.205) and Hospital for Special Surgery scores ( p  = 0.084). However, we only observed significant differences between the two groups in terms of the final hip–knee–ankle angle, weight-bearing line ratio, and medial proximal tibial angle ( p  < 0.001). Second-look arthroscopy did not reveal a significant difference in meniscal healing rate ( p  = 0.786). Conclusions Performing HTO with the aim to achieve neutral alignment leads to similar clinical outcomes in patients with MMPRT compared to classic alignment. Although subsequent research is required, the current study provides clinical evidence for the safety and efficacy of the new targeted alignment during HTO, which may avoid long-term complications associated with overcorrection when using the traditional technique.

Background A recent publication on efficacy of Sprifermin for knee osteoarthritis (OA) using quantitatively MRI-defined central medial tibio-femoral compartment cartilage thickness as the structural primary endpoint reported no statistically significant dose response. However, Sprifermin was associated with statistically significant, dose-dependent reductions in loss of total and lateral tibio-femoral cartilage thickness. Based on these preliminary promising data a post-hoc analysis of secondary assessment and endpoints was performed to evaluate potential effects of Sprifermin on semi-quantitatively evaluated structural MRI parameters. Aim of the present analysis was to determine effects of sprifermin on several knee joint tissues over a 12 month period. Methods 1.5 T or 3 T MRIs were acquired at baseline and 12 months follow-up using a standard protocol. MRIs were read according to the Whole-Organ Magnetic Resonance Imaging Score (WORMS) scoring system (in 14 articular subregions) by four muskuloskeletal radiologists independently. Analyses focused on semiquantitative changes in the 100 μg subgroup and matching placebo of multiple MRI-defined structural alterations. Analyses included a delta-subregional and delta-sum approach for the whole knee and the medial and lateral tibio-femoral (MTFJ, LTFJ), and patello-femoral (PFJ) compartments, taking into account number of subregions showing no change, improvement or worsening and changes in the sum of subregional scores. Mann–Whitney − Wilcoxon tests assessed differences between groups. Results Fifty-seven and 18 patients were included in the treatment and matched placebo subgroups. Less worsening of cartilage damage was observed from baseline to 12 months in the PFJ (0.02, 95 % confidence interval (CI) (−0.04, 0.08) vs. placebo 0.22, 95 % CI (−0.05, 0.49), p  = 0.046). For bone marrow lesions (BMLs), more improvement was observed from 6 to 12 months for whole knee analyses (−0.14, 95 % CI (−0.48, 0.19) vs. placebo 0.44, 95 % CI (−0.15, 1.04), p  = 0.042) although no significant effects were seen from the baseline visit, or in Hoffa-synovitis, effusion-synovitis, menisci and osteophytes. Conclusions In this post-hoc analysis cartilage showed less worsening from baseline to 12 months in the PFJ, and BMLs showed more improvement from 6 to 12 months for the whole knee. Trial registration ClinicalTrials.gov identifier: NCT01033994 .

Rotational deformities following intramedullary (IM) nailing of tibia has a reported incidence of as high as 20%. Common techniques to measure deformities following IM nailing of tibia are either based on clinical assessment, plain X-rays or Computed Tomography (CT) comparing the treated leg with the uninjured contralateral side. All these techniques are based on examiners manual calculation inherently subject to bias. Following our previous rigorous motion analysis and symmetry studies on hemi pelvises, femurs and orthopaedic implants, we aimed to introduce a novel fully digital technique to measure rotational deformities in the lower legs. Following formal institutional approval from the Imperial College, CT images of 10 pairs of human lower legs were retrieved. Images were anonymized and uploaded to a research server. Three dimensional CT images of the lower legs were bilaterally reconstructed. CT-based motion analysis (CTMA) was used and the mirrored images of the left side were merged with the right side proximally as stationary and distally as moving objects. Discrepancies in translation and rotation were automatically calculated. Our study population had a mean age of 54 ± 20 years. There were six males and four females. We observed a greater variation in translation (mm) of Centre of Mass (COM) in sagittal plane (95% CI − 2.959–.292) which was also presented as rotational difference alongside the antero-posterior direction or Y axis (95% CI .370–1.035). In other word the right lower legs in our study were more likely to be in varus compared to the left side. However, there were no statistically significant differences in coronal or axial planes. Using our proposed fully digital technique we found that lower legs of the human adults were symmetrical in axial and coronal plane. We found sagittal plane differences which need further addressing in future using bigger sample size. Our novel recommended technique is fully digital and commercially available. This new technique can be useful in clinical practice addressing rotational deformities following orthopaedic surgical intervention. This new technique can substitute the previously introduced techniques.

ContextOsteogenesis imperfecta (OI) is associated with reduced muscle size, dynamic muscle function, and mobility.ObjectiveTo assess the effect of whole body vibration (WBV) on bone density and geometry, muscle size and function, mobility, and balance in children with OI.DesignRandomized controlled pilot trial.SettingTertiary pediatric research center.ParticipantsTwenty-four children (5 to 16 years) with OI types 1, 4, and limited mobility [Child Health Assessment Questionnaire (CHAQ) score ≥ 0.13] recruited in sex- and pubertal stage-matched pairs. Incident fractures in two boys (WBV arm) led to exclusion of two prepubertal pairs.InterventionFive months of WBV training (3 × 3 minutes twice daily) or regular care.Main Outcome MeasuresBone and muscle variables measured by dual-energy X-ray absorptiometry (spine, hip, total body) and peripheral quantitative computed tomography (tibia). Mobility assessed by 6-minute walk tests and CHAQ; dynamic muscle function by mechanography.ResultsAll participants had reduced walking distances and muscle function (P < 0.001). Body mass index z score was associated with higher CHAQ scores (ρ + 0.552; P = 0.005) and lower walking and two-leg jumping performance (ρ − 0.405 to −0.654, P < 0.05). The WBV and control groups did not differ in the 5-month changes in bone. Total lean mass increased more in the WBV group [+1119 g (+224 to +1744)] compared with controls [+635 g (−951 to +1006)], P = 0.01, without improving mobility, muscle function, or balance.ConclusionsThe increase in lean mass without changes in muscle function or bone mass suggests reduced biomechanical responsiveness of the muscle-bone unit in children with OI.This randomized controlled study of WBV in OI children demonstrates improvements in lean mass but not in muscle function or bone mass, indicating reduced responsiveness of OI bones to WBV.