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Comparison of coracoid graft positioning between arthroscopic and open latarjet procedures: A 2D CT-Scan analysis.
APKASS 2016 Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 6 (2016) 13e71 Objectives: Safe procedures associated with FF 360, particularly intraarticular needle insertion points and extraarticular implant points were investigated by using knees of cadavers. Materials and methods: Five knees of cadavers were used. All insertions at the knee were implemented in a flexed position. The superficial layer of the medial collateral ligament and lateral collateral ligament were separated at the femoral side in cases with a narrow joint space. Anchors T1 and T2 were inserted 12 mm and 17 mm, respectively. Under endoscopy, FF 360 was inserted into 7 points of the medial meniscus (femoral side of the middle segment: 1 point, femoral side of the border of the middle and posterior segments: 2 points, femoral side of the posterior segment: 2 points, and tibial side of the posterior segment: 2 points), as well as 5 points of the lateral meniscus (femoral side of the middle segment: 1 point, femoral side in the popliteal hiatus: 1 point, femoral side of the posterior segment: 2 points, and tibial side of the posterior segment: 1 point). After the procedure, dissection was performed, and needle insertion points on the meniscus and extraarticular implant points were confirmed. Results: Anatomic sites of the placed implant included middle segment of the medial meniscus on the medial retinaculum in all five cases. With regard to the border of the middle and posterior segments of the medial meniscus, the needles were placed on the superficial layer of the medial collateral ligament in all five cases. In case of the femoral side of the posterior segment, the needles were placed on the joint capsule or on the meniscus in all cases. For the tibial side, insertion failure was observed in 3 cases. In addition, there was no insertion of the needle on the semimembranosus tendon at the posterior segments of the medial meniscus, which was a procedure we were concerned. For the middle segments of the medial meniscus, the needles were placed on the iliotibial tract in one case, and for the anterior border of the popliteal hiatus, the needles were placed on the lateral collateral ligament in four cases. In all cases, the needles were placed on the joint capsule or on the meniscus for the posterior segment. Discussion: Through examination of safe insertion sites for FF360 by using five cadavers, our results predicted that placement of the needles on the border of the middle and posterior segments of the medial meniscus and the anterior border of the popliteal hiatus of the lateral meniscus would be difficult due to grasping of the superficial layer of MCL and parenchyma of LCL. Around the middle segment, the needles were placed on the medial retinaculum for the medial side and on the iliotibial tract for the lateral side. In addition, the needle is placed on the popliteus tendon for the posterior segment when a needle was inserted in a wrong direction. These results suggest that visualization of the tissues around the meniscus where needle insertion points as well as installation sites of FF360 are located is necessary to conduct operation. Complications of suture techniques include joint irritation, cyst formation, chondral lesions and unpredicted pain; therefore, when FF360 is used, it is required to visualize the tissues around the meniscus and foresee avoidable failure to prevent unpredicted pain. In addition, the operation should be conducted not only solely dependent on FF360 but also with consideration for other suture techniques. Conclusions: Based on the needle insertion points, it is possible to predict tissues that will be grasped outside the joint. Considering postoperative pain from grasping, it is necessary to recognize the anatomy of the tissues around the knee http://dx.doi.org/10.1016/j.asmart.2016.07.181
B0794 Advantages of computer-assisted navigation system in open-wedge high tibial osteotomy S. Kirizuki 1, T. Matsushita 1, R. Kuroda 1, D. Araki 1, S. Oka 2, T. Matsumoto 1, N. Miyaji 1,2, K. Takayama 1, M. Kurosaka 1 1 Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan 2 Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Japan Background: It has been reported that posterior tibial slope (PTS) tends to increase following open-wedge high tibial osteotomy (OWHTO). The present study investigated the usefulness of the navigation system in control of PTS in OWHTO. Methods: Sixteen knees in 16 patients who underwent OWHTO using a navigation system for medial knee osteoarthritis (OA) were examined (Group NS). The amount of the change of PTS ( ) on the navigation system was recorded at the time of surgery in each patient. The PTS change was also measured by pre- and postoperative digital radiographs. The angle change was expressed as a positive values regardless of decrease or increase in the slope to evaluate the amount of the change. The PTS changes on the navigation system and on the radiographs were compared to assess the validity of the navigation system. Twenty-eight knees in 28 patients who underwent OWHTO without using the navigation system were also examined (Group nonNS). The PTS changes in Group non-NS were compared with those in Group NS on radiographs. Results: In Group NS, PTS increased in 10 knees and decreased in 5 knees on the radiographic evaluation. In Group NS, PTS increased in 15 knees and decreased in 9 knees and did not change (less than 0.5 change) in 3 knees. In Group NS, the mean PTS change was 2.4 ± 1.4 on the navigation system and 2.38 ± 1.20 on radiographs. There was no statistically significant difference between the mean values on the navigation system and the radiographs. The mean difference in the PTS change between on the navigation system and on radiographs was 0.38 ± 0.50 . There was a strong correlation between the measurement value on the navigation system and the value on radiographs (R ¼ 0.97). The mean change of the PTS in Group non-NS was 1.59 ± 4.21 . There was no statistically significant difference in the PTS change on radiographs between Group NS and Group non-NS. However, 10 knees (36%) in Group non-NS showed a change of greater than 4 while none of the knees in Group NS showed a change of greater than 4 . Discussion: The measurement values of PTS change obtained by the navigation system strongly correlated with the radiographic measurement. In addition, the mean difference between the two measurement systems was less than 0.5 . These results suggest that the navigation system is
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reliable to control PTS during surgery at least if plain radiographs are used to evaluate the PTS change. The PTS often changed greater than 4 when OWHTO was performed without using the navigation system. In contrast, the PTS changes were below 4 in all the knees when OWHTO was performed using the navigation system, suggesting that the navigation system is useful to control PTS and reduce a large error of the PTS change during OWHTO. Conclusions: Our results suggested that navigation system is useful to accurately perform OWHTO by monitoring the change of PTS during surgery. http://dx.doi.org/10.1016/j.asmart.2016.07.182
B0795 Comparison of coracoid graft positioning between arthroscopic and open latarjet procedures: A 2D CT-Scan analysis. J. Barth 1, L. Neyton 2, P. Metais 3, G. Walch 2, L. Lafosse 4, SFA 5 Centre Osteo-Articulaire des Cedres, Grenoble, France 2 Centre Orthopedique Santy, Lyon, France 3 Clinique de la Chataigneraie, Beaumont, France 4 Clinique Generale, Annecy, France 5 French Society of Arthroscopy, Paris, France
1
Background: The Latarjet procedure remains the main effective operation to treat recurrent shoulder instability. However an overhanging position of the coracoid graft (CG) may lead to early arthritis and an excessively medial position may lead to failure. It is difficult to standardize plain X-rays for accurate and reproducible position analysis; therefore CT-scans appear to be a better option. Numerous studies report evaluation of positioning of the CG (for arthroscopic or open procedures) using OSIRIXTM software. The aim of the study was: 1) To define and to evaluate a reliable and reproducible 2D CT-scan analysis protocol to assess the coracoid graft positioning after Latarjet procedure in the axial and sagittal planes (preliminary study) 2) To compare arthroscopic technique to conventional open technique in terms of positioning (SFA Symposium) Material: 9 surgeons in 9 centers participated in the multicentric prospective study promoted by the French Society of Arthroscopy, from March 2013 to June 2014 for the inclusions (IRB: CERC-VS-2016-02-1). The follow-up continued until September 2015 to obtain at least one year of follow-up. We included patients operated for recurrent shoulder instability with the Latarjet procedure (arthroscopic and open techniques). 390 patients were enrolled: 104 (27%) with the open technique as described by G. Walch (OT) performed by 2 surgeons, 222 (57%) with the arthroscopic technique as described by L. Lafosse (ATL) performed by 6 surgeons, and 64 (16%) with the arthroscopic technique as described by P. Boileau (ATB) performed by 1 surgeon. Mean age at surgery was 27.8 years old (range,13.6-66.6). Mean ISIS score was 5. Methods 1) Preliminary study (n¼15) 15 postoperative CT-scans of Latarjet (5 open, 5 mini-open and 5 arthroscopic procedures) were included to assess intra-observers reproducibility and inter-observer reproducibility according a standardized CT-scan analysis (modified protocol initially published by Kraus et. al) among 3 senior and 3 junior shoulder surgeons. DICOM images were extracted from Native CDs using OSIRIXTM software. In the axial plane, we measured: - The angle of the screws from the joint line (JL) - The positioning of the CG at 50% and 25% of the height of the glenoid. The CG was considered as too medial if it laid more than 4mm medial from the JL, overhanged if over than 1 mm lateral and flush in between. - The contact area between CG and the glenoid by measuring the angle between the undersurface of the CG and the glenoid anterior cortical In the sagittal plane, we measured the percentage of CG under the equator of the glenoid Statistical analysis with ADSCIENCETM software allowed inter-class agreement (ICC or Kappa coefficient), 2 by 2 among inter- and intra-observers. 2) SFA Symposium (n¼390) 211 CT-scans/Patients were available for position analysis (79 OT, 86 ATL, 42 ATB). The different previous parameters were analyzed to compare arthroscopic techniques versus open. For the ATB, using endobutton instead of screw for coracoid fixation, the axe of the drilled tunnel was used as “the inferior screw” for the other techniques. Results 1) Preliminary Study In the axial plane: - The angle of the screws: the ICC in Intra-observer agreement was substantial to almost perfect (mean: 0.80; range, 0.70 to 0.94) and Inter-observer agreement was moderate to almost perfect (mean: 0.60; range, 0.43 to 0.92). - The positioning of the CG at 50% and 25%: the ICC in Intra-observer agreement was slight to almost perfect (mean: 0.67; range, 0.16 to 0.90) and Inter-observer agreement was slight to substantial (mean: 0.47; range, 0.08 to 0.79). - The contact area between CG and the glenoid: the ICC in Intra-observer agreement was fair to almost perfect (mean: 0.69; range, 0.31 to 1.0) and Inter-observer agreement was moderate to almost perfect (mean: 0.53; range, 0.43 to 0.87). In the sagittal plane, when analyzing the percentage of CG under the equator of the glenoid screws: the ICC in intra-observer agreement was moderate to almost perfect (mean: 0.69; range, 0.45 to 0.85) and inter-observer agreement was slight to almost perfect (mean: 0.42; range, 0.13 to 0.90). 2) SFA Symposium
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APKASS 2016 Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 6 (2016) 13e71
In the axial plane: - The angle of the screws: ATB was the “most parallel to the JL option” whereas ATL screws were more divergent than OT (p<0.01). - The positioning of the CG: OT was significantly more flush to the JL whereas ATB was likely to be more lateral (p<0.01). There was a higher dispersion of the values with the ATL - The contact area between CG and the glenoid: There was no significant differences between the different open and arthroscopic techniques although a higher dispersion of the values with the ATL In the sagittal plane, when analyzing the percentage of CG under the equator of the glenoid screws: The CG with the ATL was significantly “higher” than with the OT, whereas ATB was “lower” (p<0.001). Discussion: A precise analysis of the positioning of the CG especially with the evolution of new arthroscopic techniques is mandatory. Standard radiographs showed insufficient reliability whereas 2D CT-scans seem to be the gold standard. Contrary to Kraus et al, we found a greater discrepancy between inter-observer ICCs but also intra-observer ICCs, except for screw angle measurements. Difficulties to orient with a reproducible manner the scapula in 3D before starting measurements in 2D were responsible of the errors. The most difficult part is certainly to find the appropriate sagittal plane. Caution in interpretation of results should be taken when analyzing of CG positioning on 2D CT-scans because of possible measurements errors. Conclusion: Orientation of the scapula by an automated system would certainly help to decrease possible measurement errors. This study showed that arthroscopic Latarjet techniques are reliable, but with a tendency to be a little bit more proud than the conventional open technique. http://dx.doi.org/10.1016/j.asmart.2016.07.183
B0797 Chondral defects in the knee: Are autologous bone marrow derived mesenchymal stem cells suitable to replace autologous chondrocyte implantation techniques? results from a mid-term observational cohort study K.L. Wong, J.H. Hui, E.H. Lee Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore Background: Autologous chondrocyte implantation (ACI) has limitations, and its position has been challenged by autologous bone marrowederived mesenchymal stem cells (BMSCs) BMSCs have an added benefit as requires 1 less surgery, reduced costs, and minimized donor-site morbidity. This study was conducted to compare the 6-year clinical outcomes of patients treated with first-generation ACI to patients treated with BMSCs and to assess its feasibility as a replacement for ACI techniques. Materials and Methods: Seventy-two matched (lesion site and age) patients underwent cartilage repair using chondrocytes (n ¼ 36) or BMSCs (n ¼ 36). Clinical outcomes were measured before operation and 3, 6, 9, 12, 18, 24 months and mid term outcomes were followed up till 6 years after operation. The International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package, which included questions from the Short-Form Health Survey, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm knee scale, and Tegner activity level scale were used for evaluation. Results: At 6-year follow-up, there were 30 patients available for evaluation (ACI ¼ 16, BMSC ¼ 14), with a loss to follow-up rate of 58.3%. There was significant improvement in the patients’ quality of life (physical and mental components of the Short Form-36 questionnaire included in the ICRS package) after cartilage repair in both groups. However, there was no difference between the BMSC and the ACI group in terms of clinical outcomes. The IKDC subjective knee evaluation (P ¼ 0.258), Lysholm (P ¼ 0.724), and Tegner (P ¼ 0.827) scores did not show any significant difference between groups over time. Patients younger than 45 years of age scored significantly better than patients older than 45 years in the ACI group, but age did not make a difference in outcomes in the BMSC group. Conclusion: BMSCs in cartilage repair is as effective as chondrocytes for articular cartilage repair. The mid term results suggest that BMSCs can be used in replacement for ACI as it provides the same effect at 6 years post intervention. In addition, it requires 1 less surgery, reduced costs, and minimized donor-site morbidity. http://dx.doi.org/10.1016/j.asmart.2016.07.184
B0803 Precise patient selection for hip arthroscopy using ultrasound-guided hip injection T. Yamasaki 1, S. Hachisuka 2, T. Shoji 2, S. Izumi 2, H. Murakami 2, S. Niimoto 2, M. Sawa 2, K. Mifuji 2, Y. Yasunaga 3, N. Adachi 2, M. Ochi 2 1 Department of Artificial Joints and Biomaterials, Hiroshima University, Japan 2 Department of Orthopaedic Surgery, Hiroshima University, Japan 3 Hiroshima Prefectural Rehabilitation Center, Japan Background: Acetabular labral tear (ALT) is considered to be the most frequent pathology as a cause of groin pain. Recently, the technique on diagnosis and arthroscopic treatment for labrum tear has progressed. Satisfactory outcomes of hip arthroscopy were reported. However, failure cases of arthroscopic treatment actually exist, and one of the most concerned problem is patient selection for hip arthroscopy. The purpose of this study is to review the patients who underwent conservative treatment including ultrasound-guided hip injection under the diagnosis of ALT,
and to assess the efficacy of the technique of hip injection in order to give a more reliable diagnosis and to reach better operative indication for hip arthroscopy. Materials and Methods: 37 patients with 40 hips (18 men and 19 women) who were diagnosed as ALT, whose groin pain was evaluated using ultrasound-guided hip injection between January 2013 and December 2015, were included in this study. Possible ALT was diagnosed with positive impingement test (flexion and internal rotation), and positive findings on the radial view of MRI. The exclusion criteria included radiographic sign of osteoarthritis of the hip; T€onnis grade 2 or higher and acetabular dysplasia (center-edge angle less than 20 ), or other previous history of hip joint pathology. The mean age of the patients at the first consultation was 45 years (17-71 years). As the procedure of hip injection, HI VISION Avius ultrasound system (Hitachi Aloka Medical, Tokyo, Japan) with a 14-6 MHz linear probe was used. Intra-articular injection was performed using an anterior parasagittal approach with the free hand technique. The needle tip was inserted toward the head-neck junction. On the other hand, extra-articular injection was performed via anterior approach targeting the layer of fascia between iliopsoas tendon and rectus femoris. Not only anterior inferior iliac spine (AIIS) but also iliopsoas tendon and proximal rectus femoris were visualized in the long axis probing. Clinical evaluation was performed with visual-analogue scale (VAS) score and outcomes of the Japanese Orthopedic Association Hip-Disease Evaluation Questionnaire (JHEQ) at pre-injection and at 4 weeks after injection. JHEQ is a validated self-administered questionnaire for QOL of patients with hip disease in the Asian lifestyle, the total score range is 0 (worst) to 84 (best). Additionally, the period between the initial injection and the last injection, frequency of injection, and location of injection (intra-articular space, iliopsoas tendon, proximal rectus femoris) were investigated. Results: Medians of the VAS score, the total score of the JHEQ, and the pain subscale score of the JHEQ significantly improved after hip injection, and the movement and mental subscale scores of the JHEQ also improved. Conservative treatment including hip injection was effective in 30 hips (75%). The mean period between the initial injection and the last injection was 5 months (range: 1-24 months), the mean times of injection was 4.5 times, and 10 hips out of 30 hips were performed injection of less than 3 times. In 7 hips, injection to iliopsoas tendon or proximal rectus femoris was more effective than that to intra-articular injection. Ten hips (25%) failed conservative treatment and required arthroscopic treatments. In these patients, the mean 2.4 times of injection were performed before surgery. Discussion: Recently, Failure factors of hip arthroscopy have been reported. Not only the etiology but also pathomorphological problem and external-articular pathology is important. Considering the source of groin pain, even if intra-articular pathology is detected by radiograph or MRI, extra-articular pathology could not be ruled out. Various causes of groin pain might be hidden behind obvious pathologies such as ALT. Ultrasound-guided injection could help surgeons to give a more precise diagnosis of the origin of groin pain, which leads to select better operative indication for hip arthroscopy. Conclusions: 37 patients with 40 hips who were diagnosed as acetabular labral tear (ALT), whose groin pain was evaluated using ultrasound-guided hip injection were investigated. Conservative treatment including hip injection was effective in 30 hips (75%). In 7 hips out of 30 hips, injection to iliopsoas tendon or proximal rectus femoris was more effective than that to intraarticular injection. Various causes of groin pain may coexist behind obvious pathologies. Ultrasound-guided injection could be useful for precise diagnosis of the cause of groin pain and could lead to better operative indication for hip arthroscopy. http://dx.doi.org/10.1016/j.asmart.2016.07.185
B0804 Medial gap technique: New surgical concept for quantitative and safer soft tissue balancing in posterior-stabilized TKA K. Kudo 1, H. Muratsu 1, T. Furukawa 1, K. Yamaura 1, S. Minamino 1, T. Oshima 1, T. Matsumoto 2, A. Maruo 1, H. Miya 1, R. Kuroda 2, M. Kurosaka 2 1 Steel Memorial Hirohata Hospital, Japan 2 Kobe University Graduate School of Medicine, Japan Background: Although gap balancing technique has been reported to be beneficial for the intraoperative soft tissue balancing in posterior-stabilized (PS)-TKA, excessive release of medial structures for achieving perfect ligament balance would be more likely to result in medial instability, which would deteriorate post-operative clinical result with persistent pain [1]. We have devised a new surgical concept; named as “medial gap technique” aiming at medial stability with permitting lateral looseness. With the quantitative soft tissue balance measurement using newly developed offset type tensor [2], we modified conventional gap balancing technique to provide quantitative and safer intra-operative soft tissue balancing with avoiding medial instability. In this study, we compared intra-operative soft tissue balance between medial gap technique (MGT) and measured resection technique (MRT) in PS-TKA. Material: The subjects were 256 patients with varus type osteoarthritic knees, underwent primary PS-TKAs. The surgical techniques were MGT in 112 patients (96 female, 16 male) and MRT in 144 patients (118 female, 26 male). There were no significant differences between two groups in the pre-operative clinical features including age, sex, ROM and deformity. Method: A distal femoral and a proximal tibial osteotomy were performed perpendicular to the mechanical axis. Ligament imbalance in the coronal plane was corrected by medial soft tissue release, which should be carefully performed not to be excessive until a spacer block corresponding to resected bone thickness from lateral tibial plateau could be inserted at extension. The residual lateral laxity was permitted. Following extension gap preparation, a varus angle ( ) and joint center gap (mm) at the knee extension and 90 of flexion were measured using an offset type tensor with applying 40 lbs. (177.9N) of joint distraction force. As for the flexion gap preparation, in the MGT group, the level of femoral posterior condylar osteotomy was determined based on the difference of joint center gap between extension and flexion, and femoral rotation angle were based on the varus angle difference.
B0794 Advantages of computer-assisted navigation system in open-wedge high tibial osteotomy S. Kirizuki 1, T. Matsushita 1, R. Kuroda 1, D. Araki 1, S. Oka 2, T. Matsumoto 1, N. Miyaji 1,2, K. Takayama 1, M. Kurosaka 1 1 Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan 2 Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Japan Background: It has been reported that posterior tibial slope (PTS) tends to increase following open-wedge high tibial osteotomy (OWHTO). The present study investigated the usefulness of the navigation system in control of PTS in OWHTO. Methods: Sixteen knees in 16 patients who underwent OWHTO using a navigation system for medial knee osteoarthritis (OA) were examined (Group NS). The amount of the change of PTS ( ) on the navigation system was recorded at the time of surgery in each patient. The PTS change was also measured by pre- and postoperative digital radiographs. The angle change was expressed as a positive values regardless of decrease or increase in the slope to evaluate the amount of the change. The PTS changes on the navigation system and on the radiographs were compared to assess the validity of the navigation system. Twenty-eight knees in 28 patients who underwent OWHTO without using the navigation system were also examined (Group nonNS). The PTS changes in Group non-NS were compared with those in Group NS on radiographs. Results: In Group NS, PTS increased in 10 knees and decreased in 5 knees on the radiographic evaluation. In Group NS, PTS increased in 15 knees and decreased in 9 knees and did not change (less than 0.5 change) in 3 knees. In Group NS, the mean PTS change was 2.4 ± 1.4 on the navigation system and 2.38 ± 1.20 on radiographs. There was no statistically significant difference between the mean values on the navigation system and the radiographs. The mean difference in the PTS change between on the navigation system and on radiographs was 0.38 ± 0.50 . There was a strong correlation between the measurement value on the navigation system and the value on radiographs (R ¼ 0.97). The mean change of the PTS in Group non-NS was 1.59 ± 4.21 . There was no statistically significant difference in the PTS change on radiographs between Group NS and Group non-NS. However, 10 knees (36%) in Group non-NS showed a change of greater than 4 while none of the knees in Group NS showed a change of greater than 4 . Discussion: The measurement values of PTS change obtained by the navigation system strongly correlated with the radiographic measurement. In addition, the mean difference between the two measurement systems was less than 0.5 . These results suggest that the navigation system is
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reliable to control PTS during surgery at least if plain radiographs are used to evaluate the PTS change. The PTS often changed greater than 4 when OWHTO was performed without using the navigation system. In contrast, the PTS changes were below 4 in all the knees when OWHTO was performed using the navigation system, suggesting that the navigation system is useful to control PTS and reduce a large error of the PTS change during OWHTO. Conclusions: Our results suggested that navigation system is useful to accurately perform OWHTO by monitoring the change of PTS during surgery. http://dx.doi.org/10.1016/j.asmart.2016.07.182
B0795 Comparison of coracoid graft positioning between arthroscopic and open latarjet procedures: A 2D CT-Scan analysis. J. Barth 1, L. Neyton 2, P. Metais 3, G. Walch 2, L. Lafosse 4, SFA 5 Centre Osteo-Articulaire des Cedres, Grenoble, France 2 Centre Orthopedique Santy, Lyon, France 3 Clinique de la Chataigneraie, Beaumont, France 4 Clinique Generale, Annecy, France 5 French Society of Arthroscopy, Paris, France
1
Background: The Latarjet procedure remains the main effective operation to treat recurrent shoulder instability. However an overhanging position of the coracoid graft (CG) may lead to early arthritis and an excessively medial position may lead to failure. It is difficult to standardize plain X-rays for accurate and reproducible position analysis; therefore CT-scans appear to be a better option. Numerous studies report evaluation of positioning of the CG (for arthroscopic or open procedures) using OSIRIXTM software. The aim of the study was: 1) To define and to evaluate a reliable and reproducible 2D CT-scan analysis protocol to assess the coracoid graft positioning after Latarjet procedure in the axial and sagittal planes (preliminary study) 2) To compare arthroscopic technique to conventional open technique in terms of positioning (SFA Symposium) Material: 9 surgeons in 9 centers participated in the multicentric prospective study promoted by the French Society of Arthroscopy, from March 2013 to June 2014 for the inclusions (IRB: CERC-VS-2016-02-1). The follow-up continued until September 2015 to obtain at least one year of follow-up. We included patients operated for recurrent shoulder instability with the Latarjet procedure (arthroscopic and open techniques). 390 patients were enrolled: 104 (27%) with the open technique as described by G. Walch (OT) performed by 2 surgeons, 222 (57%) with the arthroscopic technique as described by L. Lafosse (ATL) performed by 6 surgeons, and 64 (16%) with the arthroscopic technique as described by P. Boileau (ATB) performed by 1 surgeon. Mean age at surgery was 27.8 years old (range,13.6-66.6). Mean ISIS score was 5. Methods 1) Preliminary study (n¼15) 15 postoperative CT-scans of Latarjet (5 open, 5 mini-open and 5 arthroscopic procedures) were included to assess intra-observers reproducibility and inter-observer reproducibility according a standardized CT-scan analysis (modified protocol initially published by Kraus et. al) among 3 senior and 3 junior shoulder surgeons. DICOM images were extracted from Native CDs using OSIRIXTM software. In the axial plane, we measured: - The angle of the screws from the joint line (JL) - The positioning of the CG at 50% and 25% of the height of the glenoid. The CG was considered as too medial if it laid more than 4mm medial from the JL, overhanged if over than 1 mm lateral and flush in between. - The contact area between CG and the glenoid by measuring the angle between the undersurface of the CG and the glenoid anterior cortical In the sagittal plane, we measured the percentage of CG under the equator of the glenoid Statistical analysis with ADSCIENCETM software allowed inter-class agreement (ICC or Kappa coefficient), 2 by 2 among inter- and intra-observers. 2) SFA Symposium (n¼390) 211 CT-scans/Patients were available for position analysis (79 OT, 86 ATL, 42 ATB). The different previous parameters were analyzed to compare arthroscopic techniques versus open. For the ATB, using endobutton instead of screw for coracoid fixation, the axe of the drilled tunnel was used as “the inferior screw” for the other techniques. Results 1) Preliminary Study In the axial plane: - The angle of the screws: the ICC in Intra-observer agreement was substantial to almost perfect (mean: 0.80; range, 0.70 to 0.94) and Inter-observer agreement was moderate to almost perfect (mean: 0.60; range, 0.43 to 0.92). - The positioning of the CG at 50% and 25%: the ICC in Intra-observer agreement was slight to almost perfect (mean: 0.67; range, 0.16 to 0.90) and Inter-observer agreement was slight to substantial (mean: 0.47; range, 0.08 to 0.79). - The contact area between CG and the glenoid: the ICC in Intra-observer agreement was fair to almost perfect (mean: 0.69; range, 0.31 to 1.0) and Inter-observer agreement was moderate to almost perfect (mean: 0.53; range, 0.43 to 0.87). In the sagittal plane, when analyzing the percentage of CG under the equator of the glenoid screws: the ICC in intra-observer agreement was moderate to almost perfect (mean: 0.69; range, 0.45 to 0.85) and inter-observer agreement was slight to almost perfect (mean: 0.42; range, 0.13 to 0.90). 2) SFA Symposium
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APKASS 2016 Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 6 (2016) 13e71
In the axial plane: - The angle of the screws: ATB was the “most parallel to the JL option” whereas ATL screws were more divergent than OT (p<0.01). - The positioning of the CG: OT was significantly more flush to the JL whereas ATB was likely to be more lateral (p<0.01). There was a higher dispersion of the values with the ATL - The contact area between CG and the glenoid: There was no significant differences between the different open and arthroscopic techniques although a higher dispersion of the values with the ATL In the sagittal plane, when analyzing the percentage of CG under the equator of the glenoid screws: The CG with the ATL was significantly “higher” than with the OT, whereas ATB was “lower” (p<0.001). Discussion: A precise analysis of the positioning of the CG especially with the evolution of new arthroscopic techniques is mandatory. Standard radiographs showed insufficient reliability whereas 2D CT-scans seem to be the gold standard. Contrary to Kraus et al, we found a greater discrepancy between inter-observer ICCs but also intra-observer ICCs, except for screw angle measurements. Difficulties to orient with a reproducible manner the scapula in 3D before starting measurements in 2D were responsible of the errors. The most difficult part is certainly to find the appropriate sagittal plane. Caution in interpretation of results should be taken when analyzing of CG positioning on 2D CT-scans because of possible measurements errors. Conclusion: Orientation of the scapula by an automated system would certainly help to decrease possible measurement errors. This study showed that arthroscopic Latarjet techniques are reliable, but with a tendency to be a little bit more proud than the conventional open technique. http://dx.doi.org/10.1016/j.asmart.2016.07.183
B0797 Chondral defects in the knee: Are autologous bone marrow derived mesenchymal stem cells suitable to replace autologous chondrocyte implantation techniques? results from a mid-term observational cohort study K.L. Wong, J.H. Hui, E.H. Lee Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore Background: Autologous chondrocyte implantation (ACI) has limitations, and its position has been challenged by autologous bone marrowederived mesenchymal stem cells (BMSCs) BMSCs have an added benefit as requires 1 less surgery, reduced costs, and minimized donor-site morbidity. This study was conducted to compare the 6-year clinical outcomes of patients treated with first-generation ACI to patients treated with BMSCs and to assess its feasibility as a replacement for ACI techniques. Materials and Methods: Seventy-two matched (lesion site and age) patients underwent cartilage repair using chondrocytes (n ¼ 36) or BMSCs (n ¼ 36). Clinical outcomes were measured before operation and 3, 6, 9, 12, 18, 24 months and mid term outcomes were followed up till 6 years after operation. The International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package, which included questions from the Short-Form Health Survey, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm knee scale, and Tegner activity level scale were used for evaluation. Results: At 6-year follow-up, there were 30 patients available for evaluation (ACI ¼ 16, BMSC ¼ 14), with a loss to follow-up rate of 58.3%. There was significant improvement in the patients’ quality of life (physical and mental components of the Short Form-36 questionnaire included in the ICRS package) after cartilage repair in both groups. However, there was no difference between the BMSC and the ACI group in terms of clinical outcomes. The IKDC subjective knee evaluation (P ¼ 0.258), Lysholm (P ¼ 0.724), and Tegner (P ¼ 0.827) scores did not show any significant difference between groups over time. Patients younger than 45 years of age scored significantly better than patients older than 45 years in the ACI group, but age did not make a difference in outcomes in the BMSC group. Conclusion: BMSCs in cartilage repair is as effective as chondrocytes for articular cartilage repair. The mid term results suggest that BMSCs can be used in replacement for ACI as it provides the same effect at 6 years post intervention. In addition, it requires 1 less surgery, reduced costs, and minimized donor-site morbidity. http://dx.doi.org/10.1016/j.asmart.2016.07.184
B0803 Precise patient selection for hip arthroscopy using ultrasound-guided hip injection T. Yamasaki 1, S. Hachisuka 2, T. Shoji 2, S. Izumi 2, H. Murakami 2, S. Niimoto 2, M. Sawa 2, K. Mifuji 2, Y. Yasunaga 3, N. Adachi 2, M. Ochi 2 1 Department of Artificial Joints and Biomaterials, Hiroshima University, Japan 2 Department of Orthopaedic Surgery, Hiroshima University, Japan 3 Hiroshima Prefectural Rehabilitation Center, Japan Background: Acetabular labral tear (ALT) is considered to be the most frequent pathology as a cause of groin pain. Recently, the technique on diagnosis and arthroscopic treatment for labrum tear has progressed. Satisfactory outcomes of hip arthroscopy were reported. However, failure cases of arthroscopic treatment actually exist, and one of the most concerned problem is patient selection for hip arthroscopy. The purpose of this study is to review the patients who underwent conservative treatment including ultrasound-guided hip injection under the diagnosis of ALT,
and to assess the efficacy of the technique of hip injection in order to give a more reliable diagnosis and to reach better operative indication for hip arthroscopy. Materials and Methods: 37 patients with 40 hips (18 men and 19 women) who were diagnosed as ALT, whose groin pain was evaluated using ultrasound-guided hip injection between January 2013 and December 2015, were included in this study. Possible ALT was diagnosed with positive impingement test (flexion and internal rotation), and positive findings on the radial view of MRI. The exclusion criteria included radiographic sign of osteoarthritis of the hip; T€onnis grade 2 or higher and acetabular dysplasia (center-edge angle less than 20 ), or other previous history of hip joint pathology. The mean age of the patients at the first consultation was 45 years (17-71 years). As the procedure of hip injection, HI VISION Avius ultrasound system (Hitachi Aloka Medical, Tokyo, Japan) with a 14-6 MHz linear probe was used. Intra-articular injection was performed using an anterior parasagittal approach with the free hand technique. The needle tip was inserted toward the head-neck junction. On the other hand, extra-articular injection was performed via anterior approach targeting the layer of fascia between iliopsoas tendon and rectus femoris. Not only anterior inferior iliac spine (AIIS) but also iliopsoas tendon and proximal rectus femoris were visualized in the long axis probing. Clinical evaluation was performed with visual-analogue scale (VAS) score and outcomes of the Japanese Orthopedic Association Hip-Disease Evaluation Questionnaire (JHEQ) at pre-injection and at 4 weeks after injection. JHEQ is a validated self-administered questionnaire for QOL of patients with hip disease in the Asian lifestyle, the total score range is 0 (worst) to 84 (best). Additionally, the period between the initial injection and the last injection, frequency of injection, and location of injection (intra-articular space, iliopsoas tendon, proximal rectus femoris) were investigated. Results: Medians of the VAS score, the total score of the JHEQ, and the pain subscale score of the JHEQ significantly improved after hip injection, and the movement and mental subscale scores of the JHEQ also improved. Conservative treatment including hip injection was effective in 30 hips (75%). The mean period between the initial injection and the last injection was 5 months (range: 1-24 months), the mean times of injection was 4.5 times, and 10 hips out of 30 hips were performed injection of less than 3 times. In 7 hips, injection to iliopsoas tendon or proximal rectus femoris was more effective than that to intra-articular injection. Ten hips (25%) failed conservative treatment and required arthroscopic treatments. In these patients, the mean 2.4 times of injection were performed before surgery. Discussion: Recently, Failure factors of hip arthroscopy have been reported. Not only the etiology but also pathomorphological problem and external-articular pathology is important. Considering the source of groin pain, even if intra-articular pathology is detected by radiograph or MRI, extra-articular pathology could not be ruled out. Various causes of groin pain might be hidden behind obvious pathologies such as ALT. Ultrasound-guided injection could help surgeons to give a more precise diagnosis of the origin of groin pain, which leads to select better operative indication for hip arthroscopy. Conclusions: 37 patients with 40 hips who were diagnosed as acetabular labral tear (ALT), whose groin pain was evaluated using ultrasound-guided hip injection were investigated. Conservative treatment including hip injection was effective in 30 hips (75%). In 7 hips out of 30 hips, injection to iliopsoas tendon or proximal rectus femoris was more effective than that to intraarticular injection. Various causes of groin pain may coexist behind obvious pathologies. Ultrasound-guided injection could be useful for precise diagnosis of the cause of groin pain and could lead to better operative indication for hip arthroscopy. http://dx.doi.org/10.1016/j.asmart.2016.07.185
B0804 Medial gap technique: New surgical concept for quantitative and safer soft tissue balancing in posterior-stabilized TKA K. Kudo 1, H. Muratsu 1, T. Furukawa 1, K. Yamaura 1, S. Minamino 1, T. Oshima 1, T. Matsumoto 2, A. Maruo 1, H. Miya 1, R. Kuroda 2, M. Kurosaka 2 1 Steel Memorial Hirohata Hospital, Japan 2 Kobe University Graduate School of Medicine, Japan Background: Although gap balancing technique has been reported to be beneficial for the intraoperative soft tissue balancing in posterior-stabilized (PS)-TKA, excessive release of medial structures for achieving perfect ligament balance would be more likely to result in medial instability, which would deteriorate post-operative clinical result with persistent pain [1]. We have devised a new surgical concept; named as “medial gap technique” aiming at medial stability with permitting lateral looseness. With the quantitative soft tissue balance measurement using newly developed offset type tensor [2], we modified conventional gap balancing technique to provide quantitative and safer intra-operative soft tissue balancing with avoiding medial instability. In this study, we compared intra-operative soft tissue balance between medial gap technique (MGT) and measured resection technique (MRT) in PS-TKA. Material: The subjects were 256 patients with varus type osteoarthritic knees, underwent primary PS-TKAs. The surgical techniques were MGT in 112 patients (96 female, 16 male) and MRT in 144 patients (118 female, 26 male). There were no significant differences between two groups in the pre-operative clinical features including age, sex, ROM and deformity. Method: A distal femoral and a proximal tibial osteotomy were performed perpendicular to the mechanical axis. Ligament imbalance in the coronal plane was corrected by medial soft tissue release, which should be carefully performed not to be excessive until a spacer block corresponding to resected bone thickness from lateral tibial plateau could be inserted at extension. The residual lateral laxity was permitted. Following extension gap preparation, a varus angle ( ) and joint center gap (mm) at the knee extension and 90 of flexion were measured using an offset type tensor with applying 40 lbs. (177.9N) of joint distraction force. As for the flexion gap preparation, in the MGT group, the level of femoral posterior condylar osteotomy was determined based on the difference of joint center gap between extension and flexion, and femoral rotation angle were based on the varus angle difference.