BACKGROUND:For patients with anterior cruciate ligament re-rupture after reconstruction with abnormally increased posterior slope of the tibial plateau,anterior cruciate ligament reconstruction combined with anterior closing-wedge high tibial osteotomy was performed.However,there is a lack of precise tools for osteotomy.OBJECTIVE:To investigate the effectiveness of three-dimensional(3D)printed accurate osteotomy template in anterior cruciate ligament revision for patients with excessive posterior slope.METHODS:The medical records of 30 patients who underwent anterior cruciate ligament revision combined with anterior closing-wedge high tibial osteotomy were retrospectively collected and divided into two groups according to the operation method.The trial group(n=15)was assisted by 3D printing osteotomy guide plate.The control group(n=15)was conventional surgery.The osteotomy time,fluoroscopy times,intraoperative and 24 hours postoperative blood loss,preoperative and 3 months postoperative tibiofemoral anatomical angle,medial proximal tibial anatomical angle,posterior slope,the difference between planned posterior slope correction angle and actual correction angle,and KT-2000 side-to-side difference before operation,3 and 24 months after operation were compared between the two groups.Lachman test and Pivot shift test were performed before operation,immediately after operation,and 24 months after operation.International Knee Documentation Committee score and Lysholm score were performed before operation,3 and 24 months after operation.RESULTS AND CONCLUSION:(1)The osteotomy time,fluoroscopy times,and blood loss during operation and 24 hours after operation in the trial group were significantly less than those in the control group(P＜0.05).(2)The posterior slope of the two groups decreased significantly after operation.There was no significant change in tibiofemoral anatomical angle and medial proximal tibial anatomical angle after operation.The difference between preoperative planned and postoperative actual posterior slope degree in the trial group(0.64±0.41)° was smaller than that in the control group(2.18±0.54)°,and the difference was statistically significant(P＜0.001).(3)The KT-2000 side-to-side difference was significantly reduced in both groups after surgery(P＜0.05).At 3 and 24 months after operation,there was no significant difference in KT-2000 side-to-side difference between the two groups(P＞0.05).The Lachman test and Pivot shift test of the two groups were negative immediately after operation,3 and 24 months after operation.(4)The International Knee Documentation Committee and Lysholm scores of the two groups increased significantly after surgery(P＜0.05).At 3 months after operation,the International Knee Documentation Committee score and Lysholm score of the trial group were significantly higher than those of the control group(P＜0.05).At 24 months after operation,there was no significant difference in International Knee Documentation Committee score and Lysholm score between the two groups(P＞0.05).(5)In conclusion,with the assistance of 3D printing accurate osteotomy guide plate,anterior cruciate ligament reconstruction combined with anterior closing-wedge high tibial osteotomy is easier to operate,with shorter operation time,fewer fluoroscopy times,less intraoperative and postoperative blood loss,and faster recovery of knee joint function after operation,which has high clinical application value.

Objective:To analyze the influencing factors of extremely high cost cases under disease diagnosis related grouping (DRG) payment, for references for further improving China′s medical insurance payment system.Methods:The inpatient medical record homepage and medical insurance settlement list data of medical insurance settlement cases in a tertiary hospital in 2022 were Collected; 19 potential influencing factors such as gender, age, and hospitalization status were used as independent variables, and extremely high cost cases as dependent variables. Single factor analysis and directed acyclic graphs were used to screen for independent variables; Logistic regression model was used to analyze the influencing factors of extremely high cost cases.Results:A total of 17 028 hospitalized patients were contained, including 815 cases with extremely high costs. After analysis, the older the age, the greater the positive impact on cases with extremely high costs ( P<0.001); Third/fourth level surgery had a positive impact on these cases ( P<0.05); Emergency/critical hospitalization negative impact on extremely high cost cases ( P<0.001); Coding downgrade, surgical, intensive care unit discharge, and death positive impact cases with extremely high costs ( P<0.001); The higher the proportion of drugs, the greater the positive impact on cases with extremely high costs ( P<0.001); Compared with treatment costs accounting for ≤10%, treatment costs accounting for (10%, 30%] had a positive impact on cases with extremely high costs ( P<0.001), while treatment costs accounting for >30% had a negative impact ( P=0.007); Complications and/or comorbidities negative impact on thses cases ( P<0.001); The higher the weight of the disease group, the greater the negative impact on cases with extremely high costs ( P<0.001). Conclusions:There were many influencing factors for extremely high cost cases, among which factors such as advanced age, emergency/critical hospital admission, third/fourth level surgery, code downgrade, and high drug proportion would increase the number of extremely high cost cases, accompanied by complications and/or comorbidities, and the high weight of disease group reduce the number of extremely high cost cases. Medical institutions should strengthen internal management by standardizing admission management and optimizing the structure of hospitalization expenses; The medical insurance management department should focus on improving the DRG grouping scheme, scientifically setting the weight of disease groups, and jointly promoting the reform of China′s medical insurance payment system.

OBJECTIVE: To compare early graft healing between over-the-top (OTT) and anatomic single-bundle (SB) anterior cruciate ligament (ACL) reconstruction. METHODS: A clinical data of 40 patients underwent ACL reconstruction, who admitted between June 2021 and October 2022 and met the selective criteria, was retrospectively analyzed. Among them, 20 patients were treated with OTT reconstruction (OTT group) and 20 with SB reconstruction (SB group). There was no significant difference between groups ( P>0.05) in the gender, age, affected side, disease duration, degree of meniscus injury, body mass index, and preoperative International Knee Documentation Committee (IKDC) score, Lysholm score, pain visual analogue scale (VAS) score, and KT-2000 measurement. At 3, 6, and 12 months, MRI was performed to measure the signal noise quotient (SNQ) of the proximal end, middle, and distal end of the graft in the two groups, as well as at the corner of the graft with lateral femoral condyle and 1 cm around the femoral fixation point in the OTT group, to observe the degree of graft healing. Before operation and at 3, 6, and 12 months, the knee function and pain were evaluated by IKDC score, Lysholm score, and VAS score. Before operation and at 12 months after operation, the KT-2000 measurement was taken to evaluation the knee joint stability. RESULTS: All operations were successfully completed in both groups and the incisions healed by first intention. All patients were followed up 12-15 months (mean, 12.9 months), with no significant difference in the follow-up time between groups ( P>0.05). After operation, the IKDC score, VAS score, and Lysholm score improved gradually over time in both groups, with significant differences between different time points ( P<0.05). The differences between groups at 3, 6, and 12 months after operation were not significant ( P>0.05). The anterior and posterior stability of the knee joint improved significantly in both groups at 12 months after operation, and the difference in KT-2000 measurements was significant when compared with the preoperative value ( P<0.05), but the difference of pre- and post-operation between groups was not significant ( P>0.05). At 3, 6, and 12 months after operation, MRI showed that the differences in the SNQ of the proximal end and middle of the grafts between the two groups were not significant ( P>0.05), and the SNQ of distal end was significantly higher in the SB group than in the OTT group ( P<0.05). At each time point, grafts in the OTT group had the highest SNQ at the corner and the lowest at the fixation point, and the differences were significant compared to the other sites ( P<0.05). In the two groups, except for the fixation point, the SNQ of the remaining sites were highest at 6 months and lowest at 12 months ( P<0.05). In addition, there were significant differences in SNQ between the different sites of grafts ( P<0.05), and the SNQ was lowest at proximal end and highest at distal end. At last follow-up, the knee grafts in both groups were in good shape and no graft necrosis or loosening of the internal fixation was observed. CONCLUSION The knee joint function and graft healing after OTT reconstruction of ACL are similar to those of SB reconstruction, but it should be noted that the healing at the corner of the graft is slower.
Retrospective Studies ; Treatment Outcome ; Anterior Cruciate Ligament Reconstruction/rehabilitation* ; Follow-Up Studies ; Tibial Meniscus Injuries/surgery* ; Patient Positioning/methods* ; Recovery of Function ; Pain Measurement ; Knee Joint/surgery* ; Humans ; Male ; Female ; Adult ; Wound Healing

Anterior cruciate ligament (ACL) injury of the knee is a common sports injury that leads to knee instability, articular cartilage degeneration, periarticular ligaments and meniscus injuries. Arthroscopic anterior cruciate ligament reconstruction (ACLR) is the gold standard in the treatment of ACL injuries, but femoral fixation, being one of the main factors affecting postoperative function after ACLR, remains controversial with various methods and no universal standard. Interference screws as a commonly used fixation method are made of various materials, among which metal screws provide strong fixation but have the disadvantages of graft damage, interference with the MRI examination, and a removal surgery. Degradable metal has good mechanical properties but its degradation is unpredictable. Bioabsorbable interference screws do not require a second operation and do not interfere with the MRI examination, but there are risks of screw breakage, dislocation, and bone tunnel widening. Sheathed interference screws increase the tendon-bone contact area but require a high level of integrity of the bone tunnel. Suspension fixation, the most commonly used method for ACLR femoral side, provides high initial strength, but may cause tendon lengthening, wiper effect and bungee effect. Cross-pin fixation such as Rigidfix, fixes the graft with two absorbable transverse nails with even stress distribution. However, it has a limited choice of femoral tunnel location,poses a risk of cross-pin fracture, and is not suitable for patients with tendons smaller than 7 mm in diameter. Over-the-top fixation does not need the building of a femoral tunnel and is more commonly used in skeletally immature, partial ACL injuries and ACLR revision surgery, where damage to the epiphysis can be avoided and can be used as a means of reinforcement. However, it is not sufficient in patients with high requirements for knee flexion stability and requires longer tendon graft.

Anterior cruciate ligament (ACL) injury of the knee is a common sports injury that leads to knee instability, articular cartilage degeneration, periarticular ligaments and meniscus injuries. Arthroscopic anterior cruciate ligament reconstruction (ACLR) is the gold standard in the treatment of ACL injuries, but femoral fixation, being one of the main factors affecting postoperative function after ACLR, remains controversial with various methods and no universal standard. Interference screws as a commonly used fixation method are made of various materials, among which metal screws provide strong fixation but have the disadvantages of graft damage, interference with the MRI examination, and a removal surgery. Degradable metal has good mechanical properties but its degradation is unpredictable. Bioabsorbable interference screws do not require a second operation and do not interfere with the MRI examination, but there are risks of screw breakage, dislocation, and bone tunnel widening. Sheathed interference screws increase the tendon-bone contact area but require a high level of integrity of the bone tunnel. Suspension fixation, the most commonly used method for ACLR femoral side, provides high initial strength, but may cause tendon lengthening, wiper effect and bungee effect. Cross-pin fixation such as Rigidfix, fixes the graft with two absorbable transverse nails with even stress distribution. However, it has a limited choice of femoral tunnel location,poses a risk of cross-pin fracture, and is not suitable for patients with tendons smaller than 7 mm in diameter. Over-the-top fixation does not need the building of a femoral tunnel and is more commonly used in skeletally immature, partial ACL injuries and ACLR revision surgery, where damage to the epiphysis can be avoided and can be used as a means of reinforcement. However, it is not sufficient in patients with high requirements for knee flexion stability and requires longer tendon graft.

BACKGROUND:For patients with anterior cruciate ligament re-rupture after reconstruction with abnormally increased posterior slope of the tibial plateau,anterior cruciate ligament reconstruction combined with anterior closing-wedge high tibial osteotomy was performed.However,there is a lack of precise tools for osteotomy.OBJECTIVE:To investigate the effectiveness of three-dimensional(3D)printed accurate osteotomy template in anterior cruciate ligament revision for patients with excessive posterior slope.METHODS:The medical records of 30 patients who underwent anterior cruciate ligament revision combined with anterior closing-wedge high tibial osteotomy were retrospectively collected and divided into two groups according to the operation method.The trial group(n=15)was assisted by 3D printing osteotomy guide plate.The control group(n=15)was conventional surgery.The osteotomy time,fluoroscopy times,intraoperative and 24 hours postoperative blood loss,preoperative and 3 months postoperative tibiofemoral anatomical angle,medial proximal tibial anatomical angle,posterior slope,the difference between planned posterior slope correction angle and actual correction angle,and KT-2000 side-to-side difference before operation,3 and 24 months after operation were compared between the two groups.Lachman test and Pivot shift test were performed before operation,immediately after operation,and 24 months after operation.International Knee Documentation Committee score and Lysholm score were performed before operation,3 and 24 months after operation.RESULTS AND CONCLUSION:(1)The osteotomy time,fluoroscopy times,and blood loss during operation and 24 hours after operation in the trial group were significantly less than those in the control group(P＜0.05).(2)The posterior slope of the two groups decreased significantly after operation.There was no significant change in tibiofemoral anatomical angle and medial proximal tibial anatomical angle after operation.The difference between preoperative planned and postoperative actual posterior slope degree in the trial group(0.64±0.41)° was smaller than that in the control group(2.18±0.54)°,and the difference was statistically significant(P＜0.001).(3)The KT-2000 side-to-side difference was significantly reduced in both groups after surgery(P＜0.05).At 3 and 24 months after operation,there was no significant difference in KT-2000 side-to-side difference between the two groups(P＞0.05).The Lachman test and Pivot shift test of the two groups were negative immediately after operation,3 and 24 months after operation.(4)The International Knee Documentation Committee and Lysholm scores of the two groups increased significantly after surgery(P＜0.05).At 3 months after operation,the International Knee Documentation Committee score and Lysholm score of the trial group were significantly higher than those of the control group(P＜0.05).At 24 months after operation,there was no significant difference in International Knee Documentation Committee score and Lysholm score between the two groups(P＞0.05).(5)In conclusion,with the assistance of 3D printing accurate osteotomy guide plate,anterior cruciate ligament reconstruction combined with anterior closing-wedge high tibial osteotomy is easier to operate,with shorter operation time,fewer fluoroscopy times,less intraoperative and postoperative blood loss,and faster recovery of knee joint function after operation,which has high clinical application value.

Objective:To analyze the influencing factors of extremely high cost cases under disease diagnosis related grouping (DRG) payment, for references for further improving China′s medical insurance payment system.Methods:The inpatient medical record homepage and medical insurance settlement list data of medical insurance settlement cases in a tertiary hospital in 2022 were Collected; 19 potential influencing factors such as gender, age, and hospitalization status were used as independent variables, and extremely high cost cases as dependent variables. Single factor analysis and directed acyclic graphs were used to screen for independent variables; Logistic regression model was used to analyze the influencing factors of extremely high cost cases.Results:A total of 17 028 hospitalized patients were contained, including 815 cases with extremely high costs. After analysis, the older the age, the greater the positive impact on cases with extremely high costs ( P<0.001); Third/fourth level surgery had a positive impact on these cases ( P<0.05); Emergency/critical hospitalization negative impact on extremely high cost cases ( P<0.001); Coding downgrade, surgical, intensive care unit discharge, and death positive impact cases with extremely high costs ( P<0.001); The higher the proportion of drugs, the greater the positive impact on cases with extremely high costs ( P<0.001); Compared with treatment costs accounting for ≤10%, treatment costs accounting for (10%, 30%] had a positive impact on cases with extremely high costs ( P<0.001), while treatment costs accounting for >30% had a negative impact ( P=0.007); Complications and/or comorbidities negative impact on thses cases ( P<0.001); The higher the weight of the disease group, the greater the negative impact on cases with extremely high costs ( P<0.001). Conclusions:There were many influencing factors for extremely high cost cases, among which factors such as advanced age, emergency/critical hospital admission, third/fourth level surgery, code downgrade, and high drug proportion would increase the number of extremely high cost cases, accompanied by complications and/or comorbidities, and the high weight of disease group reduce the number of extremely high cost cases. Medical institutions should strengthen internal management by standardizing admission management and optimizing the structure of hospitalization expenses; The medical insurance management department should focus on improving the DRG grouping scheme, scientifically setting the weight of disease groups, and jointly promoting the reform of China′s medical insurance payment system.

With the popularity of sports, the number of anterior cruciate ligament (ACL) injuries in children is increasing year by year. Most ACL injuries in children are tibial avulsion fractures or ACL body tears, seriously affecting the health and sports level of the patients. Due to the special anatomical structure of the patients, unclosed epiphysis makes the diagnosis and treatment of ACL injuries more complex. It is necessary to choose the optimal treatment regimen according to the bone maturity and the type and degree of ACL injuries to reduce the damage to the epiphysis and avoid the impact on the growth and development of the patients. It was treated with non-surgical treatment and then ACL reconstruction when the bones were mature in the past, which could cause secondary meniscus and cartilage damage. In recent years, non-surgical treatment has mainly been indicated for children with low-degree ACL injuries and small demand for exercise. With the increased ratio of early surgical treatment, the patients′ levels of recovery and return to sports after injury have been improved. However, improper surgery may still lead to complications such as growth and development disorders and postoperative re-injuries. Different from traditional ACL reconstruction, personalized diagnosis and treatment regimen of ACL injuries are very important for the patients at different stages of growth and development. For a better understanding of the diagnosis and treatment of ACL injuries in children, the authors reviewed the research progress on the diagnosis and treatment of ACL injuries in children from the aspects of the characteristics, diagnosis and evaluation, treatment methods, etc., hoping to provide a reference for the personalized diagnosis and treatment.

Objective:To investigate the clinical efficacy of over-the-top reconstruction combined with the modified Lemaire technique in the treatment of anterior cruciate ligament (ACL) injuries with pivot-shift positive.Methods:From March 2020 to October 2021, a total of 46 patients with ACL injury and pivot-shift test grade II or above were admitted to Xinhua Hospital Affiliated to Dalian University. There were 28 males and 18 females, aged 28.0±10.5 years (range, 15-45 years). All cases were unilateral, including 17 cases of left knee and 29 cases of right knee. The pivot-shift test showed that 30 cases were grade II and 16 cases were grade III, and the cause of injury was sports injury. The semitendinosus muscle and gracilis muscle were harvested, and the ACL was reconstructed with the over-the-top combined modified Lemaire technique. The International Knee Documentation Committee (IKDC) score, Lysholm score and KT-2000 side-to-side difference before and after operation were compared.Results:All patients successfully completed the operation and were followed up for 26.6±2.3 months (range, 24-28 months). The Lysholm scores of the patients at 3 months and 24 months after operation were 73.6±4.3 and 91.6±2.8, which were higher than those before operation (58.5±4.6), and the difference was statistically significant ( F=18.351, P<0.001). The IKDC scores of patients at 3 months and 24 months after operation were 59.0±2.0 and 91.8±3.2, respectively, which were higher than those before operation 50.3±2.8, and the difference was statistically significant ( F=17.290, P<0.001). The side-to-side difference of KT-2000 was 1.7±0.8 mm and 1.5±0.4 mm at 3 and 24 months after operation, respectively, which was lower than that before operation (5.9±1.1 mm), and the difference was statistically significant ( F=14.192, P<0.001). At 24 months after operation, 3 patients had pivot shift test grade I and 4 patients had Lachman test grade I, but they complained of good knee stability and did not receive further treatment. At the last follow-up, there were no complications such as incision and intra-articular infection, deep vein thrombosis, knee stiffness, quadriceps musculus ossificans myositis, and reconstruction ligament rupture. All patients returned to sports with an average time of 15.7±2.6 months (range, 12-24 months). Conclusion:Over-the-top reconstruction combined with the modified Lemaire technique for the treatment of ACL injury with positive pivot shift test effectively improves knee function and promotes the patient's return to sports, with a low incidence of surgical complications.

Objective:To evaluate the short-term clinical outcomes of meniscus reconstruction using autologous peroneus longus tendon grafts.Methods:A retrospective analysis was conducted on 20 patients (12 males, 8 females) with a mean age of 37.8±5.7 years (range, 31-47 years) and a mean body mass index (BMI) of 26.3±5.8 kg/m 2 (range, 20.1-31.3 kg/m 2) who underwent meniscal reconstruction with autologous peroneus longus tendon in Affiliated Xinhua Hospital of Dalian University from June 2020 to June 2022. A control group of 20 patients (15 males, 5 females), with a mean age of 39.1±6.2 years (range, 32-47 years) and a mean BMI of 25.6±5.4 kg/m 2 (range, 20.2-32.7 kg/m 2), underwent partial meniscectomy during the same period. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, visual analogue scale (VAS) for pain, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 3, 6, 12, and 24 months postoperatively. The morphology and signal intensity of grafts, Recht grading for cartilage damage, and the need for secondary arthroscopy were also evaluated. Results:The mean follow-up duration was 24.3±4.3 months for the tendon graft group and 24.2±3.6 months for the partial meniscectomy group. At 3 and 6 months postoperatively, the partial meniscectomy group demonstrated superior knee function scores compared to the tendon graft group ( P<0.05). Similarly, VAS were lower in the partial meniscectomy group at 3 months postoperatively ( P<0.05), although no significant difference was found at 6 months ( P>0.05). By 12 months postoperatively, differences in pain and function between the two groups were no longer statistically significant ( P>0.05). At 24 months, the tendon graft group exhibited significantly better outcomes in terms of the Lysholm score (84.31±12.20 vs. 72.67±14.18), IKDC score (82.21±10.55 vs. 74.09±11.68), VAS score (2.10±1.74 vs. 3.80±1.81), and KOOS score (85.37±13.14 vs.75.14±17.94) compared to the partial meniscectomy group ( P<0.05). Regarding graft healing, 19 patients in the tendon graft group demonstrated a grade 3 graft-residual meniscus complex at 24 months, significantly improved from 5 patients at 3 months postoperatively. Furthermore, no grafts showed a grade 3 signal intensity at 3 months, while 19 patients showed such improvements by 24 months. MRI at the 24-month follow-up revealed cartilage damage in 7 patients in the tendon graft group and 20 patients in the partial meniscectomy group, with severe cartilage damage (Recht grade>II) observed in 1 patient in the tendon graft group and 7 patients in the partial meniscectomy group. All 20 patients in the tendon graft group achieved minimal clinically significant differences by 24 months, and 4 of them underwent secondary arthroscopy, which revealed vascularization between the graft and residual meniscal tissue. Conclusion:The use of the peroneus longus tendon for meniscal reconstruction reduces knee pain, enhances knee function, and effectively fills the tibiofemoral joint space while protecting the articular cartilage through graft remodeling.