Absorbable Interference Screw Research Articles

Arthroscopic Hill-Sachs Filling Technique Using an Absorbable Interference Screw

We present an arthroscopic technique used to treat traumatic shoulder instability in the patient with a Hill-Sachs lesion, especially an off-track lesion. The incidence of this bony defect is approximately 40% to 90% of all anterior shoulder instability cases—and up to 100% in patients with recurrent anterior instability. Incorrect management of this humeral bone defect can lead to treatment failure, and it is essential to define characteristics such as the lesion’s location, depth, width, and orientation. Many arthroscopic and open procedures have been described for the surgical management of the Hill-Sachs lesion. Using arthroscopy for the surgical treatment of shoulder instability offers numerous advantages. We describe an arthroscopic technique that consists of filling the Hill-Sachs lesion with absorbable interference screws made out of an advanced biocomposite material. After repair of the Hill-Sachs lesion, the Bankart lesion is repaired. As these screws are resorbed by bone tissue over several months, the bony anatomy is restored.

Comparaison clinique et radiologique des vis d’interférence biorésorbables en verre bioactif versus en acide poly-L-lactique/hydroxyapatite pour la fixation de greffe tibiale dans la reconstruction du ligament croisé antérieur

BackgroundLigament reconstruction is still the main treatment modality for patients with a complete ligament rupture. The semitendinosus tendon, alone quadrupled or double folded and combined with the gracilis tendon is still the most frequently used autologous graft for a reconstructive procedure. Absorbable interference screw usage has gained popularity in the past decade because they create less artifacts during MR imaging and tend to osteointegrate over the years, arguably leading to a more anatomic fixation. The purpose of this study was to compare the 5-year radiological and clinical results of two different tibial graft fixation screws. HypothesisWe hypothesized that bioabsorbable interference screws made of bioactive glass would lead to higher rates of osteointegration, better overall clinical results, less foreign body reaction rates and less tibial tunnel widening when compared to the poly-L-lactic acid/hydroxyapatite (PLLA-HA) screws. Patients and methodsFifty-one patients treated with an anatomic single bundle ACL reconstruction between June 2015 and July 2016 at our institution were included in the study. The tibial graft was fixed with a bioactive glass screw in 24, and with a PLLA-HA in 27 patients. Tibial tunnel widening, foreign body reaction, osteointegration and resorption rates were evaluated and compared on a magnetic resonance scan at a minimum of 5 year postoperatively. Overall clinical results and side-to-side difference on KT-1000 were also analyzed in-between groups. ResultsTibial tunnel widening was similar for both groups. Foreign body reaction, while not statistically significant, was less aggressive when bioactive glass screws were used. Osteointegration and resorption rates of the bioactive glass screws were significantly higher than the PLLA-HA group (p=0.000). While all patients showed an overall improvement on postoperative scores (p=0.000), patients with a bioactive glass interference screw had statistically higher translational stability with KT-1000, compared to the poly-L-lactic acid/hydroxyapatite group (p=0.001). DiscussionAt a minimum of 5years, compared to conventional PLLA-HA interference screws, 45S5 bioactive glass screw provide higher resorption rates, are more highly biodegradable and provide overall good clinical results. Level of evidenceIII.

Clinical and radiological comparison of bioactive glass and poly-L-lactic acid/hydroxyapatite bioabsorbable interference screws for tibial graft fixation in anterior cruciate ligament reconstruction

BackgroundLigament reconstruction is still the main treatment modality for patients with a complete ligament rupture. The semitendinosus tendon, alone quadrupled or double folded and combined with the gracilis tendon, is still the most frequently used autologous graft for a reconstructive procedure. Absorbable interference screw usage has gained popularity in the past decade because they create less artifacts during MR imaging and tend to osteointegrate over the years, arguably leading to a more anatomic fixation. The purpose of this study was to compare the 5-year radiological and clinical results of two different tibial graft fixation screws. HypothesisWe hypothesized that bioabsorbable interference screws made of bioactive glass would lead to higher rates of osteointegration, better overall clinical results, less foreign body reaction rates and less tibial tunnel widening when compared to the poly-L-lactic acid/hydroxyapatite (PLLA-HA) screws. Patients and methodsFifty-one patients treated with an anatomic single bundle ACL reconstruction between June 2015 and July 2016 at our institution were included in the study. The tibial graft was fixed with a bioactive glass screw in 24, and with a PLLA-HA in 27 patients. Tibial tunnel widening, foreign body reaction, osteointegration and resorption rates were evaluated and compared on a magnetic resonance scan at a minimum of 5 year postoperatively. Overall clinical results and side-to-side difference on KT-1000 were also analyzed in-between groups. ResultsTibial tunnel widening was similar for both groups. Foreign body reaction, while not statistically significant, was less aggressive when bioactive glass screws were used. Osteointegration and resorption rates of the bioactive glass screws were significantly higher than the PLLA-HA group (p=0.000). While all patients showed an overall improvement on postoperative scores (p=0.000), patients with a bioactive glass interference screw had statistically higher translational stability with KT-1000, compared to the poly-L-lactic acid/hydroxyapatite group (p=0.001). DiscussionAt a minimum of 5 years, compared to conventional PLLA-HA interference screws, 45S5 bioactive glass screw provide higher resorption rates, are more highly biodegradable and provide overall good clinical results. Level of evidenceIII.

English

BACKGROUND Traditionally, metallic interference screws were considered to have increased resistance to load than bio absorbable screws in anterior cruciate ligament (ACL) reconstruction. We did a comparative evaluation of biodegradable and metallic interference screws for tibial sided ACL reconstruction and also analysed complications, compared clinical outcome, did imaging study of ACL single bundle reconstruction by using titanium & newer poly–L-lactic acid (PLLA) bio absorbable screws to determine as to whether bio absorbable screw which costs double the metallic screw, is functionally better than standard metallic screws. METHODS This is a prospective comparative study conducted among 50 patients aged between 15 and 55 years with clinical and MRI confirmation of complete ACL tear, treated arthroscopically with ACL reconstruction with either bio absorbable (group 1) or metallic (group 2) interference screw and both the groups were compared on follow up for an average duration of 12 months. Lysholm and Gillquist Knee Scoring Scale were used and outcome scores were divided into excellent, good, fair and poor. RESULTS In our study 41 patients were males and 9 were females. Bio screw was used in 24 males and 6 female patients. Metallic screw was used in 17 males and 3 females. Outcome score was excellent in 26 (52 %) cases, good in 18 (36 %) cases, fair in 4 (8 %) cases, poor in 2 (4 %) cases. The mean Lysholm score in bio absorbable group was 93.13 and in metallic group was 89.70. Knee effusion was higher in bio screw group and infection rate was higher in metallic group. CONCLUSIONS In our study, the difference between bio absorbable screw group and metallic screw group was insignificant with regard to final patient outcome. Final osseointegration was better with bio absorbable screw, but increased cost of implant and almost same results compared to metallic screw does not make the bio absorbable screw superior to its counterpart. KEYWORDS ACL, Bio Absorbable Interference Screws, Metallic Interference Screws

Thumb Carpometacarpal Suspension Arthroplasty With Flexor Carpi Radialis Ligament Reconstruction and Tendon Interposition Using An Absorbable Interference Screw: A Volar Approach Technique.

The goal of operative intervention for pantrapezial arthritis is to relieve pain, maintain or improve motion, stability, and strength, and restore function. The purpose of this article is to present a volar approach to thumb carpometacarpal suspension arthroplasty using an absorbable interference screw for flexor carpi radialis ligament reconstruction and tendon interposition in the treatment of pantrapezial arthritis. This technique allows for visualization of the volar beak and avoidance of the radial artery and the branches of the superficial radial nerve while allowing optimal surgical manipulation for suspensionplasty with interference screw fixation and tendon interposition at the carpometacarpal joint.

FUNCTIONAL OUTCOME OF ARTHROSCOPIC SINGLE BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING QUADRUPLE HAMSTRING GRAFT FIXED WITH ADJUSTABLE LOOP ENDO BUTTON AND BIO INTERFERENCE SCREW AT TERTIARY RURAL CENTRE

Objective: Anterior cruciate ligament (ACL) is the most common ligament to be replaced in the knee joint and ACL reconstruction (ACLR) is one of the most commonly performed surgery in orthopaedics nowadays. This study evaluated short term results of anterior cruciate ligament reconstruction with quadruple hamstring autograft using adjustable loop endobutton for femoral fixation and Bio absorbable interference screw for tibial fixation. Material and methods: 40 patients were operated for ACL reconstruction using quadruple autologous hamstring graft with adjustable loop endobutton and bio interference screw. Following the surgery the patients undergone standard rehabilitation protocol. The patients were followed up in OPD and their functional outcomes were measured by Lysholm scoring and IKDC scoring at 2 weeks, 8 weeks, 12 weeks, 24 weeks. Result: A total of 40 patients were evaluated in which there were 36 male patients and 4 female patients with a mean age of 26.75±5.95 and 25.25±7.27. The mean Lysholm score were 89.62±8.90 at 24 weeks of follow up compared to 79.38±11.32 at preoperative. The mean IKDC score were 85.06±9.35 at 24 weeks of follow up compared to 56.703±12.27 at preoperative. Conclusion: Arthroscopic ACL reconstruction and graft fixation using adjustable loop endobutton for the femoral end fixation and bioabsorbable interference screw fixation at the tibial end give an excellent result with minor complications. Keywords: ACL reconstruction, adjustable loop endobutton, hamstring graft.

Comparative analysis of the functional outcome of arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft fixed with bio absorbable interference screw against titanium interference screw

INTRODUCTION: Knee injuries are more common in the modern era due to increase in road traffic accidents and more involvement in sports related activities by common people. Anterior cruciate ligament is the most commonly injured ligament around knee joint. Anterior cruciate ligament has a pivot role in function and stability of the knee joint, being the primary stabilizer preventing the anterior translation of tibia over femur. Arthroscopic anterior cruciate ligament reconstruction has become the gold standard in the management of these injuries. AIM OF THE STUDY: To do comparative analysis of the functional outcome of Arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft with endobutton as femoral fixation device and bioabsorbable interference screw against titanium interference screw as tibial fixation devices respectively. MATERIALS & METHODS: This study is a retrospective and prospective study of 60 patients treated with arthroscopic anterior cruciate ligament reconstruction with quadrupled hamstring graft with endobutton as the femoral fixation device and titanium interference screw (no=30) and bioabsorbable interference screw (no=30) as tibial fixation device respectively between May 2012 and November 2013 at Institute of orthopaedics and traumatology, Rajiv Gandhi Government General Hospital, Chennai. Minimum age of the patient was 20 years and maximum age was 55 years with mean age of 31. Study group included 51 male patients and 9 female patients. Minimum duration after injury was 5 weeks and maximum duration since injury was 15 months. Minimum period of follow up was 6 months and maximum was 1.5 years. Of the 60 patients, 30 patients underwent arthroscopic assisted anterior cruciate ligament reconstruction with quadrupled hamstring graft with endobutton as femoral fixation device and tiatanium interference screw as tibial fixation device. Remaining 30 patients underwent arthroscopic assisted anterior cruciate ligament reconstruction with quadrupled hamstring graft with endobutton as femoral fixation device and bioabsorbable interference screw as tibial fixation device. All patients were operated under spinal aneasthesia. Except for 2 patients, postopearative period was uneventful for others. RESULTS: All patients are evaluated with Lysholm and Gillquist scoring at the end of 6 months. The maximum score achieved was 100 and minimum score was 56. Two patients in titanium interference group and one patient in bioabsorbable interference screw group lost to followup. Statistical analysis was studied using Yate’s corrected Chi-Square test. No significant differences were identified between the two screw typeswith respect to Lysholm and Gillquist scoring. The complication rates were also similar in the two groups. CONCLUSION: The clinical results associated with titanium interference screw and bioabsorbable interference screw are statistically similar. The complication rates associated with the two screws were also similar. The results of this comparative analysis support the hypothesis that there are no significant differences in the outcomes associated with tiaanium screws compared with bioabsorbable screws for ACL reconstruction.

Effects of hydroxyapatite (HA) particles on the PLLA polymeric matrix for fabrication of absorbable interference screws

Polymeric interference screws, especially poly(l-lactic acid) (PLLA), have gained significant attention for anterior cruciate ligament (ACL) reconstruction. In this study, a polymeric composite of PLLA with hydroxyapatite (HA) particles was made with an internal mixing chamber. A two-stage injection molding machine was used for manufacturing of interference screws. PLLA and the PLLA mixture with hydroxyapatite were used for injection molding. Different characterization techniques were used to study the physical, mechanical and biological properties of the samples. Techniques such as particle size analysis (PSA), field emission scanning electron microscopy (FESEM), thermogravimetric analysis (TGA), differential scanning calorimetry (DSC), energy-dispersive spectroscopy (EDS), degradation, pH analysis, and tensile testing were performed. Some in vitro assays such as alkaline phosphatase (ALP), MTT and cell attachment for MG63 osteoblastic cells were investigated. Due to a fast cooling rate of the produced screws after injection in metallic molds, the microstructure crystallinity was reduced for both of PLLA and PLLA–HA screws. The degradation rate of composite screws was 2.58% after 4 weeks. For the same duration, it was 1.16% for PLLA. The tensile strength of PLLA–HA was 21% lower compared to the PLLA screw. According to the results of in vitro cell assays, biocomposite PLLA–HA screws have improved cell attachment, and also no cytotoxic effects were observed for both groups of screws after injection.

Treatment of patellofemoral instability in adolescent by anatomical double-bundle medial patellofemoral ligament reconstruction with double suture anchor technique

To explore the clinical outcomes of anatomical double-bundle medial patellofemoral ligament (MPFL) reconstruction with double suture anchor technique in treating patellofemoral instability in adolescent. Methods: Twenty-five young people with patellofemoral instability (25 knees) in our department from January 2013 to December 2014 were enrolled for this study. All patients were performed anatomical double-bundle MPFL reconstruction with arthroscopic-assisted suture anchors technique in the patella, and fixed in the femoral socket with absorbable interference screw. All patients are evaluated by different methods, including patient's satisfaction, patellar apprehension test, recurrent subluxation/dislocation, CT assessment of bone tunnel and patellar tilt angle. Lysholm scores, Tegner scores and Kujala scores were recorded at the final follow-up. Results: The mean follow-up was 24 (range 20-40) months. All cases were observed in negative patellar apprehension test. Infection, recurrent subluxation/dislocation and patellar fracture were not found at the last follow-up. CT results demonstrated that the tunnel position were good. The patellar tilt angle was decreased from 21.6°±2.3° to 10.5°±1.6° (P<0.05); the Lysholm scores was increased from 51.7±5.3 to 93.8±6.5 (P<0.05). Tegner scores was increased from 4.1±1.1 to 5.5±0.6 (P<0.05). Kujala scores was increased from 53.5±6.4 to 94.6±4.3 (P<0.05). Conclusion: Arthroscopic-assisted anatomical double-bundle MPFL reconstruction with the suture anchors technique is a safe, minimal invasive and effective surgical option for treating patellofemoral instability in adolescent.

ASSESSMENT of bIoresorbable Screws and bone tissue in long-term period after the anterior cruciate ligament reconstruction

The use of bioresorbable materials in the anterior cruciate ligament reconstruction is a promising direction. Thus today there is no single point of view on the long-term results of using absorbable interference screws. The article presents an analysis of the results of surgical treatment of 30 patients with use of bioresorbable materials, operated on for rupture of the anterior cruciate ligament (ACL) in the department of traumatology and orthopedics from 2010 to 2016 in the Federal Scientific Clinical Center FMBA of Russia. The aim of our study was to evaluate in vivo transformation of bioresorbable screws and bone assimilation into the tibial canal in long-term period after surgery, as well as the effect of the polymeric material and bone on these processes.

Functional outcome of anterior cruciate ligament reconstruction with quadruple hamstring tendon graft using EndoButton and bioabsorbable interference screw: minimum 2-year follow-up

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Anterior cruciate ligament (ACL) is the most common ligament to be torn in the knee joint and ACL reconstruction (ACLR) is one of the most commonly performed surgery in orthopaedics nowadays. This study evaluated short term results of anterior cruciate ligament reconstruction with quadruple hamstring tendon (QHT) graft using EndoButton for femoral fixation and Bio absorbable interference screw for tibial fixation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Out of the&lt;strong&gt; &lt;/strong&gt;68 patients who underwent single-bundle ACLR with QHT graft using EndoButton for femoral fixation and Bio absorbable interference screw for tibial fixation, 60 patients were followed up for a minimum period of 2 years. Patients were followed up at regular intervals and evaluation was done using the anterior drawer test, Lachman test, pivot-shift test, modified Cincinnati rating system and Tegner-Lysholm knee scoring scale.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; There was improvement in the Lachman test and pivot-shift test at 2 year follow-up, from grade 2 (n=47) or grade 3 (n=6) to grade 1 (n=17) or grade 0 (n=42) and from grade 1 (n=38) or grade 2 (n=12) to grade 1 (n=14) or 0 (n=45), respectively. The mean Modified Cincinnati score and Tegner-Lysholm knee score improved from 59.57 to 99.03 and 64.45 to 98.87 respectively at 2 year follow-up. Complications occurred in 3 patients, a re-rupture due to trauma at 1 year after surgery, development of a cyclops lesion with restricted range of motion and a superficial infection at the graft harvest site.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The two year follow-up results of ACLR with QHT graft using EndoButton for femoral fixation and bioabsorbable interference screw for tibial fixation are satisfactory and comparable with other modalities of graft fixation.&lt;/p&gt;

Arthroscopic anatomical medical patellofemoral ligament reconstruction to treat recurrent patellar dislocation

To investigate the procedure and efficacy of anatomical medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent patellar dislocation assisted with arthroscopy. Between January, 2010 and December 2012, 13 patients with recurrent patellar dislocation, who underwent anatomical MPFL reconstruction and the grafts of operation, were all adopted with autograft semitendinosus. The patellar side used the modified double bone tunnels and the minimally invasive percutaneous grafts through double patellar bone tunnels, and then fixed in the femoral tunnel with absorbable interference screw. Follow-up included the records of the subjective feeling, patellar apprehension test, recurrent dislocation, CT evaluation of bone tunnel position and patellar tilt angle. Knee function was evaluated by the Lysholm score and Kujala score. Twelve patients were followed up for 36 months (range 24-60 months). All patients were satisfied with the treatment. No recurrent dislocation occurred. All the patients showed negative apprehension test. Two patients felt uncomfortable after excessive activity in the knee. Another 2 cases lost 10° flexion than the healthy knee. CT showed that the bone tunnel position were all well. The patellar tilt angle was decreased from 20.52°±1.48° preoperative to 13.52°±1.32° postoperative, with significant difference (t=14.88, P<0. 05); the Kujala score was improved from 55.2±4.51 preoperative to 93.8±3.87 postoperative, with significant difference (t=-36.238, P<0.05); and the Lysholm score was improved from 56.68±5.52 to 93.08±4.68, with significant difference (t=-33.382, P<0.05). MPFL reconstruction assisted with arthroscopy is an effective surgical procedure for the treatment of recurrent patellar dislocation, which can improve the knee function with little trauma and complications.

Biomechanical Comparison Between Bashti Bone Plug Technique and Biodegradable Screw for Fixation of Grafts in Ligament surgery.

Ligament reconstruction is a common procedure in orthopedic surgery. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. We sought to introduce our new technique of Bashti bone plug for fixation of soft tissue graft in anterior cruciate ligament (ACL) reconstruction and to compare its biomechanical features with conventional absorbable interference screw technique in a bovine model. Twenty pairs of bovine knees were harvested after death. Soft tissue was removed and the Achilles tendon was harvested to be used as an ACL graft. It was secured into the bone tunnel on the tibial side via two different methods: Bashti Bone Plug technique and conventional screw method. Biomechanical strength was measured using 200 N and 300 N cyclic loading on the graft. Pull out strength was also tested until the graft fails. No graft failure was observed after 200 N and 300 N cyclic loading in either fixation methods. When testing for pull out failure, 21 tendons (53%) were torn and 19 tendons (48%) slipped out. No fixation failure occurred, which did not reveal a significant difference between the bone plug or interference screw group (P=0.11). The mean pull out force until failure of the graft was 496±66 N in the screw group and 503±67 N in the bone plug group (P=0.76). Our suggested fixation technique of Bashti bone plug is a native, cheap, and feasible method that provides comparable biomechanical strength with interference screw when soft tissue fixation was attempted in bovine model.

Comparison of grafts for anatomical reconstruction of the ACL: patellar versus semitendinosus/gracilis

ObjectiveTo compare the functional results from surgical treatment for anatomical reconstruction of the anterior cruciate ligament (ACL) with a single band, using two types of autologous grafts. MethodsTwenty-seven patients who underwent anatomical reconstruction of the ACL by means of the Chambat technique were evaluated prospectively. They were divided into two groups: A, with 14 patients, using grafts from flexor tendons; and B, with 13 patients, using grafts from the patellar tendon. In both groups, fixation was performed using an absorbable interference screw. ResultsBased on the Lysholm score, group A presented a mean score of 71.6 in the first month, while B presented 75. At the end of the sixth month, both groups presented 96.6. Evaluation of the total IKDC showed that in the first month, the majority of the patients, both in group A (85.7%) and in group B (76.9%), presented a knee assessment that was close to normal. In the sixth month, 92.9% of group A had normal presentations, and 100% of group B. ConclusionAccording to the Lysholm functional evaluation and the IKDC subjective assessment, there was no statistically significant difference in the results between the groups, and the results were better in the sixth month.

Comparação dos enxertos para reconstrução anatômica do LCA: patelar versus semitendíneo/grácil

ObjectiveTo compare the functional results from surgical treatment for anatomical reconstruction of the anterior cruciate ligament (ACL) with a single band, using two types of autologous grafts. MethodsTwenty‐seven patients who underwent anatomical reconstruction of the ACL by means of the Chambat technique were evaluated prospectively. They were divided into two groups: A, with 14 patients, using grafts from flexor tendons; and B, with 13 patients, using grafts from the patellar tendon. In both groups, fixation was performed using an absorbable interference screw. ResultsBased on the Lysholm score, group A presented a mean score of 71.6 in the first month, while B presented 75. At the end of the sixth month, both groups presented 96.6. Evaluation of the total IKDC showed that in the first month, the majority of the patients, both in group A (85.7%) and in group B (76.9%), presented a knee assessment that was close to normal. In the sixth month, 92,9% of group A had normal presentations, and 100% of group B. ConclusionAccording to the Lysholm functional evaluation and the IKDC subjective assessment, there was no statistically significant difference in the results between the groups, and the results were better in the sixth month.

Medial patellofemoral ligament reconstruction in patellar instability.

Background:Medial patellofemoral ligament (MPFL) is one of the major static medial stabilising structures of the patella. MPFL is most often damaged in patients with patellar instability. Reconstruction of MPFL is becoming a common surgical procedure in treating patellar instability. We hypothesised that MPFL reconstruction was adequate to treat patients with patellar instability if the tibial tubercle and the centre of the trochlear groove (TT-TG) value was less than 20 mm and without a dysplastic trochlea.Materials and Methods:30 patients matching our inclusion criteria and operated between April 2009 and May 2011 were included in the study. MPFL reconstruction was performed using gracilis tendon fixed with endobutton on the patellar side and bio absorbable interference screw or staple on the femoral side. Patients were followed up with subjective criteria, Kujala score and Lysholm score.Results:The mean duration of followup was 25 months (range 14-38 months). The mean preoperative Kujala score was 47.5 and Lysholm score was 44.7. The mean postoperative Kujala score was 87 and Lysholm score was 88.06. None of the patients had redislocation.Conclusion:MPFL reconstruction using gracilis tendon gives excellent results in patients with patellar instability with no redislocations. Some patients may have persistence of apprehension.

Anatomic, Physeal Sparing Anterior Cruciate Ligament Reconstruction in the Skeletally Immature

This case series evaluates an anatomic, physeal sparing ACL reconstruction technique in four patients that has preliminarily proven to be effective, both objectively and subjectively, in the skeletally immature. With the growing incidence of anterior cruciate ligament (ACL) injuries in the pediatric population, there has been interest in developing a technique to reconstruct the ligament without disturbing the physes. Previously described all epiphyseal reconstructions spare the growth plates but do not restore the native orientation of the ACL. This case series evaluates an all-epiphyseal technique where the graft is more anatomically placed, particularly on the tibial side. Four skeletally immature patients, one female and three males with an average age of 10.3 ± 2 yrs. (8.4-12.2 yrs.), underwent soft tissue allograft anterior cruciate ligament reconstruction using an all-epiphyseal approach. Two patients had acute ACL tears (< 4 weeks old) and two patients had chronic tears. One of the chronic tear patients had an acute lateral meniscal tear. All reconstructions were performed with an arthroscopically assisted approach by the senior author (CHB). The femoral tunnel was drilled parallel to the physis in the epiphysis of the lateral femoral condyle. The tibial tunnel was drilled from inside to outside using a retrograde drill to the level of the physis. A 2mm guide pin traversing the tibial physis was used to guide the tibial retrograde drill. Intraoperative C-arm imaging confirmed that drilling did not violate the physes. The tibial sided graft was fixed to the anterior tibial cortex over a button. The femoral side was secured with an absorbable interference screw placed from outside to inside. All patients underwent radiographic and MRI evaluation at final follow-up. Subjective and objective measures included KT-1000 testing as well as International Knee Documentation Committee (IKDC) subjective and objective and Lysholm scoring. Mean follow-up was 2.3 ± 0.55 yrs. (1.6-2.9 yrs.). All patients had stable knees and no evidence of limb length discrepancy or angular deformity. Pre-operative KT-1000 testing demonstrated a mean side to side difference of 6mm. Post-operative KT-1000 testing revealed a mean side to side difference of 1.4 ± 0.75mm (0.5-2.0mm). The mean IKDC subjective knee score was 95.7 ± 1.5 (93.8-96.9). The mean Lysholm knee score was 95.5 ± 5.7 (88-100). IKDC objective knee form ratings were A (normal) for the two acute patients, B (nearly normal) for one chronic patient, and C (abnormal) for the one chronic ACL/lateral meniscus repair patient. MRI at two years post operation demonstrated no meniscal or chondral injuries, intact ACL grafts, and no evidence of asymmetric physeal arrest. All patients returned to pre-injury activity levels. This anatomic, all-epiphyseal anterior cruciate ligament reconstruction has preliminarily proven to be effective, both objectively and subjectively, in the skeletally immature. In this series the acutely reconstructed patients had better knee scores. Further follow-up and larger series are needed to confirm long-term efficacy.

Single allograft medial collateral ligament and posterior oblique ligament reconstruction: a technique to improve valgus and rotational stability

We present a novel and simple method for single hamstring allograft MCL and PMC reconstruction, which can improve both joint valgus and external rotational stability and maximize utilization of allograft. All patients received arthroscopic evaluation through inferomedial and inferolateral knee incisions to ascertain whether there were intra-articular injuries. An 8-cm-length longitudinal incision was made from 1 cm above adductor tubercle to 5-cm proximal medial tibia joint line. The anterior tibia insertion was defined as 15 mm lateral from the medial tibia edge and 45 mm below the medial tibia joint line. The posterior tibia insertion was defined as 15 mm lateral from the medial tibia edge and 20 mm below the medial tibia joint line. A 5- or 6-mm reamer was used to drill the tibia tunnel along with guide pin, and a 6 or 7 mm drill was used to drill the femur tunnel to a depth of 25 or 30 mm until the proximal adductor tubercle. The allograft was harvested from tibia and placed into the tunnel and fixed with absorbable interference screw. All patients performed active rehabilitation exercises after the operation periodically.

Die anatomische Ersatzplastik des vorderen Kreuzbands in Einzelbündeltechnik

Restore the knee stability by ACL reconstruction of the anterior cruciate ligament. Acute and chronic functional instability with rupture of the anterior cruciate ligament giving way phenomena, acute rupture of the anterior cruciate ligament with concomitant meniscus repair. Local infection in the knee joint, local soft tissue damage, lack of cooperation of the patient. The operation begins with the examination under anesthesia. It follows an arthroscopic examination of the knee and the arthroscopic treatment of accompanying intra-articular lesions (meniscus and cartilage damage). The semitendinosus tendon is harvested via a 3 cm skin incision medial to the tibial tuberosity. A four stranded tendon graft is prepared with a minimum length of 6.5 cm. Alternative grafts for this technique are the patellar tendon, quadriceps tendon, and allografts. The femoral tunnel for the ACL graft is drilled via a deep anteromedial portal under arthroscopic control. For precise placement of the guide wire a specific offset aimer is used. For drilling the knee must be flexed more than 110°. Landmarks are the intercondylar line and the cartilage-bone interface. The position of the guide wire is always controlled by the medial portal (medial portal view). The guide wire is overdrilled with a cannulated drill (4.5 mm when a flip tack is used). The drill diameter for the 30 mm long blind tunnel is chosen according to the graft diameter. A gentle tunnel preparation may be achieved with the use of dilators. At the tibia, the anterior horn of the lateral meniscus is used as a landmark in the absence of ACL stump. The guide wire is first overdrilled with a 6 mm drill. Slight adjustments to the tibial tunnel location can be archieved when the guide wire is overdrilled eccentrically with a larger drill. At the femur an extracortical fixation technique with a flip button is preferred. At the tibia, a hybrid fixation with absorbable interference screw and button is used. The rehabilitation program is divided into three phases. During the inflammatory phase (1st-2nd week) control of pain and swelling is recommended. The patient is immobilized with 20 kg partial weight bearing. During the proliferative phase (3 nd-6th week), load and mobility are slowly increased. Goal of this phase is it full extension. Exercises should be performed in a closed chain. During the remodeling phase strength and coordination exercises can be started. Athletes should not return to competitive sports before the 6th to 8th month. In a prospective study, we have examined 21 patients treated with an anatomic anterior cruciate ligament reconstruction in single-bundle technique, after two years. As graft the semitendinosus was used. The postoperative MRI diagnosis showed that all tunnels were positioned anatomically. KT 1000 measurement showed that the difference of anterior translation decreased from an average of 6.4-1.7 mm. A sliding pivot shift phenomenon was detected in only one patient. The postoperative Lysholmscore was 94.2 points.

All inside transtibial arthroscopic posterior cruciate ligament reconstruction in skeletally immature: Surgical technique and a case report

Posterior cruciate ligament (PCL) tears are rare in children and may cause posterior instability of the knee. We present an original reconstruction technique. An 11-year-old boy sustained a PCL rupture. Despite initial immobilization followed by physiotherapy, he could not resume his previous sporting activities at the pre-injury level and complained of anterior knee pain. We performed an arthroscopic PCL reconstruction using a single bundle four-strand hamstring autograft. The femoral tunnel was drilled through the epiphysis and the tibial tunnel went through the physis under both arthroscopic and fluoroscopic control. The graft was secured using absorbable interference screws. At 2 years follow-up, the patient was asymptomatic and resumed sports at the same level as before the injury. Clinical examination was normal. There was no sign of growth disturbance. PCL injury is extremely rare in children. This original technique seemed appropriate in a symptomatic patient. IV.