Anatomic Placement Research Articles

Comparison of Inside-Out and Outside-In Methods of Femoral Tunnel Preparation in Anterior Cruciate Ligament (ACL) Reconstruction Using 3D-CT.

IntroductionAnterior cruciate ligament (ACL) reconstruction techniques continue to evolve and the need to address the more anatomical femoral tunnel placement of the graft is critical, and in our study, we assessed the placement of femoral tunnel via transportal and retrograde drilling techniques.Material and methodsSixty patients where n=31 for retrograde, n=29 for transportal were assessed via CT knee for the femoral tunnel aperture on the intercondylar ridge via high low and deep shallow direction ratio and interpreted accordingly.ResultsIn our study, the femoral tunnel done via transportal method (n=29) has a deep shallow ratio range of 22%-47% and mean of 31.9±6.5, and graft is anatomical in 79%. The femoral tunnel done via the retrograde method (n=31) has a deep shallow depth ratio range of 11%-41% with a mean of 27.5±6.5 and graft is anatomical in 77% of the study group and the p-value means the ratio is 0.01 (significant). The femoral tunnel done via transportal method (n=29) has a high low ratio range of 19%-45% and mean of 32.9±6.3 and graft is anatomical in 72%. The femoral tunnel done via the retrograde method (n=31) has a deep shallow depth ratio range of 20%-38% with a mean of 33.9±4.1 and graft is anatomical in 94% of the study group with a p-value mean ratio being 0.51 (insignificant).ConclusionWatch out for the femoral tunnel placement in a deep shallow direction while going for standard transportal technique and high low direction while performing retrograde technique.

Surgical Principles for Medial and Posteromedial Knee Injuries

Injuries to the medial side of the knee are among the most common knee ligament injuries. Treatment of these injuries require a thorough clinical workup and an intricate knowledge of the anatomy and biomechanics involving this region of the knee. Low grade injuries and isolated injuries to the medial collateral ligament (MCL) are treated nonoperatively with bracing and functional rehabilitation. Surgical treatment is recommended for high grade (Grade III) posteromedial corner injuries, distal MCL tears, including Stener lesions, knee dislocations and multiple ligament knee injuries involving the posterolateral corner (PLC) because of high risk of residual instability if treated non-operatively. When indicated, surgical treatment should be performed in the acute phase followed by early protected range of motion and functional rehabilitation. Preoperative planning should include stress radiographs and MRI. Important considerations for surgical technique include avoiding graft tunnel convergence in the setting of multiple ligament reconstruction and anatomic placement of the tunnels to recreate the native kinematics of the medial compartment. Postoperative rehabilitation focusing on quadriceps activation and protected range of motion is recommended beginning postoperative day one to minimize the risk of arthrofibrosis. Anatomic reconstruction of the superficial medial collateral ligament and posterior oblique ligament have been shown to produce good subjective and objective patient outcomes. Further level one studies are recommended to reinforce these findings.

Anatomic development of the upper airway during the first five years of life: A three-dimensional imaging study.

PurposeNormative data on the growth and development of the upper airway across the sexes is needed for the diagnosis and treatment of congenital and acquired respiratory anomalies and to gain insight on developmental changes in speech acoustics and disorders with craniofacial anomalies.MethodsThe growth of the upper airway in children ages birth to 5 years, as compared to adults, was quantified using an imaging database with computed tomography studies from typically developing individuals. Methodological criteria for scan inclusion and airway measurements included: head position, histogram-based airway segmentation, anatomic landmark placement, and development of a semi-automatic centerline for data extraction. A comprehensive set of 2D and 3D supra- and sub-glottal measurements from the choanae to tracheal opening were obtained including: naso-oro-laryngo-pharynx subregion volume and length, each subregion’s superior and inferior cross-sectional-area, and antero-posterior and transverse/width distances.ResultsGrowth of the upper airway during the first 5 years of life was more pronounced in the vertical and transverse/lateral dimensions than in the antero-posterior dimension. By age 5 years, females have larger pharyngeal measurement than males. Prepubertal sex-differences were identified in the subglottal region.ConclusionsOur findings demonstrate the importance of studying the growth of the upper airway in 3D. As the lumen length increases, its shape changes, becoming increasingly elliptical during the first 5 years of life. This study also emphasizes the importance of methodological considerations for both image acquisition and data extraction, as well as the use of consistent anatomic structures in defining pharyngeal regions.

Patient-Specific TKA with the VELYS™ Robotic-Assisted Solution.

The VELYS™ Robotic-Assisted Solution (VRAS) (DePuy Synthes, Warsaw, Indiana) utilises new technology to accurately collect the bony anatomy and soft tissue envelope of the knee. This enables surgeons to use this information to intraoperatively plan anatomical placement of a total knee arthroplasty (TKA) with preservation of the soft tissues with the aim of restoring functional knee motion. The robotic-assisted saw delivers precise, accurate, and efficient delivery of this implantation plan. This article describes the patient-specific TKA technique which maximises the full potential of VRAS; however, all TKA techniques and alignment philosophies can be accommodated with VRAS. The first case was performed in late 2020. An early outcome study shows an improvement in knee function and pain with activity at discharge and six weeks and a neutral surgical time comparable with the author's extensive experience with patient-specific balanced TKA with navigation. Only a limited number of patients have one-year results. However, the data of this limited cohort demonstrates favourable outcome scores and high patient satisfaction.

More anatomic tunnel placement for anterior cruciate ligament reconstruction by surgeons with high volume compared to low volume.

Correct placement of the femoral and tibial tunnels in the anatomic footprint during anterior cruciate ligament reconstruction (ACLR) is paramount for restoring rotatory knee stability.Recent studies have looked at surgeon volume and its outcomes on procedures such as total knee arthroplasty and infection rates, but only few studies have specifically examined tunnel placement after ACLR based on surgeon volume. The purpose of this study was to compare the placement of femoral and tibial tunnels during ACLR between high-volume and low-volume surgeons. It was hypothesized that high-volume surgeons would have more anatomic tunnel placement compared with low-volume surgeons. A retrospective review of all ACLR performed between 2015 and 2019 at an integrated health care system consisting of both academic and community hospitals with 68 orthopaedic surgeons was conducted. Surgeon volume was categorized as less than 35 ACLR per year (low volume) and 35 or more ACLR per year (high volume).Femoral tunnel placement for each patient was determined using an exact strict lateral radiograph (less than 6mm of offset between the posterior halves of the medial and lateral condyles) taken after the primary ACLR using the quadrant method. The centre of the femoral tunnel was measured in relation to the posterior-anterior (PA) and proximal-distal (PD) dimensions (normal centre of anatomic footprint: PA 25% and PD 29%). Tibial tunnel placement for each patient was determined on the same lateral radiographs by measuring the mid-sagittal tibial diameter and the centre of the tibial attachment area of the ACL from the anterior tibial margin (normal centre of anatomic footprint: 43%). Each lateral radiograph was reviewed by one of two blinded reviewers. A total of 4500 patients were reviewed, of which 645 patients met all the inclusion/exclusion criteria and were included in the final analysis. There were 228 patients in the low-volume group and 417 patients in the high-volume group. Low-volume surgeons performed a mean of 5 ACLRs per year, whereas surgeons in the high-volume group performed a mean of 40 ACLRs per year. In the PA dimension, the low-volume group had significantly more anterior femoral tunnel placement compared with the high-volume group (32 ± 10% vs 28 ± 9%, p < 0.01). In the PD dimension, the low-volume group had statistically significant more proximal femoral tunnel placement compared to the high-volume group (32 ± 9% vs 35 ± 9%, p < 0.01). For the tibial tunnel, the low-volume group had significantly more posterior tibial tunnel placement compared with the high-volume group (41 ± 10% vs 38 ± 7%, p < 0.01). Low-volume surgeons placed their femoral tunnels significantly more anterior and proximal (high) during ACLR, and placed their tibial tunnels significantly more posterior, compared with high-volume surgeons. Prior research has indicated that anatomic placement of the femoral and tibial tunnels during ACLR leads to improved rotatory knee stability. The findings of this study demonstrate the importance of surgical volume and experience during ACLR. III.

J arch: A contemporary soft-tissue landmark for anatomic placement of femoral tunnel in remnant-preserving anterior cruciate ligament (ACL) reconstruction

Objectives: Femoral tunnel placement is a critical step in ACL reconstruction surgery. Surgeons usually end up clearing the soft tissue to access the bony landmarks. Biological ACL reconstruction with preservation of soft tissue can be done with reliable soft tissue landmarks. Our objective is to assess the reliability of a soft tissue landmark- femoral ACL remnant, for appropriate femoral tunnel placement in soft tissue preserving ACL reconstruction. Materials and Methods: This study was a retrospective analysis of prospectively collected data of 40 consecutive patients who underwent primary ACL reconstruction in January 2018 by a single surgeon. An inverse J shaped tissue arch was identified and used as soft tissue landmark for anatomic placement of femoral tunnel. This arch was a part of femoral ACL remnant. MRI films were examined post-operatively to determine the position of the femoral tunnel. Postoperatively, MRI of these patients were reviewed to evaluate the femoral tunnel position in terms of depth and height from the proximal condylar surface and notch roof, respectively. Results: The center of the femoral tunnel was found to be at a mean depth of 27.12 ± 2.2% from the proximal condylar surface (parallel to Blumensaat’s line) and a mean height of 30.96 ± 2.75% from the notch roof (perpendicular to Blumensaat’s line), which is at par with previously defined data given by various studies. Conclusion: J arch can be used as a dependable soft tissue landmark and a guide for the anatomic placement of femoral tunnel in biological ACL Reconstruction.

An Anatomically Placed Tibial Tunnel does not Completely Surround a Simulated PCL Reconstruction Graft in the Proximal Tibia.

It is hypothesized that anatomic tunnel placement will create tunnels with violation of the posterior cortex and subsequently an oblique aperture that is not circumferentially surrounded by bone. In this article, we aimed to characterize posterior cruciate ligament (PCL) tibial tunnel using a three-dimensional (3D) computed tomography (CT) model. Ten normal knee CTs with the patella, femur, and fibula removed were used. Simulated 11 mm PCL tibial tunnels were created at 55, 50, 45, and 40 degrees. The morphology of the posterior proximal tibial exit was examined with 3D modeling software. The length of tunnel not circumferentially covered (cortex violation) was measured to where the tibial tunnel became circumferential. The surface area and volume of the cylinder both in contact with the tibial bone and that not in contact with the tibia were determined. The percentages of the stick-out length surface area and volume not in contact with bone were calculated. The mean stick-out length of uncovered graft at 55, 50, 45, and 40 degrees were 26.3, 20.5, 17.3, and 12.7 mm, respectively. The mean volume of exposed graft at 55, 50, 45, and 40 degrees were 840.8, 596.2, 425.6, and 302.9 mm3, respectively. The mean percent of volume of exposed graft at 55, 50, 45, and 40 degrees were 32, 29, 25, and 24%, respectively. The mean surface of exposed graft at 55, 50, 45, and 40 degrees were 372.2, 280.4, 208.8, and 153.3 mm2, respectively. The mean percent of surface area of exposed graft at 55, 50, 45, and 40 degrees were 40, 39, 34, and 34%, respectively. Anatomic tibial tunnel creation using standard transtibial PCL reconstruction techniques consistently risks posterior tibial cortex violation and creation of an oblique aperture posteriorly. This risk is decreased with decreasing the angle of the tibial tunnel, though the posterior cortex is still compromised with angles as low as 40 degrees. With posterior cortex violation, a surgeon should be aware that a graft within the tunnel or socket posteriorly may not be fully in contact with bone. This is especially relevant with inlay and socket techniques.

Comparison of Paresthesia Mapping With Anatomic Placement in Burst Spinal Cord Stimulation: Long-Term Results of the Prospective, Multicenter, Randomized, Double-Blind, Crossover CRISP Study

ObjectivesSpinal cord stimulation (SCS) is an effective therapy for chronic intractable pain. Conventional SCS involves electrode placement based on intraoperative paresthesia mapping; however, newer paradigms like burst may allow for anatomic placement of leads. Here, for the first time, we report the one-year safety and efficacy of burst SCS delivered using a lead placed with conventional, paresthesia mapping, or anatomic placement approach in subjects with chronic low back pain (CLBP). Materials and MethodsSubjects with CLBP were implanted with two leads. The first lead was placed to cross the T8/T9 disc and active contacts for this lead were chosen through paresthesia mapping. The second lead was placed at the T9/T10 spinal anatomic landmark. Subjects initially underwent a four-week, double-blinded, crossover trial with a two-week testing period with burst SCS delivered through each lead in a random order. At the end of trial period, subjects expressed their preference for one of the two leads. Subsequently, subjects received burst SCS with the preferred lead and were followed up at 3, 6, and 12 months. Pain intensity (visual analog scale), quality-of-life (EuroQol-5D instrument), and disability (Oswestry Disability Index) were evaluated at baseline and follow-up. ResultsForty-three subjects successfully completed the trial. Twenty-one preferred the paresthesia mapping lead and 21 preferred the anatomic placement lead. Anatomic placement lead was activated in one subject who had no preference. The pain scores (for back and leg) significantly improved from baseline for both lead placement groups at all follow-up time points, with no significant between-group differences. ConclusionsThis study demonstrated that equivalent clinical benefits could be achieved with burst SCS using either paresthesia mapping or anatomic landmark-based approaches for lead placement. Nonparesthesia-based approaches, such as anatomic landmark-based lead placement investigated here, have the potential to simplify implantation of SCS and improve current surgical practice.

Self-tuition as an essential design feature of the brain.

We are curious by nature, particularly when young. Evolution has endowed our brain with an inbuilt obligation to educate itself. In this perspectives article, we posit that self-tuition is an evolved principle of vertebrate brain design that is reflected in its basic architecture and critical for its normal development. Self-tuition involves coordination between functionally distinct components of the brain, with one set of areas motivating exploration that leads to the experiences that train another set. We review key hypothalamic and telencephalic structures involved in this interplay, including their anatomical connections and placement within the segmental architecture of conserved forebrain circuits. We discuss the nature of educative behaviours motivated by the hypothalamus, innate stimulus biases, the relationship to survival in early life, and mechanisms by which telencephalic areas gradually accumulate knowledge. We argue that this aspect of brain function is of paramount importance for systems neuroscience, as it confers neural specialization and allows animals to attain far more sophisticated behaviours than would be possible through genetic mechanisms alone. Self-tuition is of particular importance in humans and other primates, whose large brains and complex social cognition rely critically on experience-based learning during a protracted childhood period.This article is part of the theme issue ‘Systems neuroscience through the lens of evolutionary theory’.

A Modified Anatomic Transtibial Double-Bundle Anterior Cruciate Ligament Reconstruction Provides Reliable Bone Tunnel Positioning

PurposeTo evaluate the femoral and tibial tunnel positions via a modified anatomic transtibial double-bundle anterior cruciate ligament (ACL) reconstruction.MethodsPatients who underwent double-bundle ACL reconstruction using the transtibial tunnel creation technique were identified. Double-bundle ACL reconstruction was performed for 94 knees using the transtibial tunnel creation technique. Tunnel aperture configurations and center positions of the anteromedial (AM) and posterolateral (PL) tunnels via postoperative 3-dimensional computed tomography were evaluated.ResultsThere were 94 knees included. Regarding the intra-articular tunnel aperture configurations, the AM and PL tunnels overlapped at the femoral and tibial aperture in 66.0% and 94.7% cases, respectively. The mean femoral bone tunnel center was located at 23.0 ± 3.9% in the posterior-to-anterior ratio and 28.7 ± 6.0% in the proximal-to-distal ratio for the AM tunnels and at 32.8 ± 4.7% and 51.2 ± 5.2% for the PL tunnels, respectively. In the tibial tunnels, the mean AM tunnel center was located at 31.4 ± 3.6% in the anterior-to-posterior ratio and 44.3 ± 1.8% in the medial-to-lateral ratio and at 47.5 ± 3.8% and 44.3 ± 1.9% in the PL tunnel center, respectively. The femoral tunnels of outliers, both those created in nonanatomic positions as well as the posterior wall blowouts, were revealed in 7.4% cases. The nonanatomical bone tunnel group had significant heavier weight patients, lower tibial posterior slope, and were anterior in the AM and PL tunnel position. Posterior wall blowouts were related to posterior and proximal PL bone tunnel positions.ConclusionsModified transtibial double-bundle ACL reconstruction is a reliable tunnel creation technique with anatomic placement in 92.6% of the cases. The modification required that partially superimposing configuration of the 2 tibial tunnel apertures. The nonanatomic tunnels were related to patients of heavier weight and lower tibial posterior sloped knees, whereas the posterior wall blowouts were related to the posterior and proximal PL bone tunnel positions.Level of EvidenceLevel IV, therapeutic case series.

Current trends in the anterior cruciate ligament part 1: biology and biomechanics

A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.

Evaluation of Captive Bolt for Emergency Field Euthanasia in Canada Geese

ABSTRACTIn rare circumstances during research or monitoring operations for wild birds, emergency euthanasia is required. However, standard methods of euthanasia may not be humane for large birds. We evaluated the use of a Dick KTBG® spring‐powered, penetrating captive bolt for the euthanasia of Canada geese (Branta canadensis). We conducted trials on hunter‐harvested geese to determine anatomical placement of the device and to assess skull and brain penetration effectiveness. We then assessed the device for euthanasia on anesthetized geese. Although results using dead geese suggested the device may be effective (i.e., consistent skull penetration, and trajectory depth into relevant brain structures), we found the device did not produce consistent, humane euthanasia for anesthetized geese and was not suitable for emergency field euthanasia for Canada geese. We encourage further evaluations of emergency euthanasia methods using a 2‐step process of determining placement and efficacy on dead birds and then testing on live anesthetized individuals. © 2021 The Wildlife Society.

Effectiveness of high dose spinal cord stimulation for non-surgical intractable lumbar radiculopathy - HIDENS Study.

Spinal cord stimulation (SCS) is being increasingly used in non-surgical intractable low back pain. This study was designed to evaluate the efficacy of high-dose (HD) SCS utilizing sub-perception stimulation with higher frequency and pulse width in non-surgical predominant low-back pain population at 12months. A total of 20 patients were recruited (280 screened between March 2017 and July 2018) to undergo percutaneous fluoroscopic-guided SCS (Medtronic 8 contact standard leads and RestoreR IPG), with T8 and T9 midline anatomical parallel placement. Sixteen patients completed 12months follow-up (500Hz frequency, 500μs pulse width, and 25% pulse density). Differences in patients' clinical outcome (NRS back, NRS leg, ODI, PGIC, and PSQ) and medication usage (MQS) at 1, 3, and 12months from the baseline were assessed using non-parametric Wilcoxon paired test. The mean NRS scores for back pain (baseline 7.53) improved significantly at 1, 3, and 12months; 2.78 (p<0.001), 4.45 (p=0.002), and 3.85 (p=0.002), respectively. The mean NRS score for leg pain (baseline 6.09) improved significantly at 1 and 3months; 1.86 (p<0.001) and 3.13 (p=0.010), respectively. Mean NRS for leg pain at 12months was 3.85 (p=0.057). ODI and sleep demonstrated significant improvement as there was consistent improvement in medication particularly opioid usage (MQS) at 12months. This study demonstrates that anatomical placement of leads with sub-perception HD stimulation could provide effective pain relief in patients who are not candidates for spinal surgery.

Functional outcome following arthroscopic ACL reconstruction using 4 stranded hamstring autograft and preservation of hamstring graft at tibial insertion

Background: The technique of arthroscopic anterior cruciate ligament reconstruction (ACLR) has undergone many modifications in the recent times with improved understanding of anatomy, kinematics, and biology of the graft. In this study, we evaluated the functional outcome following arthroscopic single bundle ACLR with tibial attachment preserving quadrupled hamstring autograft without implant on the tibial side.Results: There is a statistically significant increase in both IKDC and Lysholm score from preoperative/pre injury to post-operative assessment at minimal 9 month follow up.The mean pre injury Tegner score was 5.7 ± 1.194 and mean post injury Tegner score was 5.2 ± 1.055. The mean pre injury lysholm score was 97.9 ± 2.308 which at minimum 9 month follow-up was 88.3 ± 8.036. Out of 52 patients 37 of the patients (71.2%) were able to return to their pre injury activity including to recreational and to competitive sports. 5 patients (9.6%) had a drop of 1 level in Tegner activity level from there pre injury level of activity. 7 patients (13.5%) had a drop of 2 level in Tegner activity level from there pre injury level of activity. 2 patients (3.8%) had a drop of 3 level in Tegner activity level from there pre injury level of activity. 1 case reported a 4 level drop from pre injury levelsConclusion: Arthroscopic single-bundle ACL reconstruction using 4 stranded hamstring autograft, anatomic femoral tunnel placement and preservation of hamstring graft tibial insertion gives excellent to good functional outcome. Tibial attachment preserving hamstring graft without a tibial implant is a simple, time saving and cost effective technique that provides a consistently satisfactory outcome.

The Depiction of Smallpox and Other Dermatologic Lesions on the Surfaces of Ancient Terracotta Statues from Mali, West Africa.

Between 1100 A.D. and 1700 A.D., terracotta statues were created in the Interior Delta of the Niger River in what is now the Republic of Mali. They are known as Djenné-Jeno terracottas because of their geographic proximity to an ancient town of that name. Some of these statues possess surface excrescences that have long perplexed archaeologists, art historians, curators, and others. This study of these surface excrescences employed clinical, diagnostic, and epidemiological methodologies to elucidate their possible meanings. It has not been possible to ascribe these excrescences to a single cause. However, examination of all the evidence permitted consideration of several possibilities. These include diseases such as smallpox, onchocerciasis, and the secondary stage of venereal syphilis. On certain statues, the anatomic placement of excrescences possibly symbolizes intentional cicatrization that resulted in keloid formation which may have been a form of beautification.

Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal

Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman’s, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman’s test. Though not significant, IKDC scores and Lysholm’s scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.

Usage of Accessory Anteromedial Portal for Anatomical Placement of Femoral Tunnel in Transportal Anterior Cruciate Ligament Reconstruction: A Prospective Study.

Background and objectiveThe anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM).Materials and methodsThis prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system.ResultsThe analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up.ConclusionAnatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

A Differential Pattern of Batokine Expression in Perivascular Adipose Tissue Depots From Mice.

Depending on its anatomical placement, perivascular adipose tissue (PVAT) has been found to possess features more (e.g., aortic thoracic) or less (e.g., aortic abdominal) similar to brown/beige adipose tissue in mice, whereas PVAT surrounding the mesenteric arteries and the caudal part of abdominal aorta is similar to white fat. PVAT is thought to influence vascular function through the effects of adipose-secreted molecules on vessels. Brown adipose tissue was recently shown to play differential secretory role via secretion of the so-called batokines but the involvement of differential batokine production in PVAT brown/beige plasticity was unclear. The current study characterizes for the first time the expression of batokines at aortic thoracic PVAT (tPVAT) and aortic abdominal PVAT (aPVAT) in comparison with typical brown and white adipose depots, in basal and thermogenically activated conditions. We found that both PVAT depots increased their expression of genes encoding the batokines bone morphogenetic protein-8b (BMP8B), fibroblast growth factor-21 (FGF21), and kininogen-2 (KNG2) in response to cold, indicating that, under cold-induced thermogenic activation, both thoracic aorta and abdominal aorta would experience intense local exposure to these PVAT-secreted batokines. In contrast, the gene expression levels of growth/differentiation factor-15 and vascular endothelial growth factor-A were induced only in tPVAT. Under short-term high-fat diet-induced thermogenic activation, the thoracic aorta would be specifically exposed to a local increase in PVAT-originating BMP8B, FGF21, and KNG2. Our data support the notion that acquisition of a brown/beige phenotype in PVAT is associated with upregulation of batokines, mainly BMP8B, FGF21, and KNG2, that can differentially target the vascular system.

Evaluation of anatomical axis-joint center distance and anatomical axis-joint center ratio in distal femur and proximal tibia in coronal plane of Indian population

BackgroundRadiographic evaluation of the anatomical geometry of the bone is important for executing reconstructive surgeries like deformity correction, limb lengthening and joint replacements. Various studies have been done in the past to define the anatomic placement of implant inside the bone. The aim of this study is to evaluate the distance between the anatomical axis and joint center of the distal femur (aJCD-f) and proximal tibia (aJCD-t) along with the ratio of anatomical axis-joint center distance of distal femur (aJCR-f) and proximal tibia (aJCR-t) of the skeletally mature individual of Indian population along with its application in day to day practice. MethodsData is procured from the standard radiographs of the knee on large films. The anatomical axis is drawn on both sides of tibia and femur in a standard fashion. These lines intersect the horizontal drawn line at the intercondylar notch of femur and joint orientation line of the tibia. The aJCD-f, aJCD-t, aJCR-f, aJCR-t are then measured. Also the center of the inter-spinous distance of the tibia is measured from the anatomical axis (aSCD-t). ResultsA total of 182 x-rays of skeletally mature individual were included with mean age of 46.35 ± 13.93 years. Of them 81 were males and 101 were females. There were 89 x-ray of left side and 93 x-ray of right side. The mean width of the femur at the intercondylar notch is found to be 76.78 mm (±7.40). The mean aJCD-f is found to be 3.87 mm (±2.44), aJCR-f to be 0.50 (±0.06). The mean width of the tibia is found to be 76.80 mm (±6.48). The aJCD-t is found to be 2.20 mm (±1.41), aJCR-t to be 0.50 (±0.03). The aSCD-t at the level of tibial spine is found to be −0.23 mm (±2.84). There was significant difference in the width of the femoral condyle of males 82.13 mm (±0.65) and females 72.48 mm (±0.55). Males showed mean aJCD-f of 3.59 mm (±2.42) and females showed 4.10 mm (±2.46). The aJCR-f is found to be significantly different between males 0.49 (±0.05) and females 0.51 (±0.07). There is significant difference between the width of the proximal tibia between males 80.83 mm (±0.68) and females 73.56 mm (±0.46). The aJCD-t of males and females is found to be 2.28 mm (±1.25) and 2.16 mm (±1.54) respectively. The aJCR-t is found to be significantly different between males 0.49 (±0.03) and females 0.50 (±0.04). While the mean distance of the anatomical axis from the lateral tibial spine is 0.23 mm lateral to the center of the inter-spinous distance and is found to be same in both males and females −0.23 mm (±2.84). ConclusionThe coronal plane parameter like aJCD, aJCR of femur and tibia and aSCD-t of tibia can be a useful parameter to calculate in the ‘real world’ settings for reconstructive surgeries like deformity correction, nailing through the knee for femur and tibia as well as replacement surgeries around knee.

Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review

Background:The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques.Purpose:To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique.Study Design:Systematic review; Level of evidence, 3.Methods:Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament.Results:Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman (P = .0005) and pivot-shift test (P = .0001) results, lower KT-1000 arthrometer maximum manual displacement (P = .00001), higher Lysholm score (P = .001), a higher incidence of IKDC grade A/B (P = .05), and better visual analog scale score for satisfaction (P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length (P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique.Conclusion:In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.