Anatomic Reconstruction Research Articles

Clinical Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Controlled Accelerated Rehabilitation.

Background An anterior cruciate ligament (ACL) tear is one of the most common sports injuries in the knee region. Currently, anatomical ACL reconstruction with quadrupled hamstring tendon autograft and controlled accelerated rehabilitation is a frequently used treatment approach. This study aims to add to the literature the early and mid-term clinical results of the controlled accelerated rehabilitation program we implemented in our clinic to enable patients to return to their daily activities faster after ACL reconstruction. Methodology In this retrospective study, 51 patients (50 males, 1 female) diagnosed with ACL tear and undergoing ACL reconstruction with quadrupled hamstring tendon graft were included in our study.In the femoral fixation of the graft, the transfix method was used in 22 patients and the Endobutton-CL method was used in 29 patients. A controlled accelerated rehabilitation program developed by Shelbourne was employed with some modifications to the patients. Clinical evaluation of patients was performed using Lysholm, Cincinnati, Tegner, and International Knee Documentation Committee (IKDC) scoring systems. Results The mean postoperative follow-up period was 18.7 months (range = 6-36 months). During the physical examination, Lachman, anterior drawer, and pivot shift, 49 (96%) patients achieved excellent or good results, while only two (5%) patients experienced fair clinical outcomes. On clinical assessment using the Lysholm and IKDC scoring systems, 50 (98%) patients demonstrated excellent or good results, whereas only one (2%) patient showed fair results. Excellent and good outcomes were observed in all patients using the Cincinnati scoring system. We found a significant decrease in Tegner activity score pre-surgery, which significantly increased post-surgery. Conclusions The combination of Endobutton and cross-pin for femoral fixation and staples and interference screw for tibial fixation is thought to be safe in patients undergoing controlled accelerated rehabilitation after ACL reconstruction. The implementation of controlled accelerated rehabilitation enables patients to return to their social lives earlier without resulting in clinically poor outcomes in grafts and implants applied in the early and middle stages.

RESULTS OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING THE ALL-INSIDE TECHNIQUE AT PHO NOI HOSPITAL: A RETROSPECTIVE STUDY

Objectives: To evaluate clinical and functional outcomes of anatomic anterior cruciate ligament (ACL) reconstruction using the all-inside technique. Methods: A retrospective study on 30 patients who underwent primary anatomic ACL reconstruction using the all-inside technique from January 2019 to January 2022 at Pho Noi Hospital, Hung Yen. The Lysholm score and International Knee Documentation Committee (IKDC) score were used to evaluate outcomes before surgery, at 6 months, and ≥ 12 months postoperatively. Results: Among 30 patients who underwent all-inside ACL reconstruction, the mean follow-up time was 26.5 months (13 - 50 months), the mean age was 32.43 ± 10.6, and the mean duration between the injury and surgery was 9.4 months. The mean graft diameter was 7.8 ± 0.5mm (6.5 - 9mm), the mean femoral tunnel length was 28.8 ± 1.7mm (25 - 35mm), and the mean tibial tunnel length was 30.5 ± 2.1mm (30 - 35mm). Functional outcomes: Preoperatively, the IKDC score was 55.2 ± 0.5, and the Lysholm score was 61.1 ± 4.5. At 6 months postoperatively, symptoms improved; at over 12 months postoperatively, the IKDC score was 91.5 ± 2.5. The rate of normal and nearly normal grades was 96.7% and the Lysholm score was 94.1 ± 2.5. The rate of excellent and good grades was 100%. Conclusion: The ACL reconstruction using the all-inside technique provides good functional outcomes and anteroposterior knee stability at short-term follow-up.

Analysis on association between sagittal stem alignment and early functional and radiological outcome following primary cementless total hip replacement.

Accurate reconstruction of hip anatomy and biomechanics is mandatory for achieving good clinical outcomes following total hip replacement (THR). Optimal stem alignment is essential to avoid impingement or loosening. This study aimed to evaluate sagittal stem position following cementless THR and its relationship with patient's functional outcome and post-operative radiological parameters. We performed analytical observational study with cross-sectional design on 71 hips (67 patients, ranged 18-85years old) that underwent primary cementless THR in two orthopedic centers in Jakarta, Indonesia. All hips were operated through either anterolateral or posterior approach using either extended/full-coating wedge-tapered stem or proximal-coated wedge-tapered stem. Clinical outcomes were evaluated at follow-up time using mHHS questionnaire, VAS level of thigh pain, and hip ROM. Stem sagittal alignment and other radiological parameters, including combined anteversion and offset, were measured from conventional radiograph. There were no significant differences on mHHS score, VAS level on thigh pain, and ROM between stem alignment groups. Post-operative anteversion and offset of the implant were not affected by the stem sagittal position. All influencing factors have significant effect on sagittal stem alignment. Linear regression test on femur morphology showed 0.69° increase in stem posterior tilt for every 1° increase in the anterior bowing (coeff. = 0.502). Stem tilting in sagittal plane did not affect patient's functional outcome or post-operative radiological parameters. In addition, for every degree of increased anterior femoral bowing, 0.69° increase in posterior stem tilting can be expected.

Résultats à long terme de l’arthroplastie totale dans les luxations congénitales de la hanche. Étude rétrospective des résultats avec 10 à 20 ans de recul

Introduction: The impact of bone deformities, previous surgeries, and the surgical technique in total hip arthroplasty (THA) for congenital dislocation of the hip (CDH) at a long-term has not been clearly defined yet. In this single-centre observational study we sought to assess patients undergoing THA due to osteoarthritis secondary to severe CDH with low or high dislocation ten- to 20-years after surgery. To determine this purpose, we assessed: 1) THA-related complications and reoperations; 2) the clinical outcome, patients´ satisfaction and radiological results; and 3) the possible risk factors for reoperation with particular attention to the surgical technique and the influence of prior surgeries.Hypothesis: We hypothesized that an anatomical reconstruction of the hip would decrease the reoperations rates in patients undergoing THA with severe CDH.Methods: Seventy-five patients (85 hips) operated between 1999 and 2012 at our large tertiary hospital were analyzed. Fifty-six hips were diagnosed as low dislocation (group 1) and 29 hips as high dislocation (group 2). The existence of prior surgeries was frequent: group 1, pelvic osteotomies 6 hips, femoral osteotomies 7, tectoplasty (shelf) 6, resection arthroplasty 1 and lowering of the greater trochanter 1; group 2 included pelvic osteotomies 10 hips, femoral osteotomies 10, and a femoral lengthening 2. The number of additional procedures during THA was: group 1 (19/56 (34%)), acetabular roof bone autograft 8 hips, acetabular medial wall autograft 2, hardware removal 6, extended femoral osteotomy 2, and a femoral shortening 1; group 2 (20/29 (69%)), acetabular bone autograft 12 hips, medial autograft 1, hardware removal 1, extended femoral osteotomy 2, and a femoral shortening 4 hips The clinical and the radiological analysis were compared in both groups for a minimum follow-up of ten years. Cox regression models were used to detect risk factors for reoperation.Results: Nine patients (13.8%) required reoperation for the following reasons: cup loosening (5 hips), periprosthetic femoral fracture (3) and stem loosening (1); seven had prior surgeries. The 12-year survival rate for reoperation for any reason was 96.3% (95% Confidence Interval (CI) 91.2-100) in group 1 and 75.7% (95% CI, 65.8-90.8) in group 2 (p=0.003). Patients with high dislocation (p=0.02, Hazard Ratio (HR): 6.25, 95% CI, 1.26-30.9) and those with an acetabular component inclination placed out of the target zone between 35º and 50º (p=0.03, HR: 4,27, 95% CI, 1.13-16.1) had a higher risk of reoperation.Discussion: An optimal placement of the acetabular component decreased the reoperation rates in patients undergoing THA for severe CDH. Hips with high dislocation and the existence of prior surgery can affect THA implantation.Level of Evidence: III; retrospective; comparative

Augmented anastomotic ureteral reconstruction using buccal mucosal graft, initial experience.

To assess the augmented anastomotic ureteral reconstruction using buccal mucosal graft based on omental flap for managing ureteral stricture. This prospective cohort study was conducted on 13 patients with ureteric strictures of different lengths secondary to Bilhalziasis, iatrogenic (post endoscopy) and post inflammatory etiology in upper and mid ureteral segments were treated with buccal mucosal patch grafts and The graft is fixed to the undersurface or the posterior surface of the omentum before doing graft anastomosis to the ureteral walls as to ensure the process of graft take sticky to the principles of tissue transfer. All patients were subjected to full history taking, clinical examination for assessment of pain, lower or upper urinary track symptoms and laboratory investigation (complete blood count, CRP, liver function test and kidney function test (serum urea and creatinine). The mean operative time was 148.85 min and mean hospital stay was 3 days. Mean blood loss was ranged from 20 to 210 ml and Stent was removed after 8-12 weeks. The mean follow up was 13 months, all patients had a non-obstructive RI value <0.7 with a non-obstructed drainage pattern on the diuretic renogram except one patient who had severe postoperative UTI necessitating nephrostomy tube insertion his drainage curve was plateau. BMG ureteroplasty is a valuable option for a carefully selected patient. The fixation of the graft on the back surface of the omentum allows for better anatomical reconstruction without any twisting to the omental pedicle.

How anatomic should anatomic total shoulder arthroplasty be? Evaluation of humeral head reconstruction with the best-fit circle

IntroductionHumeral implant designs for anatomic total shoulder arthroplasty (aTSA) focus on anatomic reconstruction of the articular segment. Likewise, the pathoanatomy of advanced glenohumeral osteoarthritis (GHOA) often results in humeral head deformity. We hypothesized the anatomic reconstruction of the humeral head in aTSA risks overstuffing the glenohumeral joint. Methods97 cases (52 females) of primary GHOA in patients treated with aTSA were evaluated. Preoperative computed tomography (CT) scans were used to classify glenoid morphology according to the Walch classification. Coronal plane images in the plane of the humerus were used to determine the anatomic perfect circle as described by Youderian et al. Humeral head thinning was determined as the distance from the center of rotation (COR) of the perfect circle to the nearest point along the humeral articular surface. aTSA was modeled with a predicted anatomic humeral head and a simulated 4 mm polyethylene glenoid component. The change in the position of the native humerus was determined. Wilcoxon Rank Sum tests were used to evaluate differences in humeral head thinning and humeral lateralization between monoconcave and biconcave glenoid morphologies. Spearman’s rank correlation coefficients were used to assess the relationship between humeral head thinning with preoperative active forward elevation and external rotation. ResultsThe mean radius of the perfect circle was 25.0±2.1 mm. There was a mean thinning of 2.4±2.0 mm (Range -1.7–8.3). Mean percent thinning of the humeral head was 9.4%±7.7%. The mean humeral lateralization was 6.4±2.0 mm. Humeral head thinning was not significantly associated with active forward elevation (r=-0.15, p=0.14) or active external rotation (r= -0.12, p=0.25). There were no significant differences in the percentage of humeral head thinning (p=0.324) or humeral lateralization (p=0.350) between concentric and eccentric glenoid wear patterns ConclusionsUtilization of the perfect circle as a guide in aTSA may risk excessive lateralization of the humerus and overstuffing the glenohumeral joint. This may have implications for subscapularis repair and healing, as well as glenoid implant and rotator cuff longevity. These findings call into question whether recreation of normal glenohumeral anatomy in aTSA is appropriate for all patients. Humeral head reconstruction in aTSA should account for glenohumeral joint volume and soft tissue contracture.

Tibial spine volume is smaller in ACL-injured athletes compared to healthy athletes.

The aim of this study was to investigate whether the whole tibial spine volume and femoral intercondylar notch volume are risk factors for anterior cruciate ligament (ACL) injury. The hypothesis was that the whole tibial spine volume and femoral notch volume would be smaller in athletes who sustained ACL injury than in athletes with no history of ACL injury. Computed tomography scans of both knees were acquired and three-dimensionalbone models were created using Mimics to measure whole tibial spine volume and femoral notch volume. Tibial spine volume, femoral notch volumeand each of these volumes normalised by tibial plateau area were compared between the ACL-injured andthe ACL-intact group. Fifty-one athletes undergoing unilateral anatomical ACL reconstruction (17 female, 34 male: average age 22.0 ± 7.5) and 19 healthy collegiate athletes with no previous knee injury (eight female, 11 male: average age 20.1 ± 1.3) were included in this study. The whole tibial spine volume in the ACL-injured group(2.1 ± 0.5 cm3) was 20.7% smaller than in the ACL-intact group (2.7 ± 0.7 cm3) (p = 0.005). No differences were observed between the femoral notch volume in the ACL-injured group(9.5 ± 2.1 cm3) and the ACL-intact group (8.7 ± 2.7 cm3) (n.s.). The main finding of this study was that the whole tibial spine volume of the ACL-injured group was smaller than the ACL-intact group. A small tibial spine volume can be added to the list of anatomical risk factors that may predispose athletes to ACL injury. Level Ⅲ.

Arthroscopic Hemitrapeziectomy and Extensor Carpis Radialis Longus Suspensioplasty With Intermetacarpal Ligament Reconstruction for Thumb Carpometacarpal Joint Osteoarthritis: Surgical Technique.

Level IV.

The Clinicoradiological Outcome of Arthroscopic-assisted Reduction and Internal Fixation of Tibial Plateau Fractures

Abstract Background: The fractures of the tibial plateau are intraarticular fractures accounting for 1% of all fractures. Surgical management of such fractures is often challenging because they require anatomical reduction and stable fixation, which will allow for early rehabilitation. Arthroscopy has evolved nowadays and arthroscopically assisted reduction and fixation is a good option among the available surgical options. Materials and Methods: This prospective study included 50 cases of tibial plateau fractures managed surgically by arthroscopic-assisted reduction and fixation starting from August 2019 to December 2022. Results: The patients were 39 years old on average and were mostly men (58%). The right knee was the most usually injured (53%), and the most common cause of injury (41.5%) was a fall from a height. The majority of these fractures (44.5%) belonged to Schatzker type 2, followed by type 1 (37%) and type 3 (18.5%). The average time to complete weight-bearing for a Schatzker type I fracture was 10 weeks, 11.5 weeks for a type II fracture, and 13.5 weeks for a type III fracture. The average time to union for Schatzker type I was 13 weeks, 15.5 weeks for type II, and 16 weeks for type III. The mean clinical and radiological scores using the modified Rasmussen criteria were 26.3 and 7.3, respectively. Conclusions: A good surgical outcome of tibial plateau fracture is acquired when anatomic articular surface reconstruction with the elevation of depressed bone fragment is combined with rigid stable fixation, which permits early rehabilitation. Arthroscopy helps in achieving these goals by providing a good visualization of the articular surfaces, adequate fracture reduction, and anatomical restoration of the joint surface and aids in thorough joint lavage to remove the intraarticular debris.

Robotic-assisted anatomic anterior cruciate ligament reconstruction: a comparative analysis of modified transtibial and anteromedial portal techniques in cadaveric knees.

Introduction: This study employed surgical robot to perform anatomic single-bundle reconstruction using the modified transtibial (TT) technique and anteromedial (AM) portal technique. The purpose was to directly compare tunnel and graft characteristics of the two techniques. Methods: Eight cadaveric knees without ligament injury were used in the study. The modified TT and AM portal technique were both conducted under surgical robotic system. Postoperative data acquisition of the tunnel and graft characteristics included tibial tunnel position, tunnel angle, tunnel length and femoral tunnel-graft angle. Results: The mean tibial tunnel length of the modified TT technique was significantly shorter than in the AM portal technique (p < 0.001). The mean length of the femoral tunnel was significantly longer for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the tibial tunnel was significantly lower for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the femoral tunnel was significantly lower for the AM portal technique than for the modified TT technique (p < 0.001). The AM portal technique resulted in a graft bending angle that was significantly more angulated in the coronal (p < 0.001) and the sagittal planes (p < 0.001) compared with the modified TT technique. Discussion: Comparison of the preoperative planning and postoperative femoral tunnel positions showed that the mean difference of the tunnel position was 1.8 ± 0.4mm. It suggested that the surgical navigation robot could make predictable tunnel position with high accuracy. The findings may support that the modified TT technique has benefits on femoral tunnel length and obliquity compared with AM portal technique. The modified TT technique showed a larger femoral tunnel angle in the coronal plane than the AM portal technique. Compared with the modified TT technique, the more horizontal trajectory of the femoral tunnel in the AM portal technique creates a shorter femoral tunnel length and a more acute graft bending angle.

Techniques and results of reconstruction of femoral head fractures: An Update

A narrative review of the literature was conducted to examine the data on femoral head fractures, with a particular focus on their management, complications and clinical outcomes.A PRISMA strategy was used. Medline and Scopus library databases were queried using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated based on OCEBM and GRADE systems. The 50 eligible articles that met the predefined inclusion criteria reported on 1403 femoral head fractures. A detailed analysis of the surgical approaches used was performed in 38 articles with 856 fractures.Most fractures were treated surgically (90,8 %) with preferred anatomical reconstruction in 76,7 % of all operatively treated cases. Posterior approaches were the most common (52.5 %). This was evenly split between surgical hip dislocation and the classic Kocher-Langenbeck approach. 70.5 % of surgically treated cases achieved excellent or good result according to Thompson-Epstein criteria. Highest rate of excellent results showed minimal invasive osteosynthesis and surgical hip dislocation. Major late complications were avascular necrosis (10.8 %), post-traumatic arthritis (16.2 %) and heterotopic ossification (20.8 %). Secondary THA was necessary in 6.9 %. Highest rate of major complications was joined with anterior approach (77 %), lowest rate from frequently used approaches surgical hip dislocation (37.8 %).Conservative treatment recedes into the background. The Ganz flip osteotomy with surgical hip dislocation allows safe treatment of all types of fractures and should be considered the first choice, offering the lowest rate of complications and one of the best functional outcomes. Reconstruction of Pipkin Type III fractures should be reserved for very young patients due to high rate of major complications.

Femoral Tunnel Position in Anatomical Double-bundle ACL Reconstruction is not Affected by Blumensaat's Line Morphology.

The aim of this study was to reveal the influence of the morphological variations of the Blumensaat's line on anteromedial (AM) and posterolateral (PL) femoral tunnel position in anatomical double-bundle anterior cruciate ligament (ACL) reconstruction.Fifty-three subjects undergoing anatomical double-bundle ACL reconstruction were included (29 female, 24 male; median age 27.4 years; range: 14-50 years). Using an inside-out transportal technique, the PL tunnel position was made on a line drawn vertically from the bottommost point of the lateral condyle at 90 degrees of knee flexion, spanning a distance of 5 to 8 mm, to the edge of the joint cartilage. AM tunnel position was made 2 mm distal to the PL tunnel position. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill (large and small) types. Femoral tunnel position was determined using the quadrant method. A Mann-Whitney U test was performed to compare straight and hill type knees according to AM and PL femoral tunnel position.There were 18 straight and 35 hill type knees (13 small and 22 large hill). AM and PL femoral tunnel position in straight type knees were 21.7 ± 7.0 and 33.6 ± 10.5% in the shallow-deep direction, and 42.1 ± 11.1 and 72.1 ± 8.5% in the high-low direction, respectively. In hill type knees, AM and PL femoral tunnel position were 21.3 ± 5.8 and 36.9 ± 7.1% in the shallow-deep direction, and 44.6 ± 10.7 and 72.1 ± 9.7% in the high-low direction, respectively. No significant difference in AM or PL femoral tunnel position was detected between straight and hill type knees.AM and PL femoral tunnel position in anatomical double-bundle ACL reconstruction was not affected by the morphological variations of the Blumensaat's line. Surgeons do not need to consider Blumensaat's line morphology if AM and PL femoral tunnel position is targeted at the bottommost point of the lateral condyle. This was a level of evidence III study.

Clinical Outcomes and Return to Preinjury Sports After Anatomic Reconstruction With a Gracilis Autograft Versus the Modified Broström Procedure in Patients With Generalized Joint Laxity

Background: Generalized joint laxity (GJL) is a risk factor for inferior outcomes after the modified Broström procedure for chronic lateral ankle instability, while anatomic reconstruction with tendons is more inclined to be recommended. However, whether anatomic reconstruction could achieve better results than the modified Broström procedure in patients with GJL is unknown. Purpose: To compare clinical outcomes and return to sports between anatomic reconstruction and the modified Broström procedure in patients with GJL. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with GJL (Beighton score ≥4) who underwent either the modified Broström procedure or anatomic reconstruction with gracilis autografts between 2017 and 2020 were reviewed. Included were 19 patients who underwent anatomic reconstruction (reconstruction group) and 49 patients who underwent the modified Broström procedure (MBP group). Clinical outcomes were compared using the Foot and Ankle Outcome Score (FAOS) and the Karlsson score. The rates of return to preinjury level in high-demand sports, sprain recurrence, and range of motion between the 2 groups were also compared. Results: The mean follow-up duration was 38.3 months in the reconstruction group and 43.7 months in the MBP group. The FAOS and Karlsson scores improved significantly after surgery in both groups ( P &lt; .001 for all), with the reconstruction group having significantly higher postoperative FAOS-Sports scores (87.9 ± 8.9 vs 80.5 ± 11.6; P = .015) and Karlsson scores (86.9 ± 6.1 vs 82 ± 8.4; P = .025) than the MBP group. The rate of return to preinjury high-demand sports was higher in the reconstruction group than in the MBP group (73.3% vs 38.9%; P = .034). The MBP group had a significantly higher rate of sprain recurrence (22.4% vs 0%; P = .027). More patients reported dorsiflexion restriction in the reconstruction group (n = 4; 21.1%) than in the MBP group (n = 1; 2%) ( P = .019); nonetheless, there was no noticeable effect on daily life and sports. Conclusion: Better clinical outcomes, less sprain recurrence, and a higher rate of return to preinjury high-demand sports were found after anatomic reconstruction with free tendons compared with the modified Broström procedure in patients with GJL. Anatomic tendon reconstruction can be recommended for such patients, especially those participating in high-demand sports.

Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

Background: Fibular collateral ligament (FCL) injuries commonly present in a multiligament knee injury pattern. These injuries are associated with significant instability leading to altered tibiofemoral biomechanics and therefore require surgical intervention. Similarly, grade 3 posterior cruciate ligament (PCL) injuries may disrupt normal tibiofemoral and patellofemoral biomechanics and increase the risk of secondary osteoarthritis. Therefore, concomitant reconstruction of the FCL and PCL should be performed to decrease knee laxity and optimize functional outcomes. Indications: Early operative treatment is indicated for patients with combined grade 3 FCL injuries and complete PCL tears. Contraindications to this procedure include patients who have significant osteoarthritis, open knee dislocations, or medical comorbidities making them unfit for surgery. Technique Description: The fundamental idea behind this technique is a stepwise treatment starting with open aspects of the procedure and followed by arthroscopic work. The technique is initiated with a lateral approach, common peroneal neurolysis, fibular and femoral FCL reconstruction tunnel preparation, and a gracilis or semitendinosus tendon autograft harvest. After that, focus shifts to intra-articular work such as associated meniscal assessment and treatment, PCL femoral and tibial tunnel preparation, graft passage, and PCL femoral tunnel fixation. Final graft fixation order is as follows: anterolateral bundle of PCL, posteromedial bundle of PCL, and finally FCL. Results: Multiple studies have reported that an anatomic FCL reconstruction in the setting of multiligament injury results in improved patient outcomes. In a prospective study of 20 patients, LaPrade et al reported −0.4 mm difference in side-to-side lateral compartment gapping and significant postoperative improvement of symptom and functional scores at a minimum 2 year postoperative follow-up after anatomic reconstruction of the FCL. Similarly, Moulton et al reported significant improvement in the average Western Ontario and Lysholm scores at 2.7 years follow-up. LaPrade et al also reported significant improvement in function and objective outcome scores at 3 years’ follow-up from anatomic double-bundle PCL reconstruction. Discussion: Anatomic FCL and PCL reconstructions successfully restore near native knee objective stability and provide superior clinical outcomes when compared to nonanatomic-based FCL reconstructions that continue to be performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anatomic Popliteus Tendon and Tibiofibular Joint Reconstructions

Background: The popliteus tendon is a primary stabilizer of external knee rotation and has been described as the “fifth ligament of the knee.” Injuries involving the posterolateral corner of the knee commonly involve the popliteus tendon; isolated injury to the popliteus tendon is relatively rare and usually involves a rotatory injury mechanism and symptoms of instability and pain. In this patient, there was a concomitant injury to the proximal tibiofibular joint. Indications: Popliteus tendon reconstruction is indicated for patients with abnormal external rotation on examination and symptoms of pain and instability. Proximal tibiofibular joint reconstruction is indicated for patients with instability of the tibiofibular joint. Technique Description: Preoperative examination under anesthesia is essential to determine the extent of external rotation and assess for additional posterolateral pathology. The popliteus tendon procedure begins with a meticulous common peroneal nerve neurolysis to minimize nerve irritation and decrease the risk of a postoperative foot drop. Semitendinosus and gracilis graft harvest is performed with at least 16 cm of graft length followed by tunnel reaming of the popliteus tendon femoral attachment and tibia tunnel identification and reaming. The femoral attachment of the popliteus tendon is secured, and the semitendinosus graft is anatomically oriented along the native path and passed from posterior to anterior through the femoral tunnel. The gracilis graft for anatomic proximal tibiofibular joint reconstruction requires an anterior to posterior tunnel through the fibular head. Finally, both grafts are secured in the tibial tunnel with the application of an anterior traction force. Results: A cadaveric study by LaPrade et al reported that an anatomic popliteus tendon reconstruction with a semitendinosus autograft significantly reduced external rotation laxity compared with the sectioned state. In addition, popliteus tendon reconstruction resulted in significantly decreased varus laxity, anterior tibial translation, and internal rotation. Discussion: This is a technique that effectively restores external rotation knee stability utilizing an anatomically oriented reconstruction of the popliteus tendon and tibiofibular joint. The popliteus tendon serves as a primary stabilizer to external rotation and facilitates static function of the knee. The proximal tibiofibular joint reconstruction restores the function of the posterior proximal tibiofibular joint ligaments. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anatomic Medial Ulnar Collateral Ligament Reconstruction With Internal Brace Augmentation in Throwing Athletes

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12 to 18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL. This presentation demonstrates the “anatomic technique” for reconstruction of the MUCL supplemented by internal brace augmentation. Indications: Initial injuries of the MUCL can often be managed conservatively; however, many complete tears and those failing nonoperative management are frequently treated with MUCL reconstruction. Technique Description: After graft harvest, a 6-cm incision is created over the medial epicondyle to expose the sublime tubercle and medial epicondyle. Sutures are placed through the torn ligament which are used to formally repair the native ligament. A 4-mm socket is drilled in the MUCL origin of the medial epicondyle, and two 2-mm penetrating sockets are drilled toward the base of the 4-mm socket. The sutures in the native ligament are passed through the sockets and later tied over the bone bridge to complete the native ligament repair. A tight rope is shuttled through the medial epicondyle socket and assembled. The palmaris longus autograft and a suture tape are loaded onto the tightrope and reduced into the humeral socket. On the ulna, soft suture anchors are placed on either side of the sublime tubercle. The distal end of the graft is then sutured utilizing a FiberWire. The graft is secured to the sublime tubercle by tying down the previously placed suture anchors. The suture tapes and internal brace are loaded into a SwiveLock suture anchor, which is fixed distally along the sublime tubercle ridge creating an anatomic reconstruction. Then, the native ligament sutures and tight rope are re-tensioned and tied across the humeral bone bridge for final fixation. Results: In our cohort of 26 professional and amateur throwers, &gt;90% returned to play at the same level at a mean of 9.9 months postoperatively. Discussion/Conclusion: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries and may allow expedited return to sport for most athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Incidence of Septic Arthritis After Vancomycin Soaking of the Graft During Arthroscopic Anatomic Anterior Talofibular Ligament and Calcaneofibular Ligament Reconstruction

Background: Vancomycin soaking of the graft during arthroscopic anterior cruciate ligament reconstruction has been shown to be effective in reducing the rate of postoperative infection. Purpose/Hypothesis: The present study aimed to (1) analyze the effect of vancomycin-soaked grafts during arthroscopic anatomic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) on the incidence of infection and (2) evaluate the influence of infection on functional outcomes and identify the risk factors of infection. It was hypothesized that vancomycin soaking of the graft would reduce the postoperative infection rate. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients at 2 centers who underwent ATFL/CFL reconstruction between December 2011 and July 2022 were included. All patients had undergone anterolateral arthroscopic debridement of the ankle and anatomic ATFL/CFL reconstruction with a gracilis tendon autograft. Vancomycin soaking of the graft was begun in both centers in January 2021. Complications, functional scores, return to sports (RTS) rates, and the level of return were compared between patients with and without vancomycin-soaked grafts and between patients with and without infection. Results: Overall, 182 patients (48% men; mean age, 34 ± 11.9 years) were included, with a mean follow-up of 23 ± 16.1 months. The rate of postoperative infection was significantly lower in the group with vancomycin soaking versus without (0/92 [0%] vs 8/90 [8.9%]; P = .001). At the final follow-up, there were 26 complications (14.3%): 8 infections, 6 recurrent tears, and 12 peripheral neuropathies. The infections developed after a mean of 17 ± 11 days. The functional scores were excellent at the final follow-up (American Orthopaedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Score, 86.5 ± 18.7; Karlsson score, 85 ± 18.3). Patients with infection had significantly decreased AOFAS scores (52.8 ± 27.6 vs 83.3 ± 21.5; P = .003), Karlsson scores (57 ± 27.7 vs 83.6 ± 20; P = .006), and RTS rates (25% vs 77%; P = .005) versus patients without infection. Conclusion: Vancomycin-soaked grafts for arthroscopic anatomic ATFL/CFL reconstruction decreased the rate of postoperative infection. Infection led to a deterioration in results. Vancomycin-soaking of the graft did not have a negative effect on functional results.

Type C1 radical hysterectomy and anatomical reconstruction of pelvic structures to enhance pelvic floor function in early-stage cervical cancer: surgical technique

Type C1 radical hysterectomy and anatomical reconstruction of pelvic structures to enhance pelvic floor function in early-stage cervical cancer: surgical technique

Reconstruction of Coracoclavicular Ligaments with Semitendinosus Autograft and Temporary Kirschner Wires is a good option for Chronic Acromioclavicular Joint Instability.

This study reports the results of surgical anatomic reconstruction of torn coracoclavicular ligaments with an autogenous semitendinosus graft and temporary Kirschner wires (K-wires) in chronic acromioclavicular (AC) joint dislocations. Nineteen shoulders underwent surgical anatomic reconstruction of torn coracoclavicular (CC) ligaments with an autogenous semitendinosus tendon graft and temporary K-wires for Rockwood grade III, IV and V chronic AC joint dislocations. Pre-operative data included patients' demographic characteristics, injury characteristics and surgical histories. The primary outcome measures were the University of California Los Angeles (UCLA) shoulder rating scale and visual analogue pain scoring (VAS), and the complications were noted for each patient. Surgical anatomic reconstruction of torn CC ligaments was performed in 19 patients with a mean age of 41.6±16 years (range 21-72 years). All of the patients were satisfied and felt better after CC ligament reconstruction. The average UCLA shoulder rating scale score was good/excellent: 29.4 (range 23-34) out of 35 points. The average pre-operative VAS score was 7.7 points out of 10 and improved to 1.1 points post-operatively (p<0.05). None of the patients experienced failure during the follow-up. One patient had a mild subluxation, but the patient was satisfied with the result. This technique is simple, reliable, and biologic without major complications. It is also a cost-effective procedure since it can be performed with Kirschner wires and autogenous grafts. It has a major advantage of leaving no implants inside the joint, which can lead to hardware complications, and it can be performed in basic operating room settings.

Current Concepts in Management of Acromioclavicular Joint Injury.

Background: The management of acromioclavicular joint injuries requires a thorough understanding of the anatomy and biomechanics of the joint, as well as knowledge of the pertinent physical exam findings and classification to determine an appropriate treatment approach, whether operative or nonoperative. In this article, we present a narrative review of the current state of understanding surrounding these issues. Although there are a large number of options for operative intervention, we additionally present our experience with anatomic coracoclavicular ligament reconstruction (ACCR) with imbrication of the deltoid fascia. Methods: A retrospective review of prospectively collected data on a total of 45 patients who had undergone ACCR between 2003 and 2016 were collected. Results: We found that improvements were seen in American Shoulder and Elbow Surgeons Score (ASES) (53 ± 19 to 81 ± 23), Simple Shoulder Test (SST) (6 ± 3 to 12 ± 13), Constant-Murley (CM) (60 ± 18 to 92 ± 8), and Rowe (67 ± 14 to 89 ± 11) and the mean post-operative SANE score was 86 ± 17. Conclusions: ACCR has the advantage of addressing both horizontal and vertical stability with good outcomes.