Femoral Drilling Research Articles

Seven percent of primary anterior crucial ligament reconstruction patients have arthroscopic resection of cyclops lesions within 2 years: A cohort study of 2556 patients.

After anterior cruciate ligament reconstruction (ACL-R), a localised scar tissue called cyclops lesion may develop anterior to the graft causing knee extension deficits, pain, oedema, clicking and reduced knee function. This study determined the incidence of arthroscopic resection of a cyclops lesion within 2 years after ACL-R and investigated the associations of patient characteristics and surgical techniques with the need for arthroscopic resection of a cyclops lesion. This study included patients who underwent primary ACL-R with adult surgical technique from 2005 to 2019 at Aarhus University Hospital, Denmark. The cohort was identified in a national registry. To identify patients who had resected a cyclops lesion within the first 2 years after ACL-R, patients' surgical records were reviewed. In 2005-2019, 2556 patients underwent primary ACL-R; 176 developed cyclops lesions that were resected within 2 years, equivalent to an incidence of 6.9% (95% confidence interval [CI]: 5.9-7.9). When stratified by the femoral drilling technique used, this incidence was 8.9% (95% CI: 7.7-10.3) with the anteromedial technique and 1.9% (95% CI: 1.0-3.1) with the transtibial technique. The incidence was 8.5% (95% CI: 6.8-10.3) in women and 5.7% (95% CI: 4.6-7.1) in men. Age, graft choice and the presence of cartilage or meniscal lesions did not affect the incidence. The overall incidence of a cyclops lesion removal within 2 years post-ACL-R was 6.9%. This was five times higher with the anteromedial femoral drilling technique than with the transtibial technique. Women had a 47% higher incidence of cyclops lesion removal than men. This is relevant for the surgeon when planning an ACL-R. Level II.

The Femur-First Technique for Oxford Medial Unicompartmental Knee Arthroplasty.

The Femur-First Technique for Oxford Medial Unicompartmental Knee Arthroplasty.

Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis

PurposeThis study sought to identify trends in anterior cruciate ligament (ACL) reconstruction (ACLR), including graft choice, femoral tunnel drilling, and augmentation techniques, and to assess how various surgeon factors impact these trends. MethodsA retrospective review of primary ACLR performed between 2014 and 2022 was performed using a multi-centered institutional database. Patient demographics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports-trained versus non-sports-trained), experience (high: minimum 15 years in practice), and volume (high: minimum 15 ACLR per year) were used to stratify technique utilization. Z-test for proportions compared categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as a p-value less than 0.05. ResultsOur cohort consisted of 2,032 ACLR performed on 2,006 patients. The average patient age was 28.3 +/- 11.6 years, with more procedures performed on males (67.3%). The average surgeon experience was 19.7 +/- 11.4 years, with an average annual procedural volume of 4.0 +/- 5.4. Most surgeons were sports-trained (55, 64.7%), high experience (44, 57.1%), and low-volume (80, 94.1%). There were increasing annual proportion of ACLR performed by sports-trained (R=0.748, p=0.020) and low experience (R=0.940, p<0.001) surgeons. Autograft reconstructions were most often performed by sports-trained (71.2%), low experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLR that utilized QT among sports-trained (R=0.739, p=0.023), high experience (R=0.768, p=0.016), and low-volume (R=0.785, p=0.012). Independent drilling (ID) techniques were used in an increasing proportion of ACLR performed by non-sports-trained (R=0.860, p=0.003) and high-volume surgeons (R=0.864, p=0.003). Augmentation of ACLR with concomitant suture augmentation (24, 1.2%) or extra-articular tenodesis (6, 0.3%) was rarely performed ConclusionIn our multi-centered institution, the QT autograft has been increasingly utilized in ACLR by sports-trained, low volume, and high experience surgeons, ID techniques have been increasingly utilized by non-sports-trained and high-volume surgeons Clinical RelevanceSurgeons must stay current with literature that affects their procedures to ensure that evidence-based medicine is being practiced.

Anterior Cruciate Ligament Reconstruction: 3-Incision Technique With Allograft Quad Tendon ACL Reconstruction

Background: Anterior cruciate ligament (ACL) ruptures are becoming more common in younger and older athletes. Approximately 250,000 ACL injuries occur each year, requiring the need for an effective and reproducible surgical technique. Indications: The 3-incision outside-in technique utilizes the donor quadriceps tendon, an extraordinarily strong graft, without damage from autogenous harvesting of patellar tendon or hamstrings. While some data suggest higher re-rupture risk with donor tissue, this is counterbalanced by avoiding secondary surgical site damage. Technique Description: The ruptured ACL is removed and the intercondylar notch is cleaned to visualize the anatomical ACL insertion site. Using the 3-tunnel technique a gaff is passed through the intercondylar notch, through a puncture hole (incision 1) and a rear entry guide hooked to its tip. The guide point is pulled into the knee and placed in posterior aspect of the anatomic footprint of the native ACL. Through incision 2, a guide pin is drilled to this point and overdrilled with a 10-mm drill. The edges of the hole in the intercodylar notch are smoothed with a currette. The tibial footprint is cleared, a tibial aiming guide placed. Through incision 3, a guide pin is placed and over drilled with a 10-mm drill followed by a Gore-Tex reamer to ensure no impingement would inhibit graft passage. The proximal bone of a quadriceps tendon graft is sized through a 10-mm sizer and compacted. Two holes are drilled to hold sutures for the proximal aspect of the femoral graft. The quadriceps tendon graft is sized to fit through a 9-mm tunnel and the free end whipped with a stitch before being passed from outside-in through the smoothed tunnels. The femoral bone block is tapped to have a press fit initially and then is fixed with a Milagro screw. The knee is cycled ten times to remove slack and the interference fit guide pin is placed on the anterior aspect of the graft, and fixed with the knee at 15° to 30° of flexion. Stability is tested with confirmation of no impingement, and then an extra-articular reconstruction with a semitendinosus allograft is performed. The extra articular reconstruction is placed at the point between Gerdy's tubercle and the fibular head, passed under the skin and the iliotibial band, and then inserted just anterior and superior to the ACL femoral drill hole. Results: Patient outcomes in our initial experience are comparable to our autogenous bone-tendon-bone (BTB) procedures without anterior knee pain. Return to sport is similar with autogenous procedures, with a delay of 6 to 12 months. In addition, there is a possibility for acceleration of healing with the addition of platelet-rich plasma and hyaluronic acid between 1 and 3 months postsurgery. We have insufficient data so far to determine if the re-rupture rate will decline compared with reported outcomes. Conclusion: The 3-incision technique with allograft quadriceps tendon for ACL reconstruction is a reproducible surgical technique that avoids harvest from the patient's own body. 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.

Previous Knee Surgery, Anteromedial Portal Drilling, Quadriceps Tendon Autograft, and Meniscal Involvement Associated With Delayed Return to Sport After Anterior Cruciate Ligament Reconstruction in Amateur Athletes

PurposeTo identify prognostic factors associated with a delayed return to sport (RTS) time in amateur athletes who return to full participation after a primary isolated anterior cruciate ligament (ACL) reconstruction. MethodsA retrospective review was performed among athletes who underwent ACL reconstruction between October 2014 and October 2021. Inclusion criteria were any amateur athletes with an ACL reconstruction that had a documented RTS and greater than one-year follow-up. Non-athletes, multiligamentous knee injury, and missing documented RTS timelines were exclusion criteria. RTS was defined as participation in athletics at a level equivalent to or higher than the pre-injury level participation. Demographic and prognostic factors, including prior knee surgery, meniscal involvement, level of participation, surgical approach, and graft type, were recorded along with RTS time and analyzed via Poisson regression. Results91 athletes, average age 18.8 (± 6.7) years, who underwent ACL reconstruction at a single institution from 2014 to 2021 were identified with an average follow-up time of 4.6 (±2.5) years [range 1.1, 9.0]. Meniscal involvement [1.11 (95% CI: 1.08, 1.15), p < 0.001] and previous knee surgery [1.43 (95% CI: 1.29, 1.58), p < 0.001] were related to a delayed RTS. Quadriceps tendon and bone-patellar tendon-bone (BTB) autografts, as well as allograft showed a significant association with a longer RTS time when compared to hamstring autograft [1.16 (95% CI: 1.13, 1.20), p < 0.001; 1.04 (95% CI: 1.01, 1.07), p = 0.020; 1.11 (95% CI: 1.03, 1.19), p=0.004, respectively], as did anteromedial portal drilling, when compared to the outside in approach for femoral drilling [1.19 (95% CI: 1.16, 1.23), p < 0.001]. ConclusionPrior knee surgery, anteromedial femoral drilling, quadriceps tendon autograft, and meniscus tear were most associated with a delayed timeline for RTS among young athletes who were able to return.

Anterolateral and Direct Lateral Tunnel: Two Safe Zones for Femoral Drilling During All-Epiphyseal Anterior Cruciate Ligament Reconstruction – A Digital Three-Dimensional MRI Simulation Model Study

Anterolateral and Direct Lateral Tunnel: Two Safe Zones for Femoral Drilling During All-Epiphyseal Anterior Cruciate Ligament Reconstruction – A Digital Three-Dimensional MRI Simulation Model Study

Safe femoral tunnel drilling angles avoid injury to the medial and posteromedial femoral anatomic structures during single-bundle posterior cruciate ligament reconstruction with the inside-out technique.

To investigate the relationship between the medial and posteromedial femoral anatomic structures and the femoral tunnel exit produced by different tunnel orientations when creating the femoral tunnel for posterior cruciate ligament reconstruction (PCLR) using the inside-out (IO) technique and to estimate safe tunnel orientations to minimize the risk of iatrogenic injury to these structures. Eleven cadaveric knees were used. The medial and posteromedial aspects of each knee joint were dissected to reveal the "safe zone," which is a bony area that avoids the distribution or attachment of at-risk structures (MCL, PMC structures, and articular cartilage), while remaining 10mm away from the articular cartilage. The hypothesis of this study was that by creating the femoral tunnel at specific angles using the IO technique, the tunnel outlet would be as close to the safe zone as possible, protecting the at-risk structures from damage. Femoral tunnels were drilled at 20 different angle combinations on each specimen: 0°, 15°, 30°, 45°, and 60° relative to a line parallel to the transepicondylar axis in the axial plane, as well as 15°, 30°, 45°, and 60° relative to a line parallel to the femoral axis in the coronal plane. The positional relationship between each tunnel exit and the safe zone was recorded, and the shortest distance between the exit center and the safe zone boundary was measured. The risk of iatrogenic injury differed depending on the drilling orientation (χ2 = 168.880, P < 0.001). Femoral drilling angle combinations of 45/45°, 45/60°, 60/30°, 60/45°, and 60/60° (axial/coronal) were considered relatively safer than other orientations (P < 0.05). The shortest distance between the tunnel exit and the safe zone boundary was negatively correlated with the angle in the axial plane (P < 0.001, r = -0.810). When creating the IO femoral tunnel for single-bundle PCL reconstruction, angle combinations of 45/45°, 45/60°, 60/30°, 60/45°, and 60/60° (axial/oblique coronal) could be utilized to prevent at-risk structures from being damaged. The drilling angles and the safe zone can be employed to optimize the femoral tunnel in PCLR.

Trajectory of bearing movement during Oxford mobile-bearing unicompartmental knee arthroplasty using a kinematic alignment technique.

Trajectory of bearing movement during Oxford mobile-bearing unicompartmental knee arthroplasty using a kinematic alignment technique.

Non-Coding-RNA-Activated Core/Chitosan Shell Nanounits Coated with Polyetheretherketone for Promoting Bone Regeneration and Osseointegration via Osteoimmunology.

Bone implant outcome and bone regeneration properties can be improved by the immunomodulation of exosomes (Exos) derived from bone marrow mesenchymal stem cells (BMSCs), which contain cytokines, signaling lipids, and regulatory miRNAs. Analysis of miRNAs in BMSCs-derived exosomes showed that miR-21a-5p exhibited the highest expression and was associated with the NF-κB pathway. Hence, we developed an implant with miR-21a-5p functionality to promote bone incorporation by immunoregulation. Mediated by the potent interaction between tannic acid (TA) and biomacromolecules, the tannic acid modified mesoporous bioactive glass nanoparticles coated with miR-21a-5p (miR-21a-5p@T-MBGNs) were reversibly attached to TA-modified polyetheretherketone (T-PEEK). Cocultured cells could phagocytose miR-21a-5p@T-MBGNs slowly released from miR-21a-5p@T-MBGNs loaded T-PEEK (miMT-PEEK). Moreover, miMT-PEEK boosted macrophage M2 polarization via the NF-κB pathway to increase BMSCs osteogenic differentiation. In vivo testing of miMT-PEEK in the rat air-pouch model and rat femoral drilling model indicated effective macrophage M2 polarization, new bone formation, and excellent osseointegration. Overall, the osteoimmunomodulation of the miR-21a-5p@T-MBGNs-functionalized implant promoted osteogenesis and osseointegration.

Enhanced recovery after surgery (ERAS) protocol in geriatric patients underwent unicompartmental knee arthroplasty: A retrospective cohort study.

The enhanced recovery after surgery (ERAS) pathway was formulated with the aim to reduce surgical stress response, alleviate pain and guarantee the best-fit experience of patients' perioperative period. However, the application of ERAS in geriatric patients who underwent unicompartmental knee arthroplasty (UKA) was relatively lacking. We hypothesize that UKA patients can benefit from the ERAS protocol. A total of 238 patients were recruited in this retrospective study from August 2018 to December 2021, and Oxford phase III UKA was applied to all patients. ERAS pathway included nutrition support, anesthesia mode, interoperative temperature, and blood pressure control, application of tranexamic acid, early initiation of oral intake and mobilization, and pain management. Demographic data, operation-relative variables, and postoperative complications were analyzed. Forgotten Joint Scores, Oxford Knee Score, Lysholm score, numerical rating scale, and knee range of motion were introduced to estimate the activity function and pain of surgical knee, and these variables were compared between the 2 groups. There were 117 patients in the ERAS group and 121 patients in the traditional group, respectively. The ERAS group had a shorter length of surgical incision and less intraoperative blood loss. Postoperative hemoglobin and albumin of patients in the ERAS group were better than those in the traditional group (P < .05), after 17.0 ± 10.8 months follow-up, the numerical rating scale, Lysholm, Oxford Knee Score, Forgotten Joint Scores, and knee range of motion of patients in the ERAS group were significantly better than the traditional group. The length of hospital stay for patients who underwent ERAS was 11.7 ± 3.8 days and the postoperative complication rate was lower for the ERAS group patients (P = .000 and 0.031). ERAS can reduce the length of hospital stay, and patients can achieve excellent postoperative knee function. The formulation and implementation of the ERAS protocol require good collaboration across multiple disciplines, as well as a deep understanding of the existing clinical evidence and the concept of the ERAS program.

Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon Femoral Ligament in Skeletally Immature Patients

The medial patellofemoral ligament (MPFL) reconstruction is challenging in skeletally immature patients due to the anatomical particularities at this age. Recently, the medial quadriceps tendon femoral ligament (MQTFL) has received great interest for its ability to restrain the patella’s instability along with MPFL. No gold-standard technique has been described so far to reconstruct both MPFL and MQTFL in skeletally immature patients. We present a technique to safely reconstruct the MPFL and the MQTFL in children and adolescents. The gracilis tendon autograft is harvested and passed through the medial collateral ligament as a pulley. The free ends of the graft are passed through the patella by an “L-shaped tunnel” and tied to itself. The other free end of the graft is pulled through the medial third of the quadriceps tendon and tied to itself to achieve tension. Our technique is reproducible, implant-free and avoids complications associated with femoral drilling and graft fixation. However no long-term follow-up results are available.

Anteromedial Portal Technique, but Not Outside-in Technique, Is Superior to Standard Transtibial Technique in Knee Stability and Functional Recovery After Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis

To compare the postoperative outcomes of 4 different femoral drilling techniques in anterior cruciate ligament reconstruction. Three databases were searched for randomized controlled trials comparing any 2 or more of the following femoral drilling techniques in anterior cruciate ligament reconstruction: standard transtibial (sTT), anteromedial portal (AMP), outside-in (OI), or modified transtibial (mTT) technique. A Bayesian network meta-analysis was performed to assess postoperative stability and functional recovery in terms of the side-to-side difference (measured by arthrometry), Lachman test, pivot-shift test, International Knee Documentation Committee subjective and objective scores, Lysholm score, and Tegner score. The Fisher exact probability test and χ2 test were used to compare the incidences of infection and graft rupture, respectively. We included 20 randomized controlled trials involving 1,515 patients. The AMP technique showed a lower side-to-side difference (standardized mean difference, -0.33; 95% credible interval [CrI], -0.53 to -0.12), higher negative rate on the pivot-shift test (odds ratio, 2.19; 95% CrI, 1.38 to 3.44), and higher International Knee Documentation Committee objective score (odds ratio, 3.13; 95% CrI, 1.42 to 7.82) than the sTT technique. However, knee stability and functional outcomes did not differ significantly between the OI and sTT techniques. Safety outcomes of the mTT technique were unavailable. The incidence of graft rupture was 5.20% for the OI technique, 2.27% for the AMP technique, and 1.51% for the sTT technique. The OI technique had a significantly higher incidence of graft rupture than the sTT technique (χ2= 4.421, P= .035). No significant difference in the incidence of infection was found between the sTT, AMP, and OI techniques (P= .281). The AMP technique, but not the OI technique, was superior to the sTT technique in knee stability and functional recovery. The OI technique had a higher incidence of graft rupture than the sTT technique. There was no significant difference between the AMP and OI techniques or between the mTT technique and any other femoral drilling technique. Level II, meta-analysis of Level I and II studies.

MPFL Reconstruction With a Double-Loop Gracilis: The Concept of “Favorable Anisometry”

Background: Medial patellofemoral ligament (MPFL) reconstruction has shown very good results in patella dislocation and patient satisfaction. However, correct positioning and tensioning of the graft can be difficult to achieve and can lead to complications. Indications: Medial patellofemoral ligament reconstruction is always indicated for recurrent patellar instability with dislocation in extension, with or without other procedures that aim to correct predisposing factors of instability. Technique Description: An arthroscopic examination is first done to assess chondral lesions. The gracilis tendon is detached from the tibia and prepared to pass through 3-mm drill holes. The medial edge of the patella is exposed, and two 3-mm drill holes are made. Dissection is performed with a scissors between the second and third layers toward the medial epicondyle, where a small skin incision is made. A guidewire is placed just anterior and distal to the adductor tubercle. A suture is used to test the isometry of the femoral drill hole. If correct tension or “favorable anisometry” is achieved, a 5-mm bone anchor is placed. The graft is looped and pulled into the femoral hole with sliding sutures. The 2 free ends of the graft are pulled through the patellar drill holes and looped back onto themselves. The graft is tensioned with the knee in maximum extension while pulling the patella proximally with a bone hook as hard as possible in the direction of the femoral shaft. The principle is that with maximum quads contraction, the tension in the patella tendon should be more than in the reconstructed MPFL. Results: Immediate full range of motion, intensive isomeric quads contraction exercises, and full weight-bearing with crutches for 2 to 4 weeks are recommended. Sport can be resumed after 3 months, but it usually takes 6 months to play at the same level as before. Discussion/Conclusion: The technique of “favorable anisometry” of the MPFL has shown a very low rate of recurrence of patella dislocation. Complications are rare and extensor lag is very uncommon, thanks to the specificity of tensioning the graft. 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.

Global variation in isolated posterior cruciate ligament reconstruction

PurposeIn the setting of persistent instability or failed non-operative management, surgical reconstruction is commonly recommended for isolated posterior cruciate ligament (PCL) tears. The purpose of this study was to systematically review published studies to evaluate regional variation in the epidemiology of and surgical approaches to primary, isolated PCL reconstruction.MethodsA systematic review was performed in June 2022 to identify studies examining operative techniques during primary, isolated PCL reconstruction. Collected variables consisted of reconstruction technique, graft type, graft source, tibial reconstruction technique, femoral and tibial drilling and fixation methods, and whether the remnant PCL was preserved or debrided. Studies were classified into four global regions: Asia, Europe, North America, and South America.ResultsForty-five studies, consisting of 1461 total patients, were identified. Most of the included studies were from Asia (69%, n = 31/45). Single bundle reconstruction was more commonly reported in studies out of Asia, Europe, and North America. Hamstring autografts were utilized in 51.7% (n = 611/1181) of patients from Asia and 60.8% (n = 124/204) of patients from Europe. Trans-tibial drilling and outside-in femoral drilling were commonly reported in all global regions. The PCL remnant was generally debrided, while remnant preservation was commonly reported in studies from Asia.ConclusionSurgical treatment of isolated PCL injuries varies by region, with the majority of published studies coming from Asia. Single-bundle reconstruction with hamstring autograft through a trans-tibial approach is the most commonly reported technique in the literature, with males reported to undergo isolated reconstruction more often than females.Level of EvidenceSystematic review, Level IV.

MRI signal intensity of anterior cruciate ligament graft after transtibial versus anteromedial portal technique (TRANSIG): A randomised controlled clinical trial

BackgroundTwo primary surgical femoral drilling techniques are used to reconstruct the anterior cruciate ligament (ACL): the transtibial (TT) technique and the anteromedial portal (AMP) technique. Currently there is no consensus on which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study was to assess MRI-derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare graft maturation of both AMP and TT ACL reconstruction techniques. MethodsThis randomised controlled trial included 33 patients admitted for primary unilateral ACL reconstruction. Primary outcome was MRI Signal intensity ratio (SIR) of the ACL graft one year after ACL reconstruction. Differences in MRI SIR were assessed on two MRI sequencies: sagittal Proton Density Turbo Spin Echo weighted images (PDTSE) and 3D T2 Gradient Echo (T2*) weighted images. Analysis of interobserver and intraobserver variability was conducted for the SIR measurements. ResultsNo difference in signal intensity of the graft was found between the TT and AMP techniques one year after ACL reconstruction (PDTSE p = 0.665, T2* p = 0.957). Both interobserver and intraobserver variability showed strong agreement (ICC 0.64–0.94). ConclusionNo differences in signal intensity of the graft on MRI were seen between the femoral drilling techniques one year after ACL reconstruction, suggesting similar graft maturation at that time. Follow-up studies are needed to determine whether graft intensity changes in the long term. Level of evidenceTherapeutic study with level of evidence I.

Current trends in anterior cruciate ligament surgery. A worldwide benchmark study

ObjectivesTo benchmark current trends on anterior cruciate ligament reconstruction (ACLR) surgery. MethodsThe largest worldwide ACLR survey to date was performed during May 2020, targeted to reach representation of all continents. It was submitted electronically to all International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports surgeons (n = 3,026), asking those who perform ACLR to respond. ResultsWith a final sample size of 2,107, the overall response rate was 69.6%. Median years of practice as orthopaedic surgeon was 15 (range 1–52) and 49.6% of all respondents were defined as high-volume surgeons (>50 ACLR annually). Hamstrings tendon autograft was the preferred graft for primary ACLR (80.3%) and the medial portal femoral drilling was the most frequently used technique (78.5%). Cortical buttons (82.7%) and bioabsorbable screws (62.7%) were the preferred fixation methods for hamstring tendon autograft ACLR in femur and tibia, respectively. Metallic screws (45.2%) were the preferred fixation methods for bone patellar tendon bone autograft in femur and tibia. Most of the respondents routinely used pre-tensioning techniques for their graft preparation (63.8%), but less than half of surgeons preferred antibiotic soaking of the grafts (45.3%). The preferred knee position for graft fixation was 10–30° of knee flexion and neutral rotation (57.0%). The addition of anterolateral augmentation (or extra-articular tenodesis) was infrequent in primary and isolated ACLR (10.0%), but a statistically significant raise was seen for revision surgeries (20.0%). Most used brace in the initial postoperative rehabilitation (54.9%) and the time to allow patients to fully resume sports was at an average of 8.9 ± 2.0 months. Treatment algorithm of paediatric ACL injuries exhibited a low consensus among the respondents. ConclusionThis worldwide survey benchmarks the current trends in ACL reconstruction, achieving the largest participation of surgeons to date. Among the great variety of options available for ACL reconstructions, surgeons’ preferences showed some differences according to their location and expertise. Reporting trends in practice, and not only the evidence, is important to medical education and providing patients the safest care possible.This is a Level V, expert opinion study.

Posterolateral Corner Reconstruction Using Double Femoral Fixation With Adjustable Loop Cortical Suspension and Interference Screw

Background: The posterolateral corner (PLC) of the knee is a complex anatomic region of the knee comprising the popliteus tendon, the popliteofibular ligament (PFL), and the fibular collateral ligament (FCL). Treatment of PLC injuries is based on the degree of varus and rotational instability on preoperative examination and is recommended in grade 3 injuries.1,6 Technique Description: The key concept of this new surgical technique is to use adjustable loop cortical suspensory fixation implants for initial femoral fixation of the popliteus and the FCL grafts. This allows for individual tensioning of the grafts prior to definitive fixation with an interference screw. An anatomic fibular tunnel is initially created, followed by popliteus and FCL anatomic femoral socket drilling. A TightRope RT implant is attached to the popliteus end of the graft and secured through a bone tunnel on the medial femoral cortex initially. The popliteus end of the graft is then pulled into the femoral socket before tunneling the graft through the fibular tunnel. A second TightRope RT implant is secured to the FCL end of the graft before securing it to the medial femoral cortex through a bone tunnel and pulling the graft into the drilled femoral socket. An interference screw is first used to secure the graft at the fibular tunnel. The knee is then taken to 60° where the TightRope device is used to remove residual creep and optimize final tensioning prior to final fixation with interference screw in femoral socket. With the knee at 30° of flexion, neutral rotation, and slight valgus, the same steps are repeated for FCL graft. A posterolateral capsular shift is completed for additional stability. Results: Residual posterolateral corner instability or failure after reconstruction surgery has been reported in 6% to 9.4% of surgical reconstruction case.2,3,5 The use of cortical suspensory devices in PLC reconstructions allows independent dialing of optimal graft tension for both the popliteus and FCL reconstruction before final interference screw fixation, therefore presumably limiting any residual creep and allowing for a double femoral fixation of the graft. Discussion: We describe a novel technique for posterolateral corner reconstruction which allows for optimal and individual tensioning of the structures of the posterolateral corner. Given the technique still uses well-described and validated graft choices and anatomic landmarks for reconstruction, we expect this new technique to allow for similar if not improved outcomes when compared with current gold standard.4

Biomechanical and Finite-Element Analysis of Femoral Pin-Site Fractures Following Navigation-Assisted Total Knee Arthroplasty.

Femoral pin-site fracture is one of the most serious complications of navigation-assisted total knee arthroplasty (TKA). Its occurrence is associated with the loss of biomechanical strength caused by intraoperative femoral drilling. This study aimed to investigate the drilling location as a risk factor for pin-site fracture. A biomechanical analysis using rabbit femora was performed to determine the effects of drilling eccentricity and height. Torsional, 3-point bending, and axial compression tests were performed to evaluate biomechanical parameters, including failure strength, failure displacement, and stiffness. Fracture type and the presence of comminution were noted and analyzed. Finite-element analysis (FEA) was utilized to assess the stress distribution and deformation. The cumulative sum (CUSUM) method was applied to define the safe range for drilling eccentricity. Drilling operations were accurately implemented. Biomechanical tests confirmed that severely eccentric drilling significantly reduced the biomechanical strength of the femur, especially in torsion. FEA results provided evidence of threatening stress concentration in severely eccentric drilling. The overall safe range of eccentricity relative to the center of the femur was found to be between 50% of the radius in the anterolateral direction and 70% of the radius in the posteromedial direction. Severely eccentric drilling significantly increased the risk of femoral pin-site fracture, especially under torsional stress. Femoral drilling should be performed in the safe zone that was identified.

Arthroscopic-Assisted Toggle Rod Stabilization in Canine Coxofemoral Luxation: A Cadaveric Study.

The aim of this study was to describe an arthroscopic-assisted technique for coxofemoral toggle rod placement, and to report on the feasibility, drill tunnel trajectory and accuracy of tunnel aperture location using this method. Cadaveric pilot study. Eight coxofemoral joints. Craniodorsal coxofemoral joint luxations were artificially created. A simulated open hip reduction and stabilization with a toggle rod were performed through a limited arthrotomy under arthroscopic guidance. Computed tomography scans were performed to evaluate drill hole trajectory across the femoral neck, and joints were disarticulated and photographed. Digital imaging software was used to determine the percent overlap of the drill hole apertures relative to the origin and insertion of the round ligament on the acetabulum and fovea. The exit point of the tunnel was entirely within the fovea capitis in five of eight femurs, three of eight femoral drill apertures were only partially within the target area. Of the eight acetabular bone tunnels examined, all were centred occupying the acetabular fossa. Coxofemoral toggle rod placement can be performed under arthroscopic guidance through a limited arthrotomy. Comparable femoral tunnel accuracy with the standard open technique should be achieved with the current method prior to its clinical use.

Percutaneous Femoral Derotational Osteotomy in the Skeletally Immature Patient.

This is a percutaneous procedure that involves creation of femoral drill holes at the osteotomy site prior to reaming the canal4. External fixator pins are placed proximal and distal to the osteotomy site prior to completing the osteotomy. These pins are derotational markers for the surgeon and act to hold the correction with use of an external fixator while the interlocking screws are being placed. The pins are placed at a degree of divergence that is equal to the degree of intended derotation so that the pins will become parallel in the axial plane following derotation of the femur. The percutaneous osteotomy is then completed with use of an osteotome, and the trochanteric entry nail is passed across the osteotomy site while correcting rotation. Once rotation is fully corrected and the pins are parallel, the external fixator is placed to hold the rotation and interlocking screws are placed. Nonoperative alternatives to this procedure include physical therapy for gait training and strengthening as well as modalities to address hip and knee pain that may be associated with version abnormalities. Although physical therapy is often prescribed, it must be noted that excess version is a fixed osseous structural pathology that therapy cannot address. Additionally, compensatory mechanisms that may be taught to improve gait and walk with a neutral foot progression angle may exacerbate hip or knee pathology as a result of the underlying version abnormality. Surgical alternatives include derotational osteotomies of the proximal or distal aspects of the femur with use of an open technique with plate fixation, as opposed to an intramedullary nail following percutaneous diaphyseal osteotomy as presented here1. Additionally, an open technique with intramedullary nail fixation may be performed5. Excessive anteversion can cause both hip and knee symptoms, including hip pain, instability, labral and psoas pathology, and patellofemoral instability6. Excessive retroversion can cause impingement between the femoral neck and acetabulum, which results in pathology of the labrum and articular cartilage7. Additionally, abnormalities of version often lead to gait disturbances with frequent tripping and difficulty running8. Children with femoral version abnormalities have limited remodeling potential after age 83. A derotational osteotomy may be performed to correct symptomatic excess femoral version in an older child or adolescent. The patient may be weight-bearing as tolerated with upper-extremity assistance immediately following the procedure. The osteotomy typically heals between 6 and 12 weeks, and the patient may return to activities as tolerated once the osteotomy is healed. Gordon et al. described the outcomes of a similar technique for femoral derotational osteotomy in skeletally immature patients with excessive femoral anteversion3. The study retrospectively reviewed the results of the technique in 13 patients and 21 limbs at a minimum follow-up of 1 year. All patients complained of tripping and gait abnormalities preoperatively. All patients noted gait improvement, and no intraoperative or postoperative complications were reported. Healing of the osteotomy occurred at a mean of 6 weeks postoperatively. No patient developed osteonecrosis. We routinely remove hardware in skeletally immature patients approximately 1 year postoperatively. Complications are rare and include hardware irritation, infection, nonunion, and neurovascular injury. Preoperative planning is critical for this procedure, and the surgeon should know the intended degree of derotation, the location of the osteotomy relative to the greater trochanter, the length of the nail, and the approximate diameter of the nail prior to entering the operating room.Percutaneous bicortical femoral drill holes are created at the site of the osteotomy prior to reaming to allow for egress of reamings and bone marrow elements at the osteotomy site, which serve as autograft and stimulate bone healing. Additionally, the drill holes provide ventilation to prevent excessive intramedullary pressure during reaming9-11.External fixator pins are placed proximal and distal to the osteotomy prior to completion of the osteotomy to allow for rotational assessment after completion of the osteotomy. Placing these pins bicortically so that they are secure in the bone and ensuring that the divergence is correct for the intended amount of derotation is critical in this procedure because once the osteotomy is complete, the pins are the only markers of rotation the surgeon has to guide the correction.An external fixator is helpful in holding the femur at the intended degree of derotation during placement of the interlocking screws. ROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingAP = anteroposteriorGT = greater trochanterAV = anteversionER = external rotationIR = internal rotationA = anteriorP = posteriorM = medialL = lateralXR = X-rayProx = proximalEx fix = external fixatorWBAT = weight-bearing as toleratedBLE = bilateral lower extremitiesDVT = deep venous thrombosisPT = physical therapyppx = prophylaxisAVN = avascular necrosis (osteonecrosis).