Medial Ligament Research Articles

Ginsenoside compound K alleviates osteoarthritis by inhibiting NLRP3‑mediated pyroptosis.

Ginsenoside compound K (GCK) has been previously reported to be a potent antiarthritic and bone-protective agent. Therefore, the present study aimed to explore the potential effects of GCK on osteoarthritis and its regulatory effects on the pyroptosis of chondrocytes. Primary mouse chondrocytes (PMCs) were used for in vitro analysis. ELISA assays revealed that compared with the untreated cells, TNF-α induced a significant increase in IL-6, MMP13, A disintegrin and metalloproteinase with thrombospondin motifs 5 and MMP3 expression but induced a significant decrease in aggrecan and collagen II expression. By contrast, GCK reversed the aforementioned alterations in a dose-dependent manner. Experimental osteoarthritis was subsequently induced in mice through transection of the medial meniscotibial ligament and medial collateral ligament in the right knee [destabilization of the medial meniscus (DMM) mice]. GCK was found to reduce cartilage degradation in vivo in DMM mice, which was assessed using the Osteoarthritis Research Society International (OARSI) score, collagen II and MMP13 expression. Cartilage degradation is associated with higher OARSI score, decreased collagen II and increased MMP13 expression. In PMCs, TNF-α treatment stimulated an increase in the expression of NLR family pyrin domain containing 3 (NLRP3), Gasdermin D-N terminal (GSDMD-NT), cleaved caspase-1 and mature IL-1β, markers that indicate the occurrence of pyroptosis. However, GCK treatment suppressed the increase of the aforementioned proteins in a dose-dependent manner. Immunohistochemistry staining of the knee joint tissue sections from the DMM mice confirmed that GCK attenuated the NLRP3 and GSDMD-NT expression that was induced by DMM surgery. In conclusion, the present study revealed that GCK can reduce cartilage degradation in an osteoarthritis model by inhibiting the NLRP3-inflammasome activation and subsequent pyroptosis.

Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction in recurrent patellar instability: A systematic review and meta-analysis.

The medial patellofemoral ligament (MPFL), along with the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament, aid in the stabilization of the patellofemoral joint. Although the MPFL is the primary stabilizer and the MPTL is a secondary limiter, this ligament is critical in maintaining joint stability. There have been few studies on the combined MPFL and MPTL reconstruction and its benefits. To look into the outcomes of combined MPFL and MPTL reconstruction in frequent patellar instability. By May 8, 2022, four electronic databases were searched: Medline (PubMed), Scopus, Web of Science, and Google Scholar. General keywords such as "patellar instability," "patellar dislocation," "MPFL," "medial patellofemoral ligament," "MPTL," and "medial patellotibial ligament" were co-searched to increase the sensitivity of the search. The pooled effects of combined MPFL and MPTL reconstruction for Kujala score (12-mo follow-up) and Kujala score (24-mo follow-up) were positive and incremental, according to the findings of this meta-analysis. The mean difference between the Cincinnati scores was also positive, but not statistically significant. The combination of the two surgeries reduces pain. According to cumulative meta-analysis, the trend of pain reduction in various studies is declining over time. The combined MPFL and MPTL reconstruction has good clinical results in knee function and, in addition to providing good control to maintain patellofemoral joint balance, the patient's pain level decreases over time, making it a valid surgical method for patella stabilization.

Intervention Progress of Anterior Cruciate Ligament (ACL) Reconstruction in Knee Osteoarthritis Caused by ACL Injury

In recent years, as the number of people exercising has increased, so has the number of sports injuries, including traumatic osteoarthritis caused by Anterior Cruciate Ligament ACL injury. Traumatic osteoarthritis is a disease caused by trauma to or around the joints. It is primarily distinguished by articular cartilage degradation and ossification, which can lead to pathological changes of periarticular ligaments, synovial inflammation and joint instability, mainly causing joint pain, dysfunction, including premature joint degradation and other clinical symptoms. Any age and age group can occur, generally to young adults more common. The treatment of ACL injury is generally divided into emergency care, surgical treatment, drug treatment, and non-surgical treatment. If patients have ACL injury combined with medial knee ligament injury, or combined with posterior cruciate ligament injury and lateral ligament injury, surgical repair is generally selected for treatment, or ligament reconstruction is selected for treatment. For patients with obsolete injuries, more treatment means of ligament reconstruction should be considered. The therapeutic effect of ACL reconstruction on post-traumatic osteoarthritis is still controversial. This article aims to review the relationship between ACL injury and the pathogenesis of post traumatic knee osteoarthritis, in order to provide assistance for the treatment of Osteoarthritis of the knee caused by a severe injury.

Poster 297: Deep medial collateral ligament reconstruction of the knee restores rotational stability throughout full range of motion while contemporary MCL reconstruction only does in extension

Objectives: The past decade has taught the importance of identifying and treating the concomitant injuries that frequently occur at the time of ACL rupture. Failure to do so can result in increased stresses on the ACL graft and subsequently increased risk of failure. While the focus has largely been on the menisci and the anterolateral soft tissues, recent studies have highlighted high frequency at which injuries to the medial structures occur in previously presumed isolated ACL tears and the increased risk of poor outcomes when they are not addressed. Injuries to the medial ligament complex result in valgus and anteromedial rotatory instability (AMRI). Historic MCL reconstruction techniques have focused on the superficial MCL in an effort to restore valgus stability while frequently ignoring the importance of the deep MCL in controlling tibial external rotation. The recent recognition of the importance of the medial ligament complex has led to multiple studies revisiting medial sided anatomy and questioning contemporary MCL reconstruction techniques. The objective of this study is to assess and compare the ability of a contemporary medial collateral ligament (MCL) reconstruction and a deep MCL (dMCL) reconstruction to restore rotational and valgus stability to the knee. Methods: Six pairs fresh-frozen cadaveric knee specimens were included and with intact soft tissue, the distal femur and tibia were potted in PVC pipes to facilitate biomechanical testing using a customized multi-axial knee activity simulator. Four states were tested: 1) intact 2) after sectioning of the sMCL and dMCL, 3) contemporary MCL reconstruction as described by LaPrade et al, and 4) dMCL reconstruction. In each state, the knees were tested under four loading conditions at varying flexion angles (0°, 20°, 40°, 60° and 90°): 8 Nm valgus torque, 5 Nm tibial external rotation torque, 90N anterior drawer, and combined 90 N anterior drawer plus 5 Nm tibial external rotation torque. Results: Transection of the sMCL and dMCL resulted in increased laxity with the application of the valgus torque, external rotation torque, and combined anterior drawer plus external rotation at all flexion angles. dMCL reconstruction restored external rotation stability to intact levels (all p<0.05) throughout all degrees of flexion (Figure 1), yet dMCL reconstruction did not restore valgus stability at any flexion angle (Figure 2). Contemporary MCL reconstruction restored valgus and external rotation stability at 0° and 20° and valgus stability at 40° (p<0.01). In response to a combined anterior drawer plus tibial external rotation, the dMCL restored stability back to the intact level at 20° and improved stability between 40° and 90° flexion (Figures 3 and 4). In contrast, the contemporary MCL reconstruction did not restore stability at any degree of flexion (p>0.05). Conclusions: Deep MCL reconstruction restored rotational stability to the knee throughout range of motion but did not restore valgus stability. The contemporary MCL reconstruction restore stability only near full extension.

Modified Endoscopic Distal Soft Tissue Procedure With Medial Metatarsosesamoid Ligament and Intermetatarsal Ligament Augmentation

Hallux valgus is one of the most common foot and ankle conditions faced by orthopaedic surgeons. Surgical correction of hallux valgus is frequently indicated for symptomatic deformity. Recently, the endoscopic technique of hallux valgus correction has been reported, which is basically an endoscopic approach to the classic distal soft tissue procedure. In this technical note, the technical details of the modified endoscopic distal soft tissue procedure with medial metatarsosesamoid ligament and intermetatarsal ligament augmentation is described. In this modified technique, the intact intermetatarsal ligament, plantar capsule of the first metatarsophalangeal joint (including the sesamoid apparatus), and medial metatarsosesamoid ligament form a soft tissue envelop that can wrap around the first metatarsal head to stabilize the first metatarsal in the reduced position.

Poster 237: Menisco-Tibial Ligament Complex Anatomy and Biomechanics – Implications for Meniscus Repairs, Ramp Lesions and Transplants

Poster 237: Menisco-Tibial Ligament Complex Anatomy and Biomechanics – Implications for Meniscus Repairs, Ramp Lesions and Transplants

HISTOMORPHOMETRIC ASSESSMENT OF ARCHITECTONICS AND VASCULARIZATION IN MAXILLARY ALVEOLAR PROCESS BONE TISSUE

The expansion of the most relevant priority fields in fundamental and applied medicine, along with the progress in modern dentistry and reconstructive maxillofacial surgery, requires in-depth understanding of the morphological and functional status of the maxillary alveolar process bone tissue and knowledge of the mandibular alveolar part, thus allowing selecting a reasonable treatment tactics for maxillofacial pathologies. Qualitative features of maxillary alveolar process microarchitectonics, angioarchitectonics, as well as the periodontal ligament arrangement at various levels of the teeth roots, histological and morphometric studies of bone tissue in the frontal and distal sections, as well as the maxillary segments of the maxillary medial incisors and the first molars were studied in 5 certified male cadavers with preserved dentition. The histological findings show, that the microarchitectonics of the maxillary alveolar process features a lamellar bone consists of plates that are adjacent tightly to each other. The bone plates orientation in the frontal section is longitudinal, while in the distal part it is along concentric circles located around the Haversian canals. The angioarchitectonics of the maxillary alveolar process features tubular structures, which run mainly perpendicular to the bone surface, with numerous anastomoses. As the morphometric analysis of the maxillary alveolar process vascular system shows, in the frontal section the number of vessels per 1 mm2 is 22.41± 1.76 - 22.87± 2.08; in the distal section − 23.94± 1.88 - 25.02±2.69 (p≤0.01); the average diameter of vessels in the frontal section is 25.34±2.45 microns – 26.06 ±3.17 microns, in the distal section − 25.72±2.31 microns – 26.14± 2.93 microns (p≤0.05); the average wall thickness in the frontal section is 1.43± 0.09 microns - 1.48± 0.12 microns, in the distal section − 1.50± 0.11 microns – 1.54± 0.14 microns (p≤ 0.01). The vestibular surface of the maxillary medial incisors at the level of the root gingival part, as well as the oral surface at the root apical level have been found to be zones of periodontal ligament compression, while the oral surface at the root gingival level and the vestibular surface at the root apical level – zones of the periodontal ligament stretching. At the root gingival level of the first maxillary molars, the medial and vestibular surfaces are zones of the periodontal ligament compression, whereas the oral and the distal surfaces stand as the zones of the periodontal ligament stretching. As a quantitative assessment showed, the structural elements of the medial incisors periodontal ligament, and the first maxillary molars had loose connective tissue – taken by its specific area – prevailing in the periodontal ligament compression zone; the specific area of dense connective tissue, though, was found to be prevailing at the periodontal ligament stretching zone under chewing stress. The data obtained through a quantitative analysis of the periodontal ligament microvascular bed of the medial incisors, and the first maxillary molars, reveal that the area with blood vessels in the compression zones by far exceeds the area of blood vessels in the stretching zones. It appears rather reasonable that in case of a biomechanical stress experienced by the incisor-maxillary and molar-maxillary segments of the upper jaw, the periodontal ligament morphology will change throughout the root, depending on the compression and stretching zone localization.

MPFL RECONSTRUCTION, USING FASCIA LATA AS AN AUTOGRAFT, AFTER FAILED PROXIMAL AND DISTAL PATELLOFEMORAL REALIGHMENT PROCEDURES. REPORT OF TWO CASES

Understanding all the technical features and functions associated with medial patellar ligament reconstruction (MPFL) with autograft will make restoration more effectual, limiting complications associated with its non-anatomical placement. We describe in this study the cases of two girls aged seven and thirteen who underwent successful MPFL reconstruction after failed proximal and distal patellofemoral realignment surgeries they had previously undergone to treat recurrent patellar dislocation. The modified Cincinnati and Kujala score were used for the preoperative and postoperative clinical evaluation of the two girls. In the final reassessment of the two girls, seven years post-operatively for the seven-year-old girl, and three years post-operatively for the thirteen-year-old girl, the modified Cincinnati score and the Kujala score were increased significantly. The restoration of the MPFL is a justified surgical method for an effective outcome of the reestablishment of patellar stability in skeletally immature patients who underwent less successful surgeries in the past.

The Blocking Points: The Keys to Consistent Success in Preservation Rhinoplasty.

Preservation rhinoplasty is a growing area of interest among rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, because of the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand on and include an additional two. The seven anatomical blocking points are as follows: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, the Webster triangle, the internal mucoperiosteum of the maxillary bone, the medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant to his or her chosen technique, and to appropriately and methodically address them to ensure consistent long-term results.

First case-series of robot-assisted pudendal nerve release: technique and outcomes.

Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR). 32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed. The Median duration of symptoms was 7 (5, 5-9) years. The median operative time was 74 (65-83) minutes. The median length of stay was 1 (1-2) days. There was only a minor complication. At 3 and 6months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, -0.81 (p = 0.01). RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

Effects of risk factors on evoked pain patterns in rat models of experimental knee osteoarthritis.

Pain experiences in patients with knee osteoarthritis (OA) may be influenced differently by OA risk factors, reducing the translatability of preclinical research into the clinic. Our objective was to contrast evoked pain patterns after exposure to different OA risk factors including acute joint trauma, chronic instability, or obesity/metabolic syndrome using rat models of experimental knee OA. We tested longitudinal patterns of evoked pain behaviors (knee pressure pain threshold and hindpaw withdrawal threshold) in young male rats exposed to different OA-inducing risk factors including (1) nonsurgical joint trauma (impact-induced anterior cruciate ligament (ACL) rupture); (2) surgical joint destabilization (ACL + medial meniscotibial ligament transection); and (3) high fat/sucrose (HFS) diet-induced obesity. Histopathology for synovitis, cartilage damage, and subchondral bone morphology was performed. Pressure pain threshold was reduced (more pain) most, and earlier by joint trauma (Week 4-12) and HFS (Week 8-28) than by joint destabilization (Week 12). Hindpaw withdrawal threshold was reduced transiently after joint trauma (Week 4), with smaller and later reductions after joint destabilization (Week 12), but not with HFS. Synovial inflammation occurred at Week 4 after joint trauma and instability but only coincided with pain behaviors after joint trauma. Cartilage and bone histopathology were most severe after joint destabilization and least severe with HFS. The pattern, intensity, and timing of evoked pain behaviors varied due to OA risk factor exposure and were inconsistently associated with histopathological OA features. These findings may help to explain the challenges with translating preclinical OA pain research to multimorbid clinical OA contexts.

Effects of udder edema on parlor behavior in first- and second-lactation Holstein dairy cows

Udder edema (UE) is a metabolic disorder that most commonly occurs around the transition period. However, there are gaps in our knowledge about its effects on parlor behavior. The aim of this study was to examine the prevalence and effects UE has on behavior in the milking parlor during udder preparation and active milking from 2 to 9 DIM in first (FL) and second lactation (SL) Holstein dairy cattle. Each cow (n = 375) was observed once and monitored from the point of first contact during udder preparation through the first 5 min of active milking. Behavior measurements include step, kick, and kicking off the milking unit (KOU). Cows were determined to have UE when the rear udder medial suspensory ligament lost definition and was softened due to the presence of interstitial fluid. In this study, 237/247 (95.6%) FL cows and 104/128 (81.3%) SL cows presented with UE. First lactation cows with UE had a higher step rate (3.97 steps/session) when in contact during udder preparation and attachment (2.80 steps/session), and kick rate during milking (2.68 kicks/milking session) when compared with SL cows with UE (2.37 steps/session, 1.25 steps/session, 1.24 kicks/milking session). FL cows with UE had a lower step rate during milking (6.04 steps/milking session) compared with FL cows without UE (7.20 steps/milking session). FL cows with UE had a higher average KOU count (μ = 0.220 kick-offs) than SL cows with UE (μ = 0.029 kick-offs) and FL cows without UE (μ = 0.091 kick-offs). The results indicate that UE is prevalent among dairy cattle, and the disorder has effects on behaviors presented in the milking parlor. Reducing UE has the potential to decrease step and kick behavior to improve welfare of transition cows and reduce risk to dairy caretakers in the milking parlor.

Allografts for Medial Patellofemoral Ligament (MPFL) Reconstruction in Adolescent Patients with Recurrent Patellofemoral Instability: A Systematic Review.

This systematic review updates the currently available evidence on medial patella-femoral ligament (MPFL) reconstruction using allografts. The outcomes were measured with patient-reported outcome measures (PROMs), redislocation and complication rates. This study was performed according to the 2020 PRISMA guidelines using the PubMed, Scopus, Web of Science databases, accessed in February 2023. Studies examining the clinical outcomes of MPFL reconstruction with allografts in adolescents and children with recurrent patellofemoral instability (PFI) were included. Data from three trials, including 113 surgical procedures in 121 children, were retrieved. 40% (48/121) of the included patients were girls. The mean age of the patients was 14.7 ± 0.8 years, and the mean follow-up length was 38.1 ± 16.5 months. With MPFL allograft reconstruction, the Kujala score improved by 14.7% (p < 0.0001) and the IKDC by 38.8% (p < 0.0001). The rate of dislocations was 5% (6 of 121), reoperation for instability was 11% (13 of 121), and subluxation was 2% (1 of 47). Conclusion: These results encourage the use of allografts for MPFL reconstruction in adolescent patients with recurrent patellofemoral instability. Though patellofemoral instability is common in clinical practice, the current literature lacks clinical evidence on allograft MPFL reconstruction. Additional high-quality investigations are required to properly establish the long-term advantages of allograft MPFL and its complication rate.

Differences in collagen types in the semitendinosus, quadriceps, and patellar tendons: A report using samples from an 11-year-old patient

BackgroundThis study aimed to determine the differences in the proportions of types I and type III collagen in the semitendinosus tendon (ST), quadriceps tendon (QT), and patellar tendon (PT), which are frequently used as autografts for anterior cruciate ligament (ACL) reconstruction. MethodsOrthopedic surgeons diagnosed habitual dislocation of the left patella and surgically treated an 11-year-old boy. Medial patellofemoral ligament reconstruction, medial patellar tibial ligament reconstruction, and arthroscopic lateral release were performed simultaneously. Tissue samples obtained during treatment that were no longer necessary were used as samples for this study. The samples were fixed, paraffin-embedded, and immunostained for type I and type III collagen. Stained samples were observed under a confocal microscope and evaluated visually and quantitatively to determine the percentages of type I and type III collagen. ResultsVisually, the ST had a higher percentage of type III collagen than the PT and QT. The QT and PT were similar in appearance; both consisted mostly of collagen type I. Quantitative evaluation using images showed that the PT comprised 100% type I collagen. The QT comprised 1% type III collagen. The ST comprised 34% type III collagen. ConclusionIn this patient, the QT and PT had higher percentages of type I collagen, which is considered physically strong. Type III collagen, which is considered physically weak, was most common in the ST. These factors may be associated with the high re-injury rates after ACL reconstruction using the ST for physically immature patients.

Medial Patellofemoral Reconstruction Techniques for Patellar Instability

The medial patellofemoral complex (MPFC) is the term used to describe the primary soft tissue stabilizer of the patella, which consists of fibers that attach to the patella (medial patellofemoral ligament, or MPFL), and the quadriceps tendon (medial quadriceps tendon femoral ligament, or MQTFL). Despite the variability of its attachment on the extensor mechanism, the midpoint of this complex is consistently at the junction of the medial quadriceps tendon with the articular surface of the patella, indicating that either patellar or quadriceps tendon fixation can be used for anatomic reconstruction. Multiple techniques exist to reconstruct the MPFC, including graft fixation on the patella, quadriceps tendon, or both structures. Various techniques using several graft types and fixation devices have all reported good outcomes. Regardless of the location of fixation on the extensor mechanism, elements critical to the success of the procedure include anatomic femoral tunnel placement, avoiding placing undue tension on the graft, and addressing concurrent morphological risk factors when present. This infographic reviews the anatomy and techniques for the reconstruction of the MPFC, including graft configuration, type, and fixation, while addressing common pearls and pitfalls in the surgical treatment of patellar instability.

Rotational ankle instability: A current concept review.

Ankle sprains are extremely common. It is important to have a clear insight of the course of recovery after such injury to evaluate the effective strategies to guide management decisions, and understand the potential risk factors involved in the development of chronic problems and recurrent ankle sprains. When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament, is involved, rotational ankle instability (RAI) can develop. Generally, a tear of the anterior fibres of the MCL accompanied by anterior talofibular ligament (ATFL) insufficiency has been associated with RAI, while injury of the intermediate fibres of the MLC has been associated with medial ankle instability (MAI). Conservative management is the first line of treatment, with surgery reserved for special cases or if rehabilitation has failed. Regarding surgery, several options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Ankle arthroscopy is increasingly used to address ligament insufficiency and to identify and treat intra-articular pathologies. Repair of MLC tears by an arthroscopic all-inside procedure is effective in both MAI and RAI.

Localization of the Adductor Tubercle in the Skeletally Immature: A Computed Tomography Study With Patellofemoral Surgical Implications

Background: The adductor tubercle of the distal femur is utilized by surgeons as an anatomic landmark to identify graft anchor placement during medial patellofemoral ligament (MPFL) and medial quadriceps tendon femoral ligament (MQTFL) reconstruction for patellofemoral instability. In the skeletally immature population, its location relative to the physis has not been well defined. Purpose: To identify the location of the adductor tubercle relative to the distal femoral physis in skeletally immature individuals and gain insight regarding optimal graft anchor placement for pediatric patients undergoing MPFL and MQTFL reconstruction. Study Design: Descriptive laboratory study. Methods: Thin-cut computed tomography scans of 37 male cadaveric specimens (age, 4-16 years) were obtained from the New Mexico Decedent Image Database. A measurement protocol to identify the adductor tubercle was created with guidance from a fellowship-trained musculoskeletal radiologist. By utilizing axial, coronal, and sagittal views of knee computed tomography scans, the adductor magnus tendon was identified and followed distally to its insertion (adductor tubercle) on the distal femur. Distance from the midpoint of the adductor magnus tendon insertion relative to the physis in the proximal-distal orientation was measured. The anterior-posterior distance of the midpoint tendon insertion relative to the posterior femoral cortex line was also evaluated. Results: The midpoint of the adductor magnus tendon was at the physis in 30 specimens. One 8-year-old cadaveric specimen had an insertion 1.1 mm distal to the physis. In all specimens ≥15 years old (n = 6), the adductor magnus tendon insertion was distal to the physis with a mean distance of 2.73 mm. The location of the adductor tubercle was always posterior (mean, 5.1 mm) with respect to the posterior femoral cortex line. Conclusion: The location of the adductor tubercle in male pediatric patients is likely at or distal to the physis. Thus, the findings of this study directly conflict with previous studies that suggested a more proximal location. Clinical Relevance: Optimal graft anchor placement during MPFL and MQTFL reconstruction in the skeletally immature patient can be challenging because of the variability reported in previous studies of the medial patellofemoral complex origin relative to the physis. This study suggests that distal—rather than proximal—graft anchor placement might better help restore patellofemoral isometry.

Modified external revision-DCR in previous failed endonasal, transcanalicular or external-DCR: technical strategy and teaching Pearls for success.

Objective: To report perioperative findings of patients with multiple failed-dacryocystorhinostomy (DCR) and to determine the success rate of revision external (rEx-DCR) performed by a modified technique. Methods: Thirty-one eyes of 31 patients (19 women, 12 men) with recurrent dacryocystitis or epiphora following at least one previous failed-DCR were assessed regarding the time from initial surgery to recurrence and revision surgery, type of primary surgery (endoscopic, transcanalicular, Ex-DCR), recurrence number, stent usage and the success rate. Relief of epiphora and positive dye test were established as functional and anatomical successes, respectively. Results: The mean age was 43.0 years (8-78), with a mean follow-up period of 21.4 months (6-46). The mean reoperation number was 1.4 (1-5). The mean time from initial surgery to recurrence was 15.2 months (1-55) and to rEx-DCR, 19.8 months (4-65). Untouched medial canthal ligament was observed in 28 (90.3%), improper rhinostomy location in 26 (83.8%), inadequate osteotomy size in 25 (80.6%), single-anterior-flap-only in 5 (16.1%), membranous ostial scar formation in four (12.5%) and no flap in three (9.6%) patients. The success rate was 93.5%, which was lower than our primary modified Ex-DCR (99.1%). Conclusions: The most common reasons for recurrence were small and unsuitable osteotomy locations with intact medial canthal ligaments. "Double-mucosal flap" approach with an anterior sacco-mucosal complex suspension increases the functional success rate, and stent implantation is not obligatory if canalicular problems or small/ atrophic sacs do not exist. The knowledge of technical strategy and teaching pearls improves the success rates of primary and revision surgeries. Abbreviations: DCR = dacryocystorhinostomy, Ex-DCR = external DCR, EE-DCR = endoscopic endonasal DCR, TC-LA-DCR = transcanalicular laser-assisted DCR.

V03-08 BILATERAL ROBOTIC NEPHRECTOMY USING A SUPINE ROBOTIC APPROACH WITHOUT REPOSITIONING THROUGH 8-18mm INCISIONS IN A YOUNG FEMALE WITH FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS: A VIDEO CASE REPORT

You have accessJournal of UrologyCME1 Apr 2023V03-08 BILATERAL ROBOTIC NEPHRECTOMY USING A SUPINE ROBOTIC APPROACH WITHOUT REPOSITIONING THROUGH 8-18mm INCISIONS IN A YOUNG FEMALE WITH FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS: A VIDEO CASE REPORT Luca Antonelli, Adrian Duss, Leutrim Zahiti, Agostino Mattei, and Christian D. Fankhauser Luca AntonelliLuca Antonelli More articles by this author , Adrian DussAdrian Duss More articles by this author , Leutrim ZahitiLeutrim Zahiti More articles by this author , Agostino MatteiAgostino Mattei More articles by this author , and Christian D. FankhauserChristian D. Fankhauser More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal segmental glomerulosclerosis (FSGS) is a histologic pattern that is associated with nephrotic syndrome in children and adults and represents an important cause of end-stage renal disease worldwide. The underlying podocytopathy is a consequence of multiple pathways either individually or collectively. The associated heavy proteinuria represents a perioperative risk factor for complications after transplantation. Therefore, a bilateral nephrectomy before transplantation is recommended to stop protein loss by the kidneys. METHODS: A 19 years-old woman with therapy resistant FSGS had a persistently low serum albumin level requiring 70g human albumin supplementation each week. A bilateral kidney embolization or surgical removal before listing for a kidney transplantation was required. To improve perioperative outcomes and cosmesis in a young female patient, she was scheduled for a robotic subumbilical access to avoid scar tissue in the upper abdomen.The patient was positioned in a supine position with 30° head down. Four robotic 8mm trocars were placed in a subumbilical line and a 5mm and 12mm assistant trocar were positioned laterally of the medial umbilical ligaments. No repositioning of the patient during the whole case was required. The peritoneum was incised at the level of the ileocecal valve up to the ligament of Treitz. A hammock-like barrier is created by suturing both lateral edges of the parietal peritoneum to the anterior abdominal wall. Subsequently the renal hilus was dissected and the kidney mobilized. The renal vessels were clipped. A 18mm laparoscopic morcellator was introduced after extending the 12mm assistant trocar incision and the kidneys were removed through the morcellator. RESULTS: Blood loss was <50 mL and theatre time 325 minutes. After the surgery the patient had mild bruises on both shoulders because of the long-time period in the Trendelenburg position but resolved without further treatment. Postoperative length of stay was 4 days. After successful removal of both kidneys, the patient was listed for a kidney transplant with priority given her age < 20 years. CONCLUSIONS: Bilateral robotic nephrectomy using a subumbilical access and removal of the kidney using a morcellator is technically demanding but feasible. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luca Antonelli More articles by this author Adrian Duss More articles by this author Leutrim Zahiti More articles by this author Agostino Mattei More articles by this author Christian D. Fankhauser More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP

You have accessJournal of UrologyCME1 Apr 2023V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP Melissa Moran, Alain Kaldany, Krishna Doppalapudi, Arnav Srivastava, and Sammy Elsamra Melissa MoranMelissa Moran More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Krishna DoppalapudiKrishna Doppalapudi More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , and Sammy ElsamraSammy Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with multiple abdominal surgeries often harbor hostile abdomens with significant bowel adhesions. It is thus difficult to obtain safe transperitoneal access when placing robotic trocars. An extraperitoneal approach, in contrast, allows for safe entry into the abdomen. In the case of a mid to distal ureteral stricture requiring extraperitoneal Boari flap ureteral reimplantation, the conventional multiport approach would be suboptimal as arm spacing would be insufficient. Here we demonstrate our surgical technique and the feasibility of a single port (SP) extraperitoneal Boari flap ureteral reimplantation. METHODS: A 70-year-old female with a history of rectal cancer treated with multiple abdominal surgeries and chemoradiation was diagnosed with a distal right ureteral stricture. She was offered SP robotic ureteral reimplantation for definitive management. The patient was positioned in steep Trendelenburg with a left-sided tilt. A 4 centimeter (cm) incision was created over the right lateral aspect of the abdomen 8 cm above the anterior superior iliac spine, and the retroperitoneal space was entered. The SP access port was placed and the robot was docked. The ureter was identified crossing the iliac vessels and was dissected proximally and distally. Once scar tissue was encountered, the ureter was transected. The bladder was mobilized and the medial umbilical ligament was cut. The distance from the ureter to the bladder was measured, and a Boari flap of this length was created. The posterior ureter was then spatulated and a Boari flap anastomosis was performed. The bladder was closed in a Heineke-Mikulicz fashion and a double-J ureteral stent was placed in the right ureter. The bladder was distended to ensure a watertight closure. A drain was placed and the Foley catheter was exchanged. RESULTS: The operative time was roughly three hours, with 50 milliliters of estimated blood loss. On post-operative day one, the drain was removed and patient was discharged home. Imaging two weeks later showed improved hydronephrosis with no urine extravasation, and the Foley catheter was removed. The ureteral stent was removed at four weeks post-operatively. Ultrasound and renal scan three months later demonstrated improved hydronephrosis with preserved renal function and no evidence of obstruction. CONCLUSIONS: To our knowledge, this is the first video demonstrating an SP extraperitoneal Boari flap ureteral reimplantation. This approach is feasible and allows a surgeon to safely and effectively perform a primarily retroperitoneal procedure without entering a hostile abdomen. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e80 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Melissa Moran More articles by this author Alain Kaldany More articles by this author Krishna Doppalapudi More articles by this author Arnav Srivastava More articles by this author Sammy Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...