Medial Portal Research Articles

Is Trochlear Dysplasia Associated with a High Prevalence of Repaired Anterior Medial Portal Lesions in Anterior Cruciate Ligament-Deficient Knees?

Abstract Introduction Meniscal tears, especially in the medial meniscus, are common in anterior cruciate ligament (ACL) injuries. Repaired anterior medial portal (RAMP) lesions, specific meniscal injuries associated with ACL ruptures, affect the peripheral attachment of the posterior horn of the medial meniscus. While the relationship between femoral trochlear morphology and ACL tears is established, its association with RAMP lesions remains unexplored. This study investigates the association between femoral trochlear morphology and RAMP lesions in ACL-deficient knees using magnetic resonance imaging (MRI) and evaluates MRI's accuracy against arthroscopy. Methods This hospital-based, cross-sectional observational study was conducted in a tertiary care center over 18 months. It included 126 adult patients who underwent arthroscopic ACL reconstruction and had preoperative MRI. Variables included age, gender, body mass index, trauma nature, and various MRI parameters, including femoral trochlear morphology and presence of RAMP lesions. MRI findings were compared to arthroscopic findings to evaluate diagnostic accuracy. Results RAMP lesions were detected in 21 participants (16.7%) via MRI and 28 participants (22.2%) via arthroscopy. MRI showed 71.4% sensitivity and 99.0% specificity for detecting RAMP lesions. No significant association was found between femoral trochlear morphology and RAMP lesions. However, medial tibial slope (TS) and posterior medial tibial bone edema (PMTBE) were significantly associated with RAMP lesions. The agreement between MRI and arthroscopy was high (Cohen's kappa = 0.773, p < 0.001). Conclusion This study found no significant association between femoral trochlear morphology and RAMP lesions in ACL-deficient knees. Instead, medial TS and PMTBE were significant predictors. MRI proved to have high specificity but moderate sensitivity compared to arthroscopy.

Intra-Tunnel Knotless Anchor Fixation for Lateral Meniscus Posterior Root Tears: A Novel Technique.

Lateral meniscus posterior root tears (LMPRTs) are radial tears that occur within 10mm of the posterior root tibial connection, also known as lateral meniscus posterior root avulsions. A common surgical approach for LMPRT (2) that contributes to positive biomechanical outcomes is independent transtibial pullout repair.(6,7,8) If this treatment is performed on people who need both LMPRT repair and ACL restoration, an extra tibial tunnel is required. The installation of a tibial tunnel increases surgical challenges and lengthens operation time, as well as the danger of iatrogenic damage to the normal architecture of the knee. To circumvent these drawbacks, we have developed a novel technique for intra-tunnel LMPRT repair using a knotless anchor construct at the upper posterior edge of the tibial tunnel. A stab incision is made to create the standard antero lateral portal and after introducing the trochar and the scope, a round of diagnostic arthroscopy is performed and the posterior root of lateral meniscus tear is identified. After creating an anteromedial portal, With help of 1 fiber tape, a loaded bite is taken with the help of a first pass mini device (Smith & Nephew), via the antero medial portal, deep into the posterior root ( around 5mm), using a self winching technique, and reduction of the LMPRT is checked. The position for the anchor entry is visualized in the superior edge of the tibial tunnel along its posterior wall, and the tapes are passed through the knotless anchor extra-articulately outside the AM portal. Thereafter, the anchor is shuttled in through the AM portal and punched in the footprint on the posterior-superior edge of the tibial tunnel with visualization of the reduction of the LMPR to the footprint. This technique offers a simple solution to a complex problem in the form of a simple procedure. This technique is a good choice when a tear of the posterior root of the LM occurs.

Screw placement through a higher medial portal provides better initial stability in arthroscopic ACL tibial avulsion fracture fixation: a finite element analysis

ObjectiveThe objective of this study was to investigate the initial stability of different screw placements in arthroscopic anterior cruciate ligament (ACL) tibial avulsion fracture fixation.MethodsA three-dimensional knee model at 90° flexion was utilized to simulate type III ACL tibial avulsion fracture and arthroscopic screw fixation through different portals, namely the central transpatellar tendon portal (CTP), anterolateral portal (ALP), anteromedial portal (AMP), lateral parapatellar portal (LPP), medial parapatellar portal (MPP), lateral suprapatellar portal (LSP), medial suprapatellar portal (MSP). A shear force of 450 N was applied to the finite element models at 30° flexion to simulate the failure condition. The displacement of the bony fragment and the volume of the bone above 25,000 µ-strain (damaged bone volume) were calculated around the screw path.ResultsWhen the screw was implanted through CTP, the displacement of the bony fragment reached the maximum displacement which was 1.10 mm and the maximum damaged bone volume around the screw path was 148.70 mm3. On the other hand, the minimum displacement of the bony fragment was 0.45 mm when the screw was implanted through LSP and MSP. The minimum damaged bone volume was 14.54 mm3 around the screw path when the screw was implanted through MSP.ConclusionScrews implanted through a higher medial portal generated less displacement of the bony fragment and a minimum detrimental strain around the screw path. The findings are clinically relevant as they provide biomechanical evidence on optimizing screw placement in arthroscopic ACL tibial avulsion fracture fixation.

Deltoid Ligament Repair

After a failed functional test and an arthroscopic evaluation of the patient’s joint that revealed both a deltoid deficiency and avulsed superficial ligaments, Dr. Eric Bluman proceeds to perform an open repair of the deltoid ligament using a medial portal.

Optimizing Femoral Tunnel Placement in ACL Reconstruction: Effect of a 70-degree Arthroscope and Portal Position

Purpose: The aim of this study was to assess the accuracy of femoral tunnel placement for anterior cruciate ligament reconstruction (ACLR) using either an accessory medial portal or a 70-degree arthroscope compared with the standard 2-portal technique. Methods: A computerized 3D model of the femur was obtained with 4 reference points marked around the LFC. Using the simulator, 2 surgeons marked 5 consecutive femoral tunnel points with a 30-degree arthroscope in the lateral portal (30AL), then with a 30-degree arthroscope in an accessory medial portal (30AM), and next with a 70-degree arthroscope in the lateral portal (70AL). This was repeated after one week. Subjects then marked their target femoral tunnel positions (T) on the free femur sawbone model. After each episode, the distances from the marked tunnel point to the 4 reference points (d1, d2, d3, d4) were measured. After mapping to the 3D femur model, the co-ordinates of each marked tunnel position were determined. The distance (r) from T was calculated for each episode. Results: The median value of r was 1.27 mm(SE 0.15 mm) using 30AL, 0.54 mm (SE 0.12 mm) using the 30AM portal, and 0.20 mm (SE 0.047 mm) with 70AL. r was significantly smaller with 70AL (P<0.0001). The difference in r between 30AM and 30AL was also statistically significant (P=0.019). Conclusions: A 70-degree arthroscope in the lateral portal allows greater accuracy in femoral tunnel placement compared with a 30-degree arthroscope in either the lateral or an accessory medial portal.

Microwave Ablation of the Pig Growth Plate: Proof of Concept for Minimally Invasive Epiphysiodesis.

Different surgical methods for epiphysiodesis of limb length discrepancy (LLD) have been described. Although these methods are variably effective, they are associated with morbidity (pain and limp) and potential complications. Microwave ablation is a less-invasive opportunity to halt growth by selectively destroying the growth plate via thermal energy to treat LLD in children. In this proof-of-concept study using an in vivo pig model, we asked: (1) What is the durability of response 2 to 4 months after microwave ablation of the tibial growth plate as measured by length and angulation of the tibia via a CT scan? (2) Was articular cartilage maintained as measured by standard histologic staining for articular cartilage viability? To develop an in vivo protocol for microwave ablation, we placed microwave antennas adjacent to the proximal tibia growth plate in the cadaveric hindlimbs of 18 3-month-old pigs. To determine the suitable time, we varied ablation from 90 to 270 seconds at 65-W power settings. After sectioning the tibia, we visually assessed for discoloration (implying growth plate destruction) that included the central growth plate but did not encroach into the epiphysis in a manner that could disrupt the articular surface. Using this information, we then performed microwave ablation on three live female pigs (3.5 to 4 months old) to evaluate physiologic changes and durability of response. A postprocedure MRI was performed to ensure the intervention led to spatial growth plate alterations similar to that seen in cadavers. This was followed by serial CT, which was used to assess the potential effect on local bone and growth until the animals were euthanized 2 to 4 months after the procedure. We analyzed LLD, angular deformity, and bony deformity using CT scans of both tibias. The visibility of articular cartilage was compared with that of the contralateral tibia via standard histologic staining, and growth rates of the proximal tibial growth plate were compared via fluorochrome labeling. Eighteen cadaveric specimens showed ablation zones across the growth plate without visual damage to the articular surface. The three live pigs did not exhibit changes in gait or require notable pain medication after the procedure. Each animal demonstrated growth plate destruction, expected limb shortening (0.8, 1.2, and 1.5 cm), and bony cavitation around the growth plate. Slight valgus bone angulation (4º, 5º, and 12º) compared with the control tibia was noted. No qualitatively observable articular cartilage damage was encountered from the histologic comparison with the contralateral tibia for articular cartilage thickness and cellular morphology. A microwave antenna placed into a pig's proximal tibia growth plate can slow the growth of the tibia without apparent pain and alteration of gait and function. Further investigation and refinement of our animal model is ongoing and includes shorter ablation times and comparison of dynamic ablation (moving the antennae during the ablation) as well as static ablation of the tibia from a medial and lateral portal. These refinements and planned comparison with standard mechanical growth arrest in our pig model may lead to a similar approach to ablate growth plates in children with LLD.

Anatomical Structures at Risk in Percutaneous Preparation Talonavicular Fusion.

The stability of the hindfoot greatly relies on the integrity of the talonavicular joint. Pathologies affecting this joint often necessitate fusion. Our study explores the risks posed to neurovascular and tendon structures during simulated percutaneous talonavicular joint preparation for fusion. In 9 fresh cadaver specimens, the talonavicular joint was accessed through two portals. A 2-mm Shannon burr was employed for joint surface preparation with distraction provided by a pin-based distractor. Dissections were performed to assess potential damage to critical structures, including the dorsalis pedis artery, superficial and deep peroneal nerves, extensor hallucis longus (EHL), and tibialis anterior (TA) tendons. The dorsal portal site was found to be significantly closer to important structures compared to the medial portal site. The Shannon burr made contact with various structures, with a single transection identified for both deep and superficial peroneal nerve branches. During the dorsal portal site approach, potential injury to the EHL tendon was identified as concern. This study sheds light on the potential risks associated with percutaneous dorsal and medial joint preparation approaches using a Shannon burr.Level of Evidence:Level V, mechanism-based reasoning..

Minimally invasive subtalar joint and talonavicular joint preparation for hindfoot arthrodesis: A Cadaveric study evaluating structures at risk

Minimally invasive surgery (MIS) is growing in popularity due to smaller incisions, faster recovery times with less post-operative pain, and measurable decreases in morbidity. Our center performed an MIS hindfoot joint preparation about the talonavicular and subtalar joints and defined structures at risk in order to make this procedure more reproducible. Using ten fresh frozen cadaver limbs, we created a medial and lateral portal for talonavicular joint (TN) access, and an additional portal for subtalar joint (STJ) access to prepare the subtalar joint. After denuding the aforementioned joints of cartilage, the specimens were dissected to identify nearby anatomical structures. We documented the position of the peroneal sheath and sural nerve relative to the STJ portal, and the position of the dorsalis pedis artery (DP), medial dorsal cutaneous nerve (MDCN), extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis anterior (TA), and tibialis posterior (TP) tendons relative to the TN portals. The average distance of the sural nerve and the peroneal sheath from the STJ portal was 34.21 mm and 14.12 mm respectively. The average distance of the DP, MDCN, and deep peroneal nerve from the medial and lateral TN portals were 13.31 mm, 11.54 mm, and 17.14 respectively. No neurovascular structures were transected throughout joint preparation. To our knowledge this is the first study looking into structures at risk for this specific procedure.

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study.

Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity. Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures. The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity. The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise. Level IV.

Arthroscopic Trans-septal Portal of the Knee With Direct Visualization and No Need for Posterolateral Portal Creation

Arthroscopic visualization and access of the posterior knee are limited when using standard anterior and posterior portals. The creation of a trans-septal portal allows for complete access to the posterior compartment as arthroscopic instruments are able to be passed back and forth between the posteromedial and posterolateral compartments. Due to the close proximity of the popliteal artery and its branches, precise portal placement and safe orientation of arthroscopic instruments are critical to avoid iatrogenic injury. The conventional technique of trans-septal portal creation, involving a posterolateral portal, can be difficult in some cases. To overcome these obstacles, a posteromedial technique of trans-septal portal creation is presented. By using the medial parapatellar portal as the viewing portal, our technique allows for direct visualization of the posterior septum on each step of creation of the trans-septal portal, eliminating the need for “blind” maneuvers. What is more, no posterolateral portal is needed, decreasing the risk of potential complications. Using the posterior cruciate ligament fibers as a main landmark for trans-septal portal placement, preservation of the posterior part of the septum is achieved. This ensures optimal safe-margin distance away from the popliteal neurovascular bundle and making the technique safe and reproducible.

DIRECT POSTERIOR KNEE PORTALS USING NEEDLE ARTHROSCOPY: A TECHNICAL FEASIBILITY STUDY

Knee arthroscopy is typically approached from the anterior, posteromedial and posterolateral portals. Access to the posterior compartments through these portals can cause iatrogenic cartilage damage and create difficulties in viewing the structures of the posterior compartments. The purpose of this study was to assess the feasibility of needle arthroscopy using direct posterior portals as both working and visualising portals.For workability, the needle scope was inserted advanced from anterior between the cruciate ligament bundle and the lateral wall of the medial femoral condyle until the posterior compartments were visualised. For visualisation, direct postero-lateral and -medial portals were established. The technique was performed in 9 knees by two experienced researchers.Workability and instrumentation of the posteromedial compartment and meniscus was achieved in 56%. The posterior horns could not be visualised in four specimens as the straight lens could not provide a more medial field of view. Visualisation from the direct medial posterior portal allowed a clear view of the medial meniscus, femoral condyle and posterior cruciate ligament in all specimens. Workability and instrumentation of the posterolateral compartment was not possible with the needle scope.Direct posterior approaches for the posteromedial compartment access are challenging with the current needle scope options and could only be achieved in over 50%. The postero-lateral compartment was not accessible. An angled lens or a flexible Needle scope would be better suited for developing this technique further.

The Medial Triquetrohamate Portal: A New Portal in Wrist Arthroscopy. Anatomical Study.

Introduction Continuing advances in wrist arthroscopy and better understanding of carpal conditions have created the need to design new wrist access portals that facilitate the implementation of new surgical techniques. The aim of this study was to define and verify the safety of the medial triquetrohamate (MTH) portal. Description of the technique The MTH portal is located about 5-10 mm ulnar and 2-3 mm distal to the midcarpal ulnar portal, ulnar to the extensor digitorum communis (EDC) tendon of the fourth and fifth fingers, and radial to the extensor digiti quinti (minimi) (EDQ) tendon. Methods An anatomical study was performed on 15 upper limb specimens from 15 human cadavers. Iatrogenic injuries to potentially at-risk neurovascular and tendinous structures were assessed, and the distance from the portal to these structures was measured. Results There were no iatrogenic injuries to the structures at risk. Mean distances from the MTH portal to the EDC tendon of the fourth and fifth fingers and to the EDQ tendon were 4.67 ± 0.35 mm and 7.27 ± 0.18 mm, respectively. No differences were observed between the left and right wrists. The distance from the MTH portal to the dorsal sensory branch of the ulnar nerve was 15.07 ± 0.44 mm. The structure with the highest risk of injury was the EDC tendon of the fourth and fifth fingers, with a distance of less than 5 mm. Conclusions The MTH portal is safe, reproducible and facilitates the implementation of various techniques related to midcarpal pathology.

Poster 160: Arthroscopic Anatomic Glenoid Reconstruction Does Not Affect Subscapularis Muscle Compared To Latarjet

Objectives: The Latarjet technique has been the gold standard treatment for glenoid bone loss following anterior shoulder instability due to its low recurrence rate, but other techniques including arthroscopic anatomic glenoid reconstruction (AAGR) have shown similar outcomes with fewer complications. The Latarjet requires a subscapularis split or take-down for placement of the coracoid, which may compromise post-operative subscapularis quality and strength. The AAGR is a subscapularis-sparing technique that obviates the need for a subscapularis split by using a far medial (Halifax) portal for graft placement. The purpose of this study was to compare subscapularis muscle changes before and after surgery between Latarjet and AAGR patients. Methods: This study was a retrospective analysis of patients treated surgically with AAGR and Latarjet that had pre- and post-operative CT scans. Patients’ charts were reviewed to obtain demographic information, as well as CT scan cross-sectional area measurements of the subscapularis muscle on pre- and post-surgery scans. We used a pre-existing validated formula (volume=[0.06(A+C)]-13.02) for calculating the volume of the subscapularis pre- and post-operatively based on the cross-sectional area of the muscle. Results: Our cohort included 40 patients in each group with pre- and post-operative CT scans. On average, patients had a CT scan one year post-operatively. Pre-operatively, patients were estimated to have similar subscapularis volumes (p>0.05). We found that the change in medial area of the subscapularis muscle was significantly higher in the Latarjet group (-325.8 mm2) compared to the AAGR group (-73.2 mm2) (p<0.05). We found that AAGR patients had a 3% increase in subscapularis volume post-operatively, while the Latarjet patients had 3% decrease in volume (p<0.05) Conclusions: The AAGR technique is subscapularis-sparing both in surgical technique and structural outcomes, resulting in comparable subscapularis cross-sectional area and volume pre- and post- operatively. Latarjet using a subscapularis split results in lower subscapularis medial volumetric area.

Poster 305: Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Retrospective, Matched Comparison Study to Anteromedial Portal and Transtibial Approaches

Objectives: Improved biomechanical and clinical outcomes have been reported when femoral anterior cruciate ligament (ACL) tunnels are centered on the native footprint. The anteromedial portal (AMP) technique achieves improved aperture position when compared to a transtibial (TT) approach but sacrifices technical ease and creates a shorter more angulated tunnel. A hybrid transtibial technique (HTT) using medial portal guidance of a flexible transtibial guide wire may combine the strengths of both the AM and TT approaches while mitigating the technical challenges of both techniques. The purpose of our study was to evaluate the clinical efficacy of ACLR using a HTT technique for femoral tunnel drilling in comparison to matched cohorts of AMP and TT drilling approaches in terms of failure/revision requirements and patient-reported outcomes. Methods: A database consisting of all patients with isolated ACL tear and primary reconstruction at a single center between 2005 and 2020 was retrospectively reviewed. Inclusion criteria were patients age ³ 13 years at the time of index ACL reconstruction (ACLR), isolated ACL tear with/without concomitant meniscal/chondral pathology and had minimum 2 year ³ postoperative follow-up. Patients with open physes, prior surgical intervention on the ipsilateral knee, chondral pathology treated with high tibial osteotomy/distal femoral osteotomy, treated for other concurrent ligamentous pathology were excluded. Patients treated with the AMP, TT, and HTT approach meeting inclusion criteria were matched based on age ± 3 years, same sex, and body mass index (BMI) ± 3 Kg/m2. Demographical data (Table 1), surgical data, plain radiographic femoral tunnel angle measurements on anteroposterior and lateral films, postoperative complications and reoperation/revision rates, and patient reported outcome (PRO) scores were collected and reported for each of the three cohorts. Results: A total of 495 patients were included; 170 patients underwent ACLR using the HTT approach, 162 using AMP approach, and 163 using the TT approach. The most common graft of choice for HTT technique was bone patellar tendon bone (BPTB) (162/170 [95.3%]) and for AMP (131/162 [80.9%] and TT (158/163 [96.9%]) technique was hamstring (Table 2). The median (IQR) femoral tunnel angle on sagittal plane showed significant differences between HTT 40° (34°, 46°) and TT 32° (27°, 38°) cohorts ( P- value < 0.0001) (Table 3). On coronal plane the median (IQR) femoral tunnel angles showed significant differences between HTT 47° (42°, 52°) and for both AMP 44° (33°, 54°) and TT 55° (47°, 60°) cohorts ( P- value: 0.001 and <0.001 respectively. Recurrent ACL injury in the ipsilateral knee was experienced in 3/170 (1.8%) HTT patients, 6/162 (3.7%) AMP patients, and 6/163 (3.7%) TT patients at minimum 2-year clinical follow-up (Table 4). When patients were surveyed via phone or email questionnaires, 6/170 (7.4%) HTT, 11/163 AMP (20%), and 18/162 (24.3%) TT patients responded to having further ACLR procedures. The Knee injury and Osteoarthritis Outcome Score (KOOS) pain score and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) function and total scores were found to be statistically significant between HTT and TT technique patients. All other PRO scores showed comparable scores between HTT patients when compared with AMP and TT patients. Conclusions: Patients that underwent ACLR with HTT approach had lower failure/revision rates and comparable or better PRO scores at medium-term follow-up when compared to AMP and TT approach. [Table: see text][Table: see text][Table: see text][Table: see text]

Freehand vs. Medial Portal Offset Aimer Technique for Accurate Femoral Tunnel Placement in Arthroscopic ACL Reconstruction.

In this study, our aim was to reveal the effect of the medial femoral offset aimer usage through the femoral tunnel entry and exit points and the tunnel length during femoral tunnel drilling in arthroscopic anterior cruciate ligament (ACL) reconstruction. One hundred patients who underwent arthroscopic single-bundle ACL reconstruction were included in the study. Group 1 consisted of 50 patients who underwent femoral tunnel drilling using a medial portal offset aimer device, while Group 2 consisted of 50 patients who were operated on using the freehand technique. Both groups were compared in terms of femoral tunnel and graft tunnel lengths, femoral tunnel angle in the coronal plane, and the location of the femoral tunnel entry and exit points. The mean femoral tunnel and graft tunnel lengths were significantly longer in Group 2 (p = 0.000). There was no significant difference in terms of localization of the femoral tunnel entry point in both the axial and sagittal planes. The tunnel exit point was located significantly more posterior in Group 1 in the axial plane (p = 0.028). There was no significant difference in terms of the coronal plane femoral tunnel angle between the two groups. In arthroscopic ACL reconstructions, more successful results may be obtained with the freehand technique compared to drilling with a femoral offset aimer. For an experienced orthopedic surgeon, using a medial portal offset aimer device during femoral tunnel drilling does not seem necessary. The online version contains supplementary material available at 10.1007/s43465-023-00929-z.

Proximal endoscopic repair of the hamstring tendons: a cadaveric anatomical study of posterior hip portals.

Arthroscopy and endoscopic hip surgery have attracted increasing attention in the orthopedic field. In the case of arthroscopy, portals and their relationships with neurovascular bundle structures at risk are well established. However, studies on endoscopic portals used for the repair of hamstring tendon injuries are insufficient. Hamstring injuries are the most common muscle injury in sports medicine, and up to 12% can present as a tendon rupture. Endoscopic surgery is advantageous because it has a lower rate of bleeding and avoids excessive handling of the gluteal muscles. The objective of this study is to perform an anatomical evaluation of endoscopic portals for hamstring repair and measure their distance to neurovascular structures-mainly sciatic nerve and posterior femoral cutaneous nerve (PFCN). Fifteen hips from frozen and formalized cadavers were evaluated. Specimens that showed any modification in their anatomy were excluded. Portals were simulated using Steinmann pins, and anatomical dissection was performed. Distances from neurovascular structures were measured using a digital caliper. Four male cadaver hips (26%) and eleven female cadaver hips (74%) were included. Two dissected hips presented PFCN injury through the posterolateral portal- mean 20.28 mm (±8.14), and one through the distal accessory portal- 21.87 mm (±12.03). The injury rate for PFCN was 3/15 or 20%. None of the portals presented sciatic nerve injury. Conclusion: There is an imminent risk of nerve injury to the PFCN by performing the lateral portals for hamstring repair. To avoid this, we recommend starting the procedure through the most medial (posteromedial) portal, and the other portals must be performed under direct visualization.

Anterior Cruciate Ligament Reconstruction With Transtibial Medial Meniscus Root Repair

Background: The incidence of anterior cruciate ligament (ACL) injuries has rapidly increased. Patients with ACL injuries frequently present with concomitant meniscal pathologies. Posterior medial meniscal root tears (PMMR) are less commonly seen with acute ACL injuries as compared with lateral tears and are often degenerative in nature or more rarely in an acute setting. Clinical studies have demonstrated medial meniscal deficiency to be a significant risk factor for graft failure and poor postoperative clinical outcomes. As such, given its demonstrated efficacy, there has been growing interest in transtibial meniscal repair mechanisms in combination with an ACL reconstruction as a potential solution to this challenging pathology. Indication: Patients are indicated for surgery when presenting with symptomatic ACL deficiency verified on provocative testing and advanced imaging and objective insufficiency of the medial meniscal root. Contraindications for this procedure include advanced osteoarthritis (Kellgren–Lawrence grade ≥3) on weight-bearing x-rays, age <50 years, and body mass index (BMI) > 30 as well as poor-quality meniscal tissue and unrepairable chondral defects. Technique Description: The ACL stump is debrided and a burr hole is created. A femoral aiming guide is used to drill the femoral tunnel. Following medial collateral ligament (MCL) release, a healing bony bed is prepared with a curette and shaver at the anatomic tibial footprint. An aiming device is then used through the anterior medial portal to create 2 transosseous tibial tunnels. A vertical mattress suture and simple suture are placed through the meniscal root, shuttled through the posterior and anterior transosseous tunnels, respectively. The tibial ACL tunnel is placed using a standard guide to avoid tunnel convergence with the root tunnels and prevent graft tunnel mismatch. After graft passage, interference screws are inserted while maintaining graft tension. The sutures are then tied over a cortical button over the tibia. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities with low rates of graft failure. Discussion/Conclusion: Recent advancements in our understanding of the relationship between the medial meniscus and the ACL should prompt surgeons to continue considering such combined treatments in indicated patients. 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.

Comparison of dorsal and medial arthroscopic approach to canine coxofemoral joint: a cadaveric study

Arthroscopic exploration of ventromedial part of canine coxofemoral joint is limited in conventional dorsal approach. We evaluated the efficacy of a medial arthroscopic approach to the coxofemoral joint of dogs by analyzing the joint visible area and performing a safety analysis. Arthroscopic approaches to the coxofemoral joint were made in five cadavers using a traditional (dorsal) and novel (medial) approach. Three observers scored the visible area of images and videos of the acetabulum and femur. A safety analysis was performed via dissection of the medial hind limb. The distance between neurovascular structures and arthroscopic portals was measured. The acetabulum was more visible in the dorsal than in the medial approach, with mean visualization scores of 16 ± 0.00 and 11.83 ± 1.26, respectively. The medioventral side of the femur was significantly more visible in the medial than in the dorsal approach, with mean visualization scores of 3.9 ± 0.99 and 6.93 ± 0.58, respectively. Safety analysis confirmed the medial portal site was safe, provided that the surgeon has comprehensive knowledge of the joint. The minimum distance from the arthroscopic medial portals to the nearest neurovascular structures was 2.5 mm. A medial arthroscopic approach to the canine coxofemoral joint has potential clinical application. Dorsal and medial approaches differ significantly and have distinct purposes. The medial approach is useful to access the ventromedial joint, making it an eligible diagnostic method for an arthroscopic evaluation of this area.

Arthroscopic-Assisted Anterior Glenoid Reconstruction Using Nonrigid Fixation With Distal Tibia Osteochondral Allograft

Introduction: Traumatic anterior glenohumeral instability events result in a capsulolabral (Bankart lesion) and/or osseous injury with subsequent attritional bone loss, particularly with recurrence. Up to 88% of patients with recurrent instability experience glenoid bone loss, which predisposes to future dislocations and subluxations, even with arthroscopic capsulolabral repair. The surgical management of glenoid bone loss includes a number of different techniques such as the Latarjet or coracoid transfer as well as other osseous and osteoarticular autografts and allografts. However, operative management of shoulder instability has increasingly shifted toward arthroscopic approaches with preservation of anatomy when possible. Indications: Arthroscopic-assisted allograft distal tibia bone block augmentation to the anterior glenoid is indicated for revision anterior glenohumeral instability procedures with anterior bone loss and in primary cases of anterior instability with critical bone loss. Technique: Our technique for nonrigid arthroscopic anterior glenoid reconstruction with allograft distal tibia and anterior labral repair is performed preferentially in the lateral position without necessitating patient repositioning. The preplanned tibial bone block is prepared on a back table prior to the arthroscopic procedure. After creation of portals and elevation of labral tissue, a guide and drill are used to introduce a retrograde reamer which is deployed to create a perpendicular edge for apposition of the allograft tibia. The bone block is then introduced through a rotator interval portal by pulling sutures retrograde through glenoid bone tunnels and is secured to the prepared surface medial to the liberated labrum. The articular surface of the graft and glenoid are aligned and suture-based fixation is used to compress the bone block against the native glenoid. The anterior labral tissue is then mobilized over the graft and repaired to the native glenoid when possible. Description/Conclusion: The benefits of allograft tibia augmentation for anterior instability with glenoid bone loss include an anatomic joint surface restoration including articular cartilage, lack of donor site morbidity, and a minimally invasive arthroscopic approach. When performed arthroscopically and with nonrigid fixation, this technique permits concurrent anterior labral repair and anatomic reconstruction, safe graft passage without necessity of a far medial portal, and expeditious return to function.

Arthroscopic Anatomic Glenoid Reconstruction in the Unstable Shoulder: Technique, Pearls, and Pitfalls

Background: Anterior shoulder instability with glenoid bone loss is a complex condition. Bankart repairs have higher failure rate in this population and the Latarjet procedure is associated with a high complication rate (15%-30%). A recent technique, the arthroscopic anatomic glenoid reconstruction, safely uses distal tibial allograft to augment the glenoid. Indications: Glenoid or bipolar bone loss in the setting of shoulder instability. Technique Description: A diagnostic shoulder arthroscopy is performed to assess bone loss and capsulolabral tissue. After the preparation of the anterior glenoid, a bone block harvested from a distal tibial allograft is prepared. This technique uses the Halifax portal, a safe, far medial portal to insert the graft, and compress it onto the anterior glenoid using screws. A Bankart repair is then performed, to reduce the capsulolabral complex onto the glenoid. Results: Results at 2 years show a 92% to 100% union of the graft, no recurrence of instability, and improved patient-reported outcome scores. Graft remodeling is regularly observed on postoperative imaging. This procedure may be faster to learn and to perform compared to an arthroscopic Latarjet. Discussion/Conclusion: Arthroscopic anatomic glenoid reconstruction is a safe, minimally invasive procedure to address shoulder instability. It has low complication rate and is associated with improved patient-reported outcomes. Patient Consent Disclosure Statement: The author(s) attest 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.