Medial Portal Research Articles

Accessibility of the Metatarsal Head Comparing Distraction and Plantarflexion in a 2-Portal Technique for First Metatarsophalangeal (MTP 1) Joint Arthroscopy

Category:Arthroscopy; Midfoot/ForefootIntroduction/Purpose:Arthroscopic treatment of osteochondral lesion of the first metatarsophalangeal (MTP1) joint is an established procedure. Non-invasive distraction is most commonly applied when a dorsal 2-portal technique is used. Alternatively, plantarflexion can be utilized. In order to compare the arthroscopic reachability of the first metatarsal head, a laboratory study in anatomical specimens was performed.Methods:Twenty matched pairs (n=40) of fresh-frozen lower leg specimens were obtained and randomly assigned into two groups, a distraction (DIS) and a plantarflexion (PF) group, respectively. A standard 2-portal approach (dorsolateral and dorsomedial portals) with a 1.9mm 30° scope was used. The arthroscopic accessibility of the first metatarsal head was evaluated using chondral picks. Markings at the metatarsal heads were made intraoperatively and measured after exarticulation.Results:In the DIS group the mean accessible area was 58.03%, while the accessible area in the PF group was 55.93%. Though there is a small difference between the two groups, this difference was not statistically significant (p=0.51). Range of motion of the MTP 1 joint did not affect reachability. In one specimen (2.5%) the dorsomedial hallucal nerve was injured during arthroscopy.Conclusion:Access to the MTP1-joint for the treatment of osteochondral lesions is similar using distraction or plantarflexion during arthroscopy. The plantarflexion technique has the advantage of less surgical equipment needed. The dorsomedial hallucal nerve is at danger at the medial portal.

Central Transpatellar Tendon Portal Is Safe When Used for Anterior Cruciate Ligament Reconstruction.

Central transpatellar tendon portal (CTP) was suggested first for complex meniscal lesion and subsequently for a better femoral footprint view during reconstruction of anterior cruciate ligament (ACL). A comprehensive evaluation of possible consequences of using the CTP performing an ACL reconstruction does not exist. Our hypothesis was that the use of CTP for ACL reconstruction does not lead to a higher rate of complications or clinically evident radiological abnormalities. In total, 141 patients were prospectively evaluated, 69 underwent ACL reconstruction using a standard high medial portal as view portal, and 72 where a CTP was used. Clinical evaluation, Kujala's score, patellar height, and magnetic resonance (MR) abnormalities were evaluated up to 1-year follow-up. Clinical complications were reported in 16 cases with no statistically significant differences between the two groups. The group 2 had significantly more MR abnormalities (p = 0.048), but the differences in MR alterations do not have any clinical repercussion even in a sports-active population. No differences were found between the groups in Kujala's score, time to return to work, and sport or patellar height. The overall mean preoperative Caton-Deschamps Index decreased significantly (p = 0.034) postoperatively. Postoperative patellar height seems to slightly decrease after ACL reconstruction regardless of the kind of the portals used intraoperatively and the initial patellar height. Nevertheless, this change in patellar height does not influence the postoperative outcome. CTP used for ACL reconstruction does not lead to significative major clinical complications.

Is viewing the femoral footprint end on while drilling the femoral tunnel in an ACL reconstruction more accurate ?

Introduction:Arthroscopic transportal ACL reconstruction traditionally involves viewing from the anterolateral portal and working from a portal on the medial side. This involves seeing the notch from the same side which evades an end on view of the whole lateral notch. Viewing from the medial side gives an end on view of the same. Working and viewing from the same side may create overcrowding of instruments. We overcame this by using a low far medial portal for drilling and viewing with a high anteromedial portal. We compared both techniques using 3D CT scans to analyse whether there was any difference in intended tunnel placements.Hypotheses:Viewing and working from the medial side would give a different tunnel position from viewing from the lateral and working from the medial portal.Methods:60 patients were recruited , equal numbers underwent transportal ACL reconstruction using semitendinosus and gracilis grafts by Technique A (Viewing from a high anterolateral portal just next to the patellar tendon at the level of the inferior pole of the patella and working from a low far medial portal) and Technique B (Viewing from high medial portal at the level of inferior pole of patella just next to the patellar tendon and working from a low far medial portal). Tunnels were made leaving 5 mm of back wall and just above the equator of the lateral aspect of the notch. 3 D CT scans were done 3 weeks after the surgery and location of the tunnels were studied using A modification of Edwards technique described by P Lertwanich et al,. A rectangle is drawn connecting the highest point of the lateral wall of the notch anteriorly, lowest point inferiorly, anterior and posterior most aspect after digitally subtracting the medial femoral condyle to expose the lateral aspect of notch. The footprint was covered by the best fit circle on a software, that covered all borders of the femoral tunnel. Centre of this circle was marked and perpendiculars bisecting it from the length and breadth of the rectangle were drawn. The centre of the femoral tunnel was expressed as a percentage from anterior and posterior.Results:60 knees were evaluated 52 right (Technique A: 27 and Technique B: 25) and 8 left knees ( Technique A :3 and Technique B:5 ). The mean age of the patients was 27.3 yrs ( Technique A : 26.7 yrs (Range 19-41yrs) and Technique B 27.6 yrs (Range 18-43yrs). There were 41 male and 19 female patients ( Technique A 18 males and 12 females, Technique B had 23 males and 7 females). Mean graft diameter was 8.8mm (range 7-10) in technique A and 8.6mm (range 8-10) in Technique B.MDS (Mean distance from superior margin)Technique A : 35.28 , Standard deviation (SD)6.7339, Technique B MDS 35.86, Standrad deviation9.4441Mean Distance from posterior margin (DP) :Technique A 35.83 ,SD:8.2008, Technique B 38.14 SD: 8.6991The t value for DS calculated is 0.2767, the P value is 0.7830 confidence interval is (-4.825, 3.653) . The t value for DP calculated is 1.060, the p value is 0.2937 confidence interval is (-6.682, 2.056)We concluded after applying the independent student t test that the p value is greater than 0.05. So mean distance of femoral tunnel from superior, posterior border in technique A does not differ significantly from mean distance of femoral tunnel from superior border, posterior border in technique BConclusion:An end on view while making the femoral tunnel does not give any added benefit in accuracy of femoral tunnel placement in this study.

The Accessory Medial Portal for Anterior Cruciate Ligament Reconstruction: A Safe Zone to Avoid Neurovascular Complications.

Background:The accessory medial portal (AMP) used for anatomic anterior cruciate ligament reconstruction (ACLR) is gaining popularity. This portal is routinely created at 60° of knee flexion, placing the infrapatellar branch of the saphenous nerve (IBSN) and, less commonly, the descending and superior medial genicular arteries at risk.Purpose/Hypothesis:The purpose of this study was to identify a safe zone for AMP placement in ACLR to minimize the risk of injury to the IBSN. We hypothesized that increased knee flexion angles would decrease the risk to neurovascular structures when creating an AMP.Study Design:Descriptive laboratory study.Methods:A total of 20 cadaveric (10 matched pairs) knees were used for dissection to identify the IBSN and other neurovascular structures. A 30° arthroscope was used to make the central medial portal and AMP at 3 knee flexion angles (60°, 90°, and 110°). Distances were measured from the AMP to branches of the IBSN. Safety of AMP placement was analyzed by assessing the frequency at which spinal needles pierced a neurovascular structure or violated a safe zone.Results:The superior IBSN was significantly closer to the AMP than inferior IBSN. The AMP was significantly farther from the superior IBSN at 110° (8.56 ± 5.28 mm) compared with 60° (5.63 ± 5.00 mm; P = .015) and 90° (6.69 ± 5.03 mm; P = .006). A triangular safe zone was identified at 110° of knee flexion. No neurovascular structures were pierced, and the IBSN was not present in the safe zone. At 90°, the IBSN was not pierced; however, the IBSN did violate the safe zone at 90° of knee flexion.Conclusion:The superior IBSN is at risk for iatrogenic injury with an AMP placed at 60° of knee flexion. The nerve moved distally with knee flexion. While no neurovascular structures were compromised at 90° of knee flexion, the nerve was found to course through the safe zone. A safe zone at 110° of knee flexion decreases the risk of neurovascular injury and makes the AMP safe for ACLR.Clinical Relevance:The AMP at 60° of knee flexion for ACLR poses risk to the IBSN. The IBSN did violate the safe zone at 90° of flexion. We recommend creating an AMP with increased knee flexion to 110° to decrease the risk of iatrogenic injury. When establishing an AMP, one should aim for the center of the defined safe zone, given that the spinal needle used in this study has a smaller diameter than a stab incision.

Anatomical Single-Bundle Transtibial Anterior Cruciate Ligament Reconstruction

Anatomical anterior cruciate ligament (ACL) reconstruction is a reasonable transition from isometric ACL reconstruction to obtain better clinical outcomes, and most authors believe that it can only be performed through the medial portal technique. However, in our clinical practice, we found that anatomical ACL reconstruction can be performed easily and accurately by creating a tibial tunnel, which is accomplished by setting the tibial tunnel with correct angulation to the sagittal plane and tibial axis. Hence, we introduce this special transtibial anatomical ACL reconstruction technique, in which the most critical step is the creation of a shallow tibial tunnel with a proximal projection to the anatomical location of the femoral tunnel. This technique is indicated for primary ACL reconstructions in skeletally mature patients. We believe this Technical Note will give a special view on anatomical ACL reconstruction.

Does Viewing the ACL Femoral Footprint End on Using a High Medial Portal Produce Better Tunnel Placement as Compared to Viewing it from a Lateral Portal while Drilling: A 3D CT-based Pilot Study.

Anatomical placement of an ACL graft is critical to the clinical outcome of an ACL reconstruction. The purpose of the study was to compare the conventional technique of drilling a femoral tunnel from a medial portal while viewing it from a lateral portal versus viewing it from a high anteromedial portal and drilling it from a low medial portal. We hypothesized that the high anteromedial portal possibly provides an end-on view of the tunnel and would lead to a more favourable tunnel position. Sixty patients underwent arthroscopic single-bundle ACL reconstruction with a soft tissue graft. All patients had the same surgeon and same surgical technique (except viewing portal). Each patient underwent a 3D-CT 1-week post-op. We classified the patients into two groups (technique A and B) of 30 each. Postoperative tunnel position in each patient was visualized on CT scan with 3D reconstruction by the quadrant method described by Bernard et al. The distance of the centre of the femoral tunnel from the superior and posterior border of the Bernard frame was obtained in each patient of the two groups and mean value in each group was obtained and compared by Student 't' test at 5% level of significance. The position of the femoral tunnels was also studied in reference to the lateral intercondylar ridge and classified into type I (well placed), type II (moderately malpositioned) and type III (grossly malpositioned). The mean distances in technique A from the posterior and superior border of the lateral femoral condyle was 35.8 ± 8.2 and 35.2 ± 6.7, and in technique B was 38.1 ± 8.6 and 35.8 ± 9.4. The two groups did not differ significantly (P > 0.05) in femoral tunnel position as visualized on 3D-CT scan postoperatively. 53.3% patients had well-placed tunnels (type I) overall with 56.67% of technique A and 50% of technique B in this group. None of the tunnels were grossly malpositioned. The absence of any statistically significant difference between the groups suggests that a high anterolateral portal close to the patellar tendon gives an almost complete view of the lateral aspect of the notch, if not end on. Both techniques produced a majority of well placed (type I) tunnels.

Safety of neurovascular structures in ankle arthroscopy: cadaveric study

Introduction: Anterior and posterior portals used for ankle arthroscopy but anterior portals are safer, provide good access and visualisation of joint. Aims: The anatomical structures nearby portals are vulnerable to injury during surgery. To study the anatomy of ankle joint using dissection method. Methods and material: 20 cadaveric limbs were dissected and the distance of different portals to the nearby neurovascular structures was measured. Results: The mean distance from anteromedial portal to the great saphenous vein and saphenous nerve was 5.28 mm, 9.12mm and that between the medial midline portal to the dorsalis pedis artery and deep peroneal nerve was 10.08 mm and 16.20mm. The mean distance from anterocentral portal to the dorsalis pedis artery was 2.38mm, to superficial peroneal nerve was 7.09mm and deep peroneal nerve was 4.12mm. The mean distance from anterolateral portal to lateral branch of superficial peroneal nerve was 3.18mm. There was injury in one specimen. Conclusions: This present study concluded that medial midline portal is comparatively safe for ankle arthroscopy. Anterocentral portal has potential risk of injury to dorsalis pedis artery.

Excellence in Research:A Hybrid Transtibial Technique Combines the Strengths of theAnteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial

Objectives:Improved biomechanical and clinical outcomes have been reported when femoral anterior cruciate ligament (ACL) tunnels are centered on the native footprint. The anteromedial (AM) portal technique achieves improved aperture position when compared to a transtibial (TT) approach but sacrifices technical ease and creates a shorter more acutely angulated tunnel. A hybrid transtibial technique (HTT) technique using medial portal guidance of a flexible transtibial guide wire without the need for knee hyperflexion may combine the strengths of both the AM and TT approaches. The authors hypothesized that this HTT technique would achieve anatomic femoral tunnel apertures similar to the AM technique, but with longer and less angulated femoral tunnels similar to a TT technique.Methods:A prospective randomized controlled trial was implemented where 30 consecutive patients with acute, primary ACL tears were randomized to receive a TT, AM or HTT technique for their reconstruction. A total of 46 patients were assessed for eligibility in the investigation (Figure 1). All patients underwent 3D CT scans of the operative knee 6 weeks postoperatively to characterize tunnel positions. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as the graft bending angle in the sagittal and coronal plane were measured.Results:There were no significant differences between the patient demographics of the three groups. Tibial tunnel lengths and aperture positions were identical between the three groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regards to both height (p=0.75) and depth (p=0.72). On the other hand, compared to the AM portal and HTT techniques, respectively, femoral apertures created by the TT technique were significantly higher (p<0.001 and p<0.001) and shallower (p=0.001 and p<0.001) in the notch. The average femoral tunnel lengths varied significantly between the three groups measuring 35.16 mm, 41.64 mm, and 54.13 mm for the AM, HTT and TT groups, respectively (p<0.001). Lastly, there were no differences between the average coronal (164.0 degrees versus 158.8 degrees, p=0.190) and sagittal (114.0 degrees versus 111.0 degrees, p=0.358) graft bending angles between the TT and HTT groups, respectively. By contrast, compared to the TT and HTT groups, respectively, the graft bending angles created with an AM technique were significantly more acutely angled in the coronal (146.3 degrees, p<0.001, p<0.006) and sagittal (100.5 degrees, p=0.014, p=0.013) planes.Conclusion:The HTT technique achieves femoral aperture positions equally as anatomic as an AM portal technique, but with longer and less acutely oriented grafts similar to a transtibial approach. These advantages will decrease the incidence of graft tunnel mismatch as well as reduce the amount of stress imparted onto the graft by avoiding an acute graft bending angle. As such, this hybrid approach may represent a beneficial combination of both transtibial and AM portal techniques.

Physeal-sparing posteromedial portal approach reduced distance between guide pin and neurovascular structures

To compare a femoral physeal sparing anterior cruciate ligament (ACL) reconstruction technique utilizing a posteromedial portal to traditional transphyseal techniques with regards to anatomic tunnel positioning and proximity to important neurovascular structures. Eight cadaveric knees were obtained for the study. Femoral tunnel guide pins were placed utilizing four different techniques: accessory anterior medial portal, posteromedial portal, trans-tibial, and figure-4 methods. The knees were then dissected and the following measurements taken: distance of each pin to the saphenous and peroneal nerve, popliteus tendon, neurovascular bundle, femoral ACL footprint and articular cartilage, and the angle of the guide pin entering the lateral femoral condyle. Fluoroscopic imaging was taken to determine the disruption of the physeal scar. Posteromedial portal guide pin was significantly closer to the neurovascular bundle, popliteal tendon and saphenous nerve when compared to the other 3 techniques, but was further from the peroneal nerve. It also had the smallest distance from the anatomic footprint of the ACL, and the largest angle to the lateral femoral condyle. The posteromedial portal guide pin had similar distance from the articular cartilage as the accessory anterior medial portal and figure-4 guide pin, with the trans-tibial guide pin being the farthest. The posteromedial portal guide pin failed to disrupt the physeal scar in all specimens, while the other three techniques consistently violated the physeal scar. The posteromedial portal technique offers an appropriate method for anatomic ACL reconstruction while protecting the distal femoral physis from injury. Care needs to be taken with this technique as it comes in closer proximity to some of the important neurovascular structures. This study indicates that posteromedial portal technique is a less technically challenging approach for physeal-sparing ACL repair with special attention required for the protection of neurovascular bundle from potential injury.

Portal placement for endoscopic surgery in the deep gluteal area: a cadaveric study.

Partial or complete avulsion of the insertion of the proximal hamstrings at the level of the ischial tuberosity is most often treated by open exploration and reinsertion. However, endoscopic reinsertion could be considered to minimize the soft tissue damage. In this study, we aimed to determine the most optimal location of four endoscopic portals that allow for a safe exploration of the proximal hamstring insertion site. The reference points for the portals run vertically through the center of the sciatic tuberosity and through a horizontal line which lies on the inferior edge of the tuberosity. The distance and relationship between the sciatic, the inferior gluteal and posterior femoral cutaneous nerves and the four proposed endoscopic portals was documented. Our results showed that it was best to start with the inferior portal followed by the medial and lateral portal. The inferior portal allowed for a clear visualization of the sciatic nerve and was along with the medial portal at a distance of >5 cm from any of the surrounding nerves. Care must be taken with the lateral portal, as the distance to the surrounding nerves varied between specimens. A fourth portal could be used as a viewing portal when necessary. Our study showed that the sequence and position of the proposed endoscopic portals provide a safe approach to the proximal part of the hamstrings and the ischial tuberosity. These findings can be helpful for endoscopic procedures to the ischium and the sciatic nerve in the gluteal region.

Endoscopic Approach to Proximal Hamstring Avulsion Repair.

Endoscopic repair of a proximal hamstring avulsion promotes precise anatomical repair and lowers the risk of neurovascular injury. Indications for proximal endoscopic repair of the proximal part of the hamstrings include acute tears of 2 tendons with >2 cm of retraction in young active patients, acute complete tears of 3 tendons with >2 cm of retraction, or failed conservative treatment of tears of ≥2 tendons with ≤2 cm of retraction. Repair of a proximal hamstring avulsion is performed using 2 portals. The medial portal is developed percutaneously under fluoroscopic guidance. The lateral portal is developed under direct visualization. The footprint of the hamstrings is identified from medial to lateral. The sciatic and posterior femoral cutaneous nerves must be carefully identified and protected. The avulsed tendons are fixed with suture anchors with the knee in flexion. Conservative treatment is commonly used to treat injuries of the musculotendinous junction (type 2), incomplete or complete avulsion with minimal retraction (≤2 cm) (type 3 or 4, respectively), and patients with limited mobility or severe comorbidities1. The initial treatments consist of RICE (rest, ice, compression, and elevation), protective ambulation, and then physical therapy. Open repair is used for incomplete or complete avulsion with >2 cm of retraction, or when conservative treatments have failed1-3. Open reconstruction is used for chronic avulsion with tendon retraction of >5 cm4-6. Endoscopic surgery is a minimally invasive procedure that offers excellent visualization of the subgluteal space without gluteus maximus muscle retraction. In open repair, the inferior border of the gluteus maximus muscle is mobilized to access the ischial tuberosity. The mean distance (and standard deviation) from the inferior border of the gluteus maximus muscle to the hamstring origin has been reported to be 6.3 ± 1.3 cm, which is close to the mean distance from the inferior border of the gluteus maximus to the inferior gluteal nerve and artery, which has been reported to be 5.0 ± 0.8 cm7. Open repair, which requires gluteus maximus retraction, poses an injury risk to the inferior gluteal nerve and artery. Open repair increases the risk of wound infection because the incision involves the perineum8. The feasibility of the endoscopic repair depends on the chronicity and amount of tendon retraction. It is feasible for a symptomatic tear of ≥2 tendons with a retraction of ≤2 cm. Mobilization of the retracted tendon is challenging in endoscopic repair. In acute injuries, the degree of retraction is not critical because the tendon is easily mobilized. Chronic injuries (>2 months) and those with far tendon retraction (>5 cm) are not suitable for endoscopy9. In chronic injuries with incomplete or complete avulsion with minimal retraction (≤2 cm) (types 3 and 4) that have failed conservative treatment, endoscopy is suitable since the tendon is not retracted1. Endoscopic repair can be converted to an open procedure in difficult endoscopic conditions.

Avoiding Injury to the Popliteal Neurovascular Bundle in All-Inside Suturing of the Posterior Horn of the Lateral Meniscus: A Magnetic Resonance Imaging Assessment of Portal Selection and Safety

We assessed the risk of injury to the popliteal neurovascular bundle (PNVB) while suturing the posterior horn of the lateral meniscus (PHLM). We simulated all-inside suturing of the PHLM using magnetic resonance imaging of 60 knees. Lines were drawn from the medial and the lateral edges of the patellar tendon to the PHLM at increasing distances from the posterior cruciate ligament (PCL) to simulate suturing device trajectory. Distance from each line to the PNVB was measured (d). A similar analysis was performed using lines drawn from 1cm medial and 1cm lateral to the patellar tendon. We compared the average "d" at increasing distances from the PCL, between the different simulated portal entry points. We have also analyzed the association between different demographic characteristics and the shortest distance from the PVNB to the PHLM. Of 1200 measurements performed, the simulated suturing trajectory transected the PNVB 343 times (28.6%). At 0mm from the PCL, the safest portal was the 1-cm lateral portal (P < .001), with an average "d" of 2.7mm. At 3mm, 6mm, 9mm, and 12mm from the PCL, the safest portal was the 1-cm medial portal (P < .001), with average "d" of 3.8mm, 6.9mm, 10.1mm, and 13.5mm, respectively. Average distance between the PHLM and the PNVB was 7.8mm. Shorter distance between the PHLM and the PNVB was associated with younger age and female sex (P= .014 and .001, respectively). All-inside suturing of the PHLM at 0mm from the PCL is safer with a more lateral portal. Beyond 3mm from the PCL, a more medial portal carries a lower risk to the PNVB. Young and female patients have a shorter distance between the PHLM and the PNVB, suggesting a greater risk for injury to the PNVB. Careful preoperative magnetic resonance imaging assessment may assist in safer portal selection when planning repair of the PHLM. This study describes a magnetic resonance imaging-based risk assessment for injury of the PVNB while suturing the PHLM. It allows the orthopaedic surgeon a better understanding of the anatomic relationship between the popliteal neurovascular bundle and the lateral meniscus and can assist in portal selection and safety.

Arthroscopic Technique for Bone Augmentation With Suture Button Fixation for Anterior Shoulder Instability

Glenoid bone loss remains a significant risk factor for recurrent instability after shoulder dislocation. Several options exist for glenoid bone graft augmentation, including autograft and allograft options. Strengths and weaknesses exist for each. Graft fixation with screws remains a key concern for technical viability requiring a medial portal as well as the risk of graft osteolysis. Suture button suspensory fixation is a new technique recently described for arthroscopic iliac crest bone graft; however, no description exists concerning osteochondral graft fixation. We describe an arthroscopic technique for distal tibial allograft glenoid augmentation with suspensory suture button fixation. The rationale and technical aspects of this procedure are discussed.

Treatment of Anterior Cruciate Ligament Injuries in Professional Soccer Players by Orthopedic Surgeons.

Objective To describe the treatment provided by specialists for ACL lesions in professional soccer players. Methods A cross-sectional study in which orthopedic surgeons affiliated to soccer teams competing in the Brazilian Soccer Championship answered a questionnaire about the treatment of ACL injuries in professional soccer players. Results The specialists wait between one to four weeks after the ACL injury to perform the surgical treatment. They use a single incision and single-bundle reconstruction, assisted by arthroscopy, femoral tunnel drilling by an accessory medial portal, and quadruple flexor tendon autografts or patellar tendon autografts. After three to four months, the players are allowed to run in a straight line; after four to six months, they begin to practice exercises with the ball without contact with other athletes; and, after six to eight months, they return to play. The main parameter used to determine the return to play is the isokinetic strength test. The specialists estimate that more than 90% of elite soccer players return to playing professionally after an ACL reconstruction, and 60 to 90% return to play at their prior or at a greater level of performance. Conclusion The present article successfully describes the main surgical practices and post-surgery management adopted by specialists in this highly-specific population of patients.

TL 18200 - Percutaneous metatarsophalangeal arthrodesis for the treatment of hallux rigidus

Introduction: Arthrodesis is considered the gold standard treatment for the final stages of hallux rigidus, promoting long-term symptom improvement. Arthrodesis is traditionally performed as open surgery. However, in recent years, the prevalence of minimally invasive surgery has increased due to its decreased aggression to soft tissue, shorter surgical time and association with a more comfortable postoperative period with reduced pain intensity. The objective of the study is to describe the percutaneous metatarsophalangeal arthrodesis technique with a single medial portal and to evaluate postoperative outcomes regarding union time, the presence of residual pain and the degree of satisfaction in a series of 22 patients. Methods: This is a series of 22 patients (23 feet) who underwent surgery between January 2017 and July 2018. The union time was assessed, and the patients reported their pre- and postoperative pain levels using the pain visual analog scale (VAS) and their degree of satisfaction. Surgical wound dehiscence, superficial and deep infection and need for orthopedic hardware removal were considered complications. Results: All patients underwent clinical evaluation. In 3 patients, union could not be assessed due to the lack of postoperative radiographs. Twenty patients were women, and 2 were men. Their mean age was 67.8 years. The mean time between the date of surgery and the evaluation was 51 weeks. The follow-up time ranged from 6 to 24 months, with a mean union time of 9 weeks. The union rate was 80%. Five cases showed no radiographic union, although the patients had stable and asymptomatic arthrodesis that required no revision. There were no cases of postoperative infection. In 3 patients, orthopedic hardware was removed. The mean preoperative pain intensity was 8.73, and the mean postoperative pain intensity was 1.26 (p&lt;0.001). All patients were satisfied with the surgery. Conclusion: Percutaneous arthrodesis of the metatarsophalangeal joint of the hallux potentially provides outcomes similar to those of the conventional method reported in the literature and tends to produce a more comfortable postoperative period and better cosmetic results because it uses smaller incisions.

Revision Anterior Cruciate Ligament (ACL) Reconstruction

The goal of an ACL reconstruction is to approximate the strength and characteristics of the native tissue. So, if the original ACL can rupture, it is logical to think that the reconstructed ligament can also tear. It is more difficult to deal with a revision case. Your decision what to do is dependent on what was done during the primary ACL reconstruction (ACLR). It is important to plan the surgery carefully and prepare for all possible scenarios intra-operatively.The three key questions you need to answer are the following? What was the GRAFT used?How were the TUNNELS made?What were the IMPLANTS used?It would be helpful to know who did the primary ACLR because you may be aware of some of the tendencies of that surgeon which may assist you in your surgery.There are seven situations that will be discussed: Bone-Patellar Tendon-Bone (BPTB) autograft using a trans-tibial techniqueSemitendinosus/Gracilis Tendon (ST/G) autograft using a trans-tibial techniqueWith the advent of the medial portal technique, the position of the femoral tunnel changed dramatically. Five other circumstances arose from this: 3. ST/G autograft using endo-buttons4. ST/G autograft using screws – femoral tunnel in ideal position5. ST/G autograft using screws – femoral tunnel near where you want it to be6. ST/G autograft using screws – femoral tunnel far from where you want it to be7. Implant-less ACLRAlways have a back-up plan when doing revisions.It is imperative that the rehabilitation program be delayed so as to give the graft more time to incorporate. Usually, twelve months before going back to sports is acceptable.

Remnant Preserving or Augmentation SB PCL Reconstruction: Tips and Tricks

Injury to the Posterior Cruciate Ligament (PCL) is thought to account for 3% to 20% of all knee ligament injuries. Accurate diagnosis of the PCL injury is the first step in determining appropriate management. Approximately 60% of PCL injuries are associated with tearing of the Posterolateral Corner (PLC) structures.When the surgery, arthroscopy PCL reconstruction, is decided then we have to think how and what the best technique will be used to reconstruct. Various techniques of PCL Reconstruction Arthroscopy are known that based on research. According the position of PCL, the procedure of reconstruction is more difficult than ACL one. If combined with PLC rupture, all the structures will be reconstructed in one step.Will be proposed the tips and tricks how to do arthroscopy remnant preserving or augmentation single bundle PCL reconstruction, such as: how to preserve the remnant, how to find the position of tibial attachment and what the landmark, how to deliver the graft into the tunnels so preventing “killer turn” on the posterior part of joint, and how to do the proper rehabilitation.By using the Posterior Medial Portal, working with Remnant Preserved of PCL Reconstruction will be made easier. Joint line of medial tibial plateau as a landmark to find the tibial tunnel. About 1.5 cm below the joint line, the point of tibial tunnel is made or directly finding the edge of the ‘shelf’ where the tunnel is made on there. The remnant will be split and the graft will be laid in between.A strong suture material is used to pull the graft with all in side technique. The tibial part of the graft goes in first through the anterolateral portal following the suture material, go into between the remnant and go into the tibial tunnel from posterior to anterior (inside out). The femoral part of the graft will go into the joint together with the wire that carrying the distal end of the graft go into the femoral tunnel. After that we make the finalization of procedure.Finally, a special rehab program is needed to get the good result of PCL reconstruction as a whole.

Evaluation of functional outcome of arthroscopic anterior cruciate ligament reconstruction by modified AMP technique

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; In anterior cruciate ligament (ACL) reconstruction, transtibial (TT) drilling of the femoral tunnel has been criticized for its vertical and less anatomical tunnel, which accompanied rotational instability of knee. Antero medial portal (AMP) drilling technique creates more oblique and anatomic femoral tunnel. However, recent researches show that oblique tunnel is related to risks of too short femoral tunnel, blowout of back wall, and posterolateral structures injury. Modified AMP technique creates vertical tunnel with anatomical FSP (femoral starting point).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In our study we have functionally evaluated 30 patients of ACL tear who underwent reconstruction by modified AMP technique. Modified AMP technique creates vertical tunnel with anatomical FSP.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean postoperative Lysholm score is 94.4±1.22 and mean postoperative subjective IKDC score is 93.308. All the cases of ACL tear reported their knees as normal or near normal according to objective IKDC score after reconstruction. Mean coronal angle is 51.112±6.3 and mean femoral tunnel length is 41.8±3.55 mm while posterior wall blowout of lateral femoral condyle and postero lateral structure injury has not been observed.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The modified AMP technique provides an anatomic and safe mode with vertical tunnel and oblique graft, by reduces the risks involved in the AMP technique.&lt;/p&gt;

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases

Background: Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies. Purpose: To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft. Study Design: Cohort study; Level of evidence, 3. Methods: From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone–patellar tendon–bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer. Results: Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone–patellar tendon–bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, P < .001); however, this difference was not significant after the 2-year interval (3.1% vs 2.5%, P = .63). The percentage of patients with a rerupture of the graft was significantly lower in the patellar tendon group than in the hamstring group (25 of 811 [3.1%] vs 57 of 811 [7%], P = .023). Similar results were recorded regarding the pain related to the hardware material (7 of 811 [0.8%] in the BPTB group vs 113 of 811 [13.9%] in the hamstring group, P = .001). The percentage of ACL ruptures contralateral to the repair was higher in the patellar tendon group (41 of 811 [5%] vs 17 of 811 [2%], P = .016). Conclusion: The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.

Switching portal technique in anterior cruciate ligament reconstruction: use of an extra low and medial portal

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Long term success of ACL reconstruction depends on accurate surgical technique of anatomic tunnel placements and proper rehabilitation protocol followed, and for accurate tunnel positioning various arthroscopic landmark should be visible clear with the use of various portals.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; All 112 surgeries were performed by a single surgeon in King Georges Medical University, Lucknow Orthopedic department operation theatre during July 2016- December 2018. An extra low and medial portal is created and then portal were switched between anteromedial and low medial one.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; With the use of this portal the average surgical time was observed to be 43 minutes and no malpositioning of tunnel was encountered.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; This switching portal technique provides an excellent view of the femoral tunnel plot and gives consistent results with minimum complications.&lt;/p&gt;