Medial Portal Research Articles

Anterior cruciate ligament reconstruction with 70° arthroscope and flexible reamers – Early operative experience

Anatomical graft position for anterior cruciate ligament (ACL) reconstruction is desirable. However, visualisation and positioning are challenges with the standard technique. It is known that graft integration can be improved by maximising femoral tunnel length and graft failure reduced by limiting bending angle. We planned to evaluate the use of new techniques whilst monitoring femoral tunnel length and angle.A 70° arthroscope, through the anterolateral portal, provided improved footprint visualisation without the need to switch to a medial portal. A flexible reamer system created the femoral tunnel without hyperflexion of the knee. Femoral tunnel length was measured intra-operatively using the graduations on the reamer, and femoral tunnel angle was assessed on the post-operative radiograph (using a digital measuring tool).In a single-surgeon, consecutive series, 55 patients were treated. When compared to the surgeon's 65 previous cases, femoral tunnel length increased significantly by 3.11mm (40.1 (±3.49)° vs. 36.9 (±3.87)°; p<0.05) with no significant change in femoral tunnel angle (37.8 (±4.97)mm vs. 39.6 (±5.11)mm; p=0.075).We discuss this technique with reference to potential advantages and disadvantages of this technology.

Avoidance of Reamer Breakage During ACL Reconstruction With Flexible Reamer System: Letter to the Editor.

Dear Editor: I read with great attentiveness the article titled “Anterior Cruciate Ligament Reconstruction Using a Flexible Reamer System: Technique and Pitfalls” by Fitzgerald et al,1 published in July 2015. It is a perfectly timed article, as surgeons are actually looking to PubMed to know the tips, tricks, and results of the “flexible drilling system for anatomical ACL reconstruction” owing to recent promotion of the Clancy System by Smith & Nephew and the VersiTomic System by Stryker. The authors have rightly described the need to flex the knee to 110°. The article also precisely highlights the potential pitfall of the system: reamer breakage. However, I differ with this view of the authors: “Using an initial 4.5-mm reamer is often advantageous as it allows for button fixation passage out over the lateral wall of the femur and for accurately measuring the femoral tunnel length. Using a 4.5-mm reamer also allows mobility of the nitinol guide wire and can position the final reamer slightly superior or more toward the [posterolateral] bundle footprint; this is useful if the nitinol guide wire is initially positioned slightly inferior or too close to the [anteromedial] bundle footprint.”1 (p4) The 4.5-mm reamer must not be used before the reaming of the proposed femoral tunnel to the desired dimension and desired length, usually by an 8- or 9-mm reamer. To elaborate, the flexible guide wire remains in the femoral tunnel, binded by the cortex of the lateral femoral condyle and by lateral femoral condylar bone. The initial reamer that we use is determined by the diameter of the graft, usually 8 or 9 mm. This reamer is not blown through and through the lateral femoral condyle, and we usually leave 5 to 10 mm of lateral wall so that the guide wire does not leave its purchase in the bone and does not move with the reamers. This, in turn, allows a reasonable length of flexible guide wire coming out of the medial portal. As well, this leads to a long contact between the flexible guide wire and flexible reamer, thereby decreasing the possibility of reamer breakage. After this step, the 4.5-mm reamer is used so as to allow flipping of the suspensory fixation system that we intend to use. Additionally, I also differ with the authors’ view of using a fixed 55° tibial guide. The entry point of the tibial guide wire on the anteromedial tibial surface must be the determinant to the tibial guide angle and not vice versa.

Emerging Trends in Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed and researched orthopedic procedures. As technology and comparative research have advanced, surgical practices have changed to achieve a superior outcome. Our group performed a survey of orthopedic surgeons to evaluate current practice trends and techniques as a follow-up to similar surveys performed in 1999 and 2006. In a survey between 2013 and 2014 consisting of 35 questions regarding the surgical technique, graft choice, fixation method, and perioperative care in ACL reconstruction was sent electronically to the members of the American Orthopaedic Society of Sports Medicine and the Arthroscopy Association of North America. Responses were recorded and compared with previous results. Survey responses were received from 824 active surgeons. Of the respondents, 89.4% are subspecialty trained, 98% of which in sports medicine. Preoperatively, full-knee extension was the only "very significant" factor in surgical timing. Approach preference via an arthroscopic-assisted single-incision approach predominated (89%)-similar to earlier results. Bone-patellar-tendon-bone use decreased relative to hamstring allograft at 45 and 41%, respectively. Tibial tunnel placement shifted anteriorly and femoral tunnel placement shifted posterosuperiorly as compared with the results obtained 5 years ago. Femoral drilling through a low medial portal was preferred in 47% of responses, increased from 15%. Preferred fixation on both the tibial and femoral sides was either metal or bioabsorbable interference screws. The use of transfixation pins and other devices decreased. Postoperative rehab protocols did not significantly change, 68.7% preferred full-weight bearing, 55% using a range of motion knee brace locked in extension, 66.4% starting physical therapy 1 week postoperatively, with unrestricted activity at 6 to 9 months. Overall, an increasing trend toward using hamstring autograft and drilling the femoral tunnel through an accessory portal in primary ACL reconstruction was observed. This may reflect recent literature supporting more anatomic reconstruction of the ACL. Considerations including deep venous thrombosis prophylaxis, brace use, timing of surgery, weight-bearing restrictions, physical therapy, graft choice in athletes, and return to activity remained largely unchanged.

A Comparative Study of the Results of the Anatomic Medial Portal and All-inside Arthroscopic ACL Reconstruction.

Many techniques of graft placement in Arthroscopic Anterior Cruciate Ligament (ACL) reconstruction is available now-a-days, like trans-tibial, anatomical accessory medial portal and anatomical all-inside technique. To compare the improvement in clinical status of patients treated by anatomic accessory medial portal and all-inside arthroscopic ACL reconstruction technique pre-operatively post-operatively using International Knee Documentation Comittee (IKDC) Subjective Knee Scores, Lysholm Knee Score, Knee Society Score, Lachman test, Visual Analog Score (VAS) in both the groups. After informed consent from patients and clearance from Ethical Committee, we included patients aged 18 to 50 years with ACL injury and clinical laxity admitted in Department of Orthopaedics, King George Medical University, Lucknow. We included 100 patients in the study, which were divided into two groups, Group1 comprised of patients treated by Anatomic accessory medial portal technique and group 2 comprised of patients treated by All-Inside technique. Then the patients were followed up post-operatively at 6 weeks, 12 weeks and 6 months, clinically for functional status using Lysholm Knee Score, IKDC Subjective Knee Score, Knee Society Score and VAS score. Grading of laxity was evaluated by Lachman test at pre-operative stage and 6 months follow-up. After collection of the data, analysis was carried out on SPSS software version 16.0 (Chicago, inc. USA) and the statistical test that was used was 2-Way Analysis of Variance (ANOVA). IKDC Subjective Knee Score, Lysholm Knee Score, Knee Society Score, Lachman Test and VAS Score was better in group 2 treated by All-inside technique as compared to group1 and the difference was significant (p<0.005). All- Inside arthroscopic ACL reconstruction technique (group2) is a better technique than arthroscopic Anatomic accessory medial portal technique (group1).

Conventional over-the-top-aiming devices with short offset fail to hit the center of the human femoral ACL footprint in medial portal technique, whereas medial-portal-aiming devices with larger offset hit the center reliably.

Aim of this study was to investigate the accuracy of a conventional over-the-top-guide (OTG) with a typically short offset to hit the center of the native femoral ACL footprint through the anteromedial portal in comparison to a specific medial-portal-aimer (MPA) with larger offset. In 20 matched human cadaveric knees, insertion sites of the ACL were marked in medial arthrotomy. An OTG with an offset of 5.5mm, respectively, the MPA with 9mm offset was used in a medial portal approach to locate the center of a single bundle ACL reconstruction tunnel with k-wires. Distances from the footprint center, the OTG drilling and the MPA drilling to the roof of the intercondylar notch and to the deep cartilage margin were determined. After positioning of radiological markers, radiographic analysis was performed according to the quadrant technique as described by Bernard and Hertel. The distance from ACL origin to the roof of the notch was 10.3 (±2.1) mm, in the OTG group 6.7 (±1.5) mm and in the MPA group 9.6 (±1.9) mm. The distance to the deep cartilage margin was 9.5 (±1.7) mm from ACL origin, 4.8 (±1.3) mm with OTG and 8.7 (±1.4) mm with MPA. There were statistically significant differences between the distances of the footprint center and the OTG group after measuring and also after radiographic analysis (p<0.0001). Using the MPA, no significant different distances in comparison to the anatomical ACL center were found (p>0.0001). There was an increased risk for femoral blow (9/10 vs. 0/10) in the OTG group after overdrilling with a 9mm drill. Short (5.5mm) offset femoral aiming devices fail to locate the native ACL footprint center in medial portal approach with an increased risk for femoral blowout when overdrilling. The special medial-portal-aiming device with 9mm offset hit the center reliably.

Variation in the shape of the tibial insertion site of the anterior cruciate ligament: classification is required.

To propose a classification system for the shape of the tibial insertion site (TIS) of the anterior cruciate ligament (ACL) and to demonstrate the intra- and inter-rater agreement of this system. Due to variation in shape and size, different surgical approaches may be feasible to improve reconstruction of the TIS. One hundred patients with a mean age of 26±11years were included. The ACL was cut arthroscopically at the base of the tibial insertion site. Arthroscopic images were taken from the lateral and medial portal. Images were de-identified and duplicated. Two blinded observers classified the tibial insertion site according to a classification system. The tibial insertion site was classified as type I (elliptical) in 51 knees (51%), type II (triangular) in 33 knees (33%) and type III (C-shaped) in 16 knees (16%). There was good agreement between raters when viewing the insertion site from the lateral portal (κ=0.65) as well as from the medial portal (κ=0.66). Intra-rater reliability was good to excellent. Agreement in the description of the insertion site between the medial and lateral portals was good for rater 1 and good for rater 2 (κ=0.74 and 0.77, respectively). There is variation in the shape of the ACL TIS. The classification system is a repeatable and reliable tool to summarize the shape of the TIS using three common patterns. For clinical relevance, different shapes may require different types of reconstruction to ensure proper footprint restoration. Consideration of the individual TIS shape is required to prevent iatrogenic damage of adjacent structures like the menisci. III.

Comparison of Knee Kinematics After Single-Bundle Anterior Cruciate Ligament Reconstruction via the Medial Portal Technique With a Central Femoral Tunnel and an Eccentric Femoral Tunnel and After Anatomic Double-Bundle Reconstruction

Background: Anatomic femoral tunnel placement in anterior cruciate ligament (ACL) reconstruction is considered to be a key to good primary stability of the knee. There is still no consensus on whether a centrally placed single bundle in the anatomical femoral footprint can compare with anatomic double-bundle (DB) reconstruction. Purpose/Hypothesis: The purpose of this study was to determine knee kinematics after single-bundle ACL reconstruction via the medial portal technique using 2 different femoral tunnel positions and to compare results with those of the anatomic DB technique. The hypotheses were that (1) single-bundle reconstruction using the medial portal technique with a centrally placed femoral tunnel relative to the native footprint (SB-central technique) would more closely restore intact knee kinematics compared with the same reconstruction technique with an eccentric femoral tunnel drilled in the anteromedial bundle footprint (SB-AM technique) and (2) DB reconstruction would result in superior kinematics compared with the SB-central technique. Study Design: Controlled laboratory study. Methods: Knee kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force-moment sensor system. Kinematics in simulated pivot-shift and 134-N anterior tibial loading tests were determined in different conditions within the same specimen: (1) intact ACL, (2) deficient ACL, (3) SB-AM, (4) SB-central, and (5) DB. Results: All reconstruction techniques significantly reduced anterior tibial translation (ATT) compared with a deficient ACL at 0°, 15°, 30°, 60°, and 90° in the anterior tibial loading test (P < .01, repeated-measures analysis of variance) and at 0°, 15°, and 30° in the simulated pivot-shift test (P < .001). There were no significant differences in the SB-central group and the DB group compared with the intact ACL. Reconstruction in the SB-AM group resulted in significantly increased ATT compared with the intact ACL in near-to-extension angles in both tests (0°, 15°, and 30°; P < .01). SB-central and DB reconstructions both resulted in significantly reduced ATT, in some tests at ≤30°, compared with SB-AM reconstruction (P < .05). No significant differences between the SB-central and DB groups were found (P > .05). Conclusion: The SB-central technique restored intact knee kinematics more closely than did SB-AM reconstruction at time zero. There were no differences in knee kinematics between the DB and SB-central techniques. Clinical Relevance: Anatomic single-bundle ACL reconstruction provides similar knee kinematics as anatomic double-bundle reconstruction.

Arthroscopic Anatomic Glenoid Reconstruction Without Subscapularis Split

The role of bone loss from the anterior glenoid in recurrent shoulder instability has been well established. We present a completely arthroscopic technique for reconstructing the anterior glenoid with distal tibial allograft and without a subscapularis split. We perform the arthroscopy in the lateral position. We measure and size an allograft distal tibial graft and place it arthroscopically. We use an inside-out medial portal to introduce the graft into the shoulder, passing it through the rotator interval and above the subscapularis. A double-cannula system is used to pass the graft, which is temporarily fixed with K-wires and held in place with cannulated screws. We then perform a Bankart-like repair of the soft tissues to balance the shoulder and augment our repair. Our technique is not only anatomic in the re-creation of the glenoid surface but also anatomic in the preservation of the coracoid and subscapularis tendon and repair of the capsulolabral complex.

Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator

BackgroundThis study aimed to present a new technique for anatomical single bundle anterior cruciate ligament (ACL) reconstruction. We developed an original rounded rectangular dilator set to create rounded rectangular femoral tunnels. This technique can increase the femoral tunnel size without roof impingement, and has the potential to reduce the graft failure rate. We investigated the tunnel position and the incidence of intraoperative complications. MethodThe presented technique is anatomical single bundle ACL reconstruction using a semitendinosus graft (with or without the gracilis tendon). The tunnel was drilled via an additional medial portal. Rounded rectangular tunnels were created using a special dilator. Tibial tunnels were created using conventional rounded tunnels. Fixation was achieved using a suspensory device on the femoral side and a plate and screw on the tibial side. PatientsFifty patients underwent this surgery, and intraoperative complications were investigated. The femoral tunnel positions were documented postoperatively from computed tomography scans using the quadrant method. The tibial tunnel positions (anterior-to-posterior, medial-to-lateral) were documented using intraoperative X-ray scans. ResultsOnly one patient had a partial posterior tunnel wall blowout. The femoral tunnel length varied between 30 and 40mm (mean, 34.9±3.3mm). All femoral and tibial tunnels were located within the area of the anatomical ACL insertions. ConclusionWe did not experience any serious intraoperative complications during anatomical single bundle ACL reconstruction using a rounded rectangle dilator, and the resulting locations of the femoral and tibial tunnels were within the anatomical ACL footprint. Level of evidenceLevel IV.

Elbow arthroscopy: An alternative to anteromedial portals

BackgroundElbow arthroscopy is considered to be a difficult procedure with a high complication rate. These two disadvantages are due to the proximity of neurovascular structures. HypothesisThe aim of our study was to evaluate the efficacy and complication rate of a new elbow arthroscopy technique without anteromedial portals. This approach was taken because of the high rate of ulnar nerve damage using the medial portal, and the difficulty of performing triangulation of opposite portals in a patient in the lateral decubitus position. Material and methodsFifteen patients were operated on by the same surgeon between 2010 and 2012. Range of motion and the “MEPS” elbow score were calculated preoperatively and at the final postoperative follow-up. The average age of patients was 38.3 years. The follow-up was 11.1 months. Personal portals (high anterolateral and intermediate anterolateral portals) were used instead of the anteromedial portals. ResultsElbow flexion increased from 113° preoperatively to 129° at the final follow-up (P=0.009). Extension increased from −33° to −10° (P<0.0001). The preoperative and final postoperative “MEPS” scores were 56.3 and 94 respectively (P<0.0001). Two patients (13.3%) had radial nerve palsy with complete recovery 6 and 9months after surgery. DiscussionThe rate of nerve complications following elbow arthroscopy varies from 0 to 14%. The rate in our series (13.3%) is comparable to the results of the literature. This rate should be placed in perspective (since one patient had multiple open surgery elbow operations before arthroscopy). All complications were transient. Improved elbow range of motion in our study is consistent with the results in literature.

Peroneus Longus Tendoscopy at the Sole: A Cadaveric Study

The aim of this study was to investigate the safety of tendoscopy of the peroneus longus (PL) at the sole in a cadaveric model. Twelve fresh-frozen foot and ankle specimens were used. The locations of the plantar medial and plantar lateral portals were studied. The relationships of the medial and lateral plantar nerves to the tendon sheath of the PL at the sole were also studied. The plantar lateral portal was located on average 11 mm (6 to 16 mm) proximal and 9 mm (6 to 15 mm) plantar to the fifth metatarsal styloid. The plantar medial portal was located on average 1 mm (12 mm proximal to the joint to 7 mm distal to the joint) proximal to the first tarsometatarsal joint. The lateral plantar nerve touched the PLT sheath in 8 specimens. The nerve was separated from the tendon sheath by a thin layer of muscle in 4 specimens. The medial plantar nerve was separated from the tendon sheath of the PL by the flexor digitorum longus and flexor hallucis longus tendons in all specimens. Tendoscopy of the PL at the sole of the foot is described; however, the lateral plantar nerve can be at risk and the tendoscopy should be performed with caution. This cadaveric study provides the anatomic basis of the PL tendoscopy of the sole.

Anterior Cruciate Ligament Reconstruction Using an “Out to In” Femoral Tunnel With Flexible Reamers

Anatomic femoral tunnel placement can be achieved by transtibial, medial portal drilling, far medial portal drilling, or “out to in” techniques percutaneously or by using open techniques. This paper describes the use of an “out to in” percutaneous technique using flexible guidepins and reamers for creating an anatomic femoral tunnel. There is no need for knee hyperflexion or an accessory portal. It is useful in revision surgery and in obese patients where hyperflexion is difficult to achieve.

Functional Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction: Accessory Medial Portal versus Transtibial

Objectives:Transtibial (TT) and accessory medial portal (AM) techniques are two of the most widely used methods for drilling the femoral tunnel in anterior cruciate ligament (ACL) reconstructions, both with the common goal of placing the graft centrally or anatomically in the ACL footprint. While previous studies have looked at drilling through a standard anteromedial portal, no study has investigated clinical outcomes, femoral tunnel length, and radiographic evaluation after drilling from either an AM portal or TT technique. The purpose of this paper is to compare these results for a single surgeon performing “anatomic” ACL reconstruction. In addition to the femoral tunnel lengths, radiographic tunnel obliquity and femoral starting points were compared between the two methods.Methods:Over a three-year period all patients who underwent anatomic ACL reconstruction by a single surgeon were evaluated for eligibility. During surgery, the center of the anatomic femoral footprint (just posterior to the bifurcate ridge) was marked with an awl viewed through the medial portal and the tibial tunnel was drilled first. If the exact mark could be reached through a transtibial approach using a freehand pin (no guide), then it was utilized; otherwise, an accessory medial portal was created and used for femoral drilling (with the knee placed in hyperflexion). Seventy-five patients met inclusion criteria for evaluation of tunnel length and radiographic analysis (tunnel obliquity, clockface starting point). The mean age of the patient population was 29.8 (+/- 10.3). Functional outcomes (IKDC scores) were evaluated at a minimum of 24 month follow-up (Avg = 26 months; range:24-32 months).Results:In the study group of 75 patients (TT group, 47; AM group, 28) there were no significant differences between AM (74.8 +/- 13.6) and TT (75 +/- 12.9) with regard to postoperative IKDC score (p = 0.95). There was a significant difference (p < 0.001) between femoral tunnel lengths, with AM tunnels averaging 34.5mm (+/- 3.3) and TT tunnels averaging 42.13 mm (+/- 6.3). There was a significant difference in femoral tunnel obliquity (AM 39.5 +/- 6.45 degrees, TT 27.2 +/- 7.7 degrees, p<0.001) and femoral starting point (AM 9:59 o’clock +/- 20 mins, TT 10:12 o’clock +/- 18 mins, p<0.001) on AP radiograph.Conclusion:This study demonstrates no significant difference in functional outcomes for ACL reconstruction between AM and TT techniques when the femoral starting point is independently judged as anatomic between techniques. Nearly 40% of the time the anatomic femoral footprint could not be reached from a TT portal and thus conversion to AM was necessary. AM tunnel lengths of less than 30mm were rare in this study.

Arthroscopic Reduction and Internal Fixation for Fracture of the Lateral Process of the Talus

Fractures of the lateral process of the talus (LPT) are relatively rare. We describe arthroscopic reduction and internal fixation for a type I fracture of the LPT according to the Hawkins classification. Preoperative computed tomography is necessary to evaluate the type and displacement of the LPT fracture because this type of fracture is often overlooked on a plain radiograph. The ankle is approached through a standard medial portal as the working portal and an anterolateral portal as the viewing portal. A 2.7-mm-diameter 30° arthroscope is used. Hematoma and soft tissues around the talus are cleared with a motorized shaver, and the anterior and lateral aspects of the talar process are visualized. Fracture reduction is obtained by pushing the lateral fragment of the lateral process medially and is fixed temporally with a 1.1-mm guidewire from the medial portal under both arthroscopy and fluoroscopy. A headless compression screw is inserted through the guidewire. Arthroscopic reduction and internal fixation for a type I LPT fracture can be easily accomplished, and return to daily and sports activities can be achieved in a relatively short time.

Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results.

Anatomic positioning of the femoral and tibial tunnels in the native ACL femoral and tibial footprints requires an independent drilling either via an accessory medial portal (trans-portal drilling) or using an outside-in drilling technique. Conventional trans-tibial drilling (dependant drilling) was found to lack the ability to accurately position the femoral tunnel in the native ACL footprint. The purpose of the current study was to evaluate the functional outcome results of anatomic single-bundle ACLR using the OI femoral tunnel drilling technique. Single surgeon single center prospective case series study. 64 patients having complete ACL tears were included in the current study. Average follow-up was 15.8months (range 8-25). Objective and subjective IKDC scores, Lysholm knee score, SF-36 score, VAS for patients' satisfaction, VAS for pain and Kellgren and Lawrence (K/L) classification of osteoarthritis were used for follow-up evaluation. Objective IKDC score revealed that 60 patients had grade ''A'' and 4 had grade ''B'', while no single patient had neither grade ''C'' nor ''D''. The average Lysholm Score was 92.4, average subjective IKDC was 91.5. Average SF-36 score was 96.7. The average VAS for operation satisfaction was 9.7. Average VAS for pain was 0.3. Forty-nine patients were classified as normal K/L classification, 7 were grade ''1'', 8 were grade ''2''. Comparing pre-operative and follow-up Objective IKDC, Subjective IKDC, Lysholm, SF-36 and VAS for pain scores revealed statistically significant differences (P value <0.05). Arthroscopic-assisted ACL reconstruction using the outside-in femoral tunnel drilling technique shows a good and satisfactory functional outcome results at short- to mid-term follow-up. Level IV.

Usefulness of the Medial Portal during Hip Arthroscopy.

The current conventional portals for hip arthroscopic surgery are the anterior, anterolateral, and posterolateral portals. For lesions in the medial anteroinferior or posteroinferior portion of the hip, these portals provide insufficient access to the lesion and consequently lead to incomplete treatment. Thus, in such a situation, a medial portal approach might be helpful. However, operators have avoided this procedure because of the risk of injury to the obturator, femoral neurovascular structures, and the medial femoral circumflex artery. Thus, to overcome the disadvantages of the conventional method for medial lesions of the hip, we performed a cadaveric study to evaluate the technique, usefulness, and risk of the medial portal technique.

The use of an Accesory Medial Portal in Anatomic ACL Reconstruction a Prospective Ct- Study

ObjectivesThe purpose of this study was to evaluate if any differences exist regarding the position and the length of the femoral tunnel between the anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of an accessory medial portal and the ACLR with no use of accessory medial portal using computed tomography (CT) imaging.MethodsTwenty-five consecutive patients that underwent ACLR with the aid of an accessory medial portal (Group A) and 25 ACL-reconstructed (ACL-R) patients with no use of the accessory medial portal (Group B) formed the two study groups. The femoral tunnel angle (FTA) was measured on CT and the femoral tunnel length (FTL) was measured intraoperatively. Unpaired t-tests were used to examine differences regarding FTA and FTL between the two groups. The level of significance was set at α=0.05.ResultsMean group values (range, standard deviation) for FTA were 33.9º (30º - 41º, 2.9º) and 48.2º (43º - 59º, 4.4 º) and for FTL 36.2mm (30-39, 2.4) and 44.2mm (39-48, 3) for groups A and B respectively (p<0.005).ConclusionWith the use of an accessory medial portal the femoral tunnel is placed in a more oblique position in coronal plane as compared to the conventional AM portal technique, closer to the real anatomical position of the posterolateral bundle. Additionally the femoral tunnel length with this new technique is shorter than this with the AM portal but long enough for using the smaller button which has been proposed to reduce the motion of the graft within the tunnel.

Evaluation of Short Term Outcomes of Transportal Femoral Cross Pin Fixation in Anterior Cruciate Ligament Reconstruction

Objectives:Many fixation techniques are currently in use for femoral side graft fixation at ACL reconstruction surgery. Short term success following ACL reconstruction highly depends on fixation strength of the graft. In this study we report short term results of anterior cruciate ligament reconstruction using double hamstring tendon autograft using double cross pin for femoral tunnel fixation.Methods:Between years 2009 and 2013, 51 male adult anterior cruciate ligament injury cases treated surgically, in a single center, with at least one year follow up were investigated. Professional athletes, multi-ligamentous instability cases, cases requiring meniscus repair or further treatment for chondral injuries and cases with concomitant medial and lateral meniscus lesions were not included in the study. Femoral tunnel was prepared anatomically through accessory medial portal, opened medially and distally. Reconstruction was performed using double loop hamstring tendon autograft. Femoral side was fixed using double cross pin, whereas tibial side was secured using single biodegradable interference screw and titanium staple. No external immobilization method such as brace was administered. Patients were encouraged to bear weight as tolerated. Standard physiotherapy was instructed to all patients postoperatively. All cases were evaluated clinically at the end of at least one year follow-up. Clinical and functional evaluation consisted of pivot shift and Lysholm, International Knee Documentation Committee (IKDC) scores and Tegner activity evaluation systems.Results:Mean age was 28.4 (18-39) years. Mean time between the injury and reconstruction was 13 (3-21) weeks. Average duration of surgery was 48 (35-70) minutes. No case of graft failure or posterior cortical fracture was encountered. In two cases, infection was treated successfully with local debridement and antibiotics with retention of the graft. At the end of follow-up period, none of the cases demonstrated positive pivot shift test. Pre-operative and follow-up Lysholm scores were 58.3±6.7 and 87.1±5.3 (p<0.001) respectively. Pre-operative IKDC scores were evaluated as C at 37 cases and D at 14, whereas, follow-up IKDC scores were evaluated as A at 42 cases, B at 8 and C at 1 case. Pre-operative and follow-up Tegner scores were 3.7±0.6 and 6.7±0.4 (p<0.001) respectively.Conclusion:Although fixation strength of transcondylar graft fixation techniques has been questioned over loop systems with cortical fixation, it was reported that transcondylar fixation causes less tunnel widening at long term. Our study revealed successful short term results, with femoral tunnel preparation using accessory medial portal and double cross pin femoral fixation, allowing early weight bearing and rehabilitation without graft and fixation failure.

Retrograde reamed femoral nailing.

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) poly trauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122°; only two knees had an extensor lag of >5°. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.

Does flexible tunnel drilling affect the femoral tunnel angle measurement after anterior cruciate ligament reconstruction?

To quantify the mean difference in femoral tunnel angle (FTA) as measured on knee radiographs between rigid and flexible tunnel drilling after anatomic anterior cruciate ligament (ACL) reconstruction. Fifty consecutive patients that underwent primary anatomic ACL reconstruction with a single femoral tunnel drilled with a flexible reamer were included in this study. The control group was comprised of 50 patients all of who underwent primary anatomic ACL reconstruction with a single femoral tunnel drilled with a rigid reamer. All femoral tunnels were drilled through a medial portal to ensure anatomic tunnel placement. The FTA was determined from post-operative anterior-to-posterior (AP) radiographs by two independent observers. A 5° difference between the two mean FTA was considered clinically significant. The average FTA, when drilled with a rigid reamer, was 42.0° ± 7.2°. Drilling with a flexible reamer resulted in a mean FTA of 44.7° ± 7.0°. The mean difference of 2.7° was not statistically significant. The intraclass correlation coefficient for inter-tester reliability was 0.895. The FTA can be reliably determined from post-operative AP radiographs and provides a useful and reproducible metric for characterizing femoral tunnel position after both rigid and flexible femoral tunnel drilling. This has implications for post-operative evaluation and preoperative treatment planning for ACL revision surgery. IV.