Retrograde Drilling Research Articles

A Simplified Technique for All-Inside Tibial Socket Retrograde Drill Guiding Using a 2- to 3.5-mm Concentric Cannula Without the All-Inside Tibial Guide Ring

The all-inside anterior cruciate ligament (ACL) technique is a minimally invasive surgical procedure that has gained popularity due to its reduced invasiveness and improved patient outcomes. The establishment of tibial sockets remains a crucial step in ACL reconstruction, which has always been difficult in ACL reconstruction research. For doctors who are not very experienced, this technique of positioning and making sockets requires a special guide ring, and the tunnel entrance is prone to be anterior. Herein, we report a simplified technique using a self-made 2- to 3.5-mm concentric cannula to help surgeons easily master the all-inside technique. Our technique for tibial socket construction does not require the specific tibial guiding ring but uses a traditional tibial guiding ring for full-length tibial tunnel construction. With a 2-mm Kirschner wire and the traditional tibial guiding ring initially locating the tunnel position, the self-made concentric cannula helps combine the Kirschner wire with the guide pin sleeve, thereby impacting the guide pin sleeve into the tibial cortex at a controlled depth. Then, retrograde drilling is performed to create the socket. This technique provides feasible approaches for surgeons to transition from traditional full-long tunnel creation to the semi-long socket construction for the all-inside ACL technique.

Commercially Available Guides Overestimate Socket Length During Anterior and Posterior Cruciate Ligament Socket Retrograde Drilling

To objectively assess the accuracy of socket measurements taken during cruciate ligament reconstruction using a retrograde reaming technique. Six complete knee sawbone specimens were used to ream anterior and posterior cruciate ligament sockets in the femur and tibia in a retrograde fashion using a standard retrograde reaming device. The longest and shortest sides of the sockets were measured using a ruler. One-sided Wilcoxon signed-rank sum tests were used to evaluate whether the actual measured socket length matched the estimated length set on the drill guide. One fellowship-trained surgeon reamed 24 total sockets in sawbone specimens using guides. Statistical analysis revealed a significant difference between the estimated measurement and the actual shortest tunnel length in each of the sockets. The median short side socket lengths were shorter than their respective intended depths by 4 mm for the femoral anterior cruciate ligament socket, 6 mm for the femoral posterior cruciate ligament socket, 6 mm for the tibial anterior cruciate ligament socket, and 4.5 mm for the tibial posterior cruciate ligament socket. All differences were significant at α= 0.05. The estimated cruciate socket lengths reamed during ligament reconstruction using a retrograde reamer and standard intra-articular measuring instrumentation were greater than the actual measured socket lengths. Successful cruciate ligament reconstruction relies on accurate socket measurements. This study examined the accuracy of commercially available cruciate ligament socket drill guides and the implications for clinical practice, to include graft-tunnel mismatch and surface area available for healing. Surgeons may consider reaming slightly longer than estimated sockets when performing all-inside cruciate ligament reconstructions to ensure appropriate socket depth for graft fixation.

Regeneration of Osteochondral Lesion of the Talus with Retrograde Drilling Technique: An In Vitro Pilot Study.

Background: Retrograde Drilling (RD) is a surgical technique employed for osteochondral lesions of the talus (OCLTs) to reach the subchondral bone lesion from behind, thus preserving cartilage integrity. The aim of the present pilot study was to set up an in vitro model of OCLTs to evaluate the regenerative potential of biological approaches that could be associated with the RD technique. Methods: For this purpose, an OCLT was created in human osteochondral specimens, to try to mimic the RD technique, and to compare the regenerative potential of two biological treatments. For this purpose, three groups of treatments were performed in vitro: (1) no treatment (empty defect); (2) autologous bone graft (ABG); (3) hyaluronic membrane enriched with autologous bone marrow cells. Tissue viability; production of Collagen I and II, Vascular Endothelial Growth Factor, and Aggrecan; and histological and microCT evaluations were performed after 30 days of culture in normal culture conditions. Results: It was observed that Group 3 showed the highest viability, and Group 2 showed the highest protein production. From a histological and microtomographic point of view, it was possible to appreciate the structure of the morcellized bone with which the defect of Group 2 was filled, while it was not yet possible to observe the deposition of mineralized tissue in Group 3. Conclusions: To conclude, this pilot study shows the feasibility of an alternative in vitro model to evaluate and compare the regenerative potential of two biological scaffolds, trying to mimic the RD technique as much as possible. The tissues remained vital for up to 4 weeks and both ABG and hyaluronic acid-based scaffolds stimulated the release of proteins linked to regenerative processes in comparison to the empty defect group.

Comparative analysis of short-term efficacy between robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus.

To investigate the short-term clinical efficacy of robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus (OCLT). This study was divided into two groups: experimental group: robot-assisted retrograde drilling group; control group: arthroscopic microfracture group. A total of 6 OCLT patients who were treated with robot navigation-assisted retrograde drilling and 10 OCLT patients who were treated with arthroscopic microfracture between October 2020 and October 2021 were retrospectively analyzed. There were 11 males and five females, with a mean age of 36 years. The patients were followed up for 6-12 months to compare the changes in the OCLT lesion area by magnetic resonance imaging (MRI), visual analogue scale/score (VAS) and American Orthopedic Foot and Ankle Society score (AOFAS) before and after surgery. All 16 patients were followed up for an average of 8 months, and no complications such as joint infection, nerve injury, or active bleeding occurred during the follow-up period. Only one patient suffered discomfort involving transient postoperative pain in the operative area, but did not experience long-term numbness or chronic pain. Postoperative MRI revealed that none of the patients had severe signs of osteonecrosis, osteolysis or cystic changes of the talus, with lesion areas smaller than those before surgery. The difference was statistically significant (P < 0.01). The patients in the experimental group showed a more significant improvement in the last 3 months than in the first 3 months of the follow-up period. At the last follow-up, the VAS score was 3 points in the experimental group and 2.2 points in the control group, and the AOFAS score was 88.6 points in the experimental group and 88 points in the control group, all of which were significantly higher than those before operation, and the differences were statistically significant, but there was no statistically significant difference between the groups. Both robot navigation-assisted retrograde drilling and arthroscopic microfracture for bone marrow stimulation (BMS) to treat OCLT in all patients obtained satisfactory effects in the short term. In addition, the follow-up revealed that with excellent efficacy and few complications, robot navigation-assisted retrograde drilling was safe and minimally invasive, and greatly reduced operative time. Consequently, robot navigation-assisted retrograde drilling for BMS was a safe and effective procedure for the treatment of OCLT.

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review.

Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT. A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated. Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported. This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Operative management of osteochondral lesions of the talus: 2024 recommendations of the working group 'clinical tissue regeneration' of the German Society of Orthopedics and Traumatology (DGOU).

The working group 'Clinical Tissue Regeneration' of the German Society of Orthopedics and Traumatology (DGOU) issues this paper with updating its guidelines. Literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLT) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available with a grade of recommendation. All group members rated the statements to identify possible gaps between literature and current clinical practice. Fixation of a vital bony fragment should be considered in large fragments. In children with open physis, retrograde drilling seems to work better than in adults, but even there, the revision rate reaches 50%. The literature supports debridement with bone marrow stimulation (BMS) in lesions smaller than 1.0 cm² without bony defect. The additional use of a scaffold can be recommended in lesions larger than 1.0 cm². For other scaffolds besides AMIC®/Chondro-Gide®, there is only limited evidence. Systematic reviews report good to excellent clinical results in 87% of the patients after osteochondral transplantation (OCT), but donor site morbidity is of concern, reaching 16.9%. There is no evidence of any additional benefit from autologous chondrocyte implantation (ACI). Minced cartilage lacks any supporting data. Metallic resurfacing of OLT can only be recommended as a second-line treatment. A medial malleolar osteotomy has a minor effect on the clinical outcome compared to the many other factors influencing the clinical result.

Osteochondritis Dissecans Lesions of the Knee: Evidence-Based Treatment.

Osteochondritis dissecans (OCD) of the knee is a potentially disabling condition in adolescent and young adults, which is likely multifactorial in origin. In recent years, there have been notable improvements in identification and treatment. Clinical presentation varies based mostly on OCD lesion stability. Patients with stable lesions generally present with vague knee pain and altered gait while mechanical symptoms and effusion are more common with unstable lesions. Lesions most commonly occur on the lateral aspect of the medial femoral condyle in patients aged 10 to 20 years. Magnetic resonance imaging is vital to diagnose and predict clinical treatment, which is largely based on stability of the fragment. Conservative treatment of stable lesions in patients with open physis is recommended with protected weight-bearing and gradual progression of activities over the course of 3 to 6 months. Stable OCD lesions which failed a nonsurgical course can be treated with transarticular or retrograde drilling while unstable lesions usually require fixation, autologous chondrocyte implantation (ACI), osteochondral autograft transfer (OATS), or osteochondral allograft transplantation. This review highlights the most current understanding of knee OCD lesions and treatment options with the goal of optimizing outcomes in this difficult pathology.

Comparison of Arthroscopic Microfracture and Retrograde Subchondral Drilling in the Treatment of Osteochondral Lesions of Talus.

In our study, it was aimed to evaluate the efficacy of microfracture and retrograde subchondral drilling on clinical outcomes in patients who underwent ankle arthroscopy due to osteochondral lesion of medial talus. Twenty eight patients with osteochondral lesion of talus less than 1.5 cm2 treated with ankle arthroscopy were evaluated retrospectively. Microfracture was performed in 16 patients and retrograde subchondral drilling was performed in 12 patients that there was no loss of integrity in the cartilage layer or cartilage layer is partially preserved during ankle arthroscopy. Postoperative evaluations of the patients were done with Foot and Ankle Ability Measure (FAAM) and results of both group were compared statistically. The mean activities of daily living scale was 93.4±3.2 and sportive activity scale was 90.1±5.7 in the retrograde drilling group. In the micro-fracture group, mean activities of daily living scale was 93.8±4.1 and mean sportive activity scale was 88.9±9.5. No significant difference was found as a result of statistical comparisons of both groups results. It has been determined that the size and preservation of the integrity of talar osteochondral lesions are important factors on clinical results. Results of arthroscopic debridement, microfracture and drilization are not good in lesions larger than 1.5 cm2 and lesions with impaired integrity. In our study, depending on the general literature, osteochondral lesions in talus were less than 1.5 cm2 in patients who underwent arthroscopic micro fracture and retrograde drilling. Both microfracture and retrograde subchondral drilling are effective treatment methods with good clinical results for talar osteochondral lesions less than 1,5cm2 . Retrograde subchondral drilling can be an alternative treatment method with the reliability of clinical results in patients with no loss of the integrity of the cartilage layer or cartilage layer is partially preserved. talus, osteochondral lesion, microfracture, subchondral drilling.

Physeal-Sparing, All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus Autograft and Suture Tape Augmentation for Skeletally Immature Patients

The anterior cruciate ligament (ACL) is the primary soft-tissue structure for anterior stabilization of the knee and is one of the most frequently injured structures. The incidence of ACL injuries in children and adolescents ranges from 92 to 151 per 100,000 person-years. The choice of surgical treatment for this population group is controversial, with a widespread concern that adult reconstruction techniques may damage the epiphyseal plate, compromise growth, or cause deformity. In this article, we describe a physeal-sparing, all-inside ACL reconstruction technique for skeletally immature patients. This technique is supported by retrograde drilling of the femoral tunnel and retrograde drilling of the tibial tunnel, both of which are able to avoid the epiphyseal growth line. Fixation of the quadrupled semitendinosus autograft and suture tape augmentation are achieved by soft-tissue buttons on the femur and tibia. The surgical details of this reproducible reconstruction technique are elaborated.

Postoperative Management of Osteochondral Lesions of the Ankle: A Survey Among German-Speaking Foot and Ankle Surgeons.

To assess the current treatment of osteochondral lesions of the ankle (OCLA) by German-speaking foot and ankle surgeons, focusing on the management of postoperative care and rehabilitation. A questionnaire was created by a panel of 4 experienced foot and ankle surgeons on behalf of the "Clinical Tissue Regeneration" (CTR) working group of the German Society of Orthopaedics and Trauma Surgery (DGOU), and distributed electronically to members of the CTR, participants of the German Cartilage Registry (Knorpelregister DGOU©), and members of 6 German-speaking orthopedics or sports medicine societies. Results were classified depending on the consensus within the answers (agreement ≥75% "strong tendency," 50%-74% "tendency," 25%-49% "weak tendency," <25% "no tendency"). A total of 60 participants returned the questionnaire. The main results are as follows: regarding the frequency of surgical procedures for OCLA, refixation of the fragment, retrograde drilling, and bone marrow stimulation with or without using a matrix were performed by at least 75% of the surgeons and was considered a strong tendency. There was a strong tendency to stabilize the ankle (76.7%) and perform corrective osteotomies (51.7%). In total, 75.5% and 75% of the surgeons performed bone marrow stimulation with and without using a matrix, respectively. Corrective osteotomy and ankle stabilization were performed in 64.5% and 65.2% cases, respectively. Most participants included published recommendations on postoperative rehabilitation and the return to sports activities in their postoperative management. The main surgical procedures were considered the most critical factor in influencing the postoperative management by 81% of the participants (strong tendency). Adjunct surgical procedures such as corrective osteotomy and stabilization of the ankle were considered important by 67.8% of the respondents (tendency). The management of OCLA varies among German-speaking foot and ankle surgeons. Therefore, guidelines remain essential to standardize the management of OCLA, to achieve improved and stable results. This survey will assist clinicians and patients with rehabilitation to return to sports after treating the ankle's cartilage injury.

Retrograde Drilling for Hepple-V Subchondral Lesion of Talus using 3D Image-based Navigation Assisted Endoscopic Technique

Category: Ankle; Arthroscopy Introduction/Purpose: Retrograde drilling remains technically challenging, due to the difficulty of identifying the accurate location of cysts on fluoroscopic images or matching the tip of the drill guide under arthroscopic visualization. This studies aim was to evaluate the 3-dimentional(3D) image-based surgical navigation system assisted endoscopic retrograde drilling technique for subchondral lesions of the talus. Methods: From Mar 2018 to Jun 2020, 21 cases with Hepple-V type subchondral lesions of the talus were treated with 3D image- based surgical navigation system assisted endoscopic retrograde drilling technique. Arthroscopic views were categorized per Pritsch’s classifications. The American Orthopaedic Foot and Ankle Society (AOFAS) scores and Visual Analog Scale (VAS) scores were evaluated at the preoperative and final follow-up appointments. All complications were also recorded. Results: The average follow-up time was 29.2 ± 9.4 months (range, 24 – 48). Only 9 cases (42.9%) showed intact and normal cartilage surfaces (grade 0, group A), 12 cases (57.1%) had intact, soft cartilage surfaces (grade I, group B). At the final follow-up, the average of the AOFAS scores and VAS scores were 89.0 ± 2.1 vs 88.3 ± 2.0 and 0.8 ± 0.2 vs 0.8 ± 0.3, respectively. There were no significant differences between both groups. In group B, however, two patients were documented with signs of recurrence after 2 years postoperative. Also, an additional overlying cartilage lesion was noticed in another patient. Finally, two patients were given revised surgery. Conclusion: The 3D image-based surgical navigation system assisted endoscopic retrograde drilling technique is accurate, effective and safe for the subchondral lesions of the talus. The ideal indication is subchondral cysts with intact and normal cartilage surfaces. However, these patients are uncommon.

Pediatric Osteochondral Lesions of the Talus: A Systematic Review and Treatment Algorithm

Category: Hindfoot; Ankle Introduction/Purpose: Osteochondral lesions of the talus (OLT) peak in incidence during childhood, yet there exists a paucity of research on treatment among skeletally immature populations due to their high potential for spontaneous recovery without interventions. Unfortunately for patients who do require treatment, existing guidelines are based on adult studies, which likely differ in prognoses and outcomes due to varying capacity for regeneration. This paper compares outcomes across conservative and various surgical interventions for pediatric OLTs, with the synthesized evidence forming the basis of a treatment algorithm. Methods: An electronic literature search was conducted across PubMed, EMBASE, and MEDLINE databases for primary studies published prior to January 2022. Pediatric status in OLTs was defined as age &lt; 18 at diagnosis, since many studies did not assess skeletal maturity. The main outcomes were clinical and radiological success rates, defined as achievement of good or fair outcomes according to measures used by individual studies. Articles were categorized by treatment method, and outcome rates were obtained via simple pooling. Results: 35 studies involving 714 lesions were included. Studies were categorized into five overarching treatment methods – (1) conservative treatment, (2) bone marrow stimulation, (3) retrograde drilling, (4) fixation, and (5) osteochondral transplantation. These interventions had pooled clinical success rates of (1) 45%, (2) 85%, (2) 90%, (4) 82%, and (5) 74%, respectively. The pooled radiological success rates were (1) 58%, (2) 85%, (3) 55%, (4) 89%, and (5) 81%. Escalation from conservative to surgical treatment occurred at a rate of 62% among studies in which this was reported. Articles were heterogeneous in measurement tools and pre- treatment characteristics; average baseline lesion size was (1) 129.8, (2) 131.0, (3) 87.8, (4) 137.8, and (5) 237.5mm^2 across the five treatment methods, and initial Berndt-Harty staging was likewise disparate. Conclusion: Conservative treatments yielded lower clinical and radiological success rates than surgical interventions, but warrant an initial trial in stable lesions due to their cost-effective and non-invasive nature. Surgery should be indicated for unstable lesions, or failed conservative treatment. Drilling and bone marrow stimulation are effective in lower grade lesions, while fixation should be considered for loosened fragments, and transplantation for large, non-salvageable lesions. Future research utilizing more robust methodology and reporting outcomes according to baseline lesion characteristics will consolidate these guidelines.

An Antegrade Soft Anchor in a Retrograde Drilling for Medial Meniscus Root Repair with High Tibial Osteotomy: A Modified Approach to Avoid Tunnel Collision

An Antegrade Soft Anchor in a Retrograde Drilling for Medial Meniscus Root Repair with High Tibial Osteotomy: A Modified Approach to Avoid Tunnel Collision

Osteochondral Lesions of the Ankle and Foot.

Osteochondral lesions (OCLs) in the ankle are more common than OCLs of the foot, but both share a similar imaging appearance. Knowledge of the various imaging modalities, as well as available surgical techniques, is important for radiologists. We discuss radiographs, ultrasonography, computed tomography, single-photon emission computed tomography/computed tomography, and magnetic resonance imaging to evaluate OCLs. In addition, various surgical techniques used to treat OCLs-debridement, retrograde drilling, microfracture, micronized cartilage-augmented microfracture, autografts, and allografts-are described with an emphasis on postoperative appearance following these techniques.

Retrograde Drilling, Ossoscopy, and Autologous Bone Grafting: An Alternative Technique for Treatment of Osteochondral Lesion of the Talus Stage 2 and 3 in Adults.

Symptomatic osteochondral lesions of the talus (OLTs) often require surgical intervention. There are various surgical methods. A generally valid, stage-dependent therapeutic algorithm does not exist. The aim of our study is to show long- term results of an alternative technique that combines retrograde drilling, debridement performed under arthroscopic visualization, and autologous bone grafting. The surgical technique was performed in 24 patients with medial or lateral OLTs, and the data were analyzed retrospectively. In our technique, the affected subchondral bone was overdrilled retrogradely and resected under arthroscopic visualization (ossoscopy) without violating the cartilage. The resulting defect was filled with autologous bone from the medial tibia metaphysis. Outcome parameters were the numeric rating scale (NRS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and range of motion (ROM). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed and a possible correlation with the clinical outcome scores was calculated. Data concerning complication rates were also collected. The mean surface size of the OLTs was 0.9 ± 0.3 cm2. The mean follow-up was 89 months. The AOFAS score improved significantly from 57.7 points preoperatively to 88.8 points at the final follow-up (P < .0001). The pain value measured by the NRS decreased significantly from 8 to a pain level of 2. ROM improved in 37.5% of the patients for dorsiflexion and 29.2% for plantarflexion. There were no significant correlations between the MOCART score and the AOFAS score or the pain value on NRS. Retrograde drilling, ossoscopy, and autologous bone grafting for OLTs is a promising technique with good long-term results. The patients' satisfaction rate, especially in OLT stages 2 and 3, was excellent. Level IV, case series.

Clinical and radiological outcomes of surgically treated osteochondral lesions of the talus in children and adolescents.

Osteochondral lesions of the talus are uncommon in children and adolescents. Surgical procedures differ from those used for adults to avoid iatrogenic physeal injuries. This study aimed to evaluate the clinical and radiological outcomes of surgical treatment in pediatric patients with osteochondral lesions, specifically investigating the patient age and the status of distal tibial physis as factors associated with surgical success. We retrospectively reviewed 28 patients who had symptomatic osteochondral lesions of the talus that were treated surgically between 2003 and 2016. If the lesion was stable and articular cartilage was intact, retrograde drilling was performed under fluoroscopic guidance. Lesions with detached overlying cartilages were treated by debridement of the cartilage combined with microfracture and drilling. Radiographic outcomes, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and skeletal maturity were evaluated. Radiological improvement was observed in 24 (24/28, 86%) patients and complete and incomplete healing in 8 and 16 patients, respectively. Changes in pain grades, American Orthopaedic Foot & Ankle Society scores, and radiological healing after surgery were significant (pain grade, p < 0.001; American Orthopaedic Foot & Ankle Society, p = 0.018; radiological healing, p < 0.001). In addition, patients in the younger age group (≤13 years) showed greater improvements in pain grades than older patients (p = 0.02). Improvement in pain grade after surgery was better in the skeletally immature group than in the skeletally mature group (p = 0.048). Clinical and radiological improvements were observed after surgical treatment. The younger age group and open physis group showed more pain improvement. Therapeutic level IV.

Simple Arthroscopic Technique to Perform Retrograde Drilling for Osteonecrosis of the Femoral Condyles with the Use of Anterior Cruciate Ligament Guide.

This technical note describes a simple arthroscopic technique that was introduced without the need for further staff during an operation to address osteonecrosis of the medial femoral condyle. A 2.4 mm pin was positioned through the sleeve of an anterior cruciate ligament (ACL) tibial guide and marked with a steri-strip at its body, aiming at 5-10 mm distance between the tips of guide and the pin. The steri-strip serves as a marker and as a stop for inadvertent violation of the cartilage. The tip of the ACL was positioned just over the bone lesion, while the marked 2.4 mm pin was inserted through the ACL tibial guide from anterior surface of the femur. A stab incision was made and without advancing the sleeve to the bone, the pin was drilled to the marked position while cartilage integrity was confirmed arthroscopically. This arthroscopic technique is simple, fast and effective and is performed without the need for special equipment.

The Short Graft ACL Reconstruction

The Short Graft Anterior Cruciate Ligament (ACL) reconstruction is increasing in popularity. Surgeons are making use of autograft lengths of between 6-6.5 cm for ACL reconstruction. The grafts of choice are the hamstring and quadriceps tendon autograft. The grafts are prepared with cortical fixation on both the femur and tibia ends for cortical fixation. Short tunnels or sockets are reamed instead of full bone tunnels. This helps with bone preservation and the patients have less postoperative pain; but will require special instrumentation for retrograde drilling. The benefit of this technique is improved postoperative hamstring strength with the gracilis preserved, as only the semitendinosus tendon is harvested to obtain a quadrupled ACL graft. The outcomes of short graft ACL reconstruction are comparable to established transportal ACL reconstruction techniques. However, there is a learning curve and additional implant costs involved. The familiarity with the surgical technique, understanding of optimal graft fixation and biology are all paramount to success of this surgery.

Knee Pain-Basketball

HISTORY: 11 yo male basketball player referred to sports medicine for B/L anterior knee pain out of proportion to exam, right worse than left. He denied trauma. It started in his right knee 1 month prior, and he began having similar left knee pain. It was worse with activity including walking. He would feel popping in his knees. They felt unstable. He had failed conservative measures. As a result of his pain, he had to quit his basketball team and wasn’t able to run or play during recess. PHYSICAL EXAMINATION: B/L Knee Exam: Antalgic gait. No swelling. Normal alignment. Tender on medial and lateral joint lines and patella, less tender in patellar and quad tendons. Significant pain with flexion, range normal. Normal extension. Normal ligament and meniscus tests. Pain with patellar compression. Pain and difficulty with single leg hop, R > L. DIFFERENTIAL DIAGNOSIS: Sickle cell disease, OCD, discoid menisci, rheumatologic disorder, SCFE vs LCP TEST AND RESULTS: X-Rays B/L knees: Suggest mild B/L trochlear OCD X-Rays AP pelvis and lateral of both hips: Negative Sickle screen: Absent MRI right knee: Superior trochlea with 2.4 x 1.4 cm osteochondritis dissecans lesion, depth 0.4 cm. Sclerosis and subchondral cysts along the rim worrisome for instability MRI left knee: Superior central trochlea with subchondral sclerosis suggesting 9 mm osteochondritis dissecans lesion. Minimal subchondral sclerosis of the medial tibial plateau weight bearing surface with OCD lesion vs subacute/healing insufficiency fracture in the differential. FINAL WORKING DIAGNOSIS: Bilateral femoral trochlea osteochondritis dissecans TREATMENT AND OUTCOMES: Patient was referred to orthopedics for staged knee arthroscopy with retrograde transcartilaginous subchondral drilling of the trochlea, starting with the right knee. After each respective knee procedure, the patient was given a specific rehab protocol. Symptoms began improving. Intermittent symptoms returned ~9 months after right knee and 4 months after left knee surgery, so B/L knee MRIs were completed and showed significant improvement in the prior pathology. At his most recent visit, the patient was overall doing better noting significant bilateral knee improvement since the surgeries. He was back to playing basketball with his friends with only some post-activity soreness.

Complications following all-inside anterior cruciate ligament reconstruction.

We conducted a comprehensive analysis of possible perioperative complications following all-inside anterior cruciate ligament reconstruction (ACLR). Additional techniques and tips are proposed to prevent and manage complications. Complications following all-inside ACLR performed between December 2015 and December 2020 were retrospectively analysed. Altogether, 348 operations were performed and 275 patients were enrolled with a minimum 12-month follow-up period. Only semitendinosus autograft was utilised in most patients, and semitendinosus-gracilis autograft and allograft were used in five and 31 patients, respectively. Simultaneous meniscal repair, partial meniscectomy, and chondral surgery were performed in 29.5%, 21.1%, and 4.4% of patients, respectively. Complications were observed based on the patient's clinical condition, plain film, and magnetic resonance imaging. Clinical outcomes were assessed pre-operatively and at 12months post-operatively, using the International Knee Documentation Committee form, Lysholm and Tegner activity scores, and KT1000 side-to-side difference. Intraoperative and post-operative complications developed in 65 patients (23.6%). The most common complication was cortical button malposition on the femoral side (19.3%). Intra-operative breakage of the retrograde drill was found in two cases (0.73%), with three cases (1.1%) of over-drilling with destruction of the outer cortex. Post-operatively, four (1.5%), 13 (4.7%), and 16 (5.8%) cases of infection, full-thickness re-rupture, and loss of extension, respectively, were recorded. Functional outcome scales showed significant post-operative improvement. Cortical button malposition was the most common but easily preventable complication. All-inside ACLR could be safe and promising after the suggested additional operative techniques and proper perioperative management which decrease complication rates and improve favourable outcomes.