Retrograde Drilling Research Articles

Core decompression ("conventional method") in atraumatic osteonecrosis of the hip

Retrograde drilling of anecrotic zone within the femoral head to reduce intraosseous pressure and stimulate revascularization. Atraumatic osteonecrosis of the hip ARCO stageI (reversible) and ARCO stageII (potentially reversible) with amedial or central necrotic zone <30% or ARCO stageIII with asubchondral fracture for reduction of pain. ARCO stageIIIC, ARCO stageIV (secondary osteoarthritis), stage-independent necrotic zone > 30%, infections. Supine position. Visualization of the necrotic zone via an image intensifier, approach is determined by using a Kirschner wire, laterodorsal skin incision on alevel with the wire, longitudinal incision of iliotibial band and vastus lateralis muscle, drilling the necrotic zone with a2-3 mm Kirschner wire, optionally placing more wires or ahollow drill, wound closure. Partial weightbearing with 20 kg for 6weeks due to risk of fracture, followed by avoidance of jumping or sprinting for another 6weeks; physiotherapy from day1 after surgery, thromboembolic prophylaxis until full weightbearing is possible. Results are dependent on ARCO stages and are promising in early stages.

The Retrograde Drilling for Osteochondral Talar Lesion in Children

Category:Ankle, ArthroscopyIntroduction/Purpose:Osteochondral talar lesions (OCL) are infrequent in children, and little is known about the treatment and clinical outcome of these defects. Clinicians normally first attempt nonoperative treatment of these lesions, but if such treatment fails, surgical many treatments including retrograde drilling (RD), are attempted. RD is usually reserved for large OCLs with intact overlying cartilage. Good clinical outcomes have been reported in RD. However, the clinical outcomes of RD for OCL in children remains unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of RD in skeletally immature children.Methods:From January 2015 to April 2018, RD was performed on eight feet with OCL in six consecutive patients in skeletally immature children. Arthroscopic lateral ankle ligament repair was also performed in one of the eight feet, and one foot was excluded; therefore, we studied seven feet in five patients. The patients comprised three boys and two girls with a mean age at surgery of 11 (range, 9–12) years. All patients were followed for a minimum of 6 months postoperatively, the average follow-up was 19.1 (range, 8–39) months.All patients were grade 0, determined according to a modified Pritsch classification system. All patients were evaluated for Japanese Society for Surgery of the Foot (JSSF) scale and radiographic outcomes at preoperatively and postoperatively final follow up.Results:The average JSSF scale improved from 79.4 points (range, 69–90 points) to 100 points in all feet at final follow-up (p<0.01). The postoperative size of OCL using CT findings was improved than preoperative size. According to the postoperative computed tomography (CT) findings, four feet were good, three foot were fair. There were no incidences of postoperative complications.Conclusion:In our study, we suggest that RD for OCL in skeletally immature children is effective surgical treatment.

Retrograde Drilling for Osteochondral Lesion of the Talar Dome in Juvenile Patients

Category:Ankle, ArthroscopyIntroduction/Purpose:Osteochondral lesion of the talar dome (OLT) is common condition that causes pain of ankle joint in juvenile patients. Several surgical options have been available such as excision of detached cartilage fragment, microfracture, autologous cancellous bone graft and osteochondral autografting depending on the status of OLT. Arthroscopic drilling including transmalleolar or retrograde technique could be a good option for OLT patients with stable osteochondral fragment with normal articular surface. Retrograde drilling has an advantage in preventing the iatrogenic articular cartilage injury. This study aimed to clarify the clinical outcome of the retrograde drilling for OLT in juvenile patients.Methods:Our retrospective analysis included 8 patients who underwent retrograde drilling for OLT, in 5 boys and 3 girls, with a mean age of 14.9 years (range, 11-19). Range of motion (ROM) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle- hindfoot score were evaluated as the clinical outcomes. OLTs were classified into 4 grades according to arthroscopic findings by international cartilage research society (ICRS) classification. Radiographic analysis was performed using preoperative and postoperative images. Growth plate was evaluated on plane radiographs, and the location and size of OLT were assessed on computed tomography. The high intensity area of the talus was also measured on T2 fat suppression images.Results:All 8 patients were followed with a mean follow-up period of 2 years, and they had no complication or revision surgery. The mean total ROM were 65.6° preoperatively and 67.1° postoperatively. AOFAS scale improved from 69.3 to 96.7 (p = 0.012). The ICRS 1 and 2 OLT lesions were identified arthroscopically in 5 and 3 patients, respectively. Growth plate remained open in 4 patients, and OLTs were located on the posteromedial in 7 patients, center in 1 patient. The mean size of OLT fragment was 9.8 mm, 6.8 mm and 3.5 mm in length, width and height. Coronal and sagittal T2 fat suppression images demonstrated that the high intensity area of 241.3 mm2, 554.5 mm2 at preoperative status and 190.9 mm2, 302.6 mm2 at final follow-up status.Conclusion:These findings revealed that the retrograde drilling remarkably improved clinical status in juvenile OLT patients. The high intensity area at the talus remained postoperatively, however, that did not affect clinical results. Retrograde drilling procedure should be considered for treating juvenile patients in the early period after detection of the OLT.

Surgical Treatments of Talar Osteochondral Lesion: A Long-term Follow-up of Return to Sport and Patient-Reported Outcome Measures

Category:Ankle, Arthroscopy, Sports, TraumaIntroduction/Purpose:Talar osteochondral lesion (TOCL) is a common problem in the young athletic population, mostly related to trauma. TOCL surgical treatment algorithm remains controversial, though results are improving as we gain experience. The results of TOCL surgical treatment on function and return to sport are promising, but quantified return to sport metrics remain largely unknown.Methods:A total of 156 consecutive patients following TOCL chondroplasty (10/1/2000-5/31/2018) by a single practice were retrospectively reviewed and included in this study. There were 54.5% female with a mean age 38.2 years, and mean follow-up 40.2 months following the index surgery. Patients were divided into four groups according to the type of chondroplasty performed: Antegrade arthroscopic drilling and/or microfracture (antegrade, 83 patients), retrograde arthroscopic drilling (retrograde, 35 patients), osteochondral autograft transfer (OATS, 26 patients), and allograft cartilage implantation (allograft, 12 patients). VAS scores for pain and function at the final clinic visit were collected. Patient-reported outcome measures including the short form-12 (SF-12), The Foot and Ankle Disability Index Sports Module (FADI-sports), Tegner score, Marx scale, Naal’s Sports inventory are also actively being collected.Results:Nearly 75% of patients are satisfied with surgical intervention of TOCLs. Allograft transplant was the least satisfying (71.4%), while OATS was the most satisfying (90%). Each surgical intervention yielded significantly decreased pain and increased function postoperatively (all p<0.001). Currently, 57 patients (36%) provided patient-reported outcome measures, with an average follow up of 79.8 months (Table 1). All surgical interventions trended toward decreased Tegner score, though only antegrade drilling showed a significant decrease (p<0.001). Based on Naal’s sports inventory, 85.7% of surgically treated patients reported participating in sport activities, on average 3 times/week and 50.6 minutes/session.Conclusion:Traditionally, TOCLs presented a difficult problem that is marred by unsatisfactory surgical outcomes in typically active patients. As our surgical understanding has evolved, we’ve continued to improve on outcomes. Our patients demonstrated a 74.5% satisfaction rate, a statistically significant improvement in pain and function, and a high rate of return to sport with little difference between surgical interventions at a long-term follow-up.

Vascular Compromising Effect of Drilling for Osteochondral Lesions of the Talus: A Three-Dimensional Micro–Computed Tomography Study

To explore an optimal drilling depth and direction for osteochondral lesions of the talus based on a 3-dimensional vascular microarchitecture model constructed with micro-computed tomography (microCT). Twelve tali were perfused with the contrast agent and then scanned with microCT. The talar dome was divided into 9 zones, and the vessel densities were measured at the subchondral depths of 0 to 5mm, 5 to 10mm and 10 to 15mm in each zone. The anterolateral (AL) and posterolateral (PL) approaches of retrograde drilling were simulated and the vascular compromising effect was evaluated. The vessel density of the 0- to 5-mm depth was lower than that of the 5- to 10-mm (P= .001) and 10- to 15-mm (P= .007) depths, but no significant difference was found between the 5- to 10-mm and 10- to 15-mm depths (P > .9999). The vessel density in the 5- to 10-mm depth of medial talar dome was similar to that of the adjacent zones (P= .05). Vessel density in the 5- to 10-mm depth around the lateral talar dome was higher in the anterior and medial side. The anterolateral approach disturbed the main intraosseous vessels from the tarsal canal-tarsal sinus, causing extensive vascular compromise in the talus neck and body, whereas the posterolateral approach disturbed only the vessels near the tunnel. The vessel density changed greatly from the subchondral 0- to 5-mm to the 5- to 10-mm depth. The vessel densities of the 5- to 10-mm depth around the medial talar dome were similar, whereas the anterior and medial side of the lateral talar dome was better vascularized. The posterolateral approach caused less vascular damage than the anterolateral approach. The anterograde drilling depth was preferable to the subchondral 5- to 10-mm depth. There was no preferred drilling direction for the osteochondral lesion in the medial talar dome, whereas it is preferable to drill anteriorly or medially in the lateral dome. The posterolateral approach might be a safer alternative for retrograde drilling.

All-Inside Partial Epiphyseal Anterior Cruciate Ligament Reconstruction Plus an Associated Modified Lemaire Procedure Sutured to the Femoral Button

Anterior cruciate ligament (ACL) tears in skeletally immature patients are on the rise; pediatric athletes are now in constant year-round sports participation. Nonoperative treatment may lead to poor functional outcomes and an increase in associated intra-articular lesions and sometimes can cause drop-out from sports activity. The treatment of these injuries is not at all clear, and appropriate guidelines do not exist. Physeal-sparing and partial physeal-sparing techniques have been described. Concerns about restoring normal knee kinematics with the previously described ACL reconstruction (ACLR) techniques are open to debate. We describe a partial epiphyseal ACLR to be done in skeletally immature patients involved in highly demanding sport activities. This technique is performed with an extraphyseal femoral tunnel drilled retrograde, a transphyseal tibial tunnel, and a retrograde tibial drilling without trespassing the tibial physis. We added a modified Lemaire procedure to improve rotational instability to the previously performed ACLR.

RETROGRADE DRILLING FOR OSTEOCHONDRITIS DISSECANS OF THE TALUS IN A PEDIATRIC POPULATION: A RETROSPECTIVE STUDY

Background There is little information in the literature about the outcomes of retrograde drilling for osteochondritis dissecans of the talus in a pediatric population. The purposes of this study were therefore to investigate the efficiency of retrograde drilling among a young population and to identify factors that are predictive for failure of the treatment. The primary objective was to retrospectively evaluate clinical outcomes of pediatric patients with OCD of the talus who have undergone retrograde drilling. The criteria for failure of treatment was the necessity for subsequent surgeries. The secondary objective was to identify factors predictive of a failure of retrograde drilling. Therefore, we tried to establish correlations between clinical outcomes and a range of factors such as demographic factors (age, sex, BMI, etc.) or clinical characteristics (lesion size, lesion stability, etc.). Methods A retrospective study was done. The data used for this study came from the medical records of pediatric patients (? 18 years old at time of treatment) who were treated by the principal investigator at the CHU Sainte-Justine. All patients were treated between September 2013 and December 2017. The selected patient files were obtained either through Chartmaxx software or by physically consulting charts at the medical archives of the hospital. The inclusion criteria for patients were: (1) an osteochondritis dissecans of the talus (2) no other lower limb injuries (3) retrograde drilling of the OCD (4) available pre- and post-operative imaging (5) at least one postop follow up visit. The information collected from each patient were the following: date of birth, age at surgery, sex, height, weight, BMI, affected ankle, location of OCD on talar dome, duration of symptoms, dimensions of lesion, history of ankle injuries, stability, status of tibial physis, date of surgery, details of surgery, follow-up duration, number of follow-up appointments, patient status at the last follow-up appointment, post-operative complications, necessity of subsequent surgeries, time interval between additional treatments and retrograde drilling. Clinical outcomes for each patient, determined at the last follow-up, were classified according to the Berndt and Harty treatment result grading. Regarding the secondary objectives, Pearson’s correlations were performed between the different patient variables and the necessity for another surgery and as well between the former and the clinical result Berndt and Harty score measured at the last follow-up appointment. Results Twenty-one patients were initially identified for this study and their medical records were reviewed. Of these original patients, 4 were left out because they had undergone microfracture procedure. In our revised population of 17 patients, there were 16 girls and 1 boy and the average age at the time of the procedure was of 14.8 (?2.12) years old. The mean follow-up period for this group was of 9.82 (?9.84) months. In terms of the osteochondral lesion, 1 patient presented with an OCD on the lateral part of the dome of the talus while 16 patients had theirs medially. Table 1 illustrates more in depth the characteristics of the group. Among the patients studied, 4/17 (24%) required a secondary surgery after retrograde drilling signifying that they had a failure of the initial treatment. Moreover, based on the Berndt and Harty treatment result grading measured at the last follow-up appointment, 8/17 (47%) had good results, 4/17 (24%) had fair results and 5/17 (29%) had poor results. The initial Pearson’s correlations do not indicate any links between the various patient variables and the necessity for a subsequent surgery or between patient variables and the clinical result scores. However, there is a correlation between the clinical results scores and the necessity for another treatment thus illustrating the reliability of the Berndt and Harty treatment result grading. Conclusion Despite being in a pediatric population, it seems that the clinical outcome of retrograde drilling has a limited success rate with only 47% of patients from this study having good results at the last follow-up appointment. Those results emphasize the importance of more studies in order to understand what factors are predictive of a bad and good outcome. [Table: see text]

Establishment of tibial tunnel via a posterior-anterior approach for all-inside posterior cruciate ligament reconstruction: short-term outcomes

Objective To introduce a new posterior-anterior approach used to establish tibial tunnel for all-inside posterior cruciate ligament (PCL) reconstruction and evaluate its short-term therapeutic effects. Methods We retrospectively analysed the 15 patients (15 knees) with PCL injury who had been treated at Department of Orthopaedics, Zhejiang Provincial People's Hospital from January 2017 to January 2018. They were 9 men and 6 women, with a mean age of 46.3 years (from 23 to 60 years). Of them, 8 left and 7 right sides were injured. The intervals from injury to surgery averaged 33.6 days (from 4 to 120 days). Their injury was complicated with medial meniscus tear in 3 cases, lateral meniscus tear in one case, lesion of medial col-lateral ligament in 2 cases and lesion of lateral medial collateral ligament in one case. After preoperative physical examination and MRI confirmed complete PLC tear in all of them, they were treated by arthroscopic all-inside PCL reconstruction in which a new posterior-anterior approach was used to establish the tibial tunnel. Lysholm scoring and International Knee Documentation Committee (IKDC) scoring were used preoperatively and postop-eratively to evaluate the knee functions. Results Their follow-ups averaged 8.3 months (from 6 to 12 months). Operation time averaged 55 minutes (from 45 to 70 minutes). All the patients got rid of the knee instability after surgery. All their posterior drawer tests and sag signs turned to be negative. At the final fol-low-up, their range of motion of the knee ranged from 110° to 130° (average, 118°); their average IKDC score was 88.1±3.3 (from 82 to 93), significantly higher than the preoperative value (52.3±2.1) (P<0.05); their average Lysholm score was 90.6±3.1 (from 84 to 96), significantly higher than the preoperative value (43.1±2.3) (P<0.05). Conclusions This new method can avoid neurovascular damage and overcome the killer turn because it provides adequate exposure of the tibial PCL footprint and accurate placement of the tibial tunnel. It is also very convenient because the new posterior-anterior approach can be used to establish the tibial tunnel in all-inside PCL reconstruction without special tools like tibial PCL guide and retrograde drill. Its short-term clinical results have proved to be satisfactory. Key words: Posterior cruciate ligament; Arthroscopy; Wounds and injuries; Tibial tunnel

Retroarticular Drilling with Supplemental Bone Marrow Aspirate Concentrate for the Treatment of Osteochondritis Dissecans of the Knee

Objectives:Osteochondritis dissecans (OCD) is an idiopathic alteration of the subchondral bone which may lead to early osteoarthritis. This condition is commonly seen in the knee and is more common in young, athletic individuals. Several techniques have been developed to address the variable presentation of OCD in the knee, each with varying results. To our knowledge the use of autogenous bone marrow supplementation to an OCD lesion has not been described. The purpose of this study was to determine the radiographic healing of OCD lesions of the knee in a cohort of young, active patients who underwent retroarticular drilling of an OCD lesion with supplemental back-filling with bone marrow aspirate concentrate as an adjuvant to facilitate healing.Methods:We evaluated adolescent patients who were diagnosed with OCD of the knee who had previously failed non-operative, conservative treatment. All subjects underwent retroarticular drilling of the knee with supplemental back-filling of the lesion with bone marrow aspirate concentrate (BMAC®), harvested from the ilium, by two Orthopaedic Surgeons from a single institution. Based off previously published definitions, lesions were assigned as small if < 320 mm2 or large >320 mm2. All lesions were then followed radiographically for evidence of healing. Healing was graded based off the ROCK (Research in OsteoChondritis of the Knee) group radiographic healing criteria, which has shown excellent reliability. The healing was rated by two independent reviewers and when disagreements were noted a third reviewer was brought in to facilitate group consensus on healing.Results:52 lesions in 49 patients were included in the study. 26 right knees, 26 left knees with 41 lesions located on the medial femoral condyle and 11 lesions located on the lateral femoral condyle. The mean age of the subjects was 12.5 (10 - 17) years old. 30 subjects were male, 19 were female. All lesions were categorized as immobile lesions based off the ROCK Arthroscopy Classification. The average OCD lesion size was 407 mm2 (132 - 899 mm2), respectively. The mean amount of BMAC® used per OCD lesion was 60 mL (45 - 120 mL). 40 lesions (76.9%) were rated as healed at a mean of 10.6 (2 - 32) months. 10 lesions (18.9%) were rated as 25-75% healed and 3.8% were rated at 0 - 25% healed at latest follow-up. 76.5% of large lesions were rated as healed at final follow-up. Whereas 77.8% of small lesions were rated as healed at final follow-up. There were three complications (1 rash from skin glue, 1 suture abscess, and 1 contact dermatitis from surgical cleansing prep) however no complications were noted from the surgical intervention or BMAC®.Conclusion:Overall healing rates with surgical treatment of OCD lesions that have failed non-operative interventions are variable. For immobile lesions, mainstay treatment options include retroarticular and transarticular drilling. Based off previous definitions of lesion size, the mean lesion size in our cohort would be categorized as “large” with 65% of our lesions falling into this category. Previously published series have shown that large lesions are significantly less likely to heal. Despite this we showed a 76.5% healing rate for large lesions. Overall, the adjuvant supplementation of BMAC® as back-fill for retrograde drilling of large OCD lesions of the knee has shown excellent results with no serious complications associated with its use. Future randomized trials are necessary to evaluate the comparative effectiveness of this treatment method.

Inside-out Tibial Tunnel Drilling Technique for All-inside Anterior Cruciate Ligament Reconstruction

All-inside anterior cruciate ligament reconstruction passed through a series of modifications over the past 2 decades, maintaining 2 common factors: half tunnels in both the femur and tibia and introduction of the graft into the knee through an arthroscopic portal. One of the disadvantages noted with this technique is the excessive cost of the instrumentation needed to perform it and its economic impact on the health care system. We describe a modification of the original technique, both maintaining the cortical bone in an intact state and avoiding the retrograde drill aiming device.

Osteochondral autologous transplantation as a treatment of osteochondral defects of the talus

Background For many years, osteochondral defects of the talus has been known as a symptomatic lesion that causes pain, recurrent synovitis, altered joint mechanics, and obstruction from loose bodies. It is a probable precursor of ankle osteoarthritis. Arthroscopic procedures, such as debridement, retrograde drilling, and bone grafting have a great advantage in treating small defects. An open method can be considered for treatment of large osteochondral lesions and unstable osteochondral defect lesions. Objective To present the functional results after autologous osteochondral transplantation in 12 patients using open surgical technique by antromedial approach and antrolateral approach for the ankle according to the site of the lesions, all lesions more than or equal to 1.5 cm the mean age of patients at the time of surgery was 20.5 years (range, 18–23 years), the mean follow up time was 27 months (range, 12–42 months), patient reported outcome measures were taken preoperatively and at final follow up using foot and ankle outcome score. Result The mean foot and ankle outcome score improved from 52.2 points preoperatively to 86.2 points postoperatively (range, 71–100 points). Two patients reported donor site knee pain after surgery, and one patient had delayed healing at medial malleolar osteotomy site.

Ultrasound Arthroscopy of Hip in Treatment of Osteochondritis Dissecans

An ultrasound arthroscopy (UA) technique is a promising tool for the evaluation of the articular cartilage during arthroscopic examination. However, the applicability of UA for the evaluation of the hip joint is unknown. We describe a UA assessment of a patient with osteochondritis dissecans at the femoral head. An ultrasound catheter designed for intravascular imaging was inserted into the hip joint by use of conventional arthroscopic portals, and the cartilage surfaces of the femoral head and acetabulum were investigated with ultrasound. UA provided essential quantitative information on the integrity of the articular cartilage and the condition of the subchondral plate not assessable with conventional arthroscopy. Furthermore, the UA technique provided the possibility to monitor arthroscopy-assisted retrograde drilling and bone transplantation in the hip joint.

Arthroscopic management of small osteochondral lesions of the talus: drilling revisited

Background: The aim of the study was to evaluate the short-term clinical outcomes of arthroscopic drilling in the management of small osteochondral lesions of the talus (OLT). Methods: Thirty-two patients with small OLT (area &lt;150 mm2 and cyst depth &lt;7 mm as measured on CT and MRI) were treated by arthroscopic debridement and drilling. Four patients underwent simultaneous modified Broström procedures. Five patients required retrograde drilling, three because the overlying cartilage was intact and two because the lesion was posterior. Outcomes were measured using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and subjective patient satisfaction. Results: The mean age at surgery was 32±8 yr (range, 18-50 yr). There were 22 men (68.75%) and 10 women (31.25%). Four patients (12.5%) were playing sports regularly, one professionally and three recreationally. After a mean follow-up duration of 26 mo (range 12-48 mo), the mean AOFAS score improved from 71.78±11 (range 51-87) preoperatively to 91±7 (range 80-100). The results were excellent in 15 patients (46.9%), good in 12 (37.5%), fair in five(15.6%). According to the Saxena criteria 16 patients (50%) were very satisfied, nine patients (28.1%) were satisfied, six patients (18.8%) were satisfied with reservations and one patient (3.1%) was unsatisfied. Conclusions: Arthroscopic drilling for small OLT is safe and easy with results comparable to microfracture but with the advantages of deeper penetration and the ability to drill retrograde into posterior lesions or lesions with intact cartilage.

Treatment of Osteochondral Lesions in the Ankle: A Guideline from the Group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU)

Background: Osteochondral lesions (OCL) of the ankle are a common cause of ankle pain. Although the precise pathophysiology has not been fully elucidated, it can be assumed that a variety of factors are responsible, mainly including traumatic events such as ankle sprains. Advances in arthroscopy and imaging techniques, in particular magnetic resonance imaging (MRI), have improved the possibilities for the diagnosis of OCLs of the ankle. Moreover, these technologies aim at developing new classification systems and modern treatment strategies. Material and Methods: This article is a review of the literature. Recommendations of the group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) for the treatment of OCLs of the ankle are presented. The review gives a concise overview on the results of clinical studies and discusses advantages and disadvantages of different treatment strategies. Results: Non-operative treatment shows good results for selected indications in children and adolescents, especially in early stages of osteochondritis dissecans (OCD). However, surgical treatment is usually indicated in OCLs in adolescents and adults, depending on the size and location of the lesion. Various arthroscopic and open procedures are frequently employed, including reattachment of the fragment, local debridement of the lesion with fragment removal and curettage of the lesion, bone marrow-stimulation by microfracture or microdrilling (antegrade or retrograde), and autologous matrix-induced chondrogenesis (AMIC®) - with or without reconstruction of a subchondral bone defect or cyst by autologous cancellous bone grafting. Isolated subchondral cysts with an intact cartilage surface can be treated by retrograde drilling and possibly additional retrograde bone grafting. For larger defects or as salvage procedure, osteochondral cylinder transplantation (OATS® or Mosaicplasty®) or matrix-induced autologous chondrocyte transplantation (MACT) are recommended. Transplantation of so-called (osteochondral) mega grafts, such as autologous bone grafts or allografts, are used for very large osteochondral defects that cannot be reconstructed otherwise. Implantation of the so-called "small metal implants" - such as HemiCAP Talus® - is reserved for selected cases after failed primary reconstruction. Corrective osteotomies are indicated in accompanying axial malalignments. Conclusions: There are several different treatment strategies for OCLs, but clinical studies are rare and evidence is limited. Therefore, interventional studies, e.g. randomised controlled trials (RCTs), but also observational studies, e.g. based on data of the Cartilage Registry of the German Society of Orthopaedics and Traumatology (www.knorpelregister-dgou.de), are needed and are recommended by the authors.

Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction

BackgroundThis paper reports the outcomes of patients undergoing ACL reconstruction using a TransLateral single bundle, all-inside hamstring technique at a minimum of two year follow-up. MethodsThe semitendinosus alone is harvested, quadrupled and attached in series to two adjustable suspensory fixation devices. Femoral and tibial sockets are produced using a retrograde drill. The graft is deployed, fixed and tensioned on both tibia and femur. Patients were evaluated preoperatively using the KOOS, Lysholm and Tegner scores and at six, 12 and 24months postoperatively. Objective assessment of knee laxity was performed using the KT-1000 along with goniometric measurement of range or motion. ResultsOne hundred and eight patients, mean age 30.9years (range 15 to 61) were included. Mean follow-up 49.8months (range 30–66). The mean increase in KOOS at two years was 30.3 points; Lysholm, 33.1 points; Tegner Activity scale, 2.0 levels. These were all statistically significant (p<0.001). Range of motion in the reconstructed knee approximated the uninjured knee by 12months and was restored by two years. KT-1000 showed significant reduction in side-side difference to no more than 2.4mm at all postoperative time points (p<0.001). Re-rupture rate in this series was 6.5%, all following episodes of significant additional postoperative trauma to the knee. ConclusionsTransLateral all-inside ACL reconstruction demonstrates good medium term subjective and objective outcomes with a low complication and failure rate.

Double-Bundle, All-Inside Posterior Cruciate Ligament Reconstruction: A Technique Using 2 Separate Autologous Grafts

In a double-bundle posterior cruciate ligament reconstruction, several surgical techniques are available. Compared with other techniques, the advantages of the all-inside technique and cortical suspension devices with variable loop length are that shorter grafts can be used, tendons can be quadrupled, and a double-bundle posterior cruciate ligament reconstruction can be performed with autologous grafts. Furthermore, the all-inside technique provides independent outside-in socket reaming and is soft tissue, cortex, and bone sparing because no full diameter tunnels but sockets are created with a small diameter guide pin, which can transform into a retrograde drill. Sockets could however lead to bottoming out of the grafts at the femoral side and subsequent residual laxity. This can be avoided by using 2 separate grafts that are fixed in 2 femoral sockets before they are independently fixed and tensioned in 1 tibial socket in their corresponding flexion angle. In this technical note, we present a double-bundle, all-inside posterior cruciate ligament reconstruction using 2 separate autologous grafts.

Femoral Screw Divergence via the Anteromedial Portal Using an Outside-In Retrograde Drill in Bone–Patella Tendon–Bone Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

To assess screw divergence when inserting an interference screw for a bone-patellar tendon-bone graft using an outside-in technique with a retrograde drill to create the femoral tunnel. Ten cadaver specimens underwent anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft, with 23-mm-deep tunnels created by a retrograde drill outside-in technique. Drilling angles were based on a previous study that established the optimal angles to recreate the anterior cruciate ligament footprint. To ensure that screw insertion angles matched the angle of socket drilling, a marking pen was used to transpose 2 lines on the skin of the anterior knee corresponding to the drill inboth the coronal and axial planes with the knee held at 90° of flexion. The femoral-sided bone plug was affixed with a 7× 23mm interference screw through an anteromedial portal. Computed tomography scans were used to calculate coronal and sagittal screw-tunnel divergence. The median screw divergence in the coronal plane was 2.79°, with a range of 1.1° to 17.2°. Of 10 specimens, 8 had no divergence (0° to 5°), 0 screws were between 5° and 10°, 1 screw was between 10° and 15°, and 1 screw was between 15° and 20°. The 95% confidence interval was 3.73° to 11.69°. No screws had ≥20° of divergence. In the sagittal plane, the median screw divergence was 5.68°, with a range of 1.2° to 18.7°. Five specimens had no divergence (0° to 5°), 3 screws were between 5° and 10°, 0 screws were between 10° and 15°, and 2 screws were between 15° and 20° of divergence. The 95% confidence interval was 3.73° to 11.69°. No screws had ≥20° of divergence. The results of this study showed that 80% of screws diverted less than 5° in the coronal plane. In the sagittal plane, only 50% of screws were found to have divergence of 5° or less. No screw in either plane had divergence of greater than or equal to 20°. When using a retrograde drill, a skin marking technique is a useful aid in placing interference screws with acceptable angles of divergence when using an inside-out technique.

Arthroscopic Retrograde Drilling in Juvenile Osteochondritis Dissecans of the Talus.

Juvenile osteochondritis dissecans of the talus is rare, and the literature provides little data to guide treatment. The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in patients who were refractory to conservative care. We retrospectively evaluated all patients with juvenile osteochondritis dissecans of the talus who underwent surgery for the treatment of stable lesions that failed conservative treatment. Medical records were reviewed for symptoms and demographic information. Preoperative and latest postoperative radiographs were used to determine degree of healing. AOFAS Ankle/Hindfoot scale and visual analog scale for pain were used to evaluate clinical outcomes. We identified 6 patients (6 ankles). The mean age was 13 years, and the mean duration of follow-up was 37 months (range, 16 to 69 mo). All of them had progressed toward healing and were asymptomatic, but only 3 out of 6 had a complete radiographic healing at last follow-up. The average AOFAS Ankle/Hindfoot score improved from 69 points (55 to 75, IQR=10) preoperatively to 98 points (90 to 100, IQR=7) (P<0.0027). Visual analog scale improved from 6.2 (4 to 8, IQR=3) to 0.3 (0 to 2, IQR=1) (P<0.002). All patients expressed satisfaction with operative results. Arthroscopic retrograde drilling seems to be effective for symptoms relief, although 50% of the cases have had persistent lesions on radiographs. A longer follow-up is necessary to assess joint function in those cases with partial radiographic healing. Level IV-therapeutic.

Overestimation of femoral tunnel length during anterior cruciate ligament reconstruction using the retrograde outside-in drilling technique.

When the femoral tunnel socket is reamed in an oblique direction from the wall of inter-condylar notch in anterior cruciate ligament (ACL) reconstruction, the tunnel length can be shorter at the periphery than at the centre. Because surgeons can manipulate the direction of tunnel in the outside-in femoral tunnel drilling technique, this length mismatch would vary depending on the direction of the tunnel. The purpose of this study was to investigate this length mismatch when reamed in various directions. In total of thirteen points were defined as femoral drilling entry points on concentric lines with 0, 1, 2, and 3cm radius from the lateral epicondyle of a three-dimensional bone model from 40 subjects. Femoral tunnel drilling was simulated on the models by connecting the centre of the ACL footprint with each defined point on the lateral femoral surface. The mismatch length was measured between the centre and the shortest peripheral side of the tunnel socket. When the distance between the drilling entry point on the lateral femoral surface and the lateral epicondyle was increased to anterior proximal direction, there was a significant increase in the mismatch length. The mismatch length became more than 2mm when the entry point was located more than 2cm away from the lateral epicondyle. When the drilling entry point is set far away from the lateral epicondyle, a significant increase was observed in tunnel length mismatch between the centre of the tunnel and its shortest peripheral side. Because the tunnel length is measured with a guide pin introduced at the centre of the tunnel before reaming in retrograde outside-in technique, this length mismatch could cause an overestimation of the tunnel length. Surgeons should recognise this mismatch when preparing the length of graft and socket to optimise the graft insertion length into the socket.

Operative Technique and Clinical Outcome in Endoscopic Core Decompression of Osteochondral Lesions of the Talus: A Pilot Study.

BackgroundRevitalizing the necrotic subchondral bone and preserving the intact cartilage layer by retrograde drilling is the preferred option for treatment of undetached osteochondral lesions of the talus (OLT). We assessed the effectiveness of Endoscopic Core Decompression (ECD) in treatment of OLT.Material/MethodsSeven patients with an undetached OLT of the medial talar dome underwent surgical treatment using an arthroscopically-guided transtalar drill meatus for core decompression of the lesion. Under endoscopic visualization the OLT was completely debrided while preserving the cartilage layer covering the defect. The drill tunnel and debrided OLT were filled using an injectable bone graft substitute. Various clinical scores, radiographic imaging, and MRI were evaluated after a mean follow-up of 24.1 months.ResultsThe American Orthopedic Foot and Ankle Society Score significantly improved from 71.0±2.4 to 90.3±5.9, and the Foot and Ankle Disability Index improved from 71.8±11.1 to 91.7±4.8. Radiographically, we observed good bone remodelling of the medial talar dome contour within 3 months. In MRI, an alteration of the bony signal of the drill tunnel and the excised OLT remained for more than 12 months.ConclusionsFirst follow-up results for the surgical technique described in this study are highly promising for treatment of undetached stable OLT grade II or transitional stage II–III according to the Pritsch classification. Even lesions larger than 150 mm2 showed good clinical scores, with full restoration of the medial talar dome contour in radiographic imaging.