Tibial Tunnel Research Articles

Less Subsequent Revision Anterior Cruciate Ligament Reconstruction Following Primary Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation—A Retrospective Comparative Therapeutic Trial With 5-Year Follow-Up

To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort. All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient. One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P= .036). All PROMs and KT-1000 measurements improved at final follow-up (P<.001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups. Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population. Level III, retrospective cohort study.

Application of multiplanar reconstruction and 3D printing in anterior cruciate ligament revision.

Anterior cruciate ligament injury is the most common type of knee joint ligament injury. Anterior cruciate ligament reconstruction has a high failure rate, with bone tunnel abnormalities as the most significant factor in these failures. Digital orthopedic technology can effectively develop implementation plans for the revision, thus increasing the success rate. This study aims to develop a surgical plan for anterior cruciate ligament revision by employing multiplanar reconstruction (MPR) for measuring bone tunnel position and diameter, and simulating bone tunnel creation via 3D printing preoperatively. A total of 12 patients who underwent anterior cruciate ligament revision at the Third Xiangya Hospital of Central South University between 2014 and 2021 were retrospectively studied. The data included patient demographics, preoperative formulated knee joint 3D printing models, and preoperative knee CT scans. The study measured the bone tunnel's diameter and position to guide the establishment of revision bone tunnels during surgery, reassessed the postoperative bone tunnels, and evaluated knee joint functional scores [including International Knee Documentation Committee Knee Evaluation Form (IKDC) score, Lysholm score, and Tegner exercise level score]. Preoperative measurements revealed suboptimal femoral tunnels positions in 4 patients and tibial tunnels positions in 2 patients. MPR and 3D printing technology were used to guide the establishment of a new bone canal during surgery, and postoperative measurements were satisfactory for all patients. Preoperative measurements demonstrated the interclass correlation coefficient for femoral tunnels and tibial tunnels diameters were 0.843 (P<0.05) and 0.889 (P<0.001), respectively. Meanwhile, the intraclass correlation coefficient were 0.811 (P<0.05) and 0.784 (P<0.05), respectively. The intraoperative diameter of femoral and tibial tunnels showed excellent correlation with postoperative CT measurements, with intraclass correlation coefficient values of 0.995 (P<0.001) and 0.987 (P<0.001), respectively. All bone tunnel positions were within the normal range. At the final follow-up, knee joint function scores in all 12 patients improved significantly compared to pre-surgery (P<0.001), and the reoperation rate was zero. MPR and 3D printing technology can accurately measure the parameters of reconstructed anterior cruciate ligament bone tunnels. Personalized revision plans for patients with reconstruction failure enhances the success rate of revision surgery and improves patient prognosis.

Retrospective analysis and comparison of total internal disability preservation technique and standardized reconstruction technique

To investigate the efficacy and clinical results of total internal protection technique in anterior cruciate ligament reconstruction. A total of 56 patients undergoing anterior cruciate ligament reconstruction treated from January 2018 to December 2019 were selected. According to the different surgical methods, they were divided into total internal reconstruction group and standard bone tunnel group. There were 21 patients in the total internal reconstruction group, including 15 males and 6 females, aged from 20 to 48 with an average of (35.6±6.7) years old, and 35 patients in the standard tibial tunnel group, including 26 males and 9 females, aged 22 to 51 years old with an average of (33.7±9.6) years old. Preoperative examination of Lachman test was positive, magnetic resonance indicated anterior cruciate ligament rupture. There were no significant differences between the two groups in age, sex, body mass index, time from injury to ACL reconstruction, combined meniscus injury and operation method, operation time, ligament diameter, ligament length and other general information. Postoperative evaluation included operation duration, length and diameter of transplanted tendon after braid. International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner score and perioperative complications 2 years after surgery. Both groups were followed up, ranging from 24 to 30 months with an average of (26.9±3.4) months. Postoperative incision healing was good, and no failure or joint infection occurred at the last follow-up. There was no statistically significant difference between the two groups in IKDC score, Lysholm score and Tegner score before, 1 year and 2 years after surgery. However, IKDC score, Lysholm score and Tegner score at 1 year and 2 years after surgery. The same postoperative function and stability of knee joint can be obtained by both the residual whole technique and the standardized reconstruction technique. In the residual whole group, only the semitendinosus muscle is taken, and the femoral thin muscle is retained, with greater tibial bone mass preserved, which is safe and effective in clinical practice.

Modified Mason-Allen vs Two Simple Stitch Fixation for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis

Background: Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a refixation technique for MMPRT instead of the conventional 2 simple stitches (TSS). This is in view of its superior biomechanical characteristics. Purpose: To perform a systematic review and meta-analysis to compare MMA and TSS configuration techniques for MMPRT repair and identify any differences between the 2 techniques in terms of clinical outcomes, medial meniscal extrusion (MME), and postoperative healing. Study Design: Meta-analysis; Level of evidence, 4. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase databases were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (“meniscus” OR “meniscal injuries”) AND (“Mason-Allen” OR “simple stitch” OR “suture techniques”). Data pertaining to all patient-reported outcome measures, postoperative complications, MME, postoperative healing, cartilage degeneration, and progression of knee osteoarthritis were extracted from each study. The pooled outcome data were analyzed using random- and fixed-effects models. Results: After abstract and full-text screening, 6 clinical studies were included. In total, there were 291 patients; 160 underwent MMA fixation, and 131 underwent the TSS technique. The majority of studies had similar surgical techniques regarding repair technique, suture material, tibial fixation, and number and position of tibial tunnels. There were no differences between the groups in terms of patient-reported outcome measures at 14.2 months. Both techniques were also similar in the degree of postoperative MME and meniscal healing. Conclusion: Both suture configurations were equivalent in terms of clinical outcomes, the extent of meniscal extrusion, and postoperative healing. The TSS technique may offer advantages in terms of faster learning curve and shorter operative time. However, randomized controlled trials with large sample sizes, longer follow-up and assessment of chondral degeneration, and presence of knee osteoarthritis are required to assess whether a true difference exists, as the majority of included studies were limited by their retrospective design.

A modified anatomical posterior cruciate ligament reconstruction technique using the posterior septum and posterior capsule as landmarks to position the low tibial tunnel

BackgroundLowering the exit position of the tibial tunnel can improve the clinical efficacy of posterior cruciate ligament (PCL) reconstruction, however, there is no unified positioning standard. This study aimed to use novel soft tissue landmarks to create a low tunnel.MethodsA total of 14 human cadaveric knees and 12 patients with PCL injury were included in this study. Firstly, we observed the anatomical position between the PCL, posterior septum, and other tissue, and evaluated the relationship between the center of the low tibial tunnel (SP tunnel) and posterior septum and distal reflection of posterior capsule, and using computed tomography (CT) to evaluate distance between the center of the SP tunnel with bony landmarks. Then, evaluated the blood vessels content in the posterior septum with HE staining. Finally, observed the posterior septum and distal reflection of the posterior capsule under arthroscopy to explore the clinical feasibility of creating a low tibial tunnel, and assessed the risk of surgery by using ultrasound to detect the distance between the popliteal artery and the posterior edge of tibial plateau bone cortex.ResultsIn all 14 cadaveric specimens, the PCL tibial insertions were located completely within the posterior medial compartment of the knee. The distance between the center of the SP tunnel and the the articular surface of tibial plateau was 9.4 ± 0.4 mm. All SP tunnels retained an intact posterior wall, which was 1.6 ± 0.3 mm from the distal reflection of the posterior capsule. The distances between the center of the SP tunnel and the the articular surface of tibial plateau, the champagne glass drop-off were 9.2 ± 0.4 mm (ICC: 0.932, 95%CI 0.806–0.978) and 1.5 ± 0.2 mm (ICC:0.925, 95%CI 0.788–0.975) in CT image. Compared with the posterior capsule, the posterior septum contained more vascular structures. Last, all 12 patients successfully established low tibial tunnels under arthroscopy, and the distance between the posterior edge of tibial plateau bone cortex and the popliteal artery was 7.8 ± 0.3, 9.4 ± 0.4 and 7.4 ± 0.3 mm at 30°, 60° and 90° flexion angels after filling with water and supporting with shaver in posterior-medial compartment of knee joint.ConclusionsA modified low tibial tunnel could be established in the PCL anatomical footprint by using the posterior septum and posterior capsule as landmarks.

Is fixation with a U-shaped staple necessary in anterior cruciate ligament reconstruction?

Aims: This study aimed to compare the clinical and functional outcomes of patients who underwent anterior cruciate ligament reconstruction using a quadruple hamstring autograft with and without U-shaped staple fixation and tibial tunnel BioScrew fixation. Methods: Patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction by a single surgeon between August 2020 and June 2022 were retrospectively analyzed. The time to return to sports after surgery and the evaluation of preoperative and postoperative Lysholm Knee scores, International Knee Documentation Committee (IKDC) scores, VAS scores, and thigh diameters, were conducted. Statistical analysis of the study data was performed using SPSS 29.0 (IBM InCorp, USA). Results: A total of 100 patients (77% male) who underwent arthroscopic ACL reconstruction were included in the analysis. There was no significant difference in Lysholm knee scores and IKDC scores between patients undergoing fixation with or without staples. However, VAS scores were significantly lower in the non staple group. Conclusion: The present study found that fixation with a staple in addition to tibial BioScrew fixation of the autograft in the tibial tunnel resulted in more pain in the patients, and there was no significant difference in clinical and functional outcomes between the staple and non staple groups.

Hyperbaric oxygen therapy enhances graft healing and mechanical properties after anterior cruciate ligament reconstruction: An experimental study in rabbits.

Hyperbaric oxygen therapy (HBOT) has proven successful in wound healing. However, its potential effects on anterior cruciate ligament (ACL) injuries remain uncertain. This study aimed to investigate the impact of HBOT on graft healing following ACL reconstruction in rabbits. Male New Zealand rabbits underwent ACL reconstruction and were randomly divided into two groups: the HBOT group and the ambient air group. The HBOT group received 100% oxygen at 2.5 atmospheres absolute for 2 h daily for 5 consecutive days, starting from the first day after surgery. The ambient air group was maintained in normal room air throughout the entire period. After 12 weeks following the surgery, animals were euthanized, and their knees were harvested for analysis. The HBOT group demonstrated superior graft maturation and integration in comparison to the ambient air group, as evidenced by lower graft signal intensity on magnetic resonance imaging, decreased femoral and tibial tunnel size, and higher bone mineral density values on high-resolution peripheral quantitative computed tomography scans. Additionally, biomechanical testing indicated that the HBOT group had greater load to failure and stiffness values than the ambient air group. In conclusion, the adjuvant use of HBOT improved ACL graft maturation and integration, reduced tunnel widening, and enhanced the biomechanical properties of the graft. These results may provide important insights into the potential clinical application of HBOT as a therapeutic intervention to enhance graft healing after ACL reconstruction, paving the way for further research in this area.

Selection of Interferential Screw for Fixation of Graft in Tibial Tunnel during Anterior Cruciate Ligament Reconstruction by Novel Probe Test.

Anterior cruciate ligament (ACL) reconstruction is a common orthopedic procedure, employing various grafts such as the hamstring tendon, bone-patellar bone, and quadriceps tendon. Fixation methods include suspensory loop with button, interferential screw, and cortical fixation. The optimal screw diameter for tibial tunnel fixation remains undefined, with choices ranging from 1mm smaller to 1-2 mm larger than the tunnel diameter. Screw-related complications such as breakage and thread flattening are concerns. This study was to determine the ideal screw diameter for secure graft fixation in the tibial tunnel during ACL reconstruction. A novel arthroscopic probe technique was utilized to assess tibial tunnel bone integrity. Bone quality was categorized into weak, strong, and very strong. Screw size selection, either equal to or 1-2 mm larger than the tunnel diameter, was based on bone quality. Screw lengths varied from 25 mm to 35 mm. The novel technique significantly reduced screw-related complications, from 9.6% (24 out of 248 patients) to 0.5% (l out of 187 patients). The need for additional cortical stabilization decreased from 14.5% (36 out of248 patients) to 1.6% (3 out of 187 patients). The low-cost, efficient 2-min probe test is a secure and effective method for selecting interferential screws in ACL reconstruction, minimizing complications, and additional stabilization needs.

An Isolated Midsubstance ACL Tear Repaired With the BEAR System

Background: Anterior cruciate ligament (ACL) repairs, once widely abandoned due to historically high failure rates, have recently regained interest with the development of the bridge-enhanced ACL repair (BEAR) implant, a novel arthroscopic technique that uses a resorbable protein-based implant combined with autologous blood to primarily repair a midsubstance ACL tear. This technical note presents a step-by-step surgical method for performing an isolated midsubstance ACL repair using the BEAR implant. Indications: The BEAR implant is indicated for skeletally mature patients at least 14 years of age with a complete rupture of the ACL, confirmed by magnetic resonance imaging. The complete ACL tear must have an attached stump to the tibia. Technique Description: A diagnostic arthroscopy is used to confirm complete rupture of the ACL and presence of residual tibial stump. A self-retrieving suture passage device is used to whipstitch a total of 6 passes with #2 Vicryl suture from distal to proximal through the residual stump. A notchplasty followed by femoral and tibial tunnels is created in a standard fashion. An Endobutton, soaked in a bacitracin solution, is then loaded with the sutures that were previously passed through the residual ACL stump and then through the femoral tunnel and cinched down to bone. The 4 suture ends that are coming from the Endobutton are then passed through the BEAR implant with the use of a Keith needle and shuttled through the tibial tunnel. The BEAR implant is hydrated with 15 cc of the patient's blood and is shuttled through the anteromedial portal with the knee in full extension. The 4 tibial sutures passed through the graft and tibial tunnel are passed, and tensioned to the proximal tibial with a second Endobutton. Standard closure and dressings are applied. Results: This new surgical implant and technique have shown noninferiority to ACL autograft reconstruction with respect to the International Knee Documentation Committee and anteroposterior laxity, with improved hamstring strength and decreased incidence of contralateral ACL tears at 2 years postoperative. Discussion/Conclusion: While initial data remain promising, future long-term designed studies are needed to determine the clinical efficacy of the BEAR technique, particularly comparing itself with bone-patellar tendon-bone autograft ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Is Anterior Cruciate Ligament Reconstruction “Silva Technique” Equal to All‐Inside Techniques? A Prospective Single‐Center Study

Background: The development of less invasive all‐inside techniques regarding anterior cruciate ligament (ACL) reconstruction surgery has been associated with various advantages, including fewer complications and reduced postoperative pain. Silva et al. described a quadruple semitendinosus graft construct and suspensory button fixation for ACL reconstruction as an alternative technique. At the end of this technique, the tibial tunnel is filled with a bone autograft plug. This paper aims to examine the incorporation of the autograft and thus evaluate whether the “Silva technique” provides the same benefits as all‐inside techniques.Methods: A prospective study assessed 31 patients undergoing ACL reconstruction surgery using the “Silva technique.” The cases involved in the study were skeletally mature patients with no previous history of ACL surgery or multiligamentous instability. All patients followed the same rehabilitation program and were examined at three standardized follow‐up visits: 4 months, 8 months, and 1 year postoperatively. Tegner–Lysholm knee score (TLKS), visual analog score (VAS) for pain, and the IKDC subjective knee score were completed at every visit. A knee MRI scan was performed at every scheduled visit to assess bone graft incorporation and remodeling.Results: TLKS scores revealed a considerable improvement compared to preoperative figures, from 57.2 points preoperatively to an average of 99.4 at the 12‐month follow‐up (p &lt; 0.0001). VAS scores were substantially ameliorated after the operation and until the second follow‐up visit, from 5 before surgery to zero 8 months after the operation, with no noteworthy alterations afterward (p &lt; 0.0001). IKDC subjective knee score outcomes were found to have increased at the last follow‐up, from 59.3 prior to surgery to 99.8 12 months postoperatively (p &lt; 0.0001). Regarding the MRI features of the bone autograft, the tibial tunnel was entirely filled by bone formation at the last MRI scan, suggesting complete integration of the autograft in all patients.Conclusions: Bone autograft employed to seal the tibial tunnel was completely incorporated in all cases 1 year postoperatively. The “Silva technique” appears to feature all the avails of all‐inside techniques, whilst it seems to be simpler and easier than them after the surgeon is familiarized with its particular aspects. It is a robust option in orthopedic surgeons’ arsenal. However, further large‐scale pertinent research is requisite to confirm the findings of this study.

Press-Fit-Hybrid Technique for Anterior Cruciate Ligament Reconstruction With Autologous Hamstring Tendons

Arthroscopic-assisted anterior cruciate ligament reconstruction follows standardized protocols. Multiple fixation techniques are known. Discussion has been raised about osseus fixation and integration. To improve a biological osseous fixation of the anterior cruciate ligament transplant, a Press-Fit-Hybrid technique has been developed. The basic principle is to recycle bony cylinders obtained from the femoral and tibial tunnel to fix the transplant in the femoral and tibial tunnel. In addition to the biological advantage, there are additional economic benefits, such as no extra fixation material is necessary compared with common fixation techniques, and the overall surgical procedure requires minimal effort.

Revision Patellar Tendon Reconstruction Using Hamstring Tendon Autograft

Background: Patellar tendon ruptures presenting in a chronic setting are rare events that impose technical surgical challenges due to proximal retraction of the patella, quadriceps muscle atrophy and contracture, and peripatellar adhesions. Various reconstruction techniques have been described using different grafts and fixation methods; however, there is a paucity of reported outcomes and there is no consensus on standard of care. Indications: The patient is a 36-year-old man who presented with a failed patellar tendon reconstruction 14 months after his initial surgery (performed 1 year after the initial injury) with functional weakness and loss of extension. The patient was indicated for a revision patellar tendon reconstruction due to persistent functional limitations. Technique Description: The revision patellar tendon reconstruction was performed with gracilis and semitendinosus tendon autografts harvested from the ipsilateral limb. Hardware was removed from the initial graft tunnels in the tibial tubercle and patella. Patellar height was estimated using fluoroscopic measurement of the contralateral patellar tendon length. The graft is first passed through the patellar tunnel, and the individual limbs of the graft are then both placed through the tibial tubercle tunnel. A sternal wire in a figure-of-eight configuration was used to progressively distalize the patella to match the native patellar height, and the graft was then tensioned and secured together. Results: The patient regained full range of motion at 2-year follow-up and was able to return to work and activities without functional limitations. Recent case series also using ipsilateral hamstring tendon autograft for chronic patellar tendon reconstruction report improved patient outcome scores, normal Insall-Salvati index, improved quadriceps strength, and high levels of patient satisfaction. Discussion/Conclusion: Chronic patellar tendon ruptures are technically challenging to treat, especially in the context of revision of a failed reconstruction. The technique presented in this video may aid orthopaedic surgeons in treating this rare but debilitating injury. Given the lack of high-quality evidence, future studies are needed to explore graft choices, graft fixation techniques, and postoperative protocols. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

How To Avoid Suture Damage in Simultaneous Anterior Cruciate Ligament Reconstruction and Lateral Meniscal Posterior Root Reinsertion With the Transtibial Pullout Technique: A Technical Note

Lateral meniscus posterior root tears (LMPRTs) are estimated to occur in 7% to 12% of anterior cruciate ligament (ACL)-injured knees. This topic is of great interest because of their biomechanical consequences in terms of interruption of hoop stress distribution. If left unrepaired, the corresponding compartment is exposed to unfavorable contact dynamics, similar to those resulting from a total meniscectomy. This Technical Note describes a transtibial LMPRT repair using a Knee Scorpion and an 18-gauge spinal needle. It is a reproducible arthroscopic LMPR reinsertion technique combined with concomitant standard ACL + anterolateral ligament reconstruction with hamstring tendons and it describes how to safely avoid damage to root traction sutures during the ACL independent tibial tunnel drilling.

The Triple Varus Knee: A Case Presentation

Background: Knee instability due to posterior cruciate ligament (PCL) and posterolateral corner (PLC) deficiency is a devastating condition that negatively affects patient quality of life. This video presents the surgical management of a triple varus knee, including combined high tibial osteotomy (HTO), revision PCL and PLC reconstruction, and meniscus root repair. Indications: Combined HTO and revision PCL and PLC reconstruction is indicated for patients with previously failed PCL and PLC reconstruction in the setting of varus malalignment. Technique Description: The procedure begins with a medial opening-wedge biplanar HTO, which is fixed with a patient-specific locking plate. The PCL femoral tunnel is drilled via a low anterolateral portal, and the tibial insertion is debrided via a posteromedial portal. The medial meniscus is carefully freed from the posterior capsule, and 2 luggage tag sutures are placed through the posterior root. The PCL tibial tunnel and meniscus root tunnels are drilled via their respective guides. The meniscal sutures are passed through the tunnel but not fixed. An Achilles bone-block allograft is passed through the PCL tibial tunnel and fixed with suspensory fixation and an interference screw on the femoral side, while the tibial side is left free. A peroneal nerve neurolysis is performed. A fibular tunnel is drilled, and a semitendinosus allograft is whip-stitched on both sides and passed through the tunnel. A Beath pin is inserted into the femur, and the tunnel is over drilled. Both limbs of the graft are passed deep to the iliotibial band and into the tunnel. The tibial side of the PCL is fixed with an interference screw at 90° of knee flexion. The PLC grafts are fixed with an interference screw at 30° of knee flexion with slight valgus. The medial meniscus root sutures are tied over a button, with 60° of knee flexion. Screws from osteotomy fixation are replaced as needed. Results: Although outcomes following the combined procedure are lacking, good to excellent clinical outcomes have been reported in isolation following each procedure. Conclusion: A combination of HTO and revision PCL and PLC reconstruction should be considered for patients with persistent instability and/or pain in the setting of triple varus knee. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Treatment of Synovial Cysts in Relation to the Tibial Tunnel of Anterior Cruciate Ligament Grafts by Filling the Tunnel with Acrylic Cement

Treatment of Synovial Cysts in Relation to the Tibial Tunnel of Anterior Cruciate Ligament Grafts by Filling the Tunnel with Acrylic Cement

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.

"Coronal Split/Overlap Repair" Patellar Tendon Shortening in Skeletally Immature Patients.

"Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy. The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks. Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap1-3. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication4, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened2,5-7, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened8,9. The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises. Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase1,3,8. Reported complications with this technique were mainly superficial infection. Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field. 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery.

Outcome Analysis of Arthroscopic Fixation of Posterior Cruciate Ligament Avulsion Fracture Using a Single Tibial Tunnel and Suture Loop with Button Configuration - A Case Series Study.

A prospective case series study to analyze the outcome of arthroscopic fixation of posterior cruciate ligament (PCL) avulsion fracture using a single tibial tunnel and suture loop with button configuration technique. PCL avulsion fracture injury requires surgical treatment to restore PCL function and stability of the knee joint. Several open and arthroscopic procedures require a steep learning curve are followed to treat these injuries; yet, our technique is a simpler technique with desirable outcomes and does not require a long learning curve. Hence, it is reported. Ten patients with the same ethnic background having avulsed PCL injury since 2015 underwent arthroscopic fixation of avulsed PCL with single tibial tunnel and suture loop with button configuration within 3 months of injury are studied prospectively till date. All patients are clinically and radiologically evaluated with varied parameters. Postoperatively structured rehabilitation protocol is followed for all the patients. Post-operative clinical and radiological assessments are done and analyzed in 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years. Ten patients were available for follow-up for a period of 6 months-3 years. Outcome analysis at the end of 3 years for all patients showed definitive improvement in the function of the knee statistically and functionally. For patients with PCL avulsion fracture, arthroscopic fixation of PCL with a single tibial tunnel and suture loop with Endobutton configuration gives definitive results. Medium-term follow-up analysis shows no failure in the outcome.

Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft and Concomitant Meniscal Ramp Repair

Background: Quadriceps autograft, though well established for anterior cruciate ligament reconstruction, is underutilized in posterior cruciate ligament (PCL) reconstruction largely due to slow adoption. All-inside meniscal ramp repair and quadriceps tendon autograft PCL reconstruction have been described in isolation, but not concomitantly in a video journal. Indications: PCL reconstruction is indicated in grade 3 isolated tears with instability that have not improved with nonoperative management and in instances with associated injuries such as meniscal ramp tears, as observed in this 18-year-old division I football player. Graft selection is dependent upon surgeon and patient preference, with quadriceps autograft delivering a viable option with desirable long-term outcomes. Technique Description: A partial-thickness quadriceps tendon autograft was harvested, the remnant PCL stump was debrided, and a reamer was used to drill the all-inside tibial tunnel for traction suture passage. An accessory low anterolateral portal was utilized to drill the femoral tunnel for passage of the femoral traction stitch. Traction sutures were withdrawn, and the graft was passed into the tibia, docked into the femur, fixated with an interference screw, and tensioned over the tibial button. A medial meniscal ramp tear was also identified and repaired in all-inside fashion with a 90° SutureLasso, polydioxanone suture (PDS), and suturetape via standard arthroscopic knot tying. Following the procedure, the patient began a PCL reconstruction rehabilitation protocol with a PCL rebound brace. Due to the meniscal ramp repair, toe touch weightbearing with the knee in extension during ambulation was completed for 6 weeks. Physical therapy (PT) focused on early quadriceps and patellar mobilization as well as active-assisted range of motion exercises. Results: At 6 months postoperation, the patient continued to progress in PT without major concerns. A full recovery and return to sport are expected approximately 9 to 12 months after surgery, as is consistent with the standard protocol. Discussion/Conclusion: This study describes the treatment of chronic PCL with concomitant meniscal ramp tear in a division I athlete. Further adoption of PCL reconstruction utilizing quadriceps autograft, even in the context of concomitant ligamentous or meniscal reconstruction, such as medial meniscal ramp repair, will aid in the widespread treatment of PCL injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Functional Outcome of Unilateral Peroneus Longus Autograft in Arthroscopic Anterior Cruciate Ligament Reconstruction

Objective: To evaluate the functional outcome of unilateral peroneus longus autograft in arthroscopic anterior cruciate ligament reconstruction Study Design: Cross-sectional study. Place and Duration of Study: Orthopedic Department, Combined Military Hospital, Lahore Pakistan, from Jul 2020 to Jun2021. Methodology: We included all the patients who underwent ipsilateral peroneus longus autograft for anterior cruciate ligament reconstruction. Fixation was achieved with a bio-absorbable screw on the tibial side and an endobutton on the femoral side. Lateral or medial menisectomy was performed according to the requirement. Post-op X-rays were done to assess the position of the endobutton and tibial tunnel. Eight millimetres tunnels were drilled, and the tendon was tailored accordingly. Results were assessed for pain, infection, range of motion and instability after three months of surgical procedure. Results: A total of 52 patients were included in the final analysis. The mean age of the study participants was 33.36±6.353 years. At the end of three months, pain 6(11.5%) and restricted range of motion 6(11.5%) were the common untoward outcomes reported by the patients. High body mass index and lack of engagement in physiotherapy had a statistically significant relationship with the presence of untoward outcomes in our study (p-value&lt;0.05). Conclusion: Peroneus longus is a strong, robust autograft for anterior cruciate ligament reconstruction with excellent functional results. Very few patients had untoward effects, and those, too, were of mild intensity. Patients with high body mass index and those not engaging in physiotherapy emerged as high-risk patients for having untoward effects after the surgery.