Technique of anatomical footprint reconstruction of the ACL with oval tunnels and medial portal aimers

Purpose

The purpose of this article was to demonstrate an anterior cruciate ligament (ACL) reconstruction technique using oval tunnels. Aim of this single bundle technique is to fit the footprint anatomy of the ACL as closely as possible.

Technique and patients

The presented technique is a single bundle technique using a semitendinosus graft. For femoral tunnel placement, a specific medial portal aimer (Karl Storz, Tuttlingen, Germany) is used. Aiming and drilling of the femoral tunnel are performed via the medial portal. Oval tunnels are created by stepwise dilatation with ovally shaped dilatators. The position of the femoral tunnel is visualized and controlled with the arthroscope via the medial portal. For the tibial tunnel placement, a specific aimer was used as well. With this technique, 24 patients were operated and all intra- and postoperative complications were analyzed prospectively. The tunnel position was documented postoperatively by CT scan.

Results

There were no significant intra- and postoperative complications associated with the oval tunnel technique. The postoperative 3D CT scan revealed that all femoral and tibial tunnels were located within the area of the anatomical ACL insertions.

Conclusions

This article presents an ACL reconstruction technique using oval dilatators and medial portal aimers to create oval tunnels. These oval tunnels match the insertion site anatomy much closer than round tunnels do.

Level of Evidence

Level IV, case series.     

Anatomy of the medial femoral circumflex artery with respect to the vascularity of the femoral head

We performed a series of 16 anatomical dissections on Caucasian cadaver material to determine the surgical anatomy of the medial femoral circumflex artery (MFCA) and its anastomoses. These confirmed that the femoral head receives its blood supply primarily from the MFCA via a group of posterior superior nutrient arteries and the posterior inferior nutrient artery. In terms of anastomoses that may also contribute to the blood supply, the anastomosis with the inferior gluteal artery, via the piriformis branch, is the most important. These dissections provide a base of knowledge for further radiological studies on the vascularity of the normal femoral head and its vascularity after dislocation of the hip.     

Monitor selection according to the defect location in the medial femoral condyle flap,

BackgroundMedial femoral condyle(MFC) flap is frequently used in hand reconstruction, but like other buried flaps, MFC is not easy to monitor and follow.In this study, we present our adipofascial and periosteal tissue technical modifications and results for MFC free flap monitoring and compare different monitoring methods.MethodsTwenty one patients with wrist bone or metacarpal defect reconstructed with MFC flap were included in the study. Adipofascial tissue in wrist defect and periosteal tissue in metacarpal defect were selected as MFC flap's monitor. Patient characteristics, type of injury, flap size, early or late-period complications, flap elevation time,satisfaction scale, visual analogue scale (VAS) and postoperative X-ray view were noted.ResultsThere were 3 female and 18 male patients in the study. The mean age of the patients was 50.8 (38–68). The elevation times of flaps with adipofascial and periosteal monitors were 48 and 53.3 min, respectively. The satisfaction scale averages for the adipofascial and periosteal monitor groups were 3.5 and 3.54, respectively. The VAS scores of the adipofascial and periosteal monitor groups were 2.9 and 3.9, respectively. The flap sizes with periosteal and adipofascial monitors were 10.48 cm³ and 1.36 cm³, respectively. There was no statistically significant difference between flap elevation, VAS, and satisfaction scale (>0.05). There was a statistically significant difference in flap sizes. (<0.05)ConclusionMFC free flap is frequently used in wrist and metacarpal reconstruction. Monitor selection according to the defect area positively affects the prognosis of the flap in the postoperative period.     

Pelvic morphology medial to the femoral head center predicts anterior coverage and range of motion after curved periacetabular osteotomy

This study observed anterior coverage extent after lateral rotation of the acetabulum, without anterior or posterior rotation, during curved periacetabular osteotomy by three-dimensional simulation, and determined if preoperative pelvic morphology affects postoperative anterior coverage and range of motion. Thirty patients scheduled for consecutive primary curved periacetabular osteotomy for developmental hip dysplasia at our hospital between 2016 and 2017 were included. Virtual acetabular osteotomies were performed to achieve a postoperative lateral center-edge angle of 30°. We measured anterior center-edge angles before curved periacetabular osteotomy through the medial one-third and one-quarter of the femoral head as an index reflecting the pelvic morphology medial to the femoral head center. The range of motion simulation was performed after virtual curved periacetabular osteotomy. Single linear regression analysis was performed to examine correlations between preoperative pelvic morphology parameters and anterior center-edge angles after virtual osteotomy. Furthermore, linear regression analysis was used to assess correlations between center-edge angles and simulated range of motions (P < .05). Anterior center-edge angle after virtual osteotomy was more strongly correlated with the anterior center-edge angle through the medial one-third (r = .92, P < .0001) and one-quarter (r = .84, P < .0001) of the femoral head. Flexion angle and internal rotation at 90° flexion showed significant correlations with anterior center-edge angle through the medial one-third (r = −.62, P = .0003; r = −.57, P = .001) and one-quarter (r = −.60, P = .0005; r = −.55, P = .002) of the femoral head and anterior center-edge angle after virtual osteotomy (r = −.67, P = .0005; r = −.62, P = .0003). Measuring preoperative parameters reflecting pelvic morphology enables surgeons to predict postoperative anterior coverage and range of motion in curved periacetabular osteotomy cases.     

Necrosis of the capital femoral epiphysis and medial approaches to the hip in piglets

In an attempt to produce necrosis of the femoral head, the medial femoral circumflex vessels were disrupted in 13 normal piglet hips through a medial approach. Femoral heads were recovered 3-6 months (average 4.2 months) postoperatively. None of these hips showed gross, radiographic, or microscopic evidence of necrosis. This demonstrates that necrosis, which may occur after the medial approach in the hip of a child, is not due to the direct damage to the medial femoral circumflex vessels.     

应用Ilizarov技术在旋转中心穹顶状截骨治疗青少年股骨远端外翻畸形

目的：探讨应用 Ilizarov 技术在旋转中心穹顶状截骨治疗青少年股骨远端外翻畸形的疗效。方法：采用回顾性研究分析 2016 年 1 月至 2020 年 10 月收治并获得完整随访的 11 例股骨远端外翻畸形患者的临床资料, 其中男7 例,女 4 例;右侧 6 例,左侧 5 例;年龄 10~14 岁。在股骨远端畸形处找出成角旋转中心(center of roration of angula-tion,CORA),以 CORA 为中点,行穹顶状截骨,根据 Ilizarov 外固定穿针原则安装环形外固定架,截断股骨远端,即时矫正股骨远端目测下外翻畸形,外固定架固定维持。术后根据双下肢负重全长正侧位 X 线片提示的下肢力线及长度结果,矫正残余畸形及短缩。结果：11 例均得到随访,时间 13~25 个月,带架时间 12~17 周。末次随访拍摄双下肢负重全长正侧位 X 线片测量 11 例双下肢长度均等长,畸形均矫正。采用美国特种外科医院(Hospital Special Surgery,HSS)评分评价膝关节功能,均为优。结论：应用 Ilizarov 技术在旋转中心穹顶状截骨治疗青少年股骨远端外翻畸形,术中即时矫正目测下股骨外翻畸形,术后根据双下肢负重正侧位片提示的下肢力线及短缩程度,动态调整矫正残余畸形及短缩,损伤小,恢复快。     

Potential risk of cartilage damage in double bundle ACL reconstruction: impact of knee flexion angle and portal location on the femoral PL bundle tunnel

The aim of this study was to compare the impact of knee flexion angle and the level of the medial drilling portal on a potential damage to the subchondral bone in double bundle ACL reconstruction, drilling the femoral PL tunnel through an accessory medial portal. We hypothesized that a knee flexion angle of 70° and 90° or a high accessory medial portal will result in a potential damage to the subchondral bone of the lateral femoral condyle. In a sawbone knee model, the medial portal location was standardized as 0 mm above the meniscus (low portal) and 10 mm above the meniscus (high portal). Femoral PL bundle tunnels were drilled at three different knee flexion angels: 70°, 90°, and 110° of knee flexion. For each portal, ten specimens were used for every flexion angle. Drilling the PL tunnel through the high medial portal at a knee flexion angle of 70° resulted in damage of the subchondral bone plate in all specimens. At 110° of flexion the distance of the tunnel exit to the subchondral bone plate was significantly higher than at 70° of flexion for both the groups, drilling through the high and low medial portal (P < 0.05). Drilling through the low portal did not result in bone plate damage at 90 and 110° of knee flexion angle. Drilling of the femoral PL bundle tunnel through a high medial portal at low knee flexion angles may damage the subchondral bone of the lateral compartment. In ACL reconstruction restoring the AM and PL bundle separately, high medial portal drilling should be avoided. We recommend drilling of the femoral PL bundle tunnel through a low medial portal in high knee flexion.     

大直径股骨头假体全髋关节置换术治疗股骨头缺血性坏死

目的探讨大直径股骨头假体全髋关节置换术治疗股骨头缺血性坏死的临床效果。方法 2007年6月至2009年6月,行大直径股骨头假体全髋关节置换术治疗36例股骨头缺血性坏死患者,男25例,女11例;年龄36岁～62岁,平均52.5岁。手术前后记录患者的Harris评分,术后进行X线检查及主观满意度调查,手术前后及随访时检测患者肾功能。结果全部获得随访,随访时间6～30个月,平均19个月。随访X线检查示假体位置良好。Harris评分由术前的30～58分,平均45.5分,改善为术后的72～94分,平均90.2分,优良率为97.2%,总体满意率为97.2%。手术前后肾功能无明显变化。结论大直径股骨头假体全髋关节置换术治疗股骨头缺血性坏死的短、中期疗效较好。     

A comparison of a conventional versus a short, anatomical metaphyseal-fitting cementless femoral stem in the treatment of patients with a fracture of the femoral neck

We compared the clinical and radiological outcomes of two cementless femoral stems in the treatment of patients with a Garden III or IV fracture of the femoral neck. A total of 70 patients (70 hips) in each group were enrolled into a prospective randomised study. One group received a short anatomical cementless stem and the other received a conventional cementless stem. Their mean age was 74.9 years (50 to 94) and 76.0 years (55 to 96), respectively (p = 0.328). The mean follow-up was 4.1 years (2 to 5) and 4.8 years (2 to 6), respectively. Perfusion lung scans and high resolution chest CTs were performed to detect pulmonary microemboli. At final follow-up there were no statistically significant differences between the short anatomical and the conventional stems with regard to the mean Harris hip score (85.7 (66 to 100) versus 86.5 (55 to 100); p = 0.791), the mean Western Ontario and McMaster Universities Osteoarthritis Index (17 (6 to 34) versus 16 (5 to 35); p = 0.13) or the mean University of California, Los Angeles activity score (5 (3 to 6) versus 4 (3 to 6); p = 0.032). No patient with a short stem had thigh pain, but 11 patients (16%) with a conventional stem had thigh pain. No patients with a short stem had symptomatic pulmonary microemboli, but 11 patients with a conventional stem had pulmonary microemboli (symptomatic in three patients and asymptomatic in eight patients). One hip (1.4%) in the short stem group and eight (11.4%) in the conventional group had an intra-operative undisplaced fracture of the calcar. No component was revised for aseptic loosening in either group. One acetabular component in the short stem group and two acetabular components in the conventional stem group were revised for recurrent dislocation. Our study demonstrated that despite the poor bone quality in these elderly patients with a fracture of the femoral neck, osseo-integration was obtained in all hips in both groups. However, the incidence of thigh pain, pulmonary microemboli and peri-prosthetic fracture was significantly higher in the conventional stem group than in the short stem group.     

Reconstruction of the medial femoral condyle and medial collateral ligament in total knee arthroplasty using tendoachilles allograft with a calcaneal bone block

Absence or compromise of the medial collateral ligament (MCL) in conjunction with osseous defects of the medial femoral condyle in total knee arthroplasty (TKA) is a challenging reconstructive problem. Treatment usually requires a highly constrained TKA with or without ligamentous reconstruction. To restore the medial femoral condylar bone and to provide ligamentous stability on the medial side of the knee, the authors present a technique for reconstruction of the medial femoral condyle and MCL using a tendoachilles allograft with a calcaneal bone block. The construct also can be augmented with a semitendinosus tendon autograft. Two illustrative cases and a review of the literature are presented.     

The new technique of precise insertion of lag screw in an operative treatment of trochanteric femoral fractures with a short intramedullary nail

In order to reduce the incidence of cut-out, which is one of the serious postoperative complications of trochanteric femoral fractures, we paid special attention to the placement of lag screw in the femoral head. As a result, we devised a new technique that allows insertion of the lag screw at the first attempt into the optimal position on both planes, inferior half on the antero-posterior view and exactly central on the lateral view, without the need for any special devices other than the basic original set, using a trochanteric nail.For this technique, we have evaluated the proximal femoral profile under image intensifier, on the true lateral view projected parallel to the axis of the femoral neck and not on the conventional lateral view (Lauenstein view) with the projection parallel to the axis of the femoral shaft in a coronal plane.With the X-ray beam lying in the same plane with the targeting device including the nail and the guide sleeve, the guide pin is intended to pass through the guide sleeve and the middle of shadow of the proximal end of the targeting device, so that it can be inserted in the optimal position without fail, aligned with the middle axis of the femoral head.The deviation angle between the axes of the lag screw and the femoral head was measured on every postoperative lateral radiograph. The mean deviation angle of 1.6° in the 39 fractures after the introduction of the new insertion technique was compared with 4.8° in the 44 fractures before the introduction, which showed a significant difference between these groups (p < 0.0001, Welch's t-test).When the lag screw can be placed exactly in the centre of the femoral head on the true lateral view, it can be set forward as closest to articular surfaces as possible on the postero-anterior view without a risk of penetration, so that the tip-apex distance could be easily achieved under 20 mm, which leads to a reduction of postoperative cut-outs.This technique can be applied in other similar trochanteric nails, which gives them an advantage over the sliding hip screws.     

Preoperative computerized radiograph measurement of Blumensaat's line as an aid to correct placement of the femoral tunnel in ACL reconstruction

Numerous studies have shown that the improper placement of the graft in anterior cruciate ligament reconstruction is a major cause of graft failure, capturing of the knee, and notch roof impingement. The ideal femoral position is located in the posterior one quarter of Blumensaat's line as seen on a true lateral knee radiograph. We present a simple method that relies on the use of preoperative radiographic measurement and a calibrated guide to ensure that the femoral tunnel is sufficiently far back along the roof of the notch, using the easily identifiable anterior end of the notch as a reference point.     

Vascular events associated with the appearance of the secondary center of ossification in the murine distal femoral epiphysis

Although the formation of a secondary center of ossification is often compared with that of the primary center, there are striking differences between these processes. In the formation of the primary center, vascular invasion is always associated with the maturation of chondrocytes, whereas vascularization of the epiphysis can proceed in two different ways. In some species, the epiphysis is vascularized by cartilage canals before the appearance of the secondary center. However, in the mouse, the distal femoral epiphysis is vascularized by peripheral vascular invasion without pre-existing cartilage canals. Histological study of serial sections and studies of vascularization by injection with India ink demonstrated the relationship between hypertrophic chondrocyte formation, vascular invasion, and the formation of the secondary center of ossification in the murine distal femoral epiphysis.