Arthroscopic double-bundled posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Summary: An arthroscopic technique for double-bundled reconstruction for posterior cruciate ligament with quadriceps tendon–patellar bone autograft is presented. Anterolateral and posteromedial tunnels were created to simulate and reproduce the double-bundle structure of the posterior cruciate ligament. The bone plug is situated at the tibial tunnel and fixed by a titanium interference screw. Each of the bundles of tendon graft is rigidly fixed at the femoral tunnel with a bioabsorbable screw.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 780–782     

Proprioceptive skills and functional outcome after anterior cruciate ligament reconstruction with a bone–tendon–bone graft

Several studies have shown that patients with anterior cruciate ligament (ACL) reconstruction have an improved proprioceptive function compared to subjects with ACL-deficient knees. The measurement of functional scores and proprioception potentially provides clinicians with more information on the status of the ACL-reconstructed knees. To evaluate proprioception in patients following ACL reconstruction with a bone–tendon–bone (BTB) graft, we used the angle reproduction in the sitting, lying and standing positions and the one-leg hop test. Forty-five patients between 19 and 52 years of age were investigated in a 36-month period after the operation. For functional performance measurement, the International Knee Documentation Committee (IKDC) score was used. Very good and good results were seen in 95% of cases. All patients returned to the same activity level as seen before ACL repair. There was a significant difference in the active angle reproduction test between the ACL-reconstructed knees and normal knees in the active sitting position. Tests with passive angle adjustment in the sitting, lying and active standing positions did not show any differences in proprioceptive skills. Good to very good results in the one-leg hop test we found in 95% of patients. After ACL reconstruction, deficiencies in the active angle reproduction test were very small but, nevertheless, were still observed. Overall, the functional and proprioceptive outcomes demonstrate results to recommend the procedure.

---

Résumé  Plusieurs études ont montré que des patients ayant bénéficié d’une reconstruction du ligament croisé antérieur ont été améliorés sur le plan de la fonction proprioceptive surtout si on compare les sujets à des sujets non traités gardant un déficit au niveau du ligament croisé antérieur. La mesure des différents scores, fonction et proprioception, donne un certain nombre d’informations sur ces genoux qui ont été opérés. Nous avons évalué la proprioception de patients opérés par greffes du ligament croisé antérieur par un greffon de type BTB et évalué cette proprioception en position assise, debout, en appui monopodal et après tests de sauts.45 patients entre 19 et 52 ans ont été analysés sur une période de 36 mois après l’intervention chirurgicale. Le score IKDC a également été mesuré. Les résultats ont été considérés comme très bons dans 95% des cas. Les patients ont repris une activité au même niveau que celle qu’ils avaient avant la réparation. Il n’y a pas de différences significatives entre les genoux reconstruits et le genou normal, notamment en ce qui concerne les tests en positions assises. Un très bon résultat des tests de sauts est retrouvé chez 95% des patients. On peut considérer après reconstruction du ligament croisé antérieur, que la récupération fonctionnelle et proprioceptive est excellente et confirme la nécessité de reconstruire les ligaments après rupture.

     

Biomechanical study on the suture strength of ligament in cruciate ligament reconstruction

Objective: To test the suture strength on the tendon or ligament end and evaluate the stitch in the reconstruction of cruciate ligament and its clinical application. Methods: Twenty-four specimens of patellar tendon with free ends were divided into 3 groups: Group I (3 Krackow stitches ), Group H ( 2 Krackow stitches ) and Group HI (2 Krackow stitches with the first stitch passing through the tendon tissue as a modified Krackow stitch).These 3 groups were further divided into 6 subgroups according to different suture materials, No 1 Ethilon or stainless steel wire (φ = 0.4 mm ). Tensile test was undertaken to f‘md out the least stitches with efficient suture pattern. Results: Two Krackow locking stitches had stronger strength than 0.4 mm-diameter stainless steel wire. The fixation strength of 2 stitches with No 1 Ethilon was more than 80 N, superior to the failure strength of the material itself. The same strength was maintained if the first stitch was across the tendon tissue transversely. There was no statistically significant difference in the suture strength between 2 and 3 Krackow locking stitches. Conclusions: The suture strength is greater than the failure strength of the suture material. Less suture exposure can be achieved when the first stitch is across the tendon tissue while maintaining a comparable strength to other sutures. To attain higher suture strength, stronger materials or multiple strands rather than more stitches are preferred. Therefore, a rapid early rehabilitation of range of motion (ROM) is possible and reliable in practice.     

Lateral collateral ligament reconstruction using quadriceps tendon–patellar bone autograft with bioscrew fixation

The lateral collateral ligament is the primary stabilizer against varus stress and is also an important contributor in maintaining posterolateral knee stability. Quadriceps tendon–patellar bone autograft has been used for anterior or posterior cruciate ligament reconstruction. We introduce a reconstructive procedure to restore the lateral collateral ligament using a quadriceps tendon–patellar bone autograft. The procedure is designed for unstable knees with concomitant cruciate ligament tear and posterolateral complex injury. This is a reasonable choice especially when allograft tissue is not available or in patients who are not suited for the use of bone–patellar tendon–bone autograft.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 551–554     

One-incision endoscopic technique for posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Quadriceps tendon–patellar bone autograft is an alternative graft choice for posterior cruciate ligament (PCL) reconstruction. A 2-incision technique with outside-in fixation at the femoral condyle is generally used. In this article, we describe a 1-incision endoscopic technique for PCL reconstruction with quadriceps tendon–patellar bone autograft. The graft consists of a proximal patellar bone plug and central quadriceps tendon. The bone plug is trapezoidal, 20 mm long, 10 mm wide, and 8 mm thick. The tendon portion is 80 mm long, 10 mm wide, and 6 mm thick, including the full-thickness of the rectus femoris and partial thickness of the vastus intermedius. Three arthroscopic portals, including anteromedial, anterolateral, and posteromedial, are used. All procedures are performed in an endoscopic manner with only 1 incision at the proximal tibia. At the femoral side, the bone plug is fixed by an interference screw. At the tibial side, the tendon portion is fixed by a suture to a screw on the anterior cortex and an interference bioscrew in the posterior tibial tunnel opening. Quadriceps tendon autograft has the advantages of being self-available, allowing for easier arthroscopic technique, and providing comparable graft size. The 1-incision technique provides a simple reconstruction method for PCL insufficiency without a second incision at the medial femoral condyle.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 329–332     

Ligamentum paracolicum dextrum--a new ligament?

Purpose

During routine laparoscopy, the authors identified an unknown ligament that stretched between the middle segment of the ascending colon and the adjacent lateral abdominal wall. This report discusses the incidence and histology and suggested name for this ligament.

Methods

Over a 5-year period, 362 hernias were repaired laparoscopically in children aged from 4 days to 14 years (median 1.7 years; 87 girls and 242 boys). None of the children had undergone previous surgery nor had had concomitant diseases or associated malformations. The ligament was searched for in every child. In addition, 22 adult cadavers were dissected searching for the ligament. Biopsies were taken from the ligament and from adjacent abdominal wall in other cadavers as controls.

Results

During laparoscopy, a ligament of variable size was identified in 152 of the children (43%). This ligament arose at the lateral aspect of the middle ascending colon, occupied half of the circumference, and inserted at the lateral abdominal wall; there was no recognizable relation to any defined structure at the abdominal wall itself. Similar ligaments were also identified during the cadaveric dissections in 14 (64%) of 22 adult cadavers, in which the variable thickness and broadness were also noted. Histological examination of samples taken from the cadavers showed a loosely structured subepithelial layer of connective tissue of variable width, which transitioned gradually into the subperitoneal fat tissue.

Conclusions

This ligament easily evades the attention of surgeons in open surgery, yet becomes evident during laparoscopy. In the semilateral or lateral position, most frequently chosen for transabdominal laparoscopic access to the kidney, the ligament stretches and keeps the colon on top of the kidney. The ligament's clinical and anatomic significance is unknown. Its existence has become more evident with recent use of laparoscopy.     

Does the phrenico-gastric ligament exist?]

On thirty cadaveric dissections, we studied the so-called "phreno-gastric" ligament. In fact, it appears that there is an adhesion between the fundus and the posterior wall in only 60 % of the cases. This adhesion is always very loose, easily cleaved and in no case is there a real fibrous suspensory ligament. Moreover, in 40 % of the cases, the posterior surface of the fundus is entirely covered by peritoneum and is free in the bursa omentalis. In that case, the posterior surface of the stomach is connected with the diaphragm by a very short meso extending on the right to the meso esophagus and on the left to the gastrosplenic ligament.     

Patellar tendon rupture 3 years after anterior cruciate ligament reconstruction with a central one third bone–patellar tendon–bone graft

Use of the central one third bone–patellar tendon–bone autograft is an accepted technique for anterior cruciate ligament (ACL) reconstruction. Patellar tendon rupture following ACL reconstruction is an acknowledged, although rarely reported, complication of this procedure. Of the limited patellar tendon rupture cases reported in the literature, most are described early in the postoperative period. We present a case of late patellar tendon rupture more than 3 years after uneventful ACL reconstruction in a 32-year-old man.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 648–652     

A modified bone-tendon-bone harvesting technique for avoiding tibial tunnel–graft mismatch in anterior cruciate ligament reconstruction

Anatomic graft fixation in anterior cruciate ligament reconstruction has been shown to be extremely important for achieving acceptable postoperative knee stability. Different methods have been proposed for customizing graft length, so that anatomic graft fixation is obtained at the native anterior cruciate ligament site. A technique has been described for avoiding potential complications during the insertion of an interference screw at femoral tunnel and, ultimately, reducing the mismatch within the femoral tunnel. The aim of this article is to present a modified application to the tibial tunnel of a previously described technique for avoiding graft-tunnel mismatch. The advantages are related to the increase in graft complex stiffness, achievement of a more anatomic fixation, and the reduction in synovial fluid leakage.     

How to treat knee ligament injuries?

Indications for conservative treatment of knee ligament injuries can be established for all grade I or II sprains (partial tears), as well as isolated grade III sprains (complete tears) of the posterior cruciate ligament (PCL) and medial collateral ligament (MCL). These injuries should be treated with immediate mobilization. Only in isolated partial anterior cruciate ligament (ACL) tears without a positive pivot shift phenomenon is conservative treatment justified. However, many of these injuries may require operative reconstruction later. In complete ACL tears the surgical treatment consists of primary reconstruction or augmented primary repair. Today, the middle third of the patella tendon with the bone blocks is regarded as the "gold standard" for augmented repairs and late reconstructions. For the present, there is no place for synthetic prostheses in the treatment of an acute ACL rupture. Allograft replacement of the ACL must now be considered an experimental procedure. In the reconstruction of the PCL the above mentioned patella tendon graft is also preferable. Lateral collateral ligament (LCL) tears, especially if they are combined with ruptures of posterolateral ligament complex, should be repaired immediately after the injury. In these injuries late reconstructions are difficult and the results are poor. Conservative treatment of partial tears and postoperative treatment of reconstructed ligaments is twofold: on the one hand, the healing tissue should be protected and on the other hand, atrophy and wasting of uninjured tissue should be avoided. Overload and stretching of the injured ligaments should be eliminated with the aid of a suitable knee brace, but early range of motion exercises of the knee are allowed immediately.(ABSTRACT TRUNCATED AT 250 WORDS)     

Simultaneous reconstruction of anterior cruciate ligament and posterior cruciate ligament by using allogeneic patellar tendon under arthroscopy

With fast development of arthroscopic surgery inChina, simple reconstruction of ACL (anteriorcrucial ligament) or PCL has been reported in number. However , the methods concerningsimultaneous reconstruction of ACL and PCL are rarelyreported. Simultaneous …     

Anterior cruciate ligament reconstruction with LARS™ artificial ligament results at a mean follow-up of eight years

Purpose

The aim of this study was to review patients that underwent ACL reconstruction with the LARS™ ligament in the First Orthopaedic Division of Pisa University during the period between January 2003 and December 2005.

Methods

Twenty-six patients were reviewed with an average follow-up of 95.3 months (7.9 years). The review protocol was articulated in three phases: (1) a subjective evaluation using three grading scales: VAS, KOOS and the Cincinnati knee rating scale, (2) a clinical and objective evaluation, and (3) a biomechanical evaluation of the knee stability.

Results

A global positive result was obtained in 92.3 % of the patients (16 optimal results and eight good results), with a fast functional recovery and a high knee stability. A global poor result was reported in two cases. In our series we did not record cases of infection or knee synovitis. We recorded only one case of mechanical graft failure. The results obtained from our study are encouraging and similar to those in the literature.

Conclusions

We conclude that the LARS™ ligament can be considered a suitable option for ACL reconstruction in carefully selected cases, especially for older patients needing a fast functional recovery.     

The diagnosis and treatment of deltoid ligament lesions in supination–external rotation ankle fractures: a review

The supination-external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.     

Comparisons of intraosseous graft healing between the doubled flexor tendon graft and the bone–Patellar tendon–Bone graft in anterior cruciate ligament reconstruction

Purpose: The purpose of this study was to compare intraosseous graft healing between the doubled flexor tendon (FT) graft and the bone–patellar tendon–bone (BPTB) graft in anterior cruciate ligament (ACL) reconstruction. Type of Study: Randomized trial. Methods: A biomechanical and histologic study was conducted with 24 adult beagle dogs. Bilateral ACL reconstructions were performed in each animal. Autogenous doubled FT and BPTB grafts were used for the left and right knees, respectively. Each end of the 2 grafts was tethered with a polyester suture to a screw post with a washer. The animals were then allowed unrestricted activities in their cages. Eight animals were killed at 3, 6, and 12 weeks, respectively. Results: Histologically, the FT graft was anchored to the tunnel wall with newly formed collagen fibers resembling Sharpey’s fibers by 12 weeks. These fibers were more abundant in the anterior (ventral) gap than in the posterior (dorsal) gap. In the BPTB graft, the bone plug was anchored with newly formed bone at 3 weeks, although osteocytes in the plug trabeculae were necrotic for 12 weeks. Degeneration of the tendon-bone junction in the plug progressed at 6 weeks. Tensile testing showed that the weakest site was different not only between the 2 grafts but also between the observation periods. In the FT graft, the weakest site was the graft-wall interface at 3 weeks and the intraosseously grafted tendon at 6 weeks. In the BPTB graft, the weakest site was the graft-wall interface at 3 weeks and the proximal site in the bone plug at 6 weeks. The ultimate failure load of the FT graft was significantly inferior (45.8%) to that of the BPTB graft at 3 weeks (P =.021). At 6 weeks, the load of the FT graft was 85% that of the BPTB graft without a significant difference (P =.395). Conclusions: As to the clinical relevance, the fixation device chosen for soft-tissue fixation appears to be more important than comparing it to the BPTB graft, although this has yet to be conclusively proven.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 461–476     

Conservation du ligament croisé postérieur

Résumé Dans les arthroplasties à glissement du genou, la conservation du ligament croisé postérieur permet un meilleur roll back articulaire. Une bonne stabilité des formations ligamentaires latérales est indispensable. Les coupes osseuses doivent être très rigoureuses et correspondre exactement à l'épaisseur des pièces prothétiques.     

Medial patellofemoral ligament reconstruction – A novel technique

Patellofemoral instability is initially treated conservatively and surgical treatment is reserved for resistant cases. Reconstruction of medial patellofemoral ligament has gained popularity these days as it attempts at restoring soft tissue anatomy and biomechanics of medial patellar restraint back to normal. Here we describe our novel transverse patella single tunnel and femoral interference screw technique to reconstruct the medial patellofemoral ligament using free autologous gracilis and semitendinosus grafts.     

Single– versus two–femoral socket anterior cruciate ligament reconstruction technique: Biomechanical analysis using a robotic simulator

Purpose: Although anterior cruciate ligament (ACL) reconstruction with multistrand autogenous hamstring tendons has been widely performed using a single femoral socket (SS), it is currently advocated to individually reconstruct 2 bundles of the ACL using 2 femoral sockets (TS). However, the difference in biomechanical characteristics between them is unknown. The objective of this study was to clarify their biomechanical differences. Type of Study: This is a cross-over trial using cadaveric knees. Methods: Seven intact human cadaveric knees were mounted in a robotic simulator developed in our laboratory. By applying anterior and posterior tibial load up to ± 100 N at 0°, 15°, 30°, 60°, and 90° of flexion, tibial displacement and load were recorded. After cutting the ACL, the knees underwent ACL reconstruction using TS, followed by that using SS, with 44 or 88 N of initial grafts tension at 20° of flexion. The above-mentioned tests were performed on each reconstructed knee. Results: The tibial displacement in the TS technique was significantly smaller than that in the SS at smaller flexion angles in response to anterior and posterior tibial load of ± 100 N, and the in situ force in the former was significantly greater than that in the latter at smaller flexion angles. Furthermore, in the TS technique, the posterolateral graft acted dominantly in extension, while the anteromedial graft mainly resisted against anterior tibial load in flexion. However, in the SS technique, the anteriorly located graft functioned more predominantly than the posteriorly located graft at all flexion angles. Conclusions: The ACL reconstruction via TS using quadrupled hamstring tendons provides better anterior-posterior stability compared with the conventional reconstruction using a single socket.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 7 (September), 2001: pp 708–716     

Is ossification of posterior longitudinal ligament an enthesopathy?

The purpose of this study was to investigate the relationship of ossification of posterior longitudinal ligament (OPLL) with enthesis, the site where the posterior longitudinal ligament (PLL) attaches to the vertebral body, by multi-detector CT reconstruction images. Twenty-nine patients with OPLL were studied. According to the plaques’ continuity to the vertebral body, OPLL plaques were classified into two categories: “free” and “contiguous”. A “broken sign” was defined as a crack between two plaques. The sites where each “contiguous” plaque attached to the vertebral body were then analysed. There were 78 ossified plaques in total, and six were “free”. There were eight cases with a “broken sign”, including six “free” ones. The site where all 72 “contiguous” plaques attached to the vertebral body included the zone where the PLL enthesis was situated, while other zones were included in only part of the plaques. Our conclusion was that there might be no real “free type” ossified plaques, and OPLL could start from enthesis, which indicated OPLL could be a kind of enthesopathy.