Segond fracture with anterior cruciate ligament tear in an adolescent

The authors report a case of acute knee injury in a 14-year-old teenager. The X-ray showed a so-called Segond’s fracture: a small avulsed bone fragment, elliptical in shape, lying immediately below the external tibial plateau, a few millimeters from the lateral tibial cortex. The fracture site was in the portion of the tibial condyle which is linked to the middle third of the lateral capsule by meniscal tibial fibers. Clinical examination under anesthesia and subsequent arthroscopy revealed a total intrasubstance ACL (anterior cruciate ligament) tear close to the proximal insertion. The authors confirm Segond’s report of a possible association of this avulsion fracture with ACL injuries, even in adolescence.     

胫骨平台前外侧撕脱骨折合并前交叉韧带损伤的诊治

胫骨平台前外侧撕脱骨折(Segond骨折)合并前交叉韧带(ACL)损伤在临床中并不少见。对于Segond骨折合并ACL损伤患者如何诊治,越发的被重视起来。本文通过对Segond骨折合并ACL损伤的准确诊断、应急处理、恰当治疗、康复锻炼等方面作一综述,旨在对Segond骨折合并ACL损伤的诊治有所帮助,同时该合并伤应根据个体损伤情况制定个性化的方案。     

Unusual combination of posterior cruciate ligament tibial avulsion fracture and Segond fracture: A case report

Introduction and importancePosterior cruciate ligament (PCL) avulsion fracture is an uncommon entity, but it poses significant morbidity to patient's knee and activities. A combination of PCL avulsion fracture with Segond fracture is rare and has not been described much before in known literature. In this case report, we present a rare case of a combination of these two injuries.Case presentationA 16-year-old cyclist who sustained left knee injury after a high-velocity fall while cycling. He fell with his anteromedial side of his left knee hitting the ground in flexion. After the fall, he felt excruciating pain and unable to bear weight. Examination revealed severe joint effusion, tenderness on posterior and lateral side of the left knee, no vascular injury and neurological deficit present. Radiographic examination revealed PCL avulsion fracture and Segond fracture. Five days after the injury, the avulsed PCL fragment and the lateral tibial plateau fragment were reduced and fixed with 3.5 mm cortical screw and washers. On the follow up, the patient stated that there is no pain on weightbearing position and after evaluated with Knee injury and Osteoarthritis Outcome Score (KOOS), the result is 90%.Clinical discussionAlthough the combination of PCL avulsion fracture and Segond fracture is rare, this pattern of injury could happen and could be considered when evaluating knee injuries.ConclusionBoth fractures need to be addressed and managed adequately to restore knee stability and prevent early joint degeneration.     

Replacement of the anterior cruciate ligament with a bone-ligament-bone anterior cruciate ligament allograft in dogs

Acute replacement of the canine anterior cruciate ligament (ACL) with a frozen, bone-ligament-bone anterior cruciate ligament preparation was studied using biochemical, immunologic, and biomechanical testing methods. Nine dogs were used for the study, six dogs received allografts and three received autografts. No tissue antigen matching was performed. All nine dogs were killed nine months after surgery. Necropsy examination revealed that the ACL was not present in three joints (one autograft, two allografts). The two autograft and four allograft ligaments available for mechanical testing sustained mean maximum loads that were 10% and 14%, respectively, of the mean maximum loads sustained by the contralateral ACL. Autoradiography indicated that cellular activity was more pronounced in the autograft specimens. Hydroxyproline uptake was 200% and 45% of normal in the autograft and allograft ligaments, respectively. Both autograft and allograft specimens were producing Type I collagen at the time of killing. Antidonor dog leukocyte antigen (DLA) antibody was detected in the synovial fluid taken at the time of killing from six of six dogs that received allografts and in zero of three dogs that received autografts.     

Lateral femoral condyle fracture after endoscopic anterior cruciate ligament reconstruction

A case is described in which a coronal plane fracture of the lateral femoral condyle propagated through the femoral tunnel 2 months after endoscopic anterior cruciate ligament reconstruction     

Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players

Purpose

The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players.

Methods

Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker–Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing.

Results

At a mean follow-up of 72.6?±?8.1 months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100 %). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture.

Discussion

The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain.

Conclusions

The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity.

     

The anterior cruciate ligament

Our knowledge of the anterior cruciate ligament has expanded rapidly over the last decade. Recent advances in arthroscopic techniques, the development and release of synthetic stents and prostheses, increasing laboratory and clinical data involving allograft implantation, and biomechanical research in knee rehabilitation have led to a bewildering array of choices for treatment of anterior cruciate ligament deficiency. As new information and techniques are presented, and new synthetic and biological materials become available, orthopedic surgeons must judge their value and modify treatment recommendations accordingly. A thorough knowledge of the basic science and clinical information is necessary to appropriately evaluate these new advances. A review of our current knowledge of the anterior cruciate ligament is presented to facilitate this evaluation process.     

Arthroscopic treatment of an anterior cruciate ligament avulsion fracture in a skeletally immature patient

Anterior cruciate ligament injuries in skeletally immature patients usually involve tibial bony avulsion fractures rather than the midsubstance tears usually observed in adults. Several surgical techniques have been reported to provide stable fixation and avoid physeal injury in this pediatric population. The authors propose a novel, reproducible surgical technique using bioabsorbable anchors to obtain biomechanical stability and minimal physeal or articular cartilage damage.     

Endoligamentous revascularization of an anterior cruciate ligament graft

After replacement of the anterior cruciate ligament with a free tendon graft, the substitute initially is avascular and without a synovial surface. To ensure long-term survival, the graft must become revascularized. Despite numerous studies on the topic, there still is discussion regarding revascularization. The goal of the current study was to investigate the endoligamentous microcapillary revascularization of the free tendon graft after anterior cruciate ligament replacement with time. Thirty-six mature sheep had an anterior cruciate ligament reconstruction with an ipsilateral flexor tendon split graft. Midsubstance tissue samples were immunostained for von Willebrand factor (Factor VIII) at 6, 9, 12, 24, 52, and 104 weeks to detect the endothelial cells of capillaries. Cross sections of vessels were determined in three zones (subsynovial, intermediate, and center of the graft) and were evaluated by means of histomorphometry using a digital imaging analysis system. The observations showed that capillary vessels, which originate from the synovial envelope, invaded the avascular graft tissue from the surface toward the center zone. The highest level of vascular density was found after 6 weeks, reaching the vascular status of the native anterior cruciate ligament after 24 weeks. These findings are in contrast to the findings of previous studies in animals. The current study showed, for the first time, the kinetics of an endoligamentous revascularization of a free tendon graft at the capillary level. In the current model, the process of revascularization terminated earlier than previously described.     

Revision anterior cruciate ligament reconstruction: an update

With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.     

带血运的髌韧带重建前交叉韧带

膝关节前交叉韧带（anterior cruciate ligament，ACL）断裂的发生率较高，新鲜的断裂伤可直接缝合修复，而陈旧性断裂因变性萎缩需要手术重建，其中自体髌腱中1／3重建ACL因取材方便、重建韧带强度高、安全可靠，已成为重建的常规手术。目前利用替代物重建术失败的原因很多，其中替代物游离后失去血供，导致替代物变性松驰为其原因之一。为防止替代物松驰，我们自1990年8月一2004年7月采用脂肪垫与髌韧带条柬相连，保持其良好的血供，重建ACL26例，取得满意效果。     

Aplasia of the anterior cruciate ligament with a compensating posterior cruciate ligament.

Aplasia of the anterior cruciate ligament is a rare condition and is usually associated with other abnormalities of the lower extremities. We report aplasia of the anterior cruciate ligament with a compensating posterior cruciate ligament in a 15-year-old boy.     

小切口治疗前交叉韧带胫骨附丽点撕脱骨折

目的 介绍一种小切口复位固定治疗前交叉韧带胫骨附丽点撕脱骨折的方法.方法 对22例前交叉韧带胫骨附丽点撕脱骨折患者采用小切口下复位固定手术.其中15例骨折复位后钢丝固定,4例用双股2号聚乙烯缝线固定,3例可吸收螺钉固定.对骨缺失影响交叉韧带长度者予以植骨.结果 19例获随访,时间6～24个月.X线及CT检查提示骨折愈合良好.采用Lysholm临床评分系统对膝关节功能进行评估:术前为20～30分,术后为92～100分.关节活动度与对侧相比基本恢复正常.19例均恢复伤前的运动水平(非专业运动).结论 小切口行前交叉韧带胫骨附丽点撕脱骨折复位固定,对膝关节软组织损伤小,有利于术后功能恢复,是一种比较理想的方法.     

关节镜下治疗前交叉韧带胫骨髁间嵴撕脱骨折

目的探讨关节镜下对前交叉韧带胫骨髁间嵴撕脱骨折应用缝合线加钢缆进行复位和内固定的疗效。方法 56例前交叉韧带胫骨髁间嵴撕脱骨折患者(Ⅱ型13例,ⅢA型15例,ⅢB型13例,Ⅳ型15例),关节镜下应用Ethibond X519缝合线加钢缆对胫骨髁间嵴撕脱骨折区进行缝合捆绑,通过胫骨髁前置双隧道牵引复位、固定。结果术后X线片显示胫骨嵴撕脱骨折完全复位。56例均获随访,时间18～21个月。末次随访时骨折完全愈合。Lachmen试验(-)56例;前抽屉试验(-)55例,1例弱阳性。IKDC评定:术前C级30例,D级26例;术后A级55例,B级1例。Lysholm评分:术前37～52(42.7±0.34)分;术后91～96(95.7±0.56)分,平均提高53.0分±0.43分,术前、术后比较差异有统计学意义(P<0.01)。结论关节镜下应用缝合线加钢缆内固定治疗膝关节前交叉韧带胫骨髁间嵴撕脱骨折,可以对移位的撕脱骨折很好地复位,最大限度地加大单位面积上的压力,增加刚性稳定。并可早期功能锻炼。     

Avulsion fracture of the anteromedial bundle of the anterior cruciate ligament

The avulsion fracture of the tibial attachment site of the anterior cruciate ligament is relatively rare among adults. Although partial avulsion fracture of this site is very rare, complex forces exerted on the knee joint could produce this type of fracture. We report on an adult patient with an avulsion fracture of the attachment site of anteromedial bundle of the anterior cruciate ligament associated with injuries of lateral and medial collateral ligament and fibular fracture. We speculate varus stress in a flexed knee coupled with rotation between the femur and tibia caused this type of injury.     

Objective anterior cruciate ligament testing

We examined subjects with the Stryker knee laxity tester as part of the clinical examination to determine its usefulness in evaluating the anterior cruciate ligament. We measured 123 athletes with no history of knee injury, as well as 30 patients with ACL injury proven by arthroscopy, and 11 injured patients with intact ACL at arthroscopy. We recorded anterior and posterior tibial displacement at 20 degrees of knee flexion and 20 lbs force in each direction. Anterior laxity and side to side difference correlated with ACL injury; posterior and total AP laxity did not. In normal subjects, mean anterior laxity was 2.5 mm. Only 8% of normal knees had anterior laxity of 5 mm or more. Ten percent of normal subjects had a side to side difference of 2 mm or more. In ACL tears, mean laxity was 8.1 mm, with 94% measuring 5 mm or more. Of the subjects, 89% with unilateral ACL injury had an increase of 2 mm or more on the injured side. Ten of ten acute ACL tears were detected by these criteria, with no false positives. In injured knees with intact ACL, measurements did not differ significantly from normal. We found the objective knee laxity measurement to be a useful complement to clinical knee examination.     

Revision anterior cruciate ligament reconstruction

Revision ACL surgery is indicated in patients who present with pathologic anterior laxity on clinical examination that reproduces their symptoms of instability during activities of daily living or athletic activities. The goals of the revision ACL surgery are to stabilize the knee, prevent further injury to the articular cartilage and menisci, and maximize the patient's function. Successful revision ACL surgery requires a thorough preoperative evaluation, including a detailed history, physical examination, and radiographic evaluation. Preoperative planning begins with a determination of the mechanisms of failure for the initial ACL reconstruction. Often a primary, as well as secondary cause, for failure can be identified. The determination of the cause of failure is the first step in a carefully-constructed treatment plan, which includes consideration of skin incisions to be used, method of graft removal, hardware removal, the need for a staged procedure or concomitant surgery, graft material selection, tunnel placement, graft fixation, and postoperative rehabilitation protocol. Despite the most meticulous planning, unanticipated findings may be encountered in the operating room, and the preoperative plan should have enough flexibility to accommodate these developments. Finally, it is crucial to counsel the patient preoperatively to limit his or her expectations regarding their surgical outcome. Given the complexity of revision ACL reconstruction, patient expectations must be adjusted to realistically match the potential for success. With proper planning, attention to detail, and appropriate patient expectations, revision ACL surgery can result in a beneficial and satisfying patient outcome.     

Imaging the anterior cruciate ligament

MR imaging has surpassed all other imaging modalities to become the "gold standard" for imaging evaluation of ACL injury. The accuracy and sensitivity of MR imaging for evaluation of ACL tears is excellent when correlated with clinical tests and arthroscopic findings, and is improved in equivocal cases with assessment of secondary signs for ACL tear. The MR imaging assessment of partial and chronic ACL tears is less accurate but is clinically useful. MR imaging provides information about associated injuries prior to surgery. Radiologic diagnostic methods for the assessment of ACL tears on MR images are well established; recent techniques such as dedicated cartilage imaging offer new information of use to clinicians about the sequelae of ACL injuries.