Arthroscopic hamstring anteriorcruciate ligament reconstruction with endobutton femoral fixation

Numerous techniques of anterior cruciate ligament (ACL) reconstruction have been described in literature. All haveinherent advantages and disadvantages. Autogenous hamstring grafts provide adequate strength while avoiding donor site morbidity associated with bone-patellar tendon-bone harvest. Endobutton femoral fixation allows precise femoral tunnel placement without a second incision. This article describes our technique of endoscopie ACL reconstruction using a doubled semitendinosus autograft with Endobutton femoral fixation.     

前交叉韧带重建失败的原因分析

目的 探讨前交叉韧带（ACL）重建失败后行翻修手术的主要原因以指导临床。方法 回顾性分析2001年11月至2006年7月收治的因ACL重建失败需要行翻修术的13例患者的临床资料,其中男性9例,女性4例,年龄16～46岁,平均29岁。结合临床病例研究分析ACL重建失败的原因。结果 本组13例患者中,初次手术选用自体骨-髌腱-骨移植物（B-PT-B）7例,自体半腱股薄肌腱（STG）4例,同种异体STG2例。翻修原因上、下两端骨道均偏前4例,单独上骨道偏前4例;同种异体STG重建出现明显排异反应取出移植物1例,骨道明显扩大而失败1例;自体B-PT-B重建固定上骨道内骨块的挤压螺钉位置异常2例;术后感染1例。翻修术中重建的ACL完全断裂和吸收7例,韧带有部分连接但已明显松弛失张力4例,内固定物位置异常2例。行膝关节粘连松解手术1例;因骨道骨质缺损严重而行一期植骨术,准备二期翻修2例;其余10例均行一期翻修手术,其中用同侧STG4例、对侧STG4例、同侧B—PT-B1例、髂胫束1例。结论 前交叉韧带重建手术失败的原因较多,但主要与手术骨道位置异常、固定失效、同种异体腱的排异反应与骨道扩大以及感染和术后粘连等有关。     

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft two-incision technique

Anterior cruciate ligament (ACL) reconstruction can be performed with a variety of techniques. Multiple graft sources for reconstruction are also available. The senior author (JRS) has used an arthroscopically assisted technique with 2 incisions that has achieved consistently good results. One incision is made over the patellar tendon, allowing harvest of the bone-patellar tendon-bone graft and tibial tunnel placement and graft fixation. A second lateral incision is used for femoral tunnel placement and fixation. This method has produced predictably good results and avoids some of the potential complications of endoscopic ACL reconstruction.     

The Removal of a Dislocated Femoral Interference Screw Through a Posteromedial Portal

The intra-articular migration of a femoral interference screw is a rare complication after anterior cruciate ligament (ACL) reconstruction in the knee. Only a few reports of cases have been published within the last few years and different approaches toward this complication have been described. We report the case of a 23-year-old female patient who was admitted with knee pain after undergoing an ACL reconstruction 4 years previously. After the clinical examination, a knee radiograph in 2 planes revealed a dislocated femoral interference screw lying in the popliteal fossa. During arthroscopy, the interference screw was retrieved through an additional posteromedial portal to avoid an arthrotomy. The causes for intra-articular screw migration are multiple and most cases were reported in the early postoperative period. The arthroscopic removal of a screw is recommended because of the lower morbidity.     

Reduction of femoral interference screw divergence during endoscopic anterior cruciate ligament reconstruction.

One of the complications of endoscopic anterior cruciate ligament (ACL) reconstruction is femoral interference screw divergence, usually occurring when the femoral screw insertion is different than the portal used for reaming the femoral tunnel. A new technique using a StraightShot graft passer (DePuy Orthopaedic Technology, Tracy, CA) allows the safe passage of a 7 mm M. Kurosaka Advantage cannulated femoral interference screw (DePuy) through the tibial tunnel with the patella tendon graft fully in position. This study compares femoral interference screw divergence in bone-patellar tendon-bone ACL reconstruction using two different screw insertion portals: the accessory anteromedial patella portal and the tibial tunnel portal (StraightShot technique). A radiographic analysis of 81 consecutive endoscopic ACL reconstructions was performed. The total divergence of each femoral screw was measured on both anteroposterior and lateral radiographs and then combined. Group I had the 7-mm femoral screw inserted through the accessory anteromedial patella portal; group II had the femoral screw inserted directly through the tibial tunnel. Group I showed more than 10 degrees of divergence in 50% of the cases, compared with only 4% percent in group II. The average divergence dropped from 11.3 degrees in group I to 1.2 degrees in group II. Femoral interference screw divergence can be virtually eliminated by inserting the femoral screw directly through the tibial tunnel using the StraightShot technique.     

Anteromedial Portal Technique for Creating the Anterior Cruciate Ligament Femoral Tunnel

There has been a renewed focus on anterior cruciate ligament (ACL) insertional anatomy and its biomechanics. It has been postulated that traditional single-bundle transtibial reconstructions have placed grafts in a less anatomic location relative to the true ACL insertion site. In traditional transtibial techniques, the femoral tunnel is predetermined by the position of the tibial tunnel. It is our belief that achieving the most anatomic position for the graft requires the femoral and tibial tunnels to be drilled independently. Use of the anteromedial portal technique provides us with more flexibility in accurately placing the femoral tunnel in the true ACL insertion site as compared with the transtibial technique. Advantages include anatomic tunnel placement, easy preservation of any remaining ACL fibers when performing ACL augmentation procedures, and flexibility in performing either single- or double-bundle reconstructions in primary or revision settings. This technique is not limited by the choice of graft or fixation and offers the advantage of true parallel screw placement through the same portal as that used for tunnel drilling in the case of interference fixation.     

Osteonecrosis of the lateral femoral condyle following anterior cruciate ligament reconstruction: is bone bruising a risk factor?

Osteonecrosis of the knee is extremely rare following anterior cruciate ligament (ACL) reconstruction surgery. We report a case of osteonecrosis of the lateral femoral condyle in a patient after ACL reconstruction. The osteonecrotic lesion occurred in the same area as a large bone bruise, which was sustained at the time of the initial injury. We hypothesize that the combination of bone bruising and femoral tunnel drilling for ACL reconstruction may have compromised the overall vascularity of the articular cartilage and the subchondral bone, thereby resulting in osteonecrosis.     

Editorial Commentary: Tunnel Widening After Anterior Cruciate Ligament Reconstruction May Increase Laxity and Complicate Revision

Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. It has been demonstrated that femoral tunnels enlarge anteriorly and distally (ie, the direction where the mechanical traction force of the graft works) rather than concentrically after anatomic double-bundle ACL reconstruction using hamstring autografts. This finding suggests that the wall supporting the graft moves closer to the direction of the pull, leading to increased laxity of the knee joint due to TW. The causes of TW are presumed to be multifactorial, with both biological and mechanical features. Biological factors include osteolytic cytokines that enter the space between the graft and the bone through the synovial fluid. Mechanical factors include longitudinal graft motion by extracortical femoral fixation (known as the bungee effect), transverse graft motion (also called the windshield-wiper effect), improper graft placement, higher initial graft tension, accelerated rehabilitation, and so on. Although TW does not seem to affect short-term clinical outcomes from studies published to date, it is plausible to speculate that the expansion of the bone tunnel (ie, the edge where the graft tendon is fixed) would theoretically increase joint laxity to some extent, and it would be premature to conclude that TW has no effect on clinical outcomes relative to graft–tunnel micromotion. In addition, there is a general consensus that the presence of expanded tunnels often severely complicates revision ACL reconstruction. In ACL reconstruction using the hamstring tendon, it is necessary to take into account the possibility of a shift in the tunnel position when determining the location of the femoral tunnel.     

Conservative management of bilateral femoral neck fractures in a child with autosomal dominant osteopetrosis

Management of minimally displaced femoral neck fractures in paediatric patients with autosomal dominant osteopetrosis (ADO) remains unclear as only small numbers have been reported. There are no detailed reports on successful conservative treatment. Common causes of failure in this particular area include non-union and development of coxa vara. Although there are no quantitative studies, case reports have influenced most authors to recommend operative treatment. It is well recognised that operative treatment of osteopetrotic bone is challenging. Problems arise intraoperatively due to the bone hardness, and postoperatively due to altered biomechanics and defective remodelling. This case of a child with ADO who suffered two asynchronous compression-side stress fractures in the femoral neck demonstrates that non-operative management can be satisfactory. After 8 weeks with partial weight-bearing the fractures were stable. At the latest follow-up 2.5 and 4 years after the fractures the patient presented with an excellent clinical and radiological outcome. There was no development of coxa vara.     

Revision anterior cruciate ligament reconstruction using the lateral third of the ipsilateral patellar tendon after failure of a central-third graft: a preliminary report on 10 patients

Long-term outcomes were reported for 10 (77%) of 13 cases of revision anterior cruciate ligament (ACL) reconstruction using the lateral third of the ipsilateral patellar tendon as a graft. All primary ACL reconstructions were ipsilateral central-third bone-patellar tendon-bone graft procedures. Mean age at follow-up was 30.7 years, and mean time from revision ACL surgery to follow-up was 42.9 months. At follow-up, average KT-1000 difference between knees was 2.4 mm. All patients had a negative pivot shift, extension within 5 degrees of the contralateral knee, and flexion within 15 degrees. Mean bilateral comparison ratios for isokinetic strength and hop testing were: extension, 83.5%; flexion, 96%; and single-leg hop 96.9%. No patella fractures or tendon ruptures had occurred. All patients had returned to their previous work level, and 8 of the 10 patients could participate in at least "moderate" sports activities (e.g., skiing and tennis). The results were comparable to published outcome reports for both primary and revision ACL reconstruction. The lateral third of the ipsilateral patellar tendon is a good graft option for revision ACL reconstruction.     

Incidence of the Remnant Femoral Attachment of the Ruptured ACL

The presence of remnant tibial and femoral attachments of the ruptured ACL has been described in the literature but the femoral remnant has not been well described as a landmark for tunnel placement during reconstruction. We reviewed operative reports, pictures, and videotapes from 111 ACL reconstructions to determine the incidence of a remnant femoral stump. Patients were divided into two groups: Group A included patients treated from January 2006 through September 2006 (n = 63) when the presence of the femoral footprint was documented retrospectively and Group B included patients treated from September 2006 through June 2007 (n = 48) when the presence or absence of the femoral footprint was documented prospectively. In Group A, there were 48 of 58 (83%) patients with a visible stump and 10 (17%) patients in whom we could not verify the existence of the stump. In Group B, 43 of 44 (98%) patients had a visible stump on the lateral femoral wall that was adequate as a guide for femoral tunnel placement. The native femoral footprint is seen in most cases of ACL reconstruction and can be used for guidance during femoral tunnel preparation.     

Stress fractures in the gapped area of a two implant construct: a case report

The concomitant occurrence of femoral shaft and hip fractures are not rare. The ideal management of ipsilateral intertrochanteric and femoral shaft fractures is still controversial and needs to be addressed. Cephalomedullary nail fixations of both the fractures have been described with excellent results. Similar results have been published with two implant constructs treating both of these injuries separately. We report the case of a stress fracture, in the gapped area above the proximal interlocking screw of a retrograde femoral nail placed for a segmental femur fracture and a trochanteric fracture treated with a sliding hip plate screw construct, 9?months after initial injury. The gapped area of a two implant construct is of concern and biomechanical studies have shown that the proximal end of the nail and the interlocking screws may act as a stress riser in the femur. A stress fracture in the gapped area of a two implant construct has not been described earlier, although a cadaveric study had shown that the area of the proximal screw hole of the retrograde nail is a common site for a fracture, on loading. Kissing or overlapping instrumentation increases the load to failure and creates a biomechanically stable construct.     

Trantibial anterior cruciate ligament double bundle reconstruction technique: two tibial bundle in one tibial tunnel

The anterior cruciate ligament (ACL) consists of two functional bundles that behave independently throughout the range of knee motion. Many two-bundle reconstruction techniques have been introduced to restore the function of the two bundles of the ACL. Generally, two femoral and two tibial tunnels are made during the surgery for a two-bundle ACL reconstruction. However, the procedure is technically demanding and time consuming. This paper describes one-tibial-two-femoral ACL double bundle reconstruction technique with a sextuple-stranded hamstring autograft. The anteromedial femoral tunnel is made using transtibial drilling technique and posterolateral femoral tunnel is made using outside-in technique. The two bundles in a single tibial tunnel are separated using biodegradable interference screw. Stable and adequate femoral fixation of the two bundles with a transtibial fixation and bioabsorbable screw can be obtained. This technique is relatively simple, and replicates the anatomy and differential behavior of the two native bundles of ACL more effectively.     

Femoral tunnel enlargement after anatomic anterior cruciate ligament reconstruction: Bone-patellar tendon-bone /single rectangular tunnel versus hamstring tendon / double tunnels

Purpose

This study aimed to prospectively compare the femoral tunnel enlargement at the aperture as well as inside the tunnel after anatomic anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) graft to that with hamstring tendon (HST) graft.

Femoral Tunnel Defect Filled With a Synthetic Dowel Graft for a Single-Staged Revision Anterior Cruciate Ligament Reconstruction

Bone defects are a common obstacle to successful revision anterior cruciate ligament (ACL) reconstruction. We describe the use of a synthetic bone graft plug to fill a cylindric defect after femoral interference screw removal. During revision ACL reconstruction performed through a 2-incision technique, we placed an outside-in guidewire for a new femoral tunnel that converged with the femoral screw from the primary ACL reconstruction. The screw was removed, and the resultant defect appeared very similar to the cylindric bone defect left after an osteochondral graft harvest. The confluence of the defect and the planned femoral tunnel would have allowed a “windshield wiper” effect of the graft at the lateral wall of the notch. We filled the screw defect with a synthetic bone graft plug to limit the aperture size of the femoral tunnel and to buttress the tendinous portion of the revision ACL graft, while maintaining proper anatomic graft position. In this article, we present a readily available all-arthroscopic option for repairing cylindric bone defects without the risk of an allograft or the morbidity of an autograft for a single-stage revision ACL reconstruction.     

A technique for resolution of graft-tunnel length mismatch in central third bone-patellar tendon-bone anterior cruciate ligament reconstruction.

The existence of graft-tunnel length mismatch in correctly reconstructed anterior cruciate ligament (ACL)-deficient patients can occur due to both anatomic variation and compromised tunnel placement encountered during revision, despite attempts at prevention with accurate measurement techniques. This study reports a method for resolution of graft-tunnel length mismatch during central third bone-patellar tendon-bone ACL reconstruction. The technique involves rotation of the graft to shorten its length. Variation in graft shortening occurs depending on the direction of rotation, with external rotation achieving greater shortening. At 630 degrees of external rotation, approximately 25% shortening of the collagenous portion of the graft can be achieved, which allows for adequate bitunnel interference fixation in most instances. This technique can be used during difficult ACL reconstructions, both primary and revision, and may also have uses in routine reconstructions. Early clinical results are presented.     

Nonunion of a pertrochanteric femur fracture due to a low-velocity gunshot

The treatment of nonunions often can be a complex and challenging venture. This case report details the treatment of a young patient's pertrochanteric femoral nonunion due to a low-velocity gunshot. Fracture fixation and union were attempted with various implants, including a sliding hip screw, blade plate, and proximal femoral locking plate; however, all eventually failed. Successful union ultimately was obtained only after use of a cephalomedullary nail. There have been few reports in the literature on the failure of proximal femoral locking plates in the treatment of pertrochanteric femur fractures, though much has been published regarding the sliding hip screw and blade plate. Multiple options for use in nonunion surgery were used and discussed in this case, such as autogenous bone graft, bone morphogenic protein, and implantable bone stimulators.     

Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Background Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone patellartendon bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts.

Methods We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bonepatellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis.

Results Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32-0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82-1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group.

Interpretation Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability.     

Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction

Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case.