Assessment of the feasibility of arthroscopic visualization of the lateral ligament of the ankle: a cadaveric study

Purpose

An anatomical study was performed to assess the feasibility of arthroscopic visualization of the lateral ligaments of the ankle.

Methods

The fibular, talar and calcanear insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) were identified by standard arthroscopy portals. After dissection of the ATFL and CFL, bone tunnels were created at the estimated centres of their footprints. Dissection was then performed to identify the footprints and their position in relation to bony landmarks. The distance from the real centre of the footprint to the corresponding tunnel entrance was measured.

Results

Fourteen fresh frozen ankles were included. The ATFL and CFL were identified in all cases. The centre of the fibular ATFL footprint was found to be 16.1 ± 3.5 mm from the tip of the fibula, and the talar footprint was 18.4 ± 2.8 mm from the apex of the lateral talar process. The centre of the fibular CFL footprint was 4.2 ± 0.8 mm from the tip of the fibula, and the calcaneal footprint was 18.4 ± 2.5 mm from the fibular process of the calcaneum. The fibular tunnel was 2.9 ± 3 mm proximally from the centre of the ATFL fibular footprint, the talar tunnel was 4.4 ± 3.2 mm proximally from the centre of the talar footprint, and the calcaneal tunnel was 3.3 ± 2.8 mm too anterior from the CFL calcaneal footprint. No iatrogenic lesions were noted.

Conclusion

Arthroscopic identification of the ATFL, CFL and their corresponding footprints can be considered safe and reliable. Tunnels entrances, in preparation for arthroscopic ligament reconstruction, are precisely positioned. Arthroscopic anatomical ligament reconstruction is a feasible option.

     

Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL

Purpose

Current methods of anterior talofibular ligament (ATFL) reconstruction fail to restore the stability of the native ATFL. Therefore, augmented anatomic ATFL reconstruction gained popularity in patients with attenuated tissue and additional stress on the lateral ankle ligament complex. The aim of the present study was to evaluate the biomechanical stability of the InternalBrace^® (Arthrex Inc., Naples, FL, USA), a tape augmentation designed to augment the traditional Broström procedure.

Methods

Twelve (12) fresh-frozen human anatomic lower leg specimens were randomized into two groups: a native ATFL (ATFL) and a tape augmentation group (IB). Dual-energy X-ray absorptiometry (DEXA) scans were carried out to determine bone mineral density (BMD) of the specimens. The ligaments were stressed by internally rotating the tibia against the inverted fixated hindfoot. Torque at failure (Nm) and angle at failure (°) were recorded.

Results

The ATFL group failed at an angle of 33 ± 10°. In the IB group, construct failure occurred at an angle of 46 ± 16°. Failure torque reached 8.3 ± 4.5 Nm in the ATFL group, whereas the IB group achieved 11.2 ± 7.1 Nm. There was no correlation between angle at ATFL or IB construct failure or torque at failure, respectively, and BMD for both groups.

Conclusion

This study reveals that tape augmentation for ATFL reconstruction shows similar biomechanical stability compared to an intact native ATFL in terms of torque at failure and angle at failure. BMD did not influence the construct stability. Tape augmentation proved an enhanced initial stability in ATFL reconstruction which may allow for an accelerated rehabilitation process.

Level of evidence

II.

     

Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability

Purpose

To incorporate a diagnostic technique for measuring subtalar motion, namely “talar rotation”, into the manual supination-anterior drawer stress radiographs for evaluation of the severity of rotational instability, and to determine its clinical relevance.

Methods

Sixty-six patients with combined injuries of the anterior talofibular (ATFL) and calcaneofibular ligament (CFL) underwent three bilateral manual stress radiographs, and mean increments of anterior talar translation (mm), talar tilt (°), and talar rotation (%) in the injured ankle compared to the normal opposite side were measured with the technique. Intraobserver and interobserver reliability of each measure was assessed, and the difference in the degree of increments was compared according to the presence of additional cervical ligament insufficiency.

Results

Ankle stress radiographic intraobserver and interobserver agreement was ICC = 0.91 and 0.82 for talar rotation (%), ICC = 0.64 and 0.51 for anterior talar translation, and ICC = 0.78 and 0.71 for talar tilt angle, respectively. In group 2 including patients with combined injuries of the ATFL and CFL along with additional cervical ligament insufficiency, a significantly higher increment of talar rotation, mean 6.4 % (SD 3.4 %), was observed compared to that of talar rotation, mean 4.1 % (SD 2.7 %), in the other group (group 1) with an intact cervical ligament (p < 0.001).

Conclusions

A new comprehensive stress radiographic technique for diagnosis of chronic lateral ankle instability presented in this study might be a reliable and representable measurement tool to assess additional injury or instability of the subtalar joint.

Level of evidence

Prospective cohort study, Level II.

     

Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test,stress radiography,magnetic resonance imaging,and arthroscopy

Purpose

Clinicians frequently diagnose chronic ankle instability using the manual anterior drawer test and stress radiography. However, both examinations can yield incorrect results and do not reveal the extent of ankle instability. Stress ultrasound has been reported to be a new diagnostic tool for the diagnosis of chronic ankle instability. The purpose of this study was to assess the diagnostic value of stress ultrasound for chronic ankle instability compared to the manual anterior drawer test, stress radiography, magnetic resonance imaging (MRI), and arthroscopy.

Methods

Twenty-eight consecutive patients who underwent ankle arthroscopy and subsequent modified Broström repair for treatment of chronic ankle instability were included. The arthroscopic findings were used as the reference standard. A standardized physical examination (manual anterior drawer test), stress radiography, MRI, and stress ultrasound were performed to assess the anterior talofibular ligament (ATFL) prior to operation. Ultrasound images were taken in the resting position and the maximal anterior drawer position.

Results

Grade 3 lateral instability was verified arthroscopically in all 28 cases with a clinical diagnosis (100 %). Twenty-two cases showed grade III instability on the manual anterior drawer test (78.6 %). Twenty-four cases displayed anterior translation exceeding 5 mm on stress radiography (86 %), and talar tilt angle exceeded 15° in three cases (11 %). Nineteen cases displayed a partial chronic tear (change in thickness or signal intensity), and nine cases displayed complete tear on MRI (100 %). Lax and wavy ATFL was evident on stress ultrasound in all cases (100 %). The mean value of the ATFL length was 2.8 ± 0.3 cm for the stressed condition and 2.1 ± 0.2 cm for the resting condition (p < 0.001).

Conclusion

Stress ultrasound may be useful for the diagnosis of chronic ankle instability in addition to the manual anterior drawer test and stress radiography.

Level of evidence

III.

     

Evaluation of the coracoclavicular reconstruction using LARS artificial ligament in acute acromioclavicular joint dislocation

Purpose

The most appropriate procedure for surgical treatment of severe acromioclavicular (AC) joint dislocation was still not clear. The purpose of this study is to evaluate the outcomes of coracoclavicular (CC) reconstruction with ligament augmentation and reconstruction system (LARS) artificial ligaments for the treatment of acute complete AC joint dislocation.

Methods

Twenty-four patients (16 male and 8 female, ages ranged from 21 to 45) with acute complete AC joint dislocations were treated with CC reconstruction using LARS artificial ligaments. All these dislocations were unstable injuries. Clinical evaluation was used by the Constant scores and VAS. The radiographic evaluation consisted of Zanca radiographs for bilateral AC joint and axillary radiographs for the injured shoulder.

Results

All patients had follow-up times of 36 months (range 6–60). The Constant scores rose from 62.3 ± 6.9 preoperatively to 94.5 ± 9.3 at final evaluation (P < 0.05). Preoperative VAS scores were 5.1 ± 1.7, and the VAS scores at the last review were 0.7 ± 1.4 (P < 0.05). Follow-up radiographs showed anatomical reduction in 20 patients and slight loss of reduction in 4 patients. Calcification of CC ligament in 4 patients, degenerative change around the AC joint in 2 patient and clavicular osteolysis around screws in one patient were found.

Conclusions

LARS artificial ligament for reconstruction of CC can provide immediate stability and allow early shoulder mobilization with good functional results and few complications. This procedure was an effective and safe method to treat grade III and more AC joint dislocations.

Level of evidence

IV.

     

Preventive lateral ligament tester (PLLT): a novel method to evaluate mechanical properties of lateral ankle joint ligaments in the intact ankle

Purpose

To construct and evaluate an ankle arthrometer that registers inversion joint deflection at standardized inversion loads and that, moreover, allows conclusions about the mechanical strain of intact ankle joint ligaments at these loads.

Methods

Twelve healthy ankles and 12 lower limb cadaver specimens were tested in a self-developed measuring device monitoring passive ankle inversion movement (Inv-ROM) at standardized application of inversion loads of 5, 10 and 15 N. To adjust in vivo and in vitro conditions, the muscular inactivity of the evertor muscles was assured by EMG in vivo. Preliminary, test–retest and trial-to-trial reliabilities were tested in vivo. To detect lateral ligament strain, the cadaveric calcaneofibular ligament was instrumented with a buckle transducer. After post-test harvesting of the ligament with its bony attachments, previously obtained resistance strain gauge results were then transferred to tensile loads, mounting the specimens with their buckle transducers into a hydraulic material testing machine.

Results

ICC reliability considering the Inv-ROM and torsional stiffness varied between 0.80 and 0.90. Inv-ROM ranged from 15.3° (±7.3°) at 5 N to 28.3° (±7.6) at 15 N. The different tests revealed a CFL tensile load of 31.9 (±14.0) N at 5 N, 51.0 (±15.8) at 10 N and 75.4 (±21.3) N at 15 N inversion load.

Conclusions

A highly reliable arthrometer was constructed allowing not only the accurate detection of passive joint deflections at standardized inversion loads but also reveals some objective conclusions of the intact CFL properties in correlation with the individual inversion deflections. The detection of individual joint deflections at predefined loads in correlation with the knowledge of tensile ligament loads in the future could enable more individual preventive measures, e.g. in high-level athletes.

     

The improvement of postural control in patients with mechanical ankle instability after lateral ankle ligaments reconstruction

Purpose

Lateral ankle sprain is the most common injury. A previous study demonstrated that patients with mechanical ankle instability suffered deficits in postural control, indicating that structural damage of the lateral ankle ligaments may produce a balance deficit. The purpose of this study was to confirm that lateral ligaments reconstruction could improve postural control in patients with mechanical ankle instability.

Methods

A total of 15 patients were included in the study. Each patient had a history of an ankle sprain with persistent symptoms of ankle instability and a positive anterior drawer test and had been treated nonoperatively for at least 3 months. All patients were diagnosed with lateral ankle ligaments tear by ultrasonography and magnetic resonance imaging. They underwent arthroscopic debridement and open lateral ankle ligaments reconstruction with a modified Broström procedure. One day before and 6 months after the operation, all of the participants underwent single-limb postural sway tests. The anterior drawer test and the American Orthopedic Foot and Ankle Society scale score were used to evaluate the clinical results in these patients.

Results

At 6 months after the operation, with the patients’ eyes closed, there was significantly decreased postural sway in the anteroposterior direction, the circumferential area, and the total path length on the operated ankles compared with those measurements before the operation. With eyes open, however, no difference was found in postural sway before and after the operation.

Conclusions

Postural control was improved by reconstructing the lateral ligaments.

Level of evidence

IV.

     

Change in collateral ligament length and tibiofemoral movement following joint line variation in TKA

Purpose

The primary intent of total knee arthroplasty is the restoration of normal knee kinematics, with ligamentous constraint being a key influential factor. Displacement of the joint line may lead to alterations in ligament attachment sites relative to knee flexion axis and variance of ligamentous constraints on tibiofemoral movement. This study aimed to investigate collaterals strains and tibiofemoral kinematics with different joint line levels.

Methods

A previously validated knee model was employed to analyse the change in length of the collateral ligaments and tibiofemoral motion during knee flexion. The models shifted the joint line by 3 and 5 mm both proximally and distally from the anatomical level. The data were captured from full extension to flexion 135°.

Results

The elevated joint line revealed a relative increase in distance between ligament attachments for both collateral ligaments in comparison with the anatomical model. Also, tibiofemoral movement decreased with an elevation in the joint line. Conversely, lowering the joint line led to a significant decrease in distance between ligament attachments, but greater tibiofemoral motion.

Conclusion

Elevation of the joint line would strengthen the capacity of collateral ligaments for knee motion constraint, whereas a distally shifted joint line might have the advantage of improving tibiofemoral movement by slackening the collaterals. It implies that surgeons can appropriately change the joint line position in accordance with patient’s requirement or collateral tensions. A lowered joint line level may improve knee kinematics, whereas joint line elevation could be useful to maintain knee stability.

Level of evidence

V.

     

Predictive factors for the progression of spontaneous osteonecrosis of the knee

Purpose

To assess potentially predictive factors that were evaluated 1 year after the onset of symptoms in patients with spontaneous osteonecrosis of the knee (SONK) and to determine receiver operating characteristic (ROC) curve cut-off values.

Methods

Within 1 year of symptom onset, patients with SONK-selected treatment options, mainly based on severity of pain, chose either conservative treatment (n = 27 knees) or operative treatment (n = 27 knees). Knee and whole-leg radiographs, knee MRIs and bone mineral density scans of the lumbar spine, femoral neck and femoral condyles were obtained. The parameters measured were: (1) anatomical angle on whole-leg radiograph and (2) lesion size and medial meniscus extrusion on MRI.

Results

The anatomical angle and lesion size in the sagittal section (depth) on MRI were markedly larger in the operative treatment group than those in the conservative treatment group. The anatomical angle and depth on MRI of SONK at Stages 1–3 were significantly different between groups, with odds ratios (95 % confidence intervals) of 1.16 (1.18–2.34) and 1.11 (1.01–1.23). One year after symptom onset, ROC curve cut-off value for anatomical angle was 180° and depth on MRI was 20 mm.

Conclusion

An anatomical angle >180° and depth >20 mm on MRI were predictive factors for a poorer prognosis 1 year after symptom onset in patients with SONK. Our results on radiographs and MRI provided a predictive prognosis for patients with SONK at the initial visit to their orthopaedic surgeons.

Level of evidence

III.

     

Posterior cruciate ligament is twisted and flat structure: new prospective on anatomical morphology

Purpose

This cadaveric study aimed to elucidate PCL morphology by observing the anatomical relationship with other structures and the fibre layers of the PCL in cross section for remnant preserving PCL reconstruction.

Methods

Seventeen fresh-frozen cadaveric knees were studied, using the clock-face method to analyse the anatomical relationship between the PCL and Humphrey’s ligament. The width and thickness of the PCL, Humphrey’s and Wrisberg’s ligaments were measured. The PCL was cut sharply perpendicular to the tibia shaft, and the fibre layers were observed in cross section.

Results

The PCL was located between 12 and 4 o’clock in the right knee (8 and 12 o’clock in the left), while Humphrey’s ligament was located between 2 and 4 o’clock in the right knee (8 and 10 o’clock in the left). Humphrey’s ligament at femoral insertion, midsubstance and lateral meniscus insertion averaged 8.7 ± 2.3, 5.9 ± 2.1 and 6.1 ± 2.0 mm, respectively, while the thickness at each level averaged 2.0 ± 1.2, 1.6 ± 0.6 and 1.9 ± 0.6 mm. The width of the PCL at midsubstance and at medial meniscus level averaged 13.3 ± 2.0 and 11.0 ± 1.6 mm, respectively, while the thickness of the PCL averaged 5.4 ± 0.8 and 5.5 ± 1.4 mm. In cross section, multiple, interconnected layers were observed which could not be divided. The main layers at each level were aligned from the posterolateral to the anteromedial aspect and formed a C-shape at the medial meniscus level.

Conclusion

The PCL at midsubstance is flat. PCL appears as a twisted ribbon composed of many small fibres without clearly separate bundles. When remnant preserving PCL reconstruction is performed, it is necessary to take account of not only PCL morphology but also the ligaments of Humphrey and Wrisberg. These findings may affect the PCL footprint and the graft shape in the future remnant preserving PCL reconstruction.

     

Radiographic positions of femoral ACL,AM and PL centres: accuracy of guidelines based on the lateral quadrant method

Purpose

Femoral tunnel positioning is an important factor in anatomical ACL reconstructions. To improve accuracy, lateral radiographic support can be used to determine the correct tunnel location, applying the quadrant method. Piefer et al. (Arthroscopy 28:872–881, 2012) combined various outcomes of eight studies applying this method to one guideline. The studies included in that guideline used various insertion margins, imaging techniques and measurement methods to determine the position of the ACL centres. The question we addressed is whether condensing data from various methods into one guideline, results in a more accurate guideline than the results of one study.

Methods

The accuracy of the Piefer’s guideline was determined and compared to a guideline developed by Luites et al. (2000). For both guidelines, we quantified the mean absolute differences in positions of the actual anatomical centres of the ACL, AM and PL measured on the lateral radiographs of twelve femora with the quadrant method and the positions according to the guidelines.

Results

The accuracy of Piefer’s guidelines was 2.4 mm (ACL), 2.7 mm (AM) and 4.6 mm (PL), resulting in positions significantly different from the actual anatomical centres. Applying Luites’ guidelines for ACL and PL resulted in positions not significantly different from the actual centres. The accuracies were 1.6 mm (ACL) and 2.2 mm (PL and AM), which were significantly different from Piefer for the PL centres, and therefore more accurate.

Conclusions

Condensing the outcomes of multiple studies using various insertion margins, imaging techniques and measurement methods, results in inaccurate guidelines for femoral ACL tunnel positioning at the lateral view.

Clinical relevance

An accurate femoral tunnel positioning for anatomical ACL reconstruction is a key issue. The results of this study demonstrate that averaging of various radiographic guidelines for anatomical femoral ACL tunnel placement in daily practice, can result in inaccurate tunnel positions.

Level of evidence

Diagnostic study, Level 1.

     

Fluoroscopic control allows for precise tunnel positioning in MPFL reconstruction

Purpose

In MPFL reconstruction, anatomical graft positioning is required to restore physiological joint biomechanics and patellofemoral stability. Considerable rates of non-anatomical femoral tunnel placement exist. The purpose of this study was to analyse whether intraoperative fluoroscopic control is applicable to reduce variability of femoral tunnel positioning.

Methods

Femoral tunnel positions of 116 consecutive MPFL reconstructions applying intraoperative fluoroscopic images were analysed. Tunnel positions were determined by two independent observers according to Schöttle’s radiographic measurement method. Mean positions, standard deviations and ranges were calculated to determine the variability of the tunnel positions. Interclass correlation coefficient (ICC) was calculated.

Results

The mean anterior/posterior distances from the anatomical insertion of the MPFL to the centre of the femoral tunnel were 2.34 mm (range 0.0–5.9 mm) and 1.7 mm (range 0.1–7.3 mm, SD 1.3) for proximal/distal deviations; 95.7 % (111/116) of femoral tunnel positions were found to be within the anatomical insertion area defined by Schöttle. Interobserver tunnel position measurements were highly reliable (ICC: depth 0.979; height 0.979).

Conclusion

The study demonstrates that intraoperative fluoroscopic control is a feasible and effective method that enables to create reproducible and precise anatomical femoral tunnel positions in MPFL reconstruction. Accordingly, the routine use of intraoperative fluoroscopy can be recommended. Furthermore, the results indicate Schöttle’s method as a reliable method for intraoperative control and postoperative analysis of femoral tunnel positioning.

Level of evidence

IV.

     

Injuries of the scapholunate and lunotriquetral ligaments as well as the TFCC in intra-articular distal radius fractures. Prevalence assessed with MDCT arthrography

Objectives

To evaluate the prevalence of injuries of the scapholunate and lunotriquetral interosseous ligaments (SLIL, LTIL) as well as the triangular fibrocartilage complex (TFCC) in intra-articular distal radius fractures (iaDRF).

Methods

Two hundred and thirty-three patients with acute iaDRF underwent MDCT arthrography. The SLIL and LTIL were described as normal, partially or completely ruptured. Major injuries of the SLIL were defined as completely ruptured dorsal segments, those of the LTIL as completely ruptured palmar segments. The TFCC was judged as normal or injured. Interobserver variability was calculated. Injury findings were correlated with the types of iaDRF (AO classification).

Results

In 159 patients (68.2 %), no SLIL injuries were seen. Minor SLIL injuries were detected in 54 patients (23.2 %), major injuries in 20 patients (8.6 %). No correlation was found between the presence of SLIL lesions and the types of iaDRF. Minor LTIL injuries were seen in 23 patients (9.9 %), major injuries in only 5 patients (2.2 %). The TFCC was altered in 141 patients (60.5 %). Interobserver variability was high for MDCT arthrography in assessing SLIL and TFC lesions, and fair for LTIL lesions.

Conclusion

In iaDRF, prevalence of major injuries of the most relevant SLIL is about 9 % as evaluated with CT arthrography.

Key Points

? The C-shaped SLIL is built of dorsal, middle and palmar segments. ? In iaDRF, major SLIL injuries are associated in 8.6 % of the cases. ? In iaDRF, the SLIL remains intact in 68.3 % of the cases. ? IaDRF and SLIL ruptures can comprehensively be depicted with MDCT arthrography. ? A three-compartment approach is recommended to assess intrinsic ligaments and the TFCC.

     

Deltoid ligament in acute ankle injury: MR imaging analysis

Objective

To identify the pattern of deltoid ligament injury after acute ankle injury and the relationship between ankle fracture and deltoid ligament tear by magnetic resonance imaging (MRI).

Materials and methods

Thirty-six patients (32 male, and 4 female; mean age, 29.8 years) with acute deltoid ligament injury who had undergone MRI participated in this study. The deltoid ligament was classified as having 3 superficial and 2 deep components. An image analysis included the integrity and tear site of the deltoid ligament, and other associated injuries. Association between ankle fracture and deltoid ligament tear was assessed using Fisher’s exact test (P?<?0.05).

Results

Of the 36 patients, 21 (58.3 %) had tears in the superficial and deep deltoid ligaments, 6 (16.7 %) in the superficial ligaments only, and 4 (11.1 %) in the deep ligaments only. The most common tear site of the three components of the superficial deltoid and deep anterior tibiotalar ligaments was their proximal attachments (94 % and 91.7 % respectively), and that of the deep posterior tibiotalar ligament (pTTL) was its distal attachment (82.6 %). The common associated injuries were ankle fracture (63.9 %), syndesmosis tear (55.6 %), and lateral collateral ligament complex tear (44.4 %). All the components of the deltoid ligament were frequently torn in patients with ankle fractures (tibionavicular ligament, P?=?0.009).

Conclusion

The observed injury pattern of the deltoid ligament was complex and frequently associated with concomitant ankle pathology. The most common tear site of the superficial deltoid ligament was the medial malleolar attachment, whereas that of the deep pTTL was near its medial talar insertion.

     

The horizontal Y-shaped graft with respective graft tension angles in anatomical two-bundle medial patellofemoral ligament reconstruction

Purpose

Various techniques for medial patellofemoral ligament (MPFL) reconstruction have been described with two bundles of graft tensioned simultaneously. The present study was to introduce an anatomical reconstruction procedure using a horizontal Y-shaped graft with respective graft tension angles and report the preliminary results.

Methods

A surgical technique for MPFL reconstruction using a horizontal Y-shaped semitendinosus tendon autograft with two bundles tensioned at 0° and 30° of knee flexion was described in detail. The patellar stability was evaluated with the apprehension test and an axial computed tomography (CT) scan at 30° of knee flexion. The knee function was evaluated using the Lysholm and Kujala scores.

Results

No recurrent dislocation or subluxation was reported for 45 patients at a mean of 33.7-month follow-up. On CT images, congruence angle, patellar tilt angle, lateral patellar angle and lateral displacement were restored to the normal range. At the last follow-up, the mean Lysholm score improved from 51.8 ± 6.2 to 91.7 ± 4.1 and mean Kujala score was from 53.4 ± 5.3 to 90.9 ± 6.6 (P < 0.01).

Conclusions

The present anatomical MPFL reconstruction technique with a horizontal Y-shaped two-bundle graft tensioned at respective knee flexion angles could not only recreate the fan-shape of MPFL but also mimic the function bundles of native ligament. Clinical follow-up confirms the good restoration of the patellar stability and significant improvement of knee function without special complications.

Level of evidence

Therapeutic, Level IV.

     

Optimal entry position on the lateral femoral surface for outside-in drilling technique to restore the anatomical footprint of anterior cruciate ligament

Purpose

To investigate the optimal starting points for drilling on the lateral femoral condyle for better coverage of the anatomical footprint of the anterior cruciate ligament (ACL) using the outside-in (OI) technique in a single-bundle ACL reconstruction.

Methods

Femoral tunnel drilling was simulated on three-dimensional bone models from 40 subjects by connecting the centre of the ACL footprint with various points on the lateral femoral surface. The percentage of the femoral footprint covered by apertures of the virtual tunnel sockets with 9 mm diameter was calculated for each tunnel.

Results

The mean percentages of the femoral footprint covered by the apertures of the virtual tunnel sockets were significantly higher when drilled at 2 and 3 cm from the lateral epicondyle on a 45° line and a 60° line anterior from the proximal–distal axis than the other points. However, articular cartilage damage was occurred in nine subjects at 3 cm on a 60° line and eight subjects at 3 cm on a 45° line. Posterior wall blowout occurred in five subjects at 3 cm on a 45° line. Thus, OI drilling at 3 cm from the epicondyle has a risk of these complications.

Conclusion

During the OI drilling of the femoral tunnel, connecting the centre of the anatomical footprint of the ACL and the entry drilling point at 2 cm from the lateral epicondyle on between the 45° line and the 60° line anterior from the proximal–distal axis provides an oval-shaped socket aperture that covers and restores the native ACL footprint as nearly as possible.

Level of evidence

III.

     

Umbilical venous catheters placement evaluation on frontal radiogram: application of a simplified flow-chart for radiology residents

Background

Umbilical Venous Catheter (UVC) are commonly used in neonatal period; they can be not correctly positioned and could be associated with complications. The purpose of this article is to suggest a flow-chart to evaluate the placement of UVC, testing it in young radiologists-in-training.

Method

We developed a simple flow-chart to asses, steps by step, UVC placement considering its course and tip location (ideally placed in the atriocaval junction). We tested the flow-chart impact asking to 20 residents to evaluate the placement of 10 UVC before and after they familiarized with the flow-chart and the anatomical findings of a newborn. The agreement among the 20 students was evaluated too.

Results

The number of correct characterizations was different due to the administration of the flow-chart. One hundred and six correct UVC assessments at the beginning switched to 196 after the administration of the flow-chart (p = 0.0001). The observed agreement among the twenty radiology residents was statistically significant, both before (kappa = 0.41, p < 0.001) and after (kappa = 0.37, p < 0.001) the flow-chart administration.

Conclusion

The developed flow-chart demonstrated to be useful in increasing residents performance in UVC placement assessment.

     

Femoral rotation in total knee arthroplasty: a comparison of patient individualized jigs with gap balancing in relation to anatomic landmarks

Purpose

The purpose of our study was to compare the accuracy of the rotational position of the femoral component in total knee arthroplasty aligned with patient individualized jigs (PSJ) to a gap balancing technique (GBT).

Methods

A consecutive series of 21 osteoarthritic patients were treated with 22 cruciate-retaining total knee prostheses. During surgery, the rotation of the femoral component pinholes was recorded for all knees using PSJ and GBT and transferred to computer tomograms (CT). The rotational differences between PSJ and GBT relative to the transepicondylar axis were analysed.

Results

The medium rotation of the femoral component pinholes was 1.3° ± 5.1° (min = ?6.3°; max = 14.4°) for PSJ and 0.1 ± 1.4° (min = ?1.6°; max = 3.4°) for GBT. Outliers of more than 3° were found more frequently with PSJ in 12 cases but only in one for GBT.

Conclusion

Based on our study, we would not recommend relying intra-operatively solely on the CT-based PSJ without the option to adjust or control femoral rotation.

Level of evidence

II.

     

Long-Term Results from the MAJESTIC Trial of the Eluvia Paclitaxel-Eluting Stent for Femoropopliteal Treatment: 3-Year Follow-up

Purpose

To report the 3-year results of the MAJESTIC first-in-human study of the Eluvia Drug-Eluting Vascular Stent System for treating femoropopliteal artery lesions.

Methods

The prospective, single-arm, multicenter clinical trial enrolled 57 patients with symptomatic lower limb ischemia (Rutherford category 2, 3, or 4) and lesions in the superficial femoral artery or proximal popliteal artery. Mean lesion length was 70.8 ± 28.1 mm, and 46% of lesions were occluded. Efficacy measures at 2 years included primary patency, defined as duplex ultrasound peak systolic velocity ratio of ≤2.5 and the absence of target lesion revascularization (TLR) or bypass. Safety monitoring through 3 years included adverse events and TLR.

Results

Primary patency was estimated as 83.5% (Kaplan–Meier analysis) at 24 months, and 90.6% (48/53) of patients maintained an improvement in Rutherford class. At 36 months, the Kaplan–Meier estimate of freedom from TLR was 85.3%. No stent fractures were identified, and no major target limb amputations occurred.

Conclusion

MAJESTIC results demonstrated long-term treatment durability among patients whose femoropopliteal arteries were treated with the paclitaxel-eluting Eluvia stent.

Level of Evidence

Level 2b, cohort study