正常踝距腓前韧带和跟腓韧带的解剖学观察及其MRI扫描方法 学的研究

目的 寻找踝节外侧韧带于自然体位下MRI显示最佳的扫描方位.资料与方法 首先解剖6例(12个踝节)自然体位的正常踝节标本,分离出外侧韧带,测量其走行角度,据此制定MRI扫描方案;然后对25名自愿者(50个踝节)行不同方位MRI扫描,比较不同扫描方位上各韧带的显示效果.结果 距腓前韧带(ATFL),在-20°斜断面显示效果最佳,评分最高;-15°和-25°斜断面显示效果次之;横断面和-30°斜断面显示效果不及上述断面;冠状面和矢状面显示效果最差.跟腓韧带(CFL)在15°斜断面显示效果最佳,评分最高;20°和25°斜断面显示效果次之;30°斜断面显示效果不及上述断面;横断面、冠状面和矢状面显示效果最差.结论 MRI评价踝节外侧韧带时,选择适当的扫描方位可以达到最佳的显示效果.     

慢性踝关节外侧不稳定距腓前韧带和跟腓韧带解剖重建

目的:探讨踝关节镜微创技术结合解剖重建距腓前韧带/跟腓韧带(ATFL/CFL)治疗慢性踝关节外侧不稳定的疗效。方法:自2010年1月至2013年12月共计52例(52踝)保守治疗无效的慢性踝关节外侧不稳定(ATFL/CFL损伤)患者纳入研究,随机分为A、B两组,A组采用改良brostrom法(锚钉-韧带-骨膜双重锚定法)缝合修复,B组取自体半腱肌腱行ATFL/CFL双束解剖重建。对术前、术后2年AOFAS足踝评分、患者主观感觉、VAS疼痛评分、距骨前移及倾斜、踝关节活动度进行评估,对比两组的疗效差异。结果:平均随访34.7月(2~5年),两组患者均无感染、神经损伤、皮缘坏死、后足僵硬等并发症,半腱肌腱供区无不适,末次随访无不稳定复发。术后2年A、B两组在踝关节跖屈、背伸、外翻活动度上无差异,在踝关节内翻(P=0.025)、距骨倾斜(P=0.025)与前移(P=0.020)改善方面B组优于A组,重建相较于修复显示出更佳的稳定性。AOFAS评分A组由术前46.90±9.10改善至术后2年87.15±4.22(P=0.000),B组由术前46.50±9.95改善至术后2年93.70±5.00(P=0.000),术后2年组间比较存在差异(P=0.035)。两组在疼痛、异常步态、自主活动及功能、前后屈伸活动、后足活动及对线评分项目上无明显差异;在地面步行(P=0.045)、最大步行距离(P=0.042)、稳定性评分(P=0.045)上组间有差异。VAS视觉疼痛评分A组由术前7.10±5.30改善至术后2年2.05±1.95(P=0.000),B组由术前6.95±4.40改善至术后2年2.12±1.88(P=0.000),术后2年组间比较无差异(P=0.450)。主观评级术后2年A组优良率87.5%,B组95.83%(P=0.001);两组内AOFAS客观评分与主观评级相当,主客观评价统一度较好。结论:依托关节镜技术,借鉴尸体解剖数据,半腱肌腱双束解剖重建ATFL/CFL在有效恢复踝关节外侧稳定性的同时避免了后足僵硬等常见并发症,尤其适用于功能期望值较高的青壮年患者及韧带残端质量较差的翻修手术。手术切口的改进及保残技术有助于降低术区神经损伤几率,恢复本体感觉,符合快速康复的理念,长期随访有待于进一步观察。     

Anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon graft in rugby players

The purpose of this study was to evaluate prospectively the results of anterior cruciate ligament (ACL) reconstruction with doubled hamstring tendon graft in a selected group of 18 rugby players. The graft was fixed with a transcondylar screw (Transfix) on the femur, and with an absorbable interference screw and a metallic staple on the tibia. All the patients followed the same rehabilitation program. Return to sports activities was allowed after 6 months. Follow-up was 2 years in all cases. The athletic level of the patients was rated according to the Tegner scoring system. Clinical results were evaluated using the International Knee Documentation Committee (IKDC) scoring system. Furthermore, an instrumented evaluation of the anterior laxity with a KT–1000 arthrometer, and an isokinetic evaluation were performed 6 and 24 months after surgery. The Tegner mean score at follow-up (8.2) was similar to that prior to injury (8.3). IKDC overall results were normal in ten cases (55.6%), nearly normal in six cases (33.3%), and abnormal in two cases (11.1%). Side-to-side difference of anterior laxity measured with KT–1000 at 6 and 24 months did not show an impairment of knee stability with time. Isokinetic evaluation showed a significant improvement on peak torque both in extension and flexion on comparison between 6- and 24-month measurements. The results reported in this study showed that the use of doubled hamstring tendon graft for ACL reconstruction in athletes that were at risk for high-energy traumas to the knees, such as rugby players, gave normal or nearly normal results in about 90% of the cases. Recovery of muscle strength was almost complete 2 years after surgery, and there was no impairment of knee stability with time.     

Is the contralateral tibia a reliable template for reconstruction: a three-dimensional anatomy cadaveric study

Purpose

The contralateral anatomy is regularly used as a reconstruction template for corrective osteotomies of several deformities and pathological conditions. However, there is lack of evidence that the intra-individual differences between both tibiae are sufficiently small to use the contralateral tibia as a 3D reconstruction template for complex osteotomies. The aim of this study was to evaluate the intra-individual side differences of the tibia in length, torsion, angulation, and translation using 3D measurement techniques.

Methods

3D surface models of both tibiae were created from computed tomography data of 51 cadavers. The (mirrored) models of the right tibiae were divided into two halves at the centre of the shaft. Thereafter, the proximal and distal segments were aligned to the left (contralateral) tibia in an automated fashion. The relative 3D transformation between both aligned segments was measured to quantify the side difference in 6° of freedom (3D translation vector, 3 angles of rotation).

Results

The mean side difference in tibia length was 2.1 mm (SD 1.3 mm; range 0.2–5.9 mm). The mean side difference in torsion was 4.9° (SD 4.1°; range 0.2°–17.6°). The mean side difference in the coronal and sagittal planes was 1.1° (SD 0.9°; range 0.0°–4.6°) and 1.0° (SD 0.8°; range 0.1°–2.9°), respectively.

Conclusion

The present study confirms small side differences in torsion between the left and right tibia, while the side differences in the coronal and sagittal plane are probably negligible. The contralateral tibia seems to be a reliable reconstruction template for the 3D preoperative planning of complex corrective osteotomies of the tibia. However, torsional differences should be interpreted with caution, as a single cut-off value of a clinically relevant torsional side difference cannot be defined. The presented results are relevant to surgeons considering the contralateral tibia as a 3D reconstruction template for corrective osteotomies of the tibia.

Level of evidence

Basic science.

     

Shape and size of the medial patellofemoral ligament for the best surgical reconstruction: a human cadaveric study

Purpose

The aim of this study was to investigate the shape and the attachments of the medial patellofemoral ligament (MPFL) in cadaver specimens to determine an anatomical basis for the best MPFL reconstruction.

Methods

Twenty fresh-frozen knees were used. Dissection protocol implied performing dissections from within the knee joint. We investigated the shape and the attachments between the MPFL and the quadriceps tendon, the patellar and femur insertions, and all the other relationships with the medial soft tissues of the knee.

Results

The distal fibers of MPFL were interdigitated with the deep layer of the medial retinaculum. All isolated ligament had a sail-like shape with the patellar side bigger than the femoral side. The femoral insertion, distinct both from medial epicondyle and adductor tubercle, was located at 9.5 mm (range 4–22) distal and anterior respect to adductor tubercle and proximal and posterior to epicondyle. The medial third of the thickness of patella was involved in the insertion. The proximal third of the patella is always involved in the MPFL attachment; in 45 % of the cases, it was extended to the medial third and in one case, an extension at the distal third was found. Additionally in 35 % (7 cases), it extended to the quadriceps tendon and it were inconstantly attached at the vastus medialis obliques (VMO) tendon and at the vastus intermedius (VI) tendon in an aponeurotic structure.

Conclusions

The MPFL is a distinct structure that goes from patella to femur with a sail-like shape; its patellar insertion, that mostly occur via an aponeurosis tissue with VMO and VI, is at the proximal third of the patella but it may extend in some cases to the medial third patella or to the quadriceps tendon, or very rarely to the distal third of the patella. In the femoral side, the MPFL is inserted in its own site, in most cases distinct both from epicondyle and adductor tubercle, located on average at a 9.5 mm distance distally and anteriorly in respect to the adductor tubercle. Its lower margin was difficult to define. Given the importance of this structure, it must be reconstructed as anatomically as possible in its insertion and in its shape. Many attempts have been made to make functional reconstructions with less than excellent results.     

Anterior cruciate ligament reconstruction with double-looped semitendinosus and gracilis tendon graft directly fixed to cortical bone: 5-year results

Forty-three patients who had undergone an anterior cruciate ligament (ACL) reconstruction using a doubled semitendinosus and gracilis graft were prospectively reviewed at 5-year follow-up. All had suffered subacute or chronic tears of the ligament. At surgery, the femoral tunnel was drilled first through the antero-medial portal. The correct position of the femoral and tibial guide wire was checked fluoroscopically. A cortical fixation to the bone was achieved in the femur with a Mitek anchor, directly passing the two tendons in the slot of the anchor, and in the tibia with an RCI screw, supplemented with a spiked washer and bicortical screw. Rehabilitation was aggressive, controlled and without braces. The International Knee Documentation Committee (IKDC) form, KT-1000 arthrometer, and Cybex dynamometer were employed for clinical evaluation. A radiographic study was also performed. At the 5-year follow-up all the patients had recovered full range of motion and 2% of them complained of pain during light sports activities. Four patients (9.5%) reported giving-way symptoms. The KT-1000 side-to-side difference was on average 2.1 mm at 30 lb, and 68% of the knees were within 2 mm. The final IKDC score showed 90% satisfactory results. There was no difference between the 2-year and 5-year evaluations in terms of stability. Extensor and flexor muscle strength recovery was almost complete (maximum deficit 5%). Radiographic study showed a tunnel widening in 32% of the femurs and 40% of the tibias. A correlation was found between the incidence of tibial tunnel widening and the distance of the RCI screw from the joint (the closer the screw to the joint, the lower the incidence of widening). In conclusion, we can state that, using a four-strand hamstring graft and a cortical fixation at both ends, we were able to achieve satisfactory 5-year results in 90% of the patients.     

Biomechanical evaluation of using one hamstrings tendon for ACL reconstruction: a human cadaveric study

Harvesting both the semitendinosus and gracilis tendons for anterior cruciate ligament (ACL) reconstruction has a negative impact on muscle strength as well as knee function and stability. With a new “All-inside” technique, using only one hamstrings tendon (semitendinosus or gracilis) is possible because of a reduction in length requirements. The research question of this in vitro study was whether the use of only one hamstrings tendon (semitendinosus or gracilis) could restore knee kinematics and in situ force in the ACL to the level of an intact knee. Ten human cadaveric knees were tested in the following conditions: (1) intact, (2) ACL-deficient, and (3) ACL reconstruction with the “All-inside” technique using the (a) single semitendinosus tendon graft, or (b) single gracilis tendon graft. Using a robotic testing system, external loads, i.e. (1) an anterior tibial load of 134-N and (2) combined rotatory loads of 10-Nm valgus and 5-Nm internal tibial torques, were applied. The multiple degrees of freedom knee kinematics and the in situ forces in the ACL and ACL grafts were determined. In response to a 134-N anterior tibial load, the use of either graft could restore anterior tibial translation to within 1.3 mm of the intact knee. The in situ forces in the two grafts were not significantly different from those of the intact ACL. Under the combined rotatory loads, both grafts could restore knee kinematics as well as the in situ force in the grafts to the level of the intact ACL. The “All-inside” technique using either the semitendinosus or gracilis tendon for ACL reconstruction could satisfactorily restore time-zero knee kinematics and the in situ forces in either graft to those for the intact ACL, supporting clinical findings.     

距腓前韧带和距腓后韧带夹角对诊断慢性距腓前韧带损伤的作用

目的:评估机械性踝关节不稳患者中距腓前韧带(anterior talofibular ligament,ATFL)和距腓后韧带(posterior talofibular ligament,PTFL)之间的夹角,以提供一种诊断慢性ATFL损伤的新的间接诊断方法。方法:100名测试对象纳入本研究,其中50名为机械性踝关节不稳患者(A组),50名为因其他疾病至我院就诊、非踝关节不稳的患者(B组)。每名测试对象均在MRI横断面上测量ATFL与PTFL的夹角,并比较两组患者的差异。结果:机械性踝关节不稳组患者较对照人群ATFL和PTFL的夹角明显增大(82.1°±8.0°vs 74.4°±5.9°,P<0.01)。计算受试者工作特征曲线(receiver operating characteristiccurve,ROC)下面积为0.784,P<0.01,有高度统计学意义,表明ATFL与PTFL的夹角对于慢性ATFL损伤的诊断有意义。利用其曲线坐标计算出当ATFL与PTFL之间的夹角为79°时具有较高的灵敏度与特异度,分别为0.88和0.64。结论:机械性踝关节不稳患者ATFL与PTFL的夹角明显增大。当ATFL与PTFL夹角大于79°时,慢性ATFL损伤的可能性升高。     

Sonography of the glenoid labrum: a cadaveric study with arthroscopic correlation

OBJECTIVE: We assessed the usefulness of sonography in evaluating the glenoid labrum in cadaveric specimens using arthroscopy as a standard of reference. MATERIALS AND METHODS: Eighty labral quadrants in 20 cadaveric shoulders were examined by two musculoskeletal radiologists using 5- to 7-MHz linear and curvilinear transducers. Agreement was reached by consensus. After sonography, arthroscopy was performed by an experienced orthopedic surgeon. Each labral quadrant was classified at the time of sonography and arthroscopy as normal, degenerated, or torn. RESULTS: Concordance between sonography and arthroscopy was 86% (69/80 quadrants). In differentiating abnormal labrum (tear or degeneration) from normal labrum using sonography, sensitivity was 63%, specificity was 98%, positive predictive value was 94%, negative predictive value was 86%, and accuracy was 88%. In differentiating labral tears from other labral conditions (degeneration or normality), sensitivity was 67%, specificity was 99%, positive predictive value was 67%, negative predictive value was 99%, and accuracy was 98%. CONCLUSION: Sonography has a promising role in the evaluation of the glenoid labrum, particularly in excluding labral tears when the labra appear normal on sonography. Further studies are required using normal and symptomatic patients to determine the usefulness of sonography in the diagnosis of labral abnormalities.     

The effectiveness of reconstruction of the anterior cruciate ligament using the novel knot/press-fit technique: a cadaveric study

BACKGROUND: A variety of fixation devices are used for anterior cruciate ligament reconstruction with hamstring tendon grafts. These devices increase costs and can present artifacts in magnetic resonance imaging as well as complications in revision surgery. Therefore, a novel knot/press-fit technique that requires no implantable devices has been introduced. NULL HYPOTHESIS: The knot/press-fit technique restores knee kinematics as well as the more commonly used EndoButton CL fixation and has similar biomechanical properties as other devices published in the literature. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric knees (52 +/- 7 years) were tested using a robotic/universal force-moment sensor testing system. The knee kinematics of the intact, anterior cruciate ligament-deficient, EndoButton-reconstructed, and knot/press-fit-reconstructed knee in response to both a 134-N anterior tibial load and a combined rotatory load at multiple knee flexion angles was determined. Differences between the 4 knee states were evaluated with a 2-factor repeated-measures analysis of variance (P < .05). To determine the stiffness and strength of the knot/press-fit fixation, the femur-graft-tibia complex was tested in uniaxial tension. RESULTS: In response to an anterior tibial load, the anterior tibial translation for the knot/press-fit reconstruction was found to be not significantly different from that of the intact anterior cruciate ligament as well as that of the EndoButton reconstruction (P > .05). In response to a combined rotatory load, neither reconstruction procedure could effectively reduce the coupled anterior tibial translation to that of the intact knee, and no significant difference between the 2 reconstructions could be detected (P > .05). The stiffness of the knot/press-fit complex was found to be 37.8 +/- 9.6 N/mm, and the load at failure was 540 +/- 97.7 N, which is equal to other devices published in the literature. CLINICAL RELEVANCE: The experiment suggests that the knot/press-fit technique may be a reliable alternative for the femoral fixation of hamstring tendon grafts.     

Knee laxity after ACL reconstruction with a BPTB graft

The objective of the study was to compare prospectively short-term and mid-term results after ACL reconstruction with special focus on changes in instrumented knee laxity. METHODS: The original study group included prospectively 58 patients who underwent arthroscopically assisted ACL reconstruction with BPTB graft in a two-tunnel technique between 1991 and 1993. Seven patients were lost to follow-up, leaving 51 patients for a first follow-up at 6 months and a second follow-up at 3-6 years (mean 4.3 years). Clinical results were evaluated by means of the Lysholm score and the IKDC score. Laxity was assessed using a KT-1000 arthrometer applying an 89 N anterior load in 20 degrees of flexion. Increased laxity was defined as a 3 mm increase in AP translation between the first and the second follow-up. RESULTS: At mid-term follow-up pivot shift was negative in 86% of cases. IKDC score: normal = 28%, nearly normal = 44%, abnormal = 24%, severely abnormal = 4%. KT-1000: < 3 mm = 68%, 3-5 mm = 24%, > 5 mm = 8%. The mean KT-1000 side-to-side difference was 1.08 (0.17) mm at 6 months and 2.01 (0.29) mm at 3-6 years. The difference was statistically significant (P < 0.005). According to the defined criteria, seven patients had increased laxity at the second follow-up, suggesting a malfunction of the graft due to stretch-out or injury. In this subgroup the mean KT-1000 measurements were 0.86 (0.26) mm at the first follow-up and 5.93 (0.54) mm at the second follow-up. In five of these patients, a malposition of the tunnels was identified as a possible cause. In the remaining group, KT-1000 measurements did not differ significantly between the first and the second follow-up [1.12 (0.20) mm versus 1.37 (0.21) mm]. CONCLUSIONS: Increase in AP laxity occurred in 14% of our cases between the first and the second follow-up. In most of these cases increased laxity was due to inadequate surgical technique, especially malposition of bony tunnels. If tunnel position was correct, there was no evidence for elongation of grafts over time as a general principle.     

Robotically assisted nerve and facet blocks: a cadaveric study

RATIONALE AND OBJECTIVES: This study was performed to evaluate the feasibility of using a joystick-controlled robotic needle driver to place a 22-gauge needle for nerve and facet blocks. MATERIALS AND METHODS: Biplane fluoroscopy and a robotic needle driver were used to place 12 needles into the lumbar paraspinal region of an embalmed female cadaver (age at death, 98 years). Small metal BB nipple markers (1 mm in diameter) were inserted percutaneously to serve as targets. Six needles were then placed near the nerve root, and six were placed near the facet root. Anteroposterior and lateral radiographs were obtained after each needle placement to assess its accuracy. RESULTS: All needles were placed within 3 mm of the target BB. The average distance was 1.44 mm +/- 0.66 (standard deviation). DISCUSSION: A robotic needle driver can be used to place needles accurately in the nerve and facet regions. Clinical studies are required to investigate the advantages and disadvantages of this system for interventional procedures involving needles.     

Morphometry of the semitendinosus and gracilis tendons with application to anterior cruciate ligament reconstruction

The length and cross-sectional area of human semitendinosus and gracilis tendons were measured in both single- and multi-strand configurations for the purpose of anterior cruciate ligament graft preparation. The average lengths of the semitendinosus and the gracilis tendons were 235±20 mm (mean±SD) and 200±17 mm, respectively. The cross-sectional area of a doubled semitendinosus tendon (two strands) was significantly less than that of a 10-mm-wide patellar tendon graft (P<0.001). The cross-sectional area of the tripled semitendinosus tendon (three strands) and the 10-mm-wide patellar tendon were similar. Doubling of the combined semitendinosus and gracilis tendons (four strands) and tripling of this combination (six strands) resulted in a significantly greater cross-sectional area in comparison to the 10-mm-wide patellar tendon (P<0.05, four strands;P<0.001 six strands). This investigation demonstrates that anterior cruciate ligament grafts fashioned using multiple-strand combinations of the semitendinosus and gracilis tendons result in a cross-sectional area that is comparable to the bone-patellar tendon-bone graft. This is an important finding since cross-sectional area reflects the intra-articular volume of collagenous tissue. This information should be helpful to surgeons considering using the hamstring tendons as an anterior cruciate ligament graft.     

The effect of graft placement on the clinical outcome of the anterior cruciate ligament reconstruction: a prospective study

The effect of the graft placement on the clinical outcome of patients after anterior cruciate ligament (ACL) reconstruction has been studied sparsely. We conducted a prospective follow-up of 140 patients who underwent an arthroscopic ACL reconstruction with a hamstring graft. One hundred and four of them (74%) could be examined at the 2-year follow-up. Clinical examination included Lysholm, Tegner, and International Knee Documentation Committee rating scores, arthrometric anterior–posterior knee laxity assessment, and muscle strength assessments. The graft placement was measured from lateral radiographs using a system recommended for measuring the attachment positions of the cruciate ligaments as well as a method called ‘the sumscore of the graft placement’, which takes into account both the femoral and the tibial graft placements simultaneously. The sumscore was smaller in knees with normal anterior–posterior knee laxity in the Lachman test (P = 0.002) and normal rotational knee laxity in the pivot shift test (P = 0.01) than in those with abnormal laxity. The tibial graft placement was more anterior when the Lachman test was normal (P = 0.04). The Lysholm score was better when the femoral graft placement was more posterior (r = −0.20, P = 0.04). The optimal femoral graft placement was between 25 and 29% of length of the femoral condyle along the Blumensaat’s line from posterior to anterior. The optimal tibial graft placement was between 32 and 37% of the length of the tibial plateau from the anterior corner, and the optimal sumscore was between 61 and 66. The sumscore and its components (the femoral and tibial graft placements) showed a clear association with the clinical outcome of the patients. The best outcome was achieved when the sumscore was small; that is the graft placement showed posterior enough in the femur, and anterior enough in the tibia.     

Complications in medial meniscus suture: a cadaveric study

The aim of this study was to examine the possibility of complications in medial meniscus repair using an inside-out suturing device. Anatomical cadaveric study. Six fresh frozen cadaveric lower limbs were used. The posterior horn of the medial meniscus was sutured using three vertical stitches. An anatomical dissection was subsequently performed to check for any possible effects upon the structures of the medial aspect of the knee. In addition, an incision was made in a safety zone in order to ascertain whether it was possible to carry out the suture without affecting the aforementioned structures. No vascular or nervous structures were pierced by the needle. On knotting, it was found that a number of different structures had become trapped: the sartorial tendon was affected in each of the specimens used. In four cases, the saphenous vein was trapped by some of the knots. The saphenous nerve was trapped in four instances. Once this had been established, a small accessory incision was made to provide access to a safety zone, where suture can be performed without affecting any neurovascular or tendinous structures. Inside-out suture of the posterior meniscal horn carries a high incidence of entrapment of the neurovascular structures of the medial aspect of the knee. The sartorial tendon is constantly affected. Such complications can easily be avoided by entering the safety zone via a small auxiliary incision. This study provides evidence that complications affecting the peripheral structures of the medial aspect of the knee may arise during inside-out suture of the posterior horn of the medial meniscus and proposes a simple method of averting them.     

Anterior cruciate ligament reconstruction with a reharvested bone-patellar tendon-bone graft

We sought to determine the results in patients who underwent revision anterior cruciate ligament reconstruction with a reharvested bone-patellar tendon-bone graft. Preoperative magnetic resonance imaging of the patellar tendon was used to determine the width of the tendon and the quality of the tissue. The section of the tendon harvested included 7 to 8 mm of the regenerated tendon and 2 to 3 mm of previously untouched tendon either medial or lateral to the healed tissue. The mean time from primary graft harvest to reharvest was 71.0 +/- 44 months (range, 32 to 180). An accelerated rehabilitation program was used postoperatively. Objective follow-up of more than 2 years after surgery was available for 8 patients at a mean of 49.0 +/- 15.4 months. The average range of motion in the anterior cruciate ligament-reconstructed knee was 6/0/133 at 1 month postoperatively and 6/0/145 at long-term follow-up. The mean manual maximum KT-1000 arthrometer difference between knees was 1.6 +/- 1.2 mm. The mean isokinetic quadriceps muscle strength of the reharvested graft donor knee was 103% +/- 7% of that of the opposite knee. Subjective scores were obtained from 11 patients (12 knees) at a mean of 51.5 +/- 35.7 months (range, 24 to 150) after surgery; the mean score was 89.3 +/- 6.9 points. We conclude that with appropriate preoperative planning, a reharvested patellar tendon can be used for revision anterior cruciate ligament reconstruction to obtain reliable stability and strength postoperatively.     

Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system

BACKGROUND: Few anatomical and minor invasive procedures have been reported for surgical reconstruction of the lateral ligaments to treat lateral instability of the ankle. Furthermore, there are no standards according to which ligaments should be reconstructed. HYPOTHESIS: A new technique for anatomically reconstructing the lateral ligaments of the ankle using an interference fit anchoring system and determining which ligaments need to be reconstructed according to the results of standard stress radiography of the talocrural and subtalar joints will be effective for treating lateral instability of the ankle. STUDY DESIGN: Case series; level of evidence, 4. METHODS: Twenty-one patients with lateral instability of the ankle underwent surgery using the proposed interference fit anchoring system. Standard stress radiographs of the subtalar joint were performed, and if the talocalcaneal angle was less than 10 degrees , only the anterior talofibular ligament was reconstructed; if there was a 10 degrees or greater opening of the talocalcaneal angle, both the anterior talofibular ligament and the calcaneofibular ligament were reconstructed. RESULTS: In the 17 patients who received only the anterior talofibular ligament reconstruction, the mean talar tilt angle on standard stress radiography of the talocrural joint was 14.5 degrees +/- 1.7 degrees before surgery and 2.6 degrees +/- 0.8 degrees 2 years after surgery (P < .0001). For the 4 patients who had both the anterior talofibular ligament and calcaneofibular ligament reconstructed, the mean talar tilt angle was 16.5 degrees +/- 1.5 degrees before surgery and 3.0 degrees +/- 0.5 degrees 2 years after surgery (P = .0015). The overall mean talocalcaneal angle on standard stress radiography of the subtalar joint was 11.3 degrees +/- 1.4 degrees before surgery and 3.5 degrees +/- 0.8 degrees 2 years after surgery (P = .0060). CONCLUSION: The proposed system has several advantages, including anatomical reconstruction with normal stability and range of motion restored, the need for only a small incision during the reconstruction, and sufficient strength at the tendon graft-bone tunnel junction, in comparison with the tension strength of the lateral ligaments of the ankle.