Anterior Cruciate Ligament Reconstruction: State of the Art

Abstract The rupture of the Anterior cruciate ligament (ACL) belongs to the most common ligament injuries of the human knee joint. ACL rupture results in an increased anterior translation and internal rotation of the tibia. Untreated knee instability causes a disintegration of the roll and sliding movement and a high incidence of secondary meniscus and chondral damages with consecutive or advanced arthritic changes. For deciding on a conservative or operative therapy, it is necessary to develop a high-risk profile. Elderly, inactive patients without instability symptoms can be treated conservatively; younger, active people and complex ligament injuries should receive an ACL replacement. The goal is to eliminate instability by maintaining the physiological kinematics of the knee. Anterior cruciate ligament may be reconstructed arthroscopically assisted by autologous tendons. Predominantly, hamstring- and bone-patellar-tendon grafts are used. No significant differences in knee laxity, clinically and functionally, were observed between both grafts. Various reconstruction techniques, single- or double-bundle techniques, were described. Successful replacement depends on a correct tunnel placement and reconstruction of the physiological band tension, a sufficient mechanical stability of fixation, an impingement-free range of motion and an adequate rehabilitation. A high degree of patient satisfaction in clinical and functional outcome could be evaluated.     

Behavioral Profiles of Genetically Selected Aggressive and Nonaggressive Male Wild House Mice in Two Anxiety Tests

Artificially selected aggressive (SAL) and non-aggressive (LAL) male house mice were tested in a hexagonal tunnel maze and light-dark preference (LD) box to determine if the bidirectional selection for aggressive behavior leads to a coselection for different levels of trait anxiety. The tunnel maze consists of an open, brightly lit central arena surrounded by a complex system of interconnecting tunnels. As in the LD box, animals which spend less time and are less active in the brightly illuminated section of the maze are considered to have higher anxiety levels. In the tunnel maze, the LAL mice showed more exploration and spent more time in the central arena than the SAL animals, but only during the final 2 min of the 6-min test. This reduced preference for the central arena was not due to general inactivity or a failure of the SAL to find the central arena and indicates a higher level of state anxiety in the aggressive animals. In contrast, no anxiety-like differences were found in the LD box, either for the percentage of time spent in the light compartment or for the number of crossings. SAL males actually showed higher levels of moving and rearing, and lower levels of freezing, than did LAL males.     

Ultrasound-Guided Versus Landmark-Guided Local Corticosteroid Injection for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To review the literature and assess the comparative effectiveness of ultrasound-guided versus landmark-guided local corticosteroid injections in patients with carpal tunnel syndrome (CTS).

CARPAL TUNNEL SYNDROME IN PATIENTS ON LONG-TERM HAEMODIALYSIS

The purpose of this study was to describe the pathophysiology of carpal tunnel syndrome (CTS) in patients on long-term haemodialysis. We examined 110 patients, who had been having haemodialysis for chronic renal failure and had CTS, to clarify the clinical features and electrophysiological changes in peripheral nerves. There was a significant correlation between the incidence of CTS and the duration of haemodialysis. Compared with idiopathic CTS, CTS caused by long-term haemodialysis had relatively limited postoperative improvement. Symptoms recurred postoperatively in 11 patients (19%) of those with CTS caused by long-term haemodialysis. Electrophysiological measurements of sensory nerve conduction velocity showed that it was slower in distal segments of the median nerve in patients on haemodialysis compared with normal volunteers. Nerve conduction velocity in the carpal tunnel was significantly delayed (p < 0.05) in the patients with CTS on long-term haemodialysis. N_9-13 interpeak latencies were significantly longer (p < 0.05) in subjects who had had haemodialysis for at least 10 years. All the patients with advanced destructive spondyloarthropathy had longer N_9-13 interpeak latency. These results suggest that CTS in patients on long-term haemodialysis has its basis in neuropathy. The clinical course of CTS in these patients is different from that of patients with idiopathic CTS, because the neuropathy involves not only the carpal tunnel region, but also the proximal part of the median nerve both diffusely and progressively.     

Effect of tibial drill-guide angle on the mechanical environment at bone tunnel aperture after anatomic single-bundle anterior cruciate ligament reconstruction

Purpose

The tibial drill-guide angle in anterior cruciate ligament (ACL) reconstruction influences the tunnel placement and graft-tunnel force, and is potentially associated with post-operative tunnel widening. This study aimed to examine the effect of the drill-guide angle on the stress redistribution at the tibial tunnel aperture after anatomic single-bundle ACL reconstruction.

Methods

A validated finite element model of human knee joint was used. The tibial tunnel with drill-guide angle ranging from 30° to 75° was investigated. The post-operative stress redistribution in tibia under the compressive, valgus, rotational and complex loadings was analysed.

Results

Compressive loading played a leading role on the stress redistribution at intra-articular tibial tunnel aperture. After ACL reconstruction, stress concentration occurred in the anterior and posterior regions of tunnel aperture while stress reduction occurred in the lateral and posteromedial regions under the compressive loading. Stress redistribution was partially alleviated by using the drill-guide angle ranging from 55° to 65°.

Conclusions

The present study quantified the effect of bone tunnel drill-guide angle on the post-operative stress redistribution. This phenomenon potentially contributed to tunnel widening. A tunnel drill-guide angle ranging from 55° to 65° was proposed based on the biomechanical rationale. It could serve as a helpful surgical guide for ACL reconstruction.     

Outcomes of trans-tibial posterior cruciate ligament reconstruction using a fovea landmark technique in relation to tunnel position and serial tunnel configuration

PurposeTo evaluate (1) the outcome of PCL reconstruction with tibial suspensory fixation using a fovea landmark technique based on the tunnel position and serial change of the tunnel configuration after trans-tibial PCL reconstruction, and (2) whether suspensory fixation has any harmful effect on the outcome.MethodsA total of 48 knees that underwent PCL reconstruction were included. The tunnel position was analyzed using CT. To analyze the tunnel configuration, the tunnel diameter, area, and volume were measured. To evaluate the outcome, pre- and postoperative International Knee Documentation Committee (IKDC) and Lysholm scores were analyzed. To evaluate stability, a side-to-side difference was evaluated using Telos stress radiographs.ResultsThe greatest configurational change occurred at the mid-portion of tibial tunnel. There was a correlation between stability and tibial tunnel mid-portion configurational change (p < 0.01). Important correlations were found between the tunnel position and serial tunnel configuration between high femoral tunnel and widest site of femoral tunnel and tibia aperture (p < 0.01 and 0.04, respectively). The diameter of widest site of tibia tunnel increased when the tibia tunnel center moved toward the posterior margin of the tibia (p = 0.02) and the percentage of femoral tunnel volume enlargement increased when the tibia tunnel center moved toward the medial edge of the PCL fovea (p = 0.02).ConclusionsA high femoral tunnel, medial tibial tunnel, and posterior tibial tunnel were related to the serial configurational change. A suspensory tibial fixation produced significant configurational change around the mid-portion of the tibial tunnel, and it induced a negative effect on stability.Level of Evidence: Level IV.     

How Important is the Tunnel Position in Outcomes Post-ACL Reconstruction: A 3D CT-Based Study

BackgroundDrilling the femoral and tibial tunnels at their anatomical locations are critical for good outcomes and involve seeing the footprints well. We intended to compare two techniques of drilling the tunnels and the patient-reported outcomes and knee stability of patients undergoing single bundle ACL reconstruction using 3D CT to evaluate if the tunnels were anatomical or not.Materials and MethodsSixty single bundle ACL reconstructions were analyzed, 30 each with Technique A and B. Pre-operative and after a minimum 27 month follow-up Lysholm, IKDC, Tegner score, hop test, and Lachman test were noted. 3D CT was done to classify femoral tunnels positions as being well placed, slightly or grossly misplaced and tibial tunnels as optimal or suboptimal and compared.ResultsSixty ACL reconstructions had full follow-up with a mean follow-up of 34 months. There was no significant difference between tunnel positions between the two techniques. Well-placed femoral tunnel had better Lysholm score (62.2 ± 16.2 v/s 48.5 ± 17.2, p 0.002) and IKDC score (62.5 ± 14.3 v/s 52.7 ± 15.1, p 0.012).). Those who had their surgeries within 3 months of their injury had better hop test (4.4 ± 0.9 v/s 3.9 ± 1, p 0.034) and IKDC scores (62.5 ± 15.8 v/s 33.2 ± 13.8, p 0.026) as compared to those that had surgery done after 3 monthsConclusionTibial tunnel positions were optimal in most cases and did not differ between the two techniques. Well-placed femoral tunnels and surgeries done within 3 months of the injury produced best results.     

Neurodynamic Techniques Versus “Sham” Therapy in the Treatment of Carpal Tunnel Syndrome: A Randomized Placebo-Controlled Trial

Objective

To evaluate the efficacy of neurodynamic techniques used as the sole therapeutic component compared with sham therapy in the treatment of mild and moderate carpal tunnel syndromes (CTS).

两种术式治疗后半蹄铁型肛瘘的疗效对比分析

为探讨治疗后半蹄铁型肛瘘的手术方式及疗效,我们采用隧道式瘘管剔除对口引流术治疗后半蹄铁型肛瘘38例（A组）,隧道式拖线术治疗34例（B组）,并对两组疗效进行对比分析。结果显示,两组治愈率均为100％,其中B组4例经二次扩创后治愈,随访3年无复发。两组均无肛门畸形、肛门失禁等并发症。A组平均疗程为（26．2±3．4）d,B组平均疗程为（28．3±3．1）d。术后2级以上疼痛A组为89．5％（34／38）,平均持续时间（7．3±3．2）d;B组为94．1％（32／34）,平均持续时间（12．8±3．8）d。结果表明,隧道式瘘管剔除对口引流术治疗后半蹄铁型肛瘘疗效显著。