Technical aspects of anterior cruciate ligament reconstruction for the general orthopaedic surgeon.

Anterior cruciate ligament reconstruction is the sixth most common procedure performed by orthopaedic surgeons. The goals of the procedure are to restore knee stability and patient function. These goals are dependent on proper graft positioning and incorporation. Anterior cruciate ligament reconstruction involves a technically complicated series of steps, all of which affect graft healing and clinical outcome. A wide variety of graft choices and surgical techniques are currently available for use. It is important for orthopaedic surgeons performing anterior cruciate ligament reconstructions to be aware of the indications for graft selection, techniques for correct graft placement, and the biologic implications related to these factors.

Retrograde femoral nailing: computed tomography angiogram demonstrates no relative safe zone for prevention of small diameter arterial vascular injury during proximal anteroposterior interlocking.

BACKGROUND: Reported iatrogenic injury to the proximal femoral vascular structures is rare after retrograde femoral nailing. Previous cadaveric dissections have recommended placement of proximal interlocking screws above the level of the lesser trochanter. METHODS: This study is designed to define the arterial vascular anatomy anterior to the proximal medullary canal of the femur, which could be damaged with the placement of anteroposterior (AP) proximal interlocking screws. RESULTS: Computed tomography angiograms of the structures anterior to the proximal femur demonstrate the presence of arterial branches >2 mm diameter in 100% of study patients at or above the level of the lesser trochanter. CONCLUSIONS: No true safe zone corridor exists anteriorly for placement of AP interlocking screws in this region. Surgical technique modifications are suggested to minimize the potential risks of iatrogenic arterial injury during retrograde femoral nail AP proximal interlocking.

Biomechanical evaluation of bioabsorbable versus metallic screws for posterior cruciate ligament inlay graft fixation: a comparative study.

BACKGROUND: Although a tibial inlay technique for posterior cruciate ligament reconstruction is advantageous, metallic screw fixation of the bone block is required. This may pose problems for future surgery (eg, osteotomies, total knee replacement). HYPOTHESIS: There is no significant difference in the biomechanical integrity of bone block fixation using stainless steel versus bioabsorbable screw fixation of the tibial inlay graft in posterior cruciate ligament reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Fourteen human cadaveric knees were randomized to receive either stainless steel or bioabsorbable screw fixation of a bone-patellar tendon-bone graft. Cyclic tensile testing of each construct was performed, followed by a load-to-failure test. Digital video digitization was used to optically determine tendon graft deformation. RESULTS: Cyclic creep deformation showed no significant difference between the 2 groups (P = .8). The failure load (stainless steel, 461 +/- 231 N; bioabsorbable, 638 +/- 492 N; P = .7) and linear stiffness (stainless steel, 116 +/- 22 N/mm, bioabsorbable, 106 +/- 44 N/mm; P = .6) also showed no significant difference between the 2 groups. Optically measured graft deformation was not significant for distal (P = .7) and midsubstance (P = .8) regions, while proximal deformation was significantly higher for bioabsorbable fixation (P = .02). All samples failed at the tibial insertion site with the tibial bone block fracturing at the screws. CONCLUSION: Bioabsorbable screw fixation using a tibial inlay technique does not compromise the strength and stiffness characteristics afforded by metallic fixation. From a biomechanical perspective, bioabsorbable screws are a viable alternative to metal in the context of tibial inlay reconstruction. CLINICAL RELEVANCE: Use of bioabsorbable fixation can potentially eliminate future hardware problems after posterior cruciate ligament reconstruction using a tibial inlay technique.

Posterior wall blowout in anterior cruciate ligament reconstruction: avoidance, recognition, and salvage.

Posterior wall blowout is an important potential source of anterior cruciate ligament reconstruction failures that can be avoided if surgeons adhere to proper technique and are vigilant in confirming appropriate femoral tunnel placement. This article reviews techniques for avoidance, recognition, and salvage of posterior wall blowouts in anterior cruciate ligament reconstruction surgery.

Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up.

BACKGROUND: Recognition of the symbiotic relationship between the meniscus and articular cartilage is critical to the success of meniscal allograft transplantation. Simultaneous combined meniscal allograft transplantation and cartilage restoration procedures have been proposed for patients with a symptomatic postmeniscectomy knee with a focal chondral defect that would have traditionally been considered a contraindication to meniscal allograft transplantation. HYPOTHESIS: Combined meniscal allograft transplantation and cartilage restoration procedures can be used to neutralize traditional contraindications to meniscal allograft transplantation with results comparable to either procedure performed in isolation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patients underwent 31 combined meniscal allograft transplantation and cartilage restoration procedures between 1997 and 2004. These patients were prospectively studied, and completed standardized outcome surveys (including Lysholm, International Knee Documentation Committee, and Short Form-12 scales) preoperatively and annually thereafter for a minimum of 2-year follow-up. Patients were grouped according to concomitant procedure: 16 (52%) underwent meniscal allograft transplantation combined with autologous chondrocyte implantation; 15 (48%) had meniscal allograft transplantation combined with an osteochondral allograft. Two patients were lost to follow-up, leaving 29 procedures for review. RESULTS: As a combined group, statistically significant improvements were observed in all standardized outcomes scores and satisfaction scales, except Short Form-12 mental, at a mean 3.1-year follow-up. Excluding the 2 lost to follow-up, 76% of all study participants (80% autologous chondrocyte implantation; 71% osteochondral allograft) reported that they were completely (31%) or mostly (45%) satisfied with their results. Overall, 48% of patients (60% autologous chondrocyte implantation; 36% osteochondral allograft) were classified as normal or nearly normal at their most recent follow-up using the International Knee Documentation Committee examination score. Ninety percent of patients would have the surgery again. CONCLUSION: Combined meniscal allograft transplantation and cartilage restoration offers a safe alternative for patients with persistent symptoms after meniscectomy and focal cartilage injury. Results of combined procedures were comparable to published reports of these procedures performed in isolation. Long-term follow-up is needed to define the survivorship of these procedures in a young patient population.

Complications of anterior cruciate ligament reconstruction with bone-patellar tendon-bone constructs: care and prevention.

Rupture of the anterior cruciate ligament is a common injury. Correct diagnosis and patient selection, along with proper surgical technique, with careful attention to anatomic graft placement, followed by attention to proper rehabilitation, leads to predictably good to excellent results. This article reviews the recognition and avoidance of complications associated with bone-patellar tendon-bone constructs of anterior cruciate ligament reconstruction.

Fresh-frozen allograft anterior cruciate ligament reconstruction.

Reconstruction of the anterior cruciate ligament provides consistently good to excellent results allowing return to work and sport. Allograft tissue is an alternative to autografts when appropriate donor tissue is not available or its use is not advisable for other reasons. The technique and results for allograft use are similar to those for autograft, making its use appropriate in a variety of clinical scenarios. This article reviews the indications for allograft ACL reconstruction, graft options, and technique for allograft use.

Hardware removal: indications and expectations.

Although hardware removal is commonly done, it should not be considered a routine procedure. The decision to remove hardware has significant economic implications, including the costs of the procedure as well as possible work time lost for postoperative recovery. The clinical indications for implant removal are not well established. There are few definitive data to guide whether implant removal is appropriate. Implant removal may be challenging and lead to complications, such as neurovascular injury, refracture, or recurrence of deformity. When implants are removed for pain relief alone, the results are unpredictable and depend on both the implant type and its anatomic location. Current literature does not support the routine removal of implants to protect against allergy, carcinogenesis, or metal detection. Surgeons and patients should be aware of appropriate indications and have realistic expectations of the risks and benefits of implant removal.

Functional outcomes following displaced talar neck fractures.

OBJECTIVES: To determine the outcome of displaced talar neck fractures at long-term follow-up in terms of functional outcome and secondary reconstructive surgery. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS: Seventy patients with displaced talar neck fractures. INTERVENTION: All patients were treated with open reduction and screw fixation. MAIN OUTCOME MEASUREMENTS: Functional outcome of patients who did not require secondary surgery was assessed using the Short Musculoskeletal Function Assessment, Ankle Osteoarthritis Scale score, and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score. The incidence of secondary reconstructive hindfoot surgery, including arthrodesis or talectomy, was measured using life table analysis. RESULTS: Mean Short Musculoskeletal Function Assessment score was 20 +/- 18 out of 100, with a lower score indicative of better outcome; mean Ankle Osteoarthritis Scale score was 3.8 +/- 2.4 out of 10 (lower score better); and mean Ankle Society Ankle-Hindfoot Score was 71 +/- 19 out of 100 points (higher score better). The incidence of secondary reconstructive surgery increased from 24 +/- 5% at 1 year to 48 +/- 10% at 10 years postinjury. CONCLUSIONS: Functional outcome varied and was most dependent upon the development of complications. The incidence of secondary reconstructive surgery following talar neck fractures increased over time and was most commonly performed to treat subtalar arthritis or misalignment.