Posteromedial Portal Technique With Bone-Patellar Tendon-Bone Graft for Inside-Out Revision of Anterior Cruciate Ligament Reconstruction.

Bone-patellar tendon-bone (BTB) is a graft material used in anterior cruciate ligament (ACL) reconstruction. We describe creating a femoral tunnel using an inside-out posteromedial (PM) portal technique during anatomic double-bundle ACL reconstruction with a hamstring graft. We hypothesized that applying this femoral tunnel creation method to the revision ACL reconstruction using BTB would enable reconstruction in 1 stage. In this technique, an anteromedial, an anterolateral, and a PM portal are created to confirm the original ACL footprint and location and direction of the bone tunnel during primary reconstruction. The surgeon then drills from the PM portal, so that the femoral tunnel opening touches the posterior proximal articular cartilage margin in the ACL footprint. Even if the opening partially overlaps with the primary tunnel, it is possible to create a new tunnel with a different direction. Finally, the BTB graft is guided from the tibial tunnel to the femoral tunnel and fixed with interference screws. Intraoperative PM arthroscopic views can confirm that the femoral tunnel has been created, avoiding overlap, and that the revision ACL has been reconstructed. This procedure may be useful for 1-stage revision ACL reconstruction for reinjury after primary ACL reconstruction by other conventional procedures.

Two cases of inferior dislocation of the patella with impaction into the femoral trochlea of osteophytes on the superior pole of the patella.

Traumatic dislocation of the patella is classified as lateral, medial, or intra-articular according to the direction of dislocation. Lateral dislocation is the most common type of patellar dislocation, and intra-articular dislocation is rare. Intra-articular dislocation is classified as superior, inferior, or vertical dislocation. Inferior dislocation is categorized as Type I, which occurs in young people, and Type II, which occurs in the elderly. In Type II, osteophytes on the superior pole of the patellar are believed to become entrapped in the intercondylar notch, dislocating the patella inferiorly. These were two extremely rare cases of inferior dislocation of the patella in elderly people. The mechanism involved was considered to be the exertion of sudden upward traction on the patella due to the muscular force of the quadriceps when the knee was flexed, causing osteophytes on the superior pole of the patella to become impacted into the femoral trochlea. Dislocations were successfully reduced without anesthesia, and osteophyte resection or complete osteophyte fracture during reduction meant that there was no recurrence of the dislocation.