Hybrid hamstring graft tibial fixation in anterior cruciate ligament reconstruction.

Tibial fixation of the anterior cruciate ligament hamstring tendon graft is commonly considered more problematic than femoral fixation. When interference screws are used for tibial hamstring tendon graft fixation, graft sometimes looses its tension, so a hybrid fixation (more than one method of fixation) must be applied. Biomechanical studies show that an implementation of interference screws combined with different indirect distal hamstring tendon fixation techniques can withstand much higher tearing forces when compared with one type of fixation. We made a technique of hybrid tibial fixation of the hamstring graft using round interference screws and an additional bi-cortical 4.5-mm diameter screw with a modified head that allows control over the initial tension of the graft.

Femoral guide breakage during the anteromedial portal technique used for ACL reconstruction.

Positioning of the femoral tunnel is very important in ACL reconstruction and it is often recommended to use an anteromedial portal technique in order to create the tunnel. This technique is more demanding but it gives a surgeon more freedom to place the ACL graft in an anatomical position compared to the transtibial technique. A case of an intraarticular femoral guide breakage associated with this particular technique is presented. That being said, the aim of this paper is not only to present this rare complication following arthroscopic reconstruction of ACL, but also to indicate how to prevent, diagnose and treat this undesired event.

THE TIBIAL APERTURE SURFACE ANALYSIS IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION PROCESS.

INTRODUCTION: The tibial tunnel aperture in the anterior cruciate ligament reconstruction is usually analyzed as an ellipse, generated as an intersection between a tibial plateau and a tibial bone tunnel. The aim of this study is to show that the tibial tunnel aperture, which utilizes 3D tibial surface bone model, differs significantly from common computations which present the tibial tunnel anterior cruciate ligament aperture surface as an ellipse. MATERIAL AND METHODS: An interactive program system was developed for the tibial tunnel aperture analysis which included the real tibia 3D surface bone model generated from a series of computed tomography images of ten male patients, their mean age being 25 years. In aperture calculation, the transverse drill angle of 10 degrees was used, whereas sagittal drill angles of 40 degrees, 50 degrees and 60 degrees were used with the drill-bit diameter set to 10 mm. The real 3D and 2D tibial tunnel aperture surface projection was calculated and compared with an ellipse. RESULTS: According to the calculations, generated 3D aperture surfaces were different for every patient even though the same drill parameters were used. For the sagittal drill angles of 40 degrees, 50 degrees and 60 degrees, the mean difference between the projected 3D and 2D area on the tibial plateau was 19.6 +/- 5.4%, 21.1 +/- 8.0% and 21.3 +/- 9.6%, respectively. The difference between the projected 3D area on the tibial plateau and ellipse surface was 54.8 +/- 16.3%, 39.6 +/- 10.4% and 25.0 +/- 8.0% for sagittal drill angles of 40 degrees, 50 degrees and 60 degrees, respectively. CONCLUSION: The tibial tunnel aperture surface area differs significantly from the ellipse surface area, which is commonly used in the anterior cruciate ligament reconstruction analysis. Inclusion of the 3D shape of the tibial attachment site in the preoperative anterior cruciate ligament reconstruction planning process can lead to a more precise individual anatomic anterior cruciate ligament reconstruction on the tibial bone. Both tibial aperture area generated in 3D and its projection on a tibial plateau are larger than the ellipse surface; therefore, individual characteristics of each patient have to be taken into consideration.

Magnetic resonance imaging comparison of lateral collateral ligament and patellar tendon length.

INTRODUCTION: The problem of using patellar tendon auto or allografts for lateral collateral ligament reconstruction results in the occurrence of ligaments mismatch. The length of patellar tendon does not match the lateral collateral ligament. MATERIAL AND METHODS: Out of 151 patients, who formed the study, 102 were men with the mean age of 30 years (18-54) and 49 women, with the mean age of 34 (18-55), and they all underwent magnetic resonance imaging of the knee. Both patellar tendon and lateral collateral ligament were measured using a three-dimensional isovoxel true-fast-imaging with steady-state precession sequence with water excitation and secondary multiplanar reformations. In order to visualize the lateral collateral ligament insertions precisely, sagittal images were reformatted according to the anatomical, oblique ligament position, in anteriorly tilted, paracoronal plane. The length of the patellar tendon was measured from the patellar apex to the tibial tuberosity insertion site. RESULTS: The mean patellar tendon length was 52.88 +/- 7.56 mm (37-75) with a significant difference between men and women. The mean lateral collateral ligament length was 61.21 +/- 5.77 mm (46-80) with a significant difference between genders. The average differences between lateral collateral ligament and patellar tendon length was 8.38 +/- 7.23 mm (-9 to 26) without a significant difference between the genders. In 18 (11.92%) patients, the patellar tendon was longer than the lateral collateral ligament; in 7 patients (4.63%) they were equal; and in 126 patients (83.44%) the patellar tendon was shorter than the lateral collateral ligament. CONCLUSION: The length of patellar tendon does not match the length of lateral collateral ligament. If patellar tendon auto or allograft is used for lateral collateral ligament reconstruction, the lengths of both ligaments must be determined preoperatively in order to avoid intraoperative complications.

Heterotopic ossification following surgical treatment of avulsion fracture of the anterior inferior iliac spine.

Avulsion fractures of the anterior inferior iliac spine are rare injuries of the pelvic ring and occur during sports activities. Hereby is presented a case of a 22-year-old professional football player who was diagnosed to have an avulsion fracture of the anterior inferior iliac spine on the right side four months after the initial injury and he was treated surgically with the excision of the avulsed fragment. The football player recovered completely and returned to his usual sports activities. Two years later, due to the pain in the hip an x-ray and MR image were made, which established the existence of crescent formation, a heterotopic bone, in the area of the anterior inferior iliac spine, which was surgically removed. Physical and medical therapy was conducted and after four months, the professional athlete was back playing football. Two years after the surgical excision of heterotopic ossification, the patient was completely asymptomatic with the same ROM without any thigh muscle hypotrophy, although isokinetic muscle testing did show some weakness of the thigh extensor muscles. An x-ray did not show any signs of heterotopic ossification.

Reconstruction of chronic patellar tendon rupture with contralateral BTB autograft: a case report.

Chronic patellar tendon rupture is a rare disabling injury that is technically difficult to repair. Many different surgical methods have been reported for the reconstruction of chronic patellar tendon ruptures. We are reporting the use of contralateral bone-tendon-bone (BTB) autograft for chronic patellar tendon rupture reconstruction followed by double-wire loop reinforcement and without postoperative immobilization. One year after the operation, our patient had full knee extension and up to 130 degrees of flexion. He had good quadriceps strength, and isokinetic muscle testing showed no deficit comparing to his right leg. Patient returned to playing basketball in his spare time, without having any limitation.