Detachment and Intra-Articular Migration of a Bone Patella Tendon Bone Graft in ACL Reconstruction.

The frequency of anterior cruciate ligament (ACL) reconstruction performed worldwide has been significantly increasing per year. Despite the common nature of the procedure, controversy remains regarding the natural history of ACL injuries, surgical technique, graft choice, and long-term outcomes. We present a case report of a 33-year-old male who had a history of an ACL reconstruction that was performed 12 years ago using bone patella tendon bone (BPTB) graft, by using a press-fit femoral technique. He was referred to our outpatient department due to a re-rupture of his ACL following a football injury. Radiographs of the knee joint that were taken revealed a rectangular prominence of bone projected over the femoral notch extending intra-articularly. The patient also had a magnetic resonance imaging (MRI) scan, which revealed a rerupture of the previously reconstructed ACL and evidence of an intra-articular bony prominence. The patient had arthroscopic revision of his ACL reconstruction by using Semitendinosus allograft, which confirmed the complete tear of previously reconstructed ACL graft. Moreover, a bony prominence was well demonstrated intra-articularly close to the femoral intercondylar notch. We hypothesized that this was a part of the BPTB graft that was reconstructed 12 years ago and had either migrated inside the joint or was never positioned appropriately (not adequately fitted in the femoral tunnel). The bony prominence was shaved by using an arthroscopic bony burr, the ACL was revised, and the patient had a good recovery. Intra-articular migration of the femoral bony ends of the BPTB is a rare complication following ACL reconstruction. The patient may be asymptomatic; however, evidence of the bony prominence is usually revealed on postoperative X-rays and magnetic resonance imaging scans.

Revision of failed anterior cruciate ligament reconstruction with quadrupled semitendinosus allograft: intermediate-term outcome.

PURPOSE: The aim of the present study is to present intermediate-term clinical outcome after revision anterior cruciate ligament (ACL) reconstruction using semitendinosus allograft from donor less than 65 years old. METHODS: A retrospective study of patients treated with ACL revision from 2003 to 2011 at a District General Hospital. A Study follow-up took place in 2014; clinical outcomes were measured by IKDC, Tegner, Lysholm, and Pain scores and KT-1000 arthrometry laxity measurements. We also registered reoperations and complications. RESULTS: Nineteen patients were available for follow-up, and one had telephonic interview. Mean follow-up time was 6 (3-9) years and mean age was 33.68 years, and 14 were men and six women. One patient required staged procedures, 5% were re-revised for early graft failure and clinical instability, and 15% had reoperations for other pathologies. The data analysis reveals statistically significant differences between preoperative and postoperative scores. Lysholm score improved from preoperatively 55.5±11 points (range 35-71 points) to postoperatively 89.7±10 points (range 55-100 points), Tegner activity scale score improved from 2.7±1.3 points (range 1-5 points) to 7.1±2.2 points (range 1-10). Pain score improved from 7.7±1.5 (range 4-10 points) to 1.1±1.9 (range 0-8 points). Level of Activity score improved from 3.6±1.1 (range 2-6 points) to 8.8±1.6 (range 3-10 points). CONCLUSION: In our patient series, revision ACL reconstruction showed a statistically significant improvement in postoperative subjective and objective scores. Five percent failure after mean 6 years (3-9 years) is less compared to other studies; surgical technique and donor age could have played a significant role in lower failure rate. In our series 50% patients had meniscal and 55% had Gr I/II chondral injury, this could also explain lower failure rate. Revision of a failed ACL reconstruction using semitendinosus allograft is a safe procedure that improves the function of the patient as demonstrated by clinical scores. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Malunion in the lower limb. A nomogram to predict the effects of osteotomy.

Nomograms derived from mathematical analysis indicate that the level of malunion is the most important determinant of changes in the moment arm of the knee, the plane of the ankle and alterations in limb length. Testing in five patients undergoing reconstruction showed a mean error of postoperative limb length of 2.2 mm (SD 0.8 mm), knee moment arm of 4.7 mm (SD 3.3 mm) and ankle angle of 2.6 degrees (SD 2.3 degrees). These nomograms provide the information required when assessing whether a particular degree of angulation may be accepted.