ABSTRACT
Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been a standard procedure. However, residual rotary instability in approximately 20% of the cases (irrespective of the graft choice and the surgical technique) forces the surgeon to improve the biomechanical quality of the reconstruction. In parallel, adjustable suspensory fixation (ASF) devices have arisen. Biomechanics has defined (both anatomical and functional) the anteromedial (AM) and posterolateral (PL) bundles that work synergistically. In the unsymmetrical "anatomic" SB ACL reconstruction, the distribution of the ACL graft fibers (for AM or PL behavior) is not under the control of the surgeon. Furthermore, different sizes of the original footprints (depending on height) suggest the need to customize the graft footprint. This customization is only possible if distances are measured during surgical procedures. We present an inside-out technique for DB ACL reconstruction ("all-inside" also possible). Semitendinosus is folded to obtain a Y-shaped trifurcate configuration graft, distributing their bundles in two different areas. Used as measuring instruments, we used the "offset" guides as measuring instruments, allowing the surgeon to know the distance between the centers of the AM and PL tunnels. It may be carried out by means of common "offset" guides and any marketed ASF devices, while generating customized footprints. CLASSIFICATION: I: knee; II: ACL.
ABSTRACT
CASE: A 48-year-old male patient with a type V acromioclavicular injury with a 3-tendon acute cuff tear, anterior glenohumeral dislocation, and an axillary posttraumatic neuropathy is presented. The rotator cuff tear was sutured and an all-arthroscopic-modified coracoclavicular ligaments (CCLs) reconstruction technique was performed with a gracilis tendon graft and a double knotless suture fixation system. CONCLUSIONS: An arthroscopic approach allows the surgeon to identify and treat associated glenohumeral lesions in type V acromioclavicular dislocations. In addition, the modified CCL reconstruction technique addresses effectively the AC instability.
Subject(s)
Acromioclavicular Joint/injuries , Acromioclavicular Joint/surgery , Arthroscopy/methods , Joint Dislocations/surgery , Acromioclavicular Joint/diagnostic imaging , Gracilis Muscle/transplantation , Humans , Joint Dislocations/diagnostic imaging , Male , Middle Aged , Tendons/transplantationABSTRACT
A double-bundle anterior cruciate ligament (ACL) reconstruction associated with an anterolateral ligament (ALL) reconstructions is performed. The semitendinosus and gracilis are harvested. At knee maximum flexion, the anteromedial (AM) femoral tunnel is performed in the AM footprint area. Through the anterolateral portal, the tip of the outside-in femoral guide is placed in the posterolateral footprint area. The guide sleeve is pushed onto the lateral femoral cortex at the ALL attachment. At 110° knee flexion, the posterolateral-ALL tunnel is performed. The tibial ACL tunnel is performed as usual. The tibial guide is placed between the ALL tibial attachment and the tibial ACL tunnel entrance to perform the ALL tibial tunnel. The gracilis graft is introduced from caudal to cranial, achieving fixation with a 6-mm diameter screw (outside-in). The AM femoral fixation is achieved with a suspension device. ACL tibial graft fixation is achieved with a screw. Afterward, the gracilis is passed under the fascia lata to the tibial entry point. A 6-mm diameter screw is placed from the external cortex into the tibial ALL tunnel. The biomechanical advantage of the double-bundle ACL reconstruction with the biomechanical advantage of the ALL anatomic reconstruction is achieved.
ABSTRACT
Ischiofemoral impingement is a source of hip pain derived from impingement between the lesser trochanter and the ischium. Lesser trochanter excision has been recommended for recalcitrant ischiofemoral impingement through either an anterior or posterior approach. However, neither of these approaches involves refixation of the iliopsoas tendon. We describe an endoscopic procedure involving anterior trochanter-plasty, minimizing the risk of sciatic complications, with refixation of the partially detached iliopsoas tendinous insertion, potentially minimizing compromise to hip flexion strength and anterior hip stability.
