Simple Cost-Effective Reinsertion of Avulsed Medial Patellofemoral Ligament in Acute Patellar Dislocation.

The medial patellofemoral ligament (MPFL) is the main restraining force against lateral patellar displacement in the first 20° of flexion and is disrupted after patellar subluxation or dislocation. Management of acute patellar dislocations is controversial, and many clinicians opt for conservative treatment in the acute phase. However, a traumatic rupture of the MPFL warrants surgical attention. Several considerations must be made by surgeons attempting reinsertion of the MPFL, including the choice of implant and timing of surgery, to restore the anatomy and biomechanics of the patellofemoral joint. Our aim is to achieve robust reinsertion of the MPFL restoring the anatomy and biomechanics of the patellofemoral joint using a simple, reproducible, and economical technique. We present MPFL reinsertion to the medial border of the patella in an acute patellar dislocation with a braided No. 2 ultrahigh-molecular-weight polyethylene suture (No. 2 Ultrabraid; Smith & Nephew, Memphis, TN) that is passed through 3 transverse parallel tunnels and tied over a bone bridge on the lateral border of the patella. This technique is simple with no implanted hardware, does not have the risk of donor-site morbidity of MPFL reconstruction, and can be performed in skeletally immature patients without growth plate concerns.

Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery.

Revision anterior cruciate ligament surgery is a technically demanding procedure. Mal-positioned tunnels together with bone loss and its management are some of the difficulties and challenges faced. Two-staged procedures have successfully been used to tackle those challenges. We present a technique that is safe, reliable, reproducible, and economic in the management of bone defects faced in anterior cruciate ligament revision surgery by using iliac crest bone graft. Preoperative assessment of tunnel position and size is done by computed tomography. Tri-cortical iliac crest bone graft is harvested through a trap door. It is then shaped to fit the tunnels to be filled. It is tapered at the advancing end to facilitate introduction. Mounted on a passing pin and a drill bit, the graft is arthroscopically introduced into the femoral and tibial tunnels. The second stage is performed after the graft has incorporated, as seen on postoperative computed tomography, done at approximately 3 months after the first stage. Iliac crest provides a natural abundant reservoir for bone graft and has all the advantages of being an autograft. With good meticulous technique, complications can be avoided with less donor-site morbidity. This technique is safe, reliable, and reproducible. It provides an ample amount of graft and harvest does not rely on implants; hence, it is economic.

Technique for Fixation of Semitendinosus to the Patella in Patellar Tendon Reconstruction.

Chronic patellar tendon injuries are rare yet challenging to treat. Timing of surgery and graft choices are debatable. Many techniques and methods of fixation have been described with pros and cons. Functional impairment of the extensor mechanism and postoperative complications triggers the quest for finding the ideal technique. In this Technical Note, we use distally based semitendinosus (ST) looped over 2 ETHIBOND sutures. The ETHIBOND is passed through 2 vertical tunnels in the patella and retrieved proximally, docking the ST in a blind tunnel created in the lower pole of the patella. The whip-stitched free ST end is passed through a tunnel behind the tibial tubercle and sutured back to its base. A polyester tape is used to augment the repair in a circumferential manner. Postoperatively full weight bearing is allowed as tolerated in a hinged knee brace locked in extension with only passive range of motion of 0-90° allowed for 6 weeks.

Different Techniques for the Management of Meniscal Ramp Lesions Using Standard Anterior Portals.

There is strong association between meniscal lesions and anterior cruciate ligament injuries. Recently, light was shown on a new entity: ramp lesions. The incidence of these lesions and their management is still unclear. Although some believe that some lesions, when stable, can be managed conservatively, most surgeons repair ramp tears. Accessibility of these tears is challenging; they are best accessed through posterior portals, which is time-consuming and poses potential risk to vital structures. Our technique allows access to and management of ramp lesions through safe standard anterior portals. Ramp lesions are searched for as a routine step during anterior cruciate ligament reconstruction by advancing the scope through the intercondylar notch just beside the medial femoral condyle. If a lesion is found, it is repaired; only very stable small tears are treated with needling to refresh the edges and induce a healing response. A simple suture, horizontal mattress suture, or a circumferential stitch is used.