The graft/femoral tunnel angles in posterior cruciate ligament reconstruction: a comparison of 3 techniques for femoral tunnel placement.

This study compared the graft/femoral tunnel angle produced with the outside-in technique with the inside-out technique at 90 degrees and 120 degrees of flexion. Three femoral tunnels were marked with guidewires and measured radiographically in 8 fresh-frozen cadaveric knees using both techniques. Results were analyzed. The mean graft/femoral tunnel angle was 34.4 degrees +/- 14.4 degrees for the outside-in technique, 52.3 degrees +/- 14.1 degrees for the inside-out technique at 120 degrees of flexion, and 74.4 degrees +/- 11 degrees for the inside-out technique at 90 degrees of flexion. The angle was smaller for the outside-in technique versus the inside-out technique at both 120 degrees (P = .019) and 90 degrees of knee flexion (P < .001). The outside-in technique for femoral tunnel placement produces the lowest graft/femoral tunnel angle in cadavers. With the inside-out technique, 120 degrees of flexion produces smaller angles than does 90 degrees of flexion. The outside-in technique results in lower angles and perhaps lower graft failure rates. However, additional clinical studies are needed.

The effect of plate position and size on tibial slope in high tibial osteotomy: a cadaveric study.

Opening wedge high tibial osteotomies are performed for degenerative changes and varus. Opening wedge osteotomies can change proximal tibial slope in the sagittal plane, possibly imparting stability in the ACL-deficient knee. The aim of this study was to assess the effect of plate position and size on change in tibial slope. Eight cadaveric knees underwent opening wedge high tibial osteotomy with Puddu plates of each different size. Plates were placed anterior, central, and posterior for each size used. Lateral radiographs were obtained. Tibial slope was measured and compared with baseline slope. Tibial slope was affected by plate position (P < 0.05) and size (P < 0.001). Smaller, posterior plates had less effect on tibial slope. However, anterior and central plates increased tibial slope over all plate sizes (P < 0.05). This study found that tibial slope increases with opening wedge high tibial osteotomy. Larger corrections and anterior placement of the plate are associated with larger increases in slope.

The effect of femoral tunnel starting position on tunnel length in anterior cruciate ligament reconstruction: a cadaveric study.

PURPOSE: The purpose of this cadaveric study was to evaluate the effect of femoral tunnel starting position on femoral tunnel length and to evaluate the effect of tibial tunnel starting position on femoral tunnel starting position in anterior cruciate ligament (ACL) reconstruction. METHODS: Seven fresh-frozen cadaver knees were studied. Tibial tunnels were placed at each of 3 different locations: anterior placement, far medial placement, and midway between the anterior and far medial placements. Femoral guidewires were placed using a 5-mm offset guide at each of 4 different locations: 1 from each of the 3 tibial tunnels and 1 from the anteromedial arthroscopic portal. The depth of the resultant femoral tunnels and the clock face location of each tunnel were measured. RESULTS: The mean clock position (o'clock) and length (mm) of the femoral tunnel versus tibial starting position were as follows. Anterior tibia: 11:30 o'clock and 61 mm. Midpoint tibia: 10:50 o'clock and 44 mm. Far medial tibia: 10:17 o'clock and 37 mm. Medial arthroscopy portal: 9:35 o'clock and 23 mm. The differences in tunnel length between starting positions were statistically significant, and the differences in femoral starting position between tibial starting positions were statistically significant. CONCLUSIONS: Tunnel length greater than 2 cm and 10:30 o'clock starting position can be achieved by medial placement of the tibial tunnel. Placement from the medial arthroscopy portal can result in femoral tunnels more lateral than 10 o'clock, but they may be shorter than 2 cm. CLINICAL RELEVANCE: Tibial starting position affects femoral starting position in the intercondylar notch. Femoral starting position affects femoral tunnel length. Femoral starting position and tunnel length are important considerations in clinical ACL reconstruction.

Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction.

The anterior cruciate ligament (ACL) serves an important stabilizing and biomechanical function for the knee. Reconstruction of the ACL remains one of the most commonly performed procedures in the field of sports medicine. Reconstruction of the ACL with bone-patella tendon-bone (BPTB) autograft secured with interference screw fixation has been the historical reference standard and remains the benchmark against which other methods are gauged. This article reviews the reconstruction of the ACL with BPTB autograft including the surgical technique, rationale for BTPB use, and outcomes.

Primary total knee arthroplasty with condylar allograft and MCL reconstruction for a comminuted medial condyle fracture in an arthritic knee--a case report.

Fractures of the distal femur in the elderly are usually due to low energy ground level fall onto a flexed knee. Pre-existing osteoarthritis and juxta-articular osteopenia in this age group result in high levels of comminution and articular damage at the time of injury, which challenges the management and treatment outcome. Preservation of knee function and early weight bearing should be the objectives of management in the geriatric population. We present in this case report of an elderly patient with comminuted medial condyle fracture with arthritic changes who had primary total knee arthroplasty utilizing condylar allograft and MCL reconstruction as an alternative to internal fixation.

Extensor mechanism disruption after total knee arthroplasty.

UNLABELLED: Extensor mechanism disruption after total knee arthroplasty is a challenging complication for orthopaedic surgeons. The treatment options for repair include observation, direct primary repair, direct primary repair with synthetic ligament or autogenous tissue augmentation, or reconstruction with allograft tissue. A computerized systemic review and literature search was performed to identify the relevant literature on extensor mechanism disruptions associated with total knee arthroplasty. A comprehensive review of the literature and description of relevant treatment options and outcomes were performed using the information gained with the literature review. A multi-center prospective study on a consecutive series of patients recruited from the North American Knee Arthroplasty Revision (NAKAR) study was performed and data collected pre-operatively, intra-operatively, and post-operatively on patients that had a failed total knee arthroplasty using validated health related quality of life measures was analyzed. Six out of 290 patients in the study had extensor mechanism disruption and this group of patients had overall worse functional outcomes. The results of the study have solidified our knowledge that patients with extensor mechanism disruptions have worse functional outcomes and will need intensive management and rehabilitation. LEVEL OF EVIDENCE: Economic and decision analyses, level III (systematic review of level III studies). See Guide for Authors for a complete description of levels of evidence.

Traumatic hemipelvectomy: case report and literature review.

Traumatic hemipelvectomy is a rare but devastating injury involving complete disruption of the hemipelvis from the pubic symphysis to the sacroiliac joints and often results in death. We present an interesting case of traumatic hemipelvectomy caused by a previously undescribed mechanism of injury in which judicious angiography and aggressive surgical treatment contributed to patient survival.