A tourniquet-less technique using saline epinephrine irrigation system in an arthroscopic ACL reconstruction in patient with history of popliteal artery ligation.

INTRODUCTION: Pneumatic tourniquets use in surgery to create a bloodless surgical field. The majority of orthopaedic surgeon use a tourniquet inflated above systemic blood pressure during arthroscopic anterior cruciate ligament (ACL) reconstruction. A tourniquet use is not free of complications. The disadvantage of tourniquet application include an increased risk of vascular injuries. An arthroscopic ACL reconstruction in patient with history of popliteal artery ligation is challenging. The popliteal artery is the major contributor to the blood supply of the knee joint. This arthroscopic ACL reconstruction does not use tourniquets to preserve the collateral circulation that provides blood supply to the leg and prevent the vascular injuries in patient with history of popliteal artery ligation. PRESENTATION OF CASE: A-23-year-old female brought to the General Hospital with ACL rupture caused by car accident. The patient had a history of knee dislocation with an open wound and rupture of popliteal artery. The patient underwent open reduction surgery of her right knee joint by orthopaedic surgeon and popliteal artery repair by vascular surgeon. The reduction of the knee joint went good, but the popliteal artery repair was failed and the patient underwent popliteal artery ligation 1 week later. The patient received non-operative treatment for her ACL rupture. After 2 years, she did not get a good improvement to her knee and the patient still felt a giving way sensation and unstability of her knee. Then the patient transferred to the General Hospital for ACL reconstruction, but the surgery required a special consideration in the technique of ACL reconstruction because of the history of popliteal artery ligation. DISCUSSION: Positioning of the patient for ACL reconstruction The patient supine on an operating table. The leg to undergo surgery has no tourniquet placed because the patient had no popliteal artery and this operation needs to preserve and prevent the vascular ischemia of the collateral artery. Operating room set up with the patient prepped and draped for the diagnostic arthroscopy. It shows a normal cartilage, rupture of the ACL and PCL, rupture of body of the lateral meniscus in the white zone and rupture of body of the medial meniscus in the white zone. To make the bloodless arthroscopic field, cold saline and epinephrine pumped into the knee. Partial meniscectomy of the lateral and medial meniscus was performed. Single bundled ACL reconstruction was performed using hamstring autograft of the contralatelal site with the diameter was 8 mm and fixated by XO button and bioscrew (ConMed). After six months follow up, the patient did not feel giving way, catched, or locking. The patient had a good vascularity of the right lower extremity. There is improvement in Modified Cincinnati Rating System. The pre operative score was 49. The post operative score was 90. Tegner Lysholm Knee Scoring system before surgery was 35 and post operative score was 91. IKDC Scoring before surgery was 21,8 and the score had a good improvement. The IKDC Scoring after surgery was 73,6. CONCLUSION: ACL reconstruction in patient with popliteal artery ligation is challenging. A tourniquet-less technique using a cold saline and epinephrine solution can be successfully done for pressure controlled into the knee to preserve the collateral arteries flow to the distal limb while still permitting acceptable visual in operative field with good outcome after the surgery.

Three dimensional morphometry of proximal femur to design best-fit Femoral stem for Indonesian population / Morfometría tridimensional del fémur proximal para diseñar prótesis a medida en la población de indonesa

To design custom-made prosthesis in a certain population, the morphometry needs to be measured. The results of this study were expected to provide basic data to design the ideal size of the total hip arthoplasty prosthesis for Indonesian population. This was an anthropometric study conducted on sex matched 100 healthy Indonesian mongoloid race subjects based on Computer Tomographic (CT) imaging on the proximal femur. The parameters being used in this study were Femoral Head Offset (FHO), Femoral Head Position (FHP), Femoral Head Diameter (FHD), Neck-Shaft Angle (NSA), Anteroposterior Width (APW) and Mediolateral Width at 3 different locations, and Canal Flare Index (CFI). This study showed that Indonesian has smaller proximal femur morphometry as compared to Western population. The mean value of all parameters in male were larger than female. Moreover, FHO and FHP showed significant difference among male and female indicating the location of male femoral head center lies superiorly as compared to female. The dimension of femoral canal was found to be mediolaterally oval, 1.43, 1.28, and 1,34, respectively, in 3 different cutting (20 mm above and 40 mm below lesser trochanter, and isthmus). CFI of Indonesian was classified to be stovepipe femoral canal (2.99) that is the suggestion to use cemented femoral stem. This study showed that Indonesian proximal femur dimension has smaller build compared with Western counterpart. The proposed dimensions can be used as the basic data to design the ideal size of the femoral stem for Indonesian population.

Para diseñar prótesis a medida en una población determinada, la morfometría necesita ser conocida. El objetivo de este estudio fue obtener resultados que sean útiles en la investigación para diseñar el tamaño ideal de una prótesis total de artroplastía de cadera para la población de Indonesia. Fue realizado un estudio antropométrico en 100 sujetos sanos de raza mongoloide de Indonesia, en los que se estudió la parte proximal del fémur por tomografía computadorizada (TC). Se consideraron como parámetros la cabeza del fémur (CF), posición de la cabeza del fémur (PCF), diámetro de la cabeza del fémur (DCF), ángulo cérvicodiafisario (ACD), ancho anteroposterior (AAP) y ancho-lateral en 3 lugares diferentes. La población Indonesia tiene una morfometría menor del fémur proximal en comparación con la población occidental. El valor medio de todos los parámetros en hombres fueron mayores a las mujeres. Por otra parte, CF y PCF mostraron diferencia significativa entre hombres y mujeres e indicó una ubicación superior del centro de la cabeza del fémur en hombres, en comparación con las mujeres. Se encontró que la dimensión del canal femoral fue mediolateral oval, 1,43, 1,28, y 1,34, en 3 cortes diferentes, respectivamente (20 mm superior y 40 mm inferior del trocánter menor e istmo). La dimensión del fémur proximal en la población de Indonesia es de menor tamaño en comparación con la contraparte occidental. Las dimensiones propuestas se pueden utilizar como datos básicos para el diseño de un tamaño ideal de vástago femoral para la población Indonesia.

Three Dimensional Morphometry of Distal Femur to Design Knee Prosthesis for Indonesian Population / Morfometría Tridimensional del Fémur Distal para Diseñar Prótesis de Rodilla para la Población Indonesia

The objective of this study was to design custom-made prosthesis in a certain population, the morphometry needs to be measured. The results of this study were expected to provide basic data to design the ideal size of the total knee arthoplasty prosthesis for Indonesian population. This was an anthropometric study conducted on 100 healthy Indonesian population based on Computer Tomographic (CT) imaging on the distal femur resected surface. The parameters being used were Femoral Medio Lateral (fML) length, Femoral Antero Posterior (fAP) length, Femoral Medial Antero Posterior (fMAP) length, Femoral Lateral Antero Posterior (fLAP) length, and Femoral Aspect Ratio (FR). We found that the mean fAP and fML were 54.60±5.71 and 65.98±6.51, respectively. The morphometry of the distal femur were significantly different between male and female (male have larger build), however one of parameters showed different result: fLAP. This study showed that Indonesian people have smaller build compared with their Western counterpart. The proposed dimensions can be used as the basic data to design the ideal size of the custom-made knee arthoplasty prosthesis for Indonesian population.

El objetivo fue diseñar una prótesis a medida para una determinada población, por tanto la morfometría debía ser medida para proporcionar datos básicos para diseñar el tamaño ideal de una prótesis total para la artroplastia de rodilla en población de Indonesia. Se realizó un estudio antropométrico sobre 100 sujetos sanos indonesios, basados en tomografías computadorizadas (TC) de la superficie resecada del fémur distal. Los parámetros que se midieron fueron longitud femoral mediolateral (FML), longitud femoral anteroposterior (FAP), longitud femoral medial anteroposterior (FMAP), longitud femoral lateral anteroposterior (FLAP), y razón de aspecto femoral (FR). Las medias FAP y FML fueron 54,60±5,71 y 65,98±6,51, respectivamente. La morfometría del fémur distal fue significativamente diferente entre hombres y mujeres (mayor tamaño en hombres), sin embargo uno de los parámetros mostró resultados diferentes, la FLAP. Las personas indonesias son de menor tamaño en comparación con su contraparte occidental. Las dimensiones propuestas se pueden utilizar como los datos básicos para diseñar el tamaño ideal para una prótesis de rodilla a medida para la población de Indonesia.

Treating natural disaster victims is dealing with shortages: an orthopaedics perspective.

During natural disasters such as earthquakes or tsunamis, most of the casualties are known to suffer from musculoskeletal injuries. This leads to an enormous need of orthopaedic (surgical) implants such as osteosynthesis plates, which are difficult to provide in developing countries that rely on imported ones. One of the alternatives is utilization of local resources, but only after they have been proven safe to use, and meet the international standards set. Through this paper we would like to urge the international community to include locally produced biomedical products, like osteosynthesis plates in their scientific evaluations and communications. When the quality of local products is proven, the reluctance to use local products also by surgeons from developing countries will disappear and larger scale production can be initiated. This in its turn solves many problems that come after natural disasters and stimulates the national economy in an efficient and effective way.