Techniques in Knee Surgery
ACL Reconstruction in Children: An Original Technique
Early reconstruction after anterior cruciate ligament (ACL) rupture in children with open physis was found to be a better strategy compared with delayed ACL reconstruction at skeletal maturity. This article focuses on an original technique for ACL reconstruction in children and adolescents. The rationale of the procedure is based on avoiding the danger of a femoral tunnel and fixation systems that may lead to growth arrest. Part of the quadriceps tendon with a trapezoidal patella bone block was harvested after arthroscopic exploration and addressing other intra-articular injuries like meniscal tears. The bone-tendon graft was inserted through a combined intraepiphyseal femoral tunnel drilled from outside-in under fluoroscopic imaging and a long vertical arthroscopically drilled transphyseal tibial tunnel. The bone block was impacted in the femoral tunnel, allowing primary fixation without any associated material. The tibial fixation is obtained with a strictly metaphyseal screw and postfixation with a staple. The advantages of the technique are multiple: anatomic and isometric reconstruction, arthroscopically surgery, strong adaptable long graft with excellent bone to bone press-fit fixation on the femur, and preservation of the femoral physis. Indications, the step-by-step procedure, postoperative care, complications, and results are reported in this paper.
Femoral Fixation With the ZipLoop System Using BPTB Graft in ACL Reconstruction
A stable and secure fixation of the graft is imperative for early aggressive rehabilitation after anterior cruciate ligament reconstruction. We describe a new femoral fixation device ToggleLoc with ZipLoop Technology (BIOMET) designed for a simple surgical technique with minimal instrumentation. This type of indirect femur fixation is characterized by a metal device designed to capture the cortical bone of the femur, connected to the zip suture, which is able to draw the graft through the tibial and femoral tunnel allowing one to apply tension on the graft after tibial fixation, eliminating the graft advancement effect. This technique provides not only strong, immediate mechanical fixation but also a long-term biological fixation supported by bone growth around the tendon graft.
Editorial
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Guest Editorial
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The Treatment of Infections After Anterior Cruciate Ligament Reconstruction
Infection after anterior cruciate ligament (ACL) reconstruction is a rare but devastating complication. Articular cartilage damage, a function of the duration of the infection and the virulence of the infecting organism, is largely responsible for poor functional outcome. Rapid diagnosis and treatment is therefore essential. We discuss the diagnostic dilemmas of differentiating infection from normal early postoperative ACL recovery, and the treatment options for both intra-articular and extra-articular infections, including graft salvage. Finally, the expected functional outcomes in patients treated for intra-articular infection after ACL reconstruction are also discussed.
Complications of ACL Surgery: Graft Failure Due to Undiagnosed Posterolateral Corner Injuries and Bony Malalignment
Anterior cruciate ligament reconstruction is a common procedure with excellent results. Failure of the anterior cruciate ligament graft has many possible etiologies, including undiagnosed posterolateral corner injuries and bony malalignment. We discuss these 2 causes of graft failure and how they can be detected preoperatively. The treatment options in both the primary setting and after graft failure are also discussed.
Rationale for Proper Arthroscopic Tunnel Placement in Anterior Cruciate Ligament Reconstruction
Correct tunnel placement is critical to the success of anterior cruciate ligament (ACL) reconstruction. In the revision setting this is more difficult as anatomic landmarks may be distorted or missing and secondary landmarks may be necessary. Native anatomy was not well replicated by early ACL reconstruction procedures and consequently did not optimally restore stability. The over-the-top position placed a nonanatomic graft too anteriorly on the tibia and too proximally on the femur with graft of supraphysiological length. This resulted in vertical grafts with a propensity to impinge, lengthen, and become lax. Notchplasty was a method of reducing impingement of grafts and is less often indicated with anatomic graft positioning. Trans-tibial drilling and clockface tunnel positioning are falling out of favor as graft positioning more closely replicates native anatomy, and more precise anatomic landmarks are used to guide graft positioning through the anteromedial portal. Current recommendations for femoral tunnel positioning are now the center of the femoral ACL origin at 1.7 mm proximal to the bifurcate ridge and 6.1 mm posterior to the intercondylar ridge. Recommendations for the tibial tunnel are the center of the tibial insertion at 7.5 mm medial to the anterior horn of the lateral meniscus, 7.9 mm lateral to the medial plateau cartilage border, and 13 mm anterior to the retroeminence ridge. Radiographically the tibial tunnel is 41% from anterior on the Amis and Jakob line and 47% from the medial side. A thorough knowledge of relevant anatomy and rationale for anatomic placement are necessary to ensure consistent optimal graft placement in revision ACL reconstructions.
Revision ACL Reconstruction: Tunnel Placement Issues
The revision rate of anterior cruciate ligament (ACL) reconstruction is between 3% and 25%, with the suboptimal surgical technique contributing to 77% to 95% of failures of the index procedure. The cause of failure of ACL reconstruction should be clearly identified before proceeding with revision ACL reconstruction. Incorrect tunnel placement is the most commonly identified surgical error. In this paper, we describe the radiographic evaluation of proper tunnel placement, discuss the indications for 1-stage and 2-stage ACL revision reconstruction, and describe techniques for 1-stage and 2-stage ACL revision reconstruction. The overall reported results after revision ACL revision reconstruction are inferior to primary ACL reconstruction. Patients should be appropriately counseled with respect to expected postoperative outcomes.
Knee Stiffness After ACL Reconstruction
Postoperative knee stiffness after anterior cruciate ligament reconstruction surgery is a significant clinical problem. Clinical deficits of knee flexion more than 10 degrees can limit function and athletic performance, and extension deficits of more than 5 degrees can cause gait changes and altered knee kinematics. The incidence reported in the literature varies significantly. Risk factors for the development of this condition include technical factors, graft selection issues, the timing of surgery relative to the traumatic injury, the presence of associated injuries, and postoperative rehabilitation. This chapter will review the incidence, risk factors, pathology, prevention, treatment options, and the clinical results of management of this condition.
Reconstruction of Chronic Patellar Tendon Ruptures With Extensor Mechanism Allograft
Chronic patellar tendon ruptures are a difficult clinical problem. Treatment options include repair and augmentation with hamstring tendons and other grafts. We describe a technique of extensor mechanism reconstruction using an allograft consisting of quadriceps tendon, a patellar bone block, patellar tendon, and a tibial bone block. This technique is a salvage procedure indicated only in the most severe cases of chronic rupture after failure of traditional treatment options. An appropriately size-matched allograft is prepared by shaping the anterior 10 mm of the patella into a graft resembling an hourglass. A similarly shaped trough 10 mm in depth is created in the patella of the patient, and a trough matching the tibial bone block is created in the recipient tibia. The graft is placed and secured with sutures in the quadriceps tendon, wires in the patella, and screws and staples in the tibia. Care must be taken to avoid iatrogenic patellar fracture and prominent hardware. Rehabilitation is slow, with gradual restoration of motion. Outcomes have been successful in 14 patients to date with a 4-year mean follow-up. Future work will include improvement of patellar fixation. This technically challenging procedure may restore extensor mechanism function in cases of chronic patellar tendon rupture that have failed other treatment modalities.