Anterior cruciate ligament femoral socket drilling with a retrograde reamer: lessons from the learning curve

Efficacy of the "Salento technique", a modified two-incision approach in distal biceps brachii tendon repair. Surgical description and outcomes analysis

INTRODUCTION

The biceps brachii lesion needs to be treated surgically. A modified two incisions technique is proposed and reviewed. Material and Methods: All patients were treated with the same technique. The outcomes were measured with the Quick-DASH Score (QDS), and the Mayo Elbow Performance Score (MEPS). Postoperative complications and distal biceps tendon strength were registered also.

RESULTS

At one year from the trauma, the QDS and the MEPS were excellent in all patients. 72.97% fully recovered and returned to work after 6 months from the trauma.

DISCUSSION

This technique, thanks to its preservation of anatomical structures, provides great outcomes.

3D-Printed Patient-Specific ACL Femoral Tunnel Guide from MRI

Background

Traditional ACL reconstruction with non-anatomic techniques can demonstrate unsatisfactory long-term outcomes with regards instability and the degenerative knee changes observed with these results. Anatomic ACL reconstruction attempts to closely reproduce the patient's individual anatomic characteristics with the aim of restoring knee kinematics, in order to improve patient short and long-term outcomes. We designed an arthroscopic, patient-specific, ACL femoral tunnel guide to aid anatomical placement of the ACL graft within the femoral tunnel.

Methods

The guide design was based on MRI scan of the subject's uninjured contralateral knee, identifying the femoral footprint and its anatomical position relative to the borders of the femoral articular cartilage. Image processing software was used to create a 3D computer aided design which was subsequently exported to a 3D-printing service.

Results

Transparent acrylic based photopolymer, PA220 plastic and 316L stainless steel patient-specific ACL femoral tunnel guides were created; the models produced were accurate with no statistical difference in size and positioning of the center of the ACL femoral footprint guide to MRI (p=0.344, p=0.189, p=0.233 respectively). The guides aim to provide accurate marking of the starting point of the femoral tunnel in arthroscopic ACL reconstruction.

Conclusion

This study serves as a proof of concept for the accurate creation of 3D-printed patient-specific guides for the anatomical placement of the femoral tunnel during ACL reconstruction.

Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis

PURPOSE

To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft.

METHODS

Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12^®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations.

RESULTS

In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture.

CONCLUSION

In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture.

CLINICAL RELEVANCE

the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively.

LEVEL OF EVIDENCE

I.

Creation of femoral tunnel by outside-in technique for ACL reconstruction: an analysis

PURPOSE

To study the outcome of ACL reconstruction by retrograde outside-in (OI) creation of femoral tunnel.

METHODS

ACL reconstruction was done in 41 cases by OI technique. The tip of 115° femoral guide was placed at posterior aspect of femoral foot print of ACL. Reaming was done from outside-in over guide pin. The length of femoral tunnel was obtained by measuring guide pin. The location of intra-articular femoral tunnel aperture and graft was recorded. Tibial tunnel was created with 50° guide placed at tibial foot print of ACL. Post-operative digital radiograph was taken. Antero-posterior view was used to calculate coronal inclination of femoral tunnel. On lateral view femoral tunnel location was marked in relation to the intersection of Blumensaat line and posterior femoral cortical line. Lysholm scoring and pivot shift test were performed at follow-up. Objective measurement of anterior tibial translation was done by rolimeter (aircast) at 1 year.

RESULTS

The mean femoral tunnel length recorded was 39.5 mm (±3.4). There was no incidence of femoral tunnel blow out or graft impingement. All cases had femoral tunnel aperture location posterior to posterior femoral cortical line and inferior to Blumensaat line. The mean coronal angle of femoral tunnel was 30.39° (±4.6). The mean preoperative Lysholm score of 53.5 (±13) increased to 95.2 (±3.5) 1 year after surgery. All the patients had full range of motion. The pivot shift test was negative and instrumented measurement of anterior translation of tibia was near normal in all cases.

CONCLUSION

OI technique of ACL reconstruction is a simple reproducible technique. The unconstrained placement and angling of femoral guide result in a femoral tunnel which is through footprint of ACL. The graft is placed very low, oblique and as posterior as possible on femoral side mimicking the native ACL.

LEVEL OF EVIDENCE

III.