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.

Deep Vein Thrombosis in Elderly Patients following Surgery for Fracture of the Proximal Femur

The incidence of Deep Vein Thrombosis (DVT) is high in orthopaedic cases, associated with morbidity and mortality. This study was done to evaluate the incidence of DVT and factors that contributed to DVT in elderly patients with proximal femur fracture who underwent surgery. Patients 60 years of age and older with proximal femur fracture who underwent surgery were enrolled into this study. Daily observation of the clinical signs of DVT was done post operatively until the subjects were discharged from the hospital. D-Dimer test and contrast venography were carried out on Day 2 and between Days 4 and 7 after surgery. Results were interpreted as normal and obstruction. There were 42 eligible patients, 18 of them (42.86 %) were diagnosed with DVT. We found that positive D-Dimer test (1.40), longer duration of surgery (1.86), and presence of clinical symptoms (1.09) increased the risk of the occurence of thrombosis although not statistically significant. There were four DVT patients who passed away within 4 months after surgery due to complication from DVT. The incidence of DVT in elderly with proximal femur fracture underwent surgery was relatively high (42.86 %) with the mortality rate was 22%.

Surface properties of Indonesian-made narrow dynamic compression plates

The enormous need of orthopaedic (surgical) implants such as osteosynthesis plates is difficult to be fulfilled in developing countries commonly rely on imported ones. One of the alternatives is utilization of local resources, but only after they have been proven safe to use, to overcome this problem. Surface properties are some of the determining factors of safety for those implants. We have succeeded in developing prototype of osteosynthesis plate and the results indicate that Indonesian-made plates need improvement with regards to the surface quality of physical characterization.

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.