National surveillance for antibiotic resistance in zoonotic enteric pathogens

Treatment of food-producing animals with antimicrobial agents that are important in human therapy may present a public health risk by the transfer of resistant zoonotic pathogens from animals to humans. Resistant bacteria can diminish the effectiveness of antibiotics and demand the use of more expensive or less safe alternatives. In 1996, the Centers for Disease Control (CDC), United States Department of Agriculture (USDA), and Food and Drug Administration (FDA) established the National Antimicrobial Monitoring System to prospectively monitor changes in antimicrobial susceptibilities of zoonotic pathogens from human and animal clinical specimens, healthy farm animals, and carcasses of food-producing animals at slaughter plants. This article describes the development, implementation, and objectives of the monitoring system and presents initial data generated by the system.

Methylmercury in fish: a review of residue levels, fish consumption and regulatory action in the United States

The dangers associated with the consumption of large amounts of methylmercury in fish are well recognized, and there is some evidence to suggest that methylmercury may be the cause of subtle neurological impairments when ingested at even low to moderate levels, particularly the prenatal and early childhood periods. This concern has prompted a continuing assessment of the risk of methylmercury toxicity among fish consumers in the United States as well as other countries. The toxicokinetics of methylmercury in humans are reviewed and used to estimate body burdens associated with toxic effects. To determine seafood consumption patterns among the continental U.S. population the Food and Drug Administration (FDA) has analyzed data from a diary study commissioned by the Tuna Research Foundation. Mercury residue levels in domestic fish sampled by the FDA were used to determine the level of exposure to methylmercury. Until evidence is presented that substantially lowers the known body burden of methylmercury which causes toxicity, calculations indicate that the current 1.0 ppm regulatory level provides adequate protection for the average fish consumer, for young children, and for a significant number of consumers exceeding the acceptable daily intake. However, additional studies are being carried out in a continuing process to ensure that safe levels of prenatal exposure to mercury residues in fish are maintained.

Therapeutic antibiotics in animal feeds and antibiotic resistance

Recent statutory changes involving animal drugs are expected to facilitate the therapeutic use of antibiotics in animal feeds in the United States of America. The use of antibiotics in animal feeds is controversial due to the potential development of resistant bacterial pathogens in food-producing animals which are exposed to the antibiotics and the resultant public health risk. Zoonotic micro-organisms can be transmitted to humans through contact with animal populations, either directly or through the consumption of contaminated food. Recommendations to address the public health concerns include the strengthening of professional education in the areas of infectious diseases and the appropriate selection and use of antimicrobial agents, the development of a comprehensive food safety education programme for food-animal veterinarians and animal producers, and the development of surveillance programmes to monitor antimicrobial resistance among zoonotic pathogens. Early identification of emerging resistance can facilitate a timely and appropriate public health response.

Dual-label retrograde transport: CNS innervation of the mouse thymus distinct from other mediastinum viscera

Two different retrogradely transported tracers were identified and used to distinguish between the innervation of the thymus gland and the innervation of adjacent tissues residing within the mouse mediastinum. To determine the best procedure for peripheral dual-labeled retrograde transport, several different tracers, vehicles, and injection protocols were developed and/or tested. In the periphery, it proved ineffective to use Rhodamine latex microspheres (Luma-Fluor) as a retrograde transport agent. Horseradish peroxidase (HRP) suspended in the water-soluble carrier KY Jelly and Fluoro-Gold (FG) in an aqueous solution was the most effective combination of retrograde transport tracers. Equivalent doses of each of these tracers were determined, and injections of HRP or FG into the thymus and the esophagus produced distinct and separate patterns of labeled neurons in the spinal cord or brain stem. Throughout these CNS areas, some neurons contained both tracers suggesting that 1) these areas are innervated by neurons that give rise to collaterals to these tissues, 2) that the retrograde tracers are transported by nerves that innervate the lymphatics of the mediastinum, and/or 3) that some diffusion of the tracers occurs from the test organs and tissues to other organs and tissues of the mediastinum.

Health implications of residues of veterinary drugs and chemicals in animal tissues

The animal drug approval process in the United States is based upon the premise that the presence of drug residues in meat and poultry above tolerance is a public health hazard. Tolerances represent the maximum level of concentration of antimicrobials permitted in animal tissues at the time of slaughter. The tolerances are intended to ensure that residual drugs will have no harmful effects if ingested. The purpose of this article is to present existing evidence of the acute and chronic health consequences that may occur because of food of animal origin contaminated with illegal residues above the tolerance. The impact of food-borne drug residues on the gut microflora, residue detection limitations, and the responsibility of the veterinary practitioner in ensuring food safety is discussed.

Nutrition: a cofactor in HIV disease

The relationships among nutritional status, infectious disease, and the immune system suggest that nutrition may be a cofactor in human immunodeficiency virus (HIV) progression. We examined nutrition as a cofactor in HIV disease by reviewing the current literature on the interactions of nutrition, infectious disease processes, and immune system dysfunction. Studies demonstrate that poor nutritional status and infection affect the immune system and interact with each other. This relationship leads to the development of opportunistic infections and malignancies, which may result in a diagnosis of acquired immunodeficiency syndrome. Moreover, evidence from our review indicates that nutritional status may play a role in HIV disease progression. We recommend that clinical trials be conducted to evaluate general malnutrition and the efficacy of supplementation with specific nutrients at various stages of HIV disease.

Foodborne bacterial infections in individuals with the human immunodeficiency virus

The literature contains reports documenting a foodborne etiology for bacterial infections caused by Salmonella spp, Listeria monocytogenes, Campylobacter jejuni, and Vibrio spp in individuals with the human immunodeficiency virus (HIV). The incidence of these infections and the life-threatening complications that result are elevated in people with HIV infection. We present practical recommendations to prevent foodborne illnesses and the resulting complications, including gastroenteritis, bacteremia, meningitis, and death. We suggest that patients with HIV infection be counseled to avoid foods at high risk for harboring bacterial pathogens and to use careful sanitary practices in food preparation.

Monitoring adverse reactions to food additives in the U.S. Food and Drug Administration

Technological advances in food science have resulted in the development of numerous food additives, most of which require premarket approval by the Food and Drug Administration (FDA). Concomitant with the benefits of these additives, such as extending the shelf life of certain food commodities, is the potential for various risks. These potential risks include the possibility of the consumer experiencing an adverse reaction to the additive. In order to ascertain the character and the gravity of alleged adverse reactions to food products which it regulates, the FDA's Center for Food Safety and Applied Nutrition has developed the Adverse Reaction Monitoring System (ARMS). This postmarketing surveillance system for food additives is designed to analyze consumer reports of adverse reactions in order to alert FDA officials about any potential public health hazard associated with an approved food additive, and to delineate specific syndromes which may lead to focused clinical investigations. To date, among the products routinely monitored in the ARMS, sulfiting agents and the artificial sweetener aspartame have generated the largest volume of consumer reports describing adverse reactions. An overview of the analyses of the sulfite and aspartame adverse reaction reports is presented, along with a description of the mechanics of the postmarketing surveillance system, and a detailed discussion of its limitations.

The use of epidemiology, scientific data, and regulatory authority to determine risk factors in cancer of some organs of the digestive system. 2. Esophageal cancer

The epidemiologic aspects of esophageal cancer are well known. The extreme geographical variations in incidence of the disease, the variability in the sex ratio, and the secular trends have been described frequently. The etiology of cancer of the esophagus is known to be complex and composed of multiple factors, those caused by the environment being of greatest importance. The disease preferentially attacks groups with a low socioeconomic status or those hindered by poverty. The esophageal cancer belt has been frequently studied to provide clues to the etiology of esophageal cancer but no definite culprit has yet been found. The majority of the factors so far implicated in cancer of the esophagus appear to act directly on the esophagus rather than systemically. This is an unusual situation in that it enables the disease to be prevented by primary means. There appears to be an enormous disparity in the etiology of the disease among various countries. This disparity may be more apparent than real if the epidemiologic data are interpreted to mean that there is a two-stage process involved, with multiple etiologies for each stage. If we assume that nutritional deficiencies, even subtle ones, predispose the esophagus to influence by carcinogenic substances, the geographic differences fade. Nutritional deficiencies can develop by chronic alcohol use as well as by poverty and lack of an adequate food supply, but diet does not explain the whole picture. External carcinogens are necessary to effect the end result. The culprit may be tobacco in one culture and fungal elements in another. The South African studies which showed an association with tobacco and not alcohol could be explained if we assume that the population's nutritional deficiencies already predisposed the esophagus for the effect of an external carcinogen, thereby making alcohol usage superfluous. It would be helpful if the relationship between esophagitis and nutritional status were elucidated and if it were determined that the condition could be improved or eliminated by dietary factors. The association between nutrition and esophagitis may suggest methods of primary prevention of esophageal cancer and provide a chance of lowering the incidence of this deadly disease.

Risk assessment for aflatoxin: an evaluation based on the multistage model

Lifetime cancer potency of aflatoxin was assessed based on the Yeh et al. study from China in which both aflatoxin exposure and hepatitis B prevalence were measured. This study provides the best available information for estimating the carcinogenic risk posed by aflatoxin to the U.S. population. Cancer potency of aflatoxin was estimated using a biologically motivated risk assessment model. The best estimate of aflatoxin potency was 9 (mg/kg/day)-1 for individuals negative for hepatitis B and 230 (mg/kg/day)-1 for individuals positive for hepatitis B.

Use of epidemiology data to assess the cancer risk of 2,3,7,8-tetrachlorodibenzo-p-dioxin

Most countries have assessed the human cancer risk of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) by extrapolating from animal data. The 1600-fold variation for acceptable intakes estimated by the Americans, Canadians, and Europeans, however, indicates a large scientific uncertainty about TCDD toxicity. Regulators are attempting to use human epidemiology data to eliminate some of the limitations inherent in using animal data to quantitatively assess cancer risk in humans, particularly now that techniques for measuring TCDD levels in adipose tissue and serum are available. This paper presents an overview of the major epidemiologic studies that associate cancer with TCDD exposure. The actual exposures experienced by the study populations are emphasized. The TCDD serum levels of the Seveso, Italy, residents and of the NIOSH Dioxin Registry participants indicate that these populations hold the best promise for future assessment of the human carcinogenic risk of dioxin. Based on the animal data, however, the calculated risk from these exposures is still moderate compared with high background cancer incidence present in most industrialized countries.

Food borne disease summary by food commodity

Microbial pathogens may be transmitted to humans via food animals and food animal products. A quick reference table is presented to provide easy access to food safety information related to the major food animal product areas. Included in the table are the pathogens, mode of transmission, public health impact, and control and prevention strategies for poultry, beef, dairy products, and pork.

Herbicide and nutrient transport from an irrigation district into the South Saskatchewan River

Pesticides and nutrients can be transported from treated agricultural land in irrigation runoff and thus can affect the quality of receiving waters. A 3-yr study was carried out to assess possible detrimental effects on the downstream water quality of the South Saskatchewan River due to herbicide and plant nutrient inputs via drainage water from an irrigation district. Automated water samplers and flow monitors were used to intensively sample the drainage water and to monitor daily flows in two major drainage ditches, which drained approximately 40% of the flood-irrigated land within the irrigation district. Over three years, there were no detectable inputs of ethalfluralin into the river and those of trifluralin were less than 0.002% of the amount applied to flood-irrigated fields. Inputs of MCPA, bromoxynil, dicamba and mecoprop were 0.06% or less of the amounts applied, whereas that for clopyralid was 0.31%. The relatively higher input (1.4%) of 2,4-D to the river was probably due its presence in the irrigation water. Corresponding inputs of P (as total P) and N (as nitrate plus ammonia) were 2.2 and 1.9% of applied fertilizer, respectively. Due to dilution of the drainage water in the river, maximum daily herbicide (with the exception of 2,4-D) and nutrient loadings to the river would not have resulted in significant concentration increases in the river water. There was no consistent remedial effect on herbicides entering the river due to passage of the drainage water through a natural wetland. In contrast, a considerable portion of the nutrients entering the river originated from the wetland.

Multiple chemical sensitivity: controlled scientific studies as proof of causation

Multiple chemical sensitivity is an environmental illness that demands exacting methods of diagnosis. Proposed associations between symptoms and specific substances, whether to one substance or to multiple chemicals, need to be critically examined through adequately designed scientific studies. Appropriate methods for controlled scientific study of adverse reactions to chemicals are discussed as well as the Food and Drug Administration's (FDA's) experience with aspartame as an example of the need for controlled scientific studies to refute or confirm anecdotal evidence. Since 1986 the FDA has received reports of 265 cases of epileptic seizures temporally associated with the ingestion of aspartame. Information obtained from the complainants' medical records as well as data on consumption patterns, temporal relationships, and challenge tests do not support the claim that the occurrences of the seizures are linked to consumption of aspartame. In addition, two double-blind, placebo-controlled crossover studies failed to demonstrate an association between epileptic seizures in children and adults and the ingestion of aspartame.

The use of epidemiology, scientific data, and regulatory authority to determine risk factors in cancer of some organs of the digestive system. 4. Colon cancer

Colon cancer accounts for over 10% of all cancers diagnosed from 1973 to 1976 in the United States. Many factors have been identified as having a role in its etiology, including the intestinal microflora, colonic mutagens, bile acids, cholesterol, estrogens, and diet. The evidence supporting or refuting the importance of each of these factors and others is discussed. Dietary factors appear to be the most important risk determinants for colon cancer. In particular, a high-fat, low-fiber diet has been most consistently incriminated as a promoting agent of this cancer. The incidence of colon cancer and consumption of total fat and animal protein are highly correlated internationally. However, further epidemiologic studies have given equivocal results. A high-fiber diet has been proposed as being protective against colon cancer although the mechanism of protection remains unclear. A major correlational study has shown that dietary fiber consumption was higher in areas with low incidence of colon cancer than in those areas with high incidence. A few case-control studies have been supportive of the fiber hypothesis but many more have shown no difference among cases and controls in their fiber consumption. More epidemiological studies are needed to clarify the role of diet in the etiology of colon cancer. Before a dietary change is recommended, the competing risks of other cancers and other diseases should be extensively researched.

Developing new regulatory approaches to antimicrobial safety

Resistance to antimicrobial agents is of concern to public health officials worldwide. In industrialized countries, a significant source of antimicrobial-resistant food-borne infections in humans is the acquisition of resistant bacteria originating from animals. The US Food and Drug Administration (FDA) is committed to resolving the public health impact arising from the use of antimicrobial drugs in food-producing animals. The FDAs goal is to ensure that significant human antimicrobial therapies are not compromised or lost while providing for the safe use of antimicrobials in food animals. Recently the FDA published a guidance document titled 'Evaluating the Safety of Antimicrobial New Animal Drugs with Regard to their Microbiological Effects on Bacteria of Human Health Concern' (US Food and Drug Administration, Center for Veterinary Medicine, 2003). This document outlines a pathway drug sponsors can use to address concerns about antimicrobial resistance prior to approval of their drug. The process uses a qualitative risk assessment approach to assess the potential of the intended use of a product to develop resistance in bacteria that may harm humans. The level of risk determines the level of risk management that is required for the drug to be used. The Food and Drug Administration (FDA) always has the option of not approving a drug if the risk of a public health consequence is too high.

Eating as a hazard to health: preventing, treating dental injuries caused by foreign objects in food

The Food and Drug Administration maintains a passive surveillance system for reporting and follow-up of complaints related to food items. The most commonly reported complaint is the discovery of foreign objects in food. The most common injuries are abrasions to the throat and buccal mucosa. Although dentists are qualified to treat oral injury resulting from foreign object ingestion, more physicians than dental professionals treat soft tissue trauma.

Slope-Reducing Proximal Tibial Osteotomy Improves Outcomes in Anterior Cruciate Ligament Reconstruction Patients With Elevated Posterior Tibial Slope, Especially Revisions and Posterior Tibial Slope ≥12

PURPOSE

To explore the indications, outcomes, and complications related to slope-reducing osteotomies in the setting of anterior cruciate ligament (ACL) tears or graft failure. A secondary aim was to create an algorithm on the basis of the current literature and authors' opinions.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Studies were included if they reported on outcomes related to slope-reducing osteotomies both for primary ACL tears and revision ACL graft tears. The studies were analyzed to determine the radiographic outcomes, patient-reported outcomes (PROs), physical examination findings, and complications. Statistical analysis could not be performed because of the heterogeneity between studies.

RESULTS

A total of 148 studies were screened for inclusion in this systematic review and after full-text review, a total of 16 studies were included in this systematic review. Fourteen of the studies reported on pre- versus postoperative posterior tibial slope (PTS) and all but one reported significant decrease in PTS. Seven studies reported on pre- versus postoperative PROs, and all studies reported significant improvements in postoperative scores. Anterior tibial translation was measured in 8 studies, and all reported a significant decrease in anterior tibial translation postoperatively. The most common complication was postoperative hyperextension and irritation from hardware. Irritation from hardware was only reported in studies that used plates to fixate the osteotomy.

CONCLUSIONS

In conclusion, slope-reducing proximal tibial osteotomies performed concurrently or as a second-stage surgery with an anterior cruciate ligament reconstruction (ACLR) resulted in improved PROs and decreased ACLR failure rates. Slope-reducing proximal tibial osteotomies are an important treatment consideration for those patients with an increased PTS, especially for patients with a failed ACLR and a PTS ≥12°, to reduce the risk of ACLR failure.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Producer quality assurance programs

Essentially all animal commodity organizations have established quality assurance programs designed to ensure food safety and quality. Most of these programs were originally implemented to address problems with veterinary drug residues. Many of the current programs have or plan to include food safety critical control points with specific guidelines on how to control or reduce pathogen load. The continued focus placed on food safety by today's consumer demands that American producers ensure that their commodities are wholesome, safe, and of high quality in order to remain competitive in the global marketplace. Veterinarians should recognize that it is important to encourage food animal producers to participate in quality assurance programs for their clients' economic health and for food safety and protection of public health. Commodities certified as being produced under good production practices or by producers certified as following a recognized and validated quality assurance program often bring a premium price. Also, some slaughter establishments are beginning to require producers to be certified as practicing under a recognized quality assurance program before animals are accepted for processing. This practice is being driven partially by the demands placed on slaughter establishments by the US Department of Agriculture's implementation of the Pathogen Reduction, Hazard Analysis and Critical Control Point Systems regulation. Regardless of why producer trade association quality assurance programs have come into existence, veterinarians should promote the programs as an excellent mechanism to help ensure everyone's goal of a safe, wholesome food supply.

The Fibular Collateral Ligament Is a More Important Restraint to Varus Laxity Compared to the Anterolateral Complex in the Anterior Cruciate Ligament-Deficient Knee in a Cadaveric Biomechanical Study

PURPOSE

To compare the influence of the fibular collateral ligament (FCL) and the anterolateral complex (ALC) on varus knee laxity in paired anterior cruciate ligament (ACL)-deficient cadaveric knees using varus stress radiographs.

METHODS

Varus laxity in 9 paired (N = 18, mean age 73.8 years) human cadaveric knees was assessed using varus stress radiographs with a 12-Nm varus stress applied at 20° of knee flexion. All knees underwent testing in the intact state and following ACL sectioning. One knee of each pair was randomly assigned to undergo FCL sectioning, and the contralateral knee was assigned to undergo ALC sectioning (anterolateral ligament [ALL] followed by the Kaplan fibers).

RESULTS

Both FCL sectioning and ALC (ALL and the Kaplan fibers) sectioning resulted in increased lateral compartment gapping compared to the intact state, 2.44 mm and 1.13 mm, respectively. ALL sectioning with intact Kaplan fibers did not result in increased lateral compartment gapping. Paired knee comparison revealed a significantly greater influence of the FCL than the ALC in restraining lateral compartment gapping under an applied varus stress (P = .0003).

CONCLUSIONS

Sectioning the FCL resulted in significantly greater lateral compartment gapping under a varus stress than combined sectioning of the ALL and Kaplan fibers in an ACL-deficient knee, although both scenarios resulted in significantly increased gapping compared to the intact state. Sectioning of the ALL with intact Kaplan fibers did not result in increased lateral compartment gapping.

CLINICAL RELEVANCE

The FCL is the most important structure in restraining varus laxity in the ACL-deficient knee, and the ALC is of secondary importance in restraining varus laxity. In ACL-deficient patients with a high-grade pivot shift, mild varus laxity on clinical examination, and an intact FCL on magnetic resonance imaging, injury to the anterolateral complex should be considered and may be evaluated with varus stress radiographs. This study validates prior biomechanical studies of FCL deficiency and demonstrates that an approximately 1-mm increase in lateral compartment gapping on varus stress radiographs may occur secondary to ALC injury, and clinicians should be aware of this when considering treatment for ACL-deficient patients with high-grade anterolateral laxity.

Anatomic Anterolateral Ligament Reconstruction with Iliotibial Band Graft and Concomitant Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction (ACLR) attempts to restore native ACL function. Persistent anterolateral instability is a common symptom after ACLR that can lead to worse patient outcomes. Additional surgeries, like anterolateral ligament reconstruction (ALLR), can augment the ACL graft and help increase anterolateral rotational stability. Certain indications for ACLR with ALLR include high-grade pivot shift, increased posterior tibial slope (>12°), revision ACLR, and concomitant ligamentous or meniscal injuries. We describe an anatomic ALLR technique using an 8 cm long × 1 cm wide strip of the inferior aspect of the iliotibial band fixed at the native attachment sites of the ALL.

Medial Opening Wedge (MOW) Versus Lateral Closing Wedge (LCW) High Tibial Osteotomies for Knee Medial Compartment Osteoarthritis Show Similar Outcomes and Survivorship, While MOW Has Higher Rates of Tibial Fracture and LCW Has Higher Rates of Nerve Injury and Conversion to Total Knee

PURPOSE

The purpose of this systematic review was to compare the clinical and radiographic outcomes and complications between medial opening wedge and lateral closing wedge high tibial osteotomies in the setting of medial compartment osteoarthritis with genu varus alignment.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies that reported on MOW- or LCWHTOs in the setting of medial compartment osteoarthritis were included. Analysis was performed based on radiographic and patient reported outcomes (PROs) and complications.

RESULTS

A total of 40 studies were included. Hip-knee-ankle (HKA) angles and PROs including Lysholm and VAS showed significant improvements postoperatively for both MOW- and LCWHTO for all included studies. For the studies that reported on it, posterior tibial slope (PTS) was significantly increased in 4 of the 9 MOW studies and significantly decreased in 8 of the 9 LCW studies, and patellar height was significantly decreased in 4 of the 5 MOW studies, while none of the 4 LCW studies reported any changes. Three comparison studies reported a higher conversion to total knee arthroplasty (TKA) in the LCW cohort, otherwise, survivorship at 10-years was comparable between studies. The MOW cohort had higher rates of tibial fractures while the LCW cohort had higher rates of nerve injuries.

CONCLUSIONS

This systematic review found comparable HKA angle correction and PROs between patients undergoing MOW- or LCWHTOs to treat medial compartment osteoarthritis. Survivorship at 10-years was comparable between MOW- and LCWHTOs; however, some MOW- and LCWHTO comparison studies reported higher conversion to TKA for LCWHTO. Medial opening wedge HTO typically results in an increased PTS, decreased patellar height, and tibial fractures, while LCWHTO typically results in decreased PTS, no change in patellar height, and common peroneal nerve injuries.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Anatomic Popliteus Tendon and Tibiofibular Joint Reconstructions

Background

The popliteus tendon is a primary stabilizer of external knee rotation and has been described as the "fifth ligament of the knee." Injuries involving the posterolateral corner of the knee commonly involve the popliteus tendon; isolated injury to the popliteus tendon is relatively rare and usually involves a rotatory injury mechanism and symptoms of instability and pain. In this patient, there was a concomitant injury to the proximal tibiofibular joint.

Indications

Popliteus tendon reconstruction is indicated for patients with abnormal external rotation on examination and symptoms of pain and instability. Proximal tibiofibular joint reconstruction is indicated for patients with instability of the tibiofibular joint.

Technique Description

Preoperative examination under anesthesia is essential to determine the extent of external rotation and assess for additional posterolateral pathology. The popliteus tendon procedure begins with a meticulous common peroneal nerve neurolysis to minimize nerve irritation and decrease the risk of a postoperative foot drop. Semitendinosus and gracilis graft harvest is performed with at least 16 cm of graft length followed by tunnel reaming of the popliteus tendon femoral attachment and tibia tunnel identification and reaming. The femoral attachment of the popliteus tendon is secured, and the semitendinosus graft is anatomically oriented along the native path and passed from posterior to anterior through the femoral tunnel. The gracilis graft for anatomic proximal tibiofibular joint reconstruction requires an anterior to posterior tunnel through the fibular head. Finally, both grafts are secured in the tibial tunnel with the application of an anterior traction force.

Results

A cadaveric study by LaPrade et al reported that an anatomic popliteus tendon reconstruction with a semitendinosus autograft significantly reduced external rotation laxity compared with the sectioned state. In addition, popliteus tendon reconstruction resulted in significantly decreased varus laxity, anterior tibial translation, and internal rotation.

Discussion

This is a technique that effectively restores external rotation knee stability utilizing an anatomically oriented reconstruction of the popliteus tendon and tibiofibular joint. The popliteus tendon serves as a primary stabilizer to external rotation and facilitates static function of the knee. The proximal tibiofibular joint reconstruction restores the function of the posterior proximal tibiofibular joint ligaments.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Bone Grafting of Anterior Cruciate Ligament and Posterior Cruciate Ligament Tibial and Femoral Tunnels as a First-Stage Procedure

Recurrent multiligament knee injuries present unique challenges when performing revision ligament reconstructions. Bone tunnel widening is relatively common and considered a multifactorial condition that involves both biomechanical and biologic factors. When indicated, two-stage procedures ensure optimal revision reconstruction tunnel sizes and locations before ligament reconstruction and promote improved outcomes. Staged bone grafting is required when addressing significant tunnel widening and improper tunnel placement that puts graft incorporation at increased risk in ligament reconstructions of the knee. In this Technical Note, we describe the first stage of a two-stage procedure to address meniscus/chondral conditions, tunnel osteolysis from previous reconstructions, and tibial and femoral bone grafting for the anterior cruciate ligament and posterior cruciate ligament.