Influence of knee flexion angle and transverse drill angle on creation of femoral tunnels in double-bundle anterior cruciate ligament reconstruction using the transportal technique: Three-dimensional computed tomography simulation analysis.

BACKGROUND: The purpose of this study was to find appropriate flexion angle and transverse drill angle for optimal femoral tunnels of anteromedial (AM) bundle and posterolateral (PL) bundle in double-bundle ACL reconstruction using transportal technique. METHODS: Thirty three-dimensional knee models were reconstructed. Knee flexion angles were altered from 100° to 130° at intervals of 10°. Maximum transverse drill angle (MTA), MTA minus 10° and 20° were set up. Twelve different tunnels were determined by four flexion angles and three transverse drill angles for each bundle. Tunnel length, wall breakage, inter-tunnel communication and graft-bending angle were assessed. RESULTS: Mean tunnel length of AM bundle was >30mm at 120° and 130° of flexion in all transverse drill angles. Mean tunnel length of PL bundle was >30mm during every condition. There were ≥1 cases of wall breakage except at 120° and 130° of flexion with MTA for AM bundle. There was no case of wall breakage for PL bundle. Considering inter-tunnel gap of >2mm without communication and obtuse graft-bending angle, 120° of flexion and MTA could be recommended as optimal condition for femoral tunnels of AM and PL bundles. CONCLUSION: Flexion angle and transverse drill angle had combined effect on femoral tunnel in double-bundle ACL reconstruction using transportal technique. Achieving flexion angle of 120° and transverse drill angle close to the medial femoral condyle could be recommended as optimal condition for femoral tunnels of AM and PL bundles to avoid insufficient tunnel length, wall breakage, inter-tunnel communication and acute graft-bending angle.

What is the best treatment for displaced Salter-Harris II physeal fractures of the distal tibia?

Background and purpose - The optimal treatment of displaced Salter-Harris (SH) II fractures of the distal tibia is controversial. We compared the outcomes of operative and nonoperative treatment of SH II distal tibial fractures with residual gap of >3 mm. Factors that may be associated with the incidence of premature physeal closure (PPC) were analyzed. Patients and methods - We retrospectively reviewed 95 patients who were treated for SH II distal tibial fractures with residual gap of >3 mm after closed reduction. Patients were assigned to 1 of 2 groups: Group 1 included 25 patients with nonoperative treatment, irrespective of size of residual gap (patients treated primarily at other hospitals). Group 2 included 70 patients with operative treatment. All patients were followed for ≥ 12 months after surgery, with a mean follow-up time of 21 months. Logistic regression analyses were performed to identify risk factors for the occurrence of PPC. Results - The incidence of PPC in patients who received nonoperative treatment was 13/52, whereas PPC incidence in patients who received operative treatment was 24/70 (p = 0.1). Multivariable logistic regression analysis determined that significant risk factors for the occurrence of PPC were age at injury, and injury mechanism. The method of treatment, sex, presence of fibular fracture, residual displacement after closed reduction, and implant type were not predictive factors for the occurrence of PPC. Interpretation - Operative treatment for displaced SH II distal tibial fractures did not seem to reduce the incidence of PPC compared with nonoperative treatment. We cannot exclude that surgery may be of value in younger children with pronation-abduction or pronation-external rotation injuries.

Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children.

PURPOSE: The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture. MATERIALS AND METHODS: We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores. RESULTS: Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up. CONCLUSION: Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity.