Isolated radial tears of the lateral meniscus midbody: a case series of professional athletes treated with outside-in repair.

PURPOSE: The main aim of the study is to assess clinical and functional outcomes of arthroscopic outside-in repair of isolated radial tears of the midbody of lateral meniscus in professional athletes and to evaluate the return to the sport activity after surgery. METHODS: A retrospective data collection on professional athletes with isolated complete lesion of the midbody of lateral meniscus, treated with arthroscopic outside-in repair was carried out. Outcome measures included functional assessment, Limb Symmetry Index (LSI) and Hamstring Quadriceps Ratio (HQR) and Lysholm score collected before surgery and at 4-month follow-up. Data on return to sport practice and re-injury were also retrieved. RESULTS: Fourteen patients satisfied the selection criteria. Full return to professional sport activity (Tegner 10) was registered in the 86% of the cohort at 4 months after the surgery. Functional testing of the athletes showed a return of the LSI and HQR to the pre-surgical condition, demonstrating a full recovery of the functional ability and muscle strength. Similarly, clinical evaluation through Lysholm score showed an improvement, reaching an average of 97.7 points at 4 months follow-up. CONCLUSION: A good functional recovery and a high rate of return to play has been observed in a population of professional athletes, at 4 months after outside-in repair.

Posterior horn instability of the medial meniscus a sign of posterior meniscotibial ligament insufficiency.

PURPOSE: In longstanding chronic anterior cruciate ligament (ACL) insufficiency, we identified an abnormal movement of the posterior medial meniscal horn, likely due to insufficiency of the posteromedial meniscotibial ligament. Passing from extension to flexion or vice versa, the medial posterior horn slides below the posterior rim of the tibia exposing the tibial plateau. Fixation with suture anchors of the meniscotibial ligament through a posteromedial portal restored normal meniscotibial tension and reduced instability of the meniscal posterior horn. The purpose of the present study was to present the arthroscopic features of posterior medial meniscus instability and to report results following arthroscopic repair. METHODS: During the two-year study period, from 2007 through 2008, this arthroscopic feature was detected in 12 patients, 5 patients had failure of a previous ACL reconstruction and 7 patients had delay in ligamentous reconstruction for various reasons. All patients were affected by severe anterior-posterior translation with 11.3 ± 4.3 mm of side-to-side difference at KT-2000 and by associated rotatory laxity with grade 3 of pivot shift. RESULTS: At follow-up of 1 year, the combined ACL reconstruction and fixation of the posteromedial horn showed a reduction in the rotatory and anteroposterior laxity. CONCLUSIONS: This study suggests the importance of a proper arthroscopic evaluation of the posterior medial capsule in patients with chronic ACL insufficiency and highlights the potential presence of an unstable posterior horn of the medial meniscus as an indirect arthroscopic sign of peripheral laxity.

Arthroscopic patellar reinsertion of the MPFL in acute patellar dislocations.

PURPOSE: The objective of this study was to evaluate the mid-term results of a new technique for the arthroscopic repair of MPFL after an acute patellar dislocation (APD). MATERIALS: The series included 17 patients (11 men and 6 women) with a first episode of acute patellar dislocation; treated over a period of 6 years. Re-dislocation, subjective symptoms and functional limitations were evaluated at an average follow-up of 2.2 years (1-5.5). The patients were evaluated with the Lysholm and the Kujala scoring systems. RESULTS: At follow-up, no re-dislocation was reported. Only one patient referred an episode of patellar instability, without a distinct dislocation. The postoperative median Lysholm score was 90 (72-100). The median Kujala score was 92 (75-100). Fourteen out of 17 patients were able to return to sports at the same level as before. CONCLUSION: When the MPFL is avulsed from the patella, the proposed technique has the advantage of restoring tension of the ligament through reattachment at the patellar border with two trans-patellar sutures. The full-arthroscopic approach has the advantage of being less invasive and having a shorter recovery time.

Magnetic resonance imaging of posterior cruciate ligament injuries: a new classification of traumatic tears.

PURPOSE: The aim of our study was to propose a new classification of acute posterior ligament (PCL) injuries based on magnetic resonance imaging (MRI). MATERIALS AND METHODS: Using MRI, we reviewed 220 patients presenting an acute posterior ligament injury. The MRI exam was performed on a 0.2-Tesla (T) magnet and a 1.5-T magnet using T1-weighted spin echo (SE), T2-weighted SE and fat-suppression scans [short-tau inversion recovery (STIR)] in axial, sagittal and coronal planes. In no case was paramagnetic contrast agent injected. RESULTS: Twenty-five per cent of patients were identified as having type I lesions and another 30% as having type II lesions according to the Gross classification. Out of 77 patients, 35% of the whole sample, 37 had a tear of the posteromedial fascicle (type II lesion), and the remaining 40 had anterolateral fascicle tears (type III). In 10% of cases, the ligaments appeared completely interrupted, and these were classified as type IV lesions. CONCLUSIONS: T1-weighted SE sequences need to be integrated with T2-weighted and STIR sequences to detect the real extent of the remaining fascicle. The MRI exam could thus be able to provide a qualitative evaluation of PCL injuries and establish how the injury compromises joint stability.

Total knee replacement: prevention of deep-vein thrombosis using pharmacological (low-molecular-weight heparin) and mechanical (intermittent foot sole pump system) combined prophylaxis. Preliminary results.

AIM: The aim of this study was to determine the role of combined mechanical and pharmacological prophylaxis in the prevention of deep venous thrombosis (DVT) after total knee replacement (TKR). DESIGN: prospective case series study. METHODS: Between October 2002 and June 2003, 38 total knee procedures were carried out on 34 patients (4 patients had bilateral TKR). To exclude the presence of a concomitant DVT echo-color-flow of the legs was performed between 2 and 1 week prior to surgery, in the postoperative period (before discharging) and 30 days after surgery. Patients received one daily subcutaneous injection of nadroparin calcium (dosage adapted to body-weight). An intermittent foot sole pump (IFSP) was applied in the recovery room postoperatively, in both feet for about 5 h a day and all night long, and continued at home until the 15(th) day. RESULTS: No major perioperative or rehabilitation phase-related complications were observed (2 patients required manual drainage of blood clots from the wound). The incidence of DVT was 7.9% (3 cases). In one of these cases we observed a previous DVT so it was classified as rethrombosis. All were successfully treated with therapeutic introduced low molecular weight heparin (LMWH) therapy. No pulmonary embolism or deaths associated with the use of LMWH or IFSP were observed. CONCLUSIONS: In our experience the combined prophylaxis with nadroparin calcium and IFSP significantly reduced the incidence of DVT.

Intentional lateral epidural catheter placement for anterior cruciate ligament reconstruction.

BACKGROUND: Unilateral epidural block might constitute a clinical option in lower limb orthopedic surgery. METHODS: Seventy-five patients undergoing anterior cruciate ligament reconstruction (ACLR) were randomized to either a laterally directed epidural catheter (IUEC, n = 40) or a classic midline catheter (CMEC, n = 35). Paresthesia encountered during catheter insertion was registered. The start dose of the anesthetic mixture clonidine 60 microg (0.4 ml), sufentanil 15 microg (0.3 ml) and ropivacaine 10 mg ml(-1)(10.3 ml) in 11 ml of total volume) was set at 5 ml and was increased by 2 ml if anesthesia was inadequate after assessment for sensory blockade to cold and pin-prick. Data were registered intra- and postoperatively regarding pain scores as well as motor block, hemodynamic parameters, adverse effects and need for supplemental analgesia other than a continuous postoperative epidural infusion. RESULTS: In the IUEC group 80% of patients reported a light paresthesia of the affected side during catheter insertion, whereas 71% of patients in the CMEC group reported no paresthesia at all. The amount of anesthetic used to establish surgical anesthesia was lower in the IUEC group (6.2 +/- 0.8 vs. 8 +/- 1.9 ml, P < 0.001). Motor block (Bromage score) of the unaffected side was significantly lower in the IUEC group (P < 0.001). Pain intensity scores, hemodynamic parameters, and supplemental analgesia given were similar between the two groups except for VAS scores at 12 h postoperatively, which were higher in the CMEC group (P < 0.01). Urinary retention was significantly more frequent in the CMEC group (19/35 vs. 5/40, P < 0.001). CONCLUSION: These results suggest that the IUEC technique is a feasible and efficient method for providing anesthesia and analgesia for ACLR and is associated with a lower consume of anesthetics, less motor block and a reduced incidence of urinary retention.

Low-intensity pulsed ultrasound in the conservative treatment of pseudoarthrosis.

AIM: The management of pseudarthrosis remains a challenge. Several in vivo animal and controlled clinical studies have demonstrated that low-intensity pulsed ultrasound can influence fracture healing. METHODS: A prospective longitudinal design was used. Fifteen patients (12 males and 3 females; mean age 35.5+/-12.9, range 18 to 60), all amateur athletes, under treatment for pseudarthrosis at different sites (average fracture age: of 336.6+/-60.1 days) were treated with a single 20 min daily application of low-intensity pulsed ultrasound (frequency 1.5 MHz and intensity 30 mW/cm2). All patients underwent clinical examination and plain radiography at the beginning of treatment and were followed up clinically and radiographically at 4, 8, 12, 16, 20 and 24 weeks until the fracture healed. RESULTS: All fractures healed with a mean healing time of 94.7+/-43.8 days. CONCLUSION: Low-intensity pulsed ultrasound is effective in the management of long standing fracture non-unions. Prospective randomized studies are needed to confirm the value of this modality of treatment.

[Surgery in severe ulcerative colitis: our experience]. / La chirurgia nella rettocolite ulcerosa grave: nostra esperienza.

BACKGROUND AND AIMS: The mortality in severe episodes of ulcerative colitis (UC) has been reduced from 31-61% in the 1950 to 1-3%. Nevertheless it remains high in non specialist centers. Simple criteria are necessary to predict the outcome of severe ulcerative colitis. METHODS: 14 patients hospitalized for severe disease (Truelove and Witts criteria) from 1996 to 2000 were retrospectively analyzed. Patients were divided into two groups: 1. Group A: patients with severe disease surgically treated. 2. Group B: patients with severe disease responders to medical therapy Sex, age, length of steroids medical therapy, fever, stool frequency, CRP, ESR, haemoglobinemia, leukocytes, serum albumin values in the three days before the operation or during the hospitalization were collected. RESULTS: Total colectomy with ileostomy was necessary in 8 patients (57.1%), while 6 patients (42.90%) were responders to medical therapy. No perioperative mortality was recorded. Stool frequency, CRP, ESR, haemoglobinemia, serum albumin were significantly related to surgical operation. CONCLUSIONS: 1. No uniform criteria off severe attacks, are clearly defined in Literature. 2. The length of pre-operative medical therapy has a tendency to be too high (in our series 19 + 8.2 days). 3. Stool frequency, CRP, ESR, haemoglobinemia, serum albumin were significantly modified in operated patients.

Rectal washout with cytotoxic solution can be extended to the whole colon.

BACKGROUND: Rectal irrigation with a cytotoxic agent does not kill viable intraluminal cancer cells proximal to the primary tumour. To prevent implantation of these cells at the time of restorative proctectomy, the feasibility of retrograde whole-colon irrigation just before surgery was explored. METHODS: The cytotoxic efficacy of different combinations of povidone-iodine (PVPI) and Gastrografin was tested with the trypan blue exclusion test on a human colon carcinoma cell line (SW620) in vitro. Subsequently, a retrograde whole-colon lavage with PVPI 5 per cent and Gastrografin 12 per cent was performed in 14 euthyroid, non-allergic patients with colorectal cancer using a colostomy irrigation set. Thyroid function and mucosal damage were assessed. RESULTS: It took 2 min and approximately 1 litre of infused solution to reach the caecum in all patients. The solution was 100 per cent tumoricidal in vitro and remained so after colonic irrigation. Total serum tri-iodothyronine (T3) levels decreased and those of reverse T3 increased, but normalized after 1 week. Superficial epithelial desquamation was observed shortly after irrigation; however, complete restoration occurred within 7 days. CONCLUSION: A rectal washout can easily be extended to a retrograde irrigation of the whole colon in elective colorectal cancer surgery. This may help to prevent anastomotic and local recurrence due to implantation of viable exfoliated tumour cells.

[Course and natural history of idiopathic ulcerative proctitis in adults]. / Decorso e storia naturale della proctite ulcerosa idiopatica nell'adulto.

BACKGROUND AND AIMS: Epidemiological studies have shown that ulcerative proctitis represents 25-55% of ulcerative colitis. In western countries, the incidence of ulcerative proctitis has been increased, while the incidence of more extensive colitis remained unchanged. Compared with extensive ulcerative colitis, the idiopathic proctitis seems to be a benign disease, with an extension to proximal segments in less than 30% of cases, low surgical and cancer risk. On the basis of epidemiological studies, not confirmed by endoscopic and histological features, it has been hypothesized that ulcerative colitis and proctitis could represent two different clinical entities. The aim of the study was to evaluate some clinical and demographic features related to the two different localizations, colitis and proctitis, in the attempt to clarify the above mentioned issues. METHODS: Demographic data of 156 patients observed in our institution from 1982 to 1999, were retrospectively analysed. Diagnosis, extension and severity of ulcerative procto-colitis were based on endoscopic and histological criteria. Local and systemic symptoms, extraintestinal manifestations, surgical and cancer risk, were also recorded. RESULTS AND CONCLUSIONS: Ulcerative proctitis has shown to be a benign disease, with a prevalence of local symptoms, less systemic and extraintestinal manifestations, and low endoscopic grades of activity. Furthermore no surgical intervention and cancer development were recorded. Extension to proximal segments was observed in 10.25% of cases. Young age of onset of symptoms,-smoking and appendectomy were associated to an higher risk of extension of the disease.

C-reactive protein and erythrocyte sedimentation rate changes following arthroscopically assisted anterior cruciate ligament reconstruction.

We studied changes in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to establish normal values after uncomplicated anterior cruciate ligament (ACL) reconstruction. The levels of CRP and ESR were determined by serial measurements in 45 consecutively treated patients. Blood samples were collected before surgery and on postoperative days 1, 3, 7, 15, and 30. Both ESR and CRP showed a marked increase postoperatively, peaking between the 3rd and 7th postoperative days, the latter showing a faster return to normal ( P=0.286). These data show that CRP can be used as a more accurate predictor than ESR of postoperative complications if the blood level remains elevated or unexpectedly rises.

One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstruction.

PURPOSE: To retrospectively evaluate 15 consecutive patients who underwent simultaneous isolated, arthroscopically assisted anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction. TYPE OF STUDY: Case series. METHODS: A bone-patellar tendon-bone autograft was used as the PCL substitute and doubled hamstring tendons were used as the ACL graft. The IKDC evaluation form and the HSS, Lysholm, and Tegner clinical rating scales were used to make clinical evaluations. Anteroposterior translation was measured with the KT-2000 arthrometer and stress view radiography. RESULTS: At final IKDC evaluation, 3 patients (20%) were graded A, 7 (46.7%) were graded B, 3 (20%) were graded C, and 1 patient (6.7%) was graded D. One patient underwent revision surgery in another hospital for severe postoperative residual laxity. Two C-graded patients had an unsatisfactory outcome as a result of serious complications related to knee injuries. All patients with a grade A or B returned to sports activity. At stress view examination, mean posterior side-to-side translation measured at the lateral tibial plateau was 5.8 +/- 1.1 mm and the mean translation at the medial tibial plateau was 7.3 +/- 1.5 mm; the mean anterior dislocation was 3.3 +/- 0.4 mm. The preoperative HSS score rated an average of 32 +/- 9. Postoperatively, the average score reached was 89.6 +/- 8.3. The preoperative Lysholm score was 65.5 +/- 9.1 (range, 48 to 78) in patients with chronic lesions and at follow-up was 95.1 +/- 4.5 (range, 88 to 100). The average Tegner activity score decreased in patients with chronic lesions from 6.9 +/- 1.7 (range, 4 to 9) before injury to 5.5 +/- 1.6 (range, 2 to 9) at follow-up (P =.053 ). At follow-up, 7 patients (50%) returned to their preinjury level after surgery. CONCLUSIONS: These results show the effectiveness and safety of simultaneous arthroscopic reconstruction of both cruciate ligaments using autografts that can adequately restore satisfactory stability, even in the presence of minimal peripheral laxity (1 degrees or 2 degrees ). We conclude that the use of autografts can restore ligament function with good patient compliance and without significant surgical complications.

Transcondylar screw fixation in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to investigate the outcomes of 2 different methods of femoral fixation for arthroscopically assisted anterior cruciate ligament (ACL) reconstruction. TYPE OF STUDY: Double-blind prospective study. METHODS: Fifty-five patients were prospectively evaluated at 2-year follow-up. In group A, 24 patients underwent arthroscopic ACL reconstruction with bone-patellar tendon-bone and interference screw fixation. In group B, 31 patients underwent arthroscopic ACL reconstruction with bone-patellar tendon-bone and transcondylar screw fixation. Patients were evaluated by using the IKDC form, Lysholm-II form, Tegner scoring system, and KT-2000 arthrometer. RESULTS: In group A, final IKDC clinical evaluation achieved 0% grade A, 62.5% grade B, 25% grade C, and 12.5% grade D. In group B, 29.1% achieved grade A, 54.8% grade B, 12.9% grade C, and 3.2% grade D. The difference was statistically significant (P <.05). The injured versus normal side-to-side KT-2000 difference at maximum manual loading was 3.68 mm (SD, 1.71) in group A and 1.64 (SD, 2.05) in group B (P <.0001). CONCLUSIONS: This prospective study could not provide significant data suggesting that 1 method of fixation is superior to the other. Therefore, we consider both methods comparable in terms of stability and functional outcome at short-term follow-up. Transcondylar fixation offers the following advantages: fixation without intra-articular hardware, greater bone-to-bone fixation, and the possibility of fixation with breakage of the posterior femoral tunnel wall. Moreover, this method may be a useful alternative in revision ACL surgery.

Pseudoaneurysm as a complication of ankle arthroscopy.

We describe a case of pseudoaneurysm of the anterior tibial artery as a complication after arthroscopic ankle synovectomy, in which standard anterolateral and anteromedial portals were used. Pseudoaneurysm has been previously reported as a complication in ankle arthroscopy with the use of the anterocentral portal. Previously described anatomic variations of the tibial artery and its close relationship with the anterior ankle capsule may complicate arthroscopic surgery, especially when aggressive synovectomy is performed. Anterior tibial artery aneurysm is a rare complication of ankle arthroscopy, but its potential catastrophic sequelae must not be underestimated.

Postoperative bleeding following notchplasty in anterior cruciate ligament reconstruction: thermal radio frequency versus powered instrumentation.

This study compared postoperative bleeding during anterior cruciate ligament (ACL) reconstruction following notchplasty by power instrumentation with that following radiofrequency. Between January 1998 and April 1998 we prospectively divided 24 consecutive patients undergoing arthroscopic ACL reconstruction with bone-patellar tendon-bone autograft into two groups. Notchplasty was performed by powered instrumentation in group A (n=12) and by radiofrequency in group B (n=12). Two Redi-Vac suction drains were placed, one intra-articularly and the other subcutaneously at the harvest site and tibial tunnel. All drains were removed 48 h postoperatively. The first drainage measurement (end of surgery, 6 a.m. postoperative day 1) showed average total bleeding of 124.16 cc in group A and 65.41 cc in group B (P<0.001); per hour this was 10.21 cc in group A and 5.49 cc in group B (P<0.001). The second drainage measurement (6 a.m. postoperative day 2) showed average total bleeding of 44.55 cc in group A and 17.78 cc in group B (P<0.01); per hour this was 1.85 cc in group A and 0.74 cc in group B (P<0.001). Radiofrequency technology can be used when performing intercondylar notchplasty in ACL reconstruction. As a result of this technique postoperative intra-articular bleeding was significantly reduced.

Current concepts in diagnosis and treatment of posterior cruciate ligament injury.

Injuries to the posterior cruciate ligament (PCL) have traditionally been reported to be rare but in the last decade, this ligament has captured the attention of orthopaedic surgeons world-wide. While new or improved surgical techniques involving the PCL have achieved attractive results, accurate evaluation of the PCL-deficient knee still remains a challenge. Despite the greater use of new, more sensitive clinical testing, stress radiography and MRI, correct diagnosis and staging of the PCL tear is still difficult. The objective of this paper is to provide an up-to-date review regarding diagnosis and treatment of the PCL tear.

The application of shock-waves therapy in the treatment of resistant chronic painful shoulder. A clinical experience.

BACKGROUND: To evaluate the efficacy of extracorporeal shockwaves therapy (ESWT) in patients with chronic painful shoulder. EXPERIMENTAL DESIGN: a prospective design was used with a short term follow-up. SETTING: data were collected at the Service of Physioterapy in Villa Stuart Clinic-Rome. PATIENTS: 72 patients of both sexes with an average age of 38 years (range 18 to 69) affected by chronic painful shoulder, whose symptoms lasted more than 6 months. INTERVENTIONS: all patients received on average, 2,000 impulses of ESWT at level 5 energy (0.21 mJ/mm2) according to Dornier Epos equipment one session per week for 8 weeks. MEASURES: all cases underwent an instrumental examination with X-ray conventional imaging and clinical assessment of pain (visual analogue scale) and functional limitation of the shoulder, two weeks before the treatment and at one month follow-up. RESULTS: 53% of patient scored excellent results, 14% good, 13% fair and 20% poor. In the group of calcifying tendinitis we had a reduction in 37% and no changes in 63%. CONCLUSIONS: Even with a limited number of cases our early results show the efficacy and safety of ESWT in the treatment of chronic painful shoulder resistant to other conservative approaches.

Aberrant crypt foci in the human colon: frequency and histologic patterns in patients with colorectal cancer or diverticular disease.

Aberrant crypt foci are considered potential markers of colorectal cancer risk. The aim of this study was to analyze a large series of human aberrant crypt foci according to frequency, distribution, and histology. Aberrant crypt foci were identified in methylene blue-stained colonic mucosa from 103 patients undergoing surgery for colorectal cancer or diverticular disease. Foci were histologically classified into surface hyperplastic type, surface and glandular hyperplastic type, mixed hyperplastic and adenomatous type, and adenomatous type. The mean frequency of aberrant crypt foci (n = 720) was higher in the colorectal cancer group (0.20/cm2) than in the diverticular disease group (0.07/cm2), and in distal colonic segments than in proximal segments. Most of the histologically examined foci (n = 366) were hyperplastic (88.8%). Surface hyperplasia accounted for 30.6% and prevailed in small lesions. Surface and glandular hyperplasia accounted for 58.2% and prevailed in medium-sized to large foci. Partially or totally dysplastic foci accounted for 10.1% of examined lesions (10.8% and 2.8% in the colorectal cancer and diverticular disease groups, respectively). Most of them (94.6%) were composed of mixed hyperplastic and adenomatous crypts and prevailed in large lesions. The higher frequency of aberrant crypt foci in patients with colorectal cancer sustains their putative role as preneoplastic markers. The high rate of mixed hyperplastic and adenomatous lesions supports the possible adenomatous transformation of hyperplastic lesions.

Magnetic resonance imaging of tunnel placement in posterior cruciate ligament reconstruction.

The aim of this study was to define a reproducible method for evaluating posterior cruciate ligament (PCL) reconstructions using magnetic resonance imaging (MRI). A 2-fold investigation was performed. In part I, the "footprints" of an intact PCL were located on MRI and their coordinates were defined. Measurements were made on the images of 50 subjects using axial, coronal, and sagittal planes. Interobserver variability was calculated by averaging the measurements of the 2 reviewers and using the Kappa coefficient. Three points of reference were located: tibial attachment on the tibial axial plane, and two femoral attachments on the sagittal and coronal oblique planes. In part II, stability of 20 PCL reconstructions with a bone-patellar tendon-bone (BPTB) autograft were evaluated and scored using the IKDC evaluation form after a 2-year follow-up. Stability was evaluated clinically and instrumentally using a KT-2000 arthrometer at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70 degrees . Seven cases were graded A (0 to 2 mm), 11 graded B (3 to 5 mm), and 2 graded C (6 to 10 mm). All patients had an MRI after an average of 16 months (range, 12 to 24 months, 2 SD). The previous measurements from part I of the study were used to make a correlation between achieved stability and tunnel location. A 1-factor analysis of variance (ANOVA), nonparametric ANOVA, and the Fisher Exact test were used to determine if clinical outcome of the 3 groups was influenced by graft placement. At MRI evaluation, excessive deep placement was observed in 4 cases and a correlation between improper femoral tunnel location and stability was statistically significant (P < .05). A correct placement of tibial tunnel was observed in all patients. In our analysis, proper location of the femoral tunnel seems to be more critical and difficult to achieve than tibial tunnel placement, probably because of the lack of specific anatomic landmarks during surgery.

[Arthroscopic reconstruction of the posterior cruciate ligament. Magnetic resonance study for bone tunnel positioning and comparison with clinical results]. / La ricostruzione artroscopica del legamento crociato posteriore. Studio con Risonanza Magnetica per il posizionamento dei tunnel ossei e confronto con i risultati clinici.

INTRODUCTION: The success of arthroscopic cruciate ligament reconstruction depends on several factors, such as patient selection, correct surgical execution, and postoperative rehabilitation. Technical considerations include graft choice, positioning, fixation, intercondylar notch enlargement, and new ligament tensioning. Graft acceptance is effected by all these factors. Tunnel position is of great importance both for biomechanical reasons and optimal function of the new ligament, and to avoid stress, friction, abnormal strain, and/or damage to the reconstructed ligament. Many orthopedic and radiographic literature studies discuss the exact site of anterior cruciate ligament insertion for the best possible anatomical reconstruction. In contrast, the debate over insertional area and anatomical landmarks is open for the posterior cruciate ligament (PCL), because of the difficult execution of this type of reconstruction and the smaller number of candidates. MATERIAL AND METHODS: Fifty patients with a healthy PCL underwent MRI of the knee for other diagnostic reasons and we measured the position of PCL insertion at the tibial and femoral condyles. We also examined with MRI 20 surgical patients with a reconstructed PCL. Graft position was assessed with the same method and the results compared with physical findings of joint stability and the IKDC form score. RESULTS: Three main landmarks were found on standard axial, coronal and sagittal MR images: T1 on the tibia, and F1 and F2 on the femur. These points refer to the fibrous ligament center and designate the medial, middle and lateral portion of the tibial plateau, as well as the anterior/posterior and high/low positions on the roof of the intercondylar notch and anteromedial side of the medial condyle, respectively. According to these data, the midline position, whether slightly medial or lateral, of tibial insertion, was clinically less important. On the contrary, correct femoral tunnel positioning was found to effect subsequent joint stability and prompt rehabilitation. CONCLUSIONS: This method for MR measurement is easy and repeatable, and can be used for surgical planning and patient follow-up. We found it extremely useful for the correct positioning of bone tunnels, particularly the femoral condyle, in all cases.