Management of maternofetal emergency in shock with fracture of femur.

Trauma is the leading nonobstetric cause of maternal death. The worst complication can be fetal compromise that threatens premature labor or even fetal death. We are reporting a case of a 30-year-old primi, short stature woman who had fracture femur with hypovolaemic shock. Managing such trauma complicated by shock in a pregnant patient needs multidisciplinary approach. Clinician team evaluating and coordinating the care of pregnant trauma patient should understand the pathophysiological changes in pregnancy with trauma to manage hypovolaemic shock, related complications, treatment of fracture, and radiation exposure to the fetus. The use of imaging studies, invasive hemodynamics and surgery, if necessary, should be individualized. A clear understanding of fetal viability, physiological changes of pregnancy, and pathophysiology of shock, is mandatory for optimal, maternal functional, and obstetrical outcome.

Tension changes within the bundles of anatomic double-bundle anterior cruciate ligament reconstruction at different knee flexion angles: a study using a 3-dimensional finite element model.

PURPOSE: The aim of this study was to determine the change in length and tension of the reconstructed anterior cruciate ligament (ACL) double bundles at different knee flexion angles by use of a 3-dimensional finite element model. METHODS: The right knees of 12 living subjects were scanned with a high-resolution computed tomography scanner at 0°, 45°, 90°, and 135° of knee flexion. Several modeling programs were used to simulate double-bundle ACL reconstruction. A finite element model of each bundle with a tension of 20 N was put into each tunnel followed by fixation of the bundles. The tension and length changes of each bundle at different knee flexion angles were assessed. RESULTS: For the anteromedial bundle, the length decreased gradually between 45° and 90° of knee flexion and then reached a plateau, whereas the length of the posterolateral bundle significantly decreased at 45° and 90° of flexion but then increased at full flexion. The reaction force of the anteromedial graft slightly decreased at 45° and then remained constant between 90° and 135° of knee flexion. The reaction force of the posterolateral bundle at full extension slightly decreased at 45° and 90° of flexion, followed by a rebound increase at 135°. CONCLUSIONS: We found that both bundles functioned throughout the arc of flexion with consistency in tension, although their lengths decreased. The 2 ACL grafts did not function in a reciprocal manner, unlike previous descriptions. CLINICAL RELEVANCE: The data obtained for length and tension versus flexion angle have the potential to suggest the appropriate knee position for graft fixation and tensioning to be near extension in clinical situations.

Trans-tendon arthroscopic repair for partial-thickness articular side tears of the rotator cuff.

PURPOSE: The purpose of this study was to describe a modified trans-tendon method of repairing partial articular surface lesions, which restored the footprint of the rotator cuff anatomically. METHODS: The 24 consecutive patients with modified trans-tendon method which allowed a wider pressurized contact area by use of additional knotless anchor were included in this study. All patients were evaluated with ASES score and visual analog scale (VAS) preoperatively, postoperative 3 and 12 months. The strength was measured using Isobex digital strength analyzer preoperatively and postoperative 12 months. RESULTS: The ASES scores significantly improved from preoperative 38 ± 13 to 63 ± 5 at 3 months, and 89 ± 5 at 12 months postoperatively. The VAS scores also significantly improved from preoperative 6.6 ± 1.1 to 2 ± 0.7 at 3 months, 0.6 ± 0.7 at 12 months. The strengths significantly increased postoperatively, and there were no significant differences between affected and unaffected shoulders at 12 months postoperatively (P > 0.05). The 22 of 24 patients were either satisfied or very satisfied with postoperative result at 12 months postoperatively. CONCLUSION: This arthroscopic-modified trans-tendon suture bridge technique for partial-thickness articular side tears of the rotator cuff has shown excellent functional results and very high satisfaction rate of patient during the 12-month follow-up period. LEVEL OF EVIDENCE: Evidence therapeutic study, Level IV.

An analysis of the posterior cruciate ligament isometric position using an in vivo 3-dimensional computed tomography-based knee joint model.

PURPOSE: This study aimed to review the isometric point of the posterior cruciate ligament (PCL) based on insertional locations identified in recent anatomic studies by use of a 3-dimensional knee model. METHODS: Ten living subjects with healthy knees were evaluated. High-resolution computed tomography scans were performed at 3 positions of 0°, 90°, and 135°, and 3-dimensional knee images were constructed. Customized software was used to define tibial and femoral insertion points of the PCL, based on recently described anatomy. The femoral attachment site of the PCL was divided into 4 sectors (labeled A through D), and the tibial attachment site was divided into 6 sectors (labeled 1 through 6). Twenty-four virtual PCL bundles were created between these sectors, and their length was measured in the 3 knee flexion positions. RESULTS: In 0° and 90° of knee flexion, the virtual bundle showing the least amount of length change (1.10 ± 0.66 mm) was at sector D-6, that is, a posteromedial bundle inserting into the most posterior femoral sector (sector D) and the most distal tibial sector (sector 6). This change was not significantly different compared with all other virtual bundles with tibial points connected to femoral sector D (P > .05). An isometric position for the PCL (length change <2 mm) could not be found in 135° of knee flexion because of lengthening of all virtual bundles. CONCLUSIONS: Our data suggest that the femoral attachment point is more important than the tibial attachment point: any of the 6 tibial bundles attached to the most posterior femoral sector had similar isometric properties. CLINICAL RELEVANCE: Reproducing normal tibial and femoral anatomy underpins PCL surgical reconstruction. These findings suggest that to perform an isometrically accurate PCL reconstruction, particular attention should be paid to the location of the femoral attachment site, once the tibial footprint has been established. There were no isometric points in any virtual PCL bundle in the fully flexed knee because of excessive lengthening. Therefore, to avoid lengthening of the reconstructed graft, we recommend that fixation is performed at knee flexion angles between 0° and 90° and that patients avoid high flexion during postoperative rehabilitation.

Changes in ACL length at different knee flexion angles: an in vivo biomechanical study.

Recently, there has been a tremendous impetus on anatomical reconstruction of the anterior cruciate ligament (ACL), and the double-bundle reconstruction concept has been advocated by many authors. It is, therefore, important to understand how the lengths of the two bundles of the ACL vary during different knee flexion angles as this could influence the angle of graft fixation during surgery. The aim of this study is to determine the change in length of the ACL bundles during different knee flexion angles. Ten subjects with normal knees were evaluated. A high-resolution computer tomography scan was performed, and 3D knee images were obtained. These images were then imported to customized software, and digital length measurement of four virtual bundles (anatomical single bundle, AM, PL and over the top) was evaluated from fixed points on the femur and tibia. Length-versus-flexion curves were drawn, and statistical analysis was performed to evaluate changes in length for each bundle at varying angles of knee flexion (0 degrees, 45 degrees, 90 degrees and 135 degrees). All virtual bundles achieved greatest lengths at full extension. There was a significant difference between the posterolateral bundle length when compared to the other bundles at full extension. There were no significant differences between the lengths of the anteromedial and the over the top single bundles at all angles of knee flexion. Three-dimensional computer tomography can be used to assess the length changes of the virtual anterior cruciate ligament bundles, thereby allowing a better understanding of bundle function in clinical situations.

Open anatomical coracoclavicular ligament reconstruction using a tendon graft with an Endobutton loop.

We describe a technique of open anatomical coracoclavicular ligament reconstruction restoring both parts of the native ligament, aiming at achieving maximum stability of the acromioclavicular joint without disturbing the normal anatomy. Using the same anatomical principle of ligament reconstruction as in other joints, transosseous tunnels are created at the native footprints of the conoid and trapezoid ligaments. An autologous graft is fixed using an Endobutton continuous loop and a PEEK screw; adequate healing of the ligament is ensured with an appropriate working length. Although an open procedure, this technique offers several advantages. It can be easily reproduced using basic anatomical principles and simple cost-effective instrumentation. The implant does not have to be removed, important anatomical structures are respected, normal acromioclavicular joint kinematics are restored, the scar is cosmetically acceptable and post-operative morbidity is very low.