Arthroscopic debridement and antibiotic-loaded cement for treatment of chronic infected tibial tunnel post-ACL reconstruction: A case report.

INTRODUCTION AND IMPORTANCE: Chronic extra-articular infections of the tibial tunnel are rare, and there are only a few cases reported in the literature, so the diagnosis and management of these infections are still unclear. CASE PRESENTATION: We report a 36-year-old patient with chronic infection of the tibial tunnel after ACL reconstruction surgery. The patient was treated with arthroscopic debridement of the tibial tunnel and antibiotic cement filling. Seven months postoperative, there were no signs of infection at the surgical site and the knee joint. The patient has no pain, no joint instability, no limitation of range of motion, and no limitation in daily activities. CLINICAL DISCUSSION: The definitive diagnosis of chronic infection of the tibial tunnel should be carefully based on clinical signs, blood tests, and imaging to rule out combined intra-articular infections. The arthroscopic technique can be a favorable method to control and debride the inflammatory tissue of the tibial tunnel, limiting the recurrence rate postoperatively. CONCLUSION: Arthroscopic debridement and antibiotic-loaded cement can be considered an alternative to traditional surgical methods in the treatment of chronic infection of the tibial bone tunnel after ACL reconstruction. LEVEL OF EVIDENCE: A case report.

Arthroscopy-assisted procedure provides less residual horizontal instability and optimal coracoid tunnel creation with less radiation exposure compared to percutaneous procedure after endo-button fixation of type III AC joint dislocations.

PURPOSE: The aim of this study was to evaluate the postoperative radiological and functional results of patients treated with arthroscopy-assisted (AA) and percutaneous (P) procedures using endo-button for type III acromioclavicular joint dislocations with a minimum 1-year follow-up. The study hypothesis was that the AA technique would provide more favourable coracoid tunnels. METHODS: This retrospective study included patients who underwent surgery between 2017 and 2022. Computed tomography images taken immediately postoperatively of all the patients were analysed to group coracoid tunnels as optimal or suboptimal based on orientation and placement within the coracoid base. Residual horizontal instability was assessed using the bilateral Alexander view at the final follow-up. Shoulder functions were evaluated at the final follow-up examination. RESULTS: Of the 63 patients, 39 underwent surgery using the percutaneous procedure and 24 with the AA procedure. Surgical duration was significantly longer in the AA group (AA: 61.1 ± 5.9 min; P: 34.7 ± 5.6 min) (p = 0.001; 95% confidence interval [CI]: 23.3-29.3), whereas fluoroscopy time was longer in the percutaneous group (AA: 2.0 ± 0.8 s; P: 15.7 ± 3.9 s) (p = 0.001; 95% CI: -14.9 to 12.3). Optimal coracoid tunnels were more frequently observed in the AA group (p = 0.001; 95% CI: 7.4-137.8). There was no significant difference in functional scores between the groups (n.s.). Postoperative horizontal instability was more common in the percutaneous procedure (p = 0.013; 95% CI: 8.3-39.2). CONCLUSIONS: Although no difference was detected between the methods in terms of complications and functional results, the higher frequency of residual horizontal instability, the high risk of suboptimal tunnel creation and greater radiation exposure were seen to be the most important disadvantages of the percutaneous technique. During surgery, such technical problems related to the percutaneous method should be kept in mind and care should be taken about the orientation of the coracoid tunnel. LEVEL OF EVIDENCE: Level III.

Graft Suturing Method Affects on Graft Diameter in Hamstring-Based Anterior Cruciate Ligament Reconstruction.

INTRODUCTION:  Various benefits of needleless suture loop techniques in anterior cruciate ligament reconstruction graft preparation have been discussed, yet their impact on graft diameter remains unexplored. We hypothesized that the suture loop technique would reduce the graft diameter compared to the conventional locking suture technique. METHODS:  Fifty-seven patients whose grafts were made with the Krackow stitch (group K) and 54 patients with the suture loop (group SL) were analyzed retrospectively. (1) The distal (sutured side) diameter of each anteromedial bundle and posterolateral bundle was compared to the proximal (non-sutured side) diameter, and (2) the average of the proximal and distal graft diameters in each group was calculated. RESULTS:  In group K, 78.9% of anteromedial bundles and 40.3% of posterolateral bundles exhibited a larger distal diameter than the proximal, while in group SL, 42.6% of anteromedial bundles and 3.7% of posterolateral bundles showed a larger distal diameter. In both bundles, there were significantly fewer grafts with larger distal diameters in group SL (p < 0.001). The mean distal diameter of anteromedial bundles was smaller in group SL (6.33 ± 0.43 mm vs. 6.07 ± 0.43 mm, p < 0.005). Consequently, the distal cross-sectional area of anteromedial bundles in group SL was 8% smaller than that in group K. CONCLUSION:  The use of the suture loop technique resulted in a significantly smaller distal diameter of the anteromedial bundle. This reduces the size of the tibial tunnel and may contribute to a reduction in potential damage to adjacent structures.

Development of an Original Three-Dimensional Computed Tomography Scan Method and Imaging Process for Surgical Support of the Anterior Cruciate Ligament.

Three-dimensional computed tomography (3D CT) scan images are useful as they can provide information essential for surgical support, particularly in orthopedic surgery. In the case of anterior cruciate ligament (ACL) reconstruction, a 3D CT scan is important in preoperative simulation. Furthermore, it is associated with a reduced risk of revision surgery because the angle of the foramen magnum changes with the femoral muscle mass. However, the CT scan system geometry has several limitations. For example, the patient's posture is limited during the procedure. Herein, we report an original CT scan method and 3D imaging process for surgical support of the ACL.

[Research progress of femoral bone tunnel positioning in anterior cruciate ligament reconstruction].

Objective: To review the concept and methods of femoral bone tunnel positioning in anterior cruciate ligament (ACL) reconstruction, in order to provide a reference for clinical treatment. Methods: The relevant literature on the concept and methods of femoral bone tunnel positioning in ACL reconstruction in domestic and international research was extensively reviewed. Results: The position of the femoral bone tunnel is a key factor in determining the prognosis of ACL reconstruction. The concept of femoral bone tunnel positioning in ACL reconstruction has experienced isometric reconstruction, anatomical reconstruction, Ribbon-like theory, I.D.E.A.L. theory, and nearly isometric reconstruction theory. The femoral bone tunnel positioning technique is also changing with the in-depth study of the anatomy and biomechanics of the ACL, and each bone tunnel positioning technique has its own advantages and disadvantages. Over-The-Top technique is now mainly used for ACL revision; the clock-face positioning method is basically no longer applicable due to the large error, poor stability, and low retrievability; the bone landmarks positioning method (the lateral condyle of the femur's Resident's ridge and bifurcation ridge, and the the apex of the deep cartilage), which is now mostly used clinically due to the more constant anatomical landmarks. The quadrant method under X-ray fluoroscopy is more cumbersome to implement intraoperatively, so it is mainly used for academic research; computer navigation-assisted positioning has gradually become popular in recent years, which is highly accurate, avoids the influence of human factors on the positioning of the bone tunnel, and has a very good prospect of application; three-dimensional printing-assisted positioning technology, which is accurate in positioning, with a high degree of reproducibility and a short learning curve. Conclusion: The concept of femoral bone tunnel positioning for ACL reconstruction has undergone several evolutions, reflecting the deepening of the understanding of ACL and the improvement of the clinical results of reconstruction. The precision, personalization, and intelligence of positioning techniques are the focus of current and future development.

Application of multiplanar reconstruction and 3D printing in anterior cruciate ligament revision. / 多平面重建及3D打印在前交叉韧带翻修术中的应用.

OBJECTIVES: Anterior cruciate ligament injury is the most common type of knee joint ligament injury. Anterior cruciate ligament reconstruction has a high failure rate, with bone tunnel abnormalities as the most significant factor in these failures. Digital orthopedic technology can effectively develop implementation plans for the revision, thus increasing the success rate. This study aims to develop a surgical plan for anterior cruciate ligament revision by employing multiplanar reconstruction (MPR) for measuring bone tunnel position and diameter, and simulating bone tunnel creation via 3D printing preoperatively. METHODS: A total of 12 patients who underwent anterior cruciate ligament revision at the Third Xiangya Hospital of Central South University between 2014 and 2021 were retrospectively studied. The data included patient demographics, preoperative formulated knee joint 3D printing models, and preoperative knee CT scans. The study measured the bone tunnel's diameter and position to guide the establishment of revision bone tunnels during surgery, reassessed the postoperative bone tunnels, and evaluated knee joint functional scores [including International Knee Documentation Committee Knee Evaluation Form (IKDC) score, Lysholm score, and Tegner exercise level score]. RESULTS: Preoperative measurements revealed suboptimal femoral tunnels positions in 4 patients and tibial tunnels positions in 2 patients. MPR and 3D printing technology were used to guide the establishment of a new bone canal during surgery, and postoperative measurements were satisfactory for all patients. Preoperative measurements demonstrated the interclass correlation coefficient for femoral tunnels and tibial tunnels diameters were 0.843 (P<0.05) and 0.889 (P<0.001), respectively. Meanwhile, the intraclass correlation coefficient were 0.811 (P<0.05) and 0.784 (P<0.05), respectively. The intraoperative diameter of femoral and tibial tunnels showed excellent correlation with postoperative CT measurements, with intraclass correlation coefficient values of 0.995 (P<0.001) and 0.987 (P<0.001), respectively. All bone tunnel positions were within the normal range. At the final follow-up, knee joint function scores in all 12 patients improved significantly compared to pre-surgery (P<0.001), and the reoperation rate was zero. CONCLUSIONS: MPR and 3D printing technology can accurately measure the parameters of reconstructed anterior cruciate ligament bone tunnels. Personalized revision plans for patients with reconstruction failure enhances the success rate of revision surgery and improves patient prognosis.

No Difference in Bone Tunnel Enlargement and Clinical Outcome between Cortical Suspension and Hybrid Femoral Fixation in Hamstring Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: The best method for femoral fixation in anterior cruciate ligament reconstruction (ACLR) remains controversial. The study assesses the bone tunnel enlargement and clinical outcome in hamstring ACLR using cortical suspension or hybrid (cortical suspension and compression) femoral fixation. METHODS: From January 2010 to December 2021, 102 patients who underwent quadruple hamstring ACLR using cortical suspension (39 patients) or hybrid (63 patients) fixation on the femoral side were retrospectively analyzed. Clinical evaluation was conducted using the international knee documentation committee score, the Lysholm score, the Tegner activity level scale, the knee injury and osteoarthritis outcome score (quality of life score), the Lachman test, and the side-to-side difference by the KT-1000 arthrometer. The complications after the surgery were also evaluated. These data were compared at baseline and last follow-up. The diameters of the femoral tunnel were calculated at three sites: the width of the entrance of the femoral tunnel, 1 cm proximal to the entrance of the femoral tunnel and the largest diameter of the femoral tunnel on magnetic resonance imaging (MRI) coronal images. Bone tunnel widening data were contrasted between MRI images conducted at least 2 years and within 2 weeks after surgery. The morphology of bone tunnel enlargement was also observed and recorded. The categorical parameters were analyzed using the χ2-test and Fisher's exact test. The continuous variables conforming to a normal distribution were analyzed using Student's t-test, and the Mann-Whitney U-test was undertaken between the two groups without normal distribution. RESULTS: Both cortical suspension and hybrid femoral fixation in quadruple hamstring ACLR achieved significantly improved patient-reported outcome scores and knee stability compared to preoperative data. However, no significant differences were found between these two methods in clinical evaluations, postoperative complications, and patient-reported outcome scores. Although the mean diameter of the enlarged bone tunnel was lowered by an additional bioabsorbable interference screw fixation near the joint line, a statistically insignificant difference was found between the hybrid and cortical suspension fixation on the femoral side. There was no statistical difference in the distribution of enlarged bone tunnel morphology between groups. CONCLUSIONS: No significant difference was found in the bone tunnel enlargement and clinical outcome between cortical suspension and hybrid femoral fixation in ACLR using hamstring autograft.

Surgical Technique for Lateral Patellofemoral Ligament Reconstruction Using Bone Tunnels: A New Method.

Medial patellar instability (lateral patellofemoral ligament tear) is a rare condition which is commonly associated with lateral release for lateral patellar instability. LPFL is a lateral stabilizer of the patellofemoral joint. Reconstruction of LPFL is necessary to provide stability to the patella-femoral joint in patients with instability. We describe a novel technique of trans-osseous reconstruction of LPFL to gain stability and have better graft incorporation. A doubled peroneus longus graft is inserted into the patellar tunnel and secured with an endo button on the anteromedial aspect of the patella; the other end is then inserted into the insertional point on the femur and secured with an interference screw. This is an easy, novel, and reproducible technique which can be used to reconstruct LPFL.

Outcomes of distal biceps repair at two-year follow-up.

PURPOSE: This single-centre study aimed to review the postoperative outcomes of distal biceps avulsion repair using a single incision with the endo-button technique. METHODS: A retrospective cohort study was performed of a single surgeon series of distal biceps repairs performed consecutively from September 2016 to September 2020. At two years, outcome measures included Oxford Elbow Score (OES), range of movement (ROM), complications and ongoing issues. RESULTS: Forty-five distal biceps tendon repairs were performed on 43 patients with a mean follow-up of 3.2 years (1.1-5.3). The average OES was 46 (11-48), and 90% of patients recovered a comparable range of movement to the contralateral side. Two patients developed re-rupture (4%) on days 0 and 9 of surgery, but there were no late re-ruptures of the repair. CONCLUSION: Short-term outcomes from distal biceps tendon repair show low complication rates, high patient satisfaction and good functional outcomes. The results would support acute surgical treatment of active, working-age, patients with distal biceps tendon ruptures.

Safe Talar Tunnel Placement During Reconstruction of the Deep Layer of the Deltoid Ligament: A Comparison of 4 Different Anatomic Landmarks on the Lateral Malleolus.

Background: Deltoid ligament reconstruction of the ankle can be considered when the ruptured ligament is insufficient for direct repair. Purpose: To compare the safety of talar tunnels oriented toward 4 different anatomic landmarks on the lateral malleolus during reconstruction of the deep layer of the deltoid ligament (DDL). Study Design: Descriptive laboratory study. Methods: A total of 30 computed tomography scans of the ankle joint in healthy adults were collected to generate 3-dimensional models. Virtual talar tunnels with a diameter of 5 mm and with different lengths (20.0, 25.0, and 30.0 mm) were created from the talar insertion of the DDL and were oriented toward the talar neck as well as the most anterior, the most distal, and the most posterior points of the distal fibula. The minimal safe distance (MSD) of a drilling route was calculated for the tunnels, and the safe distance from the end of the tunnel to the bone surface was measured for each tunnel. The nonpaired Student t test was used to detect differences among the safe distances of the 4 different bone tunnels. Results: For the 20.0-mm tunnels, the safe distance of the tunnel oriented toward the talar neck (5.90 ± 1.16 mm) did not meet the MSD (6.0 mm). For the 25.0-mm tunnels, the safe distances of the tunnels oriented toward the talar neck (4.53 ± 1.13 mm) and the anterior point of the fibula (5.91 ± 1.52 mm) did not meet the MSD (6.9 mm). Conclusion: Tunnels that were 5 mm in diameter and 20.0 and 25.0 mm in length, oriented toward the most distal or most posterior point of the distal fibula, were safe for DDL reconstruction. Clinical Relevance: Knowledge of safe talar tunnel placement is important, especially to avoid bone surface penetration during DDL reconstruction.

Serial change of femoral and tibial tunnel width after anterior cruciate ligament reconstruction with allograft.

PURPOSE: To investigate progressive tunnel widening and its correlation with postoperative outcomes after anterior cruciate ligament (ACL) reconstruction using allografts. METHODS: Sixty-five patients who underwent ACL reconstruction using a tibialis anterior allograft between 2015 and 2017 were enrolled. Femoral and tibial tunnel widths were measured on anteroposterior (AP) and lateral radiographs immediately and at 3, 6, 12, and 24 months postoperatively. Average femoral and tibial tunnel widths in AP and lateral views were calculated at three different measurement points. Tunnel widening was calculated as the difference in tunnel width immediately and 2 years postoperatively. The correlation between tunnel widening and the postoperative results was analysed. RESULTS: Tunnel width changes between immediate and 2 years postoperatively were as follows, in AP and lateral views, respectively: femur, 3.0 mm ± 1.5 mm and 2.4 mm ± 1.4 mm; and tibia, 2.8 mm ± 1.4 mm and 2.9 mm ± 1.5 mm. Femoral tunnel widths significantly increased until 1 year, but not from 1 to 2 years postoperatively. Tibial tunnel width significantly increased until 2 years postoperatively. In all tunnels, the increments in tunnel widening decreased over time. Increased knee laxity significantly correlated with greater femoral tunnel widening in AP (r = 0.346, P = 0.006) and lateral views (r = 0.261, P = 0.049). CONCLUSION: Femoral tunnel widths gradually increased until 1 year postoperatively, and tibial tunnel widths increased until 2 years after ACL reconstruction with allografts. The tunnel widening rate gradually decreased over time. Femoral tunnel widening of 3.7 mm and 3.2 mm on AP and lateral views, respectively, were the cut-off values for postoperative knee laxity. LEVEL OF EVIDENCE: Level III.

Beneficial Effect of Curved Dilator System for Femoral Tunnel Creation in Preventing Femoral Tunnel Widening after Anterior Cruciate Ligament Reconstruction.

Backgrounds and objectives: A prevalent concern in anterior cruciate ligament (ACL) reconstruction is postoperative tunnel widening. We hypothesized that employing a curved dilator system (CDS) for femoral tunnel creation can reduce this widening after ACL reconstruction compared to the use of a conventional rigid reamer. Materials and Methods: A retrospective study was conducted involving 56 patients who underwent primary ACL reconstruction between January 2012 and July 2013. The patients were categorized into two groups: the reamer group (n = 28) and CDS group (n = 28). All participants were followed up for a minimum of 2 years. Clinical assessment included the Lachman test and pivot-shift test, and the Lysholm score and subjective International Knee Documentation Committee scores. Radiographic evaluation covered the tunnel widening rate, represented as the ratio of the tunnel diameter 2 years after surgery to the tunnel diameter immediately after surgery, and the ratio (A/B) of femoral tunnel (A) to tibial tunnel (B) diameters at respective time points. Results: No significant disparities were found between the two groups in terms of clinical outcomes. However, the reamer group exhibited a greater femoral tunnel widening rate compared to the CDS group (reamer group vs. CDS group: 142.7 ± 22.0% vs. 128.0 ± 19.0% on the anteroposterior (AP) radiograph and 140.8 ± 14.2% vs. 122.9 ± 13.4% on the lateral radiograph; all p < 0.05). Two years post-operation, the A/B ratio rose in the reamer group (0.96 ± 0.05→1.00 ± 0.05 on the AP radiograph and 0.94 ± 0.03→1.00 ± 0.0.04 on the lateral radiograph; all p < 0.05), while it decreased in the CDS group (0.99 ± 0.02→0.96 ± 0.05 on the AP radiograph and 0.97 ± 0.03→0.93 ± 0.06 on the lateral radiograph; all p < 0.05). Conclusion: The use of CDS for femoral tunnel creation in primary ACL reconstruction provides a potential advantage by limiting tunnel widening compared to the conventional rigid-reamer approach.

An Improved Transosseous Pullout Suture Technique for Arthroscopic Repair of a Meniscus Root Tear.

OBJECTIVE: This study aimed to explore the clinical efficiency of an improved transosseous pullout suture technique for arthroscopic repair of a meniscus root tear. METHODS: From January 2017 to January 2021, 53 patients with posterior meniscus root tears combined with anterior cruciate ligament (ACL) and/or posterior cruciate ligament (PCL) tears were collected. Totally, in 29 patients (group A), the 2.0 mm modified pullout tunnel method was used to suture the posterior meniscus root, while 24 patients (group B) were treated with the traditional 4.5 mm pullout tunnel method. In group A, 20 patients had lateral meniscus posterior root (LMPR) combined with ACL tears, 5 patients had LMPR combined with ACL and PCL tears, and 4 patients had medial meniscus posterior root (MMPR) combined with ACL tears. In group B, 19 patients had LMPR combined with ACL tears, 3 patients had LMPR combined with ACL and PCL tears, and 2 patients had MMPR combined with ACL tears. The improvement of the Lysholm and VAS scores and the incidence of complications in group A and group B before the operation, 1 month and 3 months after the operation, and after the final follow-up were compared. RESULTS: Preoperative Lysholm score was 26.0±5.6 in group A and 26.7±5.8 in group B (P>0.05). One-month postoperative Lysholm score was 66.5±5.7 in group A and 54.3±2.4 in group B (P<0.001). Three-month postoperative Lysholm score was 81.1±7.2 in group A and 73.2±9.7 in group B (P<0.05). Lysholm scores after the final follow-up was 90.3±5.6 in group A and 90.0±5.0 in group B (P>0.05). Preoperative VAS score was 6.3±1.4 in group A and 6.3±1.2 in group B (P>0.05). One-month postoperative VAS score was 1.8±0.7 in group A and 2.4±0.9 in group B (P<0.05). Three-month postoperative VAS score was 0.7±0.6 in group A and 0.8±0.6 in group B (P>0.05). VAS score after the final follow-up was 0.2±0.4 in group A and 0.3±0.5 in group B (P>0.05). CONCLUSION: The improved transosseous pullout suture technique using a smaller 2.0 mm bone tunnel can virtually eliminate the risk of conflict with other bone tunnels and facilitate the management of bone tunnels in multiple ligament injuries, while also diminishing suture abrasion caused by the windshield wiper effect. The technique achieves good clinical efficacy.

Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Using a Calcium Phosphate-Hybridized Tendon Graft with More than an Average of 5 Years of Follow-Up: A Follow-Up Study of a Randomized Controlled Trial.

Calcium phosphate (CaP)-hybridized tendon grafting using an alternate soaking process improves tendon-to-bone healing in anterior cruciate ligament (ACL) reconstructions. This study aimed to compare bone tunnel enlargement, knee osteoarthritis, and clinical results between CaP-hybridized tendon grafting and conventional grafting in anatomical single-bundle ACL reconstruction. This study was a follow-up of a randomized controlled trial. Between July 2011 and December 2015, 90 patients underwent unilateral anatomical single-bundle ACL reconstructions and were randomly assigned to the CaP-hybridized tendon grafting (CaP group, n = 45; age, 27.1 [14-54] years; sex, 21 males and 24 females) or conventional grafting (control group, n = 45; age, 22.9 [13-58] years; sex, 26 males and 19 females). The randomization was performed according to the days of the week when the patients first visited the outpatient. The CaP-hybridized tendon grafting was created intraoperatively. The tendon grafts were soaked in a calcium solution for 30 s. After that, the tendon grafts were soaked in a NaHPO4 solution for 30 s. This soaking cycle between the calcium solution and the NaHPO4 solution was repeated 10 times. The bone tunnel enlargement, osteoarthritis grade, clinical score, and sports level were evaluated in patients who could be followed up for >3 years (CaP group, n = 20, average follow-up period 6.0 [5.1-6.9] years; control group, n = 15, average follow-up period 5.6 [4.3-6.9] years). Clinical scores, sports levels, and osteoarthritis grades were analyzed using a generalized linear mixed model (GLMM) based on repeated measurement data from preoperative and final observations, with time, group, sex, age, and BMI as fixed effects and the effect of individual differences as variable effects. In addition, bone-tunnel enlargements were analyzed using generalized linear models (GLM) with group, sex, age, and BMI as the main effects. Compared with the control group, the CaP group exhibited significantly reduced bone-tunnel enlargement on the femoral side (anteroposterior diameter; CaP group, 7.9% [-1.1-16.8] vs. control group, 29.2% [17.9-40.5], p = 0.004, MCID 16.05, proximal-distal diameter; CaP group, 7.9% [-1.9-17.8] vs. control group, 22.8% [10.9-34.7], p = 0.062, MCID 15.00). The osteoarthritis grades progressed in both groups (p < 0.001). The clinical scores and sports levels were not significantly different between the groups. This study suggests that the calcium phosphate-hybridized tendon graft reduces femoral bone-tunnel enlargement after anatomical single-bundle anterior cruciate ligament reconstruction in an average >5-year follow-up period. A longer follow-up period is necessary to reveal the clinical effects of the calcium phosphate-hybridized tendon grafts in anterior cruciate ligament reconstruction.

Computational modelling of the graft-tunnel interaction in single-bundle ACL reconstructed knee.

OBJECTIVES: Tunnel enlargement and graft failure are common complications associated with ACL reconstruction. The mechanical interaction between the graft and the tunnel aperture may play a more important role. This study aims to evaluate graft position within femoral tunnel and the graft force under external loads. METHODS: An FE model of the femur-graft-tibia complex was constructed from CT images of an anatomically reconstructed knee specimen. The model was subjected to kinematics of passive flexion extension, anterior/posterior translation, internal/external rotation and valgus kinematics, which were collected from experimental testing. Graft shift and rotation of graft-tunnel contact region during flexion/extension and external loadings were recorded and compared to experimental measurements. RESULTS: Model showed that the graft shifted in the femoral tunnel during flexion and under external loads. The graft-tunnel contact area rotated by up to 55° during flexion from full extension to 90° of extension implying that the so-called "wiper effect" occurs during most of flexion angles. CONCLUSIONS: Different regions of the femoral tunnel aperture, particularly the anterior region, were under significantly more contact force from the graft than other areas of the aperture during the anterior translation test, potentially leading to femoral tunnel enlargement to the anterior side of the aperture.

[Effectiveness of arthroscopic binding fixation using suture through single bone tunnel for posterior cruciate ligament tibial insertion fracture in adults].

Objective: To explore the effectiveness of arthroscopic binding fixation using suture through single bone tunnel for posterior cruciate ligament (PCL) tibial insertion fractures in adults. Methods: Between October 2019 and October 2021, 16 patients with PCL tibial insertion fractures were treated with arthroscopic binding fixation using suture through single bone tunnel. There were 11 males and 5 females with an average age of 41.1 years (range, 26-58 years). The fractures were caused by traffic accident in 12 cases and sports in 4 cases. The time from injury to operation ranged from 2 to 10 days with an average of 6.0 days. The fractures were classified as Meyers-McKeever type Ⅱ in 4 cases and type Ⅲ in 9 cases, and Zaricznyi type Ⅳ in 3 cases. There were 2 cases of grade Ⅰ, 7 cases of grade Ⅱ, and 7 cases of grade Ⅲ in the posterior drawer test. There were 3 cases combined with lateral collateral ligament injury and 2 cases with meniscus injury. The visual analogue scale (VAS) score, Lysholm score, International Knee Documentation Committee (IKDC) score, and knee range of motion were used to evaluate knee joint function. The posterior drawer test and knee stability tester (Kneelax 3) were used to evaluate knee joint stability. The X-ray films were used to evaluate fracture reduction and healing. Results: All incisions healed by first intention after operation. There was no incision infection, popliteal neurovascular injury, or deep venous thrombosis of lower limbs. All patients were followed up 6-12 months, with an average of 10 months. X-ray films at 6 months after operation showed the fractures obtained bone union. There were 11 cases of grade 0, 4 cases of gradeⅠ, and 1 case of grade Ⅱin posterior drawer test, showing significant difference when compared with preoperative results ( Z=23.167, P<0.001). The VAS score, Lysholm score, IKDC score, knee range of motion, and the results of Kneelax3 examination all significantly improved when compared with preoperative results ( P<0.05). Conclusion: For adult patients with PCL tibial insertion fractures, the arthroscopic binding fixation using suture through single bone tunnel has the advantages of minimal trauma, good fracture reduction, reliable fixation, and fewer complications. The patient's knee joint function recovers well.

Evaluation of the bone tunnel position and state of healing on second-look arthroscopy after pullout repair of medial meniscus posterior root tear during open-wedge high tibial osteotomy.

BACKGROUND: The aim of the present study was to evaluate the outcome of pullout repair of medial meniscus posterior root tear during open-wedge high tibial osteotomy, including the bone tunnel position and the state of healing on second-look arthroscopy. METHODS: The cohort comprised 22 patients (six men, 16 women) who underwent arthroscopic root fixation by the transtibial pullout technique for medial meniscus posterior root tear during open-wedge high tibial osteotomy. The mean patient age was 63.7 years. The location of the tibial tunnel was assessed using a percentage-dependent method, and the location of a critical point was determined by two coordinates on CT. We defined the distance between the tibial tunnel center and the medial meniscal posterior root anatomic center as the TC-AC distance. The healing state was classified as complete, partial, or failed on second-look arthroscopy. Patients were categorized into those with complete or partial healing (group H) and those with failed healing (group F). The differences in the outcomes and characteristics of groups H and F were evaluated. RESULTS: Twelve and 10 knees were classified into groups H and F, respectively. The bone tunnel position was significantly more posterior in group H than in group F. The TC-AC distance was significantly shorter in group H than in group F. CONCLUSIONS: In pullout repair of medial meniscus posterior root tear during open-wedge high tibial osteotomy, it was considered important to create a bone tunnel position more posterior to increase the healing rate on second-look arthroscopy. LEVEL OF EVIDENCE: Level Ⅳ.

Injectable FHE+BP composites hydrogel with enhanced regenerative capacity of tendon-bone interface for anterior cruciate ligament reconstruction.

Features of black phosphorous (BP) nano sheets such as enhancing mineralization and reducing cytotoxicity in bone regeneration field have been reported. Thermo-responsive FHE hydrogel (mainly composed of oxidized hyaluronic acid (OHA), poly-ε-L-lysine (ε-EPL) and F127) also showed a desired outcome in skin regeneration due to its stability and antibacterial benefits. This study investigated the application of BP-FHE hydrogel in anterior cruciate ligament reconstruction (ACLR) both in in vitro and in vivo, and addressed its effects on tendon and bone healing. This BP-FHE hydrogel is expected to bring the benefits of both components (thermo-sensitivity, induced osteogenesis and easy delivery) to optimize the clinical application of ACLR and enhance the recovery. Our in vitro results confirmed the potential role of BP-FHE via significantly increased rBMSC attachment, proliferation and osteogenic differentiation with ARS and PCR analysis. Moreover, In vivo results indicated that BP-FHE hydrogels can successfully optimize the recovery of ACLR through enhancing osteogenesis and improving the integration of tendon and bone interface. Further results of Biomechanical testing and Micro-CT analysis [bone tunnel area (mm2) and bone volume/total volume (%)] demonstrated that BP can indeed accelerate bone ingrowth. Additionally, histological staining (H&E, Masson and Safranin O/fast green) and immunohistochemical analysis (COL I, COL III and BMP-2) strongly supported the ability of BP to promote tendon-bone healing after ACLR in murine animal models.

Foveal Triangular Fibrocartilage Complex Tear Repair with Nonabsorbent Suture Tape.

PURPOSE: Arthroscopic repair is performed for fovea injuries of the triangular fibrocartilage complex (TFCC) when instability of the distal radioulnar joint results in pain, decreased grip strength, and mechanical symptoms. During TFCC repair, reconstruction of its attachment to the fovea is important. Nonabsorbent suture tapes have gained attention for ligament repair in the trapeziometacarpal joint, scapholunate ligament, and thumb metacarpophalangeal ligament. However, there are no reports of TFCC repair using suture tapes. We evaluated the early postoperative results of this approach. METHODS: Participants underwent arthroscopic suture tape repair of foveal TFCC tears and were observed for more than 1 year. All repairs were performed using suture tapes and an outside-in technique with a bone tunnel from the ulnar shaft to the fovea. The postoperative complications, postoperative wrist range of motion, grip strength, and the Modified Mayo Score were evaluated. RESULTS: Arthroscopic repair with a suture tape was performed for 20 hands using the outside-in technique. The ranges of motion for the operated and nonoperated hands were comparable 1 year after surgery (pronation, 84° ± 4°; supination, 83° ± 4°). The mean grip strength improved from 65% ± 13% before surgery to 89% ± 9% after a year. The mean Modified Mayo Score improved from 58 ± 11 before surgery to 91 ± 8 after a year. Postoperative complications included abnormal sensation of the dorsal ulnar side in 2 hands. CONCLUSIONS: After using a suture tape to attach the TFCC to the fovea, satisfactory function was achieved in the early postoperative period with grip strength restoration. For the repair of foveal TFCC tears, attachment to the ulnar fovea is important, and repair by a suture tape may be useful. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts.

Bone tunnel-related complications are frequently encountered during revision anterior cruciate ligament reconstruction (ACLR). Issues with tunnel positioning, enlargement, containment, and hardware interference may complicate surgery and compromise outcomes. As a result, several strategies have emerged to address these issues and optimize results. However, a systematic, unified approach to tunnel pathology in revision ACLR is lacking. The purpose of this review is to highlight the current state of the literature on bone tunnel complications and, although extensive literature on the subject is lacking, present an updated approach to the evaluation and management of tunnel-related issues in revision ACLR.