Arthroscopic Control for Safe and Secure Seating of Suspensory Devices for Femoral Fixation in Anterior Cruciate Ligament Reconstruction Using Three Different Techniques.

PURPOSE: The purpose of this study was to evaluate the efficacy of our technique that allows direct visualization of seating of suspensory devices in anterior cruciate ligament (ACL) reconstruction. MATERIALS AND METHODS: Three different suspensory devices (TightRope RT, RetroButton, and EndoButton) were used in ACL reconstruction using 3 different techniques (outside-in, anteromedial [AM] portal, and transtibial techniques). Positioning of a guiding material and seating pattern of the suspensory devices were evaluated according to the surgical technique and suspensory device used. RESULTS: On the transtibial technique, 21 of total 26 cases (81%) of single bundle reconstructions and 22 of total 22 cases (100%) of double bundle reconstructions required superolateral capsulotomy where buttons were found in 21 of total 21 cases (100%) and 17 of 22 cases (77%), respectively. On the AM portal technique, all patients required capsulotomy and the button was found in only 18 of total 32 cases (56%) even after capsulotomy. On the outside-in technique, all patients required capsulotomy and the button was found in 86 of total 86 cases (100%). CONCLUSIONS: Our technique for direct visualization of seating of the suspensory devices was more effective in outside-in and single bundle transtibial ACL reconstruction. However, it was less effective in double bundle transtibial and AM portal ACL reconstructions.

Osteotomy configuration of the proximal wedge and analysis of the affecting factors in the medial open-wedge high tibial osteotomy.

PURPOSE: The purposes of this study were (1) to confirm the disparity of the measured thickness at the lateral hinge between anterior-posterior (AP) radiograph and 3D CT image, (2) to evaluate the affecting factors, and (3) to evaluate the differences between uniplanar and biplanar osteotomies. METHODS: From 2012 to 2014, a prospective comparative study was performed with 30 patients who received uniplanar osteotomy (group I) and 35 patients who received biplanar osteotomy (group II). For measurement of the proximal wedge, postoperative AP radiograph and 3D CT images were used. In the AP radiograph, medial and lateral bony bridge thicknesses were measured. In the 3D CT, the anterior and posterior images parallel to the coronal plane were selected for the evaluation. Coronal osteotomy slope was measured with the anterior image of the 3D CT scan. Sagittal osteotomy slope was measured with the sagittal section of the CT scan. RESULTS: Differences between the lateral bony bridge thicknesses measured in AP radiograph and the posterolateral posterolateral bony bridge thicknesses measured in 3D CT were statistically significant in both groups. Negative correlation was observed in the biplanar osteotomy group. Differences of the sagittal osteotomy slope from the native tibial slope showed negative correlation in the biplanar osteotomy group. CONCLUSION: Thickness of the posterolateral bony bridge was smaller compared to the observed thickness on the AP radiograph image that is routinely used for the follow-up. The thickness would be getting smaller if osteotomy is performed with an abrupt angle on the coronal plane and reverse slope on the sagittal plane. Therefore, osteotomy with abrupt angle on the coronal plane and reverse slope on the sagittal plane should be avoided for the proper thickness of the posterolateral bony bridge. LEVEL OF EVIDENCE: III.

Femoral Footprint Reconstruction With a Direct Viewing of the Posterior Insertion Using a Trans-Septal Portal in the Outside-In Anterior Cruciate Ligament Reconstruction.

We established a technique for femoral tunnel preparation through direct vision of the femoral footprint with maximum preservation to the native anterior cruciate ligament (ACL) remnant using a posterior trans-septal portal. Anterior arthroscopy is difficult for the proper tunnel placement without sacrificing the ACL remnant. Posterior arthroscopy could be helpful for viewing the posterior insertion of the ACL remnant that provides excellent femoral footprint exposure without sacrificing the native ACL remnant. Therefore, a posterolateral portal technique using a 70° arthroscope through a posterolateral portal is introduced. However, using the 70° arthroscope, an oblique view is displayed and distorted view could be seen. Therefore, to achieve the goal of posterior arthroscopy and avoid obstacles of the posterolateral view with the 70° arthroscope, we introduce this technique that uses the posterior trans-septal portal with a 30° arthroscope that provides an excellent viewing to the femoral footprint through a hole of the posterior septum.

Open-Wedge High Tibial Osteotomy Using a Protective Cutting System: Technical Advancement for the Accuracy of the Osteotomy and Avoiding Intraoperative Complications.

Open-wedge high tibial osteotomy for medial unicompartmental arthritis of the knee joint is a successful treatment option but is associated with potential intraoperative complications such as tibial plateau fracture, dislocation of the osteotomy hinge, under- or over-correction of the posterior slope, and neurovascular injury. Therefore we devised a protective cutting system and describe our method for the prevention of these complications. The potential advantages of this system are protection of the posterior neurovascular structures using a curved protector, bone cutting along the natural tibial slope using a superior surface aligning with the natural tibial slope, and complete 1-plane sawing of the posterior wall before the lateral hinge.

Suspensory Anterior Tibial Fixation in the Anatomic Transtibial Posterior Cruciate Ligament Reconstruction.

The transtibial technique is the most relevant among many surgical techniques for posterior cruciate ligament reconstruction, and many types of fixation devices are used for tibial fixation according to the technique and the length of the graft. However, bone density in the fixation areas should be taken into consideration when choosing the fixation device to achieve rigid and stable fixation. However, density is not a substantial issue for anteromedial cortical fixation using a cortical suspension device. We describe tibial fixation with a TightRope RT (Arthrex, Naples, FL), which is a cortical suspension device, in anatomic transtibial posterior cruciate ligament reconstruction.

Comparison of Tibial Tunnel Techniques in Posterior Cruciate Ligament Reconstruction: C-Arm Versus Anatomic Fovea Landmark.

PURPOSE: To evaluate the accuracy of the posterior cruciate ligament (PCL) fovea landmark against conventional fluoroscopic pin placement retrospectively using 3-dimensional computed tomography (3D CT). METHODS: This retrospective comparison focused on the tibial tunnel locations determined in consecutive 26 patients using the fluoroscopic imaging technique (group I) and in consecutive 23 patients using the PCL fovea landmark technique without the help of the fluoroscopy (group II) for tibial tunnel formation. The 3D surface-modeled CT images that appropriately located the position of the PCL fovea on the tibial plateau were used. Ratios between total length of the fovea and length of the tunnel center from the medial border (coronal) and posterior edge (sagittal) were evaluated. RESULTS: The ratios between sagittal tunnel length and total sagittal length for groups I and II were 35.4% ± 12.2% and 44.1% ± 23.1%, respectively (P = .07). The ratios between the coronal tunnel lengths and total coronal lengths for groups I and II were 47.3% ± 9.2% and 57.3% ± 18.1%, respectively: group II showed a more laterally positioned tibial tunnel than did group I (P = .03). CONCLUSIONS: A more laterally located tibial tunnel was produced using the PCL fovea landmark technique. However, the differences in centers were small and probably not clinically relevant. Therefore, the PCL fovea landmark technique might be an alternative method to the fluoroscopic imaging technique for locating the anatomic tibial tunnel during transtibial PCL reconstruction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.