Intraosseous Bioplasty for a Chondral Cyst in the Lateral Tibial Plateau.

Subchondral lesions are the result of osseous modifications seen in a different array of pathologies such as osteoarthritis, rheumatoid arthritis, calcium pyrophosphate deposition, and osteonecrosis. The physiopathologic changes in all of the aforementioned pathologies are not clear yet. What is clear is that the development of a cystic change in the subchondral bone can cause pain and can lead to modification of the activity of daily life. To provide relief and treatment for such a condition, there are different options with joint replacement as last resort when the cyst develops in communication with the joint; if the cyst is not in communication with the joint, it is possible to perform a bioplasty as we present in this technical report. It is crucial to assess the bone continuity, especially when traumas are reported in the patient history. In our case, the tibial plateau did not have signs of collapse. The technique here presented is a minimally invasive technique that can be reproduced for focal and localized subchondral cysts.

Arthroscopic Bone Marrow Aspirate Concentrate Harvesting From the Intercondylar Notch of the Knee.

Bone marrow aspirate concentrate is commonly harvested to obtain mesenchymal stem cells, progenitor cells, and growth factors. The iliac crest is the most common donor site for bone marrow harvesting and is associated with donor site morbidity of an additional incision and pain from the harvest. Iliac crest harvesting can be cumbersome because it often requires different patient positioning from the surgical procedure and additional sedation or anesthesia for the harvest prior to repositioning. The purpose of this Technical Note and accompanying video is to describe a technique to arthroscopically aspirate bone marrow from the intercondylar femoral notch, reducing the need for iliac crest harvesting.

Anatomic Single-Incision Repair of Distal Biceps Tendon Ruptures Using Intramedullary Soft Anchors.

Distal biceps tendon ruptures are uncommon injuries responsible for only 3% of all injuries to the biceps tendon. For most of these cases, unless the patient is elderly or infirm, conservative management should be avoided and the injury should be treated with a surgical procedure to reattach the bicep tendon to the radial tuberosity. In this Technical Note and accompanying video, we describe an anatomic single-incision technique using 2 intramedullary soft anchors, which decreases the likelihood of complications associated with bicortical drilling and metal suspensory fixation.

The Tibial Tug Test: An Intraoperative Test to Assess Tibial Fixation During Anterior Cruciate Ligament Reconstruction.

The anterior cruciate ligament (ACL) is commonly injured, especially in athletes performing twisting and pivoting motions. ACL reconstruction is a standard procedure; however, there is no way to intraoperatively assess one of the causes of failure: the lack of adequate graft fixation on the tibial side. Different fixation devices can be used to ensure fixation, but there is as yet no consensus on which is the most effective. Moreover, there is no reliable way to assess their strength in the intraoperative setting. The tibial tug test is meant to be an important resource to help avoid fixation failure by evaluating the tibial fixation device intraoperatively and giving the surgeon the opportunity to revise the tibial fixation if deemed inadequate. The aim of this article is to describe an empirical and simple test that can demonstrate to the surgeon adequate tibial fixation during ACL reconstruction surgery.

Arthroscopic Remplissage Using a Double-Pulley System for Hill-Sachs Lesions for Recurrent Shoulder Instability.

Hills-Sachs lesions are bony lesions in the humeral head that occur as a result of an anterior shoulder dislocation. These lesions often happen in conjunction with tears of the labrum, and large, engaging lesions must be addressed in order to avoid recurrent instability. Moderate to large (≥3 mm deep) Hill-Sachs defects can be treated using arthroscopic remplissage to reduce the rotator cuff down into the lesion. We describe in this Technical Note and accompanying video an adaptation of the classic arthroscopic remplissage that uses a knotless double-pulley technique with 2 suture anchors, which increases the footprint of fixation, reduces the technical difficulty of the procedure, and minimizes the number of portals that need to be made.

Single Portal Technique for Subscapularis Tendon Repair.

The fast and steady development of arthroscopy techniques in the last couple of decades led to a drastic increase of arthroscopic rotator cuff repairs over the open procedure. Supraspinatus tears are the most common of all, but the subscapularis tendon tear is a more common injury than expected. Most of the time it presents as a partial tear or is associated with a subsequent rotator cuff tendon injury, especially the supraspinatus. Nowadays, the standard procedure to repair the subscapularis tendon is performed arthroscopically, even though a real superior result over the open repair it is yet to be reported. Ideally less operative time, less scarring, and postoperative pain would be the expected benefits, but no study has compared the long-term outcome of these 2 procedures yet. To maximize possible improvements, we would like to present an arthroscopic technique: a subscapularis tendon repair performed with the aid of an angled suture passer and using a single anterior working portal.

Anterior Cruciate Ligament Reconstruction With Amnion Biological Augmentation.

Anterior cruciate ligament (ACL) ruptures are common and unfortunate injuries for many athletes. The standard therapy for ACL rupture is ACL reconstruction with either autograft, harvested from hamstring or patellar tendon, or allograft tendon from a tissue donor. Advances in tissue engineering have produced interventions to augment the healing process and may have applications when it comes to ACL reconstruction. In this Technical Note and accompanying video, we describe a simple technique to implant an amnion matrix graft with a tendon graft during ACL reconstruction. This procedure uses the proposed anti-inflammatory, scaffolding, and stem cell-producing effects of the amniotic membrane to biologically augment the healing process of an ACL reconstruction.

Anterior Shoulder Stabilization Using a Single Portal Technique With Suture Lasso.

Open Bankart repair was the standard technique used in the past, but the request for less invasiveness, always pursued by every surgeon, pushed the development of the arthroscopic procedure. Nowadays the stabilization of the anteroinferior labrum is usually performed with an arthroscopic technique that uses the classic posterior portal and 2 anterior working portals. Because arthroscopy is progressing steadily under every aspect, there is now the chance to use only one working portal with the aid of a suture passer. One less portal not only means less invasiveness but also less postoperative pain and possible shorter operative time. This Technical Note is focalized in the description of a Bankart repair technique with a single working portal and the aid of a suture lasso.

Submeniscal Portal for Horizontal Cleavage Tear with Parameniscal Cyst of the Lateral Meniscus.

Horizontal cleavage tears of the medial and lateral meniscus can be difficult to treat using the standard anteromedial or anterolateral arthroscopy portals. In this Technical Note, we present a new surgical technique to better manage the inferior leaflet of horizontal cleavage tears of the medial and lateral meniscus and their associated parameniscal cysts.

Graft Retensioning Technique Using an Adjustable-Loop Fixation Device in Arthroscopic Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) tears are an unfortunate and devastating injury in the athletic patient. Surgical reconstruction of the ACL with a taut graft construct is necessary to restore knee stability and help expedite the patient's return to an active lifestyle. Arthroscopy-assisted ACL reconstruction can be a technically involved procedure, where strong fixation limits graft motion to allow sufficient healing within the tibial and femoral tunnels at the bone-tendon interfaces. Loss of tension in a graft can cause symptomatic anterior or rotatory instability and potential retear of the ACL graft. We describe in this Technical Note and accompanying video a simple and effective technique to implant and retension a tendon graft during ACL reconstruction using a suspensory fixation device. The technical description uses a simple adjustable-loop device to provide strong cortical fixation, along with the unique ability to retension the graft in ACL reconstruction, not otherwise possible with previously described graft fixation techniques.

Arthroscopic Reduction of Tibial Spine Avulsion: Suture Lever Reduction Technique.

Tibial spine avulsion fractures are uncommon knee injuries that predominantly occur in children and young adults. Restoration of anterior cruciate ligament length through surgical reduction and fixation of the fracture is necessary to ensure stability of the knee with suitable range of motion and minimal knee laxity. Arthroscopic repair of tibial spine avulsion fractures is a technically complex procedure, specifically when performing and maintaining the initial anatomic reduction. We describe in this technical note and accompanying video a unique 3-point fixation repair of tibial spine avulsion fractures using an arthroscopic assisted suture lever reduction technique. Our technique is both simple and efficacious in the reduction of tibial spine avulsion fractures to anatomic position by passing the first suture through the anterior cruciate ligament, and subsequently anterior to the avulsion fragment, and then beneath the fragment through a posteriorly placed bone tunnel within the tibial fracture bed.

Kinematic analysis of the indirect femoral insertion of the anterior cruciate ligament: implications for anatomic femoral tunnel placement.

PURPOSE: To determine the effect of debriding the indirect insertion component of the femoral anterior cruciate ligament (ACL) attachment on tibiofemoral kinematics when compared with the intact knee. METHODS: Knee kinematics were measured in 9 cadaveric knees with the ACL intact, after indirect insertion debridement, and after ACL transection. Three loading conditions were used: (1) a 134-N anterior tibial load, (2) a combined 10-Nm valgus and 5-Nm internal tibial torque, and (3) a simulated robotic pivot shift. Anterior tibial translation (ATT) was recorded in response to anterior and combined loads at 0°, 15°, 30°, 45°, 60°, and 90° of flexion. Posterior tibial translation and external tibial rotation were recorded during the simulated pivot shift. RESULTS: With an anterior load, indirect insertion debridement increased ATT by 0.37 ± 0.24 mm at 0° (P = .002) and by 0.16 ± 0.19 mm at 15° (P = .033; increases <1 mm in all specimens). ACL transection increased ATT in response to an anterior load (P = .0001) with maximum effect at 15° compared with the intact and debrided states (11.26 ± 1.15 mm and 11.04 ± 1.08 mm, respectively). With a combined load, indirect insertion debridement increased ATT by 0.17 ± 0.11 mm at 0° (P = .001; increases <0.3 mm in all specimens) with no effect at other angles. ACL transection increased ATT in response to a combined load (P = .001) with maximum effect at 15° (4.45 ± 0.85 mm v ACL intact and 4.44 ± 0.84 mm v debrided indirect insertion). In the ACL intact condition, the pivot shift produced 1.29 ± 1.34 mm of posterior tibial translation and 1.54 ± 1.61° of external tibial rotation, as compared with 1.28 ± 1.34 mm and 1.54 ± 1.47°, respectively, after debridement (P = .68 and P = .99, respectively) and 12.79 ± 3.22 mm and 17.60 ± 4.30°, respectively, after ACL transection (P = .0001). CONCLUSIONS: The indirect femoral ACL insertion contributes minimally to restraint of tibial translation and rotation. CLINICAL RELEVANCE: Femoral tunnel positioning for anatomic ACL reconstruction should aim to recreate the biomechanically significant direct insertion.

Safe zone for retractor placement to the lumbar spine via the transpsoas approach.

PURPOSE: To measure anatomic variations of the lumbar plexus within the psoas in relation to the L2/3, L3/4, and L4/5 disc spaces and to delineate a safe zone to avoid nerve injury during retractor placement via the transpsoas approach. METHODS: Six male and 6 female cadavers (24 psoas/ lumbar plexuses) aged 35 to 74 years were dissected. The lumbar plexus was isolated bilaterally. The L2, L3, and L4 nerve roots were identified and isolated without disturbing their natural anatomic course. The anteroposterior (AP) diameter of each intervertebral disc at L2/3, L3/4, and L4/5 was used as a reference. Four measurements were made using a caliper: the AP and mediolateral (ML) diameters of the psoas and AP and ML excursions of each nerve root. Percentages were calculated for the 4 measurements using the reference of the AP diameter of the intervertebral disc at each level. Comparison between left and right sides, between males and females, and between excursions of nerve roots were made. RESULTS: The AP diameter of the psoas increased from L2 to L4, with a mean vertebral body coverage of 80%, 86%, and 85% at L2/3, L3/4, and L4/5, respectively. Both the L2 and L3 nerve roots demonstrated substantial anterior trajectories as they coursed distally in the lumbar spine. No nerve root encroached anteriorly beyond 33% of the intervertebral disc space at L2 to L5. CONCLUSION: The lumbar plexus area corresponding to the anterior half of the intervertebral disc was the safe zone. Procedures to the lumbar spine via the transpsoas approach should be performed within the safe zone to avoid nerve injury.

A reproducible landmark for the tibial tunnel origin in anterior cruciate ligament reconstruction: avoiding a vertical graft in the coronal plane.

Improper tunnel placement during anterior cruciate ligament reconstruction may result in residual instability. Proper femoral tunnel orientation relies on tibial tunnel placement with a transtibial technique. Our recommended technique is to use the junction of the anterior border of the superficial medial collateral ligament and the superior border of the gracilis tendon as a reproducible anatomic landmark for the tibial tunnel. In a cadaveric model the mean angle for the tibial tunnel was 65.7 degrees +/- 5.5 degrees in the coronal plane and 75 degrees +/- 7.2 degrees in the sagittal plane. By use of the clock-face method, the mean angle for the femoral tunnel was 44.9 degrees +/- 13 degrees , or approximately the 10:30 position (for a right knee) or 1:30 position (for a left knee).

Anterior cruciate ligament deficiency alters the in vivo motion of the tibiofemoral cartilage contact points in both the anteroposterior and mediolateral directions.

BACKGROUND: Quantifying the effects of anterior cruciate ligament deficiency on joint biomechanics is critical in order to better understand the mechanisms of joint degeneration in anterior cruciate ligament-deficient knees and to improve the surgical treatment of anterior cruciate ligament injuries. We investigated the changes in position of the in vivo tibiofemoral articular cartilage contact points in anterior cruciate ligament-deficient and intact contralateral knees with use of a newly developed dual orthogonal fluoroscopic and magnetic resonance imaging technique. METHODS: Nine patients with an anterior cruciate ligament rupture in one knee and a normal contralateral knee were recruited. Magnetic resonance images were acquired for both the intact and anterior cruciate ligament-deficient knees to construct computer knee models of the surfaces of the bone and cartilage. Each patient performed a single-leg weight-bearing lunge as images were recorded with use of a dual fluoroscopic system at full extension and at 15 degrees , 30 degrees , 60 degrees , and 90 degrees of flexion. The in vivo knee position at each flexion angle was then reproduced with use of the knee models and fluoroscopic images. The contact points were defined as the centroids of the areas of intersection of the tibial and femoral articular cartilage surfaces. RESULTS: The contact points moved not only in the anteroposterior direction but also in the mediolateral direction in both the anterior cruciate ligament-deficient and intact knees. In the anteroposterior direction, the contact points in the medial compartment of the tibia were more posterior in the anterior cruciate ligament-deficient knees than in the intact knees at full extension and 15 degrees of flexion (p < 0.05). No significant differences were observed with regard to the anteroposterior motion of the contact points in the lateral compartment of the tibia. In the mediolateral direction, there was a significant lateral shift of the contact points in the medial compartment of the tibia toward the medial tibial spine between full extension and 60 degrees of flexion (p < 0.05). The contact points in the lateral compartment of the tibia shifted laterally, away from the lateral tibial spine, at 15 degrees and 30 degrees of flexion (p < 0.05). CONCLUSIONS: In the presence of anterior cruciate ligament injury, the contact points shift both posteriorly and laterally on the surface of the tibial plateau. In the medial compartment, the contact points shift toward the medial tibial spine, a region where degeneration is observed in patients with chronic anterior cruciate ligament injuries.

The 6 degrees of freedom kinematics of the knee after anterior cruciate ligament deficiency: an in vivo imaging analysis.

BACKGROUND: Previous studies of knee joint function after anterior cruciate ligament deficiency have focused on measuring anterior-posterior translation and internal-external rotation. Few studies have measured the effects of anterior cruciate ligament deficiency on 6 degrees of freedom knee kinematics in vivo. OBJECTIVE: To measure the 6 degrees of freedom knee kinematics of patients with anterior cruciate ligament deficiency. STUDY DESIGN: Controlled laboratory study. METHODS: The knee joint kinematics of 8 patients with unilateral anterior cruciate ligament rupture was measured during a quasi-static lunge. Kinematics was measured from full extension to 90 degrees of flexion using imaging and 3-dimensional modeling techniques. The healthy, contralateral knee of each patient served as a control. RESULTS: Anterior cruciate ligament deficiency caused a statistically significant anterior shift (approximately 3 mm) and internal rotation of the tibia (approximately 2 degrees ) at low flexion angles. However, ligament deficiency also caused a medial translation of the tibia (approximately 1 mm) between 15 degrees and 90 degrees of flexion. CONCLUSION: The medial shift of the tibia after anterior cruciate ligament deficiency might alter contact stress distributions in the tibiofemoral cartilage near the medial tibial spine. These findings correlate with the observation that osteoarthritis in patients with anterior cruciate ligament injuries is likely to occur in this region. CLINICAL RELEVANCE: The data from this study suggest that future anterior cruciate ligament reconstruction techniques should reproduce not only anterior stability but also medial-lateral stability.

Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft.

BACKGROUND: Anterior shoulder instability associated with severe glenoid bone loss is rare, and little has been reported on this problem. Recent biomechanical and anatomical studies have suggested guidelines for bony reconstruction of the glenoid. HYPOTHESIS: Anatomical glenoid reconstruction will restore stability in shoulders with recurrent anterior instability owing to glenoid bone loss. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair. RESULTS: At mean follow-up of 33 months, the mean American Shoulder and Elbow Surgeons score was 94, compared with a preoperative score of 65. The University of California, Los Angeles score improved to 33 from 18. The Rowe score improved to 94 from a preoperative score of 28. The mean motion loss compared with the contralateral, normal shoulder was 7 degrees of flexion, 14 degrees of external rotation in abduction, and one spinous process level for internal rotation. All patients returned to preinjury levels of sport, and only 2 complained of mild pain with overhead sports activities. No patients reported any recurrent instability (dislocation or subluxation). The CT scans with 3-dimensional reconstructions obtained 4 to 6 months postoperatively demonstrated union of the bone graft with incorporation along the anterior glenoid rim and preservation of joint space. CONCLUSION: Anatomical reconstruction of the glenoid with autogenous iliac crest bone graft for recurrent glenohumeral instability in the setting of bone deficiency is an effective form of treatment for this problem.