Thirty patients with chronic lesions of the ACL underwent reconstruction of the ACL with double bundle technique. A wire at 65° was used for AM tibial tunnel and a prototype was used for the PL. For femoral tunnels, a transtibial technique was applied in fifteen patients and the outside-in technique was used in fifteen more. All patients had an MRI after three months. The tunnels position was studied with Amis’ circle method, as a proportion of the circle’s height and width. We compared the proportion of the anatomical data on fourteen cadaveric knees. In the transtibial group the AM tunnel was at 56% of the circle’s height and at 65%of the depth (mean); the PL was at 40% of the circle’s height and 54% of the depth. In the out-side group the AM tunnel was 48%of the circle’s height and at 66% of the depth; the PL one was at 32%of the circle’s height and at 61%of the depth. In corpses the AM insertion was at 50% of the circle’s height and 69% of the depth (mean). In conclusion the outside-in technique allows better anatomical positioning

Postoperative surgical site infection in patients treated with lumbosacral fusion has been believed to be caused by perioperative contamination (Perioperative Inside-Out infections) in patients with comorbidities. With the proximity of these incisions to the perianal region and limited patient mobility in the early post-operative period, local contamination from gastrointestinal and/or urogenital flora (Postoperative Outside-In infections) should be considered as a major source of complication. A single center, retrospective review of adult patients treated with open posterior lumbosacral fusions between January 2014 and January 2021. We aimed to identify common factors in patients experiencing deep postoperative infections. Oncological, minimally invasive, primary infection, and index procedures carried out at other institutions were excluded. We identified 489 eligible patients, 20 of which required debridement deep to the fascia (4.1%). Mean age (62.9 vs 60.8), operative time (420 vs 390 minutes), estimated blood loss (1772 vs 1790 mL) and median levels fused (8.5 vs 9) were similar between the infected and non-infected groups. There was a higher percentage of deformity patients (75% vs 29%) and increased BMI (32.7 vs 28.4) in the infected group. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth on culture. Three showed Staphylococcus species (Perioperative Inside-Out infections) requiring debridement at a mean of 100.3 days (95%CI 0- 225 days). Thirteen patients showed infection with intestinal or urogenital pathogens (Postoperative Outside-In infections) requiring debridement at a mean of 20.0 days (95%CI 9-31 days). Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p= 0.007). In this series, 65% of deep infections were due to early local contamination by gastrointestinal and/or urogenital tracts pathogens. These infections were debrided significantly earlier than the Staphylococcus species infections. Due to the proximity of the incisions to the perianal region, there should be increased focus on post-operative local wound management to ensure these pathogens are away from the wound during the critical stages of wound healing

The objective of this study was to analyze the biomechanical effect of an implanted ACL graft by determining the tunnel position according to the aspect ratio (ASR) of the distal femur during flexion-extension motion. To analyze biomechanical characteristics according to the ASR of the knee joint, only male samples were selected to exclude the effects of gender and 89 samples were selected for measurement. The mean age was 50.73 years, and the mean height was 165.22 cm. We analyzed tunnel length, graft bending angle, and stress of the graft according to tunnel entry position and aspect ratio (ratio of antero-posterior depth to medio-lateral width) of the articular surface for the distal femur during single-bundle outside-in anterior cruciate ligament reconstruction surgery. We performed multi-flexible-body dynamic analyses with wherein four ASR (98, 105, 111, and 117%) knee models. The various ASRs were associated with approximately 1-mm changes in tunnel length. The graft bending angle increased when the entry point was far from the lateral epicondyle and was larger when the ASR was smaller. The graft was at maximum stress, 117% ASR, when the tunnel entry point was near the lateral epicondyle. The maximum stress value at a 5-mm distance from the lateral epicondyle was 3.5 times higher than the 15-mm entry position and, the cases set to 111% and 105% ASR, showed 1.9 times higher stress values when at a 5-mm distance compared with a 15-mm distance. In the case set at 98% ASR, the low-stress value showed a without-distance difference from the lateral epicondyle. Our results suggest that there is no relationship between the ASR and femoral tunnel length, A smaller ASR causes a higher graft bending angle, and a larger ASR causes greater stress in the graft

Various techniques for meniscal suturing have been described: inside-out, outside-in, and all-inside. In some, the knots are intra-articular, while in others they are outside the joints. Suture materials include barbed absorbable pins, meniscal staples, absorbable and non-absorbable monofilament sutures and non-absorbable multifilament sutures. The gold standard, however, is mattress sutures with non-absorbable multifilament sutures and extra-articular knots. Because some of the newer fixation devices are quite expensive, give inferior fixation and cause complications through breakage and synovitis following absorption of the material, a simple and inexpensive outside-in technique was developed. With this technique, it is possible to suture the meniscus from the anterior horn to the anterior third of the posterior horn. The only requirements are two no-20 hypodermic needles, 1/0 monofilament nylon and 2/0 multifilament non-absorbable suture. Mattress-type sutures can be placed either superiorly or inferiorly in the meniscus, with the knot extra-articular. For tears in the posterior two thirds of the meniscus, which is inaccessible with this technique, one of the commercially-available all-inside techniques is used

Purpose: purpose of this study is the evaluation of three techniques of arthroscopic meniscal repair: inside-out, outside-in – all inside. Materials and Method: from January 2002 to January 2003 were admitted 31 patients, (32 meniscal tears) that were underwent to arthroscopic meniscal repair. The patients 24 men and 6 women had mean of age 26.7 years. By the 32 ruptures the 8 were treated with the technique outside-in (group A), 9 with the technique inside-out (group B) and 15 with the technique all inside (group C). Preoperatively and postoperatively the patients were evaluated with the Lysholm score, the McMarray score and the pain of joint line. Results: The average follow-up for group A was 14 months, for group B 11 months and for the group C 12 months. Preoperatively 7 patients of group A had pain of joint line, 6 McMarray testn+ and the Lysholm score was 57. Preoperatively 9 patients of group B had pain of joint line, 5 McMarray test + and the Lysholm score were 46. Preoperatively 13 patients of group C had pain of joint line, 9 McMarray test + and the Lysholm score was 69. Postoperatively none of the patients of group A have pain of joint line, none have McMarray test + and the Lysholm score was 94. Postoperatively none of the patients of group B have pain of joint line, none have McMarray test + and the Lysholm score was 97. Postoperatively 4 patients of group C have joint line pain, 5 McMarray test+ and the Lysholm score was 88. Conclusions: Despite the small differences that were observed between the three groups the total results of meniscal repair are encouraging. Needs longer time of follow-up of this patients in order to it is realised if the technique of all inside it falls short if it is compared with two others techniques as they show our precocious results

Arthroscopic controlled retrograde drilling of femoral and tibial sockets and tunnels using a specially designed cannulated drill pin and retrocutter (Arthrex Inc, Naples FL.) provides greater flexibility for anatomical graft placement and in revision cases avoids previous tunnels and intra osseus hardware. Inside out drilling of femoral and tibial sockets minimises incisions and eliminates intra articular cortical bone fragmentation of tunnels rims common to conventional antegrade methods. This technique is also ideal for skeletally immature patients since drilling and graft fixation through growth plates may be avoided. Initial tunnel-referencing cannulated drill guide pin placement is carried out from outside-in. This technique (out-in/in-out) combines the advantages of the two-incision and the one-incision technique. In fact it permits us, as in the two-incision technique, to drill a pin guide from outside to inside in order to obtain the correct anatomical insertion of the ACL, otherwise not reproducible from inside-out. Since November 2004 our preferred technique for hamstring (autogenous quadrupled semitendinosis/ gracilis) ACL reconstruction incorporates the above mentioned femoral socket creation. In recent years, arthroscopically assisted ACL reconstruction has become the procedure of choice. Initially, arthroscopic techniques required two incisions for outside-in drilling of bone tunnels, but there has been a trend toward using a single incision with inside-out of the femoral tunnel. Those who advocate the two-incision technique state that they do so primarily because they believe that the two-incision procedures makes accurate femoral tunnel placement easier. Harner found no difference in tunnel placement using the two techniques, while Schiavone found that the inside-out femoral tunnels were significantly more vertical in the one-incision procedure. We have performed two-incision ACL reconstruction routinely since 1977, with very favourable results. The recent variation in our technique affords a reduction in morbidity, associated with improved cosmesis and quicker post-operative recovery. One factor related to our success appears to be a more anatomically positioned femoral tunnel, which in our hands, is difficult to accomplish with the single incision trans-tibial femoral socket creation. The retro-drill technique allows preparation of the correct anatomical femoral and tibial socket or tunnel, either with a very small lateral skin incision or without any skin incisions if the surgeon is using an allograft, and appears to represent a promising future technique in ACL reconstruction

The recognition of the role of TFCC as a major distal radioulnar joint stabilizer and a buffer to compressive forces indicates the importance of preserving as much of this structure as possible. We developed arthroscopic technique for repair of Palmer I B tears of TFCC using a hypodermic needle which obviates the need of any additional skin incision. With wrist under traction important landmarks like radial styloid process, ulnar styloid process, Lister's tubercle and extensor tendons are marked using skin marker. For placement of the arthroscope, 3–4 portal is used and for instruments 6 R and 6 U portals are used. An outside-in technique is used. A 19 G needle is inserted upward from 5mm proximal to the level of the 6 R portal through skin, subcutaneous tissue, capsular tissue and then through the 2mm inner side of detached area of TFCC, while stabilizing it with probe. A 2–0 polydioxanone-PDS suture is passed through needle and caught by grasper placed in the 6 R portal. Now needle is withdrawn and then suture is retrieved out of the joint through the 6 R portal. The procedure is repeated for required number of sutures for dorsal part of peripheral tear. Thus we have stitches with one limb exiting the joint through portal and the other limb entering the joint percutaneously. A small mosquito forceps is passed through the 6 R portal undermining subcutaneous area and these percutaneously passing limbs of sutures are withdrawn through the portal. Now we have sutures entering and exiting through the 6 R portal. Similar procedure is done for ulnar part of peripheral tear through the 6 U portal. Knots are tied and slid beneath the subcutaneous tissue. It offers advantages of a lower risk of neurovascular damage, reduced postoperative pain, faster rehabilitation and better cosmesis

Objective: To compare double bundle ACL reconstruction kinematics to single bundle reconstruction, intact knee and ACL deficient knee employing an electromagnetic device in six cadaver knees under different antero-posterior and rotational loading conditions. Methods: All the tests were performed with an intact ACL, with a deficient ACL and after single and double bundle ACL reconstruction. In double bundle ACL reconstruction two tibial tunnels were drilled: for the anteromedial the 65 degrees Howell guide was employed; the posterolaetral was drilled through a prototype jig attached to the first guide. Two femoral tunnels were drilled outside-in with the Rear Entry guide. A 6 millimetres bovine tendon graft was employed and fixed to bone with interference screws. Results: Posterior drawer loading conditions did not show differences between intact knee, single and double ACL reconstruction independently from rotational stresses. Under an anterior drawer test double bundle ACL reconstruction restored anteroposterior laxity significantly better than single bundle reconstruction at 20 and 40 degrees of flexion. A trend towards a better rotational control of double bundle reconstruction was observed in extension

Sutures are the strongest and the only time proven technique for meniscal repair. Sutures are safe and without surprises as long as the peroneal and the saphenus nerves are protected and avoided. Sutures can be placed via arthrotomy or under arthroscopic view. In pure suture techniques a sling holds the meniscus parts together or refixes the meniscus to the capsule. The orientation of the sling can be vertical, horizontal or oblique, but should always either catch the circumferential fibre bundles of the meniscal tissue or part of the densely woven meniscal surface. Suture related techniques make use of a thread but do not strive to form a sling. The earliest of these was the knot-end technique, the latest one is the Fastfix? repair. Either absorbable or non-absorbable material has been recommended but most would favour non-absorbable threads of 0 or 1–0 USP sizes. Depending on the course of the needle inside-out, outside-in and all-inside techniques have been described. For repair of intrasubstance tears the sutures have to be supplemented by measures to enhance healing as trephination of the meniscal periphery or addition of a fibrin clot to the repair side. There are regions of the menisci that are close to impossible to reach for the suture cannulas. For these it seems better to do a non-suture reconstruction with some of the innovative devices compared to leaving them alone or do meniscectomy instead of repair. Hybrid meniscal rapair, combining the advantages of sutures and new repair devices are in frequent use

Introduction: Navigation systems might enhance the accuracy of ACL replacement. Methods: The authors used a non image based navigation system with both kinematic and anatomic registration. Navigated aimers were positioned to simulate the intra-articular hole of both femoral and tibial tunnels. The system displayed the position of the guide wire, the expected isometricity of the graft and the potential impingement within the intercondylar notch. 40 patients were operated on for an arthroscopic assisted bone – patellar tendon – bone ACL replacement with an outside-in femoral tunnel. The guide wires were placed according to the standard technique, and their position recorded by the system. The recorded position was compared:. to the conventional radiographic measurement of the position of the tunnels on plain antero-posterior and lateral X-rays,. and to the 3D measurement of the position of the tunnels on a CT-scan. Results: There was a significant difference in the paired absolute values of the mediolateral position of the tibial tunnel between radiographic and navigated measurements (p = 0.008). However there was a significant correlation between these two measurements (p = 0.05). There was no significant difference in the paired absolute values of the mediolateral position of the tibial tunnel or of the antero-posterior position of the femoral tunnel between radiographic and navigated measurements. There was no significant difference in the paired absolute values of the antero-posterior and medio-lateral position of the tibial tunnel or of the antero-posterior position of the femoral tunnel between CT and navigated measurements. Discussion: CT-scan measurement of the positioning of the ACL replacement tunnels is currently the gold standard technique. According to this reference, the antero-posterior position of both the femoral and the tibial tunnels can be accurately assessed by the navigation system used. The X–ray measurement is less accurate and should not be considered as a confident control of the accuracy of the tunnel placement. Summary: The antero-posterior position of both the femoral and the tibial tunnels can be accurately assessed by the system

Purpose: the purpose of this study was to evaluate the outcome of arthroscopic repair of the medial patello femoral joint capsule (MPFJC) and its supporting structures in traumatic patello femoral instability (TPFI). Type of study: prospective case series. Material and methods: 24 patients 15 male and 9 female with traumatic patello femoral instability (TPFI) were treated with arthroscopic repair of the medial patello femoral joint capsule regardless of the injury chronology using 2/0 vicryle stitches by outside-in technique lateral release were not required, average age at the operation was 23,2 years (range 20–26) with 1 patient was 33, average time from injury to operation 3mounths (range 1–8 months) with 1 patient had the injury for 3 years. The patients evaluated at 10 days, 3 weeks, 6 weeks, 3 months and every 3 months afterward up to 1 year. Average follow up was 9,3 months (range 3–12mounths). Subjective data were calculated using the IKDC system, objective data included a comprehensive knee examination and evaluation and comparing it with normal side, which was used as a reference. Results: at the final review all patients were satisfied with their knees, the IKDC final score improves from 54pre op to 93. There has been no recurrence of the instability or tenderness around the knee, nil infection rate, normal side-to-side movement of the patella comparing with normal side, full range of motion, and normal quadriceps belly and strength. The patient returned to light sports activities at 6 weeks, and to their pre injury level of sport at 3 months. Conclusion: we feel that our approach to treat TPFI is a reliable, safe, and cost effective. Our results are encouraging, although we feel that longer follow up might be required

Introduction : The purpose of the study is to compare in a randomised clinical double blind trial two methods of hamstring ACL reconstruction, the SIngle Bundle (SB) and the Double Bundle (DB). Materials and methods: Seventy patients, with a chronic ACL insufficiency, were randomized to receive a unilateral single or double bundle ACL reconstruction. All the operations were performed by the same surgeon using the same two incision outside-in technique. The tibial guide wire was introduced with a 65 degrees Howell guide in extension to avoid impingment. To introduce the second tibial wire (posterolateral wire) a prototype guide that lets you place the wire with a fixed angulation and a fixed distance (9 mm) from the first was used. On the femoral side we used a modified Rear Entry guide. In a SB reconstruction the 10.00 o’clock position (right knee), intermediate between the two anatomic bundles, was used. In a DB reconstruction the first wire was placed in the anteromedial insertion area, close to the “over the top” position on the lateral wall and for the second wire the same prototype guide that gives you the correct angulation and distance with the first (10 mm) was used. The direction was chosen in order to exit 5 mm close to the posterior cartilage. The graft was prepared and pretensioned as to have two arms of the same diameter. It was fixed on the cortex of the tibia by means of a titanium ring bridge when doing a SB and looped around a cortical bony bridge when doing a DB. Tensioning and femoral fixation of the SB was done at 20 degrees, while in the DB tensioning and fixation of the PL bundle was achieved first after cycling at 10–15 degrees and of the AM bundle at 40–45 degrees. Femoral fixation was obtained via RCI titanium interference screws and one additional cortical titanium staple. The same moderately aggressive rehabilitation was utilized in both groups. Outcome assessment was performed by an indipendent observer, blinded to the involved leg and type of reconstruction, using the new IKDC form, the KOOS score, the KT-1000 arthrometer. Results: All patients reached a minimum follow-up of one year. No difference was found in terms of overall KOOS and IKDC subjective scores. A significant difference was found (p< .001) in KT data and in IKDC final ojective scores (Excellent-A-result: 73% SB and 95% DB). he DB group showed a tred to less pivot shift (glide). Conclusion: In the short period the DB reconstruction offered better knee stability and better objective results than the 10.00 o’clock SB. Longer follow up and accurate instrumented in vivo rotational stability assessment is probably needed to further disclose small but important differences

Introduction: Meniscal tears are common in young athletes, usually result from a twisting injury during sport and may occur in the anterior or posterior horns. Injured menisci may be treated arthroscopically by excision of the torn fragments. However, in patients with peripheral meniscal detachment, located at the “vascular zone”, operative repair is feasible and usually successful. Meniscal repair may be done by open direct suture of peripheral tears or by arthroscopic techniques as “Outside-In”, “Inside-Out” or “All-Inside”. We present our experience with arthroscopic suture of completely detached menisci. Patients & Methods: This study consisted of 33 male patients (14-48Y; mean 25Y; Follow-up: 2-6Y; mean 3.5Y). Inside-Out technique was used in 31 patients and Outside-In technique in two patients. 16/33 patients had detachment of the peripheral half of the meniscus (14-medial; 2-lateral); 13/33 patients had peripheral detachment of almost two thirds of meniscus (10-medial; 3-lateral) and 4/33 patients had detachment of one third of the meniscus (3-lateral; 1-medial injuries; all combined with fractures of the tibial plateau). 15 patients with medial meniscus detachment had complete (5 Pts) or partial (10 Pts) tear of ACL. Two other patients with medial meniscus detachment had associated small radial tears of the affected meniscus. Two of the patients with complete ACL tear had later been operated upon for reconstruction of ACL. Results were assessed by the Knee Society Knee score and by Lysholm Scoring Scale. Results: 25/33 patients (76%) had good and excellent results. Four of them developed re-tear and detachment of medial meniscus during other later additional sport injuries, usually between 1–2 years following initial treatment. Four other patients had a “second” arthroscopic look 1–2 years later following another sport twisting injury and in all of them a stable peripheral attachment of the sutured menisci was observed. Results were better in patients who had ACL reconstruction a few months following meniscal repair. 5 patients had fair results (15%) and 3 patients had poor results (9%). Conclusions: Based on this study it is suggested that meniscal suturing for peripheral tears is a satisfactory procedure. Meniscal tears suitable for repairs are those within the vascular zones (the outer third of the menis-cus), unstable on probing, are longer than 7mm and without major surgical damaging. Tears of posterior segments are the most difficult to suture and often require open arthrotomy. ACL reconstruction combined with meniscal repair appears to increase the healing rate of the meniscus. There are also adjuvant techniques for meniscal repair such as: fibrin clot or laser (both are weaker than suture alone) and adhesives. However, there is still not enough data

The importance of meniscal tears repair is discussed widely in the literature. The repair should be performed if the conditions promise some chance for healing. Due to technical difficulties many orthopaedic surgeons still prefer partial meniscectomy to meniscal repair. We describe our techniques for meniscal repair. The described techniques could be used by any surgeon with basic skills in arthroscopic surgery. No special equipment is needed. The basic equipment for this technique is a standard 18 gouge needle. The plastic cup of the needle is cut away in order to overcome the ridge between the plastic and the metal part of the needle, thus making the suture passage easier. Following the arthroscopic identification of the meniscal tear and preparing the torn parts for repair, the place for the first suture is identified. A 2–3 mm long skin incision is made. The subcutaneous tissue is bluntly developed to the capsule. The 18 gouge needle is past from outside-in in the desired point through the torn margins of the meniscus. The tip of the needle is emerged above or under the meniscal surface, depends on our decision of suture position. 1st step – Producing a loop outside the joint: Two ends of a nylon 2/0 suture are inserted through the needle into the joint cavity, and pulled out through one of the arthroscopic portals. The needle is removed. The result of this step is a nylon 2/0 suture passing through the torn parts of the meniscus with a loop outside the joint. 2nd step – Producing a double-loop inside the joint cavity: A second nylon 2/0 suture is passed through the first loop. The first suture is pulled into the joint. At this stage, both loops are inside the joint, holding each other. The free ends of the first loop are emerged through one of the arthroscopic portals, while the free ends of the second loop pass through the torn parts of the meniscus and emerge through the capsule. 3rd step – Producing the meniscal suture: A second 19 gouge needle is inserted close to the point of insertion of the first one, directed into the joint. The emerging point of this needle, on the meniscus, should be positioned according to the desired suture direction (transverse, vertical, or oblique). The tip of the needle is then directed into the “2nd” nylon loop (the “1st” nylon loop can assist at this stage). The loop is wrapped over the needle, and the 1st suture is removed. PDS suture (1/0 or 2/0) is inserted through the needle until a 5 cm free end is positioned intra articular. The needle is removed with caution without pulling the PDS suture, leaving the. PDS free end inside the nylon loop. The nylon loop is used as a pooling tool for the PDS suture. Pulling the free end of the PDS suture out of the joint results in a PDS loop for the meniscal suture (in order to avoid iatrogenic tear of the meniscal tissue while pulling the sutures, a probe should be positioned under the PDS suture during the process). The PDS is tightened over the capsule. The technique is repeated as much as necessary for perfect repair of the meniscus. The advantage of this method is that it does not necessitates unique equipment, but rather uses the ordinary arthroscopic tools and sutures. This method was used successfully upon large number of meniscal tears. We recommend its use routinely

Aims

To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements.