Functional adaptations in patients with ACL-deficient knees.
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Adaptation, Physiological↗
Biomedical subjects
B R Bach
Publications and source records attributed to B R Bach.
Cost containment: a charge comparison of anterior cruciate ligament reconstruction.
Two matched groups of patients who underwent endoscopic anterior cruciate ligament reconstruction using the middle one third of the patellar tendon were retrospectively reviewed to compare hospitalization charges. Group 1 had the procedure performed in the outpatient surgical center owned by our hospital, and group 2 underwent the surgical procedure in the main operating suite of Rush-Presbyterian-St. Luke's Medical Center. The charges of the surgical procedure and their relation to postoperative hospitalization were reviewed. An average charge difference of $7,390 (range, $3,679 to $12,202) was obtained in the outpatient surgical center. A number of surgical and anesthetic techniques are discussed that allow major reductions in charges for anterior cruciate ligament reconstruction and allow outpatient surgery to be performed routinely.
Ambulatory Surgical Procedures↗
Comparison of screw post fixation and free bone block interference fixation for anterior cruciate ligament soft tissue grafts: biomechanical considerations.
Endoscopic (single-incision) anterior cruciate ligament (ACL) reconstruction with bone patellar tendon bone can usually be secured with interference screws on the femur and tibia. Infrequently, patella alta, which results in a longer tendinous component of the graft construct, can result in construct mismatch, resulting in a large portion of the tibial bone plug extruding from the tibial tunnel, requiring graft fixation with staples or a suture/screw and post technique. This study investigated the hypothesis that initial graft fixation could be enhanced if the bone plug was removed and press fit into the tibial tunnel and then secured with an interference screw in the scenario of graft construct mismatch. Initial biomechanical fixation strengths of bovine patellar tendon were compared using a screw and post suture fixation compared with a free bone plug, which was removed from the graft and sandwiched along with the soft tissue with an interference screw. Twenty-eight bovine knees were randomly divided into two groups. Graft fixation was performed with a free bone plug excised from the tibial tubercle portion of the bone tendon bone construct. Fixation was achieved with a cannulated 9-mm x 20-mm interference screw. Fixation was performed in group 2 patients with a Krackow suture of no. 5 Ticron secured over a screw and post. An Instron materials testing system was used and loading rates at 1 mm/sec until failure was performed. Statistically significant differences were noted for load to failure and stiffness (P < .001). Group 1 specimens' mean maximum load to failure was 669 N (range, 511 to 819 N), whereas the load to failure for group 2 patients was 374 N (range, 266 to 491 N). Group 1 stiffness was 90 N/mm (range, 50 to 122 N/m) compared with a mean stiffness of 24 N/m (range, 16 to 33 N/m) for group 2 knees. In our bovine model, free bone block interference fixation was stronger and stiffer than fixation using sutures tied over a post. This fixation method of securing a soft tissue graft with an interference screw warrants further clinical investigation and may offer an improvement to the alternative of suture/post fixation.
Animals↗
Interference screw divergence in endoscopic anterior cruciate ligament reconstruction.
Interference screws are commonly used for graft fixation in bone-tendon-bone patellar tendon anterior cruciate ligament (ACL) reconstruction. The clinical significance of graft screw divergence has not been well studied. This report retrospectively reviews our initial experience in 73 consecutive endoscopic (single-incision) ACL reconstructions using interference screw fixation. Femoral divergence occurred more frequently in the lateral plane (29%) than the anteroposterior (AP) plane (15%). No early graft failures were noted clinically or by KT-1000 arthrometer testing. If properly tested at the time of operation, it does not appear that divergence of femoral screws < 30 degrees leads to early clinical failure in endoscopic ACL reconstruction. We propose that stresses on the graft-screw-tunnel construct will concentrate distally when placed in a divergent fashion, resulting in a wedge effect. No changes in early range of motion protocols or rehabilitation are recommended if screw divergence is noted and provided intraoperative stability is noted.
Adolescent↗
Comparison of "inside-out" and "outside-in" interference screw fixation for anterior cruciate ligament surgery in a bovine knee.
Despite numerous advances in graft fixation with anterior cruciate ligament (ACL) reconstruction, few studies have compared the fixation strength of interference screws placed "outside-in" and from "inside-out" techniques. To compare techniques, a bovine model was designed to fail at the femoral tunnel bone-screw interface. Twenty-four fresh bovine knees were stripped of all soft tissues except the ACL. The native ACL was loaded the failure at a strain rate of 50 cm/min with the knee flexed 45 degrees. One standardized femoral tunnel was created on all specimens. A 3/32-inch guide pin was drilled into the center of the ACL femoral origin and overreamed with an 11-mm reamer from inside-out until the lateral cortex was reamed. Consistently sized patellar bone blocks were created (8 x 5 x 25 mm) with an 8-mm tendon width. The bone blocks were randomized to an "inside-out" (group 1) and "outside-in" (group 2) technique. Bone blocks were secured with a 7 x 25 interference screw. Specimens were mounted with the femoral tunnel and bone block aligned parallel to the tensile force and strained to failure at 50 cm/min. Failure of the native bovine ACL occurred at a mean of 2,304 N (SD +/- 472 N; n = 24). The mode of failure for group 1 was 9 of 13 at the bone-screw interface and 4 of 13 interligamentous failures. The mode of failure for group 2 was 7 of 11 at the bone-screw interface, 3 of 11 interligamentous, and 1 bone block failure. The mean load to failure for group 1 was 1,151 N (SD +/- 320 N, n = 13) including the four ligamentous failures and 1,143 N (SD +/- 306 N, n = 9) excluding the ligamentous failures. The mean load to failure for group 2 was 1,017 N (SD +/- 262 N, n = 11), including all specimens and 843 N (SD +/- 262 N, n = 7) excluding the interligamentous and bone block failure specimens. The "inside-out" technique averaged 100 N greater fixation strength than the "outside-in" technique. Statistical analysis using two-sample Student's t-test showed no statistically significant differences between group 1 and group 2. Both techniques demonstrate comparable maximum load to failure in a bovine model tested at 50 cm/min.
Animals↗
Repair of chronic distal biceps brachii tendon rupture using free autogenous semitendinosus tendon.
Distal biceps brachii tendon ruptures occur much less frequently than do their proximal counterparts. Distal tendon ruptures usually are associated with considerable function deficits and may require surgical treatment. Repair of chronic distal biceps brachii ruptures are extremely unusual. A free autogenous semitendinosus tendon graft was used to reconstruct the distal biceps tendon by reattaching the graft to the radial tuberosity via a 2-incision technique in a patient with symptoms and a chronic injury.
Arm Injuries↗
Clinical and functional outcome of anterior cruciate ligament reconstruction in the recreational athlete over the age of 35.
This study examined the functional, objective, and subjective outcome of anterior cruciate ligament (ACL) reconstruction in recreational athletes > or = 35 years after a minimum of 2 years of follow-up. Patients > or = 35 years who underwent ACL reconstruction by a single surgeon were identified from our surgical database. Nineteen knees in 18 (62% follow-up) patients were available for review by an independent examiner. The patients underwent physical examination, radiographs, functional testing, isokinetic strength testing, and instrumented ligament arthrometer testing. All were seen at a minimum of 2 years of follow-up. The average age was 40 years. Five of 19 underwent reconstruction less than 1 month after injury, and the remainder underwent reconstruction for chronic injuries. All patients preoperatively had at least a grade 2 Lachman and a positive pivot shift noted on physical examination. After a minimum of 2 years of follow-up, 17 of 18 patients had a stable knee on objective testing, including a negative Lachman and pivot shift. Seventeen patients (94%) had < 3 mm side-to-side difference on maximum manual arthrometric testing. Only one patient had > 3 cm prone heel height difference, and all patients had > 125 degrees of flexion. Mean thigh circumference difference was 0.5 cm. Isokinetic testing demonstrated a mean 11%, 7%, and 4% quadriceps asymmetry at 60 degrees, 180 degrees, and 240 degrees/second, respectively. However, functional testing revealed only a mean 6% asymmetry on vertical jump, single leg hop, and timed 6 meter hop. Seventeen of 18 patients were satisfied with their results. The mean postoperative Lysholm Rating Scale score was 93. The mean Noyes Sports Activity Scale score was 86, improved from 31 preoperatively. Thirteen of 18 returned to their preinjury level of sports performance. These results indicate that ACL reconstruction in patients over the age of 35 has functional, objective, and subjective results comparable to those of a younger patient population.
Adult↗
Knee dislocation without anterior cruciate ligament disruption. A report of three cases.
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Adolescent↗
Removal of the instrument Makar shoulder staple.
When confronted with the challenge of hardware removal during revision shoulder stabilization procedures, specialized instrumentation such as the Instrument Makar staple driver/extractor may become necessary. The Synthes DHS/DCS coupler screw may be more readily available, and can effectively substitute for the Instrument Makar staple driver/extractor.
Arthroscopy↗
Trends in decreased hospitalization for anterior cruciate ligament surgery: double-incision versus single-incision reconstruction.
Over a 4-year period, hospital charges of 151 consecutive anterior cruciate ligament (ACL) reconstructions were retrospectively evaluated. Eighty-one patients who underwent a two-incision ACL central third autogenous patellar bone tendon bone reconstruction were compared with 72 patients who had a single-incision endoscopic reconstruction with a similar graft. Charges were adjusted for inflation. There was a statistically significant difference in hospital days (2.8 v 1.57, P = .0001), total hospital charges ($15,063 v $13,520, P = .0001), as well as operating room/hospital ward charges (P = .0001), pharmacy charges (P = .035), and physical therapy charges (P = .001). No statistical difference was observed for anesthesia or laboratory charges. A matched comparison of patients from each group who were in the hospital for 2 days showed a statistically significant reduction in operating room/hospital ward charges (P = .037), but no significant reduction in total costs. There was a trend in both groups toward shorter hospital stays in each successive year. The reduction in charges observed for the endoscopic procedure correlated with a reduction in postoperative hospital days.
Anterior Cruciate Ligament↗
An unusual intrinsic complication of a patellar tendon allograft and recommendations for tissue banking.
Complications of patellar-tendon allograft for anterior cruciate ligament (ACL) reconstruction in ACL-deficient patients have focused on disease transmission, strength, survivorship, technique, and processing to decrease antigenicity. Little has been described in regard to intrinsic complications of patellar-tendon allograft. This article discusses our experience with a damaged patellar-tendon allograft that was abnormally long and had a large osseous intratendinous mass. Based on this experience, we make recommendations on evaluating and procuring patellar-tendon allografts that will help orthopaedic surgeons avoid intrinsic patellar-tendon allograft complications.
Adult↗
Treatment of failed Hauser procedures via modified Maquet osteotomy. Case report.
Four cases of failed Hauser procedures were treated with an osteotomy of the patellar tendon insertion and distal realignment. The patellar tendon insertion site was moved as a large bond block and positioned in neutral alignment as well as anterior to its previous position, effectively creating a "modified Maquet effect." Proximal realignment was performed in one patient. Intraoperative assessment of patellar tracking enabled accurate determination of optimal position. The clinical findings and the operative approach are described. All four patients experienced significant improvement from ther preoperative status.
Adult↗
Distal biceps brachii repair. Results in dominant and nondominant extremities.
Nine patients with distal biceps tendon ruptures that had been repaired anatomically with a double-incision technique were evaluated. All patients were men, whose average age was 46 years old (range, 31-66 years). Three patients injured their dominant extremity and 6 their nondominant extremity. This represents the largest series of operatively treated nondominant biceps ruptures with quantitative followup in the literature. All patients responded to a questionnaire, and had clinical, radiographic, and isokinetic testing. The average followup was 30 months (range, 12-57 months). Patients were pleased uniformly with their operative results, and all would have had surgery given the option again. Strength testing results of the dominant extremities revealed full return of forearm supination strength and elbow flexion strength. Endurance data also revealed full return when compared with controls. In nondominant extremities, a 14% supination strength deficit from expected values (corrected for dominance) and a 14% flexion strength deficit (also corrected) were observed in the 6 patients. A radioulnar synostosis that required resection developed in 1 patient. Anatomic repair of distal biceps tendon rupture gives consistently good results. Dominant extremities can achieve normal function, whereas nondominant extremities may require aggressive therapy to achieve maximal strength.
Adult↗
Posterior cortical violation of the femoral tunnel during endoscopic anterior cruciate ligament reconstruction.
Endoscopic reaming of the femoral tunnel has several advantages over "two-incision" techniques but has a greater potential for posterior cortical violation. Proper guide pin placement and adequate knee flexion during endoscopic reaming are key to avoiding posterior cortical violation. When the posterior femoral cortex is compromised, options include "over-the-top" graft passage and fixation with screw and post or conversion to the traditional "two-incision" technique. The two-incision tunnel should be started more anterior on the lateral femoral cortex to achieve greater divergence from the endoscopic tunnel. This may allow interference screw fixation of a patella tendon anterior cruciate ligament graft. This article examines the technical factors affecting the development of posterior cortical violation and discusses options for management.
Anterior Cruciate Ligament↗
Intraarticular placement of Kurosaka interference screws.
Interference screws are commonly used for graft fixation in arthroscopically assisted anterior cruciate ligament reconstruction. A potential complication with the use of interference screws is intraarticular violation of the screw tip. Postoperative radiographs often lend confusion to the exact screw location. We devised an anatomic-radiologic study to evaluate factors (including local anatomy, radiographic projection, and radiographic technique) in order to clarify these misunderstandings. We found that radiographic projection, obliquity, and the local bony anatomy contribute to erroneous radiographic interpretation. The most significant finding was that the lateral radiograph and cephalad oblique lateral radiographs frequently suggest screw tip violation of the joint when in fact it has not occurred. Caudal oblique lateral radiographs fail to raise concern even when joint violation by the screw tip has occurred. Good quality true anteroposterior radiographs appear most consistent in determining true screw tip location.
Adult↗
Beneficial impact of epidural anesthesia on recovery after outpatient arthroscopy.
The ideal outpatient anesthetic provides analgesia, is readily reversible, has minimal complications, and allows for a prompt hospital discharge. Iatrogenic side effects, such as nausea/vomiting and pain, however, may hamper patient recovery and delay discharge. The influence of anesthesia [general (G) versus epidural (E)] was assessed in 260 patients (G = 181, E = 79) undergoing ambulatory knee arthroscopic surgery. Patients were studied before discharge and on follow-up (24 h) to evaluate the effect of the anesthetic technique. Discharge times were shorter in the E group (159 +/- 6 min SEM E, compared with 208 +/- 8 min SEM G), as was the incidence of pain (24.1% versus 49.7%), and nausea/vomiting (8.9% versus 32%) before discharge. Patient satisfaction was equal in the two groups. Our study shows that in select patients, epidural anesthesia is a viable alternative to general anesthesia for knee arthroscopy, offering the advantages of fewer side effects and earlier discharge times.
Adult↗
A review of early anterior cruciate ligament surgical repair or reconstruction. Results and caveats.
Earlier diagnosis and knowledge of the natural history of anterior cruciate ligament (ACL) injuries has made consideration of early operative treatment more important in the active patient at risk for further instability episodes. In a review of early operative treatment options, ACL repair alone has been disappointing for many patients, with long-term follow-up suggesting that the reinjury rate is high. Early repair with augmentation or reconstruction with hamstring or central third bone-tendon-bone graft yielded better results, but long-term follow-up is still needed, especially in the early reconstruction groups. Early ACL reconstruction, especially in patients with medial collateral ligament injury and/or extra-articular surgery, is associated with an increased incidence of arthrofibrosis. The methods of reporting data in these studies have also presented problems in interpreting and comparing data from one study with those of another. Further standardization will be needed if literature regarding ACL surgery can be easily compared from series to series.
Adolescent↗
Selection criteria for knee arthroscopy in the osteoarthritic patient.
In the current literature concerning arthroscopy in the osteoarthritic patient, there are few well-controlled studies with long-term follow-up that establish selection criteria. The effectiveness of abrasion arthroplasty has not been proved in prospective studies. Prospective factors that are associated with a better outcome include normal limb alignment, a history of mechanical symptoms, minimal roentgenographic degeneration, and a short duration of symptoms. Variables associated with poor outcomes include varus or valgus malalignment, loading symptoms, severe roentgenographic degeneration, previous surgeries, and chronic symptoms. Advanced age, per se, is not a contraindication to arthroscopy.
Age Factors↗