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Appreciation of persistent anterolateral rotatory instability and graft failure after anterior cruciate ligament (ACL) reconstruction procedures has led surgeons to adopt the addition of lateral extra-articular tenodesis (LET) in both the revision and primary setting. Multiple techniques have been shown to eliminate anterolateral rotatory instability and reduce forces on the ACL graft, which has translated to lower re-rupture rates and improved patient outcomes. The risk of ACL/LET tunnel convergence can potentially compromise the fixation of one or both graft reconstructions. This article describes a technique for LET fixation which minimizes the depth of the LET femoral bone socket and utilizes low-profile implants thus mitigating this risk. [Display omitted] [ABSTRACT FROM AUTHOR]

The medial collateral ligament (MCL) is a major contributor to knee joint stability and is the most common ligament involved in knee injuries. When conservative management for high-grade MCL injuries fails, operative treatment is indicated. Various reconstruction techniques are described in the literature. The following report describes a reconstruction technique based on the modified Bosworth. We present a step-by-step technique for using autograft semitendinosus tendon as a double limb to reconstruct the MCL and if necessary, the posterior oblique ligament. The technique is versatile with respect to a spectrum of MCL injury patterns, isometric, incorporates techniques that are common to other knee reconstructions, and uses readily available autograft. It has been used extensively by the senior authors as an adjunct/augmentation to the repair of acute MCL injuries as well as in the reconstruction of chronic MCL laxity. The technique restores stability to rotation and valgus stress while maintaining the distal insertion of the semitendinosus intact. [Display omitted] [ABSTRACT FROM AUTHOR]

Medial collateral ligament (MCL) injuries are commonly encountered in conjunction with anterior cruciate ligament injuries. MCL tears do not universally heal, and residual MCL laxity is not always well tolerated. Although residual MCL laxity results in excess stress on an anterior cruciate ligament reconstruction and may require additional treatment, relatively little interest has been paid to concomitant treatment. Adherence to the dogma of universal conservative treatment of MCL tears in this setting squanders opportunities for preservation of native anatomy and improvements in patient outcomes. Although we currently lack the necessary information to provide evidence-based decision making for combined injuries, the time has come to renew both clinical interest and research interest in pursuing better management of these injuries in high-demand patients. [ABSTRACT FROM AUTHOR]

Abstract: The lateral decubitus and beach-chair positions each offer unique benefits to the shoulder surgeon with respect to visualization, efficiency, and ease during arthroscopic shoulder procedures. The purpose of this article was to comprehensively review the reports and studies documenting independent and dependent complications related to patient positioning and anesthesia during arthroscopic shoulder surgery. The lateral decubitus position has been associated with the potential for peripheral neurapraxia, brachial plexopathy, direct nerve injury, and airway compromise. The beach-chair position has been associated with cervical neurapraxia, pneumothorax, and the potential for end-organ hypoperfusion injuries (when deliberate hypotension is used). Potentially concerning are hypotensive bradycardic events, which may be relatively common in association with the use of epinephrine-containing interscalene anesthetics in beach chair–positioned patients. Irrigant complications (fluid spread, ventricular tachycardia) are avoidable risks not unique to either specific position. Although minor transient anesthetic- and position-related complications (neurapraxia, hypotension) may occur in as many 10% to 30% of patients, major complications such as end-organ damage or permanent impairments are exceedingly rare. Regardless of position, complications are almost uniformly avoidable if surgeon and anesthetist exercise care and prudent attention to position and anesthetic choices. The purpose of this article is to review the potential for position- and anesthesia-related complications and acquaint the shoulder surgeon with the proposed pathophysiologic mechanisms that can lead to them. [Copyright &y& Elsevier]

Purpose: To clearly define the anatomic relations that exist in the posterior knee under arthroscopic conditions in a cadaveric model and to describe a technique for an all-arthroscopic posterior capsule release. Methods: Seven cadaveric knees were examined under arthroscopic conditions. After a routine diagnostic arthroscopy of the anterior compartment, posteromedial and posterolateral portals were created, the posterior capsule and septum were released, and the distance from the posterior border of the tibial insertion of the posterior cruciate ligament (PCL) to the popliteal artery was measured under direct arthroscopic visualization after capsulotomy. The distances from the posteromedial arthroscopic portal and lateral arthroscopic portal to the saphenous neurovascular bundle and peroneal nerve, respectively, were evaluated. Results: The mean distance between the PCL and popliteal artery was 19.3 mm (range, 15 to 28 mm; SD, 4.27 mm); between the posteromedial portal and saphenous vein, 22.6 mm (range, 16 to 35 mm; SD, 6.7 mm); and between the posterolateral portal and peroneal nerve, 40 mm (range, 30 to 52 mm; SD, 7.94 mm). Conclusions: When arthroscopic posterior transverse capsulotomy is performed via the author''s technique and with the knee flexed to 90°, there is an adequate safe zone between the popliteal neurovascular structures, peroneal nerve, saphenous neurovascular structures and the posterior capsule, posterolateral and posteromedial portals, respectively (minimum, 15 mm). Clinical Relevance: With a mean distance of 19.3 mm between the PCL and the popliteal artery after capsulotomy, surgeons can feel confident that a safe zone is present for posterior knee arthroscopy. In addition, they can be reassured that posterior portals are safe if created with the knee in the proper position. [Copyright &y& Elsevier]

Summary: Posterior interosseous nerve palsy is a recognized complication of 2-incision distal biceps tendon repair. We hypothesize that intraoperative forearm pronation can cause compression of the posterior interosseous nerve beneath the supinator and arcade of Frohse. Six human male cadaver upper extremities were dissected. Pressure on the posterior interosseous nerve beneath the arcade of Frohse and supinator was measured with a Swan-Ganz catheter connected to a pressure transducer. Pressure was significantly elevated in maximal pronation in all specimens with the elbow in both flexion and extension. Pressures at full pronation were significantly higher than pressures measured at 60° of pronation (5 ± 2 mm Hg in 60° of pronation and 90° of flexion, P < .0001; 7 ± 3 mm Hg in 60° of pronation and extension, P < 005). Maximal pronation can cause increased pressure on the posterior interosseous nerve. The safety of 2-incision distal biceps repair may be increased by avoiding prolonged, uninterrupted periods of hyperpronation. [Copyright &y& Elsevier]

We present a method for single-Achilles allograft medial collateral ligament (MCL) and posterior cruciate ligament (PCL) reconstruction that eliminates the risk of tunnel intersection, stiffens the construct, and maximizes utilization of allograft tissue. An Achilles tendon allograft is prepared with an 11- to 12-mm bone plug with a gradual taper to 7 mm over approximately 15 cm. A transtibial PCL tunnel is created under fluoroscopic and arthroscopic guidance. The femoral tunnel is prepared in an "outside-in" fashion under direct arthroscopic visualization, originating at the anatomic origin of the MCL on the medial epicondyle and entering the joint at the anatomic origin of the anterolateral bundle of the PCL. The Achilles graft is pulled into the joint through the tibial tunnel and routed into the femoral tunnel so that the soft tissue exits at the medial epicondyle. The bone plug is fluoroscopically guided to the posterior aperture of the tibial tunnel and fixed with a bioabsorbable interference screw. The pretensioned graft is fixed in the femoral tunnel via interference screw fixation with the knee in 90 degrees of flexion. The isometric position of the MCL insertion is identified with a K-wire isometer, and the graft is fixed in place at this point by use of an interference screw or screw and washer. [ABSTRACT FROM AUTHOR]

Abstract: We present a method for single–Achilles allograft medial collateral ligament (MCL) and posterior cruciate ligament (PCL) reconstruction that eliminates the risk of tunnel intersection, stiffens the construct, and maximizes utilization of allograft tissue. An Achilles tendon allograft is prepared with an 11- to 12-mm bone plug with a gradual taper to 7 mm over approximately 15 cm. A transtibial PCL tunnel is created under fluoroscopic and arthroscopic guidance. The femoral tunnel is prepared in an “outside-in” fashion under direct arthroscopic visualization, originating at the anatomic origin of the MCL on the medial epicondyle and entering the joint at the anatomic origin of the anterolateral bundle of the PCL. The Achilles graft is pulled into the joint through the tibial tunnel and routed into the femoral tunnel so that the soft tissue exits at the medial epicondyle. The bone plug is fluoroscopically guided to the posterior aperture of the tibial tunnel and fixed with a bioabsorbable interference screw. The pretensioned graft is fixed in the femoral tunnel via interference screw fixation with the knee in 90° of flexion. The isometric position of the MCL insertion is identified with a K-wire isometer, and the graft is fixed in place at this point by use of an interference screw or screw and washer. [Copyright &y& Elsevier]

Introduction: Attributes of femoral condyle and tibial plateau geometry may play a role in the stability of the knee. We studied differences in lateral knee length and radial geometry in ACL-injured and uninjured cohorts. Methods: 185 age- and activity-matched uninjured and non-contact unilateral (uACL)- and bilateral (bACL)-injured groups were included. MRI measurements of the articular cartilage surfaces in the mid-weight-bearing sagittal plane of the lateral compartment evaluated tibial plateau radius of curvature (TPr) and distal femoral radius of curvature (Fr). The Fr was measured at the weight-bearing segment of a best fit logarithmic curve (Fibonacci sequence). Measurements were also made of the maximum distance from anterior to posterior femur perpendicular to the femoral shaft (FAP) and anteroposterior tibial articular length (TPAP). Calculations of Fr:TPr and FAP:TPAP were used to adjust for individual variations in anatomic size. Measurements were made by 3 observers blinded to gender and injury group. Interclass correlation coefficient was performed to assess inter-rater reliability. Two-sampled Student t-tests were used to compare quantitive variables. All data represented a normal distribution. Results: Combined gender: The mean lateral plateau radius of curvature, femoral radius of curvature, and tibial plateau lengths were all significantly smaller in ACL-injured versus non-injured groups (33.6 vs. 37.4mm, p=0.003; 25.1 vs. 24.2mm, p=0.01; 31.4 vs. 33.2mm, p=0.004; respectively). Femoral length was not different between ACL-injured and uninjured groups (p=0.19). Adjusting for size differences, FAP:TPAP was significantly larger in injured versus controls, indicating that the length of the tibial plateau was significantly smaller relative to the femur in injury groups. Gender Groups (Table 1): No significant differences existed between ACL-injured females and uninjured females with respect to femoral length, tibial length, femoral radius, tibial plateau radius or FAP:TPAP. Conversely, compared to uninjured males, ACL-injured males demonstrated significantly smaller tibial plateau radius (41.1 vs. 35.3mm), femoral radius (26.7 vs. 25.5mm), and tibial plateau length (35.5 vs. 33.1mm). No differences existed between femoral length between injured and uninjured males. FAP:TPAP differences suggested that the length of the tibial plateau was significantly shorter relative to the femur in ACL-injured males (p<0.001). Furthermore, after adjusting for size differences, ACL-injured males demonstrated no significant differences than control or injured females with respect to the relative size of the plateau to distal femur (FAP:TPAP) or relative radii of the femur and tibia (Fr:TPr). Conclusion: Our data suggest that all females (injured or uninjured) and ACL-injured males share a common lateral knee geometry characterized by a shorter tibial plateau length relative to the femur and smaller (more convex) articulating surfaces of both the proximal tibia and distal femur. It is possible that the opposition of two highly-convex articulating surfaces may be inherently less stable to anterior tibial translation and rotation. These findings also may help to explain the apparent female predilection for ACL injury compared to males, but suggest that this may be as much driven by geometry as it is by gender. [Copyright &y& Elsevier]