Anatomic Outside-In Anterior Cruciate Ligament Reconstruction Using a Suspension Device for Femoral Fixation

Cortical suspension is one of the most frequently used methods of femoral fixation in anterior cruciate ligament reconstruction. We present a simple technique for anterior cruciate ligament reconstruction using a suspension device for femoral fixation. The purposes of this technique are to ensure greater contact between the graft and the tunnel walls—a goal that is achieved by using the femoral fixation device with the shortest possible loop—to avoid the flip step and the need for hyperflexion, and in short, to minimize the risk of complications that can occur when using the anteromedial portal to drill the femoral tunnel. To this end, both the femoral and tibial tunnels are created in an outside-in manner and with the same guide. The graft is passed through in a craniocaudal direction, and the suspension device is fitted inside an expansion piece for a better adaptation to the femoral cortex

Posterior Cruciate Ligament Reconstruction With Hamstring Tendons Using a Suspensory Device for Tibial Fixation and Interference Screw for Femoral Fixation

A technique for posterior cruciate ligament reconstruction is presented. Autologous hamstring tendons are selected as a graft. An interference screw is used for femoral fixation. A suspension device is used for tibial fixation to bring the fixation closer to the articular end of the tibial tunnel. Single diameter tunnels of the same diameter as the graft are created in an outside-in direction

The Finochietto Sign as a Pathognomonic Finding of Ramp Lesion of the Medial Meniscus

Ramp lesions are considered hidden injuries of the medial meniscus and are very difficult to diagnose. The Finochietto jump sign is a very specific finding that could be considered pathognomonic regarding ramp lesions. This sign consists of a sudden jerk that appears when the free edge of the posterior horn of the medial meniscus is dislocated anteriorly due to the medial condyle interposition when an anterior drawer test is performed on a knee with a ramp lesion, especially when it is associated with an anterior cruciate ligament tear. In this technical note, the Finochietto sign is described clinically, is correlated with its exploration under anesthesia, and is described for the first time under arthroscopic examination in the case of a ramp lesion, in which this finding can help to the diagnosis when present, especially when associated with anterior cruciate ligament tears

Associated Reconstruction of Anterior Cruciate and Anterolateral Ligaments With Single Asymmetric Hamstring Tendons Graft

The anterior cruciate ligament (ACL) rupture is a common disease that accounts for 250,000 cases/year in the United States. The anterolateral ligament (ALL) has been suggested to be an important restraint for rotational instability, and its reconstruction provides a reinforcement to the ACL reconstruction in this aspect, especially in high-demand athletes and in knees with high-grade pivot shift. Different techniques for associated ACL and ALL reconstruction have been described, but the ideal technique remains unclear. Several facts of these techniques may entail a concern to the surgeon, such as the need for several grafts or several bone tunnels. A technique for associated ACL and ALL is presented, using a single hamstring tendons graft, which is prepared asymmetrically, leaving one-third of the length with single diameter and two-thirds with double diameter. A single femoral tunnel is created, using a screw for fixation and differentiation of the grafts. A suspension device is used for tibial fixation, allowing for length adjustment according to the graft's length. The objective of this Technical Note is to provide the orthopaedic surgeon with a resource for ACL and ALL reconstruction even with relatively short grafts, saving bone stock and avoiding the need for allografts

Anterior Cruciate Ligament Reconstruction Using Combined Graft of Hamstring and Fascia Lata With Extra-articular Tenodesis. A Technique in Case of Insufficient Hamstrings

A technique for augmentation of the anterior cruciate ligament (ACL) with hamstring graft and lateral extra-articular tenodesis is presented. The patient is positioned supine with the knee flexed 90°. First, intra-articular injuries are addressed arthroscopically, and then autologous hamstring tendons are harvested and measured; the present technique is a resource for cases with a very small graft diameter (less than 8 mm), due to thin tendons or to tendon breakage, even after tripling the hamstring graft, which is prepared using a facia lata strip long enough to fit the lengths of the femoral tunnel, the anterior cruciate ligament graft, and the tibial tunnel. A single femoral tunnel is performed and only 2 interference screws are needed for fixation

Physeal Sparing Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients Bridging the Tibial Physis With Two Divergent Tunnels

A technique for anterior cruciate ligament (ACL) reconstruction in patients with open physis is presented. The patient is positioned supine with the knee flexed 90°. After intraarticular injuries are addressed, an autologous hamstring graft is harvested and prepared using a suspension device attached in its expansion device. All-epiphyseal femoral and tibial tunnels of the same diameter of the graft are created; both of them are drilled in an outside-in direction, sparing the physis under radioscopic control. A second divergent tibial tunnel of the same diameter of the graft, distal to the physis, is created in an outside-in, mediolateral, and craniocaudal direction, leaving a 1-cm bone bridge between the 2 tibial tunnels. The graft is passed through the all-epiphyseal tunnels, from femoral to tibial, and pulled until the suspension device leans on the lateral femoral cortex. The graft is passed through the second divergent tibial tunnel and fixed in it with an interference screw to move the pressure away from the physis

Transosseous Posterior Meniscal Root Reinsertion Using Knotless Anchor for Tibial Fixation

A technique for posterior meniscal root reinsertion is presented. With the arthroscope in the central transtendinous portal for a better view, a 5-mm transtibial tunnel is created with the aid of an anterior cruciate ligament guide open to 45°. A suture device, which consists of a long needle with an eyelet on its tip, is introduced through the tunnel with a suture thread inserted through the eyelet, while the meniscus is stabilized with a grasper inserted through the anterior portal. The meniscus is pierced with the device, and the suture thread is recovered with said grasper. A finger-tip pincer is inserted through the tunnel to recover the thread. The same procedure is followed to perform a second stitch. A lasso loop is made for both stitches, and the resultant tails are knotted to a knotless suture anchor, which is inserted in the anterior cortex of the tibia, 1 cm distal to the extra-articular end of the tibial tunnel

“Over the Top” Augmentation for Partial Anterior Cruciate Ligament Tears Using Suspension Device for Tibial Fixation

A technique for augmentation of the partial anterior cruciate ligament is presented. The patient is positioned supine with the knee flexed 90°. After addressing intra-articular injuries, the autologous semitendinosus tendon is harvested and measured in a doubled manner; after that, the tibial tunnel is performed in the outside-in direction, of the same diameter of the doubled graft. Both ends of the graft are sutured together, after inserting it through the loop of a suspension device, which is attached in its augmentation piece. A lateral femoral incision is made, to approach the joint through the “over the top” position. A looped thread is introduced inside the joint with the aid of a hook. This thread pulls the graft's sutures through the “over the top” position. A femoral tunnel is then drilled in the lateromedial and caudocranial direction. The suspension device is attached to the anterior tibial cortex and the graft is pulled in the caudocranial direction to the femoral tunnel, where an interference screw is used for fixation