Combined Assessments of Patellar Tendon and Hamstring Tendon Parameters on Preoperative Magnetic Resonance Imaging Can Improve Predictability of Hamstring Tendon Autograft Diameter in the Setting of Anterior Cruciate Ligament Reconstruction.

PURPOSE: To evaluate whether preoperative magnetic resonance imaging (MRI) measurements of multiple tendon autograft sources could be used to improve estimates of intraoperative hamstring tendon autograft (HTA) diameter. METHODS: Patients who underwent anterior cruciate ligament reconstruction with HTA at our institution were identified through electronic health records. Preoperative MRI tendon measurements of the patellar tendon (PT) length, PT width, PT thickness, quadriceps tendon thickness, semitendinosus tendon (ST) cross-sectional area (CSA), and gracilis tendon (GT) CSA were conducted by 2 independent evaluators using digital imaging measurement tools. RESULTS: A total of 53 patients met the inclusion criteria, with a mean HTA diameter of 7.98 ± 0.7 mm. Height greater than 1.63 m, weight greater than 63.4 kg, PT length greater than 4.2 cm, PT thickness greater than 0.33 cm, ST CSA greater than 10.8 mm2, and GT CSA greater than 6.3 mm2 were associated with an HTA of 8 mm or greater (P < .005). Female sex was associated with an HTA of less than 8 mm (P < .05). PT length, PT thickness, and GT CSA were the strongest predictors of an HTA of 8 mm or greater and were combined into an additive logistic regression model: Score = -23.24 + (1.68 × PT length) + (20.104 × PT thickness) + (1.48 × GT CSA). If the score was greater than 0.237, the HTA graft diameter was predicted to be 8 mm or greater with 83% specificity, 91% sensitivity, and 87% accuracy. CONCLUSIONS: By combining PT length and PT thickness measurements with GT CSA measurements in a logit function model, we were able to show improved overall specificity, sensitivity, and accuracy of estimated HTA diameters in our data set when compared with assessments of anthropometric, ST CSA, GT CSA, or combined ST-GT CSA measurements in isolation. CLINICAL RELEVANCE: Preoperative MRI measurements may be used to screen whether a patient is likely to have an 8-mm graft in the setting of anterior cruciate ligament reconstruction with HTA and thus may help guide graft choice

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

UNLABELLED: Although most patients who undergo anterior cruciate ligament (ACL) reconstruction achieve long-term functional stability and symptom relief, graft rupture rates range from 2% to 10%1,2. A small subset of these patients require a 2-stage revision ACL reconstruction because of tunnel osteolysis or tunnel malposition that will interfere with the planned revision tunnel placement3. In the present article, we describe the hybrid use of arthroscopically delivered injectable allograft matrix in the femur and pre-shaped bone dowels in the tibia for the treatment of lower-extremity bone deficiencies. DESCRIPTION: After induction of anesthesia, approximately 60 cc of bone marrow aspirate is harvested from the anterior iliac crest with use of sterile techniques and is processed to obtain bone marrow aspirate concentrate. Routine diagnostic knee arthroscopy is performed via the standard anterolateral and anteromedial portals. Any additional intra-articular pathology is addressed, followed by excision of the remnant graft material, removal of existing femoral hardware as needed, and exposure of the existing bone tunnels. The femoral tunnel is debrided arthroscopically, removing all soft-tissue remnants. The existing tibial tunnel is exposed via the previous anteromedial tibial incision when possible. Again, any existing tibial hardware is removed. The tibial tunnel is then prepared with use of a combination of sequential reaming and dilation. A shaver and curets are utilized to debride the sclerotic walls of the tunnel and remove the remnant graft material. A cannulated allograft bone dowel is then impacted into place over a guidewire, ensuring that the graft is not proud within the joint space. An injectable bone allograft matrix composite is prepared by manually mixing 5 mL of StimuBlast demineralized bone matrix (Arthrex) and 5 mL of FlexiGraft cortical fibers (Arthrex), along with the previously obtained bone marrow aspirate concentrate. Under dry arthroscopy, this bone graft is delivered into the femoral tunnel via a cannula with use of the anteromedial portal. Finally, a Freer elevator is used to contour the graft at the aperture of the tunnel. Graft osteointegration is mandatory prior to proceeding with the second stage of the procedure. Typically, a minimum 3-month follow-up is necessary to confirm adequate graft incorporation on computed tomography. ALTERNATIVES: As an alternative to the 2-stage procedure, previous studies have suggested the use of a single-stage revision utilizing cylindrical allografts or multiple stacked screws.4-6 In addition, a number of bone allograft and autograft options have been described. Autologous bone graft can be harvested from the ipsilateral iliac crest or proximal aspect of the tibia with use of a variety of techniques7-10. Allograft bone options include cancellous bone chips and commercially available bone matrices or dowels11-14. Finally, another viable option is calcium phosphate bone graft substitutes15. There is a paucity of high-quality studies comparing available bone graft materials for revision ACL reconstruction; thus, no consensus exists regarding the optimal choice16. RATIONALE: A 2-stage approach is typically indicated for cases that demonstrate tunnel enlargement (>12 mm) that would compromise graft fixation or non-anatomic tunnel placement that will interfere with placement of the revision tibial tunnel3. The aim of the first stage is to re-establish adequate bone stock to optimize future tunnel placement and healing of the ACL graft during the second stage. We believe that this 2-stage approach is a reliable and safe method of treating enlarged, irregularly shaped bone tunnel defects while minimizing the risk of complications. Furthermore, the use of allograft material avoids the donor-site morbidity and volume limitations associated with the use of autograft bone. In the case of the femoral tunnel, the injectable bone graft composite has the advantage of being easily delivered arthroscopically while completely filling irregularly shaped tunnels. The use of bone marrow aspirate concentrate may improve the rate of graft healing as well as a hydrating substance to reduce viscosity and facilitate the flow of the bone graft material through the cannula16,17. For the tibia, especially in cases of lengthy tibial bone deficiencies, allograft bone dowels are commercially available off-the-shelf in a variety of different lengths and diameters to allow for adequate fill of bone defects. EXPECTED OUTCOMES: It is well known that outcomes following revision ACL reconstruction are inferior to those following primary ACL reconstruction, with a number of variables, beyond those associated with the surgical technique, influencing clinical outcomes18. Few studies have reported on the results of 2-stage revision ACL reconstruction with use of allograft bone; however, a high rate of allograft bone integration and improved bone quality at the time of revision ACL reconstruction have been reported13. Moreover, Mitchell et al. reported no differences in either subjective outcomes or failure rates between the 1-stage and 2-stage revision ACL reconstruction groups11. IMPORTANT TIPS: Utilize computed tomography for preoperative assessment and measurement of the extent of osteolysis.If possible, obtain the operative report for the index ACL procedure in order to identify any preexisting hardware and to obtain any instrumentation that may be needed to facilitate hardware removal.Multiple bone dowel sizes are available off the shelf.A 70° arthroscope can aid in visualization of the entire tibial and femoral tunnel.Although the bone graft matrix can be injected while the joint is filled with irrigation fluid, we find it easier to administer the graft under dry arthroscopic conditions.Place the scope inside the tibial tunnel to confirm appropriate removal of soft tissue and hardware. Circumferential native cancellous bone should be visualized.It is acceptable to retain previous hardware if it does not interfere with the new tunnel placement.Utilize prior incisions to access the tibial tunnel.Do not underestimate the amount of bone graft needed for each tunnel.Avoid excessive force during impaction of the dowels. ACRONYMS AND ABBREVIATIONS: ACLR = Anterior cruciate ligament reconstructionBMAC = Bone marrow aspirate concentrateMRI = Magnetic resonance imagingCT = Computed tomographyBTB = Bone-patellar tendon-boneDVT = Deep vein thrombosisROM = Range of motion

Surgical Hip Dislocation and Fresh Osteochondral Allograft Transplantation for Femoroacetabular Impingement and Concomitant Chondral Lesion

Chondral lesions of the hip in young patients are frequently associated with additional articular pathology. Parafoveal osteochondral lesions have been reported to be a manifestation of cam lesions in the setting of femoroacetabular impingement (FAI). Although arthroscopic surgery is useful to treat intra- and extra-articular pathology, large lesions located in areas that are difficult to access represent a limitation of the technique. Open surgical dislocation and osteochondral allograft transplantation (OCA) allow treatment of larger surface areas and underlying morphologic abnormalities such as cam lesions. We present our technique for open surgical dislocation of the hip through a stepped trochanteric osteotomy, osteochondral transplantation of fresh-stored femoral head allograft, and osteoplasty of the head/neck junction

Surgical Hip Dislocation and Fresh Osteochondral Allograft Transplantation for Femoroacetabular Impingement and Concomitant Chondral Lesion

Chondral lesions of the hip in young patients are frequently associated with additional articular pathology. Parafoveal osteochondral lesions have been reported to be a manifestation of cam lesions in the setting of femoroacetabular impingement (FAI). Although arthroscopic surgery is useful to treat intra- and extra-articular pathology, large lesions located in areas that are difficult to access represent a limitation of the technique. Open surgical dislocation and osteochondral allograft transplantation (OCA) allow treatment of larger surface areas and underlying morphologic abnormalities such as cam lesions. We present our technique for open surgical dislocation of the hip through a stepped trochanteric osteotomy, osteochondral transplantation of fresh-stored femoral head allograft, and osteoplasty of the head/neck junction

Penetración de la cortical anterolateral en fracturas de fémur proximal tratadas con clavos endomedulares cortos Reporte de dos casos. [Penetration of anterior-lateral cortex in proximal femur fractures treated with short intramedullary nails Report of two cases].

Penetración de la cortical anterolateral en fracturas de fémur proximal tratadas con clavos endomedulares cortos Reporte de dos caso

Microfracture for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Survey of International Cartilage Regeneration & Joint Preservation Society.

OBJECTIVE: The purpose of this study was to describe the current practice trends for managing symptomatic cartilage lesions of the knee with microfracture among ICRS (International Cartilage Regeneration & Joint Repair Society) members. DESIGN: A 42-item electronic questionnaire was sent to all ICRS members, which explored indications, surgical technique, postoperative management, and outcomes of the microfracture procedure for the treatment of symptomatic, full thickness chondral and osteochondral defects of the knee. Responses were compared between surgeons from different regions and years of practice. RESULTS: A total of 385 surgeons answered the questionnaire. There was a significant difference noted in the use of microfracture among surgeons by region (P < 0.001). There was no association between the number of years in practice and the self-reported proportion of microfracture cases performed (P = 0.37). Fifty-eight subjects (15%) indicated that they do not perform microfracture at all. Regarding indication for surgery, 56% of surgeons would limit their indication of microfracture to lesions measuring 2 cm2 or less. Half of the surgeons reported no upper age or body mass index limit. Regarding surgical technique, 90% of surgeons would recommend a formal debridement of the calcified layer and 91% believe it is important to create stable vertical walls. Overall, 47% of surgeons use biologic augmentation, with no significant difference between regions (P = 0.35) or years of practice (P = 0.67). Rehabilitation protocols varied widely among surgeons. CONCLUSIONS: Indications, operative technique, and rehabilitation protocols utilized for patients undergoing microfracture procedures vary widely among ICRS members. Regional differences and resources likely contribute to these practice pattern variations

Penetración de la cortical anterolateral en fracturas de fémur proximal tratadas con clavos endomedulares cortos: Reporte de dos casos

Penetración de la cortical anterolateral en fracturas de fémur proximal tratadas con clavos endomedulares cortos Reporte de dos caso

Mitral Regurgitation After Transcatheter Aortic Valve Replacement: Prognosis, Imaging Predictors, and Potential Management.

This study sought to analyze the clinical impact of the degree and improvement of mitral regurgitation in TAVR recipients, validate the main imaging determinants of this improvement, and assess the potential candidates for double valve repair with percutaneous techniques. Many patients with severe aortic stenosis present with concomitant mitral regurgitation (MR). Cardiac imaging plays a key role in identifying prognostic factors of MR persistence after transcatheter aortic valve replacement (TAVR) and for planning its treatment. A total of 1,110 patients with severe aortic stenosis from 6 centers who underwent TAVR were included. In-hospital to 6-month follow-up clinical outcomes according to the degree of baseline MR were evaluated. Off-line analysis of echocardiographic and multidetector computed tomography images was performed to determine predictors of improvement, clinical outcomes, and potential percutaneous alternatives to treat persistent MR. Compared with patients without significant pre-TAVR MR, 177 patients (16%) presented with significant pre-TAVR MR, experiencing a 3-fold increase in 6-month mortality (35.0% vs. 10.2%; p 35.5 mm (odds ratio: 9.0; 95% confidence interval: 3.2 to 25.3; p  Significant MR is not uncommon in TAVR recipients and associates with greater mortality. In more than one-half of patients, the degree of MR improves after TAVR, which can be predicted by characterizing the mitral apparatus with multidetector computed tomography. According to standardized imaging criteria, at least 1 in 10 patients whose MR persists after TAVR could benefit from percutaneous mitral procedures, and even more could be treated with MitraClip after dedicated pre-imaging evaluation