- Email: [email protected]
Enveloping of Periosteum on the Hamstring Tendon Graft in Anterior Cruciate Ligament Reconstruction (SS-69)
Arthroscopy: The Journal of Arthroscopic & Related Surgery Online
Mark D. Miller, M.D.
Charlottesville, VA Alex J. Kline, B.S.
Charlottesville Joel Gonzales, M.D.
Richmond William R. Beach, M.D.
Richmond Quadriceps Tendon Graft for Posterior Cruciate Ligament REconstruction (SS-68) The PCL has historically been reconstructed with Achilles allograft or patella tendon autograft. Recently, the quadriceps tendon was described as a PCL graft where the bone plug was fixed on the femoral side. We present a technique that uses a 12 mm wide by 7 mm thick quadriceps tendon autograft. The bone plug is fixed posteriorly in the tibia and the tendon end split and fixed in the femur in a two tunnel technique. Fixation is with bioabsorbable screws. The 450 slope of the proximal tibia fits flush with the posterior cortex of the tibia and tendon fibers are protected from the tibial “killer angle” similar to a posterior onlay graft. The tendon is large enough to provide adequate bulk for a PCL graft. Our four year experience with the quadriceps tendon has produced good early results when assessed by posterior stress radiographs.
Walter R. Shelton, M.D.
Jackson,, MS Anna Laura Bomboy, B.S.
Jackson Enveloping of Periosteum on the Hamstring Tendon Graft in Anterior Cruciate Ligament Reconstruction (SS-69) Purpose: Tendon-bone incorporation of a tendon graft within the bone tunnel is a major concern when using tendon graft for ligament reconstruction. Periosteum consists of multipotent steml cells to form osteogenic and chondrogenic tissues. From our histological and biomechanical studies in animal, superior healing process and stronger healing strength could be achieved when periosteum is sutured on the tendon inserted within a bone tunnel. We applied this idea on the ACL reconstruction to enhance tendon-bone healing in ACL reconstruction with hamstring tendon graft. Materials and methods: A quadruple-stranded hamstring tendon graft is used. A piece of periosteum, 3 cm x 3 cm, harvested from the anterior cortex of proximal tibia, is split into two rectangle flaps with size of 1.5 cm x 3 cm each. The periosteum flaps are wrapped and sutured around the tendon graft at the portions near the femoral and tibial tunnel openings. The cambium layer is faced outside to the bone tunnel. Results: This technique has been used in 13 patients with follow-up of more than 12 months. 12 of 13 patients
http://www2.us.elsevierhealth.com/inst/serve?art...b&arttype=full&group=Scientific+Program+Abstract (53 of 64) [11/16/2007 9:18:42 AM]
Arthroscopy: The Journal of Arthroscopic & Related Surgery Online
(92%) could return to the same or higher level of pre-injury sports activity. Overall outcome of IKDC rating was normal or nearly normal in 12 patients (92%). Average Lysholm knee scores were 94 points. Bone tunnels enlargement of 1 mm was identified in 1 femoral tunnel (8%) and in 1 tibial tunnel (8%). Conclusion: Periosteum is easy to harvest from proximal tibia that is routine incision for hamstring tendons harvesting. Besides the potential for enhancement of tendon-bone healing, enveloped-periosteum can aid to seal off the intraarticular tunnel opening in a very early period to avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be decreased.
Chih-Hwa Chen, M.D.
Kweishan, Taoyuan Wen-Jer Chen, M.D.
Taoyuan Chen-Hsiung Shih, M.D.
Taoyuan Navigational Assistance in Positioning the Femoral and Tibial Tunnels in Anterior Cruciate Ligament Replacement (SS-70) Revision operations demonstrate that incorrect positioning of the drilling tunnels is the most frequent source of error in unsuccessful cruciate ligament therapy. Many authors (Päßler, Stäubli and others) recommend obligatory x-ray monitoring of the placement of the Kirschner wires. However, this represents a significant obstacle to the progress of the operation in many surgical departments. Many out-patient operating centres do not have image intensifiers (C-arms) available. It is certainly true that many experienced surgeons can achieve good results relying on their experience and suitable targeting equipment. However, a statistic in Germany shows that 70% of all cruciate ligament operations are performed by surgeons who perform fewer than 30 replacements per year. This cannot in any way be considered as constituting adequate experience. Increasingly, attempts are being made to replace the C-arms with computerised navigation as an aid to surgery. In my opinion, performing this operation with robotic equipment is not the right solution, since the robot does not appropriately take account of and protect many anatomical structures, such as the pes anserinus and the posterior cruciate ligament, during the surgical procedure. This paper describes navigational assistance for laying the drilling tunnels. Firstly, landmarks are entered in the operating theatre on normal x-ray images for system orientation. Then corresponding points in the knee joint are palpated. These are the tibial anterior margin, PCL, the medial and lateral fossa wall, the anterior edge, the anterior horn of the lateral meniscus, the connecting line between the anterior horn of the lateral meniscus and the medial intercondylar eminence as well as the anterior edge of the fossa. The tibial tuberosity and the dorsal limit of the tibial head at the height of the posterior horn of the medial meniscus are also palpated. The position of the tibial targeting device is monitored via infra-red cameras, so that the tibial exit point in the tibial plateau can be established with certainty. In navigation of the femur, the posterior edge of the fossa and the 10 and 11 o’clock positions (or the 1 and 2 o’clock positions respectively) are determined first, followed by the anterior rim of the fossa, in order to make certain here too of hitting the anatomical attachment point of the anterior cruciate ligament on the femur. After extensive trials, computerised navigation of targeting equipment has proved to be a good aid even for the experienced surgeon. Once the learning curve has been passed, the extra time required is less than 5 minutes. The http://www2.us.elsevierhealth.com/inst/serve?art...b&arttype=full&group=Scientific+Program+Abstract (54 of 64) [11/16/2007 9:18:42 AM]
Mark D. Miller, M.D.
Charlottesville, VA Alex J. Kline, B.S.
Charlottesville Joel Gonzales, M.D.
Richmond William R. Beach, M.D.
Richmond Quadriceps Tendon Graft for Posterior Cruciate Ligament REconstruction (SS-68) The PCL has historically been reconstructed with Achilles allograft or patella tendon autograft. Recently, the quadriceps tendon was described as a PCL graft where the bone plug was fixed on the femoral side. We present a technique that uses a 12 mm wide by 7 mm thick quadriceps tendon autograft. The bone plug is fixed posteriorly in the tibia and the tendon end split and fixed in the femur in a two tunnel technique. Fixation is with bioabsorbable screws. The 450 slope of the proximal tibia fits flush with the posterior cortex of the tibia and tendon fibers are protected from the tibial “killer angle” similar to a posterior onlay graft. The tendon is large enough to provide adequate bulk for a PCL graft. Our four year experience with the quadriceps tendon has produced good early results when assessed by posterior stress radiographs.
Walter R. Shelton, M.D.
Jackson,, MS Anna Laura Bomboy, B.S.
Jackson Enveloping of Periosteum on the Hamstring Tendon Graft in Anterior Cruciate Ligament Reconstruction (SS-69) Purpose: Tendon-bone incorporation of a tendon graft within the bone tunnel is a major concern when using tendon graft for ligament reconstruction. Periosteum consists of multipotent steml cells to form osteogenic and chondrogenic tissues. From our histological and biomechanical studies in animal, superior healing process and stronger healing strength could be achieved when periosteum is sutured on the tendon inserted within a bone tunnel. We applied this idea on the ACL reconstruction to enhance tendon-bone healing in ACL reconstruction with hamstring tendon graft. Materials and methods: A quadruple-stranded hamstring tendon graft is used. A piece of periosteum, 3 cm x 3 cm, harvested from the anterior cortex of proximal tibia, is split into two rectangle flaps with size of 1.5 cm x 3 cm each. The periosteum flaps are wrapped and sutured around the tendon graft at the portions near the femoral and tibial tunnel openings. The cambium layer is faced outside to the bone tunnel. Results: This technique has been used in 13 patients with follow-up of more than 12 months. 12 of 13 patients
http://www2.us.elsevierhealth.com/inst/serve?art...b&arttype=full&group=Scientific+Program+Abstract (53 of 64) [11/16/2007 9:18:42 AM]
Arthroscopy: The Journal of Arthroscopic & Related Surgery Online
(92%) could return to the same or higher level of pre-injury sports activity. Overall outcome of IKDC rating was normal or nearly normal in 12 patients (92%). Average Lysholm knee scores were 94 points. Bone tunnels enlargement of 1 mm was identified in 1 femoral tunnel (8%) and in 1 tibial tunnel (8%). Conclusion: Periosteum is easy to harvest from proximal tibia that is routine incision for hamstring tendons harvesting. Besides the potential for enhancement of tendon-bone healing, enveloped-periosteum can aid to seal off the intraarticular tunnel opening in a very early period to avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be decreased.
Chih-Hwa Chen, M.D.
Kweishan, Taoyuan Wen-Jer Chen, M.D.
Taoyuan Chen-Hsiung Shih, M.D.
Taoyuan Navigational Assistance in Positioning the Femoral and Tibial Tunnels in Anterior Cruciate Ligament Replacement (SS-70) Revision operations demonstrate that incorrect positioning of the drilling tunnels is the most frequent source of error in unsuccessful cruciate ligament therapy. Many authors (Päßler, Stäubli and others) recommend obligatory x-ray monitoring of the placement of the Kirschner wires. However, this represents a significant obstacle to the progress of the operation in many surgical departments. Many out-patient operating centres do not have image intensifiers (C-arms) available. It is certainly true that many experienced surgeons can achieve good results relying on their experience and suitable targeting equipment. However, a statistic in Germany shows that 70% of all cruciate ligament operations are performed by surgeons who perform fewer than 30 replacements per year. This cannot in any way be considered as constituting adequate experience. Increasingly, attempts are being made to replace the C-arms with computerised navigation as an aid to surgery. In my opinion, performing this operation with robotic equipment is not the right solution, since the robot does not appropriately take account of and protect many anatomical structures, such as the pes anserinus and the posterior cruciate ligament, during the surgical procedure. This paper describes navigational assistance for laying the drilling tunnels. Firstly, landmarks are entered in the operating theatre on normal x-ray images for system orientation. Then corresponding points in the knee joint are palpated. These are the tibial anterior margin, PCL, the medial and lateral fossa wall, the anterior edge, the anterior horn of the lateral meniscus, the connecting line between the anterior horn of the lateral meniscus and the medial intercondylar eminence as well as the anterior edge of the fossa. The tibial tuberosity and the dorsal limit of the tibial head at the height of the posterior horn of the medial meniscus are also palpated. The position of the tibial targeting device is monitored via infra-red cameras, so that the tibial exit point in the tibial plateau can be established with certainty. In navigation of the femur, the posterior edge of the fossa and the 10 and 11 o’clock positions (or the 1 and 2 o’clock positions respectively) are determined first, followed by the anterior rim of the fossa, in order to make certain here too of hitting the anatomical attachment point of the anterior cruciate ligament on the femur. After extensive trials, computerised navigation of targeting equipment has proved to be a good aid even for the experienced surgeon. Once the learning curve has been passed, the extra time required is less than 5 minutes. The http://www2.us.elsevierhealth.com/inst/serve?art...b&arttype=full&group=Scientific+Program+Abstract (54 of 64) [11/16/2007 9:18:42 AM]