Presented at the 65th Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, March 21, 1998.
MATERIALS AND METHODS
From July 1990 through March 1996, 93 arthroscopic PCL reconstructions were performed by a senior author (S.-J.K.). Patients with combined ligament injuries requiring concomitant operative treatment were excluded in this study. Follow-up more than 24 months was available in 55 patients. From July 1990 through October 1991, the arthroscopically assisted PCL reconstruction using the 2-incision technique was performed in 10 patients (group I). Bone–patellar tendon–bone (BTB) autografts were used
Pre-existing patellofemoral joint disease, patellofemoral maltracking, narrow width of the patellar tendon (<30 mm wide), or poor skin condition may be contraindications to use as a graft source. In this situation, BTB allografts were used. The graft was harvested via a midline incision with an oscillating saw. The patellar bone plug is usually 2 to 2.5 cm long. The bone plug on the tibial side should be 4.5 to 5 cm long because the tibial tunnel for PCL reconstruction is much longer than the
There was no significant difference between the 2 groups with regard to age, sex, timing of operation, combined ligament injury, duration of follow-up, preoperative scales, and measurements. Posterior drawer testing showed 6 patients in group I and 33 patients in group II as grade 1, but the others were negative. Lysholm preoperative mean values were 66.5 in group I and 68.3 in group II. Lysholm postoperative mean values were 90.0 in group I and 90.6 in group II. There was no statistically
A variety of surgical techniques have been developed and performed for PCL injuries, but PCL reconstruction still remains a challenging surgical procedure. Recently, as arthroscopic technology has advanced, many reports have been published on arthroscopic PCL reconstruction.6, 7, 8, 9, 10, 16, 17, 18, 19 Fanelli et al.20 showed satisfactory results of the conventional 2-incision technique with a minimum follow-up of 25 months (Lysholm score: preoperative, 48.2; postoperative, 93.0; and HSS
Variation in Graft Bending Angle During Range of Motion in Single-Bundle Posterior Cruciate Ligament Reconstruction: A 3-Dimensional Computed Tomography Analysis of 2 Techniques
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
To compare variations in femoral graft bending angle during range of motion (ROM) of the knee between inside-out (IO) and retro-socket outside-in (OI) techniques in posterior cruciate ligament (PCL) reconstruction using invivo 3-dimensional (3D) computed tomography analysis.
Ten patients underwent PCL reconstruction by the IO technique (5 patients) or the retro-socket OI technique (5 patients) for suspensory femoral fixation. After PCL reconstruction, 3D computed tomography was performed in 0° extension and 90° flexion to reconstruct 3D femur and tibia bone models using Mimics software. Positions of femur and tibia at 30°, 45°, and 60° flexion were reproduced by determining the kinematic factors of anteroposterior translation, mediolateral translation, and internal-external rotation angle of each patient based on previously measured kinematic data. Variation in graft bending angle according to the flexion range of the knee was calculated by the difference in graft angulation measured at each flexion angle. The results were compared between the 2 techniques.
There was significant difference in variation of femoral graft bending angle between IO and retro-socket OI techniques from 0° to 90° flexion of the knee (P= .008). Significant difference was also noticed at 30° to 45° (P= .008), 45° to 60° (P= .008), and 60° to 90° (P= .016) ROM of the knee between the 2 groups.
The retro-socket OI technique resulted in less variation in femoral graft bending angle compared with the IO technique during knee ROM. We recommend the retro-socket OI technique for femoral tunnel placement to reduce the graft motion at the intra-articular femoral tunnel aperture.
The retro-socket OI technique produces significantly less variation in femoral graft bending angle when compared with the IO technique. Such reduction in variation of femoral graft bending angle might be related to lower stress at the femoral tunnel aperture.
Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities
2006, Arthroscopy - Journal of Arthroscopic and Related Surgery(Video) Dr. Vishal Mehta Presents Posterior Cruciate Ligament Reconstruction
Purpose: The purpose of this study was to evaluate the clinical outcome after 1-stage reconstructions of the anterior and posterior cruciate ligaments (ACL, PCL) with reconstruction of the posterolateral corner (PLC) structures using autogenous hamstring grafts in chronic knee injuries. Type of Study: Prospective case series. Methods: We reviewed 17 patients (13 men and 4 women) with chronic multiligamentous injuries after a minimum follow-up of 2 years (range, 24 to 66.3 months). Arthroscopically assisted combined ACL/PCL reconstructions with autogenous semitendinosus-gracilis tendon grafts were performed using the single-incision endoscopic ACL technique and the single femoral tunnel, single-bundle transtibial tunnel PCL technique. The PLC was reconstructed with a free autogenous semitendinous tendon graft. The primary outcome measures were the International Knee Documentation Committee (IKDC) score and stress radiography. As secondary outcome measure, all patients were evaluated with a subjective questionnaire, physical examination, radiologic assessment, and KT-1000 arthrometer testing. Results: The mean time from injury to the reconstructive procedure was 70.2 ± 96.7 months (range, 5.1 to 312.6 months). At final IKDC evaluation, 4 patients (29.4%) were graded level B (nearly normal), 10 patients (58.8%) level C (abnormal), and 2 patients (11.8%) level D (grossly abnormal). The mean postoperative subjective IKDC score was 71.8 ± 19.3 points. Mean posterior tibial displacement as measured through stress radiography at 90° of knee flexion was reduced from −15.06 ± 4.68 mm preoperatively to −7.12 ± 3.37mm postoperatively (P < .001). Mean anterior tibial displacement was 0.94 ± 2.75 mm preoperatively compared with −1.59 ± 3.50 mm postoperatively (P < .01). Three patients had a fixed posterior tibial subluxation (posterior tibial displacement ≤ −3 mm on anterior stress radiographs) postoperatively. Severe subjective instability was reduced significantly by the operative procedure (P < .001). The mean postoperative total anterior-posterior side-to-side difference with the KT-1000 arthrometer testing was 2.00 ± 2.23 mm (range, −4 to 7 mm). Conclusions: Combined chronic ACL/PCL/PLC instabilities can be successfully treated with 1-stage arthroscopic cruciate ligament reconstruction combined with PLC reconstruction using autogenous hamstring grafts. Although current reconstruction techniques are not able to restore normal tibiofemoral kinematics, most patients recover a functionally stable knee and have considerably improved knee function compared with their preoperative status, based on subjective parameters and objective criteria. Level of Evidence: Level IV, case series, no historical or control group.
Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction
2005, Arthroscopy - Journal of Arthroscopic and Related SurgerySee AlsoWhat Is Sphenopalatine Ganglion Block?Facial Bone Surgery | Dr. Kenneth Kim20 Years Know-How, Jk's Before & After Photographs ㅣ Jk Plastic Surgery Certificated By Korean GovernmentA Comparative Finite Element Analysis of ‘Hexa-Zygomatic’ Implants vs Conventional Quad Zygomatic Implants for The Rehabilitation of Bilateral Maxillectomy Defects
Purpose: The purpose of this study was to evaluate the clinical outcomes after arthroscopic single-bundle posterior cruciate ligament (PCL) reconstruction in patients with isolated grade III PCL injuries. Type of Study: Retrospective review. Methods: Twenty-one patients who underwent an isolated arthroscopic single-bundle PCL reconstruction for the treatment of a grade III PCL injury between 1989 and 1998 were included in the study. There were 15 male and 6 female patients with an average age of 38 years (range, 20 to 62 years). The length of follow-up was 5.9 years (range, 2.6 to 11 years), and the average time from injury to surgery was 4.5 years (median, 1.3 years; range, 2 weeks to 25 years). All patients completed a subjective evaluation and 14 patients returned for a physical examination and radiographs. One patient underwent an acute reconstruction (<3 weeks), 4 had a subacute (<3 months), and 16 underwent a chronic (>3 months) reconstruction. The anterolateral bundle of the PCL was reconstructed using an Achilles tendon allograft passed through femoral and tibial bone tunnels. Results: The overall average Activities of Daily Living Scale (ADLS), Sports Activities Scale (SAS), and SF-36 scores were 79.3, 71.6, and 98 points, respectively. There was a significant difference identified when the ADLS (91.3 v 75.6) and the SAS (90.4 v 65.8) scores of the subacute/acute group were compared with those of the chronic reconstruction group. Using the International Knee Documentation Committee (IKDC) subjective assessment, 57% of the patients had normal/near normal knee function, and 62% had a normal/near normal activity level. The average extension and flexion losses were 1° and 5°, respectively. Instrumented laxity examination revealed that 62% had less than a 3-mm and 31% had a 3- to 5-mm side-to-side difference in corrected posterior displacement. Radiographs at follow-up showed that 75% had normal/near normal findings according to IKDC guidelines. Conclusions: The clinical outcomes after arthroscopic single-bundle PCL reconstruction in this study produced a satisfactory return of function and improvement in symptoms. All patients in this study had improved laxity of at least 1 grade. When compared with chronic reconstructions, acute reconstructions had statistically significant better ADLS and SAS scores. Level of Evidence: IV, case series.
Biomechanical comparisons of three different tibial tunnel directions in posterior cruciate ligament reconstruction
2005, Arthroscopy - Journal of Arthroscopic and Related Surgery
Purpose: To investigate the effects of 3 different tunnel directions on the outcomes of posterior cruciate ligament (PCL) reconstruction surgery based on the forces exerted on the replacement ligament from a biomechanical point of view. The 3 tunnel directions in the proximal tibia are medial, central, and lateral. Type of Study: Biomechanical study. Methods: The forces exerted on the replaced PCL were calculated using finite element analyses as well as measurements from 6 cadavers. The results of the 3 surgical approaches were then compared. In the finite element analyses, the replaced ligament was assumed to have nonlinear elastic as well as viscoelastic properties. To simulate the overload in exercise, the femur was forced to move in the anterior direction abruptly while the tibia was held. From numerical analyses, the resultant forces, von Mises stresses, and maximum shear stresses on the replacement PCLs were calculated and compared. In the cadaveric study, a pressure-sensitive thin film was inserted between the replacement PCL and the killer turn area of the tibia. The color changes in films were evaluated using digital image processing in each case. Results: The medial approach showed remarkably higher stresses and forces on the interface between the replaced PCL and the killer turn in both the numerical and cadaveric study. In contrast, the lateral approach showed the lowest stresses. Conclusions: The numerical and cadaveric studies indicate that the lateral approach is highly promising compared with the other approaches. Clinical Relevance: The lateral approach has been shown to minimize stress concentration around the killer turn during in vitro experiments and a computer simulation of PCL reconstruction for long-term stability. The lateral approach technique appears to provide a promising clinical outcome in patients undergoing PCL reconstruction.
Double-bundle technique: Endoscopic posterior cruciate ligament reconstruction using tibialis posterior allograft
2004, Arthroscopy - Journal of Arthroscopic and Related Surgery
Recently, attention has been given to the double-bundle technique for treating the posterior cruciate ligament (PCL)-deficient knee. We present an arthroscopic PCL reconstruction using a double-bundle technique with 3-stranded tibialis posterior (TP) allograft that has not been described before. The anterolateral bundle of the PCL is reconstructed using 2-stranded TP allograft and the posteromedial bundle using 1-stranded TP allograft. Three-stranded TP allograft will be an alternative graft choice for PCL reconstruction.
Arthroscopic posterior cruciate ligament tibial inlay reconstruction
2004, Arthroscopy - Journal of Arthroscopic and Related Surgery(Video) Posterior Cruciate Ligament and Posterolateral Corner Reconstruction for Failed PCL Repair
Tibial inlay posterior cruciate ligament (PCL) reconstruction was developed to avoid “killer turn” of the tibial tunnel. It requires a surgical dissection to popliteal fossa and changing of the patient’s position during operation. We report an arthroscopic tibial inlay PCL reconstruction technique to avoid morbidity from an open procedure. Achilles tendon-bone allograft was used for reconstruction, and bone plug was designed in a cylindrical shape vertical to the tendon direction for tibial fixation. The intra-articular length of PCL is measured, and the proximal graft is prepared with a whipstitch and an EndoPearl (Linvatec, Largo, FL) is connected for enhancing femoral fixation. After tibial graft fixation with an absorbable interference screw, tibial site fixation was reinforced with suture anchoring to a washer on the anterolateral surface of the tibia. Femoral fixation was done with another screw. It was possible to reproduce the original concept of PCL tibial inlay graft with our arthroscopic technique.
Surgical safety distances in the infratemporal fossa: three-dimensional measurement study
International Journal of Oral and Maxillofacial Surgery, Volume 44, Issue 5, 2015, pp. 555-561
The wedge-shaped infratemporal fossa is a constricted space and has long been a surgical challenge, mainly due to difficulties in access. Three-dimensional (3D) reconstruction of the skull, internal carotid artery (ICA), and internal jugular vein (IJV) was carried out using enhanced computed tomography (CT) data, to measure the safety distances in relation to infratemporal fossa surgery. Fifty enhanced CT datasets were selected to reconstruct 3D images by segmentation technique. The anatomical routes of the ICA, IJV, and the styloid process (SP) were observed. The following were measured: SP length, height of the pterygoid plates (PP height), distances from the pterygoid process (antero-inferior and anterosuperior border) to the leading edge of the ICA (PP–ICA (inferior), PP–ICA (superior)), and distance between the most prominent point of the zygomatic arch and the medial pterygoid plate (Zyg–MPP). The mean measurements of SP length, PP height, and the distances PP–ICA (inferior), PP–ICA (superior), and Zyg–MPP were 30.64mm, 26.61mm, 31.16mm, 34.37mm, and 51.37mm, respectively. No significant differences were observed by age group, except the distance of PP–ICA (inferior) on the left side. In centres without intraoperative navigation facilities, proper knowledge of the anatomy, particularly of bony landmarks and the safe distances to nearby neurovascular structures, can provide useful information to ensure safe operations.
New horizontal v-shaped osteotomy for correction of protrusion of the zygoma and the zygomatic arch in East Asians: indication and results
British Journal of Oral and Maxillofacial Surgery, Volume 52, Issue 7, 2014, pp. 636-640
Protrusion of the zygoma is commonly considered undesirable and unattractive among East-Asians, and many try to achieve a harmonious oval midface by having various cosmetic operations. However, effective contouring for a severe protruding zygoma has rarely been reported .The objectives of this study therefore were to investigate the feasibility and effectiveness of a horizontal V-shaped ostectomy for correction of protrusion of the zygoma and zygomatic arch, and to discuss its indications. From January 2008 to December 2011 we treated 27 patients by contouring of the zygoma with a horizontal V-shaped ostectomy through intraoral and preauricular incisions. The effectiveness was then evaluated with cephalometric radiographs, 3-dimensional computed tomography, and standard facial photographs taken before and after operation. The postoperative appearance of all 27 patients showed that the protrusion had been effectively reduced with no serious complications, and the facial contour had improved. The ﬁnal aesthetic outcomes were satisfactory for both surgeons and patients. The horizontal V-shaped osteotomy is a good technique for the reduction of protrusion of the zygoma and zygomatic arch, and it has the advantages of more convenient multishifting, better results, and fewer complications. It also ensures the integrity of the structure of the malar complex.(Video) The Posterior Cruciate Ligament
Tensor tenopexy: A clinical study to assess its effectiveness in improving Eustachian tube function and preventing hearing loss in patients with cleft palate
Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 66, Issue 9, 2013, pp. e239-e245
There is a consensus about the occurrence of otitis media in children with cleft palate before repair. However, controversy continues regarding the recovery of Eustachian tube function and level of hearing loss in the patients after cleft palate repair. Levator sling palatoplasty is an important component of the cleft repair. Most surgeons would routinely transect the tensor tendon (tensor tenotomy) during the course of palatoplasty. However, this procedure may pose a risk to Eustachian tube function. Some authorities feel that addition of tensor tenopexy during palatoplasty would maintain the Eustachian tube in an open conformation, thereby improving middle ear ventilation. The present study assesses the effectiveness of tensor tenopexy in improving Eustachian tube function and preventing hearing loss in cleft palate patients treated with palatoplasty. A prospective randomised controlled trial was conducted in the Department of Plastic Surgery at a tertiary care institute in India. A total of 17 children in the age group of 9–24 months were assigned to one of two groups: palatoplasty with either tensor tenotomy (n=8) or tensor tenotomy with tensor tenopexy (n=9). All patients were subjected to tympanometry, otoscopy and brainstem evoked response audiometry before surgery and at 3, 6, 9 and 12 months after surgery. Of these, 52.9% of patients already had hearing loss at the time of presentation. Hearing loss and middle ear effusion persisted even after palatoplasty. There was no significant difference in hearing loss and middle ear effusion between the two groups of patients. Thus, tensor tenopexy was not found to be helpful in maintaining Eustachian tube function or preventing hearing loss in cleft palate patients. However, further long-term studies are needed to confirm this study.
Maxillary Posterior Segmentation Using an Oscillating Saw in Le Fort I Posterior or Superior Movement Without Pterygomaxillary Separation
Journal of Oral and Maxillofacial Surgery, Volume 72, Issue 11, 2014, pp. 2289-2294
Any remaining tuberosity or pterygoid plate frequently interferes with posterior or superior movement of the maxilla, if no pterygomaxillary separation is performed in low-level Le Fort I osteotomy. The objective of this report is to describe a technique for maxillary posterior segmentation using an oscillating saw in Le Fort I posterior or superior movement without pterygomaxillary separation and to present the authors' preliminary multicenter experience with this technique.
The authors retrospectively evaluated patients who underwent double-jaw surgery at 3 orthognathic surgery centers from May 2010 to December 2012. In all cases, the segmentation procedure was performed using an oscillating saw on a posterior or tuberosity area of the maxilla before downfracture obtained by leverage alone without pterygomaxillary separation, below or near the lower part of the pterygoid plate.
In total, 1,231 patients (411 male and 820 female; mean age, 24.9 yr) were enrolled. Mean surgical time for the maxillary procedure was 55.9 minutes. None of the patients received a blood transfusion, and no significant soft or hard tissue complications clinically compromised the healing of the repositioned maxilla. Mean maxillary posterior and superior movements were 3.4 mm (range, 2.1 to 5.6 mm) and 4.0 mm (range, 1.3 to 5.6 mm), respectively.
The preliminary results indicate that this maxillary posterior segmentation procedure usingan oscillating saw in low-level stepped Le Fort I osteotomy can be completed safely and effectively for posterior or superior repositioning of the maxilla, with no need to disturb the integrity of the pterygoid plate.
The use of computer-aided design/manufacturing (CAD/CAM) technology to aid in the reconstruction of congenitally deficient pediatric mandibles: A case series
International Journal of Pediatric Otorhinolaryngology, Volume 79, Issue 12, 2015, pp. 2332-2342(Video) Anterior Cruciate Ligament (ACL) Reconstruction Surgery - Explained
Microvascular reconstruction of the pediatric mandible, particularly when necessitated by severe, congenital hypoplasia, presents a formidable challenge. Complex cases, however, may be simplified by computer-aided design/computer-aided manufacturing (CAD/CAM) assisted surgical planning. This series represents the senior authors’ preliminary experiences with CAD/CAM assisted, microvascular reconstruction of the pediatric mandible.
Presented are two patients with hemifacial/bifacial microsomia, both with profound mandibular hypoplasia, who underwent CAD/CAM assisted reconstruction of their mandibles with vascularized fibula flaps. Surgical techniques, CAD/CAM routines employed, complications, and long-term outcomes are reported.
Successful mandibular reconstructions were achieved in both patients with centralization of their native mandibles and augmentation of deficient mandibular subunits. No long-term complications were observed.
CAD/CAM technology can be utilized in pediatric mandibular reconstruction, and is particularly beneficial in cases of profound, congenital hypoplasia requiring extensive, multi-planar, bony reconstructions.
Classification and characteristics of pterygoid process fracture associated with maxillary transverse fracture
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Volume 117, Issue 2, 2014, pp. 243-252
This study aimed to classify pterygoid process fractures associated with maxillary transverse fractures.
Pterygoid process fractures in 100 patients with maxillary transverse fractures were observed 2- and 3-dimensionally using image processing software. Fracture line course and height and sphenoid sinus involvement were recorded.
Pterygoid process fractures were classified as follows: class I, vertical (simple separation between medial and lateral plates); or class II, transverse (3 subcategories according to location of fracture line: II-1, within pterygoid fossa; II-2, above pterygoid fossa, not extending to sphenoid sinus floor; II-3, above pterygoid fossa, involving sphenoid sinus floor). Class I fracture was observed on 5 sides (2.7%); II-1, on 125 (66.5%); II-2, on 36 (19.1%); and II-3, on 22 (1.7%).(Video) Anterior Cruciate Ligament Reconstruction with Neil Bradbury
Pterygoid process fractures were predominantly near the upper edge of the pterygoid fossa. Pneumatization of the pterygoid process is a risk in fractures involving the sphenoid sinus floor.
Copyright © 2000 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.