Brian Forsythe

The Location of Femoral and Tibial Tunnels in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Analyzed by Three-Dimensional Computed Tomography Models

BACKGROUND Characterization of the insertion site anatomy in anterior cruciate ligament reconstruction has recently received increased attention in the literature, coinciding with a growing interest in anatomic reconstruction. The purpose of this study was to visualize and quantify the position of anatomic anteromedial and posterolateral bone tunnels in anterior cruciate ligament reconstruction with use of novel methods applied to three-dimensional computed tomographic reconstruction images. METHODS Careful arthroscopic dissection and anatomic double-bundle anterior cruciate ligament tunnel drilling were performed with use of topographical landmarks in eight cadaver knees. Computed tomography scans were performed on each knee, and three-dimensional models were created and aligned into an anatomic coordinate system. Tibial tunnel aperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau. The femoral tunnel aperture centers were measured in anatomic posterior-to-anterior and proximal-to-distal directions and with the quadrant method (relative to the femoral notch). RESULTS The centers of the tunnel apertures for the anteromedial and posterolateral tunnels were located at a mean (and standard deviation) of 25% +/- 2.8% and 46.4% +/- 3.7%, respectively, of the anterior-to-posterior tibial plateau depth and at a mean of 50.5% +/- 4.2% and 52.4% +/- 2.5% of the medial-to-lateral tibial plateau width. On the medial wall of the lateral femoral condyle in the anatomic posterior-to-anterior direction, the anteromedial and posterolateral tunnels were located at 23.1% +/- 6.1% and 15.3% +/- 4.8%, respectively. The proximal-to-distal locations were at 28.2% +/- 5.4% and 58.1 +/- 7.1%, respectively. With the quadrant method, anteromedial and posterolateral tunnels were measured at 21.7% +/- 2.5% and 35.1% +/- 3.5%, respectively, from the proximal condylar surface (parallel to the Blumensaat line), and at 33.2% +/- 5.6% and 55.3% +/- 5.3% from the notch roof (perpendicular to the Blumensaat line). Intraobserver and interobserver reliability was high, with small standard errors of measurement. CONCLUSIONS This cadaver study provides reference data against which tunnel position in anterior cruciate ligament reconstruction can be compared in future clinical trials.

Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography.

BACKGROUND Transtibial drilling techniques are widely used for arthroscopic reconstruction of the anterior cruciate ligament, most likely because they simplify femoral tunnel placement and reduce surgical time. Recently, however, there has been concern that this technique results in nonanatomically positioned bone tunnels, which may cause abnormal knee function. The purpose of this study was to use three-dimensional computed tomography models to visualize and quantify the positions of femoral and tibial tunnels in patients who underwent traditional transtibial single-bundle reconstruction of the anterior cruciate ligament and to compare these positions with reference data on anatomical tunnel positions. METHODS Computed tomography scans were performed on thirty-two knees that had undergone transtibial single-bundle reconstruction of the anterior cruciate ligament. Three-dimensional computed tomography models were aligned into an anatomical coordinate system. Tibial tunnel aperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau. Femoral tunnel aperture centers were measured in anatomic posterior-to-anterior and proximal-to-distal directions and with the quadrant method. These measurements were compared with reference data on anatomical tunnel positions. RESULTS Tibial tunnels were located at a mean (and standard deviation) of 48.0% +/- 5.5% of the anterior-to-posterior plateau depth and a mean of 47.8% +/- 2.4% of the medial-to-lateral plateau width. Femoral tunnels were measured at a mean of 54.3% +/- 8.3% in the anatomic posterior-to-anterior direction and at a mean of 41.1% +/- 10.3% in the proximal-to-distal direction. With the quadrant method, femoral tunnels were measured at a mean of 37.2% +/- 5.5% from the proximal condylar surface (parallel to the Blumensaat line) and at a mean of 11.3% +/- 6.6% from the notch roof (perpendicular to the Blumensaat line). Tibial tunnels were positioned medial to the anatomic posterolateral position (p < 0.001). Femoral tunnels were positioned anterior to both anteromedial and posterolateral anatomic tunnel locations (p < 0.001 for both). CONCLUSIONS AND CLINICAL RELEVANCE Transtibial anterior cruciate ligament reconstruction failed to accurately place femoral and tibial tunnels within the native anterior cruciate ligament insertion site. If anatomical graft placement is desired, transtibial techniques should be performed only after careful identification of the native insertions. If anatomical positioning of the femoral tunnel cannot be achieved, then an alternative approach may be indicated.

Application of the Anatomic Double-Bundle Reconstruction Concept to Revision and Augmentation Anterior Cruciate Ligament Surgeries

Anatomy is the basis of orthopaedic surgery. Our approach to anterior cruciate ligament reconstruction surgery is governed by this principle. In this article, we describe the concept of anatomic anterior cruciate ligament reconstruction as well as its application to single and double-bundle anterior cruciate ligament reconstruction, revision anterior cruciate ligament surgery, and anteromedial and posterolateral-bundle anterior cruciate ligament augmentation surgery. Traditional single-bundle anterior cruciate ligament reconstruction has been shown to achieve good-to-excellent results in only 60% of patients1. As many as 20% to 30% of athletes fail to achieve their previous level of performance, suggesting that there is room for improvement. Because of this high failure rate, we have been driven to explore alternative reconstruction techniques. Our goal is to restore the native anatomy, which we believe will result in superior outcomes and performance levels. Double-bundle anterior cruciate ligament reconstruction is an application of the concept of anatomic reconstruction. Since the native anterior cruciate ligament is composed of two functional bundles, we believe that it is crucial to restore the function of both. The anteromedial bundle is the main contributor to anterior-posterior stability, while the posterolateral bundle mainly controls rotational stability, especially in deep knee flexion2,3. Cadaver biomechanical studies demonstrate that single-bundle reconstruction fails to restore the rotational stability of the knee4, whereas double-bundle anterior cruciate ligament reconstruction effectively restores rotational stability5. Recent Level-I and II short-term studies6-11 also suggest that double-bundle anterior cruciate ligament reconstruction results in superior clinical outcomes. ### Definition of Failure of Anterior Cruciate Ligament Reconstruction We define failure of anterior cruciate ligament reconstruction by both objective and subjective parameters. Objectively, a knee lacking 10° of extension or 10° of flexion or a knee that demonstrates instability and giving-way is considered a failure. Furthermore, we recognize that a patients perception of failure …

Individual Skill Progression on a Virtual Reality Simulator for Shoulder Arthroscopy: A 3-Year Follow-up Study

Background Previous studies have demonstrated a correlation between surgical experience and performance on a virtual reality arthroscopy simulator but only provided single time point evaluations. Additional longitudinal studies are necessary to confirm the validity of virtual reality simulation before these teaching aids can be more fully recommended for surgical education. Hypothesis Subjects will show improved performance on simulator retesting several years after an initial baseline evaluation, commensurate with their advanced surgical experience. Study Design Controlled laboratory study. Methods After gaining further arthroscopic experience, 10 orthopaedic residents underwent retesting 3 years after initial evaluation on a Procedicus virtual reality arthroscopy simulator. Using a paired t test, simulator parameters were compared in each subject before and after additional arthroscopic experience. Subjects were evaluated for time to completion, number of probe collisions with the tissues, average probe velocity, and distance traveled with the tip of the simulated probe compared to an optimal computer-determined distance. In addition, to evaluate consistency of simulator performance, results were compared to historical controls of equal experience. Results Subjects improved significantly (P < .02 for all) in the 4 simulator parameters: completion time (−51 %), probe collisions (−29%), average velocity (+122%), and distance traveled (−;32%). With the exception of probe velocity, there were no significant differences between the performance of this group and that of a historical group with equal experience, indicating that groups with similar arthroscopic experience consistently demonstrate equivalent scores on the simulator. Conclusion Subjects significantly improved their performance on simulator retesting 3 years after initial evaluation. Additionally, across independent groups with equivalent surgical experience, similar performance can be expected on simulator parameters; thus it may eventually be possible to establish simulator benchmarks to indicate likely arthroscopic skill. Clinical Relevance These results further validate the use of surgical simulation as an important tool for the evaluation of surgical skills.

Return to sport after ACL reconstruction

Objective guidelines permitting safe return to sport following anterior cruciate ligament (ACL) reconstruction are infrequently used. The purpose of this study was to determine the published return to sport guidelines following ACL reconstruction in Level I randomized controlled trials. A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Level I randomized controlled trials were included if they reported a minimum 2-year follow-up after ACL reconstruction and return to sport criteria. Outcomes analyzed were the timing of initiation of return to sport, follow-up duration, and use of quantitative/qualitative criteria to determine return to sport. Forty-nine studies were included (N=4178; 68% male; mean patient age, 27.5±3.2 years; mean follow-up, 3.0±1.9 years; mean time from injury to reconstruction, 379±321 days). Ninety-six percent of reconstructions used autograft and 87% were single-bundle reconstructions. Lysholm score, single-leg hop, isokinetic strength, and KT-1000 or KT-2000 arthrometer (MEDmetric, San Diego, California) testing were performed in 67%, 31%, 31%, and 82% of studies, respectively. Only 5 studies reported whether patients were able to successfully return to sport. Ninety percent and 65% of studies failed to use objective criteria or any criteria, respectively, to permit return to sport. Description of permission/allowance to return to sport was highly variable and poor. Twenty-four percent of studies failed to report when patients were allowed return to sport without restrictions. Overall, 39%, 45%, and 51% of studies permitted running at 3 months, return to cutting/pivoting sports at 6 months, and return to sport without restrictions at 6 months, respectively. Further research into validated return to sport guidelines is necessary to fill the existing void in contemporary literature and to guide clinical practice.

Return-to-Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players.

Background: Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players. Hypotheses: NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear). Study Design: Case-control. Methods: NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables. Results: Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls’ performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls. Conclusion: There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low. Clinical Relevance: There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.

Patellofemoral Instability in Athletes Treatment via Modified Fulkerson Osteotomy and Lateral Release

Background Surgical treatment of patellofemoral instability can successfully diminish episodes of subluxation and dislocation, as well as symptoms of pain and instability. Hypothesis Surgical treatment of lateral patellar instability in a strictly athletic population will facilitate return to sports. Study Design Case series; Level of evidence, 4. Methods From 1999 to 2004, 41 Fulkerson osteotomies combined with an arthroscopic lateral release were performed in 34 athletes for patellofemoral instability. Three patients were lost to follow-up. All patients participated in sports at least 3 times per week in at least one sport for 4 months of the year. There were 4 male and 30 female patients; 7 patients underwent bilateral, staged procedures. There were 14 high school, 12 collegiate, and 8 recreational athletes. Results were obtained by an independent examiner. Results The mean age was 20.05 years (range, 14-54 years) with a mean follow-up of 46 months (range, 22-71 months). Patients averaged 1.3 dislocations before reconstruction (range, 0-6). The average Lysholm score was 91.8 (range, 67-100) at follow-up. The International Knee Documentation Committee (IKDC) scores were A (normal) in 27 knees, B (near normal) in 12, and C (abnormal) in 2. Seventeen patients had symptomatic hardware removed at an average of 8 months. There were 2 complications: one saphenous neuroma that resolved, and one recurrent dislocation in a patient later diagnosed with Ehlers-Danlos syndrome. Conclusion This series is the largest to date documenting the successful treatment of patellofemoral instability in athletes with concomitant Fulkerson osteotomy and arthroscopic lateral release. Forty-nine percent of patients in our series required removal of screws from the osteotomy site.

Concomitant Arthroscopic SLAP and Rotator Cuff Repair

BACKGROUND The outcomes of combined arthroscopic repairs of a SLAP (superior labral anterior-posterior) lesion and a rotator cuff tear are not known. We compared the outcomes in a cohort of patients who had undergone concomitant arthroscopic repairs of a SLAP lesion and a rotator cuff tear with those in a cohort of patients with a stable biceps anchor who had undergone an isolated rotator cuff repair. We hypothesized that the results would be similar between the two cohorts with respect to the range of motion and preoperative and postoperative function. METHODS Thirty-four patients (average age, 56.9 years) underwent an arthroscopic repair of an unstable SLAP lesion along with a concomitant arthroscopic rotator cuff repair. Twenty-eight patients (average age, 59.6 years) underwent an isolated arthroscopic rotator cuff repair. The average durations of follow-up for the two groups were 40.9 and 42.7 months, respectively. All patients in both groups had a symptomatic full-thickness rotator cuff tear for which initial conservative treatment had failed. Patients with advanced supraspinatus fatty infiltration or advanced muscle atrophy were excluded from the study. American Shoulder and Elbow Surgeons (ASES) and Constant scores were determined preoperatively and postoperatively, as were measurements of the ranges of forward flexion, abduction, external rotation, and internal rotation. Dynamometer strength testing was performed on all patients as an adjunct to qualitative assessments, and normalized Constant scores were calculated to perform sex and age-matched functional assessments. RESULTS In the group treated with concomitant repairs of a SLAP lesion and a rotator cuff tear, the average ASES score improved from 22.6 to 96.4 points and the average normalized Constant score improved from 55.1 to 101.0 points. In the group treated with an isolated arthroscopic rotator cuff repair, the average ASES score improved from 34.3 to 92.3 points and the average normalized Constant score improved from 60.7 to 95.8 points. The average preoperative ASES score in the group with the concomitant repairs was significantly worse than that in the group with the isolated rotator cuff repair (p = 0.027). This difference is also probably clinically relevant. There was no significant difference between the groups with regard to the preoperative normalized Constant scores, but postoperatively the normalized Constant score was significantly higher in the group with the concomitant repairs (p = 0.006). The active range of motion did not differ between the groups, preoperatively or postoperatively. CONCLUSIONS Controversy surrounds the treatment of a SLAP lesion with concomitant treatment of a full-thickness rotator cuff tear. This study suggests that, in middle-aged patients, the results of combined SLAP lesion and rotator cuff repair can be comparable with those achieved with rotator cuff repair alone.

Return to Play Following Anterior Cruciate Ligament Reconstruction

In athletes, significant advances in anterior cruciate ligament reconstruction techniques and rehabilitation have led to improved surgical outcomes and increased expectations for return to play. Although an expeditious return to sport has become an achievable and often realistic goal, the factors that most influence safe, timely, and successful return to play remain unknown. The literature offers mainly anecdotal evidence to guide the team physician in the decision-making process, with a paucity of criteria and consensus guidelines available to help determine return to sport. Attempts have been made to introduce criteria-based progression in the rehabilitation process, but validation of subjective and objective criteria has been difficult. Nevertheless, several pertinent factors in the preoperative, intraoperative, and postoperative periods may affect return to play following anterior cruciate ligament reconstruction. Further research is warranted to validate reliable, consensus guidelines with objective criteria to facilitate the return to play process.

Medial Meniscus Tear Morphology and Chondral Degeneration of the Knee: Is There a Relationship?

PURPOSE The purpose of this study was to examine the association of medial meniscus tear morphology with the pathogenesis of articular cartilage degeneration. METHODS From May 2006 to December 2007, we prospectively evaluated 103 patients diagnosed with an isolated medial meniscus tear. Meniscus tear morphology and location, cartilage degeneration according to the Noyes score, and covariates including age, body mass index, gender, and injury date were documented. The relationship between severity of articular cartilage degeneration and meniscus tear morphology was analyzed by analysis of variance. Regression analysis was used to analyze predictors of severity of cartilage lesions. RESULTS Analysis of variance showed significant differences in the severity of articular cartilage lesions based on medial meniscus tear morphology (P < .05). Compared with bucket-handle/vertical tears, root and radial/flap tears were associated with significantly greater degeneration on the medial femoral condyle; root and complex tears were associated with significantly greater degeneration on the medial tibial plateau; and radial/flap tears were associated with significantly greater degeneration on the lateral tibial plateau. Age and gender were significant predictors of the Noyes medial-compartment score, and age, body mass index, and meniscus tear morphology were significant predictors of the Noyes lateral-compartment score. CONCLUSIONS Meniscus tears with increasing disruption of the circumferential meniscal fibers were significantly associated with cartilage lesions of increasing severity in both the medial and lateral compartments of the knee. LEVEL OF EVIDENCE Level IV, prognostic case series.