Colin G. Murphy

Outcome of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Technique With a Minimum 2-Year Follow-up

Background: The anterolateral ligament has recently been identified as an important structure involved in rotational laxity after anterior cruciate ligament (ACL) rupture. Results of a combined ACL and anterolateral ligament (ALL) reconstruction technique have never been reported. Purpose: To report subjective and objective outcomes after combined ACL and minimally invasive ALL reconstruction with a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: A total of 92 patients underwent a combined ACL and ALL reconstruction. Indications for a combined procedure were associated Segond fracture, chronic ACL lesion, grade 3 pivot shift, high level of sporting activity, pivoting sports, and radiographic lateral femoral notch sign. Patients were assessed pre- and postoperatively with objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. Instrumented knee testing was performed with the Rolimeter arthrometer. The Knee injury and Osteoarthritis Outcome Score (KOOS) was obtained at the last follow-up. Complications including graft failure or contralateral ACL rupture were also recorded. Results: The mean follow-up time was 32.4 ± 3.9 months. One patient (1.1%) was lost to follow-up, 1 patient (1.1%) suffered an ACL graft rupture, and 7 patients (7.6%) had a contralateral ACL rupture, leaving 83 patients for final evaluation. At the last follow-up, all patients had full range of motion. The Lysholm, subjective IKDC, and objective IKDC scores were significantly improved (all P < .0001). The Tegner activity scale at the last follow-up (7.1 ± 1.8) was slightly lower than before surgery (7.3 ± 1.7) (P < .01). The mean differential anterior laxity was 8 ± 1.9 mm before surgery and significantly decreased to 0.7 ± 0.8 mm at the last follow-up (P < .0001). Preoperatively, 41 patients had a grade 1 pivot shift, 23 had a grade 2, and 19 had a grade 3 according to the IKDC criteria. Postoperatively, 76 patients had a negative pivot shift (grade 0), and 7 patients were grade 1 (P < .0001). Conclusion: This study demonstrates that a combined reconstruction can be an effective procedure without specific complications at a minimum follow-up of 2 years. Longer term and comparative follow-up studies are necessary to determine whether these combined reconstructions improve the results of ACL treatment.

Anterior Cruciate Ligament Reconstruction and Preservation: The Single–Anteromedial Bundle Biological Augmentation (SAMBBA) Technique

Preservation of the anterior cruciate ligament (ACL) remnant during ACL reconstruction has the advantages of improved vascularity and synovial encircling of the graft tendon. We describe a technique called single-anteromedial bundle biological augmentation (SAMBBA) using complete preservation of the ACL remnant, as well as preservation of the semitendinosus tibial insertion, that uses standard portals and equipment.

Capsulotomy First: A Novel Concept for Hip Arthroscopy

Capsulotomy during hip arthroscopy improves the mobility of arthroscopic instruments and helps gain greater access to key areas of the hip. During the past decade, its use has expanded dramatically as the complexity of hip arthroscopy has advanced. We report a novel approach for hip arthroscopy that consists of performing an extra-articular capsulotomy under endoscopic control before exploration of the hip joint. The principle of this new concept is to replicate an anterior Hueter approach of the hip joint. We describe the surgical technique and discuss its advantages compared with conventional hip arthroscopy techniques using either a peripheral- or central-compartment starting point. This new approach is easy to master, can be performed with a 30° optic system, does not require fluoroscopic assistance, allows a reduction in both the force and duration of traction, and reduces the risk of labral or chondral damage.

Endoscopic Management of Gluteus Medius Tendon Tears.

Tears in the gluteus medius and minimus tendons have been recognized as an important cause of recalcitrant greater trochanteric pain syndrome. Because of the frequency of partial-thickness undersurface tears, this relatively unknown pathology is often misdiagnosed and left untreated. Surgery is indicated in case of 4 associated conditions: (i) Failure of conservative treatment with duration of symptoms >6 months; (ii) magnetic resonance imaging showing a tendon tear; (iii) positive ultrasound-guided infiltration test; and (iv) the absence of an evolved fatty degeneration or atrophy of the gluteus medius and minimus muscle. Endoscopic repair of partial or full-thickness tears, with systematic resection of the bony structures implicated in the impingement, and a complete bursectomy appear to give satisfactory results, although these results remain to be confirmed by clinical studies with longer follow-up. The degree of tendon degeneration may compromise the tissue left for reattachment, raising concerns over its healing capacity, durability, and ultimate strength of the repair.

All-Inside Bicruciate Ligament Reconstruction Technique: A Focus on Graft Tensioning Sequence

Bicruciate ligament (BCL) reconstructions are challenging procedures. One of the main operative goals is to stabilize the knee in the correct anterior-posterior position. We present an all-inside arthroscopic BCL reconstruction technique using hamstring tendon grafts. Ipsilateral semitendinosus (ST) and gracilis tendons are used for TriLink (Arthrex, Naples, FL) double-bundle posterior cruciate ligament (PCL) reconstruction and contralateral ST tendon is used for GraftLink (Arthrex) single-bundle anterior cruciate ligament (ACL) reconstruction. The use of instruments for retrograde reaming and devices for adjustable cortical suspensory fixation allows for a safe, reproducible all-inside BCL reconstruction by simplifying these difficult steps. To minimize the risk of anterior-posterior malposition, the ACL graft is first tensioned with the knee in full extension, ensuring a neutral anteroposterior positioning of the tibia under the femur. The PCL anterolateral bundle can then be independently tensioned with the knee at 90° of flexion, and the posteromedial bundle at 30° of flexion, while applying an anterior translation to the tibia to reduce the posterior drawer without any risk of overcorrection. The purpose of this Technical Note was to describe an all-inside BCL reconstruction with a specific focus on the graft tensioning sequence.

Arthroscopic Identification and Management of Recurrent Iliopsoas Impingement After Total Hip Arthroplasty

Arthroscopic release of the iliopsoas tendon for iliopsoas impingement (IPI) after total hip arthroplasty (THA) at the lesser trochanter gives good results. However, where IPI then recurs, due to adhesions between the healing iliopsoas tendon and the surrounding soft tissue, and nonoperative measures have failed, a revision THA procedure is usually considered. We propose a technique of arthroscopic visualization of the recurrent IPI and a subsequent psoas tenotomy at the level of the hip joint using an outside-in capsulotomy approach. This secondary tenotomy, located proximally directly at the level of the recurrent impingement, allows relief of the painful symptoms without compromising the muscle function of the iliopsoas and precludes the need for a complex THA revision.