weakness of their incompletely ossied tibial plateau relative to the ACL results in an avulsion fracture as tensile load is applied.3,23 Before bone failure, . Which of the following bone bruise patterns seen on magnetic resonance imaging (MRI) is most consistent with an anterior cruciate ligament (ACL) tear? jumping, cutting, side-to-side sports, heavy manual labor), must have full motion of knee restored following injury (unless meniscal tear causing mechanical block), lack of pre-operative motion risk factor for post-operative arthrofibrosis, younger, more active patients (reduces the incidence of meniscal or chondral injury), children (activity limitation is not realistic), older active patients (age >40 is not a contraindication if high demand athlete), partial/single bundle tears with clinical and functional instability, previously abandoned but increased interest recently in pediatric populations and avulsion rupture patterns, previously abandoned due to high failure rates, arthroscopic bridge-enhanced ACL repair (BEAR) trial with a bridging scaffold is ongoing, failure of prior ACL reconstruction with instability during desired activities, if low grade MCL injury amenable to non-operative treatment, allow MCL to heal prior to ACL reconstruction, if high grade MCL injury necessitating repair/reconstruction, may be done concurrently with ACL, failure to address valgus instability can jeopardize ACL graft with higher re-rupture rates, perform meniscal repair or meniscectomy at time of ACL reconstruction, increased meniscal healing rate when repaired at the same time as ACL, partial- or full-thickness chondral injury may be treated at time of ACL reconstruction in staged fashion if injury necessitates, presence of chondral defects consistently lowers long-term patient-reported outcomes following ACL reconstruction, posterior cruciate ligament and posterolateral corner injuries, may reconstruct concurrently with ACL reconstruction or as staged procedure, failure to recognize and address PCL/PLC injuries will lead to varus instability and ACL graft overload, high tibial osteotomy or distal femoral osteotomy, limb malalignment in both the coronal and sagittal plane must be addressed before or at the same time as ligament reconstruction, lateral closing wedge osteotomy is more effective at addressing posterior tibial slope than medial opening wedge osteotomy, high ACL failure rates in unaddressed limb malalignment, early symptomatic treatment followed by 3 months of supervised physical therapy, physical therapy focusing on range of motion and progressing to quad, hamstring, hip abductor and core strengthening, re-evaluation at conclusion to assess progress, functional braces demonstrate no added functional stability, goal is to anatomically reconstruct ligament to restore anterior and rotational stability, clear out remnant ACL fibers to visualize native bone landmarks, in cases of single bundle ACL tears, no difference whether removal remnant ACL or remove all fibers prior to reconstruction, no patient-reported differences between single or double-bundle reconstructions, double bundle may better restore native knee kinematics with less laxity, may be drilled trans-tibial or independent of the tibia (inside-out or outside-in), 1-2 mm rim of bone between the tunnel and posterior cortex of the femur, tunnel should be placed on the lateral wall at 2 o'clock for left knee or 10 o'clock for right knee, creates a more horizontal graft (and reduce rotational laxity), anteromedial and far medial drilling portals may enhance ability achieve these tunnel locations, no difference in clinical outcomes between trans-tibial and anteromedial drilling techniques, drilling tunnel in over 70 degrees of flexion will prevent posterior wall blowout, the center of tunnel entrance into joint should be, 10-11mm in front of the anterior border of PCL. (OBQ07.4) description of potential complications and steps to avoid them, operative table, choice of using leg post, leg holder or neither, examine the operative and non-operative leg, assess range of motion, Lachman, Pivot Shift, LCL, MCL, and pulse exam, if using a leg post, position the patients heels at the edge of the bed and shift the patient closer to the side of the post, ensure that the post is in the proper location to produce a valgus stress, if using a leg holder, the end of the bed is often lowered allowing the operative leg to flex to 90 degrees free, the non-operative leg is either placed in a well leg holder or on padding, the operative leg must be able to flex to at least 120 degrees, if using a leg holder, a non-sterile assistant will need to unlock the top of the holder when high flexion is needed, approximately 3cm incision can be made located approximately 3 finger breaths distal to the joint line and 2 finger breaths medial to the tibial tubercle, the pes tendons can usually be palpated prior to incision, dissect thought subcutaneous tissue until the sartorial fascia is identified, The pes tendons should e palpable deep to the sartorial fascia, a blunt object such as a freer elevator or the tip of the closed Metzenbaum scissors can be slid behind the sartorial fascia from superior to inferior once the superior border is found, this will protect the MCL which is deep to the sartorial fascia, once the sartorial fascia is elevated with the blunt object it can be incised longitudinally, the tendons will be located on the deep aspect of the sartorial fascia. Which of the following physical exam maneuvers would be MOST expected for a patient with the following radiograph? Strength is full compared to the other side. A 16-year-old female volleyball player presents 1 week after sustaining a knee injury while landing from a jump. (OBQ07.15) (OBQ07.66) This is a retrospective study carried out in a major trauma centre to look at the assessment and diagnosis of all patients with a dorsal talus and navicular avulsion fractures over a one year period. While no fractures were identified, the patient was found to have a tense effusion and bruising on the anterior aspect of his knee. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee "giving way." A 29-year-old male undergoes ACL reconstruction with a quadruple hamstring autograft. Compound or Open Fracture : A break where the bone has penetrated the skin to the exterior, or the wound that broke the bone has exposed the broken ends. PCL injuries are traumatic knee injuries that may lead to posterior knee instability and often present in combination with other ipsilateral ligamentous knee injuries (i.e PLC, ACL). What is the most common reason for failure of his primary ACL reconstruction? This is especially problematic in certain sports that require a stable knee joint. Avulsion fracture of the anterior cruciate ligament (ACL) from the tibial eminence is a major intra-articular injury that primarily occurs in children and adolescents. On physical exam, his Lachman is graded as 1A. Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? He insists on doing his own therapy and subsequently goes on to need revision ACL reconstruction due to graft failure. assess range of motion, Lachman, Pivot Shift, LCL, MCL, and pulse exam. Lachman 2+, negative pivot shift and higher Lysholm scores, Lachman 2+, positive pivot shift and no change in Lysholm scores, Positive pivot shift and lower Lysholm scores, Lachman 1+, negative pivot shift and lower Lysholm scores, Lachman 1+, negative pivot shift and no change in Lysholm scores. (A) Type 1 are partially stable root tears. obtain by moving tibial starting point halfway between tibial tubercle and a posterior medial edge of the tibia. avulsion-fracture involving the majority of the tibial eminence at the tibial insertion of the ACL with complete separation of the bony fragments. (OBQ09.147) He has no effusion, no pain at rest, and a stable Lachmans test. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. PCL injuries are traumatic knee injuries that may lead to posterior knee instability and often present in combination with other ipsilateral ligamentous knee injuries (i.e PLC, ACL). (OBQ18.172) With nonoperative treatment, which of the following additional findings correlate most closely with the development of future arthritis? [1] At times, these lesions can also occur in adults and are equivalent to an acute rupture of ACL. A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. Among these, 27 were pathologic fractures. A 23-year-old collegiate soccer player sustained a right knee injury 6 months ago. funny responses to hackers ldap null bind. An avulsion fracture of the head of the fibula has been described as an important indicator of posterolateral instability of the knee. Medial patellofemoral ligament injuries comprise sprains, tears and ruptures as well as avulsion fractures of the medial patellofemoral ligament (MPFL) . Lack of sufficient physical rehabilitation prior to return to basketball, Overly aggressive physical rehabilitation during the first 3 months following reconstructive surgery. A 12-year-old female sustained a right knee injury during a high-level gymnastic competition. hamstring curls) in early rehab. What is the best treatment option to allow this patient to return to competitive athletic activity? Diagnosis: Clinical and radiographic findings confirmed the presence of an avulsion fracture at the proximal attachment of the MCL, combined with complete anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) rupture. Reference article, Radiopaedia.org (Accessed on 09 Dec . (OBQ10.223) It took me paying privately to find out I had been cut the wrong way in my episiotomy, stitched too tight after and had also suffered a pelvic floor avulsion - where your muscle comes away from the bone inside the vagina. Lateral closing wedge osteotomy of the proximal tibia, Medial opening wedge osteotomy of the proximal tibia. Incision for an anteromedial portal with the knee flexed, Incision for an anteromedial portal with the knee extended, Incision for an accessory medial portal the with knee flexed, Tibial tunnel aperture fixation with the knee at 30 degrees of flexion. [1][2] Avulsion fractures can occur in any area where soft tissue is attached to bone. Diagnosis can be suspected with increased varus laxity on physical exam but require MRI for confirmation. This typically involves separation of the tibial attachment of the ACL to variable degrees. He is having difficulty ambulating without crutches. Which figure symbolizes a concomitant injury, that if missed initially, would increase the failure rate of an ACL reconstruction? The anterior cruciate ligament ( ACL ) helps to function as one of the major stabilizers of the knee joint. Positive pivot shift test and instability with cutting activities due to failure to reconstruct the posterolateral bundle of the ACL, Positive Lachman's test and instability with forward running activites due to failure to reconstruct the anteromedial bundle of the ACL, Positive pivot shift test and instability with cutting activities due to failure to reconstruct the anterolateral bundle of the ACL, Positive Lachman's test and instability with forward activites due to failure to reconstruct the posteromedial bundle of the ACL, Positive pivot shift test and instability with forward running activities due to failure to reconstruct the posterolateral bundle of the ACL. Results: In all of the included cadaveric knees, a well-defined ALL was found as a distinct ligamentous structure connecting the lateral femoral epicondyle with the anterolateral proximal tibia. (SBQ07SM.37) All of the following are true of tunnel position EXCEPT: Vertical placement of the femoral tunnel can result in rotational instability and impingement against the PCL, Anterior placement of the femoral tunnel can result in elongation of the graft, Tibial tunnel placement should be placed posterior to a line extending from Blumenstaat's line when the knee is in full extension, Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft, Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique (10:30 or 1:30 position) graft. (OBQ18.116) ACL Reconstruction - Hamstring Autograft . Which of the following structure(s) are torn? A 27-year-old recreational soccer player injures his knee after colliding with an opposing player during a game. Which of the following patterns of bone contusion shown on MRI in Figures A-E is most likely to be evident on this patient's MRI? the guide is placed at the ACL tibial footprint in line with the medial tibial spine roughly at the posterior aspect of the anterior horn of the lateral meniscus Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for confirmation. Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear MRI ACL tear best seen on sagittal view bone bruising occurs in more than half of acute ACL tears middle 1/3 of LFC (sulcus terminalis) . A few hours prior to presentation, an opposing. The "arcuate" sign is used to describe an avulsed bone fragment related to the insertion site of the arcuate complex, which consists of the fabellofibular, popliteofibular, and arcuate ligaments [].The mechanism of this injury, which leads to posterolateral . Passively, he tolerates range of motion from 5-70 degrees. (OBQ04.9) In relation to the femoral insertion of the popliteus, the femoral attachment of the lateral collateral ligament is, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 2019 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, LCL & Posterolateral Corner: When & How to Fix? Increased ACL injury rates in women athletes compared to male athletes may be due to muscular imbalance and relative weakness in which of the following muscle groups? 3b - Involves the majority of the eminence. ACL tears are common athletic injuries leading to anterior and lateral rotatory instability of the knee. MRI scan is shown in Figure A. tension is applied as the sutures are brought through the joint and out the lateral skin. There are numerous sites at which these occur. Meniscal repair orthobullets . 10% (220/2275) 2. A 35-year-old construction worker presents with medial-sided knee pain. In an avulsion fracture, your bone moves one way and your tendon or ligament moves in the opposite direction with a broken chunk of bone in tow. Suprapatellar branch of the saphenous nerve, Infrapatellar branch of the saphenous nerve. Anterior cruciate ligament (ACL) and lateral collateral ligament (LCL), Lateral collateral ligament (LCL) and posterolateral corner (PLC), Posterior cruciate ligament (PCL) and posterolateral corner (PLC), (OBQ07.200) Radiographs and MRI show an intact graft with a femoral tunnel that enters the notch at the 12 o'clock position. A stepwise approach can prevent misdiagnosis and offer rational treatment . He complains of persistent instability with certain activities. Diagnosis can be confirmed with radiographs of the knee. (OBQ08.120) (OBQ08.193) A 27-year-old professional rugby player is sprinting down the field during a game and sustains a twisting injury to his right knee with immediate onset of swelling, pain, and difficulty with ambulation. Segond fracture (avulsion fracture of the proximal lateral tibia) . When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction? This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. Being familiar with them is important . Closed chain active terminal extension exercises, Prone passive flexion with active terminal extension. (SBQ16SM.14) These clinical findings have been associated with which of the following? He has laxity to varus stress with the knee flexed to 30 degrees. (OBQ13.275) the ACL remnant is removed from the notch usually with a shaver and/or a radiofrequency ablation device while noting the anatomic footprint on the femoral and tibial side for later reconstruction. Radiographs are used to assess adequacy of reduction. Radiographic evaluation of anterior cruciate ligament (ACL) reconstruction involves: femoral component. (OBQ12.41) a partial acl reconstruction is justified because the acl remnants provide vascular and innervation supply that will improve proprioception and will help graft integration.9 furthermore, it has been shown that 15% of partial acl tears produce degenerative changes at 8-year follow-up, 10 and . The MRI image shown in Figure A is indicative of which of the following injuries? Which of the following should be discussed with this patient regarding surgical reconstruction using an allograft? Figure A is the sagittal MRI of a 32-year-old male who was evaluated by the orthopedic trauma resident following an MVC in which he hit a tree. Vertical squat with light dumbbells in each hand. (OBQ09.157) Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). These should be repaired in order to preserve meniscal biomechanics and protect from future chondral. BTB autograft is biomechanically stronger than quadrupled hamstring autograft, BTB autograft shows less evidence of post-operative pivot shift, Quadrupled hamstring autograft shows lower rate of graft failure, BTB shows higher incidence of anterior knee pain, Quadrupled hamstring autograft shows lower incidence of knee hardware removal, Houston Methodist Orthopedics & Sports Medicine, UVA Spine and Sports Medicine Clinic in Charlottesville, ACL Reconstruction in Skeletally Immature, ACL Reconstruction - Quadriceps Tendon Autograft, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2020, Distinguished Professor Lecture: Who Really Needs ACL Reconstruction? This decrease in vascularity contin-ues to. Clinical presentation Anterior cruciate ligament (ACL) avulsion fracture or tibial eminence avulsion fracture is a type of avulsion fracture of the knee. description of potential complications and steps to avoid them. During the pivot shift examination, the iliotibial band contributes to: Reduction of the medial tibial plateau with knee extension, Reduction of the lateral tibial plateau with knee extension, Reduction of the lateral tibial plateau with knee flexion, Subluxation of the lateral tibial plateau with knee extension, Subluxation of the lateral tibial plateau with knee flexion. . Physical examination revealed a significant effusion, positive anterior drawer, and 3+ Lachman. Which of the following rehabilitation principles is true regarding non-operative treatment of a grade II PCL tear? 1% (18/2552) 3. (OBQ12.94) He is diagnosed with an isolated ligamentous injury. (OBQ09.26) Ice, NSAIDS, elevation, compression wrap and restart therapy once symptoms improve, Recommend immediate knee aspiration with gram stain and cultures, Call the office staff in the morning to schedule an appointment. Talus fractures (other than neck) are rare fractures of the talus that comprise of talar body fractures, lateral process fractures, posterior process fractures, and talar head fractures. Diagnosis can be confirmed with radiographs of the knee. ORTHOBULLETS; Events. Closed reduction can be successful for some type 2 fractures but frequently is not successful for type 3 fractures. Clamp the superior border of the incised sartorial fascia and use the scissors to release the superior medial edge in a hockey stick fashion for exposure of the tendons. All of the following are true regarding excessively anterior femoral tunnel placement during ACL reconstruction EXCEPT? Anterior cruciate ligament avulsion fracture. What is the most likely diagnosis? Diagnosis can be suspected clinically with presence of a traumatic knee effusion with increased laxity on Lachman's test but requires MRI studies to confirm diagnosis. He presents today with a complaint of a persistent sensation of instability despite having a neutral radiographic mechanical alignment and appropriately placed tibial and femoral tunnels from his previous ACL reconstuction on repeat imaging. diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction. A radiograph is shown in Figure A. LaPrade et al. - Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament. If using a leg holder, a non-sterile assistant will need to unlock the top of the holder when high flexion is needed, mark the incision to be centered over the patella tendon or on the medial border of the patella tendon approximately 5-7 cm extending from the distal pole of the patella to the proximal portion of the tibial tubercle, the tibial tunnel can be created through a the same skin incision with retraction if the initial incision is on the medial border of the patella tendon, a separate skin incision can be created if the initial incision is midline, this skin marking can be created now prior to arthroscopy in case soft tissue swelling causes distortion of the tissue, the arthroscopy portals can be placed either within the same incision or through separate skin incisions, dissect down to the level of the patellar tendon paratenon, but not through it, create tissue flaps at the layer superficial to the paratenon to be able to visualize the medial and lateral border of the patella tendon as well as the proximal tibia and distal patella, the paratenon is incised in the midline of the tendon, and reflected off the underlying tendon, care is taken to establish a viable layer for later closure, the knee is flexed to 90 degrees to put the tendon under tension, the central third of the patella tendon (typically 10 mm) is incised with either a double or single bladed scalpel, bone blocks are often approximately 20-25 mm in length and the same width as the chosen tendon width (typically 10 mm), with the knee now in extension, the bone blocks are harvested with a micro oscillating saw and a small 5 mm curved osteotome, often the tibial side is harvested first, then gentle distal traction is applied to the graft to expose the more mobile patella for bony harvest, the oscillating saw is brought to a depth of approximately 10 mm, particularly on the patella side to avoid an iatrogenic fracture, the tibial bone block can be more rectangle or trapezoidal in cross section, the patella bone block should be more triangular in cross section to avoid injury to the patella, once the cuts are completed on the respected bone, the curved osteotome is used to carefully release the the bone from the harvest site, aggressive osteotome use is not recommended due to risk of fracture of the bone block or surrounding bone, shape the bone plugs to fit into a 10 mm tunnel, reduce the excess bone to morsels to later be used for bone grafting of the patellar defect, measure the total length, bony lengths and widths, and tendon length, rongeur, bone crimp, mico oscillating saw, or burr can all be used to fashion the graft to the appropriate size, drill holes in the bone blocks to accept sutures for passing and tensioning the graft, mark the bone tendon junction with a sterile marker to allow for visualization during graft passage, an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella, insert the blunt trocar at the same angle as incision, often created under direct visualization once the medial compartment is entered, place knee in approximately 30 degrees of flexion with valgus moment applied. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Houston Methodist Orthopedics & Sports Medicine. However, Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear. When comparing autologous graft options for ACL reconstruction, a hamstring graft is associated with which of the following findings when compared to a patellar tendon graft? (SAE07SM.46) I was unable to sit, stand well or hold my baby for 6 weeks due to the pain! Ensure that the post is in the proper location to produce a valgus stress, if using a leg holder, the end of the bed is often lowered allowing the operative leg to flex to 90 degrees free. The failure of bone most commonly results from an acute event with the application of usually sudden, tensile force to the bone through the soft tissue, or when chronic . Fortunately, x-rays are usually normal. (OBQ04.174) Avulsion of the posterior talotibial ligament or posterior deltoid ligament. At his two week followup he is noted to have complete loss of his extensor mechanism on exam, stable Lachman and posterior drawer tests, and patella alta radiographically. Grade 2 Grade 2 ACL injuries are rare and describe an ACL that is stretched and partially torn. isolated injury extremely rare (< 2% knee injuries), 7-16% of all knee ligament injuries when combined with concurrent injuries, isolated LCL injuries are most commonly seen in gymnasts and tennis players, direct blow or force to the medial side of the knee, excessive varus stress, external tibial rotation, and/or hyperextension, popliteus origin is 18.5 mm from LCL origin, order of insertion from anterior to posterior, anterior tibial recurrent arteries and inferolateral, primary restraint to varus stress at 5 and 30 of knee flexion, secondary restraint to posterolateral rotation with <50 flexion, resists varus in full extension along with ACL and PCL, (based on lateral joint opening compared to contralateral side), > 10 mm lateral joint opening without a firm endpoint, Subcutaneous fluid surrounding the midsubstance of the ligament at one or both insertions, Partial tearing of ligament fibers at either the midsubstance or one of the insertions, Complete tearing of ligament fibers at either the midsubstance or one of the insertions, difficulty ascending and descending stairs, difficulty with cutting or pivoting activities, ecchymosis and lateral joint soft tissue swelling, entire length of ligament can be palpated by placing patient in figure-of-4 position, intact ligament will be a palpable cordlike structure, 0 and 30 flexion - combined LCL +/- ACL/PCL injuries, increased tibial external rotation (> 10 compared to contralateral side) at 30 knee flexion, combined LCL and posterolateral corner injuries, may show asymmetric lateral joint line widening, imaging modality of choice to grade severity and location of LCL injury, most tears are noted off of fibular insertion, medial compartment bony contusions on T2-weighted images, correlate with LCL/PLC injury due to a hyperextension-varus mechanism, much higher senstivity than exam under anesthesia (58%) since lesions are often difficult to isolate on examination alone, progressive varus/hyperextension laxity can occur with unrecognized associated injuries to the PLC, isolated acute (< 2 weeks) grade III LCL injury with avulsed ligament from anatomic attachment site (i.e fibula), some studies have shown failure rates as high as 40% with repair, subacute/chronic (> 2 weeks) grade III LCL injury with persistent varus instability, complete mid-substance acute grade III LCL injury with persistent varus instability, studies shown consistently better outcomes compared to LCL repair, best results noted with anatomic reconstruction using a semitendinosus autograft, more favorable outcomes when surgeries are done acutely after injury, progressive ROM of the knee with subsequent emphasis on quadriceps and hamstring strenghthening, early studies showed treatment with 6 weeks of casting effective at healing, uses the interval between iliotibial band (superior gluteal nerve) and biceps femoris (sciatic nerve), incise the fascia between ITB and biceps to expose the LCL insertion on the fibular head, if needed, develop a second interval proximally within ITB to identify the insertion on lateral femoral epicondyle, if needed, neurolysis of peroneal nerve should be performed, traction suture should be placed in ligament to determine if repair is possible (with knee in extension), suture anchors for repair of avulsed ligament to femur or fibula, lateral approach to knee as detailed above, semitendinosus autograft, patellar tendon allograft, achilles tendon allograft, since LCL is ~70 mm, semitendinosis provides a closer anatomical size as compared to other grafts, ~50 mm is size of patellar tendon autograft, semiteninosus stronger than gracilis and less chance of saphenous nerve irritation during harvest, drill from lateral aspect of fibula head towards the posteromedial asepct of fibular styloid, just distal to popliteofibular ligament, starting point just posterior to lateral epidconyle (~ 3 mm) exiting anteromedially, lateral approach to the knee as detailed above, fibular-based reconstruction (Larson technique) for LCL and popliteofibular ligament reconstruction, hamstring graft passed through bone tunnel in fibular head, limbs crossed to create figure-of-eight which is then fixed to lateral femur, transtibial double-bundle reconstruction of LCL and popliteofibular ligament, split Achilles tendon is fixed to the isometric point of the femoral epicondyle, one limb is fixed to the fibular head with a bone tunnel and transosseous sutures to reconstruct the LCL, second limb is brought through the posterior tibia to reconstruct the popliteofibular ligament, Persistent varus or hyperextension laxity, type III injuries managed non-operatively, occurs in up to 44% of multi-ligamentous injuries that involve the LCL/PLC, prolonged immobilization following nonoperative management, errant lateral condylar LCL fixation during reconstruction in skeletally immature patient, LCL healing can be unreliable and depends on degree of injury, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). His radiograph is shown in Figure A. A Tibial Eminence Fracture, also known as a tibial spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. On examination, her knee range of motion (ROM) is limited to 10-75. Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes? Based on the location of his femoral tunnel, which of the following physical exam findings is likely present? An avulsion fracture is a failure of bone in which a bone fragment is pulled away from its main body by soft tissue that is attached to it. An avulsion fracture can happen to any bone that's connected to a tendon or ligament. She develops immediate swelling and is noted to have a hemarthrosis. thigh tourniquet is often used at least during the graft harvest, if using a leg post, position the patient's heels at the edge of the bed and shift the patient closer to the side of the post. On physical examination, the surgeon applies a valgus force to the fully extended and internally rotated knee. interference screw with screw and washer post), interference screws (aperture/compression fixation), screw and washer post (suspensory fixation), careful assessment of the underlying cause of re-rupture, high strength grafts (quad tendon, hamstring, allograft), dual or back-up fixation (suspension + interference screws), bone grafting and reconstruction in cases of previous tunnel dilation (15mm) or if interfering with anatomic tunnel creation, addition of anterolateral ligament/ALL reconstruction (lateral extra-articular tenodesis) controversial, no chance of acquiring someone else's infection, the longest history of use and considered the "gold standard", bone to bone healing leads to faster incorporation time, ability to rigidly fix the joint line (screws), the highest incidence of anterior knee pain (up to 10-30%) and kneeling pain, patella fracture (usually postop during rehab), patellar tendon rupture, associated with age < 20 years and graft size < 8mm, may be taken from contralateral side in revision situation when allograft is not desirable or available, smaller incision, less perioperative pain, less anterior knee pain, decreased peak flexion strength at 3 years compared to BPTB, concern about hamstring weakness in female athletes leading to increased risk of re-rupture, "windshield wiper" effect (suspensory fixation away from joint line causes tunnel abrasion and expansion with flexion/extension of knee), parasthesias due to injury to saphenous nerve branches during harvest, oblique or horizontal incisions lessen this risk, small incision in area that does not see pressure during kneeling, similar patient-reported and functional outcomes as other autografts, may include bone block or completely soft tissue, less commonly used so is often available in revision setting, same disadvantages as hamstring autograft with suspensory fixation, risk of disease transmission (HIV is < 1:1.6 million, hepatitis is even greater), increased risk of re-rupture in young athletes, odds of graft re-rupture are 4.3 x higher in allograft for athletes aged 10-19, fresh-frozen grafts lower re-rupture rates compared with chemically treated or irradiated, decreases the structural and mechanical properties), 2-2.8 Mrad decreases stiffness by 30%, 1-1.2 Mrad decreases stiffness by 20%, compliant, low demand patient with no additional intra-articular pathologies, partial ACL tear (60% of adolescents have partial tears) with near normal Lachman and pivot shift, trans-physeal (males 13-16, females 12-14), leave either distal femoral or proximal tibial physis undisturbed, no significant difference in growth disturbances between techniques, combined intra- and extra-articular (males 12, females 11), autogenous ITB harvested free proximally, left attached distally to Gerdy tubercle, looped through the knee in over the top position, passed through the notch and under intermeniscal ligament anteriorly, sutured to lateral femoral condyle and proximal tibia, adult type reconstruction (males >=16, females >=14). PLC, ACL). graft pre-conditioning can reduce stress relaxation up to 50%, graft tensioning at 20N or 40N had no clinical outcome effects in a level 1 study, various options for graft fixation, dictated by graft selection and surgeon preference, can be used alone (i.e. Anterior cruciate ligament (ACL) graft failure is most commonly attributed to tunnel malposition. Fall on the flexed knee with the foot in plantarflexion, Fall on the flexed knee with the foot in dorsiflexion, Non-contact twist causing knee external rotation and valgus, Non-contact twist causing knee internal rotation and varus, Direct contact blow to the posterior knee. Events Search Events ; All Events List All Events Calendar Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand . Grade 3 this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft. Doubling the childs height when she was 2 years of age to determine final height. He has difficulty performing a straight leg raise exercise. (OBQ04.212) This is an AAOS Self Assessment Exam (SAE) question. Orthobullets Team Trauma - Talus Fracture (other . Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for confirmation. The presentation, diagnosis, and nonoperative management of cuboid fractures will be reviewed here. Management should consist of? Ligamentous exam reveals a stable ACL and MCL, but opens to a varus stress and a 3+ posterior drawer and positive dial test at both 30 and 90 degrees of flexion. asses for physeal closure on femur and tibia. (SBQ04SM.32) Revision ACL reconstruction with hamstring autograft. Blood Supply and Neuroanatomic Findings At birth, the entire meniscus is vascular; by age 9 months, the inner one third has become avascular. A tibial tuberosity avulsion fracture is an incomplete or complete separation of the tibial tuberosity from the tibia. This is most commonly due to injury of which of the following? She presents to clinic with significant knee pain and swelling. At what angle of knee flexion should the graft be tensioned at during posterior cruciate ligament (PCL) reconstruction with a single bundle graft? 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