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? He is having difficulty ambulating without crutches. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee "giving way." Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear, physical therapy & lifestyle modifications, low demand patients with decreased laxity, increased meniscal/cartilage damage linked to, level I and II activity (e.g. 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. It may cause graft over-stretching and failure, It may cause interference screw divergence. (OBQ05.96) Which of the following exercises is not recommended during rehabilitation? "Bucket handle meniscal tears can be diagnosed on MRI as a double PCL sign on sagittal imaging. This typically involves separation of the tibial attachment of the ACL to variable degrees. Positive external rotation dial test at 30 degrees. Radiographs are used to assess adequacy of reduction. Tibial eminence fracture, a bony avulsion of the anterior cruciate ligament (ACL) from its insertion on the intercondylar eminence,1 was rst described by Poncet in 1875.2 . 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. El-Feky M, et al. Segond fracture (avulsion fracture of the proximal lateral tibia) . describe key steps of the operation verbally to attending prior to beginning of case. Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? A patient develops anteromedial pain and altered sensation over the anterolateral infrapatellar region of the knee after autologous hamstring tendon harvest for an ACL reconstruction. 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. 1% (18/2552) 3. tension is applied as the sutures are brought through the joint and out the lateral skin. (SBQ16SM.19) - Thomas Carter, MD (4.8, 2018 Winter SKS), Combined Knee Ligament Injury in Obese 17M. A 34-year-old recreational hockey player collides with the goalie during a game and injures his knee. Patients may complain of numbness over the anterolateral aspect of the knee following ACL reconstruction. (OBQ04.19) A football player sustains an isolated posterior cruciate ligament (PCL) tear. However, Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear. ensure that the patella is appropriate to harvest a graft. (OBQ07.87) Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear 3. (OBQ08.213) Radiographic evaluation of anterior cruciate ligament (ACL) reconstruction involves: femoral component. (OBQ11.215) MRI scan is shown in Figure A. Without an intact ACL , the knee joint may become unstable, and have a tendency to give out or buckle. diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction. He has no effusion, no pain at rest, and a stable Lachmans test. The severity an ankle avulsion fracture can result in anything from a minor issue to something that requires surgery. Again I was begging them in tears due to the pain. Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for confirmation. (SBQ04SM.32) lateral displacement of the patella with patella alta ( Modified Insall-Salvati ratio = 2.25) with small size of the medial facet and concave aspect of the lateral facet ( Wiberg type 2 or b). Which of the following is true of the injured structure shown in Figure A? Orthobullets Team Trauma - Talus Fracture (other . According to Kendall et al, [2] 40% of such fractures occur in adults. A 35-year-old construction worker presents with medial-sided knee pain. Which of the following mechanisms is most likely to have caused this injury? A 16-year-old female volleyball player presents 1 week after sustaining a knee injury while landing from a jump. - Isolated avulsion of the tibial attachment of the posterior cruciate ligament of the knee. A 25-year-old male soccer player twisted his left knee 4 days ago and developed immediate swelling and pain. check alignment, joint space and patella alignment. 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) What We've Learned Following Over 1,000 Patients For 5 Years - Lynn Snyder-Mackler, MD, ACL Reconstruction + ALL-LET (Lateral Extra-articular Tenodesis): How, Why And When In Primary & Revision Surgery - Alan Getgood, MD, Evolving Technique Update: ACL Tunnel Placement In 2020: How To Hit The Target - Mark Miller, MD, ACL and Medial and Lateral Meniscal Tears in a 40M, Delayed Diagnosis of ACL Rupture in the Community in a 25M, 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, Multi-ligament knee injury 18 mos s/p BTB ACL in an 18M football lineman. Disruption of the lateral collateral ligament was evident in seven patients, and one patient had . - Daniel Cooper, MD, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, Contemporary PCL Reconstruction: How I Do It - Michael Ellman, MD (CSMS #68, 2018). Most surgeons prefer to avoid or limit which of the following exercises in the initial post-operative rehabilitation following ACL reconstruction? On physical exam, he has a large effusion with limited knee flexion due to pain. The middle genicular artery is the primary blood supply of which of the following structures? Thank you. What is the likelihood that she has an ACL tear? Horizontal and oblique transphyseal tunnel position. A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. (OBQ07.155) A 29-year-old male undergoes ACL reconstruction with a quadruple hamstring autograft. obtain by moving tibial starting point halfway between tibial tubercle and a posterior medial edge of the tibia. Diagnosis can be suspected with increased varus laxity on physical exam but require MRI for confirmation. Acute reconstruction followed by mobilization, Rest, nonsteroidal anti-inflammatories, and follow-up in 4 weeks. . Classification of ACL avulsion fractures (diagram) | Radiology Case | Radiopaedia.org Type 1 - minimally/non-displaced fragment Type 2 - anterior elevation of the fragment Type 3 - complete separation of the fragment. 1-5 it is an important finding that frequently indicates other underlying structural injury to the knee. Conclusion: Metastasis and the first manifestation of an underlying malignancy should be suspected in adult patients with isolated LT fracture. During anterior cruciate ligament (ACL) reconstruction divergence between the graft and screw fixation within the bone tunnel can lead to complications. Avulsion fracture of the anterior cruciate ligament. ACL tears are common athletic injuries leading to anterior and lateral rotatory instability of the knee. (OBQ11.154) On physical exam, his Lachman is graded as 1A. Among these, 27 were pathologic fractures. Recently, some authors have attributed its pathogenesis to the "anterolateral ligament" (ALL). A 23-year-old soccer player suffers an ACL rupture and undergoes reconstruction. A collegiate men's basketball point guard undergoes ACL reconstruction with hamstring autograft. An 18-year-old female collegiate athlete sustains the injury seen in Figure A. Her radiographs are shown in Figures A and B. Which physical examination finding is correctly matched to the tunnel malposition?? As previously discussed, with likely underlying ligamentous and or meniscal injuries, magnetic resonance imaging (MRI) is necessary for further evaluation, which may also highlight the more subtle Segond fractures. At what angle of knee flexion should the graft be tensioned at during posterior cruciate ligament (PCL) reconstruction with a single bundle graft? (SBQ04SM.85.1) Portions of the ACL are tight in all knee positions; therefore, no single position that exists without application of traction by the ACL may prevent anatomic reduction. Vertical squat with light dumbbells in each hand. Copyright 2022 Lineage Medical, Inc. All rights reserved. this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft. describe key steps of the operation verbally to attending prior to beginning of case. Lower immune reaction compared to autograft. Other foot injuries and conditions are discussed separately. A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. 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. Avulsion of the posterior talotibial ligament or posterior deltoid ligament. description of potential complications and steps to avoid them. the femoral sided graft is pulled into the femoral tunnel, care is taken not to pull the sutures through the bone block, a probe or clamp can aid in obtaining the desired orientation of the graft, proper tensioning is applied to the graft as the tibial bone block is also fixed into place, flex to the same degree as when drilling which should be over 120 degrees, the bone tunnel can be notched to allow screw insertion, introduce a guide wire through the anteromedial portal while visualizing through the anterolateral portal, position the graft within the femoral tunnel so that the screw will engage both the graft and the tunnel when placed, ensure that the graft is positioned so that the cancellous bone is facing the screw, advance the screw over the guide wire while positioning of the graft is maintained to keep from advancing the graft into the tunnel, avoid damaging the tendon with the threads of the screw, the tibial tunnel can be notched if needed, apply appropriate tension on the graft through the tibial tunnel while placing the tibial screw, bone grafting to the patella and tibial defect can be performed with the bone taken from the grafts as well as tibial bone if a coring reamer is used for tibial tunnel creation, the paratenon layer is first closed, then the subcutaneous tissue and skin, immediate weight bearing (shown to reduce patellofemoral pain), emphasize early full passive extension (especicially if associated with MCL injury or patella dislocation). 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). 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 . 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. leg extensions mimic anterior drawer and Lachman maneuvers, no widely accepted criteria supporting clearance or timing to return to sport, previously held consensus is no sooner than 9 months following surgery, patient should pass series of functional tests that replictae sport-specific activities, various single- and double- leg hopping and jumping, dynamic valgus shown to increase risk of ipsilateral and contralateral rupture, higher rates of re-rupture following early return to sport prior to clearance, clearance for return to play should be made between surgeon and patient, psychological factors play large role in timing of return and should not be overlooked, neuromuscular training/plyometrics (jump training), land from jumping in less valgus and more knee flexion, increasing hamstring strength to decrease quadriceps dominance ratio, BPTB graft total length greater than combined length of femoral tunnel, tibial tunnel, and intra-articular distance connecting them, leads to prominent tibial bone plug and inadequate fixation, precise intra-operative measuring of tunnels and graft, twisting graft tendon on itself to effectively shorten graft length, cortical breach of posterolateral cortical wall of lateral femoral condyle, inadequate exposure of posterior wall prior to drilling, failure to evaluate tunnel walls after drilling, drilling femoral tunnel while knee flexed less than 70-90 degrees, if minimal defect at notch opening (3-5mm), can re-drill tunnel deviating anteriorly and proceed with prior intended fixation method, keep previous tunnel but graft fixed with suspensory fixation (screw and washer post, cortical button, or staple) and/or interference screw fixation, intereference screw fixation may be added to supplement suspensory device, graft failure for any cause approximates 5%, is the most common cause of ACL failure, attributed to 70% of failures, cause by starting femoral tunnel at the vertical position in the notch (12 o'clock) as opposed to lateral wall (10 o'clock), will cause continued rotational instability which can be identified on physical exam by a, occurs from failure to clear "residents ridge", leads to an ACL that will impinge with the PCL, inadequate graft fixation or hardware failure, can be caused by graft-screw divergence >30 degrees, intra-articular femoral bone plug dislodgement, missed diagnosis of concomitant ligamentous injuries or bony malalignment, in combined ACL and PLC injuries, failure to treat the PLC will overload graft lead to failure, coagulase negative Staph (S. epidermidis) most common organism, routine soaking graft intra-operative in vancomycin solution may lower risk of infection, graft contamination during routine intra-operative handling, pain, swelling, erythema, and increased WBC at 2-14 days postop, joint aspiration with gram stain and cultures, routine soaking of graft in various antibiotic solutions before placement, sequential washing in various antibiotic solutions showed no increase in infection risk for dropped grafts, often can retain graft with multiple I&Ds and antibiotics (6 weeks minimum), more likely to be successful with S. epidermidis, less likely with S. aureus, most common complication following ACL reconstruction, regained full ROM before you operate ("pre-hab"), wait until swelling (inflammatory phase) has gone down to reduce the incidence of arthrofibrosis, proper tunnel placement critical to have a full range of motion, lysis of adhesions/manipulation under anesthesia, an uncommon complication which results in knee stiffness, physical exam will show decreased patellar translation, will see patella alta on the lateral radiograph, BPTP and quadriceps grafts w bone block implicated, observation unless graft laxity and knee instability, increased rates noted in patients > age 50 at the time of ACL reconstruction, saphenous nerve due to hamstring autograft harvest, fibroproliferative tissue blocks extension, ACL deficient knees believed to lead to an accelerated progression of arthritis, near complete restoration of native kinematics following reconstruction, high level of return to sport at all levels of competition. - Thomas Carter, MD, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, LCL/PLC: How to Evaluate and How to Fix - Alan Getgood, MD, FRCS (CSMS $67, 2018), 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, LCL & Posterolateral Corner: When & How to Fix? What is the next step in management? 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. (OBQ18.172) Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for confirmation. 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. This most often happens when you suddenly change direction. 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. Which of the following is the most likely cause of his injury? Simple Fracture : A break in a bone without an accompanying wound at the fracture site. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Houston Methodist Orthopedics & Sports Medicine. 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. He has questions regarding the use of autografts. Avulsion injuries or fractures occur where the joint capsule, ligament, tendon or muscle attachment site is pulled off from the bone, usually taking a fragment of cortical bone. 1-5 this fracture is highly associated with a rupture of either the acl or . This is an AAOS Self Assessment Exam (SAE) question. Segond fracture is an avulsion fracture of the knee that involves the lateral aspect of the tibial plateau and is very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament (ACL). Post-operatively she begins a rehabilitation program and her therapist develops a series of knee conditioning exercises to help her regain strength and range of motion. (OBQ12.94) Risk of failure is eliminated using an accessory anteromedial drilling portal, Complications occur more commonly with soft tissue grafts, Loss of fixation becomes a greater risk if the graft-screw divergence is >30 degrees, Excessive graft-screw divergence more commonly occurs during tibial fixation, Graft-screw divergence is a common cause of late failure of ACL reconstructions. Clinical presentation Fortunately, x-rays are usually normal. 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. This decrease in vascularity contin-ues to. Imaging of his right knee is demonstrated in Figures A, B, and C. Which of the following structures has most likely been injured? This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. - Avulsion fractures of the posterior cruciate ligament of the knee. A 30 year-old tennis player sustains the injury seen in Figure A and is considering nonoperative treatment of this injured structure. 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. (OBQ04.240) A patient has persistent instability symptoms one year after ACL reconstruction. He complains of persistent instability with certain activities. A 16-year-old high school basketball player sustains a non-contact knee injury when she lands from a rebound. Quadriceps strengthening and prone range of motion should begin as tolerated, Hamstring strengthening and supine range of motion should begin as tolerated, Resisted quadriceps and hamstring strengthening, no early range of motion. 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. (SBQ16SM.60) [1][2] Avulsion fractures can occur in any area where soft tissue is attached to bone. A 23-year-old collegiate soccer player sustained a right knee injury 6 months ago. Which of the following physical exam maneuvers would be MOST expected for a patient with the following radiograph? Decreased incidence of anterior knee pain, Increased knee flexion strength on Cybex testing. (OBQ08.120) projector fan. (SAE07SM.84) Based on the location of his femoral tunnel, which of the following physical exam findings is likely present? What surgical treatment is the best option given his age and occupation? Copyright 2022 Lineage Medical, Inc. All rights reserved. They occur regularly in the association with acute traumatic lateral patellar dislocations and are also found in the setting of multi-ligament knee injuries. While no fractures were identified, the patient was found to have a tense effusion and bruising on the anterior aspect of his knee. A genotype within the COL5A1 gene is associated with a reduced risk of which of the following injuries in women? (OBQ07.4) PLC, ACL). He underwent an autograft hamstring reconstruction at that time. (OBQ11.129) A bony fragment (avulsion fracture) is seen in the anteroposterior view of the knee on the lateral aspect of the proximal tibia. There was an audible popping sound at the time of injury and she developed swelling later that evening. examine the operative and non-operative leg. Physical exam reveals 10 varus alignment when standing and a varus thrust with walking. This domain provided by register.com at 2006-01-30T21:41:22Z (16 Years, 121 Days ago), expired at 2026-01-30T21:41:22Z (3 Years, 244 Days left). The patient states that her father had a successful allograft reconstruction for a similar injury and would like to know if she could have the same procedure. There are numerous sites at which these occur. Treatment can be nonoperative or operative depending on the severity of injury to the LCL as well concomitant injuries to surrounding structures and ligaments in the knee. A tibial tuberosity avulsion fracture is an incomplete or complete separation of the tibial tuberosity from the tibia. When an athlete tears the ACL , surgery is often. A 35-year-old male sustained an isolated PCL injury over 5 years ago which was treated non-operatively. A high school girls basketball player sustains a non-contact knee injury and develops an acute hemarthrosis. ORTHOBULLETS; Events. The MRI image shown in Figure A is indicative of which of the following injuries? Prescribes and manages non-operative treatment . Historically, ACL reconstructions were performed using an "over-the-top" position where the graft was placed around the posterior aspect of the lateral femoral condyle rather than drilling a femoral tunnel. Isometric hamstring contractions at 60 degrees of knee flexion, Isolated quadriceps contractions with the knee at 30 degrees of flexion, Simultaneous quadricep and hamstring contractions at 15 degrees of knee flexion, Isolated quadriceps contractions with the knee at 15 degrees of flexion, Active resisted knee motion from terminal extension to 30 degrees of flexion. PLC, ACL). Copyright 2022 Lineage Medical, Inc. All rights reserved. Use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal, the medial portal should be located just superior to the medial meniscus and able to provide access to the anatomic ACL footprint on the femur as well and the medial meniscal root if needed, undersurface of the patella and trochlear groove, visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment, the foot will be positioned on your opposite hip for control, medial meniscus, medial femoral condyle, and medial tibial plateau, once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage, the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment, lateral meniscus, lateral femoral condyle, and lateral tibial plateau, a probe is used to assess the lateral meniscus and cartilage, 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, leave a small portion of the footprint intact to permit proper identification of the ACL origin and insertion, a notchplasty can be performed if needed using a large shaver or a burr, mark the center of the femoral footprint with an awl or curette with the knee flexed to 90 degrees. 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. A dial test is performed and reveals a 5-degree external rotation asymmetry compared to the contralateral knee. Epidemiology Based on his femoral tunnel position, his history and examination are most likely to reveal which of the following? Diagnosis is made radiographically with displaced injuries but CT/MRI may be required to diagnosis nondisplaced fractures. Grade 2 Grade 2 ACL injuries are rare and describe an ACL that is stretched and partially torn. Reference article, Radiopaedia.org (Accessed on 09 Dec . She is a Tanner 3 on the scale of physical development. An anterior superior iliac spine (ASIS) avulsion is a traumatic avulsion of the ASIS due to a sudden and forceful contraction of the sartorius and tensor fascia lata that occurs in young athletes. An avulsion fracture can happen to any bone that's connected to a tendon or ligament. Tenderness over MCL origin without opening on valgus. [1] [2] It can occur at numerous sites in the . One year following reconstruction, he returns to playing and complains of recurrent instability episodes. He is diagnosed with an isolated ligamentous injury. this position is typically 6-7 mm anterior to the back wall to allow 1-2 mm of back wall after tunnel reaming, confirm the position of the mark by switching the 30 degree scope to the anteromedial portal, then switch the scope back to the anterolateral portal for viewing, the surgeon can choose between an inside-out technique or an outside-in technique of femoral tunnel drilling, if performing an inside-out technique the knee is high flexed to at lease 120 degrees and a guide pin is placed through the medial portal into the medial aspect of the lateral femoral condyle at the previously determined position, guides are available to help monitor back the femoral condyle back wall distance which should be approximate 1-2 mm, the guide pin is driven out the lateral aspect of the leg through the skin, this is over reamed to a predetermined distance depending on the chosen graft fixation technique, if performing an outside-in technique the camera is placed in the anteriomedial portal for viewing, and the specific guide can be placed through the anteriolateral portal at the previously determined position. In 11 pathologic fractures, LT avulsion was the first manifestation of malignancy. uphold news polaris ranger parts. funny responses to hackers ldap null bind. A patient develops infrapatellar contracture syndrome after undergoing ACL surgery. During anterior cruciate ligament reconstruction, a graft that is tight in flexion but lax in extension may be due to which technical error? (C) Type 3 are bucket handle tears with a complete root detachment. Lateral closing wedge osteotomy of the proximal tibia, Medial opening wedge osteotomy of the proximal tibia. 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. If his follow-up radiographs show degenerative changes related to his PCL-deficiency, the changes are likely to be present in which of the following knee compartments? He has been unable to obtain full extension of the knee. (OBQ10.229) 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, Video Spotlight: PCL Reconstruction - Michael Stuart, MD, PCL Injuries: When to Fix? (OBQ05.214) assess range of motion, Lachman, Pivot Shift, LCL, MCL, and pulse exam. Center of tibia tunnel placement in-line with the posterior aspect of the anterior horn of the lateral meniscus, Horizontal femoral tunnel placement (10 or 2 oclock position), Femoral tunnel placement anterior to the lateral intercondylar ridge, One-incision instead of two-incision tunnel drilling technique, Tibial tunnel is parallel and posterior to Blumenstaat's line when knee is fully extended. Which of the following should be avoided in early rehabilitation following posterior cruciate ligament (PCL) reconstruction? What is the likely diagnosis and the best next step in management in order to optimize her outcomes? 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 . (B) Type 2 are radial tears within 10 mm of the bony attachment, subdivided into 2A, 0 <3 mm; 2B, 3 to <6 mm; and 2C, 6 to <9 mm. Anterior cruciate ligament (ACL) avulsion fracture or tibial eminence avulsion fracture is a type of avulsion fracture of the knee. (OBQ04.161) ACL Reconstruction - Hamstring Autograft . 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. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. Diagnosis can be suspected with increased varus laxity on physical exam but require MRI for confirmation. When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction? A 27-year-old recreational soccer player injures his knee after colliding with an opposing player during a game. Avulsion fracture of the biceps femoris. A radiograph is shown in Figure A. Which of the following exercises places the lowest strain in this patients properly placed ACL graft? He has laxity to varus stress with the knee flexed to 30 degrees. Avulsion fractures are commonly distracted due to the high tensile forces involved. What is the most likely diagnosis? 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? (OBQ06.112) asses for physeal closure on femur and tibia. (OBQ18.116) Anterior cruciate ligament (ACL) graft failure is most commonly attributed to tunnel malposition. He initially had loss of flexion postoperatively. She presents to clinic with significant knee pain and swelling. A radiograph is shown in Figure A. 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. An avulsion fracture of the fibular head generally involves the styloid process and causes injury of some of the major stabilizers in the posterolateral corner. Strength is full compared to the other side. Tibial Eminence (Spine) Avulsion Fracture ORIF - Pediatrics - Orthobullets 9695ms Topics Pediatrics Trauma Elbow Fractures Forearm Fractures Hip and Femur Fractures Knee and Proximal Tibia Tibial Eminence (Spine) Avulsion Fracture ORIF Infection Pediatric Conditions Hip and Pelvis Conditions Leg Conditions Pediatric Foot Cavus Deformities Fig. A 22-year-old soccer player sustained an acute ACL rupture 4 years ago. (OBQ09.35) (OBQ06.138) Factors found to increase physeal injury include: large tunnel diameter (>12mm) is most important, 8mm tunnel corresponds to <3% physeal cross-sectional area, 12mm tunnel corresponds to >7-9% of physeal cross-sectional area is violated, dissection close to the perichondral ring of LaCroix, physeal disruption without growth disturbance (10%), immediate weight bearing (shown to reduce patellofemoral pain), no long-term differences found between accelerated and non-accelerated protocols, focus rehab on exercises that do not place excess stress on graft, eccentric strengthening at 3 weeks has been shown to result in increased quadriceps volume and strength, isometric hamstring contractions at any angle, isometric quadriceps, or simultaneous quadriceps and hamstrings contraction, active knee motion between 35 degrees and 90 degrees of flexion, core and gluteal strengthening incorporated throughout therapy, isokinetic quadricep strengthening (15-30) during early rehab, i.e. Type 4 - comminuted avulsion or a rotation of the fragment. Passively, he tolerates range of motion from 5-70 degrees. Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He presents to your clinic for evaluation. Current radiographs are shown in Figure A. Physical examination revealed a significant effusion, positive anterior drawer, and 3+ Lachman. (OBQ13.275) Orthobullets Team Knee & Sports - ACL Tear Technique Guide. (OBQ04.212) (OBQ09.26) Despite adequate physical therapy, he has been unable to return to sport due to recurrent instability and elects to proceed with revision surgery. Which figure symbolizes a concomitant injury, that if missed initially, would increase the failure rate of an ACL reconstruction? (OBQ06.99) (OBQ12.249) 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, . A stepwise approach can prevent misdiagnosis and offer rational treatment . Revision ACL reconstruction with hamstring autograft. (OBQ07.274) His range of motion is from 12 to 125 compared to 0 to 140 on the contralateral knee. (OBQ09.157) You are considering performing an anterior cruciate ligament reconstruction on an adolescent female athlete but are concerned about the possibility of a resultant leg length discrepency. Events. What is the most common technical error which can account for these findings? 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. As the knee is then brought into flexion, a loud clunk occurs at 30 of flexion. 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. His radiograph is shown in Figure A. (OBQ09.82) Which of the following bone bruise patterns seen on magnetic resonance imaging (MRI) is most consistent with an anterior cruciate ligament (ACL) tear? (OBQ05.174) rethinking narcissism test x ben abbott net worth x ben abbott net worth at risk when drilling the tibial tunnel (increases with knee extension), lies just posterior to PCL insertion on the tibia, separated only by posterior capsule, Patellofemoral and medial sided pain/arthritis, PCL deficiency leads to increased contact pressures in the, 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). 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. 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. (OBQ04.246) Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes? Figures A-E are clinical examination maneuvers for assessing knee stability. It is important to see your doctor as soon as the accident takes place to prevent more damage.. Suprapatellar branch of the saphenous nerve, Infrapatellar branch of the saphenous nerve. (SAE07SM.46) (OBQ09.147) A 17-year-old male presents with left knee pain and swelling after playing football three days ago. (OBQ04.91) Classification Under the Meyers and McKeever system (with modifications by Zaricznyj) injuries are classified into four main types: type 1: minimally/nondisplaced fragment type 2: anterior elevation of the fragment Which of the following rehabilitation principles is true regarding non-operative treatment of a grade II PCL tear? Which of the following structure(s) are torn? An experimental percutaneous rigid fixation technique under arthroscopic control. (SBQ16SM.6) jumping, cutting, side-to-side sports, heavy manual labor), documents failure of nonoperative management, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, focus rehab on exercises that do not place excess stress on graft, isometric hamstring contractions at any angle, isometric quadriceps, or simultaneous quadriceps and hamstrings contraction, active knee motion between 35 degrees and 90 degrees of flexion, emphasize closed chain (foot planted) exercises, isokinetic quadricep strengthening (15-30) during early rehab, bone bruising occurs in more than half of acute ACL tears, subchondral changes on MRI can persist years after injury, quadricep avoidance gait (does not actively extend knee), grading A= firm endpoint, B= no endpoint, patient must be completely relaxed (easier to elicit under anesthesia), describe complications of surgery including, diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction, asses for physeal closure on femur and tibia. On the frontal knee radiograph, it may be referred to as the lateral capsular sign. Lack of sufficient physical rehabilitation prior to return to basketball, Overly aggressive physical rehabilitation during the first 3 months following reconstructive surgery. use a right angle clamp to bluntly release the tendons from the deep portion of the sartorial fascia, release adhesions until the tendons have good recoil when tension is applied, use the tendon stripper to harvest the tendons, keep the knee flexed when harvesting to protect the saphenous nerve, remove the remaining muscle fibers from the tendons with a metal ruler or large curette, double both tendons over a central suture or around the device for fixation, 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, use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal, the medial portal should be located just superior to the medial meniscus and able to provide access to the anatomic ACL footprint on the femur as well and the medial meniscal root if needed, visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment, the foot will be positioned on your opposite hip for control, medial meniscus, medial femoral condyle, and medial tibial plateau, once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage, the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment, lateral meniscus, lateral femoral condyle, and lateral tibial plateau, a probe is used to assess the lateral meniscus and cartilage. 67 cummins loss of power x mercedes ksa juffali. (OBQ12.41) A few hours prior to presentation, an opposing. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Houston Methodist Orthopedics & Sports Medicine. What effect might such graft positioning have on the tension observed in the graft? (OBQ10.223) (OBQ04.262) With nonoperative treatment, which of the following additional findings correlate most closely with the development of future arthritis? What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 oclock position? 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