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Graft Remodeling and Ligamentization after Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction techniques have improved over the last 10 years, but graft failure is not uncommon: 0.7%–10%. Successful ACL reconstruction requires understanding of several factors: anatomical graft placement, mechanical properties of the selected graft tissue, mechanical behavior and fixation strength of fixation materials, as well as the biological processes that occur during graft remodeling, maturation, and incorporation. They directly influence the mechanical properties…

Anterior Cruciate Ligament Reconstruction Using the Endobutton Continuous Loop Bone–Tendon–Bone Fixation System

Introduction The Endobutton continuous loop (CL) bone–tendon–bone (BTB) Fixation System (Smith and Nephew, Andover, Massachusetts) is a technique for fixation of anterior cruciate ligament (ACL) grafts that have a bone block for the femoral tunnel, such as BTB autografts, BTB allografts, Achilles tendon allografts, and quadriceps tendon grafts. The Endobutton-CL BTB System offers surgeons many advantages over current fixation methods of the femoral bone plug. You’re…

Anterior Cruciate Ligament Reconstruction Using a Mini-Arthrotomy Technique with Either an Ipsilateral or a Contralateral Autogenous Patellar Tendon Graft

Introduction There are many techniques for anterior cruciate ligament (ACL) reconstruction that involve using different surgical instruments, graft choices, fixation devices, and postoperative care. Each surgeon needs to become an expert at one technique, track patients’ results, and then make refinements in the surgery and rehabilitation to optimize outcomes. It is important to note that ACL surgery is not just a surgery but also involves specific…

Interference Screw Fixation in Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction

Introduction Interference screw fixation remains an effective technique in bone–patellar tendon–bone (BPTB) anterior cruciate ligament reconstruction (ACLR). It is a well-established and well-studied technique. Interference screws are able to achieve early stability with rigid, aperture fixation of graft to host bone. They provide greater strength than is needed during the early rehabilitation period. ACLR using BPTB autograft with interference screw fixation has been found to have…

Hamstring Anterior Cruciate Ligament Reconstruction with INTRAFIX and BioINTRAFIX Tibial Fastener Systems

Introduction Tibial side fixation of soft tissue grafts has been challenging because the line of pull on the graft in the tibia is parallel to the axis of the tunnel and because the bone in the tibia has a lower bone mineral density (BMD). Free tendon ends are more difficult to fix well than looped ends or a bone block. Finally, tendon grafts heal more slowly…

WasherLoc: Optimizing Tibial Fixation of Soft-Tissue Grafts Used for Anterior Cruciate Ligament Reconstruction

Introduction The WasherLoc (Biomet, Warsaw, Indiana) is an extratunnel two-piece lag screw and spiked washer fixation device specifically designed for soft tissue graft fixation for Anterior Cruciate Ligament (ACL) reconstruction. The method of fixation of soft tissue grafts for ACL reconstruction is an important decision surgeons must make to optimize the superior properties of soft tissue graft sources and ACL reconstruction outcomes. The biomechanical properties of…

Whipstitch-Post Tibial Fixation for Anterior Cruciate Ligament Reconstruction

Essentially, only three methods are currently used for gripping anterior cruciate ligament (ACL) grafts so that they may be fixated to bone: Friction: Fixation is applied either against cancellous bone by an intratunnel interference screw or on the cortex by a gripping washer such as a WasherLoc, staple, or similar device. Loop: The graft is looped around a post such as a cross-pin or through a…

Improving Biodegradable Interference Screw Properties by Combining Polymers

Introduction Interference screws are widely used for graft fixation in anterior cruciate ligament (ACL) reconstruction, and good clinical results have been reported by several investigators. In addition to conventional metal screws, biodegradable interference screws are commercially available and have been shown to provide at least as strong graft fixation as metal screws. In addition, the biodegradable screws do not interfere with imaging techniques and do not…

Use of TunneLoc for Anterior Cruciate Ligament Reconstruction

Introduction Similar outcomes have been reported after anterior cruciate ligament (ACL) reconstruction with either a bone–patellar tendon–bone graft or hamstring tendon graft, with no difference in graft rupture rates between the two groups at 10 years in one cohort study. Although the outcomes are similar for the two graft choices, there are unique characteristics of each graft that must be considered when obtaining fixation. Intuitively, bone–tendon–bone…

Femoral Shaft Fractures

Conflict of Interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the chapter. Introduction Fractures of the femoral shaft occur after high-energy trauma and are usually seen in the context of polytrauma, particularly in the young adult population. Traffic accidents, gunshots, and falls from height are the main causes of injury. Consequently, these fractures often present…

Sternoclavicular Joint Dislocations

Relevant Anatomy The sternoclavicular joint (SCJ) is a saddle-shaped, diarthrodial synovial joint that provides the only bony articulation between the axial skeleton and upper extremity. It is an important fulcrum for the movement of the shoulder girdle, as translation and rotation of the clavicle through the SCJ and acromioclavicular joint (ACJ) dictate the position of scapula as it moves against the posterior chest wall. , The…

Subtrochanteric Fractures of the Femur

Subtrochanteric femoral fractures are challenging to manage and differ significantly from both femoral shaft fractures and more proximal femoral injuries in their mechanism, treatment, and complications. The combination of strong muscle forces, high axial and bending loads with normal activities, and complex fracture patterns makes treatment difficult and outcomes uncertain. The subtrochanteric zone of the femur is defined as the area extending from the base of…

Posttraumatic Reconstruction of the Hip Joint

Primary reconstruction of acute femoral neck and intertrochanteric (IT) femur fractures and salvage of failed hip fixation with arthroplasty techniques are becoming more common as the absolute number of fractures involving the hip joint continues to increase. Primary reconstruction in properly selected patient groups has shown promising results. Although most fractures of the femoral neck and pertrochanteric region heal with contemporary methods of internal fixation, those…

Intertrochanteric Hip Fractures

Introduction Fractures of the hip have long been held as an injury that is largely a result of altered bone metabolism, which can significantly affect the life of a patient with regard to mortality and function. The recognition of the importance of expeditious and safe care of elderly patients with an intertrochanteric femur fracture is apparent, and the development of geriatric co-management programs has successfully improved…

Intracapsular Hip Fractures

Femoral Head Fractures Femoral head fractures often occur in association with hip dislocations. Eighty-five percent to 90% of hip dislocations are posterior. In the largest series of posterior hip dislocations, the incidence of associated femoral head fracture was 7%. The common patterns of femoral head fracture are of the shear or cleavage type. An indentation or crush fracture has been more recently recognized, and the results…

Medical Management of the Patient With Hip Fracture

The outcome of a patient with a hip fracture is only partially related to the successful surgical management of the fracture. Many elderly patients have multiple, significant concomitant illnesses. These comorbidities, as well as perioperative complications, significantly impact the patient's ultimate outcome. This chapter reviews factors affecting the outcome after a hip fracture; management of common coexisting medical conditions; postoperative complications; and interventions to optimize medical,…

Hip Dislocations

Introduction The guarded prognosis of hip dislocations has been well recognized and frequently reported. Although pure dislocations fare better than fracture-dislocations, recent reports indicate that unsatisfactory long-term results are common even with pure dislocations and can be anticipated in up to one-half of this better-prognosis group. Delayed treatment and failure to recognize and treat associated injuries have historically contributed to poor results. More recently, however, improved…

Replantation

Introduction Replantation is the reattachment of a completely amputated part, and revascularization refers to the restoration of blood flow to an incompletely amputated part with vascular compromise, regardless of the size of the bridging tissue attachment. In 1962, the first successful replantation was performed by Malt and McKhann at the Massachusetts General Hospital; the case involved an above-elbow amputation in a 12-year-old boy. Kleinert and colleagues…

Chest Wall Trauma: Rib and Sternum Fractures

Introduction This chapter focuses on high-energy injuries to the chest wall in the setting of major trauma, although fragility rib fractures are gaining increased attention in contemporary medicine. In 2004, there were 102,000 patients admitted to US hospitals and over 300,000 people treated for rib fractures in the United States. The true incidence is certainly higher than this estimate because the denominator is not known, particularly…