Between July and October 2005 a consecutive series of 60 pts. with chronic anterior knee instability had their ACL reconstructed by the senior author who has a personal experience of more than 2500 ACL reconstructions. The pts. were randomly assigned to 2 groups for surgery. Group A: single bundle ACL reconstruction with hamstrings, tibial fixation with a staple and a bioscrew, femoral tunnel at 10.30 – 13.30 and endobutton fixation. Group B: double bundle ACL reconstruction with hamstrings, tibial fixation with 1 bioscrew in each tunnel + a single staple for both grafts, in-out femoral tunnels with 2 endobuttons (according to F.Fu technique). Groups are similar for age, sex, work and sport activity. Not significant complications after surgery in both groups. Rehabilitation protocol was the same for both groups. Pts. were evaluated before surgery, at one year and at 44 months (range 42–45) using the IKDC scale, Lysholm score, KT-1000 arthrometer using the opposite knee for comparison, hop test. Evaluation was done by a surgeon not involved in the study. 3 pts. were excluded at f-u becuse of an injury in the opposite knee, 5 didn’come for revision, 52 pts. (86.6%) were available for the study, 27 in group A, 25 in group B. We show some results IKDC: group A preop. 57 revision 91; group B preop 55 rev 88. Lysholm: group A pre. 74 rev. 94; group B pre.77 rev 95. KT-1000 side to side difference max manual: group A 1.87 mm. (range -0.3 – 8.2); group B 1.76 mm. (range 0 – 7.6). Hop test (% of normal knee): group A 95% (range 73–108), group B 97 % (79–106).
Despite the encouraging data of biomechanical studies there is no evidence in our experience that a double bundle ACL reconstruction has a better outcome in term of stability anf function compared with single bundle reconstruction. Other aspects should be taken into consideration for double bundle reconstruction: time spending. costs. more complications (double trouble?) in case of revision: all of this are superior to single bundle surgery. We believe though that more studies, especially long term prospective studies with new easy-to-use tools to evaluate rotation instability and gait analysis are required.
Common peroneal nerve (CPN) palsy has been reported to be the most frequent lower extremity palsy characterized by a supinated equinovarus foot deformity and foot drop. Dynamic tendon transposition represents the gold standard for surgical restoration of dorsiflexion of a permanently paralyzed foot. Between 1998 and 2005, we operated on 16 patients with traumatic complete CPN palsy. An osseous tunnel is drilled from anterior tibialis tendon (ATT) bony insertion through the cuneiform bones in the direction of the third cuneiform, through which the ATT is extracted and then pulled proximally under the extensor retinaculum. New ATT origin on the third cuneiform is therefore created. A double tendon transfer is then performed with a direct tendon-to-tendon suture at the distal third of the leg between the rerouted ATT and the posterior tibialis tendon (PTT) (transposed anteriorly through interosseous membrane) and between the flexor digitorum longus tendon (FDL), similarly transposed and sutured side-to-side with the extensor digitorum longus and extensor hallucis longus tendons. This second transfer strengthens ankle dorsiflexion and reanimates toe extension. All 16 patients were reviewed at a minimum followup of 24 months. Results were assessed using the Stanmore system questionnaire and were classified as excellent in eight, good in five, fair in two, and poor in one. In all cases, transosseous rerouting of the ATT provided a sufficient tendon length, which permitted tendon-to-tendon suturing between the ATT and PTT to be performed proximal to the extensor retinaculum eliminating tendon length-related problems. The new origin of the ATT at the third cuneiform was confirmed to be the optimal traction line to achieve maximum dorsiflexion with minimal imbalance in accompanying pronation and supination. Double tendon transfer also avoids not only drop of the toes, but also allows some extension of the hallucis. Postoperative static and dynamic baropodometric evaluations also were performed showing an overall satisfying progression of gait characterized by the absence of external overload in toe plantar flexion and by reduction of foot contact time with the ground with improvement of heel contact and pushoff phase with evidence of a longer step. The novelty of our proposed technique is that of moving the insertion of the recipient tendon (ATT) toward the donor transferred tendon (PTT) and not the contrary, providing an appropriate direction of pull with adequate length and fixation. For treatment of complete CPN palsy, transosseous rerouting to the third cuneiform of the ATT and dual transfer of the PTT and FDL tendons is a reliable method to restore balanced foot and toe dorsiflexion producing a normal gait without the need for orthoses
Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna.
