Purpose: To determine the ideal location for anterior cruciate ligament (ACL) suspensory cortical button placement on the lateral femur with the highest failure load and to establish the relationship of tunnel diameter and cortical thickness on load to failure. Methods: Computed tomography (CT) data were obtained from 45 cadaveric distal femurs. A Cartesian coordinate system was established along the lateral femur with the lateral epicondyle (LE) as a reference point. Locations 0, 20 and 30 mm from the LE along lines 0 , 25 , 50 , and 75 posterioproximal from the axial plane were created. Tunnels connecting from each location to the center of the ACL footprint were simulated. Cortical thickness and long axis diameter of the oval cortical holes were determined for each location. Based on the CT data, custom drill guides were created and used to drill 4.5 mm tunnels at each lateral femur location to the ACL footprint on the cadaver femurs. Cortical buttons were placed at each location and pulled using a servohydraulic testing system. The correlation of tunnel diameter and cortical thickness to button failure load were analyzed using a regression analysis. Results: Significant differences were found for failure load (P<.0001) and cortical thickness between the locations tested (P<.0001). The location 30 mm proximal from the LE and 75⁰ from the axial plane had the highest failure load of 573 N. A regression analysis (R 2 ¼ .15) indicated that the cortical thickness was significantly correlated with load to failure (P <.0001), whereas the long-axis diameter was not (P ¼ .33). Conclusion: The ideal cortical button location on the lateral femur for ACL suspensory fixation was located 30 mm proximal from the lateral epicondyle, based on this area's high failure load. Oblique tunnel drilling of this proximal location may cause a larger long-axis diameter cortical hole, but the cortex is also thicker, which is more closely correlated with failure load. Clinical Relevance: Different ACL suspensory cortical button locations on the lateral femur have different failure loads based on the cortical thickness of the bone supporting the button. It is important for surgeons to understand which drilling techniques place the button in a proximal and posterior location, especially if the bone quality of the patient is of concern.

Background: Distal fingertip amputations with exposed bone is challenging for the surgeon to manage. In order to reconstruct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar advancement flap, first described by Moberg in 1964, comprises one of the most popular options. Methods: Thirteen patients (11 male, 3 female) with fingertip injuries were operated. Following the elevation of Moberg flap, proposed modifications were carried out. Joint mobility and pulp sensitivity were recorded as well and advancement scores were noted before and after the modification. These scores were assessed statistically. Results: No complications were noted and there was no need for additional surgery. Excellent joint mobility and pulp sensitivity were maintained. This modification showed a statistically significant improvement in the advancement (p<0.05). Conclusions: Moberg flap is a good option for the closure of fingertip defects. Some simple modifications, as described in here, can enhance the advancement while securing the entire advantages of the flap. IntroductionThe hand is a unique part in the body in and plays important and often irreplaceable functions. In the industrialized world, occupational hand injuries need to be healed as soon as possible. Meanwhile, several healing techniques with various options are being applied to hundreds of thousands of patients by experienced practitioners.Unlike other hand injuries, fingertip amputations need additional attention in order to establish a normal pulp sensibility and maximum range of motion, and like others to maintain the upmost level of hand functioning.In 1964, the volar advancement flap was first described by Moberg for the reconstruction of pulp defects of the thumb (1). This flap is a pedicled advancement flap proximally based on an intact skin pedicle including both neurovascular bundles. This technique establishes a successful neurosensation of the pulp with a limited advancement as well. However, a simple modification as described here, and never been reported elsewhere, can enhance additional advancement. Patients and MethodsThe study was performed with informed consents obtained from all participants.Technique Thirteen patients (11 males, 3 females) with fingertip injuries were operated under regional anaesthesia. Palmar advancement flap was raised over the parathenon (1) (Figure 1a). Both neurovascular bundles were included in the flap so that neurosensible coverage is accomplished (Figure 1b). To increase the Hand Microsurgery & ABSTRACTOsseous blastomycosis of small bones of the pediatric hand is rare. A thirteen-year-old male was reported with a missed diagnosis of right ring finger blastomycosis osteomyelitis and six-week delay in treatment. He was treated successfully with surgical debridement and long term itraconazole. Blastomycosis should be considered in any patient with a lytic bone lesion and prompt tissue cultures are crucial to timely and appropriate treatment.