Repair of the Anterior Horn of the Lateral and Medial Meniscus With Knotless Suture Anchor.

The anterior horn lateral meniscus tear often is accompanied by perimeniscal cysts, which are treated with arthroscopic cyst excision with outside-in repair of the anterior horn. After cyst excision, there is a large gap between the thin anterior capsule and the anterior horn, which sometimes does not allow a stable repair. The suture knots may be palpable below the skin postoperation and cause irritation. A recently published technique repairs the anterior horn with a suture anchor using a suture lasso technique. We suggest a modification using a knotless anchor instead of a suture anchor, which allows a predictable tension across the repair when deployed. This technique can be used for both anterior horn lateral meniscus and anterior horn medial meniscus repairs. This technique is easy to perform, less time consuming, and reproducible.

Technique for Medial Meniscus Ramp Repair: An Anatomic Approach.

Medial meniscus ramp lesions are commonly associated with anterior cruciate ligament injury. They are one of the causes of positive pivot shift and can lead to failure to obtain rotary stability if missed during the surgical procedure. Several repair methods use a suture lasso from 2 posteromedial portals to attach the posteromedial capsule to the meniscus. Because it was concluded at the consensus meeting of the European Society for Sports Traumatology, Knee Surgery and Arthroscopy in 2019 that ramp lesions are not considered a meniscal tear and the lesion is essentially in either the articular capsule, meniscal capsular ligament, or meniscotibial ligament (MTL), it should be considered as a peel-off injury of the posteromedial capsule. This lesion is a meniscocapsular separation with or without MTL injury. Thus, reattaching the capsule and MTL to the bone on the posteromedial aspect would provide adequate anatomical repair. The prevailing repair methods suture the capsule to the meniscus, ignoring the MTL attachment. This technique addresses the refixation of the meniscal capsular ligament and MTL to the bone where it is attached instead of suturing it to the meniscus, thus providing sounder anatomical repair.

Anterior Cruciate Ligament Ganglion and Decompression of Mucoid Degeneration Using a "Figure-of-4 Position".

Anterior cruciate ligament (ACL) ganglion cysts and mucoid degeneration of the ACL are 2 distinct nontraumatic lesions of the ACL that occur discretely but can coexist. The exact etiopathogenesis still needs to be clarified. Mucoid degeneration presents as pain mainly on the posterior or posterolateral aspect of the knee and loss of terminal flexion and extension range of motion of the knee. There are several methods of treatment, including ultrasound-guided decompressions and arthroscopic decompression procedures. Arthroscopic decompressions include resecting the most affected posterolateral bundle and complete takedown of the ACL, with or without notchplasty. The reason for flexion deficit is the femoral-sided thickened ACL tissue (mucoid degeneration of the ACL) or the presence of a ganglion cyst. The impinging tibial insertion ganglion, the anvil osteophyte, or the thickened tibial stump of the ACL cause the extension deficit. Hence, addressing both anterior and posterior compartments is necessary for complete decompression. This Technical Note gives a stepwise approach to bicompartmental decompression using only anterior portals with the figure-of-4 positions.

Fish Mouth Closure of Horizontal Cleavage Tear of the Meniscus using Self-locking Modified Racking Hitch Knot (HitPat knot). - A Technical Note.

Introduction: Horizontal cleavage tears (HCT) of the meniscus are treated with fish-mouth closure with sutures using different methods. Using a no. 0 fiber wire and taking bites through both the flaps using a suture passing device and tying multiple knots is a cost-effective technique. A racking hitch knot is an option for all inside repairs of HCT. It needs multiple half hitches for locking the knot. Surgical Technique: We used a modification of the racking hitch knot (HP knot), making it a self-locking knot, so it does not need half hitches. Loop of no. 0 fiber wire is passed across both the flaps of the meniscus and a modified racking hitch knot tied in one goes closing the fish mouth. Conclusion: This modification (HP knot) saves operative time, it is cost-effective and has the distinct advantage of a reduction in the size of the final knot construct.

Nontuberculous mycobacterial infection of the musculoskeletal system in immunocompetent hosts.

BACKGROUND: Nontuberculous mycobacteria (NTM) were considered saprophytic organisms for many years but now are recognized as human pathogens. Although humans are routinely exposed to NTM, the rate of clinical infection is low. Such infections usually occur in the elderly and in patients who are immunocompromised. However, there has been an increasing incidence in recent years of infections in immunocompetent hosts. NTM infections in immunocompetent individuals are secondary to direct inoculation either contamination from surgical procedures or penetrating injuries rather than hematogenous dissemination. Clinically and on histopathology, musculoskeletal infections caused by NTM resemble those caused by Mycobacterium tuberculosis but are mostly resistant to routine antituberculosis medicines. MATERIALS AND METHODS: Six cases of NTM infection in immunocompetent hosts presenting to the department from 2004 to 2015 were included in study. Of which two cases (one patella and one humerus) of infection were following an open wound due to trauma while two cases (one hip and one shoulder) of infection were by inoculation following an intraarticular injection for arthrogram of the joint, one case was infection following arthroscopy of knee joint and one case (calcaneum) was infection following local injection for the treatment of plantar fasciitis. All patients underwent inaging and tissue diagnosis with samples being sent for culture, staining, and histopathology. RESULTS: Clinical suspicion of NTM inoculation led to the correct diagnosis (four cases with culture positive and two cases with histopathological diagnosis). There treatment protocol for extrapulmonary NTM infection was radical surgical debridement and medical management based on drug sensitivity testing in culture positive cases. At a mean follow up of 3 years (range1-9 years) all patients had total remission and excellent results. CONCLUSIONS: Whenever a case of chronic granulomatous infection is encountered that does not respond to standard anti-tuberculous treatment, with a history of open trauma, surgical intervention, or injection as shown in this study, a possible NTM infection should be considered and managed appropriately.

Morbidity index: A score to assess immediate postoperative recovery in TKR patients.

BACKGROUND: Every surgical procedure involves certain amount of postoperative morbidity which varies among different surgeries and the same surgery done by different techniques. Minimally invasive surgeries have evolved in all surgical branches and are believed to have a lesser morbidity than the traditional procedures; however there is no score or index to assess the immediate recovery after any surgical procedure in the literature. We tried to devise an immediate postoperative assessment method that takes into account the early recovery phase of patient post total knee arthroplasty (TKA) from day1 to day3. We called it as morbidity index. It consists of a 10 different parameters which could overall assess the patient's postoperative recovery. MATERIALS & METHODS: A prospective study was conducted in order to evaluate feasibility of the morbidity index and its usefulness in assessing the immediate postoperative recovery in TKA. We evaluated 50 consecutive TKA patients and scored at day 1, day 2 and day 3 postoperatively by a morbidity index. RESULTS: The mean score on day one was 13.88 which decreased to 4.68 by day three indicating morbidity has decreased. CONCLUSIONS: The morbidity index can be a tool to assess the immediate postoperative recovery of the patient after TKA and can be used to compare different approaches and procedure.

Musculoskeletal melioidosis: An under-diagnosed entity in developing countries.

BACKGROUND: Melioidosis is a saprophytic infectious disease caused by Gram-negative soil-dwelling bacillus Burkholderia pseudomallei. MATERIALS & METHODS: We report three cases of musculoskeletal melioidosis that are presented to our department from 2011 to 2013. RESULTS: One of the patients died due to post-septicemic ARDS. The other two patients have recovered fully and are followed up for minimum of 6 months. There were no recurrences. CONCLUSIONS: Though musculoskeletal infection due to melioidosis is not common in India, new cases are being reported from Karnataka, Goa and Southern Maharashtra. The need for diagnosing this entity is due to the fact that the septicemic form has a mortality rate that exceeds 90%, and though culture sensitivity report shows susceptibility to various antibiotics, the infection responds to only specific set of antibiotics i.e. intravenous ceftazidime and combination of trimethoprim and sulfamethoxazole.

Limited femoral navigation versus conventional intramedullary femoral jig based instrumentation for achieving optimal restoration of mechanical axis post total knee arthroplasty: a prospective comparative study of 200 knees.

A prospective comparative study was conducted to compare the mechanical axis post total knee arthroplasty (TKA) between two groups: In the first group of 100 knees (ASM group) Articular Surface Mounted navigation system was used to guide the distal femoral cut. In the second group of 100 knees (JIG group) conventional intramedullary femoral jig was used. The postoperative mechanical axis of the leg was within 3° of neutral alignment in 90% of the TKA in the ASM group (mean 178.12°) as compared to 74% in the JIG group (mean 177.02°). This difference was statistically significant (P<0.05). The data presented show that the use of limited femoral navigation leads to more accurate restoration of mechanical axis alignment when compared to conventional intramedullary femoral jigs.