A Dilemma in the Management of Distal Tibia Fractures Solved by Minimally Invasive Percutaneous Plate Osteosynthesis Technique: A Prospective Study.

Introduction Managing distal tibia fractures is challenging for trauma surgeons because of their peculiar anatomy with less soft tissue coverage and poor blood supply. There are various treatment options for distal tibia fractures such as open reduction and plating, minimally invasive percutaneous plate osteosynthesis, and intramedullary interlocking nailing. Open reduction and internal fixation can lead to excessive soft tissue dissection and devascularization of fracture fragments. We conducted a study on the functional outcome of distal tibia fractures treated by biological fixation with minimally invasive percutaneous plate osteosynthesis. Methods A total of 23 patients with distal one-third tibia fractures, fulfilling the inclusion criteria, who were treated at St. John's Medical College Hospital with minimally invasive percutaneous plate osteosynthesis between November 2020 and November 2022 were studied using the American Orthopaedic Foot & Ankle Society (AOFAS) score at six weeks, three months, and six months postoperative follow-up. Results This study included 17 males and six females. The mean age of the study participants was 43.78 years, with most of the participants being in the age group between 51 and 60 years (29.2%, n = 7). All the study participants were employed. The mean operative time was two hours and 10 minutes. The mean duration for the radiological union was 22 weeks. The mean AOFAS score at six months was 92.43 + 5.696. There was only one case of superficial infection, which was treated with intravenous antibiotics. There were no cases of malunion/nonunion. Conclusion Minimally invasive percutaneous plate osteosynthesis is an effective treatment for distal tibia fractures avoiding most of the complications such as wound dehiscence and malunion/nonunion involved in conventional open reduction and internal fixation with plating. Therefore, we recommend this technique for all distal tibia fractures.

Periosteum-Augmented Soft-Tissue Graft for Anterior Cruciate Ligament Reconstruction.

Soft-tissue grafts are an option for anterior cruciate ligament reconstruction. One of the major drawbacks of soft-tissue grafts is the delay in the osteointegration and ligamentization of the implanted graft. Enveloping the ends of the graft with periosteum sleeves can hasten the osteointegration process and help in quicker rehabilitation of the patient. This article describes a simple and unique way to augment the soft-tissue graft with periosteum for anterior cruciate ligament reconstruction.

The Proximity of the Axillary Nerve During Keyhole Tenodesis of the Long Head of the Biceps Tendon: A Cadaveric Study.

Background: Over time, surgical management for conditions involving the long head of the biceps tendon (LHBT) has evolved. Some techniques, such as keyhole tenodesis proposes bicortical drilling, however, carries an axillary nerve injury risk. The goal of our cadaveric study was to see if we could keep a safe zone between the point of exit of keyhole tenodesis of biceps and axillary nerve. Methodology: The study was performed on ten shoulders from five fresh frozen cadavers. Between the lower border of the transverse humeral ligament (THL) and the superior margin of the pectoralis major insertion at the lowest limit of the bicipital groove, a beath pin was driven through with the help of the modified tip aimer tibial jig procured from the anterior cruciate ligament reconstruction (ACL) set, which was fixed at an arc of 45°. The distance between the axillary nerve and beath pin at the exit point was measured. Results: The biceps tendon musculotendinous junction was followed all the way to the inferiorly and biceps tendon was found in the groove. The average distance from the axillary nerve to the exit point of the beath pin was 17.7 mm (range 14.4-20.9 mm, 95% CI). Conclusion: The axillary nerve is not injured during bicortical drilling when keyhole tenodesis of biceps is performed at the distal limit of the groove of biceps. The area in the biciptal groove between inferior margin of THL and superior border of pectoralis major insertion is safe area for biceps tenodesis.

ACL repair for athletes?

Background: The current gold standard treatment for an anterior cruciate ligament (ACL) tear in an athlete is an arthroscopic ACL reconstruction with autografts. This restores the knee stability but is associated with unique complications like graft re-tear, kinesiophobia and graft donor site morbidity. ACL suture repair (ACLSR) is an attractive alternative method of surgical management of this injury. Current science of ACLSR: The potential advantages of performing a repair are the preservation of native biology and proprioceptive function of ACL, elimination of a graft and preservation of bone stock. The purported benefits are better stability, reduction of kinesiophobia and faster rehabilitation. ACLSR is now performed only for proximal (femoral-sided) tears in the acute phase, when the tissue quality is good and using high-strength nonabsorbable sutures. There are several techniques for performing ACLSR but broadly speaking are either non-augmented, static augmented with suture tape, dynamic augmented or using bio-scaffolds. Clinical outcome of ACLSR: There is a lot of literature on ACLSRs including case series, cohort studies and randomized controlled trials. The results from these studies are encouraging but mostly pertain to patient reported outcome measures, are in small numbers and in the short-term. The results are also inconsistent across different studies and not specifically performed for the athletic population. Moreover, most of these studies are from the innovator or designer surgeons and groups and have not been independently validated. Conclusion: Currently, there is insufficient evidence to recommend ACLSR as a preferred method of managing even acute proximal tears in athletes. Improved rates of return to sports, lower retear rate and lesser kinesiophobia needs to be proven in athletes.

Magnetic resonance assessment of medial plica syndrome of knee from child to adult with arthroscopic correlation: A single center experience and literature review.

OBJECTIVE: Synovial plicae are mesenchymal tissue remnants invaginating into the knee joint. Their classification is based on the location as lateral, mediopatellar, suprapatellar, and infrapatellar. Mediopatellar plica is commonly symptomatic. The purpose of this study was to identify magnetic resonance (MR) characteristics of the medial plica and to correlate with arthroscopy for cause confirmation in patients with painful knee. MATERIALS AND METHODS: The current study was undertaken over a 2-year period between July 2017 and June 2019 in the department of radiology at a tertiary care hospital in India. MR examinations of the knee joint were performed using QUADKNEE coil on a 1.5-T scanner (Signa, General Electric Medical Systems, Milwaukee, WI, USA). The criteria studied were: presence of the plica, interposition into the femoropatellar joint, intraarticular effusion, and fenestrated aspect. Twenty-two knees (20 patients) diagnosed with mediopatellar plica syndrome on MR imaging (MRI), and with no other knee pathology, were treated with arthroscopic division of plicae. RESULTS: Only two (20.0%) of the ten knees in which the plicae had not been divided have shown improvement and six (85.7%) of the seven knees in which plica had been divided (P < 0.05) have shown improvement. Subsequent division of the plicae resulted in improvement in seven of the eight knees (87.5%) (P < 0.01). Patients presented with crepitus in 9% of cases (2 of 22), instability in 13.6% (3 of 22), pseudo-locking in 45.4% (10 of 22), and quadriceps atrophy in 54.5% (12 of 22). Fourteen knees (63.6%) had Grade 2 plica based on thickness. Twelve knees demonstrated (54.5%) Grade 2 intermediary effusion. Plica was fenestrated in three patients (13.6%). All patients regained full range of motion. Lysholm knee scale scores were compared prior to and postsurgery (preoperative status, 65.22 ± 7.41 vs. postoperative status, 89.43 ± 8.72) which revealed a significant clinical improvement (P < 0.001). Average visual analog scale (VAS) scores (0 - no pain, 10 - excruciating pain) when compared demonstrated a mean improvement was 4 points; from 6 points before surgery and 2 points' postsurgery after a mean follow-up of 3 months. About 68% of patients after arthroscopic resection had an average VAS score of 0 point and were totally pain free. CONCLUSION: Noninvasive capability of MRI can be used as a screening method in the diagnosis of mediopatellar plica syndrome and should be included in the differential diagnosis of internal derangement of the knee.

Traumatic Rupture of Posterior Tibial Tendon Following Closed Supination-Adduction Ankle Fracture: A Case Report.

CASE: A 25-year-old man with no known comorbidities presented with pain and swelling of the left ankle following a twisting injury that had occurred during a road traffic accident. On examination, a 1 × 1-cm abrasion was noted on the medial malleolus and tenderness was noted over the medial and lateral malleoli. A radiograph of the left ankle revealed a fracture of the medial malleolus and an infrasyndesmotic avulsion fracture of the lateral malleolus (a supination-adduction injury). Immediate surgery was performed for the treatment of the medial malleolar fracture. On exploration, the posterior tibial tendon was found to be severed and frayed 2 cm proximal to the medial malleolar fracture. The medial malleolus was fixed with 2 parallel malleolar screws. The ruptured tendon was explored proximally, and the ends were debrided and repaired. CONCLUSION: At 1 year of follow-up, the ankle had good union and function of the tendon was restored. Posterior tibial tendon ruptures, although rare, should be suspected in cases of closed ankle fracture, irrespective of the mechanism of injury.