Biceps femoris snapping and friction on the fibular head secondary to abnormal distal tendon insertion: 15 cases and a literature review.

INTRODUCTION: Abnormal biceps femoris distal tendon insertion can cause tendon snapping, as is well-known in the literature. The presenting symptom is lateral knee pain, often during sports activities and cycling in particular. The present study tested two hypotheses: abnormal biceps femoris insertion on the fibular head may cause painful friction without clinical snapping, whether visible, audible or palpable; surgical correction achieves good results for pain and return to sport, regarding both snapping and friction. MATERIAL AND METHODS: Between 2006 and 2017, 11 patients were managed for pain secondary to abnormal biceps femoris insertion. In 4 cases, pain was bilateral, resulting in a total of 15 knees: 9 with snapping (in 6 patients), and 6 with friction syndrome without snapping (in 5 patients). All 6 patients with snapping were male, with a mean age of 29 years. Friction without snapping concerned 3 female and 2 male patients, with a mean age of 30 years. Study data included type and level of sport, clinical signs, imaging, type and results of treatment, and type of abnormality. RESULTS: The insertion abnormality consisted in excessively anterior insertion in the fibular arm in 6 cases, in predominantly tibial insertion in 2 cases, and in isolated tibial insertion in 4 cases. Surgery mainly consisted inrelease and reinsertion of the distal biceps femoris tendon (in 7 cases). All patients were able to return to sport. The mechanism underlying snapping and friction was the same: distal biceps tendon friction on the fibular head secondary to unduly anterior fibular or predominantly or exclusively tibial insertion. DISCUSSION: The literature reports 24 cases, all of snapping, with between 1 and 3 cases per author. These findings were compared with the present results. With or without snap, symptoms are secondary to abnormal tendon insertion and to activity or sport requiring repeated knee flexion greater than 90°. CONCLUSIONS: (1) Case studies show that lateral knee pain by friction on the fibular head is not systematically accompanied by snapping. (2) In all reports and in the present series, surgery was highly effective on snapping and pain, and patients returned to sport at their previous level. LEVEL OF EVIDENCE: IV.

An anterior ankle arthroscopic technique for retrograde osteochondral autograft transplantation of posteromedial and central talar dome cartilage defects.

PURPOSE: The purpose of this study was to present an arthroscopic technique for the treatment for posteromedial and central cartilage defects of the talus using anterior arthroscopic portals and without performing a medial malleolar osteotomy. METHODS: Nine fresh cadavers were dissected. Autografts were implanted under arthroscopy using a retrograde osteochondral transplantation system, and their position was estimated using specific angular calibrators and later confirmed by software analysis of two photographs of the disarticulated ankle joint. RESULTS: In eight cases, the congruence between the surrounding articular cartilage and the cartilage of the graft was high, with differences measuring <1 mm. There were no iatrogenic cartilage lesions of the tibial plafond and no fractures of the talus. All the autografts remained stable during full range of motion cycles of the ankle joint. One failure was reported. CONCLUSION: This cadaveric study showed that the retrograde osteochondral autograft transplantation technique in the talus is feasible. It can be used to restore the posteromedial and central talar articular surfaces using conventional ankle arthroscopic instrumentation and anterior arthroscopic portals without resorting to a medial malleolar osteotomy. Further clinical and biomechanical studies are required to prove the efficacy of this technique and its reproducibility in routine clinical practice.

Neurovascular anatomic relationships to arthroscopic posterior and transseptal portals in different knee positions.

BACKGROUND: No study exists that directly measures the distances between posterior portals and the popliteal artery under arthroscopic conditions. PURPOSE: To define the anatomic relationship between the neural structures and standard posterior arthroscopic portals and between the popliteal artery and posterior as well as transseptal portals in different knee positions. STUDY DESIGN: Descriptive laboratory study. METHODS: Seventeen fresh-frozen cadaveric knees were used. The posterolateral, posteromedial, and transseptal portals were established at 90° of knee flexion. The popliteal artery was revealed using a shaver placed through the posteromedial portal. The distance from those portals to the popliteal artery was measured using a precision caliper. After the measurements were made, each specimen was dissected. The distance from a needle, blade, and cannula in each portal site to the adjacent neural structures was successively measured at 30°, 90°, and 120° of knee flexion. RESULTS: The mean distance (in millimeters) from the posterolateral, posteromedial, and transseptal portals to the popliteal artery was significantly smaller at 30° (32.1 ± 4.6, 36.5 ± 4.9, and 9.0 ± 3.9, respectively) than at 90° (40.7 ± 5.1, 41.0 ± 3.8, and 18.0 ± 3.8, respectively) and 120° (38.4 ± 4.8, 38.7 ± 6.0, and 21.0 ± 4.0, respectively) of knee flexion. The mean distance from the posterolateral portal to the common peroneal nerve at 90° of flexion (needle, 26.6 ± 9.5; blade, 24.7 ± 6.9; cannula, 22.1 ± 6.9) was significantly greater than the distance at 30° (needle, 23.4 ± 6.5; blade, 21.4 ± 6.4; cannula, 18.4 ± 6.3) and 120° (needle, 21.8 ± 6.6; blade, 19.1 ± 6.3; cannula, 17.4 ± 6.7) of knee flexion. The mean distance between the posteromedial portal and the inferior infrapatellar branch of the saphenous nerve at 30° (needle, 18.6 ± 4.3; blade, 15.5 ± 3.3; cannula, 13.7 ± 5.8) of flexion was smaller than at 90° (needle, 20.1 ± 6.1; blade, 16.5 ± 5.3; cannula, 14.3 ± 4.4) and 120° (needle, 21.1 ± 3.6; blade, 17.7 ± 4.9; cannula, 15.1 ± 5.9) of flexion, but there was no statistical significance. The mean distance from the posteromedial portal to the sartorial branch of the saphenous nerve at 30° (needle, 22.8 ± 6.1; blade, 19.8 ± 5.3; cannula, 17.7 ± 6.2) of flexion was significantly smaller than that at 90° (needle, 29.7 ± 3.6; blade, 26.3 ± 6.3; cannula, 23.1 ± 4.7) and 120° (needle, 31.5 ± 3.9; blade, 28.9 ± 4.1; cannula, 25.4 ± 5.1) of flexion. Conclusion/ CLINICAL RELEVANCE: The position of 90° of knee flexion is safe to establish posterior and transseptal arthroscopic portals. The position of 120° of knee flexion is practically safe to establish posteromedial and transseptal portals, but it is unsafe to create a posterolateral portal because the risk of damaging the common peroneal nerve is high. The position of 30° of knee flexion is not recommended to establish posterior arthroscopic portals.

Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study.

BACKGROUND: There are only 2 reported cases of arthroscopic retrograde osteochondral autograft transplantations regarding tibial plateau cartilage defects. PURPOSE: To present a detailed description of arthroscopic retrograde osteochondral autograft transplantation of the tibial plateau as well as to provide its advantages and disadvantages in comparison with other techniques. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Four patients (3 men and 1 woman; mean age, 31.2 years) suffering from tibial plateau cartilage lesions underwent surgery. In each case, the lesions were caused by sports injuries. There were 3 lateral and 1 medial tibial plateau defects. The International Knee Documentation Committee (IKDC) score and Knee injury and Osteoarthritis Outcome Score (KOOS) were recorded preoperatively and postoperatively. Radiological assessment was made by plain radiographs, CT arthroscans, and MRI. RESULTS: The mean follow-up was 55 months (range, 52-60). The mean preoperative IKDC score was 53.5 (range, 37-66), while the mean postoperative IKDC score at final follow-up was 95.4 (range, 93.1-97.7). Regarding the KOOS calculation, there was significant improvement concerning each parameter after surgery. All patients were satisfied with the surgical procedure and returned to their previous activity level. Postoperative imaging showed very good adaptation and incorporation of the osteochondral autografts. CONCLUSION: Treatment of tibial plateau cartilage defects with arthroscopic retrograde osteochondral autograft transplantation could be performed on a routine basis in clinical practice. The results were encouraging and showed good incorporation of the graft, a minimal failure rate, and satisfactory functional outcomes of patients.

Fixation of posterior cruciate ligament avulsion fracture with the use of a suspensory fixation.

PURPOSE: Posterior cruciate ligament (PCL) avulsion fractures are uncommon injuries, and their treatment, still, remains difficult. There are procedures described in the literature which are minimal invasive and use either sutures or screws to stabilize the avulsed fragment. The purpose of this study was to present an innovative arthroscopic technique using a suspensory device with specific biomechanical properties. The aim of this study was to determine whether this technique was effective in the treatment of PCL avulsion fractures and applicable in everyday clinical practice. METHODS: Two patients with an isolated posterior cruciate ligament avulsion fracture were operated under arthroscopy. The Endobutton device was used to stabilize the fracture, and a double-spike plate was used to secure the fixation. The clinical assessment of patients was made by plain radiographs, CT scan, MRI and IKDC examination form. RESULTS: The median operative time was 57.5 min (range 55-60). No posterior tibial sag was noticed, and the range of motion was normal. No complications were recorded, and both patients returned to their usual daily activities. Both fractures had healed at 10 months postoperatively. CONCLUSIONS: Treatment outcomes using a suspensory device in the fixation of posterior cruciate ligament avulsion fractures are encouraging. The small size of the device makes it easy to handle, and the procedure is simple and does not require multiple sutures and bony tunnels. This technique offers sufficient compression, restores the length of posterior cruciate ligament and can fix avulsion fragments of any size. LEVEL OF EVIDENCE: Therapeutic study, Case series with no comparison group, Level IV.

Arthroscopic treatment of a talar neck fracture: a case report.

UNLABELLED: Talar neck fractures are severe injuries, and their complications can lead to significant functional disability. Open reduction and internal fixation still constitute the treatment of choice. We report a case of a patient with a Hawkins type III talar neck fracture who was treated successfully with the use of an entirely arthroscopic technique. Four arthroscopic portals were used to control fracture reduction and fixation, which was made by two cannulated screws. There were no complications, and the patient returned uneventfully to her previous daily activities. LEVEL OF EVIDENCE: Therapeutic study, Case report with no comparison group, Level IV.