Popliteal neurovascular bundle is safe during inside-out repair of medial meniscus without a safety incision.

PURPOSE: There is a theoretical risk of injury to neurovascular structures during inside-out meniscal repair without a safety incision, although there are limited studies assessing this risk. This simulation study on archival MRI films was performed to assess the risk for the popliteal neurovascular bundle and the peroneal nerve during passage of needles for inside-out meniscus repair without a "safety incision", thereby defining a "safe zone" of the menisci that can be safely repaired using this technique. METHODS: Archival MRI scans (n = 50) were retrieved and axial sections through the menisci were used for simulation. The needle passage was simulated for different points on the posterior horn and body of lateral and medial menisci at "half-hour" intervals using clock method (15° intervals) with three different portals and two different needle cannulas, resulting in six different scenarios of needle passage for each point on the meniscus. The distance of the needle in each scenario was measured from popliteal vessels (n = 50) and peroneal nerve (n = 10). The value "mean-3SD" was calculated for positive means and "Mean + 3SD" was calculated if the mean was negative. An additional 2 mm was defined as "safe distance". Thus, simulation models in which the mean - 3SD was less than 2 mm (or mean + 3SD was greater than - 2 mm for negative means) were labelled as "unsafe". RESULTS: Needle passage through medial meniscus at and medial to 1 o'clock position for a right knee (or 11 o'clock position for a left knee) was safe, irrespective of the portal and needle type. For the lateral meniscus, only the equatorial region was found to be safe with this method. CONCLUSIONS: The popliteal neurovascular bundle is safe during the inside-out medial meniscal repair without a safety incision. For the terminal-most part of the posterior horn, the AM portal and the straight cannula should be avoided. However, this method without safety incision cannot be recommended for lateral meniscus because of the risk to the popliteal vessels and the peroneal nerve. Instead, the inside-out method with a safety incision, or an all-inside method should be used for lateral meniscus. LEVEL OF EVIDENCE: III.

Optimal Angle of the Bone Tunnel for Avoiding Axillary Nerve Injuries During Arthroscopic Transosseous Rotator Cuff Repair: A Magnetic Resonance Imaging-Based Simulation Study.

BACKGROUND: Axillary nerve injury and suture cutout through the roof of the tunnel are potential complications of arthroscopic transosseous rotator cuff repair (ATORCR). PURPOSE: To determine a safe angle of drilling for the bone tunnel during ATORCR such that the axillary nerve is not at risk. The thickness of the bone bridge over the tunnel for different angles of drilling was also determined. STUDY DESIGN: Descriptive laboratory study. METHODS: The drilling of a straight tunnel was simulated on 30 magnetic resonance imaging (MRI) scans in the oblique coronal plane by drawing a straight line that passed at a "safe distance" of 5 mm from the axillary nerve and emerging at the medial border of the insertion of the rotator cuff on the greater tuberosity. The angle made by this line with the horizontal axis of the humerus was measured on 3 MRI sections: anterior (passing just posterior to the lateral lip of the bicipital groove), middle (at the most lateral point of the proximal humerus), and posterior (an equal number of cuts away from the middle section as between anterior and middle). The thickness of the overlying bone roof was measured for this line as well as for simulation lines drawn at 50°, 55°, 60°, and 65° with the horizontal axis. A "safe limit," defined as the mean - 2SD, was also calculated. RESULTS: The axillary nerve was found to be safe, with a safety margin of 5 mm, at drill angles of less than 61.1° and 60.3° in the posterior and middle sections, respectively. The safe limit value for thickness of the overlying bone roof for the tunnel drilled at 60° was 5.0 mm in the posterior section (mean, 8.2 ± 0.3 mm) and 5.5 mm in the middle section (mean, 8.1 ± 0.2 mm). In the anterior section, the minimum safe angle was 57.7°, and the mean thickness of the bone roof for the 55° angle was 6.3 ± 0.2 mm (safe limit, 3.7 mm). CONCLUSION: Straight bone tunnels in ATORCR surgery should be drilled at an angle of 60° to the horizontal axis of the humerus or 30° to the humeral shaft to ensure the safety of the axillary nerve while at the same time ensuring adequate thickness of the overlying bone roof. The anterior tunnel close to the bicipital groove should be drilled cautiously at 55° to the horizontal axis or 35° to the humeral shaft. CLINICAL RELEVANCE: The findings of the present study will help the surgeon choose the best angle for drilling tunnels during ATORCR surgery to avoid axillary nerve injuries as well as suture cut-through without the need for any proprietary device.

Multi-organ hydatidosis with extensive involvement of the hemi-pelvis and ipsilateral femur.

Bone involvement of hydatid disease is uncommon but when encountered, it presents few unique pathological features. The pattern of tissue involvement is largely different from that of visceral hydatid cyst. We describe the case of a 47 year-old man from northern India, a case of systemic hydatidosis including the liver and the right lung, presenting with an abscess like lesion in the left gluteal region with pathological fractures of the left femur. Radiographs and CT-scan images showed extensive invasion of the left hemi-pelvis and left proximal femur. Debridement of the honeycombed ilium yielded hydatid fluid, numerous small cysts and necrotic material. Multiple large devitalized and sequestrated bone pieces were recovered from the bone cavity of the affected ilium. A histopathological study of the bone sequestrums revealed the unique pattern of bone invasion by the characteristic laminated multi-layered cyst walls into areas of least resistance. Bone sequestration has not often been described or demonstrated elaborately in published studies of the past. The bone defects formed after debridement of the ilium and proximal femur were filled with bone cement along with augmentation of the femur using intra-medullary nail. The surgical technique adopted in our case although was not expected to be curative owing to the multi-system disease; it did result in significant functional improvement in the patient.

Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia.

BACKGROUND: Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail. MATERIALS AND METHODS: Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at least one year. RESULTS: The average operative time was 90 min (range, 55-125 min) for femoral fractures and 53 min (range, 25-115 min) for tibial fractures. Radiation exposure was minimum, average being 84 seconds (range, 54-132) for femoral fractures and 54 seconds (range, 36-78) for tibial fractures. All fractures healed, but few had complications, such as infection (one case with tibial fracture) bent femoral nail with malunion (n = 1), and delayed union (n = 3; 2 cases in femur and 1 case in tibia). Mean time of union was 5.1 months (range, 4-10(1/2) months) for femoral fractures and 4.8 months (range, 3-9 months) for tibial fractures. CONCLUSION: We found the nail very easy to use with effective fixation in AO type A and B fractures in our setting. Less surgical time is required with minimum complications. The main advantage of the expandable nail is that if affords. satisfactory axial, rotatory, and bending stability with decreased radiation exposure to operating staff and the patient.

One-stage osteotomy and fixation using a long proximal femoral nail and fibular graft to correct a severe shepherd's crook deformity in a patient with fibrous dysplasia: a case report.

We report a case where a one-stage osteotomy and fixation, using a long proximal femoral nail and fibular graft, was performed to correct a severe shepherd's crook deformity (70-degree varus and 50-degree retroversion) of the femoral neck with a pathological stress fracture in a patient with fibrous dysplasia. The neck shaft angle was corrected to 125 degrees. At the 57-month follow-up, the patient was free of pain and had no limp or evidence of recurrence.