A potential risk factor of total knee arthroplasty: an infected Baker's cyst - a case report.

BACKGROUND: In adults, Baker's cyst development is attributable principally to secondary alterations after degenerative changes. The latter changes often accompany osteoarthritis, and we frequently encounter patients with Baker's cysts seeking total knee arthroplasty (TKA). Baker's cysts are not usually subject to extensive preoperative evaluation because the cysts often disappear naturally after surgery, unaccompanied by any adverse symptoms. CASE PRESENTATION: A 63-year-old woman presented with moderate pain in the left knee joint that had developed 1 year ago. Posterior knee pain was aggravated on maximum knee flexion. Three months previously, a popliteal mass had become palpable and the patient had undergone needle mass aspiration twice in a local orthopedic hospital, but the mass had recurred. We initially considered TKA for her severe degenerative osteoarthritis. However, we decided to perform only arthroscopic debridement and cyst excision because the patient was experienced severe pain only on maximal knee flexion, and did not want TKA. Pus gushed from the torn cyst during the operation. We diagnosed an infected Baker's cyst. The patient was treated with a first-generation cephalosporin postoperatively. CONCLUSIONS: A Baker's cyst that was aspirated and still causes symptoms with altered blood tests needs to be evaluated accurately before TKA.

A pulled sutures technique for bony Bankart lesion.

In an attempt to present a new surgical technique for arthroscopic bony Bankart fixation, the authors developed the pulled sutures technique. In executing the new method, the authors first passed several non-absorbable sutures through labroligamentous tissue with displaced articular fragment by mimicking transglenoid suture technique. Aimed at achieving a safe and stable fixation, using a knotless anchor rather than transglenoid suture, was deployed. Overall, this pulled sutures technique was shown to be effective with the result of direct reduction, stable, and safe fixation for bony Bankart's lesion.

Simplified Technique for Arthroscopic Repair of the Meniscus Root Tear of the Knee.

This report describes the arthroscopic transtibial pullout repair technique using multiple simple stitch (MSS), which was used to treat a medial meniscus posterior root tear (MMPRT) of the knee. The most commonly used technique to address this type of MMPRT is currently arthroscopic transtibial pullout repair. MSS pullout repair technique can provide excellent pullout strength and large tissue-bone contact area, which facilitates successful healing potential. This MSS pullout repair technique may be suggested as another useful option that can be used in the treatment of MMPRT.

A technique for repairing rotator cuff transtendinous tears with a remnant attached to the footprint.

BACKGROUND: Some unusual rotator cuff (RC) tears are located in more proximal tendinous portions, with substantial remnant tissue attached to the footprint. The two options for surgical repair are sacrificing or preserving the remnant tissue. We introduce a surgical repair technique that preserves as much of the remnant footprint as possible. SURGICAL TECHNIQUE: A double-loaded suture anchor is inserted into the subchondral bone at the medial portion of the RC footprint; the lateral remnant tissue is preserved. Each strand is shuttled and repassed through the medial portion of the tendon in a mattress fashion using a suture hook device. Then, multiple no. 1 PDS sutures are passed through the medial and lateral stumps and left untied. Strands from the suture anchor are first tied in a double mattress fashion. Then, the repair is completed by tying the remaining no. 1 PDS sutures. CONCLUSIONS: We propose a remnant-preserving RC repair technique for transtendinous RC tears with sufficient tissue remaining within the RC footprint. This technique appears advantageous in terms of re-establishing an environment that promotes tendon healing after repair.

Arthroscopic treatment of Mycobacterium massiliense septic arthritis outbreak after intra-articular injection: A case-series report and literature review.

ABSTRACT: Non-tuberculous mycobacteria (NTM) comprise mycobacteria, with the exceptions of Mycobacterium (M.) leprae and the M. tuberculosis complex. Septic arthritis caused by NTM is so rare that there is no standardized treatment.Between April and September 2012, 27 patients were infected with M. massiliense in a single clinic following injection of steroid in the knee joint. Clinical data of 9 patients who received arthroscopic treatment in Seoul Hospital of Soonchunhyang University were analyzed retrospectively.Arthroscopic irrigation and debridement were performed average 2.6 times (1-3 times). As 6 out of 9 cases (67%) had joint contracture of the knee joint, arthroscopic adhesiolysis, and brisement were performed. After surgical procedures, Hospital for Special Surgery and Lysholm knee score showed improvement compared before the surgery, but a radiographic result evaluated by Kellgren-Lawrence revealed that 6 cases got deteriorated to stage 4 in the 4-year follow-up.NTM septic arthritis had a higher recurrence and a higher contracture incidence than septic arthritis caused by tuberculous mycobacteria or other bacteria. Treatment was possible with repeated arthroscopic debridement and intravenous antibiotics.

Staged patellar tendon reconstruction using doubled bone-patellar tendon-bone allograft for infected patellar tendon rupture: a rare case report of three years follow-up.

BACKGROUND: Patellar tendon rupture is a relatively rare injury that usually requires surgical treatment. The optimal therapeutic strategy is still controversial, especially when either concomitant patellar tendon infection or soft tissue infection surrounds the patellar tendon. Until recently, most reported reconstruction methods are extensive and difficult to apply because of the poor condition of the soft tissue surrounding the patellar tendon. CASE PRESENTATION: A 19-year-old male patient presented to our clinic three weeks following a motorcycle accident. There was a 5 x 4 cm sized skin defect with soft tissue infection below the inferior pole of patella. We performed a staged patellar tendon reconstruction using a doubled bone-patellar tendon-bone allograft (BPTB) to the infected patellar tendon rupture, following local random fasciocutaneous flap and split-thickness skin graft. Three months following surgery, the patient was able to perform an active knee motion with no extension lag and excellent clinical functional result. DISCUSSION AND CONCLUSIONS: Our technique introduced in this specific case is a relatively simple method to reconstruct chronic patellar tendon defects with limited incision exposing only the patellar tendon areas. We expect it can be less invasively performed on patients who have a soft tissue problem and cannot have extensive surgery.

A case of intra-articular synovial lipoma of the knee joint causing patellar dislocation.

Intra-articular synovial lipoma is rare and clinically manifested mostly by mass effect and occasionally by torsion of the stalk. Patellar dislocation rarely occurs owing to a mass effect of intra-articular tumor of the knee joint. The authors present a case of large intra-articular synovial lipoma at the lateral gutter of the knee joint, which presents as patellar dislocation. A 19-year-old man visited our clinic due to pain and limitation of motion owing to mass at his left knee. MRI revealed an intra-articular soft tissue mass at the lateral gutter of the knee joint with considerable mass effect displacing patella from the trochlear groove. Excisional biopsy confirmed the diagnosis of lipoma, and the final diagnosis was intra-articular synovial lipoma with clinical information. The final radiograph showed well-aligned patella on the trochlear groove. After marginal excision, there was no recurrence or tumor-related morbidity.

Preservation of the Tibial Remnant in Anterior Cruciate Ligament Reconstruction May Improve Postoperative Proprioceptive Function.

The purpose of this study was to retrospectively compare clinical results, including proprioceptive function, after anterior cruciate ligament (ACL) reconstruction between 2 groups using techniques that preserve and eliminate the tibial remnant. Forty-eight patients who were followed for at least 24 months after ACL reconstruction with 4-strand hamstring tendon autografts were enrolled in this study. They were then divided into 2 groups: the remnant-preserving group (group A, 26 patients), in whom more than 7 mm of the remnant tibial stump (approximately 20% of the mean length of the ACL) was preserved; and the remnant-eliminating group (group B, 22 patients), in whom the tibial remnant was eliminated during ACL reconstruction. The average duration of follow-up was 25.5 months. At last follow-up, patients were evaluated using the International Knee Documentation Committee scale, Hospital for Special Surgery score, Lachman test, arthrometer, reproduction of passive positioning (RPP) test, threshold to detection of passive motion (TTDPM) test, one-leg hop test, and single-limb standing test. The clinical results between the 2 groups were statistically compared. Group A showed significantly better results on the RPP test at 15° (P=.040) and 30° (P=.010), one-leg hop test (P=.017), and single-limb standing test (P=.007) compared with group B. The other results showed no significant differences. The remnant-preserving technique in ACL reconstruction yields better proprioceptive and functional outcomes and may help achieve postoperative patient satisfaction. [Orthopedics. 2020;43(4):e231-e236.].

Comparison of functional outcomes between single-radius and multi-radius femoral components in primary total knee arthroplasty: a meta-analysis of randomized controlled trials.

PURPOSE: Our purpose in the current meta-analysis was to compare the functional outcomes in patients who have received single-radius (SR) or multi-radius (MR) femoral components in randomized controlled trials (RCTs) for primary total knee arthroplasty (TKA). The hypothesis was that there would be no statistically significant difference between two groups in terms of functional outcomes. MATERIALS AND METHODS: We searched the international electronic databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to February 2020 for RCTs that compared functional outcomes of SR and MR femoral component designs after primary TKA. We performed a meta-analysis of nine RCTs using the Knee Society Score for the knee (KSS-knee), KSS-function, Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), degree of knee flexion, extension, and complications, including postoperative infection and revision surgery. RESULTS: The meta-analysis revealed no statistically significant differences in all the analyzed variables, including KSS-knee, KSS-function, KOOS, OKS, knee flexion, and knee extension. For postoperative complications, no statistically significant differences were detected for femoral component designs in postoperative infection or incidence of revision surgery between the two groups. CONCLUSIONS: The current meta-analysis of RCTs did not show any statistically significant differences between SR and MR femoral component designs in terms of postoperative functional outcomes. Evaluated outcomes included functional outcome scores, degree of knee flexion, extension, and complications. However, because of the limited clinical evidence of this study owing to the heterogeneity between the included RCTs, a careful approach should be made in order not to arrive at definite conclusions.

Immunohistochemical study of mechanoreceptors in the tibial remnant of the ruptured anterior cruciate ligament in human knees.

This study was performed to identify the mechanoreceptors in the tibial remnants of ruptured human anterior cruciate ligaments (ACL) by immunohistochemical staining. Thirty-six specimens of tibial ACL remnants were obtained from patients with ACL ruptures during arthroscopic ACL reconstruction. As control, two normal ACL specimens were taken from healthy knee amputated at thigh level due to trauma. The specimen was serially sectioned at 40 mum. In control group, the average number of sections per specimen was 132, and a total of 264 slices were available. In remnant group, the average number of sections per specimen was 90, and a total of 3,251 slices were available. Immunohistochemical staining was performed to detect the neural element of mechanoreceptors. Histologic examinations were performed under a light microscope and interpreted by a pathologist. Nineteen (8 Ruffini, 11 Golgi) mechanoreceptors were identified in the two normal ACLs, which were evenly distributed at both tibial and femoral attachments. In the remnant group, mechanoreceptors were observed in 12 out of 36 cases (33%), and a total of 17 (6 Ruffini and 11 Golgi) mechanoreceptors observed. No significant differences in the harvest volume, number of sections, age, or time between injury to surgery was observed between the 12 mechanoreceptor-present and the 24 mechanoreceptor-absent ones. The presence of mechanoreceptor at the tibial remnants of torn ACLs was verified. The immunohistochemical staining methodology proved useful, but requires further refinement. Although the mechanoreceptors were detected relatively less frequently than expected, the authors consider that it does not negate the necessity of remnant-preserving ACL reconstruction.

A case of compression fracture of medial tibial plateau and medial femoral condyle combined with posterior cruciate ligament and posterolateral corner injury.

We report a case of compression fracture of anterior margin of medial tibial plateau and medial femoral condyle combined with the posterior cruciate ligament and posterolateral corner disruption. A thirty-seven-year old male had undergone the left knee injury 6 months before. The physical examination revealed positive posterior drawer test and tibial dial test, which evidenced the posterior cruciate ligament and posterolateral corner insufficiency. The plain lateral knee radiographs showed a marginal fracture of the anteromedial tibial plateau and a dimpling on the adjacent part of the medial femoral condyle. On arthroscopy, there were no gross tear of the cruciates, but the posterolateral capsule disclosed stigmata of stretching injury with multiple petechiae and scarring. The compression fracture on the anteromedial side and the stretching injury on the posterolateral side altogether support the mechanism of hyperextension pivoting on the anteromedial side of the knee joint. A small bony lesion around the knee joint should be inspected rigorously with an assumed mechanism of injury for it may herald major ligamentous injury.

Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases.

We report two cases of ganglion cysts in the posterior septum of the knee joint, one as parameniscal cyst from the posterior horn of the lateral meniscus extending to posterior septum, and the other as a cyst located in the posterior septum adjacent to the posterior cruciate ligament, which were both arthroscopically excised expediently by posterior trans-septal portal. The posterior compartment of the knee is not readily accessible by ordinary arthroscopic portals, and therefore has been considered as 'blind spot' conventionally. The posterior trans-septal portal is useful for assorted diagnostic or manipulative procedures in the posterior compartment of the knee.

Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft.

PURPOSE: The purpose of this study was to analyze the clinical results of anterior cruciate ligament (ACL) reconstruction with the remnant-preserving technique by use of a hamstring graft and looped sutures according to the amount of the tibial remnant of the ACL. METHODS: Sixteen subjects had undergone ACL reconstruction with the remnant-preserving technique by use of 4 strands of a hamstring tendon and a looped suture technique and were followed up for at least 12 months. The mean follow-up was 35.1 months. At the last follow-up examination, the patients were evaluated with the International Knee Documentation Committee scale and Hospital for Special Surgery score as subjective tests; stress radiographs, Lachman test, and anterior drawer test by use of the KT-2000 arthrometer (MEDmetric, San Diego, CA) as objective tests; and single-legged hop test, reproduction of passive positioning, threshold to detection of passive motion, and single-limb standing test as functional tests. On the basis of the extent of ACL remnant, patients were then divided into 2 groups. Group I comprised patients with more than 20%, and group II comprised those with less than 20%. For each of the 2 groups, a statistical comparison of the final results was made. RESULTS: The mean Hospital for Special Surgery score improved from 65.8 (preoperatively) to 95.2 (at last follow-up). Functional evaluation revealed that the difference was not significant in terms of mechanical stability, but a significant difference was detected in functional outcome and proprioception. Regarding the threshold to detection of passive motion at 30 degrees (P = .030) and reproduction of passive positioning at 15 degrees (P = .032) and 30 degrees (P = .024), group I (> 20%) showed better results than group II (< 20%). CONCLUSIONS: We confirmed that the remnant-preserving technique described showed good proprioceptive and functional outcomes with statistical significance. Therefore it may be expected that the more the tibial remnant is kept intact, the better the preservation of proprioceptive function will be. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Migration to the popliteal fossa of broken wires from a fixed patellar fracture.

Breakage of K-wires and wires which are used for fracture fixation is not uncommon, but migration is rare. The authors experienced two cases of symptomatic migration of broken K-wire and wires used for patellar fixation to the popliteal fossa. Migration of broken hardware happened 3 and 4 years after fixation. The broken hardwares were removed surgically. We would like to suggest that K-wire and wire fixation used for treatment of patella fractures can migrate into the posterior compartment of the knee and cause clinical symptoms. Correct surgical technique and fixative choice should be considered for treatment of the patellar fracture.

Isolated tear of the cord-like middle glenohumeral ligament in Buford complex: A case report.

RATIONALE: We describe a rare case of the isolated tear in the cord-like middle glenohumeral ligament (MGHL) in Buford complex. To the best of our knowledge, this is the first report in the English literature about the isolated tear of cord-like MGHL in Buford complex. The present report describes in detail our experience with the diagnosis of isolated tear of the cord-like MGHL in Buford complex and management. PATIENT CONCERNS: A 50-year-old female patient visited our hospital with pain and stiffness in the right shoulder that lasted for 9 months. DIAGNOSES: The clinical impression was frozen shoulder by primary impingement syndrome of right shoulder and the magnetic resonance (MR) images showed tear of cord-like MGHL. INTERVENTIONS: We repaired the torn MGHL with the arthroscopic technique. OUTCOMES: Positive outcome by arthroscopic repair demonstrates that this disease entity is one of spectrum of pathologic condition in shoulder joint. LESSONS: Isolated tear of cord-like MGHL should be restored to the original anatomy for positive outcome.

Arthroscopic anterior cruciate ligament reconstruction with the tibial-remnant preserving technique using a hamstring graft.

We propose that the tibial remnant of the anterior cruciate ligament (ACL) is able to enhance the revascularization and cellular proliferation of the graft, to preserve proprioceptive function, and to be able to acquire anatomic placement of the graft without roof impingement. Therefore, it seems reasonable to assume that preserving the tibial remnant as much as possible as a source of reinnervation, if technically possible without causing impingement, would be of potential benefit to the patient. Our surgical technique was developed to maximize the preservation of the tibial remnant. The distally attached semitendinosus and gracilis tendons are harvested using the tendon stripper. After satisfactory placement of 2 guide pins convergently, a closed-end socket in the lateral femoral condyle is created using an adequately sized curved curette. For anatomic placement of the graft, the tibial tunnel should be positioned within the boundaries of the normal ACL tibial remnant. The reamer must be advanced very carefully to minimize injury to the residual remnant at the intra-articular margin of the tibial tunnel. Penetration should stop at the base of the stump. The folded grafts are then pulled intra-articularly through the tibial tunnel, the tibial remnant, and the femoral socket by pulling sutures under arthroscopic visualization. The ACL tibial remnant is compacted by the tendon passage. The graft is secured proximally by tying sutures in the lateral femoral condyle and distally at the tibia with double staples by a belt-buckle method. The advantages of our technique include maximal preservation of the tibial remnant, no roof impingement caused by intrasynovial anatomic placement of the graft, the simplicity of the procedure, the minimal need for hardware or special instruments, the economic benefit, and the potential prevention of tibial tunnel enlargement by preventing synovial fluid leakage.

Clinical features and treatment outcomes of septic arthritis due to Mycobacterium massiliense associated with intra-articular injection: a case report.

BACKGROUND: There are increasing reports on nosocomial Mycobacterium massiliense infection, but septic arthritis and osteomyelitis because of that microorganism is rare. This report focuses on the clinical aspects of M. massiliense arthritis outbreak concurrent with soft tissue infection. CASE PRESENTATION: An outbreak of septic arthritis among patients who had been injected at a single clinic occurred in South Korea between April and September 2012. This may be associated with repeated injection of triamcinolone contaminated with M. massiliense. Nine of the Korean patients visited our hospital complaining of painful swelling of the knees. During treatment course, patients are suffered from soft tissue abscess around the injection site. Acid-fast bacilli culture for infected tissue was positive in five patients, and polymerase chain reaction for non-tuberculous mycobacteria was positive in four patients. They were treated with antibiotics, repeated arthroscopic surgeries, incision and drainage for a long time. All patients were eventually cured but three patients have suffered from a decreased range of motion. CONCLUSION: Early clinical suspicion and microbiological diagnosis are key factors in reducing morbidity since septic arthritis with M. massiliense manifests late after the injection and treatment of it is a laborious process.

Does the tibial remnant of the anterior cruciate ligament promote ligamentization?

BACKGROUND: The purpose of this study was to clarify the difference in ligamentization between the remnant-preserving (RP) and remnant-sacrificing (RS) techniques in anterior cruciate ligament (ACL) reconstruction using magnetic resonance imaging (MRI). METHODS: A retrospective comparative study was carried out on 98 patients undergoing ACL reconstruction using either an RP (n=56) or RS (n=42) technique. MRI was performed at one of four time points postoperatively, and the signal intensity of the ACL graft was analyzed using the signal to noise quotient (SNQ) ratio and inter-bundle high signal intensity, along with an analysis of the survival rate of remnant tissue. RESULTS: The mean SNQ ratio of grafted tendons in the RP group was significantly higher than that seen in the RS group in the proximal and middle regions two to four months after surgery (P<0.05) and was significantly lower than that seen in the RS group in all regions at 12 -18months (P<0.05). The inter-bundle high signal intensity was observed more frequently in the RP group (73.7%) at two to four months. Tibial remnants were observed on postoperative MRI regardless of when MRI was conducted. CONCLUSION: The ACL graft of the RP group showed higher signal intensity in the early stage and lower signal intensity in the late stage compared to that of the RS group. The ligamentization of grafts in the RP group proceeded more quickly. Preserving the remnant in ACL reconstruction appears to have a positive effect on ligamentization.

Concomitant Osteochondral Autograft Transplantation and Fixation of Osteochondral Fragment for Treatment of a Massive Osteochondritis Dissecans: A Report of 8-Year Follow-up Results.

Numerous procedures exist to treat osteochondritis dissecans (OCD); however, it remains a topic of debate which procedure is most ideal. When restoring a massive osteochondral defect, the use of only one procedure may not always allow complete filling of the defect. This case report presents a massive OCD with displaced osteochondral fragment and loose body in the knee joint that occupied almost all of the weight bearing area of the medial femoral condyle and was treated with concomitant osteochondral autograft transplantation and fixation of displaced osteochondral fragment. To our knowledge, this is a rare report on OCD treated with concomitant osteochondral autograft transplantation and fixation of displaced osteochondral fragment. At 8 years after surgery, the clinical outcome was excellent, and radiographs revealed congruence of the medial femoral condyle. The patient returned to sports activities. In massive and complex OCD lesions, individual techniques have limitations. Two or more techniques are needed to increase the rate of success.

Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction With Remnant Preservation Using Outside-In Technique.

This report describes a modified anatomic single-bundle anterior cruciate ligament (ACL) reconstruction technique using the FlipCutter guide pin (Arthrex, Naples, FL) as a retrograde drill and a cortical suspensory fixation device (TightRope; Arthrex) with an adjustable graft loop length. Preservation of the ACL remnant as a biological sleeve for the graft is an important issue from the viewpoints of acceleration of revascularization and ligamentization, preservation of the proprioceptive nerve fibers, enhancement of the biological environment for healing, and maintenance of the anchor point at the native tibial attachment, in addition to yielding a lower incidence of tibial bone tunnel enlargement. The goal of our technique is to obtain some advantages of the remnant-preserving technique through an anatomic single-bundle ACL reconstruction, which is performed to minimize damage to the ACL tibial remnant.