Percutaneous Intramedullary Application of Stem Cells for Fifth Metatarsal Fractures Treated With a Cannulated Screw.

Non-union and refracture of fifth metatarsal fractures are common and devastating complications in the athletic population. Stem cell application at the fracture site, for biologic enhancement, is utilized to address this challenge. We present a simple technique to approach both the endosteum and the periosteum percutaneously, under a local anesthetic, in cases of cannulated screw intramedullary fixation.

Hypertrophied medial parapatellar plica: a case of a medial plica anatomical variation with insertion to the inter-meniscal ligament in an adolescent athlete treated arthroscopically.

PURPOSE: The present study aims to report the arthroscopic, radiological and clinical appearance of a rare anatomical variation of a hypertrophied medial parapatellar plica with its response to arthroscopic treatment. CASE PRESENTATION: A 14-year-old female handball athlete presented with a history of left knee injury during her participation in a handball training session and subsequent locked knee at 20º flexion. Tenderness was located at the medial joint line. Plain radiographs of the injured knee were normal. The magnetic resonance imaging revealed a hypertrophic medial parapatellar plica and a horizontal tear of the medial meniscus. A standard knee arthroscopy was performed. An extremely hypertrophied medial plica was identified, covering a great part of the medial femoral condyle extending up to the femoral trochlea. Distally, it was attached into the inter-meniscal ligament. The plica was excised and the medial meniscus tear was repaired. At 1-month post-operatively, the patient was completely asymptomatic and at 3-months she returned to her weekly training routine. CONCLUSIONS: This study presented a rare anatomical variation of a hypertrophied medial parapatellar plica with atypical course in the medial patellofemoral compartment and insertion into the inter-meniscal ligament. In combination with a medial meniscus tear led to a locked knee. Arthroscopic medial meniscus repair and plica excision resulted in complete resolution of symptoms.

Gross Measurement of Intraarticular Graft Length in All-Inside Anterior Cruciate Ligament Reconstruction.

Intra articular length (IAL) of the graft has not been measured yet in anatomic, single bundle, anterior cruciate ligament (ACL) reconstruction. Especially in the all-inside ACL reconstruction technique, the IAL of the graft is of great importance due to the philosophy of the technique and the risk of graft "bottoming out". We present a simple arthroscopic measurement of the IAL of the ACL graft in anatomic, single bundle ACL reconstruction, that will allow optimal application of the all-inside technique.

ACL Reconstruction and Modified Lemaire Tenodesis Utilizing Common Suspensory Femoral Fixation.

Persistent rotatory instability after anterior cruciate ligament (ACL) reconstruction has been well studied and recognized as the cause of unsatisfactory clinical results. Various anterolateral techniques have been described as an adjunct to the ACL reconstruction to improve clinical outcomes. Modified deep Lemaire lateral extra-articular tenodesis has been tested both biomechanically and clinically and proved an efficient solution in controlling tibia internal rotation, when performed in conjunction with ACL reconstruction. We describe a simple, versatile, effective, and reproducible technique of lateral extra-articular tenodesis, using common suspensory femoral fixation, with no additional cost and surgical risk.

Isolated Popliteus Tendon Avulsion: Fully Arthroscopic Repair with Suture Anchor: A Case Report.

CASE: Isolated popliteus tendon avulsion is an extremely rare injury with no consensus in the literature, regarding the therapeutic approach. In our case, the patient presented with rotational instability of the knee, and he was treated surgically. A fully arthroscopic technique with suture anchors was used, and this is the first report of such a repair in the literature. Knee stability was successfully restored, and the patient remains asymptomatic 2 years postoperatively. CONCLUSION: Isolated popliteus tendon avulsion can result in knee instability. Arthroscopic repair with suture anchors is an efficient way of treatment.

Clinical outcome of arthroscopic suture fixation for tibial eminence fractures in adults.

PURPOSE: The purpose of this study was to evaluate the clinical outcome of arthroscopic suture fixation for tibial eminence fractures in adults. METHODS: Twelve patients with a mean age of 29.9 years (range, 18 to 45 years) were prospectively followed up after arthroscopic suture fixation for tibial eminence fractures. Along with clinical examination, Lysholm, Tegner, and International Knee Documentation Committee (IKDC) rating scales were used to evaluate the patients. Anteroposterior knee laxity was measured with a Rolimeter (Aircast, Vista, CA), and range of motion was measured with a goniometer. RESULTS: Patients were followed up for a mean of 50 months (range, 25 to 69 months). There were no detectable signs or symptoms of instability postoperatively. The mean preinjury Tegner score was 6.1 (range, 3 to 9), and at follow-up, the mean Tegner score was 5.8 (range, 3 to 9). No Lysholm or IKDC scores were obtained and no range-of-motion measurements were performed preoperatively because all injuries were acute. The mean Lysholm score was 98 (range, 94 to 100), and the mean IKDC score was 94.7 (range, 89.1 to 100). Anterior translation of the tibia, measured with the Rolimeter, was 0.58 mm on average (range, 0 to 3 mm) compared with the healthy side. Postoperatively, the mean extension deficit was 1° (range, 0° to 5°) and the mean flexion deficit was 2.7° (range, 0° to 10°) compared with the unaffected side. Overall, knees were graded as normal or nearly normal in 11 patients and abnormal in 1. CONCLUSIONS: Tibial eminence fractures in adults can be effectively treated with arthroscopic suture fixation. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Isolated posterior cruciate ligament calcification.

The authors present a case of calcified posterior cruciate ligament (PCL). A 61-year-old female presented in our department reporting 12 months history of knee pain that was getting worse during the night. The patient was under medication for epileptic seizure, osteoporosis and hyperthyroidism. X-rays demonstrated calcification of the PCL. CT and MRI excluded any other intra-articular and extra-articular pathology. Arthroscopic debridement of the calcium deposits was performed and the symptoms resolved immediately, while the postoperative x-rays were normal. Histological examination confirmed the calcium nature of the lesion. Two years postoperatively the patient remains asymptomatic.

Symptomatic ring-shaped lateral meniscus. MRI findings.

Ring-shaped lateral meniscus is a rare clinical entity that is usually asymptomatic. Moreover, diagnosis is always based on arthroscopic exploration of lateral meniscus. MRI has not been proven useful so far because the inner portion of the ring-shaped lateral meniscus is usually misinterpreted as a bucket-handle tear. The authors report a case of a 16-year-old girl with ring-shaped lateral meniscus in combination with a meniscal cyst. MRI demonstrated a cyst arising from lateral meniscus and meniscal tissue into the inner portion of the lateral compartment mimicking displaced meniscal fragment. Bucket-handle tears have not been reported to cause or accompany meniscal cysts. As a result the diagnosis of a ring-shaped lateral meniscus along with meniscal cyst was assumed based on MRI and confirmed during arthroscopy. The patient was treated with arthroscopic partial lateral meniscectomy and intra-articular cyst debridement.

Acute, simultaneous tear of patellar tendon and ACL: possible mechanism of injury and rationality of the two-stage surgical treatment.

The authors report a case of a 47-year-old professional driver with an acute, simultaneous tear of patellar tendon and anterior cruciate ligament (ACL). The patient was treated in two stages. Acute patellar tendon repair and delayed (6-month postinjury) ACL reconstruction was performed. The authors discuss the possible mechanism of injury and the rationality of the two-stage surgical treatment.

Locked bucket-handle tears of both medial and lateral menisci with simultaneous anterior cruciate and medial collateral ligaments injury.

The authors report the case of a 38-year-old male who presented to the accident and emergency department with a locked knee after falling from a height. The knee was locked at 35° of flexion without any signs of instability in clinical examination. The patient was operated within 6 h from injury. During arthroscopy bucket-handle tears of both medial and lateral menisci were found. The bucket-handle fragments were displaced into the intercondylar notch causing the knee to lock. Additionally, tears of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) were also found. The patient underwent ACL reconstruction with hamstrings autograft, medial subtotal meniscectomy and lateral meniscus repair. The MCL was treated conservatively. The postoperative period was uneventful and the patient returned to the preinjury level of activity within 8 months. The patient remains asymptomatic 2 years postoperatively.

Broken bioabsorbable femoral cross-pin as a cause of a chondral lesion after anterior cruciate ligament reconstruction.

We present a case of a chondral lesion after anterior cruciate ligament (ACL) reconstruction caused by femoral cross-pin breakage and intra-articular migration of the fragment. A 20-year-old man initially underwent ACL reconstruction using a hamstring autograft. The RigidFix bioabsorbable cross-pin (DePuy Mitek) was used for the femoral fixation. The patient returned to a pre-injury level of activity (professional soccer player) 6 months postoperatively. However, 20 months postoperatively, the patient presented with effusion and lateral joint-line pain after practice, without signs of instability in clinical examination. Conservative treatment failed and at re-arthroscopy a chondral lesion of the lateral femoral and tibial condyle was found, which had been caused by the broken femoral cross-pin. The fragment was removed and the symptoms resolved. Orthopaedic surgeons should be aware of this complication when using a bioabsorbable cross-pin for femoral fixation in ACL reconstruction.

Spontaneous, bilateral, quadriceps tendon rupture caused by local exposure to methidathion.

Spontaneous, bilateral, quadriceps tendon rupture is a rare injury. Many predisposing conditions have been reported that contribute to quadriceps tendon degeneration. We report a case of a 42-year-old farmer with spontaneous, bilateral, quadriceps tendon rupture and clear medical history. Clinical and laboratory investigations revealed no risk factors for tendon degeneration but the patient reported that he was exposed locally to methidathion 1 week before the rupture. Methidathion is an organophosphate insecticide commonly used in agriculture that is highly toxic via the dermal route. Methidathion induces lipid pre-oxidation and consequently alters quadriceps tendon blood supply and ultrastructure. The injury was treated with early surgical repair and final outcome was excellent 44 months postoperatively.

RigidFix femoral fixation: a test for detecting inaccurate cross pin positioning.

The RigidFix Cross Pin System (DePuy Mitek, Raynham, MA) is a popular technique for femoral fixation of graft in ACL reconstruction. In some cases, though, cross pins miss the femoral tunnel resulting in inadequate proximal graft fixation. We present a simple test to detect the incorrect placement of cross pins. The pinholes are drilled through the guide frame, leaving 2 sleeves for cross pins insertion. The manufacturer's recommendations, at this stage, are to reinsert the femoral tunnel guidewire, remove the guide frame, and insert the graft without verifying accurate pinhole positioning. We reinsert the femoral tunnel guidewire without removing the guide frame, and a second guidewire is introduced through each of the sleeves in turn. In case of appropriate pinhole placement, the 2 guidewires will meet in the cannulated rod of the guide frame and the surgeon will have the metal-to-metal feeling. If the pinhole misses the femoral tunnel, the 2 guidewires will not meet and the surgeon will not have the metal-to-metal feeling. In our practice, 9 cases of inaccurate pinhole placement were detected with this test and verified by direct vision of the femoral tunnel with the arthroscope. We find this test simple, reliable, and not time consuming.

Meniscal tears in the ACL-deficient knee: correlation between meniscal tears and the timing of ACL reconstruction.

Despite the fact that anterior cruciate ligament reconstruction (ACLR) is a common procedure, no clear guideline regarding the timing of reconstruction has been established. We hypothesized that there is a point in post injury period, after which significant increase in meniscal tears occurs. The purpose of this study was to derive a guideline in order to reduce the rate of secondary meniscal tears in the ACL-deficient knee. A total of 451 patients were retrospectively studied and divided into six groups according to the time from injury to ACLR: (a) 105 patients had undergone ACLR within 1.5 months post injury, (b) 93 patients within 1.5-3 months, (c) 72 patients within fourth to sixth month, (d) 56 patients within seventh to twelfth month, (e) 45 patients within the second year and (f) 80 patients within the third to fifth year. The presence of meniscal tears was noted at the time of ACL reconstruction and then recorded and statistically analysed. Fifty-three (50.5%) patients from group a, 46 (49.5%) from group b, 39 (54.2%) from group c, 31 (68.9%) from group d, 28 (62.2%) from group e and 54 (67.5%) from group f had meniscal tear requiring treatment. The statistical analysis demonstrated that the earliest point of significantly higher incidence of meniscal tears was in patients undergoing ACLR more than 3 months post injury. Therefore, ACLR should be carried out within the first 3 months post injury in order to minimise the risk of secondary meniscal tears.

Circumflex femoral vein thrombosis misinterpreted as acute hamstring strain.

The case of a 24-year-old female professional, long-distance runner who presented with acute proximal posterior thigh pain is reported. History and clinical findings were consistent with acute hamstring strain but MRI demonstrated circumflex femoral vein thrombosis. This is the first case of proximal posterior thigh pain caused by circumflex femoral vein thrombosis reported in the literature. Doctors dealing with sports injuries should be aware of this clinical entity that mimics hamstring strain.