Technical pearls for hip arthroscopy in the management of synovial chondromatosis.

Synovial chondromatosis of the hip is often underdiagnosed. A high index of suspicion and good quality imaging studies are therefore essential. A wide array of long and curved instrumentation is needed at surgery. Efficient use of time and an organized surgical approach are critical to decrease joint distraction time and potential complications. A successful outcome, with pain relief and return of joint function and range of motion, is predicated on incremental follow-up.

Efficacy of hip arthroscopy in the management of synovial chondromatosis.

BACKGROUND: Synovial chondromatosis can result in intra-articular loose bodies. Open arthrotomy has been the conventional treatment for this condition in the hip. Hip arthroscopy, however, is a minimally invasive approach and avoids potential problems with open arthrotomy. PURPOSE: This series was described to evaluate the role of arthroscopy in treatment and outcome of synovial chondromatosis of the hip at early to intermediate follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-nine patients had arthroscopic treatment for synovial chondromatosis of the hip. All loose bodies were intracapsular and smaller than 10 mm. Radiographs of the painful hip, computed tomography (CT), and gadolinium-enhanced magnetic resonance imaging (MRI) were obtained preoperatively. Intraoperatively, loose bodies were removed, and partial synovectomy, partial labrectomy, chondroplasty, and microfracture were done as needed. RESULTS: There were 14 women and 15 men (mean age, 41 years; mean duration of symptoms, 52 months). All patients had hip pain and 63% reported mechanical hip symptoms. Twenty-three patients were followed for at least 12 months (mean, 64 months). Loose bodies could be seen in the imaging studies of 52% of patients: 8 on radiographs and 7 with CT or gadolinium-enhanced MRI. At surgery, 23 of the 29 (79%) patients had torn labra and femoral head changes. There were an average of 35 loose bodies per patient. Twenty-five of the 29 (86%) had acetabular chondral findings. Five of the 29 patients (17%) eventually underwent total hip reconstruction surgery at a mean of 52 months; 5 of these patients had grade III/IV lesions at the time of arthroscopy. Eleven of the 23 patients (48%) had good to excellent outcomes at an average of 60 months. Recurrent symptoms were seen in 7 patients, and revision arthroscopy was done for 1 patient at 1-year follow-up, 2 patients at 4 years, 1 at 5 years, and 1 at 7-year follow-up. Complications included transient perineal and pedal paresthesia in 2 patients. CONCLUSION: Patients with synovial chondromatosis with hip central compartment loose bodies that were less than 10 mm benefited from hip arthroscopy. Imaging studies alone failed to establish the diagnosis in 14 of 29 patients (48%). Diagnosis was made by direct visualization via arthroscopy. For patients with grade I/II cartilage change, early diagnosis and treatment via arthroscopy helped. It is a valid and effective treatment at early to intermediate follow-up.

Spinal epidural abscess.

BACKGROUND: Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality. The most important determinant of outcome is early diagnosis and initiation of appropriate treatment. OBJECTIVES: We aim to highlight the clinical manifestations, describe the early diagnostic evaluation, and outline the treatment principles for spinal epidural abscess in the adult. DISCUSSION: Spinal epidural abscess should be suspected in the patient presenting with complaints of back pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging is the diagnostic modality of choice to confirm the presence and determine the location of the abscess. Emergent surgical decompression and debridement (with or without spinal stabilization) followed by long-term antimicrobial therapy remains the treatment of choice. In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low. CONCLUSION: Patients with a spinal epidural abscess often present first in the emergency department setting. It is imperative for the emergency physician to be familiar with the clinical features, diagnostic work-up, and basic management principles of spinal epidural abscess.

The incidence of motocross injuries: a 12-year investigation.

Off-road motorcycling is one of the most popular sports activities practiced by millions of people in the world but little has been written on motocross traumatology and its prevention. This paper aims to evaluate motocross injuries in terms of injury ratio, location, causes, and possible prevention in a series of competitions organized by Motorcyclistic Federations over a 12-year period. We retrospectively evaluated 1,500 accidents with 1,870 rider injuries out of a group of 15,870 athletes participating in European off-road competition from 1980 to 1991. Data were collected from race medical reports, insurance declarations and follow-up forms filled up by riders involved in accidents. We then classified the type and location of the injury, modality of the accident, the protective gear used and the recovery of the riders. We compared our data to lesions noted in motorcycle road races using the chi-square test and the z-test. The overall incidence of motocross injuries in our study was 94.5 per thousand, while stadium cross competitions had a 150 per thousand rate and outdoor motocross a rate of 76 per thousand representing a risk of accident of 22.72 per thousand hours of riding. Among the total of 1,870 injuries, 1076 were bruises; 27.9% of these were in the upper extremities, 26.9% on the lower, 21.2% on the trunk, and 16% on the face. There were 450 fractures recorded, 50.9% in the upper extremities, 38% in the lower, and the rest were on the spine, chest, and skull. The 26 spine fractures (5.8%) produced permanent neurologic sequelae in eight patients. Ligamentous lesions accounted for 344 cases with 206 (59.9%) occurring in the lower extremities especially on the knee (42.4%). Head trauma was noted in 86 cases (5.7% of accidents) producing coma in 3%, and loss of consciousness in 14%. Limb involvement for all types of injuries were more frequent on the left side (60%). Motocross is a high-risk sport: our study revealed the most common modalities and types of lesions sustained by the riders. Despite the reduction of some injuries by better protective gears, the occurrence of knee sprain, and wrist and clavicular fractures are still high. Furthermore, the high number of spine lesions with subsequent neurologic deficit noted in indoor races raises doubts about the safety of these events.

Quadrupled bone-semitendinosus anterior cruciate ligament reconstruction: a clinical investigation in a group of athletes.

PURPOSE: The hypothesis of our study was that a quadrupled bone-semitendinosus (STB) graft could provide a clinically stable construct, allow recovery of normal limb strength, give high patient satisfaction with early return to active sports, and involve low donor-site morbidity. TYPE OF STUDY: Outcomes study. METHODS: Anterior cruciate ligament (ACL) reconstruction with an STB graft was performed on 80 athletes with isolated ACL injury from January 1996 to December 1999. Femoral fixation was obtained with EndoButton (Smith & Nephew, Andover, MA) and tibial fixation with Fastlok (Neoligaments, Leeds, England). At a mean follow-up time of 36 months (range, 24-52 months), patients were evaluated using standard knee scores (Noyes, Lysholm, Tegner, and International Knee Documentation Committee [IKDC] rating) and functional strength tests; postoperative pain rating; knee radiographs performed after surgery and at final follow-up; magnetic resonance imaging (MRI) at 3 to 6 months; isokinetic flexion-extension and internal-external rotation tests at 3, 6, and 12 months; and computed laxity analysis at final evaluation. RESULTS: At final evaluation, subjective knee rating was 87%, kneeling test was positive in 7%, and Werner score was 44 of 50 (range, 30-48). Lachman test was negative in 90% at final evaluation. Sensory changes were present in 30% at 3 months, and 10% had definite hyposthesia. Computed laxity analysis revealed 90% with less than 3 mm side-to-side difference. Isokinetic testing showed normal hamstring and quadriceps peak torques at 12 months. The one-leg hop test and vertical jump were normal by 6 months. At final evaluation, average Noyes score was 88 (range, 65-100); Lysholm score, 91 (range, 70-100); postoperative Tegner rating, 6.5 (range, 5-9); and preinjury Tegner rating, 7.5 (range, 7-10). IKDC score showed 72 knees normal or nearly normal, 7 abnormal, and 1 severely abnormal. Sixty-five percent of patients returned to the same preinjury sports level. CONCLUSIONS: The quadrupled bone-semitendinosus graft is a viable graft for ACL reconstruction and should be considered, especially for patients with extensor mechanism problems.

Hamstring graft tibial fixation: biomechanical properties of different linkage systems.

This biomechanical study analyzed the mechanical properties of different linkage systems commonly used in hamstring tendon ACL reconstruction. Two kinds of tapes, 5-mm braided polyester (Mersilene) and 3-mm woven polyester (Orthotape), were connected to a particular staple in bovine bone sections in single- and double-loop constructs with five replicates of each. These constructs underwent straight pull tensile tests, residual tensile tests, and fatigue tests at a loading regime of 540,000 cycles at 25 Hz frequency, using an Instron tensile test machine. Protrusion heights of the constructs were measured. The double-loop Mersilene-Fastlok construct was weaker than either single-loop or double-loop Orthotape-Fastlok construct. The mean failure strength of double-loop Orthotape-Fastlok was 93% higher and its mean stiffness was 40% greater at failure than that of Mersilene-Fastlok. At a 150-N load Mersilene-Fastlok was stiffer, while at 300 N Orthotape-Fastlok was stiffer. The thickness of Orthotape-Fastlok resulted in 1 mm more device protrusion. In hamstring tendon ACL reconstructions with indirect fixation we advocate the use of woven polyester (Orthotape) with Fastlok as a linkage material over braided polyester (Mersilene) with Fastlok because of its superior strength and stiffness.