Anterior cruciate ligament rupture and associated Segond fracture: Incidence and effect on associated ligamentous and meniscal injuries.

Introduction: The Segond fracture is an avulsion fracture of the lateral tibial plateau and is widely considered to be pathognomonic of anterior cruciate ligament (ACL) rupture. In addition to ACL rupture, Segond fractures have also been noted to be associated with significant intra-articular pathology such as meniscal injuries as well as extra-articular pathology such as collateral ligament injuries. This is likely due to the fact that the presence of a Segond fracture may represent increased rotatory instability. Whilst several studies have demonstrated the association of a Segond fracture with significant intra-articular pathology, there is a paucity of literature assessing if the combination of an ACL rupture and Segond fracture gives rise to higher rates of concomitant ligamentous and meniscal injuries. The primary objective of this study is to determine if patients with ACL ruptures associated with Segond fractures have higher rates of concomitant ligamentous and meniscal injury, when compared to patients with ACL ruptures without a Segond fracture. Methods: A retrospective review of all patients who underwent ACL reconstruction in a single institution between 2014 to 2018 was conducted. A review of the patients' demographics, operative notes, and radiographs was performed. X-rays and MRI scans were double-read by a board-certified radiologist and Orthopaedic surgeon. Results: A total of 414 subjects were included. The incidence of Segond fracture was 2.4%. The mean age was 24.7±7.4 (range 16 to 60) years and 26.7±7.6 (range 16 to 38) years in patients with and without Segond fractures respectively. 89.9% of patients suffered a non-contact mechanism of injury, with sports injuries being most common (79.5%). There was a significantly higher rate of isolated lateral meniscus tears in patients with Segond fractures compared to those without (50% v.s. 20.8%) based on pre-operative MRI. (p<0.05) There were no other significant differences in associated ligamentous injuries. Conclusion: The incidence of Segond fracture associated with ACL rupture is 2.4%. There is a significantly higher risk of a concomitant isolated lateral meniscus tear in ACL ruptures associated with a Segond fracture. There is no significantly higher risk of concomitant ligamentous injuries in ACL ruptures associated with a Segond fracture.

Pre-operative MRI measurements versus anthropometric data: Which is more accurate in predicting 4-stranded hamstring graft size in anterior cruciate ligament reconstruction?

BACKGROUND/OBJECTIVE: Graft diameter has been shown to play an important role in anterior cruciate ligament (ACL) autograft failure rates. The roles of pre-operative MRI measurement of graft size and anthropometric data have been studied in the prediction of hamstring graft size. Pre-operative knowledge of hamstring graft diameter allows surgeons to perform better surgical planning and provides an opportunity to discuss with patients on alternative graft options such as allografts should the need arises. The purpose of this study was to compare the accuracy of pre-operative anthropometric data and MRI measurements in the prediction of 4-stranded hamstring autograft size in anterior cruciate ligament reconstruction. METHOD: This was a cohort study involving 141 subjects (115 males and 26 females) who underwent a single bundle ACL reconstruction utilising a 4-stranded hamstring graft by a single surgeon from 2008 to 2012. Pre-operatively, the height, weight, body mass index (BMI), age, gender and smoking status was recorded. The MRI scans used for diagnosis were utilized to measure the gracilis (GT) and semi-tendinosus (ST) cross sectional area (CSA). RESULT: We found the strongest correlation between Combined (ST + GT) CSA and intra-operative graft size (r = 0.596, p < 0.001). This was followed by ST CSA (r = 0.570,p < 0.001), Body surface area (r = 0.507,p < 0.001), and GT CSA (r = 0.460,p < 0.001). No significant correlation was found between 2 anthropometric data (Age and BMI). There was also no significant difference between different strengths of MRIs (1.5T vs 3.0T) in determining the intra-operative graft size (p = 0.438). CONCLUSION: We conclude that pre-operative MRI is superior to anthropometric variables in predicting the size of 4-stranded hamstring autografts used in ACL reconstruction.

Orthopaedic surgery after COVID-19 - A blueprint for resuming elective surgery after a pandemic.

BACKGROUND: The COVID-19 outbreak was fraught with danger and despair as many medically necessary surgeries were cancelled to preserve precious healthcare resources and mitigate disease transmission. As the rate of infection starts to slow, healthcare facilities and economies attempt to return to normalcy in a graduated manner and the massive pent-up demand for surgeries needs to eventually be addressed in a systematic and equitable manner. MATERIALS AND METHODS: Guidelines from the Alliance of International Organizations of Orthopaedics and Traumatology, Orthopaedic Trauma Association, American College of Surgeons, American Society of Anaesthesiologists, Association of perioperative Registered Nurses, American Hospital Association, Centers for Medicare and Medicaid Services, World Health Organization and Centers for Disease Control and Prevention were evaluated and summarized into a working framework, relevant to orthopaedic surgeons. RESULTS: The guiding principles for restarting elective surgeries in a safe and acceptable manner include up-to-date disease awareness, projection and judicious management of equipment and facilities, effective human resource management, a fair and transparent system to prioritize cases, optimization of peri-operative workflows and continuous data gathering and clinical governance. CONCLUSION: The world was ill prepared for the initial COVID-19 outbreak. However, with effective forward planning, institutions can ramp-up elective surgical caseload in a safe and equitable manner.

A surgeon's role in fighting a medical pandemic: Experiences from the unit at the epicentre of COVID-19 in Singapore - A cohort perspective.

IMPORTANCE: Although Singapore was one of the first countries outside of China to be affected by COVID-19, for the first 2.5 months since its first reported case on January 23, 2020, it remained one of the few nations with successful containment of spread of the pandemic with little mortality and zero intra-hospital transmissions, without instituting a major lockdown of the country. In times of an infectious epidemic where medical subspecialties lead the frontline, a surgeon's role becomes rather vague. However, the only obstacle that stands in between the surgeon and fighting in the frontline of an infectious disease outbreak, is the traditional perception of what a surgeon can do. By presenting the strategies employed by our institution and its surgical unit, which remains the epicenter of the COVID-19 fight in Singapore, together with our medical counterparts, we hope to be able to improve our practices to respond and prevent the pandemic from escalating further as a collective community of surgeons across the globe. OBSERVATIONS: Contingencies should be in place for prioritization of existing patients, triaging and treatment of suspected patients, infection control, manpower management and novel strategies for inter-disciplinary communications and education in a hospital's surgical unit during a pandemic. Working in a high risk environment with manpower and resource limitations for prolonged periods of time has effect on morale and affects surgeon burn-out. Transparent communication, avenues to address psychological needs of surgeons and leadership by example are key strategies in ensuring a sustainable fight against the pandemic. CONCLUSIONS AND RELEVANCE: With the varies strategies implemented, every surgical discipline and every surgeon should be unified and place their desire to operate aside. There should not be any differentiation between surgeon and physician, but instead, everyone has to work together as one united health care front battling the common enemy - COVID-19.

A Rare Case of Intra-Articular Displacement of EndoButton Following Anterior Cruciate Ligament Reconstruction.

The EndoButton is a commonly used device for femoral fixation of anterior cruciate ligament grafts. Complications from its usage remain rare. Incorrect femoral tunnel placement may increase the risk of intra-articular displacement of the EndoButton. We present a case of anterior femoral tunnel placement resulting in intra-articular displacement of the EndoButton after failure. A 24-year-old man presented to us after failure of anterior cruciate ligament reconstruction performed 3 years prior. Radiographs revealed an intra-articular displacement of the EndoButton. Intraoperatively, it was noted that the femoral tunnel exit was within the suprapatellar pouch, with the displaced EndoButton lodged between the posterior aspect of the lateral tibial plateau and the capsule. Intra-articular displacement of the EndoButton is a rare complication and has only been reported twice in the literature. Anterior placement of the femoral tunnel may predispose patients to this complication and it is recommended to check the EndoButton position intraoperatively to avoid such a complication, especially for the unexperienced surgeon.

Patellar tendon re-rupture on the opposite end of the previous site of surgical repair.

We describe a rare case of a patellar tendon "re-rupture" at the opposite end of a previous proximal tendon repair. A 32-year-old male with a history of surgically repaired right proximal patellar tendon rupture presented with an acute non-traumatic right knee pain and instability during sports. Magnetic resonance imaging confirmed a complete rupture of his distal patellar tendon at the tibial tuberosity. The patellar tendon was repaired using two 5.5 mm BioCorkscrews (Arthrex) inserted into the tibial tuberosity; the tendon was stitched with the No. 2 fiberwires using Krackow technique. As the patellar tendon was degenerative, the repair was augmented with a semitendinosus tendon harvested using an open tendon stripper, leaving the distal attachment intact. At 2.6 years followup he had mild anterior knee pain, range of motion 0-130° and was able to squat. MRI scan done at followup revealed good healing of repaired patellar tendon.

Anterior cruciate ligament ganglion causing flexion restriction: a case report and review of literature.

Ganglion cysts originating from the anterior cruciate ligament (ACL) are uncommon. Often asymptomatic, they infrequently present with non-specific symptoms such as knee pain, stiffness, clicks, locking or restriction of knee extension. However, the patient we report presented with knee flexion restriction. A 37-year-old Chinese gentleman, with no history of knee trauma, presented with left knee pain. Left knee range of motion (ROM) was from 0 to 110 degrees. Magnetic resonance imaging (MRI) scan revealed a 1.5 cm × 3.3 cm × 1.7 cm cyst located in the intercondylar region arising from the ACL and extending predominantly posteriorly. Arthroscopy confirmed an intrasubstance ACL ganglion cyst, which was extending posteriorly. Complete excision of the cyst was performed. At 1-year follow-up, the patient regained knee flexion of 130 degrees. We describe one of the largest ACL ganglion cysts. Such cysts often extend anteriorly and impinge onto the roof of the intercondylar notch during knee extension, thus restricting extension. The restriction in knee motion in our patient was in flexion instead; this was because the cyst took an unusual course of extension predominantly in the posterior direction. Although rare, it must be included as a possible differential diagnosis when patients present with such knee symptoms.

Role of anthropometric data in the prediction of 4-stranded hamstring graft size in anterior cruciate ligament reconstruction.

To evaluate whether pre-operative anthropometric data can predict the optimal diameter and length of hamstring tendon autograft for anterior cruciate ligament (ACL) reconstruction. This was a cohort study that involved 169 patients who underwent single-bundle ACL reconstruction (single surgeon) with 4-stranded MM Gracilis and MM Semi-Tendinosus autografts. Height, weight, body mass index (BMI), gender, race, age and -smoking status were recorded pre-operatively. Intra-operatively, the diameter and functional length of the 4-stranded autograft was recorded. Multiple regression analysis was used to determine the relationship between the anthropometric measurements and the length and diameter of the implanted autografts. The strongest correlation between 4-stranded hamstring autograft diameter was height and weight. This correlation was stronger in females than males. BMI had a moderate correlation with the diameter of the graft in females. Females had a significantly smaller graft both in diameter and length when compared with males. Linear regression models did not show any significant correlation between hamstring autograft length with height and weight (p>0.05). Simple regression analysis demonstrated that height and weight can be used to predict hamstring graft diameter. The following regression equation was obtained for females: Graft diameter=0.012+0.034*Height+0.026*Weight (R2=0.358, p=0.004) The following regression equation was obtained for males: Graft diameter=5.130+0.012*Height+0.007*Weight (R2=0.086, p=0.002). Pre-operative anthropometric data has a positive correlation with the diameter of 4 stranded hamstring autografts but no significant correlation with the length. This data can be utilised to predict the autograft diameter and may be useful for pre-operative planning and patient counseling for graft selection.

Results of revision anterior cruciate ligament reconstruction using a transportal technique.

BACKGROUND: As the number of anterior cruciate ligament (ACL) injuries and primary ACL reconstruction surgeries increase, the absolute number of re-ruptures or failures has also subsequently increased. In our study, we look at the causes of failure in the primary surgery and also report the clinical and functional outcomes in our series of patients undergoing revision surgery. MATERIALS AND METHODS: We performed a retrospective review of all revision ACL reconstructions performed by the senior author over a 3-year period using a single-stage transportal technique. Causes of failure were elucidated through clinical, radiological and intraoperative assessment. Outcomes of revision surgery were assessed clinically as well as functionally through the use of a variety of subjective knee scores, with a mean follow-up time of 27.5 months (range 12-40). RESULTS: In our series of 13 patients, all primary surgeries were performed originally via a transtibial technique, with a mean time to failure of 26.4 months (range 6-65). Tunnel malposition was identified as the most common cause of failure (61.5%), while purely traumatic causes accounted for 38.5% of cases. New meniscal injuries were identified in 77% of the patients, and cartilage loss in 38.5%. There was a statistically significant improvement in functional outcomes in all patients following revision surgery, and whilst majority (92%) were able to return to sporting activities on a regular basis, only 54% were able to return to their previous level of sports. CONCLUSION: Tunnel malposition was found to be the most common cause of primary graft failure in our series of patients undergoing revision ACL reconstruction. Concomitant meniscal and cartilage pathologies were also common intraoperative findings. Improved knee stability and functional outcomes can be expected following revision surgery, and majority will be able to return to some form of sporting activity, albeit at lower levels than before for some patients.

Graft infection following arthroscopic anterior cruciate ligament reconstruction: a report of four cases.

Septic arthritis following arthroscopic anterior cruciate ligament reconstruction (ACL) is a rare complication and associated with severe morbidity. Its risk factors include (1) concomitant procedures during the reconstruction, (2) previous knee surgery, (3) allograft usage, (4) peri-operative wound contamination, and (5) presence of intra-articular foreign bodies. We present a series of 3 men and one woman aged 22 to 35 years who developed septic arthritis following ACL reconstruction. The risk factors identified were local infection (n=2), previous ipsilateral knee surgery (n=2), and the use of an allograft (n=1). All patients underwent emergency knee washout and debridement with graft retention within 24 hours, together with a course of intravenous antibiotic therapy. All the patients achieved eradication of their infections (with intact ACL grafts) and satisfactory functional outcome at a mean follow-up of 32 (range, 25-45) months.

Cutaneous hypoesthesia following plate fixation in clavicle fractures.

BACKGROUND: We report the functional impact and natural history of cutaneous hypoesthesia after plate internal fixation for mid shaft clavicle fractures with a horizontal skin incision from year 2009 to 2011. MATERIALS AND METHODS: 38 patients had complete followup data with an average followup period of 23.2 months (range 8-43 months). The impact of supraclavicular nerve injury was studied by assessment of the incidence, functional impact and natural history of numbness with detailed review of the case records and phone questionnaires. RESULTS: The incidence of postoperative numbness was 55.3% (n = 21). Most patients reported the numbness to be at its worst within the first operative month. At the time of worst numbness, 28.6% (n = 6/21) of patients reported the numbness to be severe while 42.9% (n = 9/21) reported moderate numbness and 28.6% (n = 6/21) reported mild numbness. Fifteen of these patients described increased awareness of numbness during contact with straps or clothes. Two patients were significantly bothered by this numbness; 4 patients stated that it was a moderate bother while 7 patients considered it a mild bother. A total of 8 patients reported that they were not bothered at all by the numbness. An overwhelming majority of affected patients (90.5%, n = 19/21) reported an improvement in the severity of numbness felt over time. At the last followup, the incidence of numbness declined from 55.3% to 36.8% with 7 patients reporting complete resolution of numbness. The numbness however was found to persist in 66.7% of patients. Only 1 patient reported continued severe numbness. The awareness of numbness with straps and clothing was severe in 5 patients. None of the patients were significantly bothered by this numbness. CONCLUSIONS: Cutaneous sensory loss is a common occurrence following plate fixation of the clavicle and might have been under reported in the literature. The numbness improves in the vast majority, but commonly persists to some degree for up to 2 years and maybe permanent. However, only a small minority eventually considered the numbness a significant "bother" and to affect them while wearing clothing or when in contact with shoulder straps.

Locking knee after intra-articular migration of broken patella tension band wire: an extraordinary intra-articular migration via pseudarthrosis line.

Fixation of displaced patella fractures with tension band wiring is a commonly performed technique. Broken metal wires after such surgeries are not uncommon, however, intra-articular wire migration after failure of the tension band wires in the patella is uncommon and rarely described. In this study, we report a case of locking knee symptoms secondary to the migration of a broken patella wire into the knee joint through the pseudarthrosis line.

Subacromial bursitis with giant rice bodies as initial presentation of rheumatoid arthritis.

Rice body formation is a nonspecific response to chronic synovial inflammation associated with tuberculous arthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, seronegative inflammatory arthritis, and even osteoarthritis. Such bodies were termed rice bodies because of their close resemblance to grains of polished white rice. We present a case report of a middle-aged woman with right shoulder subacromial/subdeltoid bursitis with giant rice body formation as her initial presentation of rheumatoid arthritis. Her right shoulder symptoms resolved after subacromial and subdeltoid bursectomy and removal of the rice bodies. She subsequently developed inflammatory arthritis of other joints, met the criteria for rheumatoid arthritis, and has been treated medically.

Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid.

BACKGROUND: We report a retrospective review of surface replacement hemiarthroplasty of the shoulder with biologic resurfacing of the glenoid, for relatively young patients suffering from advanced glenohumeral arthritis. It was hoped that the resurfacing fascia would prevent glenoid erosion for a period of time. METHODS: This surgery was performed by two surgeons between 1996 and 2005. The indications for the arthroplasty were severe pain and limitation of function, in relatively young patients with advanced glenohumeral arthritis but an intact rotator cuff. RESULTS: Eighteen shoulders, with an average follow-up of 4.8 years (range 2-10.6), were available for assessment. The average age was 54.8 years. Postoperative Constant-Murley Score averaged 71.4 points; the mean sex- and age-adjusted Constant Score was 83.9%. The mean American Shoulder and Elbow Surgeons score was 74.4 points. Average active forward elevation was 130 degrees. Eighty three percent of the patients were satisfied with the long-term result. Radiographic follow-up demonstrated that none of the prostheses was loose; however moderate to severe glenoid erosion was present in 56% of shoulders. CONCLUSIONS: We conclude that this procedure is useful in the treatment of younger patients suffering from advanced glenohumeral arthritis of the shoulder; however the interposed anterior capsule did not protect the glenoid from mid-term erosion by the humeral prosthesis. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Results of total elbow arthroplasty in the treatment of distal humerus fractures in elderly Asian patients.

BACKGROUND: Distal humerus fractures in elderly patients are difficult to treat as these fractures are often complicated by varying degrees of comminution intra-articular involvement and osteoporosis. We retrospectively reviewed the results of primary total elbow arthroplasty in the treatment of distal humerus fractures in seven patients followed for a minimum of 1 year. METHODS: Between July 2000 and June 2002, seven patients with distal humerus fractures were treated electively with total elbow arthroplasty using the semiconstrained Coonrad-Moorey elbow replacement prostheses. The Mayo Elbow Performance Score was used to assess the outcomes. RESULTS: The mean age of our patients was 72.9 years. The mean duration of postoperative hospitalization stay was 7.6 days. The average length of follow up was 24.9 months. Six of these patients had no pain, and one patient had mild pain. The mean arc of flexion was 88.6 degrees. Six elbows had excellent results, while 1 elbow had good result. The mean Mayo score was 94.3 points. One elbow developed blisters postoperatively but resolved with dressings and antibiotics. CONCLUSIONS: Our review suggests that total elbow arthroplasty can give good to excellent short term results when used in the treatment of distal humerus fractures in elderly Asian patients.