The Anterolateral Ligament of the Knee Is a Nonisometric Thin Ligament With High Prevalence and Almost Constant Attachment to the Lateral Meniscus: A Systematic Review With Meta-analysis.

PURPOSE: To provide comprehensive information about the anterolateral ligament (ALL) prevalence, morphometry, isometry, insertions, histology, and its relationship with the lateral meniscus (LM). METHODS: The study was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible cadaveric studies investigating the frequency of the ALL presence, and anatomical features were identified through an online search of the PubMed, Scopus, and Cochrane Central databases from inception to June 2022. Statistical analysis was conducted with the open-source R programming language using the "meta" package. The Higgins I2 statistic was used for quantifying heterogeneity. RESULTS: Thirty-three studies (1,478 cadaveric knees) were included. The ALL had a 79% prevalence. It was attached to the LM periphery in 97% of studies. Most studies reported a femoral insertion of the ALL, just proximal and posterior to the lateral epicondyle. Tibial attachment is constant at the midpoint between Gerdy's tubercle and fibular head. The mean ALL thickness at the joint line was 1.6 [1.2; 2.0] mm. The ALL length was found to significantly change across the knee flexion (P < .01). It was increased from 0° to 60° and decreased after 60° flexion. Seven histological studies demonstrated a typical ligamentous microstructure. CONCLUSION: The ALL is a thin ligament, distinct to the knee capsule, which may be found in 79% of the knees having an almost constant attachment to the LM. The ALL is not isometric. It becomes tense during internal rotation and between 30° and 60° knee flexion. Pooled results should be interpreted with caution due to the high heterogeneity among the included studies. CLINICAL RELEVANCE: This study sheds light on controversial issues and provides comprehensive and accurate information about the essential anatomical knowledge on ALL, which may contribute to optimizing ALL reconstruction surgical techniques and biomechanical settings.

Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate: A systematic review.

PURPOSE: The purpose of this study is to compare the patient-reported outcomes and return to sports of the conservative and surgical treatment of distal hamstring tendon injuries. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers searched PubMed, Scopus and Virtual Health Library databases in January 2023. Clinical studies evaluating conservative or surgical management outcomes of distal hamstring tendon injuries were considered eligible for this systematic review if predefined criteria were fulfilled: (1) published in English or Spanish; (2) evaluated any of the following: patient-reported outcomes, return-to-sports rate (RTS-R) or return-to-sports time (RTS-T). Data were presented in tables using absolute values from individual studies and derived pooled percentages. RESULTS: Eighteen studies were included for 67 patients and 68 distal hamstring tendon injuries. Initially, 39 patients (58.2%) underwent surgical treatment, whereas 28 (41.8%) were treated conservatively. Among conservative treatment patients, 15 failed and had to be operated on (53.6%), all with distal semitendinosus tendon injuries. Anchor fixation was the technique of choice in 20 lesions (36.4%), tenodesis in 16 (29.1%), tenectomy in 14 (25.5%) and sutures were preferred in five (9%). Thirteen out of 28 patients (46.4%) undergoing initial conservative treatment returned to sports at a mean of 3.6 months (range 1 week to 12 months), in contrast to surgical treatment, in which 36 out of 39 patients (92.3%) returned at a mean of 4.2 months (range 6 weeks to 12 months). Additionally, 14 of 15 patients (93.3%) converted to surgical treatment after failed conservative treatment returned to sports at a mean of 7.6 months after injury. CONCLUSION: Initial surgical treatment of distal hamstring tendon injuries yields a high RTS-R (92.3%) at a mean of 4.2 months. Furthermore, 15 out of 28 patients (53.6%) initially treated conservatively had to be operated on, delaying the RTS-T (mean 7.6 months after injury) without affecting their RTS-R. LEVEL OF EVIDENCE: IV.

Patella is rarely resurfaced during primary total knee arthroplasty in clinical trials conducted in Greece: a systematic review.

PURPOSE: The aim of the present study was to report the approach of Greek surgeons regarding patellar management and provide the outcomes and the rate of the need for secondary patella resurfacing. METHODS: Following the PRISMA guidelines, PubMed, Scopus, and The Cochrane Central Register of Controlled Trials (CENTRAL) databases were accessed in January 2024. Clinical studies evaluating the outcomes of patients undergoing primary TKA were considered eligible for this systematic review if the following predefined criteria were fulfilled: (1) published in English, (2) were conducted in Greece, and had a minimum of 2-year follow-up. The methodological quality and publication bias were assessed using the Modified Coleman Methodology Score (mCMS) and ROBIS tool, respectively. Data was presented in tables using absolute values from individual studies. Pooled data were presented as means, ranges, and percentages. RESULTS: Six clinical studies with a total of 1084 TKAs were included. Four studies were retrospectives, and two studies were prospective. Patella was only resurfaced in 0.6% of total TKAs. TKA without patellar resurfaced, which resulted in an improvement in functional outcome. Among studies, the overall need for revision incidence was 7.6% (68 out of 892 TKAs). Additionally, Aseptic loosening (2.4%) was the most common reason for revision due to patellofemoral joint complications, followed by secondary patellar resurfacing (2.1%) and deep infection (1.3%). The mean mCMS demonstrated a fair methodological quality level, and the ROBIS toll a low risk of bias in all four domains. CONCLUSION: The available evidence supports that Greek surgeons mainly do not resurface the patella. However, patellar non-resurfacing yields good functional outcomes and presents relatively low revision rates for secondary patellar resurfacing. LEVEL OF EVIDENCE: IV.

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.

Use of photogrammetry-based digital models in anatomy education: An overview.

PURPOSE: Photogrammetry is a technique which includes taking multiple digital photographs from various angles and using those photographs to create three-dimensional virtual models. We aimed to review the outcomes of the implementation of photogrammetry in anatomy education. METHODS: We searched PubMed, Scopus and Cochrane library for studies with purpose to explore the outcomes of the use of photogrammetry-based digital models in anatomy teaching. From each included paper we extracted: authors, number of participants, anatomical region of interest, educational outcomes, and their level according to Kirkpatrick hierarchy. RESULTS: Seven studies were included. Four of them concerned neuroanatomy and three of them concerned other systems. All studies comprised participants' perceptions about the educational intervention, while two of them also evaluated anatomical knowledge acquisition. Overall, the participants rated photogrammetry-based models very highly and preferred them to other teaching tools. These models were also shown able to significantly enhance the anatomical knowledge. CONCLUSIONS: Photogrammetry-based digital objects seem to have a promising anatomy teaching potential. The value of these objects seems to be especially pertinent in teaching the relatively complex field of neuroanatomy. Further research may investigate the effectiveness of photogrammetry-based models in comparison with other anatomy education tools, and with other methods of creation of three-dimensional virtual objects.

Second hip fracture in older adults: incidence and risk factors.

PURPOSE: A second hip fracture can occur in older adults who have already suffered an initial hip fracture. The aim of this study was to determine the incidence, mortality and risk factors for second hip fractures in older adults with hip fractures. METHODS: Between 2009 and 2019, 2013 patients (mean age: mean age 76.5 ± 5.4 SD) who were admitted to a tertiary care hospital for a hip fracture surgery were retrospectively analyzed. The patients were divided into two groups: those with a second hip fracture and those without a second hip fracture within the following two years after the initial fracture. RESULTS: 321 patients (15.9%, mean age: 85.3 ± 4.9 SD) sustained a second contralateral hip fracture, the first two years after the initial hip fracture whereas 136 patients (6.8%) sustained a contralateral hip fracture within 12 months. In total 274 (13.6%) died in the first two years after the initial hip fracture; among these, 139 patients (43.3%) had a contralateral second hip fracture. The mean time from the first hip fracture to second hip fracture was 13.2 ± 7.6 months. The advance age, female gender, living alone, dementia, chest and urinary tract infection, chronic heart failure, peripheral vascular disease were identified as risk factors for a second contralateral hip fracture. CONCLUSIONS: Identifying risk factors for a second contralateral hip fracture can be particularly helpful in providing focused medical assistance.

Non-Respiratory Symptoms of Patients Infected with SARS-CoV-2 (Coronavirus Disease 2019): Lessons from Their Initial Presentation at the Hospital.

Background and objectives: As the COVID-19 pandemic spreads, it is becoming increasingly evident that this coronavirus is not limited to the respiratory system and that the musculoskeletal system can also be affected. The purpose of the present study was to describe non-respiratory symptoms of laboratory-confirmed COVID-19 cases. Materials and Methods: All patients with SARS-CoV-2 admitted to our hospital, between 1 August and 30 September 2020, were included in this retrospective study. Data were extracted from medical records. Epidemiological, clinical, laboratory and radiological characteristics at the initial presentation at the hospital were collected and analyzed. Results: A total of 79 COVID-19 patients were enrolled. The mean age of the patients was 44.08 years (age range, 18-87 years) and 59.5% were male. The most common symptoms were fatigue in 60 (75.9%) patients, followed by fever (73.4%), myalgia (51.9%), cough (41.8%), anosmia (38%) and arthralgia (36.7%). The muscles of the upper back and the knee joint were the most painful anatomic region and joint, respectively. The laboratory findings on admission showed that D-dimer, CRP and procalcitonin levels were increased, without significant gender differences (p > 0.05). Chest imaging demonstrated pneumonia in 20 (25.3%) patients. Conclusions: Our results indicate that from the onset of the symptoms of COVID-19 patients, musculoskeletal symptoms, such as fatigue, myalgia and arthralgia, were present in three-quarters of all patients. These findings could help elaborate updated triage and admission protocols for suspect COVID-19 patients at the hospital and Emergency Department presentation.

Circulating angiogenic biomolecules at rest and in response to upper-limb exercise in individuals with spinal cord injury.

OBJECTIVE: Individuals with spinal cord injury (SCI) show structural and functional vascular maladaptations and muscle loss in their lower limbs. Angiogenic biomolecules play important roles in physiological and pathological angiogenesis, and are implicated in the maintenance of muscle mass. This study examined the responses of angiogenic molecules during upper-limb aerobic exercise in patients with SCI and in able-bodied (AB) individuals. METHODS: Eight SCI patients with thoracic lesions (T6-T12, ASIA A) and eight AB individuals performed an arm-cranking exercise for 30 minutes at 60% of their VO2max. Plasma concentrations of vascular endothelial growth factor (VEGF-A165), VEGF receptor 1 (sVEGFr-1), VEGF receptor 2 (sVEGFr-2), metalloproteinase 2 (MMP-2), and endostatin were measured at rest, after exercise, and at 1.5 and 3.0 hours during recovery. RESULTS: The two-way analysis of variance showed non-significant main effects of "group" and significant main effects of "time/exercise" for all angiogenic biomolecules examined (P < 0.01-0.001). The arm-cranking exercise significantly increased plasma concentrations of VEGF, sVEGFr-1, sVEGFr-2, MMP-2, and endostatin in both groups (P < 0.001-0.01). The magnitude of the increase was similar in both patients with SCI and AB individuals, as shown by the non-significant group × time interaction for all angiogenic parameters. CONCLUSIONS: Upper-limb exercise (arm-cranking for 30 minutes at 60% of VO2max) is a sufficient stimulus to trigger a coordinated circulating angiogenic response in patients with SCI. The response of angiogenic molecules to upper-limb aerobic exercise in SCI appears relatively similar to that observed in AB individuals.

Current status of stroke epidemiology in Greece: a panorama.

Although strokes have been documented since about 3 millennia, they remain today as one of the leading causes of mortality, as well as of subsequent serious long-term physical and mental morbidity, among patients in many different countries all over the world. Greece presents an increase in mortality rates according to World Health Organization, and this fact underlines the need for early diagnosis and treatment, as well as, the need to implement effective prevention strategies for strokes. This review makes an effort to describe the current status of stroke epidemiological features, as well as to present the risk factors prevalent in Greece. The incidence rate is 261-319/100,000 based on the recent population based registry. Stroke appears to be more prevalent in men than in women, and the mean age of stroke onset in Greece is at 70 years of age. Hypertension, atrial fibrillation, dyslipidaemia and diabetes mellitus are the major risk factors of stroke in the Greek population, while smoking is the most commonly documented modifiable risk factor in young adults with ischemic stroke. Similar to other parts of the world, ischemic stroke is the most common stroke type. The 28-day case fatality rate for men and women was 26.5%. The mean in-hospital cost per stroke patient was 3624.9 € and the mean rehabilitation cost of outpatients with stroke was 5553.3 €, while the cost proportion of hemorrhagic stroke is higher when compared to ischemic stroke. Stroke is a devastating condition with recognized challenges in identifying effective prevention programs. In Greece, limited data exists regarding the epidemiology of strokes. As a result, the need to conduct new studies and researches across the country is well documented.

What the Physician Needs to Know about Charcot Arthropathy and Ankle Fracture Treatment Dilemma: A Case Report and a Possible Medical Approach and Treatment Algorithm.

Introduction: Charcot arthropathy consists of a rapid and destructive complication of the joints following the loss of innervation caused by many complicated etiologies. Diabetic neuropathy has become the most common etiological factor. Case Report: We present a case of a 64-year-old female patient with a history of chronic renal failure on hemodialysis, hypertension, hypothyroidism, and Type 2 diabetes, complicated with neuropathy and Charcot disease, who referred to our department. Initially, the patient was managed with a restraint orthotic device due to a bimalleolar ankle fracture. An unsuccessful treatment and the presence of a pressure ulcer with pus-like drainage on the lateral malleolus 2 months later led to the decision for a below-knee amputation. Conclusion: High clinical suspicion by the attending physician may reduce the risk of complications and lead to proper treatment with better outcomes.

The Use of a Simple Vaginal Speculum to Harvest Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction and Avoid Any Potential Pitfalls during Harvesting Procedure: Technical note.

This technical note aimed to present a straigthforward method for harvesting quadriceps tendon autografts with the use of a simple vaginal speculum and direct visualisation of a scope. Anterior cruciate ligament reconstruction with quadriceps tendon autografts has gained popularity in recent years, with many harvesting techniques that use different harvesting systems available on the market. These techniques vary from transverse to longitudinal skin incisions and from open to minimally invasive approaches and have a learning curve, as with the majority of surgical procedures. The technique proposed in this technical note is minimally invasive, can be easily reproduced by any surgeon irrespective of their experience, has a short learning curve, requires no additional cost or technical support during the procedure and creates a stable working space that allows for freedom of manipulation of surgical instruments and the arthroscope.

Anatomic Risk Factors for Patellofemoral Joint Instability: An Infographic as a Visual Learning Tool.

Patellofemoral instability is a complex pathology with multiple risk factors, which affects mostly young females and may avert them from both activities of daily living and sports participation. Risk factors for instability include patella alta, trochlea dysplasia, abnormal lateral patellar tilt, and increased tibial tuberosity-trochlea groove distance. The knowledge of these anatomical abnormalities is the key to identifying the problem and succeeding in treating the patients.

Subchondral insufficiency fracture of the medial femoral condyle treated conservatively with early non-weightbearing.

Spontaneous osteonecrosis of the knee (SONK) is a poorly understood but debilitating disease, that is a common cause of unilateral acute knee pain and swelling. The term "SONK" has been replaced by the term "subchondral insufficiency fracture" in the latest pathology and imaging literature. Few studies investigated the pathogenesis of SONK by examining the histological changes of the tissues. Very recently, the development of SONK was associated with a meniscal root tear. In terms of the preferred imaging, plain radiographs can confirm the diagnosis in late stages; however, magnetic resonance imaging (MRI) scan is often required. Regarding the treatment, conservative management is usually the treatment of choice in early stages, including a period of non-weightbearing or the use of medications, such as nonsteroidal anti-inflammatory drug (NSAIDS) or bisphosphonates. However, when SONK progresses, often a surgical intervention is required, such as knee replacement, but also minimally invasive techniques, such as arthroscopic intervention, have been described. We present a case of early SONK and discuss the possible pathogenesis of SONK, the clinical presentation, the radiological findings, and we focus on the importance of early diagnosis and early off-load period that is required to prevent further progression of the disease.

Trochlea Dysplasia as the Major Anatomic Risk Factors for Patellofemoral Joint Instability: An Infographic as a Visual Learning Tool.

Patellofemoral instability (PFI) is a common condition in children and adolescents, ranging from mild discomfort and mal-tracking to lateral patellar dislocation [1]. A number of anatomical risk factors have been described in the literature, such as trochlear dysplasia, patella alta, excessive tibial tuberosity to trochlear groove (TT-TG) distance, patellar tilt and soft tissue alterations [2]. Among them, TD has been identified as the main anatomical risk factor with the strongest association with PFI [1, 2]. In the study by Dejour et al. [2] radiographically observed TD was identified in 96% of patients with a history of patellofemoral dislocation [1, 2]. Patients with Dejour Type D dysplasia are characterized by a prominent and convex lateral facet with a vertical connection to a hypoplastic medial facet (Figure 1), which provides inadequate tracking of the patella in the trochlea during flexion leading to patella subluxation [2]. Non-operative treatment of lateral patellar dislocation presents a rate of re-dislocation up to 70% within 24 months of the first episode [3]. Sulcus deepening trochleoplasty is indicated for Type B and D dysplasia, in order to improve patella tracking, reduce the rate of re-dislocation and achieve good functional outcomes [2, 4]. Trochlea dysplasia is defined as a shallow or flattened groove with decreased resistance to lateral patellar translation. TD can be assessed on computed tomography (CT) and magnetic resonance imaging (MRI) with the use of overlapping axial images and are able to show perfectly the global shape of the femoral trochlea [2]. The thresholds for identifying trochlear dysplasia are established based on the sulcus angle ≥ 145°, medial/lateral trochlea facet asymmetry < 40%, trochlear depth < 3 mm and lateral trochlear inclination ≤ 11° and therefore it can be used in young adolescents [4, 5]. A deep knowledge of anatomic variations and abnormalities of the patellofemoral joint, which may predispose to PFI, is crucial in order to choose the appropriate treatment for each patient.

Osteopoikilosis in a patient with familial adenopolyposis : A case report.

Osteopoikilosis, a sclerosing bone dysplasia, is an asymptomatic incidental finding characterised by multiple bone islands. Although it requires no treatment there can be diagnostic uncertainty as appearances can be similar to osteoblastic metastases or metabolic disorders such as Paget disease. We present a case of osteopoikilosis in a patient with familial adenopolyposis and discuss the clinical presentation, image findings and key considerations in diagnosis of this benign entity.

Intra-articular migration of tibial suture button in pediatric full epiphyseal anterior cruciate ligament reconstruction. A case report.

We report a case of a 12-years-old boy that underwent anterior cruciate ligament (ACL) reconstruction and lateral meniscus repair. The all-epiphyseal, all-inside technique, with quadriceps tendon autograft and adjustable suspensory button fixation was utilized due to the open physes. Intraoperative fluoroscopy confirmed optimal position of the buttons, while arthroscopic evaluation of the graft showed proper tension, with full range of motion and knee stability. Nevertheless, routine radiographic evaluation of the knee, 6 â€‹h postoperatively, revealed tibial button migration through the tunnel into the knee joint, while the knee was unstable in clinical examination. The graft was removed and reloaded with extended buttons. The femoral socket was retained in the revision surgery while a new tibial socket was drilled with the transphyseal technique (all-inside technique). The postoperative course was uneventful. The patient returned to unrestricted activities at twelve months after revision surgery and remains fully active two years postoperatively. This is the first case of tibial button migration reported in the literature, with immediate migration after surgery, intra-articular position of the button and negative impact on graft tension. Failure to recognize and treat this detrimental complication could be catastrophic for the knee. The technique of the surgical treatment is also described. Surgeons should be aware of this rare complication, that could adversely affect the clinical outcome.

Impact of Medical Education in Middle School, Directed by a Science Teacher and a Healthcare Professional, on Self-Medication and Care System Literacy. A Comparative Prospective Cohort Study.

Objectives:To assess the immediate and six-month follow-up effects of medical education simultaneously provided by a practitioner and a science teacher on middle school students regarding self-medication and knowledge of the healthcare system. Methods:Two groups were constituted: the learning group (L group), with students receiving an interactive medical education, and the control group (C group), which included students without medical education. Both groups were evaluated by using a six-multiple choice question (MCQ) evaluation form: three times for L group - just before the medical workshop (T0), immediately after the medical workshop (T1) and at six-month follow-up after the medical workshop (T2) - and only the evaluation at T0 for students in C group. Results:In L group (n=219), medical education improved all results of the evaluations related to self-medication skills (p<0.001) and knowledge of the healthcare medical system (p<0.001). Students retained their knowledge over time as no significant gap has been identified between T1 and T2 evaluations. Age, gender, grade and students' level did not have any impact on the results of L group. Students in L group had equivalent results to those in the C group (n=195) at T0 but the results increased at T1 (p<0.001) and T2 (p<0.001). Conclusion:Interactive medical education in middle school co-animated by a medical practitioner and a natural science teacher improves long-term teenagers' awareness of the current public health challenges.

Prior medial meniscus arthroscopy is not associated with worst functional outcomes in patients undergoing primary total knee arthroplasty: A retrospective single-center study with a minimum follow-up of 5 years.

INTRODUCTION: There have been controversial studies on the impact of prior knee arthroscopy (KA) on outcomes of total knee arthroplasty (TKA). The purpose of this comparative study is to investigate the impact of prior KA of medial meniscus on patients undergoing TKA by evaluating the International Knee Society Score (IKS), the complications, and revisions. METHODS: This retrospective study reviewed 84 patients with TKA who had undergone prior KA of the medial meniscus and compared them to 84 cases, without a history of prior KA as a control group. Outcomes were assessed with the original IKS scores and complications. The mean follow-up was 8 years. RESULTS: There was no significant difference between groups with respect to demographics, or pre-operative IKS. The mean pre and postoperative IKS was not different between groups. The all-cause reoperation, revision, and complication rates of the KA group were not significantly higher than those of the control group. CONCLUSION: The present study seems to reveal that previous KA of the medial meniscus does not negatively affect a subsequent TKA. Nevertheless, larger studies may be necessary to confirm this observation.