Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review

Background To determine the incidence of concomitant intra-articular glenohumeral injuries in patients undergoing surgical management from distal clavicle fractures (DCF) with shoulder arthroscopy and their impact on outcome. Methods This systematic review was conducted following the PRISMA guidelines. PubMed, EMBASE, and Virtual Health Library databases were accessed in October 2021. All the clinical studies evaluating the surgical management of DCF and using concomitant intra-operatory shoulder arthroscopy were included. Studies that did not specify the concomitant injury type were not eligible. Data from the incidence of intra-articular glenohumeral injuries, injury type, length of the follow-up, and clinical outcomes were retrieved. The quantitative content assessment was performed using the STROBE statement checklist. Evaluation of the publication bias of the included studies was performed using the risk of bias assessment tool for systematic reviews. Results Data from five retrospective and five prospective cohort studies were analyzed. Eight of the included studies were conducted on patient cohorts with Neer type II injuries. Data pooling revealed a mean of 17.70% of concomitant glenohumeral injuries, whereas 84.21% of them required additional surgical management (Table 1). Rotator cuff injuries, labral tears, and biceps pulley lesions were the most common concomitant injuries. Conclusion Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to DCF should be recommended.

AMR Sign: A Clinical Sign of Mechanical Integrity of Medial Meniscus

Introduction:Meniscus injury is now widely being diagnosed and managed. Meniscus acts as a shock absorber and transmits forces from femur to tibia. However, if the meniscus is torn, the hoop strength is lost. In hidden meniscus injuries, budding arthroscopy surgeons tend to miss the tear. AMR sign acts as a light-bearer for identifying the breach in the collagen architecture. Methods and Materials: 267 patients were included in the study. Informed written consent was taken from all the patients operated and included in the study. Following a fixed protocol of diagnostic arthroscopy, documentation of AMR sign and its relation with intactness of the medial meniscus was done. If medial meniscus tear was found, after repair, its relation with AMR sign was documented.

Evaluation of the effectiveness of hip arthroscopy in the surgical treatment of ANFH in adults

During 2017–2021 in the facilities of the orthopedic department of the Khabarovsk Krai Clinical Hospital named after prof. O.V. Vladimirtseva patients with avascular necrosis of the femoral head (ANFH) stages 0, 1 and 2 have been surgically treated with minimally invasive two-stage decompression with bone alloplasty. The results of radiological diagnosis and arthroscopic picture in the initial stages of the disease were evaluated. The results obtained, the identity of the MRI diagnostic data and the arthroscopic featers indicate the unreasonableness of performing therapeutic and diagnostic arthroscopy in combination with tunnelization, revision of the femoral head cyst and further alloplasty in stages 1 and 2 of the disease, which does not exclude the possibility of using this technology in other stages of ANFH

3T MRI of wrist ligaments and TFCC using true plane oblique 3d T2 Dual Echo Steady State (DESS) – a study of diagnostic accuracy

Objectives: This study was designed to assess the accuracy of unenhanced 3T MRI supplemented with dedicated true plane reformats of 3d T2DESS, in assessing tears of scapholunate, lunotriquetral ligaments and triangular fibrocartilage complex, using arthroscopy as gold standard. Methods: In a retrospective cohort review, patients who underwent wrist arthroscopy and MRI over 2 years (n=46) were identified. Dedicated axial and coronal reformats were obtained from 3d T2 DESS sequence for assessing intrinsic ligaments and TFCC. At arthroscopy tears were classified using Geissler’s classification and compared to MRI findings. Results: The sensitivity of unenhanced 3T MRI in detecting scapholunate ligament tears was 87% and specificity was 90% and negative predictive value of 93%. The lunate triquetral ligament was assessed with a high specificity (97%) and negative predictive value (93%), sensitivity was 63%. Triangular fibrocartilage (TFCC) tears were assessed with a sensitivity of 100%. The overall diagnostic accuracy of unenhanced 3T MRI of wrist in detecting ligament tears was 91%. Conclusion: 3T wrist MRI with dedicated reformats from 3d T2 DESS have a high diagnostic accuracy in assessing acute intrinsic ligament and TFCC injuries. High strength 3T MRI with good technical quality isotropic 3d T2 DESS is critical for accurate wrist ligament assessment. Negative predictive values of 3T MRI of 95% can lead to reduced need for diagnostic arthroscopy of the wrist. Advances in knowledge: This study assesses the diagnostic performance of unenhanced 3T MRI with 3dT2 DESS in assessing traumatic wrist ligament tears. The accuracy of T2 DESS in wrist imaging has not been previously reported.

Arthroscopic Repair of a Posterior Midcapsular Rupture Causing Posterior Shoulder Instability

Background: Gross posterior instability is rare and when found likely has an injury or deficiency to the posterior static restraints of shoulder associated with it. Traditionally, injuries to the posterior capsule have been difficult to diagnose and visualize with magnetic resonance imaging preoperatively, and very little literature regarding arthroscopic repair of posterior capsular tears exists currently. Indications: We present a repair of a posterior midcapsular and posterior labral tear in a 26-year-old man with recurrent left posterior shoulder instability using a novel all–arthroscopic technique. Technique Description: We performed a shoulder arthroscopy in a lateral decubitus position with the arm at 45° of abduction using standard posterior viewing and anterior working portals. Diagnostic arthroscopy revealed a large posterior midcapsular rupture approximately 2 cm lateral to the glenoid with an associated posterior labral tear. We created an accessory posterolateral portal with needle localization that was outside the capsular defect yet allowed access to the posterior labrum. Anatomic closure of the capsular tear was achieved arthroscopically with 3 interrupted No. 2 nonabsorbable sutures in a side–to–side fashion. Posterior labral repair and capsular shift were done to further address the instability using 2 knotless all–suture anchors percutaneously placed at the 7 o'clock and 9 o'clock position. We closed the posterior portal with a combination of curved and penetrating suture passers. Incisions were closed with interrupted 4-0 nylon. Postoperatively, the patient was placed in an ultra–sling for 4 weeks before physical therapy. We allowed light strengthening at 8 weeks, full strengthening at 12 weeks, and estimated return to sport at 4 months. Results: At 6 months postoperatively, the patient has regained symmetric motion, full strength, and has no residual pain or instability. Conclusion: Gross posterior instability is a rare and difficult condition to diagnose and manage. If no significant labral injuries are identified, injury to the posterior capsule must be considered and full assessment should be done when visualizing from the anterior portal. Repair of the posterior capsule is necessary and can be achieved all arthroscopically with this technique.

Return to work after subacromial decompression, diagnostic arthroscopy, or exercise therapy for shoulder impingement: a randomised, placebo-surgery controlled FIMPACT clinical trial with five-year follow-up

Background Arthroscopic subacromial decompression is one of the most commonly performed shoulder surgeries in the world. It is performed to treat patients with suspected shoulder impingement syndrome, i.e., subacromial pain syndrome. Only few studies have specifically assessed return-to-work rates after subacromial decompression surgery. All existing evidence comes from open, unblinded study designs and this lack of blinding introduces the potential for bias. We assessed return to work and its predictors in patients with shoulder impingement syndrome in a secondary analysis of a placebo-surgery controlled trial. Methods One hundred eighty-four patients in a randomised trial had undergone arthroscopic subacromial decompression (n = 57), diagnostic arthroscopy, a placebo surgical intervention, (n = 59), or exercise therapy (n = 68). We assessed return to work, defined as having returned to work for at least two follow-up visits by the primary 24-month time point, work status at 24 and 60 months, and trajectories of return to work per follow-up time point. Patients and outcome assessors were blinded to the assignment regarding the arthroscopic subacromial decompression vs. diagnostic arthroscopy comparison. We assessed the treatment effect on the full analysis set as the difference between the groups in return-to-work rates and work status at 24 months and at 60 months using Chi-square test and the predictors of return to work with logistic regression analysis. Results There was no difference in the trajectories of return to work between the study groups. By 24 months, 50 of 57 patients (88%) had returned to work in the arthroscopic subacromial decompression group, while the respective figures were 52 of 59 (88%) in the diagnostic arthroscopy group and 61 of 68 (90%) in the exercise therapy group. No clinically relevant predictors of return to work were found. The proportion of patients at work was 80% (147/184) at 24 months and 73% (124/184) at 60 months, with no difference between the treatment groups (p-values 0.842 and 0.943, respectively). Conclusions Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome. We did not find clinically relevant predictors of return to work either. Trial registration ClinicalTrials.gov identifier NCT00428870.

IMPACT OF PHYSIOTHERAPY REHABILITATION ON SEPTIC ARTHRITIS SECONDARY TO HANSEN’S DISEASE

Leprosy, commonly known as Hansen's disease, is a chronic infectious illness caused by the bacteria Myobacterium leprae. The presence of the musculoskeletal system is the third most common symptom. Acute onset of arthritis is documented secondary to Hansen’s disease. Septic arthritis is a joint infection that causes excruciating pain, it typically manifests as a single hot, swollen, and extremely painful joint. The main aim of physical therapy is to recover from functional impairment as a result of Hansen's disease and to tailor lifestyle changes to help the patient regain functional independence. In this case study, updated physiotherapy rehabilitation of septic arthritis following borderline Tuberculoid Hansen's disease has been demonstrated to be important in restoring range of motion (ROM), muscular strength, and pain alleviation. A male with 46 year of age presented to the orthopedic department with the symptoms of pain and swelling of the knee of the right side since 1 month without any history of fall or twisting injury. He was advised for the investigations of x-ray and MRI and arthrocentesis of right knee was done during which pus was found and aspirated. He was diagnosed with septic arthritis of right knee joint. Patient was operated with diagnostic arthroscopy of right knee where debridement was done. Patient then was referred to physiotherapy department with the complaints of pain and stiffness over right knee joint, with restricted range of motion. He was known case of Hansen’s disease. He was started with physiotherapy rehabilitation protocol for 6 weeks where cryotherapy, TENS, passive ROM, active assisted and active ROM exercises were given. Focus was also made on improving strength. In this case study physiotherapy rehabilitation protocol used had significantly reduce the pain, increased ROM, muscle strength and endurance which considerably help the patient in restoring his functional independence at home and work place.

Anomalous insertion of anterior and posterior horns of medial meniscus. Case report

Background Anatomical variations of the attachment of medial meniscus are a common finding. However, anomalies of the posterior horn are extremely rare. Only two cases of posterior root anomaly have been described prior to the routine use of arthroscopy for evaluation and treatment of meniscal pathology. In this report, we present an anomaly of both the anterior and posterior roots of the medial meniscus that posed both a diagnostic and therapeutic dilemma. Case presentation The patient is young male soccer player who is currently 16 years of age and began having the atraumatic onset of pain and symptoms that limited performance starting at age 14 and was referred for failure of response to nonoperative treatment. Diagnostic arthroscopy revealed the presence of an anteromedial meniscofemoral ligament whereas the posterior root showed no bony attachment. The radiographic and arthroscopic findings are described. The clinical decision was made after to proceed with observation, reassurance, and gradual return to full activity with physiotherapy guidance. Discussion and conclusion The absence of injury, the mild complaints reported by the patient, his age, skeletal immaturity, and remaining growth led us to adopt a conservative approach to treating this anatomic variant and currently the patient is able to participate fully in sports without symptoms or restrictions.

Arthroscopic Repair of Batter’s Shoulder

Background: Batter’s shoulder is a condition in which the posterior labrum is typically torn during the baseball swinging motion, producing a traumatic tear and posterior instability. The injury commonly occurs in the batter’s lead shoulder due to repetitive microtrauma, raising concern for switch-hitters due to the cumulative stress of throwing and swinging on the lead shoulder. Instability is commonly caused by a posterior humeral force and relative shoulder adduction, which is most prevalent during a swing attempt at a low and outside pitch. Indications: Damage to the labrum during the acute traumatic event can cause residual pain and recurrent instability of the shoulder. Indications include failed conservative management. The patient demonstrated a full-thickness longitudinal tear that was grossly unstable with gentle probing. Technique Description: After establishing presence of an unstable posterior labral tear during diagnostic arthroscopy, a 7-o’clock portal is established for the labral repair. A knotless suture anchor construct was utilized for its low-profile features. Care is taken to avoid both tangling of sutures and overtensioning of the repair. Results: Patients return to live batting practice at 6 months postoperatively and most patients return to the same level of play following surgical management. Discussion/Conclusion: Avoid overtightening of labral repair and subsequent loss of range of motion. Use of a low-profile knotless suture anchor is the senior author’s preferred method of surgical management. A majority of patients surgically managed for unstable posterior labral injuries return to the same level of play.