Dry Arthroscopy Distal Radioulnar Joint and Foveal Insertion: Surgical Technique

Background Arthroscopy of the distal radioulnar joint is considered to be difficult to perform. At this time the integrity of the foveal insertion is indirectly evaluated with a hook test. If a hook test is positive it is inferred that the foveal insertion is torn or incompetent. Description of Technique The ideal way to evaluate the foveal insertion is by direct visualization and probing. In order to do this, arthroscopic examination of the distal radioulnar joint and foveal insertion is required. The article describes how to reliably perform “dry” arthroscopy of the distal radioulnar joint and foveal insertion using a 1.9 mm arthroscope to accurately assess the triangular fibrocartilage complex and foveal insertion. Patient and Methods A total of 169 dry DRUJ arthroscopies were performed by the primary author between January 2018 and February 2021. Results Using this technique, the foveal insertion was successfully visualized in 168 cases (99%). Conclusion Dry arthroscopy of the DRUJ is a reliable technique to evaluate the integrity of the foveal insertion.

The Black Knee – A Case Report

Introduction: Ochronotic arthropathy in patients with alkaptonuria is a rare hereditary disorder. The altered metabolism causes the homogentesic acid derivatives to deposit in various connective tissues causing characteristic pigmentation. Due to the close clinical resemblance to that of a degenerative disorder, diagnosis of ochronotic arthropathy usually occurs intraoperatively. We report arthroscopic findings of a 50-year-old female with ochronotic arthropathy. Case Report: A 50-year-old woman came with complaints of pain and swelling in the left knee. Clinical examination and MRI findings were correlated to reveal a tear of lateral meniscus. On arthroscopic examination, the blackish pigmentation of the meniscus and the articular cartilage led to the diagnosis of ochronotic arthropathy. Conclusion: Arthroscopy plays an important role in diagnosis and treatment of patients with ochronotic arthropathy. The characteristic arthroscopic finding may aid diagnosis even in patients who do not have other systemic manifestations. Timely arthroscopic intervention can help delay the disease progression. Keywords: Alkaptonuria, Ochronotic arthropathy, Ochronosis, Arthroscopy.

Symptomatic Complete Discoid Medial Meniscus Completely Coalesced With the Anterior Cruciate Ligament: a Case Report

Rationale: Complete discoid medial meniscus is an extremely rare abnormality of the knee joint whose meniscus has a discoid shape rather than a normal semilunar one. Several medial meniscus anomalies including anomalous insertion have been reported in the literature. This report presents a rare case of symptomatic complete discoid medial meniscus whose anterolateral (apical) portion was completely coalesced with the ACL. MRI, radiographic and arthroscopic findings in the medial compartment are to be submitted.Patient concerns and diagnoses: A 29-year-old male presented with intermittent pain and swelling of the right knee for 2 years. Based on radiographic, MRI and physical examination findings, he was diagnosed with discoid medial meniscus tears. Interventions and outcomes: Arthroscopic saucerization were performed for the torn discoid medial meniscus of the right knee. Arthroscopic examination revealed a complete discoid medial meniscus and the anterolateral (apical) portion of which was completely coalesced with the ACL. Careful Probing of the meniscal surface revealed there was a longitudinal tear extending from the tibial spine to the midportion of the meniscus. Arthroscopic saucerization of the discoid meniscus were performed After closely cutting the meniscus around the ACL. The patient reported a satisfactory results at the 12-month follow-up.Lessons: Complete discoid medial meniscus is an extremely rare abnormality, and this case presents the third complete discoid medial meniscus whose anterolateral (apical) portion was completely coalesced with the ACL. The current case we present strongly supports the theory that ACL and meniscus were differentiated from the same mesenchyme.

Canine developmental elbow disease part 1: aetiopathogenesis and diagnosis

Elbow dysplasia or ‘developmental elbow disease’ as it is now known, is an umbrella term encompassing multiple abnormalities of the elbow joint. These include elbow incongruity, fragmented medial coronoid process, osteochondritis dissecans and ununited anconeal process. These problems may occur individually or in combination with each other and all may cause lameness, pain, reluctance to exercise and restricted movement as the disease progresses. The advanced stage of osteoarthritis associated with medial coronoid disease involving extensive damage to or loss of cartilage is known as medial compartment disease. There are multiple modalities available for imaging the elbow joint: radiography which is widely available in general practice can detect some changes but may miss others; computed tomography in conjunction with arthroscopic examination is considered the ‘gold standard’ in elbow imaging. Part 1 of this two part series of articles introduces the aetiopathogenesis of canine developmental elbow disease, and part 2 will cover the surgical and nonsurgical management.

Arthroscopically assisted evaluation of frequency and patterns of meniscal tears in operative tibial plateau fractures: a retrospective study

Background Despite tibial plateau fractures are often associated with meniscal tears, the association between meniscal tears and Schatzker classification remains unclear. The purpose of this study was to assess the frequency and patterns of meniscal tears in operatively treated tibial plateau fractures following immediate arthroscopic evaluation after internal fixation of tibial plateau fractures and to reveal the association between these concomitant meniscal tears and Schatzker classification. Methods A total of 252 consecutive patients (166 males and 86 females, mean age 46.7 (19–80) years) with operatively treated tibial plateau fractures admitted to our hospital from January 2016 to May 2019 were performed. Arthroscopic examination for frequency and patterns of meniscal tears was evaluated and documented at the time of surgery, and the association between the frequency and patterns of meniscal tears with Schatzker classification was then analyzed. Results The overall frequency of meniscal tears in TPFs was 67% (168 of 252) with 33% (84 of 252) of these being lateral meniscal tears, and 10% (26 of 252) medial meniscal tears, while 23% (58 of 252) had bilateral meniscal tears. Schatzker II was most commonly associated with meniscal tears, occurring in 72% (71 of 99) of our series. There is no significant difference between the frequency of meniscal tears and Schatzker classification (p > 0.05). The most common patterns of meniscal tears were longitudinal tears in 23% of tibial plateau fractures (59 of 252), and it occurred at a significantly higher frequency in Schatzker II with 43% (43 of 99). Schatzker IV had significantly higher prevalence of bucket-handle tears than other fracture patterns (p < 0.05), and Schatzker VI fractures had significantly higher prevalence of complex tears than other fracture patterns (p < 0.05). For other Schatzker classification, the patterns of meniscal tears demonstrated no statistical difference (p > 0.05). Conclusion The results identified that meniscal tears are commonly seen in each Schatzker classification. Although various patterns of meniscal tears occurred in tibial plateau fractures, the most common patterns were longitudinal tears. Importantly, we suggest that the status of meniscal tears associated with TPFs should be considered at the time of surgery in addition to fracture fixation.

Anteroinferior Hip Instability in Flexion During Dynamic Arthroscopic Examination Is Associated With Abnormal Anterior Acetabular Horn

Background: The stabilization of the femoral head is provided by the distal acetabulum when the hip is in a flexed position. However, the osseous parameters for the diagnosis of hip instability in flexion are not defined. Purpose/Hypothesis: To determine whether the osseous parameters of the distal acetabulum are different in hips demonstrating anteroinferior subluxation in flexion under dynamic arthroscopic examination, compared with individuals without hip symptoms. The hypothesis was that the morphometric parameters of the anterior acetabular horn are distinct in hips with anteroinferior instability compared with asymptomatic hips. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 30 hips with anteroinferior instability in flexion under dynamic arthroscopic examination were identified. A control group of 60 hips (30 patients), matched by age and sex, was formed from individuals who had undergone pelvis magnetic resonance imaging (MRI) for nonorthopaedic reasons. Unstable and control hips were compared according to the following parameters assessed on axial MRI scans of the pelvis: anterior sector angle (ASA), anterior horn angle (AHA), posterior sector angle (PSA), posterior horn angle (PHA), acetabular version, lateral center-edge angle, acetabular inclination (Tönnis angle), and femoral head diameter. Results: The coverage of the femoral head by the anterior acetabular horn was decreased in unstable hips compared with the control group (mean ASA, 54.8° vs 61°, respectively; P < .001). Unstable hips also had a steeper anterior acetabular horn, with an increased mean AHA compared with controls (52.5° vs 46.8°, respectively; P < .001). An ASA <58° had a sensitivity of 0.8, a specificity of 0.68, a negative predictive value of 0.87, and a positive predictive value of 0.56 for anteroinferior hip instability. An AHA >50° had a sensitivity of 0.77, a specificity of 0.72, a negative predictive value of 0.86, and a positive predictive value of 0.57 for anteroinferior hip instability. There was no statistically significant difference in the mean PSA, PHA, acetabular version, lateral center-edge angle, acetabular inclination, or femoral head diameter between unstable hips and controls. Conclusion: Abnormal morphology of the anterior acetabular horn is associated with anteroinferior instability in hip flexion. The ASA and AHA can aid in the diagnosis of hip instability.

Comparison of Syndesmotic Malreduction Rate following Trans-Syndesmotic Screw Fixation in SER versus PER Type Ankle Fracture: A Prospective Analytic Study

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic injury frequently presents in severe rotational ankle fracture and a trans-syndesmotic screws fixation is commonly used technique. Bases on previous literatures, syndesmotic malreduction rate can occur between 20- 70 percent following traditional trans-syndesmotic screw fixation in all type of ankle fracture. However, there is a little evidence regarding the malreduction rate in each type of ankle fractures. The purpose of this study is to demonstrate malreduction rate of syndesmosis using simultaneously bilateral post-operative CT measurement after trans-syndesmotic screw fixation between supination external rotation and pronation external rotation type ankle fracture. Methods: A prospective comparative study of patients who had acute ankle fracture with syndesmotic injury between January 2015 and December 2017 were enrolled. Lague-Hansen classification was used to classify all patient into 2 groups: SER and PER based on mechanism of injury. Syndesmotic injury was confirmed by ankle arthroscopic examination in all patients and they were treated with ORIF distal fibula using either 1/3 tubular plate or anatomical locking plate under direct visualization of syndesmosis. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. The accuracy of syndesmotic reduction was evaluated by simultaneously bilateral post-operative CT scan. Syndesmotic reduction was measured using anterior to posterior distance (AP) and medial to lateral distance (ML). A widening of distance between anterior tibia and fibula at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis. Results: There were 67 patients were enrolled in this study (SER=48 and PER=15). The syndesmotic injury was present 60% (48/70) in SER and 100% (15/15) in PER group respectively. The malreduction was significant higher in PER than SER (2.1% in SER vs 20% in PER). Operative time was 58.2 and 79.2 minutes in SER and PER. The tibiofibular clear space was 4.0mm versus 4.8mm in SER and PER. The AP distance was -0.33mm and -0.51mm and ML distance was 1.91 mm and 1.59mm for SER compared to normal side and 0.19 mm and -0.21 and ML distance was 2.59mm and 1.63mm for PER compared to normal side. There were significant improvements of functional outcomes (FAAM, SF-36, and VAS) but no significant different between the two groups. Conclusion: The incidence of concomitant syndesmotic injury and syndesmotic malreduction rate following trans-syndesmotic screw fixation was significantly higher in PER type compared SER type ankle fracture. The malposition of distal fibula was displaced anteriorly and laterally (undercompression) compared to uninjured side.

Outcomes and Complications Following Treatment of Chronic Subtle Syndemotic Injury with Arthroscopic Debridement and Fixation with Suture Button

Category: Ankle; Arthroscopy Introduction/Purpose: The syndesmotic injury can be occurred 10-18 percent associated with acute ankle sprain. This injury is commonly missed due to a difficulty to diagnosis in acute setting leading to chronic pain, swelling, and inability to return to previous level of activities and sports. Anterior ankle arthroscopic examination has been proposed to be successful technique to establish the diagnosis of this subtle injury. The purpose of this study is to demonstrate outcomes and complications of the patients who isolated syndesmotic injury and treated with anterior ankle arthroscopic debridement and fixation with suture button. Methods: A prospective case series of 62 patients who had ankle sprain with chronic pain on syndesmosis between 2015 and 2019 were enrolled in this study. All patients were failed from conservative treatment including bracing, ankle range of motion and strengthening exercises, low-does laser, and ultrasound treatment for at least 6 months after initial injury. The syndesmotic injury was considered when patients had chronic pain and swelling and athletic taping test was positive, and MRI demonstrated AITFL torn or fluid was ascended more than 10mm from ankle joint line. All patients were confirmed by intra-operatively ankle arthroscopy with a 3-mm shaver could pass through the syndesmotic joint. Syndesmotic joint was debridement and was fixed by suture button. Pre- and post-operative SF-36, FAAM, and VAS were obtained and compared using a paired t-test. Operative times, complications, and recovery times including time to return to ADL, work, and sports were recorded. Results: There were significant improvements of all functional outcomes (FAAM, SF-36, and VAS (p < 0.001 all)) with an average follow-up of 20.8 months. An average operative time was 30.2 minutes. Patients reported no previous pain after the operation (VAS 0/10, 54/62) and mild pain (VAS 1-2/10, 8/62). There were 6 patients with osteochondral injury intraoperatively and 9 patients with enlargement of anteroinferior tibiofibular ligament (AITFL). Recovery times included returned to ADL 4.9 weeks, to work 6.8 weeks, and to sports 5.8 months. Four patients had saphenous nerve irritation from the medial button and this was fully recovery at 4.8 months post-operatively and 2 patients has mild pain on fibular. There were no migration or disruption of suture button and no wound complications. Conclusion: Isolated sublte syndesmotic injury after ankle injury was successfully confirmed by anterior ankle arthroscopic examination and arthroscopic debridement and suture button fixation demonstrated significant improvement of functional outcomes as measured with FAAM, SF-36, and VAS. and patients were able to return previous activities. This technique is effective, safe, and feasible for treatment in patients with isolated subtle syndesmotic injury.

Comparative Study OCT versus MRI T2 in Diagnosis of Degenerative Cartilage Lesions

BackgroundWhen diagnosed early, degenerative cartilage lesions are reversible if the appropriate therapeutical measures are applied. Currently available diagnostic methods (radiography, MRI and arthroscopic examination) do not provide the accuracy needed in the early diagnosis of these lesions.MethodsThe aim of the study is to analyse, in an ex vivo study on osteochondral fragments taken from patients undergoing total knee arthroplasty, weather the OCT technique is effective in detecting these lesions. The results will be compared to the preoperative MRI images (especially T2 mapping technique).ResultsThe percentage of the agreement between the two reviewers was 89% (8 out of 9 cases) during the OCT examination process.ConclusionOCT is a new technique potentially useful in the diagnosis of cartilage lesions. The possibility of performing it through minimally invasive techniques currently (arthroscopic surgery) further increases the value of this technique. OCT is a non-destructive diagnosing technique in degenerative cartilage lesions whose efficiency is comparable to MRI T2 technique and superior to conventional MRI.

Sonoarthrographic examination of posterior labrocapsular structures of the shoulder joint

Objective: To describe the posterior labral lesions and labrocapsular abnormalities of the shoulder on sonoarthrography and to compare these findings with MR arthrography results. Methods: 82 shoulders were initially evaluated with ultrasonography and MRI and then were examined with sonoarthrography and MR arthrography following intraarticular injection of diluted gadolinium solution. The ultrasonography images were prospectively evaluated for the presence of posterior labral tear, sublabral cleft, and posterior capsular abnormalities by two radiologists. The diagnostic accuracy of sonoarthrography in the detection of posterior labral tears and posterior labrocapsular variants was compared with that of MR arthrography. Results: In sonoarthrographic examinations of 82 shoulders, 5 and 6 posterior labral tears were identified by Observer 1 and 2, respectively. Moreover, 6 and 7 posterior sublabral clefts, and 2 and 3 posterior synovial folds were identified by Observer 1 and 2, respectively. All the 82 patients were examined with MR arthrography; however, only 14 patients underwent arthroscopic examination. No significant difference was found among the 82 patients with regard to age, gender, and the prevalence of posterior labral tear, posterior labral cleft, and posterior synovial fold (p > 0.05). Interobserver variability showed substantial agreement between the sonoarthrographic and MR arthrographic results of the posterior labrocapsular structures (κ = 0.71, p < 0.05). Conclusion: Posterior labral tears and posterior synovial folds of the shoulder joint can be evaluated non-invasively by sonoarthrography. Advances in knowledge: Variations and pathologies of posterior labrocapsular structures of the glenohumeral joint are relatively uncommon. Direct (MR) arthrography is the gold-standard imaging modality to evaluate of posterior labrocapsular abnormalities of the glenohumeral joint. Sonoarthrography of the glenohumeral joint may be utilized in clinical practice in patients with contraindications to (MRI).