Subvastus versus medial parapatellar approach in total knee arthroplasty

The subvastus approach for total knee replacement was compared with the standard medial parapatellar approach in terms of postoperative knee scores and quadriceps strength. Two groups of patients with similar characteristics were formed: the first group consisted of 12 knees of 9 patients who were implanted via the medial parapatellar approach, and for the second group the subvastus approach was used in 10 knees of 10 patients. The groups' knee scores and quadriceps strength were compared preoperatively and postoperatively at week 6, months 3 and 6. The knee scores improved similarly in both groups, but the change was more pronounced in the subvastus group. Quadriceps strength was greater in the subvastus group at postoperative week 6, but there was no significant difference between the groups in months 3 and 6. It was concluded that although the subvastus approach offers greater quadriceps strength in the early postoperative period, it has no significant advantage in this aspect over the medial parapatellar approach.     

Arthroscopic Release of First Metatarsophalangeal Arthrofibrosis

Various degrees of first metatarsophalangeal joint arthrofibrosis frequently occur in patients with bunion surgery or big toe trauma. In those patients with functional limitation who fail to respond to conservative treatment, surgery is indicated. We describe here an arthroscopic approach to first metatarsophalangeal release that is designed to improve functional results. Dorsomedial and dorsolateral portals are established at the medial and lateral sides of the extensor hallucis longus tendon. Through these 2 portals, the dorsal capsule is released and the medial and lateral joint gutters can be cleared up. The metatarsosesamoid compartment is approached through the straight medial portal and the working portal, the latter of which is located 4 cm proximal to the joint line between the abductor hallucis tendon and the medial head of the flexor hallucis brevis. Under visualization through the medial portal, adhesions around the sesamoid apparatus can be debrided with a shaver through the working portal. This completes the release of joint circumference and improves the motion range of the joint.     

The significance of medial sural artery integrity in popliteal artery trauma: a case report

Two patients with popliteal artery trauma who underwent secondary amputations due to refractory calf sepsis despite a patent arterial repair are presented in this case report. The medial sural artery, the main arterial supply of the medial head of the gastrocnemius, was surgically severed in both patients owing to the use of a continuous medial incision from the supra level to infragenicular level. The compromised arterial supply of the medial head of the gastrocnemius muscle may have contributed to the devitalization of the muscle and the subsequent calf sepsis, and it is speculated that this was related to the unfavorable outcome.     

Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study

Thirty consecutive patients who had dislocation of the elbow without concomitant fracture and who were sixteen years old or more were examined under general anesthesia for stability of the joint at an average of four days after the injury. All of the elbows showed medial and sixteen showed both medial and lateral instability. The patients were then randomly assigned to undergo either non-surgical or surgical treatment of the ligamentous injuries. All of the surgically treated elbows showed complete rupture or avulsion of both the medial and lateral collateral ligaments, and in about half of these patients the muscle origins were found to be torn from the humeral epicondyles. At follow-up, both groups showed generally good results; the differences were not statistically significant. There was no evidence that the results of surgical repair of the ligaments were any better than those of non-surgical treatment.     

Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults

BackgroundA common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column.MethodsWe retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated.ResultsAll radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon.ConclusionDMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity.     

Episodic snapping of the medial head of the triceps due to weightlifting

We describe two patients who had episodic elbow snapping and ulnar nerve dysesthesias only after weightlifting. These symptoms would disappear soon afterward. The episodic nature of their complaints and findings led to misdiagnosis. We documented by repeated clinical examinations and magnetic resonance imaging that the presence of these symptoms correlated directly with the finding of intermittent, activity-related snapping of the medial triceps. In both patients, the symptoms disappeared when the medial portion of the triceps migrated medially but did not dislocate over the medial epicondyle with elbow flexion. Thus, a minor change in the configuration of the medial portion of the triceps (fluid accumulation) in the same individual at different times can cause intermittent dislocation of the medial triceps. Previous papers dealing with patients with snapping of the medial triceps describe symptoms exacerbated by athletic activities, but the constant finding of snapping on sequential examinations.     

Hallux metatarsophalangeal joint fusion for the rheumatoid forefoot

Forefoot problems in patients who have rheumatoid arthritis are common. The progressive joint destruction causes a redistribution of weight about the forefoot, with a diminished weightbearing capacity of the first metatarsophalangeal (MTP) joint. Changes around the first MTP joint include synovitis, joint instability with subluxation, and arthritic change. Hallux MTP fusion in patients who have rheumatoid arthritis acts to permanently restore alignment and restore the medial column support of the foot, while at the same time enabling the first MTP to resume its original weightbearing role. Rheumatoid hallux MTP fusion and its rationale are reviewed.     

Correlation of the SLAP lesion with lesions of the medial sheath of the biceps tendon and intra-articular subscapularis tendon

Background:

Superior labral anterior to posterior (SLAP) lesions have been well described in the literature and are thought to be secondary to traction injuries to the biceps anchor and/or falls on the outstretched arm. The pulley has recently been described as a structure that aids in the prevention of biceps instability. The intra-articular subscapularis insertion (IASS) has been noted to contribute to the robust nature of the medial sheath. The purpose of the study was to determine a potential correlation of SLAP lesions and pulley lesions with/without IASS lesions, (hereafter referred to as medial sheath) as forces that can disrupt the biceps anchor and may also disrupt structures of the medial sheath or vice-versa.

Materials and Methods:

Three hundred and sixteen consecutive shoulder arthroscopies performed by one surgeon were reviewed retrospectively. Operative reports and arthroscopic pictures were carefully reviewed with particular attention paid to the labral and pulley pathology. Selection bias was noted as the author had never operated primarily for a Type 1 SLAP lesion. Following, however, and as such, the exclusion criteria, was a Type 1 SLAP.

Results:

There were a total of 30 SLAP lesions and a total of 126 medial sheath lesions. There were 13 patients who had both SLAP and medial sheath lesions. There were 17 patients who had a SLAP lesion without a medial sheath lesion. There were 96 medial sheath lesions without a SLAP. A comparison of rates between patients who had a medial sheath lesion with a SLAP and those who had a medial sheath lesion without a SLAP, for the 316 patients, and when tested with a Fisher exact test revealed that there was no statistical significance, P = 0.673. The prevalence of SLAP lesions in this population of 316 patients was 9.4%, Buford 1%, medial sheath lesions 39%, and SLAP and medial sheath lesions 4%. Interestingly, there were three Buford complexes, all associated with a SLAP and one Buford complex was associated with both a SLAP and a pulley.When looking at the rate for medial sheath lesions when restricted to patients with SLAP lesions, the medial sheath lesion rate was 43.3% (13/30; 95% confidence interval 19.6–66.9%). The medial sheath lesion rate for patients with SLAP lesions differs from a rate of zero and is statistically significant, with a P value <0.05. In other words, when a SLAP lesion is present there is a statistically significant rate of medial sheath lesions, a previously unpublished association.

Conclusions:

With a 43% association of the medial sheath lesion with SLAP lesions, the author postulates that forces that affect the biceps anchor may also damage the pulley system of the bicipital sheath and, as such, this anatomic structure should be evaluated, especially when SLAP lesions are present.     

Pedicled medial sural perforator flap for the reconstruction of knee defects

Soft tissue defects exposing the patellar tendon or bone are common in patients who have experienced trauma or implant infection. The purpose of this article is to present our experience of six patients who underwent reconstruction of soft tissue defects of the knee using a pedicled medial sural perforator flap. Between November 2013 and November 2015, six patients who presented with a soft tissue defect overlying the knee were admitted to our hospital. After adequate debridement or wide excision of the tumour, these patients underwent pedicled medial sural perforator flap placement to resurface the complex soft tissue defects and to provide a gliding surface for the exposed patellar tendon. The patients' age, comorbidity, aetiology, defect size and location, flap size, perforator numbers and lengths, outcome and follow‐up period were reviewed. The six medial sural perforator flaps survived completely, and the wounds healed satisfactorily over a mean follow‐up of 21·5 months (range, 6–51 months). Donor sites were closed primarily or covered with a split‐thickness skin graft. The medial sural perforator flap is a reliable flap for coverage of defects overlying the knee. The thin and pliable flap, long pedicle length and less donor site mobility benefit patients. Thus, the medial sural perforator flap may be a valuable alternative for defect reconstructions overlying the knee, which produces satisfactory results both functionally and cosmetically.     

Current concepts in medial thighplasty

Lockwood's changes in surgical design of the medial thigh lift have improved results and decreased complications but still have the fundamental problem of poor tissue fixation to rigid tissue. To provide increased support to the medial thigh incisions, modifications to this technique have been tried. This article describes the authors' approach to the medial thigh lift in both those patients who have undergone traditional weight loss and the massive weight-loss thigh-lift patient.     

Carpometacarpal dislocations. Long-term follow-up

Twenty patients who had a dislocation of one or all of the medial four carpometacarpal joints were followed for an average of 6.5 years (range, 1.5 to 20.5 years). Fifteen patients were treated with open reduction and internal fixation during the first three weeks after injury and the long-term result was excellent in thirteen of them. Three of the four unsatisfactory results were in patients who had injuries to the normally rigid second and third carpometacarpal joints or had a concomitant ulnar-nerve injury.     

Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study

Two hundred consecutively seen patients who had an injury to either the anterior cruciate ligament or the medial collateral ligament, or both, were randomly allocated to treatment by either conservative or a surgical regimen. Injuries to the medial collateral ligament could not be demonstrated to benefit from surgical treatment in any respect--with or without surgery the results were excellent. With injuries to the anterior cruciate ligament, recovery was more rapid without surgery but otherwise the results differed between the groups in only one respect: the pivot-shift test was more often positive after conservative treatment. The results were good in both treatment groups even though most of the patients who had an injury of the anterior cruciate ligament were somewhat less pleased with the outcome after a period of time.     

Abnormal knee mobility and meniscal injury

Stress radiography for anteroposterior mobility of the knees was performed in 17 patients who had undergone medial meniscectomy and 10 patients who had undergone lateral meniscectomy. Sixteen of the patients were also tested for valgus-varus mobility. An increase in varus mobility following medial meniscectomy was primarily attributed to compression of the medial compartment space. No increase in anteroposterior mobility was found in the knees that had undergone meniscectomy compared with the uninjured contralateral knees. Anterior and total anteroposterior mobility were bilaterally greater in patients with medial meniscectomy compared with lateral meniscectomy. Furthermore, for the patients with medial meniscectomies anterior as well as total mobility were bilaterally greater than values obtained in 28 normal knees. We conclude that idiopathic anteroposterior hypermobility seems to predispose to injury of the medial meniscus. Perhaps individuals with generalized joint laxity should be warned against participating in contact sports.     

Upper tibial osteotomy for secondary osteoarthritis of the knee

Of 34 consecutive proximal tibial osteotomies for secondary degenerative arthritis in patients under 40 years of age, 33 were evaluated at least three years (mean 7.5 years) after operation. In all 73% were satisfactory, with four failures in 21 procedures in men and five failures in 12 procedures in women. The primary abnormalities were medial meniscectomy (11), medial and lateral meniscectomy (4), osteochondritis dissecans (3), osteochondritis dissecans with medial meniscectomy (4) and fracture (11). All four knees with both medial and lateral meniscectomy had unsatisfactory results despite obtaining anatomical alignment. Eight patients needed subsequent surgery; five of them had total knee replacement, four within four years of the osteotomy. Proximal tibial osteotomy in younger patients with secondary arthritis gives similar results to those for older patients with primary osteoarthritis. If it fails, this is generally within the first four years after the operation.     

Radiofrequency medial branch neurotomy in litigant and nonlitigant patients with cervical whiplash: a prospective study.

STUDY DESIGN: The efficacy of radiofrequency medial branch neurotomy to treat cervical zygapophysial joint pain from whiplash was compared prospectively in litigants and nonlitigants. OBJECTIVES: 1) To assess the effect of monetary gain on treatment of zygapophysial joint pain in cervical whiplash. 2) To determine whether radiofrequency medial branch neurotomy is effective treatment for whiplash. SUMMARY OF BACKGROUND DATA: The influence of litigation on treatment outcome is a subject of controversy in both the medical and legal professions. This is the first study to examine this issue in a prospective manner using a previously proven diagnostic and therapeutic method. METHODS: Sixty patients with cervical whiplash who remained symptomatic after 20 weeks of conservative management were referred for radiofrequency cervical medial neurotomy. The patients were classified as litigant or nonlitigant based on whether the potential for monetary gain via litigation existed. Each group underwent identical evaluation and treatment. Patients were observed for 1 year. Visual analogue scores and self-reported improvement were obtained before, immediately after, and 1 year after radiofrequency cervical medial neurotomy. RESULTS: Forty-six patients completed the study. The overall reduction in cervical whiplash symptoms and visual analogue pain scores were significant immediately after treatment (nonlitigants vs. litigants: 2.0 vs. 2.5, P = 0.36) and at 1 year (nonlitigants vs. litigants: 2.9 vs. 4.0, P = 0.05). One-year follow-up scores were higher than immediate post-treatment scores (nonlitigants vs. litigants: 2.5 vs. 3.6). The difference between litigants and nonlitigants in the degree of symptomatology or response to treatment did not reach significance. CONCLUSIONS: These results demonstrate that the potential for secondary gain in patients who have cervical facet arthropathy as a result of a whiplash injury does not influence response to treatment. These data contradict the common notion that litigation promotes malingering. This study also confirms the efficacy of radiofrequency medial branch neurotomy in the treatment of traumatic cervical facet arthropathy.     

Experiences with transconjunctival upper blepharoplasty

Upper blepharoplasty remains a valuable procedure in rejuvenating the upper eyelid. An innovative technique was recently reported whereby medial fat is removed through a transconjunctival approach. This is a preliminary report of our experience with 60 patients treated over the past 10 months using this technique. The technique will be described in detail and cases will be reported. There were no perioperative or postoperative complications. All of the patients are satisfied with the results of their surgical procedure. The technique has the advantage of avoiding an incision of the medial upper eyelid and the inherent risks of excessive scarring in this area. We have found the technique especially useful in secondary blepharoplasty with an isolated prominence of residual medial fat. Other advantages include the following: primary cases in which the surgeon is able to avoid medial extension of the cutaneous incision, patients who possess deep tarsal folds with prominent medial fat, or as an adjunct to eyebrow lifting techniques where in both cases cutaneous excision is unnecessary. No disadvantages have been noted.     

Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability.

Long-standing lateral ligament instability of the ankle results in unbalanced loading of the medial joint space and the possible development of degenerative arthritis. Thirty-six patients who had had lateral ankle instability for at least ten years and complaints of increasing ankle pain evidence degenerative changes of the articular cartilage over the medial half of the talar and tibial surfaces of the ankle joint. These changes were minimally apparent on roentgenograms unless weight-bearing roentgenograms were made, but arthroscopy of the joint accurately revealed the extent of degeneration. After reconstruction of the lateral ankle ligaments, fourteen of twenty-two patients with mild to moderate arthritic changes showed both symptomatic improvement and demonstrable widening of the medial joint space on weight-bearing roentgenograms. Four of five patients with severe degenerative arthritis subsequently had a total ankle replacement.     

Hypermobility of the first metatarsal bone in patients with Rheumatoid arthritis treated by lapidus procedure

ABSTRACT: BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3 %) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9 %). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.     

Radiographic assessment of instability of the knee due to rupture of the anterior cruciate ligament. A quadriceps-contraction technique

We compared the results of a radiographic technique for the measurement of instability of the knee with those obtained with a KT-1000 arthrometer. The study was conducted on both knees of sixty patients who had a ruptured anterior-cruciate ligament in one knee, as well as in ten control subjects. The radiographic technique included the examination of a true lateral radiograph, made while the knee was in full extension and the quadriceps was maximally contracted, with a 66.7-newton downward force produced by a 6.8-kilogram weight suspended from the ankle. As demonstrated by both techniques, the maximum difference between the displacements of the right and left knees in the control subjects was 2.5 millimeters and the mean difference between the displacements in the two knees in the patients was 7.5 millimeters. In fourteen of the sixty knees in which the ligament was ruptured, the injury was acute. The forward translation of the medial side in these fourteen knees was compared with that in the forty-six knees in which the injury was chronic. The mean difference in the displacement of the medial side in the right and left knees was 3.5 millimeters in the fourteen patients who had an acute injury and 5.0 millimeters in the forty-six patients who had a chronic injury. Thirteen of the sixty patients had disruption of the posteromedial corner of the injured knee, and the translation of the medial side in these knees was significantly increased compared with that in the intact knees of the same patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenervation of lumbar facet joints

BACKGROUND AND OBJECTIVES: At many institutions, it is not practically feasible to perform a series of controlled or placebo-controlled medial branch blocks on several facet joints in order to select patients for facet joint rhizotomy. As for uncontrolled blocks, there is no proof that medial branch blocks are superior to other types of blocks. This study was performed to compare medial branch blocks to simple pericapsular blocks for the selection of patients for lumbar facet joint cryodenervation. METHODS: Patient selection was based on history, imaging, and physical examination. Diagnostic blocks were either medial branch blocks or pericapsular blocks. Percutaneous medial branch cryodenervation was performed by use of a Lloyd Neurostat 2000. Outcome parameters were low back pain (visual analog scale [VAS]), limitation of activity (Macnab), and overall satisfaction. A total of 26 patients were recruited, 13 for each group. Follow-up was 6 months. RESULTS: Patients who had been selected by medial branch blocks had better pain relief than did patients who had been diagnosed by use of pericapsular blocks. At 6 weeks and at 3 months after treatment, these results reached statistical significance (VAS 2.2 v 4.2, P < .05). CONCLUSIONS: Our results suggest that uncontrolled medial branch blocks are superior to pericapsular blocks in selecting patients for facet joint cryodenervation, but both blocks work. If serial controlled blocks cannot be used, lumbar facet joint pain remains a diagnostic dilemma.