Pitfalls associated with FasT-Fix meniscal repair

There are several devices currently available for all-inside meniscal repair. One of the newest of these devices, the FasT-Fix (Smith & Nephew, Endoscopic Division, Andover, MA), is attractive because it combines advantages of traditional inside-out meniscal repair with an all-inside technique. We chose to critically evaluate these devices in a cadaver model. FasT-Fix devices were inserted arthroscopically in 8 fresh-frozen cadaveric knees at 5 to 7 mm intervals. A total of 45 devices were placed (24 laterally, 21 medially), and the knees were subsequently dissected to determine the location of the inserted devices. Several potential pitfalls were identified during the evaluation. When using the depth penetration limiter that comes preset with the device (to a depth of 22 mm), superficial structures, including the iliotibial tract and even the skin, were at risk for penetration with the needle. The device could not effectively be inserted into the anterior meniscus or the extreme posterior horn. Other potential pitfalls seen during insertion of the FasT-Fix meniscal repair devices include suture tensioning issues (including failure of the suture during tightening), intra-articular deployment of the implants, premature deployment of both the first and second implants, difficulty in advancing the trigger for deployment of the second implant, and difficulty in placing vertical-mattress sutures. Although the FasT-Fix is already in clinical use, additional modifications would likely enhance meniscal repair using this device.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: pp 939–943     

A cyclic testing comparison of FasT-Fix and RapidLoc devices in human cadaveric meniscus

Introduction Cyclic testing may provide a more valid depiction of how arthroscopic meniscal repairs will withstand the forces of activities of daily living (ADLs) and therapeutic exercises early post-surgery than single cycle load to failure testing. This study compared the meniscal fixation provided by vertically or horizontally placed FasT-Fix devices to horizontally placed RapidLoc devices under submaximal cyclic test conditions. Materials and methods Eighteen human cadaveric menisci were divided into three groups of six specimens. A scapel was used to create a 2 cm lesion at 3 mm from the outer edge of the posterior third of each specimen. Merselene tape loops were placed around each side of the lesion and the tears were repaired using two vertical FasT-Fix, two horizontal FasT-Fix, or two RapidLoc devices. Cyclic testing (5–50 N at 1 Hz for 500 cycles) was performed on a servo hydraulic device. One-way ANOVA and Scheffe post-hoc tests were used to evaluate group differences (P < 0.05). Results The vertical FasT-Fix group had less displacement over the initial ten loading cycles compared to the RapidLoc group (P = 0.004), but did not differ from the horizontal FasT-Fix group (P = 0.07). At 50, 100, 200, 300, 400, and 500 cycles, the vertical FasT-Fix group had less displacement than the horizontal FasT-Fix or RapidLoc groups (P ≤ 0.004). At each interval the vertical FasT-Fix group had greater relative stiffness than the other groups (P ≤ 0.009). Conclusions The vertical FasT-Fix group had comparatively less displacement (primarily repair site gapping) and greater relative stiffness.     

全关节镜下应用FasT—Fix修复半月板损伤的中期疗效观察

目的探讨关节镜下应用FasT-Fix缝合修复半月板损伤,并在有效的康复治疗后评价其中期临床疗效。方法回顾性研究因半月板损伤而在关节镜下采用FasT—Fix缝合修复治疗的患者。本组患者24例（男14例,女10例）,共计31例半月板损伤,年龄15—52岁（平均28．3岁）。其中12例是单纯的半月板修复缝合、19例患者是在前交叉韧带重建术后进行的缝合。包括内侧半月板损伤12例,外侧半月板损伤9例,内外侧半月板同时损伤5例,病程1周-23周（除去2例3年的患者）,平均12周。撕裂长度平均15mm（10～25ram）。其中红红区15例,红白区16例,没有白白区进行缝合。平均缝合针数2针（1～4针）。结果所有病例术后均无并发症的发生,随访时间2—4年,平均为2．7年,Lysholm,Tegner,IKDC评分术前、术后评分分别为：45．3、85．4;2．1、3．5;3．1、7．1,差异有统计学意义（P〈0．01）。结论FasT-Fix修复半月板损伤患者在有效康复下,通过中期随访获得88％的优良率。     

All-inside meniscal repair using the FasT-Fix meniscal repair system: Is still needed to avoid weight bearing? A systematic review

The aim of this study was to review the published clinical outcomes of meniscal repair using the FasT-Fix device comparing standard rehabilitation program to an accelerated rehabilitation protocol. A review of the Medline database was performed involving searches for clinical outcomes of all-inside meniscus repair performed with the FasT-Fix device. Eight studies were identified for inclusion. On the basis of the clinical outcomes of these studies, there appears to be no notable difference between an accelerated rehabilitation regimen with full weight bearing allowed as soon as tolerated and a standard postoperative rehabilitation program. Failure rate was 13?% for patients following an accelerated rehabilitation regimen, and 10?% for standard protocol. Accelerated rehabilitation after all-inside meniscal repair using the FasT-Fix device appears to be safe, and the incidence of retears is in line with those reported for standard rehabilitation protocol. Level of evidence IV     

Vascular risk associated with a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique

This study evaluated the risk to the popliteal artery associated with the tibial inlay technique in posterior cruciate ligament (PCL) reconstruction. Barium was injected into the femoral arteries of eight fresh-frozen cadaveric knees and anteroposterior (AP) radiographs were obtained. Dissection of the fascia overlying the gastrocnemius muscle, identification of the interval between the medial head of the gastrocnemius and the semimembranosus, and lateral retraction of the medial head of the gastrocnemius (the Burks and Schaffer approach) was performed. Subsequently, a bicortical screw was placed from posterior to anterior through the tibia as is performed in the tibial inlay technique. A second AP radiograph was obtained. The distance from the center of the screw to the edge of the popliteal artery was measured using digital calipers. The closest any screw came to the popliteal artery was 18.1 mm, and the average distance was 21.1 mm (21.1 +/- 4.6 mm, range: 18.1-31.7 mm). When this distance was calculated as a percentage of the tibial plateau width, the smallest value was 19.2% (24% +/- 4.9%, range: 19.2%-35.1%). A posterior approach for a tibial inlay PCL reconstruction procedure appears safe with respect to the popliteal artery.     

Vascular risk associated with bicortical tibial drilling during anteromedial tibial tubercle transfer

For select patients with persistent patellofemoral pain, the anteromedial tibial tubercle transfer (Fulkerson osteotomy) provides excellent clinical results. This procedure, indicated for patients with patellar malalignment, has become one of the most popular distal realignment procedures. One potential concern with this technique is the proximity of the posterior vascular structures during bicortical tibial drilling for screw placement. To address this concern, we measured the proximity of these structures in 7 consecutive fresh-frozen cadaveric knees. For each knee, barium was injected into the femoral artery, and anteroposterior (AP) radiographs were taken to document the location of the popliteal vessels. Next, the initial steps of the Fulkerson osteotomy were performed. Then, a lateral release and the tibial osteotomy were performed, the tubercle was advanced into position, and two 9/64-inch extralong drill bits were placed through the tubercle and the posterior tibial cortex. Repeat AP radiographs were obtained, and digital calipers were used to measure the distance from the drill bits to the popliteal vessels. The vascular structure closest to the exit point of the superior drill bit was the bifurcation of the popliteal artery (mean distance, 8.3 mm; SD, 9.3 mm; range, 0.0-21.3 mm), and in 2 knees this structure directly overlay the bifurcation on the AP radiograph; the vascular structure closest to the exit point of the inferior drill bit was the posterior tibial artery (mean distance, 9.0 mm; SD, 8.0 mm; range, 0.0-20.0 mm), and again in 2 knees the drill bit lay directly over the artery on the AP radiograph. Bicortical drilling for screw placement during the anteromedial tibial tubercle transfer procedure may come precariously close to the posterior vascular structures of the knee, so orthopedic surgeons must take extreme caution not to drill past the posterior cortex during this part of the operation.     

Arthroscopic meniscal repair: a posterior cannulated technique.

A modified inside-to-outside technique of meniscal repair is presented. The technique employs a 14 gauge needle that acts as the receiving conduit for a standard 10 in meniscal repair needle. The repair needle is placed into the joint through a repair cannula in a routine manner. Twenty-four meniscal repairs with an average follow-up of 26 months are presented with a clinical success rate of 92% and no complications. The technique provides a particularly effective and safe approach to the placement of meniscal repair sutures at the posterior extremes of medial and lateral meniscal tears.     

Outcomes of meniscal repair: minimum of 2-year follow-up

PURPOSE: The purpose of this study was to determine the success rate of meniscal repair achieved in our sports medicine practice, particularly with interest in characterizing the outcomes observed with the newer all-inside repair devices. TYPE OF STUDY: Retrospective chart review with telephone follow-up. METHODS: 157 patients that had undergone a meniscal repair procedure between 1996 and 2001 were identified. Twenty-four of these patients were lost to follow-up. Thus, the study group consisted of 133 patients providing a follow-up rate of 85%. All patients included had a minimum of two years of follow up. Failure was defined as the need for meniscectomy in the area of the meniscus that was initially repaired. The time interval from injury to surgery was divided into less than six weeks (acute) and greater than six weeks (chronic). The etiology of the meniscal tear was broken down into three categories; sports related trauma, non-sports trauma, and atraumatic. The repair techniques used in these patients included outside-in sutures, inside-out sutures, darts, arrows, meniscal screws, T-fix, FasT-fix, and the RapidLoc. RESULTS: The failure rate was 36%. No association was found between failure and the length of preoperative symptoms, rim width, etiology, concomitant meniscectomy, chondroplasty or anterior cruciate ligament (ACL) reconstruction. There was a higher rate of failure of tears in the medial versus lateral meniscus (20.3% vs. 44.8%). No statistical comparisons could be made between devices due to small sample sizes. CONCLUSIONS: The all-inside meniscal repair devices have simplified the meniscal repair procedure. This may have lead to a broadening of the indications for repair CLINICAL RELEVANCE: The newer generation meniscal repair devices, while simplifying the procedure, do not appear to lead to an increased clinical success rate.     

Postoperative change in medial meniscal length in concurrent all-inside meniscus repair with anterior cruciate ligament reconstruction

Purpose

Meniscus repair can restore meniscal function that transfers the axial compressive force to circumferential tensile strain. However, few reports have investigated the relationship between concurrent meniscus repair with acute anterior cruciate ligament (ACL) reconstruction and postoperative meniscal position. This study aimed to evaluate medial meniscal size and clinical results in patients who underwent ACL reconstruction and concomitant all-inside medial meniscus repair.

Methods

Twenty patients underwent ACL reconstruction and concurrent medial meniscus repair of a peripheral longitudinal tear using the FasT-Fix meniscal repair device. Medial tibial plateau length (MTPL) and width (MTPW) were determined by radiographic images. We evaluated the Lysholm score, anteroposterior instability, meniscal healing and magnetic resonance imaging (MRI)-based medial meniscal length (MML) and width (MMW). Correlations between MRI-based meniscal size, radiographic measurement and height were investigated.

Results

All patients showed complete healing of the repaired meniscus in arthroscopic evaluation. However, one patient needed a subsequent meniscus repair during the follow-up period. Lysholm score and anteroposterior instability improved significantly. A better correlation was observed between MMW and MTPW than between MML and MTPL. Concurrent all-inside medial meniscus repair with ACL reconstruction significantly increased MML percentage (%MML) (100 MML/MTPL) but did not affect MMW percentage (%MMW) (100 MMW/MTPW).

Conclusions

Concurrent all-inside medial meniscus repair with ACL reconstruction had satisfactory clinical results. %MML was increased by concurrent medial meniscus repair without affecting %MMW. Our results suggest that medial meniscus repair associated with ACL reconstruction may restore meniscal function by adjusting the anteroposterior length of the torn medial meniscus.     

Medial meniscus posterior root repairs: A comparison among three surgical techniques in short-term clinical outcomes and arthroscopic meniscal healing scores

BackgroundMedial meniscus (MM) posterior root repairs lead to favorable clinical outcomes in patients with MM posterior root tears (MMPRTs). However, there are few comparative studies in evaluating the superiority among several pullout repair techniques such as modified Mason–Allen suture, simple stitch, and concomitant posteromedial pullout repair. We hypothesized that an additional pullout suture at the MM posteromedial part would have clinical advantages in transtibial pullout repairs of the MMPRTs. The aim of this study was to compare the clinical usefulness among several types of pullout repair techniques in patients with MMPRTs.MethodsEighty-three patients who underwent arthroscopic pullout repairs of the MMPRTs were investigated. Patients were divided into three groups using different pullout repair techniques: a modified Mason–Allen suture using FasT-Fix all-inside meniscal repair device (F-MMA, n = 28), two simple stitches (TSS, n = 30), and TSS concomitant with posteromedial pullout repair using all-inside meniscal repair device (TSS-PM, n = 25). Postoperative clinical outcomes and semi-quantitative arthroscopic meniscal healing scores (0–10 points) were evaluated at second-look arthroscopies.ResultsNo significant differences among the three groups were observed in patient demographics and preoperative clinical scores, except for preoperative Lysholm scores. At second-look arthroscopies, there were no significant differences among the three techniques in postoperative clinical outcomes and meniscal healing scores.ConclusionsThis study demonstrated that the TSS-PM pullout repair technique did not show better scores in postoperative clinical outcomes and meniscal healings compared with the F-MMA and TSS techniques. Our results suggest that the concomitant posteromedial pullout suture may have no clinical advantage in the conventional pullout repairs for the patients with MMPRTs.     

Common peroneal nerve palsy as a postoperative complication in lateral meniscus repair

Arthroscopic lateral meniscus repair using an inside-out technique can potentially be hazardous to the common peroneal nerve. This is true even for a longitudinal incision posterior to the posterior border of the iliotibial band, which allows visualization of the lateral joint capsule. A 37-year-old woman presented with common peroneal nerve dysfunction after an arthroscopic lateral meniscus repair using this technique. After confirmation of nerve entrapment by magnetic resonance imaging (MRI), an early exploration to decompress the involved nerve eventually resulted in the recovery of neurological function. In addition, an all-inside technique using a FasT-Fix suture device was used as an effective and safe remedy after untying the earlier sutures from the lateral meniscus repair that were trapping the nerve.     

Two-year follow-up of meniscal repair using a bioabsorbable arrow

Purpose: The value of meniscal repair is well established. Several all-inside arthroscopic techniques have become available to achieve this goal. One such technique involves the use of a biodegradable polylactic acid tack, which has made repair technically easier to perform. This study evaluates the 2-year results of arthroscopic meniscal repair using this device. Type of Study: Retrospective case series. Methods: We reviewed charts of 38 patients who had undergone 39 meniscal repairs with the bioabsorbable arrow. All procedures were performed by one of 4 fellowship-trained sports medicine orthopaedic surgeons in 1 of 2 affiliated hospitals, with a minimum follow-up of 2 years. Review consisted of evaluation of patient records, interview, and clinical examination by an independent examiner. Lysholm and Tegner knee scores were recorded. Complications and clinical failure, defined as reoperation, were noted. Results: The average age of the patients was 29.9 years. The ratio of medial to lateral meniscal repair was 5:1. Twenty-one patients underwent concurrent anterior cruciate ligament reconstruction, and in this subgroup, there were no clinical failures. In the remaining group, isolated meniscal repairs in stable knees, the clinical failure rate was 7% (2 reoperations). Local soft-tissue complications occurred in 31.6% of patients, including 2 with arrow migration through the skin. These symptoms typically resolve over several months. Conclusions: The availability of sutureless all-inside absorbable techniques for meniscal repair has made the procedure technically easier to perform arthroscopically. In our patients, local complications related to device migration, device prominence, and soft-tissue inflammation associated with absorption of the device were common (31.6%). These complications were usually transient. We emphasize the importance of selecting the correct length of device so as to minimize these effects. As with other meniscal repair techniques, a higher success rate was found in knees undergoing concurrent anterior cruciate ligament reconstruction. Our results show a clinical success rate using an absorbable all-inside technique with an absorbable device comparable to reported results using established inside-out techniques.     

Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs

BACKGROUND: Split-depression fractures of the lateral tibial plateau (Schatzker II) are associated with a significant risk of capsuloligamentous and meniscal injury. We hypothesized that the amount of fracture depression and widening on anteroposterior (AP) plain radiographs would correlate with the incidence of injury to these structures on magnetic resonance imaging (MRI). METHODS: Sixty-two consecutive patients with Schatzker II tibial plateau fractures had a knee x-ray series and MRI preoperatively. AP plain radiographs were measured for lateral joint line depression and condylar widening, and MRIs were evaluated for injury to soft-tissue structures around the knee. For each structure, the threshold of depression and widening that led to the greatest disparity in soft-tissue injury was determined. Multiple logistic regressions were applied to calculate whether depression and/or widening above the thresholds were predictive for injury to individual soft-tissue structures. RESULTS: When depression was greater than 6 mm and widening was greater than 5 mm, lateral meniscal injury occurred in 83% of fractures, compared with 50% of fractures with less displacement (p < 0.05). When either depression or widening was at least 8 mm, medial meniscal injury occurred more frequently (depression 53%, p < 0.05; widening 78%, p < 0.05; versus neither 15%). Lateral collateral ligament and posterior cruciate ligament tears were not seen with minimally displaced fractures (< 4 mm), but the incidence of injury approached 30% with increasing displacement. CONCLUSIONS: Due to the limited availability of MRI in some centers, correlation of lateral condylar depression and widening, as measured on plain radiographs, to injury of various soft-tissue structures may be extremely helpful in planning open or arthroscopic treatment methods. Using these guidelines, Schatzker II fractures with depression or widening approaching 5 mm deserve heightened vigilance in diagnosing and treating these concomitant soft-tissue injuries.     

Arthroscopic meniscal repair: analysis of treatment failures

The rationale for meniscal repair is based on the importance of the meniscus in overall knee function and stability as well as the inferior results seen with meniscectomy. The high success rate usually seen with arthroscopic meniscal repair has made it the treatment of choice for peripheral meniscal tears. This study reviewed the records of patients who have failed meniscal repair surgery to gain greater understanding of the factors that may predispose a patient to a failed outcome. From 1987 to 2002, three hundred meniscal repairs were performed (203 medial and 97 lateral). Thirty-seven patients had failed meniscal repairs. Records were available for 33 (89%) patients. The mean patient age was 25 years (range: 13-48 years) at the time of meniscal injury. The average initial tear size was 2.7 cm with a mean rim width of 2.3 mm. Eighty-eight percent occurred in ACL tears. The average time interval from initial repair to the recurrence of symptoms was 34 months. Patients who were older at the time of meniscal repair failed significantly later than those patients who were younger at the time of repair. With age stratification, those patients who were aged > or =29 years at time of meniscal repair failed at an average of 23 months. In contrast, patients who were aged > or =30 years at the time of repair failed at an average of 53 months. Larger initial tears failed significantly sooner than smaller tears. Initial tears with larger rim widths demonstrated a trend toward shorter time to failure. Patients who underwent combined ligament reconstruction with meniscal repair failed at an average of 37 months. Deficient ACLs that were treated with isolated meniscal repairs (ACL intact) failed at an average of 16 months.     

Quantifying meniscal kinematics in dogs

The dog has been used extensively as an experimental model to study meniscal treatments such as meniscectomy, meniscal repair, transplantation, and regeneration. However, there is very little information on meniscal kinematics in the dog. This study used MR imaging to quantify in vitro meniscal kinematics in loaded dog knees in four distinct poses: extension, flexion, internal, and external rotation. A new method was used to track the meniscal poses along the convex and posteriorly tilted tibial plateau. Meniscal displacements were large, displacing 13.5 and 13.7 mm posteriorly on average for the lateral and medial menisci during flexion (p = 0.90). The medial anterior horn and lateral posterior horns were the most mobile structures, showing average translations of 15.9 and 15.1 mm, respectively. Canine menisci are highly mobile and exhibit movements that correlate closely with the relative tibiofemoral positions. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1710–1716, 2018.

     

Zone-specific inside-out meniscal repair: technical limitations of repair of posterior horns of medial and lateral menisci

Arthroscopy was performed on 15 cadaveric knees to assess the technical limitations of a zone-specific inside-out meniscal repair system (Linvatec Zone Specific II; Linvatec Corp, Largo, Fla) for accessing the posterior regions of the menisci. In addition, this system was compared with an all-inside technique (Bionx Arrows; Bionx Implants Inc, Blue Bell, Pa). Linvatec meniscal sutures and Bionx Arrows were placed arthroscopically in both medial and lateral menisci in all 15 cadaveric knees before open dissection was performed to evaluate device placement. Results showed that the Linvatec sutures may not adequately access a longitudinal 16.1-mm region of the posterior horn of the medial meniscus that is accessible with Bionx Arrows. In addition, the zone-specific inside-out technique excluded a statistically significantly larger region of the posterior horns of both menisci. With the Linvatec sutures, placement was difficult in the most posterior 14.9 mm of the medial meniscus and 10.8 mm of the lateral meniscus; with the Bionx Arrows, placement was difficult in only the most posterior 6.1 mm of the medial meniscus (P = .004) and 5.3 mm of the lateral meniscus (P < .006).     

Eight- to 14-year followup of arthroscopic meniscal repair

The current study aims to elucidate the midterm to long-term progression of arthroscopic meniscal repair which had been confirmed through a second-look arthroscopy at an average of 10 months after repair. Twenty-eight menisci of 28 patients were investigated at 8 to 14 years (mean, 10.2 +/- 1.8 years), eight after isolated meniscal repair (Isolated group) and 20 after concomitant anterior cruciate reconstruction (Anterior cruciate ligament group). All were rated excellent except four that rated good in the anterior cruciate ligament group as indicated by Lysholm's score at followup. None of the Isolated group, but 12 of the Anterior cruciate ligament group, had osteoarthritic changes seen on radiographs. Four and 19, respectively, had increased signal intensity on magnetic resonance imaging scans, 10 in the Anterior cruciate ligament group had changes of Grade 3 severity. However, no meniscal signs or symptoms were present and no significant relationship between findings of radiographs and magnetic resonance imaging scans was apparent. Anterior cruciate reconstructed knees that were changed to Grade 3 severity as seen on magnetic resonance imaging scans had higher sagittal instability seen on stress radiography than knees with Grade 2 or less severe changes. The anterior laxity of the knees influenced the severity of meniscal signal changes on the magnetic resonance imaging scans.     

Patient outcomes following T-Fix meniscal repair and a modifiable,progressive rehabilitation program,a retrospective study

INTRODUCTION: This retrospective study presents clinical patient outcomes following meniscal repair using T-Fix devices and a modifiable, progressive rehabilitation program. MATERIALS AND METHODS: Fifty-two patients (35 males and 17 females) with a mean age of 26.7 years (range 13-50 years) representing all of the patients who underwent arthroscopic meniscal repair (43 medial meniscus, 12 lateral meniscus) over a 3-year period by the same surgeon (D.C.) (55 menisci) participated in this study. Thirty-two of the patients (62%) had an associated ACL tear. All patients with an ACL tear underwent reconstruction (tibialis anterior allograft) at the time of meniscal repair. All meniscal tears were located in either the red-red zone (29) or the red-white zone (26). All patients who underwent meniscal repair participated in a modifiable (based on meniscal tear size, type, and location) progressive rehabilitation program. Operative notes and photographs were reviewed to identify the meniscal tear location, tear type, tear length, and the number of T-Fix devices used. Orthopedic clinic and physical therapy reports were also reviewed for postoperative range of motion, knee joint effusion, knee joint pain, McMurray test findings, and single-leg broad-jump test performance (90% bilateral equivalence goal). The average postoperative clinical follow-up period was 10.3 months (range 4-24 months). RESULTS: Most (22/23, 96%) patients who underwent meniscal repair alone displayed excellent results. All patients (32/32, 100%) who underwent combined ACL reconstruction-meniscal repair displayed excellent results. During an acute event such as a sudden directional change while running or contact with another player, 5 of these patients re-injured their meniscus at the repair site in conjunction with tearing the reconstructed ACL at 12+/-3 months following the index surgical procedure. Each of these 1-2 cm meniscal tears had been previously repaired with two T-Fix devices. CONCLUSION: The T-Fix device used in combination with a modifiable progressive rehabilitation program produced excellent clinical patient outcomes among this patient group.     

Deep vein thrombosis following arthroscopic meniscal root repair: A case report

IntroductionDeep vein thrombosis (DVT) following arthroscopic surgery is a rare condition, especially arthroscopic meniscal surgery. There have been three reported cases of DVT after arthroscopic meniscal procedure, all related to arthroscopic meniscectomy. In this study, we reported the first case of symptomatic DVT at the level of the femoral vein to the popliteal vein following arthroscopic meniscal root repair.Case presentationThe case was a 55-year-old Thai female who presented with left knee pain for 2 months after a fall. She was diagnosed as left medial meniscal root injury and had had an arthroscopic meniscal root repair. At 6 weeks post-operatively, she developed left leg swelling without pain. She was diagnosed as DVT and was initially treated with enoxaparin for three days then warfarin for three months.ConclusionWe report a case of symptomatic DVT that extended from the femoral vein to the popliteal vein after arthroscopic meniscal root repair. The risks of DVT following arthroscopic surgery are aged more than 40 years old and tourniquet time more than 60 min.     

Value of intraoperative true lateral radiograph of C2 pedicle for C1-2 transarticular screw insertion.

BACKGROUND CONTEXT: Transarticular C1-2 screws are widely used in posterior cervical spine instrumentation. Injury to the vertebral artery during insertion of transarticular Cl-2 screw remains a serious complication. Use of a computer-assisted surgery system decreases this complication considerably. However, this system encounters problems in ensuring complete accuracy because of positional variations during preoperative and intraoperative imaging generation. Therefore, intraoperative fluoroscopy still is one of the commonly used methods to guide insertion of transarticular Cl-2 screw. Evaluation of a true lateral radiographic view of the C2 pedicle for screw trajectory during C1-2 transarticular screw insertion may help to minimize this potential complication. PURPOSE: To evaluate the value of intraoperative true lateral radiograph of the C2 pedicle for screw trajectory during C1-2 transarticular screw insertion. STUDY DESIGN: To compare the height of the C2 pedicle area allowing instrumentation on true lateral view radiograph of the C2 pedicle and computed tomographic (CT) scan with multiplanar reconstruction. METHODS: Twenty embalmed human cadaveric cervical spine specimens were used to insert a total of 40 C1-2 transarticular screws using Magerl and Seemann technique. One side of the C2 transverse foramen was filled with radiopaque material (lead oxide) to simulate the artery and to demarcate the danger zone for better visualization on radiography. Measurements and calculation of the mean and standard deviation of the height of the area allowing instrumentation of the C2 pedicle were done on true lateral view radiograph of the C2 pedicle, the sagittal and 30 degrees sagittal views relative to the frontal plane passing exactly through the center of the C2 pedicle of CT scans. Student t test was applied to calculate the statistical significance of measured values. Statistical significance was defined as por=.36. Using sagittal CT scan views, the height of pedicles was 7.71+/-0.7 mm (right) and 7.58+/-1.01 mm (left), p>or=.23. On 30 degrees sagittal CT scan views, the height of pedicles was 7.84+/-1.00 mm (right) and 7.76+/-1.02 mm (left), p>or=.27. The p value was >or=.78, >or=.56, and >or=.49 for true lateral radiographic view and sagittal CT scan view, true lateral radiographic view and 30 degrees sagittal CT scan view, and sagittal CT scan view and 30 degrees sagittal CT scan views, respectively. On lateral view of cervical spine, the decline angle of the transarticular screw was 51.3+/-0.50 degrees (right) and 50.68+/-0.41 degrees (left), p>or=.17. Mean decline angle was 51+/-0.43 degrees . On the anteroposterior (AP) view, radiograph median angle was 6.87+/-0.53 degrees (right) and 6.0+/-0.59 degrees (left), p>or=.25. Mean median angle was 6.44+/-0.62 degrees. CONCLUSIONS: True lateral radiographic views of the pedicles provide useful information for defining screw trajectory intraoperatively. Using this view along with AP and lateral view of cervical spine and preoperative three-dimensional CT scan may narrow the margin of error in this delicate area.