Objectives: To describe a rare case of significant vascular injury that occurred following the harvest of hamstring tendon graft for anterior cruciate ligament reconstruction, with the need of repair.
Case report: A 30-year-old male soccer player presented with significant swelling and acute pain two hours after anterior cruciate ligament (ACL) reconstruction. Clinical examination and MRI scan showed bleeding, and a large hematoma in the middle of the left thigh. Hemorrhagic contention was only possible after a secondary repair, where a vessel of the sartorius muscle was bleeding profusely 12 hours after the primary surgery.
Discussion: The presence of a large number of vessels on the medial side of the knee associated with blind flexor tendons graft hamstring is cause of vascular injury during removal of the hamstring graft.
Conclusion: Although uncommon, graft hamstring of flexor tendons can have devastating consequences if some hemostasis procedures are not correctly applied.
Leung Ping Chung*
Introduction: Knee pain is one of the commonest disabling diseases of the elderly people. It has been taken for granted that it is a degenerative problem related to curtilage thinning, and the pathology does not involve much inflammatory process. Osteoarthritis is therefore the most popular term used.
Causes of osteoarthritis of the knee: Apart from in-born structural varieties that affects the function of the knee joint, many other causes have been described: "cartilage derived", "ligament derived", "meniscal derived", "bone derived" and "synovial derived" pathologies, all basing on structural changes involved.
There is an important dynamic mechanism that maintains a balanced functional position between the medial and lateral compartments of the knee joint irrespective of existing structural imperfections: the proprioceptive afferent receptor -cerebral autonomous output circuit. Proprioceptive receptors in the muscles, tendons, and joint capsules are detecting all the time the detail positions of the joint components in relation to the standing posture of the individual. They send messages up to the brain so that outputs of muscular adjustments are sent down to initiate chain reactions to maintain the joint in balanced harmony irrespective of structural imperfections.
Evidences of the proprioceptive protection of joints through an autonomous neurological circuit have been proven anatomically, clinically, and also through studies on other joints e.g. the trapezio-metacarpal joint of the thumb.
Discussion: It is therefore appropriate to introduce training activities to boost up the balancing dynamics around the knee joint, particularly for the early clinical presentations of osteoarthritis to prevent deterioration; and also before and after appropriate structural corrections, in order to maintain its functional integrity.
Athanasios N Ververidis, Konstantinos Paraskevopoulos*, Anthimos Keskinis, Georgios Papadopoulos and Konstantinos Tilkeridis
Introduction: Bone Marrow Edema Syndrome (BMES) is a self-limited condition that can affect young or middle-aged women or men. It is manifested by sudden onset of pain localized in the affected region. Extracorporeal shock wave therapy (ESWT) has been utilized in several orthopaedic conditions including avascular necrosis and due to the subsequent promising outcomes; it was attempted on patients suffering from BMES as a non-operative option of treatment. The aim of our mini review paper was to describe BMES and discuss the current studies that were conducted regarding the utilization of ESWT as a non-invasive method of treatment in patients with BMES.
Material and Methods: A review of the literature was conducted using Pubmed, Scopus and Google scholar with the terms “extracorporeal shock wave” OR “extracorporeal shockwave” AND “bone marrow edema syndrome” OR “transient osteoporosis” to gather all current knowledge regarding BMES and ESWT. In total, 6 studies concerning BMES and treatment with ESWT were identified between November 2014 and April 2020 and were further analyzed in the discussion section.
Results: A total of 177 patients who were treated with ESWT in the context of BMES either in the hip joint (74 patients) or in the knee joint (103 patients) were identified in the literature. All of the 177 patients who suffered from BMES had been successfully treated with ESWT. Specifically, in 3 studies which had compared the use of ESWT with patients who received a variety of pharmacological agents including analgesics, bisphosphonates and alprostadil (control group), the results showed higher functional improvement, higher recovery rates, as well as higher reduction of Bone Marrow Edema (BME) on MRI in favor of ESWT group.In 1 study, comparing the use of ESWT with core decompression, ESWT had better results regarding the aforementioned parameters. In another 2 observational studies, ESWT had been successfully utilized and achieved statistically significant improvement in functional and pain scores, as well as reduction of BME on MRI.
Conclusion: ESWT has been used in off-label in patients with BMES with promising results, as it seems to achieve rapid pain relief and functional improvement, hence it may be a potential regimen for the rapid recovery of BMES. Due to the small number of studies, no evidenced based recommendations can be given.
Snehansh R Chaudhary, Nathan Edwards and Catherine L McCarthy*
Femoral fractures may be caused by direct acute trauma or other causes which are broadly classified into stress fracture, insufficiency fracture, atypical femoral fracture or pathologic fracture and may be grouped together as unusual femoral fractures. Familiarity and recognition of the specific imaging features of unusual femoral fractures is important to ensure early identification, characterisation and appropriate management of these fractures. The aim of this review to is to illustrate the characteristic imaging features of unusual femoral fractures and the role of different radiological modalities including plain radiographs, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), technitium-99m bone scintigraphy and single-photon emission computed tomography (SPECT).
Reza Noktehsanj, Aidin Arabzadeh*, Turaj Rahmani, Hamed Zandian, Reza Mirzazadeh, and Seyyed-Mohsen Hosseininejad
Efficacy of extracorporeal shock wave therapy (ESWT) in the treatment of plantar fasciitis (PF) is under debate in spite of applying in treatment. We aimed to investigate the efficacy of extracorporeal shock wave therapy in decreasing plantar fasciitis heel pain.
Methods: Eighty patients fulfilled the inclusion criteria; 77 agreed to participate the study. Patients randomly divided into 2 groups of treating with NSAID and NSAID+ESWT and assessed in to periods of 4 and 8 weeks with a focus on ESWT effectiveness.
Results: Visual analog score decreased significantly after eight weeks of treatment with ESWT+NSAID in comparison with NSAID group alone. (p<0.05)
Conclusion: ESWT reduced pain of PF in our study. So it could be used as treatment options.
Gerhard E Maale, Daniel Kazemi Mohammadi, Flavio A Calderon II, Nicole Kennard and William K Montgomery
Patients can experience multiple issues following a primary Total Knee Arthroplasty (TKA). The causes of pain and swelling include infection, component loosening, Multi-Directional Instability (MDI), and arthrofibrosis. MDI following a primary TKA is a clinical syndrome characterized by global ligament laxity, pain while getting up from a seated position, audible clunking of the implant, a feeling of instability in gait, and a warm knee effusion. Furthermore, patients with metal allergies may be at a higher risk for a failed primary TKA possibly secondary to arthrofibrosis. In this study, patients presenting with clinical MDI following a primary TKA were subject to a Metal-Lymphocyte Transformation Test (metal-LTT) to determine any hypersensitivities to specific metal ions commonly seen in primary total knees. Those patients with metal hypersensitivities who elected to have a total knee revision using a Zirconium or Niobium prostheses were then included in the patient population in this study for statistical analyses. Current research has not yet elucidated a relationship between multi-directional instability following a primary TKA and metal allergies, however, of the 190 patients experiencing MDI, 157 patients tested positive for metal hypersensitivity to their implant. The Nickel allergy with MDI is gender specific. The p-value < .001 for both the nickel allergy and the gender. Metal hypersensitivities to knee implants potentially factor into the development of MDI in patients with primary TKA implants, however more research is necessary to elucidate a cause or effect relationship between metal hypersensitivity and MDI.
Cesar M Cereijo, Daniel L Worrell*, Michael Okrent, Christopher Whinney and Damien G Billow
Objective: To compare morbidity, mortality and institutional costs for hip fracture patients after implementation of an interdisciplinary protocol to expedite preoperative optimization at our institution.
Design: Single center, prospective cohort study.
Setting: Single tertiary medical center.
Patients: This study included patients with diagnosed hip fractures age 65 and older in both pilot (26 patients) and pre-pilot (43 patients) cohorts requiring surgical intervention who met inclusion and exclusion criteria.
Intervention: An interdisciplinary protocol was implemented for preoperative optimization of patients requiring surgical fixation of hip fractures which included standardized preoperative labs, tests and a pre-determined maximum time allotted for evaluating patients by consulting services.
Outcome Measurements: Primary outcomes assessed included in-hospital mortality, 30-day and 90-day mortality. Secondary outcomes included adverse patient events, 30 and 90-day readmissions, postoperative ICU admissions and institutional costs per admission.
Results: In the pilot group, there were statistically significant decreases in 90-day mortality, 30-day readmission rates and ICU admissions. A 26.1% decrease in average direct cost to the hospital per patient was observed between Pre-pilot ($16,775.65) and Pilot ($12,397.22) groups.
Conclusion: This study outlines the importance of a detailed protocol to expedite surgical intervention. It demonstrates effectiveness of patient outcomes for treatment of hip fractures in a patient population with average comorbidity index scores higher than similar studies. Protocol implementation also resulted in a dramatic decrease in overall costs at our institution, which is important as our current medico-economic environment focuses on minimizing excessive medical expenditures nationwide.
Level of Evidence: II
Extracorporeal shock wave therapy (ESWT) is one of the most common recommended electrotherapeutic modalities for the management of chronic Achilles Tendinopathy (AT). However, the term chronic AT is not clear in the literature. The term chronic AT is ranged in the literature from 4 weeks to 6 months after the first onset.
Lennart Dimberg* and Fredrik Wennerberg
Background: Polymyalgia Rheumatica (PMR) is a clinical condition characterized by pain and stiffness of proximal muscles of shoulders and hips. We here present an unusual case initially believed to be an abscess of the iliopsoas muscle.
Case presentation: An elderly man visited our clinic with symptoms of left hip pain and stiffness and an elevated erythrocyte sedimentation rate (ESR) at 96 mm/h, but no fever.
An MRI of the left hip and proximal femur suggested an iliopsoas abscess, which was aspirated with clear yellow fluid and no bacteria. A few weeks later, additional pain and stiffness of the muscles of both shoulders made a diagnosis of PMR suspicious. A prompt response to high doses of Prednisolone confirmed the diagnosis.
Conclusion: PMR may present with hip-pain due to a unilateral iliopsoas bursitis.
Nicole Kennard*, Daniel Mohammadi, Aniruth Srinivasaraghavan, Arianna Mixon and Gerhard E Maale
Background: Multidirectional Instability (MDI) and fibrosis associated with nickel allergies have been described in 1.5% of all primary total knees. The symptoms of MDI include pain getting up from the sitting position, audible clunking on varus and valgus stressing, feelings of instability in gait, increasing pain, and joint effusion. Hypoallergenic implants have been designed to alleviate this issue. One, the Genesis II primary knee replacement from Smith and Nephew contains very little nickel (<0.0035% for the zirconium femoral component and <0.1% for the titanium baseplate). We believe that, even with the small amount of nickel in the titanium baseplate, that it demonstrates all the findings that were seen with other implants in presentations of MDI and nickel allergies.
Methods: All patients referred with clinical MDI following a primary total knee joint with the Genesis II prosthesis underwent the Metal-Lymphocyte Transformation Test (metal-LTT) for metal allergies. Patients had symptomatology of MDI. They underwent routine labs including CBC, CRP, and ESR as well as staging studies including X-rays, tri-phase bone scan, WBC scan, and CT scan. Surgical revision using a fully constrained hinge coated with zirconium or niobium nitride was the treatment option.
Results: 20 patients with clinical symptoms of MDI associated with the Genesis II prosthesis were investigated. Fifteen patients were female, 5 were male with an average time to failure of 36 months (range of 5 to 96 months). Imaging revealed hypervascular synovitis, as demonstrated by the bone scan, with a large effusion with minimal prosthetic uptake.
Conclusion: Although the Genesis II prosthesis was believed to be hypoallergenic, we found that 20 of our patients with the Genesis II prosthesis and nickel allergies still had clinical symptoms of MDI. All patients required hinge revision with hypoallergenic implants.