Filon Agathangelidis

Long Head of the Biceps Pathology Combined with Rotator Cuff Tears

The long head of the biceps tendon (LHBT) is an anatomic structure commonly involved in painful shoulder conditions as a result of trauma, degeneration, or overuse. Recent studies have pointed out the close correlation between LHBT lesions and rotator cuff (RCT) tears. Clinicians need to take into account the importance of the LHBT in the presence of other shoulder pathologies. This paper provides an up-to-date overview of recent publications on anatomy, pathophysiology, diagnosis, classification, and current treatment strategies.

Arthroscopic 4-Point Suture Fixation of Anterior Cruciate Ligament Tibial Avulsion Fractures

Tibial eminence avulsion fractures are rare injuries occurring mainly in adolescents and young adults. When necessary, regardless of patient age, anatomic reduction and stable internal fixation are mandatory for fracture healing and accurate restoration of normal knee biomechanics. Various arthroscopically assisted fixation methods with sutures, anchors, wires, or screws have been described but can be technically demanding, thus elongating operative times. The purpose of this article is to present a technical variation of arthroscopic suture fixation of anterior cruciate ligament avulsion fractures. Using thoracic drain needles over 2.4-mm anterior cruciate ligament tibial guidewires, we recommend the safe and easy creation of four 2.9-mm tibial tunnels at different angles and at specific points. This technique uses thoracic drain needles as suture passage cannulas and offers 4-point fixation stability, avoiding potential complications of bony bridge fracture and tunnel connection.

Distal Locking Screws for Intramedullary Nailing of Tibial Fractures.

Recently introduced tibial intramedullary nails allow a number of distal screws to be used to reduce the incidence of malalignment and loss of fixation of distal metaphyseal fractures. However, the number of screws and the type of screw configuration to be used remains obscure. This biomechanical study was performed to address this question. Thirty-six Expert tibial nails (Synthes, Oberdorf, Switzerland) were introduced in composite bone models. The models were divided into 4 groups with different distal locking configurations ranging from 2 to 4 screws. A 7-mm gap osteotomy was performed 72 mm from the tibial plafond to simulate a 42-C3 unstable distal tibial fracture. Each group was divided in 3 subgroups and underwent nondestructive biomechanical testing in axial compression, coronal bending, and axial torsion. The passive construct stiffness was measured and statistically analyzed with one-way analysis of variance. Although some differences were noted between the stiffness of each group, these were not statistically significant in compression (P=.105), bending (P=.801), external rotation (P=.246), and internal rotation (P=.370). This in vitro study showed that, when using the Expert tibial nail for unstable distal tibial fractures, the classic configuration of 2 parallel distal screws could provide the necessary stability under partial weight-bearing conditions.

Treatment of PVNS of the Knee

To the Editor: We are in the process of writing a manuscript about the long-term results of a large series of patients with localized pigmented villonodular synovitis (LPVNS) of the knee joint treated arthroscopically and with a miniopen technique. We were very pleased to read the work of Aurégan et al., “Treatment of Pigmented Villonodular Synovitis of the Knee,” published in the October issue of Arthroscopy. Reviewing the literature ourselves we noticed that there are plenty of studies reporting the results of series with a limited number of patients. This is normal because PVNS is a rare disease and a review and meta-analysis of the existing literature is a validated method of drawing conclusions from larger number of patients. However, we noticed some inaccuracies regarding the reported numbers. According to Table 1, Dines et al. reviewed 26 patients, 12 of whom were treated arthroscopically and 14 with open synovectomy with a mean follow-up of 1.7 years. Reading the original article carefully, Dines et al. stated that only 10 patients were available for long-term follow-up, all of whom were treated arthroscopically and responded to the Lysholm knee scoring scale (average, 65.8 months postoperatively), but only 7 were evaluated with a clinical examination. Because the inclusion criteria were studies reporting the results, the study of Dines et al. should have been either excluded or part of it included in the review. Furthermore, according to Table 1, Schwartz et al. had 2 patients with arthroscopic synovectomy with no recurrence and 12 with open synovectomy and 2 recurrences. Again, reading the original article reveals that there were 12 instances of LPVNS in the knee, 3 of which were treated arthroscopically and the remaining 9 with excisional arthrotomy. There were indeed 2 patients with recurrent disease, but the authors do not mention how they were treated. As a result, it is not safe to include these 2 in the open synovectomy group. Finally, Perka et al. reported on 18 cases of knee LPVNS with a follow-up of 5.6 years. We were unable to find any details of the operative procedure in the manuscript apart from a phrase stating “all tumours were surgically excised.” According to Table 1, 2 were treated arthroscopically and 16 with an open technique with a follow-up of 6 years. However, reading the original article this division seems arbitrary and the follow-up inaccurate.

Reinforcement Rings and Cages

Rings and cages are implants used in revision THA when the remaining bone stock is deficient. They span the bone defect and act as a scaffold while protecting morcellized or structural allograft during the bone remodeling phase [1]. The use of cages has been reduced over time following mechanical failure of cages and the introduction of newer techniques of trabecular metal components [1].

Annual Seminar of Hellenic Osteoporosis Foundation Basic Knowledge of biological responses to musculoskeletal trauma

The Systemic Inflammatory Response Syndrome (SIRS) represents the generalized response of the host to a variety of significant clinical insults, such as infection and trauma. There are specific criteria in the definition, such as: a) hyperor hypothermia, b) heart rate >90/min, c) respirations >20/ minute or PaCO2 <32 mmHg and d) WBC >12,000/mm or <4,000/mm or >10% immature form, with ≥2 of these criteria being necessary. Trauma is one of the more common causes of mortality worldwide. Death is the result of a chain of events starting with the “first hit”, which includes severe organ trauma, hypovolemia, hypoxemia or head injury among others. These can lead to the activation of the immune system and the initial inflammatory immune response after trauma can lead to SIRS. If more insults follow, they become the “second hit”, which can include infection, ischemia/reperfusion or surgical operations, then the inflammatory response is augmented, together with the mortality of the patient. Musculoskeletal injury through the activation of SIRS can lead to multi-organ failure with the loss of organ systems that were not directly involved by the initial trauma. The result is the activation of various parts/subsets of the immune system, including the neuroendocrine system, and the involvement of hormones or molecules such as ACTH, catecholamines, corticosteroids, cytokines and chemokines. The goal of this presentation is to stress the fact the musculoskeletal trauma is not an isolated injury, as it can lead to the activation of a mechanism meant to protect the organism; however, if it goes “unchecked” then it can easily lead to death. endocrine And metAbolic reSPonSe to muSculoSkeletAl trAumA Panagiotis Anagnostis Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece

Severe metallosis following oxidised zirconium wear in total hip arthroplasty

We present a case of a man aged 81 years who underwent a primary cementless total hip arthroplasty. Eight years after the index surgery, failure of the arthroplasty was revealed by the presence of the radiographic ‘cloud sign’ (figure 1). The original components used were the R3 acetabular cup with a Synergy femoral stem, highly crossed linked polyethylene liner and an oxidised zirconium (Oxinium) femoral head (Smith & Nephew Synergy, Memphis, Tennessee, USA). The initial investigation included a CT scan, full blood tests and …

Massive non-traumatic calcification of the medial collateral ligament of the knee

A woman aged 69 years presented with chronic medial knee pain for the past 12 months. Apart from type 2 diabetes mellitus and hypertension, there was no medical history of gout, trauma, endocrine or metabolic disorders. Plain radiographs showed a massive well-defined calcification at the medial side of the knee joint (figure 1). The calcifications upper margin was near the origin of the medial collateral ligament (MCL) and the lower edge was at the level of the medial tibial condyle. Further …

Symptomatic enlarged fabella.

A male patient aged 20 years presented to our outpatient department reporting of a 2-year history of right knee discomfort associated with snapping episodes, especially when moving from a seated to a standing position. His medical history was unremarkable and there was no history of trauma. The oblique radiograph of the knee revealed a large ossified structure at the posterolateral corner (figure 1). Routine blood tests, erythrocyte sedimentation rate and C reactive protein were within normal limits. MRI of the knee showed the large ossified structure within the lateral head of …

Elbow Hemiarthroplasty for Late Reconstruction of a Traumatic Elbow Bone Defect in a Young Patient

Hemiarthroplasty of the human elbow was first described in 1947 by Mellen and Phalen1. Encouraging follow-up results with good range of motion and substantial pain relief after elbow hemiarthoplasty were published in 19742. Nevertheless, in cases with severe bone loss and comminution, the semiconstrained total elbow arthroplasty has been a very reliable solution during the last decades3,4, especially in elderly patients. However, in active patients with an injured dominant arm, the major mid and long-term complication of these semi or totally linked polyethylene components is the risk of loosening5. In younger patients, the new anatomic elbow hemiarthroplasty offers the possibility of greater mobility, stability, and promising long-term results6. We present the case of a young patient with a comminuted type-IIIB open fracture of the elbow with bone loss of the humeral condyles. After elbow hemiarthroplasty, the final follow-up (4.5 years postoperatively) showed that the treatment had been successful. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A thirty-one-year-old obese man (body mass index [BMI] of 35) without any other medical comorbidities presented to the emergency department following a motorcycle accident. Clinical and radiographic evaluation demonstrated an open intercondylar fracture (type IIIB according to the Gustilo-Anderson classification7) of the right dominant elbow, with bone loss of the humeral condyles and fracture of the olecranon tip. Complete radial nerve palsy was also noted. Immediate wound irrigation and surgical debridement were performed in the operating room. During surgical exploration, the radial nerve was found to be intact, and no major vascular injury was apparent. Because of extensive soft-tissue damage, internal fixation was not an option. An elbow-bridging external fixator (Orthofix, Lewisville, Texas) was applied, and a local skin flap was …