Michael J. Medvecky

Arthrofibrosis of the knee.

Abstract Better understanding of surgical timing, improved surgical technique, and advanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high‐energy, multiligament injuries continues to compromise functional outcome. Prevention, consisting of control of inflammation and early motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are reliable treatment options. Open surgical débridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for treating the patient with motion loss.

Partial-thickness rotator cuff tears.

&NA; Partial‐thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial‐thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial‐thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial‐thickness rotator cuff tears should be based on the patients symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial‐thickness rotator cuff tear.

Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: an analysis of techniques and a safe operative approach to the popliteal fossa

The arthroscopically assisted posterior cruciate ligament tibial inlay technique, frequently used in athletic individuals and in revision cases, requires a thorough and comprehensive understanding of posterior knee anatomy. Importantly, variations in the posterior vascular anatomy may be encountered. A safe and methodical posteromedial approach in a layered fashion to achieve proper and safe tibial inlay graft placement and fixation is described. The authors advocate use of a double-bundle quadriceps tendon autograft. Graft position of the double strands, fixation, and tensioning issues are presented.

A Multidisciplinary Approach to the Evaluation, Reconstruction and Rehabilitation of the Multi-Ligament Injured Athlete

AbstractKnee dislocations with multi-ligamentous involvement are potentially limb-threatening injuries that require extensive surgical and rehabilitative intervention. These knee injuries, such as combined anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and/or lateral collateral ligament injuries, are devastating injuries with results that vary from total disability to nearly full recovery of function. Recent surgical advances, including the use of allograft tissues, have increased the efficacy of these procedures while posing new challenges. By combining scientifically based surgical and rehabilitative approaches, improved outcomes in these difficult cases are being reported in the orthopaedic literature.This review details the epidemiology and biomechanics of these serious knee ligament injuries. In addition, state-of-the-art surgical and rehabilitative techniques will be outlined. Clinical and diagnostic imaging evaluation of these knee injuries is reviewed in order to plan and execute the surgical and rehabilitative practices. We review the basic science, surgical and rehabilitative theories and practices associated with bringing patients with these serious knee injury injuries to full recovery, and detail the development of strategies for developing protocols to address these complicated cases.

Surgical approaches to the posteromedial and posterolateral aspects of the knee.

Abstract Surgical approaches to the posterior aspect of the knee are not commonly needed, and their use has become even rarer with the increasing sophistication of arthroscopic technology. As a result, physicians in orthopaedic surgical training are not often exposed to the practical use of surgical dissection around the posterior corners of the knee. For certain procedures, however, greater clinical utility and decreased surgical morbidity render focused posterior exposure the preferred alternative to the classic popliteal dissection with its wide exposure of the popliteal anatomy. Surgical indications include ligament repair or reconstruction around the posteromedial or posterolateral aspect of the knee, inside‐out meniscal repair, posterior cruciate ligament tibial inlay reconstruction, and Bakers cyst excision. To minimize complications, these focused approaches require adeptness with the complex anatomy of the posterior, posteromedial, and posterolateral aspects.

Symptomatic hip plica: MR arthrographic and arthroscopic correlation

Two cases of unilateral hip pain are reported in which MR arthrography demonstrated a prominent band medial to the ligamentum teres, running in the AP direction, consistent with a hip plica. Both patients underwent hip arthroscopy with resection of the band. No labral tear or additional intra-articular pathological features was identified in either case. Both patients became asymptomatic following surgery and have remained such. The pathology report demonstrated the specimens to be a synovial band with fibroconnective tissue. This is the first MR arthrographic report of the identification and resection of a symptomatic hip plica. The symptomatic plica may represent an alternative diagnosis for mechanical hip pain.

Comparison of 3D vs. 2D fast spin echo imaging for evaluation of articular cartilage in the knee on a 3 T system scientific research

PURPOSE We sought to retrospectively compare the accuracy of a three-dimensional fat-suppressed, fast spin-echo sequences acquired in the sagittal plane, with multiplanar reconstructions to that of two-dimensional fat-suppressed, fast spin echo sequences acquired in three planes on a 3T MR system for the evaluation of articular cartilage in the knee. MATERIALS AND METHODS Our study group consisted of all patients (N=34) that underwent 3T MR imaging of the knee at our institution with subsequent arthroscopy over an 18-month period. There were 21 males and 13 females with an average age of 36 years. MR images were reviewed by 3 musculoskeletal radiologists, blinded to operative results. 3D and 2D sequences were reviewed at different sittings separated by 4 weeks to prevent bias. Six cartilage surfaces were evaluated both with MR imaging and arthroscopically with a modified Noyes scoring system and arthroscopic results were used as the gold standard. Sensitivity, specificity, and accuracy were calculated for each reader along with Fleiss Kappa assessment agreement between the readers. Accuracies for each articular surface were compared using a difference in proportions test with a 95% confidence interval and statistical significance was calculated using a Fishers Exact Test. RESULTS Two hundred and four articular surfaces were evaluated and 49 articular cartilage lesions were present at arthroscopy. For the patellofemoral surfaces, the sensitivity, specificity, and accuracy were 76.5%, 83%, and 78.2% for the 3D sequences and were 82.3%, 76%, and 82% respectively for the 2D sequences. For the medial compartment surfaces, the sensitivity, specificity, and accuracy were 81.1%, 65.1%, and 78.5% for the 3D sequences and were 82.5%, 48%, and 76.7% respectively for the 2D sequences. For the lateral compartment surfaces, the sensitivity, specificity, and accuracy were 89.3%, 39%, and 79.5% for the 3D sequences and were 94.7%, 18.8%, and 79.5% respectively for the 2D sequences. The accuracies were not significantly different between 3D and 2D sequences. Fleiss Kappa agreement values for the assessment of inter-observer agreement ranged from substantial for the patella and medial femur to moderate for the trochlea and fair for the medial tibia and lateral compartment. CONCLUSION There was no significant difference in accuracy for the evaluation of articular cartilage of a single three-dimensional, fast spin echo sequence with multi-planar reformatted images vs. two-dimensional, fast spin echo sequences acquired in all three imaging planes in the knee.

Hoffa fracture in a 14-year-old.

Coronal shear fractures of the femoral condyle (ie, Hoffa fracture) are an uncommon clinical entity typically seen in adults after higher-energy trauma. Historically poor outcomes have been reported in the literature with nonoperative treatment of these fractures. Conversely, open reduction and internal fixation of these fractures has been shown to produce good long-term clinical results in adults. These fractures appear to be even more uncommon in skeletally immature patients, with only 3 case reports documented in the literature to date. Two of the 3 cases presented as a symptomatic nonunion after initial nonoperative treatment. Herein we present a case report of a Hoffa fracture of the lateral femoral condyle in a 14-year-old boy after a wrestling injury. The fracture was treated with diagnostic arthroscopy followed by conversion to an arthrotomy for open reduction and internal fixation. Rigid fixation of the fracture was obtained with 4 headless compression screws. Twelve months postoperatively, the fracture was radiographically healed and the patient was pain free with restoration of full knee motion and return to sporting activity. The Hoffa fracture is a unique and relatively uncommon clinical entity that has a different personality than other intra-articular fractures of the knee in both adults and children. Instability of the fracture fragment can lead to a higher likelihood of nonunion with persistent pain and disability. These fractures should be treated with open reduction and internal fixation to achieve anatomic reduction with stable fixation and preservation of the blood supply to achieve early, active mobilization. We believe this optimizes the chance for good long-term functional results.

Comparison of spin echo T1-weighted sequences versus fast spin-echo proton density-weighted sequences for evaluation of meniscal tears at 1.5 T

PurposeAt our institution, fast spin-echo (FSE) proton density (PD) imaging is used to evaluate articular cartilage, while conventional spin-echo (CSE) T1-weighted sequences have been traditionally used to characterize meniscal pathology. We sought to determine if FSE PD-weighted sequences are equivalent to CSE T1-weighted sequences in the detection of meniscal tears, obviating the need to perform both sequences.Method and materialsWe retrospectively reviewed the records of knee arthroscopies performed by two arthroscopy-focused surgeons from an academic medical center over a 2-year period. The preoperative MRI images were interpreted independently by two fellowship-trained musculoskeletal radiologists who graded the sagittal CSE T1 and FSE PD sequences at different sittings with grades 1–5, where 1 = normal meniscus, 2 = probable normal meniscus, 3 = indeterminate, 4 = probable torn meniscus, and 5 = torn meniscus. Each meniscus was divided into an anterior and posterior half, and these halves were graded separately. Operative findings provided the gold standard. Receiver operating characteristic (ROC) analysis was performed to compare the two sequences.ResultsThere were 131 tears in 504 meniscal halves. Using ROC analysis, the reader 1 area under curve for FSE PD was significantly better than CSE T1 (0.939 vs. 0.902, >95% confidence). For reader 2, the difference met good criteria for statistical non-inferiority but not superiority (0.913 for FSE PD and 0.908 for CSE T1; >95% non-inferiority for difference at most of −0.027).ConclusionFSE PD-weighted sequences, using our institutional protocol, are not inferior to CSE T1-weighted sequences for the detection of meniscal tears and may be superior.

A novel technique for arthroscopically assisted femoral bone tunnel grafting in two-stage ACL revision.

This technique of bone grafting of improperly positioned bone tunnels in failed ACL reconstructions is technically straightforward and effective in challenging cases.