Xinning Li

Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study

BackgroundLateral Patella dislocations are common injuries seen in the active and young adult populations. Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies.MethodsMRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella dislocation were screened for this study. Of the 324 cases that were found, 195 patients with lateral patellar dislocation traumatic enough to cause bone bruises on the lateral femoral trochlea and the medial facet of the patella were selected for this study. The MRI images were reviewed by three independent observers for location and type of MPFL injury, osteochondral defects, loose bodies, MCL and meniscus tears. The data was analyzed as a single cohort and by gender.ResultsThis study consisted of 127 males and 68 females; mean age of 23 yrs. Tear of the MPFL at the patellar attachment occurred in 93/195 knees (47%), at the femoral attachment in 50/195 knees (26%), and at both the femoral and patella attachment sites in 26/195 knees (13%). Attenuation of the MPFL without rupture occurred in 26/195 knees (13%). Associated findings included loose bodies in 23/195 (13%), meniscus tears 41/195 (21%), patella avulsion/fracture in 14/195 (7%), medial collateral ligament sprains/tears in 37/195 (19%) and osteochondral lesions in 96/195 knees (49%). Statistical analysis showed females had significantly more associated meniscus tears than the males (27% vs. 17%, p = 0.04). Although not statistically significant, osteochondral lesions were seen more in male patients with acute patella dislocation (52% vs. 42%, p = 0.08).ConclusionPatients who present with lateral patella dislocation with the classic bone bruise pattern seen on MRI will likely rupture the MPFL at the patellar side. Females are more likely to have an associated meniscal tear than males; however, more males have underlying osteochondral lesions. Given the high percentage of associated pathology, we recommend a MRI of the knee in all patients who present with acute patella dislocation.

Ankle Fractures in the Elderly: Initial and Long-Term Outcomes

Background: Surgical management of ankle fractures will be an increasing part of the orthopaedic practice for aging adults. To date, there are few studies comparing outcomes after ankle fracture surgery between patients over and under 65 years. The purpose of this study was to evaluate short- and long-term outcomes after surgical treatment of isolated malleolar fractures in both the elderly and non-elderly population. Materials and Methods: Charts and radiographs were reviewed for 25 patients over age 65 and 46 patients under age 65 who underwent operative treatment of an ankle fracture during a 2-year period. Postoperative complications and need for placement in a skilled nursing facility following discharge were noted. The SF-36 and the Olerud and Molander Ankle Score were completed. Mean duration of followup in patients greater than 65 was 27 months and 24 months for patients less than or equal to 65 years. Results: Patients over 65 had a higher number of postoperative complications (40% vs. 11%, p < 0.007), and required nursing home placement more frequently than patients under 65 (p < 0.0001). At long-term followup, the data showed no significant difference in patient reported physical outcomes. Conclusion: Early postoperative outcomes after operative fixation of ankle fractures suggest significantly worse outcomes for patients over age 65. However, long-term function in the elderly was comparable to patients under age 65 in this sample. The elderly population had a significantly better mental composite score than the non-elderly.

Anatomical Reconstruction for Chronic Lateral Ankle Instability in the High-Demand Athlete Functional Outcomes After the Modified Broström Repair Using Suture Anchors

Background Modification of the Bröstrom repair with suture anchors has been used to address chronic lateral ankle instability. However, there are few studies in the literature reporting the functional outcomes after this particular procedure in the high-demand athlete. Hypothesis Anatomical reconstruction of the lateral ankle ligaments for chronic instability will return the high-demand athlete functionally to his or her previous level of activity. Study Design Case series; Level of evidence, 4. Methods Sixty-two patients who had grade III ankle sprain that failed at least a 6-month course of supervised conservative management with a preinjury Tegner score of ≥ 6 underwent a variant of the Gould-modified Broström procedure with suture anchors for lateral ankle instability. Each patient was given the Tegner and Karlsson questionnaire at the 6-month, 1-year, and 2-year time points. Range of motion of the operative ankle was also assessed. The mean age was 19.6 years (range, 16-26 years), and 10 patients were lost to follow-up. Results The mean follow-up was 29 months (minimum, 24 months) in the remaining 52 patients (84%). Mean Tegner scores at the 1- and 2-year time points were 8.2 (range, 5-9) and 8.6 (range, 5-9), respectively. The mean Karlsson scores were 92 ± 5.2 and 95 ± 3.1 at the 1- and 2-year time points, respectively. Range of motion was equal to the contralateral ankle in all but 3 patients at the 2-year follow up. A 6% major complication rate included 3 reruptures. Conclusion Anatomical ligament reconstruction for chronic lateral ankle instability using a variant of the Gould-modified Broström procedure with suture anchors was effective in returning high-demand athletes to their preinjury functional level.

Arthroscopic Treatment of Concomitant Superior Labral Anterior Posterior (SLAP) Lesions and Rotator Cuff Tears in Patients over the Age of 45 Years

Background Rotator cuff tears commonly occur in combination with other shoulder injuries such as superior labral anterior posterior (SLAP) lesions. The incidence of these associated lesions increases with age; however, the management of concomitant SLAP and rotator cuff tears has yet to be convincingly addressed in the literature. Hypothesis Patients over the age of 45 years who have concomitant arthroscopic rotator cuff repair and debridement of their type II SLAP lesions will have improved patient satisfaction and functional outcome compared with those who undergo simultaneous rotator cuff and type II SLAP repair. Study Design Cohort study; Level of evidence, 2. Methods We recruited 48 patients (mean age, 51.9 years; range, 45-60 years) who had concomitant rotator cuff and type II SLAP tears. All underwent arthroscopic rotator cuff repair with subacromial decompression. Patients were randomized intraoperatively into 2 groups: repair versus debridement of their type II SLAP lesions. Ten patients were lost at final follow-up (4 in debridement and 6 in repair group). The outcome was assessed by the Tegner score and University of California at Los Angeles (UCLA) score and clinically to evaluate range of motion (forward elevation/internal rotation/external rotation). Results At 2 years postoperatively, both the debridement and repair groups showed significant improvement in Tegner score, UCLA score, and range of motion. Patients who underwent rotator cuff repair in combination with debridement of their SLAP tears had significantly better overall UCLA scores (34 vs 31; P < .001) and improved function (5.5 vs 3.8; P < .005) and pain relief (9.6 vs 7.7; P < .001) compared with those who underwent simultaneous rotator cuff and SLAP repair. Range of motion in both internal and external rotation was also significantly better in those patients who had SLAP debridement as compared to SLAP repair. Conclusion In patients over the age of 45 years with a minimally retracted rotator cuff tear and associated SLAP lesion, arthroscopic repair of the rotator cuff with combined debridement of the type II SLAP lesion may provide greater patient satisfaction and functional outcome in terms of pain relief and motion.

Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction

PurposeInadvertent contamination of the hamstring autograft during ACL reconstruction is infrequent, but can result in significant complications. The purpose of this study is to evaluate bacterial contamination of hamstring autografts dropped onto the operating room floor and methods of graft decontamination.MethodsHamstring tendons were harvested from patients. Excess tendon not used in the ACL procedure was divided into 6 segments. Segments were assigned to 6 groups (A through F, Nxa0=xa030 in each group): group A: uncontaminated graft immediately postharvest (control), group B: graft dropped onto the floor (5xa0s), group C: graft dropped onto the floor (15xa0s). grafts in groups D to F were dropped onto floor for 15xa0s then rinsed with saline (group D), bacitracin solution (group E) or chlorhexidine 4xa0% solution (group F) for 3xa0min. All grafts were sent to the microbiology laboratory for anaerobic and aerobic cultures.ResultsCultures were positive in 23xa0% of graft segments from group A (7/30), 33xa0% of grafts from group B (10/30), 23xa0% from group C (7/30), 30xa0% from group D (9/30) and 3xa0% from both group E (1/30) and group F (1/30). Sixteen unique organisms were identified, with Staphylococcus aureus as the most common isolate. Grafts rinsed in either bacitracin solution or 4xa0% chlorhexidine solutions were significantly less likely to be culture positive when compared to control graft segments (pxa0<xa00.05). However, there was no significant difference between uncontaminated grafts retrieved in <5 versus 15xa0s from the floor.ConclusionThis study supports the practice of decontaminating a dropped ACL hamstring autograft using either 4xa0% chlorhexidine or bacitracin solution. Specimens should be retrieved sterilely and washed for at least 3xa0min. This study also demonstrates no advantage in retrieval time of less than 5xa0s as compared to 15xa0s for uncontaminated graft. Hamstring harvest in ACL reconstruction may result in positive cultures, thus routine soaking of the hamstring autograft in either bacitracin or 4xa0% chlorhexidine solution is recommended. In addition, dropped hamstring autograft can be effectively sterilized with bacitracin or 4xa0% chlorhexidine solution.Level of evidenceII.

Medial pelvic migration of the lag screw in a short gamma nail after hip fracture fixation: a case report and review of the literature

Hip fractures are a common injury among the elderly. Internal fixation with an intramedullary (IM) system has gained popularity for the treatment of intertrochanteric femur fractures. Multiple complications associated with IM fracture fixation have been described, however, we report a rare complication of medial pelvic migration of the lag screw of a short IM nail in a stable construct ten weeks post surgery. The patient was subsequently treated with Lag Screw removal and revision surgery with a shorter Lag Screw and an accessory cannulated screw acting as a de-rotational device. The patient did well with the revision surgery and was able to return to full activities.

Treatment of chronic lateral ankle instability: a modified broström technique using three suture anchors

Ankle sprains are very common injuries seen in the athletic and young population. Majority of patients will improve with a course of rest and physical therapy. However, with conservative management about twenty percent of all patients will go on to develop chronic lateral ankle instability. This manuscript describes our detailed surgical technique of a modification to the original Broström procedure using three suture anchors to anatomically reconstruct the lateral ankle ligaments to treat high demand patients who have developed chronic lateral ankle instability. The rationale for this modification along with patient selection and workup are discussed. Both the functional outcomes at the two year follow up along with the complications and the detailed postoperative rehabilitation protocol for the high demand athletes are also presented. This modified Broström procedure is shown in both illustrative format and intra-operative photos.

Pseudoaneurysm of the profunda femoris artery following a long anterograde intramedullary nail for an unstable intertrochanteric hip fracture: A case report and review of the literature

The incidence of hip fracture has been on the increase and projected to be higher than 6xa0million cases by the year 2050. Complications due to surgical fixation of hip fractures include, but are not limited to, infection, mal or nonunion, avascular necrosis, hardware failure, neurovascular injuries, and death. Vascular complications after surgical hip fracture fixation are very rare. We report a patient who developed Pseudoaneurysm of the profunda femoris artery following an anterograde trochanteric entry long intramedullary nail for an unstable hip fracture. This patient presented 2xa0weeks postoperatively with weakness, dizziness, and loss of strength. Her hematocrit on presentation was 19.7, and the arterial duplex showed a 6xa0×xa07xa0cm pseudoaneurysm in the profunda femoris artery. Vascular coil embolization was performed, and the patient fully recovered. Discussion of this particular case and complication along with a full literature review on the topic of pseudoaneurysm after fracture fixation is presented.

Management of type II superior labrum anterior posterior lesions: a review of the literature

Superior labrum anterior and posterior lesions were first described in 1985 by Andrews et al. and later classified into four types by Synder et al. The most prevalent is type II which is fraying of the superior glenoid labrum with detachment of the biceps anchor. Superior labrum anterior posterior (SLAP) lesions can also be associated with other shoulder pathology. Both MRI and MRA can be utilized in making the diagnosis with the coronal images being the most sensitive. The mechanism of injury can be either repetitive stress or acute trauma with the superior labrum most vulnerable to injury during the late cocking phase of throwing. A combination of the modified dynamic labral shear and OBrien test can be used clinically in making the diagnosis of SLAP lesion. However, the most sensitive and specific test used to diagnosis specifically a type II SLAP lesion is the Biceps Load Test II. The management of type II SLAP lesions is controversial and dependent on patient characteristics. In the young high demanding overhead athlete, repair of the type II lesion is recommended to prevent glenohumeral instability. In middle-aged patients (age 25–45), repair of the type II SLAP lesion with concomitant treatment of other shoulder pathology resulted in better functional outcomes and patient satisfaction. Furthermore, patients who had a distinct traumatic event resulting in the type II SLAP tear did better functionally than patients who did not have the traumatic event when the lesion was repaired. In the older patient population (age over 45 years), minimum intervention (debridement, biceps tenodesis/tenotomy) to the type II SLAP lesion results in excellent patient satisfaction and outcomes.

Arthroscopic debridement of the osteoarthritic knee combined with hyaluronic acid (Orthovisc®) treatment: A case series and review of the literature

ObjectiveAn evaluation of safety and efficacy of high molecular weight hyaluronan (HA) delivered at the time of arthroscopic debridement of the osteoarthritic knee.MethodsThirty consecutive patients who met inclusion and exclusion criteria underwent arthroscopic debridement by a single surgeon and concomitant delivery of 6 ml/90 mg HA (Orthovisc®). These patients were evaluated preoperatively, at 6 weeks, 3 and 6 months post-operatively. Evaluations consisted of WOMAC pain score, SF-36 Physical Component Summary (PCS) score and complications.ResultsNo complications occurred during this study. Pre-op average WOMAC pain score was 6.8 +/- 3.5 (n = 30) with a reduction to 3.4 +/- 3.1 at 6 weeks (n = 27). Final average WOMAC pain score improved to 3.2 +/- 3.8 at six months (n = 23). No patients had deterioration of the WOMAC pain score. Mean pre-operative SF-36 PCS score was 39.0 +/- 10.4 with SF-36 PCS score of the bottom 25th percentile at 29.9 (n = 30). Post procedure and HA delivery, mean PCS score at 6 weeks improved to 43.7 +/- 8.0 with the bottom 25th percentile at 37.5 (n = 27). At 6 months, mean PCS score was 48.0 +/- 9.8 with the bottom 25th percentile improved to 45.8 (n = 23).ConclusionThe results show that concomitant delivery of high molecular weight hyaluronan (Orthovisc® – 6 ml/90 mg) is safe when given at the time of arthroscopic debridement of the osteoarthritic knee. By delivering HA (Orthovisc®) at the time of the arthroscopic debridement, there may be a decreased risk of joint infection and/or injection site pain. Furthermore, the combination of both procedures show efficacy in reducing WOMAC pain scores and improving SF-36 PCS scores over a six month period.