Anatomy and terminology of groin pain: Current concepts.

Groin pain is a common symptom in athletes. The complex anatomy of the area and the various terms used to describe the etiology behind groin pain have led to a confusing nomenclature. To solve this problem, three consensus statements have been already published in the literature: the Manchester Position Statement in 2014, the Doha agreement in 2015, and the Italian Consensus in 2016. However, when revisiting recent literature, it is evident that the use of non-anatomic terms remains common, and the diagnoses sports hernia, sportsman's hernia, sportsman's groin, Gilmore's groin, athletic pubalgia, and core muscle injury are still used by many authors. Why are they still in use although rejected? Are they considered synonyms, or they are used to describe different pathology? This current concepts review article aims to clarify the confusing terminology by examining to which anatomical structures authors refer when using each term, revisit the complex anatomy of the area, including the adductors, the flat and vertical abdominal muscles, the inguinal canal, and the adjacent nerve branches, and propose an anatomical approach, which will provide the basis for improved communication between healthcare professionals and evidence-based treatment decisions.

Anterior and Posterior Cruciate Ligaments Mechanoreceptors: A Review of Basic Science.

Proprioception is a specialized sensory modality encompassing the movement of the joint and its position in space, and it involves the conversion of mechanical deformation of tissues into neural signals. Mechanoreceptors are specialized nerve structures able to transmit mechanical deformation through electrical signals to dorsal root ganglion sensory neurons and are abundant in the muscles, tendons and ligaments of the knee joint. They are believed to play an important role in knee proprioception and dynamic knee stability. Proprioception should always be taken into consideration for successful reconstruction of the cruciate-deficient knee and for pain and function management in the arthritic knee. Advances in histological methods of detection are numerous and continue to highlight the presence and role of mechanoreceptors after ligament reconstruction, depending on choice of graft. In this review, we present the current knowledge of anterior and posterior cruciate ligaments and grafts mechanoreceptors, and their role in proprioception of knee joint, focusing on each type of mechanoreceptors.

A Review of the Outcomes of the Implementation of Case-Based Anatomy Learning.

PURPOSE: Clinically-oriented anatomy education has been proposed as an effective strategy in anatomy curricula. We aimed to explore the level of extent the literature supports the fact that case-based learning (CBL) can play a significant role in anatomy education. MATERIALS AND METHODS: We searched PubMed, Scopus, Education Resources Information Center (ERIC), and Cochrane database to find articles with the purpose to explore the educational outcomes of case-based anatomy learning. We extracted from each paper authors, type of study (comparative or not), number of participants, level of outcome according to the Kirkpatrick hierarchy, outcomes of CBL concerning the acquisition of anatomical knowledge, and the participants' perceived enjoyment, motivation, and aid to anatomy learning. RESULTS: Nine articles were included. Three of them evaluated the acquisition of anatomical knowledge, while six papers evaluated the participants' perceptions. All studies showed positive outcomes regarding the students' anatomy examination performances, reported confidence, enjoyment, motivation, and ability of CBL to facilitate anatomy learning. CONCLUSION: Although the existing research has mainly evaluated students' perceptions, the outcomes of CBL in anatomy education encourage more extensive use of this method in anatomy curricula. Further research is expected to shed more light on the role that CBL can play in modern anatomy education and to clarify if it can replace or supplement didactic teaching.

Knee Capsule Anatomy: An MR Imaging and Cadaveric Study.

This research focuses on the anatomical insertion of the synovial capsule around the knee. The attachments of the capsule were measured in 50 knee MR imaging studies with large intraarticular effusion. Corresponding measurements were performed in 20 fresh frozen cadaveric specimens, for validation. Femoral and tibial capsular reflections were defined as the distances between the attachment sites of the capsule and the femoral or tibial joint line and they were recorded in three coronal planes (anterior/middle/posterior). On MR imaging, the lateral/medial femoral capsular reflection mean values were 6.5/4.57 cm, 2.74/1.74 cm and 1.52/1.99 cm in the anterior, middle and posterior plane, respectively. MR imaging-based measurements did not differ significantly compared to corresponding cadaveric measurements. The mean values of the lateral/medial tibial capsular reflection on MR imaging were 0.09/0.11 cm, 0.34/0.26 cm and 0.62/0.34 cm in the anterior, middle and posterior plane, respectively. On cadaveric dissection, the maximum mean value was 1.45 cm, measured on the lateral side of the anterior plane. Apart from the lateral aspect of the posterior plane, MR imaging measurements were significantly lower, compared to the corresponding cadaveric measurements. The greatest femoral and tibial capsular reflections were found on the anterior and lateral side of the anterior plane. MR imaging appears to underestimate the distal extent of the knee capsule. Anatomical details of the knee capsule should be considered for safe insertion of external fixator pins.

Surgical Implications of the Arterial Anatomy around the Knee: A Cadaveric Pictorial Essay.

We completed an anatomic cadaver study in order to examine the arterial supply around the knee and to create useful images regarding the arterial surgical anatomy around the knee. A total of four unmatched fresh-frozen cadaveric knees were utilized. There was no medical history of osteoporosis, bony or soft-tissue injury or surgery in any of the knees. The femoral arteries were cannulated with a large catheter at the proximal aspect of the cadavers, and liquid latex in different colours was injected. Τhe specimens were then placed into a bath of 8.0% sodium hypochlorite to complete debridement of the soft tissues to various degrees. The specimens were checked every 15 to 30 min until adequate debridement occurred, and photographs were taken during each stage of this process. Sodium hypochlorite, among others, chemically debrides the vessel walls leaving the casts of the vessel lumens filled with solid coloured latex in order to illustrate the vascular supply pattern to the structures of interest. Knowing the probability of where these arteries should be located adds to the knowledge that surgeons have at their disposal when performing procedures involving arthroscopy, arthroplasty and osteotomies, which can help decrease unnecessary damage to the arteries.

Surgical and Radiological Anatomy of the Medial Patellofemoral Ligament: A Magnetic Resonance Imaging and Cadaveric Study.

The purpose of this study was to compare the measurement of several anatomical features of the medial patellofemoral ligament (MPFL) between magnetic resonance imaging (MRI) and by direct fashion during dissection. We hypothesized that the measurements between these two techniques would agree. MRI of 30 fresh-frozen cadaveric knees was followed by dissection. MPFL patella and femoral attachment were evaluated; their shape, length, and width were measured; and measurements were compared. MRI was deemed unreliable for the determination of several of the aforementioned anatomical features. Important findings include: (a) observations on MPFL attachment at medial patella side and attachment to quadriceps were identical between dissection and MRI; (b) average width at patella insertion was significantly different between the two methods (p = 0.002); and (c) an attachment to the quadriceps tendon was present in 20/30 specimens and d. detailed measurements of a thin, non-linear, and three-dimensional structure, such as the MPFL, cannot be performed on MRI, due to technical difficulties. This anatomical radiological study highlights the shape, anatomical measurements (length and width), and attachment of the MPFL using a relatively large cadaveric sample and suggests that MRI is not reliable for detailed imaging of its three-dimensional anatomy.

Clinical and Radiological Outcomes After Isolated Anterior Horn Repair of Medial and Lateral Meniscus at 24 Months' Follow-up, With the Outside-In Technique.

Background The effects of repair of isolated anterior horn meniscus lesions have not been thoroughly described in the literature. We aimed to evaluate outcomes with subjective clinical scores and imaging modalities after repair of isolated anterior horn tears, at 24 months' follow-up. Methods Records of all patients that opted for surgical repair of isolated, anterior horn tears of the medial and lateral meniscus were retrospectively reviewed, between 2016 and 2018. All patients were treated with arthroscopic outside-in technique by the same surgeon. Preoperative and postoperative clinical files were accessed to recover records of preoperative symptomatology, patient-reported scores [International Knee Documentation Committee (IKDC) rating, Lysholm score and Tegner activity level], preoperative and postoperative MRI data and time from injury to surgery. Results Mean age of eight patients was 25.25 years (range 18-37 years). Diagnostic preoperative MRI revealed isolated anterior horn tear of the lateral meniscus and medial meniscus in five patients and an isolated anterior horn tear of the medial meniscus in three patients. Mean time from injury to surgical repair was 23.75 days (range 7-43). We considered seven out of eight repairs to be successfully healed. At 24 months' follow-up: Mean Lysholm score was 92.25 (range 89-95), Tegner activity scale score was 6.5 (range 5-8) and IKDC score was 91.78 (range 87.8-94.4). All scores significantly improved compared to preoperative values (p<0.001). Conclusions Outside-in is a reliable technique to repair meniscal anterior horn tears, both medially and laterally, with high healing rates and patient satisfaction in young, active patients.

Biomechanical comparison of two medial patellofemoral ligament reconstruction techniques: Quadriceps tendon fixation versus single-tunnel patella fixation with gracilis autograft did not differ in load to failure and stiffness.

BACKGROUND: The purpose of this study was to evaluate the ultimate failure load and stiffness of two patellar fixation techniques for medial patellofemoral ligament (MPFL) reconstruction: (1) quadriceps tendon fixation (QT), (2) single tunnel (STG) patella fixation with gracilis autograft. METHODS: A total of 16 fresh-frozen cadaveric knees (eight matched pairs) were randomized into two groups (QT vs. STG). The MPFL reconstructions were subjected to cyclic loading for 10 cycles to 30 N and then tested to failure at a constant displacement rate of 15 mm/min using a materials-testing machine (MTS 810 Universal Testing System). Failure mode, ultimate failure load and stiffness were recorded for each cadaveric specimen. RESULTS: There was no significant difference in mean ultimate failure load among groups (P = 0.35). The STG group failed at a mean ultimate load of 190.04 N [standard deviation (SD) 23.18] and the QT group failed at 206.24 N (SD 37.99). The STG group had a mean stiffness of 21.38 N/mm (SD 1.44). This was not significantly higher than the mean stiffness value achieved for the QT group at 20.36 N/mm (SD 1.3) (P = 0.19). In the QT group all reconstructions failed due to tendon rupture at the patella attachment. The reason for failure in the STG group was the graft-suture connection. CONCLUSIONS: This cadaver study showed no statistically significant difference in biomechanical performance of the evaluated patella fixation techniques, in terms of maximum load to failure and stiffness. Both techniques are reliable in terms of biomechanical properties and could offer additional surgical solutions.

Simultaneous bilateral posteromedial tibial epiphysis stress fractures in a healthy young man: A case report.

We present a compelling case of simultaneous, bilateral tibial stress fractures occurring in a unique epiphyseal and posterior location, with unclear aetiology. An overweight, Caucasian male in his late 20s developed synchronous bilateral medial knee pain following an intense 10-day training regimen. His radiographies were normal, but MRI revealed almost identical bilateral stress fracture lines in the posteromedial tibial epiphyses. Bone mineral densitometry and a full metabolic and hormonal panel were performed to further investigate potential underlying metabolic bone disease. He was found to have normal bone mineral densitometry and low Vitamin D serum values. Symptomatology greatly improved with activity modification. There were no further complaints and complications at 12 months' follow-up. Diagnosis can be challenging and the treating physician should be acquainted with the basic science of stress fractures and main discriminating clinical, biochemical and radiological characteristics from insufficiency fractures, to avoid pitfalls in treatment decision.

Description and Validation of an Innovative and Effective Hand-Shaped Suture-Training Model for Medical Students.

During medical education, medical students are often frustrated by difficulties in translating theoretical anatomical knowledge and basic surgical skills (suturing, tissue and instrument handling, and local anesthetic administration) into practice. A common etiological factor for this difficulty, among others, is lack of a low-cost and easy-to-assemble low fidelity suturing model. The purpose of this study is the demonstration of a validated, practical, inexpensive, hand-shaped anatomy training model. It is addressed to medical students and graduates that wish to get acquainted with neurovascular anatomy of the hand and improve their basic surgical skills. The model requires only two latex gloves, cotton, and two different color markers per trainee to draw the course of large nerve and vessels. Construction requires less than 15 minutes. For validation, 80 students participated as volunteers in the demonstration course. They evaluated course usefulness and their own confidence after the course. According to the 5-point Likert scale, the participants' confidence increased in a statistically significant way ( p < 0.05). All participants (100%) stated that their skills were "significantly improved" in terms of instrument handling, anatomy studying, performing digital anesthesia, and suturing technique. Overall experience was rated as "satisfactory" or above. The proposed model enables safe gentle soft-tissue handling, and it resembles a realistic human tissue. Low cost, availability, and fast construction are the most important characteristics, making this validated training model appropriate for acquiring fundamental local anesthesia, respect for hand neurovascular anatomy, and suturing skills.

A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up.

AIM: Small soft tissue defects of the distal tibia and hindfoot resulting from traumatic, operative, or neoplastic conditions and chronic ulcers can be successfully dealt with the use of the reverse sural artery flap (RSAF). This study aims to describe a single center's results and familiarity with this technique over a 15-year period of time. MATERIAL AND METHODS: We retrospectively reviewed the clinical files of patients who were consecutively treated with RSAF and regularly followed up between January 1, 2004 and December 31, 2018, with a minimum postoperative follow-up period of two years. Patient demographics and comorbidities, location of the defect, performing surgeon, mean operation time, flap pedicle width, mean size of the defect, days of hospitalization following the operation, healing flap rate, and complications were recorded. RESULTS: The sample consisted of 30 adult patients (25 men, 5 women), with a mean age of 51.07 years (16-80 years, SD 18.61). The mean operation time was 99.03 min (range 83-131, SD 10.57), and the mean size of the defect was 11.11 cm2 (range 6.1-19.4, SD 3.22). Successful flap rate (complete healing and coverage of the defect, with or without additional minor intervention) was 83.3% (25/30). Among successfully healed flaps, six patients with partial necrosis of the dermis were treated by an additional split-thickness skin graft. Five flaps failed to heal. Deep infection was present in two patients, leading to flap failure and reoperation. Serious venous congestion resulting in flap ischemia occurred in three cases. Circumferential keloid formation (not affecting successful outcome) was present in seven cases. Flap thickness approximated to normal within six months. All donor sites healed well (either by a split-thickness cutaneous flap or by immediate wound closure). Light paresthesia on the lateral border of the leg and foot disappeared within six months. CONCLUSIONS: A single-center experience with the RSAF has yielded satisfactory clinical outcomes, and the long-term tackle with the difficult reconstruction conditions around the ankle, has led to valuable advice on surgical technique and postoperative protocol, based on an anatomical basis.

Atypical presentation of an intra-articular osteoid osteoma in the proximal humerus excised with arthroscopy: a case report.

An adult man presented with a 5-month history of anterior right shoulder pain. He denied previous trauma or night pain. On the otherwise normal physical examination, pain was elicited in maximum abduction and external rotation. Radiographs were negative. The primary imaging findings were bone marrow oedema of the inferomedial proximal metaphysis of the humerus on MRI and cortical demineralisation on CT located posteromedially. A superficial elevation was also observed around the lesion. A provisional diagnosis of an osteoid osteoma was made based on these imaging findings. Arthroscopic excision of the lesion was performed, and histopathological examination confirmed the diagnosis of an osteoid osteoma. Diagnosis of intra-articular osteoid osteomas may be challenging due to atypical symptomatology and lack of pathognomonic imaging findings. Arthroscopic excision of such lesions in the shoulder is a safe and reliable option and should be considered as the treatment of choice.

Long-Term Functional Results of Intra- and Extra-Articular Hand Fractures Treatment With Titanium Miniature Plates and Screws With Minimum Follow-Up of 24 Months.

Introduction The purpose of this study was to evaluate the long-term outcome of an extended range of hand fractures treated with titanium, low profile plates, and screws. Materials and methods This retrospective study included adult patients with at least one phalangeal and/or metacarpal fracture, treated with mini titanium plates and screws, between 2004-2016, in a single trauma center, that were followed-up for at least 24 months and with complete, intact medical records. Results 90 patients (79 men and 11 women) with 114 hand (46 phalangeal, 68 metacarpal) fractures fulfilled the inclusion criteria. Thirty-two fractures were open (28.07%), 27 were intra-articular (23.68%), and 12 were both open and intra-articular fractures. The mean age of the patients was 36.02 years (range 17-75). Mean follow-up was 95.3 months (range 24 to 138). Open fractures had a reduced mean grip strength and total active motion. No difference was observed between intra-articular and extra-articular fractures (for grip strength and total active motion). Predictors of the final outcome included the severity of the initial injury (open vs closed) and not the anatomic location (intra- or extra-articular, metacarpal, or phalangeal) of the fracture. Conclusions Low-profile plates and screws can successfully be used to establish union and restore the alignment of the fractured bone while achieving a satisfactory clinical outcome, even in cases of open or intra-articular fractures.

Comparison of Minimally Invasive Operative Treatment with Conservative Treatment for Acute, Minimally Displaced Scaphoid Fractures at 12 Months' Follow-up.

Background Minimally displaced scaphoid fractures can be challenging to diagnose and treat. Cannulated scaphoid screws have made percutaneous stabilization highly effective. Questions Would minimally invasive operative treatment of minimally displaced scaphoid fractures yield faster return to work when compared with patients treated conservatively? How do functional and patient satisfaction scores compare between the two groups at 12-months follow-up? Patients and Methods Records from 18 patients (mean age 28.6 years) treated surgically were retrospectively reviewed and compared with a group of 10 patients (mean age 33.3 years, p = 0.74) treated nonoperatively. Inclusion criteria were a minimum follow-up period of 12 months and radiographic union. Time to return to work was compared between groups. At 12 months' follow-up, wrist range of motion (ROM) and grip strength were compared, as well as pain, satisfaction, and overall wrist function were evaluated by the visual analogue scale (VAS) and the Mayo modified wrist score (MMWS). Results The mean time to return to work for the operated group was 39.75 days, while for the nonoperated group it was 88.14 days ( p = 0.002). At the 12 months' follow-up, mean ROM, grip strength, and VAS score did not differ between groups. The mean MMWS was 98.75 for the operated group and 87.5 for the nonoperated group, indicating a better result in patients treated operatively ( p = 0.03). In addition, two failures of instrumentation were recorded, a seldom seen complication. Conclusion Percutaneous fixation of minimally displaced scaphoid fractures allows faster return to work and leaves patients more satisfied with their wrist function compared with plaster immobilization at 12 months' follow-up. Level of evidence This is a Level III, retrospective, case-control study.

University Students Perception of Online Education: Is Engagement Enough?

BACKGROUND: Universities have halted non-essential services, with many restricting campus-based teaching, and continuing courses through online resources, including (controversially) lab-work. Such technologically enhanced approaches have been proven to have high levels of engagement among university students. OBJECTIVE: This study focuses on the perception of quality of online learning by first-year university students, between two semesters, amidst the COVID-19 pandemic. METHODS: A 24-item questionnaire was designed with Likert response scale. It consisted of general perception questions of academic life and questions specific to the quality of delivery of a specific class. Eighty one eligible students were asked to fill the same questionnaire for each semester. Students' responses and their grades from the final exams in each semester were compared. RESULTS: Out of 81 eligible students, 75.31% of students responded to the survey. They were less interested in their studies in the second "online" semester (p=0.05). Students expressed dissatisfaction with the quality of online classes (p=0.03). Academic life fulfillment was also affected (p=0.02). Students' perception of the amount of free time they had between semesters did not change significantly (p=0.16). Students appeared dissatisfied with their active participation during the online class (p=0.007), even though they felt less stressed attending lectures from home (p=0.041). However, they found that workload was bearable and similar between semesters (p=0.83). Students also had significantly more trouble concentrating during online lectures (p<0.001). Students' grades significantly improved by an average of 1.07 (out of 10) in the final exams at the end of the second semester (p<0.001). CONCLUSION: These unprecedented circumstances require innovation and cooperation on the part of university programs to maintain rigorous standards of higher education, taking into account students' evolving perception and needs.

A computed tomography cadaveric study of the radiological anatomy of the patella: the size of the patella correlates with bone bridge between tunnels and R angles are introduced for safe tunnel drilling during MPFL reconstruction.

PURPOSE: To measure the safe range of angles during tunnel drilling and map ideal patella tunnel placement with the use of preoperative computed tomography (CT) scan and compare results after medial patellofemoral ligament (MPFL) reconstruction using a hardware-free patellar fixation technique with two semi-patellar tunnels between a) a free-hand technique, and b) its modification with the use of an anterior cruciate ligament (ACL) tibia aiming device. METHODS: CT scan was performed on 30 fresh-frozen cadaveric knees a) prior to any intervention and b) after MPFL reconstruction. For MPFL reconstruction, specimens were randomly allocated to 1) Group A, which consisted of knees operated with free-hand, hardware-free patellar fixation technique with two semi-patellar tunnels and 2) Group B, which consisted of knees operated on with a technique modification with the ACL tibia device. PATELLAR MEASUREMENTS: L1 was the maximal patellar length. L2 was the minimum possible distance of placement for the upper tunnel from the proximal pole of the patella. The maximum bone bridge between tunnels was calculated as half of L1 minus the L2 distance (L1/2-L2). We also measured R1 and R2 angles at the proximal and distal tunnel that represent safe angles at the entry point during tunnel drilling (without breaching the anterior cortex or articular cartilage). RESULTS: Preoperatively, mean L1 was 3.45 cm (range 3.05-4.52). Mean L2 was 0.62 cm (range 0.49-0.89). The mean maximum possible bone bridge between tunnels (L1/2-L2) was 1.1 cm (range 0.77-1.58). R1 was 6.050 (range 4.78-7.44), R2 was 6.640 (range 4.57-9.03), and their difference reached statistical significance (p = 0.03). Postoperatively, in group A, in 4 out of 15 patellas, multiple attempts were made during tunnel drilling in order to avoid anterior cortex or cartilage breaching. In group B, all tunnels were correctly drilled with the first attempt. Bone bridge between tunnels was significantly shorter postoperatively (0.93 cm, p < 0.01). CONCLUSION: Small-size patellae correlate with short maximum bone bridge between tunnels, which makes anatomic, double-bundle, hardware-free patella fixation, with two semi-patellar tunnels MPFL reconstruction challenging. Furthermore, R angles create a narrow window to avoid intraoperative breaching, rendering the use of the ACL tibia device an extremely useful instrument. LEVEL OF EVIDENCE: II.

Primary Paraspinal Hydatid Cyst in a Patient Presenting with Low Back Pain: A Case Report.

CASE: A 54-year-old man presented with low back pain and low-grade fever. Palpation revealed a focal mass of the lumbar region. Radiographs were normal, but magnetic resonance imaging demonstrated a multicystic mass at the level of L2-L4. The initial diagnosis of a hydatid cyst was confirmed after surgical excision. CONCLUSION: Although primary paraspinal hydatidosis is rare, physicians should be aware of it when dealing with patients suffering from low back pain combined with red-flag symptoms. Especially in rural regions or areas where populations live in close proximity to host animals, primary paraspinal hydatidosis should be included in the differential diagnosis.

Musculoskeletal anatomy: evaluation and comparison of common teaching and learning modalities.

Anatomy teaching has traditionally been based on dissection. However, alternative teaching modalities constantly emerge, the use of which along with a decrease in teaching hours has brought the anatomy knowledge of students and young doctors into question. In this way, the goal of the present study is to a. compare the efficacy of the most common teaching modalities and b. investigate students' perceptions on each modality. In total, 313 medical students were taught gross anatomy of the upper limb, using four different learning modalities: dissection (n = 80), prosections (n = 77), plastic models (n = 84) and 3D anatomy software (n = 72). Students' knowledge was examined by 100 multiple-choice and tag questions followed by an evaluation questionnaire. Regarding performance, the dissection and the 3D group outperformed the prosection and the plastic models group in total and multiple-choice questions. The performance of the 3D group in tag questions was also statistically significantly higher compared to the other three groups. In the evaluation questionnaire, dissection outperformed the rest three modalities in questions assessing students' satisfaction, but also fear or stress before the laboratory. Moreover, dissection and 3D software were considered more useful when preparing for clinical activities. In conclusion, dissection remains first in students' preferences and achieves higher knowledge acquisition. Contemporary, 3D anatomy software are considered equally important when preparing for clinical activities and mainly favor spatial knowledge acquisition. Prosections could be a valuable alternative when dissection is unavailable due to limited time or shortage of cadavers. Plastic models are less effective in knowledge acquisition but could be valuable when preparing for cadaveric laboratories. In conclusion, the targeted use of each learning modality is essential for a modern medical curriculum.

Reconstruction of the medial patellofemoral ligament using two blind transverse semi-patella tunnels and an implant-free technique for patellar fixation: a technical note.

BACKGROUND: The double-bundle technique with two points of patellar fixation in the upper half of the patella replicating the broad attachment site of the native medial patellofemoral ligament (MPFL) is the most commonly performed procedure for MPFL reconstruction. Complete transverse patella tunnels pose a threat to the integrity of the patella. We present an implant-free, double-bundle technique for MPFL reconstruction with gracilis autograft, overcoming the problem of complete patella bone tunnels and over-drilling. METHODS: After standard gracilis graft harvesting, the anteromedial side of the patella is exposed. With the guidance of an anterior-cruciate-ligament (ACL) tibia-aiming device, two 2-mm parallel guide pins are inserted from medial to lateral at the upper half of the patella. The two guide pins are over-drilled with a cannulated 4.5-mm drill bit 2-cm deep, to create two transverse blind semi-patellar tunnels. For the femoral fixation, a 2.4-mm guide pin with an eyelet is drilled at the Schöttle point and over-reamed with a 6-mm cannulated reamer to a depth of 30 mm. The two free ends of the graft (with two running Krakow sutures placed) are pulled into the two patella tunnels and the graft sutures are tied together with tension for stable graft fixation at the lateral patella rim. With the help of a femoral suture loop (which is inserted in the femoral bone tunnel), the graft-loop is advanced into the femoral bone tunnel and the graft is finally fixed with a 7-mm interference screw at 30° of knee flexion. RESULTS: The utilization of blind transverse tunnels (not trans-patellar tunnels) offers the advantage of avoiding stress risers at the patella. Thanks to the ACL tibia aiming device, multiple drilling, and breaching of the anterior patellar cortex or articular surface of the patella is avoided. CONCLUSIONS: This implant-free, and consequently affordable technique, isolated or combined with bony procedures, minimizes possibilities for perioperative bony complications at the patella fixation site.

An observational study of complications in patients with established multiple compartments syndrome of the leg.

INTRODUCTION: Established multiple compartments syndrome of the leg (EMCSL) is defined as permanent ischemic lesions of muscles and nerves of the compartment, leading to multiple muscle contractions, muscle weakness and wasting and reduced limb sensation. The leg is seriously affected and the patient is unable to return to prior activities. The objective of this research is to quantify long-term consequences, morbidity and socioeconomic impact of established multiple compartments syndrome of the leg MATERIALS AND METHODS: 28 patients suffering from complications from EMCSL were referred to our clinic for secondary management between January 2012 and April 2016 and were followed for mean 41.4 months. Reconstructive procedures to address multiple conditions following established tibia compartment syndrome were performed. The number of reconstructive procedures, days of hospitalization, relationship, educational and employment status per patient were recorded. Preop and postop SF-12 score at final follow-up was documented for the 21 patients who were operated on. RESULTS: A median of three reconstructive procedures was performed per patient for 21 patients. The hospitalization period ranged from 6 to 365 days, with a mean period of 47.5 days (SD 71.4). At the final follow-up, 19 patients had lost their occupation, 3 patients had returned to lighter manual labor, 5 patients had lost two school years, and 1 patient had abandoned school. At the time of injury, 24 patients were single. At final follow-up, 19 of these patients, with a mean age of 38.5 years, were still single. Preoperative and postoperative (at final follow-up) physical and mental components of the SF-12 score had a statistically significant difference (p < 0.001), but final values were not normal. CONCLUSIONS: Despite advancements in surgical reconstructive intervention, patients with established compartment tibia syndrome experience permanent grave residual disability with personal and social implications.