The effect of medial shift of supraspinatus tendon on the glenohumeral joint motion-a cadaveric study.

PURPOSE: Full-thickness retracted massive supraspinatus tears are a challenge for arthroscopic surgeons where multiple options for treatment exist, but medializing the attachment is a relatively easy procedure for which a decision can be taken intraoperatively. We investigate the viability of MATERIAL AND METHODS: Ten freshly thawed cadavers were taken and dissected. The supraspinatus tendon was resected, and then its attachment was progressively medialized. The range of motion (abduction, internal and external rotation) was recorded and compared. As a result, we noted a statistically significant decrease in abduction, internal and external rotation with progressive medialization of the supraspinatus insertion. CONCLUSION: Medialized repair of the supraspinatus can be performed only to an extent beyond which it compromises glenohumeral motion. We noted a statistically significant decrease in ROM with even a 3 mm medialization of the tendon, but the acceptable medialization has to be determined on a case-to-case basis.

Measurement of Distance Between Femoral Insertion of Fibular Collateral Ligament and Popliteus: A Cadaveric Study in Indian Population.

Background: Injuries to posterolateral corner (PLC) of knee are often neglected. The three key components of PLC are lateral collateral ligament (LCL), popliteofibular ligament (PFL) and popliteus tendon (PT). For adequate reconstruction, anatomic location of these ligaments should be well understood. Material and methods: Twenty formalin fixed cadaveric knees were dissected. PT and LCL identified. Circumference of the two structures marked with pen just after cutting them close to bone surface. Distance between the centre of LCL and PT was measured along with the measurement of distal femoral medio-lateral dimension (MLD) and Anteroposterior dimension (ALD) of lateral condyle. Result: The mean distance between PT and LCL measured in 20 specimens was 8.3 ± 0.84 mm, with a range of 7 mm to 10 mm. MLD was 81.0 ± 3.6 mm and APD was 62.7 ± 3.2 mm. Conclusion: The distance in Indian population is significantly smaller compared to the western. This has clinical implication in drilling the tunnels for PLC reconstruction.

Correlation between height and semitendinosus tendon length, prediction of minimum semitendinosus tendon length based on height-an easy and accurate method.

Purpose: To find out an easy method to predict tendon length on the basis of patient height. Methods: A prospective study which included 256 patients. All patients underwent ligament reconstruction using semitendinosus graft. Pre-operatively age, gender, height and weight were noted. Harvested semitendinosus graft's length and diameter was measured. Results: Both the patient height as well as weight correlated with tendon diameter and tendon length (p-value < 0.05). A simple equation was also derived to pre-operatively predict tendon length. Conclusion: To predict graft size, surgeon should consider anthropometric variables. If we divide height of the patient with six, we get the approximate length of the tendon and by subtracting three from the obtained value we are more than 90% sure that ST would not be shorter than this. Level of evidence: level 4.

Comparison of semitendinosus tendon length and diameter in sports and non-sports group for ACL reconstruction.

Different anthropometric parameters such as weight, height, body mass index, thigh circumference, and thigh length have been extensively studied and their correlation assessed with hamstring graft length and diameter. This study is to analyse the difference of semitendinosus graft characteristics with sports activity of the patient. METHODS: 110 patients undergoing any ligament reconstruction with semitendinosus were included, 55 in sports and 55 in non-sports group. Height, weight, BMI, sports activity were noted pre-operatively. Semitendinosus harvested and graft length and diameter measured. RESULTS: 98 patients completed the study. The mean length of the harvested semitendinosus tendons was 28.45 ± 2.54 cm in non-sports group and 28.06 ± 4.18 cm in sports group. The mean diameter of semitendinosus was 6.29 ± 0.61 mm in non-sports group and 6.35 ± 0.6 mm in sports group. Positive correlation was found between height and graft length. No statistically significant difference between tendon length (p = 0.994) and diameter (p = 0.549) of sports and non-sports group was found. CONCLUSION: Patient height should be considered for preoperative prediction of tendon length and thickness without any difference in sports or non-sports group. A taller patient has a longer and thicker graft.

Long term outcome of early single stage surgery in multi-ligamentous injuries of knee.

BACKGROUD: Multi-ligamentous knee injuries have been a grey area due to unavailability of large scale control trials with a long term follow up. Several studies have documented good results with different protocols of management regarding time of treatment, repair versus reconstruction, choice of graft and sequence of repair. The author wishes to put forward long-term results of early (<6 weeks) single-stage surgery in multi ligamentous injuries. METHODS: The prospective trial included 29 patients diagnosed with three or more ligaments involved. Patients having fractures involving proximal tibia, distal femur, patella, patients with history of compound trauma to knee, osteochondral lesions, associated neuro-vascular injury & poly-trauma patients were excluded from the study. The patients also underwent AP, lateral & stress skiagrams in addition to a standard 3T MR scan for pre-operative planning and confirmation of diagnosis. The pre & post-operative outcomes were assessed using KSS & Lysholm score. The patients were followed up for two years with clinical examination and stress skiagrams. RESULTS: The mean increase in knee scores was statistically significant at both 12 months and 24 months (p < 0.05) with mean ROM of 132.8° at final follow-up. Three patients required manipulation under anaesthesia. All patients could carry out their activities of daily living at mean period of 8.2 months. Osteoarthritis was most common complication at 2 years follow-up. CONCLUSION: The most important aspect of a single stage reconstruction lies in earlier restoration of function with a tremendous decrease in loss of medical expenses, improvement of quality of life and early & improved function in terms of both physical and psychological factors. Better restoration of kinematics from early rehabilitation is probably the factor responsible for the results. Osteoarthritis remains an important follow-up finding.

Optimal Angle of the Bone Tunnel for Avoiding Axillary Nerve Injuries During Arthroscopic Transosseous Rotator Cuff Repair: A Magnetic Resonance Imaging-Based Simulation Study.

BACKGROUND: Axillary nerve injury and suture cutout through the roof of the tunnel are potential complications of arthroscopic transosseous rotator cuff repair (ATORCR). PURPOSE: To determine a safe angle of drilling for the bone tunnel during ATORCR such that the axillary nerve is not at risk. The thickness of the bone bridge over the tunnel for different angles of drilling was also determined. STUDY DESIGN: Descriptive laboratory study. METHODS: The drilling of a straight tunnel was simulated on 30 magnetic resonance imaging (MRI) scans in the oblique coronal plane by drawing a straight line that passed at a "safe distance" of 5 mm from the axillary nerve and emerging at the medial border of the insertion of the rotator cuff on the greater tuberosity. The angle made by this line with the horizontal axis of the humerus was measured on 3 MRI sections: anterior (passing just posterior to the lateral lip of the bicipital groove), middle (at the most lateral point of the proximal humerus), and posterior (an equal number of cuts away from the middle section as between anterior and middle). The thickness of the overlying bone roof was measured for this line as well as for simulation lines drawn at 50°, 55°, 60°, and 65° with the horizontal axis. A "safe limit," defined as the mean - 2SD, was also calculated. RESULTS: The axillary nerve was found to be safe, with a safety margin of 5 mm, at drill angles of less than 61.1° and 60.3° in the posterior and middle sections, respectively. The safe limit value for thickness of the overlying bone roof for the tunnel drilled at 60° was 5.0 mm in the posterior section (mean, 8.2 ± 0.3 mm) and 5.5 mm in the middle section (mean, 8.1 ± 0.2 mm). In the anterior section, the minimum safe angle was 57.7°, and the mean thickness of the bone roof for the 55° angle was 6.3 ± 0.2 mm (safe limit, 3.7 mm). CONCLUSION: Straight bone tunnels in ATORCR surgery should be drilled at an angle of 60° to the horizontal axis of the humerus or 30° to the humeral shaft to ensure the safety of the axillary nerve while at the same time ensuring adequate thickness of the overlying bone roof. The anterior tunnel close to the bicipital groove should be drilled cautiously at 55° to the horizontal axis or 35° to the humeral shaft. CLINICAL RELEVANCE: The findings of the present study will help the surgeon choose the best angle for drilling tunnels during ATORCR surgery to avoid axillary nerve injuries as well as suture cut-through without the need for any proprietary device.

Incidence, management and outcome assessment of post operative infection following single bundle and double bundle acl reconstruction.

INTRODUCTION: Post-operative infection is a dreadful complication of ACL reconstruction with gray zone over management guidelines. We aimed to establish commonest etiology, assess incidence of infection and effect on outcome, individually for single and double bundle ACL reconstruction techniques, so as to formulate appropriate management guidelines. METHODS: Our prospective study involved 1152 patients operated for ACL reconstruction (437- DBACL, 715- SBACL) from 2010-2013. Post-operative infection was diagnosed clinically supported by positive gram stain/ culture and increased cell count in knee aspirate. All patients were started on empirical antibiotics and arthroscopic lavage and debridement was done. Graft was retained if it was stable and intact. Data recorded at follow up was analysed statistically. RESULTS: In SBACL infection rate was 0.84% while in DBACL it was 2.52%. All patients with infection presented with pain, effusion, fever and increased WBC, ESR & CRP. Average time of presentation after the surgery was 2.27 weeks for DBACL and 2.16 weeks for SBACL. In both groups, S.aureus followed by S. epidermidis were commonest isolates. Patients were given IV antibiotics for 2 weeks and oral for further 4 weeks. DISCUSSION: Incidence of infection is higher with the double bundle technique, however, the functional outcome is not affected (p value 0.231). Joint aspirate is the gold standard diagnostic test for infection. CRP and ESR are the next dependable tests with high sensitivity but their specificity is low. A thorough debridement is necessary apart from recommended antibiotic cover of 2 weeks IV followed by 4 weeks oral antibiotics.

Capsulotomy as a measure to control pain and reducing hemarthrosis in arthroscopic DB ACL reconstruction surgery: a prospective randomized control study.

PURPOSE: The aim of the study was to evaluate the effect of capsulotomy as a measure of pain relief and hemarthrosis prevention in the arthroscopic double-bundle anterior cruciate ligament reconstruction. METHODS: This was a case control study conducted between April 2013 and Dec 2013, in which 64 patients were enrolled. Capsulotomy was done at the end of the procedure in 31 patients, who were compared with a control group. Pain score (VAS) and grade of hemarthrosis on post-op day 1 and post-op day 2 were compared between the two groups and patients followed up to a minimum of 24 months. RESULTS: There was a statistically significant difference (p value < 0.05) in the pain scores and hemarthrosis grade of the capsulotomy group compared to the control group. The mean pain score on post-op day 1 in the capsulotomy group was 2.71 ± 0.97, whereas it was 4 ± 1.22 in the non-capsulotomy group. The difference between the two groups was statistically significant both at day 1 of post-op and day 2 of post-op (p value < 0.05). The difference between the two groups in terms of hemarthrosis grading was statistically significant both at day 1 of post-op and day 2 of post-op (p value < 0.05). The difference between the two groups in terms of thigh circumference measurements was statistically significant both on day 1 and day 2 of post-op (p value < 0.05). CONCLUSION: We conclude that capsulotomy is a safe and effective measure of pain relief and hemarthrosis management in arthroscopic ACL reconstruction surgeries.

Cysticercosis of Soleus muscle presenting as isolated calf pain.

CNS is the most common site of involvement by cysticercosis. Symptomatic involvement of isolated skeletal muscle by solitary cysticercosis cyst is extremely rare. We report a rare and unusual case of cysticercosis presenting as acute calf pain, which is a diagnostic challenge. But the diagnosis was reached by sero-radiological examination and patient was managed conservatively by medical means.

Vulval myiasis: An unusual presentation of a rare entity in an adolescent female.

Human myiasis refers to parasitic infestation of body tissues by larvae of several fly species. The entity has a simple management. Human myiasis is well-documented in the literature however genital myiasis in females is scarcely reported in the literature. We hereby report this entity in an adolescent female who presented with urinary retention and concomitant urinary tract infection.