Elbow Medial Ulnar Collateral Ligament chronic isolated insufficiency: anatomical M-UCL reconstruction technique and clinical experience in a mid-term follow-up.

PURPOSE: This study aims to clinically evaluate, at mid-term follow-up, a group of patients treated by the senior author in the last 6 years with our anatomical double-bundle reconstruction surgical technique for the medial ulnar collateral ligament (M-UCL) insufficiency. METHODS: In this study, we included only patients affected by chronic valgus elbow instability, diagnosed with an accurate clinical evaluation combined with an MRI, without associated fractures that had been surgically treated in the past and without additional instability detected during the first checkup and in the preoperative evaluation under anesthesia. The nine patients enrolled were operated by the senior author between 2011 and 2014 (from 16 to 49 years old at surgery, all amateur sportsmen). The average follow-up is 4 years (47.6 months). The values of the range of movement were recorded and compared. Pain assessment was performed using the VAS scoring system. The recovery of daily activities was evaluated through the validated MEPS and Quick-DASH score scales. All patients underwent an X-ray in two standard projections and a preoperative and follow-up MRI. RESULTS: The recovery of the range of motion was complete in six cases. The remaining three patients had minor loss of extension. None of the patients reported flexion deficits nor pronation-supination at follow-up. All patients achieved subjectively perceived stability and clinically objectified stability at follow-up. Five patients referred a total lack of pain at follow-up. Seven patients achieved full marks in the Mayo Elbow Performance Score and an excellent improvement in the Quick-DASH score. CONCLUSIONS: Excellent functional results indicate that M-UCL isolated reconstruction with autologous hamstrings described in this study is a reliable and replicable technique with a reduced incidence of complications. Resuming sports is consistently successful in our patients.

MR evaluation of anterior cruciate ligament reconstruction with quadriceps tendon. Preliminary experience.

PURPOSE: Anterior cruciate ligament reconstructions are becoming increasingly frequent, and MRI has been shown to be the best imaging modality for the non-invasive assessment of surgical outcome. Use of the quadriceps tendon as a biological replacement for injured cruciate ligament is a recent innovation. This study evaluated by MRI the results of anterior cruciate reconstruction in 27 consecutive patients who underwent arthroscopic reconstruction with homologous quadriceps tendon. MATERIAL AND METHODS: MRI was carried out on 27 patients who had undergone anterior cruciate ligament reconstruction with the middle third of the homolateral quadriceps tendon. The examinations were performed on two MRI units: a permanent 0.2-Tesla dedicated magnet (Artoscan, Esaote Italy) and whole-body 1.5-Tesla superconducting magnet (Signa, GE Medical Systems Milwaukee, Winsconsin USA). Axial, sagittal and coronal images were acquired with SE, GE and STIR fat suppression sequences. The examinations were performed 1, 3, and 6 months post-operatively in 16 patients, and 1 and 3 post-operatively in 11 patients. The same arthroscopic surgical technique was employed in all patients, with 20 cases of tibial mono-tunnel femoral semi-tunnel, and 7 cases with tibial bi-tunnel technique. All patients were assessed by arthrometric and clinical tests after surgery. Bioabsorbable interference screws were used for tibial fixation in all patients and metallic interference screws were used for femoral graft fixation in 8 patients. RESULTS: In all cases MRI correctly visualised the tunnel positions, the articular portion and the bone-portion of the graft inside the tibial and femoral tunnels. The absence of paramagnetic artefacts in the tibia allowed complete visualisation on the axial, sagittal and coronal MRI images with optimal spatial and contrast resolutions. In 6 cases, the presence of metal residues from the surgical cutter prevented correct evaluation of femoral tunnel content. No new graft or articular lesions were found. In 18/27 cases peri-focal marrow edema around the tibial tunnel had disappeared 3 months after surgery. The process of synovial incorporation was judged to be correct in all cases. DISCUSSION: The use of anterior cruciate ligament reconstruction with the quadriceps tendon is a important innovation given the size of the harvested material and the possibility of completely filling the osseous tunnels, without interposition of synovial proliferation or fluid collection between tendon and bone, as confirmed by MRI. Furthermore, the use of non-metallic screws allows MRI evaluation of tunnel content and oedema in the spongy bone around the tunnel. The study of the double tibial tunnel requires specific obliqueness in the coronal plane scans. CONCLUSIONS: This arthroscopic technique for anterior cruciate ligament reconstruction allows thorough MRI evaluation of all portions of the transplant, and in particular those coursing within the tibia and femur. The absence of bone oedema around the tunnels and synovial proliferation within the tunnels may be predictive of faster healing and complete bone incorporation of the grafts.

Technical note: double tibial tunnel using quadriceps tendon in anterior cruciate ligament reconstruction.

To avoid complications related to the use of patellar tendon and hamstring (semitendinosus and gracilis) tendon and to create a more anatomic reconstruction, we present a new technique based on the use of quadriceps tendon placed in a single half femoral tunnel and double tibial tunnels. The graft, harvested by a central longitudinal incision, possesses the following characteristics: (1) a bone plug 20 mm long and 10 mm in diameter; (2) a tendon component 7 to 8 cm long, 10 mm wide, and 8 mm thick; and (3) division of the tendon longitudinally into 2 bundles while maintaining the patellar insertion. Every bundle has a width and thickness of approximately 5 mm and 8 mm, respectively. The total length of the graft is 9 to 10 cm. A 10-mm half femoral tunnel is drilled through a low anteromedial portal with the knee flexed at 120 degrees. A suture loop is left in place in the half tunnel. A double tibial tunnel is drilled in a convergent manner (from outside to inside) obtaining an osseous bridge between the 2 tunnels. Two suture loops are passed trough the tibial tunnels and retrieved in a plastic cannula (10 mm) positioned in the anteromedial portal to allow the passage of the 2 bundles in the tibial tunnels. The suture loop left in the half tunnel permits the transportation of the bone plug in the femoral tunnel. Fixation is achieved by an interference screw at the femoral side and by 2 absorbable interference screws (1 for each tunnel). The advantages of this technique are a more cross-sectional area (80 mm(2)), greater bone-tendon interface, and a more anatomic reconstruction. Theoretically, easier bone incorporation, decreased windshield wiper and bungee effect, fewer donor site problems, and less tunnel enlargement can also be possible.

Evaluation of the triangular fibrocartilage complex tears by arthroscopy, arthrography, and magnetic resonance imaging.

Arthroscopic findings in 11 patients with chronic ulnar painful wrist were compared both with arthrographic and magnetic resonance (MR) imaging results to evaluate the accuracy of the former procedure in the detection of triangular fibrocartilage complex (TFCC) lesions. MR imaging and arthrography investigations appeared to be sensitive modalities when compared with arthroscopic findings in TFCC lesions (specificity 100%; sensitivity 82 and 80%). MR imaging can be advantageously employed in the screening of patients suspected of having a TFCC tear, eliminating the necessity of an arthrographic examination. However, MR imaging could not define the exact site of the tear within the degenerate TFCC or detect lesions of the articular cartilage. Arthroscopy offers sure evidence of the site of TFCC lesion and more information about the intraarticular associated causes of chronic ulnar wrist pain such as chondromalacia and synovitis. An added benefit is that many of the pathologies seen can be treated using arthroscopic surgical techniques.

Neurophysiological assessment of the early phases of carpal tunnel syndrome with the inching technique before and during operation.

In 14 patients with early carpal tunnel syndrome, the diagnostic sensitivity of the measurement of the segmental sensory nerve conduction velocity at 1 cm. steps ("inching") was compared with the distal sensory latency and the pre-operative wrist-digit and wrist-palm S.C.V. and with similar measurements made at operation immediately after surgical decompression of the nerve. Before operation, distal sensory latency and wrist-digit S.C.V. were normal in all cases, while wrist-palm S.C.V. was pathological in five patients and inching in all 14 patients. Moreover, inching allowed us to determine the site of the slowing across the carpal tunnel, this being between 1-2 cm. from the distal wrist crease in 57% and between 2-3 cm. in 21% of cases. Focal slowing disappeared immediately after decompression in five patients, as is evident from the intra-operative recordings. Inching is, therefore, the most sensitive diagnostic method in early carpal tunnel syndrome.

MR evaluation of triangular fibrocartilage complex tears in the wrist: comparison with arthrography and arthroscopy.

To evaluate the accuracy of magnetic resonance (MR) in the detection of tears of the triangular fibrocartilage complex (TFCC), 10 consecutive patients with posttraumatic chronic wrist pain were examined with MR, arthrography, and arthroscopy and the results were compared. The MR images of 16 control subjects were also examined to define the MR appearance of the normal TFCC. When compared with arthroscopic findings, both MR and arthrography had two false-negative results (sensitivity, 80%) and no false-positive results. Regarding the sites of the TFCC tears, the findings on MR did not always correlate with the findings on arthrography. In no case was MR able to visualize the cartilaginous lesions visible by arthroscopy. These preliminary results illustrate the ability of MR to assess the integrity of the TFCC and suggest its use as the first imaging technique following plain radiography in the evaluation of patients with chronic posttraumatic pain on the ulnar side of the wrist.

Vascularized nerve graft: a clinical contribution.

The authors present 4 cases of vascularized nerve graft. The results were better than those obtained with traditional grafting. The indication is a rare one, and the experimental results are contradictory. Indications are limited to Volkmann ischemic syndromes, post-actinic lesions of the brachial plexus, infections and finally, post-burning scarring. Nevertheless, traditional nerve grafts remain the treatment of choice for peripheral nerve lesions which cannot undergo direct suturing.

[Blocked metacarpophalangeal joint: etiologic factors and treatment]. / La métacarpo-phalangienne bloquée: facteurs etiologiques et traitement.

The metacarpo-phalangeal is a crucial joint and its stiffness deeply affects hand function. A series of 15 post-traumatic cases resulting in a complete and irreversible block of the joint is presented. Indication for joint release are given and the surgical technique is described. Different approaches are utilized in relationship to associated lesions. Post-operative treatment and percentages of improvement in joint excursion for each digit are reported. All working patients resumed the previous job even in presence of a limited articular gain. Best results where confined uncomplicated post-traumatic cases with crushing of surrounding soft tissues.

Meissner's corpuscles in reimplanted fingers. A study of the possible correlations between anatomical findings and sensory function tests.

A morphometric and immunohistochemical study was carried out on Meissner's corpuscles and nerve fibres of the subpapillary plexus in reimplanted fingers to determine whether there were any correlations between the anatomical findings and the results of clinical tests of sensory function. Before taking biopsy samples, the patients were submitted to tests of receptor function and classified according to the neurophysiological responses. Serial sections of standard thickness were obtained from each sample and the following morphometric parameters regarding Meissner's corpuscles determined: a) density per square millimetre of skin surface; b) size; c) major axes. On some sections, an immunoperoxidase technique for the determination of protein S-100 was used to study the nerve fibres in the subpapillary plexi. The results showed no correlation between the clinical receptor response test and the density of the Meissner's corpuscles, but some relationship was observed between the degree of neural regeneration and the execution of neurorrhaphy at reimplantation. The size and shape of the corpuscles showed wide variations in all subjects.