Using a combination of three clinical tests for detecting meniscal tears increases the accuracy of the clinical examination.

BACKGROUND: Recent studies indicate that using combination of two or more clinical tests for detecting meniscal tear gets a higher sensitivity and specificity than any clinical test performed individually. METHODS: The study involved 84 participants who were divided into two groups: the "OP group" consisting of participants diagnosed with a meniscal tear and who consequently underwent arthroscopic meniscectomy, and the "CN group" comprising of healthy participants with no history of knee injury. Two independent observers (orthopedic surgeons) recorded the results of six clinical tests: Thessaly Test, joint line tenderness, McMurray Test, Ege Test, Steinmann I Test, and atrophy of the thigh muscles. The tests were grouped into two combinations of three tests each. The first combination included Thessaly Test, joint line tenderness and McMurray Test, while the second combination comprised of remaining three tests. Cochran's Q Test was used to calculate interobserver variability for both combinations of clinical tests and for each test performed individually. RESULTS: First combination of three clinical tests when considering the combination positive if two tests are positive had high sensitivity of 95%, specificity of 90.9%, and an overall accuracy of 92.9%. Furthermore, when compared to clinical tests performed individually, the combination demonstrated superior results. CONCLUSIONS: This study shows that using a combination of three clinical tests for detection of meniscal tear (Thessaly Test, joint line tenderness, McMurray Test), when considering the combination positive if two tests are positive, has greater accuracy than six clinical tests performed individually. There were no statistically significant differences between observers.

Arthroscopic removal as an effective treatment option for intra-articular osteoid osteoma of the knee.

BACKGROUND: Intra-articular osteoid osteoma (iaOO) can be found in 5.2% up to 10% of cases. They may cause non-specific symptoms, mimicking degenerative or traumatic pathologies. If iaOO is left untreated, it may lead to severe muscle atrophy, tenderness, swelling, and limited range of motion. Therefore, surgical treatment is recommended. The main goal of surgical treatment is complete removal or destruction of iaOO. AIM: To evaluate the efficiency of arthroscopic removal of iaOO of the knee in our cases and cases available in the literature. METHODS: Analysis of available hospital records of four patients with iaOO of the knee treated by arthroscopic removal from August 2005 to December 2015 at our Department was performed. All patients had a diagnosis of iaOO confirmed by histopathologic analysis. Additional literature review of cases of iaOO of the knee available on PubMed and Google Scholar was made. All cases of iaOO of the knee treated by arthroscopic or arthroscopically assisted removal were reviewed in order to further evaluate the efficiency of the method. RESULTS: The average age of patients included in our study was 23.2 (range 16-37) years. The average duration of the symptoms prior to surgery was 14.2 (range 6-24) months. All of the patients had persistent knee pain. Three patients reported worsening of pain during the night, while two reported worsening of pain during activity. Three patients reported alleviation of pain on non-steroidal anti-inflammatory drugs (NSAIDs), while one patient reported partial alleviation of pain on NSAIDs. No intraoperative complications were noted, and the postoperative period was uneventful in all patients. The patients reported immediate pain relief in the postoperative period. No recurrence of the disease was noted in any of the patients during the follow-up period of at least 24 mo. The literature review revealed 14 cases with an average age of 27.6 (range 16-48) years and onset of symptoms 27.7 (range 6-108) months prior to surgery, with recurrence of the disease noted in a single case. CONCLUSION: Arthroscopic removal is an efficient treatment method that allows excision of iaOO that is neither insufficient nor excessive, thus avoiding disease recurrence while obtaining adequate material for histopathologic analysis.

IS THERE ANY ROOM FOR TENDOSCOPY IN THE SURGICAL TREATMENT OF POSTERIOR TIBIAL TENDON INSUFFICIENCY?

Posterior tibial tendon insufficiency (PTTI) is nowadays considered to be the main cause of adult-acquired flatfoot deformity (AAFD). The purpose of this study is to report the outcomes of tendoscopic treatment of tibialis poste- rior tendon (TP) in eleven patients with stage 1 or 2 PTTI and failed prior conservative treatment. Tendoscopy was carried out as a solitary procedure in 8 patients, while in 3 patients additional procedures such as ,,mini-open" tubularization of TP or anterior ankle arthroscopy were necessary. In a single patient transfer of flexor digitorum longus tendon was performed as a second stage surgery due to complete rupture of TP. Related with tendoscopic procedure, no complications were re- ported. TP tendoscopy is a useful and beneficial minimally invasive procedure to treat TP pathology at earlier stages of PTTI. It is a technically demanding procedure that requires extensive experience in arthroscopic management of small ioints and excellent knowledge of repional anatomy.

Periarticular osteoid osteoma of the ankle: a report of nine arthroscopically treated patients.

Periarticular osteoid osteoma often presents with unspecific clinical symptoms, mimicking other clinical conditions. This can lead a clinician to a ''diagnostic side path'' and a delayed or missed diagnosis compared with extra-articular osteoid osteoma. We report the cases of 9 patients with a mean age of 22 (range 14 to 32) years who were diagnosed with periarticular osteoid osteoma of the ankle and were surgically treated in our department during a 12-year period. The diagnostic difficulties associated with periarticular osteoid osteoma must be resolved by obtaining a detailed patient history and performing a thorough physical examination. Computed tomography is the ultimate imaging method to confirm the suspicion of osteoid osteoma. Arthroscopic removal of the osteoid osteoma was performed in all 9 patients in the present case series, with synovectomy performed when indicated. Under arthroscopic visualization, a specimen was obtained for histopathologic analysis to confirm the diagnosis, followed by tumor excision. All the patients were pain free at the final follow-up visit after a mean duration of 6 years (range 6 months to 12.7 years) postoperatively. We suggest arthroscopic removal of periarticular osteoid osteomas of the ankle as an effective treatment method, because it allows complete tumor excision, synovectomy when needed, a short postoperative rehabilitation period, and satisfactory functional results.

[Hip arthroscopy]. / Artroskopija kuka.

In the last ten years, hip arthroscopy has been developing intensively and it is rapidly gaining primacy in the treatment of various injuries and damages to the hip itself and its immediate vicinity. The basic advantage of hip arthroscopy surgery versus classic open surgery is avoiding an open dislocation of the hip and, thus, reducing patient's morbidity and accelerating his/her rehabilitation, which leads to a quicker return to everyday activities. The success of arthroscopic surgery depends on the correct indication for the surgery and on the experience and the skill of the operator. It also depends on the properly conducted rehabilitation and the patient's compliance, as well as on the patient's realistic expectations. Indications for hip arthroscopy today are the following: injury and damage to acetabular labrum and/or articular cartilage, femoroacetabular impingement syndrome, injuries and damages to the ligament of the femoral head, loose and foreign joint bodies as well as different conditions of synovial membrane (synovial chondromatosis, pigmented villonodular synovitis and other inflammatory arthropathy such as rheumatoid arthritis). In this article we describe the indications, technique, complications and the prospect of hip arthroscopy, with a detailed overview of contemporary literature data.

Current practice variations in the management of anterior cruciate ligament injuries in Croatia.

AIM: To investigate current preferences and opinions on the diagnosis, treatment and rehabilitation of patients with anterior cruciate ligament (ACL) injury in Croatia. METHODS: The survey was conducted using a questionnaire which was sent by e-mail to all 189 members of the Croatian Orthopaedic and Traumatology Association. Only respondents who had performed at least one ACL reconstruction during 2011 were asked to fill out the questionnaire. RESULTS: Thirty nine surgeons responded to the survey. Nearly all participants (95%) used semitendinosus/gracilis tendon autograft for reconstruction and only 5% used bone-patellar tendon-bone autograft. No other graft type had been used. The accessory anteromedial portal was preferred over the transtibial approach (67% vs 33%). Suspensory fixation was the most common graft fixation method (62%) for the femoral side, followed by the cross-pin (33%) and bioabsorbable interference screw (5%). Almost all respondents (97%) used a bioabsorbable interference screw for tibial side graft fixation. CONCLUSION: The results show that ACL reconstruction surgery in Croatia is in step with the recommendations from latest world literature.

Synovial chondromatosis of the elbow.

Synovial chondromatosis (SC) is a rare, mostly benign proliferation of the synovium of the joint, tendon or bursa which results in the formation of loose bodies. It can appear in one of 33 described localisations, but it is most common in the knee. In our study we gathered a group of 7 patients (6 male and 1 female) with SC of the elbow, which underwent arthroscopic surgery of the elbow, performing both removal of the loose bodies and complete synovectomy. Mayo Elbow Performance Score (MEPS) was used to evaluate and compare the patients' condition before the operation and at the final follow-up, 31 months, on average, after the operation (range 18-56 months). All patients had poor MEPS before the operation, with an average of 40.7 (range 15-50 points). At the final follow-up, 6 patients had a good or excellent MEPS, while a poor MEPS was present in a single patient. The average MEPS was 85 (range 45-100 points). The one patient who's MEPS remained poor developed heterotopic ossification in the same elbow shortly after arthroscopic surgery. This patient was reoperated 8 months later using an open technique. No other complications occurred in the rest of the operated patients and no recurrence of SC occurred in any of the operated patients. Our results confirm that arthroscopic removal of loose bodies and complete synovectomy should be the treatment of choice for SC of the elbow.

[Ligament which deserves attention--medial patellofemoral ligament]. / Ligament koji zasluzuje pozornost--medijalni patelofemoralni ligament.

There has been increasing interest in investigating the medial patellofemoral ligament (MPFL) during the last fifteen years. This is due to the recognition of the MPFL as the primary static soft-tissue restraint to lateral patellar displacement and the association of MPFL injury with primary traumatic patellar dislocation. The MPFL often heals poorly and thus rarely regains its full function. Numerous surgical techniques have been described for reconstruction of this important structure. This paper reviews the relevant anatomy and biomechanics, published reconstruction options, and describes the surgical technique performed at our institution--that of using a quadriceps autograft to reconstruct the MPFL.

[Eccentric exercises in the treatment of overuse injuries of the musculoskeletal system]. / Ekscentricne vjezbe u lijecenju sindroma prenaprezanja sustava za kretanje.

Overuse injuries of the musculoskeletal system are a common problem in both general population and among athletes. Researches made in the last decade have shown that overuse injuries are mainly caused by degenerative changes and not inflammation, as was thought before. Although they can be present everywhere in musculoskeletal system, overuse injuries are most often seen on tendons. The main goal of this article is to refer to latest guidelines in the treatment of overuse injuries, with special attention to eccentric exercise treatment program for most common tendinopathies (patellar tendinopathy, Achilles tendinopathy and lateral epicondylitis). The main reason is the fact that very good results are accomplished after eccentric exercises in the treatment of tendinopathies and are thus suggested as the first treatment option.

Removal of osteoid osteoma of the tibia using two-portal posterior ankle arthroscopy.

The case of a 30-year-old male with a history of pain in his left ankle is presented. The pain was described as predominantly nocturnal and frequently relieved by the use of nonsteroidal anti-inflammatory drugs. Computed tomography indicated a diagnosis of an osteoid osteoma in the posteromedial portion of the tibia. The patient underwent excision of the tumor using 2-portal posterior ankle arthroscopy. A clearly visualized nidus was removed using a combination of a cochlea and shaver. Histopathologic analysis of the resected tissue confirmed the diagnosis of an osteoid osteoma. The patient reported immediate relief of the pain and was rapidly allowed to bear weight on the foot. During regular follow-up, he had no pain recurrence and his joint mobility was normal. To our knowledge, this is the first report of the removal of an osteoid osteoma of the ankle using 2-portal posterior ankle arthroscopy.

[Arthroscopy of the elbow]. / Artroskopija lakta.

Elbow arthroscopy has become an indispensable method of surgical care of injuries and their consequences and damages that affect the elbow. The advantages of elbow arthroscopy in comparison to classical open surgery are multiple. Primarily, arthroscopy allows an excellent view of intra-articular structures and thus a detailed overview of the entire joint which enables us to perform complete surgery without opening the joint. Furthermore, morbidity is significantly smaller, rehabilitation is faster, and return to daily activities is also faster. Basic requirements for successful application of elbow arthroscopy are careful planning of the procedure, very good knowledge of regional anatomy of the elbow, strictly following the rules of performing the procedure, good technique and an experienced surgeon. Pathologies that can currently be addressed arthroscopically include osteochondritis dissecans of elbow, lateral epicondylitis, synovial plica syndrome, elbow osteoarthritis, elbow contracture, as well as the diseases where the synovectomy is needed, such as rheumatoid arthritis, pigmented villonodular synovitis, synovial chondromatosis and hemophiliac synovitis.

Arthroscopic treatment of localized and diffuse pigmented villonodular synovitis of the knee.

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial disorder of uncertain etiology. Two forms of this disorder, a localized (LPVNS) and diffuse (DPVNS) form, are well differentiated. The therapy of choice for LPVNS is arthroscopic partial synovectomy with excision of the lesion. Total synovectomy, whether done arthroscopically or through an open arthrotomy, is the recommended treatment for DPVNS. During an eight-year period 13 patients, six male and seven female, average age 28 years (range, 16 to 60 years) were treated for PVNS of the knee with arthroscopic synovectomy. Average follow-up was 84 months (range, 28 to 127 months). Four patients were affected by localized PVNS and were subjected to partial arthroscopic synovectomy (two to three portals) with a complete lesion excision. The remaining nine patients presented with the diffuse form of PVNS and all of them underwent total arthroscopic synovectomy (five portals). The diagnosis was confirmed by synovial biopsy. Each patient was evaluated before treatment and at final follow-up. Results were assessed clinically, radiographically and subjectively and were rated as excellent, good, fair, or poor. No complications or recurrences were noted in the LPVNS group, and all four patients were rated as excellent. In the DPVNS group, eight patients were rated as excellent and one patient was rated as fair and it was the patient who suffered the only recurrence in our case series. No relevant complications were encountered. No cases of infection, joint stiffness or neurovascular lesions were seen. Arthroscopy has become the golden standard in treatment of LPVNS, and can undoubtedly give results that are as good as with open synovectomy when treating DPVNS, if performed by an experienced arthroscopic surgeon.