Normal values of the axial patellotrochlear overlap on MRI: Good correlation with patellotrochlear index in patients with no patellofemoral pathology.

BACKGROUND: There are several imaging-based measurements for patellofemoral height, which are obtained from sagittal images. However, these methods can be misleading with sagittal oblique slices and when the patella is tilted and/or chronically subluxated. This study aimed to describe a simple method of measuring patellar height using axial patellotrochlear overlap (APTO) on MRI. METHODS: A retrospective observational study of 97 knees from 251 patients, excluding those with fractures, massive effusion, or patellofemoral conditions. APTO was measured as follows: (1) patellar length (P) - expressed as the number of axial images showing patellar articular cartilage; (2) trochlear overlap (T) - the number of axial images showing the overlap between patellar articular cartilage and articular cartilage of the lateral trochlea. APTO is the ratio T/P. All measurements were performed independently by six raters on two separate occasions. The raters were two orthopaedic consultants, one knee surgery fellow, two consultant musculoskeletal radiologists, and one radiology fellow. The conventional patellotrochlear index (PTI) was measured as a control for all patients by a senior musculoskeletal radiologist. RESULTS: The mean APTO value was 36.7% (range 14.2-66.6; standard deviation 11.4). There was a positive correlation with the PTI, Pearson correlation coefficient: 0.76, P < 0.001. Intra-observer reliability was good (intraclass correlation coefficient(ICC): 0.66, 95% confidence interval (CI) 0.54, 0.76, P < 0.001). Inter-observer reliability was fair (ICC: 0.51, 95% CI 0.41, 0.6, P < 0.001). CONCLUSIONS: APTO was shown to be a reliable measurement of patellar height and correlated with existing PTI for patellar height. Measurement of APTO on MRI could be a reliable alternative for the evaluation of patellar height. However, further studies are required to assess its validity in patients with patellofemoral pathology.

Management of mucoid degeneration of the anterior cruciate ligament: a systematic review.

PURPOSE: The purpose of this study was to investigate the outcomes of management of mucoid degeneration of the anterior cruciate ligament (MDACL) by performing a systematic review of methods of treatment that have been reported. METHODS: A systematic literature search in the databases MEDLINE, Embase, Google Scholar, Cochrane, ISI web of science and Scopus was performed through July 2020 by three independent reviewers. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42018087782). Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: A total of nine studies were eligible for review. All nine studies assessed the outcome of arthroscopic debridement of MDACL. A total of 313 knees in 292 patients were included. The mean follow up ranged from 13 to 72 months. There was strong association between MDACL and chondral lesions (82%) and between MDACL and meniscal tears (69%). The rate of simultaneous meniscectomy ranged from 13 to 44%. Postoperative pain relief ranged from 53.8 to 95%. There was an improvement in postoperative range of motion and outcome scores (Lysholm and International Knee Documentation Committee scores and the Knee Injury and Osteoarthritis Outcome Score). Postoperative Lachman test was positive in 40% of patients, and 6% of patients had symptomatic instability. The mean MINORS score was 9.5 out of 16 (4-12). CONCLUSIONS: Arthroscopic debridement of the anterior cruciate ligament (ACL) results in satisfactory pain relief and improvement in knee outcome scores. Postoperative ACL laxity is common after arthroscopic ACL debridement, however, symptomatic instability is not. The need for delayed ACL reconstruction should be discussed preoperatively, especially if complete resection of the ACL is to be performed. LEVEL OF EVIDENCE: IV.

Tarsal Tunnel Syndrome Secondary to an Unreported Ossicle of the Talus: A Case Report.

Tarsal tunnel syndrome (TTS) is a compression neuropathy of the posterior tibial nerve in the tarsal tunnel. In about 80% of patients, a specific cause can be identified for TTS. We present a case of TTS secondary to an ossicle in close relation to the talus that, to our knowledge, has not previously been reported. A 26-year-old male presented with left ankle and foot pain that increased with activity and playing football. He had a tingling sensation and paresthesia in the sole and medial border of the foot along the distribution of the medial and lateral plantar nerves. Clinically, he had hard swelling at the floor of the tarsal tunnel, and Tinel's sign was positive. Computed tomography showed an accessory ossicle articulating with the posteromedial aspect of the talus, separating the flexor digitorum longus and flexor hallucis longus tendons, with tenosynovitis of the tibialis posterior, flexor digitorum longus and flexor hallucis longus tendons. Surgical release of the tarsal tunnel and excision of the ossicle were performed. Postoperatively, the patient showed dramatic improvement and had no complications or recurrence of symptoms after 8 months of follow-up. More interestingly, to the best of our knowledge, this ossicle has not been previously reported to cause TTS.

Informed consent documentation for total hip and knee replacement using generic forms with blank spaces.

PURPOSE: To analyse informed consent documentation of 100 patients undergoing elective primary total hip replacement (THR) or total knee replacement (TKR) using generic forms with blank spaces. METHODS: Informed consent documentation of 57 men and 43 women (mean age, 54 years) undergoing elective primary THR (n=50) or TKR (n=50) using generic forms with blank spaces were analysed. The consent forms were explained to the patients mostly on the morning of surgery by a consultant surgeon (n=21), specialist registrar (n=23), or senior house officer (n=56). Data on patient demographics, planned procedure, benefits and risks of surgery, and the grade of the surgeon were collected. RESULTS: In the consent forms for THR, the most frequently documented complications included infection (98%), bleeding (96%), deep vein thrombosis (94%), nerve damage (94%), blood vessel damage (94%), and pain (90%). Common complications (2-5% of occurrence) that were less frequently documented included prosthesis wear or loosening (76%), dislocation (68%), and leg length discrepancy (62%). In the consent forms for TKR, the most frequently documented complications included infection (96%), bleeding (92%), deep vein thrombosis (90%), nerve damage (90%), and blood vessel damage (90%). Common risks (2-5% of occurrence) that were less frequently documented included pain (84%), prosthesis wear or loosening (54%), and knee stiffness (40%). CONCLUSION: Documentation of all clinically significant complications was insufficient when generic informed consent forms with blank spaces were used. The use of standardised procedure-specific consent forms is recommended.

Audit of operation notes in an orthopaedic unit.

PURPOSE: To audit operation notes of 50 patients according to the guidelines of the Royal College of Surgeons. METHODS: Proforma operation notes of 50 consecutive patients treated in an orthopaedic department were audited by a single reviewer, according to the guidelines of the Royal College of Surgeons in terms of date and time of surgery, name of surgeon, procedure, operative diagnosis, incision details, signature, closure details, tourniquet time, postoperative instructions, complications, prosthesis used, and serial numbers. RESULTS: There were 45 trauma cases and 5 elective cases. The operating surgeons were consultants (32%), senior registrars (36%), and registrars (32%). 28% and 72% of the operation notes were written by operating surgeons and assistants, respectively. Of the 14 operating surgeons who wrote their own notes, one was a consultant, 6 were senior registrars, and 7 were registrars representing 6%, 33%, and 44% of the respective grades of surgeons. All the notes were handwritten; 20% had illegible parts (all in the description of the operative technique). Documentation was good for date and time of surgery (100%), name of surgeon (100%), procedure (100%), duration of surgery (94%), operative diagnosis (92%), incision details (84%), and signature (84%). Documentation was poor for tourniquet time (32%; pneumatic tourniquet was used in 25 patients, only 8 of whom were documented), closure details (16%), and postoperative instructions (24%). CONCLUSION: Documentation of operative details in our department was generally good, except for closure details, tourniquet time, and postoperative instructions.

A new technique of single portal endoscopic carpal tunnel release.

Since the first description of endoscopic carpal tunnel release (ECTR) in 1987 by Okutsu many endoscopic techniques have been developed, but the majority of the literature on ECTR has dealt with the Chow and Agee techniques. ECTR is indicated for carpal tunnel syndrome that is not responding to conservative treatment for 6 months. This new technique of ECTR is a single-portal technique using instruments originally designed for endoscopic cubital tunnel release, with no disposable instruments used. It also has the advantage of performing the release with the median nerve protected under direct vision. Ten cases were operated with this technique after performing the procedure on 8 hands of 4 fresh frozen cadavers. There were no neurovascular or tendon injuries with this technique and patients were satisfied with the results.