Medial Tears Research Articles

Factors Associated With Meniscal Tears and Chondral Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction

Background: Increased time from anterior cruciate ligament (ACL) injury to surgery is known to be associated with increased medial meniscal tears. Few studies have examined the predictors of meniscal tears and chondral lesions, including instability episodes. Purpose: To examine the predictors of meniscal tears and chondral injuries in patients undergoing ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Data were collected prospectively from 541 patients undergoing ACL reconstruction. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals for predictors of meniscal tears, tear management, and chondral injuries. Predictors included age, sex, body mass index (25-29.99 and ≥30 vs ≤24.99 kg/m2), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports related) of injury, interval from injury to surgery (≤6 vs >6 weeks and ≤12 vs >12 weeks), and instability episodes (vs none). Results: A total of 211 lateral meniscal tears (35.3% untreated, 48.3% meniscectomized, 16.4% repaired), 197 medial meniscal tears (25% untreated, 52% meniscectomized, 23% repaired), and 82 chondral injuries occurred. Age predicted chondral injuries. Male sex predicted more lateral meniscal tears overall, untreated lateral tears, and lateral meniscectomies as well as predicting medial meniscal tears overall and medial meniscectomies. Obesity predicted more chondral injuries. Sports-related injuries predicted fewer medial meniscal tears overall and medial meniscectomies. Injuries ≤6 weeks from surgery predicted more lateral meniscal repairs but fewer medial meniscectomies. Injuries ≤12 weeks from surgery predicted more chondral injuries. More instability episodes predicted medial meniscal tears overall, untreated medial tears, medial meniscectomies, and medial repairs. Conclusion: Male sex predicted lateral meniscal tears and management. Male sex, sports, injuries ≤6 weeks from surgery, and preoperative episodes of instability predicted medial meniscal tears and management. Age predicted chondral injuries. This was one of the first studies to examine the number of instability episodes as a predictor of an intra-articular injury.

Relationship between bone bruise volume and the presence of meniscal tears in acute anterior cruciate ligament rupture

To determine whether there is a relationship between the size of the bone bruise volume after an acute anterior cruciate ligament (ACL) rupture and the presence of meniscal tears in the medial and lateral compartment. Following Institutional Review Board approval, 50 patients with an acute ACL rupture and MRI imaging within 30 days of injury were identified. Two musculoskeletal radiologists evaluated the lateral and medial menisci and graded them as one of the following: no meniscal tear, tear of one meniscus (medial or lateral) or tear of both menisci (medial and lateral). Sagittal T2 fat-suppressed images were used to calculate bone bruise volume. The relationship between bone bruise volume and the presence of a meniscus tear was calculated. Forty-three (86%) patients had a bone bruise, 16 (32%) patients had no tear, 7 (14%) patients had lateral meniscus tear, 13 (26%) patients had medial tear and 14 (28%) patients had medial and lateral tears. There was a statistically significant difference in femoral bone bruise volume when comparing no meniscal tear to medial and lateral tears as well as when comparing medial or lateral tears to medial and lateral tears. There is a statistically significant relationship between femoral bone bruise volume and the presence of meniscal tears in ACL injury, especially in the setting of medial and lateral pathology. Retrospective cohort study, Level III.

Commentary: Correlation between Trochlear Dysplasia and Anterior Cruciate Ligament Injury

Acute patellar dislocation (APD) and anterior cruciate ligament (ACL) injury are common injuries and can lead to devastating consequences if not treated appropriately. Their mechanism of injury is similar, namely, a valgus twisting injury as a result of sudden non-contact deceleration. Those at risk also share similar epidemiological and anatomical characteristics; they tend to be female, have ligamentous laxity, and be young, active adults, with dysplastic intercondylar and trochlear notches. Concurrent injuries are common: osteochondral defects and medial patellofemoral ligament tears are associated with APD, 1–3 and mensical and collateral ligament tears are associated with ACL injury. Magnetic resonance imaging (MRI) is the gold standard to diagnose these injuries and to differentiate patients that warrant surgery as opposed to conservative treatment. A large study in New Zealand estimated the incidence of ACL injuries to be 36.9 per 100 000 person-years. 4 ACL injury is possibly associated with a narrow intercondylar notch, particularly in females. Nonetheless, controversies exist as to the mechanism; whether a narrow notch leads to impingement and attritional rupture or whether a narrow notch means a smaller and more vulnerable ACL remains unknown. Anterior knee pain has many possible causes. It is associated with trochlear dysplasia on MRI. 5 The

Human autopsy study of drug-eluting stents restenosis: histomorphological predictors and neointimal characteristics

Restenosis in drug-eluting stents (DESs) occurs infrequently, however, it remains a pervasive clinical problem. We interrogated our autopsy registry to determine the underlying mechanisms of DES restenosis, and further we investigated the neointimal characteristics of DESs and compared with bare metal stents (BMSs). Coronary lesions from patients with DES implants (n = 82) were categorized into four groups based on cross-sectional area narrowing: patent (<50%), intermediate (50-74%), restenotic (≥ 75% with residual lumen), and total occlusion (organized thrombus within the stent). Restenosis and occlusion were significantly dependent on the total stented length: restenosis (26.7 mm) and occlusion (25.7 mm) compared with patent DESs (17.3 mm). Further, restenotic and occluded lesions were located more distally in the coronary arteries and had greater vessel injury and uneven strut distribution suggesting local drug gradient. Multivariate analysis revealed that normalized maximum inter-strut distance was associated with DES restenosis (OR: 17.4, P = 0.04) while medial tear length was a predictor of DES occlusion (OR: 5.1, P = 0.03). No differences were observed between different DESs (sirolimus-, paclitaxel-, and everolimus-eluting stents) for restenosis and occlusion. Further, neointimal compositions of restenotic DESs demonstrated greater proteoglycan deposition and less smooth muscle cellularity over time, when compared with BMS with greater cell density and collagen deposition. Our study indicates the impacts of inadequate drug concentration due to wider inter-strut distance and vessel injury as primary mechanisms of DES restenosis and occlusion, respectively. Moreover, the differences in neointimal compositions between DESs and BMSs might serve as a potential target for the suppression of late neointima growth via inhibition of proteoglycans in DESs.

Horizontal intra-articular patellar dislocation resulting in quadriceps avulsion and medial patellofemoral ligament tear

Intra-articular patellar dislocations are rare. We present a 13-year-old boy who sustained a complete horizontal intra-articular patellar dislocation following blunt trauma to the flexed knee. Closed reduction was unsuccessful and open reduction indicated a repairable quadriceps avulsion and medial patellofemoral ligament tear. He is the youngest patient to sustain a quadriceps rupture and the only patient to sustain a medial patellofemoral ligament tear to date. His flexed knee and the horizontally positioned patella (seen on lateral radiograph) were indicative of a complete rotational injury with extensor mechanism involvement. Open reduction allowed for the repair of both injuries and a favorable outcome.

Medial Posterior Meniscal Root Tears Are Associated with Development or Worsening of Medial Tibiofemoral Cartilage Damage: The Multicenter Osteoarthritis Study

To assess the association of meniscal root tear with the development or worsening of tibiofemoral cartilage damage. Institutional review board approval and written informed consent from all subjects were obtained. A total of 596 knees with radiographically depicted osteoarthritis were randomly selected from the Multicenter Osteoarthritis study cohort. Cartilage damage was semiquantitatively assessed by using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) system (grades 0-6). Subjects were separated into three groups: root tear only, meniscal tear without root tear, and neither meniscal nor root tear. A log-binomial regression model was used to calculate the relative risks for knees to develop incident or progressing cartilage damage in the root tear group and the meniscal tear group, with the no tear group serving as a reference. In the medial tibiofemoral joint, there were 37 knees with isolated medial posterior root tear, 294 with meniscal tear without root tear, and 264 without meniscal or root tear. There were only two lateral posterior root tears, and no anterior root tears were found. Thus, the focus was on the medial posterior root tear. The frequency of severe cartilage damage (WORMS ≥ 5) was higher in the group with root tear than in the group without root or meniscal tear (76.7% vs 19.7%, P < .0001) but not in the group with meniscal but no root tear (76.7% vs 65.2%, P = .055). Longitudinal analyses included 33 knees with isolated medial posterior root tear, 270 with meniscal tear, and 245 with no tear. Adjusted relative risk of cartilage loss was 2.03 (95% confidence interval [CI]: 1.18, 3.48) for the root tear group and 1.84 (95% CI: 1.32, 2.58) for the meniscal tear group. Isolated medial posterior meniscal root tear is associated with incident and progressive medial tibiofemoral cartilage loss.

Spectrum of injuries associated with paediatric ACL tears: an MRI pictorial review

ObjectiveMagnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) injury are well known, but most published reviews show obvious examples of associated injuries and give little focus to paediatric patients. Here, we demonstrate the spectrum of MRI appearances at common sites of associated injury in adolescents with ACL tears, emphasising age-specific issues.MethodsPictorial review using images from children with surgically confirmed ACL tears after athletic injury.ResultsACL injury usually occurs with axial rotation in the valgus near full extension. The MRI findings can be obvious and important to management (ACL rupture), subtle but clinically important (lateral meniscus posterior attachment avulsion), obvious and unimportant to management (femoral condyle impaction injury), or subtle and possibly important (medial meniscocapsular junction tear). Paediatric-specific issues of note include tibial spine avulsion, normal difficulty visualising a thin ACL and posterolateral corner structures, and differentiation between incompletely closed physis and impaction fracture.ConclusionACL tear is only the most obvious sign of a complex injury involving multiple structures. Awareness of the spectrum of secondary findings illustrated here and the features distinguishing them from normal variation can aid in accurate assessment of ACL tears and related injuries, enabling effective treatment planning and assessment of prognosis.Teaching points• The ACL in children normally appears thin or attenuated, while thickening and oedema suggest tear.• Displaced medial meniscal tears are significantly more common later post-injury than immediately.• The meniscofemoral ligaments merge with the posterior lateral meniscus, complicating tear assessment.• Tibial plateau impaction fractures can be difficult to distinguish from a partially closed physis.• Axial MR sequences are more sensitive/specific than coronal for diagnosis of medial collateral ligament (MCL) injury.

Arthroscopic Primary Rotator Cuff Repairs in Patients Aged Younger Than 45 Years

The purpose of this study was to evaluate the mechanism of injury, patient characteristics, tear size, and clinical outcomes after arthroscopic primary rotator cuff repair of full-thickness tears in patients aged younger than 45 years. A total of 70 consecutive patients were reviewed in a retrospective, multicenter (2 institutions) study evaluating prospectively collected data. Fifty-three patients, with a mean age of 37.5 years (range, 16.2 to 44.9 years), were available for follow-up at a mean of 35.8 months (range, 13.8 to 59.1 months). Exclusion criteria included patients with revision procedures, repair of partial tears, and follow-up of less than 12 months. Follow-up evaluation included physical examination with dynamometer strength testing and clinical outcome measures including the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, pain score on a visual analog scale, and Simple Shoulder Test score. A total of 60% of the patients (32 of 53) had a traumatic etiology, with 38% (12 of 32) of these related to an athletic event. Of the tears, 36 (68%) were medium tears. Concomitant procedures performed at the time of rotator cuff repair included acromioplasty (51), biceps tenodesis or tenotomy (24), distal clavicle excision (10), anteroinferior stabilization (2), and labral repair (1). The mean postoperative ASES score was 84.6 (range, 21.6 to 100.0), with 2 patients recording ASES scores of less than 50 (21.7 and 41.7) at final follow-up. In the 38 patients available for clinical follow-up examination, forward flexion improved from 158.7° (range, 45° to 180°) to 168.4° (range, 120° to 180°) (P = .014). At the time of follow-up, no patients had undergone revision surgery. On the basis of poor clinical outcome scores, 2 patients (4.0%) were considered failures. Arthroscopic primary rotator cuff repair of full-thickness tears in patients aged younger than 45 years results in improved outcomes with regard to pain, subjective patient satisfaction, and shoulder function. Level IV, therapeutic case series.

Meniscal Extrusion and Spontaneous Osteonecrosis With Root Tear of Medial Meniscus: Comparison With Horizontal Tear

The incidence of root tears in patients with spontaneous osteonecrosis of the knee has been studied, but the incidence of spontaneous osteonecrosis of the knee in patients with medial meniscus root tears has not. We assessed the latter incidence and evaluated the characteristics of medial meniscus root tears by comparing clinical status, the degree of osteonecrosis, and meniscal extrusion in patients with horizontal tears. Sixty-three patients who were diagnosed with medial meniscus posterior horn tear and treated by arthroscopic surgery between March 2005 and March 2009 were evaluated retrospectively. Patients were divided into 2 groups, the root tear group (R group) and the horizontal tear group (H group). Functional scores and radiography, simple radiography, and magnetic resonance imaging were investigated. No significant differences in age, body mass index, and symptom duration were observed between the 2groups. The incidence of osteonecrosis was 12 of 36 knees (33.3%) in the R group and 4 of 27 (14.8%) in the H group. The mean absolute extrusion was 4.1 ± 0.7 mm and 3.5 ± 1.4 mm in the R and H groups, respectively (P= not significant). The mean relative percentage of extrusion in the R group (46.1% ± 9.0%) was greater than that in the H group (35.3% ± 13.2%) (P= .01). The degree of osteonecrosis (ellipsoidal volume) was also greater in the R group (423.1 ± 236.7 mm(3)) than that in the H group (175.8 ± 43.6 mm(3)) (P= .03). Though not significant, the visual analog pain score had a tendency to be more severe and knee scores had a tendency to be lower in the R group than in the H group. Medial meniscus root tears had a greater degree of meniscal extrusion and wider osteonecrosis than horizontal tears of the posterior horn related to loss of the main function of the meniscus. Level III, retrospective comparative study.

Setting Patients’ Expectations for Range of Motion After Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repair is a reliable option for symptomatic patients who have failed conservative treatments. Limited evidence exists regarding early rehabilitation time points (less than 1 year) and the influence of tear size. The authors sought to determine whether a difference exists in pre- and postoperative range of motion among small, medium, and large isolated rotator cuff tears treated arthroscopically. Patient- and tear-specific demographics were analyzed in a retrospective series of patients who had undergone arthroscopic rotator cuff repair. Two hundred seventy-four patients (153 [56%] men and 121 [44%] women; mean age, 53 years) were analyzed. Small tears (n=158 [58%]) were more common than medium (n=70 [25%]) and large (n=46 [17%]) tears. Shoulder range of motion was measured preoperatively and at 2 and 6 weeks, 3 and 6 months, and 1 year postoperatively. At nearly all time points pre- and postoperatively, large tears were significantly stiffer than small tears in external rotation and forward elevation (P<.05). It takes 1 year to fully regain external rotation after small and medium tears, whereas mild residual stiffness remains after large tears. Full forward elevation is restored by 3 months for small tears vs 6 months for medium and large tears. Significant tear size-dependent differences exist in shoulder range of motion after arthroscopic repair of isolated rotator cuff tears. These data can be used to manage patients' expectations for range of motion after arthroscopic rotator cuff repair to improve patient satisfaction.

New strabismus surgical techniques

Five new strabismus surgical procedures were developed by the authors and were presented as a workshop at the AAPOS annual meeting of the American Association for Pediatric Ophthalmology and Strabismus. They are summarized here to introduce these methods to the reader and provide surgeons with more options in approaching difficult strabismus problems. Diagnosis and correction of consecutive strabismus attributable to stretched scar is discussed. The pulley posterior fixation procedure is a unique approach to correct high accommodative convergence or to augment a maximal medial rectus recession. Diagnosis and repair of the partial avulsion (flap tear) of a rectus muscle allows correction of some restrictive strabismus following blunt trauma. The nasal myectomy of the inferior oblique muscle corrects persistent inferior oblique overaction without sacrificing the tether effect gained by a previous anterior transposition of the inferior oblique. The full advancement of the superior oblique tendon offers another option to strengthen a weak superior oblique muscle.

Long-Term Longitudinal Follow-up of Mini-Open Rotator Cuff Repair

Rotator cuff tears are a common clinical problem, and few long-term studies concerning the outcomes of rotator cuff repairs have been performed. The purpose of this study was to report the fifteen-year outcomes of arthroscopic subacromial decompression with mini-open rotator cuff repair. The study included seventy-nine patients who had undergone arthroscopic subacromial decompression with mini-open rotator cuff repair from 1993 to 1996. Outcomes were reviewed in 1997, 2002, and 2010. At the final review, forty-nine patients (forty-nine shoulders) were available or were suitable for evaluation. There were eight large tears, forty medium tears, and one small tear. The patients were assessed with the University of California, Los Angeles (UCLA) score at each evaluation. The mean age of the patients at the time of follow-up was 70.1 years, and the mean follow-up period was 15.6 years. At the time of final follow-up, the outcome was good or excellent in thirty-four patients (69%), fair in seven, and poor in eight. Three patients required a reoperation. Between the two and fifteen-year evaluations, twenty-nine patients (59%) had maintained their good or excellent result; the overall raw scores had deteriorated for fifteen patients (31%), and they had improved for twenty-four (49%). Forty-one patients (84%) were satisfied with the final outcome of the shoulder surgery. This study shows that arthroscopic subacromial decompression with mini-open rotator cuff repair can provide a lasting, durable, and satisfactory outcome for a large proportion of patients fifteen years after surgery. Patient satisfaction at the final evaluation did not necessarily correspond with a good or an excellent UCLA score.

Three-Dimensional Evaluation of Cyclic Displacement in Single-Row and Double-Row Rotator Cuff Reconstructions Under Static External Rotation

Background: The double-row suture bridge repair was recently introduced and has demonstrated superior biomechanical results and higher yield load compared with the traditional double-row technique. It therefore seemed reasonable to compare this second generation of double-row constructs to the modified single-row double mattress reconstruction. Hypothesis: The repair technique, initial tear size, and tendon subregion will have a significant effect on 3-dimensional (3D) cyclic displacement under additional static external rotation of a modified single-row compared with a double-row rotator cuff repair. Study Design: Controlled laboratory study. Methods: Rotator cuff tears (small to medium: 25 mm; medium to large: 35 mm) were created in 24 human cadaveric shoulders. Rotator cuff repairs were performed as modified single-row or double-row repairs, and cyclic loading (10-60 N, 10-100 N) was applied under 20° of external rotation. Radiostereometric analysis was used to calculate cyclic displacement in the anteroposterior (x), craniocaudal (y), and mediolateral (z) planes with a focus on the repair constructs and the initial tear size. Moreover, differences in cyclic displacement of the anterior compared with the posterior tendon subregions were calculated. Results: Significantly lower cyclic displacement was seen in small to medium tears for the single-row compared with double-row repair at 60 and 100 N in the x plane (P = .001) and y plane (P = .001). The results were similar in medium to large tears at 100 N in the x plane (P = .004). Comparison of 25-mm versus 35-mm tears did not show any statistically significant differences for the single-row repairs. In the double-row repairs, lower gap formation was found for the 35-mm tears (P ≤ .05). Comparison of the anterior versus posterior tendon subregions revealed a trend toward higher anterior gap formation, although this was statistically not significant. Conclusion: The tested single-row reconstruction achieved superior results in 3D cyclic displacement to the tested double-row repair. Extension of the initial rupture size did not have a negative effect on the biomechanical results of the tested constructs. Clinical Relevance: Single-row repairs with modified suture configurations provide comparable biomechanical strength to double-row repairs. Furthermore, as increased gap formation in the early postoperative period might lead to failure of the construct, a strong anterior fixation and restricted external rotation protocol might be considered in rotator cuff repairs to avoid this problem.

A retrospective analysis of risk factors for meniscal co-morbidities in anterior cruciate ligament injuries

Background:The association of meniscal cartilage injury with anterior cruciate ligament (ACL) injury is well documented in literature. The aim of this study was to examine the relative risk factors for meniscal pathology at the time of arthroscopic ACL reconstruction.Materials and Methods:A review of the case records including both in-patient and out-patient charts of all patients who underwent arthroscopic ACL reconstruction during the preceding 3 years was performed by either of the authors. The relative incidences of associated meniscal pathologies were analyzed in correlation with age, side of injury, time to surgery, mode of injury, and gender as the risk factors. Statistical analysis was performed to obtain individual data correlation.Results:A total of 192 patients underwent ACL reconstruction during the 3-year time frame. Of these, complete data sets were available for 129 patients. Analysis revealed that the only factor that was statistically significant in raising the risk of meniscal pathology was the time to surgery (P = 0.001). There was a significant increase in medial, lateral, and both meniscal tears noted in cases operated beyond 24 weeks. Further, the incidence of medial meniscal tears as well as lateral meniscal tears increased with delay in presentation for surgery (P = 0.004). Mode of injury, age at presentation, sex, and side were not significantly associated with an increased incidence of meniscal pathology.Conclusion:The single factor that significantly affects incidence of meniscal co-morbidity in ACL injury is the delay in presentation (i.e. the time to surgery). The incidence of lateral meniscal tears as well as medial meniscal tears increased with delay in surgery. This should guide us toward recommending all patients irrespective of age, gender, or mode of injury to undergo early reconstruction, thereby reducing the likelihood of developing meniscal pathology.

Long-Term Results of Rehabilitative Management with Extracorporeal Shockwave Therapy in Rotator Cuff Disease with Partial Tears

The purpose of this study is to evaluate the effects of rehabilitative approach using MJS and dynamic antigravity postural system (SPAD) with extracorporeal Shockwave therapy (ESWT) on rotator cuff syndrome associated tendon supraspinatus and infraspinatus medium tear (1–3 cm) of the tendons. In the last few years, ESWT has been proposed as an elective treatment in somatic diseases with encouraging short-term results. For this study the authors enrolled 108 patients who underwent 3 treatments with ESWT associated with 24 rehabilitation sessions over 3 weeks. Outcome measures were the VAS for pain and the Constant Murley Scale. The outcomes were measured pre-training, post-training and at 2, 4, 6 month follow-ups. Additional follow-up evaluation sessions were performed every year for 5 years by a telephone interview to evaluate changes in pain and function and the efficacy of treatment. Our study shows that the therapeutic efficacy of rehabilitative approach with ESWT in the rotator cuff syndrome with medium tears persists over time and significantly improves the patient's quality of life. The results obtained are certainly to be attributed to the biological mechanisms that ESWT are able to engage in tissues of the rotator cuff. The results seen at the conclusion of the treatment were maintained over the following years, thanks to the use of MJS and SPAD. In our opinion a conservative treatment with extracorporeal shock-wave (ESW), dynamic antigravity postural system (SPAD) and multi joint system (MJS) should be considered as an alternative and effective treatment for rotator cuff syndromes with medium tears.

ARTHROSCOPIC REPAIR OF SMALL AND MEDIUM TEARS OF THE SUPRASPINATUS MUSCLE TENDON: EVALUATION OF THE CLINICAL AND FUNCTIONAL OUTCOMES AFTER TWO YEARS OF FOLLOW-UP

Objective: To evaluate the clinical and functional outcomes from arthroscopic repairs on small and medium-sized tears of the supraspinatus muscle tendon. Methods: 129 cases of isolated small and medium tears of the supraspinatus muscle tendon were evaluated retrospectively. The average duration of pain was 29 months. The average joint range of motion comprised active elevation of 136°, lateral rotation of 58° and medial rotation at T12 level; and the preoperative functional UCLA score averaged 17 points. In all the cases, complete repair could be achieved. Results: The average score on the UCLA functional scale in the postoperative period was 32 points. The average length of follow-up was 39 months. Seventy-five cases (58%) had excellent results and 42 (32%) had good results. The average final active elevation was 156° with an average gain of 20°, and the average final lateral rotation was 57° with an average gain of 9°. Both of these were statistically significant (P < 0.05). The patients who underwent tenotomy of the long head of the biceps (LHB), with or without tenodesis, did not present statistically inferior functional outcomes, in comparison with the patients who only underwent decompression and lesion repair (P = 1.00). Fourteen cases (10.8%) presented complications during the postoperative period. Six (4.6%) developed adhesive capsulitis and four (3.1%) presented re-rupture of the tendon, proven by means of magnetic resonance imaging. Conclusions: Arthroscopic repair of small and medium tears of the supraspinatus muscle tendon provided a functional clinical improvement, with good and excellent results in 90% of the cases.

Accuracy of MRI in the Diagnosis of Meniscal Tears in Older Patients

The objective of our study was to determine the accuracy of MRI in diagnosing meniscal tears in older patients and the frequency with which abnormal MRI findings correlate with degeneration, fraying, and tears at arthroscopy. Ninety-two patients 50 years old or older who had undergone knee MRI followed by knee arthroscopy within 6 months were selected. Menisci were graded on a 5-point scale: 1, definitely no tear; 2, probably no tear; 3, indeterminate or equivocal; 4, probably a tear; and 5, definitely a tear. Meniscal signal changes, meniscal surface morphology, and extrameniscal abnormalities were noted. Operative notes were reviewed, and the sensitivity and specificity of MRI results were calculated. For medial tears, MRI had a sensitivity and specificity of 0.91 and 0.94, respectively, when grade 5 was considered a tear, 0.96 and 0.76 when grades 4 and 5 were considered a tear, and 0.99 and 0.47 when grades 3-5 were considered a tear. For lateral tears, MRI had a sensitivity and specificity of 0.73 and 0.91 when grade 5 was considered a tear, 0.88 and 0.80 when grades 4 and 5 were considered a tear, and 1.0 and 0.61 when grades 3-5 were considered a tear. The positive predictive values (PPVs) of MRI for the medial meniscus were 99%, grade 5; 57%, grade 4; 29%, grade 3; 25%, grade 2; and 0%, grade 1. For the lateral meniscus, the PPVs of MRI were 76%, grade 5; 36%, grade 4; 19%, grade 3; and 0%, grades 1 and 2. The accuracy of MRI for diagnosing meniscal tears in older patients is high and similar to that in younger patients when only definitive findings are considered a tear. The specificity decreases if equivocal or probable findings are considered a tear.

Dynamic Ultrasound With Varus Stress Used to Diagnose a Previously Concealed Medial Meniscus Extrusion

A 51-year-old man with a history of bilateral knee osteoarthritis presented with new posterior right knee pain and swelling refractory to intra-articular corticosteroid injections, viscosupplementation, and a medial unloader brace. Previous radiographs demonstrated medial compartment narrowing, and magnetic resonance imaging (MRI) revealed medial meniscus posterior horn degenerative tearing but no ligamentous injury. Despite consistently palpable posterior knee fullness on physical examination, neither repeat MRI nor conventional diagnostic musculoskeletal ultrasound revealed intra-articular effusion, a Baker cyst, or another mass lesion. TECHNIQUE Diagnostic ultrasound was repeated, this time with provocative knee maneuvers, with the use of a SonoSite M-Turbo ultrasound machine (SonoSite Inc., Bothell, WA) with a high-frequency linear transducer at a frequency of 17 MHz. When varus stress was applied with the knee in 30° of flexion, ultrasound revealed an obvious posterior horn medial meniscus extrusion that was previously undetectable in traditional, neutral knee positions. Furthermore, we observed no obvious joint opening in varus or valgus stress, suggesting no underlying medial collateral ligament injury. Figure 1 shows diagnostic ultrasound images in short axis (transverse relative to the medial meniscus) in both neutral and varus positions, with the corresponding illustrations below depicting the dynamic extrusion.

The natural evolution of neglected lesser tuberosity fractures in skeletally immature patients

Isolated avulsions of the lesser humeral tuberosity are rare injuries and only account for approximately 2% of all fractures of the proximal humerus. In skeletally immature patients, these fractures tend to be even more unusual. The fact that lesser tuberosity fractures in children are uncommon injuries is reflected in the paucity of literature on the management and outcome of these injuries. The first avulsion of the lesser tuberosity was described in 1895 in a 17-year-old boy with an ipsilateral humeral fracture. In 1985, White and Riley were the first to publish a formal report an isolated subscapularis avulsion in a child. So far, 33 cases of isolated avulsions of the lesser tuberosity in adolescent patients (patients aged < younger than 21 years) have been reported (Table I). One of the main reasons is that the diagnosis of this injury is not easy and often leads to a delayed diagnosis. We report 2 patients with neglected lesser tuberosity fractures during childhood and their late treatment. We also report a patient with an acute injury, treated surgically, with an excellent functional outcome.

Functional outcomes and structural integrity after double-pulley suture bridge rotator cuff repair using serial ultrasonographic examination

We evaluated the integrity and functional outcomes of rotator cuff tear after performing the double-pulley suture bridge (DPSB) repair technique according to the tear size by using serial ultrasonographic examinations. The study included 41 consecutive arthroscopic rotator repairs using the DPSB technique. The average follow-up was 28 months. We completed the serial ultrasonographic examinations and compared the results with the functional outcome using the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, the Korean Shoulder Scoring (KSS) system, and the University of California, Los Angeles (UCLA) score. The overall retear rate was 19.5% (8 of 41), comprising 50% (2 of 4) for massive tears, 18% (2 of 11) for large tears, 17% (4 of 23) for medium tears, and no failures for small tears (0 of 3). The retear rate was 17.6% (6 of 34) after complete repair and 28.6% (2 of 7) after repair with gap formation. Seventy-five percent (6 of 8) of retears were identified within 6 months after operation and 25% (2 of 8) were identified more than 1 year after repair. The functional outcomes of the intact group and the retear group according to the ASES score, the Constant score, the KSS, and the UCLA score were 96, 93, 94, and 33, and 90, 82, 87, and 31, respectively (P > .05). The overall retear rate after DPSB repair was 19.5% with 2 time periods of retear. The outcome improved independent of the tear size and the cuff integrity.