Proximal Avulsion Research Articles

Successful conservative treatment for a subtotal proximal avulsion of the rectus femoris in an elite soccer player

Successful conservative treatment for a subtotal proximal avulsion of the rectus femoris in an elite soccer player

Proximal Adductor Avulsion Injuries: Outcomes of Surgical Reattachment in Athletes.

Background:Sports-related groin injuries are common among athletes. However, traumatic proximal adductor avulsion injuries are relatively rare groin injuries in the athletic population, with limited case reports describing suture anchor repair.Purpose:To report on the outcomes of surgical reattachment of proximal adductor avulsion injuries in athletes utilizing a suture anchor repair technique.Study Design:Case series; Level of evidence, 4.Methods:Prospective data were collected on patients undergoing surgical reattachment of proximal adductor avulsion injuries from December 2012 to May 2015 by a single surgeon. Six athletes presented after a traumatic sports-related injury with disabling groin pain, adductor weakness, and magnetic resonance imaging confirmation of fibrocartilage avulsion of the proximal adductor with retraction. Patient-reported outcomes (Hip Outcome Score–Activities of Daily Living [HOS-ADL] and Hip Outcome Score–Sport Specific [SS] subscales, modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) were collected preoperatively and at a minimum 2-year follow-up.Results:The latest follow-up of each patient averaged 33.4 months postoperatively (range, 25-42.5 months). All patients returned to sporting activities, with 1 minor wound complication that resolved. Paired-samples t tests indicated that the mean latest postoperative scores for all patients were significantly better than their mean preoperative scores (HOS-ADL: 99.0 vs 43.2, HOS-SS: 98.9 vs 8.3, and mHHS: 97.1 vs 44.6, respectively; P < .001 for all). Similarly, there was a significant improvement in mean postoperative VAS scores for all patients (from 89.2 to 2.2; P < .001).Conclusion:Patient-reported outcomes offer an objective measure of hip function and pain control. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance and a predictable return to sport.

Suture Pullout Technique of Acute Anterior Cruciate Ligament Femoral Avulsion Repair

It was in the early 1900s that anterior cruciate ligament (ACL) repair was first described with its resurgence in the mid-1900s. It however failed to gain popularity because of unsatisfactory early outcomes as a result of poorly selected patients. We describe a suture pullout technique of acute ACL repair in a carefully selected cohort of patients. Healing capabilities similar to that of the proximal medial collateral ligament have been shown in the proximal ACL avulsions. Adding microfracture of the lateral wall of the notch further enhances the healing environment by countering the synovial fluid environment. Acute ACL repair when performed in a carefully selected patient leads to good results and saves the patient of a reconstruction procedure.

Primary anatomical repair of proximal acl ruptures with suture anchors: 1 year follow-up

Aims and Objectives: ACL injuries are common. Going trough the literature, numerous studies show a healing potential for the repair of acl tears, histologically comparable to mcl healing. In this study, the postoperative follow-up after acl preservation was examined up to 1 year. Materials and Methods: We performed a prospective clinical follow-up in 13 sportive patients (case series, no comparison group). Inclusion criterias were a proximal avulsion tear of the acl, patient age under 50 years and surgery within 6 weeks after trauma. In an arthroscopic procedure, the quality of the acl tissue was examined and judged if suitable for a repair. Concomitant injuries were treated at the same time. Using a suture passer, a Bunnell stitch was created with a nonabsorbable suture through the anteromedial bundel as through the posterolateral bundel. The footprint of the acl was prepared with an awl for liberation of stem cells. The bundels were reattached to the origins of the footprint with two absorbable suture anchors. No drain was used. The postoperative protocoll was as follows: partial weight bearing for 4 weeks and wearing a protective brace with a limitation for extension and flexion of 0-0-90° for 4 weeks. At week 5, the brace was unlocked and range of motion and weight bearing were gradually increased at the level of comfort. Patients were examined at 6 weeks, 3 months, 6 months and 12 months after surgery. The stability was tested with the KT 1000, the subjective outcome with the ACL-RSI and the clinical outcome using the Tegner activity score, the Lysholm score, the KOOS score and the IKDC objective form. X-rays were done after 3 and 12 months, a MRI after 6 months. Between months 4 and 6, patients returned to their previous level of sport. Results: All 13 patients have been included in the 1 year follow-up. No rerupture was seen. There have been no major complications, as minor complications we observed 2 effusions of the knee 7 days after surgery which were treated with aspiration. The patients presented the following outcomes after 1 year: the mean anterior translation difference in the KT 1000 was 0,85 mm; the median Tegner activity score was 6 (range from 5 to 9); the median Lysholm score 95,9; the median KOOS was 94,5. The IKDC was A in 9 of 13 patients, B in 3 and C in 1 patient. The ACL-RSI in the 6 week follow-up was 64,14%, indicating a high level of subjective stability and confidence. This score increased gradually to the 1 year follow-up (94,5%). X-rays showed no pathologic bone signal or tunnel widening. MRI showed appropriately positioned and continous ligaments with scar tissue and an irregular signal due to suture material. Conclusion: In this study, the results 1 year after surgery with an anatomical repair of the acl are promising. Nearly all patients returned to their previous sports level, indicating healing potential for acl injuries. If patient selection is done carefully, this technique is a supplement in the treatment algorithm of acl injuries.

Primary Anterior Cruciate Ligament Single-Bundle Repair With Augmentation for a Partial Anterior Cruciate Ligament Tear

Although anterior cruciate ligament (ACL) reconstruction remains the gold standard for the treatment of ACL tears, repair is regaining popularity as a treatment option for proximal or distal ACL avulsions. Historically, ACL repairs had poor outcomes. To remedy this, techniques were developed using graft-based augmentation but never gained widespread popularity. Recently, there has been a renewed interest in primary ligament repairs, with newer techniques incorporating modern synthetic materials to augment the repair site. The term “internal bracing,” or ligament repair with augmentation, has been used to describe the new philosophy for primary ligament repair and augmentation. We present our technique for arthroscopic primary ACL repair with augmentation for a proximal posterolateral bundle tear. The advantages of this technique include preservation of the intact fibers of the anteromedial bundle, intuitive suture augmentation with standard ACL tunnel placement techniques, and the ability to calibrate ligament tension.

Primary Anterior Cruciate Ligament Repair With Augmentation

Anterior cruciate ligament (ACL) tears are usually managed by reconstruction with autograft or allograft, but primary repair in carefully selected patients is a reasonable option. Proximal avulsions presenting early with excellent tissue quality are amenable to repair and healing. Restoration of native ACL preserves its proprioceptive and kinematic functions. A repair is less invasive and avoids graft-related problems, and faster rehabilitation is possible. Protection for the repair in the early stages will allow better healing. We present our technique of ACL repair using knotless suture anchors with high-strength sutures and protection using high-strength sutures tapes inserted through the same anchors.

Clinical Outcomes of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears Are Maintained at Mid-term Follow-up

To assess the mid-term clinical outcomes in patients with proximal avulsion anterior cruciate ligament (ACL) tears undergoing arthroscopic primary repair with suture anchors. The first 11 consecutive patients with proximal avulsion tears treated with arthroscopic primary repair were evaluated at mid-term (minimum 5-year) follow-up. Physical examination was performed; laxity examination consisting of the Lachman, pivot-shift, and anterior drawer tests was performed; and patients were asked to complete the Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, and International Knee Documentation Committee (IKDC) questionnaires. Of the 11 patients, 10 were seen at a mean follow-up of 6.0 ± 1.5years (range, 4.8-9.2years). One patient was lost to follow-up, in whom failure had already occurred at short-term follow-up. One additional patient underwent reoperation for a medial meniscus tear and also had a partial ACL tear; this patient was clinically stable at last follow-up. All patients had full range of motion. Nine patients had negative Lachman and negative pivot-shift examination findings (IKDC score of A), and 1 patient had a 1A Lachman result and 1+ pivot-shift result (IKDC score of B). The mean Lysholm score was 96.0 ± 4.5 (range, 88-100); modified Cincinnati score, 95.6 ± 7.4 (range, 80-100); Single Assessment Numeric Evaluation score, 95.4 ± 5.4 (range, 85-100); preinjury Tegner score, 7.2 ± 1.2 (range, 5-9); postoperative Tegner score, 6.6 ± 1.8 (range, 3-9); and IKDC subjective score, 92.3 ± 11.3 (range, 64-100). The clinical outcomes of arthroscopic primary repair of proximal ACL tears with suture anchors are excellent and are maintained at mid-term follow-up in a carefully selected subset of patients with proximal tears and excellent tissue quality. Level IV, therapeutic case series.

Nonreconstruction Options for Treating Medial Ulnar Collateral Ligament Injuries of the Elbow in Overhead Athletes.

This review aims to describe the nonreconstructive options for treating ulnar collateral ligament (UCL) injuries ranging from nonoperative measures, including physical therapy and biologic injections, to ligament repair with and without augmentation. Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP). In some patients, repair of the UCL has shown promising return to sport rates by using modern suture and suture anchor techniques. Proximal avulsion injuries have shown the best results after repair. Currently, there is growing interest in augmentation of UCL repair with an internal brace. The treatment of UCL injuries involves complex decision making. UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes. However, nonreconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries. Future research comparing reconstructive versus nonreconstructive options is necessary.

Arthroscopy-aided fixation for metacarpophalangeal joint collateral ligament injury accompanied by osteochondral avulsion injury: our results and surgical technique

Aim: Though metacarpophalangeal joint collateral ligament injuries are commonly observed, the presence of accompanying avulsed osteochondral fragment or aponeurosis injury in adult patients is a situation that may require definite surgical treatment. Our study investigated patients attending our clinic after acute hand trauma with radial or ulnar collateral ligament injury who underwent arthroscopy-aided surgical treatment and who regularly attended check-ups to examine the efficacy and results of arthroscopy-aided treatment for collateral ligament injury of the metacarpophalangeal joint. Material and Methods: The study assessed fracture healing, joint movement angles and complications of 11 patients who attended our hand surgery department from December 2015 to April 2018 who had ulnar or radial collateral ligament injury of the metacarpophalangeal joint with accompanying osteochondral avulsion fracture repaired with the aid of arthroscopy with at least 1 year of continuous attendance at check-ups. Results: Four patients had 1st proximal finger avulsion fracture accompanying ulnar collateral ligament injury, four patients had 2nd proximal finger avulsion fracture accompanying ulnar collateral ligament injury, 1 patient had 4th finger and 2 patients had 5th finger proximal phalanx fractures accompanying radial collateral ligament injury. The patients’ avulsion fractures and ligament injuries healed without problem, 2 patients had limited joint movement angles and 1 patient developed complex regional pain syndrome. Conclusion: It is considered that the results of arthroscopy-aided collateral ligament injury repair and avulsed fragment fixation are good and perfect healing.

Primary single suture anchor re-fixation of anterior cruciate ligament proximal avulsion tears leads to good functional mid-term results: a preliminary study in 12 patients

BackgroundCurrent studies demonstrate encouraging short-term results after primary anterior cruciate ligament (ACL) suture anchor repair. However, earlier studies reported deterioration of knee function at 5-year follow-up following good clinical short-term recovery. Therefore, the aim of this study was to evaluate clinical long-term results after primary ACL repair at a minimum 5-year follow-up.MethodsIn a retrospective study, 13 patients were included between 2009 and 2012. Inclusion criteria were an acute proximal, femoral avulsion tear of the ACL with good tissue quality and sagittal instability in a healthy, demanding patient. Patients suffering proximal tibial fractures, arthrosis, or multiligamentous injuries of the knee were excluded. The ACL was anchored to the footprint by a single 2.9-mm push lock anchor, followed by additional microfracturing. For follow-up, patients were evaluated according to Lysholm score, modified Cincinnati score, and Tegner activity score. Clinical examination was performed using Lachman and pivot-shift testing and range of motion and sagittal stability measurement, using a Rolimeter.ResultsMean follow-up was 79 (range 60 to 98) months. One patient was lost to follow-up, and 11 out of 12 patients were examined clinically. Eight patients achieved good subjective and clinical outcome. One patient suffered an early re-tear, and one patient with additional patellar tendon tear and one patient with polyarthritis demonstrated poor subjective and clinical results due to lasting instability. Seven out of 12 patients reached preoperative Tegner activity score postoperatively again. The mean Lysholm score was 85.3 points, mean subjective IKDC score was 87.3 points, and mean modified Cincinnati score was 83.8 points. Rolimeter measurements demonstrated a mean side-to-side difference of 2 (range 1–5) mm.ConclusionIn the current study, primary surgical re-fixation of proximal, femoral ACL avulsion tears using single suture anchor repair resulted in good to excellent clinical mid-term outcomes. However, in cases of additional serious damage to extensor structures or systemic rheumatic disease, loss of function and unsatisfying clinical results occurred. Further prospective randomized controlled trials are necessary to confirm the encouraging long-term results of this study.Trial registrationBavarian National Medical Chamber of Physicians, file number 2016-095. German Clinical Trials (DRKS00013059)

The pyramidalis\u2013anterior pubic ligament\u2013adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept

PurposeAdductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.MethodsA layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.ResultsThe pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.ConclusionThe study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

The Locations of Anterior Cruciate Ligament Tears in Pediatric and Adolescent Patients: A Magnetic Resonance Study.

Recently, a resurgence of interest has been noted in anterior cruciate ligament (ACL) preservation in pediatric and adolescent patients. Different tear types, defined by their tear location, require different preservation techniques: proximal and distal avulsion tears can be treated with arthroscopic primary repair, whereas primary repair with biological scaffold has been proposed for midsubstance tears. The goal of this study was to assess the distribution of different tear types in pediatric and adolescent patients, as these are currently unknown. A retrospective search in an institutional radiographic database was performed for patients under 18.0 years undergoing knee magnetic resonance imaging (MRI) for ACL tears between June 2005 and June 2016. Patients with reports of chronic tears, partial tears, and multiligamentous injuries were excluded.Tear locations were graded using MRI as: proximal avulsion (distal remnant length >90% of total length; type I), proximal (75% to 90%; type II), midsubstance (25% to 75%; type III), distal (10% to 25%; type IV), and distal avulsion (<10%; type V). A total of 274 patients (59% girls; mean±SD age, 15.1±2.1 y; range, 6.9 to 18.0 y) were included. Frequency of type I tears was 15%, type II 23%, type III 52%, type IV 1%, and type V 8% (of which 7% had bony avulsion).Prevalence of tear types varied with age. At age 6 to 10 years, 93% were type V (bony) avulsion tears. At age 11 to 13 years, 32% were type I, 16% type II, 32% type III, and 16% type V. At age 14 to 17 years, type III tears were more common (57%) than type I (14%), type II (25%) and type V (2%) tears. It was noted that the ACL was torn at different locations depending on the patients' age. These data provide more information on the potential application for ACL preservation in pediatric and adolescent patients. Future studies correlating these findings with arthroscopy are needed before using MRI for preoperative planning of ACL preservation surgery. Diagnostic level III.

Elbow Ulnar Collateral Ligament Reconstruction Using a 4-Strand Docking Plus Technique

The “Docking Plus” technique for elbow ulnar collateral ligament (UCL) surgery is described in the following text and video. Depite the general success of UCL surgery, significant rates of retear and failure of return to competition persist. Hypothesized reasons for UCL surgery failure include insufficient graft strength (midsubstance tears), insufficient graft tensioning (functional UCL insufficiency, valgus extension overload), and insufficient healing of graft to bone (proximal avulsions). This technique is meant to incorporate the best aspects of the previously described techniques for UCL reconstruction to create a larger, stronger, better-tensioned graft with a larger healing surface area to bone, a lower retear rate, and a lower risk of complications. The Docking Plus technique has been used since 2012.

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb.

Purpose and hypothesisAlthough sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL.MethodsThis study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis.ResultsIn total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9–90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site.ConclusionsThe results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries.

Lesões dos isquiotibiais: artigo de atualização

Hamstring (HS) muscle injuries are the most common injury in sports. They are correlated to long rehabilitations and have a great tendency to recur. The HS consist of the long head of the biceps femoris, semitendinosus, and semimembranosus. The patient's clinical presentation depends on the characteristics of the lesion, which may vary from strain to avulsions of the proximal insertion. The most recognized risk factor is a previous injury. Magnetic resonance imaging is the method of choice for the injury diagnosis and classification. Many classification systems have been proposed; the current classifications aim to describe the injury and correlate it to the prognosis. The treatment is conservative, with the use of anti‐inflammatory drugs in the acute phase followed by a muscle rehabilitation program. Proximal avulsions have shown better results with surgical repair. When the patient is pain free, shows recovery of strength and muscle flexibility, and can perform the sport's movements, he/she is able to return to play. Prevention programs based on eccentric strengthening of the muscles have been indicated both to prevent the initial injury as well as preventing recurrence.

The Location of Anterior Cruciate Ligament Tears: A Prevalence Study Using Magnetic Resonance Imaging.

Background:Over the past decade, there has been a resurgence of interest in anterior cruciate ligament (ACL) preservation. Proximal and distal avulsion tears have been treated with arthroscopic primary repair, while augmented repair, remnant tensioning, primary repair with biological scaffold, and remnant preservation have been proposed for different types of midsubstance tears. Currently, the incidence of these different tear types is unknown.Purpose:To propose a magnetic resonance imaging (MRI) classification system for different tear types based on clinical relevance and to assess the distribution of these different ACL tear types.Study Design:Case series; Level of evidence, 4.Methods:A retrospective search in an institutional radiographic database was performed for patients who underwent knee MRI at our institution between June 2014 and June 2016. Patients younger than 18 years and those with reports of chronic tears, partial tears, multiligamentous injuries, were excluded. Tear types were graded as proximal avulsion (distal remnant length >90% of total ligament length, type I), proximal (75%-90%, type II), midsubstance (25%-75%, type III), distal (10%-25%, type IV), and distal avulsion (<10%, type V). An orthopaedic surgeon, a radiologist, and a research fellow graded the tear type on 30 MRIs to determine reliability, and the research fellow graded all MRIs. Inter- and intraobserver reliability were measured using kappa statistics.Results:A total of 353 patients (57% male; mean age, 37.1 years; range, 18.1-81.2 years) were included. Interobserver reliability was 0.670 (95% confidence interval, 0.505-0.836), and intraobserver reliability ranged from 0.741 to 0.934. Incidence of type I tears was 16%, type II tears 27%, type III tears 52%, type IV tears 1%, and type V tears 3% (2.5% with bony avulsion). Type I tears were more common in patients older than 35 years compared with those younger than 35 years (23% vs 8%; P < .001).Conclusion:This classification system was reliable in assessing tear location in acute ACL injuries. Type I tears were seen in 16%, type II in 27%, and type III in 52% of patients in our cohort. These data suggest that there may be greater potential application for ACL preservation techniques.

Hamstring injuries: update article

Hamstring (HS) muscle injuries are the most common injury in sports. They are correlated to long rehabilitations and have a great tendency to recur. The HS consist of the long head of the biceps femoris, semitendinosus, and semimembranosus. The patient's clinical presentation depends on the characteristics of the lesion, which may vary from strain to avulsions of the proximal insertion. The most recognized risk factor is a previous injury. Magnetic resonance imaging is the method of choice for the injury diagnosis and classification. Many classification systems have been proposed; the current classifications aim to describe the injury and correlate it to the prognosis. The treatment is conservative, with the use of anti-inflammatory drugs in the acute phase followed by a muscle rehabilitation program. Proximal avulsions have shown better results with surgical repair. When the patient is pain free, shows recovery of strength and muscle flexibility, and can perform the sport's movements, he/she is able to return to play. Prevention programs based on eccentric strengthening of the muscles have been indicated both to prevent the initial injury as well as preventing recurrence.

Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears: No Deterioration at Mid-Term Follow-Up

Open primary repair of the anterior cruciate ligament (ACL) was a popular surgical treatment for ACL injuries in the 1970s and 1980s. Although the short-term outcomes were excellent, the results deteriorated at mid-term follow-up, which ultimately led to the abandonment of open primary repair. Recently, however, excellent short-term outcomes of primary repair using arthroscopy in 11 patients with only proximal ACL tears have been reported with one failure (9%) and good clinical outcomes. Goal of this study was to assess the mid-term outcomes of these patients. The first 11 consecutive patients with proximal avulsion tears and excellent tissue quality treated with arthroscopic primary repair were evaluated at mid-term follow-up. Physical examination and laxity examination were performed and patients completed several outcome questionnaires. Eleven patients were seen at mean follow-up of 5.6 years (range: 4.2–8.4 years). No patients had failure of the repair besides the earlier failure at short-term follow-up (9%). One additional patient (9%) underwent reoperation for a medial meniscus tear. The other ten patients had full range of motion, negative Lachman test, eight patients had a negative pivot shift and two patients +1 pivot shift. IKDC objective score was A in 8 patients and B in 2. Lysholm was 97 (range 92-100), modified Cincinnati 97 (range 87-100), mean SANE score 96 (range 90-100), preinjury Tegner 7.2 (range 5-9), and postoperative Tegner 6.8, (range 3-9) and IKDC subjective score 95 (range 82-100). Seven patients had a MRI that showed ligament continuity. Historically, studies showed that the results of open primary repair deteriorated at mid-term follow-up. With appropriate patient selection (only treating patients with proximal tears and excellent tissue quality) and arthroscopy, results in this study did not deteriorate at mid-term follow-up. Arthroscopic primary repair of proximal ACL tears is an excellent, minimally invasive treatment option in these patients.

Novel Spiked-Washer Repair Is Biomechanically Superior to Suture and Bone Tunnels for Arcuate Fracture Repair.

Injuries to the posterolateral corner of the knee can lead to chronic degenerative changes, external rotation instability, and varus instability if not repaired adequately. A proximal fibula avulsion fracture, referred to as an arcuate fracture, has been described in the literature, but a definitive repair technique has yet to be described. The objective of this study was to present a novel arcuate fracture repair technique, using a spiked-washer with an intramedullary screw, and to compare its biomechanical integrity to a previously described suture and bone tunnel method. Ten fresh-frozen cadaveric knees underwent a proximal fibula osteotomy to simulate a proximal fibula avulsion fracture. The lateral knee capsule and posterior cruciate ligament were also sectioned to create maximal varus instability. Five fibulas were repaired using a novel spiked-washer technique and the other 5 were repaired using the suture and bone tunnel method. The repaired knees were subjected to a monotonic varus load using a mechanical testing system instrument until failure of the repair or associated posterolateral corner structures. Compared with the suture repair group, the spiked-washer repair group demonstrated a 100% increase in stiffness, 100% increase in yield, 110% increase in failure force, and 108% increase in energy to failure. The spiked-washer technique offers superior quasi-static biomechanical performance compared with suture repair with bone tunnels for arcuate fractures of the proximal fibula. Further clinical investigation of this technique is warranted and the results of this testing may lead to improved outcomes and patient satisfaction for proximal fibula avulsion fractures.

Immediate successful renal autotransplantation after proximal ureteral avulsion fallowing ureteroscopy: a case report

The patient was a 51-year-old lady with left flank colicky pain accompanied with nausea and vomiting for a month. Transurethral lithotripsy and ureteral stent placement was considered for the patient. The patient had a narrow ureteral lumen and while bringing the ureteroscope out, ureteral avulsion occurred at a distance approximately 4 cm from ureteropelvic junction. After bringing the uretroscope out, the avulsed ureter was observed hanging at the tip of the ureteroscope. Anastomosis of the ureter to the bladder was accomplished with Lich–Gregoir technique. A drainage tube was inserted at the site of incision and the surgical wound closed. The patient was discharged with acceptable general condition after 3 days and the drainage tube removed. The ureteral stent was removed 4 weeks later by cystoscopy. An ultrasound imaging study of the genitourinary system 8 months into the patients follow up showed normal size, echo and cortical thickness in the operated kidney after renal autotransplantation.