Abstract Purpose External snapping hip syndrome (ESHS) was historically attributed to isolated iliotibial band (ITB) contracture. However, the gluteus maximus complex (GMC) may also be involved. This study aimed to intraoperatively identify the ESHS origin and assess the outcomes of endoscopic treatment based on the identified aetiological type. Methods From 2008-2014, 30 consecutive patients (34 hips) with symptomatic ESHS cases refractory to conservative treatment underwent endoscopic stepwise “fan-like” release, gradually addressing all known reasons of ESHS: from the isolated ITB, through the fascial part of the GMC until a partial release of gluteus maximus femoral attachment occurred. Snapping was assessed intra-operatively after each surgical step and prospectively recorded. Functional outcomes were assessed via the MAHORN Hip Outcome Tool (MHOT-14). Results Twenty seven patients (31 hips) were available to follow-up at 24-56 months. In all cases, complete snapping resolution was achieved intra-operatively: in seven cases (22.6%) after isolated ITB release, in 22 cases (70.9%), after release of ITB + fascial part of the GMC, and in two cases (6.5%) after ITB + fascial GMC release + partial release of GM femoral insertion. At follow-up, there were no snapping recurrences and MHOT-14 score significantly increased from a pre-operative average of 46 to 93( p <0.001). Conclusion Intraoperative identification and gradual addressing of all known causes of ESHS allows for maximum preservation of surrounding tissue during surgery while precisely targeting the directly involved structures. Endoscopic stepwise “fan-like” release of the ITB and GMC is an effective, tailor-made treatment option for ESHS regardless of the snapping origin in the patients with possibility to manually reproduce the snapping.
Background: Contamination of sterilized surgical instruments is not a typically suspected source of increased infection rate, especially if no abnormalities in the sterilization process are detected. Purpose/Hypothesis: The purpose of this study was to report increased infection rates after knee ligament reconstructions due to undetectable sterilization process errors leading to residual moisture, not limited to a specific surgical tool. It was hypothesized that (1) residual moisture on surgical tools due to autoclave overloading would not be detected by autoclave self-diagnostics, chemical and biological tests, or organoleptic assessment and (2) this kind of contamination may elevate infection rates, especially in knee intra-articular reconstruction procedures. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of increased postoperative knee infection rate between January 2013 and January 2015 was performed. The inclusion criteria were all articular procedures. The exclusion criteria were joint arthroplasties, fractures, and open joint wounds. Criteria defining postoperative joint infections were as follows: (1) pain and effusion relapse and loss of achieved range of motion; (2) opaque/cloudy fluid on arthrocentesis; (3) fever >37.5°C lasting ≥3 days; and (4) ≥2-fold elevation in C-reactive protein levels, with symptoms onset within 21 days postoperatively. A negative culture result did not exclude a postoperative joint infection diagnosis and treatment. The data were summarized, and the infection rates of given subgroups were compared with a 2-tailed Fisher exact test. A risk ratio (RR) with 95% CIs was calculated. Results: Out of 533 orthopaedic procedures screened for inclusion, 4 joint arthroplasties, 7 fractures, and 2 open joint wounds were excluded. The remaining 520 articular procedures were included in the study—118 knee cruciate ligament reconstructions, 130 knee nonreconstruction arthroscopies, and 272 knee extra-articular/other joints arthroscopic and sports procedures. A total of 21.2% of knee intra-articular ligament reconstructions were complicated by postoperative joint infections, compared with 1.5% of knee nonreconstruction arthroscopies (RR, 13.8 [95% CI, 3.3-56.9]; P < .001) and 0.4% of knee extra-articular/other joints arthroscopic and sports procedures (RR, 57.6 [95% CI, 7.9-420.4]; P < .001). The source of the increased infection rate was identified as residual moisture on surgical tools due to autoclave overloading. This residual moisture was not detected by autoclave self-diagnostics, chemical and biological tests, or organoleptic assessment. After reducing the insert of surgical tools in the autoclave, the infection rate in the next 2 years after knee reconstructive procedures returned to <1% ( P < .001). Conclusions: Our study demonstrated that residual moisture after the sterilization process may be an underestimated source of postoperative joint infections, undetectable in routine procedures and tests. Overcrowding of surgical equipment in the autoclave may be a root cause of this residual moisture identified. This kind of contamination may elevate the infection rate, especially in knee intra-articular reconstruction procedures.
Mucoid degeneration of the ACL (MDACL, ACL ganglion cysts) is a disease involving ACL thickening due to accumulation of mucoid substance and fiber degeneration with possible formation of "ganglions". Clinically, it leads to anteroposterior impingement and painful limitation of knee range of motion due to impingement of the anterior portion of the thickened ACL with the intercondylar notch during knee extension and the thickened posterior part of the ligament with posterior structures of the knee in flexion. Different treatment methods have been described, including total or partial resection of the ACL degenerative fibers. However, these techniques do not allow for ACL preservation and are associated with a risk of postoperative instability. Also, most procedures treat anterior impingement only. Therefore, the aim of this technical note is to present an arthroscopic technique allowing for minimally invasive anteroposterior ACL decompression. The technique is focused on evacuation of the interfibrous mucoid substance, ganglions, and bony decompression, as well as maintenance of ligament integrity. Its greatest advantage is that it is safe and ACL-preserving yet allows for comprehensive treatment of all intra- and extra-ligamentous possible reasons of MDACL origin and promoting good healing conditions.
Abstract Purpose Accurate knowledge of greater palatine foramen (GPF) and greater palatine canal (GPC) anatomy is necessary to avoid injury to the greater palatine artery (GPA) when performing a variety of anesthesiologic, dental or surgical procedures. The aim of this paper was to perform a systematic review and meta-analysis of literature on the anatomy and localization of bony structures associated with the GPA, namely the GPF and GPC. Methods A systematic literature search was performed using PubMed, Embase, ScienceDirect, and Web of Science databases. Seventy-five studies were included in the meta-analysis ( n = 22,202 subjects). Results The meta-analysis showed that the GPF is positioned 17.21 mm (95% CI = 16.34–18.09 mm) from the posterior nasal spine, 2.56 mm (95% CI = 1.90–3.22 mm) from the posterior border of the hard palate, 46.24 mm (95% CI = 44.30–48.18 mm) from the anterior nasal spine, 15.22 mm (95% CI = 15.00–15.43 mm) from the midline maxillary suture, 37.32 mm (95% CI = 36.19–38.45 mm) from the incisive foramen, and opposite the third maxillary molar (M3) in 64.9% (58.7–70.7%) of the total population. Conclusion An up-to-date, comprehensive analysis of GPF and GPC clinical anatomy is presented. The results from this evidence-based anatomical study provides a unified set of data to aid clinicians in their practice.
58-year-old male presented with knee extension contracture (25°) with iatrogenic fixed anterior tibial subluxation. Consecutive arthroscopic arthrolysis, manipulation under anesthesia, and quadriceps-Z-plasty during one surgery failed to restore flexion. Therefore, shortened posterior cruciate ligament was released, which eliminated subluxation and allowed 115° flexion. Despite physiotherapy, flexion progressively decreased to 70° postoperatively. Revision quadricepsplasty by transverse incisions restored 120° of flexion maintained at 31-months follow-up. International Knee Documentation Committee increased 4/87- > 50/87, Knee injury and Osteoarthritis Outcome 7/100- > 68/100 at follow-up. Posterior cruciate ligament release and repeated quadricepsplasty could be a viable salvage option in severe extension contracture with fixed anterior tibial subluxation.
