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Surgical reconstruction of the medial collateral ligament (MCL) can be challenging during multi-ligament knee injury surgery due to the limited working space. There is risk of collision between the guide pin, pulling sutures, reamer, tunnel, implant, and graft of the different ligament reconstructions. In this Technical Note, we detail our senior author’s technique for superficial MCL reconstruction using suture anchors and cruciate ligament reconstruction with all-inside techniques. The technique mitigates the risk of collision by confining the reconstruction process and implants for MCL fixation on the medial femoral condyle and medial proximal tibia.

The primary aim of the study is to compare the patient outcome in medial patellofemoral ligament reconstruction (MPFLR) or MPFLR concurrent with trochleoplasty (MPFLR + TP) and correlate it with the degree of trochlear dysplasia (TD). The secondary aim is to review TD classification, outcome measure, chronological and geographical trend of such studies in the past decade. A systemic review of the literature in the past decade on studies of patients with patella instability and underwent either a MPFLR or MPFLR + TP. The degree of TD with the patient outcome was correlated and compared between the 2 groups. The TD classification, outcome measures, chronological and geographical trends of these studies were documented. There is no statistical difference in the overall improvement in the compared outcome scores between the 2 groups. However, the MPFLR studies reported a total of 16 re-dislocation in contrast to none in the MPFLR + TP studies. The 24 selected studies in the current review utilized different TD classification as well as outcome measures. A more homogeneous subgroup of 12 studies utilized Dejour classification as well as Kujala score that enabled comparison and showed no significant difference in outcome. The highest number of MPFLR publications was in 2019 and was from North and South Americas, Asia and Europe. The MPFLR + TP studies were from Europe during 2013 to 2017. Though there is an overall improvement in post-operative outcomes scores with no statistical significance between MPFLR and MPFLR + TP, the documented re-dislocations in the MPFLR studies suggested an undetermined zone where the choice of procedure could result in a different outcome. The current review did not show correlation between the degree of TD with the patient outcome to provide a clear indication for either procedure according to the degree of TD. The diverse TD classifications and varied outcome measures indicated the need for standardization and consistency in documentation to guide the treating clinician in the choice of procedure. MPFLR was more commonly performed and studied than MPFLR + TP in the past decade.

Meniscal repairs are preferred to meniscectomies to preserve meniscal function and mitigate the risk of degeneration. However, repair of a chronic and displaced bucket handle tear of the meniscus can be technically challenging. We introduce a systematic method for assessment, reduction, repair, or salvage in this situation with an aim of reducing operating time and improving the chance of a favorable outcome. This technique describes repair of a bucket handle tear on the medial meniscus with displacement into the intercondylar notch. An arthroscopic probe is used for reduction and suture tension (push-and-pull technique) when using an all-inside suture device (FAST-FIX 360 repair system; Smith & Nephew) on the middle and posterior part of the tear. The anterior part of the tear is repaired with an outside-in method. If reduction is not possible, then a salvage reduction and hybrid repair is carried out instead. Postoperatively, patients will be nonweight-bearing on the operated limb, and range of motion restricted from 0 to 90° for 6 weeks, with the aim of resuming running by 6 months., Technique Video Video 1 This shows the repair technique used on a medial meniscus chronic bucket handle tear in a right knee flexed to 90°. Assessment of adequate reduction is done with the scope in the anteromedial portal and the probe in the anterolateral portal. There should be no gap between the inner and outer meniscal segments, and the segment should remain reduced without the probe on it. The FAST-FIX 360 all-inside repair system is then used to place 2 suture anchors above and below the friable torn segment. The probe is used to push on the anterior part of the knot and below the tensioning length to counter the pull or tensioning of the suture, to control the tightening of the suture loop and reduce the risk of suture cut out. The same method is used to repair the posterior half of the tear. To perform an anterior repair, the scope is switched to the anterolateral portal. The repair position is determined and blunt dissection down the capsule is performed. One trocar needle is placed above and one below the torn segment. This is for the same reason to minimize the risk of further damage to a friable and thin torn segment. After passing the sutures, the meniscus reduction is optimized with the probe via the anteromedial portal.

The anatomical dual bundle medial patellofemoral ligament (MPFL) reconstruction technique is one of the surgical techniques used to treat lateral patellar instability. This commonly involves the creation of two patella bone tunnels through which the limbs of the grafts are inserted. The surgical risks include patellar fracture and penetration of patellofemoral articular surface. Thus, an easily reproducible intra-operative guiding parameter is useful to reduce such complications. The aim of this study is to demarcate a safe working zone in the axial plane for the patella tunnels. In this pilot study, we projected patella bone tunnels on the MRI knee images of 201 male patients with intact MPFLs. Two tunnel projections, superior and inferior, are made from the medial to the lateral sides of the patella. The projection of each superior and inferior tunnel is subdivided into three different angles in the axial plane. The tunnel length, thickness of the bone anterior to each tunnel and safety angle are measured. The safety angle refers to the angle between the longitudinal axis of each tunnel and the horizontal plane of the patella. Our current study population consisted of 201 male patients (104 Wiberg type 1, 97 Wiberg type 2, no type 3 or 4). For the superior tunnels, the tunnel lengths are 14.8 mm, 24.3 mm and 27.2 mm. The respective safety angles are 24.9 degrees, 24.5 degrees and 8.8 degrees. The thickness of the bone anterior to the tunnels are 5.9 mm, 2.5 mm and 6.2 mm. For the inferior tunnels, the tunnel lengths are 18.4 mm, 21.9 mm and 34.9 mm. The respective safety angles are 23.5 degrees, 22.5 degrees and 8.5 degrees. The thickness of the bone anterior to the respective tunnels are 5.9 mm, 3.1 mm and 6.0 mm. The proposed safety angle of 8.8 degree for the superior tunnel, and 8.5 degrees for the inferior tunnel is a potentially useful intra-operative guide for the surgeon and can potentially reduce the risks of fracture and articular cartilage injury in patellae with Wiberg 1 and 2 morphologies. Level II, retrospective study.

Shoulder injury related to vaccine administration (SIRVA) is an increasingly recognised complication after vaccination and presents with significant shoulder pain and stiffness. SIRVA is thought to occur as a result of improper administration of vaccine into the subdeltoid bursa or shoulder joint. This results in an inflammatory cascade that damages the structures in the shoulder region. The incidence of SIRVA is relatively higher for influenza vaccination due its widespread administration. We present a reported case of SIRVA following a mRNA COVID-19 vaccination and review the current literature. As we embark on a worldwide scale of COVID-19 vaccination, it is of utmost important that we use proper vaccination techniques and screen patients at risk of SIRVA. This would improve the efficacy of the vaccine and improve the outcomes of the vaccination programme.

Proximal tibiofibular joint (PTFJ) instability is a rare knee injury, accounting for less than 1% of knee injuries. It causes significant lateral sided knee pain and functional deficits and can be associated with up to 9% of multiligament knee injuries. Concurrent surgical treatment of posterolateral corner (PLC) and PTFJ instability poses technical challenges due to the limited working space of the fibula head and inherent risk of collision between grafts, bone tunnels, and implants. In this Technical Note, we detail our senior author’s technique for PTFJ reconstruction without the use of additional bone tunnels or implants in the fibula head, to reduce the risk of overcrowding and tunnel collision. Classifications Level I: knee; Level II: other, proximal tibiofibular joint., Technique Video Video 1 Our technique for left knee proximal tibiofibular joint (PTFJ) stabilization with concomitant posterolateral corner (PLC) reconstruction is described in a stepwise manner. A lateral incision is first made with the knee in extension. The knee is subsequently flexed, and a posterior flap is raised. The peroneal nerve is identified and neurolyzed, and its entry to the lateral leg compartment is decompressed. Soft tissue around the fibula head is released. The fibula tunnel is reamed and directed 30° in a posteromedial and proximal directions. The Ultrabraid sutures are threaded through the tunnel, followed by the PLC reconstruction graft. The anterior and posterior loops of the Ultrabraid suture are tunneled under the soft tissue on the lateral fibula head. The posterior loop sutures are threaded into the 5.5-mm Footprint Ultra PK anchor and deployed at the posterior tibia at the level and adjacent to the fibula head. This step is repeated for the anterior loop sutures, and the anchor is deployed at the anterior tibia at the level and adjacent to the fibula head. The stability of the PTFJ reconstruction is checked, and the surgeon proceeds with the subsequent PLC reconstruction.

Purpose Personal mobility devices (PMDs) have become increasingly popular as a modality of transport worldwide. Starting out as novelty toys, PMDs are gradually being adopted as the mainstream mode of travel. There is an increasing number of accidents involving both PMD riders and other road users since its introduction, leading to a concomitant increase in demand for healthcare resources to manage the injuries. The main objective of this study was to evaluate the inpatient cost and the orthopedic injury pattern due to PMD accidents. Methods All patients admitted to the Department of Orthopedic Surgery between December 2016 to February 2018 with injuries due to PMD accidents were recruited. Data collection was performed retrospectively on the demographic profiles, injury patterns, admission related outcomes and expenditures of these patients. Results 43 patients were included in this study. The mean duration of admission was 7.81 days and the median cost of admission was S$7835.01 (approximately US$5620). These were comparable to accidents arising from other modes of transport, such as motorcycles and bicycles. In addition, more than 80% of patients were not wearing protective gear at time of accident. These patients had a slightly higher median cost payable per patient as compared to those who donned protective gear, with a difference of S$1669.78 (approximately US$1221). Conclusion There is a significant health and financial cost to the individual and society from PMD injuries and admission. This can be reduced with strict regulations on PMD use, advocating protective gear use, and promoting awareness on safety measures and the consequences of PMD accidents. The most common injury mechanism and orthopedic injury type for PMD accidents are different from motorcycle accidents.

Background This is an experimental study conducted to assess whether the fibular head is a reliable reference point to identify the position of the common peroneal nerve at the posterolateral corner of the knee. Materials and methods Twelve cadaveric knees were dissected through the lateral approach. The common peroneal nerve was identified and traced. The location where the common peroneal nerve crossed the posterior border of the biceps femoris and the posterior border of the fibular neck were designated as points B and N, respectively. The tip of the fibular head was designated F. Distances FB and FN were measured and the triangular area FBN was calculated at various degrees of knee flexion. Results During knee motion, distance FN showed minimal change and was not affected by variation in degrees of knee flexion (p = 0.131). Distance FB and distance BN were affected by variation in degrees of knee flexion (p 2 and subsequently decreased with further knee flexion. Conclusion The common peroneal nerve can consistently be found at approximately 20.7 ± 1 mm on the fibular neck with respect to the tip of the fibular head. The tip of the fibular head is a consistent landmark that can be used to predict the position of the exit point of the common peroneal nerve at the posterolateral corner of the knee.