Mar 27

Ipsilateral Fracture Shaft Femur with Neglected Dislocation of Prosthesis: A Case Report

Ipsilateral Fracture Shaft Femur with Neglected Dislocation of Prosthesis: A Case Report

Ipsilateral Fracture Shaft Femur with Neglected Dislocation of Prosthesis: A Case Report

Posted on Oct 11, 2013 in Oct – Dec 2013, VOLUME 3 ISSUE 4

Ipsilateral Fracture Shaft Femur with Neglected Dislocation of Prosthesis: A Case Report

What to Learn from this Article?

An unique
decision making scenario highlighting an equally important role of
surgeons skills and Patients Preferences in Clinical Decision Making.


Case Report |  Volume 3 | Issue 4 | JOCR Oct-Dec 2013 | Page 26-30 | Jain M, Bihari AJ, Sriramka

DOI: 10.13107/jocr.2250-0685.127


Authors: Jain M[1], Bihari AJ[1], Sriramka[2]

[1]Department of Orthopaedics, Hitec medical college and Hospital, Rourkela, Odisha, India.

[2]Department of Anesthesia, Ispat General Hospital, Rourkela, Odisha, India.

Address of Correspondence:

Dr Mantu Jain, 347/J, Janata Colony, Gudiyari, Raipur, Chhattisgarh. India. E mail: montu_jn@yahoo.com


Abstract

Introduction: Neglected
hip dislocation is rare in today’s world and after prosthesis
replacement even rarer finding. However such patients may not report to
surgeons until they develop secondary complications. Management of such
patient’s is a challenge to the treating surgeon and need to be tailored
suiting to patient’s demands, expectations and constraints of financial
resources. We did not find a similar case in the electronic and print
media and therefore report this case which was innovatively managed.

Case Report: A
60 year farmer presented with fracture shaft femur and ipsilateral
dislocation prosthesis of right hip. He had a hemiarthroplasty done for
fracture neck of femur in the past but used to walk with a lurch since
he started to ambulate after discharge. However he was satisfied despite
“some problems” which had caused shortening of his limb. The patient
was informed of the various treatment options and their possible
complications. He expressed his inability to afford a Total Hip
Arthroplasty (THA) at any stage and consented for other options
discussed with him. The patient was positioned supine and adductor
tenotomy done. Next he was positioned laterally and the fracture was
fixed with heavy duty broad dynamic compression plate and screws. The
wound was temporarily closed. Now through the previous scar via
posterior approach the hip was exposed. The prosthesis was found to be
firmly fixed to the proximal femur. The acetabulum was cleared with
fibrous tissue. All attempts the prosthesis to relocate the prosthesis
failed after several attempts and it was best decided to leave alone.
Post operatively period was uneventful. At follow up he refused for any
further manoeuvre in future inform of heavy traction and attempts to
reduce the same. At one year when he was walking unaided and his X-rays
showed that fracture had well united his SF-36 score was PCS – 49.6 and
MCS – 51.9.

Conclusion: Ipsilateral
shaft femur fracture in chronically dislocated prosthesis, done for
fracture neck of femur is a rare clinical entity. Increased stress
transfers due to dislocation compounded with osteoporosis makes the
shaft vulnerable to fracture even with low velocity injury as in our
case. Though fixation of fracture shaft femur is clear and
straightforward; management of neglected prosthesis dislocation have to
be guided by patient’s level of expectations and subjective contentment
to adaptation to the altered hip state which influence the overall
functional outcome.

Keywords: Neglected dislocation, ipsilateral femoral fracture, hip arthroplasty.

Mar 27

Popliteomeniscal Fascicle Tears

http://www.healio.com/orthopedics/journals/ortho/%7B35dc91b7-8074-4f51-b43c-cdb71c4300e1%7D/popliteomeniscal-fascicle-tears

Popliteomeniscal Fascicle Tears

Tears of popliteomeniscal fascicles have been reported in high numbers of knee injuries with anterior cruciate ligament tears and injuries to the posterolateral complex.1 Yet, isolated popliteomeniscal fascicle tears are often difficult to recognize and diagnose due to the vague symptoms and often-normal magnetic resonance imaging (MRI) and physical examination findings.2,3 These isolated injuries are often misdiagnosed and mistreated, which often leads to delayed surgical treatment. Without proper diagnosis and treatment, popliteomeniscal fascicle tears can lead to continued disability, complex tears of the lateral meniscus, which are often irreparable, and chondral lesions because of the large mobile fragment.4

The popliteomeniscal fascicles are composed of 3 distinct fasciculi, anteroinferior, posterosuperior, and posteroinferior, that attach to the lateral meniscus at the popliteal hiatus (Figure 1).5 Sussmann et al6 suggested that, embryologically, the fascicles allow vascular supply to the lateral meniscus. The fascicles are important to the controlling motion of the lateral meniscus during both flexion and extension of the knee.1,7,8 Simonian et al7 showed lateral meniscal motion doubled when the popliteomeniscal fascicles were sectioned in cadaveric knees. Kimura et al9 stated that tears of the popliteomeniscal fascicles lead to the loss of normal peripheral hoop stresses, allowing the lateral meniscus to displace medially.

Figure 1:

Sagittal T2 magnetic resonance image showing intact superior and inferior popliteomeniscal fascicles (arrows).

Injuries are often seen in the younger athletic population. These injuries are typically found in athletes who engage in sports that involve repetitive twisting, such as wrestling, dancing, and taekwondo. Mechanisms of injury can involve a single traumatic event or an insidious onset after repeated microtrauma.3,10Patients typically present with vague lateral-sided knee pain with activity. Reports of locking or giving way may or may not be present.

A standard knee examination typically does not reveal abnormalities. LaPrade and Konowalchuk3 found placing patients in a figure-4 position replicated their symptoms and was therefore useful in identifying those with popliteomeniscal fascicle tears (Figure 2).

Figure 2:

Photograph of the patient demonstrating the figure-4 position.

Isolated popliteomeniscal fascicle tears can often be difficult to detect on MRI.11A high-quality MRI with 3-mm cuts and a high index of suspicion may decrease false-negative readings. Studies by Simonian et al7 and LaPrade and Konowalchuk3 showed that 9 patients who were felt to have normal findings on MRI were found, arthroscopically, to have popliteomeniscal fascicle tears. These tears were found on MRI retrospectively. Johnson and DeSmet12 and Peduto et al13 reported that popliteomeniscal fascicles can be best evaluated on T2-weighted images in the sagittal plane.

Arthroscopic evaluation, the gold standard for diagnosis, allows for direct visualization of the popliteomeniscal fascicles at popliteal hiatus and evaluation of lateral meniscal mobility.1 LaPrade14 reported visualization of the popliteomeniscal fascicles is best done with a 30° arthroscope with the knee at neutral rotation and 20° of flexion. Simonian et al7 showed that, once visualized, the lateral meniscus must be probed to assess mobility. Thompson et al8 reported that less than half of the lateral meniscus shows mobility when the popliteomeniscal fascicles are intact. Shin et al4 proposed that when more than half of the lateral meniscus shows mobility, a popliteomeniscal fascicle tear should be suspected.

Once diagnosed arthroscopically, isolated popliteomeniscal fascicle tears should be surgically repaired to prevent further disability. In the short term, a hypermobile meniscus leads to further intrinsic meniscal damage, which decreases healing rates, as well as chondral damage from abnormal wear and tear. Long term, if untreated, a hypermobile meniscus will require a “functional” complete lateral meniscectomy, meaning the beginning of the end to the lateral compartment. Several techniques have been described for repair. LaPrade nd Konowalchuk3 described open repair of the lateral meniscus back to the popliteomeniscal fascicles and popliteus tendon complex. The results were reported for 6 patients. All returned to unrestricted activity with resolution of symptoms with an average 3.8-year follow-up. Simonian et al7 reported resolution of symptoms in 3 patients with an inside-out repair technique. After repair, most patients are allowed to return to athletic activity at 4 months.

Case Reports

Patient 1

A 14-year-old female competitive dancer presented reporting lateral-sided knee pain and locking and catching of her right knee for 3 years. Initially, the locking and catching occurred every few months; it had been increasing in frequency. She stated that once her knee was at 90° of flexion, it would lock. She was unable to extend it and had to release it by going into deep flexion with a twist of the knee. Once this had occurred, her knee would swell for 2 days. She reported no inciting event. An examination revealed no effusion, knee range of motion of 0° to 150°, no patellofemoral symptoms, and stable ligamentous findings. Passively, the locking and catching could not be reproduced. She did have pain on the lateral joint line on McMurray examination. Magnetic resonance imaging revealed increased signal at the lateral meniscus and a tear of the popliteomeniscal fascicles (Figure 3).

Figure 3:

Sagittal T2 magnetic resonance image showing torn superior and inferior popliteomeniscal fascicles.

The patient was taken to the operating room, where diagnostic arthroscopy revealed a tear of the popliteomeniscal fascicles and increased mobility of the lateral meniscus (Figure 4). An inside-out meniscal repair was performed from the 9 to 11 o’clock position. A total of five 2-0 Ethibond (Ethicon, Somerville, New Jersey) sutures were placed (Figure 5). Postoperatively, the patient was toe-touch weight bearing in 30° of flexion. She was started on physical therapy postoperative day 3 working on knee range of motion of 0° to 90°. At 1 month postoperatively, the patient was allowed to weight bear with the knee brace locked in extension. Therapy continued with range of motion of 0° to 90° with quadriceps strengthening from 0° to 45°. Two months postoperatively, the knee brace was unlocked and therapy continued with quadriceps strengthening of 0° to 90°. At 3 months, the brace was discontinued and she was allowed to start plyometrics. Four months postoperatively, the patient did not report pain or locking in her knee with plyometric exercises. A functional evaluation test revealed only a 1.8% deficit. The patient was allowed to start sport-specific activity without restrictions and gradual return to full dance training.

Figure 4:

Intraoperative arthroscopic lateral compartment image showing a hypermobile lateral meniscus (Patient 1).

Figure 5:

Intraoperative arthroscopic lateral compartment image after inside-out lateral meniscal repair (Patient 1).

Patient 2

A 15-year-old female multisport athlete felt a pop in her right knee after sliding into a base. She presented reporting recurrent locking symptoms in her knee for 9 months. Magnetic resonance imaging showed tears of the popliteomeniscal fascicles and lateral meniscus. Arthroscopic evaluation showed a hypermobility of the lateral meniscus (Figure 6). An inside-out lateral meniscus repair with a fibrin clot was performed (Figure 7).

Figure 6:

Intraoperative arthroscopic lateral compartment image showing hypermobility of the lateral meniscus (Patient 2).

Figure 7:

Intraoperative arthroscopic lateral compartment image showing inside-out repair with a blood clot (Patient 2).

The patient returned to athletic activity. Nine months postoperatively, when squatting to pick up a basketball, she again felt a pop in her knee and presented with a locked knee. Magnetic resonance imaging and arthroscopic evaluation showed a re-tear of the lateral meniscus. A revision inside-out lateral meniscus repair with fibrin clot augmentation was performed. Seven months postoperatively, the patient again re-injured her knee during a collision while playing soccer. The patient had immediate swelling and limited knee extension. Diagnostic arthroscopy again revealed an unhealed re-torn lateral meniscus (Figure 8). At this point, a partial lateral meniscectomy was performed. The patient has since returned to athletic activity with a narrowed lateral joint line (Figure 9). This case illustrates the effects of late treatment for popliteomeniscal fascicle tears.

Figure 8:

Intraoperative arthroscopic lateral compartment image of a re-torn and unhealed lateral meniscus (Patient 2).

Figure 9:

Postoperative anteroposterior weight-bearing radiograph showing the right knee lateral joint space (Patient 2).

Conclusion

Isolated popliteomeniscal fascicle tears are often difficult to diagnose. Symptoms of vague lateral knee pain with or without locking should heighten one’s suspicion for a possible popliteomeniscal fascicle tear. Arthroscopic evaluation of the popliteomeniscal fascicles and mobility of the lateral meniscus provides the best diagnostic study for isolated tears. Surgical stabilization of the lateral meniscus must be performed for resolution of symptoms, preservation of the lateral compartment, and return to previous activity.

References
Staubli H, Rauschning W. Popliteus tendon and its fascicles at the popliteal hiatus: gross anatomy and functional arthroscopic evaluation with and without anterior cruciate ligament deficiency. Arthroscopy. 1990; 6:209–220. doi:10.1016/0749-8063(90)90077-Q [CrossRef]
Kimura M, Shirakura K, Hasegawa A, Kobayashi Y, Udagawa E. Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: Part 1. Arthroscopic and anatomical investigation. Arthroscopy. 1992; 8:419–423. doi:10.1016/0749-8063(92)90001-R [CrossRef]
LaPrade RF, Konowalchuk BK. Popliteomeniscal fascicle tears causing symptomatic lateral compartment knee pain: diagnosis by the figure-4 test and treatment by open repair. Am J Sports Med. 2005; 33(8):1231–1236. doi:10.1177/0363546504274144 [CrossRef]
Shin HK, Lee HS, Lee YK, et al. Popliteomeniscal fascicle tear: diagnosis and operative technique. Arthroscopy Techniques. 2012; 1:101–106. doi:10.1016/j.eats.2012.04.004 [CrossRef]
Cohn A, Mains D. Popliteal hiatus of the lateral meniscus and measurement at dissection of 10 specimens. Am J Sports Med. 1979; 7:221–226. doi:10.1177/036354657900700402 [CrossRef]
Sussmann PS, Simonian PT, Wickiewicz TL, Warren RF. Development of the popliteomeniscal fasciculi in the fetal human knee joint. Arthroscopy. 1990; 17:14–18. doi:10.1053/jars.2001.19653 [CrossRef]
Simonian PT, Simonian PS, van Thrommel M, Wickiewicz TL, Warren RF. Popliteomeniscal fasciculi and lateral meniscal stability. Am J Sports Med. 1997; 25:849–853. doi:10.1177/036354659702500620 [CrossRef]
Thompson WO, Thaete FL, Fu FH, et al. Tibial meniscal dynamics using three-dimensional reconstruction of the magnetic resonance images. Am J Sports Med. 1991: 19:210–216. doi:10.1177/036354659101900302[CrossRef]
Kimura M, Shirakura K, Hasegawa A, Kobayashi Y, Udagawa E. Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 2. Clinical investigation. Arthroscopy. 1992; 8:424–427. doi:10.1016/0749-8063(92)90002-S [CrossRef]
Park JH, Ro KH, Lee DH. Snapping knee caused by a popliteomeniscal fascicle tear of the lateral meniscus in a professional taekwondo athlete. Orthopedics. 2012; 7:1104–1107. doi:10.3928/01477447-20120621-31 [CrossRef]
Sakai H, Sasho T, Wada Y, et al. MRI of the popliteomeniscal fasciculi. AJR Am J Roentgenol. 2006; 186:446–466. doi:10.2214/AJR.04.0068 [CrossRef]
Johnson RL, DeSmet AA. MR visualization of the popliteomeniscal fascicles.Skeletal Radiol. 1999; 28:561–566. doi:10.1007/s002560050619 [CrossRef]
Peduto AJ, Nguyen A, Trudell DJ, Resnick DL. Popliteomeniscal fascicles: anatomic considerations using MR arthrography in cadavers. AJR Am J Roentgenol. 2008; 190:442–448. doi:10.2214/AJR.07.2643 [CrossRef]
LaPrade RF. Arthroscopic evaluation of the lateral compartment knees with grade 3 posterolateral knee complex injuries. Am J Sports Med. 1997; 25:596–602. doi:10.1177/036354659702500502 [CrossRef]