Background The traumatic or degenerative internal derangement of the knee requires certain investigations for the establishment of diagnosis, in addition to clinical history and a thorough physical examination. The use of arthrography and arthroscopy improves the accuracy of the diagnosis. MRI scanning of the knee joint has often been regarded as the noninvasive alternative to diagnostic arthroscopy. Objective The purpose of the study was to correlate clinical and low field MRI findings with arthroscopy in internal derangement of the knee. Methods Forty one patients with suspected internal derangement of the knee were subjected to MR examination followed by arthroscopy. Clinical criteria used were history, mode of injury, Mc Murray’s, Apley’s grinding, Thessaly’s test for meniscal injury. Drawer test was considered to be essential for clinical diagnosis of cruciate ligament injury. MRI of the knee was performed in low field open magnet (0.35T, Magnetom C, Seimens). Arthroscopy was done within two months of MR examination and was considered gold standard for the internal derangement of the knee. Results The sensitivity, specificity, diagnostic accuracy of clinical examination were 96.1%, 33.3% and 73.1% respectively for medial meniscal tear; 38.4%, 96.4% and 78.1% respectively for lateral meniscal tear. The sensitivity, specificity, diagnostic accuracy of MRI were 92.3%,100% and 95.1% for medial meniscal tear; 84.6%96.4% and 92.6% respectively for lateral meniscal tear. ConclusionClinical examination showed higher sensitivity for medial meniscal tear compared to MRI, however with low specificity and diagnostic accuracy. Low field MRI showed high sensitivity, specificity, diagnostic accuracy for meniscal and cruciate ligament injury, in addition to associated derangement like articular cartilage damage, synovial thickening.DOI: http://dx.doi.org/10.3126/kumj.v9i3.6300 Kathmandu Univ Med J 2011;9(3):174-8

Medial collateral ligament (MCL) is the most commonly injured ligament in knee. The majority of MCL tears can be managed conservatively, and reconstruction or augmentation is required in few selected cases. Anatomic MCL and posterior oblique ligament reconstruction have good functional outcome, but it requires 2 tunnels each in the tibia and femur, which may be a limitation in cases in which multiligament reconstruction is required. Several studies report the use of semitendinosus tendon with intact tibial attachment for MCL reconstruction. Since the attachment of semitendinosus is anterior to MCL footprint, it is non-anatomic and anisometric, which may lead to increased laxity of the reconstructed ligament in due course of time. To prevent the laxity in long term, the reconstruction has to be isometric and anatomic. We, hereby, are reporting our unique technique of MCL and posterior oblique ligament reconstruction using intact semitendinosus at tibial attachment and re-routing to the MCL which makes the reconstruction anatomic and isometric. A supplemental video demonstration of the technique is attached with this article.

Meniscal tears are commonly encountered conditions of the knee. In the past, torn menisci were treated by excision of the loose flap. A better understanding of the meniscus anatomy and its biomechanical characteristics has led to the concept of meniscus preservation in eligible cases. Several suture-based repair techniques have been described in literature, including the outside-in technique. Although the outside-in technique of meniscus repair is commonly indicated for the anterior two-thirds of the meniscus, it can be used to repair the posterior part of the meniscus as well. Several modifications of this technique have been described in the literature. We hereby describe our modification of the outside-in technique of meniscus repair with the help of an epidural needle and highstrength sutures that is readily available in operating rooms. The advantages of our technique are that no large incision is required around knee joint, it's inexpensive, it can be performed with basic instruments, and even the tear of meniscus extending up to the posterior horn can be repaired. A supplemental video demonstration of the technique is included with this article.

Anterior dislocation of the shoulder joint with ipsilateral humerus shaft fracture is a very rare injury. Until July 2006 only 18 cases have been reported in the literature. Here we report a case of Anterior Shoulder dislocation with greater tuberosity and shaft of humerus fracture. The patient was treated by Open reduction and internal fixation of the shaft fracture followed by closed reduction of the dislocation. A post-operative rehabilitation program was instituted for complete rehabilitation of the shoulder function. Key words: Shoulder dislocation, Ipsilateral, Humerus, Fracture, Open reduction. doi: 10.3126/kumj.v6i4.1743     Kathmandu University Medical Journal (2008), Vol. 6, No. 4, Issue 24, 502-504

Even after anterior cruciate ligament (ACL) tear, its remnant retains the vascularized synovial sheets, fibroblasts, myofibroblasts, and various mechanoreceptors within it. The aim of preserving the remnant is to retain these components during ACL reconstruction. In the recent past, there has been an increasing trend towards preserving remnants during ACL reconstruction. Although preserving remnants have physiological advantages, cyclops lesion and extension loss were among the most feared complications. Cyclops and loss of extension are due to the fallback of the remnant into the notch. Moreover, the mechanoreceptors present in the remnant are not active when the remnant is lax. These mechanoreceptors are active when the remnant is in tension. Thus, rather than merely preserving the remnant, it is essential to tension it for more physiological functions. Although there are various techniques of remnant tensioning described in the literature, these techniques require tampering of the fixation devices or an extra fixation device adding to the cost of surgery. We describe our modification of the remnant-tensioning method during anatomic ACL reconstruction. In this technique, the sutures holding the remnant are pulled out through the anatomic femoral tunnel and fixed with an interference screw along with the hamstring graft. This technique is cost-effective, reproducible, and does not require tampering with the fixation devices. Moreover, the direction of remnant pull will be the same as that of the reconstructed graft making both the graft and remnant anatomical in orientation. Suture management and visibility of the intraarticular structures during this procedure are a few downsides of this technique. The only prerequisite of this technique is a good quality remnant to hold the sutures.

Background: Anterior cruciate ligament is one of the commonly injured ligaments in knee. The shape and dimension of the femoral notch has been linked with the risk of anterior cruciate ligament injury. The aim of this study was to study the risk of Anterior cruciate ligament injury with notch morphology in the Nepalese population.Methods: This study is a case control study. Cases undergoing arthroscopic surgery at 2 tertiary level centers were enrolled. Patients with arthroscopic confirmation of Anterior cruciate ligament tear were taken as case and those without tear were taken as control. Axial Magnetic resonance Imaging sequence was used to study notch. Sections at the level of popliteal groove was taken for study and shapes were identified as A, U and W type, and notch width index was calculated. These variables were correlated with presence or absence of Anterior cruciate ligament tear.Results: Out of 118 cases, 59 had tear, and 59 had no tear. Tear was found in 74% of Type A notch compared to 30.15% in Type U notch. The femoral notch width index was low in 42.59% of A type notch patients compared to 20.63% with U type notch. Analysis of notch width index among patients with Anterior cruciate ligament tears, showed that 40.67% of Anterior cruciate ligament torn knee had narrow notch compared to 22% in non- injured group, which was statistically significant.Conclusions: Type A notch and narrow notch both are risk factors for Anterior cruciate ligament tear.Keywords: Anterior cruciate ligament; injury; notch.

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The existing literature agrees on surgical management for Rockwood grade IV and V injuries, but there is no consensus which type of surgery is the most appropriate one. More than 150 surgeries have been described for this condition in the literature. In an injury of less than 3 weeks, most surgeons prefer suture-button devices for coracoclavicular stabilization. Recent biomechanical studies have demonstrated that coracoclavicular stabilization provides good vertical stability but poor horizontal stability of acromioclavicular joint. Hence, they recommend acromioclavicular stabilization along with coracoclavicular stabilization. The use of a suture-button device for coracoclavicular stabilization requires special implants and instruments along with high surgical skills to drill precisely placed holes in the clavicle and the coracoid in order to avoid fractures from the drill hole. Due to relatively smaller clavicle and coracoid in Asian population, making holes in the clavicle and the coracoid has increased risk of fracture. We describe a technique in which no drill holes are made in the clavicle or the coracoid. In our technique, suture tape is used, which is looped around the coracoid and the clavicle, and the limbs are tied over the clavicle to maintain the coracoclavicular distance. The remaining limbs of suture tape is further looped through the tunnels made in acromion and tied over the acromion to augment the acromioclavicular ligament. The potential advantages of this technique are no costly implant and instruments are required, avoidance of complications associated with drill holes in coracoid and clavicle, both coracoclavicular and acromioclavicular joints are stabilized, direct repair of the acromioclavicular ligament can be performed, and no need of second surgery for implant removal.