ARTHROSCOPY OF THE ELBOW

Artroskopija lakta danas je neizostavna metoda kirurškog zbrinjavanja kako ozljeda i njihovih posljedica tako i oštećenja koja zahvaćaju lakat. Prednosti artroskopske kirurgije lakta prema klasičnoj otvorenoj metodi operacijskog liječenja su višestruke. U prvome redu artroskopija nam omogućuje izvanredan prikaz unutarzglobnih struktura i time detaljan pregled čitavog zgloba te kompletno izvođenje zahvata bez otvaranja zgloba. Nadalje, morbiditet je znatno manji, rehabilitacija brža, a brži je i povratak svakodnevnim aktivnostima. Osnovni preduvjeti za uspješnu primjenu artroskopije lakta su pažljivo prijeoperacijsko planiranje, izvanredno dobro poznavanje regionalne anatomije lakta, striktno praćenje pravila izvođenja zahvata, dobra tehnika te iskusan operater. Osnovnim indikacijama za artroskopiju lakta danas se smatraju osteohondritis disekans lakta, lateralni epikondilitis, sindrom sinovijalnih nabora, osteoartritis zgloba lakta, kontraktura lakta, kao i stanja kod kojih je potrebna sinoviektomija, primjerice reumatoidni artritis, pigmentirani vilonodularni sinovitis, sinovijalna hondromatoza te hemofilični sinovitis.Elbow arthroscopy has become an indispensable method of surgical care of injuries and their consequences and damages that affect the elbow. The advantages of elbow arthroscopy in comparison to classical open surgery are multiple. Primarily, arthroscopy allows an excellent view of intra-articular structures and thus a detailed overview of the entire joint which enables us to perform complete surgery without opening the joint. Furthermore, morbidity is significantly smaller, rehabilitation is faster, and return to daily activities is also faster. Basic requirements for successful application of elbow arthroscopy are careful planning of the procedure, very good knowledge of regional anatomy of the elbow, strictly following the rules of performing the procedure, good technique and an experienced surgeon. Pathologies that can currently be addressed arthroscopically include osteochondritis dissecans of elbow, lateral epicondylitis, synovial plica syndrome, elbow osteoarthritis, elbow contracture, as well as the diseases where the synovectomy is needed, such as rheumatoid arthritis, pigmented villonodular synovitis, synovial chondromatosis and hemophiliac synovitis

IS THERE ANY ROOM FOR TENDOSCOPY IN THE SURGICAL TREATMENT OF POSTERIOR TIBIAL TENDON INSUFFICIENCY?

Nedostatnost funkcije tetive tibijalis posteriora (engl. posterior tibial tendon insufficiency – PTTI) danas se ­smatra glavnim uzrokom nastanka spuštenoga medijalnog uzdužnog svoda stopala u odraslih osoba (engl. adult-acquired flatfoot deformity – AAFD). Cilj je ovog istraživanja pokazati rezultate tendoskopskog liječenja tetive tibijalis posteriora (TP) kod 11 bolesnika s 1. ili 2. stadijem PTTI-a nakon neuspješnoga neoperacijskog liječenja. Tendoskopija kao samostalan kirurški zahvat provedena je kod 8 bolesnika, dok je kod 3 bolesnika bio potreban i dodatni zahvat poput mini-open tubularizacije TP-a ili artroskopske toalete prednjeg dijela gležnja. U jednog je bolesnika s kompletnom rupturom TP-a u drugom aktu načinjen transfer tetive fleksora digitorum longusa. Nisu zabilježene komplikacije tendoskopskih zahvata ni kod jednog bolesnika. Tendoskopija TP-a djelotvorna je i minimalno invazivna operacijska tehnika u liječenju ozljeda i oštećenja TP-a u početnim stadijima PTTI-a. Ta tehnički zahtjevna endoskopska tehnika iziskuje veliko iskustvo operatera u artroskopiji malih zglobova i odlično poznavanje regionalne anatomije.Posterior tibial tendon insufficiency (PTTI) is nowadays considered to be the main cause of adult-acquired flatfoot deformity (AAFD). The purpose of this study is to report the outcomes of tendoscopic treatment of tibialis posterior tendon (TP) in eleven patients with stage 1 or 2 PTTI and failed prior conservative treatment. Tendoscopy was carried out as a solitary procedure in 8 patients, while in 3 patients additional procedures such as „mini-open” tubularization of TP or anterior ankle arthroscopy were necessary. In a single patient transfer of flexor digitorum longus tendon was performed as a second stage surgery due to complete rupture of TP. Related with tendoscopic procedure, no complications were reported. TP tendoscopy is a useful and beneficial minimally invasive procedure to treat TP pathology at earlier stages of PTTI. It is a technically demanding procedure that requires extensive experience in arthroscopic management of small joints and excellent knowledge of regional anatomy

Ima li tendoskopija mjesto u kirurškom liječenju nedostatnosti funkcije tetive tibijalis posteriora? [Is there any room for tendoscopy in the surgical treatment of posteriortibial tendon insufficiency]

Posterior tibial tendon insufficiency (PTTI) is nowadays considered to be the main cause of adult-acquired flatfoot deformity (AAFD). The purpose of this study is to report the outcomes of tendoscopic treatment of tibialis poste- rior tendon (TP) in eleven patients with stage 1 or 2 PTTI and failed prior conservative treatment. Tendoscopy was carried out as a solitary procedure in 8 patients, while in 3 patients additional procedures such as ,,mini-open" tubularization of TP or anterior ankle arthroscopy were necessary. In a single patient transfer of flexor digitorum longus tendon was performed as a second stage surgery due to complete rupture of TP. Related with tendoscopic procedure, no complications were re- ported. TP tendoscopy is a useful and beneficial minimally invasive procedure to treat TP pathology at earlier stages of PTTI. It is a technically demanding procedure that requires extensive experience in arthroscopic management of small ioints and excellent knowledge of repional anatomy

Arthroscopic Treatment of Localized and Diffuse Pigmented Villonodular Synovitis of the Knee

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial disorder of uncertain etiology. Two forms of this disorder, a localized (LPVNS) and diffuse (DPVNS) form, are well differentiated. The therapy of choice for LPVNS is arthroscopic partial synovectomy with excision of the lesion. Total synovectomy, whether done arthroscopically or through an open arthrotomy, is the recommended treatment for DPVNS. During an eight-year period 13 patients, six male and seven female, average age 28 years (range, 16 to 60 years) were treated for PVNS of the knee with arthroscopic synovectomy. Average follow-up was 84 months (range, 28 to 127 months). Four patients were affected by localized PVNS and were subjected to partial arthroscopic synovectomy (two to three portals) with a complete lesion excision. The remaining nine patients presented with the diffuse form of PVNS and all of them underwent total arthroscopic synovectomy (five portals). The diagnosis was confirmed by synovial biopsy. Each patient was evaluated before treatment and at final follow-up. Results were assessed clinically, radiographically and subjectively and were rated as excellent, good, fair, or poor. No complications or recurrences were noted in the LPVNS group, and all four patients were rated as excellent. In the DPVNS group, eight patients were rated as excellent and one patient was rated as fair and it was the patient who suffered the only recurrence in our case series. No relevant complications were encountered. No cases of infection, joint stiffness or neurovascular lesions were seen. Arthroscopy has become the golden standard in treatment of LPVNS, and can undoubtedly give results that are as good as with open synovectomy when treating DPVNS, if performed by an experienced arthroscopic surgeon

Ima li tendoskopija mjesto u kirurškom liječenju nedostatnosti funkcije tetive tibijalis posteriora? [Is there any room for tendoscopy in the surgical treatment of posteriortibial tendon insufficiency]

Posterior tibial tendon insufficiency (PTTI) is nowadays considered to be the main cause of adult-acquired flatfoot deformity (AAFD). The purpose of this study is to report the outcomes of tendoscopic treatment of tibialis poste- rior tendon (TP) in eleven patients with stage 1 or 2 PTTI and failed prior conservative treatment. Tendoscopy was carried out as a solitary procedure in 8 patients, while in 3 patients additional procedures such as ,,mini-open" tubularization of TP or anterior ankle arthroscopy were necessary. In a single patient transfer of flexor digitorum longus tendon was performed as a second stage surgery due to complete rupture of TP. Related with tendoscopic procedure, no complications were re- ported. TP tendoscopy is a useful and beneficial minimally invasive procedure to treat TP pathology at earlier stages of PTTI. It is a technically demanding procedure that requires extensive experience in arthroscopic management of small ioints and excellent knowledge of repional anatomy

Synovial Chondromatosis of the Elbow

Synovial chondromatosis (SC) is a rare, mostly benign proliferation of the synovium of the joint, tendon or bursa which results in the formation of loose bodies. It can appear in one of 33 described localisations, but it is most common in the knee. In our study we gathered a group of 7 patients (6 male and 1 female) with SC of the elbow, which underwent arthroscopic surgery of the elbow, performing both removal of the loose bodies and complete synovectomy. Mayo Elbow Performance Score (MEPS) was used to evaluate and compare the patients’ condition before the operation and at the final follow-up, 31 months, on average, after the operation (range 18–56 months). All patients had poor MEPS before the operation, with an average of 40.7 (range 15–50 points). At the final follow-up, 6 patients had a good or excellent MEPS, while a poor MEPS was present in a single patient. The average MEPS was 85 (range 45–100 points). The one patient who’s MEPS remained poor developed heterotopic ossification in the same elbow shortly after arthroscopic surgery. This patient was reoperated 8 months later using an open technique. No other complications occurred in the rest of the operated patients and no recurrence of SC occurred in any of the operated patients. Our results confirm that arthroscopic removal of loose bodies and complete synovectomy should be the treatment of choice for SC of the elbow

LIGAMENT WHICH DESERVES ATTENTION – MEDIAL PATELLOFEMORAL LIGAMENT

Istraživanja medijalnoga patelofemoralnog ligamenta (MPFL) došla su u žarište interesa tijekom posljednjih petnaestak godina. Razlog tomu su činjenice što je MPFL primarni medijalni pasivni stabilizator patele i što je gotovo uvijek ozlijeđen nakon primarne luksacije patele. Mehanička su mu svojstva nakon ozljede narušena i nikada se ponovno ne postiže njegova puna funkcija. Brojne kirurške tehnike rekonstrukcije MPFL-a opisane su u literaturi. U ovom članku dan je detaljan pregled suvremenih spoznaja o anatomiji i biomehanici MPFL-a. Prikazane su različite tehnike rekonstrukcije MPFL-a s posebnim osvrtom na metodu rekonstrukcije MPFL-a dijelom tetive kvadricepsa koju i rabimo u svojoj ustanovi.There has been increasing interest in investigating the medial patellofemoral ligament (MPFL) during the last fifteen years. This is due to the recognition of the MPFL as the primary static soft-tissue restraint to lateral patellar displacement and the association of MPFL injury with primary traumatic patellar dislocation. The MPFL often heals poorly and thus rarely regains its full function. Numerous surgical techniques have been described for reconstruction of this important structure. This paper reviews the relevant anatomy and biomechanics, published reconstruction options, and describes the surgical technique performed at our institution – that of using a quadriceps autograft to reconstruct the MPFL

The discoid meniscus

Diskoidni menisk najčešća je morfološka anomalija meniska. Učestalost ove anomalije varira ovisno o geografskom smještaju, a najviša je u području istočne Azije (Japan, Kina, Koreja). Premda je opisan prije više od stotinu godina, diskoidni menisk još je uvijek izazov u dijagnostičkom smislu i u smislu liječenja. Budući da pojavnost ove anomalije nije tako rijetka, a klinička slika nije niti uniformna niti patognomonična, pri svakoj pojavi nespecifičnih tegoba i bolova u koljenu djece i adolescenata, i to bez evidentne traume, valja posumnjati na diskoidni menisk. Asimptomatski diskoidni menisk koji je slučajno otkriven tijekom artroskopskog zahvata u sklopu kirurške obrade radi druge patologije koljena nije potrebno liječiti, već bolesnika valja samo redovito kontrolirati. Naime, smatra se da se koljeno adaptiralo na takav oblik meniska i da može i nadalje dobro funkcionirati. Kirurško liječenje rezervirano je samo za simptomatske diskoidne meniske, a danas je metoda izbora djelomična meniscektomija koju valja činiti artroskopski. Osnova artroskopske djelomične meniscektomije jest odstranjenje središnjeg dijela diskoidnog meniska te formiranje stabilnog i funkcionalnog ostatnog dijela meniska, koji će omogućiti adekvatnu apsorpciju šoka bez stvaranja novog rascjepa meniska. U ovom su preglednom radu prikazane najnovije spoznaje o etologiji, anatomskim značajkama, klasifikaciji, udruženim stanjima, kliničkoj slici, dijagnostici i liječenju diskoidnog meniska.Discoid meniscus is the most common morphological anomaly of the meniscus. The frequency of this anomaly varies depending on geographic location and is highest in eastern Asia (Japan, China, and Korea). Although discoid meniscus was described more than a hundred years ago it is still a challenge both in the diagnostic and therapeutical sense. Since the incidence of this anomaly is relatively high and clinical presentation heterogenous, differential diagnosis of any nonspecific symptom and pain without obvious trauma of the knee in children should include the discoid meniscus. Most authors recommend only observation for an asymptomatic discoid meniscus determined incidentally during arthroscopy because the knee might have adapted to the discoid anatomy and may continue to function well. Surgical intervention is indicated only for symptomatic discoid menisci. Currently, most authors recommend meniscal preservation using arthroscopic saucerization. The goal of saucerization is to create a stable and functionally remaining meniscus which will provide adequate shock absorption without re-tearing. In this review we present the latest findings regarding etiology, anatomical features, classification, accompanying conditions, clinical manifestations, diagnostic modalities and practical management considerations of discoid meniscus