Arthroscopic decompression and notchplasty for long-standing anterior cruciate ligament impingement in a patient with multiple epiphyseal dysplasia: a case report

INTRODUCTION

Multiple epiphyseal dysplasia is a genetically and clinically heterogeneous osteochondroplasia with symmetrical involvement. It is characterized by joint pain in childhood and early adulthood with early onset of osteoarthritis, mainly affecting the hips.

CASE PRESENTATION

We report the case of a 20-year-old man of Asian origin with multiple epiphyseal dysplasia presenting with bilateral knee pain, stiffness and instability found to be caused by bilateral anterior cruciate ligament impingement on abnormal medial femoral condyles. Bilateral staged arthroscopic notchplasty was performed successfully, resulting in subjective relief of pain, and improved range of movement and stability.

CONCLUSION

Care should be taken not to exclude a diagnosis of multiple epiphyseal dysplasia when few of the characteristic radiographic features are evident but clinical suspicion is high. This case highlights the scope for subjective symptomatic improvement following a minimum of surgical intervention. We recommend limiting early intervention to managing symptomatic features rather than radiographic abnormalities alone.

Crescent fracture-dislocation of the sacroiliac joint

Crescent fracture dislocations are a well-recognised subset of pelvic ring injuries which result from a lateral compression force. They are characterised by disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. We describe a classification with three distinct types. Type I is characterised by a large crescent fragment and the dislocation comprises no more than one-third of the sacroiliac joint, which is typically inferior. Type II fractures are associated with an intermediate-size crescent fragment and the dislocation comprises between one- and two-thirds of the joint. Type III fractures are associated with a small crescent fragment where the dislocation comprises most, but not all of the joint. The principal goals of surgical intervention are the accurate and stable reduction of the sacroiliac joint. This classification proves useful in the selection of both the surgical approach and the reduction technique. A total of 16 patients were managed according to this classification and achieved good functional results approximately two years from the time of the index injury. Confounding factors compromise the summary short-form-36 and musculoskeletal functional assessment instrument scores, which is a well-recognised phenomenon when reporting the outcome of high-energy trauma.

Patello-femoral tracking in the weight-bearing knee: a study of asymptomatic volunteers utilising dynamic magnetic resonance imaging: a preliminary report

Normal patello-femoral tracking is not well defined, and conventional radiological techniques do not allow imaging in the physiological, weight-bearing stance. A vertical-access open configuration magnetic resonance scanner allows imaging of patello-femoral tracking during weight-bearing and through a wide range of knee flexion. We imaged 40 asymptomatic knees in this way, producing axial scans which were analysed qualitatively and quantitatively using sulcus angle, congruence angle, lateral patello-femoral angle and patellar centralisation, to assess patellar tilt and displacement. Mild lateral tilting in hyperextension with the quadriceps relaxed was seen, but quantitative assessment of this was impeded by internal rotation of the femur in extension. One-half of the knees were slightly laterally displaced in hyper-extension, becoming central during the first 30 degrees of knee flexion. During passive flexion of the knee in a seated position, fewer knees were laterally tilted or displaced, and no consistent change was seen during flexion. These results indicate that mild lateral tilting and displacement can be normal phenomena in the weight-bearing knee in early flexion and should not necessarily be taken as evidence of abnormal tracking in symptomatic patients. Lateral to medial movement of the patella occurs during normal knee flexion. In addition, imaging in the weight-bearing knee can provide valuable information not gained by imaging during passive knee flexion.

The use of dynamic interventional MRI in developmental dysplasia of the hip

Conventional methods of imaging in the investigation of developmental dysplasia of the hip all have disadvantages, either in definition or in exposure to radiation. We describe a new open-configuration MR scanner which is unique in that it allows anaesthesia and access to the patient within the imaging volume for surgical procedures and application of casts. We performed 13 scans in eight anaesthetised infants. Dynamic imaging revealed two dislocated hips which were then visualised during reduction. Hip spicas were applied without removing the patient from the scanner. In one hip, an adductor tenotomy was carried out. In all patients, stressing the hips during dynamic imaging allowed an assessment of stability. This was particularly useful in two hips in which an analysis of stability in different positions facilitated the planning of femoral osteotomies. This method of imaging provides new and important information. It has great potential in the investigation of developmental dysplasia of the hip and, with ultrasound, may allow management without the need for radiography.

The use of dynamic interventional MRI in developmental dysplasia of the hip

Conventional methods of imaging in the investigation of developmental dysplasia of the hip all have disadvantages, either in definition or in exposure to radiation. We describe a new open-configuration MR scanner which is unique in that it allows anaesthesia and access to the patient within the imaging volume for surgical procedures and application of casts. We performed 13 scans in eight anaesthetised infants. Dynamic imaging revealed two dislocated hips which were then visualised during reduction. Hip spicas were applied without removing the patient from the scanner. In one hip, an adductor tenotomy was carried out. In all patients, stressing the hips during dynamic imaging allowed an assessment of stability. This was particularly useful in two hips in which an analysis of stability in different positions facilitated the planning of femoral osteotomies. This method of imaging provides new and important information. It has great potential in the investigation of developmental dysplasia of the hip and, with ultrasound, may allow management without the need for radiography.