Introduction: Diffused pigmented villonodular synovitis (PVNS) is a locally aggressive lesion for which surgery provides only marginal resection. An adjuvant treatment modality is therefore required to prevent local tumor recurrence. The authors describe their experience with intra-articular injection of Yttrium⁹⁰ (Y⁹⁰), a radioisotope, as an adjuvant for tumor resection.

Materials and Methods: Between 1989 and 2002, 20 patients with diffuse PVNS were treated with post-operative, intraarticular injection of Y⁹⁰. There were 15 male and 5 female patients who ranged in age from 13 to 67 years (mean, 35 years). Anatomic locations of the affected joints included: knee – 15, ankle – 4, hip – 1. Tumor resection was initially done in all patients: 13 patients required open arthrotomy, the remaining 7 underwent arthroscopic tumor resection. Ten patients were referred for treatment after having operation for a local tumor recurrence: 6 patients had one, 2 had two, 1 had three, and the remaining one had five local recurrences. Six to eight weeks after surgery, intraarticular injection of 15–25 mCi of Y⁹⁰ was done. These procedures were conducted in the operating room under local anesthesia and fluoroscopic guidance. All patients were followed for a minimum of two years (range, 25–168 months; mean, 65 months).

Results: Following Y⁹⁰ injection, all patients reported mild pain around the affected joint. This pain was well controlled with the use of NSAID’s and typically resolved within a few days or weeks. Three patients had superficial skin inflammation and associated blisters around the site of injection, probably the result of Y⁹⁰ effect on the soft-tissues. All were treated conservatively with complete resolution of their symptoms. All patients gained their pre-injection range-of-motion within 4–6 weeks. At the most recent follow-up, five patients had transient post-radiation skin changes (discoloration of the skin and dry and scaly skin) and local recurrence occurred in only one patient (5%) with PVNS around the knee; additional Y⁹⁰ injections were unsuccessful and he eventually underwent knee arthrodesis.

Conclusion: Y⁹⁰ injection is a reliable adjuvant for surgery in the management of diffused PVNS. Local tumor control and good function, associated with only mild morbidity are achieved in the majority of the patients.

Introduction: There is a controversy regarding conservative or surgical treatment of calcaneal fracture. We report our experience in surgical treatment of calcaneal fractures.

Materials and Methods: Between March 1998 and May 2004, 30 patients with 32 calcaneal fractures were treated surgically in our departments. Twenty four fractures were caused after a fall from height, 4 fractures were consequence of a road accident, 2 fractures after a blast injury and one after a football injury. There were 4 females and 26 males. Two cases were bi-lateral fractures. Age range 20–66 (mean 33). Follow-up time 7 to 72 months (mean 24 months). The fractures were classified according to Sanders classification: there were 22 patients with Sanders III, 8 patients with Sanders IV and one patient with Sanders II. All patients were operated with the same procedure and the same surgeon. The surgical procedure was delayed from 10 to 14 days post trauma, until swelling subsided. Open Reduction Internal Fixation was performed using lateral approach, “L” shape with subperiosteal dissection of lateral wall, and using a calcaneal reconstruction plate.

Results: The functional outcome was evaluated according to Rowe Score. The clinical results were excellent in 3 patients (10%), good in 22 patients (70%), fair in 4 patients (14%) and poor in 2 patients (6%). The Boehler angle was reconstructed in 29 of 32 calcaneus. 3 patients returned to their previous level of activity, 9 patients returned to work, 14 patients mentioned some pain in the site of the operation. Two patients were treated successfully with oral antibiotics for superficial wound infection. Six patients suffered from peripheral nerve damage. One patient experienced subtalar pain, and underwent a subtalar arthrodesis, furthermore the patient developed Complex Regional Pain Syndrome (CRPS), finally he underwent below knee amputation (BKA). One patient had a flap necrosis and underwent sural flap coverage with excellent results. All the patients were recognized in a process to be recognized as disabled by the social security.

Conclusion: Our results were good in majority of patients according to the known classification systems. However, the recovery period from calcaneal fractures is long and the majority of patients do not achieve their previous functional level. The secondary gain might bias the results.

The importance of meniscal tears repair is discussed widely in the literature. The repair should be performed if the conditions promise some chance for healing. Due to technical difficulties many orthopaedic surgeons still prefer partial meniscectomy to meniscal repair.

We describe our techniques for meniscal repair. The described techniques could be used by any surgeon with basic skills in arthroscopic surgery. No special equipment is needed.

The basic equipment for this technique is a standard 18 gouge needle. The plastic cup of the needle is cut away in order to overcome the ridge between the plastic and the metal part of the needle, thus making the suture passage easier.

Following the arthroscopic identification of the meniscal tear and preparing the torn parts for repair, the place for the first suture is identified.

A 2–3 mm long skin incision is made. The subcutaneous tissue is bluntly developed to the capsule. The 18 gouge needle is past from outside-in in the desired point through the torn margins of the meniscus. The tip of the needle is emerged above or under the meniscal surface, depends on our decision of suture position.

1st step – Producing a loop outside the joint: Two ends of a nylon 2/0 suture are inserted through the needle into the joint cavity, and pulled out through one of the arthroscopic portals. The needle is removed. The result of this step is a nylon 2/0 suture passing through the torn parts of the meniscus with a loop outside the joint.

2nd step – Producing a double-loop inside the joint cavity: A second nylon 2/0 suture is passed through the first loop. The first suture is pulled into the joint. At this stage, both loops are inside the joint, holding each other. The free ends of the first loop are emerged through one of the arthroscopic portals, while the free ends of the second loop pass through the torn parts of the meniscus and emerge through the capsule.

3rd step – Producing the meniscal suture: A second 19 gouge needle is inserted close to the point of insertion of the first one, directed into the joint. The emerging point of this needle, on the meniscus, should be positioned according to the desired suture direction (transverse, vertical, or oblique). The tip of the needle is then directed into the “2nd” nylon loop (the “1st” nylon loop can assist at this stage). The loop is wrapped over the needle, and the 1st suture is removed.

PDS suture (1/0 or 2/0) is inserted through the needle until a 5 cm free end is positioned intra articular. The needle is removed with caution without pulling the PDS suture, leaving the

PDS free end inside the nylon loop. The nylon loop is used as a pooling tool for the PDS suture. Pulling the free end of the PDS suture out of the joint results in a PDS loop for the meniscal suture (in order to avoid iatrogenic tear of the meniscal tissue while pulling the sutures, a probe should be positioned under the PDS suture during the process). The PDS is tightened over the capsule. The technique is repeated as much as necessary for perfect repair of the meniscus.

The advantage of this method is that it does not necessitates unique equipment, but rather uses the ordinary arthroscopic tools and sutures. This method was used successfully upon large number of meniscal tears. We recommend its use routinely.