Slow Burn (An Azar Nazemi Novel Book 1)

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The Djinn have reveled in their position as the apex predator of the supernatural world. They held the power, and they wielded it with brutal finality. Azar Nazemi has never been a fan of the Djinn regime, especially since she has been forced into fifty years of servitude. It could have been worse. She had a cushy job, a budding romance with the hunky Bast, and was given the freedom to do as she pleased. But all that changes when Djinn kids begin showing up torn to pieces and set on fire. Tasked with tracking down a hate group that has it out for her kind, she travels to Canada on her first mission with The Adel, the Djinn military.

However, what she finds in the Canadian wilderness will threaten everything she takes for granted; her relationships, her sense of self, and even the very foundations of the Djinn regime. They are about to find out that even the predators can quickly become the prey.

You are commenting using your WordPress. You are commenting using your Twitter account. You are commenting using your Facebook account. Notify me of new comments via email. Leave a Reply Cancel reply Enter your comment here From a literature review of successful nonoperative treatment, we have found that all series claimed that "complete" or "grade III" injuries did not include patients with instability in 0 degrees of flexion, with only two exceptions. Good results have been achieved with Fetto and Marshall's grade II or Hughston's grade III injuries, with most reports uniformly supporting nonoperative treatment.

With MRI now able to pinpoint the exact location of injury, treatment decisions are being based on the anatomic location of the MCL failure. Operative treatment has been recommended for situations where there is injury over the whole length of the superficial layer, or a complete injury of both the superficial and deep MCL from the tibia. The patient can start isometric and range of motion exercises immediately. Crutches are discontinued when the patient can walk without limping.

Anti-inflammatory medication appears to be beneficial for soft-tissue healing, but results are still inconclusive. After associated cruciate ligament injuries have been ruled out by MRI, we treat those patients with laxity at 0 degrees of flexion conservatively, as previously described. The exception is those patients with valgus knee alignment and laxity in 0 degrees of flexion.

In those patients, early operative repair should be considered. Though the majority of isolated medial-sided knee injuries can be managed nonoperatively with good results, surgeons may consider operative interventions in specific situations involving complete ligament disruption.

Examples include the presence of intraarticular entrapment of the end of the ligament, a large bony avulsion, a tibial plateau fracture, a complete tibial side avulsion in athletes, or when anteromedial rotatory instability is present on physical examination Figure 5. The authors' summary of operative indications for medial-sided knee injuries is shown in Table 2.

The medial meniscus is displaced medially with entrapment of the distal part of the avulsed ligament underneath it small arrow. Severe hemarthrosis is seen. Please note the bone bruise at the lateral aspect of the lateral femoral condyle suggesting a valgus mechanism large arrow. Primary repair of the MCL is usually performed within seven to ten days after the injury.

Location of the tear and the quality of the tendon as assessed by MRI or arthroscopic examination help guide surgical planning. However, repair in this location may lead to the most problems with postoperative motion because of capsular adhesions and dysfunction of the extensor mechanism. Repair can be performed using either suture anchors or staples to secure the ligament back to its anatomic location on the proximal medial tibia after tension has been restored.

Examination under anesthesia is performed to completely assess the scope of the injury preoperatively. Arthroscopy is performed to rule out any other associated injuries. In addition, arthroscopy can help determine the site of the deep MCL injury, either above or below the meniscus Figure 6. In an acute setting, arthroscopy should be performed quickly and efficiently to minimize fluid extravasation. Alternatively, the surgeon may choose to do any extended arthroscopic procedures after the exposure is made, allowing it to serve as a channel for the drainage of arthroscopic fluid.

The arthroscopic picture in a case of complete medial-sided knee injury demonstrates pathologic widening of the medial compartment and elevation of the meniscus from the medial tibial articular surface indicating a rupture of the meniscotibial ligament. In this case, the loose fibers of the superficial MCL are seen arrow. With combined valgus stress and probing, we were able to identify the loose part distally so as to localize the site of the injury.

Arthroscopy can also be used in chronic cases to direct the surgeon to the area of laxity below or above the joint. An incision is made on the medial side of the knee over the suspected site of injury. To expose the entire MCL, an incision is made from the medial proximal tibia to the medial femoral epicondyle, curving posteriorly in line with the medial intermuscular septum of the thigh.

For isolated repairs either distally or proximally, a more limited approach is used. In the case of combined treatment of acute complete MCL tear and an ACL tear, we have found exposure of the MCL easier if approached through a separate medial incision as opposed to extending the tibial incision for the ACL reconstruction. Care is necessary to preserve the infrapatellar branch of the saphenous nerve if possible.

The sartorial fascia is identified without undermining of the subcutaneous tissue sleeve. The crural and sartorial fascia is incised longitudinally. If dealing with a distal injury, the ruptured ends of the superficial MCL are identified beneath the gracilis and semitendinosus tendons Figure 8A. Hematoma may be encountered in this plane and should be removed to allow direct visualization of all the injuries.

The deep MCL is identified, and the tear is examined. The opening to the joint created by the tear and any injury to the meniscal attachment is inspected. We tend to use Hughston's concept of repairing all of the injured structures in anatomic position. A peripheral tear of the medial meniscus is commonly seen 33 percent and nearly all of these are repairable. The suture knots should be placed on the outside aspect of the posterior oblique ligament in order to recreate the dynamic function of the meniscus.

If it is injured, the posterior oblique ligament is repaired by direct suture back to the femur. The intraoperative fluoroscopic picture of a combined ACL reconstruction and a medial-sided knee repair is shown. The two anchors are used to hold the meniscus down to the tibia and the staple is for superficial MCL stabilization. The torn end of the superficial and deep MCL is elevated demonstrating the medial joint space and the medial meniscus.

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Two anchors were placed and sutures were brought through the peripheral part of the meniscus to repair the deep capsular ligament. The torn end of the superficial MCL was secured with a staple. The very distal part of the ligament is sutured to the remaining tissue. For tibial avulsion injuries, we prefer suture anchor fixation down to the tibial plateau just distal to the subchondral bone.

Repair is completed while the knee is held in varus and full extension. A gentle valgus test should not gap open the medial joint space if the repair is adequate. The avulsed superficial MCL ends can be repaired with anchors, staples, or a screw and washer Figure 8C. This can be aided by placing a locking suture into the substance of the torn end of the ligament that allows either proximal or distal traction to be placed on the ligament as fixation is applied. The semimembranosus portion of the posterior oblique ligament is repaired using interrupted absorbable sutures.

If possible, the anterior border of the torn posterior oblique ligament can be sutured to the posterior border of the repaired MCL in a pants-over-vest fashion Figure 9A — C. Avulsion of medial patellofemoral ligament and tearing of the vastus medialis muscle have been found in association with proximal injuries of the MCL and should be repaired if identified. Technique of posteromedial plication demonstrated in a case with proximal avulsion of the superficial MCL and the posterior oblique ligament. Point A demonstrates the location for suture fixation of the superficial MCL to restore tension.

With the knee in 60 degrees of flexion and the hip externally rotated, the posterior oblique ligament is pulled anteriorly and proximally to point B where it is being reattached. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the ACL. Results of long-term follow-up. J Bone Joint Surg Am The anterior aspect of the posterior oblique ligament is plicated over the superficial MCL in a pants-over-vest fashion.

The lax capsular arm of the semimembranosus tendon is plicated over the restored posterior oblique ligament. Results of long-term follow- up. If injury to the superficial MCL is extensive, augmentation of the repair may be required. The augmentation can be performed through the previously described operative approach.

The gracilis tendon is harvested using a tendon stripper while keeping the tibial insertion attached. The knee is brought to full extension and the deep limb of the figure-of-eight is secured with a suture anchor placed in a bony trough at the posterior aspect of the medial epicondyle. The tendon is stabilized at another anchor fixation point just anterior to the femoral footprint. With the knee in 30 degrees of flexion, the superficial limb of the reconstruction is fixed to the tibia with a suture anchor approximately 2 cm posterior and deep to the pes anserinus insertion.

Finally, the tourniquet is deflated and inspection and control of potential excessive bleeding from the inferior medial geniculate artery and its branches is performed. A compressive dressing is applied postoperatively. The patient is kept non-weight bearing for three weeks in a long hinged knee brace allowing degrees of motion. At 3 weeks the patient is allowed to do full range of motion and weight bearing as tolerated. Progressive activities are started at about six weeks and the brace is gradually weaned off.

Although rare, chronic valgus instability has been described following MCL injury alone or in combination with ACL tears. Multiple reconstruction techniques have been described focusing mainly on reconstruction of the superficial MCL with quadriceps tendon autograft, hamstring autograft, hamstring allograft, or Achilles allograft. Persistent valgus malalignment will cause graft stretching and recurrence of the instability if not corrected. Examination under anesthesia is performed to document all deficient structures. Arthroscopy can be done to rule out and treat intra-articular pathologies if indicated.

The surgical exposure is performed using a hockey-stick approach as described above. The soft tissue flaps are mobilized with a larger inferior flap, allowing exposure of the fascia over the MCL.

MCL Injuries of the Knee: Current Concepts Review

The native superficial MCL is identified and dissected. The soft spot between the posterior aspect of the superficial MCL and the posterior oblique ligament is sharply developed for future possible plication. The center of rotation of the knee joint is identified using a pin technique. A guide pin is drilled into the medial epicondyle parallel to the joint line along the epicondylar axis. One end of suture is fixed to the tibia at the approximate insertion of the superficial MCL. The other end is looped over the pin and the knee is taken through its range of motion.

The length of the suture should not change more than 2 mm if the center axis is correct. An approximately 10 mm reamer is used to make a tunnel 2. We have found allograft bone plugs smaller than 10 mm in diameter to be less reliable and more apt to break during preparation and fixation. An Achilles allograft is prepared so that the calcaneal bone plug can fit into the 10 mm sizer with preservation of the tendon insertion and periosteum on one side.

The 10 mm x 10 mm x 25 mm bone plug is inserted into the tunnel, either freely or using traction sutures and a Beath pin, and fixed with an interference screw on the cancellous side of the bone plug. The tendinous part of the graft can be fixed to the tibia in two ways. The first method, described next, involves drilling a tunnel in the tibia. The soft tissue expanse of the Achilles graft is whip-stitched for cm with 2 Ticron sutures and then sizing is performed. Using a mm reamer, a tibial tunnel is made approximately 5 cm distal to the joint line and just posterior to the gracilis insertion.

The graft is pre-tensioned, and the knee is moved through a range of motion several times. A Beath pin is then inserted freehand into the tunnel aiming about one centimeter lateral to the tibial crest to avoid injury to the peroneal nerve. The graft is pulled into the tunnel and fixed with a soft tissue interference screw while the knee is held in 30 degrees of flexion, valgus, and internal rotation. Alternatively, the broad expanse of the Achilles graft is drawn distally with locking traction sutures.

It then can be fixed in place with two staples or with suture anchors at its anatomic location. Again, the leg should be held in varus at 30 degrees of flexion during fixation. We then evaluate the posterior oblique ligament. With the knee in 60 degrees of flexion and hip in external rotation, the posterior oblique ligament is advanced anteriorly and proximally. It is then fixed to the adductor tubercle using suture anchors. The sutures are tied when the knee is brought to near-full extension. The anterior border of the posterior oblique ligament is sutured over the reconstructed MCL in a pants-over-vest fashion.

The wound is closed and a compressive dressing is applied. Generally, we use the same protocols previously described for postoperative care after an acute repair. The caveat to this method is that the severity of the knee injuries is not totally clear in studies supporting this technique. Such variation in the original injury would definitely impact the outcome. Therefore, at the time of ACL reconstruction, examination under anesthesia must be performed to determine the residual laxity to valgus stress.

We use a residual difference between legs of more than mm with valgus stress at full extension as an indication for MCL reconstruction. The most common complications from the medial-sided knee repair or reconstruction are knee stiffness and residual laxity. Residual instability generally stems from failure to address all the components of the injury, especially the meniscus and posteromedial structures. Repeated examinations during the various stages of repair are important to provide optimal stability.

In addition, awareness of the restraining structures for various knee flexion angles is crucial to correct repair or reconstruction. MCL and medial-sided knee injuries are still major problems in the modern era of sports medicine. With advances in imaging techniques and refined grading of injuries, surgical treatment for medial-sided knee injuries, once popularized by Hughston, may have a role in many cases.

Long-term studies of the most severe category of MCL injuries are needed to define the best treatment. Nonetheless, most medial-sided injuries are best treated nonoperatively, with proven great success. National Center for Biotechnology Information , U. Journal List Iowa Orthop J v. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Medial collateral ligament MCL injury is one of the most common knee injuries, especially in young athletic patients.

ANATOMY The anatomy of the medial side of the knee is complex, being composed of three tissue layers and multiple components with interconnections to the joint capsule, the muscle-tendon units, and the medial meniscus. Open in a separate window. Figure 4 In complete medial-sided knee injuries, the injury completely tears the superficial and deep MCL, as well as the semimembranosus attachments to the femur as shown here.

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TABLE 1 Goal-oriented rehabilitation program for isolated collateral ligament sprains in athletes Initial treatment Apply ice with compressive wrap for 20 minutes and repeat every hours for the first hours. Begin isotonic progressive restrictive exercise for quadriceps and hamstrings; supplement with isokinetic exercise if available. May return to competition if athlete has minimal pain, full range of motion, and 90 percent of normal strength. Continue to use brace for all sports participation for remainder of the season. Operations Surgical Indications Acute repair Presence of intraarticular ligamentous entrapment.

Combined with anterior cruciate or other ligament reconstruction if the examination under anesthesia shows valgus laxity in 0 degrees of flexion. Figure 6 The arthroscopic picture in a case of complete medial-sided knee injury demonstrates pathologic widening of the medial compartment and elevation of the meniscus from the medial tibial articular surface indicating a rupture of the meniscotibial ligament.

Figure 7 The intraoperative fluoroscopic picture of a combined ACL reconstruction and a medial-sided knee repair is shown. Medial collateral ligament injuries of the knee: Peterson L, et al. Incidence of football injuries and complaints in different age groups and skill-level groups. Am J Sports Med. Najibi S, Albright JP. The use of knee braces, part 1: Prophylactic knee braces in contact sports.

Warme WJ, et al. Ski injury statistics, to , Jackson Hole Ski Resort. Incidence, nature, and causes of ice hockey injuries. A three-year prospective study of a Swedish elite ice hockey team. Tegner Y, Lorentzon R. Evaluation of knee braces in Swedish ice hockey players. Br J Sports Med. Paulos LE, et al. The biomechanics of lateral knee bracing.

Response of the valgus restraints to loading. Alpine ski injuries and their prevention. Reider B, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Conservative therapy of ruptures of the medial collateral ligament of the knee. Results of a comparative follow-up study. Non-operative treatment of acute medial collateral ligament lesions of the knee joint.

Knee Surg Sports Traumatol Arthrosc. The nonoperative treatment of isolated complete tears of the medial collateral ligament of the knee. Arch Orthop Trauma Surg. Sandberg R, et al. Operative versus non-operative treatment of recent injuries to the ligaments of the knee.

A prospective randomized study. J Bone Joint Surg Am. The non-operative treatment of collateral ligament injuries of the knee in professional football players. An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically. Nonoperative management of isolated grade III collateral ligament injury in high school football players.

The nonoperative treatment of grade I and II medial collateral ligament injuries to the knee. Medial collateral ligament injuries in football. Nonoperative management of grade I and grade II sprains.

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Iowa and Eugene, Oregon, Orthopaedics. Tipton CM, et al. Influence of exercise on strength of medial collateral knee ligaments of dogs. Surgical anatomy of the knee. The supporting structures and layers on the medial side of the knee: The prime static stabilizer of the medical side of the knee. The role of the posterior oblique ligament in repairs of acute medial collateral ligament tears of the knee. Medial-sided injury patterns revisited.

Pope MH, et al. The role of the musculature in injuries to the medial collateral ligament. Grood ES, et al. Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. Kennedy JC, et al. Tension studies of human knee ligaments.

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Yield point, ultimate failure, and disruption of the cruciate and tibial collateral ligaments.