Prediction of semitendinosus and gracilis autograft sizes for ACL reconstruction

PURPOSE

The aim of this study was to predict the hamstring graft sizes prior to anterior cruciate ligament reconstruction surgery in adults by using preoperative magnetic resonance imaging (MRI).

METHODS

Fifty-one patients with anterior cruciate ligament rupture were prospectively evaluated. Diameter and cross-sectional areas of the gracilis and the semitendinosus tendons at two different levels were measured separately by preoperative MRI. In surgery, harvested gracilis and semitendinosus tendons were measured individually (2-stranded) and together (4-stranded) by using a graft sizing block. Radiological and operative sizes of the grafts were compared by Pearson's correlation test. ROC analysis was done to determine a possible cutoff value for the preoperative measurements.

RESULTS

There were statistically significant correlations between the MR cross-sectional areas of gracilis, semitendinosus, gracilis + semitendinosus and intraoperative graft sizes of 2-stranded gracilis, 2-stranded semitendinosus and 4-stranded gracilis + semitendinosus tendons [P < 0.05]. No significant correlation was observed between the MR diameters of the gracilis, semitendinosus, gracilis + semitendinosus tendons and intraoperative graft sizes of 2-stranded gracilis, 2-stranded semitendinosus and 4-stranded gracilis + semitendinosus tendons [n.s].

CONCLUSION

Cross-sectional areas of the hamstring tendons in MR images can be used to estimate the sizes of hamstring grafts prior to anterior cruciate ligament reconstruction surgery which may be very helpful to predict possible graft insufficiencies and take precautions if needed.

LEVEL OF EVIDENCE

Level IV.

3D printed poly(ε-caprolactone) scaffolds modified with hydroxyapatite and poly(propylene fumarate) and their effects on the healing of rabbit femur defects

A large variety of approaches have been used to treat large and irregular shaped bone defects with less than optimal success due to material or design issues. In recent years patient specific constructs prepared by additive manufacturing provided a solution to the need for shaping implants to fit irregular defects in the surgery theater. In this study, cylindrical disks of poly(ε-caprolactone) (PCL) were printed by fused deposition modeling and modified with nanohydroxyapatite (HAp) and poly(propylene fumarate) (PPF) to create a mechanically strong implant with well-defined pore size and porosity, controllable surface hydrophilicity (with PPF) and osteoconductivity (with HAp). Cytotoxicity, irritation and inflammation tests demonstrated that the scaffolds were biocompatible. PCL/HAp and PCL/HAp/PPF scaffolds were implanted in the femurs of rabbits with and without seeding with rabbit Bone Marrow Stem Cells (BMSC) and examined after 4 and 8 weeks with micro-CT, mechanically and histologically. BMSC seeded PCL/HAp/PPF scaffolds showed improved tissue regeneration as determined by bone mineral density and micro-CT. Compressive and tension stiffness values (394 and 463 N mm-1) were significantly higher than those of the healthy rabbit femur (316 and 392 N mm-1, respectively) after 8 weeks of implantation. These 3D implants have great potential for patient-specific bone defect treatments.

Treatment of Osgood-Schlatter disease: review of the literature

BACKGROUND

Osgood-Schlatter disease (OSD) is a self-limiting condition which occurs commonly in adolescence.

PURPOSE

The objective of this article is to review published literature regarding pathophysiology, diagnosis and treatment of OSD.

METHODS

A search of the literature was performed on the electronic databases PubMed, Cochrane and SCOPUS databases between 1962 and 2016 for pathophysiology, diagnosis and treatment of Osgood-Schlatter disease.

RESULTS

OSD, also known as apophysitis of the tibial tubercle, is a common disease with most cases resolving spontaneously with skeletal maturity. In pathophysiology, the most accepted theory is repetitive knee extensor mechanism contraction. The pain is localized to the anterior aspect of the proximal tibia over the tibial tuberosity. They may describe a dull ache exacerbated by jumping or stair climbing. Radiological evaluation may indicate superficial ossicle in the patellar tendon. Osgood-Schlatter is a self-limited disease and generally ceases with skeletal maturity. Treatment is usually symptomatic. Adults with continued symptoms may need surgical treatment if they fail to respond to conservative treatment. Surgical procedures include open, bursoscopic and arthroscopic technique. Arthroscopic surgery is beneficial over an open procedure due to early postoperative recovery, no incisional scar in front of the tuberosity that usually causes discomfort in kneeling with a better cosmetic result and the ability to address concomitant intra-articular pathology.

CONCLUSION

Osgood-Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood-Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases. Arthroscopic techniques seem to be the best choice of treatment of unresolved Osgood-Schlatter lesions.

Does bone impaction technique reduce tunnel enlargement in ACL reconstruction?

The aim of this study was to investigate effects of bone impaction technique on tunnel enlargement after ACL reconstruction at a minimum 2 years follow-up. Two groups of patients who had been operated upon with the same arthroscopic technique with the exception of tibial tunnel constitution were compared. Twenty-one patients of group A (drilling to 6 mm followed enlargement to 8-9 mm by using dilators) and 23 patients of group B (directly drilling to the size of the graft) were evaluated clinically and radiographically based on multislice computerised tomography (MSCT) retrospectively. At follow-up, there was no statistical difference between tunnel diameters between two groups at the femoral site, but significant difference at the tibial site (p = 0.00192 for coronal; p = 0.0171 for sagittal diameter). Both groups were comparable according pre- and postoperative Lysholm and IKDC scores (p < 0.5 Mann-Whitney U test). Compacted tunnel walls may resist enlargement, suggesting this technique resulted in better tunnel diameter values especially with intratunnel fixation.

The surgical treatment and outcomes of high-pressure injection injuries of the hand

High-pressure injection injuries to the hand are uncommon soft tissue traumas of the hand which are frequently underestimated. They are, however, not uncommon among workers in industry using paint, automotive grease, solvents and diesel oil. The prognostic factors are the type, amount and temperature of the material and the pressure of injection. The results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up are reported. Ten cases required soft tissue debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation, which followed major and devastating soft tissue problems. In the present study, we describe the mechanism of the soft tissue damage and the principles of treatment. This study confirms the fact that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.

Superior Labrum Anterior Posterior Lesions and Associated Injuries: Return to Play in Elite Athletes

BACKGROUND

Superior labrum anterior posterior (SLAP) lesions often cause shoulder pain, dysfunction, and instability. Professional athletes require a high level of shoulder function for competition and overhead activities.

PURPOSE

To evaluate elite athletes who had arthroscopic surgery for common shoulder pathologies and SLAP lesions with a follow-up of more than 3 years. The associated intra-articular pathologies and return to play were documented.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-five shoulders in 34 elite athletes (4 women and 30 men; mean age, 25 years [range, 18-32 years]) had arthroscopic repair of SLAP lesions and accompanying Bankart or rotator cuff tears between January 2008 and November 2011. The documentation included patient symptoms, physical examination, radiological analysis with radiographs, and magnetic resonance imaging. Shoulder function was evaluated preoperatively and at follow-up using American Shoulder and Elbow Surgeons (ASES) and Kerlan Jobe Orthopaedic Clinic (KJOC) scores. The mean follow-up was 52 months.

RESULTS

Isolated SLAP lesions were seen in 17.1% of patients, SLAP lesions and partial cuff tear occurred in 25.7%, associated Bankart lesions in 37.1%, full-thickness rotator cuff tears in 8.6%, Bankart and posterior labrum lesions in 8.6%, and Bankart and full-thickness rotator cuff tears in 2.9%. Return to play was a mean 6.4 ± 1.5 months. The mean postoperative ASES and KJOC scores were 89.6 ± 4.6 and 80.9 ± 6.8, respectively, compared with preoperative scores of 64.0 ± 7.2 and 50.5 ± 10.3 (t test, P < .01).

CONCLUSION

The majority (88.2%) of professional athletes returned to their preinjury levels. SLAP lesions may frequently occur with Bankart lesions and rotator cuff tears. A high rate of return to sport at the same level of athletic performance can be achieved by anatomic repair and effective rehabilitation.

Cytotoxicity of local anesthetics to rats' articular cartilage: an experimental study

OBJECTIVE

The aim of this study was to evaluate the effects of both in vivo and in vitro bupivacaine, levobupivacaine and tramadol on articular cartilage and chondrocytes in experimental rat models.

METHODS

Thirty mature Sprague Dawley rats weighing 230-300 g were randomized into 3 groups. Bupivacaine (Group 1), levobupivacaine (Group 2) and tramadol (Group 3) were injected into the right knee joints and a physiological 0.9% saline into the left. From each group, 5 rats were executed 48 hours following drug administration after 5 and 10 days. The specimens were fixed, decalcified and stained with hematoxylin & eosin and toluidine blue. All samples were histopathologically evaluated according to the recommendation of ICRS' osteoarthritis and cartilage histopathology grading and staging system. Articular cartilage cells of the rats were cultured and seeded into cell culture flasks. Cartilage cell seeded samples (104 cells/ml) were incubated in three different anesthetic agents (0.5%); bupivacaine, levobupivacaine, and tramadol, respectively. CellTiter 96(®) Non-Radioactive Cell Proliferation (MTS) assay was used to determine the cell density on the samples.

RESULTS

Statistically significant higher OARSI grades and OA stage and scores were detected when comparing the group injected with levobupivacaine and executed after 10 days with the levobupivacaine injected group killed after 48 hours (p<0.01 [p=0.008]). Although, statistical analysis could not be done due to insufficient number of samples in the in vitro part of the experiment, it can be concluded that tramadol is cytotoxic to rat chondrocyte in vitro after 30 min of exposure. Additionally, cell numbers in both the bupivacaine and levobupivacaine treated wells showed decrease throughout 15, 30 and 60 minute exposures.

CONCLUSION

Although chondrotoxicity of bupivacaine was less harmful than levobupivacaine and tramadol, these findings suggest that local anesthetics may negatively affect articular cartilage and chondrocytes.

Arthroscopic excision of an ununited ossicle due to Osgood-Schlatter disease

Surgical excision of the ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. A 24-year-old, male semiprofessional soccer player had anterior knee pain during sports activity and climbing stairs that had been treated conservatively for 2 years. On physical examination, there was a permanent tibial tubercle with pain. On radiographic examination, an ununited ossicle was seen beneath the patellar tendon. Arthroscopy was performed through the standard low anterolateral and anteromedial portals close to the patellar tendon. Soft tissue at the retropatellar surface and the inflamed infrapatellar fat pad beneath the patellar tendon were debrided with a motorized shaver. Localization of the ununited ossicle was performed by use of an image intensifier. The ossicle was separated from the surrounding soft tissue with a motorized shaver and removed by use of a grasper. After excision of the ossicle, the inflamed surface of the retropatellar tendon was also debrided. The contouring of the irregular surface of the tibial tubercle was performed by use of a motorized bur. After 6 weeks, the patient returned to sports activities without any restrictions. This study showed that all of the described procedures might be done arthroscopically and sports activity may be allowed earlier.

Acrylic bone cements: Effects of the poly(methyl methacrylate) powder size and chitosan addition on their properties

The effect of the particle size of poly(methyl methacrylate) (PMMA) and the incorporation of chitosan (CH) on the mechanical and thermal properties and the biocompatibility of acrylic bone cements were investigated. Three groups of bone cements were prepared with different PMMA particles. Groups 1 (BC1) and 2 (BC2) contained ground and sieved PMMA with particle sizes in the ranges 50–150 μm and 1–50 μm, and group 3 (BC3) contained synthesized PMMA microspheres with a size of about 1 μm. The mechanical properties of the three groups were similar, but their curing properties were significantly affected. The presence of CH improved the mechanical and thermal properties. For the BC1 group, the compressive strength increased more than 10 MPa, and the curing temperature decreased 12°. The cement having the optimum properties (BC1) was applied to rats, where it enhanced the bone bonding ability, and bioactivity was observed. © 2013 Wiley Periodicals, Inc. J. Appl. Polym. Sci. 2014, 131, 39662.

Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci

Osteochondritis dissecans is a form of osteochondrosis limited to the articular epiphysis and the relationship of osteochondritis dissecans and discoid lateral meniscus has been clearly identified. This article presents a 10-year-old boy with osteochondritis dissecans of the medial femoral condyle associated with hypoplastic medial and partial deficient lateral menisci. The patient presented with activity-related pain and intermittent swellings of his left knee for 2 months without any evidence of significant knee trauma. Magnetic resonance imaging revealed anomalous medial meniscus mimicking displaced bucket-handle tear and partially deficient lateral meniscus with osteochondritis dissecans at the lateral aspect of medial femoral condyle without any significant bone loss with a non-dislocated fragment. Arthroscopy of the knee revealed an incomplete separated osteochondral flap with partial discontinuity that was unstable on probing on the lateral aspect of the medial femoral condyle. The medial meniscus was hypoplastic without a body and only the meniscal rim could be seen. The lateral meniscus had an anomalous vertical insertion of the posterior horn, normal body, but an absent anterior horn. The anterior cruciate ligament was intact, but looked like a peacock's tail. Arthroscopic fixation of the chondral lesion was performed. At 30-months follow-up, the boy had no limitation in his daily and sports activity. The present case is the first description of congenital anomaly of the both menisci and osteochondritis dissecans together. Meniscal or ligamentous anomalies of the knee may be associated with osteochondritis dissecans.

Intraarticular tramadol plus pericapsular incisional bupivacaine provides better analgesia than intraarticular plus pericapsular incisional bupivacaine after outpatient arthroscopic partial meniscectomy

Postoperative analgesic effects of intraarticular tramadol plus periarticular bupivacaine, and intraarticular plus periarticular bupivacaine injections after day-case arthroscopic partial meniscectomy were compared. Seventy-four ASA I/II patients undergoing arthroscopic partial meniscectomy, performed by a single surgeon under general anesthesia were assigned in a randomized, double-blinded manner into two groups: Group TB (n = 41) received intraarticular 100 mg of tramadol in 20 ml normal saline and periarticular incisional injection of 10 ml bupivacaine 0.5%. Group BB (n = 33) received intraarticular 20 ml 0.25% and periarticular incisional 10 ml 0.5% bupivacaine injections. The injections were performed immediately after the portal closures. Pain was assessed with visual analog scale (VAS) at 0, 15, 30 min and at 1, 2, 4 h at rest and active 90 degrees knee flexion by a blinded observer. The first additional analgesic requirement time was recorded. The patients were discharged the same day with a prescription for paracetamol as required, up to six tablets a day and questioned for analgesic use and pain score at 24 h. VAS scores at rest at 15, 30 min and at movement at 0, 15, 30 min were lower in group TB (P < 0.05). First time requiring additional analgesia was lower in group TB (17.1 +/- 21.9, 33.8 +/- 26.6) (P < 0.05) and total paracetamol dose at the end of 24 h was 1.2 +/- 1.5 g in group BB and 0.9 +/- 1.3 g in group TB (P < 0.05). Intraarticular tramadol plus periarticular bupivacaine combination provides better pain relief and less analgesic requirement following arthroscopic outpatient partial meniscectomy surgery.

Results of arthroscopic treatment in unresolved Osgood-Schlatter disease in athletes

AIM OF THE STUDY

In this study we aimed to determine outcomes following arthroscopic ossicle excision in athletes with unresolved Osgood-Schlatter disease (OSD).

METHOD

Arthroscopy was performed on 11 patients (11 knees) with OSD between September 2008 and November 2014. Surgical treatment inclusion criteria were determined as: failure of conservative treatment; isolated pain over the tibial tubercle and distal patellar tendon; pain limiting sporting performance at a competitive level. All patients had a documented history of OSD; the mean duration of persistent pain over the tibial tubercle was 15.5 months. The mean age was 23 years. The mean follow-up period was 66.1 months.

RESULTS

The mean latency in returning to sports related training activities after the surgery was 6.7 weeks. The mean Kujala patello-femoral score improved from 82.9 points pre-operatively, to 98.5 points at the final follow-up (p < 0.01). The mean Lysholm knee scale score was 87.5 points in the pre-operative period, increasing to a score of 96.9 points at final follow-up (p < 0.01). The mean Tegner activity level score was 7.5 in the pre-operative period, increasing to 8.5 post-operatively (p < 0.01).

DISCUSSION

We investigated the functional outcomes after arthroscopic treatment of unresolved OSD in athletes. All athletes with OSD showed satisfactory functional recovery following arthroscopic treatment. All patients were able to return to the same level of athletic activity.

CONCLUSION

Arthroscopic surgery for unresolved OSD has the major advantage of faster recovery and avoiding damage to the patellar tendon.

Cartilage repair strategies in the knee: A survey of Turkish surgeons

OBJECTIVES

The purpose of this study was to analyze the trends in cartilage repair strategies among Turkish orthopedic surgeons for isolated focal (osteo)chondral lesions of the knee joint.

MATERIALS AND METHODS

A web-based survey of 21 questions consisting of surgical indications, techniques and time to return to sports was developed to investigate the preferences of members of the TOTBID and the TUSYAD.

RESULTS

A total of 147 surgeons answered the questionnaire.70% of the respondents were TUSYAD members. 82% of respondents had at least five years experience in arthroscopy. Half of the surgeons indicated that patient age of 50 was the upper limit for cartilage repair. Irrespective of activity level, microfracture (60-67%) was the most frequently used technique for lesions smaller 2.5 cm2. In lesions larger than 4 cm2, MACI was the most commonly advocated procedure (67%). In patients with high activity levels, mosaicplasty was the first choice (69%) for lesions between 2.5 and 4 cm2 in size, followed by MACI (27%).

CONCLUSION

Patient age, activity level, BMI and lesion size were important determinants for the choice of treatment of isolated chondral lesions in the knee. These results reflect the choices of experienced knee surgeons in the country. Although not widely performed in Turkey and has limited reimbursement by the health care system, the first choice for defects over 4 cm2 was second generation ACI. Third party payers & health reimbursement authorities should take into account that large defects require methods which are relatively expensive and need high technology. Cross-sectional survey, Level II.

Locked anatomic plate fixation in displaced clavicular fractures

OBJECTIVE

We aimed to evaluate the results and complications of open reduction and internal fixation by locked anatomic plates in adult midshaft clavicular fractures.

METHODS

Sixteen patients (11 males, 5 females; mean age: 39.6 years) who underwent open reduction and internal fixation with locked anatomic plate for displaced-comminuted midshaft clavicular fractures and were followed-up for at least one year were reviewed retrospectively. Complications in the early and late postoperative periods and functional scores according to the Constant and DASH scoring systems from the latest follow-up were evaluated.

RESULTS

Mean follow-up period was 24.6 (range: 12 to 52) months and mean union time was 13.3 (range: 10 to 23) weeks. None of the patients had superficial and/or deep infections in the early postoperative period or neurovascular complications. Two (12.5%) patients had implant irritation. In two (12.5%) patients, implant failure was detected in the late postoperative period. Delayed union was suspected in these patients and they were operated with longer plate and grafting in the 4th month. At the final follow-up, none of the patients had nonunion or malunion and the mean Constant and DASH scores were 85.5 and 12.8, respectively. Constant scores in patients with complications (p=0.007) and DASH scores in patients with no complications (p=0.001) were significantly lower.

CONCLUSION

Fixation with locked anatomic plates in displaced midshaft clavicular fractures has lower complication rates. Possible postoperative complications are generally associated with implant irritation and failure. These problems can be avoided with the development in implant technology and new implant designs.

Avulsion fractures from the base of phalanges of the fingers

Avulsion fractures of the phalanges are among challenging problems encountered in the hand surgery. These fractures are characterized by existence of small bone fragments usually attached to a collateral ligament. They mostly occur in metacarpophalangeal and proximal interphalangeal joints. Bony gamekeeper's thumb is one of the well-known. Inadequate reduction and healing of these fractures may lead to joint deformity, chronic instability and posttraumatic arthritis. Existence of very small bone fragments and involvement of joint surface are the obvious factors predisposing to technical problems in reposition and fixation of these fractures. Avulsion fractures are intraarticular according to their configuration and need anatomic reduction. AO principles depending on stable fixation and compression have difficulties to be applied to these fractures owing the inconvenience of the osteosynthesis materials and implants available are designed for fracture fixation of larger bones. Fixation may result in further comminution of the fragments.

Composite osteocutaneous groin flap combined with neurovascular island flap for thumb reconstruction

Three amputated thumbs were reconstructed with a composite osteocutaneous groin flap and a neurovascular island flap. The average age at the time of surgery was 28 (range 25-35) years. The level of the amputation was distal to metacarpophalangeal joint in two cases and proximal in one case. The injury mechanism was avulsion in all cases. The postoperative follow-up periods ranged from 27 to 30 months. There were no cases of skin necrosis, bone resorption or infection. Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients. This surgical procedure is reliable and simple and the functional results are satisfying. We reserve this technique for the treatment of thumb amputations which cannot be replanted, particularly as it does not result in bone resorption.

Investigation of Vasculogenesis Inducing Biphasic Scaffolds for Bone Tissue Engineering

Vascularization is the main obstacle for the bone tissue engineering strategies since the defect size is generally large. Incorporation of angiogenic factors is one of the strategies employed in order to accelerate vascularization and improve bone healing. In this study, a biphasic scaffold consisting of fibrous poly(lactide-co-glycolide) (PLGA) and poly(lactide-co-glycolide)-block-poly(ethylene glycol)-block-poly(lactide-co-glycolide) (PLGA-PEG-PLGA) hydrogel loaded with vascular endothelial growth factor-A (VEGF) inducer, GS4012, was constructed. Mesenchymal stem cells isolated from rat bone marrow (rBMSCs) were used for differentiation into osteogenic cells, and endothelial cells isolated from rat peripheral blood (rPBECs) were used to test the in vitro endothelial cell recruitment. The biphasic scaffold was tested for cell proliferation, ALP expression, VEGF induction, expression of osteogenic genes by rBMSCs, and recruitment of rPBECs in vitro and for improved bone healing and vascularization in vivo on critical size rat cranial defects. Endothelial migration through porous insert and VEGF induction were obtained in vitro in response to GS4012 as well as the upregulation of ALP, Runx2, Col I, and OC gene expressions. The biphasic scaffold was also shown to be effective in improving endothelial cell recruitment, vascularization, and bone healing in vivo. Thus, the proposed design has a great potential for the healing of critical size bone defect in tissue engineering studies according to both in vitro and in vivo investigations.

Does the Application of Platelet-Rich Fibrin in Anterior Cruciate Ligament Reconstruction Enhance Graft Healing and Maturation? A Comparative MRI Study of 44 Cases

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction performed with growth factors and activated platelets has been suggested to accelerate tendon ligamentization, leading to earlier return to daily activities and sports.

HYPOTHESES

Platelet-rich fibrin (PRF) will result in improved graft maturation and healing as evaluated by magnetic resonance imaging (MRI) in patients undergoing hamstring ACL reconstruction. Hemostatic and analgesic properties of PRF will lead to less postoperative blood loss and pain.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 44 patients with isolated ACL injuries who underwent arthroscopic all-inside anatomic single-bundle ACL reconstruction with semitendinosus tendon graft were enrolled. Group 1 included 23 patients who had PRF sprayed to the surface of the graft; group 2 included 21 patients for whom no PRF was used. Patients were discharged after 24 hours and examined for hemarthrosis that needed to be aspirated. MRI was performed at the fifth postoperative month. A blinded radiologist evaluated graft maturation according to its signal intensity and the presence of synovial fluid at the tunnel-graft interface.

RESULTS

PRF-treated grafts demonstrated lower MRI signal intensity and less fluid in the graft-tunnel interface as compared with controls for the entire length of the graft. The mean full-length MRI signal intensities were 9.19 versus 16.59 (P = .047) for groups 1 and 2, respectively. Subgroup analysis of the semitendinosus grafts demonstrated a signal intensity of 11.57 versus 23.98 (P = .044) for the proximal third, 9.53 versus 13.83 (P = .237) for the midbody, and 6.48 versus 11.98 (P = .087) for the distal third. Synovial fluid at the graft-tunnel interface was detected in 1 patient in group 1 (4.3%) and 3 patients in group 2 (14.3%; P < .001). Patients in group 1 had significantly less hemarthrosis that needed to be aspirated (P = .003), while postoperative analgesia requirements were similar in both groups (P = .08). No clinical benefit of PRF could be demonstrated in clinical outcomes.

CONCLUSION

Application of PRF led to superior graft integration and maturation in the proximal third of the ACL graft. There was no significant difference in MRI signal intensity in the midbody or distal tibial graft. Application of PRF also resulted in significantly lower rates of postoperative hemarthrosis that needed to be aspirated.

Single anterior portal: A better option for arthroscopic treatment of traumatic anterior shoulder instability?

OBJECTIVE

The aim of this study was to compare single and double anterior portal techniques in the arthroscopic treatment of traumatic anterior shoulder instability.

METHODS

A total of 91 cases who underwent arthroscopic Bankart repair for anterior shoulder instability were reviewed. The patients were divided into 2 groups as Group 1 (47 male and 2 female; mean age: 25.8 ± 6.8) for arthroscopic single anterior portal approach and Group 2 (41 male and 1 female; mean age: 25.4 ± 6.6) for the classical anterior double portal approach. The groups were compared for clinical scores, range of motion, analgesia requirement, complications, duration of surgery, cost and learning curve according to a short questionnaire completed by the relevant healthcare professionals.

RESULTS

No statistically significant difference was found between the 2 groups in terms of pre-operative and post-operative Constant and Rowe Shoulder Scores, range of motion and complications (p > 0.05). In Group 2 patients, the requirement for post-operative analgesics was significantly higher (p < 0.001), whereas the duration of surgery was statistically significantly shorter in Group 1 (p < 0.001). In the assessment of the questionnaire, it was seen that a single portal anterior approach was preferred at a higher ratio (p = 0.035). The cost analysis revealed that the cost was 5.7% less for patients with a single portal.

CONCLUSION

In the arthroscopic treatment of traumatic anterior shoulder instability accompanied by a Bankart lesion, the anterior single portal technique is as successful in terms of clinical results as the conventional double portal approach. The single portal technique has advantages such as less postoperative pain, a shorter surgical learning curve and lower costs.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Topical co-delivery of platelet rich fibrin and tranexamic acid does not decrease blood loss in primary total knee arthroplasty compared to the standard of care: a prospective, randomized, controlled trial

PURPOSE

The purpose of this study was to evaluate the efficacy of intra-operative co-administration of tranexamic acid (TA) and platelet rich fibrin (PRF) using a proprietary co-delivery system on the amount of blood loss, early functional outcomes and wound complications after primary total knee arthroplasty (TKA). The intervention was compared to the standard of care (combined intravenous & topical TA) in a prospective, randomized, blinded setting.

METHODS

80 patients undergoing primary cemented TKA without tourniquet were prospectively randomized into control (combined intravenous and topical TA) and PRF (intra-venous TA and co-delivery of topical PRF and TA) groups after informed consent. Total blood loss, drainage blood loss, knee range of motion, VAS pain scores, length of stay and wound complications were analysed. Data collection was performed in a double blind manner on days 1, 3 and 21.

RESULTS

There was no statistically significant difference in drainage blood loss (550 ml vs. 525 ml, p = 0.643), calculated total blood loss on day 1 (401 ml vs. 407 ml, p = 0.722), day 3 (467 ml vs 471 ml, p = 0.471) and day 21 (265 ml vs. 219 ml, p = 0.082) between the PRF and control groups respectively. The PRF group had a small but statistically significant increase in median knee extension in the early post-operative period, however this difference evened out at 3 weeks. No significant difference could be demonstrated between the PRF and control groups in length of stay, VAS pain scores, narcotic usage, wound complications and knee flexion at all time points.

CONCLUSIONS

The topical co-delivery of PRF and TA does not significantly decrease blood loss in primary TKA compared to the standard of care. Slightly better active knee extension in the first 3 postoperative days can be achieved, however this benefit is not clinically relevant.

LEVEL OF EVIDENCE

I, Therapeutic study.

Diffuse idiopathic skeletal hyperostosis as a cause of acute respiratory distress in early postoperative period of total knee arthroplasty

Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder among the elderly. The diagnosis is made on radiological findings and most of the cases are asymptomatic. In the cases with spinal involvement, bridging ossification of the anterior longitudinal ligament is a common finding. We report a case of DISH, who developed respiratory distress after bilateral total knee arthroplasty operation. The acute occurrence of symptoms after general anesthesia is a rare manifestation of the disease. Radiological findings and the result of surgical resection of anterior cervical osteophytes are discussed.

Lengthening of replanted or revascularized lower limbs: is length discrepancy a contraindication for limb salvage?

Some replantation cases require substantial bone shortening for primary closure. Leg-length discrepancy can be restored by lengthening of the replanted or revascularized extremities. Between 1991 and 2000, four patients with four total and two subtotal below-knee amputations had replantation or revascularization for their severely damaged extremities. All of them had extensive debridement, vascular repair, bone shortening and nerve repair for sensibility of their soles. One of the replanted extremities failed and had to undergo below-knee amputation because of sepsis. No other infection or vascular complications were encountered following the replantations or revascularizations. After bony consolidation, four legs were lengthened; for elimination of length discrepancy in three cases, and for obtaining balanced body proportion in one case in which the other leg was also amputated. In all procedures, a unilateral dynamic axial external fixator was used. The lengthening was performed from the proximal tibial metaphysis, with a subperiosteal osteotomy. Evaluation of injury according to the Mangled Extremity Severity Score (MESS) would encourage the surgeon to avoid salvage surgery with a shortened extremity, because of the required debridement of soft tissue and bone. These authors think the amount of limb shortening is not a major criterion in evaluating a traumatic total or subtotal below-knee amputation for salvage replantation or revascularization. A knee that has stable joint motion and the possibility of preservation of sensibility of the sole broadens the scope of indications for limb salvage, even with deliberate shortening that can be restored by lengthening; length discrepancy is not a contraindication for limb salvage.