The "Magnesium Sacrifice" Strategy Enables PMMA Bone Cement Partial Biodegradability and Osseointegration Potential

Poly (methyl methacrylate) (PMMA)-based bone cements are the most commonly used injectable orthopedic materials due to their excellent injectability and mechanical properties. However, their poor biocompatibility and excessive stiffness may cause complications such as aseptic implant loosening and stress shielding. In this study, we aimed to develop a new type of partially biodegradable composite bone cement by incorporating magnesium (Mg) microspheres, known as "Mg sacrifices" (MgSs), in the PMMA matrix. Being sensitive to the physiological environment, the MgSs in PMMA could gradually degrade to produce bioactive Mg ions and, meanwhile, result in an interconnected macroporous structure within the cement matrix. The mechanical properties, solidification, and biocompatibility, both in vitro and in vivo, of PMMA⁻Mg bone cement were characterized. Interestingly, the incorporation of Mg microspheres did not markedly affect the mechanical strength of bone cement. However, the maximum temperature upon setting of bone cement decreased. This partially biodegradable composite bone cement showed good biocompatibility in vitro. In the in vivo study, considerable bony ingrowth occurred in the pores upon MgS degradation. Together, the findings from this study indicate that such partially biodegradable PMMA⁻Mg composite may be ideal bone cement for minimally invasive orthopedic surgeries such as vertebroplasty and kyphoplasty.

Soft Tissue Atrophy Related to Corticosteroid Injection: Review of the Literature and Implications for Hand Surgeons

Corticosteroid injections (CIs) are frequently used by hand surgeons to treat a wide range of pathology including de Quervain tenosynovitis and lateral epicondylitis. Although generally viewed as a benign modality, and a way to potentially avoid or postpone surgical intervention, common complications from CI should be considered and discussed with patients before the procedure. One such complication is local soft tissue atrophy and hypopigmentation after injection. We discuss the incidence of soft tissue-related adverse effects from CI, the pathophysiology and influence of different steroid preparations on soft tissues, and potential treatment options once atrophy has occurred.

Anterior Shoulder Stabilization Using a Single Portal Technique With Suture Lasso

Open Bankart repair was the standard technique used in the past, but the request for less invasiveness, always pursued by every surgeon, pushed the development of the arthroscopic procedure. Nowadays the stabilization of the anteroinferior labrum is usually performed with an arthroscopic technique that uses the classic posterior portal and 2 anterior working portals. Because arthroscopy is progressing steadily under every aspect, there is now the chance to use only one working portal with the aid of a suture passer. One less portal not only means less invasiveness but also less postoperative pain and possible shorter operative time. This Technical Note is focalized in the description of a Bankart repair technique with a single working portal and the aid of a suture lasso.

Recent Advances in Extrusion-Based 3D Printing for Biomedical Applications

Additive manufacturing, or 3D printing, has become significantly more commonplace in tissue engineering over the past decade, as a variety of new printing materials have been developed. In extrusion-based printing, materials are used for applications that range from cell free printing to cell-laden bioinks that mimic natural tissues. Beyond single tissue applications, multi-material extrusion based printing has recently been developed to manufacture scaffolds that mimic tissue interfaces. Despite these advances, some material limitations prevent wider adoption of the extrusion-based 3D printers currently available. This progress report provides an overview of this commonly used printing strategy, as well as insight into how this technique can be improved. As such, it is hoped that the prospective report guides the inclusion of more rigorous material characterization prior to printing, thereby facilitating cross-platform utilization and reproducibility.

Does the graft-tunnel friction influence knee joint kinematics and biomechanics after anterior cruciate ligament reconstruction? A finite element study

Graft tissues within bone tunnels remain mobile for a long time after anterior cruciate ligament (ACL) reconstruction. However, whether the graft-tunnel friction affects the finite element (FE) simulation of the ACL reconstruction is still unclear. Four friction coefficients (from 0 to 0.3) were simulated in the ACL-reconstructed joint model as well as two loading levels of anterior tibial drawer. The graft-tunnel friction did not affect joint kinematics and the maximal principal strain of the graft. By contrast, both the relative graft-tunnel motion and equivalent strain for the bone tunnels were altered, which corresponded to different processes of graft-tunnel integration and bone remodeling, respectively. It implies that the graft-tunnel friction should be defined properly for studying the graft-tunnel integration or bone remodeling after ACL reconstruction using numerical simulation.

Displaced midshaft clavicle fracture in athletes - should we operate?

Objective

To assess the results of the treatment of fractures of the middle third of the clavicle with a pre-contoured plate in athletes.

Methods

The authors performed 26 osteosyntheseis in 25 patients with fractures of the middle third of the clavicle. The fractures were classified according to Robinson as 16 type B1 and ten type B2. The mean age was 37 years, ranging from 15 to 63 years, 20 patients were male and five were female, and all play sports in an amateur or professional manner. All patients were operated on in the acute phase of fracture within five days after trauma. Patients were treated with open reduction and internal fixation using pre-contoured plates. The technique and the implant used were the same, but the time of immobilization and rehabilitation protocol were individualized for each patient according to physical activity. Mean follow-up was 16.8 months (6–48 months), with return to sport activities in 45.6 days.

Results

Functional assessment was performed using the University of California at Los Angeles (UCLA) score. The results averaged 34.07 of 35 points. No cases presented nonunion. Only one complication was observed (thrombosis of the subclavian vein with good response to conservative treatment); two patients required implant removal.

Conclusion

The surgical treatment of clavicle fractures in athletes presented satisfactory functional outcome and early return sport.

Effects of a telescopic intramedullary rod for treating patients with osteogenesis imperfecta of the femur

PURPOSE

To introduce a new model of telescopic intramedullary rod (TIR), evaluate its effects on treating patients presenting with moderate and severe osteogenesis imperfecta (OI) and to compare the findings with those of other telescopic rods.

METHODS

A total of 21 patients (nine girls and 12 boys; mean age at first operation, 6.6 years, 1.52 to 13.18) who underwent 52 femoral operations were monitored during a mean of 9.96 years (3.39 to 14.54). Patient characteristics, telescoping rod capability and its complications were examined.

RESULTS

According to the Sillence classification, we investigated one patient with type I, nine with type III and 11 with type IV OI. Revision rates at up to five years (36%) were inferior to those found for the Fassier-Duval rod (46%). The main cause of revision was fracture (15 patients), followed by rod migration (nine), and infection (two). The rod exhibited higher telescopic capacity in boys than girls. Type III most commonly required an operation; the age group with the highest number of procedures was five to ten years. Male migration was the main cause of rod migration.

CONCLUSION

The TIR has a satisfactory cost-benefit ratio with less complication rates and low production costs. The TIR is a feasible alternative to the commonly used Fassier-Duval rod.

LEVEL OF EVIDENCE

IV.

Preoperative Ultrasonography Is Unreliable in Predicting Hamstring Tendon Graft Diameter for ACL Reconstruction

Background:

Hamstring autograft size <8 mm has been shown to be a predictor for failure after anterior cruciate ligament (ACL) reconstruction. The ability to predict graft size preoperatively is helpful in counseling patients about the possible need for graft augmentation.

Purpose:

To determine whether preoperative ultrasound (US) measurements of hamstring tendons can predict intraoperative graft diameter during ACL reconstruction.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Twenty patients undergoing unilateral isolated ACL reconstruction were prospectively enrolled in the study (10 males, 10 females; mean ± SD age, 22.8 ± 6.6 years; height, 175.1 ± 7.1 cm; weight, 81.4 ± 14.2 kg; body mass index, 26.5 ± 4.1 kg/m²). Hamstrings were assessed by US, and double-looped semitendinosus-gracilis hamstring size was independently calculated with a freehand selection method on a nonmagnified US image by 2 orthopaedic surgeons. Intraoperative autograft size was determined with a standard graft-sizing tool. Intra- and interrater reliability was measured with intraclass correlation coefficients (ICCs) and standard error of the measure (SEM). A receiver operating characteristic curve was calculated to assess the ability of the US measurement to predict intraoperative measurements.

Results:

The mean autograft diameter by US was 8.9 ± 0.98 mm, while the mean intraoperative hamstring graft size was 8.1 ± 0.89 mm. There was excellent intrarater (ICC_2,1 = 0.95, SEM = 0.32 mm) and interrater (ICC_2,1 = 0.88, SEM = 0.55 mm) reliability for US measurements. Receiver operating characteristic analysis showed that US did not consistently quantify graft size. Graft size did not significantly correlate with height, weight, or body mass index in our sample (P > .05).

Conclusion:

These results suggest that preoperative US imaging of the hamstring tendons is unreliable in predicting intraoperative graft diameter.

Stem Cell and Advanced Nano Bioceramic Interactions

Bioceramics are type of biomaterials generally used for orthopaedic applications due to their similar structure with bone. Especially regarding to their osteoinductivity and osteoconductivity, they are used as biodegradable scaffolds for bone regeneration along with mesenchymal stem cells. Since chemical properties of bioceramics are important for regeneration of tissue, physical properties are also important for cell proliferation. In this respect, several different manufacturing methods are used for manufacturing nano scale bioceramics. These nano scale bioceramics are used for regeneration of bone and cartilage both alone or with other types of biomaterials. They can also act as carrier for the delivery of drugs in musculoskeletal infections without causing any systemic toxicity.

The enhanced osteogenesis and osteointegration of 3-DP PCL scaffolds via structural and functional optimization using collagen networks

Optimal balance between biological activity and mechanical stability should be meticulously considered during scaffold design for bone tissue engineering applications. To fabricate an individualized construct with biomechanical and biological functionality for bone tissue regeneration, a polycaprolactone–collagen (PCL–COL) composite construct was developed through the combination of three-dimensional printing (3-DP) technology and biomimetic collagen matrix incorporation, with a 3-DP PCL framework maintaining the mechanical stability and a porous collagen matrix improving the biological activity. The results indicate that the compressive modulus of the composite constructs increased synergistically (over 40 MPa), providing sufficient mechanical support during new bone formation. On the other hand, the collagen matrix with a micro-porous architecture structurally increased scaffold areas and provided cellular adhesion sites, allowing for the functional construction of a favorable 3D microenvironment for BMSC adhesion, proliferation and extracellular matrix production. Moreover, critical-sized long bone defect (CSD) implantation demonstrated that the optimized composite constructs could promote bone tissue regeneration (5.5-fold) and bone-material osteointegration (4.7-fold), and decrease fibrosis encapsulation, compared to pristine PCL. The results indicate that these biomimetically ornamented PCL–COL constructs exhibit favorable mechanical properties and biological functionality, demonstrating great potential as an effective bone graft substitute for bone defect treatment. Meanwhile, they can also harness the advantages of 3-DP technology and a collagen-based functionalized strategy, facilitating the creation of customized and functional PCL–COL constructs for clinical translation.

Optimal balance between biological activity and mechanical stability should be meticulously considered during scaffold design for bone tissue engineering applications.

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.

The isolated posterior malleolar fracture and syndesmotic instability: A case report and review of the literature

INTRODUCTION

Ankle fractures are among the most common type of fractures in the lower extremity. A posterior malleolar fracture is frequently part of a more complex ankle fracture and only in rare cases it occurs as isolated injury. Posterior malleolar fractures often occur with associated injuries, such as a Maisonneuve fracture or with bi- or trimalleolar ligamentous injuries. Knowledge about these associated injuries is essential to prevent missed diagnoses. The aim of this article is to describe the isolated posterior malleolar fracture, the possible associated injuries, the diagnostic work-up and therapeutic consequences.

PRESENTATION OF CASE

We present a case of a 26-year-old male patient who sustained an isolated posterior malleolar fracture with 4.5 years follow-up.

DISCUSSION

Isolated fractures of the posterior malleolus are uncommon injuries. Diagnosis, treatment and outcome can seldom be extracted from large series. However, several cases have been described in literature, which we have summarized.

CONCLUSION

This case report and literature review shows that isolated posterior malleolar fractures might occur as part of a more complex ankle injury, in combination with a fracture of the lower leg or after high energy trauma. Physicians should be aware of these associated injuries. Diagnostic work-up should include X-rays of the knee and lower leg and a CT scan of the ankle. If diagnosed and treated properly, isolated posterior malleolar fractures have a good long-term functional outcome.

PCL and PCL-based materials in biomedical applications

Biodegradable polymers have met with an increasing demand in medical usage over the last decades. One of such polymers is poly(ε-caprolactone) (PCL), which is a polyester that has been widely used in tissue engineering field for its availability, relatively inexpensive price and suitability for modification. Its chemical and biological properties, physicochemical state, degradability and mechanical strength can be adjusted, and therefore, it can be used under harsh mechanical, physical and chemical conditions without significant loss of its properties. Degradation time of PCL is quite long, thus it is used mainly in the replacement of hard tissues in the body where healing also takes an extended period of time. It is also used at load-bearing tissues of the body by enhancing its stiffness. However, due to its tailorability, use of PCL is not restricted to one type of tissue and it can be extended to engineering of soft tissues by decreasing its molecular weight and degradation time. This review outlines the basic properties of PCL, its composites, blends and copolymers. We report on various techniques for the production of different forms, and provide examples of medical applications such as tissue engineering and drug delivery systems covering the studies performed in the last decades.

What is the hardware removal rate after anteroinferior plating of the clavicle? A retrospective cohort study

BACKGROUND

Plate position in the operative treatment of displaced midshaft clavicle fractures or nonunions is most often on the superior side. However, superior clavicular plating often results in complaints of plate prominence and local soft tissue irritation, necessitating hardware removal. We have used anteroinferior placement of the plate in the hope of increasing biomechanical stability and fixation and also of lowering complaints of plate prominence and soft tissue irritation. In this report, we set out to study the percentage of hardware removal in our group of patients treated with anteroinferior plating of the clavicle after long-term follow-up.

METHODS

In this retrospective review, we evaluated all patients who were surgically treated with anteroinferior plating for midshaft clavicle fracture, delayed union, or nonunion by the senior author between February 2003 and July 2015. Patients required a minimum age of 16 years at time of surgery and a follow-up of >12 months. Patients with malunion, plating on the superior aspect, or double plating were excluded.

RESULTS

The medical records of 53 patients (54 fractures) were reviewed after a mean follow-up duration of 6.4 years (range, 1.1-13.1). The mean age at follow-up was 47.8 years (range, 20.4-80.7). All fractures and nonunions healed. In only 3 cases (5.6%), hardware removal was requested by the patient because of plate prominence.

CONCLUSIONS

Anteroinferior plating of midshaft clavicle fractures, delayed unions, and nonunions resulted in low hardware removal rates in our cohort.

Midshaft Fractures of the Clavicle: A Meta-analysis Comparing Surgical Fixation Using Anteroinferior Plating Versus Superior Plating

OBJECTIVE

To compare the outcomes of clavicle fracture fixation using anteroinferior versus superior plate placement.

METHODS

We performed a meta-analysis of studies that have reported on outcomes after superior or anteroinferior plate fixation for acute midshaft clavicle fractures (Orthopaedic Trauma Association 15-B). A computerized literature search in the Pubmed, Scopus, and Cochrane Library databases was used to identify relevant articles. Only full text articles without language restrictions were evaluated. The inclusion criteria consisted of: (1) fracture of the midshaft clavicle; (2) surgery for acute fractures (within 1 month of the fracture); (3) adult patients (16 years of age and older); and (4) open reduction and internal fixation with plate application in either the anteroinferior or superior position. Studies were excluded if they did not specify plate location, evaluated multitrauma patients, investigated minimally invasive procedures, or studied operations for revision, nonunion, malunion, or infection. The primary measured outcomes were symptomatic hardware (implant prominence or irritation) and surgery for implant removal. The secondary outcomes were time to union, fracture union, nonunion, malunion, Disabilies of the Arm, Shoulder and Hand score, Constant score, and implant failure. Frequencies and proportions of cases were recorded for binary outcomes, whereas mean and standard deviations were recorded for continuous outcomes. Other summary statistics provided were used to impute mean and standard deviations under the assumption of normality when these were not reported. Continuous outcomes were compared between groups using linear mixed effects models, whereas binary outcomes were compared using mixed effects logistic regression models, including fixed group effects and random study effects. P-values less than 0.05 were considered statistically significant. All analyses were performed using SAS v. 9.4 (SAS Institute Inc, Cary, NC).

RESULTS

A total of 1428 articles were identified among the 3 databases, of which 897 remained after removing duplicates. From that pool, 57 relevant studies were evaluated. Articles were excluded because of an inability to specify plate location (6), a subject pool not exclusively consisting of acute fractures (4) or midshaft fractures (2), a minimally invasive surgical approach (6), use of nonstandard plates (1), poor reporting of functional outcomes (2), and a duplicate group of patients (2). This left 34 articles to be used in the meta-analysis. Of these, 8 studies reported on patients with anteroinferior plating (N = 390) and 27 studies reported on patients with superior plating (N = 1104). No significant differences were found with respect to the functional shoulder scores (Disabilies of the Arm, Shoulder and Hand and Constant) between the 2 groups. There was no significant difference between each group for the probability of having a union (P = 0.41), malunion (P = 0.28), nonunion (0.29), or implant failure (P = 0.39). Patients in the superior plating group had a significantly higher probability of suffering from symptomatic hardware (0.17) as compared to patients in the anteroinferior plating group (0.08), (P = 0.005). In addition, the superior plating group had a significantly higher rate of surgery for implant removal (0.11 vs. 0.05), (P = 0.008).

CONCLUSIONS

The findings of this investigation demonstrate that plating along the superior and anteroinferior aspects of the clavicle lead to similar operative outcomes with respect to union, nonunion, malunion, and implant failure, as well as similar functional outcomes scores. Plates applied to the superior aspect of the clavicle are associated with higher rates of symptomatic hardware and more frequent implant removal.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Nonoperative Management of Hand Fractures in United Kingdom

Hand fractures (excluding small avulsion fractures and scaphoid fractures) almost always unite with bone. The role of the hand surgeon is not to achieve bone union but to achieve stability in an adequate position, often with some displacement, and maintenance of good soft tissue gliding. This article establishes that many fractures treated operatively do no better and often could not realistically do better than with good nonoperative treatment. Yet many are treated surgically to satisfy surgical egos, the desire to produce excellent radiographs, or just the mistaken belief that current surgical techniques can improve on nonoperative treatment.

Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease

PURPOSE

To evaluate the functional and clinical outcome of a new closing-wedge osteotomy for the prominent tibial tubercle after Osgood-Schlatter disease.

METHODS

Between 2010 and 2014, 7 consecutive adults (mean age, 28.6 years; range, 26-35 years) were treated by closing-wedge reduction osteotomy of a painful tibial tubercle. All patients had prior nonsurgical and surgical treatment. Preoperative and postoperative tubercular prominence, Caton-Deschamps index for patellar height, the Kujala Anterior Knee Pain Scale, Lysholm Knee Score as well as visual analog scale score and Tegner activity scores were recorded.

RESULTS

Mean follow-up after reduction osteotomy was 31.3 months (27-41 months). The bony prominence of the tibial tubercle was significantly reduced (mean 8 mm, P < .001) and the Caton-Deschamps index was lowered from 1.29 to 1.09 (P < .001). From preoperative to last follow-up, the Kujala Anterior Knee Pain Scale increased from 54.71 preoperative to 84.71 (P < .001); the Lysholm Knee Score improved from 72.42 to 94.14 (P < .001); the Tegner activity score increased from 3.1 to 5.7 (P < .001), whereas the visual analog scale significantly decreased from 5.8 to 1.2 (P < .001). No complications were recorded, and all patients were satisfied with clinical outcome.

CONCLUSIONS

Closing-wedge osteotomy of the tibial tubercle effectively reduced the bony prominence after Osgood-Schlatter disease and consecutively improved the outcome in terms of knee pain and function. Thus, we can recommend this procedure in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Bone Tunnel Impaction Reduced the Tibial Tunnel Enlargement

The purpose of this study was to investigate whether the bone tunnel impaction technique performed by dilators could dwindle the tibial tunnel enlargement after anterior cruciate ligament (ACL) reconstruction with hamstring tendon using both extracortical suspensory fixation devices at femoral and tibial site. Thirty-one consecutive patients undergoing primary ACL reconstruction with the hamstring autograft were enrolled in this research. Patients were randomly allotted to group A (bone tunnel impaction technique using dilators) or group B (regular extraction bone tunnel drilling).

RESULTS

The average follow-up was 16.2 months. The mean femoral tunnel widening was 1.05 mm and 1.02 mm respectively in group A and B. The mean tibial tunnel widening was 0.61 mm and 1.08 mm respectively in group A and B. There was no statistical difference for tunnel enlargement between the two groups at the femoral site (P = 0.62) but significant difference at the tibial site (P < 0.0001).

CONCLUSION

Bone tunnel impaction technique leaded to a reduction of tibial bone tunnel enlargement after ACL reconstruction with hamstring tendon using both extracortical suspensory fixation devices at femoral and tibial site.

Current Status of Simulation-based Training Tools in Orthopedic Surgery: A Systematic Review

OBJECTIVE

To conduct a systematic review of orthopedic training and assessment simulators with reference to their level of evidence (LoE) and level of recommendation.

DESIGN

Medline and EMBASE library databases were searched for English language articles published between 1980 and 2016, describing orthopedic simulators or validation studies of these models. All studies were assessed for LoE, and each model was subsequently awarded a level of recommendation using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education.

RESULTS

A total of 76 articles describing orthopedic simulators met the inclusion criteria, 47 of which described at least 1 validation study. The most commonly identified models (n = 34) and validation studies (n = 26) were for knee arthroscopy. Construct validation was the most frequent validation study attempted by authors. In all, 62% (47 of 76) of the simulator studies described arthroscopy simulators, which also contained validation studies with the highest LoE.

CONCLUSIONS

Orthopedic simulators are increasingly being subjected to validation studies, although the LoE of such studies generally remain low. There remains a lack of focus on nontechnical skills and on cost analyses of orthopedic simulators.

Use of Magnetic Resonance Imaging to Predict Quadrupled Semitendinosus Graft Diameter in All-Inside Anterior Cruciate Ligament Reconstruction

This study was conducted to evaluate whether preoperative magnetic resonance imaging (MRI) measurements of the cross-sectional area and length of the semitendinosus tendon correlated with graft diameter. The goal of the study was to identify tendons at risk for requiring graft augmentation. The records of 140 consecutive patients undergoing anterior cruciate ligament (ACL) reconstruction between 2013 and 2016 were examined retrospectively. The study included 39 patients who underwent all-inside ACL reconstruction with a semitendinosus autograft. A single researcher used preoperative MRI scans to measure the cross-sectional area and length of the semitendinosus tendon. Graft cross-sectional area was correlated with semitendinosus tendon cross-sectional area with Pear-son's coefficients of 0.50 (95% confidence interval [CI], 0.21-0.70; P=.0013) and 0.59 (95% CI, 0.34-0.76; P=.0001) when measured under 2× and 4× magnification, respectively. In addition, MRI measurements of semitendinosus tendon length were correlated with both intraoperatively measured tendon length (r=0.75; 95% CI, 0.40-0.91; P=.0008) and graft diameter (r=0.43; 95% CI, 0.14-0.66; P=.0058). Average semitendinosus tendon cross-sectional area was 3.10 mm² (95% CI, 0.53-5.67; P=.024) greater and semitendinosus tendon length was 14.05 mm (95% CI, 1.25-26.85; P=.035) greater in cases that did not require graft augmentation. Semitendinosus tendons with cross-sectional area of less than 13.2 mm² or length of less than 81 mm are most likely to require graft augmentation. In addition, MRI measurements of the length and cross-sectional area of the semitendinosus tendon are significantly correlated with ACL graft diameter and could help to identify patients who may require graft augmentation. [Orthopedics. 2017; 40(4):e617-e622.].

The timing and importance of motor skills course in knee arthroscopy training

Objectives

The aim of this prospective study is to evaluate the impact of the simulation training program in learning duration of arthroscopic motor skills. Furthermore, we investigated the difference between junior and experienced residents in the improvement of arthroscopic motor skills duration.

Methods

We established 2 study groups according to participants' year of experience in orthopedic residency with junior group residents with three years or less than three years experience as group 1 and experienced group with over 3 years of experience as group 2. We calculated duration change of motor skill test results for each participant before and after the course. The tools used were; auto scoring mirror tracer(ASMT), 0'Conner the tweezer dexterity test(OCTDT), etch-a-sketch with overlay(ESOT), purdue the pegboard test(PPT), two-arm coordination test(TACT) and grooved pegboard test(GPT) which were all produced by Lafayette firm. These instruments were used to practice and measure the basic motor skills.

Results

All post–course test durations for participants decreased significantly when compared to pre-course. We calculated percentage change of motor skill test results for each participant before and after the course. All motor skill test percentage changes were similar between two groups. In comparison of participants according to their experiences, results revealed that there was no difference in test results of experienced and junior surgeons. Both groups had provided equal improvement in terms of motor skills.

Conlusion

As our results revealed, residents will be able to act with a strong motivation to learn applications through basic arthroscopic information gained in early period of orthopedic training and will make more successful applications of real patients.

Bilateral Hypoplasia of the Medial and Lateral Menisci

Hypoplasia of the meniscus is a very rare congenital abnormality, with only a few cases reported to date. A 9-year-old girl visited our hospital due to lateral knee pain following a hyperextension injury to the left knee. Magnetic resonance imaging showed hypoplasia of the medial and lateral menisci, as well as a posterior horn tear of the lateral meniscus, in both knee joints. To our knowledge, this is the first report of a patient with hypoplasia of the medial and lateral menisci in both knee joints.

Relationship of Musculotendinous Junction Location to Harvested Semitendinosus and Gracilis Tendon Length

Background:

Harvested hamstring tendon length has received scant attention in published anterior cruciate ligament (ACL) reconstruction literature, yet length can limit the ability to increase graft diameter by folding the tendon over more than once. Indeed, some ultrashort tendons may be too short to yield a clinically useful graft after being folded over just once. Ultimately, the total length of a harvested hamstring tendon may depend on the length of the tendon distal to its musculotendinous (MT) junction.

Purpose:

To compare the lengths of harvested hamstring tendons to the location of the MT junction to help predict abnormally short tendon harvest.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Eighty-four consecutive patients undergoing primary ACL reconstruction using hamstring tendon autografts underwent intraoperative measurement of the total length of each harvested semitendinosus (ST) and gracilis (G) tendon, as well as the distance from the MT junction to that tendon’s distal end (ie, the “tendon-only” length).

Results:

The ratio of the tendon-only portion to total harvested tendon length averaged 0.52 (range, 0.39-0.71) for the ST and 0.52 (range, 0.43-0.71) for the G, suggesting a 95% chance of harvesting a tendon <15 cm in length for the tendon-only portion is <6.45 cm for ST or <6.75 cm for G tendons. There was moderate correlation between the lengths of harvested ST and G tendons with patient height as well as with the diameter of the combined, quadruple-stranded graft.

Conclusion:

The ratio of the tendon-only length to total harvested length for both the ST and G appear to range from approximately 0.4 to 0.7. Patients with abnormally distal MT junctions of either their ST or G are likely to have an abnormally short harvest of that tendon, even in the absence of technical harvesting error.

Management of Hand Injuries: Part III

Assessment of Acute Hand Injuries was discussed in Part I (). Part I reviewed approaches to the assessment of the patient with a hand injury and established a process for basic identification of the hand structures and function. Approaches to history taking and specific evaluations for the hand were discussed, and examples of the assessments were provided. Diagnostic approaches to support physical findings were discussed, and methods of radiological assessment provided assistance to the audience in making appropriate diagnosis in relation to hand injuries. Management of bony hand injuries was discussed in Part II. In Part II, the authors also described the epidemiology, radiographs, and the management of hand lacerations, fingertip injuries, and fractures. In this article, Part III, the management of tendon, ligamentous, neurovascular, and other specific hand injuries, along with the management of selected chronic hand conditions, is discussed.

Fibrin clot prevents bone tunnel enlargement after ACL reconstruction with allograft

PURPOSE

Bone tunnel enlargement is a feared complication after ACL reconstruction. The aim of this study was to evaluate whether adding a fibrin clot to the allograft for anatomic single-bundle ACL reconstruction would reduce tunnel widening.

METHODS

Fifty patients who underwent anatomic single-bundle ACL reconstruction were included. Twenty-five patients received an allograft alone, and 25 patients received an allograft with fibrin clot. All patients underwent standard plain anteroposterior and lateral radiographs of the operated knee immediately after surgery and at 1-year follow-up. The size of the tunnels was measured at both time points to calculate tunnel widening. Tunnel widening at 1 year was compared between the allograft and the allograft + fibrin clot group.

RESULTS

There was significantly less tunnel widening in the allograft + fibrin clot group for the femoral tunnel width in the middle and distal portion of the tunnel and for the tibial tunnel width in the proximal and distal portions, as compared to the allograft only group.

CONCLUSION

Adding a fibrin clot to the allograft in anatomic single-bundle ACL reconstruction reduces the amount of tunnel widening at 1-year follow-up. Reducing tunnel widening may positively affect outcomes after ACL surgery and may prevent inadequate bone stock during ACL revision procedures.

LEVEL OF EVIDENCE

Case-control study, Level III.

Preoperative prediction of anterior cruciate ligament tibial footprint size by anthropometric variables

PURPOSE

The purpose of this study was to evaluate whether the ACL tibial footprint size can be predicted by anthropometric variables including height, weight, leg length, femur length, tibia length, and anteroposterior and mediolateral diameters of proximal tibia.

METHODS

This study included 209 out of the 378 eligible patients. The inclusion criterion was ACL with normal gross appearance. Patients with conditions that could have affected the measurement were excluded: torn ACL, osteophyte formation around the ACL tibial attachment, presence of inflammatory arthritis, or history of knee joint infection. According to the above criteria, 169 patients were excluded from this study; 138 had torn ACL, 24 had osteophyte around the ACL footprint, 5 had history of rheumatoid arthritis, and 2 had history of previous knee joint infection. The ACL tibial footprint was carefully dissected and measured during total knee arthroplasty. Anthropometric variables regarding bone lengths were measured on radiography. The association of the ACL tibial footprint size (length and width) with anthropometric variables was analysed using simple and multiple linear regression analyses.

RESULTS

The height, weight, leg length, femur length, tibia length, and the size of proximal tibia were associated with the ACL tibial footprint length and width. The ACL tibial footprint length could be predicted by the equation using tibia length: ACL tibial footprint length = -9.361 + 0.759 * (tibia length in cm) (R ² = 0.44, P < 0.001) and width by the equation using weight and tibia length: ACL tibial footprint width = -0.5615 + 0.279 * (tibia length in cm) + 0.0333 * (weight in kgs) (R ² = 0.17, P < 0.001). The concordance correlation coefficient for the measured and predicted values of ACL tibial footprint length and width showed moderate and low agreement, respectively (0.61, 95 % CI 0.53-0.68; 0.30, 95 % CI 0.21-0.38).

CONCLUSION

The ACL tibial footprint length and width are associated with anthropometric variables, especially with tibial length. The predictive equation developed from this study can serve as supplementary guides to determine the surgical techniques and graft options in preoperative planning of an individual ACL reconstruction.

LEVEL OF EVIDENCE

IV.

Correlation between body mass index and quadrupled hamstring tendon autograft size in ACL reconstruction

PURPOSE

the aim of this study was to assess the relationship of patient weight, height and body mass index (BMI) with the size of the quadrupled hamstring tendon used in anterior cruciate ligament (ACL) reconstruction.

METHODS

from patient records, we retrospectively assessed the weight, height, BMI and graft sizes of 126 patients who underwent ACL reconstruction using a quadrupled hamstring tendon autograft between January 2010 and January 2013 at our institution. The data obtained from perioperative measurements were studied using correlation analysis.

RESULTS

statistically significant relationships were found between patient height and graft diameter (p = 0.033, r = 0.19) and between patient weight and graft diameter (p < 0.0001, r = 0.33). No statistically significant relationships were found between graft diameter and BMI or between graft length and patient height, weight and BMI (p > 0.05).

CONCLUSIONS

patient height and weight were found to be related to quadrupled hamstring graft diameter in our patient population. BMI was not related to the quadrupled hamstring graft size. The exact size of the graft cannot be predicted preoperatively on the basis of these variables.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Bone tunnel enlargement following hamstring anterior cruciate ligament reconstruction: a comprehensive review

Nowadays, bone tunnel enlargement (BTE) after anterior cruciate ligament reconstruction is a well-known phenomenon. It has been identified, investigated and described by many authors during the last thirty years. Nevertheless, the etiology of bone tunnel enlargement still remains unclear. It is known that the causes are multifactorial and may include the surgical technique, the method of fixation, materials used, type of graft as well as biological factors. Due to the recent popularization of the use of hamstring grafts in anterior cruciate ligament reconstruction, the bone tunnel enlargement phenomenon is becoming increasingly common. In this review article, the authors focus on compiling current knowledge about the etiology, diagnosis, and the possibility of reducing the occurrence of this phenomenon by using the latest methods of supporting reconstruction 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.

Tunnel widening prevention with the allo-Achilles tendon graft in anterior cruciate ligament reconstruction: Surgical tips and short term followup

BACKGROUND

Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction can be a serious complication, and there is controversy over how to prevent it. This study aimed to suggest surgical approaches to prevent TW using an allo-Achilles tendon graft, and then to evaluate TW after these surgical tips were applied.

MATERIALS AND METHODS

Sixty two patients underwent ACL reconstruction with an allo-Achilles tendon graft. Four surgical approaches were used: Making a tibial tunnel by bone impaction, intraarticular reamer application, bone portion application for the femoral tunnel, and an additional bone plug application for the tibial tunnel. After more than 1-year, followup radiographs including anteroposterior and lateral views were taken in 29 patients encompassing thirty knees. The diameter of the tunnels at postoperation day 1 (POD1) and at followup was measured and compared.

RESULTS

In 18 knees (60%), there were no visible femoral tunnel margins on the radiographs at POD1 or followup. In the other 12 cases, which had visible femoral tunnel margins on followup radiographs, the mean femoral tunnel diameter was 8.6 mm. In the tibial tunnel, the mean diameters did not increase on all three levels (proximal, middle, and distal), and there was no statistically significant difference between the diameters at POD1 and followup.

CONCLUSION

The suggested tips for surgery involving an allo-Achilles tendon graft can effectively prevent TW after ACL reconstruction according to this case series. These surgical tips can prevent TW.

Using pre-operative MRI to predict intraoperative hamstring graft size for anterior cruciate ligament reconstruction

PURPOSE

Large variation in tendon size between individuals makes hamstring graft diameter for anterior cruciate ligament (ACL) reconstruction unpredictable. Inadequate graft diameter may necessitate an alternative source of tissue requiring pre-operative planning. The purpose of this study was to determine whether magnetic resonance image (MRI) measurements and clinical anthropometric data are predictive of hamstring tendon graft diameter.

METHODS

Data from 109 patients having ACL reconstruction with semitendinosus-gracilis (STGT) autograft were retrospectively evaluated. Cross-sectional area (CSA) of the gracilis tendon (GT) and semitendinosus tendon (ST) were determined from pre-operative MRI scans. Variables included pre-operative height, weight, body mass index (BMI), age and gender; and intra-operative graft diameter.

RESULTS

Correlations between anthropometric variables, hamstring tendons CSA and intra-operative graft diameter were calculated. Multiple stepwise regression was performed to assess the predictive value of these variables to graft diameter. Sensitivity and specificity were calculated to evaluate the utility of MRI CSA measurements in accurately identifying inadequate graft diameter (<8 mm). All anthropometric variables were positively correlated with intraoperative graft diameter (p < 0.01). Semitendinosus-gracilis tendon CSA (p < 0.001) and STGT CSA and weight (p < 0.001) were significantly predictive models of graft diameter. Sensitivity and specificity were 79 and 74 %, respectively.

CONCLUSION

The strongest indicators of a four-stranded STGT graft for primary ACL reconstruction were STGT CSA on MRI plus weight. Measurement of graft diameter can be performed pre-operatively via MRI to identify tendons that may be of inadequate size for ACL reconstruction. This can assist with surgical planning to determine the most appropriate graft choice.

LEVEL OF EVIDENCE

III.

Computed tomography value and tunnel enlargement of round and rounded rectangular femoral bone tunnel for anterior cruciate ligament reconstruction

INTRODUCTION

We developed a novel technique for anatomical single-bundle anterior cruciate ligament (ACL) reconstruction: creation of a rounded rectangular femoral bone tunnel. The purpose of this study was to compare the computed tomography (CT) value and tunnel enlargement ratio of the femoral bone tunnel with those of round tunnel ACL reconstruction.

MATERIALS AND METHODS

We included 39 knees that underwent round tunnel ACL reconstruction and 42 that underwent rounded rectangular ACL reconstruction. To evaluate the CT value, we compared the CT images approximately 1 week after surgery. Making a parallel slice toward the opening of bone tunnels to a depth of 3 mm, we evaluated the CT value of eight directions in the bone tunnel wall. To evaluate tunnel enlargement, we compared CT images approximately 1 week after surgery with images taken 3 months after surgery. Using a parallel slice toward the opening of the bone tunnel, we measured the bone tunnel area and calculated the tunnel enlargement ratio. The level of significance was P < 0.05, and the t test was used for statistical analyses.

RESULTS

The CT value was significantly increased for the rounded rectangular tunnel in comparison with the round tunnel in almost all directions (P < 0.05). The rounded rectangular tunnel area enlargement ratio was significantly lower (round, 110 ± 38 %; rounded rectangular, 73 ± 37 %; P = 0.001).

CONCLUSION

The rounded rectangular tunnel could have a compression effect on the cancellous bone and reduce enlargement of the bone tunnel.

Are We Economically Efficient Enough to Increase the Potential of in Vitro Proliferation of Osteoblasts by Means of Pharmacochemical Agents?

Background:

The aim of this study was to test the necessity of using expensive and unaccesible pharmacological-chemical agents in the proliferation of bone tissue cultures and in the induction of mineralized matrix formation to increase the osteogenic effect.

Methods:

For this purpose, human primary cell cultures were prepared and then divided into two groups. Whereas the cells in group I were fed with an osteoblast stimulator medium containing Dulbecco’s Modified Eagle Medium (DMEM) and β-glycerophosphate, the cells in group II were fed with DMEM containing dexamethasone and 2-phospho-L-ascorbic acid trisodium salt. Both groups were evaluated in terms of viability, toxicity, and proliferation and then compared in terms of cell surface morphology through inverted light and environmental scanning electron microscopy. In addition to immunoflow cytometric analyses, the effects of alkaline phosphatase activities were evaluated using the spectrophotometric method to examine the osteoblastic activities. Costs were calculated in the currency of the European Union (Euros). The Tukey Honestly Significant Difference test was used to reach the statistical evaluation of the data after the analysis of variance.

Results:

It was reported that the level of the alkaline phosphates was higher in group I compared to group II. It was observed that the surface morphology quality, the number of living cells, and proliferation were higher in group II and that the results were deemed statistically significant.

Conclusion:

It was found that the 2-phospho-L-ascorbic acid trisodium salt and dexamethasone mixture was as effective as the expensive commercial kits on the osteogenic effect on human primary bone tissue.

Surgical Treatment of Displaced Midshaft Clavicle Fractures: Precontoured Plates Versus Noncontoured Plates

PURPOSE

To compare the outcomes and complications of open reduction and internal fixation using precontoured versus noncontoured plates for the treatment of midshaft clavicle fractures.

METHODS

Open reduction and internal fixation using was performed on 130 patients with a midshaft clavicle fracture. Precontoured plates were used in 69 cases (group A) and noncontoured plates in 61 cases (group B).

RESULTS

The average follow-up in both groups was approximately 21 months. There was a significant difference between the 2 groups in mean surgery duration and blood loss, although Disabilities of the Arm, Shoulder, and Hand and Constant-Murley Shoulder scores at final follow-up were similar. Plate removal was required in 44.9% (31 of 69) of the precontoured group and 65.6% (40 of 61) of the noncontoured group. The indication was prominence of the hardware in 27.5% (19 of 69) of the precontoured group and 54.1% (33 of 61) of the noncontoured. In both groups, body mass index was lower in patients requiring implant removal because of hardware prominence. A higher proportion of females in both groups required implant removal.

CONCLUSIONS

Precontoured plates are associated with a lower rate of hardware removal. Body mass index and gender may be factors that influence the rate of hardware removal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Defining the Indications of Pedicled Groin and Abdominal Flaps in Hand Reconstruction in the Current Microsurgery Era

Three decades ago, pedicled flaps from the groin and abdomen were the workhorses in hand and forearm reconstruction. These pedicled flaps have several disadvantages including patient discomfort, stiffness, the need for flap division, and the inability to elevate the hand after acute trauma. Hence it is not surprising that free flap reconstruction has become the method of choice in coverage of complex hand and forearm defects. Despite this, pedicled flaps may still be indicated in the current era of microsurgery. Based on a review of the literature and the author's experience, the current review defines these indications as follows: complex defects in children aged less than 2 years; coverage of digital stump defects in preparation for toe-to-hand transfer; high-voltage electric burns with the hand surviving on collateral blood supply; salvage of the thumb ray in high-voltage electric burns with concurrent thrombosis of the radial artery; mutilating hand injuries; length preservation of multiple digital amputations in manual workers; and multiple defects within the digits, hand, or forearm. These indications are discussed along with clinical examples.

Preoperative magnetic resonance imaging evaluation of semitendinosus tendon in anterior cruciate ligament reconstruction: Does this have an effect on graft choice?

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction with ST autograft is sometimes unsuccessful because of harvested thin graft. Magnetic resonance imaging (MRI) can be a useful tool to evaluate the thickness of the graft. This study is performed to evaluate whether there is any correlation between diameters and cross-sectional area (CSA) of the semitendinosus tendon (ST) on the preoperative magnetic MRI and the diameter of the 4-stranded ST autograft in ACL reconstruction.

MATERIALS AND METHODS

Seventy patients who underwent single-bundle ACL reconstruction with 4-stranded ST for full-thickness ACL ruptures were included in this study. Anteroposterior (AP) and mediolateral (ML) diameters of ST at the levels of the joint line (JL) and femoral physeal line (PL), and also CSA at these levels were measured on T2-weighted fat-suppressed MRI examinations. The data obtained were compared with intraoperatively measured diameters of 4-stranded ST autograft. Correlations between variables were evaluated using Spearman's rho. Receiver operating characteristic and area under the curve statistics were used to evaluate the cut-off value for the correlation between 4-stranded ST graft diameter of 8 mm and CSA (mm²) on MRI.

RESULTS

On MRI measurements, no correlation was found between AP diameters at the level of the JL and 4-stranded ST diameter (P = 0.180). However, correlations were found between diameter of 4-stranded ST and ML diameter at the level of JL (P = 0.003) and PL (P = 0.002), AP diameter at the level of the PL (P = 0.009), CSA at the level of the JL (P < 0.001) and at the level of PL (P < 0.001). Correlation between the diameter of 4-stranded ST and CSA at both levels was more significant than that between AP-ML diameters of ST and diameter of autograft. The cut-off value for the 8 mm diameter CSA of 4-stranded ST was 5.9 mm² at the JL and 8.99 mm² at the PL.

CONCLUSION

Preoperative MRI evaluation of CSA at the JL of the ST is a reliable parameter to predict graft size. Other graft alternatives should better be considered if the CSA of ST is <5.9 mm² at the level of the JL.

A delayed foreign body granuloma associated with polypropylene sutures used in tendon transfer. A case report

•

Delayed suture reactions are rare.

•

We present an unusual case of foreign body granuloma to polypropylene.

•

Differential diagnosis and management are discussed.

Introduction

A delayed foreign body reaction to polypropylene sutures has not been previously reported following tendon repair.

Presentation of case

A 12-year old boy underwent tendon transfer. Tendon repair was done using polypropylene sutures. Five months later, a slowly growing granuloma was seen at the tendon repair site. Skin testing did not show an allergic reaction to the suture. Excision of the granuloma and removal of sutures were curative. Histology confirmed a foreign body granuloma.

Discussion

A mass developing several months at the site of tendon repair indicates either an allergic or foreign body reaction to the suture. Skin testing (for allergy) and histological examination of the mass differentiate allergic from foreign body reactions.

Conclusion

We report on a rare case of a giant granuloma caused by a delayed foreign body reaction to polypropylene sutures used in tendon repair.

Prediction of flexor tendon graft diameter in reconstruction of the anterior cruciate ligament by means of magnetic resonance imaging

OBJECTIVE

To evaluate the diameter of the flexor tendons in preoperative magnetic resonance imaging (MRI) examinations and compare this with the diameter of the graft obtained intraoperatively.

METHODS

This was a retrospective longitudinal epidemiological study. Forty-four patients were eligible for the study and their MRI examinations and surgical data were evaluated. The tendons were measured on MRI across their largest diameter in the axial plane, using the medial epicondyle of the femur as the slice level. In the surgery, routine graft preparation was performed, consisting of folding the gracilis and semitendinosus tendons to form a four-strand graft. Its measurement was recorded.

RESULTS

To evaluate the association between the variables, Pearson's correlation coefficient was estimated. A significant correlation was found between the measurements of the gracilis and semitendinosus tendons and the final diameter of the graft (p < 0.001). A ROC curve was fitted to the sum of the tendon diameters in order to determine a cutoff point associated with the graft diameter (≤8 mm or >8 mm). If the sum was greater than 5.28 mm, the chance of obtaining a graft larger than 8 mm would be 75%.

CONCLUSION

Measurement of the diameters of the gracilis and semitendinosus tendons through a preoperative MRI examination is a simple and effective way to predict the final size of the graft to be used in ACL reconstruction surgery.

High-pressure Injection Injuries of the Hand

High-pressure injection hand injuries are often overlooked, with severe complications owing to the acute inflammatory response. Prognosis for depends on the type of material injected, location of injection, involved pressure, and timing to surgical decompression and debridement. Acute management involves broad-spectrum antibiotics, tetanus prophylaxis, emergent decompression within 6 hours, and complete removal of the injected material. Most patients have residual sequelae of stiffness, pain, sensation loss, and difficulties in returning to work. The hand surgeon's role is prompt surgical intervention, early postoperative motion, and education of patient and staff regarding short- and long-term expectations.

Anterior Cruciate Ligament Reconstruction With Autologous Hamstring: Can Preoperative Magnetic Resonance Imaging Accurately Predict Graft Diameter?

Background:

Recent clinical investigations have identified inadequate autograft hamstring graft diameter (<8 mm) to be predictive of failure after reconstruction of the anterior cruciate ligament (ACL).

Purpose/Hypothesis:

The objective of this study was to determine the utility of preoperative magnetic resonance imaging (MRI) variables of the hamstring tendons for the prediction of graft diameter at the time of surgery. The hypothesis was that cross-sectional area (CSA) of the hamstring tendon measured on MRI could accurately predict graft diameter, and threshold measurements could be established to predict graft diameter at the time of surgery.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A total of 84 consecutive skeletally mature patients prospectively enrolled in our ACL reconstruction patient registry were identified for study purposes. Patients were included if they underwent an MRI of the affected knee at our institution prior to ACL reconstruction with hamstring (HT) autograft. Graft preparation was performed via a standard quadrupled hamstring technique after harvesting both the gracilis and semitendinosus (4-GST). The smallest diameter end of the HT autograft was then utilized for measurement analysis. Total CSA was calculated for both hamstring tendons using the “region of interest tool” on the corresponding proton density–weighted axial image of the knee at the widest condylar dimension. Three independent reviewers measured the MRI scans so that intra- and interrater reliability of the measurements could be determined. A trend analysis was then undertaken to establish correlations between the MRI CSA and graft diameter. Predictive analysis was then performed to establish threshold MRI measurement values for specific graft diameters and determine whether any patient-specific factors would affect graft diameter (age, sex, and body mass index).

Results:

Mean patient age at the time of surgery was 36 years (range, 11-57 years). Intra- and interrater reliability measurements achieved near-perfect agreement for CSA measurements, with intraclass correlation coefficients (ICCs) of 0.994 and 0.932, respectively. Trend analysis demonstrated that increasing CSA correlated well with increasing overall diameter of the graft (P < .001). Receiver operating characteristic (ROC) curves were generated to evaluate threshold CSA measurements for various graft diameters. Maximum sensitivity values of 21.64, 25.25, and 28.256 mm² were established for the respective graft diameters of 8, 9, and 10 mm in the 4-GST group. Independent patient factors of younger age, shorter stature, and female sex were significantly associated with graft diameter (P = .019, .034, and .028, respectively).

Conclusion:

Preoperative MRI can be used to accurately predict quadrupled hamstring autograft diameter at the time of surgery. A total cross-sectional area of >22 mm² can reliably provide a graft diameter of >8 mm at the time of surgery.

Are chondrocytes damaged when rheumatologic inflammation is suppressed?

AIM

The use of biological agents (BAs) for treating diseases such as rheumatoid arthritis (RA), spondyloarthropathy, and systemic lupus erythematosus to reduce inflammation has been fruitful. Especially as part of the increasing number of studies on the intra-articular application of BAs, the effects of BAs on cartilage have been widely investigated. In the present study, the effects of rituximab, abatacept, and adalimumab, all approved antirheumatic agents, on human primary chondrocytes were investigated comparatively and on the molecular level through viability, proliferation, and toxicity analyses.

MATERIALS AND METHODS

Osteochondral tissues from the distal femur and proximal tibia were resected during total knee arthroplasty from patients (n = 3) with confirmed gonarthrosis in whom all medical or conservative treatments had failed. Standard human primary chondrocyte cell culturing was carried out. Immunophenotyping was performed on the cells that adhered to the flask, and their chondrotoxicity was observed using a flow cytometry device. Images of the cells showing chondrotoxicity were analyzed using invert and environmental scanning microscopes, and microimages were obtained. The MTT-enzyme linked immunosorbent assay was performed to observe the toxic effects of BAs on the proliferation of chondrocytes at 24 and 48 h. The results were analyzed using the number of cells and proliferation; statistical comparisons among the groups were carried out using one-way ANOVA. The alpha significance level was set at <0.01.

RESULTS

These pharmaceutical agents were chondrotoxic, especially on viability and proliferation (p = 0.0000).

CONCLUSION

BAs are generally used during active inflammation, and following the management of inflammation, their dosage should be determined taking into consideration their cellular-level toxic effects on chondrocytes.

Editorial Commentary: On Kibler & Sciascia: What Did the Five Fingers Say to the Face? SLAP. A Systematic Review Wake-Up Call to Improve SLAP Repair Guidelines

Both the quality and quantity of reporting in the SLAP repair literature, especially the surgical indications and technical intraoperative characteristics, leaves significant room for improvement. In their systematic review, Kibler and Sciascia identify this considerable underlying imprecision. Based on the current literature, no consensus exists for establishing any criteria for a successful SLAP repair--surgical indications, characteristics (type, location, number of anchors), completeness of repair, or rehabilitation.

Dorsal Radiotriquetral Ligament Snapping Wrist Syndrome - A Novel Presentation and Review of Literature: Case Report

We report 2 cases of audible intrinsic wrist snapping without a palpable click resulting from dorsal radiotriquetral ligament adhesions. After its debridement, both patients demonstrated complete resolution of symptoms.

Correlation between Magnetic Resonance Imaging Characteristics of the Patellar Tendon and Clinical Scores in Osgood-Schlatter Disease

Purpose

This study aims to evaluate magnetic resonance imaging (MRI) findings in young adults with symptomatic Osgood-Schlatter disease (OSD) and compare those in young adults without OSD.

Materials and Methods

We compared MRI findings between young adults with OSD (OS group, n=30) and the equivalent number of young adults without OSD (control group). Visual analog scale scores and Kujala scores were evaluated and correlation analysis was performed in the OS group.

Results

In the OS group, MRI revealed that the patellar tendon was attached to the tibia more widely, resulting in a reduced free tendon portion, and more proximally to the articular surface (p<0.001). The correlation analysis between MRI findings and clinical scores showed statistically significant correlations (p<0.01). In the OS group, 43% presented with patellar tendinopathy or bone marrow edema at the distal attachments.

Conclusions

Compared to the control group, the relatively small free portion and relatively proximal attachment of the patellar tendon were observed with MRI in the OS group. The free portion of the patellar tendon was positively correlated with the clinical scores. Patellar tendinopathy was also frequently encountered in the OS group.