Endoscopic Management of Osgood-Schlatter Disease

Osgood-Schlatter disease is a common cause of anterior knee pain in sports-practicing adolescents. The long-term outcomes have not always been favorable, and some adolescents have persisting knee pain into adulthood. Excision of the ossicle together with debridement of the tibial tuberosity is indicated if the pain is not relieved with conservative measures. An endoscopic technique for excision of the ossicle associated with Osgood-Schlatter disease is reported. It has the advantages of avoidance of painful surgical scars and preservation of the integrity of the patellar tendon, with the potential for improved cosmetic and functional results.

Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator

BACKGROUND

This study aimed to present a new technique for anatomical single bundle anterior cruciate ligament (ACL) reconstruction. We developed an original rounded rectangular dilator set to create rounded rectangular femoral tunnels. This technique can increase the femoral tunnel size without roof impingement, and has the potential to reduce the graft failure rate. We investigated the tunnel position and the incidence of intraoperative complications.

METHOD

The presented technique is anatomical single bundle ACL reconstruction using a semitendinosus graft (with or without the gracilis tendon). The tunnel was drilled via an additional medial portal. Rounded rectangular tunnels were created using a special dilator. Tibial tunnels were created using conventional rounded tunnels. Fixation was achieved using a suspensory device on the femoral side and a plate and screw on the tibial side.

PATIENTS

Fifty patients underwent this surgery, and intraoperative complications were investigated. The femoral tunnel positions were documented postoperatively from computed tomography scans using the quadrant method. The tibial tunnel positions (anterior-to-posterior, medial-to-lateral) were documented using intraoperative X-ray scans.

RESULTS

Only one patient had a partial posterior tunnel wall blowout. The femoral tunnel length varied between 30 and 40mm (mean, 34.9±3.3mm). All femoral and tibial tunnels were located within the area of the anatomical ACL insertions.

CONCLUSION

We did not experience any serious intraoperative complications during anatomical single bundle ACL reconstruction using a rounded rectangle dilator, and the resulting locations of the femoral and tibial tunnels were within the anatomical ACL footprint.

LEVEL OF EVIDENCE

Level IV.

Minimally invasive plate osteosynthesis for midshaft clavicular fractures using superior anatomic plating

BACKGROUND

The minimally invasive plate osteosynthesis procedure has been widely applied for long-bone fixations; however, this technique is not commonly used for clavicular midshaft fractures. In this study, we introduced this technique for midshaft clavicular fractures using superior anatomic locking plates and evaluated its clinical and radiographic outcomes.

MATERIALS AND METHODS

From June 2013 to July 2014, 15 patients with acute midshaft clavicular fractures were treated with the minimally invasive plate osteosynthesis technique using a 3.5-mm clavicular superior anatomic locking plate. Anteroposterior plain X-ray images of the clavicle were taken at 4-week intervals until union was observed. The last clinical follow-up assessments were performed postoperatively at a mean of 16.54 months (range, 10-23 months). In addition, for clinical evaluations, the Constant score and the Disability of the Arm, Shoulder and Hand score were assessed.

RESULTS

The average operative time was 60.2 ± 20.1 minutes (range, 40-80 minutes), with blood loss of 25 ± 5 mL (range, 20-30 mL) during the operation. The mean union time for the patients was 10.1 ± 1.4 weeks (range, 8-12 weeks), and no delayed union or nonunion was observed. There were no major complications, including infections, plate breakages, or neurovascular injuries. No skin irritation was observed, and only 2 patients felt local incision numbness. All patients obtained satisfactory shoulder functions. The mean Constant score was 99 ± 1.8 (range, 95-100), and the mean Disability of the Arm, Shoulder and Hand score was 3.8 ± 2.9 (range, 0-10) at the last control visit.

CONCLUSION

The minimally invasive plate osteosynthesis procedure that was introduced in this study for midshaft clavicular fractures with superior anatomic locking plate is a reproducible procedure and an alternative to conventional operative methods.

Airway management for patients with ossification of the anterior longitudinal ligament of the cervical spine

Ossification of the anterior longitudinal ligament (OALL), also called Forestier's disease or diffuse idiopathic skeletal hyperostosis, is characterized by anterior bridging osteophytes of unknown etiology. OALL may cause dysphagia, dyspnea, dysphonia, and acute airway obstruction. We report difficulty in tracheal intubation during anesthesia induction in two OALL patients. In an 82-year-old man, anterior bridging osteophytes (of the cervical region) were observed on preoperative lateral radiograph after several attempts of tracheal intubation for the operation of the anterior fusion of cervical spine. During the same procedure in another 69-year-old man, fiberoptic-assisted awake intubation was extremely difficult because of posterior hypopharyngeal wall protuberance by osteophytes of cervical spine; although tracheal intubation for anesthesia was uneventful on two previous occasions over the months. OALL is usually asymptomatic, but it has been found in 12 % of autopsies and may exaggerate with age. Dysphagia, difficulties with tracheal and/or gastric intubation, acute respiratory compromise, and sleep apnea result from the presence of cervical osteophytes. Anesthesiologists should be aware that tracheal intubation for such patients may be difficult, and thus the preoperative evaluation and airway management need careful consideration.

Isolated Adult Tillaux Fracture Associated With Volkmann Fracture-A Unique Combination of Injuries: Report of Two Cases and Review of the Literature

Avulsion fractures of the anterior inferior tibiofibular ligament from its tibial attachment, Tillaux fractures, are usually seen in adolescents during the interval of the distal tibial epiphyseal closure. However, this pattern of fracture is rare in adult patients, because the ligaments will usually fail before the bone fails. Avulsion fracture of the posterior inferior tibiofibular ligament from its tibial attachment, Volkmann fracture, is the posterolateral counterpart of a similar injury. In the present study, the cases of 2 adult patients with simultaneous Tillaux and Volkmann fractures are reported and the mechanism of injury, diagnosis, and treatment discussed. This fracture pattern is extremely rare and, to the best of our knowledge, has not been previously reported.

Are the leading drugs against Staphylococcus aureus really toxic to cartilage?

Many studies have shown that the toxic effects of local antibiotics on bone and cartilage limit orthopedic surgeons. In this study, we evaluated three antibacterial agents used locally to treat highly mortal and morbid diseases in the field of orthopedics, such as septic arthritis. Are vancomycin, teicoplanin, and linezolid, which are archenemies of Staphylococcus aureus, really toxic to chondrocytes? The purpose of the study was to investigate the effects of antibiotics, which are used against S. aureus, on human chondrocytes in vitro. Primary cell cultures obtained from gonarthrosis patients were divided into two main groups. One of these groups was designated as the control chondrocyte culture. The other group was divided into three subgroups, and each group was exposed to vancomycin, teicoplanin, or linezolid. Cell culture samples were characterized by immunophenotyping following incubation with the three different antibiotics. Before and after the agents were administered, the cultures were subjected to inverted and environmental scanning electron microscopy. The number of live cells and the proliferation rate were monitored with the MTT-assay. We found that vancomycin, teicoplanin, and linezolid do not have chondrotoxic effects. Vancomycin, teicoplanin, and linezolid had no chondrotoxic activity during in vitro culture, which supports the argument that these agents can safely be used in orthopedic surgery, especially against methicillin-resistant S. aureus agents.

Efficacy of intraarticular application of ketamine or ketamine-levobupivacaine combination on post-operative pain after arthroscopic meniscectomy

PURPOSE

To evaluate the efficacy of intraarticular injection of ketamine or ketamine plus levobupivacaine on post-operative analgesia in patients undergoing arthroscopic meniscectomy.

METHODS

A prospective, randomized, double-blind study was performed on 60 patients aged 18-65 years who planned to undergo elective arthroscopic meniscectomy. The patients were divided into three groups: the ketamine group (n = 20) received 1.0 mg/kg of intraarticular ketamine in 20 ml of normal saline, the ketamine-levobupivacaine group (n = 20) received 0.5 mg/kg of intraarticular ketamine plus 50.0 mg of 0.25 % levobupivacaine in 20 ml of normal saline, and the control group (n = 20) received 20 ml of intraarticular normal saline. A visual analogue scale (VAS) was used to determine the efficacy of analgesia at 1, 2, 4, 6, 8, 12, and 24 h post-operatively.

RESULTS

There were statistically significant differences in the median VAS scores among the three groups according to Bonferroni adjustment at all time points (p < 0.01), with the exception of 6 and 24 h post-operatively. The median VAS scores at 1, 2, and 4 h post-operatively were higher in the control group than in the two treatment groups (p < 0.001). The median VAS scores in the control group at 1, 2, 4, 6, 8, and 12 h post-operatively and those in the ketamine group at 4, 8, and 12 h post-operatively were significantly higher than those in the ketamine-levobupivacaine group (p < 0.05).

CONCLUSION

Intraarticular ketamine provides effective post-operative analgesia. Addition of intraarticular levobupivacaine to ketamine may provide better amelioration of pain after outpatient arthroscopic meniscectomy.

Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade

This review synthesizes anatomical, anesthetic, surgical, and patient factors that may contribute to neurologic complications associated with peripheral nerve blockade. Peripheral nerves have anatomical features unique to a given location that may influence risk of injury. Peripheral nerve blockade-related peripheral nerve injury (PNI) is most severe with intrafascicular injection. Surgery and its associated requirements such as positioning and tourniquet have specific risks. Patients with preexisting neuropathy may be at an increased risk of postoperative neurologic dysfunction. Distinguishing potential causes of PNI require clinical assessment and investigation; a definitive diagnosis, however, is not always possible. Fortunately, most postoperative neurologic dysfunction appears to resolve with time, and the incidence of serious long-term nerve injury directly attributable to peripheral nerve blockade is relatively uncommon. Nonetheless, despite the use of ultrasound guidance, the risk of block-related PNI remains unchanged.

WHAT'S NEW

Since the 2008 Practice Advisory, new information has been published, furthering our understanding of the microanatomy of peripheral nerves, mechanisms of peripheral nerve injection injury, toxicity of local anesthetics, the etiology of and monitoring methods, and technologies that may decrease the risk of nerve block-related peripheral nerve injury.

The use of pedicled abdominal flaps for coverage of acute bilateral circumferential degloving injuries of the hand

Reconstruction of bilateral soft tissue defects in hand and distal third of the forearm, is a challenge for any reconstructive surgeon. When there is circumferential skin loss affecting the whole hand and fingers as in major degloving injuries, the extent of tissue required for reconstruction narrows down the choice of flaps. When the injury affects both hands the magnitude of the problem becomes compounded. There is no report in the literature of free skin flaps to cover circumferential degloving injuries in both hands. We are presenting the technical considerations and outcome of pedicled abdominal flaps used for immediate coverage of circumferential degloving injuries of both hands.

Are biological agents toxic to human chondrocytes and osteocytes?

Purpose

The aim of the present study is to investigate the effects of biological agents (BAs) on human chondrocytes and osteocytes in vitro.

Methods

Primary cell cultures obtained from gonarthrosis patients were divided into four groups, two of which were designated as control cultures of chondrocyte and osteocyte, and the other two groups were exposed to BAs administered via the culture medium. Cultured cells were characterized by immunophenotyping. Before and after administration of the agents, the cultures were observed by inverted and environmental scanning electron microscopy (ESEM). The number of live cells and the proliferation rate were monitored by MTT assay.

Results

Rituximab and adalimumab were the least toxic agents to chondrocytes, whereas adalimumab and etanercept were to osteocytes.

Conclusion

During periods of intense active inflammation, the concentration of the preferred BAs after inhibition of inflammation needs to be emphasized when their effects on cartilage and bone tissue are considered at the cellular level if the clinical practice is to continue.

Orthopaedic Residents Improve Confidence and Knot-Tying Speed With a Skills Course

PURPOSE

To determine the effect of a knot-tying module, within an arthroscopic training course, on resident speed, resident confidence, and biomechanical quality of arthroscopically tied knots.

METHODS

Sixty-four participants (8 postgraduate year [PGY]-3 and 8 PGY-4 orthopaedic residents annually for 4 years) were enrolled in a 5-day training course, which included a daily knot-tying module. Self-assessed confidence was obtained by pre-course (day 1) and post-course (day 5) questionnaire. Each participant tied 5 sequential knots using an arthroscopic knot-tying station. Time per knot was recorded in seconds. Knots were later preloaded, cycled, and tested for peak load to failure and displacement change. Mean peak load to failure, displacement change, speed, and confidence were compared before and after training.

RESULTS

The mean time to complete 5 knots was significantly faster after training (12.8 minutes before the course [day 1] v 9.39 minutes after the course [day 5]) (P < .0001). Confidence improved from pre-course (mean, 3.3) to post-course (mean, 7.8) questionnaires (P < .0001). No statistically significant difference was found between peak force for pre-course (mean, 136 N) and post-course (mean, 138 N) knots (P = .076). No statistically significant difference was detected in mean displacement change (mean, 3.51 mm before the course v 3.57 mm after the course) (P = .61). Comparison of PGY-3 and PGY-4 residents was significant only for a higher pre-course confidence in PGY-4 residents (P = .02).

CONCLUSIONS

Participation in an arthroscopic knot-tying module improves resident speed and confidence in tying arthroscopic knots. Our data did not show a significant change in peak load to failure or loop security with training. These findings suggest that participation in a knot-tying module improves efficiency regarding arthroscopic knot tying by residents.

CLINICAL RELEVANCE

Residents who practice arthroscopic knot tying 5 days per year as part of an arthroscopic training course may be more efficient in the operating room.

[Treatment of phalangeal fractures using the mini-hook plate. An alternative for surgical fixation of small phalangeal bone fragments?]

BACKGROUND

Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate.

PATIENTS AND METHODS

Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire.

RESULTS

A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3 ° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed.

CONCLUSION

Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.

The sizing of hamstring grafts for anterior cruciate reconstruction: intra- and inter-observer reliability

PURPOSE

The objective of this study was to establish the intra- and inter-observer reliability of hamstring graft measurement using cylindrical sizing tubes.

METHODS

Hamstring tendons (gracilis and semitendinosus) were harvested from ten cadavers by a single surgeon and whip stitched together to create ten 4-strand hamstring grafts. Ten sports medicine surgeons and fellows sized each graft independently using either hollow cylindrical sizers or block sizers in 0.5-mm increments—the sizing technique used was applied consistently to each graft. Surgeons moved sequentially from graft to graft and measured each hamstring graft twice. Surgeons were asked to state the measured proximal (femoral) and distal (tibial) diameter of each graft, as well as the diameter of the tibial and femoral tunnels that they would drill if performing an anterior cruciate ligament (ACL) reconstruction using that graft. Reliability was established using intra-class correlation coefficients.

RESULTS

Overall, both the inter-observer and intra-observer agreement were >0.9, demonstrating excellent reliability. The inter-observer reliability for drill sizes was also excellent (>0.9). Excellent correlation was seen between cylindrical sizing, and drill sizes (>0.9).

CONCLUSIONS

Sizing of hamstring grafts by multiple surgeons demonstrated excellent intra-observer and intra-observer reliability, potentially validating clinical studies exploring ACL reconstruction outcomes by hamstring graft diameter when standard techniques are used.

LEVEL OF EVIDENCE

III.

Power tool injuries to the hand and wrist

Power tool injuries to the hand and wrist are complex injuries which can have a profound impact on the function of the patient. This article gives an overview of the principles, and provides a systematic approach, to the management and rehabilitation of the injured limb and patient required to minimize future disability.

Direct bursoscopic ossicle resection in young and active patients with unresolved Osgood-Schlatter disease

PURPOSE

The aim of this study was to determine the outcomes of bursoscopic ossicle excision in young and active patients with unresolved Osgood-Schlatter disease.

METHODS

This retrospective study included 18 male military recruits. A direct bursoscopic ossicle excision was performed using low anterolateral and low anteromedial portals. Outcomes were evaluated using the Lysholm knee score, pain score on a visual analog scale (VAS) (from 0 to 10), and Tegner activity scale score. In addition, patients were asked whether they could kneel or squat and whether they were able to return to their duty after surgery. Patient satisfaction was evaluated using the VAS and by asking whether patients thought that the prominence of the tibial tuberosity was reduced and whether they would recommend the same surgical treatment to others. Complications after surgery were also evaluated.

RESULTS

The mean Lysholm knee score was 71 preoperatively and improved to 99 after surgery. The mean VAS pain score was 6.5 in the preoperative period and decreased to 0.9 after surgery. In addition, the mean Tegner activity scale score improved from 2.7 preoperatively to 6.2 at final follow-up. However, 4 patients were not able to return to their duty, and 4 patients still had difficulties with kneeling after surgery. A superficial infection occurred in 1 patient, and a recurrent ossicle formation was found in 1 patient. Of 18 patients, 17 were satisfied with their surgical outcomes, and the mean VAS score for patient satisfaction was 8.8. Furthermore, all but 1 patient would recommend the same surgical treatment to others. However, 6 patients did not believe that the prominence of the tibial tuberosity was reduced.

CONCLUSIONS

Bursoscopic ossicle excision showed satisfactory outcomes in selective young and active patients with persistent symptoms. However, bursoscopic surgery showed limitation in reducing the prominence of the tibial tuberosity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Reconstruction of the traumatized thumb

BACKGROUND

The goals of thumb reconstruction include the restoration of thumb length, strength, position, stability, mobility, sensibility, and aesthetics. It is a rare event when all of these objectives can be achieved, and prioritization should be based on the goals and functional demands of the patient.

METHODS

In this article, the authors review the most common reconstructive strategies for all types of traumatic thumb defects.

RESULTS

Replantation is approached first as the primary option for most amputations. Nonreplantable injuries are organized using a simple classification adapted from Lister, dividing thumb amputations into four functional categories: soft-tissue deficit with acceptable length, subtotal amputation with borderline length, total amputation with preservation of the carpometacarpal joint, and total amputation with destruction of the carpometacarpal joint. Within each category, relevant microsurgical and nonmicrosurgical reconstructive techniques are discussed, with a focus on appropriate technique selection for a given patient. Evidence and outcomes data are reviewed where available, and case examples from our own experience are provided.

CONCLUSIONS

Given that available options now range from simple gauze dressings to complex microsurgical reconstruction, preservation of reconstructive flexibility is essential and should be facilitated by judicious preservation of intact structures. The divergence of available reconstructive pathways underscores the importance of knowing one's patients, understanding their motivation, and assessing their goals. Only in properly matching the right reconstruction with the right patient will a mutually satisfactory result be achieved.

The non-operative management of hand fractures

Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures, such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment that the only valuable clinical research in future will be large cohort studies of non-operative treatment or randomized controlled trials comparing operative and non-operative treatments. The relevant fractures are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxer's) fractures, base of proximal phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-operative treatment cannot reliably be improved upon with surgery.

Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint

Intra-articular fractures or fracture dislocations of the proximal interphalangeal joint are difficult clinically because the bone and soft tissue structures are small and intricate. Suboptimal treatment of intra-articular fractures typically leads to functional impairment of the hand. This article reviews the current methods of treatment, together with the senior author's experience in treating difficult proximal interphalangeal joint fractures and dislocations. Besides conservative treatments, surgical treatments include open or closed reduction with traditional Osteosynthesis, such as K-wires, screws or plates. Among recent developments are the percutaneous application of thin cannulated compression screws and novel dynamic external fixators. After a preferred minimally invasive treatment with stable reconstruction of the articular surface, sufficient aftercare is necessary to improve surgical outcomes.

Meniscal suturing versus screw fixation for treatment of osteochondritis dissecans: clinical and magnetic resonance imaging results

PURPOSE

The purpose of this study was to compare meniscal stabilization alone with screw fixation in restoring subjective and objective knee function and structural cartilage integrity in skeletally immature patients with osteochondritis dissecans (OCD) of the knee.

METHODS

This study comprised 28 patients (32 knees) with magnetic resonance imaging (MRI)-confirmed OCD. Unstable menisci were treated with either stabilization (15 patients, 16 knees) or screw fixation (13 patients, 16 knees; control group). Patients were assessed by functional scoring (Hughston, International Knee Documentation Committee [IKDC]) and MRI for a minimum follow-up period of 2.5 years.

RESULTS

In the meniscus stabilization group, the Hughston score improved from 1.4 to 3.8 (P < .01). There was improvement in the IKDC grade, from grade C preoperatively to grade A in 14 knees and grade B in 2 (P < .01). Of 16 knees, 15 had complete defect resolution on MRI by 1 year. There were 3 complications: 1 wound infection, 1 case of trauma requiring reoperation, and 1 revision because of treatment failure at 6 months. In the screw fixation group, the Hughston score improved from 1.4 to 3.6 (P < .01). There was a significant improvement in IKDC grade, from grade C preoperatively to grade A in 11 knees and grade B in 5 (P < .01). At 2 years postoperatively, no differences in these variables were found between the groups.

CONCLUSIONS

Meniscal suturing alone for the treatment of an OCD of the knee shows good or excellent results in terms of clinical scoring and MRI assessment at almost 3 years' follow-up. The results are comparable with those of screw fixation but with a faster recovery in the postoperative course.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy: a randomized, controlled study

PURPOSE

The purpose of this study was to evaluate the efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy regarding the postoperative pain level.

METHODS

From January 2011 to January 2012, 70 patients underwent medial opening-wedge high tibial osteotomy. Thirty-five patients were randomly assigned to receive no injection (group I), and 35 patients were assigned to receive periarticular multimodal drug injection (group II). These 2 groups were compared regarding the postoperative pain level, frequency of additional nonsteroidal anti-inflammatory drug injections, total amount of patient-controlled analgesia, and number of times that patients pushed the patient-controlled analgesia button at each time interval. Statistical results were based on multivariate analysis of variance and repeated-measures analyses.

RESULTS

Multivariate analysis of variance of mean visual analog scale (VAS) scores over the 2-week postoperative period showed statistical significance (P < .001). Repeated-measures analysis yielded a statistically significant difference (P = .001) for the time-by-treatment interaction, showing a clear periarticular multimodal drug injection benefit over time based on VAS scores. In addition, the mean number of times that patients pushed the patient-controlled analgesia button differed significantly between groups over time (P = .01). The VAS scores, frequency of additional nonsteroidal anti-inflammatory drug injections, mean number of times that patients pushed the patient-controlled analgesia button, and mean total amount of fentanyl consumption differed significantly within each group over time (P < .001 for all variables). However, the frequency of additional nonsteroidal anti-inflammatory drug injections and mean total amount of fentanyl consumption did not differ significantly between groups over time (P = .822, P = .529, and P = .282). Opioid- and injection-related complications were not found.

CONCLUSIONS

This prospective randomized study shows that intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2 weeks postoperatively.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with statistically significant differences.

Extraskeletal symptoms and comorbidities of diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory disease characterized by calcification and ossification of soft tissues, mainly enthesis and spinal ligaments. The clinical presentation primarily includes spinal involvement-induced pain and range of motion. Although rare, life-threatening gastrointestinal, respiratory or neurological events or severe morbidity due to bone compression on the adjacent structures may develop. There is a limited amount of data on DISH-related events in the literature. In recent years, comorbid metabolic disorders are of great interest in patients with DISH. The early diagnosis of these conditions as well as rare entities allows an effective multidisciplinary approach for the treatment of DISH. In this article, we review extraskeletal symptoms and associated comorbidities in patients with DISH.

Granuloma formation secondary to Achilles tendon repair with nonabsorbable suture

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Achilles tendon ruptures are generally observed after sport traumas and results of primary repair are good.

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Several complications after surgery were reported.

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In tendon repairs generally nonabsorbable sutures are used.

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Ethibond suture is a strong and safe material for Achilles tendon repairs it may cause soft tissue problems such as granuloma.

INTRODUCTION

Several complications can be observed after Achilles tendon repairs. In this study we aimed to report granuloma formation secondary to Achilles tendon repair with Ethibond (Ethicon INC, Somerville, New Jersey) suture.

PRESENTATION OF CASE

A 31 year-old man operated for Achilles tendon rupture. The Ethibond suture was used for primary repair. The patient attended to polyclinic with the complaints of swelling and discharge around the operation site four months after operation. A mass around distal portion of the Achilles tendon was detected. The granulomatous tissue was excised. Inside the mass Ethibond suture was detected. On histopathologic examination, typical findings of the foreign body reaction were observed. No microorganism was cultivated in the tissue culture. The patient has no complaint on the twelfth month control after surgery.

DISCUSSION

The results of primary repair of Achilles tendon are good but several complications were reported. In tendon repairs generally nonabsorbable sutures are used. The Ethibond is nonabsorbable, braided suture. In the literature, granuloma formations secondary to the suture materials such as polygylactine and braided polyethylen–polyester after Achilles tendon repair were reported but granuloma secondary to the Ethibond is very rare.

CONCLUSION

Although Ethibond suture is a strong and safe material for Achilles tendon repairs it may cause soft tissue problems such as granuloma.

Steroid-induced Kager's fat pad atrophy

We report a rare case of Kager's fat pad atrophy and fibrosis in a 60-year-old woman 1 year after a steroid injection for Achilles tendinopathy. There are few published reports of steroid-induced atrophy affecting deeper layers of fat tissue. To our knowledge, this case report is the first to illustrate its features using magnetic resonance imaging. A review of the scientific literature is also presented.

Treatment of medial epicondylar tendinopathy in athletes

Medial epicondylar tendinopathy, also known as golfer's elbow, is less common than lateral elbow tendinopathy. Overhead throwing athletes and those participating in sports that require repeated forearm pronation and wrist flexion are most commonly affected by this disorder. This problem predominates in amateur as opposed to professional athletes and is also seen more commonly in patients over 40 years of age. This review will begin by outlining the incidence, history, and physical examination of medial epicondylar tendinopathy, including a new clinical test. Imaging modalities, nonoperative, and operative treatments will then be outlined. Finally, future directions will be explored including emerging biological therapies.

Ketamine is toxic to chondrocyte cell cultures

Ketamine has been used in combination with a variety of other agents for intra-articular analgesia, with promising results. However, although it has been shown to be toxic to various types of cell, there is no available information on the effects of ketamine on chondrocytes.

We conducted a prospective randomised controlled study to evaluate the effects of ketamine on cultured chondrocytes isolated from rat articular cartilage. The cultured cells were treated with 0.125 mM, 0.250 mM, 0.5 mM, 1 mM and 2 mM of ketamine respectively for 6 h, 24 hours and 48 hours, and compared with controls. Changes of apoptosis were evaluated using fluorescence microscopy with a 490 nm excitation wavelength. Apoptosis and eventual necrosis were seen at each concentration. The percentage viability of the cells was inversely proportional to both the duration and dose of treatment (p = 0.002 and p = 0.009). Doses of 0.5 mM, 1 mM and 2mM were absolutely toxic.

We concluded that in the absence of solid data to support the efficacy of intra-articular ketamine for the control of pain, and the toxic effects of ketamine on cultured chondrocytes shown by this study, intra-articular ketamine, either alone or in combination with other agents, should not be used to control pain.

Cite this article: Bone Joint J 2014; 96-B:989–94.

Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure

PURPOSE

The purposes of this systematic review were (1) to determine whether there is a minimum hamstring autograft size for anterior cruciate ligament (ACL) reconstruction that significantly decreases the risk of failure and (2) to evaluate the methods to accurately and reliably predict the size of hamstring grafts.

METHODS

We performed a systematic review of Level III and IV studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies assessing failure of quadrupled-strand autograft hamstring ACL reconstruction as a function of graft diameter with at least 1 year of follow-up and those that assessed the use of imaging or anthropometric patient-specific factors to predict hamstring autograft size were included.

RESULTS

We identified 4 clinical studies that directly compared graft size and failure rate. These correlated with a 6.8 times greater relative risk of failure if the graft diameter was equal to or less than 8 mm (P = .008). All 9 anthropometric-based prediction studies were able to significantly correlate at least 1 parameter with intraoperative graft size. Height was the most common correlation, with r = 0.45 (P < .00001). Five of 6 imaging-based prediction studies showed signification correlation, with r = 0.66 (P < .00001), between cross-sectional area and graft size. The most common method of imaging prediction was magnetic resonance imaging-derived cross-sectional area of both the semitendinosus and gracilis tendons.

CONCLUSIONS

On the basis of the available evidence, ACL reconstruction with a quadrupled-strand hamstring autograft with a diameter equal to or larger than 8 mm decreases failure rates. In addition, grafts larger than 8 mm decrease failure rates in patients aged younger than 20 years, a group identified to be at increased risk of failure. Both patient height and magnetic resonance imaging-derived cross-sectional area of the hamstring tendons can be used preoperatively to reliably predict the hamstring autograft diameter.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Graft size after anterior cruciate ligament reconstruction

PURPOSE

The native anterior cruciate ligament (ACL) is composed of two distinct bundles, the anteromedial (AM) and posterolateral (PL), and both have been shown to be reliably measured on magnetic resonance imaging (MRI). The purpose of this study was to measure the size of the AM and PL bundles after ACL double-bundle reconstructions on MRI and compare this to the relative graft size at the time of surgery.

METHODS

Between January 2007 and April 2010, 85 knees were identified after allograft double-bundle ACL reconstruction with post-operative MRI (1.5 T) and met inclusion criteria. On standard sagittal, coronal and oblique coronal MRIs, the AM and PL bundles were delineated and the midsubstance width of the ACL graft was measured. The images were independently measured in a blinded fashion by two observers. Linear and curvilinear regression analysis was used to analyse the relationship between graft size and time after reconstruction.

RESULTS

The mean age of the patients was 24.6 years (SD 10.4). Mean time from surgery to post-operative MRI was 271.5 days (SD 183.4). The mean percentage of the original size of the AM bundle was 86.9% (SD 9.9) and of the PL bundle was 88.6% (SD 9.9). There was no correlation between the relative size of the AM graft and the time from surgery (r = 0.3, n.s.) and no significant relationship for the PL graft (r = 0.1, n.s).

CONCLUSION

On average, there was no graft enlargement of the AM and PL grafts 275.1 days after allograft ACL double-bundle reconstruction, as the mean relative graft size was less than 100 % on MRI. This study suggests that surgeons, who use allografts, should measure the ACL and replace it with a similar size, as there is a low risk of hypertrophy of the graft within one year post-operative.

LEVEL OF EVIDENCE

IV.

The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction

PURPOSE

To describe the concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction.

METHODS

The PubMed/Medline database was searched using keywords pertaining to ACL reconstruction. Relevant articles were reviewed in order to summarize important concepts of individualized surgery in ACL reconstruction. Surgical experiences with case examples are also highlighted.

RESULTS

Individualized ACL surgery allows for the customization of surgery to each individual patient. Accounting for graft selection and other characteristics such as anatomy, lifestyle and activity preferences may provide the patient with the best potential for a successful outcome. The surgeon should be comfortable with a variety of graft harvests and surgical techniques when practicing individualized surgery.

CONCLUSION

Individualized anatomic ACL reconstruction is founded on the objective evaluation of functional anatomy and individual characteristics, thereby restoring the ACL as closely as possible to the native anatomy and function. The adoption and subsequent use of individualized surgery may facilitate improved clinical as well as objective outcomes, particularly in the long term.

LEVEL OF EVIDENCE

V.

Operative treatment of primary anterior cruciate ligament rupture in adults

Operative management of an acute anterior cruciate ligament (ACL) rupture may be required in young and active patients to stabilize the knee and return patients to desired daily activities. ACL reconstruction should be performed anatomically. The majority of studies show no differences between anatomic single-bundle and double-bundle ACL reconstruction with respect to patient-reported outcome scores. Double-bundle reconstruction may provide superior knee joint laxity measurements compared with the single-bundle technique. Following ACL reconstruction, the age and activity level of a patient are predictive of his or her time of return to sports and reinjury. Concomitant meniscal and/or cartilage damage at the time of surgery, in addition to a persistent knee motion deficit, are associated with the development of osteoarthritis after ACL reconstruction.

Osteochondritis dissecans of the lateral tibial condyle associated with agenesis of both cruciate ligaments

Osteochondritis dissecans is a rare cause of painful knees in children. Only 10 cases of lateral tibial condyle involvement have been reported in the literature. Congenital agenesis of both cruciate ligaments has been described even less, and its prevalence is unknown. The authors report an atypical association of osteochondritis dissecans of the tibia with congenital absence of both cruciate ligaments. A 12-year-old male soccer player presented with a painful right knee. Magnetic resonance imaging revealed the diagnosis. The child was treated conservatively. At 18-month follow-up, radiographs showed osseointegration of the osteochondritis dissecans, and the patient had resumed normal athletic activity without pain. To the authors' knowledge, this is the only report describing such an association. The authors discuss the possible etiology of osteochondritis dissecans associated with agenesis of the cruciate ligaments and highlight the possibility of this association when osteochondritis dissecans of the tibia is diagnosed in a child with a painful knee. In this patient, the strain due to anteroposterior instability may have been the cause of osteochondritis. Conservative treatment should be considered in this setting.

Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies

In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.

High-pressure injection injuries in the hand: current treatment concepts

BACKGROUND

High-pressure injection injury to the hand and upper extremity is a rare but very serious clinical entity. The objective of this article was to review the current available literature and highlight important topics.

METHODS

A PubMed literature search was undertaken with the terms "high pressure injection injuries," "injection injuries," "finger injection injuries," and other related terms. Articles were reviewed with specific attention to clinical presentation, treatment, outcome, and prognostic variables.

RESULTS

Most of the available literature included case studies, case series, retrospective cohorts, and literature reviews. The most common presentation of a high-pressure injection injury is a puncture wound on the nondominant index finger of a working class man in his mid thirties. Important factors at presentation include the time of injury and type and pressure of material injected. Initial treatment should include tetanus prophylaxis, broad-spectrum antibiotics, and urgent consultation with a hand surgeon. Injections with air, gas, or small amounts of veterinary vaccines can usually be managed with observation and serial examinations if there is not concern for compartment syndrome. Injections with other liquid materials typically require emergent surgical débridement, with the best outcomes occurring when treated within 6 hours. A wide surgical irrigation and débridement of necrotic tissues should be performed under general or regional anesthesia. Organic and caustic materials are associated with a higher amputation rate, and decreasing the time from injury to surgery improves the prognosis.

CONCLUSIONS

High-pressure injection injuries to the hand can result in permanent impairment. Proper diagnosis and urgent treatment are essential for a good outcome.

Evidence-based medicine: thumb carpometacarpal arthroplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Recount the epidemiology of basilar joint arthritis. 2. Understand how the anatomy and kinematics of this joint contribute to the development of the disease process. 3. Combine patient history, clinical examination, and radiographic findings to formulate a diagnosis and staging of the arthritis. 4. Incorporate conservative management into the patient treatment plan to aid in determining a patient's surgical candidacy. 5. Comprehend the basic principles of available surgical options, potential complications, and evidence pertaining to surgical outcome.

SUMMARY

This article has been prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured for physicians to comparatively evaluate their care of a patient with arthritis of the thumb carpometacarpal joint.

Tissue engineering stratified scaffolds for articular cartilage and subchondral bone defects repair

Due to their good biocompatibility and mechanical integrity, tissue engineering scaffolds have become a principal method of repair and regeneration of osteochondral defects. To improve their intrinsic properties, control their degenerative times, and enhance their cell adhesion and differentiation, numerous scaffold architectures and formation methods have been developed and tested, but the ideal scaffold design is still controversial. Moreover, scaffold fixation has a significant influence on repair and regeneration after implantation. The authors analyzed relative studies to address the latest scaffold designs, including biphasic scaffold, multilayered scaffold, and continuous nonstratified scaffold, and this article compares their advantages and disadvantages. In addition, the authors introduce a novel modified method for scaffold fixation known as magnetic fixation. Both stratified and nonstratified scaffolds can repair osteochondral defects, but continuous nonstratified scaffolds are more biomimetic compared with the native osteochondral structures, and they lead to a better regeneration of hyaline-like cartilage and structured bone tissue. Therefore, the authors suggest continuous nonstratified scaffolds are an effective option for treating osteochondral defects.

Operative treatment for volar plate avulsion fractures of the fingers

We present our experience with 14 volar plate avulsion fractures of the fingers that were treated by excision or internal fixation and discuss the factors affecting the operative techniques and results. Fourteen cases were divided into two groups: the volar plate avulsions with excision (eight cases) and the volar plate avulsions with fixation (six). We compared clinical factors between fracture groups and between fixation methods. Fractures treated with fixation had the larger fragment, a shorter preoperative period, and the larger articular surface involvement than fractures treated with excision. Postoperative pain, average age, patients' satisfaction measured by VAS, DASH scores, grip, and pinch strength were not different between two groups. All fixated fractures healed and the time to union did not differ based on fixation method. The true size of the fracture fragment was larger than expected based on the X-ray and the fragments were usually rotated by pull of the volar plate or ligament. The size and shape of the avulsed fragment might be important factors to determine the treatment method, but the results after operation were not significantly different whether the fragment was excised or fixed.

Finger chondroid syringoma as a hypoechoic subcutaneous nodule in ultrasound

Chondroid syringoma (CS) is an uncommon, benign epithelial skin mixed tumor. It is often located in the head and neck and is unusual in other parts of the body. It may be seen as a skin or soft tissue tumor. We present findings on high-resolution ultrasound and histology in a case of benign CS located on the right index finger. High-resolution ultrasound showed a solid hypoechoic, well-defined subcutaneous mass, adjacent to the tendon. Complete surgical excision was performed, and histopathology demonstrated an apocrine mixed tumor (CS). Although CS histological findings are well described, radiological features have been reported only in few cases and mainly in magnetic resonance. Chondroid syringoma should be suspected by high-resolution ultrasound as a differential diagnosis for a solid slow-growing soft tissue nodule in a finger, especially if the lesion has no contact with the underlying tendon.

How to improve the prediction of quadrupled semitendinosus and gracilis autograft sizes with magnetic resonance imaging and ultrasonography

BACKGROUND

Hamstring tendon grafts may have an unacceptable size for use in anterior cruciate ligament (ACL) reconstruction. Magnetic resonance imaging (MRI) has been proposed to predict the diameters of hamstring tendon grafts.

HYPOTHESIS

Preoperative ultrasonography (US) might reliably anticipate intraoperative 4-strand semitendinosus and gracilis tendon (4ST-GT) graft sizes similarly to MRI. An MRI evaluation of the hamstring tendons with a higher magnification may improve the accuracy of the method.

STUDY DESIGN

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

METHODS

A total of 33 patients undergoing ACL reconstruction with a 4ST-GT graft and MRI performed at our institution were included. The cross-sectional area (CSA) of each semitendinosus tendon (ST) and gracilis tendon (GT) was calculated preoperatively with US and with MRI under 2× and 4× magnification. Intraoperative measurement of the final diameter of the 4ST-GT using a closed-hole sizing block with 0.5-mm increments was made. Pearson correlation coefficients were calculated to determine the relationship between the final intraoperative graft diameter of the 4ST-GT and the CSA of the ST and GT measured with US and MRI with 2× and 4× magnification. Simple linear regression was also calculated to attempt to predict the graft diameter based on given measurements.

RESULTS

There were statistically significant correlations between the measured CSA with US and both MRI magnifications with the 4ST-GT diameter. However, MRI under 4× magnification showed a much higer correlation (0.86) than MRI under 2× magnification (0.54) or US (0.51). Final graft diameters ≥8 mm were observed in 80.8% of patients with a CSA >14 mm(2), in 76.9% of patients with a CSA >25 mm2, and in 96.2% of patients with a CSA >17 mm2 measured with US, 2× magnification of MRI, and 4× magnification of MRI, respectively.

CONCLUSION

Preoperative calculation of the CSA of the hamstring tendons with MRI and US can help to reliably estimate 4ST-GT grafts. In terms of correlation of the CSA with graft diameter, US was comparable to 2× MRI, but 4× MRI showed a much greater accuracy. Threshold values of the CSA of the ST and GT of 25 mm2, 17 mm2, and 14 mm2 with the 2× MRI, 4× MRI, and US methods, respectively, are needed to reliably predict a 4ST-GT graft with a minimum diameter of 8 mm.

Long-term functional and sonographic outcomes in Osgood-Schlatter disease

PURPOSE

To evaluate the sonographic characteristics, functional aspects and life quality of a group of adolescent patients 2 years after having been diagnosed with Osgood-Schlatter disease and compare them with an age-matched healthy control group.

METHODS

The study was conducted on eighteen Osgood-Schlatter patients with unilateral involvement and 14 age-matched healthy controls. The Flaviis classification and patellar tendon characteristics were observed using a GE Logiq 9 scanner. Broad and vertical jump tests were used for jumping performance. The coordination, proprioception, strength and endurance functions were assessed with the Functional Squat System. For the quality of life, the SF-36 questionnaire was used. The Wilcoxon test for the patients' initial and second-year assessment and Mann-Whitney U test for the comparison between the patient and control groups were used.

RESULTS

By the end of second year, 38.9% of the patients had totally recovered. The patellar tendon lengthened, distal diameter and distal area of the tendon had lessened, and no significant difference was observed between patient and control groups (n.s). Improvements were detected for the bilateral broad jump test scores, the quality of life and coordination of the patients after 2 years (p < 0.05). The average power of endurance and the total work of strength were significantly higher in control group (p < 0.05).

CONCLUSIONS

According to the sonography results 2 years after diagnosis, nearly half of the patients had totally recovered. Coordination was the only parameter that improved over the 2-year period. The patient group strength and endurance function remained lower than the control group.

LEVEL OF EVIDENCE

III.

Arthroscopic Excision of a Huge Ununited Ossicle Due to Osgood-Schlatter Disease in an Adult Patient

Introduction:

Surgical excision of the ununited ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. We report a case where arthroscopy was used to excise the ossicles. A bird eye view from the superolateral portal was helpful in the arthroscopic procedure for excision of the deep low lesion.

Case Series:

A 32-year-old, male driver had anterior knee pain during walking and sports activity that had been treated conservatively for 3 months. On physical examination, there was a prominent tibial tubercle, but without palpable pain. There was obvious pain when the knee was approaching full extension. On image, a huge ununited ossicle was seen behind the patellar tendon, intruding into the joint space, and there was another two small ununited ossicles beneath the bow-shaped patellar tendon. Arthroscopy was performed through a three portals technique, and a bird eye view was achieved from the superolateral portal. The ossicles were separated from the surrounding soft tissue with a motorized shaver. The small ununited ossicles were removed by use of a grasper. The huge ossicle was removed by use of a motorized bur, and the contouring of the irregular surface of the tibial tubercle was performed. After 3 months, the patient returned to sports activities without any restrictions.

Conclusion:

This report shows that a huge ossicle can cause impingement in anterior knee compartment, and it can be easily removed arthroscopically under assistance of an additional portal.

[The role of a systematic second look at 48-72 hours in high-pressure injection injuries to the hand: a retrospective study]

OBJECTIVES

Poorly standardized, the management of high pressure injections (HPI) is frequently too late and inadequate, some teams reporting up to 50% of amputations. HPI causes inoculation of toxic particles in depth, particularly difficult to remove surgically. The persistence of this foreign material maintains local inflammation and increases the risk of infection. The objective of this article is to validate the benefit of a systematic "second look" at 48-72 hours in HPI.

METHODS

We conducted a retrospective study from 2006 to 2010, of patients who had a HPI into the hand. All patients had initial debridement surgery and a "second look" was systematically performed at 48-72 hours.

RESULTS

During this period, six patients were treated for a HPI of paint (n=4) or oil (n=2). The time between the accident and surgery was 12.4 hours (2-24). Four patients had good functional outcome with no disabling sequelae. We performed two amputations. At six months, five patients returned to work.

CONCLUSIONS

Early management determines the prognosis of the HPI. Extended debridement within six hours showed a better functional outcome than later treatment. Performing a systematic "second look" allows further washing/debridement and gives the possibility to be more conservative during the initial procedure. This second debridement allows excision of the newly formed necrosis and to evacuate the remaining toxic residues. Finally, patients reported good functional outcome.

The comparison of intraarticular morphine-bupivacaine and tramadol-bupivacaine in postoperative analgesia after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

To compare intraarticular morphine-bupivacaine and tramadol-bupivacaine as postoperative analgesics in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction.

METHODS

A randomized, double blind, controlled trial study of 60 ASA I-II patients undergoing arthroscopic ACL reconstruction was performed under general anesthesia. Patients were randomly allocated into three groups. The MB group (n = 20) received 10 mg morphine and 0.5% bupivacaine; the TB group (n = 20) received 100 mg tramadol and 0.5% bupivacaine; and the control group (n = 20) received isotonic saline intraarticularly in a total volume of 20 ml after the operation. Postoperative pain was assessed with visual analogue scale (VAS) at 0, 30, 60, 90 min and 2, 4, 6, 12, 24 h being at rest. Analgesic duration as defined was the time of first request for analgesics, the first 24 h analgesic consumption, time to unassisted ambulation, discharge time and incidence of side effects were also evaluated.

RESULTS

The VAS scores at 30, 60, 90 min and 2, 4, 12, 24 h were significantly less in the MB and TB groups in comparison with the control group (P < 0.05); VAS scores also decreased significantly in the MB group compared to the TB group at 2, 4 and 24 h (P < 0.05). Analgesic duration was longer and analgesic consumption was substantially less in the MB group (P < 0.05). Moreover, unassisted ambulation time and discharge time were significantly shorter in the MB group than the TB and control groups (P < 0.05). Side effects were similar among the groups.

CONCLUSIONS

Intraarticular morphine-bupivacaine provides effective pain relief, longer analgesic duration, less analgesic requirement, shorter unassisted ambulation and discharge time were compared with intraarticular tramadol-bupivacaine after ACL reconstruction arthroscopy.

LEVEL OF EVIDENCE

I.

The hook plate technique for fixation of phalangeal avulsion fractures

BACKGROUND

Avulsion fractures of the phalanges involve small osseous fragments that are usually attached to structures that are necessary for stability or movement of the joint. Satisfactory healing of the fracture to preserve joint function may require open reduction and internal fixation, which can be difficult because of the small size of the fragments.

METHODS

We used a hook plate fashioned from a 1.3-mm Synthes titanium plate in thirteen patients with a phalangeal avulsion fracture. Four patients had an avulsion fracture of the volar plate with dorsal proximal interphalangeal joint dislocation, four had a dorsal avulsion fracture of the extensor central slip from the middle phalanx, three had a flexor digitorum profundus avulsion fracture from the distal phalanx, and two had an avulsion fracture of the phalangeal insertion of the collateral ligament.

RESULTS

Union without complications was achieved in all cases. After an average duration of follow-up of seventeen months, all patients had a good to excellent result and the average total interphalangeal motion was 149°.

CONCLUSIONS

This indirect fixation technique produces stable fixation allowing early active finger motion.