Fibroblast Growth Factor Soaked Collagen Membrane Shows No Biomechanical or Histological Advantages in the Treatment of Chronic Rotator Cuff Tears in a Rabbit Model

PURPOSE

To investigate the histological and biomechanical effects of a fibroblast growth factor (FGF-2)-soaked collagen membrane used to treat a full-thickness chronic rotator cuff (RC) rupture in a rabbit model.

METHODS

Forty-eight shoulders from 24 rabbits were used. At the beginning of the procedure, 8 rabbits were killed to assess the control group (Group IT) with intact tendons. To establish a chronic RC tear model, a full-thickness subscapularis tear was created on both shoulders of the remaining 16 rabbits and left for 3 months. The transosseous mattress suture technique was used to repair tears in the left shoulder (Group R). The tears in the right shoulder (Group CM) were treated using the same approach, with an FGF-soaked collagen membrane inserted and sutured over the repair site. Three months after the procedure, all rabbits were killed. Biomechanical testing was performed on the tendons to determine failure load, linear stiffness, elongation intervals, and displacement. Histologically, the modified Watkins score was used to evaluate tendon-bone healing.

RESULTS

There was no significant difference among the three groups in terms of failure load, displacement, linear stiffness, and elongation (P > .05). The total modified Watkins score was not affected by applying the FGF-soaked collagen membrane to the repair site (P > .05). Fibrocytes, parallel cells, large-diameter fibers, and the total modified Watkins score were significantly lower in both repair groups when compared to the intact tendon group (P < .05).

CONCLUSIONS

In addition to tendon repair, FGF-2 soaked collagen membrane -application at the repair site provides neither biomechanical nor histological advantages in the treatment of chronic RC tears.

CLINICAL RELEVANCE

FGF-soaked collagen membrane augmentation provides no impact on the chronic RC tear healing tissue. The need to investigate alternative methods that may have a positive effect on healing in chronic RC repairs continues.

CT-based, robotic-arm assisted total hip arthroplasty (Mako) through anterior approach provides improved cup placement accuracy but no difference in clinical outcomes when compared to conventional technique

BACKGROUND

With the restoration of the natural hip biomechanics, a successful total hip arthroplasty (THA) and long-term survival is pursued. Although robotic THA (rTHA) has been developed to increase accuracy of implant positioning, leg lengths and offsets, discussions about its radiological and clinical advantages over conventional THA (cTHA) continues.

OBJECTIVE

The aim of this study was to compare clinical and radiological outcomes of robotic and conventional THA.

METHODS

This retrospective study compares functional and radiological outcomes of 82 rTHA with a matched group of 82 cTHA in terms of age, sex, body mass index and preoperative functional scores. The minimum follow up was 12 months for all patients. Functional outcomes were Harris Hip Score (HHS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) evaluated pre- and postoperatively. Radiological evaluations included position of cup placement according to Lewinnek and Callanan safe zones, Canal Fill Ratio (CFR), Leg Length Discrepancy (LLD), Lateral offset (LO) and Femoral Component Alignment (FCA). Complications were also evaluated.

RESULTS

In the rTHA group, 91.5% (75 out of 82) of the acetabular cups were positioned within the safe zone whereas it was 63.4% (52 out of 82) for the cTHA group (p< 0.001). According to Callanan, they were 84.1% and 50%, respectively (p< 0.001). Between the groups, no statistically significant difference was found in CFR, LLD, HO, FCA, AI, AA, WOMAC, HHS and major complication rates.

CONCLUSION

rTHA is superior to cTHA in terms of accuracy and reproducibility of the cup placement, however no apparent clinical benefit was found in short term follow.

Is Only Peripheral Hip Arthroscopy Enough for Selected Patients with Femoroacetabular Impingement Syndrome?

Background

Peripheral compartment hip arthroscopy has gained popularity over central compartment hip arthroscopy as peripheral compartment arthroscopy does not cause perineal post compression, prolonged lower extremity traction and thus complications such as acetabular labrum and articular cartilage injuries. The study, in essence, aims to emphasize that peripheral hip arthroscopy (OPHA) alone is sufficient without an additional surgical method in the treatment of femoroacetabular impingement syndrome (FAI).

Methods

A total of 35 patients, being 21 female and 14 male, among a group of patients who were suffering from FAI syndrome and applied to private hip conservatory centers and has undergone hip arthroscopy at a later stage by a senior surgeon (I.T.) were selected from the medical-based software of the hospital. Patients with intra-articular pathology as a result of magnetic resonance imaging (MRI) were excluded from the study. The group had a mean age of 40.6, youngest being 17 and oldest 69, while the mean observation period was 26.6 months, varying between shortest 6 months and longest 63. In order to assess the patient satisfaction as well as clinical outcomes, Postel Merle d'Aubigné (PMA) score was used.

Results

When patient satisfaction was evaluated, overall decrease in pain was found and when gait characteristics were evaluated together with movement, an increase in overall satisfaction was found (P<0.05). Secondary arthroscopic procedures was not required in any of the patients included in this study. A group of three patients only needed some additional surgical interventions like stem cell therapy, hip arthroplasty and pelvic osteotomy.

Conclusion

OPHA can provide adequate treatment in selected FAI patients as it allows us to avoid critical complications such as damage to the cartilage, avascular necrosis, complications caused by traction and prolonged operation times seen in central compartment arthroscopy.

Evaluation of postural control in children with increased femoral anteversion

BACKGROUND

Femoral anteversion is defined as the angular difference between the axis of the femoral neck and the transcondylar axis of the knee and the most common cause of an in-toe gait in children.

RESEARCH QUESTION

Does increased femoral anteversion (IFA) adversely affect postural stability and balance in healthy children?

METHODS

Sixteen children with IFA aged 10-15 years and an age-matched control group of 16 children who were growing typically were included. Postural stability (PS), limits of stability (LoS), and the modified clinical test of sensory integration of balance (mCTSIB) were used to evaluate postural control by "Biodex Balance System® (BBS)" and Balance Error Scoring System (BESS), which is a visual observation of instability in 3 stance positions under 6 different conditions, were performed for all cases. SPSS v.20 program was used for data analysis. Independent Samples T-test or Mann Whitney U test were used for between-group comparisons depending on the distribution properties of the data. The significance level was set at p < 0.05.

RESULTS

A significant difference was found between the groups for overall and anterior/posterior stability index in PS (p < 0.05), all parameters of LoS (p < 0.05) and mCTSIB (p < 0.05). Also there was a significant difference between the BESS firm surface (p = 0.007), BESS foam surface (p < 0.001), and total surface scores (p < 0.001).

SIGNIFICANCE

The results indicate that the children with IFA were significantly more unstable in all parameters of BBS and BESS when compared to their healthy peers. This shows that postural stability and balance are impaired in healthy children with IFA. To the extent of our knowledge, this study is the first to examine the postural control problems associated with IFA in healthy children.

Comparison of 3 Cell-Free Matrix Scaffolds Used to Treat Osteochondral Lesions in a Rabbit Model

BACKGROUND

Various cell-free scaffolds are already in use for the treatment of osteochondral defects (OCDs); however, a gold standard material has not yet been defined.

PURPOSE

This study compared the macroscopic, histological, and scanning electron microscopy (SEM) characteristics of Chondro-Gide (CG), MaioRegen (MA), and poly-d,l-lactide-co-caprolactone (PLCL) cell-free scaffolds enhanced with small-diameter microfractures (SDMs) for OCDs in a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 54 knees from 27 rabbits were used in this study. Three rabbits were sacrificed at the beginning of the study to form an intact cartilage control group (group IC). An OCD model was created at the center of the trochlea, and SDMs were generated in 24 rabbits. Rabbits with OCDs were divided into 4 groups (n = 12 knees per group) according to the cell-free scaffold applied: CG (group CG), MA (group MA), PLCL (group PLCL), and a control group (group SDM). Half of the rabbits were sacrificed at 1 month after treatment, while the other half were sacrificed at 3 months after treatment. Healed cartilage was evaluated macroscopically (using International Cartilage Regeneration & Joint Preservation Society [ICRS] classification criteria) and histopathologically (using modified O'Driscoll scores and collagen staining). Additionally, cell-free scaffold morphologies were compared using SEM analysis.

RESULTS

ICRS and modified O'Driscoll classification and staining with collagen type 1 and type 2 demonstrated significant differences among groups at both 1 and 3 months after treatment (P < .05). The histological characteristics of the group IC samples were superior to those of all other groups, except group PLCL, at 3 months after treatment (P < .05). In addition, the histological properties of group PLCL samples were superior to those of group SDM samples at both 1 and 3 months after treatment in terms of the modified O'Driscoll scores and type 1 collagen staining (P < .05). Concerning type 2 collagen staining intensity, the groups were ranked from highest to lowest at 3 months after treatment as follows: group PLCL (30.3 ± 2.6) > group MA (26.6 ± 1.2) > group CG (23.3 ± 2.3) > group SDM (18.9 ± 0.9).

CONCLUSION

OCDs treated with enhanced SDM using cell-free PLCL scaffolds had superior histopathological and microenvironmental properties, more hyaline cartilage, and more type 2 collagen compared with those treated using CG or MA scaffolds.

CLINICAL RELEVANCE

OCDs treated with PLCL cell-free scaffolds may have superior histopathological properties and contain more type 2 collagen than do OCDs treated with CG or MA cell-free scaffolds.

Unicompartmental knee arthroplasty combined with high tibial osteotomy in anteromedial osteoarthritis: A case report

•

Anteromedial osteoarthritis is a common knee pathology.

•

Spontaneous osteonecrosis of the knee causing anteromedial osteoarthritis can be treated with different surgical options.

•

Although high tibial osteotomy and unicompartmental knee arthroplasty are alternative treatments for anteromedial osteoarthritis, successful results can be obtained using both in individual cases.

Introduction and importance

Anteromedial osteoarthritis (AMOA) is a common knee pathology. However, the best treatment of AMOA remains unclear. Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are surgical options for AMOA patients who do not benefit from conservative treatment. We aimed to show an unusual treatment option where UKA and HTO are performed simultaneously.

Case presentation

We present a 52-year-old man with AMOA secondary to spontaneous osteonecrosis of the knee (SONK) and metaphyseal tibial varus malalignment, who was successfully treated with a combined UKA and HTO. His functional scores were excellent at the 5-year follow-up.

Clinical discussion

Advanced SONK that causes AMOA can be treated with osteochondral autograft transplantation (OAT), HTO, UKA, or total knee arthroplasty (TKA). Although good results have been reported selecting appropriate patients for all of these methods, the best treatment method remains unclear.

Conclusion

Although HTO and UKA are alternative treatments for AMOA, successful results can be obtained using both in individual cases.

Tear Completion Versus In Situ Repair for 50% Partial-Thickness Bursal-Side Rotator Cuff Tears: A Biomechanical and Histological Study in an Animal Model

BACKGROUND

Tear completion followed by repair (TCR) and in situ repair (ISR) have been widely used for bursal-side partial-thickness rotator cuff tears (PTRCTs). Both techniques have shown favorable results; however, controversy continues in terms of the best management.

PURPOSE

To compare the histological and biomechanical outcomes of these 2 techniques for 50% partial-thickness bursal-side rotator cuff tear repair in a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 27 rabbits were used in this experimental study. Seven rabbits were sacrificed at the beginning of the study to form an intact tendon control group. A chronic 50% partial-thickness bursal-side tear model was created in 20 rabbits, and 5 rabbits were sacrificed for biomechanical testing of chronic partial-thickness tears (control group) without repair. In 15 rabbits, partial-thickness tears were repaired after 8 weeks. Partial-thickness tears in the right shoulders were completed to full thickness and repaired; in contrast, left shoulders were repaired in situ. All rabbits were euthanized 8 weeks after the repair. The tendons were tested biomechanically for ultimate failure, linear stiffness, and displacement. Histological evaluations of tendon-to-bone healing were performed via the modified Watkins score.

RESULTS

Macroscopically, all repaired tendons were attached to the greater tuberosity. The TCR group had a higher failure load than the ISR group, with mean values of 140.4 ± 13.8 N and 108.1 ± 16.6 N, respectively (P = .001). The modified Watkins score was significantly higher in the TCR group (23.5; range, 22-27) than in the ISR group (19.5; range, 16-22) (P = .009).

CONCLUSION

Both repair techniques are effective for 50% partial-thickness bursal-side rotator cuff tears; however, TCR yields significantly superior biomechanical and histological characteristics compared with ISR.

CLINICAL RELEVANCE

Tear completion and repair technique may increase tendon-to-bone healing and thereby reduce re-rupture rate in the partial thickness bursal side rotator cuff tears.

Mid-Term Results of Minimally Invasive Plate Osteosynthesis and Circular External Fixation in the Treatment of Complex Distal Tibia Fractures

BACKGROUND

The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators.

METHODS

We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score.

RESULTS

Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12-26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18-24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients.

CONCLUSIONS

Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.

Anthropometric measurements of tibial plateau and correlation with the current tibial implants

PURPOSE

The aim of the study was to make an anthropometric analysis at the resected surfaces of the proximal tibia in the Turkish population and to compare the data with the dimensions of tibial components in current use. We hypothesized that tibial components currently available on the market do not fulfil the requirements of this population and a new tibial component design may be required, especially for female patients with small stature.

METHODS

Anthropometric data from the proximal tibia of 226 knees in 226 Turkish subjects were measured using magnetic resonance imaging. We measured the mediolateral, middle anteroposterior, medial and lateral anteroposterior dimensions and the aspect ratio of the resected proximal tibial surface. All morphological data were compared with the dimensions of five contemporary tibial implants, including asymmetric and symmetric design types.

RESULTS

The dimensions of the tibial plateau of Turkish knees demonstrated significant differences according to gender (P < 0.05). Among the different tibial implants reviewed, neither asymmetric nor symmetric designs exhibited a perfect conformity to proximal tibial morphology in size and shape. The vast majority of tibial implants involved in this study tend to overhang anteroposteriorly, and a statistically significant number of women (21 %, P < 0.05) had tibial anteroposterior diameters smaller than the smallest available tibial component.

CONCLUSION

Tibial components designed according to anthropometric measurements of Western populations do not perfectly meet the requirements of Turkish population. These data could provide the basis for designing the optimal and smaller tibial component for this population, especially for women, is required for best fit.

LEVEL OF EVIDENCE

II.

Biomechanical Comparison of 2 Different Femoral Stems in the Shortening Osteotomy of the High-Riding Hip

BACKGROUND

We hypothesized that a rectangular cross-sectional femoral stem may produce more initial stability of the transverse subtrochanteric femoral shortening osteotomy rather than a circular cross-sectional stem.

METHODS

Twenty, fourth-generation, synthetic femur models were inserted with either circular or rectangular cross-sectional femoral stems after 3 cm of transverse subtrochanteric shortening. Half of the models were tested with axial bending and the other half with torsional loads. After the femora underwent cyclic loading, they were loaded until failure. Outcome parameters were stiffness values before and after cyclical loading, failure loads/torques, and displacements at the osteotomy sites.

RESULTS

In axial bending tests, the results were not significantly different between the groups. Under rotational forces, the mean stiffness value before cyclical loading and failure torque of the cylindrical stems was significantly higher than that of rectangular cross-sectional stems (11.8 ± 1.2 vs 7.1 ± 2.8 Nm/degree; P = .009 and 136.9 ± 60.2 vs 27.1 ± 17.5 Nm; P = .027 Nm, respectively). The mean amounts of displacements at the osteotomy sites were not significantly different between the groups in any direction in both axial and rotational tests.

CONCLUSIONS

According to the results of the study, using straight, cylindrical femoral stems can increase rotational stability of the transverse osteotomy more than the rectangular cross-sectional stems although the latter one has the advantages of rectangular geometrical design.

Can chondral healing be improved following microfracture? The effect of adipocyte tissue derived stem cell therapy

BACKGROUND

We aimed to investigate the effect of adipose tissue-derived mesenchymal stem cells (ADSCs) on chondral healing using the microfracture (MF) technique.

METHODS

Thirty male rabbits were randomly divided into three groups. Standard cylindrical osteochondral defects (OCDs) were created in the weight-bearing areas of the medial condyles of all the right knees; the defects were four millimeters in diameter and two millimeters in depth. The control group (group A) was restricted to spontaneous healing. For group B, we performed MF with a 1.5-mm drill. For group C, we applied MF using the same method and then applied 3×10(6) ADSCs to the defect area. At eight weeks post-operation, the subjects were sacrificed, and the distal femoral joint surfaces were evaluated histopathologically for chondral healing. The samples were scored according to the International Cartilage Repair Society (ICRS) scale.

RESULTS

The results for group C were significantly better than those for group A in terms of the surface properties (p=0.003). The matrix evaluation was better for group A than for group C (p=0.01). The cell distribution, cell viability and subchondral bone parameters were similar between the groups (p=0.198, p=0.387 and p=0.699). The cartilage mineralization parameter was better for group C than for group A (p=0.001). The signs of healing were better for group C than for group B, but the differences were not significant (p=0.185).

CONCLUSIONS

Improvements with additional ADSC treatments were not statistically significant in cases in which ADSC treatment was compared with isolated MF treatment.

CLINICAL RELEVANCE

Additional ADSCs treatment may have positive effect on chondral healing but it doesn't seem significant.

Effect of body mass index on functional outcomes following arthroplasty procedures

AIM: To evaluate the body mass index (BMI) change in arthroplasty patients and its impact on the patients’ functional results.

METHODS: Between October 2010 and May 2013, 606 patients who were operated due to gonarthrosis, coxarthrosis, aseptic loosening of the total knee and hip prosthesis were evaluated prospectively. Patients were operated by three surgeons in three medical centers. Patients who were between 30-90 years of age and who were underwent total knee arthroplasty, total hip arthroplasty, revision knee arthroplasty, or revision hip arthroplasty were included in the study. We excluded the patients who cannot tolerate our standard postoperative rehabilitation program. Additionally, patients who had systemic inflammatory diseases, diabetes mellitus, or endochrinopathies were excluded from the study. The remaining 513 patients comprised our study group. Preoperative functional joint scores, height, weight and BMI of all patients were recorded. We used the Knee Society Score (KSS) for knee and Harris Hip Score (HHS) for hip patients. Postoperative functional scores were measured at 1^st, 6^th and 12^th months and recorded separately at outpatient visits.

RESULTS: The mean age of the patients was 64.7 (range: 30-90) years (207 males/306 females) and the mean follow-up duration was 14.3 (range: 12-26) mo. We found that arthroplasty patients had weight gain and had an increase in BMI at the postoperative 1^st, 6^th and 12^th months. The mean BMI of the patients was 27.7 preoperatively, 27.8 at the postoperative 1^st month, 28.1 at the 6^th month and 28.6 at the 12^th month (P < 0.01). At the last visit, the mean postoperative HHS of the hip arthroplasty patients was 82.2 ± 7.12 (preoperatively, 52.3; 1^st month, 78.2; 6^th month, 81.1; 12^th month, 82.2), and the mean KSS of the knee arthroplasty patients was 79.3 ± 4.31 (preoperatively, 35.8; 1^st month, 75.2; 6^th month, 79.1; 12^th month, 79.3). Worse functional results were noted in the patients who had a BMI increase, however, this correlation was statistically significant only at the postoperative 6^th month (P = 0.03).

CONCLUSION: To prevent the negative functional effects of this weight gain during the postoperative period, arthroplasty patients should be advised for weight control and risky patients should consult with a dietician.

Acetabular dysplasia may be related to global joint hyperlaxity

PURPOSE

Some patients with shoulder laxity complain of coxalgia without a history of trauma. We hypothesised that patients who have recurrent shoulder instability accompanied with generalised joint hyperlaxity tend to have acetabular dysplasia.

METHODS

Pelvic radiographs of 26 young patients with hyperlaxity who had shoulder instability complaints without any history of hip joint trauma were evaluated by measuring their centre-edge angle (CEA) and acetabular angle (AA). In addition, Beighton generalised joint laxity tests were performed. All of the patients had shoulder pain and instability accompanied with hyperlaxity. We performed magnetic resonance imaging examination to show SLAP-Bankart lesions and pelvis anteroposterior X-rays to detect acetabular dysplasia.

RESULTS

The average age of the study group was 26 ± 8.03 years (13-39). Six patients were female and 20 were male. When CEA (<22.6 degrees) was used as a criterion for acetabular dysplasia, the dysplasia rate of our patient group was 3.84 % for the right hip, 3.84 % for the left hip and 3.84 % overall. When AA (>42.2 degrees) was used as the dysplasia criterion, the dysplasia rate of patient group was 30.76 % for the right hip, 57.69 % for the left hip and 57.69 % overall.

CONCLUSIONS

CEA values were significantly lower (p = 0.009) and AA values were significantly higher (p < 0.001) in our study group than the previously-reported average values of the Turkish population. We think that acetabular dysplasia is more frequent in patients with hyperlaxity; further studies are needed to test this idea.

Does intra-articular fracture change the lubricant content of synovial fluid?

BACKGROUND

Lubrication function is impaired and the lubricant content of synovial fluid (SF) changes immediately after plateau tibia fractures. Here, we aimed to analyze the lubricant content of SF at chronic term following plateau tibia fracture.

METHODS

Forty-eight surgically treated patients without joint incongruency (<2 mm displacement) were included in the study. Joint aspiration had been possible in 16 of the participants. However, sampling could be made from healthy knees in only ten of these patients. Twenty-six SF samples (16 injured knees, 10 healthy knees) were analyzed for concentrations of hyaluronic acid (HA), proteoglycan-4 (PRG4), TNF-α, IL-1β, and IL-6.

RESULTS

The group of experimental samples were obtained at a mean of 31 (12-66) months after injury from patients with a mean age of 45.1 (32-57) years. There were no relationships detected between biochemical analysis results and patient ages, sexes, postoperative time, and fracture type. After excluding six patients for whom we could not sample from their healthy knee, ten patients' values were compared with paired Wilcoxon signed rank test and no significant differences detected between the healthy and injured knee in terms of the SF concentrations of HA and PRG4 (p = 0.225 and 0.893, respectively). Similarly, there were no statistically significant differences in SF sample concentrations of TNF-α, IL-1β, and IL-6 between healthy and injured knees.

CONCLUSIONS

Despite acute changes, the long-term concentrations of HA and PRG4 were similar after plateau tibial fracture. We could not detect any concentration level differences between healthy knees and injured knees regarding HA and PRG4 in the long-term follow-up.

Biomechanical comparison of dynamic hip screw, proximal femoral nail, cannulated screw, and monoaxial external fixation in the treatment of basicervical femoral neck fractures

PURPOSE OF THE STUDY The objective of this study was to establish relative fixation strengths of proximal femoral nail (PFN), dynamic hip screw (DHS), monolateral external fixator (EF), and cannulated screw (CS) in basicervical hip fracture model. MATERIAL AND METHODS The study involved four groups of implanted composite proximal femoral synthetic bones of eight specimens per group; nailing with PFN, DHS, fixation with three cannulated screws, and EF. 70˚ osteotomy was performed to simulate a Pauwels Type 3 basicervical fracture. Minimum preload of 100 N was applied before loading to failure. The constructs were subjected to cyclic loading with 16˚ to midline from 100 N to 1,000 N for 10,000 cycles at 3Hz. Axial loading was applied at 10 mm/min until failure. Failure load, failure mode, and displacement were documented. RESULTS Mean failure load was 2182.5 ± 377.9 N in PFN group, 2008.75 ± 278.4 N in DHS group, 1941.25 ± 171.6 N in EF group, and 1551.6 ± 236.2 N in CS group. Average displacement was 15.6 ± 4.5 mm, 15.5 ± 6.7 mm, 11.7 ± 1.9 mm, and 15 ± 1.7 mm, respectively. No significant difference was noted among groups for fixation strength except CS group. All CS constructs failed during cyclic loading. CONCLUSION Our findings suggest that PFN, DHS and EF achieved higher fixation strengths than CS in basicervical fracture. PFN has higher failure loads and possesses biomechanical benefits for fixation of unstable basicervical fractures compared with DHS and EF. Key words: basicervical fracture, internal fixation, biomechanics.

Morphometry of the medial tibial plateau in Turkish knees: correlation to the current tibial components of unicompartmental knee arthroplasty

OBJECTIVE

The objective of this study was to measure the resected surfaces of the tibia in knees of Turkish patients and to compare these measurements with the dimensions of tibial implants in current use.

METHODS

We made measurements of seven different dimensions of the medial tibial plateau at the virtual resection level for unicompartmental knee arthroplasty (UKA) on MRIs of 260 patients and the most commonly used four UKA implants in Turkey. Statistical analysis was performed by using Student's t-test, analysis of variance (ANOVA), chi-square test and Pearson's correlation coefficient by using SPSS software.

RESULTS

The anteroposterior and widest mediolateral dimensions of the tibial plateau of Turkish knees were found relatively more approximate to the dimensions of Oxford and Zuk prostheses compared to that of Accuris and Mitus (p<0.001). The distance between the central mediolateral dimension and the widest mediolateral dimension was 2.4 (range: 0-6.3) mm in males and 2.6 (range: 0-6.2) mm in females. The maximum mediolateral dimension was found posterior to the central mediolateral dimension in the majority (202 out of 260) of cases. These findings point towards the asymmetry in the AP halves of the resected medial tibial condyle.

CONCLUSION

Tibial components designed according to anthropometric measurements based on both Western and Asian populations do not perfectly meet the requirements of Turkish population. Designing different UKA prostheses for different populations are required for best fit.

The effect of infraspinatus hypotrophy and weakness on the arthroscopic treatment of spinoglenoid notch cyst associated with superior labrum anterior-to-posterior lesions

PURPOSE

Patients with spinoglenoid notch cyst associated with superior labrum anterior-to-posterior (SLAP) lesions were evaluated. The patients were all treated by arthroscopic cyst decompression combined with SLAP repair. The hypothesis of the study was that the patients who underwent prolonged conservative treatment period prior to surgery would exhibit significant infraspinatus hypotrophy and weakness, and their postoperative clinical and functional outcomes would be less satisfactory.

METHODS

Sixteen patients exhibited positive MRI and EMG findings with clinical signs of weakness and pain. The median age was 40.5 years (range 32-52), and the study group consisted of 11 males and 5 females with a median follow-up period of 26 months (12-48). The median duration of symptoms and conservative treatment prior to the surgical intervention was 3.5 months (1-14). Seven patients in group A exhibited infraspinatus hypotrophy. Group B comprised 9 patients without infraspinatus hypotrophy.

RESULTS

The results of the pre- and postoperative Constant scores, visual analogue scale (VAS) scores, and external rotation strength test rates were compared between groups. They all improved in terms of pain, strength, and function (P < 0.05). Significant differences were observed between the pre- and postoperative external rotation strengths and Constant scores (P < 0.05). However, no significant difference was observed between the pre- and postoperative VAS scores (n.s.). A significant correlation was observed in group A between surgical timing, the preoperative external rotation strength ratio (P = 0.04) and the postoperative VAS scores (P = 0.013).

CONCLUSION

The arthroscopic treatment was satisfactory with good clinical outcomes. Infraspinatus hypotrophy occurred in cases of prolonged surgical duration and significantly affected external rotation strength and functional outcomes.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Excess retained cement in the posteromedial compartment after unicondylar knee arthroplasty

Acute mechanical symptoms due to excess retained cement in the posterior compartment of the knee joint following unicondylar knee arthroplasty (UKA) are uncommon. Infection, aseptic loosening, polyethylene wear and progressive arthritis are well-documented complications of UKA procedure. We present a patient with acute pain and 'clicking' sensation in the knee joint due to cement extrusion in the posteromedial compartment after UKA. Full functional recovery was achieved after arthroscopic removal of the cement debris. Of retrospectively screened 43 UKA cases, asymptomatic cement extrusion was detected in 8 patients in the posteromedial compartment on direct X-rays. Careful inspection of components is essential to minimize the risk of cement extrusion into the posterior compartment and perioperative fluoroscopy may be helpful during UKA procedure.

Joint debridement and metatarsal remodeling in Freiberg's infraction

BACKGROUND

Freiberg's infraction is an osteochondrosis that is characterized by osteonecrosis of the metatarsal head, with pain and tenderness around the metatarsophalangeal joint. We sought to evaluate the outcome of joint debridement and metatarsal remodeling for the treatment of advanced-stage Freiberg's infraction.

METHODS

Between March 1, 2006, and April 30, 2011, 14 patients (eight females and six males) with symptomatic unilateral Freiberg's disease refractory to conservative treatment (Smillie stages IV and V) underwent joint debridement with metatarsal head remodeling by two surgeons. To evaluate functional outcome, American Orthopaedic Foot and Ankle Society and 36-Item Short Form Health Survey forms were completed by the patients preoperatively and postoperatively at months 3, 6, and 12. Active-assisted range-of-motion exercise was allowed after 4 weeks of short-leg walking cast wear, and weightbearing on the forefoot was allowed as tolerated.

RESULTS

Mean patient age was 27.0 years (range, 16-53 years), and mean follow-up was 40.2 months (range, 14-54 months). Mean ± SD American Orthopaedic Foot and Ankle Society and 36-Item Short Form Health Survey scores were 46.8 ± 8.95 and 28.9 ± 4.3 preoperatively and 76.2 ± 9.5 and 45.6 ± 7.7 1 year after surgery, respectively. There was a significant increase in both scores (P ≤ .001).

CONCLUSIONS

In advanced-stage Freiberg's infraction of the second metatarsal, joint debridement and metatarsal head remodeling is a safe and simple therapeutic option, and it provides better quality of life for patients.

Does obesity negatively affect the functional results of arthroscopic partial meniscectomy? A retrospective cohort study

PURPOSE

The purpose of this study was to evaluate the impact of body mass index (BMI) on early functional results of patients who undergo isolated partial meniscectomy.

METHODS

The functional results for 1,090 patients who underwent partial meniscectomy, in 2 different orthopaedic clinics, were evaluated retrospectively. The study includes cases with arthroscopic partial meniscectomy for isolated meniscal tears; patients with concomitant knee pathology were excluded. Three hundred forty-one (31%) patients with isolated lateral meniscal tears, 628 (58%) patients with isolated medial meniscal tears, and 121 (11%) patients with both medial and lateral meniscal tears underwent arthroscopic partial meniscectomy. We divided these patients into 3 subgroups on the basis of their BMI; <26, between 26 and 30, ≥30. Preoperative functional results were compared with 1-year postoperative follow-up results using the International Knee Documentation Committee (IKDC),(26) Lysholm Knee Scale,(27) and Oxford Scoring System(28) scores.

RESULTS

According to all 3 knee scales, age, side of lesion, and tear type had no effect on functional outcome. When compared with the group with BMI <26, the patients with BMI between 26 and 30 and the patients with BMI ≥30 had significantly worse outcomes as measured by the IKDC, Oxford Scoring System, and Lysholm Knee Scale scores. Patients with BMI between 26 and 30 and ≥30 did not have significantly different functional outcomes.

CONCLUSIONS

Short-term outcomes after arthroscopic partial menisectomy reflect significant improvement in subjective outcome. However, patients with moderate or significant obesity (BMI >26) have inferior short-term outcomes compared with nonobese patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Total hip arthroplasty in a patient with congenital insensitivity to pain: a case report

INTRODUCTION

Congenital insensitivity to pain, a rare neurological entity, is characterized by varying degrees of sensory loss and autonomic dysfunction. Orthopedic manifestations of congenital insensitivity to pain include delayed diagnosis of fractures, nonunions, malunions, Charcot arthropathy, acro-osteolysis, avascular necrosis, osteomyelitis, heterotopic ossification and joint dislocations. We here report the case of a patient with congenital insensitivity to pain who had multiple lower extremity fractures at varying intervals, the most recent being a femoral neck fracture managed by total hip replacement. To the best of our knowledge, this is the first report of cementless hip arthroplasty in such a patient.

CASE PRESENTATION

A 37-year-old Caucasian woman was admitted to our hospital complaining of painless swellings in her lower limb and limping. She had been diagnosed with multiple lower extremity fractures at different times. On physical examination, we found multiple perioral mucosal ulcers, shortening of her nails and acro-osteolysis, a prematurely aged facial appearance, undersized skeletal structure, Charcot arthropathy of her right ankle, anosmia, insensitivity to temperature differences and evidence of mild intellectual disability. A right subtrochanteric femur fracture was treated with an intramedullary nail. Eighteen months later, she presented with similar symptoms and we diagnosed a right femoral neck fracture. We removed the nail and performed cementless total right hip arthroplasty.

CONCLUSIONS

Congenital insensitivity to pain is a rare condition that is associated with severe orthopedic problems. This case report, which will be of particular interest to orthopedic surgeons, presents several difficulties in the management of patients with congenital insensitivity to pain and notes the importance of close follow-up and early recognition of complications. Cementless total hip arthroplasty may be a good therapeutic option for femoral neck fracture in these patients.

Migration of intra-articular K-wire into the contralateral pelvis after surgery for developmental dysplasia of the hip: a case report

Transarticular fixation of femoral head into acetabulum with K-wire is a seldomly used surgical method in difficult cases of developmental dysplasia of the hip (DDH). This paper presents a child with intrapelvic transvesicular migration of a K-wire without any symptoms after treatment of DDH. Eight years old girl who had multiple surgeries 4 years ago due to bilateral DDH applied to the orthopedics clinic with limping. She had good range of motion of both hips. At the pelvis radiograph, there was an intrapelvic K-wire standing between two hemipelvises like a bridge. She did not have any enteral and urological symptoms after the previous operations. We planned to remove the K-wire in cooperation with the pediatric surgery department. On the cystoscopy, K-wire was seen passing through the urinary bladder. Wire was cut at the middle point and taken out of the body by laparotomy. The patient was discharged without any postoperative complications. K-wire retention in the body has high chance of migration. Early postoperative removal of the K-wire is necessary to prevent possible complications.

[Knee arthrodesis using a unilateral external fixator for the treatment of infectious sequelae]

OBJECTIVES

We evaluated the results of arthrodesis using a monolateral external fixator for the treatment of septic sequelae of the knee joint.

METHODS

Eleven patients (4 males, 7 females; mean age 60 years; range 29 to 75 years) underwent arthrodesis using a monolateral external fixator. Indications for arthrodesis were infected total knee prosthesis (n=6), septic arthritis sequelae (n=4), and infected distal femoral tumor prosthesis (n=1). Eight patients had active infection; of these, seven patients initially underwent complete clinical and laboratory eradication of infection with debridement, application of antibiotic-impregnated cement spacer (n=6), and parenteral antibiotics. Resection guides of total knee arthroplasty were used to create wide bleeding femoral and tibial bone surfaces. Biplanar or uniplanar monolateral external fixation was applied for a mean of eight months (range 5 to 12 months). The mean follow-up was 28 months (range 7 to 69 months). Complications were evaluated according to the Paley's classification.

RESULTS

Fusion was achieved in all the patients. There were no recurrent infections. No remarkable shortening developed following the procedure. All the patients could walk without walking aids, except for one patient who further required lengthening for marked shortening due to previous wide tumor resection. Shortening was 3 cm in one patient with infected total knee prosthesis, while it ranged from 1 cm to 2 cm (mean 1.4 cm) in the remaining patients. Pin tract infections were seen in five patients, all of which were successfully treated with oral antibiotics and local wound care.

CONCLUSION

Knee arthrodesis using a monolateral external fixator is associated with a high fusion rate and a low complication rate, and provides a more comfortable treatment option compared to a circular external fixator.

The effect of watching live arthroscopic views on postoperative anxiety of patients

Surgery is a stressful experience. Many minor interventions have been shown to cause considerable anxiety in patients, but whether arthroscopy leads to such anxiety is not well-known. Methods for lowering perioperative anxiety have been sought and listening to music or watching a movie have been recommended. The method of permitting patients to watch their own endoscopy has been studied infrequently. Our aim in this study was to find out the effect of watching simultaneous arthroscopic views on postoperative anxiety. A total of 63 patients were randomly divided into two groups: those watching their own arthroscopy formed group W, while patients that were only verbally informed formed group NW. The mean age of patients in both groups were 33 and 34, respectively. Meniscal surgery was the most commonly performed procedure (49/63 patients). The patients filled in state scale of State-trait anxiety inventory (STAI) forms and the study questionnaire (SQ) prepared for this study, just before and after the arthroscopy. Group W had significantly lower postoperative scores of STAI-S, whole questionnaire (Q-score) and all but one of individual statements in SQ. Having a previous operation history did not affect STAI scores. Age and level of education was not correlated with any of the studied parameters either. The ratio of patients that were pleased with the arthroscopy experience in group W and NW were 94 and 63%, respectively. Watching live arthroscopic views has led to a significant decrease in postoperative anxiety and worries about the surgery and the postoperative period, while increasing overall understanding and satisfaction of the patient.

Skin dimpling as a complication of hamstring harvesting following anterior cruciate ligament reconstruction

Surgical intervention to repair a torn anterior cruciate ligament (ACL) with autogenous hamstring tendons has become popular. However, hamstring graft harvesting complications can occur. This article presents a case of skin dimpling over the pes anserinus during active hamstring contraction in a 32-year-old man following arthroscopic ACL reconstruction.

The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique

In this study, mid to long-term results of anterior cruciate ligament reconstruction with hamstring tendons and Transfix technique were evaluated. Anterior cruciate ligament (ACL) reconstruction with four-strand hamstring tendon was performed with Transfix technique on 271 (198 males, 73 females; mean age 25.7; 17-52) patients with anterior cruciate ligament ruptures. The patients were followed up with clinical examination, Lysholm and Tegner activity scales, IKDC scoring system, KT-1000 test and radiological examination. The mean follow-up period was 82 (48-100) months; 204 (75%) patients had no subjective complaints. According to the KT-1000 test, only 14 (5%) patients had more than 5 mm laxity postoperatively, whereas, 161 (59%) patients had more than 5 mm laxity preoperatively. In addition to this, only 19 (7%) patients had Lysholm scores less than 80 postoperatively, whereas 154 (57%) patients scored less than 80 preoperatively. When compared with Tegner activity scale, 189 (70%) patients scored<6 preoperatively and only 24 (8%) postoperatively; 78 (29%) patients scored D preoperatively and only 5 (2%) patients scored D postoperatively on the basis of the IKDC scoring system. Our functional results were found to be satisfactory in more than 90% of patients. Commonly seen problems in ACL reconstruction such as inaccurate graft placement and tunnel widening were found to be consistent with the values in relevant literature. However, we demonstrated that the functional results and the stability of the knee were not related with tunnel widening. This study concludes that the reconstruction of ACL with hamstring tendons and the Transfix technique is reasonably successful, safe and causes low morbidity. Furthermore, we believe that proper graft preparation, accurate tunnel placement, notch-plasty, fixation and rehabilitation program are all as important as the choice of graft and fixation material.

The fascial band from semitendinosus to gastrocnemius: the critical point of hamstring harvesting: an anatomical study of 23 cadavers

BACKGROUND

Arthroscopically-assisted reconstruction of the anterior cruciate ligament with hamstring tendons has achieved widespread acceptance; however, the anatomy of these tendons may cause technical problems at harvesting.

METHODS

We studied the anatomy of the fascial band between semitendinosus and gastrocnemius and the distance between the semitendinosus insertion and the origin of this band in 23 knees from cadavers (17 male). The length of the semitendinosus tendon and the width of the fascial band were also recorded.

RESULTS

Fascial attachment was detected in all cadavers except 1. The mean width of the band was 2.6 (1-4) cm. The mean distance from the insertion of the semitendinosus to the fascial band was 7 (6-8) cm. The mean length of the semitendinosus tendon was 22 (18-26) cm.

INTERPRETATION

A better understanding of the anatomy of the hamstring tendons will reduce the risk of a disappointing complication right at the start of the operation.

Wrist Tourniquet: The Most Patient-Friendly Way of Bloodless Hand Surgery

BACKGROUND

The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers.

METHODS

Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO2, pCO2, O2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate.

RESULTS

Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO2, and O2 saturation values were decreased and pCO2 and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO2, O2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended.

CONCLUSION

The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.

Linburg–Comstock anomaly in musicians

Anomalous tendon connections from the flexor pollicis longus to the index finger flexor digitorum profundus cause lack of independent excursion of the flexor pollicis longus, first described in 1979 by Linburg-Comstock. This anatomical variation is potentially problematic for musicians. The purpose of this study was to evaluate the incidence of this anomaly in musicians and to operate on the symptomatic patients with a limited incision with the help of magnetic resonance imaging. We studied the incidence of the anomaly among 136 musician volunteers. A lower incidence rate of the anomaly was determined in this study. One of the symptomatic musicians was operated on and the tendinous connection was excised. Clinical examination of 136 volunteers suggested that the anomaly was present in 13% of the volunteers; unilateral in 9% and bilateral in 4%. Follow-up of the patient who was operated on revealed full pain-free function without any complaint. Surgical treatment although rarely necessary, is simple and effective.

The pain associated with intraarticular hyaluronic acid injections for trapeziometacarpal osteoarthritis

Trapeziometacarpal osteoarthritis predominantly affects middle-aged women. Most cases with rhizarthrosis can be managed successfully by conservative means. The purpose of this prospective study was to evaluate pain and tolerability of viscosupplementation therapy with hyaluronic acid (HA) for trapeziometacarpal osteoarthritis. Groups A and B consisted of eight patients each with Eaton stage 3 or 4 rhizarthrosis, who underwent one cycle of three injections of (one per week) 0.3 cm3 sodium hyaluronate. The injections for group A were under fluoroscopy control, but fluoroscopy was not used in group B. Pain and tolerability of both groups A and B were measured and compared. The patients of the groups were also asked to evaluate the tolerability of the treatment. The results suggested that HA injection in the carpometacarpal joint is a tolerable procedure but the patients complained of pain and discomfort during the injections. The pain in group A was much greater than in group B. Viscosupplementation for the treatment of trapeziometacarpal osteoarthritis is a viable treatment option for stages 3 and 4 patients when they do not want to be operated on. It is a tolerable but not a painless procedure especially when it is done without fluoroscopy control. We recommend giving injections under fluoroscopy control.

Anatomic localization of the popliteal artery at the level of the knee joint: a magnetic resonance imaging study

PURPOSE

The anatomic localization of the popliteal artery in the mediolateral plane at the level of the joint line was investigated on axial knee magnetic resonance imaging (MRI) scans to study anatomic variations.

METHODS

The transverse and central axes were described on axial MRI scans of 334 knees. The distance between the popliteal artery and central axis was measured; the course of the central axis bisected the posterior cruciate ligament in almost all of the cases. The differences in popliteal artery localization according to sex and side were analyzed.

RESULTS

Whereas popliteal artery localization was lateral to the central axis in 94.3% of cases, it was on the central axis in 5.7%. The popliteal artery localization was not seen on the medial side of the central axis. There was no significant effect of sex and side.

CONCLUSIONS

Arthroscopic surgeons performing posterior cruciate ligament reconstruction or interventions on the posterior horns of the menisci should bear in mind that the risk of arterial complication may be greater for cases having the popliteal artery on the central axis. In conclusion, preoperative evaluation of the popliteal artery with MR axial scans, especially in pericapsular arthroscopic procedures, may prevent popliteal artery injuries.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients.

Anatomic localization of the popliteal artery at the level of the knee joint: a magnetic resonance imaging study

PURPOSE

The anatomic localization of the popliteal artery in the mediolateral plane at the level of the joint line was investigated on axial knee magnetic resonance imaging (MRI) scans to study anatomic variations.

METHODS

The transverse and central axes were described on axial MRI scans of 334 knees. The distance between the popliteal artery and central axis was measured; the course of the central axis bisected the posterior cruciate ligament in almost all of the cases. The differences in popliteal artery localization according to sex and side were analyzed.

RESULTS

Whereas popliteal artery localization was lateral to the central axis in 94.3% of cases, it was on the central axis in 5.7%. The popliteal artery localization was not seen on the medial side of the central axis. There was no significant effect of sex and side.

CONCLUSIONS

Arthroscopic surgeons performing posterior cruciate ligament reconstruction or interventions on the posterior horns of the menisci should bear in mind that the risk of arterial complication may be greater for cases having the popliteal artery on the central axis. In conclusion, preoperative evaluation of the popliteal artery with MR axial scans, especially in pericapsular arthroscopic procedures, may prevent popliteal artery injuries.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients.

A comparison of effects of fluoroquinolones on fracture healing (an experimental study in rats)

BACKGROUND

The objective of the present study was to test and compare the effect of fluoroquinolones on fracture healing as assessed histopathologically.

METHODS

A total of twenty five Wistar rats were arbitrarily assigned to five groups with five animals each. Bilateral closed femoral fracture was constructed manually in all groups. The first group did not receive any drug as control (C). The 2nd, 3rd, 4th, and the last group were treated with norfloxacin (N), ofloxacin (O), pefloxacin (P) and ciprofloxacin (Ci) respectively. Antibiotic administration was started on the 7th day after the fracture incident. All the treatments were discontinued twenty days after the incident all the rats were sacrificed , and the fracture calluses together with affected femurs were resected en bloc at the fourth week after fracture.

RESULTS

Average healing grades of control group was higher than all the other antibiotic groups. Mean healing grades of control ( 5 ; n:8), ofloxacin (4.1; n:7), ciprofloxacin (3.9; n:8), norfloxacin (3.4 ; n:9) and pefloxacin groups (2.6 ; n:10) were recorded. Statistically significant differences between antibiotherapy groups ( excluding. norfloxacin) and the control group were detected.

CONCLUSIONS

The current histopathological study has shown that all the studied fluoroquinolones retarded fracture healing in rats.

Photogrammetric analysis of the articular surface of the distal radius

Three-dimensional measurements made using photogrammetry have recently gained popularity with the development of real-time detection facilities and up-to-date equipment. The modelling of human bones presents a particular challenge as the measurements required are difficult to obtain, especially from uneven surfaces. In this study, the articular surfaces of 12 radius bones were evaluated using photogrammetry to obtain three-dimensional coordinates of certain points. Morphometric characteristics of the digital topography of the articular surface were analysed using three-dimensional data from more than 200 points for each specimen. The coronal plane curve, from the tip of the styloid process to the centre of the distal radioulnar articular notch, was found to be similar to the fourth degree polynomial function. A mathematical expression representing the sagittal curve passing through scapholunate border could not be found. Close-range photogrammetry is a safe and precise technique that can provide reliable, reproducible and accurate data for evaluating complex morphological surfaces.

Morphologic evaluation of the ulna

Intramedullary ulnar nailing may be technically difficult. We used various methods and measurements to determine the ideal nail entry point and the shape, length, diameter and curvature of the medullary canal in 44 human cadaver ulnas. We found that the ideal nail entry point was, on average, 7 mm proximal and 3 mm lateral to the most prominent area of the olecranon. A nail of 3 mm diameter could easily be inserted through a hole at the proximal-lateral side of the most prominent part of the olecranon, but only 20% of all nails could be easily inserted through a hole in the middle of the olecranon. We found that correct selection of a nail of proper length and diameter, as well as an ideal nail entry point on the olecranon are essential to successful nailing.

Posterior interosseous artery flap in traumatic hand injuries

INTRODUCTION

Nineteen cases of posterior interosseous artery (PIOA) flap were reviewed. The patients' mean age was 24 (range 14-53) years.

MATERIALS AND METHODS

Nine patients were operated on as emergencies, and 10 patients were treated electively. Mean time of delay after trauma was 7.8 h (range 2-20 h) in emergency cases. Nine of them were non-replantable amputations. Skin defects were between 1.9 x 2.4 cm and 5.0 x 12.0 cm. Mean hospitalization time was 2.2 (range 1-5) days.

RESULTS

Mean flap sensation was evaluated as 2.83-6.65 with the Semmes-Weinstein evaluation scale (only 2 patients scored less than 3.61). Five patients presented with discoloration and coolness. Average subjective evaluation was 8.2/10. Mean web opening after first web reconstruction was 40 degrees. One posterior interosseous neuropraxia ( recovered in 4 months), one distal flap necrosis, and one flap lost (due to infection) occurred as early complications. Mean follow-up was 12.8 months (range 15 days to 30 months).

CONCLUSIONS

PIOA flap applications have reduced the need for lateral arm and radial forearm flaps and also shortened hospitalization time in clinical practice.

[Comparison between fixation with Herbert screws and Kirschner wires in the treatment of scaphoid pseudoarthrosis]

OBJECTIVES

To compare the treatment results of patients with scaphoid pseudoarthrosis, who were treated by autogenous cancellous bone grafting followed by fixation with Herbert screws or Kirschner wires.

METHODS

The study included 19 men (mean age 28 years, range 20 to 41 years) who were treated for scaphoid pseudoarthrosis and had a minimum follow-up of 12 months. Treatment was comprised of autogenous cancellous bone grafting and fixation with Herbert screws (n=10) or Kirschner wires (n=9). Fifteen right and four left hands were affected. The mean duration between the traumatic event and surgery was 20 months (range 3 to 72 months). Fractures were localized in the proximal pole (n=4, 21%), waist (n=13, 68%), and in the distal pole (n=2, 11%). The mean follow-up was 16 months for Herbert screws, and 21 months for Kirschner wires.

RESULTS

None of the patients exhibited a loss in range of motion of 10 degrees or more. The mean time to union was six months (range 3 to 20 months) with Herbert screws and eight months (range 4 to 22 months) with Kirschner wires. All patients had union with Kirschner wires, whereas non-union occurred in three patients with Herbert screws, two of whom had had proximal pole fractures. Radiologic outcome was significantly different between the two groups (p<0.01).

CONCLUSION

Because of good vascularity and union potential, scaphoid pseudoarthrosis can be successfully treated by an appropriate surgical technique using autogenous cancellous grafting independent of fixation materials.

A morphometric study on the humerus for intramedullary fixation

In recent years, the popularity of intramedullary humeral nailing is on the rise in spite of its handicaps. There are many problems in intramedullary humeral stabilization because of the anatomic structure of the bone. We performed various methods and measurements to determine shape, length and diameter and curvature of the medullary canal of the humerus in 57 human dry cadaver bones. Anterior angulation with an average of 21 cm apart from greater tubercle was found at 1/3 distal part. Mean degree of angulation was 9 degrees (max: 15, minutes: 5, S.D.: 2.84). Humerus bones with septal aperture (supratrochlear foramen) at the fossa coronoidea were observed to have very narrow medullary canal. The best point for nail insertion was found to be an area on the line from greater tubercle anteromedially to caput humeri. This study revealed that carefully evaluated structure of humeral medullary canal and various congenital constructions such as septal aperture, and correct selection of a nail with proper length and diameter are essential for successful nailing.

Comparing open surgery with endoscopic releasing in the treatment of carpal tunnel syndrome

AIM

The aim of this study is to retrospectively assess the complications and result of cases that underwent open surgery or endoscopic releasing for carpel tunnel syndrome.

METHOD

A total of 50 cases of carpel tunnel syndrome, 30 of whom underwent endoscopic release using the biportal extrabursal technique described by Chow, and the other 20 that underwent open surgery were included in the study. Average age of the cases was 41 (24 - 62), 44 of them were females and 6 males.

RESULTS

Follow-up examinations of the patients at the first and third month after operation revealed no limitation of activity in 40 (80 %) cases, minimal limitation in 4 (8 %), moderate limitation in 5 (10 %) and significant limitation in 1 (2 %). Among the group that underwent endoscopic release, as a major complication, the median nerve was almost totally cut in a patient undergoing endoscopic release. During the same operation setting perifascicular neurorrhaphy was done. Fourth and fifth digital nerve lesions occurred in three cases. Among the group that underwent open surgery fourth and fifth digital nerve injury occurred in one case, and in another case severe inflammation requiring reoperation occurred.

CONCLUSION

Before intervention, cases of carpal tunnel syndrome should be examined well as regards which technique to use. Experience of the surgeon with the technique to be used should also be taken into consideration. Endoscopic carpal tunnel releasing, though a relatively easier procedure, leads to neurovascular injuries more frequently than open surgery; thus open surgery appears to be safer.

Flexor tendon injuries of children in zone 2 (FDS repair or not)

Twenty flexor tendons in 13 children with a mean age of 7 years old (range from 9 months to 14 years) were treated by primary suture between 1994-1999. Both tendons were repaired in 12 (60%) digits and only FDP in 8 (40%) with excision of FDS. Mean follow-up was 19 months (from 6 to 55 months). In the 12 fingers with FDS repair, the results were excellent in 2, good in 4, fair in 3 and poor in 3. In the 8 fingers with FDS excision, 2 rated excellent, 5 good and 1 poor. In conclusion, repair of FDP alone with regional excision of FDS simplifies the operative procedure and reduces the number of tendon sutures inside the sheath.

Foucher's first dorsal metacarpal artery flap for thumb reconstruction: evaluation of 21 cases

BACKGROUND

Coverage of part of a soft tissue defect in the thumb, without bone shortening and without long-lasting immobilization in an inappropriate position leading to stiffness, is difficult to achieve

OBJECTIVES

To report our experience using Foucher's modification of the first dorsal metacarpal artery flap for thumb reconstruction in 21 cases.

METHODS

Foucher's flap is based on the neurovascular structures of the first dorsal metacarpal artery flap and radial nerve-sensitive branches on the dorsum of the second metacarpal and proximal phalanx. The cause of injury was work-related in all 21 cases. The patients mean age was 37 (range 17-68 years), and mean follow-up was 19 months (range 12-31). Emergency surgery was performed in 13 patients with a time delay after injury of 4-12 hours. The minimum defect was 12 x 18 mm and the maximum 20 x 40 mm. Pedicular length was 55-95 mm. A skin bridge was left intact in 16 cases. In two cases of early postoperative venous congestion and flap loss, a cross-finger flap was performed as a salvage procedure.

RESULTS

Subjective satisfaction score was 8.37/10 (range 4-10); cold intolerance was experienced in 60% and dysesthesia in 33%. All except one patient are able to use their thumb in daily activity. Loss of mobility in the proximal interphalangeal joint of the index finger was less than 20 degrees. Semmes-Weinstein sensitivity evaluation score was 3.61-4.31 on the flap and 0-6.65 on the donor site. Two-point discrimination was 10.8 mm (range 8-20). Grip strength was reduced by 15% compared to the unaffected hand (hand dominance was not taken into consideration). Rehabilitation was not consistent as almost all the patients were living in another location.

CONCLUSIONS

First DMCA pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.

Effects of hyaluronic acid on postoperative adhesion of tendo calcaneus surgery: an experimental study in rats

Adhesions are a significant problem after tendon surgery. The effects of hyaluronic acid on adhesion formation of the tendo calcaneus were investigated in this study. Twenty Wistar rats were utilized. Both tendo calcanei were incised transversely, and then repaired. Hyaluronic acid (0.2 cc) was injected into peritendinous tissue on the right side, while the same amount of normal saline was injected to the left side as a control. The animals were sacrificed 40days after the experiment. Both the right and left tendon adhesions were evaluated both macroscopically and microscopically for the presence of adhesions (grading scale 0-4). Throughout the experimental period, there was no difference in range of motion of the ankle between the two groups. Macroscopically, there were fewer adhesions in the experimental group (mean 0.6 +/- 0.8) compared to the controls (mean 1.1 +/- 0.2). This difference was not statistically significant (p = .096). Histopathologically, these parameters were similar in both the experimental (mean 1.15 +/- 0.98) and the control groups (mean 1.9 +/- 1.25). This difference was significant (p = .043). Hyaluronic acid may be effective for prevention of adhesions in the tendo calcaneus though this effect could not be demonstrated experimentally.

[Preliminary results for treatment of tibial plateau fractures with the Ilizarov technique of ligamentotaxis]

BACKGROUND

The results of the eight patients who admitted to emergency room with tibial plateau fractures and treated with Ilizarov technique, were retrospective evaluated both clinically and radiologically.

METHODS

Seven (87%) men and one (13%) woman ranging in age from 23 to 38, were evaluated. All the cases were between type IV to VI according to Hohl classification preoperatively. Closed indirect reduction by ligamentotaxis was attempted in all fractures, no open technique was performed.

RESULTS

Three (38%) cases had open fractures (type I according to Gustilo-Andersen Classification) preoperatively. Six (75%) traffic accident and two (25%) falling from a height were detected as etiology. The cases, whose average follow up was 14 (6-28) months, were evaluated according to Iowa knee score scale and seven (87%) cases were good and excellent. Both clinical and radiological solid fusion were obtained in all cases after removing the frame. Although all the cases had minimal to moderate pin tract infection, all were resolved with dressing and oral antibiotherapy without removing the wires.

CONCLUSIONS

Closed reduction with Ilizarov technique is appropriate for treatment of plateau tibia fractures with minimal morbidity.

Congenital true complete symphalangism of all proximal interphalangeal joints of hands with carpal anomalies: a case report

Symphalangism is a rare condition which manifests in either PIP or DIP joint congenital fusion. Symphalangism may be with some other skeletal deformities. In our case, all PIP joints of both hands were fused with bilateral hypoplasia of carpal bones and Minaar type III lunatotriquetral coalition congenitally. No motion was detected in PIP joints with absence of cutaneous creases over all PIP joints. Radiologically, carpal hypoplasia and lunatotriquetral coalition were seen in all fingers with the absence of PIP joints. The patient's skeletal survey revealed no other pathology. He had no complaints related to his hands. So, regular follow-up was recommended. This pathology was presented as rarely observed although clinical problem is usually not so much.

[Total bilateral carpal coalition with carpometacarpal fusion: one case]

Carpal coalition may involve more than two carpal bones which is more common when coalition occurs as part of a syndrome of congenital malformations. We describe an unusual case of congenital complete entire carpal coalition with massive carpometacarpal coalition except the first carpometacarpal joint and abnormal distal radioulnar joint bilaterally. In addition, radiocarpal joint surfaces were slightly irregular but compatible. There were abnormal distal radioulnar joints and ulnar styloids articulated with the ulnar side of the lunate of the both wrists.