Reconstruction of Coracoclavicular Ligaments with Semitendinosus Autograft and Temporary Kirschner Wires is a good option for Chronic Acromioclavicular Joint Instability

Introduction

This study reports the results of surgical anatomic reconstruction of torn coracoclavicular ligaments with an autogenous semitendinosus graft and temporary Kirschner wires (K-wires) in chronic acromioclavicular (AC) joint dislocations.

Materials and methods

Nineteen shoulders underwent surgical anatomic reconstruction of torn coracoclavicular (CC) ligaments with an autogenous semitendinosus tendon graft and temporary K-wires for Rockwood grade III, IV and V chronic AC joint dislocations. Pre-operative data included patients' demographic characteristics, injury characteristics and surgical histories. The primary outcome measures were the University of California Los Angeles (UCLA) shoulder rating scale and visual analogue pain scoring (VAS), and the complications were noted for each patient.

Results

Surgical anatomic reconstruction of torn CC ligaments was performed in 19 patients with a mean age of 41.6±16 years (range 21-72 years). All of the patients were satisfied and felt better after CC ligament reconstruction. The average UCLA shoulder rating scale score was good/excellent: 29.4 (range 23-34) out of 35 points. The average pre-operative VAS score was 7.7 points out of 10 and improved to 1.1 points post-operatively (p<0.05). None of the patients experienced failure during the follow-up. One patient had a mild subluxation, but the patient was satisfied with the result.

Conclusions

This technique is simple, reliable, and biologic without major complications. It is also a cost-effective procedure since it can be performed with Kirschner wires and autogenous grafts. It has a major advantage of leaving no implants inside the joint, which can lead to hardware complications, and it can be performed in basic operating room settings.

Aneurysmal bone cyst of the fifth metacarpal

Aneurysmal bone cyst is a rare, rapidly growing, and destructive benign bone tumor that even more rarely involves the bones of the hand. Various treatment options for aneurysmal bone cyst have been reported in the literature, but controversy exists regarding optimal treatment. Due to its rarity in the hand, no evidence-based treatment regimen has been established. A 21-year-old man presented with a history of pain and local swelling over his fifth metacarpal of 5 months' duration. Physical and radiographic examination of the hand was consistent with aneurysmal bone cyst. After biopsy, pathologic examination confirmed the diagnosis of aneurysmal bone cyst. En-block resection of the tumor and autologous bicortical strut graft fixation with Kirschner wires was performed. The hand was immobilized in a short arm cast for 3 weeks after the patient received 3 weeks of physiotherapy. Kirschner wires were removed 6 weeks postoperatively. Excellent clinical and functional results were obtained with no recurrence after 3 years of follow-up with en-block resection and reconstruction with iliac crest graft. Radiographic examination demonstrated the osseous integration of the graft with no signs of recurrence. Although treatment should be planned individually according to lesion site and size and to patient age, we suggest en-block resection to prevent recurrence and secondary surgical interventions particularly in cases with no articular involvement.

[Open reduction and low-profile plate and/or screw fixation in the treatment of phalangeal fractures]

OBJECTIVES

We evaluated the functional results and the effectiveness of open reduction and low-profile plate and/or screw fixation in the treatment of phalangeal fractures.

METHODS

The study included 17 patients (5 women, 12 men; mean age 33 + or - 10 years; range 17 to 48 years) with closed, nonarticular phalangeal fractures. One patient had two phalangeal fractures. There were 14 proximal and four mid phalangeal fractures, including seven oblique, four spiral, one transverse, and six comminuted fractures. The mean duration from injury to surgery was 2.6 + or - 2.9 days (range 0 to 11 days). Following open reduction, seven fractures were treated with a mini plate and screws, and 11 fractures with mini screws. For functional evaluations, total active motion (TARM) and grip strength were measured and the Q-DASH (Quick-Disabilities of the Arm, Shoulder and Hand) questionnaire was administered. The mean follow-up was 35 + or - 20 months (range 12 to 75 months).

RESULTS

Union was obtained in all the patients in a mean of 4.5 months. At final assessments, TARM ranged from 160 degrees to 260 degrees (mean 200 + or - 39.5 degrees ), showing excellent, good, and moderate results in six fingers (33.3%), five fingers (27.8%), and seven fingers (38.9%), respectively. An excellent or good TARM was obtained in eight fingers (72.2%) treated with mini screws, and in three fingers (42.9%) treated with plate-screw fixation. The mean grip strength decreased by 7.5% (range 0 to 20%) on the affected side. The mean Q-DASH score was 3.4 + or - 4.4. According to the classification of complications proposed by Page and Stern, seven major (38.9%) and six minor (33.3%) complications were seen. Two patients (11.1%) had delayed union.

CONCLUSION

Our findings do not justify open reduction and low-profile plate and/or screw fixation as the first choice in the treatment of phalangeal fractures. If plate and screw fixation is necessary, the most minimally invasive method such as screw fixation should be preferred.

[Treatment of femoral shaft fractures with expandable intramedullary nail]

BACKGROUND

Femoral shaft fractures are usually seen in the young population as a result of high energy traumas and are often accompanied by major organ injuries. In this paper, we aimed to assess the clinical results of expandable femoral intramedullary nails in the treatment of 20 femoral shaft fractures.

METHODS

The average age was 34.7. One fracture was the result of a gunshot wound, type 3A open fracture, and the other 19 fractures were closed. Under fluoroscopic control, all patients underwent elective closed reduction and internal fixation with intramedullary expandable femoral nails (Fixion, Disc-O-Tech; Israel). In case of failed or unacceptable closed reduction, open reduction was achieved with a second incision over the fracture site. Average operation time was 26.3 minutes.

RESULTS

Full union was achieved in all patients. The shortest union time was 12 weeks and the longest 24 weeks, with an average of 15.2 weeks. Results in 15 patients (75%) were excellent, in 4 patients (20%) good and in 1 patient (5%) moderate according to Thorensen criteria.

CONCLUSION

Use of expandable nails provides union without major complications and offers advantages such as less exposure to radiation as seen in distal locking of classical intramedullary nails. In conclusion, the good results of this study show that the expandable femoral intramedullary nail provides a successful option to classical intramedullary nails.

Free-fillet flap harvested in 'severe, high-energy landmine explosion' injuries of lower extremity: a case report

Fillet flaps harvested from the non-replantable or unsalvageable amputated segment can be used to cover tissue defects. We discuss the case of a patient who had suffered a severe high-energy landmine injury, including severe leg damage, resulting in a below-knee amputation and soft-tissue defect around the forearm region. We successfully harvested the fillet from the amputated part of the extremity to the forearm region. We conclude that harvesting of a fillet flap from severely injured lower extremity, resulting from a high-energy landmine explosion, is technically feasible.

Prevalence of flatfoot in Turkish male adolescents

OBJECTIVES

Prevalence of flatfoot in healthy Turkish male adolescents was investigated.

PATIENTS AND METHODS

The present study was carried out in a high school in Istanbul in July 2006. Twenty-two subjects with flatfoot were diagnosed among 3169 male adolescent participants. Prevalence of flatfoot was evaluated statistically in this certain age and gender group. Correlation of flatfoot with weight and height were evaluated.

RESULTS

Prevalence of flatfoot was found to be 0.69%. Correlation of flatfoot with weight or height was not significant.

CONCLUSION

Rigid and resistant flatfoot can cause severe disability. Therefore, the possibility of flatfoot should be kept in mind in symptomatic male adolescents.

Chondroprotective effect of salicylate and chloroquine in pyogenic septic arthritis

INTRODUCTION

This study aims to investigate the effectiveness of salicylate (Aspisol; Bayer AG, Leverkusen, Germany) and chloroquine on preventing cartilage damage in septic arthritis.

METHODS

A septic arthritis model was created by inoculating the knee joint of young rabbits (n=21) with Staphylococcus aureus. Some rabbits with inflicted septic arthritis did not undergo any treatment and served as the control group (n=7). The second group (n=7) was started on salicylate on day 2 to investigate the effects of salicylate on joint cartilage. The third group (n=7) was started on chloroquine on day 2 to investigate the effects of chloroquine on joint cartilage. All three groups underwent arthrotomy, drainage and synoviectomy on day 7 of the experiment. Animals were sacrificed on day 14 and the joint cartilages were extracted. Histopathology, determination of local prostaglandin (PGE)-like activity, and evaluation of hyaluronic acid loss were performed on all samples.

RESULTS

The control group and the salicylate group were similar in the extent of joint damage. Salicylate did not prevent joint cartilage damage despite inhibiting PGE synthesis. Chloroquine, despite not inhibiting PGE synthesis, did prevent cartilage destruction.

CONCLUSION

If supported by larger-scale studies, chloroquine could be added to the antibiotic regimen in the treatment of septic arthritis to prevent cartilage damage.

Radiographic correlation of symptomatic and asymptomatic flexible flatfoot in young male adults

The purpose was to evaluate the value of radiology to distinguish between symptomatic and asymptomatic flexible flatfeet in young male adults. Among young male army recruits, 56 feet of 28 recruits were diagnosed as otherwise normal, flexible flatfoot with invisible longitudinal arch on stance and either symptomatic or asymptomatic unilaterally or bilaterally. The talus-first metatarsal and calcaneal pitch angles were measured on weight-bearing lateral radiographs, and the results were evaluated statistically. The talus-first metatarsal angle showed statistical significance in both non-parametric and logistic regression tests, but the calcaneal pitch angle showed statistical significance only in non-parametric test between symptomatic and asymptomatic flatfoot groups. Although the single gender and number of samples limit the applicability of our study, these results caused us to make an interpretation that increased talus-first metatarsal angle might be an important risk factor of being symptomatic in otherwise normal flexible flatfoot.

Factitious subcutaneous emphysema of an extremity

The presence of air in the subcutaneous tissue of an extremity constitutes a fearful finding because of the potential devastating consequences for both the extremity and life of the patient. The authors present herein a rare case of self-induced subcutaneous emphysema of the thigh in a young patient, which resulted in aggressive management consisting of IV antibiotics, hyperbaric oxygen therapy, and surgical debridement. Correlation of the various findings of the history, physical examination, imaging and laboratory findings is critical in order to avoid unnecessary radical treatment. In the absence of an apparent cause, factitious disorder should always be considered.

Acute arthroscopic removal of a bullet from the shoulder

Arthroscopic procedures are frequently used for extraction of foreign bodies such as bullets from joints. Retained bullets have some effects as loose bodies that cause mechanical symptoms and destroy articular cartilage. Bullets and lead particles in synovial fluid dissolve in time and cause periarticular fibrosis, chondrolysis, hypertrophic arthropathy, and sometimes chronic lead intoxication. A 21-year-old man was treated after he sustained a gunshot wound to his left shoulder. Shoulder arthroscopy was performed through the standard posterior portal. The bullet was observed in the posterior recess and was removed by means of a 10-mm cannula placed anteriorly. The use of arthroscopy for removal of the bullet from the shoulder joint of this patient minimized surgical dissection and blood loss and reduced the likelihood of complications. The patient was free of symptoms within 1 month. Given the disadvantages of traditional techniques such as heavy blood loss, large incisions, high risk for neurovascular anatomic structures, poor visualization of articular surfaces, and prolonged recovery times, we recommend arthroscopic removal of foreign bodies from the shoulder joint as an excellent choice for the treatment of patients with such intra-articular injuries.

In vitro activity of daptomycin alone and in combination with various antimicrobials against Gram-positive cocci

The increasing prevalence of resistant Gram-positive cocci requires the need to search for more effective agents and synergistic combinations. Forty-two vancomycin-resistant Enterococcus faecium (VREF), 30 methicillin-resistant Staphylococcus aureus (MRSA) and 36 Staphylococcus epidermidis (MRSE) strains were studied. Minimum inhibitory concentrations (MICs) were determined and synergy testing was performed by using E test for daptomycin, ampicillin-sulbactam, piperacillin-tazobactam and ticarcillin-clavulanate against staphylococci; for daptomycin, ampicillin, rifampin, and gentamicin against enterococci. Daptomycin in combination with ampicillin, rifampin, and gentamicin was tested against enterococci; daptomycin in combination with ampicillin-sulbactam, piperacillin-tazobactam, and ticarcillin-clavulanate was tested against staphylococci. Interaction categories were defined by the fractional inhibitory concentration (FIC) index. All strains of staphylococci and enterococci were susceptible to daptomycin. All three combinations showed synergy against more than 70% of the MRSA strains. Daptomycin in combination with ampicillin, rifampin, and gentamicin against enterococci showed synergies of 64.2%, 57.1% and 21.4%, respectively. This study indicates that daptomycin alone and combined with beta-lactams seems to be effective against MRSA, but further in vitro and in vivo studies on the subject are required before clinical use can be recommended.

[Limitation in subtalar motion in a patient nine years after treatment for medial subtalar dislocation]

Subtalar dislocations are rare injuries. They may cause serious complications in the long-term. A 27-year-old professional soldier developed medial subtalar dislocation of the right foot due to fall from height and was treated with closed reduction under general anesthesia and below-knee cast fixation for six weeks. At the end of a nine-year follow-up, he began complaining of occasional pain around his ankle. There was minimal loss in subtalar movements. He had no stiffness or instability. The ankle-hindfoot score was 90 according to the American Orthopaedic Foot and Ankle Society clinical rating system. It should be recalled that, following treatment of subtalar dislocations, some degree of loss may occur in subtalar movements.

[Klippel-Feil syndrome and associated congenital abnormalities: evaluation of 23 cases]

OBJECTIVES

The purpose of this study was to review adult patients with Klippel-Feil syndrome.

METHODS

The study included 23 male patients (mean age 20.5 years, range 19 to 27 years) with Klippel-Feil syndrome. Besides orthopedic clinical evaluation, all the patients were assessed by anteroposterior and lateral cervical flexion/extension and thoracolumbar radiographies, abdominal ultrasonography, and were subjected to systemic examinations to detect any urological, cardiological, otorhinolaryngological, neurological, and psychiatric findings. Temporal computed tomography was performed in seven patients, and cervical magnetic resonance imaging in three patients.

RESULTS

Scoliosis, fusion of the cervical vertebrae (between 2-5 vertebrae), low hairline and short neck were found in all the cases. Lumbar fusion was detected in one patient. Other findings included renal agenesis (n=1), different types of hearing loss (n=9), cardiac pathologies (n=5), epilepsy (n=1), and marked (n=1) or mild (n=1) mirror movements.

CONCLUSION

Patients with Klippel-Feil syndrome should be assessed for associated systemic abnormalities besides cervical fusion.

In vitro activity of fluoroquinolones against common respiratory pathogens

The treatment of respiratory infections is often empiric, necessitating the use of agents with a broad range of antimicrobial activity. The fluoroquinolones, having activity against common respiratory pathogens, fit this description. New fluoroquinolones have been developed in an attempt to improve the in vitro activity against a wide variety of respiratory tract pathogens. The objective of the study is to compare in vitro activity of newest fluoroquinolones, gatifloxacin and moxifloxacin, with levofloxacin and ciprofloxacin using three major respiratory pathogens, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Minimum inhibitory concentrations (MICs) of four fluoroquinolones were tested against 93 S pneumoniae, 62 H influenzae and 60 M catarrhalis, ie 215 isolates by the E-test method. National Committee for Clinical Laboratory Standards (NCCLS)-approved interpretive criteria were used throughout. All isolates were susceptible to the tested fluoro-quinolones. Ninety per cent of S pneumoniae strains were inhibited by ciprofloxacin at concentrations of 2 mg/L. The gatifloxacin and moxifloxacin MICs were lower than the ciprofloxacin and levofloxacin MICs against S pneumoniae. In contrast to S pneumoniae, in vitro activities of gatifloxacin and moxifloxacin offered no apparent advantages over ciprofloxacin and levofloxacin for H influenzae and M catarrhalis.

Treatment of femoral nonunions by using cyclic compression and distraction

Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

[The incidence of accessory bones of the foot and their clinical significance]

OBJECTIVES

Accessory bones of the foot are often confused with avulsion fractures. This study was designed to investigate the incidence of accessory bones of the foot.

METHODS

Anteroposterior and lateral foot radiographs of 464 male patients with an age range of 20 to 46 years were examined with regard to the presence, incidence, and distribution of accessory bones. Identification of the accessory bones were made according to the Kohler classification.

RESULTS

Of 464 radiographs, accessory bones were identified in 85 feet (18.3%), all of which were symptomless. The most common accessory bones in descending order were os peroneum (31.8%), os naviculare (28.2%), os trigonum (23.5%), os vesalianum (5.9%), os supranaviculare (3.5%), os infranaviculare (3.5%), os supratalare (2.4%), and os intermetatarseum (1.2%).

CONCLUSION

Accessory bones of the foot should be well recognized and their clinical significance should be appreciated in order to decrease the rate of incorrect diagnoses and unnecessary orthopedic consultations on initial presentations of patients with foot complaints.

Decreasing inflammatory response of injured patellar tendons results in increased collagen fibril diameters

Tissue inflammation is essential in the healing process, but its effect on the quality of the healing tissue is not clear. This study determines the effect of decreasing early inflammation during wound healing in genetic deficient mice on collagen fibril diameter. Two strains of mice were used: three C3H/HeJ mice and three C3H/HeN mice for each of two time points (7 and 14 days postinjury). C3H/HeJ mice have a genetic deficiency in the production of tumor necrosis factor by macrophages and other cytokines in response to endotoxin, and C3H/HeN mice have no genetic deficiency. The right patellar tendon of both mouse strains was transversely transected, whereas the left patellar tendon was left intact for control. After 7 and 14 days, both right and left patellar tendons were harvested, and tendon samples were examined with transmission electron microscopy. We found that at 7 days, transected tendons of C3H/HeJ mice exhibited on average 1.6 times larger collagen fibril diameters than transected C3H/HeN tendons, whereas at 14 days, collagen fibril diameters of the C3H/HeJ mice were 1.3 times that of C3H/HeN mice. Also, at both 7 days and 14 days, collagen fibrils in C3H/HeJ mice appeared more organized than C3H/HeN mice. In addition, control tendons in both mouse strains showed no significant differences in collagen fibril diameter and organization. Therefore, these results suggest that decreasing the inflammatory response in the early stages of tendon wound healing enhances the quality of the healing tendon through increased collagen fiber diameter and better organization.

Prostaglandin E2 affects proliferation and collagen synthesis by human patellar tendon fibroblasts

OBJECTIVE

To determine the effect of prostaglandin E2 on proliferation and collagen synthesis by human patellar tendon fibroblasts.

DESIGN AND SETTING

Controlled laboratory study.

METHODS

Human patellar tendon fibroblasts were treated with different concentrations (1, 10, 100 ng/mL) of prostaglandin E2 in cultures. Fibroblasts without prostaglandin E2 treatment were used as the control group. The fibroblast proliferation and collagen synthesis were measured using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay and Sircol collagen assay, respectively.

MAIN OUTCOME MEASURED

Changes in proliferation and collagen production of human patellar tendon fibroblasts.

RESULTS

: At 1 ng/mL of prostaglandin E2, there was no significant effect on fibroblast proliferation compared with the control group. At concentrations of 10 ng/mL and 100 ng/mL prostaglandin E2, however, fibroblast proliferation significantly decreased, by 7.3% (P = 0.002) and 10.8% (P < 0.0001), respectively, compared with the control group. At 1 ng/mL of prostaglandin E2, collagen production of the tendon fibroblasts was unaffected. However, at both 10 ng/mL and 100 ng/mL prostaglandin E2, collagen production was significantly decreased, by 45.2% (P < 0.0001) and 45.7% (P < 0.0001), respectively, compared with the control group. The levels of collagen production between these 2 dosages did not differ significantly.

CONCLUSIONS

Prostaglandin E2 affects the proliferation of and collagen production by human patellar tendon fibroblasts in a dosage-dependent manner.

CLINICAL RELEVANCE

Based on these in vitro findings, we speculate that production of prostaglandin E2 in tendons might play some role in the acellularity and matrix disorganization seen in exercise-induced tendinopathy.