Functional outcomes of bone tendon bone versus soft tissue arthroscopic anterior cruciate ligament reconstruction: a comparative study.

OBJECTIVE: To compare functional outcomes of anterior cruciate ligament (ACL) reconstruction using 2 graft techniques and to determine factors affecting these outcomes. METHODS: Thirty-four consecutive patients with ACL injuries surgically treated at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between November 2003 and February 2011 were retrospectively assessed. Reconstruction was with bone-patellar tendon-bone autograft in 16 patients (BPTB group) and hamstring soft tissue autograft in 18 patients (ST group). Data were collected at an average of 3.5+/-1.75 years post-operatively, which included Western Ontario and McMaster Universities Arthritis Index (WOMAC) and International Knee Documentation Committee (IKDC) scores, and an 18 point questionnaire. RESULTS: The final mean WOMAC score was 82 in the BPTB group, and 80 in the ST group. The mean IKDC score was 71 in the BPTB group, and 65 in the ST group (p>0.05). Twenty-one patients (61.8%) returned to their pre-injury level of activity after surgery (47.6% in BPTB group, and 52.4% in the ST group) and 27 patients (79.4%) returned to the same job (10 in BPTB group, and 17 in ST group [p=0.021]). No differences were noted between the 2 groups with regard to anterior knee pain, or patello-femoral symptoms (p>0.05). CONCLUSION: Similar outcomes were noted with similar numbers returning to sports. Concerns of anterior knee pain and patello-femoral symptoms associated with BPTB grafts did not affect outcomes related to cultural and religious functions.

Compression screw fixation of the syndesmosis.

BACKGROUND: Screw fixation of syndesmotic injuries facilitates ligament healing and restoration of ankle stability, but little information regarding screw performance is available. This study quantified the reduction obtained with three common 2-screw configurations using different methods of reduction and novel methods of subsequently provoking and measuring diastasis. METHODS: Seven fresh-frozen lower extremities were subjected to 100 N medial and lateral tibia loads with the talus restrained. Tibia displacement, indicative of ankle clear space, was recorded. The syndesmosis and distal interosseous ligament were disrupted and measurements repeated. A pressure sensor was inserted into the syndesmosis and three 2-screw fixation methods were evaluated in each specimen: 3.5-mm screws engaging both fibula cortices and the lateral tibial cortex, inserted while using a clamp to achieve syndesmosis reduction; 3.5-mm lag screws engaging both tibia cortices; and 4.5-mm lag screws engaging both tibia cortices. One thousand 100 N medial and lateral loads were applied and clear space and syndesmosis compression were quantified every 100 cycles. RESULTS: Normal ankle clear space averaged 1.98 mm and increased to 3.02 mm after syndesmosis disruption. Fixation decreased the clear space to 1.36 mm, 1.22 mm, and 1.19 mm for the 3.5-mm tricortical, 3.5-mm lag, and 4.5-mm lag screws, respectively, remaining steady throughout cyclic loading. Syndesmosis compression dropped markedly from 61N to 23 N on clamp release after tricortical screw insertion. The 3.5-mm and 4.5-mm lag screws exerted 112 N and 131 N, respectively, after insertion, and maintained compression several-fold greater than the tricortical screws during cyclic loading. No difference was demonstrable between the two lag screw sizes. CONCLUSION: While all screw configurations successfully reduced ankle clear space, syndesmosis reduction was more effectively maintained by lag screws than by tricortical screws inserted with clamp reduction. The transient nature of compression achieved by the reduction clamp suggests that use of lag screws for this application may more reliably maintain syndesmosis reduction in vivo. CLINICAL RELEVANCE: Optimizing reduction of syndesmosis injuries is critical for favorable outcomes. This study offers concrete information on screw performance in this application.

Comparison of conventional and non-invasive techniques for the early identification of diabetic neuropathy in children and adolescents with type 1 diabetes.

BACKGROUND: Neuropathy is an important complication and contributes to the morbidity of diabetes mellitus. The availability of simple and non-invasive tests for screening of early diabetic neuropathy (DN) in children with diabetes may prevent further progression of this complication. The purpose of this study was to compare conventional nerve conduction studies (NCS) with non-invasive techniques, including vibration perception thresholds (VPT) and tactile perception thresholds (TPT) for the detection of DN in children and adolescents with type 1 diabetes. METHODS: Children from the Alberta Children's Hospital Diabetes Clinic with at least 5 yr duration of type 1 diabetes underwent detailed evaluations, including neurologic exam, NCS, VPT, and TPT testing. Information on duration of diabetes, height, and mean glycosylated hemoglobin (A1C) were also collected. Descriptive statistics, including Student's t-test and chi-squared test, were used for analysis. RESULTS: Seventy-three children (mean age of 13.7+/-2.6 yr) completed the study. The mean duration of diabetes was 8.1+/-2.6 yr, and the mean A1C was 9.0+/-1.0%. Forty-two (57%) children had DN based on NCS. Using NCS as a gold standard, the sensitivity and specificity of VPT were 62 and 65%, while the sensitivity and specificity of TPT were 19 and 64%, respectively. CONCLUSIONS: Subclinical DN is common among children and adolescents with type 1 diabetes, and there is a need for better metabolic control in this population. VPT and TPT may not be adequate screening tools for the detection of DN in children.

Unique clinical phenomenology can help distinguish primary from secondary generalized seizures in children.

The physical manifestations a seizure produces provide critical information. It is assumed that all generalized convulsions are ostensibly the same, regardless of whether they are primary or secondary generalized seizures. We undertook a pilot study to determine if the clinical phenomenology of secondary generalized seizures in children with epilepsy is different from classic descriptions of generalized tonic-clonic convulsions. A data capture sheet was created and applied to the video-electroencephalographic (EEG) records of 64 secondary generalized seizures from 13 children with intractable and/or refractory epilepsy. Many features of secondary generalized seizures were different from traditional descriptions of generalized convulsions. In 100% of cases, the mouth either remained open or repeatedly opened and closed rather than slamming shut. In 77% of cases, a variety of late motor activities were seen to occur after the seizure activity had ceased and the EEG record was quiet. The clinical features of a generalized convulsion in a child, especially mouth opening and late motor events, can be useful in establishing the origin as either focal or primary generalized.

Infantile spasms in remission may reemerge as intractable epileptic spasms.

BACKGROUND: West syndrome consists of infantile spasms with hypsarrhythmia and is perceived as a disorder of infants. METHODS: We describe 10 patients with West syndrome with spasms that remitted, started again, and persisted (followed up for 8-25 years). RESULTS: In all, West syndrome developed at younger than 17 months (five cryptogenic, six symptomatic). With initial treatment, spasms completely stopped for 4.5 months to 6 years, when epileptic spasms returned. Recurrent spasms were typical with brief arm extension, eye elevation, and head drop without falling. Spasms lasted 2-6 s in rhythmic strings over 20- to 60-min periods and occurred daily throughout follow-up. Persistent spasms were particularly troublesome, because of incontinence in one and postictal confusion in several. During the string of spasms, most refused to interact, and several would wander off. Up to 15 antiepileptic drugs did not render any patient spasm free. Only two had persistent spasms as the only seizure type; six also had intractable complex partial seizures, and three had occasional grand mal convulsions. Interictal EEGs showed multifocal spikes. Ictal recordings in six showed electrodecremental events. CONCLUSIONS: Recurrent spasms after remission of West syndrome represent an extremely resistant, distressing form of epilepsy. The onset of West syndrome is age related, but it does not reliably vanish.

Is a fast necessary when initiating the ketogenic diet?

The purpose of this study was to determine time of onset of ketosis and efficacy when the classic ketogenic diet is initiated at full calories without a prior fast in children with epilepsy. A retrospective hospital and neurology clinic chart review was done of all 14 children commenced on the classic ketogenic diet at full calories without a prior fast between January 1, 1997, and May 31, 2001, to determine time to ketosis, time to good ketosis (urine ketones > or =80 mg/dL), and success of the ketogenic diet. Median age at diet initiation was 63 months (25th-75th percentile 47-149 months). There were 7 girls and 7 boys. Four had symptomatic generalized epilepsy, whereas the remainder had partial seizures +/- secondary generalization. Twelve of 14 children suffered seizures on a daily basis prior to the ketogenic diet. Six were commenced on the diet as outpatients, whereas 8 were admitted to hospital. No patients were fasted. All admitted patients were started on a 1:1 ketogenic ratio at full calories for the first 24 hours and advanced to a 3:1 or 4:1 ratio over 3 to 4 days, while outpatients were started on a 1:1 or 2:1 ratio and similarly advanced. Thirteen of 14 patients were successfully started on the diet, with 1 developing vomiting and food refusal during the initial hospitalization but after ketosis was established. One child was lost to follow-up after initial hospital discharge. Information regarding time to ketosis was determined for all inpatients. Mean time to onset of ketosis was 33 hours (range 17 to 48) and to good ketosis, 58 hours (range 40 to 84). Five of 12 children (42%) experienced success with the ketogenic diet, and all of these had their antiepileptic medications either withdrawn (n = 3) or decreased (n = 2). The ketogenic diet can be effectively initiated without a fast in children with epilepsy. Time to ketosis and diet efficacy are similar to protocols that use a fast.