Evaluation of the relationship between the anatomical characteristics of the vastus medialis obliquus muscle and the patella chondral lesion occurrence.

OBJECTIVES: The study aims to investigate the relationship between the vastus medialis obliquus (VMO) muscle distal insertion features and patellar chondral lesion presence. PATIENTS AND METHODS: This cross-sectional study included a total of 100 patients (18 males, 82 females, mean age 67.2±7.1 years; range, 50 to 86 years) who underwent total knee arthroplasty (TKA). Radiological assessments, including merchant view and standing orthoroentgenograms, were conducted. The current osteoarthritis stage, varus angle, quadriceps angle (Q angle), patella-patellar tendon angle (P-PT angle), congruence angle, and sulcus angle were calculated. The VMO tendon length, muscle fiber angle, tendon insertion width measurements, and patellar chondral lesion localization data were obtained intraoperatively. Grouping was done according to the distal insertion width of the VMO tendon to the medial edge of the patella. The medial rim of the patella was divided into three equal-sized sectors. The first group (Group 1, n=31) consisted of patients who had an insertion from the quadriceps tendon into the upper one-third of the patella. The second group (Group 1, n=48) consisted of patients with a distal insertion expanding into the middle one-third of the patella. The third group (Group 3, n=21) consisted of patients who had a distal insertion extending into the distal third region of the medial patella margin. The patella joint surface was divided into sectors, and the presence and location of cartilage lesions were noted in detail. RESULTS: The mean tendon insertion width rate was 45.99±16.886% (range, 16.7 to 83.3%). The mean muscle fiber insertion angle was 51.85±11.67º (range, 20º to 80º). The mean tendon length was 12.45±3.289 (range, 4 to 20) mm. There was no significant difference between the mean age, weight, height, body mass index, BMI, fiber angle, tendon length, varus angle, Q angle, sulcus angle, and congruence angle data among the groups. In terms of the P-PT angle, Groups 1 and 2 had a significant relationship (p=0.008). No relationship was found between the mean fiber insertion angle, mean tendon length, or the presence of chondral lesions. There was a statistically significant difference among the groups regarding the presence of chondral lesions. The highest percentage of chondral lesion frequency was observed in Group 3 (95.24%), followed by Group 1 (90.3%) and Group 2 (89.6%), respectively. Compared to the other two groups, Group 3 had a higher average ratio of lesion areas per patient. CONCLUSION: Our study results demonstrate that the formation and localization of the patellar chondral lesions are affected by the insertion width type of the VMO muscle into the patella. Group 2-type insertion is associated with a lower lesion frequency rate than Groups 1 and 3.

Treatment of Gustilo-Anderson type III open fractures with segmental long bone loss secondary to gunshot and war injuries in paediatric patients with bone segment transport by the limb reconstruction system (LRS).

OBJECTIVE: The information on firearm- or explosive-related extremity injuries in children is very limited. Reports of segmental bone loss due to these types of fractures are even rarer and the treatment remains a problem. There has been no report of distraction osteogenesis with limb reconstruction system (LRS) specifically in children. We evaluated the treatment results of Gustilo-Anderson type 3 open fractures with segmental bone loss due to firearm injuries by distraction osteogenesis performed with LRS in skeletally immature patients. METHODS: Nine patients with Gustilo-Anderson (GA) type 3 open fractures with segmental bone loss due to firearm injuries who had not completed their skeletal development were included. Two of the patients had GA type 3a, four had type 3b, and the remaining three had type 3c. Bony and functional assessment was conducted using Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. RESULTS: Mean follow-up period was 20.1 months (range 5.5-35 months). The mean bone loss was 45.5 mm (range 15-80 mm) before the treatment started. The mean time of external fixation (day) was 180.6. The mean distraction index (distraction period per cm) was 11.3 day/cm. The mean time for bone union index (duration of bony union per cm) was 33.7 days/cm. Bony union was achieved in all patients at the end of the treatment. Bony results as per ASAMI score were excellent in seven fractures and good in three. Functional results were excellent in five patients, good in two, and fair in two. We had no fair or poor results with respect to bony results but had two fair functional results. CONCLUSIONS: LRS provides a good treatment choice for children with fractures with segmental bone loss due to firearm injuries. It also provides easy access to the wound with its monolateral construction.

Endoscopy-assisted distal locking of an intramedullary nail: A new experimental technique to reduce radiation exposure during distal locking of the intramedullary nails.

OBJECTIVES: In this study, we aimed to introduce a new technique in which distal locking step was easier and safer for orthopedic trauma surgeons involving in the treatment of long bone fractures using an intranail endoscopic visualization and illumination method. MATERIALS AND METHODS: A total of 20 fresh bovine hind limbs derived from healthy adults and killed for sale were dissected to obtain tibial bones. Two equal groups including 10 samples in each were prepared. We applied a standard nailing process in both groups: the study group (n=10) was locked by the new technique, intranail endoscopic illumination guidance and intranail visualization assistance locking technique and the control group (n=10) was locked by the classical free-hand fluoroscopic guidance technique. We measured the surgical period time and the radiation exposure time required for the distal locking in both groups. RESULTS: The radiation exposure time was statistically significantly lower in the study group compared to the control group. Also, the time period required for distal locking in the study group were statistically significantly lower than the control group. With the use of the intranail endoscopic illumination guidance and visualization assistance technique, the median period time required for the distal locking procedure reduced from 477.5 to 223.5 sec (p<0.001). The median time for radiation exposure dramatically reduced from 13.5 to 2 sec (p<0.001). The median attempt number reduced from 6.5 to 2 times (p<0.001). CONCLUSION: This experimental study indicates that the endoscopic illumination and intranail visualization assistance technique can reduce the radiation exposure time and the period time required for distal locking compared to the free-hand fluoroscopic guidance.

Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war.

BACKGROUND: In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors' institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty. METHODS: This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery. RESULTS: Mean age was 31.5 (range, 19-48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant. CONCLUSIONS: An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.

Reinforcement of the Flexor Tendon Repair Using Human Amniotic MembraneA Biomechanical Evaluation Using the Modified Kessler Method of Tendon Repair.

BACKGROUND: Human amniotic membrane is used to prevent peritendinous adhesions after tendon injuries. This study compares the mechanical properties of modified Kessler repairs and modified Kessler repairs strengthened using multiple layers of human amniotic membrane. METHODS: Twenty flexor digitorum profundus tendons of sheep forelimbs were sutured by the two-strand modified Kessler technique (group A) and by the two-strand modified Kessler repair reinforced with multiple layers of human amniotic membrane (group B). To assess the mechanical performance of the repairs, tendons were subjected to a linear noncyclic load-to-failure test using a material testing machine. Outcome measures included ultimate forces and the mode of failure. RESULTS: The mean ± SD value of the failure strength was 34.6 ± 1.64 N for group A and 50.6 ± 5.60 N for group B. The reinforced repair provided a significantly higher ultimate load compared with the nonreinforced group (P < .001). All of the specimens failed due to suture breakage at the repair site. CONCLUSIONS: The results of this study show that the modified Kessler repair can be reinforced effectively with human amniotic membrane.

The comparison of macroscopic and histologic healing of side-to-side (SS) tenorrhaphy technique and primer tendon repair in a rabbit model.

INTRODUCTION: The side-to-side (SS) tenorrhaphy technique has been used in tendon transfer surgery. The mechanical properties of SS tendon suture have been studied previously. However, the histo-pathological healing of the SS tenorrhaphy of the tendons is unknown. The aim of this study was to assess the gross and histological effects of SS tenorrhaphy in a rabbit model. MATERIALS AND METHODS: Twenty New Zealand rabbits were used. The extensor hallucis longus and tibialis anterior tendon were sewed SS at the level distal to the ankle joint. The patellar tendon (PT) at the same side was used as control group. A unilateral midline incision was made and repaired with a single suture. The animals were killed at the 12th week postoperatively. The histological sections were obtained from the side of surgery from each group. Each sample was stained with hematoxylene and eosin (H&E). Gross and microscopic healing was compared between the two groups. RESULTS: Gross examination of the control group showed complete healing with a thin peri-tendinous sheath formation around the suture site, whereas in the study group, a thick peri-tendinous sheath was formed around the area of the tendon-tendon anastomosis. In the control group, at the 12th week after surgery, the healing was almost completed in all samples. In the study group, a thick fibro vascular sheath has formed around the side of anastomosis. In all specimens few inter-digitations were observed between the tendons;however, the trough was still present. CONCLUSION: The result of the current study showed that histological healing and union of SS tenorrhaphy differ from that in primary tendon injury and healing. Further studies are required to clarify the healing stages at the tenorrhaphy site.

Management of tennis elbow with topical glyceryl trinitrate.

OBJECTIVE: The aim of this study was to evaluate the treatment results of the application of nitric oxide (NO) in the form of topical glyceryl trinitrate (GTN) for the treatment of lateral epicondylitis (LE). METHODS: The study included 40 patients with LE randomized into 2 equal groups. Selection criteria included the presence of pain, tenderness, and positive pain stimulating maneuvers. Glyceryl trinitrate patches were applied to the area of maximal tenderness once a day in the treatment group and placebo patches in the control group. Outcomes in terms of pain relief was assessed using the visual analog scale (VAS) and were evaluated according to the criteria of Verhaar et al. Excellent or good results were considered successful. Differences in VAS scores between the two groups were calculated using the Mann-Whitney U-test and the chi-square test was used to investigate distributions of categorical variables (sex, affected side) and good and excellent results among groups. RESULTS: There were no significant differences in any of the baseline clinical parameters between groups. At the 3rd week follow-up, there were statistically significant differences in the pain measured using VAS between groups (mean VAS score of the control and treatment groups were 6.45 and 3.15, respectively) (p=0.001). Patients in the GTN group and control group had lower VAS pain scores and reduced elbow pain at 3 weeks (3.15 vs 8.05 in the GTN and 6.45 vs 8.80 in the control group). In the control group, no patient had excellent or good results while 18 (90%) patients in treatment group reported successful treatment. There was statistically significant difference in the VAS measured at 6 months between groups (mean VAS score of the control and treatment groups were 4.85 and 0.70, respectively) (p=0.001). CONCLUSION: The administration of NO directly over an area of tendinopathy through a GTN patch reduces pain and other symptoms in chronic LE.

Urotensin II (U-II), a novel cyclic peptide, possibly associated with the pathophysiology of osteoarthritis.

Synovial fibrosis is one of the main outcomes of osteoarthritis. Some authors have reported that urotensin-II (U-II) may cause pathologic fibrosis in cardiovascular system, lung and liver. However there are no previous reports available in the literature about its relationship with the synovial fibrosis in osteoarthritis. The aim of this study was to compare the U-II levels in knee synovial fluids obtained from osteoarthritic and non-osteoarthritic patients. Two groups were created, the osteoarthritis group and non-osteoarthritic control group. The control group was consisted of patients who underwent arthroscopic surgery for other reasons than cartilage disorders. In the osteoarthritis group all patients had grade 4 primer degenerative osteoarthritis and were treated with total knee arthroplasty. Minimum 1 mL knee synovial fluids were obtained during operation. Levels of U-II were measured by using ELISA kit U-II levels were significantly higher in the osteoarthritic group than that in the control group. No correlation was found between U-II levels and age. In conclusion, the significantly high U-II levels in the knee synovial fluid of osteoarthritic patients supported our hypothesis that "U-II may be associated with the synovial fibrosis in osteoarthritis".

A new anchor augmentation technique with a cancellous screw in osteoporotic rotator cuff repair: an in vitro biomechanical study on sheep humerus specimens.

PURPOSE: The aim of this study was to test a simple technique to augment the pullout resistance of an anchor in an over-drilled sheep humerus model. METHODS: Sixty-four paired sheep humeri were harvested from 32 male sheep aged 18 months. Specimens were divided into an augmented group and non-augmented group. FASTIN RC 5-mm titanium screw anchors (DePuy Mitek, Raynham, MA) double loaded with suture material (braided polyester, nonabsorbable USP No. 2) were used in both groups. Osteoporosis was simulated by over-drilling with a 4.5-mm drill. Augmentation was performed by fixing 1 of the sutures 1.5 cm inferior to the anchor insertion site with a washer screw. This was followed by a pull-to-failure test at 50 mm/min. The ultimate load (the highest value of strength before anchor pullout) was recorded. A paired t test was used to compare the biomechanical properties of the augmented and non-augmented groups. RESULTS: In all specimens the failure mode was pullout of the anchor. The ultimate failure loads were statistically significantly higher in the augmented group (P < .0001). The mean pullout strength was 121.1 ± 10.17 N in the non-augmented group and 176.1 ± 10.34 N in the augmented group. CONCLUSIONS: The described augmentation technique, which is achieved by inferior-lateral fixation of 1 of the sutures of the double-loaded anchor to a fully threaded 6.5-mm cancellous screw with a washer, significantly increases the ultimate failure loads in the over-drilled sheep humerus model. CLINICAL RELEVANCE: Our technique is simple, safe, and inexpensive. It can be easily used in all osteoporotic patients and will contribute to the reduction of anchor failure. This technique might be difficult to apply arthroscopically. Cannulated smaller screws would probably be more practical for arthroscopic use. Further clinical studies are needed.

Compression of common peroneal nerve caused by an extraneural ganglion cyst mimicking intermittent claudication.

Peripheral neuropathies caused by ganglion cysts are rare. They seldom cause serious complications especially in the lower extremities. The case was a 51-year-old woman referred by her physician to the vascular surgeon with diagnosis including intermittent (vascular) claudication and deep venous thrombosis. Primarily vascular surgeon performed a doppler ultrasound of the lower extremity and calculation of the ankle-brachial index. There were no abnormal pathological findings. Careful physical examination revealed soft swelling and tenderness around the fibular head and neck. Weakness was observed in foot eversion and dorsiflexion. There was pain and tingling in the distribution of the peroneal nerve. and referring the patient to orthopedic surgeon owing to concern for a potential compressive lesion at the right proximal tibiofibular region. Electromyogram studies and physical examination confirmed a diagnosis of compression neuropathy of common peroneal nerve. Magnetic resonance imaging revealed a fluid-filled, lobulated mass indicating a ganglion cyst. One months after decompression, the patient had no complaint. Fast diagnosis and immediate management are essential to regain best possible recovery.

The comparison of freehand fluoroscopic guidance and electromagnetic navigation for distal locking of intramedullary implants.

INTRODUCTION: In locking intramedullary nails, the most important problem is to put the distal interlocking screw accurately and quickly with minimum radiation exposure. The purpose of this clinical study was to compare the fluoroscopic time and surgical time required for distal locking with either free-hand fluoroscopic guidance or with an electromagnetic navigation system. MATERIALS AND METHODS: The study comprised 54 patients with 58 fractures of the lower extremity. The patients were divided in two groups: distal locking with freehand fluoroscopic guidance (group I) and distal locking with electromagnetic navigation (group II). The primary outcome in this study was fluoroscopy time. The secondary outcome was the operative time in distal interlocking. RESULTS: In group I, the mean operation time was 108 (81-135) min, the mean time for distal interlocking was 18.35 (9-27) min, the total fluoroscopy time was 47.77 (19-74) s, the mean fluoroscopy time during distal interlocking was 18.29 (2-29) s and the mean attempt at number of distal locking for two screws was 9.96 (2-18) times. In group II, the mean operation time was 80.96 (63-100) min, the mean time for distal interlocking was 7.85 (6.5-10) min, the total fluoroscopy time was 22.59 (15-32) s, the mean fluoroscopy time during distal interlocking was 1.62 (0-2) s and the mean attempt number of distal interlocking was 2 (2-2). CONCLUSION: Fluoroscopy time to achieve equivalent precision is significantly reduced with electromagnetism-based surgical navigation compared with free hand fluoroscopic guidance. Also the operative time is significantly reduced with electromagnetic based navigation.

Aperture fixation instead of transverse tunnels at the patella for medial patellofemoral ligament reconstruction.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction is an effective option for the treatment of recurrent patellar instability. Most techniques utilize the passage of a tendon graft through tunnels at the patella with the risk of patellar fracture. The purpose of this study was to investigate the strength of the recent MPFL reconstruction techniques (transverse tunnel, interference screw, anchor, and docking technique). METHODS: Thirty-six saw bones were divided into four groups (transverse tunnel, interference screw, anchor fixation, and docking technique) with nine patellae in each. Patella-tendon constructs were pre-loaded to 10 N and cyclically loaded for 20 cycles from 2 to 30 N under load control at a rate of 5 N/sec. The construct was then tested to failure at a constant displacement rate of 6 mm/sec. Ultimate load (N), stiffness (N/mm), and failure mode were recorded for each specimen. RESULTS: The docking group had lower ultimate load [106 (SD 41) N] and stiffness [14 (SD 2) N/mm] values than the other groups tested (P = 0.007). The anchor group had lower stiffness [21 (SD 6) N/mm] values than the tunnel group [28 (SD 3) N/mm (P = 0.01)] and the interference screw group [31 (SD 6) N/mm, (P = 0.004)]. There was no significant difference in the ultimate load between anchor [299 (SD 116) N], tunnel [304 (SD 140) N], and interference screw groups [241 (SD 103) N] (n.s.). CONCLUSION: Aperture fixation techniques, especially interference screw fixation, were as strong as the technique utilizing tunnels in the patella for MPFL reconstruction.

The effect of total synovectomy in total knee arthroplasty: a prospective randomized controlled study.

PURPOSE: The apparent synovial hypertrophy in some cases of noninflammatory knee osteoarthritis suggests that total synovectomy may provide beneficial inflammatory and pain relief after total knee arthroplasty. The aim of the study was to compare the effect of synovectomy on the postoperative pain, bleeding and functional outcome after surgical treatment of knee osteoarthritis. METHODS: A total of 50 patients with bilateral, non inflammatory, primary knee osteoarthritis were included in the study. Bilateral total knee replacement was performed at the same session. Total synovectomy and total knee arthroplasty (study group) were applied to a randomly selected side, and the total knee arthroplasty alone (as control group) was applied to the contralateral side of the same patient. The overall efficacy of both procedures was assessed postoperatively by determination of blood loss from the drain, pain and functional scores. The Visual Analogue Scale of pain and the Knee Society Knee Score were used to compare the two groups at 3rd, 6th and 12th months, postoperatively. RESULTS: During the postoperative 48 h, the mean blood loss in the study group (with synovectomy) was significantly higher than the control group (P=0.005). However, in the postoperative follow-up time, there was no significant difference in pain relief and in the Knee Society Score between the two groups. CONCLUSION: Performing synovectomy in patients with primary knee osteoarthritis does not seem to have any clinical advantage besides it might increase blood loss and recurrent hemarthrosis postoperatively. Thus, during arthroplasty surgery, it should not be performed routinely.

Validation of the VISA-A questionnaire for Turkish language: the VISA-A-Tr study.

OBJECTIVES: To evaluate the validity and reliability of the Turkish version of the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire for patients with Achilles tendinopathy. DESIGN: Fifty-five patients with a diagnosis of Achilles tendinopathy and 55 healthy subjects were included in the study. VISA-A questionnaires were translated and culturally adapted into Turkish. The final Turkish version (VISA-A-Tr) was tested for reliability on healthy individuals and patients. Tests for internal consistency, validity and structure were performed on 55 patients. RESULTS: The VISA-A-Tr showed good test-retest reliability (Pearson's r=0.99, p<0.001). The patients with Achilles tendinopathy had a significantly lower score (p<0.001) than the healthy individuals. The VISA-A-Tr score correlated significantly with the Stanish tendon grading system (Spearman's r=-0.86; p<0.001). CONCLUSION: The VISA-A-Tr is a valid and reliable tool for evaluating the severity of Achilles tendinopathy.

Detection of slime and methicillin resistance genes in Staphylococci isolated from nasal samples of patients with orthopaedic implants.

BACKGROUND: The purposes of the present study were (1) to determine the prevalence of mecA and femA genes, (2) to investigate the presence of icaA and icaD genes responsible for slime synthesis, and (3) to search in vitro slime synthesis by staphylococcal strains isolated from the nares of patients with orthopaedic implants using the Congo red agar (CRA) plate test. MATERIAL/METHODS: Staphylococci strains were defined by multiplex polymerase chain reaction (PCR) technique to determine intercellular adhesion genes icaA and icaD. Slime production capability was searched by the CRA plate test, phenotypically. Also, the presence of mecA and femA genes was determined by PCR in all strains. RESULTS: The presence of icaA and icaD was detected in 101 isolates of 134 (75.4%) strains. This ratio was 74.8% (89 of 119) among the Staphylococcus epidermidis and 80% (12 of 15) among the Staphylococcus aureus isolates. A total of 63.4% of all the strains were found to be icaA and icaD positive as well as slime-forming on the CRA plate test. The percentage of icaA- and icaD-negative strains was 36.6%, and all of them were negative on the CRA plate test. Although femA presence was detected in all 15 (11.2%) S. aureus isolates, a total of 5 (3.7%) isolates carried the mecA gene. CONCLUSIONS: The frequency of icaA and icaD genes was determined to be of high prevalence among staphylococcal isolates. The staphylococcal strains that were found in the nasal flora of patients with orthopaedic implants may be important potential sources of infection for these patients.

Double plate osteosynthesis provides better biomechanical stabilization than double tension band technique in distal humerus fractures.

OBJECTIVES: In this study we evaluated the stability and effectiveness of the double tension band osteosynthesis technique compared to the double plate osteosynthesis technique used for fixation of distal humerus fractures. MATERIALS AND METHODS: The study was performed on two groups, and in each group eight cadaveric, elderly (mean age 70-80) human humeri was used. An osteotomy was performed in the supracondylar region using a manual saw. The first group (group 1) was fixed with double 3.5 mm reconstruction plates, while the second group (group 2) was fixed with the double tension band technique, using crossing Kirschner wires. The osteotomy was designed so that the distal fragment would allow only a single screw per plate. The constructs were evaluated using a material testing machine. A linear non-cyclic load was applied until the failure of the constructs. The force which produced a 3 mm gap (3 mm gap strength), as detected visually with the aid of operating loupes, and the maximum load prior to failure of the fixation (maximum force) were measured from all tests. RESULTS: The mean value for the 3 mm gap strength was 1356.29+/-226.97 N for group 1 and 882.63+/-305.21 N for group 2. The mean value of the maximum load strength was 1487.13+/-298 N for group 1 and 1232+/-107.62 N for group 2. There were significant differences in 3 mm gap strengths of the two groups (p=0.005). There was also a significant difference in the maximum load between the two groups (p=0.016). CONCLUSION: Double plate osteosynthesis technique is superior to double tension band osteosynthesis for the fixation of distal humerus fractures.

Effects of a single application of extractum cepae on the peritendinous adhesion: an experimental study in rabbits.

Peritendinous adhesion is an important cause of poor functional outcome after flexor tendon repair. The objective of this study was to investigate the effect of a single intraoperative application of extractum cepae, an extract of dietary onion, on the peritendinous adhesion, using a rabbit model of flexor tendon injury. The first, second, and third digits of the right hind paw of 18 rabbits were used for tendon operations. A standard partial division of the synovial sheath and flexor tendon was done at zone II to stimulate the adhesion formation. In the treatment group (n = 9 rabbits, 27 tendons), the flexor tendon sheath was treated with 50 mg/mL of extractum cepae which was applied locally and allowed to infiltrate for 5 minutes, the skin was sutured without suturing the sheath and the tendons. The same operation was done for the control group (n = 9 rabbits, 27 tendons) and 1 mL of normal saline solution was applied locally. Biomechanical and histologic evaluations of the specimens were done after 3 weeks. Tendons from the first toes were used for biomechanical studies. The second and third toe tendons were used for histopathologic evaluation. We have compared the peritendinous adhesions and the ultimate forces in the control and treated tendons. There were no statistically significant differences between the 2 groups with respect to the ultimate loads. Adhesion formation was absent in 1 tendon (5.5%), slight in 8 (44.4%), moderate in 6 (33.3), and severe in 3 tendons (16.7%) in the extractum cepae treated group (n = 18); while in the control group (n = 18), it was absent in 1 tendon (5.5%), slight in 1 tendon (5.5%), moderate in 3 (16.6%), and severe in 13 (72.4%) tendons. There was a significant reduction (P = 0.01) in the peritendinous adhesion in the treated group comparing to the control group. The problem of adhesion formation may be minimized using a single intraoperative application of extractum cepae.

Primary metal-on-metal total hip arthroplasty with large-diameter femoral heads: a clinical trial of 59 hips.

Large-diameter femoral heads with nearly anatomical sizes became available for metal-on-metal total hip arthroplasty after recent advances in metal-on-metal technology. We retrospectively studied the clinical and radiological results in 59 hips of 54 patients (32 women and 22 men, mean age 54.4 years) who underwent cementless metal-on-metal total hip arthroplasty with large-diameter heads. Patients were followed for a mean of 48.6 months. Range of motion improved significantly after surgery (p = 0.001). Harris hip scores improved from 38.5 points to 903 points at latest follow-up. We found no gender-related differences in Harris hip scores, whereas there was a correlation between age and Harris hip scores (p < 0.001), with excellent results being observed predominantly in younger patients. Mean acetabular inclination of the acetabular cup was 42.2 degrees (range: 37-51 degrees). Radiologically, a 1 mm thick radiolucency was detected in three acetabula, which were asymptomatic. One acetabulum was revised because of displacement. Three patients reported squeaking within their hips, which however disappeared in a short time. We did not observe any dislocation, deep infection or loosening. Grade 1 heterotopic ossification was detected in one hip. Although the inherent stability and the functional results of large anatomical heads are encouraging, longer follow-up data and larger series are essential to evaluate the real advantages of this type of prosthesis over conventional femoral heads.

Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial.

OBJECTIVE: Plantar fasciitis (PF) is a common clinical condition that usually resolves with non-operative treatments. Extracorporeal shock wave therapy (ESWT) has been used in the treatment of chronic PF not responding to other conservative measures; however, ESWT devices are expensive and available for daily practice in only few centers (In developing countries). A pneumatic lithotripter is a cheap and readily available device which uses pneumatic shock application for the intracorporeal lithotripsy. The aim of this study was to investigate the clinical efficacy of intracorporeal pneumatic shock therapy (IPST) application for the treatment of chronic PF using a cheap and readily available pneumatic lithotripter. METHODS: A randomized, double-blind, placebo-controlled study was conducted. A total of 50 patients with clinically and radiologically confirmed PF were randomly allocated to either an active- (treatment) (n = 25) or inactive (placebo) (n = 25) group. Under local anesthesia and posterior tibial nerve block, a rigid probe was directly introduced into the calcaneal spur under fluoroscopic control; a standard protocol of 1,000 shock was applied during a single session into the calcaneal spur. The main outcome measure was the patients' subjective assessment of pain by means of a Visual Analog Scale (VAS) and the Roles and Maudsley Score before the treatment and 6 months later. RESULTS: At the 6 months, the rate of successful outcomes (excellent + good results) in the treatment group (92%) were significantly higher comparing to the control group (24%) (P < 0.001). Heel pain measured 6 months after using the VAS were 2.04 +/- 1.67 in treatment group and 7.16 +/- 1.57 in control group as compared to 8.92 +/- 1.22 and 9.12 +/- 1.23 before the commencement of the treatment. No complications attributable to the procedure such as rupture of the planter fascia, hematoma, or infection were observed during the study. CONCLUSIONS: This pilot study showed that IPST is an effective and safe method of treatment of patients with chronic PF not responding to conservative measures. IPST application should be considered before surgical intervention when the extracorporeal shock devices are not available for daily practice. However, further evaluation of this novel treatment is necessary to understand the exact mechanism of action.

Morphometry of the thoracolumbar vertebrae in sickle cell disease.

Patients with sickle cell disease (SCD) who have deformities and vertebral fractures due to osteoporosis may require surgery. Spinal surgeons must become familiar with the vertebral morphometry of patients with SCD and to that aim we have examined the morphometry of the thoracolumbar spine in these patients. A cohort of 100 patients with SCD was examined using plain thoraco lumbar anteroposterior/lateral radiographs and dual energy X-ray absorptiometry (DEXA). Vertebral morphometry (vertebral body diameters, pedicle, spinal canal and deformity) was assessed for different age groups. Results were compared to published studies of healthy subjects. The vertebral dimensions for the 16-20-year and the 21+-year-old groups were significantly smaller for females than males at most spinal levels, while measurements in the 6-10 years and 11-15 years age groups were similar across both sexes at most levels. No significant statistical difference was found between the diameters of the right and left pedicles. With the exception of the sagittal diameter, most of the dimensions of the vertebral bodies measured in SCD patients were less than those of healthy individuals; multiple deformities were also observed. Low bone density was noted in 32 patients. Our data highlight the differences in vertebral bone mineral density, anatomy and deformities in patients with SCD compared to healthy individuals. When considering surgical intervention for patients with SCD, it is important that pre-operative radiography and planning is undertaken, and that the surgeon is familiar with the geometry of the pedicles of the thoracolumbar vertebrae necessary for the safe insertion of pedicle screws. Osteoporosis must be considered when planning surgical interventions in these patients.