Double-plate fixation together with bridging bone grafting in nonunion of femoral supracondylar, subtrochanteric, and shaft fractures is an effective technique.

PURPOSE: The aims of the present study were to evaluate and report the therapeutic outcomes of double-plate fixation in combination with autogenous bridging bone grafting in treatment of nonunion fractures of femur. METHODS: In this retrospective case series study, 41 patients with nonunion fracture of femur who underwent surgery by double-plate fixation and autogenous bridging bone grafting in academic referral center from July 2010 to July 2015 were enrolled. Totally, 32 males and 9 females with mean age of 35 years were evaluated. They were evaluated for related risk factors, previous therapeutic methods, time interval between injury to nonunion surgery and surgery to full clinical and radiological union, duration of follow-up, levels of postoperative limb shortening, and movement limitations. RESULTS: Ten patients had open fractures and eight patients had infected nonunion in the femoral supracondylar, subtrochanteric, and shaft fractures. Nailing was the most common used method as the primary treatment of femoral shaft fractures. In addition, the mean follow-up time was 37 months. Full union was obtained even in infected cases. Deep vein thrombosis was found in one patient and pulmonary thromboembolism in another patient, and both patients were treated successfully. Moreover, limitations of articular movements were seen in seven patients. CONCLUSION: Double-plate fixation in combination with bridging bone grafting is an effective method in the treatment of nonunion of femoral supracondylar, subtrochanteric, and shaft fractures even in the infected cases.

Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon.

BACKGROUND: Multi-ligamentous injuries to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are uncommon but debilitating injuries. They mostly lead in functional disabilities and further surgeries. HYPOTHESIS: The aim of the present study was to evaluate the outcomes of simultaneous arthroscopic reconstruction of ACL and PCL using allograft Achilles tendon. STUDY DESIGN: Case-series study. MATERIALS AND METHODS: This study was performed on patients with combined ACL-PCL injuries which attended for treatment to a referral center from January 2010 to January 2014. All of them underwent simultaneous arthroscopic reconstruction of ACL and PCL using allograft Achilles tendon. Range of motion (flexion and extension loss), giving way, anterior and posterior knee stability, proximal tibia step off, subjective assessment of knee function and patients satisfaction were evaluated at 3, 6, 12, 24 months and final follow-up. Data were analyzed by SPSS version 21 with consideration of P < 0.05 as significant difference. RESULTS: Among 28 included patients, 21 patients (75%) were male. Mean age of patients was 30.86 ±â€¯7.25 years (range: 18-49 years). The mean follow-up time was 35.7 ±â€¯6.8 months (range: 26-50 months). Our results demonstrated that knee function, stability, and range of motion were improved along the follow-up periods. At final follow-up none of the patients had giving way and all of them were completely satisfied from the surgery. CONCLUSION: Simultaneous reconstruction of injured cruciate ligaments using allograft Achilles tendon resulted in appropriate functional outcomes and acceptable range of motion. LEVEL OF EVIDENCE: IV.

Intra-sheath versus extra-sheath ultrasound guided corticosteroid injection for trigger finger: a triple blinded randomized clinical trial.

OBJECTIVE: The aim of this study is to compare clinical results of ultrasound-guided corticosteroid injection, intra-sheath versus extra-sheath of the finger flexor tendon. METHODS: A total of 166 patients with trigger finger were evaluated in a triple blind randomized clinical trial study. All the patients were injected with 1ml of 40mg/ml methyl prednisolone acetate, under the guidance of ultrasound. Half the patients were injected extra sheath, while the other half were injected intra sheath at the level of first annular pulley. RESULTS: The two groups were comparable in baseline characteristics (age, gender, dominant hand, involved hand and finger, and the symptoms duration). No significant difference was observed in the two groups with regards to Quinnell grading. In the final visit, 94% of patients from each group were symptom free. CONCLUSION: Results of corticosteroid injection intra-sheath or extra-sheath of the finger flexor tendon under ultrasound guidance in patients with trigger finger are comparably alike. Extra-sheath injection at the level of A1 pulley is as effective as an Intra-sheath administration.

Predicting the Hamstring Tendon Diameter Using Anthropometric Parameters.

BACKGROUND: Despite the importance of hamstring tendon autograft, one major disadvantage in applying this technique in the surgical reconstruction of anterior cruciate ligament is individual variability in the tendon diameter. Hence, the purpose of the present study was to use anthropometric parameters such as gender, height and body mass index to predict 4-strand (quadruple) hamstring tendons (gracilis and 2-strand semitendinosus tendons). METHODS: This is a cross-sectional study conducted on all consecutive patients who underwent arthroscopic ACL reconstruction between 2013 and 2015. The anthropometric variables (age, gender, height, and body mass index) were recorded. The quadruple hamstring tendon (gracilis and semitendinosus) autografts were measured using sizing cylinders. The relationship between these parameters was statistically determined using the Pearson Spearman test and linear regression test. RESULTS: The mean age of the 178 patients eligible for the study was 29.58±9.93 (118 males and 60 females). The mean hamstring tendon diameter was 7.8±0.7 mm, the mean for males was 7.9±0.6 and for females 7.8±9 mm (P=0.0001). There were significant correlations between the mean hamstring tendon diameter with BMI (Pearson correlation=0.375, R2=0.380, and P=0.0001), height (Pearson correlation=0.441, R2=0.121, and P=0.0001), and weight (Pearson correlation=0.528, R2= -0.104 and P=0.0001). However, patient's age and genderwerenot found to be a predictor of the size of the hamstring tendon diameter. CONCLUSION: Based on findings from this study weight, height, body mass index, and the length of the tendon may be predictors of the hamstring tendon diameter for anterior cruciate ligamentreconstruction. These findings could be used in preoperative planning of patients undergoing ACL reconstruction surgery to estimate the size of the graft and select of the appropriate type of graft.

Hamstring tendon autograft versus fresh-frozen tibialis posterior allograft in primary arthroscopic anterior cruciate ligament reconstruction: a retrospective cohort study with three to six years follow-up.

INTRODUCTION: Selection of various grafts for anterior cruciate ligament (ACL) reconstructions have been employed in order to improve on stability and function of the knee. This study aimed to compare stability and function of the knee after ACL arthroscopic reconstruction by single-loop tibialis posterior (TP) allograft and four-strand hamstring tendon (HT) autograft. MATERIALS AND METHODS: The retrospective cohort study included 104 patients in the TP group matched with 118 patients in the HT group in terms of demographic characteristics, associated meniscus injury, subjective and objective knee characteristics. All patients were followed up for at least three years with regards to mentioned criteria and time of return to former activities. RESULTS: The mean (range) age of TP (88 males and 16 females) and HT (99 males and 19 females) groups was 34.4 (19-48) and 36.9 (20-51) years, respectively. Median (range) follow-up durations were 55 (37-71) and 56 (36-72) months, respectively. No significant differences were observed post-operatively, regarding subjective and objective evaluations. Additionally, time duration for return to former activity was similar in both groups. Post-operative paresthesia and numbness of medial aspect of the calf were observed for two months in eight patients of the HT group which persisted to the final visit in one case. No similar symptom was seen in the TP group. CONCLUSION: In arthroscopic ACL reconstruction, fresh frozen doubled TP allograft compared to HT autograft was equally effective in restoring function and stability of knee, permitting return to former activities. LEVEL OF EVIDENCE: Retrospective comparative, Level III.

Treatment Outcomes of Corticosteroid Injection and Extracorporeal Shock Wave Therapy as Two Primary Therapeutic Methods for Acute Plantar Fasciitis: A Prospective Randomized Clinical Trial.

The outcome of corticosteroid injection (CSI) and extracorporeal shock wave therapy (ESWT) as primary treatment of acute plantar fasciitis has been debated. The purpose of the present study was to evaluate and compare the therapeutic effects of CSI and ESWT in patients with acute (<6-week duration) symptomatic plantar fasciitis. Of the 116 eligible patients, 68 were randomized to 2 equal groups of 34 patients, each undergoing either ESWT or CSI. The ESWT method included 2000 impulses with energy of 0.15 mJ/mm(2) and a total energy flux density of 900 mJ/mm(2) for 3 consecutive sessions at 1-week intervals. In the CSI group, 40 mg of methyl prednisolone acetate plus 1 mL of lidocaine 2% was injected into the maximal tenderness point at the inframedial calcaneal tuberosity. The success and recurrence rates and pain intensity measured using the visual analog scale, were recorded and compared at the 3-month follow-up visit. The pain intensity had reduced significantly in all patients undergoing either technique. However, the value and trend of pain reduction in the CSI group was significantly greater than those in the ESWT group (p < .0001). In the ESWT and CSI groups, 19 (55.9%) and 5 (14.7%) patients experienced treatment failure, respectively. Age, gender, body mass index, and recurrence rate were similar between the 2 groups (p > .05). Both ESWT and CSI can be used as the primary and/or initial treatment option for treating patients with acute plantar fasciitis; however, the CSI technique had better therapeutic outcomes.

Effect of obesity on arthroscopic treatment of anterolateral impingement syndrome of the ankle.

The present case series study was performed to evaluate the effect of obesity on the arthroscopic findings and the functional outcome after arthroscopic treatment of anterolateral impingement syndrome of the ankle. The study was conducted on 36 patients (26 were classified as obese [body mass index ≥30 kg/m(2)] and 10 as not obese [body mass index <25 kg/m(2)]) who had previously undergone arthroscopic treatment of anterolateral impingement syndrome of the ankle. The arthroscopic findings and demographic features were recorded. The patients were examined postoperatively at 6 and 12 months postoperatively, and AOFAS scores were obtained. Our data showed that obese patients had the same arthroscopic findings as nonobese patients, except for chondral lesions. At 1 year of follow-up after performing arthroscopy, the presence of obesity had no effect on the functional outcome of arthroscopic treatment of anterolateral impingement syndrome of the ankle.Obesity has no effect on the effectiveness of arthroscopic treatment.

Role of gracilis harvesting in four-strand hamstring tendon anterior cruciate ligament reconstruction: a double-blinded prospective randomized clinical trial.

PURPOSE: Weakness in knee flexion following anterior cruciate ligament (ACL) reconstruction is one of the key issues in the treatment of an ACL tear. The purpose of this study was to examine and compare clinical outcome measures of ACL reconstruction using semitendinosus autograft (ST) versus semitendinosus + gracilis (ST/G) reconstructive techniques. METHODS: In a double-blind randomized clinical study, 19 patients with an ACL tear underwent either ST (59) or ST/G (61) and observed for 1 year. Both patients and the final examiner were unaware as to the type of graft received. Patients were evaluated according to subjective criteria, functional assessment tests, knee isometric torques, knee laxity using KT-2000 and knee range of motion. RESULTS: The study included 21 (17.6 %) female and 99 (82.4 %) male patients with a mean age of 29.9 ± 7.8 in the ST group and 32.4 ± 6.3 in the ST/G group. There were no significant differences found in surgical complications; IKD; Knee injury and Osteoarthritis Outcome Score; Lysholm; strength of the knee isometric flexors; and flexion and extension loss between the two groups. At the final visit, 86.9 % of ST group and 89.6 % of ST/G group had side-to-side difference of laxity <3 mm (n.s.). CONCLUSIONS: Since anterior cruciate ligament reconstruction using quadrupled ST is more technically demanding than doubled STG and with there being no difference in outcomes and complications, no compulsory advice should be made on the former technique. However, gracilis harvesting may not be necessary based on the function and strength of the knee. LEVEL OF EVIDENCE: Randomized controlled trial, Level I.

Snow Catastrophe Conditions: What is its Impact on Orthopedic Injuries?

BACKGROUND: Iran places sixth amongst high risk natural disaster countries and Guilan province of Iran shoulders a large amount of socio-economic burden due to snow catastrophes. The more knowledge of circumstances we have, the more efficient our future encounters will be. METHODS: In this retrospective study, of all of the patients admitted to Poursina Hospital due to snow and ice related trauma in the first two weeks of February 2014, 306 cases were found eligible for entry into the present study. RESULTS: Of the 306 eligible patients (383 injuries), there were 175 men (57.2%) and 131 women (42.8%). Most patients suffered from orthopedic injuries (81%) and the most common fractures were distal radius fractures in the upper extremities and hip fractures in the lower extremities. Slipping was the most common and motor vehicle accidents had the rarest injury mechanisms. It was shown that the frequency of injuries were higher on icy days (67.6%) than snowy days (32.4%). CONCLUSIONS: Snow crises may lead to increased risk of slipping and falling situations, especially on icy days. The peak of injury rates is a few days after snowfall with the most common injury being distal radius fracture. Providing essential instructions and supporting resource allocation to better handle such catastrophes may improve outcomes.

Corticosteroid injection with or without thumb spica cast for de Quervain tenosynovitis.

PURPOSE: To compare the corticosteroid injection (CSI) with or without thumb spica cast (TSC) for de Quervain tendinitis. METHODS: In this prospective trial, 67 eligible patients with de Quervain tenosynovitis were randomly assigned into CSI + TSC (33 cases) and CSI (34 cases) groups. All patients received 40 mg of methylprednisolone acetate with 1 cc lidocaine 2% in the first dorsal compartment at the area of maximal point tenderness. The primary outcome was the treatment success rate, and the secondary outcome was the scale and quality of the treatment method using Quick Disabilities of Arm, Shoulder and Hand and visual analog scale scores. RESULTS: The groups had no differences in mean age, sex, and occupation. The visual analog scale and Quick Disabilities of the Arm, Shoulder and Hand scores were similar in both groups before the treatment. The treatment success rate was 93% in the CSI + TSC group and 69% in the CSI group. Although both methods improved the patients' conditions significantly in terms of relieving pain and functional ability, CSI + TSC had a significantly higher treatment success rate. CONCLUSIONS: The combined technique of corticosteroid injection and thumb spica casting was better than injection alone in the treatment of de Quervain tenosynovitis in terms of treatment success and functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Celecoxib as a pre-emptive analgesia after arthroscopic knee surgery; a triple-blinded randomized controlled trial.

BACKGROUND: Pre-emptive analgesia not only controls pain but also may result in the reduction of opioid consumption and related side effects following orthopedic surgeries. The purpose of the present study was to examine the therapeutic effects of celecoxib in reducing pain following the arthroscopic knee surgeries: anterior cruciate ligament (ACL) reconstruction and partial meniscectomy. MATERIALS AND METHODS: In this triple-blinded, randomized, placebo-controlled clinical trial, celecoxib 400 mg and identical placebo were administered, 2 h prior to operation, to 130 patient candidates for undergoing knee arthroscopic surgery of either isolated meniscectomy or ACL reconstruction. Pain intensity, 24 h opioid consumption and the related side effects were measured at 6 and 24 h post operation. RESULTS: The patients in both groups were similar with regards to demographic characteristics such as age, gender and body mass index. The results of the study indicated that the pain intensity and opioid consumption were lower in both subgroups (meniscectomy and ACL-R) in celecoxib group at 6 and 24 h post operation (P < 0.0001). The side effects of analgesics such as nausea and vomiting, sedation, and dizziness were not significantly different between the two groups (P > 0.05). CONCLUSION: It seems that celecoxib as a pre-emptive analgesia agent is effective in decreasing acute postoperative pain and 24 h opioid consumption in patients undergoing arthroscopic knee surgery.

The effects of corticosteroid injection versus local anesthetic injection in the treatment of lateral epicondylitis: a randomized single-blinded clinical trial.

INTRODUCTION: This study seeks to compare two treatment methods of lateral epicondylitis: corticosteroid injection (CSI) and a local anesthetic injection (LAI). MATERIALS AND METHODS: In this single-blinded randomized clinical trial, 138 patients with the diagnosis of lateral epicondylitis were assigned either into CSI group receiving methylprednisolone 1 ml (49 patients) or LAI group (51 patients) receiving procaine 1 ml 2 % in a single dose at the maximal point tenderness site. The primary outcome measure was elbow disability using Quick DASH, and secondary outcome measures were pain intensity using Visual Analogue Scale (VAS) and recurrence rate at pretreatment visit and at 3-, 6- and 12-week post-treatment visits. RESULTS: There were no significant differences between the patients in both groups for demographic factors including age, gender, dominant hand, involved hand, and work pressure. Before treatment, the patients in both groups were suffering from the same rates of elbow disability and pain as measured by Quick DASH and VAS, respectively, (p > 0.05). In general, the recovery rate (comparison between pretreatment visit and last post-treatment visit) was significantly more effective and higher in CSI than LAI. CSI was dramatically more effective at 3-week visit, but less and less effective at 6- and 12-week visits. At 12-week visit the recurrence rate was 34.7 % (17 patients) in CSI group. CONCLUSION: For lateral epicondylitis, CSI has the best short-term treatment results yet the highest recurrent rates. The combination of CSI with other treatment option or with a change in injection technique from single injection to peppering injection may be promising.

Evaluation of clinical outcomes of cementless total hip arthroplasty in patients under 30 years of age.

BACKGROUND: Historically, performing a successful hip joint replacement in patients aged fewer than 30 years has been an orthopedic challenge. The newer generation of prostheses and surgical techniques has the potential to increase the longevity of implants. The purpose of this study was to evaluate the outcomes of cementless hip arthroplasty in patients aged fewer than 30 years. MATERIALS AND METHODS: In this cross-sectional study, 41 patients (46 hips) were studied with a mean age of 24, 4 (from 17 to 30 years) of whom underwent cementless metal-polyethylene hip arthroplasty from 2004 to 2007. The Harris hip score (HHS) was used to assess the functional consequences. Patients were followed up in terms of early complications (thrombophlebitis of the lower limbs, dislocation, hematoma and infection) and late complications (aseptic loosening, dislocation and reoperation) at weeks 3 and 6, at 3 and 6 months, 1 year after surgery and annually thereafter. RESULTS: Patients were followed for an average of 5 years and 2 months (from 51 to 82 months). One early complication (symptomatic thrombophlebitis) and one late dislocation (2.2 %) were observed. There were no cases of aseptic loosening or osteolysis at the end of follow-up. The preoperative HHS was 59.6 (from 41 to 76), which rose to 82 and 83.5 after the 1-year and final follow-up, respectively, which was a significant increase. CONCLUSIONS: Hip arthroplasty using a new generation of cementless proximal porous prosthesis with resistant polyethylene to cover the joint surfaces in patients aged fewer than 30 years is satisfactory and is accompanied by low complications.