Phenomenon of painless knee in recurrent patellar dislocation in children.

INTRODUCTION: Cartilage lesion with patellar malalignment may be correlated with pain. Situations in which patients with recurrent patellar dislocation are painless between episodes of luxation can be approached with considerable curiosity. We evaluated the distribution of substance-P and S-100 protein expression in soft tissue of the knee in children with recurrent patellar dislocation, in order to evaluate the distribution of nociceptors and determine tissue origins of this situation. MATERIAL AND METHODS: Samples were collected from the medial and lateral synovial membrane, medial and lateral patellar retinaculum, Hoffa's body, patellar ligament, and quadriceps' aponeurosis in 10 children during the Blauth procedure and 10 adults with idiopathic osteoarthritis during total joint alloplasty. The density of nociceptive fibres was compared in the children and adults using S-100 and substance-P monoclonal antibodies. RESULTS: Statistical differences between groups were demonstrated for S-100 expression in synovial membrane of the medial knee compartment (p < 0.05) and for substance-P expression in the medial patellar retinaculum (p < 0.05) and synovial membrane of the lateral (p < 0.05) and medial (p < 0.05) knee compartment in favour of children. CONCLUSIONS: Lack of pain sensations in patients with recurrent patellar dislocation may be associated with non-increased expression of nerve endings in Hoffa's body. Increased expression of either S-100 protein or substance-P in synovial membrane and the medial retinaculum did not induce pain development in the knee joints of that group of patients.

Hip joint pain in children with cerebral palsy and developmental dysplasia of the hip: why are the differences so huge?

BACKGROUNDS: Non-traumatic hip dislocation in children is most often observed in the course of developmental dysplasia of the hip (DDH) and infantile cerebral palsy. The risk of pain sensations from dislocated hip joint differentiates the discussed groups of patients. Will every painless hip joint in children with cerebral palsy painful in the future? METHODS: Material included 34 samples of joint capsule and 34 femoral head ligaments, collected during open hip joint reduction from 19 children with CP, GMFCS level V and from 15 children with DDH and unilateral hip dislocation. All the children were surgically treated.The density of nociceptive fibres was compared between the children with CP and DDH, using S-100 and substance P monoclonal antibodies. RESULTS: More frequent positive immunohistochemical reaction to S-100 protein concerned structures of the femoral head ligaments in children with CP and cartilage losses on the femoral head, when compared to the same structures in children with DDH (p = 0.010). More frequent were found positive immunohistochemical reactions for S-100 protein in the joint capsules of children with cartilage losses (p = 0.031) and pain ailments vs. the children with DDH (p = 0.027). More frequent positive reaction to substance P concerned in femoral head ligaments in CP children and cartilage lesions (p = 0.002) or with pain ailments (p = 0.001) vs. the DDH children. CONCLUSIONS: Surgical treatment of hip joint dislocation should be regarded as a prophylactics of pain sensations, induced by tissue sensitisation, inflammatory process development or articular cartilage defects.

Development of human hip joint in the second and the third trimester of pregnancy; a cadaveric study.

BACKGROUND: The purpose of the study was an evaluation of fetal hip joint morphology during the second and the third trimester of pregnancy. Serial sections were performed on 23 cadaver infants. RESULTS: The mean lunar age was 6.6 months. Femoral shaft length (FSL) and width of the proximal and distal epiphysis were x-rayed to determine fetal age. The neck shaft angle (NSA), the femoral antetorsion angle (FAA), the acetabulum anteversion angle (AAA) and the acetabulum slope angle (ASA) were measured. Hip development ratios were plotted for all cadaveric species and revealed: flat FSL/NSA slope pattern, upward FSL/FAA slope pattern and downward slope pattern for FSL/ASA and FSL/AAA ratios. The changes, observed during the developmental period, were not statistically significant. NSA did not change during the second or the third pregnancy trimester. FAA increased during pregnancy but the changes were not statistically significant. AA, as well as ASA, showed a decreasing trend during the second and the third pregnancy trimester, however, with no correlations to age. CONCLUSION: Despite an increasing depth and growing dimensions of the acetabulum in the uterus, its orientation does not change in any significant way.

Reliability of clinical evaluation of meniscus repair with the all-inside technique.

INTRODUCTION: The study aimed to compare questionnaire data and clinical evaluation with an assessment of meniscal morphology conducted at arthroscopic anterior cruciate ligament (ACL) reconstruction following meniscal repair. MATERIAL AND METHODS: The study involved a selected group of 17 subjects (5 women and 12 men) aged 14-33 years, who underwent meniscal repair with the Fast-Fix system followed by ACL reconstruction. The mean interval between the procedures was 9 months. Prior to each procedure, the patients were requested to fill in the Lysholm Knee Questionnaire. RESULTS: At review, 14 patients met the criteria of a healed meniscal repair, whereas the remaining 3 subjects presented with signs of meniscal injury. These observations were confirmed at repeat arthroscopy. The Lysholm score for the entire study group increased from a baseline value of 57.3 to 92.2 points postoperatively, with the patients with reruptured menisci also improving, from 58 to 75.3 points. CONCLUSIONS: 1) Our results show that clinical examination is reliable to evaluate the healing of meniscal lesions following all-inside repair, as confirmed by repeat arthroscopy. 2) A far greater increase in the Lysholm score seen in patients whose menisci were confirmed to have healed by repeat arthroscopy indicates that such questionnaires may be of help in the evaluation of treatment outcomes.

Hip joint pain in spastic dislocation: aetiological aspects.

AIM: Children with severe forms of cerebral palsy (CP) are at high risk of hip joint displacement. Various studies have found that the pain from affected joints occurs in 40 to 84% of studied individuals. The purpose of this study was to establish a correlation between the density of nociceptors localized in selected areas of the spastic dislocated hip joint and clinical evidence of hip joint pain in children with CP. METHOD: Nineteen samples of articular capsule and 19 samples of teres ligaments, collected during open hip joint reduction from 19 non-ambulatory children with spastic CP (Gross Motor Function Classification System level V; mean age 9y 6mo; 10 males, nine females), were studied. Pain was assessed using the numeric rating scale completed by caregivers. The density of nociceptive fibres was compared between the children with painful and children with painless hip joints, using S-100 and substance P monoclonal antibodies. RESULTS: The presence of S-100 protein and substance P were significantly increased (p=0.024 and p=0.02 respectively) in the children with painful hip joints. There were significantly positive correlations between the intensity of pain and the density of nerve fibres with S-100 protein (teres ligament, p=0.001; joint capsule, p=0.032) as well as substance P (teres ligament, p=0.001). INTERPRETATION: Direct and indirect inflammatory factors, present in dislocated hip joints with cartilage damage in children with spastic CP, lead to hip joint sensitization.

Vascularity of the hip labrum during the foetal period.

Tears of the hip labrum have been recognized as a cause of hip pain and clicking. It has been reported that labrum tears are associated with increased microvessel formation. The purpose of this study was to identify the regional vascularity of the acetabular labrum during late foetal development. The acetabular labrum was examined from 21 formalinized foetuses of the age 5th to 10th months of gestation (mean 6.4±0.99). The acetabulum of each specimen was anatomically prepared and divided into four quadrants. The number of blood vessels in labrum quadrants was counted during microscopic examination. A total of 599 of blood vessels were found in all specimens: 159 in quadrant I, 150 in quadrant II, 127 in quadrant III and 163 in quadrant IV. The capsular part of the labrum contained 357 vessels and the articular part contained 242. The total number of blood vessels within the capsular parts of all specimens (357) was significantly greater than the number within the articular parts (242) (p<0.028). There was some evidence to suggest that with increasing foetal age, the number of blood vessels in the labrum decreased. However, taking into consideration the number of vessels in particular quadrants of the labrum, the great frequency of labral tears in the anterosuperior part of the labrum could not be explained.

[The value of bowel preparation procedure in major orthopedic procedures performed in spinal anesthesia]. / Zasadnosc stosowania procedur przygotowujacych dolny odcinek przewodu pokarmowego w duzych zabiegach ortopedycznych wykonywanych w znieczuleniu podpajeczynówkowym.

In common orthopedic practice the preoperative bowel preparation is used for orthopedic surgery made in spinal anesthesia. This procedure is done to clean bowel from remaining stool and enema or suppository made of laxative substance were used. This activity is undertaken to decrease epidemiological risk and streamline work of orthopedic theater. The purpose of this study was to analyze the value of any of the preoperative bowel preparation procedures. The study was performed randomly and prospective on two groups of patients, 50 patients in each group. The group A consisted of 50 patients who were qualified for a total hip or knee replacement made in spinal anesthesia and were not prepared in any way prior to surgery. The group B consisted of 50 patients who had any of the preoperative bowel preparation procedure. We evaluate the uncontrolled defecation in preoperative period. We have not found any uncontrolled defecation in group A compared with four of those cases in group B. The results allowed us to draw a conclusion about groundlessness of any preoperative bowel preparation procedure for surgery performed in spinal anesthesia.

Some variations in lymphatic drainage of selected bronchopulmonary segments in human lungs.

Interest in the role of the pulmonary lymphatic system in the pathophysiology of pulmonary and systemic diseases induced us to carry out anatomical research on the lung lymphatic system in the Polish population. The aim of the study was to evaluate whether lymphatic vessels respect bronchopulmonary segment borders and to determine how often lymphatic vessels run to nodes of another lymphatic region. A block of organs comprising the lungs with the trachea, larynx and tongue, the heart and esophagus was removed from the cadavers at autopsy. The research involved 96 lungs (48 left and 48 right), which were taken from 31 male and 17 female cadavers. The lymphatic vessels were visualized at the mediastinal and interlobar surface of the lung by visual inspection. These vessels were then cannulated and injected with drawing ink. Next, the course of a lymphatic vessel was checked to see whether it was compatible with the bronchopulmonary segments or lobar borders. The first lymph node to become ink-colored via injection was dissected and histologically examined. A total of 135 images of lymphatic vessels (63 in the left lungs and 72 in the right lung) running on the mediastinal or interlobar surface of the lung were evaluated. In all, 12 out of 135 vessels (8.9%) were observed to cross the border of the segment (6/12 vessels) or the border of the lobe (6/12 vessels). We found 10/135 vessels (7.4%) running to the lymph nodes of another lymphatic region.

[Facial asymmetry in children with congenital muscular torticollis after surgical treatment]. / Asymetria twarzoczaszki u dzieci z wrodzonym miesniowopochodnym kreczem szyi po leczeniu operacyjnym.

Asymmetrical position of facial skeleton and movement restriction in the cervical spine in young children could be caused by torticollis mainly muscle origin. We observe miofibrosis of sternocleidomastoid muscle. This face deformation is seen from 0.3 to 1.5% children. Torticollis could be associated with malocclusion, facial asymmetry, vision defect or vertebral body deformation. Muscle stretching is a main type of treatment at infantile age. In the case of faille and in older children sternocleidomastoid myotomy is indicated. The purpose of our study is to analyze facial asymmetry in children after torticollis surgery and determination if surgery performed after 3 years of age is associated with higher risk of facial deformity in long follow up. The study population consisted of 16 patients who underwent sternocleidomastoid tenotomy in proximal and distal part. The control group consisted of 13 persons. Booth groups underwent subjective and objective analysis consisted of computer facial symmetry analysis and measurements of range of motion in the cervical spine. The study group was divided into two subgroups--patients operated before and after 3 years of age. The follow up was 2 to 26 years (mean 13.4 years). The statistical analysis of objective evaluation revealed significant difference in horizontal face axis between subgroups (p<0.05). Range of motion at cervical vertebral column was the same in both groups. Facial asymmetry caused by muscle torticollis is persistent in horizontal axis in long follow up and is more often observed in children operated after 3 years of age, but statistical analysis does not support this thesis.

The problem of direct lymph drainage of the bronchopulmonary segments into the mediastinal and hilar lymph nodes.

The phenomenon of skip metastases depends on the occurrence of direct metastases of non-small cell lung cancer into mediastinal lymph nodes without the involvement of hilar lymph nodes. The medical literature suggests that this prevalence ranges between 13 and 37.8% of cases. The goal of our study was to evaluate the prevalence of subpleural superficial lymphatic vessels carrying the lymph from the bronchopulmonary segments directly to the mediastinal nodes thus skipping the hilar nodes and determine whether there is a tendency towards differentiation in lymph drainage between males and females. During autopsy, 27 left and 27 right lungs were removed from 19 male and eight female cadavers. The lymphatic vessels were visualized at the mediastinal and interlobar surface of the lung by visual inspection. These vessels were then cannulated and injected with drawing ink. The first lymph node to become ink-colored via injection was dissected and histologically examined. The lymph flowed into hilar lymph nodes in 79.5% of the cases and into the mediastinal nodes in 20.5% of all the 83 vessels injected; of these 13.2% were from the right lung and in 7.2% from the left lung. The upper right lobe (5/14 vessels) and its anterior segment (3/14 vessels) were the most common source of the direct lymph drainage to the mediastinum. Vessels of 15.4% in female cadavers (4/26) and 22.8% vessels in male cadavers (13/57) traveled directly to mediastinal nodes skipping the hilar nodes. This difference was not statistically significant.

Early clinical results of open and arthroscopic synovectomy in knee inflammation.

BACKGROUND: The authors compared early results of open and arthroscopic knee joint synovectomy in patients with nonspecific exudative synovitis and rheumatoid arthritis. MATERIAL AND METHODS: The study comprised two groups of patients matched for age, preoperative range of motion in the involved knee and etiology of synovitis. Group I included patients after open synovectomy and group II consisted of subjects following an arthroscopic procedure. Blood loss, analgesic intake, duration of hospitalization, range of flexion and extension in the involved knee at discharge as well as 3 and 6 months following surgery were compared, together with respective recurrence rates. RESULTS: A statistically significant decrease in blood loss and a shorter duration of hospitalization were found in group II compared to group I; no differences were observed in postoperative analgesic use. Mean flexion range was significantly greater before surgery than in the 3 analyzed time intervals in both study groups except for knee flexion in group II compared before and 6 months following the intervention. However, mean flexion range in the operated joint at discharge and 3 months postoperatively was significantly greater in group II as compared with group I. A comparison of the knee extension range between the groups revealed significantly higher values in group II at discharge, but no statistically significant differences were found in the subsequent follow-up assessments. However, flexion contractures developed 6 months after surgery in 5 patients from group I and in 1 patient from group II. No recurrence of effusion was observed in either group. CONCLUSIONS: According to the authors, arthroscopic synovectomy reduces blood loss following surgery, shortens duration of hospitalization and permits faster recovery.

[Results of treatment of displaced long bones fractures in children--comparison of different methods]. / Ocena wyników leczenia zlaman kosci dlugich z pelnym przemieszczeniem odlamów u dzieci--porównanie róznych metod leczenia.

Authors compared functional results of treatment of 48 patients; 25 children with displaced supracondylar humeral fractures, 16 treated with skeletal traction (group I, mean age 7.9 year), 9 treated with closed reduction and percutaneous K-wire fixation (group II mean age 7.7 year), and 23 patients with displaced femoral shaft fractures, 10 treated with traction (group III, mean age 7.5 year), 13 treated with closed reduction and elastic intramedullary nailing. Good results after supracondylar humeral fractures were obtained in 37.5% of patients treated with traction and in 66.7% treated with percutaneous K-wire fixation, and after femoral fractures in 70% treated with traction and 84.6% treated with intramedullary nailing. The use of instrumental methods of treatment allowed to reduce significantly the duration of hospitalization (respectively: 19.8 vs. 6.4, and 28.5 vs. 9.5 days). In authors' opinion, a closed reduction secured by percutaneous K-wire fixation as well as a closed reduction with elastic intramedullary nailing are the methods of choice in treatment of discussed fractures in children.