Delayed osteochondral fracture fixation of the knee in a pediatric patient.

The frequency of osteochondral fractures in the knee joint in the pediatric population is not clearly known. Although fragment fixation is generally considered to be the ideal treatment method in acute injuries, the data of the results of late fixation in neglected and/or late-diagnosed cases are very limited. In this paper, we report our findings regarding the fixation of a delayed large osteochondral fracture in lateral femoral condyle in a pediatric patient.

The Impact of Different Application Techniques on Fiberglass Casts: A Mechanical Experimental Study.

BACKGROUND: Cast immobilization is a part of treatment in most of the orthopaedic injuries. The fiberglass material has several advantages over plaster of Paris which makes it more preferable. Some techniques are frequently used in daily fiberglass cast application to ease molding, shorten curing time and increase stiffness. The aim of this study is to assess the effects of two techniques on fiberglass cast strength and curing time. METHODS: A cruris model was prepared to mimic a patella tendon bearing (PTB) cast. Three groups were created for the study (n = 30 each). The casts in the first group were treated with foam soap during molding. The casts in the second group were wrapped with a wet bandage after application. The third group was the control group. The samples were mechanically tested in the 5th, 15th and 30th min. Maximum load, elastic strength, and Young's modulus were assessed via 3-point bending. All data were compared using linear regression analysis and p < 0.05 was determined as statistical significance. RESULTS: The results showed statistically significant improvement in cast mechanics in the wet bandage group at full curing time by means of maximum load, elastic strength and Young's modulus (p < 0.0001). Although the foam soap group had higher values in the 5th and 15th min, there was no statistically significant difference from the control group at full curing time (p > 0.05). CONCLUSIONS: This study revealed that wet bandage wrapping over circular fiberglass casts improved the cast strength. The use of foam soap during fiberglass cast molding did not alter cast mechanics at full curing time.

Effects of a novel biodegredable implant system on a rat tibia fracture model.

OBJECTIVE: This study aimed to determine the effects of a novel biodegradable implant releasing platelet-derived growth factor (PDGF) at the fracture site on fracture healing in a rat tibia fracture model. METHODS: In this study, 35 male Sprague-Dawley rats weighing between 300 and 350 g were used. The rats were divided into four groups: Group A (control group without any treatment, n=10), Group B (spacer without PDGF Group, n=10), Group C (spacer with PDGF group, n=10), and Group D (healthy rat Group, n=5). Standardized fractures were created in the right tibias of rats, and then biodegradable implants made of poly-ß-hydroxybutyrate-co-3-hydroxy valerate were implanted at the fracture sites in Groups B and C. In Group C, implants were loaded with 600 ng of PDGF. Animals were sacrificed 30 days after the operation, and fracture healing in each group was assessed radiologically based on the Goldberg score. Furthermore, the anteroposterior (AP) and mediolateral (ML) callus diameters were measured macroscopically, and fracture sites were mechanically tested. RESULTS: In the radiological assessment, Group C showed higher fracture healing rate than Groups A and B (p=0.001), whereas no significant difference was found between group C and Group D (p>0.05). In the macroscopic assessment, while Group C exhibited the thickest AP callus diameter (p=0.02), no significant differences in ML callus diameters existed among the groups (p>0.05). Mechanical testing revealed that Group C had higher torsional strength (p=0.001) and stiffness than Groups A and B (p=0.001) while there was no significant difference between Groups C and D (p>0.05). CONCLUSION: Biodegradable implant releasing PDGF may have positive effects on fracture healing.

Objective Measurement of Medial Joint Space Widening with Percutaneous "Pie Crust" Release of Medial Collateral Ligament during Knee Arthroscopy.

Knee arthroscopy may be called the most commonly and increasingly performed orthopaedic procedure. Posterior medial compartment visualization may be quite challenging. The aim of the present study is to detect objective measurement of medial joint space widening with percutaneous "pie crust" release of medial collateral ligament (MCL) during knee arthroscopy. We used this technique for all knees that require any intervention in the posteromedial compartment and for tight knees in which adequate visualization of the posteromedial compartment cannot be obtained. Eighteen patients (18 knees) were included in this study. Patients were evaluated clinically with the Lysholm and Tegner scores at the final office visit. Joint balance, valgus instability, pain or tenderness on MCL region, and numbness over the medial side of the joint were also noted. Measurements of medial joint space (mm) were obtained at three different times with perioperative C-arm images: normal, controlled valgus force, and after pie crusting. The median follow-up time was 9 (6-12) months. Final follow-up Lysholm (p < 0.05) and Tegner scores (p < 0.05) increased significantly compared with preoperative scores. At the final follow-up, there was no pain or tenderness over MCL and there were no signs of saphenous nerve or vein injury. Medial joint space values in after pie crusting increased significantly (p < 0.05) compared with neutral position measurements and controlled valgus force application (p < 0.05). Controlled release of the MCL in knees provided ∼2.45 times wider visualization place. Furthermore, pie crusting of MCL is a safe and effective technique that provides enough space for visualization and instrumentation in knees. This is a Level IV study.

The effects of cryopreserved human amniotic membrane on fracture healing: Animal study.

OBJECTIVE: The aim of this study was to investigate the effects of human amniotic membrane (HAM) on fracture healing in an animal model. METHODS: Standard tibial diaphysial fractures were created in twenty-eight Wistar-Albino rats and treated with intramedullary Kirschner wire (K-wire) and HAM (HAM (+) group) or K-wire only (HAM (-) group). Fracture healing was evaluated by histological analysis, radiologic X-ray views and callus diameter measurements at 3rd and 6th weeks postoperatively. RESULTS: Fracture healing was histologically better in the HAM (+) group and the difference was statistically significant at both 3rd and 6th weeks postoperatively (p < 0.05). The highest histologic scores and entire woven bone formation (Huo Stage 8-9) were obtained at 6th weeks postoperatively in the HAM (+) group. Histological examination also revealed predominant fibrous tissue and partial cartilage formation (Huo Stage 2) at the postoperative 3rd week in the HAM (-) group. Equal amounts of woven bone and cartilage formation (Huo Stage 6-7) were observed at 3rd weeks postoperatively in the HAM (+) group and at 6th weeks postoperatively in the HAM (-) group. The callus diameters were greater in the HAM (+) group and the difference was statistically significant (p < 0.05) at 3rd and 6th weeks postoperatively. Although there was only a statistically significant difference (p < 0.05) at the postoperative 3rd week, radiological scores tended to be higher in the HAM (+) group at both the 3rd and 6th weeks postoperatively. CONCLUSION: HAM is a cheap and easily accessible alternative biological material. HAM may be used to support surgical treatment of fractures, particularly where bone healing is expected to last longer.

Missed Capitellar Fracture Caused by Avoidance of Radiological Evaluation in Pregnancy.

In this paper, we report a pregnant woman with a missed capitellar fracture of the elbow, who was treated successfully with open reduction and internal fixation using two headless screws. A 29-year-old 6-month pregnant woman presented to the emergency department due to a history of falling on her outstretched hand. A long-arm splint was applied without radiological evaluation due to pregnancy. She came to the orthopaedics and traumatology outpatient clinic 6 weeks after trauma and her examination after splint removal revealed pain and restriction in the elbow joint movements. Radiography was taken by using a lead shield in order to protect the fetus. Radiographs showed a displaced osteochondral capitellar fracture. Using the posterolateral approach as described by Kocher, the fracture was fixed using headless canulated compression screws. The follow-up examination showed excellent functional and radiological results. Radiological evaluation should not be avoided in case of obvious fracture findings after trauma even in case of pregnancy. It is also highlighted that good results in terms of union and functional recovery can be achieved with open reduction and headless compression screw fixation followed by early rehabilitation even in delayed treatment of capitellum fractures.

Effect of partial, distal epicondylectomy on reduction of ulnar nerve strain: a cadaver study.

PURPOSE: To compare the decrease in ulnar nerve strains using a modification of medial epicondylectomy by removing the distal half of the medial epicondyle with in situ decompression and partial medial epicondylectomy. METHODS: Using 20 elbows of 10 fresh human cadavers, we measured the strain on the ulnar nerve using a microstrain gauge before and after in situ decompression. Then, we repeated the measurements after partial medial epicondylectomy on left elbows, and after distal medial epicondylectomy on right elbows. We compared the mean strain values with 2-way analysis of variance. RESULTS: The decrease in mean ulnar nerve strain with in situ decompression from 5.4% to 5.2% on the right side and 5.4% to 5.0% on the left was not statistically significant. The decrease to 2.9% on the left elbows after partial and to 1.9% on the right elbows after distal medial epicondylectomy was statistically significant. In addition, the remaining ulnar nerve strain after distal medial epicondylectomy was significantly less compared with that after partial medial epicondylectomy. We observed nerve subluxation only with partial medial epicondylectomy. CONCLUSIONS: In situ decompression alone does not change ulnar nerve strains. The significant change in ulnar nerve strain with partial or distal medial epicondylectomy underlines the role of medial epicondyle on stretching of the ulnar nerve. Excision of the distal half of the medial epicondyle sets the contact point of the nerve with the bone proximally and decreases the strain on ulnar nerve more effectively than partial epicondylectomy. However, its efficacy and complications need to be studied clinically. CLINICAL RELEVANCE: The results of the present cadaveric study suggest that excision of the distal half of the medial epicondyle in cubital tunnel syndrome may decrease ulnar nerve strain effectively. The clinical effect of decrease in nerve strain and the indications for the procedure need to be investigated.

[The effectivity of magnetic resonance imaging findings in the diagnosis of bucket handle meniscal tears]. / Kova sapi menisküs yirtigi tanisinda manyetik rezonans görüntüleme bulgularinin etkinligi.

OBJECTIVES: This study aims to test the efficacy of magnetic resonance imaging (MRI) evaluation by a group who were blinded to the arthroscopic diagnosis in patients with known bucket handle meniscal tears. PATIENTS AND METHODS: In this study, MRI scans of 28 patients who were operated due to bucket handle meniscal tear with sufficient documentation were evaluated. Radiographic evaluation was performed by two different groups, including an orthopedist and radiologist. In the first group, evaluation of MRI scans was performed by the specialists who were aware of the arthroscopic diagnosis and marked the defined MRI signs of bucket handle meniscal tear. In the second group, evaluation was done, remaining blinded to the diagnosis, with only initial complaints at admission. The second group also evaluated the MRI scans and marked the pathologic signs. The sensitivity of radiological signs marked by both groups was compared. Invariables were found using blinded evaluation. RESULTS: Double posterior cruciate ligament and free fragment in the intercondylar notch were invariable sensitivities found in the MRI scans by blinded evaluation. The sensitivity of coronal truncation, anterior flip and any free fragment signs were significantly decreased in the setting of blinded evaluation. CONCLUSION: Preoperative differentiation of reparable bucket-handle tears from irreparable is of utmost importance. As meniscal repair improves knee stability and functional results, surgical repair of meniscal injuries particularly in younger individuals who are scheduled for anterior cruciate ligament reconstruction have a positive effect on clinical outcomes.

Dorsal cutaneous innervation of the hand with respect to anatomical landmarks: is there a safe zone?

OBJECTIVES: In this study, we aimed to define the borders of the triangular area between the radial and dorsal nerves on the dorsum of the hand and to determine its dimensions using measurements between anatomic landmarks. MATERIALS AND METHODS: We statistically analyzed the relation between the distance from Lister's tubercle to the blending point of the central branches of radial and ulnar nerves and the distance between styloids on 14 hands of seven adult human cadavers (5 males, 2 females). The distances of nerve branches to vertical lines drown distally from both styloid processes were also compared with interstyloid distances to help in presuming the course of these nerves. RESULTS: No statistical constant correlation was determined between the measurements. Neither the height of the triangular area nor the courses of both nerves seemed to be quantitatively related to any measurements between the anatomical landmarks. CONCLUSION: Variability in these measurements in our study indicates that there is no surgical safe zone on the dorsum of the hand.

Clamp fixation to prevent unfolding of a suture knot decreases tensile strength of polypropylene sutures.

PURPOSE: Although sutures evolved in last decade and the product spectrum broadened largely, they can be still classified into two: monofilament and multifilament. Sutures are the mainstay of orthopedic procedures like fascial closures, tendon repairs or tenodesis. In every repair, a suture loop is created. This suture loop is prone to failure due to suture elongation, knot slip and suture breakage. As the knot is the stress riser in a suture loop, the majority of acute loop failure occurs just adjacent to the knot. Monofilament sutures have higher bending stiffness and tendency to untie than multifilament sutures. The first throw of monofilament sutures have tendency to untie, which decrease loop tension and result in loss of achieved tissue approximation. METHODS: Although a common practice is to fix the first throw via a clamp before the locking one is tied, it can be hypothesized that a potential deforming effect can lead to a decrease in ultimate failure load of a monofilament suture loop. RESULTS: Fixing the first throw significantly reduced the ultimate failure load of monofilament nonabsorbable polypropylene sutures (Prolene) (62.2 ± 8 N vs. 72.7 ± 9 N, p = 0.019). The ultimate failure load achieved by monofilament sutures Polyglyconate (Maxon) and Nylon (Ethilon) and braided absorbable Polyglactin (Vicryl) were not affected by fixing the first throw. CONCLUSION: Under microscopic examination, polypropylene sutures were found to be deformed by clamp fixation, while the others were not. Polypropylene sutures can be easily damaged when it is fixed by a clamp during knot tying. Presented data demonstrated that in real surgical situations clamp fixation of polypropylene knots can damage the suture loop and carry the risk of acute failure of repair site during early rehabilitation.

Comparison of two techniques in achieving planned correction angles in femoral subtrochanteric derotation osteotomy.

Increased femoral anteversion in cerebral palsy alters biomechanics of gait. Femoral subtrochanteric derotational osteotomies are increasingly performed to improve gait in cerebral palsy. The amount of angular correction can be determined and planned preoperatively but, accuracy in achieving planned angular correction has not been tested experimentally before. The aim of this study was to evaluate the accuracy of the two techniques in achieving planned angular correction. Sixteen dry femora were used in this study. Specimens in both groups were derotated to achieve a desired amount of correction with two different techniques, consecutively. In technique one, the cross section of the femur was assumed to be circular and the desired amount of angular correction was calculated and expressed in terms of surface distance by a geometric formula (surface distance=2×π×radius of femur). In both groups, derotations were made based on this surface distance calculation. Consecutively the same specimens were derotated by pins and guide technique. Femoral anteversion of specimens were measured before and after derotation by computerized tomography. There was a statistically significant differance in planned and achieved correction angles (P=0.038) in both subgroups derotated by the surface distance technique. When the two techniques were compared, there was significant difference (P=0.050) between high magnitude correction subgroups (subgroups 2 vs. 4). In conclusion, the results of this study highlighted the difficulty in achieving accurate derotation angles. Derotations based on guide-pins technique yielded more accurate results than derotations based on surface distance technique. In addition, surface diameter technique was not suitable when higher degrees of derotations are needed. In achieving a planned derotation angle two techniques are described for accuracy. Both the techniques have potential pitfalls resulting in malrotations. Surgeons must be aware of these obstacles and try to avoid them.

[Bilateral traumatic patella fracture: a case report]. / Iki tarafli travmatik patella kirigi: Bir olgu sunumu.

Patellar fractures are uncommon injuries and account for approximately 1% of all fractures. In this article, a 35-year-old male patient who sustained a collision deceleration accident with bilateral comminuted transverse patellar fractures is presented. For this patient, open reduction and internal fixation with tension band technique, using two Kirschner wires and cerclage wire was applied for both fractures. At the first postoperative day, isometric quadriceps and active range of motion exercises were begun and the patient was allowed to walk full weight bearing with two crutches while both extremities were immobilized in a hinged brace allowing maximum 30 degrees of flexion. At postoperative fourth week brace immobilization was terminated. However, the patient was advised to use crutches for two weeks more to prevent any complications that may arise during walking because of the bilaterally of the injury. At six weeks solid union was achieved. During the last visit at postoperative second year, the patient had no complaints and the range of motion was full. In this paper a case of bilateral patella fractures is presented as a consequence of a dashboard injury, and the pathomechanical and therapeutical aspects of such an injury is discussed.