Five-Strand Versus Four-Strand Hamstring Autografts in Anterior Cruciate Ligament Reconstruction-A Prospective Randomized Controlled Study.

PURPOSE: To compare the clinical outcomes of the routine use of 5-strand hamstring grafts (where possible) with those of 4-strand grafts in primary anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 64 patients were enrolled in a prospective randomized controlled study comparing the use of 5-strand and 4-strand semitendinosus-gracilis autografts in single bundle ACL reconstruction (n = 32 in each group). Four participants in each group were lost to follow-up and were excluded from the outcome analysis. The outcomes of 28 patients in the 5-strand group and 28 patients in the 4-strand group were analyzed. The diameters of all grafts were measured intraoperatively. Patients were assessed postoperatively at 2 years with objective assessments (anterior knee laxity using the KT-2000 arthrometer, Lachman test, pivot-shift test, hop test) and patient-reported outcome scores (Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective knee score, SF-36 physical and mental components, Tegner activity scale). Postoperative graft ruptures were also noted. RESULTS: There were improvements in all outcome measures postoperatively regardless of the number of graft strands. When we compared the study and control groups, there were no significant differences in all subjective and objective outcome measures except the Knee Injury and Osteoarthritis Outcome Score symptoms score (5-strand group 93.3 ± 9.2 vs 4-strand group 86.2 ± 14.7, P = .04). The KT-2000 side-to-side difference was 2.79 ± 2.11 mm in the 5-strand group and 2.54 ± 1.75 mm in the 4-strand group (P = .63). The 5-strand study group had 2 graft ruptures at 1 year, whereas the 4-strand control group had one partial graft rupture at 6 months. CONCLUSIONS: At 2-year follow-up, the routine use of the 5-strand hamstring tendon autograft was not superior to that of the quadrupled or 4-strand graft in primary ACL reconstruction. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Concomitant meniscal injury in anterior cruciate ligament reconstruction does not lead to poorer short-term post-operative outcomes.

PURPOSE: The main objective was to compare post-operative outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction both with and without concomitant meniscus injury at a mean follow-up of 3.5 years. The secondary objective was to study the effect of different meniscal injury sites and treatment modalities on post-operative outcomes (PROS). METHODS: This is a retrospective analysis of a prospectively maintained database of patients undergoing ACL reconstruction at our tertiary institution between 2009 and 2012. Age, sex, graft type, graft fixation modality, location of meniscal tear and treatment (meniscal repair or meniscectomy) were recorded in the database. PROS used included the Tegner activity scale and the Lysholm score. RESULTS: There were no significant differences between patients with or without meniscal injury in terms of age, BMI or preoperative PROS. There was no significant difference in the post-operative outcome scores between patients with or without meniscal injury at a mean follow-up of 3.5 years. Regardless of the location of meniscal injury, the post-operative scores improved as compared to preoperative scores. CONCLUSION: Concomitant meniscal injury in cases of ACL reconstruction is not associated with poorer short-term post-operative PROS (mean follow-up time: 3.5 years). These findings may influence management decisions and help in preoperative counselling. LEVEL OF EVIDENCE: IV.

Functional outcome of tibial fracture with acute compartment syndrome and correlation to deep posterior compartment pressure.

AIM: To measure single baseline deep posterior compartment pressure in tibial fracture complicated by acute compartment syndrome (ACS) and to correlate it with functional outcome. METHODS: Thirty-two tibial fractures with ACS were evaluated clinically and the deep posterior compartment pressure was measured. Urgent fasciotomy was needed in 30 patients. Definite surgical fixation was performed either primarily or once fasciotomy wound was healthy. The patients were followed up at 3 mo, 6 mo and one year. At one year, the functional outcome [lower extremity functional scale (LEFS)] and complications were assessed. RESULTS: Three limbs were amputated. In remaining 29 patients, the average times for clinical and radiological union were 25.2 ± 10.9 wk (10 to 54 wk) and 23.8 ± 9.2 wk (12 to 52 wk) respectively. Nine patients had delayed union and 2 had nonunion who needed bone grafting to augment healing. Most common complaint at follow up was ankle stiffness (76%) that caused difficulty in walking, running and squatting. Of 21 patients who had paralysis at diagnosis, 13 (62%) did not recover and additional five patients developed paralysis at follow-up. On LEFS evaluation, there were 14 patients (48.3%) with severe disability, 10 patients (34.5%) with moderate disability and 5 patients (17.2%) with minimal disability. The mean pressures in patients with minimal disability, moderate disability and severe disability were 37.8, 48.4 and 58.79 mmHg respectively (P < 0.001). CONCLUSION: ACS in tibial fractures causes severe functional disability in majority of patients. These patients are prone for delayed union and nonunion; however, long term disability is mainly because of severe soft tissue contracture. Intra-compartmental pressure (ICP) correlates with functional disability; patients with relatively high ICP are prone for poor functional outcome.

Arthroscopic skills assessment and use of box model for training in arthroscopic surgery using Sawbones - "FAST" workstation.

PURPOSE: Arthroscopic skills training outside the operative room may decrease risks and errors by trainee surgeons. There is a need of simple objective method for evaluating proficiency and skill of arthroscopy trainees using simple bench model of arthroscopic simulator. The aim of this study is to correlate motor task performance to level of prior arthroscopic experience and establish benchmarks for training modules. METHODS: Twenty orthopaedic surgeons performed a set of tasks to assess a) arthroscopic triangulation, b) navigation, c) object handling and d) meniscus trimming using SAWBONES "FAST" arthroscopy skills workstation. Time to completion and the errors were computed. The subjects were divided into four levels; "Novice", "Beginner", "Intermediate" and "Advanced" based on previous arthroscopy experience, for analyses of performance. RESULTS: The task performance under transparent dome was not related to experience of the surgeon unlike opaque dome, highlighting the importance of hand-eye co-ordination required in arthroscopy. Median time to completion for each task improved as the level of experience increased and this was found to be statistically significant (p < .05) e.g. time for maze navigation (Novice - 166 s, Beginner - 135.5 s, Intermediate - 100 s, Advance - 97.5 s) and the similar results for all tasks. Majority (>85%) of subjects across all the levels reported improvement in performance with sequential tasks. CONCLUSION: Use of the arthroscope requires visuo-spatial coordination which is a skill that develops with practice. This simple box model can reliably differentiate the arthroscopic skills based on experience and can be used to monitor progression of skills of trainees in institutions.

Meniscus delivery: a maneuver for easy arthroscopic access to the posterior horn of the medial meniscus.

Pathology of posterior horn of medial meniscus is common and often presents a difficult approach during arthroscopy for various reasons. We describe an easy maneuver to facilitate "delivery of the medial meniscus" during arthroscopy.

Are pre-operative anthropometric parameters helpful in predicting length and thickness of quadrupled hamstring graft for ACL reconstruction in adults? A prospective study and literature review.

PURPOSE: Cross-sectional diameter of 7 mm or more of graft in anterior cruciate ligament reconstruction is arguably the single most important factor determining the success of the operation. Pre-operative anthropometric parameters have been reported to correlate with diameter of quadrupled hamstring graft, which is the most popular graft choice today. We conducted this prospective study to determine the value of some anthropometric measurements to predict the length of harvested semitendinosus and gracilis tendons and quadrupled hamstring graft diameter. We also assessed the reliability of the mathematical equation in accurately predicting the graft diameter. METHODS: Height, weight, BMI and thigh length of 160 patients who underwent primary ACL reconstruction was measured before surgery. Using multivariate logistic regression analysis length of harvested semitendinous and gracilis tendons along with quadrupled graft diameter were correlated to height, weight, BMI and thigh length. RESULTS: Ninety-six percent had graft diameter of 7 mm or more. Height and thigh length were found to be most strongly correlating to both the length of harvested tendons and the quadrupled graft diameter (p ≤ 0.001, r = 0.25-0.39). Patients with height less than 147 cm were found to be at highest risk for inadequate graft diameter (less than 7 mm). Although the anthropometric parameters were found to be significantly related to height and thigh length, the strength of association is moderate. The mathematical equation for prediction of graft diameter using height was found to inaccurately over-predict the graft diameter in 33.1 % of cases, assessed using Bland-Altman plot. CONCLUSION: Anthropometric parameters, especially height and thigh length, can serve as a guide to plan hamstring graft diameter and length before ACL reconstruction. But, it is not advisable to rely on mathematical equations for absolute values of graft parameters as there is risk of over-estimating hamstring length or graft thickness.

Combined acromioclavicular joint dislocation and coracoid avulsion in an adult.

Avulsion fracture of coracoid process with acromioclavicular joint dislocation is extremely rare. We report a case of coracoid avulsion with acromioclavicular disruption in a 24-year-old man who sustained injuries in a road traffic accident. Although acromioclavicular (AC) dislocation was obvious from an initial radiograph, coracoid avulsion was picked up in a CT scan. Open reduction and internal fixations of the coracoid with a 4 mm cannulated screw, an AC joint with two K-wires and an anchor suture, resulted in rapid recovery. The patient had complete range of shoulder movements at the end of 3 months and he resumed his professional activities. After 1 year, he had normal shoulder movement without any functional limitations.

Osteoid osteoma (OO) of the coracoid: a case report of arthroscopic excision and review of literature.

Osteoid osteoma (OO) of the coracoid is a rare entity that may present with variable symptoms from shoulder leading to delay in diagnosis and treatment. We present the clinical and radiological findings and management of one such case along with a review of similar cases reported in the literature. There was a delay of 2 years in diagnosis, which was later confirmed by computed tomography in addition to magnetic resonance imaging (MRI). The lesion was accessed arthroscopically and excised by unroofing and curettage. "OO" should be included in the differential diagnosis of shoulder pain in young patients not responding to long-term conservative treatment. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.

Influence of erythrocyte function-enhancing drugs on the bronchoprotective actions of chemokine receptor blockers in mice.

BACKGROUND: CC chemokine receptors are likely to have important roles in the regulation of leukocytes and mast cells. Chemokine receptors are crucial in orchestrating innate and acquired immune responses as well as in allergic inflammation. A disturbance in erythrocyte function can lead to bronchial hyperreactivity and asthma. MATERIAL/METHODS: This study was conducted on Swiss albino mice weighing between 25 to 35 g. The animals were divided into eight groups (n=8). Groups of mice (n=8) were pretreated with the chemokine receptor blockers A122058 (600 microg/kg i.p.) or cyclophosphamide (20 mg/kg i.p.). Other groups received A122058 or cyclophosphamide in combination with either erythropoietin and quercetin. The effects of these drugs on bronchoconstriction and salivation induced by carbachol were evaluated. RESULTS: The results of this study suggest that blockade of chemokine receptors significantly potentiated erythropoietin- and quercetin-induced inhibition of carbachol-induced bronchoconstriction (P<0.05) compared with the control group. However, pentoxifylline did not produce significant bronchoprotection against carbachol-induced bronchoconstriction (P>0.05). CONCLUSIONS: The results of this study suggest that blockade of chemokine receptors and enhancement of the erythrocyte function together potentiate the bronchoprotective effects of these drugs. This combination could be a novel strategy in combating bronchial hyper-responsiveness.