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.

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.

[Two different methods of supracondylar lateral wedge osteotomy in cubitus varus deformity in adults]. / Eriskin kubitus varus deformitesinde suprakondiler lateral kapali kama osteotomisinin iki farkli tespit yöntemi.

OBJECTIVES: We reviewed the results of a transverse osteotomy for cubitus varus deformity in adults stabilized by two different methods of fixation with either Kirschner wire (K-wire) or Y plate. PATIENTS AND METHODS: Sixteen soldiers were treated by a lateral closing wedge osteotomy of the distal humerus for cubitus varus deformity in the military infirmary. Two different methods of fixation were used for the osteotomy. The osteotomies were stabilized with K-wires in the initial five cases. Because of loosening of the pins and loss of correction in these five cases, Y plates were introduced for fixation in the other patients. RESULTS: Three patients in the K-wire group, and one case in the Y plate fixation group had poor results. Lateral closing wedge osteotomy is technically easy and allows three dimensional correction. Accompanying displaced ulnar nerves and snapping triceps tendons were spontaneously corrected by the osteotomy. CONCLUSION: Y plates provide rigid fixation that permits early active motion and prevents possible complications related to implant failure or loss of fixation.

Single side locking on the opposite of the modified Kessler tendon repair prevents gap formation and suture pull-out: a biomechanical evaluation in sheep tendons.

OBJECTIVES: Locking loops are invented to prevent pull-out complication during early active rehabilitation after flexor tendon repair. This study compares the mechanical properties of the side-locking modified Kessler repairs with four- and two- side locking points. MATERIALS AND METHODS: Twenty fresh flexor digitorum profundus tendons of the healthy adult sheep forelimbs were sutured by the two-strand modified Kessler with the side-locking loop technique (group A: four locking points), and by the two-strand modified Kessler repair method with a side locking knot on the opposite corners of the repair (group B: two locking points). To assess the mechanical performance of the repairs, the tendons were subjected to a linear non-cyclic load-to-failure test using a material testing machine. Outcome measures included the 2.0 mm gap force at the tendon ends, the ultimate forces and the mode of failure. RESULTS: The mean value for the 2.0 mm gap strength was 19.2+/-1.4 for group A and 19.3+/-1.9 for group B. The mean value of the failure strength was 33.1+/-2.6 for group A and 29.8+/-3.2 for group B. Regarding the 2.0 mm gap strength between the tendon ends, no significant difference was observed between the two groups. There were statistically significant differences in failure strengths of the two groups (p=0.019). As regards the mode of failure, no suture pull-out was observed. All the specimens failed due to suture breakage at the repair site. CONCLUSION: Results of this study revealed that gap formation and suture pull-out can be prevented using single side locking points on the opposite corners of the modified Kessler repair.

Cutaneous infection caused by Aspergillus terreus.

Aspergillus species are widely distributed in nature, and more than 30 species have been reported to be involved in human and animal infection. Cutaneous infections due to Aspergillus terreus are particularly rare. In this report, we describe a case of cutaneous infection caused by A. terreus in a paediatric patient who underwent surgical treatment for an open tibial fracture secondary to an agricultural accident.

Granular cell tumor of the posterior tibial nerve as a rare cause of heel pain: a case report.

Granular cell tumor of peripheral nerves is extremely rare. We present the case of a patient with a well-capsulated intraneural granular cell tumor involving the posterior tibial nerve, who presented with chronic heel pain mimicking plantar fasciitis. Magnetic resonance imaging revealed a well-defined intraneural soft-tissue mass within the substance of the posterior tibial nerve. Histopathologic examination showed a granular cell tumor, which is extremely rare in the peripheral nerves. Heel pain is one of the common conditions handled by physicians, podiatrists, and orthopedic surgeons. Posterior tibial nerve lesions at the leg should be kept in mind in the differential diagnosis of patients with persistent heel and foot pain. Magnetic resonance imaging is a useful method in the anatomical evaluation of focal intraneural lesions.

Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial.

BACKGROUND: To determine the effectiveness of four different local injection modalities in the treatment of plantar fasciitis. METHODS: In a prospective randomized multicenter study of plantar fasciitis, 100 patients were divided into four equal groups and were treated using four different methods of local injection: group A was treated with 2 mL of autologous blood alone; group B, an anesthetic (2 mL of lidocaine) combined with peppering; group C, a corticosteroid (2 mL of triamcinolone) alone; and group D, a corticosteroid (2 mL of triamcinolone) combined with peppering. The outcome was defined by using a 10-cm visual analog scale and modified criteria of the Roles and Maudsley score 3 weeks and 6 months after the injection and compared with the pretreatment condition. RESULTS: The successful results in all of the groups after injections were higher than those in the pretreatment condition (P = .000). In groups C and D, in which local corticosteroid injections were used, excellent results were obtained, with superior effect in the group in which peppering was used (P < .05). CONCLUSIONS: In the treatment of plantar fasciitis, combined corticosteroid injections and peppering is effective and produces better clinical results.

Lipoma arborescens of the peroneus longus and peroneus brevis tendon sheath: case report.

Lipoma arborescens is an uncommon pseudotumoral synovial lesion usually located in the suprapatellar pouch of the knee. Lipoma arborescens involving the synovial sheaths of the tendons is exceedingly rare. This diagnosis should be considered, particularly in patients with chronic joint effusion. We report a case with lipoma arborescens affecting the synovial sheaths of the peroneal tendons without involvement of the adjacent ankle joint. To our knowledge, this is the second reported case of lipoma arborescens involving tenosynovial sheaths of tendons around the ankle joint without ankle joint involvment.

Femoral nerve compression secondary to a ganglion cyst arising from a hip joint: a case report and review of the literature.

INTRODUCTION: Femoral nerve compression due to a cystic lesion around the hip joint is rare and only a few cases have been described in the literature. Among these, true ganglion cysts are even more rare. CASE PRESENTATION: We report the case of a 57-year-old woman with femoral nerve compression caused by a true ganglion cyst of the hip joint. CONCLUSION: A high index of suspicion is required to predict a non-palpable cystic lesion around the hip joint as it may mimic different disorders and should be kept in mind in the differential diagnosis of unusual groin pain, radicular pain and peripheral vascular disorders.

Does strand configuration and number of purchase points affect the biomechanical behavior of a tendon repair? A biomechanical evaluation using different kessler methods of flexor tendon repair.

This study compares the mechanical properties of modified Kessler and double-modified Kessler flexor tendon repair techniques and evaluates simple modifications on both methods. Forty fresh sheep flexor tendons were divided equally into four groups. A transverse sharp cut was done in the middle of each tendon and then repaired with modified Kessler technique, modified Kessler with additional purchase point in the midpoint of each longitudinal strand, double-modified Kessler technique, or a combination of outer Kessler and inner cruciate configuration based on double-modified Kessler technique. The tendons were tested in a tensile testing machine to assess the mechanical performance of the repairs. Outcome measures included gap formation and ultimate forces. The gap strengths of the double-modified Kessler technique (30.85 N, SD 1.90) and double-modified Kessler technique with inner cruciate configuration (33.60 N, SD 4.64) were statistically significantly greater than that of the two-strand modified Kessler (22.56 N, SD 3.44) and modified Kessler with additional purchase configuration (21.75 N, SD 4.03; Tukey honestly significant difference test, P < 0.000). There were statistically significant differences in failure strengths of the all groups (analysis of variance, P < 0.000). With an identical number of strands, the gap formation and ultimate forces of the repairs were not changed by additional locking purchase point in modified Kessler repair or changing the inner strand configuration in double-modified Kessler repair. The results of this study show that the number of strands across the repair site together with the number of locking loops clearly affects the strength of the repair; meanwhile, the longitudinal strand orientation and number of purchase points in a single loop did not affect its strength.

Guyon tunnel syndrome secondary to excessive healing tissue in a child: a case report.

We describe a case of an 8-year-old boy who developed a combined motor and sensory neuropathy of the distal ulnar nerve, after sustaining a superficial injury to the right flexor carpi ulnaris tendon at the level of the distal wrist crease. Guyon's canal syndrome is a very rare entity during childhood. We have noted only one prior description of this syndrome in the pediatric age group in a review of the English literature.

Insufficiency fractures of both femoral necks in a young adult caused by osteoporosis: a case report.

Insufficiency fractures of femoral necks due to osteoporosis of unknown aetiology occurring coincidentally on both sides in young adults, have not been described in English literature so far. A 18-year-old young girl presented with a 3-month history of gradual onset of bilateral thigh pain and progressive inability to walk. At the first look, plain radiographs of both hips showed no gross abnormal findings other than some tips on reduced bone mineral density of the femoral necks. MRI was ordered upon a high suspicion of fracture and T1-weighed MRI showed a linear low signal on both femoral necks. Dual-energy X-ray absorptiometry of the lumbar spine and femoral neck showed low mineral density. She was treated surgically with in-situ internal fixation using cannulated screws. The bilateral thigh pain was resolved and walking started immediately after the treatment. Insufficiency fracture of the femoral neck due to osteoporosis should be kept in mind even in young adults complaining of atypical pain without evidence of unusual activities. We used both the terms of stress fracture and insufficiency (osteoporotic) fracture interchangeably as the mechanism of fractures resemble each other.

Sciatica of nondisc origin: hydatid cyst of the sciatic nerve. Case report.

The authors report on an 81-year-old woman with a primary hydatid cyst located in the posteromedial aspect of the thigh. She presented with sciatica, and the cyst was also associated with neurological dysfunction because of its intra-neural location. Diagnosis of a cyst in a nerve body is very rare, and the one reported here might be the first such case. So far, in all the previously reported cases in which there were also neurological findings, the cysts in the vertebral column were compressing the spinal cord or there was an intrapelvic mass compressing the sciatic nerve. Hydatid cyst should be considered in the differential diagnosis of sciatica, especially when treating patients who live in or have emigrated from areas of the world where Echinococcus granulosus is prevalent.

Bilateral superficial peroneal nerve entrapment secondary to anorexia nervosa: a case report.

We report a case of severe weight loss secondary to anorexia nervosa causing bilateral superficial peroneal nerve entrapment in a young female patient who was treated successfully by bilateral surgical decompression.

Intraneural hemangioma of the median nerve: A case report.

Hemangiomas of the median nerve are very rare and, so far, only ten cases of intraneural hemangioma of this nerve have been reported in the literature. We present a case of 14-year-old girl who had a soft tissue mass in the region of the left wrist with signs and symptoms of carpal tunnel syndrome. Total removal of the mass was achieved using microsurgical epineural and interfasicular dissection. The symptoms were relieved completely, after this procedure, without any neurologic deficit. On follow-up two years later, no recurrence was observed. Whenever a child or young adult patient presents with CTS the possibility of a hemangioma involving the median nerve should be kept in mind in the differential diagnosis.

Detection of parvovirus B19 in synovial fluids of patients with osteoarthritis.

We aimed to determine the possible role of parvovirus B19 (PVB19) in the etiology of osteoarthritis. PVB19 DNA, anti-VP1 IgM and IgG, and interleukin IL-6 levels were also assayed in synovial fluids of 42 patients with osteoarthritis and 10 controls. PVB19 DNA was detected in 28 of 42 (66.66%) in patients and in 3 of 10 (30%) in controls. IgG and IgM response were detected in 21 of 42 (50.00%) and in 2 of 42 (4.76%) patients, respectively. IL-6 were positive in 15 of 42 (36%) patients and in 3 of 10 (30%) controls. All IgG (+) samples had PVB19 DNA (100%, P < 0.001). Eleven of 15 IL-6 (+) samples had PVB19 DNA (+) (73.33%, P < 0.05). Moreover, all IL-6 (+) samples (n = 5) in stage IV had PVB19 DNA (+) (100%, P < 0.001). We have detected a significant association between the stages of osteoarthritis and PVB19 DNA (P < 0.05). These findings support the presence of PVB19 acting as a transactivator of IL-6 expression as reported earlier. Our results also suggest that the higher stages of osteoarthritis might be related to the increased inflammation and cell damage on joint cartilage due to PVB19.

Spontaneous rupture of ulnar nerve due to neglected cubital tunnel syndrome associated with rheumatoid arthritis.

A case of spontaneous rupture of the ulnar nerve due to neglected cubital tunnel syndrome associated with rheumatoid arthritis is reported. Earlier decompression and anterior transposition in this patient may have prevented nerve rupture.

Long-standing Morel-Lavallée lesion of the thigh simulating a neoplasm.

We report on the case of a 56-year-old man in whom a Morel-Lavallée lesion developed in the thigh. Ultrasound revealed a well-defined thick-walled cystic mass between the hypodermis and fascial planes that in some areas constituted hyperechoic papillar extensions in its wall. Magnetic resonance T(1)-weighted images showed that the mass was well circumscribed and mildly inhomogeneous and had a high signal intensity. On T(2)-weighted images, the mass had mixed signal intensity and a fluid-fluid level. We also discuss both the difficulty in making a differential diagnosis for and the treatment of this lesion.