Plantaris Tendon Autograft Can Restore Patellar Stability in Adolescent Medial Patellofemoral Ligament Reconstruction: A Technical Note.

Medial patellofemoral ligament reconstruction is a standard treatment option for patients with patellar instability. The main purpose of this study was to determine whether isolated anatomic medial patellofemoral ligament reconstruction using double folded, four-strand plantaris tendon autograft restores patellar stability in adolescent patients. Plantaris tendon autografts were harvested through proximal approach and used in four adolescent patients. A four-strand autograft was prepared in a double-limbed configuration and fixed on the patella and the femur with suture anchors and interference screws, respectively. The mean Kujala score improved significantly from 44 ± 24 SD (range, 19 to 69) points preoperatively to 94 ± 10 SD (range, 78 to 100) points postoperatively (P< 0.001). All patients reported excellent subjective outcomes and returned to their pre-injury level of sporting activities. The use of a four-strand plantaris tendon autograft in isolated anatomic medial patellofemoral ligament reconstruction can restore patellar stability in adolescents.

Tibial tuberosity-tibial intercondylar midpoint distance measured on computed tomography scanner is not biased during knee rotation and could be clinically more relevant than current measurement systems.

PURPOSE: The purpose of this retrospective cross-sectional case-control study was to evaluate an alternative imaging test for lateralization of the tibial tuberosity, unbiased towards knee rotation. METHODS: On axial CT images of 129 knees, classified as cases (two or more patellar luxations) and controls (no patellar luxations), two raters gauged the standard tibial tuberosity-trochlear groove (TT-TG) distance, tibial tuberosity-femoral intercondylar midpoint (TT-FIM) distance, and new tibial tuberosity-tibial intercondylar midpoint (TT-TIM) distance singly, and knee longitudinal rotation angles (LRAs), and the presence of femoral trochlear dysplasia (FTD) jointly. RESULTS: All imaging tests intercorrelated and discriminated between stability groups. TT-TIM had the lowest values with the highest precision. Though poorly, TT-TG and TT-FIM negatively correlated with age and LRAs regarding femur, but positively with presence of FTD, whereas TT-TIM was unbiased. The accuracy of TT-TG (> 20 mm), TT-FIM (> 20 mm), and TT-TIM (> 13 mm) was good with almost perfect reproducibility. Only TT-TIM was sex-biased (p = 0.009), with > 12 mm cut-off in females and (presumably) > 14 mm in males. CONCLUSION: TT-TIM is an alternative imaging test for lateralization of the tibial tuberosity, unbiased towards knee rotation.

Plantaris tendon: a novel graft for anterolateral ligament reconstruction and additional reinforcement for anterior cruciate ligament autografts in combined reconstructive procedures.

The anterolateral ligament is recently recognized as an important structure in restoring rotational stability of the anterior cruciate ligament-deficient knee. Biomechanical and clinical studies confirmed the benefits of concurrent anterior cruciate ligament and anterolateral ligament reconstruction. However, present techniques mostly use hamstring tendons autografts and therefore additionally disrupt the knee biomechanics. The plantaris tendon is a well known and accessible graft and has excellent biomechanical properties for anterolateral ligament reconstruction. The present paper describes a new combined anterior cruciate ligament and anterolateral ligament reconstruction technique using plantaris tendon and semitendinosus tendon.Level of evidence V (Case report).

The physiological range of the Böhler's angle in the adult Croatian population.

BACKGROUND: To examine the relationship of the Böhler's angle with age, sex, and laterality, and to analyze the interrater agreement. METHODS: After 248 digital lateral radiographs of the foot were submitted to exclusion criteria, three raters independently measured the Böhler's angle on the remaining 130 X-rays in PACS. The variables were analyzed with correlation coefficients, and one-way ANOVA. The repeated measures of ANOVA were computed across age groups (30-39, 40-49, 50-59, and 60-69 years). The interrater agreement was calculated using intraclass correlation coefficient (ICC). RESULTS: The mean value of the Böhler's angle was 34±5° (21-46°). It was not related to age (in general [p=0.057], and across groups [p from 0.107 to 0.122]), sex (p=0.344; p=0.342), and laterality (p=0.618; p=0.617). The interrater reliability was almost perfect (ICC=0.94). CONCLUSIONS: The Böhler's angle was not related to age, sex, and laterality, whereas the interrater agreement was almost perfect.

A new reference line in diagnosing a high-riding patella on routine digital lateral radiographs of the knee.

OBJECTIVE: To propose a new reference line in diagnosing a high-riding patella (patella alta) on routine digital lateral radiographs of the knee. MATERIALS AND METHODS: On 64 routine digital lateral radiographs of adult knees with no bone pathology or surgery and over the range of knee flexion between 1.6° and 79.1° (34.4°± 16.6°), the long axis of the superimposed egg-shaped femoral condyles was drawn and moved upward to pass through the point where the posterior contours of the femoral diaphysis and the femoral condyles meet-the posterior reference point-to become a new reference line. Any part of the patella crossing the new reference line indicated a high-riding patella. The new reference line was compared with the four most common patellar height ratios (Insall-Salvati, Grelsamer-Meadows or the modified Insall-Salvati, Caton Deschamps, and Blackburne-Peel) for the drawing time, accuracy, and reproducibility (intra- and interobserver agreement). RESULTS: The new reference line required approximately one-third to one-half of the drawing time compared to the most common patellar height ratios, with equal accuracy and complete reproducibility. On the contrary, the reproducibility of the most common patellar height ratios ranged from poor to moderate, with the best results for the Insall-Salvati ratio. CONCLUSIONS: The new reference line proved to be a very simple, accurate, and reproducible tool in diagnosing a high-riding patella. We believe that our preliminary results are an encouraging impetus to more complex research.

[Flexion and version of the uterus on pelvic ultrasound examination]. / Fleksija I verzija maternice na ultrazvucnon pregledu zdjelice kroz trbusnu stijenku.

In the longitudinal (sagittal) plane, the angle between the axis of the uterine body and the cervix defines the flexion, whereas the angle between the axis of the cervix and the axis of the vagina defines the version of the uterus. In that regard, there are four uterine positions in the pelvis: anteflexion, retroflexion, anteversion and retroversion. The anteflexion with anteversion of the uterus is considered the natural position of the uterus in the pelvis. The transabdominal ultrasound examination of the female pelvis is most frequently performed if, for any reason, it is not possible to make a more appropriate transvaginal ultrasound examination. Suprapubic region is scanned with a high-frequency convex transducer in the longitudinal and transverse plane. The prerequisites for appropriate ultrasound examination are the filled urinary bladder, optimal quality of the ultrasound image, consistency in the sonographic technique and excellent knowledge of echomorphology of the pelvic organs. The commonest of the less common variants of the uterine position is retroflexion with retroversion. Although sometimes related with serious problems during childbirth as well as miscarriage, it usually does not cause any major problems. Yet, data on the uterine position may help the clinician in planning of various procedures.

Comparison of positions of the trochlear groove line and the vertical midline of the pericondylar rectangle on axial computed tomography: a retrospective pilot study.

OBJECTIVE: To compare the positions of the trochlear groove (TG) line and the vertical midline of the pericondylar rectangle on axial computed tomography (CT). MATERIALS AND METHODS: A retrospective pilot study was conducted in February and March 2011 comprising 14 knees in 9 consecutive patients with patellofemoral pain, a normal trochlear angle (124°-145°), and no medical record of prior knee surgery. After the axial CT image displaying the center of the trochlear groove ("reference cut") with a normal trochlear angle was identified, the pericondylar rectangle was drawn and located in the first quadrant of the Cartesian rectangular coordinate system. The x-coordinates of the vertical lines passing through the most posterior point of the trochlear groove (TG line) and the midpoints of the horizontal sides of the pericondylar rectangle (vertical midline) were obtained at 2-week intervals and statistically analyzed as matched pairs for differences (Wilcoxon signed rank test), agreements (Bland-Altman plot, intraclass correlation coefficient [ICC]) and relative variations (coefficient of variation [CV]). RESULTS: There were no statistically significant differences between matched pairs (2-tailed p from 0.583 to 0.641) whereas the agreements were substantial (bias = -0.37 and -0.45 respectively, ICC = 0.688 and 0.670 respectively) to almost perfect for duplicate measurements (bias = 0.11 and 0.04 respectively, ICC = 0.975 and 0.998 respectively), with much less relative variation with regard to the vertical midline (CV = 1.22% to CV = 0.34% respectively). CONCLUSION: The positions of the TG line and the vertical midline of the pericondylar rectangle on axial CT were identical. The latter was identified regardless of trochlear morphology.

Self-reported confidence, attitudes and skills in practical procedures among medical students: questionnaire study.

The aim of our study was to investigate the influence of gender, loss of academic year(s), confidence and attitudes of students on the clinical experience gained by undergraduate education. The survey was conducted during 2004 and 2005 in a sample of 182 students of the 5th and the 6th year at J.J. Strossmayer University School of Medicine in Osijek. The participants were grouped and matched according to their gender, regular studying, the number of time(s) student has performed certain practical medical procedure and the self-confidence arisen by performing one. Furthermore, participants were grouped and compared due to their own assessment of their own practical and theoretical medical knowledge, courses which provide them the least and oppositely--the most practical medical knowledge and their attitude toward current medical faculty curriculum on clinical courses as well as the possibilities of improving them. Fisher's exact test and chi2-test were used to estimate statistical differences between the groups and the parameters in research, while coefficient of contingency was introduced with the aim of defining their correlation. The results showed statistically significant differences between male students who performed more practical medical procedures than female (p < 0.001), non-repeaters performed medical procedures more often than repeaters (p < 0.001, C = 0.658) while repeaters thought higher of their theoretical knowledge than non-repeaters (p < 0.005). Data analysis showed statistically significant correlation between clinical experience and the level of confidence (C = 0.944). This study confirmed influence of male gender, regular studying, better opinion about one's own practical skills and higher confidence in one's own work on greater number of clinical skills performed during undergraduate education.

Comparative study of the efficacy and tolerability of two vaginal progesterone formulations, Crinone 8% gel and Utrogestan capsules, used for luteal support.

OBJECTIVE: To compare the efficacy and tolerability of two different types of vaginal progesterone (P), Crinone 8% gel (Fleet Laboratories Ltd., Watford, United Kingdom) and Utrogestan capsules (Laboratories Besins International, Paris, France), used for luteal support after in vitro fertilization (IVF) cycles. DESIGN: Cohort study. SETTING: In Vitro Fertilization Polyclinic, Zagreb, Croatia. PATIENTS: A total of 285 women aged < or =37 years undergoing IVF-embryo transfer treatment. INTERVENTIONS: Patients were treated with either Crinone 8% vaginal P gel (90 mg) administered daily, or Utrogestan vaginal capsules (2 x 100 mg) administered three times daily. Progesterone was administered from the day of oocyte retrieval (day 0) to menses or, in a case of pregnancy, until week 12. MAIN OUTCOME MEASURE: Clinical pregnancy rate. The tolerability and acceptability of both preparations were determined by a questionnaire given to patients. RESULTS: The similar rates of clinical pregnancies (33.1% vs. 30.9%) [corrected] were obtained by using either Crinone 8% vaginal P gel or Utrogestan vaginal capsules. Overall tolerability and acceptability were significantly better in the Crinone group than in the Utrogestan group. CONCLUSIONS: The efficacy of the two vaginal P formulations was nearly the same, but the tolerability and acceptability of Crinone 8% gel were superior, in the opinion of patients.