Less malunion and shorter bone union time with titanium elastic nail treatment for isolated femoral shaft fractures in three- to six-year-old children.

PURPOSE: Titanium elastic nail (TEN) is a good option for femoral shaft fractures in school-age children, whereas a spica cast is favored for younger patients. We aimed to compare these treatment modalities in a group of children aged three to six years. METHODS: 34 patients aged 3-6 years with an isolated closed femoral shaft fracture treated with TEN or one-leg spica cast immobilization were retrospectively assessed. Age, gender, weight, mechanism of injury, hospital stay time, bone union time, radiographic shortening, malunion, and complications were compared between the treatment groups. RESULTS: 16 (47.1%) patients who were treated with TEN (Group T) and 18 (52.9%) patients with spica casting (Group S) were included with a mean of 51 (24-94) months follow-up. The mean age was 4.98 years and statistically similar between both groups (mean, 5.2 vs. 4.8 years; p = 0.234). The patients in Group T were heavier (mean, 19.3 vs. 17.2 kg; p < 0.001) and were more likely to have a higher-energy mechanism of injury (p = 0.006). The mean late femoral shortening of Group S patient's was 6.5 ± 3.5 mm and significantly higher than Group T, which was 2.0 ± 2.9 (p = 0.050). However, effective late femoral shortening rates were not statistically different between groups (p = 0.347). Malunion was seen in six (33.3%) patients in Group S, whereas none of the patients in Group T had malunion at the last follow-up examination and were statistically different (p = 0.011). CONCLUSION: Our study identified radiographic evidence favoring TEN over spica cast immobilization in treating preschool-age children with an isolated femoral shaft fracture in terms of malunion.

Entrapment of the brachial artery in the cancellous bone in pulseless supracondylar humerus fractures with well-perfused hands: Report of three cases.

Management of pediatric pulseless supracondylar humerus fractures is a point of continuous debate. In this article, we present three cases admitted to the emergency department with pulseless, but well-perfused hands. The fractures were reduced and fixed using the antecubital approach. Prior to reduction, the brachial arteries of all three patients were entrapped in the cancellous bone of the proximal fragment segment. The arteries could only be released after freeing the adventitia by carefully scraping the adjacent bone with the tip of a hemostat. One case required thrombectomy through an arteriotomy using No. 3 Fogarty catheter. In two cases, the pulse returned after a brief period of waiting with no need for vascular intervention. Proceeding with closed reduction, as proposed by the recent guidelines, would result in further damage to the entrapped vasculature, which may go unnoticed due to collateral circulation.

Forearm Compartment Pressure Change in Children Operated for Supracondylar Humerus Fracture.

BACKGROUND: The aim of this study is to examine the preoperative and postoperative forearm compartment pressures in patients treated operatively for Gartland type III extension type supracondyler humerus fractures and understand the course of these values over postoperative period. METHODS: Deep volar compartment pressure of 31 patients were measured in the proximal one third of the forearm preoperatively, and measurements were continued every 4 hours for the first 24 hours after the operation with a catheter. Type of the reduction technique (open reduction vs. closed reduction), duration of surgery, the time from the injury to surgery were all evaluated. RESULTS: In the measurements made immediately after the operation (0 h), a sudden increase in the compartment pressure was detected in all patients (15.0±5.9 to 27.9±7.5 mm Hg) independent of the reduction technique and gradually decreased over time. The mean compartment pressure at the 12th hour postoperatively was higher in the open reduction group than in the CR group (24.5±3.4, 20.7±6.7 mm Hg, respectively) ( P =0.044). The mean preoperative compartment pressure was 17.7±5.8 mm Hg in patients with a time from injury to surgery longer than 12 hours, and 12.4±4.8 mm Hg in patients with 12 hours or less ( P =0.006). The postoperative 0-, 12-, and 20-hour pressure values were higher in the >1 hour operation time group than in the ≤1 hour group and the differences were statistically significant ( P =0.046, 0.016, and 0.032, respectively). CONCLUSIONS: In pediatric supracondylar humeral fractures, those who underwent open reduction had higher preoperative and postoperative compartment pressures. The reduction attempt was found to be a factor that increased the compartment pressure and after the operation, the compartment pressure values decrease gradually. Prolonged operative time (>1 h) and increased time from injury to operative fixation (>12 h) were associated with higher compartment pressures. LEVEL OF EVIDENCE: Level II-prospective study.

Effect of bone morphogenic protein-2 and desferoxamine on distraction osteogenesis.

BACKGROUND: Angiogenesis is crucial for formation of a stable regenerate during distraction osteogenesis (DO). This experimental study evaluates if bone morphogenic protein-2 (BMP-2) and desferrioxamine (DFO), two agents which are known to induce neoangiogenesis in vivo, would increase angiogenesis and osteogenesis, and improve mechanical properties of bone regenerate in DO model. METHODS: Twenty-four tibias of 24 New Zealand rabbits were osteotomized and fixed with semi-circular fixators. Three groups of 8 animals were formed. BMP-2 soaked scaffolds were used in the first group, whereas daily local DFO injections were made in the second group. Subjects in the control group did not receive any agents during the surgery or in the distraction period. The rabbits in all three groups underwent distraction at a rate of 0.6 mm/day for 15 days following the 7-day latent period. Animals were sacrificed on day 38, and the tibia were harvested for histological and mechanical examination of the regenerate. RESULTS: All 24 rabbits survived the surgical procedure, and there were no side effects against the BMP-2 and local DFO. Three-point bending tests revealed a higher force (361 ± 267 N.) required for fracture in Group 1 (p: 0.018). Similarly, the bending moment in Group 1 (5.4 ± 4.0 Nmm) was significantly higher than the other groups (p: 0.021). There was no significant difference between the groups in terms of deflection and stiffness (p Ëƒ 0.05). Histologically, there was no statistical difference between the groups in terms of endochondral, periosteal, and intramembranous ossification and VEGF activity (p Ëƒ 0.05). CONCLUSION: BMP-2 and DFO stimulate angiogenesis by increasing VEGF activity. Angiogenesis is one of the most important mechanisms for the initiation and maintenance of new bone formation. Stimulation of angiogenesis in unfavorable biomechanical conditions may not be sufficient for ideal bone formation.

Effect of platelet-rich plasma on bone regenerate consolidation in distraction osteogenesis: An experimental study in rabbits.

OBJECTIVE: The aim of this study was to determine the effect of platelet-rich plasma (PRP) on bone regenerate consolidation in a rabbit model of distraction osteogenesis. METHODS: In this study, 12 male New Zealand rabbits weighing 1600 to 2000 g were used. All the rabbits were randomly divided into two groups (n = 6 per group): PRP group and control group. A two-ring, circular external fixator was applied to the right tibia of each rabbit in both groups. After corticotomy, all the tibiae were distracted at a rate of 0.5 mm/day for 20 days. PRP was injected to the osteotomy sites on the 7th, 14th, and 21st days postoperatively. Mineral density of the new bone tissue formed in the distraction zone was measured using quantitative computed tomography in the 3rd, 4th, and 5th weeks. At the end of the 6th week, the animals were sacrificed, and the specimens were evaluated biomechanically and histologically. RESULTS: Microcomputed tomography assessment showed significant bone mineral density increase from the 3rd to the 6th week (62.3% and 43.7% for the PRP and control groups, respectively). In the PRP group, the measurements on the 3rd, 4th, and 5th weeks were 416 ± 29, 487 ± 9.9, and 675 ± 37.8 HU (Hounsfield units), respectively, whereas in the control group were 313, 374, and 450 HU, respectively. In the comparison of weekly measurements of the two groups, the increase in bone density in the PRP group was higher than that in the control group (P < 0.001). During the mechanical tests, in the PRP group, the mean torsion was 46.50°and the mean torque 0.53 Nm, while in the control group, the mean torsion was 19.33°and the mean torque 0.65 Nm. The mechanical analysis of the groups revealed significant differences in the mean maximum torsion angles (P = 0.024). The histological examination showed that both groups had external and internal periosteal calli. Callus tissue in four rabbits in the PRP group and two rabbits in the control group was remodeled; normal bone formation occurred and distracted bone ends were completely healed. CONCLUSION: The results of the present study have indicated that PRP injection can enhance bone regenerate consolidation and increase bone mineral density during the healing process of distraction osteogenesis.

Minimally invasive plate osteosynthesis for short oblique diaphyseal tibia fractures: does fracture site affect the outcomes?

OBJECTIVE: To report the results of patients with short oblique diaphyseal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO). The secondary aim was to understand the effect of fracture location (midshaft or distal 1/3) on outcomes. METHODS: Twenty-eight patients with short oblique (>30°) tibial shaft fractures (AO/OTA 42A2) treated with plate and MIPO technique between 2015 and 2019 were retrospectively assessed. Age, gender, follow-up time, fracture type (open or closed), operation time, postoperative infection rate, union time, ankle joint range of motion, and complications were analyzed. Patients' radiographs at a minimum 1-year follow-up were evaluated for malunion, nonunion, and implant-related complications. RESULTS: Mean age and follow-up time were 47.0 ± 15.7 years and 18.3 ± 12.1 months, respectively. Mean bone union time was 3.66 ± 1.04 months in middle 1/3 diaphysis and 4.23 ± 1.48 months in distal 1/3 tibia fractures. Seven (25%) patients developed superficial infections. Mean union time, malunion rate, coronal and sagittal angulation, operation length, and infection rate were similar between the groups. CONCLUSION: MIPO is an effective method for treatment of short oblique diaphyseal tibia fractures, and results in few complications. Both distal and midshaft fractures have similar union and malunion rates.

COMPARISON OF RADIOFREQUENCY ABLATION AND CURETTAGE IN OSTEOID OSTEOMA IN CHILDREN.

OBJECTIVE: Osteoid osteoma, which is observed in the adolescent and young adult population as benign bone tumors, appears as a single nidus with a diameter < 2 cm and is treated with open surgery. However, technological advances in medicine have made it possible to apply less invasive procedures in surgery. METHODS: Between 2006-2014, 24 patients < 18 years of age were treated for osteoid osteoma. Patient demographic data, surgical data, complications, and recurrences were noted. RESULTS: Twenty-four patients (mean age, 11 [2-18] years) were treated and followed up for a mean 3.58 (range, 1-9) years. Mean patient age in the curettage group was 12.1 (range, 3-18) years. Mean operation length was 69.5 (range, 60-120) minutes. Mean hospital stay was 1.3 (range, 0-2) days. Mean patient age in the radiofrequency ablation (RFA) group was 10.7 (range, 2-17) years. Five patients were female and 8 were male. Mean operation length was 49.6 (range, 20-90) minutes. Mean hospital stay was 0.3 (range, 0-1) days. Mean follow-up time was 1.76 (range, 1-4) years. Mean operation length, hospital stay, and follow-up were significantly shorter in the RFA group. CONCLUSIONS: Considering reduced costs due to shorter hospitalization periods and the ability to reach anatomically difficult locations, percutaneous procedures are likely to replace the conventional open approach. Level of evidence: II, retrospective study.

OBJETIVO: O osteoma osteoide, tumor ósseo benigno, acomete predominantemente adolescentes e adultos jovens. É descrito como um nicho único menor que 2 centímetros e o tratamento, nas últimas décadas, era realizado por cirurgia aberta. Com os avanços tecnológicos na medicina, os procedimentos menos invasivos tornaram-se o tratamento de escolha. MÉTODOS: Entre 2006 e 2014, 24 pacientes com menos de 18 anos foram submetidos ao tratamento de osteoma osteoide. Foram coletados os dados demográficos da população estudada e as informações sobre a cirurgia, complicações e recorrência. RESULTADOS: Os vinte e quatro pacientes com média de idade de 11 anos (2-18) foram tratados e o acompanhamento teve média de 3,58 anos (1-9). A média de idade dos pacientes no Grupo curetagem foi de 12,1 anos (3-18). O tempo médio da cirurgia foi de 69,5 minutos (60-120). A média de permanência hospitalar foi de 1,3 dias (0-2). A média de idade dos pacientes no Grupo ARF foi de 10,7 anos (2-17) anos, sendo cinco do sexo feminino e oito do sexo masculino. O tempo médio de cirurgia foi de 49,6 minutos (20-90). A permanência hospitalar média foi de 0,3 dias (0-1). O tempo médio de acompanhamento foi de 1,76 anos (1-4). As médias de tempo cirúrgico, tempo de internação e acompanhamento foram significativamente menores no Grupo ARF. CONCLUSÕES: Quando a redução de custos promovida pelo menor tempo de hospitalização e a capacidade de atingir locais anatomicamente difíceis também forem considerados, os procedimentos percutâneos provavelmente substituirão a cirurgia aberta convencional. Nível de evidência II; Estudo retrospectivo.

The biochemical and histological analysis of subcutaneous calcitonin and intramedullary methylprednisolone on bone repair after bone marrow ablation: an experimental comparative study in rats.

BACKGROUND: Although, glucocorticoid (GC) and calcitonin-induced changes in bone repair have been studied previously, the exact effects of these on fracture healing remain controversial. Hence, the purpose of this experimental study is to determine biochemical and histological effects of locally administrated GC and systemically administrated calcitonin on the kinetics of healing response after bone marrow ablation in rats. METHODS: After having undergone marrow ablation, a steroid-treated group of rats (n = 24) received a single dose of intramedullary methylprednisolone (2 mg/kg), a calcitonin-treated group (n = 24) received intermittently administrated subcutaneous salmon calcitonin (16 IU/kg), and a control group (n = 24) received intramedullary saline (25 µl). RESULTS: Blood samples taken on days 1, 3, 7, 9, and 15 after ablation showed an increase in serum calcium, alkaline phosphatase (ALP), and phosphate levels in the Calcitonin and Control groups. Levels of calcium and ALP peaked on day 7 after ablation. However, an increase in phosphate levels indicated a biphasic reaction that peaked on the third and ninth day after ablation. Hypercalcemia was not observed in Steroid group because of the inhibition of osteoclastic bone resorption. In that group, the serum levels of ALP and phosphate were lower than baseline levels. The levels of urinary calcium excretion peaked 3 to 7 days after marrow ablation in the control group and 7 to 9 days after that procedure in the steroid group. Histologic evaluation showed that the rats in the control group demonstrated the expected healing period according to the histological grades and that a delay in healing occurred in the calcitonin group after day 9 because of the inhibition of osteoclastic bone resorption. All rats in the steroid group exhibited a decrease and delayed healing response. CONCLUSION: Total serum calcium, phosphate, and ALP levels increased after bilateral tibial bone marrow ablation and urine calcium and hydroxyproline excretion also increased as a factor of bone resorption. Subcutaneously administrated salmon calcitonin did not affect biochemical changes after marrow ablation. Single-dose intramedullary methylprednisolone inhibited extra-tibial bone resorption induced by cytokines after bone marrow ablation.

The effect of HIF stabilizer on distraction osteogenesis.

OBJECTIVE: The aim of this study was to investigate the effect of an orally applicable hypoxia-inducible factor (HIF) stabilizer on distraction osteogenesis (DO) in a rat model. METHODS: The study included 24 Wistar albino rats undergoing osteotomy of the left tibia diaphysis. Rats were divided equally into experiment and control groups. Tibias were fixed using an external fixator. HIF stabilizer was administered to the experiment group. On the 5th postoperative day, distraction with increased rate (0.4 mm twice a day) was commenced and continued for 10 days. Histological and immunohistochemical evaluation was performed. RESULTS: Vascular endothelial growth factor levels of the experiment group were higher than those of the control group (p<0.05). The experiment group had slightly better intramembranous ossification quality than the control group on both Day 16 and 30. Endochondral ossification rates were better in the experiment group on Day 16. CONCLUSION: Vascular endothelial growth factor levels increased and stimulated angiogenesis in the presence of HIF pathway activation by oral administration of HIF stabilizer during DO. The biomechanical features of the distraction and angiogenesis should be coupled to achieve adequate bone homeostasis.

Approach to supracondylar humerus fractures with neurovascular compromise in children.

OBJECTIVE: The aim of this study was to evaluate neurovascular compromise in childhood Gartland Type 3 supracondylar humerus fractures (SHFs), identify the factors correlated with increased need of open reduction and compare the clinical outcome of anterior open reduction with that of closed reduction. METHODS: The study included 65 patients (46 male, 19 female; mean age: 7.03 years, range: 1 to 14 years) treated surgically for SCH fracture between January 2002 and June 2008. Fractures underwent closed reduction with percutaneous pinning when possible. Open reduction was performed when adequate reduction via the closed technique failed or vascular compromise were indications for open reduction. Patient demographics, physical examination findings, adequacy of reduction, functional and cosmetic outcomes were assessed. RESULTS: During the antecubital approach, vascular pathology was noted in all patients with signs of vascular compromise at physical examination. Half of these patients underwent vascular intervention. Closed reduction failed in 93% of patients with concomitant edema, ecchymosis and dimple sign. Of these, the median nerve was trapped between the bone fragments in 4 patients with normal neurological examinations. Functional and cosmetic results of open reduction were similar to closed reduction (p>0.05). CONCLUSION: Closed reduction should not be forced in cases with marked edema, ecchymosis, dimple sign, and absence of radial pulse. The anterior approach is the surgical approach of choice due to direct visualization of neurovascular bundle and availability of neurovascular intervention by extending the same approach.

Neonatal osteofibrous dysplasia associated with pathological tibia fracture: a case report and review of the literature.

Osteofibrous dysplasia is a rare and benign disease that originates from the tibia or fibula. The symptoms of osteofibrous dysplasia include painless enlargement and bowing of the tibia and pain occurring in the presence of pathological fracture. Herein a male infant who was admitted with redness and swelling on the right leg and diagnosed as pathological tibia fracture due to left tibia osteofibrous dysplasia on the third day of life was presented. To our knowledge, this is the earliest presentation of osteofibrous dysplasia with a pathological fracture in a neonate. Therefore, it must be suspected in neonatal bone fractures.

The effect of nicotine on distraction osteogenesis: an experimental study on rabbits.

BACKGROUND: Tobacco smoke contains more than 4,000 constituents, but not all of them are reported to have adverse effects on bone healing after distraction osteogenesis. No research on the systemic administration of nicotine has been done on distraction osteogenesis of the weight-bearing long bones of the lower extremity. METHODS: Fourteen New Zealand white male rabbits underwent distraction osteogenesis on the right tibia and lengthening by 1 cm. Transdermal nicotine bands were applied onto the dorsal skin of the rabbits in the study group. Mineral density of the distraction zone was measured at weekly intervals using quantitative computerized tomography. Mechanical properties were assessed by torsional loading, and the regenerated bone tissue was subjected to histopathological examination. RESULTS: Comparisons of weekly measurements in both groups showed that while the increase in bone density in the nicotine group was higher, relative to the initial values, it was still far behind the average density obtained in the control group at the end of the experiment. Statistical analysis of mechanical data showed significant differences in the gradient of the regression lines and maximum torsional angles between the two groups. The histopathological assessments showed noticeable neovascularization in the study group, which was concluded to be a compensatory mechanism for the negative delaying effect of nicotine on bone healing. CONCLUSION: Systemic administration of nicotine can cause delays in the process of healing in distraction osteogenesis by its negative effect on the mineralization of the regenerate. Patients should be made aware of this negative impact of nicotine before the limb-lengthening surgery.

A comparison of percutaneous and mini-open techniques of Achilles tenotomy: an experimental study in rats.

PURPOSE: To investigate the effect of Achilles tenotomy performed percutaneously and by mini-open methods on tendon healing and final strength. MATERIALS AND METHODS: In two groups, each consisting of 14 rats, percutaneous and mini-open techniques in Achilles tenotomy were compared in terms of biomechanical, histological and gross properties. RESULTS: In the gross evaluation, it was observed that an obvious thickening and adhesion to the subcutaneous tissue of the healing tendon were observed in nearly all rats in which the mini-open technique was performed. In the biomechanical analysis, there was no significant difference between percutaneous and mini-open groups and between operated and intact Achilles tendons in both groups, in terms of tendon strength (P > 0.05). In the histological evaluation, irregularity in the parallel pattern of the collagen fibres, emergence of a non-specific collagenous tissue formation and infiltration of mild mononuclear inflammatory cells were reported. These changes were more marked in the rats in which the percutaneous technique was performed. CONCLUSION: Mini-open technique for Achilles tenotomy may be considered as an alternative method of treatment to apply the tenotomy technique in a secure way. CLINICAL RELEVANCE: There are two basic advantages of Achilles tenotomy performed by the mini-incision open technique: (1) a complete tenotomy is guaranteed, as it has to be in the original Ponseti technique, (2) iatrogenic neuro-vascular injury risk is nearly completely avoided due to the subparatenon exploration of the tendon and direct visual observation during the transection. The mini-open technique may only be used in cases in which a vascular compromise is clinically suspected or confirmed by Doppler ultrasonography and/or arteriography. On the other hand, the technique may be performed in all cases routinely by the choice of the surgeon.

[The effect of tibial lengthening on gastrosoleus muscle function: an electrophysiological study].

OBJECTIVES: We evaluated the changes in electrophysiological characteristics of the contraction forces of the gastrosoleus complex due to stretching in experimental tibial lengthening. METHODS: Distraction histiogenesis was performed in 22 guinea pigs weighing 600 to 800 g. Following the application of a semicircular external fixator and right tibial osteotomy, distraction was applied at a rate of 0.25 mm two times a day for 15 days without a latency period. The animals were randomized to two groups. In the study group, a foot plate preventing ankle plantar flexion was affixed to the external fixator, while ankle motions were unrestricted in the control group. On days 5, 10, and 15, the posterior tibial nerve was stimulated with a nerve stimulator at a constant frequency. Gastrosoleus muscle contractions were measured with a transducer and contraction forces were recorded. RESULTS: On day 5, muscle contraction forces measured in the study group were much higher than the control group (p<0.05). On day 10, however, muscle contraction forces showed a rapid decline in the study group and, at the end of the study, muscle contraction forces decreased by 81% compared to the baseline values (p<0.05). Yet, throughout the study period, muscle contraction forces were always higher than the control group (p<0.05). In addition, the rate of the decrease in muscle strength slowed down after day 10 in the study group, and gastrosoleus function and strength were much better preserved. Equinus deformity developed progressively in the ankles of the control animals whose muscle contraction forces also showed significant decreases during the experiment (p<0.05). CONCLUSION: In clinical applications of tibial lengthening, the strength of the gastrosoleus complex should be preserved to prevent equines deformity and maintain ankle functions. This can be achieved through gradual stretching of the muscle during distraction. If there is shortening before surgery or muscle stiffness is expected during lengthening, measures should be taken before distraction osteogenesis and muscle length should be preserved.

Humoral immunodeficiency in congenital insensitivity to pain with anhidrosis.

Congenital insensitivity to pain with anhidrosis (CIPA) is an autosomal recessive disorder caused by mutations in the neurotrophic tyrosine receptor kinase 1 (NTRK1) gene, which encodes the receptor for nerve growth factor. We report the clinical course of a 7-year-old girl with CIPA and proven NTRK1 mutation. In addition to recurrent dislocation of the left hip joint and avascular necrosis of the left talus, the patient also presented with recurrent infections secondary to hypogammaglobulinemia, a feature not previously known to be associated with CIPA. The patient was treated with regular administration of intravenous immunoglobulins. Conservative treatment of the recurrent left hip dislocation by cast immobilization and bracing was implemented to stabilize the joint. The implication of the immune system of the reported patient broadens the clinical phenotype associated with NTRK1 mutations.

Enhancement of tendon-bone healing of anterior cruciate ligament grafts by blockage of matrix metalloproteinases.

BACKGROUND: The use of soft-tissue grafts for anterior cruciate ligament reconstruction delays the healing process. This delay may be due to biochemical and/or biomechanical insults. We hypothesized that the blocking effect of alpha2-macroglobulin on synovial matrix metalloproteinase activity may enhance the healing of tendon graft in a bone tunnel. METHODS: The study was performed on twenty-eight healthy, skeletally mature New Zealand White rabbits. Each rabbit underwent bilateral anterior cruciate ligament reconstruction with use of the ipsilateral semitendinosus tendon. Alpha-2-macroglobulin (alpha2-macroglobulin) was injected into the knee joint in one limb, and the contralateral limb served as a control. The rabbits were killed two weeks (fourteen rabbits) or five weeks (fourteen rabbits) after the operative procedures. The presence of matrix metalloproteinases in synovial fluid, and the blocking effect of alpha2-macroglobulin on them, were determined with enzymatic assays. Healing between the tendon and the bone tunnel was assessed morphologically by determining the presence of fibrovascular tissue and collagen fibers. Healing also was assessed quantitatively by measuring the ultimate load to failure of the reconstructed complex. RESULTS: There was an increase in matrix metalloproteinases in the control group; in contrast, there was a decrease in the study group (p < 0.05). In the control specimens, the fibrovascular tissue at the bone-tendon interface had developed into dense connective tissue with poor vascularization. In the treated specimens, the bone tunnel had more areas of denser connective-tissue ingrowth. The interface tissue was more mature and contained numerous perpendicular collagen bundles (Sharpey fibers). The ultimate load to failure was significantly greater in the alpha2-macroglobulin-treated specimens than in the untreated controls at both two and five weeks. CONCLUSIONS: The present study demonstrated that alpha2-macroglobulin blockade of matrix metalloproteinases can enhance bone-tendon healing. This effect of alpha2-macroglobulin could occur through its effect solely on collagenase or on a subset of matrix metalloproteinases that are present at the healing interface.

The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation.

Osgood-Schlatter disease (OSD) is a well-described clinical condition, although its origin remains controversial. Mechanical, growth or traumatic factors are suggested as causes of this lesion. Thirty-five patients were included in this study. Twenty of them had OSD (study group) and the remaining 15 adolescents constituted the control group. Magnetic resonance imaging of the knees was performed in all patients. The distance between the distal pole of the patella and the proximal margin of patellar tendon attachment to the tibial apophysis (A), the distance between the distal pole of the patella and the tibial tubercle epiphysis (B), the distance between the proximal margin of the patellar tendon attachment to the tibia and the tibial tubercle epiphysis (C) and the distance between the knee joint level and the tibial tubercle epiphysis (D) were measured. The ratio of the distance between the distal pole of the patella and the proximal margin of the patellar tendon attachment to the tibia to the distance between the distal pole of the patella and the tibial tubercle epiphysis (A : B) was lower in the study group. The ratio of the distance between the proximal margin of the patellar tendon attachment point to the tibia and the tibial tubercle epiphysis to the distance between the knee joint level and the tibial tubercle epiphysis (C : D) was higher in the control group. We conclude that if the patellar tendon attaches more proximally and in a broader area to the tibia, this might probably cause OSD.

[Necrotizing fasciitis in the lower extremity secondary to diabetic wounds]. / Bacakta diyabetik yaralara bagli nekrozitan fasiit.

OBJECTIVES: The aim of this retrospective study was to evaluate patients who developed necrotizing fasciitis (NF) in the lower extremity secondary to diabetic wounds. METHODS: The study included sixteen patients (11 men, 5 women; mean age 63 years; range 50 to 82 years) who were treated for NF arising from diabetic wounds. Associated diseases were coronary heart disease in three patients, and chronic renal failure due to diabetic nephropathy in three patients. The patients were evaluated by physical examination, direct radiographs, blood pressure measurements, and cultures, and with respect to treatment methods and results. The mean hospitalization period was 26 days (range 5 to 59 days). RESULTS: Necrotizing fasciitis was confined to the leg in four patients, extended to the thigh in 10 patients, and was bilateral in two patients. Pain was encountered in 10 patients (68.8%). Fourteen patients (87.5%) had increased creatine kinase levels. Direct radiographs showed gas appearance in soft tissues in seven patients (43.8%). Cultures showed a single microorganism in four patients (25%), and multiple microorganisms in five patients (31.3%). Of seventeen microorganisms isolated, 10 (58.8%) were Enterobacter species. Eleven patients (68.8%) underwent above-the-knee, and three patients (18.8%) underwent below-the-knee amputations. Disarticulation of the hip was performed in four patients. The mean number of debridements was five (range 2 to 21) following the initial surgical intervention. Nine patients developed septic shock. Seven patients (43.8%) died due to multiple organ failure. Increased creatine kinase levels were significantly associated with mortality (p<0.05). CONCLUSION: Early and accurate diagnosis and prompt surgical treatment may be life-saving in diabetic patients with NF of the lower extremity.

The effect of alpha-2 macroglobulin on the healing of ruptured anterior cruciate ligament in rabbits.

To investigate the effect of modification of biological environmental conditions, one of the factors influencing the healing of anterior cruciate ligament rupture, we performed experimental anterior cruciate ligament ruptures on New Zealand rabbits. After experimental rupture, intra-articular alpha-2 macroglobulin was injected into the knees of the rabbits in the experiment group to prevent structural changes resulting from the enzymatic reactions in the ruptured anterior cruciate ligament. At the end of 10th day of the experiment, we observed that the anterior cruciate ligaments in the experiment group had retained their prerupture brightness and volume when compared with the control group in which intraarticular alpha-2 macroglobulin had not been injected. We also noted that the anterior cruciate ligaments in the experiment group had not retracted or swollen, the incision sites were regular and clean, and they did not show any signs of degeneration. In the histological examination, the anterior cruciate ligaments in the control groups showed disruption of the collagen network and a significant diminution in number of fibroblasts and fibrocytes (p <.001). At the end of this study, we concluded that the necessary conditions for the healing and repair of ruptured anterior cruciate ligament could exist if the enzymatic and biological environments were under control.

Extremity injuries in children resulting from the 1999 Marmara earthquake: an epidemiologic study.

The purpose of this study was to determine the clinical features, type and severity of musculoskeletal injuries in paediatric age groups in comparison with adult victims of the Marmara earthquake, which occurred on 17 August 1999. Of 151 injured patients hospitalized due to musculoskeletal trauma, 31 (20.5%) were under 16 years of age. The most important problems in the patients were extremity trauma, crush syndrome, acute renal failure and other ensuing medical complications. Five (18.5%) out of 27 children with crush syndrome required haemodialysis because of acute renal failure and three (11.1%) required amputation. Haemodialysis was needed in 54 (93.1%) of 58 adult patients with crush syndrome; amputation was necessary in 12 (20.7%) of them. Although the types of injuries resulting from the earthquake were similar in adults and children, the orthopaedic consequences of these injuries showed significant differences, especially in the rates of crush syndrome leading to acute renal failure and amputation.