Heterotopic ossification on the volar surface of the distal radius in a child with fibrodysplasia ossificans progressiva: challenges in surgical excision of a rare condition.

Fibrodysplasia ossificans progressiva (FOP) is one of the genetic and developmental forms of heterotopic ossification. We report a case of FOP on the volar surface of the distal radius, located close to the median nerve and radial artery with neurologic symptoms secondary to median nerve entrapment. The patient underwent surgical excision of the heterotopic lesion followed by radiation therapy. He had no signs of recurrence with more than 1 year of follow-up. Careful microsurgical dissection of the heterotopic mass must be performed to prevent the formation of new painful lesions and iatrogenic neurovascular injury. In this syndrome, the possibility of nerve entrapment due to the heterotopic lesion should be considered as the cause of neuropathic pain. Early genetic testing for confirmation of the suspected diagnosis can avoid having to do an unnecessary biopsy.

Investigation of the Optimal Interval for Staged Total Knee Arthroplasty for the Treatment of Advanced Bilateral Gonarthrosis.

PURPOSE OF THE STUDY This study investigated whether there was an optimal interval between two operations for total knee arthroplasties in patients with advanced bilateral gonarthrosis scheduled to undergo staged total knee arthroplasty (TKA). MATERIAL AND METHODS A prospective cohort of 219 patients (136 females, 83 males) undergoing staged total knee arthroplasty for the treatment of advanced bilateral gonarthrosis were followed for up to 12 months. The mean was 69.51±5.02 (56-80) years. Patients were categorized into five groups based on the time between the first and second operations; Group I (21-90 days), Group II (91-180 days), Group III (181-270 days), Group IV (271-360 days), and Group V (more than 360 days). Patients were evaluated based on time from surgery and were assigned to corresponding groups. The data recorded included age, body mass index (BMI), side of operated knee, complications, and radiological and clinical findings. Visual analog scale (VAS) for non-operated knees was applied. Activities of Daily Living Score (ADLS) was applied to the patients at last follow-up. RESULTS No statistically significant difference was noted in BMI values (p=0.634), range of joint motion (RJM) (p=0.940) and age (p=0.785) distribution between the five groups. In Group I, the mean VAS score increased by 7.83 to 7.98, 7.86 to 8.53 in Group II, by 7.85 to 8.54 in Group III, 7.85 to 8.59 in Group IV, and 7.88 to 8.64 in Group V. There was no statistically significant difference in preoperative ADLS between the groups (p=0.064), but there was a statistically significant difference in postoperative ADLS (p=0.001). Group I patients had significantly lower postoperative ADLS compared to the other groups (p=0.001). The mean increase in postoperative ADLS versus preoperative scores of all groups were statistically significant The most significant improvements occurred in Groups II and III. Similarly, preexisting pain in the non-operated knee started to increase in Group II and continued in all groups. DISCUSSION Given all these findings, we believe that it is reasonable to advise patients to receive their second TKA, 3-6 months after their initial TKA, as this interval will allow for the greatest improvements in functional and daily living activities, and pain in the non-operated knee simultaneously becomes more severe. This recommended interval would minimize both the functional problems with the operated extremity due to pain, and deformity and dysfunction in the non-operated knee and the subsequent overloading. CONCLUSIONS Even though a number of factors influence the optimal interval for staged TKAs in bilateral gonarthrosis, an interval of 91-270 days appears to be the optimal interval between surgeries in terms of minimizing pain and maximizing ADL s and knee scores. Key words: bilateral total knee arthroplasty, optimal interval, knee society scores, activities of daily living.

The anatomical relationship of the neurovascular structures in direct posterior lateral gastrocnemius split approach for posterolateral tibial plateau fractures.

PURPOSE: To evaluate the distances between the incision and neurovascular structures in direct posterior split-gastrocnemius approach for tibial plateau fractures. METHODS: Thirteen fresh-frozen cadavers were used in the study. The distance between the neurovascular structures medial and lateral to the incision was measured from the tibial joint line and at a level 5 cm distal to the joint line. RESULTS: The mean distance between the incision and medial neurovascular structures was 10.09 ± 3.47 mm (range 5.63-16.51 mm) at the level of the tibial joint line and 10.39 ± 2.57 mm (range 5.79-14.09 mm) at a level 5 cm distal to the joint line. The mean distance between the incision and the common peroneal nerve was 13.44 ± 4.17 mm (range 6.28-20.72 mm) at the level of the tibial joint line and 19.56 ± 5.24 mm (range 12.58-26.74 mm) at a level 5 cm distal to the joint line. CONCLUSIONS: In isolated posterolateral tibial plateau fractures, it is possible to apply anatomical reduction and buttress plating on the posterior surface with a direct posterior split-gastrocnemius approach. With a thorough understanding of the regional anatomy, this approach can be safely performed by experienced orthopaedists.

The effect of maternal nutrition level during the periconception period on fetal muscle development and plasma hormone concentrations in sheep.

The effect of maternal nutrition level during the periconception period on the muscle development of fetus and maternal-fetal plasma hormone concentrations in sheep were examined. Estrus was synchronized in 55 Karayaka ewes and were either fed ad libitum (well-fed, WF, n=23) or 0.5×maintenance (under-fed, UF, n=32) 6 days before and 7 days after mating. Non-pregnant ewes (WF, n=13; UF, n=24) and ewes carrying twins (WF, n=1) and female (WF, n=1; UF, n=3) fetuses were removed from the experiment. The singleton male fetuses from well-fed (n=8) and under-fed (n=5) ewes were collected on day 90 of gestation and placental characteristics, fetal BWs and dimensions, fetal organs and muscles weights were recorded. Maternal (on day 7 after mating) and fetal (on day 90 of pregnancy) blood samples were collected to analyze plasma hormone concentrations. Placental characteristics, BW and dimensions, organs and muscles weights of fetuses were not affected by maternal feed intake during the periconception period. Maternal nutrition level did not affect fiber numbers and the muscle cross-sectional area of the fetal longissimus dorsi (LD), semitendinosus (ST) muscles, but the cross-sectional area of the secondary fibers in the fetal LD and ST muscles from the UF ewes were higher than those from the WF ewes (P<0.05). Also, the ratio of secondary to primary fibers in the ST muscle were tended to be lower in the fetuses from the UF ewes (P=0.07). Maternal nutrition level during the periconception period did not cause any significant changes in fetal plasma insulin and maternal and fetal plasma IGF-I, cortisol, progesterone, free T3 and T4 concentrations. However, maternal cortisol concentrations were lower while insulin concentrations were higher in the WF ewes than those in the UF ewes (P<0.05). These results indicate that the reduced maternal feed intake during the periconception period may alter muscle fiber diameter without affecting fiber types, fetal weights and organ developments and plasma hormone concentrations in the fetus.

Comparison of different femoral fixation implants and fit techniques for tunnel widening and clinical outcome in ACL reconstruction using hamstring autograft.

PURPOSE: The purpose of the current study is to investigate in different femoral fixation devices whether tight (undersize drilled) fit technique decreases the tunnel widening and improves the clinical outcome compared to conventional technique in ACL reconstruction using hamstring tendon autograft. METHODS: 93 patients, who underwent Arthroscopic ACL reconstruction whether cortical-cancellous suspension (CP) or cortical suspension (BF) used as fixation device for the hamstring tendon autograft, were included in the study. The cases also grouped as undersize drilled (tight fit) and normal drilled (normal fit) according to their autograft size. There was no difference in demographic data of these four subgroups (CP-TF, CP-NF, BF-TF, and BF-NF) preoperatively. RESULTS: The patients, who had been followed for at least 2 years were included in the study. They were looked for their clinical outcome (Lysholm and IKDC scoring), tunnel widening (on AP and lateral radiographs), and also anterior translation. The BF-TF subgroup showed significantly the best clinical results compared to other three subgroups. There was no difference between BF-TF, CP-TF, and CP-NF in terms of tunnel widening. CONCLUSION: Button fixation of femoral side in ACL reconstruction surgery has good clinical outcome and lower complication rate. Undersize drilling might be preferred in button fixation in order to reduce TW and improve stability and clinical satisfaction. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

The effect of maternal nutritional status during mid-gestation on placental characteristics in ewes.

The aim of this study was to determine the effects of maternal nutritional status during mid-gestation on placental characteristics in ewes. Time of estrus of 3-5 years old Karayaka breed ewes was synchronized and mating was monitored to determine the day 0 of gestation. The ewes had similar body weights (47.8±0.7kg) and loin eye muscle values (thickness; 20.9±1.0mm and fat thickness; 4.7±0.5mm) at mating. The ewes were allocated into two treatment groups at day 30 of gestation; under-fed (UF; n=12) and well-fed (WF; n=13) groups. The ewes in UF group were fed with a diet to provide 50% of their daily requirement from day 30 to day 80 of gestation and 100% of their daily requirement during the rest of the gestation period. The ewes in WF group were fed at least 100% of their daily requirement throughout gestation. The singleton bearing ewes in the UF group had a lesser (P<0.05) placental weight (354.1 compared with 378.3g), average cotyledon weight (1.50 compared with 1.82g) and lamb birth weight (3.8 compared with 4.2kg) than singleton bearing ewes in the WF group. There were positive correlations between placental weight and lamb birth weight (r=.469; P<0.05), placental weight and average cotyledon weight (r=.695; P<0.01), average cotyledon weight and lamb birth weight (r=.742; P<0.01) and placental efficiency and cotyledon density (r=.853; P<0.01) for ewes in WF group. Additionally, the pattern of weight gain/loss was different (P<0.05) between the two groups. Ewes in UF group lost body weight progressively from day 30 of gestation until day 80. The results of present study show that under-feeding of ewes during mid-gestation may cause an insufficient placental development and hence alter fetal development resulting in a reduced birth weight from singleton pregnancies.