IMPACT OF CEMENTLESS ZWEYMÜLLER STEM ANTEVERSION ON RESISTANCE TO PERIPROSTHETIC FRACTURE IN TOTAL HIP ARTHROPLASTY.

Total hip arthroplasty implies proper orientation of both acetabular and femoral components with a range of 25-40° of combined anteversion. The aim of the study was to examine resistance to periprosthetic fracture of the axially loaded cross section rectangular femoral stem (Zweymüller) with respect to different degrees of anteversion, implanted in the artificial bone model, in laboratory conditions. Femoral bone models with implanted femoral stems were divided into 3 groups depending on the degree of stem anteversion (A, control group 13-17°; B, stem retroverted 0°-4°; and C, stem anteverted 26-30°). The amount of axial load leading to periprosthetic fracture (PPFx) of the artificial bone model was determined experimentally for each construct. The results showed that the load at which the PPFx occurred significantly increased with the increase of the endoprosthesis anteversion angle. In our clinical practice, we are often unable to place the acetabular component in an ideal grade of anteversion for intraoperatively determined reasons. The results of this experimental study suggested that increasing rectangular femoral (Zweymüller) stem anteversion lowered the risk of PPFx. This study was limited by experimental design (laboratory conditions, artificial bone) and should be clinically verified.

HIP ARTHROSCOPY: RESIDUAL CAM DEFORMITY COMBINED WITH LOOSE BONY FRAGMENT IN HIP CAPSULE.

Hip arthroscopy is a minimally invasive, effective and innovative orthopedic procedure with a relatively low rate of complications. In our patient, residual cam deformity and a bone fragment that remained in the front hip capsule after hip arthroscopy performed three years before caused thigh numbness, muscle fasciculations, and paresthesia. It was assumed that the loose bony fragment remained following burring on prior procedure. During hip flexion, neural structures were compressed and caused the mentioned symptoms. Revision hip arthroscopy was performed and the loose fragment in addition to residual cam deformity was removed. Resolution of pain and anterior thigh numbness was reported after the revision surgery.

Current knowledge on the genetic background of developmental dysplasia of the hip and the histomorphological status of the cartilage.

Developmental dysplasia of the hip (DDH) represents a morphological abnormality characterized by the incongruity of femoral head and acetabulum. It ranges from mild dysplastic changes to complete dislocation. DDH has been associated with several hereditary and environmental risk factors, which could explain the incidence variability among different countries. Numerous genes may be involved in the disease etiology and progression. However, there are controversies in the literature regarding some of these genes. DDH-induced secondary osteoarthritis (OA) is characterized by changes in the macromolecule content of the cartilage and the expression of cartilage degradation markers. In addition, it exhibits a pattern of specific histological changes, with several reported differences between primary and DDH-induced secondary OA. The articular cartilage of patients with DDH shows specific radiological characteristics, including changes visible already in infancy, but also at pre-arthritic stages, early stages of OA, and in fully developed DDH-induced secondary OA. Although DDH has been extensively researched in different disease stages, the etiology of the disorder still remains uncertain. This review focuses on the current knowledge on the histomorphological status of the cartilage and the genetic background of DDH.

Clinical and MRI Outcomes After Surgical Treatment of Osteochondral Lesions of the Talus in Skeletally Immature Children.

BACKGROUND: The literature on the osteochondral lesion of the talus (OLT) in skeletally immature children is scarce and little is known about the clinical outcomes and the radiologic appearance of these lesions after surgical treatment. The aim of this study was to assess mid-term clinical and magnetic resonance imaging (MRI) outcomes after arthroscopic microfracture (AM) of OLT in skeletally immature children. METHODS: Thirteen patients with OLT treated by AM before skeletal maturity were included in the study. The Berndt and Harty outcome question, the Single Assessment Numeric Evaluation question, and the Martin questionnaire were used to obtain patients' subjective satisfaction with their operated ankle. Functional outcomes preoperatively and postoperatively were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. MRI scans were performed postoperatively using a magnetic resonance observation of cartilage repair tissue (MOCART) scoring system for 11 ankles. RESULTS: The median age was 15 years (range, 13 to 16 y) and the median follow-up period was 5.6 years (range, 3.8 to 13.6 y). According to the Berndt and Harty outcome question, good clinical results were reported in 10 (76.9%) and fair in 3 (23.1%) patients. The postoperative AOFAS score was significantly improved when compared with the preoperative AOFAS score, with a mean increase of 35 points (P<0.001). The overall MOCART score was 65 (range, 10 to 75). MRI variables of the MOCART scoring system showed no association with clinical outcomes. CONCLUSIONS: AM seems to be an effective surgical method for the treatment of OLT in skeletally immature children. LEVEL OF EVIDENCE: Level IV-therapeutic studies, case series.

Sport injuries in international masters rowers: a cross-sectional study.

AIM: To estimate the frequency and localization of acute (traumatic) and chronic (overuse) injuries in a population of masters rowers with respect to their age subgroups and assess the association between injury occurrence and different training modalities, rowing experience, previous competition level, and current rowing practice. METHODS: A cross-sectional study was conducted among 743 masters rowers who participated in the 34th International Federation of Rowing Associations (Fédération Internationale des Sociétés d'Aviron, FISA) World Rowing Masters Regatta held in Zagreb, September 2-9, 2007. A rowing-specific questionnaire was used, followed by an interview about the injuries sustained during the 12-month period before the competition. RESULTS: The mean injury rate per year was 0.48 injuries/masters rower (2.25 injuries/1000 training sessions/rower). The majority of injuries were chronic injuries (the ratio of acute to chronic injuries was 1:1.7), and did not lead to the loss of training/competition time. Of all acute injuries, 49.6% were acquired during rowing-specific training, 43.7% during cross-training, and 6.7% in the gym. The most commonly affected region was the low back (32.6%), followed by the knee (14.2%), shoulder/upper arm, and elbow (10.6% each). CONCLUSION: International masters rowers sustained predominantly chronic injuries of low severity, and the most commonly injured region was the low back. The mean injury rate per rower per year was lower than the rates previously reported for juniors and seniors.

Localized pigmented villonodular synovitis of the ankle: Expect the unexpected.

BACKGROUND: We present the technique, results and discuss arthroscopic treatment of the localized form of pigmented villonodular synovitis (LPVNS) of the ankle. METHODS: Medical records of five patients diagnosed and treated for ankle LPVNS with a minimum five-year followup were retrospectively reviewed. All patients were treated arthroscopically, altered synovial tissue was resected and a sample of tissue was sent for pathohistological examination for the definitive diagnosis. RESULTS: No recurrence was noted at a mean followup of 6.5 years, both clinically and by MRI at one year postoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and an improvement was noted from an average score of 65.6 prior to treatment to 94.6 at final followup. CONCLUSION: Considering the results of this case series, and the absence of complications, arthroscopy is a viable option for treating LPVNS of the ankle.

IS THERE ANY ROOM FOR TENDOSCOPY IN THE SURGICAL TREATMENT OF POSTERIOR TIBIAL TENDON INSUFFICIENCY?

Posterior tibial tendon insufficiency (PTTI) is nowadays considered to be the main cause of adult-acquired flatfoot deformity (AAFD). The purpose of this study is to report the outcomes of tendoscopic treatment of tibialis poste- rior tendon (TP) in eleven patients with stage 1 or 2 PTTI and failed prior conservative treatment. Tendoscopy was carried out as a solitary procedure in 8 patients, while in 3 patients additional procedures such as ,,mini-open" tubularization of TP or anterior ankle arthroscopy were necessary. In a single patient transfer of flexor digitorum longus tendon was performed as a second stage surgery due to complete rupture of TP. Related with tendoscopic procedure, no complications were re- ported. TP tendoscopy is a useful and beneficial minimally invasive procedure to treat TP pathology at earlier stages of PTTI. It is a technically demanding procedure that requires extensive experience in arthroscopic management of small ioints and excellent knowledge of repional anatomy.

[POSSIBILITIES AND LIMITATIONS OF SEXUAL ACTIVITY FOLLOWING TOTAL HIP REPLACEMENT].

Total hip replacement in patients with osteoarthritis significantly reduces pain and enhances the quality of life (QoL). Sexual activity is an important component of QoL about which doctors rarely discuss with patients even though it is a matter of concern to many patients. In fact, patients who have previously had impaired sexual function due to preoperative hip pain and/or stiffness find that after surgery their hips are pain free and have better motion. After total hip arthroplasty range of hip motions is usually limited by surgeon's reccomendation in order to prevent dislocation of prosthesis. This creates limitations in activities of daily living, sport activities and also sexual activities. The aim of this paper is to give guidelines for safe sexual intercourse to patients following total hip replacement. During rehabilitation, patients should be educated on what positions are and are not recommended in the context of sexual activity.

OSTEOID OSTEOMA OF THE CORACOID PROCESS: CASE REPORT WITH LITERATURE REVIEW.

Osteoid osteoma (OO) is the most common benign osteogenic bone tumor that predominantly affects young adults. OO is commonly localized in long bones, and therefore, it is rarely considered in differential diagnosis of chronic shoulder pain. We report a case of a 22-year-old male athlete, without history of previous trauma, who presented to our Department with chronic shoulder pain, which escalated during the night and responded to nonsteroidal anti-inflammatory drug treatment. Considering these typical symptoms, diagnostic pathway was immediately directed towards OO, with magnetic resonance and computed tomography confirming the diagnosis of OO of the coracoid process (CP). Since neurovascular structures are in the proximity of CP, and this very delicate area does not support radiofrequency ablation, we decided to perform an open procedure with drilling of the lesion and excochleation. The pain withdrew immediately after the procedure, and on six-month follow up the patient remained pain free. In the treatment of OO of the CP, we recommend open surgical procedure with tumor ablation by drilling instead of CP resection, presenting a safe, simple and low-cost method that simultaneously completely destroys the lesion and preserves the anatomical and functional role of CP

Peroneal tendoscopy--more than just a solitary procedure: case-series.

This study presents a series of 13 patients who underwent peroneal tendoscopy as a solitary or accessory procedure at our department in 2013. Patients were clinically diagnosed with peroneal tendons disorders and underwent an additional radiological assessment. Peroneal tendoscopy was carried out in a standard manner before any other arthroscopic or open procedure. Postoperative management depended on the type of pathology. We found 3 peroneus brevis tendon partial tears, 4 cases of a low-lying peroneus brevis muscle belly, 5 cases of tenosynovitis, and 1 case of an intrasheath peroneal tendon subluxation. In 5 patients peroneal tendoscopy was performed as a solitary procedure and in 8 patients as an accessory procedure--together with anterior or posterior ankle arthroscopy, combined posterior and anterior ankle arthroscopy, or open surgery. Both as a solitary and accessory procedure, peroneal tendoscopy was safe and successful, ie, all patients were without any symptoms at one-year follow-up. Our series of patients showed that peroneal tendoscopy can be used both as an independent procedure as well as a valuable accessory procedure.

Acute and chronic injuries among senior international rowers: a cross-sectional study.

PURPOSE: The aim of the study was to define the types of musculoskeletal injuries present in senior international rowers. According to the literature, no such study has been performed in this group. METHODS: Injury data were obtained from a total of 634 rowers (33 % female, 67 % male) who completed a 12-month retrospective questionnaire on injury incidence while participating in the Senior World Rowing Championships in Munich, Germany, in 2007. RESULTS: The mean injury rate per one year was 0.92 injuries per rower (1.75 injuries per 1,000 training sessions per rower). The vast majority of self-reported injuries were chronic injuries (acute vs chronic ratio was 1:2.63), and the majority of reported injuries did not result in loss of time from training or competition. Of all acute injuries, 58.1 % were sustained during rowing-specific training, with 20.6 % injuries sustained in the gym and 21.3 % during cross-training. The most common site of injury was the low back followed by the knee and the chest/thoracic spine. Senior open weight rowers who sustained chronic injuries achieved significantly better final ranking at the 2007 Senior World Rowing Championships compared to the same group of rowers who did not sustain any injury. CONCLUSION: Senior international rowers participating in World Rowing Championships sustained predominantly chronic (overuse) injuries during the rowing season studied. Those were mainly low severity injuries, with the low back being the most frequently injured site. This study may will help in prevention and early diagnosis of eventual injuries in top-level rowers.

Periarticular osteoid osteoma of the ankle: a report of nine arthroscopically treated patients.

Periarticular osteoid osteoma often presents with unspecific clinical symptoms, mimicking other clinical conditions. This can lead a clinician to a ''diagnostic side path'' and a delayed or missed diagnosis compared with extra-articular osteoid osteoma. We report the cases of 9 patients with a mean age of 22 (range 14 to 32) years who were diagnosed with periarticular osteoid osteoma of the ankle and were surgically treated in our department during a 12-year period. The diagnostic difficulties associated with periarticular osteoid osteoma must be resolved by obtaining a detailed patient history and performing a thorough physical examination. Computed tomography is the ultimate imaging method to confirm the suspicion of osteoid osteoma. Arthroscopic removal of the osteoid osteoma was performed in all 9 patients in the present case series, with synovectomy performed when indicated. Under arthroscopic visualization, a specimen was obtained for histopathologic analysis to confirm the diagnosis, followed by tumor excision. All the patients were pain free at the final follow-up visit after a mean duration of 6 years (range 6 months to 12.7 years) postoperatively. We suggest arthroscopic removal of periarticular osteoid osteomas of the ankle as an effective treatment method, because it allows complete tumor excision, synovectomy when needed, a short postoperative rehabilitation period, and satisfactory functional results.

[Posterior ankle impingement syndrome]. / Straznji sindrom sraza gleznja.

Posterior ankle impingement syndrome (PAIS) is a clinical syndrome characterized by posterior ankle pain which occurs in maximal forced plantar flexion of the foot. PAIS can be the result of an acute injury of the ankle, which is more often in general population, or it can be the result of the overuse syndrome, which is more often in athletes and ballet dancers. The etiology of PAIS may involve bony structures or soft tissue structures, or, more often, the combination of both. The diagnosis of PAIS is based on patient's clinical history and physical examination with the hyperplantarflexion test as a very important part of it. Physical examination should be completed with imaging techniques, which most often include magnetic resonance imaging (MRI) or computed tomography (CT) to confirm the diagnosis of PAIS. Conservative treatment is recommended as the primary treatment strategy. In those cases where 3 to 6 months of conservative treatment fails, open or, more often, arthroscopic/endoscopic surgery may be recommended. Nowadays, a 2-portal endoscopic approach introduced by van Dijk et al. in 2000 is the method of choice for the treatment of posterior ankle impingement syndrome.

[Peroneal tendons do exist, don't they?]. / I peronealne tetive postoje, zar ne?

Peroneal tendon disorders are a significant but often overlooked cause of posterolateral ankle and lateral foot pain. When left untreated, peroneal tendon disorders can lead to persistent pain and substantial functional problems. The goals of this review are to develop a current understanding of the regional anatomy, as well as diagnostic evaluation and current treatment options of the peroneal tendon disorders, and to present nowadays preferred surgical techniques for operative management of peroneal tendon disorders. More specific details related to peroneal tendon luxation, intrasheath subluxation of peroneal tendons, peroneal trendinopathy, peroneal tendon tears and painful os peroneum syndrome are reported in this review article.

Primary Bone Lymphoma of the Scapula.

Primary bone lymphoma of the scapula is a rare tumor that usually causes local pain. The presented patient suffered for two years from paresthesia, tingling, numbness, and edema of the little and ring fingers. The 45-year-old man underwent several radiological and neurological assessments of the palm, elbow, and neck before radiographs revealed a tumor of the left shoulder. Once diffuse large B-cell lymphoma was confirmed, immunochemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and methylprednisolone (R-CHOP) started. The treatment was accompanied by antiviral treatment with lamivudine due to positive hepatitis B virus serology, specifically anti-HBs (hepatitis B surface) antibody, total anti-HBc (hepatitis B core) antibody, and anti-HBe (hepatitis B e antigen) antibody, together with bisphosphonate treatment for the prevention of bone resorption. Once immunochemotherapy was finished, the treatment was supplemented by radiotherapy of the shoulder. After more than three years of remission, the patient had an ischemic stroke manifesting with right-sided hemiparesis. Following physical therapy, the patient is currently in the process of evaluation for thrombophilia, as well as further cardiac assessment due to the positive transcranial Doppler bubble test, setting high suspicion for the presence of patent foramen ovale.

Complete inclusion of adaptive rowing only 1000 m ahead.

Adaptive rowing (AR) at the Paralympic level is accessible for rowers with physical disability. AR was included for the first time in the Beijing 2008 Paralympic Games. Racing distance for all AR events is currently 1000 m, which impedes public recognition of this sport and leads to many organisational challenges during the inclusive World Rowing Championships. The aim of this report was to discuss the feasibility of increasing AR race distance to 2000 m from a sports injury and athletic health perspective. As limited data on injury and illness risks exist in AR, knowledge and experiences had to be taken from other Paralympic sports. The anticipated duration of 2000 m AR competitions is either comparable or considerably lower than that of the other Paralympic disciplines with similar characteristics. AR has inherent injury and health risks especially within thorax, shoulders and low back region, but they are not expected to be significantly modified by increased racing times. Specific considerations need to be taken into account for athletes with a spinal cord injury, like in other sport disciplines. There are no distinctive contra-indications for AR events of 2000 m based on the current literature review and a 10-year experience in this sport. Long-term follow-ups are needed to understand fully the injury and health risk associated with AR and to develop appropriate prevention strategies.

Synovial chondromatosis of the elbow.

Synovial chondromatosis (SC) is a rare, mostly benign proliferation of the synovium of the joint, tendon or bursa which results in the formation of loose bodies. It can appear in one of 33 described localisations, but it is most common in the knee. In our study we gathered a group of 7 patients (6 male and 1 female) with SC of the elbow, which underwent arthroscopic surgery of the elbow, performing both removal of the loose bodies and complete synovectomy. Mayo Elbow Performance Score (MEPS) was used to evaluate and compare the patients' condition before the operation and at the final follow-up, 31 months, on average, after the operation (range 18-56 months). All patients had poor MEPS before the operation, with an average of 40.7 (range 15-50 points). At the final follow-up, 6 patients had a good or excellent MEPS, while a poor MEPS was present in a single patient. The average MEPS was 85 (range 45-100 points). The one patient who's MEPS remained poor developed heterotopic ossification in the same elbow shortly after arthroscopic surgery. This patient was reoperated 8 months later using an open technique. No other complications occurred in the rest of the operated patients and no recurrence of SC occurred in any of the operated patients. Our results confirm that arthroscopic removal of loose bodies and complete synovectomy should be the treatment of choice for SC of the elbow.

[Hip arthroscopy]. / Artroskopija kuka.

In the last ten years, hip arthroscopy has been developing intensively and it is rapidly gaining primacy in the treatment of various injuries and damages to the hip itself and its immediate vicinity. The basic advantage of hip arthroscopy surgery versus classic open surgery is avoiding an open dislocation of the hip and, thus, reducing patient's morbidity and accelerating his/her rehabilitation, which leads to a quicker return to everyday activities. The success of arthroscopic surgery depends on the correct indication for the surgery and on the experience and the skill of the operator. It also depends on the properly conducted rehabilitation and the patient's compliance, as well as on the patient's realistic expectations. Indications for hip arthroscopy today are the following: injury and damage to acetabular labrum and/or articular cartilage, femoroacetabular impingement syndrome, injuries and damages to the ligament of the femoral head, loose and foreign joint bodies as well as different conditions of synovial membrane (synovial chondromatosis, pigmented villonodular synovitis and other inflammatory arthropathy such as rheumatoid arthritis). In this article we describe the indications, technique, complications and the prospect of hip arthroscopy, with a detailed overview of contemporary literature data.

Osteochondritis dissecans of the elbow: excellent results in teenage athletes treated by arthroscopic debridement and microfracture.

AIM: To evaluate the outcome of patients who underwent microfracture procedure on osteochondritis dissecans (OCD) lesions in the elbow, which had already been proven successful on OCD lesions in the knee and ankle. METHODS: Nine young patients who were previously treated by arthroscopic debridement and microfracture by a single surgeon were included in the study. The median age at operation was 15 years (range 12-19). The median time between the procedure and evaluation was 5 years (range 2-9). The evaluation included physical examination and patient interview with elbow function scoring. Success of treatment was determined according evaluation Mayo Elbow Performance Index scores and the patients' return to sports. RESULTS: Eight patients scored excellent results and 1 scored a good result. Four out of 9 patients were able to increase their training intensity, 2 returned to the same level of activity, 2 changed sports (due to reasons unrelated to the health of their elbow), and 1 left professional sports and started training only recreationally. No patients stopped participating in sports altogether. CONCLUSIONS: We advocate arthroscopic microfracturing, followed by a strict rehabilitation regime, as a highly effective treatment for OCD of the humeral capitellum.

Removal of osteoid osteoma of the tibia using two-portal posterior ankle arthroscopy.

The case of a 30-year-old male with a history of pain in his left ankle is presented. The pain was described as predominantly nocturnal and frequently relieved by the use of nonsteroidal anti-inflammatory drugs. Computed tomography indicated a diagnosis of an osteoid osteoma in the posteromedial portion of the tibia. The patient underwent excision of the tumor using 2-portal posterior ankle arthroscopy. A clearly visualized nidus was removed using a combination of a cochlea and shaver. Histopathologic analysis of the resected tissue confirmed the diagnosis of an osteoid osteoma. The patient reported immediate relief of the pain and was rapidly allowed to bear weight on the foot. During regular follow-up, he had no pain recurrence and his joint mobility was normal. To our knowledge, this is the first report of the removal of an osteoid osteoma of the ankle using 2-portal posterior ankle arthroscopy.