The relationship between medial meniscal subluxation and stress distribution pattern of the knee joint: Finite element analysis.

BACKGROUND: Degenerative changes of the knee joint and clinical follow-up after meniscal subluxation are well documented. In the current study three-dimensional (3D) finite element analysis (FEA) of human lower limb was used to investigate the effect medial meniscal subluxation on the loadings of the knee structures. METHODS: Apart from the reference model, a total of ten 3D models were created, according to amount of medial meniscal subluxation. ANSYS® 14 was used to analyze the stress/load distribution, that is to say the maximum equivalent stress (MES) (von Mises stress) on bones, cartilages, ligaments and menisci. MES was expressed as Newton/mm(2) = Megapascal (MPa). RESULTS: In a static and standing upright position the MES on all knee structures were evaluated in the reference model. Although MES increased in all structures with the increase of medial meniscal subluxation degree, tibia cartilage was found to be the most affected structure with an increase of 22.73-fold in the 10 mm subluxation model when compared with references values. CONCLUSION: This study showed that medial meniscus subluxation is associated with increased loadings on all knee structures especially the tibia cartilage. Also the degree of the medial meniscal subluxation correlates with distribution and the amount of loadings on tibia cartilage which may be a prominent feature of knee osteoarthritis.

Degenerative arthritis of pseudoarticulation between the os peroneum and cuboid: a rare cause of lateral foot pain.

The painful os peroneum syndrome is widely recognized. It is often the result of trauma. However degenerative changes between the os peroneum and the articular facet is much rarer and we could only find two other case reports in the literature. This report concerns a middle aged woman with chronic plantar-lateral foot pain and a limp secondary to degenerative changes between the os peroneum and its articular facet with cuboid. The aim of this study is to remind to orthopaedic surgeons about painful os peroneum syndrome and to highlight the rarity of our case. In our case the mid term result of the excision of the os peroneum with painful articulation appear good, providing symptomatic pain relief with little alteration in the function of the foot.

Comment to: Haque S, Khan A, Sharma A, Sundararajan S: Technical tip: tightrope fixation of neer type II distal clavicle fracture supported by a case series. Pol Orthop Traumatol, 2014; 79: 19-22.

Additional suture anchor fixation to coracoclaviculer area with precountered distal clavicle locking plate allows an anatomic reduction with bone-bone contact and gives additional neutralisation effect with coracoclavicular suture anchor fixation against the trapezius muscle pulling effect .Event though the effeciency of this technique reported by other authors,still there is a few articles and cases reported.In the terms of proving the efficiency of the combination technique we would like to stress to contribute the published article by Haque et al.

Trevor's disease: mimicking anterior ankle impingement syndrome: case report.

This report concerns an unusual cause of anterior ankle impingement. The case of a young male with Trevor's disease mimicking an anterior spur of the ankle that resulted in anterior impingement and treated with ankle arthroscopy is presented. The aim of this study is to explain the different diagnostic properties of Trevor's disease from a classic anterior spur. Level of evidence IV.

Relation of discoid lateral meniscus and cord-like anterior intermeniscal ligament: morphological and clinical study.

Discoid lateral meniscus is a rare disorder and its association with other variations in the knee joint has been reported. The anterior intermeniscal ligament has also been described as connecting the anterior convex margin of the lateral meniscus to the anterior horn of the medial meniscus. In the normal population, it was observed at 53-94%. Although the functional properties of the anterior intermeniscal ligament are not yet clarified, two distinct types of the ligament have been described according to their morphological characteristics as cord-like and membranous types. The purpose of this study was to evaluate any possible association between morphologic types of anterior intermeniscal ligament and discoid lateral meniscus. A retrospective study was designed; 20 discoid lateral menisci were operated using routine arthroscopic examination. Upon arthroscopic examination the thickness of the ligament and associated morphological changes were recorded systematically. The cord-like anterior intermeniscal ligament was an associated structure in 15 of the 20 knees with discoid lateral meniscus (75%). Patients with discoid lateral meniscus apparently have cord-like type anterior intermeniscal ligament, thus we conclude that cord-like type of anterior intermeniscal ligament is a frequent accompanying structure to discoid lateral meniscus and may have a potential stabilizing effect on its anterior stability.

[Correlation of basic motor skills with arthroscopic experience]. / Temel motor becerilerin artroskopik deneyim ile iliskisi.

OBJECTIVES: One of the methods in motor skill teaching is to furnish the students with the individual skills drawn from the target procedure. This method requires identification and defining of all components of the target procedure. This study aimed to define basic motor skills composing arthroscopic skillfulness. METHODS: A total of 42 orthopedists (mean age 38+/-8 years) were enrolled. The study group was comprised of 17 experienced orthopedists working at least for 10 years as a specialist and performing more than 50 arthroscopic procedures per year. The control group included 25 young orthopedists or residents having an arthroscopic experience of less than three years. All the participants were assessed simultaneously and in the same experimental setting. Each participant was tested after having been shown to use in vitro skill development instruments simulating arthroscopic basic motor skills. RESULTS: Compared to the control group, the experienced group had significantly higher mean age (42 vs. 34.4 years), longer duration of arthroscopic experience (12.4 vs. 1.6 years), and greater number of the arthroscopies performed per year (93.9 vs. 26.9) (p=0.000). The mean anticipation time (p=0.028) and two-arm coordination time (p=0.043) were significantly shorter in the experienced group. In correlation analysis, duration of arthroscopic experience was correlated with the mean anticipation time (r=-0.41, p=0.008) and two-arm coordination time (r=-0.33, p=0.033). In addition, the mean anticipation time decreased significantly as the number of arthroscopies increased (r=-0.446, p=0.003). CONCLUSION: Some basic motor skills correlate with arthroscopic competence. The use of these motor skill instruments in arthroscopy training may aid to improve arthroscopic skills.

Comminuted Distal Radial Fracture with Large Rotated Palmar Medial Osteochondral Fragment in the Joint.

INTRODUCTION: Intra-articular distal radius fractures have long been massively discussed in the literature, but regarding to fractures that possess rotated volar medial fragment in the joint a few amount papers has been written. In this article, we would like to emphasize the significance of the rotated palmar medial (lunate facet) fragment. CASE REPORT: A 39-year-old man fell from a height of about 3 m and landed on his right outstretched hand; within 40 min, he arrived at our clinic presenting with a severe pain and swelling in his right wrist. Initial X-rays of the wrist revealed dorsal subluxation of the radiocarpal joint with dorsal comminution of the radial articular surface and fracture of the radial styloid process, with (nearly inverted) ~ 140-150° rotation of the palmar medial fragment. With an additional volar approach, the fragment reduced and stabilized with two K-wires and wrist immobilized in external fixator. The patient returned to daily activities without any discomfort and pain after the 1 year from the surgery. CONCLUSION: Overlooking of palmar rotated osteochondral fragment will cause deficiency to build proper pre-operative strategy to approach the reduction of the fragment. The incompetence of reduction will deteriorate the articular surface and lead to early osteoarthritis of the wrist. The surgeon should detect this fragment and should be familiar with volar approaches of the wrist. Above average surgical experience would be needed for successful reduction.

Anterior intermeniscal ligament: an ultrastructural study.

The aim of the present study was to investigate the detailed histological characteristics of membranous and cord-like anterior intermeniscal ligaments (AIMLs) by transmission electron microscopy (TEM) and light microscopy. Ten biopsies of AIMLs were sampled from 10 knees during total knee arthroplasty procedures. Three of them were membranous and 7 of them were cord-like. They were processed for light and TEM evaluations. Histologically, the findings in the membranous and cord-like ligaments were similar. They consisted of parallel bundles of collagen fibrils and their posterior surfaces were covered by a layer of loose well-vascularized synovial tissue. The subsynovial region consisted of loose connective tissue and was rich in blood vessels and nerve endings. Fibroblasts embedded between parallel-oriented collagen fibrils were the major cell type that we observed. Free nerve endings were squeezed between bundles of collagen fibers. Electron microscopic observations revealed the presence of Ruffini corpuscles. The presence of neural mechanoreceptors in the membranous and cord-like intermeniscal ligaments may contribute to structural and proprioceptional function of the knee. Protection of those ligaments may be valuable in planning and performing meniscal surgeries.

[Chondropenia: early-stage degenerative disease]. / Kondropeni: Erken evre dejeneratif hastalik.

Chondropenia is defined as loss of the articular cartilage volume. It is the early stage of degenerative joint disease. Risk factors include advanced age, obesity, overuse (activity-related injury), menopause, and trauma. Early detection of chondropenia is important with regard to recognition of its causes and assessment of the efficacy of treatment. Magnetic resonance imaging is the most potential tool for noninvasive assessment of articular cartilage. Arthroscopy provides information about the size, surface features, and anatomic localization of cartilage lesions, and the features of the adjacent cartilage. By arthroscopy, tissue thickness and in vivo volume of the cartilage can be measured. Studies have given weight to mechano-acoustic diagnosis and optical tools (optical coherence tomography, reflectance spectroscopy). These studies are based on the relationship between the structural and mechanical features of the cartilage. Determination of breakdown products of cartilage is another potentially important method for assessment.

Intra-Articular Osteoid Osteoma as a Cause of Anteromedial Knee Pain.

A 32-year-old male patient presented to our clinic with chronic left knee pain that was ongoing for about 1.5 years. The patient visited several times our clinic and the other clinics; conservative treatment (including rest, knee brace, and ice application with NSAIDs) was recommended by various different doctors. The anamnesis, physical examination, and plain radiography were nonspecific. Early MRI findings mislead us to believe it is bone marrow edema. One and half years with noneffective treatment, the knee pain persisted. At the latest visit intra-articular osteoid osteoma was suspected and the knee MRI with CT was employed. Even though the diagnosis of intra-articular osteoid osteoma often presents a challenge for the surgeons, with a present awareness of intra-articular osteoid osteomas which lack the characteristic sclerotic lesions and nidus on plain X-rays and the aid of multislice CT, a correct diagnosis which warrants proper treatment can be achieved. The possibility of osteoid osteomas, especially in young adults with persistent knee pain with unknown reasons that show normal plain radiographs results, must not be overlooked. The treatment method of these lesions should be customized depending on the location of the lesion, experience of the surgeon, and cost of method.

[The "wheel track" technique in lateral meniscus surgery: a technical note]. / Lateral menisküs cerrahisinde "tekerlek izi" yöntemi: teknik not.

Partial meniscectomy is the most widely used intervention in the arthroscopic treatment of meniscal disorders. Despite improved arthroscopic techniques and instrumentation, surgery of the lateral compartment is still challenging. The "wheel track" technique, first described here, will facilitate partial meniscectomy in cases where surgical intervention presents difficulties, in particular at the corpus or the anterior horn of the menisci, and the discoid meniscus. In this technique, an incomplete groove resembling a "wheel track" is created on the surface of the meniscus with the use of the tip of electrocautery. This hollow pathway on the surface of the meniscus will help prevent any unintentional divergence of the punch forceps and enable meniscectomy to be completed along the desired direction. Moreover, the technique offers considerable advantages such as ease of application through the standard portals, low cost, and avoidance of iatrogenic chondral injuries due to technical difficulties.

Arthroscopic treatment of anterolateral soft tissue impingement of the ankle: evaluation of factors affecting outcome.

PURPOSE: To evaluate the results for patients treated arthroscopically for anterolateral soft tissue impingement syndrome, to determine the factors affecting the outcome, and to report on a synovial shelf. TYPE OF STUDY: Retrospective clinical review. METHODS: Forty-one patients underwent operative arthroscopy for anterolateral impingement of the ankle between 1990 and 2001; the mean follow-up was 83.7 months (range, 21 to 152 months). There were 25 men and 16 women with an average age of 33.2 years (range, 15 to 63 years). All patients reported a history of inversion injury to the ankle. The most frequent preoperative complaints were tenderness localized to the anterolateral aspect of the ankle, swelling, crepitation, and pain at weight-bearing. All patients had failed to respond to at least 3 months of conservative treatment. The results were assessed according to Meislin's criteria and the American Orthopaedics Foot and Ankle Society (AOFAS) scoring table. For statistical analysis, the Mann-Whitney U test was used where appropriate and the significance was set at P < .005. RESULTS: According to Meislin's criteria, there were excellent results in 21 patients, good in 16, fair in 2, and poor in 2. The mean AOFAS score was 89.6 points (range, 60-100) at follow-up. Four different soft tissue pathologies causing impingement were described. It has been statistically shown that cartilage damage located at the anterolateral region of the ankle and not advanced to the subchondral bone, and repeated inversion injuries had negative effects on clinical results at long-term follow-up. CONCLUSIONS: The arthroscopic diagnosis and treatment of anterolateral soft tissue impingement is a safe and effective method. Any combination of associated intra-articular pathologies, such as a chondral lesion or a new inversion injury of the ankle, after the arthroscopic procedure resulted in a poor outcome. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

[Metastatic tumors of the hand in three cases]. / Uç olguda metastatik el tümörü.

Metastatic malignancies of the hand are rare and they usually develop from lung, breast, and kidney tumors. Metastases to the bones of the hand can cause pain, swelling, soft tissue ulceration, and osteolytic destruction. We presented three patients with metastatic tumors of the hand, whose ages were 58 (male), 42 (female), and 40 (male) years. Metastases developed in the thumb and the big toe, metacarpal bone, and the nail bed following treatment for primary tumors of the bladder, colon, and chondrosarcoma of the proximal femur, respectively. One patient underwent amputation of the thumb and the big toe followed by systemic chemotherapy, one patient with metacarpal involvement was treated with Ray amputation, and the latter underwent a biopsy. Histopathological diagnoses were consistent with primary tumors.

Osteochondromas originating from unusual locations complicating orthopedic discipline: case series.

Herein, we report clinical, radiological, and follow-up results of seven cases of extraordinary located osteochondromas and highlight the importance of rare and unusual properties of unusual locations of osteochondromas. Seven patients with extraordinary located osteochondromas were treated in our institution (Antalya Memorial Hospital) between the period of February 2009 and March 2014 were reported. The patients were classified according to the localization, symptomatology, and the presence of neurovascular involvement or organ compression. The results were discussed with the existing literature data. Five of our patients had unusual symptomatology. Surgical excision was performed on six of seven patients. One patient was followed with scheduled outpatient visits alone. Our clinical follow-up results were good to excellent. In our case series, one patient with clavicular involvement had impaired shoulder mechanic which resulted in painful shoulder, while another with pubic ramus involvement had obstructive urination symptoms and dysuria. One patient with scapular involvement had snapping scapula symptoms, while two patients with fibular head involvement had peroneal nerve compression and tibial nerve compression symptoms in each. One patient with ischial ramus involvement had sciatica, whereas another with first rib involvement had radiological evidences for subclavian artery compression due to osteochondroma without any symptom. Based our experience, the flat bones which are usually ossified by intramembranous type of ossification during the fetal period (including the scapula, ilium, pubic ramus, ischium ramus, ribs and clavicle) are much less commonly affected and often have unusual symptoms. The osteochondromas originating from the fibular head may seem innocent to an orthopedic surgeon. However, an orthopedic surgeon should be alert to tibiofibular synostosis and nerve compression in this patient population.

Luxatio erecta humeri: Report of a swimming injury with analysis of the mechanism of the injury and associated injuries in literature.

Inferior shoulder dislocation also referred to as luxatio erecta is an unusual and rare type of shoulder dislocation. Its incidence is about 0.5% among all shoulder dislocations. After an exhaustive search of all the available literature we were unable to find a swimming accident case that did not have other associated injuries and an uneventful reduction. The mechanism of the injury was mostly related to direct axial loading and indirect hyperabduction lever arm. We would like to emphasize the importance of this being a swimming accident, a type of accident that requires awareness of the possibility of dangerous asphyxia injuries caused by panic in the water (swimming pool, river, lake, sea, etc.). We described the nature of the injury and review the literature concerning the mechanism of the injury and associated neurovascular impairment at admission time. We also presented a supplemental video to contribute to the education of young residents and orthopedic surgeons.

[Osteochondral lesions of the talus in adolescents]. / Ergenlik döneminde görülen talusun osteokondral lezyonlari.

Osteochondral lesions of the talus range from those confined to the hyaline cartilage covering the articular surface to those involving the subchondral bone. The lesion may not be apparent on the surface of the cartilage or it may be confined to the subchondral bone without cartilage involvement. These complex presentations often necessitates the use of computed tomography and magnetic resonance imaging to delineate the exact nature of the lesions. It has been shown that the frequency of osteochondral lesions increase following repetitive ankle sprains. Although the etiology is not well understood, both traumatic and atraumatic causes are thought to be effective. Nevertheless, early diagnosis and treatment of these lesions have improved considerably thanks to the developments in imaging techniques. It seems that arthroscopic chondral reconstruction methods using autologous chondrocyte and osteochondral transplantations will gain much interest in the near future.

Popliteal entrapment syndrome. A systematic review of the literature and case presentation.

Popliteal artery entrapment syndrome (PAES) is rare in young adults. Claudication of the young patient, which is often overlooked, is a very rare symptom for orthopedic surgeons. In elder patients, the physician might expect atherosclerotic claudication, however in young patients, popliteal artery entrapment syndrome (PAES) should be considered as a possibility in the cases of claudication. Here, an unusual presentation of an uncommon disease that is not widely known by orthopedic surgeons is reported.

Recurrence of Pelvic Chondrosarcoma through Fascial Defect into Abdominal Cavity.

Our patient was a 76-year-old female who has been operated on 2 times in 8 years for pelvic chondrosarcoma. The patient came to our clinic with a large mass in left iliac region which extended into the paravertebral area. Physical examination and preoperative imagining studies revealed a mass at the left iliac area that infiltrated sciatic notch and extended from posterior iliac region towards the anterior side of iliac bone through the sciatic notch and an incisional hernia including descending colon. The mass was also penetrating the abdominal cavity through the hernia. Surgical intervention was planned. Since the tumor infiltrated the sciatic nerve, hemipelvectomy was indicated. Patient refused hemipelvectomy. Therefore, palliative debulking surgery was considered. We treated the case with marginal excision and abdominal wall reconstruction employing prolene and vicryl suture materials in order to prevent a postoperative visceral herniation and local invasion. At the latest follow-up appointment in 2 years, the patient still had no signs of tumor recurrence. This case showed us that an incisional hernia can serve as a pathway for the recurrence invasion of the chondrosarcoma.

Proximal humerus head-splitting fracture associated with single-part anterior dislocation.

Fractures that split the humeral head are extremely rare, and usually, the split part is posteriorly dislocated. However, in our case, the split part was anteriorly dislocated and trapped between the anterior glenoid and the subscapularis muscle. In this case, the acquisition of preoperative CT results was vital to plan the exposure and reduction strategies. Open anatomic reduction and internal fixation should be considered as the first treatment of choice in young active adults.