Bizarre Parosteal Osteochondromatous Proliferation (Nora's Lesion) in the Medial Sesamoid of the First Toe.

Bizarre parosteal osteochondromatous proliferation, or Nora's lesion, is a unique bony lesion that generally originates from the small bones of the hands and feet in young adults. We report a case of a bizarre parosteal osteochondromatous proliferation originating from the medial sesamoid of the first toe that was managed surgically by en bloc excision. At 5-year follow-up, there was no evidence of recurrence.

[Other arthroscopic procedures for the treatment of chondral injuries of the knee joint]. / Diz eklemi kikirdak lezyonlarinda artroskopik cerrahi ile diger uygulamalar.

Cartilage injuries can be treated through conservative or surgical approaches upon evaluation of the lesion. In surgical approach, arthroscopic treatment has proven to be both very popular and efficient. Through arthroscopy, treatment options such as lavage, chondral shaving, debridement, microfracture, abrasion, and chondroplasty have been successfully performed in patients with appropriate indications.

Three-bundle popliteus tendon: a nonsymptomatic anatomical variation.

A 34-year-old man suffering from knee pain on the medial side of his right knee underwent knee arthroscopy. The arthroscopy revealed the popliteus tendon with an appearance of three bundles. Three-bundle popliteus tendon is a normal variant finding with no clinical significance.

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery.

PURPOSE: The purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery. TYPE OF STUDY: Prospective, randomized, double-blind, clinical study. METHODS: In this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient. RESULTS: VAS values were lower for the 3 medication groups compared with the placebo at rest and 90 degrees knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P <.05). The total amount of pethidine and analgesia time were longer for the 3 medication groups. CONCLUSIONS: Our basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects. LEVEL OF EVEIDENCE: Level I.

Biomechanical testing of hamstring graft tibial tunnel fixation with bioabsorbable interference screws.

PURPOSE: This study evaluated the failure mode, maximum load at failure, displacement at failure, and stiffness differences of quadrupled hamstring graft-tibial tunnel fixation using 28-mm, tapered 35-mm, or bicortical 17- and 20-mm bioabsorbable interference screws (Arthrex, Naples, FL). TYPE OF STUDY: Biomechanical study. METHODS: Nine matched pairs (18 specimens) of young cadaver tibias (mean bone mineral density [BMD] = 0.847 g/cm2, range, 0.689 to 1.11 g/cm2) were divided into 3 groups of 6 specimens. Kruskal Wallis analysis of variance and Mann-Whitney U tests post hoc comparisons were used to assess group differences (P <.05). RESULTS: Maximum load at failure for the 28-mm screw was 488.2 +/- 197 N, with a displacement of 18.4 +/- 7.5 mm and a stiffness modulus of 38.9 +/- 7.0 N/mm. Maximum load at failure for the tapered 35-mm screw was 844.8 +/- 121.4 N, with a displacement of 15.3 +/- 1.6 mm and a stiffness modulus of 70.5 +/- 21.1 N/mm. Maximum load at failure for bicortical screw fixation was 543.7 +/- 266.5 N, with a displacement of 17.7 +/- 6.6 mm and a stiffness modulus of 57.7 +/- 14.9 N/mm. Fixation using the tapered 35-mm screw displayed greater maximum load at failure than either 28-mm screw fixation (P =.015) or bicortical screw fixation (P =.037). Significant differences were not evident for displacement. Both tapered 35-mm (P =.016) and bicortical screw (P =.026) fixation displayed greater stiffness than 28-mm screw fixation. All constructs failed by pullout. CONCLUSIONS: Fixation using a single tapered 35-mm screw displayed increased maximum load at failure compared with the 28-mm screw or bicortical fixation. Both the tapered 35-mm screw and bicortical fixation showed greater stiffness than fixation using a 28-mm screw. Use of a single 35-mm screw for quadrupled hamstring graft-tibial tunnel fixation may be preferred for patients with poor tibial BMD.

Management of discoid lateral meniscus tears: observations in 34 knees.

PURPOSE: The goal of this study was to evaluate arthroscopic partial resection of discoid lateral meniscus tears with an emphasis on radiographic evidence of degenerative changes after this procedure. TYPE OF STUDY: Retrospective clinical study. METHODS: Of 41 patients with an arthroscopic diagnosis of discoid meniscus over an 8-year period, 34 symptomatic lateral discoid meniscus tears in 33 patients were analyzed at an average follow-up of 5.6 years. The average age at operation was 19.8 years and most patients had vague and intermittent symptoms that caused delay in clinical diagnosis. RESULTS: Eight patients were lost to follow-up and were excluded from the study. Magnetic resonance imaging, performed in 12 cases, and arthroscopy in all of these patients provided the precise diagnosis. All of the knees with symptomatic torn discoid menisci underwent arthroscopic partial meniscectomy. Only 1 Watanabe Wrisberg ligament type of discoid meniscus with posterior instability was totally meniscected. Based on Ikeuchi's grading, 39% of the knees had an excellent result, 46% had a good result, and 15% had a fair result; none of the results was poor. CONCLUSIONS: At an average 5-year follow-up, partial meniscectomy in patients with a Watanabe complete or incomplete discoid meniscus showed 85% good or excellent clinical results. However, a significant percentage of patients show femoral condyle flattening on radiography.

Partial deficiency of the lateral meniscus.

We report an abnormally shaped lateral meniscus. As far as we know, the present case is the first description of partial deficiency of the lateral meniscus in the literature. Although it is a rare abnormality, arthroscopic surgeons should be familiar with this entity for the differential diagnosis of bucket-handle meniscal tears, not only for magnetic resonance imaging, but also for arthroscopic evaluation. This entity could also be an aggravating factor for instability symptoms of partial or total anterior cruciate ligament-deficient knees.

The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture.

PURPOSE: The purpose of this study was to compare the accuracy of clinical examination versus magnetic resonance imaging (MRI) in diagnosing meniscal and anterior cruciate ligament (ACL) pathology. TYPE OF STUDY: Prospective, longitudinal study. METHODS: Between August 2001 and December 2001, we prospectively evaluated 50 consecutive patients (37 male, 13 female) with 65 pathologies of medial meniscal tears, lateral meniscal tears, and/or ACL rupture. The average preoperative period for the patients was 5 weeks (range, 5 days to 5 months) and their mean age was 22 years (range, 12 to 42 years). After initial clinical examination, the same sports medicine fellowship-trained orthopaedic surgeon (10-year practice profile of 100% sports medicine) evaluated the MRI of the patients and performed their arthroscopic procedure. Accuracy, sensitivity, specificity, and positive and negative predictive values were calculated comparing clinical examination, MRI, and arthroscopic evaluation. RESULTS: There was no statistical difference between MRI or clinical examination in diagnosing medial or lateral meniscal tears or ACL tears ( P >.05). The accuracy of the clinical examination and MRI evaluation was equal for diagnosing meniscal tears and ACL ruptures. CONCLUSIONS: A well-trained qualified surgeon can safely rely on clinical examination for diagnosing meniscal and ACL injuries. Clinical examination is at least as accurate as MRI in the skilled orthopaedic surgeon's hand. MRI should be reserved for more complicated and confusing cases. The routine ordering of an MRI scan of the knee before examination by a well-trained orthopaedic surgeon is not recommended. LEVEL OF EVIDENCE: Level II, diagnostic.

Open treatment of stage III Kienböck's disease with lunate revascularization compared with arthroscopic treatment without revascularization.

PURPOSE: The goal of this study was to compare the results of open scaphocapitate fusion and revascularization with the results of arthroscopic scaphocapitate fusion and capitate pole excision. TYPE OF STUDY: Prospective randomized study. METHODS: Between April 1997 and January 2000, 16 consecutive patients (5 men and 11 women with a mean age of 31 years [range, 18 to 61]) presenting with Kienböck's disease stage IIIA and stage IIIB were randomized to either open scaphocapitate fusion and lunate revascularization (group I) or fully arthroscopic scaphocapitate fusion and capitate pole excision (group II) groups. Cannulated 3.5-mm ASIF screws were used for the purpose of scaphocapitate fixation in both groups. Operation time, hospital stay, time to fusion, range of wrist motion at final follow-up, grip strength, and return to unrestricted activities of daily living were evaluated at 33 months' follow-up. RESULTS: The mean operating time (153 v 99 minutes), hospital stay (3.6 v 2.3 days), and return to unrestricted daily activities (15 v 5.8 weeks) were shorter in group II. Average time to radiographically evident fusion was shorter in group I (7.25 weeks v 9 weeks). There was a significant increase in grip strength and in range of motion at final follow-up in both groups, and the final grip strength and range of motion was not different between the groups. There were no major complications in either group. CONCLUSIONS: Although the number of patients was small and the follow-up period was short, arthroscopic scaphocapitate fusion and capitate pole excision in stage IIIA and IIIB Kienböck's disease resulted in shorter operating time, shorter hospital stay, earlier return to unrestricted daily activities, and equal range of motion and grip strength as compared with open scaphocapitate fusion and lunate revascularization. Determination of specific surgical indications for the benefits of arthroscopic treatment of Kienböck's disease must be analyzed in larger studies.

Conservative treatment of eminentia intercondylaris fractures of the tibia in children.

Seventeen patients (16 children, 1 adolescent) were reviewed 31 months to 71 months after sustaining the common childhood fracture of the eminentia intercondylaris of the tibia. The aim was to assess long-term results and prognosis by clinical and radiological examination and to discover whether conservative treatment was adequate for type I and type II fractures according to Meyers and McKeever. Early improvement occurred in all patients after conservative treatment, but long-term results were not satisfactory in displaced fractures,which were treated with closed reduction and immobilization in extension. Therefore, anatomic reduction and rigid fixation should be obtained for displaced fractures of the eminentia intercondylaris of the tibia.

Cervical and lumbar spinal changes diagnosed in four-view radiographs of 732 military pilots.

BACKGROUND: Pilots who fly jet fighters or helicopters frequently experience vertebral problems due to acceleration and vibration, wearing helmets and other headgear, and sitting in suboptimal postures. METHODS: We looked for spondylarthritic or spondylitic changes in 4-view radiographs (AP, lateral, left and right oblique) of the cervical and lumbar vertebrae of 732 pilots and 202 non-flying controls. The subjects included 91 F-16 jet pilots, 363 other jet pilots, 119 transport pilots, and 159 helicopter pilots. RESULTS: The prevalence of cervical changes in helicopter pilots was 19%, significantly higher than those for other pilots (8-13%) or controls (10%). There was no difference among groups with respect to prevalence of lumbar changes. Among all pilots, compression fractures were more common in the lumbar region than in the cervical region. Age was the most important variable related to spondylarthritic or spondylitic changes in all subjects, whereas height was an important factor only among jet pilots. CONCLUSION: We found an increased prevalence of cervical changes, especially osteoarthritis, in helicopter pilots. Increasing age and tall stature were associated with an increased prevalence of vertebral spondylarthritic or spondylitic changes in jet pilots.

Synovial abrasion for isolated, partial thickness, undersurface, medial meniscus tears.

Synovial abrasion and rasping provides good healing potential of isolated, partial thickness, undersurface medial meniscal tears. It is an effective, easy, and valuable treatment modality.

The sole arch indices of adolescent basketball players.

OBJECTIVE: The aim of this study was to find out the difference between sole arch indices of adolescent basketball players and an age matched non-athletic group. METHODS: This study was carried out in the Sports Education, Health and Research Center, Ankara, Turkey, between November 1998 and December 1998. In junior (16-18 years) categories 48 male basketball players and 45 age matched controls were included in the study. Body mass index and podoscopic sole images of subjects were recorded, and the arch index was calculated for each group. RESULTS: The sole arch index has no difference between basketball players and controls. The right foot arch index of the control group was 59.62 +/- 23.26 and 56.74 +/- 17.21 in players (p=0.497). The left foot arch index was 54.54 +/- 23.72 in control groups and 55.13 +/- 17.33 in players (p=0.890). There was a significant negative correlation between sole arch index and training age in basketball players (r=-0.3312 for right sole arch index, p value is less than 0.05; r=-0.3056 for left sole arch index, p less than 0.05). CONCLUSION: These results have shown that basketball might result in specific adaptation on sole arches of adolescent players.

[Wrist injuries in children and adolescent athletes: macrotrauma and overuse]. / Cocukluk ve ergenlik döneminde el bilegi yaralanmalari: Makrotravma ve asiri kullanim.

Young children and adolescents are becoming increasingly involved in recreational and professional sports. This inevitably leads to an increase in the number of sports-related injuries involving the hand and the wrist. Hence, physicians should have a good insight into macro- and microtraumas affecting the hand and the wrist. Prevention of injuries, correction of muscle-tendon imbalances, and maintenance of strength and flexibility are important issues for the prevention of disabilities in this age group.

[Patellar instability: arthroscopic surgery, indications and techniques]. / Patellar instabilite: Artroskopik cerrahi, uygulama, endikasyon ve teknikler.

A significant incidence of knee pain and disability arises from patellofemoral disorders. An accurate diagnosis relies both on a comprehensive history and a careful physical examination; radiologic modalities also play an important part in the diagnosis and follow-up. Most patellofemoral disorders can be examined in three groups: pain due to soft tissue abnormalities, patellar instability, and patellofemoral osteoarthritis. Conservative therapy can be successful in many patellofemoral disorders. Surgical treatment consists of lateral release, medial plication and reconstruction of the medial patellofemoral ligament, proximal and distal realignments, patellar osteotomies, and patellectomy. In traumatic dislocations primary reconstruction or arthroscopy assisted medial stabilization can be performed.

Rice body mass formation mimicking a neoplastic disease around the trochanteric bursae of the hip.

Multiple rice body formation is an uncommon inflammatory process. Sometimes it leads to a big mass in unusual locations. Although sometimes associated with bursitis and systemic diseases, such as rheumatoid arthritis, the pathophysiology of this rare entity is still obscure. We present a 29-year-old woman with multiple rice body mass formation in the trochanteric bursa of the left hip. She was operated, and had no recurrence at 18 months after the surgery.

Arthroscopic treatment of synovial chondromatosis of the ankle.

We report a case of synovial chondromatosis of the ankle joint, which has been successfully treated with arthroscopic removal of loose bodies and synovectomy, with the patient immediately returning to school and activities of daily living. Recovery after arthroscopic debridement and loose body removal is much shorter in comparison with arthrotomy, and there is no need of immobilization postoperatively.

A complete supra-patellar plica with an unusual presentation.

A suprapatellar plica is a persistent remnant of the embryologic synovial membrane between the suprapatellar pouch and the knee joint. Pathologic synovial plica is not a common entity, however, when present, it can mimic a variety of clinical situations. We describe here a case of pathologic suprapatellar plica that has a check-valve mechanism, which results in a clinical presentation as knee joint swelling.