Achilles tendon-splitting approach and double-row suture anchor repair for Haglund syndrome.

BACKGROUND: Haglund syndrom is characterized as a painful posterosuperior deformity of the heel with possible causes as tight Achilles tendon, high-arched foot and tendency to walk on the outside of the heel. Surgical treatment may be recommended in cases where of insufficient response to nonoperative treatment. This study aims to evaluate the clinical and radiographic results of central Achilles tendon splitting and double-row suture anchor technique in the surgical treatment of patients with Haglund syndrome. METHODS: 27 patients with Haglund syndrome who underwent central Achilles tendon splitting and double-row suture anchor were retrospectively evaluated. The results were evaluated by the pre- and post-operative American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and visual analogue scale (VAS). All patients were evaluated radiographically to assess lateral talus-first metatarsal angle (TMTA), Calcaneal pitch angle (CPA), and the Fowler-Philip angle (FPA) preoperatively and postoperatively. RESULTS: The mean preoperative AOFAS score was 47 ± 7 points; at the end of the follow-up period, it increased to 92 ± 4 points (p < 0.001). The mean preoperative VAS score was 9 ± 0.9 points; at the end of the follow-up period, it was 2 ± 0.6 points (p < 0.001). The lateral TMTA (preoperative: 5° ± 2°; follow-up: 4° ± 2°; p < 0.001), CPA (preoperative: 21° ± 5°; follow-up: 20° ± 5°; p = 0.005) and FPA (preoperative: 55° ± 6°; follow-up: 32° ± 3°; p < 0.001) values decreased at the end of the follow-up period. CONCLUSION: In the absence of an improvement to nonoperative treatment methods, central Achilles tendon-splitting approach appears to be an effective and safe treatment option. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Editorial Commentary: Anatomic or Not, the Tunnel Will Get Wider!

In our experience, arthroscopic tunnel widening is one of the major complications after anterior cruciate ligament (ACL) reconstruction. Even though this complication doesn't require an acute correction or intervention, patients with failed ACL reconstruction along with tunnel widening may need a 2-stage revision in which we have to fill the gap in the tunnels first. Otherwise, this tunnel widening after ACL reconstruction doesn't affect the clinical outcomes of the primary surgery and it won't affect the success of the surgery in the aspects of clinical and functional outcomes.

Bilateral spontaneous atraumatic rupture of the Achilles tendon in an athlete.

We report a case of spontaneous, bilateral Achilles rupture in a 33-year-old man with no specific risk factors. The rupture occurred after a heavy impact during a sports activity, and although the rupture was painful, he was able to mobilize slowly. After a clinical examination confirmed the diagnosis, ultrasonography and magnetic resonance imaging evaluation of the Achilles tendons revealed bilateral ruptures. The patient underwent bilateral conservative treatment and subsequently embarked on a comprehensive rehabilitation program with a good functional outcome at follow-up. The patient's return to premorbid work and social life was uneventful. A spontaneous rupture in a patient without any predisposing risk factors is uncommon, and for it to occur bilaterally is notably rare.

Effects of boric acid on the healing of Achilles tendons of rats.

PURPOSE: Tendinous lesions are among the most frequent pathologies encountered in sportsmen. The objectives of new treatments are to improve the healing process and reduce the recovery time. Boron plays an important role in the wound repair process by increasing components of extracellular matrix and angiogenesis. This animal study aimed to investigate the effect of boric acid on healing of the Achilles tendon. METHODS: The right Achilles tendons of 40 rats were completely sectioned, and the rats were randomly divided into five groups. Each group consisted of eight rats. Groups 1 and 2 were oral boric acid groups with the doses of 4 and 8 mg/kg/day boric acid, respectively. Group 3 was the local boric acid group (8 mg/kg boric acid intratendinous injection). Group 4 was administered both oral and local boric acid (8 mg/kg/day orally and 8 mg/kg boric acid intratendinous injection), and group 5 was the control group with no boric acid application. At the end of the fourth week, all the rats were killed and histopathological examination of the Achilles tendon repair site was made. RESULTS: Histopathological examination of the tissue sections revealed more properly oriented collagen fibres, more normal cellular distribution of tenocytes and more properly organized vascular bundles in group 1 and group 2, which were the groups administered oral boric acid. Pathological sum scores of groups 1 and 2 were less than those of the other groups, and the differences between the oral boric acid groups (group 1 and group 2) and the other three groups (groups 3, 4 and 5) were statistically significant (p = 0.001). CONCLUSION: As boric acid is safe and toxicity even after very high doses is unusual, oral boric acid may be used as an agent to improve the healing process of tendon injuries. However, biomechanical tests should also be performed to show the effect of boric acid on strength and endurance of the tendon before it can be used in clinical practice.

Anterior cruciate ligament reconstruction using a hamstring graft: a retrospective comparison of tunnel widening upon use of two different femoral fixation methods.

PURPOSE: To compare femoral and tibial tunnel widening (TW) in patients undergoing anterior cruciate ligament (ACL) reconstruction using an interference screw (IS), or an EndoButton-Continuous Loop(®) on the femoral side, and an IS/staple on the tibial side. METHODS: Between 2006 and 2009, at a single institution, 72 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring tendon grafting were retrospectively reviewed. Fixation was performed, and with the EndoButton-Continuous Loop(®) device (Group Ι) in 48 patients (mean age 29.1 ± 7.3 years) with a bioabsorbable IS (Group ΙΙ) in 24 patients (mean age 28.5 ± 8.4 years) on the femoral side. Evaluation included standardized anteroposterior (AP) and lateral radiography. The diameters of tunnels at the last follow-up visit (at a median time of 17 months postoperatively) were compared to those noted on radiographs taken 1 day postoperatively. RESULTS: The two groups were similar in terms of age and gender distribution, the operated side, the size of the tunnel created, and the follow-up period (n.s.). Femoral TW at the proximal and middle levels (on both AP and lateral views) in Group ΙΙ was significantly greater than in Group Ι (p < 0.050 for all comparisons). No significant difference in femoral TW at the distal level was evident between the groups, and tibial TW at all levels was similar in both groups (n.s.). CONCLUSION: Femoral TW is less after EndoButton-Continuous Loop(®) fixation and not reduced after IS fixation. Surgeons should be aware of TW when selecting a fixation device for hamstring graft. LEVEL OF EVIDENCE: Therapeutic, retrospective comparative study, Level III.

Intralesional curettage and cementation for low-grade chondrosarcoma of long bones: retrospective study and literature review.

BACKGROUND: Various treatment strategies for low-grade chondrosarcomas with variable outcomes have been reported in the literature. The aim of this study was to assess the oncological and functional outcomes associated with intralesional curettage followed by adjuvant therapy comprising high-speed burring, thermal cauterization, and bone cementation with polymethylmethacrylate. METHODS: We performed a retrospective review of 21 consecutive patients with intramedullary low-grade chondrosarcoma of long bones treated by intralesional curettage and adjuvant therapy comprising high-speed burring, thermal cauterization, and cementation at our institution from 2007 to 2012. RESULTS: The average age of the patients was 48.7 (range, 18-71) years. There were 7 male and 14 female patients. The mean follow-up period was 58.4 (range, 26-85) months after surgery. The treated lesions were located in the proximal humerus (n=10), proximal tibia (n=6), and distal femur (n=5). At the average follow-up time point of 58.4 (range, 26-85) months, no patient had developed local recurrence and no distant metastases were observed. The average Musculoskeletal Tumor Society score among all 21 patients was 95% (84-100). CONCLUSIONS: The combination of intralesional curettage, application of high-speed burring, thermal cauterization, and cementation is an effective treatment strategy for low-grade intramedullary chondrosarcoma of long bones. Excellent oncological and functional results can be obtained.

Evaluation of Metatarsal Head Resurfacing Hemiarthroplasty in the Surgical Treatment of Hallux Rigidus: A Retrospective Study and Mid- to Long-Term Follow-up.

BACKGROUND: The aim of this study was to evaluate the mid- to long-term outcomes of metatarsal head resurfacing hemiarthroplasty in the surgical treatment of advanced-stage hallux rigidus. METHODS: We performed a retrospective review of 57 consecutive patients (25 [43.9%] males, 32 [56.1%] females; mean age, 61.0 ± 6.4 years) who underwent first metatarsal head resurfacing hemiarthroplasty (HemiCAP) for hallux rigidus between August 2007 and September 2010. Sixty-five implantations were performed in 57 patients; 8 patients underwent bilateral procedures. All patients were clinically rated prior to surgery and at the final follow-up visit using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and first metatarsophalangeal joint range of motion (MTPJ ROM). RESULTS: The median follow-up duration was 81 (range = 8-98) months. The median preoperative AOFAS score was 34 (range = 22-59) points, which had increased to 83 (range = 26-97) points at the final follow-up visit (P < .001). The median preoperative first MTPJ ROM was 25° (range = 15° to 40°), which had increased to 75° (range = 30° to 85°) at the final follow-up visit (P < .001). CONCLUSIONS: First MTPJ hemiarthroplasty is an effective treatment method that recovers toe function and first MTPJ ROM, and provides good mid- to long-term functional outcomes. LEVELS OF EVIDENCE: Level IV: Retrospective case series.

A comparison between metatarsal head-resurfacing hemiarthroplasty and total metatarsophalangeal joint arthroplasty as surgical treatments for hallux rigidus: a retrospective study with short- to midterm follow-up.

PURPOSE: We evaluated the short- to midterm outcomes of metatarsal head-resurfacing hemiarthroplasty and total metatarsophalangeal joint arthroplasty (total joint replacement [TJR]) as surgical treatments for advanced-stage hallux rigidus (HR). PATIENTS AND METHODS: From 2012 to 2014, all data from patients who underwent surgery for the treatment of grades 2-3 HR were retrospectively reviewed, and 45 patients were included in this study. Of these patients, 26 underwent metatarsal head-resurfacing hemiarthroplasty (Group I) and 19 underwent TJR (Group II). All patients were clinically graded prior to surgery and at their final follow-up visits using the American Orthopedic Foot and Ankle Society's (AOFAS) hallux metatarsophalangeal-interphalangeal scale, a visual analog scale (VAS), and the "first metatarsophalangeal joint range of motion" (MTPJ ROM) score. RESULTS: Metatarsal head resurfacing was performed on 26 patients. Two patients underwent bilateral procedures, yielding a total of 28 cases in Group I. TJR was performed on 19 patients in Group II. Of the 26 Group I patients, 12 (46.2%) were male and 14 (53.8%) were female, with a mean age of 56.3±4.5 years (range: 47-63 years); the mean follow-up duration was 29.9±5.2 months. Of the 19 Group II patients, eight (42.1%) were male and eleven (57.9%) were female, with a mean age of 57.1±5.8 years (range: 45-66 years); the mean follow-up duration was 27.1±7.5 months. Significant improvements were evident in the AOFAS scores, and the VAS scores decreased, in both groups. No significant difference was evident between groups I and II. CONCLUSION: After failure of conservative treatment in patients with moderate-to-severe HR, both MTPJ hemiarthroplasty and TJR were associated with effective recovery of toe function and MTPJ ROM, as well as good short- to midterm functional outcomes.

Long-term result of arthroplasty in the treatment of a case of ochronotic arthropathy.

Alkaptonuria is a rare metabolic disease caused by a partial or total deficiency of homogentisic acid oxidase, which results in excess homogentisic acid (HGA) levels. Homogentisic acid and its oxidation products can accumulate in hyaline cartilage, tendons, and ligaments. A 55-year-old male was admitted complaining of worsening chronic pain in his left knee. A radiographic evaluation showed tricompartmental end- stage osteoarthritis. A cemented total knee replacement was performed. At the 10-year follow-up, he had returned to full activity, had no knee pain, and was very satisfied with the outcome. No abnormality was observed in the femoral, tibial, or patellar components on radiography. We believe that total knee replacement is a good option in a patient with marked degenerative arthritis secondary to ochronotic arthritis.

Surgical versus conservative treatment following acute rupture of the Achilles tendon: is there a pedobarographic difference?

INTRODUCTION: Controversy remains regarding the optimal treatment method and postoperative rehabilitation of acute Achilles tendon ruptures. In this study, pedobarographic assessments of surgical and conservative treatments were compared. MATERIAL AND METHODS: A prospective assessment was made of 16 patients (eight surgical, eight conservative) and eight healthy controls using a plantar pressure measurement system. Biomechanical gait parameters were obtained using the Footscan dynamic gait analysis system. Kruskal-Wallis and Mann-Whitney U-tests were used for the evaluation of data. RESULTS: Nineteen males and five females were assessed, with an average age of 42.0±11.9 years. Follow-up was completed in 16 patients. No statistically significant difference was determined between the two treatment groups with regard to the gait analysis, but a difference was observed with the control group (P<0.001). All patients were able to resume their prior activities after 6 months and regained normal ranges of motion, with a high rate of satisfaction. Most of the patients (75%) were able to return to their pre-injury level of activities. CONCLUSION: Satisfactory results were obtained through conservative treatment of acute ruptures of the Achilles tendon. No significant differences or complications were observed in the group managed conservatively versus the group treated surgically. Further studies including 3D gait analyses and tendon biomechanical research are required to further investigate this issue.

Scintigraphic evaluation of the osteoblastic activity of rabbit tibial defects after HYAFF11 membrane application.

BACKGROUND: An unfavorable condition for bone healing is the presence of bone defects. Under such conditions, a material can play a role to cover fractured or defective bone. Technological advances now allow for the use of such material. Hyalonect(®) (Fidia Advanced Biopolymers SLR, Italy), a novel membrane comprising knitted fibers of esterified hyaluronan (HYAFF11) can be used to cover fractured or grafted bone and can also serve as a scaffold to keep osteoprogenitor cells in place. The aim of this study was to compare osteoblastic activity by the use of scintigraphic methods in defective rabbit tibias during early-phase bone healing with or without a hyaluronan-based mesh. METHODS: Two groups (A and B) of New Zealand albino rabbits were used; each group included 10 animals. Operations on all rabbits were performed under general anesthesia. We also resected 10-mm bone segments from each animal's tibial diaphysis. After resection, tibias with defects were fixed using Kirschner wires. In group A, no hyaluronan-based mesh was used. In group B, tibial segmental defects were enclosed with a hyaluronan-based mesh. The rabbits were followed up for 4 weeks postoperatively, after which bone scintigraphic studies were performed on each animal to detect and compare osteoblastic activity. RESULTS: The mean count in the fracture side of the hyaluronan-based mesh group was significantly higher compared to that of the group A (p = 0.019). However, there was no significant difference between group B and control rabbits with respect to the mean count on the intact bone side (p = 0.437). The bone defect (fracture)/intact bone mean count ratio was significantly higher in group B compared to group A (p = 0.008). CONCLUSIONS: A hyaluronan-based mesh plays a role in promoting osteoblastic activity. Hyalonect(®) is suitable for restoring tissue continuity whenever the periosteal membrane is structurally impaired or inadequate. Our results demonstrated that, during early-phase bone healing, osteoblastic activity was increased in bone defect sites when a hyaluronan-based mesh was also used. The most important aspect of this study concerns its scintigraphy-based design. This study is the first to use a scintigraphic method to demonstrate the effectiveness of hyaluronic acid-based material for bone healing.

Reconstruction of periacetabular tumours with saddle prosthesis or custom-made prosthesis, functional results and complications.

Reconstruction after resection of pelvic tumours is a major challenge. We report the outcomes and complications of 7 patients who underwent limb salvage following type II or type II, III pelvic resection and reconstruction using a saddle prosthesis or custom-made hemipelvic prosthesis. In our opinion, reconstruction using custom-made prostheses is better than placement of saddle prostheses because of a lower risk of complications and improved functional outcomes.

A mechanically locked knee joint due to free-floating flake-shaped rice bodies: a case report.

Originating from the synovium, multiple free-floating intra-articular particles, called rice bodies, typically resemble cartilage and have a fibrin structure. While the etiology of rice body formation is unclear, they often occur in rheumatoid arthritis and other seronegative arthropathies; they also occur in tuberculosis, though the incidence is much lower. They are often encountered by rheumatologists or clinical orthopedists. A 33-year-old female who suffered from occasional swelling and pain of her left knee for 3 months was admitted with a mechanically locked knee. Free-floating rice bodies were identified on magnetic resonance imaging (MRI), and arthroscopic intervention was performed for diagnostic and therapeutic purposes. After the removal of all bodies and effusion with mechanical irrigation, an arthroscopic subtotal synovectomy was performed.

Wound management with vacuum-assisted closure in postoperative infections after surgery for spinal stenosis.

OBJECTIVE: To evaluate the results of negative-pressure wound therapy (NPWT) in the treatment of surgical spinal site infections. MATERIALS AND METHODS: The use of NPWT in postoperative infections after dorsal spinal surgery (transforaminal lumbar interbody fusion plus posterior instrumentation) was studied retrospectively. From February 2011 to January 2012, six patients (females) out of 317 (209 females; 108 males) were readmitted to our clinic with surgical site infections on postoperative day 14 (range 9-19) and were treated with debridement, NPWT, and antibiotics. We evaluated the clinical and laboratory data, including the ability to retain the spinal hardware and recurrent infections. RESULTS: The incidence of deep postoperative surgical site infection was six (1.89%) patients (females) out of 317 patients (209 females; 108 males) at 1 year. All patients completed their wound NPWT regimen successfully. An average of 5.1 (range 3-8) irrigation and debridement sessions was performed before definitive wound closure. The mean follow-up period was 13 (range 12-16) months. No patient had a persistent infection requiring partial or total hardware removal. The hospital stay infection parameters normalized within an average of 4.6 weeks. CONCLUSION: The study illustrates the usefulness of NPWT as an effective adjuvant treatment option for managing complicated deep spinal surgical wound infections.

Bilateral septic knee arthritis after treatment of an ectopic pregnancy with methotrexate.

We describe a case of bilateral septic knee arthritis that followed the administration of methotrexate for nonsurgical termination of an ectopic pregnancy. We believe that methotrexate is a relatively effective alternative to surgery in patients with early unruptured tubal pregnancies, but suggest that it be used with caution in view of possible septic events.

Acute forearm compartment syndrome in a newborn caused by reperfusion after spontaneous axillary artery thrombosis.

Acute compartment syndrome of the forearm in newborns is often misdiagnosed and can be disastrous if left untreated. Here, we report a full-term infant of a diabetic mother with underlying heterozygosity for MTHFR C677T and A1298C alleles. A spontaneous thrombosis occurred in the left axillary artery immediately after birth. The patient responded well to anticoagulant (heparin) and thrombolytic (tissue plasminogen activator) agents. After reperfusion of the extremity, acute compartment syndrome developed. Emergent fasciotomy was performed. In this case, effective collaboration between pediatricians and orthopedic surgeons resulted in salvage of the extremity, with good clinical and functional results.

Reducing blood loss in simultaneous bilateral total knee arthroplasty: combined intravenous-intra-articular tranexamic acid administration. A prospective randomized controlled trial.

BACKGROUND: We asked whether tranexamic acid (TXA) administration could reduce blood loss and blood transfusion requirements after simultaneous bilateral total knee arthroplasty (TKA). This study examined the role of a novel method of TXA administration in TKA. METHODS: TXA was administered as a bolus dose of 15 mg/kg 10 min before the inflation of the tourniquet on the first side. This was followed by intra-articular administration of 3 grams at 10 min before the deflation of the tourniquet. IV infusion of 10 mg/kg/h was continued for 3h following completion on the second side. We measured volume of drained blood 48 h postoperatively, decrease in hemoglobin levels 12h postoperatively, amount of blood transfused (BT), and number of patients requiring allogenic BT. RESULTS: Median postoperative volume of drained blood was lower in the group receiving TXA (500.00 mL) than in control subjects (900.00 mL) (p <0.05) [95% CI (-525.00) to (-300.00)]. The median hemoglobin decrease 12 h postoperatively was lower in patients receiving TXA (2.10 g/dL) than in control subjects (3.10 g/dL) (p<0.05) [95% CI (-1.60) to (-0.60)]. The amount of BT and number of patients requiring BT were lower in patients receiving TXA than in control subjects. Nevertheless, the number of allogeneic units of packed red blood cells transfused in the postoperative period was not significantly higher in the control group than in the TXA group (p=0.109) [95% CI (0.101) to (0.117)]. CONCLUSIONS: This prospective randomized study showed that during simultaneous bilateral TKA, TXA reduced blood loss with negligible side effects.

Iliac bone cysts adjacent to the sacroiliac joint: an unusual cause of sacroiliac pain.

OBJECTIVE: The aim of this study was to describe cystic bone lesions involving the sacroiliac region of the iliac bone as a rare cause of sacroiliac joint-related pain. METHODS: The study included 9 patients with benign cystic bone lesion in Zone 1 according to Enneking and Dunham with a minimum of 2 years follow-up. Detailed radiological examination was performed using magnetic resonance imaging or computed tomography. Extended curettage, adjuvant treatment with phenol and thermal cauterization and bone grafting with auto/allografts were performed. Patients were analyzed for age of onset, side of involvement, clinical and radiological findings, tumor stage, complications and clinical/radiological findings at the final follow-up. RESULTS: Female to male ratio was 4 to 5. Average age at the time of diagnosis was 40.3 (range: 27 to 54) years. Average diameter of the lesion was 6.6 (range: 4 to 11) cm. Superficial infection was detected in one patient and hypoesthesia around the site of incision in two. Clinical improvement in pain and limp was reported in all patients. No radiological recurrence was detected after an average follow-up time of 30.7 (range: 21 to 40) months. CONCLUSION: Benign tumor-like cystic lesions should be kept in mind in the differential diagnosis of sacroiliac joint-related pain. Such lesions can be safely and effectively managed with intralesional curettage, local adjuvant methods and bone grafting.

Comparison of bone tissue trace-element concentrations and mineral density in osteoporotic femoral neck fractures and osteoarthritis.

PURPOSE: This study examined the role of trace elements in osteoporosis by comparing the trace-element concentrations in bone and the radiographic bone density and bone mineral density (BMD) of patients with osteoporotic femur fractures and osteoarthritis. PATIENTS AND METHODS: The study enrolled 30 patients operated on for proximal femoral fractures after falls, and another 30 patients undergoing hip arthroplasty at the same center for hip osteoarthritis. Bone samples were obtained during the surgical procedures. The density of the bone samples was assessed using computed tomography and the Hounsfield scale. The levels of Ca(II), Mg(II), and other trace elements in the bone samples were determined using flame atomic absorption spectrometry and inductively coupled plasma mass spectrometry. In addition, BMD, Z-scores, and T-scores were measured in the unaffected hips of all patients using dual-energy X-ray absorptiometry. RESULTS: Magnesium (1,908 ± 507 versus 2,540 ± 435, P<0.05), calcium (10.4 ± 3.5 versus 13.9 ± 3.7, P<0.05), and zinc (2,342 ± 1,252 versus 3,145 ± 1,604, P<0.05) µg g(-1), levels were significantly lower in the bone samples in the fracture group. The groups did not differ in the other biochemical parameters. All dual-energy X-ray absorptiometry findings were significantly worse in the fracture group than in the osteoarthritis group. However, the groups did not differ in femoral neck density assessed radiologically using the Hounsfield scale. The following parameters were negatively correlated with age: magnesium, r=-0.436, P<0.001; calcium, r=-0.331, P=0.01; T-score, r=-0.381, P=0.003; Z-score, r=-0.267, P=0.043; and BMD, r=-0.365, P=0.004. CONCLUSION: Ca(II), Mg(II), and Zn(II) appear to play important roles in bone breakdown/synthesis. Further studies of the roles of trace elements in the etiology and treatment of osteoporosis are warranted. We found decreased bone levels of Ca, Mg, and Zn in patients with osteoporotic fractures compared to subjects with osteoarthritis.