Ogden Type IV Tibial Tuberosity Fractures in Healthy Adolescents: Preoperative Magnetic Resonance Imaging and 2-Year Clinical Follow-up Study

Background@#Ogden type IV tibial tuberosity fractures, defined as a type of fracture with posterior–inferior metaphyseal extension (Salter-Harris type II variant), are uncommon but challenging pediatric fractures. The purpose of this study was to investigate the clinical and radiological presentation and associated surgical outcomes. @*Methods@#Ten previously healthy patients who had been surgically treated at the authors’ institution between 2015 and 2018 with at least 2 years of postoperative follow-up were included. Demographic, clinical, and radiological characteristics and treatment/ follow-up data were investigated. @*Results@#All included patients were male. All injuries resulted from jump-landings. Unacceptable remaining angular deformity after closed reduction, particularly increased posterior tibial slope angle, was the leading cause of surgery. All preoperative magnetic resonance images (MRIs) showed entrapped periosteum on the anteromedial side of the proximal tibial physis. Surgical removal of the entrapped periosteum achieved successful reduction. Metaphyseal fracture angles between the fracture plane of the metaphyseal beak and the posterior tibial condyle on the axial image of MRI were relatively constant, with an average of 24.3° ± 6.0°. Mean bone age at the time of trauma was older than mean chronological age (16.4 ± 1.0 years vs. 14.6 ± 1.1 years, respectively; p = 0.005).All patients reached skeletal maturity within 2 postoperative years, with little posttraumatic residual height growth (mean, 1.6 ± 0.7 cm from injury to skeletal maturity). At final follow-up, no patients showed significant angular deformity, tibial length discrepancy, or functional deficit. @*Conclusions@#In healthy adolescents, Ogden type IV tibial tuberosity fractures typically occur by jump-landing injuries, when they have little residual growth remaining. Therefore, accurate fracture reduction was required because of limited remodeling potential.Patients with unacceptable reduction should be investigated for entrapped periosteum on the anteromedial side of the physis because it was the primary obstacle in achieving adequate reduction.

Injury Characteristics and Predisposing Effects of Various Outdoor Traumatic Situations in Children and Adolescents

Background@#Many studies have reported injury characteristics of individual traumatic situations. However, a comparative analysis of specific risks is meaningful to better understand injury characteristics and help establish injury-prevention measures. This study was conducted to investigate and compare injury characteristics in children and adolescents by various outdoor traumatic situations. @*Methods@#Outdoor traumatic situations were determined and classified into physical activity-related injury (n = 3,983) and pedestrian (n = 784) and passenger (n = 1,757) injuries in traffic accidents. Home injury (n = 16,121) was used as the control group. Then, the characteristics of each outdoor trauma were compared with 1:1 matched indoor trauma (among home injuries); each outdoor traumatic situation’s predisposing risk for the injured body part, injury type, and injury severity were analyzed; and changes by age of frequency ranking among physical activity-related injuries were investigated. @*Results@#Outdoor trauma showed higher risks for limb injuries (injured body part), fracture and muscle/tendon injuries (injury type), and severe injuries (severity) than indoor trauma. Various outdoor traumatic situations presented different predisposing effects on injury characteristics. Among physical activity-related injuries, bicycle injury was commonest across all ages, and playing activities were common causes for injury for individuals of age < 9 years, whereas sports activities overwhelmed the common causes thereafter. @*Conclusions@#The findings would help to better understand the specific injury risk of various outdoor traumatic situations and may potentially facilitate the establishment of more effective injury-prevention measures.

Injury Characteristics and Predisposing Effects of Various Outdoor Traumatic Situations in Children and Adolescents

Background@#Many studies have reported injury characteristics of individual traumatic situations. However, a comparative analysis of specific risks is meaningful to better understand injury characteristics and help establish injury-prevention measures. This study was conducted to investigate and compare injury characteristics in children and adolescents by various outdoor traumatic situations. @*Methods@#Outdoor traumatic situations were determined and classified into physical activity-related injury (n = 3,983) and pedestrian (n = 784) and passenger (n = 1,757) injuries in traffic accidents. Home injury (n = 16,121) was used as the control group. Then, the characteristics of each outdoor trauma were compared with 1:1 matched indoor trauma (among home injuries); each outdoor traumatic situation’s predisposing risk for the injured body part, injury type, and injury severity were analyzed; and changes by age of frequency ranking among physical activity-related injuries were investigated. @*Results@#Outdoor trauma showed higher risks for limb injuries (injured body part), fracture and muscle/tendon injuries (injury type), and severe injuries (severity) than indoor trauma. Various outdoor traumatic situations presented different predisposing effects on injury characteristics. Among physical activity-related injuries, bicycle injury was commonest across all ages, and playing activities were common causes for injury for individuals of age < 9 years, whereas sports activities overwhelmed the common causes thereafter. @*Conclusions@#The findings would help to better understand the specific injury risk of various outdoor traumatic situations and may potentially facilitate the establishment of more effective injury-prevention measures.

Analysis of Tertiary Hospital Utilization in Pediatric Orthopaedics:a Study Using Nationwide Sample Data from Korea

Background@#In the Korean medical system, the severity classification for a specific disease depends primarily on its nationwide admission rate in tertiary hospitals. Inversely, one of the important designation criteria for a tertiary hospital is the hospital's treatment ratio of patients classified as having a specific severe disease. Most diseases requiring pediatric orthopaedic surgery (POS) are not currently classified as high severity in terms of disease severity. We investigated the admission rates for the representative POS diseases in tertiary hospitals and compared these rates with those for adult orthopaedic surgery (AOS) diseases. @*Methods@#Seven POS diagnoses and three AOS diagnoses were selected based on frequency of admission. Nationwide sample data were used to investigate the admission rates for these representative diagnoses from 2008 to 2017. @*Results@#Six of the seven frequent POS diagnoses presented high admission rates in tertiary hospitals (62.5–92.3%). In contrast, all frequent AOS diagnoses presented low admission rates in tertiary hospitals. @*Conclusion@#The admission rates of frequent POS diagnoses in tertiary hospitals are high.Considering that these rates are the most important factors for the classification of disease severity, POS diseases seem to be underestimated in terms of severity. This may lead to a tendency for tertiary hospitals to intentionally reduce the admission of children with POS diseases. As a result, these children may not receive appropriate professional care. Therefore, for the disease severity, POS diseases should be classified differently from general AOS diseases by using different criteria reflecting the patient's age.

MRI in Suspected Acute Septic Arthritis of the Hip Joint in Children / 대한고관절학회지

PURPOSE: The purpose of this study is to assess the usefulness of magnetic resonance imaging (MRI) in diagnosis, planning of treatment methods for suspected acute septic arthritis in children, and evaluation of the clinical results of the operations with the help of magnetic resonance imaging as a diagnostic modality. MATERIALS AND METHODS: Between March 2003 and May 2007, 20 patients suspected of having acute septic arthritis of the hip underwent MRI. The mean age of the patients was 3 years and 5 months (range: 10 days-14 years). The average follow-up was 2 years and 2 months (range: 1 year-3 years 6 months). Assessment of MRI findings and final results with recurrence of the infection and post-infectious radiographic sequelae was performed retrospectively. RESULTS: Among the 20 cases, 17 cases(85%) showed joint effusion. Among these 17 cases, accompanying signal changes were observed in the meta-epiphyseal region in seven cases, and accompanying signal changes were observed in surrounding soft tissue in three cases. Accompanying abscess formation was observed in one case. The remaining three cases(15%), which had no joint effusion, showed an intramuscular abscess pocket around the joint, which mimicked septic arthritis. At final follow up, two cases showed unsatisfactory results, with limited joint motion and radiographic sequelae. CONCLUSION: In children who are suspected of having acute septic arthritis of the hip, MRI can provide useful information about the location and extent of infection and even the differential diagnosis of acute septic arthritis. MRI was considered to be a useful method for diagnosis of suspected acute septic arthritis in children.

Comparison of Flexible Intramedullary Nailing with External Fixation for Treating Pediatric Femoral Shaft Fractures / 대한정형외과학회잡지

PURPOSE: We wanted to compare the outcome of the flexible intramedullary nailing with that of external fixation for treating pediatric femoral shaft fractures. MATERIALS AND METHODS: Forty-two cases of pediatric femoral shaft fractures were reviewed of which thirty cases of femoral segments were treated with the flexible intramedullary nailing (the FIN group) and the other 12 cases were treated with the external fixation (the EF group). The average age of the patients was 6.9 years and the mean follow-up was 28.8 months. The clinical outcome and complications were evaluated. RESULTS: In all cases, the reduction was maintained until complete union. In the FIN group there were 20 excellent, 8 satisfactory and 2 poor results whereas there were 6 excellent, 4 satisfactory and 2 poor results in the EF group. Among the complications that required re-admission, there was one case of refracture and one case of deep infection in FIN group; one case of refracture, one case of pin breakage and three cases of deep infections in the EF group. CONCLUSION: Flexible intramedullary nailing may result in better clinical results and fewer complications when compared with the external fixation, and so the flexible intramedullary nailing may be the treatment of choice for the treatment of pediatric femoral shaft fractures, except for open fractures or fractures with severe soft tissue injury.

Diagnostic Approach of Acute Leukemia in Children with Bone and Joint Pain / 대한정형외과학회잡지

PURPOSE: To investigate the factors that indicate the requirement of a bone marrow study for a diagnosis of acute leukemia in children with bone and joint pain. MATERIALS AND METHODS: 170 children less than sixteen years old were diagnosed with acute leukemia. Eighteen (11%) of these patients, whose presenting complaints were pain in the extremities and back, were included in this study. The laboratory tests, radiographs and bone scan of patients were reviewed to identify the diagnostic clues that would indicate the need to perform a bone marrow study. RESULTS: The mean age of the patients at the time of diagnosis was 6.8 years. The CBC test revealed abnormal findings such as anemia, leukocytosis/leukocytopenia or thrombocytosis/thrombocytopenia in 15 patients. The peripheral blood smear revealed immature blast cells in 14 patients. In the remaining 4 patients, MRI and bone scan revealed diagnostic clues of a hematological malignancy that indicated the need for a bone marrow study. Based on these diagnostic clues, a bone marrow study was performed to confirm acute leukemia. CONCLUSION: Orthopedic surgeons must have high index of suspicion of acute leukemia in children with atypical bone and joint pain. A complete blood count and peripheral blood smear may be used as a screening test, and MRI may be helpful for diagnosing acute leukemia.

Comparative Study of the Clinical Results between Arthroscopic Multiple Drilling and Autologous Osteochondral Grafting for Osteochondral Lesions of the Talus / 대한정형외과학회잡지

PURPOSE: We compared the clinical results between arthroscopic multiple drilling and autologous osteochondral grafting for osteochondral lesions of the talus. MATERIALS AND METHODS: Twelve patients underwent arthroscopic multiple drilling that left the remaining cartilage at the lesions, and ten patients underwent autologous osteochondral grafting for detached cartilage lesions. We performed a modified Brostrom procedure for 9 of the cases with combined lateral ankle instability in both groups. The average follow-up period was 12.4 months. The mean ages were 31 and 28 years old, respectively. The results were compared between the two groups by assessing the AOFAS scores and patient satisfaction, based on subjective symptoms. RESULTS: The mean pre-operative AOFAS scores were 70 in the arthroscopic multiple drilling group and 70.3 in the autologous osteochondral grafting group. The post-operative AOFAS scores were 78.8 in the arthroscopic multiple drilling group and 93.5 in the autologous osteochondral grafting group (p<0.05). Patient satisfaction after multiple drilling was good in 3 cases, fair in 4 cases, poor in 5 cases, and pre-operative symptoms were not improved at all in 4 cases. After autologous osteochondral grafting, 7 cases were good and 3 were fair. CONCLUSION: The study demonstrated that in the treatment of osteochondral lesions of the talar dome, the results of autologous osteochondral grafting were superior to those of arthroscopic multiple drilling.

Diagnostic Value of Ultrasonography for Acute Tear of Tibiofibular Syndesmosis in Ankle / 대한족부족관절학회지

PURPOSE: We studied the diagnostic value of ultrasonography to confirm the presence of the syndesmosis injuries in the ankle. MATERIALS AND METHODS: Pre-operative ultrasonography were taken in 42 cases of ankle fractures to determine injury of syndesmosis between February 2000 and August 2003. Tear of syndesmosis was confirmed when they met the following criteria; widening of distal tibiofibular clear space greater than 7 mm on pre-operative AP X-rays, leakage of contrast dye during intra-operative arthrography, and operative findings revealing syndesmosis rupture. We compared these diagnoses with those made by pre-operative ultrasonography. RESULTS: Syndesmosis injuries were confirmed in 23 cases among the total 42 cases. Ultrasonography revealed syndesmosis tear in 25 cases, with 20 cases corresponding with confirmed tear and 5 cases without tear in confirm. Syndesmoses were found to be intact in 17 cases of ultrasonograph, but 3 cases were actually confirmed tear. In ankle ultrasonography, the sensitivity was 90.9%, the specificity was 75.0%. CONCLUSION: Preoperative ultrasonography is a non-invasive and useful study to determine the syndesmosis injury in ankle fractures.

Distribution of Lengths of the Normal Femur and Tibia in Korean Children from Three to Sixteen Years of Age

To develop a standard growth curve of the lower extremity in Korean children from 3 to 16 yr of age, the lengths from a total of 2087 normal long bone segments (582 femurs and 645 tibias in boys, and 417 femurs and 443 tibias in girls) were measured. Children were grouped by years of bone age, which was determined by using the Korean specific bone age standard; TW2-20 method. The growth spurt occurred in girls from eight to eleven years by bone age, and in boys from eleven to thirteen years. The mean tibial length relative to the mean femoral length was 0.78 in boys and 0.79 in girls. The overall growth pattern was similar to that observed in American children in the 1960s. Korean children and adolescents appear to have a different tempo of skeletal maturation during pubertal growth from that of English and American children and adolescents. The Korean standard growth curve and the Korean bone age chart allow determination of the presence of any existent growth abnormalities and prediction of future remaining growth in lower extremities. These normative growth standards can be used for leg-length equalization purposes in children with anisomelia.

Changes in the Expressional Levels of Sarcoplasmic Reticulum Ca2+-regulatory Proteins in the Postnatal Developing Rat Heart

In the present study, the postnatal developmental changes in the expressional levels of cardiac sarcoplasmic reticulum (SR) Ca2+ regulatory proteins, i.e. Ca2+-ATPase, phospholamban, and Ca2+ release channel, were investigated. Both SR Ca2+-ATPase and phospholamban mRNA levels were about 35% of adult levels at birth and gradually increased to adult levels. Protein levels of both SR Ca2+-ATPase and phospholamban, which were measured by quantitative immunoblotting, were closely correlated with the mRNA levels. The initial rates of Ca2+ uptake at birth were about 40% of adult rates and also increased gradually during the myocardial development. Consequently, the relative phospholamban/Ca2+-ATPase ratio was 1 in developmental hearts. Ca2+ release channel (ryanodine receptor) mRNA was about 50-60% at birth and increased gradually to adult level throughout the postnatal rat heart development. 3[H]ryanodine binding increased gradually during postnatal myocardial development, which was closely correlated with ryanodine mRNA expression levels during the development except the ryanodine mRNA level at birth. These findings indicate that cardiac SR Ca2+- ATPase, phospholamban, and Ca2+ release channel are expressed coordinately, which may be necessary for intracellular Ca2+ regulation during the rat heart development.

A Proposal for Classification of Children's Ankle Fracture / 대한정형외과학회잡지

PURPOSE: The purpose was to propose a new classification of children's ankle fracture and to evaluate the therapeutic and prognostic efficacy. MATERIALS AND METHODS: The new classification is based on the number of fractured structures among three anatomical landmarks (articular surface, growth plate of the distal tibia and the growth plate of the distal fibula). Type I: one of the landmarks is fractured. Type II: two are fractured. Type III: all three are fractured. Type IV: crushing injury of either growth plate or the articular surface of the distal tibia. Type V: Intra-articular triplane fracture of the distal tibia. We analysed the final results obtained using the modified Weber protocol. RESULTS: Of the thirty-five cases, we classified twenty-one as Type I, (excellent 17, good 4); three as Type II, (excellent 2, good 1); four as Type III, (excellent 2, good 2); two as Type IV, (fair 2); and five as Type V, (excellent 3, good 2). CONCLUSION: Most children's ankle fractures are classified using the proposed classification. However, the number of patients and the follow up period were not enough to generalize the proposed method. In the future, a more prospective, systemic study will be needed.

Tourniquet Induced Hypertension and Vital Sign Changes in Patients with Total Knee Replacement Arthroplasty under General Anesthesia with Enflurane or Propofol / 대한마취과학회지

BACKGROUND: The tourniquet is associated with severe hemodynamic changes and tourniquet-induced hypertension (T-HTN). Propofol is preferred as an anesthetic agent for rapid induction and recovery, and less nausea and vomiting. The aim of this study was to find the difference in hemodynamic changes and the T-HTN in patients with total knee replacement arthroplasty receiving enflurane or propofol anesthesia. METHODS: One hundred patients underwent total knee replacement arthroplasty were divided into four groups; enflurane-control (n = 22), enflurane-elderly (n = 28), propofol-control (n = 22), propofol-elderly (n = 28). Mean arterial blood pressure (MAP), heart rate (HR) and end-tidal CO2 (PETCO2) were recorded throughout the operations of each group. Statistical analysis was done using repeated measures of ANOVA, chi-square test (P < 0.05). RESULTS: MAP increased in the propofol group during the tourniquet inflation period compared to the period before tourniquet inflation. The incidence of T-HTN in the propofol group (58%) was higher than that of the enflurane group (36%). HR increased in the enflurane group just after tourniquet inflation. PETCO2 decreased during 20 60 minutes after tourniquet inflation in the propofol group (P < 0.05). MAP decreased and PETCO2 increased during the 1, 5 minutes after tourniquet deflation in all groups. There were minimal HR changes after tourniquet deflation in all groups. CONCLUSIONS: T-HTN occurrence and MAP were shown to be higher in the propofol anesthesia and both enflurane and propofol can be used as an anesthetic agent for total knee replacement arthroplasty without complications.

The Effect of Fluid Flow Induced Shear Stress on the Prostaglandin E2 and Nitric Oxide Production of Osteoblast / 대한정형외과연구학회지

It has been generally known that bone tissue responds to the mechanical stress with an adaptative change in the mass and the structure. Recently, the signal transduction pathways involved in fluid flow have been reported, and several mechanotransduction products were suggested. This study was designed to verify the prostaglandin E2(PGE2) and nitric oxide(NO) involving as the biomechanical transducing material of the osteoblast to the fluid flow stimuli. We have checked changes in PGE2 and NO production after applying fluid flow-induced shearing stress to the primary high-density monolayer cultures of chicken fetus osteoblasts. PGE2 and nitrite which is the stable end-product of nitric oxide oxidationas are measured spectrophotometrically, the former using enzyme immunoassay system and the latter using Griess reaction. As a result, PGE2 and NO production by osteoblast was increased after applying the fluid flow-induced shear stress: PGE2 production was increased accumulatively in response to the duration of stress. There were no significant changes in NO production after 6 hours of the stress, but production of NO was markedly increased only after 24 hours. From the above findings, it was confirmed that osteoblast increased the production of PGE2 and NO in respond to the fluid flow-induced shearing stress and that PGE2 production is an earlier response to mechanical stimuli than the production of NO.

The Reliability of HSS Knee Rating System

PURPOSE: The rating system of Hospital for Special Surgery(HSS knee score) has been used to evaluate the clinical results of knee arthroplasty, but it may happen to interobserver bias. The purpose of this study is to detect how much and what it could make the bias. MATERIALS AND METHODS: From Sept 1998 to May 1999, HSS score of 115 cases of knee which were planned for total knee arthroplasty were caku4ted by three observers(knee joint specialist: A, orthopedic specialist: B, orthapedic resident: C) and compared the result with Wilcoxon sided ranks test for the eval-uation of statistical differences and the Kappa statistics for the test of statistical reliability. RESULTS: The mean HSS knee scores of observer A, B, C were 64.8 points, 61.] points and 59.4 points respectively. The average difference were average 4.8 point in total score and it was statistically significant(p<0.05) and The items of pain(walking, at rest) and function(walking distance) showed least agreements(k<0.20). CONCLUSIONS: More objective and quantitative criteria is needed in the items of pain on walking and at rest and distance of walking for accurate evaluation of results using HSS system.

Treatment of Tibial Medial Bone Defect in Primary TKA

There are several rnethods to correct the tibial bony defect including resection, cement filling, autograft or allograft and metal augmentation. The purpose of this study is to find the adequate treatment method of tibia bony defect through analysis of the result with above methods. From Sep. 1993 to Dec. 1997, the authors analyzed 93 cases of tibial medial bony defect corrected by overresection of lateral condyle, allograft and metal wedge or block among 358 cases of primary total knee arthroplasty(TKA) operated at Asan Medical Center. All cases were devided into four groups according to the treatment method; group A(31 cases) with overresection of lateral condyle, group B(37 cases) with metal wedge, group C(21 cases) with metal block and group D(4 cases) with allograft. The mean follow up period was 23.6 months(12 56 months). The results were as follows, 1. There were no definite statistical difference between group A, B, C and D in HSS knee score, ROM, correction of deformity. But in group D, there is one case of loss of the correction. 2. Loosening of the implant was not noted, but 17 cases of mild bony resorption was found just beneath the implant. It was particularly prominent in group B(9 cases) than group A(5 cases) and C(3 cases). 3. Among 4 cases of allograft, one has developed collapse of allograft. 4. 3 cases of deep infection developed only in group C, which were followed by revision TKA. Although further follow up study should be carried out, we concluded that resection of lateral tibial condyle, allograft, metal augmentation is a good substitute to the correction of the tibial bony defect in primary TKA.

The Discrepancy between Eipcondylar and Posterior Condylar Axis of Femur in Total Knee Arthroplasty

PURPOSE: This study was to measure the angle between the femoral epicondylar axis and the femoral posterior condylar axis, to clarify which axis can be used as a guideline to achieve proper rotational align- ment of femoral component in total knee arthroplasty. MATERIAL AND METHODS: From Jan. 1997 to Dec. 1998, the axial images of MRI of 121 patients who sustained acute knee injury were selected to measure the posterior-epicondylar angle(the angle between the femoral epicondylar axis and the femoral posterior condylar axis). Congenital anomaly or any fracture cases were all excluded. Comparisons were made according to gender and ages and the student t-test was used to evaluate the statistical differences. RESULTS: The mean posterior-epicondylar angle was a 4.8(+- 2.0) and there was no significant statisti- cal difference between gender and ages except 3rd decade. CONCLUSION: It can induce an insufficient external rotation of the femoral component in total knee arthroplasty, if we usually do 3 of external rotation of femoral component from the posterior condylar axis.

Prediction of Rotationally Neutral State of the Femur by Comparing with the Shape of Contra-lateral Lesser Trohanter / 대한정형외과학회잡지

PURPOSE: To evaluate the accuracy and reliability of method for prediction of rotationally neutral state of the femur by comparing with contra-lateral lesser trochanter. MATERIALS AND METHODS: The rotationally neutral state of the femur was measured by comparing the shape of the opposite side of the lesser trochanter in a normal group of 100 adult. Each examination was performed independently by three observers. The observers predicted a position presumed to be neutral by comparing the shape of lesser trochanter with that of contra-lateral side previously recorded by the C-arm image intensifier. We evaluated the mean angular discrepancy that is different from the neutral point and assessed the inter-observer variations. RESULTS: The mean angular discrepancy (SD) was 3.4 degree(+/-2.4); 3.5 degree(+/-2.4) by observer-1,3.5 degree (+/-2.8) by observer-2, 3.2 degree(+/-2.2) by observer-3. There was no inter-observer variation (p=0.87). 77% of all observers indicated below 4 degree and no one over 15 degree. CONCLUSIONS: The method of comparing the shape of both lesser trochanters is considered to be effective in determining the rotational status of the femur. It could be used as a practical method in the operation of the femoral fracture for prevention of rotational deformity intra-operatively

Reconstruction of the Posterolateral Instability of the Knee / 대한정형외과학회잡지

PURPOSE: This study reports the results of a treatment for posterolateral instability of the knee with a modified Muller's method. MATERIALS AND METHODS: Fourteen patients (3 acute and 11 chronic cases) with a modified Muller's method and with a follow-up period of more than 12 months, average follow-up period of 15 months (range, 12 to 22 months) was included. We recorded and analysed the physical findings (reverse Lachmann test and varus stress test at 30 degree knee flexion), stress roentgenograms at preoperative 8 postoperative 12 months, magnetic resonance imagings and Lysholm score at preoperative, postoperative 3, 12 months and the last follow-up. RESULTS: Average Lysholm score was 65A preoperatively and 90.0 at postoperative 12 months. The posterolateral stabilities of the knee were improved in all cases postoperatively, according to the clinical stability tests (reverse Lachmann test and varus stress test at 30 degree knee flexion) and stress roentgenograms. CONCLUSIONS: Modified Muller's technique-the reconstruction of the popliteus tendon using iliotibial band-represents an excellent method to restore tension in the posterolateral complex of the acutely and chronically injured knee.

A Case of 2q+ Syndrome Identified by Fluorescent In Situ Hybridization

We experienced a case of 2q+ syndrome in a neonate who had multiple congenital anomalies of long philtrum, a bow-shaped mouth, long fingers, and its second and fifth fingers overlapped with the third and the fourth. In the cytogenetic studies using G banding technique, an extra band of the distal long arm of chromosome 2 was shown. Because its extra chromosomal segment was too small and the parents' chromosome were normal, it was difficult to determine the origin of the additional segment. We could find the fluorescent signal from the extra chromosomal segment by using painting probe of chromosome 2. The karyotype of the patient was confirmed as 46, XX, 2q+. We reported the case with the review of the associated literatures.