Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection.

PURPOSE: The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection. METHOD: Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems. RESULTS: In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher (P < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher (P < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems (P < 0.001). CONCLUSION: Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone. LEVEL OF EVIDENCE: Randomized, controlled trial, Level I.

Multiple osteochondroses and avulsion fracture of anterior superior iliac spine in a soccer player.

Apophysitis describes a chronic traction injury at the insertion site of a tendon. There is a gradual onset of pain with no clear history of injury. Without adequate preventive methods, an avulsion fracture may result. The case is here reported of an apophyseal avulsion fracture of the anterior superior iliac spine in an adolescent caused by playing football before the end of treatment for apophysitis. An open reduction and internal fixation was performed followed by a rehabilitation programme. No complications occurred, and the patient had returned to his previous level of sporting activity after six weeks.

Obstetrical brachial plexus palsy: an analysis of 105 cases.

Obstetrical brachial plexus palsy (OBPP) remains a dramatic consequence after complicated childbirth. An increasing number of methods are being developed for the physical therapy and the early repair of the nerve lesions in OBPP, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can be reconstructed using soft tissue and skeletal procedures. In this article we analyze our approach to 105 patients to obtain optimal functional outcome in patients with OBPP.

Arthroscopic partial resection of the discoid meniscus in children.

Thirteen children with 14 lateral discoid menisci were reviewed at an average follow-up of 2.7 years. Their average age at the time of the operation was 12.8 years. Most of the children had vague and intermittent painful symptoms, and the classical "clunk" was demonstrable in nine of the 13 patients in clinical examinations. Thirteen children underwent arthroscopic partial meniscectomy for symptomatic discoid lateral meniscus, by performing partial resection. This procedure, modifying the discoid lateral meniscus to the normal semilunar shape, was indicated only when the capsular attachment was intact. The results were excellent both clinically and radiologically. Furthermore, rehabilitation time was considerably shorter than the time required after open procedures. Arthroscopic discoid meniscus surgery performed by experienced and skilled hands gives better results. According to the literature and our experiences, it is better to perform open techniques in patients with stiff knees. Additionally, it is technically feasible to use small joint instruments in the pediatric age group.

Treatment of congenital dislocation of the hip. Results of closed reduction and immobilization in the hip spica cast.

Treatment of congenital dislocation of the hip (CDH) by closed reduction and immobilization in the hip spica cast is one of the accepted methods for use in patients under one year of age. We report 74 congenitally dislocated hips treated with premanipulation skin traction, closed reduction under anesthesia, adductor tenotomy and immobilization in the hip spica cast. Satisfactory results were obtained in 60 hips. In seven hips, avascular necrosis of the capital femoral epiphysis was observed with careful management, closed reduction and immobilization in a spica cast provides good results for treatment of CDH.

Arthroscopy-assisted anterior cruciate ligament reconstruction with patellar tendon or hamstring autografts.

Isolated ACL reconstructions were performed in 138 patients between 1994 and 1998. Patellar bone-patellar tendon-bone, and hamstring tendon autografts were used in 88 patients, and allografts were used in 50 patients. Eighty-eight knees of 88 patients with autograft reconstructions (17 female, 71 male) were included in this study and evaluation of the patients with allograft reconstruction reported separately. The mean age at the time of the operation was 32 years. All ACL reconstructions were performed arthroscopically. Twenty-seven bone-patellar tendon-bone, and 61 hamstring tendon autografts were used. The mean follow-up was 29 months. In the postoperative course the Lachman test was negative in 62 patients, 1+ in 22 patients, and 2+ in 4 patients. In 17 patients, anterior drawer sign were 1+ in comparison to the contralateral side. Pivot shift test was moderately positive only in 5 cases in the bone-patellar tendon-bone and hamstring tendon autograft groups postoperatively. There were 3 patients with subjective "giving way" symptoms. Second look arthroscopy revealed rupture of the neo-ligament. Arthroscopic washout and debridement were performed, and no revision ligamentoplasties were performed. Two of these patients improved with accelerated proprioceptive physical therapy, and one had to decrease his previous level of activity. There were no cases of arthrofibrosis, infection, or extension lag. Clinical results of patellar bone-tendon-bone and hamstring groups did not show any significant clinical difference. Avoiding the disturbance of the extensor mechanism of the knee is probably the most significant advantage of the hamstring autograft.

Effect of low-dose N-acetyl-cysteine infusion on tourniquet-induced ischaemia-reperfusion injury in arthroscopic knee surgery.

BACKGROUND: Temporary occlusion of blood flow is used during arthroscopic knee surgery in order to provide a bloodless surgical field. The resulting ischaemia-reperfusion causes lipid peroxidation, which contributes to tissue injury. The aim of the study was to investigate the effect of low-dose n-acetyl cysteine (NAC) infusion on oxidative stress by determining malondialdehyde (MDA) levels during arthroscopic knee surgery. METHODS: Thirty patients, ASA I - II, undergoing arthroscopic knee debridement under a tourniquet were divided into NAC and control groups. Anaesthesia was induced with propofol, fentanyl and vecuronium bromide and maintained with desflurane in an equal parts O(2)-N(2)O mixture. In the NAC group, an infusion of NAC, 5 mg kg(-1).h(-1), was started after intubation, and continued until extubation. An equal volume of saline was infused to the control group. Duration of ischaemia, anaesthesia time, total dose of NAC infused were also recorded. Venous blood and synovial membrane tissue samples were obtained 10 min after the onset of NAC infusion but before tourniquet inflation (t1), after 30 min of ischaemia (t2), and after 5 min of reperfusion following tourniquet release (t3). RESULTS: Plasma MDA levels were significantly lower in the NAC group on reperfusion. There were no differences between the groups in tissue MDA levels at ischaemia and reperfusion times. CONCLUSION: Low-dose n-acetyl cysteine infusion attenuates lipid peroxidation and ischaemia-reperfusion injury in arthroscopic knee surgery requiring tourniquet application.

Bilateral discoid medial menisci: association with bone changes in the tibia.

We present here the third case report of bilateral discoid medial menisci with associated bone changes. An 18-year-old man had bilateral medial tibial plateau depression (cupping) accompanying medial discoid menisci documented by magnetic resonance imaging and confirmed by arthroscopy. The patient was treated successfully by excision of the torn central anomalous discoid portion of the menisci using arthroscopic partial resection technique.

Arthroscopic fixation of the fractures of the intercondylar eminence via transquadricipital tendinous portal.

We describe a new technique for arthroscopic reduction and internal fixation of fractures of the intercondylar eminence of the tibia. In this technique cannulated screws are placed through a new portal (transquadricipital tendinous) instead of anteromedial arthroscopic portal. Twelve patients who were treated with this technique for displaced types II and III fractures of the intercondylar eminence of the tibia were reviewed after a mean of 49 months. At follow-up all patients had excellent or good results, without any case of nonunion of the fracture or related complications, such as functional instability. Placement of cannulated screws through transquadricipital tendinous portal achieves fragment reduction easily, provides rigid fixation while avoiding arthrotomy, allowing early mobilization and return to activity.