Effect of cilostazol on healing of achilles tendon ruptures: an experimental study on rats.

PURPOSE: This study aimed to evaluate whether cilostazol (phosphodiesterase III inhibitor) could enhance the healing of Achilles tendon ruptures in rats. MATERIALS AND METHODS: The Achilles tendons of 24 healthy male adult rats were incised and repaired. The rats were randomly allocated to cilostazol and control groups. The cilostazol group received daily intragastric administration of 50 mg/kg cilostazol for 28 days, while the control group did not receive any medication. The rats were sacrificed on the 30th day, and the Achilles tendon was evaluated for biomechanical properties, histopathological characteristics, and immunohistochemical analysis. RESULTS: All rats completed the experiment. The Movin sum score of the control group was significantly higher (p = 0.008) than that of the cilostazol group, with means of 11 ± 0.63 and 7.50 ± 1.15, respectively. Similarly, the mean Bonar score was significantly higher (p = 0.026) in the control group compared to the cilostazol group (8.33 ± 1.50 vs. 5.5 ± 0.54, respectively). Moreover, the Type I/Type III Collagen ratio was notably higher (p = 0.016) in the cilostazol group (52.2 ± 8.4) than in the control group (34.6 ± 10.2). The load to failure was substantially higher in the cilostazol group than in the control group (p = 0.034), suggesting that the tendons in the cilostazol group were stronger and exhibited greater resistance to failure. CONCLUSIONS: The results of this study suggest that cilostazol treatment significantly improves the biomechanical and histopathological parameters of the healing Achilles tendon in rats. Cilostazol might be a valuable supplementary therapy in treating Achilles tendon ruptures in humans. Additional clinical studies are, however, required to verify these outcomes.

Increased Involvement of Staphylococcus epidermidis in the Rise of Polymicrobial Periprosthetic Joint Infections.

BACKGROUND: In this study, we aimed to analyze the temporal distribution of polymicrobial periprosthetic joint infections (PJIs), while also evaluating the patient risk factors associated with these infections following total joint arthroplasty at our institution across 2 distinct periods. METHOD: This retrospective cross-sectional study evaluated 259 patients who had knee or hip PJI from 2001 to 2006 and 2018 to 2022. A PJI was diagnosed using the 2018 International Consensus Meeting criteria. We utilized the Polymicrobial Pathogens' Co-occurrence Network Analysis, a novel approach that leverages network theory to map and quantify the complex interplay of organisms in PJIs. RESULTS: Of the 259 patients who had polymicrobial PJI, 58.7% were men, with mean age 67 years (range, 24 to 90). Of the 579 identified pathogens, Staphylococcus epidermidis was the most common (22.1%), followed by Staphylococcus aureus (9.0%) and Cutibacterium acnes (7.8%). The co-occurrence analysis indicated that Staphylococcus epidermidis frequently coexisted with Cutibacterium acnes (26 cultures) and Staphylococcus capitis (22 cultures). A notable increase in body mass index from 27.7 ± 4.4 in 2001 to 2006 to 29.7 ± 6.2 in 2018 to 2022 was observed (P = .001). Moreover, infections from Staphylococcus epidermidis, Cutibacterium acnes, and Staphylococcus capitis saw a significant uptick (P < .001). CONCLUSIONS: The study shows that from 2001 to 2022, there was a significant change in the pathogens responsible for polymicrobial PJIs, particularly an increase in Staphylococcus epidermidis, Cutibacterium acnes, and Staphylococcus capitis. Alongside these microbial changes, there was a rise in body mass index and shifts in comorbid conditions, such as more renal disease and fewer cases of congestive heart failure. These changes highlight the dynamic interplay between host and microbial factors in the pathogenesis of polymicrobial PJIs, necessitating adaptive strategies in both surgical and postoperative care to mitigate the rising tide of these complex infections.

Risk factors associated with breakage of tibio-fibular syndesmotic screws.

PURPOSE: This retrospective study aimed to investigate the factors associated with the breakage of tibio-fibular syndesmotic screws (SS). METHODS: 69 patients with unstable AO-Weber Type 44-B ankle fractures who underwent three cortex SS (3.5 mm ø) fixation were included. Patients were followed for at least one year (mean, 18.3 ± 7.6 months). At the final follow-up, patients with broken (Group I) and intact (Group II) SS were compared regarding age, gender, height, weight, body mass index, fracture type, SS length, location, and orientation. Multivariate logistic regression was used to identify the independent risk factors associated with SS breakage. The sensitivity, specificity, cut-off value, and area under the ROC curve were analyzed. RESULTS: A stepwise backward logistic regression analysis revealed that age was the only independent predictor for SS breakage (OR = 0.938, 95% CI = 0.904-0.973, R2 = 0.270). ROC curve analysis demonstrated that patients younger than 36 years were associated with seven times increased risk of SS breakage [Odds ratio (95% CI), 7.042 (2.251-22.031)]. CONCLUSION: Age under 36 years was the only significant risk factor for SS breakage. The higher incidence of breakage of the syndesmotic screw can be informed to patients younger than 36.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review.

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint.

PURPOSE: The success of medial patellofemoral ligament (MPFL) reconstruction is closely linked to the precise positioning of the femoral tunnel. Intraoperative fluoroscopy is commonly utilized to identify the MPFL footprint. This study aimed to ascertain the most accurate fluoroscopic method among the five previously described methods used to determine the MPFL femoral footprint. MATERIALS AND METHODS: Using 44 well-preserved dry femur bones, the MPFL femoral insertion site was demarcated using anatomical bony landmarks, namely the center of the saddle sulcus between the medial epicondyle, adductor tubercle and gastrocnemius tubercle. Fluoroscopic true lateral knee images were acquired and measurements taken, referencing established methods by Schottle et al., Redfern et al., Wijdicks et al., Barnett et al., and Kaipel et al. The distance between anatomic and fluoroscopic MPFL footprints was then measured on digital fluoroscopic images. The accuracy of the locations was compared using a margin of error of 5 and 7 mm. RESULTS: The Schottle method consistently emerged superior, showcasing the smallest mean distance (3.2 ± 1.2 mm) between the anatomic and radiographic MPFL footprints and a high in-point detection rate of 90.9% under 5 mm criteria. While the Redfern method displayed perfect accuracy (100%) within the 7 mm criteria, the Schottle method also performed 97.7% accuracy. CONCLUSIONS: For intraoperative identification of the MPFL footprint using fluoroscopy, the Schottle method is the most consistent and accurate among the assessed methods. Thus, its accuracy in detecting the MPFL footprint makes it recommended for MPFLR to ensure optimal outcomes. LEVEL OF EVIDENCE: Level IV, cadaveric study.

Surface morphology of osteochondral grafts harvested from femoral condyles with free-hand technique: a cadaveric study.

PURPOSE: The purpose of this cadaver study was to examine the surface morphology of the osteochondral grafts harvested from the femoral condyles using the free-hand graft harvesting technique. MATERIALS AND METHODS: One hundred osteochondral grafts were harvested with 6.5 mm chisels at ten different donor sites using the free-hand technique in five paired knee specimens (Mean age: 56.4 years). The cartilage and subchondral bone surface angles were measured through multiplanar reconstruction computerized tomography examination. The cartilage thickness was measured with a MicroScribe G2X digitizer with an accuracy of 0.02 mm. An acceptable congruity could be obtained when these plugs were transferred to a perpendicular socket (articular step-off of less than 1 mm and 0.5 mm) was evaluated. RESULTS: Four plugs were damaged or broken during harvesting due to technical difficulties; thus remaining 96 plugs were analyzed. The cartilage thickness varied between 1.36 mm and 3.26 mm across the donor sites. The cartilage was the thinnest in the medial intercondylar notch and thickest in the lateral supracondylar notch. Twenty of ninety-six plugs (20.8%) had unacceptable cartilage surface inclination according to the > 0.5 mm protrusion criteria. Of these plugs, 14 were harvested from the lateral intercondylar notch, whereas five of 96 plugs (5.2%) had unacceptable cartilage surface inclination according to the > 1 mm protrusion criteria. Of these plugs, all were harvested from the lateral intercondylar notch. CONCLUSIONS: High rates of unacceptable plugs (up to 100%) might be harvested from the lateral intercondylar notch. In large chondral lesions that require multiple plugs, lateral and medial supracondylar ridges were the best donor sites for perpendicular plug harvesting, whereas lateral intercondylar notch should be avoided.

Comparison of two versus three-screw fixation for biplanar chevron medial malleolar osteotomy.

PURPOSE: This study was designed to compare the clinical outcomes and complications of using two versus three screws to fix the biplanar chevron medial malleolar osteotomy (MMO). PATIENTS AND METHODS: A retrospective review was conducted on 43 patients (46 ankles) who underwent biplanar chevron MMO to treat talus osteochondral lesions. Of these, MMO was fixed with two parallel screws placed perpendicular to the osteotomy plane in 16 ankles, while in the remaining 30 ankles, MMO was secured with two parallel screws plus an additional third screw inserted parallel to the tibial plafond. Patients were divided into two groups based on the fixation method and clinical outcomes, union and malunion rates, and complications were compared. RESULTS: Demographic and clinical characteristics such as age (p: 0.411), gender distribution (p: 0.119), affected side (p: 0.126), lesion grades (p: 0.056), and lesion sizes (p: 0.310), immobilization (p: 0.119) and weight-bearing periods (p: 0.252) were statistically similar across both groups. Initial malreduction were observed in five cases within the three-screw group and one case in the two-screw group (p: 0.307). However, neither group exhibited any progressive step-off or gap in the follow-up radiographs, and osteotomy union was achieved in all patients. Delayed union was observed in one patient from the three-screw group. Significant improvements in American Orthopedic Foot and Ankle Society scores were observed in both groups, with no functional discrepancies evident at the final follow-up (p: 0.488). CONCLUSIONS: The study found no significant differences in union rates, complications, or clinical outcomes between two and three-screw fixation methods for medial malleolar osteotomies (MMO). Both methods allowed for effective MMO fixation without loss or displacement post-surgery, suggesting their safety and efficacy. LEVEL OF EVIDENCE: Level III, retrospective comparison.

Effect of antioxidant lycopene on human osteoblasts.

OBJECTIVE: The aim of this in vitro study is to evaluate the effect of antioxidant lycopene on human osteoblasts. MATERIAL AND METHOD: The human osteoblast cell line (CRL-11372) was obtained from the American Type Culture Collection (ATCC Manassas, Va) and grown in Dulbecco's Modified Eagle's medium (DMEM) supplemented with 10% fetal calf serum (FCS), penicillin (100 U/ml), and streptomycin (100 mg/ ml) at 37 °C in a humidified atmosphere of 5% CO2 and 95% air. The effective dose of lycopene was determined by MTT assay and a real-time cell analysis (RTCA) system. Proliferative effects were analyzed by in vitro wound healing model. Gene expressions of type 1 collagen (COL1A1), osteocalcin (OCN), and growth differentiation factor-5 (GDF-5) were measured by quantitative real-time polymerase chain reaction (qRT-PCR) at 72 h. Statistical differences between test groups were analyzed with a one-way ANOVA test. RESULTS: MTT assay showed that the doses between 10-5 and 1 µmol of lycopene had dose-dependent proliferative effects. The doses between 10-5 and 10-1 µmol were most effective at 72 h. Lycopene accelerates the healing rate by increasing osteoblast proliferation. CONCLUSION: Results suggested that lycopene had proliferative effects on human osteoblasts, which may help to increase bone regeneration, and thus, it can be useful in tissue engineering procedures. CLINICAL RELEVANCE: By the help of antioxidants like lycopene capacity, velocity and quality of new bone forming may be increased in periodontal and dental implant treatments.

Tranexamic acid is safe and effective in patients with heterozygous factor V Leiden mutation during total joint arthroplasty.

INTRODUCTION: Patients with an inherent hypercoagulable state are at a higher risk of venous thromboembolism (VTE) following total joint arthroplasty (TJA). Further administration of tranexamic acid (TXA) during TJA may increase the risk of VTE in these high-risk patients. There is no study that specifically analyzes the safety and efficacy of TXA during TJA in patients with factor V Leiden (FVL) mutation; therefore, the purpose of this study was to evaluate the safety and efficacy of TXA use on the risk of VTE and bleeding in patients carrying FVL mutation. MATERIALS AND METHODS: A total of 42 patients with FVL mutation (22 hips, 20 knees) and 40 control patients (20 hips, 20 knees) who underwent TJA were retrospectively reviewed. All patients received 1 g TXA intravenously 15 min before the skin incision and 2 g of TXA was administered locally at the surgical site as a periarticular injection. Pharmacological thromboprophylaxis (low-molecular-weight heparin) was administered to all patients. Estimated blood loss and in-hospital thromboembolic complications were compared between the groups. RESULTS: In both total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients, there was no significant difference in the amount of estimated blood loss among the groups (p = 0.980, and p = 0963, respectively). None of the patients in the THA group received a blood transfusion. The transfusion rate was similar in the TKA group (p = 0.756, one patient in each group). No VTE, myocardial infarction, or any other complications related to TXA use were observed in any of the patients. CONCLUSIONS: The combined local and systemic administration of TXA could be safely used in patients with heterozygous FVL mutation receiving pharmacological thromboprophylaxis during TJA without increasing the risk of VTE.

Complications of peroneus longus tendon harvesting: a retrospective review of 82 cases.

OBJECTIVE: Peroneus longus tendon (PLT) has become a reliable autologous graft option for various ligament reconstructions. But there are potential risks and complications associated with its use as a graft. This retrospective study aimed to examine the complications and donor site morbidity following PLT harvesting. PATIENTS AND METHODS: A retrospective review was performed on an institutional digital patient database, and all patients who underwent ligament reconstruction using PLT autograft were identified. Intraoperative, early, and late complications were reviewed using digital patient notes and patients underwent a complete physical examination during their final follow-up. Ankle function was assessed using the AOFAS score, and manual ankle muscle testing was performed on both sides. Sural nerve iatrogenic injury was evaluated with a dermatomal light touch examination. Cosmetic satisfaction due to incision scar and footwear complaints were also assessed. RESULTS: 82 patients (74 male, eight female) with a mean age of 31.9 ± 10.4 years (range, 16-66) were included in the final analysis. The mean follow-up time was 46.6 ± 30.3 months (range, 6-109). The mean AOFAS score for the donor side was 98.7 ± 3.3 (range, 87-100), and the contralateral side score was 100, with manual muscle testing graded as 5 in all movements and similar to the contralateral side. Fifteen patients (18.3%) had hypoesthesia over the dorsolateral aspect of the foot distal to the incision scar, two patients (2.4%) had hyperalgesia over the distal incision scar, and one patient (1.2%) had mild ankle instability. There were two cases (2.4%) of compartment syndrome, both of which were treated with fasciotomy and had complete regression of symptoms after 5 days. One patient (1.2%) had a transient peroneal nerve injury and foot drop that resolved in the sixth month. CONCLUSIONS: The results of this retrospective study suggest that harvesting the PLT is associated with a high rate of complications and donor site morbidity. The most common complication was hypoesthesia around the lateral side of the foot, although the ankle functions were not affected significantly. Two cases of compartment syndrome and one transient peroneal nerve injury were observed. Care should be taken while harvesting PLT autograft, and it should be kept in mind that peroneal nerve injury might occur. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Is the Citak classification of distal femur morphology age and gender dependent?

INTRODUCTION: The purpose of this study was to compare the distal femur morphology in different age and gender groups using the Citak classification. MATERIALS AND METHODS: All patients who had standard knee anteroposterior radiographs between 2010 and 2020 were retrospectively reviewed using the electronic patient database. Patients were divided into three age groups as follows: young adults (Group I, younger than 50 years), middle-aged adults (Group II, ranging from age 51 to 73 years), and elderly (Group III, more than 74 years). From each age group, 80 patients were randomly selected with an equal number of gender (40 males/40 females). An age-stratified selection was applied to obtain the best sample that represents the selected age groups. Patients younger than 18 years of age, history of previous fracture or surgical procedure, those with fixation implants or prosthesis, and abnormalities of the lower limb, such as a congenital deformity, were excluded from the study. All measurements were performed by an experienced orthopedic surgeon familiar with the Citak classification. All measured variables were compared between age and gender groups. RESULTS: There were 240 patients (120 male and 120 female) with a mean age of 59.6 ± 20.4 (range 18-95). The distal femur morphology index was similar (p:0.811), and the morphological types were equally distributed among age groups (p:0.819). Furthermore, there was no significant difference between genders on the measured variables (p > 0.05 for all variables). Citak classification types were similarly distributed between the genders (p:0.153). No correlation was found between age and the Citak index in either gender (p:0.967 and p:0.633, respectively). CONCLUSIONS: Distal femoral morphology classified by the Citak index is not age and gender dependent. Type C, which has a wider diaphyseal diameter, and is supposed to be more common in elderly subjects, was equally distributed in all age groups. LEVEL OF EVIDENCE: Level IV. Retrospective case series.

Comparison of three methods for sealing of the intramedullary femoral canal during total knee arthroplasty; a randomized controlled trial.

PURPOSE: The purpose of this randomized controlled study was to examine the effect of sealing the intramedullary canal with a bone or cement plug or leaving it empty on postoperative bleeding and pain MATERIALS AND METHODS: A total of 120 patients with knee osteoarthritis who underwent unilateral TKA participated in the trial and were assigned to one of three groups. The femoral canal was sealed with an autogenous bone plug (Group I) or cement plug (Group II), or it was left open (Group III). Estimated blood loss, Hemoglobin decline, bleeding into the drain, and postoperative pain w compared between groups. RESULTS: Six patients were excluded due to various reasons, and the remaining 114 patients were included in the final analysis. There were no significant variations in baseline clinical characteristics between the three groups (p > 0.05). Hemoglobin reduction between preoperative and 72 h after the surgery (p: 0.034) and estimated blood loss (p: 0.003) were significantly different between groups. The cement plug group showed the least bleeding. Although there was a significant difference between the cement and empty canal groups (p: 0.03 and p: 0.002, respectively), the difference between the cement and bone groups was similar regarding both hemoglobin reduction and estimated blood loss. The blood volume in the suction drain (p: 0.598) and transfusion rate (p: 0.087) were similar between the groups. VAS at the 12 h after the surgery was similarly high in each group (p: 0.676). It declined at 36 h after surgery, but no significant difference was determined between groups (p: 0.815). CONCLUSIONS: This study showed that estimated blood loss and hemoglobin reduction were significantly lower in the cement plug group than in the empty canal group. But bone plug group did not show any difference with both empty canal and cement plug groups. Sealing the IM canal or leaving it open did not change the bleeding into the drain, transfusion rate, and postoperative pain between groups. Based on these findings, sealing the IM canal with a cement plug might be recommended to diminish bleeding during TKA despite similar transfusion rates. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Comparison of curettage vs. trephination technique for harvesting anterior iliac crest bone graft: A cadaveric study.

PURPOSE: The purpose of this cadaveric study was to compare the volume and weight of bone graft harvested using the curettage vs. the trephination technique from the anterior iliac crest. METHODS: Embalmed cadavers were studied in this experimental research. The right hemipelvis of each cadaver was used for the trephine bone harvesting technique, whereas the left hemipelvis was used for the conventional curettage technique. The weight and the volume of the harvested bone were measured and statistically compared between the 2 sides. The Wilcoxon Signed-Rank test was employed to compare the graft volume and weight obtained from the right and left sides of the hemipelvis. RESULTS: Ten embalmed adult cadavers were used in this study. All subjects were Caucasian males with a mean age of 59.8 years (range 44 - 73 years) at the time of death. A total of 81 cylindrical bone grafts were harvested from the right iliac crest. In 9 out of 81 (11.1 %), the cortex of the ilium was penetrated by the chisel. The mean weight of the bone graft harvested with the trephine technique (26.97 ± 2.32) g was heavier than the curettage technique (23.74 ± 2.09) g (p = 0.007). Similarly, the volume of the bone graft was higher in the trephine technique (8.40 ± 0.84) cm3 compared to the curettage technique (6.60 ± 1.26) cm3 (p = 0.011). The trephination technique lasted a mean of (12.76 ± 1.87) min (range 10.30-16.10 min), while the curettage technique lasted a mean of (14.53 ± 0.89) min (range 13.50-16.00 min) (p = 0.028). CONCLUSION: Harvesting anterior iliac crest bone graft with the trephine technique provides a higher bone volume and weight than the conventional curettage technique. The trephine technique might be advocated over the curettage technique, especially when a large amount of autologous bone graft is required. However, a meticulous harvesting technique should be followed to prevent complications, particularly the three-dimensional anatomy should be kept in mind, and the depth of trephination should be well-controlled. CLINICAL TRIAL REGISTRATION: Institutional Review Board registration: 2022/499.

Comparison of four different screw configurations for the fixation of Fulkerson osteotomy: a finite element analysis.

BACKGROUND: Conventionally, two 4.5 mm cortical screws inserted toward the posterior tibial cortex are usually advocated for the fixation of Fulkerson osteotomy. This finite element analysis aimed to compare the biomechanical behavior of four different screw configurations to fix the Fulkerson osteotomy. MATERIALS AND METHODS: Fulkerson osteotomy was modeled using computerized tomography (CT) data of a patient with patellofemoral instability and fixed with four different screw configurations using two 4.5 mm cortical screws in the axial plane. The configurations were as follows: (1) two screws perpendicular to the osteotomy plane, (2) two screws perpendicular to the posterior cortex of the tibia, (3) the upper screw perpendicular to the osteotomy plane, but the lower screw is perpendicular to the posterior cortex of the tibia, and (4) the reverse position of the screw configuration in the third scenario. Gap formation, sliding, displacement, frictional stress, and deformation of the components were calculated and reported. RESULTS: The osteotomy fragment moved superiorly after loading the models with 1654 N patellar tendon traction force. Since the proximal cut is sloped (bevel-cut osteotomy), the osteotomy fragment slid and rested on the upper tibial surface. Afterward, the upper surface of the osteotomy fragment acted as a fulcrum, and the distal part of the fragment began to separate from the tibia while the screws resisted the displacement. The resultant total displacement was 0.319 mm, 0.307 mm, 0.333 mm, and 0.245 mm from the first scenario to the fourth scenario, respectively. The minimum displacement was detected in the fourth scenario (upper screw perpendicular to the osteotomy plane and lower screw perpendicular to the posterior tibial cortex). Maximum frictional stress and maximum pressure between components on both surfaces were highest in the first scenario (both screws perpendicular to the osteotomy plane). CONCLUSIONS: A divergent screw configuration in which the upper screw is inserted perpendicular to the osteotomy plane and the lower screw is inserted perpendicular to the posterior tibial cortex might be a better option for the fixation of Fulkerson osteotomy. Level of evidence Level V, mechanism-based reasoning.

Anatomic risk factors for the occurrence of medial talar osteochondral lesions: a case-control study.

OBJECTIVE: This study aimed to determine the anatomical risk factors that may play a role in the etiology of medial-sided osteochondral lesions of the talus (OLT) using morphological parameters in magnetic resonance imaging (MRI). SUBJECTS AND METHODS: One hundred twenty-four patients with medial-sided OLT and age- and sex-matched 124 controls were included in this retrospective study. Two examiners conducted independent OLT classification and measurements of five MRI parameters: tibial axis-medial malleolus angle (TMM), the anterior opening angle of the talus (AOT), talus position (TalPos), the ratio of the distal tibial articular surface to the length of the trochlea tali arc (TAS/TAL), depth of the incisura fibularis (IncDep). Statistical analysis included intraclass correlation coefficients, independent t-tests, receiver-operating characteristic (ROC) analysis, area under the curve (AUC) calculation, and logistic regression analysis. A p-value < 0.05 was considered statistically significant. RESULTS: TTM, AOT, TalPos, and TAL values were significantly higher and the TAS/TAL ratio was significantly lower in the case group than in the control group (p < 0.001). Cut-off and AUC values for TMM were 15.15° (AUC 0.763), AOT 13.05° (AUC 0.826), TalPos 0.75 mm (AUC 0.887), TAL 35.45 mm (AUC 0.642), and TAS/TAL ratio 0.82 (AUC 0.784), p < 0.001. Multivariate logistic regression analysis results were odds ratio (OR) = 6.1 for TMM ≥ 15.15°, OR = 8.9 for AOT ≥ 13.05°, OR = 36.1 for TalPos ≥ 0.75 mm, and OR = 6.7 for TAS/TAL ratio ≤ 0.82. CONCLUSION: Ankle morphology might have an influence on OLT development. The talus position (TalPos) and anterior opening angle of the talus (AOT) seemed to be the strongest predisposing factors.

Variations of cross-sectional meniscal morphology between similar-sized menisci: implications on donor selection for meniscal allograft transplantation.

PURPOSE: This study aimed to investigate the morphological variations in the cross-sectional anatomy of the meniscus between similar-sized matched menisci. MATERIALS AND METHODS: Knee MRI of 329 patients with intact menisci were retrospectively reviewed, and the meniscal length (ML), meniscal width (MW), and cross-sectional dimensions (meniscal height and width) of the anterior, posterior horns, and the corpus were measured. Patients with similar-sized menisci who had less than 1 mm difference in ML and MW were matched. 330 male-to-male medial menisci (MM), 623 male-to-male lateral menisci (LM), 82 female-to-female MM, 233 female-to-female LM, 176 cross-gender MM, and 265 cross-gender LM unique combination of ideally matched pairs (total: 1709) were generated. The disparity in the cross-sectional dimensions, absolute difference, and the paired percent differences was statistically analyzed. RESULTS: The ML and MW in all groups were statistically similar, with a predefined absolute difference of 1 mm both for ML and MW (paired percent difference < 5%). The cross-sectional segmental meniscal dimensions were similar within all groups, but the paired percent differences showed high variations between a mean of 12.1-21.5% and up to 150.9%. The paired percent difference of MM in each segmental dimension was similar among different gender combinations. However, segmental paired percent differences of LM showed statistical differences in anterior horn width (AHW) (p: 0.001) and posterior horn width (PHW) (p: 0.001). In subgroup comparisons, the paired percent difference of AHW was higher in the female-to-female group compared to cross-gender (p: 0.023) and male-to-male groups (p: 0.001). The paired percent difference of PHW was smaller in the male-to-male group compared to female-to-female and cross-gender groups (p: 0.001 for both). CONCLUSIONS: Segmental cross-sectional anatomy showed wide variations despite strict matching in ML and MW. These variations were present in all gender combinations. The meniscal 3D shape is unique, but acceptable limits of similarity need further research. LEVEL OF EVIDENCE: Retrospective study, Level III.

Estimating the adequacy of the free quadriceps tendon autograft length using anthropometric measures in anterior cruciate ligament reconstruction.

OBJECTIVE: This prospective study aimed to predict the adequacy of free quadriceps tendon (QT) autograft length using simple anthropometric measures. MATERIALS AND METHODS: One hundred and eighty-four consecutive patients who underwent knee high-resolution MRI were enrolled in this study. The QT and native anterior cruciate ligament (ACL) length were measured using the oblique sagittal section. The adequate free QT length was calculated using the native ACL length and 30 mm for femoral and tibial tunnels in each patient. A QT shorter than the calculated length was considered inadequate. Age, sex, height, weight, body mass index, thigh circumference, and activity score were used to predict the adequacy of QT length with regression analysis. RESULTS: There were 92 men and 92 women with a mean age of 34.1 ± 8.0 years (range 18-45). The mean QT and ACL lengths were 69.0 ± 8.8 mm (range 48.1-90.3 mm) and 35.6 ± 2.5 mm (range 29.2-42.6 mm), respectively. The QT and the ACL lengths were longer in men (p < 0.001 for both). Twenty-three men and 39 women (total: 62, 33.7%) had inadequate QT length for a free QT autograft, and 6 patients (3 males, 3 females, 3.3%) had inadequate QT length with the bone block technique. There was a weak positive correlation between QT length and height (p < 0.001), weight (p < 0.001), and activity score (p = 0.007). Height was the only independent variable that predicted the QT length adequacy (r2 = 0.051, p = 0.009) but ROC analysis showed that height did not have an ability to detect a subject with an inadequate QT length (AUC: 0.384, 95% CI 0.300-0.468). CONCLUSIONS: Free QT autografts may be inadequate in one-third of the patients, while a QT autograft with a bone block is almost always sufficient. Inadequate free QT autograft is more common in women. Although QT length correlated with height, it cannot be used as an accurate diagnostic tool to identify patients with an inadequate QT autograft. Preoperative measurement of the ACL and QT lengths by MRI might be beneficial to decide whether QT is usable, especially when harvesting without a bone block. LEVEL OF EVIDENCE: Level II, diagnostic, prospective cohort study.

Comparison of Fixation Techniques in Oblique and Biplanar Chevron Medial Malleolar Osteotomies; a Finite Element Analysis.

This study aimed to evaluate different fixation techniques and implants in oblique and biplanar chevron medial malleolar osteotomies using finite element analysis. Both oblique and biplanar chevron osteotomy models were created, and each osteotomy was fixed with 2 different screws (3.5 mm cortical screw and 4.0 mm malleolar screw) in 2 different configurations; (1) 2 perpendicular screws, and (2) an additional third transverse screw. Nine simulation scenarios were set up, including 8 osteotomy fixations and the intact ankle. A bodyweight of 810.44 N vertical loading was applied to simulate a single leg stand on a fixed ankle. Sliding, separation, frictional stress, contact pressures between the fragments were analyzed. Maximum sliding (58.347µm) was seen in oblique osteotomy fixed with 2 malleolar screws, and the minimum sliding (17.272 µm) was seen in chevron osteotomy fixed with 3 cortical screws. The maximum separation was seen in chevron osteotomy fixed with 2 malleolar screws, and the minimum separation was seen in oblique osteotomy fixed with 3 cortical screws. Maximum contact pressure and the frictional stress at the osteotomy plane were obtained in chevron osteotomy fixed with 3 cortical screws. The closest value to normal tibiotalar contact pressures was obtained in chevron osteotomy fixed with 3 cortical screws. This study revealed that cortical screws provided better stability compared to malleolar screws in each tested osteotomy and fixation configuration. The insertion of the third transverse screw decreased both sliding and separation. Biplanar chevron osteotomy fixed with 3 cortical screws was the most stable model.

A rare cause of foot pain in an adolescent due to os paracuneiforme: a case report and review of the literature.

Os paracuneiforme is an extremely rare accessory ossicle located at the medial aspect of the medial cuneiform bone. Although foot pain secondary to accessory ossicles is well known, symptomatic os paracuneiforme that requires surgical excision is rarely reported in the current literature. Herein, a 12-year-old boy with symptomatic os paracuneiforme is presented, and its clinical and imaging findings as well as the treatment are discussed.

The relationship between quadriceps fat pad syndrome and patellofemoral morphology: a case-control study.

BACKGROUND: The purpose of this prospective case-control study is to investigate the relationship between quadriceps fat pad syndrome (QFPS) and patellofemoral morphology. MATERIALS AND METHODS: Twenty-two patients with QFPS and 22 age- and gender-matched healthy volunteers were included. The diagnosis of QFPS was supported both clinically and radiologically. On magnetic resonance imaging (MRI), patellofemoral morphology was evaluated with 13 radiological measurements including trochlear sulcus angle, trochlear sulcus depth, trochlear facet asymmetry, trochlear condyle asymmetry, lateral trochlear inclination angle, patellar translation, tibial tubercle-trochlear groove (TT-TG) distance, Insall-Salvati ratio, patellotrochlear index, patellar tilt, the ratio between lateral and medial facet lengths, interfacet angle, and quadriceps tendon thickness. The mean of measurements was compared between groups using the Mann-Whitney U test. RESULTS: There were 22 patients (12 male, 10 female) with mean age of 30.81 ± 1.41 (range 19-38) years in group I and 22 patients (12 male, 10 female) with mean age of 31.13 ± 1.31 (range 19-39) years in group II. The mean age and the gender distribution were statistically similar between groups (p = 0.845, p = 1, respectively). All measured values except for patellar tilt (p = 0.038) and TT-TG distance (p = 0.004) were similar (p > 0.05 for the other variables). However, all of the measured variables were within the normal range. CONCLUSIONS: QFPS may not be associated with anatomical variations of the patellofemoral joint. Further studies are required to understand the etiology and risk factors. LEVEL OF EVIDENCE: Level III, prospective case-control study.