The Effect of Traction Force and Hip Abduction Angle on Pudendal Nerve Compression in Hip Arthroscopy: A Cadaveric Model.

PURPOSE: To investigate the site of pudendal nerve compression and the relation between traction force and abduction angle regarding pressure levels at setup for hip arthroscopy. METHODS: A total of 17 hips from 9 fresh-frozen cadavers (6 male and 3 female cadavers) were used. The pudendal nerves were dissected, and 3 FlexiForce force sensors (Tekscan, Boston, MA) were implanted on the pudendal nerve where the inferior rectal nerve, perineal nerve, and dorsal nerve of the clitoris/penis emerge. A custom-made traction table in a supine position was used with a padded perineal post of 9 cm. Recordings were made at 0, 10, 20, 30, and 40 kg of traction at varying hip abduction angles of 0°, 15°, 30°, and 45°. RESULTS: The tuber ischiadicum (perineal nerve) and genital region (dorsal nerve of penis/clitoris) had statistically higher pressure values when compared with the pudendal canal (inferior rectal nerve) (P < .05). There was a significant increase in forces acting on the pudendal nerve with increasing application of 0 to 40 kg of traction in steps of 10 kg, with the exception of the pudendal canal sensor and reading of the perineal nerve sensor at 45° of hip abduction (P < .004 with Bonferroni correction for significant values). On the contrary, hip abduction angle had no statistically significant effect on pudendal nerve compression. (All specific P values with Bonferroni correction were greater than .003.) CONCLUSIONS: To avoid nerve palsy completely, the etiopathogenesis of compressive neuropathy should be identified. The location for compression and relation between different traction positions and forces are clarified in this study. This information can be used for further research and prevention. CLINICAL RELEVANCE: This study adds objective data on the etiopathogenesis of pudendal nerve compression, which potentially contributes to prevention of pudendal nerve palsy as a common complication of hip arthroscopy.

Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques.

PURPOSE: Infection after arthroscopic anterior cruciate ligament (ACL) reconstruction is reported to be rare but can cause significant morbidity. The purpose of this study was to test the null hypothesis that there is no difference in infection rates between techniques and no difference in outcome of different techniques after treatment of this complication. METHODS: From a consecutive case series of 1,231 patients who underwent ACL reconstructions with 3 different techniques from 1988 through 2006, we report 6 patients who developed postoperative infection. Time to presentation, clinical symptoms, patient demographics, and surgical and management details were obtained from patient charts. All 6 patients were re-examined with physical and radiographic evaluation, functional testing, KT-1000 (Medmetric, San Diego, CA), and Lysholm scales. RESULTS: Six patients (0.49%) were identified including 2 infections for each technique with incidence of 0.86%, 0.29%, and 0.64%, respectively. The graft was retained in all 6 patients and treated with debridement and continuous antibiotics. Metallic implant was removed in 5 cases. Patients were followed up for an average of 102.5 months. The average modified Lysholm score was 81.1. The average maximum manual KT-1000 value was 2.7 mm. A Kruskal-Wallis test was used for statistical analysis, and no significant differences were noted in incidence, mean Lysholm scores, or KT-1000 difference (P > .05). CONCLUSIONS: Aggressive surgical debridement, hardware removal, and appropriate antibiotic therapy have proven effective in eliminating postsurgical infection along with graft retention and preservation of knee stability after ACL reconstruction performed with 3 different techniques. Although it was a small case series, the incidence and outcome after treatment of ACL infection in our study is similar, supporting the hypothesis that treatment outcomes were similar by using different surgical methods. LEVEL OF EVIDENCE: III, retrospective comparative study.

[Chondral and osteochondral fractures]. / Kondral ve osteokondral kiriklar.

The incidence of traumatic chondral and osteochondral fractures and their role in the development of joint degeneration are not fully elucidated. While assessing traumatic knee injuries, one important criterion for the diagnosis of chondral fractures is to remember the possibility of a chondral or osteochondral fracture. Symptoms in osteochondral fractures are more obvious and cause severe pain and difficulty in movement of knee with hemarthrosis. The presence of hemarthrosis facilitates the diagnosis of an osteochondral fracture. Chondral and osteochondral fractures may be associated with other intra-articular pathologies. There are two main mechanisms of these fractures, including a direct effect causing avulsion or impaction and, a more common mechanism, flexion-rotation force to the knee, which is also the mechanism for an acute patellar dislocation. It is known that arthroscopic treatment is the best method for the diagnosis and treatment of chondral and osteochondral fractures. In osteochondral lesions, the aim of treatment is to restore the congruity of articular surfaces. In agreement with literature data, our clinical experience favors internal fixation as the most effective method for the treatment of osteochondral fractures.

Histopathologic assessment of healed osteochondral fractures.

PURPOSE: To assess the histopathologic features of healed tissue to define its biological and biomechanical properties after internal fixation of osteochondral fractures. Type of Study: Cohort study. METHODS: The general principle of management of detached acute osteochondral fractures is reattachment of the fragment by internal fixation, but the opinions on the quality and structure of the healed tissue that will be obtained after treatment is controversial. This study included 13 patients with acute osteochondral fractures who were treated arthroscopically and had surgical fixation providing joint-surface congruity. Patients with osteochondral fractures too small for fixation or with the overlying cartilage frayed, and patients with associated injuries were excluded from the study. The mean age of patients was 17 years (9 to 24 years). In 2 cases the fractures were localized at medial, in 7 at lateral femoral condyles, and in 4 at the patella. Internal fixation materials were K-wires for 1 case, Herbert screws for 3, and mini cancellous screws for 9 cases. The mean follow-up period was 6.3 years (3 to 13 years). On second-look arthroscopy, congruity of the joint surfaces and healed fractures was observed in all cases. Beside removal of the implant, punch biopsies were performed extending to the osteochondral junction; biopsy specimens were taken from the junction of the articular margin of the fragment and the edge of the remainder of the articular surface. RESULTS: On histologic examination of the specimens, scarce mature chondrocytes among regenerative stroma, which dyed more eosinophilic than the basophilic chondral stroma and which had a chondrocyte-like appearance, were seen. Maturation of histologic architecture to hyaline or articular cartilage was not recorded in any of these cases. CONCLUSIONS: The clinical results did not correlate with the histologic findings. Despite the protected joint surface congruence, restoration of the hyaline cartilage at the chondral junctions could not be obtained.

Injuries in elite youth football players: a prospective three-year study.

OBJECTIVE: The aim of this study was to investigate the incidence and nature of injuries and the influence of age on injury patterns in elite youth football. METHODS: Fifty-two players of the Under-17 (U-17) male national youth football team were followed during their progression to U-18 and U-19. Individual player exposure and injuries were recorded during the three year study period. RESULTS: Injury incidence was five times higher during matches than training. When medical attention and time loss injuries were considered, injury incidence increased during matches and decreased during training with increasing age. Traumatic injuries were more frequent in matches and were linked with increased age. Overuse injuries were two times higher during training than matches in the U-17 team. The majority of traumatic match injuries (78.3%) led to time loss and the majority of time loss injuries occurred due to traumatic mechanism (62.1%). The majority of muscle and entire ligament injuries occurred during training and contusions during competition. Re-injury rate was 25% and were all overuse injuries. CONCLUSION: Injury incidences increased during matches and decreased during training. More match injuries were caused by traumatic mechanisms as players aged. Player age might contribute to injury incidence and characteristics in youth football.

Pulmonary thromboembolism after surgical treatment of ulnar pseudoarthrosis: a case report.

Deep vein thrombosis (DVT) and the consequently developed pulmonary embolism are devastating complications in orthopedic surgery. DVT occurs less frequently (1-2% of all cases) in the upper extremity than the lower extremity. We report a 54-year-old male patient who developed DVT and pulmonary thromboembolism after surgical treatment of an ulnar pseudoarthrosis. The presented case suggested the use of a low molecular weight heparin prophylaxis after upper extremity surgeries necessitating long-term immobilization.