The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

BACKGROUND: The study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury. METHODS: We included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12 h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound. RESULTS: All data were measured within 4-6h of the injury. The average thickness in injured legs versus uninjured was 30 mm (15-46 mm) versus 20.4 mm (13-30 mm), P<0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3 mmHg (26-80 mmHg) versus 17.5 mmHg (15-20 mmHg), P<0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg. CONCLUSION: In this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.

Genome-wide expression profiles of subchondral bone in osteoarthritis.

INTRODUCTION: The aim of this study was to evaluate, for the first time, the differences in gene expression profiles of normal and osteoarthritic (OA) subchondral bone in human subjects. METHODS: Following histological assessment of the integrity of overlying cartilage and the severity of bone abnormality by micro-computed tomography, we isolated total RNA from regions of interest from human OA (n = 20) and non-OA (n = 5) knee lateral tibial (LT) and medial tibial (MT) plateaus. A whole-genome profiling study was performed on an Agilent microarray platform and analyzed using Agilent GeneSpring GX11.5. Confirmatory quantitative reverse-transcription polymerase chain reaction (qRT-PCR) analysis was performed on samples from 9 OA individuals to confirm differential expression of 85 genes identified by microarray. Ingenuity Pathway Analysis (IPA) was used to investigate canonical pathways and immunohistochemical staining was performed to validate protein expression levels in samples. RESULTS: A total of 972 differentially expressed genes were identified (fold change ≥ ± 2, P ≤0.05) between LT (minimal degeneration) and MT (significant degeneration) regions from OA samples; these data implicated 279 canonical pathways in IPA. The qRT-PCR data strongly confirmed the accuracy of microarray results (R2 = 0.58, P <0.0001). Novel pathways were identified in this study including Periostin (POSTN) and Leptin (LEP), which are implicated in bone remodeling by osteoblasts. CONCLUSIONS: To the best of our knowledge, this study represents the most comprehensive direct assessment to date of gene expression profiling in OA subchondral bone. This study provides insights that could contribute to the development of new biomarkers and therapeutic strategies for OA.

Results of infected total knee arthroplasty treated with arthroscopic debridement and continuous antibiotic irrigation system.

BACKGROUND: Arthroscopic debridement with continuous irrigation system was used with success in treating infective arthritis. We evaluated the effectiveness of arthroscopic debridement coupled with antibiotic continuous irrigation system in acute presentation of late infected total knee arthroplasty. MATERIALS AND METHODS: We performed a retrospective review of medical record of patients with acute presentation of late infected total knee arthroplasty who were treated by arthroscopic debridement coupled with continuous postoperative antibiotic irrigation system. RESULTS: Seventeen patients were included in our study. 15 (88%) patients preserved their total knee prosthesis at mean of followup of 27.5 months (range, 14-28 months). Two (12%) patients failed arthroscopic protocol and finally needed two stages revision. Our study showed an 88% prosthesis retention rate in patients with acute presentation of late prosthetic knee infection. No complication was associated with use of antibiotic irrigation system. CONCLUSION: Arthroscopic debridement combined with continuous antibiotic irrigation and suction is an effective treatment for patients with acute presentation of late infected total knee arthroplasty.

Clinical outcome of arthroscopic fixation of anterior tibial eminence avulsion fractures in skeletally mature patients: a comparison of suture and screw fixation technique.

BACKGROUND: Extreme tensile force to the anterior cruciate ligament results in an avulsion of the tibial eminence and it was believed to be more common in skeletally immature adolescent than adult. The purpose of this study is to compare the clinical results of both screw and suture fixation for surgical treatment of anterior tibial eminence fractures in skeletally mature patients. METHODS: A retrospective review was conducted on patients from 2002 to 2009 who sustained fractures of the anterior tibial eminence and were treated with arthroscopic-assisted fixation using either cannulated screws (25 patients) or Ethibond sutures (23 patients). Follow-up assessment included function evaluation, ligament laxity, and range of motion. RESULTS: Seventy-five percent of the anterior tibial eminence fractures resulted from traffic-related injuries in this study. Median operating time was 75 minutes in screw fixation group and 92 minutes in suture fixation group (p = 0.006). The objective International Knee Documentation Committee (IKDC) results for patients were 23 A, 2 B, and no C or D in screw fixation group and 16 A, 4 B, 3 C, and no D (p = 0.040) in suture fixation group. The KT-1000 side-to-side difference was greater than 5 mm in two patients (8%) in the screw fixation group and in three patients (13%) in the suture fixation group (p = 0.058). Among patients in screw fixation group, two (8%) patients had grade 1 pivot shift and 2 (8%) patients had grade 2 pivot shift. Among patients in suture fixation group, five (22%) patients had grade 1 pivot shift, three (13%) patients had grade 2 pivot shift, and 1 (9%) patient had grade 3 pivot shift (p = 0.037). CONCLUSIONS: Significant better IKDC objective evaluation, lower glide pivot shift phenomenon, and shorter operating time requirement in screw fixation group with respect to suture fixation group were shown in our study although the other functional knee scores (Lysholm score, Tegner activity level, and the IKDC subjective score) and KT-1000 manual side-to-side difference only revealed a trend with better clinical results in screw fixation group than in suture fixation group rather than significant difference.

Redisplacement of diaphyseal fractures of the forearm after closed reduction in children: a retrospective analysis of risk factors.

OBJECTIVES: Manipulation and plaster fixation is the primary management for diaphyseal fractures of the radius and/or ulna in children. This study was designed to evaluate risk factors of fracture redisplacement after closed reduction and cast immobilization. DESIGN: Retrospective study. SETTING: Tertiary hospital. PATIENTS: Fifty-seven children with fractures of the radius were included. INTERVENTION: The medical records of patients with/without ulna treated with closed reduction and casting were reviewed. MAIN OUTCOME MEASURES: Data analyzed were age, sex, dominant hand, fracture pattern, reduction quality, experience of the surgeon, and type of anesthesia. Logistic regression was used for multivariate analysis. RESULTS: There were 41 (71.9%) males and 16 (28.1%) females with a mean age of 9.74 ± 3.07 years. There were 53 radius fractures and 54 ulna fractures, and 22 subjects experienced redisplacement. The redisplacement rate of radius fractures was 34% and of ulnar fractures was 27.8%. Multivariate analysis showed that the factors associated with redisplacement of radius fractures were fair reduction quality [odds ratio (OR), 8.45] and complete fracture (OR 9.62) and those for redisplacement of ulna fractures were fair reduction quality (OR 8.10) and complete fracture (OR 8.43). CONCLUSIONS: Poorer reduction and complete fracture are more likely to result in redisplacement, and surgical management may be considered in these cases.

Outcomes in advanced Legg-Calvé-Perthes disease treated with the Staheli procedure.

BACKGROUND: Containment and preservation of hip range of motion have been the principles governing the treatment of Legg-Calvé-Perthes disease. The Staheli's slotted acetabular augmentation (SAA) procedure is an alternative approach for older children with Perthes disease with lateral subluxation, incongruent hip, and abduction hinge. It provides effective coverage, restricts lateral displacement of the femoral head, and achieves containment and congruency in short-term follow-up. MATERIALS AND METHODS: This study evaluated pre- and postoperative symptoms, range of motion (ROM), and radiographic images in advanced Perthes disease with an incongruent hip or hinge abduction in lateral pillar groups B and C of 21 children who underwent a SAA procedure. RESULTS: Postoperative evaluation showed improved abduction, internal rotation, subluxation ratio, femoral head ratio, and acetabular coverage. At final follow-up, ROM of abduction went from 20° preoperatively to 45° postoperatively, and internal rotation went from 15° preoperatively to 35° postoperatively. The radiographic findings revealed 33% and 38% of patients achieved spherical congruence of the hip and an ovoid or mushroom femoral head, respectively. CONCLUSION: SAA restricts lateral displacement or subluxation of the femoral head and preserves sphericity, resulting in containment and acetabular coverage.

Treatment of septic knee arthritis: comparison of arthroscopic debridement alone or combined with continuous closed irrigation-suction system.

BACKGROUND: Arthroscopic debridement has been widely adapted as initial treatment for septic knee arthritis. Although isolated cases of arthroscopic debridement combined with irrigation-suction systems have been reported, a comparison of two techniques has not been performed, to our knowledge. The purpose of this study was to compare the two methods of treatment. METHODS: From January 1996 to December 2008, 39 patients with 39 septic knee arthritis treated in our institution were retrospectively analyzed. Nineteen knees were initially treated with arthroscopic debridement alone (group I), and 20 knees were initially treated with arthroscopic debridement combined with continuous closed irrigation-suction system (group II). The clinical presentation, laboratory and microbiologic findings, hospital course, and clinical outcomes were compared between the two groups. RESULTS: The mean delay between the onset of the symptoms and treatment had a significant effect on the clinical outcomes. When the comparison included all the patients in the series, no significant difference between the two groups was found with regard to the number of operation procedures required or the length of the hospital stay. However, when the comparison was separated from the initial stage of infection, it was found that in stage II infection, patients had fewer reoperations and in stages II and III infection, a shorter hospital stay in group II than in group I (p < 0.05). There was no significant difference in the functional results between the two groups. CONCLUSIONS: The early diagnosis and aggressive initiation of treatment carried the success of therapy in septic knee arthritis. Arthroscopic debridement combined with continuous closed irrigation-suction system is an effective treatment for patients with septic knee arthritis; these patients had fewer operations and a shorter hospital stay than did patients who had received arthroscopic debridement alone.

Prevalence of flexible flatfoot in Taiwanese school-aged children in relation to obesity, gender, and age.

The objective of this study was to determine the prevalence of flexible flatfoot in elementary school children in Taiwan and evaluate the relationship between flatfoot and obesity, gender, and age. A sample of 2,083 children, between 7 and 12 years of age from public elementary schools in northern Taiwan was analyzed. Children were stratified into groups according to age: 7, 8, 9, 10, 11, or 12 years old. Demographic information was obtained, and the presence of flatfoot determined by footprint analysis and grading according to Denis flatfoot staging. A total of 1,222 (59%) children were documented with flatfoot. The incidence percentages of flatfoot were: 67% of males, 49% of females, and 75%, 65%, 57%, and 48% of obese, overweight, normal weight, and underweight children, respectively. A preponderance of flatfoot was observed among 8-year-olds. Multivariate analyses indicated that 8- and 9-year-olds were 1.52 and 0.72 times more likely to have flatfoot than 7-year-olds. Males were twice as likely to have flatfoot as females. Children who were obese or overweight were 2.66 and 1.39 times more likely to have flatfoot than those of average weight. The results of this study indicate that the prevalence of flexible flatfoot is highest among males who are obese and overweight, particularly in the age range of 7 to 8 years.

Biomechanical comparison of Cross-pin and Endobutton-CL femoral fixation of a flexor tendon graft for anterior cruciate ligament reconstruction--a porcine femur-graft-tibia complex study.

BACKGROUND: A stable fixation of the graft is imperative for early aggressive rehabilitation after anterior cruciate ligament (ACL) reconstruction. The suspension devices such as Endobutton-CL and Cross-pin system are common techniques of femoral fixation for the hamstring tendon graft and provide superior initial biomechanical properties than the screws system. It remains unclear how such implants perform under cyclic loading and initial pull-out strength. MATERIALS AND METHODS: Cross-pin and Endobutton-CL femoral fixation devices were tested for initial fixation strength in porcine knee joints by cyclic loads following a load-to-failure test. The Cross-pin and Endobutton-CL were used for femoral fixation of a porcine profundus flexor digitorum tendon autograft in 20 porcine knees. Ten specimens of femoral-graft-tibia complex in each group were loaded cyclically to between 0 and 150 N at 1 Hz for 1000 cycles following a load-to-failure test at a rate of 150 mm/min. RESULTS: The amount of total femur-graft-tibia complex graft displacement was significantly lower in the Cross-pin fixation group (5.37 +/- 0.28 mm) than in Endobutton-CL fixation group (6.08 +/- 0.61 mm: P < 0.05). There were no significant differences in the maximal failure load, yield load, and stiffness between the Cross-pin and Endobutton-CL fixation groups. CONCLUSIONS: This biomechanical study reveals that the Endobutton-CL and Cross-pin femoral fixation devices have an equally strong and safe fixation for ACL reconstruction. However, the Cross-pin fixation has significantly less displacement of femur-graft-tibia complex than that of Endobutton-CL fixation in response to the cyclic loading test. It indicates that the Cross-pin fixation is more suitable for early aggressive rehabilitation following ACL reconstruction.

A biomechanical comparison of all-inside meniscus repair techniques.

BACKGROUND: The aim of this study was to assess the biomechanical characteristics of six all-inside meniscal single suture repair techniques using a porcine model. MATERIALS AND METHODS: Peripheral longitudinal tears were created in freshly isolated porcine menisci. Tears were repaired using the single vertical technique with six different repair complexes including those involving sutures (#2 FiberWire, #2 Ethibone, flexible anchors (Fast-Fix, RapidLoc), and rigid anchors (Meniscal-Dart, BioStinger). Displacement, ultimate failure strength, stiffness, and site of failure were measured using a Materials Testing System machine. An initial 2 N preload was applied, followed by loading between 5 and 20 N for 300 cycles. Failure strength was determined lastly by increasing tension at a rate of 5 mm/min until failure. RESULTS: Failure strength was highest in the #2 FiberWire group (175.6 N). This was significantly higher than in all other groups (P < 0.05). The second highest failure load was evident in the #2 Ethibone group (113.8 N). This was significantly higher than in all other groups bar the #2 FiberWire group (P < 0.05). Stiffness was also significantly higher in the #2 FiberWire group compared with all other groups (8.5 N/mm, P < 0.05). There were no between-group differences in displacement. When grouped by repair technique, failure load was significantly higher, and displacement was significantly lower, in suture compared with both flexible and rigid anchor repaired menisci (P < 0.01 for all comparisons). Although stiffness was also higher in the suture group, there were no significant between-group differences detected. CONCLUSIONS: Suture techniques exhibited biomechanical superiority over biodegradable flexible and rigid anchor devices for meniscus repair.

Delayed postoperative paralysis in adolescent idiopathic scoliosis: management with partial removal of hardware and staged correction.

A delayed spinal epidural hematoma following scoliosis surgery is relatively uncommon but well recognized by clinical and radiographic findings. A 12-year-old girl with scoliosis measuring 80 degrees lower thoracic curve underwent anterior (T6-T12) and posterior fusion with posterior instrumentation from T2 to L1. She developed bilateral leg weakness and progressive left lower leg paralysis 24 hours later. Emergent decompression and partial removal of hardware was performed. Reinsertion of segmental instrumentation and correction of her curve was performed 2 weeks later. The patient had complete recovery of her neurologic deficits, and her correction was maintained at 85% at 4-months follow-up. The authors recognized that there should be no delay in returning the patient to surgery if neurological deficits are noticed. Exploration and decompression of "an occupying lesion" and release of cord tension by partial removal of hardware and re-instrument can achieve appropriate original correction of scoliosis and satisfactory clinical outcome.

Operative treatment of displaced medial epicondyle fractures in children and adolescents.

Twenty-five patients who sustained displaced medial epicondyle fractures were treated by various surgical techniques. There were 18 males and 7 females. The mean age was 13.7 years. Surgical outcome was evaluated by use of the Elbow Assessment Score of the Japanese Orthopedic Association. Many variables that might influence the surgical outcome were considered. The results revealed no significant correlation between surgical outcome and injury mechanism, displacement, interval from injury to surgery, dislocation, fixation method, or duration of immobilization. The motion arc was moderately decreased in 1 patient treated by use of screw fixation. Moderate instability to valgus stress was noted in another patient treated by use of pin fixation (K-wires). The treatment results were all scored, and the patients with medial epicondylar fractures (displacement >5 mm) showed good to excellent results with operative treatment. Residual deformity did not compromise cosmetic appearance or clinical results. Therefore, operative treatment is a suitable choice for managing these fractures in children and adolescents.

The nutcracker fracture of the cuboid in children: a case report.

The fracture of the cuboid in children is rarely diagnosed and has probably been underreported for nondisplaced fractures. The diagnosis is often missed, and overlooked cuboid fracture can lead to severe alterations in foot mechanics and function. This case report involves a displaced compression fracture of the left cuboid in a 9-year-old girl after a fall from a height, which was treated by open reduction, bone graft, internal fixation with pins, and plaster splint immobilization. Follow-up examination 2 years after the injury revealed good bone union and a very good functional result.

The effect of anesthetic techniques on hemostatic function in arthroscopic surgery: evaluation by thromboelastography.

BACKGROUND: Anesthetic techniques are known to affect blood hemostasis, which may be responsible for the pathogenesis of postoperative venous thromboembolism. The purpose of this study was to evaluate the effect of general and spinal anesthesias on blood hemostasis using thromboelastography. METHODS: Forty patients undergoing arthroscopic knee surgery were enrolled for study and randomly allocated to one of two groups, to receive either general (GA; n = 20) or spinal anesthesia (SA; n = 20). In addition to thromboelastography, prothrombin and activated partial-thromboplastin time, and haematocrit and platelet count were also examined concurrently. Blood was sampled and examined before anesthesia to provide the baseline data (Time 1). Three more evaluations were performed at different time, i.e., twenty minutes after induction of anesthesia and just prior to skin incision (Time 2), thirty minutes after skin incision (Time 3), and three hours after surgery (Time 4). RESULTS: There were no intra- or inter-group differences noted as comparing the measured parameters obtained prior to, during, or three hours after surgery. CONCLUSIONS: From the present study, we do not find any individual anesthetic technique which would have effect on the hemostasis of patients who received diagnostic arthroscopic surgery.