Injection, hematoma, abscess, systemic inflammatory response syndrome, stairway to hell: Case report.

RATIONALE: Intramuscular injections are routine outpatient procedure performed at healthcare institutions worldwide. In the current literature, there have been very few reports of gluteal superior artery injuries due to incorrect injection techniques. However, no one has ever reported a healthy middle-aged man with systemic inflammatory response syndrome with possible injection-related bleeding from the gluteus superior artery, followed by a hematoma, and then a deep abscess after 3 weeks of not receiving treatment. PATIENT CONCERNS: A 40-year-old man presented with pain in his buttock, a fever of 40°, and a lump after a dorso-gluteal injection. (November, 2022) The patient was diagnosed with systemic inflammatory response syndrome due to a deep abscess related to a hematoma caused by a possible superior gluteal artery branch injury. DIAGNOSES: He was admitted to our institution with a lump, pain in his buttock, and a fever of 40° after a dorso-gluteal injection. The patient had diffuse swelling and tenderness in the upper-posterior aspect of the gluteal region. Systemic examination revealed yellow sclera and icteric skin appearance. Blood tests showed low hemoglobin levels and increased pre-sepsis parameters (procalcitonin and indirect bilirubin). Pelvic MRI and ultrasonography revealed a gluteal abscess. INTERVENTIONS: The patient was transferred to the operating theater, where a curved incision was made behind the trochanter. The gluteus maximus was bluntly dissected, and abscess fluid was drained from the muscle. Continuous bleeding was detected, suggesting iatrogenic superior gluteal artery branch injury at the time of the injection. OUTCOME: After drainage and antibiotic treatment, the patient's parameters normalized within 5 days, and the patient was discharged. The patient's weekly follow-up examinations were normal, and he was able to walk without a limp. A postoperative visit to the outpatient clinic 2 months after the operation and a telephone call 17 months later showed that the patient was completely healthy and able to work. LESSONS: The dorso-gluteal technique has potential risks, including possible injury to the sciatic nerve and superior gluteal artery and irritation of the subcutaneous adipose tissue. This article aims to highlight the potential risks of a particular technique and advocate the use of the ventrogluteal technique instead of the traditional dorso-gluteal technique.

A case report of giant malignant schwannoma of the sciatic nerve associated with neurofibromatosis-1: A CARE-compliant article.

RATIONALE: Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous syndrome that causes multiple central and peripheral nerve sheath tumors. People with NF1 have a 10% chance of developing malignant peripheral nerve sheath tumors (MPNSTs). Here we report a unique instance of a malignant schwannoma that has remained free of metastasis since its initial removal a decade ago. The malign schwannoma has been infrequently documented in the literature, and remarkably, no instances of such an extensive postoperative time without metastases have ever been described. PATIENT CONCERNS: A 46-year-old male patient with NF had multiple neurofibromas in different parts of his body, underwent surgery about 10 years ago (2013), and was diagnosed histopathologically as MPNST. DIAGNOSES: He was admitted to our institution with a recurrent mass in the posterior third of the proximal thigh and severe pain radiating to the left lower extremity, which presented as sciatic pain (2021). A magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography examination revealed that the tumor was likely malignant. INTERVENTIONS: Surgical excision was performed. OUTCOME: A 10-year follow-up revealed no metastases or neurologic impairment. LESSONS: When articles about benign schwannomas are placed in a separate category, little is written about NF-1-related malignant schwannomas of the sciatic nerve. MPNSTs are high-grade, aggressive sarcomas with a high risk of local recurrence (40%-65%) and metastasis to other body parts. Therefore, among the various benign peripheral nerve sheath tumors in NF-1 patients, the diagnosis of MPNST is crucial.Orthopedic surgeons should be aware that neurofibromas in NF-1 have a significant risk of developing MPNSTs. This study reports the successful treatment of a giant malignant sciatic nerve schwannoma with a long follow-up period without metastasis.

Effects of Routine Antithrombotic-Adjusted Dose of Rivaroxaban and Nadroparin Calcium on Tendon Healing of Rats: An Experimental Study.

Introduction Achilles tendon injury necessitates thromboembolism prophylaxis after repair. This study aimed to investigate the effects of antithrombotic-adjusted prophylactic doses of nadroparin calcium and rivaroxaban on Achilles tendon healing. Materials and Methods Twenty-four young adult male Wistar Albino type rats were randomly divided into three groups. All rats underwent a full-thickness surgical incision of the Achilles tendon, followed by primary repair. After the procedure, group 1 was determined as the control group and received no medication. Group 2 received 2.03 mg/kg rivaroxaban daily via gastric lavage once daily, and group 3 was given subcutaneous 114 IU AXa nadroparin calcium once daily for 28 days. After euthanization, the degrees of inflammation, neovascularization, fibroblastic activity, and collagen fiber sequencing were examined and scored for histopathological evaluation. The Statistical Package for Social Science (SPSS) version 21.0 for Windows software (SPSS, Inc., Chicago, Illinois, United States) was used for all statistical analyses. The number of inflammatory cells, capillary vessels, and fibroblasts, which met the parametric tests' assumptions, were compared between three independent groups by one-way analysis of variance. The significance level was set at p- value < 0.05. Results Histological examination of the group 1 sample showed the presence of inflammatory cells, an increase in the number of fibroblasts, and sequencing of collagen fibers scattered. The presence of inflammatory cells, remarkable increases in the number of fibroblasts, the presence of mature collagen fibers, and regular sequencing of collagen fibers regular were shown in groups 2 and 3. There were statistically significant differences between the groups regarding the number of inflammatory cells and fibroblasts. In group 2, the number of inflammatory cells was lower than in groups 1 and 3. Elsewhere, the number of fibroblasts was higher in group 1 compared than in groups 2 and 3. Conclusion Both rivaroxaban and nadroparin calcium in their daily dosage have a beneficial effect on Achilles tendon healing.

Bilateral locked posterior shoulder dislocation overlooked for 15 months treated with the modified McLaughlin procedure: A case report.

Neglected bilateral posterior shoulder dislocation is a rare injury caused primarily by an epileptic seizure. The injury is usually associated with a reverse Hill-Sachs lesion in the anteromedial aspect of the humeral head. The modified McLaughlin technique may avoid instability and osteoarthritis when 20 to 40% of the articular surface is affected by reverse Hill-Sachs. In this article, we present the clinical results of a case overlooked in the literature for the longest time, i.e., for 15 months. A 46-year-old male patient was receiving treatment for epilepsy for five years. There was no fall or trauma in the four seizures he had during this time. The last seizure was 15 months ago. When the patient presented to our clinic, both shoulders were symmetrically deformed, the anterior shoulder contour disappeared (empty socket sign), and there was a loss of upper contour. The computed tomography (CT) scan revealed a posteriorly locked dislocation with a reverse Hill-Sachs lesion in 32% of the left shoulder and 36% of the right shoulder. We applied the modified McLaughlin procedure to the dominant right shoulder and, two months later, we used it to the left shoulder (with a graft taken from the anterior superior iliac spine). At one-year of follow-up, both shoulders were moderately functional: forward elevation left 70° and right 50°, abduction left 40° and right 60°, and internal rotation: the back of the hand could touch the fifth lumbar vertebra. Meanwhile, the patient did not suffer from recurrent dislocation. The pre- and postoperative Constant-Murley Scores for the right and left shoulder were 30/52 and 11/48, respectively. Although the operational outcomes using the modified McLaughlin technique were not ideal, with no recurrence, the patient seemed to be satisfied with this outcome. In conclusion, in neglected locked shoulder fracture-dislocations, the modified McLaughlin technique is a method that can respond to the pathophysiology by eliminating reverse Hill-Sachs lesion.

Factors affecting Baker cyst volume, with emphasis on cartilage lesion degree and effusion in the young and middle-aged population.

BACKGROUND: The principal aim of this study was to investigate the presence of factors affecting Baker's cyst volume in young and middle-aged populations. METHODS: Open cyst excision with valve and capsule repair, as well as knee arthroscopy, were used to treat eighty-five patients. The cases were categorized in terms of age, effusion, chondral lesion degree, meniscal tear degree, and Lindgren scores. An ultrasonography (USG) device was used to calculate the cyst volume. The IBM-SPSS 22 program was used for statistical analysis and to assess the relationships between variables using Spearman's correlation tests. RESULTS: The degree of chondral lesion was moderately and positively correlated with cyst volume in the total population (correlation coefficient: 0.469; p < 0.05). The degree of the chondral lesion was moderately and positively correlated with the degree of effusion (correlation coefficient: 0.492; p < 0.005). The cyst volume was weakly and positively correlated with the degree of effusion (correlation coefficient: 0.20; the correlation was at the limits of statistical significance p = 0.07 < 0.08). CONCLUSIONS: This study revealed that an increase in chondral lesion severity increases the amount of effusion and cyst volume.

The Ellis Jones Method of Treating Chronic Peroneal Subluxation: Revisited and Colorized After 87 Years.

Chronic cases of peroneal subluxation typically call for surgical treatment; however, research on current surgical procedures suggests nonuniformity. The purpose of this study is to remind surgeons of the efficacy of an older surgical method by using the case of a selected patient. In this study, the Ellis Jones procedure was performed on a patient who had been suffering from a chronic peroneal subluxation for 22 years, since, in this particular case, other approaches were deemed likely to be unsuccessful. The patient had hypertrophied, frayed, and swollen tendons, which were unsuitable to be rerouted, whereas the superior peroneal retinaculum was diminished and deepening procedures would not be able to establish sufficient volume for retaining the hypertrophied tendons. After the debridement and repair of the peroneal tendons, » of the lateral Achilles tendon was split, passed through a hole in the fibula, and sutured onto itself, and the subluxation path of the peroneal tendons was closed with an effective tendon barrier. The patient returned to work after 8 weeks of the surgery and was followed up for 4 years postoperatively. On selected patients, the Ellis Jones surgical method might therefore still be applied.Levels of Evidence: Level V.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Ulnar Nerve and Ulnar Artery Injury Caused by Comminuted Distal Radius Fracture.

INTRODUCTION: Distal radius fractures are one of the most frequent traumas encountered in daily orthopedic practice. With this case report, we would like to emphasize the significance of an unexpected associated ulnar nerve and artery injury with distal radius fracture to physicians. CASE REPORT: A 56-year-old male patient was evaluated in the emergency room after a motorcycle accident. The left wrist had a deformity and swelling, and about 3 × 1.5 cm of superficial skin abrasion was found in the volar surface of the wrist. It was noted that distal pulses were palpable, no neurological damage was found except hypoesthesia in the 5th finger. Radiologic examination revealed that the right shoulder was dislocated, and there was a displaced comminuted distal radius fracture in the left wrist with a non-displaced fracture of the ulnar styloid. The fracture was treated with open reduction and internal fixation using volar anatomic plate through the volar approach. After the surgery, pre-operative numbness did not resolve and opposing that expected; it increases with associated pain on the ulnar nerve innervated area within 30 days. The electromyographic analysis revealed severe partial ulnar nerve injury. The surgical exploration of the nerve was decided. The ulnar nerve was found to be trapped in scar tissue, and intimal injury and consequent thrombosis were observed at the ulnar artery. CONCLUSION: Distal radius fractures are well-known fractures among the orthopedic surgeons; median nerve compression with a fracture is also within the expectation of the physician. However, the injury of the ulnar nerve and artery is unexpected. With this case report, we would like to emphasize the awareness of the diagnosis and treatment of this kind of associated unexpected ulnar nerve and artery injuries.

An overview of thermal necrosis: present and future.

Introduction: Many orthopaedic procedures require drilling of bone, especially fracture repair cases. Bone drilling results in heat generation due to the friction between the bone and the drill bit. A high-level of heat generation kills bone cells. Bone cell death results in resorption of bone around bone screws.Methods: We searched in the literature for data on parameters that influence drilling bone and could lead to thermal necrosis. The points of view of many orthopaedists and neurosurgeons based upon on previous practices and clinical experience are presented.Results: Several potential complications that lead to thermal necrosis are discussed and highlighted.Discussion: Even in the face of growing evidence as to the negative effects of heat induction during drilling, simple and effective methods for monitoring and cooling in real-time are not in widespread usage today. For that purpose, we propose some suggestions for the future of bone drilling, taking note of recent advances in autonomous robotics, intelligent systems and computer simulation techniques.Conclusions: These advances in prevention of thermal necrosis during bone drilling surgery are expected to reduce the risk of patient injury and costs for the health service.

Comminuted Distal Radial Fracture with Large Rotated Palmar Medial Osteochondral Fragment in the Joint.

INTRODUCTION: Intra-articular distal radius fractures have long been massively discussed in the literature, but regarding to fractures that possess rotated volar medial fragment in the joint a few amount papers has been written. In this article, we would like to emphasize the significance of the rotated palmar medial (lunate facet) fragment. CASE REPORT: A 39-year-old man fell from a height of about 3 m and landed on his right outstretched hand; within 40 min, he arrived at our clinic presenting with a severe pain and swelling in his right wrist. Initial X-rays of the wrist revealed dorsal subluxation of the radiocarpal joint with dorsal comminution of the radial articular surface and fracture of the radial styloid process, with (nearly inverted) ~ 140-150° rotation of the palmar medial fragment. With an additional volar approach, the fragment reduced and stabilized with two K-wires and wrist immobilized in external fixator. The patient returned to daily activities without any discomfort and pain after the 1 year from the surgery. CONCLUSION: Overlooking of palmar rotated osteochondral fragment will cause deficiency to build proper pre-operative strategy to approach the reduction of the fragment. The incompetence of reduction will deteriorate the articular surface and lead to early osteoarthritis of the wrist. The surgeon should detect this fragment and should be familiar with volar approaches of the wrist. Above average surgical experience would be needed for successful reduction.

Posterior Shoulder Dislocation Associated With the Head (Splitting) and Humeral Neck Fracture: Impact of Understanding Radiologic Signs and Experience With an Extended Deltopectoral Approach.

In this paper, our main objective was to emphasize the competency of extended deltopectoral exposure, enforced with the supraspinatus and subscapularis detachment, to gain access to the entire head. The second important point in this paper was to underline the importance of the knowledge that is necessary for interpreting classic radiologic signs of posterior fracture-dislocation of the shoulder. A 47-year-old woman fell down directly onto her shoulder while she was skiing. She was diagnosed with posterior shoulder dislocation, associated with fracture of the head (head splitting) and humeral neck fracture, with the aid of plain radiographs and computed tomographic results. The patient was treated with open reduction and internal fixation of the fracture, through the extended deltopectoral approach, which was augmented with rotator cuff detachment. At the 1-year follow-up, x-rays showed stable fixation with good evidence of healing. One year after the surgery, the patient had no pain, and she regained most of her functionality in her right shoulder with 140 to 150 degrees of lateral elevation (abduction), 140 to 150 degrees of forward flexion , internal rotation hand at T12 vertebra (slightly restricted). These results showed good functionality, with a painless shoulder at the 1-year follow-up. The "double shadow" and "lightbulb" signs are indicative of posterior shoulder fracture-dislocation, and augmented (with the detachment of supraspinatus and subscapularis tendons) traditional deltopectoral incision is suitable for managing these kinds of difficult fracture dislocations.

Lateral Antebrachial Cutaneous Nerve as a Donor Source for Digital Nerve Grafting: A Concept Revisited.

OBJECTIVE: The main objective of this study is to evaluate the availability of lateral antebrachial cutaneous nerve (LACN) autograft for acute or delayed repair of segmented digital nerve injuries. PATIENTS AND METHODS: 13 digital nerve defects of 11 patients; treated with interposition of LACN graft that harvested from ipsilateral extremity were included in the study. Mean follow up period was 35, 7 months. The mean time from injury to grafting is 53, 3 days. The results of the mean 2PDT and SWMT values of injured /uninjured finger at the end of follow up period were evaluated with Paired T test. The correlation between the defect length and the difference of 2PDT, SWMT values between the uninjured and injured finger at the end of follow up period; were evaluated with Pearson - correlation analysis. RESULTS: The mean value of our 2PDT and SWMT results are ~5,923, ~3, 52, respectively in which can be interpreted between the normal and diminished light touch. The defect length and difference percentage of SWMT values is positively and significantly correlated statistically. Mean length of interposed nerve grafts was 18.5 mm. The age of the patient and the mean values of 2PDT and SWMT with the difference % of 2PDT and % of SWMT are not statistically correlated. CONCLUSION: Based on results regarding sensory regaining at recipient side and negligible sensory deficit at harvesting side, we suggest that lateral antebrachial cutaneous nerve might be a valuable graft option for digital nerve defects.

Intra-Articular Osteoid Osteoma as a Cause of Anteromedial Knee Pain.

A 32-year-old male patient presented to our clinic with chronic left knee pain that was ongoing for about 1.5 years. The patient visited several times our clinic and the other clinics; conservative treatment (including rest, knee brace, and ice application with NSAIDs) was recommended by various different doctors. The anamnesis, physical examination, and plain radiography were nonspecific. Early MRI findings mislead us to believe it is bone marrow edema. One and half years with noneffective treatment, the knee pain persisted. At the latest visit intra-articular osteoid osteoma was suspected and the knee MRI with CT was employed. Even though the diagnosis of intra-articular osteoid osteoma often presents a challenge for the surgeons, with a present awareness of intra-articular osteoid osteomas which lack the characteristic sclerotic lesions and nidus on plain X-rays and the aid of multislice CT, a correct diagnosis which warrants proper treatment can be achieved. The possibility of osteoid osteomas, especially in young adults with persistent knee pain with unknown reasons that show normal plain radiographs results, must not be overlooked. The treatment method of these lesions should be customized depending on the location of the lesion, experience of the surgeon, and cost of method.

Trevor's disease: up-to-date review of the literature with case series.

Trevor's disease, also known as dysplasia epiphysealis hemimelica, is a rare nonhereditary skeletal development disorder that affects epiphyses. This type of dysplastic lesion was first reported by Mouchet and Berlot in 1926 under the name 'tarsomegaly'. The main aim of this study is to raise awareness of Trevor's disease among orthopedic surgeons and underline some important aspects of treatment by a detailed presentation of four different possible manifestations of the disease. Four different treatment methods were used on four different patients (three localized in hindfoot ankle region and one classic Trevor's disease case). Treatment methods, localization of the sides involved, different characteristics of entire lower extremity, asymetry, distal femoral lateral epiphysis involvement, and hip involvement were analyzed thoroughly and the results were compared with those found in the most recent literature. Of our four patients, three were localized (hind foot ankle) cases and one was a classic dysplasia epiphysealis hemimelica with hemimelic distribution of the entire lower extremity. We used arthroscopic resection, observation, excision, and temporary hemiepiphysiodesis treatment methods in each of our cases. Clinical follow-up results were reported to be between good and excellent. In sum, our opinion is that the treatment for this condition should be customized according to lesion localization and lesion size. Majority of cases with ankle involvement show good prognosis following excision. Observation is also an alternative in patients who refuse surgery. If an intra-articular lesion is present, the surgeon should perform an arthroscopy for assessment of lesion surface. If the lesion is adapted to the joint curvature, it should be left alone and hemiepiphysiodesis should be considered for correction. The most risky involvements that are related to deformities and limb-length discrepancies are the hip and the knee. This is usually the result of corrective osteotomy targeted at the supracondylar femoral area in immature skeletons. Hemiepiphysiodesis might be a more feasible option in those cases as it provides the surgeon with the choice to remove the staples when necessary.

Pediatric Olecranon Fractures Associated With Radial Neck Fractures: Review and Report of Two Cases.

INTRODUCTION: The debate regarding the description on classification and nomenclature of the injury which includes olecranon fracture associated with radial neck fractures in children is ongoing. We report two pediatric cases that could not be classified in a Monteggia-equivalents system and were treated with open reduction and k-wire fixation. The aim of this study was to perform a systematic review regarding pediatric radial neck fractures associated with olecranon fractures and presentation of two pediatric cases of olecranon fractures associated with radial neck fractures with radiocapitellar dislocation. CASE PRESENTATION: Two boys, aged 7 and 12, came to two separate clinics on the same day after initial injury. On physical examination, the patients' elbow range of motion was limited and painful. Their upper extremities were intact. Radiographs revealed the radial neck fracture with prominent anterolateral radiocapitellar dislocation of radial head-associated with non-displaced olecranon fracture. Radial neck fracture was reduced easily by pushing posteromedially manually with the finger and secured with two K-wires .The olecranon fracture was visualized and confirmed that it was non-displaced and secured with two k-wires in the first case and one k-wire in the second case. After 2 months of follow-up, both patients had no pain in their elbow and a full functionality with a full range of motion of the elbow. The posterior intraosseous nerve functions were normal. CONCLUSIONS: The fracture of olecranon if it does not extend into the metaphyseal region; it could not fascilitate diastasis of the proximal radioulnar joint and radial head dislocation. So this type of fracture must not be addressed as a Monteggia-fracture dislocation. The description of radioulnar diastasis must be included when this type of injury is to be classified.

A Novel Surgical Approach to Coracoid-based Eosinophilic Granuloma and the Technical Trick.

The coracoid base is a very rare location for tumors. It is difficult to diagnose and approach, but easy to dismiss. In this case, the tumor (eosinophilic granuloma of the scapula) was located at the base of the coracoid, and the posterior cortex was eroded by the tumor. Accessing this lesion through the deltopectoral approach with coracoid osteotomy without penetrating the supposed tumor extending posterior soft tissue will be discussed. This approach gives a wider and safer access to the surgeon than the posterior approach. This report presents a customized solution with the deltopectoral approach, and the chevron-type osteotomy to access the coracoid base and tension band wiring to fix the osteotomy side.

The Changed Route of Anterior Tibial Artery due to Healed Fracture.

We would like to highlight unusual sequelae of healed distal third diaphyseal tibia fracture that was treated conservatively 36 years ago, in which we incidentally detected peripheral CT angiography. The anterior tibial artery was enveloped three-quarterly by the healing callus of the bone (distal tibia).

The relationship between medial meniscal subluxation and stress distribution pattern of the knee joint: Finite element analysis.

BACKGROUND: Degenerative changes of the knee joint and clinical follow-up after meniscal subluxation are well documented. In the current study three-dimensional (3D) finite element analysis (FEA) of human lower limb was used to investigate the effect medial meniscal subluxation on the loadings of the knee structures. METHODS: Apart from the reference model, a total of ten 3D models were created, according to amount of medial meniscal subluxation. ANSYS® 14 was used to analyze the stress/load distribution, that is to say the maximum equivalent stress (MES) (von Mises stress) on bones, cartilages, ligaments and menisci. MES was expressed as Newton/mm(2) = Megapascal (MPa). RESULTS: In a static and standing upright position the MES on all knee structures were evaluated in the reference model. Although MES increased in all structures with the increase of medial meniscal subluxation degree, tibia cartilage was found to be the most affected structure with an increase of 22.73-fold in the 10 mm subluxation model when compared with references values. CONCLUSION: This study showed that medial meniscus subluxation is associated with increased loadings on all knee structures especially the tibia cartilage. Also the degree of the medial meniscal subluxation correlates with distribution and the amount of loadings on tibia cartilage which may be a prominent feature of knee osteoarthritis.

Comparing Dimensions of Four-Strand Hamstring Tendon Grafts with Native Anterior and Posterior Cruciate Ligaments.

Background. The aim of the study was to evaluate whether or not there was any incompatibility between four-strand hamstring tendons taken from the same knee and the dimensions of the ACL and PCL. Methods. 15 fresh frozen cadaver hamstrings were prepared as four-strand grafts and measurements made of the ACL and PCL circumferences in the midsection were made in the narrowest part of the midsection. The cross-section areas and diameters were calculated with geometric calculations used to measure the cross-sectional area of cylinders. Accepting that the geometric insertions were elliptical, the length, width, and area were calculated for entry areas. Results. A significant relationship at 96.2% was determined between the ACL mid and the hamstring diameter. A significant relationship at 96.7% was determined between the ACL and the hamstring mid area. A significant relationship at 96.4% was determined between the PCL mid and the hamstring diameter. A significant relationship at 95.7% was determined between the PCL and the hamstring mid area. Conclusion. For the reconstruction of ACL and PCL, it was determined that there is less incompatibility between the four-strand hamstring tendons taken from the same knee and the dimensions of the midsection PCL compared to the ACL dimensions.