Comparison of two different molecular weight intra-articular injections of hyaluronic acid for the treatment of knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) is an incurable joint disorder, representing a major public health issue. Among options for symptom control, viscosupplementation with hyaluronic acid (HA) had established usefulness in pain and function improvement of the knee. However, it is not clear which form of HA yields better results. MATERIAL AND METHODS: We compared two HA preparations with high (HMW) or low molecular weight (LMW) in terms of pain control and function improvement using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the visual analog scale (VAS) score in patients with knee OA. During 2013, 80 patients were enrolled in this prospective, double-blind, randomized study. Each patient received a weekly injection of either preparation with a total of five injections for the LMW group and three for the HMW group. They were evaluated at baseline, five weeks, three months and one year after treatment. RESULTS: In both groups, HA treatment resulted in significant improvement in pain and function that begun immediately after treatment and lasted for one year. However when compared with each other, HMW and LMW groups were comparable in mean WOMAC, and VAS score at each time point. Neither preparation can interrupt disease progression as radiological findings remained constant during follow-up. CONCLUSIONS: Intra-articular injections using HMW or LMW HA can improve stiffness, joint function and pain in patients suffering from knee OA. However, no clear benefit seems to exist between the two preparations and neither can slow disease progression. Hippokratia 2016, 20(1): 26-31.

The role of CT in diagnosis and treatment of distal tibial fractures with intra-articular involvement in children.

AIM: Distal tibial fractures with intra-articular involvement during childhood are injuries with potentially severe complications if not treated promptly. Daily clinical practice indicates that sole use of plain radiographs may lead to misdiagnosis and subsequent erroneous selection of suitable treatment. The role of computed tomography (CT) in the classification and treatment decision of these injuries is unclear. This study aims to determine whether CT evaluation is required in the management of these fractures. PATIENTS AND METHODS: We assessed 64 distal tibial fractures with intra-articular involvement on two separate occasions in a blinded study, in order to classify the fracture and decide the appropriate treatment approach. In the first part of the study, plain radiographs were evaluated in order to diagnose the type of the fracture and select the appropriate treatment. In the second part, CT scans were performed in the same patients in order to re-evaluate diagnosis and treatment. The study included fractures prior to physeal closure (Salter-Harris III and IV fractures, n=32) as well as transitional fractures (J. Tillaux and triplane fractures, n=32). RESULTS: According to plain radiographs, 31 patients were diagnosed with SH III fracture, 8 with SH IV, 9 with J. Tillaux and 16 with triplane fracture. Surgical treatment was decided in 18 patients and non-surgical in 46. After CT scan evaluation, 20 patients were diagnosed with SH III, 12 with SH IV, 9 with J. Tillaux, and 23 with triplane fracture. In this occasion the number of patients referred for surgical treatment raised to 42 leaving only 22 patients to be treated conservatively. CONCLUSIONS: Computed tomography lead to changes in fracture classification and treatment decision. Treatment decision changed for 24 patients after CT evaluation. Treatment decision in patients with SH III and IV did not change significantly opposed to patients with transitional fractures, where CT scan had major impact on treatment decision. Despite the irradiation of immature skeleton and higher cost containment, this study indicates that patients with transitional distal tibial fractures as well as patients with displaced SH III and IV fractures must undergo CT examination in order to make accurate diagnosis and select the appropriate treatment.

Weaver syndrome associated with bilateral congenital hip and unilateral subtalar dislocation.

BACKGROUND: Weaver syndrome is a congenital paediatric syndrome characterized by mental, respiratory and musculoskeletal manifestations. The coexisting deformities of the skull, the face, fingers and toes are typical. We report a case of a girl with Weaver syndrome associated with rare bilateral congenital dislocation of the hips associated with congenital hypoplastic talus and subtalar dislocation of her ankle joint. CASE REPORT: A 3-year old girl was admitted in our department with typical manifestations of Weaver syndrome, associated with congenital dislocation of bilateral hips, hypoplastic talus and subtalar dislocation of her right ankle. She was in pain while standing upright and incapable of independent walking. Both hips were treated operatively with open reduction and bilateral iliac osteotomy. Two years afterwards she had an open reduction of her talus and extraarticular arthrodesis of her subtalar joint in her right ankle. Six years postoperatively after the hip operations and four years after the ankle operation the girl is ambulant with a painless independent and unaided walking with a mild limp and full range of movements in all the operated joints. CONCLUSIONS: We suggest that children with Weaver syndrome and disabling musculosceletal deformities, particularly affecting their ability to stand up and walk should be treated early, before bone maturity, in order to achieve the best potential musculoskeletal as well as developmental outcome.

Persistent median artery in the carpal tunnel: anatomy, embryology, clinical significance, and review of the literature.

The median artery usually regresses after the eighth week of intrauterine life, but in some cases it persists into adulthood. The persistent median artery (PMA) passes through the carpal tunnel of the wrist, accompanying the median nerve. During anatomical dissection in our department, we found two unilateral cases of PMA originating from the ulnar artery. In both cases the PMA passed through the carpal tunnel, reached the palm, and anastomosed with the ulnar artery, forming a medio-ulnar type of superficial palmar arch. In addition, in both cases we observed a high division of the median nerve before entering the carpal tunnel. Such an artery may result in several complications such as carpal tunnel syndrome, pronator syndrome, or compression of the anterior interosseous nerve. Therefore, the presence of a PMA should be taken into consideration in clinical practice. This study presents two cases of PMA along with an embryological explanation, analysis of its clinical significance, and a review of the literature. The review of the literature includes cases observed during surgical procedures or anatomical dissections. Cases observed by means of imaging techniques were not included in the study.

Congenital pseudarthrosis of the clavicle: a case report.

Congenital pseudarthrosis of the clavicle is a rare entity of unknown aetiology. Its pathogenesis is related to the embryology of the clavicle. We present a 6-year-old girl with congenital pseudarthrosis of the right clavicle. A prominence was noticed at birth between the middle and distal ends of the clavicle that increased in size when the right shoulder was actively mobilised. Radiographic examination revealed a hypertrophic pseudarthrosis of the clavicle. The pseudarthrosis was resected and the clavicular segments were fixed with an external fixator for 2 months until union. Clinical results were excellent at the 7-year follow-up: the right shoulder was pain-free and the appearance satisfactory. Surgical treatment of congenital pseudarthrosis of the clavicle in children using an external fixator provides a better cosmetic outcome with smaller postoperative scars and avoids a second surgical procedure to remove the implants.

Correlation between the four types of acromion and the existence of enthesophytes: a study on 423 dried scapulas and review of the literature.

The purpose of this study was to correlate the four types of acromial shape with the existence of enthesophytes, which together comprise two important parameters for subacromial impingement syndrome and rotator cuff tears. In addition, a review of the literature was carried out. Four hundred twenty-three dried scapulas were studied at the Department of Anatomy in the University of Cologne, Germany. Four types of acromion were found: the three classical ones as described by Bigliani et al. ([1986] Orthop Trans 10:216) and a fourth one, where the middle third of the undersurface of acromion was convex (Gagey et al. [1993] Surg Radiol Anat 15:63-70). The correlation between the four types of acromion and the presence of enthesophytes at its anterior undersurface was also recorded. The distribution of acromial types was as follows: type I, flat, 51 (12.1%); type II, curved, 239 (56.5%); type III, hooked, 122 (28.8%); and type IV, convex, 11 (2.6%). Enthesophytes were found in 1 of type I (2%), in 19 of type II (7.9%), in 46 of type III (37.7%), and in 0 (0%) of type IV acromions. Overall, 66 (15.6%) out of 423 scapulas had enthesophytes. In all cases, they were localized at the site of the coracoacromial ligament insertion on the acromion. Enthesophytes were significantly (P < 0.05) more common in type III acromions and this combination is particularly associated with subacromial impingement syndrome and rotator cuff tears. In type I and in type IV acromions, the incidence of enthesophytes is very small and, according to other studies, with these two acromial types rotator cuff tears are also rare.

The course of the greater occipital nerve in the suboccipital region: a proposal for setting landmarks for local anesthesia in patients with occipital neuralgia.

The anatomical relationships of the greater occipital nerve (GON) to the semispinalis capitis muscle (SCM) and the trapezius muscle aponeurosis (TMA) were examined to identify topographic landmarks for use in anesthetic blockade of the GON in occipital neuralgia. The course and the diameter of the GON were studied in 40 cadavers (29 females, 11 males), and the points where it pierced the SCM and the TMA were identified. The course of the GON did not differ between males and females. A left-right difference was detected in the site of the GON in the TMA region but not in the SCM region. The nerve became wider towards the periphery. This may be relevant to entrapment of the nerve in the development of occipital neuralgia. In three cases, the GON split into two branches before piercing the TMA and reunited after having passed the TMA, and it pierced the obliquus capitis inferior muscle in another three cases. The GON and the lesser occipital nerve reunited at the level of the occiput in 80% of the specimens. The occiput and the nuchal midline are useful topographic landmarks to guide anesthetic blockade of the GON for diagnosis and therapy of occipital neuralgia. The infiltration is probably best aimed at the site where the SCM is pierced by the GON.

Soleus accessorius, an anomalous muscle in a young athlete: case report and analysis of the literature.

The soleus accessory muscle is a rare anatomical variation. It usually appears as a soft tissue mass and may be mistaken for a tumour or an inflammatory lesion. The differential diagnoses include ganglion, lipoma, haemangioma, synovioma, and sarcoma. This is a report of such a muscle mass in the leg of a young athlete with 16 years follow up. A review of the English literature on this subject is also presented.