Total hip arthroplasty with rectangular stems and subtrochanteric transverse shortening osteotomy in Crowe type IV hips: a retrospective study.

BACKGROUND: The complexity of femoral and acetabular anatomy and restoring anatomic center of hip rotation in Crowe type IV developmental dysplasia of the hip (DDH) complicates standard reconstruction. The aim of this study is to evaluate surgical techniques and clinical outcomes of subtrochanteric transverse shortening osteotomy with the use of cementless rectangular cross-section femoral implants in Crowe IV dysplastic hips. METHODS: A total of 26 hips of 25 consecutive patients with Crowe type IV DDH who underwent cementless total hip arthroplasty with subtrochanteric femoral transverse shortening osteotomy were retrospectively analyzed. The Harris Hip Score, Visual Analog Scale-pain, leg length discrepancy, and vertical and lateral migration of hip rotation center were recorded. RESULTS: Mean age, follow-up, and time of union were 41 ± 9.7 years, 7.1 ± 1.2 years, and 3.7 ± 1.1 months, respectively. Mean Harris Hip Score significantly improved from 38 ± 5.7 to 86 ± 6.1 points postoperatively (P < .01). Mean leg length discrepancy and Visual Analog Scale significantly decreased from 4.3 ± 1.3 to 1.2 ± 0.6 cm, and 6.4 ± 1.2 to 1.8 ± 0.8 points, respectively (P < .01). One female patient had a dislocation due to acetabular liner wear, which was managed by liner and head change. One patient had Sudeck's atrophy, while another had pain on the lateral thigh, both of which were resolved with conservative management. CONCLUSIONS: Combined transverse subtrochanteric femoral osteotomy and cementless total hip arthroplasty with rectangular cross-section femoral implants is technically demanding, effective, and safe in femoral shortening for treatment of Crowe type IV DDH.

Reconstruction of intercalary bone defects following bone tumor resection with segmental bone transport using an Ilizarov circular external fixator.

AIM: The purpose of this retrospective study was to report the long-term follow-up results of the reconstruction of bony defects with Ilizarov distraction osteogenesis using the bone transport method following en bloc resection of bone tumors. MATERIALS AND METHODS: En bloc resection was performed in 13 patients with bone tumors between October 1991 and December 2010 in our clinic. The mean age of the patients was 19.46 years (range 7-42 years) at the time of surgery. Histological diagnosis was osteosarcoma in seven cases, Ewing's sarcoma in three cases, giant cell tumor in one case, osteoblastoma in one case and fibrous dysplasia in one case. In all cases either the femur or tibia was involved. RESULTS: The average follow-up period was 157.23 months (range 32-288 months), and the bone defect after resection was 14.61 cm ± (9-24 cm). The mean Musculoskeletal Tumor Society score of the patients was 89.46 (83-96) at the final follow-up. The mean Knee Society Scale scores of patients in whom reconstruction was performed around the knee joint were 74.3 (51-84). The mean foot and ankle disability index of patients with a tumor around the ankle joint was 81 (73-95). Quality of life of the patients according to the SF-36 and BQUILI indexes was scored as 104 (88-150) and 4 (0-13), respectively. CONCLUSION: From the long-term follow-up results, reconstruction with distraction osteogenesis seems to be an efficient method in patients with long life expectancies. However, a long external fixation time is a disadvantage of this technique. Problems in patient compliance and possible complications such as nonunion should be managed promptly.

The accuracy of two different extra-medullary tibial cutting guides for posterior tibial slope in total knee arthroplasty.

OBJECTIVES: This study aims to evaluate the effectiveness of two different external tibial cutting guides with and without a spike anchoring to the intercondylar eminentia to achieve a desired posterior tibial slope. PATIENTS AND METHODS: Between January 2008 and December 2011, 120 posterior cruciate ligament protecting total knee arthroplasty (TKA) surgeries of 83 patients in which two different external tibial cutting guides used were included. Fifty-nine knees were included into the spiked and 61 knees were included into the spikeless cutting guide group. Posterior tibial slope angles were measured using the postoperative X-rays. RESULTS: There was no significant difference between two groups in terms of age, sex, and body mass indexes (p<0.05). While the mean postoperative slope angle was 2.66°±2.001°(range 0°-7°) in spiked group, it was 2.46°±2.277° (range 0°-7°) in spikeless group. Both systems had identical accuracy, indicating a low rate. The comparison of variances of two groups showed that both cutting guides had similar precision (p=0.234). There was no effect of body mass index on the results in both groups. CONCLUSION: Although different extra-medullary tibial cutting guides with and without a spike can reproducibly impart a desired posterior tibial slope in TKA, we concluded that a spiked guide was considered user-friendly.

Prediction of the presence of plantaris tendon through examination of palmaris longus tendon: is there a link? / Predicción de la presencia del tendón del músculo plantar mediante el examen del tendón del músculo palmar largo: ¿hay una relación?

The purpose of this study was to investigate the relationship between palmaris longus (PL) and plantaris (P) tendons and test the clinical usefulness of symmetry patterns between these tendons in Turkish population. This prospective study comprised a total of 240 adult patients (120 men and 120 women) who were admitted to our outpatient clinic with bilateral knee complaints that required bilateral knee MR examination during two years. Standard test (Schaefer's test, oppose the thumb to the little finger while flexing the wrist) was used to assess the presence of the PL tendon both with inspection and palpation. Knee MRI was used to determine the presence of P muscle belly on both sides. We have analyzed symmetric distribution pattern using Mc-Nemar test. The PL was absent unilaterally in 34 subjects (14.2%), while it was absent bilaterally in 17 subjects (7.1%). The P was absent unilaterally in 51 subjects (21.3%), while it was absent bilaterally in 10 subjects (4.2%). If PL was absent in one hand, the chance of having an ipsilateral P tendon was 70.6%. If PL was present in one hand, the chance of having an ipsilateral P tendon was 87.6%. The Mc-Nemar test for symmetry yielded a p value of 0.841 for ipsilateral PL and P muscles. A clear-cut link between Palmaris longus and plantaris tendons could not be demonstrated in this study. Both muscles show different variations independent from each other.

El propósito de este estudio fue investigar la relación entre los tendones del músculo palmar largo (MPL ) y músculo plantar (MP) y poner a prueba la utilidad clínica de los patrones de simetría entre estos tendones de la población turca. Estudio prospectivo realizado sobre 240 pacientes adultos (120 hombres y 120 mujeres) que ingresaron en la clínica por síntomas de dolor en la rodilla bilateralmente, quienes requerían un examen de RM de rodilla durante dos años. Se utilizó la prueba estándar (prueba de Schaefer, se oponen el pulgar hasta el dedo mínimo, mientras se flexiona la muñeca) para evaluar la presencia del tendón MPL tanto con la inspección y palpación. La RM de la rodilla se utilizó para determinar la presencia de vientre muscular plantar en ambos lados. Se analizó el patrón de distribución simétrica mediante la prueba de McNemar. El tendón del MPL estuvo ausente de manera unilateral en 34 pacientes (14,2%) y bilateralmente en 17 pacientes (7,1%). El tendón del MP estuvo ausente de manera unilateral en 51 pacientes ( 21,3 %) mientras que bilateralmente no estaba en 10 pacientes (4,2%). Si el tendón del MPL estuvo ausente en un lado, la probabilidad de tener un tendón del MP ipsilateral fue del 70,6 %. Si el tendón del MPL estaba presente en un lado, la probabilidad de tener un tendón del MP ipsilateral fue 87,6%. La prueba de McNemar - simetría produjo un valor p de 0,841 para los músculos PL y P ipsilaterales. Una relación directa claro entre los tendones de los músculos PL y P no se pudo demostrar en este estudio. Ambos músculos muestran diferentes variaciones independiente uno del otro.

Late tourniquet release and drain clamping reduces postoperative blood loss in total knee arthroplasty.

BACKGROUND: Many studies have investigated the effect of tourniquet release time and closed suction drainage in total knee arthroplasty (TKA). However, controversy remains as to the advisability of preclosure tourniquet release and the advisability of closed suction drain use following total knee arthroplasty. QUESTIONS/PURPOSES: The aim of the study was to investigate if there is a benefit of performing tourniquet release after skin closure, along with drain clamping, for the first 6h following TKA. METHODS: Ninety-six patients underwent TKA between May 2009 and April 2010. Fourteen of these were excluded because of systemic diseases and simultaneous bilateral TKA. Twenty-nine of these were excluded due to use of a patellar component and posterior cruciate ligament (PCL)-sacrificing systems. Thus, 53 patients that underwent PCL-retaining cemented TKA were reviewed retrospectively. In the control group (group C), the tourniquet was released before skin closure, an attempt at hemostasis was made, and a compressive bandage was applied. The drain was not clamped in these patients. The test group of 23 patients (group T) had tourniquet release after skin closure and after the compressive bandage was applied. The drain was clamped for the first 6h after surgery. The two groups were compared as to the amount of drained blood, postoperative change in hemoglobin, postoperative complications, and knee function. RESULTS: We found that drained blood and hemoglobin drop were significantly lower in group T compared with group C. There was no difference regarding postoperative complications and knee function. CONCLUSION: We conclude that tourniquet release after skin closure and compressive dressing followed by 6h of drain clamping reduces postoperative blood loss in TKR surgery.

Amputation versus functional reconstruction in the management of complex hind foot injuries caused by land-mine explosions: a long-term retrospective comparison.

The purpose of this study is to compare the long-term clinical outcomes of patients who were treated with either hind foot reconstruction or amputation in complex hind foot injuries accompanied with bone and soft tissue loss due to land-mine explosions. Between 1994 and 2004, all patients with hind foot complex injuries due to land-mine explosion, who were operated in our clinic, were enrolled to the study. All patients were evaluated with Short-Form 36 (SF-36), Foot and Ankle Disability Index (FADI) and Body Image Quality of Life Inventory (BIQLI) after a mean of 15.1 ± 2.2 (range 9-19) years of follow-up. Demographic characteristics, number of operations, necessity of psychiatric treatment and all complications were compared between groups. There were a total of 42 patients [21 in reconstruction group (Gr I) and 21 in amputation group (Gr II)]. The mean age at the time of final follow-up was 38.4 ± 3.04 years in Gr I and 38.2 ± 4.24 years in Gr II (p = 0.732). The mean follow-up duration was 15.7 ± 2.07 years in Gr I and 14.57 ± 2.29 years in Gr II (p = 0.081). The number of operations was significantly higher in Gr I (8.66 ± 10.2 times vs. 4.42 ± 7.7 times, respectively, p = 0.001). The mean FADI score at the final follow-up was 64.3 ± 18.1 in Gr I. In amputation group, more patients needed psychotherapy due to major depression (12 patients vs. 4 patients, p = 0.012). Major complications in Gr I were musculocutaneous flap atrophy in calcaneal region (n = 8 patients), limited ankle motion (n = 11) and painful osteophytes on plantar region (n = 6). In Gr II, stump problems were dominating (pain and tenderness n = 10, ulcer n = 2, allergic skin lesions n = 7, painful neuroma n = 10, bony spur n = 5, paresthesia n = 1, excessive sweating n = 12). At the final visit, although SF-36 scores were similar between groups (p = 0.182), extremity reconstruction group had significantly higher BIQLI scores than the amputation group (p = 0.016). If the dorsalis pedis is intact and midfoot and forefoot is relatively protected, hind foot reconstruction should be attempted. Long-term outcomes of hind foot reconstruction are satisfactory with minor complications and better BIQLI.

Angiographic evaluation of arterial configuration after acute tibial shortening.

INTRODUCTION: Tibial nonunion with bone and soft tissue loss is a challenging orthopedic problem. Acute tibial shortening is a well-defined technique; however, arterial configuration following acute tibial shortening has not been demonstrated by a clinical study. MATERIALS AND METHODS: Sixteen patients with tibial nonunion and one patient with acute tibial fracture accompanied by bone and soft tissue loss were treated by acute shortening followed by compression or relengthening between 2004 and 2010. Circulation was monitored by intraoperative Doppler ultrasound and hallux pulse oximetry. Arterial configuration was examined by digital subtraction angiography at the seventh postoperative day and by CT angiography at the second year. Bone healing and functional results were evaluated according to Paley's classification, and complications were evaluated according to Dahl's classification. RESULTS: Mean amount of bone loss was 3 ± 1.4 cm (range 1-6 cm); mean size of the soft tissue defects was 7 × 6.8 cm (range 3 × 3 cm-10 × 10 cm). The mean follow-up period was 38 ± 11.3 months (range 24-57 months). The average amount of acute shortening was 5.4 ± 1.6 cm (range 3-8 cm). Average lengthening was 6 ± 1.8 cm (range 4-8 cm), and the mean external fixation index was 1.4 months/cm (range 0.1-3.7 months). There was no detectable change in the arterial configuration of patients with acute shortening up to 4 cm. Minimal arterial bending was observed in patients that 4-6 cm of shortening was performed. Arterial configuration of the patients that 8 cm acute shortening was performed showed increased tortuosity, but the patency was maintained. CONCLUSION: Acute shortening of tibia in nonunions with soft tissue defects allows for primary closure or reduces the need for grafting and secondary operations. Although the amount of acute shortening depends upon intraoperative assessment with Doppler ultrasound and hallux pulse oximetry, acute compression up to 8 cm can be attained in proximal tibia. More than 4 cm of acute shortening leads to increased tortuosity of major arteries rather than kinking, and this new arterial configuration is maintained for up to 2 years with no problem in circulation.

Serum fetuin-A levels in postmenopausal women with osteoporosis.

BACKGROUND/AIM: One of the functions of fetuin-A is the restriction of formation and expansion ofextraosseous hydroxyapatite crystals. TIhe exact correlation of fetuin-A with bone mineral density (BMD) has not been clearly elucidated yet. In this study, we aimed to assess the relationship between BMD and fetuin-A in postmenopausal women. MATERIALS AND METHODS: Fifty postmenopausal women (25 with osteoporosis, 25 healthy controls) were included in the study. All participants were comparable for age and body mass index. None of the osteoporotic patients had received any medical treatment for osteoporosis. Serum fetuin-A levels were measured by ELISA method. RESULTS: BMD scores of the groups were statistically significant (P < 0.001). Serum fetuin-A levels of the osteoporosis group were significantly lower compared to the control group (P = 0.009). Additionally, there was there was a mild to moderate positive correlation between fetuin-A and lumbar (r = 0.381, P = 0.06) and femoral (r = 0.143, P = 0.50) BMD in the osteoporotic group, though it did not reach statistical significance. CONCLUSION: Decreased fetuin-A levels in women with postmenopausal osteoporosis suggest that fetuin-A may have a role in the development of osteoporosis. Further studies are required to define the exact role of fetuin-A in bone metabolism.

Another cystic lesion in the calcaneus: benign fibrous histiocytoma of bone.

Benign fibrous histiocytoma is a rare benign primary skeletal tumor that occurs frequently in the long bones and the pelvis. The calcaneus is an unusual location for benign fibrous histiocytoma. We did not identify any case of benign fibrous histiocytoma involving the calcaneus in the relevant literature. We describe a 22-year-old male patient with benign fibrous histiocytoma involving the calcaneus treated with curettage and bone grafting. At the final follow-up visit, 1 year after surgery, the patient was free of pain and walking unaided. We discuss the differential diagnosis of cystic lesions of the calcaneus.

Lower limb salvage surgery using Ilizarov circular external frame for a landmine injury about the knee.

Limb salvage for severe trauma has been replaced amputation as the primary treatment in many trauma centers. However, the long-term outcomes after limb reconstruction or amputation have not been fully evaluated. In this report, we present the treatment results of limb salvage surgery using Ilizarov external circular frame in a male case who had a-22-cm bone loss on the left distal femur and left proximal tibia and large soft tissue defect around the knee due to stepping on a landmine with his knee. The decision to amputate a severely injured limb, being irreversible, is challenging and significantly affects the body image and the patient. Extremity salvage surgery should be considered initially when evaluating patients with high-energy injured limbs at high risk for amputation.

Use of the iPhone for radiographic evaluation of hallux valgus.

OBJECTIVE: The purpose of this study was to compare the measurements made using a smartphone accelerometer and computerized measurements as a reference in a series of 32 hallux valgus patients. MATERIALS AND METHODS: Two observers used an iPhone to measure the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (of anteroposterior foot radiographs in 32 patients with symptomatic hallux valgus on a computer screen. Digital angular measurements on the computer were set as the reference standard for analysis and comparison. The difference between computerized measurements and all iPhone measurements, and the difference between the first and second iPhone measurements for each observer were calculated. Inter- and intraobserver reliability of the smartphone measurement method was also tested. RESULTS: The variability of all measurements was similar for the iPhone and the computer-assisted techniques. The concordance between iPhone and computer-assisted angular measurements was excellent for the HVA, IMA, and DMAA. The maximum mean difference between the two techniques was 1.25 ± 1.02° for HVA, 0.92 ± 0.92° for IMA, and 1.10 ± 0.82° for DMAA. The interobserver reliability was excellent for HVA, IMA, and DMAA. The maximum mean difference between observers was 1.31 ± 0.89° for HVA, 0.90 ± 0.92° for IMA, and 0.78 ± 0.87° for DMAA. The intraobserver reliability was excellent for HVA, IMA, and DMAA. CONCLUSIONS: We conclude that the Hallux Angles software for the iPhone can be used for measurement of hallux valgus angles in clinical practice and even for research purposes. It is an accurate and reproducible method.

[A comparison of the efficacy of bupivacaine and levobupivacaine in patient-controlled epidural analgesia for postoperative pain in patients undergoing knee arthroplasty]. / Diz artroplastisi yapilan hastalarda ameliyat sonrasi agri için hasta kontrollü epidural analjezide bupivakain ve levobupivakainin etkinliginin karsilastirilmasi.

OBJECTIVES: In this study, we aimed to compare the efficacy of bupivacaine and levobupivacaine in the patient-controlled epidural analgesia (PCEA) in patients who underwent total knee arthroplasty (TKA), particularly with cardiac diseases. PATIENTS AND METHODS: Forty-four patients (16 males, 28 females; mean age 70.2±6.3 years; range 18 to 80 years) who were scheduled for TKA surgery under combined spinal and epidural anesthesia were included. Patients were randomly divided into two groups. Bupivacaine 15 mg 0.5% for group 1 (n=23) and levobupivacaine 15 mg 0.5% for group (n=23) were administered via spinal route. The amount of local anesthetics, PCEA starting times and bolus/demand ratio of local anesthetics were recorded. The level of pain, need for additional analgesic, total amount of analgesic, degree of motor block, complications were asked for patient satisfaction at postoperative 6, 12, 24 and 48 hours. RESULTS: No statistical differences were determined between group 1 and group 2 in terms of the operation times, PCEA starting times, bolus number/demand ratios, visual analog scale (VAS) scores and numerical rating scores (NRS) at the postoperative 6, 12, 24 and 48 hours, need for additional analgesic, total amount of analgesic, degree of motor block and patient satisfaction. Although the incidence of side effects was lower in the group 1 compared to group 2, it was not statistically significant. CONCLUSION: We concluded that it would be proper using levobupivacaine rather than bupivakaine for patients with cardiac diseases, as the cardiotoxic and neurotoxic effects of levobupivacaine is lower then bupivacaine with a similar analgesic efficacy.

Multiple osteochondromatosis complicated with a popliteal artery pseudoaneurysm.

In this article, we present a 21-year-old male patient who presented with swelling and pain located to right lower thigh and knee. Physical examination and subsequent diagnostic work-up revealed a pseudoaneurysm associated with an osteochondroma at lower thigh. This complication should be considered in young patients with a mass at knee and lower thigh region.

Bilateral congenital absence of flexor pollicis brevis and abductor pollicis brevis muscles with bilateral thenar atrophy: a case report.

In this paper, we report a case of a 23-year-old male patient with bilateral absence of the flexor pollicis brevis and abductor pollicis brevis muscles with an intact functioning opponens pollicis and flexor pollicis longus muscles with bilateral thenar atrophy due to its rarity. All physical, neurological, ultrasonographic, direct radiographic, electromyographic and MRI studies were used to confirm and document this congenital anomaly.

Ilizarov external fixation without removal of plate or screws: effect on hypertrophic and oligotrophic nonunion of the femoral shaft with plate failure.

Patients with hypertrophic and oligotrophic nonunion of the femoral diaphysis associated with plate failure can be treated by Ilizarov external fixation without plate removal. Advantages of this technique include a lack of damage to the blood supply and simultaneous deformity correction.

[Outcomes of multilevel orthopedic surgery in children with cerebral palsy]. / Serebral palsili çocuklarda çok seviyeli ortopedik cerrahi tedavinin sonuçlari.

OBJECTIVES: Outcomes of single-event bilateral multilevel orthopedic surgery in children with cerebral palsy were retrospectively investigated by physical findings, and gross motor function measurement (GMFM) score in all patients and additionally by joint kinematics, and time-distance parameters in ambulatory patients. PATIENTS AND METHODS: A total of 24 patients (17 ambulatory; 7 non ambulatory; mean age 12 years; range 5 to 19 years) treated with multilevel orthopedic surgery between December 2003 and December 2005 were included in the study. Patients were evaluated with physical examination and GMFM score. In addition, computed gait analysis was used to evaluate joint kinematics and time-distance parameters in ambulatory children. The following surgeries were performed on the children in the study cohort: adductor tenotomy (n=24); psoas lengthening (n=14); hamstring lengthening (n=46); distal rectus femoris transfer (n=18); bilateral Achilles tendon lengthening (n=22); distal femoral derotation osteotomy (n=1); open reduction and Dega osteotomy (n=1), and proximal femur resection (n=2). Patients were evaluated with the same parameters after an average of eight months postoperatively. The pre- and postoperative results were statistically compared. RESULTS: Improvements were achieved in the lying-rolling (7%), sitting (9%), crawling-kneeling (7%), standing (5%), and walking-running-jumping (5%) activities of GMFM score. An increase in hip abduction angle and external rotation and a decrease in the Thomas test results were observed. A decrease in popliteal angle and an increase in active and passive knee extension were provided. Active and passive ankle dorsiflexion increased. In the kinematic parameters, the minimum hip and knee flexions in the stance phase were significantly decreased, while no significant decrease was seen in the maximum hip and knee flexion in the swing phase. Both the ankle dorsiflexion in the stance and swing phase and the time-distance parameters consist of walking velocity, stride length and the cadence were significantly improved. CONCLUSION: Single-event bilateral multilevel orthopedic surgery performed in the right indication was shown to be effective with improvements in physical examination findings GMFM scores, joint kinematics and time-distance parameters in children with cerebral palsy.

The role of preconditioning and N-acetylcysteine on oxidative stress resulting from tourniquet-induced ischemia-reperfusion in arthroscopic knee surgery.

BACKGROUND: The aim of this study was to investigate the effects of ischemic preconditioning (IPC) and N-acetylcysteine (NAC) on oxidative stress resulting from tourniquet-induced ischemia-reperfusion (IR) period in arthroscopic knee surgery. METHODS: Forty-five patients who had arthroscopic knee surgery for meniscal and chondral lesions and for pathologic medial plica were included in this study. They were assigned to the following treatment groups: control (group C; n=15), IPC (group P; n=15), and NAC (group N; n=15). Subjects in the control group underwent routine surgical procedures. Subjects in the preconditioning group were subjected to temporary ischemia, with tourniquet performed by three compression cycles of 5 minutes followed by 5 minutes of reperfusion just before the application of tourniquet inflation. Subjects in the NAC group received 10 mg/kg NAC dissolved in 100 mL 0.9% normal saline intravenously 30 minutes before tourniquet inflation. An hour before the tourniquet was applied (preischemia) and 2 hours after tourniquet was removed (reperfusion), blood samples (to test for metabolites) were obtained. Levels of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), total antioxidant capacity (TAC), and total oxidant status (TOS) were measured in all serum samples. Results were compared between preischemia and reperfusion in three groups. RESULTS: MDA in the control group was found to be increased significantly compared with preischemia, whereas MDA in IPC and NAC groups did not change insignificantly. SOD and GSH activities in the control group were found to be increased significantly, whereas SOD and GSH activities in IPC and NAC groups did not change significantly after reperfusion. TAC in the control group was found to be decreased and TOS was found to be increased significantly, but TAC and TOS in IPC and NAC groups were not significantly different after reperfusion. Mean serum MDA, TOS, SOD, and GSH-Px levels were lower in group P than group C at reperfusion period (p<0.05). Mean serum SOD levels were lower in group P than group N at reperfusion period (p<0.05). CONCLUSIONS: Tourniquet-induced IR period in routine arthroscopic knee surgery resulted in oxidative stress by increasing MDA, SOD, GSH-Px, TOS and decreasing TAC. NAC and IPC had protective effect on occurrence of oxidative stress resulting from IR period by preventing MDA, SOD, GSH-Px, TAC, and TOS changes in routine arthroscopic knee surgery.

Distal femoral intraosseous ganglia: cause or result of a degenerative process: 17-year follow-up of a case.

We report a case of recurrent, resistant, huge, multilocular intraosseous ganglia cyst localized at the distal femur. A 25-year-old man presented with left knee pain. Imaging studies and histological analysis confirmed the diagnosis. Treatment was curettage and bone grafting. Long-term follow-up revealed degenerative changes at radiographs and MRI. This case may contribute to make distinction between degenerative subchondral cyst and intraosseous ganglia cyst and help to understand pathogenesis of this entity.

Effect of preconditioned hyperbaric oxygen and ozone on ischemia-reperfusion induced tourniquet in skeletal bone of rats.

BACKGROUND: The aim of the study was to investigate effect of I/R injury on bone tissue and protective role of hyperbaric oxygen precondition (HBO-PC) and ozone precondition (O(3)-PC) on I/R injury by using biochemical analysis. MATERIALS AND METHODS: Thirty-two rats were included in study. The animals were divided into four equal groups: sham operation, I/R, I/R+HBO and I/R+O(3). One session of 60 min, 3 ATA, 3-4 L/min, 100% oxygenation was defined as one dose of HBO. First dose of HBO was administrated 72 h before ischemia. Subsequent, one-dose of HBO administrated per 12 hours until ischemia time (total seven doses); 0.7 mg/kg ozone/oxygen mixture intraperitoneally was defined as one dose of ozone. First dose of O(3) was administered 72 h before ischemia (total four doses). I/R model was induced in anesthetized rats by unilateral (right) femoral artery clipping for 2 h followed by 22 h of reperfusion. The right tibia and were harvested. Tissue was assayed for levels of malondialdehyde (MDA) and protein carbonyl (PCO), activities of superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px). RESULTS: MDA and PCO levels were increased in I/R group. SOD activity was increased; GSH-Px activity was decreased in I/R group. MDA and PCO levels were decreased, SOD and GSH-Px activities were increased in both HBO+I/R and O(3)+I/R groups. CONCLUSION: It has been shown that levels of MDA and PCO in bone were increased followed by 2 h of ischemia and 22 h of reperfusion period. Ozone-PC and HBO-PC has protective effect against skeletal bone I/R injury by decreasing levels of MDA and PCO, increasing activities of SOD and GSH-Px in rats.

Utilization of axillary brachial plexus block in the postoperative rehabilitation of intra-articular fractures of the distal humerus.

OBJECTIVES: An effective rehabilitation program is essential to prevent joint stiffness and regain range of motion after surgical treatment of intra-articular fractures of the distal humerus. We evaluated the effect of a physiotherapy program on functional results, that involved passive resistive stretching exercises performed under axillary brachial plexus block after radiographic observation of bone union of intra-articular fractures of the distal humerus treated with open reduction and internal fixation. METHODS: The study included 21 patients (7 females, 14 males; mean age 34+/-5 years; range 21 to 57 years) who underwent open reduction and internal fixation for intra-articular fractures of the distal humerus. All the patients had closed fractures. Six patients had AO type C1, six patients had C2, and nine patients had C3 fractures. Surgical treatment consisted of a posterior incision, olecranon osteotomy, and fixation of the metaphyseal fragments using two reconstruction plates placed medially and laterally. Active range of motion exercises were started on the third postoperative day. To prevent early development of heterotopic ossification, passive range of motion exercises were avoided. Active stretching exercises were initiated three weeks after surgery. Upon radiographic observation of bone union, axillary brachial plexus block was performed. The physiotherapy program involved passive stretching exercises during nerve block, and active weight exercises after recovery from motor block. The catheter remained in the axillary region for three months, during which functional rehabilitation was continued 2-3 times a week on an outpatient basis. Functional results were evaluated according to the criteria of Jupiter et al. after a mean follow-up period of 31 months (range 24 to 46 months). RESULTS: All fractures united within a mean of 11.9 weeks (range 9 to 17 weeks) except for one type C3 fracture. Functional results were excellent in 10 patients (47.6%), good in eight patients (38.1%), moderate in two patients (9.5%), and poor in one patient (4.8%). Two patients with a moderate outcome had associated multiple fractures in the ipsilateral extremity. Distribution of the functional results according to the type of fractures were 4 excellent, 2 good in type C1; 4 excellent, 2 good in C2; and 2 excellent, 4 good, 2 moderate, and 1 poor in C3 fractures. The mean loss of elbow extension was 16 degrees. The mean elbow flexion, pronation, and supination were measured as 131 degrees, 90 degrees, and 75 degrees, respectively. None of the patients had nonunion at the olecranon osteotomy site, superficial or deep infection, or heterotopic ossification. Three patients developed transient ulnar nerve neuropraxia that resolved spontaneously during the follow-up period. There were no complications related to axillary catheterization. CONCLUSION: Following surgical treatment of intra-articular fractures of the distal humerus, a regular and pain-free physiotherapy program performed under axillary brachial plexus block on an outpatient basis increases patient compliance and enables early return to daily activities.