PCA-pump for analgesia following pediatric scoliosis surgery: bolus administration with/without basal infusion.

OBJECTIVES: The aim of this study is to compare the use of two different opioid delivery systems (bolus PCA with/without basal infusion) to control postoperative pain and evaluate the side effect profile in pediatric patients undergoing scoliosis surgery. PATIENTS AND METHODS: 38 patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis were included in the study. Patients were randomly divided into 2 groups by the computer. Patients who received only bolus PCA were named Group 1, and patients who received bolus PCA with basal infusion were named Group 2.Morphine consumption, postoperative pain assessmentduring rest, movement and coughing with numeric rating scale (NRS) and the Wong -Baker pain scale, heart rate and average blood pressure, sedation levels withRamsey sedation scale and side effects such as nausea, vomiting, itching, desaturation, and urinary retention were recorded. RESULTS: Total mean morphine consumption (mg) was 32.7 ± 9.7 in Group 1 and 43.4 ± 9.1 in Group 2. The mean morphine consumption (mg) at 12-24 hours and 0-48 hours in Group 1 was statistically lower than Group 2 (p = 0.001). There was no significant difference between the groups in terms of median NRS scores (p = 0.55). There was no statistically significant difference in the evaluation of the groups in terms of Wong-Baker pain scale. Wong-Baker pain scale is p:0.66 at the 2nd hour, p:0.951 at the 12th hour and p:0.467 at the 24th hour.There was no statistically significant difference in Ramsay Sedation Scale evaluation between groups during each follow-up time (p > 0.05). The Ramsay Sedation Scale was p: 0.94 at the 2nd hour, p:1.0 at the 12th hour, and p:1.0 at the 24th hour. The duration of vomiting between 0-2 h, 2-24 h and 0-48 h was higher in Group 2 (p = 0.001, p = 0.024, p = 0.001). CONCLUSION: The two administration settings of morphine sulphate by PCA pump have shown to be equally effective in the treatment of postoperative pain following PSF. In addition, PCA with basal infusion administration causes more opioid consumption and more systemic side effects. Therefore, the use of only bolus PCA in pediatric scoliosis surgery should be encouraged. LEVEL OF EVIDENCE: Level II, Randomized Controlled Trial.

Cerebrospinal fluid signal loss sign: assessment of a new radiological sign in lumbar spinal stenosis.

PURPOSE: Sedimentation sign was reported to have high sensitivity and specificity for diagnosis of lumbar spinal stenosis (LSS). We aimed to determine cerebrospinal fluid signal loss (CSFSL) at the intervertebral disc levels in the sagittal plane using a numerical scoring system and to evaluate the diagnostic value of this method in differential diagnosis of LSS and non-specific low back pain (LBP) and compare it with SS. MATERIALS AND METHODS: We included consecutive patients between 50 and 80 years old, with lumbar spinal MRI examination in our institution. These patients were divided into two groups as LSS and LBP, according to symptoms and radiological findings. CSFSL sign was evaluated for both groups by two radiologists independently, using MR images. Sensitivity and specificity of both signs were calculated. RESULTS: A total of 406 patients (98 LSS and 308 non-specific LBP) were included. SS and CSFSL sign had a sensitivity of 90.8% and 82.7% and specificity of 75.4% and 84.1% in the whole cohort, respectively. When patients were grouped by dural sac cross-sectional areas (CSA), sensitivity and specificity of SS were 100% and 4.4%, 87.5% and 31.8%, and 41.7% and 76%, respectively, and sensitivity and specificity of CSFSL sign were 95.7% and 11.1%, 75% and 77.3%, and 16.7 and 92% for severe (CSA < 80 mm2), moderate (CSA: 80-100 mm2), mild (CSA: 100-120 mm2) radiologic stenosis, respectively. In moderate stenosis, accuracies of SS and CSFSL sign were 76.3% and 55.3%, respectively. CONCLUSION: CSFSL sign might be used to distinguish LSS from LBP and unlike SS it is successful in moderate stenosis.

Excessive extremity shortness due to septic arthritis : Case report of treatment with two surgical procedures.

Septic arthritis is a common joint infection in neonates and young children. Since osteoarticular infections cause permanent disability in bones and joints, they should be treated appropriately as soon as possible. If there is a delay in starting treatment it can cause severe morbidity. It is most common in the hip and shoulder joints. In this article the surgical treatment process and postoperative clinical status of a 35-year-old patient with severe coxarthrosis and 12 cm femoral shortening due to septic arthritis are reported. To avoid damage to neurovascular structures an extremity lengthening procedure was performed first, followed by a total hip replacement. In order to complete the distraction and consolidation phase in one session and to reduce complications, a growing intramedullary nail was selected. As a result of the surgical interventions, the complaints of the patient in the hip joint and the limping due to shortness of the leg decreased and the performance of activities of daily living was improved.

Biomechanical comparison of a new handy tension band with malleolar screw, bicortical screw and conventional tension band for the fixation of transverse medial malleolar fractures.

OBJECTIVES: This study aims to compare the biomechanical features of a new handy tension band with the malleolar screw, bicortical screw and conventional tension band for the fixation of transverse medial malleolar fractures. MATERIALS AND METHODS: This study used 20 Kirschner wires, five cerclage wires, six double-hole U pins, six cortical screws, six malleolar screws, three malleolar clamps and one osteotomy set. A total of 24 tibias of two-year-old cows were obtained and stripped from soft tissue. Each tibia was cut with an electric saw at 15 cm proximal to the tibiotalar joint surface and the proximal tibia sections were discarded. A transverse fracture line was created with an osteotome on the medial malleolus. The tibias were separated into four groups with six tibias in each group. The distal tibia medial malleolar transverse fragments were fixed under guidance of fluoroscopy with the malleolar screw, bicortical screw, conventional tension band and the new handy tension band. RESULTS: In the application of both transverse and axial force, the new handy tension band resisted higher forces in respect of catastrophic damage force being more resistant compared to the bicortical screw, malleolar screw, and conventional tension band. However, in respect of the 2 mm displacement force of the forces applied in the axial and transverse sections, no difference was determined between the handy tension band and the other three implants. CONCLUSION: The new handy tension band seems to be more successful when biomechanically compared with the other implants.

HIGH TIBIAL OSTEOTOMY USING A LOCKING TITANIUM PLATE WITH OR WITHOUT AUTOGRAFTING.

OBJECTIVE: To postoperatively evaluate knee scores, radiological assessment results, deficit correction, patellar height change, bone healing time, and weight bearing time in patients undergoing high tibial osteotomy (HTO) with/without autologous iliac bone grafting. METHODS: This retrospective examination of treated controls from a randomized controlled study included 63 knees of 58 patients aged 46-59 years who underwent HTO with locking open wedge osteotomy plates. The patients were divided into two groups: Group A, HTO with autologous iliac bone grafts (n = 31); and Group B, HTO without autologous iliac bone grafts (n = 32). Clinical and radiological data were evaluated prospectively at the preoperative consultation and again at 6, 9, and 12 weeks, 6 months, and 1 year after the surgery (and annually thereafter). RESULTS: There were no significant intergroup differences in the radiological assessment, deficit correction, patellar height change, bone-healing time, and weight-bearing time at any time after surgery. The knee scores changed positively in both groups (p < 0.001). CONCLUSIONS: There was no difference in the results of patients undergoing HTO with open wedge osteotomy titanium locking plates with or without autografting, and comorbidities resulting from autografts were eliminated with the use of locking plates. Level of evidence III, Retrospective Study .

OBJETIVO: Avaliar escores de joelho, resultados da avaliação radiológica, correção de déficits, alteração da altura patelar, tempo de consolidação óssea e tempo para apoio de peso no pós-operatório em pacientes submetidos à osteotomia tibial alta (OTA) com ou sem enxerto autólogo de osso ilíaco. MÉTODOS: O exame retrospectivo de controles tratados em estudo randomizado e controlado foi realizado em 63 joelhos de 58 pacientes com idade entre 46 e 59 anos submetidos a OTA com placas bloqueadas de titânio em cunha aberta. Os pacientes foram divididos em dois grupos: Grupo A, OTA com enxerto de osso ilíaco autólogo (n = 31) e Grupo B, OTA sem enxerto autólogo de osso ilíaco (n = 32). Os dados clínicos e radiológicos foram avaliados prospectivamente na consulta pré-operatória e 6, 9 e 12 semanas e 6 meses e 1 ano após a cirurgia (e depois disso, anualmente). RESULTADOS: Não houve diferenças significativas quanto a avaliação radiológica, correção de déficit, mudança de altura da patela, tempo de cicatrização óssea e tempo para apoio de peso entre os dois grupos em nenhum momento após a cirurgia. Os escores de joelho mudaram positivamente em ambos os grupos (p < 0,001). CONCLUSÕES: Não houve diferença nos resultados dos pacientes submetidos a OTA com placas bloqueadas de titânio em cunha aberta com e sem autoenxerto, e as comorbidades resultantes dos autoenxertos foram eliminadas com o uso de placas bloqueadas. Nível de Evidência III, Estudo Retrospectivo.

High tibial osteotomy using a locking titanium plate with or without autografting / Osteotomia tibial alta com placa bloqueada de titânio com ou sem autoenxerto

ABSTRACT Objective: To postoperatively evaluate knee scores, radiological assessment results, deficit correction, patellar height change, bone healing time, and weight bearing time in patients undergoing high tibial osteotomy (HTO) with/without autologous iliac bone grafting. Methods: This retrospective examination of treated controls from a randomized controlled study included 63 knees of 58 patients aged 46-59 years who underwent HTO with locking open wedge osteotomy plates. The patients were divided into two groups: Group A, HTO with autologous iliac bone grafts (n = 31); and Group B, HTO without autologous iliac bone grafts (n = 32). Clinical and radiological data were evaluated prospectively at the preoperative consultation and again at 6, 9, and 12 weeks, 6 months, and 1 year after the surgery (and annually thereafter). Results: There were no significant intergroup differences in the radiological assessment, deficit correction, patellar height change, bone-healing time, and weight-bearing time at any time after surgery. The knee scores changed positively in both groups (p < 0.001). Conclusions: There was no difference in the results of patients undergoing HTO with open wedge osteotomy titanium locking plates with or without autografting, and comorbidities resulting from autografts were eliminated with the use of locking plates. Level of evidence III, Retrospective Study.

RESUMO Objetivo: Avaliar escores de joelho, resultados da avaliação radiológica, correção de déficits, alteração da altura patelar, tempo de consolidação óssea e tempo para apoio de peso no pós-operatório em pacientes submetidos à osteotomia tibial alta (OTA) com ou sem enxerto autólogo de osso ilíaco. Métodos: O exame retrospectivo de controles tratados em estudo randomizado e controlado foi realizado em 63 joelhos de 58 pacientes com idade entre 46 e 59 anos submetidos a OTA com placas bloqueadas de titânio em cunha aberta. Os pacientes foram divididos em dois grupos: Grupo A, OTA com enxerto de osso ilíaco autólogo (n = 31) e Grupo B, OTA sem enxerto autólogo de osso ilíaco (n = 32). Os dados clínicos e radiológicos foram avaliados prospectivamente na consulta pré-operatória e 6, 9 e 12 semanas e 6 meses e 1 ano após a cirurgia (e depois disso, anualmente). Resultados: Não houve diferenças significativas quanto a avaliação radiológica, correção de déficit, mudança de altura da patela, tempo de cicatrização óssea e tempo para apoio de peso entre os dois grupos em nenhum momento após a cirurgia. Os escores de joelho mudaram positivamente em ambos os grupos (p < 0,001). Conclusões: Não houve diferença nos resultados dos pacientes submetidos a OTA com placas bloqueadas de titânio em cunha aberta com e sem autoenxerto, e as comorbidades resultantes dos autoenxertos foram eliminadas com o uso de placas bloqueadas. Nível de Evidência III, Estudo Retrospectivo.

The importance of glenoid version in patients with anterior dislocation of the shoulder.

BACKGROUND: Although increased retroversion of the glenoid has been shown to be an important factor in posterior instability of the shoulder, there are few studies reporting glenoid bone structure as a risk factor in anterior dislocation of the shoulder. This study aimed to compare glenoid version in patients with anterior dislocation of the shoulder and individuals in a control group with no shoulder problems before undergoing computed tomography and to assess a possible relationship between demographic characteristics and glenoid version angle. METHODS: The study group comprised 63 patients (12 women and 51 men; mean age, 35.71 years) with 1 or multiple unilateral anterior dislocations of the shoulder (dislocated group), whereas 63 individuals (11 women and 52 men; mean age, 35.38 years) with no history of shoulder complaints and no signs of instability constituted the control group. The glenoid version angle was measured on an axial cut of the computed tomography scan. RESULTS: The glenoid version angles on the dislocated side in the study group were significantly more anteverted than those of the dominant (P < .001) and nondominant (P = .023) shoulders of the control group. The version angles of dislocated shoulders significantly differed from those of nondislocated shoulders of both men (P = .041) and women (P = .049). There was no significant relationship between the glenoid version angle on the dislocated side and dislocation mechanism (P = .883), age group (P = .356), or number of dislocations (P = .971). CONCLUSIONS: Glenoid version is an important factor for the development of anterior dislocation of the shoulder.

IS RDW A PREDICTIVE PARAMETER FOR CUBITAL TUNNEL SYNDROME PATIENTS REQUIRING SURGERY?

ABSTRACT Objective: The aim of this study was to investigate whether haemogram parameters are predictive factors for both the severity of the disease and a decision in favor of surgical treatment in patients with an established diagnosis of cubital tunnel syndrome (CuTS) . Methods: The medical files of patients with a diagnosis of CuTS who were followed-up conservatively (n=92) or surgically treated (n=92) were retrospectively screened and the haemogram parameters were recorded . Results: The receiver operating characteristic (ROC) curve analysis revealed an area of 0.665 under the curve, with 76.3% sensitivity and 84.8% specificity at the cut-off of a red cell distribution width (RDW) level grater than 15.45%. RDW levels higher than 15.5%, electromyography (EMG) severity, and a clinical score higher than three were found to be independently associated with surgery . Conclusion: An elevated RDW value was related to the severity of the electromyogram. RDW may, therefore, be a useful independent predictor for the decision to surgical treatment of CuTS. Level of Evidence III, Retrospective Study.

IS RDW A PREDICTIVE PARAMETER FOR CUBITAL TUNNEL SYNDROME PATIENTS REQUIRING SURGERY?

OBJECTIVE: The aim of this study was to investigate whether haemogram parameters are predictive factors for both the severity of the disease and a decision in favor of surgical treatment in patients with an established diagnosis of cubital tunnel syndrome (CuTS) . METHODS: The medical files of patients with a diagnosis of CuTS who were followed-up conservatively (n=92) or surgically treated (n=92) were retrospectively screened and the haemogram parameters were recorded . RESULTS: The receiver operating characteristic (ROC) curve analysis revealed an area of 0.665 under the curve, with 76.3% sensitivity and 84.8% specificity at the cut-off of a red cell distribution width (RDW) level grater than 15.45%. RDW levels higher than 15.5%, electromyography (EMG) severity, and a clinical score higher than three were found to be independently associated with surgery . CONCLUSION: An elevated RDW value was related to the severity of the electromyogram. RDW may, therefore, be a useful independent predictor for the decision to surgical treatment of CuTS. Level of Evidence III, Retrospective Study.

Using a Combination of Intralaminar and Pedicular Screw Constructs for Enhancement of Spinal Stability and Maintenance of Correction in Patients With Sagittal Imbalance: Clinical Applications and Finite Element Analysis.

STUDY DESIGN: Case series and finite element analysis. OBJECTIVE: To report the clinical results of using intralaminar screw-rod (ILS) constructs as supplements to regular pedicle screw (PS) constructs in "high risk for implant failure" patients and to report the results of a finite element analysis (FEA) of this new instrumentation technique. SUMMARY OF BACKGROUND DATA: Despite advances in surgery and implantation techniques, osteoporosis, obesity, revision surgeries, and neuromuscular conditions (such as the Parkinson disease) are challenges against achieving solid arthrodesis and maintaining correction. Additional fixation strategies must be considered in these patients. There is only one study in the literature suggesting that ILS can be used as alternative anchor points and/or to increase fixation strength in conjunction with the PSs. MATERIALS AND METHODS: Five patients (3 male and 2 female) with mechanical comorbidities underwent PS+ILS to treat sagittal imbalance. In radiologic analysis, thoracic kyphosis, lumbar lordosis, and sagittal vertical axis were analyzed. FEA of ILS augmentation technique were carried out.Four different models were created: (1) the full-construct model with ILS+PS 2 levels above and below the osteotomy of T10; (2) only PS 2 levels above and below T10; (3) ILS+PS 1 level above and below the osteotomy; and (4) short-segment PS with only PSs 1 level above and below the osteotomy. The stress/load distributions on the implants in vertebrae were analyzed. RESULTS: The mean age of the patients included in this study was 41 years and the mean follow-up was 28.2 months. A total of 87 PSs and 39 ILSs were used. Both sagittal vertical axis and kyphosis angles showed significant improvements maintained at the latest follow-up. No pseudarthrosis or instrumentation failures were observed. FEA indicated that addition of ILS construct to a PS construct enabled decreased load bearing and increased implant life. CONCLUSIONS: Addition of an ILS construct to PS construct decreases osteotomy line deformation and reduces stress on pedicle fixation points, and the combination improves fixation stability over the conventional PS-rod technique.

Comparação entre fio de kirshner e hastes elásticas de titânio em fraturas pediátricas da diáfase femoral / Kirschner wire versus titanium elastic nails in pediatric femoral shaft fractures

Objetivo: Avaliar a eficácia da fixação intramedular usando o fio deKirschner em comparação com hastes elásticas de titânio (HET)nas fraturas pediátricas da diáfise do fêmur. Métodos: Pacientespediátricos com fraturas da diáfise femoral foram submetidos àfixação intramedular usando o fio de Kirschner ou HET em umgrupo de 42 crianças com idade média de 6,55±2,42 (4-11) anos.Resultados: Não houve diferença significativa entre os grupos,onde 16 (38,1%) pacientes foram tratados com fio de Kirschner e26 (61,9%) pacientes com HET em termos de duração de união.Ademais, nenhum dos pacientes demonstrou má união ou uniãoretardada. Conclusões: O uso do fio de Kirschner ajustado em vezde HET na fixação intramedular de fraturas diafisárias do fêmurem crianças selecionadas pode ser uma opção cirúrgica vantajosadevido ao menor custo, fácil acessibilidade e ausência da necessidadede uma segunda cirurgia para remoção do implante. Nívelde Evidência III, Estudo Retrospectivo.

Objective: To evaluate the effectiveness of intramedullary fixationusing the Kirschner-wire (K-wire) compared to the titaniumelastic nail (TEN) in pediatric femoral shaft fractures. Methods:A sample of 42 pediatric patients with a mean age of 6.55±2.42years (range 4-11 years) presenting femoral shaft fractures underwentintramedullary fixation using the K-wire or TEN. Results:There was no significant difference found between groups, ofwhich 16 (38.1%) patients were treated with K-wire and 26(61.9%) patients were treated with TEN in terms of union duration.Moreover, none of the patients showed nonunion or adelayed union. Conclusions: The use of adjusted K-wire insteadof TEN in the intramedullary fixation of femoral shaft fracturesin selected children may be an advantageous surgical optiondue to the lower cost, easy accessibility and no need for asecond surgery for implant removal. Level of Evidence III,Retrospective Study.

Erythropoietin stimulates patellar tendon healing in rats.

BACKGROUND: Erythropoietin (EPO), regulating erythropoiesis, is used to provide protective and regenerative activity in non-haematopoietic tissues. There is insufficient knowledge about the role of EPO activity in tendon healing. Therefore, we investigated the effect of EPO treatment on healing in rat patellar tendons. METHODS: One hundred and twenty-six, four-month-old male Sprague-Dawley rats were randomly assigned to three experimental groups: 1, no treatment; 2, treatment with isotonic saline (NaCl) and 3, treatment with EPO. Each group was randomly subdivided into two groups for sacrifice at three (1a, 2a, 3a) or six weeks (1b, 2b, 3b). Complete incision of the left patellar tendon from the distal patellar pole was performed. We applied body casts for 20 days after the incised edges of the patellar tendon were brought together with a surgical technique. Both legs were harvested and specimens from each group underwent histological, biomechanical, and protein mRNA expression analyses. RESULTS: There were statistically significant differences in the ultimate breaking force between the EPO group and others at both weeks three and six (p<0.05); significant differences in fibroblast proliferation, capillary vessel formation, and local inflammation were found between groups 1a and 3a, and 2a and 3a (p<0.05). There were statistical differences between 1a, 3a and 2a, 3a for Col III, TGF-ß1, and VEGF and between 1b, 3b and 2b, 3b for Col I, Col III, TGF-ß1, and VEGF mRNA expressions. CONCLUSION: EPO had an additive effect with surgery on the injured tendon healing process in rats compared to the control groups biomechanically, histopathologically and with tissue protein mRNA expression. CLINICAL RELEVANCE: This is the first experimental study to analyze the relationship between EPO treatment and the patellar tendon repair process by biomechanical, histopathological, and tendon tissue mRNA expression methodologies.

Assessment of Postoperative Tendon Quality in Patients With Achilles Tendon Rupture Using Diffusion Tensor Imaging and Tendon Fiber Tracking.

Although pre- and postoperative imaging of Achilles tendon rupture (ATR) has been well documented, radiographic evaluations of postoperative intratendinous healing and microstructure are still lacking. Diffusion tensor imaging (DTI) is an innovative technique that offers a noninvasive method for describing the microstructure characteristics and organization of tissues. DTI was used in the present study for quantitative assessment of fiber continuity postoperatively in patients with acute ATR. The data from 16 patients with ATR from 2005 to 2012 were retrospectively analyzed. The microstructure of ART was evaluated using tendon fiber tracking, tendon continuity, fractional anisotropy, and apparent diffusion coefficient values by way of DTI. The distal and proximal portions were measured separately in both the ruptured and the healthy extremities of each patient. The mean patient age was 41.56 ± 8.49 (range 26 to 56) years. The median duration of follow-up was 21 (range 6 to 80) months. The tendon fractional anisotropy values of the ruptured Achilles tendon were significantly lower statistically than those of the normal side (p = .001). However, none of the differences between the 2 groups with respect to the distal and proximal apparent diffusion coefficient were statistically significant (p = .358 and p = .899, respectively). In addition, the fractional anisotropy and apparent diffusion coefficient measurements were not significantly different in the proximal and distal regions of the ruptured tendons compared with the healthy tendons. The present study used DTI and fiber tracking to demonstrate the radiologic properties of postoperative Achilles tendons with respect to trajectory and tendinous fiber continuity. Quantifying DTI and fiber tractography offers an innovative and effective tool that might be able to detect microstructural abnormalities not appreciable using conventional radiologic techniques.

Cohesive taping and short-leg casting in acute low-type ankle sprains in physically active patients.

BACKGROUND: Cohesive taping is commonly used for the prevention or treatment of ankle sprain injuries. Short-leg cast immobilization or splinting is another treatment option in such cases. To determine the clinical efficacy and antiedema effects of cohesive taping and short-leg cast immobilization in acute low-type ankle sprains of physically active patients, we performed a preliminary clinical study to assess objective evidence for edema and functional patient American Orthopaedic Foot and Ankle Society (AOFAS) scores with these alternative treatments. METHODS: Fifty-nine physically active patients were included: 32 in the taping group and 27 in the short-leg cast group within a year. If a sprain was moderate (grade II) or mild (grade I), we used functional taping or short-leg cast immobilization for 10 days. We evaluated the edema and the functional scores of the injured ankle using the AOFAS Clinical Rating System on days 1, 10, and 100. RESULTS: In each group, edema significantly decreased and AOFAS scores increased indicating that both treatment methods were effective. With the numbers available, no statistically significant difference could be detected. CONCLUSIONS: Each treatment method was effective in decreasing the edema and increasing the functional scores of the ankle. At the beginning of treatment, not only the level of edema but also the initial functional scores of the ankle and examinations are important in making decisions regarding the optimal treatment option.

Efficacy of intraarticular application of ketamine or ketamine-levobupivacaine combination on post-operative pain after arthroscopic meniscectomy.

PURPOSE: To evaluate the efficacy of intraarticular injection of ketamine or ketamine plus levobupivacaine on post-operative analgesia in patients undergoing arthroscopic meniscectomy. METHODS: A prospective, randomized, double-blind study was performed on 60 patients aged 18-65 years who planned to undergo elective arthroscopic meniscectomy. The patients were divided into three groups: the ketamine group (n = 20) received 1.0 mg/kg of intraarticular ketamine in 20 ml of normal saline, the ketamine-levobupivacaine group (n = 20) received 0.5 mg/kg of intraarticular ketamine plus 50.0 mg of 0.25 % levobupivacaine in 20 ml of normal saline, and the control group (n = 20) received 20 ml of intraarticular normal saline. A visual analogue scale (VAS) was used to determine the efficacy of analgesia at 1, 2, 4, 6, 8, 12, and 24 h post-operatively. RESULTS: There were statistically significant differences in the median VAS scores among the three groups according to Bonferroni adjustment at all time points (p < 0.01), with the exception of 6 and 24 h post-operatively. The median VAS scores at 1, 2, and 4 h post-operatively were higher in the control group than in the two treatment groups (p < 0.001). The median VAS scores in the control group at 1, 2, 4, 6, 8, and 12 h post-operatively and those in the ketamine group at 4, 8, and 12 h post-operatively were significantly higher than those in the ketamine-levobupivacaine group (p < 0.05). CONCLUSION: Intraarticular ketamine provides effective post-operative analgesia. Addition of intraarticular levobupivacaine to ketamine may provide better amelioration of pain after outpatient arthroscopic meniscectomy.

KIRSCHNER WIRE VERSUS TITANIUM ELASTIC NAILS IN PEDIATRIC FEMORAL SHAFT FRACTURES.

OBJECTIVE: To evaluate the effectiveness of intramedullary fixation using the Kirschner-wire (K-wire) compared to the titanium elastic nail (TEN) in pediatric femoral shaft fractures. METHODS: A sample of 42 pediatric patients with a mean age of 6.55±2.42 years (range 4-11 years) presenting femoral shaft fractures underwent intramedullary fixation using the K-wire or TEN. RESULTS: There was no significant difference found between groups, of which 16 (38.1%) patients were treated with K-wire and 26 (61.9%) patients were treated with TEN in terms of union duration. Moreover, none of the patients showed nonunion or a delayed union. CONCLUSIONS: The use of adjusted K-wire instead of TEN in the intramedullary fixation of femoral shaft fractures in selected children may be an advantageous surgical option due to the lower cost, easy accessibility and no need for a second surgery for implant removal. Level of Evidence III, Retrospective Study.

The mechanisms of medial pedicle wall violation: insertion method is as important as correct cannulation of the pedicle.

A cadaver study aims to determine the mechanisms of medial pedicle wall violation after a correct cannulation of the pedicle. The study presents finding out the effect of insertion angle and insertion force on medial wall violation. We used 100 lumbar pedicles of cadavers. Special wooden blocks were produced to simulate a fixed angle fault after a correct pedicle cannulation. Pedicles were divided into 4 groups: 10-degree free drive (group 10), 15-degree free drive (group 15), 10-degree push drive (group 10P), and 15-degree push drive (group 15P). After insertion of pedicle screws, laminectomies were done and the pedicles were evaluated from the inside. Pedicle complications were more in group 10P than group 10 (P = 0.009). Medial wall fracture (P = 0.002) and canal penetration were more in group 15P than group 15 (P = 0.001). Groups 10P and 15P were similar regarding medial wall fractures but canal penetration was significantly higher in group 15P (P = 0.001). Medial wall breaches can happen after correct cannulation of pedicles. Change in insertion angle is one factor but the most important factor is the use of a pushing force while inserting a screw. The pedicle seems to be extremely tolerant to insertion angulation mistakes up to 10 degrees and tends to lead the screw into the correct path spontaneously.