Does anterolateral ligament internal bracing improve the outcomes of anterior cruciate ligament reconstruction in patients with generalized joint hypermobility?

BACKGROUND: Generalized joint hypermobility (GJH) is a risk factor for anterior cruciate ligament (ACL) injury and ACL graft failure and is considered an indication for anterolateral ligament (ALL) reconstruction. The aim of this retrospective study was to compare functional outcomes, rupture rates, and residual instability in patients with GJH undergoing isolated ACL reconstruction or combined ACL reconstruction and ALL augmentation with internal bracing (ALL-IB). METHODS: Sixty-eight patients with GJH and unilateral ACL injury were randomly assigned to undergo either isolated ACL reconstruction (Group 1) or combined ACL reconstruction and ALL-IB (Group 2). The patients were evaluated pre- and postoperatively; their medical histories; physical examination results; anterior knee translation, as measured using the KT-1000 arthrometer; and scores of validated knee assessments were recorded. RESULTS: Groups 1 and 2 consisted of 37 and 31 patients, respectively. The mean follow-up was 30.1±4.1 and 28.1±2.9 months, respectively. In the final evaluation, the patients in Group 2 showed better rotational stability, as evaluated by the pivot-shift test (p=0.013); better anteroposterior stability, as evaluated by KT-1000 arthrometry (p=0.001); similar function (p=0.14 for the Lysholm, p=0.11 for the Cincinnati, and p=0.19 for the International Knee Documentation Committee subjective score); and failure rate (p=0.41). CONCLUSION: The functional outcomes were similar between the groups. The stability outcomes after combined ACL and ALL-IB were better than those after isolated ACL reconstruction in patients with GJH. However, the technique and its results need to be validated in larger patient series and prospective randomized controlled trials.

Clinical outcomes of single-bundle versus double-bundle ACL reconstruction in adolescent elite athletes: A retrospective comparative study.

OBJECTIVE: The aim of the study was to evaluate the single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstruction in terms of graft survival, complications, and patient reported functional outcomes in adolescent athletes. METHODS: In this retrospective study, 89 elite adolescent athletes who underwent either SB or DB ACL reconstruction were included. All patients were then divided into two groups: group 1 including 51 patients with SB ACL reconstruction (31 male, 20 female; mean age = 15.4 ± 1.03 years) and group 2 including 38 patients with DB ACL (30 male, 8 female; mean age = 15.7 ± 1.3 years). Clinical data were obtained, comprising skeletal maturity, sports type, ACL reconstruction technique, Lachman scores, KT-1000™ arthrometer measurement, additional meniscal procedures as well as International Knee Documentation Committee (IKDC) score, Cincinnati score, and graft size. RESULTS: The mean follow-up period was 53.1 ± 8.6 months in group 1 and 46.4± 9.1 months in group 2 (P = 0.61). The type of ACL reconstruction technique (SB or DB), gender, skeletal maturity, sports type, additional meniscal procedures and Lachman scores were not associated with the re-rupture of the ACL (P > 0.05). Moreover, ACL reconstruction technique did not effect the rate of re-rupture of an ACL. There were 21 re-ruptures (23.5%) and 11 (12.3%) contralateral ACL ruptures in total. Among 21 reruptures, 12 of them were in the DB group while nine of them in the SB group (P > 0.05). The groups did not differ with respect to age, the injured side, the time from injury to surgery, the postoperative follow-up time, or the preoperative physical examination results KT-1000 device (SSD), Cincinnati score, IKDC objective and subjective score,Lachman test and pivot-shift test). CONCLUSION: There are no differences in the re-rupture of an ACL, patient reported outcomes, and complications in adolescent elite players, when either an SB or DB technique is performed. LEVEL OF EVIDENCE: Level III, Therapeuthic Study.

Comparison of the outcomes of isolated anterior cruciate ligament reconstruction and combined anterolateral ligament suture tape augmentation and anterior cruciate ligament reconstruction.

OBJECTIVES: This study aims to compare the outcomes of isolated anterior cruciate ligament (ACL) reconstruction and combined anterolateral ligament (ALL) suture tape augmentation (STA) and ACL reconstruction after a minimum follow-up of two years. PATIENTS AND METHODS: This retrospective study included 63 patients (36 males, 27 females; mean age 27.8±4.0; range, 19 to 35 years) who had unilateral ACL injury and participated in pivoting sports and were randomly assigned to undergo either isolated ACL reconstruction (Group 1, n=33) or combined ACL reconstruction and ALL STA (Group 2, n=30) between January 2015 and February 2018. The presence of an associated meniscal injury, chondral pathology, contralateral ACL rupture, and residual pivot shift; subjective and objective International Knee Documentation Committee scores; Cincinnati and Lysholm functional scores; KT-1000 measurements; and graft rupture rate were evaluated. RESULTS: Patients were followed for a minimum of two years. The groups did not differ with respect to age, sex, side, time from injury to surgery, postoperative follow-up time, ACL graft size, contralateral ACL rupture, graft size, partial meniscectomy, chondral pathology or preoperative physical examination results. A total of 9.1% of the patients in Group 1 and 0% of those in Group 2 presented postoperative positive pivot shift (p=0.357). The graft failure rate was 6.06% (n=2) in Group 1 and 0% in Group 2 (p=0.270). In the final evaluation, compared with Group 1, Group 2 showed better anteroposterior clinical stability, as evaluated by KT-1000 arthrometry (p=0.006). Although better results were observed in Group 2, the clinical evaluation results for postoperative function did not differ significantly between groups. CONCLUSION: Combined ALL STA and ACL reconstruction was found to be effective in improving subjective and objective outcomes. Nevertheless, these findings were not significantly superior to those of isolated ACL reconstruction with hamstring grafts, except for the side-to-side differential anterior laxity testing results.

Long-term results of osteochondral autograft transplantation of the talus with a novel groove malleolar osteotomy technique.

OBJECTIVES: This study aims to evaluate the long-term results of osteochondral autograft transfer (OAT) of talar lesions performed using a modified osteotomy technique. PATIENTS AND METHODS: This retrospective study included 20 consecutive patients (11 males, 9 females; mean age 33.5±11 years; range, 15 to 56 years) (21 ankles) with osteochondral lesions of the talus (OLT) treated with the OAT system between August 2002 and October 2008. We performed a modified sulcus groove osteotomy, which provides better exposure of medial and central lesions. After a minimum duration of 10 years following surgery, patients' clinical functions were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle- hindfoot scale and visual analog scale (VAS). The Tegner-Lysholm scoring system was used to determine the levels of knee activity. RESULTS: The mean follow-up period was 143.5 (range, 120 to 186) months. The mean AOFAS scores significantly improved from 60.4±7.4 (range, 48 to 70) preoperatively to 86.2±9.2 (range, 60 to 94) at the last follow-up (p≤0.05). The mean ankle VAS score significantly decreased from 6.3±0.4 (range, 5 to 7) preoperatively to 2.0±1.4 (range, 0 to 4). The mean Tegner-Lysholm score for this group was 89.7±11.7 (range, 68 to 100). Revision surgery was performed in only two patients because of impingement and arthritis. Recurrent knee pain at the donor site of the osteochondral autograft was observed in three (14%) patients. CONCLUSION: In the present study, good to excellent results were obtained in the treatment of OLT with OAT for a minimum follow-up duration of 10 years. This novel technique can also simplify the steep learning curve, which is challenging for surgeons.

Arthroscopic labral repair versus labral debridement in patients with femoroacetabular impingement: a minimum 2.5 year follow-up study.

PURPOSE: To compare the clinical results of labral repair with labral debridement in patients undergoing arthroscopy for femoroacetabular impingement. METHODS: Between July 2008 and December 2011, 67 patients (73 hips) underwent arthroscopic treatment for femoroacetabular impingement. The repair group consisted of 33 patients; 18 hips with pincer only, 1 with CAM only and 15 with combined impingement. The debridement group contained 34 patients; 6 with pincer only, 5 with CAM only and 28 with combined type. The mean age in the repair group was 33.5 years (range, 30-61) and in the debridement group was 39.5 years (range, 18-59 y). At the time of last follow-up, patient's hip function was evaluated with ROM of the hip; daily Hip Outcome scores (dHOS) and Visual Analogue Score (VAS). RESULTS: The mean follow-up was 45.2 month in the repair group and 47.2 month in debridement group. Daily hip outcome scores were significantly improved from preoperatively to last follow-up in both groups (p<0.05). However, there were no statistical significant difference in dHOS between repair and debridement groups (p>0.05) at last follow-up. 2 patients in the repair group and 1 patient in the debridement group had undergone total hip replacement at an average of 16 months (range, 4-32 m) after arthroscopic treatment. Hip joint instability occurred in 1 patient in the repair group due to aggressive capsular resection. This was treated by a periacetabular osteotomy. CONCLUSIONS: No difference in hip functional outcomes was observed between labral debridement and labral repair in arthroscopic treatment of femoroacetabular impingement.

Arthroscopic retrograde osteochondral autologous transplantation to chondral lesion in femoral head.

This report describes the treatment of 2 cases of full-thickness cartilage defect of the femoral head. The authors performed osteochondral autologous transplantation with a different technique that has not been reported to date. One patient was 37 years old, and the other was 42 years old. Both presented with hip pain. In both patients, radiograph and magnetic resonance imaging scan showed a focal chondral defect on the weight-bearing area of the femoral head and acetabular impingement. A retrograde osteochondral autologous transplantation technique combined with hip arthroscopy and arthroscopic impingement treatment was performed. After a 2-month recovery period, the symptoms were resolved. In the first year of follow-up, Harris Hip scores improved significantly (case 1, 56.6 to 87.6; case 2, 58.6 to 90). The technique described yielded good short- and midterm clinical and radiologic outcomes. To the authors' knowledge, this report is the first to describe a retrograde osteochondral transplantation technique performed with hip arthroscopy in the femoral head.

Osteochondral autologous graft transfer system in the knee; mid-term results.

INTRODUCTION: The purpose of this study was to determine the effectiveness of the osteochondral autologous graft transfer system in the treatment of chondral and osteochondral lesions of the knee. METHODS: Sixty five knees of sixty four patients who underwent autologous osteochondral graft transfer were evaluated with clinical scores and imaging techniques. RESULTS: The average follow up was 82.2 (51-145) months. The patients were evaluated according to Tegner activity scale, Lysholm scale and IKDC subjective knee evaluation form. According to all these scales, all patients showed increasing results in various rates in the last follow up. Accordingly, mean increases of 59.2±15.9 points, 3.6±1.4 points, and 42.6±11.5 points were achieved in Lysholm knee scores, Tegner activity scale scores, and IKDC subjective knee evaluation form, respectively (p≤.0001). Moreover, we found no significant correlation between functional results and age, functional results and localization of osteochondral defect, functional results and additional knee pathologies. CONCLUSION: In our study we achieved significant increases in all the scales in the last follow up. Furthermore, we found no significant correlation between functional results and age, defect localization and additional knee pathologies.

Horizontal suture placement influences meniscal repair fixation strength.

PURPOSE: This in vitro biomechanical study investigated the influence of horizontal suture placement distance from the medial meniscal lesion repair site on fixation characteristics during submaximal cyclic and load to failure test conditions. METHODS: Eighteen cadaveric (20-45 years of age) medial menisci with intact joint capsules were harvested within 24-48 h after death and divided into two groups of 9 specimens each for biomechanical testing. A 2.0-cm-long antero-posterior vertical longitudinal lesion was created with a #15 scalpel 2.0-3.0 mm from the outer edge of each meniscus. Menisci were repaired using #2-0 suture material with two horizontal suture loops placed either 1.0 mm (Group 1) or 3.0 mm (Group 2) from the lesion site. Following repair, the lesion was extended completely through the meniscal horns so that no tissue secured the repair, only the two horizontal suture loops representing a "worst-case" testing scenario. Following repair, specimens were placed in a servo hydraulic device using a pair of 1.2-mm-diameter steel wire loops and underwent submaximal cyclic loading between 5 and 50 N (1 Hz) for 500 cycles prior to load to failure testing (5 mm/min crosshead speed, 20 Hz data collection). An alpha level of P < 0.05 was selected to indicate statistical significance. RESULTS: Five of nine (55.6 %) Group 1 specimens did not complete submaximal cyclic testing. All Group 2 specimens completed submaximal cyclic testing (Fisher's exact test P = 0.029). Statistically significant mean group differences were not observed for displacement during submaximal cyclic loading (Group 1 = 5.0 ± 1.5 mm and Group 2 = 5.7 ± 1.6 mm) or for construct stiffness during load to failure testing (Group 1 = 50.1 ± 6.3 N/mm and Group 2 = 52.6 ± 11.9 N/mm). Group 2 displayed greater mean load at failure (112.1 ± 40.8 N vs. 72.7 ± 11.2 N, P = 0.02) and mean displacement at failure (11.1 ± 2.2 mm vs. 7.6 ± 1.4 mm, P = 0.03) than Group 1. CONCLUSIONS: Horizontal sutures placed slightly farther away from the meniscus lesion displayed superior repair fixation than sutures placed closer to the lesion. The superior biomechanical meniscal repair fixation provided by capturing greater tissue volume may enable safe earlier participation in functional exercise activities. Studies are needed to verify these findings in vivo.

Meniscal repair using large diameter horizontal sutures increases fixation strength: an in vitro study.

PURPOSE: the purpose of this study was to compare the mechanical characteristics of meniscal repair fixation using horizontal sutures and two different diameter sutures under submaximal cyclic and load to failure test conditions. METHOD: a 2-cm long anteroposterior vertical longitudinal incision was created in two groups of bovine medial menisci. Lesions were repaired using either #2-0 (Group 1), or #2 (Group 2) Fiberwire suture. Following repair, the lesion was extended through the posterior and anterior meniscal horns so that no tissue secured the repair site. Specimens underwent submaximal cyclic (5-50 N at 1 Hz for 500 cycles) and load to failure testing (5 mm/min crosshead speed) in a servo hydraulic device. Specimen failure mode was verified by the primary investigator. An alpha level of P < 0.05 was selected to indicate statistical significance. RESULTS: group 2 displayed greater load at failure (132.1 ± 54.4 N) than Group 1 (91.9 ± 26.2 N) (P = 0.02). Group 2 also displayed greater stiffness (47.1 ± 8.3 N/mm) than Group 1 (38.5 ± 10.2 N/mm) (P = 0.03). The failure mode for all specimens was suture pull-through the meniscal tissue. Larger diameter suture provided superior mechanical meniscal fixation. CONCLUSION: if horizontal suture would be used in meniscal repair, the most suitable larger diameter suture should be used.

[All-inside meniscal repair using the RapidLoc device]. / RapidLoc fiksatörü ile menisküs tamiri.

OBJECTIVES: Although conventional suture techniques yield satisfactory results in the treatment of meniscal ruptures, they are inherent with long operative time and high complication rates. The purpose of this study was to evaluate the results of meniscal repair with the use of the RapidLoc device. METHODS: The study included 57 consecutive patients (all males; mean age 24 years; range 17 to 33 years) who underwent meniscal repair with the RapidLoc device. The mean time from injury to surgery was 20 days (range 7 to 60 days). The mean length of meniscal ruptures was 25 mm (range 10 to 35 mm). A mean of two RapidLoc fixators were used for each rupture. Thirty patients had associated anterior cruciate ligament (ACL) rupture; of whom 17 patients underwent ACL reconstruction with hamstring autografts. Thirteen patients refused ACL reconstruction and underwent only meniscal repair. Functional results were evaluated using the Tegner activity score, Lysholm score, and IKDC (International Knee Documentation Committee) subjective knee evaluation form. Clinical assessments were made using the Barrett criteria. The mean follow-up was 39 months (range 18 to 66 months). RESULTS: The mean operation time including diagnostic and surgical arthroscopy was 25 minutes (range 15 to 35 min). Compared to the preoperative scores, all functional scores showed significant improvements (p<0.001) with the following increases: Lysholm score from 58.8 + or - 13.7 to 93.3 + or - 7.7, Tegner activity score from 3.5 + or - 1.0 to 6.0 + or - 1.6, and IKDC score from 52.8 + or - 10.5 to 91.4 + or - 4.0. According to the Barrett criteria, meniscal healing was achieved in all the patients. Second-look arthroscopy was performed in one patient due to pain and swelling, which showed an unabsorbed tophat of the RapidLoc device. CONCLUSION: Our findings suggest that the RapidLoc meniscal repair device may be an appropriate choice in selected cases because of satisfactory short-term clinical results, ease of applicability, short operation time, and low complication rate.

Lateral dislocation of the knee joint after total knee arthroplasty: a case report.

BACKGROUND: Total knee arthroplasty (TKA) is a successful therapy for functional improvement and pain relief in advanced symptomatic degeneration of the knee joint. But it can be associated with many complications, one of which is instability. CASE PRESENTATION: A 70-year-old woman was referred to our hospital because of right knee dislocation after TKA was performed on her right knee due to severe varus deformity and flexion contracture. This instability was caused by persistent MCL tightness and iatrogenic lateral collateral, arcuate ligament, and popliteus tendon injury.The torn lateral collateral ligament and arcuate ligament were sutured with no. 2 non-absorbable (Ethibond) sutures with plication of the posterolateral knee capsule. A deep-dish liner was inserted to optimize soft tissue tension. CONCLUSION: This is a very severe complication, and surgeons must be cautious about ligament balancing and soft tissue resection during TKA for severe varus and valgus deformities.

Dysplasia epiphysealis hemimelica: two cases in two different regional expression.

Dysplasia epiphysealis hemimelica most commonly presents as an overgrowth of the epiphysis in the lower limb. We report two cases, one a classical form involving the lower limb, and the other in a relatively rarer location in the wrist. Both cases were treated surgically by excision of the masses. We recommend excision of symptomatic intra-articular lesions by using MRI, which provides additional information concerning physeal line and extension of the mass, to prevent the development of angulation and to keep the range of motion.

The genotoxic effects in lymphocyte cultures of children treated with radiosynovectomy by using yttrium-90 citrate colloid.

UNLABELLED: The aim of this study was to investigate the genotoxic effect on the peripheral blood lymphocytes potentially induced by yttrium-90 citrate colloid (Y-90) in children who were undergoing radiosynovectomy for hemophilic synovitis, using chromosomal aberration analysis (CA) and the micronuclei (MN) assay for detecting chromosomal aberrations, as well as the sister chromatid exchanges (SCE) technique for assessed DNA damage. MATERIALS AND METHODS: Cytogenetic analyses were undertaken in 18 boys (mean age, 14.5 +/- 2.1 years) with hemophilic synovitis who underwent radiosynovectomy with Y-90. CA, MN, and SCE were evaluated just prior to, then at 2 and 90 days following radiosynovectomy from the peripheral lymphocytes of the children. An activity of 185 MBq of Y-90 was injected into the 18 knee joints under aseptic conditions. To check the possibility of leakage from the joint and its migration within the body, the patients underwent scanning under a dual-headed gamma camera at the hours 2 and 48 following the procedure. RESULTS: The procedure was well tolerated in all the children, and there was no extra-articular activity owing to extra-articular leakage of radioactive material in whole-body imaging. The mean frequency of CA in lymphocytes determined prior to the onset of therapy (0.31 +/- 0.48/900 cells) was not significantly increased, in comparison to the control values obtained 2 (0.30 +/- 0.48/900 cells) and 90 days (0.15 +/- 0.37/900 cells) after radiosynovectomy (p = 1.0 and 0.625, respectively). We observed that MN frequency was mildly increased in lymphocytes 2 days after therapy (8.30 +/- 1.89 MN/1000 binucleated cells vs. 9.23 +/- 1.79 MN/1000 binucleated cells; p = 0.013). But there was no significant difference between the baseline and the day 90 control levels of MN (p = 0.196). In the analysis of SCE frequency, there were no significant differences between the baseline (8.11 +/- 0.77) and the control analysis performed 2 and 90 days following radiosynovectomy (8.18 +/- 0.77 and 8.07 +/- 0.74; p = 0.710 and 0.662, respectively). CONCLUSIONS: The results of this study indicated that high radiation doses are not obtained by peripheral lymphocytes of children who undergo Y-90 radiosynovectomy and, therefore, they contradict a high cancer risk.

The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique.

In this study, mid to long-term results of anterior cruciate ligament reconstruction with hamstring tendons and Transfix technique were evaluated. Anterior cruciate ligament (ACL) reconstruction with four-strand hamstring tendon was performed with Transfix technique on 271 (198 males, 73 females; mean age 25.7; 17-52) patients with anterior cruciate ligament ruptures. The patients were followed up with clinical examination, Lysholm and Tegner activity scales, IKDC scoring system, KT-1000 test and radiological examination. The mean follow-up period was 82 (48-100) months; 204 (75%) patients had no subjective complaints. According to the KT-1000 test, only 14 (5%) patients had more than 5 mm laxity postoperatively, whereas, 161 (59%) patients had more than 5 mm laxity preoperatively. In addition to this, only 19 (7%) patients had Lysholm scores less than 80 postoperatively, whereas 154 (57%) patients scored less than 80 preoperatively. When compared with Tegner activity scale, 189 (70%) patients scored<6 preoperatively and only 24 (8%) postoperatively; 78 (29%) patients scored D preoperatively and only 5 (2%) patients scored D postoperatively on the basis of the IKDC scoring system. Our functional results were found to be satisfactory in more than 90% of patients. Commonly seen problems in ACL reconstruction such as inaccurate graft placement and tunnel widening were found to be consistent with the values in relevant literature. However, we demonstrated that the functional results and the stability of the knee were not related with tunnel widening. This study concludes that the reconstruction of ACL with hamstring tendons and the Transfix technique is reasonably successful, safe and causes low morbidity. Furthermore, we believe that proper graft preparation, accurate tunnel placement, notch-plasty, fixation and rehabilitation program are all as important as the choice of graft and fixation material.

[Articular cartilage lesions in unstable knees]. / Instabil dizlerde eklem kikirdak lezyonlari.

OBJECTIVES: The purpose of this retrospective analysis was to evaluate the management of chondral defects in knees with anterior cruciate ligament (ACL) disruption. METHODS: Twenty-seven patients (mean age 35 years; range, 20 to 48 years) were randomized to osteochondral autologous transplantation (OAT, n=14) or a microfracture (MF, n=13) procedure together with ACL reconstruction in the same session for symptomatic lesions of the articular cartilage in ACL-deficient knees. The mean follow-up period was 34 months (range 24 to 53 months) in the OAT group, and 49 months (range 24 to 97 months) in the MF group. Patients were evaluated using the Lysholm and IKDC 2000 (International Knee Documentation Committee) scores. RESULTS: Patients undergoing OAT had a mean IKDC 2000 score of 49.2 (range 30.1 to 64.7), and Lysholm score of 43.4 (range 33.2 to 58.9) preoperatively. At the end of follow-up, these scores increased to 93.3 (range 73 to 98) and 97.5 (range 38.7 to 100), respectively. In the MF group, the mean IKDC 2000 score increased from 53.6 (range 47.1 to 64.7) to 72.3 (range 62.8 to 94), and the mean Lysholm score increased from 48 (range 38.2 to 58.9) to 81.3 (range 72.7 to 100). CONCLUSION: Treatment of chondral lesions should be added to ACL reconstruction in unstable knees secondary to ACL deficiency.

Pullout strength of meniscal repair after cyclic loading: comparison of vertical, horizontal, and oblique suture techniques.

This in vitro biomechanical study with cyclic loading compared the pullout strength of vertical, horizontal, and oblique sutures used for meniscal lesion repair. Following repair of vertical longitudinal lesions created in bovine medial menisci, three groups of seven specimens (vertical, horizontal, and oblique sutures) underwent cyclic loading in a randomized test order (5 mm/min, cycling between 5 and 50 N at 1 Hz for 100 cycles) prior to load to failure testing (5 mm/min). Displacement did not differ between groups during cyclic or load to failure testing. Construct stiffness during cyclic testing was superior for the oblique suture (6.9 +/- 1.5 N/mm, P = 0.007) and the vertical suture (6.4 +/- 7 N/mm, P = 0.03) groups compared to the horizontal suture group (4.4 +/- 0.52 N/mm). The oblique suture (171.9 +/- 25.9 N, P < 0.0001) and the vertical suture (145.9 +/- 32.3 N, P = 0.001) groups displayed superior load at failure compared to the horizontal suture group (88.8 +/- 8.2 N). Construct stiffness during load to failure testing did not differ between groups. Suture rupture was the failure mode for all specimens of the oblique suture group. Suture rupture was the failure mode for 57% (4/7) of the vertical suture group with the remaining specimens (3/7, 43%) failing from intact suture pullout through meniscal tissue. All horizontal suture group specimens failed by intact suture pulling through meniscal tissue. With comparable stiffness during cyclic testing, comparable load at failure as vertical sutures, and less evidence of intact suture pullout through the meniscus, an oblique suture technique may combine the beneficial characteristics of vertical (superior biomechanical strength) and horizontal (ease of application, longer sutures with a tendency to cover a larger meniscal tissue area) suture-repair techniques.

High tibial osteotomy with Puddu plate for the treatment of varus gonarthrosis.

In this study, the results of open-wedge osteotomy with Puddu plate for the treatment of varus gonarthrosis have been evaluated prospectively. This study assessed 65 knees of 60 patients with varus gonarthrosis who underwent high tibial osteotomies. Our study population consisted of 13 male and 47 female patients with a mean age of 54 (range 39-76) years. For the clinical evaluation of the patients Hospital of Special Surgery (HSS) score, American Knee Society and Oxford knee scores, and for the radiological assessment mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), femorotibial angle and Insall-Salvati index were basically taken into consideration. Our patients were followed up for an average of 34 (range 18-60) months. In the last assessments of our cases, mean improvements detected in HSS scores, Oxford knee scores, knee and functional scores of Knee Society were 26.72, 19.18, 49.9, and 30 points, respectively. The radiological examinations revealed that their mechanical axes on the average passed 5.09 mm laterally achieving an average of 6.5 degrees genu valgum, and a mean Insall-Salvati index of 1.09. As complications, superficial wound infection in two patients (3%), implant infections in one patient (1.5%), deep vein thrombosis in two patients (3%), peroperative lateral tibial plateau fracture in one patient (1.5%), and postoperative lateral tibial plateau fracture due to a falling down were encountered. According to the results obtained, postoperative pain resolves promptly and a significant degree of improvement of knee functions of the patients are achieved. Therefore, we believe that high tibial osteotomy with a Puddu plate is a valuable alternative to total knee arthroplasty in cases with varus gonarthrosis. Although early results are satisfactory, long-term follow-up studies are required especially in the middle aged and elderly patient populations.

[The effect of the tibial tunnel fixation level on the results of cyclic loading in anterior cruciate ligament reconstruction]. / On çapraz bag rekonstrüksiyonunda tibial tünel tespit seviyesinin tekrarlayici yüklenme testi sonuçlarina etkisi.

OBJECTIVES: This study was designed to compare the biomechanical characteristics of non-anatomic (far from joint) and anatomic (close to joint) levels of tibial tunnel fixation with soft tissue graft using a soft tissue interference screw in anterior cruciate ligament (ACL) reconstruction. METHODS: Twelve bovine tibiae and digital extensor tendons were divided into two homogeneously equal groups after removing soft tissues. Tibial tunnels were prepared with a 7-mm drill with the use of an ACL guide adjusted to 45 degrees . Each tunnel was then dilated to 9 mm in 0.5 mm increments. Digital extensor tendons were fixed at non-anatomic (group I) or anatomic (group II) tibial tunnel levels with a soft tissue metal interference screw, 9 x 30 mm in size. All the specimens were cycled 500 times from 50 to 250 N with 1 Hz frequency in a servo-hydraulic testing machine followed by ultimate load at-failure testing at a rate of 20 mm/min. Statistical analyses were made using the Mann-Whitney U-test. RESULTS: The mean screw insertion torque values were 8.2+/-2.4 Nm and 7.8+/-2.3 Nm in groups I and II, respectively (p=0.88). The mean values of graft displacement (1.9+/-0.75 mm versus 2.2+/-1.2 mm, p=0.63) and stiffness (132.72+/-10.93 N/mm versus 125.14+/-15.93 N/mm, p=0.63) did not differ significantly. CONCLUSION: The biomechanical properties of ACL reconstruction with soft tissue graft fixation using a soft tissue interference screw are not influenced by the level of tibial tunnel fixation.

[Retrograde osteochondral grafting for osteochondral lesion of the talus: a new technique eliminating malleolar osteotomy]. / Talusun osteokondral lezyonunda retrograd osteokondral greftleme: Malleol osteotomisi gerektirmeyen yeni bir teknik.

Osteochondral grafting is one of the most effective treatment options for osteochondral lesions of the talus. However, the necessity for a medial malleolar osteotomy is the major drawback of the technique. This report presents a case treated with retrograde osteochondral grafting that eliminated the need for a medial malleolar osteotomy. An osteochondral lesion of the medial talus was detected in a 49-year-old woman. Under arthroscopic guidance, the talus was entered from the sinus tarsi region to establish a tunnel extending to the lesion. An osteochondral graft taken from the ipsilateral knee was inserted into the distal end of the tunnel and was advanced to the joint surface. Postoperative computed tomography scans showed that the graft completely filled the tunnel and provided congruency with the articular surface. Details of this technique are described.

Radiosynovectomy in hemophilic synovitis: correlation of therapeutic response and blood-pool changes.

AIM: The aim of this study was to evaluate the efficacy of 90Y and 186Re radiosynovectomy in patients with hemophilic synovitis. METHODS: Radiosynovectomy was performed in 32 joints of 20 patients with hemophilic synovitis by using 90Y citrate colloid in the knee and 186Re sulfide colloid in the elbow, shoulder, and ankle. The indication for radiosynovectomy was the continuous presence of intra-articular blood or effusion and three or more hemorrhages into the same joint within the last 6 months. Response to therapy was first assessed at the 4th month with blood-pool imaging. Patients were followed up by clinical evaluation based on assessments of joint-bleeding frequency, using range of motion measurements at 6-month intervals for an average of 1 year (range, 9-15 months). RESULTS: A marked decrease (an 80%-100% decrease) in bleeding episodes was seen in 24 of 32 (75%) joints, a moderate decrease (51%-79% decrease) in 1 (9%) joint, and a mild decrease (30%-50%) in 3 (13%) joints. Frequency of intra-articular bleeding after treatment was unchanged in only 13% of the joints. The number of hemarthroses significantly decreased after therapy (p < 0.05). The mean bleeding frequency of the joints were 1.7 +/- 0.9 and 0.3 +/- 0.7 per month before and after therapy, respectively. The ratios of joints which had marked improvement after therapy were 86% in the ankle, 73% in the elbow, and 58% in the knee. There was no significant difference between percent joint range of motion limitations measured before and after therapy (p > 0.05). The correlation between therapeutic outcome (in terms of joint bleeding) and the difference of pre- and posttherapeutic blood-pool indices were significant (r = 0.594; p < 0.05), while the correlation between therapeutic outcome and pretherapeutic radiologic scale and pretherapeutic blood-pool indices were not significant (r = 0.095; p > 0.05; r = -0.089; p > 0.05, respectively). CONCLUSION: Radiosynovectomy is a simple but quite effective and efficient procedure in limiting the frequency of joint hemorrhage in patients with hemophilia. Blood-pool imaging may be an objective means for monitoring therapy response in these patients.