Greater presence of receptors for relaxin in the ligamentum teres of female infants who undergo open reduction for developmental dysplasia of the hip.

BACKGROUND: While many factors involved in the etiology of developmental dysplasia of the hip (DDH), one of which is the hormone relaxin. Relaxin concentrations in patients with DDH may lead to pathodynamic changes during hip development by altering the physiological nature of the ligament, as well as by long-term exposure to relaxin during pregnancy. Our objective in this study was to determine the number of relaxin receptors in the ligamentum teres and their role in causing DDH. METHODS: We identified 26 infants between birth and 3 years of age who had undergone open reduction for DDH between 2010 and 2012. 12 hips of 12 miss abortus fetus between 20 to 35 weeks of gestation were used as control group. Specimens obtained from two groups were stained with Relaxin-2 antibody, and the amount of staining for relaxin receptors was determined using an ordinal H score. RESULTS: The mean (SD) H scores of infants with DDH were significantly higher than those of controls: 215 (59) versus 52 (48); P = 0.00; 95% CI. Statistically significant difference between the two groups in terms of gender was not found. CONCLUSION: As a result, increased number of relaxin receptors in the ligamentum teres could be a risk factor for DDH. LEVEL OF EVIDENCE: Level 2, Prospective comparative study.

Mini-plate fixation via sinus tarsi approach is superior to cannulated screw in intra-articular calcaneal fractures: A prospective randomized study.

OBJECTIVE: Intra-articular displaced calcaneal fractures are common fractures and are often treated with surgical interventions. Sinüs tarsi approach provides secure access to lateral wall and joint facets. The aim of the study is to compare cannulated screw (CS) fixation and mini-plate (MP) fixation via sinus tarsi approach with Sanders types 2 and 3 fracture of calcaneus. METHODS: Sixty patients with Sanders types 2 and 3 calcaneal fracture underwent surgical intervention were randomly allocated into two groups as group MP fixation and group CS fixation regarding osteosynthesis method for 5-year period. Open reduction via sinüs tarsi approach was performed in both groups. Demographic variables, time to surgery (TS), operation duration (OD), length of hospital stay (LOS), surgical complications, and reoperations were recorded. Pre- and postoperative Gissane and Böhler angles; calcaneal length, height, and width; ankle anterior-posterior (AP) and lateral X-rays; and computed tomography were also recorded for radiological evaluation and fracture characteristics. Maryland Foot Score (MFS) was used to evaluate functional outcomes. RESULTS: Preoperative age, type of fracture, calcaneal length, height, and Gissane and Böhler angles, TS, LOS, and OD were not different between the groups. The postoperative calcaneal widening was significantly better restored in group MP compared with that of group CS. The incidence of reoperation and algoneurodystrophy was statistically higher in group CS than group MP. MFS in group MP was also higher than group CS at final visit. CONCLUSION: MP fixation via sinus tarsi approach is superior to CS fixation in Sanders types 2 and 3 calcaneal fractures.

Association between vitamin D concentrations and knee pain in patients with osteoarthritis.

OBJECTIVES: Osteoarthritis (OA) and vitamin D deficiency are common health conditions in older people. Whether vitamin D concentration is associated with knee OA is controversial. In this study, we aimed to determine the association between serum concentrations of vitamin D and osteoarthritic knee pain. SUBJECTS AND METHODS: Vitamin D concentrations were measured with the 25 hydroxyvitamin D test in patients presenting with clinical symptoms of primary knee osteoarthritis. Osteoarthritis was graded on the Kellgren-Lawrence grading scale from anteroposterior and lateral radiographs. Height, weight, and body mass index (BMI) were recorded. Patients completed a 10-cm visual analogue scale (VAS) for indicating pain and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Vitamin D concentration was defined as severely deficient (<10 ng/mL), insufficient (10 to 19 ng/mL), or normal (20 to 50 ng/mL). RESULTS: Of 149 patients (133 women), the mean age was 63.6 years. Mean vitamin D concentration was 11.53 ng/mL, and 90% patients were vitamin D deficient. Mean WOMAC score was 57.2, and VAS pain score was 7.5. Kellgren-Lawrence grade was 2 for 10 patients, grade 3 for 61, and grade 4 for 88. Mean BMI was 33.4. Mean values of VAS, WOMAC, and BMI did not differ by vitamin D status. CONCLUSION: Serum vitamin D concentration is not associated with knee pain in patients with osteoarthritis.

Effects of hyaluronic acid (Hyalonect) on callus formation in rabbits.

OBJECTIVE: Bone fragment and graft stabilization are important during reconstructive surgery of cases with comminuted fractures and bone defects. We examined the effect of Hyalonect surgical mesh on the healing dynamics of metaphyseal bone defects created in rabbit tibiae. METHODS: Approximately 5-mm defects were created on the anterior aspect of the proximal tibial metaphysis of 80 male rabbits. The rabbits were randomly assigned to four groups: Group I, bone defects left alone (control group); Group II, bone defect covered with Hyalonect; Group III, bone defect filled with allograft; and Group IV, bone defect filled with allograft and covered with Hyalonect. RESULTS: No significant histological differences were noted between Groups II and III or Groups III and IV at 3 and 6 weeks. At 3 weeks, Groups II, III, and IV had significantly better healing than Group I (p<0.05). In addition, Group IV showed significantly better healing than Group II at 3 and 6 weeks. At 6 weeks, only Group IV showed better healing than Group I (p<0.05). Radiologically, Groups II, III, and IV showed better healing than Group I at 3 and 6 weeks (p<0.05). CONCLUSION: Hyalonect application and bone grafting significantly accelerated the healing process when used alone or together. Hyalonect application along with bone grafting resulted in better early radiological healing than bone grafting alone.

Prospective study of percutaneous radiofrequency nerve ablation for chronic plantar fasciitis.

BACKGROUND: Chronic plantar heel pain is one of the most painful foot conditions and is generally associated with plantar fasciitis. This study reports 2-year follow-up results of radiofrequency nerve ablation (RFNA) of the calcaneal branches of the inferior calcaneal nerve in patients with chronic heel pain associated with plantar fasciitis. METHODS: After receiving approval from the institutional review board, we prospectively evaluated the results of the RFNA of the calcaneal branches of the inferior calcaneal nerve on 35 feet in 29 patients with plantar heel pain between 2008 and 2011. All of the patients who were treated had been complaining of heel pain for more than 6 months and had failed conservative treatment. All of the patients were evaluated (quantitatively) using the average 10-point Visual Analog Scale (VAS) before treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. We also evaluated 26 feet in 20 patients with American Orthopaedic Foot and Ankle Society scale (AOFAS) scores before the treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. RESULTS: The average VAS score of the feet was 9.2 ± 1.9 before treatment, 0.5 ± 1.3 at 1 month after the procedure, 1.5 ± 2.1 at 1-year follow-up, and 1.3 ± 1.8 at 2-year follow-up (P < .001). The average AOFAS scores of the patients were 66.9 ± 8.1 (range, 44-80) before treatment, 95.2 ± 6.1 (range, 77-100) at 1 month after the procedure, 93 ± 7.5 (range, 71-100) at the 1-year follow-up, and 93.3 ± 7.9 (range, 69-100) at the 2-year follow-up. At the 1- and 2-year follow-up, 85.7% of the patients rated their treatment as very successful or successful. CONCLUSION: These findings suggest that RFNA of the calcaneal branches of the inferior calcaneal nerve was an effective pain treatment option for chronic heel pain associated with plantar fasciitis that did not respond to other conservative treatment options. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The effects of osteoporosis on functional outcome in patients with distal radius fracture treated with plate osteosynthesis.

OBJECTIVE: The aim of this study was to evaluate the effect of osteoporosis on functional results in patients with distal radius fracture treated with plate osteosynthesis. METHODS: The study included 37 female patients who underwent osteosynthesis using volar locking plate for distal radius fracture between 2006 and 2008. Diagnosis of osteoporosis was made with bone mineral density measurement. Patients were divided into two groups; Group 1 patients (20 patients; mean age: 56.5 years) had osteoporosis and a mean T-score of -2.6 SD, and Group 2 patients (17 patients; mean age: 37.1 years) did not have osteoporosis and had a T-score of -0.7 SD. Radiological results were evaluated according to the Stewart's criteria and activities of daily living were assessed with the modified Gartland and Werley score, the modified Mayo wrist scoring system, and the DASH scoring system. RESULTS: According to the Stewart's radiological evaluation criteria and modified Gartland and Werley scores, there was no statistically significant difference between Group 1 and 2 (p>0.05). However, a statistically significant difference was found between Group 1 and 2 according to the modified Mayo wrist scoring system and DASH scoring system (p<0.05). CONCLUSION: There was no radiological difference between the osteoporotic and non-osteoporotic patients with distal radius fractures treated with plate osteosynthesis. However, osteoporosis had a negative effect on the results and range of motion of the wrist, and activities of daily living were significantly restricted.

Surgical treatment of mallet fractures by extension block Kirschner wire technique surgical treatment of mallet fractures.

OBJECTIVE: We use the extension block Kirschner wire method that orginated from Ishigura to treat mallet fracture and evaluate its efficiency. METHODS: 38 patients were treated prospectively. Mean follow-up was 18 months and all patients evaluated radiologically and clinically according to Crawford's criteria. RESULTS: Union was obtained in all patients. The results obtained were satisfactory in 34 cases, unsatisfactory 4 cases. CONCLUSION: We think that extension block technique is a safe and effective method that can be used in all mallet fractures. LEVEL OF EVIDENCE: Level IV, Case series .

Treatment of Neer Type 2 fractures of the distal clavicle with coracoclavicular screw.

OBJECTIVE: The aim of this study was to assess the outcome of coracoclavicular screw fixation in displaced distal clavicular fractures. METHODS: Sixteen patients with Neer Type 2 displaced distal clavicle fractures were treated with open reduction and internal fixation. Fixation was performed using a coracoclavicular screw with washer application. After union the screw was removed under local anesthesia. Radiographic evaluation was performed and the clinical outcome was assessed using the Constant score. RESULTS: All patients achieved painless osseous unions. However, one patient showed significant displacement of the fracture due to loosening of the screw one month after surgery. The screw was removed and the fracture was healed with some deformity. All patients returned to their preinjury level in 3 months. The mean Constant score was 98. CONCLUSION: Coracoclavicular screw fixation in the treatment of distal clavicular fractures is a reliable, simple and cost effective technique.

Relationship between meniscal tears and tibial slope on the tibial plateau.

OBJECTIVE: The geometry of the tibial plateau has a direct influence on the translation and the screw home biomechanics of the tibiofemoral joint. Little information on the relationship between the tibial slope and meniscal lesions is available. The objective of this retrospective study was to examine the effect of the tibial slope on the medial and lateral meniscus lesions in patients with intact ACLs. MATERIALS AND METHODS: The MRIs and lat roentgenograms of 212 patients with meniscus lesions were examined to determine the possible effect of the tibial slope on meniscal tears. First, the anatomic axis of the proximal tibia was established. Then, the angle between the line drawn to show the tibial slopes (medial and lateral) and the line drawn perpendicular to the proximal tibial anatomic axis was established on MRI. The patients with previously detected meniscus lesions were classified into three categories: patients with only medial meniscal tear (Group 1, 90 patients); patients with only lateral meniscal tear (Group 2, 15 patients); and patients with both medial and lateral meniscal tear (Group 3, 19 patients). Group 4 had no meniscal tear (88 patients). The MRIs of the patients who had applied to the Orthopedic Outpatient Clinic with patellofemoral pain and no meniscal tear were included as the control group. RESULTS: The average tibial slope of the medial tibial plateau was 3.18° in group 1, 3.64° in group 2, 3° in group 3, and 3.27° in group 4. The average tibial slope of the lateral tibial plateau was 2.88° in group 1, 3.6° in group 2, 2.68 in group 3, and 2.91 in group 4. The tibial slope on the medial tibial plateau was significantly larger than the lateral tibial plateaus in group 1 and group 4 (p<0.05). In group 2, there was no statistically significant difference between the tibial slopes of the two sides (p>0.05). In addition, the tibial slope on the lateral side of group 2 was significantly larger than that of groups 1, 3, and 4 (p<0.05). CONCLUSION: An increase in the tibial slopes, especially on the lateral tibial plateau, seems to increase the risk of meniscal tear.

Shoulder arthrodesis with plate fixation.

OBJECTIVE: The aim of this study was to evaluate the long-term outcome of shoulder arthrodesis with plate fixation and primary autogenous grafting in terms of pain, functional status and arthrodesis position. METHODS: The study included 8 patients (7 males and 1 female; mean age: 39.3 years; range: 22 to 68 years) who underwent arthrodesis with plate fixation and primary autogenous grafting. Mean follow-up period was 66.6 (range: 47 to 96) months. Five cases had traumatic brachial plexus palsy, 2 polio sequela and 1 sequela of an operated proximal humerus fracture due to a falling injury. One of the traumatic palsy cases was accompanied with a humerus shaft fracture. Arthrodesis was performed in all cases according to AO principles with plate fixation and primary autogenous grafting. Five of the paralytic patients also underwent Steindler flexorplasty. Follow-up assessments included monthly radiologic control for union, the visual analog scale (VAS) for pain and the Oxford shoulder score (OSS) for functional status. RESULTS: Radiological fusion was seen in all cases in an average of 16 (range: 12 to 18) weeks, and arthrodesis was stable at physical examination. The accompanying humerus shaft fracture was also fixed with plate. One patient with traumatic palsy experienced a humerus fracture distal to the arthrodesis plate at the 8th postoperative month. An additional traumatic palsy case had flexion deformity at the wrist in the second year of follow-up and a wrist arthrodesis with dorsal plate was performed. One patient (12.5%) had a donor site infection on the tenth day after surgery. The target positions of 30° of abduction, 30° of forward flexion, and 30° of internal rotation were achieved with an average deviation of 7°. Mean active abduction was 68.1° (range: 55° to 90°), flexion was 67.5° (range: 60° to 85°), and internal rotation was at the level of trochanter major. The mean OSS was 35.9 (range: 32 to 40), and the mean VAS score was 2.9 (range: 1 to 7). CONCLUSION: Our findings show that AO reconstruction plate and primary autogenous bone grafting is a safe and effective arthrodesis method that can also be used as a salvage procedure.

Reconstruction of shoulder abduction and external rotation with latissimus dorsi and teres major transfer in obstetric brachial plexus palsy.

OBJECTIVES: We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. METHODS: Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). RESULTS: Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤ 9 years and > 9 years of age (p > 0.05). CONCLUSION: Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.

Coracoclavicular ligament repair and screw fixation in acromioclavicular dislocations.

OBJECTIVES: We evaluated the long-term results of acromioclavicular dislocations treated with coracoclavicular fixation using a cancellous screw. METHODS: Coracoclavicular fixation was performed using the modified Bosworth technique in 32 patients (24 males, 8 females; mean age 35 years; range 19 to 58 years) with acromioclavicular dislocations. According to the Rockwood classification, seven patients had type III, nine patients had type IV, 13 patients had type V, and three patients had type VI dislocations. Following repair of the coracoclavicular ligament, fixation was performed with a cancellous screw in all but two patients in whom a cortical screw was used. These two patients developed redislocation due to screw cut out and underwent reoperation with cancellous screw fixation and were not included in the final assessments. The screws were removed under local anesthesia after eight weeks postoperatively. The patients were evaluated for cosmetic appearance, functional status, pain, localized tenderness, articular range of motion, and with the functional Constant scoring system. The mean follow up was 3.1 years (range 1 to 8 years). RESULTS: The mean Constant score was 98 (range 92 to 100). The results were excellent in 26 patients (86.7%) and good in four patients (13.3%). There was subluxation of the acromioclavicular joint in one patient (3.3%). The alignment of the acromioclavicular joint was normal in the remaining patients. None of the patients showed joint degeneration. All patients were pain-free and achieved full range of motion. CONCLUSION: With ease of application, low complication rate, and low rate of acromioclavicular joint arthrosis, the modified Bosworth technique is an effective surgical method in providing satisfactory shoulder function in acromioclavicular dislocations.

The relationship between morphometric parameters and Trendelenburg sign following the Hardinge incision.

OBJECTIVES: We evaluated the relationship between morphometric parameters such as height, weight, and body mass index with the development of the Trendelenburg gait following the Hardinge approach, which is one of the most commonly used approaches in total hip arthroplasty. METHODS: The study included 59 patients (43 women, 16 men; mean age 55 years; range 37 to 74 years) who underwent total hip arthroplasty via the Hardinge approach for primary coxarthrosis. The patients were examined postoperatively at 15 days, and at the end of the first and third months. The mean follow-up period was 24.3 months (range 12 to 37 months). The height, weight, and body mass index values of the patients with and without a positive Trendelenburg sign were compared. RESULTS: The Trendelenburg sign was positive in 19 patients (32.2%) following total hip arthroplasty with the Hardinge approach and persisted for a mean of 8.3 months (range 4-14 months). Patients with a positive Trendelenburg sign had a mean height of 157.4 cm (range 151 to 173 cm), mean weight of 82.5 kg (range 70 to 108 kg), and mean body mass index of 33.2 kg/m(2) (range 25.4 to 30.5 kg/m(2)). The corresponding figures in patients without a Trendelenburg sign were as follows: 166.3 cm (range 158 to 180 cm), 79.4 kg (range 72 to 94 kg), and 28.7 kg/m(2) (range 21.6 to 30.5 kg/m(2)). There was no significant difference between the two patient groups with respect to weight, but height and body mass index showed highly significant differences (p<0.0001). CONCLUSION: Based on our finding that patients having a significantly shorter height and greater body mass index sustained Trendelenburg positivity for quite a long time, we recommend that these two factors be taken into consideration in the preoperative evaluation of patients for total hip arthroplasty with the Hardinge approach. Thus, the use of the Hardinge approach in total hip arthroplasty may not be convenient in short subjects having borderline obesity.

Effects of calcitonin on the biomechanics, histopathology, and radiography of callus formation in rats.

BACKGROUND: This study was designed to examine the effect of salmon calcitonin on fracture repair. METHODS: A transverse middiaphyseal fracture of the right tibia was surgically induced, and stabilized by an intramedullary Kirschner wire. Eighty male Wistar rats were arbitrarily assigned to four groups of 20 animals each. Groups I and II were the controls and did not receive any medication but did receive placebo injections. The other two groups received 5 IU/kg/day salmon calcitonin intramuscularly for 6 weeks (Group III) or for 10 weeks (Group IV) postoperatively. The formation and healing of the bones were determined by radiographic and histopathological analyses and by biomechanical tests. RESULTS: In radiographic examinations, there were no statistically significant differences between groups I and III at week 6 or between groups II and IV at week 10. However, the histopathological evaluation scores were higher in the calcitonin group at the early stage (6 weeks) of fracture healing, which indicates a more mature callus formation (P < 0.05). The values for maximum torsional moment during fracture were higher in the calcitonin group in both stages of fracture healing (P < 0.01). CONCLUSIONS: This study could have two important clinical implications. (1) Higher scores for the histopathological evaluation and a greater resistance to moment force applied at an early stage (week 6) of fracture healing imply that calcitonin intake might enable us to allow earlier mobilization and weight-bearing in clinical cases with rigid fixation. (2) At a late stage of fracture healing (week 10), the significantly better (P < 0.0001) results obtained in the biomechanical parameters used might imply that calcitonin intake could enable us to perform early implant removal, and strongly suggest that the strength and quality of the callus formation could be improved by administering calcitonin following a fracture.

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities.

INTRODUCTION: The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet. PATIENTS AND METHODS: The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors' clinics. RESULTS: At a mean follow-up of 46 months (range 24-89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses. CONCLUSION: Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.

[The correlation between the accuracy of steroid injections and subsequent shoulder pain and function in subacromial impingement syndrome]. / Subakromiyal sikisma sendromunda steroid enjeksiyonunun dogru sekilde uygulanmasi ile omuz agrisi ve fonksiyonu arasindaki iliski.

OBJECTIVES: We assessed the relationship between proper placement of corticosteroid injections and subsequent shoulder function and pain in subacromial impingement syndrome. METHODS: The study included 48 patients (29 women, 19 men; mean age 46.5 years; range 23 to 58 years) with subacromial impingement syndrome, whose complaints of shoulder pain lasted more than two months. To monitor the site of injection, contrast material was added to a mixture of steroid and local anesthetic solution. Injections were delivered into the subacromial bursa by an anterolateral approach. Radiographs of the joint were taken immediately afterwards to ensure the accurate placement of the injection. Shoulder function and pain were evaluated by visual pain scale, range of movement of the joint, and Constant scores before treatment, and half an hour and two weeks after the injections. RESULTS: The injections were placed accurately in 42 patients (87%), while in six patients (12.5%), delivery to the target site failed. Statistically significant improvements were observed in both groups half an hour after the injections (p<0.05). However, two weeks after the treatment evaluations showed that failure to obtain an accurate placement was associated with return to pretreatment values, while significant improvement continued in the other group. CONCLUSION: Failure to deliver injections to the target site may be decreased by increased utilization of visualization and imaging methods.