Recovery of upper extremity function following endoscopically assisted contralateral C7 transfer for obstetrical brachial plexus injury.

UNLABELLED: Transfer of the contralateral C7 nerve for reconstruction of the brachial plexus in infants with obstetrical brachial plexus injury has rarely been reported. We developed a new endoscopy-assisted technique via the prevertebral (retroesophageal) route for the transfer of the contralateral C7 nerve in reconstruction of the brachial plexus. The reconstruction was performed in 20 infants (14 boys and six girls). Motor recovery was assessed using the Gilbert and Raimondi scales. The Narakas Sensory Grading System was used to evaluate hand sensation. The mean follow-up period was 45 months (SD 18.2). Of the 20 children, nine had contralateral C7 transfer to lower nerve roots, two had transfer to upper nerve roots and nine had transfer to both upper and lower roots. The postoperative shoulder and elbow functions were good or satisfactory according to the Gilbert classification in all children whose preoperative scores were poor. All patients with lower roots reconstruction (9) had satisfactory hand function. A total of 15 children had a Narakas score of S3. Our technique enables safe contralateral C7 transfer to the avulsed roots in severe obstetrical brachial plexus injury infants with a satisfactory functional recovery. LEVEL OF EVIDENCE: Level IV.

Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection.

PURPOSE: The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection. METHOD: Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems. RESULTS: In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher (P < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher (P < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems (P < 0.001). CONCLUSION: Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone. LEVEL OF EVIDENCE: Randomized, controlled trial, Level I.

Dynamic postural stability in blind athletes using the biodex stability system.

Three systems affect the upright standing posture in humans - visual, vestibular, and somatosensory. It is well known that the visually impaired individuals have bad postural balance. On the other hand, it is a well documented fact that some sports can improve postural balance. Therefore, it is aimed in this study to evaluate the dynamic postural stability in goal-ball athletes. Twenty blind goal-ball players, 20 sighted and 20 sedentary blind controls were evaluated using the Biodex Stability System. Three adaptation trials and three test evaluations (a 20-second balance test at a platform stability of 8) were applied to the blind people, and to the sighted with eyes open and closed. Dynamic postural stability was measured on the basis of three indices: overall, anteroposterior, and mediolateral. Means of each test score were calculated. The tests results were compared for the blind athletes, sighted (with eyes open and closed) subjects, and sedentary blind people. There were significant differences between the results of the blind people and the sighted subjects with regards to all of the three indices. Although the stability of goal-ball players was better than sedentary blinds', only ML index values were statistically different (4.47 +/- 1.24 in the goal-ball players; 6.46 +/- 3.42 in the sedentary blind, p = 0.04). Dynamic postural stability was demonstrated to be affected by vision; and it was found that blind people playing goal-ball 1 - 2 days per week have higher ML stability than the sedentary sighted people.

Effect of low-dose N-acetyl-cysteine infusion on tourniquet-induced ischaemia-reperfusion injury in arthroscopic knee surgery.

BACKGROUND: Temporary occlusion of blood flow is used during arthroscopic knee surgery in order to provide a bloodless surgical field. The resulting ischaemia-reperfusion causes lipid peroxidation, which contributes to tissue injury. The aim of the study was to investigate the effect of low-dose n-acetyl cysteine (NAC) infusion on oxidative stress by determining malondialdehyde (MDA) levels during arthroscopic knee surgery. METHODS: Thirty patients, ASA I - II, undergoing arthroscopic knee debridement under a tourniquet were divided into NAC and control groups. Anaesthesia was induced with propofol, fentanyl and vecuronium bromide and maintained with desflurane in an equal parts O(2)-N(2)O mixture. In the NAC group, an infusion of NAC, 5 mg kg(-1).h(-1), was started after intubation, and continued until extubation. An equal volume of saline was infused to the control group. Duration of ischaemia, anaesthesia time, total dose of NAC infused were also recorded. Venous blood and synovial membrane tissue samples were obtained 10 min after the onset of NAC infusion but before tourniquet inflation (t1), after 30 min of ischaemia (t2), and after 5 min of reperfusion following tourniquet release (t3). RESULTS: Plasma MDA levels were significantly lower in the NAC group on reperfusion. There were no differences between the groups in tissue MDA levels at ischaemia and reperfusion times. CONCLUSION: Low-dose n-acetyl cysteine infusion attenuates lipid peroxidation and ischaemia-reperfusion injury in arthroscopic knee surgery requiring tourniquet application.

Relation between foot arch index and ankle strength in elite gymnasts: a preliminary study.

BACKGROUND: Gymnasts usually start intensive training from early childhood. The impact of such strenuous training on the musculoskeletal system is not clear. OBJECTIVES: To evaluate the relation between muscle strength of the ankle joint and foot structure in gymnasts. METHODS: The study population comprised 20 high level male gymnasts and 17 non-athletic healthy male controls. Arch indices were measured using a podoscope. Ankle plantar/dorsiflexion and eversion/inversion strengths were measured using a Biodex 3 dynamometer within the protocol of concentric/concentric five repetitions at 30 degrees /s velocity. RESULTS: The mean arch index of the right and left foot of the gymnasts and the controls were respectively: 31.4 (29.1), 34.01 (34.65); 60.01 (30.3), 63.75 (32.27). Both the arch indices and the ankle dorsiflexion strengths were lower in the gymnasts. Although no correlation was found between strength and arch index in the control group, a significant correlation was observed between eversion strengths and arch indices of the gymnasts (r = 0.41, p = 0.02). CONCLUSIONS: Whether or not the findings indicate sport specific adaptation or less training of the ankle dorsiflexors, prospective data are required to elucidate the tendency for pes cavus in gymnasts, for whom stabilisation of the foot is a priority.

Multiple osteochondroses and avulsion fracture of anterior superior iliac spine in a soccer player.

Apophysitis describes a chronic traction injury at the insertion site of a tendon. There is a gradual onset of pain with no clear history of injury. Without adequate preventive methods, an avulsion fracture may result. The case is here reported of an apophyseal avulsion fracture of the anterior superior iliac spine in an adolescent caused by playing football before the end of treatment for apophysitis. An open reduction and internal fixation was performed followed by a rehabilitation programme. No complications occurred, and the patient had returned to his previous level of sporting activity after six weeks.

Differences in sole arch indices in various sports.

BACKGROUND: There are controversial data about the relation between foot morphology and athletic injuries of the lower extremity. Studies in soldiers have shown some relationship, whereas those involving athletes have not shown any significant relationship. The reason for these differences is not clear. OBJECTIVE: To determine the effect of various sports on sole arch indices (AIs). METHOD: A total of 116 elite male athletes (24 soccer players, 23 wrestlers, 19 weightlifters, 30 handball players, and 20 gymnasts) and 30 non-athletic men were included in this cross sectional study. Images of both soles were taken in a podoscope and transferred to a computer using a digital still camera. AIs were calculated from the stored images. RESULTS: The AI of the right sole of the gymnasts was significantly lower than that of the soccer players, wrestlers, and non-athletic controls (p<0.01). The AI of the right sole of the wrestlers was significantly higher than that of the soccer players, handball players, weightlifters, gymnasts, and non-athletic controls (p<0.03). The AI of the left sole of the gymnasts was significantly lower than that of the wrestlers and non-athletic controls (p<0.001). The AI of the left sole of the wrestlers was significantly higher than that of the soccer players, handball players, and gymnasts (p<0.007). The AI of both soles in handball players was significantly lower than those of the non-athletic subjects (p = 0.049). The correlation between the AI of the left and right foot was poor in the soccer players, handball players, and wrestlers (r = 0.31, 0.69, and 0.56 respectively), but was high in the gymnasts, weightlifters, and non-athletic controls (r = 0.96, 0.88, and 0.80 respectively). CONCLUSION: The AIs of the gymnasts and wrestlers were significantly different from those of other sportsmen studied, and those of the gymnasts and handball players were significantly different from those of non-athletic controls.

Variations in anatomy at the suprascapular notch possibly causing suprascapular nerve entrapment: an anatomical study.

The purpose of the study was to determine anatomical variations at the suprascapular notch for better understanding of possible predisposing factors for suprascapular nerve entrapment. We dissected 32 shoulders of 16 cadavers between the ages of 39 and 74 years. We observed abnormally oriented superior fibers of the subscapularis muscle in five shoulders of the 16 cadavers, which were covering the entire anterior surface of the suprascapular notch and significantly reducing the available space for the suprascapular nerve. We also detected anterior coracoscapular ligament in six of the 32 shoulders, and calcified superior transverse scapular ligament in four of the shoulders. In this study, we classified the variations for the superior transverse scapular ligament. In conclusion, knowing the anatomical variations in detail along the course of the suprascapular nerve might be important for better understanding of location and source of the entrapment syndrome, especially for individuals who are involved in violent overhead sports activities such as volleyball and baseball. To our knowledge, close relationship of subscapularis muscle with the suprascapular nerve as a possible risk factor for suprascapular nerve entrapment has not been mentioned previously.

Arthroscopic fixation of the fractures of the intercondylar eminence via transquadricipital tendinous portal.

We describe a new technique for arthroscopic reduction and internal fixation of fractures of the intercondylar eminence of the tibia. In this technique cannulated screws are placed through a new portal (transquadricipital tendinous) instead of anteromedial arthroscopic portal. Twelve patients who were treated with this technique for displaced types II and III fractures of the intercondylar eminence of the tibia were reviewed after a mean of 49 months. At follow-up all patients had excellent or good results, without any case of nonunion of the fracture or related complications, such as functional instability. Placement of cannulated screws through transquadricipital tendinous portal achieves fragment reduction easily, provides rigid fixation while avoiding arthrotomy, allowing early mobilization and return to activity.

Bilateral discoid medial menisci: association with bone changes in the tibia.

We present here the third case report of bilateral discoid medial menisci with associated bone changes. An 18-year-old man had bilateral medial tibial plateau depression (cupping) accompanying medial discoid menisci documented by magnetic resonance imaging and confirmed by arthroscopy. The patient was treated successfully by excision of the torn central anomalous discoid portion of the menisci using arthroscopic partial resection technique.

Arthroscopy-assisted anterior cruciate ligament reconstruction with patellar tendon or hamstring autografts.

Isolated ACL reconstructions were performed in 138 patients between 1994 and 1998. Patellar bone-patellar tendon-bone, and hamstring tendon autografts were used in 88 patients, and allografts were used in 50 patients. Eighty-eight knees of 88 patients with autograft reconstructions (17 female, 71 male) were included in this study and evaluation of the patients with allograft reconstruction reported separately. The mean age at the time of the operation was 32 years. All ACL reconstructions were performed arthroscopically. Twenty-seven bone-patellar tendon-bone, and 61 hamstring tendon autografts were used. The mean follow-up was 29 months. In the postoperative course the Lachman test was negative in 62 patients, 1+ in 22 patients, and 2+ in 4 patients. In 17 patients, anterior drawer sign were 1+ in comparison to the contralateral side. Pivot shift test was moderately positive only in 5 cases in the bone-patellar tendon-bone and hamstring tendon autograft groups postoperatively. There were 3 patients with subjective "giving way" symptoms. Second look arthroscopy revealed rupture of the neo-ligament. Arthroscopic washout and debridement were performed, and no revision ligamentoplasties were performed. Two of these patients improved with accelerated proprioceptive physical therapy, and one had to decrease his previous level of activity. There were no cases of arthrofibrosis, infection, or extension lag. Clinical results of patellar bone-tendon-bone and hamstring groups did not show any significant clinical difference. Avoiding the disturbance of the extensor mechanism of the knee is probably the most significant advantage of the hamstring autograft.

Intraarticular morphine administration provides pain relief after knee arthroscopy.

This present study investigated the effects of intraarticular morphine administration in 1 mg and 5 mg doses on post-operative pain relief and analgesic requirements for patients undergoing arthroscopic procedures. At the end of the operation patients were randomly allocated in a double-blinded fashion into three groups. The control group (Group 1) received normal saline 20 mL intraarticularly. The patients in the second and third groups received intraarticular morphine sulphate 1 and 5 mg in saline 20 mL, respectively. Post-operative pain was assessed on the 1st, 6th and 24th hour by visual analogue scale (VSA). Supplementary analgesic requirement and possible complications were also followed. The intensity of pain and analgesic requirement were reduced more in the morphine 5 mg group than in the control group. It is concluded, that the administration of intraarticular morphine 5 mg provides long-lasting and effective analgesia after knee arthroscopy.

Arthroscopic partial resection of the discoid meniscus in children.

Thirteen children with 14 lateral discoid menisci were reviewed at an average follow-up of 2.7 years. Their average age at the time of the operation was 12.8 years. Most of the children had vague and intermittent painful symptoms, and the classical "clunk" was demonstrable in nine of the 13 patients in clinical examinations. Thirteen children underwent arthroscopic partial meniscectomy for symptomatic discoid lateral meniscus, by performing partial resection. This procedure, modifying the discoid lateral meniscus to the normal semilunar shape, was indicated only when the capsular attachment was intact. The results were excellent both clinically and radiologically. Furthermore, rehabilitation time was considerably shorter than the time required after open procedures. Arthroscopic discoid meniscus surgery performed by experienced and skilled hands gives better results. According to the literature and our experiences, it is better to perform open techniques in patients with stiff knees. Additionally, it is technically feasible to use small joint instruments in the pediatric age group.