Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

OBJECTIVE: The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP). METHODS: In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group. RESULTS: PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications. CONCLUSION: Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.

Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures.

OBJECTIVES: The aim of the present study was to evaluate results, including clinical and radiological outcomes and number of complications, following minimally invasive plate osteosynthesis (MIPO) of proximal humerus fractures, using the PHILOS® proximal humerus internal locking system (Synthes Holding AG, Solothurn, Switzerland). METHODS: Retrospectively evaluated were 31 patients treated with MIPO (12 male, 19 female; average age: 58.4 years). Four patients had 2-part fractures, 14 patients had 3-part fractures, and 13 patients had 4-part fractures, according to Neer classification. Healing, complications, and head-shaft angle (HSA) were radiographically evaluated. Clinical outcomes were assessed at 1-year follow-up with Constant score. RESULTS: Average Constant scores for fractured and normal shoulders were 73.2 ± 10.9 and 84.8 ± 5.1, respectively. Varus progression, fracture type, and age had no significant effect on functional outcome. Average postoperative and follow-up HSA's were 130.80 ± 7.70 and 128.80 ± 10.00, respectively. Significant varus progression was observed during follow-up (p = 0.01). Varus progression was more prominent in patients with postoperative HSA < 130° (p < 0.001). Inferomedial calcar screw usage, fracture type, and age had no significant effect on varus progression. Complications included 2 implant failures, 1 case of avascular necrosis (AVN), 1 primary screw cut-out, 1 axillary nerve injury, and 1 radial nerve injury (22.6% overall). CONCLUSION: MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. Reduction may be difficult, resulting in varus progression. Another disadvantage is risk of axillary nerve injury. Careful surgical technique and correct implant selection is important in the prevention of nerve injury. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

The effects of low-dose radiotherapy on fresh osteochondral allografts: An experimental study in rabbits.

OBJECTIVE: The aim of this study was to investigate the effects of low-dose fractionated radiotherapy on cartilage degeneration after distal femoral fresh massive osteochondral allograft transplantation. METHODS: Twenty-four New Zealand White rabbits were divided into three groups of 8 rabbits each. All rabbits underwent distal femoral medial condyle fresh massive osteochondral allograft transplantation from California rabbits. The group 1 underwent transplantation without any preliminary process. The group 2 underwent fractionated local radiotherapy of 100 cGy for five days starting on the transplantation day. The group 3 included the rabbits to which the grafts transplanted after radiating in vitro by a single dose radiation of 1500 cGy. The hosts were sacrificed twelve weeks later. Anteroposterior and lateral radiographs were taken. Synovial tissue, cartilaginous tissue, and subchondral bone were assessed histopathologically. RESULTS: Nonunion was present in three cases of group 2 and one of group 3 in which cartilage degeneration was more severe. Synovial hypertrophy and pannus formation were more obvious in non-radiated rabbits. Hypocellularity and necrosis of the subchondral bone were rare in group 2. More cartilage tissue impairment was present in group 3 compared to group 1. CONCLUSION: In osteochondral massive allograft transplantations, the immune reaction of the host could be precluded with radiotherapy, and the side-effects can be prevented by low-dose fractionated regimen. The total dose of fractionated radiotherapy for an immune suppression should be adjusted not to damage the cartilage tissue, but to avoid articular degeneration in the long term.

Radial tears in the root of the posterior horn of the medial meniscus.

The purpose of this study is to define the clinical features and characteristics of radial tears in the root of the posterior horn of the medial meniscus and to report the outcome of arthroscopic treatment. Arthroscopic meniscus surgery was performed on 7,148 knees. Of those, 722 (10.1%) were radial tear in the root of the posterior horn of the medial meniscus. We reviewed the medical records from a random sample of 67 subjects studied (mean age 55.8 years, range 38-72, mean follow-up period 56.7 months, range, 8-123), which included surgical notes and detailed arthroscopic photographs of 70 knees. All patients were treated with arthroscopic partial meniscectomy. The age distribution, preoperative physical signs, results of magnetic resonance imaging , body mass index, and surgical findings of the study subjects were analyzed and the clinical results were graded with the Lysholm knee scoring scale and a questionnaire. Radiologic evaluation consisted of preoperative and at the latest follow-up radiographs. Eighty percent of the patients were older than 50 years, and 80.6% were either obese or morbidly obese. The mean Lysholm score improved from a preoperative value of 53 to a value of 67. The average preoperative Kellgren-Lawrence radiograph grade was 2 (range 0-3 points), a value that increased to 3 (range 2-4) at the latest follow-up, which showed a significant worsening. The preoperative MRI was reevaluated after the arthroscopic confirmation of a medial meniscal root tear. A tear could be demonstrated in only 72.9% of the patients, the rest of whom demonstrated degeneration and/or fluid accumulation at the posterior horn without a visible meniscal tear. Radial tears in the root of the medial meniscal posterior horn, which may not be visible in about one-third of the preoperative MRI scans, are common. That type of meniscal tear is strongly associated with obesity and older age and is morphologically different from the degenerative tears that often occur in the posterior horn. Partial meniscectomy provides symptomatic relief in most cases but does not arrest the progression of radiographically revealed osteoarthritis.

[Bone bruises of the knee]. / Dizde gizli kemik yaralanmalari

Bone bruises represent a spectrum of occult bone lesions around the knee, which can only be detected by magnetic resonance imaging. These lesions can be isolated or are usually associated with other soft tissue injuries of the knee. These occult lesions are mostly associated with anterior cruciate ligament (ACL) injuries and are typically located in the lateral femoral condyle and the posterolateral tibial plateau. The location of the lesion may provide information on the mechanism of injury and associated soft tissue injuries. Bone bruises are less severe after low-energy trauma and most of these lesions usually regress within a short period. However, in lesions due to high-energy trauma like ACL injuries, healing may take years and those especially located close to the subchondral bone have the risk of associated osteochondral sequelae. Bone bruises may be responsible for the late degenerative changes of the knee after an ACL injury.

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning.

INTRODUCTION: In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction. MATERIALS AND METHODS: The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated. RESULTS: At the latest follow-up the open group had an average of 5.1 degrees valgus change and the closed group 3.6 degrees valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61 degrees in the open and 5.25 degrees in the closed group. Average extension lag was 6.23 degrees in the open and 0.6 degrees in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups. CONCLUSIONS: Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.

[Ankle fractures in children and adolescents]. / Cocukluk ve ergenlik döneminde ayak bilegi kiriklari.

Ankle fractures in children and adolescents usually involve the distal tibial and fibular epiphysis. Unless adequately treated, these fractures may be associated with many complications including limb length discrepancy and angular deformities due to growth arrest, and arthritis due to joint involvement. Fractures of the distal tibial epiphysis are classified according to the type and mechanism of injury. Salter-Harris type 1 and 2 fractures of the ankle have a good prognosis and can be treated by closed reduction. However, type 3 and 4 fractures involving the medial malleolus require surgical treatment because they usually result in compression of the physeal plate and cause angular deformities. External rotation of the foot may result in juvenile Tillaux fractures and triplane fractures of the distal tibia in the transitional period during which asymmetric physiologic closure of the distal tibial physis occurs. These are combinations of Salter-Harris type 2, 3, and 4 fractures, consisting of two or three fragments. Although they are not associated with growth arrest, they may lead to arthritis due to joint involvement. The presence of residual displacement of more than two millimeters necessitates surgical treatment.