Overlapping repair and epitenon healing are more stable biomechanically than side to side repair and endotenon healing in achilles tendon lengthening with Z plasty.

BACKGROUND: The current study aimed to compare biomechanical stability and healing process of side-to-side repair with overlapping repair after Achilles tendon lengthening with Z-plasty. METHODS: In our study, 22 Sprague Dawley male rats were used. Side-to-side repairs were classified as group 1 and overlapping repairs as group 2. The left and right legs of seven rats were used to compare early group 1 and early group 2 biomechanical test results at day 0. Seven rats were used to compare late group 1 and late group 2 biomechanical test results at day 28. Both the right and left tendons were tested from the four rats examined in the biomechanically in the untreated control group. The last remaining four rats were used for histopathological evaluation of tendon repair, at 28-days from the index procedure.The ultimate load to failure was compared between groups. RESULTS: At time 0, there were no measurable differences between group 1 (3.8 ± 1.4 N) and group 2 (3.7 ± 1.1 N), and both could endure less than one-tenth of the untreated control (49 ± 12). At 28 days, ultimate load to failure improved significantly in both group 1 (16.2 ± 3.5 N) and even more in group 2 (36 ± 8.1 N). While there was a significant difference between group 1 and group 2, neither were able to meet the untreated control (49 ± 12). Histopathological evaluation in the post-healing period showed that fibrosis, neovascularization, and inflammation increased in both groups. CONCLUSION: The overlapping suture technique and epitenon healing have more stability compared to side-to-side suture technique and endotenon healing. Human population trials may or may not exist, our study suggests it should be considered and further investigation needed before actual clinical application.

Tibiofemoral subluxation in the coronal plane does not affect WOMAC and KOOS after total knee arthroplasty.

PURPOSE: To investigate the effect of preoperative coronal tibiofemoral subluxation (CTFS) on functional outcome, prosthesis type, insert thickness and revision rates in patients who underwent total knee arthroplasty (TKA). METHODS: A total of 224 knees of 186 patients were included. Patients were divided into two groups as either with (Group 1, 114 knees of 86 patients) or without (Group 2, 124 knees of 100 patients) coronal lateral tibiofemoral subluxation. The mean follow-up period was 71.3 ± 7.3 (range 60-84) months in group 1 and 69.4 ± 6.6 (range 61-79) months in group 2 (n.s.). Coronal tibiofemoral subluxation degree was measured in degrees on standing anteroposterior knee radiographs. Group 1 was divided into three subgroups according to amount of subluxation (< 5 mm, 6-10 mm and > 10 mm). Functional outcome was evaluated using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at the last follow-up visit. Prosthesis type, insert thickness and revision rates were compared between the two groups. RESULTS: There were no significant differences between the two groups regarding patient demographics, prosthesis type, and revision rates (n.s.). The insert thickness was found significantly higher in group 1 (p < 0.001). The preoperative and postoperative WOMAC and KOOS scores were found no significantly different between the two groups (n.s.). Among subluxation (+) subgroups, there was no significant difference in functional outcome scores and revision rates (n.s.). However, prosthesis type and insert thickness were significantly associated with the amount of subluxation (p = 0.009 and p = 0.001, respectively). There was no significant correlation between the degree of lower extremity deformity and coronal tibiofemoral amount of subluxation (n.s.). CONCLUSION: Preoperative CTFS does not adversely affect the WOMAC score, KOOS and revision rates after TKA. In the clinical practice, surgeons should be aware of the need for a posterior cruciate stabilizing prosthesis and a thicker insert in the presence of CTFS, especially with subluxation greater than 10 mm and to consider a spared bony resection on the tibia in patients suffering from CTFS. LEVEL OF EVIDENCE: IV.

Painful transient edema in the tibial diaphysis: the challenges and the essence of biopsy in treatment.

BACKGROUND: Some patients experience a non-traumatic pain in the tibial diaphysis similar to that in the clinical and radiological findings of a tumor, an infection or a stress fracture and cannot be definitively diagnosed even after biopsy. In this study, our aim was to exhibit the challenges in the diagnosis of this patient group and to evaluate this type of patients with a limited population in the literature. METHODS: Eighteen extremities of 16 patients, whose complaints of non-traumatic pain in the tibial diaphysis were evaluated by our tumor council and T2-weighted MR scans of the medullary bone had shown hyperintense signal changes or tumor-like appearances, were evaluated with histological, radiological, and clinical results. RESULTS: Lesions were detected in 18 extremities of the 16 patients (seven males, nine females; mean age 23 [range 7 to 51] years). Four of the lesions were in the right tibial diaphysis, ten were in the left, and two were bilateral. Laboratory findings of the patients were normal. Based on the decision of the tumor council, biopsy was performed on 12 patients. All patients' complaints were gone and MRI findings decreased during the follow-up period. The complaints of the three patients who did not have a biopsy decreased after a mean period of three months. CONCLUSIONS: Medullary stress syndrome has been reported in the literature in various forms and in a limited number of cases, including longitudinal stress fracture and transient medullary edema of the bone. In light of our findings, we deduced that biopsy of the diaphyseal lesions in this patient group is essential and that the complaints of this patient group declined in the earlier term in comparison to the patients who were not performed biopsy.

Tibial tubercle-trochlear groove distance and angle are higher in children with patellar instability.

PURPOSE: The purpose of this study was to assess the variations in tibial tubercle-trochlear groove distance and angle as a function of age and gender in a population of children without patellar instability (PI) compared with those with PI. METHODS: A retrospective review of 869 children's knee MRIs, ages 5 to 15 years, were evaluated using a control group (792 children) without evidence of PI and a group with PI (77 children). Tibial tubercle-trochlear groove distance (TT-TGd) and angle (TT-TGa) were measured twice by two readers to assess intra- and inter-observer reliability and compared between PI and control groups. In both groups, functions of age and gender on TT-TGd and TT-TGa values were evaluated. RESULTS: Both TT-TGd and TT-TGa measurements showed excellent intra- and inter-observer reliability. The mean TT-TGd for the PI group was 17.2 mm (SD 6.6) and significantly higher than the mean TT-TGd for the control group (10.4 SD 3.8 mm, P = 0.001). The mean TT-TGa for the PI was 20.8° (SD 8.3°), which was also significantly higher than the mean TT-TGa for the control group (12.5° SD 4.6°, P < 0.001). Control group revealed a positive correlation between age and TT-TGd measurements (r = 0.243, P < 0.001). The mean TT-TGa for girls (13.3° SD 4.7°) was higher than the mean TT-TGa for boys (11.9° SD 4.4°) in the control group (P < 0.001). CONCLUSION: TT-TGa and TT-TGd are reliable and can be used for the evaluation of the extansor mechanism alignment in children with and without PI. However, it must be considered that TT-TGd is increasing in growing patients. Soft-tissue procedures may be prone to failure, since bony procedures for patellar alignment cannot be done until skeletal maturity. LEVEL OF EVIDENCE: III.