A guide to facilitate the creation of a femoral tunnel for arthroscopic ligamentum teres reconstruction: a three-dimensional computed tomography study.

The ideal femoral tunnel passing through the centre of the femoral neck targeted to the footprint of the ligamentum teres (LT) is established during the LT reconstruction surgery with the free-hand technique. We aimed to quantitatively determine the entry site and define the angular orientation of the ideal femoral tunnel with its relevance to the femoral valgus angle (FVA) and the femoral anteversion angle (FAA) to facilitate the creation of an ideal femoral tunnel during the LT reconstruction surgery. A total of 60 randomly selected CT images were obtained to reconstruct three-dimensional femur models. A virtual reamer representing the ideal femoral tunnel was placed in the femur models. The femur length, FVA, FAA, the femoral tunnel anterior angle, the femoral tunnel superior angle and the skin- and bony-entry sites were measured. The femoral tunnel angular orientation was strongly correlated with the FVA and the FAA. Mathematical formulas were defined by which entry site of the reamer and the anterior and superior angulation of the femoral tunnel could be estimated before the surgery. The mean skin-entry site was 67.3 mm distal and 0.1 mm anterior to the centre of the greater trochanter's superior border. The angular orientation of the femoral tunnel using FVA and FAA can be easily estimated using mathematical formulas before LT reconstruction surgery. The entry site and angular orientation of the femoral tunnel described in this study can be used to reduce dependency on the usage of fluoroscopy and the workload on the surgeon during the LT reconstruction surgery.

Chronic recurrent multifocal osteomyelitis: A multidisciplinary experience of 22 pediatric cases with a mean follow-up of 27 months.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is not a well known disorder among nonpediatricians. The aim of this study is to retrospectively evaluate the clinical outcomes of twenty-two CRMO patients presenting to two referral centres. METHODS: This retrospective study included twenty-two children (12 males, 10 females; mean age 13 years; range 7-17 years). The diagnosis was based on clinical, radiological, and pathological findings. Data were retrieved from hospital charts. RESULTS: The mean delay in diagnosis was 26 months (range, 0-96 months). The mean follow-up after diagnosis was 27.4 months (range, 6-47 months). Symptoms included pain, limping, local swelling, morning stiffness, and fever. 18 patients had multifocal and 4 patients had unifocal disease. Bone lesions were detected with whole-body or local MRI (Magnetic Resonance Imaging). The mean number of bone lesions was 2.5 (range, 1-8). Ten cases underwent biopsy to exclude malignancy and infection. Prior to diagnosis, cast immobilization or curettage was erroneously performed in four patients. One patient suffered from vertebral compression fracture. There is no growth disturbance or deformity in any patient. CONCLUSION: This study demonstrated that early recognition of the disease can be improved by using Bristol criteria which should be evaluated by a multidisciplinary team rather than one single specialist. In this way, the reliability of these criteria is improved and the treatment could be given earlier with decreased delay in diagnosis. This multidisciplinary approach is also important for decision for biopsy, timely aggressive medical treatment, and follow-up of the disease to minimise possible complications.

The Effect of early active Movement following Repair of Extensor Tendons in Zone IV using three different suture Techniques - A cadaveric Study.

PURPOSE: The aim of this study was to investigate the effects of early active movement on the area repaired with three different suture techniques used in extensor tendon injuries in zone IV. MATERIALS AND METHODS: A total of nine cadaver's 35 extensor tendons from 9 intact upper extremities were used in this study. The proximal and distal borders of the extensor tendons in zone IV were marked. The distance between the proximal and distal border was measured with a 0.5 mm precision tape measure and the mid-point was marked. Intertendinous connections were dissected and loop sutures were prepared for each extensor digitorum. Afterwards, force was applied to each digit along the tendon axis from the loops inserted into the extensor tendons, to measure the extensor forces required to extend the MCP joints to 0˚ with a hand scale. The flexor tendons of the digits were dissected at zone III, and loop sutures were prepared individually for the tendons to enable independent flexion for each digit. The force required to fully flex the digits was measured with a hand scale. The extensor tendons were incised transversely and repaired at the mid-point in zone IV with three different suture techniques (double Kessler, double figure of eight, running interlocking horizontal mattress (RIHM)). The extenxor tendon lengths in zone IV were re-measured for all digits after suturing. The predetermined forces required for full flexion and extension of the digits were applied to the repaired digits. After force was applied 20 times to each tendon, the gap formation was checked. Totally 200 flexion and 200 extension movements were applied to each finger with the help of a hand-held scale. Formation of 2-mm gap was failure criteria. At the end of the movements the extent of the gaps was recorded. In the absence of insufficiency at the repair site, 50 additional flexion and extension movements with double the previously recorded forces were applied to the tendons. RESULTS: There was a significant shortening of the extensor tendons after repair independent from the used suture technique. No significant gap formation was detected in all three suture techniques. CONCLUSION: All three suturing techniques are reliable for early active movements following the zone IV extensor tendon repairs. Therefore, surgeons can choose one of those three suture techniques to repair extensor tendon injuries in zone IV.