Delayed or neglected meniscus tear repair and meniscectomy in addition to ACL reconstruction have similar clinical outcome.

PURPOSE: To compare the clinical outcomes of meniscus repair and meniscus resection with concurrent anterior cruciate ligament (ACL) reconstruction in patients with ACL rupture and neglected or delayed medial meniscus tears. METHODS: Thirty patients with ACL ruptures and unstable vertical longitudinal medial meniscus tears were included. Patients were divided into two groups. Group I included 15 patients who underwent meniscal repair and Group II included 15 patients who underwent meniscectomy. The knee range of motion, McMurray test, Lachman test, pivot shift test, Lysholm Knee Scoring Scale, International Knee Documentation Committee (IKDC) Questionnaire, Hospital for Special Surgery (HSS) Knee score, and Tegner activity (TA) scale were used to assess all patients. RESULTS: The median follow-up time was 3.6 (0.5-6.5) years. Median age was 28 (16-36) years. Fourteen patients (93.3%) in Group I and six patients (40%) in Group II returned to their preinjury sport activity level (P = .007). Median maximum knee flexion was 132° (121°-140°) in Group I and 134° (121°-139°) in Group II (n.s.). All patients had full knee extension and negative McMurray test results. Lachman and pivot shift test results were similar between groups. The median IKDC Questionnaire score was 99 (86-100) in Group I and 93 (70-100) in Group II (P = .016). The difference in Lysholm Knee Scoring Scale, HSS knee, and TA scale score between groups were not significant. CONCLUSION: Clinical outcomes of patients that underwent meniscus repair were better than those that underwent meniscus resection with concurrent ACL reconstruction. The technically complicated and costly meniscus repair may achieve better clinical outcomes than meniscectomy when treating a neglected or delayed meniscal tear with a concurrent ACL tear. LEVEL OF EVIDENCE: III.

The effect of HIF stabilizer on distraction osteogenesis.

OBJECTIVE: The aim of this study was to investigate the effect of an orally applicable hypoxia-inducible factor (HIF) stabilizer on distraction osteogenesis (DO) in a rat model. METHODS: The study included 24 Wistar albino rats undergoing osteotomy of the left tibia diaphysis. Rats were divided equally into experiment and control groups. Tibias were fixed using an external fixator. HIF stabilizer was administered to the experiment group. On the 5th postoperative day, distraction with increased rate (0.4 mm twice a day) was commenced and continued for 10 days. Histological and immunohistochemical evaluation was performed. RESULTS: Vascular endothelial growth factor levels of the experiment group were higher than those of the control group (p<0.05). The experiment group had slightly better intramembranous ossification quality than the control group on both Day 16 and 30. Endochondral ossification rates were better in the experiment group on Day 16. CONCLUSION: Vascular endothelial growth factor levels increased and stimulated angiogenesis in the presence of HIF pathway activation by oral administration of HIF stabilizer during DO. The biomechanical features of the distraction and angiogenesis should be coupled to achieve adequate bone homeostasis.

Effect of low-dose irradiation on structural and mechanical properties of hyaline cartilage-like fibrocartilage.

OBJECTIVE: The aim of this study was to analyze the effect of low-dose irradiation on fibrous cartilage and to obtain a hyaline cartilage-like fibrocartilage (HCLF) with similar structural and mechanical properties to hyaline cartilage. METHODS: An osteochondral defect was created in 40 knees of 20 rabbits. At the 7th postoperative day, a single knee of each rabbit was irradiated with a total dose of 5.0 Gy in 1.0 Gy fractions for 5 days (radiotherapy group), while the other knee was not irradiated (control group). Rabbits were then divided into four groups of 5 rabbits each. The first three groups were sacrificed at the 4th, 8th and the 12th postoperative weeks and cartilage defects were macroscopically and microscopically evaluated. The remaining group of 5 rabbits was sacrificed at the 12th week and biomechanical compression tests were performed on the cartilage defects. RESULTS: There was no significant biomechanical difference between the radiotherapy and the control group (p=0.686). There was no significant macroscopic and microscopic difference between groups (p=0.300). Chondrocyte clustering was observed in the irradiated group. CONCLUSION: Low-dose irradiation does not affect the mechanical properties of HCLF in vivo. However, structural changes such as chondrocyte clustering were observed.

Comparison of intraarticular bupivacaine and levobupivacaine with morphine and epinephrine for knee arthroscopy.

OBJECTIVE: To compare the efficacy of intraarticularly injected bupivacaine with levobupivacaine when administered in combination with morphine and adrenaline for post-operative analgesia and functional recovery after knee surgery. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists physical status I-II patients were randomized into three groups: Group B was administered 30 mL isobaric 0.5% bupivacaine, 2 mg morphine and 100 µg adrenaline, Group L was administered 30 mL 0.5% levobupivacaine, 2 mg morphine and 100 µg adrenaline, and Group C was administered 30 mL 0.9% NaCl solution into the knee joint by the surgeon at the end of surgery. The morphine usage and visual analog pain scores were recorded regularly afterwards. We also recorded the time that elapsed before each patients' first mobilization, positive response to straight leg raising, tolerance to 30-50° knee flexion, recovery of quadriceps reflexes and discharge from the hospital. We also recorded patient and surgeon satisfaction. RESULTS: The pain scale values were lower in Groups B and L than in Group C at 2, 4, 6, 8, 12 and 24 hours post-operatively (all p<0.001). In Groups B and L, the time for first analgesic request was longer (p<0.01), the morphine consumption was lower (p<0.001), and the duration of morphine usage was shorter (p<0.001). The times to positive response to straight leg raising, tolerance to 30-50° knee flexion and the first mobilization were shorter in Groups B and L (p<0.001 for all). CONCLUSION: After arthroscopic knee surgery, intraarticular levobupivacaine combined with morphine and adrenaline decreases analgesic requirements, shortens the postoperative duration of analgesic use and hastens mobilization as effectively as bupivacaine.

A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears.

OBJECTIVES: This study aims to compare the clinical outcome and possible complications of augmentation technique and standard reconstruction for the treatment of partial anterior cruciate ligament (ACL) tears. PATIENTS AND METHODS: Forty patients (36 males, 4 females; mean age 30 years; range 19 to 40 years) who underwent surgery due to ACL tear were included in this prospective randomized study. The patients were randomly divided into two groups, including 20 patients in each group. The patients in the group 1 underwent standard single bundle ACL reconstruction with hamstring tendon autografts, while those in the group 2 underwent augmentation where the remaining remnant ACL was not sacrificed, but instead augmented with hamstring tendon autograft as in the standard reconstruction technique. The mean follow-up was 24.3 months (range; 21-28 months). Clinical outcomes were evaluated using International Knee Documentation Committee (IKDC), Lysholm scores, physical instability tests and patient satisfaction questionnaires. The complication rates of both groups were compared. Tibial and femoral tunnel widening were assessed using lateral and anteroposterior radiographs. RESULTS: No significant differences were found between the groups in terms of IKDC, Lysholm scores, physical instability tests, patient satisfaction questionnaires and incidences of Cyclops lesions and arthrofibrosis. Tibial and femoral tunnel widening was less in the augmentation group. This difference was more significant on the tibial side. CONCLUSION: In the repair of partial ACL tears, augmentation technique is as effective as the standard technique, leading to, less tunnel widening evidently in the tibial tunnel, particularly.

Long-term outcome of unreamed intramedullary nails in femur diaphyseal fractures.

BACKGROUND: We evaluated the results of patients with traumatic femur diaphyseal fracture who had undergone biologic fixation with unreamed intramedullary nailing. METHODS: Twenty-five adults with 29 traumatic femur diaphyseal fractures who had undergone unreamed intramedullary nailing at Uludag University School of Medicine, Department of Orthopedics and Traumatology were included in the study between January 1997 and December 2007. Gender, age, cause of injury, fracture type, operation length, time lapse till surgery, blood loss, fluoroscopy duration, early and late complications, time until union, and functional results were noted. Functional results were evaluated with Klemm-Börner and Thoresen systems and Short Form (SF)-36 health survey questions. RESULTS: The mean follow-up of the patients was 65.1 +/- 31.6 months (26-138). There was no statistically significant difference between operation length, blood loss and time until union of simple and complex fractures (p > 0.05). Furthermore, the SF-36 questionnaire revealed no statistically significant difference between pain scores (p > 0.05). CONCLUSION: Sparing of the endosteal and periosteal circulation, low infection and high union rates, and good functional outcomes of unreamed intramedullary nailing fixation make it the treatment of choice for simple and comminuted fractures of the femur shaft, especially for multi-trauma patients and patients with cardiopulmonary comorbidities.

Comparative results of percutaneous cannulated screws, dynamic compression type plate and screw for the treatment of femoral neck fractures.

BACKGROUND: The purpose of this study was to compare the period of union, functional outcomes and complications of patients with femoral neck fracture treated with percutaneous cannulated screws versus dynamic hip screw (DHS). METHODS: Sixty-six patients with femoral neck fracture were treated with percutaneous cannulated screws (n=33) or with DHS (n=33) between August 1999 and October 2003. Functional outcome was measured using Harris Hip Score, and period of union, amount of bleeding and complications were also recorded. RESULTS: The period of union and functional outcomes were not different between the two groups. Risk of avascular necrosis (AVN) was associated mainly with the grade of fracture displacement. In the percutaneous cannulated screw group, duration of surgery was shorter and blood loss was less than in the other group. CONCLUSION: There was no superiority between cannulated screws and DHS according to union times and functional results. Risk of AVN is related to the degree of displacement. However, a prospective randomized study is needed to determine the outcome of each technique for patients suffering similar displacement rates.

Contribution of thin slice (1 mm) oblique coronal proton density-weighted MR images for assessment of anteromedial and posterolateral bundle damage in anterior cruciate ligament injuries.

PURPOSE: To evaluate the diagnostic efficacy of using additional oblique coronal 1 mm proton density-weighted (PDW) MR imaging of the knee for detection and grading anterior cruciate ligament (ACL), anteromedial bundle (AMB) and posterolateral bundle (PLB) injuries. MATERIALS AND METHODS: We prospectively assessed preoperative MR images of 50 patients (36 men, 14 women; age range, 18-62 years). First, we compared the diagnostic performance of routine sagittal (3 mm) and additional oblique coronal images (1 mm) for ACL tears. Then, we compared the tear types (AMB or PLB) and grade presumed from oblique coronal MR imaging with arthroscopy. RESULTS: Arthroscopy revealed ACL tear in 24 (48%) patients. There was significant difference between sagittal images and arthroscopy results for ACL tear recognition (p<0.001). No significant difference was detected for oblique coronal images when compared with arthroscopy results (p=0.180). Sensitivity and specificity values for ACL tear diagnosis were 37.04% and 95.65% for sagittal images; 74.07% and 91.30% for oblique coronal images. There was no significant difference between arthroscopy and oblique coronal MR images in grading AMB and PLB injuries (p>0.05). CONCLUSION: Addition of thin slice oblique coronal images to conventional sequences could better contribute to better verifying the presence of ACL tear and in determining its grade.

Incidence of meniscal and osteochondral lesions in patients undergoing delayed anterior cruciate ligament reconstruction.

OBJECTIVE: Unreconstructed anterior cruciate ligament (ACL) tears cause repeated incidences of giving-way and rotational-translational instability. The aim of this study was to test our hypothesis that delayed surgical treatment of patients with ACL tears, especially those with high Tegner activity levels, results in more severe and complicated meniscal and osteochondral lesions with potential affect on the outcome. METHODS: This study included 385 patients who underwent arthroscopic ACL reconstruction between 2001 and 2009. Patients arthroscopic video records or MRI scans and patient files at the time of surgery were analyzed. We defined severe meniscal and osteochondral lesions which could negatively affect the outcome and labeled them meniscal lesions affecting outcome (MLAO) and osteochondral lesions affecting outcome (OLAO). The relation between MLAO, OLAO, time since injury and Tegner activity levels were statistically analyzed. RESULTS: The incidences of MLAO and OLAO grew statistically higher as time elapsed between the injury and surgery increased (p=0.001, p<0.05; p=0.001, p<0.05). The relation between the Tegner activity score, MLAO and OLAO risk were found to be statistically insignificant (p=0.317, p=0.184, p>0.05). CONCLUSION: Delays in ACL reconstruction surgery result in an increase in the incidence of meniscal and osteochondral lesions which have the potential to negatively affect the surgical outcome.

Graft retaining debridement in patients with septic arthritis after anterior cruciate ligament reconstruction.

OBJECTIVE: Although septic arthritis following anterior cruciate ligament (ACL) reconstruction is a rare complication, it has a high morbidity deteriorating the clinical outcome. Current treatment options include long-term antibiotic therapy, open or arthroscopic surgical lavage, aspiration, continuous irrigation, graft preservation, and removal of graft and fixation materials with or without reimplantation. The aim of our study was to evaluate the results of long-term antibiotic treatment with arthroscopic debridement without graft and fixation materials removal in the treatment of septic arthritis following ACL reconstructions. METHODS: Seven patients (6 male, 1 female; mean age: 29 years; range: 21 to 40 years) who had septic arthritis following ACL reconstruction at Uludag; University, Department of Orthopaedics and Traumatology were included in this study. Three of the patients were athletes, 1 was a heavyduty worker, 3 were light-medium-duty workers and 1 was an amateur sportsman. Long-term antibiotic therapy was used for 6 weeks. Rehabilitation was arranged according to the patients effusion, pain and general condition. Evaluations were made using clinical results, manual Lachman and pivot shift tests, and Tegner activity, Lysholm, and IKDC scores. RESULTS: Patients had a mean of 6 (range: 0 to 15) degrees of flexion loss and 3 (range: 0 to 5) degrees of extension loss. Manual Lachman test was near normal for all patients. Pivot shift was positive for 3 and negative for 4 patients. Preoperative and postoperative mean Tegner activity scores were 6 (range: 4 to 7) and 5 (range: 4 to 7), respectively. Preoperative and postoperative mean Lysholm scores were 73.2 (range: 67 to 79) and 74.1 (range: 79 to 89), respectively. Preoperative and postoperative mean IKDC scores were 78.0 (range: 70 to 100) and 80.0 (range: 70 to 100), respectively. Mean leg circumference across the quadriceps muscle was 91% (range: 88 to 93) of the contralateral leg. Single-leg longitudinal jumping length was 78% (range: 63 to 100) of the uninvolved leg. Single-leg horizontal jumping was 72% (range: 88 to 93) of the contralateral leg. CONCLUSION: Long-term antibiotic therapy and arthroscopic drainage without graft or fixation material removal is effective in patients of regular activity level. Although this procedure is equally successful for treating the infection in competitive athletes and heavy workers, it also results in slight performance loss. Further review is necessary to determine which treatment is suitable for which activity level.

[Evaluation of intra-articular collagenase, TIMP-1, and TNF-alpha levels before and after anterior cruciate ligament reconstruction].

OBJECTIVES: We investigated intra-articular levels of collagenase, which presumably promotes bone-tendon healing, and collagenase mediators involved in its production (tumor necrosis factor-alpha, TNF-alpha) and inhibition (TIMP-1 enzyme) in patients following anterior cruciate ligament (ACL) reconstruction. METHODS: The study included 16 patients (15 males, 1 female; mean age 27 years; range 17 to 40 years) who underwent arthrocentesis due to effusion that developed following reconstruction of isolated ACL injuries. Intra-articular levels of collagenase, TNF-alpha, and TIMP-1 were measured using appropriate activity assay and immunoassay kits in synovial fluid samples obtained intraoperatively and during arthrocentesis. The mean time from ACL injury to surgical repair was 21+/-10 months (range 1 to 72 months). Arthrocentesis was performed in a mean of 18 hours (range 12 to 36 hours) following ACL repair. RESULTS: Measurements in synovial fluid samples obtained intra- and postoperatively yielded 1.49+/-0.06 ng/ml and 1.45+/-0.05 ng/ml for collagenase, 12+/-5 ng/ml and 22+/-9.5 ng/ml for TIMP-1, and 10.4+/-7.1 pr/ml and 14.11+/-6.1 pr/ml for TNF-alpha, respectively. Postoperative changes in the levels of collagenase (p=0.098) and TNF-alpha (p=0.069) were not significant, whereas increase in the TIMP-1 level was significant (p=0.026). CONCLUSION: This study showed elevated levels of TNF-alpha, collagenase, and TIMP-1 due to the presence of ruptured ACL. Our findings showed how these levels changed in the acute postoperative period.

Symptomatic infrapatellar plica.

To assess the clinical outcomes of a group of patients who underwent arthroscopic infrapatellar plica (IPP) excision and to determine, whether the IPP was symptomatic or not, to identify the symptoms or signs in the patient's clinical presentation and to study the correlations between arthroscopic findings and patient's clinical presentation. A retrospective clinical study. We studied all the patients undergoing arthroscopic resection of symptomatic infrapatellar plica without other intraarticular abnormality at our department from February 1996 to April 2001. Fourteen patients with isolated IPP and with regular follow-up intervals were included in the study. Arthroscopy findings, preoperative magnetic resonance imaging (MRI) findings, and clinical presentation were correlated. The mean duration of follow-up was 36 months with a range of 24-60 months. The IPP was found to be in fenestra pattern in seven patients, separate (cordlike) pattern in five patients and vertical septum pattern in two patients. IPP in all patients was excised with a powered instrument. Two patients were rated as excellent, ten patients as good and two patients as poor results. All the patients were documented with pain, popping or snapping with flexion and extension, giving way and swelling. There was no correlation between IPP type and MRI findings with being symptomatic (P>0.05). It was found that IPP type was not a prognostic factor. Infrapatellar plica should be considered as a potential cause of knee pain with probable MRI imaging and no other evidence of internal derangement. We recommend close correlation with the clinical symptoms and exclusion of other internal derangement before suggesting infrapatellar plica as a sole cause for knee symptoms.

Enhancement of tendon-bone healing of anterior cruciate ligament grafts by blockage of matrix metalloproteinases.

BACKGROUND: The use of soft-tissue grafts for anterior cruciate ligament reconstruction delays the healing process. This delay may be due to biochemical and/or biomechanical insults. We hypothesized that the blocking effect of alpha2-macroglobulin on synovial matrix metalloproteinase activity may enhance the healing of tendon graft in a bone tunnel. METHODS: The study was performed on twenty-eight healthy, skeletally mature New Zealand White rabbits. Each rabbit underwent bilateral anterior cruciate ligament reconstruction with use of the ipsilateral semitendinosus tendon. Alpha-2-macroglobulin (alpha2-macroglobulin) was injected into the knee joint in one limb, and the contralateral limb served as a control. The rabbits were killed two weeks (fourteen rabbits) or five weeks (fourteen rabbits) after the operative procedures. The presence of matrix metalloproteinases in synovial fluid, and the blocking effect of alpha2-macroglobulin on them, were determined with enzymatic assays. Healing between the tendon and the bone tunnel was assessed morphologically by determining the presence of fibrovascular tissue and collagen fibers. Healing also was assessed quantitatively by measuring the ultimate load to failure of the reconstructed complex. RESULTS: There was an increase in matrix metalloproteinases in the control group; in contrast, there was a decrease in the study group (p < 0.05). In the control specimens, the fibrovascular tissue at the bone-tendon interface had developed into dense connective tissue with poor vascularization. In the treated specimens, the bone tunnel had more areas of denser connective-tissue ingrowth. The interface tissue was more mature and contained numerous perpendicular collagen bundles (Sharpey fibers). The ultimate load to failure was significantly greater in the alpha2-macroglobulin-treated specimens than in the untreated controls at both two and five weeks. CONCLUSIONS: The present study demonstrated that alpha2-macroglobulin blockade of matrix metalloproteinases can enhance bone-tendon healing. This effect of alpha2-macroglobulin could occur through its effect solely on collagenase or on a subset of matrix metalloproteinases that are present at the healing interface.

The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation.

Osgood-Schlatter disease (OSD) is a well-described clinical condition, although its origin remains controversial. Mechanical, growth or traumatic factors are suggested as causes of this lesion. Thirty-five patients were included in this study. Twenty of them had OSD (study group) and the remaining 15 adolescents constituted the control group. Magnetic resonance imaging of the knees was performed in all patients. The distance between the distal pole of the patella and the proximal margin of patellar tendon attachment to the tibial apophysis (A), the distance between the distal pole of the patella and the tibial tubercle epiphysis (B), the distance between the proximal margin of the patellar tendon attachment to the tibia and the tibial tubercle epiphysis (C) and the distance between the knee joint level and the tibial tubercle epiphysis (D) were measured. The ratio of the distance between the distal pole of the patella and the proximal margin of the patellar tendon attachment to the tibia to the distance between the distal pole of the patella and the tibial tubercle epiphysis (A : B) was lower in the study group. The ratio of the distance between the proximal margin of the patellar tendon attachment point to the tibia and the tibial tubercle epiphysis to the distance between the knee joint level and the tibial tubercle epiphysis (C : D) was higher in the control group. We conclude that if the patellar tendon attaches more proximally and in a broader area to the tibia, this might probably cause OSD.

Knee dislocations: an evaluation of surgical and conservative treatment.

BACKGROUND: We evaluated the results of surgical or non-operative treatment of knee dislocations and the effect of associated soft tissue injuries on the planning of treatment. METHODS: The study included 12 patients (10 males, 2 females; mean age 34 years; range 17 to 75 years). Knee dislocations were caused by low-energy injuries in five patients, and by high-energy injuries in seven patients. All the knees were dislocated posteriorly. Three dislocations were open. Three patients had popliteal artery injuries and three patients had peroneal nerve injuries. Dislocations affecting the anterior and/or posterior cruciate ligaments were treated surgically (n=6), whereas the medial collateral ligament and lateral ligament injuries were treated non-operatively (n=6). The Lysholm scores and the range of motion of the knees were compared between surgically and conservatively treated groups. The mean follow-up period was 46 months (range 26 to 82 months). RESULTS: The mean range of motion of the knees (116 degrees versus 72 degrees ; p<0.01) and the mean Lysholm scores (84.6 versus 74; p<0.01) differed significantly between patients undergoing surgical and non-operative treatment. Chronic laxity occurred in two knees (one with surgical, one with conservative treatment). Arthrofibrosis developed in four patients (one with surgical, three with conservative treatment). There were no deep infections. Superficial infections occurred in two open dislocations. CONCLUSION: Knee dislocations should be regarded as significant limb-threatening injuries. Evaluation and immediate treatment of vascular insufficiency is of primary importance. Then, treatment depending on the presence and severity of ligamentous injuries is essential to provide a stable and functional extremity.

[Necrotizing fasciitis in the lower extremity secondary to diabetic wounds]. / Bacakta diyabetik yaralara bagli nekrozitan fasiit.

OBJECTIVES: The aim of this retrospective study was to evaluate patients who developed necrotizing fasciitis (NF) in the lower extremity secondary to diabetic wounds. METHODS: The study included sixteen patients (11 men, 5 women; mean age 63 years; range 50 to 82 years) who were treated for NF arising from diabetic wounds. Associated diseases were coronary heart disease in three patients, and chronic renal failure due to diabetic nephropathy in three patients. The patients were evaluated by physical examination, direct radiographs, blood pressure measurements, and cultures, and with respect to treatment methods and results. The mean hospitalization period was 26 days (range 5 to 59 days). RESULTS: Necrotizing fasciitis was confined to the leg in four patients, extended to the thigh in 10 patients, and was bilateral in two patients. Pain was encountered in 10 patients (68.8%). Fourteen patients (87.5%) had increased creatine kinase levels. Direct radiographs showed gas appearance in soft tissues in seven patients (43.8%). Cultures showed a single microorganism in four patients (25%), and multiple microorganisms in five patients (31.3%). Of seventeen microorganisms isolated, 10 (58.8%) were Enterobacter species. Eleven patients (68.8%) underwent above-the-knee, and three patients (18.8%) underwent below-the-knee amputations. Disarticulation of the hip was performed in four patients. The mean number of debridements was five (range 2 to 21) following the initial surgical intervention. Nine patients developed septic shock. Seven patients (43.8%) died due to multiple organ failure. Increased creatine kinase levels were significantly associated with mortality (p<0.05). CONCLUSION: Early and accurate diagnosis and prompt surgical treatment may be life-saving in diabetic patients with NF of the lower extremity.

The effect of alpha-2 macroglobulin on the healing of ruptured anterior cruciate ligament in rabbits.

To investigate the effect of modification of biological environmental conditions, one of the factors influencing the healing of anterior cruciate ligament rupture, we performed experimental anterior cruciate ligament ruptures on New Zealand rabbits. After experimental rupture, intra-articular alpha-2 macroglobulin was injected into the knees of the rabbits in the experiment group to prevent structural changes resulting from the enzymatic reactions in the ruptured anterior cruciate ligament. At the end of 10th day of the experiment, we observed that the anterior cruciate ligaments in the experiment group had retained their prerupture brightness and volume when compared with the control group in which intraarticular alpha-2 macroglobulin had not been injected. We also noted that the anterior cruciate ligaments in the experiment group had not retracted or swollen, the incision sites were regular and clean, and they did not show any signs of degeneration. In the histological examination, the anterior cruciate ligaments in the control groups showed disruption of the collagen network and a significant diminution in number of fibroblasts and fibrocytes (p <.001). At the end of this study, we concluded that the necessary conditions for the healing and repair of ruptured anterior cruciate ligament could exist if the enzymatic and biological environments were under control.

Cardiac arrest after interscalene brachial plexus block in the sitting position for shoulder arthroscopy: a case report.

The authors report a case of cardiac arrest following interscalene brachial plexus block in the sitting position for shoulder arthroscopy. The cardiac arrest occurred 45 minutes after interscalene brachial plexus block. It seems that it resulted from the activation of Bezold-Jarisch's reflex and a related vasovagal syncope.

[An evaluation of knee ligament injuries encountered in skiers at the Uludag Ski Center]. / Uludag Kayak Merkezi'nde kayakçilarda görülen diz bag yaralanmalarinin degerlendirilmesi.

OBJECTIVES: We evaluated the frequency, anatomic types, and predisposing factors of knee ligament injuries that occur in skiers during a winter season at the Uludag Ski Center, Bursa, Turkey. METHODS: A total of 215 patients (240 knees) presented to the Uludag University-Sabanci Health Center after sustaining a skier knee injury during the 2003-2004 winter season. The mean patient age was 31 years (range 9 to 55 years). Knee ligament injuries were assessed according to the AOSSM (American Orthopaedic Society for Sports Medicine) criteria. Cumulative data were collected from patient records and from a questionnaire administered to 100 healthy skiers. RESULTS: The mean knee injury rate was 1.14 injuries per 1000 skier-days. The mean length of time between the occurrence of knee injuries was 875 skier-days. The most frequently injured ligament was the interior cruciate ligament (35.4%) followed by the anterior cruciate ligament (27.1%). Knee ligament injuries were significantly more common in skiers than in snowboarders (odds ratio 6.83, p<0.001). Hard and steep pists were associated with a two-fold risk for knee ligament injuries (odds ratio 2.28, p<0.001). For the occurrence of knee injuries, no significant differences were found with respect to sex and age. CONCLUSION: The interior and the anterior cruciate ligaments are the most commonly injured ligaments in skiers. Two risk factors concerning the equipment (ski) and the environment (hard pists) play a significant role in the occurrence of knee injuries.

[The "false sense of absence" of the lower extremity below the knee: is it a specific sign for anterior cruciate ligament ruptures?]. / Yalanci yokluk duyusu: ön çapraz bag kopmasina özgü bir belirti olabilir mi?

OBJECTIVES: Patients whose anterior cruciate ligament (ACL) was completely ruptured described a feeling as if they had lost their lower extremity below the knee and gave an account that they had not sensed that part of their extremity at the time of ACL rupture. Thinking that this description might denote a diagnostic sign, an investigation was made to verify this feeling in patients whose ACL rupture was confirmed by knee arthroscopy. METHODS: The described feeling was named as "false sense of absence." A total of 135 patients with knee trauma were included. Those whose injuries were complicated or who had multiorgan injuries were excluded. The patients were divided into two groups according to whether they had ACL rupture (95 patients; 89 males, 6 females; mean age 28 years; range 15 to 50 years) or other knee injuries (40 patients; 34 males, 6 females; mean age 35 years; range 13 to 60 years). The above-mentioned symptom was questioned in both groups. RESULTS: The described symptom was found in 87% of patients with ACL rupture and in none of the patients with other knee pathologies (p<0.001). The specificity, sensitivity, positive and negative predictive values of this symptom in ACL ruptures were found as 100%, 98%, 100%, and 95%, respectively. CONCLUSION: The "false sense of absence" symptom, which has hitherto been undescribed in the literature, seems to occur in the majority of patients with ACL ruptures; it may be a specific and sensitive finding in determining ACL ruptures, and thus, may merit inclusion in the process of history taking.