How Many Bundles Does the Anterior Cruciate Ligament Consist of? A Case Report.

In some cases with anterior cruciate ligament (ACL) injury, physical examination and magnetic resolution imaging cannot clearly identify whether the ACL is intact or partially or completely ruptured. A 40-year-old female patient was admitted to our clinic with complaints of knee pain. After the requested examinations, we could not clearly identify whether the ACL was intact or partially or completely ruptured. Arthroscopic knee surgery was planned for the patient. In diagnostic arthroscopy, it was also determined that there was a multibundle ACL that was not surrounded by the synovium and was tight in the figure 4 position. The surgery was completed by repairing the meniscal tear. It was seen in the current case report that the ACL was a multibundle structure without overlying synovium around. In such cases, it is difficult to evaluate the ACL, and it should be kept in mind that there may also be variations of the ACL.

Bilateral Anterior Glenohumeral Dislocation Following Grand Mal Epileptic Seizure: A Case Report.

Bilateral simultaneous shoulder dislocations are very rare injuries. Majority of the cases in the literature are posterior shoulder dislocations due to widespread contractions seen in grand-map epileptic seizures, electrocutions, and electric shocks. The literature shows us that bilateral anterior shoulder dislocations are generally seen after trauma related injuries rather than subsequent to epileptic seizures. A 39-year-old male presented to the emergency department our clinic with bilateral anterior glenohumeral dislocation following grand mal epileptic seizure. The patient was treated conservatively with close reduction, Velpeau bandage, PT&R, and neurology consultation. Due to the bilateral displacement of patients shoulders and his age treatment was planned conservatively.

Prediction of clinical outcomes of single- and double- bundle anterior cruciate ligament reconstruction techniques using magnetic resonance imaging.

BACKGROUND: The objective of the study is to compare the clinical results of the single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) repairing techniques using magnetic resonance imaging (MRI). METHODS: Thirty-eight patients were randomized by block randomization into two different groups of ACL reconstruction: DB (n=19) and SB techniques (n=19). MRI evaluation and clinical examination with modified Cincinnati Knee Rating Score and Lysholm knee scores were performed pre-operatively and at the end of a follow-up period of 36 months. RESULTS: No significant differences were found in the ACL angle, posterior cruciate ligament angle, and tibial translation between the DB and the SB groups. Regarding the clinical scores, there were no significant differences between the techniques. As for the correlation of radiologic results with clinical scores in the SB group, there was a strong and significant correlation between the post-operative ACL angle values and the Lysholm clinical score (r=-0.66; p=0.002). CONCLUSION: The post-operative ACL angle can predict the degree of clinical recovery in patients undergoing SB ACL reconstruction.

Measurement of iliotibial band diameter in iliotibial band friction syndrome and comparison with an asymptomatic population.

BACKGROUND: Iliotibial band friction syndrome (ITBFS) is an overuse injury of the lateral aspect of the knee. This syndrome classically affects the active young population. PURPOSE: To determine the diameter of the ITB using magnetic resonance imaging (MRI) in patients clinically diagnosed with ITBFS, compare the results with asymptomatic patients, and assess the inter-observer agreement between a senior and a junior radiologist with different levels of experience in musculoskeletal imaging. MATERIAL AND METHODS: From April 2014 to October 2019, 78 knee MRI scans of 78 patients were included in the study group who were referred from the orthopedic clinic with a clinical diagnosis of ITBFS. In the control group, there were 114 knee MRI scans of 114 patients who had knee MRI for various reasons and had no radiological abnormality on the performed knee MRI. The ITB diameters, cut-off values, and interclass correlation coefficient (ICC) were calculated. RESULTS: Mean thickness of the ITB was higher in the study group compared to the control group in measurements done by both the senior and junior radiologists and this was statistically significant (P < 0.001). Cut-off values of the diameters of the ITB were calculated as 2.385 for the senior radiologist and 2.420 for the junior radiologist. ICC of 0.80 was determined, which showed excellent agreement among interpreters. CONCLUSION: ITB thickness in the study group was significantly higher than in the control group. There was also excellent agreement among the two observers. Measurement of ITB thickness on axial plane knee MRI is one of the reliable criteria for ITBFS.

Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial.

No consensus has been reached about the best treatment method of plantar fasciitis and the results of the treatment methods have been inconsistent. The objective of the present study was to compare the therapeutic effects of extracorporeal shock wave therapy, platelet-rich plasma injection, local corticosteroid injection, and prolotherapy for the treatment of chronic plantar fasciitis using a randomized, controlled, prospective study. We performed a randomized controlled prospective clinical study of 4 groups. The first group received extracorporeal shock wave therapy, the second group received prolotherapy, the third group received platelet-rich plasma injection, and the fourth group received a local corticosteroid injection. The study included 158 consecutive patients with a diagnosis of chronic plantar fasciitis with a symptomatic heel spur. The clinical outcomes were assessed using the visual analog scale and Revised Foot Function Index. At the end of the follow-up period, the mean visual analog scale scores for all 4 groups were similar to the mean visual analog scale scores before treatment. At the end of the follow-up period, no significant improvement was noted in the Revised Foot Function Index score in any of the groups. The corticosteroid injection was more effective in the first 3 months and extracorporeal shock wave therapy was an effective treatment method in the first 6 months in regard to pain. The corticosteroid injection lost its effectiveness during the follow-up period. The effect of prolotherapy and platelet-rich plasma was seen within 3 to 12 months; however, at the 36-month follow-up point, no differences were found among the 4 treatments.

An Observational 1-Month Trial on the Efficacy and Safety of Promerim for Improving Knee Joint.

OBJECTIVE: This study was conducted to evaluate the efficacy and tolerability of the oral intake of promerim in the elimination of acute pain and discomfort associated with knee osteoarthritis (OA). METHODS: Single-center, 1-month, prospective, observational clinical trial. A total of 92 patients not older than 70 years were included. Patients were offered to use 720-mg promerim for the first 15 days after admission after breakfast and then 360 mg for the second 15 days. All patients were analyzed with the visual analog scale (VAS) for pain, which ranges from 0 to 10, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score before the start of treatment and 1 month after the start. Statistical analysis was performed by SPSS 15.0 software. An α level of P < .05 was assumed to be statistically significant. RESULTS: This study comprised 92 patients (69 women and 23 men) with a mean age of 51.5 (range: 40-69) years. Before treatment, the mean VAS score was 5.6 ± 1.1, and after treatment, the mean VAS score was 2.6 ± 1.7. Treatment with promerim consistently showed a significant decrease in the VAS score (P < .001). The mean WOMAC score of the patients was 46.4 ± 8.2 before treatment. After treatment, the mean WOMAC score was 72.1 ± 14.4. Treatment with promerim consistently showed a significant increase in the WOMAC score (P < .001). CONCLUSIONS: The results of this single-center, open-label clinical study demonstrate that promerim is a viable natural treatment option for treating knee OA. We recommend that 720-mg promerim taken once daily for the first 15 days after admission and 360 mg taken once daily for the next 15 days significantly and rapidly reduced composite pain and stiffness in the knee OA within 1 month.

Comparison of two different vacuum-assisted closure (VAC) treatments of multiple chronic diabetic foot wounds in the same extremity.

BACKGROUND: The aim of the present study is to compare the clinical efficacy and safety of two different vacuum-assisted closure (VAC) applications in one center between two groups of patients with Wagner Grade 3-4 multiple chronic diabetic foot wounds. METHODS: The study was a randomized-controlled, prospective investigation between two groups of patients with Wagner Grade 3-4 multiple chronic diabetic foot wounds at single extremity. There were 10 patients in the first group receiving VAC treatment by means of Y-connector and 11 patients in the second group receiving bridge-VAC treatment. RESULTS: There were no significant difference in Revised Foot Function Index scores and total treatment costs between the both groups. The cost of the VAC dressing supplies in one session of the dressings was lower in the bridge-VAC group. CONCLUSIONS: In conclusion, although bridge-VAC treatment seems to be an alternative method to the VAC treatment by means of Y-connector, we found no superiority of one over the other VAC application for chronic diabetic foot wounds.

Intra-articular lipoma of the knee joint located in the posterior compartment: A rare location.

This report presents the case of a 51-year-old woman with intermittent left knee pain, especially during full flexion of the knee, which had been ongoing for 1 year. Magnetic resonance imaging (MRI) showed mild effusion and round mass at the posterior compartment without synovial changes. Computerized tomography (CT) indicated mass had homogeneous low attenuation and density measurement of -99.4±62.3 Hounsfield units (HU), correlated with a lipomatous lesion.

Epithelioid Angiosarcoma in Femur: A Case Presentation.

Primary malignant vascular tumors which constitute less than 1% of the primary bone tumors are very rarely encountered. Epithelioid angiosarcoma is a very uncommon subtype of angiosarcomas presenting with an epithelioid phenotype and mimicking carcinomas clinically. These tumors select mostly extra-skeletal locations but rarely bones as their medium. A 31-year-old male patient applied to our clinic with a nonspecific left hip pain. X-ray evaluation revealed a cystic expansile mass in the trochanteric region of the femur extending to the femoral neck. Computed tomography examination proved that the mass was cystic and 7 cm in its greatest width and contained septum. Moreover, magnetic resonance imaging examination was reported as a mass resembling aneurysmal bone cyst. The final diagnosis of epithelioid angiosarcoma was made by histological examination and biopsy of the mass. The excised specimen was examined further to verify the preoperative diagnosis.

Nontraumatic Myositis Ossificans of Hip: A Case Presentation.

In most of the cases trauma is the leading etiology and the nontraumatic myositis ossificans (MO) is a very rare condition. We present an MO case without any trauma occurring. A 36-year-old female patient with a history of pain and restriction of range of motion of the left hip was admitted. Hip motions were restricted with 10-60° of flexion, 10° of internal rotation, 20° of external rotation, 10° of abduction, and 10° of adduction. There was no history of trauma and familial involvement. The biopsy of the lesion revealed mature bone tissue confirming our diagnosis of MO. The mass was removed surgically and postoperatively the patient was treated with a single dose radiotherapy with 800 gyc. MO is a benign and well differentiated bone formation or in other words heterotopic ossification of the muscle tissue. It has a prevalence of less than 1/1 million. Trauma is the most frequent etiological factor seen in almost 60-75% of the cases. Nontraumatic MO is very rare in the literature. Our patient had no history of trauma or familial involvement. Combination of the surgical excision with radiotherapy in the treatment of the MO of the hip may give satisfactory results.

Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: A Retrospective Cohort Study.

INTRODUCTION: Most of the ACL reconstruction is done with isometric single-bundle technique. Traditionally, surgeons were trained to use the transtibial technique (TT) for drilling the femoral tunnel. Our study compared the early postoperative period functional and clinical outcomes of patients who had ACL reconstruction with TT and patients who had ACL reconstruction with anatomical single-bundle technique (AT). MATERIAL METHOD: Fifty-five patients who had ACL reconstruction and adequate follow-up between January 2010-December 2013 were included the study. Patients were grouped by their surgery technique. 28 patients included into anatomical single-bundle ACL reconstruction surgery group (group 1) and 27 patients were included into transtibial AC reconstruction group (group 2). Average age of patients in group 1 and group 2 was 28.3 ± 6, and 27.9 ± 6.4, respectively. Lachman and Pivot-shift tests were performed to patients. Laxity was measured by KT-1000 arthrometer test with 15, 20 and 30 pound power. All patients' muscle strength between both extremities were evaluated with Cybex II (Humac) at 60°/sec, 240°/sec frequencies with flexion and extension peak torque. The maximum force values of non-operated knee and the operated knee were compared to each other. Groups were evaluated by using International Knee Documentation Committee (IKDC) knee ligament healing Standard form, IKDC activity scale, modified Lysholm and Cincinnati evaluation forms. Return to work and exercise time of patients were compared. Functional and clinical outcomes of two groups were compared. NCSS 2007 and PASS 2008 Statistical Software programs were used for statistical analysis. RESULT: There was no statistically significant difference between Lachman and Pivot-shift results (p > 0.01). Positive value of Pivot-shift test and incidence of anterior translation in Lachman test were higher in the patients who had TT. Lysholm activity level of patients who had TT, 33.3% (n = 9) were excellent, 51.9% (n = 14) were good and 14.8% (n = 4) were moderate; patients who had AT, 57.1% (n = 16) were excellent, 39.3% (n = 11) were good and 3.6% (n = 1) was good level. There was no statistically significant difference between Lysholm Activity level of the patients (p < 0.01). Lysholm Activity level of patients who had AT significantly higher than TT. There was no statistically significant difference between Modified Cincinnati activity level of the patients (p < 0.05). Modified Cincinnati activity level of patients who had AT were significantly higher than those had TT. There was no statistically significant difference between two groups with post treatment IKDC activity level (p < 0.01). Intense activity after treatment rate of patient who had AT was significantly higher than those had TT. There was statistically significant difference between Cybex extension-flexion 60 measurement and extension 240 measurement of the patients (p < 0.01). KT-1000 arthrometer test results with AT was better than the TT in antero-posterior translation of the knee kinematics at 20 and 30 pound of forces. Return to exercise time of patients who had TT was significantly higher than those had AT (p < 0.01). There was no statistically significant difference between return to work time of patients (p > 0.05). CONCLUSION: Single-bundle anatomic ACL reconstruction was better than the TT in term of clinical, functional, and laboratory results. We believe that AT ACL reconstruction will increase in use and traditional method which is TT ACL reconstruction surgery will decrease in the long term. Theoretically, anatomic relocation of the ACL can provide better knee kinematics.

Bilateral bucket handle medial meniscal tears of the knee: A case report.

INTRODUCTION: Meniscal tears may cause knee pain and functional impairment. Bilateral bucket-handle meniscal tears is an uncommon condition. PRESENTATION OF CASE: This report presents the case of a 35-year-old male patient with bilateral bucket handle medial meniscal tears that occurred nonsimultaneously. The lesions were treated arthroscopically with partial resection in one knee and meniscal suture in the other. DISCUSSION: Bucket handle meniscal tear of meniscus without underlying meniscal, ligamentous pathology or lower limb deformity is a rare condition. CONCLUSION: To our knowledge, bilateral bucket handle medial meniscal tears without underlying meniscal anomalies have been reported in only two cases before, and our case is the third one.

The role of a posteriorly positioned fibula in ankle sprain.

BACKGROUND: Specific anatomic variations of the ankle mortise may predispose people to ankle sprains. HYPOTHESIS: There is a correlation between a higher malleolar index (posteriorly positioned fibula) and incidence of ankle sprain. STUDY DESIGN: Prospective case control study. METHODS: We compared the malleolar index (transverse plane of the talus) on computerized axial tomographic images of 61 patients with ankle sprain with that of 101 normal controls. A positive number for the malleolar index meant that the lateral malleolus was posterior to the plane of the medial malleolus. A negative number meant that the lateral malleolus was actually anterior to the plane of the medial malleolus. RESULTS: The average malleolar index of the patients with ankle sprain was +11.5 degrees with a standard deviation of 7 degrees. Malleolar relationships varied from -6 degrees to +39 degrees, a range of 45 degrees. The average malleolar index in the control group was +5.85 degrees with a standard deviation of 4.9 degrees, which varied from -8 degrees to +16 degrees. However, there was no correlation between recurrence of sprains and malleolar index values. CONCLUSION: Patients with an ankle sprain were more likely to have a posteriorly positioned fibula, possibly predisposing them to ankle sprain.

The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears.

PURPOSE: The purpose of this study was to document the accuracy of joint line tenderness in the diagnosis of meniscal tears. TYPE OF STUDY: Prospective cohort study. METHODS: There were 104 male recruits (age range, 18 to 20 years; mean, 19.2 years) with suspected meniscal lesions who underwent arthroscopy. A thorough history and physical examination was performed on each patient by a physician with 4 years' experience on arthroscopic knee surgery. Twenty-six (25%) patients sustained injuries while in the Turkish Army, and 78 patients (75%) sustained injuries before they came to the army. On physical examination, assessment of joint line tenderness at the lateral and medial joint lines was performed with the patient's knee flexed 90 degrees. The accuracy, sensitivity, specificity, and positive and negative predictive values of joint line tenderness for medial and lateral sides were calculated based on arthroscopic findings. RESULTS: In 104 knees, the diagnosis was correct in 71 (68%) and incorrect in 33 (32%) knees. A total of 37 medial meniscal tears and 27 lateral meniscal tears were identified at arthroscopy. Other pathology included 11 anterior cruciate ligament (ACL) tears, 5 medial femoral chondral lesions, 4 chondromalacia patellae, and 1 medial plica. No discernable abnormalities were seen in 21 knees. A preoperative diagnosis of a medial meniscal tear was made in 54 knees and 32 were confirmed at arthroscopy. A lateral meniscus tear was suspected in 27 knees and confirmed in 25. Five medial meniscus and 2 lateral meniscus tears were seen at arthroscopy. These had not been suspected with tenderness over the joint line. The accuracy of the test was lower with the presence of ACL lesions and condromalacia patella. CONCLUSIONS: I concluded that joint line tenderness as a test for lateral meniscal tears is accurate (96%), sensitive (89%), and specific (97%). However, for medial meniscal tears, rates are lower.

[Treatment of intertrochanteric fractures of the femur with Ender nails in patients over the age of 65 years]. / Altmis bes yas üzerindeki hastalarin femur intertrokanterik kiriklarinda Ender çivisi ile osteosentez.

OBJECTIVES: We evaluated the results of treatment with Ender nails in intertrochanteric fractures of the femur in patients exceeding the age of 65 years. METHODS: Thirty-three patients (18 women, 15 men; mean age 78 years; range 65 to 98 years) were treated with Ender nails for non-pathological fractures of the intertrochanteric part of the femur. The right hips were involved in 17 patients and the left in 15 patients. One patient had bilateral involvement. Serious complicating diseases existed including cardiovascular disease (n=12), pulmonary disease (n=11), and others (n=10) such as diabetes mellitus. According to the Evans-Jensen classification, there were 14 type 1, five type 2, four type 3, four type 4, and seven type 5 fractures. The mean follow-up was 20 months (range 5 to 78 months). RESULTS: The mean length of hospital stay was 15 days (range 9 to 18 days). Mortality was encountered in 10 patients (30.3%) within the first postoperative year, two of whom (6%) died during hospitalization. Twelve patients were alive on final follow-ups, of these eight patients were ambulatory without any significant problem. Postoperatively, one patient developed electrolyte imbalance, and another had urinary infection. Due to migration problems, one of the three nails had to be removed in the early period in one patient, and all nails in five patients after the union was obtained. Union was obtained in all patients within a mean of eight weeks (range 6 to 18 weeks). CONCLUSION: Ender nailing may be appropriate in stable, non-displaced intertrochanteric fractures in the elderly, as it is associated with lower mortality in the early period.

Open reduction and plate fixation of femoral shaft fractures in children aged 4 to 10.

A retrospective review of 40 children aged 4 to 10 years with 46 femur fractures treated with open reduction and plate fixation is presented. Follow-up time was 6.3 years (range 2.5-17.5). There were no nonunions. One case of osteomyelitis and one refracture occurred. Leg-length discrepancy averaging 1.2 cm (range 0.4-1.8), with lengthening on the operated side, was observed in 15 patients. Although there is some risk for complications, and although good early results have been reported with elastic intramedullary nails, plate fixation continues to be a viable alternative in the surgical treatment of femoral shaft fractures in children aged 4 to 10.

[Plate fixation of closed femoral shaft fractures in adolescents]. / Adölesan kapali femur cisim kiriklarinin tedavisinde plak ve vida ile osteosentez.

OBJECTIVES: This study was designed to evaluate the results, advantages, and disadvantages of plate fixation of closed femoral shaft fractures in adolescents between the ages of 11 and 15 years. METHODS: The study included 35 adolescents (26 males, 9 females; mean age 13.4 years) who were treated by plate fixation for closed femoral shaft fractures and had an adequate follow-up. The fractures were bilateral in two patients, on the left in 17 patients (48%), and on the right in 16 patients (45%). Traffic accidents were the most frequent etiology (57%). Nineteen patients presented with head injuries and/or multiple fractures. The mean follow-up was 34.9 months (range 22 to 156 months). RESULTS: All fractures healed in a mean of 10 weeks (range 6 to 16 weeks). No plate break or refractures occurred. Two patients had a loss of 20 degrees in knee flexion. Atrophy of the quadriceps muscle was observed in nine patients. Evaluations with the use of scanogram, orthorontgenogram, plain radiographs, and clinical examination showed an average overgrowth of 1.2 cm (range 0.4 to 1.6 cm). CONCLUSION: Despite some disadvantages, plate fixation seems to be an alternative method in the treatment of adolescent femoral fractures, enabling an anatomical reduction and stable internal fixation.

[Results of excision of the radial head in comminuted fractures]. / Radius basi parçali kiriklarinda eksizyon ve sonuçlari.

OBJECTIVES: To evaluate the results of radial head excision in the treatment of comminuted radial head fractures. METHODS: The study included 20 patients (14 men, 6 women; mean age 34 years; range 21 to 55 years) who underwent radial head excision for comminuted, closed fractures. Sixteen patients had Mason type 3 and four patients had type 4 fractures. Surgery was performed at a mean of eight days after trauma (range 1 to 30 days). Patients were assessed with regard to whether they were able to return their former activities and work, and whether they had pain, limitation, loss of strength, and instability. The results were evaluated by the Radin and Riseborough's classification. The mean follow-up period was seven years (range 2 to 12 years). RESULTS: Sixteen patients (80%) re-gained their previous activities or work. Nine patients became asymptomatic. Five patients complained of loss of strength in the arm. Pain associated with weight bearing was observed in two patients in the wrist and elbow, respectively, and in both in two patients. Two patients had limitation of more than 30 degrees in at least one of extension, flexion, supination, or pronation. Five patients had mediolateral instability. The mean elbow flexion was 125 degrees (range 100 to 140 degrees). Proximal migration of the radius was detected in five patients (1 mm), two patients (3 mm), and in three patients (5 mm). According to the Radin and Riseboroughs classification, nine (45%), seven (35%), and four (20%) patients had good, fair, and poor results, respectively. CONCLUSION: Despite its relevance in elbow kinematics, our results seem to justify excision of the radial head in Mason type 3 comminuted radial head fractures where internal fixation presents severe difficulties.