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Purpose The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). Methods The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1–3 was considered ‘inappropriate’, 4–6 ‘uncertain’, and 7–9 ‘appropriate’). Results The criteria used to define the scenarios were: age (18–35 years vs 36–50 years vs 51–60 years), sports activity and expectation (Tegner 0–3 vs 4–6 vs 7–10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren–Lawrence [KL] grade 0–I–II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51–60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). Conclusion This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. Level of evidence II.

Background Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location. Methods Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases “suprapectoral,” “subpectoral,” “tenodesis,” and “long head of biceps tendon”. Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded. Results From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis. Discussion Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area. Level of evidence: IV.

Purpose This systematic review aimed to clarify the relative strengths and weaknesses of the all-suture anchors (ASAs) in both clinical and experimental studies. Our hypothesis was that there would be similar clinical and experimental data for ASAs regarding the biomechanical properties, clinical outcomes and complication rates. Methods A systematic review of MEDLINE and Embase databases was performed. The inclusion criteria for clinical studies were both retrospective or prospective study design and minimum 1-year follow-up; for biomechanical studies, the inclusion criteria were performance on either cadaver and animal bones or synthetic surfaces. Studies were excluded if the studies were not in English or if they were review articles, commentaries, letters, case reports, or technical notes. The risk of bias assessment was done using the Methodological Index for Non-randomized Studies (MINORS) tool. Results We included 13 experimental and 3 clinical studies. The least displacement under cyclic loading was recorded with Q-Fix. Failure mode was mostly by suture breaking for the Q-Fix, whereas anchor pullout was the most common for the others. Cadaver humerus’ greater tuberosity seemed to be less durable for the ASAs. Tests on cadaver glenoid showed similar biomechanical properties when compared to a control anchor. Studies investigating clinical and radiologic findings were very few, and only 3 case series were included in this review. Clinical findings of patients treated with ASAs for instability and rotator cuff repair showed satisfactory results and little increase in the complication rate (retear or revision surgery because of loose anchor). Conclusions ASAs have similar or better biomechanical properties compared to regular anchors. Low-profile design seems to be an important advantage. Case series can not distinguish between the possible clinical benefits and/or risks. Clinical Relevance ASAs have similar biomechanical properties when compared with other types of anchors. Their strength and performance vary with anatomic location, which may influence clinical success.

Introduction While repairing a teared rotator cuff tendon with suture anchors and horizontal mattress suture configurations, knots should be secure at time zero while approximating the tendon to the bone, otherwise any failure in loop security may cause undesired clinical results. Optimum distance between suture limbs passed through the tendon, in other words the bite size, is still not clear in the literature. The aim of this study was to test the effect of loop size, which is directly related to the bite size, on loop security and elongation of a knot. Hypothesis We hypothesized that a knot with a smaller loop size would be more secure. We asked if a knot with shorter circumference (1) would offer a better knot security; (2) would produce less elongation following repeated traction cycles. Material and methods Two parallel metal rods in 3.0 mm diameter were fixed to load cells of dynamic testing machine. Four groups, from A to D, had the initial rod to rod distances of 2-4-6-8 mm respectively (n = 10). Surgeon's knots were prepared with 2/0 Ultrabraid® sutures around the rods. A tension meter was used for tying each half hitch under equal tension. Crosshead distances were recorded after 7 N pre-load and subsequent 1000 repetitive cyclic loads between 7-30 N. Results Elongations after a 7 N preload for groups A to D were 0.107 mm (± 0.006), 0.143 mm (± 0.018), 0,16 mm (± 0.025), 0.185 mm (± 0.018) respectively. This increase was significant (p 0.95) between each group except between groups B and C. Maximum elongations after 1000th cycle for groups A to D were 0.32 mm (± 0.124), 1.12 mm (± 0.333), 1.162 mm (± 0.211), 1.292 mm (± 0.241) respectively. Only samples in group A (0.732 mm ± 0.124) elongated significantly less than others (p 0.95). No knots unravelled or ruptured. Discussion This study basically reports that a knot with a shorter loop circumference has superior properties regarding loop security and resistance to elongation. From the perspective of clinical importance, shorter distance between suture limbs of mattress configuration may provide a more secure fixation of the rotator cuff tendon to the bone. Level of evidence II.

Introduction: Many factors can affect the return to pivoting sports, after an Anterior Cruciate Ligament Reconstruction. Prehabilitation, rehabilitation, surgical and psychological aspects play an essential role in the decision to return to sports. The purpose of this study is to reach an international consensus about the best conditions for returning to sports in soccer-one of the most demanding level I pivoting sports after anterior cruciate ligament (ACL) reconstruction. Methods: 34 International experts in the management of ACL injuries, representing all the Continents were convened and participated in a process based on the Delphi method to achieve a consensus. 37 statements related to ACL reconstruction were reviewed by the experts in three rounds of surveys in complete anonymity. The statements were prepared by the working group based on previous literature or systematic reviews. Rating agreement through a Likert Scale: strongly agree, agree, neither agree or disagree, disagree and strongly disagree was used. To define consensus, it was established that the assertions should achieve a 75% of agreement or disagreement. Results: Of the 37 statements, 10 achieved unanimous consensus, 18 non-unanimous consensus and 9 did not achieve consensus. In the preoperative, the correction of the range of motion deficit, the previous high level of participation in sports and a better knowledge of the injury by the patient and compliance to participate in Rehabilitation were the statements that reached unanimous consensus. During the surgery, the treatment of associated injuries, as well as the use of autografts, and the addition of a lateral extra-articular tenodesis in some particular cases (active young athletes

This study aims to examine the seasonal changes in the physical performance of female volleyball players competing in the regional division. Forty-three volunteer female players (age: 22 ± 2.1 years, height: 172.9 ± 4 cm, weight: 61.5 ± 6 kg, experience: 8.8 years) competing in the same group of the regional division of the Turkish volleyball league participated in this study. Players participated in a series of test protocols including the 20m shuttle-run, T-run, 20m sprint, vertical jump, and running anaerobic sprint (RAST) in the beginning, mid, and ending of the 16-week competition season. The results showed that all tested physical performance characteristics of the players improved significantly in both the first and second periods of the competition season. However, the improvements in the first period were significantly higher than in the second period for VO2max (4.7 vs 1.5%, p Este estudio tiene como objetivo examinar los cambios estacionales en el rendimiento físico de las jugadoras de voleibol que compiten en la división regional. En este estudio participaron 43 jugadoras voluntarias (edad: 22 ± 2,1 años, altura: 172,9 ± 4 cm, peso: 61,5 ± 6 kg, experiencia: 8,8 ± 1,8 años) que competían en el mismo grupo de la división regional de la liga turca de voleibol. Las jugadoras participaron en una serie de pruebas que incluían el test de ida y vuelta de 20 metros, T-test de agilidad, sprint de 20 m, salto vertical y carrera de sprint anaeróbico (RAST) al principio, a la mitad y al final de la temporada de competición de 16 semanas. Los resultados mostraron que todas las características de rendimiento físico evaluadas de las jugadoras mejoraron significativamente tanto en el primer como en el segundo período de la temporada de competición. Sin embargo, las mejoras en el primer período fueron significativamente más altas que en el segundo período para el VO2máx (4,7 vs 1,5%, p

Pubmed'de indekslenmektedir Introduction: Many factors could affect the supraspinatus (SSP) muscle after tendon rupture. We aimed to determine how infraspinatus and subscapularis tendon problems affect supraspinatus muscle atrophy associated with tears, in a retrospective cohort study conducted in a tertiary-level centre. Materials and Methods: Fifty-eight patients with a full-thickness SSP tendon tear who fulfilled the inclusion criteria were enrolled in the study. They were evaluated for tear retraction, fatty degeneration, and other rotator cuff tendon pathologies. Supraspinatus muscle was assessed using the Goutallier classification, and its average area was also measured. Accompanying lesions of the subscapularis and infraspinatus tendons and degree of supraspinatus muscle atrophy were evaluated using magnetic resonance imaging. Results: Our results showed that supraspinatus tendon tears ranged between 3mm and 41mm, and the estimated average cross-sectional area of the SSP muscle was 247.6mm(2). Any degree of infraspinatus tendon pathology, ranging from tendinosis to full-thickness tears, was significantly correlated with the SSP muscle area (P < 0.05). The subscapularis tendon pathologies did not show a similar correlation. The interobserver and intraobserver reliabilities of the measurements were graded as excellent. Conclusion: Impairment of any of the rotator cuff muscles may affect the other muscles inversely. Our study showed that all infraspinatus tendon pathologies and partial subscapularis tears affect and alter the SSP muscle belly. We suggest early intervention for supraspinatus tears to avoid further fatty degeneration, as muscle atrophy and fatty degeneration progress in combination with the accompanying lesions.

The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT).Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up.Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P .05).CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

Recently, there has been increasing attention to research related to the effect of skill-based or game-based training on soccer players' physical performance. Therefore, this study aimed to compare the effectiveness of skill-based training (SBT) at maximum intensity versus the small-sided game (SSG) on the physical performance characteristics of young soccer players during the pre-season period. Twenty-two male soccer players (mean age 15.3 +/- 3 years) were randomly assigned to either an SBT or SSG fully controlled intervention programme, running parallel for eight weeks and held twice a week. On three non-consecutive days before and after training players completed a test battery consisting of the 20 m sprint, T-run, countermovement jump, running anaerobic sprint test (BAST) and 20 m shuttle run. Data were analysed with a two-way ANOVA test for repeated measures. SBT and SSG interventions induced a significant improvement in the anaerobic power (10.9% vs 6.2%), explosive power (8.5% vs 5.6%), VO2max (6.7% vs 6.5%) and vertical jump (5.3% vs 2.9%), respectively. When the improvements in the physical performance variables of both groups are compared, the SBT group achieved greater improvement than the SSG group in anaerobic power (by 4.7%), in explosive power (by 2.8%), in vertical jumping (by 2.3%), in the 20 m sprint (by 2.2%) and T-test scores (by 1.7%). However, improvements in the VO2max were similar in both groups. The results of the present study suggest that SBT at maximum intensity may be more effective than SSG in improving the physical performance characteristics of young soccer players in the pre-competitive season.

The aim of our study was to evaluate the risk of medial glenoid perforation and possible injury to suprascapular nerve during arthroscopic SLAP repair using lateral transmuscular portal. Ten cadaveric shoulder girdles were isolated and drilled at superior glenoid rim from both anterior–superior portal (1 o’clock) and lateral transmuscular portal (12 o’clock) for SLAP repairs. Drill hole depth was determined by the manufacturer’s drill stop (20 mm), and any subsequent drill perforations through the medial bony surface of the glenoid were directly confirmed by dissection. The bone tunnel depth and subsequent distance to the suprascapular nerve, scapular height and width, were compared for investigated locations. Four perforations out of ten (40 %) occurred through anterior–superior portal with one associated nerve injury. One perforation out of ten (10 %) occurred through lateral transmuscular portal without any nerve injury. The mean depth was calculated as 17.6 mm (SD 3) for anterior–superior portal and 26.5 mm (SD 3.6) for lateral transmuscular portal (P

Introduction While repairing a teared rotator cuff tendon with suture anchors and horizontal mattress suture configurations, knots should be secure at time zero while approximating the tendon to the bone, otherwise any failure in loop security may cause undesired clinical results. Optimum distance between suture limbs passed through the tendon, in other words the bite size, is still not clear in the literature. The aim of this study was to test the effect of loop size, which is directly related to the bite size, on loop security and elongation of a knot. Hypothesis We hypothesized that a knot with a smaller loop size would be more secure. We asked if a knot with shorter circumference (1) would offer a better knot security, (2) would produce less elongation following repeated traction cycles. Material and methods Two parallel metal rods in 3.0 mm diameter were fixed to load cells of dynamic testing machine. Four groups, from A to D, had the initial rod to rod distances of 2–4–6–8 mm respectively (n = 10). Surgeon's knots were prepared with 2/0 Ultrabraid® sutures around the rods. A tension meter was used for tying each half hitch under equal tension. Crosshead distances were recorded after 7 N pre-load and subsequent 1000 repetitive cyclic loads between 7-30N. Results Elongations after a 7N preload for groups A to D were 0.107 mm (±0.006), 0.143 mm (±0.018), 0,16 mm (±0.025), 0.185 mm (±0.018) respectively. This increase was significant (p 0.95) between each group except between groups B and C. Maximum elongations after 1000th cycle for groups A to D were 0.32 mm (± 0.124), 1.12 mm (±0.333), 1.162 mm (±0.211), 1.292 mm (±0.241) respectively. Only samples in group A (0.732 mm ± 0.124) elongated significantly less than others (p 0.95). No knots unravelled or ruptured. Discussion This study basically reports that a knot with a shorter loop circumference has superior properties regarding loop security and resistance to elongation. From the perspective of clinical importance, shorter distance between suture limbs of mattress configuration may provide a more secure fixation of the rotator cuff tendon to the bone. Level of evidence II.

Augmentation of anterior cruciate ligament reconstruction with platelet-rich plasma and a gelatin sponge improves tendon to bone healing in a small animal model. A sponge may prolong platelet-rich plasma bioactivity time.

The purpose of this study was to evaluate safe depth for suture anchor insertion during acetabular labral repair and to determine the neighbouring structures at risk during drilling and anchor insertion. Ten human cadaveric hips (six males and four females) were obtained. Acetabular labral surface was prepared and marked for right hips as 12, 1 and 3 o’clock positions, for left hips 12, 11 and 9 o’clock positions. Those were defined as anterior, anterior–superior and superior zones, respectively. These labral positions were drilled at defined zones. After measurements, depth of the bone at 10° and 20° drill angles on zones was compared statistically. Acetabular bone widths at investigated labral insertion points did not statistically differ. A total of 14 injuries in 60 penetrations occurred (23.3 %) with free drill penetrations, and no injuries occurred with stopped drill penetrations. The bone depth was gradually decreasing from 10° to 20° drill angles and from anterior to superior inserting zones without significant importance. The risk of perforation to the pelvic cavity started with 20 mm drill depth, and the mean depth for all insertions was calculated as 31.7 mm (SD 2.6). It is anatomically possible that some pelvic structures sustain iatrogenic injury during acetabular drilling for anchor placement. Being aware of mean pelvic vault is important in which drilling after excessive pincer rim trimming could easily decrease the depth of acetabular bone without a standard. Careful drilling by using stopped drill bit is crucial to prevent iatrogenic injury.

Pain management is crucial for a successful result after various knee surgeries. Opioids may be included in the postoperative pain management protocol but may be abused if not controlled. Following knee arthroscopy and related surgery, adolescent and young adult patients are commonly overprescribed opioids. The driving force behind opioid prescription should be explored in addition to reviewing and emphasizing perioperative interventions that can reduce postoperative opioid consumption, including wound injections and peripheral nerve blocks.

The purpose of this study is to determine the immediate effects of pH change on the metabolism of bovine chondrocytes. Bovine osteochondral explants were pre-cultured and placed in Ringer’s lactate solution. Thirty explants were randomly divided into 3 groups. Buffered Ringer’s lactate, pH 7.2, was used in Group I; buffered Ringer’s lactate, pH 7.4 (normal bovine knee joint pH), was used in Group II; and this group was also set as the control group. Buffered Ringer’s lactate, pH 7.6, was used in Group III. All specimens were soaked for 2 h. RNA yield analyses were performed to evaluate the changes in cartilage metabolism at different pH levels. Mean RNA yields of (hypoxia-induced factor) 1α that were immersed at pH 7.2 and 7.6 were 10.5- and 9.9-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 15.2-fold. Mean RNA yields of aggrecan that were immersed at pH 7.2 and 7.6 were 12.2- and 13.6-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 20-fold. RNA yields of collagen type II at pH 7.2 and 7.6 were 16.1- and 16.6-fold from base, respectively, which were lower compared to explants immersed at pH 7.4 which was found as 22.1-fold. The findings of the presented study suggest that short-term exposures to both acidic and basic pH may have effects on chondrocyte function. Our findings also indicate that exposures to solutions with a pH different from normal by only 0.2 unit could suppress chondrocyte metabolism and RNA synthesis. Using buffered irrigation solutions with a pH closer to the normal joint pH could be more physiologic and causes less ultra-structural damage than regular irrigation solutions. II.

Purpose: The purpose of this study was to determine the effects of saline solution at different temperatures on the metabolism of chondrocytes. Methods: Porcine osteochondral explants were precultured under laboratory conditions. The cartilage explants were placed in saline solution. Twenty-four explants were randomly divided into 4 groups. Explants were immersed at 4°C group I, at room temperature (24°C) in group II, at normal knee temperature (32°C) in group III, and at near-core body temperature (37°C) in group IV. All specimens were immersed for 2 hours. Lactate and proteoglycan production and RNA yield analysis were performed to evaluate the changes in cartilage metabolism at different temperatures. Results: Explants immersed in cold (4°C) saline solution showed the significantly lowest RNA yields, lactate production, and proteoglycan content. Explants immersed in cold solutions (4°C and 24°C) showed significantly lower RNA yields, lower lactate production, and lower proteoglycan content than explants in warmer solution groups (32°C and 37°C). Conclusion: The findings of this study suggest that short-term exposures to cold including room temperature may have markedly detrimental effects on chondrocyte function. Our findings also indicate that exposures to cold saline solution suppress chondrocyte metabolism and RNA synthesis. Clinical Relevance: Using warmer irrigation solution that is closer to body temperature is more physiologic and causes less ultrastructural damage than colder solution.

The purpose of this study was to investigate the effect of Mitomycin C on reduction in intra-articular fibrotic adhesion formation after knee surgery. Twenty female Wistar Albino rats were divided into two equal study groups. After skin incision, the right knees of animals were opened through a medial parapatellar approach, and the medial and lateral sides of the femoral condyle were exposed. A partial capsulotomy and synovectomy were performed. In group I, Mitomycin C was applied in the articular cavity of rats after hemostasis. An identical volume of sterile normal saline was applied in group II, which served as controls. All rats received weekly (6 weeks) intra-articular both Mitomycin C and saline starting from the day of operation. Animals were killed at 45 days after surgery. The presence and severity of osteo-capsular adhesion was assessed with both macroscopic and microscopic adhesion scoring systems. Results of macroscopic observations showed a significant reduction in both incidence and severity of adhesions in group I compared to group II. Histologically, adhesions in group I were thinner with less collagenic fibers. Microscopic determination of adhesion formation was less in group I, and the difference between groups was statistically significant. Our results suggest that post-operative administration of Mitomycin C may be considered a promising preventive therapy for the reduction in fibro-adhesive scars and consequent stiffness after knee surgery.

The aim of this study was to assess the proprioception of the partial meniscectomized knee and to assess if there is an effect on the knee proprioception.We performed a case-control study involving patients with meniscus tear at the posterior horn of medial meniscus. Group 1 composed of 19 patients, with an average age of 26.3 years, who were enrolled after sustaining an injury to the medial meniscus. Twenty healthy individuals, with an average age of 25.1, without history of knee injury, constituted Group 2. In order to document the proprioceptive capabilities of the knee, angle reproduction tests were performed.At a mean of 2 years after the surgery, there was no difference between the meniscectomized and healthy knee regarding the angle deviations in the lower flexion angles (15 degrees , 30 degrees , 45 degrees ). However, mean knee joint position sense (KJPS) at 60 degrees reproduction in Group 1 and 2 was 64.3 (SD 5.3) and 69.2 (SD 4.9), respectively. Concomitantly, mean KJPS at 75 degrees reproduction in Group 1 and 2 were 80.1 (SD 6.59) and 74.4 (SD 5.6), respectively. Paired t test showed a statistically significant difference between Group 1 and 2 when compared to control angle deviations at 60 degrees and 75 degrees reproductions (P0.05).KJPS of the patients in meniscectomized group was poorer than the patients in healthy knee group at 60 degrees and 75 degrees knee flexion degrees. Those results indicated that even a partial absence of menisci causes a deterioration of proprioceptive functions of the knee.

Elbow problems in goalkeepers in team hand- ball ''handball goalie's elbow'' is common. The accepted mechanism in the common injuries is hyperextension of the elbow. The purpose of this study was to describe the elbow position at the time of impact of the ball on the hand. This study is based on video-analysis. Fifteen handball goalies (ten females and five males) who had been playing hand- ball for a mean time of 6.5 years were used in the study. The participants were not aware of the details of the study. A national team member attacker performed repetitive shots toward the right side of each goalkeeper. The goal- keepers blocked the ball with their own usual style. Each block was videotaped with three digital cameras (one side view, one superior view, and one frontal view). The cap- tured shots were later evaluated by three analysts as to the elbow position at the time of the impact. Seventy-eight out of 101 shots (77%) were valgus or mostly valgus load producing shots. The remaining 23 (23%) were hyper- extension or mostly hyperextension load producing shots. This study shows that the elbows of the handball goal- keepers experience valgus loads at the time of ball blockade during the penalty shoot-out. A detailed under- standing of the mechanism of the loads on the handball goalkeepers' elbow will help in defining ways to prevent and to treat handball goalie's elbow.

Background: The purpose of this study was to compare the functional and clinical results of Achilles tendon repairs with an Achilles tendon suture-guiding device using nonabsorbable versus absorbable sutures. We hypothesized that the absorbable suture would have clinical results comparable to those of the nonabsorbable suture for Achilles tendon repair with an Achilles tendon suture-guiding system. Methods: From January 2010 to September 2013, 48 consecutive patients who had sustained a spontaneous rupture of the Achilles tendon underwent operative repair with an Achilles tendon suture-guiding device using 2 different suture types. All ruptures were acute. The patients were divided equally into 2 groups according to suture type. In the nonabsorbable suture group, No. 2 braided nonabsorbable polyethylene terephthalate sutures were used, and in the absorbable suture group, braided absorbable polyglactin sutures were used. The average age of the patients was 38 years (range, 28-50 years). Functional outcome scores and complications were evaluated. Results: All patients had an intact Achilles repair after surgery. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot clinical outcome scores were 98 (range, 90-100) in the nonabsorbable suture group and 96.8 (range, 87-100) in the absorbable suture group. All patients returned to their previous work. The absorbable suture group had fewer postoperative complications (0%) than the nonabsorbable suture group (12.5%) ( P < .05). Conclusion: Use of an absorbable suture in the treatment of Achilles tendon repair by an Achilles tendon suture-guiding system was associated with a lower incidence of suture reaction; however, functionally the results were not notably different from those using a traditional nonabsorbable suture. We conclude that repair with absorbable sutures is appropriate for Achilles tendon ruptures. Level of Evidence: Level II, prospective comparative study.

Introduction L’anatomie du Latissimus Dorsi (LD) a ete particulierement etudiee dans le cadre de chirurgie reconstructrice et egalement comme transfert musculaire. Son pedicule neurovasculaire, ses dimensions, son potentiel moteur et d’elongation ont ete precises par de nombreuses publications. Son transfert a la partie anterieure de l’epaule reste non diffuse et delicat du fait d’un risque neurologique non negligeable. Pourtant, son vecteur d’action et ses caracteristiques en font un remarquable substitut du subscapularis. Cette etude cadaverique a analyse les relations entre le tendon du LD et le pedicule axillaire en position anatomique et lors de son transfert anterieur. Materiel et methodes Sept epaules cadaveriques fraiches ont ete etudiees. Trois dans un but analytique et 4 avec la mise en place de capteurs sur bandelettes I-Scan de Tekscan. Les trois premieres epaules ont ete dissequees chirurgicalement en respectant l’ensemble des structures osteoarticulaires et musculotendineuses. Le LD a ete preleve de son insertion humerale, mobilise et le Pectoralis major resuture. Les rapports anatomiques du tendon transfere en avant ont ete explores et photographies dans plusieurs positions et plusieurs amplitudes d’epaule. Le rapport le plus etroit retrouve se faisait avec le pedicule axillaire. Quatre nouvelles epaules ont ete alors dissequees de la meme facon. Toutes les structures ont ete preservees. Une bandelette I-Scan Tekscan a ete stabilisee autour du pedicule axillaire. Le membre superieur a ete mobilise completement dans toutes les amplitudes. Pendant l’acquisition des donnees de contact et pressions, le mouvement du membre superieur etait enregistre et synchronise sur webcam. Les donnees de la position anatomique ont servi d’etalonnage pour chaque specimen et cotees a 1. Cette meme procedure a ensuite ete repetee 4 fois (3 hauteurs de fixation differente, 1 decroisement du pedicule hauteur moyenne) pour chacune des 4 epaules. Resultats L’analyse des resultats s’est faite en comparaison avec les mesures obtenues en position anatomique. Seule le pic de pression maximale et la moyenne des pressions ont donne des resultats significatifs. Plus le transfert est place en proximal sur le trochin, plus les contraintes entre le tendon et le pedicule sont importantes. En moyenne de 1,5 a 4 fois la mesure d’etalonnage avec une mesure en pic pour le transfert decroise en rotation interne. Conclusion Seule la position la plus basse sur le trochin semble adaptee pour etre effective sur la stabilisation anterieure et non deletere sur l’environnement vasculonerveux. Malgre son positionnement bas, ce transfert permet de repondre parfaitement au deficit du subscapularis.

Tuberculosis may develop in the skeletal system apart from its primary location, the lungs. A 22-year-old male patient presented with complaints of severe pain and swelling in the left knee and difficulty in walking. The symptoms first appeared 12 years before and he underwent open surgical debridement and arthroscopic debridement at two other centers, at which time aspiration cultures taken from the knee yielded no growth. Physical examination showed a painful left knee with swelling, increased temperature, effusion, and limited range of motion. Based on history, physical examination, radiological studies, and laboratory findings, knee osteoarthritis was considered secondary to nonspecific septic arthritis and knee arthrodesis was performed. At surgery, marked destruction of articular cartilage and synovial hypertrophy were observed. In addition, a cavitary lesion was detected, about 1x1 cm in size, in the lateral femoral condyle without articular involvement. Biopsy cultures taken from the lesion showed growth of Mycobacterium tuberculosis in the third week. This enabled a diagnosis of tuberculosis of the knee joint and antituberculous drug therapy was instituted. At six months postoperatively, the patient was on antituberculous treatment and had a painless knee., Tüberküloz, esas tutulum yeri olan akciğerler dışında iskelet sisteminde de görülmektedir. Yirmi iki yaşında erkek hasta, sol dizde şiddetli ağrı, şişlik ve yürümekte güçlük yakınmalarıyla başvurdu. Yakınmaları 12 yıl önce başlayan hastaya daha önce başka merkezlerde açık cerrahi debridman ve artroskopik debridman yapılmış ve dizden alınan aspirasyon kültürlerinde herhangi bir üreme saptanmamıştı. Fizik muayenesinde sol dizde şişlik, ısı artışı ve efüzyon izlenirken, diz ağrılı ve hareket açıklığı sınırlıydı. Öykü, fizik muayene, radyoloji ve laboratuvar sonuçlarına dayanılarak, hastada geçirilmiş non-spesifik septik artrite bağlı diz osteoartiriti düşünüldü ve diz artrodezi uygulandı. Ameliyat sırasında, eklem kıkırdaklarında yaygın destrüksiyon ve sinovyal dokuda belirgin hipertrofi izlendi. Femoral lateral kondilde, ekleme uzanım göstermeyen kaviter yapıda, yaklaşık 1x1 cm büyüklükteki lezyondan alınan biyopsi kültüründe üçüncü haftada Mycobacterium tuberculosis üremesi üzerine hastaya diz eklemi tüberkülozu tanısı kondu ve antitüberküloz ilaç tedavisine başlandı. Ameliyat sonrası altıncı ay kontolü sırasında hastanın antitüberküloz tedavisi devam etmekteydi ve ağrı yakınması tamamen düzelmişti.

[Excerpt] Have you ever known any young resident full of ambition and knowledge but unable to perform a basic bone drilling despite numerous attempts? On the opposite, did you ever meet a young resident, strikingly skillful however missing basic theoretical concepts? It is statistically inevitable that you will encounter both if you have been training young colleagues for an amount of time. It is responsibility of a teaching mentor to identify the qualities and pitfalls of each trainee, from an educational perspective, so you can get the best out of both characters.[...]

Arthroscopic knot tying is an important part of arthroscopic shoulder surgery. The "Pretzel" knot is a new locking slip-knot, which is simple to learn and prepare. It can slide easily to maintain desired tension and can be locked by a simple maneuver.

instrument’s reception of the colour white to the naked eye’s reception of the same colour. The rest is done through a technology so advanced that it made it possible for Apollo 13 to go to the moon and back. To get the colour discrepancies between the damaged and healthy cartilage in MRI, the protons of the tissue are aligned in resting position in a row and followed by a noise recording while they go back to their functioning states. Most of our current readers probably never touched the dusty thick catalogues of the early Index Medicus to look for information, which would take hours if not days, that we can now obtain in minutes, if not seconds, through the current databases on the Internet. Visual learning is one of the leading styles for surgeons, especially orthopaedic surgeons. Utilisation of advanced technology in the management of our patients’ ailments has opened up new frontiers in surgical education and information distribution. Digital recording of patients’ status at the diagnostic stage or during surgery has enabled surgeons to present information in a technologically advanced way. Video clips were used in presentations for decades, but recently video presentations have become increasingly popular. As a matter of fact, an audio-visual platform is almost a necessity for an institution aiming to function at an international level. So, what is the future of surgical training and publication? We are sure that it is going to be more and more digital and online. Online learning reaches the target (the surgeon) through a mobile device with high-quality content which will be probed by the surgeon who will always be curious and bear the need to know more. Currently, smartphones have surpassed the rest as the device to be used while searching for information. However, the future may hold drastic changes such as the new ‘Glass systems’. Cloud systems are the preferred data storage systems rather than the institution’s own database. The final part of the The ‘medical profession’, which dates back as far as the history of mankind, has seen advances in technology that make their way slowly into the very heart of our daily practice. Innovations that would have amazed us outside our hospital walls are now right in our hands, and we take them for granted. Of all advanced technology available, endoscopic visualisation, magnetic resonance imaging and search engines are the leading ones. All you need to do to start an arthroscopy procedure to a knee is to push the start button and calibrate the

The SF-36 Health Survey is a patient self-administered general health status evaluation designed to measure the impact of disease on an individual’s perception of his or her health. Five hundred forty-four patients with five common shoulder conditions (anterior glenohumeral instability (149 patients), complete reparable rotator cuff tear (111 patients), adhesive capsulitis (100 patients), glenohumeral osteoarthritis (67 patients), and impingement (117 patients)) completed the SF-36 Health Survey before undergoing treatment. When compared with U.S. general population norms, the patients with each of these shoulder conditions had statistically significant decreases in their health for Physical Functioning, Role-Physical, Bodily Pain, Social Functioning, Role-Emotional, and the Physical Component Summary as measured by the SF-36 Health Survey. Comparison with published data demonstrated that these shoulder conditions rank in severity (in terms of affecting a patient’s perception of his or her general health) with five major medical conditions (hypertension, congestive heart failure, acute myocardial infarction, diabetes mellitus, and clinical depression). The data presented in this study should serve as a baseline to document the impact of shoulder musculoskeletal conditions and possibly to allow comparison among various methods of operative and nonoperative treatment. (J Shoulder Elbow Surg 1998;7:228-37.)

This study examined the effects of skill-based maximal intensity interval training on aerobic and anaerobic performance variables among female futsal players. The study included 12 elite female futsal players (training group, TG) from university league division I and 12 physically active female sports-school students (control group, CG). The CG completed volleyball and basketball courses (each 2 hours per week) as part of their school programs; the TG completed an 8-week training program (non-sequential, 4 days per week). Aerobic and anaerobic performance variables were measured before and after the training program via a 20m shuttle run and running anaerobic sprint tests (RAST). Average anaerobic power, fatigue index and VO(2)max of TG improved by 10.7%, 22.1% and 9.6% (p < 0.05), respectively. These findings demonstrate that skill-based maximal intensity interval training had significant effects on both aerobic and anaerobic performance variables of female futsal players. The results suggest that this training model may be useful as a training efficiency tool among futsal coaches.

Purpose: The aim of this study was to predict the hamstring graft sizes prior to anterior cruciate ligament reconstruction surgery in adults by using preoperative magnetic resonance imaging (MRI). Methods: Fifty-one patients with anterior cruciate ligament rupture were prospectively evaluated. Diameter and cross-sectional areas of the gracilis and the semitendinosus tendons at two different levels were measured separately by preoperative MRI. In surgery, harvested gracilis and semitendinosus tendons were measured individually (2-stranded) and together (4-stranded) by using a graft sizing block. Radiological and operative sizes of the grafts were compared by Pearson's correlation test. ROC analysis was done to determine a possible cutoff value for the preoperative measurements. Results: There were statistically significant correlations between the MR cross-sectional areas of gracilis, semitendinosus, gracilis + semitendinosus and intraoperative graft sizes of 2-stranded gracilis, 2-stranded semitendinosus and 4-stranded gracilis + semitendinosus tendons [P < 0. 05]. No significant correlation was observed between the MR diameters of the gracilis, semitendinosus, gracilis + semitendinosus tendons and intraoperative graft sizes of 2-stranded gracilis, 2-stranded semitendinosus and 4-stranded gracilis + semitendinosus tendons [n. s]. Conclusion: Cross-sectional areas of the hamstring tendons in MR images can be used to estimate the sizes of hamstring grafts prior to anterior cruciate ligament reconstruction surgery which may be very helpful to predict possible graft insufficiencies and take precautions if needed. Level of evidence: Level IV. © 2011 Springer-Verlag.

Aim of this paper is to compare the biomechanical properties of the Pretzel knot with the selected arthroscopic knots and to test the mechanical safety of this knot. The hypothesis was that the Pretzel knot may have equal or better mechanical properties than the arthroscopic knots tested in this study.SMC, Giant, Dines, Nicky's, Tennessee Slider knots were chosen for comparison. Original and backed configuration of knots were prepared with no. 2 braided polyester sutures. Cyclic loading and load to failure tests were performed. Parameters tested were loop security, maximum elongation and load at failure. Number of steps needed for preparation of each knot was also recorded. One-way ANOVA for repeated measures was performed for all knots.Steps needed for preparation were 2 for Pretzel and Tennessee Slider, 3 for Nicky's, SMC and Dines and 4 for Giant. The Pretzel knot in original configuration had significantly better loop security compared to SMC, Dines, Nicky's and Tennessee knots (P = 0.01). Loads at failure were not significantly different between knots in their original configurations. Giant and Dines knots showed better maximum elongations in cyclic loading (P = 0.0059) and load to failure tests (P = 0.0001). Backing up the knots with 3-RHAPs eliminated most of these significant differences.Clinically, simplicity and safety are two important components in arthroscopic knot tying. Despite its simple configuration, Pretzel knot has some similar and increased mechanical properties compared to the tested knots that are widely used.

We investigated the effect of mitomycin-C on the reduction of the formation of peritendinous fibrous adhesions after tendon repair. In 20 Wistar albino rats the tendo Achillis was cut and repaired using a modified Kessler technique. The rats were divided into two equal groups. In group 1, an injection of mitomycin-C was placed between the tendon and skin of the right leg. In group 2, an identical volume of sterile normal saline was injected on the left side in a similar fashion. All the rats received mitomycin-C or saline for four weeks starting from the day of operation. The animals were killed after 30 days. The formation of peritendinous fibrous tissue, the inflammatory reaction and tendon healing were evaluated. The tensile strength of the repaired tendons was measured biomechanically. Microscopic evidence of the formation of adhesions and inflammation was less in group 1. There was no significant difference in the tensile load required to rupture the repaired tendons in the two groups. Mitomycin-C may therefore provide a simple and inexpensive means of preventing of post-operative adhesions.

The goals of the present study were (1) to measure the previously unstudied isometric forces of activated human Gracilis (G) muscle as a function of knee joint angle and (2) to test whether length history effects are important also for human muscle. Experiments were conducted intraoperatively during anterior cruciate ligament (ACL) reconstruction surgery (n = 8). Mean peak G muscle force, mean peak G tendon stress and mean optimal knee angle equals 178.5 +/- 270.3 N, 24.4 +/- 20.6 MPa and 67.5 +/- 41.7 degrees, respectively. The substantial inter-subject variability found (e.g., peak G force ranges between 17.2 and 490.5 N) indicate that the contribution of the G muscle to knee flexion moment may vary considerably among subjects. Moreover, typical subject anthropometrics did not appear to provide a sound estimate of the peak G force: only a limited insignificant correlation was found between peak G force and subject mass as well as mid-thigh perimeter and no correlation was found between peak G force and thigh length. The functional joint range of motion for human G muscle was determined to be at least as wide as full knee extension to 120 degrees of knee flexion. However: the portion of the knee angle-muscle force relationship operationalized is not unique but individual specific: our data suggest for most subjects that G muscle operates in both ascending and descending limbs of its length-force characteristics whereas, for the remainder of the subjects, its function is limited to the descending limb, exclusively. Previous activity of G muscle at high muscle length attained during collection of a complete set of knee angle-force data showed for the first time that such length history effects are important also for human muscles: a significant correlation was found between optimal knee angle and absolute value of % force change. Except for two of the subjects, G muscle force measured at low length was lower than that measured during collection of knee joint-force data (maximally by 42.3%). (C) 2010 Elsevier Ltd. All rights reserved.

Aim of this study is to introduce, evaluate, and propose a basic arthroscopy training course with interactive methods as using bovine knees, joint models but mainly focusing on practices with motor skill-learning devices. This study presents the results of a skill training program which is based on “motor skill training” theory and using “bovine knees” to simulate a specific task as arthroscopy both in education and evaluation. The participants gave feedback regarding their expectations, fulfillment, and self-evaluation on the degree of their improvement levels, after which their skills were evaluated by an expert while they performed the arthroscopic procedure. During this evaluation of the task, a four-dimensional checklist which was prepared previously by the consensus of three experts was used, and a global grading of each rater was added at the end of the checklist. In this 2-day course, small group teaching sessions are integrated with active and experiential learning methods consisting of short presentations by the educators, demonstrations using joint models and audio-visual teaching material, and significant continuous feedback by the teachers during the proceedings. Participants’ expectations and post-course feedback results were obtained using a brief questionnaire which involved mostly open-ended questions. The self-rating of “own basic diagnostic arthroscopy skill” on a scale of 0–10 was completed by the participants both previous to and following the course to establish a student-centered learning environment. Overall rating of the course was asked on a 1–5 (poor–excellent) Likert scale. The questioning of the participants who took part in the course during the last five terms involved a 100% feedback. The overall rating of the course was 4.36 ± 0.47 on the 1–5 scale. The majority of the participants (90%) mentioned that the course met their expectations. The most beneficial activities were accepted to be the arthroscopic procedure applications on bovine knee, repetition of the manipulations under the supervision of the trainers, continuous feedback by experienced staff, and chance for immediate correction during the procedures (35/64). Pre- and post-course self-ratings of the participants inquiring about their ability to perform an arthroscopy alone showed significant improvement (4.2 vs. 7.7 P = 0.000, paired samples t test). All participants were found to be competent in the evaluation of their diagnostic arthroscopy skills on bovine knees. To design a skill teaching course based on the needs of the trainees, focusing on basic motor skill training exercises, and using bovine knee as a simulator is a safe, inexpensive, humanistic, and replicable method that proves a foundation for basic arthroscopic skills learning prior to patient encounter.

Objectives: One of the methods in motor skill teaching is to furnish the students with the individual skills drawn from the target procedure. This method requires identification and defining of all components of the target procedure. This study aimed to define basic motor skills composing arthroscopic skillfulness.Methods: A total of 42 orthopedists (mean age 38±8 years) were enrolled. The study group was comprised of 17 experienced orthopedists working at least for 10 years as a specialist and performing more than 50 arthroscopic procedures per year. The control group included 25 young orthopedists or residents having an arthroscopic experience of less than three years. All the participants were assessed simultaneously and in the same experimental setting. Each participant was tested after having been shown to use in vitro skill development instruments simulating arthroscopic basic motor skills.Results: Compared to the control group, the experienced group had significantly higher mean age (42 vs. 34.4 years), longer duration of arthroscopic experience (12.4 vs. 1.6 years), and greater number of the arthroscopies performed per year (93.9 vs. 26.9) (p=0.000). The mean anticipation time (p=0.028) and two-arm coordination time (p=0.043) were significantly shorter in the experienced group. In correlation analysis, duration of arthroscopic experience was correlated with the mean anticipation time (r=-0.41, p=0.008) and twoarm coordination time (r=-0.33, p=0.033). In addition, the mean anticipation time decreased significantly as the number of arthroscopies increased (r=-0.446, p=0.003).Conclusion: Some basic motor skills correlate with arthroscopic competence. The use of these motor skill instruments in arthroscopy training may aid to improve arthroscopic skills., Amaç: Motor beceri eğitimi içerisinde yer alan yöntemlerden biri, hedef işlemi oluşturan bireysel becerileri öğrenciye ayrı ayrı öğretmektir. Bu eğitim yöntemi hedef işlemin parçalarının tanımlanmasını gerektirir. Bu çalışmada, artroskopik girişimi oluşturan temel motor becerilerin tanımlanması amaçlandı.Çalışma planı: Çalışmaya toplam 42 ortopedist (ort. yaş 38±8) katıldı. Çalışma grubuna, en az 10 yıldır uzman olarak çalışmakta olan ve yıllık artroskopi sayıları 50’nin üzerinde olan 17 deneyimli ortopedist; kontrol grubuna ise deneyimi üç yıldan daha az olan 25 genç ortopedist ve asistan alındı. Tüm katılımcılar aynı zamanda ve aynı eğitim ortamında değerlendirildi. Laboratuvar ortamında, temel motor becerileri simüle eden aletler her katılımcıya tek tek tanıtıldı ve her katılımcının asıl değerlendirme öncesinde bir kez deneme yaparak işlemi tanıması sağlandı. Sonuçlar: Deneyimli grupta, kontrol grubuna göre ortalama yaş (42 ve 34.4), artroskopi deneyimi süresi (12.4 ve 1.6 yıl) ve yıllık ortalama artroskopi sayısı (93.9 ve 26.9) anlamlı derecede fazla bulundu (p=0.000). Deneyimli grupta, ortalama önceleme zamanı (p=0.028) ve iki kol koordinasyon zamanı (p=0.043) anlamlı derecede kısaydı. Korelasyon analizinde, artroskopi deneyim süresi ile ortalama önceleme zamanı (r=-0.41, p=0.008) ve iki kol koordinasyon zamanı (r=-0.33, p=0.033) arasında anlamlı ilişki saptandı. Yapılan artroskopi sayısı arttıkça ortalama önceleme zamanı anlamlı olarak kısalmaktaydı (r=-0.446, p=0.003). Çıkarımlar: Bazı temel motor beceriler artroskopik beceriklilik ile ilişkilidir. Motor becerileri geliştiren bu araçların artroskopi eğitiminde kullanılmasının artroskopik beceri geliştirilmesini kolaylaştıracağı söylenebilir.

Congenital absence of the anterior cruciate ligament (ACL) is a very rare anomaly. It is usually diagnosed during arthroscopic intervention. We presented a 15-year old male patient whose diagnosis was based on findings of physical examination and magnetic resonance imaging. Congenital absence of the ACL was associated with femoral shortening, dysplasia of the tibial intercondylar eminence, valgus knee, and compensatory scoliosis. Since the patient had no instability symptoms, and due to the presence of a negative pivot-shift test and multiple congenital anomalies, surgical treatment was not considered., Ön çapraz bağın (ÖÇB) doğuştan agenezisi nadir rastlanan bir durumdur. Tanısı genellikle artroskopi sırasında fark edilerek konmaktadır. Bu yazıda, tanısı fizik muayene ve manyetik rezonans görüntüleme ile konan 15 yaşında bir erkek hasta sunuldu. Hastada doğuştan ÖÇB agenezisine ek olarak, femur boyunda kısalık, tibial interkondiler eminenste displazi, dizde valgus ve omurgada kompansatuvar skolyoz vardı. Hastanın diziyle ilgili hiçbir instabilite şikayetinin bulunmaması, pivot-shift testinin negatif olması ve çoklu doğuştan anomaliler bulunması nedeniyle ameliyat düşünülmedi.

This animal model was designed to evaluate the effect of intra-articular iron-chelator treatment in the prevention of blood-induced joint disease.Thirty domestic male rabbits were divided into three equal groups. One milliliter of homologous blood was injected into the left knee of each rabbit in groups 1 and 2. In the second group, 0.1 ml desferroxamine mesilate (DM) was also injected to the blood. In group 3, the animals received injections of 0.1 DM which was mixed with equal amounts of sterile saline solution. The joints were injected three times each week for 12 weeks. At the end of 12 weeks, the knee joints of each rabbit were examined.The synovium in group 1 was found statistically significantly thicker than in group 2. Obvious erosion and ulceration of the cartilage were seen in all joints in group 1 and absent in group 2. Iron-chelator treatment reduced the formation of blood-induced joint damage in rabbit knees by inhibiting the iron-catalyzed formation of destructive oxygen metabolites that has an effect on joint cartilage and synovium.

Dislocation of the os trigonum presenting as a loose body is a rare clinical entity. In this report, we describe the case of a 34-year-old male who presented with symptoms of acute left ankle pain that was aggravated by motion and weight bearing. He also displayed lateral collateral ligamentous laxity, without the presence of an effusion. Radiographic inspection revealed a 10 × 15-mm loose body within the ankle joint cavity. Arthroscopic intervention showed the loose body to be round and smooth, and it could not be deformed with the tip of a probe, although it could be displaced up to 5 mm with ankle manipulation, in particular with inversion stress of the ankle. The loose body was removed with an arthroscopic forceps. Based on its location within the ankle, and the lack of any articular cartilage on the removed joint fragment, we determined the loose body to represent a dislocated os trigonum. The rarity of this case presentation makes one consider the association of symptomatic os trigonum with ankle instability. Level of Clinical Evidence: 4

Meniscus is a well innervated tissue with four types of receptors. These receptors are mainly concentrated at the anterior and posterior horns. Although they are intended to be a part in reflex arc, this function has not been thoroughly evaluated. We hypothesized that electrical stimulation of the normal meniscus would elicit electromyographic activity of the hamstring muscle via the reflex arc. Five adult domestic male rabbits were used in this study. Under general anesthesia, knee arthrotomy and thigh dissection were done to expose medial meniscus and semimembranosus muscle. Menisci were stimulated by Teflon-coated bipolar needle electrodes. Needles were placed in the posterior horn of the medial menisci. Two Teflon-coated monopolar needle electrodes were placed in semimembranosus muscle. A four-channel electromyograph was used for recording. Two different potentials were recorded from the target muscle. The first response had a very short distal latency and its amplitude was changing in accordance with the strength of the stimulus, suggesting that this response was being elicited by direct muscle stimulation. The second delayed response with less amplitude also appeared in some traces. The latency and the amplitude of this second response were fairly stable stating that this delayed response was being generated by a reflex pathway and seen in all subjects.

BackgroundNo scientific study has addressed the effects of the routine use of postoperative drains in the donor site after arthroscopic anterior cruciate ligament reconstruction using hamstring tendons.HypothesisPatients who have drains placed in their donor sites have less lower extremity edema, more motion, and more comfort in the early postoperative period.Study DesignRandomized controlled clinical trial; Level of evidence, 1.MethodsThirty-four patients undergoing arthroscopically assisted quadruple hamstring tendon anterior cruciate ligament reconstruction were randomly assigned to either receive a drain for 24 hours placed at the donor site (17 patients) or have no drain at the donor site (17 patients). Data were collected on postoperative days 1, 3, 5, and 7 regarding knee flexion, knee extension, thigh circumference, leg circumference, and visual analog scale (measuring pain).ResultsIn the study group versus the control group, there were increased knee flexion measurements on postoperative day 7 (84° vs 69°, P ConclusionDrain placement at the donor site after anterior cruciate ligament reconstruction gives more comfort to the patient and provides better flexion within the first week.

Detachment of the deltoid muscle and tendon is a rare complication that is reported to result in poor outcome after rotator cuff surgery. We performed a delayed primary repair of the detached deltoid in a 53-year-old female patient who underwent an open acromioplasty procedure. A successful result was achieved after surgical restoration of the deltoid muscle origin back to the acromion. At 25 months' follow-up the patient had recovered almost the full range of motion of the glenohumeral joint and was free of pain. Due to lack of literature on this rare condition, there are no well-defined treatment principles for the management of deltoid muscle detachments that develop as a complication of rotator cuff surgery. This paper describes a repair procedure for the management of deltoid muscle detachments. In addition, it discusses the importance of the guidelines that have to be followed during primary rotator cuff surgery.

Background: Mosaicplasty has been associated with good short- to long-term results. Nevertheless, the osteochondral harvesting is restricted to the donor-site area available and it may lead to significant donor-site morbidity. Purpose: Provide an overview of donor-site morbidity associated with harvesting of osteochondral plugs from the knee joint in mosaicplasty procedure. Methods: Comprehensive search using Pubmed, Cochrane Library, SPORTDiscus and CINAHL databases was carried out through 10th October of 2016. As inclusion criteria, all English-language studies that assessed the knee donor- site morbidity after mosaicplasty were accepted. The outcomes were the description and rate of knee donor-site morbidity, sampleâ s and cartilage defectâ s characterization and mosaicplasty-related features. Correlation between mosaicplasty features and rate of morbidity was performed. The methodological and reporting quality were assessed according to Colemanâ s methodology score. Results: Twenty-one studies were included, comprising a total of 1726 patients, with 1473 and 268 knee and ankle cartilage defects were included. The defect size ranged from 0.85 cm2 to 4.9 cm2 and most commonly 3 or less plugs (averaging 2.9 to 9.4 mm) were used. Donor-site for osteochondral harvesting included margins of the femoral trochlea (condyles), intercondylar notch, patellofemoral joint and upper tibio-fibular joint. Mean donor-site morbidity was 5.9 % and 19.6 % for knee and ankle mosaicplasty procedures, respectively. Concerning knee-to-knee mosaicplasty procedures, the most common donor-site morbidity complaints were patellofemoral disturbances (22 %) and crepitation (31 %), and in knee-to-ankle procedures there was a clear tendency for pain or instability during daily living or sports activities (44 %), followed by patellofemoral disturbances, knee stiffness and persistent pain (13 % each). There was no significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs (p > 0.05). Conclusions: Osteochondral harvesting in mosaicplasty often results in considerable donor-site morbidity. The donor-site morbidity for knee-to-ankle (16.9 %) was greater than knee-to-knee (5.9 %) mosaicplasty procedures, without any significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs. Lack or imcomplete of donor-site morbidity reporting within the mosaicplasty studies is a concern that should be addressed in future studies., (undefined)