Search

Background:A significant proportion of surgeons use intra-articular drains after arthroscopic anterior cruciate ligament (ACL) reconstruction. Hemarthrosis and pain adversely affect the functional outcomes of ACL reconstruction in the early postoperative period.Purpose:To evaluate the effects of administering tranexamic acid (TXA) to minimize knee joint hemarthrosis and associated pain.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 105 patients who underwent arthroscopic ACL reconstruction were enrolled in this prospective, randomized, double-blind study. The patients who were randomized to the TXA group (n = 53) received intravenous TXA; the control group (n = 52) did not receive TXA. The anesthetist, surgeon, observer, and patients were blinded to the study groups (double-blinded). TXA was administered as a bolus dose of 15 mg/kg 10 minutes before the inflation of the tourniquet, and an intravenous infusion of 10 mg/kg/h was continued for 3 hours after completion of the operation. In the control group, an equal volume of placebo was administered at the same rate and by the same route. The volume of drained blood was measured 24 hours postoperatively. Pain was evaluated using a visual analog scale (VAS) at a consistent time in the evening of postoperative day 3 and postoperative weeks 2 and 3. The Lysholm knee scoring scale was used to record patient satisfaction and knee function during postoperative weeks 2 and 4.Results:Significant differences were observed between the volume of fluid drained (60 mL [TXA group] vs 150 mL [control group]; P < .001) (between-group difference [95% CI], −90 [−114.15 to −65.85]) and hemarthrosis grade in postoperative weeks 1 and 2. In addition, the pain outcome improved in the TXA group after day 3 (VAS score, 1.4) compared with that in the control group (VAS score, 2.9) ( P < .001) (95% CI, −1.51 to −0.49). The VAS scores of the TXA group at the end of weeks 2 and 3 were also significantly lower than those in the control group ( P < .001) (95% CI, −2.00 to −1.00). The median Lysholm score at the end of week 2 was 70 (range, 40-85) in the control group and 75 (range, 50-90) in the TXA group; at the end of week 4, the score was 75 (range, 50-85) in the control group and 80 (range, 70-85) in the TXA group. A significant difference in the Lysholm score was observed between the 2 groups ( P < .001) (95% CIs, 0.08-9.92 and 4.00-10.00 for weeks 2 and 4, respectively). Although range of motion was similar between the groups at the end of week 4, the mean was 107.36° ± 8.36° in the TXA group and 103.65° ± 7.68° in the control group on postoperative day 2 ( P = .020) (95% CI, 0.60-6.81). The mean hemarthrosis values at the end of weeks 1 and 2 were significantly lower in the TXA group than in the control group ( P < .001), and the need for aspiration in the TXA group during the early postoperative period was significantly lower than in the control group ( P < .001). There were no infections in either group, and no patient developed deep venous thrombosis by postoperative day 3.Conclusion:The results of this prospective, randomized study show that TXA reduced the amount of postoperative hemarthrosis and decreased the need for aspiration of the knee after arthroscopic ACL reconstruction. Consequently, TXA reduced pain and improved range of motion of the knee in the early postoperative period without side effects.

Alkaptonuria is a rare metabolic disease caused by a partial or total deficiency of homogentisic acid oxidase, which results in excess homogentisic acid (HGA) levels. Homogentisic acid and its oxidation products can accumulate in hyaline cartilage, tendons, and ligaments. A 55-year-old male was admitted complaining of worsening chronic pain in his left knee. A radiographic evaluation showed tricompartmental end-stage osteoarthritis. A cemented total knee replacement was performed. At the 10-year follow-up, he had returned to full activity, had no knee pain, and was very satisfied with the outcome. No abnormality was observed in the femoral, tibial, or patellar components on radiography. We believe that total knee replacement is a good option in a patient with marked degenerative arthritis secondary to ochronotic arthritis.Keywords : Ochronotic Arthropathy,Alkaptonuria,Arthroplasty DOI: 10.3944/AOTT.2015.14.0117This abstract belongs to the un-edited version of the article and is only for informative purposes. Published version may differ from the current version., Alkaptonüri homojentisik asit oksidazın kısmen ya da tamamen eksikliği nedeniyle görülen nadir bir metabolik hastalık olup, artmış homojentisik asit (HGA) seviyeleri ile sonuçlanır. Homojentisik asit ve oksidasyon ürünleri hiyalin kıkırdak, tendon ve bağlarda birikebilir.55 yaşında erkek hasta, sol diz kronik ağrı şikayeti ile polikliğinimize başvurdu. Radyografik değerlendirmede trikompartmantal son dönem osteoartrit bulguları mevcuttu. Hastaya çimentolu total diz artroplastisi uygulandı. 10 yıllık takipte, hastanın günlük aktivitelerini tam olarak yapabildiği görüldü. Çekilen direkt grafilerde femoral ve tibial komponentlerde radyolojik olarak anormal görünüm izlenmedi.Total diz protezi uygulamasının, okronotik artropatiye ikincil gelişen dejeneratif osteoartritli hastaların tedavisinde iyi bir seçenek olduğunu düşünüyoruz.Alkaptonüri, nadir görülen otozomal resesif metabolik bir hastalıktır. 3. Kromozomda bulunan homojentizik 1,2 - dioksijenaz (HGO) geninde meydana gelen mutasyon nedeniyle artmış homojentisik asit (HGA) düzeyi ile karakterizedir.(1-3) İnsidansı 100.000-250.000 kişide bir görülmektedir.(3,4) Karaciğer ve böbreklerde bulunan homojentisik asit oksidazın kısmen ya da tamamen eksikliğinden kaynaklanır. Homogentisik asit oksidaz, HGA’ın fenilalanin ve tirozin katabolizmasından sorumludur. Homojentisik asit ve oksidasyon ürünleri hiyalin kıkırdak, tendon, bağ, sklera, deri, kalp kapakçıkları, burun ve kulaklar, böbrek tübül epitel hücreleri, pankreas ve arterlerde birikir.(4–6)Alkaptonüri teşhisi idrarda homojentisik asit miktarı ile teyit edilebilir. Günümüzde Alkaptonürinin bilinen medikal tedavisi yoktur. Tedavi semptomatik olup, fizyoterapi, analjezikler ve destek tedavisinden oluşur. Cerrahi tedavi seçenekleri arasında sinovektomi, artroskopik debridman ve artroplasti bulunur.(4,7,8) DOI: 10.3944/AOTT.2015.14.0117Bu özet, makalenin henüz redaksiyonu tamamlanmamış haline aittir ve bilgi verme amaçlıdır. Yayın aşamasında değişiklik gösterebilir.

Fatih Karaaslan,1 Musa Uğur Mermerkaya,1 Alper Çıraklı,2 Sinan Karaoğlu,3 Fuat Duygulu21Department of Orthopaedics and Traumatology, Faculty of Medicine, Bozok University, Yozgat, Turkey; 2Department of Orthopaedics and Traumatology, Kayseri Training Hospital, Kayseri, Turkey; 3Department of Orthopaedics and Traumatology, Memorial Kayseri Hospital, Kayseri, TurkeyIntroduction: Controversy remains regarding the optimal treatment method and postoperative rehabilitation of acute Achilles tendon ruptures. In this study, pedobarographic assessments of surgical and conservative treatments were compared.Material and methods: A prospective assessment was made of 16 patients (eight surgical, eightconservative) and eight healthy controls using a plantar pressure measurement system. Biomechanical gait parameters were obtained using the Footscan dynamic gait analysis system. Kruskal–Wallis and Mann–Whitney U-tests were used for the evaluation of data.Results: Nineteen males and five females were assessed, with an average age of 42.0±11.9 years. Follow-up was completed in 16 patients. No statistically significant difference was determined between the two treatment groups with regard to the gait analysis, but a difference was observed with the control group (P

The purpose of this study was to investigate whether a grafting technique using either periosteum or bone marrow as an adjunct, would reconstitute more favorable tendon anchorage morphology with improved tensile strength in a bone tunnel model. We hypothesized that autogenous bone marrow aspirate can enhance the tendon-bone attachment as well as a freshly harvested periosteum, because both tissues contain pluripotent cells. Thirty-six skeletally mature New Zealand white rabbits were utilized. For the tendon graft healing in a bone tunnel model, the extensor digitorum longus tendon was detached from its femoral insertion and transplanted through a bone tunnel into the proximal tibia. Three groups were compared. For the group P (periosteum), a periosteum-wrapped tendon was fixed into the tunnel through the proximal tibial metaphysis. For the group BM (bone marrow), instead of periosteum augmentation, fresh bone marrow was injected into the tendon graft that would sit inside the tunnel. For the group C (control), the limb underwent a similar operation with neither the periosteum enveloping nor bone marrow injecting the tendon. At 6 and 12 weeks after surgery, two rabbits were used for light and electron microscopic examinations, and ten rabbits were used for biomechanical tests in each group. The interface tissue between bone and tendon was thicker and less organized in group C compared to groups P and BM at 6 weeks. Ultra-structurally, the interface tissue was loosely organized in group C, compared to others. Bone ingrowth into tendon was more obvious in groups P and BM, compared to group C. The proliferation of cartilage islands was observed within bone tunnels of both groups P and BM; but a well-defined fibrocartilage zone was noted only in group BM at the interface at week 12. Biomechanical findings: (1) at 6 weeks, the average failure load of group P was significantly higher than the others (P < 0.01). At same time point, in terms of stiffness, while group P was significantly higher than the other groups (P < 0.01), group BM was also significantly higher than that of group C (P < 0.05); (2) at 12 weeks, in terms of failure loads, there was a statistical significant difference only between groups BM and C (P < 0.05). At the same time point, stiffness values were not statistically different among the three groups. Based on the histological and biomechanical findings, the present study demonstrated that periosteum had a positive effect when compared to bone marrow and control groups on the tendon-to-bone healing at an early time point (6 weeks), and bone marrow was also effective at 12 weeks time point compared to the control group in an extra-articular bone tunnel in rabbits. The presence of pluripotent cells in both the bone marrow and the periosteum may be the possible mechanism for enhanced healing. Periosteum had a positive effect at an early time point (6 weeks). Bone marrow was more effective at 12 weeks. Therefore, it is possible that a combination of wrapping periosteum and injecting bone marrow to the tendon graft would have a synergistic effect (early and strong). To prove this hypothesis, future studies which would combine both methods are needed.

To investigate the effects of free oxygen radicals and various antioxidants on bone healing after experimental formation of fracture. Fifty male rats were used and divided into five groups (ten rats in each). The right forelimbs of the rats were broken by bimanual compression method. One hour before this procedure, 5 ml/kg of intraperitoneal (i.p.) physiologic saline were given to the control Group 1. All 40 rats in the experimental Groups 2, 3, 4 and 5 were treated with i.p. zymosan at a dosage of 100 mg/kg to induce the production of free radicals by stimulating NADPH oxidase in polymorphonuclear leukocytes. Zymosan induction was stopped on the fifth post-fracture day. In addition to the zymosan, i.p. 1 g/kg/day of dimethyl sulfoxide were given to the animals in Group 3, 50 mg/kg/d of Ginko biloba Extract (EGb 761) in Group 4 and 500 mg/kg/day of vitamin C in Group 5. Radiographs of the fractures of all animals were obtained to assess callus formation, remodeling and bridging bone formation under ether anesthetics on postfracture day 7, 14 and 21. All rats were euthanized on day 22, and sections of the radius and ulna were examined both histologically with light and electron microscopy and ultrastructurally. Statistical analysis was made with Kruskal-Wallis variance analyze test and comparison between groups was performed by Dunn’s multiple comparision test. An impairment of bone healing was observed in Group 2 inducted with purely zymosan. Variable results were obtained for bone healing in the groups treated with various antioxidants. There was very significant difference of fracture healing between Groups 1 and 2 both histologically and radiologically (P

Originating from the synovium, multiple free-floating intra-articular particles, called rice bodies, typically resemble cartilage and have a fibrin structure. While the etiology of rice body formation is unclear, they often occur in rheumatoid arthritis and other seronegative arthropathies; they also occur in tuberculosis, though the incidence is much lower. They are often encountered by rheumatologists or clinical orthopedists. A 33-year-old female who suffered from occasional swelling and pain of her left knee for 3 months was admitted with a mechanically locked knee. Free-floating rice bodies were identified on magnetic resonance imaging (MRI), and arthroscopic intervention was performed for diagnostic and therapeutic purposes. After the removal of all bodies and effusion with mechanical irrigation, an arthroscopic subtotal synovectomy was performed.

Multiple free-floating intra-articular particles, called rice bodies, originate from the synovium, typically resemble cartilage, and have a fibrin structure. The etiology of rice body formation is unclear, although they often occur in rheumatoid arthritis and other seronegative arthropathies, and rarely in tuberculosis. They are often encountered by rheumatologists or in clinical orthopedics. A 33-year-old female who suffered from occasional swelling and pain of her left knee for 3 months was admitted with a mechanically locked knee. Free-floating rice bodies were identified on magnetic resonance imaging and arthroscopic intervention was carried out for diagnostic and therapeutic purposes. After removing all of the bodies and effusion with mechanical irrigation, an arthroscopic subtotal synovectomy was performed.Keywords: Knee, Rice bodies, Arthroscopic debridement, ÖzetPirinç tanesi cisimcikleri olarak adlandırılan, eklem içi serbest yüzen multipl partiküller sinovya kaynaklı olup tipik olarak kıkırdağa benzeyip, fibrin yapıdadırlar. Etyolojileri açık olmamasına rağmen romatoid artrit ve diğer seronegatif artropatilerle beraberlikleri yanısıra daha az sıklıkla tüberkülozda görülürler. Sıklıkla romatoloji veya ortopedi pratiğinde karşılaşılmaktadır.3 aydır sol dizinde ağrı ve zaman zaman şişme şikayetleri olan 33 yaşındaki bayan hasta, sol dizinde mekanik kilitlenme şikayeti ile başvurdu. Manyetik rezonans görüntüleme (MRG) ile diz ekleminde serbest yüzen pirinç tanesi cisimcikleri tespit edilen hastaya tanısal ve tedavi amaçlı sol diz artroskopisi uygulandı. Eklem içi effüzyon ve serbest yüzen cisimciklerin boşaltılması ardından artroskopik subtotal sinovektomi uygulandı.Anahtar sözcükler: diz eklemi, pirinç tanesi cisimcikleri, artroskopik debridman

UNLABELLED Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

The aim of this study was to evaluate the effect of SH (sodium hyaluronate—NaHA) on vascular endothelial growth factor (VEGF) and type IV collagen expression during the Achilles-tendon healing process. Adult New Zealand white rabbits (n=32) aged 4 months and weighing 2.7–3.9 kg were used. The rabbits were randomly divided into two groups, and each group was divided into two subgroups and monitored for 6 and 12 weeks. Tendo calcanei were incised transversely and repaired. An injection of 0.5 ml NaHA (15 mg/ml) was administered between the tendon and paratenon of the right leg and repeated twice at one-week intervals. Equal numbers of animals were sacrificed at the 6th and 12th weeks, and the repaired tissue was examined macroscopically and histologically for the presence of VEGF and type IV collagen expression every week. The decrease in the amount of adhesion tissue and the acceleration of tendon healing in the NaHA group were significantly high when compared with control groups at 6 and 12 weeks (p

Using an experimental model of segmental bone defect in the ulna of rabbits we investigated the effect on bone healing of fresh cancellous autograft (FCA), demineralized deep-frozen allograft (DDA), and demineralized deep-frozen allograft covered with free autogenous periosteum (DDAwP). Radiologically, it was found that the results of the FCA and DDAwP groups were superior to those of the DDA group. This superiority was statistically significant after the 3rd to the 9th week for the FCA group, and the 6th to the 9th week for the DDAwP group. However, bone formation and union in the DDA group reached the same level of those in the other groups after 12 weeks. When the all histological findings were compared at the 12th week, the FCA and DDAwP groups were statistically superior to the DDA group in terms of proximal union. On distal union, the FCA group was statistically superior to the DDA group. Biomechanically, the FCA and DDAwP groups were statistically superior to the DDA group in terms of maximum torque and energy absorption. The DDAwP group was superior to the DDA group in term of stiffness. We conclude that ossification could be more easily achieved if demineralized deep-frozen allograft is covered with periosteum when faced with the need for quicker and better quality bone integration.

This study compared the analgesic effect of intra-articular injection of tenoxicam with that of morphine on postoperative pain after anterior cruciate ligament (ACL) reconstruction. Forty-two patients undergoing arthroscopically ACL reconstructions using hamstring tendons underwent the same anesthetic protocol. The patients were randomized to receive 25 ml normal saline, 20 mg tenoxicam in 25 ml normal saline, or 2 mg morphine in 25 ml normal saline. Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements. We found both that both intra-articular tenoxicam and intra-articular morphine provided better analgesia than that in the control group. Although pain scores were similar between tenoxicam and morphine groups 30 min postoperative, the analgesic requirements in with tenoxicam were significantly lower than those with morphine group 3-6 h postoperatively.

This study compared pullout strengths of the T-fix device versus horizontal suture toward improving T-fix biomechanical properties. Twenty bovine medial menisci were used for this study. Four groups were tested and mean tearing stress were obtained. In group 1 a standard T-fix suture was performed (50.2±4.2 N); in group 2 horizontal mattress sutures were placed in the meniscus using 2-0 vicryl (54.6±4.2 N); in group 3 three T-fix suture anchors were placed: the central suture a double suture anchor and those on either side single suture anchors, resulting in two horizontal sutures (61.8±3.8 N); in group 4 we modified the technique used in group 3. The double suture anchor was placed the incision, at a 30° angle oblique to the horizontal (71.0±5.9 N). There was a statistically significant difference between groups 3 and 4 but not between groups 1 and 2. In conclusion: Using a T-fix suture anchor in the standard technique has similar biomechanical properties to the horizontal mattress suture. To improve the tensile properties of the T-fix suture a double T-fix suture anchor should be used obliquely to the other two single T-fix sutures on either side.

Seventy-four revisions of the femoral component featuring placement of a Wagner stem in 74 patients operated upon between 1995 and 2003 were reviewed. Clinical evaluation, radiological assessment, and survival analysis of revision stems were conducted. The mean follow-up duration was 14.4 years (range, 11 to 19 years). When failure was defined as stem removal for any reason, 4 of 64 stems had to be further revised during the follow-up period, yielding a cumulative stem survival rate of 93.8% (95% CI: 87.7% to 98.2%) at 18 years. The Wagner revision stem is an effective implant for revision hip surgery when bone stock is lacking. Use of the stem affords mechanical stability even when bone loss is massive.

We asked whether tranexamic acid (TXA) administration could reduce blood loss and blood transfusion requirements after simultaneous bilateral total knee arthroplasty (TKA). This study examined the role of a novel method of TXA administration in TKA.TXA was administered as a bolus dose of 15 mg/kg 10 min before the inflation of the tourniquet on the first side. This was followed by intra-articular administration of 3 grams at 10 min before the deflation of the tourniquet. IV infusion of 10 mg/kg/h was continued for 3h following completion on the second side. We measured volume of drained blood 48 h postoperatively, decrease in hemoglobin levels 12h postoperatively, amount of blood transfused (BT), and number of patients requiring allogenic BT.Median postoperative volume of drained blood was lower in the group receiving TXA (500.00 mL) than in control subjects (900.00 mL) (p0.05) [95% CI (-525.00) to (-300.00)]. The median hemoglobin decrease 12 h postoperatively was lower in patients receiving TXA (2.10 g/dL) than in control subjects (3.10 g/dL) (p0.05) [95% CI (-1.60) to (-0.60)]. The amount of BT and number of patients requiring BT were lower in patients receiving TXA than in control subjects. Nevertheless, the number of allogeneic units of packed red blood cells transfused in the postoperative period was not significantly higher in the control group than in the TXA group (p=0.109) [95% CI (0.101) to (0.117)].This prospective randomized study showed that during simultaneous bilateral TKA, TXA reduced blood loss with negligible side effects.

Brucella infection associated with arthroplasty is a rare event. An unspecific clinical symptomatology is associated with unclear radiographic signs of periprosthetic bone halisteresis. Only a positive anamnesis combined with an antibiogram of the joint liquid and a high serum antibody titer can lead to a definitive diagnosis. We herein report a case of Brucella melitensis infection in a patient who underwent total knee arthroplasty 2 years earlier. Plain radiography and bone scintigraphy confirmed septic loosening. The patient was successfully treated with two-stage revision arthroplasty.

Fatih Karaaslan,1 Mahmut Mutlu,2 Musa Ugur Mermerkaya,1 Sinan Karaoğlu,3 Şerife Saçmaci,4 Şenol Kartal4 1Department of Orthopaedics and Traumatology, Faculty of Medicine, Bozok University, Yozgat, 2Department of Orthopaedics and Traumatology, Faculty of Medicine, Erciyes University, 3Department of Orthopaedics and Traumatology, Memorial Kayseri Hospital, 4Department of Chemistry, Faculty of Sciences, Erciyes University, Kayseri, Turkey Purpose: This study examined the role of trace elements in osteoporosis by comparing the trace-element concentrations in bone and the radiographic bone density and bone mineral density (BMD) of patients with osteoporotic femur fractures and osteoarthritis.Patients and methods: The study enrolled 30patients operated on for proximal femoral fractures after falls, and another 30patients undergoing hip arthroplasty at the same center for hip osteoarthritis. Bone samples were obtained during the surgical procedures. The density of the bone samples was assessed using computed tomography and the Hounsfield scale. The levels of Ca(II), Mg(II), and other trace elements in the bone samples were determined using flame atomic absorption spectrometry and inductively coupled plasma mass spectrometry. In addition, BMD, Z-scores, and T-scores were measured in the unaffected hips of all patients using dual-energy X-ray absorptiometry.Results: Magnesium (1,908±507versus 2,540±435, P

In this article, we report two cases of arthroscopic resection of symptomatic intraarticular osteochondroma of the knee. The first case was a 27-year-old male presenting with slowly progressive left knee pain while sitting and climbing up stairs. The second case was a 24-year-old female presenting with slowly progressive right knee pain while running downhill and squatting deeply. Preoperative radiographs and magnetic resonance images revealed an intraarticular, locally expanding, mineralized mass at adjacent to the trochlea of the femur for both patients. These osteochondromas were arthroscopically resected, which led to complete relief of symptoms and return to full activity within two weeks. There has been no return of symptoms within three years and one year of follow-up, consecutively. We highlight that an arthroscopic resection of a symptomatic intraarticular osteochondroma may be less painful, has better cosmetic results and the postoperative recovery is faster, compared to the traditional open approach.

Twenty-seven adolescents with 29 femoral shaft fractures, between the ages of 10 and 16 years, were treated with closed flexible Ender intramedullary nailing from 1989 to 1992 in our clinic. In one patient who had a fracture of the distal third of the femoral shaft, the nail was inserted proximal to distal (antegrade nailing). In the other patients, the nails were inserted distal to proximal (retrograde nailing). Clinical and radiological follow up averaged 32 months (18–56 months). Hospitalization averaged 15 days (7–28 days). All fractures healed with one significant leg length discrepancy of 1.7 cm in a patient who had developed osteomyelitis. There was no significant angulation or malrotation. All patients had a normal gait and were able to participate in full activities. There was one deep wound infection in a patient with an open fracture of the femoral shaft. There were no non-unions, delayed-unions or psychological complications. For this age group, this treatment of femoral shaft fracture should be considered owing to the functional recovery with low morbidity and cost, providing early ambulation, early discharge from hospital and early return to school.

Patellofemoral pain syndrome (PFPS) is frequently seen in young adults and is the most prevalent disorder involving the knee. Although the etiology and pathogenesis of PFPS are poorly understood, many predisposing factors have been proposed. In many patients, however, there is no apparent reason for the symptoms. For most patients, a careful history and physical examination are sufficient to make the diagnosis of PFPS. In addition to detailed physical examination, radiologic imaging techniques are needed for some cases. To have precise diagnosis is crucial for successful treatment. Rehabilitation involving the entire kinetic chain is the first option for vast majority. If surgery is needed, restoration of patella homeostasis with minimal surgical intervention and precise indications for more definitive corrective surgery is very important.

This chapter reviews the properties of normal and healing ligaments and tendons and discusses the current functional tissue engineering (FTE) methods, which include the use of growth factors, gene delivery, stem cell therapy, and the use of scaffolding as well as external mechanical stimuli, aimed at enhancing tendon and ligament healing. The major function of ligaments and tendons include maintaining the proper anatomical alignment of the skeleton and guiding joint motions. They accomplish this by transmitting forces along their longitudinal axis but their biomechanical properties are measured in uniaxial tension. They demonstrate nonlinear behavior, which is governed by the recruitment of collagen. This allows ligaments to maintain normal joint laxity in response to low loads and also to stiffen dramatically in response to high loads, preventing excessive joint displacements. The events of healing of ligaments and tendons are divided into four overlapping phases: hemorrhage, inflammation, repair (proliferation), and remodeling. Following injury, the hemorrhagic and inflammatory phases occur over the first several days. Minutes after the ligament injury, blood collects and forms a platelet-rich fibrin clot at the injury site. The hemorrhage phase of the injury forms a lattice for many following cellular events. FTE has generated many significant developments; for example, there is a class of biodegradable metallic scaffolds, namely porous magnesium or magnesium oxide, that have the advantage of initial stiffness to provide the needed stability for the ligament to heal while performing its function. The degradation rate of these “smart” scaffolds could also be controlled as they are replaced by the neotissue.

Following harvest of a bone-patellar tendon-bone (BPTB) autograft, the central third of the patellar tendon (PT) does not heal well. The healing tissues also form adhesions to the fat pad and can cause abnormal patellofemoral joint motion. The hypotheses were that a bioscaffold could enhance patellar tendon healing through contact guidance and chemotaxis, and the scaffold could serve as a barrier to decrease adhesion formation between the neo-PT and infrapatellar fat pad. In 20 New Zealand White rabbits, a central-third PT defect was created. One strip of porcine small intestinal submucosa (SIS) was attached to both the anterior and posterior sides of the PT defect of the SIS-treated group (n = 10). For comparison, a central defect was left nontreated (n = 10). At 12 weeks, histomorphology was examined using Masson's trichrome staining. The cross-sectional area (CSA) was determined with a laser micrometer, and the central BPTB complexes were tested in uniaxial tension. SIS-treated samples showed a greater amount of healing tissue with denser and well-oriented collagen fibers and more spindle-shaped cells. There was no noticeable adhesion formation in the SIS-treated group. For the nontreated group, there were significantly more and diffuse adhesive formations. The SIS-treated group also had a 68% increase in neo-PT CSA, 98% higher stiffness, and 113% higher ultimate load than that in the nontreated group. SIS treatment increased the quantity of healing tissue, improved the histological appearance and biomechanical properties of the neo-PT, and prevented adhesion formation between the PT and fat pad.

Central third bone-patellar tendon-bone (BPTB) autografts are commonly used for anterior cruciate ligament (ACL) reconstructions. Following surgery, complications arise at the donor site, including extension deficits and anterior knee pain [1]. These complications are partially caused by inadequate healing of the patellar tendon (PT) as well as adhesions in the anterior interval. Recent clinical data have suggested these are contributing factors in the early development of osteoarthrosis following ACL reconstruction [2]. Thus, it is necessary to understand the changes in mechanical and viscoelastic behavior in the healing PT.Copyright © 2007 by ASME

Introduction: The aim of this study was to compare the radiographic results and clinical outcome of unreamed tibial nailing (UTN) and Ilizarov external fixation (IEF) for the treatment of type IIIA open fractures of the tibia. Materials and Methods: Sixty-one patients with open type IIIA tibial shaft fractures were treated with an IEF (n = 32) or UTN (n = 29). Both groups were compared for union time, secondary outcomes of nonunion, infections, mechanical failure of the implant, and malunion. Results: The average time-to-bone healing was 19 weeks (range 14-23 weeks) for IEF and 21 weeks (range 16-36 weeks) for UTN; it was significantly shorter in the IEF group (P = 0.039). One patient had refracture in the IEF group. Malunion occurred in four patients for each group. Posttraumatic osteomyelitis occurred in two patients in the IEF group and in three patients in the UTN group. In the IEF group, additional surgical procedures were indicated in three cases including sequestrectomy (n = 1), and pin replacement (n = 2). In the UTN group, seven patients needed additional surgery including bone grafting (n = 3), nail exchanged (n = 1), and posttraumatic osteomyelitis (n = 3). Conclusion: The results of the current study showed that IEF technique had a notable incidence of pin-tract infection, joint contracture, and shorthening related to treatment of the delayed union. The UTN technique had the disadvantage of a posttraumatic osteomyelitis and delayed union requiring additional surgery. We believe that the decision to use IEF or UTN should be made on a case-by-case basis. © Springer-Verlag 2007.

The sartorius muscle is a rare location of primary hydatid cyst. In this report, the clinical, pathologic, and radiologic features are discussed, with special emphasis on the pathologic and radiographic features. We report a case of hydatid cyst of the proximal thigh in an eight-year-old girl. Magnetic resonance (MR) images revealed muscular hydatid cyst in the sartorius muscle, with a striking appearance of daughter cysts. We did not find any visceral organ involvement. Wide excision was performed without destroying the cyst wall. Primary muscular hydatidosis should be kept in mind in the differential diagnosis of a cystic mass of a skeletal muscle.

The objective of this study was to evaluate the effect of subcutaneously injected nicotine on transversely transected and sutured achilles tendon healing in an experimental rabbit model. Adult New Zealand rabbits (n=22) weighting 3,000-3,500 g were used in this experimental study. Rabbits were randomly divided into two groups. Achilles tendon was transversely incised and repaired in all animals. In the experiment group subcutaneous injection of Nicotine tartrate 3 mg/kg/day was done. In the control group Serum physiologic injection was done at the same dosage. The injections were made three times a day in equal dosages. Nicotine and SF injections were made until the end of the 8-week, and then all animals were euthanized. Both light microscopic and electron microscopic evaluations were made on 14 animals. In N group light microscopic evaluation showed a visible gap in repair site. The total tendon score represented in N group was less than in SF group. The statistical analysis of the groups was significantly different for total tendon scores (P=0.002). Beside this electron microscopic examination showed inactive and degenerated fibroblasts and irregular collagen fibrils around them as well as collagen synthesis interruption in N group. Biomechanical evaluation was made on eight animals. The average tensile strength values in Group N (139.47 +/- 44.55 N) were significantly lower than those in Group SF (265.9 +/- 39.01 N) (z=2.309, P=0.029). Nicotine is the major chemical component common to all cigarettes and previously has been shown to affect wound and fracture healing adversely. The results of this study show that nicotine impairs achilles tendon healing after a surgical repair.

For years, bioengineers and orthopedic surgeons have applied the principles of biomechanics to gain valuable information about the complex function of the anterior cruciate ligament (ACL), as well as to improve the design of replacement grafts for ACL reconstruction. New experimental tools, such as robotic testing systems and mathematical models have been used to measure the multiple degree-of-freedom (DOF) knee kinematics, in situ forces, and biomechanical properties of the ACL. This manuscript will review specific examples of how biomechanics has impacted surgical reconstruction of the ACL by improving technical factors such as graft selection, tunnel placement, initial graft tension, graft fixation, and graft tunnel healing. Evolution of the single-bundle ACL reconstruction to the more anatomical double-bundle reconstruction will be featured. Finally, the future role of biomechanics to facilitate in vivo data for further improvement of ACL reconstruction will be discussed.

Objectives: Brucella infection associated with arthroplasty is a rare event. We present the long-term results of two-stage revision knee arthroplasty due to TKA infection by Brucella melitensis. Methods: A 62-year-old man presented with a 4-month history of night sweats, high body temperature, and right knee pain in 2003. Two years previously, he had undergone a right TKA for treatment of gonarthrosis. Upon examination, the knee appeared swollen, warm, and sore, and a sinus tract formation had developed at the incision area. Bacteriologic cultures taken from the sinus tract discharge revealed B. melitensis. The patient’s erythrocyte sedimentation rate (ESR) was 83 mm/h, C-reactive protein (CRP) level was 12.38 mg/L, and blood leukocyte concentration was 9425/mm3. Plain radiography confirmed septic loosening. A two-stage revision TKA was planned. The first stage involved removal of the infected prosthesis and debridement of the remaining cement and necrotic tissue. Removal of the prosthetic components and cement and application of an antibiotic-loaded spacer (teicoplanin-impregnated) was also performed in the first stage. Oral rifampicin (900 mg) and doxycycline (300 mg) were administered daily for 12 weeks postoperatively. At the end of the antibiotic therapy, the patient was seen as an outpatient, and his ESR, CRP level, and antibody titer had decreased to normal values. Finally, prosthetic revision was performed in the second stage of the TKA. Results: Ten years following surgery, the patient had returned to full activities of daily living, described no knee pain, and was very satisfied with the outcome. No abnormalities associated with the femoral, tibial, or patellar components were observed on plain radiography 10 years following surgery. The results of a Brucella agglutination test at that time were negative. Conclusion: Osteoarticular disease related to Brucella remains a problem in endemic regions. Brucellosis should be kept in mind in the differential diagnosis of prosthetic joint infections, especially in patients with a history of brucellosis and exposure to possible sources of the bacteria. We believe that two-stage revision arthroplasty is the first-line treatment of a loose TKA infected with B. melitensis. In addition, if a systemic Brucella infection is identified, the patient should be managed with two-stage revision surgery.

Objectives: A significant proportion of surgeons use intra-articular drains after arthroscopic anterior cruciate ligament (ACL) reconstruction. Haemarthrosis and pain adversely affects the functional outcome of ACL reconstruction. The purpose of the study was to evaluate the effect of tranexamic acid (TXA) administration to minimize pain and stiffness of knee joint by reducing haemarthrosis. Methods: The study enrolled 123 patients who underwent arthroscopic anterior cruciate ligament reconstruction in a prospective, randomized, double-blind study. The patients who were randomized into the TXA group (71 patients) received both intravenous and intra-articular TXA. The control group (52 patients) did not receive TXA. The anesthetist, surgeon, and observer were blinded to the study group (double-blinded). TXA was administered as a bolus dose of 15 mg/kg 10 minutes before the inflation of the tourniquet on the first side. This was followed by continued intra-articular administration of 3 g at 10 minutes before the deflation of the tourniquet. Intravenous infusion of 10 mg/kg/h was continued for the next 3 hours. Equal volumes of placebo were administered at the same rate and by the same route. We measured volume of drained blood 48 hours postoperatively. Results: The mean (± SD) postoperative volume of blood loss from the drain in the TXA and control groups was 100.6 ± 72mL and 164.3 ± 75mL ml, respectively. The difference between the two groups was significant (p < 0.005). Conclusion: This prospective randomized study showed that during arthroscopic anterior cruciate ligament reconstruction, TXA reduced blood loss and helped to reduce haemarthrosis amount and frequency with negligible side effects. With regard to the administration route, combined intravenous–intra-articular administration of TXA significantly reduces blood loss and the need for puncturing associated with arthroscopic anterior cruciate ligament reconstruction without enhancing the risk of deepssssssahrombosis.

Background. Inferior dislocation of the glenohumeral joint or luxatio erecta humeri is a rare form of injury, accounting for only 0.5% of all shoulder dislocations. Bilateral cases are even less frequent, with only eight cases reported in the literature. Method and result. We report one case of bilateral inferior dislocation of the shoulder. The patient made a complete functional recovery within 2 years after treatment by closed reduction and rehabilitation. Conclusion. Based on this case and the pertinent literature, the pathophysiology, diagnosis, and treatment of this rare injury are discussed.

We evaluated the results of patients who were treated with Ilizarov external fixation for type II and III open tibial fractures.Forty-five patients (4 females, 41 males; mean age 33 years; range 8 to 65 years) with open tibial fractures were treated with the Ilizarov external fixator. According to the Gustilo-Mendoza classification, the fractures were type II, IIIA, IIIB, and IIIC in 12, 20, 9, and 4 patients, respectively. The mean follow-up was 58 months and 4 days (range 42 months and 10 days to 66 months and 11 days). The fixators were applied for a mean of 17.2 weeks (range 6.8 to 55.7 weeks).Union was achieved in all cases. A significant difference was observed between type II and III fractures in terms of time to union (p0.05). Compared to type IIIA fractures, the time to union was significantly longer in type IIIB and IIIC fractures (p0.05). The most frequent complication was pin-tract infections (27.1%). Refracture occurred in four cases (8.8%). Three patients developed late infections at the fracture site. Radiographically, the results were excellent in 14 patients (31%), good in 22 patients (48.8%), moderate in five patients (11.1%), and poor in four patients (8.8%). Functional results were excellent in 21 patients (46.6%), good in 20 patients (44.4%), and moderate in four patients (8.8%).Despite technical difficulties and problems associated with pin-tract infections, the Ilizarov external fixator may be the preferred technique in open tibial fractures because of high union rates, the use of thin K-wires with minimal traumatic effect, and more successful functional results.

This prospective randomized study compared unilateral and bilateral spinal anesthesia with respect to intraoperative and postoperative complications, and time to discharge from hospital for knee arthroscopies in outpatients. We studied 70 ASA I patients scheduled for elective outpatient knee arthroscopy. The patients were randomly allocated into two groups to receive either 3 ml (15 mg) 0.5% hyperbaric bupivacaine (bilateral group) or 1.5 ml (7.5 mg) 0.5% hyperbaric bupivacaine (unilateral group). The duration of motor and sensory block and the time to discharge from the hospital were all recorded. Perioperative complications such as hypotension, bradycardia, nausea, vomiting, urinary retention, if present, were recorded. The patients were interviewed by telephone 7 days later, and each patient was asked about headache or backache. The duration of motor and sensory block, and the time to discharge from hospital was shorter in the unilateral group than in the bilateral group. Three patients in the bilateral group were treated for hypotension. Bradycardia occurred in two patients in the bilateral group, and three patients required temporary bladder catheterization due to delay in recovery of spontaneous urination. Nausea and vomiting occurred in three patients in bilateral group. Nine patients in the bilateral group and six patients in the unilateral group developed postspinal headache. Backache occurred in five patients in the bilateral group and in six patients in the unilateral group. Our data indicate that the use of unilateral spinal block is a suitable technique for knee arthroscopies in outpatients.

A case of a traumatic bilateral obturator dislocation of the hip and right side acetabular fracture in a 23-year-old man is presented. The patient was managed conservatively. After follow-up time of 24 months, the result was excellent. The importance of a pelvic radiograph and physical examination of the extremities after significant major trauma are emphasized.

We report a case study of a patient who underwent bone–patellar tendon–bone ACL reconstruction using an Endobutton. Although the fact that the Endobutton did not pass outside the femoral cortex was realized after the operation, Lachman's test was negative. The Endobutton appeared to hang onto the femoral tunnel as an anchor, and it was decided to observe rather than intervene. One year later no laxity had developed, and a second-look arthroscopy showed a good ligament reconstruction. Although it is quite easy to perform, Endobutton fixation in ACL surgery requires that maximum care be taken to ensure that the Endobutton has flipped.

We compared three different methods of anesthesia for outpatient knee arthroscopy in terms of perioperative surgical conditions, pain, and hemodynamics. In a prospective and double-blind study ( n=130) the patients were randomized into three groups. A 50-ml mixture composed of 20 ml 0.5% bupivacaine hydrochloride, 10 ml 2% lidocaine hydrochloride, and 20 ml 0.9% sodium chloride was prepared for local anesthesia. The knee joint was injected with 40 ml of the mixture. The portal sites were then injected with 10 ml of the mixture in group I. Using the same technique 250 micro g epinephrine was added to the same mixture in group II. In group III the knee joint was injected with 40 ml of the mixture, and only 50 micro g epinephrine was then added to 10 ml of the mixture left before the portal site injections. A tourniquet was not used. There were some statistically significant changes in hemodynamic data. Also the data on visual analogue scale scores, time of arthroscopy, and amount of liquid used for intra-articular flushing in group II and III were significantly lower than those in group I. According to our experience, bleeding in arthroscopy comes mostly from portal incision to intra-articular field, except when performing extensive synovial shaving, ligament reconstruction, and lateral retinacular release. Therefore, when hemostasis is obtained at portals, the arthroscopic view becomes clearer. We think that adding epinephrine to only portal site injections is sufficient to obtain a clear view and, furthermore, when carrying out arthroscopy in this manner, no significant changes are encountered in heart rate, mean arterial pressure, pain during arthroscopy, or time of arthroscopy.