Onur Bilge

Modern treatment of meniscal tears

The complex ultrastructure of the meniscus determines its vital functions for the knee, the lower extremity, and the body. The most recent concise, reliable, and valid classification system for meniscal tears is the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification, which takes into account the subsequent parameters: tear depth, tear pattern, tear length, tear location/rim width, radial location, location according to the popliteal hiatus, and quality of the meniscal tissue. It is the orthopaedic surgeon’s responsibility to combine clinical information, radiological images, and clinical experience in an effort to individualize management of meniscal tears, taking into account factors related to the patient and lesion. Surgeons should strive not to operate in most cases, but to protect, repair or reconstruct, in order to prevent early development of osteoarthritis by restoring the native structure, function, and biomechanics of the meniscus. Currently, there are three main methods of modern surgical management of meniscus tears: arthroscopic partial meniscectomy; meniscal repair with or without augmentation techniques; and meniscal reconstruction. Meniscus surgery has come a long way from the old slogan, “If it is torn, take it out!” to the currently accepted slogan, “Save the meniscus!” which has guided evolving modern treatment methods for meniscal tears. This last slogan will probably constitute the basis for newer alternative biological treatment methods in the future. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170067.

Peritoneum and omentum are natural reservoirs for chondrocytes of osteochondral autografts: A comparative animal study.

Objective The purpose of this study was to investigate the effects of the omentum, peritoneum, paratenon and skeletal muscle on the proliferation of the cartilage tissue using rabbit model as an in vivo culture medium. Methods 6 months old forty-five New Zealand rabbits were randomized into omentum, peritoneum, muscle, and Achilles paratenon groups. Standard sized osteochondral grafts were harvested from right knees and immediately placed into the specified tissues. Control group was fresh cartilage at the end of follow-up. After five months, samples were collected and evaluated macroscopically by measuring their dimensions (vertical = D1, horizontal = D2, and depth = D3) and volumes, and histologically by counting the chondrocyte number using camera lucida method. Results Macroscopically, increase in mean values for D1 and D2 dimensions of specimens from paratenon and omentum compared to pretransplant dimensions was statistically significant (p < 0.05). Although, volume measurements were higher in omentum and peritoneum group compared to pretransplant dimensions, increase was not significant (p > 0.05). Histologically, mean chondrocyte count was 14.0 ± 0.6 in fresh articular cartilage. Mean chondrocyte counts were 14.4 ± 0.9 in omentum group, 15.4 ± 1.0 in peritoneum group, 9.7 ± 1.3 in muscle group and 9.2 ± 0.4 in Achilles paratenon group respectively. However, mean chondrocyte counts were higher in samples of omentum and peritoneum group compared to fresh articular cartilage, increase was not statistically significant (p > 0.05). Discussion Transplantation of the cartilage grafts into mesothelium enhanced the chondrocyte counts and volumes compared with the pretransplant measurements. Mesothelium may have the potential to be used as an in vivo culture medium for osteochondral tissue growth.

Spinal Cord Injury Without Radiological Abnormality (SCIWORA): Is It Still a Notable Definition?

The developing Magnetic Resonance Imaging technologies have led to significant changes in the radiological diagnostic criteria of the Spinal Cord Injury without Radiological Abnormality (SCIWORA). Moreover, some authors even introduced alternative definitions for this specific disease recently. The aims of this study were to report an adolescent case with pure SCIWORA and to clarify its definition in the literature. A 16 year-old adolescent patient with thoracolumbar SCIWORA together with a pelvic fracture after a vehicle accident was presented in this case report. In neurological examination, both extremities were graded as Frankel type A. The X-ray and Magnetic Resonance Imaging revealed the right ischium-superior pubic ramus fracture and only edema of the spinal cord at T12, L1 and L2 vertebral levels, subsequently. A high dose of methyl-prednisolone was administered. Pelvic fracture was promptly fixed with an external fixator. After a follow-up period of two years, the neurological status of the patient showed progression to Frankel B. The patient continues to his life with wheelchair. In conclusion, an adolescent case with SCIWORA that fulfills all its original criteria was reported and a review of the literature was discussed in this study. In order to describe this special pathology, SCIWORA seems still to be the best ideal term.

Ultrasound-Guided Multiple Peripheral Nerve Blocks in a Superobese Patient

The number of obese patients has increased dramatically worldwide. Morbid obesity is associated with an increased incidence of medical comorbidities and restricts the application choices in anesthesiology. We report a successfully performed combined ultrasound-guided blockade of the femoral, tibial, and common peroneal nerve in a superobese patient. We present a case report of a 31-year-old, ASA-PS II, super obese man (190 kg, 180 cm, BMI: 58 kg/m2) admitted to the emergency department with a type II segmental tibia shaft fracture and ankle dislocation after a vehicle accident. After two failed spinal anesthesia attempts, we decided to apply a femoral block combined with a sciatic block. Femoral blocks were successfully performed with US guided in-plane technique. Separate blocks of the tibial and common peroneal nerves were planned after the sciatic nerve could not be located due to the thick subcutaneous tissue. We performed a tibial nerve block at 2 cm above the popliteal crease and common peroneal nerve at the level of the fibular head with US guided in-plane technique. The blocks were successful and no block-related complications were noted. Ultrasound guidance allows new approaches for multiple peripheral nerve blocks with low local anesthetic doses in obese patients.

Editorial Commentary: Arthroscopic Fixation of Tibial Eminence Fractures—Which Technique Is the Best Has Not Been Defined Yet!

The tibial eminence fractures are most frequently observed in children and adolescents increasingly. Their classification and management are mainly made by the displacement of the fracture fragment. The surgical management has evolved from open to arthroscopic techniques. Various fixation techniques have been defined. Mainly, there are 2 types of fixation: screw and suture-based methods. Although recent studies have demonstrated the biomechanical advantages of newer suture-based fixation methods, the best method of fixation has not been defined, yet. Currently, nondisplaced and reducible fractures are managed nonoperatively, and displaced and irreducible fractures are managed operatively. Until the best surgical method is defined by higher level of evidence studies clinically, functionally, radiologically, and biomechanically, the type of fixation will be chosen by considering the experience of the surgeon, the clinical status of the patient, the availability of the implants, and the morphology of these fractures.

Focal anatomic resurfacing implantation for bilateral humeral and femoral heads' avascular necrosis in a patient with Hodgkin's lymphoma and literature review.

Highlights • The avascular necrosis mostly affects young and middle-aged patients.• The optimum treatment has not been established, yet.• The focal anatomic resurfacing implantation has recently gained popularity.• The main advantage is the preservation of the joint’s anatomy and function.• These particular implants functioned well in this particular case of four joints.

The Comparison of Results of Early and Late Rehabilitation Following Arthroscopic Bankart Repair with Knotless Anchor in Recurrent Traumatic Anterior Shoulder Dislocation

Objectives: The aim of this study was to compare the clinical and functional results of early and late rehabilitation of patients who had undergone arthroscopic Bankart repair with knotless anchor for recurrent shoulder dislocation and to define the most appropriate rehabilitation time and the effect of this on recurrence. Methods: 34 patients (32 male and 2 female) were included in this study. The patients were diagnosed with recurrent anterior shoulder dislocation with Bankart lesion in our institution. The exclusion criteria in this study were multi-directional shoulder instability, wide osseous Bankart lesion, wide Hill-Sachs lesion or rotator cuff tear. All patients underwent arthroscopic Bankart repair. Knotless anchor was used in all patients. The patients were grouped into 2 groups postoperatively according to the immobilization period and rehabilitation regimen. Both groups equally consisted of 17 patients. (Group 1; early rehabilitation group, Group 2; late rehabilitation group) All patients were examined retrospectively. Gender, age, dislocated side, dominant hand, recurrence, presence of additional pathologies, time of first and last dislocations preoperatively and numbers of dislocations were the demographic data recorded. At the final follow-up; the restriction in external rotation was measured by comparative goniometry and clinical evaluation was made using the Constant and Rowe scores. One-sample T-test, Mann-Whitney U Test, Crosstabs Chi Square Test and Shapiro-Wilk Tests used for statistical analysis. Results: The mean age of the patients in Group 1 was found to be 25.1 ± 6.5 ( 17-43) years and in Group 2, 30.8 ± 6.8 (21-46) years. After a mean follow-up period of 14.7 months, no patients in Group 1 experienced a recurrence, whereas in Group 2 over the mean follow-up period of 38.5 months, there was dislocation, following episodes of subluxation, in only 1 patient (5.8%). When the parameters of first dislocation, last dislocation and number of dislocations were evaluated separately in two groups, no statistical difference was observed between the groups in the relevant parameters (n.s.). A statistically significant difference was determined between the groups in respect to the restriction in external rotation (p<0.05). There was no statistically significant difference between the groups in respect to the Constant and Rowe scores (n.s.). Conclusion: The most important result of this study was that the early beginning of rehabilitation yielded less external rotation restriction than late beginning of rehabilitation. The absence of recurrence in the group of early beginning of rehabilitation reminds the question “does early rehabilitation reduce recurrence rates?” The findings in this study should be confirmed with further prospective, randomized and longer follow-up studies.

Reverse Segond Fracture Variant Without Posterior Cruciate Ligament Injury Report of an Extremely Rare Case

Objectives: Reverse Segond fracture, which was described as the association of an avulsion of deep capsular portion of medial collateral ligament and tears of both posterior cruciate ligament (PCL) and medial meniscus, is an extremely rare injury, unlike Segond fracture. The aim is to report successful surgical treatment of a case with “Reverse Segond Fracture” with intact PCL. Methods: The patient was a 16 years old male, who admitted to emergency department of our Level I trauma center after a pedestrian traffic accident. The main complaint was pain on left knee and shoulder. Physical examination revealed mainly limitation in range of motion (ROM) of relevant joints. Radiology revealed Reverse Segond fracture in the left knee and associated left clavicula mid-shaft fracture. Imaging with MRI and CT revealed neither PCL injury or additional ligamentous pathologies of knee. MRI only revealed medial meniscus tear. Results: In surgery, avulsed bony portion of Reverse Segond fracture was fixed to tibia with a suture anchor and a cannulated screw securely under medial meniscus. Peripheral longitudinal medial meniscus tear was fixed with a 2-0 absorbable suture. Clavicle was internally fixed meanwhile. Knee range of motion (ROM) was started early on postoperative first day, then augmented progressively. The patient was mobilized partially-weight bearing after 1.5 months and returned to his active daily life after 2.5 months. He was without any residual complaints after a final follow-up period of 26 months. Conclusion: This case report would be evaluated as a Reverse Segond Fracture variant, as no injury to PCL was noted, in contrast to its original definition in the relevant literature, which is also scarse. To the best of knowledge, this is the first report of successful surgical treatment of a case with Reverse Segond Fracture variant without PCL tear in the relevant literature.

The Effects of Additional Mechanical External Compression on Hemarthrosis After Arthroscopic External Capsular Release.

Objectives: Arthroscopic external capsular release has been frequently used especially in the treatment of symptomatic lateral patellar hyperpression syndrome. Hemarthrosis was reported among one of the most important complications of this procedure. The aim of this study was to demonstrate the effects of the postoperative application of mechanical external compression -in patients who undergone arthroscopic lateral capsular release- on the rates of postoperative bleeding and on pain scores. Methods: In this study, different clinical evaluations of 39 patients, who were diagnosed both clinically and radiologically as lateral patellar hyperpression syndrome and who were treated with arthroscopic external capsular release by radiofrequency probe, were compared retrospectively. The patients were evaluated in two groups: Group I (external capsular release, N:19) and Group II (external capsular release + mechanical external compression, N:20). The mean age of the patients was 38.5 +/- 7.3 and 42.3 +/-7.8, in group I and group II, respectively. The female / male ratio and right / left ratio was 17/2 and 16/4, and 9/10 and 9/11 in group I and group II, respectively. Postoperative drainage, cold compression, postoperative 24 hours of bed rest was applied to all patients. In addition, knee range of motion together with quadriceps strengthening exercises was started after postoperative 24 hours in both groups. In group II, mechanical external lateral compression with a steril roll bandage was applied just lateral to the patella and it was ended after one week. The clinical evaluations of the patients were performed first with VAS scoring preoperatively, at 1st and 6th month postoperatively and second with measurements of intraarticular bleeding amounts within the postoperative drains. For the statistical evaluations of the data, variance analysis and independent t-test were used. Results: The amounts of bleeding through the drains were 94.2 ml +/- 29.9 and 43.0 ml +/- 16.3 in group I and II, respectively (p<0.05). The VAS scores were found to decrease significantly at both early postoperative and late postoperative periods compared with preoperative period, in both groups (p<0.05). Although the decrease in VAS scores of early postoperative period was found to be more in group II than in group I, this decrease was not significant. Conclusion: One of the most frequent complications after arthroscopic external capsular release has been reported to be hemarthrosis, which is related with worse clinical outcomes after this surgical procedure. The most important result of this study revealed that the addition of immediate postoperative mechanical external compression application lateral to patella decreased postoperative amount of bleeding and subsequent hemarthrosis, without adding a significant clinical effect on VAS scores. In addition to the results of this study, prospective randomized studies are required further.

Surgical Treatment of the Patellofemoral Joint: Lateral Release

Recent articles have ranked LR 47th among all procedures by orthopaedic surgeons [9, 14]. Despite its frequency the indications and results of an LR remain controversial. The acceptable results (good and excellent) have a wide range from 14 to 99 % [1, 4, 12, 14].