Reha N. Tandogan

Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport

The purposes of this multi-center study were: (a) to document the location and type of meniscal and chondral lesions that accompany anterior cruciate ligament (ACL) tears, and (b) to test for possible relationships between these lesions and patient age, time from initial injury (TFI), and sports level (i.e., recreation, amateur, professional, and national). The cases of 764 patients with ACL tears who underwent arthroscopy for the first time were retrospectively analyzed. The group included 684 males and 80 females of mean age 27 years (range 14–59 years). The mean TFI was 19.8 months (range 0.2–360 months). Eighty-seven percent of the group engaged in regular sporting activity. Thirty-seven percent had medial meniscal tears, 16% had lateral meniscal tears, and 20% had tears of both menisci. The most common tear types were longitudinal tears in the posterior and middle horns of both menisci. Tears of the lateral meniscus were more centrally located than those of the medial meniscus. Incomplete tears and radial tears were significantly more common in the lateral meniscus. Nineteen percent of the knees had one or more chondral lesions. Sixty percent of the chondral lesions were located in the medial tibio-femoral compartment. Patient age was statistically associated with presence of a medial meniscal tear, presence of a grade 3 or 4 chondral lesion, and presence of a complex tear of the medial meniscus. Sports level was not statistically related to any of the parameters studied. The odds of having a medial meniscal tear at 2 to 5 years TFI were 2.2 times higher than the odds in the first year post-injury, and the odds at >5 years were 5.9 times higher than at 0 to 12 months TFI. The frequency of lateral meniscal tear remained fairly constant at 2 years TFI. The odds of having a grade 3 or 4 chondral lesion were 2.7 times greater at 2 to 5 years TFI than they were at 1 year post-injury, and these odds increased to 4.7 when patients at >5 years TFI were compared to those in the 2 to 5 years category. Multivariate analysis demonstrated that TFI and age were equally important predictors of lateral meniscal tears and of grade 3 or 4 chondral lesions; however, TFI was the better predictor of medial meniscal tear.

Treatment of Scaphoid Nonunions with a Vascularized Bone Graft Based on the First Dorsal Metacarpal Artery

Four patients with chronic nonunion of the scaphoid were treated by a vascularized bone graft based on first dorsal metacarpal artery. The mean duration of the nonunion was 28.5 months (range 12–48 months). There was avascular necrosis in all patients confirmed by magnetic resonance imaging (MRI). None of the patients had previous attempts at surgical reconstruction. Two fractures were localized at the waist one in the distal part and one at the proximal pole. Osseous union of the scaphoid was confirmed by X-ray in all patients in an average of 2.1 months. We recommend this technique for the treatment of established scaphoid pseudoarthrosis with avascular necrosis since it is associated with minimal morbidity and predictable good results.

Remote cerebellar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review.

OBJECTIVE AND IMPORTANCE: This report presents a case in which cerebellar hemorrhage occurred after lumbar decompression surgery that was complicated by dural tear and prolonged cerebrospinal fluid leakage. Remote cerebellar hemorrhage after spinal surgery is extremely rare. Our objective is to describe this unusual complication, discuss the possible mechanisms of remote cerebellar hemorrhage, and review the literature. CLINICAL PRESENTATION: A 73-year-old woman underwent surgery for lumbar spinal stenosis. A dural tear occurred during decompression, and the patient developed remote cerebellar hemorrhage on postoperative Day 2. INTERVENTION: The cerebellar hemorrhage was treated surgically, and a biopsy of hemorrhagic brain parenchyma revealed an arteriovenous malformation. CONCLUSION: Although it is an extremely rare complication, remote cerebellar hemorrhage should be kept in mind as a possible complication of spinal surgery, especially in operations complicated by dural tears.

Effects of methylprednisolone and betamethasone injections on the rotator cuff: An experimental study in rats

Thirty-one female Sprague-Dawley rats were used to determine the effects of subacromial corticosteroid injections on the rotator cuff. The injection technique was tested in 6 animals, which were excluded from the study. The remaining 25 rats were randomly divided into three groups of 8 animals each; a single rat received no injections. Every other week for 8 weeks, one shoulder in each rat was injected with methylprednisolone, betamethasone, or saline in a dosage equivalent to that used in humans. The supraspinatus and infraspinatus tendons were removed 10 days after the last injection and evaluated. There were no pathologic changes in the tendons injected with saline. In 43% of the methylprednisolone-treated rats and 29% of the betamethasone-treated rats, the tendons were abnormally soft and light-colored. In 43% of the methylprednisolone group and 71% of the betamethasone group, fragmentation of collagen bundles and inflammatory cell infiltration were evident. Subacromial injections of methylprednisolone or betamethasone repeated frequently can cause deleterious changes in the normal structure of the rat rotator cuff. In light of these findings, therapy for subacromial impingement syndrome of the shoulder with frequent, repeated steroid injections is potentially harmful.

Necrotizing Soft-Tissue Infection of a Limb: Clinical Presentation and Factors Related to Mortality

Background: Necrotizing fasciitis is a rare and often fatal soft-tissue infection. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections. The purpose of this study was to analyze the clinical presentation and evaluate factors that determine mortality associated with this uncommon surgical emergency. Methods: The study retrospectively investigated the medical records of 22 patients who were diagnosed and treated for necrotizing fasciitis of the lower extremity, 14 of whom had involvement of the foot (nine patients) or foot and ankle (five patients) at our hospital. The data collected for each of the 22 patients were age, sex, underlying systemic factors, location of infection, duration of symptoms, portal of entry of infection, initial diagnosis on admission, physical, radiographic and laboratory findings, microbiological cultures, the type of therapy used (debridement or amputation), treatment outcome, and number of days in the hospital. Results: A total of 23 extremities of 22 consecutive patients with necrotizing fasciitis who underwent surgical debridement or amputation were retrospectively reviewed. Radical surgical debridement was done in 16 extremities initially, and this treatment was repeated a mean of two times (range one to four debridements) to completely remove all the necrotic tissue. Nine patients (41%) required below-knee or above-knee amputation. There were three deaths, one related directly to sepsis and organ failure, one due to gastrointestinal hemorrhage, and one caused by pulmonary embolism. There were no significant differences between patients who had the amputations and those who did not with respect to mortality rate or age (p = 0.538 and p = 0.493, respectively). Those who died were significantly older than the survivors (p = 0.038). Conclusions: The diagnosis of necrotizing fasciitis should be considered for any individual who has unexplained limb pain, especially if that person has diabetes mellitus or chronic liver disease. There was no difference in mortality rates between patients with or without amputation. The primary treatment is early and aggressive debridement of involved skin, subcutaneous fat, and fascia.

Tunnel enlargement after arthroscopic anterior cruciate ligament reconstruction: Comparison of bone-patellar tendon-bone and hamstring autografts

Bone tunnel enlargement associated with anterior cruciate ligament (ACL) reconstruction has recently become a topic of interest in the literature. This association was examined, along with the effect of femoral and tibial tunnel enlargement on the clinical results of ACL reconstruction performed with either bone-patellar tendon-bone (BPTB) or hamstring (HST) autografts. Forty-six patients underwent arthroscopic ACL reconstruction (23 receiving BPTB autograft and 23 HST) between March 1999 and July 2001. Thirty patients (13 receiving BPTB autograft and 17 HST) completed the last clinical and radiologic evaluations and were included in the study. The mean age of patients in the HST group was 29.8 years (range 18–39) and that in the BPTB group was 27.6 years (range 20–37). The mean follow-up period was 24.6 months (range 12–36) in HST group and 18.5 months (range 12–40) in BPTB group. The effect of tunnel enlargement on the clinical results was evaluated by comparing preoperative and postoperative Lysholm, Tegner, and International Knee Documentation Committee scores and ligament laxity measurements between and within the groups. Postoperative femoral and tibial tunnel diameters in both groups were significantly larger than their corresponding preoperative tunnel diameters. In an intergroup evaluation, the enlargement of the tibial tunnel was similar in both groups (P=.556), but the femoral tunnel diameter was significantly larger in the HST group than in the BPTB group (P>.001). Preoperative laxity of the knees significantly improved after the operations in both groups, but no difference between the groups was evident at the final follow-up visit. No correlation between tunnel widening and the clinical results of the BPTB and HST procedures was observed.

Synovial cysts of proximal tibiofibular joint causing peroneal nerve palsy: report of three cases and review of the literature

IntroductionSynovial cyst of the proximal tibiofibular joint is a very rare condition, for which there is no consensus regarding treatment. Case presentationWe present three patients who had synovial cysts of proximal tibiofibular joint that caused peroneal nerve palsy. We discuss the special features of synovial cysts and review the literature. ConclusionWe consider the best treatment of synovial cysts originating from proximal tibiofibular joint and causing peroneal nerve palsy to be total surgical removal as soon as possible after the diagnosis is made. It should be kept in mind that despite surgical treatment the neurological symptoms may not recover.

Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery.

This study assessed the effect of fracture displacement and elapsed time before surgery on the development of avascular necrosis and nonunion after internal fixation of femoral neck fractures. Twenty-eight patients with 30 femoral neck fractures who underwent internal fixation and completed a minimum of 2 years’ follow-up were retrospectively analyzed. The rates of avascular necrosis and nonunion were 12.5% and 25%, respectively, among patients who underwent surgery before 12 hours had elapsed and 14% and 27% among those who underwent surgery after that time. The rates of avascular necrosis and nonunion associated with fracture displacement were 6% and 18%, respectively, among patients with undisplaced (Garden stages 1 and 2) fractures and 23% and 38% among those with displaced (Garden stages 3 and 4) fractures. Nonunion and avascular necrosis led to the necessity for additional surgery in 11 of 30 (36%) hips. Internal fixation of femoral neck fractures is associated with a high initial complication rate, but if successful, the procedure ensures an excellent long-term outcome. Internal fixation should be considered the treatment of choice in young patients with nondisplaced fractures.

Analysis of outcomes for surgically treated hip fractures in patients undergoing chronic hemodialysis.

BACKGROUND Hip fractures in patients with end-stage renal disease are associated with frequent complications. This study analyzed clinical outcomes for patients on chronic hemodialysis who sustained hip fractures and were treated with a variety of fracture repair methods. METHODS Twenty-nine patients with thirty-two hip fractures were analyzed in three groups. Group 1 consisted of eleven hips in eleven patients with an intertrochanteric fracture that was treated with internal fixation; Group 2, thirteen hips in ten patients with a femoral neck fracture that was treated with screw fixation; and Group 3, eight hips in eight patients with a femoral neck fracture that was treated with hemiarthroplasty. The outcomes and early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were compared. RESULTS In Group 1, eight complications occurred in six hips and nonunion developed in five hips. In Group 2, sixteen complications developed in eleven hips. Union was achieved in two of the thirteen hips, nine hips had nonunion, and two hips had osteonecrosis develop. In Group 3, only one hip had early complications, there were no late complications, and three patients died. The mean duration of follow-up was twenty-three months, and the overall mortality rate was 45%. There were no significant differences among the groups with respect to the cumulative survival proportions. Regression analysis of age, sex, and total hemodialysis duration in relation to mortality risk revealed that only age had a significant influence on mortality (p = 0.019). CONCLUSIONS Surgical treatment of hip fractures in patients with end-stage renal disease who are on chronic hemodialysis is associated with frequent complications and a high mortality rate. Osteosynthesis is an acceptable option for treating intertrochanteric fractures and nondisplaced femoral neck fractures, but displaced femoral neck fractures should be treated with hemiarthroplasty.

Os vesalianum pedis

Os vesalianum pedis is an accessory bone located proximal to the base of the fifth metatarsal. Its prevalence has been reported to be from 0.1% to 1.0%. This bone is found within the peroneus brevis tendon and is considered to be asymptomatic in the majority of people. We describe a patient with os vesalianum pedis with a distinct mediocuboidal articulation. The radiologic differential diagnosis of the ossicle is discussed.