Effectiveness of radiofrequency ablation for treatment of plantar fasciitis

Plantar fasciitis is the most common cause of heel pain. Pain can be persistent in some patients and interrupt daily activities and sportive activities. There are a lot of treatment options available for plantar fasciitis. We hypothesized that patients with chronic persistent plantar fasciitis can be successfully treated with radiofrequency nerve ablation (RFNA).Two hundred sixty-one patients with plantar fasciitis (378 feet) treated with RFNA from February 2017 to January 2019 were retrospectively assessed. All the patients had plantar heel pain for at least 6months. Based on their body mass index (BMI), the enrolled patients were divided into obese (BMI ≥ 30kg/m2) and non-obese (BMI < 30kg/m2) groups. The patients were asked to complete a questionnaire just before and after the procedure and during the final follow-up. The BNS Radiofrequency Lesion Generator was used during a single session. The patients' information, including their visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score, was assessed. During their final follow-up, the patients were asked to rate the success of their treatment by choosing one of the following options: completely successful, very successful, moderately successful, marginally successful, or not successful.The VAS and AOFAS scores of all the patients were evaluated pre-procedure, in the first month after procedure, and during the final follow-up (8-24 months). There was a statistically significant difference between the pre-procedure and postprocedure VAS scores (P < .001), there was no statistically significant difference between the VAS scores in the first month postprocedure and during the final follow-up.There was a statistically significant difference between the pre-procedure and postprocedure AOFAS scores (P < .001), there was no statistically significant difference between the AOFAS scores in the first month postprocedure and during the final follow-up.RFNA can be used as an alternative method to surgical procedures for treating plantar fasciitis because it is safe and effective. The advantages of RFNA are that patients can quickly return to their work and resume weight-bearing activities.

A comparison of double single suture-button fixation, suture-button fixation, and screw fixation for ankle syndesmosis injury: A retrospective cohort study

Different methods have been used throughout the years for syndesmotic injury but there is no consensus on the ideal treatment. Some methods are expensive and some have more complications. The aim of this study is to compare single suture endobutton with double suture endobutton and screw fixation for syndesmotic injury.Sixty nine patients with syndesmotic injury with fibular fractures whom were treated with a single interosseous suture endobutton system (ZipTightTM, Zimmer Biomet), a double interosseous suture endobutton system (ZipTightTM, Zimmer Biomet) and 1 syndesmotic screw (TST, Istanbul, Turkey) were included in this study. Functional and radiological results from patient records between 2015 and 2018 were retrospectively evaluated.Twenty patients were treated with the double interosseous suture endobutton, 23 were treated with the single interosseous suture endobutton, and 26 were treated with traditional AO screw fixation. Three patients from the screw fixation group (11.5%) required revision surgery (P < .05). All the radiologic and clinical outcomes were statistical similar in all 3 groups.Our findings showed that the interosseous suture endobutton system is at least as safe as the screw fixation technique for treatment of syndesmosis joint injuries and can be used as an alternative to the screw method. The interosseous suture endobutton system eliminates the need for a second surgery to remove the hardware, which minimizes the probability of re-diastasis. Since our results showed no statistical difference between single and double interosseous suture endobutton systems, the less costly single endobutton system may be the better alternative.

Effects of a novel biodegredable implant system on a rat tibia fracture model

OBJECTIVE

This study aimed to determine the effects of a novel biodegradable implant releasing platelet-derived growth factor (PDGF) at the fracture site on fracture healing in a rat tibia fracture model.

METHODS

In this study, 35 male Sprague-Dawley rats weighing between 300 and 350 g were used. The rats were divided into four groups: Group A (control group without any treatment, n=10), Group B (spacer without PDGF Group, n=10), Group C (spacer with PDGF group, n=10), and Group D (healthy rat Group, n=5). Standardized fractures were created in the right tibias of rats, and then biodegradable implants made of poly-β-hydroxybutyrate-co-3-hydroxy valerate were implanted at the fracture sites in Groups B and C. In Group C, implants were loaded with 600 ng of PDGF. Animals were sacrificed 30 days after the operation, and fracture healing in each group was assessed radiologically based on the Goldberg score. Furthermore, the anteroposterior (AP) and mediolateral (ML) callus diameters were measured macroscopically, and fracture sites were mechanically tested.

RESULTS

In the radiological assessment, Group C showed higher fracture healing rate than Groups A and B (p=0.001), whereas no significant difference was found between group C and Group D (p>0.05). In the macroscopic assessment, while Group C exhibited the thickest AP callus diameter (p=0.02), no significant differences in ML callus diameters existed among the groups (p>0.05). Mechanical testing revealed that Group C had higher torsional strength (p=0.001) and stiffness than Groups A and B (p=0.001) while there was no significant difference between Groups C and D (p>0.05).

CONCLUSION

Biodegradable implant releasing PDGF may have positive effects on fracture healing.

Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery?

We report the outcomes of mechanical prophylaxis and chemoprophylaxis in patients who underwent elective surgery for idiopathic adolescent scoliosis (AIS).We retrospectively studied the patients who underwent posterior spinal instrumentation for AIS. The patients were divided into three groups: Group A low-molecular-weight heparin (LMWH) started at 8 hours after surgery; Group B LMWH started at 24 hr after surgery; Group C did not receive chemoprophylaxis. The data about wound oozing, need for transfusion, preoperative and postoperative hemoglobin level, length of stay in hospital, interval from the surgery to removal of closed suction drainage tube, postoperative blood loss from closed suction drain, deep venous thrombosis (DVT), and pulmonary embolism (PE) were investigated.The mean age and Lenke classification for all the groups were similar. No DVT or PE was detected in any group. The mean blood loss from the drain was higher in Group A (400 mL) and Group B (450 mL) when compared to Group C (150 mL) (P = .001). There were more wound oozing in Groups A (5) and B (6) than in Group C (3) (P = .585). Three patients in Group B, 3 patients in Group A, and no patient in Group C had superficial infections. However, there was no statistical difference between the groups (P = .182). Postoperative hospital stay was significantly longer in Groups A (6 days) and B (6 days) then in Group C (5 days) (P = .001).Our current study claims that chemoprophylaxis is not necessary for the patients without risk factors after AIS surgery. Early mobilization and mechanoprophylaxis represents adequate prophylaxis in addition to pain management and well hydration in patients' routine treatment. The complications of chemoprophylaxis are not correlated to the initiation time of prophylaxis.

Paediatric lateral humeral condyle fractures: internal oblique radiographs alter the course of conservative treatment

INTRODUCTION

At first presentation of paediatric humeral lateral condyle fractures, radiological methods such as computerised tomography, ultrasonography, magnetic resonance imaging, arthrography, and internal oblique radiography are used to determine stability. Very few studies show which radiological method should be used to evaluate displacement at follow-up for conservatively treated patients. This study aimed to show that internal oblique radiography is a simple, effective method to determine the subsequent development of fracture displacement in patients with an initially non-displaced or minimally displaced fracture.

MATERIALS AND METHODS

In this retrospective study, 27 paediatric patients with non-displaced or minimally displaced (<2 mm) humerus lateral condyle fracture were evaluated by elbow anteroposterior radiograph. The degree of fracture displacement was evaluated by anteroposterior then by internal oblique radiographs. The first follow-up was made between the 5th and 8th day and thereafter at intervals of 7-10 days.

RESULTS

Of the 27 patients identified with non-displaced or minimally displaced (<2 mm) fracture from the initial anteroposterior radiograph, 16 were accepted as displacement >2 mm as a result of the evaluation of the internal oblique radiography and underwent surgery. At follow-up, 2 of 11 patients were defined with displacement from anteroposterior and internal oblique radiographs and 4 from the internal oblique radiographs and underwent surgery. Conservative treatment was applied to 5 patients.

CONCLUSIONS

Internal oblique radiography is the best imaging showing subsequent fracture displacement in initially non-displaced or minimally displaced humerus lateral condyle fractures. At the first week follow-up, anteroposterior and particularly internal oblique radiographs should be taken of conservatively treated patients.

Medial humeral condyle fractures in adolescents: treatment and complications

The very rare isolated medial humeral condyle fractures in children and adolescents pose significant problems to orthopedic surgeons such as ulnar nerve injury, trochlear irregularities, fishtail deformity and motion loss. Six adolescent boys with displaced medial humeral condyle fractures with an average age of 14.8 (range 12-17) were included in this study. Patients were followed-up with a mean of 39.8 months (range 21-72). In three patients, there were clinical signs of ulnar nerve dysfunction at initial presentation. Of these, two had only mild hypoesthesia on the ulnar side. The other patient had sensory and motor loss of ulnar nerve at initial presentation complicated by hypothenar atrophy and anhydrosis during follow-up. Complete recovery was seen in this patient only at 2 years. One patient without a neurologic compliant at initial presentation developed mild hypoesthesia on the ulnarly innervated areas postoperatively with complete resolution. Medial skin incision was used for open reduction and internal fixation. No signs of gross morphologic damage were seen on the nerve. The symptoms resolved postoperatively in 3 months time in three of the patients, but in the remaining one, it took 2 years for complete resolution of the symptoms. Also, trochlear irregularity and fishtail deformity were seen on radiographs of two different patients. In all but one patients, motion loss ranging from 10° to 20° was evident on physical examination. The most important finding of this study revealed that transient ulnar nerve dysfunction was seen two-thirds of the patients in this series than any other series reported previously. In three series, only one case of ulnar nerve injury was reported from a total of 19 patients. A possible explanation for such a difference may be the older age in this series.

Cementless total hip arthroplasty with modified oblique femoral shortening osteotomy in Crowe type IV congenital hip dislocation

Midterm results of cementless total hip arthroplasty in patients with Crowe type IV congenital dislocation of the hip were evaluated. A modified oblique subtrochanteric shortening osteotomy was used in all patients. A cylindrical femoral stem was used in all patients to stabilize the osteotomy. Mean follow-up was 82 months in 20 hips of 16 patients. Mean Merle D'Aubigné pain score increased from 2.52 to 5.65 points, function score improved from 4.0 to 5.3 points, and mobility score improved from 3.95 to 5.35. Mean greater trochanter height relative to the estimated hip center was 6.8 ± 2.0 cm preoperatively and -1 ± 0.2 cm postoperatively. Complications were dislocations in 3 patients, which were successfully managed without redislocation and fracture of greater trochanter in 3 patients, which healed uneventfully in 2 but with residual Trendelenburg gait in one. Total hip arthroplasty with modified oblique subtrochanteric shortening osteotomy is an effective technique for the treatment for Crowe type IV hip dislocation.

Clamp fixation to prevent unfolding of a suture knot decreases tensile strength of polypropylene sutures

PURPOSE

Although sutures evolved in last decade and the product spectrum broadened largely, they can be still classified into two: monofilament and multifilament. Sutures are the mainstay of orthopedic procedures like fascial closures, tendon repairs or tenodesis. In every repair, a suture loop is created. This suture loop is prone to failure due to suture elongation, knot slip and suture breakage. As the knot is the stress riser in a suture loop, the majority of acute loop failure occurs just adjacent to the knot. Monofilament sutures have higher bending stiffness and tendency to untie than multifilament sutures. The first throw of monofilament sutures have tendency to untie, which decrease loop tension and result in loss of achieved tissue approximation.

METHODS

Although a common practice is to fix the first throw via a clamp before the locking one is tied, it can be hypothesized that a potential deforming effect can lead to a decrease in ultimate failure load of a monofilament suture loop.

RESULTS

Fixing the first throw significantly reduced the ultimate failure load of monofilament nonabsorbable polypropylene sutures (Prolene) (62.2 ± 8 N vs. 72.7 ± 9 N, p = 0.019). The ultimate failure load achieved by monofilament sutures Polyglyconate (Maxon) and Nylon (Ethilon) and braided absorbable Polyglactin (Vicryl) were not affected by fixing the first throw.

CONCLUSION

Under microscopic examination, polypropylene sutures were found to be deformed by clamp fixation, while the others were not. Polypropylene sutures can be easily damaged when it is fixed by a clamp during knot tying. Presented data demonstrated that in real surgical situations clamp fixation of polypropylene knots can damage the suture loop and carry the risk of acute failure of repair site during early rehabilitation.

Suture anchor tenodesis in repair of distal Achilles tendon injuries

BACKGROUND

Distal Achilles tendon avulsions are in the form of either bony and nonbony avulsion of Achilles tendon from its calcaneal insertion.

METHODS

Four patients with distal Achilles tendon avulsions or ruptures which were treated with tendon to bone repair using suture anchors are presented here. Operated leg was immobilized in above-knee cast for 4 weeks while the patient walked non-weight-bearing. Then, cast was changed to below knee, and full weight-bearing was allowed. Patients underwent gait analysis minimum at first postoperative year.

RESULTS

Mean American Orthopedics Foot Ankle Society ankle/hindfoot score of patients at last visit was 88.75 (range 85-100), and Achilles tendon total rupture score was 77.75 (range 58-87). Mean passive dorsiflexion of injured ankles (14° ± 5°) was lower than uninjured ankles (23° ± 9°). All the kinematic parameters of gait analysis were comparable to the uninjured side. Maximum plantar flexion power of injured ankle was 1.40 W/kg, and this was significantly lower than the contralateral side value 2.38 W/kg; (P = 0.0143).

CONCLUSIONS

There were no visually altered gait or problems in daily life. Suture anchor tenodesis technique of distal Achilles tendon avulsions was successful in achieving durable osteotendinous repairs.

Vascularity and histology of fetal labrum and chondrolabral junction: its relevance to chondrolabral detachment tears

PURPOSE

Recently, acetabular labral tears were recognized as a source of hip pain. Most of these tears were found to be localized at the chondrolabral junction. The purpose of this study was to evaluate the chondrolabral junction in reference to its collagen fiber orientation and its vascularity, which might be used to explain the preponderance of labral tears.

METHODS

Eighteen formalinized fetuses with a mean gestational age of 17 weeks (range: 11-24 weeks) were examined. The acetabuli were removed en bloc with the proximal femur for ease of orientation. The acetabuli were prepared and examined in four quadrants, namely, anterior, superior, posterior, and inferior.

RESULTS

The staining pattern of the posteroinferior labrum was more dense than the anterosuperior labrum, due to its high collagen content. Collagen fibers in the posteroinferior quadrants were oriented perpendicularly to the chondrolabral junction, while those in the anterosuperior quadrants had a parallel oriented. Perpendicular collagen orientation and high collagen content may explain the stronger anchorage of the labrum to the bony acetabulum in posteroinferior quadrants. All of the vessels supplying the labrum originate from the capsular connective tissue and traverse the body of the labrum to reach the articular side. None of these vessels traverse the chondrolabral junction to reach the bony acetabulum. The total number of blood vessels was significantly higher in the capsular zone than in the articular zones. The number of blood vessels did not differ between the acetabular quadrants.

CONCLUSIONS

In an effort to understand the chondrolabral junction tears, we can conclude that collagen content and fiber orientation may represent the histological basis for the predominance of tears at the anterosuperior region.

Revision of the failed pedicle screw in osteoporotic lumbar spine: biomechanical comparison of kyphoplasty versus transpedicular polymethylmethacrylate augmentation

OBJECTIVES

In this study, we aimed to compare of kyphoplasty versus transpedicular polymethylmethacrylate (PMMA) augmentation biomechanically in the revision of the failed pedicle screw in osteoporotic lumbar spine.

MATERIALS AND METHODS

Bone mineral density (BMD) of lumbar vertebrae collected from four bovines were measured. Each vertebra was decalcified with hydrochloric acid solution to obtain osteoporotic specimens. Primary polyaxial pedicle screws were inserted into the pedicles and pulled out until they failed. The pullout strength results of all specimens were recorded. Revision pedicle screws were randomly inserted into the same pedicles by either pedicle hole PMMA augmented (group 1) or kyphoplasty (Xvoid™) PMMA augmented pedicle screws (group 2). The pullout strength results of all specimens were re-recorded.

RESULTS

The mean BMD significantly decreased from 1.686 ± 227.9 g/cm(2) to 1.432 ± 157.1 g/cm(2) following decalcification (p<0.001). In group 1, the mean pullout strength of primary screws significantly decreased from 3443 ± 1086 N/m(2) to 2088 ± 924 N/m(2) following pedicle screw augmentation (p=0.006). In group 2, the mean pullout strength of primary screws decreased from 3702 ± 1063 N/m(2) to 3664 ± 1057 N/m(2) following kyphoplasty augmentation (p=0.934). Pedicle screw augmentation group achieved significantly lower pullout strength values than kyphoplasty pedicle hole augmentation group (p=0.002).

CONCLUSION

Although pedicle hole PMMA augmentation is the gold standard for the failed screws in an osteoporotic bone, kyphoplasty augmented pedicle screw seems to be more effective method increasing the pullout strength.

[The effectivity of magnetic resonance imaging findings in the diagnosis of bucket handle meniscal tears]

OBJECTIVES

This study aims to test the efficacy of magnetic resonance imaging (MRI) evaluation by a group who were blinded to the arthroscopic diagnosis in patients with known bucket handle meniscal tears.

PATIENTS AND METHODS

In this study, MRI scans of 28 patients who were operated due to bucket handle meniscal tear with sufficient documentation were evaluated. Radiographic evaluation was performed by two different groups, including an orthopedist and radiologist. In the first group, evaluation of MRI scans was performed by the specialists who were aware of the arthroscopic diagnosis and marked the defined MRI signs of bucket handle meniscal tear. In the second group, evaluation was done, remaining blinded to the diagnosis, with only initial complaints at admission. The second group also evaluated the MRI scans and marked the pathologic signs. The sensitivity of radiological signs marked by both groups was compared. Invariables were found using blinded evaluation.

RESULTS

Double posterior cruciate ligament and free fragment in the intercondylar notch were invariable sensitivities found in the MRI scans by blinded evaluation. The sensitivity of coronal truncation, anterior flip and any free fragment signs were significantly decreased in the setting of blinded evaluation.

CONCLUSION

Preoperative differentiation of reparable bucket-handle tears from irreparable is of utmost importance. As meniscal repair improves knee stability and functional results, surgical repair of meniscal injuries particularly in younger individuals who are scheduled for anterior cruciate ligament reconstruction have a positive effect on clinical outcomes.

Dorsal cutaneous innervation of the hand with respect to anatomical landmarks: is there a safe zone?

OBJECTIVES

In this study, we aimed to define the borders of the triangular area between the radial and dorsal nerves on the dorsum of the hand and to determine its dimensions using measurements between anatomic landmarks.

MATERIALS AND METHODS

We statistically analyzed the relation between the distance from Lister's tubercle to the blending point of the central branches of radial and ulnar nerves and the distance between styloids on 14 hands of seven adult human cadavers (5 males, 2 females). The distances of nerve branches to vertical lines drown distally from both styloid processes were also compared with interstyloid distances to help in presuming the course of these nerves.

RESULTS

No statistical constant correlation was determined between the measurements. Neither the height of the triangular area nor the courses of both nerves seemed to be quantitatively related to any measurements between the anatomical landmarks.

CONCLUSION

Variability in these measurements in our study indicates that there is no surgical safe zone on the dorsum of the hand.

[Bilateral traumatic patella fracture: a case report]

Patellar fractures are uncommon injuries and account for approximately 1% of all fractures. In this article, a 35-year-old male patient who sustained a collision deceleration accident with bilateral comminuted transverse patellar fractures is presented. For this patient, open reduction and internal fixation with tension band technique, using two Kirschner wires and cerclage wire was applied for both fractures. At the first postoperative day, isometric quadriceps and active range of motion exercises were begun and the patient was allowed to walk full weight bearing with two crutches while both extremities were immobilized in a hinged brace allowing maximum 30 degrees of flexion. At postoperative fourth week brace immobilization was terminated. However, the patient was advised to use crutches for two weeks more to prevent any complications that may arise during walking because of the bilaterally of the injury. At six weeks solid union was achieved. During the last visit at postoperative second year, the patient had no complaints and the range of motion was full. In this paper a case of bilateral patella fractures is presented as a consequence of a dashboard injury, and the pathomechanical and therapeutical aspects of such an injury is discussed.

Comparison of different estimation techniques for biomass concentration in large scale yeast fermentation

In this study, previously developed five different state estimation methods are examined and compared for estimation of biomass concentrations at a production scale fed-batch bioprocess. These methods are i. estimation based on kinetic model of overflow metabolism; ii. estimation based on metabolic black-box model; iii. estimation based on observer; iv. estimation based on artificial neural network; v. estimation based on differential evaluation. Biomass concentrations are estimated from available measurements and compared with experimental data obtained from large scale fermentations. The advantages and disadvantages of the presented techniques are discussed with regard to accuracy, reproducibility, number of primary measurements required and adaptation to different working conditions. Among the various techniques, the metabolic black-box method seems to have advantages although the number of measurements required is more than that for the other methods. However, the required extra measurements are based on commonly employed instruments in an industrial environment. This method is used for developing a model based control of fed-batch yeast fermentations.

Loop security and tensile properties of polyblend and traditional suture materials

Tensile and knot properties of new generation (polyblend) and traditional suture materials in orthopedic surgery were investigated in standard laboratory conditions. Study focused on Fiberwire No. 5 and 2, Ethibond No. 5, 2 and 00, Orthocord No. 2, MaxBraid No. 2, Prolene No. 0 and 00, PDS No. 0 and 00, and Vicryl No. 2, 0 and 00. A 27-cm suture loop was fastened with 10 knots for ten samples for each type. Test parameters were tensile load to failure, elongation at failure point and knot slippage, and volume of 10-fold knots. Results were compared using ANOVA test. Failure load of No. 5 Fiberwire (625.0 ± 30.0 N) was significantly higher compared to all other suture types. Tensile strengths of MaxBraid No. 2 (287 ± 11 N) was significantly stronger compared to two other No. 2 polyblend sutures types and Ethibond No. 5. Knot slippage of Fiberwire No. 5 (14 ± 1.9 mm) was significantly higher compared to all other suture types. Ethibond No. 2 (0.1 ± 0.3 mm) had the lowest knot slippage. Elongation at the failure point of Fiberwire No. 2 (5%) was significantly lower than all other suture types. Mean calculated knot volume of #5 Fiberwire (73 ± 6.9 mm(3)) was significantly higher compared to #5 Ethibond (53 ± 4.8 mm(3)). Results of the study proved presence of significant differences between tensile and knot properties of various suture types and sizes. Loop security of larger diameter sutures is not always higher than thinner sutures. Suture elongation and knot slippage are important failure modes for high-diameter sutures and short-suture loops.

[The efficacy and safety of limited incision technique in carpal tunnel release]

OBJECTIVES

This study aims to determine the safety and symptomatic and functional efficacy of median nerve decompression with 3 cm limited incision in carpal tunnel syndrome surgery.

PATIENTS AND METHODS

Carpal tunnel release with a 3 cm limited palmar incision was performed on 91 hands in 83 patients. Patients were evaluated with Boston Carpal Tunnel Questionnaire, grip strength and pinch strength measurements, Semmes-Weinstein Monofilament test and two-point discrimination tests preoperatively, and at postoperative 3rd and 6th months. The pre- and postoperative mean values for these assessment criteria were statistically analyzed by paired samples t-test. The symptoms, physical findings, electroneuromyography carpal tunnel syndrome severity scores of the patients were evaluated using descriptive statistical analyses.

RESULTS

At postoperative evaluation, there was a statistically significant increase in Boston Carpal Tunnel Questionnaire scores, grip and pinch strengths, and sensory tests results of the patients when compared with preoperative values. No complications other than pillar pain were encountered.

CONCLUSION

Carpal tunnel release with a 3 cm limited incision technique appears to be effective when compared with classical open, endoscopic and mini incision techniques. The rate of complications is lower than that of these techniques. In conclusion, a 3 cm limited incision is both effective and safe in carpal tunnel release.

Over-the-top knot placement technique enhances tensile stability of tendon repairs

BACKGROUND

Currently a major concern for the surgical treatment of Achilles tendon rupture repairs is the creation of stable enough fixation to allow early range of motion. It was documented that the weakest point in a suture loop is the knot. Thus, we hypothesized that moving the knot away from the repair junction (over-the-top Krackow technique) would increase the strength of the repair.

MATERIALS AND METHODS

Transected bovine tendons were repaired by the traditional Krackow and over-the-top Krackow techniques using four suture materials (Fiberwire Nos. 5 and 2, Ethibond Nos. 5 and 2). Tendons were cyclically tested at incremental loads beginning from 50 N until 5-mm gap formation. Then all tendons were loaded to failure. The number of cycles to 5-mm gapping, ultimate failure loads and knot slip were compared using t-test and Mann-Whitney tests (with Tukey corrections for multiple comparisons).

RESULTS

Mean number of cycles to 5-mm gapping did not reveal significant differences (p = 0.113) between repair groups. Mean failure load of tendons repaired by over-the-top Krackow technique were significantly higher (p < 0.0001) for all four paired groups than tendons repaired by traditional Krackow technique. Ethibond No. 5, No. 2, and Fiberwire No. 2 suture repairs with over-the-top configuration did not reveal any knot slip.

CONCLUSION

Over-the-top Krackow technique increases the ultimate failure load of repaired tendons. But 5-mm gapping resistivity was not enhanced either by the technique or the suture material.

CLINICAL RELEVANCE

The knot itself is a stress-riser in the suture loop so we suggest that freeing it from tension by our modificiation may achieve more durable repairs.

Effects of hyperbaric oxygen therapy on distraction osteogenesis

Investigators in the present study explored the effects of hyperbaric oxygen (HBO) therapy on distraction osteogenesis in a rabbit limb-lengthening model. HBO treatment was provided to participants in a small animal pressure chamber once a day during the latent period of distraction osteogenesis at 2.5 absolute atmospheres of pressure. Bone mineral density measurements were obtained through torsional testing. The control group received no HBO treatment. Animals were killed 8 wk postoperatively for biomechanical testing. There was a statistically significant increase in bone mineral density in the HBO group compared with that in the non-HBO group, but no statistically significant differences were observed between biomechanical parameters of the 2 groups. The investigators suggest that these results must be further studied through histologic examination to determine the stepwise effects of HBO during and after collagen synthesis.

A comparison of two osteotomy techniques for tibial lengthening

INTRODUCTION

There are various methods of long bone lengthening. The quality of the regenerated bone depends on stable external fixation, low energy corticotomy, latency period, optimum lengthening rate and rhythm, and functional use of the limb. Percutaneous corticotomy and ostetomy with multiple drill holes yield the best results for the quality of the regenerated bone. An alternative low energy osteotomy, which respects the periosteum, is the Afghan percutaneous osteotomy. The purpose of the current study was to compare a percutaneous multiple drill hole osteotomy with a Gigli saw osteotomy in terms of the healing index (HI).

MATERIALS AND METHODS

Forty-four tibias of 41 patients were lengthened at our institution between 1995 and 2000. All patients underwent limb lengthening without any deformity correction by the Ilizarov device. The etiology of the limb length discrepancy was sequelae to poliomyelitis in 16 tibias, idiopathic hypoplasia in 17 tibias, posttraumatic discrepancy in 5 tibias, bilateral tibial lengthening in achondroplastic dwarfism in 3 patients. Patients with metabolic bone diseases were not included in this series.

RESULTS

The mean amount of length discrepancy was 5.7 cm (range 2-12 cm). The mean HI of the whole group was 1.65 month/cm (range 1.1-2.4 month/cm). When comparing the osteotomy methods without taking the etiology into consideration, the percutaneous, multiple drill hole group yielded a mean HI of 1.98 month/cm (range 1.4-2.4 month/cm), while the Gigli saw group yielded a mean HI of 1.37 month/cm (range 1.1-1.8 month/cm). There was a statistically significant difference between the two groups ( p=0.022). The Gigli saw patients with poliomyelitis had a significantly better HI compared with patients who underwent lengthening by the other form of osteotomy (1.1 vs 1.9 month/cm; p=0.027).

CONCLUSION

Our results confirm the biologic superiority of the Gigli saw technique.

Surgical treatment of malignant tumors of the foot and ankle

BACKGROUND

The current study highlights the clinical features of tumors of the foot and ankle, and presents the clinical outcomes of treatment for 16 patients who were treated at the authors' institution, between 1989 and 1998.

METHODS

Four tumors occurred in the ankle, three were in the hindfoot, three were in the midfoot, three were in the forefoot, and three were on the plantar surface of the foot. The median duration of symptoms before presentation was 12 months (range, 1-50 months). Fourteen patients were managed by limb-salvage procedures. Three patients were managed by ablative surgery, due to skin, neurovascular, and/or severe bone invasion. In the 9 patients who had wide local resections, local island flaps, split-thickness skin grafts, free vascularized latissimus dorsi flaps, and a free vascularized iliac crest flap were utilized to achieve wound closure.

RESULTS

The patients were followed up for a mean of 74.2 months (range, 48-121 months). The overall survival of the whole group is 71 +/- 3.7 months. Currently, 12 patients are being followed up with no evidence of disease. Of the 14 patients who were managed by limb-salvage procedures, 6 have normal functional status.

CONCLUSION

Wide resection of malignant tumors of the foot and ankle is considered technically difficult because of technical problems of soft-tissue coverage. However, utilization of local and free flaps provides sufficient closure following wide tumor resection of the foot and ankle, thus yielding satisfactory lower extremity function and local tumor control.

Recovery of ammonia as struvite from anaerobic digester effluents

The effects of environmental conditions on ammonia removal as struvite (Magnesium ammonium phosphate, MAP) were studied in a laboratory scale batch reactor. MAP precipitation was carried out by adding phosphoric acid and magnesium source either as MgCl, or MgO. The effect of temperature, pH, MgN:P ratios were studied. Temperature did not significantly affect ammonia removal between 25-40 degrees C and over 90% removal was obtained. The effect of pH, however,was significant and highest removal was reached at pH 8.5-9.0. The various stoichiometric ratios of ammonium to Mg and P have been tested and slight excess of Mg and P found to be beneficial for higher recovery of ammonia as struvite. However further increase in Mg and P ratios did not result in further ammonia removal which is also costly for the practical application of the process. When MgO was used as M source,the ammonia recovery was 60-70% whereas the useMgCl2 has increased this figure up to 95%. In addition a two step purification process was developed to recover MAP crystals from impurities of the anaerobic digester. Firstly, precipitates were dissolved in acid and impurities were removed by centrifugation. The clarified supernatant was re-precipitated by adjusting its pH with caustic. It was shown that in the two steps process white MAP crystals could be obtained with over 85% recovery to be used for another applications. The economical analysis of the process has shown that ammonia in the digester effluents can be recovered at the cost of $7.5-8.0 kg(-1) NH4+-N. The rate of reaction is very fast and is completed almost in minutes. This simplifies the process design resulting in a smaller reaction vessel.

Oral cyclic megadose methylprednisolone therapy for chronic immune thrombocytopenic purpura in childhood

The objectives of this study were to investigate the effectiveness of oral megadose methylprednisolone (OMMP) therapy in children with chronic immune thrombocytopenic purpura (ITP). Twenty-two patients were given oral methylprednisolone daily for 7 d (30 mg/kg for 3 d and then 20 mg/kg for 4 d). OMMP therapy was repeated once per month if the platelet count was less than 20,000/mm3 at the 30th day of therapy, for up to six courses. The number of platelets of all patients increased gradually during the OMMP therapy, with a peak number at the 7th day, then decreased until the 14th day, and remained relatively stable until 12 months. During the study no patient had a platelet count less than 20,000/mm3 at the 3rd day and 50,000/mm3 at the 7th day. Although the number of platelets was gradually decreased between the 7th and 14th days, it remained above 100,000/mm3 for at least 12 months in the nine patients, and above 20,000/mm3 in the four patients. None of these 13 patients required hospitalization or therapy during the follow-up period. All of the patients tolerated the medication well. None of them reported side-effects that were severe enough to discontinue therapy. We conclude that OMMP therapy is a safe, easy and effective therapy in children with refractory chronic ITP, and it may provide long-term remission in about two thirds of the patients.

The effect of propolis extract in experimental chemical corneal injury

PURPOSE

To investigate the effect of propolis, a natural resin produced by honeybees, in the treatment of alkali-injured rabbit eyes.

METHOD

A corneal alkali burn was induced by applying filter paper immersed in 1 N NaOH on the central axis of the right corneas of 24 rabbits for 30 s. The animals were divided into three treatment groups: group 1 (control) was given 0.3% tobramycin and phosphate-buffered solution; group 2 was treated with antibiotic coverage and topical 1% ethanolic extract of propolis; group 3 received antibiotic coverage and topical 1% dexamethasone. The dexamethasone-treated group was maintained as the positive control. Drugs were instilled 4 times a day for 7 days. The corneal inflammation was evaluated by calculating the average inflammatory index obtained from clinical observation of the ciliary hyperemia, central and peripheral corneal edema at 24 h, 48 h, on day 5 and day 7, before sacrificing the animals. Then, the corneas underwent routine histological examination.

RESULTS

The effects of dexamethasone and propolis on healing of injured corneas were similar (p>0.05) and significantly better than controls at 24 h (p<0.01, p< 0.05, respectively), and on day 7 (p<0.05) with respect to the inflammatory index. On histological observation, inflammatory cell infiltration was lower as compared to control in both the dexamethasone and propolis groups (p<0.001) and similar with each other (p>0.05).

CONCLUSIONS

Our study shows that propolis has an anti-inflammatory effect comparable to dexamethasone in chemical corneal injury.

Cyclosporin A plus prednisone treatment of steroid-sensitive frequently relapsing nephrotic syndrome in children

Recently, there have been numerous reports on the use of cyclosporin A (CyA) in children with nephrotic syndrome (NS). In this prospective study, we wanted to evaluate the efficacy of CyA together with prednisone therapy in children with steroid-sensitive frequently relapsing NS. A total of 11 children (7 boys, 4 girls) with steroid-sensitive NS were included in this study. The patients ranged in age from 3.5 to 15 years (average 8.45 +/- 4.26 years). Renal biopsy showed minimal change disease in five, mesangial proliferation in four, focal glomerulosclerosis in one and membranous glomerulonephritis in one. The NS had lasted from 13 to 113 months (average 50.27 +/- 38.60 months). The number of relapses varied from three to 10 episodes with an average of 5.9 +/- 3.3 episodes. Patients received 5 mg/kg CyA daily in two divided doses for five months and prednisone for a total of eight weeks (30 mg/m2 daily for 4 weeks followed by 30 mg/m2 on alternate days for 4 weeks). After the completion of the treatment protocol, no therapy was given unless a relapse was observed. Mean follow-up period was 14.9 +/- 5.99 months with a range from six to 26 months. Before this combined treatment, there was a mean relapse rate of 0.144 +/- 0.05 relapses month with a range from 0.088 to 0.238. After discontinuation of therapy, the relapse rate dropped to a mean of 0.0179 +/- 0.031 with a range of 0 to 0.083. In conclusion, it would appear that a combination of CyA and prednisone is effective, sustaining the remission in steroid-sensitive NS. Corticosteroids in combination with CyA may be a better approach than conventional steroid treatment in such patients.

Left ventricular diastolic abnormalities in children with beta-thalassemia major: a Doppler echocardiographic study

Left ventricular filling patterns were assessed by Doppler echocardiography in 63 beta-thalassemia major patients, aged for to 21 years, with no clinical evidence of congestive heart failure and 63 age- and sex-matched normal controls. The patients with beta-thalassemia major were divided into three age groups, namely four to nine years (6.8 +/- 1.5 years), 10-15 years (12.1 +/- 1.6 years) and older than 15 years (17.3 +/- 1.7 years). They were compared with age- and sex-matched normal controls in respects of Doppler diastolic indices. The ratio between the early and late (atrial) peaks of flow velocity was higher and peak flow velocity in late diastole was significantly lower in patients with beta-thalassemia major as compared to controls in all three age groups (p < .001). As compared with the controls, peak early diastolic flow velocity was also significantly higher in the thalassemics aged 10 to 15 years (92 +/- 16 vs 80 +/- 12 cm/s, P < .01) and in those older than 15 years (95 +/- 16 vs 79 +/- 13 cm/s, p < .001). Restrictive left ventricular diastolic abnormalities were detected in a total of 34 (54%) patients with beta-thalassemia major, whereas left ventricular systolic abnormalities were identified only eight (13%) of them. None of the patients without left ventricular diastolic abnormalities showed left ventricular systolic abnormalities. There was not any significant correlation between the hematologic parameters, such as mean serum ferritin, maximum serum ferritin and the number of blood units transfused, and left ventricular Doppler diastolic indices (p > .05). From the data presented here, we therefore conclude that left ventricular diastolic abnormalities develop in patients with beta-thalassemia major in the early phase of the disease and before the appearance of systolic abnormalities, when clinical symptoms of congestive heart failure are absent.

A comparison of different filters for white cell reduction

Removal of white blood cells (WBCs) from blood components before transfusion by filters with at least 3 log10 depletion may prevent or delay leukocyte-associated transfusion reactions such as HLA alloimmunization, non-hemolytic febrile reactions, transmitted infections (e.g., CMV, HTLV-1), and immunomodulation. The aim of this study was to compare the leukocyte removal efficiency (LRE) of six commercial bedside filters that are said to achieve 3 log10 (Bio R-01), Leucostop 4LT-1, Pall RC 50) and 4 log10 (Bio R-01 Plus, Pall RC 400, Pall RC XL-1) WBC depletion. A total of 430 units of whole blood ranging from 32 to 92 for each filter type were analyzed by an automated counter before and after filtration. Postfiltration blood samples were also evaluated for WBCs by Nageotte chamber. All the filters demonstrated leukocyte removal about 1 log10 less than the manufacturer's claim. The fourth generation filters showed a better performance than the third generation filters. Of them, Pall RC XL-1 showed the best efficacy with 99.93 percent leukocyte removal and a median residual WBCs of 1.6 x 10(6) per unit. These results indicate that the fourth generation filters, which are designed for the filtration of packed red cells, in particular Pall RC XL-1, are also able to reduce WBCs from whole blood below the critical antigenic leukocyte load (5 x 10(6)), and can be efficiently used for polytransfused patients to prevent alloimmunization.

Experimental investigation of bone regeneration using Pyrost in animals

A study was undertaken to investigate bone regeneration in guinea pig mandibles implanted with Pyrost in comparison with artificial bone defects as controls. Bone defects were prepared in the angles of mandibles of 30 guinea pigs. The findings demonstrated that this bone substitute material stimulated bone healing, i.e. bone regeneration, in comparison with empty control cavities. Bone regeneration and new bone formation were found to be more extensive in Pyrost-implanted areas than in controls.

Early pulpal involvement in an unusual case of dens in dente. Case report

Dens in dente (dens invaginatus, tooth within a tooth, dilated composite odontome) is an abnormal tooth form which occurs most frequently in the permanent maxillary lateral incisor region. Dens in dente may occur, however, in any tooth in the dental arch, although these other forms are comparatively rare. It may appear within both the coronal part of the tooth and the root, although coronal forms are more common. In this paper, a case of extreme dens in dente with pulpal involvement at an early stage of eruption is presented.

A new surgical approach in genital lymphedema

A new surgical approach has been used in a case of genital lymphedema. After resection of the lymphedematous mass, U-shaped flaps were made from the suprapubic region anteriorly and the posterior scrotal skin posteriorly. The denuded penis was transposed to its original place by passing it through a buttonhole incision made on the anterior flap. The testicles were placed and fixed in pouches prepared between the anterior and posterior flaps. The patient had an acceptable postoperative outcome both in testicular function and habitual sexual activities.

[Role of odontomas on eruption difficulties of permanent teeth and surgical-orthodontical approach]

In this case report 2 odontoma cases were presented as an example for surgical-orthodontic approach for the eruption difficulties of permanent teeth. In two cases which left central incisors couldn't erupt because of an odontoma. In both cases the odontomas were enucleated with their capsules and treated orthodontically thus the results were discussed.