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Objectives: Struma ovarii (SO) accounts for approximately 1% of all ovarian tumors. The objective of our study is to contribute to the treatment algorithm by presenting our clinical experience in a comprehensive case series of patients diagnosed with SO, predominantly characterized by thyroid tissue within a monodermal teratoma., Methods: Patients aged 17 years and older who underwent surgery due to ovarian masses and were histopathologically diagnosed with SO between January 2012 and January 2022 were included in the study. The patients' files were retrospectively reviewed. Demographic data, presenting complaints, radiological findings, tumor sizes, laboratory data, surgical procedures performed, pathology reports, additional treatments, and follow-up information were recorded., Results: The median age of total 19 patients was 41.7 (17-74) years. Among them, malignant struma ovarii was present in 3 patients. In patients with histopathologically confirmed benign struma ovarii, no additional treatment was administered after tumor enucleation. In malignant cases, in addition to unilateral salpingo-oophorectomy, total thyroidectomy, radioactive iodine (RAI) ablation, and L-Thyroxine suppression were performed. No mortality occurred during the follow-up period., Conclusion: Although conservative treatments are considered acceptable treatment in cases of benign struma ovarii, the management of cases with malignant struma ovarii is controversial. Fertility-sparing surgery followed by postoperative adjuvant thyroidectomy and radioactive iodine ablation may be preferred for young women., Competing Interests: Not declared., (© Copyright 2024 by The Medical Bulletin of Sisli Etfal Hospital.)

Background: Crush Syndrome is a major cause of morbidity and mortality following large-scale catastrophic earthquakes. Since there are no randomized controlled studies on Crush Syndrome, knowledge on this subject is limited to expert experience. The primary objective is to analyze the epidemiological and demographic characteristics, clinical outcomes, and mortality factors of earthquake victims after the Pazarcik and Elbistan earthquakes on February 6, 2023., Methods: This cross-sectional and observational retrospective study evaluated 610 earthquake victims who presented to our center between February 6 and April 30, 2023. Among these patients, 128 with Crush Syndrome were included in the study. Patient information was gathered from hospital records during their stay and from national registries upon referral. The primary outcome was to identify risk factors for mortality. Demographic and laboratory data were analyzed by acute kidney injury (AKI) stages; mortality-affecting factors were identified through regression analysis., Results: Of the 128 Crush Syndrome patients (100 adults, 28 children), 64 were female. The AKI rate was 32.8%. Among patients with AKI, the frequency of hemodialysis requirement was 69%, and the mortality rate was 14.2%. The overall mortality rate for patients with Crush Syndrome was 4.6%, compared to 3.9% (19/482) in earthquake victims without Crush Syndrome (p=0.705). Notably, low systolic blood pressure at admission was the only factor significantly affecting mortality in Crush Syndrome patients (Hazard Ratio [HR]: 1.088, p=0.021, 95% Confidence Interval [CI])., Conclusion: Our study highlights low systolic blood pressure upon admission as a significant risk factor for increased mortality in Crush Syndrome patients. This finding may contribute to the literature by emphasizing the importance of monitoring blood pressure under rubble and administering more aggressive fluid therapy to patients with low systolic blood pressure.

Objective: Umbilical hernia repair can be easily performed simultaneously with laparoscopic cholecystectomy. The use of mesh is recommended for hernias larger than 1 cm. In this study, patients with primary repair of umbilical hernia simultaneously with laparoscopic cholecystectomy were evaluated. It aimed to present the effectiveness of this method and the effect of body mass index (BMI) on treatment results., Methods: The records of patients who underwent primary repair of umbilical hernia simultaneously with laparoscopic cholecystectomy between 2014 and 2021 were reviewed retrospectively. Patients' age, gender, BMI, length of hospital stay, recurrence and reoperation information, and follow-up times were analyzed. The patients were examined in three groups according to their BMI, and the effect of BMI on treatment was investigated., Results: patients were included in the study. Median values of the patients for age, BMI, hospitalization, and follow-up were 63 (28-94), 31 (20-51) kg/m 2 , 1 (1-25) days, and 23 (0.6-76) months, respectively. Recurrence was detected in 8 patients. BMI was <25 in one patient with recurrence and >30 in 5 patients. There was no significant correlation between length of stay, number of relapse and reoperation, and BMI (p>0.05)., Conclusion: In our study, the recurrence rate was found to be higher than the studies reported with the use of mesh, and most of the patients with recurrence are obese, although it is not statistically significant. If the recurrence rate is acceptable, we believe that repair with primary suture is feasible in umbilical hernia., Competing Interests: No conflict of interest was declared by the authors., (© Copyright 2023 by Istanbul Provincial Directorate of Health.)

Introduction: The purpose of this study was to evaluate the relationship between the correction rate in Cobb angle and the improvement in quality of life profile in terms of Scoliosis Research Society (SRS)-22 values., Patients and Methods: Between January 2007 and December 2013, posterior instrumentation and fusion was performed to 30 patients with adolescent idiopathic scoliosis (AIS). Patients were grouped according to their improvement rate in Cobb angles after surgery. Patients with an improvement rate of > 80% were grouped as Group A; those with an improvement rate of > 60% and ≤ 80% as Group B and those with an improvement rate of ≤ 60% were grouped as Group C. The SRS-22 questionnaire of these three groups was calculated and their relationship with the improvement in Cobb angle was evaluated., Results: No statistical difference was found among the three groups in terms of pain, appearance, function, spirit, satisfaction, and SRS-22 values (all p > 0.05)., Conclusion: The results of this study demonstrate that the degree of correction rate does not correlate with the degree of improvement in the SRS-22 questionnaire in patients with AIS that underwent posterior fusion and instrumentation., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objective: To investigate factors that may have an effect on recurrence by retrospectively analysing the data of patients who were followed up and treated for idiopathic granulomatous mastitis in this clinic., Study Design: Analytic study., Place and Duration of Study: Department of General Surgery, Faculty of Medicine, Baskent University, Konya and Adana Practice and Research Hospitals between January 2010 and January 2021., Methodology: The data of patients who were histopathologically diagnosed with granulomatous mastitis were retrospectively analysed. The patients included in the study were divided into two groups: Recurrence (Group 1) and non-recurrence (Group 2). Patients with underlying etiological factors that may cause granulomatous inflammation such as infection, trauma, tuberculosis, sarcoidosis, and autoimmune disease were excluded from the study. The effects of other parameters (involvement area, follow-up duration, the time from the onset of complaints to diagnosis, side of involvement, breastfeeding, oral contraceptive use, redness, ulceration and/or discharge, preoperative histopathological diagnosis, diagnosis by any of the preoperative imaging techniques, preferred treatment method) on recurrence, were statistically analysed., Results: Furthermore, the analysis results showed no significant difference between the groups with and without recurrence with regard to any of the other variables such as follow-up period, size of the involvement area, presenting complaints, breast-feeding, preferred treatment alternative (steroid, steroid + surgery, surgery), and preferred surgical technique (p>0.05). The time from the onset of complaints to diagnosis was significantly longer in the recurrence group (p=0.001). In addition, the frequency of oral contraceptive use was statistically significantly higher in the recurrence group (Odds ratio=7.6, p=0.044)., Conclusion: The results of this study suggest that early diagnosis could prevent recurrence in patients with idiopathic granulomatous mastitis. Prospective randomised controlled studies are needed to support this thought. Key Words: Idiopathic granulomatous mastitis, Malignancy, Oral contraceptive, Steroid.

Background: Spinopelvic dissociation (SPD) is difficult to manage and is associated with high mortality and morbidity, including concomitant orthopaedic polytrauma, spine injuries, pelvic ring disruptions, neurological, soft-tissue, and vascular injuries. The purpose of this study is to evaluate the functional and radiological outcomes; health related quality of life and complication rates of patients with traumatic spinopelvic dissociation underwent bilateral triangular osteosynthesis (TOS)., Methods: The study was approved by the medical school's institutional review board (IRB). Prospective data collection of nineteen consecutive cases of traumatic SPD were included in the study from October 2015 to August 2018. Bilateral TOS was performed to manage all patients with SPD. The clinical outcome for fractures was analyzed with Majeed function assessment. Health Related Quality of Life (HRQoL) was assessed with the EQ-6D questionnaire. The reduction quality was evaluated according to Matta criterion. CT scanning was used to verify the fracture union in patients at 24 th weeks postoperatively., Results: There were 12 women and 7 men with an average age of 47.2±8.4 years (range, 17-62 years). The average follow-up time was 25.2±3.7 months (average, 22-45 months). The most common mechanism of injury was falling (57%). According to Majeed functional scoring, the results were excellent in 12 cases, good in 5 cases and fair in 2 cases. The median EQVAS score was 78.9±8.4. 15 patients (78.9%) turned back to their original occupation. Pain and mood disorders mainly influenced patients' present general health status. According to Matta criterion for fracture reduction, the results were excellent in 14 cases, good in 4 cases and fair in 1 case. Complications were noted as wound healing problems (26%), implant loosening (5%) and iatrogenic nerve injury (5%)., Conclusion: Bilateral TOS demonstrates satisfactory functional and radiological outcomes with low complication rates except infection rate in patients with traumatic spinopelvic dissociation. HRQoL is mainly dominated by pain and mood disorders. 78.9% of the patients turned back to their original occupation. Surgeons should be aware of wound healing problems in case of increased muscle mobilization and degloving injuries.Implant removal is required to improve the lumbopelvic mobility., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: This study aims to evaluate the clinical and radiological outcomes of patients with chronic severe slipped capital femoral epiphysis (SCFE) treated by surgical dislocation and modified Dunn osteotomy (MDO)., Patients and Methods: This retrospective study, conducted between January 2010 and December 2017, included nine patients (8 males, 1 female; mean age 12.6 years; range, 7 to 16 years) with nine hips. The degree of corrections in Southwick angle and alpha angle were measured on frog-leg views. Range of motion (ROM) of the hips was measured at each follow-up visit. Heyman and Herndon classification system and Harris Hip Score (HHS) were evaluated for clinical and functional outcomes at the latest follow-up visit., Results: The mean follow-up time was 34.8 months. Avascular necrosis complication was observed in one hip. Except two patients with lateral femoral cutaneous neuropathy, none of the patients suffered from any other complications. Mean preoperative Southwick angle of 59.1° was corrected to an angle of -0.8° postoperatively. Alpha angles were calculated as 44.6° postoperatively. Modified Dunn osteotomy resulted in marked improvement in hip ROM in all directions and increased HHS., Conclusion: Our results encourage us to use this method in treating SCFE patients with chronic severe slips.

Background: Clinical perineural invasion (PNI) of the trigeminal and facial nerves from cutaneous head and neck squamous cell carcinoma (cutaneous HNSCC) is a rare clinical entity that poses unique therapeutic challenges., Methods: A retrospective chart review of a skull base oncology database was performed of patients with the diagnosis of clinical PNI from a cutaneous HNSCC. Patients who were previously untreated underwent multimodal treatment entailing surgical resection and postoperative radiotherapy (PORT) and patients who were previously treated with radiotherapy underwent salvage surgical resection between the years 2006 and 2012. Survival outcomes, such as disease-free survival (DFS) and overall survival (OS), were analyzed and correlated with surgical factors, such as margin status, previous treatment, zone involvement, and trigeminal involvement (branch-specific), as well as the pretreatment and posttreatment pain scores., Results: Of 21 patients with clinical PNI from cutaneous HNSCC, 7 patients (33%) were previously treated for their disease with primary radiotherapy. Negative tumor margins were achieved in 18 patients (86%). Three of the 7 patients (43%) undergoing salvage surgery had positive margins. One-year and 3-year DFS for previously untreated patients was 91% and 67%, respectively, whereas 1-year and 3-year DFS was 72% and 28%, respectively, for the previously treated patients. Previous radiotherapy, ophthalmic nerve involvement, and positive margins portended poorer survival outcomes in this study., Conclusion: The retrospective study of this rare clinical entity demonstrates that multimodal treatment can achieve favorable survival outcomes. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1280-1286, 2017., (© 2017 Wiley Periodicals, Inc.)

We present the case of a 76-year-old man with a 2-month history of mildly tender swelling in the right calf for which he had an initial excision and then a wide local excision followed by a split skin graft because the initial histopathology confirmed that there was a Grade I leiomyosarcoma of great saphenous vein. A simple lump in the lower limb could be a malignant vascular tumour and should always be considered in the list of differential diagnosis of a lump in the lower limb., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Introduction: Operative treatment consisting of fracture reduction and fixation, or arthroplasty to permit early patient mobilization, continues to be the treatment of choice for most femoral neck fractures. Options for internal fixation have included a variety of implants; however most recent reports and textbooks cite parallel multiple cancellous screws as the surgical technique of choice., Methods: The study was prospective, randomized and IRB approved. Inclusion criteria included skeletal maturity, closed femoral neck fracture without concomitant fractures or injuries with complete charts and adequate radiographs obtained from the initial injury till the last follow-up. Forty-four patients were enrolled in this study during one-year period at two university centers. 22 were randomized to be treated with full threaded, cannulated compression screws (Acutrak 6/7, ACUMED) (Group 1) and the other 22 with 16mm partial threaded, 6.5mm or 7.3mm cannulated screws (SYNTHES) (Group 2). Three or four screws were used in both groups according to fracture type and surgeon's preference. Data evaluated included surgical time, fluoroscopy time, fracture type, radiological outcome, complications and functional status using the Harris Hip Score., Results: Both groups were comparable in terms of age and gender. There was not a significant difference in terms of surgical time, follow-up period, fracture type, or fluoroscopy time. There were eight complications in Group 1 and two in Group 2 (P=0.049) Time to union was significantly longer in Group 1 (P=0.001). However, Hip Scores were not significantly different in both groups (P=0.20)., Conclusion: When compared with full threaded compression screws, partial-threaded cannulated screws provides a shorter union time and less complication rate while providing equivalent functional results in adult femoral neck fractures., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: The main aim of this retrospective study was to present our experience on scaphoid nonunion treated with vascularised bone graft., Methods: Between 2006 and 2012, 58 patients presenting with symptomatic scaphoid nonunion were eligible to participate in this study. Topography of the nonunion included 29 proximal, 25 waist and 4 distal scaphoid nonunions. Vascularised bone graft from distal dorsal radius was used in all cases which were stabilised with the headless cannulated compression screws. Scapholunate angles, Natrass carpal height ratio were evaluated pre and postoperatively. Range of motion of the affected side was compared to that of the contralateral side after the surgery., Results: Radiographic union was achieved in 50, out of 58 cases with an average time of 9.9 weeks (range, 6-18 weeks). Out of all the non-united cases, four of them were in proximal, three in the waist and one was in distal scaphoid. In nine proximal nonunions treated by 4+5 ECA graft all but one were united. The mean follow up was 21.7 months (12-62 months). The flexion was 91.6%, the extension was 91.5%, the radial deviation was 81.2%, and the ulnar deviation was 89.5% compared to the other side. The grip strength was 93%. Preoperative DASH score was 61.5 diminishing to 28.7 postoperatively. There was no significant change in Natrass carpal height ratio but a slight improvement occurred in scapholunate angles both pre and postoperatively., Conclusion: Vascularised bone graft is a good solution for scaphoid nonunion to enhance the healing rate especially in the presence of avascular necrosis. Proximal pole nonunions, humpback deformity and smoking are important negative factors for scaphoid nonunion despite the use of a vascularised bone graft. A trapezoidal wedge graft is necessary for the volar type nonunions with humpback deformity. 1,2 ICSRA offer an advantage with its proximity to scaphoid in all nonunion locations. Nonetheless, 4+5 ECA graft is also a good solution for proximal nonunions., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Burst fractures of the low lumbar spine constitute approximately one percent of all lumbar fractures. There is still no consensus on the optimal treatment of low lumbar burst factures. We aimed to evaluate the functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fracture., Methods: 15 patients (11 males, 4 females; mean age 32±8) who had low lumbar spine burst fracture treated with a custom-moulded thoracolumbosacral orthosis (TLSO) with a thigh extension were enrolled. The mean follow-up period was 22±6 months. 14 patients were neurologically intact and one had isolated nerve root injury. There were 24% type A fractures and 76% type B fractures according to the Denis classification system. Functional outcomes were evaluated by using Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and Visual Analogue Scale (VAS). Radiographic outcome was analyzed by measuring anterior vertebral height loss, kyphosis angle, amount of canal retropulsion. Functional and radiographic outcomes were reviewed initially and at 1, 3, 6, 12 months, and at the latest follow-up. Functional and radiographic improvements were analyzed statistically., Results: The mean bracing period was 11.9±1.7 weeks. The mean initial ODI, SF-36, and VAS score of the patients was 78.3±9.6, 23.7±8.9, and 8.7±0.7, respectively. The mean ODI, SF-36, and VAS score of the patients at the final follow-up was 26.4±6.5, 68.1±11.2, and 2.8±1.7, respectively. The improvement in functional outcomes was measured to be significant (p<0.05 for ODI, SF-36 and VAS). The mean initial anterior vertebral height loss, kyphosis angle, amount of canal retropulsion was found to be 27.2%±9.6%, -6.8°±3.2°, 37.4%±10.2%, respectively. The mean anterior vertebral height loss, kyphosis angle, and amount of canal retropulsion at the final follow-up was 23.1%±.6.7%, -4.2°±2.4°, 19.6%±7.7%, respectively. Among the radiographic outcomes, only the amount of canal retropulsion improved statistically (p=0.042)., Conclusion: Conservative treatment using a custom-moulded thoracolumbosacral orthosis with a thigh extension is a safe and effective method in patients with low lumbar spine burst fractures and can improve functional and radiographic outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

We have previously investigated electromyographic (EMG) and transcranial motor evoked potential (MEP) abnormalities after mechanical spinal cord injury. We now report thermally generated porcine spinal cord injury, characterized by spinal cord generated hindlimb EMG injury activity and spinal cord motor conduction block (MEP loss). Electrocautery (EC) was delivered to thoracic level dural root sleeves within 6-8 mm of the spinal cord (n = 6). Temperature recordings were made near the spinal cord. EMG and MEP were recorded by multiple gluteobiceps intramuscular electrodes before, during, and after EC. Duration of EC was titrated to an end-point of spinal motor conduction block (MEP loss). In 5/6 roots, ipsilateral EMG injury activity was induced by EC. In 4/5 roots, EMG injury activity was identified before MEP loss. In all roots, a minimum of 20 s EC and a temperature maximum of at least 57 °C at the dural root sleeve were required to induce MEP loss. Unexpectedly, conduction block was preceded by an enhanced MEP in 4/6 trials. EMG injury activity, preceding MEP loss, can be seen during near spinal cord EC. Depolarization and facilitation of lumbar motor neurons by thermally excited descending spinal tracts likely explains both hindlimb EMG and an enhanced MEP signal (seen before conduction block) respectively. A thermal mechanism may play a role in some unexplained MEP losses during intraoperative monitoring. EMG recordings might help to detect abnormal discharges and forewarn the monitorist during both mechanical and thermal injury to the spinal cord.

Objective: We aimed to compare the efficacy of two different injection techniques of local corticosteroid and local anesthetic in the management of lateral epicondylitis., Methods: This prospective study followed 80 consecutive patients who were diagnosed with lateral epicondylitis at our hospital outpatient clinic between 2005 and 2006. Patients were randomly assigned into two equal groups. Group 1 received a single injection of 1 ml betamethasone and 1 ml prilocaine on the lateral epicondyle at the point of maximum tenderness. Group 2 patients received an injection of the same drug mixture. Following the initial injection, the needle tip was redirected and reinserted down the bone approximately 30 to 40 times without emerging from the skin, creating a hematoma. Patients were evaluated with the Turkish version of the Disabilities of the Arm, Shoulder and Hand questionnaire before injection and at the final follow-up. The unpaired t-test and chi-square tests were used to compare results., Results: Sixteen patients in Group 1 and 15 patients in Group 2 were lost during follow-up. The average follow-up period of the remaining 49 patients was 21.6 months. There were no significant differences between the two groups with regard to gender, age, follow-up period, symptom duration, involvement side and number of dominant limbs. The Turkish DASH scores of Group 2 were significantly lower than those of Group 1 (p=0.017)., Conclusion: Long-term clinical success in the treatment of lateral epicondylitis depends on the injection method. The peppering technique appears to be more effective than the single injection technique in the long-term.

Study Design: Comparative biomechanical study was conducted in osteoporotic human cadaveric spines., Objective: Determine the influence of the volume of polymethyl methacrylate injected through a fenestrated pedicle screw on the pullout strength and on the ability to safely remove the implant., Summary of Background Data: Pedicle screw fixation in the osteoporotic spine can be improved by the addition of bone cement. Various injection techniques have been used. While improvement has been shown for the pullout strength, the optimal volume of cement to inject has not been previously studied., Methods: Seven osteoporotic spines were instrumented with a standard and a fenestrated pedicle screw augmented with polymethyl methacrylate at each level (T7-L5). Three volumes of bone cement were randomly injected and stratified to the thoracic (0.5 cc, 1.0 cc, and 1.5 cc) and lumbar spine (1.5 cc, 2.0 cc, and 2.5 cc). Axial pullout strength and removal torque of the pedicle screws were quantified., Results: The pullout strength of the fenestrated screw was normalized with respect to its contralateral control. Student paired t tests were conducted and a statistically significant increase was noted for 1.0 cc (186 ± 45%) and 1.5 cc (158 ± 46%) in the thoracic spine and for 1.5 cc (264 ± 193%), 2.0 cc (221 ± 93%), and 2.5 cc (198 ± 42%) in the lumbar spine. There was no significant difference with higher volumes of cement. The median removal torque was 0.34 Nm for the standard and 1.83 Nm for the augmented screws. When the augmented implants were removed, the bone cement sheared completely off at the fenestrations in 15 of the 17 cases., Conclusion: Significant increases in pullout strength can be accomplished by injecting a limited quantity of bone cement through a fenestrated screw while minimizing the risks associated with higher volume. The majority of implants were removed without damaging the vertebra as the bone cement sheared off at the fenestrations.

Habitual or recurrent dislocation of the patella in the skeletally immature patient is a particularly demanding problem since the etiology is frequently multifactorial. The surgical techniques successfully performed in adults with patellar instability may risk injury to an open growth plate if applied to children. We present a technique that preserves femoral and patellar insertion anatomy of medial patellofemoral ligament (MPFL) using a free semitendinosus autograft together with tenodesis to the adductor magnus tendon without damaging open physis on the patellar attachment of MPFL. A 3-cm long longitudinal skin incision is performed 10 mm distal to the tibial tuberosity on the anteromedial side. The semitendinosus tendon is harvested with the stripper. The semitendinosus tendon is placed on a preparation board and cleaned of muscle tissue. The usable part of the tendon should be at least 20 cm long and 4 mm wide. The two free ends of the graft are sutured with Krakow technique. A medial longitudinal incision 2 cm in length is made to expose the MPFL and to abrade the patellar attachment of vastus medialis obliquus. The first patellar tunnel is created with 4.5 mm drill at the mid aspect of the medial patella in the anteroposterior and proximal-distal direction. The drill hole is formed parallel to the articular surface of the center of the patella. The second tunnel is created with 3.2 mm drill and the entry point is localized at the center of the patella. These two tunnels intersect to form a single tunnel. The semitendinosus autograft is run through the bone tunnel in the patella. Double-stranded semitendinosus autograft is placed in the presynovial fatty plane between the second and the third layer of the medial retinaculum, and tenodesis to adductor magnus tendon is applied by a moderate medial force with the knee flexed at 30°. Aftercare includes immobilization of the joint limited to 30° flexion using an above-knee splint for 2 weeks. No recurrent dislocation was observed in three patients (4 knees) at a mean follow-up time of 17.7 months. Both range of motion and radiological finding were restored to normal limits.

Study Design: Biomechanical cadaveric study., Objective: To determine the torque required to remove pedicle screws augmented with polymethyl methacrylate (PMMA) or calcium phosphate cement (CPC); thus, proving the safety of back out of augmented screws in the osteopotoric model, which would be a more dangerous setting than the nonosteoporotic model., Summary of Background Data: To our knowledge, no earlier study has characterized the safety of backing out pedicle screw augmented with PMMA or CPC., Methods: Pedicle screws were inserted in 24 osteoporotic vertebrae (48 pedicles). The maximal insertion torque and pullout strength of each screw were recorded. After pullout of the pedicle screws, the vertebrae were then randomized into 2 groups of 12 (24 pedicles) each. PMMA was injected into the pedicles in the first group and CPC was injected into the second group after which the pedicle screws were inserted. The pedicle screws were inserted into the pedicle holes augmented with PMMA or CPC, respectively. Finally, all augmented screws were backed out and the maximal removal torque was recorded using a digital torque wrench., Results: Throughout the study, no incidence of pedicle or lamina fractures was observed. The average insertion torque was 0.5±0.27 and 0.45±0.29 N·m for groups 1 and 2, respectively (P=0.724). The average pullout strength was 723.1±391.7 and 671.2±383.0 N (P=0.950). After cement augmentation, the average removal torque was 0.77±0.31 and 0.81±0.26 N·m for PMMA and CPC, respectively (P=0.494)., Conclusions: The results of this study showed that pedicle screws can be easily and safely backed out after augmentation with PMMA or CPC. The result of CPC, however, may only be valid before any bony ingrowth.

The purpose of this study was to evaluate the factors affecting muscle strength of ACL-deficient knees before and after ACL reconstruction. The study included 122 male patients who underwent primary ACL reconstruction with a bone-patellar tendon-bone autograft. Preoperative loss and change in muscle strength in both extensor and flexor muscle groups after ACL reconstruction were calculated separately at 60 degrees/sec and 180 degrees/sec angular velocities. We evaluated the effect of surgical delay on the preoperative deficit and on its change after surgery. Muscle strength change after ACL reconstruction was also evaluated in relation to patient compliance to treatment. The longer the delay of ACL reconstruction the more the muscle strength deficit of flexor and extensor muscles increased. In the ACL deficient knees with high strength deficit, improvement in muscle strength was higher after ACL reconstruction for both muscle groups. When delay of ACL reconstruction was short and the patient was compliant to treatment, flexor muscle strength recovery was early. Shortening the delay to reconstruction had a positive influence on muscle strength after ACL reconstruction when preoperative muscle strength deficit was high.

Study Design: Biomechanical Cadaveric Study., Objective: To characterize the pullout strength of calcium phosphate cement augmented screws between 0 and 6 minutes after cement injection., Summary of Background Data: Earlier studies with calcium phosphate cement on pedicle screws inserted into a metal mold or sawbone have shown that the augmentation strength can be affected by the time between cement injection and screw insertion. However, these studies only compared soft cement to completely hardened cement with extended waiting times. These extended waiting times are impractical in live spinal surgeries., Methods: Twenty-four pedicle screws were inserted and pulled out axially from cadaveric bone to make revision models. The 24 screw holes were randomly divided into 4 groups, with each group having 6 holes. For each group, identical pedicle screws were inserted at 0, 2, 4, and 6 minutes after injection with bioresorbable calcium phosphate cement (CPC). After 24 hours, the augmented screws were pulled out axially and their pullout strengths were compared., Results: The difference between secondary pullout strength and primary pullout strength increased up to 4 minutes after cement injection but decreased after 6 minutes but without statistical difference among the 4 time settings (P>0.3)., Conclusions: The augmented screws had similar fixation strength regardless of the time between cement mixture and screw insertion as long as they are inserted within 6 minutes. Augmentation power tends to increase up to 4 minutes after cement injection but decreases after 6 minutes.

Objectives: In this study, the factors causing stiff knee after primary total knee arthroplasty (TKA) in patients with medial compartment osteoarthrosis were evaluated., Patients and Methods: Primary TKA surgery was performed in fifty-three knees in 48 patients (42 females, 6 males; mean age 67.2±8.5; range 59 to 76 years) diagnosed with medial compartment osteoarthrosis. Five patients (10%) out of forty-eight underwent bilateral primary TKA. In the patients who had bilateral TKA, the second operation was performed six months later. Patello-femoral arthroplasty was performed in none of the patients. In the final follow-up, the knees, which had more than 10° of extension limitation and less than 95° of flexion, were defined as post-TKA stiff knee. The patients who developed stiff knee were classified as group 1 and the patients who did not develop stiff knee were classified as group 2. The possible factors that may cause stiff knee after TKA such as age, gender, range of knee flexion and extension, flexion arc, tibiofemoral angle, tibial slope angle, the change in the height of the joint line, the length of the patellar tendon, the change in the American Knee Society scores, body mass index, and the sizes and positions of the components were evaluated and compared pre- and postoperatively within and between both groups., Results: Stiff knee was found in eight knees of six patients (16%) after TKA. In group 1, the mean extension range was 14.9°±4.6° and the mean flexion range was 82.6°±7.4°. In group 1, among the factors that may cause knee stiffness; preoperative flexion range and American Knee Society scores were found to be significant (p=0.028 and p=0.036, respectively). The American Knee Society scores were observed to be significantly lower in group 1 when compared to group 2 postoperatively (p=0.018)., Conclusion: If the preoperative flexion range is limited and the American Knee Society scores are low, then the stiff knee is more likely to occur in patients who will undergo TKA. Age, gender, tibiofemoral angle, tibial slope angle, the change in the height of the joint line, the length of the patellar tendon, and the sizes and positions of the components have no significant effect on the development of stiff knee after TKA.

Objective: To evaluate the biomechanics of lumbar motion segments instrumented with stand-alone OptiMesh system augmented with posterior fixation using facet or pedicle screws and the efficacy of discectomy and disc distraction., Background Context: OptiMesh bone graft containment system has been used for vertebral compression fractures and percutaneous lumbar interbody fusion. The filled mesh bag serves as the interbody device providing structural support to the motion segment being fused. No biomechanical data of this new device are available in the literature., Methods: Twenty-four fresh human cadaveric lumbar motion segments were divided into two groups. In the control group, multidirectional flexibility testing was conducted after an intact condition and standard transforaminal lumbar interbody fusion (TLIF) procedure. In the OptiMesh group, testing was performed following intact, stand-alone OptiMesh procedure, OptiMesh with facet screws (placed using the transfacet approach), and OptiMesh with pedicle screws and rods. Range of motion (ROM) was calculated for each surgical treatment. The lordosis and disc height change of intact and instrumented specimens were measured in the lateral radiographs to evaluate the disc space distraction. In the OptiMesh group, cyclic loading in flexion extension (FE) was applied to measure cage subsidence or collapse (10,000 cycles at 6 Nm). After biomechanical testing, all the specimens were dissected to inspect the discectomy and end plate preparation. The area of discectomy was measured., Results: The mean ROM of the intact specimens was 2.7°, 7.4°, and 7.2° in axial torsion (AT), lateral bending (LB), and FE, respectively. There was no difference between the control group and OptiMesh group. The mean ROM of the stand-alone OptiMesh system decreased to 2.4°, 5.1°, and 4.3° in AT, LB, and FE. The ROM decreased to 0.9° in AT, 2.2° in LB, and 0.9° in FE with OptiMesh system and facet screws. On average, OptiMesh system with pedicle screws and rods reduced the ROM to 1.3° in AT, 1.6° in LB, and 1.1° in FE. Compared with the intact condition and stand-alone OptiMesh system, both posterior fixation options had significant statistical difference (p<.001). In AT, ROM of facet screws was lower than that of pedicle screws (p < .05). There was no statistical difference between the facet and pedicle screws in LB and FE (p > .05). The mean volume of bone graft packed into each bag was 8.3 ± 1.5 cc. The average increase of lordosis was 0.6° ± 1.0° after meshed bag was deployed. The average distraction achieved by the OptiMesh system was 1.0 ± 0.6 mm. The average prepared area of discectomy was 42% of the total disc. The disc height change after cyclic loading was 0.2 mm. No subsidence or collapse was noticed., Conclusions: The OptiMesh system offers large volume of bone graft in the disc space with small access portals. The OptiMesh system had similar construct stability to that of standard TLIF procedure when posterior fixation was applied. However, the amount of distraction was limited without additional distraction tools. With the anterior support provided by the expandable meshed bag, facet screws had comparable construct stability to that of pedicle screws. Slightly higher stability was observed in facet screws in AT., (Copyright © 2010 Elsevier Inc. All rights reserved.)

The objective of this prospective consecutive cohort study was to investigate the effect of sagittal cervical profile, gender and age on the thoracic kyphosis in 228 subjects, mainly adults, free of spinal complaints and with a thoracic kyphosis of less than 500. The subjects, who were actually treated for lower extremity problems, were divided into two groups: the 68 subjects in group 1 (30%) had loss of cervical lordosis, while the 160 subjects in group 2 (70%) had a physiological cervical lordosis. In group 1 (loss of cervical lordosis) the mean angles of the upper (T1T6), lower (T7T12), and whole (T1T12) thoracic kyphosis were 8 degrees +/- 2 (range: 3-28 degrees), 15 degrees +/- 4 (range: 6-400), and 24 degrees +/- 6 (range: 10-46 degrees), respectively. In group 2 the normal cervical lordosis seemed to lead to a compensatory increase in these values: 13 degrees +/- 4 (range, 4-35 degrees) (p = 0.008), 21 degrees +/- 5 (range: 6-45 degrees) (p = 0.012), and 34 degrees +/- 8 (range: 12-50 degrees) (p = 0.007). In both groups gender had no significant effect on the values of the thoracic kyphosis (p> 0.05). Also age had no influence, neither in group 1 nor in group 2 as a whole, but in group 2 advanced age (> 50 years) was correlated with a significant increase in the lower (T7T12) (p = 0.009) and whole (T1T12) thoracic kyphosis (p = 0.007). This study yields standards for reference for the normal curvatures of the spine in the sagittal plane. The literature is quite controversial on this matter.

Study Design: An in vitro biomechanical study using osteoporotic cadaveric vertebrae., Objective: To compare the biomechanics of transpedicular and extrapedicular approaches in polymethylmethacrylate vertebroplasty in terms of height restoration, strength, and stiffness., Summary Background Data: Cement is typically injected through a transpedicular approach in both vertebroplasty and kyphoplasty procedures. Previous biomechanical studies were primarily focused on the transpedicular approach. Extrapedicular approach has been recently developed to provide more symmetric cement filling and has good clinical results. However, no biomechanical data are available to compare these 2 techniques., Methods: Twenty-four osteoporotic vertebral bodies were randomly divided into 2 groups for either transpedicular or extrapedicular vertebroplasty. Six lumbar and 6 thoracic vertebrae were used for each group. Each vertebral body was compressed by 25% of its original height and its strength and stiffness were measured. The vertebral bodies were treated with polymethylmethacrylate using either transpedicular or extrapedicular approach. The height restoration was measured before the treated vertebrae were recompressed to determine posttreatment strength and stiffness., Results: Both techniques increased vertebral strength by approximately 50% of the intact strength. There was no statistical difference in posttreatment strength between these 2 techniques. However, the transpedicular technique had higher stiffness recovery (70% to 80%) from the intact stiffness than the extrapedicular technique (60%). The extrapedicular approach achieved greater height restoration in thoracic vertebrae., Conclusions: Both extrapedicular and transpedicular techniques increased strength but reduced stiffness compared with the intact condition. The extrapedicular technique achieved greater height restoration possibly attributed to its easier access to the fracture site. These biomechanical data provide useful information when selecting an approach for cement injection in vertebroplasty procedures.

Pedicle screws are placed using pilot holes. The trajectory of pilot holes can be verified by pedicle sounding or radiographs. However, a pilot hole alone does not insure that the screw will follow the pilot hole. No studies have characterized the risk of misalignment of a pedicle screw with respect to its pilot hole trajectory. The objective of this study was to measure the misalignment angles between pedicle screws and pilot holes with or without tapping. Six human cadaveric thoracic spines were used. One hundred and forty pilot holes were created with a straight probe. Steel wires were temporarily inserted and their positions were recorded with CT scans. The left pedicles were tapped with 4.5 mm fluted tap and the right pedicles remained untapped. Pedicle screws (5.5 mm) were inserted into the tapped and untapped pedicles followed by CT scans. The trajectories of pilot holes and screws were calculated using three-dimensional vector analysis. A total of 133 pilot holes (95%) were inside pedicles. For the untapped side, 14 out of 68 (20%) screws did not follow the pilot holes and were outside the pedicles. For the tapped side, 2 out of 65 (3%) did not follow and breached the pedicles. The average misalignment angles between the screw and pilot hole trajectory were 7.7 degrees +/- 6.5 degrees and 5.6 degrees +/- 3.2 degrees for the untapped side and tapped side, respectively (P < 0.05). Most pedicle screws had lateral screw breach (13 out of 16) whereas most pilot holes had medial pedicle breach (6 out of 7). Tapping of pilot holes (1 mm undertap) helps align pedicle screws and reduces the risk of screw malposition. Although most pedicle screws had lateral breach, the risk of medial pedicle breach of the pilot holes must be recognized.

Background Context: Multilevel lumbar disc disease (MLDD) is a common finding in many patients. Surgical solutions for MLDD include fusion or disc replacement. The hybrid model, combining fusion and disc replacement, is a potential alternative for patients who require surgical intervention at both L5-S1 and L4-L5. The indications for this hybrid model could be posterior element insufficiency, severe facet pathology, calcified ligamentum flavum, and subarticular disease confirming spinal stenosis at L5-S1 level, or previous fusion surgery at L5-S1 and new symptomatic pathology at L4-L5. Biomechanical data of the hybrid model with the Maverick disc and anterior fusion are not available in the literature., Purpose: To compare the biomechanical properties of a two-level Maverick disc replacement at L4-L5, L5-S1, and a hybrid model consisting of an L4-L5 Maverick disc replacement with an L5-S1 anterior lumbar interbody fusion using multidirectional flexibility test., Study Design: An in vitro human cadaveric biomechanical study., Methods: Six fresh human cadaveric lumbar specimens (L4-S1) were subjected to unconstrained load in axial torsion (AT), lateral bending (LB), flexion (F), extension (E), and flexion-extension (FE) using multidirectional flexibility test. Four surgical treatments-intact, one-level Maverick at L5-S1, two-level Maverick between L4 and S1, and the hybrid model (anterior fusion at L5-S1 and Maverick at L4-L5) were tested in sequential order. The range of motion of each treatment was calculated., Results: The Maverick disc replacement slightly reduced intact motion in AT and LB at both levels. The total FE motion was similar to the intact motion. However, the E motion is significantly increased (approximately 50% higher) and F motion is significantly decreased (30%-50% lower). The anterior fusion using a cage and anterior plate significantly reduced spinal motion compared with the condition (p<.05). No significant differences were found between two-level Maverick disc prosthesis and the hybrid model in terms of all motion types at L4-L5 level (p>.05)., Conclusion: The Maverick disc preserved total motion but altered the motion pattern of the intact condition. This result is similar to unconstrained devices such as Charité. The motion at L4-L5 of the hybrid model is similar to that of two-level Maverick disc replacement. The fusion procedure using an anterior plate significantly reduced intact motion. Clinical studies are recommended to validate the efficacy of the hybrid model.

Single level axial lumbar interbody fusion (AxiaLIF) using a transsacral rod through a paracoccygeal approach has been developed with promising early clinical results and biomechanical stability. Recently, the transsacral rod has been extended to perform a two-level fusion at both L4-L5 and L5-S1 levels (AxiaLIF II). No biomechanical studies have been conducted on multilevel fusion using the AxiaLIF technique. In this study, the biomechanics of L4-S1 motion segments instrumented with the AxiaLIF II transsacral rod was evaluated. Six human cadaveric lumbosacral spine segments from L4 to S1 were used (age ranges 46-74 years). Unconstrained and non-destructive pure moments in axial torsion, lateral bending, and flexion extension were applied to each specimen following intact, standalone AxiaLIF II, and AxiaLIF II with two posterior fixation options: facet screws and pedicle screws with rods. Range of motion was calculated from the raw data collected with an optical motion tracking system. The two-level transsacral rod was successfully inserted in all the specimens. At L4-L5 level in axial torsion (AT) and flexion extension (FE), none of the surgical treatments showed statistically significant difference between the procedures (all P > 0.05) although facet screws and pedicle screws had higher stability on average. In lateral bending (LB), the two posterior fixation techniques had significantly higher construct stability (P < 0.05) than the standalone rod. No significant difference was found between facet screws and pedicle screws (P = 0.821). At L5-S1 level in AT and LB, none of the surgical treatments were found to be statistically significant (all P > 0.05). In FE, standalone two-level transsacral rod had significantly higher range of motion (ROM) compared with the posterior fixation techniques (P < 0.05). In conclusion, the standalone rod reduced intact ROM significantly. Supplementary fixations including facet screws and pedicle screws are required to achieve higher construct stability for successful fusion. Further clinical studies are essential to evaluate the practical success of this technique.

The objective of this prospective consecutive cohort study was to compare the clinical outcomes, the radiographic outcomes and the complication rates of symptomatic acute (< 10 weeks) and chronic (> 16 weeks) osteoporotic vertebral compression fractures (VCFs) treated with kyphoplasty. Twenty-eight consecutive patients had 52 symptomatic osteoporotic VCFs treated with kyphoplasty; 5 of these patients were treated in two sessions. The Oswestry Disability Index (ODI) for back pain, a Visual Analog Scale for pain assessment, a patients' satisfaction scale, and medication usage served to evaluate the clinical outcomes. All these variables improved significantly in both groups, and more so in the acute group, but the difference was most often not significant. Vertebral height, local kyphosis angle, global sagittal alignment and dynamic fracture mobility significantly improved in both groups (except global sagittal alignment), and again more so in the acute group (except global sagittal alignment); the difference between groups was significant regarding radiological variables, except global sagittal alignment. Timing of kyphoplasty certainly matters, as the clinical and radiological outcomes were mostly better in acute fractures than in chronic fractures, which somehow responded satisfactorily. Controlled studies (kyphoplasty versus natural history) are needed to establish the real value of the procedure.

Background Context: Euler and projection methods have been used to describe relative spinal motion. In the Eulerian formulation, the exiting method used vector form of Euler angles and only provides an approximation. In the projection method, local coordinate systems constructed with digitization can affect the accuracy of kinematical results. A more consistent data reduction method is desired to calculate relative spinal motion (range of motion) from raw marker data., Purpose: To develop a new data reduction method to calculate relative spinal motion based on arbitrarily oriented local coordinate systems of individual vertebrae, and to simplify experimental procedures in multidirectional testing of spines., Study Design/setting: The relative spinal motion was determined from raw marker data using transformation matrices., Methods: In the Eulerian formulation, the relative motion of a vertebra to its subjacent level was determined using transformation matrices rather than vector operation on Euler angles. In the projection method, the projection axes were determined by tranforming local coordinate systems. Both approaches can be used to analyze raw marker data., Results: The new data reduction method was successfully implemented to analyze the raw data acquired on an intact L1-L2 motion segment. There was little difference between the Euler method and projection methods., Conclusions: In conclusion, an alternative data reduction method in both Euler and projection angles to calculate range of motion for in vitro spine biomechanical studies was presented. The method was validated on a human cadaveric lumbar motion segment under axial torsion, lateral bending, and flexion extension. Because the relative spinal motion does not depend on how local coordinate systems are oriented, the digitization process can be eliminated in most multidirectional flexibility tests. Compared with previous methods, this new method provides more consistent kinematical results and significantly simplifies experimental procedures.

Hemangioma or vascular malformation of the synovium is rare and presents a difficult problem in diagnosis and treatment. A long history of joint pain and recurrent non-traumatic hemarthrosis usually draws attention to the hemangioma of the knee joint. The lesion can be seen in two different formations; the synovial hemangioma or the arteriovenous malformation named as hemangiohamartomas, both of which involve the synovium and cause non-traumatic episodes of hemarthrosis. MRI scanning together with arthroscopy is a diagnostic tool to demonstrate the extent and the nature of the lesion. We treated the three patients at different ages. All patients underwent standard radiographic examination, CT scans, MRI and diagnostic arthroscopy. After frozen section taken via arthroscopically, the lesions were excised by arthrotomy. The mean follow-up was 38 months (31-45) and all patients are asymptomatic postoperatively. Three additional cases and a review of the literature are presented because of the rarity of the lesion.

Trapezius muscle paralysis results from injury to the spinal accessory nerve. Impairment in the trapezius muscle function may destabilize the muscle resulting in winged scapula. A 25-year-old university student who was active in sports had complaints of shoulder drop and pain on abduction. He had a three-year history of fall resulting in a scapular fracture for which he received conservative treatment. Physical examination showed asymmetry and drop of the right shoulder. Lateral scapular winging was apparent particularly above 90 degrees of abduction. Electromyography revealed isolated paralysis of the trapezius muscle. The patient underwent reconstruction with the modified Eden-Lange procedure. After a two-year follow-up, asymmetry in the shoulder decreased, there was no pain on active abduction, and the patient returned to active sports and was fully satisfied with the outcome.

Objectives: We evaluated the results of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) transfers for EPL ruptures secondary to rheumatoid arthritis., Methods: Twenty-four patients (7 males, 17 females; mean age 41 years; range 22 to 72 years) with rheumatoid arthritis underwent EIP to EPL transfer for 25 ruptures. The mean duration from rupture to surgery was 4.3 months (range 1.5 to 11 months). Functional assessment of the fingers was made using a specific EIP-EPL evaluation method developed by Lemmen et al. Pinch and grip strengths were measured. Range of motion of the metacarpophalangeal and interphalangeal joints of the thumb was compared with the normal side. Patient satisfaction was evaluated by a visual analog scale. The mean follow-up period was 6.2 years (range 4.7 to 7.9 years)., Results: Functional results were perfect in 14 fingers (56%), good in six fingers (24%), moderate in four fingers (16%), and poor in one finger (4%). The pinch and grip strengths were 86% and 92% of the uninvolved hand, respectively. The mean visual analog scale score was 74 (range 24 to 99). Compared to the uninvolved side, the range of motion of the thumb and index finger decreased by 23 degrees and 7 degrees , respectively, with a 9% loss of interphalangeal motion and a 17% loss of metacarpophalangeal motion in thumb extension. Independent extension of the index finger was possible in 21 hands., Conclusion: The results of EIP to EPL transfers are successful in ruptures secondary to rheumatoid arthritis.

The purpose of this study was to evaluate arthroscopically the type, localization and prevalence of the meniscal and chondral lesions accompanying complete rupture of the anterior cruciate ligament (ACL) in patients who elected not to restrict their daily activities after the initial trauma. The size of the chondral lesions was also evaluated. Our second aim is to analyze the effects of age, time from injury, and both age and time from injury in the presence or absence of accompanying lesions in these patients. The localization and type of the accompanying lesions of 317 knees with complete rupture of the ACL were recorded by the same observer. We applied therapeutic arthroscopy to all patients after their first visit to our clinic. All of the patients were military personnel and their history revealed that they had elected to not restrict their occupational activities after the first trauma causing ACL insufficiency. We defined the first 6 week period after the initial trauma as the acute, 6 weeks to 12 months as the subchronic and 12 months or longer as the chronic period. The average time from injury to arthroscopy for these patients, who were all male, was 19.4 +/- 20.3 months. Eighty-one percent of the patients had at least one meniscal tear, and 45.1% had at least one chondral lesion. The mean ages at the time of surgery of patient groups with or without medial and lateral menisci lesions were compared, and no statistically significant difference was determined. In the chronic period, the relative risk (RR) values of meniscal tears were 7.75 for medial and 2.40 for lateral. The group consisting of patients with chondral lesions was compared with the group of patients without chondral lesions in terms of their ages and the time from injury to arthroscopy, and the difference was statistically significant. The RR value for patients with co-existence of at least two lesions was 1.761 for more than 30 years of age. The RR values for at least two lesions were 2.356 for the subchronic and 14.909 for the chronic group when compared to the acute group. The RR values in patients more than 30 years of age in the chronic group were 13.58 for medial meniscus, 3.21 for lateral meniscus and 71.88 for chondral lesions when compared to patients less than 30 years of age in the acute group. It is important to note that the combined effects of advanced age and prolonged time from injury in patients who elected to not restrict occupational activities are more severe due to the increase in the occurrence of intraarticular lesions accompanying ACL insufficiency as compared to their separate effects.

Pantibial ligamentous injury including knee dislocation and tibiotalar joint subluxation is an uncommon severe rotational injury. A 21-year-old male injured his right knee falling from a motorcycle. Physical examination revealed effusion on the right knee and ankle, and posterior translation of the tibia as well. The MRI of the right knee and ankle demonstrated the following findings: a complete disruption of cruciate ligaments, the medial collateral ligament, posteromedial corner injury together with a peripheric tear in the medial meniscus, the ruptured deltoid ligament, ankle syndesmosis space widening (>5 mm) and lateral subluxation of talus. Deltoid ligament of the right ankle was repaired and ankle syndesmosis was fixed with a cortical screw. The PCL and ACL were reconstructed arthroscopically with autogeneous bone-patellar tendon-bone graft. The midsubstance tear of MCL, posteromedial corner and medial meniscus tear were primarily repaired with nonabsorbable sutures. 3 years after the surgery, the patient was called for the final examination. MRI and X-ray findings of the knee and ankle joint demonstrated the continuity of ACL, PCL, MCL, and deltoid ligament. The patient, who is a farmer, can go back to his job and perform his daily activities. We presented a previously unreported case that involves both simultaneous occurrence of knee dislocation and tibiotalar joint subluxation. We used the term "Pantibial ligamentous injury" for this case.

We dissected 150 fresh cadaver halves by ilioinguinal exposure, and counted all vessels more than 2 mm in diameter, connecting the obturator system to the external iliac system. The distance between the symphysis pubis and the anastomotic vessels was measured. We found vascular anastomoses between the obturator and external iliac systems in 91 of 150 sides (61%), and anastomotic veins in 78 of 150 exposures (52%). Arterial connections were seen in 29 of the exposures (19%). The mean distance between the anastomotic arteries and the symphysis pubis was 64 (45-90) mm, and 56 (37-80) mm for the communicating veins. There seemed to be no significant difference between genders in the incidence of corona mortis and the distance between communicating vessels and the symphysis pubis.