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BACKGROUND AND PURPOSE: Intramedullary bone-lengthening nails have become increasingly popular. The 2 most used and successful nails are the FITBONE and the PRECICE nails. Uniform reporting is lacking on complications of intramedullary bone-lengthening nails. The purpose was therefore to assess and categorize the complications of lower limb bone-lengthening nails and investigate risk factors.PATIENTS AND METHODS: We performed a retrospective review of patients operated on with intramedullary lengthening nails at 2 hospitals. We included only lower limb lengthening with FITBONE and PRECICE nails. Recorded patient data was patient demographics, nail information, and any complication. Complications were graded according to severity and origin classification. Complication risk factors were assessed with modified Poisson regression.RESULTS: 314 segments in 257 patients were included. The FITBONE nail was predominantly used (75%), and most of the lengthenings were performed in the femur (80%). 53% of the patients had complications. 269 complications were identified in 175 segments (144 patients). Device-related complications were most frequent (0.3 complications/segment), followed by joint complications (0.2 complications/segment). An increased relative risk was found for complications in the tibia compared with the femur and for age groups above 30 years compared with the 10-19 years group.CONCLUSION: Complications with intramedullary bone lengthening nails were more frequent than has previously been reported, with 53% of patients sustaining a complication. Future studies need to document the complications meticulously so that the true risk can be established.

Assessment of bone graft material efficacy is difficult in humans, since invasive methods like staged CT scans or biopsies are ethically unjustifiable. Therefore, we developed a novel large animal model for the verification of a potential transformation of synthetic bone graft substitutes into vital bone. The model combines multiple imaging methods with corresponding histology in standardized critical sized cancellous bone defect. Cylindrical bone voids (10 ml) were created in the medial femoral condyles of both hind legs (first surgery at right hind leg, second surgery 3 months later at left hind leg) in three merino-wool sheep and either (i) left empty, filled with (ii) cancellous allograft bone or (iii) a synthetic, gentamicin eluting bone graft substitute. All samples were analysed with radiographs, MRI, μCT, DEXA and histology after sacrifice at 6 months. Unfilled defects only showed ingrowth of fibrous tissue, whereas good integration of the cancellous graft was seen in the allograft group. The bone graft substitute showed centripetal biodegradation and new trabecular bone formation in the periphery of the void as early as 3 months. μCT gave excellent insight into the structural changes within the defects, particularly progressive allograft incorporation and the bone graft substitute biodegradation process. MRI completed the picture by clearly visualizing soft tissue ingrowth into unfilled bone voids and presence of fluid collections. Histology was essential for verification of trabecular bone and osteoid formation. Conventional radiographs and DEXA could not differentiate details of the ongoing transformation process. This model appears well suited for detailed in vivo and ex vivo evaluation of bone graft substitute behaviour within large bone defects.

Background and purpose — We noted several adverse events in patients in whom the first version of the STRYDE limb-lengthening nail (NuVasive Specialized Orthopaedics, San Diego, CA) had been implanted. Pain, osteolysis, periosteal reactions, and cortical hypertrophy at the nail junction were noted. Here, we present the analysis of 23 retrieved STRYDE implants. Materials and methods — We undertook visual inspection of the retrieved nails and screws, mechanical evaluation of the junction, micro-CT analyses, microscopic inspection of the bushing, screws, screw holes, and separated parts of the implants. Positive material identification (PMI) and energy-dispersive X-ray spectroscopy (EDS) were used to analyze the chemical composition. The hardness of the material was also investigated. Results — 20/23 retrieved nails had visible signs of corrosion, i.e., discoloration at the telescopic junction. Micro-CT verified corrosion attacks in 12/12 scanned bushings. Corrosion, predominantly mechanically assisted crevice corrosion, was observed at the locking screws and screw holes in 20/23 nails. Biological material inside the nail was observed in addition to oozing from the junction of 2 nails during hardware removal, which was experimentally reproducible. Notably, the mechanical construction of the bushing changed from PRECICE P2 to STRYDE nails. Interpretation — STRYDE nails are not hermetically sealed, and liquid can pass the bushing. Biodur 108 itself is corrosion resistant; however, mechanically assisted crevice corrosion of the bushing, locking screws, and screw holes may be aggravated due to manufacturing aiming for increased strength and hardness of the alloy. Observing several adverse events, we recently published a nationwide cross-sectional analysis of all 30 STRYDE limb- lengthening nails (NuVasive, Specialized Orthopedics, San Diego, CA) that were implanted in Denmark (Rölfing et al. 2021a). 27/30 STRYDE nails have now been removed and we present data from metallurgical analysis of 23 of the retrieved implants.

Background and purpose — In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods — We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results — The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8–74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation — The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different. Background and purpose — In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods — We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results — The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8–74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation — The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different.

Purpose: It is proposed that central femoral ACL graft placement better controls rotational stability. This study evaluates the consequence of changing the femoral tunnel position from the AM position drilled transtibially to the central position drilled transportally. The difference in ACL graft failure is reported. Methods: This prospective consecutive patient single surgeon study compares the revision rates of 1016 transtibial hamstring ACL reconstructions followed for 6–15 years with 464 transportal hamstring ACL reconstructions followed for 2–6 years. Sex, age, graft size, time to surgery, meniscal repair and meniscectomy data were evaluated as contributing factors for ACL graft failure to enable a multivariate analysis. To adjust for the variable follow-up a multivariate hazard ratio, failure per 100 graft years and Kaplan–Meier survivorship was determined. Results: With transtibial ACLR 52/1016 failed (5.1%). With transportal ACLR 32/464 failed (6.9%). Significant differences between transportal and transtibial ACLR were seen for graft diameter, time to surgery, medial meniscal repair rates and meniscal tissue remaining after meniscectomy. Adjusting for these the multivariate hazard ratio was 2.3 times higher in the transportal group (p = 0.001). Central tunnel placement resulted in a significantly 3.5 times higher revision rate compared to an anteromedial tunnel placement per 100 graft years (p = 0.001). Five year survival was 980/1016 (96.5%) for transtibial versus 119/131 (90.5%) for transportal. Transportal ACLR also showed a significantly higher earlier failure rate with 20/32 (61%) of the transportal failing in the first year compared with 14/52 (27%) for transtibial. (p = 0.001.) Conclusion: Transportal central femoral tunnel ACLR has a higher failure rate and earlier failure than transtibial AM femoral tunnel ACLR. Level of evidence: Level II—prospective comparative study.

Background: The aim of this study was to compare the accuracy of the oscillating tip saw system (Precision Saw = PS) with the more conventional fully oscillating blade system (Sagittal Saw = SS) during computer-assisted total knee arthroplasty (CAS-TKA).Methods: A prospective, randomised, controlled trial included 58 consecutive patients who underwent primary CAS-TKA and were randomly assigned in the PS group or the SS group to compare the accuracy of both blades. The primary outcome was the difference between the intended cutting planes and the actual cutting planes in degrees () in two planes of both the femur and the tibia. The secondary outcome was total surgery time.Results: Tibia: In the W-plane no significant differences were registered for the mean absolute deviation (p = 0.28). The PS was more accurate in the AP-plane (p = 0.03). Femur: The PS showed significantly fewer mean absolute deviations in the W-plane (p = 0.03); however, the SS revealed better accuracy in the FE-plane (p = 0.04). The difference in the surgery time between the groups was not statistically significant (p = 0.45). Two outliers were measured using the SS, while seven outliers were detected using the PS.Conclusion: The Precision Saw is not proven to be overall more accurate than the Sagittal Saw. Significantly better accuracy was shown with the PS in the two cutting planes, with the exception of one cutting plane that favoured the SS. Greater number of outliers were found using the PS. (C) 2017 Elsevier B.V. All rights reserved.

Background Due to its bone preserving philosophy, short-stem total hip arthroplasty (THA) has primarily been recommended for young and active patients. However, there may be benefits for elderly patients given a less invasive operative technique due to the short curved implant design. The purpose of this study was to compare the clinical and radiological outcomes as well as perioperative complications of a calcar-guided short stem between a young ( 75 years) population. Methods Data were collected in a total of 5 centers, and 400 short-stems were included as part of a prospective multicentre observational study between 2010 and 2014 with a mean follow-up of 49.2 months. Preoperative femur morphology was analysed using the Dorr classification. Clinical and radiological outcomes were assessed in both groups as well as perioperative complications, rates and reasons for stem revision. Results No differences were found for the mean visual analogue scale (VAS) values of rest pain, load pain, and satisfaction, whereas Harris Hip Score (HHS) was slightly better in the young group. Comparing both groups, none of the radiological parameters that were assessed (stress-shielding, cortical hypertrophy, radiolucency, osteolysis) reached differences of statistical significance. While in young patients aseptic loosening is the main cause of implant failure, in the elderly group particularly postoperative periprosthetic fractures due to accidental fall have to be considered to be of high risk. The incidence of periprosthetic fractures was found to be 0% in Dorr type A femurs, whereas in Dorr types B and C fractures occurred in 2.1 and 22.2% respectively. Conclusions Advanced age alone is not necessarily to be considered as contra-indications for calcar-guided short-stem THA, although further follow-up is needed. However, markedly reduced bone quality with femur morphology of Dorr type C seems to be associated with increased risk for postoperative periprosthetic fractures, thus indication should be limited to Dorr types A and B. Trial registration German Clinical Trials Register; DRKS00012634, 07.07.2017 (retrospectively registered).

Among the options for femoral reconstruction in total hip arthroplasty (THA) revision procedures, in cases of extensive circumferential defects, is the use of proximal femoral allografts. This technique makes it possible to correct the hip abductor mechanism and the leg length discrepancy, as well as presenting osteoconductive potential. The authors report the clinical and radiographic results from two cases of THA revision using this technique, with a minimum follow-up of 20 years.

PURPOSE: To compare anteromedial (AM) and transtibial (TT) femoral drilling hole techniques in primary anterior cruciate ligament reconstruction, using the Danish Knee Ligament Reconstruction Register, comparing revision rates and clinical outcomes from 2 time periods, 2007 to 2010 and 2012 to 2015.METHODS: A total of 8,386 primary anterior cruciate ligament reconstructions were registered between January 2007 to December 2010 and 8,818 in the period January 2012 to December 2015. Revision ACL was the primary endpoint. Secondary endpoints were the objective and subjective clinical outcomes. Crude and adjusted relative risks (RRs) with 95% confidence interval (CIs) were calculated.RESULTS: The adjusted RR for revision surgery in the AM (2007-10) group compared with the TT (2007-10) group was 1.45 (95% CI, 1.17-1.78; P < .05), but when comparing the AM (2012-15) group with TT (2012-15) group, the RR was 0.99 (95% CI, 0.68-1.45; P = .96). One-year postoperative objective stability testing showed an RR = 1.38 (95% CI, 1.19-1.60; P < .01) for rotational stability and an RR = 1.37 (95% CI, 0.99-1.89; P < .01) for sagittal stability when comparing AM (2007-10) to TT (2007-10). No significant difference in objective stability was found in the more recent period. Lastly, comparing the subjective scores, the AM (2012-15) had a significantly higher Tegner score 1 year postoperatively compared with the TT-group (2012-15).CONCLUSIONS: This study found an increased RR of revision anterior cruciate ligament and rotational and sagittal instability 1 year postoperatively for the AM technique in the period from 2007 to 2010. However, there was no significant difference in revision surgery and objective measures between the techniques from 2012 to 2015. Nevertheless, a higher activity level was found in the AM group. The results could indicate that the results found in the period 2007 to 2010 may have been caused by a learning curve when introducing a new and more complex procedure (AM).LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Place: United States

Purpose: The HemiCAP ® implant for femoral resurfacing treatment of cartilage lesions was introduced in 2003. We present outcome from a prospective cohort study of 61 patients with both trochleal and condylar lesions treated with the HemiCAP ® implant. Methods: From 2007 to 2012, 61 patients were treated with femoral resurfacing using the HemiCAP implant. There were 36 femoral condyle implants and 25 trochleal implants. Indication for treatment with HemiCAP implant was symptomatic cartilage lesion at the femoral condyle demonstrated by MRI or arthroscopy, which was ICRS grade 3–4 and size less than 4 cm 2. There were 24 males and 37 females with a median age of 49 (range 35–65) years. Patients were followed for 2 years with Knee Society subjective outcome scores (KSS), pain scores and radiographic evaluations and for 7 years with complications and reoperations. Results: At 2-year follow-up, mean KSS was improved from 52 (6.2) to 90 (7.9), mean KSS function score was improved from 45 (7.5) to 92 (8.3), and mean Pain score improved from 7.1 (0.7) to 1.8 (1.7). Twenty-three per cent of implants were revised within 7 years to arthroplasty due to progression of cartilage lesions, progression of osteoarthritis, or increased knee pain. No difference between females and males was found for reoperation rate. Conclusion: The present study demonstrated improved subjective outcome and reduced pain after femoral resurfacing using the HemiCAP implant in a relatively large cohort of patients with symptomatic cartilage lesions. A concerning 23 % reoperation rate with conversion to arthroplasty was found. Femoral resurfacing implantation treatment can be a temporary treatment for cartilage lesions expected to develop into osteoarthritis and for younger patients not eligible for arthroplasty treatment. Level of evidence: IV.

Introduction: Revision total knee arthroplasty with a cementless metaphyseal sleeve is suggested to be used without stem in revision total knee arthroplasty (rTKA). To the best of our knowledge, no papers investigating this have been published. The purpose of this study was to evaluate clinical outcome. Method: In this retrospective study, 71 patients operated with rTKA with sleeves without stem in the period 2009–2011 were identified; 63 were examined. All patients with the prosthesis still in place were invited to a medical examination including X-rays. American Knee Society Score (AKSS) and Oxford Knee Score (OKS) were used as primary clinical outcome scores. Results: Mean number of revisions including the revision with sleeve was 1.7. AKSS increased significantly from 62.7 to 109.6; (p value

We conducted a longitudinal study including patients with the same type of primary hybrid total hip replacement and evaluated patient activity and femoral osteolysis at either five or ten years post-operatively. Activity was measured using the University of California, Los Angeles scale. The primary outcome was the radiological assessment of femoral osteolysis. Secondary outcomes were revision of the femoral component for aseptic loosening and the patients’ quality of life. Of 503 hip replacements in 433 patients with a mean age of 67.7 years (30 to 91), 241 (48%) were seen at five and 262 (52%) at ten years post-operatively. Osteolytic lesions were identified in nine of 166 total hip replacements (5.4%) in patients with low activity, 21 of 279 (7.5%) with moderate activity, and 14 of 58 (24.1%) patients with high activity. The risk of osteolysis increased with participation in a greater number of sporting activities. In multivariate logistic regression adjusting for age, gender, body mass index and the inclination angle of the acetabular component, the adjusted odds ratio for osteolysis comparing high vs moderate activity was 3.6 (95% confidence interval 1.6 to 8.3). Stratification for the cementing technique revealed that lower quality cementing increased the effect of high activity on osteolysis. Revision for aseptic loosening was most frequent with high activity. Patients with the highest activity had the best outcome and highest satisfaction. In conclusion, of patients engaged in high activity, 24% had developed femoral osteolysis five to ten years post-operatively.

Purpose: The UniCAP ® implant for femoral resurfacing treatment of large cartilage lesions and early OA was introduced in 2006. The outcome of the present study is from a prospective cohort study of 64 patients, followed 2 years clinically and 7 years for revisions. Methods: From 2009 to 2013, 64 patients were treated with femoral resurfacing using the UniCAP implant. Indication for treatment with UniCAP implant was symptomatic huge cartilage lesion or early OA at the femoral condyle demonstrated by MRI or arthroscopy, which was ICRS grades 3–4 and more than 4 cm 2. There were 28 males and 36 females with a median age of 51 (range 35–65) years. Patients were followed for 2 years clinically with Knee Society subjective outcome scores (KSS), pain scores and radiographic evaluations and for 7 years with complications and reoperations. Results: At 2 years, the follow-up mean KSS improved from 49 (6.9) to 88 (17.1), the mean KSS function score improved from 46 (8.0) to 90 (17.1), and the mean Pain score improved from 7.4 (0.5) to 2.3 (1.4). 47 % of the implants were revised within 7 years to arthroplasty due to the progression of cartilage lesions, progressing of osteoarthritis or increased knee pain. The reoperation rate did not show any significant difference between females and males. The Kaplan–Meier survival rate was 50 % at 7 years, no difference among females and males. Conclusion: The present study demonstrated an improved subjective outcome and reduced pain after femoral resurfacing using the UniCAP ® implant in a relatively large cohort of patients with symptomatic large cartilage lesions or early OA. A 47 % reoperation rate with conversion to arthroplasty was found. The femoral resurfacing implantation can be a temporary treatment for large cartilage lesions or early OA that is expected to develop into osteoarthritis. For younger patients who are ineligible for arthroplasty treatment, this implant can offer a temporary solution. Level of evidence: IV.

Objectives: This study aimed to develop an alternative thermoinactivation method for biological inactivation of microscopic contamination on the cavity wall following curettage of local aggressive tumors. Hot saline irrigation was applied at various temperatures to bone cavity, with or without tourniquet on the extremity and temperature changes and local effects were investigated in vivo.Methods: Bone cavities 12 cm3 in size were created in the condylar regions of the hind legs in nine female adult sheep. The cavities were irrigated by hot saline solution at 60, 70, 75, 80, or 100 °C, with and without the presence of a tourniquet, and the temperatures 1, 2, 3, and 10 mm distant to the cavity wall were recorded. The animals were sacrificed postoperatively at 2 days, 3 and 6 weeks, and 3 and 7 months for histologic studies.Results: The mean body temperature and temperature inside the bone prior to surgery were measured as 38.1 °C and 27.34 °C, respectively. Tourniquet application caused a mean decrease of 1.5 °C (range 1-2 °C) in bone temperature. The highest temperatures measured below 80 °C and at 80 °C were 55.5 °C and 62.5 °C in the cavity, and 40.5 °C and 42.5 °C in the bone, respectively. At 100 °C application, the color of the bone together with the surrounding soft tissue and muscle tissue turned to yellow-brown-black, and the animal died on the second postoperative day. At temperatures ≤80 °C, the color of the bone and surrounding tissues appeared normal and no early complications were encountered. Histologic studies showed no bone marrow or bone necrosis at 60 °C, only bone marrow necrosis at 70 °C and 75 °C, and in addition to bone marrow necrosis, bone necrosis at 80 °C. At these temperatures no evidence for soft tissue necrosis were observed.Conclusion: Our results show that, in order to achieve bone necrosis at 1-mm and 2-mm distances from the cavity wall, the optimum temperature for hot saline irrigations applied to the bone cavity is 80 °C., Amaç: Lokal agresif tümörlerde küretaj sonrası kavite duvarında kalan mikroskobik kontaminasyonun biyolojik inaktivasyonu için alternatif bir termoinaktivasyon yöntemi geliştirmek amacıyla, turnikeli ve turnikesiz ortamda kemik kavitelerine uygulanan değişik sıcaklıklardaki suyun, kavite duvarındaki kemik bölgesinde oluşturduğu sıcaklıklar ve etkileri in vivo olarak araştırıldı.Çalışma planı: Dokuz adet dişi erişkin koyunun turnikeli veya turnikesiz arka bacaklarında, kondiler bölgelerde 12 cm3 hacminde açılan kavitelere her biri 12 dakika süreyle aralıklı 60, 70, 75, 80 veya 100 °C sıcaklıkta serum fizyolojik uygulandı. Isının kavite duvarına 1, 2, 3 ve 10 mm uzaklıklarda yarattığı sıcaklıklar kaydedildi. Deneklerin yaşamı işlem sonrası 2. gün, 3 ve 6. haftalarda ve 3 ve 7. aylarda sonlandırılarak histolojik olarak incelendi.Sonuçlar: Ameliyat öncesinde deneklerin vücut ısısı ortalama 38.1 °C, kemik içi ısısı ortalama 27.4 °C ölçüldü. Turnike uygulaması, kemikte ortalama 1.5 °C (dağılım 1-2 °C) sıcaklık azalmasına neden oldu. Seksen derecenin altındaki ve 80 °C’deki uygulamalarda kemik kavitesi içinde ölçülen en yüksek sıcaklıklar sırasıyla 55.5 °C ve 62.5 °C, kemikte ölçülen en yüksek sıcaklıklar 40.5 °C ve 42.5 °C idi. Sıcaklık 100 °C’ye çıkarıldığında yumuşak doku, kas dokusu ve kemikte yeşil-kahverengi-siyah renk değişikliği görüldü ve denek ameliyat sonrası ikinci günde kaybedildi. Diğer sıcaklıklarda çevre kemik, kas, yumuşak dokular normal renkteydi ve bu deneklerde ameliyat sonrası erken komplikasyon gelişmedi. Histolojik incelemede, 60 °C uygulamalarında kavitede kemik iliği ve kemikte nekroz görülmezken, 70 ve 75 °C’de kemik iliği nekrozu görüldü; 80 °C’de ise kemik iliği nekrozuna ek olarak, kemik nekrozu izlendi. Bu sıcaklıklarda deneklerin hiçbirinde yumuşak doku nekrozu görülmedi.Çıkarımlar: Bulgularımız, kemik kavitelerindeki sıcak serum fizyolojik uygulamalarında, kavite duvarındaki 1-2 mm’lik kemik bölgesinde kemik nekrozu oluşturabilecek en uygun sıcaklığın 80 °C olduğunu göstermektedir.

Objectives: Using a synthetic bone model, we investigated changes in the muscle length of the gluteus medius and gluteus minimus following trochanteric osteotomy and pelvic support osteotomy (PSO) and compared the results with those of traditional PSO.Methods: On two pelvises and four femurs, the lengths of the gluteus medius and gluteus minimus were measured in the following circumstances, with the hips in neutral position and in 45 degrees of flexion: (i) alignment of the hip joint with normal congruency; (ii) dislocated hip joint; (iii) following an osteotomy 2.5 cm below the lesser trochanter and stabilization with an angulation of 45 degrees of abduction; (iv) the insertion point was then moved 2 cm distally and 1 cm laterally, simulating a translation osteotomy of the greater trochanter.Results : The muscle lengths increased with PSO compared to those of the dislocated hips (p, Amaç: Sentetik kemik modelinde trokanterik osteotomi ve pelvik destek osteotomi (PDO) kombinasyonunu uyguladıktan sonra gluteus medius ve minimus kaslarının uzunluklarında meydana gelen değişimleri inceledik ve sonuçları klasik PDO tekniğiyle karşılaştırdık.Çalışma planı: İki adet sentetik pelvis ve dört femur üzerinde, gluteus medius ve minimus kaslarının uzunlukları dört ayrı durumda ve kalça eklemi nötral ve 45° fleksiyon pozisyonundayken ölçüldü: (i) Normal pozisyon; (ii) kalça eklemi disloke; (iii) trokanter minörün 2.5 cm aşağısından osteotomi uygulanarak femur proksimali 45° abdükte pozisyonda eksternal fiksatörle tespit edildi; (iv) üçüncü durumdaki pozisyon korunurken trokanterik osteotomi uygulanarak kasların yapışma noktası 2 cm laterale ve 1 cm distale alındı.Sonuçlar: Pelvik destek osteotomisi uygulanan grupta, kas uzunluğu disloke pozisyona göre artış gösterdi (p

Objectives: This study was designed to evaluate the methods that we used for removal of components and cement in revision hip arthroplasty (RHA).Methods: Thirty-seven patients (mean age 65.6 years; range 18 to 78 years) who underwent RHA were retrospectively evaluated. Arthroplasty had been cementless, hybrid, cemented, and partial in 13, 16, 5, and 3 hips, respectively. Revision included only acetabular cup in four patients, femoral component in three, and all components in the remaining patients. Of the acetabular cups revised, five were cemented, 28 were cementless (10 expanded, 18 porouscoated); of the femoral components, 22 were cemented and 11 were cementless. The mean time to revision was 7.3 years(range 1.5 to 13 years). Extended proximal femoral osteotomy (EPFO) was performed in 28 hips (84.9%), of which 10 hips (35.7%) required the use of high speed cutting heads. All the patients were evaluated before and after revision according to the criteria of Merle d’Aubigne and Postel which were modified by Charnley. The mean follow-up period was 36.3 months (range 2 to 48 months).Results: There were no difficulties in the removal of cemented acetabular cups. Expanded cementless cups were readily removed by bending their expanded leaves. However, high speed cutting heads were used to resolve the bone-cup integration in eight porous-coated cups (44.4%); of these, two cups (25%) even required the use of high speed metal cutting heads to split several parts apart. In one patient, a spiral fracture occurred extending to the distal end of EPFO. On final follow-ups, the results were evaluated as perfect or good in 92% of the hips.Conclusion: The removal of components and cement during RHA may require the use of more complex methods and device in addition to standard ones., Amaç: Revizyon kalça artroplastisinde komponentlerin ve çimentonun çıkartılmasında kullanılan yöntemler değerlendirildi.Çalışma planı: Revizyon kalça artroplastisi uygulanan 37 hasta (ort. yaş 65.6; dağılım 18-78) retrospektif olarak incelendi. Kalça artroplastisi 13 kalçada çimentosuz, 16 kalçada hibrid şeklinde, beş kalçada çimentolu, üç kalçada parsiyel uygulanmıştı. Dört hastada sadece asetabular kap, üç hastada sadece femoral komponent revize edilirken, diğer hastalarda tüm komponentler revize edildi. Revize edilen asetabular kapların beşi çimentolu, 28’i çimentosuz (10 ekspanse, 18 poroz kaplı press-fit); femoral stemlerin 22’si çimentolu, 11’i çimentosuzdu. Revizyon cerrahisi ilk ameliyattan ortalama 7.3 yıl (dağılım 1.5-13 yıl) sonra yapıldı. Yirmi sekiz kalçada (%84.9) uzatılmış proksimal femoral osteotomi (UPFO) uygulandı. Bunların 10’unda (%35.7) yüksek devirli kesici uçlar (YDKU) kullanıldı. Kalçalar revizyon öncesi ve sonrasında Merle d’Aubigne ve Postel’in Charnley tarafından modifiye edilmiş ölçütlerine göre değerlendirildi. Ortalama izlem süresi 36.3 ay (dağılım 2-48 ay) idi.Sonuçlar: Çimentolu kapların çıkartılmasında bir zorlukla karşılaşılmadı. Çimentosuz kaplarda, ekspanse olan yaprakların osteotomla periferden merkeze doğru bükülmesiyle kolayca çıkartılabildikleri görüldü. Press-fit poroz kaplı kapların sekizinde (%44.4) kap etrafındaki kemik ilişkiyi çözebilmek için YDKU kullanıldı. Bunların ikisinde (%25) metal kesici uç kullanılarak kap parçalara bölünerek çıkartılabildi. Bir kalçada ameliyat sırasında UPFO’nun distaline uzanan spiral kırık gelişti. Son kontrollerde kalçaların %92’si klinik olarak mükemmel veya iyi olarak değerlendirildi.Çıkarımlar: Revizyon kalça artroplastisinde komponentlerin ve çimentonun çıkartılması standart aletlerin yanı sıra özel aletler ya da yaklaşımlar gerektirebilir.

Objectives: We evaluated the short-term results of reconstruction of anterior cruciate ligament (ACL) ruptures using a four-strand hamstring autograft and cross pin femoral fixation.Methods: The study included 62 male patients (mean age 24 years; range 21 to 44 years) with chronic ACL ruptures. Involvement was in the right knee in 32 patients, and in the left knee in 30 patients. All the patients were treated with a four-strand hamstring autograft, cross pin femoral fixation (Transfix, Arthrex and Sling Shot, Mitek), and an interference screw on the tibial side. Forty-one patients received treatment for other meniscal pathologies. Final evaluations were made at the end of postoperative 18 months using the Lysholm and IKDC (International Knee Documentation Committee) scoring systems, Telos stress testing, Tegner activity rating, and radiographs.Results: The Lysholm scores were good (n=23) or excellent (n=38) in 61 patients, and poor in one patient, the mean Lysholm score being 93.5. The IKDC scores were grade A (n=35) or B (n=26) in 61 patients, and grade D in one patient. Telos stress testing showed a significant difference between preoperative (mean 14.5 mm) and postoperative (mean 2.6 mm) laxity measurements (p, Amaç: Bu çalışmada, dört katlı otogreft hamstring tendonu ve proksimal tespit için tekli çapraz çivi sistemi ile tedavi edilen kronik ön çapraz bağ (ÖÇB) yırtıklarının erken dönem sonuçları incelendi.Çalışma planı: Çalışmaya kronik ÖÇB yırtığı olan 62 erkek hasta (ort. yaş 24; dağılım 21-44) alındı. Otuz iki hastada sağ dizde, 30 hastada sol dizde lezyon vardı. Tüm hastalar artroskopik olarak dört katlı otogreft hamstring tendonu ve proksimal tespit için tekli çapraz pin sistemi (Transfix, Arthrex ve Sling Shot, Mitek) ve tibial tarafta interferans vidası ile tedavi edildi. Kırk bir hastada diğer menisküs patolojilerine müdahale edildi. Tüm olgular ameliyat sonrası 18. ayda, Lysholm skorlaması, IKDC (International Knee Documentation Committee) skorlaması, Telos stres cihazı ölçümleri, Tegner aktivite skorlaması ve radyografilerle değerlendirildi.Sonuçlar: Ameliyat sonrasında Lysholm skoru 61 hastada iyi (n=23) veya mükemmel (n=38), bir hastada kötü bulundu. Ortalama Lysholm skoru 93.5 idi. IKDC skorlamasına göre 61 hasta A (n=35) veya B (n=26) grubunda, bir hasta D grubunda yer aldı. Telos stres cihazı ile ameliyat öncesi (ort. 14.5 mm) ve ameliyat sonrası (ort. 2.6 mm) ölçülen laksite değerleri arasında anlamlı fark bulundu (p

Objectives : We investigated histopathologic and morphometric changes in rat femoral arteries, veins, and nerves associated with femoral lengthening.Methods : The study included 42 male Wi s t a r-albino rats. All the rats underwent left femoral osteotomy which was stabilized with an external fixator device. The rats were divided into five groups except for seven control rats which were left untreated. Femoral lengthening was performed with a distraction of 0.35 mm four times a day, which was continued for three days in group 1 (10%), and seven days in the other groups (30%). Before sacrification of each group of rats under general anesthesia after 3, 7, 14, 21, and 31 days of osteotomy, respectively, biopsy samples were obtained from distraction sites involving femoral artery, vein, and nerves for histopathologic and histomorphometric studies.Results : Arterial changes observed in the first four groups were flattening and/or focal absence of the lamina elastica interna and externa, and hydropic degeneration and cytoplasmic vacuolization of the smooth muscle cells of the tunica media. Group 5 exhibited a normal arterial appearance except for fibrosis. Femoral vein changes were characterized by smooth muscle cell degeneration and cytoplasmic vacuolization in the first three groups, and by irregularities in elastic fibres and fibrosisin the remaining two. In group 5, the diameter of the femoral vein decreased by 27.9%. No histologic changes were noted in nerve morphology. In group 2, perineurium thickness and the diameter of myelinated nerve fibers notably increased by 164.6% and 58.4%, respectively.Conclusion : Our results show that the effect of femoral lengthening is heavily on blood vessels rather than nerves., Amaç: Femoral uzatma sonucu sıçanların femoral arter, ven ve sinirlerinde ortaya çıkan histopatolojik ve morfometrik değişiklikler araştırıldı. Çalışma planı: Çalışmada 42 adet Wistar-albino erkek sıçan kullanıldı. Genel anestezi altında sıçanlara sol femoral osteotomi yapıldı ve eksternal fiksatör uygulandı. Kontrol grubu olarak ayrılan yedi sıçan dışındaki denekler beş gruba ayrılarak, her bir gruba osteotomi sonrası birinci günden itibaren günde dört kez (4 x 0.35 mm) femoral uzatma uygulandı. Grup 1’de üç gün (%10), diğer gruplarda yedi gün (%30) uzatma yapıldı. Denekler grup sırasına göre 3, 7, 14, 21 ve 31. günlerde genel anestezi altında öldürülmeden önce uzatma bölgesinden femoral arter, ven ve sinir paketi biyopsi olarak alındı. Örneklerde histopatolojik ve histomorfometrik incelemeler yapıldı.Sonuçlar: Uzatma yapılan sıçanların arterlerinde, ilk dört grupta, internal ve eksternal elastik tabakalarda düzleşme ve/veya fokal kayıplar; tunika media düz kas hücrelerinde hidropik dejenerasyon ve sitoplazmik vakuolizasyon görüldü. Grup 5’te fibrozis dışında normal arteriyel görünüm vardı. Ven değişiklikleri açısından, ilk üç grupta sitoplazmik vakuolizasyon ve dejenerasyon, 4 ve 5. gruplarda ise elastik liflerde düzensizlik ve bağ dokuda fibrozis görüldü. Grup 5’te femoral vende %27.9 oranında incelme saptandı. Sinir yapısında histolojik olarak belirgin bir değişiklik saptanmadı. Grup 2’de perinörium kalınlığında %164.6, miyelinize sinir liflerinin çapında %58.4 artış saptandı. Çıkarımlar: Bulgularımız, femoral uzatmada, kan damarlarının sinirlere göre daha fazla etkilendiğini gösterdi.

Objectives: We evaluated the results in patients who were treated by the Ilizarov method for posttraumatic lower limb deformities.Methods: Thirty-seven patients (1 female, 36 males; mean age 26.9 years; range 8-60 years) with lower limb posttraumatic deformities (malunion or hypertrophic nonunion) were treated with the Ilizarov external circular fixation method. The reason for primary fractures causing deformities was gunshot injuries (n=22) and traffic accidents (n=15). Analysis of deformities was made according to the malaligment test defined by Paley et al.; average angulation was 23.1 degrees. The frames were dynamized with the observation of solid union in osteotomy line in radiologic examinations, after which they were removed within three weeks. Mean follow-up was 25 months (range 6-42 months).Results: Successful outcome was achieved in all patients but one, who developed recurrence. Mechanical axis deviation determined by the malalignment test at the end of treatment was observed as 0-3 mm in 36 patients and 4 mm in one patient. Complications encountered in 34 patients did not affect successful outcome.Conclusion: We concluded that Ilizarov external circular fixation method is efficient in the treatment of lower limb deformities caused by trauma, provided that appropriate preoperative planning and technical details are carefully considered., Amaç: Bu çalışmada travmatik nedenlerle oluşan alt ekstremite deformiteli hastaların Ilizarov yöntemi ile tedavisi ve sonuçları değerlendirildi.Çalışma planı: Alt ekstremite posttravmatik deformiteli (malunion veya hipertrofik nonunion) 37 hasta (1 kadın, 36 erkek; ort. yaş 26.9; yaş dağılımı 8-60) Ilizarov’un eksternal sirküler fiksatör yöntemi ile tedavi edildi. Deformite oluşumuna neden olan primer kırık nedenleri 22 hastada ateşli silah yaralanması, 15 hastada trafik kazası idi. Deformitelerin analizi Paley ve ark. tarafından tarif edilen malaligment testi ile yapıldı; ortalama angulasyon miktarı 23.1° olarak hesaplandı. Radyolojik kontrollerinde osteotomi hattında solid kaynama saptanan tüm olguların cihazları dinamize edildi ve üç hafta içinde çıkartıldı. Hastalar 6-42 ay arasında değişen sürelerle takip edildi (ort. 25 ay).Sonuçlar: Nüks gelişen bir olgu dışında bütün olgularda sonuç başarılı bulundu. Tedavi bitiminde yapılan malaligment testinde mekanik aks deviasyonu 37 olgunun 36’sında 0-3 mm arasında, 1 olguda 4 mm bulundu. Tedavi sırasında 34 komplikasyonla karşılaşılmışsa da, bu komplikasyonların hiçbiri başarılı sonucu etkilemedi.Çıkarımlar: Yöntemin, travmatik nedenlerle oluşan alt ekstremite deformitelerinin tedavisinde, ameliyat öncesi planlama ve takibinde teknik ayrıntılara dikkat edilmesi koşulu ile etkili ve güvenli bir tedavi seçeneği olduğu sonucuna varıldı.

Objectives: We evaluated total hip arthroplasty and short-term results in the treatment of coxarthrosis due to neglected congenital dislocation or severe dysplasia of the hip.Methods: Cemented total hip arthroplasty was performed in 23 hips of 22 patients (2 men, 20 women; mean age 48.6 years; range 28 to 65 years) with osteoarthrosis due to congenital dislocation or severe dysplasia of the hip. The acetabular component was placed at the level of the true acetabulum; four patients required augmentation with autogenous bone grafts due to severe acetabular deficiency. Femoral shortening osteotomy using a subtrochanteric step-cut osteotomy was performed in seven patients with high-riding hips. Five patients underwent proximal femoral shortening after the trochanter major was osteotomized and distally advanced. All patients were evaluated with the use of the Merle d’Aubigne and Postel hip scores. Radiologic evaluations were made by preoperative and follow-up radiographs. The mean follow-up was 52.8 months (range 30 to 108 months).Results: According to the Merle d’Aubigne and Postel hip scores, the results were excellent in 17 hips (74%), good in four hips (18%), fair in one hip (4%), and poor in one hip (4%). One hip required revision because of nonunion of the acetabular graft. The femoral stem was fractured in one patient. Complications included temporary sciatic nerve palsy in one patient, deep venous thrombosis in one patient, early dislocation in one patient, and nonunion of the femur in one patient who underwent subtrochanteric step-cut osteotomy. Conclusion: Total hip arthroplasty for congenitally dislocated or severely dysplastic hips is more effective than other treatment methods. Long-term results can be improved by the use of contemporary cementing techniques., Amaç: Doğuştan kalça çıkığı ya da ağır displazi zemininde gelişen koksartrozların tedavisinde total kalça artroplastisini ve kısa dönem sonuçlarını değerlendirdik.Çalışma planı: Doğuştan kalça çıkıklı ya da ağır displazili 22 hastanın (2 erkek, 20 kadın, ort yaş 48.6, dağılım 28-65) 23 kalçasına çimentolu total kalça artroplastisi uygulandı. Bütün olgularda asetabuler komponent, gerçek asetabuluma yerleştirildi. Asetabuler yetmezliği olan dört olguda otojen kemik grefti ile destekleme yapıldı. Yüksekte kalça çıkıklarında femoral kısaltma osteotomisi uygulandı. Yedi olguda femur subtrokanterik bölgeden basamaklı kısaltma osteotomisi yapıldı. Beş olguda trokanter majör osteotomisi sonrası proksimal femoral kısaltma ve trokanter majörun distale nakli uygulandı. Hastalar, Merle d’Aubigne ve Postel kalça skorlamasına göre değerlendirildi. Radyolojik değerlendirmeler, ameliyat öncesi ve izlemde çekilen ön-arka ve yan grafilerle yapıldı. Ortalama izlem süresi 52.8 ay (dağılım 30-108 ay) idi.Sonuçlar: Merle d’Aubigne ve Postel kalça skorlamasına göre sonuçlar 17 kalçada çok iyi (%74), dört kalçada iyi (%18), bir kalçada orta (%4), bir kalçada kötü (%4) bulundu. Bir olguda greft kaynamadı ve komponentin revizyonu yapıldı. Bir olguda femoral stem kırılması saptandı. Komplikasyon olarak, bir olguda geçici siyatik sinir paralizisi, bir olguda derin ven trombozu, bir olguda erken dislokasyon, subtrokanterik basamaklı kısaltma yapılan bir olguda psödoartroz gözlendi.Çıkarımlar: Doğuştan kalça çıkıklı veya ağır displazik olgularda total kalça artroplastisi, diğer tedavi şekillerine göre çok daha etkilidir. Modern çimentolama teknikleri ile uzun dönemde başarının daha da artması sağlanabilir.

We used a new surgical method in the treatment of a 19-year-old male patient with large osteochondritis dissecans involving the lateral femoral condyle of the knee joint. The osteochondral fragment was too comminuted to allow reattachment and the bone defect was considerably large in size, preventing autogenous osteochondral grafting. A two-staged surgical treatment was performed. In the first stage, the osseous defect was reconstructed using an autogenous corticocancellous iliac bone graft. In the second stage, after the graft union, an autogenous osteochondral graft was transplanted over the same area for the reconstruction of chondral defect. In the postoperative follow-up examination in the seventh month, the patient was symptomless, with full range of knee movements., Diz ekleminde lateral femoral kondilin yük binme yüzeyinin büyük bir kısmını tutan osteokondritis dissekanslı 19 yaşındaki bir erkek hastada cerrahi tedavi uyguladık. Yerinden ayrılan osteokondral fragmanın tekrar yerine tespit edilemeyecek kadar parçalandığı ve kemik defektinin fazla olduğu; bu nedenle otojen osteokondral greft naklinin mümkün olmadığı olguda iki aşamalı cerrahi tedavi uyguladık. İlk aşamada, kemik defektinin rekonstrüksiyonu için otojen iliak kortikospongioz greft kondu. İkinci aşamada, greft yerine kaynadıktan sonra, kondral defektin rekonstrüksiyonu için, bu bölgeye otojen osteokondral greft nakli yapıldı. Ameliyat sonrası yedinci ayda yapılan kontrolde klinik olarak hastanın hiçbir şikayetinin olmadığı ve diz hareketlerinin tam olduğu görüldü.

Medial patellofemoral ligament (MPFL) reconstruction has recently been broadly accepted as primary surgical treatment in adults. Reconstruction techniques with osseous fixation in femur cannot be used for patients with open growth plates. Operative treatment of patella instability in children therefore is a challenge and requires alternative MPFL reconstruction techniques. Limited knowledge exists concerning outcome after MPFL reconstruction in children and adolescents. This study present clinical outcome in a consecutive single clinic series of children treated with paediatric MPFL reconstruction using a soft tissue femoral fixation technique. Twenty-four MPFL reconstructions in 20 operated children aged 8–16 were included in the study. Indication for surgery was two or more patella dislocations. MPFL reconstruction was performed by looping the released gracilis tendon around the adductor magnus tendon insertion and through drill holes in the proximal medial patella edge. Clinical outcome was evaluated by Kujala score and NRS pain score preoperatively, at 1-year follow-up and final follow-up at 39 months. Outcome was compared with a cohort of 179 adult patients with recurrent patella instability operated with an adult MPFL reconstruction technique. Kujala score improved from 61 (13) to 81 (16). NRS pain score improved from 3.0 (3.1) to 1.5 (1.3) in activity. Four patients (20 %) experienced redislocation within the first postoperative year compared with 5 % in an adult patient population. Five patients (25 %) experienced subluxations. One patient with a redislocation was re-operated with adult MPFL reconstruction technique. Cartilage injury was seen in six patients. There are clinical relevant improvements in knee function and pain after MPFL reconstruction in paediatric patients. Patella stability after MPFL reconstruction using femoral soft tissue graft fixation in paediatric patients was inferior to MPFL reconstruction using bony femoral fixation in adult patients. Case–Control study, Level III.

Aim: The present paper describes the rationale behind the surgical technique and the clinical results of the iso-anatomical, single bundle bone patellar-tendon bone anterior cruciate ligament (ACL) reconstruction. Method: Using a second incision on the distal lateral femur an outside-in femoral tunnel is drilled. Guided by a special aiming device it is possible to place the femoral tunnel in the centre of the ACL footprint in every single case. Conclusion: Since every crucial step of the procedure is under visual control, the technique is safe and reliable, which is mirrored by good clinical results

Aim: The aim of this prospective study was to evaluate the outcome of open reduction and Tönnis acetabuloplasty as the first method of treating developmental dysplasia of the hip (DDH) in children in early childhood at walking age. Materials and methods: Between 2005 and 2009, 34 hips of 34 children were operated on with the aforementioned method. Mean age was 25.6 (range 12-44) months, and mean follow-up was 3.6 years. During the follow-up period,the hips were evaluated using the acetabular index and for development of avascular necrosis and redislocation. Functional evaluation was also conducted. Results: Clinically, 97.3 % of patients had excellent and good results. The acetabular angle decreased from 45 preoperatively to 21 early postoperatively and at the last follow-up had improved to 18. In two hips, type 2 avascular necrosis developed. Hip instability was not observed, and no additional surgery was performed. Conclusion: Tönnis acetabuloplasty is a powerful tool to increase primary stability of the hip when acetabular coverage is inadequate in DDH. Besides its acute correction ability, when performed properly, it has no unwanted effects on acetabular growth. As an isolated procedure or as a part of combined open reduction and/or femoral osteotomy, Tönnis type acetabuloplasty is a safe and effective method. © 2012 The Japanese Orthopaedic Association.

The study hypothesis was that the outcome of semitendinosus gracilis double bundle (STG-DB) anterior cruciate ligament (ACL) reconstruction is advantageous in terms of clinical results and restoration of anterior-posterior and rotational laxity in comparison to bone-patellar tendon-bone single-bundle (PTB-SB) ACL reconstruction. We analysed 41 PTB-SB and 51 STG-DB patients using the Tegner, IKDC and WOMAC scores preoperatively and at a minimum follow-up of two years. At follow-up, there was no significant difference in the clinical scores. The KT 1000 side-to-side measurement showed no significant difference between groups. The STG-DB group was significantly superior in terms of the pivot-shift sign and anterior knee pain. We conclude that the outcome of STG-DB reconstruction in the mid-term was not advantageous in terms of clinical scores and anterior-posterior laxity evaluated by the KT 1000. Nevertheless, the restored rotational laxity measured by the pivot shift test was significantly superior in the STG-DB technique.

An in vivo investigation of a new high molybdenum and nitrogen duplex stainless steel (25Cr7Ni4Mo0.3N) has been performed. Cylindrical pins and specially developed devices, to test in static conditions the in vivo localized corrosion resistance, made of this new duplex steel and of a common austenitic stainless steel were implanted in rabbit's femurs for 6 and 12 months. After sacrifice, SEM observations and EDS microanalyses to detect metallic ion release were carried out on the femur sections surrounding the pins. Morphologic observations with stereoscope and SEM were performed on the metallic surfaces of the special devices in order to detect the presence of localized corrosion. Both ion release and localized corrosion were observed for the specimens made of austentic stainless steel, but not for those made of 25Cr7Ni4Mo0.3N duplex stainless steel. © 1993 John Wiley & Sons, Inc.

Rotational deformities are common lower extremity abnormalities in children with cerebral palsy, which include intoeing and outtoeing. Intoeing is caused by one of the three types of deformity: increased femoral anteversion, internal tibial torsion, and metatarsus varus, while out-toeing, the less common form, is caused by femoral retroversion and external tibial torsion. An accurate diagnosis should be made with careful physical and radiographic examination., Rotasyonel deformiteler beyin felçli çocuklarda yaygın olarak görülen, içe dönük ve dışa dönük yürümeyi içeren alt ekstremite anormallikleridir. İçe dönük yürüme üç tür deformitenin birinden kaynaklanır: artmış femoral anteversiyon, internal tibial torsiyon ve metatarsus varus; daha nadir görülen dışa dönük yürüme ise femoral retroversiyon ve eksternal tibial torsiyondan kaynaklanır. Dikkatli fizik ve radyografik inceleme ile doğru tanı konmalıdır.

Posterior tibial subluxations because of combined or isolated posterior cruciate ligament (PCL) injuries require detailed evaluation. PCL reconstructions are difficult procedures because of the low rate of such injuries and the complex anatomy of the ligament. We report on 2 cases of failed PCL reconstruction because of malpositioned femoral tunnels. These 2 cases support the existing biomechanical evidence that the correct placement of the tunnels, especially in the femur, is a major factor in defining the outcome. It seems that the drilling of the tunnels, especially in the femur, during PCL reconstruction must be performed with accuracy and always be evaluated in cases of graft failure. In addition, failed PCL reconstructions are usually accompanied by a short-term excessive arthritis that results in poor functional outcome. Arthroscopy

This is a description of the anaesthetic management of a patient with a flow patent foramen ovale undergoing intramedullary nailing of the femur. In order to detect the flow patent foramen ovale, we used transoesophageal echocardiography. During the ventilation maneuver with positive airway pressure of 20 cmH2O, a right-to-left interatrial shunt was observed. After the administration of 500 ml hydroxy-starch solution (6%) intravenously, detection of the right-to-left shunt flow was no longer possible. This case report shows that the volume status in a patient with a patent foramen ovale could influence the right to left interatrial shunt during general anaesthesia. Anaesthesist

The effect of femoral elongation on skeletal muscle, nerves, and vessels was studied. Three groups of five lambs were used. After the intervention, the animals were killed at 2, 3, and 4 months. A left femoral elongation of 6 cm was practiced on all of them by means of callotasis, with a distraction rate of 0.5 mm every 12 hours. The femoral elongation process was evaluated by monthly x-ray films. The nucleic acid and protein levels in the muscular tissue were quantified at the level of the elongation focus and in the control extremity. The motor conduction velocity of the sciatic nerve was measured in both posterior limbs before the intervention and immediately before the lambs were killed. The arterial blood flow of both subsequent extremities was measured at the moment of death. A histological study of quadriceps muscle, sciatic nerves, artery, and subsequent femoral vein were examined histologically at the level of the elongation focus of both extremities. After elongation, no significant differences were observed in the muscle protein and nucleic acid levels with respect to the control extremity. No significant changes of the nerve conduction velocity were observed in any animal among the different groups. The arterial blood flow of the elongated extremity showed a progressive increase, reaching its maximum value 1 month after the distraction had terminated, with subsequent normalization. This increase of the blood flow was also observed in the control extremity, suggesting a possible systemic effect. The histological study revealed a comparative thickening of the endomysium and perimysium in the elongated muscle tissue, present at the end of the distraction and which was later normalized. No histological changes of the nerve stems undergoing distraction were observed either. During elongation, the arteries showed minimal histological changes. On the other hand, the veins showed areas of endothelial damage accompanied by thrombosis phenomena, especially at the end of the distraction period. The vascular morphology presented progressive normalization after the distraction phase.

Objective: To evaluate the clinical and radiographic results from patients who underwent femoral reconstruction secondary to loosening of total hip arthroplasty, using circumferential proximal femoral allografts and cemented implants. Methods: A retrospective study was conducted on 32 patients (33 hips) who underwent femoral reconstruction secondary to loosening of total hip arthroplasty, using circumferential proximal femoral allografts and cemented implants. Among these patients, 28 (29 hips) fulfilled all the requirements for this study. The mean follow-up was five years and two months. The clinical evaluation was done in accordance with the Harris Hip Score. Radiographically, the patients were assessed regarding reabsorption and consolidation of the allograft, migration of the greater trochanter, stability of the femoral component and heterotypic calcification. Results: The average preoperative Harris Hip Score was 32 points. At the last postoperative follow-up, the average score was 82 points. Allograft resorption of some degree was seen in nine hips (31%). Regarding consolidation, 24 cases (82.8%) showed full consolidation, three (10.3%) showed partial consolidation and two (6.9%) showed pseudarthrosis. All femoral components were stable. According to the criteria established, 27 cases (93.1%) were considered to be successful reconstructions after a mean follow-up of five years and two months. Conclusion: From the results obtained, it was concluded that use of circumferential proximal femoral allografts in selected cases of femoral reconstruction secondary to loosening of arthroplasty presented a high survival rate from the reconstruction over an average follow-up of five years and two months.