Distal Insertion Research Articles

The transverse carpal ligament: anatomy and clinical implications.

The anatomical characteristics of the transverse carpal ligament (TCL) have recently been further clarified. Its bony insertion sites proximally to the scaphoid and pisiform are more round, whereas the distal insertion sites to the trapezium and hamate are more oblong, with reproducible areas of insertion. The thickness of the TCL varies along the path of the median nerve, with the thickest portions distal ulnarly and proximal radially. The predominant fiber orientation is transverse. This more detailed understanding of the anatomy of the TCL may enable more novel treatments of carpal tunnel syndrome.

The tibial-tubercle trochlear groove distance in patients with trochlear dysplasia: the influence of the proximally flat trochlea.

Increased tibial tubercle trochlear groove distance (TT-TG) is frequently associated with trochlear dysplasia (TD). Since the trochlear groove appears more distally in patients with TD compared to controls, it is unknown whether TT-TG might be comparable and meaningful. Fifty patients with TD were retrospectively analysed and compared to 52 age- and gender-matched patients (CG). TT-TG was measured on transverse MR images, as the distance between the trochlear groove of minimal 2mm depth proximally and the centre of the patellar tendon at its distal insertion. The height of the femoral reference point above joint line was recorded for both groups. TT-TG measurement was repeated in CG using the first (P25), second (P50) and third quartile (P75) above joint line of TD. Patients with TD had a significantly smaller vertical distance between the most proximal trochlear deepening and the femorotibial joint line (20.6mm, range 10.3-30.9) compared to CG (33.8mm, range 25.4-41.1; p<0.001). TT-TG values measured at 20mm (P50) and 15mm (P25) proximal to the femorotibial joint line were significantly smaller compared when measured with the most proximal reference point [1.8mm (95% CI 1.3-2.3, p<0.001) and 2.4mm (95% CI 1.9-3.0, p<0.001)] in CG. The inter-rater reliability was excellent (ICC 0.99). TT-TG distance depends significantly on the femoral reference point. Since the trochlear groove is seen more distally in patients with TD compared to controls, TT-TG of the patients with highest risk of recurrent patellar instability might be underestimated. Diagnostic study, Level I.

A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty.

Proximal and distal (mid-thigh) ultrasound-guided continuous adductor canal block techniques have been described but not yet compared, and infusion benefits or side effects may be determined by catheter location. We hypothesized that proximal placement will result in faster onset of saphenous nerve anesthesia, without additional motor block, compared to a distal technique. Preoperatively, patients receiving an ultrasound-guided nonstimulating adductor canal catheter for knee arthroplasty were randomly assigned to either proximal or distal insertion. A local anesthetic bolus was administered via the catheter after successful placement. The primary outcome was the time to achieve complete sensory anesthesia in the saphenous nerve distribution. Secondary outcomes included procedural time, procedure-related pain and complications, postoperative pain, opioid consumption, and motor weakness. Proximal insertion (n = 23) took a median (10th-90th percentiles) of 12.0 (3.0-21.0) minutes versus 6.0 (3.0-21.0) minutes for distal insertion (n = 21; P= .106) to anesthetize the medial calf. Only 10 of 25 (40%) and 10 of 24 (42%) patients in the proximal and distal groups, respectively, developed anesthesia at both the medial calf and top of the patella (P= .978). Bolus-induced motor weakness occurred in 19 of 25 (76%) and 16 of 24 (67%) patients in the proximal and distal groups (P = .529). Ten of 24 patients (42%) in the distal group required intravenous morphine postoperatively, compared to 2 of 24 (8%) in the proximal group (P = .008), but there were no differences in other secondary outcomes. Continuous adductor canal blocks can be performed reliably at both proximal and distal locations. The proximal approach may offer minor analgesic and logistic advantages without an increase in motor block.

Bilateral variations of brachial plexus involving the median nerve and lateral cord: An anatomical case study with clinical implications

During the routine dissection of upper limbs of a Caucasian male cadaver, variations were observed in the brachial plexus. In the right extremity, the lateral cord was piercing the coracobrachialis muscle. The musculocutaneous nerve and lateral root of the median nerve were observed to be branching inferior to the lower attachment of coracobrachialis muscle. The left extremity exhibited the passage of the median nerve through the flat tendon of the coracobrachialis muscle near its distal insertion into the medial surface of the body of humerus. A variation in the course and branching of the nerve might lead to variant or dual innervation of a muscle and, if inappropriately compressed, could result in a distal neuropathy. Identification of these variants of brachial plexus plays an especially important role in both clinical diagnosis and surgical practice.

AB0975 Power and Colour Doppler Findings in Lower Extremity Entheses of Healthy Children – Effect of Measurement Distance from Bone and Joint Position

BackgroundMusculoskeletal ultrasound has significant potential in the assessment of the pediatric entheses. Doppler signals at the site of tendon insertions are often considered as signs of pathology for enthesitis as...

AB1016 Subclinical Entheseal Involvement in Inactive and Low Activity Inflammatory Bowel Disease

BackgroundEnthesitis is categorized as inflammation of insertion of ligaments, tendons, joint capsule or fascia to bone and is a frequently under–diagnosed feature of spondylarthritis (Sp). In fact it has been...

AB0981 Tendon Involvement in Patients with Gout. an Ultrasound (US) Prevalence Study

BackgroundChronic gout is characterized by urate monosodium crystals (MSU) deposition in different tissues, mostly in soft tissues and the joints of lower extremities. The prevalence of tendon involvement by gout...

A qualitative and quantitative analysis of the attachment sites of the proximal hamstrings.

Proximal hamstring tears represent a challenge. Surgical repair of such tears has been reported utilizing both open and endoscopic techniques. It was hypothesized that the proximal attachments of the hamstring muscle group could be reproducibly and consistently measured from pertinent bony anatomical reference landmarks. Fourteen fresh-frozen, human cadaveric specimens were dissected, and measurements were taken regarding the proximal attachments of the hamstring muscle group in reference to bony landmarks. A highly precise coordinate measuring device was used for three-dimensional measurements of tendon footprints and bony landmarks, and relevant distances between structures were calculated. The semitendinosus and long head of the biceps femoris shared a proximal origin (conjoined tendon), having an oval footprint with an average area of 567.0 mm(2) [95 % CI 481.0-652.9]. The semimembranosus (SM) footprint was crescent-shaped and located anterolateral to the conjoined tendon, with an average area of 412.4 mm(2) [95 % CI 371.0-453.8]. The SM footprint had an accessory tendinous extension that extended anteromedially forming a distinct footprint. A consistent bony landmark was found at the medial ischial margin, 14.6 mm [95 % CI 12.7-16.5] from the centre of the conjoined tendon footprint, which coincided with the distal insertion of the sacrotuberous ligament. The conjoined tendon was the largest attachment of the proximal hamstring group. Two other distinct attachment footprints were identified as the SM footprint and the accessory tendinous extension. The sacrotuberous ligament insertion served as a bony landmark. The anatomical data established in this study may aid in better restoring the anatomy during repair of proximal hamstring tears.

Bilateral variations of the brachial plexus involving the lateral cord and median nerve: an anatomical case study with clinical implications (915.8)

In the course of routine dissection of the upper limbs of a Caucasian male cadaver, bilateral variations were observed in the brachial plexus. In the right extremity, the lateral cord was found to be piercing the coracobrachialis muscle. The musculocutaneous nerve and lateral root of the median nerve were observed to be branching inferior to the lower attachment of coracobrachialis muscle. The left extremity exhibited passage of the median nerve through the flat tendon of the coracobrachialis muscle near its distal insertion into the medial surface of the body of the humerus. A variation in the course and branching of a nerve might lead to variant or dual innervation of a muscle and if inappropriately compressed, could result in a distal neuropathy. Identification of these variants of brachial plexus plays an especially important role in both the clinical diagnosis of musculoskeletal pathology and surgical practice.

DLG1 influences distal ureter maturation via a non-epithelial cell autonomous mechanism involving reduced retinoic acid signaling, Ret expression, and apoptosis

The absence of Discs-large 1 (DLG1), the mouse ortholog of the Drosophila discs-large tumor suppressor, results in congenital hydronephrosis characterized by urinary tract abnormalities, reduced ureteric bud branching, and delayed disconnection of the ureter from the common nephric duct (CND). To define the specific cellular requirements for Dlg1 expression during urogenital development, we used a floxed Dlg1 allele and Pax2-Cre, Pax3-Cre, Six2-Cre, and HoxB7-Cre transgenes to generate cell type-restricted Dlg1 mutants. In addition, we used RetGFP knockin and retinoic acid response element-lacZ transgenic mice to determine the effects of Dlg1 mutation on the respective morphogenetic signaling pathways. Mutation of Dlg1 in urothelium and collecting ducts (via HoxB7-Cre or Pax2-Cre) and in nephron precursors (via Pax2-Cre and Six2-Cre) resulted in no apparent abnormalities in ureteric bud branching or in distal ureter maturation, and no hydronephrosis. Mutation in nephrons, ureteric smooth muscle, and mesenchyme surrounding the lower urinary tract (via the Pax3-Cre transgene) resulted in congenital hydronephrosis accompanied by reduced branching, abnormal distal ureter maturation and insertion, and smooth muscle orientation defects, phenotypes very similar to those in Dlg1 null mice. Dlg1 null mice showed reduced Ret expression and apoptosis during ureter maturation and evidence of reduced retinoic acid signaling in the kidney. Taken together, these results suggest that Dlg1 expression in ureter and CND-associated mesenchymal cells is essential for ensuring distal ureter maturation by facilitating retinoic acid signaling, Ret expression, and apoptosis of the urothelium.

A Cadaveric Analysis of Tunnel Position Created Using Flexible Versus Rigid Instrumentation in a Single-Incision Distal Biceps Tendon Repair

This study was designed to determine whether the use of a flexible guide pin and reamer through an anterior single-incision approach would allow for a more anatomic insertion point on the radial tuberosity when compared with the traditional rigid instrumentation used for cortical button fixation. Seven matched pairs of fresh-frozen cadaveric upper extremity specimens were used in this study. One specimen from each matched pair was randomly assigned to undergo a simulated repair using the standard instrumentation required for a cortical button fixation device, and the other specimens were assigned to undergo the same repair using a 42° anterior cruciate ligament femoral guide with a flexible guide pin and reamer. Each specimen from both groups was positioned with the elbow in 90° of flexion and the forearm maximally supinated during guide pin insertion. The proximal portion of the radius was then harvested from the specimen and scanned using micro-computed tomography (micro-CT). Tunnel position between the 2 techniques was compared with the center of the native tendon footprint. The mean percentage of the reamed entry hole within the tendon footprint was significantly less using rigid instrumentation (36.35%) compared with flexible instrumentation (67.29%) (P = .043). Furthermore, when flexible reamers were used (mean offset ratio, 0.17), the resultant tunnel was positioned in a significantly more central position within the radial shaft (i.e., the offset ratio was lower) compared with rigid reamers (mean offset ratio, 0.35) (P = .043). The entry hole was found to be significantly more posterior relative to the center of the anatomic footprint for the flexible reamer group (mean, 0.21 mm anterior) compared with the rigid reamer group (mean, 3.22 mm anterior) (P = .028). There was no difference in tunnel length between the 2 groups. The use of a flexible guide pin and reamer allows for a more anatomically positioned repair than does rigid instrumentation through a single-incision approach. This surgical technique allows for a more anatomic re-creation of the distal biceps tendon insertion while maintaining the benefits of a single limited anterior exposure.

A29: Power and Colour Doppler Findings in Lower Extremity Entheses of Healthy Children—Effect of Measurement Distance from Insertion and Joint Position

Background/Purpose:Musculoskeletal ultrasound has significant potential in the assessment of the pediatric entheses. Doppler signals at the site of tendon insertions are often considered as signs of pathology for enthesitis as well as apophysitis. The normal pediatric enthesis can nevertheless exhibit Doppler signals as well and this might be especially relevant during periods of rapid growth with increased mechanical strain. Limited and partially confliciting data is available for Doppler charactistics of the normal pediatric enthesis. This may be due to technical factors, variable definitions of the anatomic location of the enthesis and variable positioning of the patient. The aim of this study was to examine relevant entheses of the knee and ankle joint in healthy children at the peak of linear growth and determine the effect of measurement distance from the insertion and position of the joint.Methods:35 males and females with an age range of 11–14 years volunteered for this study. All participants were free of musculoskeletal symptoms, medical conditions or medication affecting the MSK system, MSK injuries in the past three months and did not participate in sports more than three times per week. The Insertion of the Quadriceps tendon into the patella, the proximal and distal patella tendon insertion and the Achilles tendon insertion were examined with standardized settings in Power as well as Colour Doppler Ultrasound using an Esaote Mylab 70 XVG Gold machine with a linear probe ranging from 6 to 18 MHz. Both extremities were assessed in neutral as well as 30 degrees flexion. All images were acquired by a single examiner and read by two readers. A subset of volunteers was reassessed 2 days later. On all images the presence of Doppler signals was assessed directly at the bone/cartilage interface as well as within a distance of 2mm, 5mm and 10mm.Results:No Doppler signals were seen directly at the bone/cartilage surface in any of the enthesis. The highest prevalence of signals was found in the quadriceps tendon. Comparing neutral with 30 degrees flexion 30% vs. 40% of participants displayed Doppler signals within 10 mm of the insertion, 30% vs. 35% within 5 mm and 20% vs. 10% within 2 mm. A similar percentage of Doppler signals was seen within 2 mm of the tibial tuberosity although with 10% of volunteers displaying signals in neutral vs 20% in flexed position. At 10 mm distance these percentages were 30 % in flexed vs 20% in neutral position. In contrast no Doppler signals were seen at the insertion of the proximal Patella tendon and the Achilles tendon. No significant differences were seen between Colour and Power Doppler.Conclusion:The specificity of Doppler findings in Apophysitis or Enthesitis is expected to be much higher in the proximal Patella tendon and Achilles tendon than in other entheses. At all Entheses Doppler signals very close to the bone/cartilage surfaces are rarely observed in healthy children. In contrast, the tendon insertions at the proximal patella and the tibial tuberosity display a high prevalence of Doppler signals at a distance of more than 2 mm from the insertion possibly related to mechanical strain occurring physiologically. In order to increase sensitivity the exam should be performed in various positions of the joint.

Functional evaluation of patients with injury of the distal insertion of the biceps brachii muscle treated surgically

Objectiveto functionally evaluate patients with injury of the distal insertion of the biceps brachii muscle that was treated surgically. Methodsbetween April 2002 and June 2011, 15 elbows of 14 patients underwent surgical treatment performed by the Shoulder and Elbow Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. The minimum follow-up was six months, with a mean of 28 months. The patients’ ages ranged from 28 to 62 years, with a mean age of 40 years. All the patients were male and the dominant arm was affected in 64.2%. The clinical evaluation on the results was conducted using the criteria of the American Medical Association (AMA), as modified by Bruce, with evaluation of the joint range of motion (flexion–extension and pronosupination), the presence of pain and the patient's degree of satisfaction. Resultsfrom the AMA criteria, as modified by Bruce, we obtained 100% satisfactory results, of which 85.7% were considered to be excellent and 14.3% good. We observed that when distal injuries of the biceps brachii muscle affected young and active patients, surgical treatment was a good option.

Avaliação funcional dos pacientes com lesão da inserção distal do músculo bíceps braquial tratados cirurgicamente

Objectiveto functionally evaluate patients with injury of the distal insertion of the biceps brachii muscle that was treated surgically. Methodsbetween April 2002 and June 2011, 15 elbows of 14 patients underwent surgical treatment performed by the Shoulder and Elbow Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. The minimum follow‐up was six months, with a mean of 28 months. The patients’ ages ranged from 28 to 62 years, with a mean age of 40 years. All the patients were male and the dominant arm was affected in 64.2%. The clinical evaluation on the results was conducted using the criteria of the American Medical Association (AMA), as modified by Bruce, with evaluation of the joint range of motion (flexion‐extension and pronosupination), the presence of pain and the patient's degree of satisfaction. Resultsfrom the AMA criteria, as modified by Bruce, we obtained 100% satisfactory results, of which 85.7% were considered to be excellent and 14.3% good. We observed that when distal injuries of the biceps brachii muscle affected young and active patients, surgical treatment was a good option.

The Plantar Plate of the First Metatarsophalangeal Joint

The plantar plate of the first metatarsophalangeal (MP) joint is a critical structure of the forefoot that has been identified as a major stabilizer within the capsuloligamentous complex. Many studies have clarified and documented the anatomy of the lesser toe MP plantar plates, but few have looked closely at the anatomy of the first MP joint. Ten cadaveric specimens were examined to identify and document the objective anatomic relationship of the plantar plate, tibial sesamoid, and surrounding osseus structures. The average distance of the plantar plate distal insertion from the joint line into the proximal phalanx was 0.33 mm. The plantar plate was inserted into the metatarsal head on average 17.29 mm proximal from the joint line. The proximal aspect of the sesamoid was 18.55 mm proximal to the distal attachment of the plantar plate to the phalanx. The distal aspect of the sesamoid averaged 4.69 mm away from the distal attachment into the proximal phalanx. The footprint of the distal plate insertion was on average 6.33 mm in length in the sagittal plane. The authors hope that these objective data measures can aid in the understanding and subsequent surgical repair of this important forefoot structure.

Distal insertions of the semimembranosus tendon: MR imaging with anatomic correlation

The purpose of this study is to investigate the distal insertions of the semimembranosus tendon with MR imaging, correlated with findings in cadavers. Four fresh cadaveric specimens were studied with 3-T MR imaging. Sequences included proton density (PD) sequences (TE, 13; TR, 4957; FOV, 170 × 170; matrix, 424 × 413; NA, 2; slice thickness, 2.5 mm) in the axial, coronal, and sagittal planes and 3D fast field echo (FFE) sequences (TR 9.4; TE 6.9; FOV, 159 × 105; matrix, 200 × 211; NA, 2; slice thickness, 0.57 mm). One specimen was dissected and three specimens were sectioned with a bandsaw in the axial, coronal, and sagittal plane. The sections were photographed and correlated with MR images. To standardize the analysis, the semimembranosus muscle and tendon were assessed at seven levels for the axial sections, and at three levels for the coronal and sagittal sections. Anatomic dissection revealed six insertions of the distal semimembranosus tendon: direct arm, anterior arm, posterior oblique ligament extension, oblique popliteal ligament extension, distal tibial expansion (popliteus aponeurosis), and meniscal arm. Axial MR images showed five of six insertions: direct arm, anterior arm, oblique popliteal ligament extension, posterior oblique ligament extension, and distal tibial expansion. Sagittal MR images showed four of six insertions: direct arm, anterior arm, oblique popliteal ligament arm, and distal tibial expansion. Sagittal MR images were ideal for showing the direct arm insertion, but were less optimal than the axial images for showing the other insertions. The anterior arm was seen but volume averaging was present with the gracilis tendon. Coronal MR images optimally revealed the anterior arm, although magic angle artifact was present at its posterior aspect. The common semimembranosus tendon and meniscal arm were also well depicted. The division in anterior arm, direct arm, and oblique popliteal ligament arm was poorly seen on coronal images due to volume averaging. Although the anatomy of the distal semimembranosus tendon is complex, six different semimembranosus insertions can be identified on routine proton density and FFE sequences at 3 T. Analysis of images at defined levels in the three imaging planes simplifies MR interpretation of the anatomy of the distal semimembranosus tendon.

Humeral surface anatomy and percutaneous plate advancement: a cadaveric study.

The aim of this study was to identify the anatomical obstacles on the humeral surface which can complicate subcutaneous plate advancement during surgical treatment of humeral fractures. We dissected twelve upper extremities of six male cadavers, and measured the humeral length, which was defined as the distance between the greater tubercle and the lateral epicondyle. We performed a retrograde advancement of a 4.5 mm plate through the subbrachial tunnel and noted the mechanical obstacles during the procedure. In addition, we recorded the distances between the anatomic obstacles and lateral epicondyle. The average humeral length was 271.8 mm. We identified anterior insertion of the deltoid muscle and the proximal part of the brachialis muscle as the main anatomic obstacles on the anterior surface of the humerus. The average distances between the lateral epicondyle and the most proximal and distal insertion of anterior deltoid were 188.9 mm and 138.7 mm, respectively. The average distance between the lateral epicondyle and the brachialis origin was 147.4 mm. Proportions of the distances between the lateral epicondyle and proximal of anterior deltoid insertion, the lateral epicondyle and distal of anterior deltoid insertion and the lateral epicondyle and proximal of brachialis origin to humeral length were 69.4%, 51%, and 54.2%, respectively. There was a high interobserver reliability (p<0.001). The deltoid insertion and proximal attachment of the brachialis muscles were identified as mechanical obstacles when performing the percutaneous plating. These sites caused difficulties with the procedure during the retrograde plate advancement through submuscular tunnel on the anterior surface of humerus. It was also noted that for successful plate advancement, it was necessary to release the anterior part of the deltoid insertion.

A quantitative assessment of the insertional footprints of the hip joint capsular ligaments and their spanning fibers for reconstruction

Quantitative descriptions of the hip joint capsular ligament insertional footprints have been reported. Using a three-dimensional digitizing system, and computer modeling, the area, and dimensions of the three main hip capsular ligaments and their insertional footprints were quantified in eight cadaveric hips. The iliofemoral ligament (ILFL) attaches proximally to the anterolateral supra-acetabular region (mean area = 4.2 cm(2)). The mean areas of the ILFL lateral and medial arm insertional footprints are 4.8 and 3.1 cm(2), respectively. The pubofemoral ligament (proximal footprint mean area = 1.4 cm(2)) blends with the medial ILFL anteriorly and the proximal ischiofemoral ligament (ISFL) distally without a distal bony insertion. The proximal and distal ISFL footprint mean areas are 6.4 and 1.2 cm(2), respectively. The hip joint capsular ligaments have consistent anatomic and insertional patterns. Quantification of the ligaments and their attachment sites may aid in improving anatomic repairs and reconstructions of the hip joint capsule using open and/or arthroscopic techniques.

Patellar tendon rerupture in a footballer: Our personal surgical technique and review of the literature

Patellar tendon rerupture is a relatively uncommon condition that severely compromises the function of the extensor mechanism of the knee. Few cases described in the literature does not show a unique mode of treatment for this type of lesion. We report the case of a young athlete with traumatic patellar tendon rerupture. The first rupture was treated with the use of Statak anchors. Following a second rerupture incident as a result of a sporting accodent, the tendon was reconstructed with the use of an autologous graft tendon of semitendinosus and biological augmentation with gracilis tendon. For both tendons the distal insertion part was preserved to facilitate the healing process. The treatment was completed with the application of a neutralization cerclage wire and with local injection of plateket reach plasma (PRP). At 12 months follow up, a full recovery of the structure and function of the extensor mechanism was observed and the patient was able to resume normal sports competitive activity.

Reply to the Letter to the Editor: Mid-America Orthopaedic Association Physician in Training Award: Surgical Technique: Pediatric Supracondylar Humerus Fractures: A Technique to Aid Closed Reduction

To the Editor: I appreciate the exuberant and detailed response by Ozkaya and colleagues. Additionally, I appreciate the reference to their prior published “joy-stick” technique [3]. Finding more options and techniques to improve supracondylar humeral fracture care is to be encouraged [1]. First, the authors claim that the lateral to medial K-wire insertion below the level of the deltoid insertion is safer than our posterior to anterior Schantz pin distal triceps insertion. We believe that our technique is actually safer than theirs. Since the radial nerve courses from proximal to distal and ulnar, to radial distal, to the deltoid muscle, and anterior to the triceps muscle, their technique could jeopardize injury to the radial nerve more than our technique, which does not jeopardize any potential neural structures [2]. Posteriorly, we have the least risky pin insertion site. We had no clinical injury to the triceps integrity or function. In fact, percutaneous insertion of a pin through the deltoid or triceps has the same effect. We agree that more distal pin insertion allows for greater control of the diaphyseal segment and overall reduction quality. We disagree that these fractures do not require “tremendous effort,” since some fractures require extensive control of translation, rotation, flexion/extension, and length. Secondly, we had not experienced any problems utilizing 2.5 mm terminally threaded Schantz pins. In fact, the 2.5 mm size is perfectly situated between the 2 mm and 3 mm pins utilized by Parmaksizoglu and colleagues [3]. Additionally, the terminal thread prevents translation and anterior protrusion versus a smooth pin. We have not had any problems such as iatrogenic fractures, ectopic bone, or callus formation from our 2.5 mm pin technique. The one patient that had an open technique had impalement of distal humerus within the brachialis that did not get “milked out” or disengaged. We are sorry that we did not elaborate further with this example in the original article. Again, we would like to thank the CORR® journal for publishing our technique and Ozkaya et al. for continuing an important dialogue regarding treatment of the patients whom we treat.