Period Of Postoperative Immobilization Research Articles

Poster 262: The risk factors associated with failure results after arthroscopic repair for bucket handle meniscal tear. A multi-center study

Objectives: Meniscal tears are one of the common knee injuries. Large size of longitudinal-vertical tear is called bucket handle tear, and easily displaced and locked in the knee joint cavity. This type of injury is usually required arthroscopic intervention due to pain or dysfunction such as loss of range of motion of the knee. Recently, the arthroscopic meniscal repair technique and devices have been developed and reported good results. The inside-out technique, outside-in technique, and all-inside technique are well known. However, 20 to 34.2% of failure cases after primary meniscal repair were reported. The purpose of this study is to identify the risk factors to associate with the postoperative failure of bucket handle meniscal tear under multi-center study. Methods: Patients The present study was conducted in 2021, involving patient who was diagnosed and performed primary arthroscopic meniscal repair surgery for bucket handle meniscal tear at four orthopaedic centers. The study followed retrospective observational design including data collected from Jan 2000 to Aug 2021. The experimental design was reviewed and approved (Accession No. 0-0956) by the Ethics Committee of our institute. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Inclusion criteria were the cases of knee bucket handle meniscal tears which were diagnosed clinically and by MRI testing. Exclusion criteria were following; postoperative observation period was less than 12 months cases, meniscal posterior root tear cases, could not obtain full surgical and clinical information cases, infection and inflammatory disease cases, and meniscal resection cases. Senior orthopaedic surgeons were diagnosed and performed arthroscopic surgery in each center. Surgical and clinical information were obtained from four orthopaedic centers. Total 95 bucket handle tear cases were enrolled in this study. Patients were analyzed on an average of 27.14 ± 24.8 months after surgery by the use of Marx score (MS) and Tegner Activity Scale (TAS). To identify factors associated with postoperative failure, we obtained the following information; age, body mass index (BMI), height, weight, injury to surgery duration, postoperative immobilization period, postoperative non-weight bearing period, timing of full-weight bearing, timing of running, presence of knee ligament rupture, medial or lateral meniscus, total number of sutures. Moreover, the number of each suture technique such as inside-out, outside-in, and all-inside method were analyzed. Location of injury such as white-white (WW) zone, red-white (RW) zone, and red-red (RR) zone was also analyzed. Statistical comparisons between the two groups were performed using the 2x2 chi-squared test, t-test, the Mann Whitney U-test. Risk factors of postoperative failure case were determined with multiple logistic regression analysis. The level of significance was set at P < 0.05. Results: There were 69 patients (male: 32, female:37) with healed and 26 (27.4%, male: 12, female: 14) that sustained failure after primary meniscal repair. There were no significantly difference between healing group and failure group in injury to surgery duration (39.7 vs 22.4 days, p=0.65), height (165.2 vs 163.8 cm, p= 0.52), weight (67.2 vs 60.1 kg, p=0.09), postoperative immobilization period (2.0 vs 1.95 weeks, p=0.56), postoperative non-weight bearing period (2.89 vs 2.67 weeks, p=0.34), timing of full- weight bearing (5.60 vs 5.62 weeks, p=0.69), timing of running (3.4 vs 4.75 months, p=0.41), preoperative TAS (5.48 vs 6.08, p=0.33), postoperative TAS (4.50 vs 5.33, p=0.34), postoperative Marx score (6.36 vs 9.17, p=0.59). In the healing group, MM/LM was 48/21 and 21/5 in the failure group (p=0.28). Location of tear in the hearing group was following; RR / RW / WW as 29 / 27 / 3, and failure group was 11 / 9 /2 (p=0.78). Combined knee ligament injury was observed 50 cases in the healing group, and 20 cases in the failure group (p=0.48). Total number of sutures was 4.66 vs 3.85 (p=0.24). The numbers of each suture technique were 2.91 vs 2.88 (p=0.67) in all-inside method, 2.33 vs 2.00 (p=0.8) in outside-in method. On the other hand, the number of inside-out method in the healing group was significantly higher than that of failure group (3.56 vs 2.33, p=0.02, number of inside-out method. OR: 0.339, 95%CI; 0.132-0.873, p=0.02). Additionally, BMI of healing group was higher than failure group with significance (24.39 vs 22.32, p=0.05). Age of healing group was also significantly higher than failure group (26.0 vs 22.3, p=0.05). Conclusions: Failure rate of primary repair for bucket handle tear was 27.4% in this multi-center study. Lower numbers of inside-out suture technique and low value of BMI and age were significantly associated with postoperative failure. [Table: see text][Table: see text]

Poster 222: Venous Thromboembolism Risk factors and Prophylaxis Patterns in Knee Arthroscopy: A Large Database Study

Objectives:Incidence of venous thromboembolism (VTE) after knee arthroscopy is reportedly low, but rates vary significantly across literature. Current guidelines recommend against routine perioperative thromboprophylaxis, but prescribing practices and VTE risk factors are poorly understood.Methods:Medical records for patients ≥18 years of age were queried from the Pearl Diver database using CPT codes for arthroscopic knee procedures. Patients with a previous diagnosis of VTE or hyper-coagulable disorder were excluded from analyses. Procedures were grouped by rehabilitation protocols, with restrictive procedures requiring a period of non-weightbearing or postoperative immobilization. Patients who received perioperative thromboprophylaxis were identified. Patients diagnosed with VTE, including pulmonary embolism and/or deep vein thrombosis, within 90 days of surgery were identified using International Classification of Diseases (ICD) codes. Multivariable logistic regression models were utilized to identify VTE risk factors and likelihood of thromboprophylaxis prescription. Covariates included age, restrictive rehabilitation protocols, oral contraceptive pill (OCP) use, and medical comorbidities.Results:A total of 718,289 patients underwent knee arthroscopy from 2011 to 2020. 10,769 patients (1.5%) received perioperative thromboprophylaxis, including aspirin (n=5,353, 0.7%), low molecular weight heparin (n=4,563, 0.6%) and factor Xa inhibitors (n=947, 0.1%). A total of 7,618 patients (1.1%) experienced VTE. Perioperative prophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] = 0.64, 95% confidence interval [CI] = 0.51 to 0.79) (Table 1). Restrictive procedure type was associated with increased odds of experiencing VTE (aOR =1.42, 95% CI = 1.34 to 1.50) and receiving prophylaxis (aOR=1.95, 95% CI = 1.87 to 2.05). OCP use (aOR = 1.63, 95% CI = 1.37 to 1.91), renal disease (aOR = 1.33, 95% CI = 1.18 to 1.50) and congestive heart failure (aOR = 1.30, 95% CI = 1.13 to 1.49) were associated with increased odds of VTE. Tobacco use was associated with increased odds of VTE (aOR = 1.12, 95% CI 1.03 to 1.22), but decreased odds of receiving perioperative prophylaxis (aOR = 0.84, 95% CI 0.78 to 0.91). Malignancy was associated with increased odds of receiving prophylaxis (aOR = 1.18, 95% CI 1.09 to 1.29) but not with increased odds of VTE.Conclusions:Procedures with restrictive rehabilitation protocols, OCP use, renal disease, and congestive heart failure are associated with increased odds of VTE following knee arthroscopy. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower odds of VTE. Risk factors for postoperative VTE are not always correlated with increased likelihood of receiving perioperative thromboprophylaxis. Patients with a tobacco use history may be an at-risk population that can be better selected for thromboprophylaxis when clinically appropriate.Table 1.Multivariable Logistic Model of VTE and Perioperative Thromboprophylaxis Odds

Poster 178: Blood Flow Restriction Therapy Before and After Arthroscopic Rotator Cuff Repair

Objectives:To evaluate the effect of blood flow restriction (BFR) therapy conducted before and after rotator cuff repair (RCR) on rotator cuff strength and patient reported outcomes.Methods:A total of 30 patients (22 male, 8 female; age 58.2 ± 9.0 years) presenting for surgical treatment of a rotator cuff tear were randomized into two groups, BFR (N=15) and Control (N=15). Rotator cuff strength was measured utilizing a handheld dynamometer in order to calculate peak force, average force and time to peak force. Strength measurements included supraspinatus, infraspinatus and subscapularis testing in multiple positions. Prior to surgery, patients completed a rotator cuff strengthening program, with and without the use of BFR. All patients underwent arthroscopic RCR and a standardized period of post-operative immobilization. Following surgery, patients underwent physical therapy utilizing standard post-RCR therapy protocols, with exercises performed with and without the use of BFR in each respective group. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal arm, under the direction of a physical therapist. Patient Reported Outcome Measurement System Upper Extremity (PROMIS-UE), American Shoulder and Elbow Surgeons (ASES) score and shoulder range of motion were collected on the day of surgery as well as 2 weeks, 6 weeks and 3 months after surgery. Rotator cuff strength measurements were completed the day of surgery and repeated three months following RCR.Results:No significant differences were noted between the BFR and control groups in peak rotator cuff muscle force generation, time to peak force or average force at any timepoints (P>0.05). At six weeks post-surgery, the BFR group had significantly higher PROMIS-UE scores (30.3 ± 4.7 versus 26.3 ± 6.3, p=0.03, Figure 1) and active range of motion in abduction (82.4º ± 24.7 versus 65.1º ± 18.8, p=0.03) compared to the control group. These differences were not apparent at 3 month follow up.Conclusions:Blood flow restriction therapy following RCR results in improved patient reported outcomes scores and range of motion at six week follow up. At three months post-surgery, there was no noted improvement in rotator cuff strength when utilizing BFR compared to standard physical therapy.

Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults.

We sought to determine whether any relevant patient, fracture, surgical, or postoperative characteristics are associated with loss of reduction after plate fixation of isolated olecranon fractures in adults. Patients who underwent open reduction and internal fixation of an olecranon fracture at our institution over an 11-year period were analyzed. Electronic patient charts and radiographic images were reviewed to gather patient, fracture, surgical, and postoperative data. Statistical analysis to explore the differences between groups was performed. Seven of 96 patients experienced a loss of fracture reduction diagnosed at a median of 19 days after their initial surgery (range: 4-116 days). The radiographic mode of failure of all patients who lost reduction was proximal migration of the proximal fracture fragment with or without implant failure. The group that lost reduction had a significantly smaller proximal fragment (14.2 vs 18.6 mm), a higher incidence of malreduction with a persistent articular step-off greater than 2 mm (6/7 vs 14/89), a greater distance between the most proximal screw and the olecranon tip (19.8 vs 13.5 mm), a higher proportion of constructs with screws placed outside of the primary plate (4/7 vs 14/89), and a higher proportion of patients that were not immobilized postoperatively (3/7 vs 8/89). Our results suggest anatomical reduction at the articular surface and adequate fixation of the proximal fragment are key factors in maintenance of reduction, with smaller proximal fragments being at higher risk for failure. A period of postoperative immobilization may decrease the risk of loss of reduction.

Outcomes of Pediatric Scaphoid Nonunions Treated With Distal Radius Cancellous Autograft.

The optimal management of pediatric scaphoid fracture nonunions is controversial. We hypothesize that pediatric patients with scaphoid fracture nonunions will have favorable functional outcomes with the utilization of nonvascularized distal radius cancellous autograft with open reduction and internal fixation (ORIF). A review was performed from 2012 to 2017 identifying skeletally immature patients with scaphoid fracture nonunions treated with ORIF and nonvascularized distal radius cancellous autograft, including demographic data, mechanism of injury, length of time from injury to treatment, operative procedure, length of immobilization, time to union, and complications. Ten patients (9 males, 1 female) met inclusion criteria. Mean age was 14.3 SD 1.5 years. The majority of fractures were sustained during sports or secondary to a fall. Mean time between injury and orthopaedic evaluation was 33 weeks (SD 20 wk). Eight fractures occurred at the waist, and 2 occurred at the proximal pole. Four patients had a humpback deformity, and three presented with a dorsal intercalated segmental instability deformity. Nine patients were treated with a single cannulated compression screw with distal radius autograft. One patient also received a single Kirschner wire fixation in addition to a single cannulated screw and graft. Patients underwent a mean postoperative immobilization period of 14 SD 5 weeks. Two patients received a bone stimulator postoperatively. Radiographic union was documented after initial surgery in nine patients, with mean time to union of 17 SD 5 weeks. The 1 patient with persistent radiographic nonunion underwent revision fixation and repeat nonvascularized distal radius autograft, achieving union and resolution of symptoms. All patients ultimately reported full return to activity. Pediatric scaphoid fracture nonunions that undergo ORIF using nonvascularized distal radius cancellous autograft have favorable rates of consolidation and functional outcomes. Surgeons should consider this source of grafting in operative management of scaphoid nonunions in children and adolescents. Level IV, therapeutic.

Depression Following Operative Treatments for Achilles Ruptures and Ankle Fractures.

The sudden and debilitating nature of lower extremity injuries can trigger mood disturbances, including major depressive disorder. This prospective study enrolled patients undergoing operative repair of ankle fractures and Achilles ruptures and followed them for 1 year postoperatively. The validated Patient Health Questionnaire (PHQ-9) for depressive symptoms was administered at the preoperative visit and at postoperative weeks 1, 2, 4, 8, 16, 24, 32, 40, and 52. PHQ-9 is scored 0 to 27, with higher values indicating greater depression symptoms. Fifty-eight patients completed 1 year of follow-up. The mean PHQ-9 score was 2.7 (range, 0-20) at the preoperative visit, peaked at postoperative week 1 (4.9; range, 0-16), and reached its low at postoperative week 52 (0.8; range, 0-7). Cumulative incidences of depressive symptoms during the first year following surgery were 51.7% for at least mild depression, 22.4% for at least moderate depression, and 6.9% for severe depression. A history of mental health disorder and the inability to work during the period of postoperative immobilization were independently associated with greater depressive symptoms. The majority of patients undergoing operative treatment of Achilles ruptures and ankle fractures develop postoperative symptoms of mild to moderate depression that normalize after several months. Patients with a history of mental health disorder or who cannot work while immobilized postoperatively are at greatest risk. Level II, prospective cohort study.

A New Proximal Dorsal Approach for DIP Arthroplasty.

Degenerative changes of the distal interphalangeal (DIP) joints can be painful, disabling, and disfiguring. Swanson spacers can be used for DIP arthroplasty. The standard approach for Swanson spacer implantation at the DIP joint involves transecting the extensor tendon close to its insertion, which necessitates a 6-week period of postoperative immobilization. Another DIP approach involves sparing the extensor tendons, as already published. Both techniques lead to a similar range of motion of the replaced DIP joints. We present a novel approach for DIP joint arthroplasty with division of the extensor tendon in zone 2 with only 2 weeks of postoperative immobilization. Optimizing the motion-preserving operative approaches is of value to our high-demand patients. Postoperative results do not differ from the postoperative range of motion published in the literature for both tendon-sparing and standard approaches. But our approach is technically easy and requires a significantly shorter time of immobilization.

Does Immobilization Period Affects The Functional Outcomes After Bankart Repair?

There is no consensus about the absolute immobilization time period and whether the rehabilitation should start in the first or in the third week after Bankart Repair. PURPOSE: The aim of this study was to compare the clinical outcomes of 1 and 3 weeks of absolute immobilization time after the surgery and evaluate their effects on recurrent instability. METHOD: Forty-two patients with arthroscopic Bankart surgery were included to the study. Patients were randomly allocated into two groups. One week of absolute immobilization was performed to the patients in group-1 (n=21, age:24.7±7.1, BMI: 25.3±3 kg/cm2) and 3 weeks of absolute immobilization was performed to the patients in group-2 (n=21, age: 22.1±6.7 years, BMI: 24.8±2.8 kg/cm2). All of the patients come to the clinic once in a week and performed supervised exercise program and the rehabilitation program was progressed. They were also prescribed home exercise program. Shoulder ROM, pain level and shoulder function were assessed, according their groups at the first or third weeks, 4, 8 and 12 weeks of post-operative period. The pain level during resting, activity and at night was assessed with VAS. Shoulder ROM was assessed with standard goniometer and shoulder function was assessed using ASES questionnaire. At the average of 30. weeks after the surgery, it was questioned whether there was a re-dislocation. The demographics of the patients on both groups were analyzed with student t test. Two-way repeated measures ANOVA was used for the statistical analyses. RESULTS: There were no significant the “Group*time” interactions for pain at rest and activity and flexion, abduction, external rotation, internal rotation angles (p>0.05). The main effect of time was significant at rest and activity pain and all ROM measurements (p<0.05). There was a significant “Group*Time” interaction for pain at night (p<0.05). Pain at night was higher in the group-1 at post-operative 1 and 4. weeks compared to group-2. There were no statistically significant differences between the two groups in shoulder function at post-operative 12 weeks (p>0.05) and 30 weeks (p>0.05). One patient had re-dislocation in the group-2. CONCLUSION: One or three weeks of absolute post-operative immobilization period does not differ in terms of functional outcomes on patients with Bankart repair.

Risk Factors That Influence Subsequent Recurrent Instability in Terrible Triad Injury of the Elbow.

To identify risk factors associated with subsequent recurrent instability and to identify predictors of poor outcomes in terrible triad injury of the elbow. Retrospective cohort study. University trauma center. Seventy-six patients who were surgically treated for terrible triad injury of the elbow. Review of charts and standardized x-ray images before surgery and 2 years after surgery. Patients were categorized into 2 groups: recurrent instability (group A) or concentric stability (group B). Primary outcome measures were injury mechanism, time between injury and operation, fracture type, ligament injury, radial head fixation, coronoid fixation, ligament repair, period of postoperative immobilization, joint space restoration, healing progress, secondary operation, functional outcomes, and complications. Secondary outcome measures were age, sex, height, body mass index, bone mineral density, and comorbidities (hypertension and diabetes). Outcomes were measured before surgery and 2 years after surgery and were compared between groups. Recurrent instability occurred in 19.7% of cases; revision surgeries were performed in 12 cases (80%). High-energy trauma (P = 0.012), time between injury and operation (P = 0.001), radial head comminution (P = 0.001), medial collateral injury (P = 0.041), and coronoid nonrepair (P = 0.030) were associated with recurrent instability. Posttraumatic arthritis developed more often in group A (P = 0.001). Recurrent instability was associated with high-energy trauma, time between injury and operation, Mason type III radial head fracture, medial collateral injury, and coronoid nonrepair. Patients with recurrent instability were more likely to require secondary surgery and develop posttraumatic arthritis than those with concentric stability. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute traumatic rupture of the patellar tendon in pediatric population: Case series and review of the literature

BackgroundIntact knee extensor mechanism is required for the normal function of the lower extremity. Patellar tendon rupture is a relatively rare injury with peak age incidence around 40 years and usually occurs midsubstance. The occurrence of pure patellar tendon rupture without bony avulsion is an extremely rare injury in the pediatric population with few cases reported in the literature with limited information regarding frequency, complications, and outcomes in children. However, due to increased participation in sports and high-energy recreational activities during childhood, the frequency of such injuries has progressively increased. ObjectiveTo evaluate the frequency of pediatric patellar tendon rupture injuries and describe the radiological findings, treatment modalities, and outcome of such injuries. MethodsDemographic and clinical data on a series of patients who sustained patellar tendon rupture were reviewed. These data included age at time of injury, sex, laterality, mechanism of injury, associated injuries, complications, presence or absence of Osgood-Schlatter disease, diagnostic imaging such as plain radiographs and magnetic resonance images (MRI), surgical technique, method of fixation, period of postoperative immobilization, total duration of physiotherapy, time to return to sports activities and follow-up duration. Insall-Salvati ratio was calculated on the preoperative lateral x-ray. The functional outcome was evaluated with regard to final knee active range of motion (AROM), manual quadriceps muscle testing, and presence or the absence of terminal extension lag. Clinical outcome rating using knee society score (KSS) was performed and functional outcome was further classified according to the calculated score. ResultsFive male patients with patellar tendon rupture (7%) were identified among 71 pediatric patients who sustained acute traumatic injury of the knee extensor mechanism. The mean age at the time of injury was 13.6 years (range: 12–15 years). The injury occurred in relation to sports activities in 4 patients. Osteogenesis imperfecta and Osgood-Schlatter disease were identified in 2 patients. High riding patella is the hallmark diagnostic sign detected in plain x-ray with preoperative Insall-Salvati ratio ranged from 1.7 to 2.5. Three patients had pure soft tissue avulsion distally from the proximal tibia, 1 patient had pure soft tissue avulsion proximally from the inferior patellar pole, and 1 patient with midsubstance tendinous disruption. No associated intra-articular lesions were identified. Suture bridge double row technique, transpatellar suturing, and transosseous suturing through the proximal tibia were used for patellar tendon reinsertion. After a mean follow-up period of 18. 4 weeks (range: 10–30 weeks), patients achieved AROM ranging from 0 to 120° to 0–137° without terminal extension lag. The mean time to return to sports activity was 22 weeks (range: 13–30 weeks). Quadriceps muscle strength was 5/5 at the final follow-up visit in all patients; however, relative muscle atrophy was noted in comparison to the other side in one patient. The mean KSS was 91.8 points (range: 79–100 points) with excellent outcome in 4 patients and good outcome in 1 patient. ConclusionPatellar tendon rupture is rare in the pediatric population and represents 7% of pediatric patients who sustained acute traumatic injury of the knee extensor mechanism. Ruptures may occur midsubstance, or from proximal or distal insertions. High riding patella is the hallmark diagnostic sign for such injury. Although rare, it is considered a serious injury that necessitates early diagnosis and surgical intervention. Functional range of motion was obtained in all patients with different modalities of treatment.

Bone tunnel change develops within two weeks of double-bundle anterior cruciate ligament reconstruction using hamstring autograft: A comparison of different postoperative immobilization periods using computed tomography

BackgroundThe purpose of this study was to evaluate bone tunnel changes following anterior cruciate ligament (ACL) reconstruction during the early postoperative period using computed tomography (CT), and to understand the impact of postoperative immobilization on these changes. MethodsTwenty patients who underwent double-bundle ACL reconstruction using hamstring tendon autografts were included. We subcategorized patients into two groups: patients who underwent isolated ACL reconstruction and had three days of knee immobilization (Group A, n=10); and patients with concomitant meniscus injuries who underwent ACL reconstruction and meniscus repair simultaneously (Group B, n=10) had their knees immobilized for two weeks after surgery. Bone tunnel enlargement was evaluated using CT imaging at one to three days, two weeks, one month, three months and six months after surgery. The cross-sectional area of the femoral and tibial tunnels was measured, and enlargement rate was calculated. The tunnel center location at two weeks after surgery was also evaluated. ResultsThe mean cross-sectional area adjacent to the joint space of the femoral and tibial tunnels significantly increased immediately after surgery, especially in the first month (P<0.01). However, after one to six months they were not increased (P>0.01). There was no significant difference in tunnel enlargement rate between group A and B. Tunnel center location changed even in the first two weeks. ConclusionsBone tunnel enlargement following double-bundle ACL reconstruction occurred at an earlier time point after surgery than anticipated. Postoperative immobilization could not prevent bone tunnel enlargement, but might prevent tunnel migration.

Novel Suture Anchor Technique with Continuous Locking Stitch for Collateral Ligament Repair.

Collateral ligaments are difficult to repair due to large amount of fraying in detached ligaments and attenuated stumps that may not provide enough strength after the repair. Although strong locking sutures are used to repair the ligament with proper tension, these damages can cause pull-out failure or relaxation of the repaired ligaments even from undersized load that may extend postoperative splinting or casting time. Furthermore, current suture techniques can repair varus or valgus instability of the elbow and radial or ulnar instability of the fingers, but these techniques do not offer rotatory stability of these areas. We have developed a novel suture anchor technique that has overcome this problem of current suture techniques, and this can be used to correct rotatory instability in the elbow and fingers. We used this procedure in seven cases with injury of collateral ligament in the elbow and eight cases with detached collateral ligaments of finger joint. No patient experienced rerupture or any kind of residual instability. We believe that the proposed method can produce much stronger repair and may shorten the postoperative immobilization period.

Prospective Comparisons of Femoral Tunnel Enlargement With 3 Different Postoperative Immobilization Periods After Double-Bundle Anterior Cruciate Ligament Reconstruction With Hamstring Grafts

To determine the effect of differing postoperative immobilization periods on femoral bone tunnel enlargement and clinical outcome after double-bundle anterior cruciate ligament (ACL) reconstruction with hamstring grafts. Fifty-one patients undergoing primary double-bundle ACL reconstruction with hamstring grafts were divided into 3 postoperative immobilization protocol groups: 2-day immobilization with the knee in 20° of flexion postoperatively (group A, n= 18); 1-week immobilization (group B, n= 17); and 2-week immobilization (group C, n= 16). Bone tunnel enlargement was determined by computed digital radiographs taken on the first postoperative day and at 24 months in the anteroposterior (AP) and lateral views. Each tunnel diameter was shown as a percentage of the maximum joint width of the proximal tibia on the AP view or a percentage of the maximum diameter of the patella on the lateral view. To determine the incidence of tunnel enlargement, a percentage diameter change of more than 10% was defined as an enlarged tunnel. The standard clinical evaluation was also performed. This study used nonrandomized procedures. In each group there were no significant differences in the incidence and magnitude of anteromedial and posterolateral bone tunnel enlargement on both the AP and lateral views (1-factor analysis of variance). Group C showed significantly less muscle strength in knee extension compared with the contralateral knee (85.3% ± 18.4%) than group A (93.7% ± 13.1%, P= .049) and group B (96.8% ± 12.9%, P= .044). This prospective radiographic study showed that femoral bone tunnel enlargement, in both the anteromedial and posterolateral tunnels, may occur after double-bundle ACL reconstruction with hamstring grafts despite different postoperative immobilization periods, with no significant difference in the incidence and magnitude among groups with differing postoperative immobilization periods. In addition, a 2-week immobilization period after surgery showed harmful effects, such as significantly less quadriceps muscle strength. Level II, prospective comparative study.

Les plaies des tendons fléchisseurs et extenseurs des doigts chez l’enfant (réparation primitive et secondaire)

Primary or secondary flexor tendon repair after laceration in children do not have any technical specificity in comparison with adults. However, tendon ruptures may occur more frequently in case of light postoperative immobilization, especially in young children as little cooperation can be expected in the postoperative period. A closed above elbow cast should therefore be applied for onemonth. Early mobilization program has no significant effect on the final result in young children. However, these observations must be relativized in teenagers who should be rehabilitated such as adults. For extensor tendon injuries, dynamic splintage was found to be unnecessary in children. In cases with total transection in zones I, II or III, it is necessary, especially in children younger than 5 years, to transfix the IP joint in extension with a smooth Kirschner wire during postoperative immobilization period.

Selective Plantar Fascia Release for Nonhealing Diabetic Plantar Ulcerations

Achilles tendon lengthening can decrease plantar pressures, leading to resolution of forefoot ulceration in patients with diabetes mellitus. However, this procedure has been reported to have a complication rate of 10% to 30% and can require a long period of postoperative immobilization. We have developed a new technique, selective plantar fascia release, as an alternative to Achilles tendon lengthening for managing these forefoot ulcers. We evaluated sixty patients with diabetes for a mean of 23.5 months after selective plantar fascia release for the treatment of nonhealing diabetic neuropathic ulcers in the forefoot. Preoperative and postoperative dorsiflexion range of motion of the affected metatarsophalangeal joint and wound-healing data were used to evaluate the effectiveness of the procedure and to determine the relationship between plantar fascia release and ulcer healing. Complications were recorded. Thirty-six (56%) of the ulcers healed within six weeks, including twenty-nine (60%) of the plantar toe ulcers and seven (44%) of the metatarsophalangeal joint ulcers. The mean range of motion of the affected metatarsophalangeal joint increased from 15.3° ± 7.8° to 30.6° ± 14.1° postoperatively (p < 0.05). All patients in whom the preoperative dorsiflexion of the affected metatarsophalangeal joint was between 5° and 30° and in whom the range of motion of that joint increased by ≥13° after the procedure experienced healing of the ulcer. No ulcer recurrence in the original location was identified during follow-up. No patients experienced any complications associated with the selective plantar fascia release. Our results suggest that selective plantar fascia release can lead to healing of neuropathic plantar forefoot ulcers in diabetic patients. Ulcers in patients in whom the preoperative dorsiflexion angle of the affected metatarsophalangeal joint is between 5° and 30° and in whom the increase in range of motion is ≥13° postoperatively have the greatest chance of being cured. Therapeutic level IV. See Instructions for Authors for a complete description of the levels of evidence.

OPPONOPLASTY WITHOUT POSTOPERATIVE IMMOBILIZATION

Opponoplasty using tendon transfer is a useful reconstructive procedure that restores lost thenar muscle function. Tendon transfers, however, require postoperative immobilization periods of up to four weeks before the sutured tendons reach required strength. We developed an opponoplasty procedure using α-TCP (alpha-tricalcium phosphate) cement that does not require postoperative immobilization and was applied to nine hands out of nine cases. The procedure is performed under local anesthesia without a pneumatic tourniquet and on an outpatient basis. In this procedure, the flexor digitorum superficialis of the ring finger is used as the donor tendon and the palmaris longus tendon is used as a dynamic pulley. The distal end of the transferred tendon is anchored to the inside of a newly formed bone hole in the thumb's proximal phalanx using α-TCP cement. Our opponoplasty procedure was uneventful postoperatively and produced satisfactory results in all nine cases. The α-TCP cement procedure shows potential for other tendon transfer applications.

Deep vein thromboembolism after arthroscopy of the shoulder: two case reports and a review of the literature

BackgroundDeep vein thrombosis (DVT) has an incidence of 1 case per 1000 inhabitants in the general population and it is very rare after arthroscopy of the shoulder. Therefore, the current guidelines do not advise the administration of DVT prophylaxis in shoulder arthroscopy procedures.Cases presentationWe describe two cases of thrombosis of the arm after shoulder arthroscopy on a total of 10.452 shoulder arthroscopies performed during a period of ten years. One of two patients was further complicated by a bilateral pulmonary microembolism. In these two clinical cases the complication developed despite the absence of risk factors such as a concomitant neoplasm, thrombophilia, smoking habit, or a long duration of the procedure.ConclusionsThe DVT after shoulder arthroscopy procedure remain a very rare complication. However, in view of the growing number of patients undergoing this procedure, this figure is expected to rise. The clinician surgeon should take in mind this possible complication that normally appears in the first 3 weeks after surgery, so to perform anti-coagulant treatment. Further clinical studies are therefore warranted to assess the true risk of VTE. In fact, the presence of "minor" predisposing factors that are not routinely studied, as well as the postoperative immobilization period, are potential risk factors that, associated with the invasiveness of the arthroscopy procedure, could trigger a thromboembolism.

A prospective study of 3-day versus 2-week immobilization period after anterior cruciate ligament reconstruction

Background Aggressive early rehabilitation is recommended after reconstruction of the anterior cruciate ligament (ACL) using a patellar tendon–bone graft. However, rehabilitation after reconstruction of ACL using the multistranded hamstring is controversial. In this study, we compared the clinical results of 3-day immobilization after reconstruction of ACL using the multistranded hamstring, with those of 2-week immobilization prospectively. Methods A total of 30 consecutive patients with ruptured ACL underwent single-socket ACL reconstruction. 10 male and 5 female patients (mean age of 29.2 ± 10.0 years) were prospectively randomized for a 3-day immobilization period, and 6 male and 9 female patients (mean age of 27.3 ± 10.9 years) were randomized for a 2-week immobilization period. We measured the anterior laxity with a KT-2000 arthrometer, joint position sense, and thigh muscle strength at 3, 6 and 12 months after surgery. Results and conclusions There were no statistically significant differences between the two groups. We concluded that the post-operative 3-day immobilization period is preferable to the longer 2-week period in our rehabilitation program from the viewpoint of psychological load to the patients and the duration of hospitalization after ACL reconstruction using multistranded hamstring tendons.

Simultaneous post traumatic bilateral cervico-trochanteric femoral neck fractures in a child: a case report

A case is being presented of simultaneous bilateral cervico-trochanteric fractures of the neck of the femur in a five and a half-year-old girl following a road traffic accident (RTA). It is being presented because of its rarity; literature search to date revealing no previously reported similar case. The patient was managed by open reduction and internal fixation with a period of postoperative immobilization with a hip spica.

THE CLASSIC: Tuberculosis of the Spine in Children

THE CLASSIC: Tuberculosis of the Spine in Children