The purpose of this study is to determine the influence of knee flexion angle for drilling the posterolateral (PL) femoral tunnel during double-bundle anterior cruciate ligament (ACL) reconstruction via the anteromedial (AM) portal on resulting tunnel orientation and length. Methods: In nine fresh cadaveric knees, the ACL was excised and 2.4 mm guide wires were drilled through the PL bundle footprint via an AM portal. We compared knee flexion angles of 90, 110, 130 degrees. AP-, lateral- and tunnel view radiographs were measured to determine tunnel orientation, o’clock position, and direct measurement to determine intra-osseous tunnel length

On AP view, increased flexion resulted in more horizontal tunnels. The angles were 31.9 ± 7.1°, 26.4 ± 8.9° and 23.0 ± 8.1° for 90°, 110° and 130°. The pin orientation was significantly different when comparing 90° and 130°. On lateral view, increased flexion resulted in more horizontal tunnels. The angles were 68.9 ± 19.9°, 50.4 ± 11.6°, 31.3 ± 12.3° for 90°, 110° and 130°. On tunnel view, pin orientation was 22 ± 8.2°, 28.3 ± 6.7° and 35.9 ± 6.2° for 90°, 110° and 130°. Mean o’clock position was 09:00 ± 0:12. Intra-osseous length of the pins did not significantly change with knee flexion. The exit of the pins on the lateral femur with regard to femoral attachment of the LCL was proximal. The distance was 0.1 ± 6.6 mm, 6.4 ± 6.4 mm and 9.2 ± 2.4 mm for 90°, 110° and 130°. This was significant when comparing 90° and 130°. The shortest distance between the exit and the posterior femoral cortex was 4.0 ± 1.8 mm, 9.7 ± 3.5 mm, and 13.2 ± 2.8 mm for 90°, 110° and 130°. All values were significant. Conclusion: At 110°, exit of the PL pin is close to the attachment of the LCL. 90° flexion risks damage to the LCL and posterior cortex blow-out. Thus we recommend drilling the PL tunnel at 130° of knee flexion

Introduction: The aim of this study is to present the effect of various local anaesthetics, in particular solution concentrations, in peri- and post-operative analgesia in patients with carpal tunnel syndrome (CTS).

Material and Method: 105 patients with CTS (81 female, 24 male, ages 27–79) underwent carpal tunnel release under local anaesthesia. The patients were divided into 5 groups (xylocaine 2%, ropivacaine 0.75%, ropivacaine 0.375%, chirocaine 0.5%, chirocaine 0.25%). A tablet of Gabapentin (Neurontin) 400mg was administered to some patients of each group (41 pts of the 105pts) 12 hours prior to surgery. All patients were evaluated immediately after surgery, in 2 weeks and 2 months postoperatively according to VAS pain score, grip strength, finger active motion and two point discrimination. Postoperative complications were also reported.

Results: Anesthesia was immediate after the local injection. All patients improved postoperativelly regarding relief from pain and paresthesias. There was no statistically significant difference in grip strength before and after surgery. Only 10 patients used paracetamol immediately after surgery, without any statistically significant correlation to any group of patients. 1 patient developed complex regional pain syndrome 2 months after surgery.

Conclusion: The use of local anaesthesia in carpal tunnel release surgery is beneficial in providing immediate intraoperative effect and recovery and mobilization after surgery. Rehabilitation seems to be irrelevant of the type of local anaesthetic that was used during the procedure. Small solution concentrations of local anaesthetics (ropivacaine 0.375%, chirocaine 0.25%) provide adequate analgesia during surgery and provide a normal postoperative course.

Introduction: The value of arthroscopy, fluoroscopy, and e-learning courses (focusing on minimally invasive surgical techniques) for the treatment of intra-articular distal radius fractures (I-ADRF), remains controversial. This study compares the outcomes after fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures, with or without concomitant arthroscopic evaluation.

Materials and Methods: Forty-seven patients with I-ADRF underwent FA external fixation and percutaneous pinning. Among them 23 had additional arthroscopic evaluation of their wrist. For teaching purposes procedures with the use of fluoroscopy and arthroscopy were recorded and adapted as a course for the On-line Performance Support Environment for Minimally Invasive Orthopaedic Surgery (“OnLineOrtho” EU- sponsored project). The context of these courses was incorporated in an intelligent medical performance support environment. The duration of the procedure, the surgical findings and the outcomes were recorded.

Results: The follow-up period ranged from 24 to 62 months and the patients were evaluated at 3, 6, 12 and 24 months. The addition of arthroscopy prolonged the procedure by 25 minutes but diminished the number of images obtained by the image intensifier by 5. After arthroscopic evaluation the placement of subchon-dral pins was changed, because of step-off, in 11 of 23 patients. Also tears of the TFCC (14 of 23 patients), perilunate ligaments (16) were depicted. Patients who underwent additional arthroscopic evaluation had significantly better supination, extension and flexion at all time points than those who had only fluoroscopically assisted surgery. The value added by e-courses and the online performance support system is highlighted through the recognition of the systems effectiveness in e-training.

Discussion: During reduction and fixation of I-ADRF, arthroscopy is a very useful tool for the inspection of the articular surface, the ligaments and the TFCC. Long-term evaluation revealed that patients with additional arthroscopy returned to their previous activities in shorter periods and had better supination, flexion, and extension than patients with FA procedures. Fluoroscopy is essential for the minimally invasive surgical treatment of intra-articular distal radius fractures, whereas arthroscopy is an additional valuable tool that improves the outcome, and e-courses are useful adjuncts for teaching purposes.

Aim: To determine the quantity and the quality of the bone bridge between the bone tunnels, in both the femoral and tibial side, after double-bundle anterior cruciate ligament (ACL) reconstruction.

Material and methods: Twenty-seven patients undergoing primary double-bundle ACL reconstruction with hamstring tendon autograft were included in this prospective study. Computed tomography (CT) was performed in all patients at a mean of 13 months postoperatively. The amount of the bone bridge between the bone tunnels was measured, in both the femoral and tibial side, on an axial plane at three locations:

at the level of the joint line

In addition, the bone density of the bone bridge was measured in Hounsfield units (HU) in the same locations. Bone density of the anterior tibial cortex lateral femoral condyle, and adjacent cancellous area, and were measured for comparisons.

Results: CT confirmed that the bone bridge was triangular in shape in all cases in both the femoral and tibial side. On the femoral side, at the level of joint line (apex of the bone bridge) the mean thickness of the bone bridge was 1.7 mm, at the mid-portion the mean thickness of the bone bridge was 3.7 mm and at the base of the bone bridge the mean thickness was 7.1 mm. On the tibal side, at the level of joint line (apex of the bone bridge) the mean thickness of the bone bridge was 1.5 mm, at the mid-portion the mean thickness of the bone bridge was 3.2 mm and at the base of the bone bridge the mean thickness was 6.5 mm. Bone density at the mid-portion and at the base of the bone bridge was similar to the cancellous bone for both the femoral and tibial side. However, the bone density of the bone bridge, at the level of the joint line, for the femoral side was 860 HU and this was not statistically significant in comparison to the density of the lateral femoral cortex (960 HU). Similarly, the bone density of the bone bridge, at the level of the joint line, for the tibial side was 885 HU and this was not statistically significant in comparison to the density of the anterior tibial cortex (970 HU).

Conclusions: Our study demonstrated one year after double-bundle ACL reconstruction the thickness of the triangular bone bridge between the bone tunnels is sufficient at the mid-portion and at the base of the triangle but is thin at the level of the joint line. However, the bone bridge at the apex of the triangle is very strong since its density is similar to that of cortical bone. We believe that the “corticalization” of the bone bridge at the level of the joint line on both the femoral and tibial side is important and contributes significantly to avoid communication of the bone tunnels.

Purpose: To evaluate the differencies in graft orientation between transtibial and anteromedial portal technique using magnetic resonance imaging (MRI) in anterior cruciate ligament (ACL) reconstruction.

Materials and Methods: Fifty one patients who undergoing arthroscopically ACL reconstruction underwent MRI of their reconstructed knee. Thirty patients had ACL reconstruction using the transtibial technique (group A) while in the rest 21 the anteromedial technique (group B) was used. In the femoral part graft orientation was evaluated using the femoral graft angle (FGA). The FGA was depicted at the coronal views by two axes: the anatomical axis of the femur and the axis of the femoral tunnel. In the tibial part graft orientation was evaluated using the tibial graft angle (TGA). The TGA was specified as the angle between the axis of the graft and a line parallel to the tibial plateau at the sagittal view.

Results: The mean FGA for group A was 12.52° while for the group B was 27.06°. This difference was statistically significant (p< 0.001 paired t-test). The mean TGA for group A was 64.24° while for the group B was 63.11° but this was not statistically significant.

Conclusions: Using the anteromedial portal technique the ACL graft is placed in a more oblique direction in comparison with the transtibial technique in the femoral part. This may have an impact in rotatory knee stability. However, there are no differencies between the two techniques in graft orientation in the tibial part.

Purpose: Arthroscopy offers a view of intra-articular pathology, but its use in the treatment of intra-articular distal radius fractures remains controversial. This study compares functional and radiologic outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation (EF) of distal radius fractures.

Type of study: double randomised prospective, comparison of 2 different procedures.

Methods: Between January 2000 and December 2003, 20 patients with comminuted intra-articular distal radius fractures underwent AA EF and percutaneous pinning and 20 patients underwent and FA EF reduction and pinning.

Results: Follow-up period was 9–27 months. Evaluation was clinical (grip strength, range of motion) and radiographic (palmar tilt, radial shortening, stepoff). The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the MAYO wrist score were used 3-9-12 months postoperatively. In 9/20 patients of AA group the subchodral pins were changed after artrhroscopic view because of stepoff. The following tears were found: TFCC (12 of 20 patients), SL (9/20), LT (4/20). Patients who underwent AA surgery had significantly better supination; wrist extension; and flexion compared with the FA surgery group (86 vs 75; 76 vs 65; and 76 vs 63 degrees respectively). Radial shortening and DASH scores were better for the AA group compared to the FA group (AA:12, FA:25) the 3rd and 6th postoperative month but the difference decreased after the 12th month.

Conclusions: A reduction and fixation of intra-articular distal radius fractures provides improved inspection of the ulnarsided components of the injury. Long term evaluation revealed that patients with AA procedures returned in decreased periods to their previous activities (based on DASH score) and had better of supination, flexion, and extension than patients with FA surgery.

Purpose: The aim of this study was to document donor site problems one year after anterior cruciate ligament (ACL) reconstruction and to compare the differencies between hamstring and patellar tendon autografts.

Materilas and Methods: Sixty-four patients undergoing primary arthroscopically ACL reconstruction were randomized to have a central third bone patellar tendon bone (PT) autograft (30 patients) or a doubled semiten-dinosus/doubled gracilis (HS) autograft (34 patients). The postoperative rehabilitation regimen was identical for both groups. All patients were examined one year postoperatively. Objective parameters evaluated included pre and postoperative IKDC and Lysholm score, side-to-side KT-1000 maximum-manual arthrometer differences. The Shelbourne score was used to evaluate anterior knee symptoms. Loss of sensitivity in the anterior knee region postoperatively as well as scar sensitivity were also recorded.

Results: Three patients (10%) in the PT group had anterior knee symptoms while only one (3%) in the HS group. The mean Shelbourne score was 98 for the HS group and 93 for the PT group but this was not statistically significant. However, 8 pateints (23%) had disturbed sensitivity in the anterior knee region in the HS group, but none in the PT group and this was statistically significant (p< 0.005). Scar sensitivity was present in 3 patients (10%) in the PT group and in one (3%) in the HS group. No differencies were found postoperatively between the groups regarding IKDC, Lysholm score and side-to-side KT-1000 measurements.

Conclusions: Although,notstatisticallysignificantpatients in the PT group had more anterior knee symptoms and scar sensitivity, one year postoperatively. In contrast, harvesting of hamstring tendons produces significantly more sensory nerve complications in the anterior knee region than harvesting the middle third of patellar tendon. Both grafts seem to improve equally patients’ performance.

Introduction: Amputation of the fingertip with loss of the finger pulp, exposed bone and nail bed injury is a common problem, not infrequently neglected. Fingertip reconstruction requires new pulp glabrous skin coverage with sensitivity, buttressed by the nail. The aim of this study is the analysis of our experience from the use of a homodigital, island flap for the reconstruction of amputated fingertips Materials and Methods: The homodigital island flap was applied in 46 patients (57 fingers), at every level of finger amputation with special indication on fingertip coverage. For the index and the middle fingers, use of the ulnar bundle is preferred. For the thumb, ring and little finger use of the radial neurovascular bundle is preferable. The neurovascular bundle is well dissected from the flap to the base of the finger. After suturing of the flap the donor area is covered with split thickness skin graft from the hypothenar. The finger is mobilized one week after the procedure. Results: Postoperatively, ROM was normal in 45 fingers, 6 fingers had 100 loss of extension at the DIP and 6 fingers had loss of motion between 100–200 . TPD was 4mm (3–10mm). Three patients had cold intolerance for 8 months. There was no neuroma or sensitive scar formation and no need for a second operation. According to patients cosmesis was acceptable in all fingers. Conclusions: The use of homodigital island flap provides excellent functional reconstruction of the fingertips after a complex tissue loss in Allen III and IV amputations It is a straightforward operation carried out under wrist block with excellent cosmetic results.

Aim: Fixation implants are usually well tolerated by the patients for prolonged periods of time. However, it is not unusual for some patients to develop persistent pain with acute onset that is often combined with paresthesias. The purpose of this study was to verify if the acute onset of pain that is not combined with clinical or laboratory signs of infection could be attributed to an underlying bacterial colonization of implants. Methods: Sixty-four patients (38 male and 26 female) with mean age of 36 years (range, 10 to 73 years) were included in this study. Patients presented with acute onset of pain and/or paresthesias several years after the implantation of stainless-steel þxation materials (plate-screws: 52 and intramedullary nails: 12), in the upper (13) or lower extremity (51). All patients of the present series had negative clinical and laboratory signs of infection. All patients of the present series had their þxation materials removed in our department. The materials subsequently underwent microbiologic and corrosion evaluation. Results: Patients experienced immediate relief after removal of þxation materials. Cultures were positive in 18% of cases and Staph aureus and epidermidis were most frequently encountered. Pseudomonas and enterococcus were also cultured. Conclusions: The percentage of positive cultures (18%) in the patients of our series indicates that symptoms may be due to the bacterial colonization of implants, despite the absence of sings of infection. Although the administration of antibiotics remains controversial, removal of the implants is indicated in cases with acute delayed onset of pain at the site of the implanted þxation materials.