Volume 16 · Issue 05 · 2013

Abstract：Objective:To evaluate the anatomy of femoral tunnels created by simulated transtibial technique in double-bundle anterior cruciate ligament (ACL) reconstruction.Methods:Two tibial tunnels,anteromedial (AM) and posterolateral (PL),were drilled 45° and 55° to tibial plateau respectively.On the femoral side,the AM and PL tunnels were drilled through anteriomedial portal.After the four tunnels were established,the shaft of a reamer was introduced into the joint through tibial tunnel and reached against the lateral wall of intercondylar notch.The position that the reamer shaft can reach was marked and recorded.Results:Neither femoral AM nor PL tunnel opening can be fully or partially reached by the reamer shaft through the tibial AM tunnel in all cases.The evaluation through the tibial PL tunnel showed that only in 8 of 50 cases (16％) the femoral AM tunnel opening and in 4 cases (8％) the PL opening can be fully reached.On the other hand,in 12 cases (24％) the femoral AM tunnel opening and in 10 cases (20％) the PL opening can be partially reached by the shafts through the tibial PL tunnel.Conclusion:The result strongly suggests that transtibial technique is not well competent for femoral tunnel drilling in anatomic double-bundle ACL reconstruction as we have hypothesized。

Abstract：While trauma registries provide the mechanisms to collect comprehensive,timely and accurate data related to the injuries and evaluate trauma care systems,they have not been established in most developing countries.On the other hand,in complex projects that have large aims,a logical framework approach (LFA) can help summarize and describe the multiple branches of the project systematically,and elucidate the main goals,extensive objectives,activities and expected outcomes.Therefore a LFA can be used to design and guide trauma registry project management,to integrate the cultural,clinical and capacity variations among countries; and to ensure early alignment of the project's design and evaluation。

To the editor:The authors are thankful for the interest in our article by the author of letter to editor.The point wise response is as follows. The triceps splitting approach gives a little less exposure as compared to triceps reflecting or olecranon osteotomy approach but it is more than compensated by other advantages.The exposure can be improved by using lateral decubitus position and flexing the elbow beyond 90 degrees.Fixation is further helped by the sequence of fixation that we have used。

To the editor:we read the article Locking plates in distal humerus fractures:study of 43 patients1 with great interest.We would like to congratulate the authors for the excellent work but we have some concerns. First the authors used modified Campbell or Von Gordner approach for all fractures.This is an excellent approach as it maintains the triceps attachment to the olecranon,eliminates the need for triceps repair and protection postoperatively,allowing active range of motion in the injured elbow。

Abstract：A 46-year-old male sustained severe penetrating injury by a sharp instrument to his right upper sternoclavicular junction.The wound tract was from suprasternal notch to mediastinum.Exploratory operation via median sternotomy under general anesthesia found a large mediastinal septum hematoncus,as well as brachiocephalic trunk and left brachiocephalic vein injuries.The perforating vascular wounds were repaired with 5-0 prolene suture.He was recovered uneventfully and discharged 9 days after operation.There was no sequel found during 7 years follow-up。

Abstract：Objective:To assess local effect of celecoxib on nerve regeneration in a rat sciatic nerve transection model.Methods:Forty-five male healthy white Wistar rats were randomly divided into three experimental groups (n=15 for each):sham-operation (SHAM),control (SIL) and celecoxib treated (SIL/CLX) groups.In SHAM group after anesthesia left sciatic nerve was exposed and after homeostasis muscle was sutured.In SIL group the left sciatic nerve was exposed in the same way and transected proximal to tibioperoneal bifurcation leaving a 10 mm gap.Proximal and distal stumps were each inserted into a silicone tube and filled with 10 μl phosphate buffered solution.In SIL/CLX group defect was bridged using a silicone tube filled with 10 μl celecoxib (0.1 g/L).Results:Functional study and gastrocnemius muscle mass confirmed faster and better recovery of regenerated axons in SIL/CLX than in SIL group (P＜0.05).Morphometric indices of regenerated fibers showed number and diameter of the myelinated fibers in SIL/CLX were significantly greater than those in control group.In immunohistochemistry,location of reactions to S-100 in SIL/CLX was clearly more positive than that in SIL group.Conclusion:Response to local treatment ofcelecoxib demonstrates that it influences and improves functional recovery of peripheral nerve regeneration。

Abstract：Objective:The anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures.For complex fracture pattems a combined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported.In our retrospective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment ofpilon fractures with anterior or posterior fragmentation.Methods:Based on an anatomic study oftibial pilon fractures,we retrospectively analyzed the fractures with primary posterior,posterior-lateral or anterior,anterior-lateral (Tillaux-Chaput) involvement of the distal tibia.This retrospective study consisted of 18 patients with a closed tibial plafond fracture.The inclusion criteria were:(1) presence of an anterior/anterolateral type fragment or a posterior (Volkmann) type fragment involving ＞25％ of the articular surface,(2) a minimum follow-up of 12 months,(3) a fibula fracture associated with a medial column fracture of the distal tibia,and (4) soft tissue conditions at the time of operation that did not compromise the choice of surgical access (Tscherne classification for closed fractures:grade 0 and grade 1).Tibial plafond fractures were classified into two groups:one presenting anterior and the other with posterior rim (Volkmann) fragments.Results:Most patients achieved a good clinical recovery in terms of range of motion and Olerud-Molander scale scores.Only three patients presented a grade 2 osteoarthritis at the 12 month follow-up.Conclusion:Our two-choice strategy highlights concepts which have been previously debated and described in the literature.But a new extended protocol for surgical approach to the distal tibia,including more fracture patterns and their association should be further investigated。

Abstract：Objective:To observe the effect of recombinant interleukin-6 (IL-6) and osteoprotegerin (OPG)on inhibiting bone absorption induced by receptor activator for nuclear factor-κB ligand (RANKL) in murine osteoclast precursor cells (OCPs) model.Methods:RAW 264.7 cells were solely treated with 50 ng/ml RANKL for 1 day,and then they were divided into three groups:RANKL (control group),RANKL+IL-6 (IL-6 group) and RANKL+IL-6+OPG (combination group).These cells were harvested and investigated by means of HE staining under light microscope after consecutive 9 days.Furthermore,staining tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells were detected by inverted phase contrast microscope.The absorption pits of bone slices were observed under scanning electron microscope.Results:The number of mature osteoclast cells in control group was more than that in IL-6 alone or IL-6 combined with OPG group (P＜0.05).Interestingly,this experiment has also demonstrated that there was a large number of TRAP-positive multinucleated osteoclasts (more than 3 nuclei) and several bone absorption formation in the control group,whereas the outcome was completely different in both IL-6 group and IL-6+OPG group (P＜0.05).Conclusion:IL-6 can suppress the differentiation of mature osteoclasts as directly adding it into the RAW 264.7 cells induced by 50 ng/ml RANKL,and further the effect of osteolysis is remarkably reduced.When treatment with IL-6 combined with OPG,a more effective strategy for the treatment of osteoporosis is reached。

Abstract：Objective:This research analyzes data on road traffic accidents (RTA) in Fars province,whose roads are among the highly dangerous ones in Iran.It investigates educational level and age involved in RTA in order to discover patterns that can prevent or decrease accidents.Methods:This research made use of data visualization techniques to find hidden patterns.The data included mortality rate related to RTA in Fars province and were obtained from Fars Forensic Medicine Registry covering a period of 1 year from March 21,2010 to March 21,2011.All data were analyzed using SPSS 11.5.The results were reported as descriptive indices such as frequency (percentage).The Chisquare test was applied to the data concerning educational level and age.P value less than 0.05 was considered significant.Results:In the mentioned period,1 831 people were killed,out of whom un/lowly educated people (69.6％) accounted for the highest mortality rate.The significant relationship between educational level and mortality rate was found (X2=275.98,P＜0.0001).Also three was a significant association between age and mortality rate (x2=371.20,P＜0.0001).Young people (age between 20 and 29 years)contribute to higher RTA mortality rate compared with other age groups.Conclusion:The educational level and age are significantly correlated to mortality rate.The youth and un/lowly educated people suffer more fatal RTA。

Abstract：Tuberculosis (TB) occurring after a closed bone fracture in the patient with no history of TB and no evidence of TB infection at the time of initial fracture is a rare entity.We report one such case of a 48-year-old female,who presented in the emergency department with an olecranon fracture which was open reduced and internally fixed with tension band wiring.Patient presented in the outpatient department with serosanguineous discharge at 3 weeks after surgery.The discharge was sent for culture and sensitivity tests,and the patient was managed by antibiotics and daily dressings.There was wound dehiscence and the underlying implant was exposed,which was removed at 12 weeks after surgery.Repeat debridements and dressings continued for 6 months,but the discharge from the wound site continued.X-rays of the elbow performed at 6 months raised the suspicion of TB,which was confirmed by Ziel-Neelsen staining and histopathological examination of the debrided tissue.Following the confirmation,patient was put on antitubercular drugs.The patient responded to antitubercular drug therapy (ATT),the purulent discharge from the wound ceased,and eventually the wound healed after 2 months of starting ATT。

Abstract：Migrations of orthopedic wires to cardiovascular system are uncommon and rarely reported.We report a case of right ventricle embolization with the Kirschner wire that was used for right 2nd rib osteosynthesis 2 years and 8 months previously in a 50-year-old man.The patient was asymptomatic and migration of the Kirschner wire was discovered by routine chest X-ray.An 8 cm-long Kirschner wire was successfully retrieved from the right ventricle.The treatment strategy for Kirschner wire removal from right ventricle is discussed。

Abstract：The combination of ipsilateral humeral fractures at three different levels namely proximal,shaft and supracondyle has been rarely defined in the literature.We present a case report on such a complex injury in a 10-yearold child after falling down from the second floor of his house while playing.To the best of our knowledge,no such case report exists in the English literature.We define it as "double floating arm" injury.Firstly,shaft of humerus was open reduced and fixed with 4.5 mm narrow dynamic compression plate.Then closed reduction and pinning of the supracondylar humerus under an image intensifier was obtained.Open reduction using deltopectoral approach to the proximal humerus was done and the fracture was fixed with three K-wires.Ipsilateral multiple fractures in children often result from high energy trauma.Immediate reduction and fixation is required.Usually surgeons need to treat simple fractures firstly,which makes the subsequent treatment of complex fractures easier。

Abstract：Perilunate dislocations are rare injuries of the wrist and complete dislocation of the lunate is also rare.There is controversy in literature regarding the optimal management of such injuries.Complete lunate enucleation is associated with high rate of osteonecrosis of lunate thus wrist arthrodesis or proximal row carpectomy has been advocated as primary treatment for such injuries.We report a case of transradial styloid complete palmar lunate enucleation in a 25-year-old male patient who sustained injury to the left wrist due to fall on outstretched hand.Carpal row salvage surgery initially by closed reduction and wrist distractor application followed by open reduction and internal fixation with K-wires along with ligamentous repair resulted in restoration of normal wrist anatomy and good functional outcome.As many of these injuries are missed on initial presentation and outcome is poor for missed injuries,prompt diagnosis and early surgical management to restore vascularity of lunate is recommended。

Abstract：False aneurysm of the femoral artery is a rare complication ofintertrochanteric fracture.Most of these situations are due to iatrogenic trauma or the trauma itself and are rarely caused by dislocated bone fragments.Here we report a case of a 72-year-old man who presented acutely with a pseudoaneurysm of the superficial femoral artery from the spike of a lesser trochanter fragment.Percutaneous endovascular treatment of the pseudoaneurysm with a covered stent was undertaken on an urgent basis.Five days later,the patient was operated upon and the lesser trochanter fragment was excised through an anterior incision and the intertrochanteric fracture was fixed using dynamic hip screws.The fracture was united at 10 weeks.At one-year's follow-up,there were no graft-related complications.This case illustrates that an intertrochanteric fracture with a displaced lesser trochanter fragment can present acutely with bleeding and a pseudoaneurysm of the femoral artery。

Abstract：Femoral head fractures without dislocation or subluxation are extremely rare injuries.We report a neglected case of isolated comminuted fracture of femoral head without hip dislocation or subluxation of one year duration in a 36-year-old patient who sustained a high energy trauma due to road traffic accident.He presented with painful right hip and inability to bear full weight on right lower limb with Harris hip score of 39.He received cementless total hip replacement.At latest follow-up of 2.3 years,functional outcome was excellent with Harris hip score of 95.Such isolated injuries have been described only once in the literature and have not been classified till now.The purpose of this report is to highlight the extreme rarity,possible mechanism involved and a novel classification system to classify such injuries。