Does the Combination of Platelet-rich Plasma and Supervised Exercise Yield Better Pain Relief and Enhanced Function in Knee Osteoarthritis? A Randomized Controlled Trial.

BACKGROUND: Knee osteoarthritis is a leading cause of disability with substantial healthcare costs, and efficient nonsurgical treatment methods are still needed. Platelet-rich plasma (PRP) injections and exercise therapy are used frequently in clinical practice. Whether PRP or PRP combined with exercise is more effective than exercise alone is unclear. QUESTIONS/PURPOSES: (1) Which treatment relieves knee osteoarthritis pain better: PRP alone, exercise, or PRP combined with exercise? (2) Does PRP alone, exercise, or PRP combined with exercise yield better results in terms of the WOMAC score, performance on the 40-m fast-paced walk test and stair climbing test, and the SF-12 health-related quality of life score? METHODS: In this randomized, controlled, three-arm clinical trial, we recruited patients with mild-to-moderate (Kellgren-Lawrence Grade II or III) knee osteoarthritis with a minimum of 3 points on the 11-point numeric rating scale for pain. During the study period, 157 patients with a diagnosis of knee osteoarthritis were screened and 84 eligible volunteers were enrolled in the study. Patients were randomly allocated (1:1:1) into either the exercise group (28), PRP group (28), or PRP + exercise group (28). Follow-up proportions were similar between the groups (exercise: 89% [25], PRP: 86% [24], PRP + exercise: 89% [25]; p = 0.79). All patients were analyzed in an intention-to-treat manner. There were no between-group differences in age, gender, arthritis severity, and baseline clinical scores (pain, WOMAC, functional performance tests, and health-related quality of life). The exercise group underwent a 6-week structured program consisting of 12 supervised individual sessions focused on strengthening and functional exercises. Meanwhile, the PRP group received three weekly injections of fresh, leukocyte-poor PRP. The PRP + exercise group received a combined treatment with both interventions. The primary outcome was knee pain over 24 weeks, measured on an 11-point numeric rating scale for pain (ranging from 0 to 10, where 0 represents no pain and 10 represents the worst pain, with a minimum clinically important difference [MCID] of 2). The secondary outcome measures included the WOMAC index (ranging from 0 to 100, with lower scores indicating a lower level of disability and an MCID of 12), the durations of the 40-meter fast-paced walk test and stair climbing test, and the SF-12 health-related quality of life score. For the a priori sample size calculation, we used the numeric rating scale score for pain at 24 weeks as the primary outcome variable. The MCID for the numeric rating scale was deemed to be 2 points, with an estimated standard deviation of 2.4. Based on sample size calculations, a sample of 24 patients per group would provide 80% power to detect an effect of this size between the groups at the significance level of p = 0.05. RESULTS: We found no clinically important differences in improvements in pain-defined as ≥ 2 points of 10-at 24 weeks when comparing exercise alone to PRP alone to PRP + exercise (1.9 ± 0.7 versus 3.8 ± 1.8 versus 1.4 ± 0.6; mean difference between PRP + exercise group and exercise group -0.5 [95% confidence interval -1.2 to 0.4]; p = 0.69). Likewise, we found no differences in WOMAC scores at 24 weeks of follow-up when comparing exercise alone to PRP alone to PRP + exercise (10 ± 9 versus 26 ± 20 versus 7 ± 6; mean difference between PRP + exercise group and exercise group -3 [95% CI -12 to -5]; p = 0.97). There were no differences in any of the other secondary outcome metrics among the PRP + exercise and exercise groups. CONCLUSION: PRP did not improve pain at 24 weeks of follow-up in patients with mild-to-moderate knee osteoarthritis compared with exercise alone. Moreover, exercise alone was clinically superior to PRP alone, considering function and the physical component of health-related quality of life. Despite the additional costs and endeavors related to PRP products, the combination of PRP and exercise did not differ from exercise alone. The results of this randomized controlled trial do not support the use of PRP injections in the treatment of patients diagnosed with mild-to-moderate knee osteoarthritis. Consequently, exercise alone is the recommended treatment for reducing pain and enhancing function throughout this timeframe. LEVEL OF EVIDENCE: Level I, therapeutic study.

Comparison of Staple, Anchor, and Tenodesis Screw for Posterior Tibialis Tendon Fixation: A Biomechanical Analysis.

Various posterior tibialis tendon fixation techniques are described in literature. Suture anchor, staple and tenodesis screws are widely used for posterior tibialis tendon transfer, but their stiffness and the maximal ultimate failure load were not tested before. We aimed to compare the initial ultimate failure load and stiffnesses of suture anchor, staple and tenodesis screws on bovine tendon fixation to bovine metaphyseal bone. Thirty-five fresh bovine ankle joints and hooves were obtained from a local abattoir. Metatarsals bones with long extensor tendons were harvested. Staple group had 15, suture anchor group had 10, and tenodesis screw group had 10 samples. All fixations were tested with Instron® ElectroPuls® E10000 Test Instrument. Ultimate failure load and failure location were noted. Staple group's median ultimate failure load was 210.03 N (IQR: 133.43), suture anchor group's was 124.33 N (IQR: 63.67), and tenodesis screw group's was 394.46 N (IQR:115.09). Median stiffness of the staple group was 19.87 N/m (IQR: 15.29); the tenodesis screw group's was 20.28 N/m (IQR: 6.18), the anchor group's was 8.54 N/m (IQR: 4.35). Staples' failure occurred on tendon-staple interface, while suture anchors' occurred on anchor-suture interface and tenodesis screws' occurred on tendon-suture interface. Tenodesis screws' ultimate failure load was the highest (tenodesis vs anchor and staple p < .001 and p = .032, respectively). Staple fixation is less expensive than the other methods and can provide sufficient fixation strength but was weaker than the tenodesis screw fixation. Staples are still a good choice for tendon to bone fixation, whereas the suture anchors provide lower fixation strength at a higher cost.

Symptomatic osteonecrosis of the hip and knee in patients with systemic lupus erythematosus: Prevalence, pattern, and comparison of natural course.

OBJECTIVE: Osteonecrosis (ON), also known as avascular necrosis, is characterized by the collapse of the architectural bone structure secondary to the death of the bone marrow and trabecular bone. Osteonecrosis may accompany many conditions, especially rheumatic diseases. Among rheumatic diseases, osteonecrosis is most commonly associated with systemic lupus erythematosus (SLE). We assessed prevalence and distribution pattern of symptomatic ON in patients with SLE and compare the natural courses of hip and knee ON. METHODS: 912 SLE patients admitted between 1981 and 2012 were reviewed. SLE patients with symptomatic ON were retrospectively identified both from the existing SLE/APS database. The prevalence of symptomatic ON was calculated; with ON, the joint involvement pattern was determined by examining the distribution of the joints involved, and then the data about the hip and knee joints were entered in the Kaplan-Meier analysis. Kaplan-Meier methods were used to calculate 5- and 10-year rates of ON-related hip (the hip group) and knee survival (the knee group). RESULTS: Symptomatic ON developed in various joints in 97 of 912 patients with SLE, and the overall prevalence of ON was detected as 10.6%. The mean age at the time of SLE and ON diagnoses were 27.9 ± 9.9 (14-53) and 34.2 ± 11.3 (16-62) years, respectively. The mean duration from diagnosis of SLE to the first development of ON was 70.7± 60.2 (range = 0-216) months. The most common site for symptomatic ON was the hips (68%, n=66), followed by the knees (38%, n = 37). According to Kaplan-Meier analysis, hip and knee joint survival rates associated with 5-year ON were 51% and 88%, and 10-year survival rates were 43% and 84%, respectively. CONCLUSION: We observed that the prevalence of symptomatic ON in patients with SLE was 10.6%. With the estimated 10-year survival rates of 40% versus 84% for the hip and knee joints, respectively, hip involvement may demonstrate a more aggressive course to end-stage osteoarthritis than the knee involvement.

Prognostic factors of radiosynovectomy in haemophilia patients with inhibitors: Survival analysis in a 19-year period.

INTRODUCTION: People with haemophilia (PwH) with inhibitors have an increased risk of bleeding and early development of progressive arthropathy. Radiosynovectomy (RS) has been effective in dramatically reducing the frequency of haemarthroses. In the present study, the mid- and long-term results of the efficacy of RS in PwHs with inhibitors and prognostic factors that influence success and failure of RS were presented. MATERIAL AND METHOD: Radiosynovectomy was performed in 51 joints of 22 PwHs with inhibitors diagnosed with chronic haemophilic synovitis between January 2000 and December 2018. Two patients were lost to follow-up and four joints were excluded. Number of bleeding episodes within the pre- and post-treatment 6 months were documented. Treatment failure was defined as need for repeat RS injection. RESULTS: Results of 47 RS were analysed. The mean bleeding frequency of the joints was 11.2 ± 6.2 (median 9) within the last 6 months in the pre-treatment evaluation. After the treatment, the mean bleeding frequency of the joints decreased to 1.2 ± 2.8 (median 0) for first 6 months (P < .0001). The cumulative survival rate at 12 months was 87% and 78% at 36 months. The receiver operating characteristic (ROC) curve analysis revealed that cut-off points of 12 bleeding episodes within the last 6 months (sensitivity, 71.4; specificity, 81.8 P = .0022) and an inhibitor titre of 63.4 BU (sensitivity, 57.1; specificity, 75.8; P = .31) were threshold levels for a predisposition for failure. CONCLUSION: Radiosynovectomy is an effective and safe intervention in PwHs with inhibitors. Bleeding frequency is a prognostic marker for the success of RS treatment. Patients who have more than 12 bleeding episodes within the last 6 months before the RS treatment have a higher rate of failure.

Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy.

Background and purpose - Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro-arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods - Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33-82); the mean follow-up was 45 months (24-70). The primary outcomes were rates of fusion, limb salvage, and complications.Results - The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation - For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.

The natural course of pain in patients with symptomatic tarsal coalitions: A retrospective clinical study.

BACKGROUND: This study aims to examine changes in pain intensity in the long course of symptomatic tarsal coalition. METHODS: Thirty consecutive patients who were treated for symptomatic tarsal coalition was retrospectively reviewed. The patients were divided into two groups: the nonsurgical group (14 patients) and the surgical group (16 patients). To assess pain intensity, the visual analogous scale (VAS) was utilized. RESULTS: On admission, the mean VAS was 4,9 ± 1,9 in the nonsurgical group and 7,7 ± 1,3 in the surgical group (p < 0,05). After 6 months of nonoperative treatment, the mean VAS was decreased from 4,9 ± 1,9 to 2,8 ± 1,0 in the nonsurgical group (p < 0,05) and from 7,7 ± 1,3 to 7,1 ± 0,8 in the surgical group (p > 0,05). At the final follow-up, the mean VAS was 2,3 ± 2,4 in the nonsurgical group and 3,1 ± 2,7 in the surgical group (p > 0,05). The decrease in the VAS after surgery was significant in the surgical group (p < 0,01). CONCLUSION: For patients with symptomatic tarsal coalitions who present with an initial VAS score of 6 and above, early surgery may be more effective than nonoperative treatment in relieving pain intensity.

High Rates of Psychiatric Disorders and Below Normal Mental Capacity Associated With Spastic Peroneal Flatfoot: A New Relationship.

Spastic peroneal flatfoot (SPFF) is a rare hindfoot pathology usually seen in the adolescent age group that is characterized by painful spasms in the peroneal muscles. We have clinically observed that patients with SPFF also have some behavioral and emotional difficulties and problems in their academic achievements. Because of these observations, we investigated the prevalence and patterns of psychiatric disorders and intellectual disability among young subjects with SPFF. Our cohort consisted of 16 patients with SPFF. Their mean age at presentation was 21 (range 13 to 31) years. Only 6 patients had a tarsal coalition as an underlying condition. The psychometric evaluation was conducted using validated instruments (Wechsler Intelligence Scale for Children-revised form, Stanford Binet intelligence quotient [IQ] test, and Cattell IQ test). Psychiatric disorders were assessed using a semistructured diagnostic instrument (Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version). The testers and psychiatrists were unaware of the orthopedic condition and the preliminary psychiatric diagnoses. The ethical committee approved the study protocol. The mean follow-up period was 41 (range 12 to 97) months. The mean IQ score of the patients was 75.1 ± 17.9 (range 52 to 107). Compared with the general population, the rate of intellectual disability was significantly greater (p = .0001) and the rate of normal intelligence significantly lower (p = .0015) in our patient group. Furthermore, according to the community schooling ratio, our cohort also had lower junior high and secondary education rates compared with the general population. The rate of most psychiatric disorders diagnosed in the SPFF patients was greater than that in the normal population. The most commonly identified psychiatric disorders were social phobia and attention deficit and hyperactivity disorder (75%). Timely interventions of the psychosocial and academic problems of patients with SPFF might increase their compliance with orthopedic treatment and help with their psychological well-being and academic achievement. In addition, this relationship might be a clue for uncovering the etiology of this disease, which has not yet been clarified.

Long-term results of microfracture in the treatment of talus osteochondral lesions.

PURPOSE: Osteochondral lesions of the talus are common injuries, and many clinicians consider arthroscopic debridement and microfracture as the first-stage treatment. This study assessed the long-term clinical and radiographic outcomes of arthroscopic debridement and microfracture for osteochondral lesions of the talus. METHODS: A total of 82 patients (48 males, 34 females) who were treated with arthroscopic debridement and microfracture for osteochondral lesions of the talus between 1996 and 2009 with a minimum 5-year follow-up were included in our study group. Functional scores (AOFAS, VAS) and ankle range of motion were determined, and an arthrosis evaluation was performed. Subgroup evaluations based on age, lesion localization, and defect size were performed using functional outcome correlations. RESULTS: The mean age of the patients was 35.9 ± 13.4 years (14-69 years), and the mean follow-up period was 121.3 months (61-217 months). The mean defect size was 1.7 ± 0.7 cm2 (0.25-5). The mean pre-operative AOFAS score was 58.7 ± 5.2 (49-75), and the mean post-operative AOFAS score was 85.5 ± 9.9 (56-100). At the last follow-up, 35 patients (42.6%) had no symptoms and 19 patients (23.1%) had pain after walking more than 2 h or after competitive sports activities. Radiological assessments of arthrosis revealed that no patient had grade 4 arthritis but that 27 patients (32.9%) had a one-stage increase in their arthrosis level. Subgroup analyses of the lesion location demonstrated that lateral lesions had significantly better functional results (p = 0.02). CONCLUSIONS: Arthroscopic debridement and microfracture provide a good option for the treatment of osteochondral lesions of the talus over the long term in select patients. Functional outcomes do not correlate with defect size or patient age. Orthopaedic surgeons should adopt the microfracture technique, which is minimally invasive and effective for treating osteochondral lesions of the talus. LEVEL OF EVIDENCE: IV.

Biomechanical comparison of oblique and step-cut osteotomies used in total hip arthroplasty with femoral shortening.

BACKGROUND: Various types of shortening osteotomies and prosthesis are used for femoral reconstruction in total hip arthroplasty of the high hip dislocation. This biomechanical study investigates whether step-cut osteotomies result in better stability than oblique osteotomies and cylindrical femoral stems enhance stability of the osteotomy more than conical stems, and which osteotomy and prosthesis type maintain the stability better after cyclical loading. METHODS: Oblique and step-cut shortening osteotomies were compared under axial and rotational forces, using synthetic femur models and conical or cylindrical femoral prostheses. The models underwent cyclic loading for 10,000 cycles at 3 Hz (100-1000 N axial bending or 0.5-10 Nm torque). After the completion of cyclic loading, the models were loaded until failure. Stiffness values before and after cyclical loading, and failure loads were the outcome parameters. Relative displacements at the osteotomy sites were also measured using 3-Dimensions Digital Imaging Correlation System. RESULTS: The mean failure load was significantly higher in conical prosthesis groups under axial forces. In torsion tests, the mean stiffness of conical prosthesis groups after cyclical loading was higher in oblique osteotomies. The other parameters were similar between the groups. CONCLUSIONS: According to the results of the study, although some individual statistically significant parameters were obtained, step-cut osteotomies, which are technically challenging procedures, were not found biomechanically superior to oblique osteotomies, with neither conical nor cylindrical prostheses.

MMP-3 gene polymorphisms and Osteosarcoma.

Osteosarcoma (OSA) is the most common adolescence cancer among all primary bone tumors next only to multiplemyeloma. It has a substantially worse prognosis and ability to metastasize to lung. MMPs (matrix metalloproteinases) are among the major proteases that take part in regulation of ECM (extracellular matrix). MMPs play an active role in the formation of the osteoid tissue, rich in collagens and other ECM proteoglycans. They also take part in pro-osteoclast, osteoclast, osteoblast, and osteoid formation. Many members of the MMP gene family have been linked to human cancers. It has been shown that MMPs particularly play a role in the tumor's acquisition of an invasive and metastatic character. In our study, the E45K and T102T polymorphisms of MMP-3 were studied using the PCR-RFLP method in 135 Turkish subjects (54 subjects with osteosarcoma and 81 healthy controls). We found that frequencies of E45K G allele (p:0,010, χ²:6,710, OR:1,429, 95% Cl: 1,019-1,858) and AG genotype (p:0,001, χ²:14,753, OR:2,32, 95% Cl: 1,491-3,626) were elevated in patients compared to controls. Besides, there was a significant difference in.E45K AA genotype between study groups (p:0,004, χ²:8,182, OR: 2,929, 95% Cl: 1,38-6,19). There were no significant differences between any genotypes or allele in the control and patient groups for MMP-3 T102T polymorphism. Our findings indicate that the G allele and AG genotype of MMP-3 E45K polymorphism is associated with increased risk of osteosarcoma in adolescent population of Turkey.

The Turkish version of the Achilles tendon Total Rupture Score: cross-cultural adaptation, reliability and validity.

PURPOSE: The Achilles tendon Total Rupture Score (ATRS) is a questionnaire designed to evaluate pain, symptoms, function and physical activity after Achilles tendon rupture. The purpose of this study was to translate and culturally adapt the ATRS into Turkish and to determine its reliability and validity. METHODS: The ATRS was translated into Turkish in accordance with the stages recommended by Beaton. Seventy-four patients (73 male; average age: 42.3 ± 7.6; range 27-63 years) suffering from previous Achilles tendon ruptures were included for the study. The ATRS-Turkish was administered twice at 7-14 days intervals with 52 of the 74 patients (51 male, average age: 41.8 ± 7.8) to assess the test-retest reliability. Cronbach's α was used for internal consistency, and the inter-rater correlation coefficient (ICC) was used to calculate the test-retest reliability. The Turkish Short-Form-12 (SF-12) and the Foot and Ankle Outcome Score (FAOS) were employed for validity estimation. RESULTS: The internal consistency (Cronbach's α = 0.95) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 7.1 ± 3.1 days. The mean and standard deviation of the first and second assessment of the ATRS were 78.1 ± 23.1 and 79.1 ± 22.5, respectively. The correlation coefficient between the ATRS-Turkish and the FAOS subscales (pain, symptoms, activities of daily living, sports and recreational activities, and quality of life) were determined (r = 0.82, r = 0.66, r = 0.79, r = 0.83 and r = 0.60, respectively, p < 0.0001). The ATRS-Turkish displayed good correlation with the SF-12 physical component score (r = 0.63, p < 0.001) and no correlation with the SF-12 mental component score (r = 0.22, p = 0.06). CONCLUSION: The ATRS-Turkish was found to be reliable and valid for outcome evaluation after Achilles tendon ruptures. LEVEL OF EVIDENCE: II.

Suture anchor tenodesis in repair of distal Achilles tendon injuries.

BACKGROUND: Distal Achilles tendon avulsions are in the form of either bony and nonbony avulsion of Achilles tendon from its calcaneal insertion. METHODS: Four patients with distal Achilles tendon avulsions or ruptures which were treated with tendon to bone repair using suture anchors are presented here. Operated leg was immobilized in above-knee cast for 4 weeks while the patient walked non-weight-bearing. Then, cast was changed to below knee, and full weight-bearing was allowed. Patients underwent gait analysis minimum at first postoperative year. RESULTS: Mean American Orthopedics Foot Ankle Society ankle/hindfoot score of patients at last visit was 88.75 (range 85-100), and Achilles tendon total rupture score was 77.75 (range 58-87). Mean passive dorsiflexion of injured ankles (14° ± 5°) was lower than uninjured ankles (23° ± 9°). All the kinematic parameters of gait analysis were comparable to the uninjured side. Maximum plantar flexion power of injured ankle was 1.40 W/kg, and this was significantly lower than the contralateral side value 2.38 W/kg; (P = 0.0143). CONCLUSIONS: There were no visually altered gait or problems in daily life. Suture anchor tenodesis technique of distal Achilles tendon avulsions was successful in achieving durable osteotendinous repairs.

Long-term Clinical and Radiographic Outcomes Following Surgical Treatment for Ankle Fracture-Dislocations: Do poor radiographic outcomes always matter?

Background Ankle fractures constitute 10% of all traumatic fractures in clinical practice. Concurrent tibiotalar dislocations form 21-36% of all ankle fractures. Although mechanism of injury is similar to non-dislocated ankle fractures, fracture-dislocations cause more extensive bone and soft tissue damage. Treatment is a challenge for orthopedic surgeons due to concomitant pathologies. It is associated with malreduction, chronic pain and most importantly, posttraumatic osteoarthritis. We aimed to investigate the relationship between ankle osteoarthritis radiographic stage and clinical outcomes. Methods 27 patients (17 female, 10 male) were included in the study. Records and data were retrospectively analyzed. Clinical status at the final follow-up was evaluated by a single orthopedic surgeon. Range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analogue scale (VAS) were the clinical parameters that were assessed. Radiological assessment was made by standard anteroposterior [AP], lateral, and mortise views. Pre-operative osseo-ligamentous injury pattern, presence of posterior malleolar fracture, syndesmosis injury and post-operative ankle osteoarthritis were investigated. Results For 27 patients that were evaluated, at the final follow-up, mean AOFAS was 85 ± 8.12, and mean VAS during daily activities was 1.52 ± 0.70. Mean ankle dorsiflexion and plantar flexion were significantly lower on the affected sides (14.07 ± 7.97° and 36.30 ± 6.59°) than on the unaffected sides (28.15 ± 2.82° and 46.30 ± 2.97°), respectively (p < 0.001). No significant difference for inversion and eversion was observed. Twenty-four patients demonstrated radiographic signs of ankle osteoarthritis, and three remained without evidence of osteoarthritis. No significant difference was found among Takakura's stages in any of the variables. Conclusion The results illustrated that although post-traumatic osteoarthritis rate was high for ankle fracture-dislocation patients, surgical treatment achieved excellent functional results. Even if advanced stages of ankle arthritis according to Takakura's classification developed, patients had satisfactory clinical and functional results.

Translation and cultural adaptation of the Turkish Lysholm knee scale: ease of use, validity, and reliability.

BACKGROUND: The Lysholm knee scale, first published in 1982, is an eight-item questionnaire designed to evaluate patients after knee ligament injury. However, as a tool developed in English, its use as a validated instrument has been limited to English-language populations. QUESTIONS/PURPOSES: The objectives of this study were to test the ease of use, reliability, and validity of a Turkish-language, culturally adapted version of the Lysholm knee scale. METHODS: The Lysholm knee scale was translated into Turkish according to Guillemin's recommendations. Seventy patients (mean age, 36 years; range, 17-72 years) with different knee complaints were included, and the scale was completed twice by each participant at 3- to 14-day intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbach's alpha evaluated internal consistency. External validity was evaluated with correlations between the Lysholm knee scale, Kujala Anterior Knee Pain Scale, and SF-36. The distribution of floor and ceiling effects was determined. RESULTS: Patients completed the Turkish-language Lysholm questionnaire in approximately 3 minutes. The test-retest reliability was 0.82, with a Cronbach's alpha coefficient of 0.68. The Lysholm knee score was strongly correlated with the Kujala Anterior Knee Pain Scale (r = 0.78). The Turkish Lysholm knee scale showed high correlations with the SF-36 physical component score (r = 0.61) and a low association with the mental component domain (r = 0.14). CONCLUSIONS: The Turkish version of the Lysholm knee scale is quickly administered, valid, and reliable, and can be used for patients with various knee disorders.

Cementless total hip arthroplasty with modified oblique femoral shortening osteotomy in Crowe type IV congenital hip dislocation.

Midterm results of cementless total hip arthroplasty in patients with Crowe type IV congenital dislocation of the hip were evaluated. A modified oblique subtrochanteric shortening osteotomy was used in all patients. A cylindrical femoral stem was used in all patients to stabilize the osteotomy. Mean follow-up was 82 months in 20 hips of 16 patients. Mean Merle D'Aubigné pain score increased from 2.52 to 5.65 points, function score improved from 4.0 to 5.3 points, and mobility score improved from 3.95 to 5.35. Mean greater trochanter height relative to the estimated hip center was 6.8 ± 2.0 cm preoperatively and -1 ± 0.2 cm postoperatively. Complications were dislocations in 3 patients, which were successfully managed without redislocation and fracture of greater trochanter in 3 patients, which healed uneventfully in 2 but with residual Trendelenburg gait in one. Total hip arthroplasty with modified oblique subtrochanteric shortening osteotomy is an effective technique for the treatment for Crowe type IV hip dislocation.

Factors affecting the features of platelet-rich plasma in patients with knee osteoarthritis.

OBJECTIVE: The aim of this study was to present an analysis of platelet-rich plasma obtained from patients with knee osteoarthritis and reveal the factors affecting its features. METHODS: A total of 62 patients (mean age: 56.68 ± 7.13 years) with symptomatic knee osteoarthritis were included in this study. Age (years), gender, height (m), weight (kg), body mass index (kg/m2), duration of symptoms, smoking status, smoking index, general health status, and physical activity scores were recorded. Whole blood and platelet-rich plasma cell counts were performed with a hematology analyzer. White blood cell, red blood cell, and platelet counts were recorded. According to the dose of injected platelets, efficiency of the procedure, purity of platelet-rich plasma, and activation classification, dose of platelets, efficiency of the procedure (platelet recovery rate, %), and purity of the obtained platelet-rich plasma product (relative composition in platelets, %) were calculated. Correlation analysis between the features of platelet-rich plasma and the patient-related variables, including age, gender, body mass index, smoking status, smoking index, presence of other health conditions, physical activity scores, duration of symptoms, and pain levels, was performed. RESULTS: Dose of injected platelets, efficiency of the procedure, purity of platelet-rich plasma, and activation analysis showed that the dose of injected platelets was 3.25 billion, the efficiency of the process was 77%, and the purity rate of the platelet-rich plasma was 98.4%. Platelet-rich plasma platelet count was correlated with whole blood platelet count (r = 0.81, P < .001), whole blood white blood cell count (r = 0.39, P = .002), smoking status (r = 0.56, P = .03), smoking index (r = -0.63, P = .002), and the presence of hypertension (r = -0.31, P=.04). Platelet-rich plasma white blood cell and purity of platelet-rich plasma were correlated with the smoking status of the patients (r = 0.52, P = .01; r = 0.64, P = .003, respectively). CONCLUSION: This study has demonstrated that high dose and very pure platelet-rich plasma with medium efficiency was yielded with this platelet-rich plasma preparation procedure; whole blood platelet count, the presence of hypertension, and the smoking status of patients affect the features of the obtained platelet-rich plasma. LEVEL OF EVIDENCE: Level IV, Diagnostic Study.

FIXATION METHODS IN LATARJET: BIOMECHANICAL COMPARISON OF SCREW TYPES AND PLATE FIXATION.

Objective: Latarjet procedure is often preferred in recurrent shoulder dislocations accompanied by glenoid bone loss. It is observed that the superiority of bone graft fixation methods is still controversial. The aim of this study is to biomechanically compare the bone graft fixation methods in the Latarjet procedure. Methods: 15 third-generation scapula bone models were divided into 3 groups. Graft was fixated in the first group with fully-threaded cortical screws of 3.5mm diameter, in the second group two 16 mm partially-threaded cannulated screws of 4.5mm diameter, and in the third group via a mini plate and screw. The hemispherical humeral head was placed on the tip of the cyclic charge device, and thus, the charge applied to the coracoid graft was homogeneous. Results: No statistically significant difference was found between paired comparisons (p>0.05). The forces in 5 mm displacement in total vary between 502-857N. Total stiffness measurements ranged between 105 and 625; the mean value was 258.13±53.54 with no statistically significant difference by groups (p = 0.958). Conclusion: This biomechanical study showed that there is no difference between three coracoid fixation options in terms of fixation strength. Unlike previous assumptions, plate fixation is not biomechanically superior to screw fixation. Surgeons should consider their personal preferences and experience in choosing fixation methods.

Objetivo: O procedimento Latarjet é normalmente preferencial em deslocamentos recorrentes do ombro acompanhados por perda óssea da glenóide. Observa-se que a superioridade dos métodos de fixação dos enxertos ósseos ainda é controversa. O objetivo deste estudo é comparar biomecanicamente os métodos de fixação de enxerto ósseo no procedimento Latarjet. Métodos: 15 modelos de escápulas de terceira geração foram divididos em 3 grupos. O enxerto foi fixado no primeiro grupo com parafusos corticais totalmente rosqueados com 3,5 mm de diâmetro, no segundo grupo com dois parafusos canulados parcialmente rosqueados de 16 mm de diâmetro de 4,5 mm e no terceiro grupo através de miniplaca e parafuso. A cabeça hemisférica umeral foi colocada na ponta do dispositivo de carga cíclica e, desta forma, a carga aplicada ao enxerto coracoide foi homogênea. Resultados: Nenhuma diferença estatisticamente significativa foi encontrada entre as comparações pareadas (p>0,05). As forças em 5 mm de deslocamento no total variam entre 502-857N. As medidas de rigidez total variaram entre 105 e 625 e o valor médio foi 258,13±53,54, sem diferença estatisticamente significativa por grupos (p = 0,958). Conclusão: Este estudo biomecânico mostrou que não há diferença entre três opções de fixação de coracoides em termos de resistência à fixação. Ao contrário de suposições anteriores, a fixação de placas não é biomecanicamente superior à fixação de parafusos. Os cirurgiões devem considerar suas preferências pessoais e sua experiência na escolha de métodos de fixação.

Vascularity and histology of fetal labrum and chondrolabral junction: its relevance to chondrolabral detachment tears.

PURPOSE: Recently, acetabular labral tears were recognized as a source of hip pain. Most of these tears were found to be localized at the chondrolabral junction. The purpose of this study was to evaluate the chondrolabral junction in reference to its collagen fiber orientation and its vascularity, which might be used to explain the preponderance of labral tears. METHODS: Eighteen formalinized fetuses with a mean gestational age of 17 weeks (range: 11-24 weeks) were examined. The acetabuli were removed en bloc with the proximal femur for ease of orientation. The acetabuli were prepared and examined in four quadrants, namely, anterior, superior, posterior, and inferior. RESULTS: The staining pattern of the posteroinferior labrum was more dense than the anterosuperior labrum, due to its high collagen content. Collagen fibers in the posteroinferior quadrants were oriented perpendicularly to the chondrolabral junction, while those in the anterosuperior quadrants had a parallel oriented. Perpendicular collagen orientation and high collagen content may explain the stronger anchorage of the labrum to the bony acetabulum in posteroinferior quadrants. All of the vessels supplying the labrum originate from the capsular connective tissue and traverse the body of the labrum to reach the articular side. None of these vessels traverse the chondrolabral junction to reach the bony acetabulum. The total number of blood vessels was significantly higher in the capsular zone than in the articular zones. The number of blood vessels did not differ between the acetabular quadrants. CONCLUSIONS: In an effort to understand the chondrolabral junction tears, we can conclude that collagen content and fiber orientation may represent the histological basis for the predominance of tears at the anterosuperior region.

Reasons for resident resignations from Orthopedic Residency Programs in Turkey: A cross-sectional survey from residents' perspectives.

OBJECTIVE: The aim of this study was to analyse the factors that led to resignations from Orthopaedics and Traumatology Residency pro- grammes in Turkey, and to determine the overall rate of resignation among residents from Orthopaedics and Traumatology programmes. METHODS: In this cross-sectional survey,120 residents who either resigned or transferred to other OT clinics between autumn of 2013 and spring of 2020 were included. They were asked to complete a questionnare which was sent via Whatssapp application or e-mail. The ques- tionnare was comprised of 2 sections; Section A, which adressed resignation, consisted of 15 questions and Section B, which adressed transfer to another OT programme, consisted of 12 questions. Both sections had open ended and multiple choice questions. RESULTS: Of 120 residents, 96 (6.6%) resigned and then transferred to another specialty, and 24 (1.6%) transferred to another orthopedics and traumatology clinic based on our review. The overall resignation rate as per the total quotas for orthopedics and traumatology residency from 2013 to 2020 was 8.2%. Of the 120 orthopedics and traumatology residents who were eligible for the survey, 83 (70%) completed the questionnaire. Sixty-one (60 males, 1 female; median age = 26 years; age range = 25-35) of 96 residents who resigned from the orthopedics and traumatology residency completed section A (the response rate was 63.5%); 22 (22 males; median age=27.6 years; age range=25-34) out of 24 residents who transferred to another orthopedics and traumatology clinic completed section B (the response rate was 91.6%). In section A, 40 out of 61 individuals (65.5%) preferred orthopedics and traumatology specialty as the first choice in TUS, and 34 residents (55.7%) reported not to have had enough information regarding the residency program before starting their clinics. In section B, out of the 22 residents, 13 (59%) stated that orthopedics and traumatology residency was not their first choice in TUS, and 18 (81.8%) reported not to have had sufficient knowledge about the preferred clinic. The most common reason for resignation or transfer to another specialty was heavy workload (n=46, 74.19%), followed by excessive hours of work (n=45, 72.58%). The most common reason for transfer to another orthopedics and traumatology clinic was drudgery (n=10, 45.5%), followed by problems with the hierarchy in orthopedics and traumatology residency (n = 9, 40.9%). CONCLUSION: The results of this survey have shown us, with an overall resignation rate of 8.2% as per the total quotas for OT residency from 2013 to 2020, that resignation from OT residency represents an important problem in Turkey. Workload and excessive hours of work were the most common reasons for resignation from orthopaedic residency programmes. Furthermore, extra work that diverted residents from their actual job responsibilities, as well as academic and educational concerns, were the main factors leading to transfer to another OT residency programme.

Comparison of analgesic consumption of hemophilic and non-hemophilic patients in knee arthroplasty.

BACKGROUND: Hemophilia is a rare hereditary bleeding disorder that develops as a result of factor VIII or IX deficiency. Long-term complications of hemophilia such as arthropathy, synovitis, and arthritis can lead to the development of recurrent chronic pain. Pain is therefore a critical aspect of hemophilia. The gold standard treatment for end-stage hemophilic knee arthropathy is total knee arthroplasty (TKA). The hypothesis of this study was that after knee replacement surgeries that cause severe post-operative pain, hemophilia patients with chronic analgesic consumption may experience higher levels of pain than non-hemophilic patients, and use more opioid and non-opioid drugs. METHODS: This retrospective study included 82 patients who were hemophilic and non-hemophilic TKA patients operated under general anesthesia. Seventy-three patients were evaluated and divided into two groups according to the diagnosis of hemophilia: 36 patients were investigated in the hemophilic group and 37 patients in the non-hemophilic group. RESULTS: Post-operative tramadol consumption (p=0.002) and pethidine consumption (p=0.003) were significantly higher in the group hemophilia. The length of stay in the hospital was also significantly longer in the hemophilic group (p=0.0001). CONCLUSION: In the light of these informations, we think that acute post-operative pain management of hemophilia patients should be planned as personalized, multimodal preventive, and pre-emptive analgesia.