Can The Systemic Immune-Inflammation Index (SII) and Charlson Comorbidity Index (CCI) be used to predict mortality in patients with necrotizing fasciitis?

PURPOSE: This study aimed to determine the impact of mortality and morbidity indices on the diagnosis and prognosis of patients suffering from necrotizing fasciitis. METHODS: A retrospective analysis was performed on 41 patients (26 females, 15 males) with necrotizing fasciitis (NF). The SII (Systemic Immune-Inflammation Index) was computed using the formula SII = (P × N)/L, where P, N, and L measure the counts of peripheral platelets, neutrophils, and lymphocytes, respectively. This study evaluated the clinicopathological characteristics and follow-up information to assess the comparative effectiveness of SII, CCI (Charlson Comorbidity Index), and LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) scores as mortality and morbidity indices for patients with NF. RESULTS: The optimal cut-off for SII was determined to be 455. The SII value in the group with mortality was significantly higher compared to the group without mortality (p < 0.05). The CCI value in the group with mortality was significantly higher than the group without mortality (p < 0.05). The SII and CCI values were found to be effective in distinguishing between patients who suffered mortality and those who did not. CONCLUSION: SII is a powerful tool for predicting mortality in patients with necrotizing fasciitis (NF). The SII index provides a novel, easily accessible, and inexpensive indicator for monitoring the progress and predicting the survival of patients with NF.

Do the management and functional outcomes of the surgically treated spinal fractures change in suicidal jumpers?

PURPOSE: The aim of the study was to determine the effect of trauma etiology on the management, functional outcomes and psychiatric characteristics of suicide jumpers and patients who accidentally fall from height. METHODS: 89 patients (48 accidental falls and 41 suicidal jumpers) who had undergone spinal surgery were included in the study. The patients were evaluated clinically and radiologically. Visual Analog Scale (VAS), Roland Morris Disability Questionnaire (RMDQ) and McGill Pain Questionnaire (MPQ) were performed for functional evaluation. BECK hopelessness scale (BHS), BECK depression inventory (BDI), and SF-36 scales were used for the psychiatric evaluation. All outcomes were compared between suicidal jumpers and accidental falls. RESULTS: The RMDQ and ODI questionnaires stated a higher disability in the suicide jump group (p = 0.001 and p = 0.029, respectively). However, the VAS and MPQ questionnaires did not differ in significance between groups (p = 0.182 and p = 0.306, respectively). The SF-36 scale showed that physical function, role emotional, vitality and mental health subdomains were worse in the suicide jump group (p = 0.001, p = 0.029, p = 0.014 and p = 0.030, respectively). BDI scores were significantly higher in the suicide jump group while no difference was observed between the groups in terms of BSH (p = 0.017 and p = 0.940, respectively). CONCLUSION: Psychiatric disorders are more common in patients in the suicidal jumpers. The presence of underlying psychiatric problems adversely affects the postoperative functional outcomes of patients with surgically treated spinal fractures. A multidisciplinary approach together with raising awareness in this way can improve the clinical outcomes after orthopedic treatment, even if there is physical disability.

Fluroscopy-assisted transiliac antegrade lag screw placement technique in both columns of acetabulum: A novel procedure.

The use of pelvic osseous fixation corridors and lag screw fixation in acetabular and pelvic surgery has gained popularity, especially with the recent development of intraoperative imaging and navigation techniques. However, advanced intraoperative imaging and navigation techniques require technical equipment and are costly. Therefore, traditional fluoroscopic techniques still maintain their importance. In this article, we describe a novel pelvic osseous fixation corridor that traverses both columns of the acetabulum, along with the detailed methodology of its fluoroscopic imaging and the techniques for fluoroscopy-assisted screw placement. The technique of placing screws in this current fixation corridor is only under fluoroscopy assistance, without using any specially produced guide or navigation device. LEVEL OF PROOF: IV.

Reliability and Validity of the Turkish Version of the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale.

BACKGROUND: The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) scale is one of the most widely used outcome measures to evaluate hallux pathologies. This study aimed to translate the AOFAS Hallux MTP-IP scale into Turkish and investigate its psychometric properties. METHODS: The psychometric properties of the Turkish version of the AOFAS Hallux MTP-IP (AOFAS Hallux MTP-IP-T) scale were tested in 66 patients with hallux pathologies (52 women; mean age, 47.64 ± 12.75 years). Cronbach's alpha was used to assess internal consistency. The intraclass correlation coefficient (ICC) was used to estimate test-retest. Construct validity was analyzed with the Turkish version of the Manchester-Oxford Foot Questionnaire (MOXFQ), Visual Analogue Scale (VAS), and 12-item Short-Form Health Survey(SF-12). RESULTS: The AOFAS Hallux MTP-IP-T scale had adequate internal consistency (α = 0.71) and test-retest reliability (ICC2,1 = 0.93 for pain, ICC2,1 = 0.97 for function, and ICC2,1 = 0.97 for total score). The AOFAS Hallux MTP-IP-T total score has a moderate to strong correlation with VAS-activity and MOXFQ (ρ = -0.77, P = .001; ρ = -0.69, P = .001, respectively). The weakest correlation was found between the AOFAS Hallux MTP-IP-T and the SF-12 mental component scale (ρ = 0.31, P = .01). CONCLUSION: AOFAS Hallux MTP-IP-T has sufficient reliability and validity to evaluate Turkish-speaking individuals with a variety of forefoot pathologies including the hallux. LEVELS OF EVIDENCE: Level II.

Erectile Dysfunction after Conservative Treatment of Sacral Fractures in Males without Injury to the Urinary System.

BACKGROUND: This study aimed to determine the incidence of erectile dysfunction (ED) reported by patients, and to define the prognostic relationship between ED and conservatively treated sacral fracture without urethral injury. METHODS: Patients aged between 20 - 50 years who were sexually active and had no known sexual dysfunction prior to the trauma were included in the study. Seventy-seven patients (47 married, 30 single) treated conservatively for sacral fracture between April 2012 and February 2017 were retrospectively screened. Patients were compared in terms of age, marital status, body mass index (BMI), trauma mechanism, additional system injury, functional outcomes, and complications. Functional outcomes were assessed using the International Index of Erectile Function (IIEF-5) and the Majeed pelvic fracture functional assessment scale (MPS). RESULTS: No statistically significant difference was observed between fracture types with respect to age, BMI, follow-up, marital status, trauma mechanism, and accompanying injury. The incidence of ED was 27.3% for those that received conservative treatment after sacrum fracture. The mean score of IIEF-5 was 18.6 ± 6.6 and MPS was 77.2 ± 13.2. There was no significant relationship between the injury type of the patients and the IIEF-5 and MPS scores (p = 0.593 and p = 0.907, respectively). The lowest IIEF-5 score was found in Denis type 2 fractures (p = 0.020). CONCLUSION: The frequency of ED was higher in Denis type 2 sacrum fractures. Sexual function should be questioned in the follow-up, especially in those fracture types.

Does plate-screw density affect the functional outcomes in the treatment of proximal humerus fractures?

BACKGROUND: The aim of the study is to evaluate the relationship between plate-screw density (PSD), functional results, and complication rates in the treatment of proximal humerus fractures (PHFs) with proximal humerus locking anatomical plate (PHLAP). METHODS: Consecutive 43 patients (22 females and 21 males) who underwent PHLAP for the treatment of PHF between 2010 and 2016 were evaluated. AO classifications were used for the classification of fractures. Based on the biomechanical stability the-ory of Erhardt et al., the patients were divided into two groups as <60% and >60% according to the number of screws fixed to the humeral head for the determination of PSD. The patients were divided into two groups as PSD <60% (n=21) and PSD>60% (n=22) according to the number of screws fixed to the humeral head for the determination of PSD. Functional results were evaluated using the Constant-Murley shoulder score (CMS). Radiological evaluation was performed with collodiaphyseal angle (CDA), varus-valgus angulation, avascular necrosis (AVN), and arthrosis. The groups were compared in terms of demographic characteristics, functional results, radiological scores, and complications. RESULTS: The mean age was 54.47±17.43 years and the mean follow-up time was 19.51±5.27 months. Although the CMS scores of patients with a PSD of over 60% were higher than those below 60%, the CMS score did not differ statistically. In groups, the mean CDA of the operated shoulder was significantly lower than that of the non-injured side (p=0.002). Eight patients had varus angulation, whereas two patients had humerus head AVN. No significant relationship was observed between PDS and functional scores, radiolog-ical results, and complications. CONCLUSION: Functional results of PSD >60% are higher than PSD <60% group but there is no statistical difference between groups according to functional, radiological results, and complications.

Fibular fixation improves ankle functional outcomes and alignment in the intramedullary nailing of distal third tibiofibular diaphyseal fractures.

PURPOSE: The study aims to determine the effect of fibular fixation on alignment and fracture healing of tibia, and ankle functional outcomes in the treatment of distal third tibiofibular diaphyseal fractures. METHODS: Consecutive 111 patients (33 females and 78 males) with distal third tibiofibular diaphyseal fracture who met the inclusion criteria were included in the study. Patients were divided into two groups as those who underwent fibular fixation with tibia intramedullary nailing (study group) and those who did not (control group). Groups were compared in terms of demographic features, trauma and fracture characteristics, functional and radiological outcomes. RESULTS: No significant difference was observed between the groups in terms of demographic features, trauma characteristics, complications, and follow-up time (p > 0.05). Surgery time was significantly lower in the control group (p = 0.001). Ankle joint range of motion, AOFAS score, OMAS score, and full weight-bearing time were significantly better in the fibular fixation group (p = 0.023, p = 0.001, p = 0.001 and p = 0.039, respectively). Significantly better coronal alignment and sagittal alignment were found in the fibular fixation group (p = 0.001 and p = 0.001, respectively). Patients who underwent fibular fixation had significantly better radiological outcomes in terms of fibular rotation angle and ankle arthrosis (p = 0.000 and p = 0.022, respectively). CONCLUSION: Fibular fixation not only contributes to fracture union, early full weight-bearing, and alignment but also improves ankle functional outcomes in the distal third tibiofibular fractures treated with intramedullary nailing for tibia. LEVEL OF EVIDENCE: Level III, retrospective study.

Comparison of Functional and Radiological Outcomes of Transforaminal Lumbar Interbody Fusion and Posterolateral Fusion Techniques in the Treatment of Lumbar Spinal Stenosis.

BACKGROUND: This study aimed to compare posterolateral fusion with transforaminal lumbar interbody fusion (PLF + TLIF) and PLF only in terms of revision surgery rates and complications, as well as functional and radiological outcomes in lumbar spinal stenosis (LSS) patients. METHODS: Seventy-one patients (37 patients in the PLF + TLIF group and 34 patients in the PLF only group) who underwent surgery due to LSS between January 2013 and December 2016 were retrospectively investigated. Functional evaluation was performed by using the McGill-Melzack Pain Questionnaire (MPQ), Roland Morris Disability Questionnaire (RMDQ), and Oswestry Disability Index (ODI) scales pre-and postoperatively. Radiological evaluation was made by examining adjacent vertebrae, posterior ligamentous complex (PLC) morphology, and sagittal balance on magnetic resonance imaging (MRI). RESULTS: Postoperative MPQ, RMDQ, and ODI scores were significantly better in the PLF + TLIF group (p < 0.001, p < 0.001, and p = 0.001, respectively). The complication rate was significantly higher in the PLF only group (p = 0.026). In the PLF + TLIF group, postoperative functional scores showed significant improvement in terms of the instrumented segment and level of interbody fusion. Postoperative functional scores showed significant improvement in PLF + TLIF patients with no complications, no revision surgery, no postoperative MRI findings, and neutral sagittal balance compared to the preoperative functional scores (p < 0.001). CONCLUSION: PLF + TLIF is significantly superior in terms of functional scores and complications, despite the statistical similarity in terms of postoperative MRI findings and sagittal balance between the groups. Surgeons should prefer PLF + TLIF for the surgical treatment of LSS for better results.

Which external fixation method is better for the treatment of tibial shaft fractures due to gunshot injury?

INTRODUCTION: The present study aimed to evaluate the functional and radiological outcomes of AO type monolateral external fixator (AO-EF) and Ilizarov type external fixator (I-EF) in definitive fixation of tibial shaft fractures due to gunshot injury. HYPOTHESIS: Patients undergoing I-EF would have faster fracture healing with the help of early weight-bearing and the functional scores would be better compared to AO-EF. MATERIAL AND METHODS: The study consisted of 76 (67M, 9F) patients who underwent surgery between 2010 and 2016 for tibial shaft fracture due to low-velocity gunshot injury (LVGI). The patients were divided into two groups according to the fixation method (AO-EF and I-EF) which was discussed by the surgeon team due to their experience. The average age at the time of injury was 37.8±9.8 (20 to 59 years). Groups are compared according to LEFS score, coronal-sagittal-rotational angle, Johner-Rush score, and complications such as nonunion, malunion, osteomyelitis, and pin-tract infection. The mean follow-up time 31.61±3.83 months (between 24 and 44 months). RESULTS: No statistical difference was found between groups in terms of demographic characteristics. There was no statistical difference between groups regarding body mass index (BMI). LEFS score and operation duration were higher in the I-EF group (p=0.000 and p=0.006 respectively, p˂0.05). In the I-EF group, hospitalization period, full weight-bearing time, and healing time was shorter than the AO-EF group (p=0.001, p=0.000, and p=0.025 respectively, p˂0.05). DISCUSSION: Although AO-EF has advantages such as ease of application and short surgery time in the definitive fixation of LVGI tibia shaft fractures, I-EF is a superior technique in terms of functional scores. However, I-EF is a surgical approach that requires relatively more experience. Therefore, the choice of fixator should be determined according to the surgeon's experience in the permanent treatment of LVGI tibial shaft fractures. LEVEL OF EVIDENCE: IV; retrospective, case-control study.

The effect of COVID-19 positivity on inflammatory parameters and thirty day mortality rates in patients over sixty five years of age with surgically treated intertrochanteric fractures.

PURPOSE: To evaluate the effect of COVID-19 positivity on inflammatory parameters and 30-day mortality rates in patients over 65 years of age who were operated on for intertrochanteric femur fractures (IFF). METHODS: Eighty-seven patients (31 males, 56 females) who had a dynamic hip screw (DHS) or proximal femur nail (PFN) for the IFF between March 2020 and November 2020 were included in the study. The patients were divided into two groups as COVID-19 confirmed and probable positive (Group 1) and COVID-19 negative (Group 2). Time to surgery, operation duration, length of hospital stay, 30-day mortality, rates of the intensive care unit (ICU) referral, and inflammatory parameters such as haemoglobin, CRP, sedimentation, PCT, D-Dimer, and ferritin were evaluated. RESULTS: No significant difference was observed in terms of demographic data such as age, gender, comorbidity, and fracture type between the groups. Thirty-day mortality, ICU referral rate, blood transfusion rate, and hospitalization period were higher in Group 1 (p = 0.016, p = 0.012, p = 0.031, and p = 0.011, respectively). The inflammatory parameters were higher in Group 1 compared to Group 2 in the preoperative and postoperative periods (p < 0.05). CONCLUSION: COVID-19 positivity increases inflammatory parameters (as expected) and increases the 30-day mortality and ICU requirement in patients with surgically treated IFF.

Comparison of two types of fixation for proximal tibial epiphysiodesis: An experimental study in a rabbit model.

OBJECTIVES: In this study, we describe a novel hemiepiphysiodesis technique to prevent implant-related perichondrial ring injury in a rabbit model. MATERIALS AND METHODS: Proximal tibial epiphyseal plates of a total of 16 white New Zealand rabbits were used for this animal model. The subjects were divided into three equal groups as follows: Group 1 (Kirschner wire [K-wire]/cerclage), Group 2 (8-plate) right-hind legs, Group 3 (Control) left hind legs. Using anteroposterior radiography, the medial slope angle (MSA), articular line-diaphyseal angle (ALDA), and the angle between screws of 8-plate in lateral X-ray tibial slope angle (TSA) were measured. The radiographs were taken early postoperative (Day 1) and on sacrification day (Week 8). The histological evaluation of the perichondrial ring was made on a 7-mm axial section that stained with Safranin O/fast green at X10 magnification. RESULTS: In both K-wire and 8-plate groups, the early postoperative ALDA and TSA were greater than the sacrification ALDA and TSA (p=0.028 and p<0.001, respectively). The early postoperative MSA was lower than the sacrification MSA in groups, (p<0.001). The MSA in the control group was lower than the K-wire and 8-plate groups (p<0.001 and p=0.009; respectively). The perichondrial ring thickness of the K-wire group was greater than the 8-plate group in histological evaluation (p<0.001). CONCLUSION: Both of the K-wire and 8-plate groups showed similar angulation effects in the proximal tibia, although histologically less damage to the perichondrial ring was observed in the K-wire group, compared to the 8-plate group.

Injury characteristics and management of orthopaedic trauma in refugee children.

PURPOSE: Several factors affect injury types in childhood. The aim of the study was to evaluate the musculoskeletal injury types, treatment modalities, and demographic characteristics of refugee children and to reveal the differences from native children. METHODS: A total of 1297 patients (897 females, 400 males) treated in our clinic between January 2014 and January 2019 were included in the study. The mean age of the patients was 8.9 ± 5.1 in refugees and 7.5 ± 4.6 in the native group (range, 0-18 years). The patients were evaluated in terms of age, gender, mechanism of injury, location and type of fracture, presence of accompanying injuries, surgical technique, complications, and treatment modalities. RESULTS: The trauma mechanism differed significantly between the groups, high-energy traumas such as falling from a height, fight/assault injury, gunshot injury, and work injury were found more frequently in the refugee group (p = 0.001). The rates of CRIF, ORIF, graft/flap surgery, and hospitalization time were observed to be significantly higher in the refugee group (p = 0.013). No significant difference was observed between groups in terms of demographic distribution, injury location, and complications. CONCLUSION: This population-based, cross-sectional study emphasizes that the refugee children have different injury mechanisms. Improved living conditions may reduce musculoskeletal injury in this population.

Could percutaneous fixation with crossed Schanz pins be an alternative to open reduction in the treatment of intra-articular calcaneal fractures?

PURPOSE: Despite modern operative techniques and a considerable number of studies in the literature, the best treatment for calcaneal fractures remains an enigma for orthopaedic surgeons. The purpose of the study was to compare clinical and radiographic outcomes between anatomic calcaneal plate (ACP) fixation and crossed Schanz pin (CSP) fixation in the treatment of Sanders type II and III displaced intra-articular calcaneus fractures (DICFs). METHODS: Consecutive 65 patients (49 males, 16 females) who underwent surgery for DCIFs between January 2009 and February 2013 were retrospectively evaluated. The patients were divided into two groups as ACP and CSP according to the operative technique. The groups were compared in terms of demographic features, injury mechanism, operation time, fluoroscopy exposure, complications, full weight-bearing time, functional, and radiological outcomes. RESULTS: VAS-rest score did not differ significantly between the groups while the VAS-activity score was significantly higher in the CSP group (p = 0.001 and p = 0.645, respectively). Foot Function Index (FFI) was significantly lower, Maryland Foot Score (MFS) and the American Orthopaedic Foot and Ankle Society-hindfoot score (AOFAS) were significantly higher in the ACP group (p = 0.047, p = 0.016, and p < 0.001, respectively). While no difference was observed between the preoperative and the early post-operative (1st day) Böhler angle and Gissane angle, both were significantly higher in the ACP group at the post-operative last control (p < 0.001 and p < 0.001, respectively). CONCLUSION: Although crossed Schanz pin fixation shortens the operation time in displaced intra-articular calcaneus fractures compared to anatomic calcaneal plate, increased fluoroscopy exposure rates and low functional and radiological outcomes are disadvantageous of crossed Schanz pin. Anatomic calcaneal plate is still a better technique for preserving the alignment and elevating the displaced intra-articular segment for good to excellent mid-term results.

The relationship between impulsivity and anxiety and recurrent metacarpal fractures due to punch injury.

PURPOSE: The study aimed to determine the relationship between impulsivity and anxiety and recurrent metacarpal fractures (RMF) due to punching injury. METHODS: Consecutive 368 patients (301 men and 67 women) with metacarpal fracture who met the inclusion criteria and 214 healthy controls were included in the study. The study group was divided into two as the first metacarpal fracture (FMF) (245 patients) and RMF (123 patients). The control group consisted of sex- and age-matched 214 healthy participants (175 men and 39 women). Beck anxiety inventory (BAI), Barratt impulsiveness scale (BIS 11), and Quick DASH scores were the assessment of the patients in the sixth month of treatment. The groups were compared in terms of demographic features (including education status, marital status, work status, and level of income), fracture side, fracture location, dominant hand, treatment, anxiety, impulsivity, and functional results. RESULTS: In the RMF, BIS 11, BAI, and Quick DASH scores were significantly higher than the FMF and the healthy controls (p = 0.001 and p = 0.001, respectively). The patients with RMF have higher impulsivity and anxiety, worse short-term functional outcomes, and lower level of income and education status compared with healthy controls and FMF. CONCLUSION: Anxiety and impulsivity are higher in patients with RMF. It adversely affects the clinical outcome after the treatment. Psychiatric consultation is an important step for especially intentional RMF patients to prevent recurrent hand injuries and metacarpal fractures and to improve clinical outcomes associated with these injuries.

The Influence of Lumbar Modifiers on Functional and Radiological Outcomes in the Brace Treatment of Lenke Type 1 Adolescent Idiopathic Scoliosis.

BACKGROUND: Brace treatment prevents the progression of scoliosis and reduces surgical treatment rates. However, the efficacy of brace treatment varies depending on the patient's age, gender, curve magnitude and type, structure of the curve, and patient compliance at the beginning of treatment. METHODS: Between January 2009 and April 2015, 106 Lenke type 1 AIS consecutive patients (69 females, 37 males) who were treated with a brace were examined in three groups according to Lenke classification lumbar modifiers. The patients were evaluated at pre-bracing and 1 and 2 years after bracing. The Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) were used for functional evaluation. Radiological evaluation revealed the Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, trunk shift, shoulder asymmetry, and body height difference. RESULTS: Functional and radiological evaluation showed a statistically significant improvement in Lenke 1A, 1B, and 1C at 1 and 2 years after bracing compared to the pre-bracing (p = 0.000, p = 0.000, and p = 0.000, respectively). Lenke 1C had the best ODI score and followed by decreasing values of 1B and 1A respectively (p = 0.009). Lenke 1B had the best SRS-22 score and the mean scores of 1A and 1C were equal (p = 0.017). There was no significant difference between the groups in the parameters other than the trunk shift in radiological evaluation (p = 0.043). CONCLUSIONS: Significant improvement was observed in all types of lumbar modifiers at the end of the 2nd year compared to pre-bracing. The best improvement in the ODI score was in the 1C modifier, whereas the best improvement in the SRS-22 score was in the 1B modifier. The type of lumbar modifier should be directly taken into consideration before starting brace treatment in Lenke type 1 AIS. LEVEL OF EVIDENCE: Level III, retrospective study.

The effect of fibrin clot and C vitamin on the surgical treatment of Achilles tendon injury in the rat model✰.

BACKGROUND: This study aimed to determine the histological, biochemical, and biomechanical efficacy of fibrin clot and vitamin C in the healing of Achilles tendon ruptures (ATR) in a rat model. METHODS: 52 adult Wistar-Albino rats (300-450 g) were used in the study. 12 rats were divided into four groups as Monitor (Group I), Control (Group II), Fibrin Clot (Group III), Fibrin Clot with vitamin C (Group IV). Four rats were used for fibrin clot preparation. Fibroblast Growth Factor (FGF) and Vascular Endothelial Growth Factor (VEGF) were measured on the 3rd, 7th, 14th, and 21st days. Four rats were sacrificed on the 21st day from each group for histological evaluation. The rest of the rats were sacrificed at 42nd day, half for biomechanical and a half for histological evaluation. RESULTS: The 42nd-day HSS score of group IV was significantly lower than those of group I, group II and group III (p = 0.036, p = 0.019, and p = 0.036, respectively). Group IV showed a significantly higher Maximum force N value than those of group I, group II and group III (p = 0.034, p = 0.034 and, p = 0.025, respectively). The blood FGF and VEGF levels of group III and group IV on the 3rd, 7th, 14th, and 21st days were higher than those of group I and group II (p < 0.05). CONCLUSION: Fibrin clot and vitamin C produced a stronger tendon structure in terms of biomechanics while providing histological and biochemically better quality tendon healing in the surgical treatment of ATR. This model can be used to accelerate high-quality tendon healing after ATR. LEVEL OF EVIDENCE: Level II, experimental study.

Factors affecting activities of daily living, physical balance, and prosthesis adjustment in non-traumatic lower limb amputees.

OBJECTIVES: This study aims to identify the factors affecting the activities of daily living, balance, and prosthesis satisfaction in patients with non-traumatic lower limb amputation (LLA). PATIENTS AND METHODS: This cross-sectional study included a total of 195 patients (120 males, 75 females; mean age 65.9±11.6 years; range, 40 to 90 years) who underwent LLA between January 2009 and April 2017. All patients were evaluated in terms of age, sex, amputation etiology, side, level, comorbidity, length of hospital stay, prosthesis adjustment, ambulation level, functional outcome, and complications. Prosthesis adjustment, physical balance ability, and daily living activities were assessed using the Turkish versions of the Trinity Amputation and Prosthesis Experience Scales (TAPES), Berg Balance Scale (BBS), and Nottingham Extended Activities of Daily Living Scale (NEADLS), respectively. RESULTS: There was no significant difference between male and female patients in terms of prosthesis and amputation adaptation, physical balance, and activities of daily living. The BBS, TAPES, and NEADLS scores were lower in the patients aged over 65 years (p<0.001, p<0.001, and p<0.001, respectively). Prosthesis and amputation adaptation, physical balance, and daily living activities were also worse in this age group. Transfemoral amputees had lower BBS, TAPES, and NEADLS scores than the transtibial amputees (p=0.009, p=0.020, and p=0.004, respectively). Prosthesis and amputation adaptation, physical balance, and daily living activities were worse in the transfemoral amputees. CONCLUSION: Age and amputation level affect physical balance, prosthesis satisfaction, and daily living activities after non-traumatic LLA. Therefore, orthopedic surgeons and physical therapists should conduct a multidisciplinary evaluation, particularly in patients aged over 65 years and in transfemoral amputees to improve outcomes.

The common comorbidities leading to poor clinical outcomes after the surgical treatment of ankle fracture-dislocations.

BACKGROUND: The ankle fracture-dislocations are a significant traumatic incident for the bone and the soft tissue surrounding the ankle. Bone stabilization, joint immobilization, anatomic reduction and intervention for soft tissue protection should be performed as early as possible. The present study aims to determine the frequency of major comorbidities that can be seen after surgery in patients with ankle fracture-dislocations and the relationship between the trauma mechanism and clinical status with these comorbidities. METHODS: Thirty-eight patients (25 males, 13 females) who underwent surgery with ankle fracture-dislocations between May 2014 and February 2017 were evaluated retrospectively in this study. All patients were evaluated clinically and radiologically at least 24 months postoperatively. Arthrosis, synostosis, presence of the chondral lesion and AOFAS scores were detected for all patients. RESULTS: Mean AOFAS score was lower in open ankle fracture-dislocations than in closed dislocations (p=0.044). An accompanying osteochondral lesion (OCL) and increased patient age were found to be strongly associated with the development of arthrosis (p=0.005 and p=0.017; respectively). Four of 29 patients who received primer definitive surgery and four of nine patients who received step-by-step surgery had poorly calculated AOFAS scores (p=0.071). There was no significant relationship between dislocation direction and AOFAS scores (p=0.087). CONCLUSION: Clinical and functional results were found to be worse in patients with open ankle fractures, the rate of arthrosis increased with age, and the use of syndesmosis screw had a positive but not a statistically significant effect on clinical and functional outcomes.

Acute correction and intramedullary nailing of aseptic oligotrophic and atrophic tibial nonunions with deformity.

OBJECTIVES: This study aims to describe the important points for treatment of aseptic tibial oligotrophic and atrophic nonunions by intramedullary nailing (IMN). PATIENTS AND METHODS: The retrospective study included 17 biologically nonactive nonunion patients (12 males, 5 females; mean age 36.4 years; range, 19 to 49 years) operated between February 2010 and November 2017 by deformity correction, static IMN and autografting. The mean follow-up time was 4.2 (range, 3 to 7) years. The initial fracture management was external fixator for all patients. Fourteen patients had open fractures initially. Six patients had valgus, four patients had varus, three patients had oblique plane, and four patients had external rotational deformity. Nonunion diagnosis was established on the basis of the patient history and physical examination based on plain radiographs, computed tomography or both. All patients were evaluated by the same protocol to exclude any infection. RESULTS: The median time from injury to nailing was mean 10.3 (range, 6.1 to 36.5) months. Radiologic and clinical union was achieved in all patients. The mean union time was 3.64 (range, 3 to 6) months. Three patients had positive intraoperative bacteriological culture. In four patients, dynamization was necessary for consolidation. Late deep infection developed in three patients after union, and all infected cases were operated by implant removal, debridement, and appropriate antibiotics. CONCLUSION: Intramedullary nailing and autografting after external fixator provide good results for the treatment of aseptic biologically nonactive nonunions with deformity. Reamed IMN ensures sufficient deformity correction, biological environment, and mechanical stability. The infection risk should always be kept in mind and patients should be followed-up closely to prevent complications.