C-Reactive Protein and Erythrocyte Sedimentation Rates after Total and Unicompartmental Knee Arthroplasty-Less Implant Equals Quicker Normalization.

Postoperative follow up after total or unicondylar knee arthroplasty (UKA) includes C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to scan for and possibly diagnose a periprosthetic joint infection (PJI). The aim of this study was to describe the postoperative changes in CRP and ESR values after UKA and compare them with values obtained after TKA. Patients operated on between 2020 and 2022 were eligible for this retrospective study. Inclusion criteria were patients with at least 4 postoperative visits associated with blood test screening for PJI, aged > 45, with uneventful follow-up for the first 90 days. Exclusion criteria were a history of chronic inflammatory disease, revision for any reason, and readmission for any reason. Blood samples were collected on the 3rd, 15th, and 30th postoperative days and once between the 45th and the 90th day. The mean and peak values were compared between the two groups. The study included 277 patients (243 TKAs and 34 UKAs). Mean age was significantly lower in the UKA group (67.2 ± 7.5 vs. 60.0 ± 5.9). On the 3rd and the 15th postoperative day, the UKA patients had significantly lower ESR and CRP levels. The levels normalized after the first month. While the TKA patients showed higher values, the trend normalized after the 30th day. CRP and ESR values rose significantly after TKA and persisted up to the 15th day postoperatively. CRP and ESR values normalized faster in patients undergoing UKA. Patients > 65 had higher CRP and ESR values during their routine follow-ups.

Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience.

Background and Objectives: The number of hip arthroscopy procedures is on the rise worldwide, and awareness regarding proper management of the hip capsule has increased. No capsulotomy shape is agreed upon as a standard approach, with literature supporting both isolated interportal and T-shaped capsulotomies. The aim of this retrospective cohort study is to report the clinical results of a standardized extended interportal capsulotomy (EIPC) during hip arthroscopy. Materials and Methods: Patients operated on between 2017 and 2020 with a hip arthroscopy were eligible. The inclusion criteria were ages 18-60 years, failed non-operative treatment, and at least a 2-year follow-up. Exclusion criteria were bilateral femoroacetabular impingement syndrome (FAS) cases or labral lesions, ipsilateral knee injury, history of ipsilateral hip surgery, and significant spine lesions. Data regarding demographic characteristics such as age, gender, operation date, BMI, but also Beighton score, presence of postoperative pudendal nerve damage, and revision for any reason were gathered from patients' records. All patients were evaluated preoperatively with a visual analog scale (VAS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score (mHHS). Results: Of the 97 patients operated on with a hip arthroscopy between the defined dates, only 90 patients were included. The mean age was 37.9 ± 9.8, and 58.9% of patients were male. The most frequent surgical indication was an isolated FAS lesion (73.3%), followed by FAS associated with a labral tear (12.2%), an isolated labrum tear (10.0%), synovitis (3.3%), and a loose body (1.1%). The mean follow-up for the study cohort was 39.3 months. The majority of the patients had uneventful surgeries (76.7%), while there were three cases of sciatic nerve neuropraxia and 12 cases of pudendal nerve neuropraxia. Two patients underwent revision surgery during the study period. Comparison between preoperative and postoperative clinical scores showed a significant improvement with a final mHHS mean value of 67.7 ± 18.2, an HOOS value of 74.1 ± 13.2, and a low VAS score of 1.3 ± 1.2. Conclusions: A hip arthroscopy procedure with a standardized and unrepaired, extended interportal capsulotomy is a safe procedure with satisfactory mid-term results and high overall patient satisfaction. At a minimum of 2 years and a mean of 39.2 months, patients showed improved clinical scores and a low revision rate.

Surgical treatment of patellar tendon rupture after total knee arthroplasty with a double-row repair method using the hamstring tendons: A novel technique with functional results.

BACKGROUND: Patellar tendon rupture (PTR) is extremely rare but serious complication after primary or revision total knee arthroplasty. Due to the serious failure rates of end-to-end repair techniques, various augmentation techniques have been described. In this study, the results of patients with PTR after reconstruction using our own technique with semitendinosus (ST) and gracilis tendons taken from the affected side were evaluated retrospectively. METHODS: A total of 14 patients, whose diagnosis was made based on physical examination and clinical findings, and supported radiologically (ultrasonography), were included in the study. In these patients, reconstruction was performed using double-row repair technique with the ST and gracilis tendons. Active-passive knee joint range of motion, active knee extension loss, and the Caton-Deschamps index at preoperative and final follow-up visits were compared. Tegner-Lysholm knee score and Kujala score were used to evaluate functional results. RESULTS: In 14 patients (8 women and 6 men) with a mean age of 68.1 years, the median time between injury and surgery was 6.6 weeks. In all patients, the rupture was in the distal part of the patellar tendon. While the median preoperative Caton-Deschamps index was 1.8, the postoperative median value was found to be 1.25 after an average follow-up of 3.8 years (P = .014). The median preoperative knee extension loss decreased from 25° to 5° postoperatively. Tegner-Lysholm knee score and Kujala score of the patients at their last follow-up were significantly increased (P < .01). CONCLUSION: For PTR developing after total knee arthroplasty, the double-row reconstruction technique with ST and gracilis tendons is effective.

Volar fixed plating of distal radius fractures: optimizing plate position for enhanced clinical outcomes.

BACKGROUND: The precise influence of plate position on clinical outcomes in the context of volar fixed-angle plating for distal radius fractures is not fully understood. This article aims to investigate the influence of plate position on clinical results, and functional outcomes in patients treated with volar fixed plating for distal radius fractures. METHODS: A total of 58 patients with 64 distal radius fractures were included in the study. Patient demographics, fracture characteristics, surgical details, and radiographic data were collected. Post-operative AP and Lat views of all patients taken on the first day after surgery were evaluated. Volar Tilt, Radial Inclination and Radial Height measurements were used as reduction criteria. In the follow-up, the patients were called for their last control, flexion and extension angles of the wrist and Mayo Wrist Scores, the distance of the plate to the joint line and the angle between the plate and the radial shaft were measured and recorded. RESULTS: A total of 64 distal radius fractures, with a mean age of 46.9 years, and the mean follow-up period 24.9 months were included in this study. There was a significant relationship between the Radial Inclination and Plate-Shaft Angle variables and the Mayo Wrist Score at a 99% confidence interval. Additionally, a relationship was observed between the Radial Height variable and the Mayo Score at a 90% confidence interval. A significant positive association was observed between radial inclination and achieving a Good-to-Excellent Mayo score (OR = 1.28, 95% CI [1.08-1.51], p = 0.004). Plate distance to joint line demonstrated a marginally significant positive association with a Good-to-Excellent Mayo score (OR = 1.31, 95% CI [0.97-1.77], p = 0.077). Univariate analysis revealed a significant negative association between plate-shaft angle and achieving a Good-to-Excellent Mayo score (OR = 0.71, 95% CI [0.52-0.99], p = 0.045). This negative association remained statistically significant in the multivariate analysis (p = 0.016). CONCLUSION: Radial inclination, plate distance to joint line, and angle between plate and radius shaft were identified as significant factors associated with improved Mayo Wrist Scores.

Comparison of single and double incision leg fasciotomy in disaster settings-Experience from 2023 Türkiye earthquakes.

INTRODUCTION: Although there are studies comparing methods for leg fasciotomy in compartment syndrome after fractures, choice of single or double fasciotomies in disasters was not investigated. The aim of this study was to compare the efficacy of single and double incision leg fasciotomy in the setting of disaster. METHODS: Patients that have undergone fasciotomy after 2023 Kahramanmaras earthquakes were retrospectively analyzed. The cases were separated into two groups as single incision and double incision according to the method of the first fasciotomy. The number of debridements after each fasciotomy, muscle group excisions, completion time of treatment, presence of amputation, the method of closure (primary closure or graft/flap) and positive results of wound cultures were analyzed and compared between two groups. RESULTS: 62 legs of 52 patients (22 females, 30 males, age 36.9 ± 11.2 years) with compartment syndrome that have undergone fasciotomy after 2023 Kahramanmaras earthquakes were included in the study. Single-incision group included 27 legs and double incision group included 35 legs. Amputation was needed in 15 patients (%24.2), six in single incision group and nine in double incision group. (p = 0.75). Compartment excision (eight patients in single incision, nine patients in double incision groups, p = 0.81), number of debridements (median 4 in both groups, p = 0.55), wound closure time (median 17 days in single incision, 22 days in double incision groups, p = 0.52), graft or flap requirement (11 patients in single incision, 16 patients in double incision groups, p = 0.53), positive culture results (15 patients in single incision, 16 patients in double incision groups, p = 0.44) were not different statistically between two groups. CONCLUSION: Single and double incision fasciotomy methods are equally effective and safe in treatment of compartment syndrome of the leg in disaster situations. To our knowledge, this is the first study comparing outcomes of single and double incision fasciotomy in disaster settings.

Unrepaired Trochanteric Bursae as a Risk Factor for Deep Gluteal Syndrome After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: The trochanteric bursae are often left unrepaired after total hip arthroplasty (THA) and they retract posteriorly over the muscle belly of the piriformis. Deep gluteal syndrome (DGS) is a multifactorial condition presenting as buttock pain and is attributed to nondiscogenic sciatic nerve irritation or impingement causes. The purpose of this study was to investigate the relationship between bursal repair and incidence of DGS in patients undergoing THA. METHODS: This prospective randomized trial included patients treated with a THA between January and December 2022 for a diagnosis of primary osteoarthritis. Patients were randomized into 2 groups: group 1 underwent a routine bursal repair, while group 2 did not, leaving the bursae unrepaired. Follow-up was performed on the 15th, 30th, and 90th day postoperatively with clinical scores, physical examinations, and laboratory tests. In this cohort of 104 patients, mean age was 55 years (range, 26 to 88). Demographic variables as well as range of motion and overall clinical results showed no significant difference between the groups. RESULTS: DGS rates were significantly more common in the patients who had an unrepaired bursa (group 2) both on the 30th and 90th postoperative days, while comparison of lateral trochanteric pain on palpation showed similar results between the groups. CONCLUSIONS: DGS is common in individuals who have unrepaired trochanteric bursal tissue following a THA. Despite its higher frequency, these symptoms did not have a substantial impact on the overall clinical scores, which remained consistent across the study groups.

Risk Factors for Surgical Site Infections Following Fasciotomy in Patients With Acute Compartment Syndrome: A Study on the February 2023 Kahramanmaras Earthquake.

INTRODUCTION: Surgical site infections (SSIs) developing after fasciotomy are difficult to treat, costly, and an important source of mortality and morbidity. This study aimed to determine the risk factors affecting the development of SSI in patients who underwent fasciotomy with the diagnosis of acute compartment syndrome (ACS) within 72 hours after two consecutive earthquakes of 7.7 and 7.6 magnitude that occurred in Kahramanmaras on February 6, 2023. METHOD: A total of 116 patients were retrospectively analyzed. Patients were divided into two groups: those who developed SSI and those who did not. In this study, variables such as basic demographic characteristics, time of fasciotomy, center performing fasciotomy, type of wound closure, affected extremity, concomitant renal failure, hyperbaric oxygen (HBO) therapy, blood creatine kinase (CK) level were examined. RESULTS: Of 116 patients, 58 (50%) had SSI. It was statistically observed that patients who underwent treatment with vacuum-assisted closure (VAC), those who underwent primary closure with the shoelace method, those who went into renal failure, and those whose fasciotomy was performed in an earthquake zone had a higher incidence of SSI (p<0.001). Blood CK level above 17.839 seemed to be a risk factor according to receiver operating characteristic (ROC) analysis (P<0.01). Age (p=0.193), gender (p=0.125), fasciotomy time (p=0.843), lower extremity (p=0.234), upper extremity (p=0.806), and HBO treatment (p=0.56) were not associated with SSI. Infection was found to be a significant risk factor for amputation (p<0.001). CONCLUSION: The use of VAC as a wound closure technique for SSI after fasciotomy in patients who developed ACS due to the earthquake, the presence of renal failure in the patients, and performing fasciotomy in the earthquake zone were independent risk factors. A blood CK level above 17.839 was also determined as a risk factor, but the confidence interval was found to be low.

Are There Any Significant Risk Factors Associated with Lateral Trochanteric Pain in Patients Who Have Undergone Primary Hip Replacement?

Introduction Lateral pain around the greater trochanter (LTP) is a common complication after total hip arthroplasty (THA) that can significantly reduce quality of life. The aim of this study was to analyze the relationship between lateral trochanteric bursa repair, subcutaneous fat thickness, and trochanteric pain during the THA procedure. Materials and methods A total of 98 patients who underwent THA for hip arthrosis between 2021 and 2022 were evaluated retrospectively. For all evaluated patients, subcutaneous thickness was measured between the fascia and the skin at the incision site. Bursa repair was performed in 47 patients, while bursa excision was done in 51 patients. The data obtained included demographic information, functional scores, comorbidities, bursa repair and skin thickness values, radiographic evaluations, and other specific markers. These were compared between patients diagnosed with LTP following THA and the controls. Results No difference was observed between the study groups in terms of subcutaneous fat thickness, bursa repair, and other demographic or radiographic evaluations. As expected, there were statistically significant differences between the groups in terms of the visual analog scale (VAS) score (p=0.030) and the Harris hip score (HHS) (p=0.045). When comparing the groups with and without LTP, the VAS score was higher in the group with LTP, while the HHS was found to be lower. Conclusion Trochanteric pain is not associated with bursa repair or subcutaneous thickness. LTP cannot be predicted based on comorbidities such as smoking, BMI, or radiographic measurements.

Advantages of Simultaneous Cementless Bilateral Unicondylar Knee Arthroplasty Compared to Staged Surgery.

Background: Unicondylar knee arthroplasty (UKA) is an effective procedure, which reduces pain, increases range of motion, and improves function. UKA could be performed simultaneously or in staged sessions. This study aimed to compare bilateral cementless UKA performed simultaneously and in staged sessions in terms of complications, hemoglobin levels, transfusions, and functional outcomes. Methods: Patients undergoing bilateral UKA for symptomatic medial compartment osteoarthritis were retrospectively analyzed. Of the 73 patients who met the inclusion criteria, 40 underwent surgery simultaneously and 33 underwent surgery in separate sessions. Operative time, length of hospital stay, change in hemoglobin, need for blood transfusion, complications, and functional outcomes were assessed. Results: There was no statistically significant difference between the two groups in demographic data. Simultaneously operated patients had a significantly shorter hospital stay and shorter operative time. Statistically significant improvements in clinical scores were noted in both groups. The degree of improvement in functional scores did not differ between the groups. There was no difference between the two groups in terms of complication rates, but the number of periprosthetic tibial fractures was higher in the simultaneous group. Conclusions: Simultaneous bilateral cementless UKA was more advantageous in terms of cumulative hospital stay and total operation time with similar clinical results when compared to a staged procedure. While the overall complication rate was similar, the rate of periprosthetic fractures was 5% in the simultaneous group.

Better sex after hip arthroscopy; Sexual dysfunction in patients with femoro-acetabular impingement syndrome.

BACKGROUND: Femoro-acetabular impingement syndrome (FAIS) is a common cause of hip pain and functional decline. The quality of life of affected patients has been shown to be significantly diminished, with potential alterations in the ability to perform activities of daily living and recreation, including sexual function. Hip arthroscopy is the surgical technique recognized as the gold standard in FAIS. The aim of this study was to research the relationship between hip arthroscopy due to FAIS and pre- and postoperative sexual function. HYPOTHESIS: The hypothesis of the study was that sexual dysfunction would be common during the preoperative period but would significantly improve after surgery. MATERIALS AND METHODS: This retrospective study included 96 patients aged 18 to 55 years, who underwent hip arthroscopy for a FAIS diagnosis between 2015 and 2021, with a minimum follow-up of one year. Exclusion criteria were a bilateral symptomatic hip condition, history of ipsilateral hip or knee surgery, history of urological or gynecological conditions, sexual dysfunction, or a history of hip osteonecrosis or osteoarthritis. The Female Sexual Function Scale (FSFI) was used to evaluate sexual dysfunction in females and the International Erectile Function Index (IIEF-5) for males. RESULTS: The patients comprised 56.3% males and 43.82% females with a mean age of 35.3±8.3 years. Sexual dysfunction was determined preoperatively in 85.2% of the males and in 57.1% of the females. Overall improvement after surgery was statistically significant. Signs of pudendal nerve damage were seen during the postoperative period in 29 (30.2%) patients. The change in total sexual scores was significantly correlated with nerve symptoms and regression analysis showed that traction time was a significant risk factor for pudendal nerve symptoms. DISCUSSION: Sexual dysfunction is a common trait of patients suffering from FAIS and the majority of patients significantly benefit from the procedure. Sexual dysfunction persists in a category of patients during the postoperative period, regardless of the type of lesion, and this phenomenon is associated with transient pudendal nerve symptoms, which are more likely to occur with longer traction times and thus represent a clear risk factor. LEVEL OF EVIDENCE: IV.

A clinical comparison of two different surgical techniques in the treatment of acute Achilles tendon ruptures: Limited-open approach vs. percutaneous approach.

BACKGROUND: Surgical treatment is the commonly preferred method for treating acute Achilles tendon ruptures (AATRs) due to advantages such as less re-rupture rates, better functional results, and an early return to physical activities. The main aim of our study is to compare two common minimally invasive surgical methods, the limited open and the percutaneous approaches, regarding clinical outcomes. METHODS: A total of 53 patients (19 females and 34 males) who were treated with limited open (Group 1: 30 patients) and percutaneous (Group 2: 23 patients) approaches for AATRs were retrospectively evaluated between March 2019 and May 2020 in a level 1 trauma center. The evaluation included complications (soft tissue and skin problems, re-rupture, and sural nerve injury rates), the operation time, the duration of return to daily activities, The Achilles Tendon Total Rupture Score (ATRS), and the American Ortho-pedic Foot and Ankle Society (AOFAS) scores of the patients at the first and 6th months of follow-up. Patients' activity levels were compared with the Tegner Activity Scale (TAS). RESULTS: The mean age of all patients in this cohort was 45.1±14.1. The mean postoperative follow-up period for group 1 was 36.9±8.81 weeks, whereas, for group 2, it was 35.4±8.73 weeks (P=0.24). The mean age (P=0.47), gender distribution (P=0.41), and body mass index (P=0.29) were similar for both groups. The mean operation time (group 1: 47.1±5.4 vs. group 2: 44.4±6.1, P=0.06) and the duration of return to daily activities (group 1: 49.2±7.4 vs. group 2: 48.5±9.7, P=0.38) were also similar. There was no statistical difference between groups regarding functional results at first (ATRS: group 1: 79.9±3.2 vs. group 2: 79.5±3.9, [P=0.35], and AOFAS: group 1: 80.9±3.1 vs. group 2: 82.1±3.2, [P=0.10]) and 6th months (ATRS: group 1: 85.0±3.8 vs. group 2: 83.7±4.4, [P=0.13], and AO-FAS: group 1: 86.6±3.6 vs. group 2: 86.7±4.2, [P=0.46]). There were no statistically significant differences between groups regarding preoperative and last follow-up TAS scores (P= 0.94 and P=0.46, respectively). We observed no postoperative complications in group 1. There were three complications (13.1%) in group 2. One patient (4.4%) had a re-rupture, and two patients (8.7%) had sural nerve injuries. CONCLUSION: Although both groups had similar functional results, the limited open approach yielded better clinical outcomes according to the complication results than the percutaneous approach.

Clinical Examination Findings Can Accurately Diagnose Developmental Dysplasia of The Hip-A Large, Single-Center Cohort.

BACKGROUND: Physical examination findings such as limited hip abduction (LHA), asymmetric skin creases (ASC), and a popping sensation in the hip facilitate the diagnosis of developmental dysplasia of the hip (DDH). Screening with a simple physical examination during the first weeks of infancy is important for early detection of the condition, and a wide range of medical professionals, including general practitioners, obstetricians, pediatricians, and orthopedic surgeons etc. are involved in this process. The aim of this study was to determine the correlation between easily recognizable physical examination findings such as LHA, thigh/groin ACSs, and Ortolani and Barlow tests with ultrasound findings for the diagnosis of DDH. METHODS: This study included 968 patients undergoing routine hip ultrasonography between December 2012 and January 2015. All patients were examined by an experienced orthopedic surgeon who was not the physician who performed the ultrasound examination to exclude bias between physical examination findings and ultrasound findings. Asymmetric skin folds (thigh and groin), limited abduction, Barlow and Ortolani tests were recorded. The relationship between the physical examination findings, ultrasound findings, and developmental dysplasia was investigated. RESULTS: Of the 968 patients, 523 were female (54%) and 445 were male. On ultrasonography examination, 117 patients were found to have DDH. The sensitivity, specificity and negative predictive values of patients who were found to have both LHA and thigh/groin ASCs in all three physical examinations were high (83.8%, 70.2%, and 96.9%, respectively) while positive predictive values were found to be low (27.8%). CONCLUSION: Asymmetric skin creases on the thigh and groin and limited hip abduction, when evaluated together, have high sensitivity and specificity with additional high negative predictive values and could help during the initial screening process of DDH.

The painful joint after COVID-19 treatment: A study on joint osteonecrosis following COVID-19-related corticosteroid use.

OBJECTIVES: This study aims to evaluate the incidence of osteonecrosis (ONC), with a special focus on ONC of the femoral head (ONFH), in novel coronavirus disease 2019 (COVID-19) patients two years after the pandemic. PATIENTS AND METHODS: This prospective study included COVID-19 patients who were admitted to our center between March 2020 and June 2020. A total of 472 patients (289 males, 183 females; mean age: 42.3±12.0 years; range, 18 to 60 years) were arranged in a list according to their date and time of admission and, then, divided into two groups: those not receiving corticosteroid (CS) treatment (Group 1, n=236) and those receiving CS treatment (Group 2, n=236). The patients were evaluated for joint pain based on X-rays and magnetic resonance imaging scans, and the patients were routinely followed. For each patient in Group 2, additional data regarding CS use were recorded. The possible relationship between ONC and risk factors was analyzed. RESULTS: Both groups were similar in terms of age and sex. Group 2 had a significantly longer hospitalization period. A significant increase in the number of painful joints was observed in Group 2. At two years, 5.1% of the patients in Group 1 complained of at least one painful joint compared to 11.9% of patients in Group 2. Eight patients from Group 2 developed ONC. CONCLUSION: The incidence of ONC after CS therapy in COVID-19 patients is on the rise. At two years, 5% of patients receiving various doses of CSs may develop ONC. Residual joint pain is common even after recovering from the virus. No relationship is evident between the duration of treatment, cumulative dosage of medication, maximum one-day dosage received, and the presence of ONC.

To wedge or not to wedge; A cadaveric comparison study of two medial malleolar osteotomy modalities.

OBJECTIVE: To quantify the surface area of the talus accessible with a uniplanar and a biplanar medial malleolus osteotomy. Our secondary purpose study is to quantify the amount of weightbearing area that each osteotomy effects on the tibial articular surface. PATIENTS AND METHODS: Eight ankle joint specimens were dissected for this study. The uniplanar osteotomy was performed first. A K-wire marked the limits of access at two different angles: 90° and 30°. The boundaries were marked with a skin marker. Wedges were then created on the tibia plafond, and the osteotomy was converted into a biplanar one. Measurements were repeated again for this osteotomy. The talus, the tibial plafond, and the medial malleolus were then excised. Images were taken and then electronically calibrated for two-dimensional digital measurement of accessible areas. Areas of perpendicular and 30-degree access were recorded for both osteotomies. The articular surface of the tibia was also measured, and an area analysis was performed to calculate the amount of weightbearing cartilage removed by each osteotomy. RESULTS: Almost the entire sagittal plane was accessible with both osteotomies. At a 30° angle, bone purchase was achieved for 67.7 % of the talar articular surface with the uniplanar osteotomy and for 74.8 % with the biplanar osteotomy. At a 90° angle, uniplanar osteotomy provided access to 32.7 % of the talar articular area, whereas the biplanar osteotomy achieved an average coverage of 52.8 %. The difference was statistically significant. On average, 25.3 % of the weightbearing area of the tibial plafond is affected when a biplanar osteotomy is performed. CONCLUSION: Medial malleolar osteotomy provides varying degrees of access to the talar dome depending on how it is performed. A wedge-shaped biplanar osteotomy provides greater access and is therefore more suitable for defects located deeper on the talar dome. Despite providing wider access, it results in greater disruption of the weightbearing cartilage of the tibial plafond. LEVEL OF EVIDENCE: Level V.

Transosseous repair with a cortical implant for greater tubercle cyst-related rotator cuff tear results in good clinical outcomes, but significant implant migration.

PURPOSE: To evaluate whether an arthroscopic transosseous technique (ATO) with cortical implants is effective for rotator cuff tear (RCT) repair in patients with cysts of the greater tuberosity (GTC). METHODS: Patients treated with the ATO technique between January 2013 and October 2017 were evaluated. Inclusion criteria were patients treated for both cyst-related and non-cyst-related RCTs and patients with a moderate-sized tear (1-3 cm) according to the DeOrio and Cofield classification. A total of 39 patients were separated into two groups: Group 1 (n = 16) patients with cyst-associated RCT, and Group 2 (n = 23) patients with no cyst. Implant pull-out and migration were evaluated radiologically on standard antero-posterior shoulder radiographs and rotator cuff re-tear was assessed on magnetic resonance images at the final follow-up examination. Group 1 patients were separated into two subgroups according to cyst size (cyst < 5 mm and cyst ≥ 5 mm) and subgroup analysis was performed. Clinical assessment was performed using a visual analog scale, the Constant score and Oxford shoulder score. RESULTS: The mean follow-up time was 33.7 ± 11.7 months. The mean cyst size was 5.4 ± 1.5 mm. There was no significant difference in re-tear rates between the cystic and non-cystic groups. The mean implant migration distance was 3.0 ± 2.2 mm in patients with a RCT -related cyst and 0.7 ± 0.8 mm in those without a cyst. A statistically significant difference was found between the groups (p = 0.002). There was no statistically significant difference between the groups in respect of clinical scores. No implant failure was observed. CONCLUSION: The ATO method performed with a cortical implant in RCTs resulted in satisfactory recovery and clinical outcomes in the short to medium term with low failure rates. While no implant failures were observed, implant migration was associated with cyst presence. Therefore, judicious use is advocated in the choice of transosseous fixation for cyst-related RCTs and patients should be informed of the possibility of implant migration. LEVEL OF EVIDENCE: III.

Clinical and radiological comparison of bioactive glass and poly-L-lactic acid/hydroxyapatite bioabsorbable interference screws for tibial graft fixation in anterior cruciate ligament reconstruction.

BACKGROUND: Ligament reconstruction is still the main treatment modality for patients with a complete ligament rupture. The semitendinosus tendon, alone quadrupled or double folded and combined with the gracilis tendon, is still the most frequently used autologous graft for a reconstructive procedure. Absorbable interference screw usage has gained popularity in the past decade because they create less artifacts during MR imaging and tend to osteointegrate over the years, arguably leading to a more anatomic fixation. The purpose of this study was to compare the 5-year radiological and clinical results of two different tibial graft fixation screws. HYPOTHESIS: We hypothesized that bioabsorbable interference screws made of bioactive glass would lead to higher rates of osteointegration, better overall clinical results, less foreign body reaction rates and less tibial tunnel widening when compared to the poly-L-lactic acid/hydroxyapatite (PLLA-HA) screws. PATIENTS AND METHODS: Fifty-one patients treated with an anatomic single bundle ACL reconstruction between June 2015 and July 2016 at our institution were included in the study. The tibial graft was fixed with a bioactive glass screw in 24, and with a PLLA-HA in 27 patients. Tibial tunnel widening, foreign body reaction, osteointegration and resorption rates were evaluated and compared on a magnetic resonance scan at a minimum of 5 year postoperatively. Overall clinical results and side-to-side difference on KT-1000 were also analyzed in-between groups. RESULTS: Tibial tunnel widening was similar for both groups. Foreign body reaction, while not statistically significant, was less aggressive when bioactive glass screws were used. Osteointegration and resorption rates of the bioactive glass screws were significantly higher than the PLLA-HA group (p=0.000). While all patients showed an overall improvement on postoperative scores (p=0.000), patients with a bioactive glass interference screw had statistically higher translational stability with KT-1000, compared to the poly-L-lactic acid/hydroxyapatite group (p=0.001). DISCUSSION: At a minimum of 5 years, compared to conventional PLLA-HA interference screws, 45S5 bioactive glass screw provide higher resorption rates, are more highly biodegradable and provide overall good clinical results. LEVEL OF EVIDENCE: III.

Closure of the femoral medullary canal after retrograde nailing using an in-situ osteochondral autograft-Technical trick and a case series.

Retrograde intramedullary nailing (RIMN) is the favored over antegrade intramedullary nailing in fractures of the distal femur. It provides a longer working length and allows for multiple distal screw insertion and therefore a more stable construct. Concerns remain regarding the violation of the knee cartilage and the effect this has on knee function. Many studies have shown high incidence of knee pain with reports varying from 20 to 86%. We describe a novel technical trick aiming at partially restoring the knee cartilage of the operated side and decreasing the hemorrhage stemming from the medullary canal. Our experience of the technique and the case series shows that closing the entrance point of the medullary canal after a RIMN procedure leads to better function and less knee pain in the postoperative period.

Tip-neck distance ratio as a novel predictor for failure in cephalomedullary nailing of unstable trochanteric fractures (UTF).

OBJECTIVES: Intertrochanteric femur fractures (ITFF) are frequently fixed with proximal femoral nailing (PFN), and a common cause of fixation failure is cut-out of the lag screws. In the literature, many factors have been defined to determine the failure risk, including the tip-apex distance (TAD), calcar-referenced tip-apex distance (CalTAD), the Cleveland zone and Parker's ratio. In this study, a novel technique is described which favors infero-posterior placement of the lag screw and predicts failure risk for PFN. The purpose of this study was to evaluate the tip-neck distance ratio as a factor for the prediction of cut-out after PFN of ITFF. MATERIALS AND METHODS: A retrospective evaluation was made of the data of 125 patients applied with PFN for ITFF between October 2016 and September 2019. The occurrence of mechanical complications was analyzed in relation to age, gender, fracture side, American Society of Anaesthesiologists classification, fracture classification, reduction quality, bone quality, Cleveland zone, Parker's ratio, TAD, CalTAD and the TNDR. RESULTS: A total of 125 patients, including 16 with mechanical complications, were suitable for full analysis. In the univariate analysis, reduction quality (p = 0.003), the TAD (p = 0.048) and the TNDR (p = 0.030) were statistically associated with mechanical complications (p < 0.05). In the multivariate analysis, good quality of reduction reduced risk of mechanical failure (p = 0.011) and the TNDR (p < 0.001) indicated that these were two independent factors affecting mechanical complications. CONCLUSION: The results of this study provide clinical evidence that the TNDR is a predictor for cut-out risk. Placement of the lag screw posterior and inferior reduces the risk of mechanical complications. LEVEL OF EVIDENCE: Level 3.

Perfusion index: Could this be a new triage tool for upper gastrointestinal system bleeding in the emergency department? A prospective cohort study

ABSTRACT BACKGROUND: Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes. OBJECTIVE: To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage. DESIGN AND SETTING: Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019. METHODS: Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded. RESULTS: A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001). CONCLUSION: PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.

Perfusion index: Could this be a new triage tool for upper gastrointestinal system bleeding in the emergency department? A prospective cohort study.

BACKGROUND: Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes. OBJECTIVE: To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage. DESIGN AND SETTING: Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019. METHODS: Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded. RESULTS: A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001). CONCLUSION: PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.