Malpractice litigation after total hip arthroplasty: A legal 10-year database.

OBJECTIVES: In this study, we aimed to identify the most frequently reported claims after total hip arthroplasty (THA) and the reasons put forward by the plaintiffs. PATIENTS AND METHODS: Between January 2011 and December 2020, data of a total of 74 cases (21 males, 53 females; mean age: 53.7±12.8 years; range, 29 to 83 years) obtained from the Turkish Forensic Medicine Institute were retrospectively analyzed. Claims for litigation, demographic data, data regarding the identity of the accused and the hospital setting were recorded. RESULTS: The most common reason for lawsuits was death (n=15; 20.3%), followed by nerve injury (n=13; 17.6%), and eight patients had more than one complaint. According to the forensic medicine reports, malpractice was detected in 10 (12.5%) of the cases. Among the hospital types, only nerve injury made a significant difference among all complaint sources in different hospital settings (p=0.003). CONCLUSION: In our study, death was the most common reason for lawsuits regarding malpractice accusations after THA, which is different from medical malpractice allegations throughout the world.

Comparison of two surgical techniques for Lisfranc injuries; closed reduction and fixation versus primary partial arthrodesis.

BACKGROUND: This study reviewed the outcomes of Lisfranc injuries treated by primary partial arthrodesis (PPA) or closed re-duction and internal fixation (CRIF). METHODS: A retrospective review was made of patients who underwent PPA or CRIF for a Lisfranc injury after low-energy trauma, and follow-up was assessed according to radiographic, and clinical outcomes. A total of 45 patients with a median age of 38 years were followed up for an average of 47 months. RESULTS: The average American orthopaedic foot and ankle society (AOFAS) score was 83.6 points in the PPA group and 86.2 points in CRIF group (p>0.05). The mean pain score was 32.9 in the PPA group, 33.7 in the CRIF group (p>0.05). Secondary surgery for symptomatic hardware was required in 78% of the CRIF group and in 42% of the PPA group (p<0.05). CONCLUSION: Treatment of low-energy Lisfranc injuries with either PPA or closed reduction and fixation produced good clinical and radiological outcomes. The total AOFAS scores were comparable between two groups. However, the function and pain scores were seen to improve more with closed reduction and fixation while there was a greater requirement for secondary surgery in the CRIF group.

Atypical femoral neck stress fracture in a human immunodeficiency virus-infected patient despite anti-osteoporotic treatment: A case report.

Both human immunodeficiency virus (HIV) infection and antiretroviral therapy are related to an increased risk of fracture. As a result of the developments in HIV treatment in recent years, life expectancy in HIV-infected patients has increased. Therefore, HIV-related musculoskeletal problems such as osteoporosis and avascular necrosis are more common currently. There are complex mechanisms in HIV-related osteoporosis. The loss of bone mineral density is particularly distinctive in the first months of the therapy. In this report, we present a 54-year-old woman admitted to our clinic with right thigh pain for three months and diagnosed with a femoral neck stress fracture.

Does low body mass index constitute a risk of damage to the soft tissues during reaming for proximal femoral nailing? a cadaveric study.

BACKGROUND: The purpose of this cadaveric study was to evaluate the damage to the gluteus medius muscle, tendon and superior gluteal nerve in low BMI patients during the reaming of the greater trochanter tip for proximal femoral nailing. MATERIALS AND METHODS: The study used 19 femurs of 10 fresh femur intact cadavers [mean BMI: 22.79 (17.60-28.70)]. A guidewire was placed in the tip of greater trochanter under C-arm fluoroscopy, and a 17-mm reamer was advanced over the wire. After the reaming was completed, the hips were dissected and the gluteus medius muscle, tendon and superior gluteal nerve were inspected to evaluate the amount of injury. RESULTS: BMI was < 18.50 in 3 cadavers. The gluteus medius muscle was injured in all hips. The superior gluteal nerve was intact in all hips, but the thickness of gluteus medius muscle mass that remained intact was thicker in the cadavers with a higher BMI (3.86 mm for low BMI, 9.08 mm for high BMI group). The percentage of the tendon insertion disrupted by the reamer was an average of 36.20% in the low BMI group and an average of 26.93% in the high BMI group. The percentage of the tendon insertion disrupted by the reamer showed a statistically significant difference between low and high BMI cadavers. CONCLUSION: The injury to the gluteus medius muscle and tendon after proximal femoral nailing through the greater trochanter tip may be higher in patients with low BMI. It must be kept in mind that gluteal muscle could be damaged during proximal femoral nailing and this could result in limping.

Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients.

BACKGROUND: The aim of this study was to compare the clinical and radiological results of the proximal femoral nail antirotation (PFNA) with those of the dynamic hip screw (DHS) and percutaneous compression plate (PCCP) in the treatment of simple pertrochanteric fractures. METHODS: A total of 203 patients were included in the study. PFNA fixations were performed in 73 patients (PFNA group), DHS in 68 patients (DHS group), and PCCP in 62 patients (PCCP group). The main outcome measurements were perioperative properties, the Harris hip score, changes in the neck-shaft angle, and loss of the abductor muscle strength. Data were compared between the groups. RESULTS: The mean estimated total blood loss and the number of patients receiving the blood transfusion rate in the PFNA group were statistically significantly lower. The mean operation and fluoroscopy times in the PCCP group were statistically significantly higher. The mean loss of the abductor muscle strength and changes in the neck-shaft angle in the PFNA group were statistically significantly higher. The mean Harris hip scores were similar. CONCLUSION: Our findings demonstrated that although PFNA was superior with regard to the perioperative data, DHS and PCCP were superior in maintaining the reduction and the abductor muscle strenght. All three implants were similar and had satisfactory functional outcomes.

The Effect of Single High-Dose Preoperative Intravenous Tranexamic Acid Administration to Reduce Blood Loss in Patients with Primary Total Knee Replacement.

OBJECTIVES: This study aimed to analyze the efficacy of single-dose tranexamic acid (TA) 20 mg/kg preoperatively to reduce blood loss in patients undergoing total knee replacement (TKR). METHODS: A total of 387 patients (82 males, 305 females) undergoing TKR between January 2014 and December 2018 were included in the study. The T + group was administrated intravenous (iv) TA 20 mg/kg 20 min before the skin incision. We determined perioperative blood loss, the amount of drainage postoperative 24 h, the amount of drainage after postoperative 24-48 h, total volume of drains, total volume of blood loss, postoperative hemoglobin and hematocrit levels, and amount of total blood transfusion. RESULTS: In terms of demographic data, no statistically significant difference was observed between the groups. Perioperative blood loss and total volume of blood loss was found statistically higher in T - group compared to T + group. Postoperatively, the mean hemoglobin and hematocrit levels of T - group were statistically significantly lower than T + group. CONCLUSION: A single 20 mg/kg iv TA administration before TKR reduces bleeding during surgery and within 24 h postoperatively.

The Results of Core Decompression Treatment in Avascular Necrosis of the Femoral Head.

OBJECTIVE: Avascular necrosis of the femoral head (AVNFH) is a progressive disease seen in young, active patients, leaving significant disability in the joint when untreated. We retrospectively examined the results of patients with early stage AVNFH who had been operated in our clinic. METHODS: In our study, 65 hips of 46 patients were evaluated retrospectively. These patients were evaluated clinically by the Merle d'Aubigné-Postel Score and Harris Hip Score. The patients were radiologically staged according to the criteria by Ficat and Arlet with hip anterior-posterior and lateral graphs and magnetic resonance imaging. RESULTS: The mean follow-up period of the patient group was 73 months, and the mean age of the patients was 35 years. Of these patients, 59% were female and 41% were male; 41% had bilateral and 40% had right hip involvement. One of the patients developed AVNFH while she was pregnant, 7 were idiopathic, and 38 (81%) developed AVNFH due to steroid use. According to the Ficat and Arlet classification, 18 hips were found to be stage 1, 37 hips stage 2, and 9 hips stage 3 during admission. From the etiological point of view, 81% of the patients developed AVNFH while using steroid and 19% had idiopathic AVNFH. As for clinical improvement of the patients, the Harris Hip Score increased from 58 to 90 in idiopathic patients and 55 to 83 among steroid users. The Merle d'Aubigné-Postel classification scores increased from 6 to 15 in the idiopathic group and from 6 to 13 among steroid users. Radiologically, according to the Ficat and Arlet stage, progression was seen in all stages. Of the patients, 38.8% in stage 1, 70.2% in stage 2, and 88.8% in stage 3 showed progression, whereas 20% demonstrated rapid progression and needed total hip prosthesis. All patients who demonstrated progression were on chronic steroid therapy. The mean time to conversion to total hip replacement was 27 months. CONCLUSION: Osteonecrosis is a disease associated with high morbidity. Early diagnosis can reduce morbidity and improve a patient's quality of life. Core decompression has the effect of stopping the progression of AVNFH in the early (stage 1) stages, although it has a significant and long-term palliative effect in all stages. Most of the young and active patients with AVNFH still do not have any ideal method for treatment today, but core decompression in the early stages has been seen to reduce morbidity. It is a time-saving attempt before the final treatment, which is hip arthroplasty, is performed.

Minimal invasive fixation of distal tibial fractures does not result in rotational malalignment: A report of 24 cases with CT imaging.

BACKGROUND: Tibial torsion is rotation of the proximal versus the distal articular axis in the transverse plane. This study used computed tomography (CT) to examine rotational malalignment in the crus following use of minimally invasive plate osteosynthesis (MIPO) technique in distal tibial fractures and evaluated effect of rotational difference on clinical outcomes and VAS scores. METHODS: Analysis of 24 patients who were operated on for closed distal tibial fracture with MIPO technique between 2010 and 2012 was conducted. Malrotation was defined as rotational difference >10°. Operated knees were evaluated with 0.5-mm, fine-cut, 3-dimensional CT scan performed in cooperation with radiology department. Side-to-side difference in tibial torsion angle >10° was considered significant degree of malrotation. All patients were assessed clinically (visual analogue scale [VAS] and American Orthopaedic Foot and Ankle Society [AOFAS] scores) and radiologically at final visit. RESULTS: Mean follow-up period was 20.00±9.46 months (range: 18-51 months). Mean VAS score was 2.58±0.83 (range: 1-4) and mean AOFAS score was 87.50±4.05 (range: 78-93). Mean tibial rotation angle was 31.54±6.00° (range: 18-45°) on healthy side and 32.00±6.24° (range: 10-43°) on the operated side. No statistically significant difference was determined (p>0.05). CONCLUSION: Use of intraoperative fluoroscopy, cable technique, and uninjured extremity as reference, can reduce incidence of rotational malalignment of distal tibial fractures treated with MIPO.

Allografts versus Equine Xenografts in Calcaneal Fracture Repair.

Displaced intra-articular calcaneal fractures are difficult to treat. We determined the functional results and complications of using allografts or equine xenografts in treating these fractures. We reviewed patients seen at our center from May 2011 to December 2014 with Sanders type III or IV unilateral calcaneal fractures treated with locking plates and an additional bone allograft or equine xenograft. A minimum of 1 year after surgery, a history of infection and functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society clinical rating system. Changes in the Gissane angle (GA) and Böhler angle were assessed from radiographs. Of the 91 eligible patients, 15 were lost to follow-up, leaving a sample of 76 patients (42 males): 45 received allografts (19 for type III and 26 for type IV fractures) and 31 received xenografts (20 for type III and 11 for type IV fractures). The mean age was about 40 years in both groups. After ≥1 year of follow-up, the proportion of patients in the American Orthopaedic Foot and Ankle Society scoring categories did not differ significantly between the 2 groups (mean ankle score, 86.5 in the allograft group and 85.1 in the xenograft group), and the American Orthopaedic Foot and Ankle Society functional outcomes were good or excellent in 69% and 68%, respectively (p = .986). The groups did not differ in the incidence of superficial or deep infection (p = 1.000). The Böhler angles were significantly decreased in the xenograft group. Xenografts might be preferred for repairing intra-articular calcaneal fractures because they can perform as well as allografts, avoid donor site morbidities, and are more available and less expensive than allografts.

Comparison of mortality rates and functional results after transtibial and transfemoral amputations due to diabetes in elderly patients-a retrospective study.

INTRODUCTION: This study aimed to compare mortality rates and functional results of transtibial and transfemoral amputations in elderly patients with diabetes. METHODS: 87 amputees [54 (62.1%) transtibial and 33 (37.9%) transfemoral] were included. Mean ages were 70.7 and 69.3 years in transfemoral and transtibial groups, respectively. Mean follow up time was 41.8 months. Amputee Mobility Predictor scores (with and without prosthesis) and Barthel Daily Living Index were used for functional evaluation of the survivors. RESULTS: First year mortality rates were 29.6% and 30.3% in transtibial and transfemoral groups, respectively. Overall mortality rate of both groups was 65.5% (66.7% in transtibial and 63.6% in transfemoral group). There was no difference between mortality rates of two groups. Duration between surgery and death was significantly shorter in transfemoral group. The mean Amputee Mobility Predictor scores (with prosthesis) of the transtibial and transfemoral groups were 32.3 and 26.9 points, respectively. The average Amputee Mobility Predictor scores (without prosthesis) of the transtibial and transfemoral groups were 29.5 and 22.7 points respectively. The differences between two groups' scores were significant. The mean Barthel Daily Living Index scores of the transtibial and transfemoral groups were 82.5 and 80.2 points respectively. The difference was not significant. CONCLUSIONS: High mortality rates and morbidities after major lower limb amputations emphasize the importance of preventive measures and foot care in patients with diabetes.

Procedural outcomes of double vs. single fluoroscopy for fixing intertrochanteric femur fractures.

OBJECTIVE: This study compares reducing radiation and operation time between single and double C-arm fluoroscopy in the treatment of intertrochanteric femur fractures with intramedullary nails. PATIENTS AND METHODS: Forty four patients participated in the study. Patients were divided into two groups as single (23 patients) and double fluoroscope (21 patients). The time of preparation, the duration of the surgery, the total amount of blood loss, and the total duration of radiation exposure were compared, retrospectively. The collo-diaphyseal angle was compared with that of the contralateral hip on postoperative radiographs. Furthermore, the tip-apex distance and the position of the screws in the femoral head were recorded. RESULTS: The mean preparation periods, collo-diaphyseal angles and blood loss did not differ between groups. In the double-fluoroscopy group, the duration of surgery was 15.9 min shorter (p < 0.001), and the radiation time was 25.7 s shorter (p < 0.001). CONCLUSION: The double fluoroscopy technique can significantly reduce surgical and radiation exposure times during surgery.

Early mobilization with customized TLSO brace in thoracolumbar burst fractures.

OBJECTIVE: This study aimed to research the effectiveness of customized thoracolumbosacral orthosis treatment for stable burst type thoracolumbar vertebral fractures without neurological deficits. METHODS: The study included 26 patients (14 males, 12 females; mean age: 46.03 years; range: 18 to 64 years) conservatively treated for thoracolumbar (T11-L2) burst type vertebral fractures according to Denis classification between 2002 and 2009. Etiology were a fall from various heights in 12 patients (46.2%), motor vehicle accidents as an occupant in 7 (26.9%) and as a pedestrian in 4 (15.4%), and simple fall in 3 (11.5%). None of the patients had neurologic deficit and no damage was found in the posterior ligamentous complex in MRI evaluations. Denis pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Post-fracture and follow-up values were compared. Mean follow-up period was 41.30 (range: 14 to 80) months. RESULTS: Mean pain and functional scores were 1.65 and 1.15 points, respectively, at the final follow-up. Twenty patients returned to their pre-trauma work and activities completely and six patients with small limitations. Mean period for returning to work was 3.64 (range: 2 to 6) months. Local kyphosis angle, sagittal index and height loss percentage values increased significantly at follow-up (p<0.05). CONCLUSION: The conservative treatment of stable thoracolumbar burst fractures is widely accepted. Early mobilization with customized TLSO brace appears to produce effective functional results despite loss of vertebral body height.

Results of open reduction and plate osteosynthesis in comminuted fracture of the olecranon.

HYPOTHESIS: Using radiologic and clinical results, we studied the outcome of patients who underwent open reduction and plate osteosynthesis for comminuted olecranon fractures. MATERIALS AND METHODS: We retrospectively studied 18 patients (5 women [27.8%] and 13 men [72.2%]; mean age, 41 years [range, 19-67 years]) with comminuted fractures of the olecranon who underwent locking-plate osteosynthesis after open reduction between March 2005 and August 2009. According to the Mayo classification, 11 cases were classified as type IIB (61.11%) and 7 cases were classified as type IIIB (38.88%). In 7 cases, additional injuries were present in the olecranon area. We evaluated results with respect to clinical and radiologic findings. The mean follow-up duration was 22.6 months (range, 7-42 months). RESULTS: Complete union was achieved in all cases. Mean union time was 4.4 months (range, 4-6 months). According to the Morrey scale, 4 cases were considered very good; 8, good; 5, fair; and 1, poor. The mean QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score was 17 (range, 0-75). There were no statistically significant differences between the Mayo type IIB and type IIIB cases in terms of elbow range of motion, QuickDASH score, and Morrey score. On long-term follow-up, elbow stiffness developed in 1 patient, who underwent surgical release with simultaneous removal of the hardware. The cases with fair and poor scores were cases with open fractures and additional elbow injuries. CONCLUSIONS: Locking-plate osteosynthesis is an effective and safe treatment option for comminuted olecranon fractures, allowing early joint motion and yielding satisfactory radiologic and clinical results. In cases with concomitant injuries, the risk of limited elbow motion is high.

The results of surgical treatment for posttraumatic heterotopic ossification and ankylosis of the elbow.

OBJECTIVES: Heterotopic ossification which may develop following elbow injuries or elbow surgery may result in complete loss of elbow functions. We evaluated the results of surgical treatment for ankylosis of the elbow due to posttraumatic heterotopic ossification. METHODS: The study included seven patients (6 males, 1 female; mean age 36 years; range 23 to 55 years) who developed heterotopic ossification and ankylosis of the elbow joint following surgical treatment of high-energy fractures in the circumference of the elbow. Two patients had comminuted olecranon fractures and elbow luxation, and five patients had comminuted intra-articular distal humeral fractures. Three patients had open fractures. Involvement was in the right elbow in two patients, and in the left elbow in five patients. One patient was monitored and treated in the intensive care unit for head trauma for 22 days. Initially, six patients were treated with plate osteosynthesis and one patient with tension band wiring. Foci of heterotopic ossification were detected on the radiographs taken after a mean of 24 days (range 20 to 32 days) following surgical treatment of fractures. The patients were followed-up with conventional radiography and scintigraphy for a mean of 11 months (range 7 to 15 months) before surgical treatment, during which functional loss in elbow joint movements deteriorated and ankylosis developed. All the patients had Hastings type IIIC ankylosis and poor Mayo elbow performance scores (mean score 50.7). A posterior incision was used in three patients, and a double-column incision was used in four patients. At surgery, the ulnar nerve and the lateral and medial collateral ligaments were preserved, and a posterolateral capsular release, removal of heterotopic ossification, purging of the olecranon fossa, and resection of the tip of the olecranon were performed. After completion of capsular release, cartilage pathologies were evaluated. Four patients were found to have no definite cartilage damage, whereas in three patients the joint cartilage was seriously damaged. At final controls, the patients were assessed with the Mayo elbow performance score. The mean follow-up period was 23.4 months (range 10 to 36 months). RESULTS: In all cases, the range of motion and stability of the elbow joint were controlled and were found to be complete and stable at the end of the operation. At final controls, the Mayo elbow performance scores were good in three patients, moderate in one patient, and poor in three patients. All the patients with a poor elbow score had severe joint cartilage damage intraoperatively. CONCLUSION: Patients who develop heterotopic ossification and ankylosis of the elbow following trauma or elbow surgery may benefit from removal of heterotopic ossification foci and elbow relaxation procedures provided that there is not severe damage to the articular cartilage.