Tracing the disc: The novel qualitative morphometric MRI based disc degeneration classification system.

Background: This study aimed to develop a classification system for lumbar disc degeneration using routine magnetic resonance images (MRIs) that is easily applicable and unaffected by existing classifications' limitations, and to compare its reliability, reproducibility, and discriminative power to the widely used Pfirrmann classification. Methods: Five features were graded. This new classification system has eight grades, with at least one of these five features altering each grade. The T2-weighted sagittal images were acquired using a rapid spin-echo sequence with a repetition time of 2680 to 4900 milliseconds, an echo time of 100 to 109 milliseconds, and an echo train length of 17. Slice thick was 4 mm and the display field of view was 32 × 32 cm. The new classification system used five features: signal intensity, disc height, disc boundary regularity, and nucleus annulus separation. Increased signal intensity, decreased height, decreased regularity, and decreased nucleus-annulus separation indicated degeneration. Four raters classified 400 discs from 80 patients using the Pfirrmann and Novel systems. Statistical analyses were conducted to investigate reliability and correlation. Results: The overall ICC and kappa values were found to be higher in the novel classification. (0.988 indicating excellent agreement for ICC and 0.76/0.94 indicating good-very good agreement for kappa). The Kendall tau c value, which shows the correlation between the two classifications and indicates the validity of the new classification, was 0.872, which is very strong. Through the use of cross-tabulations, the discriminatory power of the two newly added classification criteria was determined. Conclusions: This study demonstrates the intra-rater and inter-rater reliability of an easy-to-use, discriminative novel morphometric MRI based classification system for lumbar disc degeneration. The differentiation of grades based on five distinct criteria may generate novel hypotheses regarding treatment selection and response monitoring, as well as new insights into the study of disc degeneration.

Revealing the Effect of Spinopelvic Alignment on Hip Disorders.

Background: Hip osteoarthritis (HOA) is a growing burden and one of the leading causes of hip pain. The relationship between the HOA and the alignment of the spinopelvic region has been intensively studied, however the issue remains controversial. Spinopelvic imbalance, HOA, and dysplasia were investigated in relation to sagittal spinopelvic parameters in this study. Methods: We collected computerized tomography (CT) topograms of the pelvis or abdomen from 380 patients. In antero-posterior (AP) topograms, Tonnis grading, center-edge angle (CEA) and Sharp's acetabular angle (AA) measurements were performed on each patient. Lateral topograms were used to evaluate the following spinopelvic parameters for each patient: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sacral table angle (STA), lumbar lordosis (LL), proximal lumbar lordosis (PLL), distal lumbar lordosis (DLL), and PI-LL difference. Initially, the cohort was divided into two subgroups based on whether or not they had HOA. Then, they were divided into two subgroups based on whether or not they had dysplasia. Ultimately, it was divided in half based on the PI-LL imbalance. Statistical analyses were conducted to determine the likely correlations between the spinopelvic parameters of these subgroups. In addition, the correlations between spinopelvic parameters were investigated. Results: There were 380 patients evaluated. We found no association between HOA or dysplasia and spinopelvic parameters. In addition, there was no association between PI-LL imbalance and HOA or dysplasia. Conclusion: There was no difference in constant PI and STA angle, besides other variable parameters, between groups having HOA and dysplasia or not. PI-LL imbalance has no effect on HOA and dysplasia.

The effect of posterior tibial slope on anteroposterior stability in posterior cruciate retaining total knee arthroplasty.

BACKGROUND: It has been suggested that the posterior tibial slope (PTS) plays an important role in increasing the anteroposterior stability following total knee arthroplasty. Although the relationship between the PTS and the flexion range has been investigated many times, studies on the relationship between PTS and anterior-posterior stability are limited. The primary aim of this study was to investigate the relationship and effects of PTS on anteroposterior stability in posterior cruciate retainer total knee arthroplasty. METHODS: 154 primary TKAs were identified retrospectively to analyze the any association between PTS and anteroposterior laxity following posterior cruciate-retaining total knee arthroplasty in the overall study populations. Anteroposterior displacement was measured at the final follow-up based on the following two procedures: KT-1000 arthrometer and sagittal drawer radiographic images. In addition, the relationship between PTS and functional scores-ROM was examined. RESULTS: There was no correlation between patients' posterior tibial slope and postoperative VAS (r: -0.060, p:0.544), WOMAC (r:0.037, p:0.709), KSS (r: -0.073, p:0.455). In addition, there was no significant correlation between postoperative knee ROM and postoperative PTS (r:0.159, p:0.106). Moreover, no correlation was found between KT-1000 arthrometer and 20 degrees AP translation with PTS. There was a negative correlation between PTS and 70 degrees AP translation (r: -0.281, p:0.008). CONCLUSIONS: This study aimed to clarify the association between instability and AP laxity in flexion of implanted knees, and to determine what degree of AP laxity results of instability. A fundamental finding of this study was that; the optimum TS angle to increase anterior-posterior stability after total knee arthroplasty is between ≥ 4 to < 6 degrees, we also proved that there is no relationship between stability and patient satisfaction.

An AI based classifier model for lateral pillar classification of Legg-Calve-Perthes.

We intended to compare the doctors with a convolutional neural network (CNN) that we had trained using our own unique method for the Lateral Pillar Classification (LPC) of Legg-Calve-Perthes Disease (LCPD). Thousands of training data sets are frequently required for artificial intelligence (AI) applications in medicine. Since we did not have enough real patient radiographs to train a CNN, we devised a novel method to obtain them. We trained the CNN model with the data we created by modifying the normal hip radiographs. No real patient radiographs were ever used during the training phase. We tested the CNN model on 81 hips with LCPD. Firstly, we detected the interobserver reliability of the whole system and then the reliability of CNN alone. Second, the consensus list was used to compare the results of 11 doctors and the CNN model. Percentage agreement and interobserver analysis revealed that CNN had good reliability (ICC = 0.868). CNN has achieved a 76.54% classification performance and outperformed 9 out of 11 doctors. The CNN, which we trained with the aforementioned method, can now provide better results than doctors. In the future, as training data evolves and improves, we anticipate that AI will perform significantly better than physicians.

Does the technique of limb lengthening affect physeal growth in patient with achondroplasia? Comparison of the simultaneous and consecutive tibia and femur lengthening with external fixators.

We aimed to retrospectively investigate and compare patients who underwent bilateral simultaneous and consecutive lengthening surgery of the femur and tibia in terms of the effect on physeal growth. We hypothesize that compared with the sequential lengthening technique, simultaneous lengthening of the bilateral femur and tibia affects physeal growth to a greater extent. Twenty-six patients with achondroplasia who operated in our clinic between 1995 and 2015 for limb lengthening were included in the study. Fourteen patients with bilateral lengthening of the femur and tibia at the same time were named as simultaneous bilateral lengthening (SBL). Twelve patients with bilateral lengthening of the femur and then bilateral tibia lengthening in other sections or vice versa, at a different time was named consecutive bilateral lengthening (CBL). All patients were followed until at least 18 years old. The physeal arrest was measured with predicted final length at the first visit (investigated with the multiplier method), the total amount of lengthening, and final clinical, and radiological length. Mean limb lengthening was 145 mm (48.5%) and 151 mm (46.6%) for simultaneous and consecutive groups respectively. For lower extremity length, the first group reached 527.6 mm while the expected was 447.3 mm. Considering 151 mm lengthening, the mean growth disturbance for the SBL group was 70.7 mm and for the CBL group was 47.5 mm. For total height comparing between two groups, disturbance for height was 80.5 mm and 65.4 mm, respectively. Although there was no statistical difference, simultaneous bilateral femoral and tibial lengthening has more physiological physeal disturbance effects than consecutive lengthening in patients with achondroplasia.

Plate fixation after lengthening with an external fixator in patients with achondroplasia : A comparative study between two centers.

BACKGROUND: This study compared internal fixation with a plate after lengthening (PAL) with an external fixator with the conventional method (CM) in terms of radiologic and clinical outcomes in the lower extremities of patients with achondroplasia. METHODS: In this study 20 patients (50 lower extremity long bones) who underwent PAL or CM were divided into 2 cohort groups. The amount of lengthening, percentage lengthening, external fixator index (EFI), external fixator time, Li regeneration index, complication rate, and knee range of motion (ROM) were compared between the groups. RESULTS: The median age was 9.4 years (range 6-16 years) in the PAL group and 12 years (range 9-16 years) in the CM group (p = 0.01). Males comprised 80% of the patients in the PAL group and 47% of the patients in the CM group (p = 0.02). The median amount of lengthening in the PAL and CM groups was 7.5 cm (range 5.5-9.5 cm) and 6.0 cm (range 5.5-9.0 cm), respectively (p < 0.01). The median percentage of lengthening in the PAL and CM groups was 44.6% (range 20.0-70.1%) and 43.0% (range 20.5-57.3%), respectively (p = 0.01). The median external fixator time in the PAL and CM groups was 127 days (range 94-185 days) and 180 days (range 105-355 days), respectively (p < 0.01). The median EFI in the PAL and CM groups was 21 days/cm (range 10-33 days/cm) and 27 days/cm (range 15-59 days/cm), respectively (p < 0.01). The Li regeneration index was 3 (interquartile range, IQR 2-4) in both groups (p = 0.2). The total complication rate was similar between the groups. CONCLUSION: In patients with achondroplasia, after lengthening with an external fixator, internal fixation with a plate can be a reliable alternative to the conventional method. LEVEL OF EVIDENCE: Level III therapeutic.

CORONAL PLANE GROWTH MODULATION FOR GENU VALGUM IN SKELETAL DYSPLASIA.

Objective: To investigate the efficiency and rates of correction by hemiepiphysiodesis using 8-plate to manage genu valgum deformity in children with skeletal dysplasia. Methods: Eleven children with skeletal dysplasia (three female, eight male; mean age = 10.5 years; age range = 7-13) who underwent temporary hemiepiphysiodesis using 8-plates for genu valgum deformity were retrospectively reviewed. There were nine bilateral cases and two unilateral cases. The mean follow-up time from the index surgery to the final follow-up was 45 (ranging from 24 to 72) months. Radiographical assessment including preoperative and final follow-up measurements of joint orientation angles and mechanical axis deviation (MAD) were conducted. Results: Deformities were completely corrected in nine lower extremities (45%) and partially corrected in seven extremities (35%). In four extremities of two children with Morquio syndrome, MAD worsened. The correction rate of MAD was 1.25 ± 1.62 mm/mo. Conclusion: Though hemiepiphysiodesis using 8-plate requires a longer treatment period, it seems to be an effective treatment for correction of genu valgum in children with skeletal dysplasia. Level of Evidence IV, Case Series.

Objetivo: Investigar a eficiência e as taxas de correção da hemiepifisiodese usando placa-8 no tratamento da deformidade de geno valgo em crianças com displasia esquelética. Métodos: Foram avaliadas retrospectivamente 11 crianças com displasia esquelética (três meninas e oito meninos; idade média = 10,5 anos; faixa etária = 7-13) que foram submetidas à hemiepifisiodese temporária com placa-8 devido à deformidade do geno valgo. Havia nove casos bilaterais e dois casos unilaterais. O acompanhamento médio desde a cirurgia de implante até o acompanhamento final foi de 45 (variação de 24 a 72) meses. Foi feita avaliação radiográfica incluindo medidas de acompanhamento pré e pós-operatórias dos ângulos de orientação da articulação e desvio mecânico do eixo (MAD). Resultados: As deformidades foram completamente corrigidas em nove extremidades inferiores (45%) e parcialmente corrigidas em sete (35%). Em quatro extremidades de duas crianças com síndrome de Morquio, o MAD piorou. A taxa de correção do MAD foi de 1,25 ± 1,62 mm/mês. Conclusão: Embora a hemiepifisiodese com placa-8 necessite de um período de tratamento mais longo, a técnica parece ser um tratamento eficaz para a correção do geno valgo em crianças com displasia esquelética. Nível de Evidência IV, Série de Casos.

The Relationship Between Limb Lengthening Rate and Callus Quality in Patients with Achondroplasia.

Objectives: This study investigated the effect of the femur, tibia, and humeral lengthening rate in patients with achondroplasia and regenerated bone quality. Methods: The records of the patients with achondroplasia who underwent limb lengthening surgery for both upper and lower extremities between 2002 and 2019 were retrospectively reviewed. Bone formation regeneration was evaluated in each segment at anteroposterior and lateral radiographs and the callus quality was determined at the first month of the consolidation period according to Li's classification system. Results: This study included 42 (28 females and 14 males), 38 (26 females and 12 males), and 17 (11 females and 6 males) patients with bilateral femoral, bilateral tibial, and bilateral humeral lengthening. The mean lengthening rate was 0.920 ± 0.23 (range, 0.53-1.67), 0.813 ± 0.17 (range, 0.51-1.26), and 1.02 ± 0.26 (range, 0.58-150) mm/day in the femoral, tibial, humeral groups, respectively. In the femoral group, 75% femur with good morphological quality, 56.6% good morphological quality in tibial group and 55.9% good morphological quality in humeral group. Statistically significant relationships were found between femoral lengthening rate and callus quality (p < 0.001; r = 0.454). However, no significant correlation was found in the humeral and tibial groups. Moreover, the sensitivity and specificity of the lengthening rate for obtaining good morphological quality callus were 72% and 80%, respectively, with an optimum diagnostic cutoff value of 0.976 mm/day for femoral lengthening. Conclusions: A higher-rate good morphological callus was obtained in femoral lengthening compared with tibia and humerus in patients with achondroplasia.

IS VOLAR PLATING IN DISTAL RADIUS FRACTURES SAFE REGARDING PRONATOR QUADRATUS?

Objective: This study aimed to investigate whether isokinetic strength decrease significantly after using volar plating for distal radius fractures and evaluate the pronator quadratus muscle regarding atrophy. Methods: This study took place between 2011 and 2015 and included 18 distal radius fracture patients (group 1) who were treated via volar plating at least one year prior and 14 healthy controls (group 2). All participants were tested isokinetically. Grip strength, radiological evaluation, wrist range of motion, disabilities of the arm, shoulder, and hand and visual analog scale scores were assessed for clinical and functional outcomes. Ultrasonography evaluated the pronator quadratus muscle thicknesses. Results: The peak supination torque (PT) and supination work per repetition (WPT) strength values significantly decreased (p:0.039, p:0.025, respectively). Although we determined an 11% pronation PT deficit and a 19% pronation WPT deficit, neither were significant. In group 1, the pronator quadratus muscle thickness decreased 5.9% ± 13.3 in the radial area and 9.7% ± 10.5 in the interosseous area according with ultrasonography; these results were not statistically significant compared to group 2. All clinical and functional outcomes were not statistically significant between the groups. Conclusion: The use of volar plating after distal radius fractures is a safe method regarding isokinetic strength and pronator quadratus muscle atrophy. Level of evidence III; Retrospective case-control study .

Objetivo: Este estudo teve como objetivo investigar se as forças isocinéticas diminuem significativamente após o uso de placa volar para tratamento de fraturas do rádio distal e avaliar o músculo pronador quadrado quanto à atrofia. Métodos: Este estudo realizado entre 2011 e 2015 incluiu 18 pacientes com fratura do rádio distal (grupo 1) que tenham sido tratadas com placa volar pelo menos um ano antes e 14 pessoas saudáveis como controle (grupo 2). Todos os participantes foram testados isocineticamente. Força de preensão, avaliação radiológica, amplitude de movimento do punho, deficiências do braço, ombro e mão e escores da escala visual analógica foram avaliados clinica e funcionalmente. A ultrassonografia avaliou a espessura do músculo pronador quadrado. Resultados: A força máxima do torque de supinação (TM) e do trabalho por repetição (ER) de supinação diminuíram significativamente (p: 0,039, p: 0,025, respectivamente). Embora tenhamos determinado um déficit de TM de pronação de 11% e um déficit de ER de pronação de 19%, nenhum dos dois foi significativo. No grupo 1, a espessura do músculo pronador quadrado diminuiu 5,9% ± 13,3 na área radial e 9,7% ± 10,5 na área interóssea, segundo ultrassonografia; estes resultados não foram estatisticamente significativos em comparação com o grupo 2. Nenhum resultados clínico ou funcional foi estatisticamente significativo entre os grupos. Conclusão: O uso de placa volar após fraturas do rádio distal é um método seguro em relação à força isocinética e atrofia do músculo pronador quadrado. Nível de evidência III; estudo retrospectivo de caso-controle .

Temporary Epiphysiodesis Using the Eight-Plate in the Management of Children with Leg Length Discrepancy: A Retrospective Case Series.

Background: Although eight-plates have been shown to be effective in correcting angular deformities of the knee, the literature is scarce regarding the efficiency of this method in treatment of children with LLD. Objectives: The aim of this study was to determine the efficiency, rates of correction and complications of epiphysiodesis using eight-plate in the management of children with leg length discrepancy (LLD). Methods: Eleven consecutive patients with LLD (7 boys, median age = 9, age range 6-11 years) who were treated by temporary epiphysiodesis using eight-plates were retrospectively reviewed and included in the study. The main indication for temporary epiphysiodesis was an LLD between 2 and 5 cm in all patients. LLD and lower limb alignment were examined on lower extremity weight-bearing radiography preoperatively and at skeletal maturity. Longitudinal correction rate was calculated. The final LLD was categorized as ''good result'' (final LLD < 1.5 cm), ''fair result'' (1.5-2 cm), and ''poor result'' (> 2 cm). Results: The mean treatment period with the eight-plate was 44 (min to max = 32-72) months, and the mean follow-up from the index surgery to the final follow-up was 62 (min to max = 39-106) months. The mean LLD was significantly reduced from 39 (range 25-50) mm preoperatively to 22.40 (range 6-55) mm postoperatively (p = 0.006). The mean longitudinal correction rate was found to be 0.48 mm/mo. Radiographic evidence of lower limb deformity in frontal and sagittal planes was determined in neither preoperative nor postoperative deformity analysis. No major complications were recorded. Conclusion: For the management of children with LLD of 2-5 cm, temporary hemiepiphysiodesis using the eight-plate seems to be an effective treatment with low complication rates.

Effects of Collagen- and Arginine-Fortified Osteokine Supplementation on Fracture Healing.

Introduction Delayed union or nonunion is an important clinical challenge for orthopedic surgeons. In addition to the main treatment algorithms, the use of nutritional supplements is increasingly common. In this study, we investigated the effects of nutritional supplements fortified with arginine and collagen on fracture healing. Materials and methods Twenty-four rats with femur fractures were divided into experimental and control groups. Intramedullary fixation was performed in both groups. 20 ml/kg nutritional supplement was given to the experimental group. Radiological examination was performed at third and sixth weeks, and histopathological examination was performed at the sixth week. Results No statistically significant difference was found between the radiological scores of the groups at the third and sixth weeks. Nutritional supplement affected the histological properties of callus. Histological evidence of bone healing was observed by the sixth week in both groups but the score was higher in nutritional supplement group. A statistically significant difference was found between the histopathological scores of the groups at the sixth week. Conclusion Arginine- and type two collagen-augmented traditional nutritional supplements may help to achieve more successful results in fracture healing.

Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia.

PURPOSE: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT). METHODS: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients. RESULT: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group. CONCLUSION: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

The Effect of Intraarticular Insulin on Chondral Defect Repair.

OBJECTIVE: The aim of this study is to evaluate the effects of intraarticular insulin on the treatment of chondral defects. DESIGN: Twenty-four mature New Zealand rabbits were randomly divided into 3 groups as control (Group 1), microfracture (Group 2), and microfracture and insulin (Group 3). Four-millimeter full-thickness cartilage defects were created to the weight-bearing surface on the medial femoral condyles of each rabbit. In the first group, any additional interventions were not performed. Microfracture was performed on defects in groups 2 and 3. Additionally, 10 IU of insulin glargine was administrated into the knee joints of the third group. Three months after surgery, the knee joints were harvested and cartilage quality was assessed according to Wakitani and ICRS (International Cartilage Repair Society) scores histopathologically. Insulin injections were performed into the knees of 2 additional rabbits without creating a cartilage defect to evaluate the potential adverse effects of insulin on healthy cartilage (Group 4). RESULTS: The total ICRS and Wakitani scores of the insulin group were found to be significantly lower than the microfracture group but similar to the control group. No negative effects of insulin on healthy cartilage were detected. Intraarticular insulin after surgery has led to a statistically significant decrease in systemic blood sugar levels whereas the decrease observed after administration to intact tissues was not statistically significant. CONCLUSIONS: Insulin had a negative influence on the quality of cartilage regeneration and had no effect on healthy cartilage. Intraarticular insulin administration does not cause significant systemic effects in intact tissue.

Quality of Life Evaluation Following Limb Lengthening Surgery in Patients with Achondroplasia.

BACKGROUND: The primary objective of this study was to evaluate the quality of life following limb lengthening surgery in patients with achondroplasia. The complications and different lengthening techniques have and effects on mid-term results were also investigated. METHODS: We performed a retrospective, multicenter study by evaluating the records of patients with achondroplasia operated in our clinic between 1999 and 2014 for limb lengthening with a minimum follow-up of 3 years. Forty nine patients were underwent bilateral lower limb lengthening surgery and 21 of 49 patients underwent bilateral humerus lengthening surgery. Patients were evaluated by the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales to assess the health-related quality of life (HRQOL) of children. Twenty patients with achondroplasia who had no lengthening surgery history were also evaluated with the PedsQL score as the control group. RESULTS: The average age at the time of first surgery was 6.17 years. The average follow-up period was 100.2 months. The average age at the time of study 14.70 ± 2.44 (11-18) years. There were significant differences between the patients with humeral lengthening and patients who did not undergo humeral lengthening in all scores. Transient complications had minimal effects on scores. Although all scores in the operated group were higher than non-operated patients with achondroplasia, there were no significant differences. CONCLUSION: Quality of life was significantly improved as a result of humerus lengthening surgery of patients with achondroplasia, despite minor complications compared with Lower limb lengthening surgery. LEVEL OF EVIDENCE: Level III, case control study.

Combined Technique for the Treatment of Infected Nonunions of the Distal Femur With Bone Loss: Short Supracondylar Nail-Augmented Acute Shortening/Lengthening.

OBJECTIVE: To evaluate a combined technique for treating distal femoral bone defects after debridement of osteomyelitis, using an external fixator together with a short supracondylar nail. DESIGN: Retrospective study. SETTING: Single tertiary referral center. METHODS: Between 2003 and 2018, 23 patients with a mean age of 37.2 years (26-56) underwent surgery with the same technique to manage postdebridement defects in the distal femur due to osteomyelitis. This involved acute shortening and intramedullary fixation of the defect site, together with relengthening from a proximal osteotomy using simultaneous external fixation. Radiographic union, range of motion of the hip and knee, external fixation time and external fixation index, and limb length discrepancy were assessed. RESULTS: The mean follow-up was 51 months (18-192). Union was achieved in all patients without recurrence of infection during this follow-up period. The mean knee flexion was 120 degrees, and the mean extension deficit was 5 degrees at final follow-up. The mean limb length discrepancy improved from 5.5 cm (3-7) to 0.5 cm (0-2). The mean external fixation index was 29.2 d/cm (20-50), and the mean external fixation time was 115 days (90-150). Radiographic scores were excellent in 15 cases, good in 6, and fair in 2. Functional scores were excellent in 14 cases, good in 7, and fair in 2. CONCLUSION: This combined strategy was an effective method for treating distal femoral segmental bone defects after debridement of osteomyelitis, with a high rate of union and acceptable complication rates. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute shortening versus bone transport for the treatment of infected femur non-unions with bone defects.

BACKGROUND: The bone transport technique has been a well-known method in the treatment of osteomyelitis of the long bones with large segmental bone defects. However, one of the major drawbacks with this traditional technique is the long-lasting consolidation period, which may entail infectious and non-infectious complications. To overcome this drawback, several techniques were developed, one of which is acute shortening and re-lengthening. The aims of this study were: 1) to present our experience with a new modified technique of acute shortening and re-lengthening using a monolateral external fixator combined with a retrograde intramedullary nail, and 2) to compare its results with the classic Ilizarov bone transport method in the management of infected non-unions of the distal femur with bone loss. METHODS: This retrospective study compared these two techniques. 17 patients were treated using our modified technique of acute shortening and re-lengthening (Group A); 15 patients were treated using segmental bone transport (Group B). The average follow-up was 66 months (range: 24-180) in Group A and 70 months (range: 24-240) in Group B. The mean bone loss was 5.5 cm (range: 3-10) in Group A and 5.9 cm (range: 3-10) in Group B. The primary outcome of the present study was to compare the external fixator time (EFT) and external fixation index (EFI) between the two groups. The bone and functional status were also assessed. RESULTS: The mean EFI was lower in Group A (mean: 31.8 days/cm; range: 24-50) than in Group B (mean 48.7 days/cm; range: 40-100) (p = 0.02). The mean EFT was shorter in Group A (mean: 120 days; range: 100-150) than in Group B (mean: 290 days; range: 100-400) (p = 0.0003). With respect to the bone and functional results, no difference was observed. CONCLUSIONS: Although both techniques could be employed safely in the treatment of infected non-union of the distal femur with size defects ranging between 3 cm and 10 cm, our modified technique of acute shortening and re-lengthening may confer greater patient satisfaction because of shorter EFI.

Outcomes of salvage total hip arthroplasty after failed osteosynthesis for collum femoris fractures.

BACKGROUND: This study is an investigation of the outcomes of salvage total hip arthroplasty (THA) to treat collum femoris fractures that resulted in complications or failure after osteosynthesis. METHODS: Twenty patients (6 male, 14 female; mean age: 56.7 years) who underwent salvage total hip arthroplasty (THA) between 1988 and 2012 due to failure developing after closed reposition and osteosynthesis in the treatment of collum femoris fractures were included in the study. The type of osteosynthesis, and the length of time until failure and before THA application after collum femoris fracture were recorded. Cementless acetabular and femoral components were used in all of the patients. Complications were defined as those occurring during and after surgery. The clinical results were assessed with the Harris Hip Score (HHS) and the presence of loosening was assessed with radiological evaluation in follow-up. RESULTS: The mean length of the follow-up period was 59.4 months (range: 15-178 months). The collum femoris fractures of the 20 patients were classified as: 5 Garden type II, 13 type III, 2 type IV, and 3 Pauwels type I, 8 type II, and 9 type III. Cannulated screws were used in 13 patients (65%) and dynamic hip screw (DHS) fixation was used in 7 patients (35%). Complications observed after osteosynthesis were nonunion in 4 cases (20%), malunion in 2 (10%), avascular necrosis in 10 (50%), and implant failure in 4 (20%). A mean of 9.66 months (range: 3-54 months) elapsed before osteosynthesis failure and the mean length of time until THA was 31.6+-51.7 months. There was no statistically significant difference between cannulated screw and DHS fixation in the development of complications (p=0.084). Early dislocation (5%), periprosthetic fracture (5%) and acetabular protrusion (5%) were recorded as complications. A revision was made upon determination of loosening in the 10th year in the patient who developed early dislocation. While the mean HHS was 54.05+-8.22 before THA, it was evaluated to be 86.45+-8.73 at the last follow-up, which was a statistically significant difference (p<0.0001). CONCLUSION: The study findings demonstrated that THA applied with suitable surgical technique is a safe and successful method that may be used after failed osteosynthesis in cases of collum femoris fracture.

A Minimally Invasive Technique Using a Modified Stoppa Approach for Periacetabular Osteotomy: A Preliminary Cadaveric Study.

BACKGROUND: Developmental hip dysplasia is diagnosed when the femoral head is not sufficiently covered by the acetabulum. Anterior and lateral cover deficiency is seen, as a result a dysplastic hip joint. Various incision modifications have been developed because of the muscle dissection and wide wound scar in Smith-Peterson incision, which was originally used in Bernese osteotomy. This study evaluates applicability of the modified Stoppa approach in the performance of Bernese periacetabular osteotomy (PAO). MATERIALS AND METHODS: Ten hemipelvises of five donor cadavers were used. The transverse Stoppa incision was made 2 cm over the symphysis pubis for quadrilateral surface exposure and pubic and ischial bone osteotomies. The second skin incision, a few centimeters lateral to the original incision, was made along the tensor fascia lata. Iliac bone osteotomy was performed starting just above the rectus femoris insertion. The displacement of the osteotomy was measured clinically and radiographically. RESULTS: The mean anterior coverage calculated with center-edge angle was improved from 22.8° ±2.8 (range 20° min-28° max) preoperatively to 44.1° ± 3.7 (range 36° min-48° max). The displacement of the osteotomy at the iliopectineal line calculated on the iliac inlet view radiographs was 22.1 ± 3.4 mm (range 15 mm min-26 mm max). The clinical amount of the anterior displacement on the cadavers was 17.8 ± 3.35 mm (range 11 mm-21 mm) and lateral displacement was 20.3 ± 3.23 mm (range 15 mm-24 mm). The amount of the posterior intact bone enlargement at the quadrilateral surface was 5.3 ± 0.48 mm. CONCLUSION: This less traumatic two-incision exposure is an adequate technique for Bernese PAO, allowing the bone to be cut under direct visual observation and reducing the need to use fluoroscopy.

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects.

INTRODUCTION: This study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10cm in length. METHODS: In a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates. RESULTS: The mean size of the bone defect was 7cm in Group A, and 5.8cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P=0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P=0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P=0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P=0.28). CONCLUSIONS: While both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures. LEVEL OF EVIDENCE: Level III; Retrospective comparative study.

Mid-Term Results of Minimally Invasive Plate Osteosynthesis and Circular External Fixation in the Treatment of Complex Distal Tibia Fractures.

BACKGROUND: The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators. METHODS: We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score. RESULTS: Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12-26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18-24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients. CONCLUSIONS: Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.