Patellar Lateralization, Absence of Joint Hypermobility, and the Mechanism of Injury Are Associated With Osteochondral Fracture After First-time Acute Lateral Patellar Dislocation in Adolescents: An MRI-based Evaluation.

BACKGROUND: Although the risk factors for patellofemoral dislocation are clearly defined, risk factors for osteochondral fracture (OCF) after patellar dislocation are not as well defined. The aim of this study was to investigate the risk factors for OCF by evaluating patients with and without OCF after first-time acute patellar dislocation. METHODS: This multicenter study was conducted as a retrospective examination of the radiologic measurements on the magnetic resonance imaging of 306 patients. The patients were divided into the OCF group and non-OCF group, and OCFs were grouped according to whether the fracture was in the patella or femur. Patellar height, patellar lateralization, trochlear morphology, patellofemoral matching, and patella types were evaluated on patient magnetic resonance imaging. The presence of joint hypermobility in the patients was determined according to the Beighton scale score. The injury mechanisms of the patients were grouped as sports-related injuries, injuries resulting from simple falls, and injuries during daily activities. RESULTS: A total of 120 OCFs were detected in 108 (35.2%) patients, of which 96 (80%) were in the patella and 24 (20%) in the femur. The rate of OCF after sports-related injuries was found to be significantly higher than in other injury mechanisms ( P =0.001). More joint hypermobility was detected in patients without OCF ( P =0.041). The measurements of tibial tubercle-trochlear groove, tibial tubercle-posterior cruciate ligament distance and lateral patellar displacement were statistically higher in cases with OCF ( P =0.001). In patients with normal joint mobility, the rate of OCF localization in the patella was significantly higher ( P =0.035). No correlation was found between any other parameters and OCF ( P >0.05). The absence of joint hypermobility and the measurements of tibial tubercle-trochlear groove distance, tibial tubercle-posterior cruciate ligament distance, and lateral patellar displacement were independent risk factors for the incidence of OCF according to the logistic regression analysis. CONCLUSIONS: The absence of joint hypermobility and patellar lateralization are independent risk factors for the occurrence of OCF after first-time patellar dislocation. Sports-related injury is a nonindependent risk factor for the presence of OCF. In patients with normal joint mobility, the incidence of OCF in the patella is higher than in the femur. These important factors should be considered when evaluating patients and starting their treatment. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

E-scooter-related orthopedic injuries and the treatments applied: are these scooters a new means of transportation or a new source of trauma?

INTRODUCTION: E-scooters have become increasingly popular in Turkey due to easy accessibility. In parallel with this, the number of e-scooter-related injuries has increased gradually. The aim of this study was to determine the types of e-scooter-related orthopedic injuries, to evaluate hospitalization and surgical treatments, and to investigate the loss of work of patients and the burden incurred by the healthcare system. MATERIALS AND METHODS: This retrospective multicentre study included all orthopaedic referrals, who were admitted to two major trauma departments in Diyarbakir from January 2022 to July 2022. Patient data were analyzed, including demographic characteristics, injury pattern, types of injury and subsequent treatment. RESULTS: In a total of 62 patients, 105 orthopaedic injuries were identified, comprising 72.5% males and 27.5% females, with a median age of 34.21 years. Fifty-six (90.3%) patients were riders, and six were pedestrians. All associated e-scooters were rented. There were 44 fractures (41.9% of the total recorded injuries) including 8 (12.9%) open fractures. Surgery was required by 32 patients (51.6%) and 35 (56.4%) required hospital admission leading to hospitalization of 3.7 days on average. The average job loss of working patients after injury was determined as 2.4 months. Helmet use was detected in 6.4% of the e-scooter users, but no other protective equipment was detected in any of the patients. Furthermore, 19,3% of the patients had a blood alcohol level of > 10 mg/dl. CONCLUSIONS: The injuries that may result from an e-scooter accident can have long-term hospitalization and long-term job loss in the community. This imposes a significant financial burden on the national healthcare system and adversely affects public health. There is a need for precautions to be implemented such as infrastructure organisation, increased awareness of motor vehicle riders and e-scooter riders, and increased enforcement of rule compliance including not using e scooters after alcohol consumption and the use of protective equipment.

Does radiation exposure during pediatric supracondylar humeral fracture surgery change according to the C-arm position? A comparison of two different techniques.

INTRODUCTION: In the surgical treatment of supracondylar humeral fractures (SHF), the surgeon has to stand right next to the fluoroscopy device, so it is very important to know how to use it in the most appropriate way to reduce radiation exposure. The aim of this study was to investigate the effect of using C-arm in uniplanar (inverted) and biplanar (standard-horizontal) configurations on (1) the radiation exposure to the surgeon, and (2) surgical time and fluoroscopy exposure time. MATERIAL AND METHODS: This prospective randomised study was conducted on 20 patients who underwent fluoroscopy during closed reduction and percutaneous pinning for a SHF. In the first configuration, the C-arm was inverted and the image intensifier was used as a surgical table. In the second configuration, the C-arm was used biplanar. The operations were performed by 5 surgeons, with each surgeon using each method only twice. During the operation, to find a value closed to direct radiation exposure measurement was made by attaching a dosimeter to the wrist and scatter radiation exposure was measured by attaching a dosimeter to the neck and waist of the surgeons. The operation time and fluoroscopy exposure time were determined. RESULTS: The duration of operations performed with the biplanar C-arm position and the fluoroscopy exposure time in operations performed with the uniplanar method were found to be statistically significantly longer (p = 0.001). The measurements on the dosimeter worn on the neck of surgeons were found to be statistically significantly higher while using the uniplanar C-arm configuration (p = 0.001). There was no statistically significant difference between the dosimeter measurements on the wrists and waists of the surgeons and the C-arm configurations (p = 0.820; p = 0.185). CONCLUSIONS: Although the use of biplanar C-arm has no effect on radiation exposure to the surgeon's wrist, the most important advantages are that the neck area is exposed to less radiation and it shortens the fluoroscopy time so the use of a biplanar C-arm can be recommended. LEVEL OF EVIDENCE: Level II.

Does COVID-19 vaccine exacerbate rotator cuff symptoms? A prospective study.

BACKGROUND: Shoulder injury related to vaccine administration (SIRVA) is a rare but increasing complication after vaccination. The aim of this study was to increase awareness of post-vaccination shoulder pain and to investigate the effect of the clinical condition of the shoulder before vaccination on the loss of function that may occur after vaccination. METHODS: This prospective study included 65 patients aged > 18 years who were diagnosed with unilateral shoulder impingement and/or bursitis. The first vaccination was performed on the shoulders with rotator cuff symptoms, then the second vaccination was performed on healthy shoulders of same patients as soon as the health system allowed. Pre-vaccination MRI of the symptomatic shoulders of the patients was performed and VAS, ASES and Constant scores were evaluated. At 2 weeks after vaccination of the symptomatic shoulder, scores were reassessed. For the patients with changes in the scores, MRI was performed again and the treatment of all patients was started. A second vaccination was given to asymptomatic shoulders and the patients were recalled two weeks later and their scores were evaluated. RESULTS: After vaccination, the symptomatic shoulder of 14 patients was affected. No clinical changes were observed in the asymptomatic shoulders after vaccination. The VAS scores of the symptomatic shoulders evaluated after vaccination were significantly higher than the scores evaluated before vaccination (p = 0.001). The ASES and Constant scores of symptomatic shoulders evaluated after vaccination were significantly decreased compared to the scores evaluated before vaccination (p = 0.001). CONCLUSIONS: Exacerbation of symptoms may occur if symptomatic shoulders are vaccinated. Before vaccination, a detailed anamnesis should be taken from the patients and vaccination should be performed to the asymptomatic side.

Foot and Ankle Forklift Injuries; Diagnosis to Treatment Options, Return to Work and Functional Outcomes.

As our tertiary-level trauma center is close to an industrial zone and associated international port, industrial injuries are seen more often than is expected in routine practice. The aim of this study was to present the demographic data, treatment options, and changes in work-life of patients with foot and ankle injuries due to a forklift accident, and to determine the factors affecting the clinical outcome. The study was conducted in our university hospital and included patients who presented with a foot and ankle injury resulting from a forklift accident. Data were collected including age, sex, dominant extremity, history of trauma, presence of fracture, management (surgical or conservative), complications, time of return to work, workforce loss, and the American Orthopaedic Foot and Ankle Society (AOFAS) and Short Form Health Survey (SF-36) scores at the final follow-up examination. Evaluation was made of 132 patients, comprising 113 (85.6%) males and 19 (14.4%) females with a mean age of 32 years (range 16-65 years). The most frequently recorded occupational group was shipyard workers (50%). The most common mechanism of injury was crushing under the forklift wheel (n = 63, 47.7%). The most frequently injured foot region was the forefoot (47%). A total of 90 (68.1%) patients continued to work in the same position on return to work. The lowest mean AOFAS score (73.4) and SF-36 (physical component) score (37.3) were determined in cases with mixed region injuries (p = .0001, p = .0001). The wearing of protective footwear had no effect on the rate of return to work (p = .195), workforce loss (p = .34) and AOFAS score (p = .166). This study is the largest series of patients with foot and ankle injuries related to forklift accidents. Forklift injuries can be treated conservatively or surgically according to the clinical condition of the patient. The main indicators of return to work and functional outcome are which foot region is injured and whether or not the injury causes a fracture.

What is the best treatment for syndesmosis fixation? Suture-button or syndesmotic screw ? Bilateral CT-based early postoperative analysis.

BACKGROUND: The aim of this study was to compare the effectiveness of syndesmotic screw (SS) and suture button (SB) on the reduction and fixation of syndesmosis via early postoperative bilateral computed tomography (CT). METHODS: This single-center retrospective study included 76 patients aged ≥ 18 years with a unilateral syndesmosis injury. SS was applied to 40 patients and SB to 36 patients. The differences between the sides stabilized using SB or SS and the intact sides were analyzed using the parameters of tibio-fibular clear space (∆CS) and anterior or posterior sagittal translation (∆ST) depending on the orientation of the fibula. The cases in which the fibula was translocated to the posterior of the tibia after the change of ∆ST and ∆CS> 2 mm were evaluated as malreduction. Axial CT images taken from the level of syndesmosis fixation were divided into 4 zones according to the orientation angle of the implant sent from the fibula to the tibia. RESULTS: No significant difference was found in the analyses performed between total patient group with malreduction and fixation groups in terms of ∆CS and ∆ST values (p = 0.708, p = 0.289). It was observed that the fixation material was in zone 3 in 54 patients and in zone 2 in 22 patients. No significant difference was found in the analyses performed between the SS and SB groups according to the implant zone (p = 0.191). In the SS group sent from Zone 2, the malreduction rate according to the ∆ST value of syndesmosis was found to be significantly higher than in the SB group (p = 0.008, p = 0.003). CONCLUSION: When the implant is applied with the correct technique, there is no difference between SS and SB in terms of early postoperative reduction. When the SS is advanced at an inappropriate angle, it negatively affects the reduction of the fibula, while SB can better tolerate angle errors up to certain degrees due to its flexible structure. Therefore, it can be presumed that the suture button system is a more convenient method in the reduction and fixation of syndesmosis than the syndesmotic screw. LEVEL OF EVIDENCE: Level IV.

Effect of rotational deformities after pediatric femoral fracture on clinical outcome.

Femoral shaft fractures are the most common pediatric injuries that require hospitalization. Early closed reduction and spica casting are one of the most popular treatment options. One of the significant complications of spica casting is rotational deformities of the fracture. The present study aimed to determine the potential effects of rotational deformities in pediatric patients who underwent early spica casting after a femoral shaft fracture. Pediatric patients who underwent early spica casting following femoral shaft fractures were screened retrospectively. Radiological measurements were made on the patients' initial postop radiographs who could be measured rotationally according to the defined radiological method. Twenty-three patients with more than 10° of rotation in their measurements were included in the study. Differences in leg length and rotation between both legs were calculated with clinical examination methods for all patients in the study. The gaits of the patients were observed; patient and family complaints were obtained. We found a strong and positive correlation between the rotational measurement made on the X-ray and the clinical measurement (R: 0.634, P: 0.001). For measurements made on X-ray, the mean rotational value was calculated as 27.2 ± 6.9 degrees. After the patients' clinical examination, an average of 3.0 ± 1.7 degrees rotational difference was found between the broken limb and the healthy limb. No patient or family complained of trauma. Early spica casting, according to the age of the patient, is an effective treatment method. There may still be certain degrees of deformity after treatment, but patients well tolerate them even at high degrees. Accordingly, it was concluded that the rotational deformities less than 30 degrees would not cause clinical problems on children under 4 years of age which may require postoperative revisions or the use of various costly imaging techniques and include radiation.

Implant survival and functional results of endoprosthetic reconstruction for proximal femoral metastases with pathological fractures.

BACKGROUND: This study aimed to evaluate the patient and implant survival, clinical and functional outcomes, and the rate of complications resulting in reconstruction failure following endoprosthetic reconstruction (EPR) of extensive proximal femoral metastases associated with actual or impending pathological fractures. METHODS: A total of 111 patients with actual or impending pathological fractures due to metastatic disease of the proximal femur were treated with EPR between 2003 and 2018. Staged surgery, bilateral EPR, was performed in 3 cases. The patients comprised 51 females and 60 males with a mean age of 52.1 ± 12.3 years. The patient and implant survival were recorded. Clinical and functional outcomes were assessed by using the visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) functional scoring, and Karnofsky Performance Scale (KPS). The different types of abductor mechanism repair were evaluated by functional tests and existence of Trendelenburg gait at postoperative follow-ups. The complications resulting in reconstruction failure were investigated. RESULTS: The mean follow-up was 23.1 ± 17.9 months. The overall survival of patients after EPR was 89% at 6 months, 72% at 1 year and 10% at 5 years. The estimated 1- and 5-year overall implant survival was 100% and 97.3% (95% CI, 0.95-0.98), respectively, as the endpoint was defined as complete removal of the prosthesis. Median VAS score before endoprosthetic replacement was 8 and after 3 months 4. Before surgery, the median MSTS score was 40 (30-56.6%) and the median KPS score was 40 (30-50). Postoperative third month, the median MSTS score was 56.6 (53.3-86.6%) and the median KPS score was 60 (40-70). Functional scores were superior in trochanter major split osteotomized group compared to trochanter major removed group. Trendelenburg gait was seen in 20 (17.5%) patients postoperatively. There were 10 (8.7%) complications resulting in reconstruction failure. CONCLUSION: Endoprosthetic replacement can provide a durable fixation with high implant survival rate and good clinical and functional results in extensive proximal femoral metastases associated with a pathological fracture.

Dorsal or Lateral Approach for Intramedullary Nailing Using Kirschner Wire in Pediatric Radius Diaphyseal Fractures: Does it really matter?

BACKGROUND: Intramedullary nailing is the most preferred fixation method for diaphyseal radius and ulna fractures in the young age group. The aim of this study was to compare the dorsal and lateral entry points in the context of entry site-related complications, fracture union and functional results. METHODS: This retrospective comparative study included pediatric patients who underwent surgery for isolated diaphyseal radius or both bone forearm fractures with intramedullary nailing using Kirschner wire between January 2013 and January 2019. K-wire was introduced from the distal radius through dorsal entry (Group A) in 19 patients and lateral entry (Group B) in 18 patients. The mean follow-up was 37 months. Complications were noted and functional outcomes were evaluated according to the CHOP criteria. RESULTS: All fractures were healed. The functional results were determined to be excellent for 30, fair for 4, and poor for 3 patients. The overall complication rate was 18.9%, including distal radius fracture, mild pain in the wrist, and minor loss in ROM. No statistically significant differences were determined between the groups in respect of functional results and complication rates. CONCLUSION: Good functional results and similar complication rates can be obtained with both dorsal and lateral entry approaches. Stainless steel K-wire is an inexpensive intramedullary fixation implant option, which provides strong stabilization. Distal radius fracture is a newly reported complication for forearm intramedullary nailing. Leaving the implant out of the skin seems safe with the benefit of avoiding a further surgical intervention to extract the implant.

Spinal osteotomies: indications, limits and pitfalls.

The aims of spinal deformity surgery are to achieve balance, relieve pain and prevent recurrence or worsening of the deformity.The main types of osteotomies are the Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO) and vertebral column resection (VCR), in order of increasing complexity.SPO is a posterior column osteotomy in which the posterior ligaments and the facet joints are removed and correction is performed through the disc space. A mobile anterior disc is essential. SPO is best in patients with +6-8 cm C7 plumbline. The amount of correction is 9.3° to 10.7°/level (1°/mm bone).PSO is a technique where the posterior elements and pedicles are removed. Then a triangular wedge through the pedicles is removed and the posterior spine is shortened using the anterior cortex as a hinge. The ideal candidates are patients with a severe sagittal imbalance. A single level osteotomy can produce 30° 40° of correction. A single level osteotomy may restore global sagittal balance by an average of 9 cm with an upper limit of 19 cm.BDBO is an osteotomy done above and below a disc level. A BDBO provides correction rates in the range of 35° to 60°. The main indications are deformities with the disc space as the apex and severe sagittal plane deformities.VCR is indicated for rigid multi-planar deformities, sharp angulated deformities, hemivertebra resections, resectable spinal tumours, post-traumatic deformities and spondyloptosis. The main indication for a VCR is fixed coronal plane deformity.The type of osteotomy must be chosen mainly according to the aetiology, type and apex of the deformity. One may start with SPOs and may gradually advance to complex osteotomies. Cite this article: EFORT Open Rev 2017;2:73-82. DOI: 10.1302/2058-5241.2.160069.