Less malunion and shorter bone union time with titanium elastic nail treatment for isolated femoral shaft fractures in three- to six-year-old children.

PURPOSE: Titanium elastic nail (TEN) is a good option for femoral shaft fractures in school-age children, whereas a spica cast is favored for younger patients. We aimed to compare these treatment modalities in a group of children aged three to six years. METHODS: 34 patients aged 3-6 years with an isolated closed femoral shaft fracture treated with TEN or one-leg spica cast immobilization were retrospectively assessed. Age, gender, weight, mechanism of injury, hospital stay time, bone union time, radiographic shortening, malunion, and complications were compared between the treatment groups. RESULTS: 16 (47.1%) patients who were treated with TEN (Group T) and 18 (52.9%) patients with spica casting (Group S) were included with a mean of 51 (24-94) months follow-up. The mean age was 4.98 years and statistically similar between both groups (mean, 5.2 vs. 4.8 years; p = 0.234). The patients in Group T were heavier (mean, 19.3 vs. 17.2 kg; p < 0.001) and were more likely to have a higher-energy mechanism of injury (p = 0.006). The mean late femoral shortening of Group S patient's was 6.5 ± 3.5 mm and significantly higher than Group T, which was 2.0 ± 2.9 (p = 0.050). However, effective late femoral shortening rates were not statistically different between groups (p = 0.347). Malunion was seen in six (33.3%) patients in Group S, whereas none of the patients in Group T had malunion at the last follow-up examination and were statistically different (p = 0.011). CONCLUSION: Our study identified radiographic evidence favoring TEN over spica cast immobilization in treating preschool-age children with an isolated femoral shaft fracture in terms of malunion.

Forearm Compartment Pressure Change in Children Operated for Supracondylar Humerus Fracture.

BACKGROUND: The aim of this study is to examine the preoperative and postoperative forearm compartment pressures in patients treated operatively for Gartland type III extension type supracondyler humerus fractures and understand the course of these values over postoperative period. METHODS: Deep volar compartment pressure of 31 patients were measured in the proximal one third of the forearm preoperatively, and measurements were continued every 4 hours for the first 24 hours after the operation with a catheter. Type of the reduction technique (open reduction vs. closed reduction), duration of surgery, the time from the injury to surgery were all evaluated. RESULTS: In the measurements made immediately after the operation (0 h), a sudden increase in the compartment pressure was detected in all patients (15.0±5.9 to 27.9±7.5 mm Hg) independent of the reduction technique and gradually decreased over time. The mean compartment pressure at the 12th hour postoperatively was higher in the open reduction group than in the CR group (24.5±3.4, 20.7±6.7 mm Hg, respectively) ( P =0.044). The mean preoperative compartment pressure was 17.7±5.8 mm Hg in patients with a time from injury to surgery longer than 12 hours, and 12.4±4.8 mm Hg in patients with 12 hours or less ( P =0.006). The postoperative 0-, 12-, and 20-hour pressure values were higher in the >1 hour operation time group than in the ≤1 hour group and the differences were statistically significant ( P =0.046, 0.016, and 0.032, respectively). CONCLUSIONS: In pediatric supracondylar humeral fractures, those who underwent open reduction had higher preoperative and postoperative compartment pressures. The reduction attempt was found to be a factor that increased the compartment pressure and after the operation, the compartment pressure values decrease gradually. Prolonged operative time (>1 h) and increased time from injury to operative fixation (>12 h) were associated with higher compartment pressures. LEVEL OF EVIDENCE: Level II-prospective study.

Osteoid Osteoma of the Talus Mimicking Pigmented Villonodular Synovitis in a 15-Year-Old Male: A Case Report.

Osteoid osteoma is a benign tumor of the bone which tends to occur in diaphysis or metaphysis of the long bones. The lesion is generally intraosseous with vague clinical symptoms, hence given the name "great mimicker". When located subperiosteally and juxtaarticulary, atypical clinical presentation and radiological may lead to a delayed or missed diagnosis. Performing surgery with a misdiagnosis carries the risk of incomplete resection of the lesion and recurrence. We report the case of a 15-year-old male with a subperiosteal osteoid osteoma of the talus, who was misdiagnosed with pigmented villonodular synovitis and operated through anterior ankle arthrotomy. A nodular lesion 1 cm in diameter with hard rubber consistency was removed from the dorsal aspect of the talar neck. The pathological specimens were consistent with subperiosteal osteoid osteoma. The patient's symptoms resolved rapidly in the early postoperative period. The patient remained asymptomatic at the 20th-month follow-up and the control MRI revealed no signs of recurrence. Atypical radiological and clinical presentation of juxtaarticular subperiosteal osteoid osteomas cause misdiagnosis, delay in diagnosis, incomplete resection and recurrence. It is important to keep in mind "juxtaarticular subperiosteal osteoid osteoma" in the differential diagnosis of cases with suspected Pigmented Villonodular Synovitis.

Outcomes of cable fixation after Vancouver type B1 periprosthetic femoral fractures.

BACKGROUND: In this study, it was aimed to evaluate the patients who underwent cable plate fixation due to a Vancouver-type B1 periprosthetic femur fracture and their clinical results. METHODS: Vancouver-type B1 patients who were operated on for periprosthetic fractures between 2014 and 2019 were investi-gated. Age, gender, body mass index (BMI), follow-up time, operation time, bleeding amount, non-union fracture, last surgery before fracture, the time between previous surgery and fracture, implant survival, patient survival, and complications were recorded. In addi-tion, the postoperative clinical functions of these patients were compared. RESULTS: 23 patients who met the study criteria (Vancouver type B1 fracture) were identified. The mean age of the patients was 60 (49-76) years, the mean BMI was 26.3 (17.5-40.7), and the postoperative mean follow-up period was 14 (6-36) months. Considering the gender distribution, there were 5 (22%) men and 18 (78%) women. The mean time between the last surgery before the fracture and the fracture was 6 months (0-30). While the mean operation time was 95 min (60-180), the average amount of bleeding was 310 mL (150-600). Functional evaluations of patients: In total, five patients had decreased ambulatory abilities after surgery. Nonunion was observed in 2 patients during the follow-ups, and these patients underwent open surgery for treatment. CONCLUSION: Cable and locking plate applications are successful in Vancouver type B1 fractures, which are one of the most common forms of periprosthetic fractures. In this technique, the duration of the operation can be shortened under ideal conditions, and the need for blood and blood products is reduced as blood loss is reduced. If there is a complication, you still have the chance to treat it with the option of revision arthroplasty.

Effect of bone morphogenic protein-2 and desferoxamine on distraction osteogenesis.

BACKGROUND: Angiogenesis is crucial for formation of a stable regenerate during distraction osteogenesis (DO). This experimental study evaluates if bone morphogenic protein-2 (BMP-2) and desferrioxamine (DFO), two agents which are known to induce neoangiogenesis in vivo, would increase angiogenesis and osteogenesis, and improve mechanical properties of bone regenerate in DO model. METHODS: Twenty-four tibias of 24 New Zealand rabbits were osteotomized and fixed with semi-circular fixators. Three groups of 8 animals were formed. BMP-2 soaked scaffolds were used in the first group, whereas daily local DFO injections were made in the second group. Subjects in the control group did not receive any agents during the surgery or in the distraction period. The rabbits in all three groups underwent distraction at a rate of 0.6 mm/day for 15 days following the 7-day latent period. Animals were sacrificed on day 38, and the tibia were harvested for histological and mechanical examination of the regenerate. RESULTS: All 24 rabbits survived the surgical procedure, and there were no side effects against the BMP-2 and local DFO. Three-point bending tests revealed a higher force (361 ± 267 N.) required for fracture in Group 1 (p: 0.018). Similarly, the bending moment in Group 1 (5.4 ± 4.0 Nmm) was significantly higher than the other groups (p: 0.021). There was no significant difference between the groups in terms of deflection and stiffness (p Ëƒ 0.05). Histologically, there was no statistical difference between the groups in terms of endochondral, periosteal, and intramembranous ossification and VEGF activity (p Ëƒ 0.05). CONCLUSION: BMP-2 and DFO stimulate angiogenesis by increasing VEGF activity. Angiogenesis is one of the most important mechanisms for the initiation and maintenance of new bone formation. Stimulation of angiogenesis in unfavorable biomechanical conditions may not be sufficient for ideal bone formation.

Entrapment of the brachial artery in the cancellous bone in pulseless supracondylar humerus fractures with well-perfused hands: Report of three cases.

Management of pediatric pulseless supracondylar humerus fractures is a point of continuous debate. In this article, we present three cases admitted to the emergency department with pulseless, but well-perfused hands. The fractures were reduced and fixed using the antecubital approach. Prior to reduction, the brachial arteries of all three patients were entrapped in the cancellous bone of the proximal fragment segment. The arteries could only be released after freeing the adventitia by carefully scraping the adjacent bone with the tip of a hemostat. One case required thrombectomy through an arteriotomy using No. 3 Fogarty catheter. In two cases, the pulse returned after a brief period of waiting with no need for vascular intervention. Proceeding with closed reduction, as proposed by the recent guidelines, would result in further damage to the entrapped vasculature, which may go unnoticed due to collateral circulation.

High-dose short-course oral corticosteroid protocol for treatment of primary frozen shoulder: a retrospective cohort study.

OBJECTIVE: To evaluate the effect of high-dose prednisolone on the functional outcome of patients with early-stage primary frozen shoulder. METHODS: Eighteen patients treated with oral prednisolone at an initial dose of 1 mg/kg/day for primary frozen shoulder were retrospectively evaluated. The patients' range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, and visual analog scale score were recorded at baseline and at 4 weeks and 6 months after treatment. RESULTS: Rapid recovery of shoulder motion was noted at 4 weeks with the exception of abduction, which was maintained at 6 months. Significant improvement in pain perception and the Constant-Murley score was evident at 4 weeks and extended to 6 months. The DASH and ASES scores did not show significant improvement in the first 4 weeks but were significantly improved at 6 months. CONCLUSION: High-dose oral prednisolone treatment provides rapid symptom resolution that persists long after drug discontinuation. The early treatment period is characterized by marked reduction in pain and rapid recovery of shoulder motion. Improvements in functional outcomes and disability indices tend to be more subtle in the early period but significantly improve during late treatment.

Primary treatment of complex proximal humerus fractures using Humelock cementless reversible shoulder arthroplasty in the elderly.

BACKGROUND: Proximal humerus fractures are quite common, constituting 5% of all fractures. Plate osteosynthesis of comminuted fractures in the elderly with osteoporotic bones is prone to complications, including loss of reduction, intraarticular protrusion of screws, avascular necrosis and non-union. Hemiarthroplasty may be preferred to achieve a stable fixation, which permits early shoulder motion. Prerequisites for the successful functional outcome of this surgical technique are to have an intact rotator cuff, which is often torn, and achieve proper soft tissue balance, which is technically demanding. In RSA design, deltoid muscle replaces the function of the supraspinatus, compensating for a dysfunctional rotator cuff or a displaced tuberculum. We designed a retrospective study to evaluate the results of proximal humerus fractures treated with reverse shoulder arthroplasty using Humelock II reversible prosthesis in elderly patients. METHODS: Thirty-one patients (25 females, six males) above 65 years old who underwent reverse shoulder arthroplasty between 2014 and 2019 for Neer 3-4 part fractures or head split injuries were included in this study. Patients with a previous internal fixation attempt, cases with neurological deficit or previous upper extremity fractures, patients who presented later than three weeks after the trauma, cases with less than six months follow-up and patients with additional fractures were excluded. Twenty-eight patients were available for final analysis. Fracture mechanism, time from trauma till surgery, hospital stay and preoperative ASA scores were noted. Humelock II Reversible (FX Solutions) implants were used in all cases. Patients' shoulder range of motion and functional outcome using UCLA, DASH and Constant scores at minimum six months follow-up were evaluated. RESULTS: The mean age was 72.2 (65-95) years, and mean follow-up time was 15.5 (6-48) months. The mean UCLA, Constant and Dash scores at the last follow-up were 27.6 (14-35), 67.9 (38-80) and 30.8 (9.9-79.2), respectively. Mean shoulder flexion, abduction, internal and external rotation were 130 (110-160), 100 (70-140), 40 (15-60) and 39 (15-75) degrees, respectively. CONCLUSION: RSA is a very reliable treatment for proximal humerus fractures in patients over 65 years old. Early active and passive shoulder exercises can be started postoperatively, and good functional outcome and wide ROM can be achieved with this age group. Although stable fixation of the tuberculum is not required for shoulder abduction, it facilitates external rotation and should be attempted in all cases. Clinical outcomes of patients who underwent RSA due to proximal humerus fracture are as good as the outcomes of patients with different etiologies.

Evaluation of titanium release from titanium alloy implants in patients with spinal instrumentation.

OBJECTIVE: This study was performed to investigate the baseline serum titanium levels in patients with short-segment titanium alloy posterior instrumentation and to assess patient-, implant-, and surgery-related factors that might affect the serum titanium level. METHOD: Two groups of patients were included in the study. The study group comprised 39 patients who had undergone short-segment posterior instrumentation from January 2013 to June 2016. The control group comprised 11 randomly selected patients who presented to the outpatient clinic with no history of orthopedic surgery. The serum titanium levels and inter-group differences were analyzed. RESULTS: The mean serum titanium level was significantly higher in the study group than in the control group. No significant difference was observed between patients with different etiologies, implants used for fusion, numbers of instrumented segments, or postoperative durations. CONCLUSION: The serum titanium levels of patients with posterior lumbar spinal instrumentation are significantly higher than those of the normal population even after achievement of solid fusion. These levels are not affected by the use of transverse connectors, the use of cages, the operated segments, or the duration of implants.

Comparison of efficacy between the genicular nerve block and the popliteal artery and the capsule of the posterior knee (IPACK) block for total knee replacement surgery: A prospective randomized controlled study.

OBJECTIVE: The aim of this study was to compare the efficacy of popliteal artery and the capsule of the posterior knee (IPACK) block and genicular nerve block on postoperative pain scores, the need for rescue analgesics, range of motion (ROM), walking distance, and perioperative monitorization variables in patients undergoing total knee replacement (TKR) surgery. METHODS: Sixty American Society of Anesthesiologists (ASA) physical status I-III patients were enrolled in this study and then were randomly assigned into three groups: the IPACK block group (17 female, 3 male; mean age=67.5±1.4 years), genicular nerve block (16 female, 4 male; mean age=68±1.76 years), and the control group (13 female, 7 male; mean age=63±1.67years). All the patients underwent TKR under spinal anesthesia. The visual analog scale (VAS) score, mobility, pre- and intra-operative monitorization of systolic and diastolic holding area, non-invasive blood pressure, heart rate, and SPO 2 were compared between the groups. RESULTS: Patients in the IPACK and genicular block groups had a significantly lower visual analogous scale (VAS) at postoperative 4 hours (p<0.01), 8h (p<0.01), 12h (p<0.01), and 24h (p<0.05). VAS score was significantly lower in the genicular block group at the postoperative 4h (5.5±0.55) and 8h (5.0±0.53) in the mobile state compared to the IPACK (8.0±0.47 and 8.0±0.43, respectively) and the control group (9.5±0.20; 10±0.28, respectively) (p< 0.01). The use of patient-controlled-analgesia (PCA) devices and button push count for analgesics demand were significantly lower in the genicular block group on the immediate postoperative period (p<0.01 at the postoperative 0 to 4 h). The total consumption of morphine equivalents on the postoperative day 0 was significantly lower in the genicular block group (p<0.01, and p<0.001 for IPACK and control groups, respectively). The degree of flexion was significantly higher in the genicular block group at the postoperative 12h compared to the IPACK and the control group (p<0.001). The length of hospital stay was significantly lower in the genicular block group compared to the IPACK and the control group (p<0.05 for both variables). CONCLUSION: IPACK and genicular blocks both are effective in improving patient comfort during and after TKR surgery and reducing the potential need for systemic analgesic and opioids. The genicular block seems to be a promising technique that can offer improved pain management in the immediate and early postoperative period without adverse effects on systemic and motor variables.

Treatment of Periarticular Fractures of the Knee Using the Less Invasive Stabilization System: A Retrospective Clinical Trial.

Introduction Periarticular fractures of the knee in adults are generally treated with internal fixation. The Less Invasive Stabilization System (LISS) plate, developed by Arbeitsgemeinschaft Osteosynthesefragen (AO)/Association for the Study of Internal Fixation (ASIF) in the late 1990s, allows reduction and biological fixation through smaller incisions without violating periosteal blood supply. It offers several advantages for the treatment of complex periarticular fractures of the knee. In this study, we have aimed to report the results of a single series of these fractures. Materials and methods Forty-eight patients with AO type 33 and AO type 41 periarticular knee fractures who were operated between 2009 and 2014 at a single institution were included in this retrospective study. Patient demographics, fracture epidemiology, intraarticular extension, concomitant injuries, American Society of Anesthesiologists (ASA) score, time to union, the average time from admission to surgery, and the mean time from operation to patient discharge were noted. The effect of patient and fracture-related factors on length of hospital stay were evaluated. Results The mean follow-up time was 23.7 (12-48) months. The average time from admission till surgery and from surgery till discharge was 10.2 (1-39) and 9.7 (2-35) days, respectively. The average time for union was 6.8 months. Femur fractures healed in mean 6.6 months whereas tibia fractures took 7.1 months to heal. Time from admission to surgery and postoperative hospital stay was longer in patients with higher ASA scores (p<0.01) and open fractures (p<0.001). Patients' body mass index (BMI) and intraarticular extension of the fracture did not cause an increase in either preoperative or postoperative hospital stay (p>0.05). The presence of concomitant major injuries caused a delay in operation (p<0.05), whereas postoperative hospital stay was not different (p>0.05). Conclusion LISS plating provides good stability through a small incision, permits biological fracture healing, may be used in multifragmentary fractures and has low complication rates. It is a good alternative for the treatment of periarticular fractures of the knee.

Efficacy of Single-Dose Radiotherapy in Preventing Posttraumatic Tendon Adhesion.

Background and Aim Posttraumatic peritendinous adhesion is the greatest obstacle to achieve normal tendon function following lacerations of extrinsic flexor tendons of the hand. In this study, we aimed to evaluate whether single-dose radiotherapy (RT) has the potential to modulate intrasynovial tendon adhesions. Materials and Methods A total of 80 tendons from the third to fourth flexor profundus of both hind paws of 20 adult New Zealand rabbits were used in this study. Rabbits in the RT group received 3 Gy of X-irradiation in a single fraction. Histopathological evaluation of longitudinal sections of tendons was made using the Tang grading system for peritendinous adhesions. Intratendinous quality of the healing tissue in the laceration zone was assessed using a modified Movin scale. Results Adhesion and inflammatory response were greater in the RT group (p˂0.001). Tendon healing in the radiation group was found to be more uniform and organized compared with the control group. However, this difference was not statistically significant. The nuclei of the tenocytes in the radiation group showed a closer resemblance to normal tendon tissue when compared with the control group (p=0.007). Conclusions Despite RT's certain advantages such as extracorporeal use, anti-inflammatory effect, and homogenous tissue penetration, 3-Gy X-irradiation resulted in increased peritendinous posttraumatic adhesion, possibly due to dose imbalance. Increased roundness in the tenocyte nuclei was present in the RT group. Studies with different dosing regimens and a higher number of subjects are necessary to establish an ideal dose suppressing the synovial response without compromising tendon healing.

Bone Loss Following Cementless Hemiarthroplasty for the Treatment of Femoral Neck Fracture.

BACKGROUND: With the advances in medicine, an increasing number of the ageing population are a public health concern in terms of age-related complications. Among them, displaced neck fractures often require surgical intervention or arthroplasty to achieve the mobilization of the elderly and good life quality. The aim of the study is to monitor the changes in bone mineral density (BMD) around the femoral stem and the effects on functional outcomes in patients treated with cementless hemiarthroplasty following femoral neck fracture. MATERIALS AND METHODS: Seventy-one patients aged 70 years or older who were treated with cementless hemiarthroplasty for a displaced femoral neck fracture were prospectively followed for 2 years. The percent change in the periprosthetic BMD in each Gruen zone was compared to the baseline using dual-energy X-ray absorptiometry (DEXA). Demographic factors [age, body mass index (BMI), and sex] that could possibly influence BMD and the clinical outcome were evaluated. RESULTS: Fifty-one patients were available for the final follow-up. The mean age was 76.5 (range 70-89) years. The mean BMI was 28.9 (range 22.7-37.2). The mean Harris hip score at the final follow-up was 84.3 (range 72-93). There was a significant decrease in BMD in all Gruen zones (p < 0.001), except in zone 3 (R3, p = 0.547). The reduction in BMD was highest in the calcar and the greater trochanter region. The femur diaphysis was relatively spared, with zone 3 showing no significant bone mineral loss. The age and BMI of the patients were not correlated with the postoperative change in BMD in any of the Gruen zones. The degree of reduction in bone density was not correlated with the clinical outcome. CONCLUSIONS: Cementless hemiarthroplasty for the treatment of femoral neck fracture in elderly patients achieves a good clinical outcome despite significant bone loss around the femoral stem. The reduction in BMD is more pronounced in the metaphyseal region.

Management of Distal Radius Fractures: Comparison of Three Methods.

Introduction Distal radius fractures are the most common type of all extremity fractures. It is generally accepted that fractures with more than 2 mm step-off in the radiocarpal joint and greater than 10 degrees dorsal tilt should be treated surgically. However, the ideal technique for surgical management is still a point of debate. We performed cross-sectional data analysis to compare the results of three treatments methods - volar locking plate (VLP), external fixation (EF), Kirschner wire (K-wire) - in patients with distal radius fractures, and compared the clinical, functional, and radiological results Materials and methods Forty-four patients with distal radius fractures who underwent fixation with VLP, K-wire or EF between 2011 and 2013 were included in the study. All fractures were classified according to the Müller's Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Frykman's classifications. Routine radiographs were taken at the postoperative three weeks, six weeks, and three months. Radial inclination, volar tilt, radial length and ulnar variance were assessed on the follow-up visits and additionally at the follow -up for the study. The patient-based Disabilities of the Arm, Shoulder and Hand (DASH) score system and the physician-based MAYO scale were used to evaluate functional outcomes. Radiological and functional outcomes between three surgical modalities were compared and statistically analyzed. Results The average age at the time of surgery was 52 years (range = 35-69 years). Of a total of 44 patients, 28 were operated with VLP, 11 were with K-wire and five with EF. Satisfactory reduction was achieved in all fractures, and all of the fractures healed. DASH and MAYO scores were similar in all groups. Regarding radiographic parameters, there was no significant difference in radial inclination, volar tilt, radial length and ulnar variance between the treatment modality groups. When evaluated based on fracture geometry, the DASH score was significantly higher in the patients with AO23A type fracture compared to the patients with AO23B and AO23C type fractures. As for MAYO score, all AO23 groups had similar outcomes. Conclusions Surgical treatment options VLP, EF, and K-wire provide adequate fixation, satisfactory radiological, and functional results for the management of distal radius fractures of various severities. The optimal treatment approach depends on individual features, and the choice for an internal fixation or closed reduction method for the restoration of wrist function should be evaluated thoroughly by the operating surgeon considering the patient-related variations.

Minimally invasive plate osteosynthesis for short oblique diaphyseal tibia fractures: does fracture site affect the outcomes?

OBJECTIVE: To report the results of patients with short oblique diaphyseal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO). The secondary aim was to understand the effect of fracture location (midshaft or distal 1/3) on outcomes. METHODS: Twenty-eight patients with short oblique (>30°) tibial shaft fractures (AO/OTA 42A2) treated with plate and MIPO technique between 2015 and 2019 were retrospectively assessed. Age, gender, follow-up time, fracture type (open or closed), operation time, postoperative infection rate, union time, ankle joint range of motion, and complications were analyzed. Patients' radiographs at a minimum 1-year follow-up were evaluated for malunion, nonunion, and implant-related complications. RESULTS: Mean age and follow-up time were 47.0 ± 15.7 years and 18.3 ± 12.1 months, respectively. Mean bone union time was 3.66 ± 1.04 months in middle 1/3 diaphysis and 4.23 ± 1.48 months in distal 1/3 tibia fractures. Seven (25%) patients developed superficial infections. Mean union time, malunion rate, coronal and sagittal angulation, operation length, and infection rate were similar between the groups. CONCLUSION: MIPO is an effective method for treatment of short oblique diaphyseal tibia fractures, and results in few complications. Both distal and midshaft fractures have similar union and malunion rates.

COMPARISON OF RADIOFREQUENCY ABLATION AND CURETTAGE IN OSTEOID OSTEOMA IN CHILDREN.

OBJECTIVE: Osteoid osteoma, which is observed in the adolescent and young adult population as benign bone tumors, appears as a single nidus with a diameter < 2 cm and is treated with open surgery. However, technological advances in medicine have made it possible to apply less invasive procedures in surgery. METHODS: Between 2006-2014, 24 patients < 18 years of age were treated for osteoid osteoma. Patient demographic data, surgical data, complications, and recurrences were noted. RESULTS: Twenty-four patients (mean age, 11 [2-18] years) were treated and followed up for a mean 3.58 (range, 1-9) years. Mean patient age in the curettage group was 12.1 (range, 3-18) years. Mean operation length was 69.5 (range, 60-120) minutes. Mean hospital stay was 1.3 (range, 0-2) days. Mean patient age in the radiofrequency ablation (RFA) group was 10.7 (range, 2-17) years. Five patients were female and 8 were male. Mean operation length was 49.6 (range, 20-90) minutes. Mean hospital stay was 0.3 (range, 0-1) days. Mean follow-up time was 1.76 (range, 1-4) years. Mean operation length, hospital stay, and follow-up were significantly shorter in the RFA group. CONCLUSIONS: Considering reduced costs due to shorter hospitalization periods and the ability to reach anatomically difficult locations, percutaneous procedures are likely to replace the conventional open approach. Level of evidence: II, retrospective study.

OBJETIVO: O osteoma osteoide, tumor ósseo benigno, acomete predominantemente adolescentes e adultos jovens. É descrito como um nicho único menor que 2 centímetros e o tratamento, nas últimas décadas, era realizado por cirurgia aberta. Com os avanços tecnológicos na medicina, os procedimentos menos invasivos tornaram-se o tratamento de escolha. MÉTODOS: Entre 2006 e 2014, 24 pacientes com menos de 18 anos foram submetidos ao tratamento de osteoma osteoide. Foram coletados os dados demográficos da população estudada e as informações sobre a cirurgia, complicações e recorrência. RESULTADOS: Os vinte e quatro pacientes com média de idade de 11 anos (2-18) foram tratados e o acompanhamento teve média de 3,58 anos (1-9). A média de idade dos pacientes no Grupo curetagem foi de 12,1 anos (3-18). O tempo médio da cirurgia foi de 69,5 minutos (60-120). A média de permanência hospitalar foi de 1,3 dias (0-2). A média de idade dos pacientes no Grupo ARF foi de 10,7 anos (2-17) anos, sendo cinco do sexo feminino e oito do sexo masculino. O tempo médio de cirurgia foi de 49,6 minutos (20-90). A permanência hospitalar média foi de 0,3 dias (0-1). O tempo médio de acompanhamento foi de 1,76 anos (1-4). As médias de tempo cirúrgico, tempo de internação e acompanhamento foram significativamente menores no Grupo ARF. CONCLUSÕES: Quando a redução de custos promovida pelo menor tempo de hospitalização e a capacidade de atingir locais anatomicamente difíceis também forem considerados, os procedimentos percutâneos provavelmente substituirão a cirurgia aberta convencional. Nível de evidência II; Estudo retrospectivo.

Long term survival analysis of cementless Spotorno femoral stem in young patients.

OBJECTIVE: The aim of this study was to analyze the survivorship and clinical outcome of Cementless Spotorno (CLS) stem in young patients. METHODS: A total of 99 consecutive hip arthroplasties using CLS stem were performed on 84 patients younger than 50 years of age between 1993 and 2001. 63 patients were available for final follow-up (mean age: 39 ± 7.8 (range: 22-50)). Patients' Harris Hip Scores (HHS) and survivorship estimates were calculated. Radiographs were analyzed for acetabular implant status, canal fill index (CFI), stem alignment, osteolysis, and stress shielding. RESULTS: Mean follow-up time was 18 years (13-3), and mean HHS was 88.7 (58-100). Patients with femoral neck fracture had a more favorable functional outcome (p = 0.027), while those with stems in varus had lower scores (p = 0.017). 31 stems (49%) were undersized and 30 hips (47%) had perifemoral osteolysis. Acetabular impairment was strongly associated with osteolysis in Gruen zones 1 and 7 (p < 0.01). Seventeen of the osteolytic lesions occurred in Gruen zone 1, 4 lesions in zone 2, 9 in zone 6 and 22 in zone 7. Forty nine stems were well aligned, 10 were in varus and 5 in valgus. Six patients presented with grade 1 stress shielding, 42 with grade 2, 9 with grade 3 and 7 with grade 4. Pedestal formation was evident in 13 cases. Kaplan-Meier survivorship estimates at 18 years with revision for any reason as the end point and with septic revisions excluded were 91.2% (95% CI: 83.7%-98.7%) and 95.1% (95% CI: 89.5%-100%), respectively. There was no difference between survival estimates of patients with different etiologies. CONCLUSION: CLS stems in young patients have high survival estimates in the long term with good-excellent results. Spotorno stems perform equally well in all etiologies with no difference in terms of survivorship. LEVEL OF EVIDENCE: Level IV Therapeutic study.

Assessment of hip abductors by MRI after total hip arthroplasty and effect of fatty atrophy on functional outcome.

OBJECTIVES: The aim of this study was to evaluate how fatty atrophy (FA) of the hip abductors in operated and non-operated hips affected the functional outcome following arthroplasty. METHODS: Forty-four hips of 22 patients (8 males and 14 females; mean age: 60 ±â€¯14.4 (range: 24-84)) who matched the inclusion criteria and willing to participate in the study were retrospectively evaluated. The mean follow-up was 13.8 ±â€¯2.3 (range: 10-18) months Magnetic resonance imaging (MRI) and Harris Hip Score (HHS) were used to evaluate muscle degeneration and functional outcome after unilateral THA through a posterolateral approach. The FA grade was evaluated using Goutallier grading system. Non-operated hips of subjects were used as the control. Age, duration after the operation, gluteal muscle FA, and the relationships with HHS were evaluated. RESULTS: FA was more evident in the operated hip (p < 0.05), and was more in the gluteus minimus than in the gluteus medius in both hips (p < 0.05). Patients' age was not correlated with gluteal muscle FA in the operated hip (p > 0.05), whereas there was a positive correlation with the contra-lateral hip (p < 0.05). Duration after surgery did not affect gluteal muscle FA in the operated hip. Older age and FA of either the operated or healthy hip resulted in poorer HHS (p < 0.05). HHS had the strongest correlations with patient age (p < 0.001) and FA (p = 0.026) of the gluteus minimus of contralateral hip. CONCLUSION: Following THA, there was marked FA in the operated hip compared to that in the contralateral hip. In these cases, degree of FA in the replaced hip did not correlate with patients' age. Fatty atrophy of the gluteus minimus precedes that of gluteus medius. FA of the contralateral gluteus minimus and patient age are strongly correlated with lower HHS. LEVEL OF EVIDENCE: Level IV, diagnostic study. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Thickness of plantar fascia is not predictive of functional outcome in plantar fasciitis treatment.

OBJECTIVE: The aim of this study was to define a quantitative parameter to indicate which cases of plantar fasciitis will benefit from local corticosteroid injection or ESWT and to compare the efficacy of two different treatment modalities. METHODS: Seventy patients (mean age: 49.10; range: 41-58) with chronic plantar fasciitis unresponsive to conservative treatment for 3 months were treated with either betamethasone injection or extracorporeal shock wave therapy (ESWT). Correlation between AOFAS scores, fascia thickness, duration of symptoms, age and calcaneal spur length were assessed. RESULTS: Degree of fascial thickening (mean 4.6 mm for all patients) did not influence baseline AOFAS scores (r = -0.054). Plantar fascia thickness significantly decreased in both groups after treatment (1.2 mm for steroid, 1.2 mm for ESWT) (p < 0.01 for both groups). Percentage of change in AOFAS scores (68% for steroid and 79% for ESWT, p = 0.069) and fascial thickness (24% for steroid and 26% for ESWT, p = 0.344) were similar between two groups. Functional recovery was not correlated with baseline fascial thickness (r = 0.047) or degree of fascial thinning after treatment (r = -0.099). Percentage of change in AOFAS scores was correlated only with baseline AOFAS scores (r = -0.943). CONCLUSIONS: Plantar fascia thickness increases significantly in plantar fasciitis and responds to treatment. Both ESWT and betamethasone injection are effective in alleviating symptoms and reducing plantar fascia thickness in chronic plantar fasciitis. However, the only predictive factor for functional recovery in terms of AOFAS scores is patients' functional status prior to treatment. Measuring of plantar fascia is not helpful as a diagnostic or prognostic tool and MRI imaging should be reserved for differential diagnosis. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes.

BACKGROUND: Management of unstable pertrochanteric fractures remains a challenge with various implant choices. Intramedullary devices are usually preferred for the management of the unstable fractures. When nailing is unsuitable for the configuration of the fracture extra medullary procedures are preferred. PFLCP is a contact limited implant that allows multiple angularly stable fixations with preserving more bone stock after implantation as an extramedullary implant. There are only a few reports in the literature about the osteosynthesis of unstable trochanteric fractures with proximal femoral locking compression plates and their results are conflicting. In the present study we aimed to evaluate the functional and radiological outcomes of proksimal femoral locking compression plates in open reduction and internal fixation of AO/OTA 31A2-2 and 3 fractures. METHODS: Patients older than 18 years of age with a minimum follow-up time of 1 year matching the inclusion criteria retrospectively evaluated. Patients' demographics, Singh index, intra and post-operative data, mobilization and union time gathered from the patients' files. Baumgaertner modified criteria of fracture reduction was used to assess the post-operative reduction quality. Early and last follow-up radiographs were used to evaluate malunion and change in neck- shaft angle. Final clinical outcome was assessed using the Harris Hip scoring system. RESULTS: 18 male and 13 female patients with the mean age of 74 (46-88) met the inclusion criteria. Reduction quality according to Baumgaertner modified criteria was good in 25 patients and acceptable in 6. Mean union time was 21.53 ± 4.18 weeks. There was neither non-union nor malunion. The mean neck-shaft angle change was -3.1° ± 2.16°. The mean HHS was 77.90 ± 4.84 and there was no significance in HHS according to reduction quality and change in neck-shaft angle (p = 0.385, p = 0.0059). HHS was negatively correlated with age, mobilization time and, longer union time (p < 0.05). There was no correlation between Singh index and reduction quality (p = 0.865). Singh index was only correlated with the patient's age (p = 0.000, rho = -0.595). There were 2 infections and, 2 backing of the proximal screws. CONCLUSION: Even though PFLCP is not the first choice in management of unstable pertrochanteric fractures, it must be kept in mind as an alternative to the other conventional plates and intramedullary implants with the properties of an increased stability by multiaxial screw locking and the results are satisfactory when appropriate settlement achieved.